2011 3-Tier Formulary Guide: Includes Generic and Brand-Name Medications

April 2011
2011 3-Tier Formulary Guide
A nonprot independent licensee of the BlueCross BlueShield Association
Includes generic and brand-name medications
excellusbcbs.com
B-1354 Y10
4774-10FLRX
Dear Member,
The prescription drug benefit is one of the most
important and frequently utilized elements of health
plan coverage. To help you identify which medications
are covered under your plan, we are pleased to provide
the 2011 3-Tier Formulary Guide. This booklet provides
you with easy to understand information about your
prescription drug coverage including descriptions of
prescription drug safety and cost-saving programs.
This booklet includes the 2011 Formulary
Guide and prescription drug benefit
information. Please refer to this booklet
when you see your healthcare practioner
or are prescribed a medication.
The drugs listed in the formulary and
program descriptions may not apply to
all plans. Please see your plan documents
for a complete description of your
pharmacy benefit.
If you have questions or need additional
information, please visit our Web site or
contact the FLRx Pharmacy Help Desk at
(800) 724-5033.
The 2011 3-Tier Formulary Guide lists commonly

prescribed medications and their tier classifications.
The medications listed have been approved by the
Food and Drug Administration as safe and effective
and were selected in consultation with a team of
health care professionals because they meet our
criteria for safety, quality and value. We continually
review and update our formulary.
The drugs listed in the formulary and program
descriptions may not apply to all plans. Please see
your plan documents or contact the FLRx Pharmacy
Help Desk for a complete description of your
pharmacy benefit.
Your prescription drug benefit is managed through our

internal prescription drug management division named FLRx.
The FLRx logo on your insurance identification card means
that you and your covered family members will receive the
maximum benefits entitled to you under your plan.
What is a Formulary?
Alphabetical Listing
A formulary is a list of brand name and generic

drugs that are covered under your prescription
drug benefit.
If you are not sure what category to look under,

look for your drug in the Index that follows the
formulary. The Index provides an alphabetical listing
of all of the drugs included in the formulary and
the page where they can be found in the formulary.
How is the Formulary Developed?

Drugs listed on the formulary were selected by our
independent Pharmacy and Therapeutics (P&T)
Committee which is made up of practicing health
care providers and clinical pharmacists. The P&T
Committee reviews each drug based upon scientific
evidence, findings by federal government agencies,
professional medical associations and journals to
help ensure that the medications covered meet
criteria for safety, effectiveness and value.
3-Tier Drug Benefit

Your 3-tier prescription drug benefit allows you
to make informed choices and encourages value
when choosing your prescription medications.
Your copayment will vary depending on the tier
in which your prescription drug is placed.
Tier One drugs are typically generics and have

the lowest copayment amount.
Tier Two drugs are brand drugs that have

unique, significant clinical advantages and offer
overall greater value over the other products in
the same drug class.
Tier Three drugs are all other brand drugs,

including new brand drugs and drugs that have
generic equivalents. Tier Three drugs have the
highest copayment amount.
How do I use the formulary?

There are two ways to find your drug within
the formulary:
Medical Condition
Drugs are listed in alphabetical order according to
drug categories. For example, drugs used to treat
heart conditions are listed under the category
Cardiovascular/Heart. Drugs are listed in
alphabetical order by condition.
The 3-Tier Formulary Guide lists commonly used

medications and their tier designations. Because
there are thousands of medications included in
your pharmacy benefit, we list only the most
commonly prescribed.
Your plan may not cover all medications listed in
this booklet. Please see your plan documents for a
complete description of your pharmacy benefit, or
call the FLRx Pharmacy Help Desk.
Can the Formulary Change?

Our P&T Committee regularly reviews the drugs on
our formulary to be sure they meet the criteria for
safety, effectiveness and value. The list is subject to
change. Drugs may be added, removed, or change
tier designation at any time.
Generics Are Real Medicine

Generic drugs: safe, effective, affordable!
To help keep your prescription drug costs down,
choose a generic drug over a brand. Generics are as
safe and effective as their brand name counterparts they just cost a lot less.
In fact, youll save money when you choose a
generic because generics have the lowest copay.
That means youll always pay the lowest out-ofpocket amount for a generic.
Generic drugs treat your illness or condition
with the same effectiveness and safety as their
brand name equivalents because they have to
meet the same rigorous FDA requirements as
brand name drugs.
Experience has shown that more than 90% of
members who start on a generic will stay on a
generic. So the next time you need your brand
prescription filled, ask your doctor or pharmacist
if a generic is right for you.
Generic Trial Program - Everyone Saves

With Generics
The Generic Trial program gives you a free 30-day
trial of selected generic medications. The first
time you fill a prescription for one of the generic
medications included in the program your copayment will be waived. All future prescriptions will be
at the usual copayment amount. For a complete list
of generic medications included in the Generic Trial
program, please visit our Web site.
Where Can I Purchase My

Prescription Medications?
You have access to more than 61,000 participating
pharmacies in our nationwide FLRx Pharmacy
Network, including national chains and most
independents. Just show your ID card at any
participating pharmacy; it identifies you as having
prescription drug coverage. A list of participating
pharmacies in your area is available on our
Web site.
Mail Service Pharmacy

Get your prescriptions delivered right to your
door! When you use our mail service pharmacy,
PrimeMail, you get the convenience of home
delivery and the ease of ordering new prescriptions
and refills either by phone or via our Web site.
Some benefits offer copay savings for ordering
prescriptions through PrimeMail.
Using mail service pharmacy is ideal for those
who take prescription medication on a continuing
basis. For more information on how to use
PrimeMail mail service pharmacy, please visit our
Web site or contact the FLRx Pharmacy Help Desk.
Specialty Pharmacy
Specialty pharmacies focus on you and your individual health care needs. Because they work exclusively
with specialty medications, they are experts in handling and administering these complex medications.
Nationally recognized specialty pharmacies
CuraScript Pharmacy and Walgreens Specialty
Pharmacy participate in our network. Both offer
outstanding customer service and are dedicated to
providing quality care to our members. With a single,
toll-free phone call they take care of all the details
they will contact your doctor for your prescription
and arrange delivery to your home. There are
several local/regional specialty pharmacies also
participating in our specialty pharmacy network.
A complete listing of participating specialty
pharmacies is available on our Web site.
Are There Any Restrictions

On Coverage?
Some covered drugs may have additional requirements or limits for coverage. If a drug has requirements or limits, it will be noted in the formulary.
If your healthcare practitioner determines that you
need a medication that has a requirement or limit,
we have an exception process in place. Your healthcare practitioner must submit a request to the
Health Plan supporting your need.
Coverage requirements or limits may include:
Prior Authorization
Prior authorization helps assure that a prescribed drug is safe and appropriate for your
medical condition. Certain medications require
that your doctor gets approval before the
medication is covered. Our clinical pharmacists
and physicians review medication requests to
make sure that the choice of drug or dose is
appropriately prescribed based on FDA and
manufacturer guidelines, medical literature,
safety, use and benefit design.
Step Therapy
In some cases you may be required to first try
one or more drugs to treat your medical
condition before another drug for that
condition will be covered. The medication
treatment moves along a series of steps.
For example, if Drug A and Drug B both treat
your medical condition, we may not cover
Drug B unless you try Drug A first. If Drug A
does not work, we will then cover Drug B.
Specialty Drug Benefit

Specialty medications are designed for conditions
like multiple sclerosis, rheumatoid arthritis,
hepatitis C, and others that are difficult to treat
with traditional medications. These medications
are self-administered; either taken orally or
by injection.
Your prescription drug benefit may require that
you purchase certain specialty medications at a
specialty pharmacy that participates in the FLRx
Specialty Pharmacy Network in order to receive
coverage. If a participating specialty pharmacy
is not used you may be responsible for the full
cost of the prescription. However, the first time
a prescription for a specialty medication is
filled, it may filled at any participating FLRx

network retail pharmacy of choice. A complete
listing of participating specialty pharmacies can
be found on our Web site.
Quantity Limits
For certain drugs, we limit the amount of the
drug that we will cover. The amount of drug we
cover is based on Food and Drug Administration
(FDA) approved dosing and usage guidelines.
Initial Fill
The first time you fill a prescription for a new
medication at a retail pharmacy, you will be
allowed up to a 30-day supply, even if your
benefit allows for a greater supply. This is so
you can be sure that the medication works for
you. Some times members fill a prescription
only to find that after the first few days the
medication does not work or causes side
effects. If the medication is effective, all future
refills can be purchased up to the maximum
amount allowed by your benefit.
Generic Advantage Program

The Generic Advantage program promotes
the use of generic medications. If you fill your
prescription with a brand name medication
when there is a generic equivalent available,
you will pay the difference between the
pharmacys charge for the more costly brand
name medication and our price for the less
expensive generic. Check your benefits
summary to find out if the Generic Advantage
program applies to your plan.
Key:
UPPERCASE Brand name medication
lowercase generic medication
PA = Prior Authorization required
QL = Quantity Limit applies
ST = Step Therapy required
MS = Drug must be purchased at a
participating FLRx network specialty
pharmacy for coverage
GT = Qualifies for the Generic Trial
Program
DRUG
TIER
COMMENTS
DRUG
Alcohol
2
3
QL
Narcotics
buprenorphine hcl
naltrexone
SUBOXONE
1
1
2
Smoking Deterrents
buproban
CHANTIX
NICOTROL INHALER
1
3
3
QL
Allergy
3
3
QL, ST
ST
3
3
1
1
1
1
1
3
QL, ST
ST
ALVESCO
ASMANEX
budesonide
FLOVENT
PULMICORT
QVAR
Antihistamines
ALLEGRA
CLARINEX
cyproheptadine
diphenhydramine
fexofenadine
levocetirizine dihydrochloride
promethazine
XYZAL
ACCOLATE
SINGULAIR
Note: Tier 2 after a diagnosis of Asthma
zafirlukast
ZYFLO
ZYFLO CR
QL
PA, QL
PA, QL
QL
QL
albuterol sulfate er
aminophylline
terbutaline
theophylline er
QL
QL
QL
MS, PA
ADDERALL XR
AMPHETAMINE/DEXTROAMPHETAMINE
CONCERTA
DAYTRANA
DESOXYN
dexmethylphenidate
dextroamphetamine sulfate er
FOCALIN
FOCALIN XR
INTUNIV
KAPVAY
METADATE CD
metadate er
methylin
methylin er
methylphenidate
RITALIN LA
STRATTERA
VYVANSE
Angioedema
Antispasmodic Drugs
bethanechol
1
DETROL
3
DETROL LA
3
dicyclomine
1
ENABLEX
3
flavoxate
1
GELNIQUE
3
glycopyrrolate
1
oxybutynin
1
oxybutynin er
1
OXYTROL
3
SANCTURA
3
SANCTURA XR
3
Note: 2 after previous trial and failure of Alzheimers medication
TOVIAZ
3
trospium chloride
1
VESICARE
2
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
QL
QL
3
2
QL
1
3
3
QL
1
1
1
1
2
3
2
3
3
1
1
3
3
3
3
3
1
1
1
1
3
3
3
PA
QL
QL, ST
QL, ST
QL
Blood
Anticoagulants
QL, ST
QL
QL
ARIXTRA
COUMADIN
enoxaparin sodium
FRAGMIN
heparin
INNOHEP
jantoven
LOVENOX
PRADAXA
ticlopidine
warfarin
Asthma
Inhaled Beta Agonists / Inhaled Respiratory Drugs
acetylcysteine
1
ADVAIR
2
Note: Tier 2 after trial and failure of an inhaled steroid
albuterol sulfate
1
ATROVENT HFA
2
BROVANA
3
COMBIVENT
2
QL
QL
QL
QL
QL
QL
Attention Deficit Disorder
Anaphylaxis Therapy Agents

2
2
2
3
2
1
2
3
2
Respiratory Drugs (oral)
ARICEPT 23MG
3
QL, ST
donepezil hcl
1
galantamine
1
NAMENDA
2
Note: Tier 2 when used in combination with an acetylcholinesterase inhibitor
rivastigmine tartrate
1
CINRYZE
QL
QL
QL
Leukotriene Inhibitors
Alzheimer's
EPIPEN
EPIPEN-JR
TWINJECT
QL
Inhaled Steroids
Antihistamine / Decongestant Combination

ALLEGRA-D
CLARINEX-D
COMMENTS
cromolyn
1
FORADIL
2
ipratropium
1
ipratropium/albuterol
1
MAXAIR
3
metaproterenol
1
PERFOROMIST
3
PROAIR HFA
2
PROVENTIL HFA
3
SEREVENT
2
SPIRIVA
2
SYMBICORT
2
VENTOLIN HFA
2
XOPENEX
3
Addiction
ANTABUSE
CAMPRAL
TIER
QL
3
2
1
3
1
3
1
3
3
1
1
QL
Antiplatelet
AGGRENOX
(Rev. 04/01/11)
DRUG
TIER
COMMENTS
DRUG
benazepril hcl/hydrochlorothiazide
captopril/hydrochlorothiazide
enalapril maleate/hydrochlorothiazide
fosinopril sodium/hydrochlorothiazide
lisinopril/hydrochlorothiazide
moexipril/hydrochlorothiazide
quinapril/hydrochlorothiazide
Antiplatelet (continued)
1
1
1
2
1
2
QL
2
2
3
3
3
3
2
2
ATACAND
AVAPRO
BENICAR
COZAAR
DIOVAN
EDARBI
losartan potassium
MICARDIS
TEVETEN
MS, PA, ST
MS, PA
MS, QL
MS, PA, QL
MS, QL
MS
MS, QL
MS, PA
isosorbide dinitrate
isosorbide mononitrate er
NITRO-BID
nitroglycerin
nitroglycerin cr
NITROMIST
RANEXA
Antineoplastic
2
2
2
2
1
3
2
1
2
1
2
2
2
1
2
2
1
2
2
2
2
1
1
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
MS, PA
MS, PA, QL
MS
QL, ST
QL
QL, ST
QL, ST
QL
QL, ST
QL, ST
QL, ST
amiodarone
digoxin
disopyramide
flecainide
LANOXIN
mexiletine
MULTAQ
NORPACE CR
pacerone
propafenone
propafenone hcl er
quinidine
RYTHMOL SR
TIKOSYN
MS, QL
MS, PA, QL
MS, QL
MS, QL
PA, QL
1
1
1
1
2
1
2
3
1
1
1
1
3
3
QL
Antihyperlipidemics
ADVICOR
ALTOPREV
ANTARA
cholestyramine
colestipol hcl
CRESTOR
fenofibrate
FENOGLIDE
gemfibrozil
LESCOL
LESCOL XL
LIPITOR
LIVALO
LOFIBRA
lovastatin
LOVAZA
MEVACOR
NIASPAN
PRAVACHOL
pravastatin
SIMCOR
simvastatin
TRICOR
TRIGLIDE
TRILIPIX
VYTORIN
WELCHOL
ZETIA
Note: Tier 2 with a statin
ZOCOR
MS, PA, QL
MS
MS, PA, QL
MS, PA, QL
MS, PA, QL
MS, PA, QL
MS
MS, PA, QL
MS
MS, QL
MS, PA, QL
MS, PA, QL
MS
MS, PA, QL
ACE Inhibitors (high blood pressure)

1
1
1
1
1
1
1
1
1
1
1
1
3
1
1
3
3
Antiarrhythmics
Cardiovascular / Heart
benazepril
captopril
enalapril
fosinopril
lisinopril
moexipril
perindopril
quinapril
ramipril
trandolapril
3
2
3
3
2
3
1
3
3
Anti-anginal Agents
Cancer
ACTIMMUNE
AFINITOR
ALFERON N
ALKERAN
anastrozole
ARIMIDEX
AROMASIN
bicalutamide
CEENU
cyclophosphamide
EMCYT
FARESTON
FEMARA
flutamide
GLEEVEC
HYCAMTIN
hydroxyurea
INTRON-A
IRESSA
LEUKERAN
LYSODREN
megestrol
mercaptopurine
MYLERAN
NEXAVAR
NILANDRON
OFORTA
REVLIMID
SPRYCEL
SUTENT
tamoxifen
TARCEVA
TARGRETIN
TASIGNA
TEMODAR
THALOMID
TYKERB
VOTRIENT
XELODA
ZOLINZA
1
1
1
1
1
1
1
Angiotensin II Receptor Blockers
QL
Blood Cell Stimulation

ARANESP
EPOGEN
LEUKINE
MOZOBIL
NEULASTA
NEUMEGA
NEUPOGEN
PROCRIT
COMMENTS
ACE Inhibitors / Diuretic Combinations
Blood (continued)
anagrelide
cilostazol
dipyridamole
EFFIENT
pentoxifylline er
PLAVIX
TIER
GT
3
3
3
1
1
2
1
3
1
3
3
3
3
3
1
3
3
2
3
1
3
1
2
3
3
3
3
2
ST
ST
QL, ST
QL
QL, ST
QL, ST
QL, ST
QL, ST
GT, QL
QL, ST
QL, ST
QL
QL, ST
GT, QL
QL
ST
QL, ST
(Rev. 04/01/11)
DRUG
TIER
COMMENTS
DRUG
amiloride
amiloride/hydrochlorothiazide
chlorthalidone
DYRENIUM
eplerenone
furosemide
hydrochlorothiazide
indapamide
metolazone
spironolactone
torsemide
triamterene/hydrochlorothiazide
Cardiovascular / Heart (continued)

Antihypertensive Combinations / Miscellaneous
amlodipine/benazepril
AMTURNIDE
ATACAND HCT
atenolol/chlorthalidone
AVALIDE
AZOR
BENICAR HCT
BIDIL
bisoprolol/hydrochlorothiazide
CADUET
chlorothiazide
clonidine
DIOVAN HCT
EXFORGE
EXFORGE HCT
HYZAAR
isoxsuprine
losartan potassium/hydrochlorothiazide
methazolamide
methyldopa
metoprolol/hydrochlorothiazide
MICARDIS HCT
minoxidil
NEXICLON XR
spironolactone/hydrochlorothiazide
TARKA
TEKAMLO
TEKTURNA
TEKTURNA HCT
TEVETEN HCT
trandolapril/verapamil hcl
TRIBENZOR
TWYNSTA
VALTURNA
1
3
3
1
2
3
3
3
1
3
1
1
2
3
3
3
1
1
1
1
1
3
1
3
1
3
3
3
3
3
1
3
3
3
QL, ST
QL, ST
QL
PA, QL
QL, ST
QL
1
1
1
3
1
3
1
1
1
1
1
1
1
1
1
CUVPOSA
NUVIGIL
PROVIGIL
XYREM
QL
QL
PA, QL
PA, QL
QL, ST
1
1
3
3
1
1
1
3
1
1
1
1
1
1
1
3
1
1
GT
3
3
3
3
PA, QL
PA, QL
PA, QL
PA, QL
benzonatate
1
hydrocodone polistirex and chlorpheniramine polistirex 1
TUSSIONEX
3
QL
QL
Antitussives & Expectorants
QL
QL, ST
Cryopyrin Associated Periodic Syndromes

ARCALYST
PA, QL
PA
3
2
3
MS
MS
Cystic Fibrosis
QL
QL, ST
QL, ST
QL, ST
QL, ST
QL
PA, QL
PA, QL
QL, ST
CAYSTON
PULMOZYME
TOBI
Dermatology
Cancer / Topical Peeling Agents
CARAC
FLUOROPLEX
PANRETIN
SOLARAZE
GT
3
3
3
3
Immunomodulators
ALDARA
ELIDEL
imiquimod
PROTOPIC
ZYCLARA
QL, ST
QL, ST
QL
GT
3
3
1
3
3
QL
QL
QL
QL
QL
Psoriasis Products
calcipotriene
DOVONEX
DOVONEX SCALP
selenium sulfide
SORIATANE
TACLONEX
TACLONEX SCALP
TAZORAC
1
2
3
1
3
3
3
3
QL
ST
PA, QL
Topical / Oral Acne Products

ACANYA
ACZONE
adapalene
amnesteem
AVITA
AZELEX
BENZACLIN
BENZAMYCIN
benzoyl peroxide
claravis
CLINDAGEL
clindamycin/benzoyl peroxide
DIFFERIN
DUAC CS
EPIDUO
erythromycin
EVOCLIN
FINACEA
QL
Diuretics
acetazolamide
1
1
1
3
1
1
1
1
1
1
1
1
Cough / Cold
Calcium Channel Blockers

afeditab cr
amlodipine
CARDENE SR
COVERA-HS
diltiazem cd
diltiazem
diltzac
DYNACIRC CR
felodipine er
isradipine
nicardipine
nifedipine
nifedipine er
nimodipine
nisoldipine
SULAR
verapamil
verapamil er
COMMENTS
Central Nervous System
PA, QL
Beta Blockers (high blood pressure)

acebutolol
atenolol
betaxolol
BYSTOLIC
carvedilol
COREG CR
labetalol
metoprolol succinate er
metoprolol tartrate
nadolol
pindolol
propranolol
propranolol er
sotalol
timolol
TIER
3
3
1
1
3
3
3
3
1
1
3
1
3
2
3
1
3
3
QL
QL, ST
ST
QL, ST
QL
QL
ST
(Rev. 04/01/11)
DRUG
TIER
COMMENTS
DRUG
EXTINA
ketoconazole
LOPROX
MENTAX
NAFTIN
NIZORAL SHAMPOO
nystatin/triamcinolone
nystop
OXISTAT
VUSION
XOLEGEL
Dermatology (continued)
Topical / Oral Acne Products (continued)
KLARON
minocycline hcl er
NEOBENZ MICRO SD
ORACEA
PLEXION
RETIN-A MICRO
sodium sulfacetamide
SOLODYN
sotret
tretinoin
TRETIN-X
TRIAZ
ZIANA
3
1
3
3
3
3
1
3
1
1
3
3
3
PA, QL
ST
QL, ST
ST
PA, QL
PA, QL
ST
PA
ST applies to selected benefits
ST
ST
ST
ST
ST
ST
Accu-Chek and OneTouch are preferred test strips/meters and Step Therapy applies
prior to all other meters.
ACCU-CHEK ACTIVE CARE KIT
2
ACCU-CHEK ACTIVE STRIPS
2
QL
ACCU-CHEK AVIVA
2
QL
ACCU-CHEK COMFORT CURVE TEST STRIPS
2
QL
ACCU-CHEK COMPACT PLUS CARE KIT
2
ACCU-CHEK COMPACT STRIPS
2
QL
ACCU-CHEK COMPACT TEST DRUM
2
QL
FASTTAKE TEST STRIPS
2
QL
ONETOUCH BASIC/PROFILE TEST STRIPS
2
QL
ONETOUCH ULTRA 2
2
ONETOUCH ULTRA MINI
2
ONETOUCH ULTRA SYSTEM KIT
2
ONETOUCH ULTRA TEST STRIPS
2
QL
ONETOUCH ULTRASMART
2
SURESTEP PRO LINEARITY KIT
2
SURESTEP TEST STRIPS
2
QL
Injectables
APIDRA
BYETTA
GLUCAGEN
HUMALOG
HUMALOG MIX 50/50
HUMALOG MIX 75/25
HUMULIN
HUMULIN 70/30 PEN
HUMULIN N
HUMULIN R
LANTUS
LEVEMIR
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG MIX 70/30
SYMLIN
VICTOZA
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
QL
Oral Hypoglycemics
ACTOPLUS MET
ACTOPLUS MET XR
ACTOS
AVANDAMET
AVANDARYL
chlorpropamide
CYCLOSET
DUETACT
FORTAMET
glimepiride
glipizide
glipizide/metformin
GLUCOVANCE
GLUMETZA
glyburide
glyburide micronized
glyburide/metformin
GLYSET
JANUMET
JANUVIA
ST
ST
ST
ST
ST
Topical Antifungals
1
1
1
3
3
ST
Blood Glucose Supplies
Topical Antibiotics
ciclopirox nail lacquer

ciclopirox olamine
econazole nitrate
ERTACZO
EXELDERM
3
1
3
3
3
3
1
1
3
3
3
DIABETIC BENEFIT and/or DME BENEFIT APPLIES. Please refer to member contract
for copayment amount. If Diabetic Benefit DOES NOT apply please refer to the
following tier classifications:
ACLOVATE
3
alclometasone dipropionate
1
amcinonide
1
augmented betamethasone
1
betamethasone dipropionate
1
betamethasone valerate
1
CAPEX
2
clobetasol propionate
1
CLOBEX
2
Note: Tier 2 after trial and failure of a high or very or very high potency steroid
CLODERM
3
ST
clotrimazole/betamethasone dipropionate
1
CORDRAN
3
ST
CORDRAN SP
3
ST
desonide
1
DESOWEN LOTION/CETAPHIL CREAM
3
PA, QL
desoximetasone
1
dexamethasone
1
DIFLORASONE DIACETATE
3
fludrocortisone acetate
1
fluocinolone acetonide
1
fluocinonide
1
fluticasone
1
halobetasol propionate
1
HALOG
3
ST
HALONATE
3
PA, QL
hydrocortisone butyrate
1
hydrocortisone valerate
1
KENALOG
3
ST
LOCOID LIPOCREAM
3
ST
LUXIQ
3
ST
methylprednisolone
1
mometasone furoate
1
OLUX
3
ST
OLUX-E
3
ST
PANDEL
3
ST
prednisolone
1
prednisone
1
triamcinolone acetonide
1
ULTRAVATE PAC
3
PA, QL
VANOS
3
ST
VERDESO
3
ST
3
2
1
3
3
1
3
1
COMMENTS
Diabetes
Topical / Oral Steroids
ALTABAX
BACTROBAN CREAM
gentamicin
METROGEL
METROGEL 1% KIT
mupirocin
NORITATE
silver sulfadiazine
TIER
ST
2
2
2
2
2
1
3
2
3
1
1
1
3
3
1
1
1
2
2
2
QL
QL
QL
QL
QL
QL
(Rev. 04/01/11)
DRUG
TIER
COMMENTS
DRUG
DUREZOL
flurbiprofen
FML FORTE
ketorolac
neomycin/polymyxin/dexamethasone
NEVANAC
POLY-PRED
PRED-G
tobramycin/dexamethasone
VEXOL
VOLTAREN
XIBROM
ZYLET
Diabetes (continued)
Oral Hypoglycemics (continued)
KOMBIGLYZE XR
metformin
metformin er
nateglinide
ONGLYZA
PRANDIMET
PRANDIN
tolazamide
tolbutamide
3
1
1
1
3
3
2
1
1
QL
QL
ALPHAGAN P
AZOPT
BETIMOL
BETOPTIC-S
brimonidine
carteolol hcl
dorzolamide
dorzolamide/timolol
IOPIDINE
latanoprost
levobunolol
LUMIGAN
metipranolol
pilocarpine
PILOPINE HS
TRAVATAN Z
XALATAN
1
1
2
1
1
1
3
Endocrine
calcitriol
DRISDOL
HECTOROL
octreotide
vitamin d
ZEMPLAR
1
3
3
1
1
2
MS
PKU
KUVAN
CYMBALTA
LYRICA
SAVELLA
3
2
1
PA
PA
PA
allopurinol
COLCRYS
probenecid
probenecid/colchicine
ULORIC
Antiallergics
3
3
3
3
1
3
3
3
2
3
3
3
QL
GENOTROPIN
HUMATROPE
INCRELEX
NORDITROPIN FLEXPRO
NUTROPIN
NUTROPIN AQ
OMNITROPE
SAIZEN
SEROSTIM
SOMAVERT
TEV-TROPIN
ZORBTIVE
QL
QL
QL
3
3
2
1
1
1
3
1
1
1
2
3
3
QL
QL
QL
3
3
3
3
3
1
3
3
3
3
1
1
1
1
3
1
1
3
1
1
3
2
3
QL
QL
3
3
3
QL, ST
QL
QL
1
2
1
1
2
QL, ST
3
3
3
3
3
3
2
3
3
3
3
3
MS, PA, ST
MS, PA, ST
MS, PA
MS, PA, ST
MS, PA, ST
MS, PA, ST
MS, PA
MS, PA, ST
MS, PA
PA
MS, PA, ST
MS, PA, QL
Hemorrhoids
ala cort
hemril-30
hydrocortisone
hydrocortisone acetate
proctocream-hc
proctozone-hc
QL
1
1
1
1
1
1
Hepatitis B
BARACLUDE
EPIVIR HBV
HEPSERA
TYZEKA
PA, QL
Anti-inflammatory
ACULAR
ACULAR LS
ACUVAIL
BLEPHAMIDE
BROMDAY
diclofenac
QL
Growth Hormone / Factors
QL
Antiinfectives
AZASITE
BESIVANCE
CILOXAN OINTMENT
ciprofloxacin
neomycin/bacitracin/polymyxin
neomycin/polymyxin/gramicidin
QUIXIN
tobramycin
trifluridine
trimethoprim sulfate/polymyxin b sulfate
VIGAMOX
Note: Tier 2 if prescribed by an ophthalmologist
ZYMAR
ZYMAXID
QL
Gout
Eye
ALAMAST
ALOCRIL
ALOMIDE
ALREX
azelastine hcl
BEPREVE
EMADINE
LASTACAFT
LOTEMAX
OPTIVAR
PATADAY
PATANOL
3
1
3
1
1
3
2
3
1
3
3
3
3
Fibromyalgia
MS, PA
Enteral Formula
Enteral formulas
PKU products
various generics
COMMENTS
Glaucoma
Ear
acetasol hc
antipyrine/benzocaine
CIPRODEX
cortomycin
neomycin/polymyxin/hydrocortisone
ofloxacin
ZINOTIC
TIER
2
2
2
2
MS, PA, QL
MS, PA
MS, PA
MS, PA, QL
3
2
2
1
1
MS, PA
MS, PA, QL
MS, PA, QL, ST
MS, PA
MS, PA
Hepatitis C
COPEGUS
PEGASYS
PEG-INTRON
ribasphere
ribavirin
QL
QL
(Rev. 04/01/11)
DRUG
TIER
COMMENTS
DRUG
ciprofloxacin er
ciprofloxacin
clarithromycin
clindamycin
dicloxacillin
DORYX
doxycycline hyclate
erythrocin stearate
FURADANTIN
isoniazid
KETEK
LEVAQUIN
metronidazole
minocycline
MOXATAG
nitrofurantoin
NOROXIN
ofloxacin
penicillin v potassium
rifampin
SPECTRACEF
sulfamethoxazole/trimethoprim
SUPRAX
tetracycline
trimethoprim
VIBRAMYCIN
XIFAXAN
ZMAX
ZYVOX
HIV
APTIVUS
ATRIPLA
COMBIVIR
CRIXIVAN
didanosine
EGRIFTA
EMTRIVA
EPIVIR
EPZICOM
FUZEON
INTELENCE
INVIRASE
ISENTRESS
KALETRA
LEXIVA
NORVIR
PREZISTA
RESCRIPTOR
REYATAZ
SELZENTRY
stavudine
SUSTIVA
TRIZIVIR
TRUVADA
VIRACEPT
VIRAMUNE
VIREAD
ZIAGEN
zidovudine
2
2
2
2
1
3
2
2
2
3
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
1
QL
MS, PA, QL
QL
QL
QL
clotrimazole
fluconazole
GRIFULVIN V
griseofulvin
GRIS-PEG
itraconazole
ketoconazole
LAMISIL GRANULES
nystatin
ORAVIG
terbinafine
terconazole
VFEND
voriconazole
MS, PA
PA
MS, PA, QL
Hyperammonemia
CARBAGLU
Idiopathic Thrombocytopenia
PROMACTA
Immune System
AZASAN
azathioprine
cyclosporine
gengraf
leflunomide
mycophenolate mofetil
MYFORTIC
NEORAL
RAPAMUNE
tacrolimus
ZORTRESS
3
1
1
1
1
1
3
3
2
1
3
MS
3
3
PA
PA, QL
MS, PA, QL
acyclovir
DENAVIR
famciclovir
FAMVIR
ganciclovir
RELENZA DISKHALER
rimantadine
TAMIFLU
valacyclovir hcl
VALCYTE
VALTREX
XERESE
ZOVIRAX
Infantile Spasms
SABRIL
Infections
QL
ST
PA, QL
QL
PA, QL
1
1
2
1
3
1
1
3
1
3
1
1
3
1
QL
PA, QL
PA, QL
QL
QL
QL
1
3
1
3
1
2
1
2
1
3
3
3
3
PA, QL
QL
1
3
3
1
3
PA
QL
QL
QL
QL
QL
Malaria
Antibiotics
ADOXA
amoxicillin
amoxicillin/clavulanate potassium
ampicillin
AVELOX
azithromycin
CEDAX
cefaclor
cefaclor er
cefadroxil
cefdinir
cefpodoxime
cefprozil
cefuroxime
cephalexin
1
1
1
1
1
3
1
1
3
1
3
3
1
1
3
1
3
1
1
1
3
1
3
1
1
3
3
3
3
Antiviral Drugs
Inborn Errors of Metabolism

ORFADIN
ZAVESCA
COMMENTS
Antifungal Drugs (oral)
Huntington's Chorea
XENAZINE
TIER
chloroquine
DARAPRIM
MALARONE
mefloquine
QUALAQUIN
3
1
1
1
3
1
3
1
1
1
1
1
1
1
1
Scabies
acticin
EURAX
lindane
permethrin
1
3
1
1
QL
QL
Inflammatory Bowel
APRISO
ASACOL
balsalazide
3
2
1
QL
(Rev. 04/01/11)
DRUG
TIER
COMMENTS
DRUG
fluoxetine
fluvoxamine
imipramine
LEXAPRO
LUVOX CR
maprotiline
mirtazapine
NARDIL
nefazodone
nortriptyline
OLEPTRO
paroxetine
paroxetine hcl er
PAXIL
PAXIL CR
PEXEVA
PRISTIQ
PROZAC
PROZAC WEEKLY
SARAFEM
selfemra
sertraline
SURMONTIL
SYMBYAX
tranylcypromine
trazodone
venlafaxine
venlafaxine hcl er
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
ZOLOFT
Inflammatory Bowel (continued)

CANASA
DIPENTUM
ENTOCORT EC
LIALDA
mesalamine
PENTASA
ROWASA KIT
sulfasalazine
2
2
3
2
1
2
3
1
PA, QL
Intranasal
Steroids / Antihistamines / Miscellaneous
ASTELIN
ASTEPRO
azelastine hcl
BECONASE AQ
FLONASE
flunisolide
fluticasone
NASACORT AQ
NASONEX
OMNARIS
PATANASE
RHINOCORT AQUA
VERAMYST
3
2
1
3
3
1
1
3
2
3
3
3
3
QL, ST
ST
QL
ST
QL, ST
QL
ST
QL, ST
Men's Health
BPH Agents (prostate)
AVODART
doxazosin
finasteride
FLOMAX
JALYN
prazosin
RAPAFLO
tamsulosin hcl
terazosin
UROXATRAL
3
1
1
3
3
1
3
1
1
3
QL, ST
ABILIFY
Note: Tier 2 after trial and failure of risperidone
ABILIFY DISCMELT
chlorpromazine
clozapine
FANAPT
FAZACLO
fluphenazine
GEODON
haloperidol
INVEGA
LATUDA
loxapine
risperidone
risperidone odt
SAPHRIS
SEROQUEL
SEROQUEL XR
thioridazine
thiothixene
trifluoperazine
ZYPREXA
ZYPREXA ZYDIS
QL, ST
PA, QL
QL, ST
QL
QL, ST
2
2
2
1
1
3
3
Sexual Dysfunction
CAVERJECT
CIALIS
EDEX
LEVITRA
MUSE
VIAGRA
yohimbine
3
3
3
3
3
3
1
QL
QL
QL
QL
QL
QL
Mental Health
Antidepressants
amoxapine
APLENZIN
budeprion sr
budeprion xl
bupropion
bupropion sr
CELEXA
citalopram
clomipramine
CYMBALTA
desipramine
doxepin
EFFEXOR XR
EMSAM
fluoxetine dr
1
3
1
1
1
1
3
1
1
3
1
1
3
3
1
COMMENTS
1
1
1
3
3
1
1
3
1
1
3
1
1
3
3
3
3
3
3
3
1
1
3
3
1
1
1
1
3
3
3
3
QL
ST
ST
ST
PA, QL
ST
QL, ST
QL, ST
ST
ST
ST
QL, ST
QL, ST
QL
ST
ST
ST
ST
Antipsychosis
Hormones
ANDRODERM
ANDROGEL
ANDROID
androxy
oxandrolone
STRIANT
TESTIM
TIER
1
1
3
3
1
2
QL, ST
1
3
3
1
1
1
3
2
PA, QL
QL, ST
QL, ST
QL, ST
1
1
1
2
2
Sedatives / Hypnotics / Anxiety
QL, ST
alprazolam
alprazolam er
AMBIEN
AMBIEN CR
buspirone
clorazepate
diazepam
EDLUAR
estazolam
flurazepam
hydroxyzine
lorazepam
LUNESTA
QL, ST
GT, QL
QL, ST
QL, ST
QL, ST
QL
1
1
3
3
1
1
1
3
1
1
1
1
3
QL, ST
QL, ST
QL, ST
QL, ST
(Rev. 04/01/11)
DRUG
TIER
COMMENTS
DRUG
CATAFLAM
CELEBREX
DAYPRO
diclofenac sodium ec
etodolac
etodolac er
FELDENE
fenoprofen
flurbiprofen
ibuprofen
indomethacin
ketoprofen
ketorolac
meclofenamate
meloxicam
MOBIC
nabumetone
NAPRELAN
NAPROSYN
naproxen
oxaprozin
piroxicam
PONSTEL
sulindac
tolmetin
VIMOVO
VOLTAREN-XR
ZIPSOR
Mental Health (continued)

Sedatives / Hypnotics / Anxiety (continued)
meprobamate
oxazepam
ROZEREM
SILENOR
SONATA
temazepam
triazolam
zaleplon
zolpidem
zolpidem tartrate er
ZOLPIMIST
1
1
3
3
3
1
1
1
1
1
3
QL, ST
QL, ST
QL, ST
QL
QL
QL
QL, ST
Migraine
AMERGE
AXERT
CAMBIA
divalproex sodium er
FROVA
IMITREX
MAXALT
MAXALT-MLT
MIGRANAL
naratriptan hcl
RELPAX
sumatriptan
SUMAVEL DOSEPRO
TREXIMET
ZOMIG
ZOMIG ZMT
3
3
3
1
3
3
2
2
2
1
3
1
3
3
3
3
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
QL
QL
QL, ST
QL
QL, ST
QL, ST
QL, ST
QL, ST
3
3
2
2
3
3
2
MS, PA, QL
MS, QL
MS, QL
MS, QL
MS, PA, QL
MS, PA, QL
MS, QL
2
1
3
3
1
2
3
1
3
3
3
3
QL, ST
GT, QL
QL, ST
QL, ST
FLECTOR
VOLTAREN
ABSTRAL
acetaminophen/codeine
ACTIQ
AVINZA
BUTRANS
DURAGESIC
EXALGO
fentanyl
fentanyl lollipops
FENTORA
hydrocodone/acetaminophen
hydrocodone/ibuprofen
hydromorphone
KADIAN
meperidine
methadone
methadose
morphine
morphine sulfate er
NUCYNTA
ONSOLIS
OPANA
OPANA ER
ORAMORPH SR
oxycodone
oxycodone/acetaminophen
oxycodone/aspirin
oxycodone/ibuprofen
OXYCONTIN
oxymorphone hydrochloride
pentazocine/naloxone
roxicet
RYBIX ODT
RYZOLT
tramadol
tramadol hcl er
tramadol hydrochloride/acetaminophen
ULTRAM ER
QL
MS, PA
QL, ST
QL, ST
Muscle Relaxants
3
1
1
1
3
1
3
1
1
1
3
3
1
PA, QL
3
3
3
ST
ST
QL, ST
PA
PA, QL
QL
QL, ST
PA
NSAIDs
ANAPROX
ANAPROX DS
ARTHROTEC 75
ST
QL, ST
QL, ST
QL, ST
ST
QL, ST
3
2
QL, ST
QL
3
1
3
3
3
3
3
1
1
3
1
1
1
2
1
1
1
1
1
3
3
3
3
3
1
1
1
1
3
1
1
1
3
3
1
1
1
3
PA, QL
ST
QL
GT
ST
QL
ST
ST
QL
ST
Narcotic
Pain / Inflammation
AMRIX
baclofen
carisoprodol
chlorzoxazone
CYCLOBENZAPRINE COMFORT PAC
cyclobenzaprine
FEXMID
metaxalone
methocarbamol
orphenadrine er
SKELAXIN
SOMA 250mg
tizanidine
3
3
3
1
1
1
3
1
1
1
1
1
1
1
1
3
1
3
3
1
1
1
3
1
1
3
3
3
Pain Relievers
Osteoporosis
ACTONEL
alendronate
ATELVIA
BONIVA
etidronate
EVISTA
FORTEO
fortical
FOSAMAX
FOSAMAX PLUS D
MIACALCIN
SKELID
COMMENTS
Topical NSAIDs
Multiple Sclerosis
AMPYRA
AVONEX
BETASERON
COPAXONE
EXTAVIA
GILENYA
REBIF
TIER
PA, QL
QL
QL, ST
QL, ST
QL, ST
QL, ST
PA, QL
PA, QL
QL
QL
QL
PA, QL
QL
QL
QL, ST
QL
QL
QL
QL
Non-Narcotic
butalbital/acetaminophen/caffeine
diflunisal
lidocaine
1
1
1
(Rev. 04/01/11)
DRUG
TIER
COMMENTS
DRUG
PEGANONE
phenobarbital
phenytoin
primidone
STAVZOR
TOPAMAX SPRINKLE
topiramate
valproic acid
VIMPAT
zonisamide
Pain Relievers (continued)

Non-Narcotic (continued)
LIDODERM
salsalate
SYNERA
3
1
3
Parkinson's Disease
amantadine
AZILECT
benztropine
bromocriptine
carbidopa/levodopa
carbidopa/levodopa odt
COMTAN
LODOSYN
MIRAPEX ER
pramipexole dihydrochloride
REQUIP XL
ropinirole
selegiline
STALEVO
TASMAR
trihexyphenidyl
ZELAPAR
1
3
1
1
1
1
2
2
3
1
3
1
1
3
3
1
3
ANZEMET
CESAMET
dronabinol
EMEND
granisetron
meclizine
ondansetron
prochlorperazine
SANCUSO
TRANSDERM-SCOP
trimethobenzamide
ZOFRAN
ZUPLENZ
QL, ST
QL, ST
QL, ST
CREON
ZENPEP
URSO 250
URSO FORTE
ursodiol
PA, QL
2
3
3
3
3
MS, PA, QL
MS, PA, QL
MS, PA, QL, ST
MS, PA
MS, PA, QL
3
3
3
1
3
1
3
MS, PA, QL
MS, PA, QL
MS, PA, QL
AMITIZA
LOTRONEX
QL
QL, ST
QL, ST
QL, ST
2
2
3
3
1
2
1
1
2
2
1
2
2
1
3
1
2
1
2
3
2
3
3
1
1
3
1
3
3
QL
QL
3
3
1
3
1
3
1
1
3
1
2
1
1
1
1
3
3
3
1
3
1
1
3
QL, ST
Ulcer / Heartburn
ACIPHEX
CARAFATE
cimetidine
DEXILANT
famotidine
HELIDAC
lansoprazole
metoclopramide
METOZOLV ODT
misoprostol
NEXIUM
nizatidine
omeprazole
omeprazole/sodium bicarbonate
pantoprazole
PREVACID
PREVPAC
PRILOSEC
prilosec otc
PROTONIX
ranitidine
sucralfate
ZEGERID
MS, PA, QL
MS, PA, QL, ST
Seizure / Pain
BANZEL
carbamazepine
carbamazepine er
CARBATROL
CELONTIN
clonazepam
DIASTAT ACUDIAL
DILANTIN
divalproex
EQUETRO
ethosuximide
FELBATOL
gabapentin
GABITRIL
KEPPRA
KEPPRA XR
LAMICTAL ODT
LAMICTAL XR
lamotrigine
levetiracetam
LYRICA
oxcarbazepine
QL
QL
Irritable Bowel
3
Rheumatoid Arthritis
CIMZIA
ENBREL
HUMIRA
hydroxychloroquine
KINERET
methotrexate
SIMPONI
QL, ST
Gallbladder
1
1
1
Pulmonary Arterial Hypertension

ADCIRCA
LETAIRIS
REVATIO
TRACLEER
TYVASO STARTER
3
3
1
2
1
1
1
1
3
3
1
3
3
Digestants
1
2
2
Pseudobulbar Affect
NUEDEXTA
2
1
1
1
3
3
1
1
2
1
Antiemetics (for nausea)
Potassium Supplements
klor-con
potassium chloride
potassium citrate extended-release
COMMENTS
Stomach / Intestinal
QL
Phosphate Binders
calcium acetate
RENAGEL
RENVELA
TIER
QL, ST
QL
QL, ST
QL, ST
GT, QL
QL
QL
QL, ST
QL, ST
GT, QL
QL, ST
QL, ST
Throat products - Miscellaneous

EVOXAC
Thyroid
ARMOUR THYROID
CYTOMEL
levothroid
levothyroxine
levoxyl
liothyronine sodium
methimazole
NATURE-THROID
QL
QL, ST
QL, ST
QL
QL
3
3
1
1
1
1
1
3
(Rev. 04/01/11)
DRUG
TIER
COMMENTS
DRUG
GANIRELIX
GONAL-F
leuprolide
LUVERIS
MENOPUR
NOVAREL
OVIDREL
PREGNYL
REPRONEX
SYNAREL
Thyroid (continued)
propylthiouracil
SYNTHROID
THYROLAR
UNITHROID
1
3
3
3
Weight Management
Anorexiants
ADIPEX-P
BONTRIL
DIDREX
diethylpropion
phendimetrazine er
phentermine
XENICAL
3
3
3
1
1
1
3
QL
QL
QL
QL
QL
QL
PA
1
1
1
1
3
1
1
3
1
1
1
1
1
1
3
3
1
3
1
1
3
1
3
1
1
3
1
2
1
3
3
2
3
3
1
1
1
1
3
1
1
3
1
1
1
3
3
1
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
COMMENTS
3
2
1
3
3
3
3
3
3
2
PA
MS, PA, QL
PA
MS, PA
MS, PA
MS, PA
MS, PA
MS, PA
MS, PA
MS
Hormones
ACTIVELLA
ALORA
ANGELIQ
CENESTIN
CLIMARA
CLIMARA PRO
COMBIPATCH
CRINONE
ENJUVIA
esterified estrogens/methyltestosterone hs
ESTRACE
ESTRADERM
estradiol
estropipate
EVAMIST
FEMHRT 1/5
jinteli
medroxyprogesterone
MENEST
methyltestosterone/esterified estrogens hs
mimvey
norethindrone
ORTHO-EST
PREMARIN
PREMPHASE
PREMPRO
PROMETRIUM
VAGIFEM
VIVELLE-DOT
Women's Health
Contraceptives
apri
aviane
camila
cryselle-28
CYCLESSA
enpresse-28
errin
ESTROSTEP FE
gianvi
jolessa
jolivette
kariva
kelnor 1/35
levora 0.15/30-28
LOESTRIN 1.5/30-21
LOESTRIN FE 1.5/30
low-ogestrel
LYBREL
microgestin 1.5/30
microgestin fe 1.5/30
MODICON-28
mononessa
NATAZIA
necon 0.5/35-28
nora-be
NORDETTE-28
nortrel 0.5/35 (28)
NUVARING
ogestrel
ORTHO EVRA
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-CYCLEN
OVCON-50 28
portia-28
previfem
quasense
reclipsen
SEASONIQUE
solia
sprintec 28
TRI-NORINYL 28
tri-previfem
tri-sprintec
trivora-28
YASMIN 28
YAZ
zovia 1/35e
zovia 1/50e
TIER
3
3
3
3
2
2
3
3
3
1
3
3
1
1
3
3
1
1
3
1
1
1
3
2
2
2
2
2
3
QL
QL
QL
QL
QL
Wound Healing
REGRANEX
SANTYL
3
3
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
Fertility Drugs
BRAVELLE
CETROTIDE
chorionic gonadotropin
clomiphene
ENDOMETRIN
FOLLISTIM AQ
2
3
1
1
3
3
MS, PA, QL
MS, PA
MS, PA, QL
PA
MS, PA, QL, ST
10
(Rev. 04/01/11)
Certain medications require prior authorization, which means approval is needed before the
prescription can be filled. If approval is not received, the drug may not be covered.
Prior Authorization List
The following prescription drugs require PRIOR AUTHORIZATION:
Allergy
Growth Hormone / Factors

Trade Name: GENOTROPIN, HUMATROPE, INCRELEX,
NORDITROPIN FLEXPRO, NUTROPIN, NUTROPIN AQ,
OMNITROPE, SAIZEN, SEROSTIM, SOMAVERT, TEV-TROPIN,
ZORBTIVE
Antihistamines
Trade Name: LEVOCETIRIZINE DIHYDROCHLORIDE, XYZAL
Angioedema
Hepatitis B
Trade Name: CINRYZE
Trade Name: BARACLUDE, EPIVIR HBV, HEPSERA, TYZEKA
Hepatitis C
Trade Name: AMPHETAMINE/DEXTROAMPHETAMINE
Trade Name: COPEGUS, PEG-INTRON, PEGASYS, RIBASPHERE,

RIBAVIRIN
Blood
HIV
Trade Name: EGRIFTA
Trade Name: ARANESP ALBUMIN FREE, EPOGEN, MOZOBIL,

PROCRIT
Huntington's Chorea
Cancer
Trade Name: XENAZINE
Antineoplastic
Hyperammonemia
Trade Name: ACTIMMUNE, AFINITOR, HYCAMTIN, NEXAVAR,

REVLIMID, SPRYCEL, SUTENT, TARCEVA, TASIGNA, TYKERB,
VOTRIENT, ZOLINZA
Trade Name: CARBAGLU
Idiopathic Thrombocytopenia
Trade Name: PROMACTA
Inborn Errors of Metabolism
Anti-anginal Agents
Trade Name: ORFADIN, ZAVESCA
Trade Name: NITROMIST
Infantile Spasms
Trade Name: SABRIL
Trade Name: AZOR, CADUET, EXFORGE, EXFORGE HCT,

NEXICLON XR, TRIBENZOR, TWYNSTA
Infections
Central Nervous System
Antibiotics
Trade Name: CUVPOSA, NUVIGIL, PROVIGIL, XYREM
Trade Name: MOXATAG, ZYVOX
Cryopyrin Associated Periodic Syndromes
Antifungal Drugs (oral)
Trade Name: ARCALYST
Trade Name: LAMISIL, ORAVIG
Dermatology
Antiviral Drugs
Psoriasis Products
Trade Name: XERESE
Trade Name: TACLONEX SCALP
Malaria
Trade Name: QUALAQUIN
Trade Name: MINOCYCLINE HCL ER, SOLODYN, TRETIN-X,

ZIANA
Inflammatory Bowel
Trade Name: ROWASA
Men's Health
Trade Name: DESOWEN LOTION/CETAPHIL CREAM, HALONATE,

ULTRAVATE PAC
BPH Agents (prostate)
Endocrine
Trade Name: JALYN
Mental Health
PKU
Trade Name: KUVAN
Antidepressants
Eye
Trade Name: PRISTIQ

Antipsychosis
Antiinfectives
Trade Name: INVEGA
Trade Name: ZYMAXID
(Rev. 04/01/11)
Certain medications require prior authorization, which means approval is needed before the
prescription can be filled. If approval is not received, the drug may not be covered.
Prior Authorization List
The following prescription drugs require PRIOR AUTHORIZATION:
Multiple Sclerosis
Trade Name: AMPYRA, EXTAVIA, GILENYA
Osteoporosis
Trade Name: FORTEO
Pain / Inflammation
Muscle Relaxants
Trade Name: AMRIX, CYCLOBENZAPRINE COMFORT PAC,
FEXMID, SOMA
Pain Relievers
Narcotic
Trade Name: ABSTRAL, ACTIQ, FENTANYL CITRATE ORAL
TRANSMUCOSAL, FENTORA, ONSOLIS
Pseudobulbar Affect
Trade Name: NUEDEXTA

Trade Name: ADCIRCA, LETAIRIS, REVATIO, TRACLEER,
TYVASO STARTER
Trade Name: CIMZIA, ENBREL, HUMIRA, KINERET, SIMPONI
Weight Management
Anorexiants
Trade Name: XENICAL
Women's Health
Fertility Drugs
Trade Name: BRAVELLE, CETROTIDE, CHORIONIC
GONADOTROPIN, ENDOMETRIN, FOLLISTIM AQ, GANIRELIX
ACETATE, GONAL-F, LEUPROLIDE ACETATE, LUVERIS,
MENOPUR, NOVAREL, OVIDREL, PREGNYL W/DILUENT BENZYL
ALCOHOL/NACL, REPRONEX
(Rev. 04/01/11)
Before certain medications are covered, we require that a generic or cost-effective alternative be tried
first. For example, if Drug A and Drug B can both be used to treat a medical condition, Drug B may
not be covered unless Drug A is tried first. If Drug A does not work, we will then cover Drug B.
Step Therapy List
The following prescription drugs have STEP THERAPY applied:
Allergy
Dermatology
Antihistamine / Decongestant Combination
Psoriasis Products
TACLONEX
Required Prerequisite Drug(s): One of the following high
potency generic topical steroids if written by dermatologist; and
two of the following high potency steroids if written by another
specialty: amcinonide, augmented betamethasone,
betamethasone, clobetasol, desoximetasone, diflor
ALLEGRA-D 12 HOUR
Required Prerequisite Drug(s): fexofenadine
CLARINEX-D 12 HOUR
Required Prerequisite Drug(s): fexofenadine or loratadine
Antihistamines
ALLEGRA
Required Prerequisite Drug(s): fexofenadine
CLARINEX
Required Prerequisite Drug(s): fexofenadine or loratadine
ACZONE
Required Prerequisite Drug(s): benzoyl peroxide AND a
topical retinoid
DIFFERIN LOTIOIN
Required Prerequisite Drug(s): DIFFERIN CREAM/GEL and
a topical retinoid
CLINDAGEL, EVOCLIN
Required Prerequisite Drug(s): topical clindamycin and
tretinoin
ORACEA
Required Prerequisite Drug(s): doxycycline and minocycline
PLEXION CLEANSING CLOTH
Required Prerequisite Drug(s): Rosacea - sulfacetamide/
sulfur and topical metronidazole
Acne - topical sulfacetamide/sulfur and tretinoin
Alzheimer's
ARICEPT 23MG
Required Prerequisite Drug(s): Aricept 10mg

INTUNIV, KAPVAY
Required Prerequisite Drug(s): Any long acting stimulant
Blood
ARANSEP ALBUMIN FREE
Required Prerequisite Drug(s): Epogen or Procrit
NEOBENZ MICRO SD, TRIAZ

Required Prerequisite Drug(s): benzoyl peroxide and tretinoin
Angiotensin II Receptor Blockers
ATACAND, BENICAR, COZAAR, EDARBI, MICARDIS, TEVETEN

Required Prerequisite Drug(s): Losartan, Diovan or Avapro
CLODERM, CORDRAN, CORDRAN SP, HALOG, KENALOG SPRAY,

LOCOID LIPOCREAM, LUXIQ, OLUX, OLUX-E, PANDEL, VERDESO
Required Prerequisite Drug(s): Two of the following generic
topical steroids: aclometasone, amcinonide, betamethasone,
clobetasol, desonide, desoximetasone, diflorasone,
fluocinolone, fluocinonide-E, fluticasone, halobetasol,
hydrocortisone 2.5%, hydrocortisone valerate, hydrocortisone
VANOS
topical steroids:
aclometasone, amcinonide, betamethasone, clobetasol,
desonide, desoximetasone, diflorasone, fluocinolone,
fluocinonide-E, fluticasone, halobetasol, hydrocortisone 2.5%,
hydrocortisone valerate, hydrocortisone
Antihyperlipidemics
ADVICOR, ALTOPREV, CRESTOR, LESCOL, LESCOL XL, LIPITOR,
MEVACOR, PRAVACHOL, SIMCOR, ZOCOR
Required Prerequisite Drug(s): lovastatin, pravastatin, or
simvastatin
LIVALO
Required Prerequisite Drug(s): lovastatin, pravastatin, or
simvastatin AND Crestor
VYTORIN
Required Prerequisite Drug(s): simvastatin and Crestor
Topical Antibiotics
ATACAND HCT, BENICAR HCT, HYZAAR, MICARDIS HCT, TEVETEN

HCT
Required Prerequisite Drug(s): Losartan/HCTZ, Diovan HCT
or Avalide
AMTURNIDE, TEKAMLO, TEKTURNA, TEKTURNA HCT, VALTURNA
Required Prerequisite Drug(s): ACE inhibitor or ARB and one
other antihypertensive medication
ALTABAX, BACTROBAN
Required Prerequisite Drug(s): mupirocin
METROGEL
Required Prerequisite Drug(s): metronidazole
Topical Antifungals
ERTACZO, EXTINA, LOPROX, MENTAX, NAFTIN, NIZORAL, OXISTAT,
XOLEGEL
topicals: ciclopirox, econazole, ketoconazole, nystatin
Beta Blockers (high blood pressure)

BYSTOLIC
Required Prerequisite Drug(s): Two of the following beta
blockers: Atenolol, Propranolol, Bisoprolol, Carvedilol, Pindolol,
Timolol, Nadolol, Betaxolol, Metoprolol, Labetalol, Acebutolol
COREG CR
Required Prerequisite Drug(s): carvedilol
Gout
ULORIC
Required Prerequisite Drug(s): allopurinol
(Rev. 04/01/11)
Step Therapy List
MAOI's: Nardil, Emsam, tranylcypromine

Modified Cyclics: nefazodone, Oleptro
SSRI: citalopram, Lexapro, fluoxetine, fluvoxamine,
Growth Hormone
GENOTROPIN, HUMATROPE, NORDITROPIN, NUTROPIN, SAIZEN,
TEV-TROPIN
Required Prerequisite Drug(s): omnitrope
Migraine
TREXIMET
Required Prerequisite Drug(s): Imitrex 100mg and one of the
following: Axert, Relpax, Frova, Amerge, Maxalt, Maxalt MLT,
Zomig (Only trial of Imitrex 100mg when prescribed by
neurologist)
Hepatitis C
PEG-INTRON
Required Prerequisite Drug(s): Pegasys
Infections
Antibiotics
Sedatives / Hypnotics / Anxiety
DORYX
AMBIEN, AMBIEN CR, EDLUAR, LUNESTA, ROZEREM, SILENOR,

SONATA, ZOLPMIST
Required Prerequisite Drug(s): zolpidem
Required Prerequisite Drug(s): doxycycline and minocycline
Intranasal
Migraine
Steroids / Antihistamines / Miscellaneous
CAMBIA
BECONASE AQ, FLONASE, NASACORT AQ, OMNARIS, RHINOCORT

AQUA, VERAMYST
Required Prerequisite Drug(s): flunisolide or fluticasone and
Nasonex
Required Prerequisite Drug(s): Perscribed by Neurologist

AXERT, FROVA, IMITREX, RELPAX, SUMAVEL DOSEPRO, ZOMIG,
ZOMIG ZMT
Required Prerequisite Drug(s): Sumatriptan and Maxalt or
Maxalt MLT
AMERGE, MAXALT, MAXALT-MLT
Required Prerequisite Drug(s): Sumatriptan
Men's Health
BPH Agents
AVODART
Osteoporosis
Required Prerequisite Drug(s): finasteride

FLOMAX, RAPAFLO, UROXATRAL
Required Prerequisite Drug(s): tamsulosin
ACTONEL, ATELVIA, BONIVA, FOSAMAX, FOSAMAX PLUS D

Required Prerequisite Drug(s): alendronate
Pain / Inflammation
Mental Health
Muscle Relaxants
Antidepressants
SKELAXIN
muscle relaxants: carisoprodol, baclofen, tizanidine,
methocarbamol, orphenadrine, cyclobenzaprine
OLEPTRA
Required Prerequisite Drug(s): One of the following:
citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline,
venlafaxine and Trazodone
APLENZIN, CELEXA, CYMBALTA, EFFEXOR XR, EMSAM, LEXAPRO,
LUVOX CR, PAXIL, PAXIL CR, PEXEVA, PROZAC, PROZAC WEEKLY,
SARAFEM, WELLBUTRIN, WELLBUTRIN SR, WELLBUTRIN XL,
ZOLOFT
Required Prerequisite Drug(s): Two of the following:
mirtazapine, citalopram, fluoxetine, paroxetine, sertraline,
venlafaxine or bupropion (Trial of one if prescribed by a
psychiatrist)
NSAIDs
ANAPROX, ANAPROX DS, ARTHROTEC 75, CATAFLAM, CELEBREX,
DAYPRO, FELDENE, FLECTOR, MOBIC, NAPRELAN, NAPROSYN,
PONSTEL, VIMOVO, VOLTAREN GEL (step requirements bypassed if 65
years of age or older), VOLTAREN-XR, ZIPSOR
Required Prerequisite Drug(s): THREE different generic
NSAIDs (Examples: diclofenac, ibuprofen, indomethacin,
ketoprofen, meloxicam, nabumetone, naproxen sodium,
piroxicam, salsalate, sulindac) one of which must be meloxicam
Antipsychosis
Pain Relievers
ABILIFY
Required Prerequisite Drug(s): One of the following
medications from two different classes of antidepressant
medications:
Tetracyclics: mirtazapine
MAOI's: Nardil, Emsam, tranylcypromine
Modified Cyclics: nefazodone, Oleptro
SSRI: citalopram, Lexapro, fluoxetine, fluvoxamine, L
FANAPT, LATUDA, SAPHRIS
Required Prerequisite Drug(s): Two of the following: Invega,
Risperdal, Seroquel XR, Zyprexa, Abilify, Geodon
SEROQUEL XR
Required Prerequisite Drug(s): One of the following
medications from two different classes of antidepressant
medications:
Tetracyclics: mirtazapine
Narcotic
BUTRANS, DURAGESIC, EXALGO, FENTANYL, OXYCONTIN
Required Prerequisite Drug(s): morphine ER, oramorph SR,
Avinza or Kadian (unless prescribed by Oncologists,
Hematologist, Palliative Care or Pain Specialist)
Parkinson's Disease
MIRAPEX ER
Required Prerequisite Drug(s): pramipexole
REQUIP XL
Required Prerequisite Drug(s): ropinirole
(Rev. 04/01/11)
Step Therapy List
ZELAPAR
Required Prerequisite Drug(s): Trial of one other Parkinsons
disease medication (such as carbidopa/levodopa,ropinirole,
selegiline, Mirapex)

REVATIO
Required Prerequisite Drug(s): Adcirca
CIMZIA, SIMPONI
Required Prerequisite Drug(s): Humira or Enbrel
Seizure / Pain
LAMICTAL ODT, LAMICTAL XR
Required Prerequisite Drug(s): lamotrigine
Stomach / Intestinal
Antiemetics (for nausea)
SANCUSO
Required Prerequisite Drug(s): ondansetron and granisetron
ANZEMET, KYTRIL, ZOFRAN, ZUPLENZ
Required Prerequisite Drug(s): ondansetron
Antispasmodic Drugs
DETROL, DETROL LA, ENABLEX, GELNIQUE, OXYTROL, TOVIAZ
Required Prerequisite Drug(s): oxybutynin or oxybutynin ER
and Vesicare
Ulcer / Heartburn
ACIPHEX, PANTOPRAZOLE SODIUM, PREVACID, PRILOSEC,
PROTONIX
Required Prerequisite Drug(s): omeprazole 40mg and
lansoprazole
DEXILANT
Required Prerequisite Drug(s): omeprazole or lansoprazole
METOZOLV ODT
Required Prerequisite Drug(s): metoclopramide
NEXIUM, ZEGERID
Required Prerequisite Drug(s): omeprazole 40mg
Women's Health
Fertility Drugs
FOLLISTIM
Required Prerequisite Drug(s): GONAL-F
(Rev. 04/01/11)
Formulary Index
A
ABILIFY ....................................................................7
ABILIFY DISCMELT ...............................................7
ABSTRAL ..................................................................8
ACANYA ...................................................................3
ACCOLATE ...............................................................1
ACCU-CHEK ACTIVE CARE KIT ..........................4
ACCU-CHEK ACTIVE STRIPS ...............................4
ACCU-CHEK AVIVA ...............................................4
ACCU-CHEK COMFORT CURVE
TEST STRIPS ............................................................4
ACCU-CHEK COMPACT PLUS
CARE KIT ..................................................................4
ACCU-CHEK COMPACT STRIPS ..........................4
ACCU-CHEK COMPACT TEST
DRUM ........................................................................4
acebutolol hcl .............................................................3
acetaminophen/codeine ..............................................8
acetasol hc ..................................................................5
acetazolamide .............................................................3
acetylcysteine ..............................................................1
ACIPHEX ...................................................................9
ACLOVATE ...............................................................4
acticin .........................................................................6
ACTIMMUNE ...........................................................2
ACTIQ ........................................................................8
ACTIVELLA ............................................................10
ACTONEL .................................................................8
ACTOPLUS MET ......................................................4
ACTOPLUS MET XR ...............................................4
ACTOS .......................................................................4
ACULAR ....................................................................5
ACULAR LS ..............................................................5
ACUVAIL ..................................................................5
acyclovir .....................................................................6
ACZONE ....................................................................3
adapalene ...................................................................3
ADCIRCA ..................................................................9
ADDERALL XR ........................................................1
ADIPEX-P ................................................................10
ADOXA ......................................................................6
ADVAIR DISKUS .....................................................1
ADVICOR ..................................................................2
afeditab cr ...................................................................3
AFINITOR .................................................................2
AGGRENOX ..............................................................1
ala cort ........................................................................5
ALAMAST .................................................................5
albuterol sulfate ..........................................................1
albuterol sulfate er .....................................................1
alclometasone dipropionate .......................................4
ALDARA ...................................................................3
alendronate sodium ....................................................8
ALFERON N ..............................................................2
ALKERAN .................................................................2
ALLEGRA .................................................................1
ALLEGRA-D 12 HOUR ............................................1
allopurinol ..................................................................5
ALOCRIL ...................................................................5
ALOMIDE ..................................................................5
ALORA .................................................................... 10
ALPHAGAN P .......................................................... 5
alprazolam ................................................................. 7
alprazolam er ............................................................. 7
ALREX ...................................................................... 5
ALTABAX ................................................................ 4
ALTOPREV ............................................................... 2
ALVESCO ................................................................. 1
amantadine hcl ........................................................... 9
AMBIEN .................................................................... 7
AMBIEN CR ............................................................. 7
amcinonide ................................................................. 4
AMERGE ................................................................... 8
amiloride hcl .............................................................. 3
amiloride/hydrochlorothiazide .................................. 3
aminophylline ............................................................. 1
amiodarone hcl .......................................................... 2
AMITIZA ................................................................... 9
amlodipine besylate ................................................... 3
amlodipine besylate/benazepril
hydrochloride ............................................................. 3
amnesteem .................................................................. 3
amoxapine .................................................................. 7
amoxicillin .................................................................. 6
amoxicillin/clavulanate potassium ............................. 6
AMPHETAMINE/
DEXTROAMPHETAMINE ...................................... 1
ampicillin ................................................................... 6
AMPYRA .................................................................. 8
AMRIX ...................................................................... 8
AMTURNIDE ............................................................ 3
anagrelide hydrochloride ........................................... 2
ANAPROX ................................................................ 8
ANAPROX DS .......................................................... 8
anastrozole ................................................................. 2
ANDRODERM .......................................................... 7
ANDROGEL .............................................................. 7
ANDROID ................................................................. 7
androxy ...................................................................... 7
ANGELIQ ................................................................ 10
ANTABUSE .............................................................. 1
ANTARA ................................................................... 2
antipyrine/benzocaine ................................................ 5
ANZEMET ................................................................ 9
APIDRA ..................................................................... 4
APLENZIN ................................................................ 7
apri ........................................................................... 10
APRISO ..................................................................... 6
APTIVUS ................................................................... 6
ARANESP ALBUMIN FREE ................................... 2
ARCALYST .............................................................. 3
ARICEPT 23MG ....................................................... 1
ARIMIDEX ................................................................ 2
ARIXTRA .................................................................. 1
ARMOUR THYROID ............................................... 9
AROMASIN .............................................................. 2
ARTHROTEC 75 ....................................................... 8
ASACOL .................................................................... 6
ASMANEX 120 METERED DOSES ....................... 1
ASTELIN ................................................................... 7
ASTEPRO .................................................................. 7
11
ATACAND.................................................................2
ATACAND HCT........................................................3
ATELVIA ...................................................................8
atenolol .......................................................................3
atenolol/chlorthalidone ..............................................3
ATRIPLA ...................................................................6
ATROVENT HFA......................................................1
augmented betamethasone dipropionate ....................4
AVALIDE ..................................................................3
AVANDAMET ..........................................................4
AVANDARYL ...........................................................4
AVAPRO ....................................................................2
AVELOX ....................................................................6
aviane .......................................................................10
AVINZA .....................................................................8
AVITA ........................................................................3
AVODART.................................................................7
AVONEX ...................................................................8
AXERT .......................................................................8
AZASAN ....................................................................6
AZASITE ...................................................................5
azathioprine ................................................................6
azelastine hcl ..........................................................5, 7
AZELEX.....................................................................3
AZILECT ...................................................................9
azithromycin ...............................................................6
AZOPT .......................................................................5
AZOR .........................................................................3
B
baclofen ......................................................................8
BACTROBAN ...........................................................4
balsalazide disodium ..................................................6
BANZEL ....................................................................9
BARACLUDE ............................................................5
BECONASE AQ ........................................................7
benazepril hcl .............................................................2
benazepril hcl/hydrochlorothiazide ............................2
BENICAR...................................................................2
BENICAR HCT..........................................................3
BENZACLIN .............................................................3
BENZAMYCIN .........................................................3
benzonatate .................................................................3
benzoyl peroxide .........................................................3
benztropine mesylate ..................................................9
BEPREVE ..................................................................5
BESIVANCE ..............................................................5
betamethasone dipropionate ......................................4
betamethasone valerate ..............................................4
BETASERON.............................................................8
betaxolol hcl ...............................................................3
bethanechol chloride ..................................................1
BETIMOL ..................................................................5
BETOPTIC-S .............................................................5
bicalutamide ...............................................................2
BIDIL .........................................................................3
bisoprolol fumarate/
hydrochlorothiazide ....................................................3
BLEPHAMIDE ..........................................................5
BONIVA.....................................................................8
Formulary Index
BONTRIL SLOW RELEASE ..................................10
BRAVELLE .............................................................10
brimonidine tartrate ...................................................5
BROMDAY ................................................................5
bromocriptine mesylate ..............................................9
BROVANA ................................................................1
budeprion sr ................................................................7
budeprion xl ................................................................7
budesonide ..................................................................1
buprenorphine hcl ......................................................1
buproban .....................................................................1
bupropion hcl ..............................................................7
bupropion hcl sr .........................................................7
buspirone hcl ..............................................................7
butalbital/acetaminophen/caffeine .............................8
BUTRANS .................................................................8
BYETTA ....................................................................4
BYSTOLIC .................................................................3
C
CADUET ....................................................................3
calcipotriene ...............................................................3
calcitriol .....................................................................5
calcium acetate ...........................................................9
CAMBIA ....................................................................8
camila .......................................................................10
CAMPRAL .................................................................1
CANASA ....................................................................7
CAPEX .......................................................................4
captopril .....................................................................2
captopril/hydrochlorothiazide ....................................2
CARAC ......................................................................3
CARAFATE ...............................................................9
CARBAGLU ..............................................................6
carbamazepine ............................................................9
carbamazepine er .......................................................9
CARBATROL ............................................................9
carbidopa/levodopa ....................................................9
carbidopa/levodopa odt ..............................................9
CARDENE SR ...........................................................3
carisoprodol ...............................................................8
carteolol hcl ................................................................5
carvedilol ....................................................................3
CATAFLAM ..............................................................8
CAVERJECT .............................................................7
CAYSTON .................................................................3
CEDAX ......................................................................6
CEENU .......................................................................2
cefaclor .......................................................................6
cefaclor er ...................................................................6
cefadroxil ....................................................................6
cefdinir ........................................................................6
cefpodoxime proxetil ..................................................6
cefprozil ......................................................................6
cefuroxime axetil ........................................................6
CELEBREX ...............................................................8
CELEXA ....................................................................7
CELONTIN ................................................................9
CENESTIN ...............................................................10
cephalexin ...................................................................6
CESAMET ................................................................. 9
CETROTIDE ........................................................... 10
CHANTIX .................................................................. 1
chloroquine phosphate ............................................... 6
chlorothiazide ............................................................ 3
chlorpromazine hcl .................................................... 7
chlorpropamide .......................................................... 4
chlorthalidone ............................................................ 3
chlorzoxazone ............................................................ 8
cholestyramine ........................................................... 2
chorionic gonadotropin ........................................... 10
CIALIS ....................................................................... 7
ciclopirox nail lacquer ............................................... 4
ciclopirox olamine ..................................................... 4
cilostazol .................................................................... 2
CILOXAN .................................................................. 5
cimetidine ................................................................... 9
CIMZIA ..................................................................... 9
CINRYZE .................................................................. 1
CIPRODEX ................................................................ 5
ciprofloxacin er .......................................................... 6
ciprofloxacin hcl .................................................... 5, 6
citalopram hydrobromide .......................................... 7
claravis ....................................................................... 3
CLARINEX ............................................................... 1
CLARINEX-D 12 HOUR .......................................... 1
clarithromycin ............................................................ 6
CLIMARA ............................................................... 10
CLIMARA PRO ...................................................... 10
CLINDAGEL ............................................................. 3
clindamycin hcl .......................................................... 6
clindamycin/benzoyl peroxide .................................... 3
clobetasol propionate ................................................. 4
CLOBEX .................................................................... 4
CLODERM ................................................................ 4
clomiphene citrate .................................................... 10
clomipramine hcl ....................................................... 7
clonazepam ................................................................ 9
clonidine hcl ............................................................... 3
clorazepate dipotassium ............................................. 7
clotrimazole ................................................................ 6
clotrimazole/betamethasone
dipropionate ............................................................... 4
clozapine .................................................................... 7
COLCRYS ................................................................. 5
colestipol hcl .............................................................. 2
COMBIPATCH ....................................................... 10
COMBIVENT ............................................................ 1
COMBIVIR ................................................................ 6
COMTAN .................................................................. 9
CONCERTA .............................................................. 1
COPAXONE .............................................................. 8
COPEGUS ................................................................. 5
CORDRAN ................................................................ 4
CORDRAN SP ........................................................... 4
COREG CR ................................................................ 3
cortomycin .................................................................. 5
COUMADIN .............................................................. 1
COVERA-HS ............................................................. 3
COZAAR ................................................................... 2
12
CREON.......................................................................9
CRESTOR ..................................................................2
CRINONE ................................................................10
CRIXIVAN.................................................................6
cromolyn sodium ........................................................1
cryselle-28 ................................................................10
CUVPOSA .................................................................3
CYCLESSA ..............................................................10
CYCLOBENZAPRINE COMFORT
PAC ............................................................................8
cyclobenzaprine hcl ....................................................8
cyclophosphamide ......................................................2
CYCLOSET ...............................................................4
cyclosporine ................................................................6
CYMBALTA ..........................................................5, 7
cyproheptadine hcl .....................................................1
CYTOMEL .................................................................9
D
DARAPRIM ...............................................................6
DAYPRO ....................................................................8
DAYTRANA ..............................................................1
DENAVIR ..................................................................6
desipramine hcl ..........................................................7
desonide ......................................................................4
DESOWEN LOTION/CETAPHIL
CREAM ......................................................................4
desoximetasone ...........................................................4
DESOXYN .................................................................1
DETROL ....................................................................1
DETROL LA ..............................................................1
dexamethasone ...........................................................4
DEXILANT ................................................................9
dexmethylphenidate hcl ..............................................1
dextroamphetamine sulfate er ....................................1
DIASTAT ACUDIAL ................................................9
diazepam .....................................................................7
diclofenac sodium .......................................................5
diclofenac sodium ec ..................................................8
dicloxacillin sodium....................................................6
dicyclomine hcl ...........................................................1
didanosine...................................................................6
DIDREX ...................................................................10
diethylpropion hcl .....................................................10
DIFFERIN ..................................................................3
DIFLORASONE DIACETATE .................................4
diflunisal .....................................................................8
digoxin ........................................................................2
DILANTIN .................................................................9
diltiazem cd .................................................................3
diltiazem hcl................................................................3
diltzac .........................................................................3
DIOVAN ....................................................................2
DIOVAN HCT ...........................................................3
DIPENTUM ...............................................................7
diphenhydramine hcl ..................................................1
dipyridamole ...............................................................2
disopyramide phosphate .............................................2
divalproex sodium ......................................................9
divalproex sodium er ..................................................8
donepezil hcl ...............................................................1
Formulary Index
DORYX ......................................................................6
dorzolamide hcl ..........................................................5
dorzolamide hcl/timolol maleate ................................5
DOVONEX ................................................................3
DOVONEX SCALP ...................................................3
doxazosin mesylate .....................................................7
doxepin hcl ..................................................................7
doxycycline hyclate .....................................................6
DRISDOL ...................................................................5
dronabinol ..................................................................9
DUAC CS ...................................................................3
DUETACT .................................................................4
DURAGESIC .............................................................8
DUREZOL .................................................................5
DYNACIRC CR .........................................................3
DYRENIUM ...............................................................3
E
econazole nitrate ........................................................4
EDARBI .....................................................................2
EDEX .........................................................................7
EDLUAR ....................................................................7
EFFEXOR XR ............................................................7
EFFIENT ....................................................................2
EGRIFTA ...................................................................6
ELIDEL ......................................................................3
EMADINE ..................................................................5
EMCYT ......................................................................2
EMEND ......................................................................9
EMSAM .....................................................................7
EMTRIVA ..................................................................6
ENABLEX .................................................................1
enalapril maleate ........................................................2
enalapril maleate/hydrochlorothiazide ......................2
ENBREL .....................................................................9
ENDOMETRIN ........................................................10
ENJUVIA .................................................................10
enoxaparin sodium .....................................................1
enpresse-28 ...............................................................10
Enteral formulas .........................................................5
ENTOCORT EC .........................................................7
EPIDUO .....................................................................3
EPIPEN .......................................................................1
EPIPEN-JR .................................................................1
EPIVIR .......................................................................6
EPIVIR HBV ..............................................................5
eplerenone ..................................................................3
EPOGEN ....................................................................2
EPZICOM ...................................................................6
EQUETRO .................................................................9
errin ..........................................................................10
ERTACZO ..................................................................4
erythrocin stearate ......................................................6
erythromycin ...............................................................3
estazolam ....................................................................7
esterified estrogens/methyltestosterone
hs ...............................................................................10
ESTRACE ................................................................10
ESTRADERM ..........................................................10
estradiol ....................................................................10
estropipate ................................................................ 10
ESTROSTEP FE ...................................................... 10
ethosuximide .............................................................. 9
etidronate disodium ................................................... 8
etodolac ...................................................................... 8
etodolac er ................................................................. 8
EURAX ...................................................................... 6
EVAMIST ................................................................ 10
EVISTA ..................................................................... 8
EVOCLIN .................................................................. 3
EVOXAC ................................................................... 9
EXALGO ................................................................... 8
EXELDERM .............................................................. 4
EXFORGE ................................................................. 3
EXFORGE HCT ........................................................ 3
EXTAVIA .................................................................. 8
EXTINA ..................................................................... 4
F
famciclovir ................................................................. 6
famotidine .................................................................. 9
FAMVIR .................................................................... 6
FANAPT .................................................................... 7
FARESTON ............................................................... 2
FASTTAKE TEST STRIPS ...................................... 4
FAZACLO ................................................................. 7
FELBATOL ............................................................... 9
FELDENE .................................................................. 8
felodipine er ............................................................... 3
FEMARA ................................................................... 2
FEMHRT 1/5 ........................................................... 10
fenofibrate micronized ............................................... 2
FENOGLIDE ............................................................. 2
fenoprofen calcium ..................................................... 8
fentanyl ....................................................................... 8
fentanyl citrate oral transmucosal ............................. 8
FENTORA ................................................................. 8
FEXMID .................................................................... 8
fexofenadine hcl ......................................................... 1
FINACEA .................................................................. 3
finasteride .................................................................. 7
flavoxate hcl ............................................................... 1
flecainide acetate ....................................................... 2
FLECTOR .................................................................. 8
FLOMAX ................................................................... 7
FLONASE .................................................................. 7
FLOVENT HFA ........................................................ 1
fluconazole ................................................................. 6
fludrocortisone acetate .............................................. 4
flunisolide ................................................................... 7
fluocinolone acetonide ............................................... 4
fluocinonide ................................................................ 4
FLUOROPLEX .......................................................... 3
fluoxetine dr ............................................................... 7
fluoxetine hcl .............................................................. 7
fluphenazine hcl ......................................................... 7
flurazepam hcl ............................................................ 7
flurbiprofen ................................................................ 8
flurbiprofen sodium .................................................... 5
flutamide .................................................................... 2
13
fluticasone propionate ............................................4, 7

fluvoxamine maleate ...................................................7
FML FORTE ..............................................................5
FOCALIN ...................................................................1
FOCALIN XR ............................................................1
FOLLISTIM AQ ......................................................10
FORADIL AEROLIZER............................................1
FORTAMET ...............................................................4
FORTEO.....................................................................8
fortical ........................................................................8
FOSAMAX.................................................................8
FOSAMAX PLUS D ..................................................8
fosinopril sodium ........................................................2
fosinopril sodium/hydrochlorothiazide ......................2
FRAGMIN ..................................................................1
FROVA.......................................................................8
FURADANTIN ..........................................................6
furosemide ..................................................................3
FUZEON ....................................................................6
G
gabapentin ..................................................................9
GABITRIL .................................................................9
galantamine hydrobromide ........................................1
ganciclovir ..................................................................6
GANIRELIX ACETATE .........................................10
GELNIQUE ................................................................1
gemfibrozil ..................................................................2
gengraf ........................................................................6
GENOTROPIN...........................................................5
gentamicin sulfate .......................................................4
GEODON ...................................................................7
gianvi ........................................................................10
GILENYA ..................................................................8
GLEEVEC ..................................................................2
glimepiride ..................................................................4
glipizide ......................................................................4
glipizide/metformin hcl ...............................................4
GLUCAGEN ..............................................................4
GLUCOVANCE .........................................................4
GLUMETZA ..............................................................4
glyburide .....................................................................4
glyburide micronized ..................................................4
glyburide/metformin hcl .............................................4
glycopyrrolate.............................................................1
GLYSET .....................................................................4
GONAL-F.................................................................10
granisetron hcl............................................................9
GRIFULVIN V ...........................................................6
griseofulvin microsize .................................................6
GRIS-PEG ..................................................................6
H
halobetasol propionate ...............................................4
HALOG ......................................................................4
HALONATE ..............................................................4
haloperidol .................................................................7
HECTOROL ...............................................................5
HELIDAC...................................................................9
hemril-30 ....................................................................5
Formulary Index
heparin sodium ...........................................................1
HEPSERA ..................................................................5
HUMALOG ................................................................4
HUMALOG MIX 50/50 .............................................4
HUMALOG MIX 75/25 .............................................4
HUMATROPE ...........................................................5
HUMIRA ....................................................................9
HUMULIN 50/50 .......................................................4
HUMULIN 70/30 PEN ...............................................4
HUMULIN N .............................................................4
HUMULIN R ..............................................................4
HYCAMTIN ...............................................................2
hydrochlorothiazide ....................................................3
hydrocodone polistirex and
chlorpheniramine polistirex .......................................3
hydrocodone/acetaminophen ......................................8
hydrocodone/ibuprofen ...............................................8
hydrocortisone ............................................................5
hydrocortisone acetate ...............................................5
hydrocortisone butyrate ..............................................4
hydrocortisone valerate ..............................................4
hydromorphone hcl .....................................................8
hydroxychloroquine sulfate ........................................9
hydroxyurea ................................................................2
hydroxyzine hcl ...........................................................7
HYZAAR ...................................................................3
I
ibuprofen .....................................................................8
imipramine hcl ............................................................7
imiquimod ...................................................................3
IMITREX ...................................................................8
INCRELEX ................................................................5
indapamide .................................................................3
indomethacin ..............................................................8
INNOHEP ...................................................................1
INTELENCE ..............................................................6
INTRON-A .................................................................2
INTUNIV ...................................................................1
INVEGA .....................................................................7
INVIRASE .................................................................6
IOPIDINE ...................................................................5
ipratropium bromide ..................................................1
ipratropium bromide/albuterol sulfate .......................1
IRESSA ......................................................................2
ISENTRESS ...............................................................6
isoniazid ......................................................................6
isosorbide dinitrate .....................................................2
isosorbide mononitrate er ...........................................2
isoxsuprine hcl ............................................................3
isradipine ....................................................................3
itraconazole ................................................................6
J
JALYN .......................................................................7
jantoven ......................................................................1
JANUMET .................................................................4
JANUVIA ...................................................................4
jinteli .........................................................................10
jolessa .......................................................................10
jolivette ..................................................................... 10
K
KADIAN .................................................................... 8
KALETRA ................................................................. 6
KAPVAY ................................................................... 1
kariva ....................................................................... 10
kelnor 1/35 ............................................................... 10
KENALOG ................................................................ 4
KEPPRA .................................................................... 9
KEPPRA XR .............................................................. 9
KETEK ...................................................................... 6
ketoconazole ........................................................... 4, 6
ketoprofen .................................................................. 8
ketorolac tromethamine ......................................... 5, 8
KINERET .................................................................. 9
KLARON ................................................................... 4
klor-con ...................................................................... 9
KOMBIGLYZE XR ................................................... 5
KUVAN ..................................................................... 5
L
labetalol hcl ............................................................... 3
LAMICTAL ODT ...................................................... 9
LAMICTAL XR ........................................................ 9
LAMISIL ................................................................... 6
lamotrigine ................................................................. 9
LANOXIN ................................................................. 2
lansoprazole ............................................................... 9
LANTUS .................................................................... 4
LASTACAFT ............................................................ 5
latanoprost ................................................................. 5
LATUDA ................................................................... 7
leflunomide ................................................................. 6
LESCOL .................................................................... 2
LESCOL XL .............................................................. 2
LETAIRIS .................................................................. 9
LEUKERAN .............................................................. 2
LEUKINE .................................................................. 2
leuprolide acetate ..................................................... 10
LEVAQUIN ............................................................... 6
LEVEMIR .................................................................. 4
levetiracetam .............................................................. 9
LEVITRA .................................................................. 7
levobunolol hcl ........................................................... 5
levocetirizine dihydrochloride ................................... 1
levora 0.15/30-28 ..................................................... 10
levothroid ................................................................... 9
levothyroxine sodium ................................................. 9
levoxyl ........................................................................ 9
LEXAPRO ................................................................. 7
LEXIVA ..................................................................... 6
LIALDA ..................................................................... 7
lidocaine ..................................................................... 8
LIDODERM .............................................................. 9
lindane ........................................................................ 6
liothyronine sodium ................................................... 9
LIPITOR .................................................................... 2
lisinopril ..................................................................... 2
lisinopril/hydrochlorothiazide ................................... 2
14
LIVALO .....................................................................2
LOCOID LIPOCREAM .............................................4
LODOSYN .................................................................9
LOESTRIN 1.5/30-21 ..............................................10
LOESTRIN FE 1.5/30 ..............................................10
LOFIBRA ...................................................................2
LOPROX ....................................................................4
lorazepam ...................................................................7
losartan potassium .....................................................2
losartan potassium/hydrochlorothiazide ....................3
LOTEMAX.................................................................5
LOTRONEX...............................................................9
lovastatin ....................................................................2
LOVAZA ....................................................................2
LOVENOX .................................................................1
low-ogestrel ..............................................................10
loxapine succinate ......................................................7
LUMIGAN .................................................................5
LUNESTA ..................................................................7
LUVERIS .................................................................10
LUVOX CR ................................................................7
LUXIQ ........................................................................4
LYBREL ...................................................................10
LYRICA .................................................................5, 9
LYSODREN ...............................................................2
M
MALARONE .............................................................6
maprotiline hcl............................................................7
MAXAIR AUTOHALER ..........................................1
MAXALT ...................................................................8
MAXALT-MLT .........................................................8
meclizine hcl ...............................................................9
meclofenamate sodium ...............................................8
medroxyprogesterone acetate ...................................10
mefloquine hcl ............................................................6
megestrol acetate ........................................................2
meloxicam ...................................................................8
MENEST ..................................................................10
MENOPUR...............................................................10
MENTAX ...................................................................4
meperidine hcl ............................................................8
meprobamate ..............................................................8
mercaptopurine...........................................................2
mesalamine .................................................................7
METADATE CD........................................................1
metadate er .................................................................1
metaproterenol sulfate ................................................1
metaxalone ..................................................................8
metformin hcl ..............................................................5
metformin hcl er .........................................................5
methadone hcl .............................................................8
methadose ...................................................................8
methazolamide ............................................................3
methimazole ................................................................9
methocarbamol ...........................................................8
methotrexate ...............................................................9
methyldopa .................................................................3
methylin ......................................................................1
methylin er ..................................................................1
Formulary Index
methylphenidate hcl ....................................................1
methylprednisolone .....................................................4
methyltestosterone/esterified estrogens
hs ...............................................................................10
metipranolol ...............................................................5
metoclopramide hcl ....................................................9
metolazone ..................................................................3
metoprolol succinate er ..............................................3
metoprolol tartrate .....................................................3
metoprolol/hydrochlorothiazide .................................3
METOZOLV ODT .....................................................9
METROGEL ..............................................................4
METROGEL 1% KIT ................................................4
metronidazole .............................................................6
MEVACOR ................................................................2
mexiletine hcl ..............................................................2
MIACALCIN .............................................................8
MICARDIS .................................................................2
MICARDIS HCT ........................................................3
microgestin 1.5/30 ....................................................10
microgestin fe 1.5/30 ................................................10
MIGRANAL ...............................................................8
mimvey ......................................................................10
minocycline hcl ...........................................................6
minocycline hcl er .......................................................4
minoxidil .....................................................................3
MIRAPEX ER ............................................................9
mirtazapine .................................................................7
misoprostol .................................................................9
MOBIC .......................................................................8
MODICON-28 ..........................................................10
moexipril hcl ...............................................................2
moexipril/hydrochlorothiazide ...................................2
mometasone furoate ....................................................4
mononessa ................................................................10
morphine sulfate .........................................................8
morphine sulfate er .....................................................8
MOXATAG ................................................................6
MOZOBIL ..................................................................2
MULTAQ ...................................................................2
mupirocin ....................................................................4
MUSE .........................................................................7
mycophenolate mofetil ................................................6
MYFORTIC ...............................................................6
MYLERAN ................................................................2
N
nabumetone .................................................................8
nadolol ........................................................................3
NAFTIN .....................................................................4
naltrexone hcl .............................................................1
NAMENDA ................................................................1
NAPRELAN ...............................................................8
NAPROSYN ...............................................................8
naproxen .....................................................................8
naratriptan hcl ............................................................8
NARDIL .....................................................................7
NASACORT AQ ........................................................7
NASONEX .................................................................7
NATAZIA ................................................................10
nateglinide .................................................................. 5
NATURE-THROID ................................................... 9
necon 0.5/35-28 ........................................................ 10
nefazodone hcl ........................................................... 7
NEOBENZ MICRO SD ............................................. 4
neomycin/bacitracin/polymyxin ................................. 5
neomycin/polymyxin/dexamethasone ......................... 5
neomycin/polymyxin/gramicidin ................................ 5
neomycin/polymyxin/hydrocortisone ......................... 5
NEORAL ................................................................... 6
NEULASTA .............................................................. 2
NEUMEGA ................................................................ 2
NEUPOGEN .............................................................. 2
NEVANAC ................................................................ 5
NEXAVAR ................................................................ 2
NEXICLON XR ......................................................... 3
NEXIUM .................................................................... 9
NIASPAN .................................................................. 2
nicardipine hcl ........................................................... 3
NICOTROL INHALER ............................................. 1
nifedipine .................................................................... 3
nifedipine er ............................................................... 3
NILANDRON ............................................................ 2
nimodipine .................................................................. 3
nisoldipine .................................................................. 3
NITRO-BID ............................................................... 2
nitrofurantoin macrocrystalline ................................. 6
nitroglycerin ............................................................... 2
nitroglycerin cr .......................................................... 2
NITROMIST .............................................................. 2
nizatidine .................................................................... 9
NIZORAL .................................................................. 4
nora-be ..................................................................... 10
NORDETTE-28 ....................................................... 10
NORDITROPIN FLEXPRO ...................................... 5
norethindrone acetate .............................................. 10
NORITATE ................................................................ 4
NOROXIN ................................................................. 6
NORPACE CR ........................................................... 2
nortrel 0.5/35 (28) .................................................... 10
nortriptyline hcl ......................................................... 7
NORVIR .................................................................... 6
NOVAREL .............................................................. 10
NOVOLIN 70/30 ....................................................... 4
NOVOLIN N.............................................................. 4
NOVOLIN R .............................................................. 4
NOVOLOG ................................................................ 4
NOVOLOG MIX 70/30 ............................................. 4
NUCYNTA ................................................................ 8
NUEDEXTA .............................................................. 9
NUTROPIN ............................................................... 5
NUTROPIN AQ ......................................................... 5
NUVARING ............................................................ 10
NUVIGIL ................................................................... 3
nystatin ....................................................................... 6
nystatin/triamcinolone ............................................... 4
nystop ......................................................................... 4
O
octreotide acetate ....................................................... 5
15
ofloxacin .................................................................5, 6
OFORTA ....................................................................2
ogestrel .....................................................................10
OLEPTRO ..................................................................7
OLUX .........................................................................4
OLUX-E .....................................................................4
omeprazole .................................................................9
omeprazole/sodium bicarbonate ................................9
OMNARIS ..................................................................7
OMNITROPE .............................................................5
ondansetron hcl ..........................................................9
ONETOUCH BASIC/PROFILE TEST
STRIPS .......................................................................4
ONETOUCH ULTRA 2 .............................................4
ONETOUCH ULTRA MINI ......................................4
ONETOUCH ULTRA SYSTEM KIT .......................4
ONETOUCH ULTRA TEST STRIPS .......................4
ONETOUCH ULTRASMART ..................................4
ONGLYZA .................................................................5
ONSOLIS ...................................................................8
OPANA ......................................................................8
OPANA ER ................................................................8
OPTIVAR ...................................................................5
ORACEA ....................................................................4
ORAMORPH SR .......................................................8
ORAVIG.....................................................................6
ORFADIN ..................................................................6
orphenadrine citrate er...............................................8
ORTHO EVRA ........................................................10
ORTHO TRI-CYCLEN............................................10
ORTHO TRI-CYCLEN LO .....................................10
ORTHO-CYCLEN ...................................................10
ORTHO-EST ............................................................10
OVCON-50 28..........................................................10
OVIDREL.................................................................10
oxandrolone ................................................................7
oxaprozin ....................................................................8
oxazepam ....................................................................8
oxcarbazepine .............................................................9
OXISTAT ...................................................................4
oxybutynin chloride ....................................................1
oxybutynin chloride er ................................................1
oxycodone hcl .............................................................8
oxycodone/acetaminophen .........................................8
oxycodone/aspirin.......................................................8
oxycodone/ibuprofen ..................................................8
OXYCONTIN ............................................................8
oxymorphone hydrochloride .......................................8
OXYTROL .................................................................1
P
pacerone .....................................................................2
PANDEL ....................................................................4
PANRETIN ................................................................3
pantoprazole sodium ..................................................9
paroxetine hcl .............................................................7
paroxetine hcl er .........................................................7
PATADAY .................................................................5
PATANASE ...............................................................7
PATANOL .................................................................5
Formulary Index
PAXIL ........................................................................7
PAXIL CR ..................................................................7
PEGANONE ...............................................................9
PEGASYS ..................................................................5
PEG-INTRON ............................................................5
penicillin v potassium .................................................6
PENTASA ..................................................................7
pentazocine/naloxone hcl ...........................................8
pentoxifylline er ..........................................................2
PERFOROMIST .........................................................1
perindopril erbumine ..................................................2
permethrin ..................................................................6
PEXEVA ....................................................................7
phendimetrazine tartrate er ......................................10
phenobarbital .............................................................9
phentermine hcl ........................................................10
phenytoin ....................................................................9
pilocarpine hcl ............................................................5
PILOPINE HS ............................................................5
pindolol .......................................................................3
piroxicam ....................................................................8
PKU products .............................................................5
PLAVIX .....................................................................2
PLEXION CLEANSING CLOTH .............................4
POLY-PRED ..............................................................5
PONSTEL ...................................................................8
portia-28 ...................................................................10
potassium chloride ......................................................9
potassium citrate extended-release ............................9
PRADAXA .................................................................1
pramipexole dihydrochloride .....................................9
PRANDIMET .............................................................5
PRANDIN ..................................................................5
PRAVACHOL ............................................................2
pravastatin sodium .....................................................2
prazosin hcl ................................................................7
PRED-G ......................................................................5
prednisolone ...............................................................4
prednisone ..................................................................4
PREGNYL W/DILUENT BENZYL
ALCOHOL/NACL ...................................................10
PREMARIN .............................................................10
PREMPHASE ...........................................................10
PREMPRO ...............................................................10
PREVACID ................................................................9
previfem ....................................................................10
PREVPAC ..................................................................9
PREZISTA .................................................................6
PRILOSEC .................................................................9
prilosec otc .................................................................9
primidone ....................................................................9
PRISTIQ .....................................................................7
PROAIR HFA ............................................................1
probenecid ..................................................................5
probenecid/colchicine .................................................5
prochlorperazine maleate ...........................................9
PROCRIT ...................................................................2
proctocream-hc ...........................................................5
proctozone-hc .............................................................5
PROMACTA ..............................................................6
promethazine hcl plain ............................................... 1

PROMETRIUM ....................................................... 10
propafenone hcl ......................................................... 2
propafenone hcl er ..................................................... 2
propranolol hcl .......................................................... 3
propranolol hcl er ...................................................... 3
propylthiouracil ....................................................... 10
PROTONIX ............................................................... 9
PROTOPIC ................................................................ 3
PROVENTIL HFA .................................................... 1
PROVIGIL ................................................................. 3
PROZAC .................................................................... 7
PROZAC WEEKLY .................................................. 7
PULMICORT FLEXHALER .................................... 1
PULMOZYME .......................................................... 3
Q
QUALAQUIN ............................................................ 6
quasense ................................................................... 10
quinapril hcl ............................................................... 2
quinapril/hydrochlorothiazide ................................... 2
quinidine gluconate cr ............................................... 2
QUIXIN ..................................................................... 5
QVAR ........................................................................ 1
R
ramipril ...................................................................... 2
RANEXA ................................................................... 2
ranitidine hcl .............................................................. 9
RAPAFLO ................................................................. 7
RAPAMUNE ............................................................. 6
REBIF ........................................................................ 8
reclipsen ................................................................... 10
REGRANEX ............................................................ 10
RELENZA DISKHALER .......................................... 6
RELPAX .................................................................... 8
RENAGEL ................................................................. 9
RENVELA ................................................................. 9
REPRONEX ............................................................ 10
REQUIP XL ............................................................... 9
RESCRIPTOR ........................................................... 6
RETIN-A MICRO ..................................................... 4
REVATIO .................................................................. 9
REVLIMID ................................................................ 2
REYATAZ ................................................................. 6
RHINOCORT AQUA ................................................ 7
ribasphere .................................................................. 5
ribavirin ..................................................................... 5
rifampin ...................................................................... 6
rimantadine hcl .......................................................... 6
risperidone ................................................................. 7
risperidone odt ........................................................... 7
RITALIN LA ............................................................. 1
rivastigmine tartrate .................................................. 1
ropinirole hcl ............................................................. 9
ROWASA .................................................................. 7
roxicet ........................................................................ 8
ROZEREM ................................................................ 8
RYBIX ODT .............................................................. 8
RYTHMOL SR .......................................................... 2
16
RYZOLT ....................................................................8
S
SABRIL ......................................................................6
SAIZEN ......................................................................5
salsalate ......................................................................9
SANCTURA...............................................................1
SANCTURA XR ........................................................1
SANCUSO .................................................................9
SANTYL ..................................................................10
SAPHRIS ....................................................................7
SARAFEM .................................................................7
SAVELLA ..................................................................5
SEASONIQUE .........................................................10
selegiline hcl ...............................................................9
selenium sulfide ..........................................................3
selfemra ......................................................................7
SELZENTRY .............................................................6
SEREVENT DISKUS ................................................1
SEROQUEL ...............................................................7
SEROQUEL XR .........................................................7
SEROSTIM ................................................................5
sertraline hcl ...............................................................7
SILENOR ...................................................................8
silver sulfadiazine .......................................................4
SIMCOR .....................................................................2
SIMPONI ....................................................................9
simvastatin ..................................................................2
SINGULAIR ...............................................................1
SKELAXIN ................................................................8
SKELID ......................................................................8
sodium sulfacetamide .................................................4
SOLARAZE ...............................................................3
solia ..........................................................................10
SOLODYN .................................................................4
SOMA.........................................................................8
SOMAVERT ..............................................................5
SONATA ....................................................................8
SORIATANE .............................................................3
sotalol hcl ...................................................................3
sotret ...........................................................................4
SPECTRACEF ...........................................................6
SPIRIVA HANDIHALER .........................................1
spironolactone ............................................................3
spironolactone/hydrochlorothiazide...........................3
sprintec 28 ................................................................10
SPRYCEL ..................................................................2
STALEVO 50 .............................................................9
stavudine .....................................................................6
STAVZOR ..................................................................9
STRATTERA .............................................................1
STRIANT ...................................................................7
SUBOXONE ..............................................................1
sucralfate ....................................................................9
SULAR .......................................................................3
sulfamethoxazole/trimethoprim ..................................6
sulfasalazine ...............................................................7
sulindac.......................................................................8
sumatriptan succinate .................................................8
SUMAVEL DOSEPRO..............................................8
Formulary Index
SUPRAX ....................................................................6
SURESTEP PRO LINEARITY KIT ..........................4
SURESTEP TEST STRIPS ........................................4
SURMONTIL .............................................................7
SUSTIVA ...................................................................6
SUTENT .....................................................................2
SYMBICORT .............................................................1
SYMBYAX ................................................................7
SYMLIN .....................................................................4
SYNAREL ................................................................10
SYNERA ....................................................................9
SYNTHROID ...........................................................10
T
TACLONEX ...............................................................3
TACLONEX SCALP .................................................3
tacrolimus ...................................................................6
TAMIFLU ..................................................................6
tamoxifen citrate .........................................................2
tamsulosin hcl .............................................................7
TARCEVA .................................................................2
TARGRETIN .............................................................2
TARKA ......................................................................3
TASIGNA ...................................................................2
TASMAR ...................................................................9
TAZORAC .................................................................3
TEKAMLO .................................................................3
TEKTURNA ...............................................................3
TEKTURNA HCT ......................................................3
temazepam ..................................................................8
TEMODAR ................................................................2
terazosin hcl ................................................................7
terbinafine hcl .............................................................6
terbutaline sulfate .......................................................1
terconazole .................................................................6
TESTIM ......................................................................7
tetracycline hcl ...........................................................6
TEVETEN ..................................................................2
TEVETEN HCT .........................................................3
TEV-TROPIN .............................................................5
THALOMID ...............................................................2
theophylline er ............................................................1
thioridazine hcl ...........................................................7
thiothixene ..................................................................7
THYROLAR-1 .........................................................10
ticlopidine hcl .............................................................1
TIKOSYN ...................................................................2
timolol maleate ...........................................................3
tizanidine hcl ..............................................................8
TOBI ...........................................................................3
tobramycin sulfate ......................................................5
tobramycin/dexamethasone ........................................5
tolazamide ...................................................................5
tolbutamide .................................................................5
tolmetin sodium ..........................................................8
TOPAMAX SPRINKLE ............................................9
topiramate ...................................................................9
torsemide ....................................................................3
TOVIAZ .....................................................................1
TRACLEER ...............................................................9
tramadol hcl ............................................................... 8

tramadol hcl er ........................................................... 8
tramadol hydrochloride/acetaminophen .................... 8
trandolapril ................................................................ 2
trandolapril/verapamil hcl ......................................... 3
TRANSDERM-SCOP ................................................ 9
tranylcypromine sulfate ............................................. 7
TRAVATAN Z .......................................................... 5
trazodone hcl .............................................................. 7
tretinoin ...................................................................... 4
TRETIN-X ................................................................. 4
TREXIMET ............................................................... 8
triamcinolone acetonide ............................................. 4
triamterene/hydrochlorothiazide ............................... 3
TRIAZ ........................................................................ 4
triazolam .................................................................... 8
TRIBENZOR ............................................................. 3
TRICOR ..................................................................... 2
trifluoperazine hcl ...................................................... 7
trifluridine .................................................................. 5
TRIGLIDE ................................................................. 2
trihexyphenidyl hcl ..................................................... 9
TRILIPIX ................................................................... 2
trimethobenzamide hcl ............................................... 9
trimethoprim .............................................................. 6
trimethoprim sulfate/polymyxin b sulfate ................... 5
TRI-NORINYL 28 ................................................... 10
tri-previfem .............................................................. 10
tri-sprintec ................................................................ 10
trivora-28 ................................................................. 10
TRIZIVIR .................................................................. 6
trospium chloride ....................................................... 1
TRUVADA ................................................................ 6
TUSSIONEX PENNKINETIC
EXTENDED RELEASE ............................................ 3
TWINJECT ................................................................ 1
TWYNSTA ................................................................ 3
TYKERB .................................................................... 2
TYVASO STARTER ................................................. 9
TYZEKA .................................................................... 5
U
ULORIC ..................................................................... 5
ULTRAM ER ............................................................. 8
ULTRAVATE PAC ................................................... 4
UNITHROID DIRECT ............................................ 10
UROXATRAL ........................................................... 7
URSO 250 .................................................................. 9
URSO FORTE ........................................................... 9
ursodiol ...................................................................... 9
V
VAGIFEM ............................................................... 10
valacyclovir hcl .......................................................... 6
VALCYTE ................................................................. 6
valproic acid .............................................................. 9
VALTREX ................................................................. 6
VALTURNA .............................................................. 3
VANOS ...................................................................... 4
Various generics ........................................................ 5
17
venlafaxine hcl ............................................................7

venlafaxine hcl er .......................................................7
VENTOLIN HFA .......................................................1
VERAMYST ..............................................................7
verapamil hcl ..............................................................3
verapamil hcl er ..........................................................3
VERDESO ..................................................................4
VESICARE.................................................................1
VEXOL.......................................................................5
VFEND .......................................................................6
VIAGRA.....................................................................7
VIBRAMYCIN ..........................................................6
VICTOZA...................................................................4
VIGAMOX .................................................................5
VIMOVO ....................................................................8
VIMPAT .....................................................................9
VIRACEPT.................................................................6
VIRAMUNE ...............................................................6
VIREAD .....................................................................6
vitamin d .....................................................................5
VIVELLE-DOT ........................................................10
VOLTAREN...........................................................5, 8
VOLTAREN-XR ........................................................8
voriconazole ...............................................................6
VOTRIENT ................................................................2
VUSION .....................................................................4
VYTORIN ..................................................................2
VYVANSE .................................................................1
W
warfarin sodium .........................................................1
WELCHOL.................................................................2
WELLBUTRIN ..........................................................7
WELLBUTRIN SR ....................................................7
WELLBUTRIN XL ....................................................7
X
XALATAN .................................................................5
XELODA ....................................................................2
XENAZINE ................................................................6
XENICAL.................................................................10
XERESE .....................................................................6
XIBROM ....................................................................5
XIFAXAN ..................................................................6
XOLEGEL ..................................................................4
XOPENEX .................................................................1
XYREM ......................................................................3
XYZAL.......................................................................1
Y
YASMIN 28 .............................................................10
YAZ ..........................................................................10
yohimbine hcl..............................................................7
Z
zafirlukast ...................................................................1
zaleplon.......................................................................8
ZAVESCA ..................................................................6
ZEGERID ...................................................................9
ZELAPAR ..................................................................9
Formulary Index
ZEMPLAR .................................................................5
ZENPEP .....................................................................9
ZETIA .........................................................................2
ZIAGEN .....................................................................6
ZIANA ........................................................................4
zidovudine ...................................................................6
ZINOTIC ....................................................................5
ZIPSOR ......................................................................8
ZMAX ........................................................................6
ZOCOR .......................................................................2
ZOFRAN ....................................................................9
ZOLINZA ...................................................................2
ZOLOFT .....................................................................7
zolpidem tartrate ........................................................8
zolpidem tartrate er ....................................................8
ZOLPIMIST ...............................................................8
ZOMIG .......................................................................8
ZOMIG ZMT ..............................................................8
zonisamide ..................................................................9
ZORBTIVE ................................................................5
ZORTRESS ................................................................6
zovia 1/35e ................................................................10
zovia 1/50e ................................................................10
ZOVIRAX ..................................................................6
ZUPLENZ ..................................................................9
ZYCLARA .................................................................3
ZYFLO .......................................................................1
ZYFLO CR .................................................................1
ZYLET .......................................................................5
ZYMAR ......................................................................5
ZYMAXID .................................................................5
ZYPREXA ..................................................................7
ZYPREXA ZYDIS .....................................................7
ZYVOX ......................................................................6
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2011 3-Tier Formulary Guide: Includes Generic and Brand-Name Medications

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2011 3-Tier Formulary Guide: Includes Generic and Brand-Name Medications

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April 2011

2011 3-Tier Formulary Guide

A nonprot independent licensee of the BlueCross BlueShield Association

Includes generic and brand-name medications

The 2011 3-Tier Formulary Guide lists commonly

Your prescription drug benefit is managed through our

A formulary is a list of brand name and generic

If you are not sure what category to look under,

How is the Formulary Developed?

3-Tier Drug Benefit

Tier One drugs are typically generics and have

Tier Two drugs are brand drugs that have

Tier Three drugs are all other brand drugs,

How do I use the formulary?

The 3-Tier Formulary Guide lists commonly used

Can the Formulary Change?

Generics Are Real Medicine

Generic Trial Program - Everyone Saves

Where Can I Purchase My

Mail Service Pharmacy

Are There Any Restrictions

Specialty Drug Benefit

filled, it may filled at any participating FLRx

Generic Advantage Program

Attention Deficit Disorder

Anaphylaxis Therapy Agents

Respiratory Drugs (oral)

Antihistamine / Decongestant Combination

ACE Inhibitors (high blood pressure)

Angiotensin II Receptor Blockers

Blood Cell Stimulation

ACE Inhibitors / Diuretic Combinations

Cardiovascular / Heart (continued)

Antitussives & Expectorants

Cryopyrin Associated Periodic Syndromes

Topical / Oral Acne Products

Calcium Channel Blockers

Central Nervous System

Beta Blockers (high blood pressure)

ST applies to selected benefits

Blood Glucose Supplies

ciclopirox nail lacquer

Topical / Oral Steroids

Growth Hormone / Factors

Inborn Errors of Metabolism

Antifungal Drugs (oral)

Inflammatory Bowel (continued)

Sedatives / Hypnotics / Anxiety

Mental Health (continued)

Pain Relievers (continued)

Pulmonary Arterial Hypertension

Antiemetics (for nausea)

Throat products - Miscellaneous

Prior Authorization List

The following prescription drugs require PRIOR AUTHORIZATION:

Growth Hormone / Factors

Trade Name: CINRYZE

Trade Name: BARACLUDE, EPIVIR HBV, HEPSERA, TYZEKA

Attention Deficit Disorder

Trade Name: AMPHETAMINE/DEXTROAMPHETAMINE

Trade Name: COPEGUS, PEG-INTRON, PEGASYS, RIBASPHERE,

Blood Cell Stimulation