level 1 and 2 medication list 1.24 - azblue · anti-virals, (cmv) level 1 ganciclovir (generic for...

Level 1 Generic and Level 2 Medication List 1/24/2019

The medications listed in blue are available at the Level 1 copayment (the lowest cost sharing amount) and the medications listed in black are available at the Level 2 copayment. Not all generic medications are listed in this Guide.

Some medications are available at a retail copay level but will still require specialty distribution limited to a maximum of a 30 day supply. BCBSAZ has selected Briova Specialty Pharmacy as the exclusive Specialty Pharmacy. The medications followed by “SP” may be obtained through Briova. Please contact Briova directly at (866) 618-6741 to establish service with them. If you are currently obtaining a Specialty Medication from a Specialty Pharmacy and need to receive that medication from a retail pharmacy instead, please contact the Pharmacy Benefit Customer Service number listed on your BCBSAZ member identification card. BCBSAZ and/or the PBM will decide whether you are eligible to receive the Specialty Medication from a retail pharmacy instead of a Specialty Pharmacy.

The Level 2 Medication List includes the specific medications available at the Level 2 copayment. For example, if Adderall XR is listed, but Adderall is not, Adderall may only be available at Level 3 or Level 4.

The medications followed by “PL” have Prescription Limitations as stated in your benefit plan booklet. To learn more about Prescription Limitations, please click here.

ANTI-INFECTIVE

ANTI-FUNGALS Level 1 itraconazole (generic for Sporonoxl)

capsule: 100mg ketoconazole (generic for N izoral) tablet: 200mg voriconazole (generic for Vfend) tablet: 50mg, 200mg oral susp: 40mg/ml

Level 2 Linezolid Tabs Linezolid oral susp

ANTI-FUNGALS, MOUTH/THROAT Level 1

nystatin (generic for M ycostatin, Nystatin)

tablet: 500,000u suspension: 100,000u/ml oral powder : 50miu, 150miu, 500miu, 2biu

ANTI-FUNGALS, VAGINAL Level 1

fluconazole (generic for D iflucan) tablet: 100mg, 150mg, 200mg

ANTI-TUBERCULOSIS Level 2

Dapsone Sirturo

ANTI-PARASITICS Level 2

Atovaquone suspension Mepron suspension

ANTI-VIRALS, (CMV) Level 1

ganciclovir (generic for C ytovene) capsule: 250mg, 500mg

ANTI-VIRALS, HEPATITIS Level 1

ANTI-VIRALS, HIV Level 1

abacavir sulfate-lamivudine-zidovudine (generic for Trizivir)

tablet: 300-150-300mg abacavir sulfate (generic for Ziagen)

tablets: 300mg oral solution: 20mg/ml

didanosine (SP) (generic for Videx EC) capsule: 125mg, 200mg, 250mg, 400mg lamivudine-zidovudine (generic for C ombivir)

tablet: 150-300mg lamivudine (generic for Epivir) tablet: 150mg, 300mg nevirapine (generic for Viramune) tablet: 200mg susp: 50mg/5ml nevirapine ER (generic for Viramune XR)

tablet:: 100mg, 400mg stavudine (generic for Zerit) capsule: 15mg, 20mg, 30mg, 40mg

oral solution: 1mg/ml valacyclovir (generic for Valtrex) tablet: 500mg, 1000mg zidovudine (generic for R etrovir) capsule: 100mg tablets: 300mg syrup: 50mg/5ml

Level 2 Aptivus Atazanavir caps (PL) Atripla (PL) Cimduo (PL) Complera Crixivan Edurant (PL) Efavirenz (PL) Emtriva (PL) Fosamprenavir Tabs Genvoya

Intelence Isentress Isentress HD Invirase Kaletra Lexiva Nevirapine susp Norvir Caps/Sol Norvir Tabs Norvir Powder P acket Odefsey Tabs Prezista (PL) Reyataz (PL) Ritonavir Tabs Selzentry Stribild Symfi (PL) Symfi Lo (PL) Tenofovir (PL) Tivicay Truvada (PL) Videx Viracept Viramune suspension Viread (PL) Vitekta

ANTI-VIRALS, OTHERS Level 1

acyclovir (generic for Zovirax)

capsule: 200mg tablet: 400mg, 800mg suspension: 200mg/5ml

Level 2 Oseltamivir phosphage capsules Oseltamivir phosphate oral suspension

CEPHALOSPORINS, 1ST GENERATION Level 1

cephalexin (generic for Keflex)

capsule: 250mg, 500mg suspension: 125mg/5ml, 250mg/5ml

cefadroxil (generic Duricef, Ultracef

capsule: 250mg, 500mg tablets: 1 gm

*Coverage may vary by benefit plan

https://www.azblue.com/~/media/azblue/files/pharmacy-forms-mastery-directory/standard-pharmacy-plans/other-forms-and-resources/retail-and-mail-order-medications-and-vaccines-with-limitations-and-precertification-requirements.pdf

Level 1 Generic and Level 2 Medication List

The medications followed by "PL" have Prescription Limitations as stated in your benefit plan booklet. To learn more about Prescription Limitations, please click here.

suspension: 250mg/5ml, 500mg/5ml

CEPHALOSPORINS, 2ND GENERATION Level 1

cefaclor (generic for C eclor) capsule: 250mg, 500mg cefuroxime (generic for C eftin) tablet: 250mg, 500mg cefprozil (generic for C efzil) tablets: 250mg, 500mg


CEPHALOSPORINS, 3RDGENERATION Level 1

cefdinir generic for Omnicef)

capsules: 300mg suspension: 125mg/5ml, 250mg/5ml

cefpodoxime proxetil generic for Vantin) tablets: 100mg, 200mg


MACROLIDES Level 1

azithromycin (generic for Zithromax) tablet: 250mg, 500mg, 600mg suspension: 100mg/5ml, 200mg/5ml clarithromycin (generic for Biaxin)

tablet: 250mg, 500mg suspension: 125mg/5ml, 250mg/5ml

clarithromycin SR (generic for Biaxin XL)

tablet: 500mg

OTHER ANTI-INFECTIVES Level 1

Nitrofurantoin monohydrate macrocrystalline (generic for M acrobid)

capsules: 100mg Chlorhexidine gluconate, Periogard (generic for P eridex)

solution: 0.12%

Level 2 Nebupent Linezolid oral suspension (PL)

OTHER ANTIMICROBIALS Level 1

clindamycin (generic for C leocin) capsule: 150mg, 300mg metronidazole (generic for Flagyl) tablet: 250mg, 500mg

PENICILLINS Level 1

amoxicillin (generic for Amoxil)

capsule: 250mg, 500mg chewable tablet: 250mg suspension: 125mg/5ml, 200mg/5ml, 250mg/5ml, 400mg/5ml

amoxicillin/clavulanic potassium (generic for Augmentin)

tablet: 500mg/125mg, 875mg/125mg

suspension: 200-28.5mg/5ml, 250-

62.5mg/5ml, 400-57mg/5ml, 600-42.9mg/5ml amoxicillin/clavulanic potassium ER (generic for Augmentin XR)

tablet: 1000-62.5mg dicloxacillin (generic for D ynapen, Pathocil)

capsule: 250mg, 500mg penicillin V potassium (generic for Penicillin VK) tablet: 250mg, 500mg

QUINOLONES (FLURO) Level 1

ciprofloxacin HCL

(generic for C ipro) tablet: 250mg, 500mg, 750mg levofloxacin (PL) (generic for L evaquin) tablet: 250mg, 500mg, 750mg moxifloxacin

(generic for A velox) tablet: 400mg ofloxacin (PL) (generic for Floxin) tablet: 200mg, 300mg, 400mg

SULFONAMIDES/MACROLIDES Level 1

erythromycin/sulfasoxazole (generic for Pediazole)

suspension: 200mg/600mg/5ml

SULFONAMIDES Level 1

trimethoprim/sulfamethoxazole (generic for Bactrim)

tablet: 80mg/400mg trimethoprim/sulfamethoxazole (generic for Bactrim DS)

tablet: 160mg/800mg trimethoprim/sulfamethoxazole (generic for Septra) suspension: 40mg/200mg/5ml

TETRACYCLINES Level 1

doxycycline Hyclate, morgidox (generic for Vibramycin)

capsule: 50mg, 100mg doxycycline hyclate (generic for Vibratab)

tablet:100mg doxycycline hyclate delayed release (generic for D oryx) (PL)

tablet:100mg doxycycline hyclate (generic for Periostat)

tablet: 20mg doxycycline monohydrate, Okebo (generic for M onodox) capsule: 50mg, 100mg minocycline (generic for M inocin)

capsule: 50mg, 75mg, 100mg tetracycline hcl

(generic for Achromycin V) capsule: 250mg, 500mg

ANTINEOPLASTIC

ALKYLATING AGENTS Level 1

Alecensa-tab (PL) SP Alkeran-tab SP Cyclophosphamide –tab SP/cap Empliciti-inj Gleostine-cap Hexalen-cap SP Leukeran-tab SP Lomustine-cap SP Melphalan-tab (generic for Alkeran) tablet: 2mg Myleran-tab SP Temodar-cap SP (PL) Temozolomide SP (generic for Temodar)

capsule: 5mg ,20mg, 100mg, 140mg,180mg, 250mg

Verzenio-tab SP (PL)

ANTIMETABOLITES Level 1

Capecitabine SP (generic for X eloda) tablet: 150mg, 500mg Purinethol-tab Purixan (PL)-susp Tabloid-tab Trexall-tab Xeloda-tab SP

ANTI-RHEUMATICS, PSORIASIS ANTIMETABOLITES

Level 1 methotrexate tablet: 2.5mg

injection: 25mg/ml, 1gm oral solution: 2.5mg/ml

HORMONAL AGENTS Level 1

Abiraterone 250mg tab (PL) SP Anastrozole (PL)-tab (generic for Arimidex) tablet: 1mg Arimidex (PL)-tab Aromasin (PL)-tab Bicalutamide-tab (generic for Casodex) tablet: 50mg Daurismo (PL) tablet: 25mg, 100mg Eligard Kit (PL)-inj SP Emcyt-cap SP Exemestane (PL)-tab (generic for Aromasin) tablet: 25mg Fareston (PL)-tab Faslodex-inj SP (PL) Femara (PL)-tab Firmagon-inj SP Iressa Letrozole (PL)-tab

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(generic for Femara) tablet: 2.5mg Leuprolide Acetate 5mg-inj (PL) SP Lupron Depot 22.5mg inj (PL) SP Lupron Depot 30mg inj (PL) SP Lupron Depot 45mg inj (PL) SP Lysodren-tab SP Megace-oral susp Megestrol Acetate (generic for M egace) suspension: 40mg/ml Nilandron (PL)-tab Nilutamide (PL)-tab (generic for N ilandron) tablet: 150mg Soltamox-sol raloxifene (PL) (generic for E vista)

tablet: 60mg tamoxifen (generic for N olvadex) tablet: 10mg, 20mg Trelstar-susp SP Vantas-inj SP Xospata (PL) Xtandi-cap SP Yonsa-tab (PL) Zoladex-implant SP Zytiga-tab SP (PL)

IMMUNOMODULATORS Level 1 Pomalyst-cap SP Thalomid-cap SP Imiquimod-cream

ENZYME INHIBITORS Level 1 Afinitor (PL)-tab/oral susp SP Alecensa (PL) SP Alunbrig tab (PL) SP Alunbrig Pak (PL) SP Bosulif-tab SP Braftovi cap (PL) Cabometyx-tab (PL) SP Calquence-cap (PL) Caprelsa-tab SP Cometriq-cap SP Cotellic-tab (PL) SP Farydak-cap Gilotrif-tab SP Gleevec (PL)-tab SP Ibrance (PL)-cap SP Iclusig-tab SP Idhifa-(PL)-tab SP Imatinib tab (PL) SP Imbruvica (PL)-cap/tab SP Inlyta-tab SP Jakafi-tab SP Kisqali-(PL) tab SP Kyprolis-IV Lenvima-cap SP Lorbrena tab Lynparza (PL)-cap SP Lynparza –(PL)-tab SP Mekinist (PL)-tab SP Mektovi cap (PL) Nexavar (PL)-tab SP Nerlynx- (PL)-tab SP Ninlaro-cap (PL) SP

Rubraca-tab (PL) SP Rydapt-cap (PL) SP Sprycel (PL)-tab SP Stivarga-tab SP Sutent (PL)-cap SP Tafinlar-cap SP Tagrisso-tab SP Talzenna-cap (PL) Tarceva-tab SP Tasigna-cap SP Tykerb (PL)-tab SP Votrient-tab SP Xalkori (PL)-cap SP Zelboraf (PL)-tab SP Zolinza (PL)-cap SP Zydelig-tab (PL) SP Zykadia (PL)-cap SP

PREMALIGNANT LESION AGENTS Level 1 Bexarotene cap SP (generic for Targretin) cap: 75mg Carac cream 0.5% (PL) Diclofenac Sodium gel (PL) (generic for Solaraze) gel: 3% Efudex-cream SP (PL) Fluorac-cream Fluoroplex 1%-cream SP (PL) Fluorouracil SP (generic for Efudex) cream: 5% Fluorouracil cream 0.5% (PL) Fluorouracil solution 2%, %5 Metvixia-cream Panretin-gel (PL) SP Picato-gel (PL) Solaraze gel (PL) Targretin cap SP Targretin gel (PL) SP Tibsovo tab (PL) Tolak-cream 4% Valchlor (PL)-gel SP

OTHER ONCOLOGICS Level 1 Actimmune-inj SP Bavencio-IV SP Bendamustine-inj SP Bendeka-inj SP Copiktra- cap (PL) Etoposide-cap SP Erivedge-cap SP Erleada- tab (PL) Hycamtin-cap SP Hydrea-cap Intron-A-inj SP Lartruvo-inj-SP Lonsurf-(PL)-tab SP Matulane-cap SP Mitoxantrone HCL-IV SP (PL) Mylotarg-IV-SP (PL) Odomzo (PL)-cap SP Revlimid (PL)-cap SP Rituxan-inj (PL) SP Rituxan Hycela (PL) SP Synribo-inj SP Tretinoin-cap SP (PL) Venclexta-tab (PL) SP

Vitrakvi (PL) capsule: 25mg, 100mg solution: 20mg/ml Vizimpro- tab (PL) Xatmep –oral sol (PL) SP Zejula-cap-(PL) SP

AUTONOMIC & CENTRAL NERVOUS SYSTEM

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) Level 1 amphetamine-dextroamphetamine (generic for Adderall)

tablet: 5mg, 7.5mg, 10mg,12.5mg, 15mg 20mg, 30mg

dextroamphetamine sulfate (generic for Zenzedi) (PL)

tablet: 5mg, 10mg dextroamphetamine

(generic for D exedrine) (PL) capsule: 5mg, 10mg, 20mg

dextroamphetamine (generic for D extrostat) tablet: 5mg,10mg

guanfacine hcl ER/SR (PL) (generic for Intiniv)

tablet: 1mg, 2mg, 3mg, 4mg methamphetamine

(generic for D esoxyn) (PL) tablet: 5mg

methylphenidate (generic for R italin) (PL) tablet: 5mg,10mg, 20mg

methylphenidate 24hrER/SR (generic for R italin LA) (PL) capsules: 10mg,20mg, 30mg, 40mg methylphenidate CR (generic for M etadate CD) (PL)

capsules: 10mg, 20mg, 30mg, 40mg,50mg, 60mg

methylphenidate (generic for, Ritalin SR) tablets extended release: 20mg

methylphenidate OSM 72mg tablet methylphenidate

(generic for Qu illichew) (PL) tablet: 20mg,30mg, 40mg

methylphenidate SOL (generic for M ethylin) (PL) solt: 5mg/5ml, 10mg/5ml

methylphenidate ER (PL) tab: 18mg, 27mg, 36mg, 54mg

Relexxii OSM 72mg tablet

Level 2 Adderall XR (PL) Vyvanse capsule (PL) Vyvanse chew tablet

ANTI-CONVULSANTS Level 1 carbamazepine (generic for Tegretol)

chewable tablet: 100mg tablet: 200mg

3




carbamazepine ER/SR (generic for Tegretol XR)

tablet: 100mg, 200mg, 400mg divalproex (generic for D epakote Delayed Release)

tablet: 125mg, 250mg, 500mg ethosuximide (generic for Zarontin)

capsule: 250 mg syrup: 250 mg/5ml

gabapentin (generic for N eurontin) capsule: 100mg, 300mg, 400mg tablet: 100mg, 300mg, 400mg, 600mg oral solution: 250mg/ml lamotrigine (generic for L amictal, Lamictal XR, Lamictal ODT) tablet: 25mg, 100mg, 150mg, 200mg chewable tablet: 5mg, 25mg

extended release: 25mg, 50mg, 100mg, 200mg, 250mg, 300mg

levetiracetam, roweepra (generic for Keppra) tablet: 250mg, 500mg, 750mg, 1000mg oral solution: 100mg/ml levetiracetam (PL) (generic for Keppra XR) tablet: 500mg, 750mg lorazepam (generic for Ativan) tablet: 0.5mg, 1mg, 2mg oral concentrate: 2mg/ml phenobarbital

tablet: multiple strengths(not all L1 copay) elixir: 20mg/5ml

phenytoin sodium (generic for D ilantin)

capsule: 100mg primidone (generic for M ysoline) tablet 50mg, 250mg topirmate (PL) (generic for Top amax) tablet 25mg, 50mg, 100mg, 200mg zonisamide (generic for Zon egran) tablet 25mg, 50mg, 100mg

Level 2 Carbatrol Depakote ER Depakote Sprinkles Dilantin Fycompa (PL) Lyrica Phenytek (PL) Tegretol Tegretol XR Topiramate ER Sprinkles Vigabatrin powder p ack (PL) Vimpat

ANTIDEPRESSANTS Level 1 bupropion (generic for Wellbutrin) tablet: 75mg, 100mg bupropion SR (PL) (generic for Wellbutrin SR)

sustained-release tablet: 100mg, 150mg, 200mg

bupropion SR 24 hour (PL) (generic for Wellbutrin XL)

sustained-release tablet: 150mg, 300mg duloxetine (generic for C ymbalta) (PL)

capsule: 20mg, 30mg, 60mg venlafaxine (generic for Effexor)

tablet: 25mg. 37.5mg, 50mg, 75mg, 100mg venlafaxine SR/ER 24 hr (generic for Effexor XR)

capsules: 37.5mg, 75mg, 150mg

ANTIDEPRESSANTS, OTHER Level 1 mirtazapine (PL) (generic for R emeron)

tablet: 7.5mg, 15mg, 30mg, 45mg mirtazapine ODT (PL) (generic for R emeron Soltab) tablet: 15mg, 30mg, 45mg trazodone (generic for D esyrel)

tablet: 50mg, 100mg, 150mg

ANTI-PARKINSON AGENTS Level 1 amantadine (generic for Symmetrel)

capsule: 100mg tablet: 100mg

benztropine (generic for C ogentin)

tablet: 0.5mg, 1mg, 2mg bromocriptine (generic for Parlodel)

tablet: 2.5mg carbidopa/levodopa (generic for Sinemet, Sinemet CR)

tablet: 10/100mg, 25/100mg, 25/250mg sustained-release tablet: 25/100mg, 50/200mg

selegiline (generic for Eldepryl)

tablet: 5mg capsule: 5mg

tolcapone (generic for Tasmar)

tablet: 100mg

Level 2 Pramipexole ER ANTIPSYCHOTICS, ATYPICAL Level 1 aripirazole (generic for Abilify) tablet: 2mg. 5mg, 10mg, 15mg, 20mg, 30mg oral sol: 1mg/ml clozapine (generic for C lozaril) tablet: 25mg, 100mg risperidone (generic for R isperdal) tablet: 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg oral solution: 1mg/ml olanzapine (PL) (generic for Zyprexa )

tablet: 2. 5mg, 5mg,7.5mg,10mg, 15mg, 20mg olanzapine odt (PL) (generic for Zyprexa Zydis) tablet: 5mg, 10mg, 15mg, 20mg quetiapine (PL) (generic for Seroquel)

tablets: 25mg, 50mg, 100mg, 150mg, 200mg, 300mg, 400mg

ziprasidone (PL) (generic for Ge odon) capsules: 20mg, 40mg, 60mg, 80mg

ANTIPSYCHOTICS, TYPICAL Level 1 chlorpromazine (generic for Thorazine)

tablet: 10mg, 25mg, 50mg, 100mg, 200mg haloperidol (generic for H aldol)

tablet: 0.5mg, 1mg, 2mg, 5mg oral solution: 2mg/ml

thioridazine (generic for M ellaril) tablet: 10mg, 25mg, 50mg, 100mg

ANXIOLYTIC/HYPNOTIC, NON BENZODIAZEPINE Level 1 buspirone (PL) (generic for Buspar)

tablet: 5mg, 10mg, 15mg eszopiclone (generic for L unesta)

tablet: 1mg, 2 mg, 3mg zolpidem tartrate (generic for Ambien)

tablet: 5mg, 10mg

Level 2 Zolpidem tartrate CR/ER

BENZODIAZEPINES 1, SHORT ACTING Level 1 alprazolam

(generic for X anax, Niravam) (PL) tablet: 0.25mg, 0.5mg, 1mg, 2mg ODT: 0.25mg, 0.5mg, 1mg, 2mg

alprazolam (generic for X anax Xr) (PL) tablet: 0.5mg, 1mg, 2mg, 3mg

midazolam (generic for v ersed) SYR: 2mg/ml (PL) oxazepam (generic for Serax) (PL)

capsule: 10mg,15mg triazolam (generic for H alcion) (PL)

tablet: 0.25mg

BENZODIAZEPINES 2, MID-ACTING Level 1 Estazolam (PL) (generic for ProSom)

tablet: 1mg, 2mg temazepam (PL) (generic for R estoril)

capsule: 15mg, 30mg

4




BENZODIAZEPINES 3, LONG ACTING Level 1 alprazolam ER (generic for X anax XR)

tablet: 0.5mg, 1mg, 2mg, 3mg alprazolam XR (generic for X anax XR)

tablet: 0.5mg, 1mg, 2mg, 3mg clonazepam (generic for Klonopin) (PL)

tablet: 0.5mg, 1mg, 2mg chlordiazepoxide (generic for L ibrium) (PL)

capsule: 5mg, 10mg, 25mg clorazepate dipotassium (PL) (generic for tranxene t) tablet: 3.75mg, 7.5mg, 15mg diazepam (generic for Valium) (PL)


IMMUNOMODULATORY AGENTS Level 2 Tecfidera (PL) Tecfidera Starter K it (PL)

MANIA/BIPOLAR Level 1 divalproex (generic for D epakote Delayed Release)

tablet: 125mg, 250mg, 500mg lithium carbonate (generic for Eskalith) capsule: 300mg lithium carbonate CR (generic for Eskalith CR) controlled-release tablet: 450mg lithium carbonate CR (generic for L ithobid SR)

controlled-release tablet: 300mg valproic acid (generic for D epakene) capsule: 250mg syrup: 250mg/5ml

Level 2 Depakote ER Depakote Sprinkles

MIGRAINE Level 1 divalproex (generic for D epakote Delayed Release)

tablet: 125mg, 250mg, 500mg naratriptan (PL) (generic for Amerge)

tables: 1mg, 2.5mg almotriptan (PL) (generic for Axert)

tablets: 6.25mg, 12.5mg sumatriptan (generic for Imitrex)

tablets: 25mg,50mg, 100mg vial: 6mg/0.5ml (PL) nasal spray: 5mg, 20mg (PL)

rizatriptan benzoate (PL) (generic for M axalt, Maxalt MLT)

tablets: 5mg, 10mg orally disintegrating: 5mg, 10mg

zolmitriptan (PL)

(generic for Zomig) tablets: 2.5mg, 5mg

orally disintegrating: 2.5mg, 5mg zolmitriptan ODT (PL) (generic for Zomig ZMT)

tablets: 2.5mg, 5mg orally disintegrating: 2.5mg, 5mg

Level 2 Depakote ER Depakote Sprinkles Zomig Nasal Spray (PL)

MUSCLE RELAXANTS Level 1 baclofen (generic for L ioresal)

tablet: 5mg, 10mg, 20mg carisoprodol (generic for Soma)

tablet: 350mg cyclobenzaprine (generic for Flexeril)

tablet: 10mg methocarbamol (generic for R obaxin)

tablet: 500mg, 750mg tizanidine (generic for Zanaflex)

tablet: 2mg, 4 mg

Level 2 Dantrolene

NARCOTICS Level 1 buprenorphine (generic for Butrans)

Patch weekly: 5mcg, 7.5mcg, 10mcg, 15mcg, 20mcg

fentanyl td (PL) (generic for D uragesic)

Patch 72 hour: 12.5mcg, 25mcg, 50mcg, 75mcg, 100mcg

morphine sulfate (generic for M S Contin)

sustained-release tablet: 15mg, 30mg, 60mg, 100mg, 200mg

morphine sulfate (generic for Roxanol)

0ral solution: 20mg morphine sulfate immediate release oral solution: 10mg/5ml, 20mg/5ml roxicodone (generic for R oxicodone, Dazidox, Oxyir)

tablet: 5mg, 10mg 15mg, 20mg, 30mg capsule: 5mg

Level 2 Hysingla ER (PL)

NARCOTICS, COMBOS Level 1 acetaminophen/codeine (generic for Tylenol/codeine)

tablet: 300mg/15mg, 300mg/30mg, 300mg/60mg elixir: 120mg/12mg/5ml

acetaminophen/hydrocodone

(generic for L orcet, Lorcet Plus) tablet: 7.5mg/650mg, 10mg/650mg

acetaminophen/hydrocodone, Lorcet HD (generic for N orco)

tablet: 5mg/325mg, 7.5mg/325mg, 10mg/325mg

acetaminophen/hydrocodone (generic for Vicodin, Vicodin ES)

tablet: 5mg/500mg, 7.5mg/500mg acetaminophen/oxycodone, roxicet, endocet (generic for Percocet)

tablet: 2.5mg/325mg, 5mg/325mg, 7.5mg/325mg, 10mg/325mg, 7.5mg/500mg 10mg/650mg solution: 5-325mg/5ml

acetaminophen/oxycodone (generic for Tylox)

capsule: 5mg/500mg acetaminophen/propoxyphene HCL (generic for Wygesic)

tablet: 65mg/650mg acetaminophen/propoxyphene-N (generic for D arvocet-N 100)

tablet: 100mg/650mg aspirin/oxycodone (generic for Percodan)

tablet: 5mg/325mg ibuprofen-hydrocodone (generic for Vicoprofen)

tablet: 7.5-200mg

NAUSEA/VOMITING Level 1 Promethazine, promethegan (generic for Phenergan)

tablet: 25mg, 50mg syrup: 6.25mg/5ml rectal suppository: 12.5mg, 25mg, 50mg

prochlorperazine tablet: 5mg, 10mg rectal suppository: 25mg

NEUROMUSCULAR DISORDERS Level 1 riluzole (generic for R ilutek)

tablet:, 50mg

NON STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) Level 1 diclofenac sodium (generic for Voltaren)

tablet: 25mg, 50mg, 75mg ibuprofen (generic for M otrin)

tablet: 400mg, 600mg, 800mg indomethacin (generic for Indocin)

capsule: 25mg, 50mg nabumetone (generic for R elafen) tablet: 500mg, 750mg naproxen (generic for N aprosyn)

tablet: 250mg, 375mg, 500mg oxaprozin (generic for D aypro)

5




tablet: 600mg

NON STEROIDAL ANTI-INFLAMMATORY DRUGS (OTHER) Level 1 ketorolac tromethamine (PL) (generic for Toradol) tablets: 10mg ketoprofen (generic for Or udis) capsules: 50mg, 75mg profeno (generic for N alfon) tablets: 600mg meloxicam (generic for M obic)

tablets: 7.5mg, 15mg

Level 2 Diclofenac 1.5% transdermal

GOUT Level 1 allopurinol (generic for Zyloprim)

tablet: 100mg, 300mg probenecid

tablet: 500mg

Level 2 Uloric (PL)

OTHER ANALGESICS Level 1 acetaminophen/acetaminophen/caffeine, phrenilinforte (generic for Fioricet)

tablet: 50mg/325mg/40mg acetaminophen/butalbital/caffeine (generic for Esgic)

capsule: 50mg/40mg/325mg aspirin/butalbital/caffeine (generic for Fiorinal)

capsule: 50mg/40mg/325mg tramadol (generic for U ltram) (PL)

tablet: 50mg tramadol HCL SR 24 hour (generic for U ltram ER) (PL)


Level 2 Zubsolv

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI) Level 1 citalopram hydrobromide (PL) (generic for C elexa) tablet: 10mg, 20mg, 40mg escitalopram (PL) (generic for L exapro) tablet: 5mg, 10mg, 20mg

solution: 5mg/5ml fluoxetine (PL) (generic for Prozac,Rapiflux)

capsule: 10mg, 20mg, 40mg

tablets : 10mg, 20mg paroxetine HCL (PL) (generic for Paxil)

tablet: 10mg, 20mg, 30mg, 40mg sertraline (generic for Zoloft)

tablet: 25mg, 50mg,100mg

Level 2 Desvenlafaxine succinate SR (PL)

TRICYCLIC ANTIDEPRESSANTS (TCA) Level 1 amitriptyline (generic for Elavil)

tablet: 10mg, 25mg, 50mg, 75mg, 100mg, 150mg

doxepin (generic for Sinequan)

capsule: 10mg, 25mg, 50mg, 75mg, 100mg, 150mg oral concentrate: 10mg/ml

imipramine (generic for Tofranil, Tofranil PM)

tablet: 10mg, 25mg, 50mg capsule: 75mg, 100mg, 125mg, 150mg (PL)

nortriptyline (generic for Pamelor)

capsule: 10mg, 25mg, 50mg, 75mg

ANTI-DEMENTIA AGENTS Level 1 donepezil hydrochloride (PL) (generic for Aricept)

tablet: 5mg, 10mg, 23mg ODT: 5mg, 10mg

galantamine hydrobromide (PL) (generic for R azadyne)

tablet: 4mg, 8mg, 12mg galantamine hydrobromide SR 24 HR (PL) (generic for R azadyne ER)

tablet: 8mg,16mg, 24mg rivastigmin tartrate (PL) (generic for Exelon)

capsule: 1.5mg, 3mg, 4.5mg, 6mg

Level 2 Exelon Patch (PL) Exelon oral solution Memantine ER Rivastigmine Patch (PL)

CARDIOVASCULAR/HEART

ANGIOTENSIN-CONVERTING ENZYME INHIBITORS (ACEI) Level 1 Acetazolamide (generic for D iamox) tablet: 125mg benazepril (generic for L otensin)

tablet: 5mg, 10mg, 20mg, 40mg captopril (generic for C apoten)

tablet: 12.5mg, 25mg, 50mg, 100mg enalapril (generic for Vasotec)

tablet: 2.5mg, 5mg, 10mg, 20mg fosinopril (generic for M onopril)

tablet: 10mg, 20mg, 40mg lisinopril (generic for Prinivil/Zestril)

tablet: 2.5mg, 5mg, 10mg, 20mg, 30mg, 40mg

quinapril HCL (generic for Accupril) tablet: 5mg, 10mg, 20mg, 40mg quinapril-hctz (generic for Accuretic) tablet: 10-12.5mg, 20-12.5mg, 20-25mg ramipril (generic for Altace)

capsules: 1.25, 2.5mg, 5mg, 10mg trandolapril (generic for M avik) tablet: 1mg, 2mg, 4mg

ANGIOTENSIN II RECEPTOR BLOCKERS (A2RB) Level 1 amlodipine/besylate/valsartan (PL) (generic for E xforge)

tablet: 5-160mg, 10-160mg, 5-320mg, 10-320mg

amlodipine/valsartan/hydrochlorothiazide (PL) (generic for E xforge HCT)

tablet: 5-160-12.5mg, 10-160mg-25mg,10-160-12.5mg, 10-160-25mg, 10-320-25mg

candesa/cilexetil/hctz (PL) (generic for Atacand HCT)

Tablets: 16-12.5 mg, 32-12.5 mg, 32-25mg, 16-12.5 mg, 32-12.5 mg

losartan (generic for C ozaar) tablet: 25mg, 50mg, 100mg losartan/hydrochlorothiazide (generic for H yzaar) tablet: 50/12.5mg, 100/12.5mg, 100/25mg telmisartan-hydrochlorothiazide (generic for M icardis HCT) (PL)

tablet: 80-12.5mg, 80-25mg, 40-12.5mg telmisartan (generic for M icardis)

tablet: 20mg, 40mg, 80mg valsartan (PL) (generic for D iovan) tablet: 40mg, 80mg, 160mg, 320mg valsartan-hydrochlorothiazide (generic for D iovan HCT) (PL)

tablet: 80-12.5mg, 160-12.5mg, 320-12.5mg, 160-25mg, 320-25mg

ANTI-ARRHYTHMICS Level 1 amiodarone, pacerone (generic for C ordarone) tablet: 200mg amiodarone, pacerone tablet: 100mg, 200mg diltiazem HCL (generic for C ardizem)

tablet: 30mg, 60mg, 90mg, 120mg procainamide (generic for Pronestyl)

capsule: 250mg sustained-release tablet: 500mg

6




Level 2 Multaq (PL) Tikosyn (PL)

ANTI-PLATELETS Level 1 anagrelide HCL (generic for Agrylin) tablet: 0.5mg, 1mg aspirin/dipyridamole SR (generic for Aggrenox) capsules: 25-200mg cilostazol (generic for Pletal) tablet: 50mg, 100mg clopidogrel bisulfate (generic for Plavix) (PL) tablet: 75mg, 300mg dipyridamole (generic for Persantine) tablet: 25mg, 50mg, 75mg pentoxifyllin ER, pentoxil CR (generic for Trental) tablet: 400mg prasugrel (generic for Effient) (PL) tablet: 5mg, 10mg ticlopidine (generic for Ticlid) tablet: 250mg

Level 2 Aggrenox Asa/Dipyridamole Brilinta Ticlopidine Zontivity (PL)

BETA BLOCKERS Level 1 atenolol (generic for Tenormin)

tablet: 25mg, 50mg, 100mg carvedilol (generic for C oreg)

tablet: 3.125mg, 6.25mg, 12.5mg, 25mg metoprolol (generic for L opressor)

tablet: 25mg, 50mg, 100mg metoprolol er (generic for Toprol XL) tablet: 25mg, 50mg, 100mg, 200mg propranolol (generic for Inderal)

tablet: 10mg, 20mg, 40mg, 60mg, 80mg, 90mg

Level 2 Bystolic

BETA BLOCKERS, COMBOS Level 1 Dutoprol Metoprolol Succinate ER/Hydrochlorothiazide atenolol & chlorthalidone (generic for Tenoretic) tablet: 50-25mg, 100-25mg Metoprolol Hydrochlorothiazide

tablet: 100-50mg

BENIGN PROSTATIC HYPERTROPHY (BPH) Level 1 doxazosin (generic for C ardura)

tablet: 1mg, 2mg, 4mg, 8mg finasteride (PL) (generic for Proscar)

tablet: 5mg tamsulosin (generic for Flomax)

tablet: 0.4mg terazosin (generic for H ytrin)

capsule: 1mg, 2mg, 5mg, 10mg

CALCIUM CHANNEL BLOCKERS (CCB) Level 1 amlodipine besylate (generic for N orvasc)

tablet: 2.5mg, 5mg, 10mg amlodipine besylate-benazepril (generic for L otrel)

capsule: 2,5-10mg, 5-20mg, 5-20mg, 5-40mg, 10-20mg, 10-40mg,

diltiazem ER (generic for Tiazac)

extended-release capsule: 120mg, 180mg, 240mg, 300mg

nifedipine ER, afeditab, nifediac CC (generic for Adalat CC)

extended-release tablet: 30mg, 60mg, 90mg nifedical XL (generic for Procardia XL) tablet: 30mg, 60mg nifedipine (generic for Procardia)

capsule:10, 20mg verapamil (generic for C alan, Isoptin)

tablet: 40mg, 80mg, 120mg verapamil SR (generic for C alan SR, Isoptin SR)

sustained-release tablet: 120mg, 180mg, 240mg

Level 2 Cardene SR

CHOLESTEROL LOWERING Level 1 atorvastatin (generic for L ipitor) (PL)

tablet: 10mg, 20mg, 40mg, 80mg cholestyramine (generic for Qu estran, Questran Lite)

Can: 4gm, bulk can only colestipol (generic for C olestid) tablet: 1gm granules & packets: 5gm ezetimibe (generic for Zetia) (PL)

tablets: 10mg ezetimibe-Simvastatin (generic for Vytorin) (PL)

tablets: 10-10mg,10-20mg, 10-40mg, 10-80mg

fenofibrate (generic for L ofibra, Triglide, Tricor) (PL)

tablet: 48mg, 54mg, 145mg, 160mg capsules: 67mg, 134mg, 200mg fluvastatin (generic for L escol) (PL)

capsules: 20mg, 40mg gemfibrozil (generic for L opid)

tablet: 600mg lovastatin (generic for M evacor)

tablet: 10mg, 20mg, 40mg (PL)

pravastatin (generic for Pravachol)

tablet: 10mg, 20mg, 40mg (PL)

rosuvastatin (generic for C restor)

tablet: 5gm. 10mg, 20mg, 40mg (PL)

simvastatin (generic for Zocor)

tablet: 5mg, 10mg, 20mg, 40mg & 80mg (PL)

omega 3 acid ethyl esters, Triklo (generic for Lovaza)

tablet: 1 gram (PL)

Level 2 Niacin ER (PL) Colesevelam tab 625mg, Colesevelam pak SUSP 3.75gm (PL) Welchol (PL)

DIRECT RENIN INHIBITORS Level 2 Amturnide Tekamlo Tekturna (PL) Tekturna HCT (PL) Valturna

DIURETICS 1, LOOP Level 1 bumetanide (generic for Bumex)

tablet: 0.5mg, 1mg, 2mg

furosemide (generic for L asix)

tablet: 20mg, 40mg, 80mg oral solution: 10mg/ml

DIURETICS 2, THIAZIDE Level 1 benazepril/HCTZ (generic for L otensin HCT)

tablet: 5mg/6.25mg, 10mg/12.5mg, 20mg/12.5mg, 20mg/25mg

chlorthalidone (generic for Hygroton)

tablet: 50mg enalapril/HCTZ (generic for Vaseretic)

tablet: 5mg/12.5mg, 10mg/25mg hydrochlorothiazide (HCTZ) (generic for H ydrodiuril)

tablet: 12.5mf, 25mg, 50mg hydrochlorothiazide (HCTZ) (generic for M icrozide)

7




capsules: 12.5mg indapamide (generic for L ozol)

tablet: 1.25mg, 2.5mg lisinopril/HCTZ (generic for Zestoretic/Prinzide)

tablet: 10mg/12.5mg, 20mg/12.5mg, 20mg/25mg

metolazone (generic for Zaroxolyn)


DIURETICS 3, OTHERS Level 1 triamterene/HCTZ (generic for D yazide)

capsule: 37.5mg/25mg triamterene/HCTZ (generic for M axzide) tablet: 37.5mg/25mg, 75mg/50mg spironolactone/HCTZ (generic for Aldactazide) tablet: 25mg/25mg spironolactone (generic for Aldactone) tablet: 25mg, 50mg, 100mg

INOTROPES/PRESSORS Level 1 digoxin (generic for L anoxin)

tablet: 0.125mg, 0.25mg midodrine (generic for ProAmatine)


Level 2 Lanoxin

OTHER ANTI-HYPERTENSION Level 1 clonidine (generic for C atapress)

tablet: 0.1mg, 0.2mg, 0.3mg hydralazine (generic for Apresoline)

tablet: 10mg, 25mg, 50mg, 100mg prazosin (generic for M inipress)

capsule: 1mg, 2mg, 5mg

NITRATES Level 1 isosorbide dinitrate (generic for Isordil,, Isordil SR)

tablet: 5mg, 10mg, 20mg, isosorbide mononitrate (generic for Imdur)

extended-release tablet: 30mg, 60mg, 120mg isosorbide mononitrate (generic for Ismo)

tablet: 20mg nitroglycerin (generic for N itro-Bid)

capsule: 2.5mg, 6.5mg, 9mg nitroglycerin (generic for N itrostat)

tablet: 0.3mg, 0.4mg, 0.6mg

Level 2 Nitromist (PL) Nitroglycerin Lingual 400mcg spray (PL)

OTHER CARDIOVASCULAR

Level 2 Ranexa (PL)

DERMATOLOGIC/ SKIN

ACNE Level 1 adapalene * (generic for D ifferin)

gel: 0.3% cream: 0.1%

benzoyl peroxide (generic for Benzefoamultra)

foam: 9.8% clindamycin (generic for C leocin-T)

gel: 10mg/ml lotion: 10mg/ml solution: 10mg/ml

clindamycin/benzoyl peroxide (generic for BenzaClin, Duac)

gel: 1%/5% gel: 1.2-5%

erythromycin (generic for T-Stat)

solution: 2% erythromycin (generic for Erygel)

gel: 2% erythromycin (generic for Erycette)

pad: 2% metronidazole (generic for M etrocream, Metrogel, Metrolotion)

cream, gel, lotion: 0.75%, 0.1% tretinoin (generic for R etin-A)

cream: 0.025%, 0.05%, 0.1% gel: 0.01%, 0.025%

tretinoin (generic for Atralin)

gel: 0.05%

sulfacetamide sodium with sulfur* (generic for Avar E -LS, Avar E Sumadan, Plexion,Sumaxin Wash, Sumaxin TS) cleanser: 10-2%, 9.8-4.8% cream: 10-2%, 9.8-4.8%

wash: 9-4.5%, 9-4% suspension: 8-4% lotion: 9.8-4.8%

Level 2 Adapalene gel 0.1% Adapalene lotion

AMINOGLYCOSIDES Level 1 gentamicin 0.01% (generic for Ga ramycin)

cream: 0.1%, 15gm

ANESTHETICS Level 1 -prilocaine (generic for Emla)

cream: 2.5%

ANTI-BACTERIALS, DERM Level 1 mupirocin (generic for Bactroban) ointment: 2% cream 2%

Level 2 Bactroban NS ointment

ANTIFUNGALS Level 1 ketoconazole (generic for N izoral)

cream: 2% shampoo: 2% tablets: 200mg

naftifine (generic for N aftin)

cream: 1%, 2% nystatin (generic for M ycostatin)

cream: 100,000u/g ointment: 100,000u/g

terbinafine (generic for Lamisil)

tablet: 250mg

ANTI-VIRALS Level 1 Podofilox solution (generic for C ondylox solution)

solution: 0.5%

Level 2 Condylox gel

OTHER DERMATOLOGICS Level 2 8-Mop Oxsoralen lotion

PSORIASIS Level 1 calcipotriene solution (generic for D ovonex)

solution: 0.005% ceam: 0.005%

STEROIDS, HIGHEST POTENCY Level 1 clobetasol propionate (generic for Temovate)

cream: 0.05% ointment: 0.05%

halobetasol proprionate (generic for U ltravate) cream: 0.05% ointment: 0.05%

8




STEROIDS, MEDIUM TO MEDIUM HIGH POTENCY Level 1 betamethasone dipropionate (generic for D iprosone)


Clotrimazole w/betamethasone (generic for L otrisone)

cream: 1-0.05% lotion: 1-0.05%

fluocinonide (generic for L idex, Lidex-E)

cream: 0.05% ointment: 0.05% gel: 0.05%

mometasone furoate (generic for Elocon) cream: 0.1% ointment: 0.1%

lotion 0.1%

STEROIDS, LOW POTENCY Level 1 augmented betamethasone dipropionate

gel: 0.05% betamethasone valerate (generic for Valisone)

cream: 0.1% lotion: 0.1% ointment: 0.1%

desonide (generic for D esOwen)


fluocinolone acetonide (generic for Synalar)


triamcinolone acetonide (generic for Kenalog)

cream: 0.025%, 0.1% ointment: 0.025%, 0.1% lotion: 0.025%, 0.1%

STEROIDS, LOWEST POTENCY Level 1 Hydrocortisone, ala-cort (generic for H ytone)

cream: 0.5%, 1%, 2.5% ointment: 0.5%, 1%, 2.5% lotion: 1%, 2.5%

OTIC/ EAR

OTICS Level 1 ofloxacin (generic for Floxin Otic) solution: 3% 5ml, 3% 10ml fluocinolone acetonide (PL) (generic for D ermotic oil)

oil: 0.01% neomycin-polymyxin-HC (generic for C ortisporinl)

solution: 1% suspension: 3.5mg/ml-10000 unit/ml-1%

Level 2

Ciprodex (PL)

NOSE

NASAL SPRAYS Level 1 azelastine hcl NS (generic for Astepro NS) solution: 0.1%, 0.15%

ipratropium bromide NS (generic for Atrovent NS) solution: 0.03%, 0.06% (PL)

ENDOCRINE/ METABOLIC CALCIUM METABOLISM Level 1 alendronate (generic for Fosamax)

tablet: 5mg, 10mg,35mg, 70mg calcitonin (generic for M iacalcin/Fortical) (PL)

nasal spray: 200 units/act ergocalciferol (generic for D risdol)

capsule: 50mg raloxifene (PL) ($0 copay) (generic for E vista)

tablet: 60mg risedronate (PL)

(generic for Actonel) tablet: 5mg, 30mg, 35mg, 150mg

risedronate delayed release (PL)* (generic for Atelvial) tablet: 35mg

CORTICOSTEROIDS Level 1 dexamethasone, baycadron (generic for D ecadron, Hexadrol)

tablet, 0.5mg, 0.75mg,1mg, 1.5mg, 2mg, 4mg, 6mg elixir: 0.5mg/5ml, 1mg/ml solution: 0.5mg/5ml

fludrocortisone acetate (generic for Florinef)

tablet: 0.1mg hydrocortisone (generic for C ortef)

tablet: 5mg, 10mg. 20mg methylprednisolone (generic for M edrol)

tablet: 4mg methylprednisolone, asmalp (generic for Or apred)

solution: 15mg/5ml prednisone (generic for D eltasone)

tablet: 1mg, 2.5mg, 5mg, 10mg, 20mg

Level 2 Orapred Orapred ODT

DIABETES MELLITUS Level 1 acarbose (generic for Precose)

tablet:25mg, 50mg, 100mg

glimepiride (PL) (generic for Amaryl)

tablet: 1mg, 2mg. 4mg glipizide (generic for G lucotrol)

tablet: 5mg, 10mg glipizide ER (generic for G lucotrol XL)

extended-release tablet: 2.5mg, 5mg, 10mg glipizide-metformin (PL) (generic for M etaglip) Tablet: 2.5-250mg, 2.5-500mg, 5mg-500mg glyburide (generic for D iabeta, Micronase)

tablet: 1.25mg, 2.5mg, 5mg glyburide micronized (generic for G lynase)

tablet: 1.5mg, 3mg, 6mg glyburide-metformin (generic for G lucovance)

tablet: 1,25-250mg, 2.5-500mg, 5-500mg Humalog Mix Vial (PL) Humalog vial (PL) Humulin vial (PL) Humulin R vial (PL) Humulin N vial Humulin 70/30 vial (PL) Insulin syringe Ketocare (acetone urine test strips) Lancets Lantus insulin vial (PL) Lifescan One Touch (glucose test strips) (PL) Lifescan One Touch Glucometer* (PL) (*No charge, any style One Touch meter i s available by calling Lifescan’s toll-free number 1-888-887-6299 or 1 -888-233-3282 Code 257BCA001) metformin (generic for G lucophage)

tablet: 500mg, 850mg, 1000mg metformin ER/SR (generic for G lucophage XR)

extended-release tablet: 500mg, 750mg metformin ER/SR Osmotic (PL) (generic for Fortamet)

sustained release tablet: 500mg, 1000mg miglitol (generic for G lyset)

Tablet: 25mg, 50mg, 100mg nateglinide (PL) (generic for Starlix) tablet: 60mg, 120mg pen needles pioglitazone (PL) (generic for Actos)

tablet: 15mg, 30mg, 45mg pioglitazone-metformin (PL) (generic for Actoplus Met) tablet: 15-500mg, 15-850mg pioglitazone-glimepiride(PL) (generic for D uetact) tablet: 30-2mg, 30-4mg repaglinide (generic for Prandin) tablet: 1mg, 2mg

Level 2 Actoplus Met XR

9




Avandia (PL) Avandamet (PL) Avandaryl (PL) Byetta (PL) Bydureon (PL) Bydureon Pen (PL) Bydureon Bcise Farxiga (PL) Freestyle Libre (PL) Glyset Humalog Cartridge Humalog Junior Kwikpen Humalog Mix Kwikpen Humulin Kwikpen Humulin N Kwikpen Humulin R U-500 Kwikpen Humulin R U-500 Concentrated vial (PL) Humulin 70/30 Kwikpen Invokana Invokamet Invokamet XR Janumet (PL) Janumet XR Januvia (PL) Kombiglyze XR Lantus Solostar Onglyza (PL) Prandin 0.5mg Repaglinide-Metformin Soliqua (PL) Symlin Pen (PL) Toujeo Solostar Pen Trulicity (PL) Victoza (PL) Xigduo XR

ESTROGENS Level 1 estradiol (generic for Estrace)

tablet: 0.5mg, 1mg, 2mg estr adiol transdermal (PL) (generic for C limara)

weekly patch: 0.025 mg/24hr, 0.0375 mg/24hr, 0.05mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1mg/24hr

estr adiol transdermal (PL) (generic for Vivelle Dot, Alora, Minivelle)

twice weekly patch: 0.025 mg, 0.0375 mg, 0.05mg, 0.075mg, 0.100mg

estrified estrogen, mtest, eemt, essian, covaryx (generic for Estratest)

tablet: 1.25-2.5 mg estrified estrogen HS, mtest HS, eemt HS, essian HS, covaryx HS (generic for Estratest HS)

tablet: 0.625-1.25 MG estropipate (generic for Og en, Ortho-Est)

tablet: 0.625mg, 0.75mg, .25mg,1.5mg, 2.5mg

Level 2 Cenestin (PL) Enjuvia (PL) Premarin

ESTROGEN/PROGESTIN COMBO Level 1 Estradiol-norethindron acetate, Mimvey,

Lopreeza, Amabelz (PL) (generic for Activella) tablet 1-0.05mg, 0.5-0.1mg Norethindrone acetate-ethinyl estradiol,Jevantique Lo, Fyavolv (PL) (generic for Femhrt)

tablet 1-0.5mg-2.5mg

Level 2 Premphase (PL) Prempro (PL)

ORAL CONTRACEPTIVE, MONOPHASIC Level 1 Amethia, Camrese , Daysee (91-day), (PL) (generic for Seasonique) tablet 0.15-0.03mg- 0.01mg Amethia Lo, Camrese Lo, Levonorgestrel/Ethinyl (91-day), (PL) (generic for L oSeasonique) tablet 0.1-0.02mg- 0.01mg Fayosim, Rivelsa, Levonorgestrel/Ethinyl Estradiol (generic for Qu artette) (PL)

tablet: 0.15-0.02/0.25/0.03mg & eth est 0.01mg

Apri, Emoquette, Enskyce, Reclipsen, Solia, Desogestrel/ethinyl estradiol, Cyred, Isibloom Juliber (PL) (generic for D esogen, Ortho-Cept) tablet 0.15mg/30mcg Drospirenone-ethinyl estradiol, Gianvi, Nikki, Vestura, Loryna (PL) (generic for Yaz) tablet 3-0.02mg Drospirenone-Ethinyl Estrad-Levomefolate, Tydemy (generic for Safyral) (PL) tablet: 3-0303-0.451mg Levonorgestrel/Ethinyl estradiol (91-day), Jolessa, Quasense, Introvale, Setlakin, (PL) (generic for Seasonale) tablet: 0.15-0.03mg Aviane, Aubra, Larissia, Lessina, Lutera, Orsythia, Sronyx, Falmina, Levonorgestrel/Ethinyl estradiol, Delyla, Vienva (PL) (generic for Alesse, Levlite) tablet: 0.1mg/20mcg Altavera, Levora, Marlissa, Portia, Kurvelo, Levonorgestrel-Ethinyl Estradiol, Chateal, Lillow (PL) (generic for N ordette) tablet: 0.15mg/30mcg Alaycen, Dasetta, Necon, Nortrel, Cyclafem, Wera , Pirmella (PL) (generic for Brevicon, Modicon, Norinyl, Ortho Novum)

tablet: 0.5/35, 1/35 Microgestin, Junel, Gildess (PL) (generic for L oestrin) tablet: 1mg/20mcg, 1.5mg/30mcg Microgestin Fe, Junel Fe, Glidess Fe, Larin Fe,

Noreth/Ethin, Tarina Fe (PL) (generic for L oestrin Fe) tablet: 1mg/20mcg, 1.5mg/30mcg Noreth/Ethin 24 FE, Gildess 24 FE, Larin 24, Lomedia 24 (generic for L oestrin Fe 24) tablet: 1mg/20mcg 24

Norethindrone/Ethinyl estradiol FE, Layolis FE, Katlib FE (PL) (generic for Ge neress FE) tablet: 0.8 mg/25 mcg CHW Norethindrone/Acetate-Ethinyl estradiol FE, Mibelas 24 FE, Melodetta 24 FE (PL) (generic for Minastrin 24 FE) tablet: 1mg-20mcg CHW

Ocella, Syeda, Zarah, Drospirenone-Ethinyl Estradiol (PL) (generic for Yasmin) tablet: 3-0.03mg Sprintec, Mononessa, Mono-Linyah, Norgestimate/Ethinyl, Previfem, Estarylla (PL) (generic for Or tho-Cyclen) tablet: 0.25-35mcg Zovia, Kelnor, Ethynodiol Diacetate/Ethinyl Estradiol (PL) (generic for D emulen) tablet: 1mg-35mcg Zenchent, Balziva, Briellyn , Philith, Gildagia, Vyfemla (PL) (generic for O vcon 35) tablet: 0.4mg-35mcg Zeosa , Zenchent FE, Wymzya FE, Norethindrone/Ethinyl Estradiol/ Ferrous Fumarate (PL) (generic for Femcon Fe) tablet: 0.4 mg-35 mcg norgestrel & ethinyl estradiol, Elinest, Low-Ogestrel, Cryselle (PL) (generic for L o/Ovral-28) tablet: 0.3mg-30mcg

Level 2 Lo Loestrin FE (PL)

ORAL CONTRACEPTIVE, BIPHASIC Level 1 Amethyst, Levonogestrel-Ethinyl (PL) (generic for L ybrel)

tablet: 90-20mcg)

ORAL CONTRACEPTIVE, TRIPHASIC Level 1 Velivet, Cesia, Caziant (PL) (generic for C yclessa)

tablet: 0.1-0.025/0.125-0.025/0.15-.025mg Alaycen, Dasetta, Necon, Nortrel, Cyclafem, Pirmella (PL) (generic for Or tho-Novum 7/7/7)

tablet: 0.5-35/0.75-35/1-35 Trivora, Enpresse, Myzilra (PL) (generic for Triphasil, Tri-Levlen)

tablet:0.05-30/0.075-40/0.125-30 Aranelle, Leena (PL) (generic for Tri-Norinyl)

tablet: 0.5-35/1-35/0.5-35mg Tilia FE, Tri-Legest FE (PL) (generic for Estrostep FE)

tablet: 1-20/1-30/1-35mg-mcg Norgest/Ethinyl estradiol, Tri-sprintec, Trinessa, Tri-Previfem. Tri-Linyah, Tri-Estarylla Tri-Lo Marzia, Tri Femynor (PL) (generic for Or tho Tri-Cyclen)

tablet:0.18-35/0.215-35/0.25-35

10




ORAL CONTRACEPTIVE, PROGESTINS Level 1 Camila, Errin, Heather, Incassia, Jencycla, Jolivette, Lyza, Nora BE, Norethindrone, Norlyroc,Deblitane, Sharobel, Norlyda (PL) (generic for Or tho-Micronor, Nor- QD) tablet: 0.35mg

ORAL CONTRACEPTIVE, OTHER Level 1 Kariva, Azurette , Viorele, Pimtrea, Deso/Ethinyl, Kimidess (PL) (generic for M ircette) tablet: 0.15-0.02-0.02/0.01mg

Level 2 Mircette (PL) Nuvaring (PL)

OTHER ENDOCRINE/METABOLIC

ANAPHYLAXIS Level 2 Mylan Epinephrine pen (PL) Glucagen Glucagon Symjepi

PROGESTINS Level 1 medroxyprogesterone (generic for Provera)

tablet: 2.5mg, 5mg, 10mg medroxyprogesterone (generic for D epo-Provera)

injection: 150mg norethindrone acetate (PL) (generic for Aygestin)

tablets: 5mg progesterone micronized (PL) (generic for Prometrium)

capsules: 100mg, 200mg

THYROID Level 1 Armour Thy roid NP Thyroid, Levothyroxine/Liothyronine (generic for Armour Thy roid)

tablet: 15mg, 30mg, 60mg, 90mg, 120mg, 180mg, 240mg, 300mg

liothyronine (generic for C ytomel)

tablet: 5mcg, 25mcg, 50mcg levoxyl, levothyroxine, levothroid, unithroid, unithroid direct, Levo-T, euthyrox (generic for Synthroid)

tablet: 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg,175mcg, 200mcg, 300mcg

Level 2 Synthroid Thyrolar

GASTROINTESTINAL/ STOMACH

ANTI-SPASMODICS Level 1 dicyclomine

(generic for Bentyl) capsules: 10mg

tablet: 20mg hyoscyamine sulfate (generic for L evsin, Levsin SL, Levsinex)

tablet: 0.125mg sublingual tablet: 0.125mg

timed-release capsule: 0.375mg

PROTON PUMP INHIBITORS (PPI) Level 1 lansoprazole (generic for Prevacid)

delayed-release capsule: 15mg, 30mg omeprazole (generic for Prilosec)

delayed-release capsule: 10mg, 20mg, 40mg pantoprazole (generic for Protonix) tablet: 20mg, 40mg rabeprazole (generic for Aciphex)

tablet: 20mg

H2 BLOCKERS Level 1 cimetidine (generic for Tagamet)

tablet: 300mg, 400mg, 800mg famotidine (generic for Pepcid)

tablet: 40mg ranitidine (generic for Zantac)

tablet: 300mg capsule: 150mg syrup: 75mg/5ml

Level 2 Nizatidine

GASTROINTESTINAL (GI), OTHER Level 1 azathioprine (generic for Imuran)

tablet: 50mg hydrocortisone cream, proctosol HC, proctozone,proctocare, procto-med (generic for H ytone/Anusol HC cream)

cream: 2.5% hydrocort AC, anucort-HC, hemmorex-HC, hemril-30 (generic for Anusol HC/Protocort suppository)

suppository: 25mg, 30mg mesalamine (generic for R owasa)

enema: 4gm sucralfate (generic for C arafate)

tablets: 1gm

Level 2 Asacol HD Canasa suppository (PL) mesalamine

(generic for C anasa) (PL) suppos: 1000mg Carafate suspension Creon Delzicol Dipentum (PL) Linzess Mesalamine DR 800mg Pancrelipase Pentasa Zenpep

NAUSEA/VOMITING Level 1 metoclopramide (generic for R eglan)

tablet: 5mg, 10mg syrup: 5mg/5ml

promethazine (generic for Phenergan)

tablet: 25mg, 50mg syrup: 6.25mg/5ml rectal suppository: 12.5mg, 25mg, 50mg

IMMUNOLOGIC

ANTI-RHEUMATICS Level 1 methotrexate

tablet: 2.5mg injection: 25mg/ml, 1gm

Level 2 Cuprimine

ANTI-MALARIALS Level 1 hydroxychloroquine (generic for Plaquenil)

tablet: 200mg atovaquone/proguanil (generic for M alaronel)

tablet: 62.5-25mg, 250/100mg

IMMUNOSUPPRESSANTS Level 1 tacrolimus (generic for Prograf) capsules: 0.5mg, 1mg, 5mg tacrolimus (PL) (generic for Protopic) ointment: 0.3mg, 0.1mg mycophenolate mofetil (generic for C ellCept) capsules: 250mg tablets: 500mg oral solution: 200mg/ml mycophenolate sodium DR (generic for M yfortic) tablets: 180mg, 360mg

Level 2 Sandimmune

NUTRIENTS & BLOOD MODIFIERS

ANTICOAGULANTS/THROMBOLYTICS

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Level 1 Jantoven, Warfarin (generic for C oumadin)

tablet: 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg

Level 2 Coumadin Pradaxa Xarelto Xarelto Starter Pack

CALCIUM METABOLISM Level 1 Calcium Acetate (generic for Eliphos)

tablet: 667mg

ELECTROLYTES, ACID BASE Level 1 Kaon, EdK+10 (generic for K-Tab)

tablet: 10mEq Klor-con (generic for K-Dur, K-Tab)

tablet: 10mEq, 20mEq potassium chloride (generic for C ena-K)

solution: 10% potassium chloride (generic for Klor-Con powder)

powder p acket: 20mEq potassium chloride, Klor-con 8meq, K-Tab 8meq (generic for K-Dur, K, Slow K)

tablet: 8mEq, 10mEq, 20mEq capsule : 10 mEq

OPIATE ANTAGONIST

Level 2 Narcan NS (PL)

OPHTHALMIC/ EYE

ANTI-BACTERIALS, OPTHALMIC Level 1 erythromycin (generic for Ilotycin)

ointment: 5mg/gm gentamicin (generic for Ga ramycin)

ointment: 0.3% solution: 0.3%

sulfacetamide (generic for Sodium Sulamyd) solution: 10%

Level 2 Restasis emulsion Restasis Multidose emulsion Tobrex ointment

ANTI-BACTERIALS W/ STEROIDS Level 1 neomycin/polymyxin B/dexamethasone (generic for M axitrol)

ointment: 0.1%

suspension: 0.1% sulfacetamide, prednisolone (generic for Blephamide, Vasocidin)

ointment suspension

tobramycin-dexamethasone (generic forTobradex)

suspension 0.03-0.1%

CORTICOSTEROIDS, OPTHALMIC prednisolone acetate (generic for Pred Forte) suspension: 1%

GLAUCOMA Level 1 brimonidine tartrate (generic for Alphagan)

solution: 2% brimonidine tartrate (generic for Alphagan P)

solution: 0.15% carteolol (generic for O cupress)

solution: 1% dorzolamide hcl (generic for Trusopt)

solution: 2% latanoprost (generic for X alatan)

solution: 0.005% levobunolol (generic for Betagan)

solution: 0.5% pilocarpine (generic for Isopto Carpine, Pilocar)

solution: 0.5%, 1%, 2%, 3%, 4%, 6% timolol opthalmic (generic Timoptic)

bottled solution: 0.25%, 5%

Level 2 Alphagan P 0.01% Bimatoprost sol 0.03% (PL) Combigan Lumigan Pred Mild Susp 0.12% Travatan Z

NON STEROIDAL ANTI-INFLAMMATORY DRUGS, OPTHALMIC (NSAIDS) Level 1 bacitracin-polymyxin-neomycin-HC (generic for C ortisporin) ophthalmic ointment: 1% ketorolac tromethamine (generic for Acular)

ophthalmic solution: 0.5% ketorolac tromethamine (generic for Acular LS)

ophthalmic solution: 0.4%

Level 2 Bromfenac 0.9% Base Equiivalent (PL) Bromfenac 0.9% Once Daily

OPTHALMIC, OTHER

Level 2

Cyclopentolate 0.5% Epinastine HCL 0.05%

RESPIRATORY

ANTIHISTAMINES, SEDATING Level 1 cyproheptadine (generic for Periactin)

tablet: 4mg hydroxyzine HCL (generic for Atarax)

tablet: 10mg, 25mg, 50mg hydroxyzine pamoate (generic for Vistaril)

capsule: 25mg, 50mg

Level 2 Semprex D

ANTITUSSIVES/EXPECTORANTS Level 1 benzonatate softgels (generic for Tessalon Perles)

capsule: 100mg hydrocodone/homatropine (generic for H ycodan, Tussigon)

tablet: 5mg/1.5mg syrup: 5mg/1.5mg/5ml

promethazine/codeine (generic for Phenergan/codeine)

syrup: 6.25mg/10mg/5 promethazine/DM (generic for Phenergan DM)

syrup: 6.25mg/15mg/5ml promethazine/PE/codeine

syrup: 6.25-5mg/5ml 6.25-5-10mg/5ml

BRONCHODILATORS Level 1 albuterol (generic for Proventil) nebulizer: 0.083%

tablet: 2mg, 4mg syrup: 2mg/5ml

levalbuterol (generic for X openex) concentrated nebulizer: 1.25mg/0.5ml nebulizer: 0.31mg, 0.63mg, 1.25mg/3ml

Level 2 Anoro Ellipta Atrovent HFA (PL) Incruse Ellipta ProAir HFA ProAir Respiclick Serevent Diskus (PL) Ventolin HFA

BRONCHODILATORS, INHALED STEROIDS Level 1 Fluticasone propionate/salmeterol (generic for Airduo)

Inhaler: 113-14mcg/act, 232-14mcg/act, 55-14mcg/act

Level 2 Advair (PL) Advair HFA (PL)

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Symbicort

ASTHMA, OTHER Level 1 dyphyllin-gg, DG 200, COPD, dyflex G (generic for L ufyllin GG)

Elixir: 100-100mg tablet: 200-200mg

difil-g fort liquid 100-100 difil g 400 tablet dilex-g liquid 100-100 dy-G liquid 100-100 dyphylline tab gg es (generic for D ifil G)

tablets: 200-300mg Ipratropium/albuterol (generic for D uoneb) nebulizer s olution: 0.5-2.5mg/3ml

montelukast (PL) (generic for Singluair) chewable tablet: 4mg, 5mg granules: 4mg tablets: 10mg zafirlukast (PL) (generic for Accolate) tablet: 10mg, 20mg budesonide suspension (generic for Pulmicort Respules) (PL) tablet: 0.25mg, 0.5mg

Level 2 Alvesco (PL) Arnuity Ellipta Asmanex Asmanex HFA Flovent Diskus Flovent HFA Pulmicort respules 1mg (PL) Pulmicort flexhaler (PL) Qvar (PL) Qvar d ose counter (PL) Qvar R edihaler Theo-24

OTHER PULMONARY Level 1 Spacer/Aerosol-Holding Chambers – Device (PL)Spacer/Aerosol-Holding Chambers – Supplies Bags (PL) Spacer/Aerosol-Holding Chambers – Masks (PL)

Level 2 Bethkis Breo Ellipta

THEOPHYLLINES Level 1 theophylline solution (generic for Slo-phyllin) solution: 80mg/15ml theophylline SR 12 HR (generic for Theo-Dur)

sustained-release tablet:100mg, 200mg, 300mg

theophylline SR 24 HR (generic for U niphyl)

sustained-release tablet:400mg, 600mg

UROLOGIC

ANTI-SPASMODICS, GENIT0-URINARY (GU) Level 1 oxybutynin chloride (generic for D itropan)

tablet: 5mg syrup: 5mg/5ml

oxybutynin chloride ER/SR (generic for D itropan XL)

tablet: 5mg, 10mg, 15mg flavoxatate HCL (generic for U rispas) tablet: 100mg tolterodine (generic for D etrol) tablet: 1mg, 2mg tolterodine SR/ER* (generic for D etrol LA) capsule: 2mg, 4mg trospium (generic for Sanctura) tablet: 20mg, 2mg

foltrospium ER/SR (PL) (generic for Sanctura XR) capsule: 60mg

Level 2 Darifenacin Hydrobromide SR/ER (PL) Myrbetriq Vesicare (PL)

MINERALS Level 2 K-Phos Original

VAGINAL PREPARATIONS

ANTIMICROBIAL Level 1 clindamycin (PL) (generic for C leocin (PL)

cream: 2%

ANTI-FUNGAL Level 1 terconazole (PL) (generic for Terazol 3)

cream: 0.8% suppository: 80mg

metronidazole vaginal gel (PL) (generic for M etrogel Vaginal Gel)

vaginal gel: 0.75%

VAGINAL, OTHER Level 2 Estrace cream (PL) Estradiol cream (PL) Premarin cream (PL

13


Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call 602-864-4884 for Spanish and 877-475-4799 for all other languages and other aids and services.

If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: BCBSAZ’s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ 85002-3466, 602-864-2288, TTY/TDD 602-864-4823, [email protected]. You can file a grievance in person or by mail or email. If you need help filing a grievance BCBSAZ’s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800- 368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

mailto:[email protected]

http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Multi-language Interpreter Services

level 1 and 2 medication list 1.24 - azblue · anti-virals, (cmv) level 1 ganciclovir (generic for...

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