BlueCross BlueShield Medicaid Formulary Guide...u = Included in tablet-splitting program. The medication can be cut in half to obtain the daily dose of medication (i.e., 20mg daily

If you have questions about your prescription drug benefit, visit the Pharmacy Services section of the BlueCross BlueShield web site at www.bcbswny.com.

A Division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. The Cross and Shield are registered trademarks of the BlueCross BlueShield Association.

BlueCross BlueShield Medicaid Formulary GuidePlease bring this guide with you the next time you visit your doctor.

MG46605A (Revise Date 07/01/2016)

M G 4 6 6 0 5 A* *

183894_MG46605A -BCBS WNY - Medicaid_v2.indd 1 6/1/16 12:51 PM


ii

IntroductIon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Formularies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

understandIng the symbols used throughout thIs book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

usIng thIs formulary book to help contaIn costs . iv

Save Money on Your Prescription Drugs . . . . . . . . . . . . . . . . . iv

Finding Medications in the Guide . . . . . . . . . . . . . . . . . . . . . . . iv

sectIon 1 — therapeutIc drug categorIes . . . . . . . . . . 1

sectIon II — medIcaId over-the-counter (otc) medIcatIon lIst . . . . . . . . . . . . . . . . . . . . . . . . . 5

sectIon III — Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

TABLE OF CONTENTS


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The BlueCross BlueShield Medicaid Formulary Guide is a list of drugs to help guide physicians and phar-macists to select the medication that provides the appropriate treatment for the best price.

IntroductIon

BlueCross Blue Shield of Western New York has established an independent committee of practicing physicians and a pharmacist to help ensure that our formularies are medically sound and that they support your patients’ health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories.

Formularies In order to serve the diverse needs of patients and their plan sponsors, BlueCross BlueShield of Western New York makes available this formulary design:

Closed Formulary—Features the requirement that prescribed drugs must be on the formulary in order for the member to receive coverage. If a prescription is written for a medication that is not on the formulary, the patient will be responsible for the full cost. If special circumstances necessitate that the patient take the nonpreferred drug, prescribers may request a coverage review. If coverage is approved, the medication will be covered. If coverage is not approved, the patient will be responsible for the full cost of the medication.

understandIng the symbols used throughout thIs book

Throughout this book, you will see certain symbols that indicate a management program is in place for selected medications. The symbols are as follows:

Key

P = A step edit applies to this drug. Step therapy means that in order to receive the medication with a step edit, a preferred medication must be tried first.

z = Specific quantity limits apply. Quantity limits are in place to ensure members receive the appropriate amount of medication not to exceed the maximum allowable daily dosage of medication.

= Prior authorization required. Prior authorization (also referred to as coverage review) means that a healthcare professional must submit clinical documentation to obtain approval for a member to receive the medication. Prior authorizations ensure medications are being used appropriately.

u = Included in tablet-splitting program. The medication can be cut in half to obtain the daily dose of medication (i.e., 20mg daily of simvastatin can be obtained by 1/2 tablet of simvastatin 40mg). A member will receive a 1-month supply for half their regular 1-month copay.

+ = Access restricted to network specialty pharmacies. Medications must be obtained through a specialty pharmacy.


iv

usIng thIs formulary book to help contaIn costs

We realize that the formulary may not include every drug from every manufacturer. However, using a generic or preferred drug can help you stay healthy at a more affordable cost.

Save Money on Your Prescription Drugs

Here’s what you can do to save money:

1. Bring this member guide to your doctor and review the cost-saving information below.

2. Ask your doctor whether a drug listed in this guide is right for you.

Lowest cost to you Highest cost to you

The amount you pay for a drug is determined by which medication you purchase and where it appears on the guide. Some drug plans also exclude certain drugs or classes of drugs from coverage. Please check your contract or other plan documents if you have a question about your specific drug coverage.

Finding Medications in the Guide

This guide lists medications two different ways:

Section 1: Alphabetically by drug category (such as Diabetes, Heart or Pain/Arthritis)

Locate a category on the guide to see what drugs are on the formulary. Generic drugs are listed as G and brand drugs are listed with a B.

Section 2: Alphabetically by drug name. Use this list to find your drug.

Questions? Please call Member Services at 1-866-544-7948 if you have any questions about the BlueCross BlueShield Medicaid Formulary Guide. For the most up-to-date version of the Guide, visit the Pharmacy Services section of our web site at www.bcbswny.com/NYSdrug.

Non-formulary drugs Formulary

brand-name drugsFormulary

generic drugs

Disclaimer: The BlueCross BlueShield Medicaid/Family Health Plus Formulary Guide is subject to change, as we regularly review medications and existing therapies for inclusion in the BlueCross BlueShield Medicaid Formulary Guide. The tier that a medication is currently in may change during the effective dates of the guides due to generic availability.


P = A step edit applies to this drug. z = Specific Quantity Limits Apply. = Prior Authorization Required.u = Included in Tablet-Splitting Program + = Access restricted to specialty pharmacy.

* Some drugs are limited to 1 unit of use package per dispensing.KEY: Note:

1

Allergy/Cough & ColdAntihistamines & Decongestants brompheniramine/

phenylephrine G brompheniramine

pseudoephedrine Gz cetirizine G chlorpheniramine/

pseudoephedrine G clemastine G cyproheptadine G dexchlorpheniramine G diphenhydramine G hydroxyzine HCL G hydroxyzine pamoate G loratadine G loratadine-D G promethazine G pseudoephedrine Gz Grastek B Histex IE Bz Oralair Bz Ragwitek B Semprex-D BExpectorant & Cough Products benzonatate G cardec/DM G guaifenesin 1200/DM G guaifenesin/codeine G hydrocodone/chlorpheniramine G hydrocodone/homatropine G promethazine/codeine G pseudoephedrine/codeine GMucolytic Agents acetylcysteine inh soln. GNasal Medicationsz azelastine 0.1% nasal spray G Flonase Allergy Relief Gz fluticasone nasal spray G ipratropium nasal spray Gz Nasacort OTC B

Alzheimer Agentsz donepezil G ergoloid mesylates Gz galantamine Gz rivastigamine Gz Exelon Patch Bz Namenda B

Bladder/KidneyAlkalinizers citric acid/sod citrate G potassium citrate GAnalgesics phenazopyridine GAnticholinergicsz oxybutynin Gz oxybutynin ER Gz tolterodine Gz tolterodine ER Gz trospium GBPHz finasteride G tamsulosin GCholinergic Agents bethanecol G

BloodAnticoagulants/antithrombotics anagrelide G clopidogrel G dipyridamole G enoxaparin G fondaparinux G heparin G jantoven G ticlopidine G warfarin G Aggrenox B Brilinta Bz Durlaza B Effient B Eliquis B Fragmin B

Innohep Bz Pradaxa Bz Savaysa B Xarelto Bz Zontivity BOther Blood Modifiers cilostazol G pentoxifylline G+z Actimmune B+ Aranesp B+ Epogen B+ Exjade B+ Jadenu B+ Leukine B Miacalcin inj. B Mircera B Neulasta B+ Neumega B+ Neupogen B+ Procrit B+z Promacta B+z Revlimid Bz Syprine B

Cancer DrugsAlkylating Agents cyclophosphamide G melphalan G CeeNu B Emcyt B Hexalen B Leukeran B Myleran BAntimetabolites capecitabine G mercaptopurine G methotrexate G Purixan BHormones anastrozole G bicalutamide G exemestane G flutamide G letrozole G leuprolide G megestrol G tamoxifen G Fareston B+z Xtandi B+z Zytiga BMiscellaneous etoposide G hydroxyurea G+z imatinib G mesna G+ temozolomide G topotecan G+z Afinitor B+ Arcalyst B+z Bosulif Bz Caprelsa Bz Cometriq Bz Cotellic B+z Erivedge B+z Farydak B+z Gilotrif B+ Hycamptin B+z Ibrance Bz Iclusig Bz Imbruvica B+z Inlyta B+ Intron A Bz Iressa B+z Jakafi B+z Lenvima B+z Lonsurf Bz Lynparza B Lysodren B Matulane B+z Mekinist B+z Nexavar B Nilandron Bz Ninlaro B+z Odomzo B+z Pomalyst B+z Signifor B

+z Sprycel B+ Stivarga B+z Sutent B+z Sylatron B+z Tafinlar Bz Tagrisso B+z Tarceva B+z Tasigna B+ Thalomid B+z Tykerb B+z Valchlor B+ Votrient B+z Xalkori B+z Zelboraf B+ Zolinza Bz Zydelig B+z Zykadia BRexinoids bexarotene G Targretin gel B

DiabetesAntidiabetic Agents, Injectable Apidra Bz Bydureon Bz Byetta B Humalog insulin B Humulin (all types) B Lantus B Levemir B Novolin B Novolog Bz Symlin Bz Tanzeum B Toujeo Bz Trulicity B Tresiba Bz Victoza BAntidiabetic Agents, Glucose Elevating Agents acarbose G chlorpropamide Gz glimepiride G glipizide Gz glipizide ER Gz glipizide/metformin G glyburide G glyburide micronized G metformin Gz metformin ER Gz metformin/glyburide Gz nateglinide Gz pioglitazone Gz repaglanide G tolazamide G tolbutamide G Afrezza Bz Avandamet Bz Avandaryl Bz Avandia Bz Farxiga B Glucagon Bz Glyxambi Bz Invokamet Bz Invokana Bz Janumet Bz Januvia Bz Jardiance B Jentadueto B Juvisync B Kazano B Kombiglyze B Nesina B Onglyza B Oseni Bz Synjardy B Tradjenta Bz Xigduo XR BDiabetic Test Strips Accu-Chek B Ascensia Breeze B Contour B FreeStyle B OneTouch B Precision B TRUEtest B

TRUEtrack B

EarAnti-infective Agents acetic acid otic G acetic acid/aluminum acetate G ofloxacin otic GAnti-infective/Anti-inflammatory combinations acetic acid HC otic G neomycin/polymyxin/HC otic G Ciprodex B

EyeAntiallergy Agents (Eye) azelastine ophth G cromolyn ophth G ketotifen opthalmic solution G Patanol BAnti-infective Agents bacitracin ophth G bacitracin/polymyxin G ciprofloxacin ophth G erythromycin ophth G gentamicin ophth G neomycin/bacitracin/poly B G ofloxacin ophth G polymyxin B/TMP G sulfacetamide 10% G tobramycin soln GAnti-inflammatory dexamethasone ophth G fluorometholone ophth G prednisolone acetate G prednisolone sod acetate G FML Forte B FML S.O.P. B Lotemax suspension B Pred Mild BAnti-inflammatory/Anti-infective combinations dexameth/neomycin/poly B G neomycin/bacitracin/poly B/HC G sulfacetamide/prednisolone

ophth G tobramycin/dexameth GAntiviralz famciclovir G trifluridine GBeta-Blockers (Eye) betaxolol HCl G carteolol G levobunolol G metipranolol G timolol G Betoptic-S BCarbonic Anhydrase Inhibitors dorzolamide 2% eye drops G dorzolamide/timolol eye drops G Azopt BMiotics pilocarpine G Isopto Carbachol 1.5% B Phospholine Iodide BMiscellaneous Cystaran BMydriatics atropine sulfate ophth G homatropine G tropicamide GNSAIDs bromfenac G flurbiprofen ophth G ketorolac tromethamine G Nevanac BProstaglandin Analogues/Prostamines latanoprost G travoprost G Lumigan BSympathomimetics brimonidine GVasoconstrictors naphazoline G phenylephrine ophth G

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Section i — therapeutic drug categorieS




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Gout allopurinol G colchicine/probenecid G indomethacin G probenecid G Colcrys B

HeartAngiotensin Converting Enzyme Inhibitors benazepril G captopril G enalapril G fosinopril G lisinopril G quinapril G ramipril GAngiotensin II Antagonistsz candesartan Gz eprosartan Gz irbesartan Gz losartan Gz telmisartan Gz valsartan GAnti-Adrenergic Blockers Centrally acting clonidine, oral, patch G guanabenz G guanfacine G methyldopa G midodrine G Dibenzyline B+z Northera BAnti-Adrenergic Blockers Peripheral doxazosin G prazosin G terazosin GAntiarrhythmics amiodarone G digoxin G disopyramide G disopyramide CR G flecainide G mexiletine G propafenone G quinidine gluconate G quinidine sulfate SR G sotalol GAntilipidemics atorvastatin calcium G cholestyramine G colestipol G fenofibrate G fenofibric acid, tab G fluvastatin G gemfibrozil Gzu lovastatin G niacin ER Gzu pravastatin G rosuvastatin Gzu simvastatin G+z Kynamro B+z Praluent B+z Repatha Bz Zetia BBeta Blockers acebutolol G atenolol G betaxolol G bisoprolol G carvedilol G labetalol G metoprolol G metoprolol ER G nadolol G pindolol G propranolol G timolol GCalcium Channel Blockers amlodipine G cartia XT G diltia XT G diltiazem G diltiazem CD/SR/ER/XR G felodipine ER G isradipine G nicardipine G

nifediac CC G nifedical XL G nifedipine G nifedipine SR G nimodipine G nisoldipine G verapamil G verapamil SR GCombination Anti-Hypertensive amlodipine/benazepril G atenolol/chlorthalidone G benazepril/HCTZ G bisoprolol/HCTZ Gz candesartan/HCTZ G captopril/HCTZ G enalapril/HCTZ Gz irbesartan/HCTZ G lisinopril/HCTZ Gz losartan HCT G methyldopa/HCTZ G metoprolol/HCTZ G propranolol/HCTZ G quinapril/HCTZ Gz telmisartan/HCTZ Gz valsartan/HCTZ GDiuretics acetazolamide G acetazolamide ER G amiloride G amiloride/HCTZ G bumetanide G chlorothiazide G chlorthalidone G furosemide G hydrochlorothiazide G indapamide G methazolamide G metolazone G spironolactone G spironolactone/HCTZ G torsemide G triamterene/HCTZ GMiscellaneous Cardiovascular Agents eplerenone G midodrine G Berinert B+ Cinryze B+ Firazyr B Ranexa Bz Ruconest Bz Samsca Bz Tekturna Bz Tekturna HCT BPulmonary Arterial Hypertension+ epoprostenol G+ veletri G+z Adcirca B+z Adempas B+z Letairis B+z Opsumit B+z Orenitram B+z Tracleer Bz Uptravi BVasodilators hydralazine G isosorbide dinitrate G isosorbide mononitrate G isosorbide mononitrate SA G isoxsuprine G minoxidil oral G nitroglycerin oint G nitroglycerin pumpspray G nitroglycerin SR G nitroglycerin transdermal patch G Dilatrate SR B Nitrostat B

HIV - AntiviralsNon-Nucleoside Reverse Transcriptase Inhibitor nevirapine G Atripla B Intelence B Rescriptor B Sustiva B Viramune XR B

Nucleoside Analog Reverse Transcriptase Inhibitor Combination abacavir/lamivudine/

zidovudine G lamivudine/zidovudine G Dutrebis B Stribild B Triumeq B Truvada B Viread BNucleoside Reverse Transcriptase Inhibitors abacavir sulfate G didanosine G lamivudine G stavudine G zidovudine G Emtriva B Epivir solution B Epzicom B Retrovir IV infusion vial B Videx B Videx pediatric solution BOther Complera B Edurant B+ Fuzeon B Genvoya B Isentress B Odefsey B Selzentry B Tivicay B Tybost B Vitekta BProtease Inhibitors Aptivus B Crixivan B Evotaz B Invirase B Lexiva B Norvir B Prezcobix B Prezista B Reyataz B Viracept BProtease Inhibitors Combinations Kaletra B

Huntington’s Disease+z tetrabenazine G

Immunosuppressants azathioprine G cyclosporine G gengraf G mycophenolate mofetil G sirolimus G tacrolimus G Astagraf XL Bz Envarsus XR B Sandimmune B

InfectionAntibacterial agents/Antibiotics amoxicillin G amoxicillin-clavulanate ER G ampicillin G azithromycin suspension G azithromycin tablets G cefaclor G cefadroxil G cefdinir G cefpodoxime G cefprozil G cefuroxime G cephalexin G ciprofloxacin G clarithromycin susp G clarithromycin tabs G clindamycin G dicloxacillin G doxycycline G erythromycin base G erythromycin ethylsuccinate G erythromycin stearate G

erythromycin/sulfisoxazole G minocycline G ofloxacin G penicillin VK G sulfamethoxazole/trimethoprim G tetracycline G Ery-Tab B Ketek B Zmax BAntifungals ciclodan G clotrimazole lozenge G fluconazole G flucytosine G griseofulvin Gz itraconazole G ketoconazole G nystatin Gz terbinafine Gz voriconazole GAntimalarials chloroquine phosphate G hydroxychloroquine G mefloquine G Daraprim B Malarone B Primaquine BAntituberculosis ethambutol G isoniazid G pyrazinamide G rifabutin G rifampin G Coartem B Rifater BAntiviralsz acyclovir oral G amantadine Gz famciclovir G ganciclovir G lamivudine tabs G ribapak G+ ribasphere G+ ribavirin G rimantadine Gz valacyclovir G valganciclovir tablets G+Pz Daklinza B Epivir-HBV solution B+z Harvoni Bz Hepsera B+z Olysio B+ Pegasys Bz Relenza B+z Sovaldi Bz Tamiflu B+Pz Technivie B+Pz Viekira Pak BPz Zepatier BOther Anti-Infectives atovaquone G methenamine combination G metronidazole G neomycin G nitrofurantoin G paromomycin G+ tobramycin amp/neb G trimethoprim G vancomycin G Dapsone B Nebupent Bz Sivextro B+ Tobi Podhaler Bz Zyvox B

Men’s HealthImpotence - possible contract exclusion; refer to individual contract yohimbine GMale Hormones Androderm patch Bz Androgel Bz Axiron Bz Fortesta Bz Natesto Bz Testim B

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Section i — therapeutic drug categorieS (cont’d)




3

z Testosterone gel Bz Vogelxo BProstate Healthz alfuzosin Gz finasteride G tamsulosin G

Mental HealthAntidepressants amitriptyline G amitriptyline/chlordiazepoxide G amitriptyline/perphenazine G amoxapine Gz bupropion Gz bupropion ER Gz bupropion XL Gu citalopram G clomipramine G desipramine G doxepin G duloxetine Gu escitalopram Gu fluoxetine 10, 20mg tablet G fluoxetine capsule G fluvoxamine ER Gu fluvoxamine tab G imipramine G maprotiline Gu mirtazapine G nefazodone G nortriptyline Gu paroxetine HCl G phenelzine Gu sertraline G tranylcypromine G trazodone Gu venlafaxine G venlafaxine ER G Desvenlafaxine ER B Desvenlafaxine fumarate B Fetzima B Fluoxetine 60mg tablet B Khedezla B Pexeva B Pristiq B Trintellix B Viibryd BAntimanic Agents lithium carbonate GAntipsychotic Agents aripiprazole G chlorpromazine G clozapine G fluphenazine decanoate G fluphenazine, oral G haloperidol decanoate G haloperidol, oral G loxapine Gz olanzapine Gz olanzapine/fluoxetine G paliperidone G perphenazine Gz quetiapine Gz risperidone Gz risperidone m-tab G thioridazine G thiothixene G trifluoperazine Gz ziprasidone caps Gz Fanapt Bz Latuda Bz Rexulti Bz Saphris Bz Seroquel XR B Versacloz Bz Vraylar BAnxiolytics, Sedatives, and Hypnotics alprazolam/ER G buspirone G chloral hydrate G chlordiazepoxide G clorazepate G diazepam G estazolam G flurazepam G lorazepam G

meprobamate G oxazepam G temazepam G triazolam Gz zaleplon Gz zolpidem Gz zolpidem CR G+z Hetlioz BCerebral Stimulants dexmethylphenidate G dexmethylphenidate ER G dextroamphetamine tabs G generic Adderall G generic Adderall XR G generic Concerta G generic Dexedrine spansules G metadate ER G methylphenidate/SR/CD Gz modafinil G procentra G Daytrana B Intuniv Bz Nuvigil B Strattera B

MiscellaneousAntidiuretic Agents desmopressin solution G desmopressin tabs G desmopressin vial 4mcg/ml G+ Stimate BOther CNS acamprosate calcium tablet EC G buprenorphine HCl G disulfiram G naltrexone G Campral dosepack Bz Narcan Nasal Spray B Rilutek B Savella B Suboxone Film BOther Endocrine danazol G fludrocortisone G+ octreotide G+z Acthar H.P. gel B+z Cerdelga B Egrifta B+ Genotropin B+ Humatrope B+z Myalept B+ Natpara B+ Norditropin B+ Nutropin B+ Omnitrope B+ Saizen B+ Sensipar B+z Somavert B Synarel B+ Tev-Tropin B+z Zavesca B+ Zorbtive BOther Miscellaneous+ Gamunex C B+ Hizentra Bz Keveyis B Procysbi B+ Ravicti B Strensiq B

Multiple Sclerosis Agents+ glatopa G+ Ampyra B+z Aubagio B+ Avonex B+ Betaseron B+ Copaxone 40mg B+ Extavia B+z Gilenya B+z Plegridy B+ Rebif B+z Tecfidera B

Muscle Relaxants baclofen G carisoprodol G carisoprodol/ASA G chlorzoxazone G cyclobenzaprine G dantrolene sodium G diazepam G methocarbamol G orphenadrine G tizanidine G

Osteoporosisz alendronate Gz calcitonin-salmon Gz fortical NS Gz ibandronate Gz raloxifene Gz risedronate 150mg Gz risedronate DR Gz Actonel 5mg, 30mg Bz Actonel with Calcium Bz Binosto Bz Fosamax Plus D B+z Forteo B

Pain/ArthritisAnalgesics, Narcotic acetaminophen w/codeine G belladonna & opium supp G butorphanol NS G codeine sulfate G endocet Gz fentanyl lozenge G fentanyl patch G hydrocodone/ibuprofen G hydromorphone G meperidine G meperidine/promethazine G methadone G morphine SR G morphine tab, soln, supp G MSIR tabs, sol G oxycodone G oxycodone/acetaminophen G oxycodone/aspirin G oxymorphone ER G pentazocine/naloxone G Opana ER BAnalgesics, Salicylates aspirin SR G choline mag. trisalicylate G diflunisal G salsalate GAnti-Rheumatic hydroxychloroquine G leflunomide G methotrexate G+z Actemra SC Bz Cuprimine B+z Enbrel B+z Humira Bz Kineret B+z Orencia B+z Otezla B Ridaura B+z Simponi B+z Xeljanz BCox-2sz celecoxib GMigraine (Analgesics, Non-narcotic) butalbital/APAP G butalbital/APAP/caffeine G butalbital/aspirin/caffeine G dihydroergotamine mesylate G ergotamine/caffeine G isometh/dichloralphen/APAP Gz naratriptan Gz sumatriptan G tramadol G Ergomar BNonsteroidal Anti-Inflammatory/ Combination Products diclofenac potassium G diclofenac sodium G

etodolac G etodolac SA G fenoprofen G flurbiprofen G ibuprofen G indomethacin G ketoprofen G ketorolac inj. Gz ketorolac tab G meclofenamate G meloxicam G nabumetone G naproxen G naproxen EC G piroxicam G sulindac G Voltaren gel B

Parkinson’s Disease amantadine G benztropine G bromocriptine G carbidopa/levodopa G carbidopa/levodopa SA G carbidopa/levodopa/entacapone G entacapone G pramipexole G ropinirole Gz selegiline G trihexyphenidyl G+ Apokyn B+z Duopa B

PotassiumPotassium agents potassium bicarbonate G potassium chloride GPotassium Removing agent sod. polystyrene sulfonate G

Respiratory/AsthmaAdrenergic epinephrine inj. G Epipen/Jr. BCorticosteroids budesonide inh. (0.25mg/2ml,

0.5mg/2ml) Gz Alvesco Bz Flovent Diskus Bz Flovent HFA Bz Pulmicort Flexhaler Bz Qvar Bz Symbicort BLeukotrienesz montelukast Gz zafirlukast GOther Agents cromolyn inh. soln. G ipratropium inh. soln. Gz Advair diskus Bz Atrovent/HFA Bz Combivent Respimat Bz Dulera B+z Esbriet B+z Kalydeco B+z Ofev B+z Orkambi B+ Pulmozyme Bz Spiriva Bz Spiriva Respimat Bz Stiolto Respimat BSympathomimeticsz albuterol sulfate ER Gz albuterol tab, syr G metaproterenol syr G terbutaline tab Gz Maxair Autohaler Bz ProAir HFA/RespiClick Bz Serevent Diskus Bz Ventolin HFA BXanthine Derivatives aminophylline G theochron G theophylline/SR tabs, liquid G

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4

SeizuresBarbiturates phenobarbital GHydantoins phenytoin GMiscellaneous carbamazepine G carbamazepine XR 200mg,

400mg G clonazepam G divalproex sodium/ER G felbamate G gabapentin G lamotrigine G levetiracetam G oxcarbazepine G primidone G tiagabine G topiramate G valproic acid G zonisamide G Aptiom B Banzel B Equetro Bz Fycompa B Gabitril B Lyrica B Onfi B Potiga B Qudexy XR B Sabril B Spritam B Topiramate ER (SSB) capsules B Trokendi XR BSuccinimides ethosuximide G Celontin B

SkinAcne adapalene G amnesteem G avita cream G benzoyl peroxide G claravis G erythromycin/benz peroxide G prascion RA G sod.sulfacetamide/sulfur

emulsion cleanser G sod. sulfacetamide/sulfur lot G sotret G sulfacetamide G tretinoin cr/gel G Tazorac BAntibiotics (Topical) acitretin G clindamycin sol/swabs/gel/

lotion G erythromycin sol/swabs/gel G gentamicin cr/oint G metronidazole cream/lotion/gel G mupirocin G Centany BAntipsoriatics calcipotriene ointment G calcipotriene solution G tacrolimus ointment G+z Cosentyx B Elidel B+z Stelara BBurn preparation silver sulfadiazine GFungicides betamethasone/clotrimazole G ciclopirox cream/gel G ciclopirox soln G econazole G ketoconazole G nystatin G nystatin/triamcinolone G nystop G Exelderm B Oxistat B

Other Topicals aluminum chloride 20% G fluorouracil G imiquimod 5% cream G podofilox G sodium chloride irrigating soln G Carac B Phisohex B Regranex BPsoralens 8-MOP B Oxsoralen Ultra BScabicides & Pediculicides acticin G Lindane B Ulesfia BTopical Anti-Inflammatory Agents alclometasone G amcinonide G betamethasone dipropionate G betamethasone dipropionate

augmented oint G betamethasone valerate G clobetasol propionate G desonide G desoximetasone G diflorasone G fluocinolone acetonide G fluocinonide 0.05% G fluticasone propionate G halobetasol G hydrocortisone 2.5% G hydrocortisone valerate G hydrocortisone/iodoquinol G hydrocortisone/urea G mometasone cr/oint Gz triamcinolone acetonide G Cordran tape BTopical Antipruritics/Anesthetics lidocaine Gz lidocaine patch G selenium sulf 2.25% shampoo GTopical Antivirals acyclovir G

Smoking CessationMembers coverage varies by plan. Patient should be in a smoking cessation program.z bupropion Gz Nicotine Gum Gz Nicotine lozenges Gz Nicotine patches various Gz Chantix Bz Commit Bz Nicotrol Inhaler/NS B

Steroids cortisone acetate G dexamethasone oral G hydrocortisone oral G methylprednisolone G prednisolone ODT G prednisolone oral G prednisone oral G

Stomach/UlcerAnorectal hydrocortisone/pramoxine G hydrocortisone rectal cr. & supp. G hydrocortisone rectal enema G pramoxine/HC acetate 2.5% G Cortifoam B Proctofoam-HC BAnticholinergics/Antispasmodic/ GI Motility belladonna/phenobarbital G chlordiazepoxide/clindinium G dicyclomine G glycopyrrolate G hyoscyamine/CR G metoclopramide G Donnatal B

Antidiarrheal diphenoxylate/atropine G paregoric Gz Alinia B Fulyzaq BAntiemetic/Antivertigoz granisetron G meclizine Gz ondansetron G prochlorperazine G promethazine G trimethobenzamide Gz Emend B Transderm Scop BBowel Evacuants peg 3350/electrolyte GDigestants Creon B Pancreaze B Pertzye B Ultresa B Viokace B Zenpep BGallstone Solubilizing Agents ursodiol GH2 Antagonists cimetidine G famotidine G nizatidine G ranitidine (all) GOther Antiulcer misoprostol G sucralfate GOther GI Products cromolyn sodium G enulose G lactulose G mesalamine enema G sulfasalazine G sulfasalazine EC G Asacol B Asacol HD B Canasa supp. B Cholbam B+z Cimzia B Delzicol B Dipentum B+ Gattex B+ Kuvan B Linzess B Pentasa Bz Relistor B Uceris ER tablet BProton Pump Inhibitorsz lansoprazole Gz omeprazole Gz pantoprazole Gz Prilosec-OTC G

ThyroidAntithyroid methimazole G propylthiouracil GThyroid levothroid G levothyroxine G levoxyl G liothyronine G thyroid G unithroid G Synthroid B Thyrolar B

Vitamins calcitriol G calcium acetate G cyanocobalamin inj. G etidronate disodium G folic acid G leucovorin G levocarnitine G multivitamin + fluoride G phytonadione G potassium aminobenzoate G pre-natal vitamins G

sodium fluoride chewable tab & drops G

vit A,D,C + fluoride G vit A,D,C + fluoride and iron G Galzin B Mephyton B Nascobal B Orfadin B Renvela B

Women’s HealthContraceptives - Otherz xulane G Mirena B NuvaRing BHormonesz estradiol/noreth ac Gz estradiol oral Gz estradiol patches Gz estropipate Gz estrogen/methyltesterone G medroxyprogesterone G norethindrone G progesterone, micronized G Cenestin Bz Climara Pro Bz Combipatch B Enjuvia Bz Estring Bz Evamist B Menest B Premarin B Premarin vag cream B Premphase B Prempro B Vagifem BMiscellaneous Brisdelle BOral Contraceptives amethia G apri G aranelle G aviane G balziva G camila G camrese G cesia G cryselle G enpresse G errin G jolessa G jolivette G junel/FE G kariva G lessina Gz levonorgestrel G levora G low-ogestrel G lutera G microgestin/FE G mononessa G necon Gz next choice Gz next choice one dose G nora-BE G norethindrone a-e estradiol/

ferrous fumarate G nortrel G ocella G ogestrel G portia G previfem G quasense G solia G sprintec G tri-sprintec G trinessa G trivora G velivet G zarah G zenchent G zovia GVaginal Preparations miconazole vag supp G nystatin vag tab G terconazole G vandazole vag G





acetaminophen

AFRIN

ALAVERT

alum/mag hydroxide w/simethicone

aluminum acetate

aluminum hydroxide

artificial tears

aspirin

aspirin buffered

B complex w/ vitamin C

bacitracin

BENADRYL

BENEFIBER

benzoyl peroxide

beta-carotene

bisacodyl

bismuth subsalicylate

calcium + vitamin D

calcium carbonate

calcium lactate

CENTRA-VITE

CENTRUM SILVER

cetirizine HCl

children’s vitamin with minerals

children’s acetaminophen

children’s cold & cough

CHILDREN’S MUCINEX

CHILDREN’S PEPTO

chlorpheniramine maleate

cimetidine

clotrimazole vaginal

cold multi-symptom nighttime

daytime cold & flu

diabetic tussin DM

DIMAPHEN

dimenhydrinate

DIMETAPP

DIMETAPP DM

diphenhydramine HCl

docusate sodium

DRAMAMINE

famotidine

fexofenadine

fiber tabs

fiber therapy

GAVISCON

guaifenesin

guaifenesin DM

hydrocortisone

hydrocortisone acetate

ibuprofen

iron

lice treatment

loperamide solution

loratadine

loratadine-D

lubricant eye drops

MAALOX

MAALOX PLUS EXTRA STRENGTH

magnesium

magnesium gluconate

mag-oxide

meclizine HCl

METAMUCIL

MICONAZOLE 3

MICONAZOLE 7

miconazole nitrate

MILK OF MAGNESIA

mineral oil

MONISTAT 1

MUCINEX

MUCINEX DM

multivitamin

multivitamin w/iron

multivitamin w/iron

multivitamin w/minerals

multivitamin with calcium-iron

MYLANTA

NASACORT OTC

nasal moisturizer

niacin

NICODERM CQ

NICOTINE GUM

nighttime cold & flu relief

NIX

OCUTABS

OCUVITE

OCUVITE PRESERVISION

omeprazole

oxymetazoline HCl

oyster shell calcium

oyster shell calcium w/vit D

pedia relief cough & cold

pediatric electrolyte

PEPCID COMPLETE

PEPTO-BISMOL

permethrin

PINX

polyethylene glycol

prenatal

PRILOSEC OTC

pyridoxine HCl

ranitidine HCl

reese’s pinworm

ROBITUSSIN

ROBITUSSIN-DM

saline nasal spray

senna

sennosides

SENOKOT

sinus congestion & pain

sochlor

SPECTRAVITE

SPECTRAVITE SENIOR

SUDAFED PE

SUDAFED SINUS NIGHTTIME

suphedrine PE

SYSTANE

THERAFLU

THERA-M

tolnaftate

tussin

tussin DM

TYLENOL SINUS

VISINE

vitamin A

vitamin B-1

vitamin C

vitamin D

vitamin D3

vitamins A-D-E

ZANTAC OTC

5

Section ii — Medicaid over-the-counter (otc) Medication LiSt




6

Aabacavir sulfate G 2abacavir/lamivudine/

zidovudine G 2acamprosate calcium

tablet EC G 3acarbose G 1Accu-Chek B 1acebutolol G 2acetaminophen w/codeine G 3acetazolamide G 2acetazolamide ER G 2acetic acid HC otic G 1acetic acid otic G 1acetic acid/aluminum acetate G 1acetylcysteine inh soln. G 1acitretin G 4+zActemra SC B 3+zActhar H.P. gel B 3acticin G 4+zActimmune B 1zActonel 5mg, 30mg B 3zActonel with Calcium B 3acyclovir G 4zacyclovir oral G 2adapalene G 4+zAdcirca B 2+zAdempas B 2zAdvair diskus B 3+zAfinitor B 1Afrezza B 1Aggrenox B 1zalbuterol sulfate ER G 3zalbuterol tab, syr G 3alclometasone G 4zalendronate G 3zalfuzosin G 3zAlinia B 4allopurinol G 2alprazolam/ER G 3aluminum chloride 20% G 4zAlvesco B 3amantadine G 2amantadine G 3amcinonide G 4amethia G 4amiloride G 2amiloride/HCTZ G 2aminophylline G 3amiodarone G 2amitriptyline G 3amitriptyline/chlordiazepoxide G 3amitriptyline/perphenazine G 3amlodipine G 2amlodipine/benazepril G 2amnesteem G 4amoxapine G 3amoxicillin G 2amoxicillin-clavulanate ER G 2ampicillin G 2+Ampyra B 3anagrelide G 1anastrozole G 1Androderm patch B 2zAndrogel B 2Apidra B 1+Apokyn B 3apri G 4Aptiom B 4Aptivus B 2aranelle G 4+Aranesp B 1+Arcalyst B 1aripiprazole G 3Asacol B 4Asacol HD B 4Ascensia Breeze B 1aspirin SR G 3Astagraf XL B 2atenolol G 2atenolol/chlorthalidone G 2atorvastatin calcium G 2atovaquone G 2Atripla B 2atropine sulfate ophth G 1zAtrovent/HFA B 3+zAubagio B 3zAvandamet B 1zAvandaryl B 1zAvandia B 1aviane G 4avita cream G 4+Avonex B 3zAxiron B 2azathioprine G 2zazelastine 0.1% nasal spray G 1azelastine ophth G 1azithromycin suspension G 2azithromycin tablets G 2Azopt B 1

Bbacitracin ophth G 1bacitracin/polymyxin G 1baclofen G 3balziva G 4Banzel B 4belladonna & opium supp G 3belladonna/phenobarbital G 4benazepril G 2benazepril/HCTZ G 2benzonatate G 1benzoyl peroxide G 4benztropine G 3Berinert B 2betamethasone dipropionate G 4betamethasone dipropionate

augmented oint G 4betamethasone valerate G 4betamethasone/

clotrimazole G 4+Betaseron B 3betaxolol G 2betaxolol HCl G 1bethanecol G 1Betoptic-S B 1bexarotene G 1bicalutamide G 1zBinosto B 3bisoprolol G 2bisoprolol/HCTZ G 2+zBosulif B 1Brilinta B 1brimonidine G 1Brisdelle B 4bromfenac G 1bromocriptine G 3brompheniramine/

pseudoephedrine G 1brompheniramine/

phenylephrine G 1budesonide inh.

(0.25mg/2ml, 0.5mg/2ml) G 3bumetanide G 2buprenorphine HCl G 3zbupropion G 3zbupropion G 4zbupropion ER G 3zbupropion XL G 3buspirone G 3butalbital/APAP G 3butalbital/APAP/caffeine G 3butalbital/aspirin/caffeine G 3butorphanol NS G 3zBydureon B 1zByetta B 1

Ccalcipotriene ointment G 4calcipotriene solution G 4zcalcitonin-salmon G 3calcitriol G 4calcium acetate G 4camila G 4Campral dosepack B 3camrese G 4Canasa supp. B 4zcandesartan G 2zcandesartan/HCTZ G 2capecitabine G 1zCaprelsa B 1captopril G 2captopril/HCTZ G 2Carac B 4carbamazepine G 4carbamazepine XR

200mg, 400mg G 4carbidopa/levodopa G 3carbidopa/levodopa SA G 3carbidopa/levodopa/

entacapone G 3cardec/DM G 1carisoprodol G 3carisoprodol/ASA G 3carteolol G 1cartia XT G 2carvedilol G 2CeeNu B 1cefaclor G 2cefadroxil G 2cefdinir G 2cefpodoxime G 2cefprozil G 2cefuroxime G 2zcelecoxib G 3Celontin B 4Cenestin B 4Centany B 4cephalexin G 2+zCerdelga B 3cesia G 4zcetirizine G 1zChantix B 4chloral hydrate G 3chlordiazepoxide G 3

chlordiazepoxide/clindinium G 4chloroquine phosphate G 2chlorothiazide G 2chlorpheniramine/

pseudoephedrine G 1chlorpromazine G 3chlorpropamide G 1chlorthalidone G 2chlorzoxazone G 3Cholbam B 4cholestyramine G 2choline mag. trisalicylate G 3ciclodan G 2ciclopirox cream/gel G 4ciclopirox soln G 4cilostazol G 1cimetidine G 4+zCimzia B 4+Cinryze B 2Ciprodex B 1ciprofloxacin G 2ciprofloxacin ophth G 1ucitalopram G 3citric acid/sod citrate G 1claravis G 4clarithromycin susp G 2clarithromycin tabs G 2clemastine G 1zClimara Pro B 4clindamycin G 2clindamycin sol/swabs/

gel/lotion G 4clobetasol propionate G 4clomipramine G 3clonazepam G 4clonidine, oral, patch G 2clopidogrel G 1clorazepate G 3clotrimazole lozenge G 2clozapine G 3Coartem B 2codeine sulfate G 3colchicine/probenecid G 2Colcrys B 2colestipol G 2zCombipatch B 4zCombivent Respimat B 3zCometriq B 1zCommit B 4Complera B 2Contour B 1+Copaxone 40mg B 3Cordran tape B 4Cortifoam B 4cortisone acetate G 4+zCosentyx B 4zCotellic B 1Creon B 4Crixivan B 2cromolyn inh. soln. G 3cromolyn ophth G 1cromolyn sodium G 4cryselle G 4zCuprimine B 3cyanocobalamin inj. G 4cyclobenzaprine G 3cyclophosphamide G 1cyclosporine G 2cyproheptadine G 1Cystaran B 1

D+PzDaklinza B 2danazol G 3dantrolene sodium G 3Dapsone B 2Daraprim B 2Daytrana B 3Delzicol B 4desipramine G 3desmopressin solution G 3desmopressin tabs G 3desmopressin vial 4mcg/ml G 3desonide G 4desoximetasone G 4Desvenlafaxine ER B 3Desvenlafaxine fumarate B 3dexameth/neomycin/poly B G 1dexamethasone ophth G 1dexamethasone oral G 4dexchlorpheniramine G 1dexmethylphenidate G 3dexmethylphenidate ER G 3dextroamphetamine tabs G 3diazepam G 3diazepam G 3Dibenzyline B 2diclofenac potassium G 3diclofenac sodium G 3dicloxacillin G 2dicyclomine G 4didanosine G 2diflorasone G 4diflunisal G 3digoxin G 2

dihydroergotamine mesylate G 3Dilatrate SR B 2diltia XT G 2diltiazem G 2diltiazem CD/SR/ER/XR G 2Dipentum B 4diphenhydramine G 1diphenoxylate/atropine G 4dipyridamole G 1disopyramide G 2disopyramide CR G 2disulfiram G 3divalproex sodium/ER G 4zdonepezil G 1Donnatal B 4dorzolamide 2% eye drops G 1dorzolamide/timolol

eye drops G 1doxazosin G 2doxepin G 3doxycycline G 2zDulera B 3duloxetine G 3+zDuopa B 3zDurlaza B 1Dutrebis B 2

Eeconazole G 4Edurant B 2Effient B 1Egrifta B 38-MOP B 4Elidel B 4Eliquis B 1Emcyt B 1zEmend B 4Emtriva B 2enalapril G 2enalapril/HCTZ G 2+zEnbrel B 3endocet G 3Enjuvia B 4enoxaparin G 1enpresse G 4entacapone G 3enulose G 4zEnvarsus XR B 2epinephrine inj. G 3Epipen/Jr. B 3Epivir solution B 2Epivir-HBV solution B 2eplerenone G 2+Epogen B 1+epoprostenol G 2zeprosartan G 2Epzicom B 2Equetro B 4ergoloid mesylates G 1Ergomar B 3ergotamine/caffeine G 3+zErivedge B 1errin G 4Ery-Tab B 2erythromycin base G 2erythromycin

ethylsuccinate G 2erythromycin ophth G 1erythromycin sol/swabs/gel G 4erythromycin stearate G 2erythromycin/benz peroxide G 4erythromycin/sulfisoxazole G 2+zEsbriet B 3uescitalopram G 3estazolam G 3zestradiol oral G 4zestradiol patches G 4zestradiol/noreth ac G 4zEstring B 4zestrogen/methyltesterone G 4zestropipate G 4ethambutol G 2ethosuximide G 4etidronate disodium G 4etodolac G 3etodolac SA G 3etoposide G 1zEvamist B 4Evotaz B 2Exelderm B 4zExelon Patch B 1exemestane G 1+Exjade B 1+Extavia B 3

Fzfamciclovir G 1zfamciclovir G 2famotidine G 4zFanapt B 3Fareston B 1zFarxiga B 1+zFarydak B 1felbamate G 4felodipine ER G 2

fenofibrate G 2fenofibric acid, tab G 2fenoprofen G 3zfentanyl lozenge G 3fentanyl patch G 3Fetzima B 3zfinasteride G 1zfinasteride G 3+Firazyr B 2flecainide G 2Flonase Allergy Relief G 1zFlovent Diskus B 3zFlovent HFA B 3fluconazole G 2flucytosine G 2fludrocortisone G 3fluocinolone acetonide G 4fluocinonide 0.05% G 4fluorometholone ophth G 1fluorouracil G 4ufluoxetine 10, 20mg tablet G 3Fluoxetine 60mg tablet B 3fluoxetine capsule G 3fluphenazine decanoate G 3fluphenazine, oral G 3flurazepam G 3flurbiprofen G 3flurbiprofen ophth G 1flutamide G 1zfluticasone nasal spray G 1fluticasone propionate G 4fluvastatin G 2fluvoxamine ER G 3ufluvoxamine tab G 3FML Forte B 1FML S.O.P. B 1folic acid G 4fondaparinux G 1+zForteo B 3zFortesta B 2zfortical NS G 3zFosamax Plus D B 3fosinopril G 2Fragmin B 1FreeStyle B 1Fulyzaq B 4furosemide G 2+Fuzeon B 2zFycompa B 4

Ggabapentin G 4Gabitril B 4zgalantamine G 1Galzin B 4+Gamunex C B 3ganciclovir G 2+Gattex B 4gemfibrozil G 2generic Adderall G 3generic Adderall XR G 3generic Concerta G 3generic Dexedrine spansules G 3gengraf G 2+Genotropin B 3gentamicin cr/oint G 4gentamicin ophth G 1Genvoya B 2+zGilenya B 3+zGilotrif B 1+glatopa G 3zglimepiride G 1glipizide G 1zglipizide ER G 1zglipizide/metformin G 1Glucagon B 1glyburide G 1glyburide micronized G 1glycopyrrolate G 4zGlyxambi B 1zgranisetron G 4zGrastek B 1griseofulvin G 2guaifenesin 1200/DM G 1guaifenesin/codeine G 1guanabenz G 2guanfacine G 2

Hhalobetasol G 4haloperidol decanoate G 3haloperidol, oral G 3+zHarvoni B 2heparin G 1zHepsera B 2+zHetlioz B 3Hexalen B 1Histex IE B 1+Hizentra B 3homatropine G 1Humalog insulin B 1+Humatrope B 3+zHumira B 3Humulin (all types) B 1+Hycamptin B 1

hydralazine G 2hydrochlorothiazide G 2hydrocodone/

chlorpheniramine G 1hydrocodone/homatropine G 1hydrocodone/ibuprofen G 3hydrocortisone 2.5% G 4hydrocortisone oral G 4hydrocortisone rectal

cr. & supp. G 4hydrocortisone rectal enema G 4hydrocortisone valerate G 4hydrocortisone/iodoquinol G 4hydrocortisone/pramoxine G 4hydrocortisone/urea G 4hydromorphone G 3hydroxychloroquine G 2hydroxychloroquine G 3hydroxyurea G 1hydroxyzine HCL G 1hydroxyzine pamoate G 1hyoscyamine/CR G 4

Izibandronate G 3+zIbrance B 1ibuprofen G 3zIclusig B 1+zimatinib G 1zImbruvica B 1imipramine G 3imiquimod 5% cream G 4indapamide G 2indomethacin G 2indomethacin G 3+zInlyta B 1Innohep B 1Intelence B 2+Intron A B 1Intuniv B 3Invirase B 2zInvokamet B 1zInvokana B 1ipratropium inh. soln. G 3ipratropium nasal spray G 1zirbesartan G 2zirbesartan/HCTZ G 2zIressa B 1Isentress B 2isometh/dichloralphen/APAP G 3isoniazid G 2Isopto Carbachol 1.5% B 1isosorbide dinitrate G 2isosorbide mononitrate G 2isosorbide mononitrate SA G 2isoxsuprine G 2isradipine G 2zitraconazole G 2

J+Jadenu B 1+zJakafi B 1jantoven G 1zJanumet B 1zJanuvia B 1zJardiance B 1Jentadueto B 1jolessa G 4jolivette G 4junel/FE G 4Juvisync B 1

KKaletra B 2+zKalydeco B 3kariva G 4Kazano B 1Ketek B 2ketoconazole G 2ketoconazole G 4ketoprofen G 3ketorolac inj. G 3zketorolac tab G 3ketorolac tromethamine G 1ketotifen opthalmic solution G 1zKeveyis B 3Khedezla B 3zKineret B 3Kombiglyze B 1+Kuvan B 4+zKynamro B 2

Llabetalol G 2lactulose G 4lamivudine G 2lamivudine tabs G 2lamivudine/zidovudine G 2lamotrigine G 4zlansoprazole G 4Lantus B 1latanoprost G 1zLatuda B 3leflunomide G 3

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Section iii — index




7

+zLenvima B 1lessina G 4+zLetairis B 2letrozole G 1leucovorin G 4Leukeran B 1+Leukine B 1leuprolide G 1Levemir B 1levetiracetam G 4levobunolol G 1levocarnitine G 4zlevonorgestrel G 4levora G 4levothroid G 4levothyroxine G 4levoxyl G 4Lexiva B 2lidocaine G 4zlidocaine patch G 4Lindane B 4Linzess B 4liothyronine G 4lisinopril G 2lisinopril/HCTZ G 2lithium carbonate G 3+zLonsurf B 1loratadine G 1loratadine-D G 1lorazepam G 3zlosartan G 2zlosartan HCT G 2Lotemax suspension B 1zulovastatin G 2low-ogestrel G 4loxapine G 3Lumigan B 1lutera G 4zLynparza B 1Lyrica B 4Lysodren B 1

MMalarone B 2maprotiline G 3Matulane B 1zMaxair Autohaler B 3meclizine G 4meclofenamate G 3medroxyprogesterone G 4mefloquine G 2megestrol G 1+zMekinist B 1meloxicam G 3melphalan G 1Menest B 4meperidine G 3meperidine/promethazine G 3Mephyton B 4meprobamate G 3mercaptopurine G 1mesalamine enema G 4mesna G 1metadate ER G 3metaproterenol syr G 3metformin G 1zmetformin ER G 1zmetformin/glyburide G 1methadone G 3methazolamide G 2methenamine combination G 2methimazole G 4methocarbamol G 3methotrexate G 1methotrexate G 3methyldopa G 2methyldopa/HCTZ G 2methylphenidate/SR/CD G 3methylprednisolone G 4metipranolol G 1metoclopramide G 4metolazone G 2metoprolol G 2metoprolol ER G 2metoprolol/HCTZ G 2metronidazole G 2metronidazole cream/

lotion/gel G 4mexiletine G 2Miacalcin inj. B 1miconazole vag supp G 4microgestin/FE G 4midodrine G 2midodrine G 2minocycline G 2minoxidil oral G 2Mircera B 1Mirena B 4umirtazapine G 3misoprostol G 4zmodafinil G 3mometasone cr/oint G 4mononessa G 4zmontelukast G 3morphine SR G 3

morphine tab, soln, supp G 3MSIR tabs, sol G 3multivitamin V fluoride G 4mupirocin G 4+zMyalept B 3mycophenolate mofetil G 2Myleran B 1

Nnabumetone G 3nadolol G 2naltrexone G 3zNamenda B 1naphazoline G 1naproxen G 3naproxen EC G 3znaratriptan G 3zNarcan Nasal Spray B 3zNasacort OTC B 1Nascobal B 4znateglinide G 1zNatesto B 2+Natpara B 3Nebupent B 2necon G 4nefazodone G 3neomycin G 2neomycin/bacitracin/poly B G 1neomycin/bacitracin/

poly B/HC G 1neomycin/polymyxin/

HC otic G 1Nesina B 1Neulasta B 1+Neumega B 1+Neupogen B 1Nevanac B 1nevirapine G 2+zNexavar B 1znext choice G 4znext choice one dose G 4niacin ER G 2nicardipine G 2zNicotine Gum G 4zNicotine lozenges G 4zNicotine patches various G 4zNicotrol Inhaler/NS B 4nifediac CC G 2nifedical XL G 2nifedipine G 2nifedipine SR G 2Nilandron B 1nimodipine G 2zNinlaro B 1nisoldipine G 2nitrofurantoin G 2nitroglycerin oint G 2nitroglycerin pumpspray G 2nitroglycerin SR G 2nitroglycerin

transdermal patch G 2Nitrostat B 2nizatidine G 4nora-BE G 4+Norditropin B 3norethindrone G 4norethindrone a-e estradiol/

ferrous fumarate G 4+zNorthera B 2nortrel G 4nortriptyline G 3Norvir B 2Novolin B 1Novolog B 1+Nutropin B 3NuvaRing B 4zNuvigil B 3nystatin G 2nystatin G 4nystatin vag tab G 4nystatin/triamcinolone G 4nystop G 4

Oocella G 4+octreotide G 3Odefsey B 2+zOdomzo B 1+zOfev B 3ofloxacin G 2ofloxacin ophth G 1ofloxacin otic G 1ogestrel G 4zolanzapine G 3zolanzapine/fluoxetine G 3+zOlysio B 2zomeprazole G 4+Omnitrope B 3zondansetron G 4OneTouch B 1Onfi B 4Onglyza B 1Opana ER B 3+zOpsumit B 2zOralair B 1

+zOrencia B 3+zOrenitram B 2Orfadin B 4+zOrkambi B 3orphenadrine G 3Oseni B 1+zOtezla B 3oxazepam G 3oxcarbazepine G 4Oxistat B 4Oxsoralen Ultra B 4zoxybutynin G 1zoxybutynin ER G 1oxycodone G 3oxycodone/acetaminophen G 3oxycodone/aspirin G 3oxymorphone ER G 3

Ppaliperidone G 3Pancreaze B 4zpantoprazole G 4paregoric G 4paromomycin G 2uparoxetine HCl G 3Patanol B 1peg 3350/electrolyte G 4+Pegasys B 2penicillin VK G 2Pentasa B 4pentazocine/naloxone G 3pentoxifylline G 1perphenazine G 3Pertzye B 4Pexeva B 3phenazopyridine G 1phenelzine G 3phenobarbital G 4phenylephrine ophth G 1phenytoin G 4Phisohex B 4Phospholine Iodide B 1phytonadione G 4pilocarpine G 1pindolol G 2zpioglitazone G 1piroxicam G 3+zPlegridy B 3podofilox G 4polymyxin B/TMP G 1+zPomalyst B 1portia G 4potassium aminobenzoate G 4potassium bicarbonate G 3potassium chloride G 3potassium citrate G 1Potiga B 4zPradaxa B 1+zPraluent B 2pramipexole G 3pramoxine/HC acetate 2.5% G 4prascion RA G 4zupravastatin G 2prazosin G 2pre-natal vitamins G 4Precision B 1Pred Mild B 1prednisolone acetate G 1prednisolone ODT G 4prednisolone oral G 4prednisolone sod acetate G 1prednisone oral G 4Premarin B 4Premarin vag cream B 4Premphase B 4Prempro B 4previfem G 4Prezcobix B 2Prezista B 2zPrilosec-OTC G 4Primaquine B 2primidone G 4Pristiq B 3zProAir HFA/RespiClick B 3probenecid G 2procentra G 3prochlorperazine G 4+Procrit B 1Proctofoam-HC B 4Procysbi B 3progesterone, micronized G 4+zPromacta B 1promethazine G 1promethazine G 4promethazine/codeine G 1propafenone G 2propranolol G 2propranolol/HCTZ G 2propylthiouracil G 4pseudoephedrine G 1pseudoephedrine/codeine G 1zPulmicort Flexhaler B 3+Pulmozyme B 3Purixan B 1pyrazinamide G 2

Qquasense G 4Qudexy XR B 4zquetiapine G 3quinapril G 2quinapril/HCTZ G 2quinidine gluconate G 2quinidine sulfate SR G 2zQvar B 3

RzRagwitek B 1zraloxifene G 3ramipril G 2Ranexa B 2ranitidine (all) G 4+Ravicti B 3+Rebif B 3Regranex B 4zRelenza B 2zRelistor B 4Renvela B 4zrepaglanide G 1+zRepatha B 2Rescriptor B 2Retrovir IV infusion vial B 2+zRevlimid B 1zRexulti B 3Reyataz B 2ribapak G 2+ribasphere G 2+ribavirin G 2Ridaura B 3rifabutin G 2rifampin G 2Rifater B 2Rilutek B 3rimantadine G 2zrisedronate 150mg G 3zrisedronate DR G 3zrisperidone G 3zrisperidone m-tab G 3zrivastigamine G 1ropinirole G 3rosuvastatin G 2zRuconest B 2

SSabril B 4+Saizen B 3salsalate G 3zSamsca B 2Sandimmune B 2zSaphris B 3zSavaysa B 1Savella B 3zselegiline G 3selenium sulf 2.25%

shampoo G 4Selzentry B 2Semprex-D B 1+Sensipar B 3zSerevent Diskus B 3zSeroquel XR B 3usertraline G 3+zSignifor B 1silver sulfadiazine G 4+zSimponi B 3zusimvastatin G 2sirolimus G 2zSivextro B 2sod. polystyrene sulfonate G 3sod. sulfacetamide/

sulfur lot G 4sod.sulfacetamide/

sulfur emulsion cleanser G 4sodium chloride

irrigating soln G 4sodium fluoride

chewable tab & drops G 4solia G 4+zSomavert B 3sotalol G 2sotret G 4+zSovaldi B 2zSpiriva B 3zSpiriva Respimat B 3spironolactone G 2spironolactone/HCTZ G 2sprintec G 4Spritam B 4+zSprycel B 1stavudine G 2+zStelara B 4+Stimate B 3zStiolto Respimat B 3+Stivarga B 1Strattera B 3Strensiq B 3Stribild B 2Suboxone Film B 3sucralfate G 4sulfacetamide G 4sulfacetamide 10% G 1

sulfacetamide/ prednisolone ophth G 1

sulfamethoxazole/ trimethoprim G 2

sulfasalazine G 4sulfasalazine EC G 4sulindac G 3zsumatriptan G 3Sustiva B 2+zSutent B 1+zSylatron B 1zSymbicort B 3zSymlin B 1Synarel B 3zSynjardy B 1Synthroid B 4zSyprine B 1

Ttacrolimus G 2tacrolimus ointment G 4+zTafinlar B 1zTagrisso B 1zTamiflu B 2tamoxifen G 1tamsulosin G 1tamsulosin G 3zTanzeum B 1+zTarceva B 1Targretin gel B 1+zTasigna B 1Tazorac B 4+zTecfidera B 3+PzTechnivie B 2zTekturna B 2zTekturna HCT B 2ztelmisartan G 2ztelmisartan/HCTZ G 2temazepam G 3+temozolomide G 1terazosin G 2zterbinafine G 2terbutaline tab G 3terconazole G 4zTestim B 2zTestosterone gel B 3+ztetrabenazine G 2tetracycline G 2+Tev-Tropin B 3+Thalomid B 1theochron G 3theophylline/SR

tabs, liquid G 3thioridazine G 3thiothixene G 3thyroid G 4Thyrolar B 4tiagabine G 4ticlopidine G 1timolol G 1timolol G 2Tivicay B 2tizanidine G 3+Tobi Podhaler B 2+tobramycin amp/neb G 2tobramycin soln G 1tobramycin/dexameth G 1tolazamide G 1tolbutamide G 1ztolterodine G 1ztolterodine ER G 1topiramate G 4Topiramate ER (SSB)

capsules B 4topotecan G 1torsemide G 2Toujeo B 1+zTracleer B 2Tradjenta B 1tramadol G 3Transderm Scop B 4tranylcypromine G 3travoprost G 1trazodone G 3Tresiba B 1tretinoin cr/gel G 4tri-sprintec G 4ztriamcinolone acetonide G 4triamterene/HCTZ G 2triazolam G 3trifluoperazine G 3trifluridine G 1trihexyphenidyl G 3trimethobenzamide G 4trimethoprim G 2trinessa G 4Trintellix B 3Triumeq B 2trivora G 4Trokendi XR B 4tropicamide G 1ztrospium G 1TRUEtest B 1TRUEtrack B 1zTrulicity B 1

Truvada B 2Tybost B 2+zTykerb B 1

UUceris ER tablet B 4Ulesfia B 4Ultresa B 4unithroid G 4zUptravi B 2ursodiol G 4

VVagifem B 4zvalacyclovir G 2+zValchlor B 1valganciclovir tablets G 2valproic acid G 4zvalsartan G 2zvalsartan/HCTZ G 2vancomycin G 2vandazole vag G 4+veletri G 2velivet G 4uvenlafaxine G 3venlafaxine ER G 3zVentolin HFA B 3verapamil G 2verapamil SR G 2Versacloz B 3zVictoza B 1Videx B 2Videx pediatric solution B 2+PzViekira Pak B 2Viibryd B 3Viokace B 4Viracept B 2Viramune XR B 2Viread B 2vit A,D,C V fluoride G 4vit A,D,C V fluoride

and iron G 4Vitekta B 2zVogelxo B 3Voltaren gel B 3zvoriconazole G 2+Votrient B 1zVraylar B 3

Wwarfarin G 1

X+zXalkori B 1Xarelto B 1+zXeljanz B 3zXigduo XR B 1+zXtandi B 1zxulane G 4

Yyohimbine G 2

Zzzafirlukast G 3zzaleplon G 3zarah G 4+zZavesca B 3+zZelboraf B 1zenchent G 4Zenpep B 4PzZepatier B 2zZetia B 2zidovudine G 2zziprasidone caps G 3Zmax B 2+Zolinza B 1zzolpidem G 3zzolpidem CR G 3zonisamide G 4zZontivity B 1+Zorbtive B 3zovia G 4zZydelig B 1+zZykadia B 1+zZytiga B 1zZyvox B 2

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Section iii — index (cont’d)


Documents

BlueCross BlueShield Medicaid Formulary Guide...u = Included in tablet-splitting program. The medication can be cut in half to obtain the daily dose of medication (i.e., 20mg daily