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Non-covered M
edications
1�
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Non-covered Medications
Your�BlueValue�Rx�Pharmacy�Program�provides�coverage�for�over��,�00�prescription�medications���Most�medications�on�our�non-covered�list�have�equally�safe,�effective,�covered�alternatives�for�treating�the�same�medical�conditions���Check�with�your�doctor�about�appropriate�alternatives�if�you�currently�take�any�of�these�medications��
For�the�most�up-to-date�list�of�medications�that�are�not�covered�and�their�covered�alternatives,�visit�our�website�at�www.bluecrossma.com,�click�on�Pharmacy�Program,�and�proceed�to�the�Medications�That�Are�Not�Covered�section��
Please note: Your doctor may request coverage for a non-covered medication if no covered alternative is appropriate for treating your condition.
Non-covered Medication ListThis list of non-covered medications is up-to-date as of 3/1/07, and may change from time to time.
�,4-Dinitrochlorobenzene®´´
A-Hydrocort®´´
A-Methapred®´´
A/T/S®´´
Abelcet®´´
Aber-Fed®´´
Aber-Tuss�DR®´´
Abilify®´´�Discmelt™
Abraxane®´´
Accolate®´´�(ST)
Accuhist®´´
Accuhist�DM®´´
Accuhist�PDX®´´
Accuneb®´´
Accupril®´´
Accuretic®´´
Accutane®´´
Accuzyme®´´
Acd-A®´´
Aceon®´´
Acid�Jelly®´´
Aciphex®´´�(QCD) (ST)
Aclaro®´´
Aclovate®´´
Acthar�HP®´´
Acthrel®´´
Actigall®´´
Activase®´´
Activella®´´
Acuflex®´´
Acular®´´�(QCD)
Acular�LS®´´�(QCD)
Acular�PF®´´�(QCD)
Acunol®´´
Adagen®´´
Adalat�CC®´´
NonCovered.indd 12 2007-01-05 4:33:15 PM
13
Non-covered M
edications
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Adderall®´´
Adderall�XR®´´�(QCD)
Adeflor�M®´´
Adenocard®´´
Adenoscan®´´
Adenosine�Phosphate®´´
Adoxa®´´
Adoxa�Pak®´´
Adrenalin�Chloride�Injection®´´
Adrenalin�Chloride�Nasal�Solution®´´
Adriamycin�RDF®´´
Aerobid®´´�(QCD)
Aerobid-M®´´�(QCD)
Aerokid®´´
AeroTuss�1�®´´
Aggrastat®´´
Aggrenox®´´
Agrylin®´´
Ah-Chew®´´
Ah-Chew�II®´´
Ah-Chew�D®´´
Ahist®´´
Airet®´´
Ak-Taine®´´
Akineton®´´
Akne-Mycin®´´
Ala-Quin®´´
Ala-Scalp�HP®´´
Ala-Tet®´´
Alacol®´´
Alamast®´´�(QCD)
Alba-3®´´
Albafort®´´
Albafort�S®´´
Albalon®´´
Albalybe®´´
Albatussin®´´
Albatussin�CF®´´
Albatussin�DM®´´
Albatussin�NN®´´
Albatussin-NN®´´
Albatussin�Pediatric®´´
Albatussin�SR®´´
Albatussin�SR�F®´´
Albatussin�SR�Senior®´´
Albuterol�Sulfate�1���5/3ml�Solution®´´
Alcaine®´´
Alcet®´´
Alcortin®´´
Aldactazide®´´
Aldactone®´´
Aldex®´´
Aldex�CT®´´
Aldex�D®´´
Aldex�DM®´´
Aldex�G®´´
Aldoclor-�50®´´
Aldomet®´´
Aldoril-�5®´´
Aldoril-D50®´´
Alesse®´´
Allclenz®´´
Allegra®´´�(QCD)
Allegra-D�1��Hour®´´�(QCD)
Allegra-D��4�Hour®´´�(QCD)
Allepak®´´
Allertan®´´
AlleRx®´´
AlleRx-D®´´
AlleRx�PE®´´
Allfen®´´
Allfen�C®´´
Allfen�CX®´´
Allfen-DM®´´
Allfen�Jr®´´
Alocril®´´�(QCD)
Alomide®´´�(QCD)
Aloprim®´´
Alphagan�P®´´
Alphatrex®´´
Alrex®´´�(QCD)
Altace®´´
Altafluor®´´
Altoprev®´´�(ST)
Alupent®´´�(QCD)
Amaryl®´´
Ambi®´´
Ambien�CR®´´�(QCD) (ST)
Ambifed-G®´´
Ambifed-G�DM®´´
Ambisome®´´
Amerge®´´�(QCD)
Amerifed®´´
Amerifed�DM®´´
NonCovered.indd 13 2007-01-05 4:33:16 PM
Non-covered M
edications
14
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Amerituss�AD®´´
Amicar®´´
Amikin®´´
Amikin�Pediatric®´´
Aminess®´´
Amino�Acid�Cervical®´´
Amino-Cerv®´´
Aminosyn®´´
Aminosyn�II®´´
Aminosyn�II�in�Dextrose®´´
Aminosyn�II�w/Elec�in�Dex�w/Ca®´´
Aminosyn-HBc®´´
Aminosyn-HF®´´
Aminosyn�M®´´
Aminosyn-PF®´´
Aminosyn-RF®´´
Aminosyn�w/Electrolytes®´´
Amitiza®´´
Ammonium�Chloride�Injection®´´
Amoxil®´´
Amphocin®´´
Amphotec®´´
Amytal�Sodium�Injection®´´
Anacaine®´´
Anadrol-50®´´
Anafranil®´´
Analpram�HC®´´
Anamantle�HC®´´
Anamantle�HC�Forte®´´
Anana�Forte®´´
Anaplex�DM®´´
Anaplex�DMX®´´
Anaplex�HD®´´
Anaprox®´´
Anaprox�DS®´´
Anaspaz®´´
Ancef®´´
Andehist®´´
Andehist�DM®´´
Androderm®´´
Androgel®´´
Android®´´
Anectine®´´
Anemagen�OB®´´
Anergan�50®´´
Anestacon®´´
Anexsia®´´
Angeliq®´´
Angiomax®´´
Ansaid®´´
Antara®´´
Antibiotic�HC®´´
Antivert�1���5mg�Tablets®´´
Antizol®´´
Anusol-HC®´´
Anzemet®´´�(QCD)
Apexicon®´´
Apexicon�E®´´
Aphthasol®´´
Apidra®´´
Apokyn®´´
Apresoline®´´
Aquachloral®´´
Aquaphilic�w/Triamcinolone®´´
Aquasol�A®´´
Aquatab�C®´´
Aquatab�D®´´
Aquatab�DM®´´
Aralen�Phosphate®´´
Aramine®´´
Arava®´´�(QCD)
Aredia®´´
Aridex®´´
Aristocort®´´
Aristocort�A®´´
Aristocort�Forte®´´
Aristocort�HP®´´
Aristospan®´´
Armour�Thyroid®´´
Arthrotec®´´
Ascensia�Autodisc®´´�(QCD)
Ascensia�Contour®´´�(QCD)
Ascensia�Elite®´´�(QCD)
Asmanex®´´�(QCD)
Asthmapack�II®´´
Astramorph®´´
At�Last�Test�Strips®´´
Atabex®´´
Atacand®´´�(ST)
Atacand�HCT®´´�(ST)
Atgam®´´
Ativan®´´
Atopiclair®´´
Atrovent�Nasal�Spray®´´�(QCD)
NonCovered.indd 14 2007-01-05 4:33:17 PM
15
Non-covered M
edications
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Atuss-1��DM®´´
Atuss-1��DX®´´
Atuss�DR®´´
Atuss�DS®´´
Atuss�G®´´
Atuss�HC®´´
Atuss�HD®´´
Atuss�HS®´´
Atuss�HX®´´
Atuss�MR®´´
Atuss�MS®´´
Atuss�NX®´´
Augmentin®´´
Augmentin�ES-600®´´
Augmentin�XR®´´
Avage®´´
Avalide®´´�(ST)
Avandaryl®´´
Avar®´´
Avar-E®´´
Avc®´´
Avinza®´´
Avita®´´
Avodart®´´
Axert®´´�(QCD)
Axid®´´
Axocet®´´
Aygestin®´´
Azactam®´´
Azasan®´´
Azelex®´´
Azmacort®´´�(QCD)
Azopt®´´
Azulfidine®´´
B�&�O�Supprettes®´´
Bacmin®´´
Bactocill®´´
Bactrim®´´
Bactrim�DS®´´
Bactroban®´´
Bactroban�Nasal®´´
Bal�in�Oil®´´
Balacet®´´
Balamine�DM®´´
Baltussin®´´
Barbidonna®´´
Baros�Granules®´´
Beconase�AQ®´´�(QCD)
Benadryl�Injection®´´
Benicar�HCT®´´�(ST)
Benoquin®´´
Bensal�HP®´´
Bentyl®´´
Benzac�AC®´´
Benzac�W®´´
Benzac�W�Wash®´´
Benzaclin®´´
Benzagel-5®´´
Benzamycin®´´
Benzamycinpak®´´
Benzashave®´´
Benziq®´´
Benziq�LS®´´
Benzotic®´´
Benzyl�Benzoate®´´
Betac®´´
Betadine®´´
Betagan®´´
Betapace®´´
Betapace�AF®´´
Betatan®´´
Betavent®´´
Betimol®´´
Betoptic�S®´´
Biafine®´´
Biafine�RE®´´
Biaxin®´´
Biaxin�XL®´´
Bichloracetic�Acid®´´
Bicillin�C-R®´´
Bicillin�L-A®´´
Bicitra®´´
Bicnu®´´
Bidex�DM®´´
Bidil®´´
Biltricide®´´
Bio-Statin®´´
Bio-Throid®´´
Biodec®´´
Biodec-DM®´´
Biohist-LA®´´
Bionect®´´
Biotuss®´´
Blenoxane®´´
Bleph-10®´´
Blephamide®´´
NonCovered.indd 15 2007-01-05 4:33:17 PM
Non-covered M
edications
16
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Blephamide�SOP®´´
Blocadren®´´
Boniva®´´�(QCD)
Branchamin®´´
Brethine®´´
Brevicon®´´
Brevoxyl®´´
Brofed®´´
Bromfed®´´
Bromfed-DM®´´
Bromfed-PD®´´
Bromphed-PD®´´
Broncap®´´
Broncholate®´´
Broncodur®´´
Broncomar-1®´´
Broncomar�GG®´´
Broncopectol®´´
Broncotron-D®´´
Brondil®´´
Bronkophylline�GG®´´
Bronkosol®´´
Brontex®´´
Brontuss�SF®´´
Brovex®´´
Brovex�Ct®´´
Brovex-D®´´
Brovex�HC®´´
Brovex�SR®´´
Bss®´´
Bss�Plus®´´
Bucalcide®´´
Bucalsep®´´
Bumex®´´
Buprenex®´´
Buspar®´´
Busulfex®´´
Butisol�Sodium®´´
Caduet®´´�(QCD)
Cafergot®´´
Calafol�Rx®´´
Calan®´´
Calan�SR®´´
Calci-Max®´´
Calcifol®´´
Calcijex®´´
Calphosan®´´
Campath®´´
Camptosar®´´
Canasa®´´
Cantil®´´
Capastat®´´
Capex�Shampoo®´´
Caphosol®´´
Capital�w/Codeine®´´
Capitrol®´´
Capoten®´´
Capozide®´´
Carac®´´
Carafate®´´
Carba-XP®´´
Carbaphen�1�®´´
Carbaphen�1��Ped®´´
Carbastat®´´
Carbatab�1�®´´
Carbatrol®´´
Carbatuss�1�®´´
Carbatuss-CL®´´
Carbocaine®´´
Carboxine-PSE®´´
Cardene®´´
Cardene�SR®´´
Cardiodoron®´´
Cardiotek�Rx®´´
Cardizem®´´
Cardizem�Cd®´´
Cardizem�LA®´´
Cardizem�SR®´´
Cardura®´´�(QCD)
Cardura�XL®´´�(QCD)
Carmol®´´
Carmol�40®´´
Carmol�HC®´´
Carmol�Scalp®´´
Carnitor®´´
Caromega®´´
Cataflam®´´
Catapres®´´
Catapres-Tts®´´�(QCD)
Caverject®´´
Cavirinse®´´
Cebocap®´´
Ceclor®´´
Cedax®´´
Cefizox®´´
Cefol®´´
NonCovered.indd 16 2007-01-05 4:33:18 PM
17
Non-covered M
edications
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Cefotan®´´
Ceftin®´´
Cefzil®´´
Celebrex®´´�(QCD) (ST)
Celestone®´´
Celexa®´´�(QCD) (ST)
Cenestin®´´
Cenocort�A-40®´´
Cenocort�Forte�Suspension®´´
Cenogen�Ultra®´´
Cenolate®´´
Centany®´´
Cephradine��50mg�Capsule®´´
Cerebyx®´´
Cerefolin®´´
Cerefolin�Nac®´´
Certuss®´´
Certuss-D®´´
Cerubidine®´´
Cerumenex®´´
Cervidil®´´
Cesamet™
Cetacaine®´´
Cetacort®´´
Chlordex�Gp®´´
Chloromycetin®´´
Choleodoron®´´
Cialis®´´
Ciloxan®´´
Cipro®´´
Cipro�XR®´´
Ciprodex®´´
Citracal�Prenatal�+�DHA®´´
Citracal�Prenatal�Rx®´´
Citrolith®´´
Claforan®´´
Clarinex®´´�(QCD)
Clarinex-D�1��Hour®´´�(QCD)
Clarinex-D��4�Hour®´´�(QCD)
Claripel®´´
Clenia®´´
Cleocin®´´
Cleocin�Ovule®´´
Cleocin�T®´´
Climara®´´�(QCD)
Climara�Pro®´´
Clinac�Bpo®´´
Clindagel®´´
Clindamax®´´
Clindesse®´´
Clindets®´´
Clinimix®´´
Clinimix�E®´´
Clinisol®´´
Clinoril®´´
Clobevate®´´
Clobex®´´
Cloderm®´´
Clomid®´´
Clorpres®´´
Clozaril®´´
Codiclear�Dh®´´
Codimal-A®´´
Codimal�Dh®´´
Codimal�LA®´´
Cogentin®´´
Cognex®´´
Colazal®´´
Coldamine®´´
Colestid®´´
Colocort®´´
Coly-Mycin�M®´´
Coly-Mycin�S®´´
Colyte®´´
Colyte�with�Flavor�Packets®´´
Colytrol®´´
Combipatch®´´
Combunox®´´
Comhist®´´
Compazine®´´
Condylox®´´
Conex®´´
Conison®´´
Conpec®´´
Conpec�LA®´´
Cophene-B®´´
Cordarone®´´
Cordran®´´
Cordran�Sp®´´
Cordron-D®´´
Cordron-DM®´´
Cordron-HC®´´
Corgard®´´
Corlopam®´´
NonCovered.indd 17 2007-01-05 4:33:19 PM
Non-covered M
edications
18
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Cormax®´´
Cortane-B®´´
Cortef®´´
Cortifoam®´´
Cortisporin®´´
Cortisporin-TC®´´
Cortrosyn®´´
Corvert®´´
Corvite®´´
Corzide®´´
Cosmegen®´´
Cosopt®´´
Covera-Hs®´´
Cozaar®´´�(ST)
Creon®´´
Cresylate®´´
Crinone®´´
Crofab®´´
Crolom®´´�(QCD)
Cutivate®´´
Cyclessa®´´
Cyclocort®´´
Cyclogyl®´´
Cyclomydril®´´
Cyklokapron®´´
Cylert®´´
Cystospaz®´´
Cystospaz-M®´´
Cytarabine®´´
Cytotec®´´
Cytovene®´´
Cytoxan®´´
D-Feda�II®´´
Dallergy®´´
Dallergy-Jr®´´
Dalmane®´´
Danocrine®´´
Darvocet�A500®´´
Darvocet-N®´´
Darvon®´´
Darvon�Compound®´´
Darvon-N®´´
Daunoxome®´´
Daypro®´´
Dayto-Sulf®´´
Daytrana®´´
Ddavp®´´
Decadron®´´
Decahist-DM®´´
Declomycin®´´
Decon-G®´´
Deconamine®´´
Deconamine�SR®´´
Deconex®´´
Deconsal�II®´´
Deconsal�CT®´´
Deconsal�DM®´´
Deka®´´
Del-Mycin®´´
Delatestryl®´´
Delestrogen®´´
Delflex�w/Dextrose®´´
Deltuss�DMX®´´
Demadex®´´
Demerol®´´
Demulen®´´
Denavir®´´
Depacon®´´
Depakene®´´
Depen®´´
Depo-Medrol®´´
Depo-Provera®´´
Depo-Subq�Provera�104®´´
Depo-Testosterone®´´
Depocyt®´´
Derma-Cas®´´
Derma-Smoothe/Fs®´´
Dermatop®´´
Dermotic®´´
Desferal®´´
Desogen®´´
Desowen®´´
Desoxyn®´´
Despec®´´
Despec�DM®´´
Despec�SR®´´
Desquam-E®´´
Desquam-X®´´
Desyrel®´´
Dex,�PC®´´
Dexacen�LA®´´
Dexacidin®´´
Dexchlorpheniramine�Syrup®´´
Dexedrine®´´
Dexedrine�Spansule®´´
NonCovered.indd 18 2007-01-05 4:33:19 PM
1�
Non-covered M
edications
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Dexpak®´´
Dexpak�Jr®´´
Dextrostat®´´
DHE�45®´´
Dht®´´
Diabeta®´´
Diabetic�Tussin�C®´´
Diabinese®´´
Diamox�Sequels®´´
Dicel®´´
Differin®´´
Difil-G®´´
Difil-G�Forte®´´
Diflucan®´´
Digesplen�Plus®´´
Digex®´´
Digoxin®´´
Dilacor�XR®´´
Dilatrate-SR®´´
Dilaudid®´´
Dilaudid-HP®´´
Dilex-G®´´
Dimethyl�Sulfoxide®´´
Diovan�HCT®´´�(ST)
Dipentum®´´
Diprolene®´´
Diprolene�AF®´´
Diprosone®´´
Disalcid®´´
Disophrol®´´
Dispermox®´´
Ditropan®´´
Ditropan�XL®´´
Diuril®´´
DMax®´´
Dobutrex®´´
Dolgic�LQ®´´
Dolgic�Plus®´´
Dolobid®´´
Dologesic®´´
Dolophine®´´
Dolorex®´´
Domeboro®´´
Dometuss�DM®´´
Donatussin®´´
Donatussin�DC®´´
Donatussin�DM®´´
Donatussin�Max®´´
Donnamar®´´
Donnatal®´´
Doral®´´
Doryx®´´
Dostinex®´´�(QCD)
Dovonex®´´
Doxil®´´
Drisdol®´´
Dritho-Scalp®´´
Drituss�DM®´´
Drituss�HD®´´
Drize-R®´´
Drocon-Cs®´´
Droperidol®´´
Droxia®´´
Drysol®´´
Drysol�Dab-O-Matic®´´
Dtic-Dome�IV®´´
Duac®´´
Duet®´´
Duet�DHA®´´
Duet�DHA�Stuartnatal®´´
Duet�Stuart�Natal�Chewable®´´
Duet�Stuartnatal®´´
Duoneb®´´
Duotan®´´
Durabac®´´
Durabac�Forte®´´
Duraclon®´´
Duradex®´´
Duradex�Forte®´´
Duraflu®´´
Duragesic®´´
Durahist®´´
Durahist�D®´´
Durahist�PE®´´
Duramorph®´´
Duraphen�1000®´´
Duraphen�II®´´
Duraphen�II�DM®´´
Duraphen�DM®´´
Duraphen�Forte®´´
Duratan�DM®´´
Duratan�Forte®´´
Duratan�PE®´´
Duratuss®´´
Duratuss�DM®´´
NonCovered.indd 19 2007-01-05 4:33:20 PM
Non-covered M
edications
�0
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Duratuss�Gp®´´
Duratuss�HD®´´
Duraxin®´´
Duricef®´´
Dyazide®´´
Dynabac®´´
Dynacin®´´
Dynacirc®´´
Dynacirc�CR®´´
Dynapen®´´
Dynatuss�Hcg®´´
Dynex®´´
Dynex�HD®´´
Dyrenium®´´
Dytan®´´
Dytan�AT®´´
Dytan-Cs®´´
Dytan-D®´´
Dytan-HC®´´
E-Mycin®´´
Easprin®´´
Ec-Naprosyn®´´
Econopred�Plus®´´
Ed-A-Hist�DM®´´
ED�Cyte�F®´´
Ed-DM®´´
Edecrin®´´
Edex®´´
EES®´´
Efudex®´´
Eldepryl®´´
Elestat®´´�(QCD)
Elimite®´´
Elitek®´´
Elixophyllin®´´
Elixophyllin�GG®´´
Elixophyllin-KI®´´
Ellence®´´
Elmiron®´´
Elocon®´´
Eloxatin®´´
Elspar®´´
Emadine®´´�(QCD)
Emcin�Clear®´´
Emersal®´´
Emgel®´´
Emla®´´
Emsam®´´
Enablex®´´
Encora®´´
Endagen-HD®´´
Endal-HD�Plus®´´
Endo-Avitene®´´
Endrate®´´
Enduron®´´
Enduronyl�Forte®´´
Enjuvia®´´
Enlon®´´
Enlon-Plus®´´
Entex®´´
Entex�ER®´´
Entex�HC®´´
Entex�LA®´´
Entex�PSE®´´
Entuss®´´
Enzymax®´´
Epifoam®´´
Equagesic®´´
Equetro®´´
Ergocaff-PB®´´
Ergomar®´´
Eritrogen®´´
Ertaczo®´´
Eryc®´´
Erycette®´´
Eryderm®´´
Erygel®´´
Eryped®´´
Erysidoron®´´
Erythrocin�Lactobionate®´´
Esgic®´´
Esgic�Plus®´´
Eskalith®´´
Eskalith�CR®´´
Estinyl®´´
Estrace®´´
Estraderm®´´�(QCD)
Estrasorb®´´�(QCD)
Estratest®´´
Estratest�HS®´´
Estring®´´
Estro-5®´´
Estrogel®´´�(QCD)
Estrostep�FE®´´
Ethamolin®´´
Ethedent®´´
NonCovered.indd 20 2007-01-05 4:33:21 PM
�1
Non-covered M
edications
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Ethezyme®´´
Ethyol®´´
Etopophos®´´
Eudal-SR®´´
Euflexxa®´´
Eulexin®´´
Evoclin®´´
Evoxac®´´
Exactacain®´´
Excof®´´
Excof-SF®´´
Exelderm®´´
Exjade®´´
Exoderm®´´
Extendryl®´´
Extendryl�DM®´´
Extendryl�HC®´´
Extendryl�Jr®´´
Extendryl�SR®´´
Ezol®´´
Factive®´´
Famvir®´´�(QCD)
Fansidar®´´
Fareston®´´
Faslodex®´´
Fast�Take�Test�Strips®´´�(QCD)
Fazaclo®´´
Feldene®´´
Femcon�FE®´´
Femhrt®´´
Femring®´´
Femtabs®´´
Femtrace®´´
Fenesin�DM®´´
Fertinex®´´
Finacea®´´
Fioricet®´´
Fioricet�w/Codeine®´´
Fiorinal®´´
Fiorinal�w/Codeine�#3®´´
First-Hydrocortisone®´´
First-Mouthwash�BLM®´´
First-Progesterone�MC®´´
First-Testosterone®´´
First-Testosterone�MC®´´
Flagyl®´´
Flagyl�ER®´´
Flarex®´´
Flexeril®´´
Flextra®´´
Flextra-DS®´´
Flolan®´´
Flonase®´´�(QCD)
Flor-Dac®´´
Florinef�Acetate®´´
Floxin®´´
Flucaine®´´
Fludara®´´
Flumadine®´´
Fluor-A-Day®´´
Fluor-Op®´´
Fluorabon®´´
Fluoracaine®´´
Fluorets®´´
Fluori-Methane®´´
Fluoritab®´´
Flura®´´
Flura-Drops®´´
Flura-Tab®´´
Flurate®´´
Fluress®´´
Fluro-Ethyl®´´
Flutuss�HC®´´
Flutuss�XP®´´
Fml®´´
Fml�Forte®´´
Fml-S®´´
Fml�SOP®´´
Focalin®´´
Focalin�XR®´´
Follistim®´´
Follistim®´´�AQ
Folysine®´´
Foradil®´´�(QCD)
Forma-Ray®´´
Formadon®´´
Formalyde-10®´´
Fortamet®´´
Fortaz®´´
Fosamax®´´�(QCD)
Fosamax�Plus�D®´´�(QCD)
Foscavir®´´
Freamine�III®´´
Freamine�III�w/Electrolytes®´´
NonCovered.indd 21 2007-01-05 4:33:21 PM
Non-covered M
edications
��
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Freestyle®´´�Test�Strips�(QCD)
Frenadol®´´
FreshKote®´´
Frova®´´�(QCD)
Fulvicin�U/F®´´
Gabarone®´´
Galzin®´´
Ganirelix�Acetate®´´
Garamycin®´´
Garylin®´´
Gastrinex®´´
Gastrocrom®´´
Gel-Kam®´´
Gelclair®´´
Gemzar®´´
Genecof-HC®´´
Genelan®´´
Genexpect�DM®´´
Genexpect-PE®´´
Genexpect-SF®´´
Genoptic®´´
Genoptic�SOP®´´
Gentafair®´´
Gentex�HC®´´
Gentex�LA®´´
Gentex�LQ®´´
Geocillin®´´
Geodon®´´
Gilchew�IR®´´
Gilphex�Tr®´´
Giltuss®´´
Giltuss�HC®´´
Giltuss�Ped-C®´´
Giltuss�Pediatric®´´
Giltuss�Tr®´´
Glucolet�Endcaps®´´
Glucometer�Dex®´´�(QCD)
Glucometer�Elite®´´�(QCD)
Glucometer�Encore®´´�(QCD)
Glucophage®´´
Glucophage�XR®´´
Glucotrol®´´
Glucotrol�XL®´´
Glucovance®´´
Glumetza™
Glutofac-MX®´´
Glutofac-ZX®´´
Glynase®´´
Glyset®´´
Golytely®´´
Goniosol®´´
Gordo-Urea®´´
Gordofilm®´´
Granulex®´´
Grifulvin�V®´´
Guaifed®´´
Guaifed-PD®´´
Guaimax-D®´´
Guanidine®´´
Gynazole-1®´´
Gynodiol®´´
H��600�SR®´´
Halcion®´´
Haldol®´´
Haldol�Decanoate®´´
Halflytely®´´
Halflytely�with�Flavor�Packs®´´
Halog®´´
HDc�DM®´´
Helidac®´´
Hemorrhoidal®´´
Hep-Lock®´´
Hepatamine®´´
Hepatasol®´´
Herceptin®´´
Hexafed®´´
Hexaflu®´´
Hextend�Lactated�Electrolyte®´´
Hiprex®´´
Histade�MX®´´
Histalet®´´
Histamax�D®´´
Histatab�Plus®´´
Histex®´´
Histex�Ct®´´
Histex�HC®´´
Histex�IE®´´
Histex�PD®´´
Histex�PD�1�®´´
Histex�SR®´´
Histor-D®´´
Histussin�D®´´
Histussin�HC®´´
HPr�End®´´
NonCovered.indd 22 2007-01-05 4:33:22 PM
�3
Non-covered M
edications
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Humatin®´´
Humibid®´´
Humibid�DM®´´
Humorsol®´´
Hyalgan®´´
Hycamtin®´´
Hycet®´´
Hycodan®´´
Hycotuss®´´
Hydrea®´´
Hydro-Tussin�DM®´´
Hydro,�PC�II®´´
Hydrocet®´´
Hydrochlorothiazide�Oral�Solution
Hydrocortisone�Sod�Succinate
Hylira™
Hyperlyte®´´
Hyperlyte�CR®´´
Hyperlyte�R®´´
Hyperstat�IV®´´
Hytan®´´
Hytone®´´
Hytrin®´´�(QCD)
Hyzaar®´´�(ST)
Ib-Stat®´´
Icar-C�Plus�SR®´´
Icar�Prenatal®´´
Idamycin�PFS®´´
Ifex®´´
Ifex/Mesnex®´´
Ilopan�Injection®´´
Imdur®´´
Imitrex®´´�(QCD)
Imodium®´´
Imuran®´´
Increlex®´´
Inderal®´´
Inderide®´´
Indocin®´´
Indocin�SR®´´
Inflamase�Forte®´´
Inflamase�Mild®´´
Innopran�XL®´´
Inova®´´
Inpersol-Lm�w/Dextrose®´´
Inpersol�w/Dextrose®´´
Inspra®´´�(ST)
Intal®´´�(QCD)
Intralipid®´´
Introl®´´
Invanz®´´
Inversine®´´
Iodosorb®´´
Ionosol�B�w/Dextrose®´´
Ionosol�Mb�w/Dextrose®´´
Ionosol�T�w/Dextrose®´´
Iopidine®´´
Irrigating�Solution�G®´´
Ismo®´´
Isochron®´´
Isolyte�E®´´
Isolyte�G®´´
Isolyte�H®´´
Isolyte�M®´´
Isolyte�P®´´
Isolyte�R®´´
Isolyte�S®´´
Isoptin�SR®´´
Isopto�Atropine®´´
Isopto�Carbachol®´´
Isopto�Carpine®´´
Isopto�Homatropine®´´
Isopto�Hyoscine®´´
Isordil®´´
Isovex®´´
Istalol®´´
Isuprel®´´
J-Max®´´
J-Tan®´´
J-Tan�D®´´
Jaycof®´´
Jaycof-HC®´´
Jaycof-XP®´´
Just�for�Kids®´´
K-Dur®´´
K-Lor®´´
K-Lyte®´´
K-Lyte�DS®´´
K-Lyte/CL®´´
K-Phos�Neutral®´´
K-Tab®´´
Kadian®´´
Kaochlor®´´
Kaochlor-Eff®´´
Kaon®´´
NonCovered.indd 23 2007-01-05 4:33:23 PM
Non-covered M
edications
�4
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Kaon-CL®´´
Kay�Ciel®´´
Kayexalate®´´
Keflex®´´
Kefzol®´´
Kemadrin®´´
Kenalog®´´
Kenalog�in�Orabase®´´
Kerafoam™
Keralac®´´
Keralyt®´´
Kerlone®´´
Kerol™
Ketalar®´´
Ketek®´´
Key-Pred®´´
Kie®´´
Kinevac®´´
Kionex®´´
Klaron®´´
Klonopin®´´
Klotrix®´´
Kristalose®´´
Kronofed-A®´´
Kronofed-A-Jr®´´
Ku-Zyme®´´
Ku-Zyme�HP®´´
Kuric®´´
Kutrase®´´
Kwelcof®´´
Kytril®´´�(QCD)
Lacrisert®´´
Lacticare-HC®´´
Lactinol®´´
Lactinol-E®´´
Lactocal-F®´´
Lagesic®´´
Lamisil®´´�(QCD) (PA)
Lanoxicaps®´´
Lanoxin®´´
Lanzatuss-NF®´´
Lariam®´´
Lartus®´´
Lasix®´´
Lazerformalyde®´´
Lemohist�Plus®´´
Lemotussin-DM®´´
Lescol®´´�(QCD) (ST)
Lescol�XL®´´�(QCD) (ST)
Leukeran®´´
Leustatin®´´
Levacet®´´
Levall®´´
Levall-1�®´´
Levall�G®´´
Levaquin®´´
Levatol®´´
Levbid®´´
Levemir®´´
Levitra®´´
Levlen®´´
Levlite®´´
Levo-Dromoran®´´
Levophed®´´
Levsin®´´
Levsin/Sl®´´
Levsinex®´´
Lexapro®´´�(QCD) (ST)
Lexxel®´´
Librax®´´
Librium®´´
Lidamantle®´´
Lidamantle�HC®´´
Lidex®´´
Lidex-E®´´
Limbitrol®´´
Limbitrol�DS®´´
Limbrel®´´
Lincocin®´´
Lioresal®´´
Lipex®´´
Liposyn�II®´´
Liposyn�III®´´
Liquibid-D®´´
Liquibid-D�1�00®´´
Liquibid-PD®´´
Liquicough�DM®´´
Liquid�Prenatal�Vitamin®´´
Lithobid®´´
Lithostat®´´
Livostin®´´�(QCD)
Lo/Ovral®´´
Locoid®´´
Lodine®´´
Lodine�XL®´´
Lodrane®´´
NonCovered.indd 24 2007-01-05 4:33:23 PM
�5
Non-covered M
edications
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Lodrane�D®´´
Lodrane�XR®´´
Loestrin®´´
Loestrin��4�FE®´´
Loestrin�FE®´´
Lofibra®´´
Lokara®´´
Lomotil®´´
Lopid®´´
Lopressor®´´
Lopressor�HCT®´´
Loprox®´´
Lorabid®´´
Lorcet®´´
Lorcet�HD®´´
Lorcet�Plus®´´
Lortab®´´
Lortuss�DM®´´
Lortuss�HC®´´
Lotemax®´´
Lotensin®´´
Lotensin�HCT®´´
Lotrel®´´
Lotrisone®´´
Loxitane®´´
Lozol®´´
Lufyllin®´´
Lufyllin-GG®´´
Lumigan®´´
Luminal®´´
Lupron®´´
Luride®´´
Lusonal®´´
Lusonex®´´
Lusonex�Plus®´´
Lutrepulse®´´
Luxiq®´´
Lynox®´´
Lyrica®´´
M-Clear®´´
Macrobid®´´
Macrodantin®´´
Magan®´´
Magnebind�400�Rx®´´
Malarone®´´
Mandelamine®´´
Mandol®´´
Mannitol®´´
Mar-Spas®´´
Marcaine®´´
Marcainew/Epinephrine®´´
Marinol®´´
Marnatal-F�Plus®´´
Marplan®´´
Materna®´´
Mavik®´´
Max�HC®´´
Maxair�Autohaler®´´�(QCD)
Maxalt®´´�(QCD)
Maxalt�Mlt®´´�(QCD)
Maxaquin®´´
Maxi-Tuss�DM®´´
Maxi-Tuss�HC®´´
Maxi-Tuss�Hcg®´´
Maxi-Tuss�Hcx®´´
Maxidex®´´
Maxidone®´´
Maxifed®´´
Maxifed�DM®´´
Maxifed�DMX®´´
Maxifed-G®´´
Maxiflor®´´
Maxinate®´´
Maxiphen®´´
Maxiphen�ADT®´´
Maxiphen�DM®´´
Maxiphen�G®´´
Maxiphen-G�DM®´´
Maxipime®´´
Maxitrol®´´
Maxzide®´´
MC�Jr�Cough®´´
Mebaral®´´
Medent�DM®´´
Medent�Ld®´´
Medrol®´´
Mefoxin®´´
Megace®´´
Megace�ES®´´
Menopur®´´
Menostar®´´�(QCD)
Meprobamate�w/Aspirin
Merrem®´´
Mesna®´´
Mestinon®´´
Metadate�ER�(10mg�
NonCovered.indd 25 2007-01-05 4:33:24 PM
Non-covered M
edications
�6
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Tablets�)®´´
Metaglip®´´
Methylene�Blue®´´
Methylin®´´
Methylprednisolone�Sod�Succ®´´
Metro�IV®´´
Metrocream®´´
Metrogel®´´
Metrogel-Vaginal®´´
Metrolotion®´´
Mevacor®´´�(QCD) (ST)
Mexitil®´´
Miacalcin®´´
Micardis®´´�(ST)
Micardis�HCT®´´�(ST)
Micro-K®´´
Micronase®´´
Micronor®´´
Microzide®´´
Midamor®´´
Midrin®´´
Migralam®´´
Migranal®´´�(QCD)
Migraten®´´
Miltown®´´
Miltuss-Ex®´´
Mimyx®´´
Minipress®´´
Minirin®´´
Minitran®´´
Minizide®´´
Minocin®´´
Minocin®´´�Combo�Pack
Mintuss�DR®´´
Mintuss�MR®´´
Miostat®´´
Miralax®´´
Mircette®´´
Moban®´´
Mobic®´´�(QCD)
Modicon®´´
Moduretic®´´
Monistat�Dual-Pak®´´
Monodox®´´
Monoket®´´
Monopril®´´
Monopril�HCT®´´
MonteFlu�HC®´´
Montephen®´´
Monurol®´´
Motofen®´´
Motrin®´´
MoviPrep®´´
MS�Contin®´´
MSir®´´
MTE®´´
Muco-Fen�DM®´´
Mucomyst®´´
Multi-1�®´´
Multitrace®´´
Murocoll-�®´´
Muse®´´
Mustargen®´´
Mutamycin®´´
MVI�1�®´´
MVI�Pediatric®´´
Myambutol®´´
Mycamine®´´
Mycelex®´´
Mycolog�II®´´
Mycostatin®´´
Mydfrin®´´
Mydriacyl®´´
Mylocel®´´
Mylotarg®´´
Myophen®´´
Mysoline®´´
Mytelase®´´
Mytrex®´´
Naftin®´´
Nalex-A®´´
Nalex�Dh®´´
Nalfon®´´
Nallpen®´´
Nandrolone�Decanoate®´´
Naprelan®´´
Naprosyn®´´
Narcan®´´
Nasacort®´´�(QCD)
Nasacort�AQ®´´�(QCD)
Nasarel®´´�(QCD)
Nascobal®´´
Nasop®´´
Natachew®´´
Natacyn®´´
NonCovered.indd 26 2007-01-05 4:33:25 PM
�7
Non-covered M
edications
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Natafort®´´
Natalcare�Rx®´´
Natalvit®´´
Natelle®´´
Natelle�C®´´
Natelle-Ez®´´
Natelle�Prefer®´´
Naturetin®´´
Navane®´´
Navelbine®´´
Nd-Gesic®´´
Nebcin®´´
Neevo®´´
Neggram®´´
Nembutal�Sodium®´´
Neo-DM®´´
Neo-Fradin®´´
Neo-Synephrine�Eye�Drops®´´
Neobenz�Micro®´´
Neoral®´´
Neosar®´´
Neosporin�Eye�Drops®´´
Neosporin�GU�Irrigant®´´
Neotrace®´´
Neotron-S®´´
Neotuss-D®´´
Nephramine®´´
Neptazane®´´
Nesacaine®´´
Nesacaine-Mpf®´´
Nestabs�CBF®´´
Nestabs�FA®´´
Nestabs�Rx®´´
Neurontin®´´
Neut®´´
Neutrexin®´´
Nevanac®´´
Nexavir®´´
Nexium®´´�(QCD) (ST)
Niferex-PN�Forte®´´
Nipent®´´
Niravam®´´
Nitro-Dur®´´
Nitrolingual®´´
Nitrostat®´´
Nizoral®´´
Nolvadex®´´
Nor-Q-D®´´
Norco®´´
Nordette®´´
Norel�LA®´´
Norel�Sd®´´
Norel�SR®´´
Norflex®´´
Norgesic®´´
Norgesic�Forte®´´
Norinyl®´´
Noritate®´´
Normodyne®´´
Normosol-M�and�Dextrose®´´
Normosol-R®´´
Normosol-R�and�Dextrose®´´
Normosol-R�PH�7��4®´´
Noroxin®´´
Norpace®´´
Norpace�CR®´´
Norpramin®´´
Notuss®´´
Notuss�PD®´´
Novacort®´´
Novamine®´´
Novanatal®´´
Novasal®´´
Novastart®´´
Novocain®´´
Novolin�70/30®´´
Novolin�N®´´
Novolin�R®´´
Novolog®´´
Novolog�Mix�70/30®´´
Nubain®´´
Nucofed®´´
Nuhist®´´
Nulev®´´
Nulytely®´´
Nulytely�with�Flavor�Packs®´´
Numobid®´´
Numobid�DX®´´
Numoisyn®´´
Numonyl®´´
Numonyl�DX®´´
Numonyl�Pediatric®´´
Numonyl�SR®´´
NonCovered.indd 27 2007-01-05 4:33:25 PM
Non-covered M
edications
�8
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Numorphan®´´
Nuox®´´
Nutracare®´´
Nutricap®´´
Nutrivit®´´
Nuvaring®´´
Nuzon®´´
Nydamax®´´
Nydrazid®´´
Nystat-Rx®´´
O-Cal�FA®´´
O-Cal�Prenatal®´´
OB�Complete®´´
Obstetrix-100®´´
Obstetrix�EC®´´
Obtrex®´´
Ocl®´´
Ocufen®´´
Ocuflox®´´
Ocutricin®´´
Ogen®´´
Olux®´´
Omacor®´´
Omnicef®´´
Omnihist�II�LA®´´
Omnii�Gel®´´
Omnii�Med®´´
Oncaspar®´´
One�Touch�Test�Strips®´´�(QCD)
One�Touch�Ultra�Test�Strips®´´�(QCD)
Ontak®´´
Opana®´´
Opana�ER®´´
Ophthetic®´´
Opium®´´
Optinate®´´
Optipranolol®´´
Optivar®´´�(QCD)
Oracea™
Oracit®´´
Oramagicrx®´´
Oramorph�SR®´´
Orap®´´
Orapred®´´
Orapred®´´�ODT
Oratuss®´´
Orencia®´´
Ortho-Cept®´´
Ortho-Cyclen®´´
Ortho-Est®´´
Ortho�Evra®´´
Ortho�Micronor®´´
Ortho-Novum®´´
Ortho-Prefest®´´
Ortho�Tri-Cyclen®´´
Ortho�Tri-Cyclen�Lo®´´
Orthoclone�Okt-3®´´
Orthovisc®´´
Orudis®´´
Oruvail®´´
Osmitrol®´´
Osmoglyn®´´
Osmoprep®´´
Otilam®´´
Otocain®´´
Otogesic®´´
Ovace®´´
Ovcon®´´
Ovide®´´
Ovral®´´
Ovrette®´´
Oxalis®´´
Oxandrin®´´
Oxical®´´
Oxiplen®´´
Oxistat®´´
Oxsoralen®´´
Oxsoralen-Ultra®´´
Oxycontin®´´
Oxyfast®´´
Oxyir®´´
Oxytrol®´´
P-Tex®´´
P-V-Tussin®´´
Pain�Ease®´´
Palgic®´´
Palgic�D®´´
Palgic�DS®´´
Palladone®´´
Pamelor®´´
Pamine®´´
Pamine�Forte®´´
Panafil®´´
Panatuss®´´
Panatuss�DX®´´
NonCovered.indd 28 2007-01-05 4:33:26 PM
��
Non-covered M
edications
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Panatuss�DXP®´´
Pancof®´´
Pancof�Exp®´´
Pancof�HC®´´
Pancof�XP®´´
Pancrease®´´
Pancrease�MT®´´
Pancreatin®´´
Pancrecarb�MS®´´
Pandel®´´
Panfil�G®´´
Panixine®´´
Panlor�DC®´´
Panlor�SS®´´
Panmist�DM®´´
Panmist�Jr®´´
Panmist�LA®´´
Pannaz®´´
Pannaz�S®´´
Panoxyl�5®´´
Panoxyl�AQ����5®´´
Panoxyl�AQ�5®´´
Panretin®´´
Parafon�Forte�DSC®´´
Paraplatin®´´
Parcopa®´´
Parlodel®´´
Paser®´´
Patanol®´´�(QCD)
Paxil®´´�(QCD) (ST)
Paxil�CR®´´�(QCD) (ST)
Paxipam®´´
Pce®´´
Pedameth®´´
Pediaflor®´´
Pediahist�DM®´´
Pediapred®´´
Pediatan®´´
Pediatan�D®´´
Pediatex®´´
Pediatex�1�®´´
Pediatex�1��D®´´
Pediatex�1��DM®´´
Pediatex-D®´´
Pediatex�DM®´´
Pediazole®´´
Pediotic®´´
Pediox®´´
Penlac®´´�(QCD) (PA)
Pentam®´´
Pentothal®´´
Percocet®´´
Percodan®´´
Percolone®´´
Peridex®´´
Periostat®´´
Permax®´´
Perry�Prenatal�Tablet®´´
Persantine®´´
Pexeva®´´�(QCD) (ST)
Pfizerpen®´´
Phanasin®´´
Phanatuss�HC®´´
Phena-HC®´´
Phena-Plus®´´
Phena-S®´´
Phenabid®´´
Phenabid�DM®´´
Phenergan®´´
Phenergan�VC�w/Codeine®´´
Phenergan�w/Codeine®´´
Phenydex®´´
Phenytek®´´
Phisohex®´´
Phos-Flur®´´
Phospholine�Iodide®´´
Photofrin®´´
Phrenilin®´´
Phrenilin�Forte®´´
Phrenilin�w/Caffeine�&�Codeine®´´
Physiolyte®´´
Physiosol®´´
Pilocar®´´
Pilopine�Hs®´´
Pima®´´
Pipracil®´´
Pirosal®´´
Pitocin®´´
Pitressin®´´
Plaquenil®´´
Plasma-Lyte®´´
Plasma-Lyte�A�PH®´´
Plasma-Lyte�M®´´
Plasma-Lyte�R®´´
Platinol-AQ®´´
NonCovered.indd 29 2007-01-05 4:33:27 PM
Non-covered M
edications
30
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Plendil®´´
Pletal®´´
Plexion®´´
Plexion�Sct®´´
Plexion�Ts®´´
Pneumotussin®´´
Podoben�Resin®´´
Podocon-�5®´´
Pododerm®´´
Polocaine®´´
Poly�Hist�DM®´´
Poly�Hist�Forte®´´
Poly�Hist�HC®´´
Poly�Hist�PD®´´
Poly-Histine®´´
Poly-Pred®´´
Poly-Tussin®´´
Poly-Tussin�DM®´´
Poly-Tussin�HD®´´
Poly-Tussin�XP®´´
Poly-Vent®´´
Poly-Vi-Flor®´´
Poly-Vi-Flor�w/Iron®´´
Polycitra®´´
Polycitra-K®´´
Polycitra-LC®´´
Polysporin®´´
Polytrim®´´
Pontocaine®´´
Potaba®´´
Pramosone®´´
Pramotic®´´
Pravigard�Pac®´´�(QCD)
Precare®´´
Precare�Conceive®´´
Precare�Premiere®´´
Precare�Prenatal®´´
Precision�Q-I-D®´´�(QCD)
Precision�Sof-Tact®´´�(QCD)
Precision�Xtr�B-Ketone®´´
Precision,�PCX®´´�(QCD)
Precision,�PCX�Plus®´´�(QCD)
Pred�Forte®´´
Pred-G®´´
Prednisone�Intensol®´´
Prehist®´´
Prekunil®´´
Prelone®´´
Premarin®´´
Premasol®´´
Premesis�Rx®´´
Premphase®´´
Prempro®´´
Prena-Cap®´´
Prenatal®´´
Prenatal�MR��0�FE®´´
Prenatal�MTR®´´
Prenatal�Rx®´´
Prenate�Elite®´´
Prenate�GT®´´
Prepidil®´´
Prevacid®´´�(QCD) (ST)
Prevacid�Naprapac®´´
Prevident®´´
Prevident�5000�Plus®´´
Prilosec®´´�(QCD) (ST)
Primacare®´´
Primacare�One®´´
Primacor®´´
Primaquine®´´
Primaxin®´´
Primsol®´´
Principen®´´
Prinivil®´´
Prinzide®´´
Pro-Banthine®´´
Pro-Clear®´´
Pro-Hyo®´´
Pro-Red®´´
Proamatine®´´
Procalamine®´´
Procanbid®´´
Procardia®´´
Procardia�XL®´´
Prochieve®´´
Proctocort®´´
Proctocream-HC®´´
Proctofoam-HC®´´
Proctosol-HC®´´
Prodigy�Test�Strips®´´
Profasi®´´
Profen�II®´´
Profen�II�DM®´´
Profen�Forte®´´
Profen�Forte�DM®´´
NonCovered.indd 30 2007-01-05 4:33:27 PM
31
Non-covered M
edications
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Proglycem®´´
Prolex�D®´´
Prolex�Dh®´´
Prolex�DM®´´
Prolex�PD®´´
Proloprim®´´
Promar®´´
Pronestyl®´´
Pronestyl-SR®´´
Propine®´´
Proquin�XR®´´
Prosed�EC®´´
Prosed/DS®´´
Prosol™
Prosom®´´
Prostin�E��Vaginal�Suppository®´´
Prostin�Vr�Pediatric®´´
Protid®´´
Protopam�Chloride®´´
Protopic®´´�(PA)
Proventil®´´�(QCD)
Proventil�HFA®´´�(QCD)
Provera®´´
Provocholine®´´
Prozac®´´�(QCD) (ST)
Prozac�Weekly®´´�(QCD) (ST)
Prudoxin®´´
PSE��0/CPM�8/MSC����5®´´
PSE�CPM®´´
PSEudo-G®´´
Psorcon®´´
Psorcon�E®´´
Psoriatec®´´
PTE-5®´´
Pulmicort®´´�Turbuhaler�(QCD)
Purinethol®´´
Pyrelle�HB®´´
Pyridium®´´
Pyridium�Plus®´´
Qdall®´´
Qdall�Ar®´´
Qualaquin™
Questran®´´
Questran�Light®´´
Quibron®´´
Quibron-300®´´
Quibron-T®´´
Quibron-T/SR®´´
Quick-K®´´
Quick�Mix�w/Lytes®´´
Quindal®´´
Quinidex®´´
Quixin®´´
R-Gene�10®´´
R-Tannamine®´´
R-Tannate®´´
Radiaplexrx®´´
Ranexa®´´
Raniclor®´´
Rapiflux®´´�(QCD) (ST)
Rebetol®´´
Rectagel�HC®´´
Refludan®´´
Reglan®´´
Regonol®´´
Relacon-DM®´´
Relacon-HC®´´
Relafen®´´
Relagard®´´
Relagesic®´´
Relpax®´´�(QCD)
Remeron®´´�(QCD)
Renacidin®´´
Renamin®´´
Renax®´´
Renoquid®´´
Reprexain®´´
Rescon-Jr®´´
Rescon-MX®´´
Resectisol®´´
Respa-1st®´´
Respa�AR®´´
Respa-DM®´´
Respa-PE®´´
Respaire®´´
Respi-Tann®´´
Respi-Tann�G®´´
Respi-Tann�PD®´´
Restoril®´´
Retin-A®´´�(PA)
Retin-A�Micro®´´�(PA)
Rev-Eyes®´´
Revatio®´´�(PA)
Revex®´´
NonCovered.indd 31 2007-01-05 4:33:28 PM
Non-covered M
edications
3�
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Revia®´´
Rheumatrex®´´
Rhinocort�Aqua®´´�(QCD)
Ribatab®´´
Ricobid®´´
Ricobid-H®´´
Ricotuss®´´
Rifadin®´´
Rifamate®´´
Rifater®´´
Rimso-50®´´
Rinate®´´
Ringers®´´
Ringers�Irrigation®´´
Riomet®´´
Risperdal�M®´´
Ritalin®´´
Ritalin�LA®´´
Ritalin-SR®´´
Rituxan®´´
Robaxin®´´
Robaxisal®´´
Robinul®´´
Robinul�Forte®´´
Rocaltrol®´´
Rocephin®´´
Romazicon®´´
Romilar�AC®´´
Rondec®´´
Rondec-DM®´´
Rondec-Tr®´´
Rosac®´´
Rosanil®´´
Rosula®´´
Rosula�Ns®´´
Rowasa®´´
Roxanol®´´
Roxanol-T®´´
Roxicet®´´
Roxicodone®´´
Roxicodone�Intensol®´´
Rozerem®´´�(QCD) (ST)
Ru-Tuss�800�DM®´´
Rum-K®´´
Ryna-1�®´´
Ryna-1��S®´´
Ryna-1�x®´´
Rynatan®´´
Rynatan�Pediatric®´´
Rynatuss®´´
Rynessa�1�®´´
Ryneze®´´
Rythmol®´´
S-T�Forte��®´´
Sal-Tropine®´´
Salagen®´´
Salex®´´
Salflex®´´
Salicept®´´
Saluron®´´
Sanctura®´´
Sandimmune®´´
Santuss®´´
Santyl®´´
Sarafem®´´�(QCD) (ST)
Scleromate®´´
Scopace®´´
Seasonale®´´
Seb-Prev®´´
Sebizon®´´
Seconal�Sodium®´´
Sectral®´´
Sel-Pen®´´
Select-OB®´´
Selepen®´´
Selseb®´´
Semprex-D®´´
Sensorcaine®´´
Sensorcaine�w/Dextrose®´´
Sensorcaine�w/Epinephrine®´´
Septra®´´
Septra�DS®´´
Serax®´´
Seromycin®´´
Shohl’s�Modified®´´
Silvadene®´´
Silver�Nitrate®´´
Simetyl®´´
Simulect®´´
Sina-1�x®´´
Sinemet®´´
Sinemet�CR®´´
Sinequan®´´
Sitrex®´´
Sitrex�PD®´´
NonCovered.indd 32 2007-01-05 4:33:29 PM
33
Non-covered M
edications
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Skelid®´´
Slofed�60®´´
Sodium�Polystyrene�Sulfonate®´´
Sodium�Thiosulfate®´´
Sof-Tact®´´�Test�Strips�(QCD)
Solaraze®´´
Solodyn™
Solu-Cortef®´´
Solu-Medrol®´´
Soma®´´
Soma�Compound®´´
Soma�Compound�w/Codeine®´´
Somnote®´´
Sonata®´´�(QCD) (ST)
Sorbutuss®´´
Spacol®´´
Spacol�T/S®´´
Spectazole®´´
Spectracef®´´
Sporanox®´´�(QCD) (PA)
Spray�and�Stretch®´´
Sps®´´
SSki®´´
Sta-D®´´
Stadol®´´
Staflex®´´
Stagesic-10®´´
Stahist®´´
Starlix®´´
Statuss�Green®´´
Sterapred®´´
Sterapred�DS®´´
Strattera®´´�(QCD) (ST)
Streptase®´´
Streptomycin�Sulfate®´´
Striant®´´
Strongstart®´´
Strovite�Advance®´´
Strovite�Forte®´´
Stuartnatal�Plus�3®´´
Sucraid®´´
Sudal®´´
Sudal�1�®´´
Sudal-1�®´´
Sudal�DM®´´
Sudal�SR®´´
Sular®´´
Sulfacet-R®´´
Sulfoxyl�Regular®´´
Sulfoxyl�Strong®´´
Sulindac®´´
Sumycin®´´
Supprelin®´´
Suprax®´´
Surestep®´´�Test�Strips�(QCD)
Surmontil®´´
Sutent®´´
Suttar-�®´´
Suttar-SF®´´
Symax�Duotab®´´
Symbyax®´´�(QCD)
Symmetrel®´´
Symtan®´´
Symtan�A®´´
Synalar®´´
Synalgos-DC®´´
Synarel®´´
Synercid®´´
Syprine®´´
Taclonex®´´
Tagamet®´´
Talacen®´´
Taladine®´´
Talwin®´´
Talwin�NX®´´
Tambocor®´´
Tanafed®´´
Tanafed�DMX®´´
Tanafed�DP®´´
Tandem�F®´´
Tandem�Forte®´´
Tandem�OB®´´
Tandem�Plus®´´
Tapazole®´´
Tarabine�PFS®´´
Tarka®´´
Tavist®´´
Taxol®´´
Taxotere®´´
Tazicef®´´
Tazorac®´´
Temovate®´´
Temovate�Emollient®´´
Tenex®´´
NonCovered.indd 33 2007-01-05 4:33:29 PM
Non-covered M
edications
34
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Tenoretic®´´
Tenormin®´´
Tequin®´´
Terazol�3®´´
Terazol�7®´´
Terramycin®´´
Terramycin�w/Polymyxin®´´
Tessalon®´´
Tessalon�Perle®´´
Testopel®´´
Testred®´´
Teveten®´´�(ST)
Teveten�HCT®´´�(ST)
Texacort®´´
Thalitone®´´
Theo-�4®´´
Theocap®´´
Theomar�GG®´´
Thera-Flur-N®´´
Theracys®´´
Thiocyl®´´
Thiola®´´
Thiotepa®´´
Thymoglobulin®´´
Thyrel�TRH®´´
Thyrogen®´´
Thyrolar®´´
Tiazac®´´
Ticar®´´
Ticlid®´´
Tigan®´´
Tilade®´´�(QCD)
Timentin®´´
Timolide®´´
Timoptic®´´
Timoptic-Xe®´´
Tindamax®´´
Tobradex®´´
Tobrex®´´
Tofranil®´´
Tofranil-Pm®´´
Tolectin®´´
Topicort®´´
Topicort�LP®´´
Toposar®´´
Toradol®´´
Torecan®´´
Totacillin-N®´´
Touro�CC®´´
Touro�CC-Ld®´´
Touro�DM®´´
Touro�HC®´´
Touro�LA®´´
Touro�La-Ld®´´
Tpn�Electrolytes®´´
Tpn�Electrolytes�II®´´
Trac��x®´´
Trace�Elements®´´
Trace�Elements-4®´´
Trace�Metals®´´
Trandate®´´
Tranxene�Sd®´´
Tranxene�T-Tab®´´
Travasol®´´
Travasol�w/Dextrose®´´
Travasol�w/Electrolytes®´´
Travatan®´´
Travatan�Z®´´
Travert®´´
Trecator®´´
Trental®´´
Tretin-X®´´�(PA)
Trexall®´´
Tri-Chlor®´´
Tri-K®´´
Tri-Levlen®´´
Tri-Norinyl®´´
Tri-Vi-Flor®´´
Tri-Vi-Flor�w/Iron®´´
Triad®´´
Triant-HC®´´
Triaz®´´
Tricare®´´
Tricitrasol®´´
Tricor®´´
Tricosal®´´
Tridal®´´
Tridesilon®´´
Trikof-D®´´
Trilisate®´´
Trilyte�with�Flavor�Packets®´´
Triostat®´´
Triphasil®´´
Triple�Sulfa®´´
Trispec�DMX®´´
NonCovered.indd 34 2007-01-05 4:33:30 PM
35
Non-covered M
edications
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Trispec�PSE®´´
Trispec�SFX®´´
Trital�DM®´´
Trituss®´´
Trituss-A®´´
Trituss-ER®´´
Trobicin®´´
Trophamine®´´
TRUE�Test®´´
Trycet®´´
Tusnel®´´
Tusnel-DM®´´
Tusnel-HC®´´
Tusnel�Ped-C®´´
Tusnel�Pediatric®´´
Tuss-Mine�DM®´´
Tussafed�Ex®´´
Tussafed-Hcg®´´
Tussall®´´
Tussall-ER®´´
Tussend®´´
Tussi-1�®´´
Tussi-1��S®´´
Tussi-1�d®´´
Tussi-1�d�S®´´
Tussi-Organidin�NR®´´
Tussi-Pres®´´
Tussi-Pres�Pediatric®´´
Tussidex®´´
Tussigon®´´
Tussilan�NF®´´
Tussinate®´´
Tussionex®´´
Tussirex®´´
Tusso-DF®´´
Tusso-DM®´´
Tusso-HC®´´
Tusso-XR®´´
Tustan�1�®´´
Tygacil®´´
Tylenol�w/Codeine®´´
Tylox®´´
Tympagesic®´´
Tyzine®´´
U-Cort®´´
Ucephan®´´
Ultiva®´´
Ultrabrom®´´
Ultrabrom�PD®´´
Ultracet®´´
Ultralytic��®´´
Ultram®´´
Ultram�ER®´´
Ultrase®´´
Ultrase�MT®´´
Ultravate®´´
Umecta®´´
Unasyn®´´
Unguentum�Bossi®´´
Uniphyl®´´
Uniretic®´´
Univasc®´´
Urecholine®´´
Urelle®´´
Uretron�D/S®´´
Urex®´´
Urimax®´´
Urised®´´
Urispas®´´
Urisym®´´
Uro�Blue®´´
Uro-KP-Neutral®´´
Urodol®´´
Urolene�Blue®´´
Uroqid-Acid�No����®´´
Urosex®´´
Urso®´´
Urso�Forte®´´
Uta®´´
Valium®´´
Valtrex®´´�(QCD)
Vanacet®´´
Vanamide®´´
Vanex�HD®´´
Vanos®´´
Vanoxide-HC®´´
Vanspar®´´
Vantin®´´
Vaseretic®´´
Vasocidin®´´
Vasodilan®´´
Vasotec®´´
Vasotuss�HC®´´
Vazol®´´
Vazol-D®´´
Veetids�500®´´
NonCovered.indd 35 2007-01-05 4:33:31 PM
Non-covered M
edications
36
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Velcade®´´
Velosef®´´
Ventolin®´´�(QCD)
Ventolin�HFA®´´�(QCD)
Vepesid®´´
Verdeso®´´
Verelan®´´
Verelan�Pm®´´
Vermox®´´
Versiclear®´´
Vesicare®´´
Vexol®´´
Vi-Daylin�F�ADC®´´
Vi-Daylin/F®´´
Vi-Daylin/F�+�Iron®´´
Vi-Daylin/F�ADC�Plus�Iron®´´
Viagra®´´
Vibra-Tabs®´´
Vibramycin®´´
Vicodin®´´
Vicodin�ES®´´
Vicodin�HP®´´
Vicoprofen®´´
Vigamox®´´�(QCD)
Viokase®´´
Viravan�DM®´´
Viravan-S®´´
Viravan-T®´´
Virazole®´´
Viroptic®´´
Viscoat®´´
Visicol®´´
Vistaril®´´
Vistide®´´
Visudyne®´´
Vita-Pren®´´
Vivactil®´´
Vivelle®´´�(QCD)
Vivelle-Dot®´´�(QCD)
Volmax®´´
Voltaren®´´
Voltaren-XR®´´
Vopac®´´
Vospire�ER®´´
Vumon®´´
Vusion®´´
Vytone®´´
Welchol®´´
Wellbutrin®´´�(ST)
Wellbutrin�SR®´´�(QCD) (ST)
Wellbutrin�XL®´´�(QCD) (ST)
Westcort®´´
Xanax®´´
Xanax�XR®´´
Xclair®´´
Xenaderm®´´
Xerac�AC®´´
Xibrom®´´
Xifaxan®´´
Xirahist®´´
Xirahist�DM®´´
Xiratuss®´´
Xodol®´´
Xolegel®´´
Xopenex®´´�(ST)
Xopenex�HFA®´´�(ST)
XPect-AT®´´
XPect-HC®´´
Xylocaine®´´
Yasmin��8®´´
Yaz®´´
Yodefan®´´
Yodefan-NF®´´
Yodoxin®´´
Z-Clinz®´´
Z-Cof�DM®´´
Z-Cof�DMX®´´
Z-Cof�HC®´´
Z-Cof�HCX®´´
Z-Cof�LA®´´
Z-Cof�LAX®´´
Zanaflex®´´
Zanosar®´´
Zantac®´´
Zarontin®´´
Zaroxolyn®´´
Zazole®´´
Zebeta®´´
Zebutal®´´
Zegerid®´´�(QCD) (ST)
Zelapar®´´
Zemplar®´´
Zenapax®´´
Zephrex®´´
Zephrex-LA®´´
NonCovered.indd 36 2007-01-05 4:33:32 PM
37
(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions
Zerlor®´´
Zestoretic®´´
Zestril®´´
Zetacet®´´
Zetia®´´�(QCD) (ST)
Ziac®´´
Zinacef®´´
Zinecard®´´
Zmax®´´
Zoderm®´´
Zoloft®´´�(QCD) (ST)
Zonalon®´´
Zorprin®´´
Zostrix®´´
Zosyn®´´
Zotex®´´
Zotex-G®´´
Zotex-Gp®´´
Zotex�GPX®´´
Zotex-LA®´´
Zotex�LAX®´´
Zoto-HC®´´
Zovirax®´´
Ztuss®´´
Zyban®´´
Zydone®´´
Zyflo®´´�(ST)
Zylet®´´
Zyloprim®´´
Zymar®´´�(QCD)
Zymine®´´
Zymine-D®´´
Zymine�HC®´´
Zyprexa�IM®´´
Zyprexa�Zydis®´´
Zyrtec®´´�(QCD)
Zyrtec-D®´´�(QCD)
Zyvox®´´
Non-covered M
edications
NonCovered.indd 37 2007-01-05 4:33:32 PM