BCBSM/BCN Formulary Alternatives - January 2011

BCBSM/BCN Formulary Alternatives - January 2011

NonFormulary

Formulary Alternative

NonFormulary

Formulary Alternative

ACIPHEX

Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), Protonix(g)*, Zegerid(g)*

ARTHROTEC

Lodine(g), Mobic(g), Motrin(g), Naprosyn(g), Voltaren(g), etc. plus Cytotec(g)

ACTIVELLA 0.50.1MG ACTOPLUS MET XR ACUVAIL ACZONE

ADCIRCA ADOXA, CK, TT ADVICOR

AEROBID, M

AGGRENOX AKNE-MYCIN ALAMAST ALLEGRA ODT, SUSP

Activella(g); Estratest(g), H.S.(g)

Glucophage(g) plus Actos*; ActoPlus Met* Acular, LS(g); Voltaren(g) Topical OTC benzoyl peroxide, clindamycin, erythromycin Revatio* Monodox(g), Vibramycin(g) Mevacor(g), Pravachol(g), Zocor(g), Crestor*; plus Niaspan Alvesco, Asmanex, Azmacort, Flovent, Pulmicort, QVAR Persantine(g) plus ASA OTC, Plavix Erythromycin topical solution & gel(g) Zaditor OTC(g), Alomide, Patanol Claritin Syr OTC(g)**, Zyrtec Syr OTC(g)**

ATACAND, HCT AVALIDE, AVAPRO AVANDAMET AVANDARYL AVANDIA

AVC AVINZA

AXERT

AZASITE AZELEX AZILECT AZOR

Cozaar(g), Hyzaar(g), Benicar*, HCT*

Cozaar(g), Hyzaar(g), Benicar*, HCT*

ActoPlus Met*

Duetact*

Glucophage(g); Insulin or a sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos*

Diflucan(g) oral, Terazol(g) vaginal

Methadone(g), MSIR(g), MS Contin(g), Oramorph SR(g)

Amerge(g)*, Imitrex(g); Maxalt*, MLT*

Ciloxan(g), Vigamox

Retin-A(g)

Eldepryl(g)

Generic ACE (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g)

ALREX

Decadron ophth(g), Pred Forte(g), Pred Mild

BECONASE AQ

Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*

ALTABAX ALTACE TABLETS ALTOPREV

Triple Antibiotic OTC, Bactroban(g)

Altace capsules(g) Mevacor(g), Pravachol(g), Zocor(g), Crestor*, Zetia*

BENZACLIN

BENZASHAVE BEPREVE

Individual agents (BPO and clindamycin)

OTC benzoyl peroxide

Zaditor OTC(g), Patanol

AMITIZA

AMRIX ANADROL-50

ANDROGEL ANGELIQ

ANTARA ANZEMET APHTHASOL

OTC laxatives and stool softeners, Glycolax(g), Lactulose(g) Flexeril(g) Androxy(g), Depo-testosterone(g), Androderm, Delatestryl Androderm FemHRT, Prempro/Premphase, or Estradiol plus Progestin Lofibra(g), Lopid(g), Tricor Kytril(g); Zofran(g), ODT(g) Kenalog in Orabase(g)

BESIVANCE BETASERON BETIMOL BEYAZ

BONIVA BROVANA BUTISOL SODIUM

BUTRANS

Ciloxan(g), Ocuflox(g), Vigamox Avonex, Copaxone, Rebif Betagan(g), Betoptic(g), Timoptic(g) Yasmin(g), Yaz(g) PLUS Folic Acid 1MG Fosamax(g), Actonel* Foradil, Serevent Diskus Ambien(g), Prosom(g), Restoril(g), Sonata(g) Duragesic(g), Methadone(g), MS Contin(g), Oramorph(g)

APLENZIN

APRISO

ARANESP ARICEPT 23MG ARIXTRA ARMOUR THYROID

Generic SSRI/SNRI (Celexa(g), Prozac(g), Zoloft (g), Effexor(g), Effexor XR(g); Wellbutrin, SR, XL(g), etc.)

Azulfidine(g), Azulfidine En-Tab(g), Asacol, HD; Pentasa

Procrit*

Aricept 5, 10mg(g)

Lovenox(g)

Synthroid(g)

BYETTA

BYSTOLIC

CADUET

CAMPRAL CANTIL CARAC CARBATROL CARDENE SR

Insulin, Glucophage(g), Sulfonylurea's, TZD's

Blocadren(g), Lopressor(g), Tenormin(g), Toprol XL(g), etc.

Mevacor(g), Pravachol(g), Zocor(g), Crestor*; plus Norvasc(g), Zetia*

Revia(g), Antabuse

Bentyl(g), Donnatal(g), Robinul(g)

Efudex(g)

Tegretol(g), XR(g)

Cardene(g), Norvasc(g), Procardia XL(g)

* Prior Authorization or Step Therapy may be required.

** Covered with a prescription for BCN members and certain BCBSM members.

Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.

NonFormulary CARDURA XL

CARMOL HC

CAYSTON CEDAX

CELEBREX

CENESTIN CESAMET CHENODAL CIMZIA SYRINGE CLARIFOAM EF CLARINEX (ALL)

CLEOCIN VAGINAL OVULES CLIMARA PRO

CLINAC BPO

CLINDESSE CLOBEX, SPRAY

COGNEX

COLESTID FLAVORED COLY-MYCIN S

COMBIPATCH

COREG CR CORTISPORIN-TC

CYMBALTA

DAYTRANA

DENAVIR DEPEN DERMASMOOTHE/FS DESONATE

DEXILANT

DIOVAN, HCT

Formulary Alternative

Cardura(g), Flomax(g), Hytrin(g), Avodart, Uroxatral Hydrocortisone plus Aquaphor OTC, Hydrocortisone plus Eucerin OTC

Tobi

Ceclor(g), Ceftin(g), Duricef(g), Keflex(g), Omnicef(g)

Lodine(g), Mobic(g), Motrin(g), Naprosyn(g), Voltaren(g), etc.

Estrace(g), Ogen(g), Premarin

Kytril(g); Zofran(g), ODT(g) Actigall(g), Urso(g)

Enbrel*, Humira*

Plexion(g), Sulfacet-R(g) Claritin OTC(g)**, Zyrtec OTC(g)**, Allegra(g), Allegra-D 12 hour(g)*, Allegra-D 24 hour*, Astelin(g)

Cleocin Vaginal Cream(g)

Climara(g), Vivelle-DOT, or Estraderm plus a progestin

Individual agents (Cleocin(g) topical and OTC BPO)

Cleocin vaginal cream(g)

Diprolene(g), Psorcon(g), Temovate(g), Ultravate(g)

Razadyne, ER(g); Aricept, ODT(g); Namenda

Colestid(g), Questran(g), Questran Light(g)

Cortisporin(g), Floxin(g) Otic, Cipro HC

Climara(g), Vivelle-DOT, Estraderm plus Progestin

Coreg(g), Toprol XL(g)

Cortisporin(g), Floxin(g) Otic, Cipro Otic HC

Generic SSRI/SNRI (Celexa(g), Effexor(g), Effexor XR(g), Prozac(g), Zoloft(g), etc.)

Adderall, XR(g)*; Ritalin, SR(g); Concerta, Metadate CD

Zovirax 5% cream/ointment Cuprimine

Elocon(g), Locoid(g), Synalar solution(g), Capex

Elocon(g), Locoid(g), Synalar solution(g), Capex

Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), Protonix(g)*, Zegerid(g)*

Cozaar(g), Hyzaar(g), Benicar*, HCT*

NonFormulary DIPENTUM

DONNATAL EXTENTABS DORAL

DORYX DUAC CS

DUREZOL

DYNACIRC CR

EDEX EDLUAR EFUDEX OCCLUSION ELESTAT ELESTRIN

ELIGARD ELLA EMADINE EMBEDA

EMSAM

ENABLEX ENJUVIA ENTOCORT EC

EPIDUO

EPOGEN EQUETRO ERTACZO

ESTRACE VAGINAL CREAM ESTRASORB

ESTROGEL

EVAMIST

EVOXAC EXALGO

Formulary Alternative

Azulfidine(g), Azulfidine En-Tab(g), Asacol, HD; Pentasa Bentyl(g), Donnatal(g), Robinul(g)

Ambien(g), Halcion(g), Prosom(g), Restoril(g), Sonata(g) Vibramycin(g) Individual agents (Cleocin(g) topical and OTC BPO) Decadron ophth(g); Inflamase, Forte(g); Pred Forte(g), etc. Cardene(g), Dynacirc(g), Norvasc(g), Procardia XL(g) Caverject*, Cialis*, Muse*, Viagra* Ambien(g), Sonata(g) Efudex(g)

Zaditor OTC(g), Alomide, Patanol Climara(g), Estrace(g), Ogen(g), Vivelle-DOT, Estraderm Lupron, Depot;Trelstar, Depot Plan B(g) Zaditor OTC(g), Alomide, Patanol Methadone(g), MSIR(g), MS Contin(g), Oramorph SR(g) Celexa(g), Effexor(g), Effexor XR(g), Paxil(g), Prozac(g), Wellbutrin, SR, XL(g); Venlafaxine ER(g), Lexapro* Ditropan(g), XL(g), Detrol, LA Premarin Prednisone(g), Prednisolone(g), Hydrocortisone(g), etc. Individual agents: Differin plus OTC BPO Procrit* Tegretol, XR(g) Lamisil AT(g) OTC; Lotrimin(g), Ultra OTC; Monistat-Derm(g), Nizoral cream(g), Spectazole(g) Premarin Vaginal Cream

Climara(g), Estrace(g), Ogen(g), Estraderm, Vivelle-DOT Climara(g), Estrace(g), Ogen(g), Estraderm, Vivelle-DOT Climara(g), Estrace(g), Ogen(g), Estraderm, Vivelle-DOT Bethanechol(g), Salagen(g) Duragesic(g), Methadone(g), MS Contin(g), Oramorph(g)

* Prior Authorization or Step Therapy may be required.

** Covered with a prescription for BCN members and certain BCBSM members.

Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.

NonFormulary

Formulary Alternative

NonFormulary

Formulary Alternative

EXFORGE

EXFORGE HCT EXJADE EXTAVIA

Lotrel(g), Generic ACE Inhibitor (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g)

Lotrel(g) plus HCTZ(g)

Desferal(g)

Avonex, Betaseron, Copaxone, Rebif

INVEGA

IOPIDINE IQUIX JALYN

Clozaril(g), Risperdal(g), Abilify, Geodon, Seroquel, Zyprexa

Alphagan(g), Alphagan P

Ciloxan(g), Ocuflox(g), Vigamox

Cardura(g), Flomax(g), Hytrin(g), Avodart, Uroxatral

EXTINA FACTIVE

FANAPT

FAZACLO

FEMCON FE

FEMRING FEMTRACE FENOGLIDE FENTORA

FEXMID FINACEA, PLUS

FLECTOR PATCH

FLOXIN OTIC SINGLES FOCALIN XR

FOLLISTIM AQ FORTAMET FORTEO

FOSAMAX PLUS D FOSRENOL

FRAGMIN FROVA

GALZIN GELNIQUE GILENYA GLUMETZA GLYSET GYNAZOLE-1

HALFLYTELY

Nizoral(g) Erythromycin(g), Vibramycin(g), Zithromax(g), Avelox Clozaril(g), Risperdal(g), Abilify, Geodon, Seroquel, Zyprexa Clozaril(g), Risperdal(g), Abilify, Geodon, Seroquel, Zyprexa Loestrin Fe(g) [NOT 24], Estrostep Fe(g) Estring Estrace(g), Ogen(g), Premarin Lofibra(g), Lopid(g), Tricor Actiq(g)*, MSIR(g), MS Contin(g), Oramorph SR(g), Roxanol(g) Flexeril(g) Metrogel topical(g), Metrolotion(g), Retin-A(g) Topical OTC analgesic balms, i.e. trolamine salicylate; Voltaren oral(g) Floxin(g)

Adderall, XR(g)*, Focalin(g); Ritalin, SR; Concerta, Metadate CD Gonal-F, Gonal RFF Glucophage(g) Fosamax(g), Miacalcin Nasal Spray(g), Actonel* Fosamax(g) plus OTC Vitamin D Tums OTC, Phoslo(g), Renagel, Renvela Lovenox(g) Amerge(g)*, Imitrex(g); Maxalt*, MLT* OTC zinc supplements Ditropan, XL(g); Detrol, LA Avonex, Copaxone, Rebif Glucophage(g) Precose(g) Lotrimin OTC, Monistat OTC, Diflucan 150mg(g), Terazol(g) Colyte(g) plus bisacodyl OTC

JANUMET

Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos*

JANUVIA

Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos*

KADIAN

Methadone(g), MSIR(g), MS Contin(g), Oramorph SR(g)

KAOCHLOR-EFF

Potassium Chloride(g) liquid, capsules or tablets

KEFLEX 750MG Keflex(g)

KEPPRA XR

Keppra(g)

KETEK

Erythromycin(g), Zithromax(g)

KINERET

Enbrel*, Humira*

LAMICTAL ODT, XR

Lamictal(g), Disper tabs(g), Tegretol(g)

LAMISIL GRANULES

Lamisil(g)

LESCOL, XL

Mevacor(g), Pravachol(g), Zocor(g), Crestor*, Zetia*

LEVAQUIN

Vibramycin(g), Avelox

LEVATOL

Inderal(g), Inderal LA(g), Lopressor(g), Sectral(g), Tenormin(g), Toprol XL(g)

LEVITRA

Cialis*, Viagra*

LIALDA

Azulfidine(g); Asacol, HD; Pentasa

LIDODERM PATCH Topical lidocaine, EMLA(g)

LIPITOR

Mevacor(g), Pravachol(g), Zocor(g), Crestor*, Zetia*

LIPOFEN

Lofibra(g), Lopid(g), Tricor

LIVALO

Mevacor(g), Pravachol(g), Zocor(g), Crestor*, Zetia*

LOCOID LIPOCREAM

Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g)

LOESTRIN 24 FE Loestrin(g), Loestrin Fe(g)

LOPROX SHAMPOO

Nizoral Shampoo 2%(g)

LOSEASONIQUE Generic biphasic contraceptives

LOTEMAX

Decadron ophth(g), Pred Forte(g), Pred Mild

LOTRONEX

OTC Anti-diarrheals; Levbid(g); Levsin, SL(g); Levsinex(g); Lomotil(g)

HECTOROL HUMATROPE

Rocaltrol(g) Genotropin*; Nutropin*, AQ*

LOVAZA

OTC Omega products, Lofibra(g), Lopid(g), Tricor

INNOPRAN XL INTUNIV

Inderal(g), Inderal LA(g), Inderide(g) Catapres(g), Tenex(g)

LUNESTA

Ambien(g), Halcion(g), Prosom(g), Restoril(g), Sonata(g)

* Prior Authorization or Step Therapy may be required.

** Covered with a prescription for BCN members and certain BCBSM members.

Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.

NonFormulary

Formulary Alternative

LUVERIS

Repronex

LUVOX CR

Luvox(g) immediate release

LUXIQ

Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g)

LYRICA

Effexor(g), Effexor XR(g), Flexeril(g), Neurontin(g), SSRI's(g), TCA's(g), Ultram(g)

MAGNACET

Percocet(g), Tylox(g)

MARPLAN

Parnate(g), Nardil

MAXIDEX

Decadron ophth(g)

MEGACE ES

Megace(g)

MENEST

Estradiol (various), Ogen(g)

MENOPUR

Repronex

MENOSTAR

Climara(g), Estrace(g), Ogen(g), Vivelle-DOT, Estraderm

MENTAX

Lamisil AT(g), OTC; Lotrimin(g), Ultra OTC; Monistat-Derm(g), Nizoral cream(g), Spectazole(g)

METHITEST

Androxy(g), Depo-Testosterone(g), Oxandrin(g), Androderm, Delatestryl

METHYLIN CHEW Adderall XR(g)*, Metadate CD (Both of which may be "sprinkled" on food)

METOZOLV ODT Reglan(g)

MICARDIS, HCT Cozaar(g), Hyzaar(g), Benicar*, HCT*

MIRAPEX ER

Mirapex(g)

MONUROL

Bactrim(g), DS(g); Macrobid(g), Cipro(g)

MOVIPREP

Colyte(g), Nulytely(g)

MOXATAG

Amoxil capsules(g)

MYFORTIC

Cellcept(g)

MYTELASE

Mestinon(g), Prostigmin

NAFTIN

Lotrimin(g), Monistat(g), Nystatin(g)

NAMENDA XR

Razadyne, ER(g); Aricept, ODT(g); Namenda

NAPRELAN

Mobic(g); Motrin(g); Naprosyn, EC(g); etc*

NASCOBAL SPRAY Cyanocobalamin tabs OTC, Cyanocobalamin injection

NASONEX

Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*

NATAZIA

Yasmin(g), Yaz(g)

NEULASTA

Neupogen

NEVANAC

Ocufen(g), Voltaren ophth(g)

NEXIUM

Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), Protonix(g)*

NICOTROL, NS

Nicotine gum(g), lozenge(g), patch(g)

NORDITROPIN, NORDIFLEX

Genotropin*; Nutropin*, AQ*

NORITATE

MetroCream(g)

NonFormulary NOROXIN

NUCYNTA NUVARING NUVIGIL OLEPTRO OLUX-E

OMNARIS

OMNITROPE ONGLYZA

ONSOLIS

OPANA, ER

ORACEA ORAPRED ODT ORAXYL ORTHO-PREFEST

OSMOPREP OVCON-50, FE

OXISTAT

OXYCONTIN

OXYTROL PANCRECARB MS - 16 PANCRECARB MS - 4 PANDEL

PANIXINE PAREMYD PATADAY

PATANASE

PCE

PENNSAID

PERANEX HC PERFOROMIST

Formulary Alternative

Bactrim DS/Septra DS(g); Cipro(g), XR(g)* Ultram(g); MSIR(g), oxycodone IR(g) Oral contraceptives, Ortho Evra Provigil* Desyrel(g) Diprolene(g), Psorcon(g), Temovate(g), Ultravate(g) Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ* Genotropin*, Nutropin*, AQ* Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos* Actiq(g)*, MSIR(g), MS Contin(g), Oramorph SR(g), Roxanol(g) Methadone(g), Morphine(g), MS Contin(g), Oramorph SR(g) Monodox(g), Vibramycin(g) Orapred(g) Vibramycin(g) Use FemHRT, Prempro/Premphase, or Estradiol plus progestin Fleet's Phospho Soda OTC, Colyte(g) Modicon(g), Ortho-Cyclen(g), OrthoNovum(g), Ovcon-35(g) Lamisil AT(g), OTC; Lotrimin(g), Ultra OTC; Monistat-Derm(g), Nizoral cream(g), Spectazole(g) Duragesic(g), Methadone(g), MS Contin(g), Oramorph(g) Ditropan, XL(g); Detrol, LA Pancrease MT - 16(g), Viokase

Pancrease MT - 4(g), Pancrealipase EC Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g), Cloderm, Cordran Keflex(g) Atropine(g), Cyclogyl(g), Mydriacyl(g) Zaditor OTC(g), Alocril, Alomide, Patanol Flonase(g), Nasalide(g), Nasarel(g), Astelin(g), Nasacort AQ* Biaxin(g), Erythromycin(g), Zithromax(g) Topical OTC analgesic balms, i.e. trolamine salicylate; Voltaren oral(g) Anusol HC(g), Proctocream HC(g) Serevent Diskus, Foradil MDI

* Prior Authorization or Step Therapy may be required.

** Covered with a prescription for BCN members and certain BCBSM members.

Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.

NonFormulary

Formulary Alternative

PEXEVA

Generic SSRI/SNRI (Celexa(g), Prozac(g), Paxil(g), Zoloft (g), etc.)

PLAN B ONE-STEP Plan B(g)

PRANDIMET

Individual agents: Prandin and Glucophage(g)

PRED-G

Garamycin(g), Pred Forte(g)

PREVACID NAPRAPAC

Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), PLUS Naprosyn(g)

PRILOSEC SUSPENSION

Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20 mg(g), Protonix(g)*

PRISTIQ

Generic SSRI/SNRI (Celexa(g), Prozac(g), Zoloft (g), Effexor(g), Effexor XR(g), etc.)

PROCENTRA

Adderall XR(g)*, Metadate CD (Both of which may be "sprinkled" on food)

PROQUIN XR

Bactrim DS/Septra DS(g), Cipro(g), XR(g) *

PROTONIX SUSP

Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g); Protonix(g)*

PROTOPIC

Topical corticosteroids, Elidel*

PROVENTIL HFA Proair HFA, Ventolin HFA

PYLERA

Use Tetracycline(g) plus Flagyl(g) plus Bismuth; or Helidac or PREVPAC

QUALAQUIN

Aralen(g), Lariam(g), Plaquenil(g)

QUIXIN

Ciloxan(g), Vigamox

RANEXA

Long-acting nitrate, plus a betablocker or calcium channel blocker

RANICLOR

Ceclor(g), Ceftin(g), Duricef(g), Keflex(g), Omnicef(g)

RAPAFLO

Cardura(g), Flomax(g), Hytrin(g), Avodart, Uroxatral

REGRANEX

Ethezyme(g), Granulex(g)

RELPAX

Amerge(g)*, Imitrex(g); Maxalt*, MLT*

REQUIP XL

Requip(g)

REVLIMID

Thalomid

RHINOCORT AQUA

Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*

RIOMET

Glucophage(g)

RITALIN LA

Adderall, XR(g)*; Ritalin(g), Concerta, Metadate CD

ROZEREM

Ambien(g), Halcion(g), Prosom(g), Restoril(g), Sonata(g)

RYBIX ODT

Ultram(g)

RYTHMOL SR

Rythmol(g)

RYZOLT

Ultram(g)

SAIZEN

Genotropin*; Nutropin*, AQ*

NonFormulary

Formulary Alternative

SANCTURA XR

Ditropan, XL(g); Sanctura(g); Detrol, LA

SANCUSO PATCH Kytril(g); Zofran, ODT(g)

SAPHRIS

Clozaril(g), Risperdal(g), Abilify, Geodon, Seroquel, Zyprexa

SARAFEM TABLET Sarafem capsule(g)

SAVELLA

Effexor(g), Effexor XR(g), Flexeril(g), Neurontin(g), SSRI(g), TCA's(g), Ultram(g)

SEASONIQUE

Generic biphasic contraceptives

SEMPREX D

Claritin OTC(g)**, Zyrtec OTC(g)**, Allegra(g), Allegra-D 12 hour(g)*, Allegra-D 24 hour*, Astelin(g)

SEROQUEL XR

Clozaril(g), Risperdal(g), Abilify, Geodon, Zyprexa, Seroquel(IR)

SEROSTIM

Genotropin*, Nutropin*, AQ*

SERZONE(g)

Generic SSRI/SNRI (Celexa(g), Prozac(g), Paxil(g), Zoloft(g), etc.)

SILENOR

Ambien(g), Desyrel(g), Sinequan(g), Sonata(g)

SIMCOR

Individual agents (Zocor(g) PLUS Niaspan)

SIMPONI

Enbrel*, Humira*

SOLARAZE

Efudex(g)

SOLODYN

Monodox(g), Vibramycin(g)

SOLTAMOX

Nolvadex(g)

SOMA 250

Soma(g)

STAXYN

Cialis*, Viagra*

STRATTERA

Adderall, XR(g)*; Focalin(g), Ritalin(g), Concerta, Metadate CD

STRIANT

Androxy(g), Depo-testosterone(g), Oxandrin(g), Androderm, Delatestryl

SUMAVEL DOSEPRO

Amerge(g)*, Imitrex(g); Maxalt*, MLT*

SUPRAX

Ceclor(g), Ceftin(g), Duricef(g), Keflex(g), Omnicef(g)

SYMBYAX

Use Zyprexa plus Prozac(g)

SYMLIN

Insulin

TACLONEX, SCALP

Use Dovonex plus Diprosone/Diprolene(g)

TASMAR

Comtan

TEKAMLO

Lotrel(g), Generic ACE Inhibitor (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g)

TEKTURNA, HCT Generic ACE Inhibitors (benazapril, enalapril, lisinopril, etc.)

TESTIM

Androderm

TESTRED, ANDROID

Androxy(g), Depo-testosterone(g), Oxandrin(g), Androderm, Delatestryl

TEVETEN, HCT

Cozaar(g), Hyzaar(g), Benicar*, HCT*

TEV-TROPIN

Genotropin*; Nutropin*, AQ*

* Prior Authorization or Step Therapy may be required.

** Covered with a prescription for BCN members and certain BCBSM members.

Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.

NonFormulary TIROSINT TOVIAZ TRANXENE SD

TREXIMET

TRIBENZOR

TRIGLIDE TRILIPIX TWYNSTA

TYZEKA ULORIC ULTRAM ER 300MG VAGIFEM

VALTURNA

VANOS 0.1% CR

VECTICAL VERAMYST

VERDESO

VEREGEN VESICARE VICTOZA

VISICOL VOLTAREN GEL

VUSION VYTORIN

VYVANSE

XENICAL

XERESE XIBROM XIFAXAN 220MG XIFAXAN 550MG XODOL XOLEGEL XOPENEX, HFA

Formulary Alternative

Synthroid(g) Ditropan, XL(g); Detrol, LA Ativan(g), Buspar(g), Serax(g), Tranxene(g), Valium(g), Xanax(g) Individual agents (Imitrex(g) PLUS naproxen); Amerge(g)*; Maxalt, MLT* Cozaar(g), HCTZ(g), Hyzaar(g), PLUS Norvasc(g) Lofibra(g), Lopid(g), Tricor Lofibra(g), Lopid(g), Tricor Lotrel(g), Generic ACE Inhibitor (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g) Baraclude, Epivir HBV, Hepsera Zyloprim(g) Ultram(g)

Climara(g), Ogen(g), Vivelle-DOT, Estraderm, Estring, Premarin Vaginal Generic ACE Inhibitors (benazapril, enalapril, lisinopril, etc.) Diprolene(g), Psorcon(g), Temovate(g), Ultravate(g) Dovonex Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ* Elocon(g), Locoid(g), Synalar solution(g), Capex Condylox Solution(g), Gel Ditropan, XL(g); Detrol, LA Insulin, Glucophage(g), Sulfonylurea's, TZD's Fleet's Phospho Soda OTC, Colyte(g) Topical OTC analgesic balms, i.e. trolamine salicylate; Voltaren oral(g) OTC diaper rash products Mevacor(g), Pravachol(g), Zocor(g), Crestor*; plus Zetia* Adderall, XR(g)*; Ritalin, SR(g); Concerta, Metadate CD Alli OTC, Bontril(g)*, Didrex(g)*, Phentermine(g)*, Tenuate(g)* Zovirax cream PLUS HC cream Ocufen(g), Voltaren (ophthalmic)(g) Bactrim DS(g), Vibramycin(g) Lactulose Vicodin(g) Nizoral(g) Albuterol(g); Maxair; Proair HFA, Ventolin HFA

NonFormulary XYREM

XYZAL SOLUTION

ZANAFLEX(g) ZANTAC EFFERDOSE ZAVESCA

ZEGERID PACKET

ZELAPAR ZEMPLAR ZIANA GEL

ZIPSOR

ZMAX ZOLPIMIST ZOMIG, ZMT, NASAL SPRAY ZORBTIVE ZUPLENZ ZYCLARA ZYDONE

ZYFLO CR

ZYLET

ZYMAR ZYMAXID

Formulary Alternative

Ambien(g), Halcion(g), Prosom(g), Restoril(g) Claritin OTC(g)**, Zyrtec OTC(g)**, Allegra(g) Dantrium(g), Flexeril(g), Lioresal(g) Zantac, OTC(g); Pepcid(g)

Ceredase, Cerezyme (medical benefit) Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), Protonix(g)*, Zegerid(g)* Eldepryl(g) Rocaltrol(g) Individual agents: Cleocin topical(g) and Retin-A(g)* Mobic(g), Motrin(g), Naprosyn, EC(g); Voltaren(g), etc* Zithromax(g) Ambien(g), Sonata(g) Amerge(g)*, Imitrex(g); Maxalt*, MLT* Genotropin*; Nutropin*, AQ* Kytril(g); Zofran, ODT(g) Aldara(g) Lortab(g), Tylenol with Codeine(g), Vicodin(g) Accolate(g), Inhaled Steroids, Singulair Maxitrol(g), Tobradex(g), Vasocidin(g) Ciloxan(g), Vigamox Ciloxan(g), Ocuflox(g)

* Prior Authorization or Step Therapy may be required.

** Covered with a prescription for BCN members and certain BCBSM members.

Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.

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