clinical drug list...11c ophthalmic anti-allergy agents 75 11d ophthalmic anti-infective and steroid...

C o n f d e n c e c o m e s w i t h e v e r y c a r d . ®

Clinical Drug List

2019

Blue Cross Clinical Drug List - January 2019

Table of contents

Blue Cross Clinical Drug List (Formulary) introduction 6

How to read the Blue Cross Clinical Drug List 13

Anti-infectives

1A Antifungals 15

1B Antimalarials 15

1C Antiparasitics and antihelmintics 16

1D Antiretrovirals 17

1E Antituberculars 18

1F Antivirals 18

1G Cephalosporins 19

1H Macrolides 19

1I Penicillins 19

1J Quinolones 20

1K Sulfonamides and combinations 20

1L Tetracyclines 20

1M Urinary tract agents 21

1N Miscellaneous anti-infectives 21

Cardiovascular, hypertension, cholesterol

2A ACE-Inhibitors and combinations 22

2B Alpha-adrenergic agents 22

2C Angiotensin II Receptor Blockers and combinations 23

2D Anticoagulants and hemostasis agents 24

2E Beta blockers and combinations 25

2F Calcium channel blockers and combinations 26

2G Cardiovascular treatment 26

2H Diuretics 27

2I Lipid-lowering agents 28

2J Nitrates and combinations 29

2K Renin-inhibitors and combinations 29

2L Miscellaneous antihypertensives 29

Page 1

Central nervous system

3A Alzheimer's therapy 30

3B Anticonvulsants 31

3C Antidepressants 32

3D Antipsychotics 33

3E Anxiolytics 34

3F CNS stimulants 34

3G Migraine therapy 35

3H Myasthenia gravis 35

3I Narcotic antagonists and withdrawal management 35

3J Narcotic mixed agonist and antagonist 36

3K Narcotic and analgesic combinations 36

3L Narcotics 37

3M Nonsteroidal anti-inflammatory drugs 38

3N Parkinsons disease and related disorders 39

3O Salicylates 39

3P Sedative and hypnotics 40

3Q Skeletal muscle relaxants 40

3R Miscellaneous CNS 41

Gastrointestinal agents

4A 5-Aminosalicylic Acid (5-ASA) agents 42

4B Antidiarrheals and antispasmodics 42

4C Antiemetics 43

4D Bile acids 43

4E Bowel preparation and cleansing agents 44

4F Digestive enzymes 44

4G H2-Receptor antagonists 44

4H Proton Pump Inhibitors (PPI) 45

4I Topical anti-Inflammatory agents 45

4J Tumor Necrosis Factor (TNF) blocking agents 45

4K Ulcer therapy 46

4L Miscellaneous gastrointestinal agents 46

Obstetrics and gynecology

5A Contraceptives-Biphasic 47

5B Contraceptives-Misc. 47

5C Contraceptives-Monophasic 48

5D Contraceptives-Postcoital 48

5E Contraceptives-Triphasic 48

5F Estrogen and progestin combinations 49

5G Estrogens 49

5H Infertility treatment* 50

5I Progestins 50

5J Vaginal anti-infective and antifungal 50

5K Miscellaneous OB-GYN 51

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Rheumatology and musculoskeletal

6A Corticosteroids 52

6B Gout therapy 52

6C Non-Tumor Necrosis Factor (TNF) blocking agents 52

6D Osteoporosis and bone resorption 52

6E Osteoporosis and hormonal treatment 53

6F Salicylates 53

6G Tumor Necrosis Factor (TNF) blocking agents 53

6H Miscellaneous rheumatologic agents 53

Endocrinology

7A Androgens 54

7B Antithyroid agents 54

7C Corticosteroids 55

7D Growth Hormone and related products 55

7E Insulins 56

7F Non-insulin hypoglycemic agents 57

7G Somatostatin analogs 58

7H Thyroid hormones 58

7I Urea cycle disorder agents 58 7J Vitamin D analogs 58 7K Miscellaneous endocrine 59

Antineoplastics and immunosuppresants

8A Adjuvant therapy 60

8B Alkylating agents 60

8C Antimetabolites 60

8D Hormonal agents 61

8E Immunomodulators 62

8F Kinase inhibitors and molecular target inhibitors 63

8G Miscellaneous antineoplastic agents 64

Immunology and hematology

9A Hematopoietic agents 65

9B Immunoglobulins 65

9C Interferons and MS therapy 65

9D Miscellaneous immunology and hematology 66

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Dermatology

10A Acne treatment 67

10B Antipsoriatic and antiseborrheic 68

10C Corticosteroids - very high potency 68

10D Corticosteroids - high potency 69

10E Corticosteroids - medium potency 69

10F Corticosteroids - low potency 70

10G Scabicides and pediculicides 70

10H Topical anesthetics 70

10I Topical antibacterials 71

10J Topical antifungals 71

10K Topical antineoplastic agents and immunomodulators 72

10L Topical antivirals 72

10M Wound and burn therapy 72

10N Miscellaneous dermatologicals 73

Ophthalmology

11A Cycloplegic mydriatics 74

11B Glaucoma agents 74

11C Ophthalmic anti-allergy agents 75

11D Ophthalmic anti-infective and steroid combinations 75

11E Ophthalmic anti-infectives 76

11F Ophthalmic anti-inflammatory agents 76

11G Ophthalmic beta blockers 77

11H Ophthalmic steroids 77

11I Miscellaneous ophthalmic agents 77

Otic and nasal preparations

12A Nasal preparations 78

12B Otic preparations 78

Respiratory, cough and cold

13A Antihistamine and decongestant combinations 79

13B Antihistamines 79

13C Antitussives 80

13D Cystic Fibrosis agents 80 13E Epinephrine 80

13F Inhaled anticholinergics 81

13G Inhaled beta-agonist and anticholinergic combinations 81

13H Inhaled beta-agonists 81

13I Inhaled steroid and beta-agonist combinations 82 13J Inhaled steroids 82

13K Intranasal steroids 82

13L Oral beta-agonists 82

13M Pulmonary Hypertension Agents 83 13N Theophyllines 83

13O Miscellaneous respiratory agents 83

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Urology

14A BPH Treatment 84

14B Ion-Removing Agents 84

14C Urinary Antispasmodics 85

14D Miscellaneous Urologicals 85

Vitamins and supplements

15A Potassium Replacement 86

15B Vitamins and Minerals 86

Diagnostic and other miscellaneous

16A Chelating Agents 87

16B Diagnostics and Other Miscellaneous 87

16C Vaccines 88

Lifestyle modification

17A Sexual Dysfunction 89

17B Smoking Cessation 89

17C Weight Loss Preparations 89

Page 5

Blue Cross Clinical Drug List

The Blue Cross Blue Shield of Michigan Clinical Drug List is a useful reference and educational tool for prescribers, pharmacists and members.

We regularly update this list with medications approved by the U.S. Food and Drug

Administration and reviewed by our Pharmacy and Therapeutics Committee. The list represents

the clinical judgment of Michigan doctors, pharmacists and other experts in the diagnosis and

treatment of disease and the promotion of health. The committee selects medications based on

safety, clinical effectiveness and opportunity for cost savings. This is how the Clinical Drug List helps maintain quality of care and contain costs for our members.

About this drug list

Use this list to find information about drug coverage and therapeutic options for Blue Cross

members. This list is divided into major drug classes or indication for use by chapter. Products

approved for more than one use may be included in more than one chapter. Within each

chapter, drugs are identified according to their tier placement. Refer to the How to Read section

for details.

We encourage doctors to prescribe preferred medications whenever possible. Blue Cross

respects the judgment of the dispensing pharmacists and expect them to contact the prescriber

when a prescription for a drug or dose may not be appropriate for a member. We also

encourage pharmacists to contact the prescriber to suggest an alternative when a Blue Cross

member’s prescription is written for a nonpreferred or excluded drug.

Coverage and applicable copay amounts for drugs on the Blue Cross Clinical Drug List are based on a member’s drug plan. Not all drugs included in the drug list are necessarily covered

by each member’s plan. Drugs not listed on the Clinical Drug List may not be covered.

Some medications excluded by a Blue Cross member’s pharmacy benefit may be covered

under his or her medical benefit. These are medications that are generally administered in a

doctor’s office under the supervision of appropriate health care personnel and aren’t normally

dispensed to the member for self-administration.

Drug list exclusions

Our goal at Blue Cross is to provide you with safe, high-quality prescription drug therapies while

also keeping your medical costs low. To accomplish this, we don’t cover some high-cost drugs

with comparable therapeutic alternatives that have similar effectiveness, quality and safety, but

at a fraction of the cost. For the most recent list of excluded drugs, read our Drug List Exclusions (PDF). If you have a question about a drug that isn’t covered and doesn’t appear on this list, call the Customer Service number on the back of your Blue Cross member ID card.

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Several drugs and drug categories are excluded from coverage under this drug list. These

include:

• Prescription drugs for which there is an over-the-counter equivalent in both strength and dosage form (unless considered preventive by the United States Preventive Services

Task Force)

• Drugs used for experimental or investigational purposes • Drugs prescribed for cosmetic purposes • Products covered as a medical benefit (for example, injectable drugs and vaccines that

are usually administered in a doctor’s office)

o Note: Most Blue Cross members can get multiple common vaccines at network retail pharmacies. Restrictions may apply.

• Compounded products — with some exceptions • Replacement prescriptions resulting from loss, theft or mishandling • Drugs not approved by the FDA

Specialty drugs

For more information on specialty drugs, see Specialty Drug Program Rx Benefit Member Guide. Specialty drugs are limited to a 30-day supply. Select specialty drugs are managed by the 15-Day Specialty Drug Limitation Program. Drugs included on this list are limited to a 15-day supply for all fills. Members pay half their copay for a 15-day supply. For more details, visit

bcbsm.com/pharmacy.

Preventive drug coverage

Under the Patient Protection and Affordable Care Act, also known as national health care

reform, most health care plans must cover certain preventive services and drugs with no cost

sharing. These drugs appear as a $0 tier on the drug list. For a complete list of preventive

drugs, and coverage requirements, please refer to Preventive drug coverage or visit bcbsm.com/pharmacy.

How do I know what type of prescription coverage I have?

For details about your drug benefit, please call the Customer Service phone number on the

back of your Blue Cross member ID card. If you have online access, log in to your account at

bcbsm.com. You can also find more general information about Blue Cross prescription

coverage at bcbsm.com/pharmacy.

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Tier descriptions

• Preferred generics Members pay the lowest copay for generics, making them the most cost-effective option

for treatment.

• Preferred brands This tier includes preferred, brand-name drugs. These drugs are more expensive than

generics.

• Nonpreferred brands This tier includes nonpreferred, brand-name drugs for which there’s a more cost-

effective generic alternative or preferred brand-name drug available.

How do I fill my prescription?

• At a retail pharmacy More than 2,400 retail pharmacies in Michigan and 65,000 retail pharmacies

outside of Michigan accept your Blue Cross member ID card.

• Mail order (home delivery) The type of drug you take determines which mail‑order vendor you use.

Order drugs as follows:

o Limited distribution specialty drugs Pharmacy varies based on drug. Please refer to the Specialty Drug

Program Pharmacy Benefit Member Guide and search based on the drug you take.

o All other specialty drugs Pharmacy: AllianceRx Walgreens Prime*

Telephone: 1‑866‑515‑1355

o All other drugs Pharmacy: Express Scripts** mail order pharmacy

Telephone: 1‑800‑778‑0735

If you have questions about which mail order vendor to use, call the Customer Service number

on the back of your Blue Cross member ID card or visit bcbsm.com/pharmacy.

*AllianceRx Walgreens Prime® is an independent company that provides pharmacy benefit management services for Blue Cross.

**Express Scripts® is an independent company that provides pharmacy benefit management services for Blue Cross.

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New generics

When a generic version of a brand-name drug becomes available, the generic version is

generally added to Tier 1. The original branded version will be moved to a nonpreferred tier by

Blue Cross.

Generic drug substitution

Generic drug substitution occurs when a pharmacist dispenses a generic equivalent in place of

the brand-name product. Generics approved by the U.S. Food and Drug Administration are

listed in the “Generic name” column to the right of the brand-name drug. Generic substitution is

required for most Blue Cross members. If both the generic and brand names are listed, the tier

number matches the available generic. The brand-name tier is always higher, reflecting the

higher copayment when there’s an available generic. Members are encouraged to receive the

generic equivalent if available.

Some Blue Cross members, depending on their plan, may be required to pay the difference

between the cost of the brand-name drug and the cost of its generic equivalent, in addition to

the applicable brand-name copay.

Vaccines

The following select vaccines are covered without cost sharing for most members at Blue Cross

participating pharmacies certified to administer vaccines.

Common name Vaccine Age restrictions

Flu Influenza virus None

Hepatitis A

Havrix® None

Vaqta® None

Hepatitis A/B Twinrix® None

Human

papillomavirus, or

HPV

Gardasil® 9 to 27 years old

Gardasil® 9 9 to 27 years old

Meningitis Menveo® None

Page 9

Common name Vaccine Age restrictions

Menactra® None

Menomune® None

Pneumonia

Pneumovax® 23 None

Prevnar 13® 65 and older

Shingles Zostavax 60 and older

Shingrix® 50 and older

Tetanus, diphtheria Boostrix® None

and whooping cough Adacel® None

How prior approval, step therapy and quantity limits work

Prior approval

Prior approval may be necessary for coverage of certain medications. In these cases, the member must meet clinical criteria or additional information must be provided before coverage is approved. Clinical criteria are based on current medical information and approved by our Pharmacy and Therapeutics Committee.

Step therapy

Drugs subject to step therapy may require previous treatment with one or more preferred drugs

before coverage is approved.

To view a current list of drugs requiring prior approval or step therapy please see the following:

Blue Cross Prior Authorization and Step Therapy Guidelines and refer to the column labeled Clinical Drug List.

Quantity limits and dose optimization

Blue Cross sets quantity limits based on clinical appropriateness and manufacturer

recommended dosing for select drugs. For certain medications, Blue Cross limits the quantity or

maximum day supply that can be dispensed per fill.

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To view a current list of drugs that have limits on quantity or maximum day supply that can be

dispensed per fill, please see the following: Blue Cross Quantity Limit Program, and refer to the column labeled Clinical/Clinical/Closed Drug List

The Blue Cross dose optimization program encourages appropriate prescribing of medications

that are intended for once-daily administration. For certain medications, doctors are encouraged

to prescribe prescription drugs in once-daily dosage regimens to help increase a member’s

adherence to the medication, as opposed to using multiple lower doses of the same drug.

Obtaining prior approval or step therapy

For members:

Blue Cross members should consult their prescription drug benefit packet for information on

how to obtain prior approval or how to request a review for coverage of a drug that isn’t included

in their plan. Members can also call the Customer Service number on the back of their Blue

Cross member ID card for more information. Members can also submit a request online by filling

out the below request form on the web at bcbsm.com.

• Blue Cross PPO form

Or write to:

Blue Cross Blue Shield of Michigan

Pharmacy Services

P.O. Box 2320

Detroit, MI 48231-2320

For doctors:

Doctors can download the medication request forms through web-DENIS under Blue Cross Provider Publications and Resources. Return completed forms to the Pharmacy Services Clinical Help Desk for review (indicate if the request is urgent). We notify the doctor of approved

requests and process the member’s claim accordingly. If a request isn’t approved, we’ll notify

the member and doctor in writing. The notification includes the reason for the denial and an

explanation of the member’s appeal rights and the appeals process.

Doctors can request approval for Blue Cross members by any of the below methods:

1. Online

• Go to bcbsm.com • Log in as a provider • Select Medication Prior Authorization

2. Call:

• 1-800-437-3803 3. Fax:

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• 1-866-601-4425 4. Write

• Blue Cross Blue Shield of Michigan Pharmacy Services

P.O. Box 2320

Detroit, MI 48231-2320

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List

How to read the Clinical Drug List

This drug list shows the drug’s tier status and whether the drug has special requirements for coverage.

Drugs are listed alphabetically by brand name within each section. If a generic version is

available, the name is included in the “Generic Name” column next to the brand name. The

brand name is included for informational purposes. If only a brand name is listed, there isn’t a

generic version available.

4

4

1

2

2

3

5

6

1

2

3

4

Drugs are organized based on drug class or indication for use.

The generic drug atorvastatin calcium is a preferred generic drug, and quantity limits apply. Strengths of 10 and 20mg for atorvastatin calcium are preventive drugs,and may be covered with $0 cost share for members who meet criteria.

The generic drug fenofibric acid

(choline) is a preferred generic drug and

doesn’t have any restrictions on

coverage.

Praluent and Repatha are preferred

brand-name drugs. Prior approval and

quantity limits apply.

5

6

Livalo is a nonpreferred brand-name

drug, and quantity limits apply.

Limits: This section lists information,

such as prior approval, step therapy and

quantity limits.

Prior approval: Plan approval is

required for coverage (listed as PA in

the chart).

Step therapy: Previous treatment with

preferred drugs is required (listed as ST

in the chart).

Quantity limits: Prescriptions can’t

exceed a specific quantity per fill (listed

as QL in the chart).

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This document is current at the time of publication and is subject to change. Please go to

bcbsm.com/pharmacy and click on Drug Lists for the most up-to-date information regarding the Clinical Drug List.

This document content was developed to comply with applicable federal and state regulations.

To learn more about your plan, go to bcbsm.com and type “How Health Insurance Works” in

the search field.

Editor’s note: Please send us your comments and suggestions regarding the Blue Cross Clinical Drug List. Your input is vital to its continued success. We review and consider all responses. Please send your comments to:

Drug Information Services — Mail Code 512C Blue Cross Blue Shield of Michigan 600 E. Lafayette Blvd. Detroit, MI 48226-2998

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1. Anti-infectives

1A. Antifungals

Trade name Generic name Limits

Preferred Generics Ancobon flucytosine

Diflucan fluconazole

Grifulvin V griseofulvin, microsize

Gris-PEG griseofulvin ultramicrosize

Lamisil tablet terbinafine hcl

Mycelex Troche clotrimazole

Nizoral ketoconazole

Nystatin nystatin

Sporanox itraconazole

Vfend voriconazole

Preferred Brands Cresemba capsule QL Noxafil suspension

Noxafil tablet QL

Nonpreferred Brands Oravig QL

1B. Antimalarials


Preferred Generics Aralen chloroquine phosphate

Lariam mefloquine hcl

Malarone atovaquone/proguanil hcl

Plaquenil hydroxychloroquine sulfate

Qualaquin quinine sulfate

Preferred Brands Coartem

Daraprim PA Primaquine

Nonpreferred Brands Arakoda QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply ver. 1 Blue Cross Clinical Drug List - January 2019 Page 15

1C. Antiparasitics and antihelmintics


Preferred Generics Albenza albendazole QL

Biltricide praziquantel

Flagyl metronidazole

Humatin paromomycin sulfate

Mepron atovaquone

Stromectol ivermectin

Tindamax tinidazole

Preferred Brands Alinia

Benznidazole QL Impavido QL Mepron blister pak

Nebupent aerosol

Nonpreferred Brands Emverm QL


1D. Antiretrovirals


Preferred Generics Combivir lamivudine/zidovudine

Epivir lamivudine

Epzicom abacavir sulfate/lamivudine

Kaletra lopinavir/ritonavir

Lexiva fosamprenavir calcium

Norvir ritonavir

Retrovir zidovudine

Reyataz atazanavir sulfate

Sustiva efavirenz

Viramune, XR nevirapine

Viread tenofovir disoproxil fumarate

Ziagen abacavir sulfate

Preferred Brands Aptivus

Atripla

Biktarvy QL Cimduo QL Complera QL Delstrigo QL Descovy QL Edurant QL Emtriva

Evotaz QL Fuzeon

Genvoya QL Intelence

Invirase

Isentress

Isentress HD

Kaletra tablet

Lexiva suspension

Norvir capsule, solution, packet

Odefsey QL Pifeltro QL Prezcobix QL Prezista

Reyataz packet

Selzentry

Stribild QL Symfi, Lo QL Symtuza QL Tivicay

Triumeq QL Truvada

Tybost QL Vemlidy QL Viread 150mg, 200mg, 250mg tablet; powder

Nonpreferred Brands Juluca QL


1E. Antituberculars


Preferred Generics Ethambutol ethambutol hcl

Isoniazid isoniazid

Mycobutin rifabutin

Pyrazinamide pyrazinamide

Rifadin rifampin

Preferred Brands Cycloserine

Sirturo PA

Nonpreferred Brands Paser

Priftin

Rifamate

Rifater

Trecator

1F. Antivirals


Preferred Generics Acyclovir acyclovir

Baraclude entecavir

Copegus ribavirin

Epivir HBV lamivudine

Famvir famciclovir

Flumadine rimantadine hcl

Hepsera adefovir dipivoxil

Rebetol ribavirin

Ribapak; Ribatab ribavirin

Ribasphere Ribapak tablet ribavirin

Symmetrel amantadine hcl

Tamiflu oseltamivir phosphate QL

Valcyte valganciclovir hcl

Valtrex valacyclovir hcl

Zovirax acyclovir

Preferred Brands Baraclude solution

Epclusa PA, QL Epivir HBV solution

Rebetol solution

Relenza QL Zepatier PA, QL

Nonpreferred Brands Daklinza PA, QL Harvoni PA, QL Mavyret PA, QL Prevymis tablet QL Sitavig ST, QL Sovaldi PA, QL Technivie PA, QL Vosevi PA, QL Xofluza QL


1G. Cephalosporins


Preferred Generics Ceclor, ER cefaclor

Ceftin cefuroxime axetil

Cefzil cefprozil

Duricef cefadroxil

Keflex cephalexin

Omnicef cefdinir

Spectracef cefditoren pivoxil

Suprax cefixime

Vantin cefpodoxime proxetil

Preferred Brands Suprax capsule, chew tablet, 500mg/5ml suspension

Nonpreferred Brands Suprax 100mg/5ml suspension

1H. Macrolides


Preferred Generics Biaxin, XL clarithromycin

E.E.S. erythromycin ethylsuccinate

Ery-tab erythromycin base

Erythromycin Base erythromycin base

Erythromycin Stearate erythromycin stearate

Zithromax azithromycin

Nonpreferred Brands Dificid QL Eryped 200mg/5ml, 400mg/5ml

Ery-tab 500mg

1I. Penicillins


Preferred Generics Amoxil amoxicillin

Ampicillin ampicillin trihydrate

Augmentin, ES, XR amoxicillin/potassium clav

Dicloxacillin dicloxacillin sodium

Penicillin VK penicillin v potassium

Preferred Brands Augmentin 125mg-31.25mg/ml suspension

Nonpreferred Brands Moxatag


1J. Quinolones


Preferred Generics Avelox moxifloxacin hcl

Cipro suspension ciprofloxacin

Cipro tablet ciprofloxacin hcl

Cipro XR ciprofloxacin/ciprofloxa hcl

Floxin tablet ofloxacin

Levaquin levofloxacin

Nonpreferred Brands Baxdela tablet

Factive

1K. Sulfonamides and combinations


Preferred Generics Bactrim, DS; Septra, DS sulfamethoxazole/trimethoprim

Sulfadiazine sulfadiazine

1L. Tetracyclines


Preferred Generics Adoxa doxycycline monohydrate PA

Avidoxy 100mg doxycycline monohydrate

Declomycin demeclocycline hcl

Doryx doxycycline hyclate PA

Dynacin minocycline hcl

Minocin capsule minocycline hcl

Monodox doxycycline monohydrate

Periostat doxycycline hyclate

Tetracycline tetracycline hcl

Vibramycin doxycycline hyclate

Vibramycin suspension doxycycline monohydrate

Preferred Brands Vibramycin syrup

Nonpreferred Brands Doryx MPC PA Doxycycline IR-DR PA Oracea PA


1M. Urinary tract agents


Preferred Generics Furadantin nitrofurantoin

Hiprex/Urex methenamine hippurate

Macrobid nitrofurantoin monohyd/m-cryst

Macrodantin nitrofurantoin macrocrystal

Trimethoprim trimethoprim

Nonpreferred Brands Monurol

Primsol

Trimpex

1N. Miscellaneous anti-infectives


Preferred Generics Cleocin capsule clindamycin hcl

Cleocin solution clindamycin palmitate hcl

Dapsone dapsone

Neomycin neomycin sulfate

Peridex chlorhexidine gluconate

Tobi tobramycin in 0.225% sod chlor QL

Vancocin vancomycin hcl

Zyvox linezolid

Preferred Brands Arikayce PA, QL Sivextro QL Xifaxan 200mg

Nonpreferred Brands Bethkis PA, QL Cayston PA, QL Firvanq QL Tobi Podhaler PA, QL


2. Cardiovascular, hypertension, cholesterol

2A. ACE-Inhibitors and combinations


Preferred Generics Accupril quinapril hcl

Accuretic quinapril/hydrochlorothiazide

Aceon perindopril erbumine

Altace ramipril

Capoten captopril

Capozide captopril/hydrochlorothiazide

Lotensin benazepril hcl

Lotensin HCT benazepril/hydrochlorothiazide

Lotrel amlodipine besylate/benazepril

Mavik trandolapril

Monopril fosinopril sodium

Monopril HCT fosinopril/hydrochlorothiazide

Prinivil; Zestril lisinopril

Prinzide; Zestoretic lisinopril/hydrochlorothiazide

Tarka trandolapril/verapamil hcl

Univasc moexipril hcl

Vaseretic enalapril/hydrochlorothiazide

Vasotec enalapril maleate

Nonpreferred Brands Epaned

Prestalia QL Qbrelis QL

2B. Alpha-adrenergic agents


Preferred Generics Aldomet methyldopa

Aldoril methyldopa/hydrochlorothiazide

Cardura doxazosin mesylate

Catapres clonidine hcl

Catapres-TTS clonidine

Clorpres clonidine hcl/chlorthalidone

Dibenzyline phenoxybenzamine hcl PA, QL

Hytrin terazosin hcl

Minipress prazosin hcl

Tenex guanfacine hcl

Preferred Brands Clorpres 0.3mg-15mg


2C. Angiotensin II Receptor Blockers and combinations


Preferred Generics Atacand candesartan cilexetil

Atacand HCT candesartan/hydrochlorothiazid

Avalide irbesartan/hydrochlorothiazide

Avapro irbesartan

Azor amlodipine bes/olmesartan med

Benicar olmesartan medoxomil

Benicar HCT olmesartan/hydrochlorothiazide

Cozaar losartan potassium

Diovan valsartan

Diovan HCT valsartan/hydrochlorothiazide

Exforge amlodipine besylate/valsartan

Exforge HCT amlodipine/valsartan/hcthiazid

Hyzaar losartan/hydrochlorothiazide

Micardis telmisartan

Micardis HCT telmisartan/hydrochlorothiazid

Teveten eprosartan mesylate

Tribenzor olmesartan/amlodipin/hcthiazid QL

Twynsta telmisartan/amlodipine

Preferred Brands Entresto QL

Nonpreferred Brands Byvalson QL Edarbi QL Edarbyclor QL


2D. Anticoagulants and hemostasis agents


Preferred Generics Aggrenox aspirin/dipyridamole

Agrylin anagrelide hcl

Arixtra fondaparinux sodium

Coumadin warfarin sodium

Effient prasugrel hcl

Heparin heparin sodium,porcine/pf

Heparin heparin sodium,porcine

Lovenox enoxaparin sodium

Mephyton phytonadione (vit k1)

Persantine dipyridamole

Plavix clopidogrel bisulfate

Pletal cilostazol

Trental pentoxifylline

Vitamin K ampule phytonadione (vit k1)

Preferred Brands Amicar

Brilinta

Eliquis QL Fragmin

Xarelto, starter kit QL

Nonpreferred Brands Bevyxxa QL Pradaxa QL Savaysa QL Zontivity QL


2E. Beta blockers and combinations


Preferred Generics Betapace, AF sotalol hcl

Blocadren timolol maleate

Coreg CR carvedilol phosphate

Coreg immediate-release carvedilol

Corgard nadolol

Corzide nadolol/bendroflumethiazide

Inderal, LA propranolol hcl

Inderide propranolol/hydrochlorothiazid

Kerlone betaxolol hcl

Lopressor metoprolol tartrate

Lopressor HCT metoprolol/hydrochlorothiazide

Normodyne labetalol hcl

Sectral acebutolol hcl

Tenoretic atenolol/chlorthalidone

Tenormin atenolol

Toprol XL metoprolol succinate

Visken pindolol

Zebeta bisoprolol fumarate

Ziac bisoprolol/hydrochlorothiazide

Preferred Brands Bystolic ST

Nonpreferred Brands Byvalson QL Dutoprol

Hemangeol QL Inderal XL

Innopran XL

Sotylize


2F. Calcium channel blockers and combinations


Preferred Generics Adalat CC; Procardia, XL nifedipine

Azor amlodipine bes/olmesartan med

Caduet amlodipine/atorvastatin QL

Calan SR; Isoptin SR verapamil hcl

Cardene nicardipine hcl

Cardizem, CD, LA, SR diltiazem hcl

Dynacirc isradipine

Exforge amlodipine besylate/valsartan

Exforge HCT amlodipine/valsartan/hcthiazid

Lotrel amlodipine besylate/benazepril

Norvasc amlodipine besylate

Plendil felodipine

Sular nisoldipine

Tarka trandolapril/verapamil hcl

Tiazac diltiazem hcl

Tribenzor olmesartan/amlodipin/hcthiazid QL

Twynsta telmisartan/amlodipine

Verelan, PM verapamil hcl

Nonpreferred Brands Cardizem LA 120mg

Prestalia ST, QL

2G. Cardiovascular treatment


Preferred Generics Betapace, AF sotalol hcl

Cordarone; Pacerone amiodarone hcl

Lanoxin digoxin

Mexitil mexiletine hcl

Norpace disopyramide phosphate

Proamatine midodrine hcl

Quinidex quinidine sulfate

Quinidine Gluconate SA quinidine gluconate

Rythmol, SR propafenone hcl

Tambocor flecainide acetate

Tikosyn dofetilide

Preferred Brands Corlanor PA, QL Multaq QL Norpace CR

Ranexa

Nonpreferred Brands Lanoxin 62.5, 187.5mcg

Northera PA, QL Sotylize


2H. Diuretics


Preferred Generics Aldactazide spironolact/hydrochlorothiazid

Aldactone spironolactone

Bumex bumetanide

Demadex torsemide

Diamox, Sequels acetazolamide

Diuril chlorothiazide

Dyazide; Maxzide triamterene/hydrochlorothiazid

Edecrin ethacrynic acid

Enduron methyclothiazide

Hydrodiuril; Microzide hydrochlorothiazide

Hygroton; Thalitone chlorthalidone

Inspra eplerenone

Lasix furosemide

Lozol indapamide

Midamor amiloride hcl

Moduretic amiloride/hydrochlorothiazide

Zaroxolyn metolazone

Preferred Brands Dyrenium

Nonpreferred Brands Aldactazide 50/50mg

Carospir

Diuril suspension


2I. Lipid-lowering agents


Preventive Drugs Crestor* 5mg, 10mg rosuvastatin calcium QL

Lescol, XL* (all strengths) fluvastatin sodium QL

Lipitor* 10mg, 20mg atorvastatin calcium QL

Mevacor* (all strengths) lovastatin QL

Pravachol* (all strengths) pravastatin sodium QL

Zocor* 5mg, 10mg, 20mg, 40mg simvastatin QL

Preferred Generics Antara fenofibrate,micronized

Caduet amlodipine/atorvastatin QL

Colestid colestipol hcl

Crestor rosuvastatin calcium QL

Fenoglide fenofibrate

Fibricor fenofibric acid

Lescol, XL fluvastatin sodium QL

Lipitor atorvastatin calcium QL

Lofibra capsule fenofibrate,micronized

Lofibra tablet fenofibrate

Lopid gemfibrozil

Lovaza omega-3 acid ethyl esters

Mevacor lovastatin QL

Niaspan niacin

Pravachol pravastatin sodium QL

Questran cholestyramine (with sugar)

Questran Light cholestyramine/aspartame

Tricor fenofibrate nanocrystallized

Trilipix fenofibric acid (choline)

Vytorin ezetimibe/simvastatin QL

Welchol colesevelam hcl

Zetia ezetimibe QL

Zocor simvastatin QL

Preferred Brands Lipofen

Praluent PA, QL Repatha PA, QL Triglide

Vascepa PA, QL

Nonpreferred Brands Antara 30, 90mg

Colestid granules, packet

Fenofibrate capsule

Flolipid

Juxtapid PA, QL Livalo QL Niacor

*Age restrictions apply.


2J. Nitrates and combinations


Preferred Generics Imdur; Ismo; Monoket isosorbide mononitrate

Isordil isosorbide dinitrate

Nitro-bid ointment nitroglycerin

Nitroglycerin capsule, patch nitroglycerin

Nitrostat nitroglycerin

Preferred Brands Bidil

Dilatrate-SR

Nitro-Dur

Nonpreferred Brands GoNitro

Isordil 40mg

Minitran

Nitromist

2K. Renin-inhibitors and combinations


Nonpreferred Brands Tekturna, HCT

2L. Miscellaneous antihypertensives


Preferred Generics Apresoline hydralazine hcl

Loniten minoxidil

Nonpreferred Brands Demser

Vecamyl PA, QL


3. Central nervous system

3A. Alzheimer's therapy


Preferred Generics Aricept 23mg donepezil hcl QL

Aricept 5, 10mg; ODT donepezil hcl

Exelon capsule rivastigmine tartrate

Exelon patch rivastigmine

Namenda memantine hcl

Namenda XR memantine hcl ST, QL

Razadyne, ER galantamine hbr

Preferred Brands Namenda dose pack

Nonpreferred Brands Namzaric ST, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply Preventative drugs may be covered at $0 if criteria are met

ver. 1 Blue Cross Clinical Drug List - January 2019 Page 30

3B. Anticonvulsants


Preferred Generics Carbatrol carbamazepine

Depakene capsule valproic acid

Depakene solution valproic acid (as sodium salt)

Depakote, ER, Sprinkles divalproex sodium

Diamox, Sequels acetazolamide

Diastat 2.5mg diazepam

Diastat Acudial diazepam

Dilantin phenytoin

Dilantin; Phenytek capsule phenytoin sodium extended

Felbatol felbamate

Gabitril tiagabine hcl

Keppra, XR levetiracetam

Klonopin, Wafer clonazepam

Lamictal ODT, XR lamotrigine

Mysoline primidone

Neurontin gabapentin

Onfi clobazam PA, QL

Phenobarbital phenobarbital

Sabril vigabatrin

Tegretol, XR carbamazepine

Topamax, Sprinkle topiramate

Trileptal oxcarbazepine

Valproic Acid valproic acid (as sodium salt)

Zarontin ethosuximide

Zonegran zonisamide

Preferred Brands Banzel

Diastat 2.5mg

Dilantin 30mg capsule

Peganone

Sabril tablet ST, QL Vimpat

Nonpreferred Brands Acthar H.P. PA, QL Aptiom ST, QL Briviact PA, QL Celontin

Epidiolex PA, QL Equetro

Fycompa QL Lamictal XR dose pack

Lyrica PA Lyrica CR PA, QL Oxtellar XR PA, QL Qudexy XR PA, QL Spritam PA, QL Topiramate ER PA, QL Trokendi XR PA, QL



3C. Antidepressants


Preferred Generics Adapin; Sinequan doxepin hcl

Amoxapine amoxapine

Anafranil clomipramine hcl

Aventyl; Pamelor nortriptyline hcl

Celexa citalopram hydrobromide

Cymbalta duloxetine hcl

Desyrel trazodone hcl

Effexor, XR; Venlafaxine hcl ER venlafaxine hcl

Elavil amitriptyline hcl

Etrafon perphenazine/amitriptyline hcl

Fluoxetine 60mg fluoxetine hcl QL

Irenka duloxetine hcl

Lexapro escitalopram oxalate

Limbitrol, DS amitriptyline/chlordiazepoxide

Luvox, CR fluvoxamine maleate

Maprotiline hcl maprotiline hcl

Nardil phenelzine sulfate

Norpramin desipramine hcl

Parnate tranylcypromine sulfate

Paxil, CR paroxetine hcl

Pristiq desvenlafaxine succinate

Prozac fluoxetine hcl

Prozac weekly fluoxetine hcl QL

Remeron mirtazapine

Serzone nefazodone hcl

Surmontil trimipramine maleate

Tofranil imipramine hcl

Tofranil-PM imipramine pamoate

Vivactil protriptyline hcl

Wellbutrin, SR, XL bupropion hcl

Zoloft sertraline hcl

Preferred Brands Paxil suspension

Nonpreferred Brands Aplenzin ST Desvenlafaxine ER ST, QL Emsam

Fetzima ST, QL Forfivo XL ST, QL Khedezla ST, QL Marplan

Pexeva ST Trintellix ST, QL Viibryd, dose pack ST, QL



3D. Antipsychotics


Preferred Generics Abilify aripiprazole

Clozaril clozapine

Etrafon perphenazine/amitriptyline hcl

Fazaclo clozapine

Fluphenazine decanoate fluphenazine decanoate

Fluphenazine liquid fluphenazine hcl

Geodon ziprasidone hcl

Haldol liquid haloperidol lactate

Haldol tablet haloperidol

Haldol vial haloperidol decanoate

Invega paliperidone QL

Loxitane loxapine succinate

Mellaril thioridazine hcl

Molindone molindone hcl

Navane thiothixene

Orap pimozide

Perphenazine perphenazine

Prolixin fluphenazine hcl

Risperdal, M-Tab risperidone

Seroquel quetiapine fumarate

Seroquel XR quetiapine fumarate QL

Stelazine trifluoperazine hcl

Symbyax olanzapine/fluoxetine hcl

Thorazine chlorpromazine hcl

Zyprexa, Zydis olanzapine

Nonpreferred Brands Aristada QL Clozapine ODT

Fanapt ST Fazaclo 150, 200mg

Latuda ST Nuplazid PA, QL Rexulti PA, QL Saphris ST, QL Versacloz

Vraylar ST, QL



3E. Anxiolytics


Preferred Generics Ativan lorazepam

Buspar buspirone hcl

Equanil; Miltown meprobamate

Librium chlordiazepoxide hcl

Lorazepam intensol lorazepam

Niravam alprazolam

Serax oxazepam

Tranxene T-Tab clorazepate dipotassium

Valium diazepam

Xanax, XR alprazolam

3F. CNS stimulants


Preferred Generics Adderall, XR dextroamphetamine/amphetamine QL

Concerta methylphenidate hcl

Desoxyn methamphetamine hcl

Dexedrine dextroamphetamine sulfate

Evekeo amphetamine sulfate PA, QL

Focalin, XR dexmethylphenidate hcl

Metadate CD methylphenidate hcl

Methylin, ER methylphenidate hcl

Nuvigil armodafinil QL

Procentra dextroamphetamine sulfate

Provigil modafinil QL

Ritalin, LA, SR methylphenidate hcl

Preferred Brands Daytrana

Vyvanse QL

Nonpreferred Brands Adzenys ER PA, QL Adzenys XR-ODT PA, QL Aptensio XR QL Dyanavel XR PA, QL Methylphenidate ER 72mg QL Quillichew ER PA, QL Quillivant XR ST, QL Relexxii QL Zenzedi



3G. Migraine therapy


Preferred Generics Alsuma sumatriptan succinate QL

Amerge naratriptan hcl QL

Axert almotriptan malate ST, QL

Cafergot ergotamine tartrate/caffeine

D.H.E.45 dihydroergotamine mesylate

Esgic; Fioricet butalb/acetaminophen/caffeine

Fioricet w/codeine 50/300/30mg butalbit/acetamin/caff/codeine QL


Fiorinal butalbital/aspirin/caffeine

Fiorinal w/codeine codeine/butalbital/asa/caffein QL

Frova frovatriptan succinate ST, QL

Imitrex sumatriptan succinate QL

Imitrex nasal spray sumatriptan QL

Maxalt, MLT rizatriptan benzoate QL

Migergot ergotamine tartrate/caffeine

Migranal dihydroergotamine mesylate QL

Phrenilin 50mg/325mg butalbital/acetaminophen

Relpax eletriptan hydrobromide ST, QL

Treximet sumatriptan succ/naproxen sod PA, QL

Zomig, ZMT zolmitriptan QL

Preferred Brands Aimovig PA, QL Emgality PA, QL Ergomar

Nonpreferred Brands Onzetra Xsail ST, QL Sumavel Dosepro ST, QL Treximet 10mg-60mg PA, QL Zembrace Symtouch ST, QL Zomig nasal spray ST, QL

3H. Myasthenia gravis


Preferred Generics Mestinon, Timespan pyridostigmine bromide

Preferred Brands Mestinon syrup

3I. Narcotic antagonists and withdrawal management


Preferred Generics Naloxone hcl injection naloxone hcl

Revia naltrexone hcl

Preferred Brands Lucemyra QL Narcan nasal spray QL



3J. Narcotic mixed agonist and antagonist


Preferred Generics Butrans buprenorphine QL

Ryzolt tramadol hcl QL

Stadol NS butorphanol tartrate QL

Suboxone buprenorphine hcl/naloxone hcl QL

Subutex buprenorphine hcl PA, QL

Talwin NX pentazocine hcl/naloxone hcl QL

Ultracet tramadol hcl/acetaminophen QL

Ultram, ER tramadol hcl QL

Preferred Brands Buprenorphine 7.5 MCG/HR patch QL Butrans 7.5 MCG/HR QL Suboxone film QL Zubsolv QL

Nonpreferred Brands Belbuca PA, QL Bunavail QL Conzip QL Tramadol hcl ER QL

3K. Narcotic and analgesic combinations


Preferred Generics Combunox ibuprofen/oxycodone hcl QL

Esgic; Fioricet butalb/acetaminophen/caffeine



Fiorinal butalbital/aspirin/caffeine

Fiorinal w/codeine codeine/butalbital/asa/caffein QL

Hycet hydrocodone/acetaminophen QL

Norco; Vicodin; Xodol hydrocodone/acetaminophen QL

Percocet oxycodone hcl/acetaminophen QL

Percodan oxycodone hcl/aspirin QL

Phrenilin 50mg/325mg butalbital/acetaminophen

Roxicet oxycodone hcl/acetaminophen QL

Trezix acetaminophen/caff/dihydrocod QL

Tylenol w/codeine acetaminophen with codeine QL

Tylenol w/codeine solution acetaminophen with codeine QL

Vicoprofen hydrocodone/ibuprofen QL

Nonpreferred Brands Ibudone 5mg/200mg QL Lortab solution QL Trezix QL



3L. Narcotics


Preferred Generics Actiq fentanyl citrate PA, QL

Avinza morphine sulfate QL

Belladonna & Opium opium/belladonna alkaloids QL

Codeine sulfate tablet codeine sulfate QL

Demerol meperidine hcl QL

Dilaudid hydromorphone hcl QL

Duragesic fentanyl QL

Exalgo hydromorphone hcl QL

Kadian morphine sulfate QL

Levorphanol Tartrate levorphanol tartrate QL

Methadone methadone hcl QL

MS Contin morphine sulfate QL

MSIR morphine sulfate QL

Nubain nalbuphine hcl

Opana oxymorphone hcl QL

Opana ER oxymorphone hcl PA, QL

Opium opium tincture

Oxycodone immediate release, solution oxycodone hcl QL

RMS Suppository morphine sulfate QL

Roxanol morphine sulfate QL

Preferred Brands Nucynta PA, QL Oxycontin PA, QL

Nonpreferred Brands Abstral PA, QL Embeda PA, QL Fentora PA, QL Hysingla ER PA, QL Kadian 200mg QL Lazanda PA, QL Nucynta ER PA, QL Oxycodone hcl ER PA, QL Subsys PA, QL Zohydro ER PA, QL



3M. Nonsteroidal anti-inflammatory drugs


Preferred Generics Anaprox, DS naproxen sodium

Ansaid flurbiprofen

Arthrotec diclofenac sodium/misoprostol

Cataflam diclofenac potassium

Celebrex celecoxib

Clinoril sulindac

Daypro oxaprozin

EC-Naproxyn naproxen

Feldene piroxicam

Indocin, SR indomethacin

Ketoprofen ketoprofen

Lodine, XL etodolac

Meclomen meclofenamate sodium

Mobic meloxicam

Motrin (Rx Only) ibuprofen

Nalfon fenoprofen calcium PA, QL

Naprosyn (Rx Only) naproxen

Pennsaid 1.5% diclofenac sodium QL

Ponstel mefenamic acid

Relafen nabumetone

Tolectin, DS tolmetin sodium

Toradol injection ketorolac tromethamine

Toradol tablet ketorolac tromethamine QL

Voltaren gel diclofenac sodium QL

Voltaren, XR diclofenac sodium

Nonpreferred Brands Fenoprofen Calcium 200mg, 400mg PA, QL Fenortho PA, QL Flector Patch PA, QL Indocin suppository, suspension

Nalfon 400mg PA, QL Pennsaid 2% ST, QL Sprix QL Tivorbex ST, QL Vivlodex PA, QL Zipsor PA, QL Zorvolex PA, QL



3N. Parkinsons disease and related disorders


Preferred Generics Artane trihexyphenidyl hcl

Azilect rasagiline mesylate

Cogentin benztropine mesylate

Comtan entacapone

Eldepryl selegiline hcl

Lodosyn carbidopa

Mirapex ER pramipexole di-hcl ST, QL

Mirapex immediate-release pramipexole di-hcl

Parcopa carbidopa/levodopa

Parlodel bromocriptine mesylate

Requip, XL ropinirole hcl

Sinemet, CR carbidopa/levodopa

Stalevo carbidopa/levodopa/entacapone

Symmetrel amantadine hcl

Tasmar tolcapone

Preferred Brands Apokyn

Duopa PA, QL

Nonpreferred Brands Neupro PA, QL Nuplazid PA, QL Rytary ST, QL Xadago QL Zelapar

3O. Salicylates


Preventive Drugs Aspirin; Ecotrin 81mg, 325mg (OTC) aspirin

Preferred Generics Disalcid salsalate

Dolobid diflunisal



3P. Sedative and hypnotics


Preferred Generics Ambien, CR zolpidem tartrate QL

Dalmane flurazepam hcl QL

Halcion triazolam QL

Intermezzo zolpidem tartrate PA, QL

Lunesta eszopiclone QL

Prosom estazolam QL

Restoril temazepam QL

Seconal secobarbital sodium

Sonata zaleplon QL

Versed syrup midazolam hcl

Nonpreferred Brands Belsomra ST, QL Butisol sodium

Doral QL Edluar ST, QL Hetlioz PA, QL Quazepam QL Rozerem QL Silenor ST, QL

3Q. Skeletal muscle relaxants


Preferred Generics Baclofen baclofen

Dantrium dantrolene sodium

Fexmid cyclobenzaprine hcl

Flexeril cyclobenzaprine hcl

Norflex orphenadrine citrate

Parafon Forte DSC 500mg chlorzoxazone

Robaxin methocarbamol

Skelaxin metaxalone

Soma carisoprodol

Soma Compound carisoprodol/aspirin

Soma Compound w/codeine carisoprodol/aspirin/codeine QL

Valium diazepam

Zanaflex tizanidine hcl

Preferred Brands Lorzone

Nonpreferred Brands Amrix ST, QL Baclofen 5mg



3R. Miscellaneous CNS


Preferred Generics Antabuse disulfiram

Cafcit caffeine citrate

Campral acamprosate calcium

Ergoloid Mesylates ergoloid mesylates

Eskalith, CR; Lithobid lithium carbonate

Guanidine hcl guanidine hcl

Intuniv guanfacine hcl QL

Kapvay clonidine hcl QL

Lithium Citrate lithium citrate

Nimotop nimodipine

Rilutek riluzole

Strattera atomoxetine hcl

Xenazine tetrabenazine PA, QL

Preferred Brands Nuedexta PA, QL

Nonpreferred Brands Austedo PA, QL Cuvposa

Gralise ST, QL Horizant ST, QL Ingrezza PA, QL Nymalize QL Savella PA, QL Savella dosepack PA Tiglutik PA, QL Xyrem PA, QL



4. Gastrointestinal agents

4A. 5-Aminosalicylic Acid (5-ASA) agents


Preferred Generics Asacol HD mesalamine

Azulfidine, EN-tab sulfasalazine

Colazal balsalazide disodium

Lialda mesalamine

SfRowasa enema mesalamine

Preferred Brands Canasa

Delzicol

Pentasa

Nonpreferred Brands Apriso

Dipentum

4B. Antidiarrheals and antispasmodics


Preferred Generics Bentyl dicyclomine hcl

Imodium loperamide hcl

Levbid hyoscyamine sulfate

Levsin, SL hyoscyamine sulfate

Librax chlordiazepoxide/clidinium br

Lomotil diphenoxylate hcl/atropine

Preferred Brands Motofen

Mytesi PA, QL



4C. Antiemetics


Preferred Generics Antivert meclizine hcl

Compazine suppository prochlorperazine

Compazine tablet prochlorperazine maleate

Emend aprepitant

Kytril granisetron hcl

Marinol dronabinol

Phenergan promethazine hcl

Tigan trimethobenzamide hcl

Transderm-Scop scopolamine

Zofran ondansetron hcl

Zofran ODT ondansetron

Preferred Brands Anzemet

Emend 40mg (1 pack, 6 pack)

Emend suspension QL

Nonpreferred Brands Akynzeo PA, QL Bonjesta PA, QL Cesamet

Diclegis PA, QL Sancuso PA, QL Syndros

Varubi PA, QL Zuplenz PA

4D. Bile acids


Preferred Generics Actigall ursodiol

Urso; Forte ursodiol

Preferred Brands Ocaliva PA, QL

Nonpreferred Brands Chenodal PA



4E. Bowel preparation and cleansing agents


Preventive Drugs Bisacodyl OTC bisacodyl QL

Citrate of Magnesia OTC magnesium citrate QL

Colyte peg3350/sod sulf,bicarb,cl/kcl QL

Glycolax OTC polyethylene glycol 3350 QL

Golytely peg3350/sod sulf,bicarb,cl/kcl QL

Halflytely-Bisacodyl bisac/nacl/nahco3/kcl/peg 3350 QL

Milk of Magnesia OTC magnesium hydroxide QL

Nulytely sodium chloride/nahco3/kcl/peg QL

Oral Saline Laxative liquid OTC sodium phosphate,mono-dibasic QL

PEG-PREP bisac/nacl/nahco3/kcl/peg 3350 QL

Preferred Generics Golytely peg3350/sod sulf,bicarb,cl/kcl

Nulytely sodium chloride/nahco3/kcl/peg

Peg-Prep bisac/nacl/nahco3/kcl/peg 3350

Preferred Brands Golytely flavored

Suprep

Nonpreferred Brands Clenpiq

Moviprep

Osmoprep

Plenvu

Prepopik

4F. Digestive enzymes


Preferred Brands Creon

Viokace

Zenpep

Nonpreferred Brands Pancreaze

Pertzye

4G. H2-Receptor antagonists


Preferred Generics Axid (Rx only) nizatidine

Pepcid (Rx Only) famotidine

Tagamet (Rx only) cimetidine

Tagamet liquid (Rx only) cimetidine hcl

Zantac (Rx Only) ranitidine hcl



4H. Proton Pump Inhibitors (PPI)


Preferred Generics Aciphex tablet rabeprazole sodium

Nexium esomeprazole magnesium

Prevacid capsule (Rx Only) lansoprazole

Prevacid Solutab lansoprazole

Prilosec capsule (Rx Only) omeprazole

Protonix tablet pantoprazole sodium

Nonpreferred Brands Aciphex Sprinkle ST, QL Dexilant ST Esomeprazole strontium QL Nexium suspension ST Prilosec suspension

Protonix suspension

4I. Topical anti-Inflammatory agents


Preferred Generics Analpram-HC cream 2.5-1%, 1-1% hydrocortisone/pramoxine

Anamantle HC, Forte; Kit lidocaine/hydrocortisone ac

Cortenema hydrocortisone

Proctocort hydrocortisone

Proctocort suppository hydrocortisone acetate

Procto-pak hydrocortisone

Proctosol-HC suppository hydrocortisone acetate

Preferred Brands Analpram-HC 1-1% cream

Epifoam

Proctofoam-HC

Nonpreferred Brands Cortifoam

Uceris foam ST

4J. Tumor Necrosis Factor (TNF) blocking agents


Preferred Brands Humira PA, QL

Nonpreferred Brands Cimzia syringe PA, QL Simponi PA, QL



4K. Ulcer therapy


Preferred Generics Carafate tablet, suspension sucralfate

Cytotec misoprostol

Pamine, Forte methscopolamine bromide

Prevpac lansoprazole/amoxiciln/clarith

Pro-Banthine propantheline bromide

Robinul tablet, Forte glycopyrrolate

Preferred Brands Carafate suspension

Pylera

Nonpreferred Brands Omeclamox-pak

4L. Miscellaneous gastrointestinal agents


Preferred Generics Evoxac cevimeline hcl

Gastrocrom cromolyn sodium

Kristalose lactulose

Lactulose lactulose

Lotronex alosetron hcl

Metozolv ODT metoclopramide hcl

Reglan metoclopramide hcl

Salagen pilocarpine hcl

Preferred Brands Amitiza QL Gattex PA, QL Kristalose 20g packet

Linzess QL Stelara 45mg, 90mg PA, QL Viberzi PA, QL Xifaxan 200mg

Xifaxan 550mg PA, QL

Nonpreferred Brands Movantik PA, QL Rectiv QL Relistor tablet PA, QL Sucraid

Symproic PA, QL Zorbtive PA



5. Obstetrics and gynecology

5A. Contraceptives-Biphasic


Preventive Drugs Loseasonique l-norgest/e.estradiol-e.estrad QL

Mircette desog-e.estradiol/e.estradiol

Seasonique l-norgest/e.estradiol-e.estrad QL

Preferred Brands Lo Loestrin Fe

5B. Contraceptives-Misc.


Preventive Drugs Conceptrol QL Depo-Provera 150mg medroxyprogesterone acetate

FC2 Female Condom QL Gynol II nonoxynol 9 QL

Nuvaring QL Ortho Evra norelgestromin/ethin.estradiol QL

Ortho Micronor; Nor-QD norethindrone

Quartette l-norgest/e.estradiol-e.estrad QL

Safyral drospir/eth estra/levomefol ca

Today contraceptive sponge QL VCF film, gel QL VCF foam nonoxynol 9 QL

Preferred Brands Depo-subq Provera 104

Natazia



5C. Contraceptives-Monophasic


Preventive Drugs Alesse; Levlite levonorgestrel-ethin estradiol

Beyaz drospir/eth estra/levomefol ca

Demulen ethynodiol d-ethinyl estradiol

Desogen; Ortho-cept desogestrel-ethinyl estradiol

Femcon Fe noreth-ethinyl estradiol/iron

Generess Fe noreth-ethinyl estradiol/iron

Levlen; Nordette levonorgestrel-ethin estradiol

Lo/Ovral norgestrel-ethinyl estradiol

Loestrin norethindrone ac-eth estradiol

Loestrin 24 Fe norethindrone-e.estradiol-iron

Loestrin Fe norethindrone-e.estradiol-iron

Lybrel levonorgestrel-ethin estradiol

Minastrin 24 Fe norethindrone-e.estradiol-iron

Modicon norethindrone-ethinyl estrad

Norinyl 1/35; Ortho-novum 1/35 norethindrone-ethinyl estrad

Ortho-Cyclen norgestimate-ethinyl estradiol

Ovcon 35 norethindrone-ethinyl estrad

Ovral norgestrel-ethinyl estradiol

Seasonale levonorgestrel-ethin estradiol QL

Yasmin 28 ethinyl estradiol/drospirenone

Yaz ethinyl estradiol/drospirenone

Nonpreferred Brands Balcoltra

Taytulla

5D. Contraceptives-Postcoital


Preventive Drugs Ella QL Plan B One-step levonorgestrel QL

5E. Contraceptives-Triphasic


Preventive Drugs Cyclessa desogestrel-ethinyl estradiol

Estrostep Fe norethindrone-e.estradiol-iron

Ortho Tri-Cyclen norgestimate-ethinyl estradiol

Ortho Tri-Cyclen Lo norgestimate-ethinyl estradiol

Ortho-Novum 7/7/7 norethindrone-ethinyl estrad

Trilevlen levonorgestrel-ethin estradiol

Tri-Norinyl norethindrone-ethinyl estrad



5F. Estrogen and progestin combinations


Preferred Generics Activella estradiol/norethindrone acet

FemHRT norethindrone ac-eth estradiol

Preferred Brands Climara Pro

Combipatch

Prempro, Low Dose; Premphase

Nonpreferred Brands Angeliq

Prefest

5G. Estrogens


Preferred Generics Climara estradiol

Delestrogen estradiol valerate

Estrace estradiol

Minivelle, Vivelle-Dot estradiol

Vagifem estradiol

Preferred Brands Alora

Estring

Estrogel

Premarin, cream, Low Dose

Nonpreferred Brands Delestrogen 10mg/ml

Depo-estradiol

Divigel

Elestrin

Evamist

Femring

Imvexxy QL Menest

Menostar



5H. Infertility treatment*


Preferred Generics Clomid clomiphene citrate

Lupron leuprolide acetate

Preferred Brands Bravelle

Cetrotide

Crinone 8%

Endometrin

Ganirelix Acetate

Gonal-F, RFF, Redi-ject

Menopur

Ovidrel

Pregnyl PA

Nonpreferred Brands Chorionic Gonadotropin PA Follistim AQ ST Novarel PA

*Drugs used for the treatment of infertility may not be covered for select benefits.

5I. Progestins


Preferred Generics Aygestin norethindrone acetate

Progesterone In Oil (inj) progesterone

Prometrium progesterone, micronized

Provera medroxyprogesterone acetate

Preferred Brands Crinone 4%

Depo-subq Provera 104

5J. Vaginal anti-infective and antifungal


Preferred Generics Cleocin vaginal cream clindamycin phosphate

Diflucan fluconazole

Metrogel-Vaginal metronidazole

Monistat 3 miconazole nitrate

Terazol- 3, 7 terconazole

Preferred Brands Gynazole-1

Nonpreferred Brands AVC

Cleocin vaginal ovules

Clindesse

Nuvessa



5K. Miscellaneous OB-GYN


Preferred Generics Brisdelle paroxetine mesylate ST, QL

Covaryx, H.S. estrogen,ester/me-testosterone

Lysteda tranexamic acid QL

Methergine methylergonovine maleate QL

Preferred Brands Lupron Depot 3.75mg, 11.25mg

Synarel

Nonpreferred Brands Bonjesta PA, QL Diclegis PA, QL Duavee

Intrarosa QL Lupaneta Pack

Orilissa PA, QL Osphena



6. Rheumatology and musculoskeletal

6A. Corticosteroids


Corticosteroids See Chapter 7C

6B. Gout therapy


Preferred Generics Colbenemid probenecid/colchicine

Probenecid probenecid

Zyloprim allopurinol

Preferred Brands Colchicine tablet

Colcrys

Uloric ST, QL

Nonpreferred Brands Colchicine capsule

Mitigare

6C. Non-Tumor Necrosis Factor (TNF) blocking agents


Preferred Brands Actemra syringe PA, QL Cosentyx PA, QL Otezla PA, QL Stelara 45mg, 90mg PA, QL Xeljanz, XR PA, QL

Nonpreferred Brands Kevzara PA, QL Kineret PA, QL Olumiant PA, QL Orencia Clickject, sub-q PA, QL

6D. Osteoporosis and bone resorption


Preferred Generics Actonel risedronate sodium QL

Atelvia risedronate sodium ST, QL

Boniva ibandronate sodium QL

Didronel etidronate disodium QL

Evista raloxifene hcl QL

Fosamax alendronate sodium QL

Miacalcin nasal spray calcitonin,salmon,synthetic

Preferred Brands Miacalcin injection

Nonpreferred Brands Binosto ST, QL Fosamax Plus D ST, QL


6E. Osteoporosis and hormonal treatment


Preferred Generics Climara estradiol

Estrace estradiol

FemHRT norethindrone ac-eth estradiol

Minivelle, Vivelle-Dot estradiol

Preferred Brands Alora

Forteo PA, QL Premarin, cream, Low Dose

Prempro, Low Dose; Premphase

Tymlos PA, QL

Nonpreferred Brands Duavee

Menest

6F. Salicylates


Salicylates and NSAIDS See Chapters 3O & 3M

6G. Tumor Necrosis Factor (TNF) blocking agents


Preferred Brands Enbrel PA, QL Humira PA, QL

Nonpreferred Brands Cimzia syringe PA, QL Simponi PA, QL

6H. Miscellaneous rheumatologic agents


Preferred Generics Arava leflunomide

Azulfidine, EN-tab sulfasalazine

Gengraf; Neoral cyclosporine, modified

Imuran azathioprine

Methotrexate methotrexate sodium

Methotrexate PF injection methotrexate sodium/pf

Plaquenil hydroxychloroquine sulfate

Preferred Brands Azasan

Depen

Ridaura

Trexall

Nonpreferred Brands Otrexup PA, QL Rasuvo PA, QL Xatmep


7. Endocrinology

7A. Androgens


Preferred Generics Androgel testosterone PA, QL

Android, Testred methyltestosterone

Axiron testosterone ST, QL

Danocrine danazol

Delatestryl testosterone enanthate

Depo-Testosterone testosterone cypionate

Fortesta testosterone ST, QL

Oxandrin oxandrolone PA

Testim testosterone ST, QL

Preferred Brands Androderm PA, QL Depo-Testosterone

Nonpreferred Brands Anadrol-50

Methitest

Natesto ST, QL Striant ST, QL Testosterone (Brand) packet, pump ST, QL Vogelxo ST, QL Xyosted PA, QL

7B. Antithyroid agents


Preferred Generics Propylthiouracil propylthiouracil

Strong Iodine potassium iodide/iodine

Tapazole methimazole

Nonpreferred Brands SSKI


7C. Corticosteroids


Preferred Generics Cortef; Hydrocortisone hydrocortisone

Cortisone acetate cortisone acetate

Decadron dexamethasone

Deltasone prednisone

Dexpak dexamethasone

Entocort EC budesonide

Florinef fludrocortisone acetate

Medrol, Dosepak methylprednisolone

Millipred solution prednisolone sod phosphate

Millipred, dose pack prednisolone

Orapred ODT prednisolone sod phosphate

Orapred solution prednisolone sod phosphate

Pediapred solution prednisolone sod phosphate

Prednisolone solution, tablet prednisolone

Prednisone prednisone

Solu-cortef hydrocortisone sod succinate

Uceris tablet budesonide PA, QL

Nonpreferred Brands Emflaza PA Medrol 2mg

Rayos PA, QL Solu-cortef (pf)

7D. Growth Hormone and related products


Preferred Brands Genotropin PA Norditropin FlexPro PA Nutropin AQ, Nuspin PA

Nonpreferred Brands Humatrope PA Increlex PA Omnitrope PA Saizen PA Serostim PA Zomacton PA


7E. Insulins


Preferred Brands Fiasp, Flextouch

Humulin R U-500

Lantus, Solostar

Levemir, Flextouch

Novolin; 70/30 vial

Novolog, Mix (all forms)

Toujeo, Max Solostar

Tresiba Flextouch

Xultophy 100-3.6 QL

Nonpreferred Brands Afrezza ST Basaglar Kwikpen U-100

Humalog Junior Kwikpen

Soliqua 100-33 PA, QL


7F. Non-insulin hypoglycemic agents


Preferred Generics Actoplus Met pioglitazone hcl/metformin hcl

Actos pioglitazone hcl

Amaryl glimepiride

Diabeta; Micronase glyburide

Diabinese chlorpropamide

Duetact pioglitazone hcl/glimepiride

Fortamet metformin hcl PA

Glucophage, XR metformin hcl

Glucotrol, XL glipizide

Glucovance glyburide/metformin hcl

Glynase glyburide,micronized

Glyset miglitol

Metaglip glipizide/metformin hcl

Orinase tolbutamide

PrandiMet repaglinide/metformin hcl

Prandin repaglinide

Precose acarbose

Starlix nateglinide

Tolinase tolazamide

Preferred Brands Actoplus Met XR

Farxiga QL Glyxambi QL Invokamet, XR QL Invokana QL Janumet

Janumet XR QL Januvia QL Jardiance QL Jentadueto QL Jentadueto XR QL Ozempic QL Qtern QL Symlinpen

Synjardy, XR QL Tradjenta QL Trulicity QL Victoza QL Xigduo XR QL

Nonpreferred Brands Adlyxin PA, QL Avandia

Cycloset PA, QL Riomet

Segluromet QL Steglatro QL


7G. Somatostatin analogs


Preferred Generics Sandostatin octreotide acetate

Preferred Brands Sandostatin LAR Depot PA Signifor PA, QL Somatuline Depot PA, QL

Nonpreferred Brands Signifor LAR PA, QL

7H. Thyroid hormones


Preferred Generics Armour Thyroid thyroid,pork

Cytomel liothyronine sodium

Levoxyl; Synthroid levothyroxine sodium

Nature-Throid thyroid,pork

NP Thyroid thyroid,pork

Westhroid thyroid,pork

Preferred Brands Thyrolar

Nonpreferred Brands Armour Thyroid 15mg, 30mg, 60mg, 90mg, 120mg, 180mg, 240mg, 300mg

Tirosint

WP Thyroid 32.5mg, 65mg, 81.25mg, 130mg

7I. Urea cycle disorder agents


Preferred Generics Buphenyl powder sodium phenylbutyrate

Buphenyl tablet sodium phenylbutyrate QL

Preferred Brands Carbaglu PA

Nonpreferred Brands Ravicti PA, QL

7J. Vitamin D analogs


Preferred Generics Calciferol (Rx Only) ergocalciferol (vitamin d2)

Hectorol doxercalciferol

Rocaltrol calcitriol

Zemplar paricalcitol

Nonpreferred Brands Rayaldee QL


7K. Miscellaneous endocrine


Preferred Generics DDAVP desmopressin acetate

DDAVP desmopressin (nonrefrigerated)

Dostinex cabergoline

Miacalcin nasal spray calcitonin,salmon,synthetic

Zavesca miglustat PA, QL

Preferred Brands Cholbam PA, QL Galafold PA, QL GlucaGen HypoKit

Glucagon Emergency Kit

Korlym PA, QL Kuvan PA Lupron Depot-PED

Miacalcin injection

Natpara PA, QL Palynziq PA, QL Sensipar

Somavert PA Strensiq PA, QL Synarel

Xermelo PA, QL

Nonpreferred Brands Cerdelga PA, QL Cetylev

DDAVP solution

Egrifta PA, QL Myalept PA, QL Proglycem

Stimate


8. Antineoplastics and immunosuppresants

8A. Adjuvant therapy


Preferred Generics Leucovorin tablet leucovorin calcium

Preferred Brands Aranesp PA Granix

Leukine

Mesnex tablet

Neulasta QL Neupogen

Procrit PA

Nonpreferred Brands Epogen PA Mircera PA, QL Zarxio

8B. Alkylating agents


Preferred Generics Alkeran tablet melphalan

Cyclophosphamide capsule cyclophosphamide

Temodar temozolomide

Preferred Brands Emcyt

Gleostine; Lomustine

Leukeran

Matulane

Myleran

8C. Antimetabolites


Preferred Generics Methotrexate methotrexate sodium

Methotrexate PF injection methotrexate sodium/pf

Purinethol mercaptopurine

Xeloda capecitabine

Preferred Brands Lonsurf PA, QL Tabloid

Trexall

Nonpreferred Brands Purixan

Xatmep



8D. Hormonal agents


Preventive Drugs Evista raloxifene hcl PA, QL

Tamoxifen tamoxifen citrate PA, QL

Preferred Generics Arimidex anastrozole PA

Aromasin exemestane PA

Casodex bicalutamide

Eulexin flutamide

Evista raloxifene hcl QL

Femara letrozole PA

Lupron leuprolide acetate

Megace, ES megestrol acetate

Nilandron nilutamide

Tamoxifen tamoxifen citrate QL

Zytiga abiraterone acetate QL

Preferred Brands Depo-Provera 400mg

Erleada PA, QL Fareston

Kisqali Femara co-pack PA, QL Lupron Depot

Trelstar, Depot, LA

Xtandi QL Yonsa PA, QL Zoladex QL Zytiga 500mg QL

Nonpreferred Brands Eligard

Faslodex

Lupaneta Pack

Soltamox



8E. Immunomodulators


Preferred Generics Cellcept mycophenolate mofetil

Gengraf; Neoral cyclosporine, modified

Imuran azathioprine

Myfortic mycophenolate sodium

Prednisone prednisone

Prograf tacrolimus

Rapamune tablet sirolimus

Sandimmune capsule cyclosporine

Preferred Brands Arcalyst PA Azasan

Rapamune solution

Sandimmune solution

Somatuline Depot PA, QL Thalomid

Nonpreferred Brands Astagraf XL

Envarsus XR

Kineret PA, QL Pomalyst PA, QL Revlimid QL



8F. Kinase inhibitors and molecular target inhibitors


Preferred Generics Gleevec imatinib mesylate QL

Preferred Brands Afinitor, Disperz PA, QL Alecensa PA, QL Alunbrig PA, QL Bosulif PA, QL Braftovi PA, QL Cabometyx PA, QL Calquence PA, QL Caprelsa PA, QL Cometriq PA, QL Copiktra PA, QL Cotellic PA, QL Gilotrif PA, QL Ibrance PA, QL Iclusig PA, QL Idhifa PA, QL Imbruvica; 280mg, 420mg, 560mg tablet PA, QL Inlyta PA, QL Iressa PA, QL Jakafi PA, QL Kisqali, Femara co-pack PA, QL Lenvima PA, QL Lynparza PA, QL Mekinist PA, QL Mektovi PA, QL Nerlynx PA, QL Nexavar PA, QL Ninlaro PA, QL Rubraca PA, QL Rydapt PA, QL Sprycel PA, QL Stivarga PA, QL Sutent PA, QL Tafinlar PA, QL Tagrisso PA, QL Tarceva PA, QL Tasigna PA, QL Tibsovo PA, QL Tykerb PA Venclexta PA, QL Verzenio PA, QL Vizimpro PA, QL Votrient PA, QL Xalkori PA, QL Zejula PA, QL Zelboraf PA, QL Zydelig PA, QL Zykadia PA, QL

Nonpreferred Brands Daurismo PA, QL Lorbrena PA, QL Talzenna PA, QL Vitrakvi PA, QL



Limits

8F. Kinase inhibitors and molecular target inhibitors (Continued)

Trade name Generic name Xospata PA, QL Zortress

8G. Miscellaneous antineoplastic agents


Preferred Generics Hydrea hydroxyurea

Sandostatin octreotide acetate

Targretin capsule bexarotene PA, QL

Vepesid etoposide

Vesanoid tretinoin

Preferred Brands Droxia

Erivedge PA, QL Farydak PA, QL Hycamtin capsule

Lysodren

Odomzo PA, QL Sandostatin LAR Depot PA Zolinza PA, QL



9. Immunology and hematology

9A. Hematopoietic agents


Preferred Brands Aranesp PA Granix

Leukine

Mulpleta PA, QL Neulasta QL Neupogen

Procrit PA Promacta PA

Nonpreferred Brands Doptelet PA, QL Epogen PA Mircera PA, QL Tavalisse PA, QL Zarxio

9B. Immunoglobulins


Nonpreferred Brands Cuvitru PA Gammagard liquid PA Gammaked PA Gamunex-C sub-q PA Hizentra PA HyQvia PA

9C. Interferons and MS therapy


Preferred Generics Ampyra dalfampridine PA, QL

Copaxone glatiramer acetate QL

Glatopa glatiramer acetate QL

Preferred Brands Actimmune

Avonex QL Gilenya QL Intron A

Pegasys, Proclick QL Peg-Intron, Redipen QL Plegridy QL Rebif, Rebidose QL Tecfidera QL

Nonpreferred Brands Alferon N

Aubagio QL Betaseron QL Extavia QL Sylatron QL


9D. Miscellaneous immunology and hematology


Preferred Brands Benlysta PA, QL Haegarda PA

Nonpreferred Brands Firazyr PA, QL Ruconest PA, QL Siklos PA Takhzyro PA, QL


10. Dermatology

10A. Acne treatment


Preferred Generics Acanya clindamycin phos/benzoyl perox

Aczone 5% dapsone

Adoxa doxycycline monohydrate PA

Amnesteem; Claravis; Myorisan; Zenatane isotretinoin

Atralin tretinoin

Avidoxy 100mg doxycycline monohydrate

Benzaclin clindamycin phos/benzoyl perox

Benzamycin erythromycin/benzoyl peroxide

Cleocin-T, swabs clindamycin phosphate

Differin cream, gel adapalene

Doryx doxycycline hyclate PA

Duac clindamycin phos/benzoyl perox

Epiduo adapalene/benzoyl peroxide

Erythromycin topical gel, solution, swab erythromycin base in ethanol

Klaron