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March 2015
Blue Cross and Blue Shield of Alabama Standard
Prescription Drug List
The Prescription Drug List is regularly updated. Please visit AlabamaBlue.com/pharmacy
and click on Prescription Drug Guides for the most up-to-date information.
Contents
Therapeutic Class Drug List
Introduction ...................................................................... I Anti-Infective Drugs ......................................................... 1
How Drugs are Selected .................................................. I Biologicals ..................................................................... 16
Coverage Considerations ................................................ I Antineoplastic Agents.................................................... 21
Member Prescription Benefit .......................................... II Endocrine and Metabolic Drugs .................................... 26
Brand Drugs and Generic Drugs .................................... II Cardiovascular Agents .................................................. 50
Generic Substitution ....................................................... II Respiratory Agents ........................................................ 75
Affordable Care Act ........................................................ II Gastrointestinal Agents ................................................. 83
Compound Drugs ........................................................... III Genitourinary Agents .................................................... 91
Contraceptives ............................................................... III Central Nervous System Drugs .................................... 94
Specialty ........................................................................ III Analgesics and Anesthetics ........................................ 118
Utilization Management ................................................. III Neuromuscular Drugs ................................................. 134
Step Therapy ................................................................. III Nutritional Products ..................................................... 145
Prior Authorization ......................................................... IV Hematological Agents ................................................. 148
Dispensing Limits........................................................... IV Topical Products ......................................................... 158
Limited Distribution Drugs ............................................. IV Miscellaneous Products .............................................. 177
Notice ............................................................................. IV Index............................................................................ 193
Key .................................................................................. V
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or
go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking
for and click on Search.
Prime Therapeutics LLC®, an independent company, provides pharmacy benefit management services for Blue Cross and Blue Shield of
Alabama, an independent licensee of the Blue Cross and Blue Shield Association.
4157-F AL HIM © Prime Therapeutics LLC 03/16
Introduction
The attached Blue Cross and Blue Shield of Alabama Standard Prescription Drug List shows covered drugs for
a broad range of diseases.
Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand
drug in (parentheses). Some generic products have no reference brand.
Brand prescription drugs are shown in capital letters followed by the generic name.
The Blue Cross and Blue Shield of Alabama Standard Prescription Drug List is organized into broad categories
(e.g. Anti-Infective drugs). Within most categories, drugs are sub-grouped by drug class (e.g. Penicillins) or by
use for a specific medical condition (e.g. Diabetes).
Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to
prescribe drugs on this list, when right for the member. However, decisions regarding therapy and treatment are
always between members and their physician.
The current version of this Prescription Drug List is available by visiting AlabamaBlue.com/pharmacy and
clicking on Prescription Drug Guides or by calling the customer service number listed on the back of your
identification card. Online pharmacy tools are available at AlabamaBlue.com/pharmacy. Blue Cross
members can find drug cost estimates or check if a particular drug is on the Standard Prescription Drug List.
How Drugs are Selected
Drugs on this list are selected based on the recommendations of a committee made up of physicians and
pharmacists from throughout the country. The committee, which includes at least one representative from the
health insurer or claims administrator of your health plan, reviews drugs regulated by the U.S. Food and Drug
Administration (FDA).
Both drugs that are newly approved by the FDA as well as those that have been on the market for some time
are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs
currently on the list.
Coverage Considerations
Coverage is limited to prescription products approved by the Food and Drug Administration (FDA) as evidenced
by a New Drug Application (NDA), Abbreviated New Drug Application (ANDA), or Biologics License Application
(BLA) on file. Any legal requirements or group specific benefits for coverage will supersede this (e.g. preventive
drugs per the Affordable Care Act). In addition, some plans may exclude coverage for certain agents or drug
categories, like those used for sexual dysfunction (example: Viagra) or infertility (example: Follistim AQ).
Most prescription drug benefit plans provide coverage for up to a 30- to 34-day supply of medication, with some
exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications.
Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood
pressure, diabetes or high cholesterol.
You should refer to your benefit plan booklet for details about your particular benefits.
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
I
Member Prescription Benefit
The Blue Cross prescription benefit is multi-tiered, placing prescription drugs into one of four tier levels;
Generic drugs and select Preferred Brand Drugs (Tier 1), Preferred Brand drugs (Tier 2), Other Brand
drugs (Tier 3) and Specialty drugs (Tier 4). Coverage and copayment/co-insurance levels vary depending
on the plan. Drugs that require Prior Authorization, Step Therapy, or that have Dispensing Limits or are
considered Limited Distribution are noted in the Prescription Drug List.
• Generic drugs and select Preferred Brand Drugs (Tier 1)
• Preferred Brand drugs (Tier 2)
• Other Brand drugs (Tier 3)
• Specialty drugs (Tier 4)
Note: An “NA” displayed in the drug tier field indicates the drug may only be covered if a member meets criteria
for $0 preventative coverage under the Affordable Care Act (ACA). If a member does not meet ACA coverage
criteria, these drugs are not covered under the plan and may be available over the counter without a prescription.
Brand Drugs and Generic Drugs
Classification
Prescription drugs are classified as either a Brand drug or a Generic drug. Blue Cross uses the Brand or
Generic status provided by a nationally recognized company providing drug product information. The
Brand/Generic status for a specific drug/specific marketer can sometimes change over the life of a
product in the marketplace and change from Brand to Generic or from Generic to Brand. Such changes
might change your copayment/co-insurance share. Brand drug or Generic drug status is never based
upon a product having a trade name. Generic drugs often have trade names.
Generic Substitution
Blue Cross encourages generic utilization as a way to provide high quality drugs at a reduced cost. Generic drugs
are as safe and effective as their brand counterparts, but are usually less expensive. Generic drugs are
manufactured under the same strict requirements of FDA’s current Good Manufacturing Practice regulations
required for Brand drugs and cover the manufacturing, and identity, strength, purity and quality.
An FDA-approved Generic drug may be substituted for the Brand counterpart when it:
• Contains the same active ingredient(s) as the brand drug;
• Is identical in strength, dosage form and route of administration; and
• Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile.
Affordable Care Act
Drugs marked with a dot in the ACA column may have limited or $0 cost-sharing under the Affordable Care Act if
certain criteria are met. Examples of categories of drugs that may be subject to limited or $0 cost share include
aspirin, breast cancer preventive, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn),
iron supplements, tobacco cessation, vaccines, vitamin D supplements, and some contraceptive drugs and
devices. If you do not find the drug you are searching for, consult or contact Blue Cross to find out if the drug is
available over the counter or is covered under your medical benefit. Please visit AlabamaBlue.com/pharmacy
and click on Prescription Drug Guides to obtain a list of drugs available under the ACA.
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
II
Compound Drugs
Compound drugs are defined as a drug product made or modified to have characteristics that are specifically
prescribed for an individual patient when commercial drug products are not available or appropriate. To be
eligible for coverage, compounded drugs must contain at least one FDA-approved prescription ingredient
and must not be a copy of a commercially available product. All compounded drugs are subject to review
and may require prior authorization. Drugs used in compounded drugs may be subject to additional coverage
criteria and utilization management edits. Compounds are covered only when medically necessary.
Compound drugs are always classified as the highest cost-sharing non-specialty drug Tier.
Contraceptives
Under the Affordable Care Act, members are afforded coverage for FDA approved contraceptive methods
and drugs at a $0 cost-share. If a contraceptive drug is available at $0 cost-share, it will be noted next to the
drug with a dot under the ACA column.
If you have health coverage through your employer, some or all of the contraceptive methods or prescription
drugs listed in this Prescription Drug Guide may not be covered under your plan because of your employer’s
religious beliefs. To find out if contraceptive methods and prescription drugs are excluded, you may find this
information in the exclusions section of your benefit booklet or you may contact your group administrator.
Specialty
Specialty drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and
rheumatoid arthritis. Specialty drugs covered under this prescription benefit may be oral or injectable
medications that are self-administered.
Some Blue Cross members must obtain their specialty drugs from Prime Therapeutics Specialty Pharmacy
as the preferred provider. If the preferred provider is not utilized you may be responsible for up to 100
percent of the drug cost. If you have questions about your coverage for specialty drugs or your prescription
drug benefit, call the number on the back of your ID card. You may also visit AlabamaBlue.com/pharmacy
and click on Prescription Drug Guides to obtain a complete listing of specialty drugs.
Utilization Management
Blue Cross is committed to supporting proper selection and use of drugs for its members. To help assure
these goals are met, several programs have been developed to promote drug selection that encourages both
effectiveness and safety. Detailed coverage criteria can be found by visiting AlabamaBlue.com/pharmacy
and clicking on Prescription Drug Guides. Drugs requiring Prior Authorization or Step Therapy, or drugs with
Dispensing Limits will be noted in the Therapeutic Class Drug List portion of the Prescription Drug List.
Step Therapy
Your benefit plan may include a step therapy program. This means you may need to try another proven,
cost-effective medication before coverage may be available for the drug included in the program. Many
brand drugs have less-expensive generic or brand alternatives that might be an option for you. If step
therapy is required for a medication listed in this document, it will be noted next to the medication with a dot
under the step therapy column.
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
III
Prior Authorization
Your benefit plan may require prior authorization for certain drugs that are high-cost or have the potential for
misuse. This means that your doctor will need to submit a prior authorization request for coverage of these
medications, and the request will need to be approved, before the medication will be covered under your
plan. If prior authorization is required for a medication listed in this document, it will be noted next to the
medication with a dot under the prior authorization column.
Dispensing Limits
Drug dispensing limits help encourage medication use as intended by the FDA. Dispensing limits are placed on
medications in certain drug categories. For the medications listed in this document, if a dispensing limit applies,
it will be noted next to the medication with a dot under the dispensing limits column.
Limits may include: quantity of covered medication per prescription and/or quantity of covered medication in a
given time period. If your doctor prescribes a greater quantity of medication than what the dispensing limit
allows, you can still get the medication. However, you will be responsible for the full cost of the prescription
beyond what your coverage allows. For a list of medications and their dispensing limits, visit
AlabamaBlue.com/pharmacy and click on Prescription Drug Guides.
There may also be limits for members within a certain age range, and coverage only for members of a
specific gender.
Limited Distribution Drugs
Limited distribution drugs have a restriction on where the member may fill the prescription. Blue Cross
members may be required to use Prime Therapeutics Specialty Pharmacy or other pharmacy designated by
the plan to fill a prescription. If a drug has limits on where it can be filled, it will be noted next to the drug with
a dot under the limited distribution column.
Notice
The purpose of the Blue Cross and Blue Shield of Alabama Standard Prescription Drug List is to provide a
guide to coverage. This Standard Prescription Drug List is not intended to dictate to physicians how to
practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most
appropriate for their patients.
Drug List, nor the successful adjudication of a pharmacy claim, is guarantee of payment
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
IV
Key
cap ................................................................. capsules
odt. ....................................... orally disintegrating tabs
chew ............................................................. chewable
oint ................................................................ ointment
conc ..........................................................concentrate
ophth ............................................................ opthalmic
cr...................................................... controlled release
osm ..................................................... osmotic release
dr ........................................................ delayed release
powd................................................................ powder
ec ........................................................... enteric coated
sa ....................................................... sustained action
effe............................................................ effervescent
sl .................................................................. sublingual
equiv ........................................................... equivalent
soln .................................................................. solution
er....................................................... extended release
sr ...................................................... sustained release
inhal.............................................................. inhalation
suppos ................................................... suppositories
inj .................................................................... injection
susp ........................................................... suspension
liq ......................................................................... liquid
tab ...................................................................... tablets
lotn ...................................................................... lotion
td ............................................................... transdermal
nebu .............................................................. nebulizer
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
V
1
1
AMOXICILLIN/CLAVULANATE
P - amoxicillin & k
clavulanate chew tab 400-57
mg
3
1
AMPICILLIN - ampicillin for
susp 125 mg/5ml
3
1
AMPICILLIN - ampicillin for
susp 250 mg/5ml
ampicillin cap 250 mg
1
1
amoxicillin (trihydrate) tab
500 mg
amoxicillin (trihydrate) tab
875 mg
amoxicillin & k clavulanate
for susp 200-28.5 mg/5ml
1
1
ampicillin cap 500 mg
1
AUGMENTIN - amoxicillin
& k clavulanate for susp
125-31.25 mg/5ml
3
AUGMENTIN - amoxicillin
& k clavulanate for susp
250-62.5 mg/5ml
3
AUGMENTIN - amoxicillin & k
clavulanate tab 500-125 mg
3
amoxicillin & k clavulanate
for susp 250-62.5 mg/5ml
(Augmentin)
1
amoxicillin & k clavulanate
for susp 400-57 mg/5ml
1
AUGMENTIN - amoxicillin & k
clavulanate tab 875-125 mg
3
amoxicillin & k clavulanate
for susp 600-42.9 mg/5ml
(Augmentin es-600)
1
AUGMENTIN ES-600 amoxicillin & k clavulanate
for susp 600-42.9 mg/5ml
3
amoxicillin & k clavulanate
tab sr 12hr 1000-62.5 mg
(Augmentin xr)
1
AUGMENTIN XR - amoxicillin
& k clavulanate tab sr 12hr
1000-62.5 mg
3
amoxicillin & k clavulanate
tab 250-125 mg
1
dicloxacillin sodium cap
250 mg
1
1
dicloxacillin sodium cap
500 mg
amoxicillin & k clavulanate
tab 500-125 mg
(Augmentin)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
1
1
Prior Authorization
Drug Tier
1
amoxicillin (trihydrate) cap
250 mg
amoxicillin (trihydrate) for
susp 400 mg/5ml
Limited Distribution
AMOXICILLIN/CLAVULANATE
P - amoxicillin & k
clavulanate chew tab
200-28.5 mg
3
amoxicillin (trihydrate) for
susp 250 mg/5ml
ACA Preventive
3
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 250 mg
amoxicillin (trihydrate) for
susp 200 mg/5ml
Dispensing Limits
AMOXICILLIN ER - amoxicillin
(trihydrate) tab sr 24hr 775
mg
3
amoxicillin (trihydrate) for
susp 125 mg/5ml
Step Therapy
1
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 125 mg
amoxicillin (trihydrate) cap
500 mg
Drug Name
amoxicillin & k clavulanate
tab 875-125 mg
(Augmentin)
ANTI-INFECTIVE AGENTS
PENICILLINS
Prior Authorization
Drug Name
Drug Tier
2015
1
1
MOXATAG - amoxicillin
(trihydrate) tab sr 24hr 775
mg
3
CEFDITOREN PIVOXIL cefditoren pivoxil tab 200 mg
(base equivalent)
3
penicillin v potassium for
soln 125 mg/5ml
1
3
1
CEFDITOREN PIVOXIL cefditoren pivoxil tab 400 mg
(base equivalent)
1
1
cefixime for susp
100 mg/5ml (Suprax)
1
cefixime for susp
200 mg/5ml (Suprax)
penicillin v potassium for
soln 250 mg/5ml
penicillin v potassium tab
250 mg
penicillin v potassium tab
500 mg
CEPHALOSPORINS
cefpodoxime proxetil for
susp 50 mg/5ml
CEDAX - ceftibuten cap 400
mg
3
cefpodoxime proxetil for
susp 100 mg/5ml
CEDAX - ceftibuten for susp 90
mg/5ml
3
cefpodoxime proxetil tab
100 mg
CEDAX - ceftibuten for susp
180 mg/5ml
3
cefpodoxime proxetil tab
200 mg
CEFACLOR - cefaclor for susp
125 mg/5ml
3
cefprozil for susp
125 mg/5ml
CEFACLOR - cefaclor for susp
250 mg/5ml
3
cefprozil for susp
250 mg/5ml
CEFACLOR - cefaclor for susp
375 mg/5ml
3
cefprozil tab 250 mg
cefaclor cap 250 mg
1
cefaclor cap 500 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
1
1
CEFTIN - cefuroxime axetil for
susp 250 mg/5ml
3
1
CEFTIN - cefuroxime axetil tab
250 mg
3
1
CEFTIN - cefuroxime axetil tab
500 mg
3
cefuroxime axetil tab 250 mg
(Ceftin)
1
cefuroxime axetil tab 500 mg
(Ceftin)
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
1
1
1
ACA Preventive
1
3
1
Dispensing Limits
1
CEFTIN - cefuroxime axetil for
susp 125 mg/5ml
1
Step Therapy
1
3
1
cefdinir cap 300 mg
1
CEFTIBUTEN - ceftibuten for
susp 180 mg/5ml
1
cefadroxil cap 500 mg
cefadroxil tab 1 gm
1
3
3
cefadroxil for susp
500 mg/5ml
1
CEFTIBUTEN - ceftibuten cap
400 mg
CEFACLOR ER - cefaclor
monohydrate tab sr 12hr 500
mg
cefadroxil for susp
250 mg/5ml
cefprozil tab 500 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
2
CEPHALEXIN - cephalexin tab
250 mg
3
CEPHALEXIN - cephalexin tab
500 mg
3
3
AZITHROMYCIN azithromycin powd pack for
susp 1 gm
1
cephalexin cap 250 mg
(Keflex)
1
azithromycin for susp
100 mg/5ml (Zithromax)
cephalexin cap 500 mg
(Keflex)
1
azithromycin for susp
200 mg/5ml (Zithromax)
1
cephalexin cap 750 mg
(Keflex)
1
azithromycin tab 250 mg
(Zithromax)
1
cephalexin for susp
125 mg/5ml
1
azithromycin tab 500 mg
(Zithromax)
1
1
azithromycin tab 600 mg
(Zithromax)
3
KEFLEX - cephalexin cap 250
mg
3
BIAXIN - clarithromycin for
susp 250 mg/5ml
KEFLEX - cephalexin cap 500
mg
3
KEFLEX - cephalexin cap 750
mg
3
SPECTRACEF - cefditoren
pivoxil tab 200 mg (base
equivalent)
3
SPECTRACEF - cefditoren
pivoxil tab 400 mg (base
equivalent)
3
SUPRAX - cefixime cap 400
mg
2
SUPRAX - cefixime chew tab
100 mg
2
SUPRAX - cefixime chew tab
200 mg
2
SUPRAX - cefixime for susp
100 mg/5ml
2
SUPRAX - cefixime for susp
200 mg/5ml
2
SUPRAX - cefixime for susp
500 mg/5ml
2
cephalexin for susp
250 mg/5ml
MACROLIDES
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
BIAXIN - clarithromycin tab 250 3
mg
BIAXIN - clarithromycin tab 500 3
mg
BIAXIN XL - clarithromycin tab 3
sr 24hr 500 mg
3
BIAXIN XL PAC clarithromycin tab sr 24hr
500 mg
1
clarithromycin for susp
125 mg/5ml
1
clarithromycin for susp
250 mg/5ml (Biaxin)
1
clarithromycin tab sr 24hr
500 mg (Biaxin xl pac)
1
clarithromycin tab 250 mg
(Biaxin)
1
clarithromycin tab 500 mg
(Biaxin)
3
DIFICID - fidaxomicin tab 200
mg
3
E.E.S. GRANULES erythromycin ethylsuccinate
for susp 200 mg/5ml
3
E.E.S. 400 - erythromycin
ethylsuccinate tab 400 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
3
ERY-TAB - erythromycin tab
delayed release 250 mg
3
ZITHROMAX - azithromycin
tab 600 mg
3
ERY-TAB - erythromycin tab
delayed release 333 mg
3
ZITHROMAX TRI-PAK azithromycin tab 500 mg
3
ERY-TAB - erythromycin tab
delayed release 500 mg
3
ZITHROMAX Z-PAK azithromycin tab 250 mg
3
ERYPED 200 - erythromycin
ethylsuccinate for susp 200
mg/5ml
3
ZMAX - azithromycin extended
release for oral susp 2 gm
3
ERYPED 400 - erythromycin
ethylsuccinate for susp 400
mg/5ml
3
ERYTHROCIN STEARATE erythromycin stearate tab
250 mg
3
ERYTHROMYCIN BASE erythromycin tab 250 mg
3
ERYTHROMYCIN BASE erythromycin tab 500 mg
3
ERYTHROMYCIN
ETHYLSUCCINA erythromycin ethylsuccinate
tab 400 mg
3
erythromycin w/ delayed
release particles cap
250 mg
TETRACYCLINES
ACTICLATE - doxycycline
hyclate tab 75 mg
3
•
ACTICLATE - doxycycline
hyclate tab 150 mg
3
•
ADOXA - doxycycline
monohydrate cap 150 mg
3
•
ADOXA - doxycycline
monohydrate tab 50 mg
3
•
ADOXA - doxycycline
monohydrate tab 75 mg
3
•
ADOXA - doxycycline
monohydrate tab 100 mg
3
•
3
1
ADOXA PAK 1/100 doxycycline monohydrate
tab 100 mg
•
3
3
•
PCE - erythromycin w/ enteric
coated particles tab 333 mg
ADOXA PAK 1/150 doxycycline monohydrate
tab 150 mg
PCE - erythromycin w/ enteric
coated particles tab 500 mg
3
3
•
ZITHROMAX - azithromycin for
susp 100 mg/5ml
3
ADOXA PAK 2/100 doxycycline monohydrate
tab 100 mg
1
ZITHROMAX - azithromycin for
susp 200 mg/5ml
3
demeclocycline hcl tab
150 mg
ZITHROMAX - azithromycin
powd pack for susp 1 gm
3
ZITHROMAX - azithromycin
tab 250 mg
3
ZITHROMAX - azithromycin
tab 500 mg
3
demeclocycline hcl tab
300 mg
Limited Distribution
ACA Preventive
1
DORYX - doxycycline hyclate
tab delayed release 50 mg
3
•
DORYX - doxycycline hyclate
tab delayed release 200 mg
3
•
doxycycline hyclate cap
50 mg
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
4
doxycycline hyclate cap
100 mg (Vibramycin)
1
1
minocycline hcl cap 75 mg
(Minocin)
1
minocycline hcl cap 100 mg
(Minocin)
1
minocycline hcl tab sr 24hr
45 mg
1
•
1
•
1
•
•
1
•
doxycycline hyclate tab
delayed release 150 mg
(Doryx)
1
•
doxycycline hyclate tab
20 mg
1
minocycline hcl tab sr 24hr
90 mg
1
minocycline hcl tab sr 24hr
135 mg
doxycycline hyclate tab
delayed release 100 mg
doxycycline hyclate tab
100 mg
doxycycline monohydrate
cap 50 mg
doxycycline monohydrate
cap 75 mg (Monodox)
doxycycline monohydrate
cap 100 mg (Monodox)
doxycycline monohydrate
cap 150 mg (Adoxa)
minocycline hcl tab 75 mg
minocycline hcl tab 100 mg
1
1
1
doxycycline monohydrate
for susp 25 mg/5ml
(Vibramycin)
1
doxycycline monohydrate
tab 50 mg (Adoxa)
1
doxycycline monohydrate
tab 75 mg (Adoxa)
minocycline hcl tab 50 mg
1
1
doxycycline monohydrate
tab 100 mg (Adoxa pak
1/100)
1
doxycycline monohydrate
tab 150 mg (Adoxa pak
1/150)
1
MINOCIN - minocycline hcl cap
50 mg
3
MINOCIN - minocycline hcl cap
75 mg
3
MINOCIN - minocycline hcl cap
100 mg
3
•
•
•
Limited Distribution
ACA Preventive
1
1
1
MONODOX - doxycycline
monohydrate cap 75 mg
3
•
MONODOX - doxycycline
monohydrate cap 100 mg
3
•
NUTRIDOX - doxycycline
monohyd cap 75 mg w/
omega 3-vit e cap kit
3
•
SOLODYN - minocycline hcl
tab sr 24hr 55 mg
3
•
SOLODYN - minocycline hcl
tab sr 24hr 65 mg
3
•
SOLODYN - minocycline hcl
tab sr 24hr 80 mg
3
•
SOLODYN - minocycline hcl
tab sr 24hr 105 mg
3
•
SOLODYN - minocycline hcl
tab sr 24hr 115 mg
3
•
TARGADOX - doxycycline
hyclate tab 50 mg
3
•
TETRACYCLINE HCL tetracycline hcl cap 250 mg
3
TETRACYCLINE HCL tetracycline hcl cap 500 mg
3
VIBRAMYCIN - doxycycline
calcium syrup 50 mg/5ml
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Dispensing Limits
Step Therapy
minocycline hcl cap 50 mg
(Minocin)
1
doxycycline hyclate tab
delayed release 75 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
5
FLUOROQUINOLONES
AVELOX - moxifloxacin hcl tab
400 mg (base equiv)
3
AVELOX ABC PACK moxifloxacin hcl tab 400 mg
(base equiv)
3
CIPRO - ciprofloxacin for oral
susp 250 mg/5ml (5%) (5
gm/100ml)
3
CIPRO - ciprofloxacin for oral
susp 500 mg/5ml (10%) (10
gm/100ml)
3
CIPRO - ciprofloxacin hcl tab
250 mg (base equiv)
3
CIPRO - ciprofloxacin hcl tab
500 mg (base equiv)
3
CIPRO XR - ciprofloxacinciprofloxacin hcl tab sr 24hr
500 mg (base eq)
3
CIPRO XR - ciprofloxacinciprofloxacin hcl tab sr 24hr
1000 mg(base eq)
3
ciprofloxacin for oral
susp 250 mg/5ml (5%)
(5 gm/100ml) (Cipro)
1
ciprofloxacin for oral
susp 500 mg/5ml (10%)
(10 gm/100ml) (Cipro)
1
CIPROFLOXACIN HCL ciprofloxacin hcl tab 100 mg
(base equiv)
3
ciprofloxacin hcl tab 250 mg
(base equiv) (Cipro)
ciprofloxacin hcl tab 500 mg
(base equiv) (Cipro)
ciprofloxacin-ciprofloxacin
hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)
Limited Distribution
ACA Preventive
Dispensing Limits
•
Step Therapy
3
ciprofloxacin hcl tab 750 mg
(base equiv)
Prior Authorization
VIBRAMYCIN - doxycycline
monohydrate for susp 25
mg/5ml
Drug Name
Drug Tier
•
Limited Distribution
3
ACA Preventive
VIBRAMYCIN - doxycycline
hyclate cap 100 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
ciprofloxacin-ciprofloxacin
hcl tab sr 24hr
1000 mg(base eq) (Cipro xr)
3
FACTIVE - gemifloxacin
mesylate tab 320 mg (base
equiv)
3
LEVAQUIN - levofloxacin tab
250 mg
3
LEVAQUIN - levofloxacin tab
500 mg
3
LEVAQUIN - levofloxacin tab
750 mg
levofloxacin oral soln 25 mg/ 1
ml (Levaquin)
1
levofloxacin tab 250 mg
(Levaquin)
1
levofloxacin tab 500 mg
(Levaquin)
1
levofloxacin tab 750 mg
(Levaquin)
1
moxifloxacin hcl tab 400 mg
(base equiv) (Avelox)
3
OFLOXACIN - ofloxacin tab
400 mg
AMINOGLYCOSIDES
amikacin sulfate inj
500 mg/2ml (250 mg/ml)
amikacin sulfate inj
1 gm/4ml (250 mg/ml)
1
1
4
1
BETHKIS - tobramycin nebu
soln 300 mg/4ml
•
•
4
1
KITABIS PAK - tobramycin
nebu soln 300 mg/5ml
•
•
neomycin sulfate tab 500 mg
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
6
paromomycin sulfate cap
250 mg
1
•
•
TOBI - tobramycin nebu soln
300 mg/5ml
4
TOBI PODHALER - tobramycin
inhal cap 28 mg
4
•
•
tobramycin nebu soln
300 mg/5ml (Tobi)
4
•
•
tobramycin sulfate for inj
1.2 gm
tobramycin sulfate inj
10 mg/ml
tobramycin sulfate inj
80 mg/2ml (40 mg/ml)
tobramycin sulfate inj
1.2 gm/30ml (40 mg/ml)
tobramycin sulfate inj
2 gm/50ml (40 mg/ml)
SULFONAMIDES
SULFADIAZINE - sulfadiazine
tab 500 mg
PRIFTIN - rifapentine tab 150
mg
2
pyrazinamide tab 500 mg
1
rifabutin cap 150 mg
(Mycobutin)
1
RIFADIN - rifampin cap 150 mg
3
RIFADIN - rifampin cap 300 mg
3
1
RIFAMATE - isoniazid &
rifampin cap 150-300 mg
3
1
rifampin cap 150 mg (Rifadin) 1
rifampin cap 300 mg (Rifadin) 1
1
1
1
3
RIFATER - isoniazid-rifampin
w/ pyrazinamide tab
50-120-300 mg
3
SEROMYCIN - cycloserine cap
250 mg
3
SIRTURO - bedaquiline
fumarate tab 100 mg (base
equiv)
3
TRECATOR - ethionamide tab
250 mg
3
ANTIMYCOBACTERIAL AGENTS
3
CYCLOSERINE - cycloserine
cap 250 mg
1
ethambutol hcl tab 100 mg
(Myambutol)
1
ethambutol hcl tab 400 mg
(Myambutol)
ISONIAZID - isoniazid syrup 50 3
mg/5ml
1
isoniazid tab 100 mg
ANTIFUNGALS
isoniazid tab 300 mg
1
MYAMBUTOL - ethambutol hcl
tab 100 mg
3
MYAMBUTOL - ethambutol hcl
tab 400 mg
3
MYCOBUTIN - rifabutin cap
150 mg
3
PASER - aminosalicylic acid cr
granules packet 4 gm
3
ANCOBON - flucytosine cap
250 mg
3
ANCOBON - flucytosine cap
500 mg
3
CRESEMBA isavuconazonium sulfate cap
186 mg
3
DIFLUCAN - fluconazole for
susp 10 mg/ml
3
DIFLUCAN - fluconazole for
susp 40 mg/ml
3
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
DIFLUCAN - fluconazole tab 50 3
mg
3
DIFLUCAN - fluconazole tab
100 mg
3
DIFLUCAN - fluconazole tab
150 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
7
DIFLUCAN - fluconazole tab
200 mg
3
NOXAFIL - posaconazole susp
40 mg/ml
2
fluconazole for susp 10 mg/
ml (Diflucan)
1
NOXAFIL - posaconazole tab
delayed release 100 mg
2
1
nystatin tab 500000 unit
1
1
ONMEL - itraconazole tab 200
mg
3
fluconazole tab 50 mg
(Diflucan)
1
SPORANOX - itraconazole cap
100 mg
3
fluconazole tab 100 mg
(Diflucan)
SPORANOX - itraconazole oral
soln 10 mg/ml
3
fluconazole tab 150 mg
(Diflucan)
1
SPORANOX PULSEPAK itraconazole cap 100 mg
3
fluconazole tab 200 mg
(Diflucan)
1
terbinafine hcl tab 250 mg
(Lamisil)
1
flucytosine cap 250 mg
(Ancobon)
1
1
VFEND - voriconazole for susp
40 mg/ml
3
flucytosine cap 500 mg
(Ancobon)
VFEND - voriconazole tab 50
mg
3
GRIS-PEG - griseofulvin
ultramicrosize tab 125 mg
3
VFEND - voriconazole tab 200
mg
3
GRIS-PEG - griseofulvin
ultramicrosize tab 250 mg
3
voriconazole for susp
40 mg/ml (Vfend)
1
griseofulvin microsize susp
125 mg/5ml
1
1
voriconazole tab 50 mg
(Vfend)
1
1
voriconazole tab 200 mg
(Vfend)
1
fluconazole for susp 40 mg/
ml (Diflucan)
griseofulvin microsize tab
500 mg (Grifulvin v)
griseofulvin ultramicrosize
tab 125 mg (Gris-peg)
griseofulvin ultramicrosize
tab 250 mg (Gris-peg)
1
itraconazole cap 100 mg
(Sporanox)
1
ketoconazole tab 200 mg
1
LAMISIL - terbinafine hcl oral
granules packet 125 mg
3
LAMISIL - terbinafine hcl oral
granules packet 187.5 mg
LAMISIL - terbinafine hcl tab
250 mg
ANTIVIRALS
abacavir sulfate tab 300 mg
(base equiv) (Ziagen)
abacavir sulfatelamivudine-zidovudine tab
300-150-300 mg (Trizivir)
•
1
•
1
3
acyclovir susp 200 mg/5ml
(Zovirax)
1
3
acyclovir tab 400 mg
(Zovirax)
1
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
acyclovir cap 200 mg
(Zovirax)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
8
•
EDURANT - rilpivirine hcl tab
25 mg (base equivalent)
3
•
EMTRIVA - emtricitabine caps
200 mg
3
•
EMTRIVA - emtricitabine soln
10 mg/ml
3
•
entecavir tab 0.5 mg
(Baraclude)
1
entecavir tab 1 mg
(Baraclude)
1
BARACLUDE - entecavir oral
soln 0.05 mg/ml
2
EPIVIR - lamivudine oral soln
10 mg/ml
3
BARACLUDE - entecavir tab
0.5 mg
3
•
3
3
BARACLUDE - entecavir tab 1
mg
EPIVIR - lamivudine tab 150
mg
•
3
•
EPIVIR - lamivudine tab 300
mg
3
COMBIVIR - lamivudinezidovudine tab 150-300 mg
•
•
EPIVIR HBV - lamivudine oral
soln 5 mg/ml (hbv)
3
COMPLERA - emtricitabinerilpivirine-tenofovir df tab
200-25-300 mg
2
3
COPEGUS - ribavirin tab 200
mg
4
EPIVIR HBV - lamivudine tab
100 mg (hbv)
2
•
CRIXIVAN - indinavir sulfate
cap 200 mg
3
•
EPZICOM - abacavir sulfatelamivudine tab 600-300 mg
2
•
CRIXIVAN - indinavir sulfate
cap 400 mg
3
•
EVOTAZ - atazanavir sulfatecobicistat tab 300-150 mg
(base equiv)
famciclovir tab 125 mg
(Famvir)
1
DAKLINZA - daclatasvir
dihydrochloride tab 30 mg
(base equivalent)
4
1
DAKLINZA - daclatasvir
dihydrochloride tab 60 mg
(base equivalent)
4
famciclovir tab 250 mg
(Famvir)
famciclovir tab 500 mg
(Famvir)
1
didanosine delayed release
capsule 125 mg (Videx ec)
1
•
FAMVIR - famciclovir tab 125
mg
3
1
•
FAMVIR - famciclovir tab 250
mg
3
1
•
FAMVIR - famciclovir tab 500
mg
3
1
adefovir dipivoxil tab 10 mg
(Hepsera)
1
APTIVUS - tipranavir cap 250
mg
3
•
APTIVUS - tipranavir oral soln
100 mg/ml
3
•
ATRIPLA - efavirenzemtricitabine-tenofovir df tab
600-200-300 mg
2
•
didanosine delayed release
capsule 200 mg (Videx ec)
didanosine delayed release
capsule 250 mg (Videx ec)
didanosine delayed release
capsule 400 mg (Videx ec)
•
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
1
acyclovir tab 800 mg
(Zovirax)
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
9
3
FUZEON - enfuvirtide for inj 90
mg
4
•
GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab
150-150-200-10 mg
3
•
HARVONI - ledipasvirsofosbuvir tab 90-400 mg
4
HEPSERA - adefovir dipivoxil
tab 10 mg
3
INTELENCE - etravirine tab 25
mg
2
•
INTELENCE - etravirine tab
100 mg
2
•
INTELENCE - etravirine tab
200 mg
2
•
INVIRASE - saquinavir
mesylate cap 200 mg
3
•
INVIRASE - saquinavir
mesylate tab 500 mg
3
•
ISENTRESS - raltegravir
potassium chew tab 25 mg
(base equiv)
2
•
ISENTRESS - raltegravir
potassium chew tab 100 mg
(base equiv)
2
•
ISENTRESS - raltegravir
potassium packet for susp
100 mg (base equiv)
2
•
ISENTRESS - raltegravir
potassium tab 400 mg (base
equiv)
2
•
KALETRA - lopinavir-ritonavir
soln 400-100 mg/5ml (80-20
mg/ml)
2
•
KALETRA - lopinavir-ritonavir
tab 100-25 mg
2
•
NORVIR - ritonavir oral soln 80
mg/ml
2
•
•
KALETRA - lopinavir-ritonavir
tab 200-50 mg
2
•
NORVIR - ritonavir tab 100 mg
2
•
OLYSIO - simeprevir sodium
cap 150 mg (base
equivalent)
4
•
•
•
Limited Distribution
ACA Preventive
Dispensing Limits
•
FLUMADINE - rimantadine
hydrochloride tab 100 mg
lamivudine oral soln 10 mg/
ml (Epivir)
1
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
lamivudine tab 100 mg (hbv)
(Epivir hbv)
1
lamivudine tab 150 mg
(Epivir)
1
•
lamivudine tab 300 mg
(Epivir)
1
•
lamivudine-zidovudine tab
150-300 mg (Combivir)
1
•
LEXIVA - fosamprenavir
calcium susp 50 mg/ml
(base equiv)
3
•
LEXIVA - fosamprenavir
calcium tab 700 mg (base
equiv)
3
•
MODERIBA - ribavirin tab 200
mg & ribavirin tab 400 mg
dose pack
4
•
MODERIBA - ribavirin tab 400
mg & ribavirin tab 600 mg
dose pack
4
•
MODERIBA 1200 DOSE
PACK - ribavirin tab 600 mg
4
•
MODERIBA 800 DOSE PACK - 4
ribavirin tab 400 mg
NEVIRAPINE - nevirapine susp 3
50 mg/5ml
1
nevirapine tab sr 24hr
100 mg
1
nevirapine tab sr 24hr
400 mg (Viramune xr)
1
nevirapine tab 200 mg
(Viramune)
NORVIR - ritonavir cap 100 mg 3
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
•
•
•
•
10
4
•
•
PEG-INTRON - peginterferon
alfa-2b for inj kit 120
mcg/0.5ml
4
•
•
PEG-INTRON - peginterferon
alfa-2b for inj kit 150
mcg/0.5ml
4
•
•
PEG-INTRON REDIPEN peginterferon alfa-2b for inj
kit 50 mcg/0.5ml
4
•
•
PEG-INTRON REDIPEN peginterferon alfa-2b for inj
kit 80 mcg/0.5ml
4
•
•
PEG-INTRON REDIPEN peginterferon alfa-2b for inj
kit 120 mcg/0.5ml
4
•
•
PEG-INTRON REDIPEN peginterferon alfa-2b for inj
kit 150 mcg/0.5ml
4
•
PEG-INTRON REDIPEN PAK
4 - peginterferon alfa-2b for
inj kit 50 mcg/0.5ml
4
PEG-INTRON REDIPEN PAK
4 - peginterferon alfa-2b for
inj kit 80 mcg/0.5ml
4
PEG-INTRON REDIPEN PAK
4 - peginterferon alfa-2b for
inj kit 120 mcg/0.5ml
Limited Distribution
PEG-INTRON - peginterferon
alfa-2b for inj kit 80
mcg/0.5ml
ACA Preventive
PEGASYS PROCLICK peginterferon alfa-2a inj 135
mcg/0.5ml
4
•
PEGASYS PROCLICK peginterferon alfa-2a inj 180
mcg/0.5ml
4
•
•
PEGINTRON - peginterferon
alfa-2b for inj kit 50
mcg/0.5ml
4
•
•
PEGINTRON - peginterferon
alfa-2b for inj kit 80
mcg/0.5ml
4
•
•
PEGINTRON - peginterferon
alfa-2b for inj kit 120
mcg/0.5ml
4
•
•
PEGINTRON - peginterferon
alfa-2b for inj kit 150
mcg/0.5ml
4
•
•
PREZCOBIX - darunavircobicistat tab 800-150 mg
2
•
•
PREZISTA - darunavir
ethanolate susp 100 mg/ml
(base equiv)
2
•
•
PREZISTA - darunavir
ethanolate tab 75 mg (base
equiv)
2
•
•
•
PREZISTA - darunavir
ethanolate tab 150 mg (base
equiv)
2
•
4
•
•
PREZISTA - darunavir
ethanolate tab 600 mg (base
equiv)
2
•
•
•
PREZISTA - darunavir
ethanolate tab 800 mg (base
equiv)
2
PEG-INTRON REDIPEN PAK
4 - peginterferon alfa-2b for
inj kit 150 mcg/0.5ml
4
•
•
•
REBETOL - ribavirin cap 200
mg
4
PEGASYS - peginterferon
alfa-2a inj 180 mcg/ml
4
•
4
•
•
REBETOL - ribavirin soln 40
mg/ml
4
PEGASYS - peginterferon
alfa-2a inj 180 mcg/0.5ml
•
RELENZA DISKHALER zanamivir aero powder
breath activated 5 mg/blister
3
•
•
Dispensing Limits
•
Step Therapy
4
Prior Authorization
PEG-INTRON - peginterferon
alfa-2b for inj kit 50
mcg/0.5ml
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
11
3
•
RETROVIR - zidovudine cap
100 mg
3
•
RETROVIR - zidovudine syrup
10 mg/ml
3
•
REYATAZ - atazanavir sulfate
cap 150 mg (base equiv)
2
•
REYATAZ - atazanavir sulfate
cap 200 mg (base equiv)
2
•
REYATAZ - atazanavir sulfate
cap 300 mg (base equiv)
2
•
REYATAZ - atazanavir sulfate
oral powder packet 50 mg
(base equiv)
3
RIBASPHERE - ribavirin tab
400 mg
4
•
stavudine for oral soln 1 mg/
ml (Zerit)
RIBASPHERE - ribavirin tab
600 mg
4
•
RIBASPHERE RIBAPAK ribavirin tab 400 mg
4
•
RIBASPHERE RIBAPAK ribavirin tab 600 mg
4
•
RIBASPHERE RIBAPAK ribavirin tab 200 mg &
ribavirin tab 400 mg dose
pack
4
•
RIBASPHERE RIBAPAK ribavirin tab 400 mg &
ribavirin tab 600 mg dose
pack
4
RIBATAB - ribavirin tab 400 mg
4
RIBATAB - ribavirin tab 600 mg
4
RIBATAB - ribavirin tab 400 mg
& ribavirin tab 600 mg dose
pack
4
ribavirin cap 200 mg
(Rebetol)
4
4
rimantadine hydrochloride
tab 100 mg (Flumadine)
1
SELZENTRY - maraviroc tab
150 mg
3
•
SELZENTRY - maraviroc tab
300 mg
3
•
SITAVIG - acyclovir buccal tab
50 mg
3
SOVALDI - sofosbuvir tab 400
mg
4
stavudine cap 15 mg (Zerit)
1
1
STRIBILD - elvitegrav-cobicisemtricitab-tenofov tab
150-150-200-300 mg
2
•
SUSTIVA - efavirenz cap 50
mg
2
•
SUSTIVA - efavirenz cap 200
mg
2
•
SUSTIVA - efavirenz tab 600
mg
2
•
TAMIFLU - oseltamivir
phosphate cap 30 mg (base
equiv)
2
•
TAMIFLU - oseltamivir
phosphate cap 45 mg (base
equiv)
2
•
TAMIFLU - oseltamivir
phosphate cap 75 mg (base
equiv)
2
•
TAMIFLU - oseltamivir
phosphate for susp 6 mg/ml
(base equiv)
2
•
stavudine cap 30 mg (Zerit)
stavudine cap 40 mg (Zerit)
•
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
1
1
1
•
•
•
•
•
•
•
stavudine cap 20 mg (Zerit)
•
•
Limited Distribution
RESCRIPTOR - delavirdine
mesylate tab 200 mg
ribavirin tab 200 mg
(Copegus)
ACA Preventive
•
Dispensing Limits
3
Step Therapy
RESCRIPTOR - delavirdine
mesylate tab 100 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
12
•
VIDEX EC - didanosine
delayed release capsule 200
mg
3
•
VIDEX EC - didanosine
delayed release capsule 250
mg
3
•
VIDEX EC - didanosine
delayed release capsule 400
mg
3
•
VIEKIRA PAK - ombitasparitapre-riton & dasab tab
pak 12.5-75-50 & 250 mg
4
3
•
3
VIRACEPT - nelfinavir
mesylate tab 250 mg
3
•
valacyclovir hcl tab 500 mg
(Valtrex)
1
VIRACEPT - nelfinavir
mesylate tab 625 mg
2
•
valacyclovir hcl tab 1 gm
(Valtrex)
1
VIRAMUNE - nevirapine susp
50 mg/5ml
3
•
VALCYTE - valganciclovir hcl
for soln 50 mg/ml (base
equiv)
2
VIRAMUNE - nevirapine tab
200 mg
VIRAMUNE XR - nevirapine
tab sr 24hr 100 mg
2
•
VALCYTE - valganciclovir
hcl tab 450 mg (base
equivalent)
3
VIRAMUNE XR - nevirapine
tab sr 24hr 400 mg
3
•
1
VIRAZOLE - ribavirin for inhal
soln 6 gm
3
valganciclovir hcl tab
450 mg (base equivalent)
(Valcyte)
2
•
VALTREX - valacyclovir hcl tab
500 mg
3
VIREAD - tenofovir disoproxil
fumarate oral powder 40 mg/
gm
VIREAD - tenofovir disoproxil
fumarate tab 150 mg
2
VALTREX - valacyclovir hcl tab
1 gm
3
•
VIREAD - tenofovir disoproxil
fumarate tab 200 mg
2
VICTRELIS - boceprevir cap
200 mg
4
•
2
•
VIREAD - tenofovir disoproxil
fumarate tab 250 mg
2
VIDEX - didanosine for soln 2
gm
•
•
VIREAD - tenofovir disoproxil
fumarate tab 300 mg
2
VIDEX - didanosine for soln 4
gm
2
•
TIVICAY - dolutegravir sodium
tab 50 mg (base equiv)
2
•
TRIUMEQ - abacavirdolutegravir-lamivudine tab
600-50-300 mg
2
•
TRIZIVIR - abacavir sulfatelamivudine-zidovudine tab
300-150-300 mg
3
TRUVADA - emtricitabinetenofovir disoproxil fumarate
tab 200-300 mg
2
TYBOST - cobicistat tab 150
mg
3
TYZEKA - telbivudine tab 600
mg
•
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
Limited Distribution
3
4
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
VIDEX EC - didanosine
delayed release capsule 125
mg
TECHNIVIE - ombitasvirparitaprevir-ritonavir tab
12.5-75-50 mg
•
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
13
3
ZERIT - stavudine cap 20 mg
3
ZERIT - stavudine cap 30 mg
3
ZERIT - stavudine cap 40 mg
3
ZERIT - stavudine for oral soln
1 mg/ml
3
•
•
•
•
•
ZIAGEN - abacavir sulfate soln
20 mg/ml (base equiv)
2
•
ZIAGEN - abacavir sulfate tab
300 mg (base equiv)
3
•
zidovudine cap 100 mg
(Retrovir)
1
•
zidovudine syrup 10 mg/ml
(Retrovir)
1
zidovudine tab 300 mg
1
2
hydroxychloroquine sulfate
tab 200 mg (Plaquenil)
1
MALARONE - atovaquoneproguanil hcl tab 62.5-25 mg
3
MALARONE - atovaquoneproguanil hcl tab 250-100
mg
3
mefloquine hcl tab 250 mg
1
3
2
•
PRIMAQUINE PHOSPHATE primaquine phosphate tab
26.3 mg (15 mg base)
•
QUALAQUIN - quinine sulfate
cap 324 mg
3
•
1
•
3
quinine sulfate cap 324 mg
(Qualaquin)
ZOVIRAX - acyclovir susp 200
mg/5ml
3
ANTHELMINTICS
3
2
ZOVIRAX - acyclovir tab 400
mg
ALBENZA - albendazole tab
200 mg
3
BILTRICIDE - praziquantel tab
600 mg
2
ZOVIRAX - acyclovir tab 800
mg
ivermectin tab 3 mg
(Stromectol)
1
3
ANTIMALARIALS
ARALEN - chloroquine
phosphate tab 500 mg
3
STROMECTOL - ivermectin
tab 3 mg
atovaquone-proguanil hcl
tab 62.5-25 mg (Malarone)
1
ANTI-INFECTIVE AGENTS - MISC.
ALINIA - nitazoxanide for susp 3
100 mg/5ml
3
ALINIA - nitazoxanide tab 500
mg
1
atovaquone susp
750 mg/5ml (Mepron)
BACTRIM - sulfamethoxazole- 3
trimethoprim tab 400-80 mg
atovaquone-proguanil hcl
tab 250-100 mg (Malarone)
chloroquine phosphate tab
250 mg
chloroquine phosphate tab
500 mg (Aralen)
1
1
1
•
PLAQUENIL hydroxychloroquine sulfate
tab 200 mg
ZOVIRAX - acyclovir cap 200
mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ZERIT - stavudine cap 15 mg
DARAPRIM - pyrimethamine
tab 25 mg
ACA Preventive
•
Dispensing Limits
3
3
Step Therapy
VITEKTA - elvitegravir tab 150
mg
COARTEM - artemetherlumefantrine tab 20-120 mg
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
VITEKTA - elvitegravir tab 85
mg
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
14
BACTRIM DS sulfamethoxazoletrimethoprim tab 800-160 mg
3
CAYSTON - aztreonam lysine
for inhal soln 75 mg (base
equivalent)
4
CLEOCIN - clindamycin hcl cap 3
75 mg
CLEOCIN - clindamycin hcl cap 3
150 mg
CLEOCIN - clindamycin hcl cap 3
300 mg
3
CLEOCIN PEDIATRIC
GRANULE - clindamycin
palmitate hcl for soln 75
mg/5ml (base equiv)
1
clindamycin hcl cap 75 mg
(Cleocin)
1
clindamycin hcl cap 150 mg
(Cleocin)
1
clindamycin hcl cap 300 mg
(Cleocin)
1
clindamycin palmitate hcl
for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)
2
DAPSONE - dapsone tab 25
mg
2
DAPSONE - dapsone tab 100
mg
3
FLAGYL - metronidazole cap
375 mg
3
FLAGYL - metronidazole tab
250 mg
3
FLAGYL - metronidazole tab
500 mg
3
FLAGYL ER - metronidazole
tab sr 24hr 750 mg
3
KETEK - telithromycin tab 300
mg
3
KETEK - telithromycin tab 400
mg
linezolid for susp
100 mg/5ml (Zyvox)
•
•
linezolid tab 600 mg (Zyvox)
metronidazole cap 375 mg
(Flagyl)
1
metronidazole tab 250 mg
(Flagyl)
1
metronidazole tab 500 mg
(Flagyl)
1
NEBUPENT - pentamidine
isethionate for nebulization
soln 300 mg
3
PRIMSOL - trimethoprim hcl
oral soln 50 mg/5ml (base
equiv)
3
SIVEXTRO - tedizolid
phosphate tab 200 mg
3
sulfamethoxazoletrimethoprim susp
200-40 mg/5ml
1
Limited Distribution
ACA Preventive
1
1
TINDAMAX - tinidazole tab 250
mg
3
TINDAMAX - tinidazole tab 500
mg
3
tinidazole tab 250 mg
(Tindamax)
1
tinidazole tab 500 mg
(Tindamax)
1
trimethoprim tab 100 mg
1
VANCOCIN HCL - vancomycin
hcl cap 125 mg
3
VANCOCIN HCL - vancomycin
hcl cap 250 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Dispensing Limits
1
3
sulfamethoxazoletrimethoprim tab
800-160 mg (Bactrim ds)
Step Therapy
1
MEPRON - atovaquone susp
750 mg/5ml
sulfamethoxazoletrimethoprim tab
400-80 mg (Bactrim)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
15
vancomycin hcl cap 125 mg
(Vancocin hcl)
1
vancomycin hcl cap 250 mg
(Vancocin hcl)
1
XIFAXAN - rifaximin tab 200
mg
3
XIFAXAN - rifaximin tab 550
mg
2
ZYVOX - linezolid for susp 100
mg/5ml
2
ZYVOX - linezolid tab 600 mg
3
BIOLOGICALS
AFLURIA 2014-2015 influenza virus vaccine split
im susp
3
AFLURIA 2015-2016 influenza virus vaccine split
im susp
3
BEXSERO - meningococcal
vac b (recomb adsorbed) inj
prefilled syringe
3
CERVARIX - human
papillomavirus (hpv) bival
(type 16, 18) recmb vac inj
3
3
ACTHIB - haemophilus b
polysaccharide conjugate
vaccine for inj
3
COMVAX - haemophilus b
polysac conj-hepatitis b
(recomb) vac im susp
3
AFLURIA PF 2011-2012 influenza virus vaccine split
pf susp pref syringe 0.5 ml
3
ENGERIX-B - hepatitis b
vaccine (recombinant) susp
10 mcg/0.5ml
3
AFLURIA PF 2012-2013 influenza virus vaccine split
pf susp pref syringe 0.5 ml
3
ENGERIX-B - hepatitis b
vaccine (recombinant) susp
20 mcg/ml
3
AFLURIA PF 2013-2014 influenza virus vaccine split
pf susp pref syringe 0.5 ml
3
ENGERIX-B - hepatitis b
vaccine (recombinant) 10
mcg/0.5ml
3
AFLURIA PF 2014-2015 influenza virus vaccine split
pf susp pref syringe 0.5 ml
3
ENGERIX-B - hepatitis b
vaccine (recombinant) 20
mcg/ml
3
AFLURIA PF 2015-2016 influenza virus vaccine split
pf susp pref syringe 0.5 ml
3
FLUARIX QUADRIVALENT
2013 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
3
AFLURIA 2011-2012 influenza virus vaccine split
im susp
3
FLUARIX QUADRIVALENT
2014 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
AFLURIA 2012-2013 influenza virus vaccine split
im susp
3
3
AFLURIA 2013-2014 influenza virus vaccine split
im susp
3
FLUARIX QUADRIVALENT
2015 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
FLUARIX 2011-2012 influenza virus vaccine split
pf susp pref syringe 0.5 ml
3
VACCINES
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
16
FLUARIX 2012-2013 influenza virus vaccine split
pf susp pref syringe 0.5 ml
3
FLULAVAL 2013-2014 influenza virus vaccine split
im susp
3
FLUARIX 2013-2014 influenza virus vaccine split
pf susp pref syringe 0.5 ml
3
FLULAVAL 2014-2015 influenza virus vaccine split
im susp
3
FLUARIX 2014-2015 influenza virus vaccine split
pf susp pref syringe 0.5 ml
3
FLUMIST QUADRIVALENT influenza virus vaccine live
quadrivalent intranasal susp
3
FLUBLOK 2013-2014 influenza virus vac
recombinant hemagglutinin
(ha) inj
3
FLUVIRIN PF 2011-2012 influenza virus vac types a &
b pf susp prefilled syr 0.5 ml
3
FLUVIRIN PF 2012-2013 influenza virus vac types a &
b pf susp prefilled syr 0.5 ml
3
FLUBLOK 2014-2015 influenza virus vac
recombinant hemagglutinin
(ha) inj
3
3
FLUBLOK 2015-2016 influenza virus vac
recombinant hemagglutinin
(ha) inj
3
FLUVIRIN PF 2013-2014 influenza virus vac types a &
b pf susp prefilled syr 0.5 ml
3
FLUCELVAX 2013-2014 influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml
3
FLUVIRIN PF 2014-2015 influenza virus vac types a &
b pf susp prefilled syr 0.5 ml
3
FLUCELVAX 2014-2015 influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml
3
FLUVIRIN 2011-2012 influenza virus vaccine types
a & b surface antigen im
susp
3
FLUCELVAX 2015-2016 influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml
3
FLUVIRIN 2012-2013 influenza virus vaccine types
a & b surface antigen im
susp
3
FLUVIRIN 2013-2014 influenza virus vaccine types
a & b surface antigen im
susp
3
FLULAVAL QUADRIVALENT
201 - influenza virus vac split
quadrivalent susp pref syr
0.5ml
FLUVIRIN 2014-2015 influenza virus vaccine types
a & b surface antigen im
susp
3
FLULAVAL QUADRIVALENT
201 - influenza virus vaccine
split quadrivalent im inj
3
FLULAVAL 2011-2012 influenza virus vaccine split
im susp
3
3
FLULAVAL 2012-2013 influenza virus vaccine split
im susp
3
FLUVIRIN 2015-2016 influenza vac type a&b
surface antigen susp pref syr
0.5 ml
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
17
FLUVIRIN 2015-2016 influenza virus vaccine types
a & b surface antigen im
susp
3
FLUZONE QUADRIVALENT
2013 - influenza virus
vaccine split quadrivalent inj
0.5 ml
3
FLUZONE HIGH-DOSE PF
2012 - influenza virus vac
split high-dose pf susp pref
syr 0.5ml
3
FLUZONE QUADRIVALENT
2014 - influenza virus vac
split quadrivalent susp pref
syr 0.25 ml
3
FLUZONE HIGH-DOSE PF
2013 - influenza virus vac
split high-dose pf susp pref
syr 0.5ml
3
FLUZONE QUADRIVALENT
2014 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
3
FLUZONE HIGH-DOSE PF
2014 - influenza virus vac
split high-dose pf susp pref
syr 0.5ml
3
FLUZONE QUADRIVALENT
2014 - influenza virus
vaccine split quadrivalent im
inj
3
FLUZONE HIGH-DOSE PF
2015 - influenza virus vac
split high-dose pf susp pref
syr 0.5ml
3
FLUZONE QUADRIVALENT
2014 - influenza virus
vaccine split quadrivalent inj
0.5 ml
3
FLUZONE INTRADERMAL
QUADR - influenza virus vac
split quad intradermal pen 9
mcg/strain
3
FLUZONE QUADRIVALENT
2015 - influenza virus vac
split quadrivalent susp pref
syr 0.25 ml
3
FLUZONE PF 2012-2013 influenza virus vaccine split
pf susp pref syringe 0.5 ml
3
3
FLUZONE PF 2013-2014 influenza virus vaccine split
pf susp pref syringe 0.5 ml
3
FLUZONE QUADRIVALENT
2015 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
3
FLUZONE PF 2014-2015 influenza virus vaccine split
pf susp pref syringe 0.5 ml
3
FLUZONE QUADRIVALENT
2015 - influenza virus
vaccine split quadrivalent im
inj
3
FLUZONE QUADRIVALENT
2013 - influenza virus vac
split quadrivalent susp pref
syr 0.25 ml
3
FLUZONE QUADRIVALENT
2015 - influenza virus
vaccine split quadrivalent inj
0.5 ml
3
FLUZONE QUADRIVALENT
2013 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
3
FLUZONE SPLIT 2012-2013 influenza virus vaccine split
im susp
FLUZONE SPLIT 2013-2014 influenza virus vaccine split
im susp
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
18
FLUZONE SPLIT 2014-2015 influenza virus vaccine split
im susp
3
PNEUMOVAX 23 pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml
3
FLUZONE SPLIT 2015-2016 influenza virus vaccine split
im susp
3
PNEUMOVAX 23/1 DOSE pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml
3
GARDASIL - human
papillomavirus (hpv)
quadrivalent recombinant
vac inj
3
PNEUMOVAX 23/5 DOSE pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml
3
PREVNAR 13 - pneumococcal
13-valent conjugate vaccine
inj
3
GARDASIL 9 - human
papillomavirus (hpv) 9-valent
recomb vac im susp
3
PROQUAD - measles-mumpsrubella-varicella virus
vaccines for inj
3
GARDASIL 9 - human
papillomavirus (hpv) 9-valent
recomb vac susp pref syr
3
RABAVERT - rabies vaccine,
pcec for inj
3
HAVRIX - hepatitis a vaccine
inj susp 720 el unit/0.5ml
3
3
RECOMBIVAX HB - hepatitis b
vaccine (recombinant) susp
5 mcg/0.5ml
3
HAVRIX - hepatitis a vaccine
inj susp 1440 el unit/ml
HIBERIX - haemophilus b
polysaccharide conjugate
vac for inj 10 mcg
3
RECOMBIVAX HB - hepatitis b
vaccine (recombinant) susp
10 mcg/ml
3
IMOVAX RABIES (H.D.C.V.) rabies virus vaccine, hdc inj
3
3
IPOL INACTIVATED IPV poliovirus vaccine, ipv
injection
3
RECOMBIVAX HB - hepatitis b
vaccine (recombinant) susp
40 mcg/ml
ROTARIX - rotavirus vaccine,
live for oral susp
3
M-M-R II - measles, mumps &
rubella virus vaccines for inj
3
ROTATEQ - rotavirus vaccine,
live oral pentavalent soln
3
MENACTRA - meningococcal
(a, c, y, and w-135)
conjugate vaccine inj
3
TRUMENBA - meningococcal
group b vaccine im susp
prefilled syringe
3
MENOMUNE-A/C/Y/W-135 meningococcal vaccine a, c,
y, and w-135 inj
3
TWINRIX - hepatitis a (inact)hep b (recomb) vac inj
720-20 elu-mcg/ml
3
MENVEO - meningococcal (a,
c, y, and w-135) oligo conj
vac for inj
3
VAQTA - hepatitis a vaccine inj
susp 25 unit/0.5ml
3
3
VAQTA - hepatitis a vaccine inj
susp 50 unit/ml
3
PEDVAX HIB - haemophilus b
polysaccharide conj vac im
susp 7.5 mcg/0.5 ml
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
19
VARIVAX - varicella virus vac
live for subcutaneous inj
1350 pfu/0.5ml
3
ZOSTAVAX - zoster vaccine
live for inj 19400 unit/0.65ml
3
ADACEL - tet tox-diph-acell
pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml
3
BOOSTRIX - tet tox-diph-acell
pertuss ad inj 5-2.5-18.5 lf-lfmcg/0.5ml
3
DAPTACEL - diph, acellular
pert & tet tox inj 15 lf-10
mcg-5 lf/0.5ml
3
DIPHTHERIA/TETANUS
TOXOID - diphtheria-tetanus
tox adsorbed (dt) im inj 25-5
unit/0.5ml
3
INFANRIX - diph, acellular pert
& tet tox inj 25 lf-58 mcg-10
lf/0.5ml
3
KINRIX - diph-tetanus tox adacell pert & polio virus, ipv
vac inj
3
PEDIARIX - diph-tetanus toxacell pert-hepatitis b-polio
ipv vac inj
3
PENTACEL - diph-ac per-tet
tox ad-poliov-haemoph b
poly vac for im susp
3
QUADRACEL - diph-tetanus
tox ad-acell pert & polio
virus, ipv vac inj
3
TENIVAC - tetanus-diphtheria
toxoids (td) inj 5-2 lfu
3
TETANUS/DIPHTHERIA
TOXOID - tetanus-diphtheria
toxoids (td) inj 2-2 lf/0.5ml
3
PASSIVE IMMUNIZING AGENTS
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
GAMUNEX-C - immune
globulin (human) iv or
subcutaneous soln 1
gm/10ml
4
•
GAMUNEX-C - immune
globulin (human) iv or
subcutaneous soln 2.5
gm/25ml
4
•
•
GAMUNEX-C - immune
globulin (human) iv or
subcutaneous soln 5
gm/50ml
4
•
•
GAMUNEX-C - immune
globulin (human) iv or
subcutaneous soln 10
gm/100ml
4
•
•
GAMUNEX-C - immune
globulin (human) iv or
subcutaneous soln 20
gm/200ml
4
•
•
GAMUNEX-C - immune
globulin (human) iv or
subcutaneous soln 40
gm/400ml
4
•
•
HIZENTRA - immune globulin
(human) subcutaneous inj 1
gm/5ml
4
•
•
HIZENTRA - immune globulin
(human) subcutaneous inj 2
gm/10ml
4
•
•
HIZENTRA - immune globulin
(human) subcutaneous inj 4
gm/20ml
4
•
•
HIZENTRA - immune globulin
(human) subcutaneous inj
10 gm/50ml
4
•
•
HYQVIA - immun glob inj 2.5
gm/25ml-hyaluron inj 200
unt/1.25 ml kit
3
•
•
HYQVIA - immun glob inj 5
gm/50ml-hyaluron inj 400
unt/2.5 ml kit
3
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
20
HYQVIA - immun glob inj 10
gm/100ml-hyaluron inj 800
unt/5 ml kit
3
HYQVIA - immun glob inj 20
gm/200ml-hyaluron inj 1600
unt/10 ml kit
3
HYQVIA - immun glob inj 30
gm/300ml-hyaluron inj 2400
unt/15 ml kit
3
•
•
•
•
ANTINEOPLASTIC AGENTS
ANTINEOPLASTICS
•
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
ARIMIDEX - anastrozole tab 1
mg
3
AROMASIN - exemestane tab
25 mg
3
bexarotene cap 75 mg
(Targretin)
4
bicalutamide tab 50 mg
(Casodex)
1
BOSULIF - bosutinib tab 100
mg
4
•
•
•
BOSULIF - bosutinib tab 500
mg
4
•
•
•
capecitabine tab 150 mg
(Xeloda)
4
•
•
•
•
•
ACTIMMUNE - interferon
gamma-1b inj 100
mcg/0.5ml (2000000
unit/0.5ml)
4
AFINITOR - everolimus tab 2.5
mg
4
•
•
•
capecitabine tab 500 mg
(Xeloda)
4
•
AFINITOR - everolimus tab 5
mg
4
•
•
•
CAPRELSA - vandetanib tab
100 mg
4
•
•
•
AFINITOR - everolimus tab 7.5
mg
4
•
•
•
CAPRELSA - vandetanib tab
300 mg
4
•
•
•
AFINITOR - everolimus tab 10
mg
4
•
•
•
CASODEX - bicalutamide tab
50 mg
3
AFINITOR DISPERZ everolimus tab for oral susp
2 mg
4
•
•
•
CEENU - lomustine cap 10 mg
2
CEENU - lomustine cap 40 mg
2
2
AFINITOR DISPERZ everolimus tab for oral susp
3 mg
4
CEENU - lomustine cap 100
mg
4
•
•
•
AFINITOR DISPERZ everolimus tab for oral susp
5 mg
4
COMETRIQ - cabozantinib smal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit
4
•
•
•
ALECENSA - alectinib hcl cap
150 mg (base equivalent)
4
COMETRIQ - cabozantinib smal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit
4
•
•
•
ALFERON N - interferon alfan3 inj 5000000 unit/ml
4
COMETRIQ - cabozantinib smalate cap 3 x 20 mg (60
mg dose) kit
ALKERAN - melphalan tab 2
mg
2
4
•
•
•
anastrozole tab 1 mg
(Arimidex)
1
COTELLIC - cobimetinib
fumarate tab 20 mg (base
equivalent)
CYCLOPHOSPHAMIDE cyclophosphamide cap 25
mg
2
•
•
•
•
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
21
CYCLOPHOSPHAMIDE cyclophosphamide cap 50
mg
2
ELIGARD - leuprolide acetate
(3 month) for subcutaneous
inj kit 22.5mg
4
ELIGARD - leuprolide acetate
(4 month) for subcutaneous
inj kit 30 mg
4
•
ELIGARD - leuprolide acetate
(6 month) for subcutaneous
inj kit 45 mg
4
•
ELIGARD - leuprolide acetate
for subcutaneous inj kit 7.5
mg
4
•
EMCYT - estramustine
phosphate sodium cap 140
mg
2
ERIVEDGE - vismodegib cap
150 mg
4
ETOPOSIDE - etoposide cap
50 mg
2
exemestane tab 25 mg
(Aromasin)
1
FARESTON - toremifene citrate 2
tab 60 mg (base equivalent)
4
FARYDAK - panobinostat
lactate cap 10 mg (base
equivalent)
4
FARYDAK - panobinostat
lactate cap 15 mg (base
equivalent)
4
FARYDAK - panobinostat
lactate cap 20 mg (base
equivalent)
FEMARA - letrozole tab 2.5 mg 3
•
•
•
•
•
•
•
•
•
•
•
•
•
FIRMAGON - degarelix acetate
for inj 80 mg (base equiv)
4
•
FIRMAGON - degarelix acetate
for inj 120 mg (base equiv)
4
•
flutamide cap 125 mg
1
Limited Distribution
GILOTRIF - afatinib dimaleate
tab 20 mg (base equivalent)
4
•
GILOTRIF - afatinib dimaleate
tab 30 mg (base equivalent)
4
•
•
•
GILOTRIF - afatinib dimaleate
tab 40 mg (base equivalent)
4
•
•
•
GLEEVEC - imatinib
mesylate tab 100 mg (base
equivalent)
4
•
•
•
GLEEVEC - imatinib
mesylate tab 400 mg (base
equivalent)
4
•
•
•
GLEOSTINE - lomustine cap 5
mg
2
GLEOSTINE - lomustine cap
10 mg
2
GLEOSTINE - lomustine cap
40 mg
2
GLEOSTINE - lomustine cap
100 mg
2
HEXALEN - altretamine cap 50
mg
4
•
•
HYCAMTIN - topotecan hcl cap 4
0.25 mg (base equiv)
HYCAMTIN - topotecan hcl cap 4
1 mg (base equiv)
3
HYDREA - hydroxyurea cap
500 mg
1
hydroxyurea cap 500 mg
(Hydrea)
4
IBRANCE - palbociclib cap 75
mg
IBRANCE - palbociclib cap 100 4
mg
IBRANCE - palbociclib cap 125 4
mg
ICLUSIG - ponatinib hcl tab 15 4
mg (base equiv)
ICLUSIG - ponatinib hcl tab 45 4
mg (base equiv)
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
22
INLYTA - axitinib tab 5 mg
4
•
•
INTRON A - interferon alfa-2b
inj 6000000 unit/ml
4
•
•
•
INTRON A - interferon alfa-2b
inj 10000000 unit/ml
4
•
INTRON A - interferon alfa-2b
for inj 10000000 unit
4
•
INTRON A - interferon alfa-2b
for inj 18000000 unit
4
•
INTRON A - interferon alfa-2b
for inj 50000000 unit
4
•
INTRON A W/DILUENT interferon alfa-2b for inj
10000000 unit
4
•
INTRON A W/DILUENT interferon alfa-2b for inj
18000000 unit
4
•
INTRON A W/DILUENT interferon alfa-2b for inj
50000000 unit
4
•
IRESSA - gefitinib tab 250 mg
4
JAKAFI - ruxolitinib phosphate
tab 5 mg (base equivalent)
Limited Distribution
4
•
ACA Preventive
INLYTA - axitinib tab 1 mg
•
•
•
Dispensing Limits
•
Step Therapy
4
Prior Authorization
IMBRUVICA - ibrutinib cap 140
mg
Drug Name
Drug Tier
Limited Distribution
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
LENVIMA 14MG DAILY
DOSE - lenvatinib cap
therapy pack 10 & 4 mg (14
mg daily dose)
4
•
•
LENVIMA 20MG DAILY
DOSE - lenvatinib cap
therapy pack 10 (2) mg (20
mg daily dose)
4
•
•
•
LENVIMA 24MG DAILY
DOSE - lenvatinib cap
therapy pack 10 (2) & 4 mg
(24 mg daily dose)
4
•
•
•
letrozole tab 2.5 mg (Femara) 1
2
LEUCOVORIN CALCIUM leucovorin calcium tab 10
mg
2
LEUCOVORIN CALCIUM leucovorin calcium tab 15
mg
leucovorin calcium tab 5 mg 1
leucovorin calcium tab
25 mg
1
LEUKERAN - chlorambucil tab
2 mg
2
leuprolide acetate inj kit
5 mg/ml
4
4
•
•
•
•
•
•
4
•
•
•
LOMUSTINE - lomustine cap
10 mg
2
JAKAFI - ruxolitinib phosphate
tab 10 mg (base equivalent)
•
•
•
LOMUSTINE - lomustine cap
40 mg
2
JAKAFI - ruxolitinib phosphate
tab 15 mg (base equivalent)
4
•
•
•
LOMUSTINE - lomustine cap
100 mg
2
JAKAFI - ruxolitinib phosphate
tab 20 mg (base equivalent)
4
•
LONSURF - trifluridine-tipiracil
tab 15-6.14 mg
4
JAKAFI - ruxolitinib phosphate
tab 25 mg (base equivalent)
4
•
•
•
4
•
4
LENVIMA 10MG DAILY
DOSE - lenvatinib cap
therapy pack 10 mg (10 mg
daily dose)
LONSURF - trifluridine-tipiracil
tab 20-8.19 mg
•
•
•
LUPRON DEPOT - leuprolide
acetate (3 month) for inj kit
11.25 mg
4
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
23
4
LUPRON DEPOT - leuprolide
acetate (4 month) for inj kit
30 mg
4
LUPRON DEPOT - leuprolide
acetate (6 month) for inj kit
45 mg
4
•
LUPRON DEPOT - leuprolide
acetate for inj kit 3.75 mg
4
•
LUPRON DEPOT - leuprolide
acetate for inj kit 7.5 mg
4
•
LYNPARZA - olaparib cap 50
mg
4
•
LYSODREN - mitotane tab 500
mg
4
•
MATULANE - procarbazine hcl
cap 50 mg
4
•
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
•
LUPRON DEPOT - leuprolide
acetate (3 month) for inj kit
22.5 mg
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
MYLERAN - busulfan tab 2 mg
2
NEXAVAR - sorafenib
tosylate tab 200 mg (base
equivalent)
4
NILANDRON - nilutamide tab
150 mg
2
NINLARO - ixazomib
citrate cap 2.3 mg (base
equivalent)
4
•
NINLARO - ixazomib citrate
cap 3 mg (base equivalent)
4
•
NINLARO - ixazomib citrate
cap 4 mg (base equivalent)
4
•
4
•
•
•
•
ODOMZO - sonidegib
phosphate cap 200 mg
(base equivalent)
•
POMALYST - pomalidomide
cap 1 mg
4
•
•
•
POMALYST - pomalidomide
cap 2 mg
4
MEGACE ORAL - megestrol
acetate susp 40 mg/ml
3
•
•
•
POMALYST - pomalidomide
cap 3 mg
4
megestrol acetate susp
40 mg/ml (Megace oral)
1
•
•
•
1
POMALYST - pomalidomide
cap 4 mg
4
•
•
•
•
PURIXAN - mercaptopurine
susp 2000 mg/100ml (20
mg/ml)
4
•
SOLTAMOX - tamoxifen citrate
oral soln 10 mg/5ml (base
equivalent)
3
SPRYCEL - dasatinib tab 20
mg
4
•
•
•
SPRYCEL - dasatinib tab 50
mg
4
•
•
•
1
SPRYCEL - dasatinib tab 70
mg
4
•
•
•
1
SPRYCEL - dasatinib tab 80
mg
4
•
•
•
1
SPRYCEL - dasatinib tab 100
mg
4
•
•
•
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
1
MEKINIST - trametinib dimethyl 4
sulfoxide tab 0.5 mg (base
equivalent)
MEKINIST - trametinib dimethyl 4
sulfoxide tab 2 mg (base
equivalent)
1
mercaptopurine tab 50 mg
(Purinethol)
3
MESNEX - mesna tab 400 mg
methotrexate sodium inj pf
25 mg/ml
methotrexate sodium inj
25 mg/ml
methotrexate sodium tab
2.5 mg (base equiv)
•
•
•
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
•
•
24
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Limited Distribution
•
TARCEVA - erlotinib hcl tab
150 mg (base equivalent)
4
•
TARGRETIN - bexarotene cap
75 mg
4
•
TASIGNA - nilotinib hcl cap 150 4
mg (base equivalent)
TASIGNA - nilotinib hcl cap 200 4
mg (base equivalent)
TEMODAR - temozolomide cap 4
5 mg
TEMODAR - temozolomide cap 4
20 mg
TEMODAR - temozolomide cap 4
100 mg
TEMODAR - temozolomide cap 4
140 mg
TEMODAR - temozolomide cap 4
180 mg
TEMODAR - temozolomide cap 4
250 mg
TEMODAR - temozolomide for 3
iv soln 100 mg
4
temozolomide cap 5 mg
(Temodar)
4
temozolomide cap 20 mg
(Temodar)
4
temozolomide cap 100 mg
(Temodar)
4
temozolomide cap 140 mg
(Temodar)
4
temozolomide cap 180 mg
(Temodar)
4
temozolomide cap 250 mg
(Temodar)
4
tretinoin cap 10 mg
•
•
•
•
•
•
TREXALL - methotrexate
sodium tab 5 mg (base
equiv)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
ACA Preventive
•
Dispensing Limits
STIVARGA - regorafenib tab 40 4
mg
SUTENT - sunitinib malate cap 4
12.5 mg (base equivalent)
SUTENT - sunitinib malate cap 4
25 mg (base equivalent)
SUTENT - sunitinib malate cap 4
37.5 mg (base equivalent)
SUTENT - sunitinib malate cap 4
50 mg (base equivalent)
4
SYLATRON - peginterferon
alfa-2b for inj kit 200 mcg
4
SYLATRON - peginterferon
alfa-2b for inj kit 300 mcg
4
SYLATRON - peginterferon
alfa-2b for inj kit 600 mcg
2
TABLOID - thioguanine tab 40
mg
4
TAFINLAR - dabrafenib
mesylate cap 50 mg (base
equivalent)
4
TAFINLAR - dabrafenib
mesylate cap 75 mg (base
equivalent)
4
TAGRISSO - osimertinib
mesylate tab 40 mg (base
equivalent)
4
TAGRISSO - osimertinib
mesylate tab 80 mg (base
equivalent)
1
tamoxifen citrate tab 10 mg
(base equivalent)
1
tamoxifen citrate tab 20 mg
(base equivalent)
TARCEVA - erlotinib hcl tab 25 4
mg (base equivalent)
4
TARCEVA - erlotinib hcl tab
100 mg (base equivalent)
Step Therapy
•
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
4
SPRYCEL - dasatinib tab 140
mg
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
3
25
TREXALL - methotrexate
sodium tab 7.5 mg (base
equiv)
3
TREXALL - methotrexate
sodium tab 10 mg (base
equiv)
3
TREXALL - methotrexate
sodium tab 15 mg (base
equiv)
3
TYKERB - lapatinib ditosylate
tab 250 mg (base equiv)
4
•
•
•
VOTRIENT - pazopanib hcl tab
200 mg (base equiv)
4
•
•
•
XALKORI - crizotinib cap 200
mg
4
•
•
•
XALKORI - crizotinib cap 250
mg
4
•
•
•
XELODA - capecitabine tab
150 mg
4
•
•
XELODA - capecitabine tab
500 mg
4
•
•
XTANDI - enzalutamide cap 40
mg
4
•
•
•
ZELBORAF - vemurafenib tab
240 mg
4
•
•
•
dexamethasone tab 1.5 mg
ZOLINZA - vorinostat cap 100
mg
4
•
•
•
dexamethasone tab 6 mg
ZYDELIG - idelalisib tab 100
mg
4
•
•
•
ZYDELIG - idelalisib tab 150
mg
4
•
•
•
ZYKADIA - ceritinib cap 150
mg
4
•
•
•
ZYTIGA - abiraterone acetate
tab 250 mg
4
•
•
•
ENDOCRINE AND METABOLIC DRUGS
CORTICOSTEROIDS
budesonide cap sr 24hr
3 mg (Entocort ec)
1
CORTEF - hydrocortisone tab
5 mg
3
CORTEF - hydrocortisone tab
10 mg
3
CORTEF - hydrocortisone tab
20 mg
3
CORTISONE ACETATE cortisone acetate tab 25 mg
2
DEXAMETHASONE dexamethasone soln 0.5
mg/5ml
3
DEXAMETHASONE dexamethasone tab 1 mg
3
DEXAMETHASONE dexamethasone tab 2 mg
3
dexamethasone elixir
0.5 mg/5ml
1
DEXAMETHASONE
INTENSOL - dexamethasone
conc 1 mg/ml
3
dexamethasone tab 0.5 mg
1
dexamethasone tab 0.75 mg
dexamethasone tab 4 mg
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
1
1
1
DEXPAK 10 DAY dexamethasone tab 1.5 mg
taper pack
3
DEXPAK 13 DAY dexamethasone tab 1.5 mg
taper pack
3
DEXPAK 6 DAY dexamethasone tab 1.5 mg
taper pack
3
ENTOCORT EC - budesonide
cap sr 24hr 3 mg
3
FLO-PRED - prednisolone
acetate oral susp 16.7
mg/5ml (15 mg/5ml base)
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
26
fludrocortisone acetate tab
0.1 mg
1
hydrocortisone tab 5 mg
(Cortef)
1
hydrocortisone tab 10 mg
(Cortef)
1
hydrocortisone tab 20 mg
(Cortef)
1
MEDROL - methylprednisolone
tab 2 mg
3
MEDROL - methylprednisolone
tab 4 mg
3
MEDROL - methylprednisolone
tab 8 mg
3
MEDROL - methylprednisolone
tab 16 mg
3
MEDROL - methylprednisolone
tab 32 mg
3
MEDROL DOSEPAK methylprednisolone tab 4 mg
dose pack
3
methylprednisolone tab
4 mg dose pack (Medrol
dosepak)
1
methylprednisolone tab
4 mg (Medrol)
1
methylprednisolone tab
8 mg (Medrol)
methylprednisolone tab
16 mg (Medrol)
methylprednisolone tab
32 mg (Medrol)
1
1
1
MILLIPRED - prednisolone
sod phosphate oral soln 10
mg/5ml (base equiv)
3
MILLIPRED - prednisolone tab
5 mg
3
MILLIPRED DP - prednisolone
tab 5 mg dose pack
3
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
ORAPRED ODT - prednisolone 3
sod phos orally disintegr tab
10 mg (base eq)
ORAPRED ODT - prednisolone 3
sod phos orally disintegr tab
15 mg (base eq)
ORAPRED ODT - prednisolone 3
sod phos orally disintegr tab
30 mg (base eq)
3
PEDIAPRED - prednisolone
sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)
1
prednisolone sod phos
orally disintegr tab 10 mg
(base eq) (Orapred odt)
1
prednisolone sod phos
orally disintegr tab 15 mg
(base eq) (Orapred odt)
1
prednisolone sod phos
orally disintegr tab 30 mg
(base eq) (Orapred odt)
1
prednisolone sod phosph
oral soln 6.7 mg/5ml
(5 mg/5ml base)
(Pediapred)
prednisolone sod phosphate 1
oral soln 15 mg/5ml (base
equiv)
3
PREDNISOLONE SODIUM
PHOSP - prednisolone
sodium phosphate oral soln
25 mg/5ml (base eq)
1
prednisolone syrup
15 mg/5ml (usp solution
equivalent) (Prelone)
3
PREDNISONE - prednisone
oral soln 5 mg/5ml
3
PREDNISONE - prednisone
tab 50 mg
3
PREDNISONE - prednisone
tab 5 mg dose pack
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
27
PREDNISONE - prednisone
tab 10 mg dose pack
3
PREDNISONE INTENSOL prednisone conc 5 mg/ml
3
prednisone tab 1 mg
1
prednisone tab 2.5 mg
prednisone tab 5 mg
prednisone tab 10 mg
prednisone tab 20 mg
RAYOS - prednisone tab
delayed release 5 mg
3
UCERIS - budesonide tab sr
24hr 9 mg
3
VERIPRED 20 - prednisolone
sod phosphate oral soln 20
mg/5ml (base equiv)
3
ANADROL-50 - oxymetholone
tab 50 mg
3
ANDRODERM - testosterone
td patch 24hr 2 mg/24hr
2
ANDRODERM - testosterone
td patch 24hr 4 mg/24hr
danazol cap 200 mg
•
1
1
•
• •
•
•
•
DEPO-TESTOSTERONE testosterone cypionate im inj
in oil 100 mg/ml
3
DEPO-TESTOSTERONE testosterone cypionate im inj
in oil 200 mg/ml
3
FORTESTA - testosterone td
gel 10mg/act (2%)
3
METHITEST methyltestosterone oral tab
10 mg
3
•
methyltestosterone cap
10 mg (Testred)
1
•
• •
• •
•
NATESTO - testosterone nasal
gel 5.5 mg/act
3
2
•
OXANDRIN - oxandrolone tab
2.5 mg
3
•
•
OXANDRIN - oxandrolone tab
10 mg
3
ANDROGEL - testosterone td
gel 25 mg/2.5gm (1%)
2
•
•
oxandrolone tab 2.5 mg
(Oxandrin)
1
ANDROGEL - testosterone td
gel 50 mg/5gm (1%)
2
•
•
oxandrolone tab 10 mg
(Oxandrin)
1
ANDROGEL - testosterone
td gel 20.25 mg/1.25gm
(1.62%)
2
•
3
• •
ANDROGEL - testosterone td
gel 40.5 mg/2.5gm (1.62%)
2
•
STRIANT - testosterone buccal
mucoadhesive system 30
mg
•
TESTIM - testosterone td gel
50 mg/5gm (1%)
3
ANDROGEL PUMP testosterone td gel 12.5 mg/
act (1%)
2
• •
TESTONE CIK - testosterone
cypionate im inj in oil 200
mg/ml kit
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
danazol cap 100 mg
1
3
ACA Preventive
Dispensing Limits
Step Therapy
1
RAYOS - prednisone tab
delayed release 2 mg
2
ANDROID - methyltestosterone 3
cap 10 mg
AXIRON - testosterone td soln 3
30 mg/act
1
danazol cap 50 mg
1
3
Drug Name
ANDROGEL PUMP testosterone td gel 20.25
mg/act (1.62%)
1
RAYOS - prednisone tab
delayed release 1 mg
ANDROGEN-ANABOLIC
Prior Authorization
Drug Name
Drug Tier
2015
28
TESTOSTERONE testosterone td gel 25
mg/2.5gm (1%)
3
TESTOSTERONE testosterone td gel 50
mg/5gm (1%)
3
TESTOSTERONE testosterone td gel 10mg/act
(2%)
3
testosterone cypionate im
inj in oil 100 mg/ml (Depotestosterone)
1
testosterone cypionate im
inj in oil 200 mg/ml (Depotestosterone)
1
testosterone enanthate im
inj in oil 200 mg/ml
1
• •
• •
TESTOSTERONE PUMP testosterone td gel 12.5 mg/
act (1%)
3
• •
testosterone td gel
25 mg/2.5gm (1%)
(Androgel)
1
•
testosterone td gel
50 mg/5gm (1%) (Androgel)
1
testosterone td gel 12.5 mg/
act (1%) (Androgel pump)
•
1
TESTRED - methyltestosterone 3
cap 10 mg
VOGELXO - testosterone td gel 3
50 mg/5gm (1%)
3
VOGELXO PUMP testosterone td gel 12.5 mg/
act (1%)
ESTROGENS
•
ACTIVELLA - estradiol &
norethindrone acetate tab
0.5-0.1 mg
3
ACTIVELLA - estradiol &
norethindrone acetate tab
1-0.5 mg
3
•
• •
• •
ALORA - estradiol td patch
twice weekly 0.025 mg/24hr
3
ALORA - estradiol td patch
twice weekly 0.05 mg/24hr
3
ALORA - estradiol td patch
twice weekly 0.075 mg/24hr
3
ALORA - estradiol td patch
twice weekly 0.1 mg/24hr
3
ANGELIQ - drospirenoneestradiol tab 0.25-0.5 mg
3
ANGELIQ - drospirenoneestradiol tab 0.5-1 mg
3
CLIMARA - estradiol td patch
weekly 0.025 mg/24hr
3
CLIMARA - estradiol td patch
weekly 0.0375 mg/24hr
(37.5 mcg/24hr)
3
CLIMARA - estradiol td patch
weekly 0.05 mg/24hr
3
CLIMARA - estradiol td patch
weekly 0.06 mg/24hr
3
CLIMARA - estradiol td patch
weekly 0.075 mg/24hr
3
CLIMARA - estradiol td patch
weekly 0.1 mg/24hr
3
CLIMARA PRO - estradiollevonorgestrel td patch
weekly 0.045-0.015 mg/day
3
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.14 mg/day
2
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.25 mg/day
2
DELESTROGEN - estradiol
valerate im in oil 10 mg/ml
3
DELESTROGEN - estradiol
valerate im in oil 20 mg/ml
3
DELESTROGEN - estradiol
valerate im in oil 40 mg/ml
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
• •
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
29
DEPO-ESTRADIOL - estradiol
cypionate im in oil 5 mg/ml
3
DIVIGEL - estradiol td gel 0.25
mg/0.25gm (0.1%)
2
DIVIGEL - estradiol td gel 0.5
mg/0.5gm (0.1%)
2
DIVIGEL - estradiol td gel 1
mg/gm (0.1%)
2
DUAVEE - conjugated
estrogens-bazedoxifene tab
0.45-20 mg
3
ELESTRIN - estradiol gel
0.06% (0.52 mg/0.87 gm
metered-dose pump)
estradiol & norethindrone
acetate tab 0.5-0.1 mg
(Activella)
1
estradiol & norethindrone
acetate tab 1-0.5 mg
(Activella)
1
estradiol tab 2 mg (Estrace)
3
1
ENJUVIA - estrogens,
conjugated synthetic b tab
0.3 mg
3
estradiol td patch twice
weekly 0.0375 mg/24hr
(Vivelle-dot)
1
ENJUVIA - estrogens,
conjugated synthetic b tab
0.45 mg
3
estradiol td patch twice
weekly 0.05 mg/24hr
(Vivelle-dot)
1
ENJUVIA - estrogens,
conjugated synthetic b tab
0.625 mg
3
estradiol td patch twice
weekly 0.075 mg/24hr
(Vivelle-dot)
1
ENJUVIA - estrogens,
conjugated synthetic b tab
0.9 mg
3
estradiol td patch twice
weekly 0.1 mg/24hr
(Vivelle-dot)
1
ENJUVIA - estrogens,
conjugated synthetic b tab
1.25 mg
3
estradiol td patch weekly
0.025 mg/24hr (Climara)
esterified estrogens &
methyltestosterone tab
0.625-1.25 mg
1
ESTRACE - estradiol tab 0.5
mg
3
ESTRACE - estradiol tab 1 mg
3
ESTRACE - estradiol tab 2 mg
3
Limited Distribution
ACA Preventive
Dispensing Limits
1
1
1
Step Therapy
estradiol tab 0.5 mg (Estrace) 1
1
estradiol tab 1 mg (Estrace)
estradiol td patch twice
weekly 0.025 mg/24hr
(Vivelle-dot)
esterified estrogens &
methyltestosterone tab
1.25-2.5 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
estradiol td patch
weekly 0.0375 mg/24hr
(37.5 mcg/24hr) (Climara)
estradiol td patch weekly
0.05 mg/24hr (Climara)
estradiol td patch weekly
0.06 mg/24hr (Climara)
estradiol td patch weekly
0.075 mg/24hr (Climara)
estradiol td patch weekly
0.1 mg/24hr (Climara)
estradiol valerate im in oil
20 mg/ml (Delestrogen)
estradiol valerate im in oil
40 mg/ml (Delestrogen)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
1
1
1
1
1
1
1
30
ESTROGEL - estradiol gel
0.06% (0.75 mg/1.25 gm
metered-dose pump)
3
PREFEST - estradiol tab 1
mg(15)/estrad-norgestimate
tab 1-0.09mg(15)
3
ESTROPIPATE - estropipate
tab 3 mg
3
PREMARIN - estrogens,
conjugated tab 0.3 mg
2
estropipate tab 0.75 mg
1
PREMARIN - estrogens,
conjugated tab 0.45 mg
2
PREMARIN - estrogens,
conjugated tab 0.625 mg
2
PREMARIN - estrogens,
conjugated tab 0.9 mg
2
PREMARIN - estrogens,
conjugated tab 1.25 mg
2
PREMPHASE - conj est
0.625(14)/conj estmedroxypro ac tab
0.625-5mg(14)
2
PREMPRO - conjugated
estrogen-medroxyprogest
acetate tab 0.3-1.5 mg
2
PREMPRO - conjugated
estrogen-medroxyprogest
acetate tab 0.45-1.5 mg
2
PREMPRO - conjugated
estrogen-medroxyprogest
acetate tab 0.625-2.5 mg
2
PREMPRO - conjugated
estrogen-medroxyprogest
acetate tab 0.625-5 mg
2
VIVELLE-DOT - estradiol td
patch twice weekly 0.025
mg/24hr
2
VIVELLE-DOT - estradiol td
patch twice weekly 0.0375
mg/24hr
2
VIVELLE-DOT - estradiol td
patch twice weekly 0.05
mg/24hr
2
VIVELLE-DOT - estradiol td
patch twice weekly 0.075
mg/24hr
2
estropipate tab 1.5 mg
1
EVAMIST - estradiol
transdermal spray 1.53 mg/
spray
3
FEMHRT LOW DOSE norethindrone acetateethinyl estradiol tab 0.5
mg-2.5 mcg
3
MENEST - esterified estrogens
tab 0.3 mg
3
MENEST - esterified estrogens
tab 0.625 mg
3
MENEST - esterified estrogens
tab 1.25 mg
3
MENEST - esterified estrogens
tab 2.5 mg
3
MENOSTAR - estradiol td
patch weekly 14 mcg/24hr
3
MINIVELLE - estradiol td patch
twice weekly 0.025 mg/24hr
3
MINIVELLE - estradiol td
patch twice weekly 0.0375
mg/24hr
3
MINIVELLE - estradiol td patch
twice weekly 0.05 mg/24hr
3
MINIVELLE - estradiol td patch
twice weekly 0.075 mg/24hr
3
MINIVELLE - estradiol td patch
twice weekly 0.1 mg/24hr
3
1
norethindrone acetateethinyl estradiol tab
0.5 mg-2.5 mcg (Femhrt low
dose)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
31
VIVELLE-DOT - estradiol
td patch twice weekly 0.1
mg/24hr
CONTRACEPTIVES
BEYAZ - drospirenone-ethinyl
estrad-levomefolate tab
3-0.02-0.451 mg
BREVICON-28 - norethindrone NA
& ethinyl estradiol tab 0.5
mg-35 mcg
NA
CYCLESSA - desogestethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg
NA
DEPO-PROVERA
CONTRACEPTIV medroxyprogesterone
acetate im susp 150 mg/ml
NA
DEPO-SUBQ PROVERA
104 - medroxyprogesterone
acetate subcutaneous susp
104 mg/0.65ml
NA
DESOGEN - desogestrel &
ethinyl estradiol tab 0.15
mg-30 mcg
NA
desogest-eth estrad
& eth estrad tab
0.15-0.02/0.01 mg(21/5)
(Mircette)
NA
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
NA
desogestrel & ethinyl
estradiol tab
0.15 mg-30 mcg (Desogen)
NA
drospirenone-ethinyl
estradiol tab 3-0.02 mg
(Yaz)
NA
drospirenone-ethinyl
estradiol tab 3-0.03 mg
(Yasmin 28)
ELLA - ulipristal acetate tab 30 NA
mg
NA
•
•
ethynodiol diacetate &
ethinyl estradiol tab
1 mg-35 mcg
NA
•
•
FALESSA - levonorgest-eth
estrad tab 0.1 mg-20 mcg &
fa tab 1 mg kit
NA
•
•
FEMCON FE - norethindrone & NA
ethinyl estradiol-fe chew tab
0.4 mg-35 mcg
NA
GENERESS FE norethindrone & ethinyl
estradiol-fe chew tab 0.8
mg-25 mcg
NA
levonorg-eth est tab
0.1-0.02mg(84) & eth
est tab 0.01mg(7)
(Loseasonique)
NA
levonorg-eth est tab
0.15-0.03mg(84) & eth est
tab 0.01mg(7) (Seasonique)
NA
levonorgestrel & ethinyl
estradiol (91-day) tab
0.15-0.03 mg
NA
levonorgestrel &
ethinyl estradiol tab
0.1 mg-20 mcg
NA
levonorgestrel &
ethinyl estradiol tab
0.15 mg-30 mcg
NA
levonorgestrel tab 1.5 mg
(Plan b one-step)
levonorgestrel-eth estra tab NA
0.05-30/0.075-40/0.125-30mgmcg
NA
levonorgestrel-ethinyl
estradiol (continuous) tab
90-20 mcg
•
•
•
•
•
•
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Drug Name
ESTROSTEP FE norethindrone ac-ethinyl
estrad-fe tab 1-20/1-30/1-35
mg-mcg
2
NA
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
32
LO LOESTRIN FE - norethineth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)
NA
LOESTRIN FE 1.5/30 norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30
mcg
NA
NA
LOESTRIN FE 1/20 norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg
NA
LOESTRIN 1.5/30-21 norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg
NA
LOESTRIN 1/20-21 norethindrone ace & ethinyl
estradiol tab 1 mg-20 mcg
LOSEASONIQUE - levonorg- NA
eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)
NA
medroxyprogesterone
acetate im susp 150 mg/ml
(Depo-provera contrac)
NA
MINASTRIN 24 FE norethindrone ace-eth
estradiol-fe chew tab 1
mg-20 mcg (24)
NA
MIRCETTE - desogest-eth
estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5)
NA
MODICON - norethindrone
& ethinyl estradiol tab 0.5
mg-35 mcg
NA
NATAZIA - estradiol valeratedienogest tab 3 mg /2-2
mg/2-3 mg/1 mg
NA
NECON 1/50-28 norethindrone & mestranol
tab 1 mg-50 mcg
NA
NECON 10/11-28 norethindrone-eth estradiol
tab 0.5-35/1-35 mg-mcg
(10/11)
NOR-QD - norethindrone tab
0.35 mg
NA
•
•
norethindrone &
ethinyl estradiol tab
0.4 mg-35 mcg (Ovcon-35)
NA
•
NA
•
•
norethindrone &
ethinyl estradiol
tab 0.5 mg-35 mcg
(Brevicon-28)
•
norethindrone & ethinyl
estradiol tab 1 mg-35 mcg
(Norinyl 1+35)
NA
•
NA
norethindrone & ethinyl
estradiol-fe chew tab
0.4 mg-35 mcg (Femcon fe)
NA
norethindrone & ethinyl
estradiol-fe chew tab
0.8 mg-25 mcg (Generess
fe)
NA
norethindrone acethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg
(Estrostep fe)
norethindrone ace & ethinyl NA
estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)
NA
norethindrone ace &
ethinyl estradiol tab
1.5 mg-30 mcg (Loestrin
1.5/30-21)
NA
norethindrone ace &
ethinyl estradiol-fe tab
1 mg-20 mcg (Loestrin fe
1/20)
NA
norethindrone ace &
ethinyl estradiol-fe tab
1.5 mg-30 mcg (Loestrin fe
1.5/30)
NA
norethindrone aceethinyl estradiol-fe tab
1 mg-20 mcg (24) (Lomedia
24 fe)
•
•
•
•
•
•
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
•
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
33
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25
mg-mcg
NA
•
•
ORTHO-CEPT - desogestrel
& ethinyl estradiol tab 0.15
mg-30 mcg
NA
•
•
ORTHO-CYCLEN norgestimate & ethinyl
estradiol tab 0.25 mg-35
mcg
NA
•
•
ORTHO-NOVUM 1/35 norethindrone & ethinyl
estradiol tab 1 mg-35 mcg
NA
•
•
ORTHO-NOVUM 7/7/7 norethindrone-eth estradiol
tab 0.5-35/0.75-35/1-35 mgmcg
NA
•
•
OVCON-35 - norethindrone
& ethinyl estradiol tab 0.4
mg-35 mcg
NA
•
•
PLAN B ONE-STEP levonorgestrel tab 1.5 mg
NA
•
QUARTETTE - levonor-eth est NA
tab 0.15-0.02/0.025/0.03 mg
&eth est 0.01 mg
NA
SAFYRAL - drospirenoneethinyl estrad-levomefolate
tab 3-0.03-0.451 mg
SEASONIQUE - levonorg-eth NA
est tab 0.15-0.03mg(84) &
eth est tab 0.01mg(7)
NA
TRI-NORINYL 28 norethindrone-eth estradiol
tab 0.5-35/1-35/0.5-35 mgmcg
NA
XULANE - norelgestrominethinyl estradiol td ptwk
150-35 mcg/24hr
NA
YASMIN 28 - drospirenoneethinyl estradiol tab 3-0.03
mg
•
•
•
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
•
Step Therapy
norethindrone-eth estradiol NA
tab 0.5-35/0.75-35/1-35 mgmcg (Ortho-novum 7/7/7)
norethindrone-eth estradiol NA
tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)
NA
norgestimate &
ethinyl estradiol tab
0.25 mg-35 mcg (Orthocyclen)
norgestimate-eth estrad tab NA
0.18-25/0.215-25/0.25-25 mgmcg (Ortho tri-cyclen lo)
norgestimate-eth estrad tab NA
0.18-35/0.215-35/0.25-35 mgmcg (Ortho tri-cyclen)
NA
norgestrel & ethinyl
estradiol tab
0.3 mg-30 mcg
NORINYL 1+35 - norethindrone NA
& ethinyl estradiol tab 1
mg-35 mcg
NORINYL 1+50 - norethindrone NA
& mestranol tab 1 mg-50
mcg
NA
NUVARING - etonogestrelethinyl estradiol va ring
0.120-0.015 mg/24hr
NA
OGESTREL - norgestrel &
ethinyl estradiol tab 0.5
mg-50 mcg
NA
ORTHO EVRA norelgestromin-ethinyl
estradiol td ptwk 150-35
mcg/24hr
NA
ORTHO MICRONOR norethindrone tab 0.35 mg
NA
ORTHO TRI-CYCLEN norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35
mg-mcg
Prior Authorization
•
Drug Name
Drug Tier
NA
norethindrone tab 0.35 mg
(Nor-qd)
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
34
PROGESTINS
AYGESTIN - norethindrone
acetate tab 5 mg
3
medroxyprogesterone
acetate tab 2.5 mg
(Provera)
1
medroxyprogesterone
acetate tab 5 mg (Provera)
1
1
medroxyprogesterone
acetate tab 10 mg (Provera)
3
MEGACE ES - megestrol
acetate susp 625 mg/5ml
1
megestrol acetate susp
625 mg/5ml (Megace es)
1
norethindrone acetate tab
5 mg (Aygestin)
1
progesterone im in oil
50 mg/ml
1
progesterone micronized
cap 100 mg (Prometrium)
1
progesterone micronized
cap 200 mg (Prometrium)
PROMETRIUM - progesterone 3
micronized cap 100 mg
PROMETRIUM - progesterone 3
micronized cap 200 mg
3
PROVERA medroxyprogesterone
acetate tab 2.5 mg
3
PROVERA medroxyprogesterone
acetate tab 5 mg
3
PROVERA medroxyprogesterone
acetate tab 10 mg
ANTIDIABETICS
acarbose tab 50 mg
(Precose)
1
acarbose tab 100 mg
(Precose)
1
ACTOPLUS MET - pioglitazone 3
hcl-metformin hcl tab 15-500
mg
ACTOPLUS MET - pioglitazone 3
hcl-metformin hcl tab 15-850
mg
3
ACTOPLUS MET XR pioglitazone hcl-metformin
hcl tab sr 24hr 15-1000 mg
3
ACTOPLUS MET XR pioglitazone hcl-metformin
hcl tab sr 24hr 30-1000 mg
3
ACTOS - pioglitazone hcl tab
15 mg (base equiv)
3
ACTOS - pioglitazone hcl tab
30 mg (base equiv)
3
ACTOS - pioglitazone hcl tab
45 mg (base equiv)
AMARYL - glimepiride tab 1 mg 3
AMARYL - glimepiride tab 2 mg 3
AMARYL - glimepiride tab 4 mg 3
•
•
•
•
•
•
•
AVANDIA - rosiglitazone
maleate tab 2 mg (base
equiv)
3
•
AVANDIA - rosiglitazone
maleate tab 4 mg (base
equiv)
3
•
AVANDIA - rosiglitazone
maleate tab 8 mg (base
equiv)
3
•
BD GLUCOSE - glucose chew
tab 5 gm
3
BYDUREON - exenatide
extended release for susp
pen-injector 2 mg
2
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
•
ACA Preventive
NA
1
Dispensing Limits
ZOVIA 1/50E - ethynodiol
diacetate & ethinyl estradiol
tab 1 mg-50 mcg
acarbose tab 25 mg
(Precose)
Step Therapy
•
Prior Authorization
NA
Drug Name
Drug Tier
YAZ - drospirenone-ethinyl
estradiol tab 3-0.02 mg
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
• •
35
3
CHLORPROPAMIDE chlorpropamide tab 250 mg
3
CVS GLUCOSE - glucose
chew tab 4 gm
3
CVS GLUCOSE BITS glucose chew tab 1 gm
3
CYCLOSET - bromocriptine
mesylate tab 0.8 mg (base
equivalent)
3
DEX4 - glucose chew tab 1 gm
3
DEX4 FAST ACTING
GLUCOSE - glucose gel 15
gm/33gm
3
DEX4 FAST ACTING
GLUCOSE - glucose oral
liquid 15 gm/59ml
3
DEX4 GLUCOSE - glucose
chew tab 4 gm
3
DEX4 GLUCOSE - glucose
oral liquid 15 gm/59ml
3
DEX4 QUICK DISSOLVE
GLUCO - glucose chew tab 4
gm
3
DIABETA - glyburide tab 1.25
mg
3
DIABETA - glyburide tab 2.5
mg
3
DIABETA - glyburide tab 5 mg
3
DRUG MART GLUCOSE glucose chew tab 4 gm
3
DUETACT - pioglitazone hclglimepiride tab 30-2 mg
3
•
DUETACT - pioglitazone hclglimepiride tab 30-4 mg
3
•
Limited Distribution
CHLORPROPAMIDE chlorpropamide tab 100 mg
•
ACA Preventive
• •
Dispensing Limits
2
3
Step Therapy
BYETTA - exenatide soln peninjector 10 mcg/0.04ml
FARXIGA - dapagliflozin
propanediol tab 10 mg (base
equivalent)
Prior Authorization
• •
Drug Name
Drug Tier
2
Limited Distribution
BYETTA - exenatide soln peninjector 5 mcg/0.02ml
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
FORTAMET - metformin hcl tab 3
sr 24hr osmotic 500 mg
FORTAMET - metformin hcl tab 3
sr 24hr osmotic 1000 mg
1
glimepiride tab 1 mg
(Amaryl)
1
glimepiride tab 2 mg
(Amaryl)
1
glimepiride tab 4 mg
(Amaryl)
1
glipizide tab sr 24hr 2.5 mg
(Glucotrol xl)
1
glipizide tab sr 24hr 5 mg
(Glucotrol xl)
1
glipizide tab sr 24hr 10 mg
(Glucotrol xl)
glipizide tab 5 mg (Glucotrol) 1
glipizide tab 10 mg
(Glucotrol)
1
glipizide-metformin hcl tab
2.5-250 mg
1
glipizide-metformin hcl tab
2.5-500 mg
glipizide-metformin hcl tab
5-500 mg
1
1
GLUCAGEN HYPOKIT glucagon hcl (rdna) for inj 1
mg (base equiv)
3
GLUCAGON EMERGENCY
KIT - glucagon (rdna) for inj
kit 1 mg
2
GLUCOPHAGE - metformin hcl 3
tab 500 mg
GLUCOPHAGE - metformin hcl 3
tab 850 mg
GLUCOPHAGE - metformin hcl 3
tab 1000 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
36
GLUCOPHAGE XR metformin hcl tab sr 24hr
500 mg
3
GLUCOPHAGE XR metformin hcl tab sr 24hr
750 mg
3
GLUCOSE - glucose chew tab
4 gm
3
glucose gel 40%
1
glucose oral liquid
15 gm/59ml
glyburide micronized tab
3 mg (Glynase)
glyburide micronized tab
6 mg (Glynase)
glyburide tab 1.25 mg
1
GLUCOTROL - glipizide tab 5
mg
3
GLUCOTROL - glipizide tab 10
mg
3
GLUCOTROL XL - glipizide tab
sr 24hr 2.5 mg
3
GLUCOTROL XL - glipizide tab
sr 24hr 5 mg
3
GLUCOTROL XL - glipizide tab
sr 24hr 10 mg
3
GLUCOVANCE - glyburidemetformin tab 1.25-250 mg
3
GLUCOVANCE - glyburidemetformin tab 2.5-500 mg
3
GLUCOVANCE - glyburidemetformin tab 5-500 mg
3
GLUMETZA - metformin hcl tab 3
sr 24hr modified release 500
mg
3
GLUMETZA - metformin hcl
tab sr 24hr modified release
1000 mg
3
GLYBURIDE - glyburide tab
1.25 mg
GLYBURIDE - glyburide tab 2.5 3
mg
3
GLYBURIDE - glyburide tab 5
mg
1
glyburide micronized tab
1.5 mg (Glynase)
glyburide tab 2.5 mg
glyburide tab 5 mg
glyburide-metformin tab
1.25-250 mg (Glucovance)
glyburide-metformin tab
2.5-500 mg (Glucovance)
glyburide-metformin tab
5-500 mg (Glucovance)
Limited Distribution
1
1
1
1
1
1
1
1
GLYNASE - glyburide
micronized tab 1.5 mg
3
GLYNASE - glyburide
micronized tab 3 mg
3
GLYNASE - glyburide
micronized tab 6 mg
3
GLYSET - miglitol tab 25 mg
3
GLYSET - miglitol tab 50 mg
3
GLYSET - miglitol tab 100 mg
3
GLYXAMBI - empagliflozinlinagliptin tab 10-5 mg
3
•
GLYXAMBI - empagliflozinlinagliptin tab 25-5 mg
3
•
GNP GLUCOSE - glucose
chew tab 4 gm
3
GNP QUICK DISSOLVE
GLUCOS - glucose chew tab
4 gm
3
INSTA-GLUCOSE - glucose
gel 77.4%
3
INVOKAMET - canagliflozinmetformin hcl tab 50-500 mg
2
•
INVOKAMET - canagliflozinmetformin hcl tab 50-1000
mg
2
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
37
3
•
JENTADUETO - linagliptinmetformin hcl tab 2.5-1000
mg
3
•
INVOKANA - canagliflozin tab
100 mg
2
•
KAZANO - alogliptin-metformin
hcl tab 12.5-500 mg
3
•
INVOKANA - canagliflozin tab
300 mg
2
•
KAZANO - alogliptin-metformin
hcl tab 12.5-1000 mg
3
•
JANUMET - sitagliptinmetformin hcl tab 50-500 mg
2
•
KOMBIGLYZE XR saxagliptin-metformin hcl tab
sr 24hr 2.5-1000 mg
2
•
JANUMET - sitagliptinmetformin hcl tab 50-1000
mg
2
•
KOMBIGLYZE XR saxagliptin-metformin hcl tab
sr 24hr 5-500 mg
2
•
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
50-500 mg
2
KOMBIGLYZE XR saxagliptin-metformin hcl tab
sr 24hr 5-1000 mg
2
•
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
50-1000 mg
2
KORLYM - mifepristone tab
300 mg
4
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
100-1000 mg
2
KROGER GLUCOSE - glucose
chew tab 4 gm
3
JANUVIA - sitagliptin
phosphate tab 25 mg (base
equiv)
2
•
LEADER GLUCOSE - glucose
chew tab 4 gm
3
3
•
LEADER QUICK DISSOLVE
GLU - glucose chew tab 4
gm
JANUVIA - sitagliptin
phosphate tab 50 mg (base
equiv)
2
LONGS GLUCOSE - glucose
chew tab 4 gm
3
JANUVIA - sitagliptin
phosphate tab 100 mg (base
equiv)
2
•
MEDICINE SHOPPE
GLUCOSE - glucose chew
tab 4 gm
3
JARDIANCE - empagliflozin
tab 10 mg
2
•
metformin hcl tab sr 24hr
500 mg (Glucophage xr)
1
JARDIANCE - empagliflozin
tab 25 mg
2
•
JENTADUETO - linagliptinmetformin hcl tab 2.5-500
mg
3
•
•
•
•
metformin hcl tab sr 24hr
750 mg (Glucophage xr)
metformin hcl tab sr 24hr
osmotic 500 mg (Fortamet)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
Limited Distribution
JENTADUETO - linagliptinmetformin hcl tab 2.5-850
mg
ACA Preventive
•
Dispensing Limits
2
Step Therapy
INVOKAMET - canagliflozinmetformin hcl tab 150-1000
mg
Prior Authorization
•
Drug Name
Drug Tier
2
Limited Distribution
INVOKAMET - canagliflozinmetformin hcl tab 150-500
mg
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
1
1
38
•
1
•
1
•
1
•
1
pioglitazone hcl-metformin
hcl tab 15-500 mg (Actoplus
met)
1
pioglitazone hcl-metformin
hcl tab 15-850 mg (Actoplus
met)
3
PRANDIMET - repaglinidemetformin hcl tab 1-500 mg
3
PRANDIMET - repaglinidemetformin hcl tab 2-500 mg
PRANDIN - repaglinide tab 0.5 3
mg
3
PRANDIN - repaglinide tab 1
mg
3
PRANDIN - repaglinide tab 2
mg
3
PRECOSE - acarbose tab 25
mg
3
PRECOSE - acarbose tab 50
mg
PRECOSE - acarbose tab 100 3
mg
3
PREFERRED PLUS
GLUCOSE - glucose chew
tab 4 gm
PROGLYCEM - diazoxide susp 3
50 mg/ml
1
repaglinide tab 0.5 mg
(Prandin)
1
repaglinide tab 1 mg
(Prandin)
1
repaglinide tab 2 mg
(Prandin)
•
1
metformin hcl tab 500 mg
(Glucophage)
1
pioglitazone hcl tab 45 mg
(base equiv) (Actos)
metformin hcl tab 850 mg
(Glucophage)
1
pioglitazone hcl-glimepiride
tab 30-2 mg (Duetact)
metformin hcl tab 1000 mg
(Glucophage)
1
pioglitazone hcl-glimepiride
tab 30-4 mg (Duetact)
MS QUICK DISSOLVE
GLUCOSE - glucose chew
tab 4 gm
3
nateglinide tab 60 mg
(Starlix)
1
nateglinide tab 120 mg
(Starlix)
1
NESINA - alogliptin benzoate
tab 6.25 mg (base equiv)
3
•
NESINA - alogliptin benzoate
tab 12.5 mg (base equiv)
3
•
NESINA - alogliptin benzoate
tab 25 mg (base equiv)
3
•
ONGLYZA - saxagliptin hcl tab
2.5 mg (base equiv)
2
•
ONGLYZA - saxagliptin hcl tab
5 mg (base equiv)
2
•
OSENI - alogliptin-pioglitazone
tab 12.5-15 mg
3
•
OSENI - alogliptin-pioglitazone
tab 12.5-30 mg
3
•
OSENI - alogliptin-pioglitazone
tab 12.5-45 mg
3
•
OSENI - alogliptin-pioglitazone
tab 25-15 mg
3
•
OSENI - alogliptin-pioglitazone
tab 25-30 mg
3
•
OSENI - alogliptin-pioglitazone
tab 25-45 mg
3
•
pioglitazone hcl tab 15 mg
(base equiv) (Actos)
1
•
pioglitazone hcl tab 30 mg
(base equiv) (Actos)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
1
metformin hcl tab sr
24hr osmotic 1000 mg
(Fortamet)
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
39
3
• •
TRULICITY - dulaglutide soln
pen-injector 1.5 mg/0.5ml
3
• •
VALUE PLUS GLUCOSE glucose chew tab 4 gm
3
VICTOZA - liraglutide soln peninjector 18 mg/3ml (6 mg/ml)
2
WALGREENS GLUCOSE glucose chew tab 4 gm
3
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
5-500 mg
3
•
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
5-1000 mg
3
SYMLINPEN 120 - pramlintide
acetate pen-inj 2700
mcg/2.7ml (1000 mcg/ml)
2
•
2
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
10-500 mg
3
SYMLINPEN 60 - pramlintide
acetate pen-inj 1500
mcg/1.5ml (1000 mcg/ml)
•
•
•
SYNJARDY - empagliflozinmetformin hcl tab 5-1000 mg
3
•
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
10-1000 mg
3
SYNJARDY - empagliflozinmetformin hcl tab 5-500 mg
3
Rapid-Acting Insulins
•
APIDRA - insulin glulisine inj
100 unit/ml
3
SYNJARDY - empagliflozinmetformin hcl tab 12.5-500
mg
3
•
3
•
SYNJARDY - empagliflozinmetformin hcl tab 12.5-1000
mg
3
•
APIDRA SOLOSTAR - insulin
glulisine soln pen-injector inj
100 unit/ml
3
•
TANZEUM - albiglutide for soln
pen-injector 30 mg
3
• •
HUMALOG - insulin lispro
(human) inj 100 unit/ml
3
•
TANZEUM - albiglutide for soln
pen-injector 50 mg
3
• •
HUMALOG - insulin lispro
(human) soln cartridge 100
unit/ml
HUMALOG KWIKPEN - insulin
lispro (human) soln peninjector 100 unit/ml
3
TOLAZAMIDE - tolazamide tab
500 mg
3
•
tolazamide tab 250 mg
1
HUMALOG KWIKPEN - insulin
lispro (human) soln peninjector 200 unit/ml
3
•
NOVOLOG - insulin aspart inj
100 unit/ml
2
1
REPAGLINIDE/METFORMIN
HYD - repaglinide-metformin
hcl tab 2-500 mg
1
RIOMET - metformin hcl oral
soln 500 mg/5ml
3
SM GLUCOSE - glucose chew
tab 4 gm
3
STARLIX - nateglinide tab 60
mg
3
STARLIX - nateglinide tab 120
mg
3
TOLBUTAMIDE - tolbutamide
tab 500 mg
3
TRADJENTA - linagliptin tab 5
mg
3
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
TRULICITY - dulaglutide soln
pen-injector 0.75 mg/0.5ml
REPAGLINIDE/METFORMIN
HYD - repaglinide-metformin
hcl tab 1-500 mg
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
• •
40
NOVOLOG FLEXPEN - insulin
aspart soln pen-injector 100
unit/ml
2
NOVOLOG PENFILL - insulin
aspart soln cartridge 100
unit/ml
2
Short-Acting Insulins
HUMULIN N - insulin nph
(human) (isophane) inj 100
unit/ml
3
•
HUMULIN N KWIKPEN insulin nph (human)
(isophane) susp pen-injector
100 unit/ml
3
•
3
•
AFREZZA - insulin regular
(human) inh powd 8 (60) &
12 (30) unit/cart
3
•
•
AFREZZA - insulin regular
(human) inhal powd 4 (30) &
8 (60) unit/cart
3
•
•
AFREZZA - insulin regular
(human) inhal powd 4 (60) &
8 (30) unit/cart
3
•
•
HUMULIN N U-100 PEN insulin nph (human)
(isophane) susp pen-injector
100 unit/ml
3
•
AFREZZA - insulin regular
(human) inhalation powder 4
unit/cartridge
3
•
HUMULIN 70/30 - insulin nph
isophane & regular human
inj 100 unit/ml (70-30)
3
•
HUMULIN R - insulin regular
(human) inj 100 unit/ml
3
HUMULIN 70/30 KWIKPEN insulin nph & regular susp
pen-inj 100 unit/ml (70-30)
HUMULIN 70/30 PEN - insulin
nph & regular susp pen-inj
100 unit/ml (70-30)
3
•
NOVOLIN N - insulin nph
(human) (isophane) inj 100
unit/ml
2
NOVOLIN N RELION - insulin
nph (human) (isophane) inj
100 unit/ml
2
NOVOLIN 70/30 - insulin nph
isophane & regular human
inj 100 unit/ml (70-30)
2
NOVOLIN 70/30 RELION insulin nph isophane &
regular human inj 100 unit/
ml (70-30)
2
NOVOLOG MIX 70/30 - insulin
aspart prot & aspart (human)
inj 100 unit/ml (70-30)
2
3
HUMULIN R U-500
(CONCENTR - insulin regular
(human) inj 500 unit/ml
2
NOVOLIN R - insulin regular
(human) inj 100 unit/ml
2
NOVOLIN R RELION - insulin
regular (human) inj 100 unit/
ml
2
RELION R - insulin regular
(human) inj 100 unit/ml
Intermediate-Acting Insulins
•
•
•
HUMALOG MIX 50/50 - insulin
lispro prot & lispro (human)
inj 100 unit/ml (50-50)
3
•
HUMALOG MIX 50/50
KWIKPEN - insulin lispro prot
& lispro sus pen-inj 100 unit/
ml (50-50)
3
•
HUMALOG MIX 75/25 - insulin
lispro prot & lispro (human)
inj 100 unit/ml (75-25)
3
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
•
ACA Preventive
3
Dispensing Limits
HUMALOG MIX 75/25
KWIKPEN - insulin lispro prot
& lispro sus pen-inj 100 unit/
ml (75-25)
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
41
3
ARMOUR THYROID - thyroid
tab 300 mg (5 grain)
3
CYTOMEL - liothyronine
sodium tab 5 mcg
3
LANTUS - insulin glargine inj
100 unit/ml
2
2
CYTOMEL - liothyronine
sodium tab 25 mcg
3
LANTUS SOLOSTAR - insulin
glargine soln pen-injector
100 unit/ml
3
LEVEMIR - insulin detemir inj
100 unit/ml
2
CYTOMEL - liothyronine
sodium tab 50 mcg
1
LEVEMIR FLEXPEN - insulin
detemir soln pen-injector
100 unit/ml
2
levothyroxine sodium tab
25 mcg (Synthroid)
LEVEMIR FLEXTOUCH insulin detemir soln peninjector 100 unit/ml
2
TOUJEO SOLOSTAR - insulin
glargine soln pen-injector
300 unit/ml
2
TRESIBA FLEXTOUCH insulin degludec soln peninjector 100 unit/ml
3
TRESIBA FLEXTOUCH insulin degludec soln peninjector 200 unit/ml
3
Basal Insulins
THYROID AGENTS
levothyroxine sodium tab
50 mcg (Synthroid)
levothyroxine sodium tab
75 mcg (Synthroid)
levothyroxine sodium tab
88 mcg (Synthroid)
levothyroxine sodium tab
100 mcg (Synthroid)
levothyroxine sodium tab
112 mcg (Synthroid)
levothyroxine sodium tab
125 mcg (Synthroid)
levothyroxine sodium tab
137 mcg (Synthroid)
ARMOUR THYROID - thyroid
tab 15 mg (1/4 grain)
3
levothyroxine sodium tab
150 mcg (Synthroid)
ARMOUR THYROID - thyroid
tab 30 mg (1/2 grain)
3
levothyroxine sodium tab
175 mcg (Synthroid)
ARMOUR THYROID - thyroid
tab 60 mg (1 grain)
3
levothyroxine sodium tab
200 mcg (Synthroid)
ARMOUR THYROID - thyroid
tab 90 mg (1 1/2 grain)
3
levothyroxine sodium tab
300 mcg (Synthroid)
ARMOUR THYROID - thyroid
tab 120 mg (2 grain)
3
liothyronine sodium tab
5 mcg (Cytomel)
ARMOUR THYROID - thyroid
tab 180 mg (3 grain)
3
liothyronine sodium tab
25 mcg (Cytomel)
liothyronine sodium tab
50 mcg (Cytomel)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Drug Name
ARMOUR THYROID - thyroid
tab 240 mg (4 grain)
NOVOLOG MIX 70/30
PREFILL - insulin aspart prot
& aspart sus pen-inj 100
unit/ml (70-30)
2
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
1
1
1
1
1
1
1
1
1
1
1
42
methimazole tab 5 mg
(Tapazole)
1
SYNTHROID - levothyroxine
sodium tab 100 mcg
2
methimazole tab 10 mg
(Tapazole)
1
SYNTHROID - levothyroxine
sodium tab 112 mcg
2
NATURE-THROID - thyroid tab
16.25 mg
3
SYNTHROID - levothyroxine
sodium tab 125 mcg
2
NATURE-THROID - thyroid tab
32.5 mg
3
SYNTHROID - levothyroxine
sodium tab 137 mcg
2
NATURE-THROID - thyroid tab
48.75 mg (3/4 grain)
3
SYNTHROID - levothyroxine
sodium tab 150 mcg
2
NATURE-THROID - thyroid tab
65 mg
3
SYNTHROID - levothyroxine
sodium tab 175 mcg
2
NATURE-THROID - thyroid tab
81.25 mg
3
SYNTHROID - levothyroxine
sodium tab 200 mcg
2
NATURE-THROID - thyroid tab
97.5 mg
3
SYNTHROID - levothyroxine
sodium tab 300 mcg
2
NATURE-THROID - thyroid tab
113.75 mg
3
TAPAZOLE - methimazole tab
5 mg
3
NATURE-THROID - thyroid tab
130 mg
3
TAPAZOLE - methimazole tab
10 mg
3
NATURE-THROID - thyroid tab
195 mg
3
thyroid tab 30 mg (1/2 grain)
(Armour thyroid)
1
NATURE-THROID - thyroid tab
260 mg
3
thyroid tab 60 mg (1 grain)
(Armour thyroid)
1
NATURE-THROID - thyroid tab
325 mg (5 grain)
3
1
NATURE-THROID - thyroid tab
146.25 mg
3
thyroid tab 90 mg (1
1/2 grain) (Armour thyroid)
NATURE-THROID NT-2.5 thyroid tab 162.5 mg (2 1/2
grain)
3
propylthiouracil tab 50 mg
1
THYROLAR-1 - liotrix (t3-t4)
tab 60 mg (12.5-50 mcg)
3
THYROLAR-1/2 - liotrix (t3-t4)
tab 30 mg (6.25-25 mcg)
3
THYROLAR-1/4 - liotrix (t3-t4)
tab 15 mg (3.1-12.5 mcg)
3
SYNTHROID - levothyroxine
sodium tab 25 mcg
2
THYROLAR-2 - liotrix (t3-t4)
tab 120 mg (25-100 mcg)
3
SYNTHROID - levothyroxine
sodium tab 50 mcg
2
THYROLAR-3 - liotrix (t3-t4)
tab 180 mg (37.5-150 mcg)
3
SYNTHROID - levothyroxine
sodium tab 75 mcg
2
TIROSINT - levothyroxine
sodium cap 13 mcg
3
SYNTHROID - levothyroxine
sodium tab 88 mcg
2
TIROSINT - levothyroxine
sodium cap 25 mcg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
43
TIROSINT - levothyroxine
sodium cap 50 mcg
3
WESTHROID - thyroid tab
146.25 mg
3
TIROSINT - levothyroxine
sodium cap 75 mcg
3
WESTHROID-P - thyroid tab
16.25 mg
3
TIROSINT - levothyroxine
sodium cap 88 mcg
3
WESTHROID-P - thyroid tab
32.5 mg
3
TIROSINT - levothyroxine
sodium cap 100 mcg
3
WESTHROID-P - thyroid tab
48.75 mg (3/4 grain)
3
TIROSINT - levothyroxine
sodium cap 112 mcg
3
WESTHROID-P - thyroid tab
65 mg
3
TIROSINT - levothyroxine
sodium cap 125 mcg
3
WESTHROID-P - thyroid tab
97.5 mg
3
TIROSINT - levothyroxine
sodium cap 137 mcg
3
WESTHROID-P - thyroid tab
130 mg
3
TIROSINT - levothyroxine
sodium cap 150 mcg
3
WP THYROID - thyroid tab
16.25 mg
3
WESTHROID - thyroid tab
16.25 mg
3
WP THYROID - thyroid tab
32.5 mg
3
WESTHROID - thyroid tab 32.5
mg
3
WP THYROID - thyroid tab
48.75 mg (3/4 grain)
3
WESTHROID - thyroid tab
48.75 mg (3/4 grain)
3
WP THYROID - thyroid tab 65
mg
3
WESTHROID - thyroid tab 65
mg
3
WP THYROID - thyroid tab
81.25 mg
3
WESTHROID - thyroid tab
81.25 mg
3
WP THYROID - thyroid tab
97.5 mg
3
WESTHROID - thyroid tab 97.5
mg
3
WP THYROID - thyroid tab
113.75 mg
3
WESTHROID - thyroid tab
113.75 mg
3
WP THYROID - thyroid tab 130
mg
3
WESTHROID - thyroid tab 130
mg
3
OXYTOCICS
CERVIDIL - dinoprostone
vaginal inserts 10 mg
3
WESTHROID - thyroid tab
162.5 mg (2 1/2 grain)
3
3
methylergonovine maleate
tab 0.2 mg
1
WESTHROID - thyroid tab 195
mg
3
PREPIDIL - dinoprostone
cervical gel 0.5 mg/3gm
3
WESTHROID - thyroid tab 260
mg
PROSTIN E2 - dinoprostone
vaginal suppos 20 mg
3
WESTHROID - thyroid tab 325
mg (5 grain)
3
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
ENDOCRINE and METABOLIC AGENTS - MISC.
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
44
•
ACTONEL - risedronate
sodium tab 35 mg
2
•
ACTONEL - risedronate
sodium tab 150 mg
3
•
ALENDRONATE SODIUM alendronate sodium oral soln
70 mg/75ml
3
•
ALENDRONATE SODIUM alendronate sodium tab 40
mg
3
•
alendronate sodium tab
5 mg
1
•
1
•
1
•
1
•
ATELVIA - risedronate sodium
tab delayed release 35 mg
2
•
BINOSTO - alendronate
sodium effervescent tab 70
mg
3
BONIVA - ibandronate
sodium tab 150 mg (base
equivalent)
3
BRAVELLE - urofollitropin
purified for inj 75 unit
4
BUPHENYL - sodium
phenylbutyrate oral powder
3 gm/teaspoonful
4
•
•
BUPHENYL - sodium
phenylbutyrate tab 500 mg
4
•
•
cabergoline tab 0.5 mg
1
alendronate sodium tab
10 mg
alendronate sodium tab
35 mg
alendronate sodium tab
70 mg (Fosamax)
calcitonin (salmon)
nasal soln 200 unit/act
(Miacalcin)
1
calcitriol cap 0.25 mcg
(Rocaltrol)
1
calcitriol cap 0.5 mcg
(Rocaltrol)
1
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
1
CARBAGLU - carglumic acid
tab 200 mg
4
CARNITOR - levocarnitine oral
soln 1 gm/10ml (10%)
3
CARNITOR - levocarnitine tab
330 mg
3
CARNITOR SF - levocarnitine
oral soln 1 gm/10ml (10%)
3
CETROTIDE - cetrorelix
acetate for inj kit 0.25 mg
4
•
chorionic gonadotropin for
inj 10000 unit
4
•
clomiphene citrate tab
50 mg
3
3
•
DDAVP - desmopressin
acetate nasal soln 0.01%
(refrigerated)
3
•
DDAVP - desmopressin
acetate nasal spray soln
0.01%
DDAVP - desmopressin
acetate tab 0.1 mg
3
DDAVP - desmopressin
acetate tab 0.2 mg
3
desmopressin acetate nasal
soln 0.01% (refrigerated)
(Ddavp)
1
desmopressin acetate nasal
spray soln 0.01% (Ddavp)
1
desmopressin acetate
nasal spray soln 0.01%
(refrigerated)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
1
CYSTADANE - betaine powder
for oral solution
•
Limited Distribution
2
ACA Preventive
ACTONEL - risedronate
sodium tab 30 mg
Dispensing Limits
•
Step Therapy
2
Prior Authorization
ACTONEL - risedronate
sodium tab 5 mg
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
1
45
desmopressin acetate tab
0.1 mg (Ddavp)
desmopressin acetate tab
0.2 mg (Ddavp)
1
1
DIDRONEL - etidronate
disodium tab 400 mg
3
doxercalciferol cap 0.5 mcg
(Hectorol)
1
doxercalciferol cap 1 mcg
(Hectorol)
1
doxercalciferol cap 2.5 mcg
(Hectorol)
1
ETIDRONATE DISODIUM etidronate disodium tab 200
mg
3
ETIDRONATE DISODIUM etidronate disodium tab 400
mg
3
EVISTA - raloxifene hcl tab 60
mg
3
FOLLISTIM AQ - follitropin beta 4
inj 75 unit/0.5ml
FOLLISTIM AQ - follitropin beta 4
inj 300 unit/0.36ml
FOLLISTIM AQ - follitropin beta 4
inj 600 unit/0.72ml
FOLLISTIM AQ - follitropin beta 4
inj 900 unit/1.08ml
4
FORTEO - teriparatide
(recombinant) inj 600
mcg/2.4ml
3
FORTICAL - calcitonin
(salmon) nasal soln 200 unit/
act
3
FOSAMAX - alendronate
sodium tab 70 mg
3
FOSAMAX PLUS D alendronate sodiumcholecalciferol tab 70-2800
mg-unit
•
•
•
•
•
•
•
•
FOSAMAX PLUS D alendronate sodiumcholecalciferol tab 70-5600
mg-unit
3
GANIRELIX ACETATE ganirelix acetate inj 250
mcg/0.5ml
4
GENOTROPIN - somatropin for 4
inj 12 mg (13.8 mg overfill)
GENOTROPIN - somatropin for 4
subcutaneous inj 5 mg
4
GENOTROPIN MINIQUICK somatropin for inj 0.2 mg
4
GENOTROPIN MINIQUICK somatropin for inj 0.4 mg
4
GENOTROPIN MINIQUICK somatropin for inj 0.6 mg
4
GENOTROPIN MINIQUICK somatropin for inj 0.8 mg
4
GENOTROPIN MINIQUICK somatropin for inj 1 mg
4
GENOTROPIN MINIQUICK somatropin for inj 1.2 mg
4
GENOTROPIN MINIQUICK somatropin for inj 1.4 mg
4
GENOTROPIN MINIQUICK somatropin for inj 1.6 mg
4
GENOTROPIN MINIQUICK somatropin for inj 1.8 mg
4
GENOTROPIN MINIQUICK somatropin for inj 2 mg
GONAL-F - follitropin alfa for inj 4
450 unit
GONAL-F - follitropin alfa for inj 4
1050 unit
GONAL-F RFF - follitropin alfa 4
for inj 75 unit
GONAL-F RFF PEN - follitropin 4
alfa inj 300 unit/0.5ml
GONAL-F RFF PEN - follitropin 4
alfa inj 450 unit/0.75ml
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
46
•
GONAL-F RFF REDIJECT follitropin alfa inj 450
unit/0.75ml
4
•
GONAL-F RFF REDIJECT follitropin alfa inj 900
unit/1.5ml
4
H.P. ACTHAR - corticotropin inj
gel 80 unit/ml
4
HECTOROL - doxercalciferol
cap 0.5 mcg
3
HECTOROL - doxercalciferol
cap 1 mcg
3
HECTOROL - doxercalciferol
cap 2.5 mcg
3
HUMATROPE - somatropin for
inj 5 mg
4
•
•
HUMATROPE - somatropin for
inj 6 mg (18 unit)
4
•
•
HUMATROPE - somatropin for
inj 12 mg (36 unit)
4
•
•
HUMATROPE - somatropin for
inj 24 mg
4
•
•
HUMATROPE COMBO PACK - 4
somatropin for inj 5 mg
1
ibandronate sodium tab
150 mg (base equivalent)
(Boniva)
INCRELEX - mecasermin inj 40 4
mg/4ml (10 mg/ml)
4
KUVAN - sapropterin
dihydrochloride powder
packet 100 mg
4
KUVAN - sapropterin
dihydrochloride powder
packet 500 mg
•
•
•
levocarnitine oral soln
1 gm/10ml (10%) (Carnitor)
1
Limited Distribution
4
4
ACA Preventive
GONAL-F RFF REDIJECT follitropin alfa inj 300
unit/0.5ml
KUVAN - sapropterin
dihydrochloride soluble tab
100 mg
Dispensing Limits
•
Step Therapy
4
Prior Authorization
GONAL-F RFF PEN - follitropin
alfa inj 900 unit/1.5ml
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
levocarnitine tab 330 mg
(Carnitor)
1
•
LUPRON DEPOT-PED leuprolide acetate (3 month)
for inj pediatric kit 11.25 mg
4
•
•
LUPRON DEPOT-PED leuprolide acetate (3 month)
for inj pediatric kit 30 mg
4
•
LUPRON DEPOT-PED leuprolide acetate for inj
pediatric kit 7.5 mg
4
•
LUPRON DEPOT-PED leuprolide acetate for inj
pediatric kit 11.25 mg
4
•
LUPRON DEPOT-PED leuprolide acetate for inj
pediatric kit 15 mg
4
•
MENOPUR - menotropins for
subcutaneous inj 75 unit
4
•
MIACALCIN - calcitonin
(salmon) inj 200 unit/ml
3
MIACALCIN - calcitonin
(salmon) nasal soln 200 unit/
act
3
MYALEPT - metreleptin for
subcutaneous inj 11.3 mg
4
•
NATPARA - parathyroid
hormone (recombinant) for
inj cartridge 25 mcg
4
•
•
•
•
NATPARA - parathyroid
hormone (recombinant) for
inj cartridge 50 mcg
4
•
•
•
•
NATPARA - parathyroid
hormone (recombinant) for
inj cartridge 75 mcg
4
•
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
47
4
NORDITROPIN FLEXPRO somatropin inj 5 mg/1.5ml
4
•
•
NORDITROPIN FLEXPRO somatropin inj 10 mg/1.5ml
4
•
•
NORDITROPIN FLEXPRO somatropin inj 15 mg/1.5ml
4
•
•
NORDITROPIN FLEXPRO somatropin inj 30 mg/3ml
4
•
•
NORDITROPIN NORDIFLEX
PEN - somatropin inj 30
mg/3ml
4
•
•
NUTROPIN AQ NUSPIN 10 somatropin inj 10 mg/2ml
4
•
•
NUTROPIN AQ NUSPIN 20 somatropin inj 20 mg/2ml
4
•
•
NUTROPIN AQ NUSPIN 5 somatropin inj 5 mg/2ml
4
•
•
NUTROPIN AQ PEN somatropin inj 10 mg/2ml
4
•
•
NUTROPIN AQ PEN somatropin inj 20 mg/2ml
4
•
•
octreotide acetate inj
50 mcg/ml (0.05 mg/ml)
(Sandostatin)
4
octreotide acetate inj
100 mcg/ml (0.1 mg/ml)
(Sandostatin)
4
octreotide acetate inj
200 mcg/ml (0.2 mg/ml)
(Sandostatin)
4
•
octreotide acetate inj
500 mcg/ml (0.5 mg/ml)
(Sandostatin)
4
•
octreotide acetate inj
1000 mcg/ml (1 mg/ml)
(Sandostatin)
4
OMNITROPE - somatropin for
inj 5.8 mg
4
•
•
•
•
•
OMNITROPE - somatropin inj 5 4
mg/1.5ml
4
OMNITROPE - somatropin inj
10 mg/1.5ml
ORFADIN - nitisinone cap 2 mg 4
ORFADIN - nitisinone cap 5 mg 4
4
ORFADIN - nitisinone cap 10
mg
OSPHENA - ospemifene tab 60 3
mg
OVIDREL - choriogonadotropin 4
alfa inj 250 mcg/0.5ml
1
paricalcitol cap 1 mcg
(Zemplar)
1
paricalcitol cap 2 mcg
(Zemplar)
1
paricalcitol cap 4 mcg
(Zemplar)
1
raloxifene hcl tab 60 mg
(Evista)
4
RAVICTI - glycerol
phenylbutyrate liquid 1.1 gm/
ml
REPRONEX - menotropins for 4
inj 75 unit
1
risedronate sodium tab
delayed release 35 mg
(Atelvia)
risedronate sodium tab 5 mg 1
(Actonel)
1
risedronate sodium tab
30 mg (Actonel)
1
risedronate sodium tab
35 mg (Actonel)
1
risedronate sodium tab
150 mg (Actonel)
3
ROCALTROL - calcitriol cap
0.25 mcg
3
ROCALTROL - calcitriol cap
0.5 mcg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
Limited Distribution
ACA Preventive
Dispensing Limits
•
Step Therapy
Prior Authorization
•
NATPARA - parathyroid
hormone (recombinant) for
inj cartridge 100 mcg
Drug Name
Drug Tier
Limited Distribution
•
ACA Preventive
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
48
ROCALTROL - calcitriol oral
soln 1 mcg/ml
3
SAIZEN - somatropin (nonrefrigerated) for inj 5 mg
4
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
SEROSTIM - somatropin
(non-refrigerated) for
subcutaneous inj 4 mg
4
•
•
SEROSTIM - somatropin
(non-refrigerated) for
subcutaneous inj 5 mg
4
•
•
•
•
SAIZEN - somatropin (nonrefrigerated) for inj 8.8 mg
4
•
•
SAIZEN CLICK.EASY somatropin (nonrefrigerated) for inj 8.8 mg
4
•
•
SEROSTIM - somatropin
(non-refrigerated) for
subcutaneous inj 6 mg
4
•
•
SAMSCA - tolvaptan tab 15 mg
4
•
•
4
SANDOSTATIN - octreotide
acetate inj 50 mcg/ml (0.05
mg/ml)
4
SIGNIFOR - pasireotide
diaspartate inj 0.3 mg/ml
(base equiv)
4
SAMSCA - tolvaptan tab 30 mg
•
•
•
4
•
•
SANDOSTATIN - octreotide
acetate inj 100 mcg/ml (0.1
mg/ml)
4
•
SIGNIFOR - pasireotide
diaspartate inj 0.6 mg/ml
(base equiv)
4
•
•
SANDOSTATIN - octreotide
acetate inj 200 mcg/ml (0.2
mg/ml)
4
•
SIGNIFOR - pasireotide
diaspartate inj 0.9 mg/ml
(base equiv)
4
•
•
SANDOSTATIN - octreotide
acetate inj 500 mcg/ml (0.5
mg/ml)
4
•
sodium phenylbutyrate oral
powder 3 gm/teaspoonful
(Buphenyl)
SOMAVERT - pegvisomant for
inj 10 mg (as protein)
4
•
SANDOSTATIN - octreotide
acetate inj 1000 mcg/ml (1
mg/ml)
4
•
SOMAVERT - pegvisomant for
inj 15 mg (as protein)
4
•
4
•
SANDOSTATIN LAR DEPOT octreotide acetate for im inj
kit 10 mg
4
•
SOMAVERT - pegvisomant for
inj 20 mg (as protein)
SOMAVERT - pegvisomant for
inj 25 mg (as protein)
4
•
SANDOSTATIN LAR DEPOT octreotide acetate for im inj
kit 20 mg
4
•
SOMAVERT - pegvisomant for
inj 30 mg (as protein)
4
•
2
SANDOSTATIN LAR DEPOT octreotide acetate for im inj
kit 30 mg
4
STIMATE - desmopressin
acetate nasal soln 1.5 mg/ml
4
•
SENSIPAR - cinacalcet hcl tab
30 mg (base equiv)
2
STRENSIQ - asfotase alfa
subcutaneous inj 18
mg/0.45ml
4
•
SENSIPAR - cinacalcet hcl tab
60 mg (base equiv)
2
STRENSIQ - asfotase alfa
subcutaneous inj 28
mg/0.7ml
SENSIPAR - cinacalcet hcl tab
90 mg (base equiv)
2
STRENSIQ - asfotase alfa
subcutaneous inj 40 mg/ml
4
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
49
4
SYNAREL - nafarelin acetate
nasal soln 2 mg/ml
2
TEV-TROPIN - somatropin for
subcutaneous inj 5 mg
4
ZEMPLAR - paricalcitol cap 1
mcg
3
ZEMPLAR - paricalcitol cap 2
mcg
3
ZOMACTON - somatropin for
inj 10 mg
4
•
•
ZOMACTON - somatropin for
subcutaneous inj 5 mg
4
•
•
ZORBTIVE - somatropin
(non-refrigerated) for
subcutaneous inj 8.8 mg
4
•
•
CARDIOVASCULAR AGENTS
CARDIOTONICS
DIGOXIN - digoxin oral soln
0.05 mg/ml
3
digoxin tab 125 mcg
(0.125 mg) (Lanoxin)
1
digoxin tab 250 mcg
(0.25 mg) (Lanoxin)
1
LANOXIN - digoxin tab 62.5
mcg (0.0625 mg)
3
LANOXIN - digoxin tab 125
mcg (0.125 mg)
3
LANOXIN - digoxin tab 187.5
mcg (0.1875 mg)
3
LANOXIN - digoxin tab 250
mcg (0.25 mg)
1
LANOXIN - digoxin tab 250
mcg (0.25 mg)
3
ANTIANGINAL AGENTS
DILATRATE SR - isosorbide
dinitrate cap cr 40 mg
3
•
•
ISORDIL TITRADOSE isosorbide dinitrate tab 5 mg
3
ISORDIL TITRADOSE isosorbide dinitrate tab 40
mg
3
ISOSORBIDE DINITRATE isosorbide dinitrate tab 30
mg
3
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
•
STRENSIQ - asfotase alfa
subcutaneous inj 80
mg/0.8ml
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
ISOSORBIDE DINITRATE ER - 3
isosorbide dinitrate tab cr 40
mg
isosorbide dinitrate tab 5 mg 1
(Isordil titradose)
1
isosorbide dinitrate tab
10 mg
1
isosorbide dinitrate tab
20 mg
1
isosorbide mononitrate tab
sr 24hr 30 mg (Imdur)
1
isosorbide mononitrate tab
sr 24hr 60 mg (Imdur)
1
isosorbide mononitrate tab
sr 24hr 120 mg (Imdur)
1
isosorbide mononitrate tab
10 mg
1
isosorbide mononitrate tab
20 mg
3
NITRO-BID - nitroglycerin oint
2%
3
NITRO-DUR - nitroglycerin td
patch 24hr 0.1 mg/hr
3
NITRO-DUR - nitroglycerin td
patch 24hr 0.2 mg/hr
3
NITRO-DUR - nitroglycerin td
patch 24hr 0.3 mg/hr
3
NITRO-DUR - nitroglycerin td
patch 24hr 0.4 mg/hr
3
NITRO-DUR - nitroglycerin td
patch 24hr 0.6 mg/hr
3
NITRO-DUR - nitroglycerin td
patch 24hr 0.8 mg/hr
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
50
nitroglycerin cap cr 2.5 mg
nitroglycerin cap cr 6.5 mg
nitroglycerin cap cr 9 mg
1
1
1
atenolol tab 25 mg
(Tenormin)
1
atenolol tab 50 mg
(Tenormin)
1
atenolol tab 100 mg
(Tenormin)
1
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol
400 mcg/spray
3
nitroglycerin td patch 24hr
0.1 mg/hr (Nitro-dur)
1
BETAPACE - sotalol hcl tab 80
mg
3
1
BETAPACE - sotalol hcl tab
120 mg
3
1
BETAPACE - sotalol hcl tab
160 mg
3
1
BETAPACE AF - sotalol hcl
(afib/afl) tab 80 mg
3
nitroglycerin tl soln 0.4 mg/
spray (400 mcg/spray)
(Nitrolingual pumpspr)
1
BETAPACE AF - sotalol hcl
(afib/afl) tab 120 mg
3
3
NITROLINGUAL
PUMPSPRAY - nitroglycerin
tl soln 0.4 mg/spray (400
mcg/spray)
3
BETAPACE AF - sotalol hcl
(afib/afl) tab 160 mg
betaxolol hcl tab 10 mg
(Kerlone)
1
betaxolol hcl tab 20 mg
(Kerlone)
1
NITROMIST - nitroglycerin
lingual aerosol 400 mcg/
spray
3
1
NITROSTAT - nitroglycerin sl
tab 0.3 mg
2
bisoprolol fumarate tab 5 mg
(Zebeta)
1
NITROSTAT - nitroglycerin sl
tab 0.4 mg
2
bisoprolol fumarate tab
10 mg (Zebeta)
NITROSTAT - nitroglycerin sl
tab 0.6 mg
2
RANEXA - ranolazine tab sr
12hr 500 mg
3
RANEXA - ranolazine tab sr
12hr 1000 mg
3
nitroglycerin td patch 24hr
0.2 mg/hr (Nitro-dur)
nitroglycerin td patch 24hr
0.4 mg/hr (Nitro-dur)
nitroglycerin td patch 24hr
0.6 mg/hr (Nitro-dur)
BETA BLOCKERS
BYSTOLIC - nebivolol hcl tab
2.5 mg (base equivalent)
3
BYSTOLIC - nebivolol hcl tab 5
mg (base equivalent)
3
BYSTOLIC - nebivolol hcl tab
10 mg (base equivalent)
3
BYSTOLIC - nebivolol hcl tab
20 mg (base equivalent)
3
1
carvedilol tab 3.125 mg
(Coreg)
1
acebutolol hcl cap 200 mg
(Sectral)
1
carvedilol tab 6.25 mg
(Coreg)
1
acebutolol hcl cap 400 mg
(Sectral)
carvedilol tab 12.5 mg
(Coreg)
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
51
carvedilol tab 25 mg (Coreg)
1
3
COREG - carvedilol tab 3.125
mg
3
INNOPRAN XL - propranolol
hcl sustained-release beads
cap sr 24hr 120 mg
COREG - carvedilol tab 6.25
mg
3
KERLONE - betaxolol hcl tab
10 mg
3
COREG - carvedilol tab 12.5
mg
3
KERLONE - betaxolol hcl tab
20 mg
3
COREG - carvedilol tab 25 mg
3
1
COREG CR - carvedilol
phosphate cap sr 24hr 10
mg
3
labetalol hcl tab 100 mg
(Trandate)
labetalol hcl tab 200 mg
(Trandate)
1
COREG CR - carvedilol
phosphate cap sr 24hr 20
mg
3
labetalol hcl tab 300 mg
(Trandate)
1
3
COREG CR - carvedilol
phosphate cap sr 24hr 40
mg
3
LEVATOL - penbutolol sulfate
tab 20 mg
LOPRESSOR - metoprolol
tartrate tab 50 mg
3
COREG CR - carvedilol
phosphate cap sr 24hr 80
mg
3
LOPRESSOR - metoprolol
tartrate tab 100 mg
3
metoprolol succinate tab sr
24hr 25 mg (Toprol xl)
1
CORGARD - nadolol tab 20 mg 3
CORGARD - nadolol tab 40 mg 3
CORGARD - nadolol tab 80 mg 3
3
INDERAL LA - propranolol hcl
cap sr 24hr 60 mg
3
INDERAL LA - propranolol hcl
cap sr 24hr 80 mg
3
INDERAL LA - propranolol hcl
cap sr 24hr 120 mg
3
INDERAL LA - propranolol hcl
cap sr 24hr 160 mg
3
INDERAL XL - propranolol hcl
sustained-release beads cap
sr 24hr 80 mg
3
INDERAL XL - propranolol hcl
sustained-release beads cap
sr 24hr 120 mg
3
INNOPRAN XL - propranolol
hcl sustained-release beads
cap sr 24hr 80 mg
metoprolol succinate tab sr
24hr 50 mg (Toprol xl)
metoprolol succinate tab sr
24hr 100 mg (Toprol xl)
metoprolol succinate tab sr
24hr 200 mg (Toprol xl)
metoprolol tartrate tab
25 mg
metoprolol tartrate tab
50 mg (Lopressor)
metoprolol tartrate tab
100 mg (Lopressor)
nadolol tab 20 mg (Corgard)
nadolol tab 40 mg (Corgard)
nadolol tab 80 mg (Corgard)
pindolol tab 5 mg
pindolol tab 10 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
1
1
1
1
1
1
1
1
52
PROPRANOLOL HCL propranolol hcl oral soln 20
mg/5ml
3
PROPRANOLOL HCL propranolol hcl oral soln 40
mg/5ml
3
propranolol hcl cap sr 24hr
60 mg (Inderal la)
1
propranolol hcl cap sr 24hr
80 mg (Inderal la)
propranolol hcl cap sr 24hr
120 mg (Inderal la)
propranolol hcl cap sr 24hr
160 mg (Inderal la)
propranolol hcl tab 10 mg
propranolol hcl tab 20 mg
propranolol hcl tab 40 mg
propranolol hcl tab 60 mg
propranolol hcl tab 80 mg
1
1
1
1
1
1
1
1
SECTRAL - acebutolol hcl cap
200 mg
3
SECTRAL - acebutolol hcl cap
400 mg
3
sotalol hcl (afib/afl) tab
80 mg (Betapace af)
1
sotalol hcl (afib/afl) tab
120 mg (Betapace af)
sotalol hcl (afib/afl) tab
160 mg (Betapace af)
1
1
sotalol hcl tab 80 mg
(Betapace)
1
sotalol hcl tab 120 mg
(Betapace)
1
sotalol hcl tab 160 mg
(Betapace)
1
sotalol hcl tab 240 mg
1
SOTYLIZE - sotalol hcl oral
solution 5 mg/ml
3
TENORMIN - atenolol tab 25
mg
3
TENORMIN - atenolol tab 50
mg
3
TENORMIN - atenolol tab 100
mg
3
TIMOLOL MALEATE - timolol
maleate tab 5 mg
3
TIMOLOL MALEATE - timolol
maleate tab 10 mg
3
TIMOLOL MALEATE - timolol
maleate tab 20 mg
3
TOPROL XL - metoprolol
succinate tab sr 24hr 25 mg
3
TOPROL XL - metoprolol
succinate tab sr 24hr 50 mg
3
TOPROL XL - metoprolol
succinate tab sr 24hr 100
mg
3
TOPROL XL - metoprolol
succinate tab sr 24hr 200
mg
3
ZEBETA - bisoprolol fumarate
tab 5 mg
3
ZEBETA - bisoprolol fumarate
tab 10 mg
3
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
CALCIUM CHANNEL BLOCKERS
ADALAT CC - nifedipine tab sr 3
24hr 30 mg
ADALAT CC - nifedipine tab sr 3
24hr 60 mg
ADALAT CC - nifedipine tab sr 3
24hr 90 mg
1
amlodipine besylate tab
2.5 mg (Norvasc)
1
amlodipine besylate tab
5 mg (Norvasc)
1
amlodipine besylate tab
10 mg (Norvasc)
3
CALAN - verapamil hcl tab 80
mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
53
CALAN - verapamil hcl tab 120
mg
3
CALAN SR - verapamil hcl tab
cr 120 mg
3
CALAN SR - verapamil hcl tab
cr 180 mg
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr
360 mg
3
3
3
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr
420 mg
CALAN SR - verapamil hcl tab
cr 240 mg
3
diltiazem hcl cap sr 12hr
60 mg
1
CARDIZEM - diltiazem hcl tab
30 mg
3
diltiazem hcl cap sr 12hr
90 mg
CARDIZEM - diltiazem hcl tab
60 mg
3
diltiazem hcl cap sr 12hr
120 mg
CARDIZEM - diltiazem hcl tab
120 mg
3
diltiazem hcl cap sr 24hr
120 mg
CARDIZEM CD - diltiazem hcl
coated beads cap sr 24hr
120 mg
3
diltiazem hcl cap sr 24hr
180 mg
CARDIZEM CD - diltiazem hcl
coated beads cap sr 24hr
180 mg
3
diltiazem hcl cap sr 24hr
240 mg
1
CARDIZEM CD - diltiazem hcl
coated beads cap sr 24hr
240 mg
3
diltiazem hcl coated beads
cap sr 24hr 120 mg
(Cardizem cd)
1
CARDIZEM CD - diltiazem hcl
coated beads cap sr 24hr
300 mg
3
diltiazem hcl coated beads
cap sr 24hr 180 mg
(Cardizem cd)
1
CARDIZEM CD - diltiazem hcl
coated beads cap sr 24hr
360 mg
3
diltiazem hcl coated beads
cap sr 24hr 240 mg
(Cardizem cd)
1
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr
120 mg
3
diltiazem hcl coated beads
cap sr 24hr 300 mg
(Cardizem cd)
1
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr
180 mg
3
diltiazem hcl coated beads
cap sr 24hr 360 mg
(Cardizem cd)
1
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr
240 mg
3
diltiazem hcl coated beads
tab sr 24hr 180 mg
(Cardizem la)
1
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr
300 mg
3
diltiazem hcl coated beads
tab sr 24hr 240 mg
(Cardizem la)
diltiazem hcl coated beads
tab sr 24hr 300 mg
(Cardizem la)
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
1
1
54
diltiazem hcl coated beads
tab sr 24hr 360 mg
(Cardizem la)
1
diltiazem hcl coated beads
tab sr 24hr 420 mg
(Cardizem la)
1
nicardipine hcl cap 30 mg
nifedipine cap 10 mg
(Procardia)
1
diltiazem hcl extended
release beads cap sr 24hr
120 mg (Tiazac)
1
nifedipine cap 20 mg
1
diltiazem hcl extended
release beads cap sr 24hr
180 mg (Tiazac)
diltiazem hcl extended
release beads cap sr 24hr
240 mg (Tiazac)
diltiazem hcl extended
release beads cap sr 24hr
300 mg (Tiazac)
diltiazem hcl extended
release beads cap sr 24hr
360 mg (Tiazac)
diltiazem hcl extended
release beads cap sr 24hr
420 mg (Tiazac)
isradipine cap 5 mg
nicardipine hcl cap 20 mg
1
1
nifedipine tab sr 24hr 90 mg
(Adalat cc)
1
1
1
nifedipine tab sr 24hr
osmotic release 30 mg
(Procardia xl)
1
1
nifedipine tab sr 24hr
osmotic release 60 mg
(Procardia xl)
1
1
nifedipine tab sr 24hr
osmotic release 90 mg
(Procardia xl)
nimodipine cap 30 mg
1
diltiazem hcl tab 30 mg
(Cardizem)
1
NISOLDIPINE - nisoldipine tab
sr 24hr 20 mg
3
diltiazem hcl tab 60 mg
(Cardizem)
1
NISOLDIPINE - nisoldipine tab
sr 24hr 30 mg
3
diltiazem hcl tab 90 mg
1
NISOLDIPINE - nisoldipine tab
sr 24hr 40 mg
3
NISOLDIPINE ER - nisoldipine
tab sr 24hr 25.5 mg
3
nisoldipine tab sr 24hr
8.5 mg (Sular)
1
felodipine tab sr 24hr 2.5 mg
1
felodipine tab sr 24hr 5 mg
felodipine tab sr 24hr 10 mg
1
1
Limited Distribution
1
ISOPTIN SR - verapamil hcl
tab cr 120 mg
3
nisoldipine tab sr 24hr
17 mg (Sular)
ISOPTIN SR - verapamil hcl
tab cr 180 mg
3
nisoldipine tab sr 24hr
34 mg (Sular)
3
ISOPTIN SR - verapamil hcl
tab cr 240 mg
3
NORVASC - amlodipine
besylate tab 2.5 mg
3
isradipine cap 2.5 mg
1
NORVASC - amlodipine
besylate tab 5 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
ACA Preventive
1
nifedipine tab sr 24hr 60 mg
(Adalat cc)
1
Dispensing Limits
1
1
diltiazem hcl tab 120 mg
(Cardizem)
Step Therapy
1
nifedipine tab sr 24hr 30 mg
(Adalat cc)
1
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
55
NORVASC - amlodipine
besylate tab 10 mg
3
NYMALIZE - nimodipine oral
soln 60 mg/20ml
3
PROCARDIA - nifedipine cap
10 mg
3
PROCARDIA XL - nifedipine
tab sr 24hr osmotic release
30 mg
3
PROCARDIA XL - nifedipine
tab sr 24hr osmotic release
60 mg
3
PROCARDIA XL - nifedipine
tab sr 24hr osmotic release
90 mg
3
SULAR - nisoldipine tab sr 24hr 3
8.5 mg
SULAR - nisoldipine tab sr 24hr 3
17 mg
SULAR - nisoldipine tab sr 24hr 3
34 mg
3
TIAZAC - diltiazem hcl
extended release beads cap
sr 24hr 120 mg
3
TIAZAC - diltiazem hcl
extended release beads cap
sr 24hr 180 mg
3
TIAZAC - diltiazem hcl
extended release beads cap
sr 24hr 240 mg
3
TIAZAC - diltiazem hcl
extended release beads cap
sr 24hr 300 mg
3
TIAZAC - diltiazem hcl
extended release beads cap
sr 24hr 360 mg
3
TIAZAC - diltiazem hcl
extended release beads cap
sr 24hr 420 mg
1
verapamil hcl cap sr 24hr
100 mg (Verelan pm)
verapamil hcl cap sr 24hr
120 mg (Verelan)
verapamil hcl cap sr 24hr
180 mg (Verelan)
verapamil hcl cap sr 24hr
200 mg (Verelan pm)
verapamil hcl cap sr 24hr
240 mg (Verelan)
verapamil hcl cap sr 24hr
300 mg (Verelan pm)
verapamil hcl cap sr 24hr
360 mg (Verelan)
Limited Distribution
ACA Preventive
1
1
1
1
verapamil hcl tab cr 180 mg
(Calan sr)
1
verapamil hcl tab cr 240 mg
(Calan sr)
1
verapamil hcl tab 40 mg
1
verapamil hcl tab 80 mg
(Calan)
1
verapamil hcl tab 120 mg
(Calan)
1
VERELAN - verapamil hcl cap
sr 24hr 120 mg
3
VERELAN - verapamil hcl cap
sr 24hr 180 mg
3
VERELAN - verapamil hcl cap
sr 24hr 240 mg
3
VERELAN - verapamil hcl cap
sr 24hr 360 mg
3
VERELAN PM - verapamil hcl
cap sr 24hr 100 mg
3
VERELAN PM - verapamil hcl
cap sr 24hr 200 mg
3
VERELAN PM - verapamil hcl
cap sr 24hr 300 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Dispensing Limits
1
1
amiodarone hcl tab 100 mg
Step Therapy
1
verapamil hcl tab cr 120 mg
(Calan sr)
ANTIARRHYTHMICS
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
56
amiodarone hcl tab 200 mg
(Cordarone)
1
amiodarone hcl tab 400 mg
1
quinidine gluconate tab cr
324 mg
3
CORDARONE - amiodarone
hcl tab 200 mg
3
1
disopyramide phosphate
cap 100 mg (Norpace)
1
QUINIDINE SULFATE quinidine sulfate tab 300 mg
3
1
QUINIDINE SULFATE ER quinidine sulfate tab cr 300
mg
1
RYTHMOL - propafenone hcl
tab 150 mg
2
RYTHMOL - propafenone hcl
tab 225 mg
2
RYTHMOL SR - propafenone
hcl cap sr 12hr 225 mg
3
RYTHMOL SR - propafenone
hcl cap sr 12hr 325 mg
3
RYTHMOL SR - propafenone
hcl cap sr 12hr 425 mg
3
MULTAQ - dronedarone hcl tab
400 mg (base equivalent)
2
TIKOSYN - dofetilide cap 125
mcg (0.125 mg)
3
NORPACE - disopyramide
phosphate cap 100 mg
3
TIKOSYN - dofetilide cap 250
mcg (0.25 mg)
3
NORPACE - disopyramide
phosphate cap 150 mg
3
3
3
NORPACE CR - disopyramide
phosphate cap sr 12hr 100
mg
TIKOSYN - dofetilide cap 500
mcg (0.5 mg)
NORPACE CR - disopyramide
phosphate cap sr 12hr 150
mg
3
propafenone hcl cap sr 12hr
225 mg (Rythmol sr)
1
flecainide acetate tab 50 mg
flecainide acetate tab
100 mg
flecainide acetate tab
150 mg
mexiletine hcl cap 150 mg
mexiletine hcl cap 200 mg
mexiletine hcl cap 250 mg
propafenone hcl cap sr 12hr
325 mg (Rythmol sr)
propafenone hcl cap sr 12hr
425 mg (Rythmol sr)
1
1
1
1
1
ANTIHYPERTENSIVES
1
1
propafenone hcl tab 150 mg
(Rythmol)
1
propafenone hcl tab 225 mg
(Rythmol)
1
propafenone hcl tab 300 mg
1
ACCUPRIL - quinapril hcl tab 5
mg
3
ACCUPRIL - quinapril hcl tab
10 mg
3
ACCUPRIL - quinapril hcl tab
20 mg
3
ACCUPRIL - quinapril hcl tab
40 mg
3
ACCURETIC - quinaprilhydrochlorothiazide tab
10-12.5 mg
3
ACCURETIC - quinaprilhydrochlorothiazide tab
20-12.5 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
QUINIDINE SULFATE quinidine sulfate tab 200 mg
disopyramide phosphate
cap 150 mg (Norpace)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
57
ACCURETIC - quinaprilhydrochlorothiazide tab
20-25 mg
3
ACEON - perindopril erbumine
tab 4 mg
3
ACEON - perindopril erbumine
tab 8 mg
3
ALTACE - ramipril cap 1.25 mg
3
ALTACE - ramipril cap 2.5 mg
3
ALTACE - ramipril cap 5 mg
3
ALTACE - ramipril cap 10 mg
3
amlodipine besylatebenazepril hcl cap
2.5-10 mg (Lotrel)
amlodipine-valsartanhydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)
amlodipine-valsartanhydrochlorothiazide tab
5-160-25 mg (Exforge hct)
1
1
amlodipine-valsartanhydrochlorothiazide tab
10-160-25 mg (Exforge hct)
amlodipine besylatebenazepril hcl cap 5-10 mg
(Lotrel)
1
amlodipine-valsartanhydrochlorothiazide tab
10-320-25 mg (Exforge hct)
amlodipine besylatebenazepril hcl cap 5-20 mg
(Lotrel)
1
amlodipine besylatebenazepril hcl cap 5-40 mg
(Lotrel)
1
amlodipine besylatebenazepril hcl cap
10-20 mg (Lotrel)
1
amlodipine besylatevalsartan tab 5-160 mg
(Exforge)
1
amlodipine besylatevalsartan tab 5-320 mg
(Exforge)
1
amlodipine besylatevalsartan tab 10-160 mg
(Exforge)
1
amlodipine besylatevalsartan tab 10-320 mg
(Exforge)
1
Limited Distribution
ACA Preventive
1
ATACAND - candesartan
cilexetil tab 4 mg
3
•
ATACAND - candesartan
cilexetil tab 8 mg
3
•
ATACAND - candesartan
cilexetil tab 16 mg
3
•
ATACAND - candesartan
cilexetil tab 32 mg
3
•
ATACAND HCT - candesartan
cilexetil-hydrochlorothiazide
tab 16-12.5 mg
3
•
ATACAND HCT - candesartan
cilexetil-hydrochlorothiazide
tab 32-12.5 mg
3
•
ATACAND HCT - candesartan
cilexetil-hydrochlorothiazide
tab 32-25 mg
3
•
atenolol & chlorthalidone
tab 50-25 mg (Tenoretic 50)
1
atenolol & chlorthalidone
tab 100-25 mg (Tenoretic
100)
1
AVALIDE - irbesartanhydrochlorothiazide tab
150-12.5 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Dispensing Limits
1
1
1
Step Therapy
1
amlodipine-valsartanhydrochlorothiazide tab
10-160-12.5 mg (Exforge
hct)
amlodipine besylatebenazepril hcl cap
10-40 mg (Lotrel)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
58
•
BENICAR - olmesartan
medoxomil tab 20 mg
3
•
•
BENICAR - olmesartan
medoxomil tab 40 mg
3
AVAPRO - irbesartan tab 150
mg
3
•
3
•
•
AZOR - amlodipine besylateolmesartan medoxomil tab
5-20 mg
3
•
BENICAR HCT olmesartan medoxomilhydrochlorothiazide tab
20-12.5 mg
3
AVAPRO - irbesartan tab 300
mg
3
•
AZOR - amlodipine besylateolmesartan medoxomil tab
5-40 mg
3
BENICAR HCT olmesartan medoxomilhydrochlorothiazide tab
40-12.5 mg
•
AZOR - amlodipine besylateolmesartan medoxomil tab
10-20 mg
•
3
3
BENICAR HCT olmesartan medoxomilhydrochlorothiazide tab
40-25 mg
AZOR - amlodipine besylateolmesartan medoxomil tab
10-40 mg
3
•
bisoprolol &
hydrochlorothiazide tab
2.5-6.25 mg (Ziac)
1
benazepril &
hydrochlorothiazide tab
5-6.25 mg
1
bisoprolol &
hydrochlorothiazide tab
5-6.25 mg (Ziac)
1
bisoprolol &
hydrochlorothiazide tab
10-6.25 mg (Ziac)
1
candesartan cilexetil tab
4 mg (Atacand)
AVAPRO - irbesartan tab 75
mg
3
benazepril &
hydrochlorothiazide tab
10-12.5 mg (Lotensin hct)
benazepril &
hydrochlorothiazide tab
20-12.5 mg (Lotensin hct)
benazepril &
hydrochlorothiazide tab
20-25 mg (Lotensin hct)
benazepril hcl tab 5 mg
1
1
benazepril hcl tab 10 mg
(Lotensin)
1
benazepril hcl tab 20 mg
(Lotensin)
1
benazepril hcl tab 40 mg
(Lotensin)
1
•
candesartan cilexetil tab
8 mg (Atacand)
candesartan cilexetil tab
16 mg (Atacand)
candesartan cilexetil tab
32 mg (Atacand)
candesartan cilexetilhydrochlorothiazide tab
16-12.5 mg (Atacand hct)
candesartan cilexetilhydrochlorothiazide tab
32-12.5 mg (Atacand hct)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
•
ACA Preventive
3
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA Preventive
Drug Name
BENICAR - olmesartan
medoxomil tab 5 mg
AVALIDE - irbesartanhydrochlorothiazide tab
300-12.5 mg
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
1
1
1
1
1
59
candesartan cilexetilhydrochlorothiazide tab
32-25 mg (Atacand hct)
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
1
CATAPRES-TTS-1 - clonidine
hcl td patch weekly 0.1
mg/24hr
3
1
CATAPRES-TTS-2 - clonidine
hcl td patch weekly 0.2
mg/24hr
3
CATAPRES-TTS-3 - clonidine
hcl td patch weekly 0.3
mg/24hr
3
clonidine hcl tab 0.1 mg
(Catapres)
1
clonidine hcl tab 0.2 mg
(Catapres)
1
clonidine hcl tab 0.3 mg
(Catapres)
1
clonidine hcl td patch
weekly 0.1 mg/24hr
(Catapres-tts-1)
1
clonidine hcl td patch
weekly 0.2 mg/24hr
(Catapres-tts-2)
1
clonidine hcl td patch
weekly 0.3 mg/24hr
(Catapres-tts-3)
1
CLORPRES - clonidine &
chlorthalidone tab 0.1-15 mg
3
1
1
1
CAPTOPRIL/
HYDROCHLOROTHIA captopril &
hydrochlorothiazide tab
25-15 mg
3
CAPTOPRIL/
HYDROCHLOROTHIA captopril &
hydrochlorothiazide tab
25-25 mg
3
CAPTOPRIL/
HYDROCHLOROTHIA captopril &
hydrochlorothiazide tab
50-15 mg
3
CAPTOPRIL/
HYDROCHLOROTHIA captopril &
hydrochlorothiazide tab
50-25 mg
3
CARDURA - doxazosin
mesylate tab 1 mg
3
CLORPRES - clonidine &
chlorthalidone tab 0.2-15 mg
3
CARDURA - doxazosin
mesylate tab 2 mg
3
CLORPRES - clonidine &
chlorthalidone tab 0.3-15 mg
3
CARDURA - doxazosin
mesylate tab 4 mg
3
3
CARDURA - doxazosin
mesylate tab 8 mg
3
CORZIDE - nadolol &
bendroflumethiazide tab
40-5 mg
3
CATAPRES - clonidine hcl tab
0.1 mg
3
CORZIDE - nadolol &
bendroflumethiazide tab
80-5 mg
3
COZAAR - losartan potassium
tab 25 mg
3
CATAPRES - clonidine hcl tab
0.2 mg
•
3
COZAAR - losartan potassium
tab 50 mg
3
CATAPRES - clonidine hcl tab
0.3 mg
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
60
COZAAR - losartan potassium
tab 100 mg
3
DEMSER - metyrosine cap 250
mg
3
DIBENZYLINE phenoxybenzamine hcl cap
10 mg
3
DIOVAN - valsartan tab 40 mg
3
DIOVAN - valsartan tab 80 mg
3
DIOVAN HCT - valsartanhydrochlorothiazide tab
80-12.5 mg
3
•
•
•
•
•
DIOVAN HCT - valsartanhydrochlorothiazide tab
160-12.5 mg
3
•
DIOVAN HCT - valsartanhydrochlorothiazide tab
160-25 mg
3
•
DIOVAN HCT - valsartanhydrochlorothiazide tab
320-12.5 mg
3
•
DIOVAN HCT - valsartanhydrochlorothiazide tab
320-25 mg
3
•
doxazosin mesylate tab
1 mg (Cardura)
1
DIOVAN - valsartan tab 160 mg 3
DIOVAN - valsartan tab 320 mg 3
doxazosin mesylate tab
2 mg (Cardura)
doxazosin mesylate tab
4 mg (Cardura)
doxazosin mesylate tab
8 mg (Cardura)
1
1
1
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr
24hr 25-12.5 mg
3
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr
24hr 50-12.5 mg
3
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr
24hr 100-12.5 mg
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
3
EDARBI - azilsartan medoxomil 3
tab 40 mg
EDARBI - azilsartan medoxomil 3
tab 80 mg
3
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone
tab 40-12.5 mg
3
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone
tab 40-25 mg
1
enalapril maleate &
hydrochlorothiazide tab
5-12.5 mg
1
enalapril maleate &
hydrochlorothiazide tab
10-25 mg (Vaseretic)
1
enalapril maleate tab 2.5 mg
(Vasotec)
1
enalapril maleate tab 5 mg
(Vasotec)
1
enalapril maleate tab 10 mg
(Vasotec)
1
enalapril maleate tab 20 mg
(Vasotec)
EPANED - enalapril maleate for 3
oral soln 1 mg/ml
1
eplerenone tab 25 mg
(Inspra)
1
eplerenone tab 50 mg
(Inspra)
3
EPROSARTAN MESYLATE eprosartan mesylate tab 600
mg
3
EXFORGE - amlodipine
besylate-valsartan tab 5-160
mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
61
EXFORGE - amlodipine
besylate-valsartan tab 5-320
mg
3
EXFORGE - amlodipine
besylate-valsartan tab
10-160 mg
3
EXFORGE - amlodipine
besylate-valsartan tab
10-320 mg
3
EXFORGE HCT amlodipine-valsartanhydrochlorothiazide tab
5-160-12.5 mg
3
EXFORGE HCT amlodipine-valsartanhydrochlorothiazide tab
5-160-25 mg
3
EXFORGE HCT amlodipine-valsartanhydrochlorothiazide tab
10-160-12.5 mg
3
EXFORGE HCT amlodipine-valsartanhydrochlorothiazide tab
10-160-25 mg
3
EXFORGE HCT amlodipine-valsartanhydrochlorothiazide tab
10-320-25 mg
3
fosinopril sodium &
hydrochlorothiazide tab
10-12.5 mg
1
irbesartanhydrochlorothiazide tab
300-12.5 mg (Avalide)
1
lisinopril &
hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
1
lisinopril &
hydrochlorothiazide tab
20-12.5 mg (Zestoretic)
fosinopril sodium &
hydrochlorothiazide tab
20-12.5 mg
fosinopril sodium tab 10 mg
fosinopril sodium tab 20 mg
fosinopril sodium tab 40 mg
hydralazine hcl tab 10 mg
hydralazine hcl tab 25 mg
1
1
guanfacine hcl tab 1 mg
(Tenex)
1
guanfacine hcl tab 2 mg
(Tenex)
1
1
•
HYZAAR - losartan potassium
& hydrochlorothiazide tab
50-12.5 mg
3
•
•
HYZAAR - losartan potassium
& hydrochlorothiazide tab
100-12.5 mg
3
•
3
•
•
HYZAAR - losartan potassium
& hydrochlorothiazide tab
100-25 mg
INSPRA - eplerenone tab 25
mg
3
•
INSPRA - eplerenone tab 50
mg
3
irbesartan tab 75 mg
(Avapro)
1
irbesartan tab 150 mg
(Avapro)
1
irbesartan tab 300 mg
(Avapro)
1
irbesartanhydrochlorothiazide tab
150-12.5 mg (Avalide)
1
•
lisinopril &
hydrochlorothiazide tab
20-25 mg (Zestoretic)
lisinopril tab 2.5 mg (Zestril)
lisinopril tab 5 mg (Prinivil)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
1
hydralazine hcl tab 50 mg
•
ACA Preventive
1
•
hydralazine hcl tab 100 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
1
1
1
1
62
lisinopril tab 10 mg (Prinivil)
lisinopril tab 20 mg (Prinivil)
lisinopril tab 30 mg (Zestril)
lisinopril tab 40 mg (Zestril)
1
1
1
1
LOPRESSOR HCT metoprolol &
hydrochlorothiazide tab
50-25 mg
3
LOPRESSOR HCT metoprolol &
hydrochlorothiazide tab
100-25 mg
3
losartan potassium &
hydrochlorothiazide tab
50-12.5 mg (Hyzaar)
1
losartan potassium &
hydrochlorothiazide tab
100-12.5 mg (Hyzaar)
losartan potassium &
hydrochlorothiazide tab
100-25 mg (Hyzaar)
losartan potassium tab
25 mg (Cozaar)
losartan potassium tab
50 mg (Cozaar)
losartan potassium tab
100 mg (Cozaar)
1
LOTENSIN HCT - benazepril
& hydrochlorothiazide tab
20-25 mg
Limited Distribution
ACA Preventive
Dispensing Limits
LOTREL - amlodipine besylate- 3
benazepril hcl cap 2.5-10 mg
LOTREL - amlodipine besylate- 3
benazepril hcl cap 5-10 mg
LOTREL - amlodipine besylate- 3
benazepril hcl cap 5-20 mg
LOTREL - amlodipine besylate- 3
benazepril hcl cap 10-20 mg
LOTREL - amlodipine besylate- 3
benazepril hcl cap 10-40 mg
3
MAVIK - trandolapril tab 1 mg
MAVIK - trandolapril tab 2 mg
3
MAVIK - trandolapril tab 4 mg
3
methyldopa tab 250 mg
1
1
methyldopa tab 500 mg
3
1
METHYLDOPA/
HYDROCHLOROTHI methyldopa &
hydrochlorothiazide tab
250-15 mg
METHYLDOPA/
HYDROCHLOROTHI methyldopa &
hydrochlorothiazide tab
250-25 mg
3
metoprolol &
hydrochlorothiazide tab
50-25 mg (Lopressor hct)
1
1
Step Therapy
3
1
1
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
LOTENSIN - benazepril hcl tab
10 mg
3
LOTENSIN - benazepril hcl tab
20 mg
3
LOTENSIN - benazepril hcl tab
40 mg
3
LOTENSIN HCT - benazepril
& hydrochlorothiazide tab
10-12.5 mg
3
metoprolol &
hydrochlorothiazide tab
100-25 mg (Lopressor hct)
LOTENSIN HCT - benazepril
& hydrochlorothiazide tab
20-12.5 mg
3
metoprolol &
hydrochlorothiazide tab
100-50 mg
1
1
MICARDIS - telmisartan tab 20
mg
3
•
MICARDIS - telmisartan tab 40
mg
3
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
63
3
MINIPRESS - prazosin hcl cap
1 mg
3
MINIPRESS - prazosin hcl cap
2 mg
3
MINIPRESS - prazosin hcl cap
5 mg
3
minoxidil tab 2.5 mg
1
minoxidil tab 10 mg
1
•
1
1
1
prazosin hcl cap 1 mg
(Minipress)
1
prazosin hcl cap 2 mg
(Minipress)
1
prazosin hcl cap 5 mg
(Minipress)
1
PRESTALIA - perindopril
arginine-amlodipine besylate
tab 3.5-2.5 mg
3
PRESTALIA - perindopril
arginine-amlodipine besylate
tab 7-5 mg
3
3
moexipril hcl tab 7.5 mg
(Univasc)
1
PRESTALIA - perindopril
arginine-amlodipine besylate
tab 14-10 mg
moexipril hcl tab 15 mg
(Univasc)
1
PRINIVIL - lisinopril tab 5 mg
3
PRINIVIL - lisinopril tab 10 mg
3
moexiprilhydrochlorothiazide tab
7.5-12.5 mg
1
PRINIVIL - lisinopril tab 20 mg
3
3
1
PRINZIDE - lisinopril &
hydrochlorothiazide tab
10-12.5 mg
PROPRANOLOL/
HYDROCHLOROTH propranolol &
hydrochlorothiazide tab
40-25 mg
3
PROPRANOLOL/
HYDROCHLOROTH propranolol &
hydrochlorothiazide tab
80-25 mg
3
quinapril hcl tab 5 mg
(Accupril)
1
quinapril hcl tab 10 mg
(Accupril)
1
moexiprilhydrochlorothiazide tab
15-12.5 mg (Uniretic)
moexiprilhydrochlorothiazide tab
15-25 mg
nadolol &
bendroflumethiazide tab
40-5 mg (Corzide)
nadolol &
bendroflumethiazide tab
80-5 mg (Corzide)
perindopril erbumine tab
2 mg
1
1
1
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
MICARDIS HCT - telmisartanhydrochlorothiazide tab
80-25 mg
•
phenoxybenzamine hcl cap
10 mg (Dibenzyline)
ACA Preventive
MICARDIS HCT - telmisartanhydrochlorothiazide tab
80-12.5 mg
3
perindopril erbumine tab
8 mg (Aceon)
Dispensing Limits
•
Step Therapy
3
perindopril erbumine tab
4 mg (Aceon)
Prior Authorization
MICARDIS HCT - telmisartanhydrochlorothiazide tab
40-12.5 mg
Drug Name
Drug Tier
•
Limited Distribution
3
ACA Preventive
MICARDIS - telmisartan tab 80
mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
64
quinapril hcl tab 20 mg
(Accupril)
1
quinapril hcl tab 40 mg
(Accupril)
1
quinaprilhydrochlorothiazide tab
10-12.5 mg (Accuretic)
1
quinaprilhydrochlorothiazide tab
20-12.5 mg (Accuretic)
quinaprilhydrochlorothiazide tab
20-25 mg (Accuretic)
ramipril cap 1.25 mg (Altace)
ramipril cap 2.5 mg (Altace)
ramipril cap 5 mg (Altace)
ramipril cap 10 mg (Altace)
1
1
1
1
3
•
telmisartan tab 20 mg
(Micardis)
1
telmisartan tab 40 mg
(Micardis)
1
telmisartan tab 80 mg
(Micardis)
1
telmisartan-amlodipine tab
40-5 mg (Twynsta)
1
RESERPINE - reserpine tab
0.1 mg
3
RESERPINE - reserpine tab
0.25 mg
3
TARKA - trandolapril-verapamil
hcl tab cr 1-240 mg
3
TARKA - trandolapril-verapamil
hcl tab cr 2-180 mg
3
TARKA - trandolapril-verapamil
hcl tab cr 2-240 mg
3
TARKA - trandolapril-verapamil
hcl tab cr 4-240 mg
3
TEKTURNA - aliskiren
fumarate tab 150 mg (base
equivalent)
3
TEKTURNA - aliskiren
fumarate tab 300 mg (base
equivalent)
3
•
TEKTURNA HCT - aliskirenhydrochlorothiazide tab
150-12.5 mg
3
•
TEKTURNA HCT - aliskirenhydrochlorothiazide tab
150-25 mg
3
•
telmisartan-amlodipine tab
80-10 mg (Twynsta)
telmisartanhydrochlorothiazide tab
40-12.5 mg (Micardis hct)
telmisartanhydrochlorothiazide tab
80-12.5 mg (Micardis hct)
telmisartanhydrochlorothiazide tab
80-25 mg (Micardis hct)
•
1
1
1
1
1
1
TENEX - guanfacine hcl tab 1
mg
3
TENEX - guanfacine hcl tab 2
mg
3
TENORETIC 100 - atenolol &
chlorthalidone tab 100-25
mg
3
TENORETIC 50 - atenolol &
chlorthalidone tab 50-25 mg
3
terazosin hcl cap 1 mg
1
terazosin hcl cap 2 mg
terazosin hcl cap 5 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
TEKTURNA HCT - aliskirenhydrochlorothiazide tab
300-25 mg
ACA Preventive
•
Dispensing Limits
3
telmisartan-amlodipine tab
80-5 mg (Twynsta)
1
Step Therapy
TEKTURNA HCT - aliskirenhydrochlorothiazide tab
300-12.5 mg
telmisartan-amlodipine tab
40-10 mg (Twynsta)
1
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
65
terazosin hcl cap 10 mg
1
TEVETEN - eprosartan
mesylate tab 600 mg
3
trandolapril tab 1 mg (Mavik)
1
trandolapril tab 2 mg (Mavik)
trandolapril tab 4 mg (Mavik)
trandolapril-verapamil hcl
tab cr 1-240 mg (Tarka)
trandolapril-verapamil hcl
tab cr 2-180 mg (Tarka)
trandolapril-verapamil hcl
tab cr 2-240 mg (Tarka)
trandolapril-verapamil hcl
tab cr 4-240 mg (Tarka)
•
TWYNSTA - telmisartanamlodipine tab 80-10 mg
3
valsartan tab 40 mg (Diovan)
1
valsartan tab 80 mg (Diovan)
1
1
1
valsartan tab 320 mg
(Diovan)
1
1
valsartanhydrochlorothiazide tab
80-12.5 mg (Diovan hct)
1
1
valsartanhydrochlorothiazide tab
160-12.5 mg (Diovan hct)
1
•
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab
20-5-12.5 mg
3
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab
40-5-12.5 mg
3
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab
40-5-25 mg
3
•
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab
40-10-12.5 mg
3
•
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab
40-10-25 mg
3
•
valsartanhydrochlorothiazide tab
160-25 mg (Diovan hct)
valsartanhydrochlorothiazide tab
320-12.5 mg (Diovan hct)
valsartanhydrochlorothiazide tab
320-25 mg (Diovan hct)
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
1
1
1
VASERETIC enalapril maleate &
hydrochlorothiazide tab
10-25 mg
3
VASOTEC - enalapril maleate
tab 2.5 mg
3
•
VASOTEC - enalapril maleate
tab 5 mg
3
VASOTEC - enalapril maleate
tab 10 mg
3
•
VASOTEC - enalapril maleate
tab 20 mg
3
TWYNSTA - telmisartanamlodipine tab 40-5 mg
3
TWYNSTA - telmisartanamlodipine tab 40-10 mg
3
•
TWYNSTA - telmisartanamlodipine tab 80-5 mg
3
•
VECAMYL - mecamylamine hcl 3
tab 2.5 mg
3
ZESTORETIC - lisinopril &
hydrochlorothiazide tab
10-12.5 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
1
valsartan tab 160 mg
(Diovan)
1
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
66
ZESTORETIC - lisinopril &
hydrochlorothiazide tab
20-12.5 mg
3
ZESTORETIC - lisinopril &
hydrochlorothiazide tab
20-25 mg
3
ZESTRIL - lisinopril tab 2.5 mg
3
ZESTRIL - lisinopril tab 5 mg
3
ZESTRIL - lisinopril tab 10 mg
3
ZESTRIL - lisinopril tab 20 mg
3
BUMEX - bumetanide tab 0.5
mg
3
ZESTRIL - lisinopril tab 30 mg
3
ZESTRIL - lisinopril tab 40 mg
3
BUMEX - bumetanide tab 1 mg
3
ZIAC - bisoprolol &
hydrochlorothiazide tab
2.5-6.25 mg
3
BUMEX - bumetanide tab 2 mg
3
3
ZIAC - bisoprolol &
hydrochlorothiazide tab
5-6.25 mg
3
CHLOROTHIAZIDE chlorothiazide tab 250 mg
chlorothiazide tab 500 mg
1
ZIAC - bisoprolol &
hydrochlorothiazide tab
10-6.25 mg
3
DIURETICS
ACETAZOLAMIDE acetazolamide tab 125 mg
3
acetazolamide cap sr 12hr
500 mg (Diamox)
1
acetazolamide tab 250 mg
1
ALDACTONE - spironolactone
tab 100 mg
3
amiloride &
hydrochlorothiazide tab
5-50 mg
1
amiloride hcl tab 5 mg
bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
1
1
1
CHLORTHALIDONE chlorthalidone tab 25 mg
3
CHLORTHALIDONE chlorthalidone tab 50 mg
3
DEMADEX - torsemide tab 5
mg
3
DEMADEX - torsemide tab 10
mg
3
DEMADEX - torsemide tab 20
mg
3
DIAMOX - acetazolamide cap
sr 12hr 500 mg
3
DIURIL - chlorothiazide susp
250 mg/5ml
3
DYAZIDE - triamterene &
hydrochlorothiazide cap
37.5-25 mg
3
3
ALDACTAZIDE spironolactone &
hydrochlorothiazide tab
25-25 mg
3
ALDACTAZIDE spironolactone &
hydrochlorothiazide tab
50-50 mg
3
ALDACTONE - spironolactone
tab 25 mg
3
DYRENIUM - triamterene cap
50 mg
3
ALDACTONE - spironolactone
tab 50 mg
3
DYRENIUM - triamterene cap
100 mg
EDECRIN - ethacrynic acid tab
25 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
67
FUROSEMIDE - furosemide
oral soln 8 mg/ml
3
furosemide oral soln 10 mg/
ml
furosemide tab 20 mg (Lasix)
furosemide tab 40 mg (Lasix)
furosemide tab 80 mg (Lasix)
hydrochlorothiazide cap
12.5 mg (Microzide)
hydrochlorothiazide tab
12.5 mg
hydrochlorothiazide tab
25 mg
hydrochlorothiazide tab
50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
3
1
MICROZIDE hydrochlorothiazide cap 12.5
mg
3
1
NEPTAZANE - methazolamide
tab 25 mg
NEPTAZANE - methazolamide
tab 50 mg
3
spironolactone &
hydrochlorothiazide tab
25-25 mg (Aldactazide)
1
1
1
1
1
1
1
1
1
KEVEYIS - dichlorphenamide
tab 50 mg
3
LASIX - furosemide tab 20 mg
3
LASIX - furosemide tab 40 mg
3
LASIX - furosemide tab 80 mg
3
MAXZIDE - triamterene &
hydrochlorothiazide tab
75-50 mg
3
MAXZIDE-25 - triamterene
& hydrochlorothiazide tab
37.5-25 mg
3
methazolamide tab 25 mg
(Neptazane)
1
methazolamide tab 50 mg
(Neptazane)
1
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
3
metolazone tab 2.5 mg
(Zaroxolyn)
1
metolazone tab 5 mg
(Zaroxolyn)
1
metolazone tab 10 mg
1
•
spironolactone tab 25 mg
(Aldactone)
1
spironolactone tab 50 mg
(Aldactone)
1
spironolactone tab 100 mg
(Aldactone)
1
torsemide tab 5 mg
(Demadex)
1
torsemide tab 10 mg
(Demadex)
1
torsemide tab 20 mg
(Demadex)
1
torsemide tab 100 mg
(Demadex)
1
triamterene &
hydrochlorothiazide cap
37.5-25 mg (Dyazide)
1
triamterene &
hydrochlorothiazide tab
37.5-25 mg (Maxzide-25)
triamterene &
hydrochlorothiazide tab
75-50 mg (Maxzide)
TRIAMTERENE/
HYDROCHLOROTH triamterene &
hydrochlorothiazide cap
50-25 mg
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
3
VASOPRESSORS
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
68
ADRENACLICK - epinephrine
solution auto-injector 0.15
mg/0.15ml (1:1000)
3
ADRENACLICK - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
3
AUVI-Q - epinephrine solution
auto-injector 0.15 mg/0.15ml
(1:1000)
3
AUVI-Q - epinephrine solution
auto-injector 0.3 mg/0.3ml
(1:1000)
3
EPINEPHRINE - epinephrine
solution auto-injector 0.15
mg/0.15ml (1:1000)
3
EPINEPHRINE - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
3
EPIPEN 2-PAK - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
2
EPIPEN-JR 2-PAK epinephrine solution autoinjector 0.15 mg/0.3ml
(1:2000)
2
midodrine hcl tab 2.5 mg
1
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
1
1
NORTHERA - droxidopa cap
100 mg
3
•
•
•
NORTHERA - droxidopa cap
200 mg
3
•
•
•
NORTHERA - droxidopa cap
300 mg
3
•
•
•
ANTIHYPERLIPIDEMICS
ADVICOR - niacin-lovastatin
tab sr 24hr 500-20 mg
3
•
ADVICOR - niacin-lovastatin
tab sr 24hr 750-20 mg
3
•
ADVICOR - niacin-lovastatin
tab sr 24hr 1000-20 mg
3
•
•
ALTOPREV - lovastatin tab sr
24hr 20 mg
3
•
ALTOPREV - lovastatin tab sr
24hr 40 mg
3
•
ALTOPREV - lovastatin tab sr
24hr 60 mg
3
•
ANTARA - fenofibrate
micronized cap 30 mg
3
ANTARA - fenofibrate
micronized cap 90 mg
3
atorvastatin calcium tab
10 mg (base equivalent)
(Lipitor)
1
atorvastatin calcium tab
20 mg (base equivalent)
(Lipitor)
1
atorvastatin calcium tab
40 mg (base equivalent)
(Lipitor)
1
atorvastatin calcium tab
80 mg (base equivalent)
(Lipitor)
1
cholestyramine light powder
packets 4 gm
1
cholestyramine light powder
4 gm/dose (Questran light)
cholestyramine powder
packets 4 gm (Questran)
cholestyramine powder
4 gm/dose (Questran)
choline fenofibrate cap dr
45 mg (fenofibric acid
equiv) (Trilipix)
choline fenofibrate cap dr
135 mg (fenofibric acid
equiv) (Trilipix)
COLESTID - colestipol hcl
granule packets 5 gm
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
3
ACA Preventive
ADVICOR - niacin-lovastatin
tab sr 24hr 1000-40 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
1
1
3
69
COLESTID - colestipol hcl
granules 5 gm
3
COLESTID - colestipol hcl tab
1 gm
3
COLESTID FLAVORED colestipol hcl granule
packets 5 gm
3
COLESTID FLAVORED colestipol hcl granules 5 gm
3
colestipol hcl granule
packets 5 gm (Colestid
flavored)
1
colestipol hcl granules 5 gm
(Colestid flavored)
fenofibrate micronized cap
200 mg (Lofibra)
fenofibrate tab 48 mg (Tricor)
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
fenofibrate tab 54 mg
(Lofibra)
1
fenofibrate tab 145 mg
(Tricor)
1
fenofibrate tab 160 mg
(Lofibra)
1
FENOFIBRIC ACID - fenofibric
acid tab 35 mg
3
1
FENOFIBRIC ACID - fenofibric
acid tab 105 mg
3
colestipol hcl tab 1 gm
(Colestid)
1
FENOGLIDE - fenofibrate tab
40 mg
3
CRESTOR - rosuvastatin
calcium tab 5 mg
2
•
FENOGLIDE - fenofibrate tab
120 mg
3
CRESTOR - rosuvastatin
calcium tab 10 mg
2
•
FIBRICOR - fenofibric acid tab
35 mg
3
CRESTOR - rosuvastatin
calcium tab 20 mg
2
•
FIBRICOR - fenofibric acid tab
105 mg
3
CRESTOR - rosuvastatin
calcium tab 40 mg
2
•
fluvastatin sodium cap
20 mg (Lescol)
1
FENOFIBRATE - fenofibrate
cap 50 mg
3
fluvastatin sodium cap
40 mg (Lescol)
FENOFIBRATE - fenofibrate
cap 150 mg
3
fluvastatin sodium tab sr 24
hr 80 mg (Lescol xl)
FENOFIBRATE - fenofibrate
tab 40 mg
3
gemfibrozil tab 600 mg
(Lopid)
1
FENOFIBRATE - fenofibrate
tab 120 mg
3
4
•
•
•
fenofibrate micronized cap
43 mg
1
JUXTAPID - lomitapide
mesylate cap 5 mg (base
equiv)
JUXTAPID - lomitapide
mesylate cap 10 mg (base
equiv)
4
•
•
•
JUXTAPID - lomitapide
mesylate cap 20 mg (base
equiv)
4
•
•
•
JUXTAPID - lomitapide
mesylate cap 30 mg (base
equiv)
4
•
•
•
fenofibrate micronized cap
67 mg (Lofibra)
fenofibrate micronized cap
130 mg
fenofibrate micronized cap
134 mg (Lofibra)
1
1
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
1
1
70
3
LESCOL XL - fluvastatin
sodium tab sr 24 hr 80 mg
1
LOVAZA - omega-3-acid ethyl
esters cap 1 gm
3
•
MEVACOR - lovastatin tab 40
mg
3
3
•
1
LIPITOR - atorvastatin calcium
tab 10 mg (base equivalent)
3
•
niacin tab cr 500 mg
(antihyperlipidemic)
(Niaspan)
1
LIPITOR - atorvastatin calcium
tab 20 mg (base equivalent)
3
•
niacin tab cr 750 mg
(antihyperlipidemic)
(Niaspan)
LIPITOR - atorvastatin calcium
tab 40 mg (base equivalent)
3
•
1
LIPITOR - atorvastatin calcium
tab 80 mg (base equivalent)
3
•
niacin tab cr 1000 mg
(antihyperlipidemic)
(Niaspan)
3
LIPOFEN - fenofibrate cap 50
mg
2
NIACOR - niacin
(antihyperlipidemic) tab 500
mg
NIASPAN - niacin tab cr 500
mg (antihyperlipidemic)
3
LIPOFEN - fenofibrate cap 150
mg
2
3
•
3
LIVALO - pitavastatin calcium
tab 1 mg (base equiv)
NIASPAN - niacin tab cr 750
mg (antihyperlipidemic)
3
•
NIASPAN - niacin tab cr 1000
mg (antihyperlipidemic)
3
LIVALO - pitavastatin calcium
tab 2 mg (base equiv)
•
omega-3-acid ethyl esters
cap 1 gm (Lovaza)
1
LIVALO - pitavastatin calcium
tab 4 mg (base equiv)
3
LOFIBRA - fenofibrate
micronized cap 67 mg
3
LOFIBRA - fenofibrate
micronized cap 134 mg
3
LOFIBRA - fenofibrate
micronized cap 200 mg
3
LOFIBRA - fenofibrate tab 54
mg
3
LOFIBRA - fenofibrate tab 160
mg
3
•
•
Limited Distribution
LESCOL - fluvastatin sodium
cap 20 mg
lovastatin tab 40 mg
(Mevacor)
•
ACA Preventive
4
1
•
Dispensing Limits
KYNAMRO - mipomersen
sodium soln prefilled syringe
200 mg/ml
LOPID - gemfibrozil tab 600 mg 3
1
lovastatin tab 10 mg
lovastatin tab 20 mg
(Mevacor)
•
Step Therapy
•
Prior Authorization
4
•
Drug Name
Drug Tier
JUXTAPID - lomitapide
mesylate cap 60 mg (base
equiv)
•
Limited Distribution
•
ACA Preventive
4
Dispensing Limits
JUXTAPID - lomitapide
mesylate cap 40 mg (base
equiv)
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
OMEGA-3/D-3 WELLNESS
PACK - omega-3-acid ethyl
esters cap 1gm & vit d3 cap
1000 unit kit
3
PRALUENT - alirocumab
subcutaneous soln peninjector 75 mg/ml
4
•
•
•
PRALUENT - alirocumab
subcutaneous soln peninjector 150 mg/ml
4
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
71
PRALUENT - alirocumab
subcutaneous soln prefilled
syringe 75 mg/ml
4
PRALUENT - alirocumab
subcutaneous soln prefilled
syringe 150 mg/ml
4
PRAVACHOL - pravastatin
sodium tab 20 mg
3
•
PRAVACHOL - pravastatin
sodium tab 40 mg
3
•
PRAVACHOL - pravastatin
sodium tab 80 mg
3
•
pravastatin sodium tab
10 mg
•
•
•
3
•
SIMCOR - niacin-simvastatin
tab sr 24hr 1000-20 mg
3
•
SIMCOR - niacin-simvastatin
tab sr 24hr 1000-40 mg
3
•
simvastatin tab 5 mg (Zocor)
1
1
simvastatin tab 20 mg
(Zocor)
1
1
simvastatin tab 40 mg
(Zocor)
1
1
simvastatin tab 80 mg
(Zocor)
1
1
TRICOR - fenofibrate tab 48
mg
3
QUESTRAN - cholestyramine
powder packets 4 gm
3
TRICOR - fenofibrate tab 145
mg
3
QUESTRAN - cholestyramine
powder 4 gm/dose
3
TRIGLIDE - fenofibrate tab 160
mg
3
QUESTRAN LIGHT cholestyramine light powder
4 gm/dose
3
TRILIPIX - choline fenofibrate
cap dr 45 mg (fenofibric acid
equiv)
3
REPATHA - evolocumab
subcutaneous soln prefilled
syringe 140 mg/ml
4
•
•
•
TRILIPIX - choline fenofibrate
cap dr 135 mg (fenofibric
acid equiv)
3
REPATHA - evolocumab
subcutaneous soln prefilled
syringe 140 mg/ml
4
•
•
•
REPATHA SURECLICK evolocumab subcutaneous
soln auto-injector 140 mg/ml
4
•
•
•
REPATHA SURECLICK evolocumab subcutaneous
soln auto-injector 140 mg/ml
4
•
•
•
SIMCOR - niacin-simvastatin
tab sr 24hr 500-20 mg
3
VASCEPA - icosapent ethyl cap 2
1 gm
3
VYTORIN - ezetimibesimvastatin tab 10-10 mg
3
VYTORIN - ezetimibesimvastatin tab 10-20 mg
3
VYTORIN - ezetimibesimvastatin tab 10-40 mg
3
VYTORIN - ezetimibesimvastatin tab 10-80 mg
pravastatin sodium tab
80 mg (Pravachol)
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
SIMCOR - niacin-simvastatin
tab sr 24hr 750-20 mg
ACA Preventive
•
Dispensing Limits
3
1
pravastatin sodium tab
40 mg (Pravachol)
Step Therapy
SIMCOR - niacin-simvastatin
tab sr 24hr 500-40 mg
simvastatin tab 10 mg
(Zocor)
pravastatin sodium tab
20 mg (Pravachol)
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
•
ACA Preventive
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
72
WELCHOL - colesevelam hcl
packet for susp 3.75 gm
2
WELCHOL - colesevelam hcl
tab 625 mg
2
ZETIA - ezetimibe tab 10 mg
2
ZOCOR - simvastatin tab 5 mg
3
ZOCOR - simvastatin tab 10
mg
3
•
•
ZOCOR - simvastatin tab 20
mg
3
•
ZOCOR - simvastatin tab 40
mg
3
•
ZOCOR - simvastatin tab 80
mg
3
amlodipine besylateatorvastatin calcium tab
5-40 mg (Caduet)
amlodipine besylateatorvastatin calcium tab
5-80 mg (Caduet)
amlodipine besylateatorvastatin calcium tab
10-10 mg (Caduet)
amlodipine besylateatorvastatin calcium tab
10-20 mg (Caduet)
amlodipine besylateatorvastatin calcium tab
10-40 mg (Caduet)
•
CARDIOVASCULAR AGENTS - MISC.
ADCIRCA - tadalafil tab 20 mg 4 •
(pah)
4 •
ADEMPAS - riociguat tab 0.5
mg
ADEMPAS - riociguat tab 1 mg 4 •
•
•
•
•
•
•
•
•
amlodipine besylateatorvastatin calcium tab
10-80 mg (Caduet)
1
1
BIDIL - isosorbide dinitratehydralazine hcl tab 20-37.5
mg
3
CADUET - amlodipine
besylate-atorvastatin
calcium tab 2.5-10 mg
3
CADUET - amlodipine
besylate-atorvastatin
calcium tab 2.5-20 mg
3
ADEMPAS - riociguat tab 2 mg
4
ADEMPAS - riociguat tab 2.5
mg
4
•
•
•
•
amlodipine besylateatorvastatin calcium tab
2.5-10 mg (Caduet)
1
CADUET - amlodipine
besylate-atorvastatin
calcium tab 2.5-40 mg
3
1
CADUET - amlodipine
besylate-atorvastatin
calcium tab 5-10 mg
3
1
CADUET - amlodipine
besylate-atorvastatin
calcium tab 5-20 mg
3
1
CADUET - amlodipine
besylate-atorvastatin
calcium tab 5-40 mg
3
1
CADUET - amlodipine
besylate-atorvastatin
calcium tab 5-80 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
1
•
amlodipine besylateatorvastatin calcium tab
5-20 mg (Caduet)
ACA Preventive
1
4
amlodipine besylateatorvastatin calcium tab
5-10 mg (Caduet)
Dispensing Limits
1
ADEMPAS - riociguat tab 1.5
mg
amlodipine besylateatorvastatin calcium tab
2.5-40 mg (Caduet)
Step Therapy
1
•
•
amlodipine besylateatorvastatin calcium tab
2.5-20 mg (Caduet)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
73
CADUET - amlodipine
besylate-atorvastatin
calcium tab 10-10 mg
3
CADUET - amlodipine
besylate-atorvastatin
calcium tab 10-20 mg
3
CADUET - amlodipine
besylate-atorvastatin
calcium tab 10-40 mg
3
CADUET - amlodipine
besylate-atorvastatin
calcium tab 10-80 mg
3
CIALIS - tadalafil tab 2.5 mg
2
CIALIS - tadalafil tab 5 mg
2
CIALIS - tadalafil tab 10 mg
2
CIALIS - tadalafil tab 20 mg
2
CORLANOR - ivabradine hcl
tab 5 mg (base equiv)
3
•
•
•
•
•
CORLANOR - ivabradine hcl
tab 7.5 mg (base equiv)
3
•
•
ENTRESTO - sacubitrilvalsartan tab 24-26 mg
3
•
•
ENTRESTO - sacubitrilvalsartan tab 49-51 mg
3
•
•
ENTRESTO - sacubitrilvalsartan tab 97-103 mg
3
•
•
epoprostenol sodium for inj
0.5 mg (Flolan)
4
•
4
•
FLOLAN - epoprostenol
sodium for inj 0.5 mg
4
•
FLOLAN - epoprostenol
sodium for inj 1.5 mg
4
•
LETAIRIS - ambrisentan tab 5
mg
4
•
•
•
LETAIRIS - ambrisentan tab 10
mg
4
•
•
•
LEVITRA - vardenafil hcl tab
2.5 mg
3
•
•
Limited Distribution
•
LEVITRA - vardenafil hcl tab 10 3
mg
LEVITRA - vardenafil hcl tab 20 3
mg
4
OPSUMIT - macitentan tab 10
mg
4
ORENITRAM - treprostinil
diolamine tab cr 0.125 mg
(base equiv)
4
ORENITRAM - treprostinil
diolamine tab cr 0.25 mg
(base equiv)
4
ORENITRAM - treprostinil
diolamine tab cr 1 mg (base
equiv)
4
ORENITRAM - treprostinil
diolamine tab cr 2.5 mg
(base equiv)
4
REMODULIN - treprostinil
sodium inj 1 mg/ml (base
equiv)
4
REMODULIN - treprostinil
sodium inj 2.5 mg/ml (base
equiv)
4
REMODULIN - treprostinil
sodium inj 5 mg/ml (base
equiv)
4
REMODULIN - treprostinil
sodium inj 10 mg/ml (base
equiv)
REVATIO - sildenafil citrate for 4
suspension 10 mg/ml
4
REVATIO - sildenafil citrate iv
soln 10 mg/12.5ml (base
equivalent)
REVATIO - sildenafil citrate tab 4
20 mg
4
sildenafil citrate iv soln
10 mg/12.5ml (base
equivalent) (Revatio)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
3
LEVITRA - vardenafil hcl tab 5
mg
•
•
•
•
•
epoprostenol sodium for inj
1.5 mg (Flolan)
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
•
•
74
3
•
•
STENDRA - avanafil tab 50 mg
3
STENDRA - avanafil tab 100
mg
3
•
•
•
•
STENDRA - avanafil tab 200
mg
3
•
•
TRACLEER - bosentan tab
62.5 mg
4
•
•
•
TRACLEER - bosentan tab 125 4
mg
4
TYVASO - treprostinil
inhalation solution 0.6 mg/ml
4
TYVASO REFILL - treprostinil
inhalation solution 0.6 mg/ml
4
TYVASO STARTER treprostinil inhalation
solution 0.6 mg/ml
4
UPTRAVI - selexipag tab
therapy pack 200 mcg (140)
& 800 mcg (60)
4
UPTRAVI - selexipag tab 200
mcg
4
UPTRAVI - selexipag tab 400
mcg
4
UPTRAVI - selexipag tab 600
mcg
4
UPTRAVI - selexipag tab 800
mcg
UPTRAVI - selexipag tab 1000 4
mcg
UPTRAVI - selexipag tab 1200 4
mcg
UPTRAVI - selexipag tab 1400 4
mcg
UPTRAVI - selexipag tab 1600 4
mcg
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
4
•
VENTAVIS - iloprost inhalation
solution 20 mcg/ml
4
•
•
VIAGRA - sildenafil citrate tab
25 mg
3
•
•
VIAGRA - sildenafil citrate tab
50 mg
3
•
•
VIAGRA - sildenafil citrate tab
100 mg
3
•
•
CIALIS - tadalafil tab 2.5 mg
2
CIALIS - tadalafil tab 5 mg
2
CIALIS - tadalafil tab 10 mg
2
CIALIS - tadalafil tab 20 mg
2
LEVITRA - vardenafil hcl tab
2.5 mg
3
•
•
•
•
•
•
•
•
•
•
LEVITRA - vardenafil hcl tab 5
mg
3
•
•
LEVITRA - vardenafil hcl tab 10 3
mg
LEVITRA - vardenafil hcl tab 20 3
mg
3
STAXYN - vardenafil hcl orally
disintegrating tab 10 mg
STENDRA - avanafil tab 50 mg 3
•
•
•
•
•
•
•
•
ERECTLIE DYSFUNCTION
•
STENDRA - avanafil tab 100
mg
3
•
•
STENDRA - avanafil tab 200
mg
3
•
•
VIAGRA - sildenafil citrate tab
25 mg
3
•
•
VIAGRA - sildenafil citrate tab
50 mg
3
•
•
VIAGRA - sildenafil citrate tab
100 mg
3
•
•
Limited Distribution
STAXYN - vardenafil hcl orally
disintegrating tab 10 mg
VENTAVIS - iloprost inhalation
solution 10 mcg/ml
ACA Preventive
•
Dispensing Limits
•
Step Therapy
4
Prior Authorization
sildenafil citrate tab 20 mg
(Revatio)
Drug Name
Drug Tier
Limited Distribution
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
RESPIRATORY AGENTS
ANTIHISTAMINES
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
75
1
1
3
1
PHENERGAN - promethazine
hcl inj 25 mg/ml
3
CLARINEX - desloratadine
syrup 0.5 mg/ml
3
PHENERGAN - promethazine
hcl inj 50 mg/ml
1
CLARINEX - desloratadine tab
5 mg
3
promethazine hcl inj 25 mg/
ml (Phenergan)
CLARINEX REDITABS desloratadine tab orally
disintegrating 2.5 mg
3
promethazine hcl inj 50 mg/
ml (Phenergan)
CLARINEX REDITABS desloratadine tab orally
disintegrating 5 mg
3
clemastine fumarate tab
2.68 mg
1
promethazine hcl suppos
50 mg
1
promethazine hcl syrup
6.25 mg/5ml
1
promethazine hcl tab
12.5 mg
carbinoxamine maleate tab
4 mg
cetirizine hcl oral soln 1 mg/
ml (5 mg/5ml)
cyproheptadine hcl syrup
2 mg/5ml
cyproheptadine hcl tab 4 mg
desloratadine tab orally
disintegrating 2.5 mg
(Clarinex reditabs)
1
desloratadine tab orally
disintegrating 5 mg
(Clarinex reditabs)
1
desloratadine tab 5 mg
(Clarinex)
1
diphenhydramine hcl cap
50 mg
1
diphenhydramine hcl elixir
12.5 mg/5ml
promethazine hcl suppos
12.5 mg
promethazine hcl suppos
25 mg
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
1
KARBINAL ER - carbinoxamine 3
maleate er susp 4 mg/5ml
1
levocetirizine
dihydrochloride soln
2.5 mg/5ml (0.5 mg/ml)
(Xyzal)
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Drug Name
levocetirizine
dihydrochloride tab 5 mg
(Xyzal)
carbinoxamine maleate soln
4 mg/5ml
1
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
1
1
1
1
1
XYZAL - levocetirizine
dihydrochloride soln 2.5
mg/5ml (0.5 mg/ml)
3
XYZAL - levocetirizine
dihydrochloride tab 5 mg
3
NASAL AGENTS - SYSTEMIC and TOPICAL
3
•
ASTEPRO - azelastine hcl
nasal spray 0.15% (205.5
mcg/spray)
3
•
ATROVENT - ipratropium
bromide nasal soln 0.03%
(21 mcg/spray)
3
•
ATROVENT - ipratropium
bromide nasal soln 0.06%
(42 mcg/spray)
1
•
azelastine hcl nasal spray
0.1% (137 mcg/spray)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
76
1
BACTROBAN NASAL mupirocin calcium nasal oint
2%
3
BECONASE AQ beclomethasone
dipropionate monohyd nasal
susp 42 mcg/spray
3
budesonide nasal susp
32 mcg/act (Rhinocort
aqua)
1
•
DYMISTA - azelastine hclfluticasone prop nasal spray
137-50 mcg/act
3
•
flunisolide nasal soln
25 mcg/act (0.025%)
(Flunisolide)
1
fluticasone propionate nasal
susp 50 mcg/act (Flonase)
•
3
•
QNASL CHILDRENS beclomethasone
dipropionate nasal aerosol
40 mcg/act
3
•
RHINOCORT AQUA budesonide nasal susp 32
mcg/act
3
•
triamcinolone acetonide
nasal aerosol suspension
55 mcg/act (Nasacort aq)
1
•
TYZINE - tetrahydrozoline hcl
nasal soln 0.1%
3
•
TYZINE PEDIATRIC NASAL
DR - tetrahydrozoline hcl
nasal soln 0.05%
3
1
•
3
•
ipratropium bromide nasal
soln 0.03% (21 mcg/spray)
(Atrovent)
1
•
VERAMYST - fluticasone
furoate nasal susp 27.5 mcg/
spray
3
•
ipratropium bromide nasal
soln 0.06% (42 mcg/spray)
(Atrovent)
1
•
ZETONNA - ciclesonide nasal
aerosol soln 37 mcg/act (50
mcg/valve)
NASACORT AQ triamcinolone acetonide
nasal aerosol suspension 55
mcg/act
3
NASONEX - mometasone
furoate nasal susp 50 mcg/
act
2
•
olopatadine hcl nasal soln
0.6% (Patanase)
1
•
•
OMNARIS - ciclesonide nasal
susp 50 mcg/act
3
•
PATANASE - olopatadine hcl
nasal soln 0.6%
3
•
COUGH/COLD/ALLERGY
acetylcysteine inhal soln
10%
acetylcysteine inhal soln
20%
1
1
benzonatate cap 100 mg
(Tessalon perles)
1
benzonatate cap 150 mg
(Zonatuss)
1
benzonatate cap 200 mg
1
CAPCOF - phenylephrinechlorphen w/ codeine syrup
5-2-10 mg/5ml
3
CLARINEX-D 12 HOUR desloratadine &
pseudoephedrine tab sr 12hr
2.5-120 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
QNASL - beclomethasone
dipropionate nasal aerosol
80 mcg/act
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
azelastine hcl nasal spray
0.15% (205.5 mcg/spray)
(Astepro)
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
77
CODAR D - pseudoephedrine
w/ codeine liquid 30-8
mg/5ml
3
DEX-TUSS - guaifenesincodeine liquid 300-10
mg/5ml
3
FLOWTUSS - hydrocodoneguaifenesin soln 2.5-200
mg/5ml
3
guaifenesin-codeine liquid
200-8 mg/5ml
1
guaifenesin-codeine liquid
225-7.5 mg/5ml
guaifenesin-codeine soln
100-6.3 mg/5ml
guaifenesin-codeine soln
100-10 mg/5ml
1
1
3
HYCOFENIX pseudoephedrine w/
hydrocodone-gg soln
30-2.5-200 mg/5ml
3
hydrocod polst-chlorphen
polst cr susp 10-8 mg/5ml
(Tussionex pennkineti)
1
hydrocodone w/
homatropine syrup
5-1.5 mg/5ml
1
1
LORTUSS EX pseudoephedrine w/ cod-gg
liquid 30-10-100 mg/5ml
3
M-END MAX D pseudoephedrinedexbromphen-codeine liqd
20-0.667-6 mg/5ml
3
M-END PE - phenylephrinebromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml
3
•
MAR-COF BP pseudoephedrinebromphen-codeine liqd
30-2-7.5 mg/5ml
3
MAR-COF CG
EXPECTORANT guaifenesin-codeine liquid
225-7.5 mg/5ml
3
OBREDON - hydrocodoneguaifenesin soln 2.5-200
mg/5ml
3
phenylephrinebrompheniramine-dm
liquid 7.5-4-15 mg/5ml
1
PHENYLHISTINE DH pseudoephedrine-chlorphen
w/ codeine liq 30-2-10
mg/5ml
3
POLY-TUSSIN AC phenylephrine-bromphen
w/ codeine liquid 10-4-10
mg/5ml
3
PRO-CLEAR AC - codeinepyrilamine syrup 9-8.33
mg/5ml
3
PRO-RED AC - phenylephrinedexchlorphenir-codeine
syrup 5-1-9 mg/5ml
3
promethazine w/ codeine
syrup 6.25-10 mg/5ml
1
promethazine-dm syrup
6.25-15 mg/5ml
pseudoeph-chlorphen
w/ hydrocodone soln
60-4-5 mg/5ml (Zutripro)
pseudoephed-bromphen-dm
syrup 30-2-10 mg/5ml
pseudoephedrine w/ cod-gg
soln 30-10-100 mg/5ml
pseudoephedrine w/ cod-gg
syrup 30-10-100 mg/5ml
(Suttar-sf)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
HISTEX-AC - phenylephrinetriprolidine-codeine syrup
10-2.5-10 mg/5ml
hydrocodone w/
homatropine tab 5-1.5 mg
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
1
1
78
3
ZONATUSS - benzonatate cap
150 mg
3
REZIRA - pseudoephedrine
w/ hydrocodone soln 60-5
mg/5ml
3
3
RYDEX - pseudoephedrinebromphen-codeine liq
10-1.33-6.33 mg/5ml
3
ZUTRIPRO - pseudoephchlorphen w/ hydrocodone
soln 60-4-5 mg/5ml
SEMPREX-D - acrivastine &
pseudoephedrine cap 8-60
mg
3
STATUSS GREEN - codeinepseudoephedrinechlorcyclizine liq 9-30-12.5
mg/5ml
3
TESSALON PERLES benzonatate cap 100 mg
3
TRICODE AR pseudoephedrine-chlorphen
w/ codeine liq 30-2-8 mg/5ml
3
TRICODE GF pseudoephedrine w/ cod-gg
liquid 30-8-200 mg/5ml
3
TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr
5-4 mg
3
•
TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr
10-8 mg
3
•
TUSSIONEX PENNKINETIC
EXT - hydrocod polstchlorphen polst cr susp 10-8
mg/5ml
3
•
TUZISTRA XR - codeine polistchlorphen polist er susp
14.7-2.8 mg/5ml
3
•
VANACOF CD - phenylephrine- 3
dexchlorphenir-codeine
liquid 5-1-10 mg/5ml
3
VITUZ - hydrocodonechlorpheniramine soln 5-4
mg/5ml
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
Drug Name
Z-TUSS AC - chlorpheniramine
w/ codeine liquid 2-9 mg/5ml
pseudoephedrinebromphen-codeine liq
10-1.33-6.33 mg/5ml
1
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
ANTIASTHMATIC and BRONCHODILATOR AGENTS
•
ACCOLATE - zafirlukast tab 10 3
mg
•
ACCOLATE - zafirlukast tab 20 3
mg
•
ADVAIR DISKUS - fluticasone- 2
salmeterol aer powder ba
100-50 mcg/dose
•
ADVAIR DISKUS - fluticasone- 2
salmeterol aer powder ba
250-50 mcg/dose
•
ADVAIR DISKUS - fluticasone- 2
salmeterol aer powder ba
500-50 mcg/dose
2
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol
45-21 mcg/act
2
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol
115-21 mcg/act
2
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol
230-21 mcg/act
3
•
AEROSPAN - flunisolide hfa
inhal aerosol 80 mcg/act
1
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml)
1
albuterol sulfate soln nebu
0.5% (5 mg/ml)
1
albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
1
albuterol sulfate soln nebu
1.25 mg/3ml (base equiv)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
79
albuterol sulfate syrup
2 mg/5ml
albuterol sulfate tab sr 12hr
4 mg (Vospire er)
albuterol sulfate tab sr 12hr
8 mg (Vospire er)
albuterol sulfate tab 2 mg
albuterol sulfate tab 4 mg
1
1
1
1
1
ALVESCO - ciclesonide inhal
aerosol 80 mcg/act
3
•
ALVESCO - ciclesonide inhal
aerosol 160 mcg/act
3
•
ANORO ELLIPTA umeclidinium-vilanterol aero
powd ba 62.5-25 mcg/inh
2
•
ARCAPTA NEOHALER indacaterol maleate inhal
powder cap 75 mcg (base
equiv)
3
•
ARNUITY ELLIPTA fluticasone furoate aerosol
powder breath activ 100
mcg/act
2
ARNUITY ELLIPTA fluticasone furoate aerosol
powder breath activ 200
mcg/act
2
ASMANEX HFA - mometasone
furoate inhal aerosol
suspension 100 mcg/act
2
•
ASMANEX HFA - mometasone
furoate inhal aerosol
suspension 200 mcg/act
2
•
ASMANEX TWISTHALER 120
ME - mometasone furoate
inhal powd 220 mcg/inh
(breath activated)
2
•
ASMANEX TWISTHALER 14
MET - mometasone furoate
inhal powd 220 mcg/inh
(breath activated)
2
•
•
•
2
•
ASMANEX TWISTHALER 30
MET - mometasone furoate
inhal powd 220 mcg/inh
(breath activated)
2
•
ASMANEX TWISTHALER 60
MET - mometasone furoate
inhal powd 220 mcg/inh
(breath activated)
2
•
ASMANEX TWISTHALER 7
METE - mometasone furoate
inhal powd 110 mcg/inh
(breath activated)
2
•
ATROVENT HFA - ipratropium
bromide hfa inhal aerosol 17
mcg/act
2
•
BREO ELLIPTA - fluticasone
furoate-vilanterol aero powd
ba 100-25 mcg/inh
2
•
BREO ELLIPTA - fluticasone
furoate-vilanterol aero powd
ba 200-25 mcg/inh
2
•
BROVANA - arformoterol
tartrate soln nebu 15
mcg/2ml (base equiv)
3
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
1
budesonide inhalation susp
0.5 mg/2ml (Pulmicort)
budesonide inhalation susp
1 mg/2ml (Pulmicort)
Limited Distribution
ASMANEX TWISTHALER 30
MET - mometasone furoate
inhal powd 110 mcg/inh
(breath activated)
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
COMBIVENT RESPIMAT ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act
2
CROMOLYN SODIUM cromolyn sodium soln nebu
20 mg/2ml
3
•
DALIRESP - roflumilast tab 500 3
mcg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
80
3
FLOVENT DISKUS fluticasone propionate aer
pow ba 50 mcg/blister
2
FLOVENT DISKUS fluticasone propionate aer
pow ba 100 mcg/blister
2
•
FLOVENT DISKUS fluticasone propionate aer
pow ba 250 mcg/blister
2
•
FLOVENT HFA - fluticasone
propionate hfa inhal aero 44
mcg/act (50/valve)
2
•
FLOVENT HFA - fluticasone
propionate hfa inhal aer 110
mcg/act (125/valve)
2
•
FLOVENT HFA - fluticasone
propionate hfa inhal aer 220
mcg/act (250/valve)
2
•
FORADIL AEROLIZER formoterol fumarate inhal
cap 12 mcg
2
•
INCRUSE ELLIPTA umeclidinium br aero powd
breath act 62.5 mcg/inh
(base eq)
2
•
ipratropium bromide inhal
soln 0.02%
ipratropium-albuterol nebu
soln 0.5-2.5(3) mg/3ml
levalbuterol hcl soln nebu
conc 1.25 mg/0.5ml
(base equiv) (XOPENEX
CONCENTRATE)
1
levalbuterol hcl soln nebu
0.63 mg/3ml (base equiv)
(Xopenex)
1
levalbuterol hcl soln nebu
1.25 mg/3ml (base equiv)
(Xopenex)
1
LUFYLLIN - dyphylline tab 400
mg
3
METAPROTERENOL
SULFATE - metaproterenol
sulfate syrup 10 mg/5ml
3
METAPROTERENOL
SULFATE - metaproterenol
sulfate tab 10 mg
3
METAPROTERENOL
SULFATE - metaproterenol
sulfate tab 20 mg
3
montelukast sodium chew
tab 4 mg (base equiv)
(Singulair)
1
•
montelukast sodium chew
tab 5 mg (base equiv)
(Singulair)
1
•
montelukast sodium
oral granules packet 4 mg
(base equiv) (Singulair)
1
•
montelukast sodium tab
10 mg (base equiv)
(Singulair)
1
•
1
NUCALA - mepolizumab for inj
100 mg
3
1
PERFOROMIST - formoterol
fumarate soln nebu 20
mcg/2ml
3
1
•
PROAIR HFA - albuterol sulfate 2
inhal aero 108 mcg/act
(90mcg base equiv)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ELIXOPHYLLIN - theophylline
elixir 80 mg/15ml
levalbuterol hcl soln nebu
0.31 mg/3ml (base equiv)
(Xopenex)
ACA Preventive
•
Dispensing Limits
2
Step Therapy
DULERA - mometasone
furoate-formoterol fumarate
aerosol 200-5 mcg/act
Prior Authorization
•
Drug Name
Drug Tier
2
Limited Distribution
DULERA - mometasone
furoate-formoterol fumarate
aerosol 100-5 mcg/act
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
81
2
•
PROVENTIL HFA - albuterol
sulfate inhal aero 108 mcg/
act (90mcg base equiv)
3
•
SPIRIVA RESPIMAT tiotropium bromide
monohydrate inhal aerosol
1.25 mcg/act
2
•
PULMICORT - budesonide
inhalation susp 0.25 mg/2ml
3
SPIRIVA RESPIMAT tiotropium bromide
monohydrate inhal aerosol
2.5 mcg/act
2
•
PULMICORT - budesonide
inhalation susp 0.5 mg/2ml
3
PULMICORT - budesonide
inhalation susp 1 mg/2ml
3
3
•
•
STIOLTO RESPIMAT tiotropium br-olodaterol inhal
aero soln 2.5-2.5 mcg/act
PULMICORT FLEXHALER budesonide inhal aero
powd 90 mcg/act (breath
activated)
3
3
•
•
STRIVERDI RESPIMAT olodaterol hcl inhal aerosol
soln 2.5 mcg/act (base
equiv)
PULMICORT FLEXHALER budesonide inhal aero
powd 180 mcg/act (breath
activated)
3
SYMBICORT - budesonideformoterol fumarate dihyd
aerosol 80-4.5 mcg/act
2
•
QVAR - beclomethasone
diprop inhal aero soln 40
mcg/act (50/valve)
2
•
SYMBICORT - budesonideformoterol fumarate dihyd
aerosol 160-4.5 mcg/act
2
•
QVAR - beclomethasone
diprop inhal aero soln 80
mcg/act (100/valve)
2
•
terbutaline sulfate tab
2.5 mg
1
SEREVENT DISKUS salmeterol xinafoate aer
pow ba 50 mcg/dose (base
equiv)
3
•
terbutaline sulfate tab 5 mg
THEO-24 - theophylline cap sr
24hr 100 mg
3
•
THEO-24 - theophylline cap sr
24hr 200 mg
3
SINGULAIR - montelukast
sodium chew tab 4 mg (base
equiv)
3
3
SINGULAIR - montelukast
sodium chew tab 5 mg (base
equiv)
3
•
THEO-24 - theophylline cap sr
24hr 300 mg
THEO-24 - theophylline cap sr
24hr 400 mg
3
SINGULAIR - montelukast
sodium oral granules packet
4 mg (base equiv)
3
•
theophylline soln
80 mg/15ml
1
SINGULAIR - montelukast
sodium tab 10 mg (base
equiv)
3
•
theophylline tab sr 12hr
100 mg
theophylline tab sr 12hr
200 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
SPIRIVA HANDIHALER tiotropium bromide
monohydrate inhal cap 18
mcg (base equiv)
ACA Preventive
•
Dispensing Limits
2
Step Therapy
PROAIR RESPICLICK albuterol sulfate aer pow ba
108 mcg/act (90 mcg base
equiv)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
82
theophylline tab sr 12hr
300 mg
theophylline tab sr 12hr
450 mg
theophylline tab sr 24hr
400 mg
theophylline tab sr 24hr
600 mg
Limited Distribution
1
KALYDECO - ivacaftor tab 150
mg
4
•
1
OFEV - nintedanib esylate cap
100 mg (base equivalent)
4
•
•
•
1
OFEV - nintedanib esylate cap
150 mg (base equivalent)
4
•
•
•
1
ORKAMBI - lumacaftorivacaftor tab 200-125 mg
4
•
•
•
PULMOZYME - dornase alfa
inhal soln 1 mg/ml
4
SURFAXIN - lucinactant
intratracheal susp 30 mg/ml
3
SURVANTA
INTRATRACHEAL beractant in nacl 0.9%
intratracheal susp 25 mg/ml
3
•
TUDORZA PRESSAIR aclidinium bromide aerosol
powd breath activated 400
mcg/act
3
VENTOLIN HFA - albuterol
sulfate inhal aero 108 mcg/
act (90mcg base equiv)
2
VOSPIRE ER - albuterol
sulfate tab sr 12hr 4 mg
3
VOSPIRE ER - albuterol
sulfate tab sr 12hr 8 mg
3
XOPENEX HFA - levalbuterol
tartrate inhal aerosol 45
mcg/act (base equiv)
3
•
bisacodyl tab & peg 3350kcl-sod bicarb-nacl for
soln kit
zafirlukast tab 10 mg
(Accolate)
1
•
3
zafirlukast tab 20 mg
(Accolate)
1
•
COLYTE-FLAVOR PACKS peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm
3
ZYFLO - zileuton tab 600 mg
3
ZYFLO CR - zileuton tab sr
12hr 600 mg
3
•
•
GOLYTELY - peg 3350-kcl-na
bicarb-nacl-na sulfate packet
227.1 gm
GOLYTELY - peg 3350-kcl-na
bicarb-nacl-na sulfate for
soln 236 gm
3
KRISTALOSE - lactulose oral
crystal packet 10 gm
3
KRISTALOSE - lactulose oral
crystal packet 20 gm
3
lactulose solution
10 gm/15ml
1
RESPIRATORY AGENTS - MISC.
3
CUROSURF - poractant alfa
intratracheal susp 80 mg/ml
ESBRIET - pirfenidone cap 267 4
mg
3
INFASURF - calfactant in nacl
0.9% intratracheal susp 35
mg/ml
4
KALYDECO - ivacaftor packet
50 mg
4
KALYDECO - ivacaftor packet
75 mg
•
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
GASTROINTESTINAL AGENTS
LAXATIVES
•
•
•
•
•
•
•
•
•
MOVIPREP - peg 3350kcl-nacl-na sulfate-na
ascorbate-c for soln 100 gm
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
1
3
83
NULYTELY/FLAVOR PACKS peg 3350-kcl-sod bicarb-nacl
for soln 420 gm
3
OSMOPREP - sod phos
mono-sod phos di tabs
1.102-0.398 gm(1.5gm na
phos)
3
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm (Nulytely/
flavor pack)
1
ACIPHEX - rabeprazole
sodium ec tab 20 mg
3
• •
3
1
• •
peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm
(Golytely)
ACIPHEX SPRINKLE rabeprazole sodium capsule
sprinkle dr 5 mg
3
1
• •
peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm
(Colyte-flavor packs)
ACIPHEX SPRINKLE rabeprazole sodium capsule
sprinkle dr 10 mg
1
polyethylene glycol 3350
oral packet
1
amoxicillin cap-clarithro tablansopraz cap dr therapy
pack (Prevpac)
1
AXID - nizatidine cap 300 mg
3
3
PREPOPIK - sod picosulfatemg oxide-citric acid pack 10
mg-3.5 gm-12 gm
3
BENTYL - dicyclomine hcl cap
10 mg
3
SENNA LEAVES - senna
leaves
3
BENTYL - dicyclomine hcl tab
20 mg
3
SUPREP BOWEL PREP sodium sulfate-potassium
sulfate-magnesium sulfate
oral soln
3
CANTIL - mepenzolate
bromide tab 25 mg
CARAFATE - sucralfate susp 1
gm/10ml
3
CARAFATE - sucralfate tab 1
gm
3
chlordiazepoxide hclclidinium bromide cap
5-2.5 mg (Librax)
1
polyethylene glycol 3350
oral powder
ANTIDIARRHEALS
diphenoxylate w/ atropine
tab 2.5-0.025 mg (Lomotil)
MOTOFEN - difenoxin w/
atropine tab 1-0.025 mg
ANTACIDS
SODIUM BICARBONATE sodium bicarbonate powder
ULCER DRUGS
1
DIPHENOXYLATE/
ATROPINE - diphenoxylate
w/ atropine liq 2.5-0.025
mg/5ml
3
FULYZAQ - crofelemer tab
delayed release 125 mg
3
cimetidine tab 300 mg
LOMOTIL - diphenoxylate w/
atropine tab 2.5-0.025 mg
3
cimetidine tab 800 mg
loperamide hcl cap 2 mg
1
cimetidine hcl soln
300 mg/5ml
cimetidine tab 200 mg
cimetidine tab 400 mg
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
3
3
1
1
1
1
1
CUVPOSA - glycopyrrolate oral 3
soln 1 mg/5ml
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
84
CYTOTEC - misoprostol tab
100 mcg
3
CYTOTEC - misoprostol tab
200 mcg
3
3
LIBRAX - chlordiazepoxide hclclidinium bromide cap 5-2.5
mg
1
DEXILANT - dexlansoprazole
cap delayed release 30 mg
3
methscopolamine bromide
tab 2.5 mg (Pamine)
DEXILANT - dexlansoprazole
cap delayed release 60 mg
3
dicyclomine hcl cap 10 mg
(Bentyl)
dicyclomine hcl oral soln
10 mg/5ml
• •
• •
methscopolamine bromide
tab 5 mg (Pamine forte)
1
1
misoprostol tab 100 mcg
(Cytotec)
1
1
misoprostol tab 200 mcg
(Cytotec)
NEXIUM - esomeprazole
magnesium cap delayed
release 20 mg (base eq)
3
• •
1
DIGEX NF - hyoscyaminephenyltoloxamine cap
0.0625-15 mg
3
NEXIUM - esomeprazole
magnesium cap delayed
release 40 mg (base eq)
3
• •
esomeprazole magnesium
cap delayed release 20 mg
(base eq) (NEXIUM)
1
NEXIUM - esomeprazole
magnesium for delayed
release susp packet 5 mg
2
• •
1
NEXIUM - esomeprazole
magnesium for delayed
release susp packet 10 mg
2
• •
1
NEXIUM - esomeprazole
magnesium for delayed
release susp packet 20 mg
2
• •
NEXIUM - esomeprazole
magnesium for delayed
release susp packet 40 mg
2
• •
NEXIUM - esomeprazole
magnesium for delayed
release susp pack 2.5 mg
2
• •
nizatidine cap 150 mg
1
famotidine for susp
40 mg/5ml (Pepcid)
famotidine tab 20 mg
(Pepcid)
1
famotidine tab 40 mg
(Pepcid)
1
glycopyrrolate tab 1 mg
(Robinul)
1
glycopyrrolate tab 2 mg
(Robinul forte)
1
hyoscyamine sulfate tab sr
12hr 0.375 mg (Levbid)
1
lansoprazole cap delayed
release 15 mg (Prevacid)
lansoprazole cap delayed
release 30 mg (Prevacid)
nizatidine cap 300 mg (Axid)
1
•
1
•
1
nizatidine oral soln 15 mg/ml
(Axid)
1
OMECLAMOX-PAK amoxicillin cap-clarithro tab
w/ omepraz cap dr therapy
pack
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
1
dicyclomine hcl tab 20 mg
(Bentyl)
esomeprazole magnesium
cap delayed release 40 mg
(base eq) (NEXIUM)
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
85
omeprazole cap delayed
release 10 mg (Prilosec)
omeprazole cap delayed
release 20 mg (Prilosec)
omeprazole cap delayed
release 40 mg (Prilosec)
omeprazole-sodium
bicarbonate cap
20-1100 mg (Zegerid)
omeprazole-sodium
bicarbonate cap
40-1100 mg (Zegerid)
• •
1
• •
3
PREVPAC - amoxicillin capclarithro tab-lansopraz cap
dr therapy pack
3
PRILOSEC - omeprazole cap
delayed release 10 mg
3
• •
PRILOSEC - omeprazole cap
delayed release 20 mg
3
• •
PRILOSEC - omeprazole cap
delayed release 40 mg
3
• •
3
• •
3
• •
PAMINE - methscopolamine
bromide tab 2.5 mg
3
PAMINE FORTE methscopolamine bromide
tab 5 mg
3
PRILOSEC - omeprazole
magnesium for delayed
release susp packet 2.5 mg
PAMINE FQ methscopolamine tab 5 mg
& misc intestinal flora reg
cap
3
PRILOSEC - omeprazole
magnesium for delayed
release susp packet 10 mg
pantoprazole sodium ec
tab 20 mg (base equiv)
(Protonix)
1
•
pantoprazole sodium ec
tab 40 mg (base equiv)
(Protonix)
1
•
PEPCID - famotidine for susp
40 mg/5ml
3
PEPCID - famotidine tab 20 mg 3
PEPCID - famotidine tab 40 mg 3
PREVACID - lansoprazole cap
delayed release 15 mg
3
• •
PREVACID - lansoprazole cap
delayed release 30 mg
3
• •
PREVACID SOLUTAB lansoprazole tab delayed
release orally disintegrating
15 mg
3
• •
PROPANTHELINE BROMIDE - 3
propantheline bromide tab
15 mg
3
PROTONIX - pantoprazole
sodium ec tab 20 mg (base
equiv)
3
PROTONIX - pantoprazole
sodium ec tab 40 mg (base
equiv)
3
PROTONIX - pantoprazole
sodium for delayed release
susp packet 40 mg
3
PYLERA - bismuth subcitmetronidazole-tetracycline
cap 140-125-125 mg
1
rabeprazole sodium ec tab
20 mg (Aciphex)
1
ranitidine hcl cap 150 mg
ranitidine hcl cap 300 mg
ranitidine hcl syrup 15 mg/
ml (75 mg/5ml)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
1
• •
PREVACID SOLUTAB lansoprazole tab delayed
release orally disintegrating
30 mg
ACA Preventive
•
Dispensing Limits
1
Step Therapy
•
Prior Authorization
1
Drug Name
Drug Tier
•
Limited Distribution
1
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
• •
• •
• •
•
1
1
86
ranitidine hcl tab 150 mg
(Zantac)
1
dronabinol cap 5 mg
(Marinol)
1
ranitidine hcl tab 300 mg
(Zantac)
1
dronabinol cap 10 mg
(Marinol)
1
ROBINUL - glycopyrrolate tab
1 mg
3
EMEND - aprepitant capsule
therapy pack 80 & 125 mg
2
ROBINUL FORTE glycopyrrolate tab 2 mg
3
EMEND - aprepitant capsule
40 mg
2
sucralfate tab 1 gm
(Carafate)
1
EMEND - aprepitant capsule
80 mg
2
•
ZANTAC - ranitidine hcl tab
150 mg
3
EMEND - aprepitant capsule
125 mg
2
•
ZANTAC - ranitidine hcl tab
300 mg
3
granisetron hcl tab 1 mg
1
•
ZEGERID - omeprazolesodium bicarbonate cap
20-1100 mg
3
ZEGERID - omeprazolesodium bicarbonate cap
40-1100 mg
3
• •
ZEGERID - omeprazolesodium bicarbonate powd
pack for susp 20-1680 mg
3
• •
ZEGERID - omeprazolesodium bicarbonate powd
pack for susp 40-1680 mg
3
ANTIEMETICS
• •
MARINOL - dronabinol cap 2.5
mg
3
MARINOL - dronabinol cap 5
mg
3
MARINOL - dronabinol cap 10
mg
3
meclizine hcl tab 12.5 mg
1
meclizine hcl tab 25 mg
1
1
•
• •
ondansetron hcl tab 4 mg
(Zofran)
1
•
•
ondansetron hcl tab 8 mg
(Zofran)
1
•
ondansetron hcl tab 24 mg
1
3
ANZEMET - dolasetron
mesylate tab 50 mg
3
•
ANZEMET - dolasetron
mesylate tab 100 mg
3
•
CESAMET - nabilone cap 1 mg
3
•
DICLEGIS - doxylaminepyridoxine tab delayed
release 10-10 mg
dronabinol cap 2.5 mg
(Marinol)
ondansetron orally
disintegrating tab 4 mg
(Zofran odt)
1
•
•
ondansetron orally
disintegrating tab 8 mg
(Zofran odt)
1
•
3
SANCUSO - granisetron td
patch 3.1 mg/24hr (contains
34.3 mg)
3
• •
1
TIGAN - trimethobenzamide hcl 3
cap 300 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
•
ondansetron hcl oral soln
4 mg/5ml (Zofran)
AKYNZEO - netupitantpalonosetron cap 300-0.5
mg
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
87
TRANSDERM-SCOP scopolamine td patch 72hr 1
mg/3days
2
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
10500-25000-43750 unit
3
trimethobenzamide hcl cap
300 mg (Tigan)
1
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
16800-40000-70000 unit
3
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
21000-37000-61000 unit
3
PANCRELIPASE pancrelipase (lip-prot-amyl)
dr cap 5000-17000-27000
unit
3
PERTZYE - pancrelipase
(lip-prot-amyl) dr cap
8000-28750-30250 unit
3
3
•
•
VARUBI - rolapitant hcl tab 90
mg (base equiv)
3
ZOFRAN - ondansetron hcl
oral soln 4 mg/5ml
3
•
ZOFRAN - ondansetron hcl tab
4 mg
3
•
ZOFRAN - ondansetron hcl tab
8 mg
3
•
ZOFRAN ODT - ondansetron
orally disintegrating tab 4 mg
3
•
ZOFRAN ODT - ondansetron
orally disintegrating tab 8 mg
3
•
ZUPLENZ - ondansetron oral
soluble film 4 mg
3
•
PERTZYE - pancrelipase
(lip-prot-amyl) dr cap
16000-57500-60500 unit
•
SUCRAID - sacrosidase soln
8500 unit/ml
4
ZUPLENZ - ondansetron oral
soluble film 8 mg
3
3
CREON - pancrelipase
(lip-prot-amyl) dr cap
3000-9500-15000 unit
2
VIOKACE - pancrelipase
(lip-prot-amyl) tab
10440-39150-39150 unit
3
CREON - pancrelipase
(lip-prot-amyl) dr cap
6000-19000-30000 unit
2
VIOKACE - pancrelipase
(lip-prot-amyl) tab
20880-78300-78300 unit
2
CREON - pancrelipase
(lip-prot-amyl) dr cap
12000-38000-60000 unit
2
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
3000-10000-16000 unit
2
CREON - pancrelipase
(lip-prot-amyl) dr cap
24000-76000-120000 unit
2
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
5000-17000-27000 unit
2
CREON - pancrelipase
(lip-prot-amyl) dr cap
36000-114000-180000 unit
2
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
10000-34000-55000 unit
2
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
4200-10000-17500 unit
3
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
15000-51000-82000 unit
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
20000-68000-109000 unit
2
DIGESTIVE AIDS
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
88
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
25000-85000-136000 unit
2
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
40000-136000-218000 unit
2
GASTROINTESTINAL AGENTS- MISC.
3
ACTIGALL - ursodiol cap 300
mg
1
alosetron hcl tab 0.5 mg
(base equiv) (Lotronex)
alosetron hcl tab 1 mg (base 1
equiv) (Lotronex)
3 •
AMITIZA - lubiprostone cap 8
mcg
AMITIZA - lubiprostone cap 24 3 •
mcg
3
APRISO - mesalamine cap sr
24hr 0.375 gm
ASACOL HD - mesalamine tab 2
delayed release 800 mg
3
AURYXIA - ferric citrate tab 1
gm (210 mg ferric iron)
3
AZULFIDINE - sulfasalazine
tab 500 mg
3
AZULFIDINE EN-TABS sulfasalazine tab delayed
release 500 mg
1
balsalazide disodium cap
750 mg (Colazal)
1
calcium acetate (phosphate
binder) cap 667 mg
(169 mg ca) (Phoslo)
1
calcium acetate (phosphate
binder) tab 667 mg
(Eliphos)
CANASA - mesalamine suppos 2
1000 mg
4
CHENODAL - chenodiol tab
250 mg
•
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
CHOLBAM - cholic acid cap 50
mg
4
•
CHOLBAM - cholic acid cap
250 mg
4
•
CIMZIA - certolizumab pegol inj 4
kit 2 x 200 mg/ml
4
CIMZIA STARTER KIT certolizumab pegol inj kit 6 x
200 mg/ml
3
COLAZAL - balsalazide
disodium cap 750 mg
1
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
2
DELZICOL - mesalamine cap
dr 400 mg
3
DIPENTUM - olsalazine
sodium cap 250 mg
3
ELIPHOS - calcium acetate
(phosphate binder) tab 667
mg
ENTEREG - alvimopan cap 12 3
mg
3
FOSRENOL - lanthanum
carbonate chew tab 500 mg
(elemental)
3
FOSRENOL - lanthanum
carbonate chew tab 750 mg
(elemental)
3
FOSRENOL - lanthanum
carbonate chew tab 1000
mg (elemental)
3
FOSRENOL - lanthanum
carbonate oral powder pack
750 mg (elemental)
3
FOSRENOL - lanthanum
carbonate oral powder pack
1000 mg (elemental)
3
GASTROCROM - cromolyn
sodium oral conc 100
mg/5ml
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
• •
•
• •
•
89
GATTEX - teduglutide (rdna)
for inj kit 5 mg
4
GIAZO - balsalazide disodium
tab 1.1 gm
lactulose (encephalopathy)
solution 10 gm/15ml
PENTASA - mesalamine cap cr
250 mg
2
3
PENTASA - mesalamine cap cr
500 mg
2
1
PHOSLO - calcium acetate
(phosphate binder) cap 667
mg (169 mg ca)
3
3
LIALDA - mesalamine tab
delayed release 1.2 gm
2
LINZESS - linaclotide cap 145
mcg
3
•
PHOSLYRA - calcium acetate
(phosphate binder) oral soln
667 mg/5ml
LINZESS - linaclotide cap 290
mcg
3
•
REGLAN - metoclopramide hcl
tab 5 mg
3
LOTRONEX - alosetron hcl tab
0.5 mg (base equiv)
3
REGLAN - metoclopramide hcl
tab 10 mg
3
LOTRONEX - alosetron hcl tab
1 mg (base equiv)
3
3
•
mesalamine enema 4 gm
1
RELISTOR - methylnaltrexone
bromide inj 8 mg/0.4ml (20
mg/ml)
RELISTOR - methylnaltrexone
bromide inj 12 mg/0.6ml (20
mg/ml)
3
•
RENAGEL - sevelamer hcl tab
400 mg
3
RENAGEL - sevelamer hcl tab
800 mg
3
RENVELA - sevelamer
carbonate packet 0.8 gm
3
RENVELA - sevelamer
carbonate packet 2.4 gm
3
RENVELA - sevelamer
carbonate tab 800 mg
3
ROWASA - mesalamine rectal
enema 4 gm & cleanser
wipe kit
3
SEVELAMER CARBONATE sevelamer carbonate tab
800 mg
3
SFROWASA - mesalamine
sulfite-free (sf) enema 4
gm/60ml
3
mesalamine rectal enema
4 gm & cleanser wipe kit
(Rowasa)
1
metoclopramide hcl orally
disintegrating tab 5 mg
(Metozolv odt)
1
metoclopramide hcl soln
5 mg/5ml (10 mg/10ml)
1
metoclopramide hcl tab
5 mg (Reglan)
metoclopramide hcl tab
10 mg (Reglan)
1
1
METOCLOPRAMIDE ODT metoclopramide hcl orally
disintegrating tab 10 mg
3
METOZOLV ODT metoclopramide hcl orally
disintegrating tab 5 mg
3
MOVANTIK - naloxegol
oxalate tab 12.5 mg (base
equivalent)
3
•
MOVANTIK - naloxegol oxalate
tab 25 mg (base equivalent)
3
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
90
sulfasalazine tab delayed
release 500 mg (Azulfidine
en-tabs)
1
sulfasalazine tab 500 mg
(Azulfidine)
1
URSO FORTE - ursodiol tab
500 mg
3
URSO 250 - ursodiol tab 250
mg
3
ursodiol cap 300 mg
(Actigall)
1
ursodiol tab 250 mg (Urso
250)
1
ursodiol tab 500 mg (Urso
forte)
1
VELPHORO - sucroferric
oxyhydroxide chew tab 500
mg
3
VIBERZI - eluxadoline tab 75
mg
3
VIBERZI - eluxadoline tab 100
mg
3
methenamine hippurate tab
1 gm (Hiprex)
3
nitrofurantoin
macrocrystalline cap
25 mg (Macrodantin)
1
nitrofurantoin
macrocrystalline cap
100 mg (Macrodantin)
nitrofurantoin monohydrate
macrocrystalline cap
100 mg (Macrobid)
nitrofurantoin susp
25 mg/5ml (Furadantin)
UREX - methenamine
hippurate tab 1 gm
URINARY ANTISPASMODICS
FURADANTIN - nitrofurantoin
susp 25 mg/5ml
3
bethanechol chloride tab
10 mg (Urecholine)
HIPREX - methenamine
hippurate tab 1 gm
3
bethanechol chloride tab
25 mg (Urecholine)
MACROBID - nitrofurantoin
monohydrate
macrocrystalline cap 100 mg
3
bethanechol chloride tab
50 mg (Urecholine)
MACRODANTIN nitrofurantoin
macrocrystalline cap 25 mg
3
MACRODANTIN nitrofurantoin
macrocrystalline cap 50 mg
3
MACRODANTIN nitrofurantoin
macrocrystalline cap 100 mg
3
Limited Distribution
ACA Preventive
Dispensing Limits
1
1
1
1
3
1
1
1
1
DETROL - tolterodine tartrate
tab 1 mg
3
DETROL - tolterodine tartrate
tab 2 mg
3
DETROL LA - tolterodine
tartrate cap sr 24hr 2 mg
3
DETROL LA - tolterodine
tartrate cap sr 24hr 4 mg
3
DITROPAN XL - oxybutynin
chloride tab sr 24hr 5 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Step Therapy
1
MONUROL - fosfomycin
tromethamine powd pack 3
gm (base equivalent)
nitrofurantoin
macrocrystalline cap
50 mg (Macrodantin)
Prior Authorization
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Drug Name
bethanechol chloride tab
5 mg (Urecholine)
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
Prior Authorization
Drug Name
Drug Tier
2015
91
DITROPAN XL - oxybutynin
chloride tab sr 24hr 10 mg
3
TOVIAZ - fesoterodine
fumarate tab sr 24hr 4 mg
3
DITROPAN XL - oxybutynin
chloride tab sr 24hr 15 mg
3
TOVIAZ - fesoterodine
fumarate tab sr 24hr 8 mg
3
ENABLEX - darifenacin
hydrobromide tab sr 24hr 7.5
mg (base equiv)
3
trospium chloride cap sr
24hr 60 mg
1
ENABLEX - darifenacin
hydrobromide tab sr 24hr 15
mg (base equiv)
3
flavoxate hcl tab 100 mg
1
trospium chloride tab 20 mg
3
URECHOLINE - bethanechol
chloride tab 10 mg
3
URECHOLINE - bethanechol
chloride tab 25 mg
3
URECHOLINE - bethanechol
chloride tab 50 mg
3
GELNIQUE - oxybutynin
chloride td gel 10%
3
GELNIQUE - oxybutynin td
gel 3% (28 mg/act metereddose pump)
3
MYRBETRIQ - mirabegron tab
sr 24 hr 25 mg
2
VESICARE - solifenacin
succinate tab 5 mg
2
MYRBETRIQ - mirabegron tab
sr 24 hr 50 mg
2
VESICARE - solifenacin
succinate tab 10 mg
2
oxybutynin chloride syrup
5 mg/5ml
1
oxybutynin chloride tab sr
24hr 5 mg (Ditropan xl)
oxybutynin chloride tab sr
24hr 10 mg (Ditropan xl)
oxybutynin chloride tab sr
24hr 15 mg (Ditropan xl)
oxybutynin chloride tab
5 mg
1
1
1
1
OXYTROL - oxybutynin td
patch twice weekly 3.9
mg/24hr
3
tolterodine tartrate cap sr
24hr 2 mg (Detrol la)
1
tolterodine tartrate cap sr
24hr 4 mg (Detrol la)
1
tolterodine tartrate tab 1 mg
(Detrol)
1
tolterodine tartrate tab 2 mg
(Detrol)
1
AVC - sulfanilamide vaginal
cream 15%
3
CLEOCIN - clindamycin
phosphate vaginal cream
2%
3
CLEOCIN - clindamycin
phosphate vaginal suppos
100 mg
3
clindamycin phosphate
vaginal cream 2% (Cleocin)
1
CLINDESSE - clindamycin
phosphate (one dose)
vaginal cream 2%
3
CRINONE - progesterone
vaginal gel 4%
3
CRINONE - progesterone
vaginal gel 8%
3
ENCARE - nonoxynol-9 vaginal NA
suppos 100 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
URECHOLINE - bethanechol
chloride tab 5 mg
VAGINAL PRODUCTS
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
92
ENDOMETRIN - progesterone
vaginal insert 100 mg
3
TERAZOL 7 - terconazole
vaginal cream 0.4%
3
ESTRACE - estradiol vaginal
cream 0.1 mg/gm
2
1
ESTRING - estradiol vaginal
ring 2 mg (7.5 mcg/24hrs)
3
terconazole vaginal cream
0.4% (Terazol 7)
FEMRING - estradiol acetate
vaginal ring 0.05 mg/24hr
3
FEMRING - estradiol acetate
vaginal ring 0.1 mg/24hr
3
GYNAZOLE-1 - butoconazole
nitrate (one dose) vaginal
cream 2%
3
METROGEL-VAGINAL metronidazole vaginal gel
0.75%
3
VCF VAGINAL
CONTRACEPTIVE nonoxynol-9 film 28%
NA
•
metronidazole vaginal gel
0.75% (Metrogel-vaginal)
1
VCF VAGINAL
CONTRACEPTIVE nonoxynol-9 foam 12.5%
NA
•
miconazole nitrate vaginal
supp 200 mg & 2% cream
9 gm kit
MICONAZOLE 3 - miconazole
nitrate vaginal suppos 200
mg
nonoxynol-9 gel 4%
terconazole vaginal cream
0.8% (Terazol 3)
terconazole vaginal suppos
80 mg
TODAY SPONGE nonoxynol-9 vaginal sponge
1000 mg
VAGIFEM - estradiol vaginal
tab 10 mcg
1
3
NA
•
NUVESSA - metronidazole
vaginal gel 1.3%
3
OPTIONS CONCEPTROL
VAGINA - nonoxynol-9 gel
4%
NA
•
OPTIONS GYNOL II
VAGINAL - nonoxynol-9 gel
3%
NA
•
PREMARIN - estrogens,
conjugated vaginal cream
0.625 mg/gm
3
SHUR-SEAL - nonoxynol-9 gel NA
2%
3
TERAZOL 3 - terconazole
vaginal cream 0.8%
•
1
1
NA
•
2
GENITOURINARY AGENTS - MISC.
1
alfuzosin hcl tab sr 24hr
10 mg (Uroxatral)
3
AVODART - dutasteride cap
0.5 mg
3
CARDURA XL - doxazosin
mesylate tab sr 24 hr 4 mg
(base equiv)
3
CARDURA XL - doxazosin
mesylate tab sr 24 hr 8 mg
(base equiv)
4
CYSTAGON - cysteamine
bitartrate cap 50 mg
4
CYSTAGON - cysteamine
bitartrate cap 150 mg
1
dutasteride cap 0.5 mg
(Avodart)
1
dutasteride-tamsulosin hcl
cap 0.5-0.4 mg (Jalyn)
3
ELMIRON - pentosan
polysulfate sodium caps 100
mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
93
finasteride tab 5 mg
(Proscar)
1
UROXATRAL - alfuzosin hcl
tab sr 24hr 10 mg
FLOMAX - tamsulosin hcl cap
0.4 mg
3
CENTRAL NERVOUS SYSTEM DRUGS
JALYN - dutasteride-tamsulosin 3
hcl cap 0.5-0.4 mg
LITHOSTAT - acetohydroxamic 3
acid tab 250 mg
1
phenazopyridine hcl tab
100 mg (Pyridium)
1
phenazopyridine hcl tab
200 mg (Pyridium)
1
potassium citrate tab cr 5
meq (540 mg) (Urocit-k 5)
1
potassium citrate tab cr 10
meq (1080 mg) (Urocit-k 10)
1
potassium citrate tab cr 15
meq (1620 mg) (Urocit-k 15)
4
PROCYSBI - cysteamine
bitartrate cap delayed
release 25 mg (base equiv)
4
PROCYSBI - cysteamine
bitartrate cap delayed
release 75 mg (base equiv)
3
PROSCAR - finasteride tab 5
mg
RAPAFLO - silodosin cap 4 mg 3
RAPAFLO - silodosin cap 8 mg
3
tamsulosin hcl cap 0.4 mg
(Flomax)
1
THIOLA - tiopronin tab 100 mg
3
UROCIT-K 10 - potassium
citrate tab cr 10 meq (1080
mg)
3
UROCIT-K 15 - potassium
citrate tab cr 15 meq (1620
mg)
3
UROCIT-K 5 - potassium
citrate tab cr 5 meq (540 mg)
3
ANTIANXIETY AGENTS
3
alprazolam orally
disintegrating tab 0.25 mg
(Niravam)
1
alprazolam orally
disintegrating tab 0.5 mg
1
alprazolam orally
disintegrating tab 2 mg
alprazolam tab sr 24hr
0.5 mg (Xanax xr)
•
•
•
Limited Distribution
ACA Preventive
Dispensing Limits
3
ALPRAZOLAM INTENSOL alprazolam conc 1 mg/ml
alprazolam orally
disintegrating tab 1 mg
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
alprazolam tab sr 24hr 1 mg
(Xanax xr)
1
alprazolam tab sr 24hr 2 mg
(Xanax xr)
1
alprazolam tab sr 24hr 3 mg
(Xanax xr)
1
alprazolam tab 0.25 mg
(Xanax)
1
alprazolam tab 0.5 mg
(Xanax)
1
alprazolam tab 1 mg (Xanax)
1
alprazolam tab 2 mg (Xanax)
1
ATIVAN - lorazepam tab 2 mg
3
buspirone hcl tab 5 mg
1
ATIVAN - lorazepam tab 0.5 mg 3
3
ATIVAN - lorazepam tab 1 mg
buspirone hcl tab 7.5 mg
buspirone hcl tab 10 mg
buspirone hcl tab 15 mg
buspirone hcl tab 30 mg
chlordiazepoxide hcl cap
5 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
1
1
1
1
1
94
chlordiazepoxide hcl cap
10 mg
chlordiazepoxide hcl cap
25 mg
1
1
oxazepam cap 15 mg
oxazepam cap 30 mg
TRANXENE T - clorazepate
dipotassium tab 7.5 mg
3
TRANXENE T - clorazepate
dipotassium tab 15 mg
3
VALIUM - diazepam tab 2 mg
3
VALIUM - diazepam tab 5 mg
3
VALIUM - diazepam tab 10 mg
3
VISTARIL - hydroxyzine
pamoate cap 25 mg
3
VISTARIL - hydroxyzine
pamoate cap 50 mg
3
1
XANAX - alprazolam tab 0.25
mg
3
1
XANAX - alprazolam tab 0.5
mg
3
1
XANAX - alprazolam tab 1 mg
3
1
XANAX - alprazolam tab 2 mg
3
HYDROXYZINE PAMOATE hydroxyzine pamoate cap
100 mg
3
XANAX XR - alprazolam tab sr
24hr 0.5 mg
3
1
XANAX XR - alprazolam tab sr
24hr 1 mg
3
hydroxyzine pamoate cap
25 mg (Vistaril)
1
XANAX XR - alprazolam tab sr
24hr 2 mg
3
XANAX XR - alprazolam tab sr
24hr 3 mg
3
lorazepam conc 2 mg/ml
(Lorazepam intensol)
1
lorazepam tab 0.5 mg
(Ativan)
1
lorazepam tab 1 mg (Ativan)
1
clorazepate dipotassium tab
7.5 mg (Tranxene t)
clorazepate dipotassium tab
15 mg (Tranxene t)
1
1
DIAZEPAM - diazepam soln 1
mg/ml
3
diazepam conc 5 mg/ml
1
diazepam tab 2 mg (Valium)
diazepam tab 5 mg (Valium)
diazepam tab 10 mg (Valium)
hydroxyzine hcl syrup
10 mg/5ml
hydroxyzine hcl tab 10 mg
hydroxyzine hcl tab 25 mg
hydroxyzine hcl tab 50 mg
hydroxyzine pamoate cap
50 mg (Vistaril)
lorazepam tab 2 mg (Ativan)
meprobamate tab 200 mg
meprobamate tab 400 mg
1
1
1
1
1
1
NIRAVAM - alprazolam orally
disintegrating tab 0.25 mg
3
oxazepam cap 10 mg
1
ANTIDEPRESSANTS
amitriptyline hcl tab 10 mg
amitriptyline hcl tab 25 mg
amitriptyline hcl tab 50 mg
amitriptyline hcl tab 75 mg
amitriptyline hcl tab 100 mg
amitriptyline hcl tab 150 mg
AMOXAPINE - amoxapine tab
25 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
1
3
1
Step Therapy
1
TRANXENE T - clorazepate
dipotassium tab 3.75 mg
clorazepate dipotassium tab
3.75 mg (Tranxene t)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
1
1
1
3
95
AMOXAPINE - amoxapine tab
50 mg
3
AMOXAPINE - amoxapine tab
100 mg
3
AMOXAPINE - amoxapine tab
150 mg
3
ANAFRANIL - clomipramine hcl 3
cap 25 mg
ANAFRANIL - clomipramine hcl 3
cap 50 mg
ANAFRANIL - clomipramine hcl 3
cap 75 mg
APLENZIN - bupropion hbr tab 3
sr 24hr 174 mg
APLENZIN - bupropion hbr tab 3
sr 24hr 348 mg
APLENZIN - bupropion hbr tab 3
sr 24hr 522 mg
BRINTELLIX - vortioxetine hbr 3
tab 5 mg (base equiv)
BRINTELLIX - vortioxetine hbr 3
tab 10 mg (base equiv)
BRINTELLIX - vortioxetine hbr 3
tab 20 mg (base equiv)
1
bupropion hcl tab sr 12hr
100 mg (Wellbutrin sr)
1
bupropion hcl tab sr 12hr
150 mg (Wellbutrin sr)
1
bupropion hcl tab sr 12hr
200 mg (Wellbutrin sr)
1
bupropion hcl tab sr 24hr
150 mg (Wellbutrin xl)
1
bupropion hcl tab sr 24hr
300 mg (Wellbutrin xl)
1
bupropion hcl tab 75 mg
(Wellbutrin)
1
bupropion hcl tab 100 mg
(Wellbutrin)
CELEXA - citalopram
hydrobromide tab 10 mg
(base equiv)
3
CELEXA - citalopram
hydrobromide tab 20 mg
(base equiv)
3
CELEXA - citalopram
hydrobromide tab 40 mg
(base equiv)
3
citalopram hydrobromide
oral soln 10 mg/5ml
1
citalopram hydrobromide
tab 10 mg (base equiv)
(Celexa)
1
citalopram hydrobromide
tab 20 mg (base equiv)
(Celexa)
1
1
•
citalopram hydrobromide
tab 40 mg (base equiv)
(Celexa)
•
clomipramine hcl cap 25 mg
(Anafranil)
1
•
clomipramine hcl cap 50 mg
(Anafranil)
1
•
clomipramine hcl cap 75 mg
(Anafranil)
1
•
CYMBALTA - duloxetine hcl
enteric coated pellets cap 20
mg
3
•
CYMBALTA - duloxetine hcl
enteric coated pellets cap 30
mg
3
•
•
CYMBALTA - duloxetine hcl
enteric coated pellets cap 60
mg
3
•
•
desipramine hcl tab 10 mg
(Norpramin)
1
•
desipramine hcl tab 25 mg
(Norpramin)
1
desipramine hcl tab 50 mg
(Norpramin)
1
•
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
96
desipramine hcl tab 75 mg
(Norpramin)
1
desipramine hcl tab 100 mg
(Norpramin)
1
desipramine hcl tab 150 mg
(Norpramin)
1
DESVENLAFAXINE ER desvenlafaxine fumarate tab
sr 24hr 50 mg (base equiv)
3
DESVENLAFAXINE ER desvenlafaxine fumarate tab
sr 24hr 100 mg (base equiv)
3
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr
50 mg
3
•
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr
100 mg
3
•
DOXEPIN HCL - doxepin hcl
cap 75 mg
3
doxepin hcl cap 10 mg
1
doxepin hcl cap 25 mg
doxepin hcl cap 50 mg
doxepin hcl cap 100 mg
doxepin hcl cap 150 mg
doxepin hcl conc 10 mg/ml
•
•
1
1
1
1
1
3
•
EFFEXOR XR - venlafaxine hcl
cap sr 24hr 150 mg (base
equivalent)
3
•
EMSAM - selegiline td patch
24hr 6 mg/24hr
3
EMSAM - selegiline td patch
24hr 9 mg/24hr
3
EMSAM - selegiline td patch
24hr 12 mg/24hr
3
escitalopram oxalate soln
5 mg/5ml (base equiv)
(Lexapro)
1
escitalopram oxalate
tab 5 mg (base equiv)
(Lexapro)
1
escitalopram oxalate
tab 10 mg (base equiv)
(Lexapro)
1
escitalopram oxalate
tab 20 mg (base equiv)
(Lexapro)
1
FETZIMA - levomilnacipran
hcl cap sr 24hr 20 mg (base
equivalent)
3
•
DULOXETINE HCL duloxetine hcl enteric coated
pellets cap 40 mg
3
•
FETZIMA - levomilnacipran
hcl cap sr 24hr 40 mg (base
equivalent)
3
•
duloxetine hcl enteric
coated pellets cap 20 mg
(Cymbalta)
1
•
FETZIMA - levomilnacipran
hcl cap sr 24hr 80 mg (base
equivalent)
3
•
duloxetine hcl enteric
coated pellets cap 30 mg
(Cymbalta)
1
•
FETZIMA - levomilnacipran hcl
cap sr 24hr 120 mg (base
equivalent)
3
•
duloxetine hcl enteric
coated pellets cap 60 mg
(Cymbalta)
1
•
3
•
EFFEXOR XR - venlafaxine hcl
cap sr 24hr 37.5 mg (base
equivalent)
3
•
FETZIMA TITRATION PACK levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy
pack
FLUOXETINE HCL - fluoxetine
hcl tab 60 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
EFFEXOR XR - venlafaxine
hcl cap sr 24hr 75 mg (base
equivalent)
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
97
fluoxetine hcl cap delayed
release 90 mg (Prozac
weekly)
1
fluoxetine hcl cap 10 mg
(Prozac)
1
fluoxetine hcl cap 20 mg
(Prozac)
1
fluoxetine hcl cap 40 mg
(Prozac)
1
fluoxetine hcl solution
20 mg/5ml
1
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
fluvoxamine maleate cap sr
24hr 100 mg (Luvox cr)
fluvoxamine maleate cap sr
24hr 150 mg (Luvox cr)
fluvoxamine maleate tab
25 mg
fluvoxamine maleate tab
50 mg
fluvoxamine maleate tab
100 mg
1
1
1
1
1
imipramine hcl tab 10 mg
(Tofranil)
1
imipramine hcl tab 25 mg
(Tofranil)
1
imipramine hcl tab 50 mg
(Tofranil)
1
imipramine pamoate cap
75 mg (Tofranil-pm)
1
imipramine pamoate cap
150 mg (Tofranil-pm)
1
•
IRENKA - duloxetine hcl enteric 3
coated pellets cap 40 mg
3
KHEDEZLA - desvenlafaxine
tab sr 24hr 50 mg
3
KHEDEZLA - desvenlafaxine
tab sr 24hr 100 mg
3
LEXAPRO - escitalopram
oxalate soln 5 mg/5ml (base
equiv)
3
LEXAPRO - escitalopram
oxalate tab 5 mg (base
equiv)
3
LEXAPRO - escitalopram
oxalate tab 10 mg (base
equiv)
3
LEXAPRO - escitalopram
oxalate tab 20 mg (base
equiv)
3
MAPROTILINE HCL maprotiline hcl tab 25 mg
3
MAPROTILINE HCL maprotiline hcl tab 50 mg
3
MAPROTILINE HCL maprotiline hcl tab 75 mg
MARPLAN - isocarboxazid tab 3
10 mg
1
mirtazapine orally
disintegrating tab 15 mg
(Remeron soltab)
1
mirtazapine orally
disintegrating tab 30 mg
(Remeron soltab)
1
mirtazapine orally
disintegrating tab 45 mg
(Remeron soltab)
1
mirtazapine tab 7.5 mg
1
mirtazapine tab 15 mg
(Remeron)
1
1
mirtazapine tab 30 mg
(Remeron)
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
1
3
imipramine pamoate cap
125 mg (Tofranil-pm)
Step Therapy
1
FORFIVO XL - bupropion hcl
tab sr 24hr 450 mg
imipramine pamoate cap
100 mg (Tofranil-pm)
Prior Authorization
Drug Name
Drug Tier
2015
•
•
98
mirtazapine tab 45 mg
(Remeron)
1
PAMELOR - nortriptyline hcl
cap 10 mg
3
NARDIL - phenelzine sulfate
tab 15 mg
3
PAMELOR - nortriptyline hcl
cap 25 mg
3
NEFAZODONE HCL nefazodone hcl tab 100 mg
3
PAMELOR - nortriptyline hcl
cap 50 mg
3
NEFAZODONE HCL nefazodone hcl tab 150 mg
3
PAMELOR - nortriptyline hcl
cap 75 mg
3
NEFAZODONE HCL nefazodone hcl tab 200 mg
3
PARNATE - tranylcypromine
sulfate tab 10 mg
3
nefazodone hcl tab 50 mg
1
paroxetine hcl tab sr 24hr
12.5 mg (Paxil cr)
1
nefazodone hcl tab 250 mg
1
NORPRAMIN - desipramine hcl 3
tab 10 mg
NORPRAMIN - desipramine hcl 3
tab 25 mg
NORPRAMIN - desipramine hcl 3
tab 50 mg
NORPRAMIN - desipramine hcl 3
tab 75 mg
NORPRAMIN - desipramine hcl 3
tab 100 mg
NORPRAMIN - desipramine hcl 3
tab 150 mg
3
NORTRIPTYLINE HCL nortriptyline hcl soln 10
mg/5ml
1
nortriptyline hcl cap 10 mg
(Pamelor)
1
nortriptyline hcl cap 25 mg
(Pamelor)
1
nortriptyline hcl cap 50 mg
(Pamelor)
1
nortriptyline hcl cap 75 mg
(Pamelor)
3
OLEPTRO - trazodone hcl tab
sr 24hr 150 mg
3
OLEPTRO - trazodone hcl tab
sr 24hr 300 mg
paroxetine hcl tab sr 24hr
25 mg (Paxil cr)
paroxetine hcl tab sr 24hr
37.5 mg (Paxil cr)
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
1
paroxetine hcl tab 10 mg
(Paxil)
1
paroxetine hcl tab 20 mg
(Paxil)
1
paroxetine hcl tab 30 mg
(Paxil)
1
paroxetine hcl tab 40 mg
(Paxil)
1
PAXIL - paroxetine hcl oral
susp 10 mg/5ml (base equiv)
3
PAXIL - paroxetine hcl tab 10
mg
3
PAXIL - paroxetine hcl tab 20
mg
3
PAXIL - paroxetine hcl tab 30
mg
3
PAXIL - paroxetine hcl tab 40
mg
3
PAXIL CR - paroxetine hcl tab
sr 24hr 12.5 mg
3
PAXIL CR - paroxetine hcl tab
sr 24hr 25 mg
3
PAXIL CR - paroxetine hcl tab
sr 24hr 37.5 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
99
PEXEVA - paroxetine mesylate
tab 10 mg (base equiv)
3
PEXEVA - paroxetine mesylate
tab 20 mg (base equiv)
3
PEXEVA - paroxetine mesylate
tab 30 mg (base equiv)
REMERON SOLTAB mirtazapine orally
disintegrating tab 30 mg
3
3
3
REMERON SOLTAB mirtazapine orally
disintegrating tab 45 mg
PEXEVA - paroxetine mesylate
tab 40 mg (base equiv)
3
sertraline hcl oral conc
20 mg/ml (Zoloft)
1
phenelzine sulfate tab 15 mg
(Nardil)
1
sertraline hcl tab 25 mg
(Zoloft)
1
PRISTIQ - desvenlafaxine
succinate tab sr 24hr 25 mg
(base equiv)
3
sertraline hcl tab 50 mg
(Zoloft)
1
1
PRISTIQ - desvenlafaxine
succinate tab sr 24hr 50 mg
(base equiv)
3
sertraline hcl tab 100 mg
(Zoloft)
SURMONTIL - trimipramine
maleate cap 25 mg
3
PRISTIQ - desvenlafaxine
succinate tab sr 24hr 100
mg (base equiv)
3
SURMONTIL - trimipramine
maleate cap 50 mg
3
SURMONTIL - trimipramine
maleate cap 100 mg
3
protriptyline hcl tab 5 mg
(Vivactil)
1
protriptyline hcl tab 10 mg
(Vivactil)
1
PROZAC - fluoxetine hcl cap
10 mg
3
PROZAC - fluoxetine hcl cap
20 mg
3
PROZAC - fluoxetine hcl cap
40 mg
3
PROZAC WEEKLY - fluoxetine
hcl cap delayed release 90
mg
3
REMERON - mirtazapine tab
15 mg
3
REMERON - mirtazapine tab
30 mg
3
REMERON - mirtazapine tab
45 mg
3
REMERON SOLTAB mirtazapine orally
disintegrating tab 15 mg
3
•
•
•
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
TOFRANIL - imipramine hcl tab 3
10 mg
TOFRANIL - imipramine hcl tab 3
25 mg
TOFRANIL - imipramine hcl tab 3
50 mg
3
TOFRANIL-PM - imipramine
pamoate cap 75 mg
3
TOFRANIL-PM - imipramine
pamoate cap 100 mg
3
TOFRANIL-PM - imipramine
pamoate cap 125 mg
3
TOFRANIL-PM - imipramine
pamoate cap 150 mg
1
tranylcypromine sulfate tab
10 mg (Parnate)
1
trazodone hcl tab 50 mg
trazodone hcl tab 100 mg
trazodone hcl tab 150 mg
trazodone hcl tab 300 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
1
1
1
100
1
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr
37.5 mg (base equivalent)
3
•
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr
75 mg (base equivalent)
3
•
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr
150 mg (base equivalent)
3
•
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr
225 mg (base equivalent)
3
•
venlafaxine hcl tab sr 24hr
37.5 mg (base equivalent)
(Venlafaxine hcl er)
1
venlafaxine hcl tab sr 24hr
75 mg (base equivalent)
(Venlafaxine hcl er)
1
•
venlafaxine hcl tab sr 24hr
150 mg (base equivalent)
(Venlafaxine hcl er)
1
•
venlafaxine hcl tab 25 mg
1
venlafaxine hcl tab 37.5 mg
venlafaxine hcl tab 50 mg
venlafaxine hcl tab 75 mg
venlafaxine hcl tab 100 mg
1
1
1
1
VIIBRYD - vilazodone hcl tab
10 mg
3
VIIBRYD - vilazodone hcl tab
20 mg
3
VIIBRYD - vilazodone hcl tab
40 mg
3
•
•
3
WELLBUTRIN - bupropion hcl
tab 75 mg
3
•
WELLBUTRIN - bupropion hcl
tab 100 mg
3
•
WELLBUTRIN SR - bupropion
hcl tab sr 12hr 100 mg
3
•
WELLBUTRIN SR - bupropion
hcl tab sr 12hr 150 mg
3
•
WELLBUTRIN SR - bupropion
hcl tab sr 12hr 200 mg
3
•
WELLBUTRIN XL - bupropion
hcl tab sr 24hr 150 mg
3
•
WELLBUTRIN XL - bupropion
hcl tab sr 24hr 300 mg
3
•
ZOLOFT - sertraline hcl oral
conc 20 mg/ml
3
ZOLOFT - sertraline hcl tab 25
mg
3
ZOLOFT - sertraline hcl tab 50
mg
3
ZOLOFT - sertraline hcl tab
100 mg
3
Limited Distribution
venlafaxine hcl cap sr 24hr
150 mg (base equivalent)
(Effexor xr)
VIIBRYD STARTER PACK vilazodone hcl tab starter kit
10 (7) & 20 (23) mg
ACA Preventive
•
Dispensing Limits
1
Step Therapy
venlafaxine hcl cap sr 24hr
75 mg (base equivalent)
(Effexor xr)
Prior Authorization
•
Drug Name
Drug Tier
1
Limited Distribution
venlafaxine hcl cap sr 24hr
37.5 mg (base equivalent)
(Effexor xr)
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
ANTIPSYCHOTICS
ABILIFY - aripiprazole tab 2 mg 3
ABILIFY - aripiprazole tab 5 mg 3
ABILIFY - aripiprazole tab 10
mg
3
ABILIFY - aripiprazole tab 15
mg
3
ABILIFY - aripiprazole tab 20
mg
3
ABILIFY - aripiprazole tab 30
mg
3
ABILIFY DISCMELT aripiprazole orally
disintegrating tab 10 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
101
ABILIFY DISCMELT aripiprazole orally
disintegrating tab 15 mg
3
CHLORPROMAZINE HCL chlorpromazine hcl inj 25
mg/ml
3
ABILIFY MAINTENA aripiprazole im for extended
release susp 300 mg
3
CHLORPROMAZINE HCL chlorpromazine hcl inj 50
mg/2ml
3
ABILIFY MAINTENA aripiprazole im for extended
release susp 400 mg
3
chlorpromazine hcl tab
10 mg
1
ADASUVE - loxapine aerosol
powder breath activated 10
mg
3
ARIPIPRAZOLE ODT aripiprazole orally
disintegrating tab 10 mg
3
ARIPIPRAZOLE ODT aripiprazole orally
disintegrating tab 15 mg
3
aripiprazole oral solution
1 mg/ml
1
aripiprazole tab 2 mg (Abilify)
aripiprazole tab 5 mg (Abilify)
1
1
aripiprazole tab 10 mg
(Abilify)
1
aripiprazole tab 15 mg
(Abilify)
1
aripiprazole tab 20 mg
(Abilify)
1
aripiprazole tab 30 mg
(Abilify)
1
ARISTADA - aripiprazole
lauroxil im er susp prefilled
syr 441 mg/1.6ml
3
ARISTADA - aripiprazole
lauroxil im er susp prefilled
syr 662 mg/2.4ml
3
ARISTADA - aripiprazole
lauroxil im er susp prefilled
syr 882 mg/3.2ml
3
chlorpromazine hcl tab
25 mg
chlorpromazine hcl tab
50 mg
chlorpromazine hcl tab
100 mg
chlorpromazine hcl tab
200 mg
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
1
1
1
CLOZAPINE ODT - clozapine
orally disintegrating tab 12.5
mg
3
CLOZAPINE ODT - clozapine
orally disintegrating tab 150
mg
3
CLOZAPINE ODT - clozapine
orally disintegrating tab 200
mg
3
clozapine orally
disintegrating tab 25 mg
(Fazaclo)
1
clozapine orally
disintegrating tab 100 mg
(Fazaclo)
1
clozapine tab 25 mg
(Clozaril)
1
clozapine tab 50 mg
1
clozapine tab 100 mg
(Clozaril)
1
clozapine tab 200 mg
1
CLOZARIL - clozapine tab 25
mg
3
CLOZARIL - clozapine tab 100
mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
102
COMPAZINE prochlorperazine maleate
tab 5 mg (base equivalent)
3
FLUPHENAZINE HCL fluphenazine hcl elixir 2.5
mg/5ml
3
COMPAZINE prochlorperazine maleate
tab 10 mg (base equivalent)
3
FLUPHENAZINE HCL fluphenazine hcl inj 2.5 mg/
ml
3
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr
100 mg
3
FLUPHENAZINE HCL fluphenazine hcl oral conc 5
mg/ml
3
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr
200 mg
3
fluphenazine hcl tab 1 mg
1
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr
300 mg
3
fluphenazine hcl tab 5 mg
3
FANAPT - iloperidone tab 1 mg
3
GEODON - ziprasidone hcl cap
20 mg
FANAPT - iloperidone tab 2 mg
3
3
FANAPT - iloperidone tab 4 mg
3
GEODON - ziprasidone hcl cap
40 mg
FANAPT - iloperidone tab 6 mg
3
3
FANAPT - iloperidone tab 8 mg
3
GEODON - ziprasidone hcl cap
60 mg
GEODON - ziprasidone hcl cap
80 mg
3
FANAPT - iloperidone tab 10
mg
3
GEODON - ziprasidone
mesylate for inj 20 mg (base
equivalent)
3
FANAPT - iloperidone tab 12
mg
3
FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak
3
HALDOL - haloperidol lactate
inj 5 mg/ml
3
3
HALDOL DECANOATE 100 haloperidol decanoate im
soln 100 mg/ml
3
FAZACLO - clozapine orally
disintegrating tab 12.5 mg
FAZACLO - clozapine orally
disintegrating tab 25 mg
3
3
FAZACLO - clozapine orally
disintegrating tab 100 mg
3
HALDOL DECANOATE 50 haloperidol decanoate im
soln 50 mg/ml
1
FAZACLO - clozapine orally
disintegrating tab 150 mg
3
haloperidol decanoate im
soln 50 mg/ml (Haldol
decanoate 50)
FAZACLO - clozapine orally
disintegrating tab 200 mg
3
1
fluphenazine decanoate inj
25 mg/ml
1
haloperidol decanoate im
soln 100 mg/ml (Haldol
decanoate 100)
haloperidol lactate inj 5 mg/
ml (Haldol)
1
fluphenazine hcl tab 2.5 mg
fluphenazine hcl tab 10 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
103
haloperidol lactate oral conc
2 mg/ml
haloperidol tab 0.5 mg
haloperidol tab 1 mg
haloperidol tab 2 mg
haloperidol tab 5 mg
haloperidol tab 10 mg
haloperidol tab 20 mg
1
1
1
1
1
1
1
INVEGA - paliperidone tab sr
24hr 1.5 mg
3
INVEGA - paliperidone tab sr
24hr 3 mg
3
INVEGA - paliperidone tab sr
24hr 6 mg
3
INVEGA - paliperidone tab sr
24hr 9 mg
3
INVEGA SUSTENNA paliperidone palmitate im
extend-release susp 117
mg/0.75ml
3
INVEGA SUSTENNA paliperidone palmitate im
extended-release susp 39
mg/0.25ml
3
INVEGA SUSTENNA paliperidone palmitate im
extended-release susp 78
mg/0.5ml
3
INVEGA SUSTENNA paliperidone palmitate im
extended-release susp 156
mg/ml
3
INVEGA SUSTENNA paliperidone palmitate im
extended-release susp 234
mg/1.5ml
3
INVEGA TRINZA - paliperidone 3
palmitate im extend-release
susp 273 mg/0.875ml
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
INVEGA TRINZA - paliperidone 3
palmitate im extend-release
susp 410 mg/1.315ml
INVEGA TRINZA - paliperidone 3
palmitate im extend-release
susp 546 mg/1.75ml
INVEGA TRINZA - paliperidone 3
palmitate im extend-release
susp 819 mg/2.625ml
LATUDA - lurasidone hcl tab 20 3
mg
LATUDA - lurasidone hcl tab 40 3
mg
LATUDA - lurasidone hcl tab 60 3
mg
LATUDA - lurasidone hcl tab 80 3
mg
3
LATUDA - lurasidone hcl tab
120 mg
LITHIUM - lithium oral solution 3
8 meq/5ml
3
LITHIUM CARBONATE lithium carbonate cap 150
mg
3
LITHIUM CARBONATE lithium carbonate cap 600
mg
1
lithium carbonate cap
150 mg (Lithium carbonate)
1
lithium carbonate cap
300 mg
1
lithium carbonate cap
600 mg (Lithium carbonate)
1
lithium carbonate tab cr
300 mg (Lithobid)
1
lithium carbonate tab cr
450 mg
1
lithium carbonate tab
300 mg
3
LITHOBID - lithium carbonate
tab cr 300 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
104
1
1
1
1
paliperidone tab sr 24hr
1.5 mg (Invega)
1
paliperidone tab sr 24hr
3 mg (Invega)
MOLINDONE
HYDROCHLORIDE molindone hcl tab 5 mg
3
paliperidone tab sr 24hr
6 mg (Invega)
MOLINDONE
HYDROCHLORIDE molindone hcl tab 10 mg
3
MOLINDONE
HYDROCHLORIDE molindone hcl tab 25 mg
3
perphenazine tab 8 mg
olanzapine for im inj 10 mg
(Zyprexa)
1
prochlorperazine edisylate
inj 5 mg/ml
olanzapine orally
disintegrating tab 5 mg
(Zyprexa zydis)
loxapine succinate cap
10 mg
loxapine succinate cap
25 mg
loxapine succinate cap
50 mg
paliperidone tab sr 24hr
9 mg (Invega)
perphenazine tab 2 mg
perphenazine tab 4 mg
perphenazine tab 16 mg
Limited Distribution
1
1
1
1
1
1
olanzapine orally
disintegrating tab 10 mg
(Zyprexa zydis)
1
prochlorperazine maleate
tab 10 mg (base
equivalent) (Compazine)
olanzapine orally
disintegrating tab 15 mg
(Zyprexa zydis)
1
olanzapine orally
disintegrating tab 20 mg
(Zyprexa zydis)
1
olanzapine tab 2.5 mg
(Zyprexa)
1
quetiapine fumarate tab
100 mg (Seroquel)
olanzapine tab 5 mg
(Zyprexa)
1
quetiapine fumarate tab
200 mg (Seroquel)
olanzapine tab 7.5 mg
(Zyprexa)
1
quetiapine fumarate tab
300 mg (Seroquel)
olanzapine tab 10 mg
(Zyprexa)
1
quetiapine fumarate tab
400 mg (Seroquel)
1
REXULTI - brexpiprazole tab
0.25 mg
3
olanzapine tab 15 mg
(Zyprexa)
REXULTI - brexpiprazole tab
0.5 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
ACA Preventive
1
1
quetiapine fumarate tab
50 mg (Seroquel)
Dispensing Limits
1
1
quetiapine fumarate tab
25 mg (Seroquel)
Step Therapy
1
prochlorperazine maleate
tab 5 mg (base equivalent)
(Compazine)
prochlorperazine suppos
25 mg
Prior Authorization
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Drug Name
olanzapine tab 20 mg
(Zyprexa)
loxapine succinate cap 5 mg
1
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
1
1
1
1
105
REXULTI - brexpiprazole tab 1
mg
3
REXULTI - brexpiprazole tab 2
mg
3
REXULTI - brexpiprazole tab 3
mg
3
REXULTI - brexpiprazole tab 4
mg
3
RISPERDAL - risperidone soln
1 mg/ml
3
RISPERDAL - risperidone tab
0.25 mg
3
RISPERDAL - risperidone tab
0.5 mg
3
RISPERDAL - risperidone tab 1 3
mg
RISPERDAL - risperidone tab 2 3
mg
RISPERDAL - risperidone tab 3 3
mg
RISPERDAL - risperidone tab 4 3
mg
3
RISPERDAL CONSTA risperidone microspheres for
inj 12.5 mg
3
RISPERDAL CONSTA risperidone microspheres for
inj 25 mg
3
RISPERDAL CONSTA risperidone microspheres for
inj 37.5 mg
3
RISPERDAL CONSTA risperidone microspheres for
inj 50 mg
3
RISPERDAL M-TAB risperidone orally
disintegrating tab 0.5 mg
3
RISPERDAL M-TAB risperidone orally
disintegrating tab 1 mg
RISPERDAL M-TAB risperidone orally
disintegrating tab 2 mg
3
RISPERDAL M-TAB risperidone orally
disintegrating tab 3 mg
3
RISPERDAL M-TAB risperidone orally
disintegrating tab 4 mg
3
risperidone orally
disintegrating tab 0.25 mg
1
risperidone orally
disintegrating tab 0.5 mg
(Risperdal m-tab)
1
risperidone orally
disintegrating tab 1 mg
(Risperdal m-tab)
1
risperidone orally
disintegrating tab 2 mg
(Risperdal m-tab)
1
risperidone orally
disintegrating tab 3 mg
(Risperdal m-tab)
1
risperidone orally
disintegrating tab 4 mg
(Risperdal m-tab)
1
risperidone soln 1 mg/ml
(Risperdal)
1
risperidone tab 0.25 mg
(Risperdal)
1
risperidone tab 0.5 mg
(Risperdal)
1
risperidone tab 1 mg
(Risperdal)
1
risperidone tab 2 mg
(Risperdal)
1
risperidone tab 3 mg
(Risperdal)
1
risperidone tab 4 mg
(Risperdal)
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
106
SAPHRIS - asenapine maleate
sl tab 2.5 mg (base equiv)
3
trifluoperazine hcl tab 10 mg
VERSACLOZ - clozapine susp
50 mg/ml
3
SAPHRIS - asenapine maleate
sl tab 5 mg (base equiv)
3
ziprasidone hcl cap 20 mg
(Geodon)
1
SAPHRIS - asenapine maleate
sl tab 10 mg (base equiv)
3
3
ziprasidone hcl cap 40 mg
(Geodon)
1
SEROQUEL - quetiapine
fumarate tab 25 mg
3
ziprasidone hcl cap 60 mg
(Geodon)
1
SEROQUEL - quetiapine
fumarate tab 50 mg
ziprasidone hcl cap 80 mg
(Geodon)
1
SEROQUEL - quetiapine
fumarate tab 100 mg
3
ZYPREXA - olanzapine for im
inj 10 mg
3
SEROQUEL - quetiapine
fumarate tab 200 mg
3
ZYPREXA - olanzapine tab 2.5
mg
3
SEROQUEL - quetiapine
fumarate tab 300 mg
3
3
ZYPREXA - olanzapine tab 5
mg
3
SEROQUEL - quetiapine
fumarate tab 400 mg
ZYPREXA - olanzapine tab 7.5
mg
3
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 50 mg
2
ZYPREXA - olanzapine tab 10
mg
3
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 150 mg
2
ZYPREXA - olanzapine tab 15
mg
3
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 200 mg
2
2
3
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 300 mg
ZYPREXA - olanzapine tab 20
mg
2
thioridazine hcl tab 10 mg
1
ZYPREXA RELPREVV olanzapine pamoate for
extended rel im susp 210 mg
(base eq)
3
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 400 mg
ZYPREXA RELPREVV olanzapine pamoate for
extended rel im susp 300 mg
(base eq)
3
ZYPREXA RELPREVV olanzapine pamoate for
extended rel im susp 405 mg
(base eq)
3
ZYPREXA ZYDIS - olanzapine
orally disintegrating tab 5 mg
3
thioridazine hcl tab 25 mg
thioridazine hcl tab 50 mg
thioridazine hcl tab 100 mg
thiothixene cap 1 mg
thiothixene cap 2 mg
thiothixene cap 5 mg
thiothixene cap 10 mg
trifluoperazine hcl tab 1 mg
trifluoperazine hcl tab 2 mg
trifluoperazine hcl tab 5 mg
1
1
1
1
1
1
1
1
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
107
ZYPREXA ZYDIS - olanzapine
orally disintegrating tab 10
mg
3
ZYPREXA ZYDIS - olanzapine
orally disintegrating tab 15
mg
3
ZYPREXA ZYDIS - olanzapine
orally disintegrating tab 20
mg
3
HYPNOTICS
AMBIEN - zolpidem tartrate tab
5 mg
3
•
AMBIEN - zolpidem tartrate tab
10 mg
3
•
AMBIEN CR - zolpidem tartrate
tab cr 6.25 mg
3
•
AMBIEN CR - zolpidem tartrate
tab cr 12.5 mg
3
•
BELSOMRA - suvorexant tab 5
mg
3
•
BELSOMRA - suvorexant tab
10 mg
3
•
BELSOMRA - suvorexant tab
15 mg
3
•
BELSOMRA - suvorexant tab
20 mg
3
•
BUTISOL SODIUM butabarbital sodium tab 30
mg
3
BUTISOL SODIUM butabarbital sodium tab 50
mg
3
DORAL - quazepam tab 15 mg
3
EDLUAR - zolpidem tartrate sl
tab 5 mg
3
•
EDLUAR - zolpidem tartrate sl
tab 10 mg
3
•
estazolam tab 1 mg
1
estazolam tab 2 mg
1
1
•
eszopiclone tab 2 mg
(Lunesta)
1
•
eszopiclone tab 3 mg
(Lunesta)
1
•
FLURAZEPAM HCL flurazepam hcl cap 15 mg
3
FLURAZEPAM HCL flurazepam hcl cap 30 mg
3
HALCION - triazolam tab 0.25
mg
3
HETLIOZ - tasimelteon capsule 3
20 mg
3
INTERMEZZO - zolpidem
tartrate sl tab 1.75 mg
3
INTERMEZZO - zolpidem
tartrate sl tab 3.5 mg
3
LUNESTA - eszopiclone tab 1
mg
3
LUNESTA - eszopiclone tab 2
mg
3
LUNESTA - eszopiclone tab 3
mg
1
midazolam hcl syrup 2 mg/
ml (base equivalent)
3
PHENOBARBITAL phenobarbital tab 15 mg
3
PHENOBARBITAL phenobarbital tab 30 mg
3
PHENOBARBITAL phenobarbital tab 60 mg
3
PHENOBARBITAL phenobarbital tab 100 mg
1
phenobarbital elixir
20 mg/5ml
1
phenobarbital tab 16.2 mg
phenobarbital tab 32.4 mg
phenobarbital tab 64.8 mg
phenobarbital tab 97.2 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
Limited Distribution
eszopiclone tab 1 mg
(Lunesta)
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
1
1
1
108
3
zolpidem tartrate tab 10 mg
(Ambien)
1
•
RESTORIL - temazepam cap
7.5 mg
3
ZOLPIMIST - zolpidem tartrate
oral spray 5 mg/act
3
•
RESTORIL - temazepam cap
15 mg
3
RESTORIL - temazepam cap
22.5 mg
3
RESTORIL - temazepam cap
30 mg
3
ROZEREM - ramelteon tab 8
mg
3
SECONAL - secobarbital
sodium cap 100 mg
3
SILENOR - doxepin hcl (sleep)
tab 3 mg (base equiv)
3
•
SILENOR - doxepin hcl (sleep)
tab 6 mg (base equiv)
3
•
SONATA - zaleplon cap 5 mg
3
SONATA - zaleplon cap 10 mg
3
•
•
temazepam cap 7.5 mg
(Restoril)
1
temazepam cap 15 mg
(Restoril)
1
temazepam cap 22.5 mg
(Restoril)
1
temazepam cap 30 mg
(Restoril)
1
triazolam tab 0.125 mg
1
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
3
ADDERALL - amphetaminedextroamphetamine tab 5
mg
3
ADDERALL - amphetaminedextroamphetamine tab 7.5
mg
3
ADDERALL - amphetaminedextroamphetamine tab 10
mg
3
ADDERALL - amphetaminedextroamphetamine tab 12.5
mg
3
ADDERALL - amphetaminedextroamphetamine tab 15
mg
3
ADDERALL - amphetaminedextroamphetamine tab 20
mg
3
ADDERALL - amphetaminedextroamphetamine tab 30
mg
1
ADDERALL XR amphetaminedextroamphetamine cap sr
24hr 5 mg
1
ADDERALL XR amphetaminedextroamphetamine cap sr
24hr 10 mg
1
ADDERALL XR amphetaminedextroamphetamine cap sr
24hr 15 mg
1
ADDERALL XR amphetaminedextroamphetamine cap sr
24hr 20 mg
triazolam tab 0.25 mg
(Halcion)
1
zaleplon cap 5 mg (Sonata)
1
zaleplon cap 10 mg (Sonata)
zolpidem tartrate tab cr
6.25 mg (Ambien cr)
zolpidem tartrate tab cr
12.5 mg (Ambien cr)
zolpidem tartrate tab 5 mg
(Ambien)
•
1
•
•
•
1
•
1
•
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
QUAZEPAM - quazepam tab
15 mg
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
109
amphetaminedextroamphetamine tab
20 mg (Adderall)
amphetaminedextroamphetamine tab
30 mg (Adderall)
3
•
1
APTENSIO XR methylphenidate hcl cap er
24hr 60 mg (xr)
1
1
caffeine citrate oral soln
60 mg/3ml (10 mg/ml base
equiv) (Cafcit)
clonidine hcl tab sr 12hr
0.1 mg (Kapvay)
1
1
1
1
1
1
CONCERTA - methylphenidate
hcl tab sa osm 18 mg
3
•
CONCERTA - methylphenidate
hcl tab sa osm 27 mg
3
•
CONCERTA - methylphenidate
hcl tab sa osm 36 mg
3
•
CONCERTA - methylphenidate
hcl tab sa osm 54 mg
3
•
DAYTRANA - methylphenidate
td patch 10 mg/9hr
3
•
DAYTRANA - methylphenidate
td patch 15 mg/9hr
3
•
DAYTRANA - methylphenidate
td patch 20 mg/9hr
3
•
DAYTRANA - methylphenidate
td patch 30 mg/9hr
3
•
APTENSIO XR methylphenidate hcl cap er
24hr 10 mg (xr)
3
•
•
DESOXYN methamphetamine hcl tab 5
mg
3
APTENSIO XR methylphenidate hcl cap er
24hr 15 mg (xr)
3
•
DEXEDRINE dextroamphetamine sulfate
cap sr 24hr 5 mg
3
APTENSIO XR methylphenidate hcl cap er
24hr 20 mg (xr)
3
3
•
DEXEDRINE dextroamphetamine sulfate
cap sr 24hr 10 mg
3
APTENSIO XR methylphenidate hcl cap er
24hr 30 mg (xr)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
•
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
3
amphetaminedextroamphetamine tab
5 mg (Adderall)
amphetaminedextroamphetamine tab
15 mg (Adderall)
ACA Preventive
APTENSIO XR methylphenidate hcl cap er
24hr 50 mg (xr)
ADDERALL XR amphetaminedextroamphetamine cap sr
24hr 30 mg
amphetaminedextroamphetamine tab
12.5 mg (Adderall)
Dispensing Limits
•
1
amphetaminedextroamphetamine tab
10 mg (Adderall)
Step Therapy
3
1
•
Drug Name
APTENSIO XR methylphenidate hcl cap er
24hr 40 mg (xr)
ADDERALL XR amphetaminedextroamphetamine cap sr
24hr 25 mg
amphetaminedextroamphetamine tab
7.5 mg (Adderall)
Prior Authorization
Drug Name
Drug Tier
2015
110
DEXEDRINE dextroamphetamine sulfate
cap sr 24hr 15 mg
3
dexmethylphenidate hcl cap
sr 24 hr 5 mg (Focalin xr)
1
•
1
•
FOCALIN dexmethylphenidate hcl tab
2.5 mg
3
FOCALIN dexmethylphenidate hcl tab
5 mg
3
FOCALIN dexmethylphenidate hcl tab
10 mg
3
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 5 mg
3
•
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 10 mg
3
•
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 15 mg
3
•
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 20 mg
3
•
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 25 mg
2
dextroamphetamine
sulfate cap sr 24hr 5 mg
(Dexedrine)
1
•
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 30 mg
3
dextroamphetamine
sulfate cap sr 24hr 10 mg
(Dexedrine)
1
•
1
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 35 mg
2
dextroamphetamine
sulfate cap sr 24hr 15 mg
(Dexedrine)
•
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 40 mg
3
dextroamphetamine sulfate
oral solution 5 mg/5ml
(Procentra)
1
•
guanfacine hcl tab sr 24hr
1 mg (base equiv) (Intuniv)
1
dextroamphetamine sulfate
tab 5 mg
1
1
guanfacine hcl tab sr 24hr
2 mg (base equiv) (Intuniv)
EVEKEO - amphetamine
sulfate tab 5 mg
3
guanfacine hcl tab sr 24hr
3 mg (base equiv) (Intuniv)
EVEKEO - amphetamine
sulfate tab 10 mg
3
guanfacine hcl tab sr 24hr
4 mg (base equiv) (Intuniv)
dexmethylphenidate hcl cap
sr 24 hr 10 mg (Focalin xr)
dexmethylphenidate hcl cap
sr 24 hr 15 mg (Focalin xr)
dexmethylphenidate hcl cap
sr 24 hr 20 mg (Focalin xr)
dexmethylphenidate hcl cap
sr 24 hr 30 mg (Focalin xr)
dexmethylphenidate hcl cap
sr 24 hr 40 mg (Focalin xr)
dexmethylphenidate hcl tab
2.5 mg (Focalin)
dexmethylphenidate hcl tab
5 mg (Focalin)
dexmethylphenidate hcl tab
10 mg (Focalin)
dextroamphetamine sulfate
tab 10 mg
1
•
1
•
1
•
1
•
1
1
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
111
INTUNIV - guanfacine hcl tab
sr 24hr 1 mg (base equiv)
3
INTUNIV - guanfacine hcl tab
sr 24hr 2 mg (base equiv)
3
INTUNIV - guanfacine hcl tab
sr 24hr 3 mg (base equiv)
3
INTUNIV - guanfacine hcl tab
sr 24hr 4 mg (base equiv)
3
KAPVAY - clonidine hcl tab sr
12hr 0.1 mg
3
METADATE CD methylphenidate hcl cap cr
10 mg
3
METADATE CD methylphenidate hcl cap cr
20 mg
3
METADATE CD methylphenidate hcl cap cr
30 mg
3
•
METADATE CD methylphenidate hcl cap cr
40 mg
3
•
METADATE CD methylphenidate hcl cap cr
50 mg
3
•
METADATE CD methylphenidate hcl cap cr
60 mg
3
•
methamphetamine hcl tab
5 mg (Desoxyn)
1
METHYLIN - methylphenidate
hcl chew tab 2.5 mg
3
METHYLIN - methylphenidate
hcl chew tab 5 mg
3
METHYLIN - methylphenidate
hcl chew tab 10 mg
3
METHYLIN - methylphenidate
hcl soln 5 mg/5ml
3
METHYLIN - methylphenidate
hcl soln 10 mg/5ml
3
methylphenidate hcl cap cr
10 mg (Metadate cd)
methylphenidate hcl cap cr
20 mg (Metadate cd)
methylphenidate hcl cap cr
30 mg (Metadate cd)
methylphenidate hcl cap cr
40 mg (Metadate cd)
•
•
methylphenidate hcl cap cr
50 mg (Metadate cd)
methylphenidate hcl cap cr
60 mg (Metadate cd)
methylphenidate hcl cap sr
24hr 20 mg (la) (Ritalin la)
methylphenidate hcl cap sr
24hr 30 mg (la) (Ritalin la)
methylphenidate hcl cap sr
24hr 40 mg (la) (Ritalin la)
methylphenidate hcl chew
tab 2.5 mg (Methylin)
methylphenidate hcl chew
tab 5 mg (Methylin)
methylphenidate hcl chew
tab 10 mg (Methylin)
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
1
1
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sa osm 18 mg
3
•
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sa osm 27 mg
3
•
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sa osm 36 mg
3
•
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sa osm 54 mg
3
•
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sr 24hr 18 mg
3
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
1
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
112
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sr 24hr 27 mg
3
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sr 24hr 36 mg
3
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sr 24hr 54 mg
3
methylphenidate hcl soln
5 mg/5ml (Methylin)
1
methylphenidate hcl soln
10 mg/5ml (Methylin)
methylphenidate hcl tab cr
10 mg
methylphenidate hcl tab cr
20 mg (Ritalin sr)
methylphenidate hcl tab
5 mg (Ritalin)
methylphenidate hcl tab
10 mg (Ritalin)
methylphenidate hcl tab
20 mg (Ritalin)
•
QUILLIVANT XR methylphenidate hcl for er
susp 25 mg/5ml (5 mg/ml)
3
•
RITALIN - methylphenidate hcl
tab 5 mg
3
RITALIN - methylphenidate hcl
tab 10 mg
3
RITALIN - methylphenidate hcl
tab 20 mg
3
RITALIN LA - methylphenidate
hcl cap sr 24hr 10 mg (la)
3
•
RITALIN LA - methylphenidate
hcl cap sr 24hr 20 mg (la)
3
•
RITALIN LA - methylphenidate
hcl cap sr 24hr 30 mg (la)
3
•
RITALIN LA - methylphenidate
hcl cap sr 24hr 40 mg (la)
3
•
RITALIN LA - methylphenidate
hcl cap sr 24hr 60 mg (la)
3
•
STRATTERA - atomoxetine hcl
cap 10 mg (base equiv)
3
•
STRATTERA - atomoxetine hcl
cap 18 mg (base equiv)
3
•
STRATTERA - atomoxetine hcl
cap 25 mg (base equiv)
3
•
STRATTERA - atomoxetine hcl
cap 40 mg (base equiv)
3
•
STRATTERA - atomoxetine hcl
cap 60 mg (base equiv)
3
•
STRATTERA - atomoxetine hcl
cap 80 mg (base equiv)
3
•
STRATTERA - atomoxetine hcl
cap 100 mg (base equiv)
3
•
VYVANSE - lisdexamfetamine
dimesylate cap 10 mg
2
•
VYVANSE - lisdexamfetamine
dimesylate cap 20 mg
2
•
1
1
1
1
1
modafinil tab 100 mg
(Provigil)
1
•
•
modafinil tab 200 mg
(Provigil)
1
•
•
NUVIGIL - armodafinil tab 50
mg
3
•
•
NUVIGIL - armodafinil tab 150
mg
3
•
•
NUVIGIL - armodafinil tab 200
mg
3
•
•
NUVIGIL - armodafinil tab 250
mg
3
•
•
PROCENTRA dextroamphetamine sulfate
oral solution 5 mg/5ml
3
PROVIGIL - modafinil tab 100
mg
3
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
•
3
ACA Preventive
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Tier
Drug Name
PROVIGIL - modafinil tab 200
mg
1
•
Limited Distribution
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
113
2
•
VYVANSE - lisdexamfetamine
dimesylate cap 60 mg
2
•
VYVANSE - lisdexamfetamine
dimesylate cap 70 mg
2
•
ZENZEDI - dextroamphetamine 3
sulfate tab 2.5 mg
ZENZEDI - dextroamphetamine 3
sulfate tab 7.5 mg
ZENZEDI - dextroamphetamine 3
sulfate tab 15 mg
ZENZEDI - dextroamphetamine 3
sulfate tab 20 mg
ZENZEDI - dextroamphetamine 3
sulfate tab 30 mg
PSYCHOTHERAPEUTIC and NEUROLOGICAL
AGENTS - MISC.
1
acamprosate calcium tab
delayed release 333 mg
(Campral)
•
AMPYRA - dalfampridine tab sr 4 •
12hr 10 mg
3
ANTABUSE - disulfiram tab
250 mg
3
ANTABUSE - disulfiram tab
500 mg
3
ARICEPT - donepezil
hydrochloride tab 5 mg
3
ARICEPT - donepezil
hydrochloride tab 10 mg
3
ARICEPT - donepezil
hydrochloride tab 23 mg
• •
AUBAGIO - teriflunomide tab 7 4
mg
AUBAGIO - teriflunomide tab
14 mg
4
• •
AVONEX - interferon beta-1a
for im inj kit 30mcg
(33mcg(6.6 mu)/vial)
4
• •
•
AVONEX - interferon beta-1a
im prefilled syringe kit 30
mcg/0.5ml
4
• •
•
AVONEX PEN - interferon
beta-1a im auto-injector kit
30 mcg/0.5ml
4
• •
•
BETASERON - interferon
beta-1b for inj kit 0.3 mg
4
•
•
BRISDELLE - paroxetine
mesylate cap 7.5 mg (base
equiv)
3
NA
• •
CHANTIX - varenicline tartrate NA
tab 0.5 mg (base equiv)
CHANTIX - varenicline tartrate NA
tab 1 mg (base equiv)
NA
CHANTIX CONTINUING
MONTH - varenicline tartrate
tab 1 mg (base equiv)
CHANTIX STARTING MONTH NA
PA - varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42
pack
3
CHLORDIAZEPOXIDE/
AMITRIPT chlordiazepoxideamitriptyline tab 5-12.5 mg
3
CHLORDIAZEPOXIDE/
AMITRIPT chlordiazepoxideamitriptyline tab 10-25 mg
NA
COMMIT - nicotine polacrilex
lozenge 2 mg
NA
COMMIT - nicotine polacrilex
lozenge 4 mg
• •
bupropion hcl (smoking
deterrent) tab sr 12hr
150 mg (Zyban)
•
•
Limited Distribution
VYVANSE - lisdexamfetamine
dimesylate cap 50 mg
ACA Preventive
•
Dispensing Limits
2
Step Therapy
VYVANSE - lisdexamfetamine
dimesylate cap 40 mg
Prior Authorization
•
Drug Name
Drug Tier
2
Limited Distribution
VYVANSE - lisdexamfetamine
dimesylate cap 30 mg
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
• •
• •
• •
•
•
114
COPAXONE - glatiramer
acetate soln prefilled syringe
20 mg/ml
4
COPAXONE - glatiramer
acetate soln prefilled syringe
40 mg/ml
4
disulfiram tab 250 mg
(Antabuse)
1
disulfiram tab 500 mg
(Antabuse)
1
donepezil hydrochloride
orally disintegrating tab
5 mg
•
•
fluoxetine hcl (pmdd) cap
10 mg
fluoxetine hcl (pmdd) cap
20 mg
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
GALANTAMINE
HYDROBROMIDE galantamine hydrobromide
oral soln 4 mg/ml
3
1
1
galantamine hydrobromide
cap sr 24hr 8 mg
(Razadyne er)
1
1
galantamine hydrobromide
cap sr 24hr 16 mg
(Razadyne er)
1
1
galantamine hydrobromide
cap sr 24hr 24 mg
(Razadyne er)
1
1
galantamine hydrobromide
tab 4 mg (Razadyne)
1
galantamine hydrobromide
tab 8 mg (Razadyne)
ERGOLOID MESYLATES ergoloid mesylates tab 1 mg
3
galantamine hydrobromide
tab 12 mg (Razadyne)
4
• •
•
EXELON - rivastigmine tartrate
cap 1.5 mg
3
GILENYA - fingolimod hcl cap
0.5 mg (base equiv)
4
•
•
EXELON - rivastigmine tartrate
cap 3 mg
3
glatiramer acetate soln
prefilled syringe 20 mg/ml
(Copaxone)
EXELON - rivastigmine tartrate
cap 4.5 mg
3
GRALISE - gabapentin (oncedaily) tab 300 mg
3
•
EXELON - rivastigmine tartrate
cap 6 mg
3
GRALISE - gabapentin (oncedaily) tab 600 mg
3
•
EXELON - rivastigmine td
patch 24hr 4.6 mg/24hr
2
3
•
EXELON - rivastigmine td
patch 24hr 9.5 mg/24hr
2
GRALISE STARTER gabapentin (once-daily) tab
pack 300 mg (9) & 600 mg
(69)
EXELON - rivastigmine td
patch 24hr 13.3 mg/24hr
2
HORIZANT - gabapentin
enacarbil tab cr 300 mg
3
•
EXTAVIA - interferon beta-1b
for inj kit 0.3 mg
4
HORIZANT - gabapentin
enacarbil tab cr 600 mg
3
•
donepezil hydrochloride
orally disintegrating tab
10 mg (Aricept odt)
donepezil hydrochloride tab
5 mg (Aricept)
donepezil hydrochloride tab
10 mg (Aricept)
donepezil hydrochloride tab
23 mg (Aricept)
• •
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
1
1
115
1
NICODERM CQ - nicotine td
patch 24hr 21 mg/24hr
NA
•
memantine hcl tab 5 mg
(Namenda)
1
NICORETTE - nicotine
polacrilex gum 2 mg
NA
•
memantine hcl tab 10 mg
(Namenda)
1
NICORETTE - nicotine
polacrilex gum 4 mg
NA
•
memantine hcl tab 5 mg (28)
& 10 mg (21) titration pak
(Namenda titration pa)
1
NICORETTE - nicotine
polacrilex lozenge 2 mg
NA
•
NICORETTE - nicotine
polacrilex lozenge 4 mg
NA
NAMENDA - memantine hcl
oral solution 2 mg/ml
3
•
NICORETTE MINI - nicotine
polacrilex lozenge 2 mg
NA
NAMENDA - memantine hcl
tab 5 mg
3
•
NICORETTE MINI - nicotine
polacrilex lozenge 4 mg
NA
NAMENDA - memantine hcl
tab 10 mg
3
•
NAMENDA TITRATION PAK memantine hcl tab 5 mg (28)
& 10 mg (21) titration pak
3
•
NAMENDA XR - memantine
hcl cap sr 24hr 7 mg
3
NAMENDA XR - memantine
hcl cap sr 24hr 14 mg
3
NAMENDA XR - memantine
hcl cap sr 24hr 21 mg
3
NAMENDA XR - memantine
hcl cap sr 24hr 28 mg
3
NICORETTE STARTER KIT - NA
nicotine polacrilex gum 2 mg
NICORETTE STARTER KIT - NA
nicotine polacrilex gum 4 mg
NA
nicotine polacrilex gum
2 mg
NA
nicotine polacrilex gum
4 mg
NA
nicotine polacrilex lozenge
2 mg
NA
nicotine polacrilex lozenge
4 mg
NA
nicotine td patch 24hr
7 mg/24hr
NA
nicotine td patch 24hr
14 mg/24hr
NA
nicotine td patch 24hr
21 mg/24hr
NA
NICOTINE TRANSDERMAL
SYST - nicotine td patch 24
hr kit 21-14-7 mg/24hr
NA
NICOTROL INHALER nicotine inhaler system 10
mg (4 mg delivered)
NICOTROL NS - nicotine nasal NA
spray 10 mg/ml (0.5 mg/
spray)
memantine hcl oral solution
2 mg/ml (Namenda)
3
NAMENDA XR TITRATION
PACK - memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg
& 28 mg pack
3
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr
14-10 mg
3
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr
28-10 mg
NA
NICODERM CQ - nicotine td
patch 24hr 7 mg/24hr
NA
NICODERM CQ - nicotine td
patch 24hr 14 mg/24hr
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
•
116
NUEDEXTA dextromethorphan hbrquinidine sulfate cap 20-10
mg
3
olanzapine-fluoxetine hcl
cap 3-25 mg (Symbyax)
1
olanzapine-fluoxetine hcl
cap 6-25 mg (Symbyax)
olanzapine-fluoxetine hcl
cap 6-50 mg (Symbyax)
olanzapine-fluoxetine hcl
cap 12-25 mg (Symbyax)
olanzapine-fluoxetine hcl
cap 12-50 mg (Symbyax)
1
1
ORAP - pimozide tab 2 mg
3
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 2-10 mg
3
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 2-25 mg
3
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 4-10 mg
3
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 4-25 mg
3
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 4-50 mg
3
pimozide tab 1 mg (Orap)
1
1
4
•
•
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
1
3
PLEGRIDY - peginterferon
beta-1a soln pen-injector
125 mcg/0.5ml
Step Therapy
1
ORAP - pimozide tab 1 mg
pimozide tab 2 mg (Orap)
Prior Authorization
Drug Name
Drug Tier
2015
PLEGRIDY - peginterferon
beta-1a soln prefilled syringe
125 mcg/0.5ml
4
•
PLEGRIDY STARTER PACK peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml
pack
4
•
•
PLEGRIDY STARTER PACK peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml
pack
4
•
•
RAZADYNE - galantamine
hydrobromide oral soln 4
mg/ml
3
RAZADYNE - galantamine
hydrobromide tab 4 mg
3
RAZADYNE - galantamine
hydrobromide tab 8 mg
3
RAZADYNE - galantamine
hydrobromide tab 12 mg
3
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 8
mg
3
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 16
mg
3
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 24
mg
3
REBIF - interferon beta-1a
soln pref syr 22 mcg/0.5ml
(12mu/ml)
4
•
•
REBIF - interferon beta-1a
soln pref syr 44 mcg/0.5ml
(24mu/ml)
4
•
•
REBIF REBIDOSE - interferon
beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml)
4
•
•
REBIF REBIDOSE - interferon
beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml)
4
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
117
REBIF REBIDOSE
TITRATION - interferon
beta-1a auto-inj 6x8.8
mcg/0.2ml & 6x22
mcg/0.5ml
4
REBIF TITRATION PACK interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22
mcg/0.5ml
4
rivastigmine tartrate cap
1.5 mg (Exelon)
1
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
SYMBYAX - olanzapinefluoxetine hcl cap 6-25 mg
3
SYMBYAX - olanzapinefluoxetine hcl cap 6-50 mg
3
SYMBYAX - olanzapinefluoxetine hcl cap 12-25 mg
3
SYMBYAX - olanzapinefluoxetine hcl cap 12-50 mg
3
TECFIDERA - dimethyl
fumarate capsule delayed
release 120 mg
4
•
•
TECFIDERA - dimethyl
fumarate capsule delayed
release 240 mg
4
•
•
4
•
•
1
TECFIDERA STARTER
PACK - dimethyl fumarate
capsule dr starter pack 120
mg & 240 mg
1
tetrabenazine tab 12.5 mg
(Xenazine)
4
•
1
tetrabenazine tab 25 mg
(Xenazine)
4
•
XENAZINE - tetrabenazine tab
12.5 mg
4
SARAFEM - fluoxetine hcl
(pmdd) tab 10 mg
3
•
XENAZINE - tetrabenazine tab
25 mg
4
SARAFEM - fluoxetine hcl
(pmdd) tab 20 mg
3
•
3
XYREM - sodium oxybate oral
solution 500 mg/ml
4
SAVELLA - milnacipran hcl tab
12.5 mg
SAVELLA - milnacipran hcl tab
25 mg
3
ZYBAN - bupropion hcl
(smoking deterrent) tab sr
12hr 150 mg
SAVELLA - milnacipran hcl tab
50 mg
3
ANALGESICS AND ANESTHETICS
SAVELLA - milnacipran hcl tab
100 mg
3
ANALGESICS - NON-NARCOTIC
NA
aspirin chew tab 81 mg
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg
(5) & 25 mg (8) & 50 mg (42)
pak
3
aspirin tab delayed release
81 mg
SYMBYAX - olanzapinefluoxetine hcl cap 3-25 mg
3
rivastigmine tartrate cap
3 mg (Exelon)
rivastigmine tartrate cap
4.5 mg (Exelon)
rivastigmine tartrate cap
6 mg (Exelon)
rivastigmine td patch 24hr
4.6 mg/24hr (Exelon)
rivastigmine td patch 24hr
9.5 mg/24hr (Exelon)
rivastigmine td patch 24hr
13.3 mg/24hr (Exelon)
1
1
1
•
•
aspirin tab 81 mg
BUPAP - butalbitalacetaminophen tab 50-300
mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
NA
•
•
•
• •
NA
•
•
NA
•
3
•
118
3
•
1
butalbital-aspirin-caffeine
cap 50-325-40 mg (Fiorinal)
1
ABSTRAL - fentanyl citrate sl
tab 400 mcg (base equiv)
3
•
•
•
ABSTRAL - fentanyl citrate sl
tab 600 mcg (base equiv)
3
•
•
•
ABSTRAL - fentanyl citrate sl
tab 800 mcg (base equiv)
3
•
•
acetaminophen w/ codeine
soln 120-12 mg/5ml
1
•
acetaminophen w/ codeine
tab 300-15 mg (Tylenol/
codeine)
1
•
acetaminophen w/ codeine
tab 300-30 mg (Tylenol/
codeine #3)
1
•
acetaminophen w/ codeine
tab 300-60 mg (Tylenol/
codeine #4)
1
•
acetaminophen-caffeinedihydrocodeine cap
320.5-30-16 mg (Trezix)
1
•
•
1
ESGIC - butalbitalacetaminophen-caffeine tab
50-325-40 mg
3
•
FIORICET - butalbitalacetaminophen-caffeine cap
50-300-40 mg
3
•
FIORICET - butalbitalacetaminophen-caffeine tab
50-325-40 mg
3
•
FIORINAL - butalbital-aspirincaffeine cap 50-325-40 mg
3
•
ORBIVAN - butalbitalacetaminophen-caffeine cap
50-300-40 mg
3
•
ORBIVAN CF - butalbitalacetaminophen tab 50-300
mg
3
salsalate tab 500 mg
1
salsalate tab 750 mg
VANATOL LQ - butalbitalacetaminophen-caffeine soln
50-325-40 mg/15ml
ANALGESICS - NARCOTIC
1
3
•
ACTIQ - fentanyl citrate
lozenge on a handle 200
mcg
3
•
•
3
•
•
•
ACTIQ - fentanyl citrate
lozenge on a handle 400
mcg
ACTIQ - fentanyl citrate
lozenge on a handle 600
mcg
3
•
•
3
•
•
•
ACTIQ - fentanyl citrate
lozenge on a handle 800
mcg
ACTIQ - fentanyl citrate
lozenge on a handle 1200
mcg
3
•
•
ACTIQ - fentanyl citrate
lozenge on a handle 1600
mcg
3
•
•
ABSTRAL - fentanyl citrate sl
tab 100 mcg (base equiv)
3
•
•
ABSTRAL - fentanyl citrate sl
tab 200 mcg (base equiv)
3
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
butalbital-acetaminophencaffeine tab 50-325-40 mg
(Esgic)
diflunisal tab 500 mg
ABSTRAL - fentanyl citrate sl
tab 300 mcg (base equiv)
ACA Preventive
butalbital-acetaminophencaffeine cap 50-325-40 mg
1
Dispensing Limits
•
Step Therapy
1
Prior Authorization
butalbital-acetaminophencaffeine cap 50-300-40 mg
(Fioricet)
Drug Name
Drug Tier
•
Limited Distribution
1
butalbital-acetaminophen
tab 50-325 mg
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
119
3
AVINZA - morphine sulfate
beads cap sr 24hr 30 mg
3
•
AVINZA - morphine sulfate
beads cap sr 24hr 45 mg
3
•
AVINZA - morphine sulfate
beads cap sr 24hr 60 mg
3
•
AVINZA - morphine sulfate
beads cap sr 24hr 75 mg
3
•
AVINZA - morphine sulfate
beads cap sr 24hr 90 mg
3
•
AVINZA - morphine sulfate
beads cap sr 24hr 120 mg
3
BELBUCA - buprenorphine hcl
buccal film 75 mcg (base
equivalent)
3
BELBUCA - buprenorphine hcl
buccal film 150 mcg (base
equivalent)
3
BELBUCA - buprenorphine hcl
buccal film 300 mcg (base
equivalent)
3
BELBUCA - buprenorphine hcl
buccal film 450 mcg (base
equivalent)
3
BELBUCA - buprenorphine hcl
buccal film 600 mcg (base
equivalent)
3
BELBUCA - buprenorphine hcl
buccal film 750 mcg (base
equivalent)
3
BELBUCA - buprenorphine hcl
buccal film 900 mcg (base
equivalent)
3
BUNAVAIL - buprenorphinenaloxone buccal film 2.1-0.3
mg (base equiv)
3
•
•
•
3
•
BUNAVAIL - buprenorphinenaloxone buccal film 6.3-1
mg (base equiv)
3
•
•
buprenorphine hcl sl tab
2 mg (base equiv)
1
•
•
1
•
•
1
•
•
1
•
•
buprenorphine hcl sl tab
8 mg (base equiv)
buprenorphine hcl-naloxone
hcl sl tab 2-0.5 mg (base
equiv)
buprenorphine hcl-naloxone
hcl sl tab 8-2 mg (base
equiv)
•
butalbital-acetaminophencaff w/ cod cap
50-300-40-30 mg (Fioricet/
codeine)
1
•
butalbital-acetaminophencaff w/ cod cap
50-325-40-30 mg
1
•
butalbital-aspirincaff w/ codeine cap
50-325-40-30 mg (Fiorinal/
codeine #3)
1
•
butorphanol tartrate nasal
soln 10 mg/ml
1
BUTRANS - buprenorphine td
patch weekly 5 mcg/hr
3
•
BUTRANS - buprenorphine td
patch weekly 7.5 mcg/hr
3
•
BUTRANS - buprenorphine td
patch weekly 10 mcg/hr
3
•
BUTRANS - buprenorphine td
patch weekly 15 mcg/hr
3
•
BUTRANS - buprenorphine td
patch weekly 20 mcg/hr
3
•
CAPITAL/CODEINE acetaminophen w/ codeine
susp 120-12 mg/5ml
3
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
BUNAVAIL - buprenorphinenaloxone buccal film 4.2-0.7
mg (base equiv)
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ASPIRIN-CAFFEINEDIHYDROC - aspirincaffeine-dihydrocodeine cap
356.4-30-16 mg
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
120
3
•
codeine sulfate tab 15 mg
(Codeine sulfate)
1
•
codeine sulfate tab 30 mg
1
•
•
•
codeine sulfate tab 60 mg
1
3
•
DURAGESIC - fentanyl td
patch 72hr 75 mcg/hr
3
•
DURAGESIC - fentanyl td
patch 72hr 100 mcg/hr
3
•
EMBEDA - morphinenaltrexone cap cr 20-0.8 mg
3
•
EMBEDA - morphinenaltrexone cap cr 30-1.2 mg
3
•
EMBEDA - morphinenaltrexone cap cr 50-2 mg
3
•
EMBEDA - morphinenaltrexone cap cr 60-2.4 mg
3
•
EMBEDA - morphinenaltrexone cap cr 80-3.2 mg
3
•
EMBEDA - morphinenaltrexone cap cr 100-4 mg
3
•
CONZIP - tramadol hcl cap sr
24hr biphasic release 100
mg
3
CONZIP - tramadol hcl cap sr
24hr biphasic release 200
mg
3
CONZIP - tramadol hcl cap sr
24hr biphasic release 300
mg
3
•
DEMEROL - meperidine hcl tab 3
50 mg
DEMEROL - meperidine hcl tab 3
100 mg
3
DILAUDID - hydromorphone
hcl liqd 1 mg/ml
3
DILAUDID - hydromorphone
hcl tab 2 mg
3
DILAUDID - hydromorphone
hcl tab 4 mg
3
DILAUDID - hydromorphone
hcl tab 8 mg
3
DOLOPHINE - methadone hcl
tab 5 mg
3
DOLOPHINE - methadone hcl
tab 10 mg
3
DURAGESIC - fentanyl td
patch 72hr 12 mcg/hr
3
DURAGESIC - fentanyl td
patch 72hr 25 mcg/hr
•
EXALGO - hydromorphone hcl
tab er 24hr deter 8 mg
3
•
•
EXALGO - hydromorphone hcl
tab er 24hr deter 12 mg
3
•
•
EXALGO - hydromorphone hcl
tab er 24hr deter 16 mg
3
•
•
EXALGO - hydromorphone hcl
tab er 24hr deter 32 mg
3
•
•
FENTANYL - fentanyl td patch
72hr 37.5 mcg/hr
3
•
•
FENTANYL - fentanyl td patch
72hr 62.5 mcg/hr
3
•
•
FENTANYL - fentanyl td patch
72hr 87.5 mcg/hr
3
•
•
fentanyl citrate lozenge on a
handle 200 mcg (Actiq)
1
•
•
•
fentanyl citrate lozenge on a
handle 400 mcg (Actiq)
1
•
•
•
fentanyl citrate lozenge on a
handle 600 mcg (Actiq)
1
•
•
1
•
•
•
fentanyl citrate lozenge on a
handle 800 mcg (Actiq)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
CODEINE SULFATE - codeine
sulfate tab 60 mg
DURAGESIC - fentanyl td
patch 72hr 50 mcg/hr
ACA Preventive
•
Dispensing Limits
3
Step Therapy
CODEINE SULFATE - codeine
sulfate tab 30 mg
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
CODEINE SULFATE - codeine
sulfate tab 15 mg
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
121
fentanyl citrate lozenge on a
handle 1200 mcg (Actiq)
fentanyl citrate lozenge on a
handle 1600 mcg (Actiq)
fentanyl td patch 72hr
12 mcg/hr (Duragesic)
fentanyl td patch 72hr
25 mcg/hr (Duragesic)
fentanyl td patch 72hr
50 mcg/hr (Duragesic)
fentanyl td patch 72hr
75 mcg/hr (Duragesic)
fentanyl td patch 72hr
100 mcg/hr (Duragesic)
•
1
•
1
•
1
•
1
•
1
•
FENTORA - fentanyl citrate
buccal tab 100 mcg (base
equiv)
3
•
•
FENTORA - fentanyl citrate
buccal tab 200 mcg (base
equiv)
3
•
•
FENTORA - fentanyl citrate
buccal tab 400 mcg (base
equiv)
3
•
•
FENTORA - fentanyl citrate
buccal tab 600 mcg (base
equiv)
3
•
•
FENTORA - fentanyl citrate
buccal tab 800 mcg (base
equiv)
3
•
•
FIORICET/CODEINE butalbital-acetaminophencaff w/ cod cap
50-300-40-30 mg
3
•
FIORINAL/CODEINE #3 butalbital-aspirin-caff w/
codeine cap 50-325-40-30
mg
3
•
HYCET - hydrocodoneacetaminophen soln 7.5-325
mg/15ml
3
•
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
HYDROMORPHONE HCL
ER - hydromorphone hcl tab
er 24hr deter 32 mg
3
•
hydromorphone hcl liqd
1 mg/ml (Dilaudid)
1
•
1
•
1
•
1
•
hydrocodoneacetaminophen tab
2.5-325 mg
hydrocodoneacetaminophen tab
10-325 mg (Norco)
hydrocodoneacetaminophen tab
5-300 mg (Xodol)
hydrocodoneacetaminophen tab
7.5-300 mg (Xodol)
hydrocodoneacetaminophen tab
5-325 mg (Norco)
hydrocodoneacetaminophen tab
7.5-325 mg (Norco)
hydrocodoneacetaminophen tab
10-300 mg (Xodol)
hydrocodone-ibuprofen tab
5-200 mg (Reprexain)
hydrocodone-ibuprofen tab
7.5-200 mg (Vicoprofen)
hydrocodone-ibuprofen tab
10-200 mg (Ibudone)
hydromorphone hcl tab er
24hr deter 8 mg (Exalgo)
hydromorphone hcl tab er
24hr deter 12 mg (Exalgo)
hydromorphone hcl tab er
24hr deter 16 mg (Exalgo)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
1
hydrocodoneacetaminophen soln
7.5-325 mg/15ml (Hycet)
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
•
Limited Distribution
1
•
ACA Preventive
•
Dispensing Limits
1
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
122
3
•
KADIAN - morphine sulfate cap
sr 24hr 60 mg
3
•
KADIAN - morphine sulfate cap
sr 24hr 80 mg
3
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
20 mg
3
•
KADIAN - morphine sulfate cap
sr 24hr 100 mg
3
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
30 mg
3
•
KADIAN - morphine sulfate cap
sr 24hr 200 mg
3
•
3
•
•
•
LAZANDA - fentanyl citrate
nasal spray 100 mcg/act
(base equiv)
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
40 mg
3
3
•
•
•
LAZANDA - fentanyl citrate
nasal spray 400 mcg/act
(base equiv)
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
60 mg
3
LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg
3
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
80 mg
3
•
MEPERIDINE HCL meperidine hcl oral soln 50
mg/5ml
3
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
100 mg
3
•
meperidine hcl tab 50 mg
(Demerol)
1
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
120 mg
3
•
meperidine hcl tab 100 mg
(Demerol)
1
•
3
•
•
METHADONE HCL methadone hcl soln 5
mg/5ml
IBUDONE - hydrocodoneibuprofen tab 10-200 mg
3
IONSYS - fentanyl hcl
iontophoretic td system 40
mcg/act (base equiv)
3
METHADONE HCL methadone hcl soln 10
mg/5ml
3
•
KADIAN - morphine sulfate cap
sr 24hr 10 mg
3
•
methadone hcl conc 10 mg/
ml (Methadose)
1
•
KADIAN - morphine sulfate cap
sr 24hr 20 mg
3
•
methadone hcl soln
5 mg/5ml (Methadone hcl)
1
•
KADIAN - morphine sulfate cap
sr 24hr 30 mg
3
•
methadone hcl soln
10 mg/5ml (Methadone hcl)
1
•
KADIAN - morphine sulfate cap
sr 24hr 40 mg
3
•
methadone hcl tab for oral
susp 40 mg
1
•
1
•
hydromorphone hcl tab
4 mg (Dilaudid)
hydromorphone hcl tab
8 mg (Dilaudid)
methadone hcl tab 5 mg
(Dolophine hcl)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
KADIAN - morphine sulfate cap
sr 24hr 50 mg
hydromorphone hcl tab
2 mg (Dilaudid)
ACA Preventive
•
Dispensing Limits
1
Step Therapy
•
Prior Authorization
1
Drug Name
Drug Tier
•
Limited Distribution
1
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
123
MORPHINE SULFATE morphine sulfate tab 15 mg
2
•
MORPHINE SULFATE morphine sulfate tab 30 mg
2
•
morphine sulfate cap sr 24hr
10 mg (Kadian)
1
•
1
•
1
•
1
•
1
•
1
•
1
•
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 30 mg
3
•
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 45 mg
3
•
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 60 mg
3
•
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 75 mg
3
•
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 90 mg
3
•
morphine sulfate cap sr 24hr
20 mg (Kadian)
morphine sulfate cap sr 24hr
30 mg (Kadian)
morphine sulfate cap sr 24hr
50 mg (Kadian)
morphine sulfate cap sr 24hr
60 mg (Kadian)
morphine sulfate cap sr 24hr
80 mg (Kadian)
morphine sulfate cap sr 24hr
100 mg (Kadian)
•
3
•
morphine sulfate oral soln
10 mg/5ml
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
MS CONTIN - morphine sulfate
tab cr 15 mg
3
•
MS CONTIN - morphine sulfate
tab cr 30 mg
3
•
MS CONTIN - morphine sulfate
tab cr 60 mg
3
•
MS CONTIN - morphine sulfate
tab cr 100 mg
3
•
MS CONTIN - morphine sulfate
tab cr 200 mg
3
•
nalbuphine hcl inj 10 mg/ml
1
morphine sulfate oral soln
20 mg/5ml
morphine sulfate oral soln
100 mg/5ml (20 mg/ml)
morphine sulfate tab cr
15 mg (Ms contin)
morphine sulfate tab cr
30 mg (Ms contin)
morphine sulfate tab cr
60 mg (Ms contin)
morphine sulfate tab cr
100 mg (Ms contin)
morphine sulfate tab cr
200 mg (Ms contin)
nalbuphine hcl inj 20 mg/ml
1
NORCO - hydrocodoneacetaminophen tab 10-325
mg
3
•
NORCO - hydrocodoneacetaminophen tab 5-325
mg
3
•
NORCO - hydrocodoneacetaminophen tab 7.5-325
mg
3
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
METHADOSE SUGAR-FREE methadone hcl conc 10 mg/
ml
3
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 120 mg
ACA Preventive
•
Dispensing Limits
3
Step Therapy
METHADOSE - methadone hcl
conc 10 mg/ml
Prior Authorization
•
Drug Name
Drug Tier
1
Limited Distribution
methadone hcl tab 10 mg
(Dolophine)
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
124
3
•
OXAYDO - oxycodone hcl tab
abuse deter 7.5 mg
3
•
NUCYNTA - tapentadol hcl tab
100 mg
3
•
OXYCODONE HCL oxycodone hcl conc 100
mg/5ml (20 mg/ml)
3
•
NUCYNTA ER - tapentadol hcl
tab sr 12hr 50 mg
2
•
•
OXYCODONE HCL oxycodone hcl soln 5
mg/5ml
3
•
NUCYNTA ER - tapentadol hcl
tab sr 12hr 100 mg
2
NUCYNTA ER - tapentadol hcl
tab sr 12hr 150 mg
2
•
oxycodone hcl cap 5 mg
1
NUCYNTA ER - tapentadol hcl
tab sr 12hr 200 mg
2
•
NUCYNTA ER - tapentadol hcl
tab sr 12hr 250 mg
2
•
OPANA - oxymorphone hcl tab
5 mg
3
•
OPANA - oxymorphone hcl tab
10 mg
3
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 5 mg
3
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 7.5 mg
oxycodone hcl conc
100 mg/5ml (20 mg/ml)
(Oxycodone hcl)
1
•
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 10 mg
3
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 20 mg
3
•
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 40 mg
3
•
3
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 80 mg
3
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 10 mg
3
•
oxycodone hcl soln
5 mg/5ml (Oxycodone hcl)
1
•
1
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 15 mg
3
oxycodone hcl tab 5 mg
(Roxicodone)
oxycodone hcl tab 10 mg
1
•
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 20 mg
3
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 30 mg
3
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 40 mg
3
•
•
oxycodone hcl tab 15 mg
(Roxicodone)
1
oxycodone hcl tab 20 mg
1
•
oxycodone hcl tab 30 mg
(Roxicodone)
1
1
•
oxycodone w/
acetaminophen tab
2.5-325 mg (Percocet)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
•
Limited Distribution
OXAYDO - oxycodone hcl tab
abuse deter 5 mg
ACA Preventive
•
Dispensing Limits
3
Step Therapy
NUCYNTA - tapentadol hcl tab
75 mg
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
NUCYNTA - tapentadol hcl tab
50 mg
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
125
oxycodone w/
acetaminophen tab
5-325 mg (Percocet)
oxycodone w/
acetaminophen tab
7.5-325 mg (Percocet)
oxycodone w/
acetaminophen tab
10-325 mg (Percocet)
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
oxycodone-ibuprofen tab
5-400 mg
1
1
•
1
•
1
•
1
•
1
•
oxymorphone hcl tab 10 mg
(Opana)
1
•
pentazocine w/ naloxone tab
50-0.5 mg
1
PERCOCET - oxycodone w/
acetaminophen tab 2.5-325
mg
3
•
PERCOCET - oxycodone w/
acetaminophen tab 5-325
mg
3
•
PERCOCET - oxycodone w/
acetaminophen tab 7.5-325
mg
3
•
PERCOCET - oxycodone w/
acetaminophen tab 10-325
mg
3
•
PERCODAN - oxycodoneaspirin tab 4.8355-325 mg
3
•
PRIMLEV - oxycodone w/
acetaminophen tab 5-300
mg
3
•
PRIMLEV - oxycodone w/
acetaminophen tab 7.5-300
mg
3
•
3
•
OXYCONTIN - oxycodone hcl
tab er 12hr deter 10 mg
2
•
OXYCONTIN - oxycodone hcl
tab er 12hr deter 15 mg
2
•
OXYCONTIN - oxycodone hcl
tab er 12hr deter 20 mg
2
•
OXYCONTIN - oxycodone hcl
tab er 12hr deter 30 mg
2
OXYCONTIN - oxycodone hcl
tab er 12hr deter 40 mg
2
•
OXYCONTIN - oxycodone hcl
tab er 12hr deter 60 mg
2
•
OXYCONTIN - oxycodone hcl
tab er 12hr deter 80 mg
2
•
oxymorphone hcl tab sr 12hr
5 mg
1
•
PRIMLEV - oxycodone w/
acetaminophen tab 10-300
mg
1
•
REPREXAIN - hydrocodoneibuprofen tab 5-200 mg
3
•
1
•
3
•
1
•
ROXICET - oxycodone w/
acetaminophen soln 5-325
mg/5ml
3
•
1
•
ROXICODONE - oxycodone
hcl tab 5 mg
3
•
1
•
ROXICODONE - oxycodone
hcl tab 15 mg
3
•
1
•
ROXICODONE - oxycodone
hcl tab 30 mg
oxymorphone hcl tab sr 12hr
7.5 mg
oxymorphone hcl tab sr 12hr
10 mg
oxymorphone hcl tab sr 12hr
15 mg
oxymorphone hcl tab sr 12hr
20 mg
oxymorphone hcl tab sr 12hr
30 mg
oxymorphone hcl tab sr 12hr
40 mg
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
oxymorphone hcl tab 5 mg
(Opana)
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
126
3
•
•
tramadol hcl tab sr 24hr
100 mg (Ultram er)
1
•
1
SUBOXONE - buprenorphine
hcl-naloxone hcl sl film 8-2
mg (base equiv)
2
•
1
•
SUBOXONE - buprenorphine
hcl-naloxone hcl sl film 12-3
mg (base equiv)
2
•
•
1
•
SUBSYS - fentanyl sublingual
spray 100 mcg
3
•
•
tramadol hcl tab sr 24hr
biphasic release 200 mg
1
•
SUBSYS - fentanyl sublingual
spray 200 mcg
3
•
•
tramadol hcl tab sr 24hr
biphasic release 300 mg
1
•
SUBSYS - fentanyl sublingual
spray 400 mcg
3
•
•
tramadol hcl tab 50 mg
(Ultram)
1
•
SUBSYS - fentanyl sublingual
spray 600 mcg
3
•
•
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
1
•
SUBSYS - fentanyl sublingual
spray 800 mcg
3
•
•
3
•
3
•
•
TREZIX - acetaminophencaffeine-dihydrocodeine cap
320.5-30-16 mg
SUBSYS - fentanyl sublingual
spray 1200 mcg (600 mcg x
2)
3
•
SUBSYS - fentanyl sublingual
spray 1600 mcg (800 mcg x
2)
3
•
•
TYLENOL/CODEINE #3 acetaminophen w/ codeine
tab 300-30 mg
3
•
SYNALGOS-DC - aspirincaffeine-dihydrocodeine cap
356.4-30-16 mg
3
•
TYLENOL/CODEINE #4 acetaminophen w/ codeine
tab 300-60 mg
3
•
TRAMADOL HCL ER tramadol hcl cap sr 24hr
biphasic release 100 mg
3
•
ULTRACET - tramadolacetaminophen tab 37.5-325
mg
ULTRAM - tramadol hcl tab 50
mg
3
•
TRAMADOL HCL ER tramadol hcl cap sr 24hr
biphasic release 150 mg
3
•
ULTRAM ER - tramadol hcl tab
sr 24hr 100 mg
3
•
3
•
TRAMADOL HCL ER tramadol hcl cap sr 24hr
biphasic release 200 mg
3
ULTRAM ER - tramadol hcl tab
sr 24hr 200 mg
ULTRAM ER - tramadol hcl tab
sr 24hr 300 mg
3
•
VICOPROFEN - hydrocodoneibuprofen tab 7.5-200 mg
3
•
•
•
•
tramadol hcl tab sr 24hr
200 mg (Ultram er)
tramadol hcl tab sr 24hr
300 mg (Ultram er)
tramadol hcl tab sr 24hr
biphasic release 100 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
TRAMADOL HCL ER tramadol hcl cap sr 24hr
biphasic release 300 mg
ACA Preventive
2
Dispensing Limits
SUBOXONE - buprenorphine
hcl-naloxone hcl sl film 4-1
mg (base equiv)
Step Therapy
•
Prior Authorization
2
Drug Tier
Limited Distribution
Drug Name
SUBOXONE - buprenorphine
hcl-naloxone hcl sl film 2-0.5
mg (base equiv)
•
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
127
3
•
XODOL - hydrocodoneacetaminophen tab 10-300
mg
3
•
ZAMICET - hydrocodoneacetaminophen soln 10-325
mg/15ml
3
•
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 10 mg
3
•
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 15 mg
3
•
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 20 mg
3
•
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 30 mg
3
•
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 40 mg
3
•
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 50 mg
3
•
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 1.4-0.36
mg (base eq)
3
•
•
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 2.9-0.71
mg (base eq)
3
•
•
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 5.7-1.4
mg (base eq)
3
•
•
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 11.4-2.9
mg (base eq)
3
•
ANALGESICS - ANTI-INFLAMMATORY
4
ACTEMRA - tocilizumab
subcutaneous soln prefilled
syringe 162 mg/0.9ml
ANAPROX - naproxen sodium 3
tab 275 mg
3
ANAPROX DS - naproxen
sodium tab 550 mg
ARAVA - leflunomide tab 10 mg 3
ARAVA - leflunomide tab 20 mg 3
4
ARCALYST - rilonacept for inj
220 mg
3
ARTHROTEC 50 - diclofenac
w/ misoprostol tab delayed
release 50-0.2 mg
3
ARTHROTEC 75 - diclofenac
w/ misoprostol tab delayed
release 75-0.2 mg
CELEBREX - celecoxib cap 50 3
mg
3
CELEBREX - celecoxib cap
100 mg
3
CELEBREX - celecoxib cap
200 mg
3
CELEBREX - celecoxib cap
400 mg
1
celecoxib cap 50 mg
(Celebrex)
1
celecoxib cap 100 mg
(Celebrex)
1
celecoxib cap 200 mg
(Celebrex)
1
celecoxib cap 400 mg
(Celebrex)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
Limited Distribution
XODOL - hydrocodoneacetaminophen tab 7.5-300
mg
•
ACA Preventive
•
3
Dispensing Limits
3
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 8.6-2.1
mg (base eq)
Step Therapy
XODOL - hydrocodoneacetaminophen tab 5-300
mg
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
XARTEMIS XR - oxycodone
w/ acetaminophen tab cr
7.5-325 mg
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
• •
•
•
•
•
•
•
•
•
•
•
•
128
DAYPRO - oxaprozin tab 600
mg
3
diclofenac potassium tab
50 mg (Cataflam)
1
diclofenac sodium tab
delayed release 25 mg
diclofenac sodium tab
delayed release 50 mg
diclofenac sodium tab
delayed release 75 mg
diclofenac sodium tab sr
24hr 100 mg (Voltaren-xr)
diclofenac w/ misoprostol
tab delayed release
50-0.2 mg (Arthrotec 50)
diclofenac w/ misoprostol
tab delayed release
75-0.2 mg (Arthrotec 75)
etodolac tab sr 24hr 600 mg
etodolac tab 400 mg
etodolac tab 500 mg
1
FELDENE - piroxicam cap 20
mg
3
FENOPROFEN CALCIUM fenoprofen calcium cap 400
mg
3
FENOPROFEN CALCIUM fenoprofen calcium tab 600
mg
3
flurbiprofen tab 50 mg
1
flurbiprofen tab 100 mg
1
Limited Distribution
ACA Preventive
1
3
1
Dispensing Limits
1
FELDENE - piroxicam cap 10
mg
1
Step Therapy
1
1
1
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
HUMIRA - adalimumab
prefilled syringe kit 10
mg/0.2ml
4
• •
•
HUMIRA - adalimumab
prefilled syringe kit 20
mg/0.4ml
4
• •
•
HUMIRA - adalimumab
prefilled syringe kit 40
mg/0.8ml
4
• •
•
4
• •
•
DUEXIS - ibuprofen-famotidine
tab 800-26.6 mg
3
EC-NAPROSYN - naproxen
tab ec 375 mg
3
EC-NAPROSYN - naproxen
tab ec 500 mg
3
ENBREL - etanercept for
subcutaneous inj kit 25 mg
4
• •
•
ENBREL - etanercept
subcutaneous soln prefilled
syringe 25 mg/0.5ml
4
• •
•
HUMIRA PEDIATRIC
CROHNS D - adalimumab
prefilled syringe kit 40
mg/0.8ml
• •
•
HUMIRA PEN - adalimumab
pen-injector kit 40 mg/0.8ml
4
ENBREL - etanercept
subcutaneous soln prefilled
syringe 50 mg/ml
4
• •
•
4
• •
•
ENBREL SURECLICK etanercept subcutaneous
solution auto-injector 50 mg/
ml
4
•
HUMIRA PEN-CROHNS
DISEASE - adalimumab peninjector kit 40 mg/0.8ml
4
• •
•
etodolac cap 200 mg
1
HUMIRA PEN-PSORIASIS
STAR - adalimumab peninjector kit 40 mg/0.8ml
ibuprofen susp 100 mg/5ml
1
etodolac cap 300 mg
etodolac tab sr 24hr 400 mg
etodolac tab sr 24hr 500 mg
1
1
1
• •
ibuprofen tab 400 mg
ibuprofen tab 600 mg
ibuprofen tab 800 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
1
1
1
129
IC 400 - ibuprofen tab 400 mg
& caffeine-vitamins cap kit
3
IC 800 - ibuprofen tab 800 mg
& caffeine-vitamins cap kit
3
ILARIS - canakinumab for inj
180 mg
4
INDOCIN - indomethacin
suppos 50 mg
MECLOFENAMATE SODIUM meclofenamate sodium cap
50 mg
3
MECLOFENAMATE SODIUM meclofenamate sodium cap
100 mg
3
3
mefenamic acid cap 250 mg
(Ponstel)
1
INDOCIN - indomethacin susp
25 mg/5ml
3
MELOXICAM - meloxicam
susp 7.5 mg/5ml
3
indomethacin cap cr 75 mg
1
meloxicam tab 7.5 mg
(Mobic)
1
indomethacin cap 25 mg
indomethacin cap 50 mg
ketoprofen cap 50 mg
ketoprofen cap 75 mg
KETOPROFEN ER ketoprofen cap sr 24hr 200
mg
•
•
•
1
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
meloxicam tab 15 mg (Mobic) 1
3
MOBIC - meloxicam susp 7.5
mg/5ml
MOBIC - meloxicam tab 7.5 mg 3
1
1
1
3
3
KETOROLAC
TROMETHAMINE - ketorolac
tromethamine inj 300
mg/10ml (30 mg/ml)
1
ketorolac tromethamine im
inj 60 mg/2ml (30 mg/ml)
1
ketorolac tromethamine inj
15 mg/ml
1
ketorolac tromethamine inj
30 mg/ml
1
ketorolac tromethamine inj
60 mg/2ml (30 mg/ml)
1
ketorolac tromethamine tab
10 mg
4
KINERET - anakinra
subcutaneous soln prefilled
syringe 100 mg/0.67ml
1
leflunomide tab 10 mg
(Arava)
1
leflunomide tab 20 mg
(Arava)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
MOBIC - meloxicam tab 15 mg
3
nabumetone tab 500 mg
1
nabumetone tab 750 mg
NALFON - fenoprofen calcium
cap 400 mg
• •
•
1
3
NAPRELAN - naproxen sodium 3
tab sr 24hr 375 mg (base
equiv)
NAPRELAN - naproxen sodium 3
tab sr 24hr 500 mg (base
equiv)
NAPRELAN - naproxen sodium 3
tab sr 24hr 750 mg (base
equiv)
3
NAPROSYN - naproxen susp
125 mg/5ml
3
NAPROSYN - naproxen tab
250 mg
3
NAPROSYN - naproxen tab
500 mg
3
NAPROXEN - naproxen susp
125 mg/5ml
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
130
naproxen sodium tab sr
24hr 375 mg (base equiv)
(Naprelan)
1
naproxen sodium tab sr
24hr 500 mg (base equiv)
(Naprelan)
1
naproxen sodium tab
275 mg (Anaprox)
1
naproxen sodium tab
550 mg (Anaprox ds)
1
piroxicam cap 10 mg
(Feldene)
1
piroxicam cap 20 mg
(Feldene)
1
PONSTEL - mefenamic acid
cap 250 mg
3
PRASTERA - prasterone cap
200 mg & ibuprofen tab 400
mg kit
3
RASUVO - methotrexate
soln pf auto-injector 7.5
mg/0.15ml
3
•
naproxen tab ec 375 mg (Ecnaprosyn)
1
naproxen tab ec 500 mg (Ecnaprosyn)
1
RASUVO - methotrexate soln
pf auto-injector 10 mg/0.2ml
3
•
naproxen tab 250 mg
(Naprosyn)
1
3
•
naproxen tab 375 mg
(Naprosyn)
1
RASUVO - methotrexate
soln pf auto-injector 12.5
mg/0.25ml
3
•
naproxen tab 500 mg
(Naprosyn)
1
RASUVO - methotrexate soln
pf auto-injector 15 mg/0.3ml
3
•
ORENCIA - abatacept
subcutaneous soln prefilled
syringe 125 mg/ml
4
RASUVO - methotrexate
soln pf auto-injector 17.5
mg/0.35ml
3
•
OTEZLA - apremilast tab
starter therapy pack 10 mg &
20 mg & 30 mg
4
RASUVO - methotrexate soln
pf auto-injector 20 mg/0.4ml
3
•
OTEZLA - apremilast tab 30
mg
4
RASUVO - methotrexate
soln pf auto-injector 22.5
mg/0.45ml
3
•
OTREXUP - methotrexate soln
pf auto-injector 7.5 mg/0.4ml
3
RASUVO - methotrexate soln
pf auto-injector 25 mg/0.5ml
•
3
•
3
OTREXUP - methotrexate soln
pf auto-injector 10 mg/0.4ml
RASUVO - methotrexate
soln pf auto-injector 27.5
mg/0.55ml
OTREXUP - methotrexate soln
pf auto-injector 15 mg/0.4ml
3
•
RASUVO - methotrexate soln
pf auto-injector 30 mg/0.6ml
3
•
OTREXUP - methotrexate soln
pf auto-injector 20 mg/0.4ml
3
•
3
OTREXUP - methotrexate soln
pf auto-injector 25 mg/0.4ml
3
•
RHEUMATREX - methotrexate
sodium tab 2.5 mg
(antirheumatic)
oxaprozin tab 600 mg
(Daypro)
1
• •
•
• •
•
• •
•
•
RIDAURA - auranofin cap 3 mg 3
4
SIMPONI - golimumab
subcutaneous soln autoinjector 50 mg/0.5ml
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
• •
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
131
4
SIMPONI - golimumab
subcutaneous soln prefilled
syringe 50 mg/0.5ml
4
• •
•
SIMPONI - golimumab
subcutaneous soln prefilled
syringe 100 mg/ml
4
• •
•
SPRIX - ketorolac
tromethamine nasal spray
15.75 mg/spray
3
sulindac tab 150 mg
1
sulindac tab 200 mg
1
TIVORBEX - indomethacin cap
20 mg
3
TIVORBEX - indomethacin cap
40 mg
3
TOLMETIN SODIUM - tolmetin
sodium tab 200 mg
3
TOLMETIN SODIUM - tolmetin
sodium tab 600 mg
3
tolmetin sodium cap 400 mg
1
VIMOVO - naproxenesomeprazole magnesium
tab dr 375-20 mg
3
VIMOVO - naproxenesomeprazole magnesium
tab dr 500-20 mg
3
VIVLODEX - meloxicam cap 5
mg
3
VIVLODEX - meloxicam cap 10 3
mg
4
XELJANZ - tofacitinib citrate
tab 5 mg (base equivalent)
ZIPSOR - diclofenac potassium 3
cap 25 mg
3
ZORVOLEX - diclofenac cap
18 mg
3
ZORVOLEX - diclofenac cap
35 mg
• •
•
MIGRAINE PRODUCTS
1
•
1
•
ALSUMA - sumatriptan
succinate solution autoinjector 6 mg/0.5ml
3
• •
AMERGE - naratriptan hcl tab
1 mg (base equiv)
3
• •
AMERGE - naratriptan hcl tab
2.5 mg (base equiv)
3
• •
AXERT - almotriptan malate
tab 6.25 mg
3
• •
AXERT - almotriptan malate
tab 12.5 mg
3
• •
CAFERGOT - ergotamine w/
caffeine tab 1-100 mg
3
CAMBIA - diclofenac
potassium packet 50 mg
3
DIHYDROERGOTAMINE
MESYLAT dihydroergotamine mesylate
nasal spray 4 mg/ml
3
dihydroergotamine mesylate
inj 1 mg/ml (D.h.e. 45)
1
almotriptan malate tab
6.25 mg (Axert)
almotriptan malate tab
12.5 mg (Axert)
ERGOMAR - ergotamine
tartrate sl tab 2 mg
3
FROVA - frovatriptan succinate
tab 2.5 mg (base equivalent)
3
• •
IMITREX - sumatriptan nasal
spray 5 mg/act
3
• •
IMITREX - sumatriptan nasal
spray 20 mg/act
3
• •
IMITREX - sumatriptan
succinate inj 6 mg/0.5ml
3
• •
IMITREX - sumatriptan
succinate tab 25 mg
3
• •
IMITREX - sumatriptan
succinate tab 50 mg
3
• •
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
•
SIMPONI - golimumab
subcutaneous soln autoinjector 100 mg/ml
Drug Name
Drug Tier
Limited Distribution
• •
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
132
3
IMITREX STATDOSE
SYSTEM - sumatriptan
succinate solution autoinjector 4 mg/0.5ml
3
IMITREX STATDOSE
SYSTEM - sumatriptan
succinate solution autoinjector 6 mg/0.5ml
3
MAXALT - rizatriptan benzoate
tab 5 mg
3
• •
MAXALT - rizatriptan benzoate
tab 10 mg
3
• •
MAXALT-MLT - rizatriptan
benzoate orally
disintegrating tab 5 mg
3
• •
MAXALT-MLT - rizatriptan
benzoate orally
disintegrating tab 10 mg
3
• •
MIGERGOT - ergotamine w/
caffeine suppos 2-100 mg
3
MIGRANAL dihydroergotamine mesylate
nasal spray 4 mg/ml
3
naratriptan hcl tab 1 mg
(base equiv) (Amerge)
1
•
1
•
RELPAX - eletriptan
hydrobromide tab 20 mg
(base equivalent)
3
• •
RELPAX - eletriptan
hydrobromide tab 40 mg
(base equivalent)
3
• •
naratriptan hcl tab 2.5 mg
(base equiv) (Amerge)
• •
• •
• •
1
•
rizatriptan benzoate orally
disintegrating tab 10 mg
(Maxalt-mlt)
1
•
rizatriptan benzoate tab
5 mg (Maxalt)
1
•
1
•
SUMATRIPTAN - sumatriptan
nasal spray 5 mg/act
2
• •
SUMATRIPTAN - sumatriptan
nasal spray 20 mg/act
2
• •
SUMATRIPTAN SUCCINATE sumatriptan succinate
solution prefilled syringe 6
mg/0.5ml
3
• •
sumatriptan succinate inj
6 mg/0.5ml (Imitrex)
1
•
1
sumatriptan succinate
solution auto-injector
4 mg/0.5ml (Imitrex statdose
sys)
1
sumatriptan succinate
solution auto-injector
6 mg/0.5ml (Imitrex statdose
sys)
1
sumatriptan succinate
solution cartridge
4 mg/0.5ml (Imitrex statdose
ref)
1
sumatriptan succinate
solution cartridge
6 mg/0.5ml (Imitrex statdose
ref)
1
sumatriptan succinate tab
25 mg (Imitrex)
1
sumatriptan succinate tab
50 mg (Imitrex)
1
sumatriptan succinate tab
100 mg (Imitrex)
•
rizatriptan benzoate tab
10 mg (Maxalt)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
IMITREX STATDOSE REFILL sumatriptan succinate
solution cartridge 6 mg/0.5ml
rizatriptan benzoate orally
disintegrating tab 5 mg
(Maxalt-mlt)
ACA Preventive
• •
Dispensing Limits
3
Step Therapy
IMITREX STATDOSE REFILL sumatriptan succinate
solution cartridge 4 mg/0.5ml
Prior Authorization
• •
Drug Name
Drug Tier
3
Limited Distribution
IMITREX - sumatriptan
succinate tab 100 mg
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
133
3
SUMAVEL DOSEPRO sumatriptan succinate
solution jet-injector 6
mg/0.5ml
3
TREXIMET - sumatriptannaproxen sodium tab 85-500
mg
3
• •
ZECUITY - sumatriptan
succinate td iontophoretic
patch 6.5 mg/4hr
3
• •
zolmitriptan orally
disintegrating tab 2.5 mg
(Zomig zmt)
1
zolmitriptan orally
disintegrating tab 5 mg
(Zomig zmt)
1
zolmitriptan tab 2.5 mg
(Zomig)
1
•
zolmitriptan tab 5 mg
(Zomig)
1
•
ZOMIG - zolmitriptan nasal
spray 2.5 mg/spray unit
3
• •
ZOMIG - zolmitriptan nasal
spray 5 mg/spray unit
3
ZOMIG - zolmitriptan tab 2.5
mg
3
ZOMIG - zolmitriptan tab 5 mg
3
ZOMIG NASAL SPRAY zolmitriptan nasal spray 5
mg/spray unit
3
ZOMIG ZMT - zolmitriptan
orally disintegrating tab 2.5
mg
3
ZOMIG ZMT - zolmitriptan
orally disintegrating tab 5 mg
3
GOUT AGENTS
• •
allopurinol tab 100 mg
(Zyloprim)
1
allopurinol tab 300 mg
(Zyloprim)
1
COLCHICINE - colchicine cap
0.6 mg
3
COLCHICINE - colchicine tab
0.6 mg
3
colchicine w/ probenecid tab
0.5-500 mg
1
COLCRYS - colchicine tab 0.6
mg
2
•
MITIGARE - colchicine cap 0.6
mg
3
probenecid tab 500 mg
1
•
ULORIC - febuxostat tab 40 mg 3
ULORIC - febuxostat tab 80 mg 3
ZYLOPRIM - allopurinol tab
100 mg
3
ZYLOPRIM - allopurinol tab
300 mg
3
• •
• •
• •
• •
• •
• •
•
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
• •
SUMAVEL DOSEPRO sumatriptan succinate
solution jet-injector 4
mg/0.5ml
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
NEUROMUSCULAR DRUGS
ANTICONVULSANTS
APTIOM - eslicarbazepine
acetate tab 200 mg
3
APTIOM - eslicarbazepine
acetate tab 400 mg
3
APTIOM - eslicarbazepine
acetate tab 600 mg
3
APTIOM - eslicarbazepine
acetate tab 800 mg
3
BANZEL - rufinamide susp 40
mg/ml
3
BANZEL - rufinamide tab 200
mg
3
BANZEL - rufinamide tab 400
mg
3
carbamazepine cap sr 12hr
100 mg (Carbatrol)
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
134
carbamazepine cap sr 12hr
200 mg (Carbatrol)
carbamazepine cap sr 12hr
300 mg (Carbatrol)
carbamazepine chew tab
100 mg
carbamazepine susp
100 mg/5ml (Tegretol)
carbamazepine tab sr 12hr
200 mg (Tegretol-xr)
carbamazepine tab sr 12hr
400 mg (Tegretol-xr)
1
3
1
DEPAKENE - valproate sodium
syrup 250 mg/5ml (base
equiv)
3
1
DEPAKENE - valproic acid cap
250 mg
DEPAKOTE - divalproex
sodium tab delayed release
125 mg
3
DEPAKOTE - divalproex
sodium tab delayed release
250 mg
3
DEPAKOTE - divalproex
sodium tab delayed release
500 mg
3
1
1
1
carbamazepine tab 200 mg
(Tegretol)
1
CARBATROL - carbamazepine
cap sr 12hr 100 mg
3
DEPAKOTE ER - divalproex
sodium tab sr 24 hr 250 mg
3
CARBATROL - carbamazepine
cap sr 12hr 200 mg
3
DEPAKOTE ER - divalproex
sodium tab sr 24 hr 500 mg
3
CARBATROL - carbamazepine
cap sr 12hr 300 mg
3
DEPAKOTE SPRINKLES divalproex sodium cap
sprinkle 125 mg
3
CELONTIN - methsuximide cap 3
300 mg
1
clonazepam orally
disintegrating tab
0.125 mg
1
clonazepam orally
disintegrating tab 0.25 mg
1
clonazepam orally
disintegrating tab 0.5 mg
1
clonazepam orally
disintegrating tab 1 mg
1
clonazepam orally
disintegrating tab 2 mg
1
clonazepam tab 0.5 mg
(Klonopin)
1
clonazepam tab 1 mg
(Klonopin)
1
clonazepam tab 2 mg
(Klonopin)
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
DIASTAT ACUDIAL - diazepam 2
rectal gel delivery system 10
mg
DIASTAT ACUDIAL - diazepam 2
rectal gel delivery system 20
mg
2
DIASTAT PEDIATRIC diazepam rectal gel delivery
system 2.5 mg
3
DIAZEPAM - diazepam rectal
gel delivery system 2.5 mg
3
DIAZEPAM - diazepam rectal
gel delivery system 10 mg
3
DIAZEPAM - diazepam rectal
gel delivery system 20 mg
2
DILANTIN - phenytoin sodium
extended cap 30 mg
2
DILANTIN - phenytoin sodium
extended cap 100 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
135
DILANTIN INFATABS phenytoin chew tab 50 mg
3
FYCOMPA - perampanel tab 6
mg
3
DILANTIN-125 - phenytoin
susp 125 mg/5ml
3
FYCOMPA - perampanel tab 8
mg
3
divalproex sodium cap
sprinkle 125 mg (Depakote
sprinkles)
1
FYCOMPA - perampanel tab
10 mg
3
1
FYCOMPA - perampanel tab
12 mg
3
divalproex sodium tab
delayed release 125 mg
(Depakote)
1
divalproex sodium tab
delayed release 250 mg
(Depakote)
1
gabapentin cap 100 mg
(Neurontin)
gabapentin cap 300 mg
(Neurontin)
1
divalproex sodium tab
delayed release 500 mg
(Depakote)
1
gabapentin cap 400 mg
(Neurontin)
1
1
divalproex sodium tab sr 24
hr 250 mg (Depakote er)
1
gabapentin oral soln
250 mg/5ml (Neurontin)
divalproex sodium tab sr 24
hr 500 mg (Depakote er)
1
ethosuximide cap 250 mg
(Zarontin)
1
ethosuximide soln
250 mg/5ml (Zarontin)
1
felbamate susp 600 mg/5ml
(Felbatol)
1
felbamate tab 400 mg
(Felbatol)
1
felbamate tab 600 mg
(Felbatol)
1
FELBATOL - felbamate susp
600 mg/5ml
3
FELBATOL - felbamate tab 400 3
mg
FELBATOL - felbamate tab 600 3
mg
FYCOMPA - perampanel tab 2 3
mg
FYCOMPA - perampanel tab 4 3
mg
gabapentin tab 600 mg
(Neurontin)
1
gabapentin tab 800 mg
(Neurontin)
1
GABITRIL - tiagabine hcl tab 2
mg
3
GABITRIL - tiagabine hcl tab 4
mg
3
GABITRIL - tiagabine hcl tab
12 mg
3
GABITRIL - tiagabine hcl tab
16 mg
3
KEPPRA - levetiracetam oral
soln 100 mg/ml
3
KEPPRA - levetiracetam tab
250 mg
3
KEPPRA - levetiracetam tab
500 mg
3
KEPPRA - levetiracetam tab
750 mg
3
KEPPRA - levetiracetam tab
1000 mg
3
KEPPRA XR - levetiracetam
tab sr 24hr 500 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
136
KEPPRA XR - levetiracetam
tab sr 24hr 750 mg
3
KLONOPIN - clonazepam tab
0.5 mg
3
KLONOPIN - clonazepam tab 1 3
mg
KLONOPIN - clonazepam tab 2 3
mg
LAMICTAL - lamotrigine tab 25 3
mg
3
LAMICTAL - lamotrigine tab
100 mg
3
LAMICTAL - lamotrigine tab
150 mg
3
LAMICTAL - lamotrigine tab
200 mg
3
LAMICTAL CHEWABLE
DISPERS - lamotrigine tab
chewable dispersible 5 mg
3
LAMICTAL CHEWABLE
DISPERS - lamotrigine tab
chewable dispersible 25 mg
3
LAMICTAL ODT - lamotrigine
orally disintegrating tab 25
mg
3
LAMICTAL ODT - lamotrigine
orally disintegrating tab 50
mg
3
LAMICTAL ODT - lamotrigine
orally disintegrating tab 100
mg
3
LAMICTAL ODT - lamotrigine
orally disintegrating tab 200
mg
3
LAMICTAL ODT - lamotrigine
tab disp 25 mg (21) & 50 mg
(7) titration kit
3
LAMICTAL ODT - lamotrigine
tab disp 50 mg (42) & 100
mg (14) titration kit
LAMICTAL ODT - lamotrigine
tab disp 25 (14) & 50 mg
(14) & 100 mg (7) kit
3
LAMICTAL STARTER/NOT
TAKI - lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit
3
LAMICTAL STARTER/TAKING
C - lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit
3
LAMICTAL STARTER/TAKING
V - lamotrigine tab 25 mg
(35) starter kit
3
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
LAMICTAL XR - lamotrigine tab 3
sr 24hr 25 mg (21) & 50 mg
(7) titration kit
LAMICTAL XR - lamotrigine tab 3
sr 24hr 25 (14) & 50 mg (14)
& 100 mg(7) kit
3
LAMICTAL XR - lamotrigine
tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit
LAMICTAL XR - lamotrigine tab 3
sr 24hr 25 mg
LAMICTAL XR - lamotrigine tab 3
sr 24hr 50 mg
LAMICTAL XR - lamotrigine tab 3
sr 24hr 100 mg
LAMICTAL XR - lamotrigine tab 3
sr 24hr 200 mg
LAMICTAL XR - lamotrigine tab 3
sr 24hr 250 mg
LAMICTAL XR - lamotrigine tab 3
sr 24hr 300 mg
1
lamotrigine orally
disintegrating tab 25 mg
(Lamictal odt)
1
lamotrigine orally
disintegrating tab 50 mg
(Lamictal odt)
1
lamotrigine orally
disintegrating tab 100 mg
(Lamictal odt)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
137
lamotrigine orally
disintegrating tab 200 mg
(Lamictal odt)
1
lamotrigine tab chewable
dispersible 5 mg (Lamictal
chewable di)
1
1
lamotrigine tab chewable
dispersible 25 mg (Lamictal
chewable di)
1
lamotrigine tab sr 24hr
25 mg (Lamictal xr)
1
lamotrigine tab sr 24hr
50 mg (Lamictal xr)
1
lamotrigine tab sr 24hr
100 mg (Lamictal xr)
1
lamotrigine tab sr 24hr
200 mg (Lamictal xr)
1
lamotrigine tab sr 24hr
250 mg (Lamictal xr)
1
lamotrigine tab sr 24hr
300 mg (Lamictal xr)
1
lamotrigine tab 25 mg
(Lamictal)
1
lamotrigine tab 100 mg
(Lamictal)
1
lamotrigine tab 150 mg
(Lamictal)
1
lamotrigine tab 200 mg
(Lamictal)
1
levetiracetam oral soln
100 mg/ml (Keppra)
1
levetiracetam tab sr 24hr
500 mg (Keppra xr)
1
levetiracetam tab sr 24hr
750 mg (Keppra xr)
1
levetiracetam tab 250 mg
(Keppra)
1
levetiracetam tab 500 mg
(Keppra)
1
levetiracetam tab 750 mg
(Keppra)
levetiracetam tab 1000 mg
(Keppra)
1
LYRICA - pregabalin cap 25
mg
2
•
LYRICA - pregabalin cap 50
mg
2
•
LYRICA - pregabalin cap 75
mg
2
•
LYRICA - pregabalin cap 100
mg
2
•
LYRICA - pregabalin cap 150
mg
2
•
LYRICA - pregabalin cap 200
mg
2
•
LYRICA - pregabalin cap 225
mg
2
•
LYRICA - pregabalin cap 300
mg
2
•
LYRICA - pregabalin soln 20
mg/ml
3
•
MYSOLINE - primidone tab 50
mg
3
MYSOLINE - primidone tab
250 mg
3
NEURONTIN - gabapentin cap
100 mg
3
NEURONTIN - gabapentin cap
300 mg
3
NEURONTIN - gabapentin cap
400 mg
3
NEURONTIN - gabapentin oral
soln 250 mg/5ml
3
NEURONTIN - gabapentin tab
600 mg
3
NEURONTIN - gabapentin tab
800 mg
3
ONFI - clobazam suspension
2.5 mg/ml
3
ONFI - clobazam tab 10 mg
3
ONFI - clobazam tab 20 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
138
oxcarbazepine susp
300 mg/5ml (60 mg/ml)
(Trileptal)
1
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
POTIGA - ezogabine tab 400
mg
3
primidone tab 50 mg
(Mysoline)
1
oxcarbazepine tab 150 mg
(Trileptal)
1
primidone tab 250 mg
(Mysoline)
1
oxcarbazepine tab 300 mg
(Trileptal)
1
1
QUDEXY XR - topiramate cap
er 24hr sprinkle 25 mg
3
oxcarbazepine tab 600 mg
(Trileptal)
QUDEXY XR - topiramate cap
er 24hr sprinkle 50 mg
3
OXTELLAR XR oxcarbazepine tab sr 24hr
150 mg
3
3
OXTELLAR XR oxcarbazepine tab sr 24hr
300 mg
3
QUDEXY XR - topiramate cap
er 24hr sprinkle 100 mg
QUDEXY XR - topiramate cap
er 24hr sprinkle 150 mg
3
OXTELLAR XR oxcarbazepine tab sr 24hr
600 mg
3
QUDEXY XR - topiramate cap
er 24hr sprinkle 200 mg
3
3
•
PEGANONE - ethotoin tab 250
mg
3
SABRIL - vigabatrin powd pack
500 mg
3
•
PHENYTEK - phenytoin
sodium extended cap 200
mg
3
SABRIL - vigabatrin tab 500
mg
STAVZOR - valproic acid cap
delayed release 125 mg
3
PHENYTEK - phenytoin
sodium extended cap 300
mg
3
STAVZOR - valproic acid cap
delayed release 250 mg
3
3
phenytoin chew tab 50 mg
(Dilantin infatabs)
1
STAVZOR - valproic acid cap
delayed release 500 mg
3
phenytoin sodium extended
cap 100 mg (Dilantin)
1
TEGRETOL - carbamazepine
susp 100 mg/5ml
3
1
TEGRETOL - carbamazepine
tab 200 mg
TEGRETOL-XR carbamazepine tab sr 12hr
100 mg
2
TEGRETOL-XR carbamazepine tab sr 12hr
200 mg
3
TEGRETOL-XR carbamazepine tab sr 12hr
400 mg
3
tiagabine hcl tab 2 mg
(Gabitril)
1
phenytoin sodium extended
cap 200 mg (Phenytek)
phenytoin sodium extended
cap 300 mg (Phenytek)
phenytoin susp 125 mg/5ml
(Dilantin)
1
1
POTIGA - ezogabine tab 50 mg 3
3
POTIGA - ezogabine tab 200
mg
3
POTIGA - ezogabine tab 300
mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
139
tiagabine hcl tab 4 mg
(Gabitril)
1
TRILEPTAL - oxcarbazepine
tab 150 mg
3
TOPAMAX - topiramate tab 25
mg
3
TRILEPTAL - oxcarbazepine
tab 300 mg
3
TOPAMAX - topiramate tab 50
mg
3
TRILEPTAL - oxcarbazepine
tab 600 mg
3
TOPAMAX - topiramate tab 100 3
mg
TOPAMAX - topiramate tab 200 3
mg
3
TOPAMAX SPRINKLE topiramate sprinkle cap 15
mg
3
TOPAMAX SPRINKLE topiramate sprinkle cap 25
mg
TOPIRAMATE ER - topiramate 3
cap er 24hr sprinkle 25 mg
TOPIRAMATE ER - topiramate 3
cap er 24hr sprinkle 50 mg
TOPIRAMATE ER - topiramate 3
cap er 24hr sprinkle 100 mg
TOPIRAMATE ER - topiramate 3
cap er 24hr sprinkle 150 mg
TOPIRAMATE ER - topiramate 3
cap er 24hr sprinkle 200 mg
1
topiramate sprinkle cap
15 mg (Topamax sprinkle)
1
topiramate sprinkle cap
25 mg (Topamax sprinkle)
1
topiramate tab 25 mg
(Topamax)
1
topiramate tab 50 mg
(Topamax)
1
topiramate tab 100 mg
(Topamax)
1
topiramate tab 200 mg
(Topamax)
3
TRILEPTAL - oxcarbazepine
susp 300 mg/5ml (60 mg/ml)
TROKENDI XR - topiramate
cap sr 24hr 25 mg
3
TROKENDI XR - topiramate
cap sr 24hr 50 mg
3
TROKENDI XR - topiramate
cap sr 24hr 100 mg
3
TROKENDI XR - topiramate
cap sr 24hr 200 mg
3
valproate sodium syrup
250 mg/5ml (base equiv)
(Depakene)
1
valproic acid cap 250 mg
(Depakene)
1
VIMPAT - lacosamide oral
solution 10 mg/ml
3
VIMPAT - lacosamide tab 50
mg
3
VIMPAT - lacosamide tab 100
mg
3
VIMPAT - lacosamide tab 150
mg
3
VIMPAT - lacosamide tab 200
mg
3
ZARONTIN - ethosuximide cap
250 mg
3
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
ZARONTIN - ethosuximide soln 3
250 mg/5ml
ZONEGRAN - zonisamide cap 3
25 mg
ZONEGRAN - zonisamide cap 3
100 mg
1
zonisamide cap 25 mg
(Zonegran)
1
zonisamide cap 50 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
140
zonisamide cap 100 mg
(Zonegran)
ANTIPARKINSON AGENTS
1
carbidopa & levodopa tab
25-100 mg (Sinemet)
3
1
amantadine hcl cap 100 mg
1
carbidopa tab 25 mg
(Lodosyn)
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
12.5-50-200 mg
3
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
18.75-75-200 mg
3
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
25-100-200 mg
3
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
31.25-125-200 mg
3
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
37.5-150-200 mg
3
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
50-200-200 mg
3
APOKYN - apomorphine
hydrochloride inj 10 mg/ml
4
AZILECT - rasagiline mesylate
tab 0.5 mg (base equiv)
3
AZILECT - rasagiline mesylate
tab 1 mg (base equiv)
3
benztropine mesylate tab
0.5 mg
1
benztropine mesylate tab
1 mg
benztropine mesylate tab
2 mg
bromocriptine mesylate cap
5 mg (Parlodel)
bromocriptine mesylate tab
2.5 mg
carbidopa & levodopa
orally disintegrating tab
10-100 mg
carbidopa & levodopa
orally disintegrating tab
25-100 mg
carbidopa & levodopa
orally disintegrating tab
25-250 mg
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
carbidopa & levodopa tab
10-100 mg (Sinemet)
1
1
1
1
1
1
1
1
1
1
•
COMTAN - entacapone tab 200 3
mg
3
DUOPA - carbidopa-levodopa
enteral susp 4.63-20 mg/ml
ELDEPRYL - selegiline hcl cap 3
5 mg
1
entacapone tab 200 mg
(Comtan)
3
LODOSYN - carbidopa tab 25
mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
1
AMANTADINE HCL amantadine hcl tab 100 mg
1
Step Therapy
1
carbidopa & levodopa tab
25-250 mg (Sinemet)
amantadine hcl syrup
50 mg/5ml
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
141
MIRAPEX - pramipexole
dihydrochloride tab 0.125
mg
3
NEUPRO - rotigotine td patch
24hr 4 mg/24hr
3
NEUPRO - rotigotine td patch
24hr 6 mg/24hr
3
MIRAPEX - pramipexole
dihydrochloride tab 0.25 mg
3
NEUPRO - rotigotine td patch
24hr 8 mg/24hr
3
MIRAPEX - pramipexole
dihydrochloride tab 0.5 mg
3
3
PARLODEL - bromocriptine
mesylate cap 5 mg
3
MIRAPEX - pramipexole
dihydrochloride tab 0.75 mg
pramipexole dihydrochloride
tab sr 24hr 0.375 mg
(Mirapex er)
1
MIRAPEX - pramipexole
dihydrochloride tab 1 mg
3
MIRAPEX - pramipexole
dihydrochloride tab 1.5 mg
3
1
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr
0.375 mg
3
pramipexole dihydrochloride
tab sr 24hr 0.75 mg
(Mirapex er)
1
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr
0.75 mg
3
pramipexole dihydrochloride
tab sr 24hr 1.5 mg (Mirapex
er)
1
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr
1.5 mg
3
pramipexole dihydrochloride
tab sr 24hr 2.25 mg
(Mirapex er)
1
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr
2.25 mg
3
pramipexole dihydrochloride
tab sr 24hr 3 mg (Mirapex
er)
1
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 3
mg
3
pramipexole dihydrochloride
tab sr 24hr 4.5 mg (Mirapex
er)
1
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr
3.75 mg
3
pramipexole dihydrochloride
tab 0.125 mg (Mirapex)
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr
4.5 mg
3
NEUPRO - rotigotine td patch
24hr 1 mg/24hr
3
NEUPRO - rotigotine td patch
24hr 2 mg/24hr
3
NEUPRO - rotigotine td patch
24hr 3 mg/24hr
3
pramipexole dihydrochloride
tab 0.25 mg (Mirapex)
pramipexole dihydrochloride
tab 0.5 mg (Mirapex)
pramipexole dihydrochloride
tab 0.75 mg (Mirapex)
pramipexole dihydrochloride
tab 1 mg (Mirapex)
pramipexole dihydrochloride
tab 1.5 mg (Mirapex)
REQUIP - ropinirole
hydrochloride tab 0.25 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
1
1
3
142
REQUIP - ropinirole
hydrochloride tab 0.5 mg
3
REQUIP - ropinirole
hydrochloride tab 1 mg
3
REQUIP - ropinirole
hydrochloride tab 2 mg
3
REQUIP - ropinirole
hydrochloride tab 3 mg
3
REQUIP - ropinirole
hydrochloride tab 4 mg
3
REQUIP - ropinirole
hydrochloride tab 5 mg
3
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 2
mg (base equivalent)
3
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 4
mg (base equivalent)
ropinirole hydrochloride tab
0.25 mg (Requip)
ropinirole hydrochloride tab
0.5 mg (Requip)
ropinirole hydrochloride tab
1 mg (Requip)
ropinirole hydrochloride tab
2 mg (Requip)
ropinirole hydrochloride tab
3 mg (Requip)
ropinirole hydrochloride tab
4 mg (Requip)
ropinirole hydrochloride tab
5 mg (Requip)
1
1
1
3
RYTARY - carbidopa &
levodopa cap cr 36.25-145
mg
3
RYTARY - carbidopa &
levodopa cap cr 48.75-195
mg
3
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 8
mg (base equivalent)
3
RYTARY - carbidopa &
levodopa cap cr 61.25-245
mg
3
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 12
mg (base equivalent)
3
1
selegiline hcl cap 5 mg
(Eldepryl)
1
ropinirole hydrochloride
tab sr 24hr 2 mg (base
equivalent) (Requip xl)
selegiline hcl tab 5 mg
1
ropinirole hydrochloride
tab sr 24hr 8 mg (base
equivalent) (Requip xl)
ropinirole hydrochloride
tab sr 24hr 12 mg (base
equivalent) (Requip xl)
1
1
SINEMET - carbidopa &
levodopa tab 10-100 mg
3
SINEMET - carbidopa &
levodopa tab 25-100 mg
3
SINEMET - carbidopa &
levodopa tab 25-250 mg
3
SINEMET CR - carbidopa &
levodopa tab cr 25-100 mg
3
SINEMET CR - carbidopa &
levodopa tab cr 50-200 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
1
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 6
mg (base equivalent)
1
ACA Preventive
1
3
ropinirole hydrochloride
tab sr 24hr 6 mg (base
equivalent) (Requip xl)
Dispensing Limits
1
3
1
Step Therapy
1
RYTARY - carbidopa &
levodopa cap cr 23.75-95
mg
ropinirole hydrochloride
tab sr 24hr 4 mg (base
equivalent) (Requip xl)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
143
STALEVO 100 - carbidopalevodopa-entacapone tabs
25-100-200 mg
3
STALEVO 125 - carbidopalevodopa-entacapone tabs
31.25-125-200 mg
3
STALEVO 150 - carbidopalevodopa-entacapone tabs
37.5-150-200 mg
3
STALEVO 200 - carbidopalevodopa-entacapone tabs
50-200-200 mg
3
STALEVO 50 - carbidopalevodopa-entacapone tabs
12.5-50-200 mg
3
STALEVO 75 - carbidopalevodopa-entacapone tabs
18.75-75-200 mg
3
TASMAR - tolcapone tab 100
mg
3
tolcapone tab 100 mg
(Tasmar)
trihexyphenidyl hcl elixir
0.4 mg/ml
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg
ZELAPAR - selegiline hcl orally
disintegrating tab 1.25 mg
NEUROMUSCULAR AGENTS
carisoprodol w/ aspirin &
codeine tab 200-325-16 mg
carisoprodol w/ aspirin tab
200-325 mg
1
cyclobenzaprine hcl tab
5 mg
1
cyclobenzaprine hcl tab
10 mg
DANTRIUM - dantrolene
sodium cap 100 mg
3
3
1
DANTROLENE SODIUM dantrolene sodium cap 100
mg
1
dantrolene sodium cap
25 mg (Dantrium)
1
1
dantrolene sodium cap
50 mg (Dantrium)
riluzole tab 50 mg (Rilutek)
1
MUSCULOSKELETAL THERAPY AGENTS
3
AMRIX - cyclobenzaprine hcl
cap sr 24hr 15 mg
3
AMRIX - cyclobenzaprine hcl
cap sr 24hr 30 mg
1
baclofen tab 10 mg
1
1
Limited Distribution
1
FEXMID - cyclobenzaprine hcl
tab 7.5 mg
3
LORZONE - chlorzoxazone tab
375 mg
3
LORZONE - chlorzoxazone tab
750 mg
3
METAXALONE - metaxalone
tab 400 mg
3
metaxalone tab 800 mg
(Skelaxin)
1
methocarbamol tab 500 mg
(Robaxin)
1
methocarbamol tab 750 mg
(Robaxin-750)
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
ACA Preventive
1
3
3
Dispensing Limits
1
DANTRIUM - dantrolene
sodium cap 50 mg
1
Step Therapy
1
chlorzoxazone tab 500 mg
(Parafon forte dsc)
cyclobenzaprine hcl tab
7.5 mg (Fexmid)
Prior Authorization
Limited Distribution
ACA Preventive
Drug Tier
1
3
2
carisoprodol tab 350 mg
(Soma)
Drug Name
DANTRIUM - dantrolene
sodium cap 25 mg
RILUTEK - riluzole tab 50 mg
baclofen tab 20 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
144
orphenadrine citrate tab sr
12hr 100 mg
orphenadrine w/ aspirin &
caffeine tab 25-385-30 mg
PARAFON FORTE DSC chlorzoxazone tab 500 mg
GUANIDINE HCL - guanidine
hcl tab 125 mg
MESTINON - pyridostigmine
bromide syrup 60 mg/5ml
3
1
MESTINON - pyridostigmine
bromide tab 60 mg
3
3
MESTINON TIMESPAN pyridostigmine bromide tab
cr 180 mg
3
pyridostigmine bromide
tab cr 180 mg (Mestinon
timespan)
1
pyridostigmine bromide tab
60 mg (Mestinon)
1
3
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Drug Name
1
ROBAXIN - methocarbamol tab 3
500 mg
3
ROBAXIN-750 methocarbamol tab 750 mg
3
SKELAXIN - metaxalone tab
800 mg
3
SOMA - carisoprodol tab 250
mg
3
SOMA - carisoprodol tab 350
mg
1
tizanidine hcl cap 2 mg
(base equivalent)
(Zanaflex)
1
tizanidine hcl cap 4 mg
(base equivalent)
(Zanaflex)
1
tizanidine hcl cap 6 mg
(base equivalent)
(Zanaflex)
tizanidine hcl tab 2 mg (base 1
equivalent)
tizanidine hcl tab 4 mg (base 1
equivalent) (Zanaflex)
ZANAFLEX - tizanidine hcl cap 3
2 mg (base equivalent)
ZANAFLEX - tizanidine hcl cap 3
4 mg (base equivalent)
ZANAFLEX - tizanidine hcl cap 3
6 mg (base equivalent)
ZANAFLEX - tizanidine hcl tab 3
4 mg (base equivalent)
ANTIMYASTHENIC AGENTS
Prior Authorization
Drug Name
Drug Tier
2015
NUTRITIONAL PRODUCTS
VITAMINS
BABY DDROPS cholecalciferol drops 400
unit/0.03ml (per drop)
NA
•
cholecalciferol cap 400 unit
NA
•
•
cholecalciferol cap 1000 unit NA
1
cholecalciferol cap 50000
unit
cholecalciferol chew tab 400 NA
unit
NA
cholecalciferol chew tab
1000 unit
NA
cholecalciferol drops 5000
unit/ml (1000 unit/0.2ml)
NA
cholecalciferol drops 400
unit/0.03ml (per drop)
NA
cholecalciferol oral liquid
400 unit/ml
NA
cholecalciferol tab 400 unit
cholecalciferol tab 1000 unit
cholecalciferol tab 50000
unit
NA
•
•
•
•
•
•
1
D-VI-SOL - cholecalciferol oral NA
liquid 400 unit/ml
NA
DDROPS - cholecalciferol
drops 1000 unit/0.03ml (per
drop)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
•
145
DECARA - cholecalciferol cap
25000 unit
3
DRISDOL - ergocalciferol cap
50000 unit
3
ergocalciferol cap 50000 unit
(Drisdol)
1
pediatric multiple vitamins
w/ fluoride chew tab
0.5 mg
MEPHYTON - phytonadione
tab 5 mg
2
pediatric multiple vitamins
w/ fluoride chew tab 1 mg
POTABA - potassium
aminobenzoate tab 500 mg
3
SUPER DAILY D3 cholecalciferol drops 1000
unit/0.03ml (per drop)
NA
thiamine hcl inj 100 mg/ml
1
MINERALS and ELECTROLYTES
FLORICAL - sodium fluoride w/ NA
calcium carb cap 8.3-364 mg
FLORICAL - sodium fluoride w/ NA
calcium carb tab 8.3-364 mg
3
FLORIVA - sodium fluoridevitamin d liqd drops 0.25 mg/
ml-400 unit/ml
3
FLUOR-A-DAY - sodium
fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg
3
FLUOR-A-DAY - sodium
fluoride-xylitol chew tab 1.1
(0.5 mg f)-236.79 mg
3
FLUOR-A-DAY - sodium
fluoride-xylitol chew tab 2.2
(1 mg f)-236.79 mg
FLUORABON - sodium fluoride 3
soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf)
3
FLURA-DROPS - sodium
fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf)
3
GALZIN - zinc acetate cap 25
mg (elemental zinc)
3
GALZIN - zinc acetate cap 50
mg (elemental zinc)
GNP VITAMIN D-400 - calcium 3
carbonate-cholecalciferol tab
90 mg-400 unit
K-TAB - potassium chloride tab 3
cr 8 meq (600 mg)
pediatric multiple vitamins
w/ fluoride chew tab
0.25 mg
•
•
VITAMELTS VITAMIN D cholecalciferol orally
disintegrating tab 1000 unit
NA
VITAMIN D2 - ergocalciferol
tab 400 unit
NA
•
VITAMIN D3 - cholecalciferol
oral liquid 1200 unit/15ml
NA
•
VITAMIN D3 - cholecalciferol
spray 1000 unit/spray
NA
•
WELLESSE VITAMIN D3 cholecalciferol oral liquid
1000 unit/10ml
NA
•
MULTIVITAMINS
CITRANATAL HARMONY prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg
2
COD LIVER OIL - cod liver oil
3
NEPHROCAPS - b-complex w/
c & folic acid cap 1 mg
3
NEPHROCAPS QT - bcomplex w/ c-biotin-d & folic
acid tab disp 1 mg
3
NEXA SELECT - prenatal w/
o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
•
•
•
•
•
•
•
•
146
K-TAB - potassium chloride tab
cr 10 meq
3
K-TAB - potassium chloride tab
cr 20 meq (1500 mg)
3
KLOR-CON M15 - potassium
chloride microencapsulated
crys cr tab 15 meq
3
LOZI-FLUR - sodium fluoride
lozenge 1 mg f (from 2.2 mg
naf)
3
LURIDE - sodium fluoride chew 3
tab 0.25 mg f (from 0.55 mg
naf)
LURIDE - sodium fluoride chew 3
tab 0.5 mg f (from 1.1 mg
naf)
LURIDE - sodium fluoride chew 3
tab 1 mg f (from 2.2 mg naf)
LURIDE - sodium fluoride soln 3
0.5 mg/ml f (from 1.1 mg/ml
naf)
MICRO-K - potassium chloride 3
cap cr 8 meq
MICRO-K - potassium chloride 3
cap cr 10 meq
NA
MONOCAL - sodium
monofluorophosphatecalcium carb tab 22.75-625
mg
1
potassium bicarbonate effer
tab 25 meq
1
potassium chloride cap cr 8
meq (Micro-k)
1
potassium chloride cap cr
10 meq (Micro-k)
POTASSIUM CHLORIDE ER - 3
potassium chloride tab cr 8
meq (600 mg)
POTASSIUM CHLORIDE ER - 3
potassium chloride tab cr 20
meq (1500 mg)
potassium chloride
microencapsulated crys cr
tab 10 meq
potassium chloride
microencapsulated crys cr
tab 20 meq
•
•
•
•
•
•
potassium chloride oral soln
10% (20 meq/15ml)
potassium chloride oral soln
20% (40 meq/15ml)
potassium chloride powder
packet 20 meq
potassium chloride tab cr 8
meq (600 mg)
potassium chloride tab cr 10
meq (K-tab)
sodium chloride tab 1 gm
1
1
1
1
1
1
1
1
SODIUM FLUORIDE - sodium
fluoride tab 0.5 mg f (from
1.1 mg naf)
3
•
SODIUM FLUORIDE - sodium
fluoride tab 1 mg f (from 2.2
mg naf)
3
•
sodium fluoride chew tab
0.25 mg f (from 0.55 mg
naf) (Luride)
1
•
sodium fluoride chew tab
0.5 mg f (from 1.1 mg naf)
(Luride)
1
•
sodium fluoride chew tab
1 mg f (from 2.2 mg naf)
(Luride)
1
•
sodium fluoride soln
0.125 mg/drop f (0.275 mg/
drop naf)
1
•
1
•
sodium fluoride soln 0.5 mg/
ml f (from 1.1 mg/ml naf)
(Luride)
NUTRIENTS
GLUCOSE NURSETTE glucose oral soln 5%
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
3
147
glucose oral liquid
glucose oral soln 5%
NUTRESTORE - glutamine
powd pack 5 gm
DIETARY PRODUCTS
folic acid-pyridoxinecyanocobalamin tab
2.5-25-2 mg
ZYTAZE - zinc citrate-phytase
cap 25-500 mg
1
1
3
1
3
HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
ARANESP ALBUMIN
FREE - darbepoetin alfa
soln prefilled syringe 40
mcg/0.4ml
4
•
ARANESP ALBUMIN
FREE - darbepoetin alfa
soln prefilled syringe 60
mcg/0.3ml
4
•
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 100
mcg/0.5ml
4
•
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 150
mcg/0.3ml
4
•
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 200
mcg/0.4ml
4
•
4
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 25
mcg/ml
4
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 40
mcg/ml
4
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 60
mcg/ml
4
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 100
mcg/ml
4
•
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 300
mcg/0.6ml
4
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 200
mcg/ml
4
•
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 500 mcg/ml
3
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 300
mcg/ml
4
•
BIFERARX - polysacch fe
cmplx-fe heme poly-fa-b12
tab 22-6-1-0.025 mg
NA
ARANESP ALBUMIN
FREE - darbepoetin alfa
soln prefilled syringe 10
mcg/0.4ml
4
•
carbonyl iron susp
15 mg/1.25ml (elemental
iron)
ARANESP ALBUMIN
FREE - darbepoetin alfa
soln prefilled syringe 25
mcg/0.42ml
4
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
CERDELGA - eliglustat tartrate
cap 84 mg (base equivalent)
4
cyanocobalamin inj
1000 mcg/ml
1
DROXIA - hydroxyurea cap
200 mg
3
DROXIA - hydroxyurea cap
300 mg
3
DROXIA - hydroxyurea cap
400 mg
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
148
•
EPOGEN - epoetin alfa inj
4000 unit/ml
4
EPOGEN - epoetin alfa inj
10000 unit/ml
4
EPOGEN - epoetin alfa inj
20000 unit/ml
4
FA-8 - folic acid cap 0.8 mg
NA
fe fumarate w/ b12vit c-fa-ifc cap
110-0.015-75-0.5-240 mg
1
•
FERRETTS CHEWABLE
IRON - carbonyl iron chew
tab 18 mg (elemental iron)
NA
FERROUS SULFATE - ferrous NA
sulfate liquid 220 mg/5ml (44
mg/5ml elemental fe)
FERROUS SULFATE - ferrous NA
sulfate syrup 300 mg/5ml
(60 mg/5ml elemental fe)
NA
ferrous sulfate elixir
220 mg/5ml (44 mg/5ml
elemental fe)
NA
ferrous sulfate soln 75 mg/
ml (15 mg/ml elemental fe)
NA
folic acid tab 400 mcg
folic acid tab 1 mg
folic acid-vitamin b6-vitamin
b12 tab 2.2-25-0.5 mg
GRANIX - tbo-filgrastim
soln prefilled syringe 300
mcg/0.5ml
NA
NA
•
•
ICAR PEDIATRIC - carbonyl
iron susp 15 mg/1.25ml
(elemental iron)
NA
•
•
INFED - iron dextran inj 50 mg/
ml (elemental iron)
•
NA
folic acid tab 800 mcg
ICAR - carbonyl iron chew tab
15 mg (elemental iron)
•
FER-IN-SOL - ferrous sulfate
soln 75 mg/ml (15 mg/ml
elemental fe)
IRON CHEWS PEDIATRIC carbonyl iron chew tab 15
mg (elemental iron)
iron polysacch complex-vit
b12-fa cap 150-0.025-1 mg
•
3
NA
•
1
LEUKINE - sargramostim
lyophilized for inj 250 mcg
4
•
•
MOZOBIL - plerixafor
subcutaneous inj 24
mg/1.2ml (20 mg/ml)
4
•
•
MYKIDZ IRON 10 - iron susp
15 mg/1.5ml
•
•
•
•
•
1
1
4
4
Limited Distribution
4
ACA Preventive
EPOGEN - epoetin alfa inj
3000 unit/ml
GRANIX - tbo-filgrastim
soln prefilled syringe 480
mcg/0.8ml
Dispensing Limits
•
Step Therapy
4
Prior Authorization
EPOGEN - epoetin alfa inj
2000 unit/ml
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
NA
•
NASCOBAL - cyanocobalamin
nasal spray 500 mcg/0.1ml
3
NEULASTA - pegfilgrastim soln
prefilled syringe 6 mg/0.6ml
4
•
NEULASTA ONPRO KIT pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml
4
•
NEUPOGEN - filgrastim inj 300
mcg/ml
4
•
NEUPOGEN - filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
4
•
NEUPOGEN - filgrastim
soln prefilled syringe 300
mcg/0.5ml
4
•
NEUPOGEN - filgrastim
soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)
4
•
PROCRIT - epoetin alfa inj
2000 unit/ml
4
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
149
•
PROCRIT - epoetin alfa inj
10000 unit/ml
4
•
PROCRIT - epoetin alfa inj
20000 unit/ml
4
•
PROCRIT - epoetin alfa inj
40000 unit/ml
4
•
PROMACTA - eltrombopag
olamine tab 12.5 mg (base
equiv)
4
PROMACTA - eltrombopag
olamine tab 25 mg (base
equiv)
4
PROMACTA - eltrombopag
olamine tab 50 mg (base
equiv)
4
•
•
PROMACTA - eltrombopag
olamine tab 75 mg (base
equiv)
4
•
•
SPATONE PUR-ABSORB
IRON - ferrous sulfate liquid
5 mg/20ml (elemental iron)
3
ZAVESCA - miglustat cap 100
mg
4
ANTICOAGULANTS
ARIXTRA - fondaparinux
sodium subcutaneous inj 2.5
mg/0.5ml
3
ARIXTRA - fondaparinux
sodium subcutaneous inj 5
mg/0.4ml
3
ARIXTRA - fondaparinux
sodium subcutaneous inj 7.5
mg/0.6ml
3
ARIXTRA - fondaparinux
sodium subcutaneous inj 10
mg/0.8ml
3
•
•
•
•
•
•
•
•
•
3
COUMADIN - warfarin sodium
tab 2 mg
3
COUMADIN - warfarin sodium
tab 2.5 mg
3
COUMADIN - warfarin sodium
tab 3 mg
3
COUMADIN - warfarin sodium
tab 4 mg
3
COUMADIN - warfarin sodium
tab 5 mg
3
COUMADIN - warfarin sodium
tab 6 mg
3
COUMADIN - warfarin sodium
tab 7.5 mg
3
COUMADIN - warfarin sodium
tab 10 mg
3
ELIQUIS - apixaban tab 2.5 mg
3
ELIQUIS - apixaban tab 5 mg
3
enoxaparin sodium inj
30 mg/0.3ml (Lovenox)
1
•
•
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
enoxaparin sodium inj
40 mg/0.4ml (Lovenox)
enoxaparin sodium inj
60 mg/0.6ml (Lovenox)
enoxaparin sodium inj
80 mg/0.8ml (Lovenox)
enoxaparin sodium inj
100 mg/ml (Lovenox)
enoxaparin sodium inj
120 mg/0.8ml (Lovenox)
enoxaparin sodium inj
150 mg/ml (Lovenox)
enoxaparin sodium inj
300 mg/3ml (Lovenox)
fondaparinux sodium
subcutaneous inj
2.5 mg/0.5ml (Arixtra)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
4
COUMADIN - warfarin sodium
tab 1 mg
ACA Preventive
PROCRIT - epoetin alfa inj
4000 unit/ml
Dispensing Limits
•
Step Therapy
4
Prior Authorization
PROCRIT - epoetin alfa inj
3000 unit/ml
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
150
fondaparinux sodium
subcutaneous inj
5 mg/0.4ml (Arixtra)
fondaparinux sodium
subcutaneous inj
7.5 mg/0.6ml (Arixtra)
1
1
•
3
•
LOVENOX - enoxaparin
sodium inj 80 mg/0.8ml
3
•
LOVENOX - enoxaparin
sodium inj 100 mg/ml
3
•
LOVENOX - enoxaparin
sodium inj 120 mg/0.8ml
3
•
1
•
FRAGMIN - dalteparin sodium
inj 10000 unit/ml
3
•
LOVENOX - enoxaparin
sodium inj 150 mg/ml
3
•
FRAGMIN - dalteparin sodium
inj 2500 unit/0.2ml
3
•
LOVENOX - enoxaparin
sodium inj 300 mg/3ml
3
•
FRAGMIN - dalteparin sodium
inj 5000 unit/0.2ml
3
•
3
•
FRAGMIN - dalteparin sodium
inj 12500 unit/0.5ml
3
•
PRADAXA - dabigatran
etexilate mesylate cap 75
mg (etexilate base eq)
3
•
FRAGMIN - dalteparin sodium
inj 15000 unit/0.6ml
3
•
PRADAXA - dabigatran
etexilate mesylate cap 110
mg (etexilate base eq)
•
•
FRAGMIN - dalteparin sodium
inj 95000 unit/3.8ml
3
•
PRADAXA - dabigatran
etexilate mesylate cap 150
mg (etexilate base eq)
3
FRAGMIN - dalteparin sodium
inj 18000 unit/0.72ml
3
SAVAYSA - edoxaban tosylate
tab 15 mg (base equivalent)
3
•
heparin sodium (porcine) inj
5000 unit/ml
1
SAVAYSA - edoxaban tosylate
tab 30 mg (base equivalent)
3
•
1
SAVAYSA - edoxaban tosylate
tab 60 mg (base equivalent)
3
•
1
warfarin sodium tab 1 mg
(Coumadin)
1
warfarin sodium tab 2 mg
(Coumadin)
1
warfarin sodium tab 2.5 mg
(Coumadin)
1
warfarin sodium tab 3 mg
(Coumadin)
1
warfarin sodium tab 4 mg
(Coumadin)
1
warfarin sodium tab 5 mg
(Coumadin)
1
warfarin sodium tab 6 mg
(Coumadin)
1
fondaparinux sodium
subcutaneous inj
10 mg/0.8ml (Arixtra)
heparin sodium (porcine) inj
10000 unit/ml
heparin sodium (porcine)
lock flush iv soln 10 unit/
ml
heparin sodium (porcine)
lock flush iv soln 100 unit/
ml
heparin sodium (porcine) pf
inj 5000 unit/0.5ml
1
1
IPRIVASK - desirudin for inj 15
mg
3
LOVENOX - enoxaparin
sodium inj 30 mg/0.3ml
3
•
LOVENOX - enoxaparin
sodium inj 40 mg/0.4ml
3
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
LOVENOX - enoxaparin
sodium inj 60 mg/0.6ml
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
151
warfarin sodium tab 7.5 mg
(Coumadin)
1
warfarin sodium tab 10 mg
(Coumadin)
1
XARELTO - rivaroxaban tab 10
mg
3
XARELTO - rivaroxaban tab 15
mg
RECOTHROM - thrombin
(recombinant) for soln 20000
unit
3
•
RECOTHROM SPRAY KIT thrombin (recombinant) for
soln 20000 unit
3
3
•
THROMBIN-JMI DILUENT thrombin for soln 5000 unit
3
XARELTO - rivaroxaban tab 20
mg
3
•
THROMBIN-JMI DILUENT thrombin for soln 20000 unit
3
XARELTO STARTER PACK rivaroxaban tab starter
therapy pack 15 mg & 20 mg
3
•
THROMBIN-JMI EPISTAXIS thrombin for soln kit 5000
unit
3
THROMBIN-JMI SYRINGE
SPRA - thrombin for soln kit
5000 unit
3
THROMBIN-JMI SYRINGE
SPRA - thrombin for soln kit
20000 unit
3
3
HEMOSTATICS
AMICAR - aminocaproic acid
oral soln 0.25 gm/ml
3
AMICAR - aminocaproic acid
syrup 25%
3
AMICAR - aminocaproic acid
tab 500 mg
3
AMICAR - aminocaproic acid
tab 1000 mg
3
THROMBIN-JMI W/DIL
SPRAY - thrombin for soln kit
20000 unit
TISSEEL - fibrin sealant
component kit 2 ml
3
AMINOCAPROIC ACID aminocaproic acid tab 1000
mg
3
3
ARTISS - fibrin sealant
component solution
3
TISSEEL - fibrin sealant
component kit 4 ml
3
EVICEL - fibrin sealant
component kit 2 ml
3
TISSEEL - fibrin sealant
component kit 10 ml
3
EVICEL - fibrin sealant
component kit 5 ml
3
TISSEEL - fibrin sealant
component solution
3
EVITHROM - thrombin
(human) topical soln
800-1200 unit/ml
3
TISSEEL VH - fibrin sealant
component kit 2 ml
TISSEEL VH - fibrin sealant
component kit 4 ml
3
LYSTEDA - tranexamic acid
tab 650 mg
3
TISSEEL VH - fibrin sealant
component kit 10 ml
3
RECOTHROM - thrombin
(recombinant) for soln 5000
unit
3
tranexamic acid tab 650 mg
(Lysteda)
1
HEMATOLOGICAL AGENTS - MISC.
ADVATE - antihemophilic factor 4
rahf-pfm for inj 250 unit
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
152
ADVATE - antihemophilic factor 4
rahf-pfm for inj 500 unit
ADVATE - antihemophilic factor 4
rahf-pfm for inj 1000 unit
ADVATE - antihemophilic factor 4
rahf-pfm for inj 1500 unit
ADVATE - antihemophilic factor 4
rahf-pfm for inj 2000 unit
ADVATE - antihemophilic factor 4
rahf-pfm for inj 3000 unit
ADVATE - antihemophilic factor 4
rahf-pfm for inj 4000 unit
4
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 250 unit
4
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 500 unit
4
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 1000 unit
4
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 2000 unit
2
AGGRENOX - aspirindipyridamole cap sr 12hr
25-200 mg
3
AGRYLIN - anagrelide hcl cap
0.5 mg
4
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 250 unit
4
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 500 unit
4
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 1000 unit
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 1500 unit
4
•
4
•
•
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 2000 unit
•
ALPHANINE SD - coagulation
factor ix for inj 500 unit
4
•
•
ALPHANINE SD - coagulation
factor ix for inj 1000 unit
4
•
•
ALPHANINE SD - coagulation
factor ix for inj 1500 unit
4
•
4
•
•
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj 500
unit
4
•
•
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj
1000 unit
4
•
•
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj
2000 unit
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj
3000 unit
4
•
anagrelide hcl cap 0.5 mg
(Agrylin)
1
anagrelide hcl cap 1 mg
1
•
•
•
•
•
ASPIRIN/DIPYRIDAMOLE aspirin-dipyridamole cap sr
12hr 25-200 mg
3
BEBULIN - factor ix complex
for inj 200-1200 unit
4
•
BEBULIN VH - factor ix
complex for inj 200-1200 unit
4
•
BENEFIX - coagulation factor
ix (recombinant) for inj 250
unit
4
•
BENEFIX - coagulation factor
ix (recombinant) for inj 500
unit
4
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
153
BENEFIX - coagulation factor
ix (recombinant) for inj 1000
unit
4
BENEFIX - coagulation factor
ix (recombinant) for inj 2000
unit
4
BENEFIX - coagulation factor
ix (recombinant) for inj 3000
unit
4
BERINERT - c1 esterase
inhibitor (human) for iv inj kit
500 unit
4
BRILINTA - ticagrelor tab 60
mg
3
BRILINTA - ticagrelor tab 90
mg
3
cilostazol tab 50 mg (Pletal)
1
cilostazol tab 100 mg (Pletal)
clopidogrel bisulfate tab
75 mg (base equiv) (Plavix)
•
•
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
EFFIENT - prasugrel hcl tab 5
mg (base equiv)
3
•
EFFIENT - prasugrel hcl tab 10
mg (base equiv)
3
4
•
•
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
250 unit
4
•
•
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
500 unit
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
750 unit
4
•
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
1000 unit
4
•
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
1500 unit
4
•
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
2000 unit
4
•
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
3000 unit
4
•
FEIBA - antiinhibitor coagulant
complex for inj
4
•
FEIBA NF - antiinhibitor
coagulant complex for inj
4
•
FIRAZYR - icatibant acetate inj
30 mg/3ml (base equivalent)
4
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 250 unit
4
•
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 500 unit
4
•
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 1000 unit
4
•
1
1
clopidogrel bisulfate tab
300 mg (base equiv)
(Plavix)
1
COAGADEX - coagulation
factor x (human) for inj 250
unit
4
COAGADEX - coagulation
factor x (human) for inj 500
unit
4
•
CORIFACT - factor xiii
concentrate (human) for inj
kit 1000-1600 unit
4
•
dipyridamole tab 25 mg
(Persantine)
1
dipyridamole tab 50 mg
(Persantine)
1
dipyridamole tab 75 mg
(Persantine)
1
DURLAZA - aspirin capsule sr
24hr 162.5 mg
3
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
•
154
•
HEMOFIL M - antihemophilic
factor (human) for inj
220-400 unit
4
•
HEMOFIL M - antihemophilic
factor (human) for inj 250
unit
4
HEMOFIL M - antihemophilic
factor (human) for inj
401-800 unit
4
Limited Distribution
4
ACA Preventive
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 3000 unit
Dispensing Limits
•
Step Therapy
4
Prior Authorization
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 2000 unit
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
IXINITY - coagulation factor ix
(recombinant) for inj 1000
unit
4
•
IXINITY - coagulation factor ix
(recombinant) for inj 1500
unit
4
•
KALBITOR - ecallantide inj 10
mg/ml
4
•
KOATE-DVI - antihemophilic
factor (human) for inj 250
unit
4
•
•
KOATE-DVI - antihemophilic
factor (human) for inj 500
unit
4
•
•
KOATE-DVI - antihemophilic
factor (human) for inj 1000
unit
4
HEMOFIL M - antihemophilic
factor (human) for inj 500
unit
4
•
4
•
•
HEMOFIL M - antihemophilic
factor (human) for inj 1700
unit
4
•
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 250
unit
4
HEMOFIL M - antihemophilic
factor (human) for inj 1000
unit
4
•
HEMOFIL M - antihemophilic
factor (human) for inj
801-1500 unit
4
•
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 500
unit
4
•
HEMOFIL M - antihemophilic
factor (human) for inj
1501-2000 unit
4
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 1000
unit
•
4
•
4
HUMATE-P - antihemophilic
factor/vwf (human) for inj
250-600 unit
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 2000
unit
HUMATE-P - antihemophilic
factor/vwf (human) for inj
500-1200 unit
4
•
4
•
HUMATE-P - antihemophilic
factor/vwf (human) for inj
1000-2400 unit
4
•
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 3000
unit
4
•
IXINITY - coagulation factor ix
(recombinant) for inj 500 unit
4
•
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 250
unit
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
•
155
4
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 1000
unit
4
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 2000
unit
4
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 3000
unit
4
•
MONOCLATE-P antihemophilic factor
(human) for inj kit 250 unit
4
•
MONOCLATE-P antihemophilic factor
(human) for inj kit 500 unit
4
•
MONOCLATE-P antihemophilic factor
(human) for inj kit 1000 unit
4
•
MONOCLATE-P antihemophilic factor
(human) for inj kit 1500 unit
4
•
MONONINE - coagulation
factor ix for inj 250 unit
4
•
MONONINE - coagulation
factor ix for inj 500 unit
4
•
MONONINE - coagulation
factor ix for inj 1000 unit
4
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
250 unit
4
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
500 unit
4
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
1000 unit
4
•
•
•
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
•
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 500
unit
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
1500 unit
4
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
2000 unit
4
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
3000 unit
4
•
NOVOSEVEN RT - coagulation 4
factor viia (recomb) for inj 1
mg (1000 mcg)
NOVOSEVEN RT - coagulation 4
factor viia (recomb) for inj 2
mg (2000 mcg)
NOVOSEVEN RT - coagulation 4
factor viia (recomb) for inj 5
mg (5000 mcg)
NOVOSEVEN RT - coagulation 4
factor viia (recomb) for inj 8
mg (8000 mcg)
NUWIQ - antihemophilic factor 4
(recombinant) for inj kit 250
unit
NUWIQ - antihemophilic factor 4
(recombinant) for inj kit 500
unit
NUWIQ - antihemophilic factor 4
(recombinant) for inj kit 1000
unit
NUWIQ - antihemophilic factor 4
(recombinant) for inj kit 2000
unit
NUWIQ - antihemophilic factor 4
(recombinant) for inj 250 unit
NUWIQ - antihemophilic factor 4
(recombinant) for inj 500 unit
NUWIQ - antihemophilic factor 4
(recombinant) for inj 1000
unit
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
•
•
•
•
•
•
•
•
156
•
pentoxifylline tab cr 400 mg
1
Limited Distribution
4
ACA Preventive
OBIZUR - antihemophilic factor
(recomb porc) rpfviii for inj
500 unit
Dispensing Limits
•
Step Therapy
4
Prior Authorization
NUWIQ - antihemophilic factor
(recombinant) for inj 2000
unit
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
RECOMBINATE antihemophilic factor
(recombinant) for inj
1241-1800 unit
4
•
RECOMBINATE antihemophilic factor
(recombinant) for inj
1801-2400 unit
4
•
RIASTAP - fibrinogen conc
(human) inj approximately 1
gm (900-1300 mg)
3
•
PERSANTINE - dipyridamole
tab 25 mg
3
PERSANTINE - dipyridamole
tab 50 mg
3
PERSANTINE - dipyridamole
tab 75 mg
3
RIXUBIS - coagulation factor ix
(recombinant) for inj 250 unit
4
•
PLAVIX - clopidogrel bisulfate
tab 75 mg (base equiv)
3
RIXUBIS - coagulation factor ix
(recombinant) for inj 500 unit
4
•
PLAVIX - clopidogrel bisulfate
tab 300 mg (base equiv)
3
4
•
PROFILNINE - factor ix
complex for inj 500 unit
4
•
RIXUBIS - coagulation factor
ix (recombinant) for inj 1000
unit
4
•
PROFILNINE - factor ix
complex for inj 1000 unit
4
•
RIXUBIS - coagulation factor
ix (recombinant) for inj 2000
unit
•
•
PROFILNINE SD - factor ix
complex for inj 500 unit
4
•
RIXUBIS - coagulation factor
ix (recombinant) for inj 3000
unit
4
PROFILNINE - factor ix
complex for inj 1500 unit
4
4
PROFILNINE SD - factor ix
complex for inj 1000 unit
4
•
RUCONEST - c1 esterase
inhibitor (recombinant) for iv
inj 2100 unit
•
4
•
4
PROFILNINE SD - factor ix
complex for inj 1500 unit
THROMBATE III W/10
ML STE - antithrombin iii
(human) for inj 500 unit
RECOMBINATE antihemophilic factor
(recombinant) for inj 220-400
unit
4
•
THROMBATE III W/20
ML STE - antithrombin iii
(human) for inj 1000 unit
4
•
4
•
RECOMBINATE antihemophilic factor
(recombinant) for inj 401-800
unit
4
TRETTEN - coagulation
factor xiii a-subunit for inj
2000-3125 unit
•
RECOMBINATE antihemophilic factor
(recombinant) for inj
801-1240 unit
4
WILATE - antihemophilic factor/ 4
vwf (human) for inj 500-500
unit
4
WILATE - antihemophilic
factor/vwf (human) for inj
1000-1000 unit
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
•
•
•
157
•
XYNTHA - antihemophilic
factor recombinant paf for inj
kit 1000 unit
4
XYNTHA - antihemophilic
factor recombinant paf for inj
kit 2000 unit
4
•
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
250 unit
4
•
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
500 unit
4
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
1000 unit
4
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
2000 unit
4
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
3000 unit
4
ZONTIVITY - vorapaxar
sulfate tab 2.08 mg (base
equivalent)
3
TOPICAL PRODUCTS
OPHTHALMIC AGENTS
ACULAR - ketorolac
tromethamine ophth soln
0.5%
3
ACULAR LS - ketorolac
tromethamine ophth soln
0.4%
3
•
•
•
•
•
AKTEN - lidocaine hcl ophth
gel 3.5%
3
ALCAINE - proparacaine hcl
ophth soln 0.5%
3
ALOCRIL - nedocromil sodium
ophth soln 2%
3
ALOMIDE - lodoxamide
tromethamine ophth soln
0.1%
3
ALPHAGAN P - brimonidine
tartrate ophth soln 0.1%
3
ALPHAGAN P - brimonidine
tartrate ophth soln 0.15%
3
ALREX - loteprednol etabonate
ophth susp 0.2%
3
apraclonidine hcl ophth soln
0.5% (base equivalent)
(Iopidine)
1
atropine sulfate ophth soln
1% (Isopto atropine)
1
AZASITE - azithromycin ophth
soln 1%
3
azelastine hcl ophth soln
0.05% (Optivar)
1
AZOPT - brinzolamide ophth
susp 1%
Limited Distribution
4
3
ACA Preventive
XYNTHA - antihemophilic
factor recombinant paf for inj
kit 500 unit
ACUVAIL - ketorolac
tromethamine ophth soln
0.45%
Dispensing Limits
•
Step Therapy
4
Prior Authorization
XYNTHA - antihemophilic
factor recombinant paf for inj
kit 250 unit
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
3
BACITRACIN - bacitracin ophth 2
oint 500 unit/gm
1
bacitracin-polymyxin b
ophth oint
1
bacitracin-polymyxinneomycin-hc ophth oint
1%
3
BEPREVE - bepotastine
besilate ophth soln 1.5%
3
BESIVANCE - besifloxacin
hcl ophth susp 0.6% (base
equiv)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
158
BETADINE OPHTHALMIC
PREP - povidone-iodine
ophth soln 5%
3
COMBIGAN - brimonidine
tartrate-timolol maleate
ophth soln 0.2-0.5%
3
BETAGAN - levobunolol hcl
ophth soln 0.5%
3
3
betaxolol hcl ophth soln
0.5%
1
COSOPT - dorzolamide hcltimolol maleate ophth soln
22.3-6.8 mg/ml
BETIMOL - timolol ophth soln
0.25%
3
BETIMOL - timolol ophth soln
0.5%
3
BETOPTIC-S - betaxolol hcl
ophth susp 0.25%
3
BIMATOPROST - bimatoprost
ophth soln 0.03%
3
BLEPH-10 - sulfacetamide
sodium ophth soln 10%
3
BLEPHAMIDE - sulfacetamide
sodium-prednisolone ophth
susp 10-0.2%
3
BLEPHAMIDE S.O.P. sulfacetamide sodiumprednisolone ophth oint
10-0.2%
3
brimonidine tartrate ophth
soln 0.15% (Alphagan p)
1
brimonidine tartrate ophth
soln 0.2%
1
BROMFENAC - bromfenac
sodium ophth soln 0.09%
(base equivalent)
1
bromfenac sodium ophth
soln 0.09% (base equiv)
(once-daily)
1
carteolol hcl ophth soln 1%
1
CILOXAN - ciprofloxacin hcl
ophth oint 0.3%
3
CILOXAN - ciprofloxacin hcl
ophth soln 0.3%
3
ciprofloxacin hcl ophth soln
0.3% (Ciloxan)
1
•
COSOPT PF - dorzolamide hcl- 3
timolol maleate ophth sol
22.3-6.8 mg/ml pf
cromolyn sodium ophth soln 1
4%
3
CYCLOGYL - cyclopentolate
hcl ophth soln 0.5%
3
CYCLOGYL - cyclopentolate
hcl ophth soln 1%
3
CYCLOGYL - cyclopentolate
hcl ophth soln 2%
3
CYCLOMYDRIL cyclopentolate w/
phenylephrine ophth soln
0.2-1%
1
cyclopentolate hcl ophth
soln 1% (Cyclogyl)
1
cyclopentolate hcl ophth
soln 2% (Cyclogyl)
4
CYSTARAN - cysteamine hcl
ophth soln 0.44% (base
equivalent)
3
DEXAMETHASONE SODIUM
PHOS - dexamethasone
sodium phosphate ophth
soln 0.1%
1
diclofenac sodium ophth
soln 0.1%
1
dorzolamide hcl ophth soln
2% (Trusopt)
1
dorzolamide hcl-timolol
maleate ophth soln
22.3-6.8 mg/ml (Cosopt)
3
DUREZOL - difluprednate
ophth emulsion 0.05%
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
159
ELESTAT - epinastine hcl
ophth soln 0.05%
3
EMADINE - emedastine
difumarate ophth soln 0.05%
(base equiv)
epinastine hcl ophth soln
0.05% (Elestat)
3
3
ISOPTO CARPINE pilocarpine hcl ophth soln
2%
3
1
ISOPTO CARPINE pilocarpine hcl ophth soln
4%
3
1
ISTALOL - timolol maleate
ophth soln 0.5% (once-daily)
1
FLAREX - fluorometholone
acetate ophth susp 0.1%
3
ketorolac tromethamine
ophth soln 0.4% (Acular ls)
fluorometholone ophth susp
0.1% (Fml liquifilm)
1
ketorolac tromethamine
ophth soln 0.5% (Acular)
3
1
LACRISERT - artificial tear
ophth insert
3
FML - fluorometholone ophth
oint 0.1%
3
LASTACAFT - alcaftadine
ophth soln 0.25%
1
FML FORTE - fluorometholone
ophth susp 0.25%
3
latanoprost ophth soln
0.005% (Xalatan)
FML LIQUIFILM fluorometholone ophth susp
0.1%
3
GARAMYCIN - gentamicin
sulfate ophth soln 0.3%
3
gatifloxacin ophth soln 0.5%
(Zymaxid)
1
gentamicin sulfate ophth
oint 0.3%
erythromycin ophth oint
5 mg/gm
flurbiprofen sodium ophth
soln 0.03% (Ocufen)
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
LEVOBUNOLOL HCL levobunolol hcl ophth soln
0.25%
3
levobunolol hcl ophth soln
0.5% (Betagan)
1
levofloxacin ophth soln 0.5%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
1
LOTEMAX - loteprednol
etabonate ophth gel 0.5%
2
1
LOTEMAX - loteprednol
etabonate ophth oint 0.5%
2
1
LOTEMAX - loteprednol
etabonate ophth susp 0.5%
2
ILEVRO - nepafenac ophth
susp 0.3%
3
4
•
IOPIDINE - apraclonidine
hcl ophth soln 0.5% (base
equivalent)
3
LUCENTIS - ranibizumab
intravitreal inj 0.3 mg/0.05ml
(6 mg/ml)
4
•
IOPIDINE - apraclonidine
hcl ophth soln 1% (base
equivalent)
3
LUCENTIS - ranibizumab
intravitreal inj 0.5 mg/0.05ml
(10 mg/ml)
LUMIGAN - bimatoprost ophth
soln 0.01%
2
ISOPTO CARPINE pilocarpine hcl ophth soln
1%
3
MAXIDEX - dexamethasone
ophth susp 0.1%
3
gentamicin sulfate ophth
soln 0.3% (Garamycin)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
160
MAXITROL - neomycinpolymyxin-dexamethasone
ophth oint 0.1%
3
MAXITROL - neomycinpolymyxin-dexamethasone
ophth susp 0.1%
3
METIPRANOLOL metipranolol ophth soln
0.3%
3
MITOSOL - mitomycin for
ophth soln kit 0.2 mg
3
MOXEZA - moxifloxacin hcl
ophth soln 0.5% (base eq) (2
times daily)
3
MYDRIACYL - tropicamide
ophth soln 1%
3
NAPHAZOLINE HCL naphazoline hcl ophth soln
0.1%
3
NATACYN - natamycin ophth
susp 5%
2
neomycin-bacitrac
zn-polymyx
5(3.5)mg-400unt-10000unt
op oin
1
neomycin-polymygramicid op sol
1.75-10000-0.025mg-untmg/ml (Neosporin)
neomycin-polymyxindexamethasone ophth oint
0.1% (Maxitrol)
neomycin-polymyxindexamethasone ophth
susp 0.1% (Maxitrol)
1
NEVANAC - nepafenac ophth
susp 0.1%
3
OCUFEN - flurbiprofen sodium
ophth soln 0.03%
3
OCUFLOX - ofloxacin ophth
soln 0.3%
3
ofloxacin ophth soln 0.3%
(Ocuflox)
1
olopatadine hcl ophth soln
0.1% (base equivalent)
(Patanol)
1
OMNIPRED - prednisolone
acetate ophth susp 1%
3
ophthalmic irrigation
solution - intraocular (Bss
plus)
1
PATADAY - olopatadine hcl
ophth soln 0.2% (base
equivalent)
2
PATANOL - olopatadine hcl
ophth soln 0.1% (base
equivalent)
3
PAZEO - olopatadine hcl ophth
soln 0.7% (base equivalent)
2
phenylephrine hcl ophth
soln 2.5%
1
phenylephrine hcl ophth
soln 10%
PHOSPHOLINE IODIDE echothiophate iodide ophth
for soln 0.125%
3
1
pilocarpine hcl ophth soln
1% (Isopto carpine)
1
NEOMYCIN/POLYMYXIN/
HYDROC - neomycinpolymyxin-hc ophth susp
3
NEOSPORIN - neomycinpolymy-gramicid op sol
1.75-10000-0.025mg-untmg/ml
3
pilocarpine hcl ophth soln
4% (Isopto carpine)
polymyxin b-trimethoprim
ophth soln 10000 unit/
ml-0.1% (Polytrim)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
1
pilocarpine hcl ophth soln
2% (Isopto carpine)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
161
POLYTRIM - polymyxin btrimethoprim ophth soln
10000 unit/ml-0.1%
3
timolol maleate ophth gel
forming soln 0.5%
(Timoptic-xe)
1
PRED FORTE - prednisolone
acetate ophth susp 1%
3
1
PRED MILD - prednisolone
acetate ophth susp 0.12%
3
timolol maleate ophth soln
0.25% (Timoptic)
PRED-G - gentamicinprednisolone ace ophth susp
0.3-1%
3
timolol maleate ophth soln
0.5% (Timoptic)
3
TIMOPTIC - timolol maleate
ophth soln 0.5%
3
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint
0.3-0.6%
3
3
prednisolone acetate ophth
susp 1% (Pred forte)
1
TIMOPTIC OCUDOSE - timolol
maleate preservative free
ophth soln 0.25%
TIMOPTIC OCUDOSE - timolol
maleate preservative free
ophth soln 0.5%
3
3
PREDNISOLONE SODIUM
PHOSP - prednisolone
sodium phosphate ophth
soln 1%
3
PROLENSA - bromfenac
sodium ophth soln 0.07%
(base equivalent)
3
TIMOPTIC-XE - timolol
maleate ophth gel forming
soln 0.25%
3
proparacaine hcl ophth soln
0.5% (Alcaine)
1
TIMOPTIC-XE - timolol
maleate ophth gel forming
soln 0.5%
TOBRADEX - tobramycindexamethasone ophth oint
0.3-0.1%
3
3
RESCULA - unoprostone
isopropyl ophth soln 0.15%
3
RESTASIS - cyclosporine
(ophth) emulsion 0.05%
3
SIMBRINZA - brinzolamidebrimonidine tartrate ophth
susp 1-0.2%
3
TOBRADEX - tobramycindexamethasone ophth susp
0.3-0.1%
3
SULFACETAMIDE SODIUM sulfacetamide sodium ophth
oint 10%
3
TOBRADEX ST - tobramycindexamethasone ophth susp
0.3-0.05%
tobramycin ophth soln 0.3%
(Tobrex)
1
sulfacetamide sodium ophth
soln 10% (Bleph-10)
1
tobramycin-dexamethasone
ophth susp 0.3-0.1%
(Tobradex)
1
TOBREX - tobramycin ophth
oint 0.3%
3
TOBREX - tobramycin ophth
soln 0.3%
3
timolol maleate ophth gel
forming soln 0.25%
(Timoptic-xe)
1
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
TIMOPTIC - timolol maleate
ophth soln 0.25%
sulfacetamide sodiumprednisolone ophth soln
10-0.23(0.25)%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
162
TRAVATAN Z - travoprost
ophth soln 0.004%
(benzalkonium free) (bak
free)
2
TRAVOPROST - travoprost
ophth soln 0.004%
3
trifluridine ophth soln 1%
(Viroptic)
1
tropicamide ophth soln 0.5%
1
•
CETRAXAL - ciprofloxacin
hcl otic soln 0.2% (base
equivalent)
3
CIPRO HC - ciprofloxacinhydrocortisone otic susp
0.2-1%
3
CIPRODEX - ciprofloxacindexamethasone otic susp
0.3-0.1%
2
CIPROFLOXACIN ciprofloxacin hcl otic soln
0.2% (base equivalent)
3
COLY-MYCIN S - neomycincolistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml
3
tropicamide ophth soln 1%
(Mydriacyl)
1
TRUSOPT - dorzolamide hcl
ophth soln 2%
3
VEXOL - rimexolone ophth
susp 1%
3
VIGAMOX - moxifloxacin hcl
ophth soln 0.5% (base
equiv)
2
CORTISPORIN - neomycinpolymyxin-hc otic soln 1%
3
3
VIROPTIC - trifluridine ophth
soln 1%
3
XALATAN - latanoprost ophth
soln 0.005%
3
•
CORTISPORIN-TC neomycin-colistin-hcthonzonium otic susp
3.3-3-10-0.5 mg/ml
3
ZIOPTAN - tafluprost ophth
soln 0.0015%
3
•
DERMOTIC - fluocinolone
acetonide (otic) oil 0.01%
1
ZIRGAN - ganciclovir ophth gel
0.15%
3
fluocinolone acetonide (otic)
oil 0.01% (Dermotic)
ZYLET - loteprednol etabonate- 3
tobramycin ophth susp
0.5-0.3%
3
ZYMAXID - gatifloxacin ophth
soln 0.5%
OTIC AGENTS
hydrocortisone w/ acetic
acid otic soln 1-2% (Vosol
hc)
1
neomycin-polymyxin-hc otic
soln 1% (Cortisporin)
1
neomycin-polymyxin-hc otic
susp 3.5 mg/ml-10000 unit/
ml-1%
Limited Distribution
ACA Preventive
1
ofloxacin otic soln 0.3%
ACETIC ACID/ALUMINUM
ACET - acetic acid 2% in
aluminum acetate otic soln
3
antipyrine-benzocaine
otic soln 54-14 mg/ml
(5.4-1.4%)
1
MOUTH/THROAT/DENTAL AGENTS
NA
ACT TOTAL CARE DRY
MOUTH - sodium fluoride
rinse 0.02%
1
cevimeline hcl cap 30 mg
(Evoxac)
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Dispensing Limits
1
1
acetic acid otic soln 2%
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
163
chlorhexidine gluconate
soln 0.12% (Peridex)
clotrimazole troche 10 mg
1
1
COLGATE DRY MOUTH
RELIEF - sodium fluoride
mouthwash 2.1 mg/10ml
NA
•
CREST COMPLETE - sodium
fluoride paste 0.243%
NA
•
EVOXAC - cevimeline hcl cap
30 mg
3
FLUORIDEX DAILY
DEFENSE S - sodium
fluoride-potassium nitrate gel
1.1-5%
3
•
GEL-KAM - stannous fluoride
gel 0.4%
NA
•
GEL-KAM ORAL CARE
RINSE - stannous fluoride
conc 0.63%
3
•
lidocaine hcl
laryngotracheal soln 4%
(Lta 360 kit)
1
lidocaine hcl viscous soln
2%
1
•
LISTERINE ESSENTIAL
CARE - sod
monofluorophosph-eucalmen-methyl sal-thymol gel
0.76%
NA
LISTERINE RESTORING sodium fluoride rinse
0.0221% (0.01% f)
NA
LISTERINE SMART RINSE sodium fluoride rinse
0.0221% (0.01% f)
NA
LISTERINE TOOTH
DEFENSE - sodium fluoride
rinse 0.0221% (0.01% f)
NA
•
LISTERINE TOTAL CARE sodium fluoride rinse
0.0221% (0.01% f)
NA
•
NA
LISTERINE TOTAL CARE
PLUS - sodium fluoride rinse
0.0221% (0.01% f)
NA
LISTERINE TOTAL CARE
ZERO - sodium fluoride rinse
0.02%
NA
LISTERINE WHITENING/
RESTO - sodium fluoride
rinse 0.0221% (0.01% f)
3
LTA 360 KIT - lidocaine hcl
laryngotracheal soln 4%
1
mouthwashes - liquid
•
•
•
NAFRINSE DAILY/
ACIDULATED - sodium
fluoride-phosphoric acid for
soln 1 mg/5ml (f equiv)
3
•
NAFRINSE DAILY/NEUTRAL sodium fluoride for soln rinse
0.05%
3
•
NAFRINSE WEEKLY - sodium
fluoride for soln rinse 0.2%
3
•
nystatin susp 100000 unit/ml
1
OMNI GEL - stannous fluoride
gel 0.4%
NA
ORAVIG - miconazole buccal
tab 50 mg (mouth-throat)
3
PERIDEX - chlorhexidine
gluconate soln 0.12%
3
•
•
PHOS FLUR - sodium fluoride
rinse 0.044%
NA
•
NA
•
•
PHOS-FLUR ORTHO
DEFENSE - sodium fluoride
rinse 0.044%
pilocarpine hcl tab 5 mg
(Salagen)
1
pilocarpine hcl tab 7.5 mg
(Salagen)
1
PREVIDENT - sodium fluoride
rinse 0.2%
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
164
PREVIDENT FLUORIDE sodium fluoride gel 1.1%
(0.5% f)
3
PREVIDENT 5000 BOOSTER - 3
sodium fluoride paste 1.1%
3
PREVIDENT 5000 BOOSTER
PL - sodium fluoride paste
1.1%
3
PREVIDENT 5000 DRY
MOUTH - sodium fluoride gel
1.1% (0.5% f)
3
PREVIDENT 5000 ENAMEL
PRO - sodium fluoridepotassium nitrate paste
1.1-5%
3
PREVIDENT 5000 PLUS sodium fluoride cream 1.1%
3
PREVIDENT 5000
SENSITIVE - sodium
fluoride-potassium nitrate
paste 1.1-5%
REACH KIDS - sodium fluoride NA
paste 0.15%
NA
REMBRANDT DEEPLY
WHITE+PE - sodium
monofluorophosphate paste
0.884%
NA
REMBRANDT INTENSE
STAIN - sodium fluoride
paste 0.243%
NA
REMBRANDT WHITENING sodium fluoride rinse 0.02%
SALAGEN - pilocarpine hcl tab 3
5 mg
SALAGEN - pilocarpine hcl tab 3
7.5 mg
NA
SENSODYNE REPAIR &
PROTEC - stannous fluoride
paste 0.454%
1
sodium fluoride cream 1.1%
(Prevident 5000 plus)
sodium fluoride gel 1.1%
(0.5% f) (Prevident fluoride)
•
sodium fluoride paste 1.1%
(Prevident 5000 boost)
•
sodium fluoride rinse
0.0221% (0.01% f)
1
•
1
•
NA
•
NA
•
sodium fluoride rinse 0.2%
(Prevident)
1
•
•
1
•
•
sodium fluoride-potassium
nitrate paste 1.1-5%
(Prevident 5000 sensi)
•
NA
stannous fluoride conc
0.63% (Gel-kam oral care ri)
NA
stannous fluoride gel 0.4%
sodium fluoride rinse 0.05%
•
•
NA
STANNOUS FLUORIDE
RINSE - stannous fluoride liq
0.1%
3
THERA-FLUR-N - sodium
fluoride gel 1.1% (0.5% f)
1
triamcinolone acetonide
dental paste 0.1%
•
ANORECTAL AGENTS
3
•
ANALPRAM HC hydrocortisone acetate w/
pramoxine rectal cream
2.5-1%
ANALPRAM HC SINGLES hydrocortisone acetate w/
pramoxine rectal cream
2.5-1%
3
ANALPRAM-HC hydrocortisone acetate w/
pramoxine rectal cream
1-1%
3
ANALPRAM-HC hydrocortisone acetate w/
pramoxine rectal lotn 2.5-1%
3
•
•
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
•
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
165
ANALPRAM-HC SINGLES hydrocortisone acetate w/
pramoxine rectal cream
1-1%
3
ANUSOL-HC - hydrocortisone
rectal cream 2.5%
3
CORTENEMA - hydrocortisone
enema 100 mg/60ml
3
CORTIFOAM - hydrocortisone
acetate rectal foam 10% (90
mg/dose)
2
hydrocortisone acetate
suppos 25 mg (Anusol-hc)
1
hydrocortisone acetate w/
pramoxine rectal cream
1-1% (Analpram-hc)
hydrocortisone enema
100 mg/60ml (Cortenema)
hydrocortisone rectal cream
1% (Proctocort)
hydrocortisone rectal cream
2.5% (Anusol-hc)
lidocaine-hydrocortisone
acetate rectal cream kit
3-1%
lidocaine-hydrocortisone
acetate rectal gel kit
3-2.5%
3
ABSORICA - isotretinoin cap
30 mg
3
ABSORICA - isotretinoin cap
35 mg
3
ABSORICA - isotretinoin cap
40 mg
3
ACANYA - clindamycin
phosphate-benzoyl peroxide
gel 1.2-2.5%
3
acitretin cap 10 mg
(Soriatane)
1
acitretin cap 17.5 mg
(Soriatane)
1
1
acitretin cap 25 mg
(Soriatane)
1
1
ACLOVATE - alclometasone
dipropionate cream 0.05%
3
acyclovir oint 5% (Zovirax)
1
1
1
1
1
3
RECTIV - nitroglycerin oint
0.4%
UCERIS - budesonide rectal
foam 2 mg/act
ACZONE - dapsone gel 5%
3
ADAPALENE - adapalene
lotion 0.1%
3
•
adapalene cream 0.1%
(Differin)
1
•
adapalene gel 0.1% (Differin)
1
•
•
adapalene gel 0.3% (Differin)
1
ALA SCALP - hydrocortisone
lotion 2%
3
3
alclometasone dipropionate
cream 0.05% (Aclovate)
1
3
alclometasone dipropionate
oint 0.05%
ABSORICA - isotretinoin cap
10 mg
3
ABSORICA - isotretinoin cap
20 mg
3
Limited Distribution
ACA Preventive
Dispensing Limits
1
ALDARA - imiquimod cream
5%
3
ALTABAX - retapamulin oint
1%
3
ALUMINUM ACETATE aluminum acetate soln
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Drug Name
ABSORICA - isotretinoin cap
25 mg
PROCTOFOAM HC hydrocortisone acetate w/
pramoxine rectal foam 1-1%
DERMATOLOGICALS
Prior Authorization
Drug Name
Drug Tier
2015
166
AMCINONIDE - amcinonide
cream 0.1%
3
benzoyl peroxide lotion 6%
benzoyl peroxideerythromycin gel 5-3%
(Benzamycin)
1
AMCINONIDE - amcinonide
lotion 0.1%
3
AMCINONIDE - amcinonide
oint 0.1%
3
1
APEXICON E - diflorasone
diacetate emollient base
cream 0.05%
3
betamethasone dipropionate
augmented cream 0.05%
(Diprolene af)
1
ATRALIN - tretinoin gel 0.05%
3
betamethasone dipropionate
augmented gel 0.05%
AVAR-E LS - sulfacetamide
sodium w/ sulfur cream
10-2%
•
1
3
1
AZELEX - azelaic acid cream
20%
3
betamethasone dipropionate
augmented oint 0.05%
(Diprolene)
BACTROBAN - mupirocin
calcium cream 2%
3
betamethasone dipropionate
cream 0.05%
1
BACTROBAN - mupirocin oint
2%
3
betamethasone dipropionate
lotion 0.05%
BENZACLIN - clindamycin
phosphate-benzoyl peroxide
gel 1-5%
3
betamethasone dipropionate
oint 0.05%
BENZACLIN WITH PUMP clindamycin phosphatebenzoyl peroxide gel 1-5%
3
BENZAMYCIN - benzoyl
peroxide-erythromycin gel
5-3%
3
BENZAMYCINPAK - benzoyl
peroxide-erythromycin gel
pack 5-3%
3
BENZOIN COMPOUND
TINCTURE - benzoin
compound tincture
3
benzoyl peroxide creamy
wash 8% &benzoyl
peroxide bar 5% kit (Bpo
creamy wash comp)
1
benzoyl peroxide foam 5.3%
(Benzefoam)
1
benzoyl peroxide gel 5%
1
betamethasone valerate
cream 0.1%
betamethasone valerate
lotion 0.1%
betamethasone valerate oint
0.1%
Limited Distribution
ACA Preventive
1
1
1
1
1
3
BPO CREAMY WASH
COMPLETE - benzoyl
peroxide creamy wash 8%
&benzoyl peroxide bar 5%
kit
3
calcipotriene cream 0.005%
(Dovonex)
1
calcipotriene oint 0.005%
1
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Dispensing Limits
1
BORIC ACID - boric acid
granules
calcipotriene soln 0.005%
(50 mcg/ml)
Step Therapy
1
betamethasone dipropionate
augmented lotion 0.05%
(Diprolene)
betamethasone valerate
aerosol foam 0.12% (Luxiq)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
167
calcipotrienebetamethasone
dipropionate oint
0.005-0.064% (Taclonex)
1
CALCITRIOL - calcitriol oint 3
mcg/gm
3
CAPEX - fluocinolone
acetonide shampoo 0.01%
clindamycin phosphate soln
1% (Cleocin-t)
clindamycin phosphate
swab 1% (Cleocin-t)
3
3
clobetasol propionate cream
0.05% (Temovate)
1
CARAC - fluorouracil cream
0.5%
CENTANY - mupirocin oint 2%
3
ciclopirox gel 0.77%
1
clobetasol propionate
emollient base cream
0.05% (Temovate e)
ciclopirox olamine susp
0.77% (base equiv)
1
ciclopirox shampoo 1%
(Loprox shampoo)
1
ciclopirox solution 8%
(Penlac Nail Lacquer)
1
CLEOCIN-T - clindamycin
phosphate gel 1%
3
CLEOCIN-T - clindamycin
phosphate lotion 1%
3
CLEOCIN-T - clindamycin
phosphate soln 1%
3
CLEOCIN-T - clindamycin
phosphate swab 1%
3
CLINDAGEL - clindamycin
phosphate gel 1%
3
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2
(1)-5% (Duac)
1
clindamycin phosphate
foam 1% (Evoclin)
clindamycin phosphate gel
1% (Cleocin-t)
clindamycin phosphate
lotion 1% (Cleocin-t)
1
clobetasol propionate foam
0.05% (Olux)
1
clobetasol propionate lotion
0.05% (Clobex)
clobetasol propionate oint
0.05% (Temovate)
clobetasol propionate
shampoo 0.05% (Clobex)
clobetasol propionate soln
0.05% (Temovate)
clobetasol propionate spray
0.05% (Clobex)
1
1
1
1
1
3
CLOBEX - clobetasol
propionate shampoo 0.05%
3
1
CLOBEX - clobetasol
propionate spray 0.05%
3
1
CLOCORTOLONE PIVALATE clocortolone pivalate cream
0.1%
3
CLOCORTOLONE PIVALATE
PUM - clocortolone pivalate
cream 0.1%
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
1
CLOBEX - clobetasol
propionate lotion 0.05%
1
ACA Preventive
1
clobetasol propionate
emulsion foam 0.05%
(Olux-e)
clobetasol propionate gel
0.05% (Temovate)
Dispensing Limits
1
1
1
Step Therapy
1
clindamycin phosphatebenzoyl peroxide gel 1-5%
(Benzaclin)
ciclopirox olamine cream
0.77% (base equiv)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
168
CLODERM - clocortolone
pivalate cream 0.1%
3
CUTIVATE - fluticasone
propionate lotion 0.05%
3
CLODERM PUMP clocortolone pivalate cream
0.1%
3
DENAVIR - penciclovir cream
1%
3
DERMA-SMOOTHE/FS
BODY - fluocinolone
acetonide oil 0.01% (body
oil)
3
clotrimazole cream 1%
1
DERMA-SMOOTHE/FS BODY
OIL - fluocinolone acetonide
oil 0.01% (body oil)
3
DERMA-SMOOTHE/FS
SCALP - fluocinolone
acetonide oil 0.01% (scalp
oil)
3
3
clotrimazole soln 1%
clotrimazole w/
betamethasone cream
1-0.05% (Lotrisone)
clotrimazole w/
betamethasone lotion
1-0.05%
1
1
1
CONDYLOX - podofilox gel
0.5%
3
CONDYLOX - podofilox soln
0.5%
3
CORDRAN - flurandrenolide
cream 0.05%
3
DERMA-SMOOTHE/FS
SCALP OI - fluocinolone
acetonide oil 0.01% (scalp
oil)
DERMATOP - prednicarbate
cream 0.1%
3
CORDRAN - flurandrenolide
lotion 0.05%
3
DERMATOP - prednicarbate
oint 0.1%
3
CORDRAN - flurandrenolide
oint 0.05%
3
DESONATE - desonide gel
0.05%
3
CORDRAN TAPE flurandrenolide tape 4 mcg/
sqcm
3
1
CORTISPORIN - bacitracinpolymyxin-neomycin hc oint
1%
2
desonide cream 0.05%
(Desowen)
desonide lotion 0.05%
(Desowen)
1
CORTISPORIN - neomycinpolymyxin-hc cream 0.5%
2
desonide oint 0.05%
(Desowen)
1
COSENTYX - secukinumab
subcutaneous soln prefilled
syringe 150 mg/ml
4
DESOWEN - desonide cream
0.05%
3
3
COSENTYX SENSOREADY
PEN - secukinumab
subcutaneous soln autoinjector 150 mg/ml
4
DESOWEN - desonide lotion
0.05%
DESOWEN - desonide oint
0.05%
3
3
CUTIVATE - fluticasone
propionate cream 0.05%
3
DESOXIMETASONE desoximetasone cream
0.05%
• •
• •
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
169
DESOXIMETASONE desoximetasone oint 0.05%
3
desoximetasone cream
0.25% (Topicort)
1
desoximetasone gel 0.05%
(Topicort)
1
desoximetasone oint 0.25%
(Topicort)
DUAC - clindamycin phosphbenzoyl peroxide (refrig) gel
1.2 (1)-5%
3
econazole nitrate cream 1%
1
ECOZA - econazole nitrate
foam 1%
3
1
EFUDEX - fluorouracil cream
5%
3
diclofenac sodium (actinic
keratoses) gel 3%
(Solaraze)
1
ELIDEL - pimecrolimus cream
1%
2
ELIMITE - permethrin cream
5%
3
diclofenac sodium soln 1.5%
(Pennsaid)
1
•
ELOCON - mometasone
furoate cream 0.1%
3
DIFFERIN - adapalene cream
0.1%
3
3
•
3
DIFFERIN - adapalene gel
0.1%
ELOCON - mometasone
furoate oint 0.1%
3
•
ELOCON - mometasone
furoate solution 0.1% (lotion)
3
DIFFERIN - adapalene gel
0.3%
•
EMLA - lidocaine-prilocaine
cream 2.5-2.5%
3
DIFFERIN - adapalene lotion
0.1%
2
ENSTILAR - calcipotrienebetamethasone dipropionate
foam 0.005-0.064%
3
DIFLORASONE DIACETATE diflorasone diacetate cream
0.05%
3
EPIDUO - adapalene-benzoyl
peroxide gel 0.1-2.5%
3
DIFLORASONE DIACETATE diflorasone diacetate oint
0.05%
3
•
3
•
DIPROLENE - betamethasone
dipropionate augmented
lotion 0.05%
3
EPIDUO FORTE - adapalenebenzoyl peroxide gel
0.3-2.5%
3
DIPROLENE - betamethasone
dipropionate augmented oint
0.05%
3
EPIFOAM - pramoxine-hc
aerosol foam 1-1%
ERTACZO - sertaconazole
nitrate cream 2%
3
DIPROLENE AF betamethasone dipropionate
augmented cream 0.05%
3
DOVONEX - calcipotriene
cream 0.005%
3
DOXYCYCLINE - doxycycline
(rosacea) cap delayed
release 40 mg
3
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
ERYGEL - erythromycin gel 2% 3
erythromycin gel 2% (Erygel) 1
erythromycin pads 2%
erythromycin soln 2%
•
1
1
EUCALYPTUS OIL eucalyptus (topical) oil
3
EURAX - crotamiton cream
10%
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
170
EURAX - crotamiton lotion 10% 3
3
EVOCLIN - clindamycin
phosphate foam 1%
3
EXELDERM - sulconazole
nitrate cream 1%
3
EXELDERM - sulconazole
nitrate solution 1%
3
EXTINA - ketoconazole foam
2%
3
FABIOR - tazarotene (acne)
foam 0.1%
2
FINACEA - azelaic acid foam
15%
2
FINACEA - azelaic acid gel
15%
3
FLECTOR - diclofenac
epolamine patch 1.3%
1
fluocinolone acetonide
cream 0.01%
1
fluocinolone acetonide
cream 0.025% (Synalar)
1
fluocinolone acetonide oil
0.01% (body oil) (Dermasmoothe/fs bod)
1
fluocinolone acetonide oil
0.01% (scalp oil) (Dermasmoothe/fs sca)
1
fluocinolone acetonide oint
0.025% (Synalar)
1
fluocinolone acetonide soln
0.01% (Synalar)
1
fluocinonide cream 0.05%
fluocinonide cream 0.1%
(Vanos)
1
fluocinonide emulsified base
cream 0.05%
1
fluocinonide gel 0.05%
fluocinonide oint 0.05%
fluocinonide soln 0.05%
1
1
1
FLUOROPLEX - fluorouracil
cream 1%
3
FLUOROURACIL - fluorouracil
cream 0.5%
3
fluorouracil cream 5%
(Efudex)
1
fluorouracil soln 2%
1
fluorouracil soln 5%
fluticasone propionate
cream 0.05% (Cutivate)
•
fluticasone propionate lotion
0.05% (Cutivate)
fluticasone propionate oint
0.005% (Cutivate)
•
•
halobetasol propionate
cream 0.05% (Ultravate)
1
1
HALOG - halcinonide cream
0.1%
3
HALOG - halcinonide oint 0.1%
3
hydrocortisone butyrate
cream 0.1% (Locoid)
1
hydrocortisone butyrate
hydrophilic lipo base
cream 0.1% (Locoid
lipocream)
1
hydrocortisone butyrate oint
0.1% (Locoid)
1
hydrocortisone lotion 2.5%
hydrocortisone oint 1%
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
1
3
hydrocortisone cream 2.5%
ACA Preventive
1
GENTAMICIN SULFATE gentamicin sulfate oint 0.1%
hydrocortisone cream 1%
Dispensing Limits
1
3
hydrocortisone butyrate
soln 0.1% (Locoid)
Step Therapy
1
GENTAMICIN SULFATE gentamicin sulfate cream
0.1%
halobetasol propionate oint
0.05% (Ultravate)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
1
1
1
1
171
hydrocortisone oint 2.5%
hydrocortisone valerate
cream 0.2%
hydrocortisone valerate oint
0.2% (Westcort)
1
1
1
imiquimod cream 5%
(Aldara)
1
isotretinoin cap 10 mg
1
isotretinoin cap 20 mg
isotretinoin cap 30 mg
isotretinoin cap 40 mg
1
1
1
JUBLIA - efinaconazole soln
10%
3
KENALOG - triamcinolone
acetonide aerosol soln 0.147
mg/gm
3
KERYDIN - tavaborole soln 5%
3
ketoconazole cream 2%
1
LAVOCLEN-4 CREAMY
WASH - benzoyl peroxide liq
4%
3
LAVOCLEN-8 CREAMY
WASH - benzoyl peroxide liq
8%
3
LEVULAN KERASTICK aminolevulinic acid hcl for
soln 20% (stick applicator)
3
lidocaine hcl cream 3%
1
lidocaine hcl gel 2%
1
lidocaine oint 5%
1
lidocaine patch 5%
(Lidoderm)
1
lidocaine-prilocaine cream
2.5-2.5% (Emla)
1
LIDODERM - lidocaine patch
5%
3
lindane lotion 1%
1
ketoconazole foam 2%
(Extina)
1
ketoconazole shampoo 2%
(Nizoral)
1
KLARON - sulfacetamide
sodium lotion 10% (acne)
3
LOCOID - hydrocortisone
butyrate cream 0.1%
3
LAC-HYDRIN - lactic acid
(ammonium lactate) cream
12%
3
LOCOID - hydrocortisone
butyrate lotion 0.1%
3
3
LAC-HYDRIN - lactic acid
(ammonium lactate) lotion
12%
3
LOCOID - hydrocortisone
butyrate oint 0.1%
LOCOID - hydrocortisone
butyrate soln 0.1%
3
lactic acid (ammonium
lactate) cream 12% (Lachydrin)
1
3
lactic acid (ammonium
lactate) lotion 12% (Lachydrin)
1
LOCOID LIPOCREAM hydrocortisone butyrate
hydrophilic lipo base cream
0.1%
LOPROX SHAMPOO ciclopirox shampoo 1%
3
LAMISIL SPRAY - terbinafine
hcl soln 1%
3
LOTRISONE - clotrimazole
w/ betamethasone cream
1-0.05%
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
lidocaine hcl soln 4%
(Xylocaine)
lindane shampoo 1%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
172
LUXIQ - betamethasone
valerate aerosol foam 0.12%
3
NAFTIN - naftifine hcl cream
1%
3
LUZU - luliconazole cream 1%
3
3
malathion lotion 0.5%
(Ovide)
1
NAFTIN - naftifine hcl cream
2%
NAFTIN - naftifine hcl gel 1%
3
MENTAX - butenafine hcl
cream 1%
2
NAFTIN - naftifine hcl gel 2%
3
1
NATROBA - spinosad susp
0.9%
3
methoxsalen rapid cap
10 mg (Oxsoralen ultra)
NEO-SYNALAR - neomycinfluocinolone cream
0.35-0.025%
3
METHYL SALICYLATE methyl salicylate liquid
3
METROCREAM metronidazole cream 0.75%
3
NIZORAL - ketoconazole
shampoo 2%
3
METROGEL - metronidazole
gel 1%
3
NORITATE - metronidazole
cream 1%
3
METROLOTION metronidazole lotion 0.75%
3
1
metronidazole cream 0.75%
(Metrocream)
1
nystatin cream 100000 unit/
gm
metronidazole gel 0.75%
1
metronidazole gel 1%
(Metrogel)
1
metronidazole lotion 0.75%
(Metrolotion)
1
METVIXIA - methyl
aminolevulinate hcl cream
16.8% (base equiv)
3
mometasone furoate cream
0.1% (Elocon)
1
mometasone furoate oint
0.1% (Elocon)
1
mometasone furoate
solution 0.1% (lotion)
(Elocon)
1
mupirocin calcium cream
2% (Bactroban)
1
mupirocin oint 2%
(Bactroban)
1
NAFTIFINE HCL - naftifine hcl
cream 1%
1
nystatin oint 100000 unit/gm
nystatin topical powder
nystatin-triamcinolone
cream 100000-0.1 unit/gm%
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
1
1
1
OLUX - clobetasol propionate
foam 0.05%
3
OLUX-E - clobetasol
propionate emulsion foam
0.05%
3
ONEXTON - clindamycin
phosphate-benzoyl peroxide
gel 1.2-3.75%
3
OPTASE - trypsin w/ castor oil
& peruvian balsam gel
3
ORACEA - doxycycline
(rosacea) cap delayed
release 40 mg
3
OVIDE - malathion lotion 0.5%
3
OXISTAT - oxiconazole nitrate
cream 1%
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
173
OXISTAT - oxiconazole nitrate
lotion 1%
3
PROTOPIC - tacrolimus oint
0.1%
3
OXSORALEN - methoxsalen
lotion 1%
3
PRUDOXIN - doxepin hcl
cream 5%
3
OXSORALEN ULTRA methoxsalen rapid cap 10
mg
3
PSORCON - diflorasone
diacetate cream 0.05%
3
3
REGRANEX - becaplermin gel
0.01%
3
PANDEL - hydrocortisone
probutate cream 0.1%
RETIN-A - tretinoin cream
0.025%
3
PANRETIN - alitretinoin gel
0.1%
3
•
RETIN-A - tretinoin cream
0.05%
3
PENLAC NAIL LACQUER ciclopirox solution 8%
3
•
RETIN-A - tretinoin cream
0.1%
3
•
RETIN-A - tretinoin gel 0.01%
3
RETIN-A - tretinoin gel 0.025%
3
•
RETIN-A MICRO - tretinoin
microsphere gel 0.04%
3
•
•
•
•
RETIN-A MICRO - tretinoin
microsphere gel 0.1%
3
•
RETIN-A MICRO PUMP tretinoin microsphere gel
0.04%
3
•
RETIN-A MICRO PUMP tretinoin microsphere gel
0.08%
3
•
RETIN-A MICRO PUMP tretinoin microsphere gel
0.1%
3
•
salicylic acid shampoo 6%
(Salex)
1
PENNSAID - diclofenac sodium 3
soln 2%
1
permethrin cream 5%
(Elimite)
PICATO - ingenol mebutate gel 2
0.015%
PICATO - ingenol mebutate gel 2
0.05%
PLIAGLIS - lidocaine-tetracaine 3
cream 7-7%
1
podofilox soln 0.5%
(Condylox)
PRAMOSONE - pramoxine-hc 3
cream 1-1%
PRAMOSONE - pramoxine-hc 3
cream 1-2.5%
PRAMOSONE - pramoxine-hc 3
lotion 1-1%
PRAMOSONE - pramoxine-hc 3
lotion 1-2.5%
1
prednicarbate cream 0.1%
(Dermatop)
1
prednicarbate oint 0.1%
(Dermatop)
3
PROTOPIC - tacrolimus oint
0.03%
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
SANTYL - collagenase oint 250 3
unit/gm
1
selenium sulfide lotion 2.5%
SILVADENE - silver
sulfadiazine cream 1%
3
silver sulfadiazine cream 1%
(Silvadene)
1
SKLICE - ivermectin lotion
0.5%
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
174
SOLARAZE - diclofenac
sodium (actinic keratoses)
gel 3%
3
TACLONEX - calcipotrienebetamethasone dipropionate
oint 0.005-0.064%
3
SOOLANTRA - ivermectin
cream 1%
3
3
SORIATANE - acitretin cap 10
mg
3
TACLONEX - calcipotrienebetamethasone dipropionate
susp 0.005-0.064%
1
SORIATANE - acitretin cap
17.5 mg
3
tacrolimus oint 0.03%
(Protopic)
1
SORIATANE - acitretin cap 25
mg
3
tacrolimus oint 0.1%
(Protopic)
4
SORILUX - calcipotriene foam
0.005%
3
TARGRETIN - bexarotene gel
1%
2
•
SPINOSAD - spinosad susp
0.9%
3
TAZORAC - tazarotene cream
0.05%
2
•
STELARA - ustekinumab soln
prefilled syringe 45 mg/0.5ml
4
TAZORAC - tazarotene cream
0.1%
2
•
STELARA - ustekinumab soln
prefilled syringe 90 mg/ml
4
TAZORAC - tazarotene gel
0.05%
2
•
sulfacetamide sodium lotion
10% (acne) (Klaron)
1
TAZORAC - tazarotene gel
0.1%
3
1
TEMOVATE - clobetasol
propionate cream 0.05%
3
sulfacetamide sodium
w/ sulfur wash 9-4.5%
(Sumadan wash)
1
TEMOVATE - clobetasol
propionate gel 0.05%
TEMOVATE - clobetasol
propionate oint 0.05%
3
SULFAMYLON - mafenide
acetate cream 85 mg/gm
3
TEMOVATE - clobetasol
propionate soln 0.05%
3
SULFAMYLON - mafenide
acetate packet for topical
soln 5% (50 gm)
3
TEMOVATE E - clobetasol
propionate emollient base
cream 0.05%
3
SYNALAR - fluocinolone
acetonide cream 0.025%
3
TEXACORT - hydrocortisone
soln 2.5%
3
SYNALAR - fluocinolone
acetonide oint 0.025%
3
TOLAK - fluorouracil cream 4%
3
3
TOPICORT - desoximetasone
cream 0.05%
3
SYNALAR - fluocinolone
acetonide soln 0.01%
3
TOPICORT - desoximetasone
cream 0.25%
3
SYNERA - lidocaine-tetracaine
topical patch 70-70 mg
TOPICORT - desoximetasone
gel 0.05%
3
sulfacetamide sodium w/
sulfur cream 10-5%
• •
•
• •
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
175
TOPICORT - desoximetasone
oint 0.05%
3
TOPICORT - desoximetasone
oint 0.25%
3
TOPICORT - desoximetasone
spray 0.25%
3
TRETIN-X - tretinoin cream
0.075%
3
•
TRETIN-X - tretinoin cream
0.05% w/ cleanser &
moisturizer kit
3
•
tretinoin cream 0.025%
(Retin-a)
1
tretinoin cream 0.05% (Retina)
1
tretinoin cream 0.1% (Retina)
1
•
tretinoin gel 0.01% (Retin-a)
1
•
•
•
tretinoin gel 0.025% (Retin-a)
triamcinolone acetonide oint
0.1%
3
ULESFIA - benzyl alcohol
lotion 5%
3
•
ULTRAVATE - halobetasol
propionate cream 0.05%
3
•
ULTRAVATE - halobetasol
propionate oint 0.05%
3
urea lotion 45% (Uramaxin)
1
VECTICAL - calcitriol oint 3
mcg/gm
3
VELTIN - clindamycin
phosphate-tretinoin gel
1.2-0.025%
3
VERDESO - desonide foam
0.05%
3
VEREGEN - sinecatechins oint
15%
3
VOLTAREN - diclofenac
sodium gel 1%
2
3
1
VUSION - miconazole-zinc
oxide-white petrolatum oint
0.25-15-81.35%
3
1
WESTCORT - hydrocortisone
valerate oint 0.2%
3
1
XERESE - acyclovirhydrocortisone cream 5-1%
XOLEGEL - ketoconazole gel
2%
3
1
TRIAMCINOLONE
ACETONIDE - triamcinolone
acetonide oint 0.5%
3
triamcinolone acetonide
aerosol soln 0.147 mg/gm
(Kenalog)
1
triamcinolone acetonide
cream 0.025%
1
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
1
TRIANEX - triamcinolone
acetonide oint 0.05%
•
Prior Authorization
Limited Distribution
ACA Preventive
Dispensing Limits
Drug Tier
1
3
1
triamcinolone acetonide
lotion 0.025%
triamcinolone acetonide oint
0.025%
1
VANOS - fluocinonide cream
0.1%
1
tretinoin microsphere gel
0.04% (Retin-a micro)
triamcinolone acetonide
cream 0.5%
triamcinolone acetonide
lotion 0.1%
4
1
triamcinolone acetonide
cream 0.1%
Drug Name
VALCHLOR - mechlorethamine
hcl gel 0.016% (base
equivalent)
tretinoin gel 0.05%
(ATRALIN)
tretinoin microsphere gel
0.1% (Retin-a micro)
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
176
XYLOCAINE - lidocaine hcl
soln 4%
3
ZIANA - clindamycin
phosphate-tretinoin gel
1.2-0.025%
3
ZONALON - doxepin hcl cream
5%
3
•
ZOVIRAX - acyclovir cream 5% 3
3
ZOVIRAX - acyclovir oint 5%
Limited Distribution
JADENU - deferasirox tab 180
mg
4
•
JADENU - deferasirox tab 360
mg
4
•
naltrexone hcl tab 50 mg
(Revia)
1
3
3
ZYCLARA PUMP - imiquimod
cream 2.5%
3
RADIOGARDASE - prussian
blue insoluble cap 0.5 gm
3
ZYCLARA PUMP - imiquimod
cream 3.75%
3
REVIA - naltrexone hcl tab 50
mg
8-MOP - methoxsalen cap 10
mg
3
DIAGNOSTIC PRODUCTS
ACCU-CHEK ACTIVE
STRIPS - glucose blood test
strip
2
•
ACCU-CHEK AVIVA - glucose
blood test strip
2
•
ACCU-CHEK AVIVA PLUS glucose blood test strip
2
•
ACCU-CHEK COMFORT
CURVE T - glucose blood
test strip
2
•
ACCU-CHEK COMPACT
PLUS - glucose blood test
strip
2
•
ACCU-CHEK COMPACT
STRIPS - glucose blood test
strip
2
•
ACCU-CHEK COMPACT
TEST DR - glucose blood
test strip
2
•
2
•
CHEMET - succimer cap 100
mg
2
EVZIO - naloxone hcl solution
auto-injector 0.4 mg/0.4ml
3
EXJADE - deferasirox tab for
oral susp 125 mg
4
•
EXJADE - deferasirox tab for
oral susp 250 mg
4
•
EXJADE - deferasirox tab for
oral susp 500 mg
4
•
ACCU-CHEK SMARTVIEW
STRIP - glucose blood test
strip
FERRIPROX - deferiprone oral
soln 100 mg/ml
4
•
ACCUTREND GLUCOSE glucose blood test strip
2
•
FERRIPROX - deferiprone tab
500 mg
4
•
ASCENSIA AUTODISC TEST
ST - glucose blood test disk
2
•
•
ACA Preventive
•
3
ANTIDOTES
Dispensing Limits
4
ZYCLARA - imiquimod cream
3.75%
ANTISEPTICS & DISINFECTANTS
3
IODINE TINCTURE MILD iodine tincture
IODINE TINCTURE STRONG - 3
iodine tincture strong
3
IODINE TINCTURE STRONG
DE - iodine tincture strong
Step Therapy
JADENU - deferasirox tab 90
mg
NARCAN - naloxone hcl nasal
spray 4 mg/0.1ml
MISCELLANEOUS PRODUCTS
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
177
2
GLUCAGEN DIAGNOSTIC glucagon hcl (rdna)
diagnostic for inj 1 mg (base
equiv)
3
GLUCOSE BLOOD TEST
STRIPS VARIOUS
3
CHEMICALS
DENATURED ALCOHOL alcohol, rubbing 95%
MEDICAL DEVICES
3
ACCU-CHEK ACTIVE
GLUCOSE - blood glucose
calibration - liquid
2
ACCU-CHEK AVIVA - blood
glucose calibration - liquid
2
ACCU-CHEK AVIVA
CONNECT - blood glucose
monitoring kit w/ device
2
ACCU-CHEK AVIVA PLUS blood glucose monitoring kit
w/ device
2
ACCU-CHEK COMFORT
CURVE C - blood glucose
calibration - liquid
2
ACCU-CHEK COMFORT
CURVE L - blood glucose
calibration - liquid
2
ACCU-CHEK COMPACT
BLUE CO - blood glucose
calibration - liquid
2
ACCU-CHEK COMPACT
PLUS CA - blood glucose
monitoring kit
2
•
• •
2
ACCU-CHEK INSTANT
GLUCOSE - blood glucose
calibration - liquid
2
ACCU-CHEK MULTICLIX
LANCE - lancets
2
Limited Distribution
BAYER CONTOUR NEXT
BLOOD - glucose blood test
strip
ACCU-CHEK FASTCLIX
LANCET - lancets
ACA Preventive
•
Dispensing Limits
2
2
Step Therapy
BAYER CONTOUR BLOOD
GLUCO - glucose blood test
strip
ACCU-CHEK COMPACT
PLUS CL - blood glucose
calibration - liquid
Prior Authorization
•
Drug Name
Drug Tier
2
Limited Distribution
BAYER BREEZE 2 TEST
DISC - glucose blood test
disk
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
2
ACCU-CHEK NANO
SMARTVIEW - blood glucose
monitoring kit w/ device
2
ACCU-CHEK SAFE-T-PRO
LANC - lancets
2
ACCU-CHEK SAFE-T-PRO
PLUS - lancets
2
ACCU-CHEK SMARTVIEW
CONTR - blood glucose
calibration - liquid
2
ACCU-CHEK SOFT TOUCH
LANC - lancets
2
ACCU-CHEK SOFTCLIX
LANCET - lancets
2
ACCU-CHEK VOICEMATE blood glucose monitoring kit
w/ device
2
ACCUTREND GLUCOSE
CONTROL - blood glucose
calibration - liquid
3
ACURA BLOOD GLUCOSE
MONIT - blood glucose
monitoring kit w/ device
3
ACURA PLUS BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
3
ADVANCE INTUITION
BLOOD G - blood glucose
monitoring devices
3
ADVANCE INTUITION
BLOOD G - blood glucose
monitoring kit w/ device
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
178
ADVANCE MICRO-DRAW
METER - blood glucose
monitoring devices
3
ASSURE PLATINUM BLOOD
GLU - blood glucose
monitoring devices
3
ADVOCATE BLOOD
GLUCOSE MO - blood
glucose monitoring devices
3
ASSURE PRISM MULTI
BLOOD - blood glucose
monitoring devices
3
ADVOCATE BLOOD
GLUCOSE MO - blood
glucose monitoring kit w/
device
3
ASSURE PRO BLOOD
GLUCOSE - blood glucose
monitoring devices
3
ASSURE 3 METER - blood
glucose monitoring kit
3
ADVOCATE REDI-CODE blood glucose monitoring
devices
3
3
ADVOCATE REDI-CODE
+ BLOOD - blood glucose
monitoring devices
3
ASSURE 4 BLOOD
GLUCOSE ME - blood
glucose monitoring devices
3
ADVOCATE REDI-CODE
+/ TALK - blood glucose
monitoring kit w/ device
3
AT LAST BLOOD GLUCOSE
SYS - blood glucose
monitoring kit
2
ADVOCATE REDI-CODE/
TALKIN - blood glucose
monitoring devices
3
BAYER BREEZE 2 BLOOD
GLUC - blood glucose
monitoring kit w/ device
2
ADVOCATE REDI-CODE/
TALKIN - blood glucose
monitoring kit w/ device
3
BAYER BREEZE 2 HIGH
CONTR - blood glucose
calibration - liquid - high
2
AGAMATRIX AMP NO
CODE ADV - blood glucose
monitoring devices
3
BAYER BREEZE 2 LOW
CONTRO - blood glucose
calibration - liquid - low
2
AGAMATRIX JAZZ - blood
glucose monitoring kit w/
device
3
BAYER BREEZE 2 NORMAL
CON - blood glucose
calibration - liquid - normal
2
AGAMATRIX PRESTO - blood
glucose monitoring kit w/
device
3
BAYER CONTOUR BLOOD
GLUCO - blood glucose
monitoring devices
2
AGAMATRIX PRESTO PRO
METE - blood glucose
monitoring devices
3
BAYER CONTOUR BLOOD
GLUCO - blood glucose
monitoring kit w/ device
2
ASCENSIA AUTODISC
LOW AND - blood glucose
calibration - liquid
2
BAYER CONTOUR HIGH
CONTRO - blood glucose
calibration - liquid - high
2
ASCENSIA AUTODISC
NORMAL - blood glucose
calibration - liquid - normal
2
BAYER CONTOUR LINK
BLOOD - blood glucose
monitoring kit w/ device
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
179
BAYER CONTOUR LOW
CONTROL - blood glucose
calibration - liquid - low
2
BLOOD GLUCOSE
CALIBRATION LIQUID
VARIOUS
3
BAYER CONTOUR NEXT
BLOOD - blood glucose
monitoring kit w/ device
2
3
BAYER CONTOUR NEXT
CONTRO - blood glucose
calibration - liquid - low
2
BLOOD GLUCOSE
MONITORING - blood
glucose monitoring kit w/
device
3
BAYER CONTOUR NEXT
CONTRO - blood glucose
calibration - liquid - normal
2
BLOOD GLUCOSE SYSTEM
PAK - blood glucose
monitoring kit w/ device
2
BAYER CONTOUR NEXT
EZ BLO - blood glucose
monitoring kit w/ device
2
BREEZE 2 BLOOD
GLUCOSE MO - blood
glucose monitoring devices
3
BAYER CONTOUR NEXT
LINK B - blood glucose
monitoring kit w/ device
2
CAREONE BLOOD
GLUCOSE MON - blood
glucose monitoring kit w/
device
3
BAYER CONTOUR NEXT
LINK W - blood glucose
monitoring kit w/ device
2
CARESENS N BLOOD
GLUCOSE - blood glucose
monitoring devices
3
BAYER CONTOUR NEXT
USB BL - blood glucose
monitoring kit w/ device
2
CARESENS N GLUCOSE
MONITO - blood glucose
monitoring devices
3
BAYER CONTOUR NORMAL
CONT - blood glucose
calibration - liquid - normal
2
CARESENS N VOICE
BLOOD GL - blood glucose
monitoring devices
CAYA - diaphragm arc-spring
NA
BAYER CONTOUR USB
BLOOD G - blood glucose
monitoring kit w/ device
2
CHEMSTRIP BG LOG BOOK blood glucose monitoring
misc.
3
BAYER MICROLET
LANCETS - lancets
2
3
BD LATITUDE DIABETES
MANA - blood glucose
monitoring kit w/ device
3
CHOICE DM DIABETES RISK
I - blood glucose monitoring
kit
3
BD LOGIC BLOOD GLUCOSE
MO - blood glucose
monitoring kit w/ device
3
CHOICE DM FORA G20
BLOOD - blood glucose
monitoring devices
3
BD MAGNI-GUIDE
MAGNIFIER - blood glucose
monitoring supplies
3
CLEVER CHEK AUTO
CODE VOI - blood glucose
monitoring devices
CLEVER CHEK AUTOCODE BLO - blood glucose
monitoring devices
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
180
CLEVER CHEK AUTOCODE VOI - blood glucose
monitoring devices
3
CLEVER CHEK BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
3
CLEVER CHOICE AUTOCODE P - blood glucose
monitoring devices
3
CLEVER CHOICE MICRO
BLOOD - blood glucose
monitoring kit w/ device
3
CLEVER CHOICE MINI
BLOOD - blood glucose
monitoring devices
3
COAGUCHEK LANCETS lancets
2
CONTROL BLOOD
GLUCOSE MON - blood
glucose monitoring kit w/
device
3
CVS ADVANCED GLUCOSE
METE - blood glucose
monitoring kit w/ device
3
DIDGET - blood glucose
monitoring kit w/ device
2
3
EASY PLUS BLOOD
GLUCOSE M - blood glucose
monitoring devices
3
EASY PLUS BLOOD
GLUCOSE M - blood glucose
monitoring kit w/ device
3
EASY PLUS II BLOOD
GLUCOS - blood glucose
monitoring devices
3
EASY STEP BLOOD
GLUCOSE M - blood glucose
monitoring devices
3
EASY STEP BLOOD
GLUCOSE M - blood glucose
monitoring kit w/ device
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
3
EASY TALK BLOOD
GLUCOSE M - blood glucose
monitoring devices
3
EASY TALK BLOOD
GLUCOSE M - blood glucose
monitoring kit w/ device
3
EASY TOUCH GLUCOSE
MONITO - blood glucose
monitoring kit w/ device
3
EASY TOUCH HEALTHPRO
GLUC - blood glucose
monitoring kit w/ device
3
EASY TRAK BLOOD
GLUCOSE M - blood glucose
monitoring devices
3
EASY TRAK BLOOD
GLUCOSE M - blood glucose
monitoring kit w/ device
3
EASYGLUCO - blood glucose
monitoring kit
3
EASYGLUCO VALUE PACK blood glucose monitoring kit
3
EASYMAX L BLOOD
GLUCOSE S - blood glucose
monitoring devices
3
EASYMAX L BLOOD
GLUCOSE S - blood glucose
monitoring kit w/ device
3
EASYMAX N BLOOD
GLUCOSE S - blood glucose
monitoring devices
3
EASYMAX N BLOOD
GLUCOSE S - blood glucose
monitoring kit w/ device
3
EASYMAX NG SELFMONITORIN - blood glucose
monitoring devices
3
EASYMAX NG SELFMONITORIN - blood glucose
monitoring kit w/ device
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
181
EASYMAX V BLOOD
GLUCOSE S - blood glucose
monitoring devices
3
EMBRACE PRO BLOOD
GLUCOSE - blood glucose
monitoring devices
3
EASYMAX V BLOOD
GLUCOSE S - blood glucose
monitoring kit w/ device
3
EQL TRUE2GO BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
3
EASYMAX V2 SELFMONITORIN - blood glucose
monitoring devices
3
EVENCARE BLOOD
GLUCOSE MO - blood
glucose monitoring kit
3
EASYMAX V2 SELFMONITORIN - blood glucose
monitoring kit w/ device
3
EVENCARE G2 BLOOD
GLUCOSE - blood glucose
monitoring devices
3
EASYPLUS R13N SELFMONITO - blood glucose
monitoring kit w/ device
3
EVENCARE G3 BLOOD
GLUCOSE - blood glucose
monitoring devices
3
EASYPLUS V SELFMONITORIN - blood glucose
monitoring kit w/ device
3
EVENCARE MINI BLOOD
GLUCO - blood glucose
monitoring devices
3
EASYPRO BLOOD
GLUCOSE MON - blood
glucose monitoring kit w/
device
3
EVOLUTION AUTOCODE blood glucose monitoring
devices
3
EZ SMART DIABETES
MONITOR - blood glucose
monitoring devices
3
EASYPRO PLUS - blood
glucose monitoring kit w/
device
3
EZ SMART PLUS DIABETES
MO - blood glucose
monitoring devices
3
ELEMENT AUTOCODE
SYSTEM - blood glucose
monitoring kit w/ device
3
3
FASTTAKE COMPACT
MONITORI - blood glucose
monitoring kit w/ device
3
ELEMENT COMPACT
BLOOD GLU - blood glucose
monitoring devices
FC FEMALE CONDOM condoms - female
NA
ELEMENT COMPACT V
BLOOD - blood glucose
monitoring devices
3
•
NA
•
ELEMENT PLUS BLOOD
GLUCOS - blood glucose
monitoring devices
3
FC2 FEMALE CONDOM condoms - female
EMBRACE BLOOD
GLUCOSE MON - blood
glucose monitoring devices
3
EMBRACE EVO BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
3
FIFTY50 GLUCOSE
METER 2.0 - blood glucose
monitoring kit w/ device
3
FINGERSTIX LANCETS lancets
2
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
3
FORA GD20 BLOOD
GLUCOSE M - blood glucose
monitoring devices
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
182
3
FORA GD50 BLOOD
GLUCOSE M - blood glucose
monitoring devices
3
FORA G20 BLOOD
GLUCOSE MO - blood
glucose monitoring kit w/
device
3
FORA G30A BLOOD
GLUCOSE M - blood glucose
monitoring devices
3
FORA G71A BLOOD
GLUCOSE M - blood glucose
monitoring kit w/ device
3
FORA G90 BLOOD
GLUCOSE MO - blood
glucose monitoring devices
3
FORA TEST N' GO VOICE
BLO - blood glucose
monitoring devices
3
FORA TN'G VOICE BLOOD
GLU - blood glucose
monitoring kit w/ device
3
FORA V10 BLOOD
GLUCOSE MO - blood
glucose monitoring devices
3
FORA V10/V12/D10/D20
BLOO - blood glucose
monitoring kit
3
FORA V12 BLOOD
GLUCOSE MO - blood
glucose monitoring devices
3
FORA V20 BLOOD
GLUCOSE MO - blood
glucose monitoring devices
3
FORA V22 BLOOD
GLUCOSE MO - blood
glucose monitoring kit w/
device
3
FORA V30A BLOOD
GLUCOSE M - blood glucose
monitoring devices
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
3
FORA V30A BLOOD
GLUCOSE M - blood glucose
monitoring kit w/ device
3
FORACARE GD40 BLOOD
GLUCO - blood glucose
monitoring devices
3
FORACARE PREMIUM
V10 BLOO - blood glucose
monitoring devices
3
FORACARE TEST N GO
BLOOD - blood glucose
monitoring devices
3
FORTISCARE SELFMONITORIN - blood glucose
monitoring kit w/ device
3
FREESTYLE FLASH
SYSTEM - blood glucose
monitoring kit
3
FREESTYLE FREEDOM blood glucose monitoring kit
w/ device
3
FREESTYLE FREEDOM
LITE - blood glucose
monitoring kit w/ device
3
FREESTYLE INSULINX
BLOOD - blood glucose
monitoring kit w/ device
3
FREESTYLE LITE BLOOD
GLUC - blood glucose
monitoring devices
3
FREESTYLE PRECISION
NEO B - blood glucose
monitoring kit w/ device
3
FREESTYLE SIDEKICK
II VAL - blood glucose
monitoring kit w/ device
3
FREESTYLE SYSTEM KIT blood glucose monitoring kit
3
GE100 BLOOD GLUCOSE
MONIT - blood glucose
monitoring kit w/ device
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
183
GHT BLOOD GLUCOSE
MONITO - blood glucose
monitoring kit w/ device
3
GMATE ORIGIN BLOOD
GLUCOS - blood glucose
monitoring devices
3
GLUCO PERFECT 3 BLOOD
GLU - blood glucose
monitoring devices
3
GMATE SMART METER KIT blood glucose monitoring
devices
3
GLUCOCARD EXPRESSION
AUDI - blood glucose
monitoring kit w/ device
3
GMATE SMART STARTER
KIT - blood glucose
monitoring kit w/ device
3
GLUCOCARD SHINE - blood
glucose monitoring devices
3
3
GLUCOCARD SHINE - blood
glucose monitoring kit w/
device
3
GMATE VOICE BLOOD
GLUCOSE - blood glucose
monitoring devices
3
GLUCOCARD VITAL BLOOD
GLU - blood glucose
monitoring kit w/ device
3
IBG STAR BLOOD GLUCOSE
MO - blood glucose
monitoring kit w/ device
IN TOUCH - blood glucose
monitoring devices
3
GLUCOCARD X-METER blood glucose monitoring kit
w/ device
3
IN TOUCH DIABETES
MANAGEM - blood glucose
monitoring misc.
3
GLUCOCARD 01 BLOOD
GLUCOS - blood glucose
monitoring devices
3
INFINITY BLOOD GLUCOSE
MO - blood glucose
monitoring kit w/ device
3
GLUCOCARD 01 BLOOD
GLUCOS - blood glucose
monitoring kit w/ device
3
INSUL-TOTE - blood glucose
monitoring supplies
3
INSUL-TOTE JR - blood
glucose monitoring supplies
3
GLUCOCARD 01-MINI
BLOOD G - blood glucose
monitoring kit w/ device
3
3
GLUCOCOM AUTOLINK
TELEMON - blood glucose
monitoring misc.
3
KROGER BLOOD GLUCOSE
MONI - blood glucose
monitoring kit w/ device
3
GLUCOCOM BLOOD
GLUCOSE MO - blood
glucose monitoring devices
3
KROGER PREMIUM BLOOD
GLUC - blood glucose
monitoring kit w/ device
3
GLUCOCOM BLOOD
GLUCOSE MO - blood
glucose monitoring kit w/
device
3
LDR BLOOD GLUCOSE
TRUETES - blood glucose
monitoring kit w/ device
3
GLUCONAVII BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
3
LIBERTY BLOOD GLUCOSE
MET - blood glucose
monitoring devices
LIBERTY BLOOD GLUCOSE
MON - blood glucose
monitoring devices
3
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
184
LIBERTY NEXT
GENERATION B - blood
glucose monitoring devices
3
MAXIMA BLOOD GLUCOSE
MONI - blood glucose
monitoring kit w/ device
3
MAXIMA METER KIT - blood
glucose monitoring kit w/
device
3
MAXIMA STARTER KIT - blood 3
glucose monitoring kit w/
device
3
MEIJER BLOOD GLUCOSE
MONI - blood glucose
monitoring kit w/ device
3
MEIJER ESSENTIAL
BLOOD GL - blood glucose
monitoring kit w/ device
3
MEIJER PREMIUM BLOOD
GLUC - blood glucose
monitoring kit w/ device
3
MEIJER TRUERESULT
BLOOD G - blood glucose
monitoring kit w/ device
3
MEIJER TRUETRACK
BLOOD GL - blood glucose
monitoring kit w/ device
3
MEIJER TRUE2GO BLOOD
GLUC - blood glucose
monitoring kit w/ device
3
MICRODOT BLOOD
GLUCOSE MO - blood
glucose monitoring kit w/
device
2
MICROLET LANCETS lancets
2
MONOJECT INSULIN
SYRINGE - insulin syringe
(disp) u-100 1 ml
2
MONOJECT INSULIN
SYRINGE/ - insulin syringe
(disp) u-100 1 ml
MONOJECT INSULIN
SYRINGE/ - insulin syringe/
needle u-100 0.3 ml 29 x
1/2"
2
MONOJECT INSULIN
SYRINGE/ - insulin syringe/
needle u-100 0.3 ml 30 x
5/16"
2
MONOJECT INSULIN
SYRINGE/ - insulin syringe/
needle u-100 1/2 ml 28 x
1/2"
2
MONOJECT INSULIN
SYRINGE/ - insulin syringe/
needle u-100 1/2 ml 29 x
1/2"
2
MONOJECT INSULIN
SYRINGE/ - insulin syringe/
needle u-100 1/2 ml 30 x
5/16"
2
MONOJECT INSULIN
SYRINGE/ - insulin syringe/
needle u-100 1 ml 25 x 5/8"
2
MONOJECT INSULIN
SYRINGE/ - insulin syringe/
needle u-100 1 ml 27 x 1/2"
2
MONOJECT INSULIN
SYRINGE/ - insulin syringe/
needle u-100 1 ml 28 x 1/2"
2
MONOJECT INSULIN
SYRINGE/ - insulin syringe/
needle u-100 1 ml 29 x 1/2"
2
MONOJECT INSULIN
SYRINGE/ - insulin syringe/
needle u-100 1 ml 30 x 5/16"
2
MONOJECT INSULIN
SYRINGE/ - insulin syringe/
needle u-100 1 ml 31 x 5/16"
2
MONOJECT ULTRA
COMFORT IN - insulin
syringe/needle u-100 0.3 ml
29 x 1/2"
2
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
185
MONOJECT ULTRA
COMFORT IN - insulin
syringe/needle u-100 0.3 ml
30 x 5/16"
2
MONOJECT ULTRA
COMFORT IN - insulin
syringe/needle u-100 1/2 ml
31 x 5/16"
2
MONOJECT ULTRA
COMFORT IN - insulin
syringe/needle u-100 1/2 ml
28 x 1/2"
2
MONOJECT ULTRA
COMFORT IN - insulin
syringe/needle u-100 1/2 ml
29 x 1/2"
2
MONOJECT ULTRA
COMFORT IN - insulin
syringe/needle u-100 1/2 ml
30 x 5/16"
2
MONOJECT ULTRA
COMFORT IN - insulin
syringe/needle u-100 1 ml
28 x 1/2"
2
MONOJECT ULTRA
COMFORT IN - insulin
syringe/needle u-100 1 ml
29 x 1/2"
2
MONOJECT ULTRA
COMFORT IN - insulin
syringe/needle u-100 1 ml
30 x 5/16"
2
MONOJECT ULTRA
COMFORT IN - insulin
syringe/needle u-100 0.3 ml
31 x 5/16"
2
MYGLUCOHEALTH BLOOD
GLUCO - blood glucose
monitoring kit w/ device
3
NEXGEN METER KIT - blood
glucose monitoring kit
3
NOVA MAX BLOOD
GLUCOSE MO - blood
glucose monitoring devices
3
NOVA MAX BLOOD
GLUCOSE MO - blood
glucose monitoring kit w/
device
3
OMNIFLEX DIAPHRAGM diaphragms
NA
ON CALL EXPRESS BLOOD
GLU - blood glucose
monitoring devices
3
ON CALL EXPRESS BLOOD
GLU - blood glucose
monitoring kit w/ device
3
ON CALL PLUS BLOOD
GLUCOS - blood glucose
monitoring devices
3
ON CALL PLUS BLOOD
GLUCOS - blood glucose
monitoring kit w/ device
3
ON CALL VIVID BLOOD
GLUCO - blood glucose
monitoring devices
3
ON CALL VIVID BLOOD
GLUCO - blood glucose
monitoring kit w/ device
3
ON CALL VIVID PAL BLOOD
G - blood glucose monitoring
devices
3
ON CALL VIVID PAL BLOOD
G - blood glucose monitoring
kit w/ device
3
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
ONETOUCH BASIC SYSTEM - 3
blood glucose monitoring kit
w/ device
3
ONETOUCH PING METER
REMOT - blood glucose
monitoring supplies
3
ONETOUCH PROFILE
SYSTEM - blood glucose
monitoring kit w/ device
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
186
ONETOUCH ULTRA MINI blood glucose monitoring kit
w/ device
3
ONETOUCH ULTRA SYSTEM
KIT - blood glucose
monitoring kit w/ device
3
ONETOUCH ULTRA 2 - blood
glucose monitoring kit w/
device
3
ONETOUCH ULTRALINK
SYSTEM - blood glucose
monitoring kit w/ device
3
ONETOUCH ULTRASMART blood glucose monitoring kit
w/ device
3
ONETOUCH VERIO - blood
glucose monitoring kit w/
device
3
ONETOUCH VERIO FLEX
BLOOD - blood glucose
monitoring kit w/ device
3
ONETOUCH VERIO IQ
BLOOD G - blood glucose
monitoring kit w/ device
3
ONETOUCH VERIO SYNC
BLOOD - blood glucose
monitoring kit w/ device
3
OPTIUM BLOOD GLUCOSE
MONI - blood glucose
monitoring devices
3
OPTIUM BLOOD GLUCOSE
MONI - blood glucose
monitoring kit w/ device
3
OPTUMRX BLOOD
GLUCOSE MET - blood
glucose monitoring kit w/
device
3
OPTUMRX BLOOD
GLUCOSE MON - blood
glucose monitoring kit w/
device
3
NA
ORTHO DIAPHRAGM COIL
SPRI - diaphragm coil spring
kit 50 mm
NA
ORTHO DIAPHRAGM COIL
SPRI - diaphragm coil spring
kit 100 mm
NA
ORTHO DIAPHRAGM COIL
SPRI - diaphragm coil spring
kit 105 mm
NA
ORTHO DIAPHRAGM FLAT
SPRI - diaphragm flat spring
kit 55 mm
NA
ORTHO DIAPHRAGM FLAT
SPRI - diaphragm flat spring
kit 60 mm
NA
ORTHO DIAPHRAGM FLAT
SPRI - diaphragm flat spring
kit 65 mm
NA
ORTHO DIAPHRAGM FLAT
SPRI - diaphragm flat spring
kit 70 mm
NA
ORTHO DIAPHRAGM FLAT
SPRI - diaphragm flat spring
kit 75 mm
NA
ORTHO DIAPHRAGM FLAT
SPRI - diaphragm flat spring
kit 80 mm
NA
ORTHO DIAPHRAGM FLAT
SPRI - diaphragm flat spring
kit 85 mm
NA
ORTHO DIAPHRAGM FLAT
SPRI - diaphragm flat spring
kit 90 mm
NA
ORTHO DIAPHRAGM FLAT
SPRI - diaphragm flat spring
kit 95 mm
3
PARADIGM LINK BLOOD
GLUCO - blood glucose
monitoring kit w/ device
3
PEN-TOTE - blood glucose
monitoring supplies
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
•
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
•
187
PHARMACIST CHOICE
AUTOCOD - blood glucose
monitoring kit w/ device
3
RA TRUERESULT BLOOD
GLUCO - blood glucose
monitoring kit w/ device
3
POCKETCHEM EZ BLOOD
GLUCO - blood glucose
monitoring kit w/ device
3
RA TRUE2GO BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
3
PRECISION LINK - blood
glucose monitoring kit w/
device
3
REALITY INSULIN SYRINGE/
U - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"
2
PRECISION QID MONITOR blood glucose monitoring
devices
3
REALITY INSULIN SYRINGE/
U - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"
2
PRECISION SOF-TACT
MONITO - blood glucose
monitoring devices
3
REALITY INSULIN SYRINGE/
U - insulin syringe/needle
u-100 1 ml 28 x 1/2"
2
PRECISION XTRA - blood
glucose monitoring devices
3
2
PRECISION XTRA - blood
glucose monitoring kit
3
REALITY INSULIN SYRINGE/
U - insulin syringe/needle
u-100 1 ml 29 x 1/2"
REFUAH PLUS BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
3
RELION CONFIRM BLOOD
GLUC - blood glucose
monitoring kit w/ device
3
RELION MICRO BLOOD
GLUCOS - blood glucose
monitoring kit w/ device
3
RELION PRIME BLOOD
GLUCOS - blood glucose
monitoring devices
3
RELION ULTIMA BLOOD
GLUCO - blood glucose
monitoring kit w/ device
3
REVEAL BLOOD GLUCOSE
MONI - blood glucose
monitoring kit w/ device
3
REXALL BLOOD GLUCOSE
MONI - blood glucose
monitoring kit w/ device
3
RIGHTEST GM100 BLOOD
GLUC - blood glucose
monitoring kit w/ device
3
PRECISION XTRA MONITOR - 3
blood glucose monitoring
devices
3
PRODIGY AUTOCODE
BLOOD GL - blood glucose
monitoring devices
3
PRODIGY AUTOCODE
BLOOD GL - blood glucose
monitoring kit w/ device
3
PRODIGY POCKET BLOOD
GLUC - blood glucose
monitoring kit w/ device
3
PRODIGY VOICE BLOOD
GLUCO - blood glucose
monitoring kit w/ device
3
QUICKTEK - blood glucose
monitoring kit w/ device
3
QUICKTEK - blood glucose
monitoring kit
3
RA BLOOD GLUCOSE
MONITOR - blood glucose
monitoring devices
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
188
RIGHTEST GM300 BLOOD
GLUC - blood glucose
monitoring kit w/ device
3
SOLUS V2 AUDIBLE
BLOOD GL - blood glucose
monitoring kit w/ device
3
RIGHTEST GM550 BLOOD
GLUC - blood glucose
monitoring kit w/ device
3
SUPREME II CONFIDENCE
PAD - blood glucose
monitoring misc.
3
RIGHTSOURCE BLOOD
GLUCOSE - blood glucose
monitoring devices
3
SINGLE-LET - lancets
2
SMART DIABETES XPRES
BLOO - blood glucose
monitoring kit w/ device
3
SMART SENSE PREMIUM
BLOOD - blood glucose
monitoring kit w/ device
3
SMART SENSE VALUE
BLOOD - blood glucose
monitoring kit w/ device
3
SMARTEST EJECT BLOOD
GLUC - blood glucose
monitoring devices
3
SMARTEST EJECT STARTER
KI - blood glucose monitoring
kit w/ device
3
SMARTEST PERSONA
STARTER - blood glucose
monitoring kit w/ device
3
SMARTEST PRONTO
STARTER - blood glucose
monitoring kit w/ device
3
SMARTEST PROTEGE
BLOOD GL - blood glucose
monitoring devices
3
SMARTEST PROTEGE
STARTER - blood glucose
monitoring kit w/ device
3
SOLUS V2 AUDIBLE
BLOOD GL - blood glucose
monitoring devices
3
3
SURE EDGE BLOOD
GLUCOSE M - blood glucose
monitoring devices
SURE-TEST EASYPLUS MINI 3
S - blood glucose monitoring
devices
3
SURECHEK BLOOD
GLUCOSE MO - blood
glucose monitoring devices
3
SURECHEK BLOOD
GLUCOSE MO - blood
glucose monitoring kit w/
device
3
SURESTEP PRO LINEARITY
KI - blood glucose monitoring
misc.
TELCARE BLOOD GLUCOSE 3
MON - blood glucose
monitoring kit w/ device
3
TGT BLOOD GLUCOSE
METER M - blood glucose
monitoring kit w/ device
3
TGT BLOOD GLUCOSE
MONITOR - blood glucose
monitoring kit w/ device
TRACER II 3 VOLT BATTERY - 3
blood glucose monitoring
misc.
3
TRUE METRIX AIR BLOOD
GLU - blood glucose
monitoring devices
3
TRUE METRIX AIR BLOOD
GLU - blood glucose
monitoring kit w/ device
3
TRUE METRIX BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
189
3
WAVESENSE KEYNOTE
PRO MET - blood glucose
monitoring devices
3
3
TRUETRACK BLOOD
GLUCOSE M - blood glucose
monitoring devices
3
TRUETRACK BLOOD
GLUCOSE M - blood glucose
monitoring kit w/ device
3
TRUETRACK SMART
SYSTEM - blood glucose
monitoring kit w/ device
3
TRUE2GO BLOOD
GLUCOSE MON - blood
glucose monitoring kit w/
device
3
ULTIMA - blood glucose
monitoring kit
3
ULTRA TRAK PRO BLOOD
GLUC - blood glucose
monitoring kit w/ device
3
ULTRATRAK ACTIVE - blood
glucose monitoring devices
3
ULTRATRAK PRO - blood
glucose monitoring devices
3
ULTRATRAK ULTIMATE
MONITO - blood glucose
monitoring devices
3
VICTORY BLOOD GLUCOSE
MON - blood glucose
monitoring devices
3
VOCAL POINT BLOOD
GLUCOSE - blood glucose
monitoring devices
3
WAVESENSE AMP - blood
glucose monitoring kit w/
device
3
WAVESENSE KEYNOTE blood glucose monitoring kit
w/ device
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 60 mm
NA
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 65 mm
NA
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 70 mm
NA
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 75 mm
NA
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 80 mm
NA
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 85 mm
NA
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 90 mm
NA
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 95 mm
NA
•
TRUERESULT BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
ASSORTED CLASSES
AMMONIA AROMATIC
INHALANT - ammonia
aromatic spirit
3
ASTAGRAF XL - tacrolimus
cap sr 24hr 0.5 mg
3
ASTAGRAF XL - tacrolimus
cap sr 24hr 1 mg
3
ASTAGRAF XL - tacrolimus
cap sr 24hr 5 mg
3
AZASAN - azathioprine tab 75
mg
3
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
AZASAN - azathioprine tab 100 3
mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
190
azathioprine tab 50 mg
(Imuran)
1
CELLCEPT - mycophenolate
mofetil cap 250 mg
3
CELLCEPT - mycophenolate
mofetil for oral susp 200 mg/
ml
3
CELLCEPT - mycophenolate
mofetil tab 500 mg
3
CELLCEPT INTRAVENOUS mycophenolate mofetil hcl
for iv soln 500 mg (base
equiv)
3
CUPRIMINE - penicillamine
cap 250 mg
4
cyclosporine cap 25 mg
(Sandimmune)
1
cyclosporine cap 100 mg
(Sandimmune)
mycophenolate mofetil cap
250 mg (Cellcept)
•
1
mycophenolate mofetil tab
500 mg (Cellcept)
1
mycophenolate sodium tab
dr 360 mg (mycophenolic
acid equiv) (Myfortic)
3
1
MYFORTIC - mycophenolate
sodium tab dr 360 mg
(mycophenolic acid equiv)
CYCLOSPORINE MODIFIED cyclosporine modified cap
50 mg
2
NEORAL - cyclosporine
modified cap 25 mg
3
3
cyclosporine modified cap
25 mg (Neoral)
1
NEORAL - cyclosporine
modified cap 100 mg
3
1
NEORAL - cyclosporine
modified oral soln 100 mg/ml
1
DEPEN TITRATABS penicillamine tab 250 mg
4
ENVARSUS XR - tacrolimus
tab sr 24hr 0.75 mg
3
ENVARSUS XR - tacrolimus
tab sr 24hr 1 mg
3
ENVARSUS XR - tacrolimus
tab sr 24hr 4 mg
3
IMURAN - azathioprine tab 50
mg
3
KAYEXALATE - sodium
polystyrene sulfonate
powder
3
•
Limited Distribution
ACA Preventive
1
3
cyclosporine modified oral
soln 100 mg/ml (Neoral)
Dispensing Limits
1
MYFORTIC - mycophenolate
sodium tab dr 180 mg
(mycophenolic acid equiv)
cyclosporine modified cap
100 mg (Neoral)
Step Therapy
1
mycophenolate mofetil
for oral susp 200 mg/ml
(Cellcept)
mycophenolate sodium tab
dr 180 mg (mycophenolic
acid equiv) (Myfortic)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
PROGRAF - tacrolimus cap 0.5 3
mg
3
PROGRAF - tacrolimus cap 1
mg
3
PROGRAF - tacrolimus cap 5
mg
2
PROGRAF - tacrolimus inj 5
mg/ml
2
RAPAMUNE - sirolimus oral
soln 1 mg/ml
RAPAMUNE - sirolimus tab 0.5 3
mg
3
RAPAMUNE - sirolimus tab 1
mg
3
RAPAMUNE - sirolimus tab 2
mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
191
•
•
•
•
•
•
•
•
•
•
•
•
•
Limited Distribution
•
THALOMID - thalidomide cap
50 mg
4
•
THALOMID - thalidomide cap
100 mg
4
•
•
•
THALOMID - thalidomide cap
150 mg
4
•
•
•
THALOMID - thalidomide cap
200 mg
4
•
•
•
VELTASSA - patiromer sorbitex 3
calcium for susp packet 8.4
gm (base eq)
VELTASSA - patiromer sorbitex 3
calcium for susp packet 16.8
gm (base eq)
VELTASSA - patiromer sorbitex 3
calcium for susp packet 25.2
gm (base eq)
2
ZORTRESS - everolimus tab
0.25 mg
2
ZORTRESS - everolimus tab
0.5 mg
2
ZORTRESS - everolimus tab
0.75 mg
•
ACA Preventive
•
Dispensing Limits
REVLIMID - lenalidomide cap 5 4
mg
4
REVLIMID - lenalidomide cap
10 mg
4
REVLIMID - lenalidomide cap
15 mg
4
REVLIMID - lenalidomide cap
20 mg
4
REVLIMID - lenalidomide cap
25 mg
3
SANDIMMUNE - cyclosporine
cap 25 mg
3
SANDIMMUNE - cyclosporine
cap 100 mg
2
SANDIMMUNE - cyclosporine
oral soln 100 mg/ml
1
sirolimus tab 0.5 mg
(Rapamune)
1
sirolimus tab 1 mg
(Rapamune)
1
sirolimus tab 2 mg
(Rapamune)
1
sodium polystyrene
sulfonate oral susp
15 gm/60ml (Sps)
1
sodium polystyrene
sulfonate powder
(Kayexalate)
1
sodium polystyrene
sulfonate rectal susp
30 gm/120ml
4
SYPRINE - trientine hcl cap
250 mg
1
tacrolimus cap 0.5 mg
(Prograf)
1
tacrolimus cap 1 mg
(Prograf)
1
tacrolimus cap 5 mg
(Prograf)
Step Therapy
•
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
4
REVLIMID - lenalidomide caps
2.5 mg
•
ACA Preventive
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
192
2015
INDEX
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir)................................................ 8
abacavir sulfate tab 300 mg (base equiv) (Ziagen)........ 8
ABILIFY -aripiprazole tab 2 mg....................................... 101
ABILIFY -aripiprazole tab 5 mg....................................... 101
ABILIFY -aripiprazole tab 10 mg..................................... 101
ABILIFY -aripiprazole tab 15 mg..................................... 101
ABILIFY -aripiprazole tab 20 mg..................................... 101
ABILIFY -aripiprazole tab 30 mg..................................... 101
ABILIFY DISCMELT -aripiprazole orally disintegrating tab
10 mg............................................................................ 101
ABILIFY DISCMELT -aripiprazole orally disintegrating tab
15 mg............................................................................ 102
ABILIFY MAINTENA -aripiprazole im for extended release
susp 300 mg................................................................. 102
ABILIFY MAINTENA -aripiprazole im for extended release
susp 400 mg................................................................. 102
ABSORICA -isotretinoin cap 10 mg................................ 166
ABSORICA -isotretinoin cap 20 mg................................ 166
ABSORICA -isotretinoin cap 25 mg................................ 166
ABSORICA -isotretinoin cap 30 mg................................ 166
ABSORICA -isotretinoin cap 35 mg................................ 166
ABSORICA -isotretinoin cap 40 mg................................ 166
ABSTRAL -fentanyl citrate sl tab 100 mcg (base
equiv)............................................................................. 119
ABSTRAL -fentanyl citrate sl tab 200 mcg (base
equiv)............................................................................. 119
ABSTRAL -fentanyl citrate sl tab 300 mcg (base
equiv)............................................................................. 119
ABSTRAL -fentanyl citrate sl tab 400 mcg (base
equiv)............................................................................. 119
ABSTRAL -fentanyl citrate sl tab 600 mcg (base
equiv)............................................................................. 119
ABSTRAL -fentanyl citrate sl tab 800 mcg (base
equiv)............................................................................. 119
acamprosate calcium tab delayed release 333 mg
(Campral)...................................................................... 114
ACANYA -clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%........................................................................ 166
acarbose tab 25 mg (Precose)....................................... 35
acarbose tab 50 mg (Precose)....................................... 35
acarbose tab 100 mg (Precose)..................................... 35
ACCOLATE -zafirlukast tab 10 mg....................................79
ACCOLATE -zafirlukast tab 20 mg....................................79
ACCU-CHEK ACTIVE GLUCOSE -blood glucose
calibration - liquid..........................................................178
ACCU-CHEK ACTIVE STRIPS -glucose blood test
strip................................................................................ 177
ACCU-CHEK AVIVA -blood glucose calibration liquid.............................................................................. 178
ACCU-CHEK AVIVA CONNECT -blood glucose
monitoring kit w/ device................................................ 178
ACCU-CHEK AVIVA -glucose blood test strip................ 177
ACCU-CHEK AVIVA PLUS -blood glucose monitoring kit
w/ device....................................................................... 178
ACCU-CHEK AVIVA PLUS -glucose blood test strip...... 177
ACCU-CHEK COMFORT CURVE C -blood glucose
calibration - liquid..........................................................178
ACCU-CHEK COMFORT CURVE L -blood glucose
calibration - liquid..........................................................178
ACCU-CHEK COMFORT CURVE T -glucose blood test
strip................................................................................ 177
ACCU-CHEK COMPACT BLUE CO -blood glucose
calibration - liquid..........................................................178
ACCU-CHEK COMPACT PLUS CA -blood glucose
monitoring kit................................................................. 178
ACCU-CHEK COMPACT PLUS CL -blood glucose
calibration - liquid..........................................................178
ACCU-CHEK COMPACT PLUS -glucose blood test
strip................................................................................ 177
ACCU-CHEK COMPACT STRIPS -glucose blood test
strip................................................................................ 177
ACCU-CHEK COMPACT TEST DR -glucose blood test
strip................................................................................ 177
ACCU-CHEK FASTCLIX LANCET -lancets.................... 178
ACCU-CHEK INSTANT GLUCOSE -blood glucose
calibration - liquid..........................................................178
ACCU-CHEK MULTICLIX LANCE -lancets.....................178
ACCU-CHEK NANO SMARTVIEW -blood glucose
monitoring kit w/ device................................................ 178
ACCU-CHEK SAFE-T-PRO LANC -lancets.................... 178
ACCU-CHEK SAFE-T-PRO PLUS -lancets.................... 178
ACCU-CHEK SMARTVIEW CONTR -blood glucose
calibration - liquid..........................................................178
ACCU-CHEK SMARTVIEW STRIP -glucose blood test
strip................................................................................ 177
ACCU-CHEK SOFTCLIX LANCET -lancets................... 178
ACCU-CHEK SOFT TOUCH LANC -lancets.................. 178
ACCU-CHEK VOICEMATE -blood glucose monitoring kit
w/ device....................................................................... 178
ACCUPRIL -quinapril hcl tab 5 mg................................... 57
ACCUPRIL -quinapril hcl tab 10 mg................................. 57
ACCUPRIL -quinapril hcl tab 20 mg................................. 57
ACCUPRIL -quinapril hcl tab 40 mg................................. 57
ACCURETIC -quinapril-hydrochlorothiazide tab 10-12.5
mg.................................................................................... 57
ACCURETIC -quinapril-hydrochlorothiazide tab 20-12.5
mg.................................................................................... 57
ACCURETIC -quinapril-hydrochlorothiazide tab 20-25
mg.................................................................................... 58
ACCUTREND GLUCOSE CONTROL -blood glucose
calibration - liquid..........................................................178
ACCUTREND GLUCOSE -glucose blood test strip........ 177
acebutolol hcl cap 200 mg (Sectral).............................. 51
acebutolol hcl cap 400 mg (Sectral).............................. 51
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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2015
ACEON -perindopril erbumine tab 4 mg........................... 58
ACEON -perindopril erbumine tab 8 mg........................... 58
acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg (Trezix).............................................. 119
acetaminophen w/ codeine soln 120-12 mg/5ml........ 119
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine)........................................................................ 119
acetaminophen w/ codeine tab 300-30 mg (Tylenol/
codeine #3).................................................................. 119
acetaminophen w/ codeine tab 300-60 mg (Tylenol/
codeine #4).................................................................. 119
ACETAZOLAMIDE -acetazolamide tab 125 mg............... 67
acetazolamide cap sr 12hr 500 mg (Diamox)............... 67
acetazolamide tab 250 mg.............................................. 67
ACETIC ACID/ALUMINUM ACET -acetic acid 2% in
aluminum acetate otic soln...........................................163
acetic acid otic soln 2%................................................ 163
acetylcysteine inhal soln 10%........................................ 77
acetylcysteine inhal soln 20%........................................ 77
ACIPHEX -rabeprazole sodium ec tab 20 mg.................. 84
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 5 mg.............................................................. 84
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 10 mg............................................................ 84
acitretin cap 10 mg (Soriatane).................................... 166
acitretin cap 17.5 mg (Soriatane)................................. 166
acitretin cap 25 mg (Soriatane).................................... 166
ACLOVATE -alclometasone dipropionate cream
0.05%.............................................................................166
ACTEMRA -tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml................................................... 128
ACTHIB -haemophilus b polysaccharide conjugate
vaccine for inj.................................................................. 16
ACTICLATE -doxycycline hyclate tab 75 mg...................... 4
ACTICLATE -doxycycline hyclate tab 150 mg.................... 4
ACTIGALL -ursodiol cap 300 mg...................................... 89
ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)....................................................... 21
ACTIQ -fentanyl citrate lozenge on a handle 200
mcg................................................................................ 119
ACTIQ -fentanyl citrate lozenge on a handle 400
mcg................................................................................ 119
ACTIQ -fentanyl citrate lozenge on a handle 600
mcg................................................................................ 119
ACTIQ -fentanyl citrate lozenge on a handle 800
mcg................................................................................ 119
ACTIQ -fentanyl citrate lozenge on a handle 1200
mcg................................................................................ 119
ACTIQ -fentanyl citrate lozenge on a handle 1600
mcg................................................................................ 119
ACTIVELLA -estradiol & norethindrone acetate tab
0.5-0.1 mg....................................................................... 29
ACTIVELLA -estradiol & norethindrone acetate tab 1-0.5
mg.................................................................................... 29
ACTONEL -risedronate sodium tab 5 mg......................... 45
ACTONEL -risedronate sodium tab 30 mg....................... 45
ACTONEL -risedronate sodium tab 35 mg....................... 45
ACTONEL -risedronate sodium tab 150 mg..................... 45
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-500 mg....................................................................... 35
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-850 mg....................................................................... 35
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 15-1000 mg........................................................ 35
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 30-1000 mg........................................................ 35
ACTOS -pioglitazone hcl tab 15 mg (base equiv)............. 35
ACTOS -pioglitazone hcl tab 30 mg (base equiv)............. 35
ACTOS -pioglitazone hcl tab 45 mg (base equiv)............. 35
ACT TOTAL CARE DRY MOUTH -sodium fluoride rinse
0.02%.............................................................................163
ACULAR -ketorolac tromethamine ophth soln 0.5%....... 158
ACULAR LS -ketorolac tromethamine ophth soln
0.4%...............................................................................158
ACURA BLOOD GLUCOSE MONIT -blood glucose
monitoring kit w/ device................................................ 178
ACURA PLUS BLOOD GLUCOSE -blood glucose
monitoring kit w/ device................................................ 178
ACUVAIL -ketorolac tromethamine ophth soln
0.45%.............................................................................158
acyclovir cap 200 mg (Zovirax)........................................ 8
acyclovir oint 5% (Zovirax)........................................... 166
acyclovir susp 200 mg/5ml (Zovirax).............................. 8
acyclovir tab 400 mg (Zovirax)........................................ 8
acyclovir tab 800 mg (Zovirax)........................................ 9
ACZONE -dapsone gel 5%............................................. 166
ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml........................................................................ 20
ADALAT CC -nifedipine tab sr 24hr 30 mg....................... 53
ADALAT CC -nifedipine tab sr 24hr 60 mg....................... 53
ADALAT CC -nifedipine tab sr 24hr 90 mg....................... 53
ADAPALENE -adapalene lotion 0.1%............................. 166
adapalene cream 0.1% (Differin).................................. 166
adapalene gel 0.1% (Differin)....................................... 166
adapalene gel 0.3% (Differin)....................................... 166
ADASUVE -loxapine aerosol powder breath activated 10
mg.................................................................................. 102
ADCIRCA -tadalafil tab 20 mg (pah)................................. 73
ADDERALL -amphetamine-dextroamphetamine tab 5
mg.................................................................................. 109
ADDERALL -amphetamine-dextroamphetamine tab 7.5
mg.................................................................................. 109
ADDERALL -amphetamine-dextroamphetamine tab 10
mg.................................................................................. 109
ADDERALL -amphetamine-dextroamphetamine tab 12.5
mg.................................................................................. 109
ADDERALL -amphetamine-dextroamphetamine tab 15
mg.................................................................................. 109
ADDERALL -amphetamine-dextroamphetamine tab 20
mg.................................................................................. 109
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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2015
ADDERALL -amphetamine-dextroamphetamine tab 30
mg.................................................................................. 109
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 5 mg................................................................. 109
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 10 mg............................................................... 109
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 15 mg............................................................... 109
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 20 mg............................................................... 109
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 25 mg............................................................... 110
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 30 mg............................................................... 110
adefovir dipivoxil tab 10 mg (Hepsera)........................... 9
ADEMPAS -riociguat tab 0.5 mg....................................... 73
ADEMPAS -riociguat tab 1 mg.......................................... 73
ADEMPAS -riociguat tab 1.5 mg....................................... 73
ADEMPAS -riociguat tab 2 mg.......................................... 73
ADEMPAS -riociguat tab 2.5 mg....................................... 73
ADOXA -doxycycline monohydrate cap 150 mg................. 4
ADOXA -doxycycline monohydrate tab 50 mg....................4
ADOXA -doxycycline monohydrate tab 75 mg....................4
ADOXA -doxycycline monohydrate tab 100 mg..................4
ADOXA PAK 1/100 -doxycycline monohydrate tab 100
mg...................................................................................... 4
ADOXA PAK 1/150 -doxycycline monohydrate tab 150
mg...................................................................................... 4
ADOXA PAK 2/100 -doxycycline monohydrate tab 100
mg...................................................................................... 4
ADRENACLICK -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 69
ADRENACLICK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 69
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................ 79
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
250-50 mcg/dose............................................................ 79
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
500-50 mcg/dose............................................................ 79
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................ 79
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21
mcg/act............................................................................ 79
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 230-21
mcg/act............................................................................ 79
ADVANCE INTUITION BLOOD G -blood glucose
monitoring devices........................................................ 178
ADVANCE INTUITION BLOOD G -blood glucose
monitoring kit w/ device................................................ 178
ADVANCE MICRO-DRAW METER -blood glucose
monitoring devices........................................................ 179
ADVATE -antihemophilic factor rahf-pfm for inj 250
unit................................................................................. 152
ADVATE -antihemophilic factor rahf-pfm for inj 500
unit................................................................................. 153
ADVATE -antihemophilic factor rahf-pfm for inj 1000
unit................................................................................. 153
ADVATE -antihemophilic factor rahf-pfm for inj 1500
unit................................................................................. 153
ADVATE -antihemophilic factor rahf-pfm for inj 2000
unit................................................................................. 153
ADVATE -antihemophilic factor rahf-pfm for inj 3000
unit................................................................................. 153
ADVATE -antihemophilic factor rahf-pfm for inj 4000
unit................................................................................. 153
ADVICOR -niacin-lovastatin tab sr 24hr 500-20 mg......... 69
ADVICOR -niacin-lovastatin tab sr 24hr 750-20 mg......... 69
ADVICOR -niacin-lovastatin tab sr 24hr 1000-20 mg....... 69
ADVICOR -niacin-lovastatin tab sr 24hr 1000-40 mg....... 69
ADVOCATE BLOOD GLUCOSE MO -blood glucose
monitoring devices........................................................ 179
ADVOCATE BLOOD GLUCOSE MO -blood glucose
monitoring kit w/ device................................................ 179
ADVOCATE REDI-CODE/TALKIN -blood glucose
monitoring devices........................................................ 179
ADVOCATE REDI-CODE/TALKIN -blood glucose
monitoring kit w/ device................................................ 179
ADVOCATE REDI-CODE+/ TALK -blood glucose
monitoring kit w/ device................................................ 179
ADVOCATE REDI-CODE+ BLOOD -blood glucose
monitoring devices........................................................ 179
ADVOCATE REDI-CODE -blood glucose monitoring
devices.......................................................................... 179
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 250 unit.................................................................... 153
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 500 unit.................................................................... 153
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 1000 unit.................................................................. 153
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 2000 unit.................................................................. 153
AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act...... 79
AFINITOR DISPERZ -everolimus tab for oral susp 2
mg.................................................................................... 21
AFINITOR DISPERZ -everolimus tab for oral susp 3
mg.................................................................................... 21
AFINITOR DISPERZ -everolimus tab for oral susp 5
mg.................................................................................... 21
AFINITOR -everolimus tab 2.5 mg.................................... 21
AFINITOR -everolimus tab 5 mg....................................... 21
AFINITOR -everolimus tab 7.5 mg.................................... 21
AFINITOR -everolimus tab 10 mg..................................... 21
AFLURIA 2011-2012 -influenza virus vaccine split im
susp................................................................................. 16
AFLURIA 2012-2013 -influenza virus vaccine split im
susp................................................................................. 16
AFLURIA 2013-2014 -influenza virus vaccine split im
susp................................................................................. 16
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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2015
AFLURIA 2014-2015 -influenza virus vaccine split im
susp................................................................................. 16
AFLURIA 2015-2016 -influenza virus vaccine split im
susp................................................................................. 16
AFLURIA PF 2011-2012 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 16
AFLURIA PF 2012-2013 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 16
AFLURIA PF 2013-2014 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 16
AFLURIA PF 2014-2015 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 16
AFLURIA PF 2015-2016 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 16
AFREZZA -insulin regular (human) inhalation powder 4
unit/cartridge.................................................................... 41
AFREZZA -insulin regular (human) inhal powd 4 (30) & 8
(60) unit/cart.................................................................... 41
AFREZZA -insulin regular (human) inhal powd 4 (60) & 8
(30) unit/cart.................................................................... 41
AFREZZA -insulin regular (human) inh powd 8 (60) & 12
(30) unit/cart.................................................................... 41
AGAMATRIX AMP NO CODE ADV -blood glucose
monitoring devices........................................................ 179
AGAMATRIX JAZZ -blood glucose monitoring kit w/
device............................................................................ 179
AGAMATRIX PRESTO -blood glucose monitoring kit w/
device............................................................................ 179
AGAMATRIX PRESTO PRO METE -blood glucose
monitoring devices........................................................ 179
AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................. 153
AGRYLIN -anagrelide hcl cap 0.5 mg............................. 153
AKTEN -lidocaine hcl ophth gel 3.5%............................. 158
AKYNZEO -netupitant-palonosetron cap 300-0.5 mg....... 87
ALA SCALP -hydrocortisone lotion 2%........................... 166
ALBENZA -albendazole tab 200 mg................................. 14
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)......... 79
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 79
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 79
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 79
albuterol sulfate syrup 2 mg/5ml................................... 80
albuterol sulfate tab 2 mg...............................................80
albuterol sulfate tab 4 mg...............................................80
albuterol sulfate tab sr 12hr 4 mg (Vospire er)............ 80
albuterol sulfate tab sr 12hr 8 mg (Vospire er)............ 80
ALCAINE -proparacaine hcl ophth soln 0.5%................. 158
alclometasone dipropionate cream 0.05%
(Aclovate)..................................................................... 166
alclometasone dipropionate oint 0.05%......................166
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
25-25 mg......................................................................... 67
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
50-50 mg......................................................................... 67
ALDACTONE -spironolactone tab 25 mg......................... 67
ALDACTONE -spironolactone tab 50 mg......................... 67
ALDACTONE -spironolactone tab 100 mg....................... 67
ALDARA -imiquimod cream 5%...................................... 166
ALECENSA -alectinib hcl cap 150 mg (base
equivalent)....................................................................... 21
ALENDRONATE SODIUM -alendronate sodium oral soln
70 mg/75ml..................................................................... 45
ALENDRONATE SODIUM -alendronate sodium tab 40
mg.................................................................................... 45
alendronate sodium tab 5 mg........................................ 45
alendronate sodium tab 10 mg...................................... 45
alendronate sodium tab 35 mg...................................... 45
alendronate sodium tab 70 mg (Fosamax)................... 45
ALFERON N -interferon alfa-n3 inj 5000000 unit/ml......... 21
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 93
ALINIA -nitazoxanide for susp 100 mg/5ml.......................14
ALINIA -nitazoxanide tab 500 mg..................................... 14
ALKERAN -melphalan tab 2 mg....................................... 21
allopurinol tab 100 mg (Zyloprim)............................... 134
allopurinol tab 300 mg (Zyloprim)............................... 134
almotriptan malate tab 6.25 mg (Axert).......................132
almotriptan malate tab 12.5 mg (Axert).......................132
ALOCRIL -nedocromil sodium ophth soln 2%................ 158
ALOMIDE -lodoxamide tromethamine ophth soln
0.1%...............................................................................158
ALORA -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 29
ALORA -estradiol td patch twice weekly 0.05 mg/24hr..... 29
ALORA -estradiol td patch twice weekly 0.075
mg/24hr........................................................................... 29
ALORA -estradiol td patch twice weekly 0.1 mg/24hr....... 29
alosetron hcl tab 0.5 mg (base equiv) (Lotronex)........ 89
alosetron hcl tab 1 mg (base equiv) (Lotronex)........... 89
ALPHAGAN P -brimonidine tartrate ophth soln 0.1%..... 158
ALPHAGAN P -brimonidine tartrate ophth soln
0.15%.............................................................................158
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 250 unit......................................... 153
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 500 unit......................................... 153
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 1000 unit....................................... 153
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 1500 unit....................................... 153
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 2000 unit....................................... 153
ALPHANINE SD -coagulation factor ix for inj 500
unit................................................................................. 153
ALPHANINE SD -coagulation factor ix for inj 1000
unit................................................................................. 153
ALPHANINE SD -coagulation factor ix for inj 1500
unit................................................................................. 153
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/
ml..................................................................................... 94
alprazolam orally disintegrating tab 0.5 mg................. 94
alprazolam orally disintegrating tab 1 mg.................... 94
alprazolam orally disintegrating tab 2 mg.................... 94
alprazolam orally disintegrating tab 0.25 mg
(Niravam)........................................................................ 94
alprazolam tab 0.25 mg (Xanax).................................... 94
alprazolam tab 0.5 mg (Xanax)...................................... 94
alprazolam tab 1 mg (Xanax)..........................................94
alprazolam tab 2 mg (Xanax)..........................................94
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 94
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 94
alprazolam tab sr 24hr 2 mg (Xanax xr)........................ 94
alprazolam tab sr 24hr 3 mg (Xanax xr)........................ 94
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
500 unit......................................................................... 153
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
1000 unit....................................................................... 153
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
2000 unit....................................................................... 153
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
3000 unit....................................................................... 153
ALREX -loteprednol etabonate ophth susp 0.2%........... 158
ALSUMA -sumatriptan succinate solution auto-injector 6
mg/0.5ml........................................................................ 132
ALTABAX -retapamulin oint 1%.......................................166
ALTACE -ramipril cap 1.25 mg.......................................... 58
ALTACE -ramipril cap 2.5 mg............................................ 58
ALTACE -ramipril cap 5 mg............................................... 58
ALTACE -ramipril cap 10 mg............................................. 58
ALTOPREV -lovastatin tab sr 24hr 20 mg........................ 69
ALTOPREV -lovastatin tab sr 24hr 40 mg........................ 69
ALTOPREV -lovastatin tab sr 24hr 60 mg........................ 69
ALUMINUM ACETATE -aluminum acetate soln..............166
ALVESCO -ciclesonide inhal aerosol 80 mcg/act............. 80
ALVESCO -ciclesonide inhal aerosol 160 mcg/act........... 80
AMANTADINE HCL -amantadine hcl tab 100 mg........... 141
amantadine hcl cap 100 mg......................................... 141
amantadine hcl syrup 50 mg/5ml................................ 141
AMARYL -glimepiride tab 1 mg......................................... 35
AMARYL -glimepiride tab 2 mg......................................... 35
AMARYL -glimepiride tab 4 mg......................................... 35
AMBIEN CR -zolpidem tartrate tab cr 6.25 mg............... 108
AMBIEN CR -zolpidem tartrate tab cr 12.5 mg............... 108
AMBIEN -zolpidem tartrate tab 5 mg.............................. 108
AMBIEN -zolpidem tartrate tab 10 mg............................ 108
AMCINONIDE -amcinonide cream 0.1%........................ 167
AMCINONIDE -amcinonide lotion 0.1%.......................... 167
AMCINONIDE -amcinonide oint 0.1%.............................167
AMERGE -naratriptan hcl tab 1 mg (base equiv)........... 132
AMERGE -naratriptan hcl tab 2.5 mg (base equiv)........ 132
AMICAR -aminocaproic acid oral soln 0.25 gm/ml......... 152
AMICAR -aminocaproic acid syrup 25%......................... 152
AMICAR -aminocaproic acid tab 500 mg........................ 152
AMICAR -aminocaproic acid tab 1000 mg...................... 152
amikacin sulfate inj 1 gm/4ml (250 mg/ml)..................... 6
amikacin sulfate inj 500 mg/2ml (250 mg/ml)................. 6
amiloride & hydrochlorothiazide tab 5-50 mg.............. 67
amiloride hcl tab 5 mg.................................................... 67
AMINOCAPROIC ACID -aminocaproic acid tab 1000
mg.................................................................................. 152
amiodarone hcl tab 100 mg............................................ 56
amiodarone hcl tab 400 mg............................................ 57
amiodarone hcl tab 200 mg (Cordarone)...................... 57
AMITIZA -lubiprostone cap 8 mcg.................................... 89
AMITIZA -lubiprostone cap 24 mcg.................................. 89
amitriptyline hcl tab 10 mg............................................. 95
amitriptyline hcl tab 25 mg............................................. 95
amitriptyline hcl tab 50 mg............................................. 95
amitriptyline hcl tab 75 mg............................................. 95
amitriptyline hcl tab 100 mg........................................... 95
amitriptyline hcl tab 150 mg........................................... 95
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)................................................................... 73
amlodipine besylate-atorvastatin calcium tab 2.5-20
mg (Caduet)................................................................... 73
amlodipine besylate-atorvastatin calcium tab 2.5-40
mg (Caduet)................................................................... 73
amlodipine besylate-atorvastatin calcium tab 5-10 mg
(Caduet).......................................................................... 73
amlodipine besylate-atorvastatin calcium tab 5-20 mg
(Caduet).......................................................................... 73
amlodipine besylate-atorvastatin calcium tab 5-40 mg
(Caduet).......................................................................... 73
amlodipine besylate-atorvastatin calcium tab 5-80 mg
(Caduet).......................................................................... 73
amlodipine besylate-atorvastatin calcium tab 10-10
mg (Caduet)................................................................... 73
amlodipine besylate-atorvastatin calcium tab 10-20
mg (Caduet)................................................................... 73
amlodipine besylate-atorvastatin calcium tab 10-40
mg (Caduet)................................................................... 73
amlodipine besylate-atorvastatin calcium tab 10-80
mg (Caduet)................................................................... 73
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel)............................................................................ 58
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel)............................................................................ 58
amlodipine besylate-benazepril hcl cap 5-20 mg
(Lotrel)............................................................................ 58
amlodipine besylate-benazepril hcl cap 5-40 mg
(Lotrel)............................................................................ 58
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel)............................................................................ 58
amlodipine besylate-benazepril hcl cap 10-40 mg
(Lotrel)............................................................................ 58
amlodipine besylate tab 2.5 mg (Norvasc)................... 53
amlodipine besylate tab 5 mg (Norvasc)...................... 53
amlodipine besylate tab 10 mg (Norvasc).................... 53
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amlodipine besylate-valsartan tab 5-160 mg
(Exforge)......................................................................... 58
amlodipine besylate-valsartan tab 5-320 mg
(Exforge)......................................................................... 58
amlodipine besylate-valsartan tab 10-160 mg
(Exforge)......................................................................... 58
amlodipine besylate-valsartan tab 10-320 mg
(Exforge)......................................................................... 58
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)........................................ 58
amlodipine-valsartan-hydrochlorothiazide tab
5-160-25 mg (Exforge hct)........................................... 58
amlodipine-valsartan-hydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)...................................... 58
amlodipine-valsartan-hydrochlorothiazide tab
10-160-25 mg (Exforge hct)......................................... 58
amlodipine-valsartan-hydrochlorothiazide tab
10-320-25 mg (Exforge hct)......................................... 58
AMMONIA AROMATIC INHALANT -ammonia aromatic
spirit............................................................................... 190
AMOXAPINE -amoxapine tab 25 mg................................ 95
AMOXAPINE -amoxapine tab 50 mg................................ 96
AMOXAPINE -amoxapine tab 100 mg.............................. 96
AMOXAPINE -amoxapine tab 150 mg.............................. 96
AMOXICILLIN/CLAVULANATE P -amoxicillin & k
clavulanate chew tab 200-28.5 mg.................................. 1
AMOXICILLIN/CLAVULANATE P -amoxicillin & k
clavulanate chew tab 400-57 mg..................................... 1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.............................................................................. 1
amoxicillin & k clavulanate for susp 400-57 mg/5ml..... 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)........................................................ 1
amoxicillin & k clavulanate tab 250-125 mg................... 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................ 1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 125
mg...................................................................................... 1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 250
mg...................................................................................... 1
amoxicillin cap-clarithro tab-lansopraz cap dr therapy
pack (Prevpac).............................................................. 84
AMOXICILLIN ER -amoxicillin (trihydrate) tab sr 24hr 775
mg...................................................................................... 1
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml..................1
amoxicillin (trihydrate) for susp 200 mg/5ml..................1
amoxicillin (trihydrate) for susp 250 mg/5ml..................1
amoxicillin (trihydrate) for susp 400 mg/5ml..................1
amoxicillin (trihydrate) tab 500 mg.................................. 1
amoxicillin (trihydrate) tab 875 mg.................................. 1
amphetamine-dextroamphetamine tab 5 mg
(Adderall)...................................................................... 110
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)...................................................................... 110
amphetamine-dextroamphetamine tab 10 mg
(Adderall)...................................................................... 110
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)...................................................................... 110
amphetamine-dextroamphetamine tab 15 mg
(Adderall)...................................................................... 110
amphetamine-dextroamphetamine tab 20 mg
(Adderall)...................................................................... 110
amphetamine-dextroamphetamine tab 30 mg
(Adderall)...................................................................... 110
AMPICILLIN -ampicillin for susp 125 mg/5ml..................... 1
AMPICILLIN -ampicillin for susp 250 mg/5ml..................... 1
ampicillin cap 250 mg....................................................... 1
ampicillin cap 500 mg....................................................... 1
AMPYRA -dalfampridine tab sr 12hr 10 mg.................... 114
AMRIX -cyclobenzaprine hcl cap sr 24hr 15 mg............. 144
AMRIX -cyclobenzaprine hcl cap sr 24hr 30 mg............. 144
ANADROL-50 -oxymetholone tab 50 mg.......................... 28
ANAFRANIL -clomipramine hcl cap 25 mg....................... 96
ANAFRANIL -clomipramine hcl cap 50 mg....................... 96
ANAFRANIL -clomipramine hcl cap 75 mg....................... 96
anagrelide hcl cap 1 mg............................................... 153
anagrelide hcl cap 0.5 mg (Agrylin)............................ 153
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal cream 1-1%........................................................ 165
ANALPRAM HC -hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1%..................................................... 165
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal lotn 2.5-1%..........................................................165
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 1-1%...................................... 166
ANALPRAM HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%................................... 165
ANAPROX DS -naproxen sodium tab 550 mg............... 128
ANAPROX -naproxen sodium tab 275 mg......................128
anastrozole tab 1 mg (Arimidex)................................... 21
ANCOBON -flucytosine cap 250 mg................................... 7
ANCOBON -flucytosine cap 500 mg................................... 7
ANDRODERM -testosterone td patch 24hr 2 mg/24hr..... 28
ANDRODERM -testosterone td patch 24hr 4 mg/24hr..... 28
ANDROGEL PUMP -testosterone td gel 12.5 mg/act
(1%)................................................................................. 28
ANDROGEL PUMP -testosterone td gel 20.25 mg/act
(1.62%)............................................................................ 28
ANDROGEL -testosterone td gel 25 mg/2.5gm (1%)....... 28
ANDROGEL -testosterone td gel 50 mg/5gm (1%).......... 28
ANDROGEL -testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................ 28
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ANDROGEL -testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................ 28
ANDROID -methyltestosterone cap 10 mg....................... 28
ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg.......... 29
ANGELIQ -drospirenone-estradiol tab 0.5-1 mg............... 29
ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh.............................................................. 80
ANTABUSE -disulfiram tab 250 mg................................ 114
ANTABUSE -disulfiram tab 500 mg................................ 114
ANTARA -fenofibrate micronized cap 30 mg.................... 69
ANTARA -fenofibrate micronized cap 90 mg.................... 69
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)...................................................................... 163
ANUSOL-HC -hydrocortisone rectal cream 2.5%........... 166
ANZEMET -dolasetron mesylate tab 50 mg..................... 87
ANZEMET -dolasetron mesylate tab 100 mg................... 87
APEXICON E -diflorasone diacetate emollient base
cream 0.05%................................................................. 167
APIDRA -insulin glulisine inj 100 unit/ml........................... 40
APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj
100 unit/ml.......................................................................40
APLENZIN -bupropion hbr tab sr 24hr 174 mg.................96
APLENZIN -bupropion hbr tab sr 24hr 348 mg.................96
APLENZIN -bupropion hbr tab sr 24hr 522 mg.................96
APOKYN -apomorphine hydrochloride inj 10 mg/ml....... 141
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)...................................................................... 158
APRISO -mesalamine cap sr 24hr 0.375 gm.................... 89
APTENSIO XR -methylphenidate hcl cap er 24hr 10 mg
(xr)................................................................................. 110
APTENSIO XR -methylphenidate hcl cap er 24hr 15 mg
(xr)................................................................................. 110
APTENSIO XR -methylphenidate hcl cap er 24hr 20 mg
(xr)................................................................................. 110
APTENSIO XR -methylphenidate hcl cap er 24hr 30 mg
(xr)................................................................................. 110
APTENSIO XR -methylphenidate hcl cap er 24hr 40 mg
(xr)................................................................................. 110
APTENSIO XR -methylphenidate hcl cap er 24hr 50 mg
(xr)................................................................................. 110
APTENSIO XR -methylphenidate hcl cap er 24hr 60 mg
(xr)................................................................................. 110
APTIOM -eslicarbazepine acetate tab 200 mg............... 134
APTIOM -eslicarbazepine acetate tab 400 mg............... 134
APTIOM -eslicarbazepine acetate tab 600 mg............... 134
APTIOM -eslicarbazepine acetate tab 800 mg............... 134
APTIVUS -tipranavir cap 250 mg........................................ 9
APTIVUS -tipranavir oral soln 100 mg/ml........................... 9
ARALEN -chloroquine phosphate tab 500 mg.................. 14
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 25
mcg/ml........................................................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 40
mcg/ml........................................................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 60
mcg/ml........................................................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 100
mcg/ml........................................................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 200
mcg/ml........................................................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 300
mcg/ml........................................................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 10 mcg/0.4ml..................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 25 mcg/0.42ml................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 40 mcg/0.4ml..................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 60 mcg/0.3ml..................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 100 mcg/0.5ml................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 150 mcg/0.3ml................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 200 mcg/0.4ml................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 300 mcg/0.6ml................................... 148
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 500 mcg/ml........................................ 148
ARAVA -leflunomide tab 10 mg....................................... 128
ARAVA -leflunomide tab 20 mg....................................... 128
ARCALYST -rilonacept for inj 220 mg.............................128
ARCAPTA NEOHALER -indacaterol maleate inhal powder
cap 75 mcg (base equiv)................................................80
ARICEPT -donepezil hydrochloride tab 5 mg................. 114
ARICEPT -donepezil hydrochloride tab 10 mg............... 114
ARICEPT -donepezil hydrochloride tab 23 mg............... 114
ARIMIDEX -anastrozole tab 1 mg..................................... 21
ARIPIPRAZOLE ODT -aripiprazole orally disintegrating
tab 10 mg...................................................................... 102
ARIPIPRAZOLE ODT -aripiprazole orally disintegrating
tab 15 mg...................................................................... 102
aripiprazole oral solution 1 mg/ml............................... 102
aripiprazole tab 2 mg (Abilify)...................................... 102
aripiprazole tab 5 mg (Abilify)...................................... 102
aripiprazole tab 10 mg (Abilify).................................... 102
aripiprazole tab 15 mg (Abilify).................................... 102
aripiprazole tab 20 mg (Abilify).................................... 102
aripiprazole tab 30 mg (Abilify).................................... 102
ARISTADA -aripiprazole lauroxil im er susp prefilled syr
441 mg/1.6ml................................................................ 102
ARISTADA -aripiprazole lauroxil im er susp prefilled syr
662 mg/2.4ml................................................................ 102
ARISTADA -aripiprazole lauroxil im er susp prefilled syr
882 mg/3.2ml................................................................ 102
ARIXTRA -fondaparinux sodium subcutaneous inj 2.5
mg/0.5ml........................................................................ 150
ARIXTRA -fondaparinux sodium subcutaneous inj 5
mg/0.4ml........................................................................ 150
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ARIXTRA -fondaparinux sodium subcutaneous inj 7.5
mg/0.6ml........................................................................ 150
ARIXTRA -fondaparinux sodium subcutaneous inj 10
mg/0.8ml........................................................................ 150
ARMOUR THYROID -thyroid tab 15 mg (1/4 grain)......... 42
ARMOUR THYROID -thyroid tab 30 mg (1/2 grain)......... 42
ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)...... 42
ARMOUR THYROID -thyroid tab 60 mg (1 grain)............ 42
ARMOUR THYROID -thyroid tab 120 mg (2 grain).......... 42
ARMOUR THYROID -thyroid tab 180 mg (3 grain).......... 42
ARMOUR THYROID -thyroid tab 240 mg (4 grain).......... 42
ARMOUR THYROID -thyroid tab 300 mg (5 grain).......... 42
ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 100 mcg/act................................................ 80
ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 200 mcg/act................................................ 80
AROMASIN -exemestane tab 25 mg................................ 21
ARTHROTEC 50 -diclofenac w/ misoprostol tab delayed
release 50-0.2 mg.........................................................128
ARTHROTEC 75 -diclofenac w/ misoprostol tab delayed
release 75-0.2 mg.........................................................128
ARTISS -fibrin sealant component solution.................... 152
ASACOL HD -mesalamine tab delayed release 800
mg.................................................................................... 89
ASCENSIA AUTODISC LOW AND -blood glucose
calibration - liquid..........................................................179
ASCENSIA AUTODISC NORMAL -blood glucose
calibration - liquid - normal........................................... 179
ASCENSIA AUTODISC TEST ST -glucose blood test
disk................................................................................ 177
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 100 mcg/act................................................. 80
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 200 mcg/act................................................. 80
ASMANEX TWISTHALER 120 ME -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 80
ASMANEX TWISTHALER 7 METE -mometasone furoate
inhal powd 110 mcg/inh (breath activated).................... 80
ASMANEX TWISTHALER 14 MET -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 80
ASMANEX TWISTHALER 30 MET -mometasone furoate
inhal powd 110 mcg/inh (breath activated).................... 80
ASMANEX TWISTHALER 30 MET -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 80
ASMANEX TWISTHALER 60 MET -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 80
ASPIRIN/DIPYRIDAMOLE -aspirin-dipyridamole cap sr
12hr 25-200 mg............................................................ 153
ASPIRIN-CAFFEINE-DIHYDROC -aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg........................... 120
aspirin chew tab 81 mg.................................................118
aspirin tab delayed release 81 mg...............................118
aspirin tab 81 mg........................................................... 118
ASSURE 4 BLOOD GLUCOSE ME -blood glucose
monitoring devices........................................................ 179
ASSURE 3 METER -blood glucose monitoring kit.......... 179
ASSURE PLATINUM BLOOD GLU -blood glucose
monitoring devices........................................................ 179
ASSURE PRISM MULTI BLOOD -blood glucose
monitoring devices........................................................ 179
ASSURE PRO BLOOD GLUCOSE -blood glucose
monitoring devices........................................................ 179
ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 190
ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 190
ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 190
ASTEPRO -azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)............................................................................... 76
ATACAND -candesartan cilexetil tab 4 mg....................... 58
ATACAND -candesartan cilexetil tab 8 mg....................... 58
ATACAND -candesartan cilexetil tab 16 mg..................... 58
ATACAND -candesartan cilexetil tab 32 mg..................... 58
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 16-12.5 mg............................................................... 58
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 32-12.5 mg............................................................... 58
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 32-25 mg...................................................................58
ATELVIA -risedronate sodium tab delayed release 35
mg.................................................................................... 45
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50).................................................................................... 58
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100).................................................................................. 58
atenolol tab 25 mg (Tenormin)....................................... 51
atenolol tab 50 mg (Tenormin)....................................... 51
atenolol tab 100 mg (Tenormin)..................................... 51
ATIVAN -lorazepam tab 0.5 mg......................................... 94
ATIVAN -lorazepam tab 1 mg............................................ 94
ATIVAN -lorazepam tab 2 mg............................................ 94
AT LAST BLOOD GLUCOSE SYS -blood glucose
monitoring kit................................................................. 179
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 69
atorvastatin calcium tab 20 mg (base equivalent)
(Lipitor)........................................................................... 69
atorvastatin calcium tab 40 mg (base equivalent)
(Lipitor)........................................................................... 69
atorvastatin calcium tab 80 mg (base equivalent)
(Lipitor)........................................................................... 69
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone)...................................................................... 14
atovaquone-proguanil hcl tab 250-100 mg
(Malarone)...................................................................... 14
atovaquone susp 750 mg/5ml (Mepron)....................... 14
ATRALIN -tretinoin gel 0.05%......................................... 167
ATRIPLA -efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................9
atropine sulfate ophth soln 1% (Isopto atropine)...... 158
ATROVENT HFA -ipratropium bromide hfa inhal aerosol
17 mcg/act.......................................................................80
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ATROVENT -ipratropium bromide nasal soln 0.03% (21
mcg/spray)....................................................................... 76
ATROVENT -ipratropium bromide nasal soln 0.06% (42
mcg/spray)....................................................................... 76
AUBAGIO -teriflunomide tab 7 mg.................................. 114
AUBAGIO -teriflunomide tab 14 mg................................ 114
AUGMENTIN -amoxicillin & k clavulanate for susp
125-31.25 mg/5ml............................................................. 1
AUGMENTIN -amoxicillin & k clavulanate for susp
250-62.5 mg/5ml............................................................... 1
AUGMENTIN -amoxicillin & k clavulanate tab 500-125
mg...................................................................................... 1
AUGMENTIN -amoxicillin & k clavulanate tab 875-125
mg...................................................................................... 1
AUGMENTIN ES-600 -amoxicillin & k clavulanate for
susp 600-42.9 mg/5ml...................................................... 1
AUGMENTIN XR -amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg.................................................................... 1
AURYXIA -ferric citrate tab 1 gm (210 mg ferric iron)....... 89
AUVI-Q -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 69
AUVI-Q -epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)........................................................................... 69
AVALIDE -irbesartan-hydrochlorothiazide tab 150-12.5
mg.................................................................................... 58
AVALIDE -irbesartan-hydrochlorothiazide tab 300-12.5
mg.................................................................................... 59
AVANDIA -rosiglitazone maleate tab 2 mg (base
equiv)............................................................................... 35
AVANDIA -rosiglitazone maleate tab 4 mg (base
equiv)............................................................................... 35
AVANDIA -rosiglitazone maleate tab 8 mg (base
equiv)............................................................................... 35
AVAPRO -irbesartan tab 75 mg........................................ 59
AVAPRO -irbesartan tab 150 mg...................................... 59
AVAPRO -irbesartan tab 300 mg...................................... 59
AVAR-E LS -sulfacetamide sodium w/ sulfur cream
10-2%............................................................................ 167
AVC -sulfanilamide vaginal cream 15%............................ 92
AVELOX ABC PACK -moxifloxacin hcl tab 400 mg (base
equiv)................................................................................. 6
AVELOX -moxifloxacin hcl tab 400 mg (base equiv).......... 6
AVINZA -morphine sulfate beads cap sr 24hr 30 mg......120
AVINZA -morphine sulfate beads cap sr 24hr 45 mg......120
AVINZA -morphine sulfate beads cap sr 24hr 60 mg......120
AVINZA -morphine sulfate beads cap sr 24hr 75 mg......120
AVINZA -morphine sulfate beads cap sr 24hr 90 mg......120
AVINZA -morphine sulfate beads cap sr 24hr 120
mg.................................................................................. 120
AVODART -dutasteride cap 0.5 mg.................................. 93
AVONEX -interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)..................................................... 114
AVONEX -interferon beta-1a im prefilled syringe kit 30
mcg/0.5ml...................................................................... 114
AVONEX PEN -interferon beta-1a im auto-injector kit 30
mcg/0.5ml...................................................................... 114
AXERT -almotriptan malate tab 6.25 mg........................ 132
AXERT -almotriptan malate tab 12.5 mg........................ 132
AXID -nizatidine cap 300 mg............................................ 84
AXIRON -testosterone td soln 30 mg/act.......................... 28
AYGESTIN -norethindrone acetate tab 5 mg.................... 35
AZASAN -azathioprine tab 75 mg................................... 190
AZASAN -azathioprine tab 100 mg................................. 190
AZASITE -azithromycin ophth soln 1%........................... 158
azathioprine tab 50 mg (Imuran).................................. 191
azelastine hcl nasal spray 0.1% (137 mcg/spray)........ 76
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro).........................................................................77
azelastine hcl ophth soln 0.05% (Optivar).................. 158
AZELEX -azelaic acid cream 20%.................................. 167
AZILECT -rasagiline mesylate tab 0.5 mg (base
equiv)............................................................................. 141
AZILECT -rasagiline mesylate tab 1 mg (base
equiv)............................................................................. 141
AZITHROMYCIN -azithromycin powd pack for susp 1
gm...................................................................................... 3
azithromycin for susp 100 mg/5ml (Zithromax)............. 3
azithromycin for susp 200 mg/5ml (Zithromax)............. 3
azithromycin tab 250 mg (Zithromax)............................. 3
azithromycin tab 500 mg (Zithromax)............................. 3
azithromycin tab 600 mg (Zithromax)............................. 3
AZOPT -brinzolamide ophth susp 1%............................. 158
AZOR -amlodipine besylate-olmesartan medoxomil tab
5-20 mg........................................................................... 59
AZOR -amlodipine besylate-olmesartan medoxomil tab
5-40 mg........................................................................... 59
AZOR -amlodipine besylate-olmesartan medoxomil tab
10-20 mg......................................................................... 59
AZOR -amlodipine besylate-olmesartan medoxomil tab
10-40 mg......................................................................... 59
AZULFIDINE EN-TABS -sulfasalazine tab delayed
release 500 mg............................................................... 89
AZULFIDINE -sulfasalazine tab 500 mg........................... 89
B
BABY DDROPS -cholecalciferol drops 400 unit/0.03ml
(per drop)...................................................................... 145
BACITRACIN -bacitracin ophth oint 500 unit/gm............ 158
bacitracin-polymyxin b ophth oint.............................. 158
bacitracin-polymyxin-neomycin-hc ophth oint
1%.................................................................................. 158
baclofen tab 10 mg........................................................ 144
baclofen tab 20 mg........................................................ 144
BACTRIM DS -sulfamethoxazole-trimethoprim tab
800-160 mg..................................................................... 15
BACTRIM -sulfamethoxazole-trimethoprim tab 400-80
mg.................................................................................... 14
BACTROBAN -mupirocin calcium cream 2%................. 167
BACTROBAN -mupirocin oint 2%................................... 167
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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BACTROBAN NASAL -mupirocin calcium nasal oint
2%.................................................................................... 77
balsalazide disodium cap 750 mg (Colazal)................. 89
BANZEL -rufinamide susp 40 mg/ml............................... 134
BANZEL -rufinamide tab 200 mg.................................... 134
BANZEL -rufinamide tab 400 mg.................................... 134
BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 9
BARACLUDE -entecavir tab 0.5 mg................................... 9
BARACLUDE -entecavir tab 1 mg...................................... 9
BAYER BREEZE 2 BLOOD GLUC -blood glucose
monitoring kit w/ device................................................ 179
BAYER BREEZE 2 HIGH CONTR -blood glucose
calibration - liquid - high............................................... 179
BAYER BREEZE 2 LOW CONTRO -blood glucose
calibration - liquid - low................................................ 179
BAYER BREEZE 2 NORMAL CON -blood glucose
calibration - liquid - normal........................................... 179
BAYER BREEZE 2 TEST DISC -glucose blood test
disk................................................................................ 178
BAYER CONTOUR BLOOD GLUCO -blood glucose
monitoring devices........................................................ 179
BAYER CONTOUR BLOOD GLUCO -blood glucose
monitoring kit w/ device................................................ 179
BAYER CONTOUR BLOOD GLUCO -glucose blood test
strip................................................................................ 178
BAYER CONTOUR HIGH CONTRO -blood glucose
calibration - liquid - high............................................... 179
BAYER CONTOUR LINK BLOOD -blood glucose
monitoring kit w/ device................................................ 179
BAYER CONTOUR LOW CONTROL -blood glucose
calibration - liquid - low................................................ 180
BAYER CONTOUR NEXT BLOOD -blood glucose
monitoring kit w/ device................................................ 180
BAYER CONTOUR NEXT BLOOD -glucose blood test
strip................................................................................ 178
BAYER CONTOUR NEXT CONTRO -blood glucose
calibration - liquid - low................................................ 180
BAYER CONTOUR NEXT CONTRO -blood glucose
calibration - liquid - normal........................................... 180
BAYER CONTOUR NEXT EZ BLO -blood glucose
monitoring kit w/ device................................................ 180
BAYER CONTOUR NEXT LINK B -blood glucose
monitoring kit w/ device................................................ 180
BAYER CONTOUR NEXT LINK W -blood glucose
monitoring kit w/ device................................................ 180
BAYER CONTOUR NEXT USB BL -blood glucose
monitoring kit w/ device................................................ 180
BAYER CONTOUR NORMAL CONT -blood glucose
calibration - liquid - normal........................................... 180
BAYER CONTOUR USB BLOOD G -blood glucose
monitoring kit w/ device................................................ 180
BAYER MICROLET LANCETS -lancets......................... 180
BD GLUCOSE -glucose chew tab 5 gm........................... 35
BD LATITUDE DIABETES MANA -blood glucose
monitoring kit w/ device................................................ 180
BD LOGIC BLOOD GLUCOSE MO -blood glucose
monitoring kit w/ device................................................ 180
BD MAGNI-GUIDE MAGNIFIER -blood glucose
monitoring supplies....................................................... 180
BEBULIN -factor ix complex for inj 200-1200 unit.......... 153
BEBULIN VH -factor ix complex for inj 200-1200
unit................................................................................. 153
BECONASE AQ -beclomethasone dipropionate monohyd
nasal susp 42 mcg/spray............................................... 77
BELBUCA -buprenorphine hcl buccal film 75 mcg (base
equivalent)..................................................................... 120
BELBUCA -buprenorphine hcl buccal film 150 mcg (base
equivalent)..................................................................... 120
BELBUCA -buprenorphine hcl buccal film 300 mcg (base
equivalent)..................................................................... 120
BELBUCA -buprenorphine hcl buccal film 450 mcg (base
equivalent)..................................................................... 120
BELBUCA -buprenorphine hcl buccal film 600 mcg (base
equivalent)..................................................................... 120
BELBUCA -buprenorphine hcl buccal film 750 mcg (base
equivalent)..................................................................... 120
BELBUCA -buprenorphine hcl buccal film 900 mcg (base
equivalent)..................................................................... 120
BELSOMRA -suvorexant tab 5 mg................................. 108
BELSOMRA -suvorexant tab 10 mg............................... 108
BELSOMRA -suvorexant tab 15 mg............................... 108
BELSOMRA -suvorexant tab 20 mg............................... 108
benazepril & hydrochlorothiazide tab 5-6.25 mg......... 59
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................ 59
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................ 59
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................ 59
benazepril hcl tab 5 mg.................................................. 59
benazepril hcl tab 10 mg (Lotensin).............................. 59
benazepril hcl tab 20 mg (Lotensin).............................. 59
benazepril hcl tab 40 mg (Lotensin).............................. 59
BENEFIX -coagulation factor ix (recombinant) for inj 250
unit................................................................................. 153
BENEFIX -coagulation factor ix (recombinant) for inj 500
unit................................................................................. 153
BENEFIX -coagulation factor ix (recombinant) for inj 1000
unit................................................................................. 154
BENEFIX -coagulation factor ix (recombinant) for inj 2000
unit................................................................................. 154
BENEFIX -coagulation factor ix (recombinant) for inj 3000
unit................................................................................. 154
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg...............................59
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg...............................59
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-25 mg.................................. 59
BENICAR -olmesartan medoxomil tab 5 mg.....................59
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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BENICAR -olmesartan medoxomil tab 20 mg...................59
BENICAR -olmesartan medoxomil tab 40 mg...................59
BENTYL -dicyclomine hcl cap 10 mg............................... 84
BENTYL -dicyclomine hcl tab 20 mg................................ 84
BENZACLIN -clindamycin phosphate-benzoyl peroxide
gel 1-5%........................................................................ 167
BENZACLIN WITH PUMP -clindamycin phosphatebenzoyl peroxide gel 1-5%........................................... 167
BENZAMYCIN -benzoyl peroxide-erythromycin gel
5-3%.............................................................................. 167
BENZAMYCINPAK -benzoyl peroxide-erythromycin gel
pack 5-3%..................................................................... 167
BENZOIN COMPOUND TINCTURE -benzoin compound
tincture........................................................................... 167
benzonatate cap 200 mg................................................. 77
benzonatate cap 100 mg (Tessalon perles).................. 77
benzonatate cap 150 mg (Zonatuss)............................. 77
benzoyl peroxide creamy wash 8% &benzoyl peroxide
bar 5% kit (Bpo creamy wash comp)....................... 167
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)............................................................... 167
benzoyl peroxide foam 5.3% (Benzefoam)................. 167
benzoyl peroxide gel 5%...............................................167
benzoyl peroxide lotion 6%.......................................... 167
benztropine mesylate tab 0.5 mg................................ 141
benztropine mesylate tab 1 mg................................... 141
benztropine mesylate tab 2 mg................................... 141
BEPREVE -bepotastine besilate ophth soln 1.5%.......... 158
BERINERT -c1 esterase inhibitor (human) for iv inj kit 500
unit................................................................................. 154
BESIVANCE -besifloxacin hcl ophth susp 0.6% (base
equiv)............................................................................. 158
BETADINE OPHTHALMIC PREP -povidone-iodine ophth
soln 5%......................................................................... 159
BETAGAN -levobunolol hcl ophth soln 0.5%.................. 159
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)............................................................... 167
betamethasone dipropionate augmented gel
0.05%.............................................................................167
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)................................................................... 167
betamethasone dipropionate augmented oint 0.05%
(Diprolene)................................................................... 167
betamethasone dipropionate cream 0.05%................ 167
betamethasone dipropionate lotion 0.05%................. 167
betamethasone dipropionate oint 0.05%.................... 167
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 167
betamethasone valerate cream 0.1%.......................... 167
betamethasone valerate lotion 0.1%........................... 167
betamethasone valerate oint 0.1%.............................. 167
BETAPACE AF -sotalol hcl (afib/afl) tab 80 mg................ 51
BETAPACE AF -sotalol hcl (afib/afl) tab 120 mg.............. 51
BETAPACE AF -sotalol hcl (afib/afl) tab 160 mg.............. 51
BETAPACE -sotalol hcl tab 80 mg.................................... 51
BETAPACE -sotalol hcl tab 120 mg.................................. 51
BETAPACE -sotalol hcl tab 160 mg.................................. 51
BETASERON -interferon beta-1b for inj kit 0.3 mg......... 114
betaxolol hcl ophth soln 0.5%......................................159
betaxolol hcl tab 10 mg (Kerlone)................................. 51
betaxolol hcl tab 20 mg (Kerlone)................................. 51
bethanechol chloride tab 5 mg (Urecholine)................ 91
bethanechol chloride tab 10 mg (Urecholine).............. 91
bethanechol chloride tab 25 mg (Urecholine).............. 91
bethanechol chloride tab 50 mg (Urecholine).............. 91
BETHKIS -tobramycin nebu soln 300 mg/4ml.................... 6
BETIMOL -timolol ophth soln 0.25%............................... 159
BETIMOL -timolol ophth soln 0.5%................................. 159
BETOPTIC-S -betaxolol hcl ophth susp 0.25%.............. 159
bexarotene cap 75 mg (Targretin)..................................21
BEXSERO -meningococcal vac b (recomb adsorbed) inj
prefilled syringe............................................................... 16
BEYAZ -drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg..............................................................32
BIAXIN -clarithromycin for susp 250 mg/5ml...................... 3
BIAXIN -clarithromycin tab 250 mg..................................... 3
BIAXIN -clarithromycin tab 500 mg..................................... 3
BIAXIN XL -clarithromycin tab sr 24hr 500 mg................... 3
BIAXIN XL PAC -clarithromycin tab sr 24hr 500 mg........... 3
bicalutamide tab 50 mg (Casodex)................................ 21
BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 73
BIFERARX -polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg........................................................... 148
BILTRICIDE -praziquantel tab 600 mg.............................. 14
BIMATOPROST -bimatoprost ophth soln 0.03%............ 159
BINOSTO -alendronate sodium effervescent tab 70
mg.................................................................................... 45
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit..................................................................................... 83
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 59
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 59
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 59
bisoprolol fumarate tab 5 mg (Zebeta)..........................51
bisoprolol fumarate tab 10 mg (Zebeta)........................51
BLEPHAMIDE S.O.P. -sulfacetamide sodiumprednisolone ophth oint 10-0.2%................................. 159
BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth
susp 10-0.2%................................................................ 159
BLEPH-10 -sulfacetamide sodium ophth soln 10%........ 159
BLOOD GLUCOSE CALIBRATION LIQUID
VARIOUS....................................................................... 180
BLOOD GLUCOSE MONITORING -blood glucose
monitoring kit w/ device................................................ 180
BLOOD GLUCOSE SYSTEM PAK -blood glucose
monitoring kit w/ device................................................ 180
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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BONIVA -ibandronate sodium tab 150 mg (base
equivalent)....................................................................... 45
BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lflf-mcg/0.5ml..................................................................... 20
BORIC ACID -boric acid granules................................... 167
BOSULIF -bosutinib tab 100 mg....................................... 21
BOSULIF -bosutinib tab 500 mg....................................... 21
BPO CREAMY WASH COMPLETE -benzoyl peroxide
creamy wash 8% &benzoyl peroxide bar 5% kit.......... 167
BRAVELLE -urofollitropin purified for inj 75 unit............... 45
BREEZE 2 BLOOD GLUCOSE MO -blood glucose
monitoring devices........................................................ 180
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh.......................................................... 80
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh.......................................................... 80
BREVICON-28 -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg...................................................................... 32
BRILINTA -ticagrelor tab 60 mg...................................... 154
BRILINTA -ticagrelor tab 90 mg...................................... 154
brimonidine tartrate ophth soln 0.2%......................... 159
brimonidine tartrate ophth soln 0.15% (Alphagan
p)................................................................................... 159
BRINTELLIX -vortioxetine hbr tab 5 mg (base equiv)....... 96
BRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)..... 96
BRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)..... 96
BRISDELLE -paroxetine mesylate cap 7.5 mg (base
equiv)............................................................................. 114
BROMFENAC -bromfenac sodium ophth soln 0.09%
(base equivalent).......................................................... 159
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily).................................................................. 159
bromocriptine mesylate cap 5 mg (Parlodel)............. 141
bromocriptine mesylate tab 2.5 mg............................. 141
BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml
(base equiv).................................................................... 80
budesonide cap sr 24hr 3 mg (Entocort ec)................. 26
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)......................................................................80
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)......................................................................80
budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 80
budesonide nasal susp 32 mcg/act (Rhinocort
aqua)............................................................................... 77
bumetanide tab 0.5 mg................................................... 67
bumetanide tab 1 mg...................................................... 67
bumetanide tab 2 mg...................................................... 67
BUMEX -bumetanide tab 0.5 mg...................................... 67
BUMEX -bumetanide tab 1 mg......................................... 67
BUMEX -bumetanide tab 2 mg......................................... 67
BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3
mg (base equiv)............................................................ 120
BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7
mg (base equiv)............................................................ 120
BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg
(base equiv).................................................................. 120
BUPAP -butalbital-acetaminophen tab 50-300 mg......... 118
BUPHENYL -sodium phenylbutyrate oral powder 3 gm/
teaspoonful...................................................................... 45
BUPHENYL -sodium phenylbutyrate tab 500 mg............. 45
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv)............................................................................ 120
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv)............................................................................ 120
buprenorphine hcl sl tab 2 mg (base equiv).............. 120
buprenorphine hcl sl tab 8 mg (base equiv).............. 120
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban).......................................................................... 114
bupropion hcl tab 75 mg (Wellbutrin)........................... 96
bupropion hcl tab 100 mg (Wellbutrin)......................... 96
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 96
bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr)........ 96
bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)........ 96
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)........ 96
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)........ 96
buspirone hcl tab 5 mg................................................... 94
buspirone hcl tab 7.5 mg................................................ 94
buspirone hcl tab 10 mg................................................. 94
buspirone hcl tab 15 mg................................................. 94
buspirone hcl tab 30 mg................................................. 94
butalbital-acetaminophen-caffeine cap 50-325-40
mg................................................................................. 119
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)....................................................................... 119
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)........................................................................... 119
butalbital-acetaminophen-caff w/ cod cap
50-325-40-30 mg.......................................................... 120
butalbital-acetaminophen-caff w/ cod cap
50-300-40-30 mg (Fioricet/codeine).......................... 120
butalbital-acetaminophen tab 50-325 mg....................119
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)....................................................................... 119
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)................................................... 120
BUTISOL SODIUM -butabarbital sodium tab 30 mg.......108
BUTISOL SODIUM -butabarbital sodium tab 50 mg.......108
butorphanol tartrate nasal soln 10 mg/ml.................. 120
BUTRANS -buprenorphine td patch weekly 5 mcg/
hr.................................................................................... 120
BUTRANS -buprenorphine td patch weekly 7.5 mcg/
hr.................................................................................... 120
BUTRANS -buprenorphine td patch weekly 10 mcg/
hr.................................................................................... 120
BUTRANS -buprenorphine td patch weekly 15 mcg/
hr.................................................................................... 120
BUTRANS -buprenorphine td patch weekly 20 mcg/
hr.................................................................................... 120
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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BYDUREON -exenatide extended release for susp peninjector 2 mg................................................................... 35
BYETTA -exenatide soln pen-injector 5 mcg/0.02ml........ 36
BYETTA -exenatide soln pen-injector 10 mcg/0.04ml...... 36
BYSTOLIC -nebivolol hcl tab 2.5 mg (base
equivalent)....................................................................... 51
BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent).......51
BYSTOLIC -nebivolol hcl tab 10 mg (base
equivalent)....................................................................... 51
BYSTOLIC -nebivolol hcl tab 20 mg (base
equivalent)....................................................................... 51
C
cabergoline tab 0.5 mg................................................... 45
CADUET -amlodipine besylate-atorvastatin calcium tab
2.5-10 mg........................................................................ 73
CADUET -amlodipine besylate-atorvastatin calcium tab
2.5-20 mg........................................................................ 73
CADUET -amlodipine besylate-atorvastatin calcium tab
2.5-40 mg........................................................................ 73
CADUET -amlodipine besylate-atorvastatin calcium tab
5-10 mg........................................................................... 73
CADUET -amlodipine besylate-atorvastatin calcium tab
5-20 mg........................................................................... 73
CADUET -amlodipine besylate-atorvastatin calcium tab
5-40 mg........................................................................... 73
CADUET -amlodipine besylate-atorvastatin calcium tab
5-80 mg........................................................................... 73
CADUET -amlodipine besylate-atorvastatin calcium tab
10-10 mg......................................................................... 74
CADUET -amlodipine besylate-atorvastatin calcium tab
10-20 mg......................................................................... 74
CADUET -amlodipine besylate-atorvastatin calcium tab
10-40 mg......................................................................... 74
CADUET -amlodipine besylate-atorvastatin calcium tab
10-80 mg......................................................................... 74
CAFERGOT -ergotamine w/ caffeine tab 1-100 mg....... 132
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv) (Cafcit).............................................................. 110
CALAN SR -verapamil hcl tab cr 120 mg......................... 54
CALAN SR -verapamil hcl tab cr 180 mg......................... 54
CALAN SR -verapamil hcl tab cr 240 mg......................... 54
CALAN -verapamil hcl tab 80 mg..................................... 53
CALAN -verapamil hcl tab 120 mg................................... 54
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)............................................ 168
calcipotriene cream 0.005% (Dovonex).......................167
calcipotriene oint 0.005%..............................................167
calcipotriene soln 0.005% (50 mcg/ml)....................... 167
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)...................................................................... 45
CALCITRIOL -calcitriol oint 3 mcg/gm............................ 168
calcitriol cap 0.25 mcg (Rocaltrol)................................. 45
calcitriol cap 0.5 mcg (Rocaltrol)................................... 45
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................45
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................. 89
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)......................................................................... 89
CAMBIA -diclofenac potassium packet 50 mg................ 132
CANASA -mesalamine suppos 1000 mg.......................... 89
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct).......................................................... 59
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct).......................................................... 59
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct).......................................................... 60
candesartan cilexetil tab 4 mg (Atacand)..................... 59
candesartan cilexetil tab 8 mg (Atacand)..................... 59
candesartan cilexetil tab 16 mg (Atacand)................... 59
candesartan cilexetil tab 32 mg (Atacand)................... 59
CANTIL -mepenzolate bromide tab 25 mg....................... 84
CAPCOF -phenylephrine-chlorphen w/ codeine syrup
5-2-10 mg/5ml................................................................. 77
capecitabine tab 150 mg (Xeloda)................................. 21
capecitabine tab 500 mg (Xeloda)................................. 21
CAPEX -fluocinolone acetonide shampoo 0.01%........... 168
CAPITAL/CODEINE -acetaminophen w/ codeine susp
120-12 mg/5ml.............................................................. 120
CAPRELSA -vandetanib tab 100 mg................................ 21
CAPRELSA -vandetanib tab 300 mg................................ 21
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-15 mg.................................. 60
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-25 mg.................................. 60
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 50-15 mg.................................. 60
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 50-25 mg.................................. 60
captopril tab 12.5 mg...................................................... 60
captopril tab 25 mg......................................................... 60
captopril tab 50 mg......................................................... 60
captopril tab 100 mg....................................................... 60
CARAC -fluorouracil cream 0.5%.................................... 168
CARAFATE -sucralfate susp 1 gm/10ml........................... 84
CARAFATE -sucralfate tab 1 gm.......................................84
CARBAGLU -carglumic acid tab 200 mg.......................... 45
carbamazepine cap sr 12hr 100 mg (Carbatrol)......... 134
carbamazepine cap sr 12hr 200 mg (Carbatrol)......... 135
carbamazepine cap sr 12hr 300 mg (Carbatrol)......... 135
carbamazepine chew tab 100 mg................................ 135
carbamazepine susp 100 mg/5ml (Tegretol)............... 135
carbamazepine tab 200 mg (Tegretol)......................... 135
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)....... 135
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)....... 135
CARBATROL -carbamazepine cap sr 12hr 100 mg....... 135
CARBATROL -carbamazepine cap sr 12hr 200 mg....... 135
CARBATROL -carbamazepine cap sr 12hr 300 mg....... 135
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg................................ 141
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2015
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg.............................. 141
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg................................. 141
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg............................ 141
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg.............................. 141
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg................................. 141
carbidopa & levodopa orally disintegrating tab 10-100
mg................................................................................. 141
carbidopa & levodopa orally disintegrating tab 25-100
mg................................................................................. 141
carbidopa & levodopa orally disintegrating tab 25-250
mg................................................................................. 141
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................. 141
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................. 141
carbidopa & levodopa tab 10-100 mg (Sinemet)........ 141
carbidopa & levodopa tab 25-100 mg (Sinemet)........ 141
carbidopa & levodopa tab 25-250 mg (Sinemet)........ 141
carbidopa tab 25 mg (Lodosyn)................................... 141
carbinoxamine maleate soln 4 mg/5ml......................... 76
carbinoxamine maleate tab 4 mg.................................. 76
carbonyl iron susp 15 mg/1.25ml (elemental
iron)............................................................................... 148
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
120 mg............................................................................ 54
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
180 mg............................................................................ 54
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
240 mg............................................................................ 54
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
300 mg............................................................................ 54
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
360 mg............................................................................ 54
CARDIZEM -diltiazem hcl tab 30 mg................................ 54
CARDIZEM -diltiazem hcl tab 60 mg................................ 54
CARDIZEM -diltiazem hcl tab 120 mg.............................. 54
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
120 mg............................................................................ 54
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
180 mg............................................................................ 54
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
240 mg............................................................................ 54
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
300 mg............................................................................ 54
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
360 mg............................................................................ 54
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
420 mg............................................................................ 54
CARDURA -doxazosin mesylate tab 1 mg....................... 60
CARDURA -doxazosin mesylate tab 2 mg....................... 60
CARDURA -doxazosin mesylate tab 4 mg....................... 60
CARDURA -doxazosin mesylate tab 8 mg....................... 60
CARDURA XL -doxazosin mesylate tab sr 24 hr 4 mg
(base equiv).................................................................... 93
CARDURA XL -doxazosin mesylate tab sr 24 hr 8 mg
(base equiv).................................................................... 93
CAREONE BLOOD GLUCOSE MON -blood glucose
monitoring kit w/ device................................................ 180
CARESENS N BLOOD GLUCOSE -blood glucose
monitoring devices........................................................ 180
CARESENS N GLUCOSE MONITO -blood glucose
monitoring devices........................................................ 180
CARESENS N VOICE BLOOD GL -blood glucose
monitoring devices........................................................ 180
carisoprodol tab 350 mg (Soma)................................. 144
carisoprodol w/ aspirin & codeine tab 200-325-16
mg................................................................................. 144
carisoprodol w/ aspirin tab 200-325 mg......................144
CARNITOR -levocarnitine oral soln 1 gm/10ml (10%)...... 45
CARNITOR -levocarnitine tab 330 mg.............................. 45
CARNITOR SF -levocarnitine oral soln 1 gm/10ml
(10%)............................................................................... 45
carteolol hcl ophth soln 1%......................................... 159
carvedilol tab 3.125 mg (Coreg)..................................... 51
carvedilol tab 6.25 mg (Coreg)....................................... 51
carvedilol tab 12.5 mg (Coreg)....................................... 51
carvedilol tab 25 mg (Coreg).......................................... 52
CASODEX -bicalutamide tab 50 mg................................. 21
CATAPRES -clonidine hcl tab 0.1 mg............................... 60
CATAPRES -clonidine hcl tab 0.2 mg............................... 60
CATAPRES -clonidine hcl tab 0.3 mg............................... 60
CATAPRES-TTS-1 -clonidine hcl td patch weekly 0.1
mg/24hr........................................................................... 60
CATAPRES-TTS-2 -clonidine hcl td patch weekly 0.2
mg/24hr........................................................................... 60
CATAPRES-TTS-3 -clonidine hcl td patch weekly 0.3
mg/24hr........................................................................... 60
CAYA -diaphragm arc-spring........................................... 180
CAYSTON -aztreonam lysine for inhal soln 75 mg (base
equivalent)....................................................................... 15
CEDAX -ceftibuten cap 400 mg.......................................... 2
CEDAX -ceftibuten for susp 90 mg/5ml.............................. 2
CEDAX -ceftibuten for susp 180 mg/5ml............................ 2
CEENU -lomustine cap 10 mg.......................................... 21
CEENU -lomustine cap 40 mg.......................................... 21
CEENU -lomustine cap 100 mg........................................ 21
cefaclor cap 250 mg.......................................................... 2
cefaclor cap 500 mg.......................................................... 2
CEFACLOR -cefaclor for susp 125 mg/5ml........................ 2
CEFACLOR -cefaclor for susp 250 mg/5ml........................ 2
CEFACLOR -cefaclor for susp 375 mg/5ml........................ 2
CEFACLOR ER -cefaclor monohydrate tab sr 12hr 500
mg...................................................................................... 2
cefadroxil cap 500 mg....................................................... 2
cefadroxil for susp 250 mg/5ml....................................... 2
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cefadroxil for susp 500 mg/5ml....................................... 2
cefadroxil tab 1 gm............................................................ 2
cefdinir cap 300 mg........................................................... 2
cefdinir for susp 125 mg/5ml........................................... 2
cefdinir for susp 250 mg/5ml........................................... 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg
(base equivalent).............................................................. 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg
(base equivalent).............................................................. 2
cefixime for susp 100 mg/5ml (Suprax).......................... 2
cefixime for susp 200 mg/5ml (Suprax).......................... 2
cefpodoxime proxetil for susp 50 mg/5ml...................... 2
cefpodoxime proxetil for susp 100 mg/5ml.................... 2
cefpodoxime proxetil tab 100 mg.................................... 2
cefpodoxime proxetil tab 200 mg.................................... 2
cefprozil for susp 125 mg/5ml..........................................2
cefprozil for susp 250 mg/5ml..........................................2
cefprozil tab 250 mg.......................................................... 2
cefprozil tab 500 mg.......................................................... 2
CEFTIBUTEN -ceftibuten cap 400 mg................................ 2
CEFTIBUTEN -ceftibuten for susp 180 mg/5ml.................. 2
CEFTIN -cefuroxime axetil for susp 125 mg/5ml................ 2
CEFTIN -cefuroxime axetil for susp 250 mg/5ml................ 2
CEFTIN -cefuroxime axetil tab 250 mg............................... 2
CEFTIN -cefuroxime axetil tab 500 mg............................... 2
cefuroxime axetil tab 250 mg (Ceftin)............................. 2
cefuroxime axetil tab 500 mg (Ceftin)............................. 2
CELEBREX -celecoxib cap 50 mg.................................. 128
CELEBREX -celecoxib cap 100 mg................................ 128
CELEBREX -celecoxib cap 200 mg................................ 128
CELEBREX -celecoxib cap 400 mg................................ 128
celecoxib cap 50 mg (Celebrex).................................. 128
celecoxib cap 100 mg (Celebrex)................................ 128
celecoxib cap 200 mg (Celebrex)................................ 128
celecoxib cap 400 mg (Celebrex)................................ 128
CELEXA -citalopram hydrobromide tab 10 mg (base
equiv)............................................................................... 96
CELEXA -citalopram hydrobromide tab 20 mg (base
equiv)............................................................................... 96
CELEXA -citalopram hydrobromide tab 40 mg (base
equiv)............................................................................... 96
CELLCEPT INTRAVENOUS -mycophenolate mofetil hcl
for iv soln 500 mg (base equiv)................................... 191
CELLCEPT -mycophenolate mofetil cap 250 mg........... 191
CELLCEPT -mycophenolate mofetil for oral susp 200 mg/
ml................................................................................... 191
CELLCEPT -mycophenolate mofetil tab 500 mg............ 191
CELONTIN -methsuximide cap 300 mg.......................... 135
CENTANY -mupirocin oint 2%.........................................168
cephalexin cap 250 mg (Keflex)....................................... 3
cephalexin cap 500 mg (Keflex)....................................... 3
cephalexin cap 750 mg (Keflex)....................................... 3
CEPHALEXIN -cephalexin tab 250 mg............................... 3
CEPHALEXIN -cephalexin tab 500 mg............................... 3
cephalexin for susp 125 mg/5ml...................................... 3
cephalexin for susp 250 mg/5ml...................................... 3
CERDELGA -eliglustat tartrate cap 84 mg (base
equivalent)..................................................................... 148
CERVARIX -human papillomavirus (hpv) bival (type 16,
18) recmb vac inj............................................................ 16
CERVIDIL -dinoprostone vaginal inserts 10 mg............... 44
CESAMET -nabilone cap 1 mg......................................... 87
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml).................. 76
CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 163
CETROTIDE -cetrorelix acetate for inj kit 0.25 mg........... 45
cevimeline hcl cap 30 mg (Evoxac)............................. 163
CHANTIX CONTINUING MONTH -varenicline tartrate tab
1 mg (base equiv)........................................................ 114
CHANTIX STARTING MONTH PA -varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42 pack............................... 114
CHANTIX -varenicline tartrate tab 0.5 mg (base
equiv)............................................................................. 114
CHANTIX -varenicline tartrate tab 1 mg (base
equiv)............................................................................. 114
CHEMET -succimer cap 100 mg.................................... 177
CHEMSTRIP BG LOG BOOK -blood glucose monitoring
misc............................................................................... 180
CHENODAL -chenodiol tab 250 mg................................. 89
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg........................................... 114
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg............................................ 114
chlordiazepoxide hcl cap 5 mg...................................... 94
chlordiazepoxide hcl cap 10 mg.................................... 95
chlordiazepoxide hcl cap 25 mg.................................... 95
chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg
(Librax)........................................................................... 84
chlorhexidine gluconate soln 0.12% (Peridex)...........164
chloroquine phosphate tab 250 mg.............................. 14
chloroquine phosphate tab 500 mg (Aralen)................ 14
CHLOROTHIAZIDE -chlorothiazide tab 250 mg............... 67
chlorothiazide tab 500 mg.............................................. 67
CHLORPROMAZINE HCL -chlorpromazine hcl inj 25 mg/
ml................................................................................... 102
CHLORPROMAZINE HCL -chlorpromazine hcl inj 50
mg/2ml........................................................................... 102
chlorpromazine hcl tab 10 mg..................................... 102
chlorpromazine hcl tab 25 mg..................................... 102
chlorpromazine hcl tab 50 mg..................................... 102
chlorpromazine hcl tab 100 mg................................... 102
chlorpromazine hcl tab 200 mg................................... 102
CHLORPROPAMIDE -chlorpropamide tab 100 mg.......... 36
CHLORPROPAMIDE -chlorpropamide tab 250 mg.......... 36
CHLORTHALIDONE -chlorthalidone tab 25 mg............... 67
CHLORTHALIDONE -chlorthalidone tab 50 mg............... 67
chlorzoxazone tab 500 mg (Parafon forte dsc).......... 144
CHOICE DM DIABETES RISK I -blood glucose
monitoring kit................................................................. 180
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CHOICE DM FORA G20 BLOOD -blood glucose
monitoring devices........................................................ 180
CHOLBAM -cholic acid cap 50 mg................................... 89
CHOLBAM -cholic acid cap 250 mg................................. 89
cholecalciferol cap 400 unit......................................... 145
cholecalciferol cap 1000 unit....................................... 145
cholecalciferol cap 50000 unit..................................... 145
cholecalciferol chew tab 400 unit................................ 145
cholecalciferol chew tab 1000 unit.............................. 145
cholecalciferol drops 400 unit/0.03ml (per drop)....... 145
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml).....................................................................145
cholecalciferol oral liquid 400 unit/ml......................... 145
cholecalciferol tab 400 unit.......................................... 145
cholecalciferol tab 1000 unit........................................ 145
cholecalciferol tab 50000 unit...................................... 145
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................ 69
cholestyramine light powder packets 4 gm................. 69
cholestyramine powder 4 gm/dose (Questran)............ 69
cholestyramine powder packets 4 gm (Questran)....... 69
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix).............................................................. 69
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix).............................................................. 69
chorionic gonadotropin for inj 10000 unit.................... 45
CIALIS -tadalafil tab 2.5 mg......................................... 74,75
CIALIS -tadalafil tab 5 mg............................................ 74,75
CIALIS -tadalafil tab 10 mg.......................................... 74,75
CIALIS -tadalafil tab 20 mg.......................................... 74,75
ciclopirox gel 0.77%...................................................... 168
ciclopirox olamine cream 0.77% (base equiv)............168
ciclopirox olamine susp 0.77% (base equiv).............. 168
ciclopirox shampoo 1% (Loprox shampoo)............... 168
ciclopirox solution 8% (Penlac Nail Lacquer)............ 168
cilostazol tab 50 mg (Pletal)......................................... 154
cilostazol tab 100 mg (Pletal)....................................... 154
CILOXAN -ciprofloxacin hcl ophth oint 0.3%.................. 159
CILOXAN -ciprofloxacin hcl ophth soln 0.3%..................159
cimetidine hcl soln 300 mg/5ml..................................... 84
cimetidine tab 200 mg..................................................... 84
cimetidine tab 300 mg..................................................... 84
cimetidine tab 400 mg..................................................... 84
cimetidine tab 800 mg..................................................... 84
CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............ 89
CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200
mg/ml............................................................................... 89
CIPRO -ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml).......................................................................... 6
CIPRO -ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml).......................................................................... 6
CIPRO -ciprofloxacin hcl tab 250 mg (base equiv)............. 6
CIPRO -ciprofloxacin hcl tab 500 mg (base equiv)............. 6
CIPRODEX -ciprofloxacin-dexamethasone otic susp
0.3-0.1%........................................................................ 163
CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 163
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)................................................... 6
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)........................................................ 6
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro)........................................................... 6
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)........................................................... 6
CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg
(base equiv)...................................................................... 6
ciprofloxacin hcl ophth soln 0.3% (Ciloxan).............. 159
ciprofloxacin hcl tab 750 mg (base equiv)..................... 6
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 6
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 6
CIPRO HC -ciprofloxacin-hydrocortisone otic susp
0.2-1%........................................................................... 163
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr
1000 mg(base eq)............................................................ 6
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500
mg (base eq).....................................................................6
citalopram hydrobromide oral soln 10 mg/5ml............ 96
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 96
citalopram hydrobromide tab 20 mg (base equiv)
(Celexa)........................................................................... 96
citalopram hydrobromide tab 40 mg (base equiv)
(Celexa)........................................................................... 96
CITRANATAL HARMONY -prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg............................................... 146
CLARINEX -desloratadine syrup 0.5 mg/ml......................76
CLARINEX -desloratadine tab 5 mg................................. 76
CLARINEX-D 12 HOUR -desloratadine &
pseudoephedrine tab sr 12hr 2.5-120 mg......................77
CLARINEX REDITABS -desloratadine tab orally
disintegrating 2.5 mg...................................................... 76
CLARINEX REDITABS -desloratadine tab orally
disintegrating 5 mg......................................................... 76
clarithromycin for susp 125 mg/5ml............................... 3
clarithromycin for susp 250 mg/5ml (Biaxin)................. 3
clarithromycin tab 250 mg (Biaxin)................................. 3
clarithromycin tab 500 mg (Biaxin)................................. 3
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)......... 3
clemastine fumarate tab 2.68 mg.................................. 76
CLEOCIN -clindamycin hcl cap 75 mg............................. 15
CLEOCIN -clindamycin hcl cap 150 mg........................... 15
CLEOCIN -clindamycin hcl cap 300 mg........................... 15
CLEOCIN -clindamycin phosphate vaginal cream 2%......92
CLEOCIN -clindamycin phosphate vaginal suppos 100
mg.................................................................................... 92
CLEOCIN PEDIATRIC GRANULE -clindamycin palmitate
hcl for soln 75 mg/5ml (base equiv)...............................15
CLEOCIN-T -clindamycin phosphate gel 1%.................. 168
CLEOCIN-T -clindamycin phosphate lotion 1%.............. 168
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CLEOCIN-T -clindamycin phosphate soln 1%................ 168
CLEOCIN-T -clindamycin phosphate swab 1%.............. 168
CLEVER CHEK AUTO-CODE BLO -blood glucose
monitoring devices........................................................ 180
CLEVER CHEK AUTO-CODE VOI -blood glucose
monitoring devices........................................................ 181
CLEVER CHEK AUTO CODE VOI -blood glucose
monitoring devices........................................................ 180
CLEVER CHEK BLOOD GLUCOSE -blood glucose
monitoring kit w/ device................................................ 181
CLEVER CHOICE AUTO-CODE P -blood glucose
monitoring devices........................................................ 181
CLEVER CHOICE MICRO BLOOD -blood glucose
monitoring kit w/ device................................................ 181
CLEVER CHOICE MINI BLOOD -blood glucose
monitoring devices........................................................ 181
CLIMARA -estradiol td patch weekly 0.025 mg/24hr........ 29
CLIMARA -estradiol td patch weekly 0.05 mg/24hr.......... 29
CLIMARA -estradiol td patch weekly 0.06 mg/24hr.......... 29
CLIMARA -estradiol td patch weekly 0.075 mg/24hr........ 29
CLIMARA -estradiol td patch weekly 0.1 mg/24hr............ 29
CLIMARA -estradiol td patch weekly 0.0375 mg/24hr
(37.5 mcg/24hr)...............................................................29
CLIMARA PRO -estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day........................................................ 29
CLINDAGEL -clindamycin phosphate gel 1%................. 168
clindamycin hcl cap 75 mg (Cleocin)............................ 15
clindamycin hcl cap 150 mg (Cleocin).......................... 15
clindamycin hcl cap 300 mg (Cleocin).......................... 15
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)........................................15
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)................................................................... 168
clindamycin phosphate foam 1% (Evoclin)................ 168
clindamycin phosphate gel 1% (Cleocin-t)................. 168
clindamycin phosphate lotion 1% (Cleocin-t)............ 168
clindamycin phosphate soln 1% (Cleocin-t)............... 168
clindamycin phosphate swab 1% (Cleocin-t)............. 168
clindamycin phosphate vaginal cream 2%
(Cleocin)......................................................................... 92
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)............................................................... 168
CLINDESSE -clindamycin phosphate (one dose) vaginal
cream 2%........................................................................ 92
clobetasol propionate cream 0.05% (Temovate)........ 168
clobetasol propionate emollient base cream 0.05%
(Temovate e)................................................................ 168
clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 168
clobetasol propionate foam 0.05% (Olux).................. 168
clobetasol propionate gel 0.05% (Temovate)............. 168
clobetasol propionate lotion 0.05% (Clobex)............. 168
clobetasol propionate oint 0.05% (Temovate)............ 168
clobetasol propionate shampoo 0.05% (Clobex)....... 168
clobetasol propionate soln 0.05% (Temovate)........... 168
clobetasol propionate spray 0.05% (Clobex)............. 168
CLOBEX -clobetasol propionate lotion 0.05%................ 168
CLOBEX -clobetasol propionate shampoo 0.05%.......... 168
CLOBEX -clobetasol propionate spray 0.05%................ 168
CLOCORTOLONE PIVALATE -clocortolone pivalate
cream 0.1%................................................................... 168
CLOCORTOLONE PIVALATE PUM -clocortolone pivalate
cream 0.1%................................................................... 168
CLODERM -clocortolone pivalate cream 0.1%............... 169
CLODERM PUMP -clocortolone pivalate cream
0.1%...............................................................................169
clomiphene citrate tab 50 mg........................................ 45
clomipramine hcl cap 25 mg (Anafranil)....................... 96
clomipramine hcl cap 50 mg (Anafranil)....................... 96
clomipramine hcl cap 75 mg (Anafranil)....................... 96
clonazepam orally disintegrating tab 0.125 mg......... 135
clonazepam orally disintegrating tab 0.25 mg........... 135
clonazepam orally disintegrating tab 0.5 mg............. 135
clonazepam orally disintegrating tab 1 mg................ 135
clonazepam orally disintegrating tab 2 mg................ 135
clonazepam tab 0.5 mg (Klonopin).............................. 135
clonazepam tab 1 mg (Klonopin)................................. 135
clonazepam tab 2 mg (Klonopin)................................. 135
clonidine hcl tab 0.1 mg (Catapres).............................. 60
clonidine hcl tab 0.2 mg (Catapres).............................. 60
clonidine hcl tab 0.3 mg (Catapres).............................. 60
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................. 110
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 60
clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2)................................................................................ 60
clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3)................................................................................ 60
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix).......................................................................... 154
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix).......................................................................... 154
clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 95
clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 95
clorazepate dipotassium tab 15 mg (Tranxene t)......... 95
CLORPRES -clonidine & chlorthalidone tab 0.1-15
mg.................................................................................... 60
CLORPRES -clonidine & chlorthalidone tab 0.2-15
mg.................................................................................... 60
CLORPRES -clonidine & chlorthalidone tab 0.3-15
mg.................................................................................... 60
clotrimazole cream 1%.................................................. 169
clotrimazole soln 1%..................................................... 169
clotrimazole troche 10 mg............................................ 164
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).................................................................... 169
clotrimazole w/ betamethasone lotion 1-0.05%..........169
CLOZAPINE ODT -clozapine orally disintegrating tab 12.5
mg.................................................................................. 102
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CLOZAPINE ODT -clozapine orally disintegrating tab 150
mg.................................................................................. 102
CLOZAPINE ODT -clozapine orally disintegrating tab 200
mg.................................................................................. 102
clozapine orally disintegrating tab 25 mg
(Fazaclo)....................................................................... 102
clozapine orally disintegrating tab 100 mg
(Fazaclo)....................................................................... 102
clozapine tab 50 mg...................................................... 102
clozapine tab 200 mg.................................................... 102
clozapine tab 25 mg (Clozaril)..................................... 102
clozapine tab 100 mg (Clozaril)................................... 102
CLOZARIL -clozapine tab 25 mg.................................... 102
CLOZARIL -clozapine tab 100 mg.................................. 102
COAGADEX -coagulation factor x (human) for inj 250
unit................................................................................. 154
COAGADEX -coagulation factor x (human) for inj 500
unit................................................................................. 154
COAGUCHEK LANCETS -lancets.................................. 181
COARTEM -artemether-lumefantrine tab 20-120 mg....... 14
CODAR D -pseudoephedrine w/ codeine liquid 30-8
mg/5ml............................................................................. 78
CODEINE SULFATE -codeine sulfate tab 15 mg........... 121
CODEINE SULFATE -codeine sulfate tab 30 mg........... 121
CODEINE SULFATE -codeine sulfate tab 60 mg........... 121
codeine sulfate tab 30 mg............................................ 121
codeine sulfate tab 60 mg............................................ 121
codeine sulfate tab 15 mg (Codeine sulfate).............. 121
COD LIVER OIL -cod liver oil......................................... 146
COLAZAL -balsalazide disodium cap 750 mg.................. 89
COLCHICINE -colchicine cap 0.6 mg............................. 134
COLCHICINE -colchicine tab 0.6 mg.............................. 134
colchicine w/ probenecid tab 0.5-500 mg................... 134
COLCRYS -colchicine tab 0.6 mg................................... 134
COLESTID -colestipol hcl granule packets 5 gm.............. 69
COLESTID -colestipol hcl granules 5 gm......................... 70
COLESTID -colestipol hcl tab 1 gm.................................. 70
COLESTID FLAVORED -colestipol hcl granule packets 5
gm.................................................................................... 70
COLESTID FLAVORED -colestipol hcl granules 5 gm..... 70
colestipol hcl granule packets 5 gm (Colestid
flavored)......................................................................... 70
colestipol hcl granules 5 gm (Colestid flavored)......... 70
colestipol hcl tab 1 gm (Colestid)..................................70
COLGATE DRY MOUTH RELIEF -sodium fluoride
mouthwash 2.1 mg/10ml.............................................. 164
COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml.............................................. 163
COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm............................................. 83
COMBIGAN -brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%................................................................ 159
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.14 mg/day............................................................ 29
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.25 mg/day............................................................ 29
COMBIVENT RESPIMAT -ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act.......................................... 80
COMBIVIR -lamivudine-zidovudine tab 150-300 mg.......... 9
COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg
dose) kit........................................................................... 21
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit............................................................21
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit............................................................21
COMMIT -nicotine polacrilex lozenge 2 mg.................... 114
COMMIT -nicotine polacrilex lozenge 4 mg.................... 114
COMPAZINE -prochlorperazine maleate tab 5 mg (base
equivalent)..................................................................... 103
COMPAZINE -prochlorperazine maleate tab 10 mg (base
equivalent)..................................................................... 103
COMPLERA -emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................. 9
COMTAN -entacapone tab 200 mg................................. 141
COMVAX -haemophilus b polysac conj-hepatitis b
(recomb) vac im susp..................................................... 16
CONCERTA -methylphenidate hcl tab sa osm 18
mg.................................................................................. 110
CONCERTA -methylphenidate hcl tab sa osm 27
mg.................................................................................. 110
CONCERTA -methylphenidate hcl tab sa osm 36
mg.................................................................................. 110
CONCERTA -methylphenidate hcl tab sa osm 54
mg.................................................................................. 110
CONDYLOX -podofilox gel 0.5%.................................... 169
CONDYLOX -podofilox soln 0.5%................................... 169
CONTROL BLOOD GLUCOSE MON -blood glucose
monitoring kit w/ device................................................ 181
CONZIP -tramadol hcl cap sr 24hr biphasic release 100
mg.................................................................................. 121
CONZIP -tramadol hcl cap sr 24hr biphasic release 200
mg.................................................................................. 121
CONZIP -tramadol hcl cap sr 24hr biphasic release 300
mg.................................................................................. 121
COPAXONE -glatiramer acetate soln prefilled syringe 20
mg/ml............................................................................. 115
COPAXONE -glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................. 115
COPEGUS -ribavirin tab 200 mg........................................ 9
CORDARONE -amiodarone hcl tab 200 mg..................... 57
CORDRAN -flurandrenolide cream 0.05%...................... 169
CORDRAN -flurandrenolide lotion 0.05%....................... 169
CORDRAN -flurandrenolide oint 0.05%.......................... 169
CORDRAN TAPE -flurandrenolide tape 4 mcg/sqcm..... 169
COREG -carvedilol tab 3.125 mg..................................... 52
COREG -carvedilol tab 6.25 mg....................................... 52
COREG -carvedilol tab 12.5 mg....................................... 52
COREG -carvedilol tab 25 mg.......................................... 52
COREG CR -carvedilol phosphate cap sr 24hr 10 mg..... 52
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COREG CR -carvedilol phosphate cap sr 24hr 20 mg..... 52
COREG CR -carvedilol phosphate cap sr 24hr 40 mg..... 52
COREG CR -carvedilol phosphate cap sr 24hr 80 mg..... 52
CORGARD -nadolol tab 20 mg......................................... 52
CORGARD -nadolol tab 40 mg......................................... 52
CORGARD -nadolol tab 80 mg......................................... 52
CORIFACT -factor xiii concentrate (human) for inj kit
1000-1600 unit.............................................................. 154
CORLANOR -ivabradine hcl tab 5 mg (base equiv)......... 74
CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)...... 74
CORTEF -hydrocortisone tab 5 mg...................................26
CORTEF -hydrocortisone tab 10 mg.................................26
CORTEF -hydrocortisone tab 20 mg.................................26
CORTENEMA -hydrocortisone enema 100 mg/60ml..... 166
CORTIFOAM -hydrocortisone acetate rectal foam 10%
(90 mg/dose)................................................................. 166
CORTISONE ACETATE -cortisone acetate tab 25 mg..... 26
CORTISPORIN -bacitracin-polymyxin-neomycin hc oint
1%.................................................................................. 169
CORTISPORIN -neomycin-polymyxin-hc cream
0.5%...............................................................................169
CORTISPORIN -neomycin-polymyxin-hc otic soln
1%.................................................................................. 163
CORTISPORIN-TC -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml.............................................. 163
CORZIDE -nadolol & bendroflumethiazide tab 40-5
mg.................................................................................... 60
CORZIDE -nadolol & bendroflumethiazide tab 80-5
mg.................................................................................... 60
COSENTYX -secukinumab subcutaneous soln prefilled
syringe 150 mg/ml........................................................ 169
COSENTYX SENSOREADY PEN -secukinumab
subcutaneous soln auto-injector 150 mg/ml................ 169
COSOPT -dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml.............................................................. 159
COSOPT PF -dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf..........................................................159
COTELLIC -cobimetinib fumarate tab 20 mg (base
equivalent)....................................................................... 21
COUMADIN -warfarin sodium tab 1 mg.......................... 150
COUMADIN -warfarin sodium tab 2 mg.......................... 150
COUMADIN -warfarin sodium tab 2.5 mg....................... 150
COUMADIN -warfarin sodium tab 3 mg.......................... 150
COUMADIN -warfarin sodium tab 4 mg.......................... 150
COUMADIN -warfarin sodium tab 5 mg.......................... 150
COUMADIN -warfarin sodium tab 6 mg.......................... 150
COUMADIN -warfarin sodium tab 7.5 mg....................... 150
COUMADIN -warfarin sodium tab 10 mg........................ 150
COZAAR -losartan potassium tab 25 mg..........................60
COZAAR -losartan potassium tab 50 mg..........................60
COZAAR -losartan potassium tab 100 mg........................61
CREON -pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit.....................................................88
CREON -pancrelipase (lip-prot-amyl) dr cap
6000-19000-30000 unit...................................................88
CREON -pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit................................................ 88
CREON -pancrelipase (lip-prot-amyl) dr cap
24000-76000-120000 unit.............................................. 88
CREON -pancrelipase (lip-prot-amyl) dr cap
36000-114000-180000 unit............................................. 88
CRESEMBA -isavuconazonium sulfate cap 186 mg.......... 7
CREST COMPLETE -sodium fluoride paste 0.243%..... 164
CRESTOR -rosuvastatin calcium tab 5 mg.......................70
CRESTOR -rosuvastatin calcium tab 10 mg.....................70
CRESTOR -rosuvastatin calcium tab 20 mg.....................70
CRESTOR -rosuvastatin calcium tab 40 mg.....................70
CRINONE -progesterone vaginal gel 4%.......................... 92
CRINONE -progesterone vaginal gel 8%.......................... 92
CRIXIVAN -indinavir sulfate cap 200 mg............................ 9
CRIXIVAN -indinavir sulfate cap 400 mg............................ 9
CROMOLYN SODIUM -cromolyn sodium soln nebu 20
mg/2ml............................................................................. 80
cromolyn sodium ophth soln 4%................................ 159
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom).................................................................. 89
CUPRIMINE -penicillamine cap 250 mg......................... 191
CUROSURF -poractant alfa intratracheal susp 80 mg/
ml..................................................................................... 83
CUTIVATE -fluticasone propionate cream 0.05%........... 169
CUTIVATE -fluticasone propionate lotion 0.05%.............169
CUVPOSA -glycopyrrolate oral soln 1 mg/5ml................. 84
CVS ADVANCED GLUCOSE METE -blood glucose
monitoring kit w/ device................................................ 181
CVS GLUCOSE BITS -glucose chew tab 1 gm................ 36
CVS GLUCOSE -glucose chew tab 4 gm......................... 36
cyanocobalamin inj 1000 mcg/ml................................ 148
CYCLESSA -desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg...................... 32
cyclobenzaprine hcl tab 5 mg...................................... 144
cyclobenzaprine hcl tab 10 mg.................................... 144
cyclobenzaprine hcl tab 7.5 mg (Fexmid)................... 144
CYCLOGYL -cyclopentolate hcl ophth soln 0.5%........... 159
CYCLOGYL -cyclopentolate hcl ophth soln 1%.............. 159
CYCLOGYL -cyclopentolate hcl ophth soln 2%.............. 159
CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth
soln 0.2-1%................................................................... 159
cyclopentolate hcl ophth soln 1% (Cyclogyl).............159
cyclopentolate hcl ophth soln 2% (Cyclogyl).............159
CYCLOPHOSPHAMIDE -cyclophosphamide cap 25
mg.................................................................................... 21
CYCLOPHOSPHAMIDE -cyclophosphamide cap 50
mg.................................................................................... 22
CYCLOSERINE -cycloserine cap 250 mg.......................... 7
CYCLOSET -bromocriptine mesylate tab 0.8 mg (base
equivalent)....................................................................... 36
cyclosporine cap 25 mg (Sandimmune)..................... 191
cyclosporine cap 100 mg (Sandimmune)................... 191
cyclosporine modified cap 25 mg (Neoral).................191
cyclosporine modified cap 100 mg (Neoral)...............191
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CYCLOSPORINE MODIFIED -cyclosporine modified cap
50 mg............................................................................ 191
cyclosporine modified oral soln 100 mg/ml
(Neoral)......................................................................... 191
CYMBALTA -duloxetine hcl enteric coated pellets cap 20
mg.................................................................................... 96
CYMBALTA -duloxetine hcl enteric coated pellets cap 30
mg.................................................................................... 96
CYMBALTA -duloxetine hcl enteric coated pellets cap 60
mg.................................................................................... 96
cyproheptadine hcl syrup 2 mg/5ml.............................. 76
cyproheptadine hcl tab 4 mg......................................... 76
CYSTADANE -betaine powder for oral solution................ 45
CYSTAGON -cysteamine bitartrate cap 50 mg.................93
CYSTAGON -cysteamine bitartrate cap 150 mg...............93
CYSTARAN -cysteamine hcl ophth soln 0.44% (base
equivalent)..................................................................... 159
CYTOMEL -liothyronine sodium tab 5 mcg.......................42
CYTOMEL -liothyronine sodium tab 25 mcg.....................42
CYTOMEL -liothyronine sodium tab 50 mcg.....................42
CYTOTEC -misoprostol tab 100 mcg................................85
CYTOTEC -misoprostol tab 200 mcg................................85
D
DAKLINZA -daclatasvir dihydrochloride tab 30 mg (base
equivalent)......................................................................... 9
DAKLINZA -daclatasvir dihydrochloride tab 60 mg (base
equivalent)......................................................................... 9
DALIRESP -roflumilast tab 500 mcg................................. 80
danazol cap 50 mg.......................................................... 28
danazol cap 100 mg........................................................ 28
danazol cap 200 mg........................................................ 28
DANTRIUM -dantrolene sodium cap 25 mg................... 144
DANTRIUM -dantrolene sodium cap 50 mg................... 144
DANTRIUM -dantrolene sodium cap 100 mg................. 144
dantrolene sodium cap 25 mg (Dantrium).................. 144
dantrolene sodium cap 50 mg (Dantrium).................. 144
DANTROLENE SODIUM -dantrolene sodium cap 100
mg.................................................................................. 144
DAPSONE -dapsone tab 25 mg....................................... 15
DAPSONE -dapsone tab 100 mg..................................... 15
DAPTACEL -diph, acellular pert & tet tox inj 15 lf-10
mcg-5 lf/0.5ml................................................................. 20
DARAPRIM -pyrimethamine tab 25 mg............................ 14
DAYPRO -oxaprozin tab 600 mg.................................... 129
DAYTRANA -methylphenidate td patch 10 mg/9hr......... 110
DAYTRANA -methylphenidate td patch 15 mg/9hr......... 110
DAYTRANA -methylphenidate td patch 20 mg/9hr......... 110
DAYTRANA -methylphenidate td patch 30 mg/9hr......... 110
DDAVP -desmopressin acetate nasal soln 0.01%
(refrigerated).................................................................... 45
DDAVP -desmopressin acetate nasal spray soln
0.01%...............................................................................45
DDAVP -desmopressin acetate tab 0.1 mg...................... 45
DDAVP -desmopressin acetate tab 0.2 mg...................... 45
DDROPS -cholecalciferol drops 1000 unit/0.03ml (per
drop).............................................................................. 145
DECARA -cholecalciferol cap 25000 unit....................... 146
DELESTROGEN -estradiol valerate im in oil 10 mg/
ml..................................................................................... 29
DELESTROGEN -estradiol valerate im in oil 20 mg/
ml..................................................................................... 29
DELESTROGEN -estradiol valerate im in oil 40 mg/
ml..................................................................................... 29
DELZICOL -mesalamine cap dr 400 mg........................... 89
DEMADEX -torsemide tab 5 mg....................................... 67
DEMADEX -torsemide tab 10 mg..................................... 67
DEMADEX -torsemide tab 20 mg..................................... 67
demeclocycline hcl tab 150 mg....................................... 4
demeclocycline hcl tab 300 mg....................................... 4
DEMEROL -meperidine hcl tab 50 mg........................... 121
DEMEROL -meperidine hcl tab 100 mg......................... 121
DEMSER -metyrosine cap 250 mg................................... 61
DENATURED ALCOHOL -alcohol, rubbing 95%............ 178
DENAVIR -penciclovir cream 1%.................................... 169
DEPAKENE -valproate sodium syrup 250 mg/5ml (base
equiv)............................................................................. 135
DEPAKENE -valproic acid cap 250 mg...........................135
DEPAKOTE -divalproex sodium tab delayed release 125
mg.................................................................................. 135
DEPAKOTE -divalproex sodium tab delayed release 250
mg.................................................................................. 135
DEPAKOTE -divalproex sodium tab delayed release 500
mg.................................................................................. 135
DEPAKOTE ER -divalproex sodium tab sr 24 hr 250
mg.................................................................................. 135
DEPAKOTE ER -divalproex sodium tab sr 24 hr 500
mg.................................................................................. 135
DEPAKOTE SPRINKLES -divalproex sodium cap sprinkle
125 mg.......................................................................... 135
DEPEN TITRATABS -penicillamine tab 250 mg............. 191
DEPO-ESTRADIOL -estradiol cypionate im in oil 5 mg/
ml..................................................................................... 30
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml........ 32
DEPO-SUBQ PROVERA 104 -medroxyprogesterone
acetate subcutaneous susp 104 mg/0.65ml.................. 32
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 100 mg/ml.................................................................. 28
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 200 mg/ml.................................................................. 28
DERMA-SMOOTHE/FS BODY -fluocinolone acetonide oil
0.01% (body oil)............................................................ 169
DERMA-SMOOTHE/FS BODY OIL -fluocinolone
acetonide oil 0.01% (body oil)...................................... 169
DERMA-SMOOTHE/FS SCALP -fluocinolone acetonide
oil 0.01% (scalp oil)...................................................... 169
DERMA-SMOOTHE/FS SCALP OI -fluocinolone
acetonide oil 0.01% (scalp oil)..................................... 169
DERMATOP -prednicarbate cream 0.1%........................ 169
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DERMATOP -prednicarbate oint 0.1%............................ 169
DERMOTIC -fluocinolone acetonide (otic) oil 0.01%...... 163
desipramine hcl tab 10 mg (Norpramin)....................... 96
desipramine hcl tab 25 mg (Norpramin)....................... 96
desipramine hcl tab 50 mg (Norpramin)....................... 96
desipramine hcl tab 75 mg (Norpramin)....................... 97
desipramine hcl tab 100 mg (Norpramin)..................... 97
desipramine hcl tab 150 mg (Norpramin)..................... 97
desloratadine tab 5 mg (Clarinex)................................. 76
desloratadine tab orally disintegrating 2.5 mg
(Clarinex reditabs)........................................................ 76
desloratadine tab orally disintegrating 5 mg (Clarinex
reditabs)......................................................................... 76
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)........................................................................... 45
desmopressin acetate nasal spray soln 0.01%
(Ddavp)........................................................................... 45
desmopressin acetate nasal spray soln 0.01%
(refrigerated).................................................................. 45
desmopressin acetate tab 0.1 mg (Ddavp)................... 46
desmopressin acetate tab 0.2 mg (Ddavp)................... 46
DESOGEN -desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg...................................................................... 32
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette)........................................................ 32
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
(Cyclessa).......................................................................32
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)....................................................................... 32
DESONATE -desonide gel 0.05%................................... 169
desonide cream 0.05% (Desowen).............................. 169
desonide lotion 0.05% (Desowen)............................... 169
desonide oint 0.05% (Desowen).................................. 169
DESOWEN -desonide cream 0.05%...............................169
DESOWEN -desonide lotion 0.05%................................ 169
DESOWEN -desonide oint 0.05%................................... 169
desoximetasone cream 0.25% (Topicort)....................170
DESOXIMETASONE -desoximetasone cream
0.05%.............................................................................169
DESOXIMETASONE -desoximetasone oint 0.05%........ 170
desoximetasone gel 0.05% (Topicort)......................... 170
desoximetasone oint 0.25% (Topicort)........................ 170
DESOXYN -methamphetamine hcl tab 5 mg.................. 110
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)................................................ 97
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv).............................................. 97
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 50
mg.................................................................................... 97
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 100
mg.................................................................................... 97
DETROL LA -tolterodine tartrate cap sr 24hr 2 mg.......... 91
DETROL LA -tolterodine tartrate cap sr 24hr 4 mg.......... 91
DETROL -tolterodine tartrate tab 1 mg............................. 91
DETROL -tolterodine tartrate tab 2 mg............................. 91
DEXAMETHASONE -dexamethasone soln 0.5
mg/5ml............................................................................. 26
DEXAMETHASONE -dexamethasone tab 1 mg...............26
DEXAMETHASONE -dexamethasone tab 2 mg...............26
dexamethasone elixir 0.5 mg/5ml.................................. 26
DEXAMETHASONE INTENSOL -dexamethasone conc 1
mg/ml............................................................................... 26
DEXAMETHASONE SODIUM PHOS -dexamethasone
sodium phosphate ophth soln 0.1%............................. 159
dexamethasone tab 0.5 mg............................................ 26
dexamethasone tab 0.75 mg.......................................... 26
dexamethasone tab 1.5 mg............................................ 26
dexamethasone tab 4 mg............................................... 26
dexamethasone tab 6 mg............................................... 26
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 5
mg.................................................................................. 110
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 10
mg.................................................................................. 110
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 15
mg.................................................................................. 111
DEX4 FAST ACTING GLUCOSE -glucose gel 15
gm/33gm.......................................................................... 36
DEX4 FAST ACTING GLUCOSE -glucose oral liquid 15
gm/59ml........................................................................... 36
DEX4 -glucose chew tab 1 gm......................................... 36
DEX4 GLUCOSE -glucose chew tab 4 gm....................... 36
DEX4 GLUCOSE -glucose oral liquid 15 gm/59ml........... 36
DEXILANT -dexlansoprazole cap delayed release 30
mg.................................................................................... 85
DEXILANT -dexlansoprazole cap delayed release 60
mg.................................................................................... 85
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr).................................................................................. 111
dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin
xr).................................................................................. 111
dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin
xr).................................................................................. 111
dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin
xr).................................................................................. 111
dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin
xr).................................................................................. 111
dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin
xr).................................................................................. 111
dexmethylphenidate hcl tab 2.5 mg (Focalin)............ 111
dexmethylphenidate hcl tab 5 mg (Focalin)............... 111
dexmethylphenidate hcl tab 10 mg (Focalin)............. 111
DEXPAK 10 DAY -dexamethasone tab 1.5 mg taper
pack................................................................................. 26
DEXPAK 13 DAY -dexamethasone tab 1.5 mg taper
pack................................................................................. 26
DEXPAK 6 DAY -dexamethasone tab 1.5 mg taper
pack................................................................................. 26
DEX4 QUICK DISSOLVE GLUCO -glucose chew tab 4
gm.................................................................................... 36
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dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)................................................................... 111
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)................................................................... 111
dextroamphetamine sulfate cap sr 24hr 15 mg
(Dexedrine)................................................................... 111
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)................................................................... 111
dextroamphetamine sulfate tab 5 mg......................... 111
dextroamphetamine sulfate tab 10 mg....................... 111
DEX-TUSS -guaifenesin-codeine liquid 300-10
mg/5ml............................................................................. 78
DIABETA -glyburide tab 1.25 mg...................................... 36
DIABETA -glyburide tab 2.5 mg........................................ 36
DIABETA -glyburide tab 5 mg........................................... 36
DIAMOX -acetazolamide cap sr 12hr 500 mg.................. 67
DIASTAT ACUDIAL -diazepam rectal gel delivery system
10 mg............................................................................ 135
DIASTAT ACUDIAL -diazepam rectal gel delivery system
20 mg............................................................................ 135
DIASTAT PEDIATRIC -diazepam rectal gel delivery
system 2.5 mg.............................................................. 135
diazepam conc 5 mg/ml.................................................. 95
DIAZEPAM -diazepam rectal gel delivery system 2.5
mg.................................................................................. 135
DIAZEPAM -diazepam rectal gel delivery system 10
mg.................................................................................. 135
DIAZEPAM -diazepam rectal gel delivery system 20
mg.................................................................................. 135
DIAZEPAM -diazepam soln 1 mg/ml................................. 95
diazepam tab 2 mg (Valium)........................................... 95
diazepam tab 5 mg (Valium)........................................... 95
diazepam tab 10 mg (Valium)......................................... 95
DIBENZYLINE -phenoxybenzamine hcl cap 10 mg..........61
DICLEGIS -doxylamine-pyridoxine tab delayed release
10-10 mg......................................................................... 87
diclofenac potassium tab 50 mg (Cataflam)............... 129
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)..................................................................... 170
diclofenac sodium ophth soln 0.1%............................ 159
diclofenac sodium soln 1.5% (Pennsaid)................... 170
diclofenac sodium tab delayed release 25 mg........... 129
diclofenac sodium tab delayed release 50 mg........... 129
diclofenac sodium tab delayed release 75 mg........... 129
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................. 129
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50)........................................................129
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75)........................................................129
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 85
dicyclomine hcl oral soln 10 mg/5ml............................ 85
dicyclomine hcl tab 20 mg (Bentyl)............................... 85
didanosine delayed release capsule 125 mg (Videx
ec)...................................................................................... 9
didanosine delayed release capsule 200 mg (Videx
ec)...................................................................................... 9
didanosine delayed release capsule 250 mg (Videx
ec)...................................................................................... 9
didanosine delayed release capsule 400 mg (Videx
ec)...................................................................................... 9
DIDGET -blood glucose monitoring kit w/ device........... 181
DIDRONEL -etidronate disodium tab 400 mg................... 46
DIFFERIN -adapalene cream 0.1%................................ 170
DIFFERIN -adapalene gel 0.1%...................................... 170
DIFFERIN -adapalene gel 0.3%...................................... 170
DIFFERIN -adapalene lotion 0.1%.................................. 170
DIFICID -fidaxomicin tab 200 mg........................................ 3
DIFLORASONE DIACETATE -diflorasone diacetate
cream 0.05%................................................................. 170
DIFLORASONE DIACETATE -diflorasone diacetate oint
0.05%.............................................................................170
DIFLUCAN -fluconazole for susp 10 mg/ml........................ 7
DIFLUCAN -fluconazole for susp 40 mg/ml........................ 7
DIFLUCAN -fluconazole tab 50 mg..................................... 7
DIFLUCAN -fluconazole tab 100 mg................................... 7
DIFLUCAN -fluconazole tab 150 mg................................... 7
DIFLUCAN -fluconazole tab 200 mg................................... 8
diflunisal tab 500 mg..................................................... 119
DIGEX NF -hyoscyamine-phenyltoloxamine cap
0.0625-15 mg.................................................................. 85
DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 50
digoxin tab 125 mcg (0.125 mg) (Lanoxin)................... 50
digoxin tab 250 mcg (0.25 mg) (Lanoxin)..................... 50
DIHYDROERGOTAMINE MESYLAT -dihydroergotamine
mesylate nasal spray 4 mg/ml..................................... 132
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45).................................................................................. 132
DILANTIN INFATABS -phenytoin chew tab 50 mg......... 136
DILANTIN -phenytoin sodium extended cap 30 mg........135
DILANTIN -phenytoin sodium extended cap 100 mg......135
DILANTIN-125 -phenytoin susp 125 mg/5ml.................. 136
DILATRATE SR -isosorbide dinitrate cap cr 40 mg.......... 50
DILAUDID -hydromorphone hcl liqd 1 mg/ml.................. 121
DILAUDID -hydromorphone hcl tab 2 mg....................... 121
DILAUDID -hydromorphone hcl tab 4 mg....................... 121
DILAUDID -hydromorphone hcl tab 8 mg....................... 121
diltiazem hcl cap sr 12hr 60 mg.....................................54
diltiazem hcl cap sr 12hr 90 mg.....................................54
diltiazem hcl cap sr 12hr 120 mg...................................54
diltiazem hcl cap sr 24hr 120 mg...................................54
diltiazem hcl cap sr 24hr 180 mg...................................54
diltiazem hcl cap sr 24hr 240 mg...................................54
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................ 54
diltiazem hcl coated beads cap sr 24hr 180 mg
(Cardizem cd)................................................................ 54
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diltiazem hcl coated beads cap sr 24hr 240 mg
(Cardizem cd)................................................................ 54
diltiazem hcl coated beads cap sr 24hr 300 mg
(Cardizem cd)................................................................ 54
diltiazem hcl coated beads cap sr 24hr 360 mg
(Cardizem cd)................................................................ 54
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la)................................................................. 54
diltiazem hcl coated beads tab sr 24hr 240 mg
(Cardizem la)................................................................. 54
diltiazem hcl coated beads tab sr 24hr 300 mg
(Cardizem la)................................................................. 54
diltiazem hcl coated beads tab sr 24hr 360 mg
(Cardizem la)................................................................. 55
diltiazem hcl coated beads tab sr 24hr 420 mg
(Cardizem la)................................................................. 55
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).................................................................... 55
diltiazem hcl extended release beads cap sr 24hr 180
mg (Tiazac).................................................................... 55
diltiazem hcl extended release beads cap sr 24hr 240
mg (Tiazac).................................................................... 55
diltiazem hcl extended release beads cap sr 24hr 300
mg (Tiazac).................................................................... 55
diltiazem hcl extended release beads cap sr 24hr 360
mg (Tiazac).................................................................... 55
diltiazem hcl extended release beads cap sr 24hr 420
mg (Tiazac).................................................................... 55
diltiazem hcl tab 90 mg................................................... 55
diltiazem hcl tab 30 mg (Cardizem)............................... 55
diltiazem hcl tab 60 mg (Cardizem)............................... 55
diltiazem hcl tab 120 mg (Cardizem)............................. 55
DIOVAN HCT -valsartan-hydrochlorothiazide tab 80-12.5
mg.................................................................................... 61
DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-12.5
mg.................................................................................... 61
DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-25
mg.................................................................................... 61
DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-12.5
mg.................................................................................... 61
DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-25
mg.................................................................................... 61
DIOVAN -valsartan tab 40 mg........................................... 61
DIOVAN -valsartan tab 80 mg........................................... 61
DIOVAN -valsartan tab 160 mg......................................... 61
DIOVAN -valsartan tab 320 mg......................................... 61
DIPENTUM -olsalazine sodium cap 250 mg.....................89
diphenhydramine hcl cap 50 mg................................... 76
diphenhydramine hcl elixir 12.5 mg/5ml....................... 76
DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine
liq 2.5-0.025 mg/5ml....................................................... 84
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)......................................................................... 84
DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox
adsorbed (dt) im inj 25-5 unit/0.5ml............................... 20
DIPROLENE AF -betamethasone dipropionate
augmented cream 0.05%............................................. 170
DIPROLENE -betamethasone dipropionate augmented
lotion 0.05%.................................................................. 170
DIPROLENE -betamethasone dipropionate augmented
oint 0.05%..................................................................... 170
dipyridamole tab 25 mg (Persantine).......................... 154
dipyridamole tab 50 mg (Persantine).......................... 154
dipyridamole tab 75 mg (Persantine).......................... 154
disopyramide phosphate cap 100 mg (Norpace)......... 57
disopyramide phosphate cap 150 mg (Norpace)......... 57
disulfiram tab 250 mg (Antabuse)............................... 115
disulfiram tab 500 mg (Antabuse)............................... 115
DITROPAN XL -oxybutynin chloride tab sr 24hr 5 mg...... 91
DITROPAN XL -oxybutynin chloride tab sr 24hr 10
mg.................................................................................... 92
DITROPAN XL -oxybutynin chloride tab sr 24hr 15
mg.................................................................................... 92
DIURIL -chlorothiazide susp 250 mg/5ml......................... 67
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles)......................................................................136
divalproex sodium tab delayed release 125 mg
(Depakote).................................................................... 136
divalproex sodium tab delayed release 250 mg
(Depakote).................................................................... 136
divalproex sodium tab delayed release 500 mg
(Depakote).................................................................... 136
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................. 136
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................. 136
DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)........... 30
DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)............... 30
DIVIGEL -estradiol td gel 1 mg/gm (0.1%)....................... 30
DOLOPHINE -methadone hcl tab 5 mg.......................... 121
DOLOPHINE -methadone hcl tab 10 mg........................ 121
donepezil hydrochloride orally disintegrating tab 5
mg................................................................................. 115
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt).......................................................... 115
donepezil hydrochloride tab 5 mg (Aricept)............... 115
donepezil hydrochloride tab 10 mg (Aricept)............. 115
donepezil hydrochloride tab 23 mg (Aricept)............. 115
DORAL -quazepam tab 15 mg........................................ 108
DORYX -doxycycline hyclate tab delayed release 50
mg...................................................................................... 4
DORYX -doxycycline hyclate tab delayed release 200
mg...................................................................................... 4
dorzolamide hcl ophth soln 2% (Trusopt).................. 159
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt)............................................................159
DOVONEX -calcipotriene cream 0.005%........................170
doxazosin mesylate tab 1 mg (Cardura)....................... 61
doxazosin mesylate tab 2 mg (Cardura)....................... 61
doxazosin mesylate tab 4 mg (Cardura)....................... 61
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doxazosin mesylate tab 8 mg (Cardura)....................... 61
doxepin hcl cap 10 mg....................................................97
doxepin hcl cap 25 mg....................................................97
doxepin hcl cap 50 mg....................................................97
doxepin hcl cap 100 mg..................................................97
doxepin hcl cap 150 mg..................................................97
doxepin hcl conc 10 mg/ml............................................ 97
DOXEPIN HCL -doxepin hcl cap 75 mg........................... 97
doxercalciferol cap 0.5 mcg (Hectorol)......................... 46
doxercalciferol cap 1 mcg (Hectorol)............................ 46
doxercalciferol cap 2.5 mcg (Hectorol)......................... 46
DOXYCYCLINE -doxycycline (rosacea) cap delayed
release 40 mg............................................................... 170
doxycycline hyclate cap 50 mg....................................... 4
doxycycline hyclate cap 100 mg (Vibramycin)...............5
doxycycline hyclate tab delayed release 75 mg............ 5
doxycycline hyclate tab delayed release 100 mg.......... 5
doxycycline hyclate tab delayed release 150 mg
(Doryx).............................................................................. 5
doxycycline hyclate tab 20 mg........................................ 5
doxycycline hyclate tab 100 mg...................................... 5
doxycycline monohydrate cap 50 mg............................. 5
doxycycline monohydrate cap 150 mg (Adoxa).............5
doxycycline monohydrate cap 75 mg (Monodox)..........5
doxycycline monohydrate cap 100 mg (Monodox)........5
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)..................................................................... 5
doxycycline monohydrate tab 50 mg (Adoxa)............... 5
doxycycline monohydrate tab 75 mg (Adoxa)............... 5
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100)................................................................................. 5
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150)................................................................................. 5
DRISDOL -ergocalciferol cap 50000 unit........................ 146
dronabinol cap 2.5 mg (Marinol).................................... 87
dronabinol cap 5 mg (Marinol)....................................... 87
dronabinol cap 10 mg (Marinol)..................................... 87
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28).................................................................................... 32
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 32
DROXIA -hydroxyurea cap 200 mg................................ 148
DROXIA -hydroxyurea cap 300 mg................................ 148
DROXIA -hydroxyurea cap 400 mg................................ 148
DRUG MART GLUCOSE -glucose chew tab 4 gm...........36
DUAC -clindamycin phosph-benzoyl peroxide (refrig) gel
1.2 (1)-5%..................................................................... 170
DUAVEE -conjugated estrogens-bazedoxifene tab
0.45-20 mg...................................................................... 30
DUETACT -pioglitazone hcl-glimepiride tab 30-2 mg....... 36
DUETACT -pioglitazone hcl-glimepiride tab 30-4 mg....... 36
DUEXIS -ibuprofen-famotidine tab 800-26.6 mg............ 129
DULERA -mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act.................................................... 81
DULERA -mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act.................................................... 81
DULOXETINE HCL -duloxetine hcl enteric coated pellets
cap 40 mg....................................................................... 97
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 97
duloxetine hcl enteric coated pellets cap 30 mg
(Cymbalta)...................................................................... 97
duloxetine hcl enteric coated pellets cap 60 mg
(Cymbalta)...................................................................... 97
DUOPA -carbidopa-levodopa enteral susp 4.63-20 mg/
ml................................................................................... 141
DURAGESIC -fentanyl td patch 72hr 12 mcg/hr............. 121
DURAGESIC -fentanyl td patch 72hr 25 mcg/hr............. 121
DURAGESIC -fentanyl td patch 72hr 50 mcg/hr............. 121
DURAGESIC -fentanyl td patch 72hr 75 mcg/hr............. 121
DURAGESIC -fentanyl td patch 72hr 100 mcg/hr........... 121
DUREZOL -difluprednate ophth emulsion 0.05%........... 159
DURLAZA -aspirin capsule sr 24hr 162.5 mg................. 154
dutasteride cap 0.5 mg (Avodart).................................. 93
dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)...... 93
DUTOPROL -metoprolol & hydrochlorothiazide tab sr
24hr 25-12.5 mg............................................................. 61
DUTOPROL -metoprolol & hydrochlorothiazide tab sr
24hr 50-12.5 mg............................................................. 61
DUTOPROL -metoprolol & hydrochlorothiazide tab sr
24hr 100-12.5 mg........................................................... 61
D-VI-SOL -cholecalciferol oral liquid 400 unit/ml............ 145
DYAZIDE -triamterene & hydrochlorothiazide cap 37.5-25
mg.................................................................................... 67
DYMISTA -azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act............................................................... 77
DYRENIUM -triamterene cap 50 mg................................. 67
DYRENIUM -triamterene cap 100 mg............................... 67
E
EASYGLUCO -blood glucose monitoring kit................... 181
EASYGLUCO VALUE PACK -blood glucose monitoring
kit................................................................................... 181
EASYMAX L BLOOD GLUCOSE S -blood glucose
monitoring devices........................................................ 181
EASYMAX L BLOOD GLUCOSE S -blood glucose
monitoring kit w/ device................................................ 181
EASYMAX N BLOOD GLUCOSE S -blood glucose
monitoring devices........................................................ 181
EASYMAX N BLOOD GLUCOSE S -blood glucose
monitoring kit w/ device................................................ 181
EASYMAX NG SELF-MONITORIN -blood glucose
monitoring devices........................................................ 181
EASYMAX NG SELF-MONITORIN -blood glucose
monitoring kit w/ device................................................ 181
EASYMAX V BLOOD GLUCOSE S -blood glucose
monitoring devices........................................................ 182
EASYMAX V BLOOD GLUCOSE S -blood glucose
monitoring kit w/ device................................................ 182
EASYMAX V2 SELF-MONITORIN -blood glucose
monitoring devices........................................................ 182
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EASYMAX V2 SELF-MONITORIN -blood glucose
monitoring kit w/ device................................................ 182
EASY PLUS BLOOD GLUCOSE M -blood glucose
monitoring devices........................................................ 181
EASY PLUS BLOOD GLUCOSE M -blood glucose
monitoring kit w/ device................................................ 181
EASY PLUS II BLOOD GLUCOS -blood glucose
monitoring devices........................................................ 181
EASYPLUS R13N SELF-MONITO -blood glucose
monitoring kit w/ device................................................ 182
EASYPLUS V SELF-MONITORIN -blood glucose
monitoring kit w/ device................................................ 182
EASYPRO BLOOD GLUCOSE MON -blood glucose
monitoring kit w/ device................................................ 182
EASYPRO PLUS -blood glucose monitoring kit w/
device............................................................................ 182
EASY STEP BLOOD GLUCOSE M -blood glucose
monitoring devices........................................................ 181
EASY STEP BLOOD GLUCOSE M -blood glucose
monitoring kit w/ device................................................ 181
EASY TALK BLOOD GLUCOSE M -blood glucose
monitoring devices........................................................ 181
EASY TALK BLOOD GLUCOSE M -blood glucose
monitoring kit w/ device................................................ 181
EASY TOUCH GLUCOSE MONITO -blood glucose
monitoring kit w/ device................................................ 181
EASY TOUCH HEALTHPRO GLUC -blood glucose
monitoring kit w/ device................................................ 181
EASY TRAK BLOOD GLUCOSE M -blood glucose
monitoring devices........................................................ 181
EASY TRAK BLOOD GLUCOSE M -blood glucose
monitoring kit w/ device................................................ 181
EC-NAPROSYN -naproxen tab ec 375 mg.....................129
EC-NAPROSYN -naproxen tab ec 500 mg.....................129
econazole nitrate cream 1%......................................... 170
ECOZA -econazole nitrate foam 1%............................... 170
EDARBI -azilsartan medoxomil tab 40 mg........................61
EDARBI -azilsartan medoxomil tab 80 mg........................61
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-12.5 mg...................................................................... 61
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-25 mg......................................................................... 61
EDECRIN -ethacrynic acid tab 25 mg.............................. 67
EDLUAR -zolpidem tartrate sl tab 5 mg..........................108
EDLUAR -zolpidem tartrate sl tab 10 mg........................108
EDURANT -rilpivirine hcl tab 25 mg (base equivalent)....... 9
E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg......... 3
E.E.S. GRANULES -erythromycin ethylsuccinate for susp
200 mg/5ml....................................................................... 3
EFFEXOR XR -venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)....................................................................... 97
EFFEXOR XR -venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)....................................................................... 97
EFFEXOR XR -venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)....................................................................... 97
EFFIENT -prasugrel hcl tab 5 mg (base equiv).............. 154
EFFIENT -prasugrel hcl tab 10 mg (base equiv)............ 154
EFUDEX -fluorouracil cream 5%..................................... 170
ELDEPRYL -selegiline hcl cap 5 mg...............................141
ELEMENT AUTOCODE SYSTEM -blood glucose
monitoring kit w/ device................................................ 182
ELEMENT COMPACT BLOOD GLU -blood glucose
monitoring devices........................................................ 182
ELEMENT COMPACT V BLOOD -blood glucose
monitoring devices........................................................ 182
ELEMENT PLUS BLOOD GLUCOS -blood glucose
monitoring devices........................................................ 182
ELESTAT -epinastine hcl ophth soln 0.05%................... 160
ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)...................................................... 30
ELIDEL -pimecrolimus cream 1%................................... 170
ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5
mg.................................................................................... 22
ELIGARD -leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg...................................................................22
ELIGARD -leuprolide acetate (4 month) for subcutaneous
inj kit 30 mg.................................................................... 22
ELIGARD -leuprolide acetate (6 month) for subcutaneous
inj kit 45 mg.................................................................... 22
ELIMITE -permethrin cream 5%...................................... 170
ELIPHOS -calcium acetate (phosphate binder) tab 667
mg.................................................................................... 89
ELIQUIS -apixaban tab 2.5 mg....................................... 150
ELIQUIS -apixaban tab 5 mg.......................................... 150
ELIXOPHYLLIN -theophylline elixir 80 mg/15ml............... 81
ELLA -ulipristal acetate tab 30 mg.................................... 32
ELMIRON -pentosan polysulfate sodium caps 100
mg.................................................................................... 93
ELOCON -mometasone furoate cream 0.1%................. 170
ELOCON -mometasone furoate oint 0.1%......................170
ELOCON -mometasone furoate solution 0.1%
(lotion)............................................................................ 170
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
250 unit......................................................................... 154
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
500 unit......................................................................... 154
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
750 unit......................................................................... 154
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
1000 unit....................................................................... 154
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
1500 unit....................................................................... 154
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
2000 unit....................................................................... 154
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
3000 unit....................................................................... 154
EMADINE -emedastine difumarate ophth soln 0.05%
(base equiv).................................................................. 160
EMBEDA -morphine-naltrexone cap cr 20-0.8 mg..........121
EMBEDA -morphine-naltrexone cap cr 30-1.2 mg..........121
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EMBEDA -morphine-naltrexone cap cr 50-2 mg.............121
EMBEDA -morphine-naltrexone cap cr 60-2.4 mg..........121
EMBEDA -morphine-naltrexone cap cr 80-3.2 mg..........121
EMBEDA -morphine-naltrexone cap cr 100-4 mg...........121
EMBRACE BLOOD GLUCOSE MON -blood glucose
monitoring devices........................................................ 182
EMBRACE EVO BLOOD GLUCOSE -blood glucose
monitoring kit w/ device................................................ 182
EMBRACE PRO BLOOD GLUCOSE -blood glucose
monitoring devices........................................................ 182
EMCYT -estramustine phosphate sodium cap 140
mg.................................................................................... 22
EMEND -aprepitant capsule 40 mg.................................. 87
EMEND -aprepitant capsule 80 mg.................................. 87
EMEND -aprepitant capsule 125 mg................................ 87
EMEND -aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 87
EMLA -lidocaine-prilocaine cream 2.5-2.5%................... 170
EMSAM -selegiline td patch 24hr 6 mg/24hr.................... 97
EMSAM -selegiline td patch 24hr 9 mg/24hr.................... 97
EMSAM -selegiline td patch 24hr 12 mg/24hr.................. 97
EMTRIVA -emtricitabine caps 200 mg................................ 9
EMTRIVA -emtricitabine soln 10 mg/ml.............................. 9
ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv).................................................................... 92
ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv).................................................................... 92
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg................................................................................... 61
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)...................................................................... 61
enalapril maleate tab 2.5 mg (Vasotec)......................... 61
enalapril maleate tab 5 mg (Vasotec)............................ 61
enalapril maleate tab 10 mg (Vasotec).......................... 61
enalapril maleate tab 20 mg (Vasotec).......................... 61
ENBREL -etanercept for subcutaneous inj kit 25 mg......129
ENBREL -etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml.................................................................. 129
ENBREL -etanercept subcutaneous soln prefilled syringe
50 mg/ml....................................................................... 129
ENBREL SURECLICK -etanercept subcutaneous solution
auto-injector 50 mg/ml.................................................. 129
ENCARE -nonoxynol-9 vaginal suppos 100 mg............... 92
ENDOMETRIN -progesterone vaginal insert 100 mg....... 93
ENGERIX-B -hepatitis b vaccine (recombinant) 10
mcg/0.5ml........................................................................ 16
ENGERIX-B -hepatitis b vaccine (recombinant) 20 mcg/
ml..................................................................................... 16
ENGERIX-B -hepatitis b vaccine (recombinant) susp 10
mcg/0.5ml........................................................................ 16
ENGERIX-B -hepatitis b vaccine (recombinant) susp 20
mcg/ml............................................................................. 16
ENJUVIA -estrogens, conjugated synthetic b tab 0.3
mg.................................................................................... 30
ENJUVIA -estrogens, conjugated synthetic b tab 0.45
mg.................................................................................... 30
ENJUVIA -estrogens, conjugated synthetic b tab 0.625
mg.................................................................................... 30
ENJUVIA -estrogens, conjugated synthetic b tab 0.9
mg.................................................................................... 30
ENJUVIA -estrogens, conjugated synthetic b tab 1.25
mg.................................................................................... 30
enoxaparin sodium inj 30 mg/0.3ml (Lovenox).......... 150
enoxaparin sodium inj 40 mg/0.4ml (Lovenox).......... 150
enoxaparin sodium inj 60 mg/0.6ml (Lovenox).......... 150
enoxaparin sodium inj 80 mg/0.8ml (Lovenox).......... 150
enoxaparin sodium inj 100 mg/ml (Lovenox)............. 150
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........ 150
enoxaparin sodium inj 150 mg/ml (Lovenox)............. 150
enoxaparin sodium inj 300 mg/3ml (Lovenox)........... 150
ENSTILAR -calcipotriene-betamethasone dipropionate
foam 0.005-0.064%...................................................... 170
entacapone tab 200 mg (Comtan)............................... 141
entecavir tab 0.5 mg (Baraclude)..................................... 9
entecavir tab 1 mg (Baraclude)........................................ 9
ENTEREG -alvimopan cap 12 mg.................................... 89
ENTOCORT EC -budesonide cap sr 24hr 3 mg............... 26
ENTRESTO -sacubitril-valsartan tab 24-26 mg................ 74
ENTRESTO -sacubitril-valsartan tab 49-51 mg................ 74
ENTRESTO -sacubitril-valsartan tab 97-103 mg.............. 74
ENVARSUS XR -tacrolimus tab sr 24hr 0.75 mg............191
ENVARSUS XR -tacrolimus tab sr 24hr 1 mg................ 191
ENVARSUS XR -tacrolimus tab sr 24hr 4 mg................ 191
EPANED -enalapril maleate for oral soln 1 mg/ml............ 61
EPIDUO -adapalene-benzoyl peroxide gel 0.1-2.5%......170
EPIDUO FORTE -adapalene-benzoyl peroxide gel
0.3-2.5%........................................................................ 170
EPIFOAM -pramoxine-hc aerosol foam 1-1%.................170
epinastine hcl ophth soln 0.05% (Elestat).................. 160
EPINEPHRINE -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 69
EPINEPHRINE -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 69
EPIPEN-JR 2-PAK -epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000).................................................. 69
EPIPEN 2-PAK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 69
EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)............... 9
EPIVIR HBV -lamivudine tab 100 mg (hbv)........................ 9
EPIVIR -lamivudine oral soln 10 mg/ml.............................. 9
EPIVIR -lamivudine tab 150 mg.......................................... 9
EPIVIR -lamivudine tab 300 mg.......................................... 9
eplerenone tab 25 mg (Inspra)....................................... 61
eplerenone tab 50 mg (Inspra)....................................... 61
EPOGEN -epoetin alfa inj 2000 unit/ml...........................149
EPOGEN -epoetin alfa inj 3000 unit/ml...........................149
EPOGEN -epoetin alfa inj 4000 unit/ml...........................149
EPOGEN -epoetin alfa inj 10000 unit/ml.........................149
EPOGEN -epoetin alfa inj 20000 unit/ml.........................149
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2015
epoprostenol sodium for inj 0.5 mg (Flolan)................ 74
epoprostenol sodium for inj 1.5 mg (Flolan)................ 74
EPROSARTAN MESYLATE -eprosartan mesylate tab 600
mg.................................................................................... 61
EPZICOM -abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 9
EQL TRUE2GO BLOOD GLUCOSE -blood glucose
monitoring kit w/ device................................................ 182
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
100 mg.......................................................................... 103
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
200 mg.......................................................................... 103
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
300 mg.......................................................................... 103
ergocalciferol cap 50000 unit (Drisdol)....................... 146
ERGOLOID MESYLATES -ergoloid mesylates tab 1
mg.................................................................................. 115
ERGOMAR -ergotamine tartrate sl tab 2 mg.................. 132
ERIVEDGE -vismodegib cap 150 mg............................... 22
ERTACZO -sertaconazole nitrate cream 2%.................. 170
ERYGEL -erythromycin gel 2%....................................... 170
ERYPED 200 -erythromycin ethylsuccinate for susp 200
mg/5ml............................................................................... 4
ERYPED 400 -erythromycin ethylsuccinate for susp 400
mg/5ml............................................................................... 4
ERY-TAB -erythromycin tab delayed release 250 mg........ 4
ERY-TAB -erythromycin tab delayed release 333 mg........ 4
ERY-TAB -erythromycin tab delayed release 500 mg........ 4
ERYTHROCIN STEARATE -erythromycin stearate tab
250 mg.............................................................................. 4
ERYTHROMYCIN BASE -erythromycin tab 250 mg.......... 4
ERYTHROMYCIN BASE -erythromycin tab 500 mg.......... 4
ERYTHROMYCIN ETHYLSUCCINA -erythromycin
ethylsuccinate tab 400 mg............................................... 4
erythromycin gel 2% (Erygel)....................................... 170
erythromycin ophth oint 5 mg/gm............................... 160
erythromycin pads 2%.................................................. 170
erythromycin soln 2%................................................... 170
erythromycin w/ delayed release particles cap 250
mg......................................................................................4
ESBRIET -pirfenidone cap 267 mg................................... 83
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)........................................................................ 97
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro)........................................................................ 97
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro)........................................................................ 97
escitalopram oxalate tab 20 mg (base equiv)
(Lexapro)........................................................................ 97
ESGIC -butalbital-acetaminophen-caffeine tab 50-325-40
mg.................................................................................. 119
esomeprazole magnesium cap delayed release 20 mg
(base eq) (NEXIUM)...................................................... 85
esomeprazole magnesium cap delayed release 40 mg
(base eq) (NEXIUM)...................................................... 85
estazolam tab 1 mg....................................................... 108
estazolam tab 2 mg....................................................... 108
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................ 30
esterified estrogens & methyltestosterone tab
1.25-2.5 mg.....................................................................30
ESTRACE -estradiol tab 0.5 mg....................................... 30
ESTRACE -estradiol tab 1 mg.......................................... 30
ESTRACE -estradiol tab 2 mg.......................................... 30
ESTRACE -estradiol vaginal cream 0.1 mg/gm................ 93
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)....................................................................... 30
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)....................................................................... 30
estradiol tab 0.5 mg (Estrace)........................................ 30
estradiol tab 1 mg (Estrace)........................................... 30
estradiol tab 2 mg (Estrace)........................................... 30
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 30
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot).................................................................... 30
estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot).................................................................................. 30
estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot).................................................................................. 30
estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot).................................................................................. 30
estradiol td patch weekly 0.025 mg/24hr (Climara)......30
estradiol td patch weekly 0.05 mg/24hr (Climara)........30
estradiol td patch weekly 0.06 mg/24hr (Climara)........30
estradiol td patch weekly 0.075 mg/24hr (Climara)......30
estradiol td patch weekly 0.1 mg/24hr (Climara)..........30
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)...................................................... 30
estradiol valerate im in oil 20 mg/ml (Delestrogen)..... 30
estradiol valerate im in oil 40 mg/ml (Delestrogen)..... 30
ESTRING -estradiol vaginal ring 2 mg (7.5
mcg/24hrs).......................................................................93
ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)...................................................... 31
ESTROPIPATE -estropipate tab 3 mg.............................. 31
estropipate tab 0.75 mg.................................................. 31
estropipate tab 1.5 mg.................................................... 31
ESTROSTEP FE -norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg.................................................. 32
eszopiclone tab 1 mg (Lunesta).................................. 108
eszopiclone tab 2 mg (Lunesta).................................. 108
eszopiclone tab 3 mg (Lunesta).................................. 108
ethambutol hcl tab 100 mg (Myambutol)........................ 7
ethambutol hcl tab 400 mg (Myambutol)........................ 7
ethosuximide cap 250 mg (Zarontin).......................... 136
ethosuximide soln 250 mg/5ml (Zarontin).................. 136
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg................................................................................. 32
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ETIDRONATE DISODIUM -etidronate disodium tab 200
mg.................................................................................... 46
ETIDRONATE DISODIUM -etidronate disodium tab 400
mg.................................................................................... 46
etodolac cap 200 mg..................................................... 129
etodolac cap 300 mg..................................................... 129
etodolac tab 400 mg...................................................... 129
etodolac tab 500 mg...................................................... 129
etodolac tab sr 24hr 400 mg........................................ 129
etodolac tab sr 24hr 500 mg........................................ 129
etodolac tab sr 24hr 600 mg........................................ 129
ETOPOSIDE -etoposide cap 50 mg..................................22
EUCALYPTUS OIL -eucalyptus (topical) oil.................... 170
EURAX -crotamiton cream 10%...................................... 170
EURAX -crotamiton lotion 10%....................................... 171
EVAMIST -estradiol transdermal spray 1.53 mg/spray..... 31
EVEKEO -amphetamine sulfate tab 5 mg.......................111
EVEKEO -amphetamine sulfate tab 10 mg.....................111
EVENCARE BLOOD GLUCOSE MO -blood glucose
monitoring kit................................................................. 182
EVENCARE G2 BLOOD GLUCOSE -blood glucose
monitoring devices........................................................ 182
EVENCARE G3 BLOOD GLUCOSE -blood glucose
monitoring devices........................................................ 182
EVENCARE MINI BLOOD GLUCO -blood glucose
monitoring devices........................................................ 182
EVICEL -fibrin sealant component kit 2 ml..................... 152
EVICEL -fibrin sealant component kit 5 ml..................... 152
EVISTA -raloxifene hcl tab 60 mg..................................... 46
EVITHROM -thrombin (human) topical soln 800-1200
unit/ml............................................................................ 152
EVOCLIN -clindamycin phosphate foam 1%.................. 171
EVOLUTION AUTOCODE -blood glucose monitoring
devices.......................................................................... 182
EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv)...................................................................... 9
EVOXAC -cevimeline hcl cap 30 mg.............................. 164
EVZIO -naloxone hcl solution auto-injector 0.4
mg/0.4ml........................................................................ 177
EXALGO -hydromorphone hcl tab er 24hr deter 8
mg.................................................................................. 121
EXALGO -hydromorphone hcl tab er 24hr deter 12
mg.................................................................................. 121
EXALGO -hydromorphone hcl tab er 24hr deter 16
mg.................................................................................. 121
EXALGO -hydromorphone hcl tab er 24hr deter 32
mg.................................................................................. 121
EXELDERM -sulconazole nitrate cream 1%................... 171
EXELDERM -sulconazole nitrate solution 1%................ 171
EXELON -rivastigmine tartrate cap 1.5 mg..................... 115
EXELON -rivastigmine tartrate cap 3 mg........................ 115
EXELON -rivastigmine tartrate cap 4.5 mg..................... 115
EXELON -rivastigmine tartrate cap 6 mg........................ 115
EXELON -rivastigmine td patch 24hr 4.6 mg/24hr.......... 115
EXELON -rivastigmine td patch 24hr 9.5 mg/24hr.......... 115
EXELON -rivastigmine td patch 24hr 13.3 mg/24hr........ 115
exemestane tab 25 mg (Aromasin)................................ 22
EXFORGE -amlodipine besylate-valsartan tab 5-160
mg.................................................................................... 61
EXFORGE -amlodipine besylate-valsartan tab 5-320
mg.................................................................................... 62
EXFORGE -amlodipine besylate-valsartan tab 10-160
mg.................................................................................... 62
EXFORGE -amlodipine besylate-valsartan tab 10-320
mg.................................................................................... 62
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg......................... 62
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg............................ 62
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg....................... 62
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg.......................... 62
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg.......................... 62
EXJADE -deferasirox tab for oral susp 125 mg.............. 177
EXJADE -deferasirox tab for oral susp 250 mg.............. 177
EXJADE -deferasirox tab for oral susp 500 mg.............. 177
EXTAVIA -interferon beta-1b for inj kit 0.3 mg................ 115
EXTINA -ketoconazole foam 2%..................................... 171
EZ SMART DIABETES MONITOR -blood glucose
monitoring devices........................................................ 182
EZ SMART PLUS DIABETES MO -blood glucose
monitoring devices........................................................ 182
F
FABIOR -tazarotene (acne) foam 0.1%.......................... 171
FACTIVE -gemifloxacin mesylate tab 320 mg (base
equiv)................................................................................. 6
FA-8 -folic acid cap 0.8 mg............................................. 149
FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa
tab 1 mg kit..................................................................... 32
famciclovir tab 125 mg (Famvir)...................................... 9
famciclovir tab 250 mg (Famvir)...................................... 9
famciclovir tab 500 mg (Famvir)...................................... 9
famotidine for susp 40 mg/5ml (Pepcid)....................... 85
famotidine tab 20 mg (Pepcid)....................................... 85
famotidine tab 40 mg (Pepcid)....................................... 85
FAMVIR -famciclovir tab 125 mg........................................ 9
FAMVIR -famciclovir tab 250 mg........................................ 9
FAMVIR -famciclovir tab 500 mg........................................ 9
FANAPT -iloperidone tab 1 mg....................................... 103
FANAPT -iloperidone tab 2 mg....................................... 103
FANAPT -iloperidone tab 4 mg....................................... 103
FANAPT -iloperidone tab 6 mg....................................... 103
FANAPT -iloperidone tab 8 mg....................................... 103
FANAPT -iloperidone tab 10 mg..................................... 103
FANAPT -iloperidone tab 12 mg..................................... 103
FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak......................................... 103
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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FARESTON -toremifene citrate tab 60 mg (base
equivalent)....................................................................... 22
FARXIGA -dapagliflozin propanediol tab 10 mg (base
equivalent)....................................................................... 36
FARYDAK -panobinostat lactate cap 10 mg (base
equivalent)....................................................................... 22
FARYDAK -panobinostat lactate cap 15 mg (base
equivalent)....................................................................... 22
FARYDAK -panobinostat lactate cap 20 mg (base
equivalent)....................................................................... 22
FASTTAKE COMPACT MONITORI -blood glucose
monitoring kit w/ device................................................ 182
FAZACLO -clozapine orally disintegrating tab 12.5
mg.................................................................................. 103
FAZACLO -clozapine orally disintegrating tab 25 mg..... 103
FAZACLO -clozapine orally disintegrating tab 100
mg.................................................................................. 103
FAZACLO -clozapine orally disintegrating tab 150
mg.................................................................................. 103
FAZACLO -clozapine orally disintegrating tab 200
mg.................................................................................. 103
FC FEMALE CONDOM -condoms - female....................182
FC2 FEMALE CONDOM -condoms - female..................182
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg................................................................................. 149
FEIBA -antiinhibitor coagulant complex for inj................ 154
FEIBA NF -antiinhibitor coagulant complex for inj.......... 154
felbamate susp 600 mg/5ml (Felbatol)........................ 136
felbamate tab 400 mg (Felbatol).................................. 136
felbamate tab 600 mg (Felbatol).................................. 136
FELBATOL -felbamate susp 600 mg/5ml........................136
FELBATOL -felbamate tab 400 mg................................. 136
FELBATOL -felbamate tab 600 mg................................. 136
FELDENE -piroxicam cap 10 mg.................................... 129
FELDENE -piroxicam cap 20 mg.................................... 129
felodipine tab sr 24hr 2.5 mg......................................... 55
felodipine tab sr 24hr 5 mg............................................ 55
felodipine tab sr 24hr 10 mg.......................................... 55
FEMARA -letrozole tab 2.5 mg......................................... 22
FEMCON FE -norethindrone & ethinyl estradiol-fe chew
tab 0.4 mg-35 mcg......................................................... 32
FEMHRT LOW DOSE -norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg......................................... 31
FEMRING -estradiol acetate vaginal ring 0.05
mg/24hr........................................................................... 93
FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr..... 93
FENOFIBRATE -fenofibrate cap 50 mg............................ 70
FENOFIBRATE -fenofibrate cap 150 mg.......................... 70
FENOFIBRATE -fenofibrate tab 40 mg............................. 70
FENOFIBRATE -fenofibrate tab 120 mg........................... 70
fenofibrate micronized cap 43 mg................................. 70
fenofibrate micronized cap 130 mg............................... 70
fenofibrate micronized cap 67 mg (Lofibra)................. 70
fenofibrate micronized cap 134 mg (Lofibra)............... 70
fenofibrate micronized cap 200 mg (Lofibra)............... 70
fenofibrate tab 54 mg (Lofibra)...................................... 70
fenofibrate tab 160 mg (Lofibra).................................... 70
fenofibrate tab 48 mg (Tricor)........................................ 70
fenofibrate tab 145 mg (Tricor)...................................... 70
FENOFIBRIC ACID -fenofibric acid tab 35 mg................. 70
FENOFIBRIC ACID -fenofibric acid tab 105 mg............... 70
FENOGLIDE -fenofibrate tab 40 mg................................. 70
FENOGLIDE -fenofibrate tab 120 mg............................... 70
FENOPROFEN CALCIUM -fenoprofen calcium cap 400
mg.................................................................................. 129
FENOPROFEN CALCIUM -fenoprofen calcium tab 600
mg.................................................................................. 129
fentanyl citrate lozenge on a handle 200 mcg
(Actiq)........................................................................... 121
fentanyl citrate lozenge on a handle 400 mcg
(Actiq)........................................................................... 121
fentanyl citrate lozenge on a handle 600 mcg
(Actiq)........................................................................... 121
fentanyl citrate lozenge on a handle 800 mcg
(Actiq)........................................................................... 121
fentanyl citrate lozenge on a handle 1200 mcg
(Actiq)........................................................................... 122
fentanyl citrate lozenge on a handle 1600 mcg
(Actiq)........................................................................... 122
FENTANYL -fentanyl td patch 72hr 37.5 mcg/hr.............121
FENTANYL -fentanyl td patch 72hr 62.5 mcg/hr.............121
FENTANYL -fentanyl td patch 72hr 87.5 mcg/hr.............121
fentanyl td patch 72hr 12 mcg/hr (Duragesic)............ 122
fentanyl td patch 72hr 25 mcg/hr (Duragesic)............ 122
fentanyl td patch 72hr 50 mcg/hr (Duragesic)............ 122
fentanyl td patch 72hr 75 mcg/hr (Duragesic)............ 122
fentanyl td patch 72hr 100 mcg/hr (Duragesic).......... 122
FENTORA -fentanyl citrate buccal tab 100 mcg (base
equiv)............................................................................. 122
FENTORA -fentanyl citrate buccal tab 200 mcg (base
equiv)............................................................................. 122
FENTORA -fentanyl citrate buccal tab 400 mcg (base
equiv)............................................................................. 122
FENTORA -fentanyl citrate buccal tab 600 mcg (base
equiv)............................................................................. 122
FENTORA -fentanyl citrate buccal tab 800 mcg (base
equiv)............................................................................. 122
FER-IN-SOL -ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe)................................................................. 149
FERRETTS CHEWABLE IRON -carbonyl iron chew tab
18 mg (elemental iron)................................................. 149
FERRIPROX -deferiprone oral soln 100 mg/ml.............. 177
FERRIPROX -deferiprone tab 500 mg............................ 177
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe).................................................................................. 149
FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)............................................. 149
FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml
(60 mg/5ml elemental fe)............................................. 149
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe).................................................................................. 149
FETZIMA -levomilnacipran hcl cap sr 24hr 20 mg (base
equivalent)....................................................................... 97
FETZIMA -levomilnacipran hcl cap sr 24hr 40 mg (base
equivalent)....................................................................... 97
FETZIMA -levomilnacipran hcl cap sr 24hr 80 mg (base
equivalent)....................................................................... 97
FETZIMA -levomilnacipran hcl cap sr 24hr 120 mg (base
equivalent)....................................................................... 97
FETZIMA TITRATION PACK -levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack...................................... 97
FEXMID -cyclobenzaprine hcl tab 7.5 mg.......................144
FIBRICOR -fenofibric acid tab 35 mg............................... 70
FIBRICOR -fenofibric acid tab 105 mg............................. 70
FIFTY50 GLUCOSE METER 2.0 -blood glucose
monitoring kit w/ device................................................ 182
FINACEA -azelaic acid foam 15%.................................. 171
FINACEA -azelaic acid gel 15%..................................... 171
finasteride tab 5 mg (Proscar)....................................... 94
FINGERSTIX LANCETS -lancets.................................... 182
FIORICET/CODEINE -butalbital-acetaminophen-caff w/
cod cap 50-300-40-30 mg............................................ 122
FIORICET -butalbital-acetaminophen-caffeine cap
50-300-40 mg................................................................119
FIORICET -butalbital-acetaminophen-caffeine tab
50-325-40 mg................................................................119
FIORINAL/CODEINE #3 -butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg................................................... 122
FIORINAL -butalbital-aspirin-caffeine cap 50-325-40
mg.................................................................................. 119
FIRAZYR -icatibant acetate inj 30 mg/3ml (base
equivalent)..................................................................... 154
FIRMAGON -degarelix acetate for inj 80 mg (base
equiv)............................................................................... 22
FIRMAGON -degarelix acetate for inj 120 mg (base
equiv)............................................................................... 22
FLAGYL ER -metronidazole tab sr 24hr 750 mg.............. 15
FLAGYL -metronidazole cap 375 mg................................ 15
FLAGYL -metronidazole tab 250 mg................................ 15
FLAGYL -metronidazole tab 500 mg................................ 15
FLAREX -fluorometholone acetate ophth susp 0.1%..... 160
flavoxate hcl tab 100 mg.................................................92
flecainide acetate tab 50 mg.......................................... 57
flecainide acetate tab 100 mg........................................ 57
flecainide acetate tab 150 mg........................................ 57
FLECTOR -diclofenac epolamine patch 1.3%................ 171
FLOLAN -epoprostenol sodium for inj 0.5 mg.................. 74
FLOLAN -epoprostenol sodium for inj 1.5 mg.................. 74
FLOMAX -tamsulosin hcl cap 0.4 mg............................... 94
FLO-PRED -prednisolone acetate oral susp 16.7 mg/5ml
(15 mg/5ml base)............................................................ 26
FLORICAL -sodium fluoride w/ calcium carb cap 8.3-364
mg.................................................................................. 146
FLORICAL -sodium fluoride w/ calcium carb tab 8.3-364
mg.................................................................................. 146
FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/
ml-400 unit/ml............................................................... 146
FLOVENT DISKUS -fluticasone propionate aer pow ba 50
mcg/blister....................................................................... 81
FLOVENT DISKUS -fluticasone propionate aer pow ba
100 mcg/blister................................................................ 81
FLOVENT DISKUS -fluticasone propionate aer pow ba
250 mcg/blister................................................................ 81
FLOVENT HFA -fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)........................................................ 81
FLOVENT HFA -fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)........................................................ 81
FLOVENT HFA -fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)...........................................................81
FLOWTUSS -hydrocodone-guaifenesin soln 2.5-200
mg/5ml............................................................................. 78
FLUARIX 2011-2012 -influenza virus vaccine split pf susp
pref syringe 0.5 ml.......................................................... 16
FLUARIX 2012-2013 -influenza virus vaccine split pf susp
pref syringe 0.5 ml.......................................................... 17
FLUARIX 2013-2014 -influenza virus vaccine split pf susp
pref syringe 0.5 ml.......................................................... 17
FLUARIX 2014-2015 -influenza virus vaccine split pf susp
pref syringe 0.5 ml.......................................................... 17
FLUARIX QUADRIVALENT 2013 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 16
FLUARIX QUADRIVALENT 2014 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 16
FLUARIX QUADRIVALENT 2015 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 16
FLUBLOK 2013-2014 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 17
FLUBLOK 2014-2015 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 17
FLUBLOK 2015-2016 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 17
FLUCELVAX 2013-2014 -influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml........................................... 17
FLUCELVAX 2014-2015 -influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml........................................... 17
FLUCELVAX 2015-2016 -influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml........................................... 17
fluconazole for susp 10 mg/ml (Diflucan)....................... 8
fluconazole for susp 40 mg/ml (Diflucan)....................... 8
fluconazole tab 50 mg (Diflucan)..................................... 8
fluconazole tab 100 mg (Diflucan)................................... 8
fluconazole tab 150 mg (Diflucan)................................... 8
fluconazole tab 200 mg (Diflucan)................................... 8
flucytosine cap 250 mg (Ancobon)................................. 8
flucytosine cap 500 mg (Ancobon)................................. 8
fludrocortisone acetate tab 0.1 mg............................... 27
FLULAVAL 2011-2012 -influenza virus vaccine split im
susp................................................................................. 17
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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FLULAVAL 2012-2013 -influenza virus vaccine split im
susp................................................................................. 17
FLULAVAL 2013-2014 -influenza virus vaccine split im
susp................................................................................. 17
FLULAVAL 2014-2015 -influenza virus vaccine split im
susp................................................................................. 17
FLULAVAL QUADRIVALENT 201 -influenza virus vaccine
split quadrivalent im inj................................................... 17
FLULAVAL QUADRIVALENT 201 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 17
FLUMADINE -rimantadine hydrochloride tab 100 mg.......10
FLUMIST QUADRIVALENT -influenza virus vaccine live
quadrivalent intranasal susp...........................................17
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)................................................................... 77
fluocinolone acetonide cream 0.01%.......................... 171
fluocinolone acetonide cream 0.025% (Synalar)........171
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).......................................................... 171
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)...........................................................171
fluocinolone acetonide oint 0.025% (Synalar)............ 171
fluocinolone acetonide (otic) oil 0.01%
(Dermotic).................................................................... 163
fluocinolone acetonide soln 0.01% (Synalar)............. 171
fluocinonide cream 0.05%............................................ 171
fluocinonide cream 0.1% (Vanos)................................ 171
fluocinonide emulsified base cream 0.05%................ 171
fluocinonide gel 0.05%.................................................. 171
fluocinonide oint 0.05%................................................ 171
fluocinonide soln 0.05%................................................ 171
FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf)........................................................146
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg..................................................146
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 1.1 (0.5
mg f)-236.79 mg........................................................... 146
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg
f)-236.79 mg.................................................................. 146
FLUORIDEX DAILY DEFENSE S -sodium fluoridepotassium nitrate gel 1.1-5%........................................164
fluorometholone ophth susp 0.1% (Fml liquifilm)..... 160
FLUOROPLEX -fluorouracil cream 1%........................... 171
fluorouracil cream 5% (Efudex)................................... 171
FLUOROURACIL -fluorouracil cream 0.5%.................... 171
fluorouracil soln 2%...................................................... 171
fluorouracil soln 5%...................................................... 171
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly)............................................................................ 98
fluoxetine hcl cap 10 mg (Prozac)................................. 98
fluoxetine hcl cap 20 mg (Prozac)................................. 98
fluoxetine hcl cap 40 mg (Prozac)................................. 98
FLUOXETINE HCL -fluoxetine hcl tab 60 mg................... 97
fluoxetine hcl (pmdd) cap 10 mg................................. 115
fluoxetine hcl (pmdd) cap 20 mg................................. 115
fluoxetine hcl solution 20 mg/5ml................................. 98
fluoxetine hcl tab 10 mg................................................. 98
fluoxetine hcl tab 20 mg................................................. 98
fluphenazine decanoate inj 25 mg/ml......................... 103
FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5
mg/5ml........................................................................... 103
FLUPHENAZINE HCL -fluphenazine hcl inj 2.5 mg/
ml................................................................................... 103
FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/
ml................................................................................... 103
fluphenazine hcl tab 1 mg............................................ 103
fluphenazine hcl tab 2.5 mg......................................... 103
fluphenazine hcl tab 5 mg............................................ 103
fluphenazine hcl tab 10 mg.......................................... 103
FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf)............................................... 146
FLURAZEPAM HCL -flurazepam hcl cap 15 mg............ 108
FLURAZEPAM HCL -flurazepam hcl cap 30 mg............ 108
flurbiprofen sodium ophth soln 0.03% (Ocufen)........160
flurbiprofen tab 50 mg.................................................. 129
flurbiprofen tab 100 mg................................................ 129
flutamide cap 125 mg...................................................... 22
fluticasone propionate cream 0.05% (Cutivate)......... 171
fluticasone propionate lotion 0.05% (Cutivate).......... 171
fluticasone propionate nasal susp 50 mcg/act
(Flonase)......................................................................... 77
fluticasone propionate oint 0.005% (Cutivate)........... 171
fluvastatin sodium cap 20 mg (Lescol)......................... 70
fluvastatin sodium cap 40 mg (Lescol)......................... 70
fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl)........70
FLUVIRIN 2015-2016 -influenza vac type a&b surface
antigen susp pref syr 0.5 ml...........................................17
FLUVIRIN 2011-2012 -influenza virus vaccine types a & b
surface antigen im susp................................................. 17
FLUVIRIN 2012-2013 -influenza virus vaccine types a & b
surface antigen im susp................................................. 17
FLUVIRIN 2013-2014 -influenza virus vaccine types a & b
surface antigen im susp................................................. 17
FLUVIRIN 2014-2015 -influenza virus vaccine types a & b
surface antigen im susp................................................. 17
FLUVIRIN 2015-2016 -influenza virus vaccine types a & b
surface antigen im susp................................................. 18
FLUVIRIN PF 2011-2012 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml............................................. 17
FLUVIRIN PF 2012-2013 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml............................................. 17
FLUVIRIN PF 2013-2014 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml............................................. 17
FLUVIRIN PF 2014-2015 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml............................................. 17
fluvoxamine maleate cap sr 24hr 100 mg (Luvox
cr).................................................................................... 98
fluvoxamine maleate cap sr 24hr 150 mg (Luvox
cr).................................................................................... 98
fluvoxamine maleate tab 25 mg..................................... 98
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fluvoxamine maleate tab 50 mg..................................... 98
fluvoxamine maleate tab 100 mg................................... 98
FLUZONE HIGH-DOSE PF 2012 -influenza virus vac split
high-dose pf susp pref syr 0.5ml....................................18
FLUZONE HIGH-DOSE PF 2013 -influenza virus vac split
high-dose pf susp pref syr 0.5ml....................................18
FLUZONE HIGH-DOSE PF 2014 -influenza virus vac split
high-dose pf susp pref syr 0.5ml....................................18
FLUZONE HIGH-DOSE PF 2015 -influenza virus vac split
high-dose pf susp pref syr 0.5ml....................................18
FLUZONE INTRADERMAL QUADR -influenza virus vac
split quad intradermal pen 9 mcg/strain......................... 18
FLUZONE PF 2012-2013 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 18
FLUZONE PF 2013-2014 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 18
FLUZONE PF 2014-2015 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 18
FLUZONE QUADRIVALENT 2014 -influenza virus
vaccine split quadrivalent im inj..................................... 18
FLUZONE QUADRIVALENT 2015 -influenza virus
vaccine split quadrivalent im inj..................................... 18
FLUZONE QUADRIVALENT 2013 -influenza virus
vaccine split quadrivalent inj 0.5 ml............................... 18
FLUZONE QUADRIVALENT 2014 -influenza virus
vaccine split quadrivalent inj 0.5 ml............................... 18
FLUZONE QUADRIVALENT 2015 -influenza virus
vaccine split quadrivalent inj 0.5 ml............................... 18
FLUZONE QUADRIVALENT 2013 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml......................... 18
FLUZONE QUADRIVALENT 2013 -influenza virus vac
split quadrivalent susp pref syr 0.5ml............................ 18
FLUZONE QUADRIVALENT 2014 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml......................... 18
FLUZONE QUADRIVALENT 2014 -influenza virus vac
split quadrivalent susp pref syr 0.5ml............................ 18
FLUZONE QUADRIVALENT 2015 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml......................... 18
FLUZONE QUADRIVALENT 2015 -influenza virus vac
split quadrivalent susp pref syr 0.5ml............................ 18
FLUZONE SPLIT 2012-2013 -influenza virus vaccine split
im susp............................................................................ 18
FLUZONE SPLIT 2013-2014 -influenza virus vaccine split
im susp............................................................................ 18
FLUZONE SPLIT 2014-2015 -influenza virus vaccine split
im susp............................................................................ 19
FLUZONE SPLIT 2015-2016 -influenza virus vaccine split
im susp............................................................................ 19
FML -fluorometholone ophth oint 0.1%........................... 160
FML FORTE -fluorometholone ophth susp 0.25%.......... 160
FML LIQUIFILM -fluorometholone ophth susp 0.1%...... 160
FOCALIN -dexmethylphenidate hcl tab 2.5 mg.............. 111
FOCALIN -dexmethylphenidate hcl tab 5 mg................. 111
FOCALIN -dexmethylphenidate hcl tab 10 mg............... 111
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 5
mg.................................................................................. 111
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 10
mg.................................................................................. 111
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 15
mg.................................................................................. 111
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 20
mg.................................................................................. 111
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 25
mg.................................................................................. 111
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 30
mg.................................................................................. 111
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 35
mg.................................................................................. 111
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 40
mg.................................................................................. 111
folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2
mg................................................................................. 148
folic acid tab 400 mcg................................................... 149
folic acid tab 800 mcg................................................... 149
folic acid tab 1 mg......................................................... 149
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5
mg................................................................................. 149
FOLLISTIM AQ -follitropin beta inj 75 unit/0.5ml.............. 46
FOLLISTIM AQ -follitropin beta inj 300 unit/0.36ml.......... 46
FOLLISTIM AQ -follitropin beta inj 600 unit/0.72ml.......... 46
FOLLISTIM AQ -follitropin beta inj 900 unit/1.08ml.......... 46
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
(Arixtra).........................................................................150
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra).........................................................................151
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra).........................................................................151
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra).........................................................................151
FORACARE GD40 BLOOD GLUCO -blood glucose
monitoring devices........................................................ 183
FORACARE PREMIUM V10 BLOO -blood glucose
monitoring devices........................................................ 183
FORACARE TEST N GO BLOOD -blood glucose
monitoring devices........................................................ 183
FORADIL AEROLIZER -formoterol fumarate inhal cap 12
mcg.................................................................................. 81
FORA G30A BLOOD GLUCOSE M -blood glucose
monitoring devices........................................................ 183
FORA G71A BLOOD GLUCOSE M -blood glucose
monitoring kit w/ device................................................ 183
FORA G90 BLOOD GLUCOSE MO -blood glucose
monitoring devices........................................................ 183
FORA G20 BLOOD GLUCOSE MO -blood glucose
monitoring kit w/ device................................................ 183
FORA GD20 BLOOD GLUCOSE M -blood glucose
monitoring devices........................................................ 182
FORA GD50 BLOOD GLUCOSE M -blood glucose
monitoring devices........................................................ 183
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FORA TEST N' GO VOICE BLO -blood glucose
monitoring devices........................................................ 183
FORA TN'G VOICE BLOOD GLU -blood glucose
monitoring kit w/ device................................................ 183
FORA V10/V12/D10/D20 BLOO -blood glucose
monitoring kit................................................................. 183
FORA V30A BLOOD GLUCOSE M -blood glucose
monitoring devices........................................................ 183
FORA V30A BLOOD GLUCOSE M -blood glucose
monitoring kit w/ device................................................ 183
FORA V10 BLOOD GLUCOSE MO -blood glucose
monitoring devices........................................................ 183
FORA V12 BLOOD GLUCOSE MO -blood glucose
monitoring devices........................................................ 183
FORA V20 BLOOD GLUCOSE MO -blood glucose
monitoring devices........................................................ 183
FORA V22 BLOOD GLUCOSE MO -blood glucose
monitoring kit w/ device................................................ 183
FORFIVO XL -bupropion hcl tab sr 24hr 450 mg............. 98
FORTAMET -metformin hcl tab sr 24hr osmotic 500
mg.................................................................................... 36
FORTAMET -metformin hcl tab sr 24hr osmotic 1000
mg.................................................................................... 36
FORTEO -teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 46
FORTESTA -testosterone td gel 10mg/act (2%)............... 28
FORTICAL -calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 46
FORTISCARE SELF-MONITORIN -blood glucose
monitoring kit w/ device................................................ 183
FOSAMAX -alendronate sodium tab 70 mg......................46
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-2800 mg-unit....................................................... 46
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-5600 mg-unit....................................................... 46
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg................................................................................... 62
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg................................................................................... 62
fosinopril sodium tab 10 mg.......................................... 62
fosinopril sodium tab 20 mg.......................................... 62
fosinopril sodium tab 40 mg.......................................... 62
FOSRENOL -lanthanum carbonate chew tab 500 mg
(elemental).......................................................................89
FOSRENOL -lanthanum carbonate chew tab 750 mg
(elemental).......................................................................89
FOSRENOL -lanthanum carbonate chew tab 1000 mg
(elemental).......................................................................89
FOSRENOL -lanthanum carbonate oral powder pack 750
mg (elemental)................................................................ 89
FOSRENOL -lanthanum carbonate oral powder pack
1000 mg (elemental).......................................................89
FRAGMIN -dalteparin sodium inj 10000 unit/ml..............151
FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml...........151
FRAGMIN -dalteparin sodium inj 5000 unit/0.2ml...........151
FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml.........151
FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml.........151
FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml.......151
FRAGMIN -dalteparin sodium inj 95000 unit/3.8ml.........151
FREESTYLE FLASH SYSTEM -blood glucose monitoring
kit................................................................................... 183
FREESTYLE FREEDOM -blood glucose monitoring kit w/
device............................................................................ 183
FREESTYLE FREEDOM LITE -blood glucose monitoring
kit w/ device.................................................................. 183
FREESTYLE INSULINX BLOOD -blood glucose
monitoring kit w/ device................................................ 183
FREESTYLE LITE BLOOD GLUC -blood glucose
monitoring devices........................................................ 183
FREESTYLE PRECISION NEO B -blood glucose
monitoring kit w/ device................................................ 183
FREESTYLE SIDEKICK II VAL -blood glucose monitoring
kit w/ device.................................................................. 183
FREESTYLE SYSTEM KIT -blood glucose monitoring
kit................................................................................... 183
FROVA -frovatriptan succinate tab 2.5 mg (base
equivalent)..................................................................... 132
FULYZAQ -crofelemer tab delayed release 125 mg......... 84
FURADANTIN -nitrofurantoin susp 25 mg/5ml................. 91
FUROSEMIDE -furosemide oral soln 8 mg/ml..................68
furosemide oral soln 10 mg/ml...................................... 68
furosemide tab 20 mg (Lasix)........................................ 68
furosemide tab 40 mg (Lasix)........................................ 68
furosemide tab 80 mg (Lasix)........................................ 68
FUZEON -enfuvirtide for inj 90 mg................................... 10
FYCOMPA -perampanel tab 2 mg.................................. 136
FYCOMPA -perampanel tab 4 mg.................................. 136
FYCOMPA -perampanel tab 6 mg.................................. 136
FYCOMPA -perampanel tab 8 mg.................................. 136
FYCOMPA -perampanel tab 10 mg................................ 136
FYCOMPA -perampanel tab 12 mg................................ 136
G
gabapentin cap 100 mg (Neurontin)............................ 136
gabapentin cap 300 mg (Neurontin)............................ 136
gabapentin cap 400 mg (Neurontin)............................ 136
gabapentin oral soln 250 mg/5ml (Neurontin)............ 136
gabapentin tab 600 mg (Neurontin)............................. 136
gabapentin tab 800 mg (Neurontin)............................. 136
GABITRIL -tiagabine hcl tab 2 mg.................................. 136
GABITRIL -tiagabine hcl tab 4 mg.................................. 136
GABITRIL -tiagabine hcl tab 12 mg................................ 136
GABITRIL -tiagabine hcl tab 16 mg................................ 136
galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne er).............................................................. 115
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er).............................................................. 115
galantamine hydrobromide cap sr 24hr 24 mg
(Razadyne er).............................................................. 115
GALANTAMINE HYDROBROMIDE -galantamine
hydrobromide oral soln 4 mg/ml.................................. 115
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galantamine hydrobromide tab 4 mg (Razadyne)...... 115
galantamine hydrobromide tab 8 mg (Razadyne)...... 115
galantamine hydrobromide tab 12 mg
(Razadyne)................................................................... 115
GALZIN -zinc acetate cap 25 mg (elemental zinc)......... 146
GALZIN -zinc acetate cap 50 mg (elemental zinc)......... 146
GAMUNEX-C -immune globulin (human) iv or
subcutaneous soln 1 gm/10ml....................................... 20
GAMUNEX-C -immune globulin (human) iv or
subcutaneous soln 2.5 gm/25ml.................................... 20
GAMUNEX-C -immune globulin (human) iv or
subcutaneous soln 5 gm/50ml....................................... 20
GAMUNEX-C -immune globulin (human) iv or
subcutaneous soln 10 gm/100ml................................... 20
GAMUNEX-C -immune globulin (human) iv or
subcutaneous soln 20 gm/200ml................................... 20
GAMUNEX-C -immune globulin (human) iv or
subcutaneous soln 40 gm/400ml................................... 20
GANIRELIX ACETATE -ganirelix acetate inj 250
mcg/0.5ml........................................................................ 46
GARAMYCIN -gentamicin sulfate ophth soln 0.3%........ 160
GARDASIL -human papillomavirus (hpv) quadrivalent
recombinant vac inj.........................................................19
GARDASIL 9 -human papillomavirus (hpv) 9-valent
recomb vac im susp....................................................... 19
GARDASIL 9 -human papillomavirus (hpv) 9-valent
recomb vac susp pref syr............................................... 19
GASTROCROM -cromolyn sodium oral conc 100
mg/5ml............................................................................. 89
gatifloxacin ophth soln 0.5% (Zymaxid)..................... 160
GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 90
GE100 BLOOD GLUCOSE MONIT -blood glucose
monitoring kit w/ device................................................ 183
GEL-KAM ORAL CARE RINSE -stannous fluoride conc
0.63%.............................................................................164
GEL-KAM -stannous fluoride gel 0.4%........................... 164
GELNIQUE -oxybutynin chloride td gel 10%.................... 92
GELNIQUE -oxybutynin td gel 3% (28 mg/act metereddose pump)..................................................................... 92
gemfibrozil tab 600 mg (Lopid)...................................... 70
GENERESS FE -norethindrone & ethinyl estradiol-fe
chew tab 0.8 mg-25 mcg................................................32
GENOTROPIN MINIQUICK -somatropin for inj 0.2
mg.................................................................................... 46
GENOTROPIN MINIQUICK -somatropin for inj 0.4
mg.................................................................................... 46
GENOTROPIN MINIQUICK -somatropin for inj 0.6
mg.................................................................................... 46
GENOTROPIN MINIQUICK -somatropin for inj 0.8
mg.................................................................................... 46
GENOTROPIN MINIQUICK -somatropin for inj 1 mg....... 46
GENOTROPIN MINIQUICK -somatropin for inj 1.2
mg.................................................................................... 46
GENOTROPIN MINIQUICK -somatropin for inj 1.4
mg.................................................................................... 46
GENOTROPIN MINIQUICK -somatropin for inj 1.6
mg.................................................................................... 46
GENOTROPIN MINIQUICK -somatropin for inj 1.8
mg.................................................................................... 46
GENOTROPIN MINIQUICK -somatropin for inj 2 mg....... 46
GENOTROPIN -somatropin for inj 12 mg (13.8 mg
overfill)............................................................................. 46
GENOTROPIN -somatropin for subcutaneous inj 5
mg.................................................................................... 46
GENTAMICIN SULFATE -gentamicin sulfate cream
0.1%...............................................................................171
GENTAMICIN SULFATE -gentamicin sulfate oint
0.1%...............................................................................171
gentamicin sulfate ophth oint 0.3%............................. 160
gentamicin sulfate ophth soln 0.3% (Garamycin)...... 160
GENVOYA -elvitegrav-cobic-emtricitab-tenofov af tab
150-150-200-10 mg........................................................ 10
GEODON -ziprasidone hcl cap 20 mg............................ 103
GEODON -ziprasidone hcl cap 40 mg............................ 103
GEODON -ziprasidone hcl cap 60 mg............................ 103
GEODON -ziprasidone hcl cap 80 mg............................ 103
GEODON -ziprasidone mesylate for inj 20 mg (base
equivalent)..................................................................... 103
GHT BLOOD GLUCOSE MONITO -blood glucose
monitoring kit w/ device................................................ 184
GIAZO -balsalazide disodium tab 1.1 gm......................... 90
GILENYA -fingolimod hcl cap 0.5 mg (base equiv)......... 115
GILOTRIF -afatinib dimaleate tab 20 mg (base
equivalent)....................................................................... 22
GILOTRIF -afatinib dimaleate tab 30 mg (base
equivalent)....................................................................... 22
GILOTRIF -afatinib dimaleate tab 40 mg (base
equivalent)....................................................................... 22
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)................................................................... 115
GLEEVEC -imatinib mesylate tab 100 mg (base
equivalent)....................................................................... 22
GLEEVEC -imatinib mesylate tab 400 mg (base
equivalent)....................................................................... 22
GLEOSTINE -lomustine cap 5 mg.................................... 22
GLEOSTINE -lomustine cap 10 mg.................................. 22
GLEOSTINE -lomustine cap 40 mg.................................. 22
GLEOSTINE -lomustine cap 100 mg................................ 22
glimepiride tab 1 mg (Amaryl)........................................36
glimepiride tab 2 mg (Amaryl)........................................36
glimepiride tab 4 mg (Amaryl)........................................36
glipizide-metformin hcl tab 2.5-250 mg......................... 36
glipizide-metformin hcl tab 2.5-500 mg......................... 36
glipizide-metformin hcl tab 5-500 mg............................ 36
glipizide tab 5 mg (Glucotrol).........................................36
glipizide tab 10 mg (Glucotrol).......................................36
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).................... 36
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 36
glipizide tab sr 24hr 10 mg (Glucotrol xl)..................... 36
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GLUCAGEN DIAGNOSTIC -glucagon hcl (rdna)
diagnostic for inj 1 mg (base equiv)............................. 178
GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg
(base equiv).................................................................... 36
GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj
kit 1 mg........................................................................... 36
GLUCOCARD 01 BLOOD GLUCOS -blood glucose
monitoring devices........................................................ 184
GLUCOCARD 01 BLOOD GLUCOS -blood glucose
monitoring kit w/ device................................................ 184
GLUCOCARD EXPRESSION AUDI -blood glucose
monitoring kit w/ device................................................ 184
GLUCOCARD 01-MINI BLOOD G -blood glucose
monitoring kit w/ device................................................ 184
GLUCOCARD SHINE -blood glucose monitoring
devices.......................................................................... 184
GLUCOCARD SHINE -blood glucose monitoring kit w/
device............................................................................ 184
GLUCOCARD VITAL BLOOD GLU -blood glucose
monitoring kit w/ device................................................ 184
GLUCOCARD X-METER -blood glucose monitoring kit w/
device............................................................................ 184
GLUCOCOM AUTOLINK TELEMON -blood glucose
monitoring misc............................................................. 184
GLUCOCOM BLOOD GLUCOSE MO -blood glucose
monitoring devices........................................................ 184
GLUCOCOM BLOOD GLUCOSE MO -blood glucose
monitoring kit w/ device................................................ 184
GLUCONAVII BLOOD GLUCOSE -blood glucose
monitoring kit w/ device................................................ 184
GLUCO PERFECT 3 BLOOD GLU -blood glucose
monitoring devices........................................................ 184
GLUCOPHAGE -metformin hcl tab 500 mg...................... 36
GLUCOPHAGE -metformin hcl tab 850 mg...................... 36
GLUCOPHAGE -metformin hcl tab 1000 mg.................... 36
GLUCOPHAGE XR -metformin hcl tab sr 24hr 500
mg.................................................................................... 37
GLUCOPHAGE XR -metformin hcl tab sr 24hr 750
mg.................................................................................... 37
GLUCOSE BLOOD TEST STRIPS VARIOUS................ 178
glucose gel 40%............................................................... 37
GLUCOSE -glucose chew tab 4 gm................................. 37
GLUCOSE NURSETTE -glucose oral soln 5%...............147
glucose oral liquid......................................................... 148
glucose oral liquid 15 gm/59ml...................................... 37
glucose oral soln 5%..................................................... 148
GLUCOTROL -glipizide tab 5 mg..................................... 37
GLUCOTROL -glipizide tab 10 mg................................... 37
GLUCOTROL XL -glipizide tab sr 24hr 2.5 mg.................37
GLUCOTROL XL -glipizide tab sr 24hr 5 mg....................37
GLUCOTROL XL -glipizide tab sr 24hr 10 mg..................37
GLUCOVANCE -glyburide-metformin tab 1.25-250
mg.................................................................................... 37
GLUCOVANCE -glyburide-metformin tab 2.5-500 mg...... 37
GLUCOVANCE -glyburide-metformin tab 5-500 mg......... 37
GLUMETZA -metformin hcl tab sr 24hr modified release
500 mg............................................................................ 37
GLUMETZA -metformin hcl tab sr 24hr modified release
1000 mg.......................................................................... 37
GLYBURIDE -glyburide tab 1.25 mg................................. 37
GLYBURIDE -glyburide tab 2.5 mg................................... 37
GLYBURIDE -glyburide tab 5 mg...................................... 37
glyburide-metformin tab 1.25-250 mg
(Glucovance).................................................................. 37
glyburide-metformin tab 2.5-500 mg (Glucovance)..... 37
glyburide-metformin tab 5-500 mg (Glucovance)........ 37
glyburide micronized tab 1.5 mg (Glynase)..................37
glyburide micronized tab 3 mg (Glynase).....................37
glyburide micronized tab 6 mg (Glynase).....................37
glyburide tab 1.25 mg..................................................... 37
glyburide tab 2.5 mg....................................................... 37
glyburide tab 5 mg.......................................................... 37
glycopyrrolate tab 1 mg (Robinul)................................. 85
glycopyrrolate tab 2 mg (Robinul forte)........................85
GLYNASE -glyburide micronized tab 1.5 mg.................... 37
GLYNASE -glyburide micronized tab 3 mg....................... 37
GLYNASE -glyburide micronized tab 6 mg....................... 37
GLYSET -miglitol tab 25 mg.............................................. 37
GLYSET -miglitol tab 50 mg.............................................. 37
GLYSET -miglitol tab 100 mg............................................ 37
GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............ 37
GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............ 37
GMATE ORIGIN BLOOD GLUCOS -blood glucose
monitoring devices........................................................ 184
GMATE SMART METER KIT -blood glucose monitoring
devices.......................................................................... 184
GMATE SMART STARTER KIT -blood glucose monitoring
kit w/ device.................................................................. 184
GMATE VOICE BLOOD GLUCOSE -blood glucose
monitoring devices........................................................ 184
GNP GLUCOSE -glucose chew tab 4 gm........................ 37
GNP QUICK DISSOLVE GLUCOS -glucose chew tab 4
gm.................................................................................... 37
GNP VITAMIN D-400 -calcium carbonate-cholecalciferol
tab 90 mg-400 unit....................................................... 146
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm.................................................................... 83
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm............................................................. 83
GONAL-F -follitropin alfa for inj 450 unit........................... 46
GONAL-F -follitropin alfa for inj 1050 unit......................... 46
GONAL-F RFF -follitropin alfa for inj 75 unit..................... 46
GONAL-F RFF PEN -follitropin alfa inj 300 unit/0.5ml...... 46
GONAL-F RFF PEN -follitropin alfa inj 450
unit/0.75ml....................................................................... 46
GONAL-F RFF PEN -follitropin alfa inj 900 unit/1.5ml...... 47
GONAL-F RFF REDIJECT -follitropin alfa inj 300
unit/0.5ml......................................................................... 47
GONAL-F RFF REDIJECT -follitropin alfa inj 450
unit/0.75ml....................................................................... 47
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GONAL-F RFF REDIJECT -follitropin alfa inj 900
unit/1.5ml......................................................................... 47
GRALISE -gabapentin (once-daily) tab 300 mg..............115
GRALISE -gabapentin (once-daily) tab 600 mg..............115
GRALISE STARTER -gabapentin (once-daily) tab pack
300 mg (9) & 600 mg (69)........................................... 115
granisetron hcl tab 1 mg................................................ 87
GRANIX -tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml...................................................................... 149
GRANIX -tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml...................................................................... 149
griseofulvin microsize susp 125 mg/5ml........................ 8
griseofulvin microsize tab 500 mg (Grifulvin v)............. 8
griseofulvin ultramicrosize tab 125 mg (Gris-peg)........ 8
griseofulvin ultramicrosize tab 250 mg (Gris-peg)........ 8
GRIS-PEG -griseofulvin ultramicrosize tab 125 mg............ 8
GRIS-PEG -griseofulvin ultramicrosize tab 250 mg............ 8
guaifenesin-codeine liquid 200-8 mg/5ml..................... 78
guaifenesin-codeine liquid 225-7.5 mg/5ml.................. 78
guaifenesin-codeine soln 100-6.3 mg/5ml.................... 78
guaifenesin-codeine soln 100-10 mg/5ml..................... 78
guanfacine hcl tab 1 mg (Tenex)................................... 62
guanfacine hcl tab 2 mg (Tenex)................................... 62
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv)........................................................................ 111
guanfacine hcl tab sr 24hr 2 mg (base equiv)
(Intuniv)........................................................................ 111
guanfacine hcl tab sr 24hr 3 mg (base equiv)
(Intuniv)........................................................................ 111
guanfacine hcl tab sr 24hr 4 mg (base equiv)
(Intuniv)........................................................................ 111
GUANIDINE HCL -guanidine hcl tab 125 mg................. 145
GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal
cream 2%........................................................................ 93
H
HALCION -triazolam tab 0.25 mg................................... 108
HALDOL DECANOATE 100 -haloperidol decanoate im
soln 100 mg/ml............................................................. 103
HALDOL DECANOATE 50 -haloperidol decanoate im soln
50 mg/ml....................................................................... 103
HALDOL -haloperidol lactate inj 5 mg/ml........................ 103
halobetasol propionate cream 0.05% (Ultravate)....... 171
halobetasol propionate oint 0.05% (Ultravate)........... 171
HALOG -halcinonide cream 0.1%................................... 171
HALOG -halcinonide oint 0.1%....................................... 171
haloperidol decanoate im soln 50 mg/ml (Haldol
decanoate 50).............................................................. 103
haloperidol decanoate im soln 100 mg/ml (Haldol
decanoate 100)............................................................ 103
haloperidol lactate inj 5 mg/ml (Haldol)...................... 103
haloperidol lactate oral conc 2 mg/ml.........................104
haloperidol tab 0.5 mg.................................................. 104
haloperidol tab 1 mg..................................................... 104
haloperidol tab 2 mg..................................................... 104
haloperidol tab 5 mg..................................................... 104
haloperidol tab 10 mg................................................... 104
haloperidol tab 20 mg................................................... 104
HARVONI -ledipasvir-sofosbuvir tab 90-400 mg.............. 10
HAVRIX -hepatitis a vaccine inj susp 720 el
unit/0.5ml......................................................................... 19
HAVRIX -hepatitis a vaccine inj susp 1440 el unit/ml....... 19
HECTOROL -doxercalciferol cap 0.5 mcg........................ 47
HECTOROL -doxercalciferol cap 1 mcg........................... 47
HECTOROL -doxercalciferol cap 2.5 mcg........................ 47
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 250 unit.................................................................... 154
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 500 unit.................................................................... 154
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 1000 unit.................................................................. 154
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 2000 unit.................................................................. 155
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 3000 unit.................................................................. 155
HEMOFIL M -antihemophilic factor (human) for inj 250
unit................................................................................. 155
HEMOFIL M -antihemophilic factor (human) for inj 500
unit................................................................................. 155
HEMOFIL M -antihemophilic factor (human) for inj 1000
unit................................................................................. 155
HEMOFIL M -antihemophilic factor (human) for inj 1700
unit................................................................................. 155
HEMOFIL M -antihemophilic factor (human) for inj
220-400 unit.................................................................. 155
HEMOFIL M -antihemophilic factor (human) for inj
401-800 unit.................................................................. 155
HEMOFIL M -antihemophilic factor (human) for inj
801-1500 unit................................................................ 155
HEMOFIL M -antihemophilic factor (human) for inj
1501-2000 unit.............................................................. 155
heparin sodium (porcine) inj 5000 unit/ml.................. 151
heparin sodium (porcine) inj 10000 unit/ml................ 151
heparin sodium (porcine) lock flush iv soln 10 unit/
ml................................................................................... 151
heparin sodium (porcine) lock flush iv soln 100 unit/
ml................................................................................... 151
heparin sodium (porcine) pf inj 5000 unit/0.5ml........ 151
HEPSERA -adefovir dipivoxil tab 10 mg........................... 10
HETLIOZ -tasimelteon capsule 20 mg............................ 108
HEXALEN -altretamine cap 50 mg................................... 22
HIBERIX -haemophilus b polysaccharide conjugate vac
for inj 10 mcg.................................................................. 19
HIPREX -methenamine hippurate tab 1 gm......................91
HISTEX-AC -phenylephrine-triprolidine-codeine syrup
10-2.5-10 mg/5ml............................................................ 78
HIZENTRA -immune globulin (human) subcutaneous inj 1
gm/5ml............................................................................. 20
HIZENTRA -immune globulin (human) subcutaneous inj 2
gm/10ml........................................................................... 20
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HIZENTRA -immune globulin (human) subcutaneous inj 4
gm/20ml........................................................................... 20
HIZENTRA -immune globulin (human) subcutaneous inj
10 gm/50ml..................................................................... 20
HORIZANT -gabapentin enacarbil tab cr 300 mg........... 115
HORIZANT -gabapentin enacarbil tab cr 600 mg........... 115
H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 47
HUMALOG -insulin lispro (human) inj 100 unit/ml............ 40
HUMALOG -insulin lispro (human) soln cartridge 100 unit/
ml..................................................................................... 40
HUMALOG KWIKPEN -insulin lispro (human) soln peninjector 100 unit/ml......................................................... 40
HUMALOG KWIKPEN -insulin lispro (human) soln peninjector 200 unit/ml......................................................... 40
HUMALOG MIX 50/50 -insulin lispro prot & lispro (human)
inj 100 unit/ml (50-50).................................................... 41
HUMALOG MIX 75/25 -insulin lispro prot & lispro (human)
inj 100 unit/ml (75-25).................................................... 41
HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................41
HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................41
HUMATE-P -antihemophilic factor/vwf (human) for inj
250-600 unit.................................................................. 155
HUMATE-P -antihemophilic factor/vwf (human) for inj
500-1200 unit................................................................ 155
HUMATE-P -antihemophilic factor/vwf (human) for inj
1000-2400 unit.............................................................. 155
HUMATROPE COMBO PACK -somatropin for inj 5
mg.................................................................................... 47
HUMATROPE -somatropin for inj 5 mg............................ 47
HUMATROPE -somatropin for inj 24 mg.......................... 47
HUMATROPE -somatropin for inj 6 mg (18 unit).............. 47
HUMATROPE -somatropin for inj 12 mg (36 unit)............ 47
HUMIRA -adalimumab prefilled syringe kit 10
mg/0.2ml........................................................................ 129
HUMIRA -adalimumab prefilled syringe kit 20
mg/0.4ml........................................................................ 129
HUMIRA -adalimumab prefilled syringe kit 40
mg/0.8ml........................................................................ 129
HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled
syringe kit 40 mg/0.8ml................................................ 129
HUMIRA PEN -adalimumab pen-injector kit 40
mg/0.8ml........................................................................ 129
HUMIRA PEN-CROHNS DISEASE -adalimumab peninjector kit 40 mg/0.8ml................................................ 129
HUMIRA PEN-PSORIASIS STAR -adalimumab peninjector kit 40 mg/0.8ml................................................ 129
HUMULIN 70/30 -insulin nph isophane & regular human
inj 100 unit/ml (70-30).................................................... 41
HUMULIN 70/30 KWIKPEN -insulin nph & regular susp
pen-inj 100 unit/ml (70-30)............................................. 41
HUMULIN 70/30 PEN -insulin nph & regular susp pen-inj
100 unit/ml (70-30)......................................................... 41
HUMULIN N -insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 41
HUMULIN N KWIKPEN -insulin nph (human) (isophane)
susp pen-injector 100 unit/ml......................................... 41
HUMULIN N U-100 PEN -insulin nph (human) (isophane)
susp pen-injector 100 unit/ml......................................... 41
HUMULIN R -insulin regular (human) inj 100 unit/ml........ 41
HUMULIN R U-500 (CONCENTR -insulin regular (human)
inj 500 unit/ml..................................................................41
HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)...... 22
HYCAMTIN -topotecan hcl cap 1 mg (base equiv)........... 22
HYCET -hydrocodone-acetaminophen soln 7.5-325
mg/15ml......................................................................... 122
HYCOFENIX -pseudoephedrine w/ hydrocodone-gg soln
30-2.5-200 mg/5ml.......................................................... 78
hydralazine hcl tab 10 mg.............................................. 62
hydralazine hcl tab 25 mg.............................................. 62
hydralazine hcl tab 50 mg.............................................. 62
hydralazine hcl tab 100 mg............................................ 62
HYDREA -hydroxyurea cap 500 mg................................. 22
hydrochlorothiazide cap 12.5 mg (Microzide).............. 68
hydrochlorothiazide tab 12.5 mg................................... 68
hydrochlorothiazide tab 25 mg...................................... 68
hydrochlorothiazide tab 50 mg...................................... 68
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet).......................................................................... 122
hydrocodone-acetaminophen tab 2.5-325 mg............ 122
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco).......................................................................... 122
hydrocodone-acetaminophen tab 5-325 mg
(Norco).......................................................................... 122
hydrocodone-acetaminophen tab 10-325 mg
(Norco).......................................................................... 122
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol).......................................................................... 122
hydrocodone-acetaminophen tab 5-300 mg
(Xodol).......................................................................... 122
hydrocodone-acetaminophen tab 10-300 mg
(Xodol).......................................................................... 122
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)..... 122
hydrocodone-ibuprofen tab 5-200 mg
(Reprexain)................................................................... 122
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)................................................................. 122
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml...... 78
hydrocodone w/ homatropine tab 5-1.5 mg..................78
hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml
(Tussionex pennkineti)................................................. 78
hydrocortisone acetate suppos 25 mg (Anusolhc)................................................................................. 166
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc).................................................... 166
hydrocortisone butyrate cream 0.1% (Locoid)...........171
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)............................................ 171
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hydrocortisone butyrate oint 0.1% (Locoid)............... 171
hydrocortisone butyrate soln 0.1% (Locoid).............. 171
hydrocortisone cream 1%.............................................171
hydrocortisone cream 2.5%..........................................171
hydrocortisone enema 100 mg/60ml
(Cortenema)................................................................. 166
hydrocortisone lotion 2.5%.......................................... 171
hydrocortisone oint 1%................................................. 171
hydrocortisone oint 2.5%..............................................172
hydrocortisone rectal cream 2.5% (Anusol-hc)......... 166
hydrocortisone rectal cream 1% (Proctocort)............ 166
hydrocortisone tab 5 mg (Cortef).................................. 27
hydrocortisone tab 10 mg (Cortef)................................ 27
hydrocortisone tab 20 mg (Cortef)................................ 27
hydrocortisone valerate cream 0.2%...........................172
hydrocortisone valerate oint 0.2% (Westcort)............ 172
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc)................................................................................. 163
HYDROMORPHONE HCL ER -hydromorphone hcl tab er
24hr deter 32 mg.......................................................... 122
hydromorphone hcl liqd 1 mg/ml (Dilaudid)...............122
hydromorphone hcl tab er 24hr deter 8 mg
(Exalgo)........................................................................ 122
hydromorphone hcl tab er 24hr deter 12 mg
(Exalgo)........................................................................ 122
hydromorphone hcl tab er 24hr deter 16 mg
(Exalgo)........................................................................ 122
hydromorphone hcl tab 2 mg (Dilaudid)..................... 123
hydromorphone hcl tab 4 mg (Dilaudid)..................... 123
hydromorphone hcl tab 8 mg (Dilaudid)..................... 123
hydroxychloroquine sulfate tab 200 mg
(Plaquenil)...................................................................... 14
hydroxyurea cap 500 mg (Hydrea)................................ 22
hydroxyzine hcl syrup 10 mg/5ml................................. 95
hydroxyzine hcl tab 10 mg............................................. 95
hydroxyzine hcl tab 25 mg............................................. 95
hydroxyzine hcl tab 50 mg............................................. 95
hydroxyzine pamoate cap 25 mg (Vistaril)................... 95
hydroxyzine pamoate cap 50 mg (Vistaril)................... 95
HYDROXYZINE PAMOATE -hydroxyzine pamoate cap
100 mg............................................................................ 95
hyoscyamine sulfate tab sr 12hr 0.375 mg
(Levbid)........................................................................... 85
HYQVIA -immun glob inj 2.5 gm/25ml-hyaluron inj 200
unt/1.25 ml kit................................................................. 20
HYQVIA -immun glob inj 5 gm/50ml-hyaluron inj 400
unt/2.5 ml kit................................................................... 20
HYQVIA -immun glob inj 10 gm/100ml-hyaluron inj 800
unt/5 ml kit...................................................................... 21
HYQVIA -immun glob inj 20 gm/200ml-hyaluron inj 1600
unt/10 ml kit.................................................................... 21
HYQVIA -immun glob inj 30 gm/300ml-hyaluron inj 2400
unt/15 ml kit.................................................................... 21
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
20 mg............................................................................ 123
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
30 mg............................................................................ 123
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
40 mg............................................................................ 123
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
60 mg............................................................................ 123
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
80 mg............................................................................ 123
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
100 mg.......................................................................... 123
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
120 mg.......................................................................... 123
HYZAAR -losartan potassium & hydrochlorothiazide tab
50-12.5 mg...................................................................... 62
HYZAAR -losartan potassium & hydrochlorothiazide tab
100-12.5 mg.................................................................... 62
HYZAAR -losartan potassium & hydrochlorothiazide tab
100-25 mg....................................................................... 62
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva).......................................................................... 47
IBG STAR BLOOD GLUCOSE MO -blood glucose
monitoring kit w/ device................................................ 184
IBRANCE -palbociclib cap 75 mg..................................... 22
IBRANCE -palbociclib cap 100 mg................................... 22
IBRANCE -palbociclib cap 125 mg................................... 22
IBUDONE -hydrocodone-ibuprofen tab 10-200 mg........ 123
ibuprofen susp 100 mg/5ml.......................................... 129
ibuprofen tab 400 mg.................................................... 129
ibuprofen tab 600 mg.................................................... 129
ibuprofen tab 800 mg.................................................... 129
ICAR -carbonyl iron chew tab 15 mg (elemental
iron)................................................................................149
ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml
(elemental iron)............................................................. 149
IC 400 -ibuprofen tab 400 mg & caffeine-vitamins cap
kit................................................................................... 130
IC 800 -ibuprofen tab 800 mg & caffeine-vitamins cap
kit................................................................................... 130
ICLUSIG -ponatinib hcl tab 15 mg (base equiv)............... 22
ICLUSIG -ponatinib hcl tab 45 mg (base equiv)............... 22
ILARIS -canakinumab for inj 180 mg.............................. 130
ILEVRO -nepafenac ophth susp 0.3%............................ 160
IMBRUVICA -ibrutinib cap 140 mg................................... 23
imipramine hcl tab 10 mg (Tofranil).............................. 98
imipramine hcl tab 25 mg (Tofranil).............................. 98
imipramine hcl tab 50 mg (Tofranil).............................. 98
imipramine pamoate cap 75 mg (Tofranil-pm)............. 98
imipramine pamoate cap 100 mg (Tofranil-pm)........... 98
imipramine pamoate cap 125 mg (Tofranil-pm)........... 98
imipramine pamoate cap 150 mg (Tofranil-pm)........... 98
imiquimod cream 5% (Aldara)...................................... 172
IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 4 mg/0.5ml....................................... 133
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IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 6 mg/0.5ml....................................... 133
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 4 mg/0.5ml................................. 133
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 6 mg/0.5ml................................. 133
IMITREX -sumatriptan nasal spray 5 mg/act.................. 132
IMITREX -sumatriptan nasal spray 20 mg/act................ 132
IMITREX -sumatriptan succinate inj 6 mg/0.5ml............. 132
IMITREX -sumatriptan succinate tab 25 mg................... 132
IMITREX -sumatriptan succinate tab 50 mg................... 132
IMITREX -sumatriptan succinate tab 100 mg................. 133
IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc
inj..................................................................................... 19
IMURAN -azathioprine tab 50 mg................................... 191
INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)..........47
INCRUSE ELLIPTA -umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq)............................................ 81
indapamide tab 1.25 mg..................................................68
indapamide tab 2.5 mg.................................................... 68
INDERAL LA -propranolol hcl cap sr 24hr 60 mg............. 52
INDERAL LA -propranolol hcl cap sr 24hr 80 mg............. 52
INDERAL LA -propranolol hcl cap sr 24hr 120 mg........... 52
INDERAL LA -propranolol hcl cap sr 24hr 160 mg........... 52
INDERAL XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg.......................................................... 52
INDERAL XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg........................................................ 52
INDOCIN -indomethacin suppos 50 mg..........................130
INDOCIN -indomethacin susp 25 mg/5ml....................... 130
indomethacin cap cr 75 mg.......................................... 130
indomethacin cap 25 mg.............................................. 130
indomethacin cap 50 mg.............................................. 130
INFANRIX -diph, acellular pert & tet tox inj 25 lf-58
mcg-10 lf/0.5ml............................................................... 20
INFASURF -calfactant in nacl 0.9% intratracheal susp 35
mg/ml............................................................................... 83
INFED -iron dextran inj 50 mg/ml (elemental iron)......... 149
INFINITY BLOOD GLUCOSE MO -blood glucose
monitoring kit w/ device................................................ 184
INLYTA -axitinib tab 1 mg.................................................. 23
INLYTA -axitinib tab 5 mg.................................................. 23
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg.......................................................... 52
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg........................................................ 52
INSPRA -eplerenone tab 25 mg....................................... 62
INSPRA -eplerenone tab 50 mg....................................... 62
INSTA-GLUCOSE -glucose gel 77.4%............................. 37
INSUL-TOTE -blood glucose monitoring supplies.......... 184
INSUL-TOTE JR -blood glucose monitoring supplies..... 184
INTELENCE -etravirine tab 25 mg.................................... 10
INTELENCE -etravirine tab 100 mg.................................. 10
INTELENCE -etravirine tab 200 mg.................................. 10
INTERMEZZO -zolpidem tartrate sl tab 1.75 mg............ 108
INTERMEZZO -zolpidem tartrate sl tab 3.5 mg.............. 108
IN TOUCH -blood glucose monitoring devices............... 184
IN TOUCH DIABETES MANAGEM -blood glucose
monitoring misc............................................................. 184
INTRON A -interferon alfa-2b for inj 10000000 unit.......... 23
INTRON A -interferon alfa-2b for inj 18000000 unit.......... 23
INTRON A -interferon alfa-2b for inj 50000000 unit.......... 23
INTRON A -interferon alfa-2b inj 6000000 unit/ml............ 23
INTRON A -interferon alfa-2b inj 10000000 unit/ml.......... 23
INTRON A W/DILUENT -interferon alfa-2b for inj
10000000 unit................................................................. 23
INTRON A W/DILUENT -interferon alfa-2b for inj
18000000 unit................................................................. 23
INTRON A W/DILUENT -interferon alfa-2b for inj
50000000 unit................................................................. 23
INTUNIV -guanfacine hcl tab sr 24hr 1 mg (base
equiv)............................................................................. 112
INTUNIV -guanfacine hcl tab sr 24hr 2 mg (base
equiv)............................................................................. 112
INTUNIV -guanfacine hcl tab sr 24hr 3 mg (base
equiv)............................................................................. 112
INTUNIV -guanfacine hcl tab sr 24hr 4 mg (base
equiv)............................................................................. 112
INVEGA -paliperidone tab sr 24hr 1.5 mg...................... 104
INVEGA -paliperidone tab sr 24hr 3 mg......................... 104
INVEGA -paliperidone tab sr 24hr 6 mg......................... 104
INVEGA -paliperidone tab sr 24hr 9 mg......................... 104
INVEGA SUSTENNA -paliperidone palmitate im
extended-release susp 39 mg/0.25ml.......................... 104
INVEGA SUSTENNA -paliperidone palmitate im
extended-release susp 78 mg/0.5ml............................ 104
INVEGA SUSTENNA -paliperidone palmitate im
extended-release susp 156 mg/ml............................... 104
INVEGA SUSTENNA -paliperidone palmitate im
extended-release susp 234 mg/1.5ml.......................... 104
INVEGA SUSTENNA -paliperidone palmitate im extendrelease susp 117 mg/0.75ml........................................ 104
INVEGA TRINZA -paliperidone palmitate im extendrelease susp 273 mg/0.875ml...................................... 104
INVEGA TRINZA -paliperidone palmitate im extendrelease susp 410 mg/1.315ml...................................... 104
INVEGA TRINZA -paliperidone palmitate im extendrelease susp 546 mg/1.75ml........................................ 104
INVEGA TRINZA -paliperidone palmitate im extendrelease susp 819 mg/2.625ml...................................... 104
INVIRASE -saquinavir mesylate cap 200 mg................... 10
INVIRASE -saquinavir mesylate tab 500 mg.................... 10
INVOKAMET -canagliflozin-metformin hcl tab 50-500
mg.................................................................................... 37
INVOKAMET -canagliflozin-metformin hcl tab 150-500
mg.................................................................................... 38
INVOKAMET -canagliflozin-metformin hcl tab 50-1000
mg.................................................................................... 37
INVOKAMET -canagliflozin-metformin hcl tab 150-1000
mg.................................................................................... 38
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INVOKANA -canagliflozin tab 100 mg.............................. 38
INVOKANA -canagliflozin tab 300 mg.............................. 38
IODINE TINCTURE MILD -iodine tincture...................... 177
IODINE TINCTURE STRONG DE -iodine tincture
strong............................................................................. 177
IODINE TINCTURE STRONG -iodine tincture
strong............................................................................. 177
IONSYS -fentanyl hcl iontophoretic td system 40 mcg/act
(base equiv).................................................................. 123
IOPIDINE -apraclonidine hcl ophth soln 0.5% (base
equivalent)..................................................................... 160
IOPIDINE -apraclonidine hcl ophth soln 1% (base
equivalent)..................................................................... 160
IPOL INACTIVATED IPV -poliovirus vaccine, ipv
injection........................................................................... 19
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 81
ipratropium bromide inhal soln 0.02%.......................... 81
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)....................................................................... 77
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)....................................................................... 77
IPRIVASK -desirudin for inj 15 mg.................................. 151
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................62
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................62
irbesartan tab 75 mg (Avapro)....................................... 62
irbesartan tab 150 mg (Avapro)..................................... 62
irbesartan tab 300 mg (Avapro)..................................... 62
IRENKA -duloxetine hcl enteric coated pellets cap 40
mg.................................................................................... 98
IRESSA -gefitinib tab 250 mg........................................... 23
IRON CHEWS PEDIATRIC -carbonyl iron chew tab 15 mg
(elemental iron)............................................................. 149
iron polysacch complex-vit b12-fa cap 150-0.025-1
mg................................................................................. 149
ISENTRESS -raltegravir potassium chew tab 25 mg (base
equiv)............................................................................... 10
ISENTRESS -raltegravir potassium chew tab 100 mg
(base equiv).................................................................... 10
ISENTRESS -raltegravir potassium packet for susp 100
mg (base equiv).............................................................. 10
ISENTRESS -raltegravir potassium tab 400 mg (base
equiv)............................................................................... 10
ISONIAZID -isoniazid syrup 50 mg/5ml.............................. 7
isoniazid tab 100 mg......................................................... 7
isoniazid tab 300 mg......................................................... 7
ISOPTIN SR -verapamil hcl tab cr 120 mg....................... 55
ISOPTIN SR -verapamil hcl tab cr 180 mg....................... 55
ISOPTIN SR -verapamil hcl tab cr 240 mg....................... 55
ISOPTO CARPINE -pilocarpine hcl ophth soln 1%........ 160
ISOPTO CARPINE -pilocarpine hcl ophth soln 2%........ 160
ISOPTO CARPINE -pilocarpine hcl ophth soln 4%........ 160
ISORDIL TITRADOSE -isosorbide dinitrate tab 5 mg.......50
ISORDIL TITRADOSE -isosorbide dinitrate tab 40
mg.................................................................................... 50
ISOSORBIDE DINITRATE ER -isosorbide dinitrate tab cr
40 mg.............................................................................. 50
ISOSORBIDE DINITRATE -isosorbide dinitrate tab 30
mg.................................................................................... 50
isosorbide dinitrate tab 10 mg....................................... 50
isosorbide dinitrate tab 20 mg....................................... 50
isosorbide dinitrate tab 5 mg (Isordil titradose).......... 50
isosorbide mononitrate tab 10 mg................................ 50
isosorbide mononitrate tab 20 mg................................ 50
isosorbide mononitrate tab sr 24hr 30 mg (Imdur)...... 50
isosorbide mononitrate tab sr 24hr 60 mg (Imdur)...... 50
isosorbide mononitrate tab sr 24hr 120 mg
(Imdur)............................................................................ 50
isotretinoin cap 10 mg.................................................. 172
isotretinoin cap 20 mg.................................................. 172
isotretinoin cap 30 mg.................................................. 172
isotretinoin cap 40 mg.................................................. 172
isradipine cap 2.5 mg...................................................... 55
isradipine cap 5 mg......................................................... 55
ISTALOL -timolol maleate ophth soln 0.5% (oncedaily).............................................................................. 160
itraconazole cap 100 mg (Sporanox).............................. 8
ivermectin tab 3 mg (Stromectol).................................. 14
IXINITY -coagulation factor ix (recombinant) for inj 500
unit................................................................................. 155
IXINITY -coagulation factor ix (recombinant) for inj 1000
unit................................................................................. 155
IXINITY -coagulation factor ix (recombinant) for inj 1500
unit................................................................................. 155
J
JADENU -deferasirox tab 90 mg..................................... 177
JADENU -deferasirox tab 180 mg................................... 177
JADENU -deferasirox tab 360 mg................................... 177
JAKAFI -ruxolitinib phosphate tab 5 mg (base
equivalent)....................................................................... 23
JAKAFI -ruxolitinib phosphate tab 10 mg (base
equivalent)....................................................................... 23
JAKAFI -ruxolitinib phosphate tab 15 mg (base
equivalent)....................................................................... 23
JAKAFI -ruxolitinib phosphate tab 20 mg (base
equivalent)....................................................................... 23
JAKAFI -ruxolitinib phosphate tab 25 mg (base
equivalent)....................................................................... 23
JALYN -dutasteride-tamsulosin hcl cap 0.5-0.4 mg.......... 94
JANUMET -sitagliptin-metformin hcl tab 50-500 mg......... 38
JANUMET -sitagliptin-metformin hcl tab 50-1000 mg....... 38
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-500 mg....................................................................... 38
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-1000 mg..................................................................... 38
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
100-1000 mg................................................................... 38
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JANUVIA -sitagliptin phosphate tab 25 mg (base
equiv)............................................................................... 38
JANUVIA -sitagliptin phosphate tab 50 mg (base
equiv)............................................................................... 38
JANUVIA -sitagliptin phosphate tab 100 mg (base
equiv)............................................................................... 38
JARDIANCE -empagliflozin tab 10 mg............................. 38
JARDIANCE -empagliflozin tab 25 mg............................. 38
JENTADUETO -linagliptin-metformin hcl tab 2.5-1000
mg.................................................................................... 38
JENTADUETO -linagliptin-metformin hcl tab 2.5-500
mg.................................................................................... 38
JENTADUETO -linagliptin-metformin hcl tab 2.5-850
mg.................................................................................... 38
JUBLIA -efinaconazole soln 10%.................................... 172
JUXTAPID -lomitapide mesylate cap 5 mg (base
equiv)............................................................................... 70
JUXTAPID -lomitapide mesylate cap 10 mg (base
equiv)............................................................................... 70
JUXTAPID -lomitapide mesylate cap 20 mg (base
equiv)............................................................................... 70
JUXTAPID -lomitapide mesylate cap 30 mg (base
equiv)............................................................................... 70
JUXTAPID -lomitapide mesylate cap 40 mg (base
equiv)............................................................................... 71
JUXTAPID -lomitapide mesylate cap 60 mg (base
equiv)............................................................................... 71
K
KADIAN -morphine sulfate cap sr 24hr 10 mg................123
KADIAN -morphine sulfate cap sr 24hr 20 mg................123
KADIAN -morphine sulfate cap sr 24hr 30 mg................123
KADIAN -morphine sulfate cap sr 24hr 40 mg................123
KADIAN -morphine sulfate cap sr 24hr 50 mg................123
KADIAN -morphine sulfate cap sr 24hr 60 mg................123
KADIAN -morphine sulfate cap sr 24hr 80 mg................123
KADIAN -morphine sulfate cap sr 24hr 100 mg.............. 123
KADIAN -morphine sulfate cap sr 24hr 200 mg.............. 123
KALBITOR -ecallantide inj 10 mg/ml...............................155
KALETRA -lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml).............................................................................. 10
KALETRA -lopinavir-ritonavir tab 100-25 mg.................... 10
KALETRA -lopinavir-ritonavir tab 200-50 mg.................... 10
KALYDECO -ivacaftor packet 50 mg................................ 83
KALYDECO -ivacaftor packet 75 mg................................ 83
KALYDECO -ivacaftor tab 150 mg.................................... 83
KAPVAY -clonidine hcl tab sr 12hr 0.1 mg...................... 112
KARBINAL ER -carbinoxamine maleate er susp 4
mg/5ml............................................................................. 76
KAYEXALATE -sodium polystyrene sulfonate
powder........................................................................... 191
KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg....... 38
KAZANO -alogliptin-metformin hcl tab 12.5-500 mg......... 38
KEFLEX -cephalexin cap 250 mg....................................... 3
KEFLEX -cephalexin cap 500 mg....................................... 3
KEFLEX -cephalexin cap 750 mg....................................... 3
KENALOG -triamcinolone acetonide aerosol soln 0.147
mg/gm............................................................................ 172
KEPPRA -levetiracetam oral soln 100 mg/ml................. 136
KEPPRA -levetiracetam tab 250 mg............................... 136
KEPPRA -levetiracetam tab 500 mg............................... 136
KEPPRA -levetiracetam tab 750 mg............................... 136
KEPPRA -levetiracetam tab 1000 mg............................. 136
KEPPRA XR -levetiracetam tab sr 24hr 500 mg............ 136
KEPPRA XR -levetiracetam tab sr 24hr 750 mg............ 137
KERLONE -betaxolol hcl tab 10 mg................................. 52
KERLONE -betaxolol hcl tab 20 mg................................. 52
KERYDIN -tavaborole soln 5%........................................172
KETEK -telithromycin tab 300 mg..................................... 15
KETEK -telithromycin tab 400 mg..................................... 15
ketoconazole cream 2%................................................ 172
ketoconazole foam 2% (Extina)................................... 172
ketoconazole shampoo 2% (Nizoral)........................... 172
ketoconazole tab 200 mg.................................................. 8
ketoprofen cap 50 mg................................................... 130
ketoprofen cap 75 mg................................................... 130
KETOPROFEN ER -ketoprofen cap sr 24hr 200 mg...... 130
ketorolac tromethamine im inj 60 mg/2ml (30 mg/
ml)................................................................................. 130
ketorolac tromethamine inj 15 mg/ml......................... 130
ketorolac tromethamine inj 30 mg/ml......................... 130
ketorolac tromethamine inj 60 mg/2ml (30 mg/
ml)................................................................................. 130
KETOROLAC TROMETHAMINE -ketorolac tromethamine
inj 300 mg/10ml (30 mg/ml)......................................... 130
ketorolac tromethamine ophth soln 0.5%
(Acular)......................................................................... 160
ketorolac tromethamine ophth soln 0.4% (Acular
ls)................................................................................... 160
ketorolac tromethamine tab 10 mg............................. 130
KEVEYIS -dichlorphenamide tab 50 mg........................... 68
KHEDEZLA -desvenlafaxine tab sr 24hr 50 mg............... 98
KHEDEZLA -desvenlafaxine tab sr 24hr 100 mg............. 98
KINERET -anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml.............................................................. 130
KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj.............................................................................. 20
KITABIS PAK -tobramycin nebu soln 300 mg/5ml.............. 6
KLARON -sulfacetamide sodium lotion 10% (acne)....... 172
KLONOPIN -clonazepam tab 0.5 mg.............................. 137
KLONOPIN -clonazepam tab 1 mg................................. 137
KLONOPIN -clonazepam tab 2 mg................................. 137
KLOR-CON M15 -potassium chloride microencapsulated
crys cr tab 15 meq....................................................... 147
KOATE-DVI -antihemophilic factor (human) for inj 250
unit................................................................................. 155
KOATE-DVI -antihemophilic factor (human) for inj 500
unit................................................................................. 155
KOATE-DVI -antihemophilic factor (human) for inj 1000
unit................................................................................. 155
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KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 250 unit............................................................... 155
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 500 unit............................................................... 155
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 1000 unit............................................................. 155
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 2000 unit............................................................. 155
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 3000 unit............................................................. 155
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 250 unit.................................. 155
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 500 unit.................................. 156
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 1000 unit................................ 156
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 2000 unit................................ 156
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 3000 unit................................ 156
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 38
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
5-500 mg......................................................................... 38
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 38
KORLYM -mifepristone tab 300 mg.................................. 38
KRISTALOSE -lactulose oral crystal packet 10 gm.......... 83
KRISTALOSE -lactulose oral crystal packet 20 gm.......... 83
KROGER BLOOD GLUCOSE MONI -blood glucose
monitoring kit w/ device................................................ 184
KROGER GLUCOSE -glucose chew tab 4 gm................. 38
KROGER PREMIUM BLOOD GLUC -blood glucose
monitoring kit w/ device................................................ 184
K-TAB -potassium chloride tab cr 10 meq...................... 147
K-TAB -potassium chloride tab cr 8 meq (600 mg)......... 146
K-TAB -potassium chloride tab cr 20 meq (1500 mg)..... 147
KUVAN -sapropterin dihydrochloride powder packet 100
mg.................................................................................... 47
KUVAN -sapropterin dihydrochloride powder packet 500
mg.................................................................................... 47
KUVAN -sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 47
KYNAMRO -mipomersen sodium soln prefilled syringe
200 mg/ml....................................................................... 71
L
labetalol hcl tab 100 mg (Trandate)............................... 52
labetalol hcl tab 200 mg (Trandate)............................... 52
labetalol hcl tab 300 mg (Trandate)............................... 52
LAC-HYDRIN -lactic acid (ammonium lactate) cream
12%................................................................................172
LAC-HYDRIN -lactic acid (ammonium lactate) lotion
12%................................................................................172
LACRISERT -artificial tear ophth insert...........................160
lactic acid (ammonium lactate) cream 12% (Lachydrin).......................................................................... 172
lactic acid (ammonium lactate) lotion 12% (Lachydrin).......................................................................... 172
lactulose (encephalopathy) solution 10 gm/15ml........ 90
lactulose solution 10 gm/15ml....................................... 83
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 5 mg........................................... 137
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 25 mg......................................... 137
LAMICTAL -lamotrigine tab 25 mg.................................. 137
LAMICTAL -lamotrigine tab 100 mg................................ 137
LAMICTAL -lamotrigine tab 150 mg................................ 137
LAMICTAL -lamotrigine tab 200 mg................................ 137
LAMICTAL ODT -lamotrigine orally disintegrating tab 25
mg.................................................................................. 137
LAMICTAL ODT -lamotrigine orally disintegrating tab 50
mg.................................................................................. 137
LAMICTAL ODT -lamotrigine orally disintegrating tab 100
mg.................................................................................. 137
LAMICTAL ODT -lamotrigine orally disintegrating tab 200
mg.................................................................................. 137
LAMICTAL ODT -lamotrigine tab disp 25 (14) & 50 mg
(14) & 100 mg (7) kit.................................................... 137
LAMICTAL ODT -lamotrigine tab disp 25 mg (21) & 50 mg
(7) titration kit................................................................ 137
LAMICTAL ODT -lamotrigine tab disp 50 mg (42) & 100
mg (14) titration kit....................................................... 137
LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit.........................................137
LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit.......................................137
LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg
(35) starter kit............................................................... 137
LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit..................................................... 137
LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit................................................ 137
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg............... 137
LAMICTAL XR -lamotrigine tab sr 24hr 50 mg............... 137
LAMICTAL XR -lamotrigine tab sr 24hr 100 mg............. 137
LAMICTAL XR -lamotrigine tab sr 24hr 200 mg............. 137
LAMICTAL XR -lamotrigine tab sr 24hr 250 mg............. 137
LAMICTAL XR -lamotrigine tab sr 24hr 300 mg............. 137
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit......................................................... 137
LAMISIL SPRAY -terbinafine hcl soln 1%....................... 172
LAMISIL -terbinafine hcl oral granules packet 125 mg....... 8
LAMISIL -terbinafine hcl oral granules packet 187.5
mg...................................................................................... 8
LAMISIL -terbinafine hcl tab 250 mg.................................. 8
lamivudine oral soln 10 mg/ml (Epivir)......................... 10
lamivudine tab 150 mg (Epivir)...................................... 10
lamivudine tab 300 mg (Epivir)...................................... 10
lamivudine tab 100 mg (hbv) (Epivir hbv)..................... 10
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lamivudine-zidovudine tab 150-300 mg (Combivir)..... 10
lamotrigine orally disintegrating tab 25 mg (Lamictal
odt)................................................................................ 137
lamotrigine orally disintegrating tab 50 mg (Lamictal
odt)................................................................................ 137
lamotrigine orally disintegrating tab 100 mg (Lamictal
odt)................................................................................ 137
lamotrigine orally disintegrating tab 200 mg (Lamictal
odt)................................................................................ 138
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................ 138
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................ 138
lamotrigine tab 25 mg (Lamictal)................................. 138
lamotrigine tab 100 mg (Lamictal)............................... 138
lamotrigine tab 150 mg (Lamictal)............................... 138
lamotrigine tab 200 mg (Lamictal)............................... 138
lamotrigine tab sr 24hr 25 mg (Lamictal xr)............... 138
lamotrigine tab sr 24hr 50 mg (Lamictal xr)............... 138
lamotrigine tab sr 24hr 100 mg (Lamictal xr)............. 138
lamotrigine tab sr 24hr 200 mg (Lamictal xr)............. 138
lamotrigine tab sr 24hr 250 mg (Lamictal xr)............. 138
lamotrigine tab sr 24hr 300 mg (Lamictal xr)............. 138
LANOXIN -digoxin tab 62.5 mcg (0.0625 mg).................. 50
LANOXIN -digoxin tab 125 mcg (0.125 mg)..................... 50
LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................ 50
LANOXIN -digoxin tab 250 mcg (0.25 mg)....................... 50
lansoprazole cap delayed release 15 mg
(Prevacid)....................................................................... 85
lansoprazole cap delayed release 30 mg
(Prevacid)....................................................................... 85
LANTUS -insulin glargine inj 100 unit/ml.......................... 42
LANTUS SOLOSTAR -insulin glargine soln pen-injector
100 unit/ml.......................................................................42
LASIX -furosemide tab 20 mg........................................... 68
LASIX -furosemide tab 40 mg........................................... 68
LASIX -furosemide tab 80 mg........................................... 68
LASTACAFT -alcaftadine ophth soln 0.25%................... 160
latanoprost ophth soln 0.005% (Xalatan).................... 160
LATUDA -lurasidone hcl tab 20 mg.................................104
LATUDA -lurasidone hcl tab 40 mg.................................104
LATUDA -lurasidone hcl tab 60 mg.................................104
LATUDA -lurasidone hcl tab 80 mg.................................104
LATUDA -lurasidone hcl tab 120 mg...............................104
LAVOCLEN-4 CREAMY WASH -benzoyl peroxide liq
4%.................................................................................. 172
LAVOCLEN-8 CREAMY WASH -benzoyl peroxide liq
8%.................................................................................. 172
LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base
equiv)............................................................................. 123
LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base
equiv)............................................................................. 123
LDR BLOOD GLUCOSE TRUETES -blood glucose
monitoring kit w/ device................................................ 184
LEADER GLUCOSE -glucose chew tab 4 gm.................. 38
LEADER QUICK DISSOLVE GLU -glucose chew tab 4
gm.................................................................................... 38
leflunomide tab 10 mg (Arava)..................................... 130
leflunomide tab 20 mg (Arava)..................................... 130
LENVIMA 14MG DAILY DOSE -lenvatinib cap therapy
pack 10 & 4 mg (14 mg daily dose)............................... 23
LENVIMA 24MG DAILY DOSE -lenvatinib cap therapy
pack 10 (2) & 4 mg (24 mg daily dose)......................... 23
LENVIMA 10MG DAILY DOSE -lenvatinib cap therapy
pack 10 mg (10 mg daily dose)..................................... 23
LENVIMA 20MG DAILY DOSE -lenvatinib cap therapy
pack 10 (2) mg (20 mg daily dose)................................ 23
LESCOL -fluvastatin sodium cap 20 mg........................... 71
LESCOL XL -fluvastatin sodium tab sr 24 hr 80 mg......... 71
LETAIRIS -ambrisentan tab 5 mg..................................... 74
LETAIRIS -ambrisentan tab 10 mg................................... 74
letrozole tab 2.5 mg (Femara)........................................ 23
LEUCOVORIN CALCIUM -leucovorin calcium tab 10
mg.................................................................................... 23
LEUCOVORIN CALCIUM -leucovorin calcium tab 15
mg.................................................................................... 23
leucovorin calcium tab 5 mg.......................................... 23
leucovorin calcium tab 25 mg........................................ 23
LEUKERAN -chlorambucil tab 2 mg................................. 23
LEUKINE -sargramostim lyophilized for inj 250 mcg...... 149
leuprolide acetate inj kit 5 mg/ml.................................. 23
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv) (XOPENEX CONCENTRATE)........................... 81
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)....................................................................... 81
levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)
(Xopenex)....................................................................... 81
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)
(Xopenex)....................................................................... 81
LEVAQUIN -levofloxacin tab 250 mg.................................. 6
LEVAQUIN -levofloxacin tab 500 mg.................................. 6
LEVAQUIN -levofloxacin tab 750 mg.................................. 6
LEVATOL -penbutolol sulfate tab 20 mg........................... 52
LEVEMIR FLEXPEN -insulin detemir soln pen-injector
100 unit/ml.......................................................................42
LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector
100 unit/ml.......................................................................42
LEVEMIR -insulin detemir inj 100 unit/ml..........................42
levetiracetam oral soln 100 mg/ml (Keppra)...............138
levetiracetam tab 250 mg (Keppra)............................. 138
levetiracetam tab 500 mg (Keppra)............................. 138
levetiracetam tab 750 mg (Keppra)............................. 138
levetiracetam tab 1000 mg (Keppra)........................... 138
levetiracetam tab sr 24hr 500 mg (Keppra xr)............ 138
levetiracetam tab sr 24hr 750 mg (Keppra xr)............ 138
LEVITRA -vardenafil hcl tab 2.5 mg.............................74,75
LEVITRA -vardenafil hcl tab 5 mg............................... 74,75
LEVITRA -vardenafil hcl tab 10 mg..............................74,75
LEVITRA -vardenafil hcl tab 20 mg..............................74,75
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LEVOBUNOLOL HCL -levobunolol hcl ophth soln
0.25%.............................................................................160
levobunolol hcl ophth soln 0.5% (Betagan)............... 160
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 47
levocarnitine tab 330 mg (Carnitor)............................... 47
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5
mg/ml) (Xyzal)................................................................ 76
levocetirizine dihydrochloride tab 5 mg (Xyzal)...........76
levofloxacin ophth soln 0.5%....................................... 160
levofloxacin oral soln 25 mg/ml (Levaquin)................... 6
levofloxacin tab 250 mg (Levaquin)................................ 6
levofloxacin tab 500 mg (Levaquin)................................ 6
levofloxacin tab 750 mg (Levaquin)................................ 6
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg.................................................................. 32
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg................................................................................. 32
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg................................................................................. 32
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg............................... 32
levonorgestrel-ethinyl estradiol (continuous) tab
90-20 mcg.......................................................................32
levonorgestrel tab 1.5 mg (Plan b one-step)................ 32
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)........................................... 32
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)............................................... 32
LEVORPHANOL TARTRATE -levorphanol tartrate tab 2
mg.................................................................................. 123
levothyroxine sodium tab 25 mcg (Synthroid)............. 42
levothyroxine sodium tab 50 mcg (Synthroid)............. 42
levothyroxine sodium tab 75 mcg (Synthroid)............. 42
levothyroxine sodium tab 88 mcg (Synthroid)............. 42
levothyroxine sodium tab 100 mcg (Synthroid)........... 42
levothyroxine sodium tab 112 mcg (Synthroid)........... 42
levothyroxine sodium tab 125 mcg (Synthroid)........... 42
levothyroxine sodium tab 137 mcg (Synthroid)........... 42
levothyroxine sodium tab 150 mcg (Synthroid)........... 42
levothyroxine sodium tab 175 mcg (Synthroid)........... 42
levothyroxine sodium tab 200 mcg (Synthroid)........... 42
levothyroxine sodium tab 300 mcg (Synthroid)........... 42
LEVULAN KERASTICK -aminolevulinic acid hcl for soln
20% (stick applicator)................................................... 172
LEXAPRO -escitalopram oxalate soln 5 mg/5ml (base
equiv)............................................................................... 98
LEXAPRO -escitalopram oxalate tab 5 mg (base
equiv)............................................................................... 98
LEXAPRO -escitalopram oxalate tab 10 mg (base
equiv)............................................................................... 98
LEXAPRO -escitalopram oxalate tab 20 mg (base
equiv)............................................................................... 98
LEXIVA -fosamprenavir calcium susp 50 mg/ml (base
equiv)............................................................................... 10
LEXIVA -fosamprenavir calcium tab 700 mg (base
equiv)............................................................................... 10
LIALDA -mesalamine tab delayed release 1.2 gm........... 90
LIBERTY BLOOD GLUCOSE MET -blood glucose
monitoring devices........................................................ 184
LIBERTY BLOOD GLUCOSE MON -blood glucose
monitoring devices........................................................ 184
LIBERTY NEXT GENERATION B -blood glucose
monitoring devices........................................................ 185
LIBRAX -chlordiazepoxide hcl-clidinium bromide cap
5-2.5 mg.......................................................................... 85
lidocaine hcl cream 3%................................................. 172
lidocaine hcl gel 2%...................................................... 172
lidocaine hcl laryngotracheal soln 4% (Lta 360
kit)................................................................................. 164
lidocaine hcl soln 4% (Xylocaine)............................... 172
lidocaine hcl viscous soln 2%..................................... 164
lidocaine-hydrocortisone acetate rectal cream kit
3-1%.............................................................................. 166
lidocaine-hydrocortisone acetate rectal gel kit
3-2.5%........................................................................... 166
lidocaine oint 5%........................................................... 172
lidocaine patch 5% (Lidoderm).................................... 172
lidocaine-prilocaine cream 2.5-2.5% (Emla)............... 172
LIDODERM -lidocaine patch 5%..................................... 172
lindane lotion 1%........................................................... 172
lindane shampoo 1%..................................................... 172
linezolid for susp 100 mg/5ml (Zyvox).......................... 15
linezolid tab 600 mg (Zyvox).......................................... 15
LINZESS -linaclotide cap 145 mcg................................... 90
LINZESS -linaclotide cap 290 mcg................................... 90
liothyronine sodium tab 5 mcg (Cytomel).................... 42
liothyronine sodium tab 25 mcg (Cytomel).................. 42
liothyronine sodium tab 50 mcg (Cytomel).................. 42
LIPITOR -atorvastatin calcium tab 10 mg (base
equivalent)....................................................................... 71
LIPITOR -atorvastatin calcium tab 20 mg (base
equivalent)....................................................................... 71
LIPITOR -atorvastatin calcium tab 40 mg (base
equivalent)....................................................................... 71
LIPITOR -atorvastatin calcium tab 80 mg (base
equivalent)....................................................................... 71
LIPOFEN -fenofibrate cap 50 mg...................................... 71
LIPOFEN -fenofibrate cap 150 mg.................................... 71
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 62
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 62
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 62
lisinopril tab 5 mg (Prinivil)............................................ 62
lisinopril tab 10 mg (Prinivil).......................................... 63
lisinopril tab 20 mg (Prinivil).......................................... 63
lisinopril tab 2.5 mg (Zestril).......................................... 62
lisinopril tab 30 mg (Zestril)........................................... 63
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lisinopril tab 40 mg (Zestril)........................................... 63
LISTERINE ESSENTIAL CARE -sod monofluorophospheucal-men-methyl sal-thymol gel 0.76%...................... 164
LISTERINE RESTORING -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................164
LISTERINE SMART RINSE -sodium fluoride rinse
0.0221% (0.01% f)........................................................ 164
LISTERINE TOOTH DEFENSE -sodium fluoride rinse
0.0221% (0.01% f)........................................................ 164
LISTERINE TOTAL CARE PLUS -sodium fluoride rinse
0.0221% (0.01% f)........................................................ 164
LISTERINE TOTAL CARE -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................164
LISTERINE TOTAL CARE ZERO -sodium fluoride rinse
0.02%.............................................................................164
LISTERINE WHITENING/RESTO -sodium fluoride rinse
0.0221% (0.01% f)........................................................ 164
lithium carbonate cap 300 mg..................................... 104
lithium carbonate cap 150 mg (Lithium
carbonate).................................................................... 104
lithium carbonate cap 600 mg (Lithium
carbonate).................................................................... 104
LITHIUM CARBONATE -lithium carbonate cap 150
mg.................................................................................. 104
LITHIUM CARBONATE -lithium carbonate cap 600
mg.................................................................................. 104
lithium carbonate tab cr 450 mg.................................. 104
lithium carbonate tab cr 300 mg (Lithobid)................ 104
lithium carbonate tab 300 mg...................................... 104
LITHIUM -lithium oral solution 8 meq/5ml....................... 104
LITHOBID -lithium carbonate tab cr 300 mg................... 104
LITHOSTAT -acetohydroxamic acid tab 250 mg............... 94
LIVALO -pitavastatin calcium tab 1 mg (base equiv)........ 71
LIVALO -pitavastatin calcium tab 2 mg (base equiv)........ 71
LIVALO -pitavastatin calcium tab 4 mg (base equiv)........ 71
LOCOID -hydrocortisone butyrate cream 0.1%.............. 172
LOCOID -hydrocortisone butyrate lotion 0.1%................172
LOCOID -hydrocortisone butyrate oint 0.1%.................. 172
LOCOID -hydrocortisone butyrate soln 0.1%..................172
LOCOID LIPOCREAM -hydrocortisone butyrate
hydrophilic lipo base cream 0.1%................................ 172
LODOSYN -carbidopa tab 25 mg................................... 141
LOESTRIN 1.5/30-21 -norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg.......................................... 33
LOESTRIN 1/20-21 -norethindrone ace & ethinyl estradiol
tab 1 mg-20 mcg............................................................ 33
LOESTRIN FE 1.5/30 -norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg...................................... 33
LOESTRIN FE 1/20 -norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg......................................... 33
LOFIBRA -fenofibrate micronized cap 67 mg................... 71
LOFIBRA -fenofibrate micronized cap 134 mg................. 71
LOFIBRA -fenofibrate micronized cap 200 mg................. 71
LOFIBRA -fenofibrate tab 54 mg...................................... 71
LOFIBRA -fenofibrate tab 160 mg.................................... 71
LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)....................................................... 33
LOMOTIL -diphenoxylate w/ atropine tab 2.5-0.025
mg.................................................................................... 84
LOMUSTINE -lomustine cap 10 mg.................................. 23
LOMUSTINE -lomustine cap 40 mg.................................. 23
LOMUSTINE -lomustine cap 100 mg................................ 23
LONGS GLUCOSE -glucose chew tab 4 gm.................... 38
LONSURF -trifluridine-tipiracil tab 15-6.14 mg................. 23
LONSURF -trifluridine-tipiracil tab 20-8.19 mg................. 23
loperamide hcl cap 2 mg................................................ 84
LOPID -gemfibrozil tab 600 mg......................................... 71
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
50-25 mg......................................................................... 63
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
100-25 mg....................................................................... 63
LOPRESSOR -metoprolol tartrate tab 50 mg................... 52
LOPRESSOR -metoprolol tartrate tab 100 mg................. 52
LOPROX SHAMPOO -ciclopirox shampoo 1%.............. 172
lorazepam conc 2 mg/ml (Lorazepam intensol)........... 95
lorazepam tab 0.5 mg (Ativan)....................................... 95
lorazepam tab 1 mg (Ativan).......................................... 95
lorazepam tab 2 mg (Ativan).......................................... 95
LORTUSS EX -pseudoephedrine w/ cod-gg liquid
30-10-100 mg/5ml........................................................... 78
LORZONE -chlorzoxazone tab 375 mg.......................... 144
LORZONE -chlorzoxazone tab 750 mg.......................... 144
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar)....................................................................63
losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).................................................... 63
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar)....................................................................63
losartan potassium tab 25 mg (Cozaar)........................ 63
losartan potassium tab 50 mg (Cozaar)........................ 63
losartan potassium tab 100 mg (Cozaar)...................... 63
LOSEASONIQUE -levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)..................................................... 33
LOTEMAX -loteprednol etabonate ophth gel 0.5%......... 160
LOTEMAX -loteprednol etabonate ophth oint 0.5%........ 160
LOTEMAX -loteprednol etabonate ophth susp 0.5%...... 160
LOTENSIN -benazepril hcl tab 10 mg.............................. 63
LOTENSIN -benazepril hcl tab 20 mg.............................. 63
LOTENSIN -benazepril hcl tab 40 mg.............................. 63
LOTENSIN HCT -benazepril & hydrochlorothiazide tab
10-12.5 mg...................................................................... 63
LOTENSIN HCT -benazepril & hydrochlorothiazide tab
20-12.5 mg...................................................................... 63
LOTENSIN HCT -benazepril & hydrochlorothiazide tab
20-25 mg......................................................................... 63
LOTREL -amlodipine besylate-benazepril hcl cap 2.5-10
mg.................................................................................... 63
LOTREL -amlodipine besylate-benazepril hcl cap 5-10
mg.................................................................................... 63
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LOTREL -amlodipine besylate-benazepril hcl cap 5-20
mg.................................................................................... 63
LOTREL -amlodipine besylate-benazepril hcl cap 10-20
mg.................................................................................... 63
LOTREL -amlodipine besylate-benazepril hcl cap 10-40
mg.................................................................................... 63
LOTRISONE -clotrimazole w/ betamethasone cream
1-0.05%......................................................................... 172
LOTRONEX -alosetron hcl tab 0.5 mg (base equiv)......... 90
LOTRONEX -alosetron hcl tab 1 mg (base equiv)............ 90
lovastatin tab 10 mg........................................................ 71
lovastatin tab 20 mg (Mevacor)..................................... 71
lovastatin tab 40 mg (Mevacor)..................................... 71
LOVAZA -omega-3-acid ethyl esters cap 1 gm.................71
LOVENOX -enoxaparin sodium inj 30 mg/0.3ml.............151
LOVENOX -enoxaparin sodium inj 40 mg/0.4ml.............151
LOVENOX -enoxaparin sodium inj 60 mg/0.6ml.............151
LOVENOX -enoxaparin sodium inj 80 mg/0.8ml.............151
LOVENOX -enoxaparin sodium inj 100 mg/ml................151
LOVENOX -enoxaparin sodium inj 120 mg/0.8ml...........151
LOVENOX -enoxaparin sodium inj 150 mg/ml................151
LOVENOX -enoxaparin sodium inj 300 mg/3ml..............151
loxapine succinate cap 5 mg....................................... 105
loxapine succinate cap 10 mg..................................... 105
loxapine succinate cap 25 mg..................................... 105
loxapine succinate cap 50 mg..................................... 105
LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg
naf)................................................................................. 147
LTA 360 KIT -lidocaine hcl laryngotracheal soln 4%....... 164
LUCENTIS -ranibizumab intravitreal inj 0.3 mg/0.05ml (6
mg/ml)............................................................................ 160
LUCENTIS -ranibizumab intravitreal inj 0.5 mg/0.05ml (10
mg/ml)............................................................................ 160
LUFYLLIN -dyphylline tab 400 mg.................................... 81
LUMIGAN -bimatoprost ophth soln 0.01%...................... 160
LUNESTA -eszopiclone tab 1 mg....................................108
LUNESTA -eszopiclone tab 2 mg....................................108
LUNESTA -eszopiclone tab 3 mg....................................108
LUPRON DEPOT -leuprolide acetate for inj kit 3.75
mg.................................................................................... 24
LUPRON DEPOT -leuprolide acetate for inj kit 7.5
mg.................................................................................... 24
LUPRON DEPOT -leuprolide acetate (3 month) for inj kit
11.25 mg......................................................................... 23
LUPRON DEPOT -leuprolide acetate (3 month) for inj kit
22.5 mg........................................................................... 24
LUPRON DEPOT -leuprolide acetate (4 month) for inj kit
30 mg.............................................................................. 24
LUPRON DEPOT -leuprolide acetate (6 month) for inj kit
45 mg.............................................................................. 24
LUPRON DEPOT-PED -leuprolide acetate for inj pediatric
kit 7.5 mg........................................................................ 47
LUPRON DEPOT-PED -leuprolide acetate for inj pediatric
kit 11.25 mg.................................................................... 47
LUPRON DEPOT-PED -leuprolide acetate for inj pediatric
kit 15 mg......................................................................... 47
LUPRON DEPOT-PED -leuprolide acetate (3 month) for
inj pediatric kit 11.25 mg................................................ 47
LUPRON DEPOT-PED -leuprolide acetate (3 month) for
inj pediatric kit 30 mg..................................................... 47
LURIDE -sodium fluoride chew tab 0.25 mg f (from 0.55
mg naf).......................................................................... 147
LURIDE -sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf)................................................................................. 147
LURIDE -sodium fluoride chew tab 1 mg f (from 2.2 mg
naf)................................................................................. 147
LURIDE -sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf)................................................................................. 147
LUXIQ -betamethasone valerate aerosol foam
0.12%.............................................................................173
LUZU -luliconazole cream 1%......................................... 173
LYNPARZA -olaparib cap 50 mg....................................... 24
LYRICA -pregabalin cap 25 mg.......................................138
LYRICA -pregabalin cap 50 mg.......................................138
LYRICA -pregabalin cap 75 mg.......................................138
LYRICA -pregabalin cap 100 mg.....................................138
LYRICA -pregabalin cap 150 mg.....................................138
LYRICA -pregabalin cap 200 mg.....................................138
LYRICA -pregabalin cap 225 mg.....................................138
LYRICA -pregabalin cap 300 mg.....................................138
LYRICA -pregabalin soln 20 mg/ml................................. 138
LYSODREN -mitotane tab 500 mg....................................24
LYSTEDA -tranexamic acid tab 650 mg......................... 152
M
MACROBID -nitrofurantoin monohydrate macrocrystalline
cap 100 mg..................................................................... 91
MACRODANTIN -nitrofurantoin macrocrystalline cap 25
mg.................................................................................... 91
MACRODANTIN -nitrofurantoin macrocrystalline cap 50
mg.................................................................................... 91
MACRODANTIN -nitrofurantoin macrocrystalline cap 100
mg.................................................................................... 91
MALARONE -atovaquone-proguanil hcl tab 62.5-25
mg.................................................................................... 14
MALARONE -atovaquone-proguanil hcl tab 250-100
mg.................................................................................... 14
malathion lotion 0.5% (Ovide)...................................... 173
MAPROTILINE HCL -maprotiline hcl tab 25 mg............... 98
MAPROTILINE HCL -maprotiline hcl tab 50 mg............... 98
MAPROTILINE HCL -maprotiline hcl tab 75 mg............... 98
MAR-COF BP -pseudoephedrine-bromphen-codeine liqd
30-2-7.5 mg/5ml.............................................................. 78
MAR-COF CG EXPECTORANT -guaifenesin-codeine
liquid 225-7.5 mg/5ml..................................................... 78
MARINOL -dronabinol cap 2.5 mg.................................... 87
MARINOL -dronabinol cap 5 mg....................................... 87
MARINOL -dronabinol cap 10 mg..................................... 87
MARPLAN -isocarboxazid tab 10 mg............................... 98
MATULANE -procarbazine hcl cap 50 mg........................ 24
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MAVIK -trandolapril tab 1 mg............................................ 63
MAVIK -trandolapril tab 2 mg............................................ 63
MAVIK -trandolapril tab 4 mg............................................ 63
MAXALT-MLT -rizatriptan benzoate orally disintegrating
tab 5 mg........................................................................ 133
MAXALT-MLT -rizatriptan benzoate orally disintegrating
tab 10 mg...................................................................... 133
MAXALT -rizatriptan benzoate tab 5 mg......................... 133
MAXALT -rizatriptan benzoate tab 10 mg....................... 133
MAXIDEX -dexamethasone ophth susp 0.1%................ 160
MAXIMA BLOOD GLUCOSE MONI -blood glucose
monitoring kit w/ device................................................ 185
MAXIMA METER KIT -blood glucose monitoring kit w/
device............................................................................ 185
MAXIMA STARTER KIT -blood glucose monitoring kit w/
device............................................................................ 185
MAXITROL -neomycin-polymyxin-dexamethasone ophth
oint 0.1%....................................................................... 161
MAXITROL -neomycin-polymyxin-dexamethasone ophth
susp 0.1%..................................................................... 161
MAXZIDE -triamterene & hydrochlorothiazide tab 75-50
mg.................................................................................... 68
MAXZIDE-25 -triamterene & hydrochlorothiazide tab
37.5-25 mg...................................................................... 68
meclizine hcl tab 12.5 mg............................................... 87
meclizine hcl tab 25 mg.................................................. 87
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 50 mg..................................................................... 130
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 100 mg................................................................... 130
MEDICINE SHOPPE GLUCOSE -glucose chew tab 4
gm.................................................................................... 38
MEDROL DOSEPAK -methylprednisolone tab 4 mg dose
pack................................................................................. 27
MEDROL -methylprednisolone tab 2 mg.......................... 27
MEDROL -methylprednisolone tab 4 mg.......................... 27
MEDROL -methylprednisolone tab 8 mg.......................... 27
MEDROL -methylprednisolone tab 16 mg........................ 27
MEDROL -methylprednisolone tab 32 mg........................ 27
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................ 33
medroxyprogesterone acetate tab 2.5 mg
(Provera)......................................................................... 35
medroxyprogesterone acetate tab 5 mg (Provera)...... 35
medroxyprogesterone acetate tab 10 mg
(Provera)......................................................................... 35
mefenamic acid cap 250 mg (Ponstel)........................ 130
mefloquine hcl tab 250 mg............................................. 14
MEGACE ES -megestrol acetate susp 625 mg/5ml......... 35
MEGACE ORAL -megestrol acetate susp 40 mg/ml........ 24
megestrol acetate susp 625 mg/5ml (Megace es)........ 35
megestrol acetate susp 40 mg/ml (Megace oral)......... 24
megestrol acetate tab 20 mg.......................................... 24
megestrol acetate tab 40 mg.......................................... 24
MEIJER BLOOD GLUCOSE MONI -blood glucose
monitoring kit w/ device................................................ 185
MEIJER ESSENTIAL BLOOD GL -blood glucose
monitoring kit w/ device................................................ 185
MEIJER PREMIUM BLOOD GLUC -blood glucose
monitoring kit w/ device................................................ 185
MEIJER TRUE2GO BLOOD GLUC -blood glucose
monitoring kit w/ device................................................ 185
MEIJER TRUERESULT BLOOD G -blood glucose
monitoring kit w/ device................................................ 185
MEIJER TRUETRACK BLOOD GL -blood glucose
monitoring kit w/ device................................................ 185
MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................ 24
MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)....................................................................... 24
MELOXICAM -meloxicam susp 7.5 mg/5ml....................130
meloxicam tab 7.5 mg (Mobic)..................................... 130
meloxicam tab 15 mg (Mobic)...................................... 130
memantine hcl oral solution 2 mg/ml (Namenda)...... 116
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa)............................................... 116
memantine hcl tab 5 mg (Namenda)........................... 116
memantine hcl tab 10 mg (Namenda)......................... 116
MENACTRA -meningococcal (a, c, y, and w-135)
conjugate vaccine inj...................................................... 19
M-END MAX D -pseudoephedrine-dexbromphen-codeine
liqd 20-0.667-6 mg/5ml................................................... 78
M-END PE -phenylephrine-bromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml....................................................78
MENEST -esterified estrogens tab 0.3 mg....................... 31
MENEST -esterified estrogens tab 0.625 mg................... 31
MENEST -esterified estrogens tab 1.25 mg..................... 31
MENEST -esterified estrogens tab 2.5 mg....................... 31
MENOMUNE-A/C/Y/W-135 -meningococcal vaccine a, c,
y, and w-135 inj.............................................................. 19
MENOPUR -menotropins for subcutaneous inj 75
unit................................................................................... 47
MENOSTAR -estradiol td patch weekly 14 mcg/24hr....... 31
MENTAX -butenafine hcl cream 1%................................173
MENVEO -meningococcal (a, c, y, and w-135) oligo conj
vac for inj........................................................................ 19
MEPERIDINE HCL -meperidine hcl oral soln 50
mg/5ml........................................................................... 123
meperidine hcl tab 50 mg (Demerol)........................... 123
meperidine hcl tab 100 mg (Demerol)......................... 123
MEPHYTON -phytonadione tab 5 mg............................. 146
meprobamate tab 200 mg............................................... 95
meprobamate tab 400 mg............................................... 95
MEPRON -atovaquone susp 750 mg/5ml......................... 15
mercaptopurine tab 50 mg (Purinethol)........................ 24
mesalamine enema 4 gm................................................ 90
mesalamine rectal enema 4 gm & cleanser wipe kit
(Rowasa).........................................................................90
MESNEX -mesna tab 400 mg........................................... 24
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MESTINON -pyridostigmine bromide syrup 60
mg/5ml........................................................................... 145
MESTINON -pyridostigmine bromide tab 60 mg.............145
MESTINON TIMESPAN -pyridostigmine bromide tab cr
180 mg.......................................................................... 145
METADATE CD -methylphenidate hcl cap cr 10 mg....... 112
METADATE CD -methylphenidate hcl cap cr 20 mg....... 112
METADATE CD -methylphenidate hcl cap cr 30 mg....... 112
METADATE CD -methylphenidate hcl cap cr 40 mg....... 112
METADATE CD -methylphenidate hcl cap cr 50 mg....... 112
METADATE CD -methylphenidate hcl cap cr 60 mg....... 112
METAPROTERENOL SULFATE -metaproterenol sulfate
syrup 10 mg/5ml............................................................. 81
METAPROTERENOL SULFATE -metaproterenol sulfate
tab 10 mg........................................................................ 81
METAPROTERENOL SULFATE -metaproterenol sulfate
tab 20 mg........................................................................ 81
METAXALONE -metaxalone tab 400 mg........................ 144
metaxalone tab 800 mg (Skelaxin).............................. 144
metformin hcl tab 500 mg (Glucophage)...................... 39
metformin hcl tab 850 mg (Glucophage)...................... 39
metformin hcl tab 1000 mg (Glucophage).................... 39
metformin hcl tab sr 24hr 500 mg (Glucophage xr)..... 38
metformin hcl tab sr 24hr 750 mg (Glucophage xr)..... 38
metformin hcl tab sr 24hr osmotic 500 mg
(Fortamet)....................................................................... 38
metformin hcl tab sr 24hr osmotic 1000 mg
(Fortamet)....................................................................... 39
methadone hcl conc 10 mg/ml (Methadose).............. 123
METHADONE HCL -methadone hcl soln 5 mg/5ml........123
METHADONE HCL -methadone hcl soln 10 mg/5ml......123
methadone hcl soln 5 mg/5ml (Methadone hcl)......... 123
methadone hcl soln 10 mg/5ml (Methadone hcl)....... 123
methadone hcl tab for oral susp 40 mg...................... 123
methadone hcl tab 10 mg (Dolophine)........................ 124
methadone hcl tab 5 mg (Dolophine hcl)................... 123
METHADOSE -methadone hcl conc 10 mg/ml............... 124
METHADOSE SUGAR-FREE -methadone hcl conc 10
mg/ml............................................................................. 124
methamphetamine hcl tab 5 mg (Desoxyn)................ 112
methazolamide tab 25 mg (Neptazane)......................... 68
methazolamide tab 50 mg (Neptazane)......................... 68
methenamine hippurate tab 1 gm (Hiprex)................... 91
methimazole tab 5 mg (Tapazole).................................. 43
methimazole tab 10 mg (Tapazole)................................ 43
METHITEST -methyltestosterone oral tab 10 mg............. 28
methocarbamol tab 750 mg (Robaxin-750).................144
methocarbamol tab 500 mg (Robaxin)........................ 144
methotrexate sodium inj 25 mg/ml................................ 24
methotrexate sodium inj pf 25 mg/ml........................... 24
methotrexate sodium tab 2.5 mg (base equiv)............. 24
methoxsalen rapid cap 10 mg (Oxsoralen ultra)........ 173
methscopolamine bromide tab 2.5 mg (Pamine)......... 85
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................85
METHYCLOTHIAZIDE -methyclothiazide tab 5 mg..........68
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-15 mg................................ 63
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-25 mg................................ 63
methyldopa tab 250 mg.................................................. 63
methyldopa tab 500 mg.................................................. 63
methylergonovine maleate tab 0.2 mg.......................... 44
METHYLIN -methylphenidate hcl chew tab 2.5 mg........ 112
METHYLIN -methylphenidate hcl chew tab 5 mg........... 112
METHYLIN -methylphenidate hcl chew tab 10 mg......... 112
METHYLIN -methylphenidate hcl soln 5 mg/5ml............ 112
METHYLIN -methylphenidate hcl soln 10 mg/5ml.......... 112
methylphenidate hcl cap cr 10 mg (Metadate cd)...... 112
methylphenidate hcl cap cr 20 mg (Metadate cd)...... 112
methylphenidate hcl cap cr 30 mg (Metadate cd)...... 112
methylphenidate hcl cap cr 40 mg (Metadate cd)...... 112
methylphenidate hcl cap cr 50 mg (Metadate cd)...... 112
methylphenidate hcl cap cr 60 mg (Metadate cd)...... 112
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin
la)................................................................................... 112
methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin
la)................................................................................... 112
methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin
la)................................................................................... 112
methylphenidate hcl chew tab 2.5 mg (Methylin)...... 112
methylphenidate hcl chew tab 5 mg (Methylin)......... 112
methylphenidate hcl chew tab 10 mg (Methylin)....... 112
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sa osm 18 mg............................................................... 112
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sa osm 27 mg............................................................... 112
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sa osm 36 mg............................................................... 112
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sa osm 54 mg............................................................... 112
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 18 mg............................................................... 112
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 27 mg............................................................... 113
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 36 mg............................................................... 113
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 54 mg............................................................... 113
methylphenidate hcl soln 5 mg/5ml (Methylin).......... 113
methylphenidate hcl soln 10 mg/5ml (Methylin)........ 113
methylphenidate hcl tab cr 10 mg............................... 113
methylphenidate hcl tab cr 20 mg (Ritalin sr)............ 113
methylphenidate hcl tab 5 mg (Ritalin)....................... 113
methylphenidate hcl tab 10 mg (Ritalin)..................... 113
methylphenidate hcl tab 20 mg (Ritalin)..................... 113
methylprednisolone tab 4 mg dose pack (Medrol
dosepak)......................................................................... 27
methylprednisolone tab 4 mg (Medrol)......................... 27
methylprednisolone tab 8 mg (Medrol)......................... 27
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methylprednisolone tab 16 mg (Medrol)....................... 27
methylprednisolone tab 32 mg (Medrol)....................... 27
METHYL SALICYLATE -methyl salicylate liquid............. 173
methyltestosterone cap 10 mg (Testred)...................... 28
METIPRANOLOL -metipranolol ophth soln 0.3%........... 161
metoclopramide hcl orally disintegrating tab 5 mg
(Metozolv odt)................................................................ 90
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)........ 90
metoclopramide hcl tab 5 mg (Reglan)......................... 90
metoclopramide hcl tab 10 mg (Reglan)....................... 90
METOCLOPRAMIDE ODT -metoclopramide hcl orally
disintegrating tab 10 mg................................................. 90
metolazone tab 10 mg..................................................... 68
metolazone tab 2.5 mg (Zaroxolyn)............................... 68
metolazone tab 5 mg (Zaroxolyn).................................. 68
metoprolol & hydrochlorothiazide tab 100-50 mg....... 63
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)..............................................................63
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct)..............................................................63
metoprolol succinate tab sr 24hr 25 mg (Toprol xl)..... 52
metoprolol succinate tab sr 24hr 50 mg (Toprol xl)..... 52
metoprolol succinate tab sr 24hr 100 mg (Toprol
xl)..................................................................................... 52
metoprolol succinate tab sr 24hr 200 mg (Toprol
xl)..................................................................................... 52
metoprolol tartrate tab 25 mg........................................ 52
metoprolol tartrate tab 50 mg (Lopressor)................... 52
metoprolol tartrate tab 100 mg (Lopressor)................. 52
METOZOLV ODT -metoclopramide hcl orally
disintegrating tab 5 mg................................................... 90
METROCREAM -metronidazole cream 0.75%............... 173
METROGEL -metronidazole gel 1%............................... 173
METROGEL-VAGINAL -metronidazole vaginal gel
0.75%...............................................................................93
METROLOTION -metronidazole lotion 0.75%................ 173
metronidazole cap 375 mg (Flagyl)............................... 15
metronidazole cream 0.75% (Metrocream)................. 173
metronidazole gel 0.75%............................................... 173
metronidazole gel 1% (Metrogel)................................. 173
metronidazole lotion 0.75% (Metrolotion)................... 173
metronidazole tab 250 mg (Flagyl)................................ 15
metronidazole tab 500 mg (Flagyl)................................ 15
metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 93
METVIXIA -methyl aminolevulinate hcl cream 16.8%
(base equiv).................................................................. 173
MEVACOR -lovastatin tab 40 mg...................................... 71
mexiletine hcl cap 150 mg.............................................. 57
mexiletine hcl cap 200 mg.............................................. 57
mexiletine hcl cap 250 mg.............................................. 57
MIACALCIN -calcitonin (salmon) inj 200 unit/ml............... 47
MIACALCIN -calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 47
MICARDIS HCT -telmisartan-hydrochlorothiazide tab
40-12.5 mg...................................................................... 64
MICARDIS HCT -telmisartan-hydrochlorothiazide tab
80-12.5 mg...................................................................... 64
MICARDIS HCT -telmisartan-hydrochlorothiazide tab
80-25 mg......................................................................... 64
MICARDIS -telmisartan tab 20 mg.................................... 63
MICARDIS -telmisartan tab 40 mg.................................... 63
MICARDIS -telmisartan tab 80 mg.................................... 64
MICONAZOLE 3 -miconazole nitrate vaginal suppos 200
mg.................................................................................... 93
miconazole nitrate vaginal supp 200 mg & 2% cream 9
gm kit.............................................................................. 93
MICRODOT BLOOD GLUCOSE MO -blood glucose
monitoring kit w/ device................................................ 185
MICRO-K -potassium chloride cap cr 8 meq.................. 147
MICRO-K -potassium chloride cap cr 10 meq................ 147
MICROLET LANCETS -lancets....................................... 185
MICROZIDE -hydrochlorothiazide cap 12.5 mg................68
midazolam hcl syrup 2 mg/ml (base equivalent)....... 108
midodrine hcl tab 2.5 mg................................................ 69
midodrine hcl tab 5 mg................................................... 69
midodrine hcl tab 10 mg................................................. 69
MIGERGOT -ergotamine w/ caffeine suppos 2-100
mg.................................................................................. 133
MIGRANAL -dihydroergotamine mesylate nasal spray 4
mg/ml............................................................................. 133
MILLIPRED DP -prednisolone tab 5 mg dose pack.......... 27
MILLIPRED -prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)....................................................... 27
MILLIPRED -prednisolone tab 5 mg................................. 27
MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24)........................................... 33
MINIPRESS -prazosin hcl cap 1 mg................................. 64
MINIPRESS -prazosin hcl cap 2 mg................................. 64
MINIPRESS -prazosin hcl cap 5 mg................................. 64
MINIVELLE -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 31
MINIVELLE -estradiol td patch twice weekly 0.0375
mg/24hr........................................................................... 31
MINIVELLE -estradiol td patch twice weekly 0.05
mg/24hr........................................................................... 31
MINIVELLE -estradiol td patch twice weekly 0.075
mg/24hr........................................................................... 31
MINIVELLE -estradiol td patch twice weekly 0.1
mg/24hr........................................................................... 31
MINOCIN -minocycline hcl cap 50 mg................................ 5
MINOCIN -minocycline hcl cap 75 mg................................ 5
MINOCIN -minocycline hcl cap 100 mg.............................. 5
minocycline hcl cap 50 mg (Minocin)............................. 5
minocycline hcl cap 75 mg (Minocin)............................. 5
minocycline hcl cap 100 mg (Minocin)........................... 5
minocycline hcl tab 50 mg............................................... 5
minocycline hcl tab 75 mg............................................... 5
minocycline hcl tab 100 mg............................................. 5
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minocycline hcl tab sr 24hr 45 mg.................................. 5
minocycline hcl tab sr 24hr 90 mg.................................. 5
minocycline hcl tab sr 24hr 135 mg................................ 5
minoxidil tab 2.5 mg........................................................ 64
minoxidil tab 10 mg......................................................... 64
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
0.375 mg....................................................................... 142
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
0.75 mg......................................................................... 142
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
1.5 mg........................................................................... 142
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
2.25 mg......................................................................... 142
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3
mg.................................................................................. 142
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
3.75 mg......................................................................... 142
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
4.5 mg........................................................................... 142
MIRAPEX -pramipexole dihydrochloride tab 0.125
mg.................................................................................. 142
MIRAPEX -pramipexole dihydrochloride tab 0.25
mg.................................................................................. 142
MIRAPEX -pramipexole dihydrochloride tab 0.5 mg.......142
MIRAPEX -pramipexole dihydrochloride tab 0.75
mg.................................................................................. 142
MIRAPEX -pramipexole dihydrochloride tab 1 mg..........142
MIRAPEX -pramipexole dihydrochloride tab 1.5 mg.......142
MIRCETTE -desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5)................................................. 33
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)............................................................................. 98
mirtazapine orally disintegrating tab 30 mg (Remeron
soltab)............................................................................. 98
mirtazapine orally disintegrating tab 45 mg (Remeron
soltab)............................................................................. 98
mirtazapine tab 7.5 mg....................................................98
mirtazapine tab 15 mg (Remeron)................................. 98
mirtazapine tab 30 mg (Remeron)................................. 98
mirtazapine tab 45 mg (Remeron)................................. 99
misoprostol tab 100 mcg (Cytotec)............................... 85
misoprostol tab 200 mcg (Cytotec)............................... 85
MITIGARE -colchicine cap 0.6 mg.................................. 134
MITOSOL -mitomycin for ophth soln kit 0.2 mg.............. 161
M-M-R II -measles, mumps & rubella virus vaccines for
inj..................................................................................... 19
MOBIC -meloxicam susp 7.5 mg/5ml............................. 130
MOBIC -meloxicam tab 7.5 mg....................................... 130
MOBIC -meloxicam tab 15 mg........................................ 130
modafinil tab 100 mg (Provigil).................................... 113
modafinil tab 200 mg (Provigil).................................... 113
MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg...... 10
MODERIBA 800 DOSE PACK -ribavirin tab 400 mg........ 10
MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg
dose pack........................................................................ 10
MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack........................................................................ 10
MODICON -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg...................................................................... 33
moexipril hcl tab 7.5 mg (Univasc)................................ 64
moexipril hcl tab 15 mg (Univasc)................................. 64
moexipril-hydrochlorothiazide tab 7.5-12.5 mg........... 64
moexipril-hydrochlorothiazide tab 15-25 mg............... 64
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)......................................................................... 64
MOLINDONE HYDROCHLORIDE -molindone hcl tab 5
mg.................................................................................. 105
MOLINDONE HYDROCHLORIDE -molindone hcl tab 10
mg.................................................................................. 105
MOLINDONE HYDROCHLORIDE -molindone hcl tab 25
mg.................................................................................. 105
mometasone furoate cream 0.1% (Elocon)................ 173
mometasone furoate oint 0.1% (Elocon).................... 173
mometasone furoate solution 0.1% (lotion)
(Elocon)........................................................................ 173
MONOCAL -sodium monofluorophosphate-calcium carb
tab 22.75-625 mg......................................................... 147
MONOCLATE-P -antihemophilic factor (human) for inj kit
250 unit......................................................................... 156
MONOCLATE-P -antihemophilic factor (human) for inj kit
500 unit......................................................................... 156
MONOCLATE-P -antihemophilic factor (human) for inj kit
1000 unit....................................................................... 156
MONOCLATE-P -antihemophilic factor (human) for inj kit
1500 unit....................................................................... 156
MONODOX -doxycycline monohydrate cap 75 mg............ 5
MONODOX -doxycycline monohydrate cap 100 mg.......... 5
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 185
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 185
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 1/2 ml 30 x 5/16"................................................ 185
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 0.3 ml 29 x 1/2".................................................. 185
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 0.3 ml 30 x 5/16"................................................ 185
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 1 ml 25 x 5/8".....................................................185
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 1 ml 27 x 1/2".....................................................185
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................185
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................185
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 1 ml 30 x 5/16"...................................................185
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 1 ml 31 x 5/16"...................................................185
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MONOJECT INSULIN SYRINGE/ -insulin syringe (disp)
u-100 1 ml..................................................................... 185
MONOJECT INSULIN SYRINGE -insulin syringe (disp)
u-100 1 ml..................................................................... 185
MONOJECT ULTRA COMFORT IN -insulin syringe/
needle u-100 1/2 ml 31 x 5/16".................................... 186
MONOJECT ULTRA COMFORT IN -insulin syringe/
needle u-100 1/2 ml 28 x 1/2"...................................... 186
MONOJECT ULTRA COMFORT IN -insulin syringe/
needle u-100 1/2 ml 29 x 1/2"...................................... 186
MONOJECT ULTRA COMFORT IN -insulin syringe/
needle u-100 1/2 ml 30 x 5/16".................................... 186
MONOJECT ULTRA COMFORT IN -insulin syringe/
needle u-100 0.3 ml 29 x 1/2"...................................... 185
MONOJECT ULTRA COMFORT IN -insulin syringe/
needle u-100 0.3 ml 30 x 5/16".................................... 186
MONOJECT ULTRA COMFORT IN -insulin syringe/
needle u-100 1 ml 28 x 1/2"......................................... 186
MONOJECT ULTRA COMFORT IN -insulin syringe/
needle u-100 1 ml 29 x 1/2"......................................... 186
MONOJECT ULTRA COMFORT IN -insulin syringe/
needle u-100 1 ml 30 x 5/16"....................................... 186
MONOJECT ULTRA COMFORT IN -insulin syringe/
needle u-100 0.3 ml 31 x 5/16".................................... 186
MONONINE -coagulation factor ix for inj 250 unit.......... 156
MONONINE -coagulation factor ix for inj 500 unit.......... 156
MONONINE -coagulation factor ix for inj 1000 unit........ 156
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)....................................................................... 81
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)....................................................................... 81
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)...........................................................81
montelukast sodium tab 10 mg (base equiv)
(Singulair)....................................................................... 81
MONUROL -fosfomycin tromethamine powd pack 3 gm
(base equivalent)............................................................ 91
8-MOP -methoxsalen cap 10 mg.................................... 177
morphine sulfate cap sr 24hr 10 mg (Kadian)............ 124
morphine sulfate cap sr 24hr 20 mg (Kadian)............ 124
morphine sulfate cap sr 24hr 30 mg (Kadian)............ 124
morphine sulfate cap sr 24hr 50 mg (Kadian)............ 124
morphine sulfate cap sr 24hr 60 mg (Kadian)............ 124
morphine sulfate cap sr 24hr 80 mg (Kadian)............ 124
morphine sulfate cap sr 24hr 100 mg (Kadian).......... 124
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 30 mg....................................................................124
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 45 mg....................................................................124
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 60 mg....................................................................124
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 75 mg....................................................................124
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 90 mg....................................................................124
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 120 mg..................................................................124
MORPHINE SULFATE -morphine sulfate tab 15 mg...... 124
MORPHINE SULFATE -morphine sulfate tab 30 mg...... 124
morphine sulfate oral soln 10 mg/5ml........................ 124
morphine sulfate oral soln 20 mg/5ml........................ 124
morphine sulfate oral soln 100 mg/5ml (20 mg/
ml)................................................................................. 124
morphine sulfate tab cr 15 mg (Ms contin)................ 124
morphine sulfate tab cr 30 mg (Ms contin)................ 124
morphine sulfate tab cr 60 mg (Ms contin)................ 124
morphine sulfate tab cr 100 mg (Ms contin).............. 124
morphine sulfate tab cr 200 mg (Ms contin).............. 124
MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............84
mouthwashes - liquid.................................................... 164
MOVANTIK -naloxegol oxalate tab 12.5 mg (base
equivalent)....................................................................... 90
MOVANTIK -naloxegol oxalate tab 25 mg (base
equivalent)....................................................................... 90
MOVIPREP -peg 3350-kcl-nacl-na sulfate-na ascorbate-c
for soln 100 gm...............................................................83
MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg...... 2
MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2
times daily).................................................................... 161
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 6
MOZOBIL -plerixafor subcutaneous inj 24 mg/1.2ml (20
mg/ml)............................................................................ 149
MS CONTIN -morphine sulfate tab cr 15 mg.................. 124
MS CONTIN -morphine sulfate tab cr 30 mg.................. 124
MS CONTIN -morphine sulfate tab cr 60 mg.................. 124
MS CONTIN -morphine sulfate tab cr 100 mg................ 124
MS CONTIN -morphine sulfate tab cr 200 mg................ 124
MS QUICK DISSOLVE GLUCOSE -glucose chew tab 4
gm.................................................................................... 39
MULTAQ -dronedarone hcl tab 400 mg (base
equivalent)....................................................................... 57
mupirocin calcium cream 2% (Bactroban)................. 173
mupirocin oint 2% (Bactroban).................................... 173
MYALEPT -metreleptin for subcutaneous inj 11.3 mg...... 47
MYAMBUTOL -ethambutol hcl tab 100 mg......................... 7
MYAMBUTOL -ethambutol hcl tab 400 mg......................... 7
MYCOBUTIN -rifabutin cap 150 mg.................................... 7
mycophenolate mofetil cap 250 mg (Cellcept)........... 191
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept)...................................................................... 191
mycophenolate mofetil tab 500 mg (Cellcept)............191
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic)................................................. 191
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic)................................................. 191
MYDRIACYL -tropicamide ophth soln 1%...................... 161
MYFORTIC -mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)............................................ 191
MYFORTIC -mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)............................................ 191
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MYGLUCOHEALTH BLOOD GLUCO -blood glucose
monitoring kit w/ device................................................ 186
MYKIDZ IRON 10 -iron susp 15 mg/1.5ml...................... 149
MYLERAN -busulfan tab 2 mg.......................................... 24
MYRBETRIQ -mirabegron tab sr 24 hr 25 mg.................. 92
MYRBETRIQ -mirabegron tab sr 24 hr 50 mg.................. 92
MYSOLINE -primidone tab 50 mg.................................. 138
MYSOLINE -primidone tab 250 mg................................ 138
N
nabumetone tab 500 mg............................................... 130
nabumetone tab 750 mg............................................... 130
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)......................................................................... 64
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)......................................................................... 64
nadolol tab 20 mg (Corgard).......................................... 52
nadolol tab 40 mg (Corgard).......................................... 52
nadolol tab 80 mg (Corgard).......................................... 52
NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................. 164
NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln
rinse 0.05%................................................................... 164
NAFRINSE WEEKLY -sodium fluoride for soln rinse
0.2%...............................................................................164
NAFTIFINE HCL -naftifine hcl cream 1%........................173
NAFTIN -naftifine hcl cream 1%..................................... 173
NAFTIN -naftifine hcl cream 2%..................................... 173
NAFTIN -naftifine hcl gel 1%........................................... 173
NAFTIN -naftifine hcl gel 2%........................................... 173
nalbuphine hcl inj 10 mg/ml......................................... 124
nalbuphine hcl inj 20 mg/ml......................................... 124
NALFON -fenoprofen calcium cap 400 mg..................... 130
naltrexone hcl tab 50 mg (Revia)................................. 177
NAMENDA -memantine hcl oral solution 2 mg/ml.......... 116
NAMENDA -memantine hcl tab 5 mg............................. 116
NAMENDA -memantine hcl tab 10 mg........................... 116
NAMENDA TITRATION PAK -memantine hcl tab 5 mg
(28) & 10 mg (21) titration pak..................................... 116
NAMENDA XR -memantine hcl cap sr 24hr 7 mg.......... 116
NAMENDA XR -memantine hcl cap sr 24hr 14 mg........ 116
NAMENDA XR -memantine hcl cap sr 24hr 21 mg........ 116
NAMENDA XR -memantine hcl cap sr 24hr 28 mg........ 116
NAMENDA XR TITRATION PACK -memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack................ 116
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
14-10 mg....................................................................... 116
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
28-10 mg....................................................................... 116
NAPHAZOLINE HCL -naphazoline hcl ophth soln
0.1%...............................................................................161
NAPRELAN -naproxen sodium tab sr 24hr 375 mg (base
equiv)............................................................................. 130
NAPRELAN -naproxen sodium tab sr 24hr 500 mg (base
equiv)............................................................................. 130
NAPRELAN -naproxen sodium tab sr 24hr 750 mg (base
equiv)............................................................................. 130
NAPROSYN -naproxen susp 125 mg/5ml...................... 130
NAPROSYN -naproxen tab 250 mg................................ 130
NAPROSYN -naproxen tab 500 mg................................ 130
NAPROXEN -naproxen susp 125 mg/5ml...................... 130
naproxen sodium tab 275 mg (Anaprox).................... 131
naproxen sodium tab 550 mg (Anaprox ds)............... 131
naproxen sodium tab sr 24hr 375 mg (base equiv)
(Naprelan)..................................................................... 131
naproxen sodium tab sr 24hr 500 mg (base equiv)
(Naprelan)..................................................................... 131
naproxen tab ec 375 mg (Ec-naprosyn)...................... 131
naproxen tab ec 500 mg (Ec-naprosyn)...................... 131
naproxen tab 250 mg (Naprosyn)................................ 131
naproxen tab 375 mg (Naprosyn)................................ 131
naproxen tab 500 mg (Naprosyn)................................ 131
naratriptan hcl tab 1 mg (base equiv) (Amerge)........ 133
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)..... 133
NARCAN -naloxone hcl nasal spray 4 mg/0.1ml............ 177
NARDIL -phenelzine sulfate tab 15 mg............................ 99
NASACORT AQ -triamcinolone acetonide nasal aerosol
suspension 55 mcg/act................................................... 77
NASCOBAL -cyanocobalamin nasal spray 500
mcg/0.1ml...................................................................... 149
NASONEX -mometasone furoate nasal susp 50 mcg/
act.................................................................................... 77
NATACYN -natamycin ophth susp 5%............................ 161
NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2
mg/2-3 mg/1 mg............................................................. 33
nateglinide tab 60 mg (Starlix)....................................... 39
nateglinide tab 120 mg (Starlix)..................................... 39
NATESTO -testosterone nasal gel 5.5 mg/act.................. 28
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 25 mcg............................................................. 47
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 50 mcg............................................................. 47
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 75 mcg............................................................. 47
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 100 mcg........................................................... 48
NATROBA -spinosad susp 0.9%..................................... 173
NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2
grain)................................................................................43
NATURE-THROID -thyroid tab 16.25 mg..........................43
NATURE-THROID -thyroid tab 32.5 mg............................43
NATURE-THROID -thyroid tab 65 mg...............................43
NATURE-THROID -thyroid tab 81.25 mg..........................43
NATURE-THROID -thyroid tab 97.5 mg............................43
NATURE-THROID -thyroid tab 113.75 mg........................ 43
NATURE-THROID -thyroid tab 130 mg.............................43
NATURE-THROID -thyroid tab 146.25 mg....................... 43
NATURE-THROID -thyroid tab 195 mg.............................43
NATURE-THROID -thyroid tab 260 mg.............................43
NATURE-THROID -thyroid tab 48.75 mg (3/4 grain)........ 43
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NATURE-THROID -thyroid tab 325 mg (5 grain).............. 43
NEBUPENT -pentamidine isethionate for nebulization
soln 300 mg.................................................................... 15
NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50
mcg.................................................................................. 33
NECON 10/11-28 -norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)........................................... 33
NEFAZODONE HCL -nefazodone hcl tab 100 mg........... 99
NEFAZODONE HCL -nefazodone hcl tab 150 mg........... 99
NEFAZODONE HCL -nefazodone hcl tab 200 mg........... 99
nefazodone hcl tab 50 mg.............................................. 99
nefazodone hcl tab 250 mg............................................ 99
NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp.............................................. 161
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin............................. 161
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)........... 161
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)...................................................................... 161
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol).............................................................161
neomycin-polymyxin-hc otic soln 1%
(Cortisporin).................................................................163
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.................................................................... 163
neomycin sulfate tab 500 mg........................................... 6
NEORAL -cyclosporine modified cap 25 mg...................191
NEORAL -cyclosporine modified cap 100 mg.................191
NEORAL -cyclosporine modified oral soln 100 mg/
ml................................................................................... 191
NEOSPORIN -neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml................................... 161
NEO-SYNALAR -neomycin-fluocinolone cream
0.35-0.025%.................................................................. 173
NEPHROCAPS -b-complex w/ c & folic acid cap 1
mg.................................................................................. 146
NEPHROCAPS QT -b-complex w/ c-biotin-d & folic acid
tab disp 1 mg................................................................ 146
NEPTAZANE -methazolamide tab 25 mg......................... 68
NEPTAZANE -methazolamide tab 50 mg......................... 68
NESINA -alogliptin benzoate tab 6.25 mg (base
equiv)............................................................................... 39
NESINA -alogliptin benzoate tab 12.5 mg (base
equiv)............................................................................... 39
NESINA -alogliptin benzoate tab 25 mg (base equiv).......39
NEULASTA ONPRO KIT -pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml.................................................. 149
NEULASTA -pegfilgrastim soln prefilled syringe 6
mg/0.6ml........................................................................ 149
NEUPOGEN -filgrastim inj 300 mcg/ml........................... 149
NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/
ml).................................................................................. 149
NEUPOGEN -filgrastim soln prefilled syringe 300
mcg/0.5ml...................................................................... 149
NEUPOGEN -filgrastim soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)............................................... 149
NEUPRO -rotigotine td patch 24hr 1 mg/24hr................ 142
NEUPRO -rotigotine td patch 24hr 2 mg/24hr................ 142
NEUPRO -rotigotine td patch 24hr 3 mg/24hr................ 142
NEUPRO -rotigotine td patch 24hr 4 mg/24hr................ 142
NEUPRO -rotigotine td patch 24hr 6 mg/24hr................ 142
NEUPRO -rotigotine td patch 24hr 8 mg/24hr................ 142
NEURONTIN -gabapentin cap 100 mg........................... 138
NEURONTIN -gabapentin cap 300 mg........................... 138
NEURONTIN -gabapentin cap 400 mg........................... 138
NEURONTIN -gabapentin oral soln 250 mg/5ml............ 138
NEURONTIN -gabapentin tab 600 mg............................ 138
NEURONTIN -gabapentin tab 800 mg............................ 138
NEVANAC -nepafenac ophth susp 0.1%........................ 161
NEVIRAPINE -nevirapine susp 50 mg/5ml....................... 10
nevirapine tab 200 mg (Viramune).................................10
nevirapine tab sr 24hr 100 mg....................................... 10
nevirapine tab sr 24hr 400 mg (Viramune xr)............... 10
NEXA SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg..................................................... 146
NEXAVAR -sorafenib tosylate tab 200 mg (base
equivalent)....................................................................... 24
NEXGEN METER KIT -blood glucose monitoring kit...... 186
NEXIUM -esomeprazole magnesium cap delayed release
20 mg (base eq)............................................................. 85
NEXIUM -esomeprazole magnesium cap delayed release
40 mg (base eq)............................................................. 85
NEXIUM -esomeprazole magnesium for delayed release
susp packet 5 mg........................................................... 85
NEXIUM -esomeprazole magnesium for delayed release
susp packet 10 mg......................................................... 85
NEXIUM -esomeprazole magnesium for delayed release
susp packet 20 mg......................................................... 85
NEXIUM -esomeprazole magnesium for delayed release
susp packet 40 mg......................................................... 85
NEXIUM -esomeprazole magnesium for delayed release
susp pack 2.5 mg........................................................... 85
niacin tab cr 500 mg (antihyperlipidemic)
(Niaspan)........................................................................ 71
niacin tab cr 750 mg (antihyperlipidemic)
(Niaspan)........................................................................ 71
niacin tab cr 1000 mg (antihyperlipidemic)
(Niaspan)........................................................................ 71
NIACOR -niacin (antihyperlipidemic) tab 500 mg............. 71
NIASPAN -niacin tab cr 500 mg (antihyperlipidemic)........71
NIASPAN -niacin tab cr 750 mg (antihyperlipidemic)........71
NIASPAN -niacin tab cr 1000 mg (antihyperlipidemic)......71
nicardipine hcl cap 20 mg.............................................. 55
nicardipine hcl cap 30 mg.............................................. 55
NICODERM CQ -nicotine td patch 24hr 7 mg/24hr........ 116
NICODERM CQ -nicotine td patch 24hr 14 mg/24hr...... 116
NICODERM CQ -nicotine td patch 24hr 21 mg/24hr...... 116
NICORETTE MINI -nicotine polacrilex lozenge 2 mg..... 116
NICORETTE MINI -nicotine polacrilex lozenge 4 mg..... 116
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NICORETTE -nicotine polacrilex gum 2 mg................... 116
NICORETTE -nicotine polacrilex gum 4 mg................... 116
NICORETTE -nicotine polacrilex lozenge 2 mg.............. 116
NICORETTE -nicotine polacrilex lozenge 4 mg.............. 116
NICORETTE STARTER KIT -nicotine polacrilex gum 2
mg.................................................................................. 116
NICORETTE STARTER KIT -nicotine polacrilex gum 4
mg.................................................................................. 116
nicotine polacrilex gum 2 mg.......................................116
nicotine polacrilex gum 4 mg.......................................116
nicotine polacrilex lozenge 2 mg................................. 116
nicotine polacrilex lozenge 4 mg................................. 116
nicotine td patch 24hr 7 mg/24hr.................................116
nicotine td patch 24hr 14 mg/24hr...............................116
nicotine td patch 24hr 21 mg/24hr...............................116
NICOTINE TRANSDERMAL SYST -nicotine td patch 24
hr kit 21-14-7 mg/24hr.................................................. 116
NICOTROL INHALER -nicotine inhaler system 10 mg (4
mg delivered)................................................................ 116
NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/
spray)............................................................................. 116
nifedipine cap 20 mg....................................................... 55
nifedipine cap 10 mg (Procardia).................................. 55
nifedipine tab sr 24hr 30 mg (Adalat cc).......................55
nifedipine tab sr 24hr 60 mg (Adalat cc).......................55
nifedipine tab sr 24hr 90 mg (Adalat cc).......................55
nifedipine tab sr 24hr osmotic release 30 mg
(Procardia xl)................................................................. 55
nifedipine tab sr 24hr osmotic release 60 mg
(Procardia xl)................................................................. 55
nifedipine tab sr 24hr osmotic release 90 mg
(Procardia xl)................................................................. 55
NILANDRON -nilutamide tab 150 mg............................... 24
nimodipine cap 30 mg..................................................... 55
NINLARO -ixazomib citrate cap 2.3 mg (base
equivalent)....................................................................... 24
NINLARO -ixazomib citrate cap 3 mg (base
equivalent)....................................................................... 24
NINLARO -ixazomib citrate cap 4 mg (base
equivalent)....................................................................... 24
NIRAVAM -alprazolam orally disintegrating tab 0.25
mg.................................................................................... 95
NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg.......... 55
NISOLDIPINE -nisoldipine tab sr 24hr 20 mg................... 55
NISOLDIPINE -nisoldipine tab sr 24hr 30 mg................... 55
NISOLDIPINE -nisoldipine tab sr 24hr 40 mg................... 55
nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 55
nisoldipine tab sr 24hr 17 mg (Sular)............................55
nisoldipine tab sr 24hr 34 mg (Sular)............................55
NITRO-BID -nitroglycerin oint 2%..................................... 50
NITRO-DUR -nitroglycerin td patch 24hr 0.1 mg/hr.......... 50
NITRO-DUR -nitroglycerin td patch 24hr 0.2 mg/hr.......... 50
NITRO-DUR -nitroglycerin td patch 24hr 0.3 mg/hr.......... 50
NITRO-DUR -nitroglycerin td patch 24hr 0.4 mg/hr.......... 50
NITRO-DUR -nitroglycerin td patch 24hr 0.6 mg/hr.......... 50
NITRO-DUR -nitroglycerin td patch 24hr 0.8 mg/hr.......... 50
nitrofurantoin macrocrystalline cap 25 mg
(Macrodantin).................................................................91
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin).................................................................91
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin).................................................................91
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)............................................................... 91
nitrofurantoin susp 25 mg/5ml (Furadantin)................ 91
nitroglycerin cap cr 2.5 mg............................................ 51
nitroglycerin cap cr 6.5 mg............................................ 51
nitroglycerin cap cr 9 mg............................................... 51
NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol
400 mcg/spray................................................................ 51
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 51
nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)......... 51
nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)......... 51
nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)......... 51
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
(Nitrolingual pumpspr)................................................. 51
NITROLINGUAL PUMPSPRAY -nitroglycerin tl soln 0.4
mg/spray (400 mcg/spray)..............................................51
NITROMIST -nitroglycerin lingual aerosol 400 mcg/
spray................................................................................ 51
NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 51
NITROSTAT -nitroglycerin sl tab 0.4 mg........................... 51
NITROSTAT -nitroglycerin sl tab 0.6 mg........................... 51
nizatidine cap 150 mg..................................................... 85
nizatidine cap 300 mg (Axid).......................................... 85
nizatidine oral soln 15 mg/ml (Axid)..............................85
NIZORAL -ketoconazole shampoo 2%........................... 173
nonoxynol-9 gel 4%......................................................... 93
NORCO -hydrocodone-acetaminophen tab 7.5-325
mg.................................................................................. 124
NORCO -hydrocodone-acetaminophen tab 5-325
mg.................................................................................. 124
NORCO -hydrocodone-acetaminophen tab 10-325
mg.................................................................................. 124
NORDITROPIN FLEXPRO -somatropin inj 5
mg/1.5ml.......................................................................... 48
NORDITROPIN FLEXPRO -somatropin inj 10
mg/1.5ml.......................................................................... 48
NORDITROPIN FLEXPRO -somatropin inj 15
mg/1.5ml.......................................................................... 48
NORDITROPIN FLEXPRO -somatropin inj 30
mg/3ml............................................................................. 48
NORDITROPIN NORDIFLEX PEN -somatropin inj 30
mg/3ml............................................................................. 48
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg (Femcon fe)............................................... 33
norethindrone & ethinyl estradiol-fe chew tab 0.8
mg-25 mcg (Generess fe)............................................ 33
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
(Brevicon-28)................................................................. 33
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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2015
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
(Norinyl 1+35)................................................................ 33
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
(Ovcon-35)...................................................................... 33
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg (Loestrin fe 1/20).................................................. 33
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)............................................... 33
norethindrone ace & ethinyl estradiol tab 1 mg-20
mcg (Loestrin 1/20-21)................................................. 33
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg (Loestrin 1.5/30-21).............................................. 33
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20
mcg (24) (Lomedia 24 fe)............................................. 33
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose)................................................ 31
norethindrone acetate tab 5 mg (Aygestin).................. 35
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg (Estrostep fe)................................................. 33
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg (Ortho-novum 7/7/7)...................................... 34
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)...................................................... 34
norethindrone tab 0.35 mg (Nor-qd).............................. 34
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
(Ortho-cyclen)................................................................ 34
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg (Ortho tri-cyclen)........................................... 34
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25
mg-mcg (Ortho tri-cyclen lo)....................................... 34
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 34
NORINYL 1+35 -norethindrone & ethinyl estradiol tab 1
mg-35 mcg...................................................................... 34
NORINYL 1+50 -norethindrone & mestranol tab 1 mg-50
mcg.................................................................................. 34
NORITATE -metronidazole cream 1%.............................173
NORPACE CR -disopyramide phosphate cap sr 12hr 100
mg.................................................................................... 57
NORPACE CR -disopyramide phosphate cap sr 12hr 150
mg.................................................................................... 57
NORPACE -disopyramide phosphate cap 100 mg........... 57
NORPACE -disopyramide phosphate cap 150 mg........... 57
NORPRAMIN -desipramine hcl tab 10 mg........................99
NORPRAMIN -desipramine hcl tab 25 mg........................99
NORPRAMIN -desipramine hcl tab 50 mg........................99
NORPRAMIN -desipramine hcl tab 75 mg........................99
NORPRAMIN -desipramine hcl tab 100 mg......................99
NORPRAMIN -desipramine hcl tab 150 mg......................99
NOR-QD -norethindrone tab 0.35 mg............................... 33
NORTHERA -droxidopa cap 100 mg................................ 69
NORTHERA -droxidopa cap 200 mg................................ 69
NORTHERA -droxidopa cap 300 mg................................ 69
nortriptyline hcl cap 10 mg (Pamelor)...........................99
nortriptyline hcl cap 25 mg (Pamelor)...........................99
nortriptyline hcl cap 50 mg (Pamelor)...........................99
nortriptyline hcl cap 75 mg (Pamelor)...........................99
NORTRIPTYLINE HCL -nortriptyline hcl soln 10
mg/5ml............................................................................. 99
NORVASC -amlodipine besylate tab 2.5 mg.................... 55
NORVASC -amlodipine besylate tab 5 mg....................... 55
NORVASC -amlodipine besylate tab 10 mg..................... 56
NORVIR -ritonavir cap 100 mg......................................... 10
NORVIR -ritonavir oral soln 80 mg/ml...............................10
NORVIR -ritonavir tab 100 mg.......................................... 10
NOVA MAX BLOOD GLUCOSE MO -blood glucose
monitoring devices........................................................ 186
NOVA MAX BLOOD GLUCOSE MO -blood glucose
monitoring kit w/ device................................................ 186
NOVOEIGHT -antihemophilic factor (recombinant) for inj
250 unit......................................................................... 156
NOVOEIGHT -antihemophilic factor (recombinant) for inj
500 unit......................................................................... 156
NOVOEIGHT -antihemophilic factor (recombinant) for inj
1000 unit....................................................................... 156
NOVOEIGHT -antihemophilic factor (recombinant) for inj
1500 unit....................................................................... 156
NOVOEIGHT -antihemophilic factor (recombinant) for inj
2000 unit....................................................................... 156
NOVOEIGHT -antihemophilic factor (recombinant) for inj
3000 unit....................................................................... 156
NOVOLIN 70/30 -insulin nph isophane & regular human
inj 100 unit/ml (70-30).................................................... 41
NOVOLIN 70/30 RELION -insulin nph isophane & regular
human inj 100 unit/ml (70-30)........................................ 41
NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 41
NOVOLIN N RELION -insulin nph (human) (isophane) inj
100 unit/ml.......................................................................41
NOVOLIN R -insulin regular (human) inj 100 unit/ml........ 41
NOVOLIN R RELION -insulin regular (human) inj 100
unit/ml.............................................................................. 41
NOVOLOG FLEXPEN -insulin aspart soln pen-injector
100 unit/ml.......................................................................41
NOVOLOG -insulin aspart inj 100 unit/ml......................... 40
NOVOLOG MIX 70/30 -insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)...................................... 41
NOVOLOG MIX 70/30 PREFILL -insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)........................... 42
NOVOLOG PENFILL -insulin aspart soln cartridge 100
unit/ml.............................................................................. 41
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
1 mg (1000 mcg).......................................................... 156
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
2 mg (2000 mcg).......................................................... 156
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
5 mg (5000 mcg).......................................................... 156
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
8 mg (8000 mcg).......................................................... 156
NOXAFIL -posaconazole susp 40 mg/ml............................ 8
NOXAFIL -posaconazole tab delayed release 100 mg....... 8
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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2015
NUCALA -mepolizumab for inj 100 mg............................. 81
NUCYNTA ER -tapentadol hcl tab sr 12hr 50 mg........... 125
NUCYNTA ER -tapentadol hcl tab sr 12hr 100 mg......... 125
NUCYNTA ER -tapentadol hcl tab sr 12hr 150 mg......... 125
NUCYNTA ER -tapentadol hcl tab sr 12hr 200 mg......... 125
NUCYNTA ER -tapentadol hcl tab sr 12hr 250 mg......... 125
NUCYNTA -tapentadol hcl tab 50 mg............................. 125
NUCYNTA -tapentadol hcl tab 75 mg............................. 125
NUCYNTA -tapentadol hcl tab 100 mg........................... 125
NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap
20-10 mg....................................................................... 117
NULYTELY/FLAVOR PACKS -peg 3350-kcl-sod bicarbnacl for soln 420 gm.......................................................84
NUTRESTORE -glutamine powd pack 5 gm.................. 148
NUTRIDOX -doxycycline monohyd cap 75 mg w/ omega
3-vit e cap kit.................................................................... 5
NUTROPIN AQ NUSPIN 10 -somatropin inj 10
mg/2ml............................................................................. 48
NUTROPIN AQ NUSPIN 20 -somatropin inj 20
mg/2ml............................................................................. 48
NUTROPIN AQ NUSPIN 5 -somatropin inj 5 mg/2ml....... 48
NUTROPIN AQ PEN -somatropin inj 10 mg/2ml.............. 48
NUTROPIN AQ PEN -somatropin inj 20 mg/2ml.............. 48
NUVARING -etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr...................................................... 34
NUVESSA -metronidazole vaginal gel 1.3%.....................93
NUVIGIL -armodafinil tab 50 mg..................................... 113
NUVIGIL -armodafinil tab 150 mg................................... 113
NUVIGIL -armodafinil tab 200 mg................................... 113
NUVIGIL -armodafinil tab 250 mg................................... 113
NUWIQ -antihemophilic factor (recombinant) for inj kit 250
unit................................................................................. 156
NUWIQ -antihemophilic factor (recombinant) for inj kit 500
unit................................................................................. 156
NUWIQ -antihemophilic factor (recombinant) for inj kit
1000 unit....................................................................... 156
NUWIQ -antihemophilic factor (recombinant) for inj kit
2000 unit....................................................................... 156
NUWIQ -antihemophilic factor (recombinant) for inj 250
unit................................................................................. 156
NUWIQ -antihemophilic factor (recombinant) for inj 500
unit................................................................................. 156
NUWIQ -antihemophilic factor (recombinant) for inj 1000
unit................................................................................. 156
NUWIQ -antihemophilic factor (recombinant) for inj 2000
unit................................................................................. 157
NYMALIZE -nimodipine oral soln 60 mg/20ml.................. 56
nystatin cream 100000 unit/gm.................................... 173
nystatin oint 100000 unit/gm........................................ 173
nystatin susp 100000 unit/ml....................................... 164
nystatin tab 500000 unit....................................................8
nystatin topical powder................................................ 173
nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 173
nystatin-triamcinolone oint 100000-0.1 unit/gm%.................................................................................... 173
O
OBIZUR -antihemophilic factor (recomb porc) rpfviii for inj
500 unit......................................................................... 157
OBREDON -hydrocodone-guaifenesin soln 2.5-200
mg/5ml............................................................................. 78
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
(Sandostatin)................................................................. 48
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin)................................................................. 48
octreotide acetate inj 200 mcg/ml (0.2 mg/ml)
(Sandostatin)................................................................. 48
octreotide acetate inj 500 mcg/ml (0.5 mg/ml)
(Sandostatin)................................................................. 48
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin)................................................................. 48
OCUFEN -flurbiprofen sodium ophth soln 0.03%........... 161
OCUFLOX -ofloxacin ophth soln 0.3%........................... 161
ODOMZO -sonidegib phosphate cap 200 mg (base
equivalent)....................................................................... 24
OFEV -nintedanib esylate cap 100 mg (base
equivalent)....................................................................... 83
OFEV -nintedanib esylate cap 150 mg (base
equivalent)....................................................................... 83
OFLOXACIN -ofloxacin tab 400 mg.................................... 6
ofloxacin ophth soln 0.3% (Ocuflox)........................... 161
ofloxacin otic soln 0.3%................................................163
OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg.................................................................................. 34
olanzapine-fluoxetine hcl cap 3-25 mg
(Symbyax).................................................................... 117
olanzapine-fluoxetine hcl cap 6-25 mg
(Symbyax).................................................................... 117
olanzapine-fluoxetine hcl cap 6-50 mg
(Symbyax).................................................................... 117
olanzapine-fluoxetine hcl cap 12-25 mg
(Symbyax).................................................................... 117
olanzapine-fluoxetine hcl cap 12-50 mg
(Symbyax).................................................................... 117
olanzapine for im inj 10 mg (Zyprexa)........................ 105
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis).............................................................................105
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis).............................................................................105
olanzapine orally disintegrating tab 15 mg (Zyprexa
zydis).............................................................................105
olanzapine orally disintegrating tab 20 mg (Zyprexa
zydis).............................................................................105
olanzapine tab 2.5 mg (Zyprexa)................................. 105
olanzapine tab 5 mg (Zyprexa).................................... 105
olanzapine tab 7.5 mg (Zyprexa)................................. 105
olanzapine tab 10 mg (Zyprexa).................................. 105
olanzapine tab 15 mg (Zyprexa).................................. 105
olanzapine tab 20 mg (Zyprexa).................................. 105
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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2015
OLEPTRO -trazodone hcl tab sr 24hr 150 mg..................99
OLEPTRO -trazodone hcl tab sr 24hr 300 mg..................99
olopatadine hcl nasal soln 0.6% (Patanase).................77
olopatadine hcl ophth soln 0.1% (base equivalent)
(Patanol)....................................................................... 161
OLUX -clobetasol propionate foam 0.05%......................173
OLUX-E -clobetasol propionate emulsion foam
0.05%.............................................................................173
OLYSIO -simeprevir sodium cap 150 mg (base
equivalent)....................................................................... 10
OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/
omepraz cap dr therapy pack........................................ 85
OMEGA-3/D-3 WELLNESS PACK -omega-3-acid ethyl
esters cap 1gm & vit d3 cap 1000 unit kit......................71
omega-3-acid ethyl esters cap 1 gm (Lovaza)............. 71
omeprazole cap delayed release 10 mg (Prilosec)...... 86
omeprazole cap delayed release 20 mg (Prilosec)...... 86
omeprazole cap delayed release 40 mg (Prilosec)...... 86
omeprazole-sodium bicarbonate cap 20-1100 mg
(Zegerid)......................................................................... 86
omeprazole-sodium bicarbonate cap 40-1100 mg
(Zegerid)......................................................................... 86
OMNARIS -ciclesonide nasal susp 50 mcg/act................ 77
OMNIFLEX DIAPHRAGM -diaphragms.......................... 186
OMNI GEL -stannous fluoride gel 0.4%.......................... 164
OMNIPRED -prednisolone acetate ophth susp 1%........ 161
OMNITROPE -somatropin for inj 5.8 mg.......................... 48
OMNITROPE -somatropin inj 5 mg/1.5ml......................... 48
OMNITROPE -somatropin inj 10 mg/1.5ml....................... 48
ON CALL EXPRESS BLOOD GLU -blood glucose
monitoring devices........................................................ 186
ON CALL EXPRESS BLOOD GLU -blood glucose
monitoring kit w/ device................................................ 186
ON CALL PLUS BLOOD GLUCOS -blood glucose
monitoring devices........................................................ 186
ON CALL PLUS BLOOD GLUCOS -blood glucose
monitoring kit w/ device................................................ 186
ON CALL VIVID BLOOD GLUCO -blood glucose
monitoring devices........................................................ 186
ON CALL VIVID BLOOD GLUCO -blood glucose
monitoring kit w/ device................................................ 186
ON CALL VIVID PAL BLOOD G -blood glucose
monitoring devices........................................................ 186
ON CALL VIVID PAL BLOOD G -blood glucose
monitoring kit w/ device................................................ 186
ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 87
ondansetron hcl tab 24 mg............................................ 87
ondansetron hcl tab 4 mg (Zofran)................................87
ondansetron hcl tab 8 mg (Zofran)................................87
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................. 87
ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................. 87
ONETOUCH BASIC SYSTEM -blood glucose monitoring
kit w/ device.................................................................. 186
ONETOUCH PING METER REMOT -blood glucose
monitoring supplies....................................................... 186
ONETOUCH PROFILE SYSTEM -blood glucose
monitoring kit w/ device................................................ 186
ONETOUCH ULTRA 2 -blood glucose monitoring kit w/
device............................................................................ 187
ONETOUCH ULTRALINK SYSTEM -blood glucose
monitoring kit w/ device................................................ 187
ONETOUCH ULTRA MINI -blood glucose monitoring kit
w/ device....................................................................... 187
ONETOUCH ULTRASMART -blood glucose monitoring kit
w/ device....................................................................... 187
ONETOUCH ULTRA SYSTEM KIT -blood glucose
monitoring kit w/ device................................................ 187
ONETOUCH VERIO -blood glucose monitoring kit w/
device............................................................................ 187
ONETOUCH VERIO FLEX BLOOD -blood glucose
monitoring kit w/ device................................................ 187
ONETOUCH VERIO IQ BLOOD G -blood glucose
monitoring kit w/ device................................................ 187
ONETOUCH VERIO SYNC BLOOD -blood glucose
monitoring kit w/ device................................................ 187
ONEXTON -clindamycin phosphate-benzoyl peroxide gel
1.2-3.75%...................................................................... 173
ONFI -clobazam suspension 2.5 mg/ml.......................... 138
ONFI -clobazam tab 10 mg............................................. 138
ONFI -clobazam tab 20 mg............................................. 138
ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv)......... 39
ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............ 39
ONMEL -itraconazole tab 200 mg....................................... 8
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 5 mg....................................................... 125
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 7.5 mg.................................................... 125
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 10 mg..................................................... 125
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 15 mg..................................................... 125
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 20 mg..................................................... 125
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 30 mg..................................................... 125
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 40 mg..................................................... 125
OPANA -oxymorphone hcl tab 5 mg............................... 125
OPANA -oxymorphone hcl tab 10 mg............................. 125
ophthalmic irrigation solution - intraocular (Bss
plus).............................................................................. 161
OPSUMIT -macitentan tab 10 mg..................................... 74
OPTASE -trypsin w/ castor oil & peruvian balsam
gel.................................................................................. 173
OPTIONS CONCEPTROL VAGINA -nonoxynol-9 gel
4%.................................................................................... 93
OPTIONS GYNOL II VAGINAL -nonoxynol-9 gel 3%....... 93
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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2015
OPTIUM BLOOD GLUCOSE MONI -blood glucose
monitoring devices........................................................ 187
OPTIUM BLOOD GLUCOSE MONI -blood glucose
monitoring kit w/ device................................................ 187
OPTUMRX BLOOD GLUCOSE MET -blood glucose
monitoring kit w/ device................................................ 187
OPTUMRX BLOOD GLUCOSE MON -blood glucose
monitoring kit w/ device................................................ 187
ORACEA -doxycycline (rosacea) cap delayed release 40
mg.................................................................................. 173
ORAP -pimozide tab 1 mg.............................................. 117
ORAP -pimozide tab 2 mg.............................................. 117
ORAPRED ODT -prednisolone sod phos orally disintegr
tab 10 mg (base eq)....................................................... 27
ORAPRED ODT -prednisolone sod phos orally disintegr
tab 15 mg (base eq)....................................................... 27
ORAPRED ODT -prednisolone sod phos orally disintegr
tab 30 mg (base eq)....................................................... 27
ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................ 164
ORBIVAN -butalbital-acetaminophen-caffeine cap
50-300-40 mg................................................................119
ORBIVAN CF -butalbital-acetaminophen tab 50-300
mg.................................................................................. 119
ORENCIA -abatacept subcutaneous soln prefilled syringe
125 mg/ml..................................................................... 131
ORENITRAM -treprostinil diolamine tab cr 0.125 mg
(base equiv).................................................................... 74
ORENITRAM -treprostinil diolamine tab cr 0.25 mg (base
equiv)............................................................................... 74
ORENITRAM -treprostinil diolamine tab cr 1 mg (base
equiv)............................................................................... 74
ORENITRAM -treprostinil diolamine tab cr 2.5 mg (base
equiv)............................................................................... 74
ORFADIN -nitisinone cap 2 mg......................................... 48
ORFADIN -nitisinone cap 5 mg......................................... 48
ORFADIN -nitisinone cap 10 mg....................................... 48
ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg............. 83
orphenadrine citrate tab sr 12hr 100 mg.................... 145
orphenadrine w/ aspirin & caffeine tab 25-385-30
mg................................................................................. 145
ORTHO-CEPT -desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg...................................................................... 34
ORTHO-CYCLEN -norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg.............................................................. 34
ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring
kit 50 mm...................................................................... 187
ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring
kit 100 mm.................................................................... 187
ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring
kit 105 mm.................................................................... 187
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 55 mm...................................................................... 187
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 60 mm...................................................................... 187
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 65 mm...................................................................... 187
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 70 mm...................................................................... 187
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 75 mm...................................................................... 187
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 80 mm...................................................................... 187
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 85 mm...................................................................... 187
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 90 mm...................................................................... 187
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 95 mm...................................................................... 187
ORTHO EVRA -norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr............................................................. 34
ORTHO MICRONOR -norethindrone tab 0.35 mg............34
ORTHO-NOVUM 7/7/7 -norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg.......................................... 34
ORTHO-NOVUM 1/35 -norethindrone & ethinyl estradiol
tab 1 mg-35 mcg............................................................ 34
ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg................................. 34
ORTHO TRI-CYCLEN -norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg................................. 34
OSENI -alogliptin-pioglitazone tab 12.5-15 mg................. 39
OSENI -alogliptin-pioglitazone tab 12.5-30 mg................. 39
OSENI -alogliptin-pioglitazone tab 12.5-45 mg................. 39
OSENI -alogliptin-pioglitazone tab 25-15 mg.................... 39
OSENI -alogliptin-pioglitazone tab 25-30 mg.................... 39
OSENI -alogliptin-pioglitazone tab 25-45 mg.................... 39
OSMOPREP -sod phos mono-sod phos di tabs
1.102-0.398 gm(1.5gm na phos).................................... 84
OSPHENA -ospemifene tab 60 mg................................... 48
OTEZLA -apremilast tab 30 mg...................................... 131
OTEZLA -apremilast tab starter therapy pack 10 mg & 20
mg & 30 mg.................................................................. 131
OTREXUP -methotrexate soln pf auto-injector 7.5
mg/0.4ml........................................................................ 131
OTREXUP -methotrexate soln pf auto-injector 10
mg/0.4ml........................................................................ 131
OTREXUP -methotrexate soln pf auto-injector 15
mg/0.4ml........................................................................ 131
OTREXUP -methotrexate soln pf auto-injector 20
mg/0.4ml........................................................................ 131
OTREXUP -methotrexate soln pf auto-injector 25
mg/0.4ml........................................................................ 131
OVCON-35 -norethindrone & ethinyl estradiol tab 0.4
mg-35 mcg...................................................................... 34
OVIDE -malathion lotion 0.5%........................................ 173
OVIDREL -choriogonadotropin alfa inj 250 mcg/0.5ml..... 48
OXANDRIN -oxandrolone tab 2.5 mg............................... 28
OXANDRIN -oxandrolone tab 10 mg................................ 28
oxandrolone tab 2.5 mg (Oxandrin).............................. 28
oxandrolone tab 10 mg (Oxandrin)............................... 28
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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oxaprozin tab 600 mg (Daypro)................................... 131
OXAYDO -oxycodone hcl tab abuse deter 5 mg............ 125
OXAYDO -oxycodone hcl tab abuse deter 7.5 mg..........125
oxazepam cap 10 mg...................................................... 95
oxazepam cap 15 mg...................................................... 95
oxazepam cap 30 mg...................................................... 95
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)...................................................................... 139
oxcarbazepine tab 150 mg (Trileptal).......................... 139
oxcarbazepine tab 300 mg (Trileptal).......................... 139
oxcarbazepine tab 600 mg (Trileptal).......................... 139
OXISTAT -oxiconazole nitrate cream 1%........................ 173
OXISTAT -oxiconazole nitrate lotion 1%......................... 174
OXSORALEN -methoxsalen lotion 1%........................... 174
OXSORALEN ULTRA -methoxsalen rapid cap 10
mg.................................................................................. 174
OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg...... 139
OXTELLAR XR -oxcarbazepine tab sr 24hr 300 mg...... 139
OXTELLAR XR -oxcarbazepine tab sr 24hr 600 mg...... 139
oxybutynin chloride syrup 5 mg/5ml............................ 92
oxybutynin chloride tab 5 mg........................................ 92
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)..... 92
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl)..................................................................................... 92
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl)..................................................................................... 92
oxycodone-aspirin tab 4.8355-325 mg
(Percodan).................................................................... 126
oxycodone hcl cap 5 mg.............................................. 125
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl).......................................................... 125
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
10 mg............................................................................ 125
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
20 mg............................................................................ 125
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
40 mg............................................................................ 125
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
80 mg............................................................................ 125
OXYCODONE HCL -oxycodone hcl conc 100 mg/5ml (20
mg/ml)............................................................................ 125
OXYCODONE HCL -oxycodone hcl soln 5 mg/5ml........ 125
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl).........125
oxycodone hcl tab 10 mg............................................. 125
oxycodone hcl tab 20 mg............................................. 125
oxycodone hcl tab 5 mg (Roxicodone)....................... 125
oxycodone hcl tab 15 mg (Roxicodone)..................... 125
oxycodone hcl tab 30 mg (Roxicodone)..................... 125
oxycodone-ibuprofen tab 5-400 mg............................ 126
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)..................................................................... 125
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)..................................................................... 126
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)..................................................................... 126
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)..................................................................... 126
OXYCONTIN -oxycodone hcl tab er 12hr deter 10
mg.................................................................................. 126
OXYCONTIN -oxycodone hcl tab er 12hr deter 15
mg.................................................................................. 126
OXYCONTIN -oxycodone hcl tab er 12hr deter 20
mg.................................................................................. 126
OXYCONTIN -oxycodone hcl tab er 12hr deter 30
mg.................................................................................. 126
OXYCONTIN -oxycodone hcl tab er 12hr deter 40
mg.................................................................................. 126
OXYCONTIN -oxycodone hcl tab er 12hr deter 60
mg.................................................................................. 126
OXYCONTIN -oxycodone hcl tab er 12hr deter 80
mg.................................................................................. 126
oxymorphone hcl tab 5 mg (Opana)............................126
oxymorphone hcl tab 10 mg (Opana)..........................126
oxymorphone hcl tab sr 12hr 5 mg............................. 126
oxymorphone hcl tab sr 12hr 7.5 mg.......................... 126
oxymorphone hcl tab sr 12hr 10 mg........................... 126
oxymorphone hcl tab sr 12hr 15 mg........................... 126
oxymorphone hcl tab sr 12hr 20 mg........................... 126
oxymorphone hcl tab sr 12hr 30 mg........................... 126
oxymorphone hcl tab sr 12hr 40 mg........................... 126
OXYTROL -oxybutynin td patch twice weekly 3.9
mg/24hr........................................................................... 92
P
paliperidone tab sr 24hr 1.5 mg (Invega).................... 105
paliperidone tab sr 24hr 3 mg (Invega)....................... 105
paliperidone tab sr 24hr 6 mg (Invega)....................... 105
paliperidone tab sr 24hr 9 mg (Invega)....................... 105
PAMELOR -nortriptyline hcl cap 10 mg............................ 99
PAMELOR -nortriptyline hcl cap 25 mg............................ 99
PAMELOR -nortriptyline hcl cap 50 mg............................ 99
PAMELOR -nortriptyline hcl cap 75 mg............................ 99
PAMINE FORTE -methscopolamine bromide tab 5
mg.................................................................................... 86
PAMINE FQ -methscopolamine tab 5 mg & misc intestinal
flora reg cap.................................................................... 86
PAMINE -methscopolamine bromide tab 2.5 mg.............. 86
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
4200-10000-17500 unit...................................................88
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
10500-25000-43750 unit................................................ 88
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
16800-40000-70000 unit................................................ 88
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
21000-37000-61000 unit................................................ 88
PANCRELIPASE -pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit...................................................88
PANDEL -hydrocortisone probutate cream 0.1%............ 174
PANRETIN -alitretinoin gel 0.1%..................................... 174
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................86
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................86
PARADIGM LINK BLOOD GLUCO -blood glucose
monitoring kit w/ device................................................ 187
PARAFON FORTE DSC -chlorzoxazone tab 500 mg..... 145
paricalcitol cap 1 mcg (Zemplar)................................... 48
paricalcitol cap 2 mcg (Zemplar)................................... 48
paricalcitol cap 4 mcg (Zemplar)................................... 48
PARLODEL -bromocriptine mesylate cap 5 mg.............. 142
PARNATE -tranylcypromine sulfate tab 10 mg................. 99
paromomycin sulfate cap 250 mg................................... 7
paroxetine hcl tab 10 mg (Paxil).................................... 99
paroxetine hcl tab 20 mg (Paxil).................................... 99
paroxetine hcl tab 30 mg (Paxil).................................... 99
paroxetine hcl tab 40 mg (Paxil).................................... 99
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)............... 99
paroxetine hcl tab sr 24hr 25 mg (Paxil cr).................. 99
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)............... 99
PASER -aminosalicylic acid cr granules packet 4 gm.........7
PATADAY -olopatadine hcl ophth soln 0.2% (base
equivalent)..................................................................... 161
PATANASE -olopatadine hcl nasal soln 0.6%................... 77
PATANOL -olopatadine hcl ophth soln 0.1% (base
equivalent)..................................................................... 161
PAXIL CR -paroxetine hcl tab sr 24hr 12.5 mg................. 99
PAXIL CR -paroxetine hcl tab sr 24hr 25 mg.................... 99
PAXIL CR -paroxetine hcl tab sr 24hr 37.5 mg................. 99
PAXIL -paroxetine hcl oral susp 10 mg/5ml (base
equiv)............................................................................... 99
PAXIL -paroxetine hcl tab 10 mg...................................... 99
PAXIL -paroxetine hcl tab 20 mg...................................... 99
PAXIL -paroxetine hcl tab 30 mg...................................... 99
PAXIL -paroxetine hcl tab 40 mg...................................... 99
PAZEO -olopatadine hcl ophth soln 0.7% (base
equivalent)..................................................................... 161
PCE -erythromycin w/ enteric coated particles tab 333
mg...................................................................................... 4
PCE -erythromycin w/ enteric coated particles tab 500
mg...................................................................................... 4
PEDIAPRED -prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)................................................ 27
PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv
vac inj.............................................................................. 20
pediatric multiple vitamins w/ fluoride chew tab 0.25
mg................................................................................. 146
pediatric multiple vitamins w/ fluoride chew tab 0.5
mg................................................................................. 146
pediatric multiple vitamins w/ fluoride chew tab 1
mg................................................................................. 146
PEDVAX HIB -haemophilus b polysaccharide conj vac im
susp 7.5 mcg/0.5 ml....................................................... 19
PEGANONE -ethotoin tab 250 mg.................................. 139
PEGASYS -peginterferon alfa-2a inj 180 mcg/ml............. 11
PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml........ 11
PEGASYS PROCLICK -peginterferon alfa-2a inj 135
mcg/0.5ml........................................................................ 11
PEGASYS PROCLICK -peginterferon alfa-2a inj 180
mcg/0.5ml........................................................................ 11
PEG-INTRON -peginterferon alfa-2b for inj kit 50
mcg/0.5ml........................................................................ 11
PEG-INTRON -peginterferon alfa-2b for inj kit 80
mcg/0.5ml........................................................................ 11
PEG-INTRON -peginterferon alfa-2b for inj kit 120
mcg/0.5ml........................................................................ 11
PEG-INTRON -peginterferon alfa-2b for inj kit 150
mcg/0.5ml........................................................................ 11
PEGINTRON -peginterferon alfa-2b for inj kit 50
mcg/0.5ml........................................................................ 11
PEGINTRON -peginterferon alfa-2b for inj kit 80
mcg/0.5ml........................................................................ 11
PEGINTRON -peginterferon alfa-2b for inj kit 120
mcg/0.5ml........................................................................ 11
PEGINTRON -peginterferon alfa-2b for inj kit 150
mcg/0.5ml........................................................................ 11
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 50 mcg/0.5ml........................................................ 11
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 80 mcg/0.5ml........................................................ 11
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 120 mcg/0.5ml...................................................... 11
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 150 mcg/0.5ml...................................................... 11
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
50 mcg/0.5ml.................................................................. 11
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
80 mcg/0.5ml.................................................................. 11
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
120 mcg/0.5ml................................................................ 11
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
150 mcg/0.5ml................................................................ 11
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240
gm (Colyte-flavor packs)............................................. 84
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236
gm (Golytely)................................................................. 84
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack)................................................... 84
penicillin v potassium for soln 125 mg/5ml................... 2
penicillin v potassium for soln 250 mg/5ml................... 2
penicillin v potassium tab 250 mg...................................2
penicillin v potassium tab 500 mg...................................2
PENLAC NAIL LACQUER -ciclopirox solution 8%......... 174
PENNSAID -diclofenac sodium soln 2%......................... 174
PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly
vac for im susp............................................................... 20
PENTASA -mesalamine cap cr 250 mg............................ 90
PENTASA -mesalamine cap cr 500 mg............................ 90
pentazocine w/ naloxone tab 50-0.5 mg......................126
PEN-TOTE -blood glucose monitoring supplies............. 187
pentoxifylline tab cr 400 mg......................................... 157
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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2015
PEPCID -famotidine for susp 40 mg/5ml.......................... 86
PEPCID -famotidine tab 20 mg......................................... 86
PEPCID -famotidine tab 40 mg......................................... 86
PERCOCET -oxycodone w/ acetaminophen tab 2.5-325
mg.................................................................................. 126
PERCOCET -oxycodone w/ acetaminophen tab 5-325
mg.................................................................................. 126
PERCOCET -oxycodone w/ acetaminophen tab 7.5-325
mg.................................................................................. 126
PERCOCET -oxycodone w/ acetaminophen tab 10-325
mg.................................................................................. 126
PERCODAN -oxycodone-aspirin tab 4.8355-325 mg..... 126
PERFOROMIST -formoterol fumarate soln nebu 20
mcg/2ml........................................................................... 81
PERIDEX -chlorhexidine gluconate soln 0.12%............. 164
perindopril erbumine tab 2 mg...................................... 64
perindopril erbumine tab 4 mg (Aceon)........................ 64
perindopril erbumine tab 8 mg (Aceon)........................ 64
permethrin cream 5% (Elimite).................................... 174
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg.............................................. 117
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-25 mg.............................................. 117
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-10 mg.............................................. 117
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-25 mg.............................................. 117
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-50 mg.............................................. 117
perphenazine tab 2 mg................................................. 105
perphenazine tab 4 mg................................................. 105
perphenazine tab 8 mg................................................. 105
perphenazine tab 16 mg............................................... 105
PERSANTINE -dipyridamole tab 25 mg......................... 157
PERSANTINE -dipyridamole tab 50 mg......................... 157
PERSANTINE -dipyridamole tab 75 mg......................... 157
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
8000-28750-30250 unit...................................................88
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
16000-57500-60500 unit................................................ 88
PEXEVA -paroxetine mesylate tab 10 mg (base
equiv)............................................................................. 100
PEXEVA -paroxetine mesylate tab 20 mg (base
equiv)............................................................................. 100
PEXEVA -paroxetine mesylate tab 30 mg (base
equiv)............................................................................. 100
PEXEVA -paroxetine mesylate tab 40 mg (base
equiv)............................................................................. 100
PHARMACIST CHOICE AUTOCOD -blood glucose
monitoring kit w/ device................................................ 188
phenazopyridine hcl tab 100 mg (Pyridium).................94
phenazopyridine hcl tab 200 mg (Pyridium).................94
phenelzine sulfate tab 15 mg (Nardil)......................... 100
PHENERGAN -promethazine hcl inj 25 mg/ml................. 76
PHENERGAN -promethazine hcl inj 50 mg/ml................. 76
phenobarbital elixir 20 mg/5ml.................................... 108
PHENOBARBITAL -phenobarbital tab 15 mg................. 108
PHENOBARBITAL -phenobarbital tab 30 mg................. 108
PHENOBARBITAL -phenobarbital tab 60 mg................. 108
PHENOBARBITAL -phenobarbital tab 100 mg............... 108
phenobarbital tab 16.2 mg............................................ 108
phenobarbital tab 32.4 mg............................................ 108
phenobarbital tab 64.8 mg............................................ 108
phenobarbital tab 97.2 mg............................................ 108
phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 64
phenylephrine-brompheniramine-dm liquid 7.5-4-15
mg/5ml............................................................................ 78
phenylephrine hcl ophth soln 2.5%............................. 161
phenylephrine hcl ophth soln 10%.............................. 161
PHENYLHISTINE DH -pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml............................................ 78
PHENYTEK -phenytoin sodium extended cap 200
mg.................................................................................. 139
PHENYTEK -phenytoin sodium extended cap 300
mg.................................................................................. 139
phenytoin chew tab 50 mg (Dilantin infatabs)............139
phenytoin sodium extended cap 100 mg
(Dilantin)....................................................................... 139
phenytoin sodium extended cap 200 mg
(Phenytek).................................................................... 139
phenytoin sodium extended cap 300 mg
(Phenytek).................................................................... 139
phenytoin susp 125 mg/5ml (Dilantin)........................ 139
PHOS-FLUR ORTHO DEFENSE -sodium fluoride rinse
0.044%.......................................................................... 164
PHOS FLUR -sodium fluoride rinse 0.044%................... 164
PHOSLO -calcium acetate (phosphate binder) cap 667
mg (169 mg ca).............................................................. 90
PHOSLYRA -calcium acetate (phosphate binder) oral soln
667 mg/5ml..................................................................... 90
PHOSPHOLINE IODIDE -echothiophate iodide ophth for
soln 0.125%.................................................................. 161
PICATO -ingenol mebutate gel 0.015%.......................... 174
PICATO -ingenol mebutate gel 0.05%............................ 174
pilocarpine hcl ophth soln 1% (Isopto carpine)......... 161
pilocarpine hcl ophth soln 2% (Isopto carpine)......... 161
pilocarpine hcl ophth soln 4% (Isopto carpine)......... 161
pilocarpine hcl tab 5 mg (Salagen)..............................164
pilocarpine hcl tab 7.5 mg (Salagen)...........................164
pimozide tab 1 mg (Orap)............................................. 117
pimozide tab 2 mg (Orap)............................................. 117
pindolol tab 5 mg............................................................. 52
pindolol tab 10 mg........................................................... 52
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)..... 39
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)..... 39
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)............................................................... 39
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)............................................................... 39
pioglitazone hcl tab 15 mg (base equiv) (Actos)..........39
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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2015
pioglitazone hcl tab 30 mg (base equiv) (Actos)..........39
pioglitazone hcl tab 45 mg (base equiv) (Actos)..........39
piroxicam cap 10 mg (Feldene)................................... 131
piroxicam cap 20 mg (Feldene)................................... 131
PLAN B ONE-STEP -levonorgestrel tab 1.5 mg............... 34
PLAQUENIL -hydroxychloroquine sulfate tab 200 mg...... 14
PLAVIX -clopidogrel bisulfate tab 75 mg (base
equiv)............................................................................. 157
PLAVIX -clopidogrel bisulfate tab 300 mg (base
equiv)............................................................................. 157
PLEGRIDY -peginterferon beta-1a soln pen-injector 125
mcg/0.5ml...................................................................... 117
PLEGRIDY -peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml.............................................................. 117
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack.................................. 117
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack................................. 117
PLIAGLIS -lidocaine-tetracaine cream 7-7%.................. 174
PNEUMOVAX 23/1 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................ 19
PNEUMOVAX 23/5 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................ 19
PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj
25 mcg/0.5ml.................................................................. 19
POCKETCHEM EZ BLOOD GLUCO -blood glucose
monitoring kit w/ device................................................ 188
podofilox soln 0.5% (Condylox)................................... 174
polyethylene glycol 3350 oral packet............................ 84
polyethylene glycol 3350 oral powder.......................... 84
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)...................................................... 161
POLYTRIM -polymyxin b-trimethoprim ophth soln 10000
unit/ml-0.1%.................................................................. 162
POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine
liquid 10-4-10 mg/5ml..................................................... 78
POMALYST -pomalidomide cap 1 mg.............................. 24
POMALYST -pomalidomide cap 2 mg.............................. 24
POMALYST -pomalidomide cap 3 mg.............................. 24
POMALYST -pomalidomide cap 4 mg.............................. 24
PONSTEL -mefenamic acid cap 250 mg........................ 131
POTABA -potassium aminobenzoate tab 500 mg.......... 146
potassium bicarbonate effer tab 25 meq.................... 147
potassium chloride cap cr 8 meq (Micro-k)................ 147
potassium chloride cap cr 10 meq (Micro-k).............. 147
POTASSIUM CHLORIDE ER -potassium chloride tab cr 8
meq (600 mg)............................................................... 147
POTASSIUM CHLORIDE ER -potassium chloride tab cr
20 meq (1500 mg)........................................................ 147
potassium chloride microencapsulated crys cr tab 10
meq............................................................................... 147
potassium chloride microencapsulated crys cr tab 20
meq............................................................................... 147
potassium chloride oral soln 10% (20 meq/15ml)...... 147
potassium chloride oral soln 20% (40 meq/15ml)...... 147
potassium chloride powder packet 20 meq............... 147
potassium chloride tab cr 10 meq (K-tab).................. 147
potassium chloride tab cr 8 meq (600 mg)................. 147
potassium citrate tab cr 5 meq (540 mg) (Urocit-k
5)...................................................................................... 94
potassium citrate tab cr 10 meq (1080 mg) (Urocit-k
10).................................................................................... 94
potassium citrate tab cr 15 meq (1620 mg) (Urocit-k
15).................................................................................... 94
POTIGA -ezogabine tab 50 mg....................................... 139
POTIGA -ezogabine tab 200 mg..................................... 139
POTIGA -ezogabine tab 300 mg..................................... 139
POTIGA -ezogabine tab 400 mg..................................... 139
PRADAXA -dabigatran etexilate mesylate cap 75 mg
(etexilate base eq)........................................................ 151
PRADAXA -dabigatran etexilate mesylate cap 110 mg
(etexilate base eq)........................................................ 151
PRADAXA -dabigatran etexilate mesylate cap 150 mg
(etexilate base eq)........................................................ 151
PRALUENT -alirocumab subcutaneous soln pen-injector
75 mg/ml......................................................................... 71
PRALUENT -alirocumab subcutaneous soln pen-injector
150 mg/ml....................................................................... 71
PRALUENT -alirocumab subcutaneous soln prefilled
syringe 75 mg/ml............................................................ 72
PRALUENT -alirocumab subcutaneous soln prefilled
syringe 150 mg/ml.......................................................... 72
pramipexole dihydrochloride tab 0.125 mg
(Mirapex).......................................................................142
pramipexole dihydrochloride tab 0.25 mg
(Mirapex).......................................................................142
pramipexole dihydrochloride tab 0.5 mg
(Mirapex).......................................................................142
pramipexole dihydrochloride tab 0.75 mg
(Mirapex).......................................................................142
pramipexole dihydrochloride tab 1 mg (Mirapex)...... 142
pramipexole dihydrochloride tab 1.5 mg
(Mirapex).......................................................................142
pramipexole dihydrochloride tab sr 24hr 0.375 mg
(Mirapex er).................................................................. 142
pramipexole dihydrochloride tab sr 24hr 0.75 mg
(Mirapex er).................................................................. 142
pramipexole dihydrochloride tab sr 24hr 1.5 mg
(Mirapex er).................................................................. 142
pramipexole dihydrochloride tab sr 24hr 2.25 mg
(Mirapex er).................................................................. 142
pramipexole dihydrochloride tab sr 24hr 3 mg
(Mirapex er).................................................................. 142
pramipexole dihydrochloride tab sr 24hr 4.5 mg
(Mirapex er).................................................................. 142
PRAMOSONE -pramoxine-hc cream 1-1%.................... 174
PRAMOSONE -pramoxine-hc cream 1-2.5%................. 174
PRAMOSONE -pramoxine-hc lotion 1-1%...................... 174
PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 174
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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2015
PRANDIMET -repaglinide-metformin hcl tab 1-500
mg.................................................................................... 39
PRANDIMET -repaglinide-metformin hcl tab 2-500
mg.................................................................................... 39
PRANDIN -repaglinide tab 0.5 mg.................................... 39
PRANDIN -repaglinide tab 1 mg....................................... 39
PRANDIN -repaglinide tab 2 mg....................................... 39
PRASTERA -prasterone cap 200 mg & ibuprofen tab 400
mg kit............................................................................. 131
PRAVACHOL -pravastatin sodium tab 20 mg................... 72
PRAVACHOL -pravastatin sodium tab 40 mg................... 72
PRAVACHOL -pravastatin sodium tab 80 mg................... 72
pravastatin sodium tab 10 mg....................................... 72
pravastatin sodium tab 20 mg (Pravachol)...................72
pravastatin sodium tab 40 mg (Pravachol)...................72
pravastatin sodium tab 80 mg (Pravachol)...................72
prazosin hcl cap 1 mg (Minipress)................................ 64
prazosin hcl cap 2 mg (Minipress)................................ 64
prazosin hcl cap 5 mg (Minipress)................................ 64
PRECISION LINK -blood glucose monitoring kit w/
device............................................................................ 188
PRECISION QID MONITOR -blood glucose monitoring
devices.......................................................................... 188
PRECISION SOF-TACT MONITO -blood glucose
monitoring devices........................................................ 188
PRECISION XTRA -blood glucose monitoring
devices.......................................................................... 188
PRECISION XTRA -blood glucose monitoring kit........... 188
PRECISION XTRA MONITOR -blood glucose monitoring
devices.......................................................................... 188
PRECOSE -acarbose tab 25 mg...................................... 39
PRECOSE -acarbose tab 50 mg...................................... 39
PRECOSE -acarbose tab 100 mg.................................... 39
PRED FORTE -prednisolone acetate ophth susp
1%.................................................................................. 162
PRED-G -gentamicin-prednisolone ace ophth susp
0.3-1%........................................................................... 162
PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint
0.3-0.6%........................................................................ 162
PRED MILD -prednisolone acetate ophth susp
0.12%.............................................................................162
prednicarbate cream 0.1% (Dermatop)....................... 174
prednicarbate oint 0.1% (Dermatop)........................... 174
prednisolone acetate ophth susp 1% (Pred forte)..... 162
PREDNISOLONE SODIUM PHOSP -prednisolone
sodium phosphate ophth soln 1%................................ 162
PREDNISOLONE SODIUM PHOSP -prednisolone
sodium phosphate oral soln 25 mg/5ml (base eq)......... 27
prednisolone sod phos orally disintegr tab 10 mg
(base eq) (Orapred odt)............................................... 27
prednisolone sod phos orally disintegr tab 15 mg
(base eq) (Orapred odt)............................................... 27
prednisolone sod phos orally disintegr tab 30 mg
(base eq) (Orapred odt)............................................... 27
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)................................................................... 27
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred)............................................27
prednisolone syrup 15 mg/5ml (usp solution
equivalent) (Prelone).................................................... 27
PREDNISONE INTENSOL -prednisone conc 5 mg/ml..... 28
PREDNISONE -prednisone oral soln 5 mg/5ml................ 27
PREDNISONE -prednisone tab 50 mg............................. 27
PREDNISONE -prednisone tab 5 mg dose pack.............. 27
PREDNISONE -prednisone tab 10 mg dose pack............ 28
prednisone tab 1 mg....................................................... 28
prednisone tab 2.5 mg.................................................... 28
prednisone tab 5 mg....................................................... 28
prednisone tab 10 mg..................................................... 28
prednisone tab 20 mg..................................................... 28
PREFERRED PLUS GLUCOSE -glucose chew tab 4
gm.................................................................................... 39
PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate
tab 1-0.09mg(15)............................................................ 31
PREMARIN -estrogens, conjugated tab 0.3 mg............... 31
PREMARIN -estrogens, conjugated tab 0.45 mg............. 31
PREMARIN -estrogens, conjugated tab 0.625 mg........... 31
PREMARIN -estrogens, conjugated tab 0.9 mg............... 31
PREMARIN -estrogens, conjugated tab 1.25 mg............. 31
PREMARIN -estrogens, conjugated vaginal cream 0.625
mg/gm.............................................................................. 93
PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac
tab 0.625-5mg(14).......................................................... 31
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.3-1.5 mg................................................... 31
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.45-1.5 mg................................................. 31
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.625-2.5 mg............................................... 31
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.625-5 mg.................................................. 31
PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm............44
PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10
mg-3.5 gm-12 gm........................................................... 84
PRESTALIA -perindopril arginine-amlodipine besylate tab
3.5-2.5 mg....................................................................... 64
PRESTALIA -perindopril arginine-amlodipine besylate tab
7-5 mg............................................................................. 64
PRESTALIA -perindopril arginine-amlodipine besylate tab
14-10 mg......................................................................... 64
PREVACID -lansoprazole cap delayed release 15 mg..... 86
PREVACID -lansoprazole cap delayed release 30 mg..... 86
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 15 mg............................................. 86
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 30 mg............................................. 86
PREVIDENT 5000 BOOSTER PL -sodium fluoride paste
1.1%...............................................................................165
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PREVIDENT 5000 BOOSTER -sodium fluoride paste
1.1%...............................................................................165
PREVIDENT 5000 DRY MOUTH -sodium fluoride gel
1.1% (0.5% f)................................................................ 165
PREVIDENT 5000 ENAMEL PRO -sodium fluoridepotassium nitrate paste 1.1-5%................................... 165
PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5%
f)..................................................................................... 165
PREVIDENT 5000 PLUS -sodium fluoride cream
1.1%...............................................................................165
PREVIDENT 5000 SENSITIVE -sodium fluoridepotassium nitrate paste 1.1-5%................................... 165
PREVIDENT -sodium fluoride rinse 0.2%....................... 164
PREVNAR 13 -pneumococcal 13-valent conjugate
vaccine inj....................................................................... 19
PREVPAC -amoxicillin cap-clarithro tab-lansopraz cap dr
therapy pack................................................................... 86
PREZCOBIX -darunavir-cobicistat tab 800-150 mg..........11
PREZISTA -darunavir ethanolate susp 100 mg/ml (base
equiv)............................................................................... 11
PREZISTA -darunavir ethanolate tab 75 mg (base
equiv)............................................................................... 11
PREZISTA -darunavir ethanolate tab 150 mg (base
equiv)............................................................................... 11
PREZISTA -darunavir ethanolate tab 600 mg (base
equiv)............................................................................... 11
PREZISTA -darunavir ethanolate tab 800 mg (base
equiv)............................................................................... 11
PRIFTIN -rifapentine tab 150 mg........................................ 7
PRILOSEC -omeprazole cap delayed release 10 mg.......86
PRILOSEC -omeprazole cap delayed release 20 mg.......86
PRILOSEC -omeprazole cap delayed release 40 mg.......86
PRILOSEC -omeprazole magnesium for delayed release
susp packet 2.5 mg........................................................ 86
PRILOSEC -omeprazole magnesium for delayed release
susp packet 10 mg......................................................... 86
PRIMAQUINE PHOSPHATE -primaquine phosphate tab
26.3 mg (15 mg base).................................................... 14
primidone tab 50 mg (Mysoline).................................. 139
primidone tab 250 mg (Mysoline)................................ 139
PRIMLEV -oxycodone w/ acetaminophen tab 5-300
mg.................................................................................. 126
PRIMLEV -oxycodone w/ acetaminophen tab 7.5-300
mg.................................................................................. 126
PRIMLEV -oxycodone w/ acetaminophen tab 10-300
mg.................................................................................. 126
PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base
equiv)............................................................................... 15
PRINIVIL -lisinopril tab 5 mg............................................. 64
PRINIVIL -lisinopril tab 10 mg........................................... 64
PRINIVIL -lisinopril tab 20 mg........................................... 64
PRINZIDE -lisinopril & hydrochlorothiazide tab 10-12.5
mg.................................................................................... 64
PRISTIQ -desvenlafaxine succinate tab sr 24hr 25 mg
(base equiv).................................................................. 100
PRISTIQ -desvenlafaxine succinate tab sr 24hr 50 mg
(base equiv).................................................................. 100
PRISTIQ -desvenlafaxine succinate tab sr 24hr 100 mg
(base equiv).................................................................. 100
PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)........................................................ 81
PROAIR RESPICLICK -albuterol sulfate aer pow ba 108
mcg/act (90 mcg base equiv)......................................... 82
probenecid tab 500 mg................................................. 134
PROCARDIA -nifedipine cap 10 mg................................. 56
PROCARDIA XL -nifedipine tab sr 24hr osmotic release
30 mg.............................................................................. 56
PROCARDIA XL -nifedipine tab sr 24hr osmotic release
60 mg.............................................................................. 56
PROCARDIA XL -nifedipine tab sr 24hr osmotic release
90 mg.............................................................................. 56
PROCENTRA -dextroamphetamine sulfate oral solution 5
mg/5ml........................................................................... 113
prochlorperazine edisylate inj 5 mg/ml....................... 105
prochlorperazine maleate tab 5 mg (base equivalent)
(Compazine)................................................................. 105
prochlorperazine maleate tab 10 mg (base equivalent)
(Compazine)................................................................. 105
prochlorperazine suppos 25 mg.................................. 105
PRO-CLEAR AC -codeine-pyrilamine syrup 9-8.33
mg/5ml............................................................................. 78
PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 149
PROCRIT -epoetin alfa inj 3000 unit/ml.......................... 150
PROCRIT -epoetin alfa inj 4000 unit/ml.......................... 150
PROCRIT -epoetin alfa inj 10000 unit/ml........................ 150
PROCRIT -epoetin alfa inj 20000 unit/ml........................ 150
PROCRIT -epoetin alfa inj 40000 unit/ml........................ 150
PROCTOFOAM HC -hydrocortisone acetate w/
pramoxine rectal foam 1-1%........................................ 166
PROCYSBI -cysteamine bitartrate cap delayed release 25
mg (base equiv).............................................................. 94
PROCYSBI -cysteamine bitartrate cap delayed release 75
mg (base equiv).............................................................. 94
PRODIGY AUTOCODE BLOOD GL -blood glucose
monitoring devices........................................................ 188
PRODIGY AUTOCODE BLOOD GL -blood glucose
monitoring kit w/ device................................................ 188
PRODIGY POCKET BLOOD GLUC -blood glucose
monitoring kit w/ device................................................ 188
PRODIGY VOICE BLOOD GLUCO -blood glucose
monitoring kit w/ device................................................ 188
PROFILNINE -factor ix complex for inj 500 unit............. 157
PROFILNINE -factor ix complex for inj 1000 unit........... 157
PROFILNINE -factor ix complex for inj 1500 unit........... 157
PROFILNINE SD -factor ix complex for inj 500 unit........157
PROFILNINE SD -factor ix complex for inj 1000 unit......157
PROFILNINE SD -factor ix complex for inj 1500 unit......157
progesterone im in oil 50 mg/ml.................................... 35
progesterone micronized cap 100 mg
(Prometrium).................................................................. 35
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progesterone micronized cap 200 mg
(Prometrium).................................................................. 35
PROGLYCEM -diazoxide susp 50 mg/ml......................... 39
PROGRAF -tacrolimus cap 0.5 mg................................. 191
PROGRAF -tacrolimus cap 1 mg.................................... 191
PROGRAF -tacrolimus cap 5 mg.................................... 191
PROGRAF -tacrolimus inj 5 mg/ml................................. 191
PROLENSA -bromfenac sodium ophth soln 0.07% (base
equivalent)..................................................................... 162
PROMACTA -eltrombopag olamine tab 12.5 mg (base
equiv)............................................................................. 150
PROMACTA -eltrombopag olamine tab 25 mg (base
equiv)............................................................................. 150
PROMACTA -eltrombopag olamine tab 50 mg (base
equiv)............................................................................. 150
PROMACTA -eltrombopag olamine tab 75 mg (base
equiv)............................................................................. 150
promethazine-dm syrup 6.25-15 mg/5ml.......................78
promethazine hcl inj 25 mg/ml (Phenergan).................76
promethazine hcl inj 50 mg/ml (Phenergan).................76
promethazine hcl suppos 12.5 mg................................ 76
promethazine hcl suppos 25 mg................................... 76
promethazine hcl suppos 50 mg................................... 76
promethazine hcl syrup 6.25 mg/5ml............................ 76
promethazine hcl tab 12.5 mg........................................ 76
promethazine hcl tab 25 mg........................................... 76
promethazine hcl tab 50 mg........................................... 76
promethazine w/ codeine syrup 6.25-10 mg/5ml..........78
PROMETRIUM -progesterone micronized cap 100
mg.................................................................................... 35
PROMETRIUM -progesterone micronized cap 200
mg.................................................................................... 35
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)...... 57
propafenone hcl cap sr 12hr 325 mg (Rythmol sr)...... 57
propafenone hcl cap sr 12hr 425 mg (Rythmol sr)...... 57
propafenone hcl tab 300 mg.......................................... 57
propafenone hcl tab 150 mg (Rythmol)........................ 57
propafenone hcl tab 225 mg (Rythmol)........................ 57
PROPANTHELINE BROMIDE -propantheline bromide tab
15 mg.............................................................................. 86
proparacaine hcl ophth soln 0.5% (Alcaine).............. 162
PROPRANOLOL/HYDROCHLOROTH -propranolol &
hydrochlorothiazide tab 40-25 mg.................................. 64
PROPRANOLOL/HYDROCHLOROTH -propranolol &
hydrochlorothiazide tab 80-25 mg.................................. 64
propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 53
propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 53
propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 53
propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 53
PROPRANOLOL HCL -propranolol hcl oral soln 20
mg/5ml............................................................................. 53
PROPRANOLOL HCL -propranolol hcl oral soln 40
mg/5ml............................................................................. 53
propranolol hcl tab 10 mg.............................................. 53
propranolol hcl tab 20 mg.............................................. 53
propranolol hcl tab 40 mg.............................................. 53
propranolol hcl tab 60 mg.............................................. 53
propranolol hcl tab 80 mg.............................................. 53
propylthiouracil tab 50 mg............................................. 43
PROQUAD -measles-mumps-rubella-varicella virus
vaccines for inj................................................................ 19
PRO-RED AC -phenylephrine-dexchlorphenir-codeine
syrup 5-1-9 mg/5ml.........................................................78
PROSCAR -finasteride tab 5 mg...................................... 94
PROSTIN E2 -dinoprostone vaginal suppos 20 mg......... 44
PROTONIX -pantoprazole sodium ec tab 20 mg (base
equiv)............................................................................... 86
PROTONIX -pantoprazole sodium ec tab 40 mg (base
equiv)............................................................................... 86
PROTONIX -pantoprazole sodium for delayed release
susp packet 40 mg......................................................... 86
PROTOPIC -tacrolimus oint 0.03%................................. 174
PROTOPIC -tacrolimus oint 0.1%................................... 174
protriptyline hcl tab 5 mg (Vivactil)............................. 100
protriptyline hcl tab 10 mg (Vivactil)........................... 100
PROVENTIL HFA -albuterol sulfate inhal aero 108 mcg/
act (90mcg base equiv).................................................. 82
PROVERA -medroxyprogesterone acetate tab 2.5
mg.................................................................................... 35
PROVERA -medroxyprogesterone acetate tab 5 mg....... 35
PROVERA -medroxyprogesterone acetate tab 10 mg..... 35
PROVIGIL -modafinil tab 100 mg................................... 113
PROVIGIL -modafinil tab 200 mg................................... 113
PROZAC -fluoxetine hcl cap 10 mg................................ 100
PROZAC -fluoxetine hcl cap 20 mg................................ 100
PROZAC -fluoxetine hcl cap 40 mg................................ 100
PROZAC WEEKLY -fluoxetine hcl cap delayed release 90
mg.................................................................................. 100
PRUDOXIN -doxepin hcl cream 5%............................... 174
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5
mg/5ml (Zutripro).......................................................... 78
pseudoephed-bromphen-dm syrup 30-2-10
mg/5ml............................................................................ 78
pseudoephedrine-bromphen-codeine liq 10-1.33-6.33
mg/5ml............................................................................ 79
pseudoephedrine w/ cod-gg soln 30-10-100
mg/5ml............................................................................ 78
pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml
(Suttar-sf)....................................................................... 78
PSORCON -diflorasone diacetate cream 0.05%............ 174
PULMICORT -budesonide inhalation susp 0.25
mg/2ml............................................................................. 82
PULMICORT -budesonide inhalation susp 0.5
mg/2ml............................................................................. 82
PULMICORT -budesonide inhalation susp 1 mg/2ml....... 82
PULMICORT FLEXHALER -budesonide inhal aero powd
90 mcg/act (breath activated).........................................82
PULMICORT FLEXHALER -budesonide inhal aero powd
180 mcg/act (breath activated)...................................... 82
PULMOZYME -dornase alfa inhal soln 1 mg/ml............... 83
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PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/
ml).................................................................................... 24
PYLERA -bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg..............................................................86
pyrazinamide tab 500 mg..................................................7
pyridostigmine bromide tab cr 180 mg (Mestinon
timespan)......................................................................145
pyridostigmine bromide tab 60 mg (Mestinon).......... 145
Q
QNASL -beclomethasone dipropionate nasal aerosol 80
mcg/act............................................................................ 77
QNASL CHILDRENS -beclomethasone dipropionate
nasal aerosol 40 mcg/act............................................... 77
QUADRACEL -diph-tetanus tox ad-acell pert & polio
virus, ipv vac inj.............................................................. 20
QUALAQUIN -quinine sulfate cap 324 mg........................14
QUARTETTE -levonor-eth est tab 0.15-0.02/0.025/0.03
mg &eth est 0.01 mg...................................................... 34
QUAZEPAM -quazepam tab 15 mg................................ 109
QUDEXY XR -topiramate cap er 24hr sprinkle 25
mg.................................................................................. 139
QUDEXY XR -topiramate cap er 24hr sprinkle 50
mg.................................................................................. 139
QUDEXY XR -topiramate cap er 24hr sprinkle 100
mg.................................................................................. 139
QUDEXY XR -topiramate cap er 24hr sprinkle 150
mg.................................................................................. 139
QUDEXY XR -topiramate cap er 24hr sprinkle 200
mg.................................................................................. 139
QUESTRAN -cholestyramine powder 4 gm/dose............. 72
QUESTRAN -cholestyramine powder packets 4 gm........ 72
QUESTRAN LIGHT -cholestyramine light powder 4 gm/
dose................................................................................. 72
quetiapine fumarate tab 25 mg (Seroquel)................. 105
quetiapine fumarate tab 50 mg (Seroquel)................. 105
quetiapine fumarate tab 100 mg (Seroquel)............... 105
quetiapine fumarate tab 200 mg (Seroquel)............... 105
quetiapine fumarate tab 300 mg (Seroquel)............... 105
quetiapine fumarate tab 400 mg (Seroquel)............... 105
QUICKTEK -blood glucose monitoring kit....................... 188
QUICKTEK -blood glucose monitoring kit w/ device....... 188
QUILLIVANT XR -methylphenidate hcl for er susp 25
mg/5ml (5 mg/ml)..........................................................113
quinapril hcl tab 5 mg (Accupril)................................... 64
quinapril hcl tab 10 mg (Accupril)................................. 64
quinapril hcl tab 20 mg (Accupril)................................. 65
quinapril hcl tab 40 mg (Accupril)................................. 65
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)...................................................................... 65
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)...................................................................... 65
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)...................................................................... 65
quinidine gluconate tab cr 324 mg................................ 57
QUINIDINE SULFATE ER -quinidine sulfate tab cr 300
mg.................................................................................... 57
QUINIDINE SULFATE -quinidine sulfate tab 200 mg....... 57
QUINIDINE SULFATE -quinidine sulfate tab 300 mg....... 57
quinine sulfate cap 324 mg (Qualaquin)....................... 14
QVAR -beclomethasone diprop inhal aero soln 40 mcg/act
(50/valve)......................................................................... 82
QVAR -beclomethasone diprop inhal aero soln 80 mcg/act
(100/valve)....................................................................... 82
R
RABAVERT -rabies vaccine, pcec for inj.......................... 19
rabeprazole sodium ec tab 20 mg (Aciphex)................ 86
RA BLOOD GLUCOSE MONITOR -blood glucose
monitoring devices........................................................ 188
RADIOGARDASE -prussian blue insoluble cap 0.5
gm.................................................................................. 177
raloxifene hcl tab 60 mg (Evista)................................... 48
ramipril cap 1.25 mg (Altace)......................................... 65
ramipril cap 2.5 mg (Altace)........................................... 65
ramipril cap 5 mg (Altace).............................................. 65
ramipril cap 10 mg (Altace)............................................ 65
RANEXA -ranolazine tab sr 12hr 500 mg......................... 51
RANEXA -ranolazine tab sr 12hr 1000 mg....................... 51
ranitidine hcl cap 150 mg............................................... 86
ranitidine hcl cap 300 mg............................................... 86
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 86
ranitidine hcl tab 150 mg (Zantac)................................. 87
ranitidine hcl tab 300 mg (Zantac)................................. 87
RAPAFLO -silodosin cap 4 mg..........................................94
RAPAFLO -silodosin cap 8 mg..........................................94
RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 191
RAPAMUNE -sirolimus tab 0.5 mg..................................191
RAPAMUNE -sirolimus tab 1 mg.....................................191
RAPAMUNE -sirolimus tab 2 mg.....................................191
RASUVO -methotrexate soln pf auto-injector 7.5
mg/0.15ml...................................................................... 131
RASUVO -methotrexate soln pf auto-injector 10
mg/0.2ml........................................................................ 131
RASUVO -methotrexate soln pf auto-injector 12.5
mg/0.25ml...................................................................... 131
RASUVO -methotrexate soln pf auto-injector 15
mg/0.3ml........................................................................ 131
RASUVO -methotrexate soln pf auto-injector 17.5
mg/0.35ml...................................................................... 131
RASUVO -methotrexate soln pf auto-injector 20
mg/0.4ml........................................................................ 131
RASUVO -methotrexate soln pf auto-injector 22.5
mg/0.45ml...................................................................... 131
RASUVO -methotrexate soln pf auto-injector 25
mg/0.5ml........................................................................ 131
RASUVO -methotrexate soln pf auto-injector 27.5
mg/0.55ml...................................................................... 131
RASUVO -methotrexate soln pf auto-injector 30
mg/0.6ml........................................................................ 131
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RA TRUE2GO BLOOD GLUCOSE -blood glucose
monitoring kit w/ device................................................ 188
RA TRUERESULT BLOOD GLUCO -blood glucose
monitoring kit w/ device................................................ 188
RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml...........48
RAYOS -prednisone tab delayed release 1 mg................ 28
RAYOS -prednisone tab delayed release 2 mg................ 28
RAYOS -prednisone tab delayed release 5 mg................ 28
RAZADYNE ER -galantamine hydrobromide cap sr 24hr 8
mg.................................................................................. 117
RAZADYNE ER -galantamine hydrobromide cap sr 24hr
16 mg............................................................................ 117
RAZADYNE ER -galantamine hydrobromide cap sr 24hr
24 mg............................................................................ 117
RAZADYNE -galantamine hydrobromide oral soln 4 mg/
ml................................................................................... 117
RAZADYNE -galantamine hydrobromide tab 4 mg.........117
RAZADYNE -galantamine hydrobromide tab 8 mg.........117
RAZADYNE -galantamine hydrobromide tab 12 mg.......117
REACH KIDS -sodium fluoride paste 0.15%.................. 165
REALITY INSULIN SYRINGE/U -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 188
REALITY INSULIN SYRINGE/U -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 188
REALITY INSULIN SYRINGE/U -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................188
REALITY INSULIN SYRINGE/U -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................188
REBETOL -ribavirin cap 200 mg....................................... 11
REBETOL -ribavirin soln 40 mg/ml................................... 11
REBIF -interferon beta-1a soln pref syr 22 mcg/0.5ml
(12mu/ml)...................................................................... 117
REBIF -interferon beta-1a soln pref syr 44 mcg/0.5ml
(24mu/ml)...................................................................... 117
REBIF REBIDOSE -interferon beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml).................................................... 117
REBIF REBIDOSE -interferon beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml).................................................... 117
REBIF REBIDOSE TITRATION -interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml........................ 118
REBIF TITRATION PACK -interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................. 118
RECOMBINATE -antihemophilic factor (recombinant) for
inj 220-400 unit............................................................. 157
RECOMBINATE -antihemophilic factor (recombinant) for
inj 401-800 unit............................................................. 157
RECOMBINATE -antihemophilic factor (recombinant) for
inj 801-1240 unit........................................................... 157
RECOMBINATE -antihemophilic factor (recombinant) for
inj 1241-1800 unit......................................................... 157
RECOMBINATE -antihemophilic factor (recombinant) for
inj 1801-2400 unit......................................................... 157
RECOMBIVAX HB -hepatitis b vaccine (recombinant)
susp 5 mcg/0.5ml........................................................... 19
RECOMBIVAX HB -hepatitis b vaccine (recombinant)
susp 10 mcg/ml.............................................................. 19
RECOMBIVAX HB -hepatitis b vaccine (recombinant)
susp 40 mcg/ml.............................................................. 19
RECOTHROM SPRAY KIT -thrombin (recombinant) for
soln 20000 unit............................................................. 152
RECOTHROM -thrombin (recombinant) for soln 5000
unit................................................................................. 152
RECOTHROM -thrombin (recombinant) for soln 20000
unit................................................................................. 152
RECTIV -nitroglycerin oint 0.4%..................................... 166
REFUAH PLUS BLOOD GLUCOSE -blood glucose
monitoring kit w/ device................................................ 188
REGLAN -metoclopramide hcl tab 5 mg........................... 90
REGLAN -metoclopramide hcl tab 10 mg......................... 90
REGRANEX -becaplermin gel 0.01%............................. 174
RELENZA DISKHALER -zanamivir aero powder breath
activated 5 mg/blister......................................................11
RELION CONFIRM BLOOD GLUC -blood glucose
monitoring kit w/ device................................................ 188
RELION MICRO BLOOD GLUCOS -blood glucose
monitoring kit w/ device................................................ 188
RELION PRIME BLOOD GLUCOS -blood glucose
monitoring devices........................................................ 188
RELION R -insulin regular (human) inj 100 unit/ml........... 41
RELION ULTIMA BLOOD GLUCO -blood glucose
monitoring kit w/ device................................................ 188
RELISTOR -methylnaltrexone bromide inj 8 mg/0.4ml (20
mg/ml).............................................................................. 90
RELISTOR -methylnaltrexone bromide inj 12 mg/0.6ml
(20 mg/ml)....................................................................... 90
RELPAX -eletriptan hydrobromide tab 20 mg (base
equivalent)..................................................................... 133
RELPAX -eletriptan hydrobromide tab 40 mg (base
equivalent)..................................................................... 133
REMBRANDT DEEPLY WHITE+PE -sodium
monofluorophosphate paste 0.884%........................... 165
REMBRANDT INTENSE STAIN -sodium fluoride paste
0.243%.......................................................................... 165
REMBRANDT WHITENING -sodium fluoride rinse
0.02%.............................................................................165
REMERON -mirtazapine tab 15 mg................................ 100
REMERON -mirtazapine tab 30 mg................................ 100
REMERON -mirtazapine tab 45 mg................................ 100
REMERON SOLTAB -mirtazapine orally disintegrating tab
15 mg............................................................................ 100
REMERON SOLTAB -mirtazapine orally disintegrating tab
30 mg............................................................................ 100
REMERON SOLTAB -mirtazapine orally disintegrating tab
45 mg............................................................................ 100
REMODULIN -treprostinil sodium inj 1 mg/ml (base
equiv)............................................................................... 74
REMODULIN -treprostinil sodium inj 2.5 mg/ml (base
equiv)............................................................................... 74
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REMODULIN -treprostinil sodium inj 5 mg/ml (base
equiv)............................................................................... 74
REMODULIN -treprostinil sodium inj 10 mg/ml (base
equiv)............................................................................... 74
RENAGEL -sevelamer hcl tab 400 mg............................. 90
RENAGEL -sevelamer hcl tab 800 mg............................. 90
RENVELA -sevelamer carbonate packet 0.8 gm.............. 90
RENVELA -sevelamer carbonate packet 2.4 gm.............. 90
RENVELA -sevelamer carbonate tab 800 mg.................. 90
REPAGLINIDE/METFORMIN HYD -repaglinide-metformin
hcl tab 1-500 mg.............................................................40
REPAGLINIDE/METFORMIN HYD -repaglinide-metformin
hcl tab 2-500 mg.............................................................40
repaglinide tab 0.5 mg (Prandin)................................... 39
repaglinide tab 1 mg (Prandin)...................................... 39
repaglinide tab 2 mg (Prandin)...................................... 39
REPATHA -evolocumab subcutaneous soln prefilled
syringe 140 mg/ml.......................................................... 72
REPATHA SURECLICK -evolocumab subcutaneous soln
auto-injector 140 mg/ml.................................................. 72
REPREXAIN -hydrocodone-ibuprofen tab 5-200 mg...... 126
REPRONEX -menotropins for inj 75 unit.......................... 48
REQUIP -ropinirole hydrochloride tab 0.25 mg...............142
REQUIP -ropinirole hydrochloride tab 0.5 mg.................143
REQUIP -ropinirole hydrochloride tab 1 mg....................143
REQUIP -ropinirole hydrochloride tab 2 mg....................143
REQUIP -ropinirole hydrochloride tab 3 mg....................143
REQUIP -ropinirole hydrochloride tab 4 mg....................143
REQUIP -ropinirole hydrochloride tab 5 mg....................143
REQUIP XL -ropinirole hydrochloride tab sr 24hr 2 mg
(base equivalent).......................................................... 143
REQUIP XL -ropinirole hydrochloride tab sr 24hr 4 mg
(base equivalent).......................................................... 143
REQUIP XL -ropinirole hydrochloride tab sr 24hr 6 mg
(base equivalent).......................................................... 143
REQUIP XL -ropinirole hydrochloride tab sr 24hr 8 mg
(base equivalent).......................................................... 143
REQUIP XL -ropinirole hydrochloride tab sr 24hr 12 mg
(base equivalent).......................................................... 143
RESCRIPTOR -delavirdine mesylate tab 100 mg............ 12
RESCRIPTOR -delavirdine mesylate tab 200 mg............ 12
RESCULA -unoprostone isopropyl ophth soln
0.15%.............................................................................162
RESERPINE -reserpine tab 0.1 mg.................................. 65
RESERPINE -reserpine tab 0.25 mg................................ 65
RESTASIS -cyclosporine (ophth) emulsion 0.05%......... 162
RESTORIL -temazepam cap 7.5 mg.............................. 109
RESTORIL -temazepam cap 15 mg............................... 109
RESTORIL -temazepam cap 22.5 mg............................ 109
RESTORIL -temazepam cap 30 mg............................... 109
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.04%.............................................................................174
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.08%.............................................................................174
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.1%...............................................................................174
RETIN-A MICRO -tretinoin microsphere gel 0.04%........ 174
RETIN-A MICRO -tretinoin microsphere gel 0.1%.......... 174
RETIN-A -tretinoin cream 0.025%................................... 174
RETIN-A -tretinoin cream 0.05%..................................... 174
RETIN-A -tretinoin cream 0.1%....................................... 174
RETIN-A -tretinoin gel 0.01%.......................................... 174
RETIN-A -tretinoin gel 0.025%........................................ 174
RETROVIR -zidovudine cap 100 mg................................ 12
RETROVIR -zidovudine syrup 10 mg/ml.......................... 12
REVATIO -sildenafil citrate for suspension 10 mg/ml....... 74
REVATIO -sildenafil citrate iv soln 10 mg/12.5ml (base
equivalent)....................................................................... 74
REVATIO -sildenafil citrate tab 20 mg............................... 74
REVEAL BLOOD GLUCOSE MONI -blood glucose
monitoring kit w/ device................................................ 188
REVIA -naltrexone hcl tab 50 mg................................... 177
REVLIMID -lenalidomide cap 5 mg................................. 192
REVLIMID -lenalidomide cap 10 mg............................... 192
REVLIMID -lenalidomide cap 15 mg............................... 192
REVLIMID -lenalidomide cap 20 mg............................... 192
REVLIMID -lenalidomide cap 25 mg............................... 192
REVLIMID -lenalidomide caps 2.5 mg............................ 192
REXALL BLOOD GLUCOSE MONI -blood glucose
monitoring kit w/ device................................................ 188
REXULTI -brexpiprazole tab 0.25 mg............................. 105
REXULTI -brexpiprazole tab 0.5 mg............................... 105
REXULTI -brexpiprazole tab 1 mg.................................. 106
REXULTI -brexpiprazole tab 2 mg.................................. 106
REXULTI -brexpiprazole tab 3 mg.................................. 106
REXULTI -brexpiprazole tab 4 mg.................................. 106
REYATAZ -atazanavir sulfate cap 150 mg (base
equiv)............................................................................... 12
REYATAZ -atazanavir sulfate cap 200 mg (base
equiv)............................................................................... 12
REYATAZ -atazanavir sulfate cap 300 mg (base
equiv)............................................................................... 12
REYATAZ -atazanavir sulfate oral powder packet 50 mg
(base equiv).................................................................... 12
REZIRA -pseudoephedrine w/ hydrocodone soln 60-5
mg/5ml............................................................................. 79
RHEUMATREX -methotrexate sodium tab 2.5 mg
(antirheumatic).............................................................. 131
RHINOCORT AQUA -budesonide nasal susp 32 mcg/
act.................................................................................... 77
RIASTAP -fibrinogen conc (human) inj approximately 1
gm (900-1300 mg)........................................................ 157
RIBASPHERE RIBAPAK -ribavirin tab 400 mg................. 12
RIBASPHERE RIBAPAK -ribavirin tab 600 mg................. 12
RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin
tab 400 mg dose pack....................................................12
RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin
tab 600 mg dose pack....................................................12
RIBASPHERE -ribavirin tab 400 mg................................. 12
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RIBASPHERE -ribavirin tab 600 mg................................. 12
RIBATAB -ribavirin tab 400 mg......................................... 12
RIBATAB -ribavirin tab 600 mg......................................... 12
RIBATAB -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack........................................................................ 12
ribavirin cap 200 mg (Rebetol)....................................... 12
ribavirin tab 200 mg (Copegus)..................................... 12
RIDAURA -auranofin cap 3 mg....................................... 131
rifabutin cap 150 mg (Mycobutin).................................... 7
RIFADIN -rifampin cap 150 mg........................................... 7
RIFADIN -rifampin cap 300 mg........................................... 7
RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 7
rifampin cap 150 mg (Rifadin).......................................... 7
rifampin cap 300 mg (Rifadin).......................................... 7
RIFATER -isoniazid-rifampin w/ pyrazinamide tab
50-120-300 mg.................................................................. 7
RIGHTEST GM100 BLOOD GLUC -blood glucose
monitoring kit w/ device................................................ 188
RIGHTEST GM300 BLOOD GLUC -blood glucose
monitoring kit w/ device................................................ 189
RIGHTEST GM550 BLOOD GLUC -blood glucose
monitoring kit w/ device................................................ 189
RIGHTSOURCE BLOOD GLUCOSE -blood glucose
monitoring devices........................................................ 189
RILUTEK -riluzole tab 50 mg.......................................... 144
riluzole tab 50 mg (Rilutek).......................................... 144
rimantadine hydrochloride tab 100 mg
(Flumadine).................................................................... 12
RIOMET -metformin hcl oral soln 500 mg/5ml.................. 40
risedronate sodium tab delayed release 35 mg
(Atelvia).......................................................................... 48
risedronate sodium tab 5 mg (Actonel)........................ 48
risedronate sodium tab 30 mg (Actonel)...................... 48
risedronate sodium tab 35 mg (Actonel)...................... 48
risedronate sodium tab 150 mg (Actonel).................... 48
RISPERDAL CONSTA -risperidone microspheres for inj
12.5 mg......................................................................... 106
RISPERDAL CONSTA -risperidone microspheres for inj
25 mg............................................................................ 106
RISPERDAL CONSTA -risperidone microspheres for inj
37.5 mg......................................................................... 106
RISPERDAL CONSTA -risperidone microspheres for inj
50 mg............................................................................ 106
RISPERDAL M-TAB -risperidone orally disintegrating tab
0.5 mg........................................................................... 106
RISPERDAL M-TAB -risperidone orally disintegrating tab
1 mg.............................................................................. 106
RISPERDAL M-TAB -risperidone orally disintegrating tab
2 mg.............................................................................. 106
RISPERDAL M-TAB -risperidone orally disintegrating tab
3 mg.............................................................................. 106
RISPERDAL M-TAB -risperidone orally disintegrating tab
4 mg.............................................................................. 106
RISPERDAL -risperidone soln 1 mg/ml.......................... 106
RISPERDAL -risperidone tab 0.25 mg............................ 106
RISPERDAL -risperidone tab 0.5 mg.............................. 106
RISPERDAL -risperidone tab 1 mg................................. 106
RISPERDAL -risperidone tab 2 mg................................. 106
RISPERDAL -risperidone tab 3 mg................................. 106
RISPERDAL -risperidone tab 4 mg................................. 106
risperidone orally disintegrating tab 0.25 mg............ 106
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab)............................................................................ 106
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab)............................................................................ 106
risperidone orally disintegrating tab 2 mg (Risperdal
m-tab)............................................................................ 106
risperidone orally disintegrating tab 3 mg (Risperdal
m-tab)............................................................................ 106
risperidone orally disintegrating tab 4 mg (Risperdal
m-tab)............................................................................ 106
risperidone soln 1 mg/ml (Risperdal).......................... 106
risperidone tab 0.25 mg (Risperdal)............................ 106
risperidone tab 0.5 mg (Risperdal).............................. 106
risperidone tab 1 mg (Risperdal)................................. 106
risperidone tab 2 mg (Risperdal)................................. 106
risperidone tab 3 mg (Risperdal)................................. 106
risperidone tab 4 mg (Risperdal)................................. 106
RITALIN LA -methylphenidate hcl cap sr 24hr 10 mg
(la).................................................................................. 113
RITALIN LA -methylphenidate hcl cap sr 24hr 20 mg
(la).................................................................................. 113
RITALIN LA -methylphenidate hcl cap sr 24hr 30 mg
(la).................................................................................. 113
RITALIN LA -methylphenidate hcl cap sr 24hr 40 mg
(la).................................................................................. 113
RITALIN LA -methylphenidate hcl cap sr 24hr 60 mg
(la).................................................................................. 113
RITALIN -methylphenidate hcl tab 5 mg......................... 113
RITALIN -methylphenidate hcl tab 10 mg....................... 113
RITALIN -methylphenidate hcl tab 20 mg....................... 113
rivastigmine tartrate cap 1.5 mg (Exelon)...................118
rivastigmine tartrate cap 3 mg (Exelon)......................118
rivastigmine tartrate cap 4.5 mg (Exelon)...................118
rivastigmine tartrate cap 6 mg (Exelon)......................118
rivastigmine td patch 24hr 4.6 mg/24hr (Exelon)....... 118
rivastigmine td patch 24hr 9.5 mg/24hr (Exelon)....... 118
rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)..... 118
RIXUBIS -coagulation factor ix (recombinant) for inj 250
unit................................................................................. 157
RIXUBIS -coagulation factor ix (recombinant) for inj 500
unit................................................................................. 157
RIXUBIS -coagulation factor ix (recombinant) for inj 1000
unit................................................................................. 157
RIXUBIS -coagulation factor ix (recombinant) for inj 2000
unit................................................................................. 157
RIXUBIS -coagulation factor ix (recombinant) for inj 3000
unit................................................................................. 157
rizatriptan benzoate orally disintegrating tab 5 mg
(Maxalt-mlt).................................................................. 133
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rizatriptan benzoate orally disintegrating tab 10 mg
(Maxalt-mlt).................................................................. 133
rizatriptan benzoate tab 5 mg (Maxalt)........................133
rizatriptan benzoate tab 10 mg (Maxalt)......................133
ROBAXIN-750 -methocarbamol tab 750 mg...................145
ROBAXIN -methocarbamol tab 500 mg.......................... 145
ROBINUL FORTE -glycopyrrolate tab 2 mg..................... 87
ROBINUL -glycopyrrolate tab 1 mg.................................. 87
ROCALTROL -calcitriol cap 0.25 mcg...............................48
ROCALTROL -calcitriol cap 0.5 mcg.................................48
ROCALTROL -calcitriol oral soln 1 mcg/ml....................... 49
ropinirole hydrochloride tab 0.25 mg (Requip).......... 143
ropinirole hydrochloride tab 0.5 mg (Requip)............ 143
ropinirole hydrochloride tab 1 mg (Requip)............... 143
ropinirole hydrochloride tab 2 mg (Requip)............... 143
ropinirole hydrochloride tab 3 mg (Requip)............... 143
ropinirole hydrochloride tab 4 mg (Requip)............... 143
ropinirole hydrochloride tab 5 mg (Requip)............... 143
ropinirole hydrochloride tab sr 24hr 2 mg (base
equivalent) (Requip xl)............................................... 143
ropinirole hydrochloride tab sr 24hr 4 mg (base
equivalent) (Requip xl)............................................... 143
ropinirole hydrochloride tab sr 24hr 6 mg (base
equivalent) (Requip xl)............................................... 143
ropinirole hydrochloride tab sr 24hr 8 mg (base
equivalent) (Requip xl)............................................... 143
ropinirole hydrochloride tab sr 24hr 12 mg (base
equivalent) (Requip xl)............................................... 143
ROTARIX -rotavirus vaccine, live for oral susp................. 19
ROTATEQ -rotavirus vaccine, live oral pentavalent
soln.................................................................................. 19
ROWASA -mesalamine rectal enema 4 gm & cleanser
wipe kit............................................................................ 90
ROXICET -oxycodone w/ acetaminophen soln 5-325
mg/5ml........................................................................... 126
ROXICODONE -oxycodone hcl tab 5 mg....................... 126
ROXICODONE -oxycodone hcl tab 15 mg..................... 126
ROXICODONE -oxycodone hcl tab 30 mg..................... 126
ROZEREM -ramelteon tab 8 mg..................................... 109
RUCONEST -c1 esterase inhibitor (recombinant) for iv inj
2100 unit....................................................................... 157
RYDEX -pseudoephedrine-bromphen-codeine liq
10-1.33-6.33 mg/5ml....................................................... 79
RYTARY -carbidopa & levodopa cap cr 23.75-95 mg..... 143
RYTARY -carbidopa & levodopa cap cr 36.25-145
mg.................................................................................. 143
RYTARY -carbidopa & levodopa cap cr 48.75-195
mg.................................................................................. 143
RYTARY -carbidopa & levodopa cap cr 61.25-245
mg.................................................................................. 143
RYTHMOL -propafenone hcl tab 150 mg......................... 57
RYTHMOL -propafenone hcl tab 225 mg......................... 57
RYTHMOL SR -propafenone hcl cap sr 12hr 225 mg...... 57
RYTHMOL SR -propafenone hcl cap sr 12hr 325 mg...... 57
RYTHMOL SR -propafenone hcl cap sr 12hr 425 mg...... 57
S
SABRIL -vigabatrin powd pack 500 mg.......................... 139
SABRIL -vigabatrin tab 500 mg...................................... 139
SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab
3-0.03-0.451 mg..............................................................34
SAIZEN CLICK.EASY -somatropin (non-refrigerated) for
inj 8.8 mg........................................................................ 49
SAIZEN -somatropin (non-refrigerated) for inj 5 mg......... 49
SAIZEN -somatropin (non-refrigerated) for inj 8.8 mg...... 49
SALAGEN -pilocarpine hcl tab 5 mg............................... 165
SALAGEN -pilocarpine hcl tab 7.5 mg............................ 165
salicylic acid shampoo 6% (Salex).............................. 174
salsalate tab 500 mg..................................................... 119
salsalate tab 750 mg..................................................... 119
SAMSCA -tolvaptan tab 15 mg......................................... 49
SAMSCA -tolvaptan tab 30 mg......................................... 49
SANCUSO -granisetron td patch 3.1 mg/24hr (contains
34.3 mg).......................................................................... 87
SANDIMMUNE -cyclosporine cap 25 mg....................... 192
SANDIMMUNE -cyclosporine cap 100 mg..................... 192
SANDIMMUNE -cyclosporine oral soln 100 mg/ml......... 192
SANDOSTATIN LAR DEPOT -octreotide acetate for im inj
kit 10 mg......................................................................... 49
SANDOSTATIN LAR DEPOT -octreotide acetate for im inj
kit 20 mg......................................................................... 49
SANDOSTATIN LAR DEPOT -octreotide acetate for im inj
kit 30 mg......................................................................... 49
SANDOSTATIN -octreotide acetate inj 50 mcg/ml (0.05
mg/ml).............................................................................. 49
SANDOSTATIN -octreotide acetate inj 100 mcg/ml (0.1
mg/ml).............................................................................. 49
SANDOSTATIN -octreotide acetate inj 200 mcg/ml (0.2
mg/ml).............................................................................. 49
SANDOSTATIN -octreotide acetate inj 500 mcg/ml (0.5
mg/ml).............................................................................. 49
SANDOSTATIN -octreotide acetate inj 1000 mcg/ml (1
mg/ml).............................................................................. 49
SANTYL -collagenase oint 250 unit/gm.......................... 174
SAPHRIS -asenapine maleate sl tab 2.5 mg (base
equiv)............................................................................. 107
SAPHRIS -asenapine maleate sl tab 5 mg (base
equiv)............................................................................. 107
SAPHRIS -asenapine maleate sl tab 10 mg (base
equiv)............................................................................. 107
SARAFEM -fluoxetine hcl (pmdd) tab 10 mg.................. 118
SARAFEM -fluoxetine hcl (pmdd) tab 20 mg.................. 118
SAVAYSA -edoxaban tosylate tab 15 mg (base
equivalent)..................................................................... 151
SAVAYSA -edoxaban tosylate tab 30 mg (base
equivalent)..................................................................... 151
SAVAYSA -edoxaban tosylate tab 60 mg (base
equivalent)..................................................................... 151
SAVELLA -milnacipran hcl tab 12.5 mg.......................... 118
SAVELLA -milnacipran hcl tab 25 mg............................. 118
SAVELLA -milnacipran hcl tab 50 mg............................. 118
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SAVELLA -milnacipran hcl tab 100 mg........................... 118
SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg
(5) & 25 mg (8) & 50 mg (42) pak............................... 118
SEASONIQUE -levonorg-eth est tab 0.15-0.03mg(84) &
eth est tab 0.01mg(7)..................................................... 34
SECONAL -secobarbital sodium cap 100 mg................. 109
SECTRAL -acebutolol hcl cap 200 mg............................. 53
SECTRAL -acebutolol hcl cap 400 mg............................. 53
selegiline hcl cap 5 mg (Eldepryl)............................... 143
selegiline hcl tab 5 mg.................................................. 143
selenium sulfide lotion 2.5%........................................ 174
SELZENTRY -maraviroc tab 150 mg................................ 12
SELZENTRY -maraviroc tab 300 mg................................ 12
SEMPREX-D -acrivastine & pseudoephedrine cap 8-60
mg.................................................................................... 79
SENNA LEAVES -senna leaves........................................ 84
SENSIPAR -cinacalcet hcl tab 30 mg (base equiv).......... 49
SENSIPAR -cinacalcet hcl tab 60 mg (base equiv).......... 49
SENSIPAR -cinacalcet hcl tab 90 mg (base equiv).......... 49
SENSODYNE REPAIR & PROTEC -stannous fluoride
paste 0.454%................................................................ 165
SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50
mcg/dose (base equiv)................................................... 82
SEROMYCIN -cycloserine cap 250 mg.............................. 7
SEROQUEL -quetiapine fumarate tab 25 mg................. 107
SEROQUEL -quetiapine fumarate tab 50 mg................. 107
SEROQUEL -quetiapine fumarate tab 100 mg............... 107
SEROQUEL -quetiapine fumarate tab 200 mg............... 107
SEROQUEL -quetiapine fumarate tab 300 mg............... 107
SEROQUEL -quetiapine fumarate tab 400 mg............... 107
SEROQUEL XR -quetiapine fumarate tab sr 24hr 50
mg.................................................................................. 107
SEROQUEL XR -quetiapine fumarate tab sr 24hr 150
mg.................................................................................. 107
SEROQUEL XR -quetiapine fumarate tab sr 24hr 200
mg.................................................................................. 107
SEROQUEL XR -quetiapine fumarate tab sr 24hr 300
mg.................................................................................. 107
SEROQUEL XR -quetiapine fumarate tab sr 24hr 400
mg.................................................................................. 107
SEROSTIM -somatropin (non-refrigerated) for
subcutaneous inj 4 mg................................................... 49
SEROSTIM -somatropin (non-refrigerated) for
subcutaneous inj 5 mg................................................... 49
SEROSTIM -somatropin (non-refrigerated) for
subcutaneous inj 6 mg................................................... 49
sertraline hcl oral conc 20 mg/ml (Zoloft).................. 100
sertraline hcl tab 25 mg (Zoloft).................................. 100
sertraline hcl tab 50 mg (Zoloft).................................. 100
sertraline hcl tab 100 mg (Zoloft)................................ 100
SEVELAMER CARBONATE -sevelamer carbonate tab
800 mg............................................................................ 90
SFROWASA -mesalamine sulfite-free (sf) enema 4
gm/60ml........................................................................... 90
SHUR-SEAL -nonoxynol-9 gel 2%.................................... 93
SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base
equiv)............................................................................... 49
SIGNIFOR -pasireotide diaspartate inj 0.6 mg/ml (base
equiv)............................................................................... 49
SIGNIFOR -pasireotide diaspartate inj 0.9 mg/ml (base
equiv)............................................................................... 49
sildenafil citrate iv soln 10 mg/12.5ml (base
equivalent) (Revatio).................................................... 74
sildenafil citrate tab 20 mg (Revatio)............................ 75
SILENOR -doxepin hcl (sleep) tab 3 mg (base
equiv)............................................................................. 109
SILENOR -doxepin hcl (sleep) tab 6 mg (base
equiv)............................................................................. 109
SILVADENE -silver sulfadiazine cream 1%.....................174
silver sulfadiazine cream 1% (Silvadene)................... 174
SIMBRINZA -brinzolamide-brimonidine tartrate ophth
susp 1-0.2%.................................................................. 162
SIMCOR -niacin-simvastatin tab sr 24hr 500-20 mg........ 72
SIMCOR -niacin-simvastatin tab sr 24hr 500-40 mg........ 72
SIMCOR -niacin-simvastatin tab sr 24hr 750-20 mg........ 72
SIMCOR -niacin-simvastatin tab sr 24hr 1000-20 mg...... 72
SIMCOR -niacin-simvastatin tab sr 24hr 1000-40 mg...... 72
SIMPONI -golimumab subcutaneous soln auto-injector 50
mg/0.5ml........................................................................ 131
SIMPONI -golimumab subcutaneous soln auto-injector
100 mg/ml..................................................................... 132
SIMPONI -golimumab subcutaneous soln prefilled syringe
50 mg/0.5ml.................................................................. 132
SIMPONI -golimumab subcutaneous soln prefilled syringe
100 mg/ml..................................................................... 132
simvastatin tab 5 mg (Zocor)......................................... 72
simvastatin tab 10 mg (Zocor)....................................... 72
simvastatin tab 20 mg (Zocor)....................................... 72
simvastatin tab 40 mg (Zocor)....................................... 72
simvastatin tab 80 mg (Zocor)....................................... 72
SINEMET -carbidopa & levodopa tab 10-100 mg........... 143
SINEMET -carbidopa & levodopa tab 25-100 mg........... 143
SINEMET -carbidopa & levodopa tab 25-250 mg........... 143
SINEMET CR -carbidopa & levodopa tab cr 25-100
mg.................................................................................. 143
SINEMET CR -carbidopa & levodopa tab cr 50-200
mg.................................................................................. 143
SINGLE-LET -lancets...................................................... 189
SINGULAIR -montelukast sodium chew tab 4 mg (base
equiv)............................................................................... 82
SINGULAIR -montelukast sodium chew tab 5 mg (base
equiv)............................................................................... 82
SINGULAIR -montelukast sodium oral granules packet 4
mg (base equiv).............................................................. 82
SINGULAIR -montelukast sodium tab 10 mg (base
equiv)............................................................................... 82
sirolimus tab 0.5 mg (Rapamune)............................... 192
sirolimus tab 1 mg (Rapamune).................................. 192
sirolimus tab 2 mg (Rapamune).................................. 192
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SIRTURO -bedaquiline fumarate tab 100 mg (base
equiv)................................................................................. 7
SITAVIG -acyclovir buccal tab 50 mg................................ 12
SIVEXTRO -tedizolid phosphate tab 200 mg....................15
SKELAXIN -metaxalone tab 800 mg............................... 145
SKLICE -ivermectin lotion 0.5%...................................... 174
SMART DIABETES XPRES BLOO -blood glucose
monitoring kit w/ device................................................ 189
SMARTEST EJECT BLOOD GLUC -blood glucose
monitoring devices........................................................ 189
SMARTEST EJECT STARTER KI -blood glucose
monitoring kit w/ device................................................ 189
SMARTEST PERSONA STARTER -blood glucose
monitoring kit w/ device................................................ 189
SMARTEST PRONTO STARTER -blood glucose
monitoring kit w/ device................................................ 189
SMARTEST PROTEGE BLOOD GL -blood glucose
monitoring devices........................................................ 189
SMARTEST PROTEGE STARTER -blood glucose
monitoring kit w/ device................................................ 189
SMART SENSE PREMIUM BLOOD -blood glucose
monitoring kit w/ device................................................ 189
SMART SENSE VALUE BLOOD -blood glucose
monitoring kit w/ device................................................ 189
SM GLUCOSE -glucose chew tab 4 gm........................... 40
SODIUM BICARBONATE -sodium bicarbonate
powder............................................................................. 84
sodium chloride tab 1 gm.............................................147
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride)......................................................................... 147
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride)......................................................................... 147
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride)......................................................................... 147
sodium fluoride cream 1.1% (Prevident 5000
plus).............................................................................. 165
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)........................................................................ 165
sodium fluoride paste 1.1% (Prevident 5000
boost)............................................................................ 165
sodium fluoride-potassium nitrate paste 1.1-5%
(Prevident 5000 sensi)............................................... 165
sodium fluoride rinse 0.05%.........................................165
sodium fluoride rinse 0.0221% (0.01% f).................... 165
sodium fluoride rinse 0.2% (Prevident)...................... 165
SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from
1.1 mg naf)....................................................................147
SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from
2.2 mg naf)....................................................................147
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf)................................................................................ 147
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride)......................................................................... 147
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl)...................................................................... 49
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps).............................................................................. 192
sodium polystyrene sulfonate powder
(Kayexalate)................................................................. 192
sodium polystyrene sulfonate rectal susp 30
gm/120ml...................................................................... 192
SOLARAZE -diclofenac sodium (actinic keratoses) gel
3%.................................................................................. 175
SOLODYN -minocycline hcl tab sr 24hr 55 mg.................. 5
SOLODYN -minocycline hcl tab sr 24hr 65 mg.................. 5
SOLODYN -minocycline hcl tab sr 24hr 80 mg.................. 5
SOLODYN -minocycline hcl tab sr 24hr 105 mg................ 5
SOLODYN -minocycline hcl tab sr 24hr 115 mg................. 5
SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base
equivalent)....................................................................... 24
SOLUS V2 AUDIBLE BLOOD GL -blood glucose
monitoring devices........................................................ 189
SOLUS V2 AUDIBLE BLOOD GL -blood glucose
monitoring kit w/ device................................................ 189
SOMA -carisoprodol tab 250 mg..................................... 145
SOMA -carisoprodol tab 350 mg..................................... 145
SOMAVERT -pegvisomant for inj 10 mg (as protein)....... 49
SOMAVERT -pegvisomant for inj 15 mg (as protein)....... 49
SOMAVERT -pegvisomant for inj 20 mg (as protein)....... 49
SOMAVERT -pegvisomant for inj 25 mg (as protein)....... 49
SOMAVERT -pegvisomant for inj 30 mg (as protein)....... 49
SONATA -zaleplon cap 5 mg.......................................... 109
SONATA -zaleplon cap 10 mg........................................ 109
SOOLANTRA -ivermectin cream 1%.............................. 175
SORIATANE -acitretin cap 10 mg................................... 175
SORIATANE -acitretin cap 17.5 mg................................ 175
SORIATANE -acitretin cap 25 mg................................... 175
SORILUX -calcipotriene foam 0.005%............................ 175
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 53
sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 53
sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 53
sotalol hcl tab 240 mg.....................................................53
sotalol hcl tab 80 mg (Betapace)................................... 53
sotalol hcl tab 120 mg (Betapace)................................. 53
sotalol hcl tab 160 mg (Betapace)................................. 53
SOTYLIZE -sotalol hcl oral solution 5 mg/ml.................... 53
SOVALDI -sofosbuvir tab 400 mg..................................... 12
SPATONE PUR-ABSORB IRON -ferrous sulfate liquid 5
mg/20ml (elemental iron)..............................................150
SPECTRACEF -cefditoren pivoxil tab 200 mg (base
equivalent)......................................................................... 3
SPECTRACEF -cefditoren pivoxil tab 400 mg (base
equivalent)......................................................................... 3
SPINOSAD -spinosad susp 0.9%................................... 175
SPIRIVA HANDIHALER -tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)....................................... 82
SPIRIVA RESPIMAT -tiotropium bromide monohydrate
inhal aerosol 1.25 mcg/act............................................. 82
SPIRIVA RESPIMAT -tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act............................................... 82
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide).................................................................. 68
spironolactone tab 25 mg (Aldactone).......................... 68
spironolactone tab 50 mg (Aldactone).......................... 68
spironolactone tab 100 mg (Aldactone)........................ 68
SPORANOX -itraconazole cap 100 mg.............................. 8
SPORANOX -itraconazole oral soln 10 mg/ml....................8
SPORANOX PULSEPAK -itraconazole cap 100 mg.......... 8
SPRIX -ketorolac tromethamine nasal spray 15.75 mg/
spray.............................................................................. 132
SPRYCEL -dasatinib tab 20 mg........................................ 24
SPRYCEL -dasatinib tab 50 mg........................................ 24
SPRYCEL -dasatinib tab 70 mg........................................ 24
SPRYCEL -dasatinib tab 80 mg........................................ 24
SPRYCEL -dasatinib tab 100 mg...................................... 24
SPRYCEL -dasatinib tab 140 mg...................................... 25
STALEVO 100 -carbidopa-levodopa-entacapone tabs
25-100-200 mg..............................................................144
STALEVO 125 -carbidopa-levodopa-entacapone tabs
31.25-125-200 mg........................................................ 144
STALEVO 150 -carbidopa-levodopa-entacapone tabs
37.5-150-200 mg.......................................................... 144
STALEVO 200 -carbidopa-levodopa-entacapone tabs
50-200-200 mg..............................................................144
STALEVO 50 -carbidopa-levodopa-entacapone tabs
12.5-50-200 mg.............................................................144
STALEVO 75 -carbidopa-levodopa-entacapone tabs
18.75-75-200 mg.......................................................... 144
stannous fluoride conc 0.63% (Gel-kam oral care
ri)................................................................................... 165
stannous fluoride gel 0.4%........................................... 165
STANNOUS FLUORIDE RINSE -stannous fluoride liq
0.1%...............................................................................165
STARLIX -nateglinide tab 60 mg....................................... 40
STARLIX -nateglinide tab 120 mg..................................... 40
STATUSS GREEN -codeine-pseudoephedrinechlorcyclizine liq 9-30-12.5 mg/5ml................................ 79
stavudine cap 15 mg (Zerit)............................................12
stavudine cap 20 mg (Zerit)............................................12
stavudine cap 30 mg (Zerit)............................................12
stavudine cap 40 mg (Zerit)............................................12
stavudine for oral soln 1 mg/ml (Zerit)......................... 12
STAVZOR -valproic acid cap delayed release 125
mg.................................................................................. 139
STAVZOR -valproic acid cap delayed release 250
mg.................................................................................. 139
STAVZOR -valproic acid cap delayed release 500
mg.................................................................................. 139
STAXYN -vardenafil hcl orally disintegrating tab 10
mg............................................................................... 75,75
STELARA -ustekinumab soln prefilled syringe 45
mg/0.5ml........................................................................ 175
STELARA -ustekinumab soln prefilled syringe 90 mg/
ml................................................................................... 175
STENDRA -avanafil tab 50 mg.................................... 75,75
STENDRA -avanafil tab 100 mg.................................. 75,75
STENDRA -avanafil tab 200 mg.................................. 75,75
STIMATE -desmopressin acetate nasal soln 1.5 mg/
ml..................................................................................... 49
STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aero
soln 2.5-2.5 mcg/act....................................................... 82
STIVARGA -regorafenib tab 40 mg................................... 25
STRATTERA -atomoxetine hcl cap 10 mg (base
equiv)............................................................................. 113
STRATTERA -atomoxetine hcl cap 18 mg (base
equiv)............................................................................. 113
STRATTERA -atomoxetine hcl cap 25 mg (base
equiv)............................................................................. 113
STRATTERA -atomoxetine hcl cap 40 mg (base
equiv)............................................................................. 113
STRATTERA -atomoxetine hcl cap 60 mg (base
equiv)............................................................................. 113
STRATTERA -atomoxetine hcl cap 80 mg (base
equiv)............................................................................. 113
STRATTERA -atomoxetine hcl cap 100 mg (base
equiv)............................................................................. 113
STRENSIQ -asfotase alfa subcutaneous inj 18
mg/0.45ml........................................................................ 49
STRENSIQ -asfotase alfa subcutaneous inj 28
mg/0.7ml.......................................................................... 49
STRENSIQ -asfotase alfa subcutaneous inj 40 mg/ml..... 49
STRENSIQ -asfotase alfa subcutaneous inj 80
mg/0.8ml.......................................................................... 50
STRIANT -testosterone buccal mucoadhesive system 30
mg.................................................................................... 28
STRIBILD -elvitegrav-cobicis-emtricitab-tenofov tab
150-150-200-300 mg...................................................... 12
STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln
2.5 mcg/act (base equiv)................................................ 82
STROMECTOL -ivermectin tab 3 mg................................14
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5
mg (base equiv)............................................................ 127
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv)............................................................ 127
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 8-2
mg (base equiv)............................................................ 127
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 12-3
mg (base equiv)............................................................ 127
SUBSYS -fentanyl sublingual spray 100 mcg................. 127
SUBSYS -fentanyl sublingual spray 200 mcg................. 127
SUBSYS -fentanyl sublingual spray 400 mcg................. 127
SUBSYS -fentanyl sublingual spray 600 mcg................. 127
SUBSYS -fentanyl sublingual spray 800 mcg................. 127
SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x
2).................................................................................... 127
SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x
2).................................................................................... 127
SUCRAID -sacrosidase soln 8500 unit/ml........................ 88
sucralfate tab 1 gm (Carafate)....................................... 87
SULAR -nisoldipine tab sr 24hr 8.5 mg............................ 56
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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SULAR -nisoldipine tab sr 24hr 17 mg............................. 56
SULAR -nisoldipine tab sr 24hr 34 mg............................. 56
sulfacetamide sodium lotion 10% (acne) (Klaron)..... 175
sulfacetamide sodium ophth soln 10%
(Bleph-10)..................................................................... 162
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%............................................................. 162
SULFACETAMIDE SODIUM -sulfacetamide sodium ophth
oint 10%........................................................................ 162
sulfacetamide sodium w/ sulfur cream 10-5%........... 175
sulfacetamide sodium w/ sulfur wash 9-4.5%
(Sumadan wash)......................................................... 175
SULFADIAZINE -sulfadiazine tab 500 mg.......................... 7
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml............................................................................ 15
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)......................................................................... 15
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds)................................................................... 15
SULFAMYLON -mafenide acetate cream 85 mg/gm...... 175
SULFAMYLON -mafenide acetate packet for topical soln
5% (50 gm)................................................................... 175
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 91
sulfasalazine tab 500 mg (Azulfidine)........................... 91
sulindac tab 150 mg...................................................... 132
sulindac tab 200 mg...................................................... 132
sumatriptan succinate inj 6 mg/0.5ml (Imitrex).......... 133
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)............................... 133
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)............................... 133
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref).................................................. 133
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref).................................................. 133
SUMATRIPTAN SUCCINATE -sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml........................... 133
sumatriptan succinate tab 25 mg (Imitrex)................. 133
sumatriptan succinate tab 50 mg (Imitrex)................. 133
sumatriptan succinate tab 100 mg (Imitrex)............... 133
SUMATRIPTAN -sumatriptan nasal spray 5 mg/act....... 133
SUMATRIPTAN -sumatriptan nasal spray 20 mg/act..... 133
SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 4 mg/0.5ml....................................................... 134
SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 6 mg/0.5ml....................................................... 134
SUPER DAILY D3 -cholecalciferol drops 1000 unit/0.03ml
(per drop)...................................................................... 146
SUPRAX -cefixime cap 400 mg.......................................... 3
SUPRAX -cefixime chew tab 100 mg................................. 3
SUPRAX -cefixime chew tab 200 mg................................. 3
SUPRAX -cefixime for susp 100 mg/5ml............................ 3
SUPRAX -cefixime for susp 200 mg/5ml............................ 3
SUPRAX -cefixime for susp 500 mg/5ml............................ 3
SUPREME II CONFIDENCE PAD -blood glucose
monitoring misc............................................................. 189
SUPREP BOWEL PREP -sodium sulfate-potassium
sulfate-magnesium sulfate oral soln.............................. 84
SURECHEK BLOOD GLUCOSE MO -blood glucose
monitoring devices........................................................ 189
SURECHEK BLOOD GLUCOSE MO -blood glucose
monitoring kit w/ device................................................ 189
SURE EDGE BLOOD GLUCOSE M -blood glucose
monitoring devices........................................................ 189
SURESTEP PRO LINEARITY KI -blood glucose
monitoring misc............................................................. 189
SURE-TEST EASYPLUS MINI S -blood glucose
monitoring devices........................................................ 189
SURFAXIN -lucinactant intratracheal susp 30 mg/ml....... 83
SURMONTIL -trimipramine maleate cap 25 mg............. 100
SURMONTIL -trimipramine maleate cap 50 mg............. 100
SURMONTIL -trimipramine maleate cap 100 mg........... 100
SURVANTA INTRATRACHEAL -beractant in nacl 0.9%
intratracheal susp 25 mg/ml........................................... 83
SUSTIVA -efavirenz cap 50 mg........................................ 12
SUSTIVA -efavirenz cap 200 mg...................................... 12
SUSTIVA -efavirenz tab 600 mg....................................... 12
SUTENT -sunitinib malate cap 12.5 mg (base
equivalent)....................................................................... 25
SUTENT -sunitinib malate cap 25 mg (base
equivalent)....................................................................... 25
SUTENT -sunitinib malate cap 37.5 mg (base
equivalent)....................................................................... 25
SUTENT -sunitinib malate cap 50 mg (base
equivalent)....................................................................... 25
SYLATRON -peginterferon alfa-2b for inj kit 200 mcg...... 25
SYLATRON -peginterferon alfa-2b for inj kit 300 mcg...... 25
SYLATRON -peginterferon alfa-2b for inj kit 600 mcg...... 25
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act................................................... 82
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act................................................. 82
SYMBYAX -olanzapine-fluoxetine hcl cap 3-25 mg........ 118
SYMBYAX -olanzapine-fluoxetine hcl cap 6-25 mg........ 118
SYMBYAX -olanzapine-fluoxetine hcl cap 6-50 mg........ 118
SYMBYAX -olanzapine-fluoxetine hcl cap 12-25 mg...... 118
SYMBYAX -olanzapine-fluoxetine hcl cap 12-50 mg...... 118
SYMLINPEN 120 -pramlintide acetate pen-inj 2700
mcg/2.7ml (1000 mcg/ml)............................................... 40
SYMLINPEN 60 -pramlintide acetate pen-inj 1500
mcg/1.5ml (1000 mcg/ml)............................................... 40
SYNALAR -fluocinolone acetonide cream 0.025%......... 175
SYNALAR -fluocinolone acetonide oint 0.025%............. 175
SYNALAR -fluocinolone acetonide soln 0.01%.............. 175
SYNALGOS-DC -aspirin-caffeine-dihydrocodeine cap
356.4-30-16 mg.............................................................127
SYNAREL -nafarelin acetate nasal soln 2 mg/ml............. 50
SYNERA -lidocaine-tetracaine topical patch 70-70
mg.................................................................................. 175
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SYNJARDY -empagliflozin-metformin hcl tab 12.5-1000
mg.................................................................................... 40
SYNJARDY -empagliflozin-metformin hcl tab 12.5-500
mg.................................................................................... 40
SYNJARDY -empagliflozin-metformin hcl tab 5-500
mg.................................................................................... 40
SYNJARDY -empagliflozin-metformin hcl tab 5-1000
mg.................................................................................... 40
SYNTHROID -levothyroxine sodium tab 25 mcg.............. 43
SYNTHROID -levothyroxine sodium tab 50 mcg.............. 43
SYNTHROID -levothyroxine sodium tab 75 mcg.............. 43
SYNTHROID -levothyroxine sodium tab 88 mcg.............. 43
SYNTHROID -levothyroxine sodium tab 100 mcg............ 43
SYNTHROID -levothyroxine sodium tab 112 mcg............ 43
SYNTHROID -levothyroxine sodium tab 125 mcg............ 43
SYNTHROID -levothyroxine sodium tab 137 mcg............ 43
SYNTHROID -levothyroxine sodium tab 150 mcg............ 43
SYNTHROID -levothyroxine sodium tab 175 mcg............ 43
SYNTHROID -levothyroxine sodium tab 200 mcg............ 43
SYNTHROID -levothyroxine sodium tab 300 mcg............ 43
SYPRINE -trientine hcl cap 250 mg................................ 192
T
TABLOID -thioguanine tab 40 mg..................................... 25
TACLONEX -calcipotriene-betamethasone dipropionate
oint 0.005-0.064%......................................................... 175
TACLONEX -calcipotriene-betamethasone dipropionate
susp 0.005-0.064%....................................................... 175
tacrolimus cap 0.5 mg (Prograf).................................. 192
tacrolimus cap 1 mg (Prograf)..................................... 192
tacrolimus cap 5 mg (Prograf)..................................... 192
tacrolimus oint 0.03% (Protopic)................................. 175
tacrolimus oint 0.1% (Protopic)................................... 175
TAFINLAR -dabrafenib mesylate cap 50 mg (base
equivalent)....................................................................... 25
TAFINLAR -dabrafenib mesylate cap 75 mg (base
equivalent)....................................................................... 25
TAGRISSO -osimertinib mesylate tab 40 mg (base
equivalent)....................................................................... 25
TAGRISSO -osimertinib mesylate tab 80 mg (base
equivalent)....................................................................... 25
TAMIFLU -oseltamivir phosphate cap 30 mg (base
equiv)............................................................................... 12
TAMIFLU -oseltamivir phosphate cap 45 mg (base
equiv)............................................................................... 12
TAMIFLU -oseltamivir phosphate cap 75 mg (base
equiv)............................................................................... 12
TAMIFLU -oseltamivir phosphate for susp 6 mg/ml (base
equiv)............................................................................... 12
tamoxifen citrate tab 10 mg (base equivalent)............. 25
tamoxifen citrate tab 20 mg (base equivalent)............. 25
tamsulosin hcl cap 0.4 mg (Flomax)............................. 94
TANZEUM -albiglutide for soln pen-injector 30 mg........... 40
TANZEUM -albiglutide for soln pen-injector 50 mg........... 40
TAPAZOLE -methimazole tab 5 mg.................................. 43
TAPAZOLE -methimazole tab 10 mg................................ 43
TARCEVA -erlotinib hcl tab 25 mg (base equivalent)....... 25
TARCEVA -erlotinib hcl tab 100 mg (base equivalent)..... 25
TARCEVA -erlotinib hcl tab 150 mg (base equivalent)..... 25
TARGADOX -doxycycline hyclate tab 50 mg...................... 5
TARGRETIN -bexarotene cap 75 mg................................25
TARGRETIN -bexarotene gel 1%....................................175
TARKA -trandolapril-verapamil hcl tab cr 1-240 mg..........65
TARKA -trandolapril-verapamil hcl tab cr 2-180 mg..........65
TARKA -trandolapril-verapamil hcl tab cr 2-240 mg..........65
TARKA -trandolapril-verapamil hcl tab cr 4-240 mg..........65
TASIGNA -nilotinib hcl cap 150 mg (base equivalent)...... 25
TASIGNA -nilotinib hcl cap 200 mg (base equivalent)...... 25
TASMAR -tolcapone tab 100 mg.....................................144
TAZORAC -tazarotene cream 0.05%.............................. 175
TAZORAC -tazarotene cream 0.1%................................ 175
TAZORAC -tazarotene gel 0.05%................................... 175
TAZORAC -tazarotene gel 0.1%..................................... 175
TECFIDERA -dimethyl fumarate capsule delayed release
120 mg.......................................................................... 118
TECFIDERA -dimethyl fumarate capsule delayed release
240 mg.......................................................................... 118
TECFIDERA STARTER PACK -dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg................... 118
TECHNIVIE -ombitasvir-paritaprevir-ritonavir tab
12.5-75-50 mg................................................................. 13
TEGRETOL -carbamazepine susp 100 mg/5ml............. 139
TEGRETOL -carbamazepine tab 200 mg....................... 139
TEGRETOL-XR -carbamazepine tab sr 12hr 100
mg.................................................................................. 139
TEGRETOL-XR -carbamazepine tab sr 12hr 200
mg.................................................................................. 139
TEGRETOL-XR -carbamazepine tab sr 12hr 400
mg.................................................................................. 139
TEKTURNA -aliskiren fumarate tab 150 mg (base
equivalent)....................................................................... 65
TEKTURNA -aliskiren fumarate tab 300 mg (base
equivalent)....................................................................... 65
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
150-12.5 mg.................................................................... 65
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
150-25 mg....................................................................... 65
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
300-12.5 mg.................................................................... 65
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
300-25 mg....................................................................... 65
TELCARE BLOOD GLUCOSE MON -blood glucose
monitoring kit w/ device................................................ 189
telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 65
telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 65
telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 65
telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 65
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)................................................................. 65
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)................................................................. 65
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
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telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)................................................................. 65
telmisartan tab 20 mg (Micardis)................................... 65
telmisartan tab 40 mg (Micardis)................................... 65
telmisartan tab 80 mg (Micardis)................................... 65
temazepam cap 7.5 mg (Restoril)................................ 109
temazepam cap 15 mg (Restoril)................................. 109
temazepam cap 22.5 mg (Restoril).............................. 109
temazepam cap 30 mg (Restoril)................................. 109
TEMODAR -temozolomide cap 5 mg................................ 25
TEMODAR -temozolomide cap 20 mg.............................. 25
TEMODAR -temozolomide cap 100 mg............................ 25
TEMODAR -temozolomide cap 140 mg............................ 25
TEMODAR -temozolomide cap 180 mg............................ 25
TEMODAR -temozolomide cap 250 mg............................ 25
TEMODAR -temozolomide for iv soln 100 mg.................. 25
TEMOVATE -clobetasol propionate cream 0.05%.......... 175
TEMOVATE -clobetasol propionate gel 0.05%............... 175
TEMOVATE -clobetasol propionate oint 0.05%.............. 175
TEMOVATE -clobetasol propionate soln 0.05%..............175
TEMOVATE E -clobetasol propionate emollient base
cream 0.05%................................................................. 175
temozolomide cap 5 mg (Temodar)............................... 25
temozolomide cap 20 mg (Temodar)............................. 25
temozolomide cap 100 mg (Temodar)........................... 25
temozolomide cap 140 mg (Temodar)........................... 25
temozolomide cap 180 mg (Temodar)........................... 25
temozolomide cap 250 mg (Temodar)........................... 25
TENEX -guanfacine hcl tab 1 mg..................................... 65
TENEX -guanfacine hcl tab 2 mg..................................... 65
TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu......... 20
TENORETIC 100 -atenolol & chlorthalidone tab 100-25
mg.................................................................................... 65
TENORETIC 50 -atenolol & chlorthalidone tab 50-25
mg.................................................................................... 65
TENORMIN -atenolol tab 25 mg....................................... 53
TENORMIN -atenolol tab 50 mg....................................... 53
TENORMIN -atenolol tab 100 mg..................................... 53
TERAZOL 3 -terconazole vaginal cream 0.8%................. 93
TERAZOL 7 -terconazole vaginal cream 0.4%................. 93
terazosin hcl cap 1 mg....................................................65
terazosin hcl cap 2 mg....................................................65
terazosin hcl cap 5 mg....................................................65
terazosin hcl cap 10 mg..................................................66
terbinafine hcl tab 250 mg (Lamisil)................................ 8
terbutaline sulfate tab 2.5 mg........................................ 82
terbutaline sulfate tab 5 mg........................................... 82
terconazole vaginal cream 0.4% (Terazol 7)................. 93
terconazole vaginal cream 0.8% (Terazol 3)................. 93
terconazole vaginal suppos 80 mg............................... 93
TESSALON PERLES -benzonatate cap 100 mg.............. 79
TESTIM -testosterone td gel 50 mg/5gm (1%)................. 28
TESTONE CIK -testosterone cypionate im inj in oil 200
mg/ml kit.......................................................................... 28
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................. 29
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................. 29
testosterone enanthate im inj in oil 200 mg/ml............ 29
TESTOSTERONE PUMP -testosterone td gel 12.5 mg/act
(1%)................................................................................. 29
testosterone td gel 12.5 mg/act (1%) (Androgel
pump).............................................................................. 29
testosterone td gel 25 mg/2.5gm (1%) (Androgel)....... 29
testosterone td gel 50 mg/5gm (1%) (Androgel).......... 29
TESTOSTERONE -testosterone td gel 10mg/act
(2%)................................................................................. 29
TESTOSTERONE -testosterone td gel 25 mg/2.5gm
(1%)................................................................................. 29
TESTOSTERONE -testosterone td gel 50 mg/5gm
(1%)................................................................................. 29
TESTRED -methyltestosterone cap 10 mg....................... 29
TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria
toxoids (td) inj 2-2 lf/0.5ml.............................................. 20
tetrabenazine tab 12.5 mg (Xenazine)......................... 118
tetrabenazine tab 25 mg (Xenazine)............................ 118
TETRACYCLINE HCL -tetracycline hcl cap 250 mg...........5
TETRACYCLINE HCL -tetracycline hcl cap 500 mg...........5
TEVETEN -eprosartan mesylate tab 600 mg....................66
TEV-TROPIN -somatropin for subcutaneous inj 5 mg...... 50
TEXACORT -hydrocortisone soln 2.5%.......................... 175
TGT BLOOD GLUCOSE METER M -blood glucose
monitoring kit w/ device................................................ 189
TGT BLOOD GLUCOSE MONITOR -blood glucose
monitoring kit w/ device................................................ 189
THALOMID -thalidomide cap 50 mg............................... 192
THALOMID -thalidomide cap 100 mg............................. 192
THALOMID -thalidomide cap 150 mg............................. 192
THALOMID -thalidomide cap 200 mg............................. 192
theophylline soln 80 mg/15ml........................................ 82
theophylline tab sr 12hr 100 mg.................................... 82
theophylline tab sr 12hr 200 mg.................................... 82
theophylline tab sr 12hr 300 mg.................................... 83
theophylline tab sr 12hr 450 mg.................................... 83
theophylline tab sr 24hr 400 mg.................................... 83
theophylline tab sr 24hr 600 mg.................................... 83
THEO-24 -theophylline cap sr 24hr 100 mg..................... 82
THEO-24 -theophylline cap sr 24hr 200 mg..................... 82
THEO-24 -theophylline cap sr 24hr 300 mg..................... 82
THEO-24 -theophylline cap sr 24hr 400 mg..................... 82
THERA-FLUR-N -sodium fluoride gel 1.1% (0.5% f)...... 165
thiamine hcl inj 100 mg/ml........................................... 146
THIOLA -tiopronin tab 100 mg.......................................... 94
thioridazine hcl tab 10 mg............................................ 107
thioridazine hcl tab 25 mg............................................ 107
thioridazine hcl tab 50 mg............................................ 107
thioridazine hcl tab 100 mg.......................................... 107
thiothixene cap 1 mg..................................................... 107
thiothixene cap 2 mg..................................................... 107
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thiothixene cap 5 mg..................................................... 107
thiothixene cap 10 mg...................................................107
THROMBATE III W/10 ML STE -antithrombin iii (human)
for inj 500 unit............................................................... 157
THROMBATE III W/20 ML STE -antithrombin iii (human)
for inj 1000 unit............................................................. 157
THROMBIN-JMI DILUENT -thrombin for soln 5000
unit................................................................................. 152
THROMBIN-JMI DILUENT -thrombin for soln 20000
unit................................................................................. 152
THROMBIN-JMI EPISTAXIS -thrombin for soln kit 5000
unit................................................................................. 152
THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit
5000 unit....................................................................... 152
THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit
20000 unit..................................................................... 152
THROMBIN-JMI W/DIL SPRAY -thrombin for soln kit
20000 unit..................................................................... 152
thyroid tab 30 mg (1/2 grain) (Armour thyroid)............ 43
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)......... 43
thyroid tab 60 mg (1 grain) (Armour thyroid)............... 43
THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25
mcg)................................................................................. 43
THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5
mcg)................................................................................. 43
THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg)......43
THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100
mcg)................................................................................. 43
THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150
mcg)................................................................................. 43
tiagabine hcl tab 2 mg (Gabitril).................................. 139
tiagabine hcl tab 4 mg (Gabitril).................................. 140
TIAZAC -diltiazem hcl extended release beads cap sr
24hr 120 mg....................................................................56
TIAZAC -diltiazem hcl extended release beads cap sr
24hr 180 mg....................................................................56
TIAZAC -diltiazem hcl extended release beads cap sr
24hr 240 mg....................................................................56
TIAZAC -diltiazem hcl extended release beads cap sr
24hr 300 mg....................................................................56
TIAZAC -diltiazem hcl extended release beads cap sr
24hr 360 mg....................................................................56
TIAZAC -diltiazem hcl extended release beads cap sr
24hr 420 mg....................................................................56
TIGAN -trimethobenzamide hcl cap 300 mg..................... 87
TIKOSYN -dofetilide cap 125 mcg (0.125 mg)................. 57
TIKOSYN -dofetilide cap 250 mcg (0.25 mg)................... 57
TIKOSYN -dofetilide cap 500 mcg (0.5 mg)..................... 57
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe)................................................................ 162
timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe)................................................................ 162
timolol maleate ophth soln 0.25% (Timoptic)............. 162
timolol maleate ophth soln 0.5% (Timoptic)............... 162
TIMOLOL MALEATE -timolol maleate tab 5 mg............... 53
TIMOLOL MALEATE -timolol maleate tab 10 mg............. 53
TIMOLOL MALEATE -timolol maleate tab 20 mg............. 53
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.25%.......................................................... 162
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.5%............................................................ 162
TIMOPTIC -timolol maleate ophth soln 0.25%................162
TIMOPTIC -timolol maleate ophth soln 0.5%..................162
TIMOPTIC-XE -timolol maleate ophth gel forming soln
0.25%.............................................................................162
TIMOPTIC-XE -timolol maleate ophth gel forming soln
0.5%...............................................................................162
TINDAMAX -tinidazole tab 250 mg................................... 15
TINDAMAX -tinidazole tab 500 mg................................... 15
tinidazole tab 250 mg (Tindamax)..................................15
tinidazole tab 500 mg (Tindamax)..................................15
TIROSINT -levothyroxine sodium cap 13 mcg..................43
TIROSINT -levothyroxine sodium cap 25 mcg..................43
TIROSINT -levothyroxine sodium cap 50 mcg..................44
TIROSINT -levothyroxine sodium cap 75 mcg..................44
TIROSINT -levothyroxine sodium cap 88 mcg..................44
TIROSINT -levothyroxine sodium cap 100 mcg................44
TIROSINT -levothyroxine sodium cap 112 mcg................ 44
TIROSINT -levothyroxine sodium cap 125 mcg................44
TIROSINT -levothyroxine sodium cap 137 mcg................44
TIROSINT -levothyroxine sodium cap 150 mcg................44
TISSEEL -fibrin sealant component kit 2 ml................... 152
TISSEEL -fibrin sealant component kit 4 ml................... 152
TISSEEL -fibrin sealant component kit 10 ml................. 152
TISSEEL -fibrin sealant component solution.................. 152
TISSEEL VH -fibrin sealant component kit 2 ml............. 152
TISSEEL VH -fibrin sealant component kit 4 ml............. 152
TISSEEL VH -fibrin sealant component kit 10 ml........... 152
TIVICAY -dolutegravir sodium tab 50 mg (base equiv)..... 13
TIVORBEX -indomethacin cap 20 mg............................ 132
TIVORBEX -indomethacin cap 40 mg............................ 132
tizanidine hcl cap 2 mg (base equivalent)
(Zanaflex)......................................................................145
tizanidine hcl cap 4 mg (base equivalent)
(Zanaflex)......................................................................145
tizanidine hcl cap 6 mg (base equivalent)
(Zanaflex)......................................................................145
tizanidine hcl tab 2 mg (base equivalent)................... 145
tizanidine hcl tab 4 mg (base equivalent)
(Zanaflex)......................................................................145
TOBI PODHALER -tobramycin inhal cap 28 mg.................7
TOBI -tobramycin nebu soln 300 mg/5ml........................... 7
TOBRADEX ST -tobramycin-dexamethasone ophth susp
0.3-0.05%...................................................................... 162
TOBRADEX -tobramycin-dexamethasone ophth oint
0.3-0.1%........................................................................ 162
TOBRADEX -tobramycin-dexamethasone ophth susp
0.3-0.1%........................................................................ 162
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex).................................................................... 162
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tobramycin nebu soln 300 mg/5ml (Tobi)....................... 7
tobramycin ophth soln 0.3% (Tobrex)......................... 162
tobramycin sulfate for inj 1.2 gm.....................................7
tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml).............. 7
tobramycin sulfate inj 2 gm/50ml (40 mg/ml)................. 7
tobramycin sulfate inj 10 mg/ml...................................... 7
tobramycin sulfate inj 80 mg/2ml (40 mg/ml)................. 7
TOBREX -tobramycin ophth oint 0.3%........................... 162
TOBREX -tobramycin ophth soln 0.3%........................... 162
TODAY SPONGE -nonoxynol-9 vaginal sponge 1000
mg.................................................................................... 93
TOFRANIL -imipramine hcl tab 10 mg............................ 100
TOFRANIL -imipramine hcl tab 25 mg............................ 100
TOFRANIL -imipramine hcl tab 50 mg............................ 100
TOFRANIL-PM -imipramine pamoate cap 75 mg........... 100
TOFRANIL-PM -imipramine pamoate cap 100 mg......... 100
TOFRANIL-PM -imipramine pamoate cap 125 mg......... 100
TOFRANIL-PM -imipramine pamoate cap 150 mg......... 100
TOLAK -fluorouracil cream 4%........................................175
tolazamide tab 250 mg.................................................... 40
TOLAZAMIDE -tolazamide tab 500 mg.............................40
TOLBUTAMIDE -tolbutamide tab 500 mg......................... 40
tolcapone tab 100 mg (Tasmar)................................... 144
tolmetin sodium cap 400 mg........................................ 132
TOLMETIN SODIUM -tolmetin sodium tab 200 mg........ 132
TOLMETIN SODIUM -tolmetin sodium tab 600 mg........ 132
tolterodine tartrate cap sr 24hr 2 mg (Detrol la).......... 92
tolterodine tartrate cap sr 24hr 4 mg (Detrol la).......... 92
tolterodine tartrate tab 1 mg (Detrol)............................ 92
tolterodine tartrate tab 2 mg (Detrol)............................ 92
TOPAMAX SPRINKLE -topiramate sprinkle cap 15
mg.................................................................................. 140
TOPAMAX SPRINKLE -topiramate sprinkle cap 25
mg.................................................................................. 140
TOPAMAX -topiramate tab 25 mg...................................140
TOPAMAX -topiramate tab 50 mg...................................140
TOPAMAX -topiramate tab 100 mg.................................140
TOPAMAX -topiramate tab 200 mg.................................140
TOPICORT -desoximetasone cream 0.05%................... 175
TOPICORT -desoximetasone cream 0.25%................... 175
TOPICORT -desoximetasone gel 0.05%........................ 175
TOPICORT -desoximetasone oint 0.05%....................... 176
TOPICORT -desoximetasone oint 0.25%....................... 176
TOPICORT -desoximetasone spray 0.25%.................... 176
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25
mg.................................................................................. 140
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 50
mg.................................................................................. 140
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 100
mg.................................................................................. 140
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 150
mg.................................................................................. 140
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 200
mg.................................................................................. 140
topiramate sprinkle cap 15 mg (Topamax
sprinkle)........................................................................140
topiramate sprinkle cap 25 mg (Topamax
sprinkle)........................................................................140
topiramate tab 25 mg (Topamax)................................. 140
topiramate tab 50 mg (Topamax)................................. 140
topiramate tab 100 mg (Topamax)............................... 140
topiramate tab 200 mg (Topamax)............................... 140
TOPROL XL -metoprolol succinate tab sr 24hr 25 mg..... 53
TOPROL XL -metoprolol succinate tab sr 24hr 50 mg..... 53
TOPROL XL -metoprolol succinate tab sr 24hr 100
mg.................................................................................... 53
TOPROL XL -metoprolol succinate tab sr 24hr 200
mg.................................................................................... 53
torsemide tab 5 mg (Demadex)...................................... 68
torsemide tab 10 mg (Demadex).................................... 68
torsemide tab 20 mg (Demadex).................................... 68
torsemide tab 100 mg (Demadex).................................. 68
TOUJEO SOLOSTAR -insulin glargine soln pen-injector
300 unit/ml.......................................................................42
TOVIAZ -fesoterodine fumarate tab sr 24hr 4 mg.............92
TOVIAZ -fesoterodine fumarate tab sr 24hr 8 mg.............92
TRACER II 3 VOLT BATTERY -blood glucose monitoring
misc............................................................................... 189
TRACLEER -bosentan tab 62.5 mg.................................. 75
TRACLEER -bosentan tab 125 mg................................... 75
TRADJENTA -linagliptin tab 5 mg..................................... 40
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)....................................................................... 127
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 100 mg............................................................. 127
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 150 mg............................................................. 127
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 200 mg............................................................. 127
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 300 mg............................................................. 127
tramadol hcl tab 50 mg (Ultram).................................. 127
tramadol hcl tab sr 24hr biphasic release 100 mg..... 127
tramadol hcl tab sr 24hr biphasic release 200 mg..... 127
tramadol hcl tab sr 24hr biphasic release 300 mg..... 127
tramadol hcl tab sr 24hr 100 mg (Ultram er).............. 127
tramadol hcl tab sr 24hr 200 mg (Ultram er).............. 127
tramadol hcl tab sr 24hr 300 mg (Ultram er).............. 127
trandolapril tab 1 mg (Mavik)......................................... 66
trandolapril tab 2 mg (Mavik)......................................... 66
trandolapril tab 4 mg (Mavik)......................................... 66
trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)...... 66
trandolapril-verapamil hcl tab cr 2-180 mg (Tarka)...... 66
trandolapril-verapamil hcl tab cr 2-240 mg (Tarka)...... 66
trandolapril-verapamil hcl tab cr 4-240 mg (Tarka)...... 66
tranexamic acid tab 650 mg (Lysteda)........................ 152
TRANSDERM-SCOP -scopolamine td patch 72hr 1
mg/3days......................................................................... 88
TRANXENE T -clorazepate dipotassium tab 3.75 mg...... 95
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TRANXENE T -clorazepate dipotassium tab 7.5 mg........ 95
TRANXENE T -clorazepate dipotassium tab 15 mg......... 95
tranylcypromine sulfate tab 10 mg (Parnate)............. 100
TRAVATAN Z -travoprost ophth soln 0.004%
(benzalkonium free) (bak free)..................................... 163
TRAVOPROST -travoprost ophth soln 0.004%.............. 163
trazodone hcl tab 50 mg............................................... 100
trazodone hcl tab 100 mg............................................. 100
trazodone hcl tab 150 mg............................................. 100
trazodone hcl tab 300 mg............................................. 100
TRECATOR -ethionamide tab 250 mg................................ 7
TRESIBA FLEXTOUCH -insulin degludec soln peninjector 100 unit/ml......................................................... 42
TRESIBA FLEXTOUCH -insulin degludec soln peninjector 200 unit/ml......................................................... 42
tretinoin cap 10 mg......................................................... 25
tretinoin cream 0.025% (Retin-a)................................. 176
tretinoin cream 0.05% (Retin-a)................................... 176
tretinoin cream 0.1% (Retin-a)..................................... 176
tretinoin gel 0.05% (ATRALIN)......................................176
tretinoin gel 0.01% (Retin-a)......................................... 176
tretinoin gel 0.025% (Retin-a)....................................... 176
tretinoin microsphere gel 0.04% (Retin-a micro)....... 176
tretinoin microsphere gel 0.1% (Retin-a micro)......... 176
TRETIN-X -tretinoin cream 0.075%................................ 176
TRETIN-X -tretinoin cream 0.05% w/ cleanser &
moisturizer kit................................................................ 176
TRETTEN -coagulation factor xiii a-subunit for inj
2000-3125 unit.............................................................. 157
TREXALL -methotrexate sodium tab 5 mg (base
equiv)............................................................................... 25
TREXALL -methotrexate sodium tab 7.5 mg (base
equiv)............................................................................... 26
TREXALL -methotrexate sodium tab 10 mg (base
equiv)............................................................................... 26
TREXALL -methotrexate sodium tab 15 mg (base
equiv)............................................................................... 26
TREXIMET -sumatriptan-naproxen sodium tab 85-500
mg.................................................................................. 134
TREZIX -acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg.............................................................127
triamcinolone acetonide aerosol soln 0.147 mg/gm
(Kenalog)...................................................................... 176
triamcinolone acetonide cream 0.025%...................... 176
triamcinolone acetonide cream 0.1%.......................... 176
triamcinolone acetonide cream 0.5%.......................... 176
triamcinolone acetonide dental paste 0.1%............... 165
triamcinolone acetonide lotion 0.025%....................... 176
triamcinolone acetonide lotion 0.1%........................... 176
triamcinolone acetonide nasal aerosol suspension 55
mcg/act (Nasacort aq).................................................. 77
triamcinolone acetonide oint 0.025%.......................... 176
triamcinolone acetonide oint 0.1%.............................. 176
TRIAMCINOLONE ACETONIDE -triamcinolone acetonide
oint 0.5%....................................................................... 176
TRIAMTERENE/HYDROCHLOROTH -triamterene &
hydrochlorothiazide cap 50-25 mg................................. 68
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide).........................................................................68
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)................................................................... 68
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)........................................................................ 68
TRIANEX -triamcinolone acetonide oint 0.05%.............. 176
triazolam tab 0.125 mg.................................................. 109
triazolam tab 0.25 mg (Halcion)................................... 109
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 20-5-12.5 mg............................................................ 66
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 40-5-12.5 mg............................................................ 66
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 40-5-25 mg............................................................... 66
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 40-10-12.5 mg.......................................................... 66
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 40-10-25 mg............................................................. 66
TRICODE AR -pseudoephedrine-chlorphen w/ codeine liq
30-2-8 mg/5ml................................................................. 79
TRICODE GF -pseudoephedrine w/ cod-gg liquid
30-8-200 mg/5ml............................................................. 79
TRICOR -fenofibrate tab 48 mg........................................ 72
TRICOR -fenofibrate tab 145 mg...................................... 72
trifluoperazine hcl tab 1 mg......................................... 107
trifluoperazine hcl tab 2 mg......................................... 107
trifluoperazine hcl tab 5 mg......................................... 107
trifluoperazine hcl tab 10 mg....................................... 107
trifluridine ophth soln 1% (Viroptic)............................ 163
TRIGLIDE -fenofibrate tab 160 mg................................... 72
trihexyphenidyl hcl elixir 0.4 mg/ml............................ 144
trihexyphenidyl hcl tab 2 mg........................................144
trihexyphenidyl hcl tab 5 mg........................................144
TRILEPTAL -oxcarbazepine susp 300 mg/5ml (60 mg/
ml).................................................................................. 140
TRILEPTAL -oxcarbazepine tab 150 mg........................ 140
TRILEPTAL -oxcarbazepine tab 300 mg........................ 140
TRILEPTAL -oxcarbazepine tab 600 mg........................ 140
TRILIPIX -choline fenofibrate cap dr 45 mg (fenofibric
acid equiv)....................................................................... 72
TRILIPIX -choline fenofibrate cap dr 135 mg (fenofibric
acid equiv)....................................................................... 72
trimethobenzamide hcl cap 300 mg (Tigan)................. 88
trimethoprim tab 100 mg................................................ 15
TRI-NORINYL 28 -norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg............................................ 34
TRIUMEQ -abacavir-dolutegravir-lamivudine tab
600-50-300 mg................................................................13
TRIZIVIR -abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg..............................................................13
TROKENDI XR -topiramate cap sr 24hr 25 mg.............. 140
TROKENDI XR -topiramate cap sr 24hr 50 mg.............. 140
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TROKENDI XR -topiramate cap sr 24hr 100 mg............ 140
TROKENDI XR -topiramate cap sr 24hr 200 mg............ 140
tropicamide ophth soln 0.5%....................................... 163
tropicamide ophth soln 1% (Mydriacyl)...................... 163
trospium chloride cap sr 24hr 60 mg............................ 92
trospium chloride tab 20 mg.......................................... 92
TRUE2GO BLOOD GLUCOSE MON -blood glucose
monitoring kit w/ device................................................ 190
TRUE METRIX AIR BLOOD GLU -blood glucose
monitoring devices........................................................ 189
TRUE METRIX AIR BLOOD GLU -blood glucose
monitoring kit w/ device................................................ 189
TRUE METRIX BLOOD GLUCOSE -blood glucose
monitoring kit w/ device................................................ 189
TRUERESULT BLOOD GLUCOSE -blood glucose
monitoring kit w/ device................................................ 190
TRUETRACK BLOOD GLUCOSE M -blood glucose
monitoring devices........................................................ 190
TRUETRACK BLOOD GLUCOSE M -blood glucose
monitoring kit w/ device................................................ 190
TRUETRACK SMART SYSTEM -blood glucose
monitoring kit w/ device................................................ 190
TRULICITY -dulaglutide soln pen-injector 0.75
mg/0.5ml.......................................................................... 40
TRULICITY -dulaglutide soln pen-injector 1.5
mg/0.5ml.......................................................................... 40
TRUMENBA -meningococcal group b vaccine im susp
prefilled syringe............................................................... 19
TRUSOPT -dorzolamide hcl ophth soln 2%....................163
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
200-300 mg..................................................................... 13
TUDORZA PRESSAIR -aclidinium bromide aerosol powd
breath activated 400 mcg/act......................................... 83
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
5-4 mg............................................................................. 79
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
10-8 mg........................................................................... 79
TUSSIONEX PENNKINETIC EXT -hydrocod polstchlorphen polst cr susp 10-8 mg/5ml............................. 79
TUZISTRA XR -codeine polist-chlorphen polist er susp
14.7-2.8 mg/5ml.............................................................. 79
TWINRIX -hepatitis a (inact)-hep b (recomb) vac inj
720-20 elu-mcg/ml.......................................................... 19
TWYNSTA -telmisartan-amlodipine tab 40-5 mg.............. 66
TWYNSTA -telmisartan-amlodipine tab 80-5 mg.............. 66
TWYNSTA -telmisartan-amlodipine tab 40-10 mg............ 66
TWYNSTA -telmisartan-amlodipine tab 80-10 mg............ 66
TYBOST -cobicistat tab 150 mg....................................... 13
TYKERB -lapatinib ditosylate tab 250 mg (base
equiv)............................................................................... 26
TYLENOL/CODEINE #3 -acetaminophen w/ codeine tab
300-30 mg..................................................................... 127
TYLENOL/CODEINE #4 -acetaminophen w/ codeine tab
300-60 mg..................................................................... 127
TYVASO REFILL -treprostinil inhalation solution 0.6 mg/
ml..................................................................................... 75
TYVASO STARTER -treprostinil inhalation solution 0.6
mg/ml............................................................................... 75
TYVASO -treprostinil inhalation solution 0.6 mg/ml.......... 75
TYZEKA -telbivudine tab 600 mg...................................... 13
TYZINE PEDIATRIC NASAL DR -tetrahydrozoline hcl
nasal soln 0.05%............................................................ 77
TYZINE -tetrahydrozoline hcl nasal soln 0.1%................. 77
U
UCERIS -budesonide rectal foam 2 mg/act.................... 166
UCERIS -budesonide tab sr 24hr 9 mg............................ 28
ULESFIA -benzyl alcohol lotion 5%................................ 176
ULORIC -febuxostat tab 40 mg....................................... 134
ULORIC -febuxostat tab 80 mg....................................... 134
ULTIMA -blood glucose monitoring kit............................ 190
ULTRACET -tramadol-acetaminophen tab 37.5-325
mg.................................................................................. 127
ULTRAM ER -tramadol hcl tab sr 24hr 100 mg.............. 127
ULTRAM ER -tramadol hcl tab sr 24hr 200 mg.............. 127
ULTRAM ER -tramadol hcl tab sr 24hr 300 mg.............. 127
ULTRAM -tramadol hcl tab 50 mg...................................127
ULTRATRAK ACTIVE -blood glucose monitoring
devices.......................................................................... 190
ULTRA TRAK PRO BLOOD GLUC -blood glucose
monitoring kit w/ device................................................ 190
ULTRATRAK PRO -blood glucose monitoring
devices.......................................................................... 190
ULTRATRAK ULTIMATE MONITO -blood glucose
monitoring devices........................................................ 190
ULTRAVATE -halobetasol propionate cream 0.05%....... 176
ULTRAVATE -halobetasol propionate oint 0.05%........... 176
UPTRAVI -selexipag tab 200 mcg.....................................75
UPTRAVI -selexipag tab 400 mcg.....................................75
UPTRAVI -selexipag tab 600 mcg.....................................75
UPTRAVI -selexipag tab 800 mcg.....................................75
UPTRAVI -selexipag tab 1000 mcg...................................75
UPTRAVI -selexipag tab 1200 mcg...................................75
UPTRAVI -selexipag tab 1400 mcg...................................75
UPTRAVI -selexipag tab 1600 mcg...................................75
UPTRAVI -selexipag tab therapy pack 200 mcg (140) &
800 mcg (60)...................................................................75
urea lotion 45% (Uramaxin).......................................... 176
URECHOLINE -bethanechol chloride tab 5 mg................ 92
URECHOLINE -bethanechol chloride tab 10 mg.............. 92
URECHOLINE -bethanechol chloride tab 25 mg.............. 92
URECHOLINE -bethanechol chloride tab 50 mg.............. 92
UREX -methenamine hippurate tab 1 gm......................... 91
UROCIT-K 10 -potassium citrate tab cr 10 meq (1080
mg)................................................................................... 94
UROCIT-K 15 -potassium citrate tab cr 15 meq (1620
mg)................................................................................... 94
UROCIT-K 5 -potassium citrate tab cr 5 meq (540
mg)................................................................................... 94
UROXATRAL -alfuzosin hcl tab sr 24hr 10 mg................. 94
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272
2015
ursodiol cap 300 mg (Actigall)....................................... 91
ursodiol tab 250 mg (Urso 250)..................................... 91
ursodiol tab 500 mg (Urso forte)................................... 91
URSO FORTE -ursodiol tab 500 mg.................................91
URSO 250 -ursodiol tab 250 mg....................................... 91
V
VAGIFEM -estradiol vaginal tab 10 mcg........................... 93
valacyclovir hcl tab 1 gm (Valtrex)................................ 13
valacyclovir hcl tab 500 mg (Valtrex)............................ 13
VALCHLOR -mechlorethamine hcl gel 0.016% (base
equivalent)..................................................................... 176
VALCYTE -valganciclovir hcl for soln 50 mg/ml (base
equiv)............................................................................... 13
VALCYTE -valganciclovir hcl tab 450 mg (base
equivalent)....................................................................... 13
valganciclovir hcl tab 450 mg (base equivalent)
(Valcyte).......................................................................... 13
VALIUM -diazepam tab 2 mg............................................ 95
VALIUM -diazepam tab 5 mg............................................ 95
VALIUM -diazepam tab 10 mg.......................................... 95
valproate sodium syrup 250 mg/5ml (base equiv)
(Depakene)................................................................... 140
valproic acid cap 250 mg (Depakene)......................... 140
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct).................................................................................. 66
valsartan-hydrochlorothiazide tab 160-12.5 mg
(Diovan hct)................................................................... 66
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct).................................................................................. 66
valsartan-hydrochlorothiazide tab 320-12.5 mg
(Diovan hct)................................................................... 66
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct).................................................................................. 66
valsartan tab 40 mg (Diovan)......................................... 66
valsartan tab 80 mg (Diovan)......................................... 66
valsartan tab 160 mg (Diovan)....................................... 66
valsartan tab 320 mg (Diovan)....................................... 66
VALTREX -valacyclovir hcl tab 1 gm................................. 13
VALTREX -valacyclovir hcl tab 500 mg............................. 13
VALUE PLUS GLUCOSE -glucose chew tab 4 gm.......... 40
VANACOF CD -phenylephrine-dexchlorphenir-codeine
liquid 5-1-10 mg/5ml....................................................... 79
VANATOL LQ -butalbital-acetaminophen-caffeine soln
50-325-40 mg/15ml....................................................... 119
VANCOCIN HCL -vancomycin hcl cap 125 mg................ 15
VANCOCIN HCL -vancomycin hcl cap 250 mg................ 15
vancomycin hcl cap 125 mg (Vancocin hcl)................. 16
vancomycin hcl cap 250 mg (Vancocin hcl)................. 16
VANOS -fluocinonide cream 0.1%.................................. 176
VAQTA -hepatitis a vaccine inj susp 25 unit/0.5ml............19
VAQTA -hepatitis a vaccine inj susp 50 unit/ml.................19
VARIVAX -varicella virus vac live for subcutaneous inj
1350 pfu/0.5ml................................................................ 20
VARUBI -rolapitant hcl tab 90 mg (base equiv)................ 88
VASCEPA -icosapent ethyl cap 1 gm............................... 72
VASERETIC -enalapril maleate & hydrochlorothiazide tab
10-25 mg......................................................................... 66
VASOTEC -enalapril maleate tab 2.5 mg......................... 66
VASOTEC -enalapril maleate tab 5 mg............................ 66
VASOTEC -enalapril maleate tab 10 mg.......................... 66
VASOTEC -enalapril maleate tab 20 mg.......................... 66
VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 film
28%.................................................................................. 93
VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 foam
12.5%...............................................................................93
VECAMYL -mecamylamine hcl tab 2.5 mg....................... 66
VECTICAL -calcitriol oint 3 mcg/gm................................ 176
VELPHORO -sucroferric oxyhydroxide chew tab 500
mg.................................................................................... 91
VELTASSA -patiromer sorbitex calcium for susp packet
8.4 gm (base eq).......................................................... 192
VELTASSA -patiromer sorbitex calcium for susp packet
16.8 gm (base eq)........................................................ 192
VELTASSA -patiromer sorbitex calcium for susp packet
25.2 gm (base eq)........................................................ 192
VELTIN -clindamycin phosphate-tretinoin gel
1.2-0.025%.................................................................... 176
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)................................................................... 101
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)................................................................... 101
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)................................................................... 101
VENLAFAXINE HCL ER -venlafaxine hcl tab sr 24hr 37.5
mg (base equivalent).................................................... 101
VENLAFAXINE HCL ER -venlafaxine hcl tab sr 24hr 75
mg (base equivalent).................................................... 101
VENLAFAXINE HCL ER -venlafaxine hcl tab sr 24hr 150
mg (base equivalent).................................................... 101
VENLAFAXINE HCL ER -venlafaxine hcl tab sr 24hr 225
mg (base equivalent).................................................... 101
venlafaxine hcl tab 25 mg.............................................101
venlafaxine hcl tab 37.5 mg......................................... 101
venlafaxine hcl tab 50 mg.............................................101
venlafaxine hcl tab 75 mg.............................................101
venlafaxine hcl tab 100 mg.......................................... 101
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)
(Venlafaxine hcl er)..................................................... 101
venlafaxine hcl tab sr 24hr 75 mg (base equivalent)
(Venlafaxine hcl er)..................................................... 101
venlafaxine hcl tab sr 24hr 150 mg (base equivalent)
(Venlafaxine hcl er)..................................................... 101
VENTAVIS -iloprost inhalation solution 10 mcg/ml........... 75
VENTAVIS -iloprost inhalation solution 20 mcg/ml........... 75
VENTOLIN HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)........................................................ 83
VERAMYST -fluticasone furoate nasal susp 27.5 mcg/
spray................................................................................ 77
verapamil hcl cap sr 24hr 120 mg (Verelan)................. 56
verapamil hcl cap sr 24hr 180 mg (Verelan)................. 56
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verapamil hcl cap sr 24hr 240 mg (Verelan)................. 56
verapamil hcl cap sr 24hr 360 mg (Verelan)................. 56
verapamil hcl cap sr 24hr 100 mg (Verelan pm)........... 56
verapamil hcl cap sr 24hr 200 mg (Verelan pm)........... 56
verapamil hcl cap sr 24hr 300 mg (Verelan pm)........... 56
verapamil hcl tab cr 120 mg (Calan sr)......................... 56
verapamil hcl tab cr 180 mg (Calan sr)......................... 56
verapamil hcl tab cr 240 mg (Calan sr)......................... 56
verapamil hcl tab 40 mg................................................. 56
verapamil hcl tab 80 mg (Calan).................................... 56
verapamil hcl tab 120 mg (Calan).................................. 56
VERDESO -desonide foam 0.05%.................................. 176
VEREGEN -sinecatechins oint 15%................................176
VERELAN PM -verapamil hcl cap sr 24hr 100 mg........... 56
VERELAN PM -verapamil hcl cap sr 24hr 200 mg........... 56
VERELAN PM -verapamil hcl cap sr 24hr 300 mg........... 56
VERELAN -verapamil hcl cap sr 24hr 120 mg..................56
VERELAN -verapamil hcl cap sr 24hr 180 mg..................56
VERELAN -verapamil hcl cap sr 24hr 240 mg..................56
VERELAN -verapamil hcl cap sr 24hr 360 mg..................56
VERIPRED 20 -prednisolone sod phosphate oral soln 20
mg/5ml (base equiv)....................................................... 28
VERSACLOZ -clozapine susp 50 mg/ml........................ 107
VESICARE -solifenacin succinate tab 5 mg..................... 92
VESICARE -solifenacin succinate tab 10 mg................... 92
VEXOL -rimexolone ophth susp 1%............................... 163
VFEND -voriconazole for susp 40 mg/ml............................ 8
VFEND -voriconazole tab 50 mg........................................ 8
VFEND -voriconazole tab 200 mg...................................... 8
VIAGRA -sildenafil citrate tab 25 mg........................... 75,75
VIAGRA -sildenafil citrate tab 50 mg........................... 75,75
VIAGRA -sildenafil citrate tab 100 mg......................... 75,75
VIBERZI -eluxadoline tab 75 mg....................................... 91
VIBERZI -eluxadoline tab 100 mg..................................... 91
VIBRAMYCIN -doxycycline calcium syrup 50 mg/5ml........ 5
VIBRAMYCIN -doxycycline hyclate cap 100 mg.................6
VIBRAMYCIN -doxycycline monohydrate for susp 25
mg/5ml............................................................................... 6
VICOPROFEN -hydrocodone-ibuprofen tab 7.5-200
mg.................................................................................. 127
VICTORY BLOOD GLUCOSE MON -blood glucose
monitoring devices........................................................ 190
VICTOZA -liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml).................................................................................... 40
VICTRELIS -boceprevir cap 200 mg................................. 13
VIDEX -didanosine for soln 2 gm...................................... 13
VIDEX -didanosine for soln 4 gm...................................... 13
VIDEX EC -didanosine delayed release capsule 125
mg.................................................................................... 13
VIDEX EC -didanosine delayed release capsule 200
mg.................................................................................... 13
VIDEX EC -didanosine delayed release capsule 250
mg.................................................................................... 13
VIDEX EC -didanosine delayed release capsule 400
mg.................................................................................... 13
VIEKIRA PAK -ombitas-paritapre-riton & dasab tab pak
12.5-75-50 & 250 mg..................................................... 13
VIGAMOX -moxifloxacin hcl ophth soln 0.5% (base
equiv)............................................................................. 163
VIIBRYD STARTER PACK -vilazodone hcl tab starter kit
10 (7) & 20 (23) mg..................................................... 101
VIIBRYD -vilazodone hcl tab 10 mg................................101
VIIBRYD -vilazodone hcl tab 20 mg................................101
VIIBRYD -vilazodone hcl tab 40 mg................................101
VIMOVO -naproxen-esomeprazole magnesium tab dr
375-20 mg..................................................................... 132
VIMOVO -naproxen-esomeprazole magnesium tab dr
500-20 mg..................................................................... 132
VIMPAT -lacosamide oral solution 10 mg/ml.................. 140
VIMPAT -lacosamide tab 50 mg...................................... 140
VIMPAT -lacosamide tab 100 mg.................................... 140
VIMPAT -lacosamide tab 150 mg.................................... 140
VIMPAT -lacosamide tab 200 mg.................................... 140
VIOKACE -pancrelipase (lip-prot-amyl) tab
10440-39150-39150 unit................................................ 88
VIOKACE -pancrelipase (lip-prot-amyl) tab
20880-78300-78300 unit................................................ 88
VIRACEPT -nelfinavir mesylate tab 250 mg..................... 13
VIRACEPT -nelfinavir mesylate tab 625 mg..................... 13
VIRAMUNE -nevirapine susp 50 mg/5ml.......................... 13
VIRAMUNE -nevirapine tab 200 mg................................. 13
VIRAMUNE XR -nevirapine tab sr 24hr 100 mg............... 13
VIRAMUNE XR -nevirapine tab sr 24hr 400 mg............... 13
VIRAZOLE -ribavirin for inhal soln 6 gm........................... 13
VIREAD -tenofovir disoproxil fumarate oral powder 40
mg/gm.............................................................................. 13
VIREAD -tenofovir disoproxil fumarate tab 150 mg.......... 13
VIREAD -tenofovir disoproxil fumarate tab 200 mg.......... 13
VIREAD -tenofovir disoproxil fumarate tab 250 mg.......... 13
VIREAD -tenofovir disoproxil fumarate tab 300 mg.......... 13
VIROPTIC -trifluridine ophth soln 1%............................. 163
VISTARIL -hydroxyzine pamoate cap 25 mg.................... 95
VISTARIL -hydroxyzine pamoate cap 50 mg.................... 95
VITAMELTS VITAMIN D -cholecalciferol orally
disintegrating tab 1000 unit.......................................... 146
VITAMIN D3 -cholecalciferol oral liquid 1200
unit/15ml........................................................................ 146
VITAMIN D3 -cholecalciferol spray 1000 unit/spray........146
VITAMIN D2 -ergocalciferol tab 400 unit.........................146
VITEKTA -elvitegravir tab 85 mg....................................... 14
VITEKTA -elvitegravir tab 150 mg..................................... 14
VITUZ -hydrocodone-chlorpheniramine soln 5-4
mg/5ml............................................................................. 79
VIVELLE-DOT -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 31
VIVELLE-DOT -estradiol td patch twice weekly 0.0375
mg/24hr........................................................................... 31
VIVELLE-DOT -estradiol td patch twice weekly 0.05
mg/24hr........................................................................... 31
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VIVELLE-DOT -estradiol td patch twice weekly 0.075
mg/24hr........................................................................... 31
VIVELLE-DOT -estradiol td patch twice weekly 0.1
mg/24hr........................................................................... 32
VIVLODEX -meloxicam cap 5 mg................................... 132
VIVLODEX -meloxicam cap 10 mg................................. 132
VOCAL POINT BLOOD GLUCOSE -blood glucose
monitoring devices........................................................ 190
VOGELXO PUMP -testosterone td gel 12.5 mg/act
(1%)................................................................................. 29
VOGELXO -testosterone td gel 50 mg/5gm (1%)............. 29
VOLTAREN -diclofenac sodium gel 1%.......................... 176
voriconazole for susp 40 mg/ml (Vfend)......................... 8
voriconazole tab 50 mg (Vfend)....................................... 8
voriconazole tab 200 mg (Vfend)..................................... 8
VOSPIRE ER -albuterol sulfate tab sr 12hr 4 mg............. 83
VOSPIRE ER -albuterol sulfate tab sr 12hr 8 mg............. 83
VOTRIENT -pazopanib hcl tab 200 mg (base equiv)....... 26
VUSION -miconazole-zinc oxide-white petrolatum oint
0.25-15-81.35%............................................................. 176
VYTORIN -ezetimibe-simvastatin tab 10-10 mg............... 72
VYTORIN -ezetimibe-simvastatin tab 10-20 mg............... 72
VYTORIN -ezetimibe-simvastatin tab 10-40 mg............... 72
VYTORIN -ezetimibe-simvastatin tab 10-80 mg............... 72
VYVANSE -lisdexamfetamine dimesylate cap 10 mg..... 113
VYVANSE -lisdexamfetamine dimesylate cap 20 mg..... 113
VYVANSE -lisdexamfetamine dimesylate cap 30 mg..... 114
VYVANSE -lisdexamfetamine dimesylate cap 40 mg..... 114
VYVANSE -lisdexamfetamine dimesylate cap 50 mg..... 114
VYVANSE -lisdexamfetamine dimesylate cap 60 mg..... 114
VYVANSE -lisdexamfetamine dimesylate cap 70 mg..... 114
W
WALGREENS GLUCOSE -glucose chew tab 4 gm......... 40
warfarin sodium tab 1 mg (Coumadin)....................... 151
warfarin sodium tab 2 mg (Coumadin)....................... 151
warfarin sodium tab 2.5 mg (Coumadin).................... 151
warfarin sodium tab 3 mg (Coumadin)....................... 151
warfarin sodium tab 4 mg (Coumadin)....................... 151
warfarin sodium tab 5 mg (Coumadin)....................... 151
warfarin sodium tab 6 mg (Coumadin)....................... 151
warfarin sodium tab 7.5 mg (Coumadin).................... 152
warfarin sodium tab 10 mg (Coumadin)..................... 152
WAVESENSE AMP -blood glucose monitoring kit w/
device............................................................................ 190
WAVESENSE KEYNOTE -blood glucose monitoring kit w/
device............................................................................ 190
WAVESENSE KEYNOTE PRO MET -blood glucose
monitoring devices........................................................ 190
WELCHOL -colesevelam hcl packet for susp 3.75 gm..... 73
WELCHOL -colesevelam hcl tab 625 mg......................... 73
WELLBUTRIN -bupropion hcl tab 75 mg........................ 101
WELLBUTRIN -bupropion hcl tab 100 mg...................... 101
WELLBUTRIN SR -bupropion hcl tab sr 12hr 100
mg.................................................................................. 101
WELLBUTRIN SR -bupropion hcl tab sr 12hr 150
mg.................................................................................. 101
WELLBUTRIN SR -bupropion hcl tab sr 12hr 200
mg.................................................................................. 101
WELLBUTRIN XL -bupropion hcl tab sr 24hr 150
mg.................................................................................. 101
WELLBUTRIN XL -bupropion hcl tab sr 24hr 300
mg.................................................................................. 101
WELLESSE VITAMIN D3 -cholecalciferol oral liquid 1000
unit/10ml........................................................................ 146
WESTCORT -hydrocortisone valerate oint 0.2%............ 176
WESTHROID-P -thyroid tab 16.25 mg............................. 44
WESTHROID-P -thyroid tab 32.5 mg............................... 44
WESTHROID-P -thyroid tab 65 mg.................................. 44
WESTHROID-P -thyroid tab 97.5 mg............................... 44
WESTHROID-P -thyroid tab 130 mg................................ 44
WESTHROID-P -thyroid tab 48.75 mg (3/4 grain)............ 44
WESTHROID -thyroid tab 16.25 mg................................. 44
WESTHROID -thyroid tab 32.5 mg................................... 44
WESTHROID -thyroid tab 65 mg...................................... 44
WESTHROID -thyroid tab 81.25 mg................................. 44
WESTHROID -thyroid tab 97.5 mg................................... 44
WESTHROID -thyroid tab 113.75 mg............................... 44
WESTHROID -thyroid tab 130 mg.................................... 44
WESTHROID -thyroid tab 146.25 mg............................... 44
WESTHROID -thyroid tab 195 mg.................................... 44
WESTHROID -thyroid tab 260 mg.................................... 44
WESTHROID -thyroid tab 48.75 mg (3/4 grain)............... 44
WESTHROID -thyroid tab 162.5 mg (2 1/2 grain)............ 44
WESTHROID -thyroid tab 325 mg (5 grain)..................... 44
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 60
mm................................................................................. 190
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 65
mm................................................................................. 190
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 70
mm................................................................................. 190
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 75
mm................................................................................. 190
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 80
mm................................................................................. 190
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 85
mm................................................................................. 190
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 90
mm................................................................................. 190
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 95
mm................................................................................. 190
WILATE -antihemophilic factor/vwf (human) for inj
500-500 unit.................................................................. 157
WILATE -antihemophilic factor/vwf (human) for inj
1000-1000 unit.............................................................. 157
WP THYROID -thyroid tab 16.25 mg................................ 44
WP THYROID -thyroid tab 32.5 mg.................................. 44
WP THYROID -thyroid tab 65 mg..................................... 44
WP THYROID -thyroid tab 81.25 mg................................ 44
WP THYROID -thyroid tab 97.5 mg.................................. 44
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WP THYROID -thyroid tab 113.75 mg.............................. 44
WP THYROID -thyroid tab 130 mg................................... 44
WP THYROID -thyroid tab 48.75 mg (3/4 grain).............. 44
X
XALATAN -latanoprost ophth soln 0.005%..................... 163
XALKORI -crizotinib cap 200 mg...................................... 26
XALKORI -crizotinib cap 250 mg...................................... 26
XANAX -alprazolam tab 0.25 mg...................................... 95
XANAX -alprazolam tab 0.5 mg........................................ 95
XANAX -alprazolam tab 1 mg........................................... 95
XANAX -alprazolam tab 2 mg........................................... 95
XANAX XR -alprazolam tab sr 24hr 0.5 mg......................95
XANAX XR -alprazolam tab sr 24hr 1 mg........................ 95
XANAX XR -alprazolam tab sr 24hr 2 mg........................ 95
XANAX XR -alprazolam tab sr 24hr 3 mg........................ 95
XARELTO -rivaroxaban tab 10 mg..................................152
XARELTO -rivaroxaban tab 15 mg..................................152
XARELTO -rivaroxaban tab 20 mg..................................152
XARELTO STARTER PACK -rivaroxaban tab starter
therapy pack 15 mg & 20 mg.......................................152
XARTEMIS XR -oxycodone w/ acetaminophen tab cr
7.5-325 mg.................................................................... 128
XELJANZ -tofacitinib citrate tab 5 mg (base
equivalent)..................................................................... 132
XELODA -capecitabine tab 150 mg.................................. 26
XELODA -capecitabine tab 500 mg.................................. 26
XENAZINE -tetrabenazine tab 12.5 mg.......................... 118
XENAZINE -tetrabenazine tab 25 mg............................. 118
XERESE -acyclovir-hydrocortisone cream 5-1%............ 176
XIFAXAN -rifaximin tab 200 mg........................................ 16
XIFAXAN -rifaximin tab 550 mg........................................ 16
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
5-500 mg......................................................................... 40
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 40
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
10-500 mg....................................................................... 40
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
10-1000 mg..................................................................... 40
XODOL -hydrocodone-acetaminophen tab 7.5-300
mg.................................................................................. 128
XODOL -hydrocodone-acetaminophen tab 5-300
mg.................................................................................. 128
XODOL -hydrocodone-acetaminophen tab 10-300
mg.................................................................................. 128
XOLEGEL -ketoconazole gel 2%.................................... 176
XOPENEX HFA -levalbuterol tartrate inhal aerosol 45
mcg/act (base equiv)...................................................... 83
XTANDI -enzalutamide cap 40 mg.................................... 26
XULANE -norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr.......................................................................... 34
XYLOCAINE -lidocaine hcl soln 4%................................ 177
XYNTHA -antihemophilic factor recombinant paf for inj kit
250 unit......................................................................... 158
XYNTHA -antihemophilic factor recombinant paf for inj kit
500 unit......................................................................... 158
XYNTHA -antihemophilic factor recombinant paf for inj kit
1000 unit....................................................................... 158
XYNTHA -antihemophilic factor recombinant paf for inj kit
2000 unit....................................................................... 158
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 250 unit................................................... 158
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 500 unit................................................... 158
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 1000 unit................................................. 158
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 2000 unit................................................. 158
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 3000 unit................................................. 158
XYREM -sodium oxybate oral solution 500 mg/ml......... 118
XYZAL -levocetirizine dihydrochloride soln 2.5 mg/5ml
(0.5 mg/ml)...................................................................... 76
XYZAL -levocetirizine dihydrochloride tab 5 mg............... 76
Y
YASMIN 28 -drospirenone-ethinyl estradiol tab 3-0.03
mg.................................................................................... 34
YAZ -drospirenone-ethinyl estradiol tab 3-0.02 mg...........35
Z
zafirlukast tab 10 mg (Accolate).................................... 83
zafirlukast tab 20 mg (Accolate).................................... 83
zaleplon cap 5 mg (Sonata).......................................... 109
zaleplon cap 10 mg (Sonata)........................................ 109
ZAMICET -hydrocodone-acetaminophen soln 10-325
mg/15ml......................................................................... 128
ZANAFLEX -tizanidine hcl cap 2 mg (base
equivalent)..................................................................... 145
ZANAFLEX -tizanidine hcl cap 4 mg (base
equivalent)..................................................................... 145
ZANAFLEX -tizanidine hcl cap 6 mg (base
equivalent)..................................................................... 145
ZANAFLEX -tizanidine hcl tab 4 mg (base
equivalent)..................................................................... 145
ZANTAC -ranitidine hcl tab 150 mg.................................. 87
ZANTAC -ranitidine hcl tab 300 mg.................................. 87
ZARONTIN -ethosuximide cap 250 mg.......................... 140
ZARONTIN -ethosuximide soln 250 mg/5ml................... 140
ZAVESCA -miglustat cap 100 mg................................... 150
ZEBETA -bisoprolol fumarate tab 5 mg............................ 53
ZEBETA -bisoprolol fumarate tab 10 mg.......................... 53
ZECUITY -sumatriptan succinate td iontophoretic patch
6.5 mg/4hr..................................................................... 134
ZEGERID -omeprazole-sodium bicarbonate cap 20-1100
mg.................................................................................... 87
ZEGERID -omeprazole-sodium bicarbonate cap 40-1100
mg.................................................................................... 87
ZEGERID -omeprazole-sodium bicarbonate powd pack
for susp 20-1680 mg...................................................... 87
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ZEGERID -omeprazole-sodium bicarbonate powd pack
for susp 40-1680 mg...................................................... 87
ZELAPAR -selegiline hcl orally disintegrating tab 1.25
mg.................................................................................. 144
ZELBORAF -vemurafenib tab 240 mg.............................. 26
ZEMPLAR -paricalcitol cap 1 mcg.................................... 50
ZEMPLAR -paricalcitol cap 2 mcg.................................... 50
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit...................................................88
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit...................................................88
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
10000-34000-55000 unit................................................ 88
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
15000-51000-82000 unit................................................ 88
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
20000-68000-109000 unit.............................................. 88
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
25000-85000-136000 unit.............................................. 89
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
40000-136000-218000 unit............................................ 89
ZENZEDI -dextroamphetamine sulfate tab 2.5 mg......... 114
ZENZEDI -dextroamphetamine sulfate tab 7.5 mg......... 114
ZENZEDI -dextroamphetamine sulfate tab 15 mg.......... 114
ZENZEDI -dextroamphetamine sulfate tab 20 mg.......... 114
ZENZEDI -dextroamphetamine sulfate tab 30 mg.......... 114
ZERIT -stavudine cap 15 mg............................................ 14
ZERIT -stavudine cap 20 mg............................................ 14
ZERIT -stavudine cap 30 mg............................................ 14
ZERIT -stavudine cap 40 mg............................................ 14
ZERIT -stavudine for oral soln 1 mg/ml............................ 14
ZESTORETIC -lisinopril & hydrochlorothiazide tab
10-12.5 mg...................................................................... 66
ZESTORETIC -lisinopril & hydrochlorothiazide tab
20-12.5 mg...................................................................... 67
ZESTORETIC -lisinopril & hydrochlorothiazide tab 20-25
mg.................................................................................... 67
ZESTRIL -lisinopril tab 2.5 mg.......................................... 67
ZESTRIL -lisinopril tab 5 mg............................................. 67
ZESTRIL -lisinopril tab 10 mg........................................... 67
ZESTRIL -lisinopril tab 20 mg........................................... 67
ZESTRIL -lisinopril tab 30 mg........................................... 67
ZESTRIL -lisinopril tab 40 mg........................................... 67
ZETIA -ezetimibe tab 10 mg............................................. 73
ZETONNA -ciclesonide nasal aerosol soln 37 mcg/act (50
mcg/valve)....................................................................... 77
ZIAC -bisoprolol & hydrochlorothiazide tab 2.5-6.25
mg.................................................................................... 67
ZIAC -bisoprolol & hydrochlorothiazide tab 5-6.25 mg..... 67
ZIAC -bisoprolol & hydrochlorothiazide tab 10-6.25
mg.................................................................................... 67
ZIAGEN -abacavir sulfate soln 20 mg/ml (base equiv)..... 14
ZIAGEN -abacavir sulfate tab 300 mg (base equiv)......... 14
ZIANA -clindamycin phosphate-tretinoin gel
1.2-0.025%.................................................................... 177
zidovudine cap 100 mg (Retrovir)................................. 14
zidovudine syrup 10 mg/ml (Retrovir)........................... 14
zidovudine tab 300 mg.................................................... 14
ZIOPTAN -tafluprost ophth soln 0.0015%....................... 163
ziprasidone hcl cap 20 mg (Geodon).......................... 107
ziprasidone hcl cap 40 mg (Geodon).......................... 107
ziprasidone hcl cap 60 mg (Geodon).......................... 107
ziprasidone hcl cap 80 mg (Geodon).......................... 107
ZIPSOR -diclofenac potassium cap 25 mg..................... 132
ZIRGAN -ganciclovir ophth gel 0.15%............................ 163
ZITHROMAX -azithromycin for susp 100 mg/5ml............... 4
ZITHROMAX -azithromycin for susp 200 mg/5ml............... 4
ZITHROMAX -azithromycin powd pack for susp 1 gm....... 4
ZITHROMAX -azithromycin tab 250 mg............................. 4
ZITHROMAX -azithromycin tab 500 mg............................. 4
ZITHROMAX -azithromycin tab 600 mg............................. 4
ZITHROMAX TRI-PAK -azithromycin tab 500 mg.............. 4
ZITHROMAX Z-PAK -azithromycin tab 250 mg.................. 4
ZMAX -azithromycin extended release for oral susp 2
gm...................................................................................... 4
ZOCOR -simvastatin tab 5 mg.......................................... 73
ZOCOR -simvastatin tab 10 mg........................................ 73
ZOCOR -simvastatin tab 20 mg........................................ 73
ZOCOR -simvastatin tab 40 mg........................................ 73
ZOCOR -simvastatin tab 80 mg........................................ 73
ZOFRAN ODT -ondansetron orally disintegrating tab 4
mg.................................................................................... 88
ZOFRAN ODT -ondansetron orally disintegrating tab 8
mg.................................................................................... 88
ZOFRAN -ondansetron hcl oral soln 4 mg/5ml................. 88
ZOFRAN -ondansetron hcl tab 4 mg................................ 88
ZOFRAN -ondansetron hcl tab 8 mg................................ 88
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 10 mg................................................. 128
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 15 mg................................................. 128
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 20 mg................................................. 128
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 30 mg................................................. 128
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 40 mg................................................. 128
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 50 mg................................................. 128
ZOLINZA -vorinostat cap 100 mg..................................... 26
zolmitriptan orally disintegrating tab 2.5 mg (Zomig
zmt)............................................................................... 134
zolmitriptan orally disintegrating tab 5 mg (Zomig
zmt)............................................................................... 134
zolmitriptan tab 2.5 mg (Zomig)................................... 134
zolmitriptan tab 5 mg (Zomig)...................................... 134
ZOLOFT -sertraline hcl oral conc 20 mg/ml.................... 101
ZOLOFT -sertraline hcl tab 25 mg.................................. 101
ZOLOFT -sertraline hcl tab 50 mg.................................. 101
ZOLOFT -sertraline hcl tab 100 mg................................ 101
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List March 2015
277
2015
zolpidem tartrate tab cr 6.25 mg (Ambien cr)............. 109
zolpidem tartrate tab cr 12.5 mg (Ambien cr)............. 109
zolpidem tartrate tab 5 mg (Ambien)...........................109
zolpidem tartrate tab 10 mg (Ambien).........................109
ZOLPIMIST -zolpidem tartrate oral spray 5 mg/act........ 109
ZOMACTON -somatropin for inj 10 mg.............................50
ZOMACTON -somatropin for subcutaneous inj 5 mg....... 50
ZOMIG NASAL SPRAY -zolmitriptan nasal spray 5 mg/
spray unit.......................................................................134
ZOMIG ZMT -zolmitriptan orally disintegrating tab 2.5
mg.................................................................................. 134
ZOMIG ZMT -zolmitriptan orally disintegrating tab 5
mg.................................................................................. 134
ZOMIG -zolmitriptan nasal spray 2.5 mg/spray unit........134
ZOMIG -zolmitriptan nasal spray 5 mg/spray unit...........134
ZOMIG -zolmitriptan tab 2.5 mg...................................... 134
ZOMIG -zolmitriptan tab 5 mg......................................... 134
ZONALON -doxepin hcl cream 5%................................. 177
ZONATUSS -benzonatate cap 150 mg............................. 79
ZONEGRAN -zonisamide cap 25 mg............................. 140
ZONEGRAN -zonisamide cap 100 mg........................... 140
zonisamide cap 50 mg.................................................. 140
zonisamide cap 25 mg (Zonegran).............................. 140
zonisamide cap 100 mg (Zonegran)............................ 141
ZONTIVITY -vorapaxar sulfate tab 2.08 mg (base
equivalent)..................................................................... 158
ZORBTIVE -somatropin (non-refrigerated) for
subcutaneous inj 8.8 mg................................................ 50
ZORTRESS -everolimus tab 0.25 mg............................. 192
ZORTRESS -everolimus tab 0.5 mg............................... 192
ZORTRESS -everolimus tab 0.75 mg............................. 192
ZORVOLEX -diclofenac cap 18 mg................................ 132
ZORVOLEX -diclofenac cap 35 mg................................ 132
ZOSTAVAX -zoster vaccine live for inj 19400
unit/0.65ml....................................................................... 20
ZOVIA 1/50E -ethynodiol diacetate & ethinyl estradiol tab
1 mg-50 mcg................................................................... 35
ZOVIRAX -acyclovir cap 200 mg...................................... 14
ZOVIRAX -acyclovir cream 5%....................................... 177
ZOVIRAX -acyclovir oint 5%........................................... 177
ZOVIRAX -acyclovir susp 200 mg/5ml.............................. 14
ZOVIRAX -acyclovir tab 400 mg....................................... 14
ZOVIRAX -acyclovir tab 800 mg....................................... 14
Z-TUSS AC -chlorpheniramine w/ codeine liquid 2-9
mg/5ml............................................................................. 79
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
1.4-0.36 mg (base eq).................................................. 128
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
2.9-0.71 mg (base eq).................................................. 128
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 5.7-1.4
mg (base eq)................................................................ 128
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 8.6-2.1
mg (base eq)................................................................ 128
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 11.4-2.9
mg (base eq)................................................................ 128
ZUPLENZ -ondansetron oral soluble film 4 mg................ 88
ZUPLENZ -ondansetron oral soluble film 8 mg................ 88
ZUTRIPRO -pseudoeph-chlorphen w/ hydrocodone soln
60-4-5 mg/5ml................................................................. 79
ZYBAN -bupropion hcl (smoking deterrent) tab sr 12hr
150 mg.......................................................................... 118
ZYCLARA -imiquimod cream 3.75%...............................