florida blue healthy kids 2015 medication guide for ... · florida blue healthy kids medication...
Post on 23-Jul-2019
214 Views
Preview:
TRANSCRIPT
3022-G FL © Prime Therapeutics LLC 01/15
Click to search for a drug name in this document
January 2015
Florida Blue Healthy Kids Medication Guide
Contents
Introduction .................................................................... I
Prescriptions for non-preferred
medications .............................................................. II
Using the medication guide .......................................... II
Key .............................................................................. III
Responsible Rx programs ........................................... III
Medications requiring Prior Authorization ................... III
Responsible Quantity .................................................. IV
Responsible Steps ...................................................... IV
Covered over-the-counter (OTC) products ................. IV
Preventive Medications ............................................... IV
Immunizations ............................................................. IV
Women’s Preventive Services ..................................... V
Notice .......................................................................... VI
Preferred Medication List
Anti-Infective Drugs ...................................................... 1
Immunizing Agents ....................................................... 3
Cancer Drugs ............................................................... 3
Hormones, Diabetes and Related Drugs ..................... 4
Heart and Circulatory Drugs ......................................... 6
Respiratory Drugs ........................................................ 9
Gastrointestinal Drugs ................................................ 10
Genitourinary Drugs ................................................... 11
Central Nervous System Drugs .................................. 11
Pain Relief Drugs ....................................................... 13
Neuromuscular Drugs ................................................ 14
Supplements .............................................................. 15
Blood Modifying Drugs ............................................... 15
Topical Products......................................................... 16
Miscellaneous Categories .......................................... 19
Index ............................................................................. 20
Please consider talking to your doctor about prescribing formulary medications, which may help reduce your
out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.
The drug formulary is regularly updated. Please visit www.floridablue.com for the most up-to-date information.
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in
the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.
Florida Blue January 2015 Healthy Kids Medication Drug Guide I
Introduction
This Medication Guide includes an abbreviated listing of Generic, and a complete listing of Brand Prescription Drugs
on the Healthy Kids Preferred Medication List (PML). Changes in the PML can occur over time. The most up-to-date
listing can always be found by viewing the Healthy Kids Medication Guide online at www.floridablue.com or by
calling the customer service number listed on your identification card. For the hearing impaired, call Florida TTY
Relay Service 711.
We reserve the right to add or remove any Drug or Supply on the Healthy Kids Preferred Medication List at any time.
NOTE: Any decision concerning whether a Prescription Drug or Supply should be prescribed must be made by you
and your doctor. Any and all decisions that require or pertain to independent professional medical judgments or
training, or the need for, and dosage of, a Prescription Drug, must be made solely by you and your treating doctor in
accordance with the patient/doctor relationship
Florida Blue January 2015 Healthy Kids Medication Drug Guide II
Prescriptions for non-preferred medications
A formulary exception process is provided to allow for cases where the Healthy Kids PML may not
accommodate the unique medical needs of a member (e.g. documented allergy, ineffectiveness, or intolerable
adverse effects from drugs on the formulary).
The formulary exception form is available at www.floridablue.com/.
Click on the Providers tab
Click Pharmacy, then click Medication Guides
Click Formulary Exception Physician Fax form
Ask your doctor to complete the Healthy Kids Formulary Exception Form at www.floridablue.com, to request
an exception.
Using the medication guide
The Medication List is organized into broad categories (e.g., Antibacterials).
The first column of the chart lists the medication name. Generic medications are listed in lowercase boldface
(e.g., metformin). Brand name medications are capitalized (e.g., CRESTOR).
Separate medication entries are required for some dosage forms or routes of administration including
extended-release, delayed-release, rectal, injectable, otic, ophthalmic, vaginal, nasal, orally disintegrating,
patches, and topical products.
NOTE: Self-administered injectable medications are designated in the Medication List with inj following the
medication name (e.g., enoxaparin inj ).
The second column indicates the Tier level:
1 (Lowest Cost): Covered Generic Prescription Medications.
2 (Higher Cost): Covered Preferred Brand Prescription Medications.
The third column indicates if the medication is a Self-Administered Specialty* medication.
The remaining columns indicate the Responsible Rx Pharmacy program(s) that apply to the prescription
medication (e.g., Prior Authorization, Quantity Limits and Responsible Steps). If an indicator is present in the
column(s), then the Responsible Rx Program applies.
An asterisk (*) next to a drug name signifies that this drug may not be covered. Please refer to your individual
coverage policy.
III Florida Blue January 2015 Healthy Kids Medication Drug Guide
Key
caps ................................................................... capsules
chew tabs ............................................ chewable tablets
conc.............................................................. concentrate
crm ........................................................................ cream
ext-release .......................................... extended-release
inhal .................................................................. inhalation
inj ...................................................................... injection
lotn .......................................................................... lotion
NP ............................................................. non-preferred
ODT ...................................... orally disintegrating tablets
OSM ........................................................ osmotic-release
OTC ............................................... over-the-counter drug
oint ........................................................................... ointment
PA .............................. Prior Coverage Authorization required
QL .......Responsible Quantity Program–quantity limit applies
RS .......................................... Responsible Steps Program—
prerequisite drug required
SI .............................................. Self-Administered Injectable
SL .......................................................................... sublingual
SP ............................. Self-Administered Specialty Pharmacy
soln ........................................................................... solution
supp ................................................................. suppositories
susp .................................................................... suspension
tabs ............................................................................. tablets
Generic Drugs
Florida Blue encourages the use of Generic Drugs as a way to provide high-quality Drugs at a reduced cost. Generic
Drugs are as safe and effective as their Brand Name counterparts, and are usually less expensive.
A Food and Drug Administration (FDA) approved Generic Drug may be substituted for its Brand name counterpart
because it:
Contains the same active ingredient(s) as the Brand Name Drug
Is identical in strength, dosage form, and route of administration
Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile
Check with your doctor or health care provider to determine if switching to a Generic Drug is appropriate
for you.
Responsible Rx programs
Some covered medications may have additional requirements or limits on coverage. These requirements and limits
may include:
Medications requiring Prior Authorization
Drugs selected for Prior Authorization (PA) may require that specific clinical criteria are met before the drugs
will be covered under a member’s prescription benefit. Drugs on the Preferred Medication List that may
require a PA for coverage are indicated in the Prior Authorization column following the product name. Your
doctor or health care provider can request a prior authorization by completing the appropriate Prior
Authorization Form at www.floridablue.com.
Florida Blue January 2015 Healthy Kids Medication Drug Guide IV
Responsible Quantity
Drugs included in this program allow a maximum quantity per time period. Quantity limits are typically developed
based upon FDA-approved Drug labeling and nationally recognized therapeutic clinical guidelines. Responsible
Quantity Program Drugs are indicated in the Quantity Limits column following the product name. In cases where a
larger quantity of a Responsible Quantity Drug is medically required, your doctor or health care provider can request
an authorization by completing the Quantity Limit Authorization Form at www.floridablue.com. Florida Blue
reserves the right to change the Drugs and the quantity limits subject to the Responsible Quantity Program at any
time and for any reason.
Responsible Steps
Drugs included in this program are not covered unless you first try another designated or prerequisite Drug.
Responsible Steps Program Drugs are indicated in the Responsible Steps column following the product name.
If you cannot use the prerequisite Drug for medical reasons, your doctor or health care provider may request
prior authorization for an override by completing the appropriate Responsible Step Authorization Form at
www.floridablue.com. If the prior authorization request is approved, coverage will be provided for the Responsible
Step Drug. Florida Blue reserves the right to change the Drugs subject to the Responsible Step program at any time
and for any reason.
Covered over-the-counter (OTC) products
Your Pharmacy benefit provides coverage for certain OTC Drugs, if your doctor or health care provider prescribes
them. However, only those OTC Drugs designated on the PML with “OTC” following the product name are eligible
for coverage. Florida Blue reserves the right to change the OTC Drugs covered at any time and for any reason.
Patient Protection Affordable Care Act (PPACA) Mandated Coverage
Preventive Medications
The Patient Protection and Affordable Care Act (PPACA) provide for members to receive coverage for certain
preventive care services, medications, and immunizations at no out-of-pocket costs based on recommendations
from the U.S. Preventive Services Task Force (USPSTF). These USPSTF recommendations include services that
have been shown to be important in preventing disease as well as providing for additional women’s services such as
FDA-approved contraception.
Immunizations
Certain vaccines which are covered under your Wellness Benefits can be administered by Pharmacists that are
certified. Not all pharmacies provide services for vaccine administration. It is important to contact the pharmacy
prior to your visit to ensure availability and administration of the vaccine.
Oral Chemotherapy Drugs Oral chemotherapy drugs are drugs prescribed by a physician to kill or slow the growth of cancerous cells in a manner consistent with the national accepted standards of practice. A list of these drugs can be found at: Oral Chemotherapy Drug List
V Florida Blue January 2015 Healthy Kids Medication Drug Guide
Women’s Preventive Services
As a result of the expanded PPACA Preventive Services benefits for women’s services, certain generic
contraceptive medications or devices (e.g., oral contraceptives, emergency contraceptive, and diaphragms) are
covered at no cost share when purchased at a participating pharmacy.
Lists of drugs and devices included in the Preventive Medications, Immunizations and Women’s Preventive Services
can be found at www.floridablue.com
Florida Blue January 2015 Healthy Kids Medication Drug Guide VI
Notice
This Healthy Kids Medication Guide shall not extend, vary, alter, replace, or waive any of the provisions, benefits,
exclusions, limitations, or conditions contained in the Policy, Benefit Booklet, Certificate of Coverage or Pharmacy
Program Endorsement. In the event of any inconsistencies between the Healthy Kids Medication Guide and the
provisions contained in the Policy, Benefit Booklet, Certificate of Coverage or Pharmacy Program Endorsement, the
provisions contained in the Policy, Benefit Booklet, Certificate of Coverage or Pharmacy Program Endorsement shall
control to the extent necessary to effectuate the intent of Florida Blue.
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
Florida Blue January 2015 Healthy Kids Medication Drug Guide 1
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
ANTI-INFECTIVE DRUGS
PENICILLINS
AMOXICILLIN chew tabs, 250 mg 2
amoxicillin/potassiumclavulanate (Augmentin)
1
amoxicillin/potassiumclavulanate ext-release (Augmentin XR)
1
amoxicillin, NP = chew tabs,125 mg
1
ampicillin caps 1
AMPICILLIN susp 2
AUGMENTIN susp, 125 mg/5 mL 2
dicloxacillin 1
penicillin v potassium 1
CEPHALOSPORINS
cefaclor caps 1
cefadroxil 1
cefdinir 1
cefpodoxime 1
cefprozil 1
cefuroxime (Ceftin) 1
cephalexin, NP = tabs (Keflex) 1
MACROLIDES
azithromycin susp,tabs (Zithromax)
1
clarithromycin (Biaxin) 1
clarithromycin ext-release (BiaxinXL)
1
ERY-TAB 2
ERYTHROMYCIN BASE 2
erythromycin delayed-releasecaps
1
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
ERYTHROMYCINETHYLSUCCINATE
2
ZITHROMAX packets 2
TETRACYCLINES
demeclocycline 1
doxycycline hyclatecaps (Vibramycin)
1
doxycycline hyclate tabs 1
doxycyclinemonohydrate (Adoxa, Monodox)
1
minocycline (Dynacin, Minocin) 1
TETRACYCLINE 2
FLUOROQUINOLONES
ciprofloxacin (Cipro) 1
ciprofloxacin ext-release (CiproXR)
1
levofloxacin (Levaquin) 1
ofloxacin 200 mg, 300 mg 1
SULFONAMIDES
SULFADIAZINE 2
AMINOGLYCOSIDES
BETHKIS 2 Xneomycin sulfate 1
paromomycin 1
TOBI PODHALER 2 Xtobramycin (Tobi) 1 XTUBERCULOSIS
ethambutol (Myambutol) 1
ISONIAZID syrup 2
isoniazid tabs 1
PRIFTIN 2
pyrazinamide 1
rifabutin (Mycobutin) 1
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
2 Florida Blue January 2015 Healthy Kids Medication Drug Guide
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
RIFAMATE 2
rifampin (Rifadin) 1
FUNGAL INFECTIONS
fluconazole (Diflucan) 1
flucytosine (Ancobon) 1
griseofulvin microsize (GrifulvinV)
1
itraconazole (Sporanox) 1 •NOXAFIL 2 •nystatin oral 1
SPORANOX soln 2 •terbinafine (Lamisil) 1 •voriconazole (Vfend) 1 •VIRAL INFECTIONS
Cytomegalovirus
VALCYTE 2
Hepatitis
adefovir (Hepsera) 1
BARACLUDE soln 2
entecavir (Baraclude) 1
EPIVIR HBV soln 2
INTRON-A 2 Xlamivudine (Epivir HBV) 1
OLYSIO 2 X •PEGASYS 2 X •RIBATAB 2 X •ribavirin (Copegus, Rebetol) 1 X •SOVALDI 2 X •Herpes
acyclovir (Zovirax) 1
famciclovir (Famvir) 1
valacyclovir (Valtrex) 1
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
HIV/AIDS
abacavir (Ziagen) 1 •abacavir/lamivudine/
zidovudine (Trizivir)1 •
APTIVUS 2 •ATRIPLA 2 •COMPLERA 2 •CRIXIVAN 2 •didanosine delayed-
release (Videx EC)1 •
EDURANT 2 •EMTRIVA 2 •EPIVIR soln 2 •EPZICOM 2 •FUZEON 2 X •INTELENCE 2 •INVIRASE 2 •ISENTRESS 2 •KALETRA 2 •lamivudine (Epivir) 1 •lamivudine/zidovudine (Combivir) 1 •LEXIVA 2 •NEVIRAPINE susp 2 •nevirapine tabs (Viramune) 1 •nevirapine ext-release (Viramune
XR)1 •
NORVIR 2 •PREZISTA tabs 2 •RESCRIPTOR 2 •REYATAZ 2 •SELZENTRY 2 •stavudine (Zerit) 1 •
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
Florida Blue January 2015 Healthy Kids Medication Drug Guide 3
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
STRIBILD 2 •SUSTIVA 2 •TIVICAY 2 •TRUVADA 2 •VIDEX 2 •VIRACEPT 2 •VIRAMUNE susp 2 •VIRAMUNE XR 100 mg 2 •VIREAD 2 •ZIAGEN soln 2 •zidovudine (Retrovir) 1 •Influenza
TAMIFLU 2 •MALARIA
atovaquone/proguanil (Malarone) 1
chloroquine phosphate (Aralen) 1
DARAPRIM 2
hydroxychloroquine (Plaquenil) 1
mefloquine 1
PRIMAQUINE 2
WORM INFECTIONS
ALBENZA 2
BILTRICIDE 2
ivermectin (Stromectol) 1
OTHER ANTI-INFECTIVES
ALINIA 2
CAYSTON 2
clindamycin (Cleocin, CleocinPediatric)
1
colistimethate (Coly-Mycin M) 1
DAPSONE 2
erythromycin/sulfisoxazole 1
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
metronidazole oral (Flagyl) 1
NEBUPENT 2
PRIMSOL 2
SIVEXTRO tabs 2 • •sulfamethoxazole/
trimethoprim (Bactrim)1
trimethoprim 1
vancomycin (Vancocin) 1
XIFAXAN 550 mg 2 • •YODOXIN 2
ZYVOX 2 • •IMMUNIZING AGENTS
FLU VACCINES, NP = FLUBLOK 2 •GAMMAGARD LIQUID 2 X •GAMMAKED 2 X •GAMUNEX-C 2 X •HIZENTRA 2 X •MENACTRA 2
MENOMUNE-A/C/Y/W-135 2
MENVEO 2
PNEUMOVAX 23 2
PREVNAR 13 2
ZOSTAVAX 2
CANCER DRUGS
ACTIMMUNE 2 XAFINITOR 2 X • •AFINITOR DISPERZ 2 X • •ALKERAN tabs 2
anastrozole (Arimidex) 1
bicalutamide (Casodex) 1
BOSULIF 2 X • •capecitabine (Xeloda) 1 X • •
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
4 Florida Blue January 2015 Healthy Kids Medication Drug Guide
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
CAPRELSA 2 X • •COMETRIQ 2 X • •CYCLOPHOSPHAMIDE tabs 2
EMCYT 2
ERIVEDGE 2 X • •ETOPOSIDE caps 2
exemestane (Aromasin) 1
FARESTON 2
flutamide 1
GILOTRIF 2 X • •GLEEVEC 2 X • •HEXALEN 2 XHYCAMTIN caps 2 X •hydroxyurea (Hydrea) 1
ICLUSIG 2 X • •IMBRUVICA 2 X • •INLYTA 2 X • •JAKAFI 2 X • •letrozole (Femara) 1
LEUCOVORIN CALCIUM tabs,10 mg, 15 mg
2
leucovorin calcium tabs, 5 mg,25 mg
1
LEUKERAN 2
leuprolide acetate 1 X •LOMUSTINE 2
LYSODREN 2 XMATULANE 2 Xmegestrol (Megace) 1
MEKINIST 2 X • •mercaptopurine (Purinethol) 1
MESNEX tabs 2
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
methotrexate 1
MYLERAN 2
NEXAVAR 2 X • •NILANDRON 2
POMALYST 2 X • •PURIXAN 2 XSPRYCEL 2 X • •STIVARGA 2 X • •SUTENT 2 X • •SYLATRON 2 XTABLOID 2
TAFINLAR 2 X • •tamoxifen 1
TARCEVA 2 X • •TARGRETIN caps 2 X •TASIGNA 2 X • •temozolomide (Temodar) 1 X • •tretinoin caps 1 X •TYKERB 2 X • •VOTRIENT 2 X • •XALKORI 2 X • •XTANDI 2 X • •ZELBORAF 2 X • •ZOLINZA 2 X • •ZYDELIG 2 X •ZYKADIA 2 X • •ZYTIGA 2 X • •HORMONES, DIABETES AND RELATED DRUGS
CORTICOSTEROIDS
budesonide ext-release (EntocortEC)
1
CORTISONE 2
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
Florida Blue January 2015 Healthy Kids Medication Drug Guide 5
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
dexamethasone elixir; tabs,0.5 mg, 0.75 mg, 1.5 mg, 4 mg,6 mg
1
DEXAMETHASONE soln; tabs,1 mg, 2 mg
2
fludrocortisone 1
hydrocortisone (Cortef) 1
methylprednisolone (Medrol) 1
prednisolone (Prelone) 1
prednisolone sodiumphosphate (Orapred)
1
prednisolone sodium phosphatesoln, 5 mg/5 mL
1
PREDNISONE soln, 5 mg/5 mL;tabs, 50 mg; NP = dose packs
2
prednisone tabs, 1 mg, 2.5 mg,5 mg, 10 mg, 20 mg
1
MALE HORMONES
ANDRODERM 2 • •ANDROGEL 2 • •danazol 1
ESTROGENS
CLIMARA PRO 2 •DIVIGEL 2 •estradiol patches (Climara) 1 •estradiol tabs (Estrace) 1
estradiol/norethindroneacetate (Activella)
1
estropipate 0.75 mg, 1.5 mg 1
MENEST 2
PREMARIN 2
PREMPHASE 2
PREMPRO 2
PROGESTINS
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
medroxyprogesterone acetatetabs (Provera)
1
norethindrone acetate (Aygestin) 1
progesteronemicronized (Prometrium)
1
BIRTH CONTROL
ELLA 2
levonorgestrel (Plan B, Plan BOne-Step)
1
norelgestromin/ethinylestradiol (Ortho Evra)
1
oral contraceptives –all generics
1
DIABETES
acarbose (Precose) 1
BYDUREON 2 • •BYETTA inj 2 • •glimepiride (Amaryl) 1
glipizide (Glucotrol) 1
glipizide ext-release (Glucotrol XL) 1
glipizide/metformin 1
GLUCAGON EMERGENCY inj kit 2
glyburide (Micronase) 1
glyburide micronized (Glynase) 1
glyburide/metformin (Glucovance) 1
GLYBURIDE, distributor of Diabeta 2
INVOKAMET 2 • •INVOKANA 2 • •JANUMET 2 • •JANUMET XR 2 • •JANUVIA 2 • •KOMBIGLYZE XR 2 • •metformin (Glucophage) 1
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
6 Florida Blue January 2015 Healthy Kids Medication Drug Guide
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
metformin ext-release (Glucophage XR)
1
metformin ext-releaseOSM (Fortamet)
1
nateglinide (Starlix) 1
ONGLYZA 2 • •pioglitazone (Actos) 1 •pioglitazone/metformin (Actoplus
Met)1 •
PROGLYCEM 2
repaglinide (Prandin) 1
SYMLINPEN inj 2
Insulins
Rapid-Acting Insulins
NOVOLOG inj 2
Short-Acting Insulins
NOVOLIN R inj 2
RELION R inj 2
Intermediate-Acting Insulins
NOVOLIN N inj 2
NOVOLIN 70/30 inj 2
NOVOLOG MIX 70/30 inj 2
Basal Insulins
LANTUS inj 2
LEVEMIR inj 2
THYROID REGULATION
levothyroxine (Synthroid) 1
liothyronine (Cytomel) 1
methimazole (Tapazole) 1
propylthiouracil 1
SYNTHROID 2
GROWTH HORMONE
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
INCRELEX 2 X •NORDITROPIN 2 X •OTHER HORMONES AND RELATED DRUGS
alendronate tabs, 5 mg, 10 mg,35 mg, 70 mg (Fosamax)
1 •
cabergoline 1
calcitonin-salmon (Miacalcin) 1
calcitriol (Rocaltrol) 1
desmopressin inj, nasal,tabs (DDAVP)
1
ibandronate (Boniva) 1 •levocarnitine (Carnitor) 1
methylergonovine 1
octreotide (Sandostatin) 1 X •ORFADIN 2 X •paricalcitol (Zemplar) 1
raloxifene (Evista) 1
risedronate (Actonel) 1 •SENSIPAR 2
SOMAVERT 2 XSTIMATE 2
SYNAREL 2 XHEART AND CIRCULATORY DRUGS
ANGIOTENSIN CONVERTING ENZYME (ACE)INHIBITORS AND COMBINATIONS
benazepril (Lotensin) 1
benazepril/hydrochlorothiazide (LotensinHCT)
1
captopril 1
CAPTOPRIL/HYDROCHLOROTHIAZIDE25-15 mg, 50-15 mg
2
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
Florida Blue January 2015 Healthy Kids Medication Drug Guide 7
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
enalapril (Vasotec) 1
enalapril/hydrochlorothiazide (Vaseretic)
1
fosinopril 1
fosinopril/hydrochlorothiazide 1
lisinopril (Prinivil, Zestril) 1
lisinopril/hydrochlorothiazide (Prinzide,Zestoretic)
1
moexipril (Univasc) 1
moexipril/hydrochlorothiazide (Uniretic)
1
perindopril (Aceon) 1
quinapril (Accupril) 1
quinapril/hydrochlorothiazide (Accuretic)
1
ramipril (Altace) 1
trandolapril (Mavik) 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)AND COMBINATIONS
irbesartan (Avapro) 1 •irbesartan/
hydrochlorothiazide (Avalide)1 •
losartan (Cozaar) 1 •losartan/
hydrochlorothiazide (Hyzaar)1 •
valsartan (Diovan) 1 •valsartan/
hydrochlorothiazide (DiovanHCT)
1 •
BETA BLOCKERS AND COMBINATIONS
acebutolol (Sectral) 1
atenolol (Tenormin) 1
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
atenolol/chlorthalidone (Tenoretic)
1
bisoprolol (Zebeta) 1
bisoprolol/hydrochlorothiazide (Ziac)
1
carvedilol (Coreg) 1
labetalol (Trandate) 1
metoprolol succinate ext-release (Toprol XL)
1
metoprolol tartrate (Lopressor) 1
nadolol (Corgard) 1
pindolol 1
propranolol ext-release (InderalLA)
1
PROPRANOLOL soln, 20 mg/5 mL 2
propranolol tabs 1
PROPRANOLOL/HYDROCHLOROTHIAZIDE80-25 mg
2
TIMOLOL tabs 2
CALCIUM CHANNEL BLOCKERS ANDCOMBINATIONS
amlodipine (Norvasc) 1
amlodipine/benazepril (Lotrel) 1
amlodipine/valsartan (Exforge) 1 •diltiazem (Cardizem) 1
diltiazem ext-release (CardizemCD, Tiazac)
1
felodipine ext-release 1
ISRADIPINE caps, 2.5 mg 2
nifedipine ext-release (Adalat CC,Procardia XL)
1
NISOLDIPINE ext-release 25.5 mg 2
VERAPAMIL 40 mg 2
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
8 Florida Blue January 2015 Healthy Kids Medication Drug Guide
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
verapamil 80 mg, 120 mg (Calan) 1
verapamil ext-release (Calan SR,Isoptin SR, Verelan, Verelan PM)
1
CHEST PAIN
ISOSORBIDE DINITRATE tabs,30 mg
2
isosorbide dinitrate tabs, 5 mg,10 mg, 20 mg (Isordil)
1
isosorbide mononitrate (Monoket) 1
isosorbide mononitrate ext-release (Imdur)
1
NITRO-BID 2
nitroglycerin 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr (Nitro-Dur)
1
NITROSTAT 2
CHOLESTEROL LOWERING
atorvastatin (Lipitor) 1 •cholestyramine (Questran,
Questran Light)1
colestipol (Colestid) 1
CRESTOR 2 • •fenofibrate (Lofibra, Tricor) 1 •fenofibrate micronized (Lofibra) 1 •fenofibric acid delayed-
release (Trilipix)1 •
gemfibrozil (Lopid) 1 •lovastatin (Mevacor) 1 •niacin ext-release (Niaspan) 1
pravastatin (Pravachol) 1 •simvastatin (Zocor) 1 •WELCHOL 2
FLUID RETENTION
ACETAZOLAMIDE 125 mg 2
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
acetazolamide 250 mg 1
acetazolamide ext-release (Diamox Sequels)
1
amiloride 1
amiloride/hydrochlorothiazide 1
bumetanide 1
chlorothiazide 500 mg 1
CHLORTHALIDONE 25 mg, 50 mg 2
furosemide, NP = soln, 8 mg/mL (Lasix)
1
hydrochlorothiazidecaps (Microzide)
1
hydrochlorothiazide tabs 1
indapamide 1
methazolamide (Neptazane) 1
metolazone (Zaroxolyn) 1
spironolactone (Aldactone) 1
spironolactone/hydrochlorothiazide (Aldactazide)
1
torsemide (Demadex) 1
triamterene/hydrochlorothiazide,NP = caps, 50-25 mg (Dyazide,Maxzide, Maxzide-25)
1
HEART RHYTHM
amiodarone (Cordarone) 1
disopyramide (Norpace) 1
flecainide 1
mexiletine 1
propafenone (Rythmol) 1
propafenone ext-release (RythmolSR)
1
quinidine gluconate ext-release 1
QUINIDINE SULFATE ext-release 2
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
Florida Blue January 2015 Healthy Kids Medication Drug Guide 9
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
QUINIDINE SULFATE 200 mg 2
quinidine sulfate 300 mg 1
sotalol (Betapace, Betapace AF) 1
OTHER HEART RELATED DRUGS
amlodipine/atorvastatin (Caduet) 1
clonidine (Catapres, Catapres-TTS)
1
DIGOXIN soln 2
digoxin tabs (Lanoxin) 1
doxazosin (Cardura) 1
eplerenone (Inspra) 1
guanfacine (Tenex) 1
hydralazine 1
LETAIRIS 2 X • •methyldopa 1
midodrine (Proamatine) 1
minoxidil 1
OPSUMIT 2 X • •prazosin (Minipress) 1
sildenafil (Revatio) 1 X • •terazosin 1
TRACLEER 2 X • •VENTAVIS 2 X • •ERECTILE DYSFUNCTION
LEVITRA* 2
ALLERGIC REACTION KITS
EPIPEN inj 2
EPIPEN-JR inj 2
RESPIRATORY DRUGS
ANTIHISTAMINES
cyproheptadine 1
loratadine (Claritin – OTC) 1
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
promethazine 1
NASAL PRODUCTS
azelastine (Astepro) 1 •flunisolide 25 mcg/
spray (Flunisolide)1 •
fluticasone propionate (Flonase) 1 •ipratropium (Atrovent) 1 •triamcinolone (Nasacort AQ) 1 •COUGH/COLD/ALLERGY
acetylcysteine 1
loratadine/pseudoephedrine (Claritin-D –OTC)
1
ASTHMA/COPD
albuterol 1
ATROVENT HFA 2 •budesonide (Pulmicort Respules) 1
COMBIVENT RESPIMAT 2 •cromolyn sodium inhal soln 1
DULERA 2 •FORADIL AEROLIZER 2 •ipratropium inhal soln 1
ipratropium/albuterol (Duoneb) 1
levalbuterol, NP =1.25 mg/0.5 mL (Xopenex)
1
montelukast (Singulair) 1 •PROAIR HFA 2 •PULMICORT FLEXHALER 2 •PULMICORT RESPULES
1 mg/2 mL2
QVAR 2 •SPIRIVA HANDIHALER 2 •SPIRIVA RESPIMAT 2 •
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
10 Florida Blue January 2015 Healthy Kids Medication Drug Guide
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
SYMBICORT 2 •terbutaline 1
theophylline ext-release 1
VENTOLIN HFA 2 •zafirlukast (Accolate) 1 •OTHER RESPIRATORY DRUGS
KALYDECO 2 X • •PULMOZYME 2 XGASTROINTESTINAL DRUGS
LAXATIVES
lactulose 1
PEG – electrolytes forsoln (Colyte, Golytely, Nulytely)
1
ULCER/GERD
CARAFATE susp 2
cimetidine 1
dicyclomine caps, tabs (Bentyl) 1
famotidine (Pepcid) 1
glycopyrrolate (Robinul) 1
hyoscyamine (Anaspaz, Levsin,Levsin/SL)
1
hyoscyamine ext-release (Levbid) 1
lansoprazole delayed-release (Prevacid)
1 •
methscopolamine (Pamine,Pamine Forte)
1
misoprostol (Cytotec) 1
OMEPRAZOLE (Prilosec OTC) 2
omeprazole delayed-release (Prilosec)
1 •
pantoprazole delayed-release (Protonix)
1 •
PROPANTHELINE 15 mg 2
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
ranitidine (Zantac) 1
sucralfate (Carafate) 1
SYMAX DUOTAB 2
NAUSEA AND VOMITING
EMEND caps, therapy pack 2 •granisetron 1 •meclizine 1
ondansetron (Zofran, Zofran ODT) 1 •ondansetron tabs, 24 mg 1 •trimethobenzamide (Tigan) 1
DIGESTIVE ENZYMES– Pancreatic enzyme products:
CREON 2
ZENPEP 2
OTHER GASTROINTESTINAL DRUGS
ASACOL HD 2
balsalazide (Colazal) 1
calcium acetate (Eliphos, Phoslo) 1
CANASA 2
CHENODAL 2
DELZICOL 2
diphenoxylate/atropinetabs (Lomotil)
1
lactulose 1
LIALDA 2
loperamide 1
mesalamine 1
metoclopramide (Reglan) 1
PENTASA 2
RENVELA 2
sulfasalazine (Azulfidine) 1
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
Florida Blue January 2015 Healthy Kids Medication Drug Guide 11
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
sulfasalazine delayed-release (Azulfidine EN-Tabs)
1
ursodiol (Actigall, Urso 250, UrsoForte)
1
GENITOURINARY DRUGS
URINARY TRACT INFECTIONS
nitrofurantoin (Furadantin) 1
nitrofurantoinmacrocrystalline (Macrodantin)
1
nitrofurantoin monohydrate/macrocrystalline (Macrobid)
1
URINARY TRACT SPASMS
oxybutynin 1 •oxybutynin ext-release (Ditropan
XL)1 •
tolterodine (Detrol) 1 •tolterodine ext-release (Detrol LA) 1 •VESICARE 2 •VAGINAL PRODUCTS
AVC 2
CLEOCIN supp 2
clindamycin (Cleocin) 1
metronidazole (MetroGel-Vaginal) 1
PREMARIN 2
terconazole (Terazol) 1
VAGIFEM 2
OTHER GENITOURINARY DRUGS
alfuzosin ext-release (Uroxatral) 1
CYSTAGON 2
finasteride (Proscar) 1
K-PHOS NO. 2 2
potassium citrate ext-release (Urocit-K)
1
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
potassium citrate/citricacid (Polycitra-K)
1
sodium citrate/citric acid (Shohl's) 1
tamsulosin (Flomax) 1
CENTRAL NERVOUS SYSTEM DRUGS
ANXIETY
alprazolam (Xanax) 1
alprazolam ext-release (XanaxXR)
1
buspirone 1
DIAZEPAM oral soln, 1 mg/mL 2
diazepam tabs (Valium) 1
hydroxyzine hcl 1
hydroxyzine pamoate 25 mg,50 mg (Vistaril)
1
lorazepam (Ativan) 1
lorazepam conc (LorazepamIntensol)
1
DEPRESSION
amitriptyline 1
bupropion (Wellbutrin) 1 •bupropion ext-release (Wellbutrin
SR, Wellbutrin XL)1 •
citalopram (Celexa) 1 •clomipramine (Anafranil) 1
desipramine (Norpramin) 1
doxepin 1
DOXEPIN 75 mg 2
duloxetine delayed-release (Cymbalta)
1 •
escitalopram (Lexapro) 1 •fluoxetine, 60 mg not
covered (Prozac)1 •
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
12 Florida Blue January 2015 Healthy Kids Medication Drug Guide
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
fluvoxamine 1 •imipramine hcl (Tofranil) 1
mirtazapine (Remeron, RemeronSolTab)
1 •
nortriptyline caps (Pamelor) 1
paroxetine hcl (Paxil) 1 •paroxetine hcl ext-release (Paxil
CR)1 •
PAXIL susp 2 • •phenelzine (Nardil) 1
sertraline (Zoloft) 1 •tranylcypromine (Parnate) 1
trazodone 1
venlafaxine 1 •venlafaxine ext-release
caps (Effexor XR)1 •
VENLAFAXINE ext-release tabs,225 mg
2 • •
venlafaxine ext-release tabs,37.5 mg, 75 mg, 150 mg
1 •
PSYCHOTIC AND BIPOLAR DISORDERS
chlorpromazine 1
clozapine (Clozaril) 1 •fluphenazine hcl tabs 1
haloperidol lactate oral soln 1
haloperidol tabs 1
LITHIUM soln 2
lithium carbonate 1
LITHIUM CARBONATE caps,600 mg
2
lithium carbonate ext-release300 mg (Lithobid)
1
lithium carbonate ext-release450 mg
1
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
loxapine (Loxitane) 1
olanzapine (Zyprexa, ZyprexaZydis)
1 •
perphenazine 1
prochlorperazine 1
quetiapine (Seroquel) 1 •risperidone (Risperdal, Risperdal
M-Tab)1 •
SEROQUEL XR 2 •thiothixene 1
trifluoperazine 1
ziprasidone (Geodon) 1 •SLEEP AIDS
estazolam 1
phenobarbital soln; tabs,16.2 mg, 32.4 mg
1
PHENOBARBITAL tabs, 15 mg,30 mg, 60 mg, 64.8 mg, 100 mg;NP = 97.2 mg
2
temazepam (Restoril) 1
zaleplon (Sonata) 1 •zolpidem (Ambien) 1 •zolpidem ext-release (Ambien CR) 1 •HYPERACTIVITY/NARCOLEPSY
amphetamine/dextroamphetamine (Adderall)
1 • •
amphetamine/dextroamphetamine ext-release (Adderall XR)
1 • •
caffeine citrate (Cafcit) 1
dextroamphetamine 1 • •dextroamphetamine ext-
release (Dexedrine Spansule)1 • •
methylphenidate tabs (Ritalin) 1 • •
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
Florida Blue January 2015 Healthy Kids Medication Drug Guide 13
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
methylphenidate ext-releasecaps; tabs, 20 mg (MetadateCD, Ritalin LA)
1 • •
modafinil (Provigil) 1 • •MULTIPLE SCLEROSIS
BETASERON 2 X • •COPAXONE 2 X • •PLEGRIDY 2 X • •REBIF 2 X • •TECFIDERA 2 X • •OTHER CENTRAL NERVOUS SYSTEM DRUGS
acamprosate delayed-release (Campral)
1
disulfiram (Antabuse) 1
donepezil (Aricept, Aricept ODT) 1
EXELON patches 2
galantamine (Razadyne) 1
galantamine ext-release (Razadyne ER)
1
naltrexone (ReVia) 1
rivastigmine (Exelon) 1
TOBACCO CESSATION
bupropion ext-release (Zyban) 1
CHANTIX* 2
NICOTROL INHALER* 2
NICOTROL NS* 2
PAIN RELIEF DRUGS
NON-NARCOTIC DRUGS
butalbital/acetaminophen 1 •butalbital/acetaminophen/
caffeine (Esgic, Fioricet)1 •
butalbital/aspirin/caffeinecaps (Fiorinal)
1 •
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
salsalate 1
NARCOTIC DRUGS
acetaminophen/codeine (Tylenolw/Codeine)
1 •
buprenorphine 1 • •buprenorphine/naloxone 1 • •butalbital/aspirin/caffeine/
codeine (Fiorinal w/Codeine)1 •
butorphanol nasal 1 •fentanyl (Duragesic) 1 •fentanyl (Actiq) 1 • •hydrocodone/acetaminophen,
NP = soln, 10-325 mg/15 mL1 •
hydrocodone/ibuprofen (Ibudone,Reprexain, Vicoprofen)
1 •
hydromorphone soln,tabs (Dilaudid)
1 •
methadone conc, soln 1 •methadone tabs (Dolophine) 1 •morphine sulfate conc, soln 1 •morphine sulfate ext-
release (Avinza, Kadian, MSContin)
1 •
MORPHINE SULFATE tabs 2 •oxycodone 1 •oxycodone/
acetaminophen (Percocet)1 •
oxycodone/acetaminophen caps,5-500 mg
1 •
oxycodone/aspirin (Percodan) 1 •OXYCONTIN 2 •ROXICET soln 2 •SUBOXONE film 2 • •tramadol (Ultram) 1 •
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
14 Florida Blue January 2015 Healthy Kids Medication Drug Guide
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
tramadol ext-release (Ultram ER) 1 •tramadol/
acetaminophen (Ultracet)1 •
RHEUMATOID AND OSTEOARTHRITIS
diclofenac potassium (Cataflam) 1
diclofenac sodium delayed-release
1
diclofenac sodium ext-release (Voltaren-XR)
1
ENBREL 2 X • •etodolac 1
etodolac ext-release 1
flurbiprofen 1
HUMIRA 2 X • •ibuprofen 1
indomethacin 1
ketoprofen 1
leflunomide (Arava) 1
MELOXICAM susp 2
meloxicam tabs (Mobic) 1
nabumetone 1
naproxen (Naprosyn) 1
naproxen delayed-release (EC-Naprosyn)
1
naproxen sodium (Anaprox) 1
oxaprozin (Daypro) 1
piroxicam (Feldene) 1
SIMPONI 2 X • •sulindac 1
MIGRAINE HEADACHES
acetaminophen/isometheptene/dichloralphenazone
1
IMITREX nasal 2 •
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
naratriptan (Amerge) 1 •rizatriptan (Maxalt, Maxalt-MLT) 1 •sumatriptan auto-injector;
cartridge; inj, 6 mg/0.5 mL;tabs (Imitrex)
1 •
SUMATRIPTAN inj, 4 mg/0.5 mL 2 •GOUT
allopurinol (Zyloprim) 1
COLCRYS 2
probenecid 1
probenecid/colchicine 1
NEUROMUSCULAR DRUGS
SEIZURES
carbamazepine (Tegretol) 1
carbamazepine ext-release (Carbatrol, Tegretol-XR)
1
clonazepam (Klonopin) 1
DIASTAT 2
DILANTIN caps 2
divalproex delayed-release (Depakote, DepakoteSprinkles)
1
divalproex ext-release (DepakoteER)
1
ethosuximide (Zarontin) 1
gabapentin (Neurontin) 1
lamotrigine (Lamictal) 1
levetiracetam (Keppra) 1
oxcarbazepine (Trileptal) 1
phenytoin (Dilantin) 1
phenytoin sodium ext-release (Dilantin, Phenytek)
1
primidone (Mysoline) 1
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
Florida Blue January 2015 Healthy Kids Medication Drug Guide 15
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
SABRIL 2
topiramate (Topamax, TopamaxSprinkle)
1
valproic acid (Depakene) 1
zonisamide (Zonegran) 1
PARKINSON'S DISEASE
amantadine caps, syrup 1
AMANTADINE tabs 2
benztropine 1
bromocriptine (Parlodel) 1
carbidopa/levodopa (Parcopa,Sinemet)
1
carbidopa/levodopa ext-release (Sinemet CR)
1
entacapone (Comtan) 1
pramipexole (Mirapex) 1
ropinirole (Requip) 1
selegiline caps (Eldepryl) 1
selegiline tabs 1
trihexyphenidyl 1
MUSCLE RELAXANTS
baclofen 1
chlorzoxazone (Parafon Forte) 1
cyclobenzaprine 1
DANTROLENE 100 mg 2
dantrolene 25 mg,50 mg (Dantrium)
1
metaxalone (Skelaxin) 1
methocarbamol (Robaxin) 1
orphenadrine citrate ext-release 1
orphenadrine/aspirin/caffeine25-385-30 mg
1
tizanidine (Zanaflex) 1
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
OTHER NEUROMUSCULAR DRUGS
MESTINON syrup 2
MESTINON TIMESPAN 2
PROSTIGMIN tabs 2
pyridostigmine (Mestinon) 1
riluzole (Rilutek) 1
SUPPLEMENTS
VITAMINS
ergocalciferol (Drisdol) 1
MEPHYTON 2
MULTIVITAMINS
PRENATAL MULTIVITAMINS/FOLIC ACID
2
MINERALS AND ELECTROLYTES
potassium bicarbonate/chlorideeffervescent tabs, 25 mEq
1
potassium chloride packets;soln
1
potassium chloride ext-release,NP = 20 mEq
1
potassium phosphate/sodiumphosphates (K-Phos Neutral)
1
SODIUM FLUORIDE tabs, 2.2 mg 2
sodium fluoride, NP = tabs,1.1 mg (Luride)
1
BLOOD MODIFYING DRUGS
anagrelide (Agrylin) 1
ARANESP 2 X •cilostazol (Pletal) 1
CINRYZE 2 X •clopidogrel (Plavix) 1
cyanocobalamin inj 1
dipyridamole (Persantine) 1
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
16 Florida Blue January 2015 Healthy Kids Medication Drug Guide
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
DROXIA 2
ELIQUIS 2 •enoxaparin inj (Lovenox) 1 •FIRAZYR 2 X •folic acid tabs, 1 mg 1
LEUKINE 2 XNEULASTA 2 X • •NEUPOGEN 2 X •pentoxifylline ext-release (Trental) 1
PRADAXA 2 •PROCRIT 2 X •warfarin (Coumadin) 1
XARELTO 2 •ZAVESCA 2 X •COAGULATION FACTORS
ADVATE 2 X •ALPHANATE/VWF 2 X •ALPHANINE SD 2 X •ALPROLIX 2 X •BEBULIN/VH 2 X •BENEFIX 2 X •CORIFACT 2 X •ELOCTATE 2 X •FEIBA NF 2 X •HELIXATE FS 2 X •HEMOFIL M 2 X •HUMATE-P 2 X •KOATE-DVI 2 X •KOGENATE FS 2 X •MONOCLATE-P 2 X •MONONINE 2 X •NOVOSEVEN/RT 2 X •
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
PROFILNINE SD 2 X •RECOMBINATE 2 X •RIXUBIS 2 X •TRETTEN 2 X •WILATE 2 X •XYNTHA/SOLOFUSE 2 X •TOPICAL PRODUCTS
EYE
Anti-infectives
BACITRACIN oint 2
bacitracin/polymyxin B oint 1
ciprofloxacin soln (Ciloxan) 1
erythromycin oint 1
gentamicin oint, soln (Garamycin) 1
NATACYN 2
neomycin/polymyxin B/bacitracin oint
1
neomycin/polymyxin B/gramicidin soln (Neosporin)
1
ofloxacin soln (Ocuflox) 1
polymyxin B/trimethoprimsoln (Polytrim)
1
sulfacetamide sodiumsoln (Bleph-10)
1
tobramycin soln (Tobrex) 1
trifluridine soln (Viroptic) 1
VIGAMOX 2
Steroids and Combination Products
dexamethasone sodiumphosphate soln
1
fluorometholone susp, 0.1% (FMLLiquifilm)
1
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
Florida Blue January 2015 Healthy Kids Medication Drug Guide 17
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
neomycin/polymyxin B/bacitracin/hydrocortisone oint
1
neomycin/polymyxin B/dexamethasone oint,susp (Maxitrol)
1
prednisolone acetate susp (PredForte)
1
sulfacetamide sodium/prednisolone soln
1
TOBRADEX oint 2
tobramycin/dexamethasonesusp (Tobradex)
1
Glaucoma
brimonidine soln,0.15% (Alphagan P)
1
brimonidine soln, 0.2% 1
carteolol soln 1
dorzolamide soln (Trusopt) 1
dorzolamide/timolol maleatesoln (Cosopt)
1
latanoprost soln (Xalatan) 1 •levobunolol soln, 0.5% (Betagan) 1
pilocarpine soln (Isopto Carpine) 1
timolol maleate soln (Timoptic,Timoptic-XE)
1
Other Eye Products
ATROPINE SULFATE oint 2
atropine sulfate soln (IsoptoAtropine)
1
azelastine soln (Optivar) 1
cromolyn sodium soln 1
cyclopentolate soln (Cyclogyl) 1
diclofenac soln (Voltaren) 1
flurbiprofen soln (Ocufen) 1
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
homatropine soln (IsoptoHomatropine)
1
ketorolac soln (Acular, Acular LS) 1
tropicamide soln (Mydriacyl) 1
EAR
acetic acid soln 1
ACETIC ACID/ALUMINUMACETATE soln
2
benzocaine/antipyrine soln 1
CIPRODEX 2
hydrocortisone/acetic acidsoln (Vosol HC)
1
neomycin/polymyxin B/hydrocortisone soln,susp (Cortisporin)
1
ofloxacin soln 1
MOUTH AND THROAT (LOCAL)
cevimeline (Evoxac) 1
chlorhexidine rinse (Peridex) 1
clotrimazole troche 1
lidocaine viscous 1
nystatin susp 1
pilocarpine (Salagen) 1
triamcinolone paste 1
ANORECTAL AGENTS
hydrocortisone acetate crm,supp (Anusol-HC, Proctocort)
1
hydrocortisoneenema (Cortenema)
1
PROCTOFOAM HC 2
SKIN CONDITIONS/PRODUCTS
Acne
adapalene* (Differin) 1
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
18 Florida Blue January 2015 Healthy Kids Medication Drug Guide
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
CLARAVIS 30 mg 2
clindamycin (Cleocin-T) 1
clindamycin/benzoylperoxide (Benzaclin, Duac)
1
erythromycin (Erygel) 1
erythromycin pads, soln 1
erythromycin/benzoylperoxide (Benzamycin)
1
FINACEA 2
isotretinoin 10 mg, 20 mg,40 mg – Amnesteem, Claravis,Myorisan, Zenatane
1
metronidazole (Metrocream,Metrogel, Metrolotion)
1
sulfacetamide sodium (Klaron) 1
sulfacetamide sodium/sulfur, NP= susp, 10-5% (Plexion)
1
TAZORAC* 2 •tretinoin microsphere* (Retin-A
Micro)1
tretinoin* (Retin-A) 1
Anti-infectives
ciclopirox crm, gel, shampoo,susp (Loprox)
1
ciclopirox soln, 8% (Penlac) 1 •econazole 1
ketoconazole (Nizoral) 1
mupirocin (Bactroban) 1
nystatin topical 1
silver sulfadiazine (Silvadene) 1
ZOVIRAX crm 2
Corticosteroids
alclometasone (Aclovate) 1
betamethasone dipropionate 1
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
betamethasone dipropionate,augmented (Diprolene)
1
betamethasone valerate 1
clobetasol (Olux, Temovate) 1
desonide (Desowen) 1
desoximetasone crm, 0.25%; gel;oint, 0.25% (Topicort)
1
diflorasone oint 1
fluocinolone (Derma-Smoothe/FS,Synalar)
1
fluocinonide 1
fluticasone propionate (Cutivate) 1
halobetasol (Ultravate) 1
hydrocortisone topical 1
hydrocortisonevalerate (Westcort)
1
mometasone (Elocon) 1
nystatin/triamcinolone 1
triamcinolone, NP = oint, 0.5% 1
Other Skin Products
acitretin (Soriatane) 1
calcipotriene (Dovonex) 1 •diclofenac sodium (Solaraze) 1
fluorouracil (Efudex) 1
imiquimod (Aldara) 1
lidocaine jelly, 2%; oint, 5%;soln, 4% (Xylocaine)
1
lidocaine patches (Lidoderm) 1
lidocaine/prilocaine crm (Emla) 1
lindane 1
malathion (Ovide) 1
permethrin crm 1
podofilox (Condylox) 1
2015
TierKEY 1 = Covered Generic Drugs • = Responsible Rx Program X = Self-Administered Specialty Medication
2 = Preferred Brand Drugs * = May not be covered – see endorsement
Florida Blue January 2015 Healthy Kids Medication Drug Guide 19
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
selenium sulfide 2.5% 1
STELARA 2 X • •VALCHLOR 2 XMISCELLANEOUS CATEGORIES
DIABETIC SUPPLIES
BLOOD GLUCOSE METERS –BAYER BREEZE 2
2
BLOOD GLUCOSE METERS –BAYER CONTOUR
2
BLOOD GLUCOSE METERS –BAYER CONTOUR NEXT/EZ/LINK/USB
2
INSULIN PEN NEEDLES –NOVOFINE, NOVOTWIST,OTHER VARIOUSMANUFACTURERS
2
LANCET DEVICES – VARIOUSMANUFACTURERS
2
LANCETS – VARIOUSMANUFACTURERS
2
SYRINGES/NEEDLES – VARIOUSMANUFACTURERS – for self-injectable drug administration
2
TEST DISCS – BAYER BREEZE 2 2 •TEST STRIPS – BAYER
CONTOUR/NEXT2 •
MISCELLANEOUS DRUGS
azathioprine (Imuran) 1
CELLCEPT oral susp 2
CHEMET 2
CUPRIMINE 2
cyclosporine (Sandimmune) 1
cyclosporine modified caps,25 mg, 100 mg; soln (Neoral)
1
Drug Name Dru
g T
ier
Spe
cial
ty
Prio
r A
utho
rizat
ion
Qua
nitit
y Li
mits
Res
pons
ible
Ste
ps
CYCLOSPORINE modified caps,50 mg
2
EXJADE 2 Xmycophenolate mofetil (Cellcept) 1
mycophenolate sodium delayed-release (Myfortic)
1
naloxone inj, 0.4 mg/mL 1
RAPAMUNE soln 2
REVLIMID 2 X • •sirolimus (Rapamune) 1
sodium polystyrene sulfonate 1
tacrolimus (Prograf) 1
THALOMID 2 X • •ZORTRESS 2
2015
20 Florida Blue January 2015 Healthy Kids Medication Drug Guide
INDEX
A
abacavir.............................................................................. 2abacavir/lamivudine/zidovudine.......................................2acamprosate delayed-release........................................ 13acarbose............................................................................. 5acebutolol...........................................................................7acetaminophen/codeine..................................................13acetaminophen/isometheptene/dichloralphenazone....................................................... 14
ACETAZOLAMIDE 125 mg.................................................8acetazolamide 250 mg...................................................... 8acetazolamide ext-release................................................ 8ACETIC ACID/ALUMINUM ACETATE ear soln................ 17acetic acid ear soln.........................................................17acetylcysteine.................................................................... 9acitretin.............................................................................18ACTIMMUNE....................................................................... 3acyclovir oral..................................................................... 2adapalene......................................................................... 17adefovir...............................................................................2ADVATE............................................................................ 16AFINITOR............................................................................ 3AFINITOR DISPERZ........................................................... 3ALBENZA............................................................................ 3albuterol..............................................................................9alclometasone..................................................................18alendronate tabs, 5 mg, 10 mg, 35 mg, 70 mg................6alfuzosin ext-release....................................................... 11ALINIA................................................................................. 3ALKERAN tabs....................................................................3allopurinol........................................................................ 14ALPHANATE/VWF............................................................ 16ALPHANINE SD................................................................ 16alprazolam........................................................................ 11alprazolam ext-release....................................................11ALPROLIX......................................................................... 16amantadine caps, syrup................................................. 15AMANTADINE tabs........................................................... 15amiloride.............................................................................8amiloride/hydrochlorothiazide......................................... 8amiodarone........................................................................ 8amitriptyline..................................................................... 11amlodipine..........................................................................7amlodipine/atorvastatin.................................................... 9amlodipine/benazepril....................................................... 7amlodipine/valsartan......................................................... 7amoxicillin, NP = chew tabs, 125 mg.............................. 1amoxicillin/potassium clavulanate.................................. 1amoxicillin/potassium clavulanate ext-release...............1AMOXICILLIN chew tabs, 250 mg...................................... 1amphetamine/dextroamphetamine................................ 12amphetamine/dextroamphetamine ext-release.............12
ampicillin caps...................................................................1AMPICILLIN susp................................................................1anagrelide.........................................................................15anastrozole.........................................................................3ANDRODERM..................................................................... 5ANDROGEL.........................................................................5APTIVUS............................................................................. 2ARANESP..........................................................................15ASACOL HD......................................................................10atenolol............................................................................... 7atenolol/chlorthalidone..................................................... 7atorvastatin........................................................................ 8atovaquone/proguanil....................................................... 3ATRIPLA..............................................................................2ATROPINE SULFATE eye oint......................................... 17atropine sulfate eye soln................................................17ATROVENT HFA.................................................................9AUGMENTIN susp, 125 mg/5 mL.......................................1AVC................................................................................... 11azathioprine......................................................................19azelastine eye soln..........................................................17azelastine nasal................................................................. 9azithromycin susp, tabs................................................... 1
B
bacitracin/polymyxin B eye oint.................................... 16BACITRACIN eye oint.......................................................16baclofen............................................................................ 15balsalazide........................................................................10BARACLUDE soln...............................................................2BEBULIN/VH..................................................................... 16benazepril........................................................................... 6benazepril/hydrochlorothiazide........................................6BENEFIX........................................................................... 16benzocaine/antipyrine ear soln......................................17benztropine...................................................................... 15betamethasone dipropionate......................................... 18betamethasone dipropionate, augmented.................... 18betamethasone valerate..................................................18BETASERON.....................................................................13BETHKIS............................................................................. 1bicalutamide.......................................................................3BILTRICIDE......................................................................... 3bisoprolol........................................................................... 7bisoprolol/hydrochlorothiazide........................................ 7BLOOD GLUCOSE METERS – BAYER BREEZE 2.........19BLOOD GLUCOSE METERS – BAYER CONTOUR........ 19BLOOD GLUCOSE METERS – BAYER CONTOURNEXT/EZ/LINK/USB........................................................ 19
BOSULIF............................................................................. 3brimonidine eye soln, 0.15%..........................................17brimonidine eye soln, 0.2%............................................17bromocriptine...................................................................15budesonide.........................................................................9budesonide ext-release.....................................................4bumetanide.........................................................................8
2015
Florida Blue January 2015 Healthy Kids Medication Drug Guide 21
buprenorphine................................................................. 13buprenorphine/naloxone.................................................13bupropion......................................................................... 11bupropion ext-release.....................................................11bupropion ext-release – smoking deterrent..................13buspirone......................................................................... 11butalbital/acetaminophen............................................... 13butalbital/acetaminophen/caffeine.................................13butalbital/aspirin/caffeine/codeine.................................13butalbital/aspirin/caffeine caps...................................... 13butorphanol nasal........................................................... 13BYDUREON........................................................................ 5BYETTA inj..........................................................................5
C
cabergoline.........................................................................6caffeine citrate................................................................. 12calcipotriene.....................................................................18calcitonin-salmon.............................................................. 6calcitriol.............................................................................. 6calcium acetate................................................................10CANASA............................................................................ 10capecitabine....................................................................... 3CAPRELSA..........................................................................4captopril..............................................................................6CAPTOPRIL/HYDROCHLOROTHIAZIDE 25-15 mg,50-15 mg........................................................................... 6
CARAFATE susp...............................................................10carbamazepine.................................................................14carbamazepine ext-release.............................................14carbidopa/levodopa.........................................................15carbidopa/levodopa ext-release.....................................15carteolol eye soln............................................................17carvedilol............................................................................ 7CAYSTON........................................................................... 3cefaclor caps..................................................................... 1cefadroxil............................................................................1cefdinir................................................................................1cefpodoxime.......................................................................1cefprozil.............................................................................. 1cefuroxime..........................................................................1CELLCEPT oral susp........................................................ 19cephalexin, NP = tabs.......................................................1cevimeline........................................................................ 17CHANTIX........................................................................... 13CHEMET............................................................................19CHENODAL.......................................................................10chlorhexidine oral rinse..................................................17chloroquine phosphate.....................................................3chlorothiazide 500 mg...................................................... 8chlorpromazine................................................................ 12CHLORTHALIDONE 25 mg, 50 mg....................................8chlorzoxazone..................................................................15cholestyramine.................................................................. 8ciclopirox crm, gel, shampoo, susp.............................. 18ciclopirox soln................................................................. 18
cilostazol.......................................................................... 15cimetidine......................................................................... 10CINRYZE........................................................................... 15CIPRODEX........................................................................ 17ciprofloxacin ext-release.................................................. 1ciprofloxacin eye soln.................................................... 16ciprofloxacin oral.............................................................. 1citalopram.........................................................................11CLARAVIS 30 mg............................................................. 18clarithromycin.................................................................... 1clarithromycin ext-release................................................1CLEOCIN supp..................................................................11CLIMARA PRO....................................................................5clindamycin/benzoyl peroxide....................................... 18clindamycin oral................................................................ 3clindamycin topical......................................................... 18clindamycin vaginal crm................................................ 11clobetasol......................................................................... 18clomipramine................................................................... 11clonazepam...................................................................... 14clonidine............................................................................. 9clopidogrel....................................................................... 15clotrimazole troche......................................................... 17clozapine.......................................................................... 12COLCRYS......................................................................... 14colestipol............................................................................ 8colistimethate.....................................................................3COMBIVENT RESPIMAT....................................................9COMETRIQ......................................................................... 4COMPLERA.........................................................................2COPAXONE...................................................................... 13CORIFACT........................................................................ 16CORTISONE....................................................................... 4CREON..............................................................................10CRESTOR........................................................................... 8CRIXIVAN............................................................................2cromolyn sodium eye soln.............................................17cromolyn sodium inhal soln............................................ 9CUPRIMINE.......................................................................19cyanocobalamin inj......................................................... 15cyclobenzaprine...............................................................15cyclopentolate eye soln..................................................17CYCLOPHOSPHAMIDE tabs..............................................4cyclosporine.....................................................................19cyclosporine modified caps, 25 mg, 100 mg; soln.......19CYCLOSPORINE modified caps, 50 mg.......................... 19cyproheptadine.................................................................. 9CYSTAGON.......................................................................11
D
danazol............................................................................... 5DANTROLENE 100 mg.....................................................15dantrolene 25 mg, 50 mg................................................15DAPSONE........................................................................... 3DARAPRIM..........................................................................3DELZICOL......................................................................... 10
2015
22 Florida Blue January 2015 Healthy Kids Medication Drug Guide
demeclocycline.................................................................. 1desipramine......................................................................11desmopressin inj, nasal, tabs..........................................6desonide........................................................................... 18desoximetasone crm, 0.25%; gel; oint, 0.25%.............. 18dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg, 4mg, 6 mg.......................................................................... 5
dexamethasone sodium phosphate eye soln............... 16DEXAMETHASONE soln; tabs, 1 mg, 2 mg....................... 5dextroamphetamine.........................................................12dextroamphetamine ext-release.....................................12DIASTAT............................................................................14DIAZEPAM oral soln, 1 mg/mL.........................................11diazepam tabs..................................................................11diclofenac eye soln......................................................... 17diclofenac potassium......................................................14diclofenac sodium delayed-release...............................14diclofenac sodium ext-release....................................... 14diclofenac sodium gel.................................................... 18dicloxacillin........................................................................ 1dicyclomine caps, tabs...................................................10didanosine delayed-release..............................................2diflorasone oint............................................................... 18DIGOXIN soln......................................................................9digoxin tabs....................................................................... 9DILANTIN caps................................................................. 14diltiazem............................................................................. 7diltiazem ext-release......................................................... 7diphenoxylate/atropine tabs...........................................10dipyridamole.................................................................... 15disopyramide..................................................................... 8disulfiram..........................................................................13divalproex delayed-release.............................................14divalproex ext-release.....................................................14DIVIGEL...............................................................................5donepezil.......................................................................... 13dorzolamide/timolol maleate eye soln...........................17dorzolamide eye soln......................................................17doxazosin........................................................................... 9doxepin............................................................................. 11DOXEPIN 75 mg...............................................................11doxycycline hyclate caps................................................. 1doxycycline hyclate tabs..................................................1doxycycline monohydrate................................................ 1DROXIA............................................................................. 16DULERA.............................................................................. 9duloxetine delayed-release.............................................11
E
econazole......................................................................... 18EDURANT........................................................................... 2ELIQUIS.............................................................................16ELLA.................................................................................... 5ELOCTATE........................................................................16EMCYT................................................................................ 4EMEND caps, therapy pack..............................................10
EMTRIVA.............................................................................2enalapril.............................................................................. 7enalapril/hydrochlorothiazide...........................................7ENBREL............................................................................ 14enoxaparin inj.................................................................. 16entacapone.......................................................................15entecavir............................................................................. 2EPIPEN inj...........................................................................9EPIPEN-JR inj..................................................................... 9EPIVIR HBV soln................................................................ 2EPIVIR soln......................................................................... 2eplerenone..........................................................................9EPZICOM............................................................................ 2ergocalciferol................................................................... 15ERIVEDGE.......................................................................... 4ERY-TAB............................................................................. 1erythromycin/benzoyl peroxide..................................... 18erythromycin/sulfisoxazole.............................................. 3ERYTHROMYCIN BASE.....................................................1erythromycin delayed-release caps................................ 1ERYTHROMYCIN ETHYLSUCCINATE.............................. 1erythromycin eye oint.....................................................16erythromycin gel............................................................. 18erythromycin topical pads, soln.................................... 18escitalopram.....................................................................11estazolam......................................................................... 12estradiol/norethindrone acetate.......................................5estradiol patches...............................................................5estradiol tabs..................................................................... 5estropipate 0.75 mg, 1.5 mg.............................................5ethambutol......................................................................... 1ethosuximide....................................................................14etodolac............................................................................ 14etodolac ext-release........................................................14ETOPOSIDE caps...............................................................4EXELON patches.............................................................. 13exemestane........................................................................ 4EXJADE.............................................................................19
F
famciclovir..........................................................................2famotidine.........................................................................10FARESTON......................................................................... 4FEIBA NF.......................................................................... 16felodipine ext-release........................................................7fenofibrate.......................................................................... 8fenofibrate micronized......................................................8fenofibric acid delayed-release........................................8fentanyl lozenges............................................................ 13fentanyl patches.............................................................. 13FINACEA........................................................................... 18finasteride.........................................................................11FIRAZYR........................................................................... 16flecainide............................................................................ 8fluconazole......................................................................... 2flucytosine..........................................................................2
2015
Florida Blue January 2015 Healthy Kids Medication Drug Guide 23
fludrocortisone.................................................................. 5flunisolide 25 mcg/spray.................................................. 9fluocinolone..................................................................... 18fluocinonide..................................................................... 18fluorometholone eye susp, 0.1%................................... 16fluorouracil....................................................................... 18fluoxetine, 60 mg not covered....................................... 11fluphenazine hcl tabs......................................................12flurbiprofen eye soln.......................................................17flurbiprofen tabs..............................................................14flutamide.............................................................................4fluticasone propionate nasal............................................9fluticasone propionate topical....................................... 18FLU VACCINES, NP = FLUBLOK...................................... 3fluvoxamine......................................................................12folic acid tabs, 1 mg....................................................... 16FORADIL AEROLIZER....................................................... 9fosinopril............................................................................ 7fosinopril/hydrochlorothiazide......................................... 7furosemide, NP = soln, 8 mg/mL..................................... 8FUZEON.............................................................................. 2
G
gabapentin........................................................................14galantamine......................................................................13galantamine ext-release..................................................13GAMMAGARD LIQUID........................................................3GAMMAKED........................................................................3GAMUNEX-C.......................................................................3gemfibrozil..........................................................................8gentamicin eye oint, soln............................................... 16GILOTRIF............................................................................ 4GLEEVEC............................................................................4glimepiride..........................................................................5glipizide.............................................................................. 5glipizide/metformin............................................................5glipizide ext-release.......................................................... 5GLUCAGON EMERGENCY inj kit...................................... 5glyburide.............................................................................5GLYBURIDE, distributor of Diabeta.................................... 5glyburide/metformin.......................................................... 5glyburide micronized........................................................ 5glycopyrrolate.................................................................. 10granisetron....................................................................... 10griseofulvin microsize.......................................................2guanfacine..........................................................................9
H
halobetasol.......................................................................18haloperidol lactate oral soln.......................................... 12haloperidol tabs...............................................................12HELIXATE FS................................................................... 16HEMOFIL M...................................................................... 16HEXALEN............................................................................ 4HIZENTRA...........................................................................3homatropine eye soln..................................................... 17
HUMATE-P........................................................................ 16HUMIRA.............................................................................14HYCAMTIN caps................................................................. 4hydralazine......................................................................... 9hydrochlorothiazide caps.................................................8hydrochlorothiazide tabs..................................................8hydrocodone/acetaminophen, NP = soln, 10-325 mg/15mL....................................................................................13
hydrocodone/ibuprofen.................................................. 13hydrocortisone/acetic acid ear soln..............................17hydrocortisone acetate rectal crm, supp...................... 17hydrocortisone enema....................................................17hydrocortisone oral...........................................................5hydrocortisone topical....................................................18hydrocortisone valerate..................................................18hydromorphone soln, tabs.............................................13hydroxychloroquine.......................................................... 3hydroxyurea....................................................................... 4hydroxyzine hcl............................................................... 11hydroxyzine pamoate 25 mg, 50 mg............................. 11hyoscyamine.................................................................... 10hyoscyamine ext-release................................................10
I
ibandronate........................................................................ 6ibuprofen.......................................................................... 14ICLUSIG.............................................................................. 4IMBRUVICA.........................................................................4imipramine hcl................................................................. 12imiquimod.........................................................................18IMITREX nasal.................................................................. 14INCRELEX...........................................................................6indapamide.........................................................................8indomethacin................................................................... 14INLYTA................................................................................ 4INSULIN PEN NEEDLES – NOVOFINE, NOVOTWIST,OTHER VARIOUS MANUFACTURERS......................... 19
INTELENCE.........................................................................2INTRON-A........................................................................... 2INVIRASE............................................................................ 2INVOKAMET........................................................................5INVOKANA.......................................................................... 5ipratropium/albuterol.........................................................9ipratropium inhal soln...................................................... 9ipratropium nasal.............................................................. 9irbesartan........................................................................... 7irbesartan/hydrochlorothiazide........................................ 7ISENTRESS........................................................................ 2ISONIAZID syrup.................................................................1isoniazid tabs.....................................................................1ISOSORBIDE DINITRATE tabs, 30 mg.............................. 8isosorbide dinitrate tabs, 5 mg, 10 mg, 20 mg............... 8isosorbide mononitrate.....................................................8isosorbide mononitrate ext-release.................................8isotretinoin 10 mg, 20 mg, 40 mg – Amnesteem,Claravis, Myorisan, Zenatane....................................... 18
2015
24 Florida Blue January 2015 Healthy Kids Medication Drug Guide
ISRADIPINE caps, 2.5 mg.................................................. 7itraconazole........................................................................2ivermectin...........................................................................3
J
JAKAFI.................................................................................4JANUMET............................................................................5JANUMET XR..................................................................... 5JANUVIA..............................................................................5
K
KALETRA............................................................................ 2KALYDECO....................................................................... 10ketoconazole crm, shampoo.......................................... 18ketoprofen........................................................................ 14ketorolac eye soln...........................................................17KOATE-DVI....................................................................... 16KOGENATE FS.................................................................16KOMBIGLYZE XR............................................................... 5K-PHOS NO. 2..................................................................11
L
labetalol.............................................................................. 7lactulose........................................................................... 10lactulose........................................................................... 10lamivudine.......................................................................... 2lamivudine.......................................................................... 2lamivudine/zidovudine...................................................... 2lamotrigine....................................................................... 14LANCET DEVICES – VARIOUS MANUFACTURERS...... 19LANCETS – VARIOUS MANUFACTURERS.................... 19lansoprazole delayed-release.........................................10LANTUS inj..........................................................................6latanoprost eye soln....................................................... 17leflunomide.......................................................................14LETAIRIS.............................................................................9letrozole.............................................................................. 4LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg................... 4leucovorin calcium tabs, 5 mg, 25 mg............................ 4LEUKERAN......................................................................... 4LEUKINE........................................................................... 16leuprolide acetate..............................................................4levalbuterol neb soln, NP = 1.25 mg/0.5 mL................... 9LEVEMIR inj........................................................................ 6levetiracetam....................................................................14LEVITRA..............................................................................9levobunolol eye soln, 0.5%............................................ 17levocarnitine.......................................................................6levofloxacin oral................................................................ 1levonorgestrel.................................................................... 5levothyroxine..................................................................... 6LEXIVA................................................................................ 2LIALDA.............................................................................. 10lidocaine/prilocaine crm................................................. 18lidocaine jelly, 2%; oint, 5%; soln, 4%.......................... 18lidocaine patches............................................................ 18
lidocaine viscous............................................................ 17lindane.............................................................................. 18liothyronine........................................................................ 6lisinopril..............................................................................7lisinopril/hydrochlorothiazide.......................................... 7lithium carbonate............................................................ 12LITHIUM CARBONATE caps, 600 mg..............................12lithium carbonate ext-release 300 mg........................... 12lithium carbonate ext-release 450 mg........................... 12LITHIUM soln.................................................................... 12LOMUSTINE........................................................................4loperamide........................................................................10loratadine............................................................................9loratadine/pseudoephedrine.............................................9lorazepam conc............................................................... 11lorazepam tabs................................................................ 11losartan...............................................................................7losartan/hydrochlorothiazide........................................... 7lovastatin............................................................................ 8loxapine............................................................................ 12LYSODREN......................................................................... 4
M
malathion..........................................................................18MATULANE......................................................................... 4meclizine...........................................................................10medroxyprogesterone acetate tabs.................................5mefloquine..........................................................................3megestrol............................................................................4MEKINIST............................................................................4MELOXICAM susp............................................................ 14meloxicam tabs............................................................... 14MENACTRA.........................................................................3MENEST..............................................................................5MENOMUNE-A/C/Y/W-135................................................. 3MENVEO............................................................................. 3MEPHYTON...................................................................... 15mercaptopurine..................................................................4mesalamine...................................................................... 10MESNEX tabs..................................................................... 4MESTINON syrup..............................................................15MESTINON TIMESPAN.................................................... 15metaxalone....................................................................... 15metformin........................................................................... 5metformin ext-release....................................................... 6metformin ext-release OSM..............................................6methadone conc, soln.................................................... 13methadone tabs...............................................................13methazolamide...................................................................8methimazole....................................................................... 6methocarbamol................................................................ 15methotrexate...................................................................... 4methscopolamine............................................................ 10methyldopa.........................................................................9methylergonovine..............................................................6methylphenidate ext-release caps; tabs, 20 mg........... 13
2015
Florida Blue January 2015 Healthy Kids Medication Drug Guide 25
methylphenidate tabs......................................................12methylprednisolone...........................................................5metoclopramide............................................................... 10metolazone......................................................................... 8metoprolol succinate ext-release.................................... 7metoprolol tartrate............................................................ 7metronidazole oral............................................................ 3metronidazole topical......................................................18metronidazole vaginal gel.............................................. 11mexiletine........................................................................... 8midodrine........................................................................... 9minocycline........................................................................ 1minoxidil............................................................................. 9mirtazapine.......................................................................12misoprostol...................................................................... 10modafinil...........................................................................13moexipril.............................................................................7moexipril/hydrochlorothiazide......................................... 7mometasone.....................................................................18MONOCLATE-P................................................................ 16MONONINE....................................................................... 16montelukast........................................................................9morphine sulfate conc, soln.......................................... 13morphine sulfate ext-release..........................................13MORPHINE SULFATE tabs..............................................13mupirocin......................................................................... 18mycophenolate mofetil................................................... 19mycophenolate sodium delayed-release...................... 19MYLERAN........................................................................... 4
N
nabumetone..................................................................... 14nadolol................................................................................ 7naloxone inj, 0.4 mg/mL................................................. 19naltrexone.........................................................................13naproxen...........................................................................14naproxen delayed-release.............................................. 14naproxen sodium............................................................ 14naratriptan........................................................................ 14NATACYN..........................................................................16nateglinide..........................................................................6NEBUPENT......................................................................... 3neomycin/polymyxin B/bacitracin/hydrocortisone eyeoint.................................................................................. 17
neomycin/polymyxin B/bacitracin eye oint...................16neomycin/polymyxin B/dexamethasone eye oint,susp.................................................................................17
neomycin/polymyxin B/gramicidin eye soln.................16neomycin/polymyxin B/hydrocortisone ear soln,susp.................................................................................17
neomycin sulfate............................................................... 1NEULASTA........................................................................16NEUPOGEN...................................................................... 16nevirapine ext-release.......................................................2NEVIRAPINE susp.............................................................. 2nevirapine tabs.................................................................. 2
NEXAVAR............................................................................4niacin ext-release.............................................................. 8NICOTROL INHALER....................................................... 13NICOTROL NS..................................................................13nifedipine ext-release........................................................7NILANDRON........................................................................4NISOLDIPINE ext-release 25.5 mg.....................................7NITRO-BID.......................................................................... 8nitrofurantoin................................................................... 11nitrofurantoin macrocrystalline..................................... 11nitrofurantoin monohydrate/macrocrystalline..............11nitroglycerin 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr....................................................................................... 8
NITROSTAT........................................................................ 8NORDITROPIN....................................................................6norelgestromin/ethinyl estradiol......................................5norethindrone acetate.......................................................5nortriptyline caps............................................................ 12NORVIR...............................................................................2NOVOLIN 70/30 inj............................................................. 6NOVOLIN N inj....................................................................6NOVOLIN R inj....................................................................6NOVOLOG inj......................................................................6NOVOLOG MIX 70/30 inj....................................................6NOVOSEVEN/RT.............................................................. 16NOXAFIL............................................................................. 2nystatin/triamcinolone.................................................... 18nystatin oral....................................................................... 2nystatin susp................................................................... 17nystatin topical................................................................ 18
O
octreotide........................................................................... 6ofloxacin 200 mg, 300 mg................................................ 1ofloxacin ear soln............................................................17ofloxacin eye soln........................................................... 16olanzapine........................................................................ 12OLYSIO............................................................................... 2OMEPRAZOLE (Prilosec OTC).........................................10omeprazole delayed-release...........................................10ondansetron..................................................................... 10ondansetron tabs, 24 mg............................................... 10ONGLYZA............................................................................6OPSUMIT............................................................................ 9oral contraceptives – all generics................................... 5ORFADIN.............................................................................6orphenadrine/aspirin/caffeine 25-385-30 mg................ 15orphenadrine citrate ext-release....................................15oxaprozin..........................................................................14oxcarbazepine..................................................................14oxybutynin........................................................................11oxybutynin ext-release....................................................11oxycodone........................................................................13oxycodone/acetaminophen caps, 5-500 mg................. 13oxycodone/acetaminophen tabs....................................13oxycodone/aspirin........................................................... 13
2015
26 Florida Blue January 2015 Healthy Kids Medication Drug Guide
OXYCONTIN..................................................................... 13
P
pantoprazole delayed-release........................................ 10paricalcitol..........................................................................6paromomycin..................................................................... 1paroxetine hcl.................................................................. 12paroxetine hcl ext-release.............................................. 12PAXIL susp........................................................................12PEGASYS............................................................................2PEG – electrolytes for soln............................................ 10penicillin v potassium.......................................................1PENTASA.......................................................................... 10pentoxifylline ext-release................................................16perindopril.......................................................................... 7permethrin crm................................................................ 18perphenazine....................................................................12phenelzine........................................................................ 12phenobarbital soln; tabs, 16.2 mg, 32.4 mg..................12PHENOBARBITAL tabs, 15 mg, 30 mg, 60 mg, 64.8 mg,100 mg; NP = 97.2 mg....................................................12
phenytoin..........................................................................14phenytoin sodium ext-release........................................14pilocarpine eye soln........................................................17pilocarpine tabs...............................................................17pindolol...............................................................................7pioglitazone........................................................................6pioglitazone/metformin..................................................... 6piroxicam..........................................................................14PLEGRIDY.........................................................................13PNEUMOVAX 23................................................................ 3podofilox...........................................................................18polymyxin B/trimethoprim eye soln.............................. 16POMALYST......................................................................... 4potassium bicarbonate/chloride effervescent tabs, 25mEq................................................................................. 15
potassium chloride ext-release, NP = 20 mEq..............15potassium chloride packets; soln................................. 15potassium citrate/citric acid...........................................11potassium citrate ext-release.........................................11potassium phosphate/sodium phosphates.................. 15PRADAXA..........................................................................16pramipexole......................................................................15pravastatin..........................................................................8prazosin.............................................................................. 9prednisolone acetate eye susp......................................17prednisolone sodium phosphate oral soln, 15 mg/5mL......................................................................................5
prednisolone sodium phosphate oral soln, 5 mg/5mL......................................................................................5
prednisolone soln, 15 mg/5 mL....................................... 5PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg; NP = dosepacks..................................................................................5
prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg......5PREMARIN crm................................................................ 11PREMARIN tabs..................................................................5
PREMPHASE...................................................................... 5PREMPRO...........................................................................5PRENATAL MULTIVITAMINS/FOLIC ACID......................15PREVNAR 13...................................................................... 3PREZISTA tabs................................................................... 2PRIFTIN...............................................................................1PRIMAQUINE...................................................................... 3primidone......................................................................... 14PRIMSOL.............................................................................3PROAIR HFA...................................................................... 9probenecid....................................................................... 14probenecid/colchicine.....................................................14prochlorperazine..............................................................12PROCRIT...........................................................................16PROCTOFOAM HC.......................................................... 17PROFILNINE SD...............................................................16progesterone micronized..................................................5PROGLYCEM......................................................................6promethazine..................................................................... 9propafenone....................................................................... 8propafenone ext-release...................................................8PROPANTHELINE 15 mg.................................................10PROPRANOLOL/HYDROCHLOROTHIAZIDE 80-25mg...................................................................................... 7
propranolol ext-release.....................................................7PROPRANOLOL soln, 20 mg/5 mL.................................... 7propranolol tabs................................................................ 7propylthiouracil..................................................................6PROSTIGMIN tabs............................................................15PULMICORT FLEXHALER................................................. 9PULMICORT RESPULES 1 mg/2 mL.................................9PULMOZYME.................................................................... 10PURIXAN.............................................................................4pyrazinamide......................................................................1pyridostigmine................................................................. 15
Q
quetiapine.........................................................................12quinapril..............................................................................7quinapril/hydrochlorothiazide.......................................... 7quinidine gluconate ext-release.......................................8QUINIDINE SULFATE 200 mg........................................... 9quinidine sulfate 300 mg.................................................. 9QUINIDINE SULFATE ext-release......................................8QVAR...................................................................................9
R
raloxifene............................................................................6ramipril................................................................................7ranitidine...........................................................................10RAPAMUNE soln.............................................................. 19REBIF................................................................................ 13RECOMBINATE................................................................ 16RELION R inj...................................................................... 6RENVELA.......................................................................... 10repaglinide..........................................................................6
2015
Florida Blue January 2015 Healthy Kids Medication Drug Guide 27
RESCRIPTOR..................................................................... 2REVLIMID..........................................................................19REYATAZ............................................................................ 2RIBATAB............................................................................. 2ribavirin...............................................................................2rifabutin.............................................................................. 1RIFAMATE...........................................................................2rifampin...............................................................................2riluzole.............................................................................. 15risedronate......................................................................... 6risperidone....................................................................... 12rivastigmine......................................................................13RIXUBIS............................................................................ 16rizatriptan......................................................................... 14ropinirole.......................................................................... 15ROXICET soln...................................................................13
S
SABRIL.............................................................................. 15salsalate............................................................................13selegiline caps.................................................................15selegiline tabs..................................................................15selenium sulfide 2.5%.....................................................19SELZENTRY........................................................................2SENSIPAR...........................................................................6SEROQUEL XR................................................................ 12sertraline...........................................................................12sildenafil............................................................................. 9silver sulfadiazine........................................................... 18SIMPONI............................................................................14simvastatin......................................................................... 8sirolimus...........................................................................19SIVEXTRO tabs.................................................................. 3sodium citrate/citric acid................................................11sodium fluoride oral, NP = tabs, 1.1 mg........................15SODIUM FLUORIDE tabs, 2.2 mg....................................15sodium polystyrene sulfonate....................................... 19SOMAVERT.........................................................................6sotalol................................................................................. 9SOVALDI............................................................................. 2SPIRIVA HANDIHALER...................................................... 9SPIRIVA RESPIMAT...........................................................9spironolactone................................................................... 8spironolactone/hydrochlorothiazide................................8SPORANOX soln................................................................ 2SPRYCEL............................................................................ 4stavudine............................................................................ 2STELARA.......................................................................... 19STIMATE............................................................................. 6STIVARGA...........................................................................4STRIBILD.............................................................................3SUBOXONE film............................................................... 13sucralfate..........................................................................10sulfacetamide sodium/prednisolone eye soln..............17sulfacetamide sodium/sulfur, NP = susp, 10-5%..........18sulfacetamide sodium eye soln..................................... 16
sulfacetamide sodium lotn.............................................18SULFADIAZINE................................................................... 1sulfamethoxazole/trimethoprim....................................... 3sulfasalazine.................................................................... 10sulfasalazine delayed-release........................................ 11sulindac............................................................................ 14sumatriptan auto-injector; cartridge; inj, 6 mg/0.5 mL;tabs..................................................................................14
SUMATRIPTAN inj, 4 mg/0.5 mL......................................14SUSTIVA............................................................................. 3SUTENT.............................................................................. 4SYLATRON......................................................................... 4SYMAX DUOTAB..............................................................10SYMBICORT..................................................................... 10SYMLINPEN inj................................................................... 6SYNAREL............................................................................ 6SYNTHROID........................................................................6SYRINGES/NEEDLES – VARIOUS MANUFACTURERS –for self-injectable drug administration..............................19
T
TABLOID............................................................................. 4tacrolimus.........................................................................19TAFINLAR........................................................................... 4TAMIFLU............................................................................. 3tamoxifen............................................................................4tamsulosin........................................................................11TARCEVA............................................................................4TARGRETIN caps............................................................... 4TASIGNA............................................................................. 4TAZORAC..........................................................................18TECFIDERA...................................................................... 13temazepam....................................................................... 12temozolomide.....................................................................4terazosin............................................................................. 9terbinafine.......................................................................... 2terbutaline........................................................................ 10terconazole.......................................................................11TEST DISCS – BAYER BREEZE 2.................................. 19TEST STRIPS – BAYER...................................................19TETRACYCLINE................................................................. 1THALOMID........................................................................ 19theophylline ext-release..................................................10thiothixene........................................................................12timolol maleate eye soln................................................ 17TIMOLOL tabs.....................................................................7TIVICAY...............................................................................3tizanidine.......................................................................... 15TOBI PODHALER............................................................... 1TOBRADEX oint................................................................17tobramycin/dexamethasone eye susp...........................17tobramycin eye soln....................................................... 16tobramycin inhal soln....................................................... 1tolterodine........................................................................ 11tolterodine ext-release.................................................... 11topiramate........................................................................ 15
2015
28 Florida Blue January 2015 Healthy Kids Medication Drug Guide
torsemide............................................................................8TRACLEER..........................................................................9tramadol............................................................................13tramadol/acetaminophen................................................ 14tramadol ext-release....................................................... 14trandolapril......................................................................... 7tranylcypromine...............................................................12trazodone..........................................................................12tretinoin caps.....................................................................4tretinoin crm, gel.............................................................18tretinoin microsphere......................................................18TRETTEN.......................................................................... 16triamcinolone dental paste.............................................17triamcinolone nasal...........................................................9triamcinolone topical, NP = oint, 0.5%.......................... 18triamterene/hydrochlorothiazide, NP = caps, 50-25mg......................................................................................8
trifluoperazine.................................................................. 12trifluridine eye soln......................................................... 16trihexyphenidyl................................................................ 15trimethobenzamide..........................................................10trimethoprim.......................................................................3tropicamide eye soln...................................................... 17TRUVADA............................................................................3TYKERB.............................................................................. 4
U
ursodiol.............................................................................11
V
VAGIFEM...........................................................................11valacyclovir........................................................................ 2VALCHLOR....................................................................... 19VALCYTE............................................................................ 2valproic acid.................................................................... 15valsartan............................................................................. 7valsartan/hydrochlorothiazide..........................................7vancomycin........................................................................ 3venlafaxine....................................................................... 12venlafaxine ext-release caps..........................................12VENLAFAXINE ext-release tabs, 225 mg.........................12venlafaxine ext-release tabs, 37.5 mg, 75 mg, 150mg....................................................................................12
VENTAVIS........................................................................... 9VENTOLIN HFA................................................................ 10VERAPAMIL 40 mg.............................................................7verapamil 80 mg, 120 mg................................................. 8verapamil ext-release........................................................8VESICARE.........................................................................11VIDEX.................................................................................. 3VIGAMOX.......................................................................... 16VIRACEPT...........................................................................3VIRAMUNE susp.................................................................3VIRAMUNE XR 100 mg......................................................3VIREAD............................................................................... 3voriconazole.......................................................................2
VOTRIENT...........................................................................4
W
warfarin.............................................................................16WELCHOL........................................................................... 8WILATE............................................................................. 16
X
XALKORI............................................................................. 4XARELTO.......................................................................... 16XIFAXAN 550 mg................................................................3XTANDI................................................................................4XYNTHA/SOLOFUSE........................................................16
Y
YODOXIN............................................................................ 3
Z
zafirlukast......................................................................... 10zaleplon............................................................................ 12ZAVESCA.......................................................................... 16ZELBORAF..........................................................................4ZENPEP............................................................................ 10ZIAGEN soln....................................................................... 3zidovudine.......................................................................... 3ziprasidone.......................................................................12ZITHROMAX packets..........................................................1ZOLINZA..............................................................................4zolpidem........................................................................... 12zolpidem ext-release....................................................... 12zonisamide....................................................................... 15ZORTRESS....................................................................... 19ZOSTAVAX..........................................................................3ZOVIRAX crm....................................................................18ZYDELIG............................................................................. 4ZYKADIA............................................................................. 4ZYTIGA................................................................................4ZYVOX.................................................................................3
top related