2006 Effective April , 2006 Blue Cross and Blue Shield of Oklahoma Drug Formulary D R U G L I S T B Y THERAPEUTI C C LASS Blue Cross and Blue Shield of Oklahoma members are requested to talk to their physicians about prescribing medications included on the Drug List. This document reflects the Blue Cross and Blue Shield of Oklahoma and BlueLincs HMO Drug Formulary as of April 1, 2006. The Drug List is updated quarterly. Please visit www.bcbsok.com for recent updates. 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. TA B LE OF C ONTENTS KEY Introduction. 2 caps. capsules Member Prescription Benefit. 2 conc . concentrate Pharmacy and Therapeutics (P&T) Committee. 2 crm. cream How to use this Drug List. 2 delayed-release. enteric-coated Cost Index. 3 ext-release . extended-release Generic Substitution. 3 inj . injection liq . liquid Quantity Limits (QL). 4 oint. ointment Step Therapy (ST) . 5 QL. quantity limit Pharmacologic and Therapeutic Categories. 6 SL . sublingual Anti-infective Drugs. 6 soln. solution Cancer Drugs. 6 ST. step therapy Hormones, Diabetes and Related Drugs. 7 supp. suppositories Heart and Circulatory Drugs. 8 susp. suspension tabs. tablets Respiratory Drugs . 9 Gastrointestinal Drugs. 10 CONTA C T I NFORMATION Genitourinary Drugs . 11 Central Nervous System Drugs . 11 If you have any questions regarding the Blue Cross and Blue Shield of Oklahoma Drug Formulary, or if you have Pain Relief Drugs. 12 comments or suggestions that can improve the useful- Neuromuscular Drugs. 13 ness of this publication, please direct them to: Supplements . 13 Ronald C. White, D.Ph. Blood Modifying Drugs. .14 Manager Pharmacy Programs Topical Drugs. 14 1400 South Boston Miscellaneous Categories . 15 Tulsa, OK 74119-3612 Phone: 918-561-9906 Fax: 918-561-9963 E-mail: [email protected] A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, 2 9 2 0 A © P rime T herape U tics L L C 3 / 0 6 an Independent Licensee of the Blue Cross and Blue Shield Association BLUE CROSS AND BLUE SHIELD OF OKLAHOMA 2006 DRUG LIST BY THERAPEUTIC CLASS – OF 5 INTRODU C TION PHARMA C Y AND THERAPEUTI C S ( P & T ) C OMMITTEE Blue Cross and Blue Shield of Oklahoma is pleased to present the 2006 Blue Cross and Blue Shield of Oklahoma The Prime Therapeutics P&T Committee includes and BlueLincs HMO Drug Formulary. The formulary listing physicians and pharmacists from throughout the country, and includes all Tier II Preferred Brand drugs and a partial listing includes a voting member from Blue Cross and Blue Shield of Tier I generic drugs and Tier III Brand drugs. The formulary of Oklahoma. Prime Therapeutics does not have voting only lists drugs recommended by Blue Cross and Blue Shield privileges on this committee. of Oklahoma based upon clinical recommendations of the Prime Therapeutics National Pharmacy and Therapeutics Blue Cross and Blue Shield of Oklahoma also works with (P&T) Committee. Drugs are recommended for addition to the Health Care Service Corporation (HCSC) Preferred the formulary after considering safety, efficacy, uniqueness and Drug Committee. They consider the P&T Committee’s cost. Physicians are encouraged to prescribe drugs listed in this recommendations before making the final determination formulary. Members are encouraged to show this formulary to regarding drug changes to the formulary. Members and their physicians and pharmacists. physicians can view the most up-to-date version of the formulary at www.bcbsok.com. The formulary is multi-tiered, placing prescription drugs into one of three copayment levels; generic, Preferred Brand, HO W TO USE THIS FORMULARY or Brand. The drug benefit includes almost all prescription drugs, although some exclusions do apply. For example, drugs The formulary is organized into broad therapeutic categories. indicated for cosmetic purposes, e.g., Propecia, for hair growth, Within most categories, drugs are grouped based upon drug are not covered. Copayment levels vary depending on your class, e.g. Macrolides, or use for a specific medical condition, plan. When you have a prescription filled, prescription costs e.g. diabetes. All the drugs listed, whether generic, Preferred will be lower if you choose generic drugs. Preferred Brand drugs Brand or Brand, are recommended drugs. cost less than Brand drugs, which have the highest copayment. The majority of Brand drugs have a generic or Preferred Brand Generic drugs are shown in lowercase boldface type in the alternative. Generic drugs, including those that are unlisted, left-hand column. Most generic drugs are followed by a are available to members at a lower copayment. All Preferred reference brand drug (in parentheses) to assist in product Brand drugs are listed in this formulary. Brand drugs not listed recognition. Some generic products have no brand reference. in this formulary are available to members and, depending Brand reference drugs usually take the highest copayment. on the plan, may have the highest copayment. Some drugs, generic and brand, have a quantity limit per month and are Example: ibuprofen (Motrin) listed on pages 4-5. Preferred Brand and Brand drugs are noted in capital letters M EM B E R P RES C RIPTION BENEFIT in the center and right-hand columns. Generally, prescription drugs are available to members at one Example: LIPITOR of three copayment levels. However, coverage and cost sharing may vary depending on the member’s group benefits: Generic versions of immediate-release dosage forms and strengths of reference brand drugs (shown in parentheses) Tier I – Lowest copay: Generic drugs – listed and unlisted and all strengths and dosage forms of the Preferred Brand generic drugs and Brand drugs (shown in capital letters) usually apply to Tier II – Middle copay: Preferred Brand drugs – all are listed in the entry in the formulary. Exceptions are noted. this formulary Tier III – Highest copay: Brand drugs – listed and unlisted Example: atenolol (Tenormin) brand drugs Tenormin is marketed as 25 mg, 50 mg and 100 mg tablets. Each strength is available generically. Generic atenolol is recommended for use. Tenormin is noted for reference only and is not on the formulary. Example: sucralfate tabs (Carafate) BLUE CROSS AND BLUE SHIELD OF OKLAHOMA 2006 DRUG LIST BY THERAPEUTIC CLASS – 2 OF 5 Carafate is marketed as 1 g tablets and 500 mg/5 mL oral C OST INDE X suspension. The tablets have generic versions available; the oral suspension is only available as brand Carafate. The Dollar signs are based $. $20.00 or less formulary entry includes generic tablets. Carafate suspension upon Average Wholesale $$. $20.01 to $40 would require a separate entry to be included. Because the Price (AWP) or Maximum $$$. $40.01 to $80 suspension is not listed, it would take the highest copayment. Allowable Cost (MAC) and $$$$. $80.01 to $160 range from one ($) to five $$$$$ More than $160 • Individual formulary entries are required for specific dosage ($$$$$), ranking the drugs forms including oral immediate-release, extended-release, from least to most expensive. delayed-release, rectal, injectable, otic, ophthalmic, vaginal, Typically, dollar signs assigned to maintenance drugs are nasal, orally disintegrating tablets, transdermal, and topical. based upon a 30-day supply at the most commonly prescribed strength and dosage. For drugs that are not for maintenance Example: estradiol patches (Climara) conditions, other more appropriate quantities are used to estradiol tabs (Estrace) determine dollar signs. Oral immediate-release and transdermal dosage forms of GENERI C SU B STITUTION estradiol require separate entries in the formulary. Blue Cross and Blue Shield of Oklahoma encourages generic • The category where a product is listed determines which utilization as a way to provide high-quality drugs at a reduced dosage form(s) are in the formulary. cost. Generic drugs are as safe and effective as their brand- name counterparts, but are usually less expensive. Generic Example: VOLTAREN drugs are manufactured under the same strict standards of When listed in the Eye category, this entry indicates that FDA’s Good Manufacturing Practice regulations that are Voltaren ophthalmic solution is a Preferred Brand. Voltaren required for brand products including batch requirements for tablets would require a separate entry in Rheumatoid and identity, strength, purity and quality. Osteoarthritis category to be included in the formulary. An FDA-approved generic drug may be substituted for the • The brand reference drug (shown in parentheses) defines the brand counterpart because it: extended-release or combination product listed in the formulary. • Contains the same active ingredient(s) as the brand-name drug Example: verapamil ext-release (Verelan) • Is identical in strength, dosage form and route of administration • Is therapeutically equivalent and can be expected to have The generic version of Verelan is recommended for use based the same clinical effects and safety profile upon this entry. Other extended-release verapamil products such as Verelan PM or Calan SR would require a separate entry. To encourage use of generic drugs, Preferred Brand and Brand drugs typically are removed from the formulary book after a Example: sulfacetamide/sulfur (Sulfacet-R) generic version becomes available. Based upon this entry, the generic version of Sulfacet-R is In determining the brand or generic classification for covered recommended for use. Brand Sulfacet-R and other strengths prescription drugs, Blue Cross and Blue Shield of Oklahoma and formulations of sulfacetamide/sulfur brand products would utilizes the generic/brand status assigned by a nationally require a separate entry to be included in the formulary. recognized provider of drug product data base information. The brand/generic status of a drug from a specific marketer is subject to change.