july 2013 blue cross and blue shield generics plus …blue cross and blue shield generics plus july...

4621 HCSC © Prime Therapeutics LLC 05/13

Content

Introduction................................................................. I How preferred 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 Abbreviation/Acronym 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 ................................................ 7 Genitourinary Drugs .................................................... 8 Central Nervous System Drugs .................................. 9 Pain Relief Drugs ...................................................... 10 Neuromuscular Drugs ............................................... 11 Supplements ............................................................. 12 Blood Modifying Drugs .............................................. 13 Topical Drugs ............................................................ 13 Miscellaneous Categories ......................................... 15 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. You can view the most up-to-date list of preferred drugs, or the specialty drug list at myprime.com.

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.

Prime Therapeutics LLC is a pharmacy benefit management company. PrimeMail is a mail order pharmacy owned and operated by Prime Therapeutics. BCBSIL, BCBSNM, BCBSOK and BCBSTX, as well as several other independent Blue Cross and Blue Shield Plans, have an ownership interest in Prime Therapeutics.

July 2013 Blue Cross and Blue Shield Generics Plus Drug Formulary

In Texas and Oklahoma referred to as Preferred Drug List 2

Blue Cross and Blue Shield Generics Plus July 2013 Drug Formulary I

Introduction

This is a list of preferred drugs which includes Preferred Brand drugs and a partial listing of generic drugs. Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However decisions regarding therapy and treatment are always between members and their physician.

Drug formulary updates – This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. 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, Preferred Brand or Non-Preferred Brand (not listed in this document). Specialty drugs can either be within the previous three tiers or can be a separate fourth tier depending on your benefit design.

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

Blue Cross and Blue Shield of Illinois April 2013 Drug Formulary II

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 preferred 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-preferred (NP) 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 NP)

Preferred brand drugs are listed in all CAPITAL letters.

Example: ZYTIGA

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 preferred drug list.

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 Generics Plus July 2013 Drug Formulary III

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.

Blue Cross and Blue Shield of Illinois April 2013 Drug Formulary IV

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 preferred medications listed in this document, if a prior authorization is commonly required, it will be noted next to the medication with a dot under the prior authorization column as stated in the section “How To Use This List.” Some plans may have prior authorization on additional medications beyond those noted in this document.

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

Dispensing Limits (DL): Drug Dispensing limits help encourage medication use as intended by the FDA. Coverage limits are placed on medications in certain drug categories. For the formulary medications listed in this document, if a dispensing limit applies, it will be noted next to the medication with a dot under the dispensing limits column as explained in the section “How to Use This List.” Limits may include: quantity of covered medication per prescription, quantity of covered medication in a given time period, coverage only for members within a certain age range, and coverage only for members of a specific gender. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows. For a list of medications and their dispensing limits, visit myprime.com.

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.

Blue Cross and Blue Shield Generics Plus July 2013 Drug Formulary V

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 Illinois April 2013 Drug Formulary VI

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 Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, Blue Cross

and Blue Shield of Texas, Divisions 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.

Abbreviation/acronym key

caps ............................................................... capsules chew tabs .......................................... chewable tablets conc ........................................................... concentrate crm ...................................................................... cream DL ....................................................... dispensing limits ext-release ........................................ extended-release inhal .............................................................. inhalation inj..................................................................... injection lotn ....................................................................... lotion NP ............................................................ non-preferred ODT .................................... orally disintegrating tablets

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

D

2013

Blue Cross and Blue Shield Generics Plus July 2013 Drug Formulary 1

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

ANTI-INFECTIVE DRUGS

PENICILLINS

amoxicillin/potassiumclavulanate (Augmentin – brand isNP)

amoxicillin/potassium clavulanateext-release (Augmentin XR – brand isNP)

amoxicillin, NP = chew tabs

ampicillin caps

dicloxacillin

penicillin v potassium

CEPHALOSPORINS

cefadroxil

cefdinir

cefpodoxime

cefprozil

ceftriaxone (Rocephin – brand is NP)

cefuroxime (Ceftin – brand is NP)

cephalexin, NP = tabs (Keflex – brandis NP)

SUPRAX tabs

MACROLIDES

azithromycin susp (Zithromax – brandis NP)

azithromycin tabs (Zithromax – brandis NP)

•

clarithromycin (Biaxin – brand is NP)

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

•

TETRACYCLINES

demeclocycline

doxycycline hyclate (Vibramycin –brand is NP)

minocycline (Dynacin, Minocin –brands are NP)

FLUOROQUINOLONES

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

ciprofloxacin (Cipro – brand is NP)

levofloxacin (Levaquin – brand is NP)

AMINOGLYCOSIDES

neomycin sulfate

paromomycin

TOBI, NP = Podhaler • •TUBERCULOSIS

ethambutol (Myambutol – brand is NP)

isoniazid tabs

isoniazid/rifampin (Rifamate – brand isNP)

MYCOBUTIN

PRIFTIN

pyrazinamide

rifampin (Rifadin – brand is NP)

FUNGAL INFECTIONS

fluconazole (Diflucan – brand is NP)

flucytosine (Ancobon – brand is NP)

griseofulvin microsize (Grifulvin V –brand is NP)

itraconazole (Sporanox – brand is NP)

ketoconazole tabs

NOXAFIL •nystatin oral

terbinafine (Lamisil – brand is NP)

VFEND susp •voriconazole (Vfend – brand is NP) •VIRAL INFECTIONS

Cytomegalovirus

VALCYTE

Hepatitis

BARACLUDE

HEPSERA

INCIVEK • •PEGASYS • •

2013

2 Blue Cross and Blue Shield Generics Plus July 2013 Drug Formulary

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

ribavirin (Copegus, Rebetol – brandsare NP)

•

VICTRELIS • •Herpes

acyclovir (Zovirax – brand is NP)

famciclovir (Famvir – brand is NP)

valacyclovir (Valtrex – brand is NP)

HIV/AIDS

abacavir tabs (Ziagen – brand is NP)

APTIVUS

ATRIPLA

CRIXIVAN

didanosine delayed-release (Videx EC– brand is NP)

EMTRIVA

EPIVIR soln

EPZICOM

FUZEON •INTELENCE

INVIRASE

ISENTRESS

KALETRA

lamivudine (Epivir – brand is NP)

lamivudine/zidovudine (Combivir –brand is NP)

LEXIVA

nevirapine tabs (Viramune – brand isNP)

NORVIR

PREZISTA tabs

RESCRIPTOR

REYATAZ

SELZENTRY

stavudine (Zerit – brand is NP)

STRIBILD

SUSTIVA

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

TRIZIVIR

TRUVADA

VIDEX

VIRACEPT

VIRAMUNE XR

VIREAD

ZIAGEN soln

zidovudine

MALARIA

atovaquone/proguanil250-100 mg (Malarone – brand is NP)

chloroquine phosphate (Aralen –brand is NP)

DARAPRIM

hydroxychloroquine (Plaquenil –brand is NP)

MALARONE

mefloquine

PRIMAQUINE

WORM INFECTIONS

ALBENZA

BILTRICIDE

MEBENDAZOLE

STROMECTOL

OTHER ANTI-INFECTIVES

clindamycin (Cleocin, CleocinPediatric – brands are NP)

DAPSONE

erythromycin/sulfisoxazole

metronidazole (Flagyl – brand is NP)

sulfamethoxazole/trimethoprim (Bactrim – brand is NP)

trimethoprim

vancomycin (Vancocin – brand is NP)

XIFAXAN 550 mg •ZYVOX •

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

SYNAGIS •CANCER DRUGS

ACTIMMUNE •ALKERAN tabs

anastrozole (Arimidex – brand is NP)

bicalutamide (Casodex – brand is NP)

CEENU

CYCLOPHOSPHAMIDE tabs

exemestane (Aromasin – brand is NP)

FIRMAGON •flutamide

GLEEVEC • •hydroxyurea (Hydrea – brand is NP)

letrozole (Femara – brand is NP)

LEUCOVORIN CALCIUM tabs, 10 mg,15 mg

leucovorin calcium tabs, 5 mg,25 mg

LEUKERAN

megestrol (Megace – brand is NP)

mercaptopurine (Purinethol – brand isNP)

methotrexate

MYLERAN

NEXAVAR • •SPRYCEL • •SUTENT • •SYLATRON • •tamoxifen

TARCEVA • •TASIGNA • •TEMODAR • •tretinoin caps • •VOTRIENT • •XALKORI • •XELODA • •

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

ZELBORAF • •ZYTIGA • •HORMONES, DIABETES AND RELATED DRUGS

CORTICOSTEROIDS

budesonide ext-release (Entocort EC –brand is NP)

CORTISONE ACETATE

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

fludrocortisone

hydrocortisone (Cortef – brand is NP)

methylprednisolone (Medrol – brand isNP)

prednisolone (Prelone – brand is NP)

prednisolone sodium phosphatesoln (Orapred – brand is NP)

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

MALE HORMONES

danazol •ESTROGENS

COMBIPATCH

DIVIGEL

estradiol patches (Climara – brand isNP)

•

estradiol tabs (Estrace – brand is NP)

estradiol/norethindroneacetate (Activella – brand is NP)

estropipate 0.75 mg, 1.5 mg

PROGESTINS

medroxyprogesterone acetatetabs (Provera – brand is NP)

norethindrone acetate (Aygestin –brand is NP)

progesterone micronized (Prometrium– brand is NP)

BIRTH CONTROL

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

ELLA •levonorgestrel (Plan B, Plan B One

Step – brands are NP)•

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

MIRENA

NUVARING

oral contraceptives – all generics •ORTHO EVRA •SKYLA

INFERTILITY

chorionic gonadotropin • •clomiphene (Clomid – brand is NP) •FOLLISTIM AQ • •SYNAREL

DIABETES

acarbose (Precose – brand is NP)

glimepiride (Amaryl – brand is NP)

glipizide (Glucotrol – brand is NP)

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

glipizide/metformin (Metaglip – brandis NP)

GLUCAGON EMERGENCY KIT

glyburide (Micronase – brand is NP)

glyburide micronized (Glynase –brand is NP)

glyburide/metformin (Glucovance –brand is NP)

metformin (Glucophage – brand is NP)

metformin ext-release (GlucophageXR – brand is NP)

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

nateglinide (Starlix – brand is NP)

pioglitazone (Actos – brand is NP)

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

pioglitazone/metformin (Actoplus Met– brand is NP)

VICTOZA • •DIABETES - INSULINS

Rapid-Acting Insulins

NOVOLOG •Short-Acting Insulins

NOVOLIN R •Intermediate-Acting Insulins

NOVOLIN N •NOVOLIN 70/30 •NOVOLOG MIX 70/30 •Basal Insulins

LANTUS •LEVEMIR •THYROID REGULATION

levothyroxine (Synthroid – brand isNP)

liothyronine (Cytomel – brand is NP)

methimazole (Tapazole – brand is NP)

propylthiouracil

GROWTH HORMONE

INCRELEX •OMNITROPE • •OTHER HORMONES AND RELATED DRUGS

ALDURAZYME •alendronate 5 mg, 10 mg, 35 mg,

70 mg (Fosamax – brand is NP)•

cabergoline

calcitonin-salmon (Miacalcin – brand isNP)

calcitriol (Rocaltrol – brand is NP)

desmopressin (DDAVP – brand is NP)

ELAPRASE •EVISTA

FABRAZYME •

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

ibandronate (Boniva – brand is NP) •levocarnitine (Carnitor – brand is NP)

LUMIZYME •methylergonovine

MYOZYME •NAGLAZYME •octreotide (Sandostatin – brand is NP) •ORFADIN •SENSIPAR

STIMATE

ZEMPLAR

HEART AND CIRCULATORY DRUGS

ANGIOTENSIN CONVERTING ENZYME (ACE)INHIBITORS AND COMBINATIONS

benazepril (Lotensin – brand is NP)

benazepril/hydrochlorothiazide (Lotensin HCT– brand is NP)

captopril

enalapril (Vasotec – brand is NP)

enalapril/hydrochlorothiazide (Vaseretic –brand is NP)

fosinopril

fosinopril/hydrochlorothiazide

lisinopril (Prinivil – brand is NP)

lisinopril/hydrochlorothiazide (Prinzide –brand is NP)

moexipril (Univasc – brand is NP)

moexipril/hydrochlorothiazide (Uniretic –brand is NP)

perindopril (Aceon – brand is NP)

quinapril (Accupril – brand is NP)

quinapril/hydrochlorothiazide (Accuretic –brand is NP)

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

ramipril (Altace – brand is NP)

trandolapril (Mavik – brand is NP)

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)AND COMBINATIONS

irbesartan (Avapro – brand is NP)

irbesartan/hydrochlorothiazide (Avalide –brand is NP)

losartan (Cozaar – brand is NP)

losartan/hydrochlorothiazide (Hyzaar– brand is NP)

valsartan/hydrochlorothiazide (DiovanHCT – brand is NP)

BETA BLOCKERS AND COMBINATIONS

acebutolol (Sectral – brand is NP)

atenolol (Tenormin – brand is NP)

atenolol/chlorthalidone (Tenoretic –brand is NP)

bisoprolol (Zebeta – brand is NP)

bisoprolol/hydrochlorothiazide (Ziac– brand is NP)

carvedilol (Coreg – brand is NP)

labetalol (Trandate – brand is NP)

metoprolol succinate ext-release (Toprol XL – brand is NP)

metoprolol tartrate (Lopressor – brandis NP)

nadolol (Corgard – brand is NP)

propranolol tabs

propranolol ext-release (Inderal LA –brand is NP)

CALCIUM CHANNEL BLOCKERS ANDCOMBINATIONS

amlodipine (Norvasc – brand is NP)

amlodipine/benazepril (Lotrel – brandis NP)

diltiazem (Cardizem – brand is NP)

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

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

felodipine ext-release

nifedipine ext-release (Adalat CC,Procardia XL – brands are NP)

verapamil ext-release (Calan SR,Isoptin SR, Verelan, Verelan PM –brands are NP)

verapamil, NP = 40 mg (Calan – brandis NP)

CHEST PAIN

isosorbide dinitrate, NP = SLtabs (Isordil – brand is NP)

isosorbide mononitrate (Monoket –brand is NP)

isosorbide mononitrate ext-release (Imdur – brand is NP)

nitroglycerin (Nitro-Dur – brand is NP)

NITROSTAT

CHOLESTEROL LOWERING

atorvastatin (Lipitor – brand is NP)

cholestyramine (Questran, QuestranLight – brands are NP)

colestipol (Colestid – brand is NP)

CRESTOR

fenofibrate (Lofibra, Tricor – brandsare NP)

fenofibrate micronized (Lofibra –brand is NP)

gemfibrozil (Lopid – brand is NP)

lovastatin (Mevacor – brand is NP)

NIASPAN

pravastatin (Pravachol – brand is NP)

simvastatin (Zocor – brand is NP)

FLUID RETENTION

acetazolamide tabs, 250 mg

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

acetazolamide ext-release (DiamoxSequels – brand is NP)

amiloride

amiloride/hydrochlorothiazide

bumetanide

chlorothiazide

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

hydrochlorothiazide caps (Microzide –brand is NP)

hydrochlorothiazide tabs

indapamide

methazolamide (Neptazane – brand isNP)

metolazone (Zaroxolyn – brand is NP)

spironolactone (Aldactone – brand isNP)

spironolactone/hydrochlorothiazide (Aldactazide –brand is NP)

torsemide (Demadex – brand is NP)

triamterene/hydrochlorothiazide (Dyazide –brand is NP)

triamterene/hydrochlorothiazide(Maxzide-25, Maxzide – brands areNP)

HEART RHYTHM

amiodarone (Cordarone, Pacerone –brands are NP)

disopyramide (Norpace – brand is NP)

flecainide (Tambocor – brand is NP)

propafenone (Rythmol – brand is NP)

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

quinidine gluconate ext-release

quinidine sulfate, NP = ext-releasetabs

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

sotalol (Betapace, Betapace AF –brands are NP)

OTHER HEART RELATED DRUGS

ADCIRCA • • •clonidine (Catapres, Catapres-TTS –

brands are NP)

DIBENZYLINE

digoxin tabs (Lanoxin – brand is NP)

doxazosin (Cardura – brand is NP)

eplerenone (Inspra – brand is NP)

guanfacine (Tenex – brand is NP)

hydralazine

methyldopa

midodrine (Proamatine – brand is NP)

minoxidil

prazosin (Minipress – brand is NP)

sildenafil (Revatio – brand is NP) • • •terazosin

TRACLEER • • •ERECTILE DYSFUNCTION

CIALIS • •BEE STING KITS

EPIPEN

EPIPEN-JR

RESPIRATORY AGENTS

ANTIHISTAMINES

AEROHIST

cetirizine syrup

cyproheptadine

promethazine, NP = supp, 50 mg

NASAL PRODUCTS

azelastine (Astelin – brand is NP) •fluticasone propionate (Flonase –

brand is NP)•

ipratropium (Atrovent – brand is NP) •

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

triamcinolone (Nasacort AQ – brand isNP)

•

COUGH/COLD/ALLERGY

acetylcysteine

ASTHMA/COPD

albuterol inhal soln, 0.083%, 0.5% •albuterol syrup, tabs

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

•

budesonide (Pulmicort Respules –brand is NP)

•

cromolyn sodium inhal soln •FLOVENT DISKUS •FLOVENT HFA •FORADIL AEROLIZER •ipratropium inhal soln •ipratropium/albuterol (Duoneb – brand

is NP)•

montelukast (Singulair – brand is NP)

PROAIR HFA •QVAR •SPIRIVA HANDIHALER •SYMBICORT •terbutaline

theophylline ext-release

VENTOLIN HFA •zafirlukast (Accolate – brand is NP)

OTHER RESPIRATORY DRUGS

FIRAZYR • •KALYDECO • •PULMOZYME •GASTROINTESTINAL DRUGS

LAXATIVES

lactulose

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

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

loperamide caps

ULCER/GERD

cimetidine

dicyclomine caps, tabs (Bentyl –brand is NP)

famotidine (Pepcid – brand is NP)

glycopyrrolate (Robinul – brand is NP)

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

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

lansoprazole delayed-release (Prevacid – brand is NP)

•

methscopolamine (Pamine, PamineForte – brands are NP)

misoprostol (Cytotec – brand is NP)

omeprazole delayed-release (Prilosec– brand is NP)

•

pantoprazole delayed-release (Protonix – brand is NP)

•

PREVPAC

ranitidine (Zantac – brand is NP)

sucralfate (Carafate – brand is NP)

NAUSEA AND VOMITING

EMEND caps •granisetron •ondansetron (Zofran, Zofran ODT –

brands are NP)•

ondansetron tabs, 24 mg •trimethobenzamide (Tigan – brand is

NP)

DIGESTIVE ENZYMES

ZENPEP

OTHER GASTROINTESTINAL DRUGS

balsalazide (Colazal – brand is NP)

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

calcium acetate (Eliphos, Phoslo –brands are NP)

CANASA

CHENODAL •diphenoxylate/atropine tabs (Lomotil –

brand is NP)

lactulose

mesalamine

metoclopramide (Reglan – brand isNP)

REMICADE •sulfasalazine (Azulfidine – brand is NP)

sulfasalazine delayed-release (Azulfidine EN-Tabs – brandis NP)

ursodiol (Actigall, Urso 250, Urso Forte– brands are NP)

GENITOURINARY DRUGS

URINARY TRACT INFECTIONS

nitrofurantoin (Furadantin – brand isNP)

nitrofurantoinmacrocrystalline (Macrodantin –brand is NP)

nitrofurantoin monohydrate/macrocrystalline (Macrobid – brandis NP)

URINARY TRACT SPASMS

oxybutynin

oxybutynin ext-release (Ditropan XL –brand is NP)

tolterodine (Detrol – brand is NP)

VAGINAL PRODUCTS

clindamycin (Cleocin – brand is NP)

ESTRACE crm

metronidazole (MetroGel-Vaginal –brand is NP)

terconazole (Terazol – brand is NP)

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

VAGIFEM

OTHER GENITOURINARY DRUGS

alfuzosin ext-release (Uroxatral –brand is NP)

CYSTAGON

finasteride (Proscar – brand is NP)

POTASSIUM CITRATE

potassium citrate/citric acidpowder (Polycitra-K – brand is NP)

sodium citrate/citric acid (Shohls –brand is NP)

tamsulosin (Flomax – brand is NP)

CENTRAL NERVOUS SYSTEM DRUGS

ANXIETY

alprazolam (Xanax – brand is NP)

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

•

buspirone, NP = 7.5 mg

diazepam tabs (Valium – brand is NP)

hydroxyzine hcl

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

lorazepam (Ativan – brand is NP)

lorazepam conc (Lorazepam Intensol –brand is NP)

DEPRESSION

amitriptyline

bupropion (Wellbutrin – brand is NP)

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

citalopram (Celexa – brand is NP)

clomipramine (Anafranil – brand is NP)

desipramine (Norpramin – brand is NP)

doxepin, NP = caps, 75 mg

escitalopram (Lexapro – brand is NP)

fluoxetine, NP = tabs, 60 mg (Prozac –brand is NP)

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

fluvoxamine

imipramine hcl (Tofranil – brand is NP)

mirtazapine (Remeron, RemeronSolTab – brands are NP)

nortriptyline caps (Pamelor – brand isNP)

paroxetine hcl (Paxil – brand is NP)

paroxetine hcl ext-release (Paxil CR –brand is NP)

phenelzine (Nardil – brand is NP)

sertraline (Zoloft – brand is NP)

tranylcypromine (Parnate – brand isNP)

trazodone

venlafaxine

venlafaxine ext-release caps (EffexorXR – brand is NP)

venlafaxine ext-release tabs, NP =225 mg

•

PSYCHOTIC AND BIPOLAR DISORDERS

chlorpromazine

clozapine (Clozaril – brand is NP)

FLUPHENAZINE conc, elixir

fluphenazine hcl tabs

haloperidol

haloperidol lactate

lithium carbonate

lithium carbonate ext-release300 mg (Lithobid – brand is NP)

lithium carbonate ext-release 450 mg

loxapine (Loxitane – brand is NP)

olanzapine (Zyprexa, Zyprexa Zydis –brands are NP)

perphenazine

prochlorperazine

quetiapine (Seroquel – brand is NP)

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

risperidone (Risperdal, Risperdal M-Tab – brands are NP)

SEROQUEL XR

thiothixene

trifluoperazine

ziprasidone (Geodon – brand is NP)

SLEEP AIDS

estazolam

phenobarbital, NP = 64.8 mg,97.2 mg

temazepam (Restoril – brand is NP)

zaleplon (Sonata – brand is NP) •zolpidem (Ambien – brand is NP) •zolpidem ext-release (Ambien CR –

brand is NP)•

HYPERACTIVITY/NARCOLEPSY

amphetamine/dextroamphetamine (Adderall –brand is NP)

•

amphetamine/dextroamphetamineext-release (Adderall XR – brand isNP)

•

caffeine citrate (Cafcit – brand is NP)

dextroamphetamine •dextroamphetamine ext-

release (Dexedrine Spansule – brandis NP)

•

INTUNIV •methylphenidate (Ritalin – brand is

NP)•

methylphenidate ext-release caps;tabs, 20 mg (Ritalin LA, Ritalin SR –brands are NP)

•

modafinil (Provigil – brand is NP) •MULTIPLE SCLEROSIS

BETASERON • •COPAXONE • •REBIF • •

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

OTHER CENTRAL NERVOUS SYSTEM DRUGS

bupropion ext-release (Zyban – brandis NP)

CHANTIX

disulfiram (Antabuse – brand is NP)

donepezil (Aricept, Aricept ODT –brands are NP)

galantamine (Razadyne – brand is NP)

galantamine ext-release (RazadyneER – brand is NP)

naltrexone (Revia – brand is NP) •NICOTROL INHALER

NICOTROL NS

NUEDEXTA

rivastigmine (Exelon – brand is NP)

PAIN RELIEF DRUGS

NON-NARCOTIC DRUGS

butalbital/acetaminophen

butalbital/acetaminophen/caffeine(Esgic, Esgic Plus, Fioricet – brandsare NP)

butalbital/aspirin/caffeinecaps (Fiorinal – brand is NP)

salsalate

NARCOTIC DRUGS

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

buprenorphine (Subutex – brand isNP)

• •

buprenorphine/naloxone SLtabs (Suboxone – brand is NP)

• •

butalbital/aspirin/caffeine/codeinecaps (Fiorinal w/Codeine – brand isNP)

fentanyl (Duragesic – brand is NP) •fentanyl (Actiq – brand is NP) • •

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

hydrocodone/acetaminophen, NP =tabs, 2.5-325 mg (Lortab – brand isNP)

hydrocodone/ibuprofen (Ibudone,Reprexain, Vicoprofen – brands areNP)

hydromorphone soln, tabs (Dilaudid –brand is NP)

methadone conc, soln

methadone tabs (Dolophine – brand isNP)

morphine sulfate conc, 20 mg/mL;soln

MORPHINE SULFATE supp, tabs

morphine sulfate ext-release (Kadian– brand is NP)

•

morphine sulfate ext-release (MSContin – brand is NP)

oxycodone (Roxicodone – brand is NP)

oxycodone caps

oxycodone/acetaminophen (Percocet– brand is NP)

oxycodone/aspirin (Percodan – brandis NP)

OXYCONTIN •tramadol (Ultram – brand is NP) •tramadol ext-release (Ultram ER –

brand is NP)•

tramadol/acetaminophen (Ultracet –brand is NP)

RHEUMATOID AND OSTEOARTHRITIS

diclofenac potassium (Cataflam –brand is NP)

diclofenac sodium delayed-release

diclofenac sodium ext-release (Voltaren-XR – brand is NP)

etodolac

flurbiprofen

HUMIRA • •

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

ibuprofen

indomethacin

ketoprofen

leflunomide (Arava – brand is NP)

meloxicam tabs (Mobic – brand is NP)

nabumetone

naproxen (Naprosyn – brand is NP)

naproxen delayed-release (EC-Naprosyn – brand is NP)

naproxen sodium (Anaprox – brand isNP)

oxaprozin (Daypro – brand is NP)

piroxicam (Feldene – brand is NP)

sulindac (Clinoril – brand is NP)

MIGRAINE HEADACHES

acetaminophen/isometheptene/dichloralphenazone

IMITREX nasal •naratriptan (Amerge – brand is NP) •rizatriptan (Maxalt, Maxalt MLT –

brands are NP)•

sumatriptan inj, tabs (Imitrex – brandis NP)

•

GOUT

allopurinol (Zyloprim – brand is NP)

probenecid

probenecid/colchicine

NEUROMUSCULAR DRUGS

SEIZURES

carbamazepine (Tegretol – brand isNP)

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

clonazepam (Klonopin – brand is NP)

DIASTAT •

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

divalproex delayed-release (DepakoteSprinkles, Depakote – brands areNP)

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

ethosuximide (Zarontin – brand is NP)

gabapentin (Neurontin – brand is NP)

lamotrigine (Lamictal – brand is NP)

levetiracetam (Keppra – brand is NP)

oxcarbazepine (Trileptal – brand is NP)

phenytoin chew tabs (Dilantin Infatabs– brand is NP)

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

phenytoin susp (Dilantin – brand isNP)

primidone (Mysoline – brand is NP)

SABRIL

topiramate (Topamax Sprinkle,Topamax – brands are NP)

valproic acid (Depakene – brand is NP)

zonisamide (Zonegran – brand is NP)

PARKINSON'S DISEASE

amantadine, NP = tabs

APOKYN •benztropine

bromocriptine (Parlodel – brand is NP)

carbidopa/levodopa (Parcopa,Sinemet – brands are NP)

carbidopa/levodopa ext-release (Sinemet CR – brand is NP)

COMTAN

entacapone (Comtan)

pramipexole (Mirapex – brand is NP)

ropinirole (Requip – brand is NP)

selegiline caps (Eldepryl – brand isNP)

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

selegiline tabs

trihexyphenidyl

MUSCLE RELAXANTS

baclofen

chlorzoxazone (Parafon Forte DSC –brand is NP)

cyclobenzaprine (Fexmid, Flexeril –brands are NP)

dantrolene (Dantrium – brand is NP)

metaxalone (Skelaxin – brand is NP)

methocarbamol (Robaxin – brand isNP)

orphenadrine citrate ext-release

orphenadrine/aspirin/caffeine25-385-30 mg

tizanidine (Zanaflex – brand is NP) •OTHER NEUROMUSCULAR DRUGS

pyridostigmine (Mestinon – brand isNP)

RILUTEK

SUPPLEMENTS

VITAMINS

ergocalciferol (Drisdol – brand is NP)

MEPHYTON

MULTIVITAMINS

pediatric multivitamins

pediatric vitamins ADC

PRENATAL PLUS, PRENATAL PLUS/IRON, PRENATAL VITAMINS PLUS

MINERALS AND ELECTROLYTES

potassium bicarbonate/chlorideeffervescent tabs, 25 mEq

potassium chloride packets; soln,10%

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

potassium chloride ext-release tabs

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

potassium phosphate/sodiumphosphates (K-Phos Neutral – brandis NP)

sodium fluoride, NP = tabs (Luride –brand is NP)

BLOOD MODIFYING DRUGS

ADVATE •ALPHANATE •ALPHANINE SD •anagrelide (Agrylin – brand is NP)

BEBULIN •BEBULIN VH •BENEFIX •CEREZYME •cilostazol (Pletal – brand is NP)

clopidogrel (Plavix – brand is NP)

CORIFACT •cyanocobalamin inj

dipyridamole (Persantine – brand isNP)

enoxaparin (Lovenox – brand is NP) •FEIBA NF •FEIBA VH •folic acid tabs, 1 mg

HELIXATE FS •HEMOFIL M •KOATE-DVI •KOGENATE FS •MONOCLATE-P •MONONINE •NEUPOGEN •NOVOSEVEN RT •pentoxifylline ext-release (Trental –

brand is NP)

PROCRIT • •PROFILNINE SD •

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

RECOMBINATE •SOLIRIS •warfarin (Coumadin – brand is NP)

WILATE •XYNTHA •XYNTHA SOLOFUSE •TOPICAL DRUGS

EYE

Anti-infectives

BACITRACIN oint

bacitracin/polymyxin B oint

ciprofloxacin soln (Ciloxan – brand isNP)

erythromycin oint

gentamicin oint, soln (Garamycin –brand is NP)

NATACYN

neomycin/polymyxin B/bacitracinoint

neomycin/polymyxin B/gramicidinsoln (Neosporin – brand is NP)

ofloxacin soln (Ocuflox – brand is NP)

polymyxin B/trimethoprimsoln (Polytrim – brand is NP)

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

tobramycin soln (Tobrex – brand isNP)

trifluridine soln (Viroptic – brand is NP)

Steroids and Combination Products

dexamethasone sodium phosphatesoln

fluorometholone susp, 0.1% (FMLLiquifilm – brand is NP)

neomycin/polymyxin B/bacitracin/hydrocortisone oint

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

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

prednisolone acetate susp (Pred Forte– brand is NP)

sulfacetamide sodium/prednisolonesoln

tobramycin/dexamethasonesusp (Tobradex – brand is NP)

Glaucoma

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

brimonidine soln, 0.2%

carteolol soln

dorzolamide soln (Trusopt – brand isNP)

dorzolamide/timolol maleatesoln (Cosopt – brand is NP)

latanoprost soln (Xalatan – brand isNP)

•

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

metipranolol soln (Optipranolol –brand is NP)

pilocarpine soln, 1%, 2%, 4% (IsoptoCarpine – brand is NP)

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

Other Eye Products

atropine sulfate soln (Isopto Atropine –brand is NP)

azelastine soln (Optivar – brand is NP)

cromolyn sodium soln

cyclopentolate soln (Cyclogyl – brandis NP)

diclofenac soln (Voltaren – brand isNP)

flurbiprofen soln (Ocufen – brand isNP)

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

homatropine soln (Isopto Homatropine– brand is NP)

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

tropicamide soln (Mydriacyl – brand isNP)

EAR

acetic acid soln

benzocaine/antipyrine soln

hydrocortisone/acetic acidsoln (Vosol HC – brand is NP)

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

ofloxacin soln

MOUTH AND THROAT (local)

cevimeline (Evoxac – brand is NP)

chlorhexidine (Peridex – brand is NP)

clotrimazole troche

lidocaine viscous

nystatin susp

pilocarpine (Salagen – brand is NP)

sodium fluoride (Prevident – brand isNP)

triamcinolone paste

ANORECTAL AGENTS

CORTIFOAM

hydrocortisone acetate crm, supp(Anusol-HC, Proctocort – brands areNP)

hydrocortisone enema (Cortenema –brand is NP)

SKIN CONDITIONS/PRODUCTS

Acne

adapalene (Differin – brand is NP) • •clindamycin (Cleocin T – brand is NP)

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

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

erythromycin pads, soln, 2%

erythromycin/benzoylperoxide (Benzamycin – brand is NP)

FINACEA

isotretinoin, NP = caps, 30 mg

metronidazole (Metrocream,Metrolotion – brands are NP)

metronidazole gel

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

TAZORAC •tretinoin (Retin-A – brand is NP) • •Anti-infectives

ciclopirox (Loprox – brand is NP)

ciclopirox soln, 8% (Penlac – brand isNP)

econazole

ketoconazole (Nizoral – brand is NP)

mupirocin (Bactroban – brand is NP)

nystatin topical

silver sulfadiazine (Silvadene – brandis NP)

Corticosteroids

alclometasone (Aclovate – brand isNP)

amcinonide crm

betamethasone dipropionate

betamethasone dipropionate,augmented (Diprolene – brand is NP)

betamethasone valerate

clobetasol (Olux, Temovate – brandsare NP)

desonide (Desowen – brand is NP)

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

diflorasone oint

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

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

fluocinolone crm, oint

fluocinonide

fluticasone propionate (Cutivate –brand is NP)

halobetasol (Ultravate – brand is NP)

hydrocortisone topical

hydrocortisone valerate (Westcort –brand is NP)

mometasone (Elocon – brand is NP)

nystatin/triamcinolone crm

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

Other Skin Products

aluminum chloride (Drysol – brand isNP)

calcipotriene crm, soln (Dovonex)

DOVONEX crm

fluorouracil (Efudex – brand is NP)

imiquimod (Aldara – brand is NP) •lidocaine jelly, 2%; oint, 5% (Xylocaine

– brand is NP)

lidocaine/prilocaine crm (Emla –brand is NP)

lindane

malathion (Ovide – brand is NP)

permethrin crm, 5%

podofilox (Condylox – brand is NP)

selenium sulfide (Selsun – brand isNP)

MISCELLANEOUS CATEGORIES (includes suppliesand devices)

DIABETIC SUPPLIES

TEST STRIPS – BAYER ASCENSIAAUTODISC, BREEZE 2, CONTOUR,CONTOUR NEXT

•

MEDICAL DEVICES

2013


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

BREATHERITE

MISCELLANEOUS DRUGS

azathioprine (Imuran – brand is NP)

CELLCEPT oral susp

CHEMET

CUPRIMINE

cyclosporine (Sandimmune – brand isNP)

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

CYCLOSPORINE MODIFIED caps,50 mg

mycophenolate mofetil (Cellcept –brand is NP)

RAPAMUNE

REVLIMID • •sodium polystyrene sulfonate

tacrolimus (Prograf – brand is NP)

THALOMID • •

2013


INDEX

A

abacavir tabs...................................................................2acarbose.......................................................................... 4acebutolol........................................................................ 5acetaminophen/codeine............................................... 10acetaminophen/isometheptene/dichloralphenazone 11acetazolamide ext-release............................................. 6acetazolamide tabs, 250 mg..........................................6acetic acid ear soln......................................................14acetylcysteine................................................................. 7ACTIMMUNE.................................................................... 3acyclovir.......................................................................... 2adapalene...................................................................... 14ADCIRCA..........................................................................7ADVATE..........................................................................13AEROHIST........................................................................7ALBENZA..........................................................................2albuterol 0.63 mg/3 mL, 1.25 mg/3 mL......................... 7albuterol inhal soln, 0.083%, 0.5%................................7albuterol syrup, tabs...................................................... 7alclometasone............................................................... 15ALDURAZYME................................................................. 4alendronate 5 mg, 10 mg, 35 mg, 70 mg...................... 4alfuzosin ext-release...................................................... 9ALKERAN tabs................................................................. 3allopurinol......................................................................11ALPHANATE...................................................................13ALPHANINE SD............................................................. 13alprazolam....................................................................... 9alprazolam ext-release................................................... 9aluminum chloride........................................................15amantadine, NP = tabs.................................................12amcinonide crm............................................................ 15amiloride.......................................................................... 6amiloride/hydrochlorothiazide.......................................6amiodarone......................................................................6amitriptyline.....................................................................9amlodipine....................................................................... 5amlodipine/benazepril.................................................... 5amoxicillin, NP = chew tabs.......................................... 1amoxicillin/potassium clavulanate................................1amoxicillin/potassium clavulanate ext-release............1amphetamine/dextroamphetamine..............................10amphetamine/dextroamphetamine ext-release..........10ampicillin caps................................................................1anagrelide...................................................................... 13anastrozole...................................................................... 3APOKYN......................................................................... 12APTIVUS...........................................................................2atenolol............................................................................ 5atenolol/chlorthalidone.................................................. 5atorvastatin......................................................................6

atovaquone/proguanil 250-100 mg............................... 2ATRIPLA........................................................................... 2atropine sulfate eye soln............................................. 14azathioprine...................................................................16azelastine eye soln.......................................................14azelastine nasal.............................................................. 7azithromycin susp.......................................................... 1azithromycin tabs........................................................... 1

B

bacitracin/polymyxin B eye oint................................. 13BACITRACIN eye oint.................................................... 13baclofen......................................................................... 12balsalazide.......................................................................8BARACLUDE.................................................................... 1BEBULIN.........................................................................13BEBULIN VH.................................................................. 13benazepril........................................................................ 5benazepril/hydrochlorothiazide.....................................5BENEFIX.........................................................................13benzocaine/antipyrine ear soln................................... 14benztropine....................................................................12betamethasone dipropionate.......................................15betamethasone dipropionate, augmented................. 15betamethasone valerate...............................................15BETASERON..................................................................10bicalutamide.................................................................... 3BILTRICIDE...................................................................... 2bisoprolol.........................................................................5bisoprolol/hydrochlorothiazide..................................... 5BREATHERITE...............................................................16brimonidine eye soln, 0.15%....................................... 14brimonidine eye soln, 0.2%......................................... 14bromocriptine................................................................12budesonide......................................................................7budesonide ext-release..................................................3bumetanide......................................................................6buprenorphine...............................................................10buprenorphine/naloxone SL tabs............................... 10bupropion........................................................................ 9bupropion ext-release.................................................... 9bupropion ext-release.................................................. 10buspirone, NP = 7.5 mg................................................. 9butalbital/acetaminophen.............................................10butalbital/acetaminophen/caffeine.............................. 10butalbital/aspirin/caffeine/codeine caps.....................10butalbital/aspirin/caffeine caps................................... 10

C

cabergoline......................................................................4caffeine citrate.............................................................. 10calcipotriene crm, soln................................................ 15calcitonin-salmon........................................................... 4calcitriol........................................................................... 4calcium acetate...............................................................8CANASA........................................................................... 8

2013


captopril...........................................................................5carbamazepine.............................................................. 11carbamazepine ext-release.......................................... 11carbidopa/levodopa...................................................... 12carbidopa/levodopa ext-release.................................. 12carteolol eye soln.........................................................14carvedilol......................................................................... 5CEENU............................................................................. 3cefadroxil......................................................................... 1cefdinir............................................................................. 1cefpodoxime....................................................................1cefprozil........................................................................... 1ceftriaxone.......................................................................1cefuroxime.......................................................................1CELLCEPT oral susp..................................................... 16cephalexin, NP = tabs.................................................... 1CEREZYME.................................................................... 13cetirizine syrup............................................................... 7cevimeline......................................................................14CHANTIX........................................................................ 10CHEMET.........................................................................16CHENODAL...................................................................... 8chlorhexidine.................................................................14chloroquine phosphate..................................................2chlorothiazide..................................................................6chlorpromazine............................................................... 9chlorzoxazone............................................................... 12cholestyramine................................................................6chorionic gonadotropin................................................. 4CIALIS...............................................................................7ciclopirox....................................................................... 15ciclopirox soln, 8%.......................................................15cilostazol........................................................................13cimetidine........................................................................ 8ciprofloxacin....................................................................1ciprofloxacin eye soln..................................................13citalopram........................................................................9clarithromycin................................................................. 1clarithromycin ext-release............................................. 1clindamycin..................................................................... 8clindamycin................................................................... 14clindamycin/benzoyl peroxide.....................................14clindamycin crm............................................................. 2clobetasol...................................................................... 15clomiphene...................................................................... 4clomipramine...................................................................9clonazepam................................................................... 11clonidine.......................................................................... 7clopidogrel.....................................................................13clotrimazole troche.......................................................14clozapine..........................................................................9colestipol......................................................................... 6COMBIPATCH.................................................................. 3COMTAN........................................................................ 12COPAXONE....................................................................10CORIFACT......................................................................13

CORTIFOAM.................................................................. 14CORTISONE ACETATE...................................................3CRESTOR........................................................................ 6CRIXIVAN......................................................................... 2cromolyn sodium eye soln..........................................14cromolyn sodium inhal soln..........................................7CUPRIMINE....................................................................16cyanocobalamin inj...................................................... 13cyclobenzaprine............................................................12cyclopentolate eye soln...............................................14CYCLOPHOSPHAMIDE tabs........................................... 3cyclosporine..................................................................16cyclosporine modified caps, 25 mg, 100 mg; soln.... 16CYCLOSPORINE MODIFIED caps, 50 mg....................16cyproheptadine............................................................... 7CYSTAGON......................................................................9

D

danazol.............................................................................3dantrolene......................................................................12DAPSONE........................................................................ 2DARAPRIM....................................................................... 2demeclocycline............................................................... 1desipramine.....................................................................9desmopressin..................................................................4desonide........................................................................ 15desoximetasone crm, 0.25%; gel; oint, 0.25%........... 15dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg,4 mg, 6 mg.................................................................... 3

dexamethasone sodium phosphate eye soln............ 13dextroamphetamine......................................................10dextroamphetamine ext-release..................................10DIASTAT.........................................................................11diazepam tabs.................................................................9DIBENZYLINE.................................................................. 7diclofenac eye soln...................................................... 14diclofenac potassium...................................................11diclofenac sodium delayed-release............................ 11diclofenac sodium ext-release.................................... 11dicloxacillin..................................................................... 1dicyclomine caps, tabs.................................................. 8didanosine delayed-release...........................................2diflorasone oint.............................................................15digoxin tabs.................................................................... 7diltiazem...........................................................................5diltiazem ext-release...................................................... 6diphenoxylate/atropine tabs.......................................... 8dipyridamole..................................................................13disopyramide...................................................................6disulfiram.......................................................................10divalproex delayed-release..........................................12divalproex ext-release..................................................12DIVIGEL............................................................................3donepezil....................................................................... 10dorzolamide/timolol maleate eye soln........................14dorzolamide eye soln...................................................14

2013


DOVONEX crm...............................................................15doxazosin........................................................................ 7doxepin, NP = caps, 75 mg........................................... 9doxycycline hyclate........................................................1

E

econazole.......................................................................15ELAPRASE....................................................................... 4ELLA................................................................................. 4EMEND caps.................................................................... 8EMTRIVA.......................................................................... 2enalapril........................................................................... 5enalapril/hydrochlorothiazide........................................5enoxaparin.....................................................................13entacapone.................................................................... 12EPIPEN.............................................................................7EPIPEN-JR....................................................................... 7EPIVIR soln...................................................................... 2eplerenone.......................................................................7EPZICOM..........................................................................2ergocalciferol................................................................ 12erythromycin/benzoyl peroxide...................................15erythromycin/sulfisoxazole............................................2erythromycin eye oint.................................................. 13erythromycin pads, soln, 2%.......................................15escitalopram....................................................................9estazolam.......................................................................10ESTRACE crm..................................................................8estradiol/norethindrone acetate.................................... 3estradiol patches............................................................ 3estradiol tabs.................................................................. 3estropipate 0.75 mg, 1.5 mg..........................................3ethambutol.......................................................................1ethosuximide.................................................................12etodolac......................................................................... 11EVISTA............................................................................. 4exemestane..................................................................... 3

F

FABRAZYME.................................................................... 4famciclovir....................................................................... 2famotidine........................................................................8FEIBA NF....................................................................... 13FEIBA VH....................................................................... 13felodipine ext-release.....................................................6fenofibrate....................................................................... 6fenofibrate micronized................................................... 6fentanyl.......................................................................... 10fentanyl.......................................................................... 10FINACEA........................................................................ 15finasteride........................................................................9FIRAZYR...........................................................................7FIRMAGON.......................................................................3flecainide......................................................................... 6FLOVENT DISKUS...........................................................7FLOVENT HFA.................................................................7

fluconazole...................................................................... 1flucytosine....................................................................... 1fludrocortisone................................................................3fluocinolone...................................................................15fluocinolone crm, oint..................................................15fluocinonide...................................................................15fluorometholone eye susp, 0.1%................................ 13fluorouracil.................................................................... 15fluoxetine, NP = tabs, 60 mg......................................... 9FLUPHENAZINE conc, elixir............................................ 9fluphenazine hcl tabs.....................................................9flurbiprofen....................................................................11flurbiprofen eye soln....................................................14flutamide.......................................................................... 3fluticasone propionate................................................... 7fluticasone propionate................................................. 15fluvoxamine..................................................................... 9folic acid tabs, 1 mg.................................................... 13FOLLISTIM AQ.................................................................4FORADIL AEROLIZER.....................................................7fosinopril..........................................................................5fosinopril/hydrochlorothiazide...................................... 5furosemide, NP = soln, 8 mg/mL.................................. 6FUZEON........................................................................... 2

G

gabapentin.....................................................................12galantamine................................................................... 10galantamine ext-release...............................................10gemfibrozil.......................................................................6gentamicin eye oint, soln............................................ 13GLEEVEC......................................................................... 3glimepiride.......................................................................4glipizide............................................................................4glipizide/metformin......................................................... 4glipizide ext-release....................................................... 4GLUCAGON EMERGENCY KIT...................................... 4glyburide..........................................................................4glyburide/metformin....................................................... 4glyburide micronized..................................................... 4glycopyrrolate................................................................. 8granisetron...................................................................... 8griseofulvin microsize....................................................1guanfacine....................................................................... 7

H

halobetasol.................................................................... 15haloperidol.......................................................................9haloperidol lactate..........................................................9HELIXATE FS.................................................................13HEMOFIL M....................................................................13HEPSERA.........................................................................1homatropine eye soln.................................................. 14HUMIRA..........................................................................11hydralazine...................................................................... 7hydrochlorothiazide caps.............................................. 6

2013


hydrochlorothiazide tabs...............................................6hydrocodone/acetaminophen, NP = tabs, 2.5-325mg.................................................................................11

hydrocodone/ibuprofen................................................11hydrocortisone................................................................3hydrocortisone/acetic acid ear soln........................... 14hydrocortisone acetate rectal crm, supp................... 14hydrocortisone enema................................................. 14hydrocortisone topical.................................................15hydrocortisone valerate...............................................15hydromorphone soln, tabs.......................................... 11hydroxychloroquine....................................................... 2hydroxyurea.................................................................... 3hydroxyzine hcl.............................................................. 9hydroxyzine pamoate 25 mg, 50 mg.............................9hyoscyamine................................................................... 8hyoscyamine ext-release............................................... 8

I

ibandronate..................................................................... 5ibuprofen....................................................................... 11imipramine hcl................................................................ 9imiquimod......................................................................15IMITREX nasal............................................................... 11INCIVEK............................................................................1INCRELEX........................................................................ 4indapamide...................................................................... 6indomethacin.................................................................11INTELENCE......................................................................2INTUNIV..........................................................................10INVIRASE......................................................................... 2ipratropium/albuterol......................................................7ipratropium inhal soln....................................................7ipratropium nasal........................................................... 7irbesartan.........................................................................5irbesartan/hydrochlorothiazide..................................... 5ISENTRESS......................................................................2isoniazid/rifampin........................................................... 1isoniazid tabs..................................................................1isosorbide dinitrate, NP = SL tabs................................6isosorbide mononitrate..................................................6isosorbide mononitrate ext-release..............................6isotretinoin, NP = caps, 30 mg....................................15itraconazole..................................................................... 1

J

K

KALETRA..........................................................................2KALYDECO...................................................................... 7ketoconazole................................................................. 15ketoconazole tabs.......................................................... 1ketoprofen..................................................................... 11ketorolac eye soln........................................................ 14KOATE-DVI.....................................................................13KOGENATE FS.............................................................. 13

L

labetalol........................................................................... 5lactulose.......................................................................... 7lactulose.......................................................................... 8lamivudine....................................................................... 2lamivudine/zidovudine................................................... 2lamotrigine.....................................................................12lansoprazole delayed-release........................................8LANTUS............................................................................4latanoprost eye soln.................................................... 14leflunomide....................................................................11letrozole........................................................................... 3LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg.................3leucovorin calcium tabs, 5 mg, 25 mg......................... 3LEUKERAN.......................................................................3LEVEMIR.......................................................................... 4levetiracetam................................................................. 12levobunolol eye soln, 0.5%..........................................14levocarnitine....................................................................5levofloxacin..................................................................... 1levonorgestrel................................................................. 4levothyroxine...................................................................4LEXIVA............................................................................. 2lidocaine/prilocaine crm...............................................15lidocaine jelly, 2%; oint, 5%........................................ 15lidocaine viscous..........................................................14lindane........................................................................... 15liothyronine..................................................................... 4lisinopril........................................................................... 5lisinopril/hydrochlorothiazide........................................5lithium carbonate............................................................9lithium carbonate ext-release 300 mg.......................... 9lithium carbonate ext-release 450 mg.......................... 9loperamide caps............................................................. 8lorazepam........................................................................ 9lorazepam conc.............................................................. 9losartan............................................................................ 5losartan/hydrochlorothiazide.........................................5lovastatin......................................................................... 6loxapine........................................................................... 9LUMIZYME....................................................................... 5

M

MALARONE......................................................................2malathion....................................................................... 15MEBENDAZOLE...............................................................2medroxyprogesterone acetate inj, 150 mg/mL............ 4medroxyprogesterone acetate tabs..............................3mefloquine.......................................................................2megestrol.........................................................................3meloxicam tabs.............................................................11MEPHYTON....................................................................12mercaptopurine...............................................................3mesalamine..................................................................... 8metaxalone.................................................................... 12

2013


metformin........................................................................ 4metformin ext-release.................................................... 4metformin ext-release OSM...........................................4methadone conc, soln................................................. 11methadone tabs............................................................ 11methazolamide................................................................ 6methimazole.................................................................... 4methocarbamol............................................................. 12methotrexate................................................................... 3methscopolamine........................................................... 8methyldopa......................................................................7methylergonovine........................................................... 5methylphenidate........................................................... 10methylphenidate ext-release caps; tabs, 20 mg........ 10methylprednisolone........................................................3metipranolol eye soln.................................................. 14metoclopramide.............................................................. 8metolazone...................................................................... 6metoprolol succinate ext-release..................................5metoprolol tartrate..........................................................5metronidazole..................................................................2metronidazole..................................................................8metronidazole................................................................15metronidazole topical gel............................................ 15midodrine.........................................................................7minocycline..................................................................... 1minoxidil.......................................................................... 7MIRENA............................................................................ 4mirtazapine...................................................................... 9misoprostol..................................................................... 8modafinil........................................................................ 10moexipril.......................................................................... 5moexipril/hydrochlorothiazide.......................................5mometasone..................................................................15MONOCLATE-P..............................................................13MONONINE.................................................................... 13montelukast.....................................................................7morphine sulfate conc, 20 mg/mL; soln.....................11morphine sulfate ext-release.......................................11morphine sulfate ext-release.......................................11MORPHINE SULFATE supp, tabs................................. 11mupirocin.......................................................................15MYCOBUTIN.................................................................... 1mycophenolate mofetil.................................................16MYLERAN.........................................................................3MYOZYME........................................................................5

N

nabumetone...................................................................11nadolol............................................................................. 5NAGLAZYME....................................................................5naltrexone......................................................................10naproxen........................................................................11naproxen delayed-release............................................11naproxen sodium..........................................................11naratriptan..................................................................... 11

NATACYN.......................................................................13nateglinide....................................................................... 4neomycin/polymyxin B/bacitracin/hydrocortisoneeye oint........................................................................ 13

neomycin/polymyxin B/bacitracin eye oint................ 13neomycin/polymyxin B/dexamethasone eye oint,susp..............................................................................14

neomycin/polymyxin B/gramicidin eye soln.............. 13neomycin/polymyxin B/hydrocortisone ear soln,susp..............................................................................14

neomycin sulfate............................................................ 1NEUPOGEN................................................................... 13nevirapine tabs............................................................... 2NEXAVAR.........................................................................3NIASPAN.......................................................................... 6NICOTROL INHALER.................................................... 10NICOTROL NS............................................................... 10nifedipine ext-release.....................................................6nitrofurantoin.................................................................. 8nitrofurantoin macrocrystalline.....................................8nitrofurantoin monohydrate/macrocrystalline............. 8nitroglycerin.................................................................... 6NITROSTAT......................................................................6norethindrone acetate....................................................3nortriptyline caps........................................................... 9NORVIR............................................................................ 2NOVOLIN 70/30............................................................... 4NOVOLIN N......................................................................4NOVOLIN R......................................................................4NOVOLOG........................................................................4NOVOLOG MIX 70/30......................................................4NOVOSEVEN RT........................................................... 13NOXAFIL...........................................................................1NUEDEXTA.................................................................... 10NUVARING....................................................................... 4nystatin/triamcinolone crm..........................................15nystatin oral.................................................................... 1nystatin susp................................................................ 14nystatin topical............................................................. 15

O

octreotide.........................................................................5ofloxacin ear soln.........................................................14ofloxacin eye soln........................................................ 13olanzapine....................................................................... 9omeprazole delayed-release..........................................8OMNITROPE.................................................................... 4ondansetron.................................................................... 8ondansetron tabs, 24 mg...............................................8oral contraceptives – all generics.................................4ORFADIN..........................................................................5orphenadrine/aspirin/caffeine 25-385-30 mg..............12orphenadrine citrate ext-release................................. 12ORTHO EVRA..................................................................4oxaprozin....................................................................... 11oxcarbazepine............................................................... 12

2013


oxybutynin.......................................................................8oxybutynin ext-release...................................................8oxycodone..................................................................... 11oxycodone/acetaminophen..........................................11oxycodone/aspirin........................................................ 11oxycodone caps........................................................... 11OXYCONTIN...................................................................11

P

pantoprazole delayed-release....................................... 8paromomycin.................................................................. 1paroxetine hcl................................................................. 9paroxetine hcl ext-release............................................. 9pediatric multivitamins.................................................12pediatric vitamins ADC................................................ 12PEGASYS.........................................................................1PEG – electrolytes for soln........................................... 8penicillin v potassium....................................................1pentoxifylline ext-release.............................................13perindopril....................................................................... 5permethrin crm, 5%......................................................15perphenazine...................................................................9phenelzine....................................................................... 9phenobarbital, NP = 64.8 mg, 97.2 mg........................10phenytoin chew tabs....................................................12phenytoin sodium ext-release.....................................12phenytoin susp............................................................. 12pilocarpine.....................................................................14pilocarpine eye soln, 1%, 2%, 4%............................... 14pioglitazone..................................................................... 4pioglitazone/metformin.................................................. 4piroxicam....................................................................... 11podofilox........................................................................15polymyxin B/trimethoprim eye soln............................13potassium bicarbonate/chloride effervescent tabs,25 mEq......................................................................... 12

potassium chloride ext-release...................................12potassium chloride ext-release tabs.......................... 12potassium chloride packets; soln, 10%..................... 12POTASSIUM CITRATE.................................................... 9potassium citrate/citric acid powder............................ 9potassium phosphate/sodium phosphates................13pramipexole...................................................................12pravastatin.......................................................................6prazosin........................................................................... 7prednisolone................................................................... 3prednisolone acetate eye susp................................... 14prednisolone sodium phosphate soln..........................3prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg... 3PRENATAL PLUS, PRENATAL PLUS/IRON,PRENATAL VITAMINS PLUS...................................... 12

PREVPAC.........................................................................8PREZISTA tabs................................................................ 2PRIFTIN............................................................................ 1PRIMAQUINE................................................................... 2primidone.......................................................................12

PROAIR HFA....................................................................7probenecid.....................................................................11probenecid/colchicine.................................................. 11prochlorperazine.............................................................9PROCRIT........................................................................13PROFILNINE SD............................................................ 13progesterone micronized...............................................3promethazine, NP = supp, 50 mg..................................7propafenone.................................................................... 6propafenone ext-release................................................ 6propranolol ext-release..................................................5propranolol tabs............................................................. 5propylthiouracil...............................................................4PULMOZYME................................................................... 7pyrazinamide................................................................... 1pyridostigmine.............................................................. 12

Q

quetiapine........................................................................ 9quinapril...........................................................................5quinapril/hydrochlorothiazide....................................... 5quinidine gluconate ext-release....................................6quinidine sulfate, NP = ext-release tabs.......................6QVAR................................................................................7

R

ramipril.............................................................................5ranitidine..........................................................................8RAPAMUNE....................................................................16REBIF............................................................................. 10RECOMBINATE..............................................................13REMICADE....................................................................... 8RESCRIPTOR.................................................................. 2REVLIMID....................................................................... 16REYATAZ......................................................................... 2ribavirin............................................................................2rifampin............................................................................1RILUTEK.........................................................................12risperidone.................................................................... 10rivastigmine...................................................................10rizatriptan.......................................................................11ropinirole....................................................................... 12

S

SABRIL........................................................................... 12salsalate.........................................................................10selegiline caps.............................................................. 12selegiline tabs...............................................................12selenium sulfide........................................................... 15SELZENTRY.....................................................................2SENSIPAR........................................................................5SEROQUEL XR..............................................................10sertraline..........................................................................9sildenafil.......................................................................... 7silver sulfadiazine.........................................................15simvastatin...................................................................... 6

2013


SKYLA.............................................................................. 4sodium citrate/citric acid............................................... 9sodium fluoride.............................................................14sodium fluoride, NP = tabs..........................................13sodium polystyrene sulfonate.....................................16SOLIRIS..........................................................................13sotalol.............................................................................. 7SPIRIVA HANDIHALER................................................... 7spironolactone................................................................ 6spironolactone/hydrochlorothiazide.............................6SPRYCEL......................................................................... 3stavudine......................................................................... 2STIMATE.......................................................................... 5STRIBILD..........................................................................2STROMECTOL................................................................. 2sucralfate......................................................................... 8sulfacetamide sodium/prednisolone eye soln........... 14sulfacetamide sodium/sulfur NP = susp, 10-5%........ 15sulfacetamide sodium eye soln.................................. 13sulfamethoxazole/trimethoprim.....................................2sulfasalazine....................................................................8sulfasalazine delayed-release....................................... 8sulindac......................................................................... 11sumatriptan inj, tabs.................................................... 11SUPRAX tabs................................................................... 1SUSTIVA...........................................................................2SUTENT............................................................................3SYLATRON.......................................................................3SYMBICORT.....................................................................7SYNAGIS.......................................................................... 3SYNAREL......................................................................... 4

T

tacrolimus......................................................................16tamoxifen......................................................................... 3tamsulosin....................................................................... 9TARCEVA......................................................................... 3TASIGNA.......................................................................... 3TAZORAC.......................................................................15temazepam.................................................................... 10TEMODAR........................................................................ 3terazosin.......................................................................... 7terbinafine........................................................................1terbutaline........................................................................7terconazole...................................................................... 8TEST STRIPS – BAYER ASCENSIA AUTODISC,BREEZE 2, CONTOUR, CONTOUR NEXT..................15

THALOMID..................................................................... 16theophylline ext-release.................................................7thiothixene.....................................................................10timolol maleate eye soln..............................................14tizanidine....................................................................... 12TOBI, NP = Podhaler....................................................... 1tobramycin/dexamethasone eye susp........................14tobramycin eye soln.....................................................13tolterodine....................................................................... 8

topiramate......................................................................12torsemide.........................................................................6TRACLEER.......................................................................7tramadol.........................................................................11tramadol/acetaminophen............................................. 11tramadol ext-release.....................................................11trandolapril...................................................................... 5tranylcypromine.............................................................. 9trazodone.........................................................................9tretinoin..........................................................................15tretinoin caps.................................................................. 3triamcinolone.................................................................. 7triamcinolone, crm; lotn; oint, 0.025%, 0.1%..............15triamcinolone dental paste..........................................14triamterene/hydrochlorothiazide................................... 6triamterene/hydrochlorothiazide................................... 6trifluoperazine............................................................... 10trifluridine eye soln...................................................... 13trihexyphenidyl............................................................. 12trimethobenzamide......................................................... 8trimethoprim....................................................................2TRIZIVIR........................................................................... 2tropicamide eye soln....................................................14TRUVADA.........................................................................2

U

ursodiol............................................................................8

V

VAGIFEM..........................................................................9valacyclovir..................................................................... 2VALCYTE..........................................................................1valproic acid..................................................................12valsartan/hydrochlorothiazide.......................................5vancomycin..................................................................... 2venlafaxine...................................................................... 9venlafaxine ext-release caps.........................................9venlafaxine ext-release tabs, NP = 225 mg.................. 9VENTOLIN HFA............................................................... 7verapamil, NP = 40 mg...................................................6verapamil ext-release..................................................... 6VFEND susp.....................................................................1VICTOZA.......................................................................... 4VICTRELIS....................................................................... 2VIDEX............................................................................... 2VIRACEPT........................................................................ 2VIRAMUNE XR.................................................................2VIREAD.............................................................................2voriconazole.................................................................... 1VOTRIENT........................................................................3

W

warfarin.......................................................................... 13WILATE...........................................................................13

2013


X

XALKORI.......................................................................... 3XELODA........................................................................... 3XIFAXAN 550 mg.............................................................2XYNTHA......................................................................... 13XYNTHA SOLOFUSE.................................................... 13

Y

Z

zafirlukast........................................................................ 7zaleplon..........................................................................10ZELBORAF....................................................................... 3ZEMPLAR......................................................................... 5ZENPEP............................................................................8ZIAGEN soln.....................................................................2zidovudine....................................................................... 2ziprasidone.................................................................... 10zolpidem........................................................................ 10zolpidem ext-release.................................................... 10zonisamide.................................................................... 12ZYTIGA............................................................................. 3ZYVOX..............................................................................2

july 2013 blue cross and blue shield generics plus …blue cross and blue shield generics plus july...

Documents