2007

Effective January 1, 2007

Blue Cross and Blue Shield of Oklahoma Drug Formulary

Drug List by ther apeutic cl ass 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 January 1, 2007. 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 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Member Prescription Benefit. . . . . . . . . . . . . . . . . . . 2 Pharmacy and Therapeutics (P&T) Committee. . . . 2 How to use this Drug List . . . . . . . . . . . . . . . . . . . . . . 2 Cost Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Generic Substitution. . . . . . . . . . . . . . . . . . . . . . . . . . 3 Prior Authorization. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Dispensing Limits (DL) . . . . . . . . . . . . . . . . . . . . . . . . 5 Step Therapy (ST) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Pharmacologic and Therapeutic Categories. . . . . . 7 Anti-infective Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . 7 Cancer Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Hormones, Diabetes and Related Drugs . . . . . . . . . 8 Heart and Circulatory Drugs. . . . . . . . . . . . . . . . . . 10 Respiratory Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Gastrointestinal Drugs. . . . . . . . . . . . . . . . . . . . . . . 14 Genitourinary Drugs . . . . . . . . . . . . . . . . . . . . . . . . 15 Central Nervous System Drugs . . . . . . . . . . . . . . . 15 Pain Relief Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Neuromuscular Drugs. . . . . . . . . . . . . . . . . . . . . . . 18 Supplements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Topical Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Skin Conditions/Products. . . . . . . . . . . . . . . . . . . . 21 Miscellaneous Categories . . . . . . . . . . . . . . . . . . 22

2 9 2 0 - A © P rime T herape u tics L L C

12 / 0 6

KEY caps. . . . . . . . . . . . . . . conc . . . . . . . . . . . . . . . crm. . . . . . . . . . . . . . . . delayed-release. . . . . ext-release . . . . . . . . . inj . . . . . . . . . . . . . . . . . liq . . . . . . . . . . . . . . . . . oint. . . . . . . . . . . . . . . . QL. . . . . . . . . . . . . . . . . SL . . . . . . . . . . . . . . . . . soln. . . . . . . . . . . . . . . . ST . . . . . . . . . . . . . . . . . supp. . . . . . . . . . . . . . . susp. . . . . . . . . . . . . . . tabs. . . . . . . . . . . . . . . .

capsules concentrate cream enteric-coated extended-release injection liquid ointment quantity limit sublingual solution step therapy suppositories suspension tablets

C o n ta c t I n f o r m at i o n If you have any questions regarding the Blue Cross and Blue Shield of Oklahoma Drug Formulary, or if you have comments or suggestions that can improve the usefulness of this publication, please direct them to: Ronald C. White, D.Ph. Manager Pharmacy Programs 1400 South Boston Tulsa, OK 74119-3612 Phone: 918-551-3493 Fax: 918-551-3546 E-mail: [email protected] A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

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INTRODU C TION

HO W TO USE THIS DRUG LIST

Blue Cross and Blue Shield of Oklahoma is pleased to present the 2007 Blue Cross and Blue Shield of Oklahoma and BlueLincs HMO Drug Formulary. The formulary listing includes all Tier 2 Preferred Brand drugs and a partial listing of Tier 1 Generic drugs and Tier 3 Brand drugs. Physicians are encouraged to prescribe drugs listed in this formulary. Members are encouraged to show this formulary to their physicians and pharmacists.

The formulary is organized into broad therapeutic categories. Within most categories, drugs are grouped based upon drug class, e.g. Macrolides, or use for a specific medical condition, e.g. Diabetes. All the drugs listed, whether Generic, Preferred Brand or Brand, are recommended drugs.

Member Prescription Benefit The formulary is multi-tiered, placing prescription drugs into one of three copayment levels; generic, Preferred Brand, or Brand. The drug benefit includes almost all prescription drugs, although some exclusions do apply. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, are not covered. Coverage and copayment levels vary depending on the plan. Drugs that require Prior Authorization, have Dispensing Limits, or that are included in the Step Therapy program are listed on pages 7-11.

Generic drugs are shown in lowercase boldface type. Most generic drugs are followed by a reference brand drug (in parentheses) to assist in product recognition. Some generic products have no brand reference. Brand reference drugs usually take the highest copayment.

Example: ibuprofen (Motrin)

Preferred Brand and Brand drugs are noted in capital letters, followed by the generic name.

Example: COREG – carvedilol

Tier 2 – Middle copayment: Preferred Brand drugs – all are

Generic versions of immediate-release dosage forms and strengths of reference brand drugs (shown in parentheses) and all strengths and dosage forms of Preferred Brand and Brand drugs (shown in capital letters) apply to the entry in the formulary. Exceptions are typically noted.

Tier 3 – Highest copayment: Brand drugs – listed and unlisted



PHARMA C Y AND THERAPEUTI C S ( P & T ) C OMMITTEE

Tenormin is marketed as 25 mg, 50 mg and 100 mg tablets. Each strength is available generically. Generic atenolol is a formulary drug. Tenormin would take the highest copayment (tier 3), and is only noted for reference.

Tier 1 – Lowest copayment: Generic drugs – listed and

unlisted generic drugs

listed in this Formulary brand drugs

The Prime Therapeutics P&T Committee includes physicians and pharmacists from throughout the country, and includes a voting member from Blue Cross and Blue Shield of Oklahoma. Prime Therapeutics does not have voting privileges on this Committee. Drugs are recommended for addition to the PrimeNational Formulary after considering safety, efficacy, uniqueness and cost. Blue Cross and Blue Shield of Oklahoma also uses the HCSC Preferred Drug Committee. This Committee, which includes representatives of Blue Cross and Blue Shield of Oklahoma, considers the recommendations of the P&T Committee and makes the final determination regarding drug changes to the formulary. Members and physicians can view the most up-todate version of the formulary at www.bcbsok.com.



Example: atenolol (Tenormin)

Example: cefuroxime tabs (Ceftin)

Ceftin is marketed as 250 mg and 500 mg tablets and 125 mg/5 mL and 250 mg/5 mL oral suspension. The tablets have generic versions available; the oral suspension is only available as brand Ceftin. The formulary entry includes generic tablets. Ceftin suspension would require a separate entry to be a Preferred Brand (tier 2). Because the suspension is not listed, it would take the highest copayment(tier 3). • Individual formulary entries are required for many different dosage forms or routes of administration including oral immediate-release, extended-release, delayed-release, rectal, injectable, otic, ophthalmic, vaginal, nasal, orally disintegrating tablets, transdermal, and topical.

Example: e  stradiol patches (Climara) estradiol tabs (Estrace)

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Oral immediate-release and transdermal dosage forms of estradiol require separate entries in the formulary. •T  he category where a product is listed determines which dosage form(s) are in the formulary.

Example: VOLTAREN – diclofenac

When listed in the Eye category, this entry indicates that Voltaren ophthalmic solution is a Preferred Brand (tier 2). Voltaren tablets would require a separate entry in the Rheumatoid and Osteoarthritis category to be a Preferred Brand (tier 2). • The brand reference drug (shown in parentheses) defines the extended-release or combination product listed in the formulary.

Example: verapamil ext-release (Verelan)

The generic version of Verelan is a formulary drug based upon this entry. Other extended-release verapamil products such as Verelan PM or Calan SR would require separate entries to be Preferred Brands.

Example: sulfacetamide/sulfur (Sulfacet-R)

Based upon this entry, generic versions of Sulfacet-R are formulary drugs. Sulfacet-R and other brand sulfacetamide/sulfur products would require the highest copayment (tier 3), unless separate brand entries are present.

C OST INDE X Dollar signs are based upon $. . . . . $20.00 or less Average Wholesale Price $$. . . . $20.01 to $40 (AWP) or Maximum Allowable $$$. . . $40.01 to $80 Cost (MAC) and range from $$$$. . $80.01 to $160 one ($) to five ($$$$$), $$$$$ More than $160 ranking the drugs from least to most expensive. Within the same dollar sign, drugs are listed alphabetically. Dollar signs for maintenance drugs are typically based upon a 30 day supply at a commonly prescribed dosage. For drugs not usually taken 30 days per month, a more appropriate basis is used to determine dollar sign assignment.

GENERI C SU B STITUTION Blue Cross and Blue Shield of Oklahoma encourages generic utilization as a way to provide high-quality drugs at a reduced cost. Generic drugs are as safe and effective as their brand-name counterparts, but are usually less expensive. Generic drugs are manufactured under the same strict standards of FDA’s Good Manufacturing Practice regulations that are required for brand products including batch requirements for identity, strength, purity and quality. An FDA-approved generic drug may be substituted for the brand counterpart because it: • Contains the same active ingredient(s) as the brand drug • Is identical in strength, dosage form and route of administration • Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile To encourage use of generic drugs, Preferred Brand and Brand drugs typically require the highest copayment (tier 3) after a generic version becomes available. Blue Cross and Blue Shield of Oklahoma also encourages generics by having the lowest copayment apply. In determining the brand or generic classification for covered prescription drugs, Blue Cross and Blue Shield of Oklahoma utilizes the generic/brand status as assigned by a nationally recognized provider of drug product information. The brand/ generic classification of a drug might change over time, which usually changes the copayment level.

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P r i o r A u t h o r i z at i o n A number of drugs including injectables are subject to prior authorization. The medications listed below require prior authorization for most Blue Cross and Blue Shield of Oklahoma members. Physicians must submit the request and provide appropriate documentation indicating the diagnosis and supporting medical necessity criteria. To obtain a request form, call the number on the back of the member’s card. Please provide the following information on the prior authorization request: • Patient name and member number • Prescribing physician’s name and phone number • Drug, dosage form, strength, directions and indication for use Please note that this list is not intended to be comprehensive and only includes the most commonly requested drugs. Call the customer service number on the back of the ID card if you are uncertain whether a drug will require prior authorization. Adderall (amphetamine/dextroamphetamine mixed salts) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier, Generic = First Tier Amevive (alefacept) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Aranesp (darbepoetin alfa) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Caverject (alprostadil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Cialis (tadalafil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Copegus tabs (ribavirin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier, Generic = First Tier Denavir (penciclovir) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Desoxyn (methamphetamine) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Dexedrine (dextroamphetamine). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier, Generic = First Tier Dextrostat 10mg (dextroamphetamine) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier, Generic = First Tier Diflucan 150 mg (fluconazole) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier, Generic = First Tier Edex (alprostadil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Enbrel (etanercept) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Epogen (epoetin alfa) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Focalin (dexmethylphenidate) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Forteo (teriparatide) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Grifulvin V Susp (griseofulvin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier, Generic = First Tier Hepsera (adefovir) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Second Tier Humira (adalimumab) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Kineret (anakinra) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Lamisil tabs (terbinafine) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Leukine (sargramostim) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Levitra (vardenafil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Metadate CD (methylphenidate extended release) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Metadate ER 10 mg (methylphenidate extended-release) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier, Generic = First Tier Methylin chew tabs, oral soln (methylphenidate) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Muse (alprostadil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Neulasta (pegfilgrastim) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Neumega (oprelvekin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Neupogen (filgrastim) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Nexium (esomeprazole delayed-release) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier OxyContin (oxycodone extended-release) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier, Generic = First Tier Peg-Intron (peginterferon alfa-2b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Pegasys (peginterferon alfa-2a) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Penlac (ciclopirox) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Plenaxis (abarelix) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Prevacid (lansoprazole delayed-release) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Prilosec (omeprazole delayed-release) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier, Generic = First Tier Procrit (epoetin alfa) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier

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Provigil (modafinil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Raptiva (efalizumab) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Rebetol caps (ribavirin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier, Generic = First Tier Revatio (sildenafil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Ritalin (methylphenidate) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier, Generic = First Tier Sporanox caps (itraconazole) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier, Generic = First Tier Viagra (sildenafil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Second Tier Xolair (omalizumab) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier Yocon (yohimbine) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier, Generic = First Tier Zelnorm (tegaserod) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Tier

dispensing Limits ( dL) Dispensing Limits identify gender or age restrictions, and/or the maximum quantity that can be dispensed over a specific period of time. Limits are in place to encourage appropriate drug utilization, enhance member outcomes, and reduce drug benefit costs. Limits are typically developed based upon FDA-approved drug labeling. The following brand drugs, and generic versions shown in bold type if available, have dispensing limits as of January 1, 2007. This list is subject to change. BRAN D

(generic name),or generic name

D O SAGE FORM/STRENGTH

Actiq (fentanyl citrate) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advair Diskus (salmeterol/fluticasone) . . . . . . . . . . . . . . . . . . Advair HFA (salmeterol/fluticasone) . . . . . . . . . . . . . . . . . . . . Aerobid, Aerobid M (flunisolide) . . . . . . . . . . . . . . . . . . . . . . . albuterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alora (estradiol) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alupent (metaproterenol) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Amerge (naratriptan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anzemet (dolesetron) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Astelin (azelastine) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Atrovent (ipratropium) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Atrovent (ipratropium) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Atrovent HFA (ipratropium) . . . . . . . . . . . . . . . . . . . . . . . . . . . Avonex (interferon beta-1a) . . . . . . . . . . . . . . . . . . . . . . . . . . . Axert (almotriptan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Azmacort (triamcinolone acetonide) . . . . . . . . . . . . . . . . . . . . Bactroban Nasal (mupirocin) . . . . . . . . . . . . . . . . . . . . . . . . . . Beconase AQ (beclomethasone dipropionate) . . . . . . . . . . . . Betaseron (interferon beta-1b) . . . . . . . . . . . . . . . . . . . . . . . . . Caverject (alprostadil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cialis (tadalafil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Climara (estradiol) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Combivent (albuterol/ipratropium) . . . . . . . . . . . . . . . . . . . . . Copaxone (glatiramer acetate) . . . . . . . . . . . . . . . . . . . . . . . . Diflucan (fluconazole) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Duoneb (albuterol sulfate/ipratropium) . . . . . . . . . . . . . . . . . . Duragesic (fentanyl) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Edex (alprostadil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emend (aprepitant) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emend Therapy Pack (aprepitant) . . . . . . . . . . . . . . . . . . . . . . Esclim (estradiol) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Estraderm (estradiol) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Flonase (fluticasone) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DISPENSING LIMITS per 30-day supply

transmucosal, all strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 units inhalers, 100/50, 250/50, 500/50 mcg . . . . . . . . . . . . . . . . . . 60 powder disks (1 inhaler) inhalers, 45/21, 115/21, 230/21 mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 g (2 inhalers) inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 g (3 inhalers) inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 g (2 inhalers) patch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 patches inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 g (2 inhalers) tablets, 1 mg, 2.5 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 tablets tablets, 50 mg, 100 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 tablets nasal solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 mL (1 bottle) nasal solution, 0.03% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 mL (1 bottle) nasal solution, 0.06% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 mL (2 bottles) inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.8 g (2 inhalers) vial or syringe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 pkg (4 doses) tablets, 6.25 mg, 12.5 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 tablets inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 g (2 inhalers) ointment, 2% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 - 1 g single use tubes nasal suspension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 g (2 bottles) vial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 pkg (15 vials) injection, all strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 vials tablets, all strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 tablets patch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 patches inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29.4 g (2 inhalers) syringe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 pkg (30 syringes) tablets, 150 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 tablets nebulization solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540 mL (3 - pkg of 60) patch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 patches injection, all strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 cartridges capsules, 80 mg, 125 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 capsules capsules, 2 - 80 mg + 1 - 125 mg . . . . . . . . . . . . . . . . . . . . 6 capsules (2 Therapy Packs) patch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 patches patch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 patches nasal solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 g (1 bottle)

Blue Cross and Bl ue S hield of Oklahoma 2007 Drug list b y therapeuti c c l a s s –  of 22

BRAN D

(generic name),or generic name

D O SAGE FORM/STRENGTH

Flovent HFA (fluticasone) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Flovent HFA (fluticasone) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Flovent HFA (fluticasone) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Foradil Aerolizer (fomoterol) . . . . . . . . . . . . . . . . . . . . . . . . . . . Frova (frovatriptan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Golytely (PEG-electrolytes) . . . . . . . . . . . . . . . . . . . . . . . . . . . Imitrex (sumatriptan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Imitrex (sumatriptan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Imitrex (sumatriptan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intal (cromolyn) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kadian (morphine sulfate extended-release) . . . . . . . . . . . . . Kytril (granisetron) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Levitra (vardenafil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lovenox (enoxaparin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maxair Autohaler (pirbuterol) . . . . . . . . . . . . . . . . . . . . . . . . . . Maxalt, Maxalt-MLT (rizatriptan) . . . . . . . . . . . . . . . . . . . . . . . Muse (alprostadil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nasacort AQ (triamcinolone acetonide) . . . . . . . . . . . . . . . . . Nasarel (flunisolide) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nasonex (mometasone) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ortho Evra (norelgestromin/ethinyl estradiol) . . . . . . . . . . . . . OxyContin (oxycodone extended-release) . . . . . . . . . . . . . . . ProAir HFA (albuterol sulfate). . . . . . . . . . . . . . . . . . . . . . . . . . Proventil (albuterol) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Proventil HFA (albuterol sulfate) . . . . . . . . . . . . . . . . . . . . . . . . Pulmicort Turbuhaler (budesonide) . . . . . . . . . . . . . . . . . . . . . Qvar (beclomethasone dipropionate) . . . . . . . . . . . . . . . . . . . Rebif (interferon beta-1A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Relpax (eletriptan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rhinocort Aqua (budesonide) . . . . . . . . . . . . . . . . . . . . . . . . . Serevent Diskus (salmeterol) . . . . . . . . . . . . . . . . . . . . . . . . . . Spiriva Handihaler (tiotropium) . . . . . . . . . . . . . . . . . . . . . . . . . Tilade (nedocromil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ventolin HFA (albuterol sulfate) . . . . . . . . . . . . . . . . . . . . . . . . Viagra (sildenafil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vivelle, Vivelle-Dot (estradiol) . . . . . . . . . . . . . . . . . . . . . . . . . . Xopenex HFA (levalbuterol) . . . . . . . . . . . . . . . . . . . . . . . . . . . Zofran (ondansetron) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zofran (ondansetron) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zofran ODT (ondansetron) . . . . . . . . . . . . . . . . . . . . . . . . . . . Zomig (zolmitriptan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zomig, Zomig ZMT (zolmitriptan) . . . . . . . . . . . . . . . . . . . . . . .

DISPENSING LIMITS per 30-day supply

inhaler, 44 mcg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 g (5 inhalers) inhaler, 110 mcg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 g (2 inhalers) inhaler, 220 mcg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 g (1 inhaler) nasal solution, 0.025% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 mL (3 bottles) inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 pkg (60 caps) tablets, 2.5 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 tablets powder for solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4000 mL (1 bottle) tablets, 25, 50, 100 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 tablets nasal solution, 5 mg, 20 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 units (1 box) syringe, vial, 6 mg/0.5 mL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 mL (8 injections) inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28.4 g (2 inhalers) extended-release capsules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 capsules tablets, 1 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 tablets tablets, all strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 tablets syringe, all strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 syringes inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 g (1 inhaler) tablets, 5 mg, 10 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 tablets suppository, all strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 suppositories nasal suspension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 g (2 bottles) nasal solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 mL (2 bottles) nasal suspension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 g (1 bottle) patch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 patches extended-release tablets, all strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 tablets inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 g (2 inhalers) inhaler, 17 g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 g (2 inhalers) inhaler, 6.7 g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.4 g (2 inhalers) inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 inhalers inhaler, 7.3 g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.6 g (2 inhalers) syringe, 22 mcg, 44 mcg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 syringes tablets, 20 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 tablets nasal suspension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 g (2 bottles) inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 blisters (1 inhaler) inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 capsules (2 boxes) inhaler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.4 g (2 inhalers) inhaler, 18 g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 g (2 inhalers) tablets, all strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 tablets patch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 patches inhaler, 15 g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 g (2 inhalers) oral solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 mL (2 bottles) tablets, 4 mg, 8 mg, 24 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 tablets tablets, 4 mg, 8 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 tablets nasal solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 units (2 boxes) tablets, 2.5 mg, 5 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 tablets

step therapy The step therapy program helps ensure member safety while managing the cost of specific medications. Step therapy typically targets highcost drugs and drug classes of drugs which should have careful assessment of patient selection or prior treatment before providing the drug. Drugs included in this program require that a prerequisite drug be tried before the step therapy drug will be approved for coverage. If the member meets the initial step therapy criteria, then the requested medication will be covered automatically under the member’s current prescription benefit. Drug groups subject to step therapy as of January 1, 2007: proton-pump inhibitors and drugs used to treat attention deficit hyperactivity disorder (ADHD) and narcolepsy. This list is subject to change.

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P h a r m a c o l o g i c a n d t h e r a p e u t i c c at e g o r i e s Tier

ANTI-INFECTIVE AGENTS PENICILLINS $ $ $ $ $$ $$ $$$$

amoxicillin AMOXIL drops – amoxicillin ampicillin penicillin v potassium amoxicillin/potassium clavulanate (Augmentin) dicloxacillin AUGMENTIN – 8 hr dosing – amoxicillin/potassium clavulanate

1 2 1 1 1 (3) 1 2

CEPHALOSPORINS $ $$ $$$ $$$ $$$$

cephalexin (Keflex) cefadroxil (Duricef) cefuroxime tabs (Ceftin) OMNICEF – cefdinir VANTIN – cefpodoxime

1 (3) 1 (3) 1 (3) 2 3

MACROLIDES $ $ $ $ $ $$ $$ $$$

ERY-TAB – erythromycin delayed-release tabs erythromycin delayed-release caps (Eryc) erythromycin ethylsuccinate ERYTHROMYCIN FILMTABS – erythromycin base erythromycin stearate azithromycin (Zithromax) ZITHROMAX powder packets – azithromycin BIAXIN XL – clarithromycin ext-release

2 1 (3) 1 2 1 1 (3) 2 3

TETRACYCLINES $ $ $ $$$$$

doxycycline hyclate minocycline caps, tabs (Minocin, Dynacin) tetracycline demeclocycline (Declomycin)

1 1 (3) 1 1 (3)

FLUOROQUINOLONES $ $$ $$$$ $$$$

ciprofloxacin tabs (Cipro) CIPROFLOXACIN tabs, 100 mg AVELOX – moxifloxacin LEVAQUIN – levofloxacin

1 (3) 2 3 2

AMINOGLYCOSIDES $ $$$$$

neomycin sulfate TOBI – tobramycin

1 3

TUBERCULOSIS $ $$ $$$ $$$$ $$$$$ $$$$$

isoniazid tabs ISONIAZID syrup rifampin (Rifadin) pyrazinamide ethambutol (Myambutol) MYCOBUTIN – rifabutin

1 2 1 (3) 1 1 (3) 2

FUNGAL INFECTIONS $ $ $$$ $$$ $$$$ $$$$$

fluconazole (Diflucan) – DL, PA – 150 mg tabs ketoconazole (Nizoral) griseofulvin microsize susp (Grifulvin V) – PA GRIS-PEG – griseofulvin ultramicrosize GRIFULVIN V tabs – griseofulvin microsize itraconazole caps (Sporanox) – PA

1 (3) 1 (3) 1 (3) 2 2 1 (3)

VIRAL INFECTIONS • Hepatitis $$$$$

HEPSERA – adefovir – PA

2

Blue Cross and Bl ue S hield of Oklahoma 2007 Drug list b y therapeuti c c l a s s –  of 22

Tier $$$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$

INFERGEN – interferon alfacon-1 INTRON A – interferon alfa-2b PEG-INTRON – peginterferon alfa-2b – PA ribavirin caps (Rebetol) – PA ribavirin tabs (Copegus) – PA ROFERON-A – interferon alfa-2a

3 3 3 1 (3) 1 (3) 3

• Herpes $$ $$$$$

acyclovir (Zovirax) VALTREX – valacyclovir

1 (3) 2

• HIV/AIDS $$$$ $$$$$ $$$$$

zidovudine (Retrovir) didanosine delayed-release (Videx EC) ALL BRANDS FOR HIV

1 (3) 1 (3) 3

• Influenza $$ $$

FLUMADINE syrup – rimantadine rimantadine tabs (Flumadine)

2 1 (3)

MALARIA $ $ $ $$ $$$$

chloroquine phosphate (Aralen) hydroxychloroquine (Plaquenil) PRIMAQUINE PHOSPHATE mefloquine (Lariam) MALARONE – atovaquone/proguanil

1 (3) 1 (3) 2 1 (3) 2

WORM INFECTIONS $ $

mebendazole MINTEZOL– thiabendazole

1 3

OTHER ANTI-INFECTIVES $ $ $ $ $ $ $$$$$

clindamycin (Cleocin) DAPSONE erythromycin/sulfisoxazole (Pediazole) metronidazole tabs (Flagyl) sulfamethoxazole/trimethoprim (Bactrim, Septra) trimethoprim (Proloprim) ZYVOX – linezolid

1 (3) 2 1 (3) 1 (3) 1 (3) 1 (3) 2

CANCER DRUGS ALKERAN – melphalan AROMASIN – exemestane CASODEX – bicalutamide CEENU – lomustine cyclophosphamide (Cytoxan) etoposide (Vepesid) flutamide hydroxyurea (Hydrea) leucovorin calcium 5 mg, 25 mg LEUKERAN – chlorambucil MATULANE – procarbazine megestrol (Megace) mercaptopurine (Purinethol) methotrexate tabs, 2.5 mg tamoxifen TARGRETIN caps – bexarotene TEMODAR – temozolomide

2 2 2 2 1 (3) 1 (3) 1 1 (3) 1 2 2 1 (3) 1 (3) 1 1 2 2

HORMONES, DIABETES AND RELATED DRUGS CORTICOSTEROIDS $ $ $ $

cortisone acetate dexamethasone DEXAMETHASONE soln, 0.5 mg/5 mL fludrocortisone (Florinef)

1 1 2 1 (3)

Blue Cross and Bl ue S hield of Oklahoma 2007 Drug list b y therapeuti c c l a s s –  of 22

Tier $ $ $ $ $ $ $$ $$ $$$ $$$$$

hydrocortisone 20 mg (Cortef) methylprednisolone (Medrol) prednisolone sodium phosphate soln (Orapred, Pediapred) prednisolone syrup (Prelone) prednisolone tabs prednisone CORTEF 5 mg, 10 mg – hydrocortisone PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg PREDNISONE INTENSOL ENTOCORT EC – budesonide ext-release

1 (3) 1 (3) 1 (3) 1 (3) 1 1 2 2 2 2

MALE HORMONES $$$$ $$$$$ $$$$$ $$$$$

ANDROXY – fluoxymesterone ANDROGEL – testosterone danazol 200 mg TESTIM – testosterone

2 2 1 2

ESTROGENS $ $ $$ $$ $$ $$ $$ $$ $$ $$ $$$ $$$

estradiol tabs (Estrace) estropipate (Ogen) ACTIVELLA – estradiol/norethindrone CENESTIN – conjugated estrogens, synthetic A ENJUVIA – conjugated estrogens, synthetic B ESTRADERM – estradiol – DL estradiol patches (Climara) – DL PREMARIN tabs – conjugated estrogens VIVELLE – estradiol – DL VIVELLE-DOT – estradiol – DL PREMPHASE – conjugated estrogens/medroxyprogesterone PREMPRO – conjugated estrogens/medroxyprogesterone

1 (3) 1 (3) 2 2 2 2 1 (3) 2 2 2 2 2

PROGESTINS $ $ $$

medroxyprogesterone acetate (Provera) norethindrone acetate (Aygestin) PROMETRIUM – progesterone micronized

1 (3) 1 (3) 2

BIRTH CONTROL $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$

desogestrel/ethinyl estradiol (Mircette) desogestrel/ethinyl estradiol (Ortho-Cept) ethynodiol/ethinyl estradiol (Demulen) levonorgestrel/ethinyl estradiol (Alesse) levonorgestrel/ethinyl estradiol (Levlite) levonorgestrel/ethinyl estradiol (Nordette) levonorgestrel/ethinyl estradiol (Triphasil) norethindrone (Nor-QD) norethindrone (Ortho Micronor) norethindrone acetate/ethinyl estradiol (Loestrin) norethindrone acetate/ethinyl estradiol/Fe (Loestrin Fe) norethindrone/ethinyl estradiol (Modicon) norethindrone/ethinyl estradiol (Ortho-Novum 1/35) norethindrone/ethinyl estradiol (Ortho-Novum 7/7/7) norethindrone/mestranol (Ortho-Novum 1/50) norgestimate/ethinyl estradiol (Ortho-Cyclen) norgestimate/ethinyl estradiol (Ortho Tri-Cyclen) norgestrel/ethinyl estradiol (Lo/Ovral) PLAN B – levonorgestrel

1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 2

$$$ $$$ $$$ $$$ $$$ $$$

NUVARING – etonogestrel/ethinyl estradiol OGESTREL – norgestrel/ethinyl estradiol ORTHO EVRA – norelgestromin/ethinyl estradiol – DL ORTHO TRI-CYCLEN LO – norgestimate/ethinyl estradiol YASMIN – drospirenone/ethinyl estradiol YAZ – drospirenone/ethinyl estradiol

2 2 2 2 2 2

Blue Cross and Bl ue S hield of Oklahoma 2007 Drug list b y therapeuti c c l a s s –  of 22

Tier

DIABETES $ $ $ $ $$ $$ $$ $$$ $$$$ $$$$ $$$$ $$$$ $$$$$ $$$$$ $$$$$

glimepiride (Amaryl) glipizide (Glucotrol) glyburide (Diabeta, Micronase) metformin (Glucophage) glipizide ext-release (Glucotrol XL) glyburide/metformin (Glucovance) metformin ext-release (Glucophage XR) PRECOSE – acarbose AVANDAMET – rosiglitazone/metformin AVANDIA – rosiglitazone GLUCAGON EMERGENCY KIT PRANDIN – repaglinide ACTOPLUS MET – pioglitazone/metformin ACTOS – pioglitazone DUETACT – pioglitazone/glimepiride

1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 2 2 2 3 2 2 2 2

DIABETES – INSULINS Rapid-Acting Insulins $$$$ $$$$

HUMALOG – insulin lispro NOVOLOG – insulin aspart

2 2

Short-Acting Insulins $$ $$

HUMULIN R – insulin regular NOVOLIN R – insulin regular

2 2

Intermediate-Acting Insulins $$ $$ $$ $$ $$ $$$$ $$$$ $$$$

HUMULIN 50/50 – insulin isophane/regular HUMULIN 70/30 – insulin isophane/regular HUMULIN N – insulin isophane NOVOLIN 70/30 – insulin isophane/regular NOVOLIN N – insulin isophane HUMALOG MIX 50/50 – insulin lispro protamine/lispro HUMALOG MIX 75/25 – insulin lispro protamine/lispro NOVOLOG MIX 70/30 – insulin aspart protamine/aspart

2 2 2 2 2 2 2 2

Basal Insulins $$$$

LANTUS – insulin glargine

2

THYROID REGULATION $ $ $$ $$ $$

levothyroxine – includes Levoxyl (Synthroid) propylthiouracil CYTOMEL – liothyronine methimazole (Tapazole) THYROLAR – liotrix

1 (3) 1 2 1 (3) 3

OTHER HORMONES AND RELATED DRUGS $ $$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$

METHERGINE – methylergonovine clomiphene (Clomid) ACTONEL – risedronate ACTONEL with CALCIUM – risedronate + calcium calcitonin-salmon nasal – Fortical EVISTA – raloxifene FOSAMAX – alendronate FOSAMAX PLUS D – alendronate/cholecalciferol cabergoline (Dostinex) desmopressin nasal (DDAVP) desmopressin tabs (DDAVP) HECTOROL – doxercalciferol SENSIPAR – cinacalcet

2 1 (3) 2 2 1 2 2 2 1 (3) 1 (3) 1 (3) 2 2

HEART AND CIRCULATORY DRUGS ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS $

benazepril (Lotensin)

1 (3)

Blue Cross and Blue Shield of Oklahoma 2007 Drug list b y therapeuti c cl a s s – 10 of 22

Tier $ $ $ $ $ $ $ $$ $$ $$$ $$$

benazepril/hydrochlorothiazide (Lotensin HCT) captopril (Capoten) captopril/hydrochlorothiazide (Capozide) enalapril (Vasotec) enalapril/hydrochlorothiazide (Vaseretic) lisinopril (Prinivil) lisinopril/hydrochlorothiazide (Prinzide) quinapril (Accupril) quinapril/hydrochlorothiazide (Accuretic) ALTACE – ramipril TARKA – trandolapril/verapamil

1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 2 3

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBs) AND COMBINATIONS $$$ $$$ $$$ $$$

BENICAR – olmesartan BENICAR HCT – olmesartan/hydrochlorothiazide DIOVAN – valsartan DIOVAN HCT – valsartan/hydrochlorothiazide

2 2 2 2

BETA BLOCKERS AND COMBINATIONS $ $ $ $ $ $ $ $$ $$ $$ $$ $$ $$ $$$ $$$ $$$ $$$$

acebutolol (Sectral) atenolol (Tenormin) atenolol/chlorthalidone (Tenoretic) bisoprolol/hydrochlorothiazide (Ziac) metoprolol (Lopressor) propranolol tabs (Inderal) propranolol/hydrochlorothiazide (Inderide) labetalol (Trandate) nadolol (Corgard) PROPRANOLOL soln TIMOLOL 5 mg, 20 mg timolol 10 mg TOPROL XL – metoprolol ext-release INDERAL LA – propranolol ext-release INNOPRAN XL – propranolol ext-release PINDOLOL COREG – carvedilol

1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 2 2 1 2 2 2 2 2

CALCIUM CHANNEL BLOCKERS AND COMBINATIONS $ $ $ $$ $$ $$ $$ $$$ $$$ $$$ $$$$

diltiazem (Cardizem) verapamil (Calan) verapamil ext-release (Calan SR) diltiazem ext-release (Dilacor XR) nifedipine ext-release (Adalat CC) nifedipine ext-release (Procardia XL) verapamil ext-release (Verelan) diltiazem ext-release (Cardizem CD) diltiazem ext-release (Tiazac) NORVASC – amlodipine LOTREL – amlodipine/benazepril

1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 2 2

CHEST PAIN $ $ $ $ $$ $$ $$$$

isosorbide dinitrate (Isordil) isosorbide mononitrate ext-release (Imdur) NITRO-BID oint – nitroglycerin nitroglycerin sublingual tabs (Nitrostat) isosorbide mononitrate (Monoket) nitroglycerin patches (Nitro-Dur) NITROLINGUAL – nitroglycerin

1 (3) 1 (3) 2 1 (3) 1 (3) 1 (3) 3

CHOLESTEROL LOWERING $ $$ $$$

gemfibrozil (Lopid) lovastatin (Mevacor) cholestyramine (Questran, Questran Light)

1 (3) 1 (3) 1 (3)

Blue Cross and Blue Shield of Oklahoma 2007 Drug list b y therapeuti c cl a s s – 11 of 22

Tier $$$ $$$ $$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$$

COLESTID tabs – colestipol colestipol bulk granules, packets (Colestid) LESCOL – fluvastatin ADVICOR – niacin/lovastatin ext-release CRESTOR – rosuvastatin NIASPAN – niacin ext-release PRAVACHOL – pravastatin pravastatin 10, 20, 40 mg (Pravachol) simvastatin (Zocor) TRICOR – fenofibrate VYTORIN – ezetimibe/simvastatin ZETIA – ezetimibe WELCHOL – colesevelam

2 1 (3) 3 3 2 2 3 1 (3) 1 (3) 2 2 2 2

FLUID RETENTION $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $$ $$ $$

acetazolamide amiloride/hydrochlorothiazide bumetanide (Bumex) chlorothiazide chlorthalidone 25 mg, 50 mg furosemide soln, 10 mg/mL; tabs (Lasix) hydrochlorothiazide caps (Microzide) hydrochlorothiazide tabs indapamide spironolactone (Aldactone) spironolactone/hydrochlorothiazide 25/25 (Aldactazide) triamterene/hydrochlorothiazide caps, 37.5/25 (Dyazide) triamterene/hydrochlorothiazide tabs, 37.5/25 (Maxzide-25) triamterene/hydrochlorothiazide tabs, 75/50 (Maxzide) AMILORIDE methazolamide metolazone (Zaroxolyn) triamterene/hydrochlorothiazide caps, 50/25

1 1 1 (3) 1 1 1 (3) 1 (3) 1 1 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 2 1 1 (3) 1

HEART RHYTHM $ $$ $$ $$$ $$$ $$$ $$$ $$$$ $$$$ $$$$ $$$$

sotalol (Betapace) amiodarone 200 mg (Cordarone) quinidine sulfate disopyramide (Norpace) flecainide (Tambocor) mexiletine propafenone (Rythmol) disopyramide ext-release 150 mg (Norpace CR) ETHMOZINE – moricizine quinidine gluconate ext-release sotalol (Betapace AF)

1 (3) 1 (3) 1 1 (3) 1 (3) 1 1 (3) 1 (3) 2 1 1 (3)

OTHER HEART RELATED DRUGS $ $ $ $ $ $ $$ $$ $$ $$$ $$$ $$$$ $$$$$ $$$$$

clonidine (Catapres) digoxin tabs (Lanoxin) doxazosin (Cardura) guanfacine (Tenex) methyldopa terazosin (Hytrin) DIGOXIN soln minoxidil prazosin (Minipress) EPIPEN – epinephrine hydralazine CATAPRES-TTS – clonidine DIBENZYLINE – phenoxybenzamine midodrine (Proamatine)

1 (3) 1 (3) 1 (3) 1 (3) 1 1 (3) 2 1 1 (3) 3 1 2 2 1 (3)

Blue Cross and Blue Shield of Oklahoma 2007 Drug list b y therapeuti c cl a s s – 12 of 22

Tier $$$$$

TRACLEER – bosentan

2

ERECTILE DYSFUNCTION $$$

VIAGRA – sildenafil – DL, PA

2

RESPIRATORY AGENTS ANTIHISTAMINES $ $ $ $$$ $$$ $$$ $$$

cyproheptadine promethazine supp promethazine syrup, tabs CLARINEX syrup – desloratadine DEXCHLORPHENIRAMINE MALEATE syrup fexofenadine (Allegra) ZYRTEC – cetirizine

1 1 1 3 2 1 (3) 2

NASAL PRODUCTS $$$ $$$ $$$

ASTELIN – azelastine – DL flunisolide 25 mcg/spray – DL fluticasone (Flonase) – DL

2 1 1 (3)

$$$ $$$$ $$$$ $$$$

ipratropium (Atrovent) – DL BECONASE AQ – beclomethasone – DL NASACORT AQ – triamcinolone – DL NASONEX – mometasone – DL

1 (3) 3 2 2

COUGH/COLD/ALLERGY $ $ $ $ $ $ $ $$ $$$ $$$ $$$$ $$$$

chlorpheniramine/pseudoephedrine/codeine soln, 2/30/10 per 5 mL codeine/guaifenesin soln, 10/100 per 5 mL codeine/guaifenesin syrup, 10/100 per 5 mL codeine/guaifenesin tabs, 10/300 (Brontex) hydrocodone/guaifenesin syrup, 2.5/200 per 5 mL (Pneumotussin) hydrocodone/guaifenesin syrup, 5/100 per 5 mL (Hycotuss) pseudoephedrine/guaifenesin ext-release caps, 60/300; ext-release tabs, 45/600, 60/600, 120/600 brompheniramine/pseudoephedrine ext-release caps, 6/60, 12/120 TUSSIONEX – chlorpheniramine/hydrocodone ext-release ZYRTEC-D – cetirizine/pseudoephedrine ext-release acetylcysteine (Mucomyst) ALLEGRA-D – fexofenadine/pseudoephedrine ext-release

1 1 1 1 (3) 1 (3) 1 (3) 1 1 3 2 1 2

ASTHMA/COPD $ $$ $$ $$ $$ $$ $$ $$$ $$$ $$$ $$$ $$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$$ $$$$$ $$$$$

albuterol sulfate syrup, tabs albuterol inhaler (Proventil) – DL albuterol sulfate neb soln (Accuneb, Proventil) PROAIR HFA – albuterol sulfate – DL terbutaline (Brethine) theophylline ext-release caps – 12 hr dosing theophylline ext-release tabs – 12 hr dosing – Theochron ATROVENT HFA – ipratropium – DL cromolyn sodium neb soln (Intal) ipratropium neb soln METAPROTERENOL tabs TILADE – nedocromil sodium – DL COMBIVENT – albuterol sulfate/ipratropium – DL FLOVENT HFA – fluticasone – DL FORADIL AEROLIZER – formoterol – DL INTAL INHALER – cromolyn sodium – DL MAXAIR AUTOHALER – pirbuterol – DL QVAR – beclomethasone – DL SEREVENT DISKUS – salmeterol – DL SINGULAIR – montelukast ADVAIR DISKUS – fluticasone/salmeterol – DL ADVAIR HFA – fluticasone/salmeterol – DL DUONEB – albuterol sulfate/ipratropium – DL

1 1 (3) 1 (3) 2 1 (3) 1 1 2 1 (3) 1 2 2 2 2 2 2 3 2 2 2 2 2 2

Blue Cross and Blue Shield of Oklahoma 2007 Drug list b y therapeuti c cl a s s – 13 of 22

Tier $$$$$ $$$$$

PULMICORT RESPULES – budesonide PULMICORT TURBUHALER – budesonide – DL

2 2

OTHER RESPIRATORY DRUGS $$$$$

PULMOZYME – dornase alfa

3

GASTROINTESTINAL DRUGS LAXATIVES $ $ $ $$

lactulose PEG – electrolytes for soln (Colyte) PEG – electrolytes for soln (Nulytely) polyethylene glycol 3350 (Miralax)

1 1 (3) 1 (3) 1 (3)

ULCER/GERD $ $ $ $ $ $ $ $$ $$$ $$$ $$$ $$$ $$$$ $$$$ $$$$ $$$$$

cimetidine (Tagamet) dicyclomine (Bentyl) famotidine (Pepcid) hyoscyamine ext-release caps (Levsinex) hyoscyamine ext-release tabs (Levbid) hyoscyamine tabs (Levsin) ranitidine (Zantac) ZANTAC syrup – ranitidine CARAFATE susp – sucralfate omeprazole delayed-release (Prilosec) – PA PROPANTHELINE BROMIDE 15 mg sucralfate tabs (Carafate) ACIPHEX – rabeprazole delayed-release misoprostol (Cytotec) PROTONIX – pantoprazole delayed-release PREVPAC – amoxicillin + clarithromycin + lansoprazole delayed-release

1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 2 2 1 (3) 2 1 (3) 2 1 (3) 2 2

NAUSEA AND VOMITING $ $ $$ $$$$ $$$$$ $$$$$ $$$$$

trimethobenzamide caps (Tigan) trimethobenzamide supp TRANSDERM-SCOP – scopolamine ANZEMET – dolasetron – DL EMEND – aprepitant – DL ZOFRAN – ondansetron – DL ZOFRAN ODT – ondansetron – DL

1 (3) 1 3 3 2 2 2

DIGESTIVE ENZYMES – Pancreatic enzyme (pancrelipase) immediate-release and delayed-release products: $$$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$

CREON LIPRAM/PN/UL PANCREASE MT PANCRELIPASE IR caps, 20-4-25 PANCRELIPASE IR tabs, 30-8-30 – various tradenames PANOKASE-16 ULTRASE/MT VIOKASE

2 2 2 2 2 2 2 2

OTHER GASTROINTESTINAL DRUGS $ $ $ $$$ $$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$

lactulose – encephalopathy metoclopramide (Reglan) sulfasalazine (Azulfidine) PHOSLO – calcium acetate ursodiol (Actigall) ASACOL – mesalamine delayed-release CANASA – mesalamine supp DIPENTUM – olsalazine mesalamine enema (Rowasa) PENTASA – mesalamine ext-release RENAGEL – sevelamer URSO – ursodiol

1 1 (3) 1 (3) 2 1 (3) 2 2 2 1 (3) 2 2 2

Blue Cross and Blue Shield of Oklahoma 2007 Drug list b y therapeuti c cl a s s – 14 of 22

Tier $$$$$

ZELNORM – tegaserod – PA

3

GENITOURINARY DRUGS URINARY TRACT INFECTIONS $ $$

nitrofurantoin monohydrate/macrocrystals (Macrobid) nitrofurantoin macrocrystals (Macrodantin)

1 (3) 1 (3)

URINARY TRACT SPASMS $ $$$$ $$$$ $$$$

oxybutynin (Ditropan) DETROL – tolterodine DETROL LA – tolterodine ext-release oxybutynin ext-release (Ditropan XL)

1 (3) 2 2 1 (3)

VAGINAL PRODUCTS $ $$ $$ $$ $$ $$$ $$$$ $$$$$

amino acid/urea crm (Amino-Cerv) acetic acid gel ESTRACE crm – estradiol PREMARIN crm – conjugated estrogens VAGIFEM – estradiol vaginal tabs clindamycin crm (Cleocin) METROGEL VAGINAL – metronidazole CRINONE 8% – progesterone gel

1 (3) 1 2 2 2 1 (3) 2 2

OTHER GENITOURINARY DRUGS $$ $$$ $$$ $$$ $$$ $$$ $$$$

potassium citrate ext-release (Urocit-K) finasteride (Proscar) FLOMAX – tamsulosin potassium citrate/citric acid powder, soln (Polycitra-K) sodium citrate/citric acid (Bicitra) tricitrates soln (Polycitra) AVODART – dutasteride

1 (3) 1 (3) 2 1 (3) 1 (3) 1 (3) 2

CENTRAL NERVOUS SYSTEM DRUGS ANXIETY $ $ $ $ $ $ $$

alprazolam (Xanax) buspirone (Buspar) DIAZEPAM oral soln, 1 mg/mL diazepam tabs (Valium) hydroxyzine pamoate (Vistaril) lorazepam (Ativan) hydroxyzine hcl

1 (3) 1 (3) 2 1 (3) 1 (3) 1 (3) 1

DEPRESSION $ $ $ $ $ $ $$ $$ $$ $$ $$ $$$ $$$ $$$ $$$$ $$$$ $$$$ $$$$ $$$$

amitriptyline citalopram (Celexa) doxepin fluoxetine (Prozac) nortriptyline (Pamelor) trazodone bupropion (Wellbutrin) clomipramine (Anafranil) desipramine (Norpramin) imipramine hcl (Tofranil) mirtazapine (Remeron) bupropion ext-release (Wellbutrin SR) NARDIL – phenelzine paroxetine hcl (Paxil) CYMBALTA – duloxetine delayed-release EFFEXOR XR – venlafaxine ext-release LEXAPRO – escitalopram sertraline (Zoloft) tranylcypromine (Parnate)

1 1 (3) 1 1 (3) 1 (3) 1 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 2 1 (3) 3 2 2 1 (3) 1 (3)

Blue Cross and Blue Shield of Oklahoma 2007 Drug list b y therapeuti c cl a s s – 15 of 22

Tier $$$$ $$$$ $$$$

venlafaxine (Effexor) VIVACTIL – protriptyline WELLBUTRIN XL – bupropion ext-release

1 (3) 3 2

PSYCHOTIC AND BIPOLAR DISORDERS $ $ $ $ $ $ $ $$ $$ $$ $$ $$$ $$$ $$$ $$$ $$$$ $$$$$ $$$$$ $$$$$ $$$$$

fluphenazine hcl haloperidol lactate oral soln haloperidol tabs, 0.5 mg, 1mg, 2 mg, 5 mg, 10 mg lithium carbonate caps, 150 mg, 300 mg prochlorperazine supp prochlorperazine tabs thiothixene (Navane) lithium carbonate ext-release 450 mg perphenazine thioridazine trifluoperazine chlorpromazine clozapine 25 mg, 50 mg, 100 mg (Clozaril) lithium carbonate ext-release 300 mg (Lithobid) lithium citrate loxapine (Loxitane) GEODON – ziprasidone RISPERDAL – risperidone RISPERDAL M-TAB – risperidone SEROQUEL – quetiapine

1 1 1 1 1 1 1 (3) 1 1 1 1 1 1 (3) 1 (3) 1 1 (3) 2 2 2 2

SLEEP AIDS $ $ $ $ $ $$$ $$$$

CHLORAL HYDRATE supp chloral hydrate syrup estazolam (Prosom) phenobarbital temazepam (Restoril) RESTORIL 7.5 mg – temazepam AMBIEN – zolpidem

2 1 1 (3) 1 1 (3) 2 2

HYPERACTIVITY/NARCOLEPSY $$ $$ $$ $$$ $$$ $$$$ $$$$ $$$$

dextroamphetamine – PA methylphenidate (Ritalin) – PA methylphenidate ext-release (Metadate ER, Ritalin SR) – PA amphetamine/dextroamphetamine mixed salts (Adderall) – PA dextroamphetamine ext-release (Dexedrine Spansules) ADDERALL XR – amphetamine/dextroamphetamine mixed salts ext-release CONCERTA – methylphenidate ext-release RITALIN LA – methylphenidate ext-release

1 1 (3) 1 (3) 1 (3) 1 (3) 2 2 2

MULTIPLE SCLEROSIS $$$$$ $$$$$ $$$$$

AVONEX – interferon beta-1A – DL BETASERON – interferon beta-1B – DL COPAXONE – glatiramer – DL

3 3 3

OTHER CENTRAL NERVOUS SYSTEM DRUGS $$$ $$$ $$$ $$$$$ $$$$$ $$$$$

ANTABUSE – disulfiram bupropion ext-release (Zyban) ORAP – pimozide ARICEPT – donepezil EXELON – rivastigmine NAMENDA – memantine

2 1 (3) 2 3 3 3

PAIN RELIEF DRUGS NON-NARCOTIC DRUGS $ $ $ $

butalbital/acetaminophen tabs, 50/325 (Phrenilin) butalbital/acetaminophen tabs, 50/650 (Sedapap) butalbital/acetaminophen/caffeine caps, 50/325/40 (Esgic) butalbital/acetaminophen/caffeine tabs, 50/325/40 (Fioricet)

1 (3) 1 (3) 1 (3) 1 (3)

Blue Cross and Blue Shield of Oklahoma 2007 Drug list b y therapeuti c cl a s s – 16 of 22

Tier $ $ $$ $$$

butalbital/aspirin/caffeine tabs, 50/325/40 salsalate butalbital/aspirin/caffeine caps, 50/325/40 (Fiorinal) butalbital/acetaminophen/caffeine tabs, 50/500/40 (Esgic Plus)

1 1 1 (3) 1 (3)

NARCOTIC DRUGS $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $$ $$ $$ $$ $$ $$ $$ $$$ $$$ $$$ $$$$$ $$$$$ $$$$$ $$$$$

codeine/acetaminophen (Tylenol w/Codeine) codeine/aspirin CODEINE PHOSPHATE CODEINE SULFATE 15 mg codeine sulfate 30 mg, 60 mg hydrocodone/acetaminophen caps, 5/500 (Bancap HC) hydrocodone/acetaminophen tabs, 2.5/500, 5/500, 7.5/500, 10/500 (Lortab) hydrocodone/acetaminophen tabs, 5/500, 7.5/750, 10/660 (Vicodin, Vicodin ES, Vicodin HP) hydrocodone/acetaminophen tabs, 7.5/650, 10/650 (Lorcet, Lorcet Plus) hydromorphone tabs (Dilaudid) methadone conc, tabs morphine sulfate supp (RMS) oxycodone caps (OxyIR) oxycodone/acetaminophen caps, 5/500 (Tylox) oxycodone/acetaminophen tabs, 5/325, 7.5/325, 7.5/500, 10/325, 10/650 (Percocet) propoxyphene hcl (Darvon) propoxyphene hcl/acetaminophen tabs, 65/650 propoxyphene napsylate/acetaminophen 50/325, 100/650 (Darvocet-N) tramadol (Ultram) butalbital/aspirin/caffeine/codeine caps (Fiorinal w/Codeine) DILAUDID soln – hydromorphone hydrocodone/acetaminophen soln, 7.5/500 per 15 mL (Lortab) hydrocodone/acetaminophen tabs, 5/325, 7.5/325, 10/325 (Norco) hydrocodone/acetaminophen tabs, 10/750 (Maxidone) morphine sulfate soln, 20 mg/mL; tabs oxycodone conc, soln, tabs (Roxicodone) pentazocine/naloxone (Talwin NX) hydromorphone supp (Dilaudid) morphine sulfate ext-release (MS Contin) oxycodone/aspirin tabs, 5/325 (Percodan) fentanyl patches (Duragesic) – DL oxycodone ext-release (OxyContin) – DL, PA SUBOXONE – buprenorphine/naloxone SUBUTEX – buprenorphine

1 (3) 1 2 2 1 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 1 (3) 1 (3) 1 (3) 2 1 (3) 1 (3) 1 (3) 1 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 2 2

RHEUMATOID AND OSTEOARTHRITIS $ $ $ $ $ $ $ $ $$ $$ $$$ $$$ $$$$$ $$$$$ $$$$$

etodolac ibuprofen (Motrin) ketoprofen meloxicam (Mobic) naproxen (Naprosyn) naproxen sodium (Anaprox) piroxicam (Feldene) sulindac diclofenac sodium delayed-release (Voltaren) indomethacin diclofenac sodium ext-release (Voltaren XR) nabumetone ENBREL – etanercept – PA leflunomide (Arava) RIDAURA – auranofin

1 1 (3) 1 1 (3) 1 (3) 1 (3) 1 (3) 1 1 (3) 1 1 (3) 1 3 1 (3) 3

MIGRAINE HEADACHES $ $$$$

acetaminophen/isometheptene/dichloralphenazone (Midrin) DEPAKOTE ER – divalproex ext-release

1 (3) 2

Blue Cross and Blue Shield of Oklahoma 2007 Drug list b y therapeuti c cl a s s – 17 of 22

Tier $$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$

MIGRANAL – dihydroergotamine AXERT – almotriptan – DL IMITREX inj – sumatriptan – DL IMITREX nasal – sumatriptan – DL IMITREX tabs – sumatriptan – DL ZOMIG nasal – zolmitriptan – DL ZOMIG tabs – zolmitriptan – DL ZOMIG ZMT – zolmitriptan – DL

2 3 3 2 2 2 2 2

allopurinol colchicine probenecid probenecid/colchicine

1 1 1 1

GOUT $ $ $$ $$$

NEUROMUSCULAR DRUGS SEIZURES $ $ $$ $$ $$ $$$ $$$ $$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$

carbamazepine (Tegretol) clonazepam (Klonopin) PHENYTEK – phenytoin sodium extended phenytoin sodium extended (Dilantin) phenytoin susp (Dilantin) DILANTIN 30 mg – phenytoin sodium extended DILANTIN INFATABS; susp – phenytoin primidone (Mysoline) CELONTIN – methsuximide ethosuximide (Zarontin) gabapentin caps, tabs (Neurontin) NEURONTIN soln – gabapentin TEGRETOL XR – carbamazepine ext-release valproic acid (Depakene) zonisamide (Zonegran) DEPAKOTE – divalproex delayed-release DIASTAT – diazepam KEPPRA – levetiracetam LAMICTAL chew tabs, 2 mg; tabs – lamotrigine lamotrigine chew tabs (Lamictal) TOPAMAX – topiramate

1 (3) 1 (3) 2 1 (3) 1 (3) 2 2 1 (3) 2 1 (3) 1 (3) 2 2 1 (3) 1 (3) 2 2 2 2 1 (3) 2

PARKINSON'S DISEASE $ $ $$ $$ $$ $$$ $$$$ $$$$ $$$$ $$$$$ $$$$$ $$$$$ $$$$$

benztropine trihexyphenidyl amantadine selegiline caps (Eldepryl) selegiline tabs carbidopa/levodopa (Sinemet) bromocriptine (Parlodel) carbidopa/levodopa ext-release (Sinemet CR) PARCOPA – carbidopa/levodopa COMTAN – entacapone MIRAPEX – pramipexole pergolide (Permax) REQUIP – ropinirole

1 1 1 1 (3) 1 1 (3) 1 (3) 1 (3) 2 2 2 1 (3) 2

MUSCLE RELAXANTS $ $$ $$ $$ $$ $$ $$$$

cyclobenzaprine (Flexeril) baclofen methocarbamol (Robaxin) orphenadrine citrate ext-release orphenadrine/aspirin/caffeine tizanidine (Zanaflex) dantrolene (Dantrium)

1 (3) 1 1 (3) 1 1 1 (3) 1 (3)

Blue Cross and Blue Shield of Oklahoma 2007 Drug list b y therapeuti c cl a s s – 18 of 22

Tier

OTHER NEUROMUSCULAR DRUGS $$ $$$$ $$$$ $$$$$

MESTINON TIMESPAN – pyridostigmine ext-release MESTINON syrup – pyridostigmine pyridostigmine tabs (Mestinon) RILUTEK – riluzole

2 2 1 (3) 2

SUPPLEMENTS VITAMINS $ $$ $$$

MEPHYTON – phytonadione ergocalciferol (Drisdol) calcitriol (Rocaltrol)

2 1 (3) 1 (3)

MULTIVITAMINS $ $ $ $ $

pediatric multivitamins/fluoride (Poly-Vi-Flor) pediatric multivitamins/fluoride/iron (Poly-Vi-Flor + iron) pediatric vitamins ADC/fluoride pediatric vitamins ADC/fluoride/iron prenatal multivitamins/folic acid 1 mg

1 (3) 1 (3) 1 1 1

MINERALS AND ELECTROLYTES $ $ $ $ $ $ $ $ $ $$

potassium bicarbonate/chloride effervescent tabs, 25 mEq (K-Lyte/Cl) potassium chloride ext-release caps, 10 mEq (Micro-K 10) potassium chloride ext-release tabs, 8 mEq potassium chloride ext-release tabs, 10 mEq (K-Tabs) potassium chloride ext-release tabs, 10 mEq, 20 mEq (K-Dur) potassium chloride packets, 20 mEq (K-Lor) potassium chloride soln, 10%, 20% potassium phosphate/sodium phosphates (K-Phos Neutral) sodium fluoride K-PHOS – potassium phosphate monobasic

1 (3) 1 (3) 1 1 (3) 1 (3) 1 (3) 1 1 (3) 1 2

BLOOD MODIFYING DRUGS $ $ $ $$$ $$$ $$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$

folic acid tabs, 1 mg pentoxifylline ext-release (Trental) warfarin (Coumadin) anagrelide (Agrylin) cilostazol (Pletal) PLAVIX – clopidogrel EPOGEN – epoetin alfa – PA LEUKINE – sargramostim – PA LOVENOX – enoxaparin – DL NEUMEGA – oprelvekin – PA NEUPOGEN – filgrastim – PA PROCRIT – epoetin alfa – PA

1 1 (3) 1 (3) 1 (3) 1 (3) 2 3 3 3 3 3 3

TOPICAL PRODUCTS EYE • Anti-infectives $ $ $ $ $ $ $ $ $ $ $$ $$$ $$$

bacitracin/polymyxin B oint (Polysporin) ciprofloxacin soln (Ciloxan) erythromycin oint gentamicin oint, soln neomycin/polymyxin B/bacitracin oint neomycin/polymyxin B/gramicidin soln (Neosporin) polymyxin B/trimethoprim soln (Polytrim) SULFACETAMIDE SODIUM oint sulfacetamide sodium soln (Bleph-10) tobramycin soln (Tobrex) ofloxacin soln (Ocuflox) CILOXAN oint – ciprofloxacin trifluridine soln (Viroptic)

1 (3) 1 (3) 1 1 1 1 (3) 1 (3) 2 1 (3) 1 (3) 1 (3) 2 1 (3)

Blue Cross and Blue Shield of Oklahoma 2007 Drug list b y therapeuti c cl a s s – 19 of 22

Tier $$$

VIGAMOX – moxifloxacin

2

• Steroid and Combination Products $ $ $ $ $ $ $ $$ $$$ $$$ $$$ $$$ $$$

dexamethasone sodium phosphate soln fluorometholone susp (FML) neomycin/polymyxin B/bacitracin/hydrocortisone oint neomycin/polymyxin B/dexamethasone oint, susp (Maxitrol) prednisolone acetate susp (Pred Forte) prednisolone sodium phosphate soln, 1% sulfacetamide sodium/prednisolone soln LOTEMAX – loteprednol ALREX – loteprednol BLEPHAMIDE – sulfacetamide/prednisolone BLEPHAMIDE S.O.P. – sulfacetamide/prednisolone TOBRADEX – tobramycin/dexamethasone ZYLET – loteprednol/tobramycin

1 1 (3) 1 1 (3) 1 (3) 1 1 2 2 2 2 2 2

• Glaucoma $ $ $ $ $ $ $$ $$ $$ $$ $$$ $$$ $$$ $$$ $$$ $$$

carteolol soln levobunolol soln (Betagan) metipranolol soln (Optipranolol) pilocarpine soln (Isopto Carpine) timolol maleate gel-forming soln (Timoptic-XE) timolol maleate soln (Timoptic) AZOPT – brinzolamide BETAXOLOL soln, 0.5% carbachol soln (Isopto Carbachol) TRUSOPT – dorzolamide ALPHAGAN P – brimonidine BETOPTIC-S – betaxolol brimonidine soln, 0.2% COSOPT – dorzolamide/timolol TRAVATAN – travoprost, NF = TRAVATAN Z XALATAN – latanoprost

1 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 2 2 1 (3) 2 2 2 1 2 2 2

• Other Eye Products $ $ $ $ $$ $$$ $$$ $$$ $$$ $$$ $$$ $$$ $$$ $$$

atropine sulfate oint, soln (Isopto Atropine) cyclopentolate soln (Cyclogyl) flurbiprofen soln (Ocufen) homatropine soln (Isopto Homatropine) cromolyn sodium soln (Crolom) ACULAR – ketorolac ACULAR LS – ketorolac ACULAR PF – ketorolac CYCLOGYL – cyclopentolate ketotifen soln (Zaditor) LACRISERT – hydroxypropyl cellulose insert OPTIVAR – azelastine PATANOL – olopatadine VOLTAREN – diclofenac

1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 2 2 2 3 1 (3) 3 2 2 2

benzocaine/antipyrine hydrocortisone/acetic acid neomycin/polymyxin B/hydrocortisone (Cortisporin) acetic acid FLOXIN OTIC – ofloxacin CIPRODEX – ciprofloxacin/dexamethasone CIPRO HC – ciprofloxacin/hydrocortisone

1 1 1 (3) 1 2 2 2

EAR $ $ $ $$$ $$$ $$$$ $$$$

MOUTH AND THROAT (local) $ $ $

lidocaine viscous (Xylocaine) sodium fluoride dental crm, gel (Prevident) triamcinolone paste

1 (3) 1 (3) 1

Blue Cross and Blue Shield of Oklahoma 2007 Drug list b y therapeuti c cl a s s – 20 of 22

Tier $$$ $$$ $$$$$ $$$$$

chlorhexidine oral rinse (Peridex) nystatin susp EVOXAC – cevimeline pilocarpine tabs (Salagen)

1 (3) 1 2 1 (3)

ANORECTAL AGENTS $ $ $$$$ $$$$$

hydrocortisone acetate supp, 25 mg (Anusol-HC) hydrocortisone crm, 2.5% (Anusol-HC) CORTIFOAM – hydrocortisone acetate hydrocortisone enema

1 (3) 1 (3) 2 1

SKIN CONDITIONS/PRODUCTS • Acne $ $ $ $$$ $$$ $$$ $$$ $$$ $$$ $$$$ $$$$ $$$$ $$$$ $$$$$

clindamycin (Cleocin T) erythromycin (Erygel) erythromycin pads, soln, 2% metronidazole 0.75% (Metrocream) metronidazole gel, 0.75% metronidazole (Metrolotion) sulfacetamide sodium/sulfur crm, emulsion, susp (Plexion) sulfacetamide sodium/sulfur lotn (Sulfacet-R) tretinoin (Retin-A) DIFFERIN – adapalene erythromycin/benzoyl peroxide (Benzamycin) FINACEA – azelaic acid TAZORAC – tazarotene isotretinoin caps (Accutane)

1 (3) 1 (3) 1 1 (3) 1 1 (3) 1 (3) 1 (3) 1 (3) 2 1 (3) 2 2 1 (3)

• Anti-infectives $ $ $ $ $ $$ $$ $$$ $$$ $$$ $$$ $$$ $$$$ $$$$ $$$$$

econazole gentamicin nystatin (Mycostatin) nystatin/triamcinolone silver sulfadiazine (Silvadene) ketoconazole crm ketoconazole shampoo, 2% (Nizoral) ciclopirox crm, lotn (Loprox) LOPROX gel – ciclopirox LOPROX shampoo – ciclopirox mupirocin oint (Bactroban) OXISTAT – oxiconazole nitrate podofilox soln (Condylox) ZOVIRAX – acyclovir CONDYLOX – podofilox

1 1 1 1 1 (3) 1 1 (3) 1 (3) 2 2 1 (3) 3 1 (3) 3 3

• Corticosteroids $ $ $ $ $ $ $ $ $ $ $ $$ $$ $$ $$ $$$

betamethasone dipropionate betamethasone valerate clobetasol (Temovate) desonide (Desowen) desoximetasone (Topicort) fluocinolone (Synalar) fluocinonide (Lidex) hydrocortisone 2.5% (Hytone) hydrocortisone valerate (Westcort) triamcinolone (Kenalog) TRIAMCINOLONE oint, 0.05% betamethasone dipropionate, augmented crm, gel, oint (Diprolene) DESOXIMETASONE crm, 0.05% diflorasone mometasone (Elocon) hydrocortisone acetate 2.5%/pramoxine 1% crm (Pramosone)

1 1 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 1 (3) 2 1 (3) 2 1 1 (3) 1 (3)

Blue Cross and Blue Shield of Oklahoma 2007 Drug list b y therapeuti c cl a s s – 21 of 22

Tier

• Other Skin Products $ $ $ $ $ $$ $$$ $$$ $$$ $$$ $$$$ $$$$ $$$$ $$$$ $$$$ $$$$$ $$$$$ $$$$$ $$$$$

aluminum chloride soln (Drysol) lidocaine crm, 3%; lotn, 3% (LidaMantle) lidocaine jelly, 2%; oint, 5%; soln, 4% (Xylocaine) selenium sulfide 2.5% (Selsun) XERAC-AC – aluminum chloride permethrin crm, 5% (Elimite) doxepin crm (Zonalon) ELIDEL – pimecrolimus fluorouracil soln, 2%, 5% (Efudex) lidocaine/prilocaine crm (Emla) CARAC – fluorouracil DOVONEX – calcipotriene FLUOROPLEX – fluorouracil LINDANE PROTOPIC – tacrolimus ALDARA – imiquimod REGRANEX – becaplermin SOLARAZE – diclofenac sodium SORIATANE – acitretin caps

1 (3) 1 (3) 1 (3) 1 (3) 2 1 (3) 1 (3) 2 1 (3) 1 (3) 2 2 2 2 2 2 2 2 2

MISCELLANEOUS CATEGORIES DIABETIC SUPPLIES – Blood Glucose Test Strips FREESTYLE ONE TOUCH FASTTAKE ONE TOUCH II/BASIC/PROFILE ONE TOUCH SURESTEP ONE TOUCH ULTRA

2 2 2 2 2

MEDICAL DEVICES ASCENCIA LANCETS BD INSULIN SYRINGES BD LANCETS LIFESCAN LANCETS PRECISION QID PRECISION XTRA

2 2 2 2 2 2

MISCELLANEOUS DRUGS $$$ $$$ $$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$ $$$$$

azathioprine (Imuran) sodium polystyrene sulfonate CUPRIMINE – penicillamine CELLCEPT – mycophenolate mofetil CHEMET – succimer cyclosporine (Sandimmune) cyclosporine modified caps, 25 mg, 100 mg; soln (Neoral) MYFORTIC – mycophenolate PROGRAF – tacrolimus RAPAMUNE – sirolimus

1 (3) 1 2 2 2 1 (3) 1 (3) 2 2 2

Blue Cross and Blue Shield of Oklahoma 2007 Drug list b y therapeuti c cl a s s – 22 of 22