April 2013 Blue Cross and Blue Shield of New Mexico Drug List

Contents

Introduction ...... I Preferred Medication List ...... 12 How Preferred Drugs Are Selected ...... I Anti -Infective Drugs ...... 12 How Member Payment Is Determined . . . . . I Hormones, Diabetes And Related Drugs . . . 14 How To Use This List ...... II Heart And Circulatory Drugs ...... 16 Drugs Used To Treat Multiple Conditions . . . III Respiratory Agents ...... 18 Generic Drugs ...... III Gastrointestinal Drugs ...... 19 Consider Talking To Your Doctor Genitourinary Drugs ...... 19 About Generic Drugs ...... III Central Nervous System Drugs ...... 20 Coverage Considerations ...... III Pain Relief Drugs ...... 21 Prior Authorization (PA) ...... IV Neuromuscular Drugs ...... 23 Step Therapy (ST) ...... IV Supplements ...... 24 Specialty Drugs ...... IV Blood Modifying Drugs ...... 24 Prime Therapeutics Specialty Topical Drugs ...... 24 Pharmacy Program ...... IV Miscellaneous Categories ...... 27 Key ...... V Index ...... 28 Dispensing Limits (Dl) ...... 1

Please consider talking to your doctor about prescribing preferred medications, which may help reduce your out‑of -pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.

The Preferred Drug List is regularly updated. Please visit bcbsnm.com for the most up-to-date information.

To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.

Blue Cross and Blue Shield of New Mexico – A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of Blue Cross and Blue Shield Association.

Prime Therapeutics is the pharmacy benefit manager for Blue Cross and Blue Shield of New Mexico.

2695-A NM © Prime Therapeutics LLC 03/13 INTRODUCTION Blue Cross and Blue Shield of New Mexico is pleased to present the 2013 Preferred Drug List. This is a list of preferred drugs which includes Preferred Brand drugs and a partial listing of generic drugs. Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However decisions regarding therapy and treatment are always between members and their physician.

Preferred Drug List Updates — This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit bcbsnm.com and log in to Blue Access for MembersSM or call the number on the back of your ID card. Physicians can access the list from the provider portal at bcbsnm.com. HOW PREFERRED DRUGS ARE SELECTED Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from your health plan, reviews drugs regulated by the U.S. Food and Drug Administration (FDA).

Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list. HOW MEMBER PAYMENT IS DETERMINED This list shows prescription drug products in tiers. Generally, each drug is placed into one of three or four member payment tiers: generic, Preferred Brand or Non-Preferred Brand (not listed in this document). Specialty drugs can either be within the previous three tiers or can be a separate fourth tier depending on your benefit design. To verify your payment amount for a specialty drug, visit bcbsnm.com and log in to Blue Access for Members or call the number on the back of your ID card.

Your pharmacy benefit includes coverage for almost all prescription drugs, although some exclusions may apply. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Some drugs may only be available through your medical benefit (example: Testopel).

Blue Cross and Blue Shield of New Mexico April 2013 Drug List I 2013

Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step anastrozole (Arimidex – brand is NP) methylprednisolone (Medrol – bicalutamide (Casodex – brand is NP) brand is NP) CEENU prednisolone (Prelone – brand is NP) CYCLOPHOSPHAMIDE tabs prednisolone sodium phosphate soln, 15 mg/5 mL (Orapred – brand is NP) EMCYT PREDNISONE soln, 5 mg/5 mL; tabs, exemestane (Aromasin – 50 mg HOW TO USE THIS LISTbrand is NP) prednisone tabs, 1 mg, 2.5 mg, FARESTON This list is organized into broad therapeutic categories. For example, Hormones,5 mg, 10 mg, Diabetes20 mg and Related Drugs is a flutamide PREDNISONE INTENSOL broad category. Within mosthydroxyurea categories, (Hydrea drugs– brand isare NP) sub-grouped basedMALE upon HORMONES drug class, for example under Hormones, Diabetes and Related Drugsletrozole you (Femara will find – brand Estrogens. is NP) All drugs listed, ANDRODERMwhether generic or brand, are preferred•• drugs. LEUCOVORIN CALCIUM tabs, 10 mg, ANDROGEL •• 2013 15 mg 1 2 3 ANDROXY • leucovorin calcium tabs, 5 mg, 25 mg danazol • LEUKERAN testosterone cypionate •• megestrol (Megace – brand is NP) (Depo‑Testosterone – brand is NP) mercaptopurine (Purinethol – testosterone enanthate (Delatestryl – •• brand is NP) brand is NP) MESNEX tabs ESTROGENS

methotrexateDrug Name Specialty Authorization Prior Dispensing Limits Therapy Step COMBIPATCHDrug Name Specialty Authorization Prior Dispensing Limits Therapy Step anastrozoleMYLERAN (Arimidex – brand is NP) methylprednisoloneDIVIGEL (Medrol – bicalutamideNILANDRON (Casodex – brand is NP) ENJUVIAbrand is NP) (Prelone – brand is NP) CEENUTABLOID prednisoloneESTRADERM prednisolone sodium phosphate soln, tamoxifenCYCLOPHOSPHAMIDE tabs estradiol (Climara – brand is NP) • 15 mg/5 mL (Orapred – brand is NP) tretinoinEMCYT caps •• estradiol (Estrace – brand is NP) PREDNISONE soln, 5 mg/5 mL; tabs, exemestaneTREXALL (Aromasin – estradiol/norethindrone50 mg acetate brand is NP) (Activella – brand is NP) HORMONES, DIABETES AND RELATED DRUGS prednisone tabs, 1 mg, 2.5 mg, CORTICOSTEROIDSFARESTON estropipate,5 mg, 10 mg, NP 20 = mg3 mg budesonideflutamide ext-release PREDNISONEVIVELLE‑DOT INTENSOL • hydroxyurea(Entocort EC (Hydrea– brand –is brand NP) is NP) MALEPROGESTINS HORMONES CORTISONEletrozole (Femara – brand is NP) ANDRODERMmedroxyprogesterone acetate •• (Provera – brand is NP) dexamethasoneLEUCOVORIN CALCIUM elixir; tabs, tabs, 0.5 10 mg, mg, ANDROGEL •• 0.7515 mg mg, 1.5 mg, 4 mg, 6 mg norethindrone acetate (Aygestin – 1 The first column of the chart lists the drug name. Generic drugs ANDROXYare shown in lower-case boldface type.• Most DEXAMETHASONEleucovorin calcium tabs, soln, 50.5 mg, mg/5 25 mgmL brand is NP) generic drugs are followed by a reference brand drug in (parentheses).danazol The reference brand drug is a• non-preferred fludrocortisoneLEUKERAN progesterone micronized (NP) brand and is only included as a reference to the brand. Sometestosterone(Prometrium generic products cypionate– brand is NP) have no reference•• brand. hydrocortisonemegestrol (Megace (Cortef – brand – brand is NP) is NP) (Depo‑Testosterone – brand is NP) Example: budesonidemercaptopurine ext-release (Purinethol (Entocort – EC – brand is NP)testosterone enanthate (Delatestryl – •• brand is NP) brand is NP) Preferred brand drugsMESNEX are tabs listed in all CAPITAL letters. ESTROGENS Bluemethotrexate Cross and Blue Shield of New Mexico April 2013 Drug ListCOMBIPATCH 14 Example: TREXALLMYLERAN DIVIGEL NILANDRON ENJUVIA The following examplesTABLOID are given to assist you and your doctor in readingESTRADERM listings that include specific strengths and tamoxifen dosage forms. These examples can be applied to other drugs on the preferredestradiol (Climara drug –list. brand Any is NP) exceptions are• noted and tretinoin caps •• estradiol (Estrace – brand is NP) some listings contain additional information about specific products or dosage forms. TREXALL estradiol/norethindrone acetate • Extended-releaseHORMONES, and delayed-release DIABETES AND RELATED products DRUGS require their(Activella own – brandentry. is NP) CORTICOSTEROIDS estropipate, NP = 3 mg Example: DETROLbudesonide LA ext-release VIVELLE‑DOT • (Entocort EC – brand is NP) The long-acting product Detrol LA is on the preferred drug list,PROGESTINS but requires a separate entry from the non ext- CORTISONE medroxyprogesterone acetate release productdexamethasone Detrol. elixir; tabs, 0.5 mg, (Provera – brand is NP) 0.75 mg, 1.5 mg, 4 mg, 6 mg norethindrone acetate (Aygestin – • Some productsDEXAMETHASONE may show a soln,strength, 0.5 mg/5 if mL so only that strengthbrand indicated is NP) is on the preferred drug list. Example: XIFAXANfludrocortisone 550 mg progesterone micronized (Prometrium – brand is NP) hydrocortisone (Cortef – brand is NP) The Xifaxan 550 mg is on preferred drug list in this case, but the Xifaxan 200 mg is not because it is not listed.

2 The second column indicates if the drug is a specialty drug. Note: Additional information about specialty drugs can be found in thisBlue document Cross and Blue under Shield the of New header Mexico for April Specialty 2013 Drug Drugs.List 14

3 The remaining columns indicate the Utilization Management (UM) program(s) that apply to the prescription drug (e.g., Prior Authorization, Dispensing Limits, and Step Therapy). If an indicator is present in the column(s), then the UM program noted is possibly applied to your benefit. Some plans may have UM on additional medications beyond those noted in this document.

Blue Cross and Blue Shield of New Mexico April 2013 Drug List II Drugs used to treat multiple conditions

Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances, each medication is classified according to its first FDA-approved use. Please check the index if you do not find your particular medication in the class/condition section that corresponds to your use. GENERIC DRUGS Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs must be approved by the FDA just as brand drugs are, and must meet the same strict standards.

There are two types of generic drugs:

• A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug.

• A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s) differs from the brand drug.

According to the FDA, compared to its brand counterpart, an FDA-approved generic drug:

• Is chemically the same

• Works just as well in the body

• Is as safe and effective

• Meets the same standards set by the FDA

The main difference between the reference brand drug and the generic equivalent is that the generic often costs much less.

Brand drugs in Tier 2 typically move to Tier 3 after a generic equivalent becomes available. You may be responsible for the generic member payment amount plus the difference in cost between the brand and generic drug if you or your doctor requests the reference brand rather than the generic. Generic drugs have the lowest member payment amount.

Consider talking to your doctor about generic drugs

If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an appropriate generic alternative is available.

You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new prescription from your doctor.

Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.

COVERAGE CONSIDERATIONS Most prescription drug benefit plans provide coverage for up to a 30- to 34- day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90- day supply of maintenance medications. Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories, like those used for erectile dysfunction (example: Viagra) or infertility (example: Follistim AQ).

Over-the-Counter Exclusions: Some benefit plans do not provide coverage for prescription medications that have an over -the-counter version. You should refer to your benefit plan booklet for details about your particular benefits.

Blue Cross and Blue Shield of New Mexico April 2013 Drug List III Compounded Medications: Some benefit plans do not provide coverage for compounded medications. Please see your plan materials or call the number on the back of your ID card to determine whether compounded medications are covered and/or verify your payment amount.

Repackaged Medications: Repackaged versions of medications already available on the market are not covered.

Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs that are high-cost or have the potential for misuse. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. For the preferred medications listed in this document, if a prior authorization is commonly required it will be noted next to the medication with a dot under the prior authorization column as stated in the section “How To Use This List.” Some plans may have prior authorization on additional medications beyond those noted in this document.

Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the preferred medications listed in this document, if a step therapy is commonly required it will be noted next to the medication with a dot under the step therapy column as noted in the section “How To Use This List.” Some plans may have step therapy programs on additional medications beyond those noted in this document.

Remember, medication decisions are between you and your doctor. Only your doctor can determine which medication is right for you. Discuss any questions or concerns you have about medications you are taking or are prescribed with your doctor.

SPECIALTY DRUGS Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral or injectable medications that can either be self-administered or administered by a health care professional. For a current list of specialty medications, visit myprime.com or bcbsnm.‌com and log into Blue Access for Members.

Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit. Your plan may have a different coverage level for specialty drugs. If you have questions about your coverage for specialty medications or your prescription drug benefit, call the number on the back of your ID card.

Prime Therapeutics Specialty Pharmacy Program

Through Prime Therapeutics Specialty Pharmacy, members can have covered specialty medications delivered directly to them or their doctor’s office. When you receive specialty medications through Prime, you also receive at no additional charge the following services:

• Coordination of coverage between you, your doctor and your health plan

• Educational materials about your particular condition and information about managing potential medication side effects

• Syringes, sharps containers and other supplies with every shipment for self-injectables

• 24/7/365 phone access to a pharmacist for urgent medication issues

Blue Cross and Blue Shield of New Mexico April 2013 Drug List IV To order through Prime Therapeutics Specialty Pharmacy:

• Have your doctor call or fax your prescription to Prime Therapeutics Specialty Pharmacy. Your doctor can call 877.627.6337 or fax to 877.828.3939.

• If you have an existing prescription for a covered specialty medication, you can call 877.627.6337 to transfer your prescription.

• A Prime Therapeutics coordinator will contact you to arrange delivery of your medication.

• The prescription can be shipped directly to you or your prescribing doctor’s office. Each package is individually marked for each member. Refrigerated drugs are shipped in temperature-controlled packaging.

If you have questions, please contact Prime Therapeutics Specialty Pharmacy at 877.627.6337, visit www. ‌PrimeTherapeutics.com/specialty, or call the number on the back of your ID card.

* Blue Cross and Blue Shield of New Mexico is a Division of Health Care Services Corporation, a Mutual Legal Reserve Company (HCSC). HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to provide pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC.

KEY caps ...... capsules oint ...... ointment chew tabs ...... chewable tablets ophth ...... ophthalmic conc ...... concentrate OSM ...... osmotic-release crm ...... cream PA ...... prior authorization DL ...... dispensing limits SL ...... sublingual ext-release ...... extended-release soln ...... solution inhal ...... inhalation supp ...... suppositories inj ...... injection susp ...... suspension lotn ...... lotion ST ...... step therapy NP ...... non-preferred tabs ...... tablets ODT ...... orally disintegrating tablets

Blue Cross and Blue Shield of New Mexico April 2013 Drug List V Dispensing Limits (DL)

Drug dispensing limits help encourage medication use as intended by the FDA. For the formulary medications listed in this document, if a dispensing limit applies, it will be noted next to the medication with a dot under the dispensing limits column as explained in the section “How to Use This List.” Coverage limits are placed on medications in certain drug categories. Limits may include: • Quantity of covered medication per prescription

• Quantity of covered medication in a given time period

• Coverage only for members within a certain age range

• Coverage only for members of a specific gender

If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows.

The following brand drugs, and their generic equivalents, if available, have dispensing limits. Some of these dispensing limits may not apply to all members or may vary based on state regulations. Some dispensing limits listed below may apply across multiple medications within a drug class. Some plans may exclude coverage for certain agents or drug categories, like those used for erectile dysfunction (example: Viagra). Some drugs may not be available through mail service. Coverage for some drug categories, such as specialty or other select non-specialty medications, may be limited to a 30-day supply at a time depending on your particular benefit plan. Some drugs may only be available through your medical benefit (example: Testopel). Please see your plan materials or call the number on the back of your ID card to verify if you are uncertain of any plan limitations or exclusions. This list is subject to change.

Brand Name (Generic Name) and Dosage Form Dispensing Limit Abilify 2 mg, 5 mg tabs (aripiprazole) 60 tabs/30 days Abilify 10 mg, 15 mg, 20 mg, 30 mg tabs (aripiprazole) 30 tabs/30 days Abilify Discmelt tabs (aripiprazole) 60 tabs/30 days Abilify oral soln (aripiprazole) 750 mL/30 days Abstral (fentanyl) 120 tabs/30 days (across all oral fentanyl) Accuneb 0.63 mg/3 mL, 1.25 mg/3 mL inhal soln (albuterol) 375 mL/30 days Aciphex tabs (rabeprazole delayed-release) 60 tabs/30 days Actiq lollipops (fentanyl) 120 lollipops/30 days (across all oral fentanyl) Actonel 5 mg, 30 mg tabs (risedronate) 30 tabs/30 days Actonel 35 mg tabs (risedronate) 4 tabs/28 days Actonel 150 mg tabs (risedronate) 1 tab/30 days Adcirca tabs (tadalafil) 60 tabs/30 days Adderall 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 30 mg tabs 60 tabs/30 days (amphetamine/dextroamphetamine) Adderall 20 mg tabs (amphetamine/dextroamphetamine) 90 tabs/30 days Adderall XR caps (amphetamine/dextroamphetamine ext-release) 30 caps/30 days Advair Diskus inhaler (fluticasone/salmeterol) 1 inhaler (60 doses)/30 days Advair HFA inhaler (fluticasone/salmeterol) 1 inhaler/30 days albuterol 0.083% inhal soln 375 mL/30 days albuterol 0.5% inhal soln 60 mL/30 days

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 1 Brand Name (Generic Name) and Dosage Form Dispensing Limit Aldara crm (imiquimod) 48 packets/365 days; 12 packets/Rx alendronate 5 mg tabs 30 tabs/30 days Alendronate 40 mg tabs 30 tabs/30 days Alinia oral soln (nitazoxanide) 60 mL/30 days Alora patches (estradiol) 28 patches/28 days Alsuma inj (sumatriptan) 12 syringe cartridges/30 days Alvesco inhaler (ciclesonide) 2 inhalers/30 days Ambien tabs (zolpidem) 30 tabs/30 days Ambien CR tabs (zolpidem ext-release) 30 tabs/30 days Amerge tabs (naratriptan) 18 tabs/30 days (across all oral migraine agents) Ampyra tabs (dalfampridine ext-release) 60 tabs/30 days Androderm patches (testosterone) 30 patches/30 days Androgel 1% gel (testosterone) 4 bottles (300 g)/30 days Androgel 1% gel (testosterone) 60 packets/30 days Androgel 1.62% gel (testosterone) 2 bottles (150 g)/30 days Androgel 1.62%, 1.25 g gel (testosterone) 30 packets/30 days Androgel 1.62%, 2.5 g gel (testosterone) 60 packets/30 days Anzemet 50 mg tabs (dolasetron) tabs 6 tabs/30 days Anzemet 100 mg tabs (dolasetron) 3 tabs/30 days Aptivus 100 mg/mL oral soln (tipranavir) 380 mL/30 days Aptivus 250 mg caps (tipranavir) 120 caps/30 days Arcalyst inj (rilonacept) 4 vials/30 days Arcapta inhaler (indacaterol) 1 package (30 doses)/30 days Arixtra inj (fondaparinux) 360 units/270 days (across Arixtra, Fragmin and Lovenox) Asmanex inhaler (mometasone) 1 inhaler/30 days Astelin nasal spray (azelastine) 2 bottles/30 days Astepro nasal spray (azelastine) 2 bottles/30 days Atelvia tabs (risedronate delayed-release) 4 tabs/28 days Atralin gel (tretinoin) Under age 40 Atripla tabs (efavirenz/emtricitabine/tenofovir) 30 tabs/30 days Atrovent 0.03% nasal spray (ipratropium) 2 bottles/30 days Atrovent 0.06% nasal spray (ipratropium) 3 bottles/30 days Atrovent HFA inhaler (ipratropium) 2 inhalers/30 days Aubagio tabs (teriflunomide) 30 tabs/30 days Avinza caps (morphine sulfate ext-release) 30 caps/30 days Avonex inj (interferon beta-1a) 1 package/28 days Avita – tretinoin crm, gel Under age 40 Axert tabs (almotriptan) 18 tabs/30 days (across all oral migraine agents)

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 2 Brand Name (Generic Name) and Dosage Form Dispensing Limit Axiron soln (testosterone) 2 bottles/30 days Bactroban Nasal oint (mupirocin) 10 -1 g single-use tubes/30 days Beconase AQ (beclomethasone) nasal spray 2 bottles/30 days Betaseron (interferon beta-1b) inj 14 vials/28 days Biaxin XL tabs (clarithromycin ext-release) 28 tabs/30 days Binosto tabs (alendronate) 4 tabs/28 days Boniva 3 mg/3 mL inj (ibandronate) 1 injection/90 days Boniva 150 mg tabs (ibandronate) 1 tab/30 days Bravelle inj (urofollitropin) 60 vials/30 days butorphanol nasal spray 2 bottles/30 days Butrans patches (buprenorphine) 4 patches/30 days Bydureon inj (exenatide ext-release) 4 vials/28 days Byetta pen (exenatide) 1 pen/30 days Caverject inj (alprostadil) 8 units/30 days (males only) Cayston inhal soln (aztreonam) 84 vials/56 days Celebrex 50 mg, 100 mg, 200 mg caps (celecoxib) 60 caps/30 days Celebrex 400 mg caps (celecoxib) 30 caps/30 days Cetrotide 0.25 mg inj (cetrorelix) 12 kits/30 days Cetrotide 3 mg inj (cetrorelix) 1 kit/30 days chorionic gonadotropin inj 20 mL/30 days Cialis 2.5 mg, 5 mg tabs (tadalafil) 30 tabs/30 days (males only) Cialis 10 mg, 20 mg tabs (tadalafil) 8 tabs/30 days (males only) ciprofloxacin ext-release 500 mg tabs 3 tabs/30 days ciprofloxacin ext-release 1000 mg tabs 14 tabs/30 days Climara (estradiol) patches 28 patches/28 days Clomid (clomiphene) tabs 10 tabs/30 days Cold and cough products various Age 5 or older Combivent inhaler (ipratropium/albuterol) 2 inhalers/30 days Combivent Respimat inhaler (ipratropium/albuterol) 2 inhalers/30 days Combivir tabs (lamivudine/zidovudine) 60 tabs/30 days Complera tabs (emtricitabine/rilpivirine/tenofovir) 30 tabs/30 days Concerta 18 mg, 54 mg tabs (methylphenidate ext-release) 30 tabs/30 days Concerta 27 mg tabs (methylphenidate ext-release) 30 tabs/30 days Concerta 36 mg tabs (methylphenidate ext-release) 60 tabs/30 days Copaxone inj (glatiramer) 30 syringes/30 days Crinone vaginal gel (progesterone) 60 applicators/30 days Crixivan 100 mg caps (indinavir) 90 caps/30 days Crixivan 200 mg caps (indinavir) 270 caps/30 days Crixivan 400 mg caps (indinavir) 180 caps/30 days cromolyn sodium inhal soln 240 mL/30 days Cymbalta 20 mg, 60 mg caps (duloxetine) 60 caps/30 days

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 3 Brand Name (Generic Name) and Dosage Form Dispensing Limit Cymbalta 30 mg caps (duloxetine) 90 caps/30 days D.H.E. 45 1 mg/mL inj (dihydroergotamine) 10 mL/30 days Daytrana patches (methylphenidate) 30 patches/30 days Delatestryl 200 mg/mL inj (testosterone enanthate) 1 vial/28 days Depo -testosterone 100 mg/mL, 200 mg/mL; 10 mL vial inj 1 vial/28 days (testosterone cypionate) Depo -testosterone 200 mg/mL; 1 mL vial inj (testosterone cypionate) 4 vials/28 days Desoxyn tabs (methamphetamine) 150 tabs/30 days Dexedrine 5 mg caps (dextroamphetamine ext-release) 90 caps/30 days Dexedrine 10 mg, 15 mg caps (dextroamphetamine ext-release) 120 caps/30 days Dexilant caps (dexlansoprazole delayed-release) 60 caps/30 days dextroamphetamine 5 mg tabs 60 tabs/30 days dextroamphetamine 10 mg tabs 180 tabs/30 days Diastat rectal gel (diazepam) 5 packages/30 days Differin 0.1% crm, gel (adapalene) Under age 40 Differin 0.3% gel (adapalene) Under age 40 Differin lotn (adapalene) Under age 40 Diflucan tabs fluconazole( ) 90 tabs/180 days Diflucan oral susp fluconazole( ) 35 mL/30 days Duexis tabs (ibuprofen/famotidine) 90 tabs/30 days Dulera inhaler (mometasone/formoterol) 1 inhaler/30 days Duoneb inhal soln (ipratropium/albuterol) 540 mL/30 days Duragesic patches (fentanyl) 15 patches/30 days Dymista nasal spray (azelastine/fluticasone) 1 bottle/30 days Edex inj (alprostadil) 8 cartridges/30 days (males only) Edluar SL tabs (zolpidem) 30 tabs/30 days Edurant tabs (rilpivirine) 30 tabs/30 days Ella tabs (ulipristal) 2 tabs/365 days Emend 40 mg, 80 mg, and 125 mg caps (aprepitant) 12 caps/30 days Emend Tri-Pack caps (aprepitant) 6 caps/30 days Emtriva 10 mg/mL oral soln (emtricitabine) 720 mL/30 days Emtriva 200 mg caps (emtricitabine) 30 caps/30 days Epiduo gel (adapalene/benzoyl peroxide) Under age 40 Epivir 10 mg/10 mL oral soln (lamivudine) 960 mL/30 days Epivir 150 mg, 300 mg tabs (lamivudine) 30 tabs/30 days Epzicom tabs (lamivudine/abacavir) 30 tabs/30 days Exalgo tabs (hydromorphone ext-release) 60 tabs/30 days (across all strengths Extavia inj (interferon beta-1b) 1 package/30 days Fentora buccal tabs (fentanyl) 120 tabs/30 days (across all oral fentanyl) Firazyr inj (icatibant) 3 syringes/Rx First -Testosterone oint, crm (testosterone) 60 grams/30 days Flonase nasal spray (fluticasone propionate) 1 bottle/30 days

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 4 Brand Name (Generic Name) and Dosage Form Dispensing Limit Flovent Diskus, Flovent HFA inhaler (fluticasone) 2 inhalers/30 days Flunisolide nasal spray 3 bottles/30 days Focalin tabs (dexmethylphenidate) 60 tabs/30 days Focalin XR caps (dexmethylphenidate ext-release) 30 caps/30 days Follistim AQ 75 units/vial inj (follitropin beta) 60 vials/30 days Follistim AQ 150 units/vial inj (follitropin beta) 30 vials/30 days Follistim AQ 300 units/cartridge inj (follitropin beta) 15 cartridges/30 days Follistim AQ 600 units/cartridge inj (follitropin beta) 8 cartridges/30 days Follistim AQ 900 units/cartridge inj (follitropin beta) 5 cartridges/30 days Foradil Aerolizer inhaler (formoterol) 1 inhaler (60 doses)/30 days Forteo inj (teriparatide) 1 pen/30 days Fortesta gel (testosterone) 2 bottles/30 days Fosamax 10 mg tabs (alendronate) 30 tabs/30 days Fosamax 35 mg, 70 mg tabs (alendronate) 4 tabs/28 days Fosamax Plus D tabs (alendronate/cholecalciferol) 4 tabs/28 days Fragmin inj (dalteparin) 360 unit/270 days (across Arixtra, Fragmin and Lovenox) Frova tabs (frovatriptan) 18 tabs/30 days (across all oral migraine agents) Fuzeon inj, kit (enfuvirtide) 60 vials/30 days Ganirelix Acetate inj 12 syringes (0.5 mL/syringe)/30 days Gelnique gel (oxybutynin) 30 packets/30 days Gilenya caps (fingolimod) 30 caps/30 days Glucose test strips (All) 204 strips/30 days Gonal F 450 units/vial inj (follitropin alfa) 10 vials/30 days Gonal F 1,050 units/vial inj (follitropin alfa) 5 vials/30 days Gonal F RFF 75 units/vial inj (follitropin alfa) 60 vials/30 days Gonal F RFF Pen 300 units/cartridge inj (follitropin alfa) 15 cartridges/30 days Gonal F RFF Pen 450 units/cartridge inj (follitropin alfa) 10 cartridges/30 days Gonal F RFF Pen 900 units/cartridge inj (follitropin alfa) 5 cartridges/30 days Gralise 300 mg tabs (gabapentin) 30 tabs/30 days Gralise 600 mg tabs (gabapentin) 90 tabs/30 days Gralise Starter Pack tabs (gabapentin) 1 pack/30 days granisetron tabs 15 tabs/30 days Granisol oral soln (granisetron) 30 mL/30 days Horizant tabs (gabapentin ext-release) 60 tabs/30 days Imitrex nasal spray (sumatriptan) 12 spray unit devices/30 days Imitrex STATDose inj (sumatriptan) 12 syringe cartridges/30 days Imitrex inj (sumatriptan) 12 vials/30 days Imitrex tabs (sumatriptan) 18 tabs/30 days (across all oral migraine agents) Insulins (All) inj 100 mL/30 days

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 5 Brand Name (Generic Name) and Dosage Form Dispensing Limit Insulin pen needles, syringes (All) 300 units/30 days Intelence 25 mg tabs (etravirine) 120 tabs/30 days Intelence 100 mg, 200 mg tabs (etravirine) 60 tabs/30 days Intermezzo SL tabs (zolpidem) 30 tabs/30 days Intuniv tabs (guanfacine ext-release) 30 tabs/30 days Invirase 200 mg caps (saquinavir) 300 caps/30 days Invirase 500 mg tabs (saquinavir) 120 tabs/30 days ipratropium inhal soln 375 mL/30 days Isentress 25 mg, 100 mg chew tabs (raltegravir) 180 tabs/30 days Isentress 400 mg tabs (raltegravir) 60 tabs/30 days Janumet tabs (sitagliptin/metformin) 60 tabs/30 days Janumet XR 50-500 mg, 100-1000 mg tabs (sitagliptin/metformin 30 tabs/30 days ext‑release) Janumet XR 50-1000 mg tabs (sitagliptin/metformin ext-release) 60 tabs/30 days Januvia tabs (sitagliptin) 30 tabs/30 days Jentadueto tabs (linagliptin/metformin) 60 tabs/30 days Juvisync tabs (sitagliptin/simvastatin) 30 tabs/30 days Kadian 10 mg, 40 mg, 70 mg, 130 mg, 150 mg, 200 mg caps 120 caps/30 days (morphine sulfate ext-release) Kadian 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg caps 120 caps/30 days (morphine sulfate ext-release) Kalbitor inj (ecallantide) 2 syringes/Rx Kaletra 80-20 mg/mL oral soln (lopinavir/ritonavir) 320 mL/30 days Kaletra 100-25 mg tabs (lopinavir/ritonavir) 300 tabs/30 days Kaletra 200-50 mg tabs (lopinavir/ritonavir) 120 tabs/30 days Kapvay 0.1 mg tabs (clonidine ext-release) 120 tabs/30 days Kapvay 0.1 mg, 0.2 mg therapy pack tabs (clonidine ext-release) 60 tabs/30 days ketorolac tabs 20 tabs/30 days Kombiglyze XR 5-500 mg, 5-1000 mg tabs (saxagliptin/metformin 30 tabs/30 days ext‑release) Kombiglyze XR 2.5-1000 mg tabs (saxagliptin/metformin ext-release) 60 tabs/30 days Lamisil tabs (terbinafine) 90 tabs/180 days Latuda tabs (lurasidone) 30 tabs/30 days Lazanda nasal spray (fentanyl) 30 bottles/30 days Letairis tabs (ambrisentan) 30 tabs/30 days Levitra tabs (vardenafil) 8 tabs/30 days (males only) Lexiva 50 mg/mL oral susp (fosamprenavir) 1800 mL/30 days Lexiva 700 mg tabs (fosamprenavir) 120 tabs/30 days Lovenox inj (enoxaparin) 360 units/270 days (across Arixtra, Fragmin and Lovenox) Lumigan ophth soln (bimatoprost) 2.5 mL/30 days Lunesta tabs (eszopiclone) 30 tabs/30 days

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 6 Brand Name (Generic Name) and Dosage Form Dispensing Limit Luveris inj (lutropin alfa) 14 vials/30 days Marinol caps (dronabinol) 60 caps/30 days Maxair Autohaler inhaler (pirbuterol) 1 inhaler/30 days Maxalt/Maxalt-MLT tabs (rizatriptan) 18 tabs/30 days (across all oral migraine agents) Menopur inj (menotropins) 60 vials/30 days Menostar patches (estradiol) 28 patches/28 days Metadate CD caps (methylphenidate ext-release) 30 caps/30 days Metadate ER – methylphenidate ext-release tabs 90 tabs/30 days Methylin 2.5 mg, 5 mg chew tabs (methylphenidate) 90 tabs/30 days Methylin 10 mg chew tabs (methylphenidate) 180 tabs/30 days Methylin 5 mg/5 mL soln (methylphenidate) 450 mL/30 days Methylin 10 mg/5 mL soln (methylphenidate) 900 mL/30 days Methylphenidate ext-release 10 mg tabs 90 tabs/30 days Migranal nasal spray (dihydroergotamine) 8 vials/30 days Minivelle patches (estradiol) 30 patches/30 days Muse supp (alprostadil) 8 supps/30 days (males only) Nasacort AQ nasal spray (triamcinolone) 1 bottle/30 days Nasonex nasal spray (mometasone) 1 bottle/30 days Nexium caps (esomeprazole delayed-release) 60 caps/30 days Nexium packets (esomeprazole delayed-release) 60 packets/30 days Norvir 100 mg caps (ritonavir) 360 caps/30 days Norvir 100 mg tabs (ritonavir) 360 tabs/30 days Norvir 80 mg/mL soln (ritonavir) 480 mL/30 days Nucynta tabs (tapentadol) 180 tabs/30 days Nucynta ER tabs (tapentadol ext-release) 60 tabs/30 days Omnaris nasal spray (ciclesonide) 1 bottle/30 days ondansetron 24 mg tabs 4 tabs/30 days Onglyza tabs (saxagliptin) 30 tabs/30 days Onmel tabs (itraconazole) 180 tabs/180 days Onsolis buccal film (fentanyl) 120 films/30 days (across all oral fentanyl) Oral contraceptive tabs 1 pack (28-day supply)/21 days Oravig buccal tabs (miconazole) 14 tabs/30 days Ortho Evra patches (norelgestromin/ethinyl estradiol) 4 patches/30 days Ovidrel inj (choriogonadotropin alfa) 2 syringes/30 days Oxycontin tabs (oxycodone ext-release) 120 tabs/30 days Oxytrol patches (oxybutynin) 8 patches/30 days Patanase nasal spray (olopatadine) 1 bottle/30 days Penlac nail soln (ciclopirox) 13.2 mL/30 days Plan B tabs (levonorgestrel) Covered for females age 16 yrs and under with Rx - 4 tabs/365 days

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 7 Brand Name (Generic Name) and Dosage Form Dispensing Limit Plan B One-Step tabs (levonorgestrel) Covered for females age 16 yrs and under with Rx - 2 tabs/365 days Pradaxa caps (dabigatran) 60 caps/30 days Prevacid caps (lansoprazole delayed-release) 60 caps/30 days Prevacid Solutab tabs (lansoprazole delayed-release) 60 tabs/30 days Prezista 75 mg tabs (darunavir) 300 tabs/30 days Prezista 150 mg tabs (darunavir) 180 tabs/30 days Prezista 400 mg, 600 mg tabs (darunavir) 60 tabs/30 days Prezista 800 mg tabs (darunavir) 30 tabs/30 days Prilosec caps (omeprazole delayed-release) 60 caps/30 days Prilosec oral susp (omeprazole) 60 packets/30 days Pristiq tabs (desvenlafaxine ext-release) 60 tabs/30 days ProAir HFA inhaler (albuterol) 2 inhalers/30 days Procentra soln (dextroamphetamine) 1800 mL/30 days Promacta 25 mg tabs (eltrombopag) 90 tabs/30 days Promacta 12.5 mg, 50 mg, 75 mg tabs (eltrombopag) 30 tabs/30 days Protonix granules (pantoprazole delayed-release) 60 packets/30 days (limit one proton pump inhibitor in 30 days) Protonix tabs (pantoprazole delayed-release) 60 tabs/30 days Proventil HFA inhaler (albuterol) 2 inhalers/30 days Prozac Weekly caps (fluoxetine delayed-release) 4 caps/28 days Pulmicort Flexhaler 180 mcg inhaler (budesonide) 2 inhalers/30 days Pulmicort Flexhaler 90 mcg inhaler (budesonide) 1 inhaler/30 days Pulmicort Respules 1 mg/2 mL inhal susp (budesonide) 180 mL/30 days Pulmicort Respules 0.25 mg/2 mL, 0.5 mg/2 mL inhal susp 180 mL/30 days (budesonide) Pylera caps (bismuth/metronidazole/tetracycline) 120 caps/30 days Qnasl nasal spray (beclomethasone) 1 bottle/30 days QVAR inhaler (beclomethasone) 2 inhalers/30 days Quillivant XR oral susp (methylphenidate ext-release) 360 mL/30 days Rebif 22 mcg/0.5 mL, 44 mcg/0.5 mL inj (interferon beta-1a) 12 syringes/28 days Rebif titration pack inj (interferon beta-1a) 1 kit/28 days Regranex gel (becaplermin) 60 grams/365 days Relenza inhaler (zanamivir) 1 inhaler (20 doses)/120 days Relpax tabs (eletriptan) 18 tabs/30 days (across all oral migraine agents) Repronex inj (menotropins) 60 vials/30 days Rescriptor 100 mg tabs (delavirdine) 90 tabs/30 days Rescriptor 200 mg tabs (delavirdine) 180 tabs/30 days Retin -A crm, gel (tretinoin) Under age 40 Retin -A Micro gel (tretinoin microsphere) Under age 40 Revatio tabs (sildenafil) 90 tabs/30 days (across all strengths)

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 8 Brand Name (Generic Name) and Dosage Form Dispensing Limit ReVia tabs (naltrexone) 180 tabs/365 days Reyataz 100 mg, 150 mg, 300 mg caps (atazanavir) 30 caps/30 days Reyataz 200 mg caps (atazanavir) 60 caps/30 days Rhinocort Aqua nasal spray (budesonide) 2 bottles/30 days Ritalin tabs (methylphenidate) 90 tabs/30 days Ritalin LA 10 mg caps (methylphenidate ext-release) 30 caps/30 days Ritalin LA 20 mg, 40 mg caps (methylphenidate ext-release) 30 caps/30 days Ritalin LA 30 mg caps (methylphenidate ext-release) 60 caps/30 days Ritalin SR 20 mg tabs (methylphenidate ext-release) 90 tabs/30 days Rozerem tabs (ramelteon) 30 tabs/30 days Ryzolt tabs (tramadol ext-release) 30 tabs/30 days Samsca 15 mg tabs (tolvaptan) 30 tabs/30 days Samsca 30 mg tabs (tolvaptan) 60 tabs/30 days Sancuso patches (granisetron) 2 patches/30 days Savella tabs (milnacipran) 60 tabs/30 days Savella Titration Pack pack (milnacipran) 1 pack/30 days Selzentry 150 mg tabs (maraviroc) 60 tabs/30 days Selzentry 300 mg tabs (maraviroc) 120 tabs/30 days Serevent Diskus inhaler (salmeterol) 1 inhaler (60 doses)/30 days Silenor tabs (doxepin) 30 tabs/30 days Simponi inj (golimumab) 1 syringe/30 days Sonata caps (zaleplon) 30 caps/30 days Spiriva Handihaler inhaler (tiotropium) 1 package (30 doses)/30 days Sporanox caps (itraconazole) 360 caps/180 days Sporanox soln (itraconazole) 22 bottles (3,300 mL)/180 days Sprix nasal spray (ketorolac) 5 bottles/30 days Staxyn tabs (vardenafil) 8 tabs/30 days (males only) Strattera 10 mg, 18 mg, 25 mg, 40 mg, 60 mg caps (atomoxetine) 60 caps/30 days Strattera 80 mg, 100 mg caps (atomoxetine) 30 caps/30 days Striant buccal tabs (testosterone) 60 buccal tabs/30 days Stribild tabs (elvitegravir/cobicistat/emtricitabine/tenofovir) 30 tabs/30 days Suboxone SL films, tabs (buprenorphine/naloxone) 90 films, tabs/30 days Subsys SL spray (fentanyl) 120 doses/30 days (across all oral fentanyl) Subutex SL tabs (buprenorphine) 90 tabs/30 days Sumatriptan nasal spray 12 spray unit devices/30 days Sumavel DosePro inj (sumatriptan) 12 injection devices/30 days Sustiva 50 mg caps (efavirenz) 90 caps/30 days Sustiva 200 mg caps (efavirenz) 60 caps/30 days Sustiva 600 mg tabs (efavirenz) 30 tabs/30 days Symbicort inhaler (budesonide/formoterol) 1 inhaler/30 days Symlin inj (pramlintide) 4 vials/30 days SymlinPen inj (pramlintide) 2 boxes/30 days

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 9 Brand Name (Generic Name) and Dosage Form Dispensing Limit Tamiflu 30 mg caps (oseltamivir) 40 caps/120 days Tamiflu 45 mg, 75 mg caps (oseltamivir) 20 caps/120 days Tamiflu 6 mg/mL oral susp (oseltamivir) 360 mL/120 days Testopel pellets (testosterone) 6 pellets/90 days Testim gel (testosterone) 60 tubes (300 g)/30 days tizanidine 2 mg tabs 180 tabs/30 days Tobi inhal soln (tobramycin) 1 package (56 ampules)/56 days Tracleer tabs (bosentan) 60 tabs/30 days Tradjenta tabs (linagliptin) 30 tabs/30 days Travatan Z ophth soln (travoprost) 2.5 mL/30 days Tretin -X crm (tretinoin) Under age 40 Treximet tabs (sumatriptan/naproxen sodium) 18 tabs/30 days (across all oral migraine agents) Trizivir tabs (abacavir/lamivudine/zidovudine) 60 tabs/30 days Truvada tabs (emtricitabine/tenofovir) 30 tabs/30 days Tudorza Pressair inhaler (aclidinium) 1 inhaler/30 days Ultram tabs (tramadol) 240 tabs/30 days Ultram ER tabs (tramadol ext-release) 30 tabs/30 days Veltin gel (clindamycin/tretinoin) Under age 40 Ventolin HFA inhaler (albuterol) 2 inhalers/30 days Veramyst nasal spray (fluticasone furoate) 1 bottle/30 days Viagra tabs (sildenafil) 8 tabs/30 days (males only) Victoza inj (liraglutide) 3 pens/30 days Videx 10 mg/mL oral susp (didanosine) 1200 mL/30 days Videx 125 mg, 200 mg, 250 mg, 400 mg caps (didanosine) 30 caps/30 days Vimovo tabs (naproxen/esomeprazole) 60 tabs/30 days Viracept 250 mg tabs (nelfinavir) 270 tabs/30 days Viracept 625 mg tabs (nelfinavir) 120 tabs/30 days Viramune 50 mg/5 mL oral susp (nevirapine) 1200 mL/30 days Viramune 200 mg tabs (nevirapine) 60 tabs/30 days Viramune XR tabs (nevirapine extended-release) 30 tabs/30 days Viread 40 mg/1 g powder (tenofovir) 240 g/30 days Viread 150 mg, 200 mg, 250 mg, 300 mg tabs (tenofovir) 30 tabs/30 days Vivelle -Dot patches (estradiol) patches 28 patches/28 days Vyvanse caps (lisdexamfetamine) caps 30 caps/30 days Xalatan ophth soln (latanoprost) 2.5 mL/30 days Xanax XR tabs (alprazolam ext-release) 60 tabs/30 days Xarelto 10 mg tabs (rivaroxaban) 35 tabs/90 days Xarelto 15 mg, 20 mg tabs (rivaroxaban) 30 tabs/30 days Xenazine 12.5 mg tabs (tetrabenazine) 240 tabs/30 days Xenazine 25 mg tabs (tetrabenazine) 120 tabs/30 days Xifaxan 200 mg tabs (rifaximin) 9 tabs/30 days

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 10 Brand Name (Generic Name) and Dosage Form Dispensing Limit Xifaxan 550 mg tabs (rifaximin) 60 tabs/30 days Xopenex 0.31 mg, 0.63 mg, 1.25 mg inhal soln (levalbuterol) 375 mL/30 days Xopenex Concentrate 1.25 mg/0.5 mL inhal soln (levalbuterol) 90 units/30 days Xopenex HFA inhaler (levalbuterol) 2 inhalers/30 days Xyrem oral soln (sodium oxybate) 540 mL/30 days Zanaflex caps tizanidine( ) 180 caps/30 days Zanaflex 4 mg tabs tizanidine( ) 180 tabs/30 days Zegerid caps (omeprazole/sodium bicarbonate) 60 units/30 days Zegerid powder (omeprazole/sodium bicarbonate) 60 units/30 days Zerit 1 mg/mL oral soln (stavudine) 2400 mL/30 days Zerit 15 mg, 20 mg, 30 mg, 40 mg caps (stavudine) 60 caps/30 days Zetia tabs (ezetimibe) 30 tabs/30 days Zetonna nasal spray (ciclesonide) 1 bottle/30 days Ziagen 20 mg/mL oral solution (abacavir) 960 mL/30 days Ziagen 300 mg tabs (abacavir) 60 tabs/30 days Ziana gel (clindamycin/tretinoin) Under age 40 zidovudine 50 mg/5 mL syrup 1920 mL/30 days zidovudine 100 mg caps 180 caps/30 days zidovudine 300 mg tabs 60 tabs/30 days Zioptan ophth soln (tafluprost) 30 single-use containers/30 days Zithromax tabs (azithromycin) 60 tabs/150 days Zofran oral soln (ondansetron) 100 mL/30 days Zofran 4 mg, 8 mg tabs (ondansetron) 30 tabs/30 days Zofran ODT 4 mg, 8 mg tabs (ondansetron) 30 tabs/30 days Zolpimist oral spray (zolpidem) 1 bottle/30 days Zomig nasal spray (zolmitriptan) 2 bottles (12 spray units)/30 days Zomig tabs (zolmitriptan) 18 tabs/30 days (across all oral migraine agents) Zomig ZMT tabs (zolmitriptan) 18 tabs/30 days (across all oral migraine agents) Zuplenz films (ondansetron) 12 films/30 days Zyvox oral susp (linezolid) 600 mL/180 days Zyvox tabs (linezolid) 56 tabs/180 days

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 11 2013

Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step ANTI-INFECTIVEPreferred Medication DRUGS List FLUOROQUINOLONES PENICILLINS ciprofloxacin (Cipro – brand is NP) amoxicillin/potassium clavulanate levofloxacin (Levaquin – brand is NP) (Augmentin – brand is NP) AMINOGLYCOSIDES amoxicillin/potassium clavulanate neomycin sulfate ext-release (Augmentin XR – brand is NP) paromomycin amoxicillin, NP = chew tabs TUBERCULOSIS ampicillin caps ethambutol (Myambutol – brand is NP) dicloxacillin isoniazid tabs penicillin v potassium isoniazid/rifampin (Rifamate – brand is NP) CEPHALOSPORINS MYCOBUTIN cefadroxil PRIFTIN cefdinir pyrazinamide cefpodoxime rifampin (Rifadin – brand is NP) cefprozil FUNGAL INFECTIONS ceftriaxone (Rocephin – brand is NP) fluconazole (Diflucan – brand is NP) • cefuroxime (Ceftin – brand is NP) flucytosine (Ancobon – brand is NP) cephalexin, NP = tabs (Keflex – brand is NP) griseofulvin microsize (Grifulvin V – brand is NP) SUPRAX tabs itraconazole (Sporanox – • MACROLIDES brand is NP) azithromycin susp (Zithromax – ketoconazole tabs brand is NP) NOXAFIL • azithromycin tabs (Zithromax – • brand is NP) nystatin oral clarithromycin (Biaxin – brand is NP) terbinafine (Lamisil – brand is NP) • clarithromycin ext-release • VFEND susp • (Biaxin XL – brand is NP) voriconazole (Vfend tabs – • ZITHROMAX packets brand is NP) TETRACYCLINES VIRAL INFECTIONS demeclocycline Cytomegalovirus doxycycline hyclate (Vibramycin – • VALCYTE brand is NP) Hepatitis minocycline (Dynacin, Minocin – BARACLUDE brands are NP) HEPSERA

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 12 2013

Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step ribavirin (Copegus, Rebetol – • VIDEX • brands are NP) VIRACEPT • Herpes VIRAMUNE susp • acyclovir (Zovirax – brand is NP) VIRAMUNE XR • famciclovir (Famvir – brand is NP) VIREAD • valacyclovir (Valtrex – brand is NP) zidovudine (Retrovir – brand is NP) • HIV/AIDS MALARIA (Ziagen tabs – brand is NP) abacavir • atovaquone/proguanil 250-100 mg APTIVUS • (Malarone 250-100 mg – brand is NP) ATRIPLA • chloroquine phosphate (Aralen – CRIXIVAN • brand is NP) didanosine delayed-release • DARAPRIM (Videx EC – brand is NP) hydroxychloroquine (Plaquenil – EMTRIVA • brand is NP) EPIVIR soln • MALARONE 62.5-25 mg EPZICOM • mefloquine INTELENCE • PRIMAQUINE INVIRASE • WORM INFECTIONS ALBENZA ISENTRESS • BILTRICIDE KALETRA • STROMECTOL lamivudine (Epivir – brand is NP) • OTHER ANTI-INFECTIVES lamivudine/zidovudine (Combivir – • brand is NP) clindamycin (Cleocin, Cleocin Pediatric – brands are NP) LEXIVA • DAPSONE nevirapine tabs (Viramune tabs – • brand is NP) erythromycin/sulfisoxazole NORVIR • metronidazole (Flagyl – brand is NP) PREZISTA • sulfamethoxazole/trimethoprim (Bactrim – brand is NP) RESCRIPTOR • trimethoprim REYATAZ • vancomycin (Vancocin – brand is NP) SELZENTRY • XIFAXAN 550 mg stavudine (Zerit – brand is NP) • • ZYVOX STRIBILD • • CANCER DRUGS SUSTIVA • AFINITOR • • TRIZIVIR • ALKERAN TRUVADA •

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 13 2013

Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step anastrozole (Arimidex – brand is NP) methylprednisolone (Medrol – bicalutamide (Casodex – brand is NP) brand is NP) CEENU prednisolone (Prelone – brand is NP) CYCLOPHOSPHAMIDE tabs prednisolone sodium phosphate soln, 15 mg/5 mL (Orapred – brand is NP) EMCYT PREDNISONE soln, 5 mg/5 mL; tabs, exemestane (Aromasin – 50 mg brand is NP) prednisone tabs, 1 mg, 2.5 mg, FARESTON 5 mg, 10 mg, 20 mg flutamide PREDNISONE INTENSOL hydroxyurea (Hydrea – brand is NP) MALE HORMONES letrozole (Femara – brand is NP) ANDRODERM • • LEUCOVORIN CALCIUM tabs, 10 mg, ANDROGEL • • 15 mg ANDROXY • leucovorin calcium tabs, 5 mg, 25 mg danazol • LEUKERAN testosterone cypionate • • megestrol (Megace – brand is NP) (Depo‑Testosterone – brand is NP) mercaptopurine (Purinethol – testosterone enanthate (Delatestryl – • • brand is NP) brand is NP) MESNEX tabs ESTROGENS methotrexate COMBIPATCH MYLERAN DIVIGEL NILANDRON ENJUVIA TABLOID ESTRADERM tamoxifen estradiol (Climara – brand is NP) • tretinoin caps • • estradiol (Estrace – brand is NP) TREXALL estradiol/norethindrone acetate HORMONES, DIABETES AND RELATED DRUGS (Activella – brand is NP) CORTICOSTEROIDS estropipate, NP = 3 mg budesonide ext-release VIVELLE-DOT • (Entocort EC – brand is NP) PROGESTINS CORTISONE medroxyprogesterone acetate dexamethasone elixir; tabs, 0.5 mg, (Provera – brand is NP) 0.75 mg, 1.5 mg, 4 mg, 6 mg norethindrone acetate (Aygestin – DEXAMETHASONE soln, 0.5 mg/5 mL brand is NP) fludrocortisone progesterone micronized (Prometrium – brand is NP) hydrocortisone (Cortef – brand is NP)

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 14 2013 Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name BIRTH CONTROL ONGLYZA • ELLA • pioglitazone (Actos – brand is NP) levonorgestrel (Plan B, Plan • pioglitazone/metformin B‑One‑Step – brands are NP) (Actoplus Met – brand is NP) medroxyprogesterone acetate PRANDIN (Depo-Provera – brand is NP) VICTOZA • • NUVARING DIABETES - INSULINS oral contraceptives – all generics • Rapid-Acting Insulins ORTHO EVRA • HUMALOG • INFERTILITY NOVOLOG • chorionic gonadotropin • • Short-Acting Insulins clomiphene (Clomid – brand is NP) • HUMULIN R • DIABETES NOVOLIN R • acarbose (Precose – brand is NP) Intermediate-Acting Insulins glimepiride (Amaryl – brand is NP) HUMALOG MIX 50/50, 75/25 • glipizide (Glucotrol – brand is NP) HUMULIN N • glipizide ext-release (Glucotrol XL – HUMULIN 70/30 • brand is NP) NOVOLIN N • glipizide/metformin (Metaglip – brand is NP) NOVOLIN 70/30 • GLUCAGON EMERGENCY KIT NOVOLOG MIX 70/30 • glyburide (Micronase – brand is NP) Basal Insulins glyburide micronized (Glynase – LANTUS • brand is NP) LEVEMIR • glyburide/metformin (Glucovance – THYROID REGULATION brand is NP) levothyroxine (Synthroid – brand is NP) JANUMET • liothyronine (Cytomel – brand is NP) JANUMET XR • methimazole (Tapazole – JANUVIA • brand is NP) JUVISYNC • propylthiouracil KOMBIGLYZE XR • OTHER HORMONES AND RELATED DRUGS metformin (Glucophage – brand is NP) ACTONEL • metformin ext-release alendronate 5 mg, 10 mg, 35 mg, • (Glucophage XR – brand is NP) 70 mg (Fosamax – brand is NP) metformin ext-release OSM cabergoline (Fortamet – brand is NP) calcitonin-salmon (Miacalcin – nateglinide (Starlix – brand is NP) brand is NP)

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 15 2013 Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name calcitriol (Rocaltrol – brand is NP) ANGIOTENSIN II RECEPTOR ANTAGONISTS desmopressin (DDAVP – (ARBS) AND COMBINATIONS brand is NP) BENICAR etidronate 400 mg (Didronel – BENICAR HCT brand is NP) losartan (Cozaar – brand is NP) EVISTA losartan/hydrochlorothiazide ibandronate (Boniva – brand is NP) • (Hyzaar – brand is NP) levocarnitine (Carnitor – brand is NP) valsartan/hydrochlorothiazide methylergonovine (Diovan HCT – brand is NP) SENSIPAR BETA BLOCKERS AND COMBINATIONS STIMATE acebutolol (Sectral – brand is NP) ZEMPLAR atenolol (Tenormin – brand is NP) (Tenoretic – HEART AND CIRCULATORY DRUGS atenolol/chlorthalidone brand is NP) ANGIOTENSIN CONVERTING ENZYME (Zebeta – brand is NP) (ACE) INHIBITORS AND COMBINATIONS bisoprolol

benazepril (Lotensin – brand is NP) bisoprolol/hydrochlorothiazide (Ziac – brand is NP) benazepril/hydrochlorothiazide (Coreg – brand is NP) (Lotensin HCT – brand is NP) carvedilol INNOPRAN XL captopril (Trandate – brand is NP) enalapril (Vasotec – brand is NP) labetalol

enalapril/hydrochlorothiazide metoprolol succinate ext-release (Vaseretic – brand is NP) (Toprol XL – brand is NP) (Lopressor – fosinopril metoprolol tartrate brand is NP) fosinopril/hydrochlorothiazide nadolol (Corgard – brand is NP) lisinopril (Prinivil, Zestril – PINDOLOL brands are NP) PROPRANOLOL soln lisinopril/hydrochlorothiazide (Prinzide, Zestoretic – brands are NP) propranolol tabs moexipril (Univasc – brand is NP) propranolol ext-release (Inderal LA – moexipril/hydrochlorothiazide brand is NP) (Uniretic – brand is NP) TIMOLOL tabs perindopril (Aceon – brand is NP) CALCIUM CHANNEL BLOCKERS quinapril (Accupril – brand is NP) AND COMBINATIONS quinapril/hydrochlorothiazide amlodipine (Norvasc – brand is NP) (Accuretic – brand is NP) amlodipine/benazepril (Lotrel – ramipril (Altace – brand is NP) brand is NP) trandolapril (Mavik – brand is NP) diltiazem (Cardizem – brand is NP)

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 16 2013 Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name diltiazem ext-release (Cardizem CD, FLUID RETENTION Cardizem LA, Dilacor XR, Tiazac – acetazolamide 250 mg brands are NP) acetazolamide ext-release felodipine ext-release (Diamox Sequels – brand is NP) nifedipine ext-release (Adalat CC, amiloride Procardia XL - brands are NP) amiloride/hydrochlorothiazide verapamil 80 mg, 120 mg (Calan – brand is NP) bumetanide verapamil ext-release (Calan SR, chlorothiazide Isoptin SR, Verelan, Verelan PM – chlorthalidone 25 mg brands are NP) furosemide, NP = soln, 8 mg/mL CHEST PAIN (Lasix – brand is NP) isosorbide dinitrate, NP = SL tabs hydrochlorothiazide caps (Microzide – (Isordil – brand is NP) brand is NP) isosorbide mononitrate (Monoket – hydrochlorothiazide tabs brand is NP) indapamide isosorbide mononitrate ext-release methazolamide (Neptazane – (Imdur – brand is NP) brand is NP) nitroglycerin (Nitro-Dur – brand is NP) metolazone (Zaroxolyn – brand is NP) NITROSTAT spironolactone (Aldactone – CHOLESTEROL LOWERING brand is NP) atorvastatin (Lipitor – brand is NP) spironolactone/hydrochlorothiazide cholestyramine (Questran, (Aldactazide – brand is NP) Questran Light – brands are NP) torsemide (Demadex – brand is NP) colestipol (Colestid – brand is NP) triamterene/hydrochlorothiazide CRESTOR (Dyazide, Maxzide, Maxzide-25 – brands are NP) fenofibrate (Lofibra, Tricor – brands are NP) HEART RHYTHM fenofibrate micronized (Lofibra – amiodarone (Cordarone, Pacerone – brand is NP) brands are NP) gemfibrozil (Lopid – brand is NP) disopyramide (Norpace – brand is NP) lovastatin (Mevacor – brand is NP) flecainide (Tambocor – brand is NP) NIASPAN MEXILETINE pravastatin (Pravachol – brand is NP) MULTAQ simvastatin (Zocor – brand is NP) propafenone (Rythmol – brand is NP) TRICOR propafenone ext-release TRILIPIX (Rythmol SR – brand is NP) WELCHOL quinidine gluconate ext-release

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 17 2013

Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step quinidine sulfate triamcinolone (Nasacort AQ – • sotalol (Betapace, Betapace AF – brand is NP) brands are NP) COUGH/COLD/ALLERGY OTHER HEART RELATED DRUGS acetylcysteine clonidine (Catapres, Catapres-TTS – ASTHMA/COPD brands are NP) ADVAIR DISKUS • DIBENZYLINE ADVAIR HFA • digoxin tabs (Lanoxin – brand is NP) albuterol inhal soln, 0.083%, 0.5% • doxazosin (Cardura – brand is NP) albuterol 0.63 mg/3 mL, 1.25 mg/3 mL • eplerenone (Inspra – brand is NP) (Accuneb – brand is NP) guanfacine (Tenex – brand is NP) albuterol syrup, tabs hydralazine ASMANEX • methyldopa ATROVENT HFA • midodrine budesonide (Pulmicort Respules – • minoxidil brand is NP) COMBIVENT prazosin (Minipress – brand is NP) • COMBIVENT RESPIMAT sildenafil (Revatio – brand is NP) • • • • terazosin cromolyn inhal soln • ERECTILE DYSFUNCTION DULERA • FLOVENT DISKUS CIALIS • • • BEE STING KITS FLOVENT HFA • EPIPEN FORADIL AEROLIZER • EPIPEN-JR ipratropium inhal soln • RESPIRATORY AGENTS ipratropium/albuterol (Duoneb – • brand is NP) ANTIHISTAMINES montelukast (Singulair – brand is NP) AEROHIST PROAIR HFA • cetirizine syrup QVAR • cyproheptadine SPIRIVA HANDIHALER • promethazine, NP = supp, 50 mg SYMBICORT • NASAL PRODUCTS terbutaline ASTEPRO • theophylline ext-release azelastine (Astelin – brand is NP) • VENTOLIN HFA • fluticasone propionate (Flonase – • brand is NP) zafirlukast (Accolate – brand is NP) ipratropium (Atrovent – brand is NP) • NASONEX •

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 18 2013

Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step OTHER RESPIRATORY DRUGS ondansetron 24 mg • FIRAZYR • • trimethobenzamide (Tigan – PULMOZYME • brand is NP) GASTROINTESTINAL DRUGS DIGESTIVE ENZYMES LAXATIVES CREON lactulose ZENPEP PEG – electrolytes for soln (Colyte, OTHER GASTROINTESTINAL DRUGS Golytely, Nulytely – brands are NP) ASACOL ULCER/GERD ASACOL HD cimetidine balsalazide (Colazal – brand is NP) dicyclomine caps, tabs (Bentyl – calcium acetate (Eliphos, Phoslo – brand is NP) brands are NP) famotidine (Pepcid – brand is NP) CANASA glycopyrrolate (Robinul – DELZICOL brand is NP) diphenoxylate/atropine tabs hyoscyamine (Anaspaz, Levsin, (Lomotil – brand is NP) Levsin/SL – brands are NP) lactulose hyoscyamine ext-release (Levbid, LIALDA Symax DuoTab – brands are NP) loperamide lansoprazole delayed-release • (Prevacid – brand is NP) mesalamine methscopolamine (Pamine, metoclopramide (Reglan – Pamine Forte – brands are NP) brand is NP) misoprostol (Cytotec – brand is NP) PENTASA NEXIUM • • RENVELA omeprazole delayed-release • sulfasalazine (Azulfidine – brand is NP) (Prilosec – brand is NP) sulfasalazine delayed-release pantoprazole delayed-release • (Azulfidine EN-Tabs – brand is NP) (Protonix – brand is NP) ursodiol (Actigall, Urso 250, PREVPAC Urso Forte – brands are NP) PYLERA • GENITOURINARY DRUGS ranitidine (Zantac – brand is NP) URINARY TRACT INFECTIONS sucralfate (Carafate – brand is NP) nitrofurantoin (Furadantin – brand is NP) NAUSEA AND VOMITING nitrofurantoin macrocrystalline EMEND caps • (Macrodantin – brand is NP) granisetron • nitrofurantoin monohydrate/ meclizine (Antivert – brand is NP) macrocrystalline (Macrobid – ondansetron (Zofran, Zofran ODT – • brand is NP) brands are NP)

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 19 2013 Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step URINARY TRACT SPASMS diazepam tabs (Valium – brand is NP) DETROL LA hydroxyzine hcl oxybutynin hydroxyzine pamoate 25 mg, 50 mg oxybutynin ext-release (Ditropan XL – (Vistaril – brand is NP) brand is NP) lorazepam (Ativan – brand is NP) tolterodine (Detrol – brand is NP) lorazepam conc (Lorazepam Intensol – VESICARE brand is NP) VAGINAL PRODUCTS DEPRESSION CLEOCIN supp amitriptyline clindamycin (Cleocin crm – bupropion (Wellbutrin – brand is NP) brand is NP) bupropion ext-release (Wellbutrin SR, CRINONE • Wellbutrin XL – brands are NP) ESTRACE crm citalopram (Celexa – brand is NP) metronidazole (MetroGel-Vaginal – clomipramine (Anafranil – brand is NP) brand is NP) desipramine (Norpramin – brand is NP) terconazole (Terazol – brand is NP) doxepin, NP = caps, 75 mg VAGIFEM escitalopram (Lexapro – brand is NP) OTHER GENITOURINARY DRUGS fluoxetine, NP = 60 mg (Prozac – alfuzosin ext-release (Uroxatral – brand is NP) brand is NP) fluvoxamine AVODART imipramine hcl (Tofranil – brand is NP) CYSTAGON mirtazapine (Remeron, finasteride (Proscar – brand is NP) Remeron SolTab – brands are NP) potassium citrate ext-release nortriptyline caps (Pamelor – (Urocit-K – brand is NP) brand is NP) potassium citrate/citric acid paroxetine hcl (Paxil – brand is NP) powder (Polycitra-K – brand is NP) paroxetine hcl ext-release (Paxil CR – sodium citrate/citric acid (Shohl’s – brand is NP) brand is NP) phenelzine (Nardil – brand is NP) tamsulosin (Flomax – brand is NP) sertraline (Zoloft – brand is NP) CENTRAL NERVOUS SYSTEM DRUGS tranylcypromine (Parnate – ANXIETY brand is NP) alprazolam (Xanax – brand is NP) trazodone alprazolam ext-release (Xanax XR – • venlafaxine brand is NP) venlafaxine ext-release caps buspirone, NP = 7.5 mg (Effexor XR – brand is NP) DIAZEPAM oral soln, 1 mg/mL venlafaxine ext-release tabs, • NP = 225 mg

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 20 2013

Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step PSYCHOTIC AND BIPOLAR DISORDERS HYPERACTIVITY/NARCOLEPSY chlorpromazine amphetamine/dextroamphetamine • clozapine (Clozaril – brand is NP) (Adderall – brand is NP) FLUPHENAZINE hcl conc, elixir amphetamine/dextroamphetamine • (Adderall XR – brand is NP) fluphenazine hcl tabs caffeine citrate (Cafcit – brand is NP) haloperidol decanoate (Haldol – brand is NP) dextroamphetamine • haloperidol lactate oral soln dextroamphetamine ext-release • (Dexedrine Spansule – brand is NP) haloperidol tabs INTUNIV • lithium carbonate methylphenidate tabs (Ritalin – • lithium carbonate ext-release 300 mg brand is NP) (Lithobid – brand is NP) methylphenidate ext-release caps; • lithium carbonate ext-release tabs, 20 mg (Ritalin LA, Ritalin SR – 450 mg brands are NP) loxapine (Loxitane – brand is NP) modafinil (Provigil – brand is NP) • olanzapine (Zyprexa, Zyprexa Zydis – VYVANSE • brands are NP) OTHER CENTRAL NERVOUS SYSTEM DRUGS perphenazine CHANTIX prochlorperazine disulfiram (Antabuse – brand is NP) quetiapine (Seroquel – brand is NP) donepezil (Aricept, Aricept ODT – risperidone, NP = ODT, 0.25 mg brands are NP) (Risperdal, Risperdal M-Tab – EXELON patches, soln brands are NP) SEROQUEL XR galantamine (Razadyne – brand is NP)

thiothixene galantamine ext-release (Razadyne ER – brand is NP) trifluoperazine naltrexone (ReVia – brand is NP) • ziprasidone hcl (Geodon – NICOTROL INHALER brand is NP) SLEEP AIDS NICOTROL NS estazolam NUEDEXTA phenobarbital, NP = 64.8 mg, 97.2 mg ORAP temazepam (Restoril – brand is NP) rivastigmine (Exelon – brand is NP) zaleplon (Sonata – brand is NP) • PAIN RELIEF DRUGS NON -NARCOTIC DRUGS zolpidem (Ambien – brand is NP) • butalbital/acetaminophen zolpidem ext-release (Ambien CR – • brand is NP) butalbital/acetaminophen/caffeine (Esgic, Esgic-Plus, Fioricet – brands are NP)

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 21 2013

Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step butalbital/aspirin/caffeine (Fiorinal – tramadol (Ultram – brand is NP) • brand is NP) tramadol/acetaminophen (Ultracet – salsalate brand is NP) NARCOTIC DRUGS RHEUMATOID AND OSTEOARTHRITIS acetaminophen/codeine CELEBREX • • (Tylenol w/Codeine – brand is NP) diclofenac potassium (Cataflam – buprenorphine (Subutex – brand is NP) • brand is NP) butalbital/aspirin/caffeine/codeine diclofenac sodium delayed-release (Fiorinal w/Codeine – brand is NP) diclofenac sodium ext-release CODEINE SULFATE 15 mg (Voltaren-XR – brand is NP) fentanyl (Actiq – brand is NP) • etodolac fentanyl (Duragesic – brand is NP) • flurbiprofen hydrocodone/acetaminophen, ibuprofen NP = soln, 10-325 mg/15 mL indomethacin hydrocodone/ibuprofen ketoprofen (Ibudone, Reprexain, Vicoprofen – brands are NP) leflunomide (Arava – brand is NP) hydromorphone soln, tabs meloxicam tabs (Mobic – brand is NP) (Dilaudid – brand is NP) nabumetone KADIAN • naproxen (Naprosyn – brand is NP) methadone conc, soln naproxen delayed-release methadone tabs (Dolophine – (EC‑Naprosyn – brand is NP) brand is NP) naproxen sodium (Anaprox – morphine sulfate conc, soln brand is NP) morphine sulfate ext-release oxaprozin (Daypro – brand is NP) (MS Contin – brand is NP) piroxicam (Feldene – brand is NP) MORPHINE SULFATE supp, tabs sulindac (Clinoril – brand is NP) NUCYNTA ER • MIGRAINE HEADACHES oxycodone caps acetaminophen/isometheptene/ oxycodone/acetaminophen dichloralphenazone (Percocet – brand is NP) IMITREX nasal spray • oxycodone/aspirin (Percodan – MIGRANAL • brand is NP) naratriptan (Amerge – brand is NP) • oxycodone conc, 20 mg/mL; tabs, rizatriptan (Maxalt, Maxalt MLT – • 5 mg, 15 mg, 30 mg (Roxicodone – brands are NP) brand is NP) sumatriptan inj, tabs (Imitrex – OXYCONTIN • • brand is NP) SUBOXONE •

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 22 2013 Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step GOUT TEGRETOL-XR 100 mg allopurinol (Zyloprim – brand is NP) topiramate (Topamax Sprinkle, COLCRYS Topamax – brands are NP) probenecid valproic acid (Depakene – brand is NP) probenecid/colchicine zonisamide (Zonegran – brand is NP) NEUROMUSCULAR DRUGS PARKINSON’S DISEASE SEIZURES amantadine, NP = tabs carbamazepine (Tegretol – brand is NP) AZILECT carbamazepine ext-release (Carbatrol, benztropine Tegretol-XR – brands are NP) bromocriptine (Parlodel – CELONTIN brand is NP) clonazepam (Klonopin – brand is NP) carbidopa/levodopa (Parcopa, Sinemet – brands are NP) DIASTAT • carbidopa/levodopa ext-release DILANTIN 30 mg (Sinemet CR – brand is NP) DILANTIN INFATABS COMTAN divalproex delayed-release pramipexole (Mirapex – brand is NP) (Depakote Sprinkles, Depakote – brands are NP) ropinirole (Requip – brand is NP) divalproex ext-release (Depakote ER – selegiline caps (Eldepryl – brand is NP) brand is NP) ethosuximide (Zarontin – selegiline tabs brand is NP) trihexyphenidyl gabapentin (Neurontin – brand is NP) MUSCLE RELAXANTS GABITRIL baclofen lamotrigine (Lamictal – brand is NP) chlorzoxazone (Parafon Forte – levetiracetam (Keppra – brand is NP) brand is NP) LYRICA cyclobenzaprine (Flexeril, Fexmid – brands are NP) oxcarbazepine (Trileptal – brand is NP) dantrolene (Dantrium – brand is NP) phenytoin chew tabs (Dilantin Infatabs – brand is NP) metaxalone (Skelaxin – brand is NP) phenytoin sodium ext-release methocarbamol (Robaxin – (Dilantin, Phenytek – brands are NP) brand is NP) phenytoin susp (Dilantin – orphenadrine citrate ext-release brand is NP) orphenadrine/aspirin/caffeine primidone (Mysoline – brand is NP) 25 ‑385-30 mg SABRIL tizanidine (Zanaflex – brand is NP) •

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 23 2013

Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step OTHER NEUROMUSCULAR DRUGS enoxaparin (Lovenox – brand is NP) • MESTINON syrup folic acid tabs, 1 mg MESTINON TIMESPAN pentoxifylline ext-release (Trental – pyridostigmine (Mestinon – brand is NP) brand is NP) warfarin (Coumadin – brand is NP) RILUTEK TOPICAL DRUGS SUPPLEMENTS EYE VITAMINS Anti-infectives ergocalciferol (Drisdol – brand is NP) BACITRACIN oint MEPHYTON bacitracin/polymyxin B oint MULTIVITAMINS ciprofloxacin soln (Ciloxan – pediatric multivitamins brand is NP) pediatric vitamins ADC erythromycin oint PRENAPLUS gentamicin oint, soln (Garamycin – brand is NP) PRENATABS FA NATACYN PRENATAL 19, LOW IRON, PLUS, PLUS/IRON, VITAMINS PLUS neomycin/polymyxin B/bacitracin oint SE-NATAL 19 neomycin/polymyxin B/gramicidin MINERALS AND ELECTROLYTES soln (Neosporin – brand is NP) K-PHOS ofloxacin soln (Ocuflox – brand is NP) potassium bicarbonate/chloride polymyxin B/trimethoprim soln effervescent tabs, 25 mEq (Polytrim – brand is NP) potassium chloride packets; soln, sulfacetamide sodium soln 10% (Bleph-10 – brand is NP) potassium chloride ext-release tobramycin soln (Tobrex – potassium phosphate/sodium brand is NP) phosphates (K-Phos Neutral – trifluridine soln (Viroptic – brand is NP) brand is NP) sodium fluoride, NP = tabs VIGAMOX BLOOD MODIFYING DRUGS Steroids and Combination Products anagrelide (Agrylin – brand is NP) dexamethasone sodium phosphate cilostazol (Pletal – brand is NP) soln clopidogrel (Plavix – brand is NP) fluorometholone susp, 1% (FML Liquifilm – brand is NP) cyanocobalamin inj LOTEMAX dipyridamole (Persantine – brand is NP) neomycin/polymyxin B/bacitracin/ hydrocortisone oint DROXIA

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 24 2013

Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step neomycin/polymyxin B/ cromolyn sodium soln dexamethasone oint, susp cyclopentolate soln (Cyclogyl – (Maxitrol – brand is NP) brand is NP) prednisolone acetate susp diclofenac soln (Voltaren – (Pred Forte – brand is NP) brand is NP) PREDNISOLONE SODIUM flurbiprofen soln (Ocufen – PHOSPHATE soln, 1% brand is NP) sulfacetamide sodium/ homatropine soln (Isopto prednisolone soln Homatropine – brand is NP) TOBRADEX oint ketorolac soln (Acular, Acular LS – tobramycin/dexamethasone susp brands are NP) (Tobradex – brand is NP) PATADAY ZYLET tropicamide soln (Mydriacyl – Glaucoma brand is NP) AZOPT EAR brimonidine soln, 0.15% (Alphagan P – acetic acid soln brand is NP) benzocaine/antipyrine soln brimonidine soln, 0.2% CIPRODEX carteolol soln hydrocortisone/acetic acid soln dorzolamide soln (Trusopt – (Vosol HC – brand is NP) brand is NP) neomycin/polymyxin B/ dorzolamide/timolol maleate soln hydrocortisone soln, susp (Cosopt – brand is NP) (Cortisporin – brand is NP) latanoprost soln (Xalatan – • ofloxacin soln brand is NP) MOUTH AND THROAT (local) levobunolol soln, 0.5% (Betagan – cevimeline (Evoxac – brand is NP) brand is NP) chlorhexidine oral rinse (Peridex – LUMIGAN • brand is NP) metipranolol soln (Optipranolol – clotrimazole troche brand is NP) lidocaine viscous pilocarpine soln, 1%, 4% (Isopto Carpine – brand is NP) nystatin susp timolol maleate soln (Timoptic, pilocarpine (Salagen – brand is NP) Timoptic-XE – brand is NP) sodium fluoride (Prevident – TRAVATAN Z • brand is NP) Other Eye Products triamcinolone dental paste atropine sulfate soln (Isopto Atropine – brand is NP) azelastine soln (Optivar – brand is NP)

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 25 2013

Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step ANORECTAL AGENTS Corticosteroids CORTIFOAM alclometasone (Aclovate – brand is NP) hydrocortisone acetate rectal crm, amcinonide crm supp (Anusol-HC, Proctocort – betamethasone dipropionate brands are NP) betamethasone dipropionate, hydrocortisone enema (Cortenema – augmented (Diprolene – brand is NP) brand is NP) betamethasone valerate crm, lotn SKIN CONDITIONS/PRODUCTS clobetasol (Olux, Temovate – Acne brands are NP) (Differin – brand is NP) adapalene • • desonide (Desowen – brand is NP) (Cleocin-T – brand is NP) clindamycin desoximetasone crm, 0.25%; gel; clindamycin/benzoyl peroxide oint, 0.25% (Topicort – brand is NP) (Benzaclin, Duac – brands are NP) diflorasone oint DIFFERIN gel, 0.3% • • fluocinolone erythromycin pads, soln fluocinolone oil (Derma-Smoothe/FS – erythromycin/benzoyl peroxide brand is NP) (Benzamycin – brand is NP) fluocinonide FINACEA fluticasone propionate (Cutivate – isotretinoin brand is NP) metronidazole (Metrocream, halobetasol (Ultravate – brand is NP) Metrolotion – brands are NP) hydrocortisone topical metronidazole topical gel hydrocortisone valerate (Westcort – sulfacetamide sodium/sulfur, brand is NP) NP = susp, 10-5% mometasone (Elocon – brand is NP) TAZORAC • triamcinolone crm; lotn; oint, tretinoin (Retin-A – brand is NP) • • 0.025%, 0.1% Anti-infectives Other Skin Products ciclopirox (Loprox – brand is NP) aluminum chloride (Drysol – ciclopirox (Penlac – brand is NP) • brand is NP) econazole calcipotriene crm, soln (Dovonex – brand is NP) ketoconazole (Nizoral – brand is NP) CARAC mupirocin (Bactroban, Centany – brands are NP) ELIDEL nystatin topical FLUOROPLEX silver sulfadiazine (Silvadene – fluorouracil (Efudex – brand is NP) brand is NP) imiquimod (Aldara – brand is NP) • lidocaine jelly, 2%; oint, 5%; soln, 4% (Xylocaine – brand is NP)

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 26 2013

Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step Drug Name Specialty Authorization Prior Dispensing Limits Therapy Step lidocaine/prilocaine crm (Emla – cyclosporine modified caps, 25 mg, brand is NP) 100 mg; soln (Neoral – brand is NP) lindane CYCLOSPORINE MODIFIED caps, malathion (Ovide – brand is NP) 50 mg permethrin mycophenolate mofetil (Cellcept – brand is NP) podofilox (Condylox – brand is NP) MYFORTIC PROTOPIC RAPAMUNE selenium sulfide (Selsun – brand is NP) sodium polystyrene sulfonate SOLARAZE tacrolimus (Prograf – brand is NP) SORIATANE ZORTRESS XERAC AC ZYCLARA MISCELLANEOUS CATEGORIES (includes supplies and devices) DIABETIC SUPPLIES INSULIN PEN NEEDLES – • BD ULTRAFINE, NOVOFINE, NOVOTWIST INSULIN SYRINGES – BD • LANCETS – BAYER, BD, ROCHE TEST STRIPS – BAYER ASCENSIA • AUTODISC, BREEZE 2, CONTOUR, CONTOUR NEXT TEST STRIPS – ROCHE ACCU- • CHEK ACTIVE, AVIVA, AVIVA PLUS, COMFORT CURVE, COMPACT, SMARTVIEW; ACCUTREND RESPIRATORY INHALER-ASSIST DEVICES AEROCHAMBER BREATHERITE MISCELLANEOUS DRUGS azathioprine (Imuran – brand is NP) CELLCEPT oral susp CHEMET CUPRIMINE cyclosporine (Sandimmune – brand is NP)

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 27 2013

Index amlodipine (Norvasc – brand is NP) ...... 16 amoxicillin, NP = chew tabs ...... 12 A amoxicillin/potassium clavulanate (Augmentin – abacavir (Ziagen tabs – brand is NP) ...... 13 brand is NP) ...... 12 acarbose (Precose – brand is NP) ...... 15 amoxicillin/potassium clavulanate ext-release acebutolol (Sectral – brand is NP) ...... 16 (Augmentin XR – brand is NP) ...... 12 acetaminophen/codeine (Tylenol w/Codeine – amphetamine/dextroamphetamine (Adderall – brand is NP) ...... 22 brand is NP) ...... 21 acetaminophen/isometheptene/ amphetamine/dextroamphetamine (Adderall XR – dichloralphenazone ...... 22 brand is NP) ...... 21 acetazolamide 250 mg ...... 17 ampicillin caps ...... 12 acetazolamide ext-release (Diamox Sequels – anagrelide (Agrylin – brand is NP) ...... 24 brand is NP) ...... 17 anastrozole (Arimidex – brand is NP) ...... 14 acetic acid ear soln ...... 25 ANDRODERM ...... 14 acetylcysteine ...... 18 ANDROGEL ...... 14 ACTONEL ...... 15 ANDROXY ...... 14 acyclovir (Zovirax – brand is NP) ...... 13 APTIVUS ...... 13 adapalene (Differin – brand is NP) ...... 26 ASACOL ...... 19 ADVAIR DISKUS ...... 18 ASACOL HD ...... 19 ADVAIR HFA ...... 18 ASMANEX ...... 18 AEROCHAMBER ...... 27 ASTEPRO ...... 18 AEROHIST ...... 18 atenolol/chlorthalidone (Tenoretic – brand is NP) . .16 AFINITOR ...... 13 atenolol (Tenormin – brand is NP) ...... 16 ALBENZA ...... 13 atorvastatin (Lipitor – brand is NP) ...... 17 albuterol 0.63 mg/3 mL, 1.25 mg/3 mL (Accuneb – atovaquone/proguanil 250-100 mg brand is NP) ...... 18 (Malarone 250-100 mg – brand is NP) ...... 13 albuterol inhal soln, 0.083%, 0.5% ...... 18 ATRIPLA ...... 13 albuterol syrup, tabs ...... 18 atropine sulfate eye soln (Isopto Atropine – alclometasone (Aclovate – brand is NP) ...... 26 brand is NP) ...... 25 alendronate 5 mg, 10 mg, 35 mg, 70 mg ATROVENT HFA ...... 18 (Fosamax – brand is NP) ...... 15 AVODART ...... 20 alfuzosin ext-release (Uroxatral – brand is NP) . . .20 azathioprine (Imuran – brand is NP) ...... 27 ALKERAN ...... 13 azelastine (Astelin – brand is NP) ...... 18 allopurinol (Zyloprim – brand is NP) ...... 23 azelastine eye soln (Optivar – brand is NP) . . . . 25 alprazolam ext-release (Xanax XR – brand is NP) . .20 AZILECT ...... 23 alprazolam (Xanax – brand is NP) ...... 20 azithromycin susp (Zithromax – brand is NP) . . . 12 aluminum chloride (Drysol – brand is NP) . . . . .26 azithromycin tabs (Zithromax – brand is NP) . . . .12 amantadine, NP = tabs ...... 23 AZOPT ...... 25 amcinonide crm ...... 26 B amiloride ...... 17 BACITRACIN eye oint ...... 24 amiloride/hydrochlorothiazide ...... 17 bacitracin/polymyxin B eye oint ...... 24 amiodarone (Cordarone, Pacerone – brands are NP) .17 baclofen ...... 23 amitriptyline ...... 20 balsalazide (Colazal – brand is NP) ...... 19 amlodipine/benazepril (Lotrel – brand is NP) . . . .16 BARACLUDE ...... 12

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 28 2013 benazepril/hydrochlorothiazide (Lotensin HCT – carbamazepine ext-release (Carbatrol, brand is NP) ...... 16 Tegretol -XR – brands are NP) ...... 23 benazepril (Lotensin – brand is NP) ...... 16 carbamazepine (Tegretol – brand is NP) ...... 23 BENICAR ...... 16 carbidopa/levodopa ext-release (Sinemet CR – BENICAR HCT ...... 16 brand is NP) ...... 23 benzocaine/antipyrine ear soln ...... 25 carbidopa/levodopa (Parcopa, Sinemet – benztropine ...... 23 brands are NP) ...... 23 betamethasone dipropionate ...... 26 carteolol eye soln ...... 25 betamethasone dipropionate, augmented carvedilol (Coreg – brand is NP) ...... 16 (Diprolene – brand is NP) ...... 26 CEENU ...... 14 betamethasone valerate crm, lotn ...... 26 cefadroxil ...... 12 bicalutamide (Casodex – brand is NP) ...... 14 cefdinir ...... 12 BILTRICIDE ...... 13 cefpodoxime ...... 12 bisoprolol/hydrochlorothiazide (Ziac – brand is NP) .16 cefprozil ...... 12 bisoprolol (Zebeta – brand is NP) ...... 16 ceftriaxone (Rocephin – brand is NP) ...... 12 BREATHERITE ...... 27 cefuroxime (Ceftin – brand is NP) ...... 12 brimonidine eye soln, 0.2% ...... 25 CELEBREX ...... 22 brimonidine eye soln, 0.15% (Alphagan P – CELLCEPT oral susp ...... 27 brand is NP) ...... 25 CELONTIN ...... 23 bromocriptine (Parlodel – brand is NP) ...... 23 cephalexin, NP = tabs (Keflex – brand is NP) . . . .12 budesonide ext-release (Entocort EC – brand is NP) . .14 cetirizine syrup ...... 18 budesonide (Pulmicort Respules – brand is NP) . . .18 cevimeline (Evoxac – brand is NP) ...... 25 bumetanide ...... 17 CHANTIX ...... 21 buprenorphine (Subutex – brand is NP) . . . . . 22 CHEMET ...... 27 bupropion ext-release (Wellbutrin SR, chlorhexidine oral rinse (Peridex – brand is NP) . . 25 Wellbutrin XL – brands are NP) ...... 20 chloroquine phosphate (Aralen – brand is NP) . . .13 bupropion (Wellbutrin – brand is NP) ...... 20 chlorothiazide ...... 17 buspirone, NP = 7.5 mg ...... 20 chlorpromazine ...... 21 butalbital/acetaminophen ...... 21 chlorthalidone 25 mg ...... 17 butalbital/acetaminophen/caffeine chlorzoxazone (Parafon Forte – brand is NP) . . . .23 (Esgic, Esgic-Plus, Fioricet – brands are NP) . . . 21 cholestyramine (Questran, Questran Light – butalbital/aspirin/caffeine/codeine brands are NP) ...... 17 (Fiorinal w/Codeine – brand is NP) ...... 22 chorionic gonadotropin ...... 15 butalbital/aspirin/caffeine (Fiorinal – brand is NP) . 22 CIALIS ...... 18 C ciclopirox (Loprox – brand is NP) ...... 26 ciclopirox (Penlac – brand is NP) ...... 26 cabergoline ...... 15 cilostazol (Pletal – brand is NP) ...... 24 caffeine citrate (Cafcit – brand is NP) ...... 21 cimetidine ...... 19 calcipotriene crm, soln (Dovonex – brand is NP) . .26 CIPRODEX ...... 25 calcitonin-salmon (Miacalcin – brand is NP) . . . .15 ciprofloxacin (Cipro – brand is NP) ...... 12 calcitriol (Rocaltrol – brand is NP) ...... 16 ciprofloxacin eye soln (Ciloxan – brand is NP) . . . 24 calcium acetate (Eliphos, Phoslo – brands are NP) . 19 citalopram (Celexa – brand is NP) ...... 20 CANASA ...... 19 clarithromycin (Biaxin – brand is NP) ...... 12 captopril ...... 16 clarithromycin ext-release (Biaxin XL – brand is NP) .12 CARAC ...... 26

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 29 2013

CLEOCIN vaginal supp ...... 20 D clindamycin/benzoyl peroxide (Benzaclin, danazol ...... 14 Duac – brands are NP) ...... 26 dantrolene (Dantrium – brand is NP) ...... 23 clindamycin (Cleocin, Cleocin Pediatric – DAPSONE ...... 13 brands are NP) ...... 13 DARAPRIM ...... 13 clindamycin (Cleocin-T – brand is NP) ...... 26 DELZICOL ...... 19 clindamycin crm (Cleocin crm – brand is NP) . . . .20 demeclocycline ...... 12 clobetasol (Olux, Temovate – brands are NP) . . . .26 desipramine (Norpramin – brand is NP) ...... 20 clomiphene (Clomid – brand is NP) ...... 15 desmopressin (DDAVP – brand is NP) ...... 16 clomipramine (Anafranil – brand is NP) ...... 20 desonide (Desowen – brand is NP) ...... 26 clonazepam (Klonopin – brand is NP) ...... 23 desoximetasone crm, 0.25%; gel; oint, 0.25% clonidine (Catapres, Catapres-TTS – brands are NP) .18 (Topicort – brand is NP) ...... 26 clopidogrel (Plavix – brand is NP) ...... 24 DETROL LA ...... 20 clotrimazole troche ...... 25 dexamethasone elixir; tabs, 0.5 mg, clozapine (Clozaril – brand is NP) ...... 21 0.75 mg, 1.5 mg, 4 mg, 6 mg ...... 14 CODEINE SULFATE 15 mg ...... 22 dexamethasone sodium phosphate eye soln . . .24 COLCRYS ...... 23 DEXAMETHASONE soln, 0.5 mg/5 mL ...... 14 colestipol (Colestid – brand is NP) ...... 17 dextroamphetamine ...... 21 COMBIPATCH ...... 14 dextroamphetamine ext-release COMBIVENT ...... 18 (Dexedrine Spansule – brand is NP) ...... 21 COMBIVENT RESPIMAT ...... 18 DIASTAT ...... 23 COMTAN ...... 23 DIAZEPAM oral soln, 1 mg/mL ...... 20 CORTIFOAM ...... 26 diazepam tabs (Valium – brand is NP) ...... 20 CORTISONE ...... 14 DIBENZYLINE ...... 18 CREON ...... 19 diclofenac eye soln (Voltaren – brand is NP) . . . .25 CRESTOR ...... 17 diclofenac potassium (Cataflam – brand is NP) . . 22 CRINONE ...... 20 diclofenac sodium delayed-release ...... 22 CRIXIVAN ...... 13 diclofenac sodium ext-release (Voltaren-XR – cromolyn inhal soln ...... 18 brand is NP) ...... 22 cromolyn sodium eye soln ...... 25 dicloxacillin ...... 12 CUPRIMINE ...... 27 dicyclomine caps, tabs (Bentyl – brand is NP) . . .19 cyanocobalamin inj ...... 24 didanosine delayed-release (Videx EC – cyclobenzaprine (Flexeril, Fexmid – brands are NP) .23 brand is NP) ...... 13 cyclopentolate eye soln (Cyclogyl – brand is NP) . .25 DIFFERIN gel, 0.3% ...... 26 CYCLOPHOSPHAMIDE tabs ...... 14 diflorasone oint ...... 26 cyclosporine modified caps, 25 mg, 100 mg; digoxin tabs (Lanoxin – brand is NP) ...... 18 soln (Neoral – brand is NP) ...... 27 DILANTIN 30 mg ...... 23 CYCLOSPORINE MODIFIED caps, 50 mg . . . . . 27 DILANTIN INFATABS ...... 23 cyclosporine (Sandimmune – brand is NP) . . . . .27 diltiazem (Cardizem – brand is NP) ...... 16 cyproheptadine ...... 18 diltiazem ext-release (Cardizem CD, Cardizem LA, CYSTAGON ...... 20 Dilacor XR, Tiazac – brands are NP) ...... 17 diphenoxylate/atropine tabs (Lomotil – brand is NP) .19 dipyridamole (Persantine – brand is NP) . . . . . 24 disopyramide (Norpace – brand is NP) ...... 17

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 30 2013 disulfiram (Antabuse – brand is NP) ...... 21 estradiol/norethindrone acetate (Activella – divalproex delayed-release (Depakote Sprinkles, brand is NP) ...... 14 Depakote – brands are NP) ...... 23 estropipate, NP = 3 mg ...... 14 divalproex ext-release (Depakote ER – brand is NP) .23 ethambutol (Myambutol – brand is NP) ...... 12 DIVIGEL ...... 14 ethosuximide (Zarontin – brand is NP) ...... 23 donepezil (Aricept, Aricept ODT – brands are NP) . .21 etidronate 400 mg (Didronel – brand is NP) . . . . 16 dorzolamide eye soln (Trusopt – brand is NP) . . . 25 etodolac ...... 22 dorzolamide/timolol maleate eye soln EVISTA ...... 16 (Cosopt – brand is NP) ...... 25 EXELON patches, soln ...... 21 doxazosin (Cardura – brand is NP) ...... 18 exemestane (Aromasin – brand is NP) ...... 14 doxepin, NP = caps, 75 mg ...... 20 F doxycycline hyclate (Periostat, Vibramycin – famciclovir (Famvir – brand is NP) ...... 13 brands are NP) ...... 12 famotidine (Pepcid – brand is NP) ...... 19 DROXIA ...... 24 FARESTON ...... 14 DULERA ...... 18 felodipine ext-release ...... 17 E fenofibrate(Lofibra, Tricor – brands are NP) . . . . 17 econazole ...... 26 fenofibrate micronized (Lofibra – brand is NP) . . .17 ELIDEL ...... 26 fentanyl (Actiq – brand is NP) ...... 22 ELLA ...... 15 fentanyl (Duragesic – brand is NP) ...... 22 EMCYT ...... 14 FINACEA ...... 26 EMEND caps ...... 19 finasteride (Proscar – brand is NP) ...... 20 EMTRIVA ...... 13 FIRAZYR ...... 19 enalapril/hydrochlorothiazide (Vaseretic – flecainide (Tambocor – brand is NP) ...... 17 brand is NP) ...... 16 FLOVENT DISKUS ...... 18 enalapril (Vasotec – brand is NP) ...... 16 FLOVENT HFA ...... 18 ENJUVIA ...... 14 fluconazole (Diflucan – brand is NP) ...... 12 enoxaparin (Lovenox – brand is NP) ...... 24 flucytosine (Ancobon – brand is NP) ...... 12 EPIPEN ...... 18 fludrocortisone ...... 14 EPIPENR -J ...... 18 fluocinolone ...... 26 EPIVIR soln ...... 13 fluocinolone oil (Derma-Smoothe/FS – brand is NP) .26 eplerenone (Inspra – brand is NP) ...... 18 fluocinonide ...... 26 EPZICOM ...... 13 fluorometholone eye susp, 0.1% (FML Liquifilm – ergocalciferol (Drisdol – brand is NP) ...... 24 brand is NP) ...... 24 erythromycin/benzoyl peroxide (Benzamycin – FLUOROPLEX ...... 26 brand is NP) ...... 26 fluorouracil (Efudex – brand is NP) ...... 26 erythromycin eye oint ...... 24 fluoxetine, NP = 60 mg (Prozac – brand is NP) . . .20 erythromycin pads, soln ...... 26 FLUPHENAZINE hcl conc, elixir ...... 21 erythromycin/sulfisoxazole ...... 13 fluphenazine hcl tabs ...... 21 escitalopram (Lexapro – brand is NP) ...... 20 flurbiprofen ...... 22 estazolam ...... 21 flurbiprofen eye soln (Ocufen – brand is NP) . . . .25 ESTRACE crm ...... 20 flutamide ...... 14 ESTRADERM ...... 14 fluticasone propionate (Cutivate – brand is NP) . . 26 estradiol (Climara – brand is NP) ...... 14 fluticasone propionate (Flonase – brand is NP) . . 18 estradiol (Estrace – brand is NP) ...... 14 fluvoxamine ...... 20

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 31 2013 folic acid tabs, 1 mg ...... 24 hydrocodone/ibuprofen (Ibudone, Reprexain, FORADIL AEROLIZER ...... 18 Vicoprofen – brands are NP) ...... 22 fosinopril ...... 16 hydrocortisone acetate rectal crm, supp fosinopril/hydrochlorothiazide ...... 16 (Anusol -HC, Proctocort – brands are NP) . . . . .26 furosemide, NP = soln, 8 mg/mL (Lasix – hydrocortisone/acetic acid ear soln (Vosol HC – brand is NP) ...... 17 brand is NP) ...... 25 G hydrocortisone (Cortef – brand is NP) ...... 14 hydrocortisone enema (Cortenema – brand is NP) . . 26 gabapentin (Neurontin – brand is NP) ...... 23 hydrocortisone topical ...... 26 GABITRIL ...... 23 hydrocortisone valerate (Westcort – brand is NP) . .26 galantamine ext-release (Razadyne ER – hydromorphone soln, tabs (Dilaudid – brand is NP) .22 brand is NP) ...... 21 hydroxychloroquine (Plaquenil – brand is NP) . . . 13 galantamine (Razadyne – brand is NP) ...... 21 hydroxyurea (Hydrea – brand is NP) ...... 14 gemfibrozil (Lopid – brand is NP) ...... 17 hydroxyzine hcl ...... 20 gentamicin eye oint, soln (Garamycin – brand is NP) .24 hydroxyzine pamoate 25 mg, 50 mg (Vistaril – glimepiride (Amaryl – brand is NP) ...... 15 brand is NP) ...... 20 glipizide ext-release (Glucotrol XL – brand is NP) . .15 hyoscyamine (Anaspaz, Levsin, Levsin/SL – glipizide (Glucotrol – brand is NP) ...... 15 brands are NP) ...... 19 glipizide/metformin (Metaglip – brand is NP) . . . .15 hyoscyamine ext-release (Levbid, Symax DuoTab – GLUCAGON EMERGENCY KIT ...... 15 brands are NP) ...... 19 glyburide/metformin (Glucovance – brand is NP) . .15 glyburide (Micronase – brand is NP) ...... 15 I glyburide micronized (Glynase – brand is NP) ...... 15 ibandronate (Boniva – brand is NP) ...... 16 glycopyrrolate (Robinul – brand is NP) ...... 19 ibuprofen ...... 22 granisetron ...... 19 imipramine hcl (Tofranil – brand is NP) ...... 20 griseofulvin microsize (Grifulvin V – brand is NP) . .12 imiquimod (Aldara – brand is NP) ...... 26 guanfacine (Tenex – brand is NP) ...... 18 IMITREX nasal spray ...... 22 H indapamide ...... 17 indomethacin ...... 22 halobetasol (Ultravate – brand is NP) ...... 26 INNOPRAN XL ...... 16 haloperidol decanoate (Haldol – brand is NP) . . . 21 INSULIN PEN NEEDLES – BD ULTRAFINE, haloperidol lactate oral soln ...... 21 NOVOFINE, NOVOTWIST ...... 27 haloperidol tabs ...... 21 INSULIN SYRINGES – BD ...... 27 HEPSERA ...... 12 INTELENCE ...... 13 homatropine eye soln (Isopto Homatropine – INTUNIV ...... 21 brand is NP) ...... 25 INVIRASE ...... 13 HUMALOG ...... 15 ipratropium/albuterol (Duoneb – brand is NP) . . . 18 HUMALOG MIX 50/50, 75/25 ...... 15 ipratropium (Atrovent – brand is NP) ...... 18 HUMULIN 70/30 ...... 15 ipratropium inhal soln ...... 18 HUMULIN N ...... 15 ISENTRESS ...... 13 HUMULIN R ...... 15 isoniazid/rifampin (Rifamate – brand is NP) . . . . 12 hydralazine ...... 18 isoniazid tabs ...... 12 hydrochlorothiazide caps (Microzide – brand is NP) .17 isosorbide dinitrate, NP = SL tabs (Isordil – hydrochlorothiazide tabs ...... 17 brand is NP) ...... 17 hydrocodone/acetaminophen, NP = soln, 10-325 mg/15 mL ...... 22

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 32 2013 isosorbide mononitrate ext-release (Imdur – levothyroxine (Synthroid – brand is NP) ...... 15 brand is NP) ...... 17 LEXIVA ...... 13 isosorbide mononitrate (Monoket – brand is NP) . .17 LIALDA ...... 19 isotretinoin ...... 26 lidocaine jelly, 2%; oint, 5%; soln, 4% (Xylocaine – itraconazole (Sporanox – brand is NP) ...... 12 brand is NP) ...... 26 J lidocaine/prilocaine crm (Emla – brand is NP) . . .27 lidocaine viscous ...... 25 JANUMET ...... 15 lindane ...... 27 JANUMET XR ...... 15 liothyronine (Cytomel – brand is NP) ...... 15 JANUVIA ...... 15 lisinopril/hydrochlorothiazide (Prinzide, Zestoretic – JUVISYNC ...... 15 brands are NP) ...... 16 K lisinopril (Prinivil, Zestril – brands are NP) . . . . .16 KADIAN ...... 22 lithium carbonate ...... 21 KALETRA ...... 13 lithium carbonate ext-release 300 mg (Lithobid – ketoconazole (Nizoral – brand is NP) ...... 26 brand is NP) ...... 21 ketoconazole tabs ...... 12 lithium carbonate ext-release 450 mg ...... 21 ketoprofen ...... 22 loperamide ...... 19 ketorolac eye soln (Acular, Acular LS – lorazepam (Ativan – brand is NP) ...... 20 brands are NP) ...... 25 lorazepam conc (Lorazepam Intensol – brand is NP) .20 KOMBIGLYZE XR ...... 15 losartan (Cozaar – brand is NP) ...... 16 KHOS-P ...... 24 losartan/hydrochlorothiazide (Hyzaar – brand is NP) .16 L LOTEMAX ...... 24 lovastatin (Mevacor – brand is NP) ...... 17 labetalol (Trandate – brand is NP) ...... 16 loxapine (Loxitane – brand is NP) ...... 21 lactulose ...... 19 LUMIGAN ...... 25 lamivudine (Epivir – brand is NP) ...... 13 LYRICA ...... 23 lamivudine/zidovudine (Combivir – brand is NP) . . 13 lamotrigine (Lamictal – brand is NP) ...... 23 M LANCETS – BAYER, BD, ROCHE ...... 27 MALARONE 62.5-25 mg ...... 13 lansoprazole delayed-release (Prevacid – malathion (Ovide – brand is NP) ...... 27 brand is NP) ...... 19 meclizine (Antivert – brand is NP) ...... 19 LANTUS ...... 15 medroxyprogesterone acetate (Depo-Provera – latanoprost eye soln (Xalatan – brand is NP) . . . .25 brand is NP) ...... 15 leflunomide (Arava – brand is NP) ...... 22 medroxyprogesterone acetate (Provera – letrozole (Femara – brand is NP) ...... 14 brand is NP) ...... 14 leucovorin calcium tabs, 5 mg, 25 mg ...... 14 mefloquine ...... 13 LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg . . . .14 megestrol (Megace – brand is NP) ...... 14 LEUKERAN ...... 14 meloxicam tabs (Mobic – brand is NP) ...... 22 LEVEMIR ...... 15 MEPHYTON ...... 24 levetiracetam (Keppra – brand is NP) ...... 23 mercaptopurine (Purinethol – brand is NP) ...... 14 levobunolol eye soln, 0.5% (Betagan – brand is NP) .25 mesalamine ...... 19 levocarnitine (Carnitor – brand is NP) ...... 16 MESNEX tabs ...... 14 levofloxacin (Levaquin – brand is NP) ...... 12 MESTINON syrup ...... 24 levonorgestrel (Plan B, Plan B One-Step – MESTINON TIMESPAN ...... 24 brands are NP) ...... 15 metaxalone (Skelaxin – brand is NP) ...... 23

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 33 2013 metformin ext-release (Glucophage XR – morphine sulfate ext-release (MS Contin – brand is NP) ...... 15 brand is NP) ...... 22 metformin ext-release OSM (Fortamet – brand is NP) .15 MORPHINE SULFATE supp, tabs ...... 22 metformin (Glucophage – brand is NP) ...... 15 MULTAQ ...... 17 methadone conc, soln ...... 22 mupirocin (Bactroban, Centany – brands are NP) . . 26 methadone tabs (Dolophine – brand is NP) . . . . 22 MYCOBUTIN ...... 12 methazolamide (Neptazane – brand is NP) . . . . 17 mycophenolate mofetil (Cellcept – brand is NP) . . 27 methimazole (Tapazole – brand is NP) ...... 15 MYFORTIC ...... 27 methocarbamol (Robaxin – brand is NP) . . . . . 23 MYLERAN ...... 14 methotrexate ...... 14 N methscopolamine (Pamine, Pamine Forte – nabumetone ...... 22 brands are NP) ...... 19 nadolol (Corgard – brand is NP) ...... 16 methyldopa ...... 18 naltrexone (ReVia – brand is NP) ...... 21 methylergonovine ...... 16 naproxen delayed-release (EC-Naprosyn – methylphenidate ext-release caps; tabs, 20 mg brand is NP) ...... 22 (Ritalin LA, Ritalin SR – brands are NP) . . . . . 21 naproxen (Naprosyn – brand is NP) ...... 22 methylphenidate tabs (Ritalin – brand is NP) . . . .21 naproxen sodium (Anaprox – brand is NP) . . . . 22 methylprednisolone (Medrol – brand is NP) . . . . 14 naratriptan (Amerge – brand is NP) ...... 22 metipranolol eye soln (Optipranolol – brand is NP) . 25 NASONEX ...... 18 metoclopramide (Reglan – brand is NP) ...... 19 NATACYN ...... 24 metolazone (Zaroxolyn – brand is NP) ...... 17 nateglinide (Starlix – brand is NP) ...... 15 metoprolol succinate ext-release (Toprol XL – neomycin/polymyxin B/bacitracin eye oint . . . .24 brand is NP) ...... 16 neomycin/polymyxin B/bacitracin/hydrocortisone metoprolol tartrate (Lopressor – brand is NP) . . . 16 eye oint ...... 24 metronidazole (Flagyl – brand is NP) ...... 13 neomycin/polymyxin B/dexamethasone eye oint, metronidazole (Metrocream, Metrolotion – susp (Maxitrol – brand is NP) ...... 25 brands are NP) ...... 26 neomycin/polymyxin B/gramicidin eye soln metronidazole (MetroGel-Vaginal – brand is NP) . . 20 (Neosporin – brand is NP) ...... 24 metronidazole topical gel ...... 26 neomycin/polymyxin B/hydrocortisone MEXILETINE ...... 17 ear soln, susp (Cortisporin – brand is NP) . . . . 25 midodrine ...... 18 neomycin sulfate ...... 12 MIGRANAL ...... 22 nevirapine tabs (Viramune tabs – brand is NP) . . .13 minocycline (Dynacin, Minocin – brands are NP) . . 12 NEXIUM ...... 19 minoxidil ...... 18 NIASPAN ...... 17 mirtazapine (Remeron, Remeron SolTab – NICOTROL INHALER ...... 21 brands are NP) ...... 20 NICOTROL NS ...... 21 misoprostol (Cytotec – brand is NP) ...... 19 nifedipine ext-release (Adalat CC, Procardia XL – modafinil (Provigil – brand is NP) ...... 21 brands are NP) ...... 17 moexipril/hydrochlorothiazide (Uniretic – NILANDRON ...... 14 brand is NP) ...... 16 nitrofurantoin (Furadantin – brand is NP) . . . . . 19 moexipril (Univasc – brand is NP) ...... 16 nitrofurantoin macrocrystalline (Macrodantin – mometasone (Elocon – brand is NP) ...... 26 brand is NP) ...... 19 montelukast (Singulair – brand is NP) ...... 18 nitrofurantoin monohydrate/macrocrystalline morphine sulfate conc, soln ...... 22 (Macrobid – brand is NP) ...... 19

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 34 2013 nitroglycerin (Nitro-Dur – brand is NP) ...... 17 paromomycin ...... 12 NITROSTAT ...... 17 paroxetine hcl ext-release (Paxil CR – brand is NP) .20 norethindrone acetate (Aygestin – brand is NP) . . 14 paroxetine hcl (Paxil – brand is NP) ...... 20 nortriptyline caps (Pamelor – brand is NP) . . . . 20 PATADAY ...... 25 NORVIR ...... 13 pediatric multivitamins ...... 24 NOVOLIN 70/30 ...... 15 pediatric vitamins ADC ...... 24 NOVOLIN N ...... 15 PEG – electrolytes for soln (Colyte, Golytely, NOVOLIN R ...... 15 Nulytely – brands are NP) ...... 19 NOVOLOG ...... 15 penicillin v potassium ...... 12 NOVOLOG MIX 70/30 ...... 15 PENTASA ...... 19 NOXAFIL ...... 12 pentoxifylline ext-release (Trental – brand is NP) . .24 NUCYNTA ER ...... 22 perindopril (Aceon – brand is NP) ...... 16 NUEDEXTA ...... 21 permethrin ...... 27 NUVARING ...... 15 perphenazine ...... 21 nystatin oral ...... 12 phenelzine (Nardil – brand is NP) ...... 20 nystatin susp ...... 25 phenobarbital, NP = 64.8 mg, 97.2 mg ...... 21 nystatin topical ...... 26 phenytoin chew tabs (Dilantin Infatabs – brand is NP) .23 O phenytoin sodium ext-release (Dilantin, Phenytek – brands are NP) ...... 23 ofloxacin ear soln ...... 25 phenytoin susp (Dilantin – brand is NP) ...... 23 ofloxacin eye soln (Ocuflox – brand is NP) . . . . .24 pilocarpine eye soln, 1%, 4% (Isopto Carpine – olanzapine (Zyprexa, Zyprexa Zydis – brands are NP) .21 brand is NP) ...... 25 omeprazole delayed-release (Prilosec – brand is NP) .19 pilocarpine (Salagen – brand is NP) ...... 25 ondansetron 24 mg ...... 19 PINDOLOL ...... 16 ondansetron (Zofran, Zofran ODT – brands are NP) .19 pioglitazone (Actos – brand is NP) ...... 15 ONGLYZ A ...... 15 pioglitazone/metformin (Actoplus Met – brand is NP) 15 oral contraceptives – all generics ...... 15 piroxicam (Feldene – brand is NP) ...... 22 ORAP ...... 21 podofilox (Condylox – brand is NP) ...... 27 orphenadrine/aspirin/caffeine 25-385-30 mg . . . 23 polymyxin B/trimethoprim eye soln (Polytrim – orphenadrine citrate ext-release ...... 23 brand is NP) ...... 24 ORTHO EVRA ...... 15 potassium bicarbonate/chloride oxaprozin (Daypro – brand is NP) ...... 22 effervescent tabs, 25 mEq ...... 24 oxcarbazepine (Trileptal – brand is NP) ...... 23 potassium chloride ext-release ...... 24 oxybutynin ...... 20 potassium chloride packets; soln, 10% . . . . . 24 oxybutynin ext-release (Ditropan XL – brand is NP) .20 potassium citrate/citric acid powder oxycodone/acetaminophen (Percocet – brand is NP) .22 (Polycitra-K – brand is NP) ...... 20 oxycodone/aspirin (Percodan – brand is NP) . . . 22 potassium citrate ext-release (Urocit-K – oxycodone caps ...... 22 brand is NP) ...... 20 oxycodone, conc 20 mg/mL; tabs, 5 mg, potassium phosphate/sodium phosphates 15 mg, 30 mg (Roxicodone – brand is NP) . . . . 22 (K -Phos Neutral – brand is NP) ...... 24 OXYCONTIN ...... 22 pramipexole (Mirapex – brand is NP) ...... 23 P PRANDIN ...... 15 pantoprazole delayed-release (Protonix – pravastatin (Pravachol – brand is NP) ...... 17 brand is NP) ...... 19 prazosin (Minipress – brand is NP) ...... 18

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 35 2013 prednisolone acetate eye susp (Pred Forte – R brand is NP) ...... 25 ramipril (Altace – brand is NP) ...... 16 prednisolone (Prelone – brand is NP) ...... 14 ranitidine (Zantac – brand is NP) ...... 19 PREDNISOLONE SODIUM PHOSPHATE RAPAMUNE ...... 27 eye soln, 1% ...... 25 RENVELA ...... 19 prednisolone sodium phosphate soln, 15 mg/5 mL RESCRIPTOR ...... 13 (Orapred – brand is NP) ...... 14 REYATAZ ...... 13 PREDNISONE INTENSOL ...... 14 ribavirin (Copegus, Rebetol – brands are NP) . . . .13 PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg . . . . 14 rifampin (Rifadin – brand is NP) ...... 12 prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg .14 RILUTEK ...... 24 PRENAPLUS ...... 24 risperidone, NP = ODT, 0.25 mg PRENATABS FA ...... 24 (Risperdal, Risperdal M-Tab – brands are NP) . . .21 PRENATAL 19, LOW IRON, PLUS, PLUS/IRON, rivastigmine (Exelon – brand is NP) ...... 21 VITAMINS PLUS ...... 24 rizatriptan (Maxalt, Maxalt MLT – brands are NP) . . 22 PREVPAC ...... 19 ropinirole (Requip – brand is NP) ...... 23 PREZISTA ...... 13 S PRIFTIN ...... 12 SABRIL ...... 23 PRIMAQUINE ...... 13 salsalate ...... 22 primidone (Mysoline – brand is NP) ...... 23 (Eldepryl – brand is NP) ...... 23 PROAIR HFA ...... 18 selegiline caps selegiline tabs ...... 23 probenecid ...... 23 selenium sulfide (Selsun – brand is NP) ...... 27 probenecid/colchicine ...... 23 SELZENTRY ...... 13 prochlorperazine ...... 21 SE -NATAL 19 ...... 24 progesterone micronized (Prometrium – brand is NP) .14 SENSIPAR ...... 16 promethazine, NP = supp, 50 mg ...... 18 SEROQUEL XR ...... 21 propafenone ext-release (Rythmol SR – brand is NP) .17 sertraline (Zoloft – brand is NP) ...... 20 propafenone (Rythmol – brand is NP) ...... 17 sildenafil (Revatio – brand is NP) ...... 18 propranolol ext-release (Inderal LA – brand is NP) . 16 (Silvadene – brand is NP) . . . .26 PROPRANOLOL soln ...... 16 silver sulfadiazine simvastatin (Zocor – brand is NP) ...... 17 propranolol tabs ...... 16 sodium citrate/citric acid (Shohl’s – brand is NP) . .20 propylthiouracil ...... 15 ...... 24 PROTOPIC ...... 27 sodium fluoride, NP = tabs (Prevident – brand is NP) . . . . .25 PULMOZYME ...... 19 sodium fluoride ...... 27 PYLERA ...... 19 sodium polystyrene sulfonate SOLARAZE ...... 27 pyrazinamide ...... 12 SORIATANE ...... 27 pyridostigmine (Mestinon – brand is NP) . . . . . 24 sotalol (Betapace, Betapace AF – brands are NP) . .18 Q SPIRIVA HANDIHALER ...... 18 quetiapine (Seroquel – brand is NP) ...... 21 spironolactone (Aldactone – brand is NP) . . . . .17 quinapril (Accupril – brand is NP) ...... 16 spironolactone/hydrochlorothiazide quinapril/hydrochlorothiazide (Accuretic – (Aldactazide – brand is NP) ...... 17 brand is NP) ...... 16 stavudine (Zerit – brand is NP) ...... 13 quinidine gluconate ext-release ...... 17 STIMATE ...... 16 quinidine sulfate ...... 18 STRIBILD ...... 13 QVAR ...... 18 STROMECTOL ...... 13

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 36 2013

SUBOXONE ...... 22 tobramycin/dexamethasone eye susp (Tobradex – sucralfate (Carafate – brand is NP) ...... 19 brand is NP) ...... 25 sulfacetamide sodium eye soln (Bleph-10 – tobramycin eye soln (Tobrex – brand is NP) ...... 24 brand is NP) ...... 24 tolterodine (Detrol – brand is NP) ...... 20 sulfacetamide sodium/prednisolone eye soln . . .25 topiramate (Topamax Sprinkle, Topamax – sulfacetamide sodium/sulfur, NP = susp, 10-5% . .26 brands are NP) ...... 23 sulfamethoxazole/trimethoprim (Bactrim – torsemide (Demadex – brand is NP) ...... 17 brand is NP) ...... 13 tramadol/acetaminophen (Ultracet – brand is NP) . . 22 sulfasalazine (Azulfidine – brand is NP) ...... 19 tramadol (Ultram – brand is NP) ...... 22 sulfasalazine delayed-release (Azulfidine EN-Tabs – trandolapril (Mavik – brand is NP) ...... 16 brand is NP) ...... 19 tranylcypromine (Parnate – brand is NP) . . . . . 20 sulindac (Clinoril – brand is NP) ...... 22 TRAVATAN Z ...... 25 sumatriptan inj, tabs (Imitrex – brand is NP) . . . 22 trazodone ...... 20 SUPRAX tabs ...... 12 tretinoin caps ...... 14 SUSTIVA ...... 13 tretinoin (Retin-A – brand is NP) ...... 26 SYMBICORT ...... 18 TREXALL ...... 14 T triamcinolone crm; lotn; oint, 0.025%, 0.1% . . . .26 triamcinolone dental paste ...... 25 TABLOID ...... 14 triamcinolone (Nasacort AQ – brand is NP) . . . . 18 tacrolimus (Prograf – brand is NP) ...... 27 triamterene/hydrochlorothiazide (Dyazide, tamoxifen ...... 14 Maxzide, Maxzide-25 – brands are NP) ...... 17 tamsulosin (Flomax – brand is NP) ...... 20 TRICOR ...... 17 TAZORAC ...... 26 trifluoperazine ...... 21 TEGRETOL-XR 100 mg ...... 23 trifluridine eye soln (Viroptic – brand is NP) . . . . 24 temazepam (Restoril – brand is NP) ...... 21 trihexyphenidyl ...... 23 terazosin ...... 18 TRILIPIX ...... 17 terbinafine (Lamisil – brand is NP) ...... 12 trimethobenzamide (Tigan – brand is NP) . . . . .19 terbutaline ...... 18 trimethoprim ...... 13 terconazole (Terazol – brand is NP) ...... 20 TRIZIVIR ...... 13 testosterone cypionate (Depo-Testosterone – tropicamide eye soln (Mydriacyl – brand is NP) . . .25 brand is NP) ...... 14 TRUVADA ...... 13 testosterone enanthate (Delatestryl – brand is NP) . .14 TEST STRIPS – BAYER ASCENSIA AUTODISC, U BREEZE 2, CONTOUR, CONTOUR NEXT ...... 27 ursodiol (Actigall, Urso 250, Urso Forte – TEST STRIPS – ROCHE ACCU-CHEK ACTIVE, AVIVA, brands are NP) ...... 19 AVIVA PLUS, COMFORT CURVE, COMPACT, V SMARTVIEW; ACCUTREND ...... 27 valacyclovir (Valtrex – brand is NP) ...... 13 theophylline ext-release ...... 18 VALCYTE ...... 12 thiothixene ...... 21 valproic acid (Depakene – brand is NP) ...... 23 timolol maleate eye soln (Timoptic, Timoptic-XE – valsartan/hydrochlorothiazide (Diovan HCT – brand is NP) ...... 25 brand is NP) ...... 16 TIMOLOL tabs ...... 16 vancomycin (Vancocin – brand is NP) ...... 13 tizanidine (Zanaflex – brand is NP) ...... 23 venlafaxine ...... 20 TOBRADEX eye oint ...... 25

Blue Cross and Blue Shield of New Mexico April 2013 Drug List 37 2013 venlafaxine ext-release caps (Effexor XR – brand is NP) ...... 20 venlafaxine ext-release tabs, NP = 225 mg . . . .20 VENTOLIN HFA ...... 18 verapamil 80 mg, 120 mg (Calan – brand is NP) . . 17 verapamil ext-release (Calan SR, Isoptin SR, Verelan, Verelan PM – brands are NP) ...... 17 VESICARE ...... 20 VFEND susp ...... 12 VICTOZA ...... 15 VIDEX ...... 13 VIGAMOX ...... 24 VIRACEPT ...... 13 VIRAMUNE susp ...... 13 VIRAMUNE XR ...... 13 VIREAD ...... 13 VIVELLE-DOT ...... 14 voriconazole (Vfend tabs – brand is NP) ...... 12 VYVANSE ...... 21 W warfarin (Coumadin – brand is NP) ...... 24 WELCHOL ...... 17 X XERAC AC ...... 27 XIFAXAN 550 mg ...... 13 Z zafirlukast (Accolate – brand is NP) ...... 18 zaleplon (Sonata – brand is NP) ...... 21 ZEMPLAR ...... 16 ZENPEP ...... 19 zidovudine (Retrovir – brand is NP) ...... 13 ziprasidone hcl (Geodon – brand is NP) ...... 21 ZITHROMAX packets ...... 12 zolpidem (Ambien – brand is NP) ...... 21 zolpidem ext-release (Ambien CR – brand is NP) . .21 zonisamide (Zonegran – brand is NP) ...... 23 ZORTRESS ...... 27 ZYCLARA ...... 27 ZYLET ...... 25 ZYVOX ...... 13

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