Blue Cross and Blue Shield of Oklahoma Drug Formulary

October 2013 Blue Cross and Blue Shield of Oklahoma Drug Formulary Contents Introduction...............................................................
Author: Betty Griffin
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October 2013

Blue Cross and Blue Shield of Oklahoma Drug Formulary

Contents Introduction................................................................. I How formulary drugs are selected ............................. I How member payment is determined ........................ I How to use this list .................................................... II Drugs used to treat multiple conditions ................... III Generic drugs .......................................................... III Consider talking to your doctor about generic drugs ....................................................... III Coverage considerations ........................................ IV Prior Authorization (PA) .......................................... IV Step Therapy (ST) .................................................. IV Specialty drugs ....................................................... IV Prime Therapeutics Specialty Pharmacy Program ............................................................... V Key ........................................................................... V

Preferred Medication List ......................................... 1 Anti-Infective Drugs .................................................. 1 Cancer Drugs............................................................ 3 Hormones, Diabetes and Related Drugs ................. 3 Heart and Circulatory Drugs ..................................... 5 Respiratory Agents ................................................... 7 Gastrointestinal Drugs .............................................. 8 Genitourinary Drugs ................................................. 9 Central Nervous System Drugs ................................ 9 Pain Relief Drugs.................................................... 11 Neuromuscular Drugs............................................. 12 Supplements ........................................................... 13 Blood Modifying Drugs ........................................... 13 Topical Drugs.......................................................... 13 Miscellaneous Categories ...................................... 16 Index ......................................................................... 17

Please consider talking to your doctor about prescribing formulary 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 drug formulary is regularly updated. Please visit bcbsok.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.

2920-A OK © Prime Therapeutics LLC 10/13

Introduction Blue Cross and Blue Shield of Oklahoma is pleased to present the 2013 Drug Formulary. This is a list of formulary drugs which includes Formulary 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. Drug Formulary 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 bcbsok.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 bcbsok.com.

How formulary 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, Formulary Brand or Non-Formulary 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 bcbsok.com and log in to Blue Access for MembersSM 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. Prescription products that have over-the-counter (OTC) equivalents may not be covered. Some drugs may only be available through your medical benefit (example: Testopel).

I

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

How to use this list This list is organized into broad therapeutic categories. For example, Hormones, Diabetes and Related Drugs is a broad category. Within most categories, drugs are sub-grouped based upon drug class, for example under Hormones, Diabetes and Related Drugs you will find Estrogens. All drugs listed, whether generic or brand, are formulary drugs.

T

The first column of the chart lists the drug name. Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). The reference brand drug is a non-formulary (NF) brand and is only included as a reference to the brand. Some generic products have no reference brand. Example: budesonide ext-release (Entocort EC  –  brand is NF) Preferred brand drugs are listed in all CAPITAL letters. Example: DIASTAT The following examples are given to assist you and your doctor in reading listings that include specific strengths and dosage forms. These examples can be applied to other drugs on the formulary. Any exceptions are noted and some listings contain additional information about specific products or dosage forms. •

Extended-release and delayed-release products require their own entry. Example: DETROL LA The long-acting product Detrol LA is on the preferred drug list, but requires a separate entry from the non ext-release product Detrol.



Some products may show a strength, if so only that strength indicated is on the formulary. Example: XIFAXAN 550 mg The Xifaxan 550 mg is on preferred drug list in this case, but the Xifaxan 200 mg is not because it is not listed.

The second column indicates if the drug is a specialty drug. Note: Additional information about specialty drugs can be found in this document under the header for Specialty Drugs.

T

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 Oklahoma October 2013 Drug Formulary

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.

III

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

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. 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 formulary 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 noted 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 formulary 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 bcbsok.com and log in to Blue Access for MembersSM. 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.

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

IV

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

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 Oklahoma is a Division of Health Care Service 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 chew tabs ..........................................chewable tablets conc ........................................................... concentrate crm ......................................................................cream DL ....................................................... dispensing limits ext-release ........................................extended-release inhal .............................................................. inhalation inj..................................................................... injection lotn ....................................................................... lotion NF ........................................................... non-formulary ODT ....................................orally disintegrating tablets

V

oint .................................................................. ointment ophth........................................................... ophthalmic OSM .................................................... osmotic-release PA.....................................................prior authorization SL ................................................................. sublingual soln .................................................................. solution supp ........................................................ suppositories susp ........................................................... suspension ST ..............................................................step therapy tabs .................................................................... tablets

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

ANTI-INFECTIVE DRUGS amoxicillin/potassium clavulanate (Augmentin – brand is NF)

minocycline (Dynacin, Minocin – brands are NF)

amoxicillin/potassium clavulanate ext-release (Augmentin XR – brand is NF)

ciprofloxacin (Cipro – brand is NF)

Step Therapy

FLUOROQUINOLONES



ciprofloxacin ext-release levofloxacin (Levaquin – brand is NF)

amoxicillin, NF = chew tabs

ofloxacin tabs

ampicillin caps

AMINOGLYCOSIDES

dicloxacillin

neomycin sulfate

penicillin v potassium

paromomycin

CEPHALOSPORINS

TUBERCULOSIS

cefaclor caps

ethambutol (Myambutol – brand is NF)

cefadroxil

isoniazid tabs

cefdinir cefpodoxime

isoniazid/rifampin (Rifamate – brand is NF)

cefprozil

MYCOBUTIN

ceftriaxone (Rocephin – brand is NF)

PRIFTIN

cefuroxime (Ceftin – brand is NF)

pyrazinamide

cephalexin, NF = tabs (Keflex – brand is NF)

rifampin (Rifadin – brand is NF) FUNGAL INFECTIONS

SUPRAX tabs

fluconazole (Diflucan – brand is NF)

MACROLIDES

flucytosine (Ancobon – brand is NF)

azithromycin susp (Zithromax – brand is NF)



griseofulvin microsize (Grifulvin V – brand is NF) itraconazole (Sporanox – brand is NF) ketoconazole tabs

clarithromycin (Biaxin – brand is NF) clarithromycin ext-release (Biaxin XL – brand is NF)

Dispensing Limits

doxycycline monohydrate (Adoxa, Monodox - brands are NF)

PENICILLINS

azithromycin tabs (Zithromax – brand is NF)

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013



NOXAFIL



nystatin oral

erythromycin delayed-release caps

terbinafine (Lamisil – brand is NF)

ZITHROMAX packets

VFEND susp

TETRACYCLINES

voriconazole (Vfend – brand is NF)

demeclocycline

VIRAL INFECTIONS

doxycycline hyclate (Vibramycin – brand is NF)

Cytomegalovirus

• •

VALCYTE

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

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Hepatitis

SUSTIVA

BARACLUDE

TRIZIVIR

HEPSERA

TRUVADA

ribavirin (Copegus, Rebetol – brands are NF)



VIDEX VIRACEPT

Herpes

VIRAMUNE susp

acyclovir (Zovirax – brand is NF)

VIRAMUNE XR

famciclovir (Famvir – brand is NF)

VIREAD

valacyclovir (Valtrex – brand is NF)

ZIAGEN soln

HIV/AIDS abacavir tabs (Ziagen – brand is NF) APTIVUS ATRIPLA CRIXIVAN didanosine delayed-release (Videx EC – brand is NF) EMTRIVA EPIVIR soln EPZICOM INTELENCE INVIRASE ISENTRESS KALETRA lamivudine (Epivir tabs – brand is NF) lamivudine/zidovudine (Combivir – brand is NF) LEXIVA nevirapine tabs (Viramune – brand is NF) NORVIR PREZISTA RESCRIPTOR REYATAZ SELZENTRY stavudine (Zerit – brand is NF) STRIBILD

2

• • • • •

zidovudine (Retrovir – brand is NF)

• • • • • • • • • •

MALARIA atovaquone/proguanil 250-100 mg (Malarone – brand is NF) chloroquine phosphate (Aralen – brand is NF) DARAPRIM

• • • • • • • • •

hydroxychloroquine (Plaquenil – brand is NF) MALARONE 62.5-25 mg mefloquine PRIMAQUINE WORM INFECTIONS ALBENZA BILTRICIDE STROMECTOL OTHER ANTI-INFECTIVES

• •

clindamycin (Cleocin, Cleocin Pediatric – brands are NF) DAPSONE

• • • • • • •

erythromycin/sulfisoxazole metronidazole tabs (Flagyl – brand is NF) sulfamethoxazole/ trimethoprim (Bactrim – brand is NF) trimethoprim vancomycin (Vancocin – brand is NF)

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

• •

XIFAXAN 550 mg ZYVOX

DEXAMETHASONE soln, 0.5 mg/5 mL

ALKERAN tabs

fludrocortisone

anastrozole (Arimidex – brand is NF)

hydrocortisone (Cortef – brand is NF)

bicalutamide (Casodex – brand is NF)

methylprednisolone (Medrol – brand is NF) prednisolone sodium soln (Orapred – brand is NF)

exemestane (Aromasin – brand is NF) FARESTON

PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg

flutamide

prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg

hydroxyurea (Hydrea – brand is NF) letrozole (Femara – brand is NF) LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg

PREDNISONE INTENSOL

leucovorin calcium tabs, 5 mg, 25 mg

ANDRODERM

LEUKERAN

ANDROXY

megestrol (Megace – brand is NF)

danazol

mercaptopurine (Purinethol – brand is NF)

testosterone cypionate (DepoTestosterone – brand is NF)

MESNEX tabs methotrexate

testosterone enanthate (Delatestryl – brand is NF)

MYLERAN

ESTROGENS

NILANDRON

COMBIPATCH

TABLOID

DIVIGEL

tamoxifen

ENJUVIA

tretinoin caps

MALE HORMONES ANDROGEL

• • • •

estradiol patches (Climara – brand is NF)

TREXALL

estradiol tabs (Estrace – brand is NF)

HORMONES, DIABETES AND RELATED DRUGS

estradiol/norethindrone acetate (Activella – brand is NF)

CORTICOSTEROIDS budesonide ext-release (Entocort EC – brand is NF) CORTISONE

Step Therapy

prednisolone (Prelone – brand is NF)

EMCYT

temozolomide (Temodar – brand is NF)

Dispensing Limits

dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg, 4 mg, 6 mg

CANCER DRUGS

CYCLOPHOSPHAMIDE tabs

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

• • • • • • • • • •



estropipate, NF = 3 mg VIVELLE-DOT



PROGESTINS

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

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medroxyprogesterone acetate (Provera – brand is NF)

KOMBIGLYZE XR

norethindrone acetate (Aygestin – brand is NF)

metformin ext-release (Glucophage XR – brand is NF)

progesterone micronized (Prometrium – brand is NF)

metformin ext-release OSM (Fortamet – brand is NF)

• •

ELLA levonorgestrel (Plan B, Plan B OneStep – brands are NF)

ONGLYZA

• •

ORTHO EVRA

VICTOZA DIABETES - INSULINS



• •

HUMALOG NOVOLOG

DIABETES

Short-Acting Insulins

acarbose (Precose – brand is NF)

HUMULIN R

glimepiride (Amaryl – brand is NF)

NOVOLIN R

glipizide (Glucotrol – brand is NF)

Intermediate-Acting Insulins

glipizide ext-release (Glucotrol XL – brand is NF)

HUMALOG MIX 50/50, 75/25

glipizide/metformin (Metaglip – brand is NF)

HUMULIN 70/30

GLUCAGON EMERGENCY KIT

NOVOLIN 70/30

glyburide

NOVOLOG MIX 70/30

glyburide micronized (Glynase – brand is NF)

Basal Insulins

glyburide/metformin (Glucovance – brand is NF)

LEVEMIR

JUVISYNC

• •

Rapid-Acting Insulins

INFERTILITY

JANUVIA

HUMULIN N NOVOLIN N

LANTUS

• • • •

• • • • • • • • • • • •

THYROID REGULATION levothyroxine (Synthroid – brand is NF) liothyronine (Cytomel – brand is NF) methimazole (Tapazole – brand is NF) propylthiouracil

4

Step Therapy

pioglitazone (Actos – brand is NF)

repaglinide (Prandin)

oral contraceptives – all generics

JANUMET XR



PRANDIN

NUVARING

JANUMET

Dispensing Limits

nateglinide (Starlix – brand is NF)

pioglitazone/metformin (Actoplus Met – brand is NF)

medroxyprogesterone acetate inj, 150 mg/mL (Depo-Provera – brand is NF)

clomiphene (Clomid – brand is NF)



metformin (Glucophage – brand is NF)

BIRTH CONTROL

chorionic gonadotropin

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

OTHER HORMONES AND RELATED DRUGS

• •

ACTONEL alendronate 5 mg, 10 mg, 35 mg, 70 mg (Fosamax – brand is NF) calcitonin-salmon (Miacalcin – brand is NF)

quinapril/ hydrochlorothiazide (Accuretic – brand is NF) ramipril (Altace – brand is NF)

desmopressin (DDAVP – brand is NF)

trandolapril (Mavik – brand is NF)

EVISTA



ibandronate (Boniva – brand is NF) levocarnitine (Carnitor – brand is NF)

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS BENICAR

methylergonovine



SENSIPAR

BENICAR HCT irbesartan (Avapro – brand is NF)

ZEMPLAR caps

irbesartan/ hydrochlorothiazide (Avalide – brand is NF)

HEART AND CIRCULATORY DRUGS

losartan (Cozaar – brand is NF)

ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS

losartan/hydrochlorothiazide (Hyzaar – brand is NF)

benazepril (Lotensin – brand is NF)

valsartan/hydrochlorothiazide (Diovan HCT – brand is NF)

STIMATE

benazepril/ hydrochlorothiazide (Lotensin HCT – brand is NF)

BETA BLOCKERS AND COMBINATIONS acebutolol (Sectral – brand is NF)

captopril

atenolol (Tenormin – brand is NF)

enalapril (Vasotec – brand is NF)

atenolol/chlorthalidone (Tenoretic – brand is NF)

enalapril/ hydrochlorothiazide (Vaseretic – brand is NF)

bisoprolol (Zebeta – brand is NF)

fosinopril

bisoprolol/hydrochlorothiazide (Ziac – brand is NF)

fosinopril/hydrochlorothiazide

carvedilol (Coreg – brand is NF)

lisinopril (Prinivil, Zestril – brands are NF)

INNOPRAN XL

lisinopril/ hydrochlorothiazide (Zestoretic – brand is NF)

metoprolol succinate extrelease (Toprol XL – brand is NF)

moexipril (Univasc – brand is NF)

Step Therapy

perindopril (Aceon – brand is NF) quinapril (Accupril – brand is NF)

octreotide (Sandostatin – brand is NF)

Dispensing Limits

moexipril/ hydrochlorothiazide (Uniretic – brand is NF)

cabergoline

calcitriol (Rocaltrol – brand is NF)

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

labetalol (Trandate – brand is NF)

metoprolol tartrate (Lopressor – brand is NF)

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

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nadolol (Corgard – brand is NF) PROPRANOLOL soln propranolol tabs propranolol ext-release (Inderal LA – brand is NF) TIMOLOL tabs CALCIUM CHANNEL BLOCKERS AND COMBINATIONS

fenofibrate micronized (Lofibra – brand is NF) fenofibric acid delayed-release caps (Trilipix) gemfibrozil (Lopid – brand is NF) lovastatin (Mevacor – brand is NF) NIASPAN

amlodipine/benazepril (Lotrel – brand is NF)

pravastatin (Pravachol – brand is NF)

diltiazem (Cardizem – brand is NF)

TRILIPIX

diltiazem ext-release (Cardizem CD/ LA, Dilacor XR, Tiazac – brands are NF)

WELCHOL

nifedipine ext-release (Adalat CC, Procardia XL – brands are NF) verapamil ext-release (Calan SR, Isoptin SR, Verelan/PM – brands are NF) verapamil, NF = 40 mg (Calan – brand is NF)

simvastatin (Zocor – brand is NF)

FLUID RETENTION acetazolamide 250 mg acetazolamide ext-release (Diamox Sequels – brand is NF) amiloride amiloride/hydrochlorothiazide bumetanide chlorothiazide

CHEST PAIN

furosemide, NF = soln, 8 mg/ mL (Lasix – brand is NF)

isosorbide dinitrate, NF = SL tabs (Isordil – brand is NF)

hydrochlorothiazide caps (Microzide – brand is NF)

isosorbide mononitrate (Monoket – brand is NF)

hydrochlorothiazide tabs

isosorbide mononitrate extrelease (Imdur – brand is NF)

methazolamide (Neptazane – brand is NF)

nitroglycerin (Nitro-Dur – brand is NF)

metolazone (Zaroxolyn – brand is NF)

NITROSTAT

spironolactone (Aldactone – brand is NF)

CHOLESTEROL LOWERING atorvastatin (Lipitor – brand is NF)

indapamide

cholestyramine (Questran, Questran Light – brands are NF)

spironolactone/ hydrochlorothiazide (Aldactazide – brand is NF)

colestipol (Colestid – brand is NF)

torsemide (Demadex – brand is NF)

CRESTOR

6

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

Step Therapy

Dispensing Limits

fenofibrate (Lofibra, Tricor – brands are NF)

amlodipine (Norvasc – brand is NF)

felodipine ext-release

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

triamterene/hydrochlorothiazide (Dyazide, Maxzide, Maxzide-25 – brands are NF)

Step Therapy

RESPIRATORY AGENTS ANTIHISTAMINES cyproheptadine

amiodarone (Cordarone, Pacerone – brands are NF)

promethazine, NF = supp, 50 mg

disopyramide (Norpace – brand is NF)

NASAL PRODUCTS

flecainide (Tambocor – brand is NF)

ASTEPRO

mexiletine

azelastine (Astelin – brand is NF)

MULTAQ

flunisolide

propafenone (Rythmol – brand is NF)

fluticasone propionate (Flonase – brand is NF)

propafenone ext-release (Rythmol SR – brand is NF)

ipratropium (Atrovent – brand is NF)

quinidine gluconate ext-release

NASONEX

quinidine sulfate, NF = ext-release

triamcinolone (Nasacort AQ – brand is NF)

sotalol (Betapace, Betapace AF – brands are NF)

• • • • • • •

COUGH/COLD/ALLERGY

OTHER HEART RELATED DRUGS

acetylcysteine

clonidine (Catapres, Catapres-TTS – brands are NF)

ASTHMA/COPD

DIBENZYLINE

ADVAIR HFA

digoxin tabs (Lanoxin – brand is NF)

albuterol inhal soln, 0.083%, 0.5%

doxazosin (Cardura – brand is NF)

albuterol 0.63 mg/3 mL, 1.25 mg/3 mL (Accuneb – brand is NF)

ADVAIR DISKUS

eplerenone (Inspra – brand is NF) guanfacine (Tenex – brand is NF)

• • • •

albuterol syrup, tabs

hydralazine

ASMANEX

methyldopa

ATROVENT HFA

midodrine

budesonide (Pulmicort Respules – brand is NF)

minoxidil prazosin (Minipress – brand is NF)

• • •

terazosin

COMBIVENT COMBIVENT RESPIMAT cromolyn inhal soln

ERECTILE DYSFUNCTION CIALIS

Dispensing Limits

EPIPEN-JR 2-PAK

HEART RHYTHM

sildenafil (Revatio – brand is NF)

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

• •

DULERA FLOVENT DISKUS

BEE STING KITS

FLOVENT HFA

EPIPEN 2-PAK

FORADIL AEROLIZER

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

• • • • • • • • • • 7

ipratropium inhal soln ipratropium/albuterol (Duoneb – brand is NF)

• •

QVAR SPIRIVA HANDIHALER SYMBICORT

• • • •

terbutaline

EMEND caps granisetron ondansetron (Zofran, Zofran ODT – brands are NF) ondansetron 24 mg



CREON

GASTROINTESTINAL DRUGS

ZENPEP

LAXATIVES

OTHER GASTROINTESTINAL DRUGS

lactulose

ASACOL

PEG – electrolytes for soln (Colyte, Golytely, Nulytely – brands are NF)

ASACOL HD

ULCER/GERD

calcium acetate (Eliphos, Phoslo – brands are NF)

dicyclomine caps, tabs (Bentyl – brand is NF)

CANASA

famotidine (Pepcid – brand is NF)

diphenoxylate/atropine tabs (Lomotil – brand is NF)

hyoscyamine (Anaspaz, Levsin, Levsin/SL – brands are NF)

lactulose

hyoscyamine ext-release (Levbid, Symax DuoTab – brands are NF)

loperamide

LIALDA



methscopolamine (Pamine, Pamine Forte – brands are NF)

8

mesalamine metoclopramide (Reglan – brand is NF) PENTASA RENVELA

misoprostol (Cytotec – brand is NF)

pantoprazole delayedrelease (Protonix – brand is NF)

• • • •

sulfasalazine (Azulfidine – brand is NF) sulfasalazine delayedrelease (Azulfidine EN-Tabs – brand is NF) ursodiol (Actigall, Urso 250, Urso Forte – brands are NF)

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

Step Therapy

Dispensing Limits

DELZICOL

glycopyrrolate (Robinul – brand is NF)

omeprazole delayed-release (Prilosec – brand is NF)



balsalazide (Colazal – brand is NF)

cimetidine

NEXIUM

• • •

DIGESTIVE ENZYMES

zafirlukast (Accolate – brand is NF)

lansoprazole delayedrelease (Prevacid – brand is NF)

Prior Authorization

sucralfate (Carafate – brand is NF)

trimethobenzamide (Tigan – brand is NF)

theophylline ext-release VENTOLIN HFA

ranitidine (Zantac – brand is NF) NAUSEA AND VOMITING

montelukast (Singulair – brand is NF) PROAIR HFA

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

GENITOURINARY DRUGS

tamsulosin (Flomax – brand is NF)

URINARY TRACT INFECTIONS

CENTRAL NERVOUS SYSTEM DRUGS

nitrofurantoin (Furadantin – brand is NF)

ANXIETY

nitrofurantoin macrocrystalline (Macrodantin – brand is NF)

alprazolam ext-release (Xanax XR – brand is NF)

nitrofurantoin monohydrate/ macrocrystalline (Macrobid – brand is NF)

DIAZEPAM oral soln, 1 mg/mL

hydroxyzine pamoate 25 mg, 50 mg (Vistaril – brand is NF)

oxybutynin

lorazepam (Ativan – brand is NF)

oxybutynin ext-release (Ditropan XL – brand is NF) tolterodine (Detrol – brand is NF)

lorazepam conc (Lorazepam Intensol – brand is NF)

VESICARE

DEPRESSION

VAGINAL PRODUCTS

amitriptyline

CLEOCIN supp

bupropion (Wellbutrin – brand is NF)

clindamycin (Cleocin – brand is NF)

bupropion ext-release (Wellbutrin SR, Wellbutrin XL – brands are NF)



citalopram (Celexa – brand is NF) clomipramine (Anafranil – brand is NF) desipramine (Norpramin – brand is NF)

terconazole (Terazol – brand is NF)

doxepin, NF = caps, 75 mg

VAGIFEM

escitalopram (Lexapro – brand is NF)

OTHER GENITOURINARY DRUGS

fluoxetine, NF = 60 mg (Prozac – brand is NF)

alfuzosin ext-release (Uroxatral – brand is NF)

fluvoxamine

AVODART

imipramine hcl (Tofranil – brand is NF)

CYSTAGON

mirtazapine (Remeron, Remeron SolTab – brands are NF)

finasteride (Proscar – brand is NF) POTASSIUM CITRATE

nortriptyline caps (Pamelor – brand is NF)

potassium citrate/citric acid powder (Polycitra-K – brand is NF)

paroxetine hcl (Paxil – brand is NF)

sodium citrate/citric acid (Shohl's – brand is NF)

Step Therapy

diazepam tabs (Valium – brand is NF)

DETROL LA

metronidazole (MetroGel-Vaginal – brand is NF)



buspirone

hydroxyzine hcl

ESTRACE crm

Dispensing Limits

alprazolam (Xanax – brand is NF)

URINARY TRACT SPASMS

CRINONE

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

paroxetine hcl ext-release (Paxil CR – brand is NF) phenelzine (Nardil – brand is NF)

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

9

sertraline (Zoloft – brand is NF)

zaleplon (Sonata – brand is NF)

tranylcypromine (Parnate – brand is NF)

zolpidem (Ambien – brand is NF)

• • •

trazodone

zolpidem ext-release (Ambien CR – brand is NF)

venlafaxine

HYPERACTIVITY/NARCOLEPSY

venlafaxine ext-release caps (Effexor XR – brand is NF)

amphetamine/ dextroamphetamine (Adderall – brand is NF)



amphetamine/dextroamphetamine ext-release (Adderall XR – brand is NF)



venlafaxine ext-release tabs, NF = 225 mg PSYCHOTIC AND BIPOLAR DISORDERS chlorpromazine clozapine (Clozaril – brand is NF) FLUPHENAZINE HCL conc, elixir



caffeine citrate (Cafcit – brand is NF)

haloperidol tabs

dextroamphetamine extrelease (Dexedrine Spansule – brand is NF)

haloperidol lactate oral conc

INTUNIV

lithium carbonate

methylphenidate tabs (Ritalin – brand is NF)

fluphenazine hcl tabs

lithium carbonate ext-release 300 mg (Lithobid – brand is NF) lithium carbonate ext-release 450 mg loxapine (Loxitane – brand is NF) olanzapine (Zyprexa, Zyprexa Zydis – brands are NF)

• •

dextroamphetamine

• • •

methylphenidate ext-release caps; tabs, 20 mg (Metadate CD, Ritalin LA, Ritalin SR - brands are NF) modafinil (Provigil – brand is NF)



VYVANSE

perphenazine

OTHER CENTRAL NERVOUS SYSTEM DRUGS

prochlorperazine

bupropion ext-release (Zyban – brand is NF)

quetiapine (Seroquel – brand is NF) risperidone (Risperdal, Risperdal MTab – brands are NF) SEROQUEL XR

CHANTIX (Member benefits determine coverage) disulfiram (Antabuse – brand is NF)

thiothixene

donepezil (Aricept, Aricept ODT – brands are NF)

trifluoperazine

EXELON patches, soln

ziprasidone (Geodon – brand is NF)

galantamine (Razadyne – brand is NF)

SLEEP AIDS

galantamine ext-release (Razadyne ER – brand is NF)

estazolam phenobarbital, NF = tabs, 64.8 mg, 97.2 mg



naltrexone (ReVia – brand is NF)



NICOTROL INHALER

temazepam (Restoril – brand is NF)

10

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

NICOTROL NS

morphine sulfate conc, soln

NUEDEXTA

morphine sulfate ext-release (Kadian)

ORAP rivastigmine (Exelon – brand is NF)

morphine sulfate ext-release (MS Contin – brand is NF)

PAIN RELIEF DRUGS

MORPHINE SULFATE supp, tabs

NON-NARCOTIC DRUGS

NUCYNTA ER

butalbital/acetaminophen

oxycodone (Roxicodone – brand is NF)

butalbital/acetaminophen/caffeine (Esgic, Esgic-Plus, Fioricet – brands are NF)

oxycodone caps

butalbital/aspirin/caffeine caps (Fiorinal – brand is NF)

oxycodone/aspirin (Percodan – brand is NF)

salsalate

OXYCONTIN

NARCOTIC DRUGS

SUBOXONE SL film

acetaminophen/codeine (Tylenol w/ Codeine – brand is NF)

tramadol (Ultram – brand is NF)

buprenorphine (Subutex – brand is NF) buprenorphine/naloxone SL tabs (Suboxone – brand is NF)

• • • •

• • •

Step Therapy

Dispensing Limits

• •

diclofenac sodium extrelease (Voltaren-XR – brand is NF) etodolac flurbiprofen ibuprofen indomethacin ketoprofen leflunomide (Arava – brand is NF) meloxicam tabs (Mobic – brand is NF)

hydromorphone soln, tabs (Dilaudid – brand is NF)

methadone tabs (Dolophine – brand is NF)

RHEUMATOID AND OSTEOARTHRITIS

diclofenac sodium delayed-release

hydrocodone/ibuprofen (Ibudone, Reprexain, Vicoprofen – brands are NF)

methadone conc, soln

• • • •

diclofenac potassium (Cataflam – brand is NF)

hydrocodone/acetaminophen, NF = tabs, 2.5-325 mg (Lortab – brand is NF)

KADIAN



tramadol/acetaminophen (Ultracet – brand is NF) CELEBREX

CODEINE SULFATE 15 mg fentanyl patches (Duragesic – brand is NF)



oxycodone/acetaminophen (Percocet – brand is NF)

butalbital/aspirin/caffeine/ codeine (Fiorinal w/Codeine – brand is NF) fentanyl lollipop (Actiq – brand is NF)

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

nabumetone



naproxen (Naprosyn – brand is NF) naproxen delayed-release (ECNaprosyn – brand is NF) naproxen sodium (Anaprox – brand is NF)

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

11

oxaprozin (Daypro – brand is NF)

lamotrigine (Lamictal – brand is NF)

piroxicam (Feldene – brand is NF)

levetiracetam (Keppra – brand is NF)

sulindac (Clinoril – brand is NF)

LYRICA caps

MIGRAINE HEADACHES

oxcarbazepine (Trileptal – brand is NF)

acetaminophen/isometheptene/ dichloralphenazone

phenytoin chew tabs (Dilantin Infatabs – brand is NF)

IMITREX nasal spray MIGRANAL naratriptan (Amerge – brand is NF) rizatriptan (Maxalt, Maxalt-MLT – brands are NF) sumatriptan inj, tabs (Imitrex – brand is NF)

• • • •

phenytoin susp (Dilantin – brand is NF) primidone (Mysoline – brand is NF) SABRIL



TEGRETOL-XR 100 mg topiramate (Topamax, Topamax Sprinkle – brands are NF)

allopurinol (Zyloprim – brand is NF)

valproic acid (Depakene – brand is NF)

COLCRYS

zonisamide (Zonegran – brand is NF)

probenecid

PARKINSON'S DISEASE

probenecid/colchicine

amantadine, NF = tabs

NEUROMUSCULAR DRUGS

AZILECT

SEIZURES

benztropine

carbamazepine (Tegretol – brand is NF)

bromocriptine (Parlodel – brand is NF) carbidopa/levodopa (Parcopa, Sinemet – brands are NF)

carbamazepine ext-release (Carbatrol, Tegretol-XR – brands are NF)

carbidopa/levodopa extrelease (Sinemet CR – brand is NF)

CELONTIN

entacapone (Comtan)

clonazepam (Klonopin – brand is NF)



pramipexole (Mirapex – brand is NF) ropinirole (Requip – brand is NF)

DILANTIN 30 mg

selegiline caps (Eldepryl – brand is NF)

divalproex delayed-release (Depakote, Depakote Sprinkles – brands are NF)

selegiline tabs

divalproex ext-release (Depakote ER – brand is NF)

MUSCLE RELAXANTS

ethosuximide (Zarontin – brand is NF) gabapentin (Neurontin – brand is NF)

chlorzoxazone (Parafon Forte DSC – brand is NF)

GABITRIL 12 mg, 16 mg

cyclobenzaprine

12

trihexyphenidyl baclofen

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

Step Therapy

Dispensing Limits

phenytoin sodium ext-release (Dilantin, Phenytek – brands are NF)

GOUT

DIASTAT

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

dantrolene (Dantrium – brand is NF) methocarbamol (Robaxin – brand is NF)



cilostazol (Pletal – brand is NF) clopidogrel (Plavix – brand is NF)

MESTINON syrup

cyanocobalamin inj

MESTINON TIMESPAN

dipyridamole (Persantine – brand is NF) DROXIA

RILUTEK

enoxaparin (Lovenox – brand is NF)

riluzole (Rilutek)

folic acid tabs, 1 mg

SUPPLEMENTS

pentoxifylline ext-release (Trental – brand is NF)

MEPHYTON MULTIVITAMINS pediatric multivitamins pediatric vitamins ADC PRENAPLUS PRENATABS FA PRENATAL LOW IRON, PLUS, PLUS/ IRON, VITAMINS PLUS, 19 SE-NATAL 19



warfarin (Coumadin – brand is NF) XARELTO



TOPICAL DRUGS EYE Anti-infectives BACITRACIN oint bacitracin/polymyxin B oint ciprofloxacin soln (Ciloxan – brand is NF) erythromycin oint

MINERALS AND ELECTROLYTES

gentamicin oint, soln (Garamycin – brand is NF)

K-PHOS

NATACYN

potassium bicarbonate/chloride effervescent tabs, 25 mEq

neomycin/polymyxin B/bacitracin oint

potassium chloride packets; soln, 10%

neomycin/polymyxin B/gramicidin soln (Neosporin – brand is NF)

potassium chloride ext-release (KTabs – brand is NF)

ofloxacin soln (Ocuflox – brand is NF)

potassium chloride ext-release caps (Micro-K – brand is NF)

Step Therapy

anagrelide (Agrylin – brand is NF)

OTHER NEUROMUSCULAR DRUGS

ergocalciferol (Drisdol – brand is NF)

Dispensing Limits

BLOOD MODIFYING DRUGS

orphenadrine/aspirin/caffeine 25-385-30 mg

VITAMINS

Prior Authorization

sodium fluoride chew tabs, soln (Luride – brand is NF)

orphenadrine citrate ext-release

pyridostigmine (Mestinon – brand is NF)

Specialty

Drug Name potassium phosphate/sodium phosphates (K-Phos Neutral – brand is NF)

metaxalone (Skelaxin – brand is NF)

tizanidine (Zanaflex – brand is NF)

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

polymyxin B/trimethoprim soln (Polytrim – brand is NF)

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

13

sulfacetamide sodium soln (Bleph-10 – brand is NF)

latanoprost soln (Xalatan – brand is NF)

tobramycin soln (Tobrex – brand is NF)

levobunolol soln, 0.5% (Betagan – brand is NF)

trifluridine soln (Viroptic – brand is NF)

LUMIGAN

VIGAMOX Steroids and Combination Products

metipranolol soln (Optipranolol – brand is NF)

dexamethasone sodium phosphate soln

pilocarpine soln (Isopto Carpine – brand is NF)

fluorometholone susp (FML Liquifilm – brand is NF)

timolol maleate soln (Timoptic, Timoptic-XE – brands are NF)

LOTEMAX

TRAVATAN Z

neomycin/polymyxin B/bacitracin/ hydrocortisone oint

Other Eye Products

neomycin/polymyxin B/ dexamethasone oint, susp (Maxitrol – brand is NF)

diclofenac soln (Voltaren – brand is NF)

sulfacetamide sodium/prednisolone soln

flurbiprofen soln (Ocufen – brand is NF)

TOBRADEX oint

homatropine soln (Isopto Homatropine – brand is NF)

ZYLET

ketorolac soln (Acular, Acular LS – brands are NF)

Glaucoma

PATADAY

ALPHAGAN P 0.1%

tropicamide soln (Mydriacyl – brand is NF)

brimonidine soln, 0.15% (Alphagan P – brand is NF)

EAR

brimonidine soln, 0.2%

benzocaine/antipyrine soln

carteolol soln

CIPRODEX

dorzolamide soln (Trusopt – brand is NF)

hydrocortisone/acetic acid soln (Vosol HC – brand is NF)

dorzolamide/timolol maleate soln (Cosopt – brand is NF)

neomycin/polymyxin B/ hydrocortisone soln, susp (Cortisporin – brand is NF)

acetic acid soln

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

Step Therapy

Dispensing Limits



cromolyn soln

PREDNISOLONE SODIUM PHOSPHATE soln, 1%

14



azelastine soln (Optivar – brand is NF) cyclopentolate soln (Cyclogyl – brand is NF)

AZOPT



atropine sulfate soln (Isopto Atropine – brand is NF)

prednisolone acetate susp (Pred Forte – brand is NF)

tobramycin/dexamethasone susp (Tobradex – brand is NF)

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

ofloxacin soln

TAZORAC

MOUTH AND THROAT (local)

tretinoin (Retin-A – brand is NF)

cevimeline (Evoxac - brand is NF)

tretinoin microsphere gel, 0.1% (Retin-A Micro – brand is NF)

chlorhexidine oral rinse (Peridex – brand is NF) lidocaine viscous

ciclopirox crm, gel, shampoo, susp (Loprox – brand is NF)

nystatin susp

ciclopirox soln (Penlac – brand is NF)

pilocarpine (Salagen – brand is NF)

econazole

sodium fluoride (Prevident – brand is NF)

ketoconazole (Nizoral – brand is NF)

triamcinolone dental paste

nystatin topical

ANORECTAL AGENTS

silver sulfadiazine (Silvadene – brand is NF) alclometasone (Aclovate – brand is NF)

hydrocortisone acetate crm, supp (Anusol-HC, Protocort – brands are NF)

amcinonide crm betamethasone dipropionate

SKIN CONDITIONS/PRODUCTS

betamethasone dipropionate, augmented (Diprolene – brand is NF)

Acne



clindamycin (Cleocin-T – brand is NF)

betamethasone valerate clobetasol (Clobex, Olux, Temovate – brands are NF)

clindamycin/benzoyl peroxide (Benzaclin, Duac – brands are NF)

erythromycin/benzoyl peroxide (Benzamycin – brand is NF)

Step Therapy

Corticosteroids

hydrocortisone enema (Cortenema – brand is NF)

erythromycin pads, soln

Dispensing Limits

mupirocin (Bactroban – brand is NF)

CORTIFOAM

DIFFERIN gel, 0.3%

• •

Anti-infectives

clotrimazole troche

adapalene (Differin – brand is NF)

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

desonide (Desowen – brand is NF)



desoximetasone crm, 0.25%; gel; oint, 0.25% (Topicort – brand is NF) diflorasone oint

FINACEA

fluocinolone (Derma-Smoothe/FS, Synalar – brands are NF)

isotretinoin, NF = 30 mg

fluocinonide

metronidazole (Metrocream, Metrolotion – brands are NF)

fluticasone propionate (Cutivate – brand is NF)

metronidazole topical gel (Metrogel – brand is NF)

halobetasol (Ultravate – brand is NF)

sulfacetamide sodium/sulfur, NF = susp, 10-5%

hydrocortisone valerate (Westcort – brand is NF)

hydrocortisone topical

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

15

mometasone (Elocon – brand is NF) nystatin/triamcinolone crm

LANCETS – BAYER FINGERSTIX, MICROLET, SINGLE-LET

triamcinolone crm; lotn; oint, 0.025%, 0.1%

LANCETS – BD MICROTAINER ULTRAFINE

Other Skin Products

LANCETS – ROCHE ACCU-CHEK FASTCLIX, MULTICLIX, SOFT TOUCH, SOFTCLIX

acitretin (Soriatane) aluminum chloride (Drysol – brand is NF) calcipotriene crm, soln (Dovonex – brand is NF) CARAC ELIDEL FLUOROPLEX fluorouracil (Efudex – brand is NF) imiquimod (Aldara – brand is NF)





TEST STRIPS – ROCHE ACCU-CHEK ACTIVE, AVIVA, AVIVA PLUS, COMFORT CURVE, COMPACT, SMARTVIEW



TEST STRIPS – ROCHE ACCUTREND



RESPIRATORY INHALER-ASSIST DEVICES BREATHERITE

lidocaine/prilocaine crm (Emla – brand is NF)

azathioprine (Imuran – brand is NF)

MISCELLANEOUS DRUGS

lindane

CELLCEPT oral susp

malathion (Ovide – brand is NF)

CHEMET

permethrin (Elimite – brand is NF)

CUPRIMINE

podofilox (Condylox – brand is NF)

cyclosporine (Sandimmune – brand is NF)

PROTOPIC

cyclosporine modified caps, 25 mg, 100 mg; soln (Neoral – brand is NF)

selenium sulfide (Selsun – brand is NF)

CYCLOSPORINE modified caps, 50 mg

SOLARAZE SORIATANE XERAC AC

mycophenolate mofetil (Cellcept – brand is NF)

ZYCLARA

MYFORTIC

ZYCLARA PUMP

RAPAMUNE

MISCELLANEOUS CATEGORIES

sodium polystyrene sulfonate

DIABETIC SUPPLIES

tacrolimus (Prograf – brand is NF)

INSULIN PEN NEEDLES – BD ULTRAFINE, NOVOFINE, NOVOTWIST



INSULIN SYRINGES – BD



ZORTRESS

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

Step Therapy

Dispensing Limits

TEST STRIPS – BAYER ASCENSIA AUTODISC, BREEZE 2, CONTOUR, CONTOUR NEXT

lidocaine topical, NF = lotn (Xylocaine – brand is NF)

16

Prior Authorization

Drug Name

Specialty

Step Therapy

Dispensing Limits

Prior Authorization

Drug Name

Specialty

2013

2013 INDEX A abacavir tabs...................................................................2 acarbose.......................................................................... 4 acebutolol........................................................................ 5 acetaminophen/codeine............................................... 11 acetaminophen/isometheptene/dichloralphenazone 12 acetazolamide 250 mg................................................... 6 acetazolamide ext-release............................................. 6 acetic acid ear soln...................................................... 14 acetylcysteine................................................................. 7 acitretin.......................................................................... 16 ACTONEL......................................................................... 5 acyclovir.......................................................................... 2 adapalene...................................................................... 15 ADVAIR DISKUS..............................................................7 ADVAIR HFA.................................................................... 7 ALBENZA..........................................................................2 albuterol 0.63 mg/3 mL, 1.25 mg/3 mL......................... 7 albuterol inhal soln, 0.083%, 0.5%................................ 7 albuterol syrup, tabs...................................................... 7 alclometasone............................................................... 15 alendronate 5 mg, 10 mg, 35 mg, 70 mg...................... 5 alfuzosin ext-release...................................................... 9 ALKERAN tabs................................................................. 3 allopurinol......................................................................12 ALPHAGAN P 0.1%....................................................... 14 alprazolam....................................................................... 9 alprazolam ext-release................................................... 9 aluminum chloride........................................................16 amantadine, NF = tabs................................................. 12 amcinonide crm............................................................ 15 amiloride.......................................................................... 6 amiloride/hydrochlorothiazide.......................................6 amiodarone......................................................................7 amitriptyline.....................................................................9 amlodipine....................................................................... 6 amlodipine/benazepril.................................................... 6 amoxicillin, NF = chew tabs.......................................... 1 amoxicillin/potassium clavulanate................................1 amoxicillin/potassium clavulanate ext-release............ 1 amphetamine/dextroamphetamine..............................10 amphetamine/dextroamphetamine ext-release..........10 ampicillin caps................................................................1 anagrelide...................................................................... 13 anastrozole...................................................................... 3 ANDRODERM.................................................................. 3 ANDROGEL......................................................................3 ANDROXY........................................................................ 3 APTIVUS...........................................................................2 ASACOL........................................................................... 8 ASACOL HD.....................................................................8 ASMANEX........................................................................ 7

ASTEPRO.........................................................................7 atenolol............................................................................ 5 atenolol/chlorthalidone.................................................. 5 atorvastatin......................................................................6 atovaquone/proguanil 250-100 mg............................... 2 ATRIPLA........................................................................... 2 atropine sulfate eye soln............................................. 14 ATROVENT HFA..............................................................7 AVODART.........................................................................9 azathioprine...................................................................16 azelastine.........................................................................7 azelastine eye soln.......................................................14 AZILECT......................................................................... 12 azithromycin susp.......................................................... 1 azithromycin tabs........................................................... 1 AZOPT............................................................................ 14 B bacitracin/polymyxin B eye oint................................. 13 BACITRACIN eye oint.................................................... 13 baclofen......................................................................... 12 balsalazide.......................................................................8 BARACLUDE.................................................................... 2 benazepril........................................................................ 5 benazepril/hydrochlorothiazide.....................................5 BENICAR.......................................................................... 5 BENICAR HCT................................................................. 5 benzocaine/antipyrine ear soln................................... 14 benztropine....................................................................12 betamethasone dipropionate.......................................15 betamethasone dipropionate, augmented................. 15 betamethasone valerate...............................................15 bicalutamide.................................................................... 3 BILTRICIDE...................................................................... 2 bisoprolol.........................................................................5 bisoprolol/hydrochlorothiazide..................................... 5 BREATHERITE...............................................................16 brimonidine eye soln, 0.15%....................................... 14 brimonidine eye soln, 0.2%......................................... 14 bromocriptine................................................................12 budesonide......................................................................7 budesonide ext-release..................................................3 bumetanide......................................................................6 buprenorphine...............................................................11 buprenorphine/naloxone SL tabs............................... 11 bupropion........................................................................ 9 bupropion ext-release.................................................... 9 bupropion ext-release.................................................. 10 buspirone.........................................................................9 butalbital/acetaminophen.............................................11 butalbital/acetaminophen/caffeine.............................. 11 butalbital/aspirin/caffeine/codeine.............................. 11 butalbital/aspirin/caffeine caps................................... 11 C cabergoline......................................................................5

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

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2013 caffeine citrate.............................................................. 10 calcipotriene crm, soln................................................ 16 calcitonin-salmon........................................................... 5 calcitriol........................................................................... 5 calcium acetate...............................................................8 CANASA........................................................................... 8 captopril...........................................................................5 CARAC........................................................................... 16 carbamazepine.............................................................. 12 carbamazepine ext-release.......................................... 12 carbidopa/levodopa...................................................... 12 carbidopa/levodopa ext-release.................................. 12 carteolol eye soln......................................................... 14 carvedilol......................................................................... 5 cefaclor caps...................................................................1 cefadroxil......................................................................... 1 cefdinir............................................................................. 1 cefpodoxime....................................................................1 cefprozil........................................................................... 1 ceftriaxone.......................................................................1 cefuroxime.......................................................................1 CELEBREX.....................................................................11 CELLCEPT oral susp..................................................... 16 CELONTIN......................................................................12 cephalexin, NF = tabs.................................................... 1 cevimeline......................................................................15 CHANTIX (Member benefits determine coverage)......... 10 CHEMET.........................................................................16 chlorhexidine oral rinse............................................... 15 chloroquine phosphate.................................................. 2 chlorothiazide..................................................................6 chlorpromazine............................................................. 10 chlorzoxazone............................................................... 12 cholestyramine................................................................6 chorionic gonadotropin................................................. 4 CIALIS...............................................................................7 ciclopirox crm, gel, shampoo, susp........................... 15 ciclopirox soln.............................................................. 15 cilostazol........................................................................13 cimetidine........................................................................ 8 CIPRODEX..................................................................... 14 ciprofloxacin....................................................................1 ciprofloxacin ext-release................................................1 ciprofloxacin eye soln..................................................13 citalopram........................................................................9 clarithromycin................................................................. 1 clarithromycin ext-release............................................. 1 CLEOCIN supp.................................................................9 clindamycin..................................................................... 2 clindamycin................................................................... 15 clindamycin/benzoyl peroxide.....................................15 clindamycin crm............................................................. 9 clobetasol...................................................................... 15 clomiphene...................................................................... 4 clomipramine...................................................................9 clonazepam................................................................... 12

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clonidine.......................................................................... 7 clopidogrel.....................................................................13 clotrimazole troche.......................................................15 clozapine........................................................................10 CODEINE SULFATE 15 mg...........................................11 COLCRYS.......................................................................12 colestipol......................................................................... 6 COMBIPATCH.................................................................. 3 COMBIVENT.....................................................................7 COMBIVENT RESPIMAT................................................. 7 CORTIFOAM.................................................................. 15 CORTISONE.....................................................................3 CREON............................................................................. 8 CRESTOR........................................................................ 6 CRINONE......................................................................... 9 CRIXIVAN......................................................................... 2 cromolyn eye soln........................................................14 cromolyn inhal soln....................................................... 7 CUPRIMINE....................................................................16 cyanocobalamin inj...................................................... 13 cyclobenzaprine............................................................12 cyclopentolate eye soln............................................... 14 CYCLOPHOSPHAMIDE tabs........................................... 3 cyclosporine..................................................................16 CYCLOSPORINE........................................................... 16 cyclosporine modified caps, 25 mg, 100 mg; soln.... 16 cyproheptadine............................................................... 7 CYSTAGON......................................................................9 D danazol.............................................................................3 dantrolene......................................................................13 DAPSONE........................................................................ 2 DARAPRIM....................................................................... 2 DELZICOL........................................................................ 8 demeclocycline............................................................... 1 desipramine.....................................................................9 desmopressin..................................................................5 desonide........................................................................ 15 desoximetasone crm, 0.25%; gel; oint, 0.25%........... 15 DETROL LA......................................................................9 dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg, 4 mg, 6 mg.................................................................... 3 dexamethasone sodium phosphate eye soln............ 14 DEXAMETHASONE soln, 0.5 mg/5 mL........................... 3 dextroamphetamine......................................................10 dextroamphetamine ext-release..................................10 DIASTAT.........................................................................12 DIAZEPAM oral soln, 1 mg/mL........................................ 9 diazepam tabs.................................................................9 DIBENZYLINE.................................................................. 7 diclofenac eye soln...................................................... 14 diclofenac potassium................................................... 11 diclofenac sodium delayed-release............................ 11 diclofenac sodium ext-release.................................... 11 dicloxacillin..................................................................... 1

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

2013 dicyclomine caps, tabs.................................................. 8 didanosine delayed-release...........................................2 DIFFERIN gel, 0.3%.......................................................15 diflorasone oint.............................................................15 digoxin tabs.................................................................... 7 DILANTIN 30 mg............................................................ 12 diltiazem...........................................................................6 diltiazem ext-release...................................................... 6 diphenoxylate/atropine tabs.......................................... 8 dipyridamole..................................................................13 disopyramide...................................................................7 disulfiram.......................................................................10 divalproex delayed-release..........................................12 divalproex ext-release.................................................. 12 DIVIGEL............................................................................3 donepezil....................................................................... 10 dorzolamide/timolol maleate eye soln........................14 dorzolamide eye soln...................................................14 doxazosin........................................................................ 7 doxepin, NF = caps, 75 mg............................................9 doxycycline hyclate........................................................1 doxycycline monohydrate............................................. 1 DROXIA.......................................................................... 13 DULERA........................................................................... 7 E econazole.......................................................................15 ELIDEL............................................................................16 ELLA................................................................................. 4 EMCYT............................................................................. 3 EMEND caps.................................................................... 8 EMTRIVA.......................................................................... 2 enalapril........................................................................... 5 enalapril/hydrochlorothiazide........................................5 ENJUVIA...........................................................................3 enoxaparin.....................................................................13 entacapone.................................................................... 12 EPIPEN 2-PAK................................................................. 7 EPIPEN-JR 2-PAK........................................................... 7 EPIVIR soln...................................................................... 2 eplerenone.......................................................................7 EPZICOM..........................................................................2 ergocalciferol................................................................ 13 erythromycin/benzoyl peroxide...................................15 erythromycin/sulfisoxazole............................................2 erythromycin delayed-release caps..............................1 erythromycin eye oint.................................................. 13 erythromycin pads, soln.............................................. 15 escitalopram....................................................................9 estazolam.......................................................................10 ESTRACE crm..................................................................9 estradiol/norethindrone acetate.................................... 3 estradiol patches............................................................ 3 estradiol tabs.................................................................. 3 estropipate, NF = 3 mg.................................................. 3 ethambutol.......................................................................1

ethosuximide.................................................................12 etodolac......................................................................... 11 EVISTA............................................................................. 5 EXELON patches, soln...................................................10 exemestane..................................................................... 3 F famciclovir....................................................................... 2 famotidine........................................................................8 FARESTON...................................................................... 3 felodipine ext-release..................................................... 6 fenofibrate....................................................................... 6 fenofibrate micronized................................................... 6 fenofibric acid delayed-release caps............................6 fentanyl.......................................................................... 11 fentanyl lollipop............................................................ 11 FINACEA........................................................................ 15 finasteride........................................................................9 flecainide......................................................................... 7 FLOVENT DISKUS...........................................................7 FLOVENT HFA.................................................................7 fluconazole...................................................................... 1 flucytosine....................................................................... 1 fludrocortisone................................................................3 flunisolide........................................................................ 7 fluocinolone...................................................................15 fluocinonide...................................................................15 fluorometholone eye susp...........................................14 FLUOROPLEX................................................................16 fluorouracil.................................................................... 16 fluoxetine, NF = 60 mg...................................................9 FLUPHENAZINE HCL conc, elixir..................................10 fluphenazine hcl tabs...................................................10 flurbiprofen....................................................................11 flurbiprofen eye soln....................................................14 flutamide.......................................................................... 3 fluticasone propionate................................................... 7 fluticasone propionate................................................. 15 fluvoxamine..................................................................... 9 folic acid tabs, 1 mg.................................................... 13 FORADIL AEROLIZER.....................................................7 fosinopril..........................................................................5 fosinopril/hydrochlorothiazide...................................... 5 furosemide, NF = soln, 8 mg/mL...................................6 G gabapentin.....................................................................12 GABITRIL 12 mg, 16 mg................................................12 galantamine................................................................... 10 galantamine ext-release............................................... 10 gemfibrozil.......................................................................6 gentamicin eye oint, soln............................................ 13 glimepiride.......................................................................4 glipizide............................................................................4 glipizide/metformin......................................................... 4 glipizide ext-release....................................................... 4

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

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2013 GLUCAGON EMERGENCY KIT...................................... 4 glyburide..........................................................................4 glyburide/metformin....................................................... 4 glyburide micronized..................................................... 4 glycopyrrolate................................................................. 8 granisetron...................................................................... 8 griseofulvin microsize....................................................1 guanfacine....................................................................... 7 H halobetasol.................................................................... 15 haloperidol lactate oral conc.......................................10 haloperidol tabs............................................................10 HEPSERA.........................................................................2 homatropine eye soln.................................................. 14 HUMALOG........................................................................4 HUMALOG MIX 50/50, 75/25...........................................4 HUMULIN 70/30............................................................... 4 HUMULIN N......................................................................4 HUMULIN R......................................................................4 hydralazine...................................................................... 7 hydrochlorothiazide caps.............................................. 6 hydrochlorothiazide tabs............................................... 6 hydrocodone/acetaminophen, NF = tabs, 2.5-325 mg.................................................................................11 hydrocodone/ibuprofen................................................11 hydrocortisone................................................................3 hydrocortisone/acetic acid ear soln........................... 14 hydrocortisone acetate rectal crm, supp................... 15 hydrocortisone enema................................................. 15 hydrocortisone topical................................................. 15 hydrocortisone valerate............................................... 15 hydromorphone soln, tabs.......................................... 11 hydroxychloroquine....................................................... 2 hydroxyurea.................................................................... 3 hydroxyzine hcl.............................................................. 9 hydroxyzine pamoate 25 mg, 50 mg.............................9 hyoscyamine................................................................... 8 hyoscyamine ext-release............................................... 8 I ibandronate..................................................................... 5 ibuprofen....................................................................... 11 imipramine hcl................................................................ 9 imiquimod......................................................................16 IMITREX nasal spray..................................................... 12 indapamide...................................................................... 6 indomethacin.................................................................11 INNOPRAN XL................................................................. 5 INSULIN PEN NEEDLES – BD ULTRAFINE, NOVOFINE, NOVOTWIST........................................... 16 INSULIN SYRINGES – BD............................................ 16 INTELENCE......................................................................2 INTUNIV..........................................................................10 INVIRASE......................................................................... 2 ipratropium/albuterol......................................................8

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ipratropium inhal soln....................................................8 ipratropium nasal........................................................... 7 irbesartan.........................................................................5 irbesartan/hydrochlorothiazide..................................... 5 ISENTRESS......................................................................2 isoniazid/rifampin........................................................... 1 isoniazid tabs..................................................................1 isosorbide dinitrate, NF = SL tabs................................6 isosorbide mononitrate..................................................6 isosorbide mononitrate ext-release.............................. 6 isotretinoin, NF = 30 mg.............................................. 15 itraconazole..................................................................... 1 J JANUMET......................................................................... 4 JANUMET XR...................................................................4 JANUVIA...........................................................................4 JUVISYNC........................................................................ 4 K KADIAN...........................................................................11 KALETRA..........................................................................2 ketoconazole................................................................. 15 ketoconazole tabs.......................................................... 1 ketoprofen..................................................................... 11 ketorolac eye soln........................................................ 14 KOMBIGLYZE XR............................................................ 4 K-PHOS.......................................................................... 13 L labetalol........................................................................... 5 lactulose.......................................................................... 8 lactulose.......................................................................... 8 lamivudine....................................................................... 2 lamivudine/zidovudine................................................... 2 lamotrigine.....................................................................12 LANCETS – BAYER FINGERSTIX, MICROLET, SINGLE-LET................................................................. 16 LANCETS – BD MICROTAINER ULTRAFINE............... 16 LANCETS – ROCHE ACCU-CHEK FASTCLIX, MULTICLIX, SOFT TOUCH, SOFTCLIX...................... 16 lansoprazole delayed-release........................................8 LANTUS............................................................................4 latanoprost eye soln.................................................... 14 leflunomide....................................................................11 letrozole........................................................................... 3 LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg.................3 leucovorin calcium tabs, 5 mg, 25 mg......................... 3 LEUKERAN.......................................................................3 LEVEMIR.......................................................................... 4 levetiracetam................................................................. 12 levobunolol eye soln, 0.5%..........................................14 levocarnitine....................................................................5 levofloxacin..................................................................... 1 levonorgestrel................................................................. 4 levothyroxine...................................................................4

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

2013 LEXIVA............................................................................. 2 LIALDA..............................................................................8 lidocaine/prilocaine crm...............................................16 lidocaine topical, NP = lotn......................................... 16 lidocaine viscous..........................................................15 lindane........................................................................... 16 liothyronine..................................................................... 4 lisinopril........................................................................... 5 lisinopril/hydrochlorothiazide........................................5 lithium carbonate..........................................................10 lithium carbonate ext-release 300 mg........................ 10 lithium carbonate ext-release 450 mg........................ 10 loperamide.......................................................................8 lorazepam........................................................................ 9 lorazepam conc.............................................................. 9 losartan............................................................................ 5 losartan/hydrochlorothiazide.........................................5 LOTEMAX.......................................................................14 lovastatin......................................................................... 6 loxapine......................................................................... 10 LUMIGAN........................................................................14 LYRICA caps.................................................................. 12 M MALARONE 62.5-25 mg.................................................. 2 malathion....................................................................... 16 medroxyprogesterone acetate...................................... 4 medroxyprogesterone acetate inj, 150 mg/mL............ 4 mefloquine.......................................................................2 megestrol.........................................................................3 meloxicam tabs.............................................................11 MEPHYTON....................................................................13 mercaptopurine...............................................................3 mesalamine..................................................................... 8 MESNEX tabs...................................................................3 MESTINON syrup...........................................................13 MESTINON TIMESPAN................................................. 13 metaxalone.................................................................... 13 metformin........................................................................ 4 metformin ext-release.................................................... 4 metformin ext-release OSM........................................... 4 methadone conc, soln................................................. 11 methadone tabs............................................................ 11 methazolamide................................................................ 6 methimazole.................................................................... 4 methocarbamol............................................................. 13 methotrexate................................................................... 3 methscopolamine........................................................... 8 methyldopa......................................................................7 methylergonovine........................................................... 5 methylphenidate ext-release caps; tabs, 20 mg........ 10 methylphenidate tabs...................................................10 methylprednisolone........................................................3 metipranolol eye soln.................................................. 14 metoclopramide.............................................................. 8 metolazone...................................................................... 6

metoprolol succinate ext-release..................................5 metoprolol tartrate..........................................................5 metronidazole..................................................................9 metronidazole................................................................15 metronidazole tabs.........................................................2 metronidazole topical gel............................................ 15 mexiletine........................................................................ 7 midodrine.........................................................................7 MIGRANAL..................................................................... 12 minocycline..................................................................... 1 minoxidil.......................................................................... 7 mirtazapine...................................................................... 9 misoprostol..................................................................... 8 modafinil........................................................................ 10 moexipril.......................................................................... 5 moexipril/hydrochlorothiazide.......................................5 mometasone..................................................................16 montelukast.....................................................................8 morphine sulfate conc, soln........................................11 morphine sulfate ext-release.......................................11 morphine sulfate ext-release.......................................11 MORPHINE SULFATE supp, tabs................................. 11 MULTAQ........................................................................... 7 mupirocin.......................................................................15 MYCOBUTIN.................................................................... 1 mycophenolate mofetil.................................................16 MYFORTIC..................................................................... 16 MYLERAN.........................................................................3 N nabumetone...................................................................11 nadolol............................................................................. 6 naltrexone......................................................................10 naproxen........................................................................11 naproxen delayed-release............................................11 naproxen sodium..........................................................11 naratriptan..................................................................... 12 NASONEX........................................................................ 7 NATACYN.......................................................................13 nateglinide....................................................................... 4 neomycin/polymyxin B/bacitracin/hydrocortisone eye oint........................................................................ 14 neomycin/polymyxin B/bacitracin eye oint................ 13 neomycin/polymyxin B/dexamethasone eye oint, susp..............................................................................14 neomycin/polymyxin B/gramicidin eye soln.............. 13 neomycin/polymyxin B/hydrocortisone ear soln, susp..............................................................................14 neomycin sulfate............................................................ 1 nevirapine tabs............................................................... 2 NEXIUM............................................................................ 8 NIASPAN.......................................................................... 6 NICOTROL INHALER.................................................... 10 NICOTROL NS............................................................... 11 nifedipine ext-release..................................................... 6 NILANDRON.....................................................................3

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

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2013 nitrofurantoin.................................................................. 9 nitrofurantoin macrocrystalline.....................................9 nitrofurantoin monohydrate/macrocrystalline............. 9 nitroglycerin.................................................................... 6 NITROSTAT......................................................................6 norethindrone acetate.................................................... 4 nortriptyline caps........................................................... 9 NORVIR............................................................................ 2 NOVOLIN 70/30............................................................... 4 NOVOLIN N......................................................................4 NOVOLIN R......................................................................4 NOVOLOG........................................................................4 NOVOLOG MIX 70/30......................................................4 NOXAFIL...........................................................................1 NUCYNTA ER................................................................ 11 NUEDEXTA.................................................................... 11 NUVARING....................................................................... 4 nystatin/triamcinolone crm..........................................16 nystatin oral.................................................................... 1 nystatin susp................................................................ 15 nystatin topical............................................................. 15 O octreotide.........................................................................5 ofloxacin ear soln.........................................................15 ofloxacin eye soln........................................................ 13 ofloxacin tabs................................................................. 1 olanzapine..................................................................... 10 omeprazole delayed-release..........................................8 ondansetron.................................................................... 8 ondansetron 24 mg........................................................ 8 ONGLYZA.........................................................................4 oral contraceptives – all generics.................................4 ORAP..............................................................................11 orphenadrine/aspirin/caffeine 25-385-30 mg..............13 orphenadrine citrate ext-release................................. 13 ORTHO EVRA..................................................................4 oxaprozin....................................................................... 12 oxcarbazepine............................................................... 12 oxybutynin.......................................................................9 oxybutynin ext-release...................................................9 oxycodone..................................................................... 11 oxycodone/acetaminophen..........................................11 oxycodone/aspirin........................................................ 11 oxycodone caps........................................................... 11 OXYCONTIN...................................................................11 P pantoprazole delayed-release....................................... 8 paromomycin.................................................................. 1 paroxetine hcl................................................................. 9 paroxetine hcl ext-release............................................. 9 PATADAY....................................................................... 14 pediatric multivitamins.................................................13 pediatric vitamins ADC................................................ 13 PEG – electrolytes for soln........................................... 8

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penicillin v potassium....................................................1 PENTASA......................................................................... 8 pentoxifylline ext-release.............................................13 perindopril....................................................................... 5 permethrin..................................................................... 16 perphenazine.................................................................10 phenelzine....................................................................... 9 phenobarbital, NF = tabs, 64.8 mg, 97.2 mg...............10 phenytoin chew tabs....................................................12 phenytoin sodium ext-release.....................................12 phenytoin susp............................................................. 12 pilocarpine.....................................................................15 pilocarpine eye soln.....................................................14 pioglitazone..................................................................... 4 pioglitazone/metformin.................................................. 4 piroxicam....................................................................... 12 podofilox........................................................................16 polymyxin B/trimethoprim eye soln............................13 potassium bicarbonate/chloride effervescent tabs, 25 mEq......................................................................... 13 potassium chloride ext-release...................................13 potassium chloride ext-release caps..........................13 potassium chloride packets; soln, 10%..................... 13 POTASSIUM CITRATE.................................................... 9 potassium citrate/citric acid powder............................ 9 potassium phosphate/sodium phosphates................13 pramipexole...................................................................12 PRANDIN..........................................................................4 pravastatin.......................................................................6 prazosin........................................................................... 7 prednisolone................................................................... 3 prednisolone acetate eye susp................................... 14 PREDNISOLONE SODIUM PHOSPHATE eye soln, 1%................................................................................. 14 prednisolone sodium soln.............................................3 PREDNISONE INTENSOL............................................... 3 PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg.................. 3 prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg... 3 PRENAPLUS.................................................................. 13 PRENATABS FA............................................................ 13 PRENATAL LOW IRON, PLUS, PLUS/IRON, VITAMINS PLUS, 19...................................................................... 13 PREZISTA........................................................................ 2 PRIFTIN............................................................................ 1 PRIMAQUINE................................................................... 2 primidone.......................................................................12 PROAIR HFA....................................................................8 probenecid.....................................................................12 probenecid/colchicine.................................................. 12 prochlorperazine...........................................................10 progesterone micronized...............................................4 promethazine, NF = supp, 50 mg..................................7 propafenone.................................................................... 7 propafenone ext-release................................................ 7 propranolol ext-release.................................................. 6 PROPRANOLOL soln.......................................................6

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

2013 propranolol tabs............................................................. 6 propylthiouracil...............................................................4 PROTOPIC..................................................................... 16 pyrazinamide................................................................... 1 pyridostigmine.............................................................. 13 Q quetiapine...................................................................... 10 quinapril...........................................................................5 quinapril/hydrochlorothiazide....................................... 5 quinidine gluconate ext-release....................................7 quinidine sulfate, NF = ext-release............................... 7 QVAR................................................................................8 R ramipril.............................................................................5 ranitidine..........................................................................8 RAPAMUNE....................................................................16 RENVELA......................................................................... 8 repaglinide.......................................................................4 RESCRIPTOR.................................................................. 2 REYATAZ......................................................................... 2 ribavirin............................................................................2 rifampin............................................................................1 RILUTEK.........................................................................13 riluzole........................................................................... 13 risperidone.................................................................... 10 rivastigmine...................................................................11 rizatriptan.......................................................................12 ropinirole....................................................................... 12 S SABRIL........................................................................... 12 salsalate.........................................................................11 selegiline caps.............................................................. 12 selegiline tabs...............................................................12 selenium sulfide........................................................... 16 SELZENTRY.....................................................................2 SE-NATAL 19................................................................. 13 SENSIPAR........................................................................5 SEROQUEL XR..............................................................10 sertraline........................................................................10 sildenafil.......................................................................... 7 silver sulfadiazine.........................................................15 simvastatin...................................................................... 6 sodium citrate/citric acid............................................... 9 sodium fluoride.............................................................15 sodium fluoride chew tabs, soln.................................13 sodium polystyrene sulfonate.....................................16 SOLARAZE.....................................................................16 SORIATANE................................................................... 16 sotalol.............................................................................. 7 SPIRIVA HANDIHALER................................................... 8 spironolactone................................................................ 6 spironolactone/hydrochlorothiazide.............................6 stavudine......................................................................... 2

STIMATE.......................................................................... 5 STRIBILD..........................................................................2 STROMECTOL................................................................. 2 SUBOXONE SL film....................................................... 11 sucralfate......................................................................... 8 sulfacetamide sodium/prednisolone eye soln........... 14 sulfacetamide sodium/sulfur, NF = susp, 10-5%....... 15 sulfacetamide sodium eye soln.................................. 14 sulfamethoxazole/trimethoprim.....................................2 sulfasalazine....................................................................8 sulfasalazine delayed-release....................................... 8 sulindac......................................................................... 12 sumatriptan inj, tabs.................................................... 12 SUPRAX tabs................................................................... 1 SUSTIVA...........................................................................2 SYMBICORT.....................................................................8 T TABLOID...........................................................................3 tacrolimus......................................................................16 tamoxifen......................................................................... 3 tamsulosin....................................................................... 9 TAZORAC.......................................................................15 TEGRETOL-XR 100 mg.................................................12 temazepam.................................................................... 10 temozolomide..................................................................3 terazosin.......................................................................... 7 terbinafine........................................................................1 terbutaline........................................................................8 terconazole...................................................................... 9 testosterone cypionate.................................................. 3 testosterone enanthate.................................................. 3 TEST STRIPS – BAYER ASCENSIA AUTODISC, BREEZE 2, CONTOUR, CONTOUR NEXT..................16 TEST STRIPS – ROCHE ACCU-CHEK ACTIVE, AVIVA, AVIVA PLUS, COMFORT CURVE, COMPACT, SMARTVIEW................................................................ 16 TEST STRIPS – ROCHE ACCUTREND........................16 theophylline ext-release.................................................8 thiothixene.....................................................................10 timolol maleate eye soln..............................................14 TIMOLOL tabs.................................................................. 6 tizanidine....................................................................... 13 TOBRADEX eye oint...................................................... 14 tobramycin/dexamethasone eye susp........................14 tobramycin eye soln.....................................................14 tolterodine....................................................................... 9 topiramate......................................................................12 torsemide.........................................................................6 tramadol.........................................................................11 tramadol/acetaminophen............................................. 11 trandolapril...................................................................... 5 tranylcypromine............................................................ 10 TRAVATAN Z................................................................. 14 trazodone.......................................................................10 tretinoin..........................................................................15

Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

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2013 tretinoin caps.................................................................. 3 tretinoin microsphere gel, 0.1%.................................. 15 TREXALL.......................................................................... 3 triamcinolone.................................................................. 7 triamcinolone crm; lotn; oint, 0.025%, 0.1%.............. 16 triamcinolone dental paste.......................................... 15 triamterene/hydrochlorothiazide................................... 7 trifluoperazine............................................................... 10 trifluridine eye soln...................................................... 14 trihexyphenidyl............................................................. 12 TRILIPIX........................................................................... 6 trimethobenzamide......................................................... 8 trimethoprim....................................................................2 TRIZIVIR........................................................................... 2 tropicamide eye soln....................................................14 TRUVADA.........................................................................2 U ursodiol............................................................................8 V

Y Z zafirlukast........................................................................ 8 zaleplon..........................................................................10 ZEMPLAR caps................................................................ 5 ZENPEP............................................................................8 ZIAGEN soln.....................................................................2 zidovudine....................................................................... 2 ziprasidone.................................................................... 10 ZITHROMAX packets....................................................... 1 zolpidem........................................................................ 10 zolpidem ext-release.................................................... 10 zonisamide.................................................................... 12 ZORTRESS.................................................................... 16 ZYCLARA....................................................................... 16 ZYCLARA PUMP............................................................16 ZYLET.............................................................................14 ZYVOX..............................................................................3

VAGIFEM..........................................................................9 valacyclovir..................................................................... 2 VALCYTE..........................................................................1 valproic acid..................................................................12 valsartan/hydrochlorothiazide.......................................5 vancomycin..................................................................... 2 venlafaxine.................................................................... 10 venlafaxine ext-release caps....................................... 10 venlafaxine ext-release tabs, NF = 225 mg................ 10 VENTOLIN HFA............................................................... 8 verapamil, NF = 40 mg...................................................6 verapamil ext-release..................................................... 6 VESICARE........................................................................9 VFEND susp.....................................................................1 VICTOZA.......................................................................... 4 VIDEX............................................................................... 2 VIGAMOX....................................................................... 14 VIRACEPT........................................................................ 2 VIRAMUNE susp.............................................................. 2 VIRAMUNE XR.................................................................2 VIREAD.............................................................................2 VIVELLE-DOT...................................................................3 voriconazole.................................................................... 1 VYVANSE....................................................................... 10 W warfarin.......................................................................... 13 WELCHOL........................................................................ 6 X XARELTO....................................................................... 13 XERAC AC..................................................................... 16 XIFAXAN 550 mg............................................................. 3

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Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary

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