13
Blue Cross and Blue Shield of North Carolina Formulary Updates January 2016 January 2016 | Blue Cross and Blue Shield of North Carolina Updates TRADE NAME (generic name) Brand/Generic Product Effective Date Description of Change ABILIFY (aripiprazole oral solution 1 mg/ml) Brand 10/6/2015 Moved to Tier 3 - generics available ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE BITARTRATE (acetaminophen-caffeine-dihydrocodeine tab 712.8-60-32 mg) Brand 1/1/2016 Moved to Tier 3 ACETAZOLAMIDE (acetazolamide tab 125 mg) Brand 1/1/2016 Moved to Tier 3 ACETIC ACID/ALUMINUM ACETATE (acetic acid 2% in aluminum acetate otic soln) Brand 1/1/2016 Moved to Tier 3 ADVANCED AM/PM (*multiple vitamins w/ calcium therapy pack**) Brand 1/1/2016 Moved to Tier 3 ADVATE (antihemophilic factor rahf-pfm for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4 ADVATE (antihemophilic factor rahf-pfm for inj 1500 unit) Brand 1/1/2016 Addition, Tier 4 ADVATE (antihemophilic factor rahf-pfm for inj 2000 unit) Brand 1/1/2016 Addition, Tier 4 ADVATE (antihemophilic factor rahf-pfm for inj 250 unit) Brand 1/1/2016 Addition, Tier 4 ADVATE (antihemophilic factor rahf-pfm for inj 3000 unit) Brand 1/1/2016 Addition, Tier 4 ADVATE (antihemophilic factor rahf-pfm for inj 4000 unit) Brand 1/1/2016 Addition, Tier 4 ADVATE (antihemophilic factor rahf-pfm for inj 500 unit) Brand 1/1/2016 Addition, Tier 4 ALENDRONATE SODIUM (alendronate sodium tab 40 mg) Brand 1/1/2016 Moved to Tier 3 ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN (antihemophilic factor/vwf (human) for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4 ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN (antihemophilic factor/vwf (human) for inj 1500 unit) Brand 1/1/2016 Addition, Tier 4 ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN (antihemophilic factor/vwf (human) for inj 2000 unit) Brand 1/1/2016 Addition, Tier 4 ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN (antihemophilic factor/vwf (human) for inj 250 unit) Brand 1/1/2016 Addition, Tier 4 ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN (antihemophilic factor/vwf (human) for inj 500 unit) Brand 1/1/2016 Addition, Tier 4 ALPHANINE SD (coagulation factor ix for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4 ALPHANINE SD (coagulation factor ix for inj 1500 unit) Brand 1/1/2016 Addition, Tier 4 ALPHANINE SD (coagulation factor ix for inj 500 unit) Brand 1/1/2016 Addition, Tier 4 ALPROLIX (coagulation factor ix (recomb) (rfixfc) for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4 ALPROLIX (coagulation factor ix (recomb) (rfixfc) for inj 2000 unit) Brand 1/1/2016 Addition, Tier 4 ALPROLIX (coagulation factor ix (recomb) (rfixfc) for inj 3000 unit) Brand 1/1/2016 Addition, Tier 4 ALPROLIX (coagulation factor ix (recomb) (rfixfc) for inj 500 unit) Brand 1/1/2016 Addition, Tier 4 AMANTADINE HCL (amantadine hcl tab 100 mg) Brand 1/1/2016 Moved to Tier 3 AMCINONIDE (amcinonide cream 0.1%) Brand 1/1/2016 Moved to Tier 3 AMCINONIDE (amcinonide lotion 0.1%) Brand 1/1/2016 Moved to Tier 3 AMCINONIDE (amcinonide oint 0.1%) Brand 1/1/2016 Moved to Tier 3 AMINOBENZOATE POTASSIUM (potassium aminobenzoate packet 2 gm) Brand 1/1/2016 Moved to Tier 3 AMOXAPINE (amoxapine tab 100 mg) Brand 1/1/2016 Moved to Tier 3 AMOXAPINE (amoxapine tab 150 mg) Brand 1/1/2016 Moved to Tier 3 AMOXAPINE (amoxapine tab 25 mg) Brand 1/1/2016 Moved to Tier 3 AMOXAPINE (amoxapine tab 50 mg) Brand 1/1/2016 Moved to Tier 3 AMOXICILLIN (amoxicillin (trihydrate) chew tab 125 mg) Brand 1/1/2016 Moved to Tier 3 AMOXICILLIN (amoxicillin (trihydrate) chew tab 250 mg) Brand 1/1/2016 Moved to Tier 3 AMPICILLIN (ampicillin for susp 125 mg/5ml) Brand 1/1/2016 Moved to Tier 3 continued

North Carolina Formulary Updates - Elon University Member... · North Carolina Formulary Updates . January 2016. January 2016 | Blue Cross and Blue Shield of North Carolina Updates

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Page 1: North Carolina Formulary Updates - Elon University Member... · North Carolina Formulary Updates . January 2016. January 2016 | Blue Cross and Blue Shield of North Carolina Updates

Blue Cross and Blue Shield of North Carolina Formulary Updates

January 2016

January 2016 | Blue Cross and Blue Shield of North Carolina Updates

TRADE NAME (generic name) Brand/Generic

Product Effective Date Description of Change

ABILIFY (aripiprazole oral solution 1 mg/ml) Brand 10/6/2015 Moved to Tier 3 - generics available

ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE BITARTRATE (acetaminophen-caffeine-dihydrocodeine tab 712.8-60-32 mg)

Brand 1/1/2016 Moved to Tier 3

ACETAZOLAMIDE (acetazolamide tab 125 mg) Brand 1/1/2016 Moved to Tier 3

ACETIC ACID/ALUMINUM ACETATE (acetic acid 2% in aluminum acetate otic soln) Brand 1/1/2016 Moved to Tier 3

ADVANCED AM/PM (*multiple vitamins w/ calcium therapy pack**) Brand 1/1/2016 Moved to Tier 3

ADVATE (antihemophilic factor rahf-pfm for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

ADVATE (antihemophilic factor rahf-pfm for inj 1500 unit) Brand 1/1/2016 Addition, Tier 4

ADVATE (antihemophilic factor rahf-pfm for inj 2000 unit) Brand 1/1/2016 Addition, Tier 4

ADVATE (antihemophilic factor rahf-pfm for inj 250 unit) Brand 1/1/2016 Addition, Tier 4

ADVATE (antihemophilic factor rahf-pfm for inj 3000 unit) Brand 1/1/2016 Addition, Tier 4

ADVATE (antihemophilic factor rahf-pfm for inj 4000 unit) Brand 1/1/2016 Addition, Tier 4

ADVATE (antihemophilic factor rahf-pfm for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

ALENDRONATE SODIUM (alendronate sodium tab 40 mg) Brand 1/1/2016 Moved to Tier 3

ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN (antihemophilic factor/vwf (human) for inj 1000 unit)

Brand 1/1/2016 Addition, Tier 4

ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN (antihemophilic factor/vwf (human) for inj 1500 unit)

Brand 1/1/2016 Addition, Tier 4

ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN (antihemophilic factor/vwf (human) for inj 2000 unit)

Brand 1/1/2016 Addition, Tier 4

ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN (antihemophilic factor/vwf (human) for inj 250 unit)

Brand 1/1/2016 Addition, Tier 4

ALPHANATE/VON WILLEBRANDFACTOR COMPLEX/HUMAN (antihemophilic factor/vwf (human) for inj 500 unit)

Brand 1/1/2016 Addition, Tier 4

ALPHANINE SD (coagulation factor ix for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

ALPHANINE SD (coagulation factor ix for inj 1500 unit) Brand 1/1/2016 Addition, Tier 4

ALPHANINE SD (coagulation factor ix for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

ALPROLIX (coagulation factor ix (recomb) (rfixfc) for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

ALPROLIX (coagulation factor ix (recomb) (rfixfc) for inj 2000 unit) Brand 1/1/2016 Addition, Tier 4

ALPROLIX (coagulation factor ix (recomb) (rfixfc) for inj 3000 unit) Brand 1/1/2016 Addition, Tier 4

ALPROLIX (coagulation factor ix (recomb) (rfixfc) for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

AMANTADINE HCL (amantadine hcl tab 100 mg) Brand 1/1/2016 Moved to Tier 3

AMCINONIDE (amcinonide cream 0.1%) Brand 1/1/2016 Moved to Tier 3

AMCINONIDE (amcinonide lotion 0.1%) Brand 1/1/2016 Moved to Tier 3

AMCINONIDE (amcinonide oint 0.1%) Brand 1/1/2016 Moved to Tier 3

AMINOBENZOATE POTASSIUM (potassium aminobenzoate packet 2 gm) Brand 1/1/2016 Moved to Tier 3

AMOXAPINE (amoxapine tab 100 mg) Brand 1/1/2016 Moved to Tier 3

AMOXAPINE (amoxapine tab 150 mg) Brand 1/1/2016 Moved to Tier 3

AMOXAPINE (amoxapine tab 25 mg) Brand 1/1/2016 Moved to Tier 3

AMOXAPINE (amoxapine tab 50 mg) Brand 1/1/2016 Moved to Tier 3

AMOXICILLIN (amoxicillin (trihydrate) chew tab 125 mg) Brand 1/1/2016 Moved to Tier 3

AMOXICILLIN (amoxicillin (trihydrate) chew tab 250 mg) Brand 1/1/2016 Moved to Tier 3

AMPICILLIN (ampicillin for susp 125 mg/5ml) Brand 1/1/2016 Moved to Tier 3

continued

Page 2: North Carolina Formulary Updates - Elon University Member... · North Carolina Formulary Updates . January 2016. January 2016 | Blue Cross and Blue Shield of North Carolina Updates

TRADE NAME (generic name) Brand/Generic

Product Effective Date Description of Change

AMPICILLIN (ampicillin for susp 250 mg/5ml) Brand 1/1/2016 Moved to Tier 3

ANASPAZ (hyoscyamine sulfate tab disp 0.125 mg) Brand 1/1/2016 Moved to Tier 3 - generics available

ANDROGEL (testosterone td gel 50 mg/5gm (1%)) Brand 10/21/2015 Moved to Tier 3 - generics available

ANDROXY (fluoxymesterone tab 10 mg) Brand 1/1/2016 Moved to Tier 3

ANTIPYRINE/BENZOCAINE (antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%)) Brand 1/1/2016 Moved to Tier 3

APEXICON E (diflorasone diacetate emollient base cream 0.05%) Brand 1/1/2016 Moved to Tier 3

ARZOL SILVER NITRATE APPLICATORS (silver nitrate-potassium nitrate applicator 75-25%) Brand 1/1/2016 Moved to Tier 3 - generics available

ATROPINE SULFATE (atropine sulfate ophth oint 1%) Brand 1/1/2016 Moved to Tier 3

AZITHROMYCIN (azithromycin powd pack for susp 1 gm) Brand 1/1/2016 Moved to Tier 3

BACITRACIN (bacitracin ophth oint 500 unit/gm) Brand 1/1/2016 Moved to Tier 3

BEBULIN (factor ix complex for inj 200-1200 unit) Brand 1/1/2016 Addition, Tier 4

BEBULIN VH (factor ix complex for inj 200-1200 unit) Brand 1/1/2016 Addition, Tier 4

BELLADONNA & OPIUM (belladonna alkaloids & opium suppos 16.2-30 mg) Brand 1/1/2016 Moved to Tier 3

BELLADONNA ALKALOIDS & OPIUM (belladonna alkaloids & opium suppos 16.2-60 mg) Brand 1/1/2016 Moved to Tier 3

BENEFIX (coagulation factor ix (recombinant) for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

BENEFIX (coagulation factor ix (recombinant) for inj 2000 unit) Brand 1/1/2016 Addition, Tier 4

BENEFIX (coagulation factor ix (recombinant) for inj 250 unit) Brand 1/1/2016 Addition, Tier 4

BENEFIX (coagulation factor ix (recombinant) for inj 3000 unit) Brand 1/1/2016 Addition, Tier 4

BENEFIX (coagulation factor ix (recombinant) for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

BIOREGESIC (phenyltoloxamine-acetaminophen tab 50-650 mg) Brand 1/1/2016 Moved to Tier 3

BP CLEANSING WASH (sulfacetamide sodium-sulfur in urea emulsion 10-4%) Brand 1/1/2016 Moved to Tier 3

BP VIT 3 (*folic acid-vit b6-vit b12-omega 3-phytosterols cap 1 mg***) Brand 1/1/2016 Moved to Tier 3

BPO (benzoyl peroxide gel 8%) Brand 1/1/2016 Moved to Tier 3

BROMPHENIRAMINE TANNATE (brompheniramine tannate chew tab 12 mg) Brand 1/1/2016 Moved to Tier 3

BUTALBITAL/ASPIRIN/CAFFEINE (butalbital-aspirin-caffeine tab 50-325-40 mg) Brand 1/1/2016 Moved to Tier 3

CALCITRIOL (calcitriol oint 3 mcg/gm) Brand 1/1/2016 Moved to Tier 3

CALCIUM-FOLIC ACID PLUS D (ca carb-folic acid-vit d-b6-b12-boron-mag wafer 1342-1 mg) Brand 1/1/2016 Moved to Tier 3

CAPTOPRIL/HYDROCHLOROTHIAZIDE (captopril & hydrochlorothiazide tab 25-15 mg) Brand 1/1/2016 Moved to Tier 3

CAPTOPRIL/HYDROCHLOROTHIAZIDE (captopril & hydrochlorothiazide tab 25-25 mg) Brand 1/1/2016 Moved to Tier 3

CAPTOPRIL/HYDROCHLOROTHIAZIDE (captopril & hydrochlorothiazide tab 50-15 mg) Brand 1/1/2016 Moved to Tier 3

CAPTOPRIL/HYDROCHLOROTHIAZIDE (captopril & hydrochlorothiazide tab 50-25 mg) Brand 1/1/2016 Moved to Tier 3

CARISOPRODOL (carisoprodol tab 250 mg) Brand 1/1/2016 Moved to Tier 3

CEFACLOR ER (cefaclor monohydrate tab sr 12hr 500 mg) Brand 1/1/2016 Moved to Tier 3

CEFDITOREN PIVOXIL (cefditoren pivoxil tab 200 mg (base equivalent)) Brand 1/1/2016 Moved to Tier 3

CEFDITOREN PIVOXIL (cefditoren pivoxil tab 400 mg (base equivalent)) Brand 1/1/2016 Moved to Tier 3

CEM-UREA (urea soln 45%) Brand 1/1/2016 Moved to Tier 3

CENTANY (mupirocin oint 2%) Brand 1/1/2016 Moved to Tier 3

CEPHALEXIN (cephalexin tab 250 mg) Brand 1/1/2016 Moved to Tier 3

CEPHALEXIN (cephalexin tab 500 mg) Brand 1/1/2016 Moved to Tier 3

January 2016 | Blue Cross and Blue Shield of North Carolina Updates

Blue Cross and Blue Shield of North Carolina Formulary Updates continued

January 2016

continued

Page 3: North Carolina Formulary Updates - Elon University Member... · North Carolina Formulary Updates . January 2016. January 2016 | Blue Cross and Blue Shield of North Carolina Updates

January 2016 | Blue Cross and Blue Shield of North Carolina Updates

Blue Cross and Blue Shield of North Carolina Formulary Updates continued

January 2016

TRADE NAME (generic name) Brand/Generic

Product Effective Date Description of Change

CHLORDIAZEPOXIDE/AMITRIPTYLINE (chlordiazepoxide-amitriptyline tab 10-25 mg) Brand 1/1/2016 Moved to Tier 3

CHLORDIAZEPOXIDE/AMITRIPTYLINE (chlordiazepoxide-amitriptyline tab 5-12.5 mg) Brand 1/1/2016 Moved to Tier 3

CHLOROTHIAZIDE (chlorothiazide tab 250 mg) Brand 1/1/2016 Moved to Tier 3

CHLORPROPAMIDE (chlorpropamide tab 100 mg) Brand 1/1/2016 Moved to Tier 3

CHLORPROPAMIDE (chlorpropamide tab 250 mg) Brand 1/1/2016 Moved to Tier 3

CHLORTHALIDONE (chlorthalidone tab 25 mg) Brand 1/1/2016 Moved to Tier 3

CHLORTHALIDONE (chlorthalidone tab 50 mg) Brand 1/1/2016 Moved to Tier 3

CHOLINE MAGNESIUM TRISALICYLATE (choline & magnesium salicylates tab 1000 mg) Brand 1/1/2016 Moved to Tier 3

CICLOPIROX TOPICAL SOLUTION KIT (*ciclopirox solution 8% & vitamin e 5% topical kit**) Brand 1/1/2016 Moved to Tier 3

CIPROFLOXACIN HCL (ciprofloxacin hcl tab 100 mg (base equiv)) Brand 1/1/2016 Moved to Tier 3

CLEMASTINE FUMARATE (clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq)) Brand 1/1/2016 Moved to Tier 3

CLORPRES (clonidine & chlorthalidone tab 0.1-15 mg) Brand 1/1/2016 Moved to Tier 3

CLORPRES (clonidine & chlorthalidone tab 0.2-15 mg) Brand 1/1/2016 Moved to Tier 3

COCAINE HCL (cocaine hcl soln 10%) Brand 1/1/2016 Moved to Tier 3

COCAINE HCL (cocaine hcl soln 4%) Brand 1/1/2016 Moved to Tier 3

CORIFACT (factor xiii concentrate (human) for inj kit 1000-1600 unit) Brand 1/1/2016 Addition, Tier 4

CORTALO (hydrocortisone acetate-aloe vera gel 2%) Brand 1/1/2016 Moved to Tier 3

CORTANE-B AQUEOUS (pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1 mg/ml) Brand 1/1/2016 Moved to Tier 3

CORTANE-B-OTIC (pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml) Brand 1/1/2016 Moved to Tier 3 - generics available

CORTISONE ACETATE (cortisone acetate tab 25 mg) Brand 1/1/2016 Moved to Tier 3

CROMOLYN SODIUM (cromolyn sodium soln nebu 20 mg/2ml) Brand 1/1/2016 Moved to Tier 3

CYTRA-3 (pot & sod citrates w/ cit ac syrup 550-500-334 mg/5ml) Brand 1/1/2016 Moved to Tier 3

DANTROLENE SODIUM (dantrolene sodium cap 100 mg) Brand 1/1/2016 Moved to Tier 3

DESOXIMETASONE (desoximetasone cream 0.05%) Brand 1/1/2016 Moved to Tier 3

DEXAMETHASONE (dexamethasone tab 1 mg) Brand 1/1/2016 Moved to Tier 3

DEXAMETHASONE (dexamethasone tab 2 mg) Brand 1/1/2016 Moved to Tier 3

DEXCHLORPHENIRAMINE MALEATE (dexchlorpheniramine maleate syrup 2 mg/5ml) Brand 1/1/2016 Moved to Tier 3

DEXTROMETHORPHAN HBR/CHLORPHENIRAMINE/PHENYLEPHRINE HCL (phenylephrine-chlorphen-dm liquid 1.75-0.75-2.75 mg/ml)

Brand 1/1/2016 Moved to Tier 3

DIALYVITE/ZINC (*b-complex w/ c-zn & folic acid tab 1 mg***) Brand 1/1/2016 Moved to Tier 3

DIAZEPAM (diazepam rectal gel delivery system 10 mg) Brand 1/1/2016 Moved to Tier 3

DIAZEPAM (diazepam rectal gel delivery system 2.5 mg) Brand 1/1/2016 Moved to Tier 3

DIAZEPAM (diazepam rectal gel delivery system 20 mg) Brand 1/1/2016 Moved to Tier 3

DIFLORASONE DIACETATE (diflorasone diacetate cream 0.05%) Brand 1/1/2016 Moved to Tier 3

DIFLORASONE DIACETATE (diflorasone diacetate oint 0.05%) Brand 1/1/2016 Moved to Tier 3

DIGOXIN (digoxin oral soln 0.05 mg/ml) Brand 1/1/2016 Moved to Tier 3

DIPHENOXYLATE/ATROPINE (diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml) Brand 1/1/2016 Moved to Tier 3

DOXEPIN HCL (doxepin hcl cap 75 mg) Brand 1/1/2016 Moved to Tier 3

DOXYTEX (doxylamine succinate liquid 2.5 mg/2.5ml) Brand 1/1/2016 Moved to Tier 3

E.E.S. 400 (erythromycin ethylsuccinate tab 400 mg) Brand 1/1/2016 Moved to Tier 3

ELETONE (*dermatological products misc - cream**) Brand 1/1/2016 Moved to Tier 3

continued

Page 4: North Carolina Formulary Updates - Elon University Member... · North Carolina Formulary Updates . January 2016. January 2016 | Blue Cross and Blue Shield of North Carolina Updates

January 2016 | Blue Cross and Blue Shield of North Carolina Updates

Blue Cross and Blue Shield of North Carolina Formulary Updates continued

January 2016

TRADE NAME (generic name) Brand/Generic

Product Effective Date Description of Change

ELIPHOS (calcium acetate (phosphate binder) tab 667 mg) Brand 1/1/2016 Moved to Tier 3 - generics available

ELOCTATE (antihemophilic factor (recomb) rfviiifc for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

ELOCTATE (antihemophilic factor (recomb) rfviiifc for inj 1500 unit) Brand 1/1/2016 Addition, Tier 4

ELOCTATE (antihemophilic factor (recomb) rfviiifc for inj 2000 unit) Brand 1/1/2016 Addition, Tier 4

ELOCTATE (antihemophilic factor (recomb) rfviiifc for inj 250 unit) Brand 1/1/2016 Addition, Tier 4

ELOCTATE (antihemophilic factor (recomb) rfviiifc for inj 3000 unit) Brand 1/1/2016 Addition, Tier 4

ELOCTATE (antihemophilic factor (recomb) rfviiifc for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

ELOCTATE (antihemophilic factor (recomb) rfviiifc for inj 750 unit) Brand 1/1/2016 Addition, Tier 4

EMULSION SB (*dermatological products misc - emulsion**) Brand 1/1/2016 Moved to Tier 3

ENVARSUS XR (tacrolimus tab sr 24hr 0.75 mg) Brand 10/1/2015 Addition, Tier 4

ENVARSUS XR (tacrolimus tab sr 24hr 1 mg) Brand 10/1/2015 Addition, Tier 4

ENVARSUS XR (tacrolimus tab sr 24hr 4 mg) Brand 10/1/2015 Addition, Tier 4

EPROSARTAN MESYLATE (eprosartan mesylate tab 600 mg) Brand 1/1/2016 Moved to Tier 3

ERY-TAB (erythromycin tab delayed release 250 mg) Brand 1/1/2016 Moved to Tier 3

ERY-TAB (erythromycin tab delayed release 333 mg) Brand 1/1/2016 Moved to Tier 3

ERYTHROCIN STEARATE (erythromycin stearate tab 250 mg) Brand 1/1/2016 Moved to Tier 3

ERYTHROMYCIN ETHYLSUCCINATE (erythromycin ethylsuccinate tab 400 mg) Brand 1/1/2016 Moved to Tier 3

ESCAVITE LQ (*pediatric multiple vitamins w/ fl-fe drops 0.25-6 mg/ml**) Brand 1/1/2016 Moved to Tier 3

ESTROPIPATE (estropipate tab 3 mg) Brand 1/1/2016 Moved to Tier 3

ETIDRONATE DISODIUM (etidronate disodium tab 200 mg) Brand 1/1/2016 Moved to Tier 3

ETIDRONATE DISODIUM (etidronate disodium tab 400 mg) Brand 1/1/2016 Moved to Tier 3

EXODERM (sodium thiosulfate-salicylic acid lotion 25-1%) Brand 1/1/2016 Moved to Tier 3

FEIBA (*antiinhibitor coagulant complex for inj**) Brand 1/1/2016 Addition, Tier 4

FEIBA NF (*antiinhibitor coagulant complex for inj**) Brand 1/1/2016 Addition, Tier 4

FEM PH (acetic acid-oxyquinoline vaginal gel 0.9-0.025%) Brand 1/1/2016 Moved to Tier 3

FENOFIBRIC ACID (fenofibric acid tab 105 mg) Brand 1/1/2016 Moved to Tier 3

FENOFIBRIC ACID (fenofibric acid tab 35 mg) Brand 1/1/2016 Moved to Tier 3

FENOPROFEN CALCIUM (fenoprofen calcium tab 600 mg) Brand 1/1/2016 Moved to Tier 3

FERRAPLUS 90 (*iron-folic acid-vit b12-vit c-docusate sod tab 90-1 mg***) Brand 1/1/2016 Moved to Tier 3

FERREX 150 FORTE PLUS (*fe asp gly-fe polysacch-succ ac-c-threon ac-b12-fa cap***) Brand 1/1/2016 Moved to Tier 3

FERREX 28 (*fe asparto gly-fe fum-b12-fa-c-succinic ac tab ther pack**) Brand 1/1/2016 Moved to Tier 3

FLUPHENAZINE HCL (fluphenazine hcl elixir 2.5 mg/5ml) Brand 1/1/2016 Moved to Tier 3

FLUPHENAZINE HCL (fluphenazine hcl oral conc 5 mg/ml) Brand 1/1/2016 Moved to Tier 3

FLURAZEPAM HCL (flurazepam hcl cap 15 mg) Brand 1/1/2016 Moved to Tier 3

FLURAZEPAM HCL (flurazepam hcl cap 30 mg) Brand 1/1/2016 Moved to Tier 3

FOLIVANE-F (*fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe)***) Brand 1/1/2016 Moved to Tier 3

FOLIVANE-PLUS (*fe fum-iron polysacch complex-fa-b complex-c-biotin cap***) Brand 1/1/2016 Moved to Tier 3

FORANE (isoflurane inhal soln) Brand 1/1/2016 Moved to Tier 3 - generics available

FORMA-RAY (formaldehyde solution 20%) Brand 1/1/2016 Moved to Tier 3

FORTICAL (calcitonin (salmon) nasal soln 200 unit/act) Brand 1/1/2016 Moved to Tier 3

continued

Page 5: North Carolina Formulary Updates - Elon University Member... · North Carolina Formulary Updates . January 2016. January 2016 | Blue Cross and Blue Shield of North Carolina Updates

January 2016 | Blue Cross and Blue Shield of North Carolina Updates

Blue Cross and Blue Shield of North Carolina Formulary Updates continued

January 2016

TRADE NAME (generic name) Brand/Generic

Product Effective Date Description of Change

GALANTAMINE HYDROBROMIDE (galantamine hydrobromide oral soln 4 mg/ml) Brand 1/1/2016 Moved to Tier 3

GASTRINEX NF (hyoscyamine-phenyltoloxamine cap 0.0625-15 mg) Brand 1/1/2016 Moved to Tier 3

GENTAMICIN SULFATE (gentamicin sulfate cream 0.1%) Brand 1/1/2016 Moved to Tier 3

GENTAMICIN SULFATE (gentamicin sulfate oint 0.1%) Brand 1/1/2016 Moved to Tier 3

GENVOYA (elvitegrav-cobic-emtricitab-tenofov af tab 150-150-200-10 mg) Brand 11/12/2015 Addition, Tier 4

GLEOSTINE (lomustine cap 5 mg) Brand 11/15/2015 Addition, Tier 4

GLYBURIDE (glyburide tab 1.25 mg) Brand 1/1/2016 Moved to Tier 3

GLYBURIDE (glyburide tab 2.5 mg) Brand 1/1/2016 Moved to Tier 3

GLYBURIDE (glyburide tab 5 mg) Brand 1/1/2016 Moved to Tier 3

HALAC (halobetasol prop oint 0.05% & ammonium lactate lot 12% kit) Brand 1/1/2016 Moved to Tier 3

HALONATE (halobetasol prop oint 0.05% & ammonium lactate foam 12% kit) Brand 1/1/2016 Moved to Tier 3

HELIXATE FS (antihemophilic factor (recombinant) for inj kit 1000 unit) Brand 1/1/2016 Addition, Tier 4

HELIXATE FS (antihemophilic factor (recombinant) for inj kit 2000 unit) Brand 1/1/2016 Addition, Tier 4

HELIXATE FS (antihemophilic factor (recombinant) for inj kit 250 unit) Brand 1/1/2016 Addition, Tier 4

HELIXATE FS (antihemophilic factor (recombinant) for inj kit 3000 unit) Brand 1/1/2016 Addition, Tier 4

HELIXATE FS (antihemophilic factor (recombinant) for inj kit 500 unit) Brand 1/1/2016 Addition, Tier 4

HEMATOGEN FA (fe fumarate-vit c-vit b12-fa cap 200-250-0.01-1 mg) Brand 1/1/2016 Moved to Tier 3

HEMOFIL M (antihemophilic factor (human) for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

HEMOFIL M (antihemophilic factor (human) for inj 1501-2000 unit) Brand 1/1/2016 Addition, Tier 4

HEMOFIL M (antihemophilic factor (human) for inj 1700 unit) Brand 1/1/2016 Addition, Tier 4

HEMOFIL M (antihemophilic factor (human) for inj 220-400 unit) Brand 1/1/2016 Addition, Tier 4

HEMOFIL M (antihemophilic factor (human) for inj 250 unit) Brand 1/1/2016 Addition, Tier 4

HEMOFIL M (antihemophilic factor (human) for inj 401-800 unit) Brand 1/1/2016 Addition, Tier 4

HEMOFIL M (antihemophilic factor (human) for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

HEMOFIL M (antihemophilic factor (human) for inj 801-1500 unit) Brand 1/1/2016 Addition, Tier 4

HEPARIN SODIUM/D5W (heparin sodium (porcine) 100 unit/ml in d5w) Brand 1/1/2016 Moved to Tier 3

HEPARIN SODIUM/D5W (heparin sodium (porcine) 50 unit/ml in d5w) Brand 1/1/2016 Moved to Tier 3 - generics available

HEPARIN SODIUM/SODIUM CHLORIDE 0.9% (heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9%)

Brand 1/1/2016 Moved to Tier 3 - generics available

HUMATE-P (antihemophilic factor/vwf (human) for inj 1000-2400 unit) Brand 1/1/2016 Addition, Tier 4

HUMATE-P (antihemophilic factor/vwf (human) for inj 250-600 unit) Brand 1/1/2016 Addition, Tier 4

HUMATE-P (antihemophilic factor/vwf (human) for inj 500-1200 unit) Brand 1/1/2016 Addition, Tier 4

HYDROCODONE BITARTRATE/ACETAMINOPHEN (hydrocodone-acetaminophen tab 10-750 mg) Brand 1/1/2016 Moved to Tier 3

HYDROCODONE/ACETAMINOPHEN (hydrocodone-acetaminophen soln 10-325 mg/15ml) Brand 1/1/2016 Moved to Tier 3

HYDROCODONE/ACETAMINOPHEN (hydrocodone-acetaminophen soln 7.5-500 mg/15ml) Brand 1/1/2016 Moved to Tier 3

HYDROCODONE/ACETAMINOPHEN (hydrocodone-acetaminophen tab 7.5-500 mg) Brand 1/1/2016 Moved to Tier 3

HYDROCODONE/ACETAMINOPHEN (hydrocodone-acetaminophen tab 7.5-650 mg) Brand 1/1/2016 Moved to Tier 3

HYDROCODONE/ACETAMINOPHEN (hydrocodone-acetaminophen tab 7.5-750 mg) Brand 1/1/2016 Moved to Tier 3

HYDROMORPHONE HCL (hydromorphone hcl suppos 3 mg) Brand 1/1/2016 Moved to Tier 3

HYDROXOCOBALAMIN (hydroxocobalamin inj 1000 mcg/ml) Brand 1/1/2016 Moved to Tier 3

HYDROXYZINE PAMOATE (hydroxyzine pamoate cap 100 mg) Brand 1/1/2016 Moved to Tier 3

continued

Page 6: North Carolina Formulary Updates - Elon University Member... · North Carolina Formulary Updates . January 2016. January 2016 | Blue Cross and Blue Shield of North Carolina Updates

January 2016 | Blue Cross and Blue Shield of North Carolina Updates

Blue Cross and Blue Shield of North Carolina Formulary Updates continued

January 2016

TRADE NAME (generic name) Brand/Generic

Product Effective Date Description of Change

INCRUSE ELLIPTA (umeclidinium br aero powd breath act 62.5 mcg/inh (base eq)) Brand 10/15/2015 Addition, Tier 2

IODINE STRONG (iodine solution strong 5% (lugol's)) Brand 1/1/2016 Moved to Tier 3

ISOMETHEPTENE/CAFFEINE/ACETAMINOPHEN (isometheptene-caffeine-acetaminophen tab 130-20-500 mg)

Brand 1/1/2016 Moved to Tier 3

ISOSORBIDE DINITRATE (isosorbide dinitrate sl tab 2.5 mg) Brand 1/1/2016 Moved to Tier 3

ISOSORBIDE DINITRATE (isosorbide dinitrate tab 30 mg) Brand 1/1/2016 Moved to Tier 3

ISOSORBIDE DINITRATE ER (isosorbide dinitrate tab cr 40 mg) Brand 1/1/2016 Moved to Tier 3

ISOXSUPRINE HCL (isoxsuprine hcl tab 20 mg) Brand 1/1/2016 Moved to Tier 3

IXINITY (coagulation factor ix (recombinant) for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

IXINITY (coagulation factor ix (recombinant) for inj 1500 unit) Brand 1/1/2016 Addition, Tier 4

IXINITY (coagulation factor ix (recombinant) for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

KETOPROFEN ER (ketoprofen cap sr 24hr 200 mg) Brand 1/1/2016 Moved to Tier 3

KETOROLAC TROMETHAMINE (ketorolac tromethamine inj 300 mg/10ml (30 mg/ml)) Brand 1/1/2016 Moved to Tier 3

KEVEYIS (dichlorphenamide tab 50 mg) Brand 9/24/2015 Addition, Tier 4

KOATE-DVI (antihemophilic factor (human) for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

KOATE-DVI (antihemophilic factor (human) for inj 250 unit) Brand 1/1/2016 Addition, Tier 4

KOATE-DVI (antihemophilic factor (human) for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

KOGENATE FS (antihemophilic factor (recombinant) for inj kit 1000 unit) Brand 1/1/2016 Addition, Tier 4

KOGENATE FS (antihemophilic factor (recombinant) for inj kit 2000 unit) Brand 1/1/2016 Addition, Tier 4

KOGENATE FS (antihemophilic factor (recombinant) for inj kit 250 unit) Brand 1/1/2016 Addition, Tier 4

KOGENATE FS (antihemophilic factor (recombinant) for inj kit 3000 unit) Brand 1/1/2016 Addition, Tier 4

KOGENATE FS (antihemophilic factor (recombinant) for inj kit 500 unit) Brand 1/1/2016 Addition, Tier 4

KOGENATE FS BIO-SET (antihemophilic factor (recombinant) for inj kit 1000 unit) Brand 1/1/2016 Addition, Tier 4

KOGENATE FS BIO-SET (antihemophilic factor (recombinant) for inj kit 2000 unit) Brand 1/1/2016 Addition, Tier 4

KOGENATE FS BIO-SET (antihemophilic factor (recombinant) for inj kit 250 unit) Brand 1/1/2016 Addition, Tier 4

KOGENATE FS BIO-SET (antihemophilic factor (recombinant) for inj kit 3000 unit) Brand 1/1/2016 Addition, Tier 4

KOGENATE FS BIO-SET (antihemophilic factor (recombinant) for inj kit 500 unit) Brand 1/1/2016 Addition, Tier 4

K-PHOS NEUTRAL (pot phos monobasic w/sod phos di & monobas tab 155-852-130mg) Brand 1/1/2016 Moved to Tier 3 - generics available

LATRIX XM (urea in zinc undecylenate-lactic acid vehicle emulsion 45%) Brand 1/1/2016 Moved to Tier 3

LEVACET (aspirin-apap-salicylamide-caffeine tab 500-250-150-32.5 mg) Brand 1/1/2016 Moved to Tier 3

LEVOBUNOLOL HCL (levobunolol hcl ophth soln 0.25%) Brand 1/1/2016 Moved to Tier 3

LEVONORGESTREL (levonorgestrel tab 0.75 mg) Brand 1/1/2016 Moved to Tier 3

LEVORPHANOL TARTRATE (levorphanol tartrate tab 2 mg) Brand 1/1/2016 Moved to Tier 3

LEXUSS 210 (chlorpheniramine w/ codeine liquid 2-10 mg/5ml) Brand 1/1/2016 Moved to Tier 3

LIDOCAINE HCL (lidocaine hcl lotion 3%) Brand 1/1/2016 Moved to Tier 3

LIDOCAINE HCL-HYDROCORTISONE ACETATE WITH ALOE (lidocaine-hydrocortisone acetate rectal gel 2.8-0.55%)

Brand 1/1/2016 Moved to Tier 3

LITHIUM (lithium oral solution 8 meq/5ml) Brand 1/1/2016 Moved to Tier 3

LITHIUM CARBONATE (lithium carbonate cap 150 mg) Brand 1/1/2016 Moved to Tier 3 - generics available

LITHIUM CARBONATE (lithium carbonate cap 600 mg) Brand 1/1/2016 Moved to Tier 3 - generics available

continued

Page 7: North Carolina Formulary Updates - Elon University Member... · North Carolina Formulary Updates . January 2016. January 2016 | Blue Cross and Blue Shield of North Carolina Updates

January 2016 | Blue Cross and Blue Shield of North Carolina Updates

Blue Cross and Blue Shield of North Carolina Formulary Updates continued

January 2016

TRADE NAME (generic name) Brand/Generic

Product Effective Date Description of Change

LONSURF (trifluridine-tipiracil tab 15-6.14 mg) Brand 10/4/2015 Addition, Tier 4

LONSURF (trifluridine-tipiracil tab 20-8.19 mg) Brand 10/4/2015 Addition, Tier 4

LOZI-FLUR (sodium fluoride lozenge 1 mg f (from 2.2 mg naf)) Brand 1/1/2016 Moved to Tier 3

LTA 360 KIT (lidocaine hcl laryngotracheal soln 4%) Brand 1/1/2016 Moved to Tier 3 - generics available

MAPROTILINE HCL (maprotiline hcl tab 25 mg) Brand 1/1/2016 Moved to Tier 3

MAPROTILINE HCL (maprotiline hcl tab 50 mg) Brand 1/1/2016 Moved to Tier 3

MAPROTILINE HCL (maprotiline hcl tab 75 mg) Brand 1/1/2016 Moved to Tier 3

MECLOFENAMATE SODIUM (meclofenamate sodium cap 100 mg) Brand 1/1/2016 Moved to Tier 3

MECLOFENAMATE SODIUM (meclofenamate sodium cap 50 mg) Brand 1/1/2016 Moved to Tier 3

MELOXICAM (meloxicam susp 7.5 mg/5ml) Brand 1/1/2016 Moved to Tier 3

MEPERIDINE HCL (meperidine hcl oral soln 50 mg/5ml) Brand 1/1/2016 Moved to Tier 3

METAPROTERENOL SULFATE (metaproterenol sulfate syrup 10 mg/5ml) Brand 1/1/2016 Moved to Tier 3

METAPROTERENOL SULFATE (metaproterenol sulfate tab 10 mg) Brand 1/1/2016 Moved to Tier 3

METAPROTERENOL SULFATE (metaproterenol sulfate tab 20 mg) Brand 1/1/2016 Moved to Tier 3

METHADONE HCL (methadone hcl soln 5 mg/5ml) Brand 1/1/2016 Moved to Tier 3 - generics available

METHENAMINE MANDELATE (methenamine mandelate tab 0.5 gm) Brand 1/1/2016 Moved to Tier 3

METHYCLOTHIAZIDE (methyclothiazide tab 5 mg) Brand 1/1/2016 Moved to Tier 3

METHYL SALICYLATE (*methyl salicylate liquid**) Brand 1/1/2016 Moved to Tier 3

METHYLDOPA/HYDROCHLOROTHIAZIDE (methyldopa & hydrochlorothiazide tab 250-15 mg) Brand 1/1/2016 Moved to Tier 3

METHYLDOPA/HYDROCHLOROTHIAZIDE (methyldopa & hydrochlorothiazide tab 250-25 mg) Brand 1/1/2016 Moved to Tier 3

METIPRANOLOL (metipranolol ophth soln 0.3%) Brand 1/1/2016 Moved to Tier 3

MICONAZOLE 3 (miconazole nitrate vaginal suppos 200 mg) Brand 1/1/2016 Moved to Tier 3

MIGERGOT (ergotamine w/ caffeine suppos 2-100 mg) Brand 1/1/2016 Moved to Tier 3

MILLIPRED (prednisolone tab 5 mg) Brand 1/1/2016 Moved to Tier 3

MILLIPRED DP (prednisolone tab 5 mg dose pack) Brand 1/1/2016 Moved to Tier 3

MONOCLATE-P (antihemophilic factor (human) for inj kit 1000 unit) Brand 1/1/2016 Addition, Tier 4

MONOCLATE-P (antihemophilic factor (human) for inj kit 1500 unit) Brand 1/1/2016 Addition, Tier 4

MONOCLATE-P (antihemophilic factor (human) for inj kit 250 unit) Brand 1/1/2016 Addition, Tier 4

MONOCLATE-P (antihemophilic factor (human) for inj kit 500 unit) Brand 1/1/2016 Addition, Tier 4

MONONINE (coagulation factor ix for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

MONONINE (coagulation factor ix for inj 250 unit) Brand 1/1/2016 Addition, Tier 4

MONONINE (coagulation factor ix for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

MORPHINE SULFATE (morphine sulfate suppos 10 mg) Brand 1/1/2016 Moved to Tier 3

MORPHINE SULFATE (morphine sulfate suppos 20 mg) Brand 1/1/2016 Moved to Tier 3

MORPHINE SULFATE (morphine sulfate suppos 30 mg) Brand 1/1/2016 Moved to Tier 3

MORPHINE SULFATE (morphine sulfate suppos 5 mg) Brand 1/1/2016 Moved to Tier 3

MORPHINE SULFATE (morphine sulfate tab 15 mg) Brand 1/1/2016 Moved to Tier 3

MORPHINE SULFATE (morphine sulfate tab 30 mg) Brand 1/1/2016 Moved to Tier 3

MORPHINE SULFATE ER (morphine sulfate beads cap sr 24hr 120 mg) Brand 1/1/2016 Moved to Tier 3

MORPHINE SULFATE ER (morphine sulfate beads cap sr 24hr 30 mg) Brand 1/1/2016 Moved to Tier 3

continued

Page 8: North Carolina Formulary Updates - Elon University Member... · North Carolina Formulary Updates . January 2016. January 2016 | Blue Cross and Blue Shield of North Carolina Updates

January 2016 | Blue Cross and Blue Shield of North Carolina Updates

Blue Cross and Blue Shield of North Carolina Formulary Updates continued

January 2016

TRADE NAME (generic name) Brand/Generic

Product Effective Date Description of Change

MORPHINE SULFATE ER (morphine sulfate beads cap sr 24hr 45 mg) Brand 1/1/2016 Moved to Tier 3

MORPHINE SULFATE ER (morphine sulfate beads cap sr 24hr 60 mg) Brand 1/1/2016 Moved to Tier 3

MORPHINE SULFATE ER (morphine sulfate beads cap sr 24hr 75 mg) Brand 1/1/2016 Moved to Tier 3

MORPHINE SULFATE ER (morphine sulfate beads cap sr 24hr 90 mg) Brand 1/1/2016 Moved to Tier 3

MULTIGEN (*fe asparto gly-succ acd-c-threonic acd-b12-des stom tab***) Brand 1/1/2016 Moved to Tier 3

MULTIGEN FOLIC (*fe asparto gly-succinic acd-vit c-threonic acd-b12-fa tab**) Brand 1/1/2016 Moved to Tier 3

MULTIGEN PLUS (*fe aspart gly-fe fum-succ acd-c-threonic acd-b12-fa tab***) Brand 1/1/2016 Moved to Tier 3

MYOXIN (benzocaine-chloroxylenol-hc otic susp 15-1-10 mg/ml) Brand 1/1/2016 Moved to Tier 3

NAFRINSE DAILY/ACIDULATED (sodium fluoride-phosphoric acid for soln 1 mg/5ml (f equiv)) Brand 1/1/2016 Moved to Tier 3

NAFRINSE DAILY/NEUTRAL (sodium fluoride for soln rinse 0.05%) Brand 1/1/2016 Moved to Tier 3

NAPHAZOLINE HCL (naphazoline hcl ophth soln 0.1%) Brand 1/1/2016 Moved to Tier 3

NAPROXEN (naproxen susp 125 mg/5ml) Brand 1/1/2016 Moved to Tier 3

NATURE-THROID (thyroid tab 130 mg) Brand 1/1/2016 Moved to Tier 3

NATURE-THROID (thyroid tab 195 mg) Brand 1/1/2016 Moved to Tier 3

NATURE-THROID (thyroid tab 32.5 mg) Brand 1/1/2016 Moved to Tier 3

NATURE-THROID (thyroid tab 65 mg) Brand 1/1/2016 Moved to Tier 3

NECON 1/50-28 (norethindrone & mestranol tab 1 mg-50 mcg) Brand 1/1/2016 Moved to Tier 3

NECON 10/11-28 (norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11)) Brand 1/1/2016 Moved to Tier 3

NEFAZODONE HCL (nefazodone hcl tab 100 mg) Brand 1/1/2016 Moved to Tier 3

NEFAZODONE HCL (nefazodone hcl tab 150 mg) Brand 1/1/2016 Moved to Tier 3

NEFAZODONE HCL (nefazodone hcl tab 200 mg) Brand 1/1/2016 Moved to Tier 3

NEOMYCIN/POLYMYXIN/HYDROCORTISONE (neomycin-polymyxin-hc ophth susp) Brand 1/1/2016 Moved to Tier 3

NIACOR (niacin (antihyperlipidemic) tab 500 mg) Brand 1/1/2016 Moved to Tier 3

NISOLDIPINE (nisoldipine tab sr 24hr 20 mg) Brand 1/1/2016 Moved to Tier 3

NISOLDIPINE (nisoldipine tab sr 24hr 30 mg) Brand 1/1/2016 Moved to Tier 3

NISOLDIPINE (nisoldipine tab sr 24hr 40 mg) Brand 1/1/2016 Moved to Tier 3

NISOLDIPINE ER (nisoldipine tab sr 24hr 25.5 mg) Brand 1/1/2016 Moved to Tier 3

NITRO-BID (nitroglycerin oint 2%) Brand 1/1/2016 Moved to Tier 3

NORTRIPTYLINE HCL (nortriptyline hcl soln 10 mg/5ml) Brand 1/1/2016 Moved to Tier 3

NOVOEIGHT (antihemophilic factor (recombinant) for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

NOVOEIGHT (antihemophilic factor (recombinant) for inj 1500 unit) Brand 1/1/2016 Addition, Tier 4

NOVOEIGHT (antihemophilic factor (recombinant) for inj 2000 unit) Brand 1/1/2016 Addition, Tier 4

NOVOEIGHT (antihemophilic factor (recombinant) for inj 250 unit) Brand 1/1/2016 Addition, Tier 4

NOVOEIGHT (antihemophilic factor (recombinant) for inj 3000 unit) Brand 1/1/2016 Addition, Tier 4

NOVOEIGHT (antihemophilic factor (recombinant) for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

NOVOSEVEN RT (coagulation factor viia (recomb) for inj 1 mg (1000 mcg)) Brand 1/1/2016 Addition, Tier 4

NOVOSEVEN RT (coagulation factor viia (recomb) for inj 2 mg (2000 mcg)) Brand 1/1/2016 Addition, Tier 4

NOVOSEVEN RT (coagulation factor viia (recomb) for inj 5 mg (5000 mcg)) Brand 1/1/2016 Addition, Tier 4

NOVOSEVEN RT (coagulation factor viia (recomb) for inj 8 mg (8000 mcg)) Brand 1/1/2016 Addition, Tier 4

NUWIQ (antihemophilic factor (human) for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

NUWIQ (antihemophilic factor (recombinant) for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

continued

Page 9: North Carolina Formulary Updates - Elon University Member... · North Carolina Formulary Updates . January 2016. January 2016 | Blue Cross and Blue Shield of North Carolina Updates

January 2016 | Blue Cross and Blue Shield of North Carolina Updates

Blue Cross and Blue Shield of North Carolina Formulary Updates continued

January 2016

TRADE NAME (generic name) Brand/Generic

Product Effective Date Description of Change

NUWIQ (antihemophilic factor (recombinant) for inj 2000 unit) Brand 1/1/2016 Addition, Tier 4

NUWIQ (antihemophilic factor (recombinant) for inj 250 unit) Brand 1/1/2016 Addition, Tier 4

NUWIQ (antihemophilic factor (recombinant) for inj kit 1000 unit) Brand 1/1/2016 Addition, Tier 4

NUWIQ (antihemophilic factor (recombinant) for inj kit 2000 unit) Brand 1/1/2016 Addition, Tier 4

NUWIQ (antihemophilic factor (recombinant) for inj kit 250 unit) Brand 1/1/2016 Addition, Tier 4

NUWIQ (antihemophilic factor (recombinant) for inj kit 500 unit) Brand 1/1/2016 Addition, Tier 4

OBIZUR (antihemophilic factor (recomb porc) rpfviii for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

OCUDOX (*doxycycline hyclate cap 50 mg & eyelid cleans & spray kit**) Brand 1/1/2016 Moved to Tier 3

ODOMZO (sonidegib phosphate cap 200 mg (base equivalent)) Brand 10/4/2015 Addition, Tier 4

OFLOXACIN (ofloxacin tab 400 mg) Brand 1/1/2016 Moved to Tier 3

OGESTREL (norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg) Brand 1/1/2016 Moved to Tier 3

OPIUM TINCTURE (PAREGORIC) (paregoric 2 mg/5ml) Brand 1/1/2016 Moved to Tier 3

OTICIN HC NR (pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml) Brand 1/1/2016 Moved to Tier 3 - generics available

OTOZIN (antipyrine-benzocaine-glycerin-zinc ace otic liqd 5.4-1-2-1%) Brand 1/1/2016 Moved to Tier 3

OTREXUP (methotrexate soln pf auto-injector 7.5 mg/0.4ml) Brand 8/23/2015 Addition, Tier 4

OXYCODONE HCL (oxycodone hcl conc 100 mg/5ml (20 mg/ml)) Brand 1/1/2016 Moved to Tier 3 - generics available

PALGIC (carbinoxamine maleate soln 4 mg/5ml) Brand 1/1/2016 Moved to Tier 3 - generics available

PERPHENAZINE/AMITRIPTYLINE (perphenazine-amitriptyline tab 2-10 mg) Brand 1/1/2016 Moved to Tier 3

PERPHENAZINE/AMITRIPTYLINE (perphenazine-amitriptyline tab 2-25 mg) Brand 1/1/2016 Moved to Tier 3

PERPHENAZINE/AMITRIPTYLINE (perphenazine-amitriptyline tab 4-10 mg) Brand 1/1/2016 Moved to Tier 3

PERPHENAZINE/AMITRIPTYLINE (perphenazine-amitriptyline tab 4-25 mg) Brand 1/1/2016 Moved to Tier 3

PERPHENAZINE/AMITRIPTYLINE (perphenazine-amitriptyline tab 4-50 mg) Brand 1/1/2016 Moved to Tier 3

PHENOBARBITAL (phenobarbital tab 100 mg) Brand 1/1/2016 Moved to Tier 3

PHENOBARBITAL (phenobarbital tab 15 mg) Brand 1/1/2016 Moved to Tier 3

PHENOBARBITAL (phenobarbital tab 30 mg) Brand 1/1/2016 Moved to Tier 3

PHENOBARBITAL (phenobarbital tab 60 mg) Brand 1/1/2016 Moved to Tier 3

POTASSIUM CHLORIDE ER (potassium chloride tab cr 8 meq (600 mg)) Brand 1/1/2016 Moved to Tier 3

PR CREAM (*dermatological products misc - kit**) Brand 1/1/2016 Moved to Tier 3

PREDNISOLONE SODIUM PHOSPHATE (prednisolone sodium phosphate ophth soln 1%) Brand 1/1/2016 Moved to Tier 3

PREDNISONE (prednisone oral soln 5 mg/5ml) Brand 1/1/2016 Moved to Tier 3

PREDNISONE (prednisone tab 10 mg dose pack) Brand 1/1/2016 Moved to Tier 3

PREDNISONE (prednisone tab 5 mg dose pack) Brand 1/1/2016 Moved to Tier 3

PREDNISONE (prednisone tab 50 mg) Brand 1/1/2016 Moved to Tier 3

PRIMLEV (oxycodone w/ acetaminophen tab 5-300 mg) Brand 1/1/2016 Moved to Tier 3

PRIMLEV (oxycodone w/ acetaminophen tab 7.5-300 mg) Brand 1/1/2016 Moved to Tier 3

PROFILNINE (factor ix complex for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

PROFILNINE (factor ix complex for inj 1500 unit) Brand 1/1/2016 Addition, Tier 4

PROFILNINE (factor ix complex for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

PROFILNINE SD (factor ix complex for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

continued

Page 10: North Carolina Formulary Updates - Elon University Member... · North Carolina Formulary Updates . January 2016. January 2016 | Blue Cross and Blue Shield of North Carolina Updates

January 2016 | Blue Cross and Blue Shield of North Carolina Updates

Blue Cross and Blue Shield of North Carolina Formulary Updates continued

January 2016

TRADE NAME (generic name) Brand/Generic

Product Effective Date Description of Change

PROFILNINE SD (factor ix complex for inj 1500 unit) Brand 1/1/2016 Addition, Tier 4

PROFILNINE SD (factor ix complex for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

PROPANTHELINE BROMIDE (propantheline bromide tab 15 mg) Brand 1/1/2016 Moved to Tier 3

PROPRANOLOL HCL (propranolol hcl oral soln 20 mg/5ml) Brand 1/1/2016 Moved to Tier 3

PROPRANOLOL HCL (propranolol hcl oral soln 40 mg/5ml) Brand 1/1/2016 Moved to Tier 3

PROPRANOLOL/HYDROCHLOROTHIAZIDE (propranolol & hydrochlorothiazide tab 40-25 mg) Brand 1/1/2016 Moved to Tier 3

PROPRANOLOL/HYDROCHLOROTHIAZIDE (propranolol & hydrochlorothiazide tab 80-25 mg) Brand 1/1/2016 Moved to Tier 3

PRUCLAIR (*dermatological products misc - cream**) Brand 1/1/2016 Moved to Tier 3

PRUDOXIN (doxepin hcl cream 5%) Brand 1/1/2016 Moved to Tier 3

PRUMYX (*dermatological products misc - cream**) Brand 1/1/2016 Moved to Tier 3

PRUTECT (*wound dressings - emulsion***) Brand 1/1/2016 Moved to Tier 3

PULMICORT (budesonide inhalation susp 1 mg/2ml) Brand 9/4/2015 Moved to Tier 3 - generics available

QUFLORA PEDIATRIC (*pediatric multiple vitamins w/ fluoride chew tab 0.25 mg***) Brand 1/1/2016 Moved to Tier 3

QUFLORA PEDIATRIC (*pediatric multiple vitamins w/ fluoride chew tab 1 mg***) Brand 1/1/2016 Moved to Tier 3

QUFLORA PEDIATRIC (*pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml***) Brand 1/1/2016 Moved to Tier 3

QUFLORA PEDIATRIC (*pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml***) Brand 1/1/2016 Moved to Tier 3

QUINIDINE SULFATE (quinidine sulfate tab 200 mg) Brand 1/1/2016 Moved to Tier 3

QUINIDINE SULFATE ER (quinidine sulfate tab cr 300 mg) Brand 1/1/2016 Moved to Tier 3

RECOMBINATE (antihemophilic factor (recombinant) for inj 1241-1800 unit) Brand 1/1/2016 Addition, Tier 4

RECOMBINATE (antihemophilic factor (recombinant) for inj 1801-2400 unit) Brand 1/1/2016 Addition, Tier 4

RECOMBINATE (antihemophilic factor (recombinant) for inj 220-400 unit) Brand 1/1/2016 Addition, Tier 4

RECOMBINATE (antihemophilic factor (recombinant) for inj 401-800 unit) Brand 1/1/2016 Addition, Tier 4

RECOMBINATE (antihemophilic factor (recombinant) for inj 801-1240 unit) Brand 1/1/2016 Addition, Tier 4

RELAMINE (*glucosamine-chondroitin-paba-vit e-alpha lipoic acid tab***) Brand 1/1/2016 Moved to Tier 3

RELHIST (bromphen tan-phenyleph tan chew tab 6-15 mg) Brand 1/1/2016 Moved to Tier 3

RELYYKS (lidocaine-menthol patch 4-5%) Brand 10/14/2015 Moved to Tier 3 - generics available

REPATHA (evolocumab subcutaneous soln prefilled syringe 140 mg/ml) Brand 9/6/2015 Addition, Tier 4

REPATHA SURECLICK (evolocumab subcutaneous soln auto-injector 140 mg/ml) Brand 9/6/2015 Addition, Tier 4

RESERPINE (reserpine tab 0.1 mg) Brand 1/1/2016 Moved to Tier 3

RESERPINE (reserpine tab 0.25 mg) Brand 1/1/2016 Moved to Tier 3

RHINOFLEX-650 (phenyltoloxamine-acetaminophen tab 50-650 mg) Brand 1/1/2016 Moved to Tier 3

RIASTAP (fibrinogen conc (human) inj approximately 1 gm (900-1300 mg)) Brand 1/1/2016 Addition, Tier 4

RIBASPHERE (ribavirin tab 400 mg) Brand 1/1/2016 Moved to Tier 3

RIBASPHERE (ribavirin tab 600 mg) Brand 1/1/2016 Moved to Tier 3

RIBASPHERE RIBAPAK (ribavirin tab 200 mg & ribavirin tab 400 mg dose pack) Brand 1/1/2016 Moved to Tier 3

RIBASPHERE RIBAPAK (ribavirin tab 400 mg & ribavirin tab 600 mg dose pack) Brand 1/1/2016 Moved to Tier 3

RIBASPHERE RIBAPAK (ribavirin tab 400 mg) Brand 1/1/2016 Moved to Tier 3

RIBASPHERE RIBAPAK (ribavirin tab 600 mg) Brand 1/1/2016 Moved to Tier 3

RIXUBIS (coagulation factor ix (recombinant) for inj 1000 unit) Brand 1/1/2016 Addition, Tier 4

RIXUBIS (coagulation factor ix (recombinant) for inj 2000 unit) Brand 1/1/2016 Addition, Tier 4

continued

Page 11: North Carolina Formulary Updates - Elon University Member... · North Carolina Formulary Updates . January 2016. January 2016 | Blue Cross and Blue Shield of North Carolina Updates

January 2016 | Blue Cross and Blue Shield of North Carolina Updates

Blue Cross and Blue Shield of North Carolina Formulary Updates continued

January 2016

TRADE NAME (generic name) Brand/Generic

Product Effective Date Description of Change

RIXUBIS (coagulation factor ix (recombinant) for inj 250 unit) Brand 1/1/2016 Addition, Tier 4

RIXUBIS (coagulation factor ix (recombinant) for inj 3000 unit) Brand 1/1/2016 Addition, Tier 4

RIXUBIS (coagulation factor ix (recombinant) for inj 500 unit) Brand 1/1/2016 Addition, Tier 4

SALICYLIC ACID (salicylic acid soln 26%) Brand 1/1/2016 Moved to Tier 3

SALICYLIC ACID IN AMMONIUM LACTATE VEHICLE (salicylic acid in ammonium lactate vehicle foam 6%)

Brand 1/1/2016 Moved to Tier 3

SALVAX (salicylic acid foam 6%) Brand 1/1/2016 Moved to Tier 3 - generics available

SODIUM FLUORIDE (sodium fluoride tab 0.5 mg f (from 1.1 mg naf)) Brand 1/1/2016 Moved to Tier 3

SODIUM FLUORIDE (sodium fluoride tab 1 mg f (from 2.2 mg naf)) Brand 1/1/2016 Moved to Tier 3

SODIUM SULFACETAMIDE/SULFUR (sulfacetamide sodium w/ sulfur susp 10-5%) Brand 1/1/2016 Moved to Tier 3

SODIUM SULFACETAMIDE/SULFUR CLEANSER IN UREA (sulfacetamide sodium-sulfur in urea emulsion 10-5%)

Brand 1/1/2016 Moved to Tier 3

SONAFINE (*wound dressings - emulsion***) Brand 1/1/2016 Moved to Tier 3

SPINOSAD (spinosad susp 0.9%) Brand 1/1/2016 Moved to Tier 3

SPIRIVA RESPIMAT (tiotropium bromide monohydrate inhal aerosol 1.25 mcg/act) Brand 10/13/2015 Addition, Tier 2

SULFACETAMIDE SODIUM (sulfacetamide sodium ophth oint 10%) Brand 1/1/2016 Moved to Tier 3

SULFADIAZINE (sulfadiazine tab 500 mg) Brand 1/1/2016 Moved to Tier 3

SUMATRIPTAN (sumatriptan nasal spray 20 mg/act) Brand 1/1/2016 Moved to Tier 3

SUMATRIPTAN (sumatriptan nasal spray 5 mg/act) Brand 1/1/2016 Moved to Tier 3

SUTTAR-2 (pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml) Brand 1/1/2016 Moved to Tier 3 - generics available

SUTTAR-SF (pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml) Brand 1/1/2016 Moved to Tier 3 - generics available

TARON FORTE (*fe bisglycinate-fe polysacch-vit c-vit b12-fa cap***) Brand 1/1/2016 Moved to Tier 3

TENCON (butalbital-acetaminophen tab 50-650 mg) Brand 1/1/2016 Moved to Tier 3

tetrabenazine tab 12.5 mg Generic 8/23/2015 Addition, Tier 4

tetrabenazine tab 25 mg Generic 8/23/2015 Addition, Tier 4

TETRACYCLINE HCL (tetracycline hcl cap 250 mg) Brand 1/1/2016 Moved to Tier 3

TETRACYCLINE HCL (tetracycline hcl cap 500 mg) Brand 1/1/2016 Moved to Tier 3

TGQ 15DM/5PEH/2CPM (phenylephrine-chlorphen-dm syrup 5-2-15 mg/5ml) Brand 1/1/2016 Moved to Tier 3

TGQ 30PSE/150GFN/15DM (pseudoephedrine w/ dm-gg syrup 30-15-150 mg/5ml) Brand 1/1/2016 Moved to Tier 3

TGQ 30PSE/3BRM/15DM (pseudoephed-bromphen-dm syrup 30-3-15 mg/5ml) Brand 1/1/2016 Moved to Tier 3

TGQ 50PSE/3BRM/30DM (pseudoephed-bromphen-dm syrup 50-3-30 mg/5ml) Brand 1/1/2016 Moved to Tier 3

TICLOPIDINE HCL (ticlopidine hcl tab 250 mg) Brand 1/1/2016 Moved to Tier 3

TIMOLOL MALEATE (timolol maleate tab 10 mg) Brand 1/1/2016 Moved to Tier 3

TIMOLOL MALEATE (timolol maleate tab 20 mg) Brand 1/1/2016 Moved to Tier 3

TIMOLOL MALEATE (timolol maleate tab 5 mg) Brand 1/1/2016 Moved to Tier 3

TL G-FOL OS (*multiple vit w/ min & calcium-folic acid tab 500-1.1 mg**) Brand 1/1/2016 Moved to Tier 3

TOLAZAMIDE (tolazamide tab 500 mg) Brand 1/1/2016 Moved to Tier 3

TOLBUTAMIDE (tolbutamide tab 500 mg) Brand 1/1/2016 Moved to Tier 3

TOLMETIN SODIUM (tolmetin sodium tab 200 mg) Brand 1/1/2016 Moved to Tier 3

TOLMETIN SODIUM (tolmetin sodium tab 600 mg) Brand 1/1/2016 Moved to Tier 3

continued

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January 2016 | Blue Cross and Blue Shield of North Carolina Updates

Blue Cross and Blue Shield of North Carolina Formulary Updates continued

January 2016

TRADE NAME (generic name) Brand/Generic

Product Effective Date Description of Change

TREAGAN OTIC (*antipyrine-benzocaine-polycosanol otic sol 5.4-1.4-0.0097%*) Brand 1/1/2016 Moved to Tier 3 - generics available

TRETTEN (coagulation factor xiii a-subunit for inj 2000-3125 unit) Brand 1/1/2016 Addition, Tier 4

TREZIX (acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg) Brand 10/6/2015 Moved to Tier 3 - generics available

TREZIX (acetaminophen-caffeine-dihydrocodeine cap 356.4-30-16 mg) Brand 1/1/2016 Moved to Tier 3

TRIAMCINOLONE ACETONIDE (triamcinolone acetonide oint 0.5%) Brand 1/1/2016 Moved to Tier 3

TRIAMTERENE/HYDROCHLOROTHIAZIDE (triamterene & hydrochlorothiazide cap 50-25 mg) Brand 1/1/2016 Moved to Tier 3

TRIANEX (triamcinolone acetonide oint 0.05%) Brand 1/1/2016 Moved to Tier 3

TRI-CHLOR (trichloroacetic acid liqd 80%) Brand 1/1/2016 Moved to Tier 3

TRI-VIT/FLUORIDE/IRON (*pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml***) Brand 1/1/2016 Moved to Tier 3

UREA NAIL (urea in zinc undecylenate-lactic acid vehicle stick 50%) Brand 1/1/2016 Moved to Tier 3

UREA NAIL KIT (urea susp 40% & hyaluronate sodium gel 0.2% kit) Brand 1/1/2016 Moved to Tier 3

URETRON D/S (*methenamine-hyosc-meth blue-sod phos-phen sal tab 120 mg***) Brand 1/1/2016 Moved to Tier 3

UROGESIC-BLUE (*methenamine-hyoscamine-meth blue-sod phos tab 81.6 mg***) Brand 1/1/2016 Moved to Tier 3 - generics available

VANATOL LQ (butalbital-acetaminophen-caffeine soln 50-325-40 mg/15ml) Brand 1/1/2016 Moved to Tier 3

VARUBI (rolapitant hcl tab 90 mg (base equiv)) Brand 10/29/2015 Addition, Tier 4

VENLAFAXINE HCL ER (venlafaxine hcl tab sr 24hr 150 mg (base equivalent)) Brand 1/1/2016 Moved to Tier 3 - generics available

VENLAFAXINE HCL ER (venlafaxine hcl tab sr 24hr 225 mg (base equivalent)) Brand 1/1/2016 Moved to Tier 3

VENLAFAXINE HCL ER (venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)) Brand 1/1/2016 Moved to Tier 3 - generics available

VENLAFAXINE HCL ER (venlafaxine hcl tab sr 24hr 75 mg (base equivalent)) Brand 1/1/2016 Moved to Tier 3 - generics available

VERAPAMIL HCL (verapamil hcl tab 40 mg) Brand 1/1/2016 Moved to Tier 3

VIDAZA (azacitidine for inj 100 mg) Brand 8/29/2015 Addition, Tier 4

VITAMIN K1 (phytonadione inj 10 mg/ml) Brand 1/1/2016 Moved to Tier 3

VP-ZEL (*multiple vitamins w/ minerals tab**) Brand 1/1/2016 Moved to Tier 3

WESTHROID (thyroid tab 130 mg) Brand 1/1/2016 Moved to Tier 3

WESTHROID (thyroid tab 195 mg) Brand 1/1/2016 Moved to Tier 3

WESTHROID (thyroid tab 32.5 mg) Brand 1/1/2016 Moved to Tier 3

WESTHROID (thyroid tab 65 mg) Brand 1/1/2016 Moved to Tier 3

WILATE (antihemophilic factor/vwf (human) for inj 1000-1000 unit) Brand 1/1/2016 Addition, Tier 4

WILATE (antihemophilic factor/vwf (human) for inj 500-500 unit) Brand 1/1/2016 Addition, Tier 4

WP THYROID (thyroid tab 130 mg) Brand 1/1/2016 Moved to Tier 3

WP THYROID (thyroid tab 32.5 mg) Brand 1/1/2016 Moved to Tier 3

WP THYROID (thyroid tab 65 mg) Brand 1/1/2016 Moved to Tier 3

XOLOX (oxycodone w/ acetaminophen tab 10-500 mg) Brand 1/1/2016 Moved to Tier 3

XYNTHA (antihemophilic factor recombinant paf for inj kit 1000 unit) Brand 1/1/2016 Addition, Tier 4

XYNTHA (antihemophilic factor recombinant paf for inj kit 2000 unit) Brand 1/1/2016 Addition, Tier 4

XYNTHA (antihemophilic factor recombinant paf for inj kit 250 unit) Brand 1/1/2016 Addition, Tier 4

XYNTHA (antihemophilic factor recombinant paf for inj kit 500 unit) Brand 1/1/2016 Addition, Tier 4

continued

Page 13: North Carolina Formulary Updates - Elon University Member... · North Carolina Formulary Updates . January 2016. January 2016 | Blue Cross and Blue Shield of North Carolina Updates

5154-B NC © Prime Therapeutics LLC 01/16January 2016 | Blue Cross and Blue Shield of North Carolina Updates

Blue Cross and Blue Shield of North Carolina Formulary Updates continued

January 2016

TRADE NAME (generic name) Brand/Generic

Product Effective Date Description of Change

XYNTHA SOLOFUSE (antihemophilic factor recombinant paf for inj kit 1000 unit) Brand 1/1/2016 Addition, Tier 4

XYNTHA SOLOFUSE (antihemophilic factor recombinant paf for inj kit 2000 unit) Brand 1/1/2016 Addition, Tier 4

XYNTHA SOLOFUSE (antihemophilic factor recombinant paf for inj kit 250 unit) Brand 1/1/2016 Addition, Tier 4

XYNTHA SOLOFUSE (antihemophilic factor recombinant paf for inj kit 3000 unit) Brand 1/1/2016 Addition, Tier 4

XYNTHA SOLOFUSE (antihemophilic factor recombinant paf for inj kit 500 unit) Brand 1/1/2016 Addition, Tier 4

ZARXIO (filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml) Brand 9/12/2015 Addition, Tier 4

ZARXIO (filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml) Brand 9/12/2015 Addition, Tier 4

ZGESIC (phenyltoloxamine-acetaminophen tab cr 66-600 mg) Brand 1/1/2016 Moved to Tier 3

ZOVIA 1/50E (ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg) Brand 1/1/2016 Moved to Tier 3

Special Note: As of January 1, 2016, all Prenatal Vitamins will Move to Tier 3.