Blue Cross and Blue Shield of North Carolina Closed

April 2015
Blue Cross and Blue Shield of North Carolina Closed Basic 5 Tier Formulary
Click to search for a drug name in this document
Contents
Preface ............................................................................ I Preferred Medication List............................................. 1
Member guide to covered medications on
Anti-Infective Agents.................................................... 1
the Basic Formulary................................................. I
Antineoplastic Agents ................................................ 11
Formulary tiers ............................................................ I
Endocrine and Metabolic Drugs ................................ 14
5-Tier formulary ........................................................... I
Cardiovascular Agents .............................................. 28
Generic drugs .............................................................. I
Respiratory Agents .................................................... 45
Compounded prescriptions ........................................ II
Gastrointestinal Agents ............................................. 49
Prior review, quantity limitations and
Genitourinary Agents ................................................. 54
restricted-access drugs ......................................... II
Central Nervous System Drugs ................................. 56
Specialty drugs ........................................................... II
Analgesics and Anesthetics ...................................... 68
Using the member guide to the
Neuromuscular Drugs................................................ 76
Basic Formulary .................................................... III
Nutritional Products ................................................... 83
Abbreviation/acronym key ......................................... IV
Hematological Agents................................................ 93
Topical Products ........................................................ 97
Miscellaneous Products .......................................... 110
Index ........................................................................... 113
Please consider talking to your doctor about prescribing formulary medications, which may help reduce your
out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.
The drug formulary is regularly updated. Please visit bcbsnc.com for the most up-to-date information.
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to
Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click
on Search.
5154-C NC © Prime Therapeutics LLC 04/15
Member guide to covered medications on the Basic Formulary
This guide lists the approved brand name and generic prescription drugs that have been reviewed by Blue Cross
and Blue Shield of North Carolina (BCBSNC) and are the only covered medications on BCBSNC’s Basic Formulary,
a closed formulary. Please refer to this formulary guide for information about medications covered by this formulary,
and present this guide to your doctor if you or another covered family member requires a prescription. This guide
was current at the time of printing and is subject to change. For a more complete listing of drug coverage
and costs, you may use our drug search at bcbsnc.com. You may also call BCBSNC Customer Service at
the number listed on the back of your ID card to verify prescription drug benefits.
A formulary is a list of prescription drugs covered by a health plan. BCBSNC Pharmacy & Therapeutics (P&T)
Committee reviews medications at least quarterly. This includes ongoing reviews of clinical information about new
drugs and reviews of new safety and efficacy information about older drugs. The majority of BCBSNC’s P&T
Committee is composed of practicing physicians and pharmacists independent of BCBSNC.
Please refer to your member guide for detailed information regarding your pharmacy benefits, including your benefit
design, out-of-pocket costs, non-formulary exception requests and applicable exclusions.
Formulary tiers
The 5-Tier Basic Formulary covers many medications approved by the United States Food & Drug Administration
(FDA), within existing benefits. The plan design determines the member’s payment obligation. Note: Drugs listed as
covered on Tier 1 and Tier 2 are generics. Brand names listed for Tier 1 and Tier 2 drugs are for reference only.
Brands for which generic equivalents are available are listed on Tier 4 unless indicated otherwise.
5-Tier formulary
Here are the definitions of each tier for the five-tiered benefit structure:

Tier 1: Generic medications. Medications listed in Tier 1 have the lowest co-payment.

Tier 2: Non-preferred generic medications. Medications listed in Tier 2 have the second-lowest co-payment.

Tier 3: Includes select brand-name drugs recommended by the BCBSNC P&T Committee as preferred
brand-name products based on safety, efficacy, and cost.

Tier 4: Contains 1) brand-name products that, as recommended by the P&T Committee, usually have
preferred and often less costly therapeutic alternatives at a lower tier, 2) some brands with therapeutically
equivalent generics, and 3) selected biosimilar specialty drugs. Medications listed in Tier 4 have the
second-highest co-payment.

Tier 5: Specialty drugs. Those medications, as classified by the P&T Committee, that generally have unique
uses, require special dosing or administration, are typically prescribed by a specialist provider and are
significantly more costly than alternative drugs or therapies. This may include biosimilar specialty drugs.
Medications listed in Tier 5 generally have the highest co-payment or co-insurance amount.
Generic drugs
In most cases choosing a generic drug equivalent, when available, will mean significant savings to you.
We encourage you to discuss with your physician whether a generic alternative is available as these drugs
represent safe, effective treatment options. Especially for drugs that are taken daily and refilled frequently, you will
experience the long-term savings of a lower drug payment month after month. If you choose a brand name
prescription drug and a generic equivalent is available, you may be subject to a reduced benefit and a
higher out-of-pocket expense.
I
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Compounded prescriptions
Compounded prescriptions contain two or more drugs mixed together. Compounded prescriptions are processed
according to member benefits. To be eligible for coverage, compounded medications must contain at least one
FDA-approved prescription ingredient and must not be a copy of a commercially available product. Compounded
medications may be subject to prior review.
Prior review, quantity limitations and restricted-access drugs
Certain medications may be subject to prior review, quantity limitations, or restricted-access programs. BCBSNC’s
P&T Committee reviews the clinical criteria for these programs.

Drugs that have prior review requirements must be reviewed by BCBSNC before coverage can be
authorized.

Certain medications may also have limitations on the quantity and days’ supply coverage. Quantities in
excess of the coverage limit must be reviewed and approved by BCBSNC before coverage can be
authorized for amounts in excess of the limits.

For coverage of restricted-access and non-formulary drugs, BCBSNC requires that the member has tried
preferred formulary drugs first. Coverage for restricted-access drugs may be provided without the use of
a preferred drug if the provider certifies in writing that the member has previously used preferred drugs
and the preferred drug has been detrimental to the member's health or has been ineffective in treating
the same condition and, in the opinion of the provider, are likely to be detrimental to the member's health
or ineffective in treating the condition in the future. Clinical rationale and documentation for exception
requests may be required. If approval of coverage of a non-formulary drug is granted, the non-formulary
non-specialty drug will be covered on the non-preferred brand tier (Tier 4) and the non-formulary specialty
drug will be covered on the specialty tier (Tier 5).
The FDA is responsible for approving medications for use based on clinical data proving the medication is safe and
effective for that specific use. BCBSNC’s prior review and quantity limitations programs follow FDA-approved uses
for these drugs. However, BCBSNC recognizes that in many cases, “off-label” (non-FDA approved) uses of
prescription drugs may be acceptable. In determining the acceptability of off-label uses, BCBSNC utilizes several
sources of clinical information including but not limited to 1) nationally recognized clinical references including
American Hospital Formulary Service Drug Information; 2) the results of at least two randomized controlled clinical
studies that support a specific off-label use, and that are published in peer-reviewed professional medical journals;
and 3) consultations with internal and external physician experts regarding community standards. Additional
searches for current supporting medical literature may be performed utilizing standard electronic databases.
Specialty drugs
These medications, as classified by BCBSNC, generally have unique uses, require special dosing or administration,
are typically prescribed by a specialist provider and are significantly more costly than alternative drugs or therapies.
Most specialty drugs can be found on Tier 5, but some are found on Tier 4.
Some of these specialty drugs will need to be filled at a participating specialty pharmacy in our network. These
drugs are identified in the specialty column of the formulary guide. Call the customer service number on the back of
your ID card to determine which pharmacy can fill your specialty drug prescription.
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
II
Using the member guide to the Basic Formulary
The Medication List is organized into broad categories (e.g., ANTI-INFECTIVE AGENTS). The graphic below shows
the information that is provided in each column of the medication list and is an example only. Please use the drug
search function to find current information for drugs on the medication list.
The first column of the chart lists the medication name. Generic medications are listed in lowercase boldface .
Brand name medications are capitalized.
Separate medication entries are required for some dosage forms such as extended-release and
delayed-release.
The second column indicates the Tier level.
The third column indicates if the medication is a Specialty medication and needs to be filled at a participating
specialty pharmacy in our network.
The remaining columns indicate the Pharmacy Program(s) that apply to the prescription medication
(e.g., Prior Review, Restricted Access and Quantity Limitations). If an indicator is present in the column(s),
then the Pharmacy Program applies.
III
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Abbreviation/acronym key
cap ................................................................ capsules
chew ............................................................ chewable
odt ......................................... orally disintegrating tabs
oint ................................................................. ointment
conc .........................................................concentrate
cr ..................................................... controlled release
ophth ........................................................... opthalmic
osm .....................................................osmotic release
dr ........................................................ delayed release
ec ........................................................... enteric coated
powd ................................................................ powder
sa ....................................................... sustained action
effe............................................................ effervescent
equiv ........................................................... equivalent
sl .................................................................. sublingual
soln ..................................................................solution
er ...................................................... extended release
inhal............................................................. inhalation
sr ......................................................sustained release
suppos.................................................... suppositories
inj .................................................................... injection
liq ......................................................................... liquid
susp ........................................................... suspension
tab ..................................................................... tablets
lotn ...................................................................... lotion
nebu .............................................................. nebulizer
td ............................................................... transdermal
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
IV
ANTI-INFECTIVE AGENTS
PENICILLINS
amoxicillin & k clavulanate tab
250-125 mg
1
AMOXICILLIN – amoxicillin
(trihydrate) chew tab 125 mg
1
amoxicillin & k clavulanate tab
500-125 mg (Augmentin)
1
AMOXICILLIN – amoxicillin
(trihydrate) chew tab 250 mg
1
amoxicillin & k clavulanate tab
875-125 mg (Augmentin)
1
amoxicillin (trihydrate) cap
250 mg
1
AMPICILLIN – ampicillin for susp
125 mg/5ml
1
amoxicillin (trihydrate) cap
500 mg
1
AMPICILLIN – ampicillin for susp
250 mg/5ml
1
amoxicillin (trihydrate) for susp
125 mg/5ml
1
ampicillin cap 250 mg
1
ampicillin cap 500 mg
1
amoxicillin (trihydrate) for susp
200 mg/5ml
1
AUGMENTIN – amoxicillin & k
clavulanate tab 500-125 mg
4
amoxicillin (trihydrate) for susp
250 mg/5ml
1
AUGMENTIN – amoxicillin & k
clavulanate tab 875-125 mg
4
amoxicillin (trihydrate) for susp
400 mg/5ml
1
3
amoxicillin (trihydrate) tab
500 mg
1
AUGMENTIN – amoxicillin & k
clavulanate for susp 125-31.25
mg/5ml
4
amoxicillin (trihydrate) tab
875 mg
1
AUGMENTIN – amoxicillin & k
clavulanate for susp 250-62.5
mg/5ml
amoxicillin & k clavulanate chew
tab 200-28.5 mg
2
4
amoxicillin & k clavulanate chew
tab 400-57 mg
1
AUGMENTIN XR – amoxicillin
& k clavulanate tab sr 12hr
1000-62.5 mg
dicloxacillin sodium cap 250 mg
1
amoxicillin & k clavulanate for
susp 200-28.5 mg/5ml
1
dicloxacillin sodium cap 500 mg
1
1
amoxicillin & k clavulanate
for susp 250-62.5 mg/5ml
(Augmentin)
1
penicillin v potassium for soln
125 mg/5ml
penicillin v potassium for soln
250 mg/5ml
1
amoxicillin & k clavulanate for
susp 400-57 mg/5ml
1
penicillin v potassium tab
250 mg
1
amoxicillin & k clavulanate
for susp 600-42.9 mg/5ml
(Augmentin es-600)
1
penicillin v potassium tab
500 mg
1
amoxicillin & k clavulanate tab sr
12hr 1000-62.5 mg (Augmentin
xr)
2
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
CEPHALOSPORINS
CEFACLOR – cefaclor for susp
125 mg/5ml
3
CEFACLOR – cefaclor for susp
250 mg/5ml
3
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
1
CEFACLOR – cefaclor for susp
375 mg/5ml
3
cefuroxime axetil tab 500 mg
(Ceftin)
1
cefaclor cap 250 mg
2
cephalexin cap 250 mg (Keflex)
1
cefaclor cap 500 mg
2
cephalexin cap 500 mg (Keflex)
1
cefadroxil cap 500 mg
1
cephalexin cap 750 mg (Keflex)
2
cefadroxil for susp 250 mg/5ml
2
cephalexin for susp 125 mg/5ml
1
cefadroxil for susp 500 mg/5ml
2
cephalexin for susp 250 mg/5ml
1
cefadroxil tab 1 gm
2
KEFLEX – cephalexin cap 250 mg
4
cefdinir cap 300 mg
1
KEFLEX – cephalexin cap 500 mg
4
cefdinir for susp 125 mg/5ml
1
SUPRAX – cefixime cap 400 mg
4
cefdinir for susp 250 mg/5ml
1
4
cefpodoxime proxetil for susp
100 mg/5ml
2
SUPRAX – cefixime for susp 100
mg/5ml
4
cefpodoxime proxetil for susp
50 mg/5ml
2
SUPRAX – cefixime for susp 200
mg/5ml
4
cefpodoxime proxetil tab 100 mg
2
SUPRAX – cefixime for susp 500
mg/5ml
cefpodoxime proxetil tab 200 mg
2
MACROLIDES
cefprozil for susp 125 mg/5ml
1
4
cefprozil for susp 250 mg/5ml
1
AZITHROMYCIN – azithromycin
powd pack for susp 1 gm
1
azithromycin for susp
100 mg/5ml (Zithromax)
1
cefprozil tab 250 mg
cefprozil tab 500 mg
1
1
CEFTIBUTEN – ceftibuten cap 400
mg
4
azithromycin for susp
200 mg/5ml (Zithromax)
4
azithromycin tab 250 mg
(Zithromax)
1
CEFTIBUTEN – ceftibuten for susp
180 mg/5ml
CEFTIN – cefuroxime axetil tab
250 mg
azithromycin tab 500 mg
(Zithromax)
1
4
CEFTIN – cefuroxime axetil tab
500 mg
azithromycin tab 600 mg
(Zithromax)
1
4
4
CEFTIN – cefuroxime axetil for
susp 125 mg/5ml
4
BIAXIN – clarithromycin tab 250
mg
3
BIAXIN – clarithromycin tab 500
mg
4
CEFTIN – cefuroxime axetil for
susp 250 mg/5ml
cefuroxime axetil for susp
125 mg/5ml (Ceftin)
BIAXIN – clarithromycin for susp
250 mg/5ml
4
1
cefuroxime axetil tab 250 mg
(Ceftin)
BIAXIN XL – clarithromycin tab sr
24hr 500 mg
4
1
BIAXIN XL PAC – clarithromycin
tab sr 24hr 500 mg
4
2
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
clarithromycin for susp
125 mg/5ml
2
ZITHROMAX – azithromycin for
susp 200 mg/5ml
4
clarithromycin for susp
250 mg/5ml (Biaxin)
2
ZITHROMAX – azithromycin powd
pack for susp 1 gm
4
clarithromycin tab sr 24hr
500 mg (Biaxin xl pac)
2
ZITHROMAX TRI-PAK –
azithromycin tab 500 mg
4
clarithromycin tab 250 mg
(Biaxin)
2
ZITHROMAX Z-PAK –
azithromycin tab 250 mg
4
clarithromycin tab 500 mg
(Biaxin)
2
TETRACYCLINES
DIFICID – fidaxomicin tab 200 mg
5
E.E.S. 400 – erythromycin
ethylsuccinate tab 400 mg
1
ERY-TAB – erythromycin tab
delayed release 250 mg
1
ERY-TAB – erythromycin tab
delayed release 333 mg
demeclocycline hcl tab 150 mg
2
demeclocycline hcl tab 300 mg
2
doxycycline hyclate cap 100 mg
(Vibramycin)
1
doxycycline hyclate cap 50 mg
1
1
doxycycline hyclate tab delayed
release 100 mg
2
1
doxycycline hyclate tab delayed
release 150 mg (Doryx)
2
ERY-TAB – erythromycin tab
delayed release 500 mg
3
doxycycline hyclate tab delayed
release 75 mg
2
ERYTHROCIN STEARATE –
erythromycin stearate tab 250
mg
doxycycline hyclate tab 100 mg
1
ERYTHROMYCIN BASE –
erythromycin tab 250 mg
4
doxycycline hyclate tab 20 mg
1
2
ERYTHROMYCIN BASE –
erythromycin tab 500 mg
4
doxycycline monohydrate cap
100 mg (Monodox)
2
ERYTHROMYCIN
ETHYLSUCCINA – erythromycin
ethylsuccinate tab 400 mg
1
doxycycline monohydrate cap
150 mg (Adoxa)
doxycycline monohydrate cap
50 mg
2
erythromycin w/ delayed release
particles cap 250 mg
1
doxycycline monohydrate cap
75 mg (Monodox)
2
ZITHROMAX – azithromycin tab
250 mg
4
doxycycline monohydrate for
susp 25 mg/5ml (Vibramycin)
2
ZITHROMAX – azithromycin tab
500 mg
4
doxycycline monohydrate tab
100 mg (Adoxa pak 1/100)
2
ZITHROMAX – azithromycin tab
600 mg
4
doxycycline monohydrate tab
150 mg (Adoxa pak 1/150)
2
ZITHROMAX – azithromycin for
susp 100 mg/5ml
4
doxycycline monohydrate tab
50 mg (Adoxa)
2
•
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
3
doxycycline monohydrate tab
75 mg (Adoxa)
2
MINOCIN – minocycline hcl cap 50
mg
1
4
CIPROFLOXACIN HCL –
ciprofloxacin hcl tab 100 mg
(base equiv)
1
MINOCIN – minocycline hcl cap 75
mg
4
ciprofloxacin hcl tab 250 mg
(base equiv) (Cipro)
1
MINOCIN – minocycline hcl cap
100 mg
4
ciprofloxacin hcl tab 500 mg
(base equiv) (Cipro)
1
minocycline hcl cap 100 mg
(Minocin)
1
ciprofloxacin hcl tab 750 mg
(base equiv)
1
minocycline hcl cap 50 mg
(Minocin)
1
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 1000 mg(base eq)
(Cipro xr)
minocycline hcl cap 75 mg
(Minocin)
1
2
minocycline hcl tab sr 24hr
135 mg
2
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 500 mg (base eq)
(Cipro xr)
4
minocycline hcl tab sr 24hr
45 mg
2
LEVAQUIN – levofloxacin tab 250
mg
4
minocycline hcl tab sr 24hr
90 mg
2
LEVAQUIN – levofloxacin tab 500
mg
4
minocycline hcl tab 100 mg
2
LEVAQUIN – levofloxacin tab 750
mg
2
LEVAQUIN – levofloxacin oral soln
25 mg/ml
4
minocycline hcl tab 50 mg
minocycline hcl tab 75 mg
2
TETRACYCLINE HCL –
tetracycline hcl cap 250 mg
levofloxacin oral soln 25 mg/ml
(Levaquin)
2
1
1
levofloxacin tab 250 mg
(Levaquin)
1
TETRACYCLINE HCL –
tetracycline hcl cap 500 mg
levofloxacin tab 500 mg
(Levaquin)
1
FLUOROQUINOLONES
CIPRO – ciprofloxacin hcl tab 250
mg (base equiv)
4
levofloxacin tab 750 mg
(Levaquin)
1
CIPRO – ciprofloxacin hcl tab 500
mg (base equiv)
4
OFLOXACIN – ofloxacin tab 400
mg
2
CIPRO XR – ciprofloxacinciprofloxacin hcl tab sr 24hr 500
mg (base eq)
4
AMINOGLYCOSIDES
CIPRO XR – ciprofloxacinciprofloxacin hcl tab sr 24hr 1000
mg(base eq)
4
4
BETHKIS – tobramycin nebu soln
300 mg/4ml
5
•
KITABIS PAK – tobramycin nebu
soln 300 mg/5ml
5
•
neomycin sulfate tab 500 mg
1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
paromomycin sulfate cap
250 mg
2
TOBI – tobramycin nebu soln 300
mg/5ml
5
TOBI PODHALER – tobramycin
inhal cap 28 mg
tobramycin nebu soln
300 mg/5ml (Tobi)
DIFLUCAN – fluconazole for susp
10 mg/ml
4
•
DIFLUCAN – fluconazole for susp
40 mg/ml
4
5
•
fluconazole for susp 10 mg/ml
(Diflucan)
1
5
•
fluconazole for susp 40 mg/ml
(Diflucan)
1
fluconazole tab 100 mg (Diflucan)
1
fluconazole tab 150 mg (Diflucan)
1
fluconazole tab 200 mg (Diflucan)
1
fluconazole tab 50 mg (Diflucan)
1
flucytosine cap 250 mg
(Ancobon)
2
flucytosine cap 500 mg
(Ancobon)
2
GRIFULVIN V – griseofulvin
microsize tab 500 mg
4
GRIS-PEG – griseofulvin
ultramicrosize tab 125 mg
4
GRIS-PEG – griseofulvin
ultramicrosize tab 250 mg
4
griseofulvin microsize susp
125 mg/5ml
2
griseofulvin microsize tab
500 mg (Grifulvin v)
2
griseofulvin ultramicrosize tab
125 mg (Gris-peg)
2
griseofulvin ultramicrosize tab
250 mg (Gris-peg)
2
itraconazole cap 100 mg
(Sporanox)
2
ketoconazole tab 200 mg
1
ANTIMYCOBACTERIAL AGENTS
ethambutol hcl tab 100 mg
(Myambutol)
2
ethambutol hcl tab 400 mg
(Myambutol)
2
isoniazid tab 100 mg
1
isoniazid tab 300 mg
1
MYAMBUTOL – ethambutol hcl tab 4
100 mg
MYAMBUTOL – ethambutol hcl tab 4
400 mg
2
pyrazinamide tab 500 mg
RIFADIN – rifampin cap 150 mg
4
RIFADIN – rifampin cap 300 mg
4
RIFAMATE – isoniazid & rifampin
cap 150-300 mg
4
rifampin cap 150 mg (Rifadin)
2
rifampin cap 300 mg (Rifadin)
2
ANTIFUNGALS
• •
ANCOBON – flucytosine cap 250
mg
4
ANCOBON – flucytosine cap 500
mg
4
DIFLUCAN – fluconazole tab 50
mg
4
4
LAMISIL – terbinafine hcl tab 250
mg
4
DIFLUCAN – fluconazole tab 100
mg
4
NOXAFIL – posaconazole tab
delayed release 100 mg
5
DIFLUCAN – fluconazole tab 150
mg
•
4
NOXAFIL – posaconazole susp 40
mg/ml
5
DIFLUCAN – fluconazole tab 200
mg
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
•
5
•
SPORANOX – itraconazole cap
100 mg
4
•
COMBIVIR – lamivudinezidovudine tab 150-300 mg
5
•
SPORANOX PULSEPAK –
itraconazole cap 100 mg
4
•
COMPLERA – emtricitabinerilpivirine-tenofovir df tab
200-25-300 mg
5
•
terbinafine hcl tab 250 mg
(Lamisil)
1
COPEGUS – ribavirin tab 200 mg
5
CRIXIVAN – indinavir sulfate cap
200 mg
5
5
•
•
•
•
•
VFEND – voriconazole tab 50 mg
5
VFEND – voriconazole tab 200 mg
5
VFEND – voriconazole for susp 40
mg/ml
CRIXIVAN – indinavir sulfate cap
400 mg
5
•
5
•
didanosine delayed release
capsule 125 mg (Videx ec)
2
voriconazole for susp 40 mg/ml
(Vfend)
•
5
didanosine delayed release
capsule 200 mg (Videx ec)
•
voriconazole tab 50 mg (Vfend)
5
•
•
2
voriconazole tab 200 mg (Vfend)
didanosine delayed release
capsule 250 mg (Videx ec)
2
•
abacavir sulfate tab 300 mg
(base equiv) (Ziagen)
2
•
didanosine delayed release
capsule 400 mg (Videx ec)
2
•
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
5
•
EDURANT – rilpivirine hcl tab 25
mg (base equivalent)
5
•
acyclovir cap 200 mg (Zovirax)
EMTRIVA – emtricitabine caps 200
mg
5
1
acyclovir susp 200 mg/5ml
(Zovirax)
1
EMTRIVA – emtricitabine soln 10
mg/ml
5
•
acyclovir tab 400 mg (Zovirax)
1
entecavir tab 0.5 mg (Baraclude)
5
acyclovir tab 800 mg (Zovirax)
1
entecavir tab 1 mg (Baraclude)
5
adefovir dipivoxil tab 10 mg
(Hepsera)
5
EPIVIR – lamivudine tab 150 mg
5
EPIVIR – lamivudine tab 300 mg
5
APTIVUS – tipranavir cap 250 mg
5
5
APTIVUS – tipranavir oral soln 100
mg/ml
5
EPIVIR – lamivudine oral soln 10
mg/ml
•
•
•
•
•
5
•
EPIVIR HBV – lamivudine tab 100
mg
•
EPIVIR HBV – lamivudine oral soln
5 mg/ml
5
•
•
EPZICOM – abacavir sulfatelamivudine tab 600-300 mg
5
•
•
famciclovir tab 125 mg (Famvir)
2
ANTIVIRALS
ATRIPLA – efavirenz-emtricitabine- 5
tenofovir df tab 600-200-300 mg
5
BARACLUDE – entecavir tab 0.5
mg
BARACLUDE – entecavir tab 1 mg 5
6
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
5
Restricted Access
Specialty
BARACLUDE – entecavir oral soln
0.05 mg/ml
Drug Name
Prior Review
Drug Tier
1
Quantity Limits
nystatin tab 500000 unit
Restricted Access
2
Prior Review
nystatin oral powder
Specialty
Drug Name
Drug Tier
2015
FAMVIR – famciclovir tab 500 mg
4
FLUMADINE – rimantadine
hydrochloride tab 100 mg
4
FUZEON – enfuvirtide for inj 90 mg 5
5
HARVONI – ledipasvir-sofosbuvir
tab 90-400 mg
5
HEPSERA – adefovir dipivoxil tab
10 mg
INTELENCE – etravirine tab 25 mg 5
•
lamivudine tab 100 mg (Epivir
hbv)
5
•
lamivudine tab 150 mg (Epivir)
2
lamivudine tab 300 mg (Epivir)
2
lamivudine-zidovudine tab
150-300 mg (Combivir)
2
•
•
•
LEXIVA – fosamprenavir calcium
tab 700 mg (base equiv)
5
•
•
LEXIVA – fosamprenavir calcium
susp 50 mg/ml (base equiv)
5
•
MODERIBA – ribavirin tab 400 mg
& ribavirin tab 600 mg dose pack
5
•
MODERIBA 1200 DOSE PACK –
ribavirin tab 600 mg
5
•
MODERIBA 800 DOSE PACK –
ribavirin tab 400 mg
5
•
NEVIRAPINE – nevirapine susp 50
mg/5ml
5
•
nevirapine tab sr 24hr 400 mg
(Viramune xr)
5
•
nevirapine tab 200 mg (Viramune) 2
5
NORVIR – ritonavir cap 100 mg
•
• •
INTELENCE – etravirine tab 100
mg
5
•
•
INTELENCE – etravirine tab 200
mg
5
•
INVIRASE – saquinavir mesylate
cap 200 mg
5
•
INVIRASE – saquinavir mesylate
tab 500 mg
5
•
ISENTRESS – raltegravir
potassium tab 400 mg (base
equiv)
5
•
ISENTRESS – raltegravir
potassium chew tab 25 mg (base
equiv)
5
•
ISENTRESS – raltegravir
potassium chew tab 100 mg
(base equiv)
5
ISENTRESS – raltegravir
potassium packet for susp 100
mg (base equiv)
5
KALETRA – lopinavir-ritonavir tab
100-25 mg
5
•
KALETRA – lopinavir-ritonavir tab
200-50 mg
5
•
KALETRA – lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
5
•
•
•
NORVIR – ritonavir tab 100 mg
5
NORVIR – ritonavir oral soln 80
mg/ml
5
•
•
•
•
OLYSIO – simeprevir sodium cap
150 mg (base equivalent)
5
• •
PEG-INTRON – peginterferon
alfa-2b for inj kit 50 mcg/0.5ml
5
• •
PEG-INTRON – peginterferon
alfa-2b for inj kit 80 mcg/0.5ml
5
• •
PEG-INTRON – peginterferon
alfa-2b for inj kit 120 mcg/0.5ml
5
• •
PEG-INTRON – peginterferon
alfa-2b for inj kit 150 mcg/0.5ml
5
• •
PEG-INTRON REDIPEN –
peginterferon alfa-2b for inj kit 50
mcg/0.5ml
5
• •
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
4
5
Restricted Access
FAMVIR – famciclovir tab 250 mg
lamivudine oral soln 10 mg/ml
(Epivir)
Drug Name
Prior Review
4
Specialty
FAMVIR – famciclovir tab 125 mg
Drug Tier
2
Quantity Limits
famciclovir tab 500 mg (Famvir)
Restricted Access
2
Prior Review
famciclovir tab 250 mg (Famvir)
Specialty
Drug Name
Drug Tier
2015
7
5
•
PEG-INTRON REDIPEN –
peginterferon alfa-2b for inj kit
120 mcg/0.5ml
5
PREZISTA – darunavir ethanolate
tab 600 mg (base equiv)
5
•
PREZISTA – darunavir ethanolate
tab 800 mg (base equiv)
5
•
PEG-INTRON REDIPEN –
peginterferon alfa-2b for inj kit
150 mcg/0.5ml
5
• •
PREZISTA – darunavir ethanolate
susp 100 mg/ml (base equiv)
5
•
PEG-INTRON REDIPEN PAK 4 –
peginterferon alfa-2b for inj kit 50
mcg/0.5ml
5
• •
REBETOL – ribavirin cap 200 mg
5
RESCRIPTOR – delavirdine
mesylate tab 100 mg
5
•
•
PEG-INTRON REDIPEN PAK 4 –
peginterferon alfa-2b for inj kit 80
mcg/0.5ml
5
• •
RESCRIPTOR – delavirdine
mesylate tab 200 mg
5
•
RETROVIR – zidovudine cap 100
mg
5
PEG-INTRON REDIPEN PAK 4
– peginterferon alfa-2b for inj kit
120 mcg/0.5ml
5
•
RETROVIR – zidovudine syrup 10
mg/ml
5
•
PEG-INTRON REDIPEN PAK 4
– peginterferon alfa-2b for inj kit
150 mcg/0.5ml
5
• •
REYATAZ – atazanavir sulfate cap
150 mg (base equiv)
5
•
PEGASYS – peginterferon alfa-2a
inj 180 mcg/ml
5
REYATAZ – atazanavir sulfate cap
200 mg (base equiv)
5
• •
•
PEGASYS – peginterferon alfa-2a
inj 180 mcg/0.5ml
5
REYATAZ – atazanavir sulfate cap
300 mg (base equiv)
5
• •
•
• •
•
PEGASYS PROCLICK –
peginterferon alfa-2a inj 135
mcg/0.5ml
REYATAZ – atazanavir sulfate
oral powder packet 50 mg (base
equiv)
5
5
• •
•
5
RIBASPHERE – ribavirin tab 400
mg
5
PEGASYS PROCLICK –
peginterferon alfa-2a inj 180
mcg/0.5ml
5
•
PEGINTRON – peginterferon
alfa-2b for inj kit 50 mcg/0.5ml
5
• •
RIBASPHERE – ribavirin tab 600
mg
•
PEGINTRON – peginterferon
alfa-2b for inj kit 80 mcg/0.5ml
5
• •
PEGINTRON – peginterferon
alfa-2b for inj kit 120 mcg/0.5ml
5
• •
PEGINTRON – peginterferon
alfa-2b for inj kit 150 mcg/0.5ml
5
• •
PREZISTA – darunavir ethanolate
tab 75 mg (base equiv)
5
•
RIBASPHERE RIBAPAK – ribavirin 5
tab 400 mg
RIBASPHERE RIBAPAK – ribavirin 5
tab 600 mg
RIBASPHERE RIBAPAK – ribavirin 5
tab 400 mg & ribavirin tab 600
mg dose pack
5
RIBATAB – ribavirin tab 400 mg
8
• •
• •
RIBATAB – ribavirin tab 600 mg
5
•
•
•
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
PREZISTA – darunavir ethanolate
tab 150 mg (base equiv)
Drug Name
Restricted Access
Specialty
• •
Drug Name
Prior Review
Drug Tier
5
Quantity Limits
Specialty
PEG-INTRON REDIPEN –
peginterferon alfa-2b for inj kit 80
mcg/0.5ml
Restricted Access
Drug Tier
Prior Review
2015
TYZEKA – telbivudine tab 600 mg
5
•
•
ribavirin tab 200 mg (Copegus)
2
•
•
valacyclovir hcl tab 1 gm
(Valtrex)
2
rimantadine hydrochloride tab
100 mg (Flumadine)
2
valacyclovir hcl tab 500 mg
(Valtrex)
2
SELZENTRY – maraviroc tab 150
mg
5
•
VALCYTE – valganciclovir hcl tab
450 mg
5
•
SELZENTRY – maraviroc tab 300
mg
5
•
VALCYTE – valganciclovir hcl for
soln 50 mg/ml (base equiv)
5
•
SOVALDI – sofosbuvir tab 400 mg
5
•
2
valganciclovir hcl tab 450 mg
(Valcyte)
5
stavudine cap 15 mg (Zerit)
stavudine cap 20 mg (Zerit)
2
2
VALTREX – valacyclovir hcl tab
500 mg
4
stavudine cap 30 mg (Zerit)
2
VALTREX – valacyclovir hcl tab 1
gm
4
stavudine cap 40 mg (Zerit)
stavudine for oral soln 1 mg/ml
(Zerit)
2
• •
•
•
•
•
•
5
• •
STRIBILD – elvitegrav-cobicisemtricitab-tenofov tab
150-150-200-300 mg
5
•
VICTRELIS – boceprevir cap 200
mg
VIDEX – didanosine for soln 2 gm
5
VIDEX – didanosine for soln 4 gm
5
SUSTIVA – efavirenz cap 50 mg
5
5
SUSTIVA – efavirenz cap 200 mg
5
VIDEX EC – didanosine delayed
release capsule 125 mg
•
•
•
5
VIDEX EC – didanosine delayed
release capsule 200 mg
5
SUSTIVA – efavirenz tab 600 mg
•
TAMIFLU – oseltamivir phosphate
cap 30 mg (base equiv)
4
VIDEX EC – didanosine delayed
release capsule 250 mg
5
•
TAMIFLU – oseltamivir phosphate
cap 45 mg (base equiv)
4
VIDEX EC – didanosine delayed
release capsule 400 mg
5
•
TAMIFLU – oseltamivir phosphate
cap 75 mg (base equiv)
4
5
• •
TAMIFLU – oseltamivir phosphate
for susp 6 mg/ml (base equiv)
4
VIEKIRA PAK – ombitas-paritapreriton & dasab tab pak 12.5-75-50
& 250 mg
5
5
•
•
TIVICAY – dolutegravir sodium tab
50 mg (base equiv)
VIRACEPT – nelfinavir mesylate
tab 250 mg
•
•
5
VIRACEPT – nelfinavir mesylate
tab 625 mg
5
TRIZIVIR – abacavir sulfatelamivudine-zidovudine tab
300-150-300 mg
VIRAMUNE – nevirapine tab 200
mg
5
•
VIRAMUNE – nevirapine susp 50
mg/5ml
5
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
ribavirin cap 200 mg (Rebetol)
2
•
5
Restricted Access
•
TRUVADA – emtricitabine-tenofovir 5
disoproxil fumarate tab 200-300
mg
TYBOST – cobicistat tab 150 mg
Prior Review
5
•
•
•
Drug Name
Specialty
RIBATAB – ribavirin tab 400 mg &
ribavirin tab 600 mg dose pack
Drug Name
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
9
2
VIRAMUNE XR – nevirapine tab sr
24hr 400 mg
5
•
chloroquine phosphate tab
250 mg
1
VIREAD – tenofovir disoproxil
fumarate tab 150 mg
5
•
chloroquine phosphate tab
500 mg (Aralen)
1
VIREAD – tenofovir disoproxil
fumarate tab 200 mg
5
•
COARTEM – artemetherlumefantrine tab 20-120 mg
3
VIREAD – tenofovir disoproxil
fumarate tab 250 mg
5
•
DARAPRIM – pyrimethamine tab
25 mg
4
VIREAD – tenofovir disoproxil
fumarate tab 300 mg
5
•
hydroxychloroquine sulfate tab
200 mg (Plaquenil)
1
VIREAD – tenofovir disoproxil
fumarate oral powder 40 mg/gm
5
•
MALARONE – atovaquoneproguanil hcl tab 62.5-25 mg
4
ZERIT – stavudine cap 15 mg
5
5
MALARONE – atovaquoneproguanil hcl tab 250-100 mg
4
ZERIT – stavudine cap 20 mg
ZERIT – stavudine cap 30 mg
5
mefloquine hcl tab 250 mg
1
ZERIT – stavudine cap 40 mg
5
4
PLAQUENIL – hydroxychloroquine
sulfate tab 200 mg
4
ZERIT – stavudine for oral soln 1
mg/ml
•
•
•
•
•
3
ZIAGEN – abacavir sulfate tab 300
mg (base equiv)
5
•
PRIMAQUINE PHOSPHATE –
primaquine phosphate tab 26.3
mg
ZIAGEN – abacavir sulfate soln 20
mg/ml (base equiv)
5
•
AMEBICIDES
YODOXIN – iodoquinol tab 210 mg
2
zidovudine cap 100 mg (Retrovir)
2
YODOXIN – iodoquinol tab 650 mg
2
zidovudine syrup 10 mg/ml
(Retrovir)
2
•
•
zidovudine tab 300 mg
2
ZOVIRAX – acyclovir cap 200 mg
ANTHELMINTICS
ALBENZA – albendazole tab 200
mg
4
4
ivermectin tab 3 mg (Stromectol)
2
ZOVIRAX – acyclovir tab 400 mg
4
4
ZOVIRAX – acyclovir tab 800 mg
4
STROMECTOL – ivermectin tab 3
mg
ZOVIRAX – acyclovir susp 200
mg/5ml
4
ANTIMALARIALS
ARALEN – chloroquine phosphate
tab 500 mg
4
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
2
10
•
ANTI-INFECTIVE AGENTS - MISC.
BACTRIM – sulfamethoxazoletrimethoprim tab 400-80 mg
4
BACTRIM DS – sulfamethoxazoletrimethoprim tab 800-160 mg
4
CAYSTON – aztreonam lysine
for inhal soln 75 mg (base
equivalent)
5
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
Restricted Access
•
Prior Review
5
Drug Name
Specialty
VIRAMUNE XR – nevirapine tab sr
24hr 100 mg
Drug Name
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
CLEOCIN – clindamycin hcl cap 75 4
mg
4
CLEOCIN – clindamycin hcl cap
150 mg
4
CLEOCIN – clindamycin hcl cap
300 mg
4
CLEOCIN PEDIATRIC GRANULE
– clindamycin palmitate hcl for
soln 75 mg/5ml (base equiv)
1
clindamycin hcl cap 150 mg
(Cleocin)
1
clindamycin hcl cap 300 mg
(Cleocin)
1
clindamycin hcl cap 75 mg
(Cleocin)
2
clindamycin palmitate hcl for
soln 75 mg/5ml (base equiv)
(Cleocin pediatric gr)
3
DAPSONE – dapsone tab 25 mg
TINDAMAX – tinidazole tab 500
mg
4
tinidazole tab 250 mg (Tindamax)
2
tinidazole tab 500 mg (Tindamax)
2
trimethoprim tab 100 mg
1
VANCOCIN HCL – vancomycin hcl
cap 125 mg
4
VANCOCIN HCL – vancomycin hcl
cap 250 mg
4
vancomycin hcl cap 125 mg
(Vancocin hcl)
2
vancomycin hcl cap 250 mg
(Vancocin hcl)
2
XIFAXAN – rifaximin tab 200 mg
4
XIFAXAN – rifaximin tab 550 mg
5
ZYVOX – linezolid tab 600 mg
5
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
ANTINEOPLASTIC AGENTS
DAPSONE – dapsone tab 100 mg
3
FLAGYL – metronidazole cap 375
mg
4
FLAGYL – metronidazole tab 250
mg
4
AFINITOR – everolimus tab 7.5 mg 5
AFINITOR – everolimus tab 10 mg 5
5
FLAGYL – metronidazole tab 500
mg
4
AFINITOR DISPERZ – everolimus
tab for oral susp 2 mg
•
•
•
•
•
5
•
metronidazole cap 375 mg
(Flagyl)
2
AFINITOR DISPERZ – everolimus
tab for oral susp 3 mg
5
•
metronidazole tab 250 mg
(Flagyl)
1
AFINITOR DISPERZ – everolimus
tab for oral susp 5 mg
ALKERAN – melphalan tab 2 mg
5
•
metronidazole tab 500 mg
(Flagyl)
1
anastrozole tab 1 mg (Arimidex)
1
ARIMIDEX – anastrozole tab 1 mg
4
sulfamethoxazole-trimethoprim
susp 200-40 mg/5ml
1
AROMASIN – exemestane tab 25
mg
4
sulfamethoxazole-trimethoprim
tab 400-80 mg (Bactrim)
1
azacitidine for inj 100 mg
(Vidaza)
2
sulfamethoxazole-trimethoprim
tab 800-160 mg (Bactrim ds)
1
bicalutamide tab 50 mg
(Casodex)
1
TINDAMAX – tinidazole tab 250
mg
4
capecitabine tab 150 mg (Xeloda) 5
capecitabine tab 500 mg (Xeloda) 5
AFINITOR – everolimus tab 2.5 mg 5
5
AFINITOR – everolimus tab 5 mg
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
•
•
•
11
5
•
CAPRELSA – vandetanib tab 300
mg
5
FEMARA – letrozole tab 2.5 mg
4
flutamide cap 125 mg
1
CASODEX – bicalutamide tab 50
mg
4
•
•
COMETRIQ – cabozantinib smalate cap 3 x 20 mg (60 mg
dose) kit
5
•
GILOTRIF – afatinib dimaleate tab
20 mg (base equivalent)
5
GILOTRIF – afatinib dimaleate tab
30 mg (base equivalent)
5
•
5
•
GILOTRIF – afatinib dimaleate tab
40 mg (base equivalent)
5
COMETRIQ – cabozantinib s-mal
cap 1 x 80 mg & 1 x 20 mg (100
dose) kit
•
4
•
COMETRIQ – cabozantinib s-mal
cap 1 x 80 mg & 3 x 20 mg (140
dose) kit
5
GLEEVEC – imatinib mesylate tab
100 mg (base equivalent)
GLEEVEC – imatinib mesylate tab
400 mg (base equivalent)
4
•
CYCLOPHOSPHAMIDE –
cyclophosphamide cap 25 mg
2
CYCLOPHOSPHAMIDE –
cyclophosphamide cap 50 mg
2
ELIGARD – leuprolide acetate for
subcutaneous inj kit 7.5 mg
5
ELIGARD – leuprolide acetate (3
month) for subcutaneous inj kit
22.5mg
5
ELIGARD – leuprolide acetate (4
month) for subcutaneous inj kit
30 mg
5
•
ELIGARD – leuprolide acetate (6
month) for subcutaneous inj kit
45 mg
5
•
5
INLYTA – axitinib tab 5 mg
5
EMCYT – estramustine phosphate
sodium cap 140 mg
5
ERIVEDGE – vismodegib cap 150
mg
5
JAKAFI – ruxolitinib phosphate tab
5 mg (base equivalent)
•
•
•
5
•
ETOPOSIDE – etoposide cap 50
mg
5
JAKAFI – ruxolitinib phosphate tab
10 mg (base equivalent)
5
•
exemestane tab 25 mg
(Aromasin)
2
JAKAFI – ruxolitinib phosphate tab
15 mg (base equivalent)
5
•
FARESTON – toremifene citrate
tab 60 mg (base equivalent)
5
JAKAFI – ruxolitinib phosphate tab
20 mg (base equivalent)
JAKAFI – ruxolitinib phosphate tab
25 mg (base equivalent)
5
•
12
•
•
•
•
•
•
•
HEXALEN – altretamine cap 50 mg 5
5
HYCAMTIN – topotecan hcl cap
0.25 mg (base equiv)
5
HYCAMTIN – topotecan hcl cap 1
mg (base equiv)
4
HYDREA – hydroxyurea cap 500
mg
1
hydroxyurea cap 500 mg
(Hydrea)
ICLUSIG – ponatinib hcl tab 15 mg 5
(base equiv)
ICLUSIG – ponatinib hcl tab 45 mg 5
(base equiv)
5
INLYTA – axitinib tab 1 mg
•
•
•
•
•
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
FASLODEX – fulvestrant inj 250
mg/5ml
Restricted Access
Specialty
5
Drug Name
Prior Review
Drug Tier
Quantity Limits
Restricted Access
Prior Review
CAPRELSA – vandetanib tab 100
mg
Drug Name
Specialty
Drug Tier
2015
mercaptopurine tab 50 mg
(Purinethol)
1
LEUCOVORIN CALCIUM –
leucovorin calcium tab 15 mg
2
•
MESNEX – mesna tab 400 mg
5
methotrexate sodium inj pf
25 mg/ml
1
leucovorin calcium tab 25 mg
2
leucovorin calcium tab 5 mg
2
methotrexate sodium inj 25 mg/
ml
1
LEUKERAN – chlorambucil tab 2
mg
5
methotrexate sodium tab 2.5 mg
(base equiv)
1
leuprolide acetate inj kit 5 mg/ml
5
LOMUSTINE – lomustine cap 10
mg
5
MYLERAN – busulfan tab 2 mg
4
5
•
NEXAVAR – sorafenib tosylate tab
200 mg (base equivalent)
LOMUSTINE – lomustine cap 40
mg
5
5
•
NILANDRON – nilutamide tab 150
mg
LOMUSTINE – lomustine cap 100
mg
5
4
•
PURINETHOL – mercaptopurine
tab 50 mg
LUPRON DEPOT – leuprolide
acetate for inj kit 3.75 mg
5
SPRYCEL – dasatinib tab 20 mg
5
SPRYCEL – dasatinib tab 50 mg
5
SPRYCEL – dasatinib tab 70 mg
5
SPRYCEL – dasatinib tab 80 mg
5
SPRYCEL – dasatinib tab 100 mg
5
SPRYCEL – dasatinib tab 140 mg
5
SUTENT – sunitinib malate cap
12.5 mg (base equivalent)
5
•
•
•
•
•
•
•
LUPRON DEPOT – leuprolide
acetate for inj kit 7.5 mg
5
LUPRON DEPOT – leuprolide
acetate (3 month) for inj kit 11.25
mg
5
LUPRON DEPOT – leuprolide
acetate (3 month) for inj kit 22.5
mg
5
LUPRON DEPOT – leuprolide
acetate (4 month) for inj kit 30
mg
5
•
SUTENT – sunitinib malate cap 25
mg (base equivalent)
5
•
LUPRON DEPOT – leuprolide
acetate (6 month) for inj kit 45
mg
5
•
SUTENT – sunitinib malate cap
37.5 mg (base equivalent)
5
•
SUTENT – sunitinib malate cap 50
mg (base equivalent)
5
•
SYLATRON – peginterferon alfa-2b 5
for inj kit 296 mcg
SYLATRON – peginterferon alfa-2b 5
for inj kit 444 mcg
SYLATRON – peginterferon alfa-2b 5
for inj kit 888 mcg
SYLATRON – peginterferon alfa-2b 5
for inj kit 4 x 296 mcg
•
•
•
•
•
•
•
•
•
•
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
•
Restricted Access
1
Prior Review
megestrol acetate tab 40 mg
Specialty
Drug Tier
2
Quantity Limits
LEUCOVORIN CALCIUM –
leucovorin calcium tab 10 mg
Restricted Access
1
Prior Review
letrozole tab 2.5 mg (Femara)
LYSODREN – mitotane tab 500 mg 5
5
MATULANE – procarbazine hcl
cap 50 mg
4
MEGACE ORAL – megestrol
acetate susp 40 mg/ml
megestrol acetate susp 40 mg/ml 2
(Megace oral)
1
megestrol acetate tab 20 mg
Drug Name
Specialty
Drug Name
Drug Tier
2015
•
•
•
•
•
13
temozolomide cap 250 mg
(Temodar)
5
•
•
temozolomide cap 5 mg
(Temodar)
5
•
tretinoin cap 10 mg
5
TYKERB – lapatinib ditosylate tab
250 mg (base equiv)
5
•
•
•
VOTRIENT – pazopanib hcl tab
200 mg (base equiv)
5
•
•
XALKORI – crizotinib cap 200 mg
5
XALKORI – crizotinib cap 250 mg
5
XELODA – capecitabine tab 150
mg
5
•
•
•
XELODA – capecitabine tab 500
mg
5
•
tamoxifen citrate tab 10 mg
(base equivalent)
1
tamoxifen citrate tab 20 mg
(base equivalent)
1
TARCEVA – erlotinib hcl tab 25 mg 5
(base equivalent)
5
TARCEVA – erlotinib hcl tab 100
mg (base equivalent)
5
TARCEVA – erlotinib hcl tab 150
mg (base equivalent)
TARGRETIN – bexarotene cap 75 5
mg
5
TASIGNA – nilotinib hcl cap 150
mg (base equivalent)
5
TASIGNA – nilotinib hcl cap 200
mg (base equivalent)
5
TEMODAR – temozolomide cap 5
mg
TEMODAR – temozolomide cap 20 5
mg
5
TEMODAR – temozolomide cap
100 mg
5
TEMODAR – temozolomide cap
140 mg
5
TEMODAR – temozolomide cap
180 mg
5
TEMODAR – temozolomide cap
250 mg
5
temozolomide cap 100 mg
(Temodar)
5
temozolomide cap 140 mg
(Temodar)
5
temozolomide cap 180 mg
(Temodar)
5
temozolomide cap 20 mg
(Temodar)
14
•
•
•
•
•
•
XTANDI – enzalutamide cap 40 mg 5
ZELBORAF – vemurafenib tab 240 5
mg (base equivalent)
ZOLINZA – vorinostat cap 100 mg 5
ZYTIGA – abiraterone acetate tab
250 mg
5
• • •
• •
•
• •
ENDOCRINE AND METABOLIC DRUGS
•
CORTICOSTEROIDS
2
•
budesonide cap sr 24hr 3 mg
(Entocort ec)
4
•
CORTEF – hydrocortisone tab 5
mg
4
•
CORTEF – hydrocortisone tab 10
mg
4
•
CORTEF – hydrocortisone tab 20
mg
3
•
CORTISONE ACETATE –
cortisone acetate tab 25 mg
1
•
DEXAMETHASONE –
dexamethasone tab 1 mg
1
•
DEXAMETHASONE –
dexamethasone tab 2 mg
DEXAMETHASONE –
dexamethasone soln 0.5 mg/5ml
4
• •
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
•
Drug Name
Restricted Access
Specialty
SYLATRON – peginterferon alfa-2b 5
for inj kit 4 x 444 mcg
TABLOID – thioguanine tab 40 mg 4
Drug Name
Prior Review
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
1
4
methylprednisolone tab 32 mg
(Medrol)
1
dexamethasone tab 0.5 mg
1
methylprednisolone tab 4 mg
(Medrol)
dexamethasone tab 0.75 mg
1
1
dexamethasone tab 1.5 mg
1
methylprednisolone tab 4 mg
dose pack (Medrol dosepak)
1
methylprednisolone tab 8 mg
(Medrol)
1
dexamethasone tab 4 mg
dexamethasone tab 6 mg
1
DEXPAK 10 DAY –
dexamethasone tab 1.5 mg taper
pack
MILLIPRED – prednisolone tab 5
mg
1
4
4
DEXPAK 13 DAY –
dexamethasone tab 1.5 mg taper
pack
4
MILLIPRED – prednisolone sod
phosphate oral soln 10 mg/5ml
(base equiv)
MILLIPRED DP – prednisolone tab
5 mg dose pack
4
DEXPAK 6 DAY – dexamethasone
tab 1.5 mg taper pack
4
1
ENTOCORT EC – budesonide cap
sr 24hr 3 mg
4
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml
base) (Pediapred)
fludrocortisone acetate tab
0.1 mg
prednisolone sod phosphate
oral soln 15 mg/5ml (base
equiv)
1
1
hydrocortisone tab 10 mg
(Cortef)
1
1
hydrocortisone tab 20 mg
(Cortef)
1
prednisolone syrup 15 mg/5ml
(usp solution equivalent)
(Prelone)
hydrocortisone tab 5 mg (Cortef)
1
MEDROL – methylprednisolone tab 4
2 mg
MEDROL – methylprednisolone tab 4
4 mg
MEDROL – methylprednisolone tab 4
8 mg
MEDROL – methylprednisolone tab 4
16 mg
MEDROL – methylprednisolone tab 4
32 mg
4
MEDROL DOSEPAK –
methylprednisolone tab 4 mg
dose pack
1
methylprednisolone tab 16 mg
(Medrol)
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
DEXAMETHASONE INTENSOL –
dexamethasone conc 1 mg/ml
Restricted Access
1
Prior Review
dexamethasone elixir 0.5 mg/5ml
Specialty
Drug Name
Drug Tier
2015
PREDNISONE – prednisone tab 50 1
mg
3
PREDNISONE – prednisone oral
soln 5 mg/5ml
PREDNISONE – prednisone tab 5 1
mg dose pack
PREDNISONE – prednisone tab 10 1
mg dose pack
4
PREDNISONE INTENSOL –
prednisone conc 5 mg/ml
1
prednisone tab 1 mg
prednisone tab 10 mg
1
prednisone tab 2.5 mg
1
prednisone tab 20 mg
1
prednisone tab 5 mg
1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
15
PRELONE – prednisolone syrup 15 4
mg/5ml (usp solution equivalent)
VERIPRED 20 – prednisolone sod 4
phosphate oral soln 20 mg/5ml
(base equiv)
oxandrolone tab 2.5 mg
(Oxandrin)
2
•
testosterone cypionate im
inj in oil 100 mg/ml (Depotestosterone)
1
•
ANDROGEN-ANABOLIC
1
•
ANDRODERM – testosterone td
patch 24hr 2 mg/24hr
3
•
testosterone cypionate im
inj in oil 200 mg/ml (Depotestosterone)
ANDRODERM – testosterone td
patch 24hr 4 mg/24hr
3
•
testosterone enanthate im inj in
oil 200 mg/ml
1
•
ANDROGEL – testosterone td gel
25 mg/2.5gm (1%)
3
•
TESTRED – methyltestosterone
cap 10 mg
4
•
ANDROGEL – testosterone td gel
50 mg/5gm (1%)
3
•
ESTROGENS
4
ANDROGEL – testosterone td gel
20.25 mg/1.25gm (1.62%)
3
•
ACTIVELLA – estradiol &
norethindrone acetate tab 0.5-0.1
mg
ANDROGEL – testosterone td gel
40.5 mg/2.5gm (1.62%)
3
•
4
ANDROGEL PUMP – testosterone
td gel 12.5 mg/act (1%)
3
•
ACTIVELLA – estradiol &
norethindrone acetate tab 1-0.5
mg
4
• •
ANDROGEL PUMP – testosterone
td gel 20.25 mg/act (1.62%)
3
ALORA – estradiol td patch
biweekly 0.025 mg/24hr
4
• •
ANDROID – methyltestosterone
cap 10 mg
4
ALORA – estradiol td patch
biweekly 0.05 mg/24hr
4
• •
danazol cap 100 mg
2
ALORA – estradiol td patch
biweekly 0.075 mg/24hr
2
ALORA – estradiol td patch
biweekly 0.1 mg/24hr
4
danazol cap 200 mg
• •
danazol cap 50 mg
2
DEPO-TESTOSTERONE –
testosterone cypionate im inj in
oil 100 mg/ml
•
CLIMARA – estradiol td patch
weekly 0.025 mg/24hr
4
4
4
DEPO-TESTOSTERONE –
testosterone cypionate im inj in
oil 200 mg/ml
4
•
CLIMARA – estradiol td patch
weekly 0.0375 mg/24hr (37.5
mcg/24hr)
4
OXANDRIN – oxandrolone tab 2.5
mg
4
•
CLIMARA – estradiol td patch
weekly 0.05 mg/24hr
4
OXANDRIN – oxandrolone tab 10
mg
4
•
CLIMARA – estradiol td patch
weekly 0.06 mg/24hr
4
oxandrolone tab 10 mg
(Oxandrin)
2
•
CLIMARA – estradiol td patch
weekly 0.075 mg/24hr
CLIMARA – estradiol td patch
weekly 0.1 mg/24hr
4
16
•
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
DELESTROGEN – estradiol
valerate im in oil 10 mg/ml
4
estradiol td patch weekly
0.025 mg/24hr (Climara)
1
DELESTROGEN – estradiol
valerate im in oil 20 mg/ml
4
1
DELESTROGEN – estradiol
valerate im in oil 40 mg/ml
4
estradiol td patch weekly
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
1
DIVIGEL – estradiol td gel 0.25
mg/0.25gm (0.1%)
4
estradiol td patch weekly
0.05 mg/24hr (Climara)
1
DIVIGEL – estradiol td gel 0.5
mg/0.5gm (0.1%)
4
estradiol td patch weekly
0.06 mg/24hr (Climara)
estradiol td patch weekly
0.075 mg/24hr (Climara)
1
estradiol td patch weekly
0.1 mg/24hr (Climara)
1
estradiol valerate im in oil 20 mg/
ml (Delestrogen)
2
estradiol valerate im in oil 40 mg/
ml (Delestrogen)
2
ESTROPIPATE – estropipate tab 3
mg
1
DIVIGEL – estradiol td gel 1 mg/gm 4
(0.1%)
1
esterified estrogens &
methyltestosterone tab
0.625-1.25 mg
1
esterified estrogens &
methyltestosterone tab
1.25-2.5 mg
4
ESTRACE – estradiol tab 0.5 mg
ESTRACE – estradiol tab 1 mg
4
estropipate tab 0.75 mg
1
ESTRACE – estradiol tab 2 mg
4
estropipate tab 1.5 mg
1
estradiol & norethindrone
acetate tab 0.5-0.1 mg
(Activella)
2
FEMHRT LOW DOSE –
norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
4
estradiol & norethindrone
acetate tab 1-0.5 mg (Activella)
2
JINTELI – norethindrone acetateethinyl estradiol tab 1 mg-5 mcg
2
estradiol tab 0.5 mg (Estrace)
1
3
estradiol tab 1 mg (Estrace)
1
PREMARIN – estrogens,
conjugated tab 0.3 mg
estradiol tab 2 mg (Estrace)
1
3
estradiol td patch twice weekly
0.025 mg/24hr (Vivelle-dot)
2
PREMARIN – estrogens,
conjugated tab 0.45 mg
3
estradiol td patch twice weekly
0.0375 mg/24hr (Vivelle-dot)
2
PREMARIN – estrogens,
conjugated tab 0.625 mg
3
estradiol td patch twice weekly
0.05 mg/24hr (Vivelle-dot)
2
PREMARIN – estrogens,
conjugated tab 0.9 mg
3
estradiol td patch twice weekly
0.075 mg/24hr (Vivelle-dot)
2
PREMARIN – estrogens,
conjugated tab 1.25 mg
estradiol td patch twice weekly
0.1 mg/24hr (Vivelle-dot)
2
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
• •
PREMPHASE – conj est 0.625(14)/ 3
conj est-medroxypro ac tab
0.625-5mg(14)
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
17
PREMPRO – conjugated estrogenmedroxyprogest acetate tab
0.3-1.5 mg
3
PREMPRO – conjugated estrogenmedroxyprogest acetate tab
0.45-1.5 mg
3
PREMPRO – conjugated estrogenmedroxyprogest acetate tab
0.625-2.5 mg
3
PREMPRO – conjugated estrogenmedroxyprogest acetate tab
0.625-5 mg
3
VIVELLE-DOT – estradiol td patch
biweekly 0.025 mg/24hr
4
VIVELLE-DOT – estradiol td patch
biweekly 0.0375 mg/24hr
4
VIVELLE-DOT – estradiol td patch
biweekly 0.05 mg/24hr
4
VIVELLE-DOT – estradiol td patch
biweekly 0.075 mg/24hr
4
VIVELLE-DOT – estradiol td patch
biweekly 0.1 mg/24hr
drospirenone-ethinyl estradiol
tab 3-0.02 mg (Yaz)
2
drospirenone-ethinyl estradiol
tab 3-0.03 mg (Yasmin 28)
2
ELLA – ulipristal acetate tab 30 mg
3
ESTROSTEP FE – norethindrone
ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg
4
ethynodiol diacetate & ethinyl
estradiol tab 1 mg-35 mcg
1
FEMCON FE – norethindrone &
ethinyl estradiol-fe chew tab 0.4
mg-35 mcg
4
levonorg-eth est tab
0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)
2
2
4
levonorg-eth est tab
0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)
1
4
levonorgestrel & ethinyl
estradiol (91-day) tab
0.15-0.03 mg
levonorgestrel & ethinyl
estradiol tab 0.1 mg-20 mcg
1
levonorgestrel & ethinyl
estradiol tab 0.15 mg-30 mcg
1
levonorgestrel tab 0.75 mg (Plan
b)
1
levonorgestrel tab 1.5 mg (Plan b
one-step)
1
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mgmcg
1
LOESTRIN FE 1.5/30 –
norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
4
LOESTRIN FE 1/20 –
norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg
4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
Quantity Limits
Restricted Access
1
4
CYCLESSA – desogestethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg
4
DEPO-PROVERA
CONTRACEPTIV –
medroxyprogesterone acetate im
susp 150 mg/ml
DESOGEN – desogestrel & ethinyl 4
estradiol tab 0.15 mg-30 mcg
desogest-eth estrad & eth estrad 1
tab 0.15-0.02/0.01 mg(21/5)
(Mircette)
1
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
18
Drug Name
desogestrel & ethinyl estradiol
tab 0.15 mg-30 mcg (Desogen)
CONTRACEPTIVES
BREVICON-28 – norethindrone &
ethinyl estradiol tab 0.5 mg-35
mcg
Prior Review
Drug Name
Specialty
Drug Tier
2015
LOESTRIN 1.5/30-21 –
norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg
4
norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg
(Loestrin fe 1/20)
1
LOESTRIN 1/20-21 –
norethindrone ace & ethinyl
estradiol tab 1 mg-20 mcg
4
norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
(Loestrin fe 1.5/30)
1
LOSEASONIQUE – levonorg-eth
est tab 0.1-0.02mg(84) & eth est
tab 0.01mg(7)
4
norethindrone tab 0.35 mg (Norqd)
1
1
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg
(Ortho-novum 7/7/7)
1
medroxyprogesterone acetate im
susp 150 mg/ml (Depo-provera
contrac)
MIRCETTE – desogest-eth estrad
& eth estrad tab 0.15-0.02/0.01
mg(21/5)
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28)
1
4
MODICON – norethindrone &
ethinyl estradiol tab 0.5 mg-35
mcg
norgestimate & ethinyl estradiol
tab 0.25 mg-35 mcg (Orthocyclen)
1
4
4
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mgmcg (Ortho tri-cyclen)
1
NOR-QD – norethindrone tab 0.35
mg
norgestrel & ethinyl estradiol tab
0.3 mg-30 mcg
1
NORINYL 1+35 – norethindrone &
ethinyl estradiol tab 1 mg-35 mcg
4
NUVARING – etonogestrel-ethinyl
estradiol va ring 0.120-0.015
mg/24hr
3
ORTHO EVRA – norelgestrominethinyl estradiol td ptwk 150-35
mcg/24hr
4
ORTHO MICRONOR –
norethindrone tab 0.35 mg
4
ORTHO TRI-CYCLEN –
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mgmcg
4
ORTHO-CEPT – desogestrel &
ethinyl estradiol tab 0.15 mg-30
mcg
4
ORTHO-CYCLEN – norgestimate
& ethinyl estradiol tab 0.25
mg-35 mcg
4
2
norelgestromin-ethinyl estradiol
td ptwk 150-35 mcg/24hr (Ortho
evra)
norethindrone & ethinyl estradiol 1
tab 0.4 mg-35 mcg (Ovcon-35)
1
norethindrone & ethinyl
estradiol tab 0.5 mg-35 mcg
(Brevicon-28)
norethindrone & ethinyl estradiol 1
tab 1 mg-35 mcg (Norinyl 1+35)
2
norethindrone & ethinyl
estradiol-fe chew tab
0.4 mg-35 mcg (Femcon fe)
1
norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg
(Estrostep fe)
1
norethindrone ace & ethinyl
estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)
1
norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg
(Loestrin 1.5/30-21)
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
19
ORTHO-NOVUM 1/35 –
norethindrone & ethinyl estradiol
tab 1 mg-35 mcg
4
ORTHO-NOVUM 7/7/7 –
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg
4
OVCON-35 – norethindrone &
ethinyl estradiol tab 0.4 mg-35
mcg
4
PLAN B – levonorgestrel tab 0.75
mg
4
PLAN B ONE-STEP –
levonorgestrel tab 1.5 mg
4
QUARTETTE – levonor-eth est tab
0.15-0.02/0.025/0.03 mg &eth est
0.01 mg
4
SEASONIQUE – levonorg-eth est
tab 0.15-0.03mg(84) & eth est
tab 0.01mg(7)
4
TRI-NORINYL 28 –
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg
4
YASMIN 28 – drospirenone-ethinyl
estradiol tab 3-0.03 mg
YAZ – drospirenone-ethinyl
estradiol tab 3-0.02 mg
progesterone micronized cap
200 mg (Prometrium)
2
PROMETRIUM – progesterone
micronized cap 100 mg
4
PROMETRIUM – progesterone
micronized cap 200 mg
4
2
acarbose tab 25 mg (Precose)
2
acarbose tab 50 mg (Precose)
2
ACTOPLUS MET – pioglitazone
hcl-metformin hcl tab 15-500 mg
4
ACTOPLUS MET – pioglitazone
hcl-metformin hcl tab 15-850 mg
4
4
ACTOS – pioglitazone hcl tab 15
mg (base equiv)
4
4
ACTOS – pioglitazone hcl tab 30
mg (base equiv)
4
ACTOS – pioglitazone hcl tab 45
mg (base equiv)
4
AMARYL – glimepiride tab 1 mg
4
AMARYL – glimepiride tab 2 mg
4
AMARYL – glimepiride tab 4 mg
4
4
medroxyprogesterone acetate
tab 10 mg (Provera)
1
medroxyprogesterone acetate
tab 2.5 mg (Provera)
1
DEX4 GLUCOSE – glucose oral
liquid 15 gm/59ml
4
medroxyprogesterone acetate
tab 5 mg (Provera)
1
DUETACT – pioglitazone hclglimepiride tab 30-2 mg
4
norethindrone acetate tab 5 mg
(Aygestin)
2
DUETACT – pioglitazone hclglimepiride tab 30-4 mg
4
progesterone im in oil 50 mg/ml
2
4
progesterone micronized cap
100 mg (Prometrium)
2
FORTAMET – metformin hcl tab sr
24hr osmotic 500 mg
FORTAMET – metformin hcl tab sr
24hr osmotic 1000 mg
4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
ANTIDIABETICS
AYGESTIN – norethindrone
acetate tab 5 mg
20
Prior Review
PROVERA – medroxyprogesterone 4
acetate tab 2.5 mg
PROVERA – medroxyprogesterone 4
acetate tab 5 mg
PROVERA – medroxyprogesterone 4
acetate tab 10 mg
acarbose tab 100 mg (Precose)
PROGESTINS
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
glipizide tab sr 24hr 2.5 mg
(Glucotrol xl)
1
glipizide tab sr 24hr 5 mg
(Glucotrol xl)
1
glipizide tab 10 mg (Glucotrol)
1
glipizide tab 5 mg (Glucotrol)
1
glipizide-metformin hcl tab
2.5-250 mg
2
glipizide-metformin hcl tab
2.5-500 mg
2
glipizide-metformin hcl tab
5-500 mg
2
GLUCAGEN – glucagon hcl (rdna)
for inj 1 mg (base equiv)
4
GLUCOTROL XL – glipizide tab sr
24hr 10 mg
4
GLUCOVANCE – glyburidemetformin tab 1.25-250 mg
4
GLUCOVANCE – glyburidemetformin tab 2.5-500 mg
4
GLUCOVANCE – glyburidemetformin tab 5-500 mg
4
GLYBURIDE – glyburide tab 1.25
mg
1
GLYBURIDE – glyburide tab 2.5
mg
1
GLYBURIDE – glyburide tab 5 mg
1
3
glyburide micronized tab 1.5 mg
(Glynase)
1
3
glyburide micronized tab 3 mg
(Glynase)
1
GLUCAGEN HYPOKIT – glucagon
hcl (rdna) for inj 1 mg (base
equiv)
1
GLUCAGON EMERGENCY KIT –
glucagon (rdna) for inj kit 1 mg
3
glyburide micronized tab 6 mg
(Glynase)
glyburide tab 1.25 mg
1
GLUCOPHAGE – metformin hcl
tab 500 mg
4
glyburide tab 2.5 mg
1
glyburide tab 5 mg
1
GLUCOPHAGE – metformin hcl
tab 850 mg
4
glyburide-metformin tab
1.25-250 mg (Glucovance)
1
GLUCOPHAGE – metformin hcl
tab 1000 mg
4
glyburide-metformin tab
2.5-500 mg (Glucovance)
1
GLUCOPHAGE XR – metformin
hcl tab sr 24hr 500 mg
4
glyburide-metformin tab
5-500 mg (Glucovance)
1
GLUCOPHAGE XR – metformin
hcl tab sr 24hr 750 mg
4
GLYNASE – glyburide micronized
tab 1.5 mg
4
glucose gel 40%
2
4
glucose oral liquid 15 gm/59ml
2
GLYNASE – glyburide micronized
tab 3 mg
GLUCOTROL – glipizide tab 5 mg
4
GLYNASE – glyburide micronized
tab 6 mg
4
INSTA-GLUCOSE – glucose gel
77.4%
2
GLUCOTROL – glipizide tab 10 mg 4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
1
GLUCOTROL XL – glipizide tab sr
24hr 5 mg
Restricted Access
glipizide tab sr 24hr 10 mg
(Glucotrol xl)
4
Prior Review
1
GLUCOTROL XL – glipizide tab sr
24hr 2.5 mg
Specialty
glimepiride tab 4 mg (Amaryl)
Drug Name
Drug Tier
1
Quantity Limits
glimepiride tab 2 mg (Amaryl)
Restricted Access
1
Prior Review
glimepiride tab 1 mg (Amaryl)
Specialty
Drug Name
Drug Tier
2015
21
INVOKAMET – canagliflozinmetformin hcl tab 50-500 mg
3
ONGLYZA – saxagliptin hcl tab 5
mg (base equiv)
3
INVOKAMET – canagliflozinmetformin hcl tab 50-1000 mg
3
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
2
INVOKAMET – canagliflozinmetformin hcl tab 150-500 mg
3
pioglitazone hcl tab 30 mg (base
equiv) (Actos)
2
INVOKAMET – canagliflozinmetformin hcl tab 150-1000 mg
3
pioglitazone hcl tab 45 mg (base
equiv) (Actos)
2
INVOKANA – canagliflozin tab 100
mg
3
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
2
INVOKANA – canagliflozin tab 300
mg
3
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
2
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr
2.5-1000 mg
3
pioglitazone hcl-metformin hcl
tab 15-500 mg (Actoplus met)
2
2
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-500
mg
3
pioglitazone hcl-metformin hcl
tab 15-850 mg (Actoplus met)
PRANDIN – repaglinide tab 0.5 mg
4
3
PRANDIN – repaglinide tab 1 mg
4
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-1000
mg
PRANDIN – repaglinide tab 2 mg
4
PRECOSE – acarbose tab 25 mg
4
metformin hcl tab sr 24hr
osmotic 1000 mg (Fortamet)
2
PRECOSE – acarbose tab 50 mg
4
PRECOSE – acarbose tab 100 mg
4
metformin hcl tab sr 24hr
osmotic 500 mg (Fortamet)
2
repaglinide tab 0.5 mg (Prandin)
2
1
repaglinide tab 1 mg (Prandin)
2
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
repaglinide tab 2 mg (Prandin)
2
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
1
RIOMET – metformin hcl oral soln
500 mg/5ml
4
metformin hcl tab 1000 mg
(Glucophage)
1
STARLIX – nateglinide tab 60 mg
4
STARLIX – nateglinide tab 120 mg
4
metformin hcl tab 500 mg
(Glucophage)
1
TOLAZAMIDE – tolazamide tab
500 mg
1
metformin hcl tab 850 mg
(Glucophage)
1
tolazamide tab 250 mg
1
2
TOLBUTAMIDE – tolbutamide tab
500 mg
1
nateglinide tab 120 mg (Starlix)
nateglinide tab 60 mg (Starlix)
2
3
ONGLYZA – saxagliptin hcl tab 2.5
mg (base equiv)
3
VICTOZA – liraglutide soln peninjector 18 mg/3ml (6 mg/ml)
22
• •
Rapid-Acting Insulins
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
NOVOLOG – insulin aspart inj 100
unit/ml
3
ARMOUR THYROID – thyroid tab
15 mg (1/4 grain)
4
NOVOLOG FLEXPEN – insulin
aspart soln pen-injector 100 unit/
ml
3
ARMOUR THYROID – thyroid tab
30 mg (1/2 grain)
4
NOVOLOG PENFILL – insulin
aspart soln cartridge 100 unit/ml
ARMOUR THYROID – thyroid tab
60 mg (1 grain)
4
3
3
ARMOUR THYROID – thyroid tab
90 mg (1 1/2 grain)
4
NOVOLOG PENFILL – insulin
aspart inj 100 unit/ml
ARMOUR THYROID – thyroid tab
120 mg (2 grain)
4
Short-Acting Insulins
NOVOLIN R – insulin regular
(human) inj 100 unit/ml
3
ARMOUR THYROID – thyroid tab
180 mg (3 grain)
4
NOVOLIN R RELION – insulin
regular (human) inj 100 unit/ml
3
ARMOUR THYROID – thyroid tab
240 mg (4 grain)
4
RELION R – insulin regular
(human) inj 100 unit/ml
3
ARMOUR THYROID – thyroid tab
300 mg (5 grain)
4
4
Intermediate-Acting Insulins
NOVOLIN N – insulin isophane
(human) inj 100 unit/ml
3
CYTOMEL – liothyronine sodium
tab 5 mcg
4
NOVOLIN N RELION – insulin
isophane (human) inj 100 unit/ml
3
CYTOMEL – liothyronine sodium
tab 25 mcg
4
NOVOLIN 70/30 – insulin isophane
& regular (human) inj 100 unit/ml
(70-30)
3
CYTOMEL – liothyronine sodium
tab 50 mcg
levothyroxine sodium tab
100 mcg (Synthroid)
1
NOVOLIN 70/30 RELION – insulin
isophane & regular (human) inj
100 unit/ml (70-30)
3
levothyroxine sodium tab
112 mcg (Synthroid)
1
3
levothyroxine sodium tab
125 mcg (Synthroid)
1
NOVOLOG MIX 70/30 – insulin
aspart prot & aspart (human) inj
100 unit/ml (70-30)
levothyroxine sodium tab
137 mcg (Synthroid)
1
NOVOLOG MIX 70/30 PREFILL –
insulin aspart prot & aspart sus
pen-inj 100 unit/ml (70-30)
3
levothyroxine sodium tab
150 mcg (Synthroid)
1
levothyroxine sodium tab
175 mcg (Synthroid)
1
levothyroxine sodium tab
200 mcg (Synthroid)
1
levothyroxine sodium tab
25 mcg (Synthroid)
1
levothyroxine sodium tab
300 mcg (Synthroid)
1
Basal Insulins
LANTUS – insulin glargine inj 100
unit/ml
3
LANTUS SOLOSTAR – insulin
glargine soln pen-injector 100
unit/ml
3
THYROID AGENTS
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
23
levothyroxine sodium tab
50 mcg (Synthroid)
1
levothyroxine sodium tab
75 mcg (Synthroid)
1
NATURE-THROID NT-2.5 – thyroid 1
tab 162.5 mg (2 1/2 grain)
1
propylthiouracil tab 50 mg
levothyroxine sodium tab
88 mcg (Synthroid)
SYNTHROID – levothyroxine
sodium tab 25 mcg
4
1
1
SYNTHROID – levothyroxine
sodium tab 50 mcg
4
liothyronine sodium tab 25 mcg
(Cytomel)
1
SYNTHROID – levothyroxine
sodium tab 75 mcg
4
liothyronine sodium tab 5 mcg
(Cytomel)
liothyronine sodium tab 50 mcg
(Cytomel)
SYNTHROID – levothyroxine
sodium tab 88 mcg
4
1
methimazole tab 10 mg
(Tapazole)
SYNTHROID – levothyroxine
sodium tab 100 mcg
4
1
methimazole tab 5 mg (Tapazole)
SYNTHROID – levothyroxine
sodium tab 112 mcg
4
1
NATURE-THROID – thyroid tab
16.25 mg
1
SYNTHROID – levothyroxine
sodium tab 125 mcg
4
NATURE-THROID – thyroid tab
32.5 mg
1
SYNTHROID – levothyroxine
sodium tab 137 mcg
4
NATURE-THROID – thyroid tab
48.75 mg (3/4 grain)
1
SYNTHROID – levothyroxine
sodium tab 150 mcg
4
NATURE-THROID – thyroid tab 65
mg
1
SYNTHROID – levothyroxine
sodium tab 175 mcg
4
NATURE-THROID – thyroid tab
81.25 mg
1
SYNTHROID – levothyroxine
sodium tab 200 mcg
4
NATURE-THROID – thyroid tab
97.5 mg
1
SYNTHROID – levothyroxine
sodium tab 300 mcg
4
NATURE-THROID – thyroid tab
113.75 mg
1
TAPAZOLE – methimazole tab 5
mg
4
NATURE-THROID – thyroid tab
130 mg
1
TAPAZOLE – methimazole tab 10
mg
4
NATURE-THROID – thyroid tab
195 mg
1
thyroid tab 30 mg (1/2 grain)
(Armour thyroid)
1
NATURE-THROID – thyroid tab
260 mg
1
thyroid tab 60 mg (1 grain)
(Armour thyroid)
1
NATURE-THROID – thyroid tab
325 mg (5 grain)
1
thyroid tab 90 mg (1 1/2 grain)
(Armour thyroid)
1
NATURE-THROID – thyroid tab
146.25 mg
1
TIROSINT – levothyroxine sodium
cap 13 mcg
4
24
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
TIROSINT – levothyroxine sodium
cap 25 mcg
4
TIROSINT – levothyroxine sodium
cap 50 mcg
4
TIROSINT – levothyroxine sodium
cap 75 mcg
4
TIROSINT – levothyroxine sodium
cap 88 mcg
4
TIROSINT – levothyroxine sodium
cap 100 mcg
4
TIROSINT – levothyroxine sodium
cap 112 mcg
4
TIROSINT – levothyroxine sodium
cap 125 mcg
4
TIROSINT – levothyroxine sodium
cap 137 mcg
4
TIROSINT – levothyroxine sodium
cap 150 mcg
4
WESTHROID – thyroid tab 16.25
mg
1
WESTHROID-P – thyroid tab 16.25 1
mg
WESTHROID-P – thyroid tab 32.5 1
mg
WESTHROID-P – thyroid tab 48.75 1
mg (3/4 grain)
1
WESTHROID-P – thyroid tab 65
mg
WESTHROID-P – thyroid tab 97.5 1
mg
1
WESTHROID-P – thyroid tab 130
mg
1
WP THYROID – thyroid tab 16.25
mg
1
WP THYROID – thyroid tab 32.5
mg
1
WP THYROID – thyroid tab 48.75
mg (3/4 grain)
WP THYROID – thyroid tab 65 mg 1
WESTHROID – thyroid tab 32.5
mg
WP THYROID – thyroid tab 81.25
mg
1
1
WESTHROID – thyroid tab 48.75
mg (3/4 grain)
WP THYROID – thyroid tab 97.5
mg
1
1
1
WESTHROID – thyroid tab 65 mg
1
WP THYROID – thyroid tab 113.75
mg
WESTHROID – thyroid tab 81.25
mg
1
WP THYROID – thyroid tab 130
mg
1
WESTHROID – thyroid tab 97.5
mg
1
OXYTOCICS
WESTHROID – thyroid tab 113.75
mg
1
methylergonovine maleate tab
0.2 mg
WESTHROID – thyroid tab 130 mg
1
WESTHROID – thyroid tab 162.5
mg (2 1/2 grain)
1
WESTHROID – thyroid tab 195 mg
1
WESTHROID – thyroid tab 260 mg
1
WESTHROID – thyroid tab 325 mg
(5 grain)
1
WESTHROID – thyroid tab 146.25
mg
1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
1
ENDOCRINE and METABOLIC AGENTS - MISC.
4
ACTONEL – risedronate sodium
tab 150 mg
1
ALENDRONATE SODIUM –
alendronate sodium tab 40 mg
4
•
ALENDRONATE SODIUM –
alendronate sodium oral soln 70
mg/75ml
1
alendronate sodium tab 10 mg
alendronate sodium tab 35 mg
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
•
1
25
2
1
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
2
BONIVA – ibandronate sodium tab
150 mg (base equivalent)
4
desmopressin acetate nasal
spray soln 0.01% (Ddavp)
2
BRAVELLE – Benefit Limits may
apply – urofollitropin purified for
inj 75 unit
5
desmopressin acetate nasal
spray soln 0.01% (refrigerated)
desmopressin acetate tab 0.1 mg
(Ddavp)
2
cabergoline tab 0.5 mg
2
2
calcitonin (salmon) nasal soln
200 unit/act (Miacalcin)
2
desmopressin acetate tab 0.2 mg
(Ddavp)
2
calcitriol cap 0.25 mcg (Rocaltrol)
1
ETIDRONATE DISODIUM –
etidronate disodium tab 400 mg
calcitriol cap 0.5 mcg (Rocaltrol)
1
EVISTA – raloxifene hcl tab 60 mg
4
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
2
5
CARBAGLU – carglumic acid tab
200 mg
5
FOLLISTIM AQ – Benefit Limits
may apply – follitropin beta inj 75
unit/0.5ml
5
CARNITOR – levocarnitine tab 330
mg
4
FOLLISTIM AQ – Benefit Limits
may apply – follitropin beta inj
150 unit/0.5ml
4
FOLLISTIM AQ – Benefit Limits
may apply – follitropin beta inj
300 unit/0.36ml
5
CARNITOR – levocarnitine oral
soln 1 gm/10ml (10%)
CARNITOR SF – levocarnitine oral
soln 1 gm/10ml (10%)
4
5
CETROTIDE – Benefit Limits may
apply – cetrorelix acetate for inj
kit 0.25 mg
5
FOLLISTIM AQ – Benefit Limits
may apply – follitropin beta inj
600 unit/0.72ml
5
chorionic gonadotropin for inj
10000 unit – Benefit Limits
may apply
5
FOLLISTIM AQ – Benefit Limits
may apply – follitropin beta inj
900 unit/1.08ml
FORTEO – teriparatide
(recombinant) inj 600 mcg/2.4ml
5
clomiphene citrate tab 50 mg –
Benefit Limits may apply
1
FORTICAL – calcitonin (salmon)
nasal soln 200 unit/act
2
DDAVP – desmopressin acetate
tab 0.1 mg
4
FOSAMAX – alendronate sodium
tab 70 mg
4
DDAVP – desmopressin acetate
tab 0.2 mg
4
5
DDAVP – desmopressin acetate
nasal soln 0.01% (refrigerated)
4
GANIRELIX ACETATE – Benefit
Limits may apply – ganirelix
acetate inj 250 mcg/0.5ml
DDAVP – desmopressin acetate
nasal spray soln 0.01%
GONAL-F – Benefit Limits may
apply – follitropin alfa for inj 450
unit
5
4
26
• •
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
alendronate sodium tab 70 mg
(Fosamax)
Restricted Access
1
Prior Review
alendronate sodium tab 5 mg
Specialty
Drug Name
Drug Tier
2015
GONAL-F RFF – Benefit Limits
may apply – follitropin alfa for inj
75 unit
5
GONAL-F RFF PEN – Benefit
Limits may apply – follitropin alfa
inj 300 unit/0.5ml
5
GONAL-F RFF PEN – Benefit
Limits may apply – follitropin alfa
inj 450 unit/0.75ml
5
GONAL-F RFF PEN – Benefit
Limits may apply – follitropin alfa
inj 900 unit/1.5ml
5
GONAL-F RFF REDIJECT –
Benefit Limits may apply –
follitropin alfa inj 300 unit/0.5ml
5
GONAL-F RFF REDIJECT –
Benefit Limits may apply –
follitropin alfa inj 450 unit/0.75ml
5
GONAL-F RFF REDIJECT –
Benefit Limits may apply –
follitropin alfa inj 900 unit/1.5ml
5
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
2
levocarnitine oral soln
1 gm/10ml (10%) (Carnitor)
2
levocarnitine tab 330 mg
(Carnitor)
2
LUPRON DEPOT-PED – leuprolide 5
acetate for inj pediatric kit 7.5 mg
LUPRON DEPOT-PED – leuprolide 5
acetate for inj pediatric kit 11.25
mg
LUPRON DEPOT-PED – leuprolide 5
acetate for inj pediatric kit 15 mg
LUPRON DEPOT-PED – leuprolide 5
acetate (3 month) for inj pediatric
kit 11.25 mg
•
•
•
•
paricalcitol cap 2 mcg (Zemplar)
2
paricalcitol cap 4 mcg (Zemplar)
2
raloxifene hcl tab 60 mg (Evista)
2
REPRONEX – Benefit Limits may
apply – menotropins for inj 75
unit
5
risedronate sodium tab 150 mg
(Actonel)
2
ROCALTROL – calcitriol cap 0.25
mcg
4
ROCALTROL – calcitriol cap 0.5
mcg
4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
•
Restricted Access
LUPRON DEPOT-PED – leuprolide 5
acetate (3 month) for inj pediatric
kit 30 mg
5
MENOPUR – Benefit Limits
may apply – menotropins for
subcutaneous inj 75 unit
4
MIACALCIN – calcitonin (salmon)
nasal soln 200 unit/act
octreotide acetate inj 100 mcg/ml 2
(0.1 mg/ml) (Sandostatin)
2
octreotide acetate inj 1000 mcg/
ml (1 mg/ml) (Sandostatin)
octreotide acetate inj 200 mcg/ml 2
(0.2 mg/ml) (Sandostatin)
2
octreotide acetate inj 50 mcg/ml
(0.05 mg/ml) (Sandostatin)
octreotide acetate inj 500 mcg/ml 2
(0.5 mg/ml) (Sandostatin)
5
OMNITROPE – somatropin inj 5
mg/1.5ml
5
OMNITROPE – somatropin inj 10
mg/1.5ml
5
OMNITROPE – somatropin for inj
5.8 mg
5
OVIDREL – Benefit Limits may
apply – choriogonadotropin alfa
inj 250 mcg/0.5ml
2
paricalcitol cap 1 mcg (Zemplar)
Drug Name
Prior Review
Quantity Limits
Restricted Access
Prior Review
Specialty
5
Drug Tier
GONAL-F – Benefit Limits may
apply – follitropin alfa for inj 1050
unit
Specialty
Drug Name
Drug Tier
2015
•
•
•
•
•
• •
• •
• •
27
ROCALTROL – calcitriol oral soln 1 4
mcg/ml
5
SAMSCA – tolvaptan tab 15 mg
•
•
•
SAMSCA – tolvaptan tab 30 mg
5
SANDOSTATIN – octreotide
acetate inj 50 mcg/ml (0.05 mg/
ml)
4
SANDOSTATIN – octreotide
acetate inj 100 mcg/ml (0.1 mg/
ml)
4
SANDOSTATIN – octreotide
acetate inj 200 mcg/ml (0.2 mg/
ml)
4
•
SANDOSTATIN – octreotide
acetate inj 500 mcg/ml (0.5 mg/
ml)
4
•
SANDOSTATIN – octreotide
acetate inj 1000 mcg/ml (1 mg/
ml)
4
•
SENSIPAR – cinacalcet hcl tab 30
mg (base equiv)
4
•
SENSIPAR – cinacalcet hcl tab 60
mg (base equiv)
4
•
SENSIPAR – cinacalcet hcl tab 90
mg (base equiv)
4
•
SIGNIFOR – pasireotide
diaspartate inj 0.3 mg/ml (base
equiv)
5
•
SIGNIFOR – pasireotide
diaspartate inj 0.6 mg/ml (base
equiv)
5
•
SIGNIFOR – pasireotide
diaspartate inj 0.9 mg/ml (base
equiv)
5
•
sodium phenylbutyrate oral
powder 3 gm/teaspoonful
(Buphenyl)
2
•
ZEMPLAR – paricalcitol cap 1 mcg
4
ZEMPLAR – paricalcitol cap 2 mcg
4
CARDIOVASCULAR AGENTS
•
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
1
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
1
LANOXIN – digoxin tab 62.5 mcg
(0.0625 mg)
4
LANOXIN – digoxin tab 125 mcg
(0.125 mg)
4
LANOXIN – digoxin tab 187.5 mcg
(0.1875 mg)
4
LANOXIN – digoxin tab 250 mcg
(0.25 mg)
4
ANTIANGINAL AGENTS
ISORDIL TITRADOSE – isosorbide 4
dinitrate tab 5 mg
ISORDIL TITRADOSE – isosorbide 4
dinitrate tab 40 mg
1
ISOSORBIDE DINITRATE –
isosorbide dinitrate tab 30 mg
isosorbide dinitrate tab cr 40 mg 1
isosorbide dinitrate tab 10 mg
1
isosorbide dinitrate tab 20 mg
1
isosorbide dinitrate tab 5 mg
(Isordil titradose)
1
isosorbide mononitrate tab sr
24hr 120 mg (Imdur)
1
isosorbide mononitrate tab sr
24hr 30 mg (Imdur)
1
isosorbide mononitrate tab sr
24hr 60 mg (Imdur)
1
isosorbide mononitrate tab
10 mg
1
isosorbide mononitrate tab
20 mg
1
NITRO-BID – nitroglycerin oint 2%
1
NITRO-DUR – nitroglycerin td
patch 24hr 0.1 mg/hr
4
NITRO-DUR – nitroglycerin td
patch 24hr 0.2 mg/hr
4
CARDIOTONICS
28
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
NITRO-DUR – nitroglycerin td
patch 24hr 0.3 mg/hr
4
BETAPACE – sotalol hcl tab 120
mg
4
NITRO-DUR – nitroglycerin td
patch 24hr 0.4 mg/hr
4
BETAPACE – sotalol hcl tab 160
mg
4
NITRO-DUR – nitroglycerin td
patch 24hr 0.6 mg/hr
4
BETAPACE AF – sotalol hcl (afib/
afl) tab 80 mg
4
NITRO-DUR – nitroglycerin td
patch 24hr 0.8 mg/hr
4
BETAPACE AF – sotalol hcl (afib/
afl) tab 120 mg
4
nitroglycerin cap cr 2.5 mg
1
4
nitroglycerin cap cr 6.5 mg
1
BETAPACE AF – sotalol hcl (afib/
afl) tab 160 mg
nitroglycerin cap cr 9 mg
1
betaxolol hcl tab 10 mg (Kerlone)
1
nitroglycerin td patch 24hr
0.1 mg/hr (Nitro-dur)
1
betaxolol hcl tab 20 mg (Kerlone)
1
1
nitroglycerin td patch 24hr
0.2 mg/hr (Nitro-dur)
1
bisoprolol fumarate tab 10 mg
(Zebeta)
1
nitroglycerin td patch 24hr
0.4 mg/hr (Nitro-dur)
1
bisoprolol fumarate tab 5 mg
(Zebeta)
carvedilol tab 12.5 mg (Coreg)
1
nitroglycerin td patch 24hr
0.6 mg/hr (Nitro-dur)
1
carvedilol tab 25 mg (Coreg)
1
carvedilol tab 3.125 mg (Coreg)
1
NITROSTAT – nitroglycerin sl tab
0.3 mg
3
carvedilol tab 6.25 mg (Coreg)
1
3
COREG – carvedilol tab 3.125 mg
4
NITROSTAT – nitroglycerin sl tab
0.4 mg
COREG – carvedilol tab 6.25 mg
4
NITROSTAT – nitroglycerin sl tab
0.6 mg
3
COREG – carvedilol tab 12.5 mg
4
COREG – carvedilol tab 25 mg
4
RANEXA – ranolazine tab sr 12hr
500 mg
4
CORGARD – nadolol tab 20 mg
4
CORGARD – nadolol tab 40 mg
4
RANEXA – ranolazine tab sr 12hr
1000 mg
4
CORGARD – nadolol tab 80 mg
4
INDERAL LA – propranolol hcl cap
sr 24hr 60 mg
4
INDERAL LA – propranolol hcl cap
sr 24hr 80 mg
4
INDERAL LA – propranolol hcl cap
sr 24hr 120 mg
4
INDERAL LA – propranolol hcl cap
sr 24hr 160 mg
4
KERLONE – betaxolol hcl tab 10
mg
4
BETA BLOCKERS
acebutolol hcl cap 200 mg
(Sectral)
1
acebutolol hcl cap 400 mg
(Sectral)
1
atenolol tab 100 mg (Tenormin)
1
atenolol tab 25 mg (Tenormin)
1
atenolol tab 50 mg (Tenormin)
1
BETAPACE – sotalol hcl tab 80 mg 4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
29
1
labetalol hcl tab 100 mg
(Trandate)
labetalol hcl tab 200 mg
(Trandate)
1
labetalol hcl tab 300 mg
(Trandate)
1
LOPRESSOR – metoprolol tartrate
tab 50 mg
4
LOPRESSOR – metoprolol tartrate
tab 100 mg
4
metoprolol succinate tab sr 24hr
100 mg (Toprol xl)
1
metoprolol succinate tab sr 24hr
200 mg (Toprol xl)
1
sotalol hcl tab 160 mg (Betapace) 1
1
sotalol hcl tab 240 mg
metoprolol succinate tab sr 24hr
25 mg (Toprol xl)
1
sotalol hcl tab 80 mg (Betapace)
1
TENORMIN – atenolol tab 25 mg
4
metoprolol succinate tab sr 24hr
50 mg (Toprol xl)
1
TENORMIN – atenolol tab 50 mg
4
TENORMIN – atenolol tab 100 mg
4
metoprolol tartrate tab 100 mg
(Lopressor)
1
4
metoprolol tartrate tab 25 mg
1
TOPROL XL – metoprolol
succinate tab sr 24hr 25 mg
metoprolol tartrate tab 50 mg
(Lopressor)
TOPROL XL – metoprolol
succinate tab sr 24hr 50 mg
4
1
1
TOPROL XL – metoprolol
succinate tab sr 24hr 100 mg
4
nadolol tab 20 mg (Corgard)
nadolol tab 40 mg (Corgard)
1
4
nadolol tab 80 mg (Corgard)
1
TOPROL XL – metoprolol
succinate tab sr 24hr 200 mg
propranolol hcl cap sr 24hr
120 mg (Inderal la)
1
TRANDATE – labetalol hcl tab 100
mg
4
propranolol hcl cap sr 24hr
160 mg (Inderal la)
1
TRANDATE – labetalol hcl tab 200
mg
4
propranolol hcl cap sr 24hr
60 mg (Inderal la)
1
TRANDATE – labetalol hcl tab 300
mg
4
propranolol hcl cap sr 24hr
80 mg (Inderal la)
1
ZEBETA – bisoprolol fumarate tab
5 mg
4
propranolol hcl tab 10 mg
1
4
propranolol hcl tab 20 mg
1
ZEBETA – bisoprolol fumarate tab
10 mg
propranolol hcl tab 40 mg
1
30
SECTRAL – acebutolol hcl cap 200 4
mg
SECTRAL – acebutolol hcl cap 400 4
mg
1
sotalol hcl (afib/afl) tab 120 mg
(Betapace af)
1
sotalol hcl (afib/afl) tab 160 mg
(Betapace af)
1
sotalol hcl (afib/afl) tab 80 mg
(Betapace af)
sotalol hcl tab 120 mg (Betapace) 1
CALCIUM CHANNEL BLOCKERS
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
propranolol hcl tab 80 mg
1
Restricted Access
1
4
Prior Review
propranolol hcl tab 60 mg
KERLONE – betaxolol hcl tab 20
mg
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
ADALAT CC – nifedipine tab sr
24hr 30 mg
4
CARDIZEM LA – diltiazem hcl
coated beads tab sr 24hr 120 mg
4
ADALAT CC – nifedipine tab sr
24hr 60 mg
4
CARDIZEM LA – diltiazem hcl
coated beads tab sr 24hr 180 mg
4
ADALAT CC – nifedipine tab sr
24hr 90 mg
4
CARDIZEM LA – diltiazem hcl
coated beads tab sr 24hr 240 mg
4
amlodipine besylate tab 10 mg
(Norvasc)
1
CARDIZEM LA – diltiazem hcl
coated beads tab sr 24hr 300 mg
4
amlodipine besylate tab 2.5 mg
(Norvasc)
1
CARDIZEM LA – diltiazem hcl
coated beads tab sr 24hr 360 mg
4
amlodipine besylate tab 5 mg
(Norvasc)
1
CARDIZEM LA – diltiazem hcl
coated beads tab sr 24hr 420 mg
4
CALAN – verapamil hcl tab 80 mg
4
diltiazem hcl cap sr 12hr 120 mg
1
diltiazem hcl cap sr 12hr 60 mg
1
diltiazem hcl cap sr 12hr 90 mg
1
diltiazem hcl cap sr 24hr 120 mg
1
diltiazem hcl cap sr 24hr 180 mg
1
diltiazem hcl cap sr 24hr 240 mg
1
diltiazem hcl coated beads cap
sr 24hr 120 mg (Cardizem cd)
1
diltiazem hcl coated beads cap
sr 24hr 180 mg (Cardizem cd)
1
diltiazem hcl coated beads cap
sr 24hr 240 mg (Cardizem cd)
1
diltiazem hcl coated beads cap
sr 24hr 300 mg (Cardizem cd)
1
diltiazem hcl coated beads cap
sr 24hr 360 mg (Cardizem cd)
1
diltiazem hcl coated beads tab sr
24hr 180 mg (Cardizem la)
2
diltiazem hcl coated beads tab sr
24hr 240 mg (Cardizem la)
2
diltiazem hcl coated beads tab sr
24hr 300 mg (Cardizem la)
2
diltiazem hcl coated beads tab sr
24hr 360 mg (Cardizem la)
2
diltiazem hcl coated beads tab sr
24hr 420 mg (Cardizem la)
2
CALAN – verapamil hcl tab 120 mg 4
4
CALAN SR – verapamil hcl tab cr
120 mg
4
CALAN SR – verapamil hcl tab cr
180 mg
4
CALAN SR – verapamil hcl tab cr
240 mg
4
CARDIZEM – diltiazem hcl tab 30
mg
4
CARDIZEM – diltiazem hcl tab 60
mg
CARDIZEM – diltiazem hcl tab 120 4
mg
4
CARDIZEM CD – diltiazem hcl
coated beads cap sr 24hr 120
mg
4
CARDIZEM CD – diltiazem hcl
coated beads cap sr 24hr 180
mg
4
CARDIZEM CD – diltiazem hcl
coated beads cap sr 24hr 240
mg
4
CARDIZEM CD – diltiazem hcl
coated beads cap sr 24hr 300
mg
4
CARDIZEM CD – diltiazem hcl
coated beads cap sr 24hr 360
mg
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
31
diltiazem hcl extended release
beads cap sr 24hr 120 mg
(Tiazac)
1
diltiazem hcl extended release
beads cap sr 24hr 180 mg
(Tiazac)
1
diltiazem hcl extended release
beads cap sr 24hr 240 mg
(Tiazac)
1
diltiazem hcl extended release
beads cap sr 24hr 300 mg
(Tiazac)
1
diltiazem hcl extended release
beads cap sr 24hr 360 mg
(Tiazac)
1
diltiazem hcl extended release
beads cap sr 24hr 420 mg
(Tiazac)
1
diltiazem hcl tab 120 mg
(Cardizem)
nifedipine tab sr 24hr osmotic
60 mg (Procardia xl)
1
nifedipine tab sr 24hr osmotic
90 mg (Procardia xl)
1
nifedipine tab sr 24hr 30 mg
(Adalat cc)
1
nifedipine tab sr 24hr 60 mg
(Adalat cc)
1
nifedipine tab sr 24hr 90 mg
(Adalat cc)
1
nimodipine cap 30 mg
2
NISOLDIPINE – nisoldipine tab sr
24hr 40 mg
2
nisoldipine tab sr 24hr 17 mg
(Sular)
2
nisoldipine tab sr 24hr 34 mg
(Sular)
2
1
nisoldipine tab sr 24hr 8.5 mg
(Sular)
2
diltiazem hcl tab 30 mg
(Cardizem)
1
NORVASC – amlodipine besylate
tab 2.5 mg
4
diltiazem hcl tab 60 mg
(Cardizem)
1
NORVASC – amlodipine besylate
tab 5 mg
4
diltiazem hcl tab 90 mg
1
4
felodipine tab sr 24hr 10 mg
2
NORVASC – amlodipine besylate
tab 10 mg
felodipine tab sr 24hr 2.5 mg
2
5
felodipine tab sr 24hr 5 mg
2
NYMALIZE – nimodipine oral soln
60 mg/20ml
4
PROCARDIA – nifedipine cap 10
mg
4
ISOPTIN SR – verapamil hcl tab cr
120 mg
ISOPTIN SR – verapamil hcl tab cr
180 mg
4
ISOPTIN SR – verapamil hcl tab cr
240 mg
4
nicardipine hcl cap 20 mg
1
nicardipine hcl cap 30 mg
1
nifedipine cap 10 mg (Procardia)
2
nifedipine cap 20 mg
2
nifedipine tab sr 24hr osmotic
30 mg (Procardia xl)
1
32
• •
PROCARDIA XL – nifedipine tab sr 4
24hr osmotic 30 mg
PROCARDIA XL – nifedipine tab sr 4
24hr osmotic 60 mg
PROCARDIA XL – nifedipine tab sr 4
24hr osmotic 90 mg
4
SULAR – nisoldipine tab sr 24hr
8.5 mg
SULAR – nisoldipine tab sr 24hr 17 4
mg
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
SULAR – nisoldipine tab sr 24hr 34 4
mg
4
TIAZAC – diltiazem hcl extended
release beads cap sr 24hr 120
mg
4
TIAZAC – diltiazem hcl extended
release beads cap sr 24hr 180
mg
4
TIAZAC – diltiazem hcl extended
release beads cap sr 24hr 240
mg
4
TIAZAC – diltiazem hcl extended
release beads cap sr 24hr 300
mg
4
TIAZAC – diltiazem hcl extended
release beads cap sr 24hr 360
mg
4
TIAZAC – diltiazem hcl extended
release beads cap sr 24hr 420
mg
1
VERAPAMIL HCL – verapamil hcl
tab 40 mg
1
verapamil hcl cap sr 24hr
100 mg (Verelan pm)
1
verapamil hcl cap sr 24hr
120 mg (Verelan)
1
verapamil hcl cap sr 24hr
180 mg (Verelan)
1
verapamil hcl cap sr 24hr
200 mg (Verelan pm)
1
verapamil hcl cap sr 24hr
240 mg (Verelan)
1
verapamil hcl cap sr 24hr
300 mg (Verelan pm)
1
verapamil hcl cap sr 24hr
360 mg (Verelan)
1
verapamil hcl tab cr 120 mg
(Calan sr)
1
verapamil hcl tab cr 180 mg
(Calan sr)
verapamil hcl tab cr 240 mg
(Calan sr)
1
verapamil hcl tab 120 mg (Calan)
1
verapamil hcl tab 80 mg (Calan)
1
VERELAN – verapamil hcl cap sr
24hr 120 mg
4
VERELAN – verapamil hcl cap sr
24hr 180 mg
4
VERELAN – verapamil hcl cap sr
24hr 240 mg
4
VERELAN – verapamil hcl cap sr
24hr 360 mg
4
VERELAN PM – verapamil hcl cap
sr 24hr 100 mg
4
VERELAN PM – verapamil hcl cap
sr 24hr 200 mg
4
VERELAN PM – verapamil hcl cap
sr 24hr 300 mg
4
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
ANTIARRHYTHMICS
amiodarone hcl tab 100 mg
2
amiodarone hcl tab 200 mg
(Cordarone)
1
amiodarone hcl tab 400 mg
1
amiodarone hcl tab 400 mg
2
CORDARONE – amiodarone hcl
tab 200 mg
4
disopyramide phosphate cap
100 mg (Norpace)
1
disopyramide phosphate cap
150 mg (Norpace)
1
flecainide acetate tab 100 mg
1
flecainide acetate tab 150 mg
1
flecainide acetate tab 50 mg
1
mexiletine hcl cap 150 mg
2
mexiletine hcl cap 200 mg
2
mexiletine hcl cap 250 mg
2
NORPACE – disopyramide
phosphate cap 100 mg
4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
33
NORPACE – disopyramide
phosphate cap 150 mg
4
ACCUPRIL – quinapril hcl tab 40
mg
4
propafenone hcl cap sr 12hr
225 mg (Rythmol sr)
2
4
propafenone hcl cap sr 12hr
325 mg (Rythmol sr)
2
ACCURETIC – quinaprilhydrochlorothiazide tab 10-12.5
mg
4
propafenone hcl cap sr 12hr
425 mg (Rythmol sr)
2
ACCURETIC – quinaprilhydrochlorothiazide tab 20-12.5
mg
propafenone hcl tab 150 mg
(Rythmol)
1
ACCURETIC – quinaprilhydrochlorothiazide tab 20-25 mg
4
propafenone hcl tab 225 mg
(Rythmol)
1
ACEON – perindopril erbumine tab
4 mg
4
propafenone hcl tab 300 mg
1
4
quinidine gluconate tab cr
324 mg
2
ACEON – perindopril erbumine tab
8 mg
ALTACE – ramipril cap 1.25 mg
4
QUINIDINE SULFATE – quinidine
sulfate tab 200 mg
2
ALTACE – ramipril cap 2.5 mg
4
ALTACE – ramipril cap 5 mg
4
quinidine sulfate tab 300 mg
2
ALTACE – ramipril cap 10 mg
4
RYTHMOL – propafenone hcl tab
150 mg
4
amlodipine besylate-benazepril
hcl cap 10-20 mg (Lotrel)
2
RYTHMOL – propafenone hcl tab
225 mg
4
amlodipine besylate-benazepril
hcl cap 10-40 mg (Lotrel)
2
RYTHMOL SR – propafenone hcl
cap sr 12hr 225 mg
4
amlodipine besylate-benazepril
hcl cap 2.5-10 mg (Lotrel)
2
RYTHMOL SR – propafenone hcl
cap sr 12hr 325 mg
4
amlodipine besylate-benazepril
hcl cap 5-10 mg (Lotrel)
2
RYTHMOL SR – propafenone hcl
cap sr 12hr 425 mg
4
amlodipine besylate-benazepril
hcl cap 5-20 mg (Lotrel)
2
TIKOSYN – dofetilide cap 125 mcg
(0.125 mg)
4
amlodipine besylate-benazepril
hcl cap 5-40 mg (Lotrel)
2
TIKOSYN – dofetilide cap 250 mcg
(0.25 mg)
4
amlodipine besylate-valsartan
tab 10-160 mg (Exforge)
2
TIKOSYN – dofetilide cap 500 mcg
(0.5 mg)
4
amlodipine besylate-valsartan
tab 10-320 mg (Exforge)
2
amlodipine besylate-valsartan
tab 5-160 mg (Exforge)
2
amlodipine besylate-valsartan
tab 5-320 mg (Exforge)
2
ANTIHYPERTENSIVES
ACCUPRIL – quinapril hcl tab 5 mg 4
4
ACCUPRIL – quinapril hcl tab 10
mg
4
ACCUPRIL – quinapril hcl tab 20
mg
34
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
4
AVAPRO – irbesartan tab 300 mg
4
benazepril &
hydrochlorothiazide tab
10-12.5 mg (Lotensin hct)
1
benazepril &
hydrochlorothiazide tab
20-12.5 mg (Lotensin hct)
1
benazepril &
hydrochlorothiazide tab
20-25 mg (Lotensin hct)
1
benazepril &
hydrochlorothiazide tab
5-6.25 mg
1
benazepril hcl tab 10 mg
(Lotensin)
1
benazepril hcl tab 20 mg
(Lotensin)
1
benazepril hcl tab 40 mg
(Lotensin)
1
benazepril hcl tab 5 mg
1
bisoprolol & hydrochlorothiazide
tab 10-6.25 mg (Ziac)
1
bisoprolol & hydrochlorothiazide
tab 2.5-6.25 mg (Ziac)
1
bisoprolol & hydrochlorothiazide
tab 5-6.25 mg (Ziac)
1
candesartan cilexetil tab 16 mg
(Atacand)
2
amlodipine-valsartanhydrochlorothiazide tab
10-160-25 mg (Exforge hct)
2
amlodipine-valsartanhydrochlorothiazide tab
10-320-25 mg (Exforge hct)
2
amlodipine-valsartanhydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)
2
amlodipine-valsartanhydrochlorothiazide tab
5-160-25 mg (Exforge hct)
2
ATACAND – candesartan cilexetil
tab 4 mg
4
ATACAND – candesartan cilexetil
tab 8 mg
4
ATACAND – candesartan cilexetil
tab 16 mg
4
ATACAND – candesartan cilexetil
tab 32 mg
4
ATACAND HCT – candesartan
cilexetil-hydrochlorothiazide tab
16-12.5 mg
4
ATACAND HCT – candesartan
cilexetil-hydrochlorothiazide tab
32-12.5 mg
4
ATACAND HCT – candesartan
cilexetil-hydrochlorothiazide tab
32-25 mg
4
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
candesartan cilexetil tab 32 mg
(Atacand)
2
1
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
candesartan cilexetil tab 4 mg
(Atacand)
2
1
4
candesartan cilexetil tab 8 mg
(Atacand)
2
AVALIDE – irbesartanhydrochlorothiazide tab 150-12.5
mg
2
AVALIDE – irbesartanhydrochlorothiazide tab 300-12.5
mg
4
candesartan cilexetilhydrochlorothiazide tab
16-12.5 mg (Atacand hct)
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
AVAPRO – irbesartan tab 150 mg
Restricted Access
4
2
Prior Review
AVAPRO – irbesartan tab 75 mg
amlodipine-valsartanhydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
35
candesartan cilexetilhydrochlorothiazide tab
32-12.5 mg (Atacand hct)
2
candesartan cilexetilhydrochlorothiazide tab
32-25 mg (Atacand hct)
2
captopril tab 100 mg
1
captopril tab 12.5 mg
1
captopril tab 25 mg
1
captopril tab 50 mg
1
CAPTOPRIL/
HYDROCHLOROTHIA –
captopril & hydrochlorothiazide
tab 25-15 mg
1
CAPTOPRIL/
HYDROCHLOROTHIA –
captopril & hydrochlorothiazide
tab 25-25 mg
1
CAPTOPRIL/
HYDROCHLOROTHIA –
captopril & hydrochlorothiazide
tab 50-15 mg
1
CAPTOPRIL/
HYDROCHLOROTHIA –
captopril & hydrochlorothiazide
tab 50-25 mg
1
CARDURA – doxazosin mesylate
tab 1 mg
CATAPRES-TTS-1 – clonidine hcl
td patch weekly 0.1 mg/24hr
4
CATAPRES-TTS-2 – clonidine hcl
td patch weekly 0.2 mg/24hr
4
CATAPRES-TTS-3 – clonidine hcl
td patch weekly 0.3 mg/24hr
4
clonidine hcl tab 0.1 mg
(Catapres)
1
clonidine hcl tab 0.2 mg
(Catapres)
1
clonidine hcl tab 0.3 mg
(Catapres)
1
clonidine hcl td patch weekly
0.1 mg/24hr (Catapres-tts-1)
2
clonidine hcl td patch weekly
0.2 mg/24hr (Catapres-tts-2)
2
clonidine hcl td patch weekly
0.3 mg/24hr (Catapres-tts-3)
2
CORZIDE – nadolol &
bendroflumethiazide tab 40-5 mg
4
CORZIDE – nadolol &
bendroflumethiazide tab 80-5 mg
4
COZAAR – losartan potassium tab
25 mg
4
4
4
COZAAR – losartan potassium tab
50 mg
4
CARDURA – doxazosin mesylate
tab 2 mg
4
COZAAR – losartan potassium tab
100 mg
DIOVAN – valsartan tab 40 mg
4
CARDURA – doxazosin mesylate
tab 4 mg
4
DIOVAN – valsartan tab 80 mg
4
DIOVAN – valsartan tab 160 mg
4
CARDURA – doxazosin mesylate
tab 8 mg
4
DIOVAN – valsartan tab 320 mg
4
4
CATAPRES – clonidine hcl tab 0.2
mg
4
DIOVAN HCT – valsartanhydrochlorothiazide tab 80-12.5
mg
4
CATAPRES – clonidine hcl tab 0.1
mg
4
CATAPRES – clonidine hcl tab 0.3
mg
4
DIOVAN HCT – valsartanhydrochlorothiazide tab 160-12.5
mg
36
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
4
DIOVAN HCT – valsartanhydrochlorothiazide tab 320-12.5
mg
4
DIOVAN HCT – valsartanhydrochlorothiazide tab 320-25
mg
4
doxazosin mesylate tab 1 mg
(Cardura)
1
doxazosin mesylate tab 2 mg
(Cardura)
1
doxazosin mesylate tab 4 mg
(Cardura)
1
doxazosin mesylate tab 8 mg
(Cardura)
1
DUTOPROL – metoprolol &
hydrochlorothiazide tab sr 24hr
25-12.5 mg
3
DUTOPROL – metoprolol &
hydrochlorothiazide tab sr 24hr
50-12.5 mg
3
DUTOPROL – metoprolol &
hydrochlorothiazide tab sr 24hr
100-12.5 mg
3
enalapril maleate &
hydrochlorothiazide tab
10-25 mg (Vaseretic)
1
enalapril maleate &
hydrochlorothiazide tab
5-12.5 mg
1
enalapril maleate tab 10 mg
(Vasotec)
1
enalapril maleate tab 2.5 mg
(Vasotec)
1
enalapril maleate tab 20 mg
(Vasotec)
1
enalapril maleate tab 5 mg
(Vasotec)
1
eplerenone tab 25 mg (Inspra)
2
2
EXFORGE – amlodipine besylatevalsartan tab 5-160 mg
4
EXFORGE – amlodipine besylatevalsartan tab 5-320 mg
4
EXFORGE – amlodipine besylatevalsartan tab 10-160 mg
4
EXFORGE – amlodipine besylatevalsartan tab 10-320 mg
4
EXFORGE HCT – amlodipinevalsartan-hydrochlorothiazide tab
5-160-12.5 mg
4
EXFORGE HCT – amlodipinevalsartan-hydrochlorothiazide tab
5-160-25 mg
4
EXFORGE HCT – amlodipinevalsartan-hydrochlorothiazide tab
10-160-12.5 mg
4
EXFORGE HCT – amlodipinevalsartan-hydrochlorothiazide tab
10-160-25 mg
4
EXFORGE HCT – amlodipinevalsartan-hydrochlorothiazide tab
10-320-25 mg
4
fosinopril sodium &
hydrochlorothiazide tab
10-12.5 mg
1
fosinopril sodium &
hydrochlorothiazide tab
20-12.5 mg
1
fosinopril sodium tab 10 mg
1
fosinopril sodium tab 20 mg
1
fosinopril sodium tab 40 mg
1
guanfacine hcl tab 1 mg (Tenex)
1
guanfacine hcl tab 2 mg (Tenex)
1
hydralazine hcl tab 10 mg
1
hydralazine hcl tab 100 mg
1
hydralazine hcl tab 25 mg
1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
eprosartan mesylate tab 600 mg
(Teveten)
Restricted Access
2
Prior Review
eplerenone tab 50 mg (Inspra)
Specialty
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
DIOVAN HCT – valsartanhydrochlorothiazide tab 160-25
mg
Specialty
Drug Name
Drug Tier
2015
37
1
4
losartan potassium &
hydrochlorothiazide tab
100-25 mg (Hyzaar)
1
HYZAAR – losartan potassium &
hydrochlorothiazide tab 100-12.5
mg
4
losartan potassium &
hydrochlorothiazide tab
50-12.5 mg (Hyzaar)
1
HYZAAR – losartan potassium &
hydrochlorothiazide tab 100-25
mg
4
losartan potassium tab 100 mg
(Cozaar)
losartan potassium tab 25 mg
(Cozaar)
1
INSPRA – eplerenone tab 25 mg
4
1
INSPRA – eplerenone tab 50 mg
4
losartan potassium tab 50 mg
(Cozaar)
irbesartan tab 150 mg (Avapro)
2
4
irbesartan tab 300 mg (Avapro)
2
LOTENSIN – benazepril hcl tab 10
mg
2
LOTENSIN – benazepril hcl tab 20
mg
4
irbesartan tab 75 mg (Avapro)
irbesartan-hydrochlorothiazide
tab 150-12.5 mg (Avalide)
2
LOTENSIN – benazepril hcl tab 40
mg
4
irbesartan-hydrochlorothiazide
tab 300-12.5 mg (Avalide)
2
4
lisinopril & hydrochlorothiazide
tab 10-12.5 mg (Zestoretic)
1
LOTENSIN HCT – benazepril &
hydrochlorothiazide tab 10-12.5
mg
lisinopril & hydrochlorothiazide
tab 20-12.5 mg (Zestoretic)
LOTENSIN HCT – benazepril &
hydrochlorothiazide tab 20-12.5
mg
4
1
lisinopril & hydrochlorothiazide
tab 20-25 mg (Zestoretic)
1
LOTENSIN HCT – benazepril &
hydrochlorothiazide tab 20-25 mg
4
lisinopril tab 10 mg (Prinivil)
1
4
lisinopril tab 2.5 mg (Zestril)
1
LOTREL – amlodipine besylatebenazepril hcl cap 2.5-10 mg
lisinopril tab 20 mg (Prinivil)
1
4
lisinopril tab 30 mg (Zestril)
1
LOTREL – amlodipine besylatebenazepril hcl cap 5-10 mg
1
LOTREL – amlodipine besylatebenazepril hcl cap 5-20 mg
4
lisinopril tab 40 mg (Zestril)
lisinopril tab 5 mg (Prinivil)
1
4
LOPRESSOR HCT – metoprolol &
hydrochlorothiazide tab 50-25 mg
4
LOTREL – amlodipine besylatebenazepril hcl cap 5-40 mg
4
LOPRESSOR HCT – metoprolol &
hydrochlorothiazide tab 100-25
mg
4
LOTREL – amlodipine besylatebenazepril hcl cap 10-20 mg
LOTREL – amlodipine besylatebenazepril hcl cap 10-40 mg
4
losartan potassium &
hydrochlorothiazide tab
100-12.5 mg (Hyzaar)
1
MAVIK – trandolapril tab 1 mg
4
MAVIK – trandolapril tab 2 mg
4
38
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
HYZAAR – losartan potassium &
hydrochlorothiazide tab 50-12.5
mg
Restricted Access
1
Prior Review
hydralazine hcl tab 50 mg
Specialty
Drug Name
Drug Tier
2015
METHYLDOPA/
HYDROCHLOROTHI
– methyldopa &
hydrochlorothiazide tab 250-25
mg
1
metoprolol &
hydrochlorothiazide tab
100-25 mg (Lopressor hct)
1
metoprolol &
hydrochlorothiazide tab
100-50 mg
1
metoprolol &
hydrochlorothiazide tab
50-25 mg (Lopressor hct)
1
MICARDIS – telmisartan tab 20 mg 4
MICARDIS – telmisartan tab 40 mg 4
MICARDIS – telmisartan tab 80 mg 4
4
MICARDIS HCT – telmisartanhydrochlorothiazide tab 40-12.5
mg
4
MICARDIS HCT – telmisartanhydrochlorothiazide tab 80-12.5
mg
4
MICARDIS HCT – telmisartanhydrochlorothiazide tab 80-25 mg
4
MINIPRESS – prazosin hcl cap 1
mg
4
MINIPRESS – prazosin hcl cap 2
mg
4
MINIPRESS – prazosin hcl cap 5
mg
1
minoxidil tab 10 mg
minoxidil tab 2.5 mg
Quantity Limits
1
Restricted Access
METHYLDOPA/
HYDROCHLOROTHI
– methyldopa &
hydrochlorothiazide tab 250-15
mg
Prior Review
1
Specialty
methyldopa tab 500 mg
Drug Name
Drug Tier
1
Quantity Limits
methyldopa tab 250 mg
Restricted Access
4
Prior Review
MAVIK – trandolapril tab 4 mg
Specialty
Drug Name
Drug Tier
2015
moexipril hcl tab 15 mg (Univasc) 1
1
moexipril hcl tab 7.5 mg
(Univasc)
1
moexipril-hydrochlorothiazide
tab 15-12.5 mg (Uniretic)
1
moexipril-hydrochlorothiazide
tab 15-25 mg
1
moexipril-hydrochlorothiazide
tab 7.5-12.5 mg
2
nadolol & bendroflumethiazide
tab 40-5 mg (Corzide)
2
nadolol & bendroflumethiazide
tab 80-5 mg (Corzide)
1
perindopril erbumine tab 2 mg
perindopril erbumine tab 4 mg
(Aceon)
1
perindopril erbumine tab 8 mg
(Aceon)
1
prazosin hcl cap 1 mg (Minipress) 1
prazosin hcl cap 2 mg (Minipress) 1
prazosin hcl cap 5 mg (Minipress) 1
4
PRINIVIL – lisinopril tab 5 mg
PRINIVIL – lisinopril tab 10 mg
4
PRINIVIL – lisinopril tab 20 mg
4
PROPRANOLOL/
HYDROCHLOROTH
– propranolol &
hydrochlorothiazide tab 40-25 mg
1
PROPRANOLOL/
HYDROCHLOROTH
– propranolol &
hydrochlorothiazide tab 80-25 mg
1
quinapril hcl tab 10 mg (Accupril)
1
quinapril hcl tab 20 mg (Accupril)
1
quinapril hcl tab 40 mg (Accupril)
1
quinapril hcl tab 5 mg (Accupril)
1
quinapril-hydrochlorothiazide
tab 10-12.5 mg (Accuretic)
1
1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
39
1
trandolapril tab 2 mg (Mavik)
1
trandolapril tab 4 mg (Mavik)
1
TWYNSTA – telmisartanamlodipine tab 40-5 mg
4
TWYNSTA – telmisartanamlodipine tab 40-10 mg
4
quinapril-hydrochlorothiazide
tab 20-25 mg (Accuretic)
ramipril cap 1.25 mg (Altace)
1
ramipril cap 10 mg (Altace)
1
ramipril cap 2.5 mg (Altace)
1
ramipril cap 5 mg (Altace)
1
RESERPINE – reserpine tab 0.1
mg
3
TWYNSTA – telmisartanamlodipine tab 80-5 mg
4
RESERPINE – reserpine tab 0.25
mg
3
TWYNSTA – telmisartanamlodipine tab 80-10 mg
4
telmisartan tab 20 mg (Micardis)
2
valsartan tab 160 mg (Diovan)
2
telmisartan tab 40 mg (Micardis)
2
valsartan tab 320 mg (Diovan)
2
telmisartan tab 80 mg (Micardis)
2
valsartan tab 40 mg (Diovan)
2
telmisartan-amlodipine tab
40-10 mg (Twynsta)
2
valsartan tab 80 mg (Diovan)
2
telmisartan-amlodipine tab
40-5 mg (Twynsta)
valsartan-hydrochlorothiazide
tab 160-12.5 mg (Diovan hct)
2
2
telmisartan-amlodipine tab
80-10 mg (Twynsta)
valsartan-hydrochlorothiazide
tab 160-25 mg (Diovan hct)
2
2
telmisartan-amlodipine tab
80-5 mg (Twynsta)
valsartan-hydrochlorothiazide
tab 320-12.5 mg (Diovan hct)
2
2
2
valsartan-hydrochlorothiazide
tab 320-25 mg (Diovan hct)
2
telmisartan-hydrochlorothiazide
tab 40-12.5 mg (Micardis hct)
2
valsartan-hydrochlorothiazide
tab 80-12.5 mg (Diovan hct)
2
telmisartan-hydrochlorothiazide
tab 80-12.5 mg (Micardis hct)
telmisartan-hydrochlorothiazide
tab 80-25 mg (Micardis hct)
VASERETIC – enalapril maleate &
hydrochlorothiazide tab 10-25 mg
4
2
TENEX – guanfacine hcl tab 1 mg
VASOTEC – enalapril maleate tab
2.5 mg
4
4
TENEX – guanfacine hcl tab 2 mg
4
4
TENORETIC 100 – atenolol &
chlorthalidone tab 100-25 mg
4
VASOTEC – enalapril maleate tab
5 mg
4
TENORETIC 50 – atenolol &
chlorthalidone tab 50-25 mg
4
VASOTEC – enalapril maleate tab
10 mg
4
terazosin hcl cap 1 mg
1
VASOTEC – enalapril maleate tab
20 mg
terazosin hcl cap 10 mg
1
4
terazosin hcl cap 2 mg
1
ZESTORETIC – lisinopril &
hydrochlorothiazide tab 10-12.5
mg
40
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
trandolapril tab 1 mg (Mavik)
1
Restricted Access
1
1
Prior Review
terazosin hcl cap 5 mg
quinapril-hydrochlorothiazide
tab 20-12.5 mg (Accuretic)
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
4
ZESTORETIC – lisinopril &
hydrochlorothiazide tab 20-25 mg
4
ZESTRIL – lisinopril tab 2.5 mg
4
ZESTRIL – lisinopril tab 5 mg
4
ZESTRIL – lisinopril tab 10 mg
4
ZESTRIL – lisinopril tab 20 mg
4
ZESTRIL – lisinopril tab 30 mg
4
ZESTRIL – lisinopril tab 40 mg
4
ZIAC – bisoprolol &
hydrochlorothiazide tab 2.5-6.25
mg
4
ZIAC – bisoprolol &
hydrochlorothiazide tab 5-6.25
mg
4
ZIAC – bisoprolol &
hydrochlorothiazide tab 10-6.25
mg
4
DIURETICS
ACETAZOLAMIDE –
acetazolamide tab 125 mg
1
acetazolamide cap sr 12hr
500 mg (Diamox)
2
acetazolamide sodium for inj
500 mg
2
acetazolamide tab 250 mg
1
ALDACTAZIDE – spironolactone &
hydrochlorothiazide tab 25-25 mg
4
ALDACTAZIDE – spironolactone &
hydrochlorothiazide tab 50-50 mg
4
ALDACTONE – spironolactone tab
25 mg
1
bumetanide tab 1 mg
1
bumetanide tab 2 mg
1
CHLOROTHIAZIDE –
chlorothiazide tab 250 mg
1
chlorothiazide tab 500 mg
1
CHLORTHALIDONE –
chlorthalidone tab 25 mg
1
CHLORTHALIDONE –
chlorthalidone tab 50 mg
1
CHLORTHALIDONE –
chlorthalidone tab 100 mg
4
DEMADEX – torsemide tab 5 mg
4
DEMADEX – torsemide tab 10 mg
4
DEMADEX – torsemide tab 20 mg
4
Quantity Limits
bumetanide tab 0.5 mg
Restricted Access
1
Prior Review
amiloride hcl tab 5 mg
Specialty
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
ZESTORETIC – lisinopril &
hydrochlorothiazide tab 20-12.5
mg
Specialty
Drug Name
Drug Tier
2015
DEMADEX – torsemide tab 100 mg 4
4
DIAMOX – acetazolamide cap sr
12hr 500 mg
4
DYAZIDE – triamterene &
hydrochlorothiazide cap 37.5-25
mg
4
DYRENIUM – triamterene cap 50
mg
DYRENIUM – triamterene cap 100 4
mg
3
FUROSEMIDE – furosemide oral
soln 8 mg/ml
1
furosemide oral soln 10 mg/ml
furosemide tab 20 mg (Lasix)
1
furosemide tab 40 mg (Lasix)
1
4
furosemide tab 80 mg (Lasix)
1
4
hydrochlorothiazide cap 12.5 mg
(Microzide)
1
ALDACTONE – spironolactone tab
50 mg
hydrochlorothiazide tab 12.5 mg
2
ALDACTONE – spironolactone tab
100 mg
4
hydrochlorothiazide tab 25 mg
1
1
hydrochlorothiazide tab 50 mg
1
amiloride & hydrochlorothiazide
tab 5-50 mg
indapamide tab 1.25 mg
1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
41
MAXZIDE – triamterene &
hydrochlorothiazide tab 75-50 mg
4
MAXZIDE-25 – triamterene &
hydrochlorothiazide tab 37.5-25
mg
4
methazolamide tab 25 mg
(Neptazane)
2
methazolamide tab 50 mg
(Neptazane)
2
metolazone tab 10 mg
1
metolazone tab 2.5 mg
(Zaroxolyn)
1
metolazone tab 5 mg (Zaroxolyn)
1
MICROZIDE – hydrochlorothiazide
cap 12.5 mg
4
NEPTAZANE – methazolamide tab
25 mg
4
NEPTAZANE – methazolamide tab
50 mg
4
spironolactone &
hydrochlorothiazide tab
25-25 mg (Aldactazide)
1
spironolactone tab 100 mg
(Aldactone)
1
spironolactone tab 25 mg
(Aldactone)
1
spironolactone tab 50 mg
(Aldactone)
1
torsemide tab 10 mg (Demadex)
1
torsemide tab 100 mg (Demadex)
1
torsemide tab 20 mg (Demadex)
1
torsemide tab 5 mg (Demadex)
1
triamterene &
hydrochlorothiazide cap
37.5-25 mg (Dyazide)
1
42
triamterene &
hydrochlorothiazide tab
75-50 mg (Maxzide)
1
VASOPRESSORS
ADRENALIN – epinephrine inj 1
mg/ml (1:1000)
4
ADRENALIN – epinephrine inj 30
mg/30ml (1 mg/ml) (1:1000)
4
EPINEPHRINE – epinephrine
solution auto-injector 0.15
mg/0.15ml (1:1000)
4
EPINEPHRINE – epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
4
EPIPEN 2-PAK – epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
3
EPIPEN-JR 2-PAK – epinephrine
solution auto-injector 0.15
mg/0.3ml (1:2000)
3
midodrine hcl tab 10 mg
1
midodrine hcl tab 2.5 mg
1
midodrine hcl tab 5 mg
1
ANTIHYPERLIPIDEMICS
ANTARA – fenofibrate micronized
cap 30 mg
4
ANTARA – fenofibrate micronized
cap 90 mg
4
atorvastatin calcium tab 10 mg
(base equivalent) (Lipitor)
2
atorvastatin calcium tab 20 mg
(base equivalent) (Lipitor)
2
atorvastatin calcium tab 40 mg
(base equivalent) (Lipitor)
2
atorvastatin calcium tab 80 mg
(base equivalent) (Lipitor)
2
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
4
Restricted Access
LASIX – furosemide tab 80 mg
1
Prior Review
4
triamterene &
hydrochlorothiazide tab
37.5-25 mg (Maxzide-25)
Specialty
LASIX – furosemide tab 40 mg
Drug Name
Drug Tier
4
Quantity Limits
LASIX – furosemide tab 20 mg
Restricted Access
1
Prior Review
indapamide tab 2.5 mg
Specialty
Drug Name
Drug Tier
2015
cholestyramine light powder
packets 4 gm
2
fenofibrate micronized cap
134 mg (Lofibra)
1
cholestyramine light powder
4 gm/dose (Questran light)
2
fenofibrate micronized cap
200 mg (Lofibra)
1
cholestyramine powder packets
4 gm (Questran)
2
fenofibrate micronized cap
43 mg
2
cholestyramine powder 4 gm/
dose (Questran)
2
fenofibrate micronized cap
67 mg (Lofibra)
1
choline fenofibrate cap dr
135 mg (fenofibric acid equiv)
(Trilipix)
2
fenofibrate tab 145 mg (Tricor)
2
fenofibrate tab 160 mg (Lofibra)
1
2
fenofibrate tab 48 mg (Tricor)
2
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
fenofibrate tab 54 mg (Lofibra)
1
COLESTID – colestipol hcl tab 1
gm
4
fluvastatin sodium cap 20 mg
(Lescol)
2
COLESTID – colestipol hcl
granules 5 gm
4
fluvastatin sodium cap 40 mg
(Lescol)
2
COLESTID – colestipol hcl granule
packets 5 gm
4
gemfibrozil tab 600 mg (Lopid)
1
4
COLESTID FLAVORED –
colestipol hcl granules 5 gm
4
LESCOL – fluvastatin sodium cap
20 mg
4
COLESTID FLAVORED –
colestipol hcl granule packets 5
gm
4
LESCOL – fluvastatin sodium cap
40 mg
LIPITOR – atorvastatin calcium tab
10 mg (base equivalent)
4
colestipol hcl granule packets
5 gm (Colestid flavored)
2
LIPITOR – atorvastatin calcium tab
20 mg (base equivalent)
4
colestipol hcl granules 5 gm
(Colestid flavored)
2
LIPITOR – atorvastatin calcium tab
40 mg (base equivalent)
4
colestipol hcl tab 1 gm (Colestid)
2
4
CRESTOR – rosuvastatin calcium
tab 5 mg
3
LIPITOR – atorvastatin calcium tab
80 mg (base equivalent)
LOFIBRA – fenofibrate tab 54 mg
4
CRESTOR – rosuvastatin calcium
tab 10 mg
3
LOFIBRA – fenofibrate tab 160 mg
4
CRESTOR – rosuvastatin calcium
tab 20 mg
LOFIBRA – fenofibrate micronized
cap 67 mg
4
3
3
LOFIBRA – fenofibrate micronized
cap 134 mg
4
CRESTOR – rosuvastatin calcium
tab 40 mg
2
LOFIBRA – fenofibrate micronized
cap 200 mg
4
fenofibrate micronized cap
130 mg
LOPID – gemfibrozil tab 600 mg
4
lovastatin tab 10 mg
1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
43
lovastatin tab 40 mg (Mevacor)
1
simvastatin tab 5 mg (Zocor)
1
MEVACOR – lovastatin tab 40 mg
4
simvastatin tab 80 mg (Zocor)
1
niacin tab cr 1000 mg
(antihyperlipidemic) (Niaspan)
2
TRICOR – fenofibrate tab 48 mg
4
TRICOR – fenofibrate tab 145 mg
4
niacin tab cr 500 mg
(antihyperlipidemic) (Niaspan)
2
TRILIPIX – choline fenofibrate cap
dr 45 mg (fenofibric acid equiv)
4
niacin tab cr 750 mg
(antihyperlipidemic) (Niaspan)
2
TRILIPIX – choline fenofibrate cap
dr 135 mg (fenofibric acid equiv)
4
NIACOR – niacin
(antihyperlipidemic) tab 500 mg
1
ZETIA – ezetimibe tab 10 mg
4
4
ZOCOR – simvastatin tab 5 mg
4
NIASPAN – niacin tab cr 500 mg
(antihyperlipidemic)
ZOCOR – simvastatin tab 10 mg
4
NIASPAN – niacin tab cr 750 mg
(antihyperlipidemic)
4
ZOCOR – simvastatin tab 20 mg
4
ZOCOR – simvastatin tab 40 mg
4
NIASPAN – niacin tab cr 1000 mg
(antihyperlipidemic)
4
ZOCOR – simvastatin tab 80 mg
4
PRAVACHOL – pravastatin sodium 4
tab 20 mg
PRAVACHOL – pravastatin sodium 4
tab 40 mg
PRAVACHOL – pravastatin sodium 4
tab 80 mg
1
pravastatin sodium tab 10 mg
pravastatin sodium tab 20 mg
(Pravachol)
1
pravastatin sodium tab 40 mg
(Pravachol)
1
pravastatin sodium tab 80 mg
(Pravachol)
1
QUESTRAN – cholestyramine
powder 4 gm/dose
4
QUESTRAN – cholestyramine
powder packets 4 gm
4
QUESTRAN LIGHT –
cholestyramine light powder 4
gm/dose
4
simvastatin tab 10 mg (Zocor)
1
simvastatin tab 20 mg (Zocor)
1
44
CARDIOVASCULAR AGENTS - MISC.
amlodipine besylate-atorvastatin 2
calcium tab 10-10 mg (Caduet)
amlodipine besylate-atorvastatin 2
calcium tab 10-20 mg (Caduet)
amlodipine besylate-atorvastatin 2
calcium tab 10-40 mg (Caduet)
amlodipine besylate-atorvastatin 2
calcium tab 10-80 mg (Caduet)
amlodipine besylate-atorvastatin 2
calcium tab 2.5-10 mg (Caduet)
amlodipine besylate-atorvastatin 2
calcium tab 2.5-20 mg (Caduet)
amlodipine besylate-atorvastatin 2
calcium tab 2.5-40 mg (Caduet)
amlodipine besylate-atorvastatin 2
calcium tab 5-10 mg (Caduet)
amlodipine besylate-atorvastatin 2
calcium tab 5-20 mg (Caduet)
amlodipine besylate-atorvastatin 2
calcium tab 5-40 mg (Caduet)
amlodipine besylate-atorvastatin 2
calcium tab 5-80 mg (Caduet)
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
1
Restricted Access
simvastatin tab 40 mg (Zocor)
Prior Review
1
Specialty
Drug Tier
Quantity Limits
Restricted Access
lovastatin tab 20 mg (Mevacor)
Prior Review
Drug Name
Specialty
Drug Name
Drug Tier
2015
BIDIL – isosorbide dinitratehydralazine hcl tab 20-37.5 mg
4
VIAGRA – Benefit Limits may apply
– sildenafil citrate tab 25 mg
3
CADUET – amlodipine besylateatorvastatin calcium tab 2.5-10
mg
4
VIAGRA – Benefit Limits may apply
– sildenafil citrate tab 50 mg
3
CADUET – amlodipine besylateatorvastatin calcium tab 2.5-20
mg
VIAGRA – Benefit Limits may apply
– sildenafil citrate tab 100 mg
3
4
CADUET – amlodipine besylateatorvastatin calcium tab 2.5-40
mg
4
CADUET – amlodipine besylateatorvastatin calcium tab 5-10 mg
Quantity Limits
Restricted Access
Prior Review
RESPIRATORY AGENTS
ANTIHISTAMINES
brompheniramine maleate tab sr
12hr 6 mg
1
4
carbinoxamine maleate soln
4 mg/5ml
1
CADUET – amlodipine besylateatorvastatin calcium tab 5-20 mg
4
carbinoxamine maleate tab 4 mg
1
4
CADUET – amlodipine besylateatorvastatin calcium tab 5-40 mg
4
CLARINEX – desloratadine tab 5
mg
4
CADUET – amlodipine besylateatorvastatin calcium tab 5-80 mg
4
CLARINEX REDITABS –
desloratadine tab orally
disintegrating 2.5 mg
CADUET – amlodipine besylateatorvastatin calcium tab 10-10
mg
4
CLARINEX REDITABS –
desloratadine tab orally
disintegrating 5 mg
4
CADUET – amlodipine besylateatorvastatin calcium tab 10-20
mg
4
cyproheptadine hcl syrup
2 mg/5ml
1
cyproheptadine hcl tab 4 mg
1
CADUET – amlodipine besylateatorvastatin calcium tab 10-40
mg
4
desloratadine tab orally
disintegrating 2.5 mg (Clarinex
reditabs)
2
CADUET – amlodipine besylateatorvastatin calcium tab 10-80
mg
4
desloratadine tab orally
disintegrating 5 mg (Clarinex
reditabs)
2
OPSUMIT – macitentan tab 10 mg
4
desloratadine tab 5 mg (Clarinex)
2
REVATIO – sildenafil citrate tab 20
mg
5
• •
• •
2
sildenafil citrate tab 20 mg
(Revatio)
5
• •
levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
(Xyzal)
2
TRACLEER – bosentan tab 62.5
mg
4
• •
levocetirizine dihydrochloride
tab 5 mg (Xyzal)
1
TRACLEER – bosentan tab 125
mg
4
• •
promethazine hcl suppos
12.5 mg
promethazine hcl suppos 25 mg
1
promethazine hcl suppos 50 mg
1
ERECTLIE DYSFUNCTION
Specialty
Drug Name
Drug Tier
Quantity Limits
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Drug Name
Drug Tier
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45
promethazine hcl syrup
6.25 mg/5ml
1
OMNARIS – ciclesonide nasal
susp 50 mcg/act
4
promethazine hcl tab 12.5 mg
1
4
promethazine hcl tab 25 mg
1
promethazine hcl tab 50 mg
1
QNASL – beclomethasone
dipropionate nasal aerosol 80
mcg/act
4
QNASL CHILDRENS –
beclomethasone dipropionate
nasal aerosol 40 mcg/act
4
XYZAL – levocetirizine
dihydrochloride tab 5 mg
XYZAL – levocetirizine
dihydrochloride soln 2.5 mg/5ml
(0.5 mg/ml)
4
RHINOCORT AQUA – budesonide
nasal susp 32 mcg/act
4
triamcinolone acetonide nasal
aerosol suspension 55 mcg/act
(Nasacort aq)
2
VERAMYST – fluticasone furoate
nasal susp 27.5 mcg/spray
4
ZETONNA – ciclesonide nasal
aerosol soln 37 mcg/act (50 mcg/
valve)
4
NASAL AGENTS - SYSTEMIC and TOPICAL
ATROVENT – ipratropium bromide 4
nasal soln 0.03% (21 mcg/spray)
ATROVENT – ipratropium bromide 4
nasal soln 0.06% (42 mcg/spray)
2
azelastine hcl nasal spray
137 mcg/spray (1 mg/ml)
2
budesonide nasal susp 32 mcg/
act (Rhinocort aqua)
4
DYMISTA – azelastine hclfluticasone prop nasal spray
137-50 mcg/act
FLONASE – fluticasone propionate 4
nasal susp 50 mcg/act
4
FLUNISOLIDE – flunisolide nasal
soln 25 mcg/act (0.025%)
flunisolide nasal soln 25 mcg/act 2
(0.025%) (Flunisolide)
1
fluticasone propionate nasal
susp 50 mcg/act (Flonase)
1
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
1
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
4
NASACORT AQ – triamcinolone
acetonide nasal aerosol
suspension 55 mcg/act
NASONEX – mometasone furoate 3
nasal susp 50 mcg/act
46
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10%
2
acetylcysteine inhal soln 20%
2
benzonatate cap 100 mg
(Tessalon perles)
1
benzonatate cap 200 mg
1
2
hydrocod polst-chlorphen polst
cr susp 10-8 mg/5ml (Tussionex
pennkineti)
1
hydrocodone w/ homatropine
syrup 5-1.5 mg/5ml
1
hydrocodone w/ homatropine
tab 5-1.5 mg
4
HYPER-SAL – sodium chloride
soln nebu 7%
HYPERSAL – sodium chloride soln 4
nebu 7%
2
PROMETHAZINE VC PLAIN –
promethazine & phenylephrine
syrup 6.25-5 mg/5ml
PROMETHAZINE VC/CODEINE – 2
phenylephrine-promethazine w/
codeine syrup 5-6.25-10 mg/5ml
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
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Specialty
Drug Tier
2015
promethazine w/ codeine syrup
6.25-10 mg/5ml
2
albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
1
promethazine-dm syrup
6.25-15 mg/5ml
2
albuterol sulfate soln nebu
1.25 mg/3ml (base equiv)
1
sodium chloride soln nebu 0.9%
1
albuterol sulfate syrup 2 mg/5ml
1
sodium chloride soln nebu 3%
1
1
sodium chloride soln nebu 7%
(Hyper-sal)
1
albuterol sulfate tab sr 12hr 4 mg
(Vospire er)
1
TESSALON PERLES –
benzonatate cap 100 mg
4
albuterol sulfate tab sr 12hr 8 mg
(Vospire er)
albuterol sulfate tab 2 mg
1
TUSSIONEX PENNKINETIC EXT
– hydrocod polst-chlorphen polst
cr susp 10-8 mg/5ml
4
albuterol sulfate tab 4 mg
1
3
ZONATUSS – benzonatate cap
150 mg
4
ANORO ELLIPTA – umeclidiniumvilanterol aero powd ba 62.5-25
mcg/inh
ASMANEX HFA – mometasone
furoate inhal aerosol suspension
100 mcg/act
3
ASMANEX HFA – mometasone
furoate inhal aerosol suspension
200 mcg/act
3
ASMANEX TWISTHALER 120
ME – mometasone furoate
inhal powd 220 mcg/inh (breath
activated)
3
ASMANEX TWISTHALER 14
MET – mometasone furoate
inhal powd 220 mcg/inh (breath
activated)
3
• •
ANTIASTHMATIC and BRONCHODILATOR AGENTS
ACCOLATE – zafirlukast tab 10 mg 4
ACCOLATE – zafirlukast tab 20 mg 4
3
ADVAIR DISKUS – fluticasonesalmeterol aer powder ba 100-50
mcg/dose
3
ADVAIR DISKUS – fluticasonesalmeterol aer powder ba 250-50
mcg/dose
3
ADVAIR DISKUS – fluticasonesalmeterol aer powder ba 500-50
mcg/dose
3
ADVAIR HFA – fluticasonesalmeterol inhal aerosol 45-21
mcg/act
3
ADVAIR HFA – fluticasonesalmeterol inhal aerosol 115-21
mcg/act
3
ADVAIR HFA – fluticasonesalmeterol inhal aerosol 230-21
mcg/act
1
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml)
1
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
Quantity Limits
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2015
ASMANEX TWISTHALER 30 ME – 3
mometasone furoate inhal powd
220 mcg/inh (breath activated)
3
ASMANEX TWISTHALER 30
MET – mometasone furoate
inhal powd 110 mcg/inh (breath
activated)
3
ASMANEX TWISTHALER 60
MET – mometasone furoate
inhal powd 220 mcg/inh (breath
activated)
3
ASMANEX TWISTHALER 7
METE – mometasone furoate
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
47
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml
2
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
(Xopenex concentrate)
1
levalbuterol hcl soln nebu
0.31 mg/3ml (base equiv)
(Xopenex)
2
BREO ELLIPTA – fluticasone
furoate-vilanterol aero powd ba
100-25 mcg/inh
3
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
2
budesonide inhalation susp
0.5 mg/2ml (Pulmicort)
2
3
levalbuterol hcl soln nebu
0.63 mg/3ml (base equiv)
(Xopenex)
2
COMBIVENT RESPIMAT –
ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act
CROMOLYN SODIUM – cromolyn
sodium soln nebu 20 mg/2ml
levalbuterol hcl soln nebu
1.25 mg/3ml (base equiv)
(Xopenex)
2
2
DALIRESP – roflumilast tab 500
mcg
4
METAPROTERENOL SULFATE –
metaproterenol sulfate tab 10 mg
1
ELIXOPHYLLIN – theophylline
elixir 80 mg/15ml
1
METAPROTERENOL SULFATE –
metaproterenol sulfate tab 20 mg
1
FLOVENT DISKUS – fluticasone
propionate aer pow ba 50 mcg/
blister
3
METAPROTERENOL SULFATE –
metaproterenol sulfate syrup 10
mg/5ml
1
FLOVENT DISKUS – fluticasone
propionate aer pow ba 100 mcg/
blister
3
montelukast sodium chew tab
4 mg (base equiv) (Singulair)
2
FLOVENT DISKUS – fluticasone
propionate aer pow ba 250 mcg/
blister
montelukast sodium chew tab
5 mg (base equiv) (Singulair)
2
3
montelukast sodium tab 10 mg
(base equiv) (Singulair)
2
FLOVENT HFA – fluticasone
propionate hfa inhal aero 44
mcg/act (50/valve)
3
PROAIR HFA – albuterol sulfate
inhal aero 108 mcg/act (90mcg
base equiv)
3
FLOVENT HFA – fluticasone
propionate hfa inhal aer 110
mcg/act (125/valve)
3
PULMICORT – budesonide
inhalation susp 0.25 mg/2ml
4
3
PULMICORT – budesonide
inhalation susp 0.5 mg/2ml
4
FLOVENT HFA – fluticasone
propionate hfa inhal aer 220
mcg/act (250/valve)
3
FORADIL AEROLIZER –
formoterol fumarate inhal cap 12
mcg
3
SEREVENT DISKUS – salmeterol
xinafoate aer pow ba 50 mcg/
dose (base equiv)
4
ipratropium bromide inhal soln
0.02%
1
SINGULAIR – montelukast sodium
tab 10 mg (base equiv)
SINGULAIR – montelukast sodium
chew tab 4 mg (base equiv)
4
48
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Drug Name
inhal powd 110 mcg/inh (breath
activated)
Drug Tier
2015
SINGULAIR – montelukast sodium
chew tab 5 mg (base equiv)
4
PULMOZYME – dornase alfa inhal
soln 1 mg/ml
SPIRIVA HANDIHALER –
tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)
3
GASTROINTESTINAL AGENTS
SPIRIVA RESPIMAT – tiotropium
bromide monohydrate inhal
aerosol 2.5 mcg/act
3
SYMBICORT – budesonideformoterol fumarate dihyd
aerosol 80-4.5 mcg/act
3
SYMBICORT – budesonideformoterol fumarate dihyd
aerosol 160-4.5 mcg/act
3
terbutaline sulfate tab 2.5 mg
1
terbutaline sulfate tab 5 mg
LAXATIVES
COLYTE-FLAVOR PACKS –
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 227.1 gm
3
• •
COLYTE-FLAVOR PACKS –
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm
4
• •
GOLYTELY – peg 3350-kcl-na
bicarb-nacl-na sulfate for soln
236 gm
4
3
1
GOLYTELY – peg 3350-kcl-na
bicarb-nacl-na sulfate packet
227.1 gm
theophylline soln 80 mg/15ml
1
lactulose solution 10 gm/15ml
1
theophylline tab sr 12hr 100 mg
1
4
theophylline tab sr 12hr 200 mg
1
theophylline tab sr 12hr 300 mg
1
NULYTELY/FLAVOR PACKS –
peg 3350-kcl-sod bicarb-nacl for
soln 420 gm
1
theophylline tab sr 24hr 400 mg
1
peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm
(Golytely)
1
theophylline tab sr 12hr 450 mg
theophylline tab sr 24hr 600 mg
1
1
VOSPIRE ER – albuterol sulfate
tab sr 12hr 4 mg
4
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm (Colyteflavor packs)
VOSPIRE ER – albuterol sulfate
tab sr 12hr 8 mg
4
1
XOPENEX – levalbuterol hcl soln
nebu 0.31 mg/3ml (base equiv)
4
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm (Nulytely/flavor
pack)
2
XOPENEX – levalbuterol hcl soln
nebu 0.63 mg/3ml (base equiv)
4
polyethylene glycol 3350 oral
packet
2
XOPENEX – levalbuterol hcl soln
nebu 1.25 mg/3ml (base equiv)
4
polyethylene glycol 3350 oral
powder
XOPENEX CONCENTRATE –
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
4
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
1
1
zafirlukast tab 10 mg (Accolate)
2
zafirlukast tab 20 mg (Accolate)
2
DIPHENOXYLATE/ATROPINE
– diphenoxylate w/ atropine liq
2.5-0.025 mg/5ml
LOMOTIL – diphenoxylate w/
atropine tab 2.5-0.025 mg
4
RESPIRATORY AGENTS - MISC.
Quantity Limits
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5
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Drug Tier
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ANTIDIARRHEALS
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
49
ULCER DRUGS
ACIPHEX – rabeprazole sodium ec 4
tab 20 mg
2
amoxicillin cap-clarithro tablansopraz cap dr therapy pack
(Prevpac)
4
ANASPAZ – hyoscyamine sulfate
tab disp 0.125 mg
4
AXID – nizatidine cap 300 mg
AXID – nizatidine oral soln 15 mg/
ml
4
BENTYL – dicyclomine hcl cap 10
mg
4
BENTYL – dicyclomine hcl tab 20
mg
4
CARAFATE – sucralfate tab 1 gm
4
CARAFATE – sucralfate susp 1
gm/10ml
4
cimetidine hcl soln 300 mg/5ml
1
cimetidine tab 200 mg
1
cimetidine tab 300 mg
1
cimetidine tab 400 mg
1
cimetidine tab 800 mg
1
clidinium & chlordiazepoxide
cap 2.5-5 mg (Librax)
2
CYTOTEC – misoprostol tab 100
mcg
4
CYTOTEC – misoprostol tab 200
mcg
4
dicyclomine hcl cap 10 mg
(Bentyl)
1
dicyclomine hcl tab 20 mg
(Bentyl)
1
DONNATAL – pb-hyoscyatrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg
4
DONNATAL – pb-hyoscyatrop-scopol elix
4
50
famotidine for susp 40 mg/5ml
(Pepcid)
2
famotidine tab 20 mg (Pepcid)
1
famotidine tab 40 mg (Pepcid)
1
GASTRINEX NF – hyoscyaminephenyltoloxamine cap 0.0625-15
mg
2
glycopyrrolate tab 1 mg (Robinul) 2
glycopyrrolate tab 2 mg (Robinul 2
forte)
1
hyoscyamine sulfate elixir
0.125 mg/5ml
1
hyoscyamine sulfate soln
0.125 mg/ml
1
hyoscyamine sulfate tab disp
0.125 mg (Anaspaz)
1
hyoscyamine sulfate tab sl
0.125 mg (Levsin/sl)
2
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
1
hyoscyamine sulfate tab
0.125 mg (Levsin)
2
lansoprazole cap delayed
release 15 mg (Prevacid)
2
lansoprazole cap delayed
release 30 mg (Prevacid)
LEVBID – hyoscyamine sulfate tab 4
sr 12hr 0.375 mg
LEVSIN – hyoscyamine sulfate tab 4
0.125 mg
LEVSIN/SL – hyoscyamine sulfate 4
tab sl 0.125 mg
4
LIBRAX – clidinium &
chlordiazepoxide cap 2.5-5 mg
2
methscopolamine bromide tab
2.5 mg (Pamine)
2
methscopolamine bromide tab
5 mg (Pamine forte)
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Drug Name
16.2-0.1037-0.0194-0.0065
mg/5ml
Drug Tier
Quantity Limits
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1
Prior Review
loperamide hcl cap 2 mg
Specialty
Drug Name
Drug Tier
2015
misoprostol tab 100 mcg
(Cytotec)
1
pantoprazole sodium ec tab
20 mg (base equiv) (Protonix)
1
misoprostol tab 200 mcg
(Cytotec)
1
pantoprazole sodium ec tab
40 mg (base equiv) (Protonix)
1
NEXIUM – esomeprazole
magnesium for delayed release
susp pack 2.5 mg
3
PEPCID – famotidine tab 20 mg
4
PEPCID – famotidine tab 40 mg
4
3
PEPCID – famotidine for susp 40
mg/5ml
4
NEXIUM – esomeprazole
magnesium for delayed release
susp packet 5 mg
4
NEXIUM – esomeprazole
magnesium for delayed release
susp packet 10 mg
3
PREVACID – lansoprazole cap
delayed release 15 mg
PREVACID – lansoprazole cap
delayed release 30 mg
4
NEXIUM – esomeprazole
magnesium for delayed release
susp packet 20 mg
3
PREVPAC – amoxicillin capclarithro tab-lansopraz cap dr
therapy pack
4
NEXIUM – esomeprazole
magnesium for delayed release
susp packet 40 mg
3
PRILOSEC – omeprazole cap
delayed release 10 mg
4
4
NEXIUM – esomeprazole
magnesium cap delayed release
20 mg
3
PRILOSEC – omeprazole cap
delayed release 20 mg
PRILOSEC – omeprazole cap
delayed release 40 mg
4
NEXIUM – esomeprazole
magnesium cap delayed release
40 mg
3
nizatidine cap 150 mg
1
nizatidine cap 300 mg (Axid)
1
nizatidine oral soln 15 mg/ml
(Axid)
2
omeprazole cap delayed release
10 mg (Prilosec)
1
ranitidine hcl cap 300 mg
1
omeprazole cap delayed release
20 mg (Prilosec)
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
1
1
omeprazole cap delayed release
40 mg (Prilosec)
1
ranitidine hcl tab 150 mg (Zantac) 1
ranitidine hcl tab 300 mg (Zantac) 1
4
ROBINUL – glycopyrrolate tab 1
mg
4
PAMINE – methscopolamine
bromide tab 2.5 mg
4
ROBINUL FORTE – glycopyrrolate
tab 2 mg
4
PAMINE FORTE –
methscopolamine bromide tab 5
mg
sucralfate tab 1 gm (Carafate)
1
Quantity Limits
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Drug Tier
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PROTONIX – pantoprazole sodium 4
ec tab 20 mg (base equiv)
PROTONIX – pantoprazole sodium 4
ec tab 40 mg (base equiv)
2
rabeprazole sodium ec tab
20 mg (Aciphex)
1
ranitidine hcl cap 150 mg
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
51
SYMAX DUOTAB – hyoscyamine
sulfate tab cr 0.375 mg (0.125
mg ir/0.25 mg cr)
4
ZANTAC – ranitidine hcl tab 150
mg
4
ZANTAC – ranitidine hcl tab 300
mg
4
ANTIEMETICS
TIGAN – trimethobenzamide hcl
cap 300 mg
4
TRANSDERM-SCOP –
scopolamine td patch 72hr 1.5
mg
4
trimethobenzamide hcl cap
300 mg (Tigan)
2
ZOFRAN – ondansetron hcl tab 4
mg
4
ZOFRAN – ondansetron hcl tab 8
mg
4
dronabinol cap 10 mg (Marinol)
2
dronabinol cap 2.5 mg (Marinol)
2
dronabinol cap 5 mg (Marinol)
2
5
ZOFRAN – ondansetron hcl oral
soln 4 mg/5ml
4
EMEND – aprepitant capsule 40
mg
5
ZOFRAN ODT – ondansetron
orally disintegrating tab 4 mg
4
EMEND – aprepitant capsule 80
mg
5
ZOFRAN ODT – ondansetron
orally disintegrating tab 8 mg
4
EMEND – aprepitant capsule 125
mg
EMEND – aprepitant capsule
therapy pack 80 & 125 mg
5
MARINOL – dronabinol cap 2.5 mg
4
MARINOL – dronabinol cap 5 mg
4
MARINOL – dronabinol cap 10 mg
4
meclizine hcl tab 12.5 mg
1
meclizine hcl tab 25 mg
1
meclizine hcl tab 32 mg
2
ondansetron hcl oral soln
4 mg/5ml (Zofran)
2
ondansetron hcl tab 24 mg
1
ondansetron hcl tab 4 mg
(Zofran)
1
ondansetron hcl tab 8 mg
(Zofran)
1
ondansetron orally
disintegrating tab 4 mg (Zofran
odt)
ondansetron orally
disintegrating tab 8 mg (Zofran
odt)
52
DIGESTIVE AIDS
ZENPEP – pancrelipase (lip-protamyl) dr cap 3000-10000-16000
unit
3
ZENPEP – pancrelipase (lip-protamyl) dr cap 5000-17000-27000
unit
3
ZENPEP – pancrelipase (lip-protamyl) dr cap 10000-34000-55000
unit
3
ZENPEP – pancrelipase (lip-protamyl) dr cap 15000-51000-82000
unit
3
ZENPEP – pancrelipase
(lip-prot-amyl) dr cap
20000-68000-109000 unit
3
3
1
ZENPEP – pancrelipase
(lip-prot-amyl) dr cap
25000-85000-136000 unit
3
1
ZENPEP – pancrelipase
(lip-prot-amyl) dr cap
40000-136000-218000 unit
GASTROINTESTINAL AGENTS- MISC.
4
ACTIGALL – ursodiol cap 300 mg
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AZULFIDINE – sulfasalazine tab
500 mg
4
metoclopramide hcl inj 5 mg/ml
2
AZULFIDINE EN-TABS –
sulfasalazine tab delayed release
500 mg
metoclopramide hcl soln
5 mg/5ml (10 mg/10ml)
1
4
metoclopramide hcl tab 10 mg
(Reglan)
1
balsalazide disodium cap
750 mg (Colazal)
2
metoclopramide hcl tab 5 mg
(Reglan)
1
calcium acetate (phosphate
binder) cap 667 mg (169 mg
ca) (Phoslo)
2
PENTASA – mesalamine cap cr
250 mg
4
2
PENTASA – mesalamine cap cr
500 mg
4
calcium acetate (phosphate
binder) tab 667 mg (Eliphos)
4
PHOSLO – calcium acetate
(phosphate binder) cap 667 mg
(169 mg ca)
4
CANASA – mesalamine suppos
1000 mg
COLAZAL – balsalazide disodium
cap 750 mg
4
REGLAN – metoclopramide hcl tab
5 mg
4
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
2
REGLAN – metoclopramide hcl tab
10 mg
4
DELZICOL – mesalamine cap dr
400 mg
3
DIPENTUM – olsalazine sodium
cap 250 mg
5
ELIPHOS – calcium acetate
(phosphate binder) tab 667 mg
4
ENTEREG – alvimopan cap 12 mg
5
GASTROCROM – cromolyn
sodium oral conc 100 mg/5ml
4
lactulose (encephalopathy)
solution 10 gm/15ml
1
LIALDA – mesalamine tab delayed
release 1.2 gm
4
•
• •
•
•
LINZESS – linaclotide cap 145 mcg 3
LINZESS – linaclotide cap 290 mcg 3
LOTRONEX – alosetron hcl tab 0.5 5
mg (base equiv)
5
LOTRONEX – alosetron hcl tab 1
mg (base equiv)
2
mesalamine enema 4 gm
mesalamine rectal enema 4 gm &
cleanser wipe kit (Rowasa)
2
• •
• •
Quantity Limits
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Drug Name
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Quantity Limits
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Drug Name
Drug Tier
2015
RENAGEL – sevelamer hcl tab 400 4
mg
RENAGEL – sevelamer hcl tab 800 4
mg
RENVELA – sevelamer carbonate 4
tab 800 mg
RENVELA – sevelamer carbonate 4
packet 0.8 gm
RENVELA – sevelamer carbonate 4
packet 2.4 gm
4
ROWASA – mesalamine rectal
enema 4 gm & cleanser wipe kit
1
sulfasalazine tab delayed
release 500 mg (Azulfidine entabs)
1
sulfasalazine tab 500 mg
(Azulfidine)
4
URSO FORTE – ursodiol tab 500
mg
4
URSO 250 – ursodiol tab 250 mg
ursodiol cap 300 mg (Actigall)
2
ursodiol tab 250 mg (Urso 250)
2
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
53
GENITOURINARY AGENTS
UREX – methenamine hippurate
tab 1 gm
URINARY ANTI-INFECTIVES
URINARY ANTISPASMODICS
4
bethanechol chloride tab 10 mg
(Urecholine)
1
HIPREX – methenamine hippurate
tab 1 gm
4
bethanechol chloride tab 25 mg
(Urecholine)
1
MACROBID – nitrofurantoin
monohydrate macrocrystalline
cap 100 mg
4
bethanechol chloride tab 5 mg
(Urecholine)
1
1
MACRODANTIN – nitrofurantoin
macrocrystalline cap 25 mg
4
bethanechol chloride tab 50 mg
(Urecholine)
4
MACRODANTIN – nitrofurantoin
macrocrystalline cap 50 mg
4
DETROL – tolterodine tartrate tab
1 mg
4
MACRODANTIN – nitrofurantoin
macrocrystalline cap 100 mg
4
DETROL – tolterodine tartrate tab
2 mg
4
methenamine hippurate tab 1 gm
(Hiprex)
2
DITROPAN XL – oxybutynin
chloride tab sr 24hr 5 mg
4
METHENAMINE MANDELATE –
methenamine mandelate tab 0.5
gm
3
DITROPAN XL – oxybutynin
chloride tab sr 24hr 10 mg
DITROPAN XL – oxybutynin
chloride tab sr 24hr 15 mg
4
methenamine mandelate tab
1 gm
2
flavoxate hcl tab 100 mg
2
methenamine-hyos-meth bluesod phos-phen sal tab 81.6 mg
oxybutynin chloride syrup
5 mg/5ml
1
2
2
oxybutynin chloride tab sr 24hr
10 mg (Ditropan xl)
2
methenamine-hyosc-meth bluebenz acid-phenyl sal tab
81.6mg (Prosed/ds)
oxybutynin chloride tab sr 24hr
15 mg (Ditropan xl)
2
nitrofurantoin macrocrystalline
cap 100 mg (Macrodantin)
1
oxybutynin chloride tab sr 24hr
5 mg (Ditropan xl)
2
nitrofurantoin macrocrystalline
cap 50 mg (Macrodantin)
1
oxybutynin chloride tab 5 mg
1
1
tolterodine tartrate tab 1 mg
(Detrol)
2
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
(Macrobid)
2
nitrofurantoin susp 25 mg/5ml
(Furadantin)
2
tolterodine tartrate tab 2 mg
(Detrol)
2
PROSED/DS – methenaminehyosc-meth blue-benz acidphenyl sal tab 81.6mg
4
trospium chloride cap sr 24hr
60 mg
trospium chloride tab 20 mg
2
URECHOLINE – bethanechol
chloride tab 5 mg
4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
4
FURADANTIN – nitrofurantoin
susp 25 mg/5ml
54
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
2
Prior Review
ursodiol tab 500 mg (Urso forte)
Specialty
Drug Name
Drug Tier
2015
URECHOLINE – bethanechol
chloride tab 10 mg
4
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
2
URECHOLINE – bethanechol
chloride tab 25 mg
4
ELMIRON – pentosan polysulfate
sodium caps 100 mg
4
URECHOLINE – bethanechol
chloride tab 50 mg
4
finasteride tab 5 mg (Proscar)
1
FLOMAX – tamsulosin hcl cap 0.4
mg
4
phenazopyridine hcl tab 100 mg
(Pyridium)
1
phenazopyridine hcl tab 200 mg
(Pyridium)
1
potassium citrate & citric acid
powder pack 3300-1002 mg
1
potassium citrate tab cr 10 meq
(1080 mg) (Urocit-k 10)
2
potassium citrate tab cr 15 meq
(1620 mg) (Urocit-k 15)
2
potassium citrate tab cr 5 meq
(540 mg) (Urocit-k 5)
2
PROSCAR – finasteride tab 5 mg
4
PYRIDIUM – phenazopyridine hcl
tab 100 mg
4
PYRIDIUM – phenazopyridine hcl
tab 200 mg
4
SHOHLS SOLUTION MODIFIED
– sodium citrate & citric acid soln
500-334 mg/5ml
4
sodium chloride irrigation soln
0.9%
1
VAGINAL PRODUCTS
CLEOCIN – clindamycin phosphate 4
vaginal cream 2%
1
clindamycin phosphate vaginal
cream 2% (Cleocin)
4
CRINONE – progesterone vaginal
gel 4%
4
CRINONE – progesterone vaginal
gel 8%
5
ENDOMETRIN – progesterone
vaginal insert 100 mg
3
ESTRACE – estradiol vaginal
cream 0.1 mg/gm
ESTRING – estradiol vaginal ring 2 4
mg (7.5 mcg/24hrs)
4
METROGEL-VAGINAL –
metronidazole vaginal gel 0.75%
1
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
3
PREMARIN – estrogens,
conjugated vaginal cream 0.625
mg/gm
TERAZOL 3 – terconazole vaginal 4
cream 0.8%
TERAZOL 7 – terconazole vaginal 4
cream 0.4%
1
terconazole vaginal cream 0.4%
(Terazol 7)
1
terconazole vaginal cream 0.8%
(Terazol 3)
1
terconazole vaginal suppos
80 mg
GENITOURINARY AGENTS - MISC.
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
1
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution
modi)
1
tamsulosin hcl cap 0.4 mg
(Flomax)
4
UROCIT-K 10 – potassium citrate
tab cr 10 meq (1080 mg)
4
UROCIT-K 15 – potassium citrate
tab cr 15 meq (1620 mg)
4
UROCIT-K 5 – potassium citrate
tab cr 5 meq (540 mg)
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
55
UROXATRAL – alfuzosin hcl tab sr
24hr 10 mg
4
CENTRAL NERVOUS SYSTEM DRUGS
ANTIANXIETY AGENTS
alprazolam orally disintegrating
tab 0.25 mg (Niravam)
2
alprazolam orally disintegrating
tab 0.5 mg
2
alprazolam orally disintegrating
tab 1 mg
2
alprazolam orally disintegrating
tab 2 mg
2
alprazolam tab sr 24hr 0.5 mg
(Xanax xr)
1
alprazolam tab sr 24hr 1 mg
(Xanax xr)
1
alprazolam tab sr 24hr 2 mg
(Xanax xr)
1
alprazolam tab sr 24hr 3 mg
(Xanax xr)
1
alprazolam tab 0.25 mg (Xanax)
1
alprazolam tab 0.5 mg (Xanax)
1
alprazolam tab 1 mg (Xanax)
1
alprazolam tab 2 mg (Xanax)
1
ATIVAN – lorazepam tab 0.5 mg
4
ATIVAN – lorazepam tab 1 mg
4
ATIVAN – lorazepam tab 2 mg
4
buspirone hcl tab 10 mg
1
buspirone hcl tab 15 mg
1
buspirone hcl tab 30 mg
1
buspirone hcl tab 5 mg
1
buspirone hcl tab 7.5 mg
2
chlordiazepoxide hcl cap 10 mg
1
chlordiazepoxide hcl cap 25 mg
1
chlordiazepoxide hcl cap 5 mg
1
clorazepate dipotassium tab
15 mg (Tranxene t)
1
56
clorazepate dipotassium tab
3.75 mg (Tranxene t)
1
clorazepate dipotassium tab
7.5 mg (Tranxene t)
1
diazepam tab 10 mg (Valium)
1
diazepam tab 2 mg (Valium)
1
diazepam tab 5 mg (Valium)
1
hydroxyzine hcl syrup 10 mg/5ml
1
hydroxyzine hcl tab 10 mg
1
hydroxyzine hcl tab 25 mg
1
hydroxyzine hcl tab 50 mg
1
HYDROXYZINE PAMOATE –
hydroxyzine pamoate cap 100
mg
1
hydroxyzine pamoate cap 25 mg
(Vistaril)
1
hydroxyzine pamoate cap 50 mg
(Vistaril)
1
LORAZEPAM INTENSOL –
lorazepam conc 2 mg/ml
4
lorazepam tab 0.5 mg (Ativan)
1
lorazepam tab 1 mg (Ativan)
1
lorazepam tab 2 mg (Ativan)
1
meprobamate tab 200 mg
2
meprobamate tab 400 mg
2
NIRAVAM – alprazolam orally
disintegrating tab 0.25 mg
4
oxazepam cap 10 mg
1
oxazepam cap 15 mg
1
oxazepam cap 30 mg
1
TRANXENE T – clorazepate
dipotassium tab 3.75 mg
4
TRANXENE T – clorazepate
dipotassium tab 7.5 mg
4
TRANXENE T – clorazepate
dipotassium tab 15 mg
4
VALIUM – diazepam tab 2 mg
4
VALIUM – diazepam tab 5 mg
4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
1
4
bupropion hcl tab sr 24hr
300 mg (Wellbutrin xl)
1
VISTARIL – hydroxyzine pamoate
cap 50 mg
4
bupropion hcl tab 100 mg
(Wellbutrin)
1
XANAX – alprazolam tab 0.25 mg
4
bupropion hcl tab 75 mg
(Wellbutrin)
XANAX – alprazolam tab 0.5 mg
4
4
XANAX – alprazolam tab 1 mg
4
CELEXA – citalopram
hydrobromide tab 10 mg (base
equiv)
XANAX – alprazolam tab 2 mg
4
XANAX XR – alprazolam tab sr
24hr 0.5 mg
CELEXA – citalopram
hydrobromide tab 20 mg (base
equiv)
4
4
XANAX XR – alprazolam tab sr
24hr 1 mg
4
4
XANAX XR – alprazolam tab sr
24hr 2 mg
4
CELEXA – citalopram
hydrobromide tab 40 mg (base
equiv)
1
XANAX XR – alprazolam tab sr
24hr 3 mg
4
citalopram hydrobromide oral
soln 10 mg/5ml
citalopram hydrobromide tab
10 mg (base equiv) (Celexa)
1
citalopram hydrobromide tab
20 mg (base equiv) (Celexa)
1
citalopram hydrobromide tab
40 mg (base equiv) (Celexa)
1
clomipramine hcl cap 25 mg
(Anafranil)
1
1
ANTIDEPRESSANTS
amitriptyline hcl tab 10 mg
1
amitriptyline hcl tab 100 mg
1
amitriptyline hcl tab 150 mg
1
amitriptyline hcl tab 25 mg
1
amitriptyline hcl tab 50 mg
1
amitriptyline hcl tab 75 mg
1
ANAFRANIL – clomipramine hcl
cap 25 mg
4
clomipramine hcl cap 50 mg
(Anafranil)
1
ANAFRANIL – clomipramine hcl
cap 50 mg
4
clomipramine hcl cap 75 mg
(Anafranil)
4
ANAFRANIL – clomipramine hcl
cap 75 mg
4
CYMBALTA – duloxetine hcl
enteric coated pellets cap 20 mg
4
bupropion hcl tab sr 12hr
100 mg (Wellbutrin sr)
1
CYMBALTA – duloxetine hcl
enteric coated pellets cap 30 mg
4
bupropion hcl tab sr 12hr
150 mg (Wellbutrin sr)
1
CYMBALTA – duloxetine hcl
enteric coated pellets cap 60 mg
2
bupropion hcl tab sr 12hr
200 mg (Wellbutrin sr)
1
desipramine hcl tab 10 mg
(Norpramin)
2
bupropion hcl tab sr 24hr
150 mg (Wellbutrin xl)
1
desipramine hcl tab 100 mg
(Norpramin)
desipramine hcl tab 150 mg
(Norpramin)
2
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
VISTARIL – hydroxyzine pamoate
cap 25 mg
Restricted Access
4
Prior Review
VALIUM – diazepam tab 10 mg
Specialty
Drug Name
Drug Tier
2015
57
desipramine hcl tab 25 mg
(Norpramin)
2
fluoxetine hcl cap delayed
release 90 mg (Prozac weekly)
desipramine hcl tab 50 mg
(Norpramin)
2
fluoxetine hcl cap 10 mg (Prozac) 1
fluoxetine hcl cap 20 mg (Prozac) 1
desipramine hcl tab 75 mg
(Norpramin)
2
DOXEPIN HCL – doxepin hcl cap
75 mg
1
doxepin hcl cap 10 mg
1
fluoxetine hcl cap 40 mg (Prozac) 1
1
fluoxetine hcl solution
20 mg/5ml
1
fluoxetine hcl tab 10 mg
doxepin hcl cap 100 mg
1
doxepin hcl cap 150 mg
2
doxepin hcl cap 25 mg
1
doxepin hcl cap 50 mg
1
doxepin hcl conc 10 mg/ml
1
duloxetine hcl enteric coated
pellets cap 20 mg (Cymbalta)
2
duloxetine hcl enteric coated
pellets cap 30 mg (Cymbalta)
2
duloxetine hcl enteric coated
pellets cap 60 mg (Cymbalta)
2
EFFEXOR XR – venlafaxine
hcl cap sr 24hr 37.5 mg (base
equivalent)
4
EFFEXOR XR – venlafaxine
hcl cap sr 24hr 75 mg (base
equivalent)
4
EFFEXOR XR – venlafaxine
hcl cap sr 24hr 150 mg (base
equivalent)
4
escitalopram oxalate soln
5 mg/5ml (base equiv)
(Lexapro)
2
escitalopram oxalate tab 10 mg
(base equiv) (Lexapro)
2
escitalopram oxalate tab 20 mg
(base equiv) (Lexapro)
2
escitalopram oxalate tab 5 mg
(base equiv) (Lexapro)
2
FLUOXETINE HCL – fluoxetine hcl
tab 60 mg
4
58
2
fluoxetine hcl tab 20 mg
1
fluvoxamine maleate tab 100 mg
1
fluvoxamine maleate tab 25 mg
1
fluvoxamine maleate tab 50 mg
1
imipramine hcl tab 10 mg
(Tofranil)
1
imipramine hcl tab 25 mg
(Tofranil)
1
imipramine hcl tab 50 mg
(Tofranil)
1
LEXAPRO – escitalopram oxalate
tab 5 mg (base equiv)
4
LEXAPRO – escitalopram oxalate
tab 10 mg (base equiv)
4
LEXAPRO – escitalopram oxalate
tab 20 mg (base equiv)
4
LEXAPRO – escitalopram oxalate
soln 5 mg/5ml (base equiv)
4
mirtazapine orally disintegrating
tab 15 mg (Remeron soltab)
1
mirtazapine orally disintegrating
tab 30 mg (Remeron soltab)
1
mirtazapine orally disintegrating
tab 45 mg (Remeron soltab)
1
mirtazapine tab 15 mg (Remeron)
1
mirtazapine tab 30 mg (Remeron)
1
mirtazapine tab 45 mg (Remeron)
1
mirtazapine tab 7.5 mg
1
NARDIL – phenelzine sulfate tab
15 mg
4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
4
NORPRAMIN – desipramine hcl
tab 25 mg
4
NORPRAMIN – desipramine hcl
tab 50 mg
4
NORPRAMIN – desipramine hcl
tab 75 mg
4
NORPRAMIN – desipramine hcl
tab 100 mg
4
NORPRAMIN – desipramine hcl
tab 150 mg
4
nortriptyline hcl cap 10 mg
(Pamelor)
1
nortriptyline hcl cap 25 mg
(Pamelor)
1
nortriptyline hcl cap 50 mg
(Pamelor)
1
nortriptyline hcl cap 75 mg
(Pamelor)
1
PAMELOR – nortriptyline hcl cap
10 mg
4
PAMELOR – nortriptyline hcl cap
25 mg
4
PAMELOR – nortriptyline hcl cap
50 mg
4
PAMELOR – nortriptyline hcl cap
75 mg
4
PARNATE – tranylcypromine
sulfate tab 10 mg
4
paroxetine hcl tab sr 24hr
12.5 mg (Paxil cr)
2
paroxetine hcl tab sr 24hr 25 mg
(Paxil cr)
2
paroxetine hcl tab sr 24hr
37.5 mg (Paxil cr)
2
paroxetine hcl tab 10 mg (Paxil)
1
paroxetine hcl tab 20 mg (Paxil)
1
paroxetine hcl tab 30 mg (Paxil)
1
paroxetine hcl tab 40 mg (Paxil)
1
4
PAXIL – paroxetine hcl tab 30 mg
4
PAXIL – paroxetine hcl tab 40 mg
4
PAXIL CR – paroxetine hcl tab sr
24hr 12.5 mg
4
PAXIL CR – paroxetine hcl tab sr
24hr 25 mg
4
PAXIL CR – paroxetine hcl tab sr
24hr 37.5 mg
4
phenelzine sulfate tab 15 mg
(Nardil)
2
protriptyline hcl tab 10 mg
(Vivactil)
2
protriptyline hcl tab 5 mg
(Vivactil)
2
PROZAC – fluoxetine hcl cap 10
mg
4
PROZAC – fluoxetine hcl cap 20
mg
4
PROZAC – fluoxetine hcl cap 40
mg
4
PROZAC WEEKLY – fluoxetine hcl
cap delayed release 90 mg
4
REMERON – mirtazapine tab 15
mg
4
REMERON – mirtazapine tab 30
mg
4
REMERON – mirtazapine tab 45
mg
4
Quantity Limits
PAXIL – paroxetine hcl tab 20 mg
Restricted Access
4
Prior Review
PAXIL – paroxetine hcl tab 10 mg
Specialty
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
NORPRAMIN – desipramine hcl
tab 10 mg
Specialty
Drug Name
Drug Tier
2015
REMERON SOLTAB – mirtazapine 4
orally disintegrating tab 15 mg
REMERON SOLTAB – mirtazapine 4
orally disintegrating tab 30 mg
REMERON SOLTAB – mirtazapine 4
orally disintegrating tab 45 mg
sertraline hcl oral conc 20 mg/ml 2
(Zoloft)
sertraline hcl tab 100 mg (Zoloft) 1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
59
TOFRANIL – imipramine hcl tab 50
mg
4
tranylcypromine sulfate tab
10 mg (Parnate)
2
trazodone hcl tab 100 mg
1
trazodone hcl tab 150 mg
1
trazodone hcl tab 300 mg
1
trazodone hcl tab 50 mg
1
venlafaxine hcl cap sr 24hr
150 mg (base equivalent)
(Effexor xr)
1
venlafaxine hcl cap sr 24hr
37.5 mg (base equivalent)
(Effexor xr)
1
venlafaxine hcl cap sr 24hr
75 mg (base equivalent)
(Effexor xr)
1
VENLAFAXINE HCL ER –
venlafaxine hcl tab sr 24hr 37.5
mg (base equivalent)
4
VENLAFAXINE HCL ER –
venlafaxine hcl tab sr 24hr 75 mg
(base equivalent)
4
VENLAFAXINE HCL ER –
venlafaxine hcl tab sr 24hr 150
mg (base equivalent)
4
VENLAFAXINE HCL ER –
venlafaxine hcl tab sr 24hr 225
mg (base equivalent)
4
venlafaxine hcl tab sr 24hr
150 mg (base equivalent)
(Venlafaxine hcl er)
2
venlafaxine hcl tab sr 24hr
37.5 mg (base equivalent)
(Venlafaxine hcl er)
2
60
1
venlafaxine hcl tab 25 mg
1
venlafaxine hcl tab 37.5 mg
1
venlafaxine hcl tab 50 mg
1
venlafaxine hcl tab 75 mg
1
WELLBUTRIN – bupropion hcl tab
75 mg
4
WELLBUTRIN – bupropion hcl tab
100 mg
4
WELLBUTRIN SR – bupropion hcl
tab sr 12hr 100 mg
4
WELLBUTRIN SR – bupropion hcl
tab sr 12hr 150 mg
4
WELLBUTRIN SR – bupropion hcl
tab sr 12hr 200 mg
4
WELLBUTRIN XL – bupropion hcl
tab sr 24hr 150 mg
4
WELLBUTRIN XL – bupropion hcl
tab sr 24hr 300 mg
4
ZOLOFT – sertraline hcl tab 25 mg
4
ZOLOFT – sertraline hcl tab 50 mg
4
ZOLOFT – sertraline hcl tab 100
mg
4
ZOLOFT – sertraline hcl oral conc
20 mg/ml
4
ANTIPSYCHOTICS
ABILIFY – aripiprazole tab 2 mg
4
ABILIFY – aripiprazole tab 5 mg
4
ABILIFY – aripiprazole tab 10 mg
4
ABILIFY – aripiprazole tab 15 mg
4
ABILIFY – aripiprazole tab 20 mg
4
ABILIFY – aripiprazole tab 30 mg
4
ABILIFY – aripiprazole oral solution 4
1 mg/ml
1
chlorpromazine hcl tab 10 mg
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
4
venlafaxine hcl tab 100 mg
Restricted Access
TOFRANIL – imipramine hcl tab 25
mg
2
Prior Review
4
venlafaxine hcl tab sr 24hr 75 mg
(base equivalent) (Venlafaxine
hcl er)
Specialty
TOFRANIL – imipramine hcl tab 10
mg
Drug Name
Drug Tier
1
Quantity Limits
sertraline hcl tab 50 mg (Zoloft)
Restricted Access
1
Prior Review
sertraline hcl tab 25 mg (Zoloft)
Specialty
Drug Name
Drug Tier
2015
clozapine tab 100 mg (Clozaril)
2
clozapine tab 200 mg
2
clozapine tab 25 mg (Clozaril)
2
1
lithium carbonate cap 300 mg
1
lithium carbonate cap 600 mg
(Lithium carbonate)
1
clozapine tab 50 mg
lithium carbonate tab cr 300 mg
(Lithobid)
1
2
CLOZARIL – clozapine tab 25 mg
4
lithium carbonate tab cr 450 mg
1
CLOZARIL – clozapine tab 100 mg
4
lithium carbonate tab 300 mg
1
fluphenazine hcl tab 1 mg
1
4
fluphenazine hcl tab 10 mg
1
LITHOBID – lithium carbonate tab
cr 300 mg
fluphenazine hcl tab 2.5 mg
1
loxapine succinate cap 10 mg
1
fluphenazine hcl tab 5 mg
1
loxapine succinate cap 25 mg
1
GEODON – ziprasidone hcl cap 20
mg
4
loxapine succinate cap 5 mg
1
loxapine succinate cap 50 mg
1
GEODON – ziprasidone hcl cap 40
mg
4
olanzapine orally disintegrating
tab 10 mg (Zyprexa zydis)
2
GEODON – ziprasidone hcl cap 60
mg
4
olanzapine orally disintegrating
tab 15 mg (Zyprexa zydis)
2
GEODON – ziprasidone hcl cap 80
mg
4
olanzapine orally disintegrating
tab 20 mg (Zyprexa zydis)
2
haloperidol lactate oral conc
2 mg/ml
2
olanzapine orally disintegrating
tab 5 mg (Zyprexa zydis)
2
haloperidol tab 0.5 mg
1
olanzapine tab 10 mg (Zyprexa)
2
haloperidol tab 1 mg
1
olanzapine tab 15 mg (Zyprexa)
2
haloperidol tab 10 mg
1
olanzapine tab 2.5 mg (Zyprexa)
2
haloperidol tab 2 mg
1
olanzapine tab 20 mg (Zyprexa)
2
haloperidol tab 20 mg
1
olanzapine tab 5 mg (Zyprexa)
2
haloperidol tab 5 mg
1
olanzapine tab 7.5 mg (Zyprexa)
2
LATUDA – lurasidone hcl tab 60
mg
4
perphenazine tab 16 mg
2
perphenazine tab 2 mg
2
LITHIUM – lithium oral solution 8
meq/5ml
3
perphenazine tab 4 mg
2
4
perphenazine tab 8 mg
2
LITHIUM CARBONATE – lithium
carbonate cap 150 mg
prochlorperazine maleate tab
10 mg (Compazine)
1
• •
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
1
lithium carbonate cap 150 mg
(Lithium carbonate)
Restricted Access
chlorpromazine hcl tab 50 mg
4
Prior Review
1
LITHIUM CARBONATE – lithium
carbonate cap 600 mg
Specialty
chlorpromazine hcl tab 25 mg
Drug Name
Drug Tier
1
Quantity Limits
chlorpromazine hcl tab 200 mg
Restricted Access
1
Prior Review
chlorpromazine hcl tab 100 mg
Specialty
Drug Name
Drug Tier
2015
61
prochlorperazine maleate tab
5 mg (Compazine)
1
risperidone orally disintegrating
tab 0.25 mg
2
prochlorperazine suppos 25 mg
1
2
quetiapine fumarate tab 100 mg
(Seroquel)
2
risperidone orally disintegrating
tab 0.5 mg (Risperdal m-tab)
2
quetiapine fumarate tab 200 mg
(Seroquel)
2
risperidone orally disintegrating
tab 1 mg (Risperdal m-tab)
2
quetiapine fumarate tab 25 mg
(Seroquel)
2
risperidone orally disintegrating
tab 2 mg (Risperdal m-tab)
2
quetiapine fumarate tab 300 mg
(Seroquel)
2
risperidone orally disintegrating
tab 3 mg (Risperdal m-tab)
2
quetiapine fumarate tab 400 mg
(Seroquel)
2
risperidone orally disintegrating
tab 4 mg (Risperdal m-tab)
2
quetiapine fumarate tab 50 mg
(Seroquel)
2
risperidone soln 1 mg/ml
(Risperdal)
risperidone tab 0.25 mg
(Risperdal)
1
risperidone tab 0.5 mg
(Risperdal)
1
risperidone tab 1 mg (Risperdal)
1
risperidone tab 2 mg (Risperdal)
1
risperidone tab 3 mg (Risperdal)
1
risperidone tab 4 mg (Risperdal)
1
SEROQUEL – quetiapine fumarate
tab 25 mg
4
SEROQUEL – quetiapine fumarate
tab 50 mg
4
SEROQUEL – quetiapine fumarate
tab 100 mg
4
SEROQUEL – quetiapine fumarate
tab 200 mg
4
SEROQUEL – quetiapine fumarate
tab 300 mg
4
SEROQUEL – quetiapine fumarate
tab 400 mg
4
thioridazine hcl tab 10 mg
1
thioridazine hcl tab 100 mg
1
thioridazine hcl tab 25 mg
1
thioridazine hcl tab 50 mg
1
thiothixene cap 1 mg
1
RISPERDAL – risperidone tab 0.25 4
mg
4
RISPERDAL – risperidone tab 0.5
mg
4
RISPERDAL – risperidone tab 1
mg
4
RISPERDAL – risperidone tab 2
mg
4
RISPERDAL – risperidone tab 3
mg
4
RISPERDAL – risperidone tab 4
mg
4
RISPERDAL – risperidone soln 1
mg/ml
RISPERDAL M-TAB – risperidone 4
orally disintegrating tab 0.5 mg
RISPERDAL M-TAB – risperidone 4
orally disintegrating tab 1 mg
RISPERDAL M-TAB – risperidone 4
orally disintegrating tab 2 mg
RISPERDAL M-TAB – risperidone 4
orally disintegrating tab 3 mg
RISPERDAL M-TAB – risperidone 4
orally disintegrating tab 4 mg
62
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
thiothixene cap 2 mg
1
eszopiclone tab 2 mg (Lunesta)
2
thiothixene cap 5 mg
1
eszopiclone tab 3 mg (Lunesta)
2
trifluoperazine hcl tab 1 mg
1
1
trifluoperazine hcl tab 10 mg
1
FLURAZEPAM HCL – flurazepam
hcl cap 15 mg
trifluoperazine hcl tab 2 mg
1
1
trifluoperazine hcl tab 5 mg
1
FLURAZEPAM HCL – flurazepam
hcl cap 30 mg
2
HALCION – triazolam tab 0.25 mg
4
ziprasidone hcl cap 20 mg
(Geodon)
LUNESTA – eszopiclone tab 1 mg
4
ziprasidone hcl cap 40 mg
(Geodon)
2
LUNESTA – eszopiclone tab 2 mg
4
LUNESTA – eszopiclone tab 3 mg
4
ziprasidone hcl cap 60 mg
(Geodon)
2
midazolam hcl syrup 2 mg/ml
(base equivalent)
1
ziprasidone hcl cap 80 mg
(Geodon)
2
PHENOBARBITAL – phenobarbital
tab 15 mg
1
ZYPREXA – olanzapine tab 2.5 mg 4
4
ZYPREXA – olanzapine tab 5 mg
PHENOBARBITAL – phenobarbital
tab 30 mg
1
ZYPREXA – olanzapine tab 7.5 mg 4
ZYPREXA – olanzapine tab 10 mg 4
PHENOBARBITAL – phenobarbital
tab 60 mg
1
PHENOBARBITAL – phenobarbital
tab 100 mg
1
phenobarbital elixir 20 mg/5ml
1
phenobarbital tab 16.2 mg
1
phenobarbital tab 32.4 mg
1
phenobarbital tab 64.8 mg
1
phenobarbital tab 97.2 mg
1
RESTORIL – temazepam cap 7.5
mg
4
ZYPREXA – olanzapine tab 15 mg
4
ZYPREXA – olanzapine tab 20 mg
4
ZYPREXA ZYDIS – olanzapine
orally disintegrating tab 10 mg
4
ZYPREXA ZYDIS – olanzapine
orally disintegrating tab 15 mg
4
ZYPREXA ZYDIS – olanzapine
orally disintegrating tab 20 mg
4
HYPNOTICS
AMBIEN – zolpidem tartrate tab 5
mg
4
RESTORIL – temazepam cap 15
mg
4
AMBIEN – zolpidem tartrate tab 10
mg
4
RESTORIL – temazepam cap 22.5
mg
4
AMBIEN CR – zolpidem tartrate
tab cr 6.25 mg
4
RESTORIL – temazepam cap 30
mg
4
AMBIEN CR – zolpidem tartrate
tab cr 12.5 mg
4
SONATA – zaleplon cap 5 mg
4
SONATA – zaleplon cap 10 mg
4
estazolam tab 1 mg
1
temazepam cap 15 mg (Restoril)
1
estazolam tab 2 mg
1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
2
Restricted Access
eszopiclone tab 1 mg (Lunesta)
Prior Review
1
Specialty
Drug Tier
Quantity Limits
Restricted Access
thiothixene cap 10 mg
Prior Review
Drug Name
Specialty
Drug Name
Drug Tier
2015
63
temazepam cap 22.5 mg
(Restoril)
2
temazepam cap 30 mg (Restoril)
1
temazepam cap 7.5 mg (Restoril)
2
triazolam tab 0.125 mg
1
triazolam tab 0.25 mg (Halcion)
1
zaleplon cap 10 mg (Sonata)
1
zaleplon cap 5 mg (Sonata)
1
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
2
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
2
zolpidem tartrate tab 10 mg
(Ambien)
1
zolpidem tartrate tab 5 mg
(Ambien)
1
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
4
ADDERALL – amphetaminedextroamphetamine tab 5 mg
4
ADDERALL – amphetaminedextroamphetamine tab 7.5 mg
4
ADDERALL – amphetaminedextroamphetamine tab 10 mg
4
ADDERALL – amphetaminedextroamphetamine tab 12.5 mg
4
ADDERALL – amphetaminedextroamphetamine tab 15 mg
4
ADDERALL – amphetaminedextroamphetamine tab 20 mg
4
ADDERALL – amphetaminedextroamphetamine tab 30 mg
4
ADDERALL XR – amphetaminedextroamphetamine cap sr 24hr
5 mg
4
ADDERALL XR – amphetaminedextroamphetamine cap sr 24hr
10 mg
64
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
ADDERALL XR – amphetaminedextroamphetamine cap sr 24hr
15 mg
4
•
ADDERALL XR – amphetaminedextroamphetamine cap sr 24hr
20 mg
4
•
ADDERALL XR – amphetaminedextroamphetamine cap sr 24hr
25 mg
4
•
ADDERALL XR – amphetaminedextroamphetamine cap sr 24hr
30 mg
4
•
amphetaminedextroamphetamine cap sr
24hr 10 mg (Adderall xr)
2
•
amphetaminedextroamphetamine cap sr
24hr 15 mg (Adderall xr)
2
•
amphetaminedextroamphetamine cap sr
24hr 20 mg (Adderall xr)
2
•
amphetaminedextroamphetamine cap sr
24hr 25 mg (Adderall xr)
2
•
amphetaminedextroamphetamine cap sr
24hr 30 mg (Adderall xr)
2
•
amphetaminedextroamphetamine cap sr
24hr 5 mg (Adderall xr)
2
•
amphetaminedextroamphetamine tab 10 mg
(Adderall)
2
•
2
•
•
amphetaminedextroamphetamine tab
12.5 mg (Adderall)
2
•
•
amphetaminedextroamphetamine tab 15 mg
(Adderall)
amphetaminedextroamphetamine tab 20 mg
(Adderall)
2
•
•
•
•
•
•
•
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
•
amphetaminedextroamphetamine tab 30 mg
(Adderall)
2
amphetaminedextroamphetamine tab 5 mg
(Adderall)
2
amphetaminedextroamphetamine tab 7.5 mg
(Adderall)
2
•
clonidine hcl tab sr 12hr 0.1 mg
(Kapvay)
2
•
CONCERTA – methylphenidate hcl 3
tab sa osm 18 mg
CONCERTA – methylphenidate hcl 3
tab sa osm 27 mg
CONCERTA – methylphenidate hcl 3
tab sa osm 36 mg
CONCERTA – methylphenidate hcl 3
tab sa osm 54 mg
4
DEXEDRINE –
dextroamphetamine sulfate cap
sr 24hr 5 mg
4
DEXEDRINE –
dextroamphetamine sulfate cap
sr 24hr 10 mg
4
DEXEDRINE –
dextroamphetamine sulfate cap
sr 24hr 15 mg
1
dexmethylphenidate hcl tab
10 mg (Focalin)
1
dexmethylphenidate hcl tab
2.5 mg (Focalin)
1
dexmethylphenidate hcl tab
5 mg (Focalin)
2
dextroamphetamine sulfate cap
sr 24hr 10 mg (Dexedrine)
2
dextroamphetamine sulfate cap
sr 24hr 15 mg (Dexedrine)
2
dextroamphetamine sulfate cap
sr 24hr 5 mg (Dexedrine)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
dextroamphetamine sulfate tab
10 mg
1
•
dextroamphetamine sulfate tab
5 mg
1
•
FOCALIN – dexmethylphenidate
hcl tab 2.5 mg
4
•
FOCALIN – dexmethylphenidate
hcl tab 5 mg
4
•
FOCALIN – dexmethylphenidate
hcl tab 10 mg
4
•
KAPVAY – clonidine hcl tab sr 12hr 4
0.1 mg
4
METHYLIN – methylphenidate hcl
soln 5 mg/5ml
4
METHYLIN – methylphenidate hcl
soln 10 mg/5ml
2
methylphenidate hcl cap sr 24hr
20 mg (Ritalin la)
2
methylphenidate hcl cap sr 24hr
30 mg (Ritalin la)
2
methylphenidate hcl cap sr 24hr
40 mg (Ritalin la)
2
METHYLPHENIDATE HCL ER –
methylphenidate hcl tab cr 10 mg
3
METHYLPHENIDATE HCL ER –
methylphenidate hcl tab sa osm
18 mg
3
METHYLPHENIDATE HCL ER –
methylphenidate hcl tab sa osm
27 mg
3
METHYLPHENIDATE HCL ER –
methylphenidate hcl tab sa osm
36 mg
3
METHYLPHENIDATE HCL ER –
methylphenidate hcl tab sa osm
54 mg
2
methylphenidate hcl soln
10 mg/5ml (Methylin)
2
methylphenidate hcl soln
5 mg/5ml (Methylin)
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
•
•
•
•
•
•
•
•
•
•
•
•
65
methylphenidate hcl tab cr
20 mg (Ritalin sr)
2
•
methylphenidate hcl tab 10 mg
(Ritalin)
1
•
methylphenidate hcl tab 20 mg
(Ritalin)
1
•
methylphenidate hcl tab 5 mg
(Ritalin)
1
•
modafinil tab 100 mg (Provigil)
2
modafinil tab 200 mg (Provigil)
2
PROVIGIL – modafinil tab 100 mg
4
PROVIGIL – modafinil tab 200 mg
4
RITALIN – methylphenidate hcl tab
5 mg
4
•
•
•
•
•
RITALIN – methylphenidate hcl tab
10 mg
4
•
RITALIN – methylphenidate hcl tab
20 mg
4
•
RITALIN LA – methylphenidate hcl
cap sr 24hr 10 mg
4
•
RITALIN LA – methylphenidate hcl
cap sr 24hr 20 mg
4
•
RITALIN LA – methylphenidate hcl
cap sr 24hr 30 mg
4
•
RITALIN LA – methylphenidate hcl
cap sr 24hr 40 mg
4
•
VYVANSE – lisdexamfetamine
dimesylate cap 10 mg
4
• • •
VYVANSE – lisdexamfetamine
dimesylate cap 20 mg
4
• • •
VYVANSE – lisdexamfetamine
dimesylate cap 30 mg
4
• • •
VYVANSE – lisdexamfetamine
dimesylate cap 40 mg
4
• • •
VYVANSE – lisdexamfetamine
dimesylate cap 50 mg
4
• • •
VYVANSE – lisdexamfetamine
dimesylate cap 60 mg
4
• • •
VYVANSE – lisdexamfetamine
dimesylate cap 70 mg
4
• • •
66
•
•
•
•
PSYCHOTHERAPEUTIC and NEUROLOGICAL
AGENTS - MISC.
2
acamprosate calcium tab
delayed release 333 mg
(Campral)
5 • •
AMPYRA – dalfampridine tab sr
12hr 10 mg
4
ANTABUSE – disulfiram tab 250
mg
4
ANTABUSE – disulfiram tab 500
mg
4
ARICEPT – donepezil
hydrochloride tab 5 mg
4
ARICEPT – donepezil
hydrochloride tab 10 mg
4
ARICEPT – donepezil
hydrochloride tab 23 mg
4
ARICEPT ODT – donepezil
hydrochloride orally
disintegrating tab 10 mg
BETASERON – interferon beta-1b 5 • •
for inj kit 0.3 mg
1
bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
(Zyban)
CHANTIX – varenicline tartrate tab 3
0.5 mg (base equiv)
CHANTIX – varenicline tartrate tab 3
1 mg (base equiv)
3
CHANTIX CONTINUING MONTH
– varenicline tartrate tab 1 mg
(base equiv)
3
CHANTIX STARTING MONTH PA
– varenicline tartrate tab 0.5 mg x
11 & tab 1 mg x 42 pack
5 • •
COPAXONE – glatiramer acetate
soln prefilled syringe 40 mg/ml
5 • •
COPAXONE – glatiramer acetate
inj kit 20 mg/ml
disulfiram tab 250 mg (Antabuse) 2
disulfiram tab 500 mg (Antabuse)
2
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
donepezil hydrochloride orally
disintegrating tab 10 mg
(Aricept odt)
2
NICOTROL NS – nicotine nasal
spray 10 mg/ml (0.5 mg/spray)
4
donepezil hydrochloride orally
disintegrating tab 5 mg
olanzapine-fluoxetine hcl cap
12-25 mg (Symbyax)
2
2
donepezil hydrochloride tab
10 mg (Aricept)
olanzapine-fluoxetine hcl cap
12-50 mg (Symbyax)
2
2
2
olanzapine-fluoxetine hcl cap
3-25 mg (Symbyax)
2
donepezil hydrochloride tab
23 mg (Aricept)
donepezil hydrochloride tab
5 mg (Aricept)
olanzapine-fluoxetine hcl cap
6-25 mg (Symbyax)
2
2
EXELON – rivastigmine tartrate
cap 1.5 mg
olanzapine-fluoxetine hcl cap
6-50 mg (Symbyax)
2
4
• •
EXELON – rivastigmine tartrate
cap 3 mg
PLEGRIDY – peginterferon
beta-1a soln pen-injector 125
mcg/0.5ml
5
4
EXELON – rivastigmine tartrate
cap 4.5 mg
4
5
• •
EXELON – rivastigmine tartrate
cap 6 mg
4
PLEGRIDY – peginterferon
beta-1a soln prefilled syringe 125
mcg/0.5ml
5
• •
fluoxetine hcl (pmdd) cap 10 mg
1
fluoxetine hcl (pmdd) cap 20 mg
1
PLEGRIDY STARTER PACK –
peginterferon beta-1a soln peninj 63 & 94 mcg/0.5ml pack
2
PLEGRIDY STARTER PACK –
peginterferon beta-1a soln pref
syr 63 & 94 mcg/0.5ml pack
5
GALANTAMINE HYDROBROMIDE
– galantamine hydrobromide oral
soln 4 mg/ml
• •
2
RAZADYNE – galantamine
hydrobromide tab 4 mg
4
galantamine hydrobromide cap
sr 24hr 16 mg (Razadyne er)
2
RAZADYNE – galantamine
hydrobromide tab 8 mg
4
galantamine hydrobromide cap
sr 24hr 24 mg (Razadyne er)
2
RAZADYNE – galantamine
hydrobromide tab 12 mg
4
galantamine hydrobromide cap
sr 24hr 8 mg (Razadyne er)
2
RAZADYNE – galantamine
hydrobromide oral soln 4 mg/ml
4
galantamine hydrobromide tab
12 mg (Razadyne)
2
RAZADYNE ER – galantamine
hydrobromide cap sr 24hr 8 mg
4
galantamine hydrobromide tab
4 mg (Razadyne)
2
RAZADYNE ER – galantamine
hydrobromide cap sr 24hr 16 mg
4
galantamine hydrobromide tab
8 mg (Razadyne)
4
RAZADYNE ER – galantamine
hydrobromide cap sr 24hr 24 mg
4
NICOTROL INHALER – nicotine
inhaler system 10 mg (4 mg
delivered)
REBIF – interferon beta-1a inj 22
mcg/0.5ml (12mu/ml) (44 mcg/
ml)
5
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
• •
67
REBIF REBIDOSE TITRATION
– interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
5
REBIF TITRATION PACK –
interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
5
rivastigmine tartrate cap 1.5 mg
(Exelon)
2
rivastigmine tartrate cap 3 mg
(Exelon)
2
rivastigmine tartrate cap 4.5 mg
(Exelon)
2
rivastigmine tartrate cap 6 mg
(Exelon)
2
SYMBYAX – olanzapine-fluoxetine
hcl cap 3-25 mg
4
SYMBYAX – olanzapine-fluoxetine
hcl cap 6-25 mg
4
SYMBYAX – olanzapine-fluoxetine
hcl cap 6-50 mg
4
SYMBYAX – olanzapine-fluoxetine
hcl cap 12-25 mg
4
SYMBYAX – olanzapine-fluoxetine
hcl cap 12-50 mg
4
TECFIDERA – dimethyl fumarate
capsule delayed release 120 mg
5
• •
TECFIDERA – dimethyl fumarate
capsule delayed release 240 mg
5
• •
TECFIDERA STARTER PACK –
dimethyl fumarate capsule dr
starter pack 120 mg & 240 mg
5
• •
68
5
• •
ZYBAN – bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
4
Quantity Limits
5
XYREM – sodium oxybate oral
solution 500 mg/ml
Drug Name
Restricted Access
REBIF REBIDOSE – interferon
beta-1a inj 44 mcg/0.5ml (24mu/
ml) (88 mcg/ml)
• •
Prior Review
REBIF REBIDOSE – interferon
beta-1a inj 22 mcg/0.5ml (12mu/
ml) (44 mcg/ml)
5
Specialty
• •
Drug Tier
5
Quantity Limits
Specialty
REBIF – interferon beta-1a inj 44
mcg/0.5ml (24mu/ml) (88 mcg/
ml)
Drug Name
Restricted Access
Drug Tier
Prior Review
2015
ANALGESICS AND ANESTHETICS
• •
ANALGESICS - NON-NARCOTIC
butalbital-acetaminophen tab
50-325 mg
2
• •
butalbital-acetaminophencaffeine cap 50-325-40 mg
2
2
• •
butalbital-acetaminophencaffeine tab 50-325-40 mg
(Esgic)
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
2
diflunisal tab 500 mg
1
ESGIC – butalbital-acetaminophen- 4
caffeine tab 50-325-40 mg
4
FIORICET – butalbitalacetaminophen-caffeine tab
50-325-40 mg
4
FIORINAL – butalbital-aspirincaffeine cap 50-325-40 mg
1
salsalate tab 500 mg
salsalate tab 750 mg
1
ANALGESICS - NARCOTIC
acetaminophen w/ codeine soln
120-12 mg/5ml
1
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
1
acetaminophen w/ codeine tab
300-30 mg (Tylenol/codeine #3)
1
acetaminophen w/ codeine tab
300-60 mg (Tylenol/codeine #4)
1
ACTIQ – fentanyl citrate lollipop
200 mcg
5
•
•
ACTIQ – fentanyl citrate lollipop
400 mcg
5
•
•
ACTIQ – fentanyl citrate lollipop
600 mcg
5
•
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
ACTIQ – fentanyl citrate lollipop
800 mcg
5
•
•
DILAUDID – hydromorphone hcl
tab 4 mg
4
ACTIQ – fentanyl citrate lollipop
1200 mcg
5
•
•
DILAUDID – hydromorphone hcl
tab 8 mg
4
ACTIQ – fentanyl citrate lollipop
1600 mcg
5
•
•
DOLOPHINE – methadone hcl tab
10 mg
4
buprenorphine hcl sl tab 2 mg
(base equiv)
2
•
•
DOLOPHINE HCL – methadone
hcl tab 5 mg
4
buprenorphine hcl sl tab 8 mg
(base equiv)
2
•
•
DURAGESIC – fentanyl td patch
72hr 12 mcg/hr
4
buprenorphine hcl-naloxone hcl
sl tab 2-0.5 mg (base equiv)
2
•
•
DURAGESIC – fentanyl td patch
72hr 25 mcg/hr
4
buprenorphine hcl-naloxone hcl
sl tab 8-2 mg (base equiv)
2
•
•
DURAGESIC – fentanyl td patch
72hr 50 mcg/hr
4
butalbital-acetaminophen-caff
w/ cod cap 50-300-40-30 mg
(Fioricet/codeine)
2
DURAGESIC – fentanyl td patch
72hr 75 mcg/hr
4
2
DURAGESIC – fentanyl td patch
72hr 100 mcg/hr
4
butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg
•
•
butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg (Fiorinal/
codeine #3)
fentanyl citrate lollipop
1200 mcg (Actiq)
5
2
fentanyl citrate lollipop
1600 mcg (Actiq)
5
•
•
butorphanol tartrate nasal soln
10 mg/ml
2
fentanyl citrate lollipop 200 mcg
(Actiq)
5
•
•
CODEINE SULFATE – codeine
sulfate tab 15 mg
1
fentanyl citrate lollipop 400 mcg
(Actiq)
5
•
•
CODEINE SULFATE – codeine
sulfate tab 30 mg
1
fentanyl citrate lollipop 600 mcg
(Actiq)
5
•
•
CODEINE SULFATE – codeine
sulfate tab 60 mg
1
fentanyl citrate lollipop 800 mcg
(Actiq)
5
•
•
codeine sulfate tab 15 mg
(Codeine sulfate)
1
fentanyl td patch 72hr 100 mcg/
hr (Duragesic)
2
codeine sulfate tab 30 mg
1
codeine sulfate tab 60 mg
fentanyl td patch 72hr 12 mcg/hr
(Duragesic)
2
1
fentanyl td patch 72hr 25 mcg/hr
(Duragesic)
2
fentanyl td patch 72hr 50 mcg/hr
(Duragesic)
2
fentanyl td patch 72hr 75 mcg/hr
(Duragesic)
2
DEMEROL – meperidine hcl tab 50 4
mg
4
DEMEROL – meperidine hcl tab
100 mg
4
DILAUDID – hydromorphone hcl
tab 2 mg
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
69
FIORICET/CODEINE – butalbitalacetaminophen-caff w/ cod cap
50-300-40-30 mg
4
FIORICET/CODEINE – butalbitalacetaminophen-caff w/ cod cap
50-325-40-30 mg
4
FIORINAL/CODEINE #3 –
butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg
4
HYCET – hydrocodoneacetaminophen soln 7.5-325
mg/15ml
4
hydrocodone-acetaminophen
soln 7.5-325 mg/15ml (Hycet)
2
hydrocodone-acetaminophen
tab 10-300 mg (Xodol)
2
hydrocodone-acetaminophen
tab 10-325 mg (Norco)
1
hydrocodone-acetaminophen
tab 5-300 mg (Xodol)
2
hydrocodone-acetaminophen
tab 5-325 mg (Norco)
1
hydrocodone-acetaminophen
tab 7.5-300 mg (Xodol)
2
hydrocodone-acetaminophen
tab 7.5-325 mg (Norco)
1
hydrocodone-ibuprofen tab
10-200 mg (Ibudone)
2
hydrocodone-ibuprofen tab
2.5-200 mg (Reprexain)
2
hydrocodone-ibuprofen tab
5-200 mg (Reprexain)
1
hydrocodone-ibuprofen tab
7.5-200 mg (Vicoprofen)
1
HYDROCODONE/
ACETAMINOPHEN –
hydrocodone-acetaminophen
soln 7.5-500 mg/15ml
2
HYDROMORPHONE HCL –
hydromorphone hcl suppos 3 mg
3
70
hydromorphone hcl tab 2 mg
(Dilaudid)
1
hydromorphone hcl tab 4 mg
(Dilaudid)
1
hydromorphone hcl tab 8 mg
(Dilaudid)
1
IBUDONE – hydrocodoneibuprofen tab 10-200 mg
4
KADIAN – morphine sulfate cap sr
24hr 10 mg
4
KADIAN – morphine sulfate cap sr
24hr 20 mg
4
KADIAN – morphine sulfate cap sr
24hr 30 mg
4
KADIAN – morphine sulfate cap sr
24hr 50 mg
4
KADIAN – morphine sulfate cap sr
24hr 60 mg
4
KADIAN – morphine sulfate cap sr
24hr 80 mg
4
KADIAN – morphine sulfate cap sr
24hr 100 mg
4
KADIAN – morphine sulfate cap sr
24hr 200 mg
4
meperidine hcl tab 100 mg
(Demerol)
1
meperidine hcl tab 50 mg
(Demerol)
1
METHADONE HCL – methadone
hcl soln 5 mg/5ml
4
METHADONE HCL – methadone
hcl soln 10 mg/5ml
4
methadone hcl conc 10 mg/ml
(Methadose)
2
methadone hcl tab for oral susp
40 mg
2
methadone hcl tab 10 mg
(Dolophine)
1
methadone hcl tab 5 mg
(Dolophine hcl)
1
• •
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
METHADOSE – methadone hcl
conc 10 mg/ml
4
morphine sulfate tab cr 200 mg
(Ms contin)
1
METHADOSE SUGAR-FREE –
methadone hcl conc 10 mg/ml
4
morphine sulfate tab cr 30 mg
(Ms contin)
1
MORPHINE SULFATE – morphine
sulfate tab 15 mg
1
morphine sulfate tab cr 60 mg
(Ms contin)
1
MORPHINE SULFATE – morphine
sulfate tab 30 mg
1
MS CONTIN – morphine sulfate
tab cr 15 mg
4
MORPHINE SULFATE – morphine
sulfate suppos 5 mg
4
MS CONTIN – morphine sulfate
tab cr 30 mg
4
MORPHINE SULFATE – morphine
sulfate suppos 10 mg
4
MS CONTIN – morphine sulfate
tab cr 60 mg
4
MORPHINE SULFATE – morphine
sulfate suppos 20 mg
4
MS CONTIN – morphine sulfate
tab cr 100 mg
4
MORPHINE SULFATE – morphine
sulfate suppos 30 mg
4
MS CONTIN – morphine sulfate
tab cr 200 mg
4
morphine sulfate (concentrate)
oral soln 20 mg/ml
1
NORCO – hydrocodoneacetaminophen tab 10-325 mg
4
morphine sulfate cap sr 24hr
10 mg (Kadian)
2
NORCO – hydrocodoneacetaminophen tab 5-325 mg
4
morphine sulfate cap sr 24hr
100 mg (Kadian)
2
NORCO – hydrocodoneacetaminophen tab 7.5-325 mg
4
morphine sulfate cap sr 24hr
20 mg (Kadian)
2
NUCYNTA – tapentadol hcl tab 50
mg
4
morphine sulfate cap sr 24hr
30 mg (Kadian)
2
NUCYNTA – tapentadol hcl tab 75
mg
4
morphine sulfate cap sr 24hr
50 mg (Kadian)
2
NUCYNTA – tapentadol hcl tab
100 mg
4
morphine sulfate cap sr 24hr
60 mg (Kadian)
2
NUCYNTA ER – tapentadol hcl tab
sr 12hr 50 mg
4
morphine sulfate cap sr 24hr
80 mg (Kadian)
2
NUCYNTA ER – tapentadol hcl tab
sr 12hr 100 mg
4
morphine sulfate oral soln
10 mg/5ml
1
NUCYNTA ER – tapentadol hcl tab
sr 12hr 150 mg
4
morphine sulfate oral soln
20 mg/5ml
1
NUCYNTA ER – tapentadol hcl tab
sr 12hr 200 mg
4
morphine sulfate tab cr 100 mg
(Ms contin)
1
NUCYNTA ER – tapentadol hcl tab
sr 12hr 250 mg
4
morphine sulfate tab cr 15 mg
(Ms contin)
1
OPANA – oxymorphone hcl tab 5
mg
4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
71
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
OPANA – oxymorphone hcl tab 10
mg
4
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
1
OXYCODONE HCL – oxycodone
hcl conc 100 mg/5ml (20 mg/ml)
4
oxycodone-ibuprofen tab
5-400 mg
2
OXYCODONE HCL – oxycodone
hcl soln 5 mg/5ml
4
OXYCONTIN – oxycodone hcl tab
er 12hr deter 10 mg
4
•
oxycodone hcl cap 5 mg
1
4
•
oxycodone hcl conc 100 mg/5ml
(20 mg/ml) (Oxycodone hcl)
2
OXYCONTIN – oxycodone hcl tab
er 12hr deter 15 mg
4
•
OXYCODONE HCL ER –
oxycodone hcl tab er 12hr deter
10 mg
4
OXYCONTIN – oxycodone hcl tab
er 12hr deter 20 mg
OXYCONTIN – oxycodone hcl tab
er 12hr deter 30 mg
4
•
OXYCODONE HCL ER –
oxycodone hcl tab er 12hr deter
20 mg
4
OXYCONTIN – oxycodone hcl tab
er 12hr deter 40 mg
4
•
4
•
OXYCODONE HCL ER –
oxycodone hcl tab er 12hr deter
40 mg
4
OXYCONTIN – oxycodone hcl tab
er 12hr deter 60 mg
OXYCONTIN – oxycodone hcl tab
er 12hr deter 80 mg
4
•
OXYCODONE HCL ER –
oxycodone hcl tab er 12hr deter
80 mg
4
oxymorphone hcl tab 10 mg
(Opana)
2
2
oxymorphone hcl tab 5 mg
(Opana)
2
oxycodone hcl soln 5 mg/5ml
(Oxycodone hcl)
2
pentazocine w/ naloxone tab
50-0.5 mg
2
oxycodone hcl tab 10 mg
oxycodone hcl tab 15 mg
(Roxicodone)
1
PERCOCET – oxycodone w/
acetaminophen tab 2.5-325 mg
4
oxycodone hcl tab 20 mg
2
1
PERCOCET – oxycodone w/
acetaminophen tab 5-325 mg
4
oxycodone hcl tab 30 mg
(Roxicodone)
oxycodone hcl tab 5 mg
(Roxicodone)
PERCOCET – oxycodone w/
acetaminophen tab 7.5-325 mg
4
1
oxycodone w/ acetaminophen
tab 10-325 mg (Percocet)
PERCOCET – oxycodone w/
acetaminophen tab 10-325 mg
4
1
oxycodone w/ acetaminophen
tab 2.5-325 mg (Percocet)
PERCODAN – oxycodone-aspirin
tab 4.8355-325 mg
4
1
1
REPREXAIN – hydrocodoneibuprofen tab 2.5-200 mg
4
oxycodone w/ acetaminophen
tab 5-325 mg (Percocet)
1
REPREXAIN – hydrocodoneibuprofen tab 5-200 mg
4
oxycodone w/ acetaminophen
tab 7.5-325 mg (Percocet)
ROXICODONE – oxycodone hcl
tab 5 mg
4
72
•
•
•
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
ROXICODONE – oxycodone hcl
tab 15 mg
4
ULTRAM ER – tramadol hcl tab sr
24hr 100 mg
4
ROXICODONE – oxycodone hcl
tab 30 mg
4
ULTRAM ER – tramadol hcl tab sr
24hr 200 mg
4
SUBOXONE – buprenorphine hclnaloxone hcl sl film 2-0.5 mg
(base equiv)
3
•
•
ULTRAM ER – tramadol hcl tab sr
24hr 300 mg
4
3
•
•
VICOPROFEN – hydrocodoneibuprofen tab 7.5-200 mg
4
SUBOXONE – buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
4
SUBOXONE – buprenorphine hclnaloxone hcl sl film 8-2 mg (base
equiv)
3
•
•
XODOL – hydrocodoneacetaminophen tab 5-300 mg
XODOL – hydrocodoneacetaminophen tab 7.5-300 mg
4
3
•
•
XODOL – hydrocodoneacetaminophen tab 10-300 mg
4
SUBOXONE – buprenorphine hclnaloxone hcl sl film 12-3 mg
(base equiv)
tramadol hcl tab sr 24hr biphasic
release 200 mg
2
tramadol hcl tab sr 24hr biphasic
release 300 mg
2
tramadol hcl tab sr 24hr 100 mg
(Ultram er)
2
tramadol hcl tab sr 24hr 200 mg
(Ultram er)
2
tramadol hcl tab sr 24hr 300 mg
(Ultram er)
2
tramadol hcl tab 50 mg (Ultram)
1
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
1
TYLENOL/CODEINE –
acetaminophen w/ codeine tab
300-15 mg
4
TYLENOL/CODEINE #3 –
acetaminophen w/ codeine tab
300-30 mg
4
TYLENOL/CODEINE #4 –
acetaminophen w/ codeine tab
300-60 mg
4
ULTRACET – tramadolacetaminophen tab 37.5-325 mg
4
ULTRAM – tramadol hcl tab 50 mg
4
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
ANALGESICS - ANTI-INFLAMMATORY
ANAPROX – naproxen sodium tab 4
275 mg
ANAPROX DS – naproxen sodium 4
tab 550 mg
5
ARAVA – leflunomide tab 10 mg
ARAVA – leflunomide tab 20 mg
5
ARTHROTEC 50 – diclofenac w/
misoprostol tab delayed release
50-0.2 mg
4
ARTHROTEC 75 – diclofenac w/
misoprostol tab delayed release
75-0.2 mg
4
CELEBREX – celecoxib cap 50 mg
4
CELEBREX – celecoxib cap 100
mg
4
•
•
CELEBREX – celecoxib cap 200
mg
4
•
CELEBREX – celecoxib cap 400
mg
4
•
celecoxib cap 100 mg (Celebrex)
2
celecoxib cap 200 mg (Celebrex)
2
celecoxib cap 400 mg (Celebrex)
2
celecoxib cap 50 mg (Celebrex)
2
•
•
•
•
DAYPRO – oxaprozin tab 600 mg
4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
73
1
diclofenac sodium tab delayed
release 25 mg
1
diclofenac sodium tab delayed
release 50 mg
1
diclofenac sodium tab delayed
release 75 mg
1
diclofenac sodium tab sr 24hr
100 mg (Voltaren-xr)
2
diclofenac w/ misoprostol tab
delayed release 50-0.2 mg
(Arthrotec 50)
2
diclofenac w/ misoprostol tab
delayed release 75-0.2 mg
(Arthrotec 75)
2
EC-NAPROSYN – naproxen tab ec 4
375 mg
EC-NAPROSYN – naproxen tab ec 4
500 mg
5
ENBREL – etanercept
subcutaneous soln prefilled
syringe 25 mg/0.5ml
5
ENBREL – etanercept
subcutaneous soln prefilled
syringe 50 mg/ml
5
ENBREL – etanercept for
subcutaneous inj kit 25 mg
5
ENBREL SURECLICK –
etanercept subcutaneous
solution auto-injector 50 mg/ml
1
etodolac cap 200 mg
• •
• •
•
• •
•
• •
•
Quantity Limits
Restricted Access
1
flurbiprofen tab 50 mg
1
HUMIRA – adalimumab prefilled
syringe kit 10 mg/0.2ml
5
• •
•
HUMIRA – adalimumab inj kit 20
mg/0.4ml
5
• •
•
HUMIRA – adalimumab inj kit 40
mg/0.8ml (50 mg/ml)
5
• •
•
HUMIRA PEDIATRIC CROHNS D
– adalimumab inj kit 40 mg/0.8ml
(50 mg/ml)
5
• •
•
HUMIRA PEN – adalimumab inj kit
40 mg/0.8ml (50 mg/ml)
5
• •
•
HUMIRA PEN-CROHNS DISEASE
– adalimumab inj kit 40 mg/0.8ml
(50 mg/ml)
5
• •
•
HUMIRA PEN-PSORIASIS STAR
– adalimumab inj kit 40 mg/0.8ml
(50 mg/ml)
5
• •
•
ibuprofen tab 400 mg
1
ibuprofen tab 600 mg
1
ibuprofen tab 800 mg
1
indomethacin cap cr 75 mg
2
indomethacin cap 25 mg
1
indomethacin cap 50 mg
1
ketoprofen cap 50 mg
1
ketoprofen cap 75 mg
1
ketorolac tromethamine im inj
60 mg/2ml (30 mg/ml)
1
1
etodolac cap 300 mg
1
ketorolac tromethamine tab
10 mg
1
leflunomide tab 10 mg (Arava)
1
etodolac tab sr 24hr 400 mg
1
leflunomide tab 20 mg (Arava)
1
etodolac tab sr 24hr 500 mg
1
etodolac tab 400 mg
1
MELOXICAM – meloxicam susp
7.5 mg/5ml
4
etodolac tab sr 24hr 600 mg
meloxicam tab 15 mg (Mobic)
1
etodolac tab 500 mg
1
meloxicam tab 7.5 mg (Mobic)
1
FELDENE – piroxicam cap 10 mg
4
MOBIC – meloxicam tab 7.5 mg
4
FELDENE – piroxicam cap 20 mg
4
74
Prior Review
flurbiprofen tab 100 mg
Specialty
Restricted Access
Quantity Limits
•
Drug Name
Drug Tier
diclofenac potassium tab 50 mg
(Cataflam)
Prior Review
Drug Name
Specialty
Drug Tier
2015
• •
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
5
• •
1
sulindac tab 150 mg
1
nabumetone tab 750 mg
1
sulindac tab 200 mg
1
NAPROSYN – naproxen tab 250
mg
4
tolmetin sodium cap 400 mg
2
4
NAPROSYN – naproxen tab 375
mg
4
VOLTAREN-XR – diclofenac
sodium tab sr 24hr 100 mg
5
NAPROSYN – naproxen tab 500
mg
4
XELJANZ – tofacitinib citrate tab 5
mg (base equivalent)
NAPROSYN – naproxen susp 125
mg/5ml
4
naproxen sodium tab 275 mg
(Anaprox)
• •
Quantity Limits
SIMPONI – golimumab
subcutaneous soln prefilled
syringe 100 mg/ml
Drug Name
Restricted Access
Specialty
nabumetone tab 500 mg
Prior Review
Drug Tier
4
Quantity Limits
MOBIC – meloxicam susp 7.5
mg/5ml
Restricted Access
4
Prior Review
MOBIC – meloxicam tab 15 mg
Specialty
Drug Name
Drug Tier
2015
•
• • • •
MIGRAINE PRODUCTS
2
1
acetaminophen-isometheptenecaffeine tab 325-65-20 mg
(Prodrin)
2
naproxen sodium tab 550 mg
(Anaprox ds)
1
acetaminophen-isometheptenedichloral cap 325-65-100 mg
4
•
naproxen susp 125 mg/5ml
(Naprosyn)
1
AMERGE – naratriptan hcl tab 1
mg (base equiv)
4
•
naproxen tab ec 375 mg (Ecnaprosyn)
1
AMERGE – naratriptan hcl tab 2.5
mg (base equiv)
5
•
naproxen tab ec 500 mg (Ecnaprosyn)
1
D.H.E. 45 – dihydroergotamine
mesylate inj 1 mg/ml
2
•
naproxen tab 250 mg (Naprosyn)
1
dihydroergotamine mesylate inj
1 mg/ml (D.h.e. 45)
naproxen tab 375 mg (Naprosyn)
1
4
•
naproxen tab 500 mg (Naprosyn)
1
IMITREX – sumatriptan nasal
spray 5 mg/act
1
IMITREX – sumatriptan nasal
spray 20 mg/act
4
oxaprozin tab 600 mg (Daypro)
•
piroxicam cap 10 mg (Feldene)
2
•
piroxicam cap 20 mg (Feldene)
IMITREX – sumatriptan succinate
tab 25 mg
4
2
SIMPONI – golimumab
subcutaneous soln auto-injector
50 mg/0.5ml
5
IMITREX – sumatriptan succinate
tab 50 mg
4
•
4
•
SIMPONI – golimumab
subcutaneous soln auto-injector
100 mg/ml
5
IMITREX – sumatriptan succinate
tab 100 mg
IMITREX – sumatriptan succinate
inj 6 mg/0.5ml
4
•
SIMPONI – golimumab
subcutaneous soln prefilled
syringe 50 mg/0.5ml
5
IMITREX STATDOSE REFILL –
sumatriptan succinate solution
cartridge 4 mg/0.5ml
4
•
• •
• •
• •
•
•
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
75
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
IMITREX STATDOSE REFILL –
sumatriptan succinate solution
cartridge 6 mg/0.5ml
4
•
SUMATRIPTAN SUCCINATE –
sumatriptan succinate solution
prefilled syringe 6 mg/0.5ml
2
•
IMITREX STATDOSE SYSTEM –
sumatriptan succinate solution
auto-injector 4 mg/0.5ml
4
•
SUMATRIPTAN SUCCINATE
– sumatriptan succinate inj 4
mg/0.5ml
2
•
IMITREX STATDOSE SYSTEM –
sumatriptan succinate solution
auto-injector 6 mg/0.5ml
4
•
sumatriptan succinate inj
6 mg/0.5ml (Imitrex)
2
•
•
•
4
sumatriptan succinate solution
auto-injector 4 mg/0.5ml
(Imitrex statdose sys)
2
MAXALT – rizatriptan benzoate tab
5 mg
MAXALT – rizatriptan benzoate tab
10 mg
4
•
2
•
MAXALT-MLT – rizatriptan
benzoate orally disintegrating tab
5 mg
4
•
sumatriptan succinate solution
auto-injector 6 mg/0.5ml
(Imitrex statdose sys)
2
•
MAXALT-MLT – rizatriptan
benzoate orally disintegrating tab
10 mg
4
•
sumatriptan succinate solution
cartridge 4 mg/0.5ml (Imitrex
statdose ref)
2
•
naratriptan hcl tab 1 mg (base
equiv) (Amerge)
2
•
sumatriptan succinate solution
cartridge 6 mg/0.5ml (Imitrex
statdose ref)
1
•
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
2
•
sumatriptan succinate tab
100 mg (Imitrex)
1
•
PRODRIN – acetaminophenisometheptene-caffeine tab
325-65-20 mg
4
sumatriptan succinate tab 25 mg
(Imitrex)
sumatriptan succinate tab 50 mg
(Imitrex)
1
•
rizatriptan benzoate orally
disintegrating tab 10 mg
(Maxalt-mlt)
2
rizatriptan benzoate orally
disintegrating tab 5 mg
(Maxalt-mlt)
2
rizatriptan benzoate tab 10 mg
(Maxalt)
•
GOUT AGENTS
allopurinol tab 100 mg (Zyloprim)
1
•
allopurinol tab 300 mg (Zyloprim)
1
COLCHICINE – colchicine tab 0.6
mg
3
2
•
colchicine w/ probenecid tab
0.5-500 mg
1
rizatriptan benzoate tab 5 mg
(Maxalt)
2
•
COLCRYS – colchicine tab 0.6 mg
3
probenecid tab 500 mg
1
SUMATRIPTAN – sumatriptan
nasal spray 5 mg/act
4
•
ZYLOPRIM – allopurinol tab 100
mg
4
SUMATRIPTAN – sumatriptan
nasal spray 20 mg/act
4
•
ZYLOPRIM – allopurinol tab 300
mg
4
NEUROMUSCULAR DRUGS
76
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
ANTICONVULSANTS
4
carbamazepine cap sr 12hr
100 mg (Carbatrol)
2
DEPAKOTE – divalproex sodium
tab delayed release 125 mg
4
carbamazepine cap sr 12hr
200 mg (Carbatrol)
2
DEPAKOTE – divalproex sodium
tab delayed release 250 mg
4
carbamazepine cap sr 12hr
300 mg (Carbatrol)
2
DEPAKOTE – divalproex sodium
tab delayed release 500 mg
4
carbamazepine chew tab 100 mg
1
DEPAKOTE ER – divalproex
sodium tab sr 24 hr 250 mg
carbamazepine susp 100 mg/5ml
(Tegretol)
1
DEPAKOTE ER – divalproex
sodium tab sr 24 hr 500 mg
4
carbamazepine tab sr 12hr
200 mg (Tegretol-xr)
2
4
carbamazepine tab sr 12hr
400 mg (Tegretol-xr)
2
DEPAKOTE SPRINKLES –
divalproex sodium cap sprinkle
125 mg
4
carbamazepine tab 200 mg
(Tegretol)
1
DIASTAT ACUDIAL – diazepam
rectal gel delivery system 10 mg
4
CARBATROL – carbamazepine
cap sr 12hr 100 mg
4
DIASTAT ACUDIAL – diazepam
rectal gel delivery system 20 mg
4
CARBATROL – carbamazepine
cap sr 12hr 200 mg
4
DIASTAT PEDIATRIC – diazepam
rectal gel delivery system 2.5 mg
4
CARBATROL – carbamazepine
cap sr 12hr 300 mg
4
DIAZEPAM – diazepam rectal gel
delivery system 2.5 mg
4
clonazepam orally disintegrating
tab 0.125 mg
2
DIAZEPAM – diazepam rectal gel
delivery system 10 mg
4
clonazepam orally disintegrating
tab 0.25 mg
2
DIAZEPAM – diazepam rectal gel
delivery system 20 mg
4
clonazepam orally disintegrating
tab 0.5 mg
2
DILANTIN – phenytoin susp 125
mg/5ml
4
clonazepam orally disintegrating
tab 1 mg
2
DILANTIN – phenytoin sodium
extended cap 30 mg
4
clonazepam orally disintegrating
tab 2 mg
2
DILANTIN – phenytoin sodium
extended cap 100 mg
4
clonazepam tab 0.5 mg
(Klonopin)
1
DILANTIN INFATABS – phenytoin
chew tab 50 mg
2
clonazepam tab 1 mg (Klonopin)
1
divalproex sodium cap sprinkle
125 mg (Depakote sprinkles)
1
divalproex sodium tab delayed
release 125 mg (Depakote)
1
clonazepam tab 2 mg (Klonopin)
DEPAKENE – valproate sodium
syrup 250 mg/5ml (base equiv)
4
divalproex sodium tab delayed
release 250 mg (Depakote)
1
DEPAKENE – valproic acid cap
250 mg
4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
77
divalproex sodium tab delayed
release 500 mg (Depakote)
1
KEPPRA – levetiracetam tab 1000
mg
4
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
1
KEPPRA – levetiracetam oral soln
100 mg/ml
4
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
1
KEPPRA XR – levetiracetam tab sr
24hr 500 mg
4
ethosuximide cap 250 mg
(Zarontin)
1
KEPPRA XR – levetiracetam tab sr
24hr 750 mg
4
ethosuximide soln 250 mg/5ml
(Zarontin)
1
KLONOPIN – clonazepam tab 0.5
mg
4
felbamate susp 600 mg/5ml
(Felbatol)
2
KLONOPIN – clonazepam tab 1
mg
4
felbamate tab 400 mg (Felbatol)
2
4
felbamate tab 600 mg (Felbatol)
2
KLONOPIN – clonazepam tab 2
mg
FELBATOL – felbamate tab 400
mg
4
FELBATOL – felbamate tab 600
mg
4
FELBATOL – felbamate susp 600
mg/5ml
4
gabapentin cap 100 mg
(Neurontin)
1
gabapentin cap 300 mg
(Neurontin)
1
gabapentin cap 400 mg
(Neurontin)
1
gabapentin oral soln 250 mg/5ml
(Neurontin)
2
gabapentin tab 600 mg
(Neurontin)
1
gabapentin tab 800 mg
(Neurontin)
1
GABITRIL – tiagabine hcl tab 2 mg
4
GABITRIL – tiagabine hcl tab 4 mg
4
KEPPRA – levetiracetam tab 250
mg
4
KEPPRA – levetiracetam tab 500
mg
4
KEPPRA – levetiracetam tab 750
mg
4
78
LAMICTAL – lamotrigine tab 25 mg 4
4
LAMICTAL – lamotrigine tab 100
mg
4
LAMICTAL – lamotrigine tab 150
mg
4
LAMICTAL – lamotrigine tab 200
mg
LAMICTAL CHEWABLE DISPERS 4
– lamotrigine tab chewable
dispersible 5 mg
LAMICTAL CHEWABLE DISPERS 4
– lamotrigine tab chewable
dispersible 25 mg
4
LAMICTAL ODT – lamotrigine
orally disintegrating tab 25 mg
4
LAMICTAL ODT – lamotrigine
orally disintegrating tab 50 mg
4
LAMICTAL ODT – lamotrigine
orally disintegrating tab 100 mg
4
LAMICTAL ODT – lamotrigine
orally disintegrating tab 200 mg
LAMICTAL STARTER/NOT TAKI – 4
lamotrigine tab 25 mg (42) & 100
mg (7) starter kit
LAMICTAL STARTER/TAKING C – 4
lamotrigine tab 25 mg (84) & 100
mg (14) starter kit
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
1
lamotrigine tab 200 mg (Lamictal)
1
lamotrigine tab 25 mg (Lamictal)
1
levetiracetam oral soln 100 mg/
ml (Keppra)
1
levetiracetam tab sr 24hr 500 mg
(Keppra xr)
2
levetiracetam tab sr 24hr 750 mg
(Keppra xr)
2
levetiracetam tab 1000 mg
(Keppra)
1
levetiracetam tab 250 mg
(Keppra)
1
levetiracetam tab 500 mg
(Keppra)
1
levetiracetam tab 750 mg
(Keppra)
1
LYRICA – pregabalin cap 25 mg
4
LYRICA – pregabalin cap 50 mg
4
LYRICA – pregabalin cap 75 mg
4
LYRICA – pregabalin cap 100 mg
4
LYRICA – pregabalin cap 150 mg
4
LYRICA – pregabalin cap 200 mg
4
LYRICA – pregabalin cap 225 mg
4
LYRICA – pregabalin cap 300 mg
4
LYRICA – pregabalin soln 20 mg/
ml
4
MYSOLINE – primidone tab 50 mg
4
MYSOLINE – primidone tab 250
mg
4
NEURONTIN – gabapentin cap
100 mg
4
NEURONTIN – gabapentin cap
300 mg
4
NEURONTIN – gabapentin cap
400 mg
4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
lamotrigine tab 150 mg (Lamictal)
Restricted Access
1
Prior Review
lamotrigine tab 100 mg (Lamictal)
Specialty
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
LAMICTAL STARTER/TAKING V – 4
lamotrigine tab 25 mg (35) starter
kit
LAMICTAL XR – lamotrigine tab sr 4
24hr 25 mg
LAMICTAL XR – lamotrigine tab sr 4
24hr 50 mg
LAMICTAL XR – lamotrigine tab sr 4
24hr 100 mg
LAMICTAL XR – lamotrigine tab sr 4
24hr 200 mg
LAMICTAL XR – lamotrigine tab sr 4
24hr 250 mg
LAMICTAL XR – lamotrigine tab sr 4
24hr 300 mg
2
lamotrigine orally disintegrating
tab 100 mg (Lamictal odt)
2
lamotrigine orally disintegrating
tab 200 mg (Lamictal odt)
2
lamotrigine orally disintegrating
tab 25 mg (Lamictal odt)
2
lamotrigine orally disintegrating
tab 50 mg (Lamictal odt)
2
lamotrigine tab chewable
dispersible 25 mg (Lamictal
chewable di)
2
lamotrigine tab chewable
dispersible 5 mg (Lamictal
chewable di)
2
lamotrigine tab sr 24hr 100 mg
(Lamictal xr)
2
lamotrigine tab sr 24hr 200 mg
(Lamictal xr)
2
lamotrigine tab sr 24hr 25 mg
(Lamictal xr)
2
lamotrigine tab sr 24hr 250 mg
(Lamictal xr)
2
lamotrigine tab sr 24hr 300 mg
(Lamictal xr)
2
lamotrigine tab sr 24hr 50 mg
(Lamictal xr)
Specialty
Drug Name
Drug Tier
2015
79
primidone tab 50 mg (Mysoline)
1
TEGRETOL – carbamazepine tab
200 mg
4
TEGRETOL – carbamazepine susp 4
100 mg/5ml
4
TEGRETOL-XR – carbamazepine
tab sr 12hr 100 mg
4
TEGRETOL-XR – carbamazepine
tab sr 12hr 200 mg
4
TEGRETOL-XR – carbamazepine
tab sr 12hr 400 mg
2
tiagabine hcl tab 2 mg (Gabitril)
tiagabine hcl tab 4 mg (Gabitril)
80
4
TOPAMAX – topiramate tab 100
mg
4
TOPAMAX – topiramate tab 200
mg
4
TOPAMAX SPRINKLE –
topiramate sprinkle cap 15 mg
4
TOPAMAX SPRINKLE –
topiramate sprinkle cap 25 mg
4
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
2
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
2
topiramate tab 100 mg (Topamax) 1
topiramate tab 200 mg (Topamax) 1
topiramate tab 25 mg (Topamax)
1
topiramate tab 50 mg (Topamax)
1
TRILEPTAL – oxcarbazepine tab
150 mg
4
TRILEPTAL – oxcarbazepine tab
300 mg
4
TRILEPTAL – oxcarbazepine tab
600 mg
4
valproate sodium syrup
250 mg/5ml (base equiv)
(Depakene)
1
valproic acid cap 250 mg
(Depakene)
1
ZARONTIN – ethosuximide cap
250 mg
4
ZARONTIN – ethosuximide soln
250 mg/5ml
4
ZONEGRAN – zonisamide cap 25
mg
4
ZONEGRAN – zonisamide cap 100 4
mg
1
zonisamide cap 100 mg
(Zonegran)
2
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
TOPAMAX – topiramate tab 50 mg
Restricted Access
4
Prior Review
TOPAMAX – topiramate tab 25 mg
Specialty
Quantity Limits
Restricted Access
Drug Name
Drug Tier
NEURONTIN – gabapentin tab 600 4
mg
NEURONTIN – gabapentin tab 800 4
mg
4
NEURONTIN – gabapentin oral
soln 250 mg/5ml
1
oxcarbazepine tab 150 mg
(Trileptal)
1
oxcarbazepine tab 300 mg
(Trileptal)
1
oxcarbazepine tab 600 mg
(Trileptal)
4
PHENYTEK – phenytoin sodium
extended cap 200 mg
4
PHENYTEK – phenytoin sodium
extended cap 300 mg
2
phenytoin chew tab 50 mg
(Dilantin infatabs)
1
phenytoin sodium extended cap
100 mg (Dilantin)
1
phenytoin sodium extended cap
200 mg (Phenytek)
1
phenytoin sodium extended cap
300 mg (Phenytek)
2
phenytoin susp 125 mg/5ml
(Dilantin)
primidone tab 250 mg (Mysoline) 1
Prior Review
Drug Name
Specialty
Drug Tier
2015
zonisamide cap 25 mg
(Zonegran)
1
zonisamide cap 50 mg
1
ANTIPARKINSON AGENTS
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 31.25-125-200
mg
3
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 37.5-150-200
mg
3
3
AMANTADINE HCL – amantadine
hcl tab 100 mg
1
amantadine hcl cap 100 mg
1
amantadine hcl syrup 50 mg/5ml
1
AZILECT – rasagiline mesylate tab
0.5 mg (base equiv)
4
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 50-200-200 mg
AZILECT – rasagiline mesylate tab
1 mg (base equiv)
4
COMTAN – entacapone tab 200
mg
4
benztropine mesylate tab 0.5 mg
1
4
benztropine mesylate tab 1 mg
1
ELDEPRYL – selegiline hcl cap 5
mg
1
entacapone tab 200 mg (Comtan)
2
benztropine mesylate tab 2 mg
2
LODOSYN – carbidopa tab 25 mg
4
bromocriptine mesylate cap
5 mg (Parlodel)
4
bromocriptine mesylate tab
2.5 mg
2
MIRAPEX – pramipexole
dihydrochloride tab 0.125 mg
4
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
1
MIRAPEX – pramipexole
dihydrochloride tab 0.25 mg
4
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
1
MIRAPEX – pramipexole
dihydrochloride tab 0.5 mg
4
carbidopa & levodopa tab
10-100 mg (Sinemet)
1
MIRAPEX – pramipexole
dihydrochloride tab 0.75 mg
4
carbidopa & levodopa tab
25-100 mg (Sinemet)
1
MIRAPEX – pramipexole
dihydrochloride tab 1 mg
4
carbidopa & levodopa tab
25-250 mg (Sinemet)
1
MIRAPEX – pramipexole
dihydrochloride tab 1.5 mg
4
carbidopa tab 25 mg (Lodosyn)
2
PARLODEL – bromocriptine
mesylate cap 5 mg
3
pramipexole dihydrochloride tab
0.125 mg (Mirapex)
1
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 12.5-50-200 mg
1
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 18.75-75-200
mg
3
pramipexole dihydrochloride tab
0.25 mg (Mirapex)
pramipexole dihydrochloride tab
0.5 mg (Mirapex)
1
1
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 25-100-200 mg
3
pramipexole dihydrochloride tab
0.75 mg (Mirapex)
pramipexole dihydrochloride tab
1 mg (Mirapex)
1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
81
pramipexole dihydrochloride tab
1.5 mg (Mirapex)
1
REQUIP – ropinirole hydrochloride
tab 0.25 mg
4
REQUIP – ropinirole hydrochloride
tab 0.5 mg
ropinirole hydrochloride tab sr
24hr 6 mg (base equivalent)
(Requip xl)
2
2
4
ropinirole hydrochloride tab sr
24hr 8 mg (base equivalent)
(Requip xl)
REQUIP – ropinirole hydrochloride
tab 1 mg
4
ropinirole hydrochloride tab
0.25 mg (Requip)
1
REQUIP – ropinirole hydrochloride
tab 2 mg
4
ropinirole hydrochloride tab
0.5 mg (Requip)
1
REQUIP – ropinirole hydrochloride
tab 3 mg
4
ropinirole hydrochloride tab
1 mg (Requip)
1
REQUIP – ropinirole hydrochloride
tab 4 mg
4
ropinirole hydrochloride tab
2 mg (Requip)
1
REQUIP – ropinirole hydrochloride
tab 5 mg
4
ropinirole hydrochloride tab
3 mg (Requip)
1
REQUIP XL – ropinirole
hydrochloride tab sr 24hr 2 mg
(base equivalent)
4
ropinirole hydrochloride tab
4 mg (Requip)
1
1
REQUIP XL – ropinirole
hydrochloride tab sr 24hr 4 mg
(base equivalent)
4
ropinirole hydrochloride tab
5 mg (Requip)
selegiline hcl cap 5 mg (Eldepryl)
2
selegiline hcl tab 5 mg
2
REQUIP XL – ropinirole
hydrochloride tab sr 24hr 6 mg
(base equivalent)
4
SINEMET – carbidopa & levodopa
tab 10-100 mg
4
4
SINEMET – carbidopa & levodopa
tab 25-100 mg
4
REQUIP XL – ropinirole
hydrochloride tab sr 24hr 8 mg
(base equivalent)
4
REQUIP XL – ropinirole
hydrochloride tab sr 24hr 12 mg
(base equivalent)
4
SINEMET – carbidopa & levodopa
tab 25-250 mg
SINEMET CR – carbidopa &
levodopa tab cr 25-100 mg
4
ropinirole hydrochloride tab sr
24hr 12 mg (base equivalent)
(Requip xl)
2
SINEMET CR – carbidopa &
levodopa tab cr 50-200 mg
4
4
ropinirole hydrochloride tab sr
24hr 2 mg (base equivalent)
(Requip xl)
2
STALEVO 100 – carbidopalevodopa-entacapone tabs
25-100-200 mg
4
ropinirole hydrochloride tab sr
24hr 4 mg (base equivalent)
(Requip xl)
2
STALEVO 125 – carbidopalevodopa-entacapone tabs
31.25-125-200 mg
STALEVO 150 – carbidopalevodopa-entacapone tabs
37.5-150-200 mg
4
82
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
STALEVO 200 – carbidopalevodopa-entacapone tabs
50-200-200 mg
4
STALEVO 50 – carbidopalevodopa-entacapone tabs
12.5-50-200 mg
4
STALEVO 75 – carbidopalevodopa-entacapone tabs
18.75-75-200 mg
4
trihexyphenidyl hcl elixir 0.4 mg/
ml
2
trihexyphenidyl hcl tab 2 mg
1
trihexyphenidyl hcl tab 5 mg
1
5
riluzole tab 50 mg (Rilutek)
5
•
•
MUSCULOSKELETAL THERAPY AGENTS
1
baclofen tab 10 mg
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
Quantity Limits
Restricted Access
Drug Name
FEXMID – cyclobenzaprine hcl tab
7.5 mg
NEUROMUSCULAR AGENTS
RILUTEK – riluzole tab 50 mg
Prior Review
Specialty
Drug Name
Drug Tier
2015
4
metaxalone tab 800 mg (Skelaxin) 2
1
methocarbamol tab 500 mg
(Robaxin)
1
methocarbamol tab 750 mg
(Robaxin-750)
1
orphenadrine citrate tab sr 12hr
100 mg
4
PARAFON FORTE DSC –
chlorzoxazone tab 500 mg
4
ROBAXIN – methocarbamol tab
500 mg
4
ROBAXIN-750 – methocarbamol
tab 750 mg
4
SKELAXIN – metaxalone tab 800
mg
4
SOMA – carisoprodol tab 350 mg
tizanidine hcl cap 2 mg (Zanaflex) 2
tizanidine hcl cap 4 mg (Zanaflex) 2
baclofen tab 20 mg
1
carisoprodol tab 350 mg (Soma)
2
chlorzoxazone tab 500 mg
(Parafon forte dsc)
1
tizanidine hcl cap 6 mg (Zanaflex) 2
1
tizanidine hcl tab 2 mg
cyclobenzaprine hcl tab 10 mg
1
tizanidine hcl tab 4 mg (Zanaflex)
1
cyclobenzaprine hcl tab 5 mg
1
4
cyclobenzaprine hcl tab 7.5 mg
(Fexmid)
1
ZANAFLEX – tizanidine hcl cap 2
mg
4
DANTRIUM – dantrolene sodium
cap 25 mg
4
ZANAFLEX – tizanidine hcl cap 4
mg
4
DANTRIUM – dantrolene sodium
cap 50 mg
4
ZANAFLEX – tizanidine hcl cap 6
mg
4
DANTRIUM – dantrolene sodium
cap 100 mg
4
ZANAFLEX – tizanidine hcl tab 4
mg
DANTROLENE SODIUM –
dantrolene sodium cap 100 mg
2
MESTINON – pyridostigmine
bromide tab 60 mg
4
dantrolene sodium cap 25 mg
(Dantrium)
2
pyridostigmine bromide tab
60 mg (Mestinon)
1
dantrolene sodium cap 50 mg
(Dantrium)
2
NUTRITIONAL PRODUCTS
ANTIMYASTHENIC AGENTS
VITAMINS
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
83
DRISDOL – ergocalciferol cap
50000 unit
4
ergocalciferol cap 50000 unit
(Drisdol)
1
MEPHYTON – phytonadione tab 5
mg
4
MULTIVITAMINS
CITRANATAL ASSURE – prenat
w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack
4
CITRANATAL B-CALM – prenat w/
o a w/fecbn-feglu-fa tab 20-1 mg
& vit b6 tab pak
4
CITRANATAL DHA – prenat w/o
a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack
4
CITRANATAL HARMONY –
prenatal w/o a w/fe cbn-dss-fadha cap 29-1-265 mg
4
CITRANATAL HARMONY –
prenatal w/o vit a w/ fe cbn-dssfa-dha cap 30-1-260 mg
4
CITRANATAL HARMONY – prenat
w/o a w/fe fum-fe cbn-dss-fa-dha
cap 27-1-260 mg
4
CITRANATAL RX – prenatal w/o a
w/ fe carbonyl-fe gluc-dss-fa tab
27-1mg
4
ACTIVE OB – prenatal w/o a w/fe
cbn-fa-dha cap 20-1-320 mg
4
ATABEX EC – prenatal vit w/ dssiron carbonyl-fa tab dr 29-1 mg
4
ATABEX PRENATAL – prenatal vit
w/ iron carbonyl-fa tab 65-1 mg
4
b-complex w/ c & folic acid cap
1 mg (Nephrocaps)
1
b-complex w/ c & folic acid tab
1 mg (Nephro-vite rx)
1
b-complex w/ c & folic acid tab
1
B-NEXA – prenatal w/ calcium-vit
b6-fa-ginger tab 1.22 mg
4
BAL-CARE DHA – prenat w/fe
poly-na fered-fa tab 27-1 &
omega cap dr 430mg
4
CITRANATAL 90 DHA – prenat w/
o a w/fecbn-fegl-dss-fa tab 90
&dha cap 300mg pak
4
BP FOLINATAL PLUS B – prenatal 4
w/ calcium carbonate-b6-b12-fa
tab 1 mg
BP MULTINATAL PLUS – prenatal 4
w/o a vit w/ fe fumarate-fa tab
30-1 mg
BP MULTINATAL PLUS – prenatal 4
w/o a vit w/ fe fum-fa tab chew
40-1 mg
4
C-NATE DHA – prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-200
mg
4
CALCIUM PNV – prenatal w/o
vit a w/ fe fum-fa-omega 3 cap
28-1-250 mg
4
CHOICE-OB+DHA – prenatal mv
w/fe poly-fa chw 29-1 mg & dha
cap 250 mg pak
CO-NATAL FA – prenatal vit w/ fe
fumarate-fa tab 29-1 mg
4
84
COMPLETE NATAL DHA – prenat- 4
fe bis-fe prot succ-fa-ca tab &
omega 3 cap 250 pk
COMPLETENATE – prenatal vit w/ 4
fe fumarate-fa chew tab 29-1 mg
4
CONCEPT DHA – prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
CONCEPT OB – prenatal w/o a w/ 4
fe fum-fe poly-fa cap 130-92.4-1
mg
4
DUET DHA – prenat w/fe poly-na
fered-fa tab 25-1 & omega cap
400 mg
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
DUET DHA BALANCED – prenat
w/fe poly-na fered-fa tab 25-1 &
omega cap 267 mg
4
GESTICARE DHA – prenatal w/fe
fum-fa tab dr 27-1 mg & dha cap
250 mg pack
4
DUET DHA BALANCED – prenat
w/fe poly-na fered-fa tab 27-1 &
omega cap dr 380mg
4
HEMENATAL OB – prenat vit-fe
poly cmplx-fe heme poly-fa tab
28-6-1 mg
4
DUET DHA 400 – prenat w/fe polyna fered-fa tab 25-1 & omega
cap 400 mg
4
HEMENATAL OB + DHA – prenatfe poly cmplx-fe heme poly-fa tab
& omega 3 cap pck
4
ELITE-OB – prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
4
4
ESCAVITE LQ – pediatric multiple
vitamins w/ fl-fe drops 0.25-6 mg/
ml
1
INATAL ADVANCE – prenatal vit
w/ dss-iron carbonyl-fa tab 90-1
mg
INATAL GT – prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
4
EXTRA-VIRT PLUS DHA –
prenatal w/o vit a w/ fe fum-docfa-dha cap 29-1.25-350 mg
4
INATAL ULTRA – prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
4
4
INFANATE BALANCE – prenatal
w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg
4
FOCALGIN-B – prenatal w/
calcium-vit b6-fa-ginger tab 1.22
mg
FOLBECAL – prenatal w/ calcium
carbonate-b6-b12-fa tab 1 mg
INFANATE PLUS – prenat w/o a
w/fe fum-fe cbn-dss-fa-dha cap
27-1-260 mg
4
4
FOLCAL DHA – prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
4
L-METHYLFOLATE PNV DHA –
prenat w/fe fum-l methylfolate-fadha cap 27-1.13-0.4 mg
4
FOLCAPS OMEGA 3 – prenatal vit
w/ fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
4
FOLET DHA – prenat w/fecbnbisg-methylf-dss tab dr & dha
cap pak
4
FOLET ONE – prenat w/o a w/
fecbn-bisg-methylf-dss-dha cap
38-1-225 mg
4
FOLIVANE-OB – prenatal w/o a w/
fe fum-fe poly-fa cap 130-92.4-1
mg
4
FOLIVANE-PRX DHA NF –
prenatal w/o vit a w/fe fum-dssfa-dha cap 30-1.24-265 mg
4
M-VIT – prenatal vit w/ fe fumarate- 1
fa tab 27-1 mg
4
MACNATAL CN DHA – prenatal
w/o a w/fe cbn-dss-fa-dha cap
28-1-250 mg
4
MARNATAL-F – prenatal w/o vit a
w/ fe polysac cmplx-fa cap 60-1
mg
4
MULTI PRENATAL – prenatal vit
w/ fe fumarate-fa tab 27-0.8 mg
MYNATAL – prenatal multivitamins 4
& minerals w/ iron & fa cap 1 mg
4
MYNATAL ADVANCE – prenatal
vit w/ dss-iron carbonyl-fa tab
90-1 mg
4
MYNATAL PLUS – prenatal vit w/
fe fumarate-fa tab 65-1 mg
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85
MYNATAL ULTRACAPLET –
prenatal vit w/ dss-iron carbonylfa tab 90-1 mg
4
NEXA PLUS – prenatal w/o vit
a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
4
MYNATAL-Z – prenatal vit w/ fe
fumarate-fa tab 65-1 mg
4
NUTRI-TAB OB – prenatal vit w/o
vit a w/ fe bisglycinate-fa tab 32-1
mg
4
NUTRI-TAB OB + DHA – prenat w/
o a w/ fe bisglyc-fa tab 32-1 mg &
omega cap pack
4
O-CAL FA – prenatal vit w/ fe
fumarate-fa tab 27-1 mg
1
O-CAL PRENATAL – prenatal vit
w/ fe fumarate-fa tab 15-1 mg
4
OB COMPLETE – prenatal vit w/
iron carbonyl-fa tab 50-1.25 mg
4
OB COMPLETE ONE – prenatal
w/o a w/fecbn-fe asp glyc-fa-fish
cap 50-1-476 mg
4
OB COMPLETE PETITE – prenat
w/o a w/fecbn-feaspglyc-faomega cap 35-5-1-200 mg
4
OB COMPLETE PREMIER –
prenatal vit w/ fe cbn-fe asp glycfa tab 30-20-1 mg
4
OB COMPLETE/DHA – prenat w/
iron cbn-fe asp glyc-fa-omega
cap 30-10-1-200 mg
4
OB-NATAL ONE – prenatal vit w/
fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
4
OBSTETRIX DHA – prenat w/
fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak
4
OBSTETRIX EC – prenatal vit w/
dss-iron carbonyl-fa tab 29-1 mg
4
PAIRE OB – prenat w/ fe poly
cmplx-fe asp-fe gly-fa tab & dha
cap pak
4
pediatric multiple vitamins w/ flfe drops 0.25-10 mg/ml
1
pediatric multiple vitamins w/
fluoride chew tab 0.25 mg
1
MYNATE 90 PLUS – prenatal vit w/ 4
dss-fe fumarate-fa tab cr 90-1 mg
4
NATACHEW – prenatal vit w/ fe
fum-fe bisglycin-fa chew tab 28-1
mg
NATAL-V RX – prenatal vit w/ iron 4
carbonyl-fa tab 29-1 mg
4
NATALVIRT CA – prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap
300 mg pack
4
NATALVIRT 90 DHA – prenat w/
o a w/fecbn-fegl-dss-fa tab 90
&dha cap 300mg pak
4
NATALVIT – prenatal vit w/ fe
fumarate-fa tab 75-1 mg
4
NATELLE ONE – prenatal w/o
vit a w/ fe fum-fa-omega 3 cap
28-1-250 mg
4
NEEVO DHA – prenat w/o a w/
fefum-methylfol-omegas cap
27-1.13 mg
NEPHRO-VITE RX – b-complex w/ 4
c & folic acid tab 1 mg
NEPHROCAPS – b-complex w/ c & 4
folic acid cap 1 mg
4
NESTABS – prenatal vit w/o vit a
w/ fe bisglycinate-fa tab 32-1 mg
NESTABS ABC – prenatal w/o vit a 4
w/fe polysac-fa-ca tab & omega 3
cap
4
NESTABS DHA – prenat w/o a
w/ fe bisglyc-fa tab 32-1 mg &
omega cap pack
NEWGEN – prenatal vit w/o vit a w/ 4
fe bisglycinate-fa tab 32-1 mg
86
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pediatric multiple vitamins w/
fluoride chew tab 1 mg
1
pediatric multiple vitamins w/
fluoride soln 0.25 mg/ml
4
1
PNV-TOTAL – prenat w/ fe cbnfe bisglyc-fa-fish oil cap 35-5-1.2
mg
4
pediatric multiple vitamins w/
fluoride soln 0.5 mg/ml
1
PNV-VP-U – prenatal w/o a vit w/
fe fumarate-fa cap 106.5-1 mg
4
pediatric vitamins acd w/
fluoride soln 0.25 mg/ml
1
PR NATAL 400 – prenat-fe bis-fe
prot succ-fa-ca tab & omega 3
cap 400 pk
pediatric vitamins acd w/
fluoride soln 0.5 mg/ml
1
4
PNV FERROUS FUMARATE/
DOCU – prenatal vit w/ dss-fe
fumarate-fa tab 29-1 mg
4
PR NATAL 400 EC – prenat-fe bisfe prot succ-fa-ca tab & omega
cap dr 400 pk
4
PNV FOLIC ACID + IRON MUL –
prenatal vit w/ fe fumarate-fa tab
27-1 mg
1
PR NATAL 430 – prenat-fe bis-fe
prot succ-fa-ca tab & omega 3
cap 430 pk
4
PNV OB+DHA – prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap
250 mg pack
4
PR NATAL 430 EC – prenat-fe bisfe prot succ-fa-ca tab & omega
cap dr 430 pk
4
PNV PRENATAL PLUS MULTIVI –
prenatal vit w/ fe fumarate-fa tab
27-1 mg
1
PREFERA OB – prenat vit-fe poly
cmplx-fe heme poly-fa tab 28-6-1
mg
4
PNV TABS 29-1 – prenatal vit w/
iron carbonyl-fa tab 29-1 mg
4
PREFERA OB + DHA – prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
4
PNV-DHA – prenat w/o a w/
fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
4
PREFERAOB ONE – prenat-fe
poly cmplx-fe heme poly-fa-dha
cap 22-6-1-200 mg
4
PNV-DHA+DOCUSATE – prenatal
w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg
4
PREFOL-DHA – prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg
4
PNV-FIRST – prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
4
PRENAISSANCE – prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
4
PNV-OB/DHA – prenatal mv w/fe
fum-fa tab 65-1 mg & dha cap
250 mg pack
4
PRENAISSANCE BALANCE –
prenatal w/o vit a w/ fe cbn-dssfa-dha cap 30-1-260 mg
4
PNV-OMEGA – prenat w/o a w/ fe
fumerate-methylfolate-fa-omega
3 cap
4
PRENAISSANCE DHA – prenat w/
o a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack
4
PNV-SELECT – prenatal vit
w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg
4
PRENAISSANCE HARMONY DHA
– prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 380mg
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87
PRENAISSANCE NEXT – prenatal
w/ calcium-vit b6-fa-ginger tab
1.2 mg
4
PRENATAL VITAMINS PLUS –
prenatal vit w/ fe fumarate-fa tab
27-1 mg
1
PRENAISSANCE NEXT-B –
prenatal w/ calcium-vit b6-faginger tab 1.22 mg
4
PRENATAL 19 – prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
4
4
PRENAISSANCE PLUS – prenatal
w/o a w/fe cbn-dss-fa-dha cap
28-1-250 mg
4
PRENATAL 19 – prenatal vit w/
dss-fe fumarate-fa tab 29-1 mg
PRENATAL-U – prenatal w/o a vit
w/ fe fumarate-fa cap 106.5-1 mg
4
PRENAISSANCE PROMISE –
prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack
4
PRENATE – prenat mv & min w/ lmethylfolate-fa chew tab 0.6-0.4
mg
4
PRENAISSANCE 90 DHA – prenat
w/o a w/fecbn-fegl-dss-fa tab 90
&dha cap 300mg pak
4
PRENATE AM – prenatal w/
calcium-vit b6-vit b12-fa-ginger
tab 1 mg
4
PRENAPLUS – prenatal vit w/ fe
fumarate-fa tab 27-1 mg
1
4
PRENATABS FA – prenatal vit w/
fe fumarate-fa tab 29-1 mg
4
PRENATE DHA – prenat w/o a
w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg
4
PRENATE DHA – prenat w/o a
w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
4
PRENATABS RX – prenatal vit w/
iron carbonyl-fa tab 29-1 mg
PRENATAL – prenatal vit w/ fe
fumarate-fa tab 27-0.8 mg
4
4
PRENATAL – prenatal vit w/ fe
fumarate-fa tab 27-1 mg
1
PRENATE ELITE – prenatal w/
fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg
4
PRENATAL AD – prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
4
PRENATE ELITE – prenatal vit
w/ fe fum-methylfolate-fa tab
26-0.6-0.4 mg
PRENATAL LOW IRON – prenatal
vit w/ fe fumarate-fa tab 27-0.8
mg
4
PRENATE ENHANCE – prenat w/
o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-400 mg
4
PRENATAL LOW IRON – prenatal
vit w/ fe fumarate-fa tab 27-1 mg
1
PRENATE ESSENTIAL – prenat w/ 4
o a w/feasp-methylf-fa-omeg cap
29-0.6-0.4-340 mg
PRENATE ESSENTIAL – prenat w/ 4
o a w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
4
PRENATE MINI – prenat w/oa
w/fecb-feasp-meth-fa-dha cap
18-0.6-0.4-350 mg
4
PRENATE PIXIE – prenat w/o a
w/feaspg-methfol-fa-dha cap
10-0.6-0.4-200 mg
PRENATAL ONE DAILY – prenatal 4
vit w/ fe fumarate-fa tab 27-0.8
mg
PRENATAL PLUS – prenatal vit w/ 1
fe fumarate-fa tab 27-1 mg
PRENATAL PLUS IRON – prenatal 4
vit w/ iron carbonyl-fa tab 29-1
mg
88
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PRENATE RESTORE – prenat w/
o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-400 mg
4
QUFLORA PEDIATRIC – pediatric
multiple vitamins w/ fluoride soln
0.5 mg/ml
1
PRENATE STAR – prenatal vit w/
fe asparto glycinate-fa tab 20-1
mg
4
R-NATAL OB – prenatal w/o a w/fe
cbn-fa-dha cap 20-1-320 mg
4
4
PRENA1 CHEW – prenat w/ b2b6-b12-d3-folic acid chew tab 1.4
mg
4
REAPHIRM – prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
4
RELNATE DHA – prenatal vit w/
fe fum-fa-omega 3 cap 28-1-200
mg
4
PRENA1 PEARL – prenat w/oa
w/fefum-na fered-fa-dha cap cr
30-1.4-200 mg
PRENA1 PLUS/QUATREFOLIC
– prenat w/o a w/ fe chelate-l
methylfol-fa tab & dha cap pk
RIGHT STEP PRENATAL –
prenatal vit w/ fe fumarate-fa tab
27-0.8 mg
4
4
PRENA1/QUATREFOLIC – prenat
w/o a w/fefum-methfol-fa-dha cap
30-0.6-0.4-200 mg
SE-NATAL 19 – prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
4
4
PRENEXA – prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
4
PREPLUS – prenatal vit w/ fe
fumarate-fa tab 27-1 mg
1
PREQUE 10 – prenatal mv w/
fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg
4
PRETAB – prenatal vit w/ fe
fumarate-fa tab 29-1 mg
4
PROVIDA OB – prenatal w/o a w/fe 4
fum-fe poly-fa cap 20-20-1.25 mg
4
PUREFE OB PLUS – prenatal
w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg
QUFLORA PEDIATRIC – pediatric 1
multiple vitamins w/ fluoride chew
tab 0.25 mg
QUFLORA PEDIATRIC – pediatric 1
multiple vitamins w/ fluoride chew
tab 1 mg
QUFLORA PEDIATRIC – pediatric 1
multiple vitamins w/ fluoride soln
0.25 mg/ml
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SE-NATAL 19 – prenatal vit w/ dss- 4
fe fumarate-fa tab 29-1 mg
SE-TAN DHA – prenatal w/fe fum- 4
fe poly -fa-omega 3 cap 15-15-1
mg
4
SELECT-OB – prenatal vit w/ fe
polysac cmplx-fa chew tab 29-1
mg
4
SELECT-OB – prenat w/
fepolycmplx-methylfol-fa chew
tab 29-0.6-0.4 mg
4
SELECT-OB+DHA – prenatal mv
w/fe poly-fa chw 29-1 mg & dha
cap 250 mg pak
4
SETON ET-EC – prenat-fe bis-fe
prot succ-fa-ca tab & omega cap
dr 430 pk
4
SETONET – prenat-fe bis-fe prot
succ-fa-ca tab & omega 3 cap
430 pk
4
STROVITE – b-complex w/ c &
folic acid tab
4
TARON-BC – prenat w/o a w/ fe
cbnyl-fa tab 20-1 mg & vit b6 tab
pak
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
89
TARON-C DHA – prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
4
TARON-DUO EC – prenat-fe bis-fe
prot succ-fa-ca tab & omega cap
dr 400 pk
4
TARON-PREX – prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
30-1.2-265 mg
4
THERANATAL CORE NUTRITION
– prenatal vit w/ fe fumarate-fa
tab 27-1 mg
1
TL FOLATE – prenatal vit w/
fe fum-methylfolate-fa tab
27-0.5-0.5 mg
4
TL-CARE DHA – prenatal w/fe
fumarate-fa-dss-fish oil cap
27-1-500 mg
4
TL-SELECT – prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
4
TL-SELECT DHA – prenatal w/o
vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
4
TRI-TABS DHA – prenat w/o a
w/ fe bisglyc-fa tab 32-1 mg &
omega cap pack
4
TRIADVANCE – prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
4
TRICARE – prenatal vit w/ fe
fumarate-fa tab 27-1 mg
1
TRICARE PRENATAL COMPLEAT
– prenat w/o a fefum-fa tab 27-1
mg & fish oil chew cap pak
4
TRICARE PRENATAL DHA ONE
– prenatal w/fe fumarate-fa-dssfish oil cap 27-1-500 mg
4
TRINATAL GT – prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
4
TRINATAL RX 1 – prenatal vit w/ fe 4
fumarate-fa tab 60-1 mg
90
TRINATAL ULTRA – prenatal vit w/ 4
dss-iron carbonyl-fa tab 90-1 mg
4
TRINATE – prenatal vit w/ fe
fumarate-fa tab 28-1 mg
4
TRIVEEN-DUO DHA – prenatfe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk
4
TRIVEEN-PRX RNF – prenatal w/
o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg
ULTIMATE OB DHA – prenat w/ fe 4
poly cmplx-fe asp-fe gly-fa tab &
dha cap pak
4
ULTIMATECARE ONE – prenatal
vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg
4
ULTIMATECARE ONE NF –
prenatal w/fe cbnyl-fe asp glycfa-dss-omega cap 20-7-1 mg
ULTRA TABS – prenatal vit w/ dss- 4
iron carbonyl-fa tab 90-1 mg
V-NATAL – prenatal vit w/o vit a w/ 4
fe bisglycinate-fa tab 32-1 mg
V-NATAL DHA – prenat w/o a w/ fe 4
bisglyc-fa tab 32-1 mg & omega
cap pack
4
VEMAVITE-PRX 2 – prenatal w/
o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
4
VENA-BAL DHA – prenat w/fe
poly-na fered-fa tab 27-1 &
omega cap dr 430mg
4
VENATAL-FA – prenatal vit w/ fe
fumarate-fa tab 29-1 mg
4
VINACAL – prenatal w/o a w/
fe carbonyl-fe gluc-dss-fa tab
27-1mg
4
VINACAL B – prenat w/o a w/
fecbn-feglu-fa tab 20-1 mg & vit
b6 tab pak
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VINATE AZ EXTRA – prenatal vit
w/ fe bisglycinate chelate-fa tab
29-1 mg
4
VINATE C – prenatal w/o a vit w/ fe 4
fumarate-fa tab 30-1 mg
VINATE CALCIUM – prenatal vit w/ 4
iron carbonyl-fe gluc-fa tab 27-1
mg
VINATE CARE – prenatal w/o a vit 4
w/ fe fum-fa tab chew 40-1 mg
4
VINATE DHA RF – prenat w/o a
w/fefum-methylfol-omegas cap
27-1.13 mg
4
VINATE GT – prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
4
VINATE IC – prenatal w/o a w/fe
fum-fe poly-fa cap 162.115.2-1
mg
4
VINATE II – prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1
mg
4
VINATE M – prenatal vit w/ sel-fe
fumarate-fa tab 27-1 mg
4
VINATE ONE – prenatal vit w/ fe
fumarate-fa tab 60-1 mg
4
VINATE ULTRA – prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
4
VIRT NATE – prenatal vit w/ fe
fumarate-fa tab 28-1 mg
4
VIRT-ADVANCE – prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
4
VIRT-BAL DHA PLUS – prenat w/
fe poly-na fered-fa tab 27-1 &
omega cap dr 380mg
VIRT-C DHA – prenatal w/fe fum-fe 4
poly -fa-omega 3 cap 53.5-38-1
mg
VIRT-CARE ONE – prenatal vit w/ 4
fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
VIRT-PN – prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
4
VIRT-PN DHA – prenat w/o a
w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
4
VIRT-PN PLUS – prenat w/o a
w/ fe fumerate-methylfolate-faomega 3 cap
4
VIRT-SELECT – prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
4
VIRT-VITE GT – prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
4
VIRTPREX – prenatal w/o vit a w/
fe fum-dss-fa-dha cap 26-1.2-300
mg
4
VITA-PREN – prenatal vit w/
docusate-iron-fa tab 65-1 mg
4
VITAFOL ULTRA – prenat w/
fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg
4
VITAFOL-NANO – prenatal w/
o a w/ fefum-l methylfol-fa tab
18-0.6-0.4 mg
4
VITAFOL-OB – prenatal vit w/ fe
fumarate-fa tab 65-1 mg
4
VITAFOL-OB+DHA – prenatal mv
w/fe fum-fa tab 65-1 mg & dha
cap 250 mg pack
4
VITAFOL-ONE – prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
4
VITAFOL-PN – prenatal vit w/ fe
fumarate-fa tab 65-1 mg
4
VITAMEDMD ONE RX/
QUATREFO – prenat w/o a
w/fefum-methfol-fa-dha cap
30-0.6-0.4-200 mg
4
VITAMEDMD PLUS RX/QUATRE
– prenat w/o a w/ fe chelate-l
methylfol-fa tab & dha cap pk
4
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91
VITAMEDMD REDICHEW RX –
prenat w/ b2-b6-b12-d3-folic acid
chew tab 1.4 mg
4
ZATEAN-PN DHA – prenat w/o
a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
4
VITAPEARL – prenat w/oa w/
fefum-na fered-fa-dha cap cr
30-1.4-200 mg
4
ZATEAN-PN PLUS – prenat w/o a
w/ fe fumerate-methylfolate-faomega 3 cap
4
VIVA DHA – prenatal vit w/ fe fumfa-omega 3 cap 28-1-200 mg
4
ZINGIBER – prenatal w/ calcium-vit 4
b6-fa-ginger tab 1.2 mg
VOL-NATE – prenatal vit w/ fe
fumarate-fa tab 28-1 mg
4
MINERALS and ELECTROLYTES
VOL-PLUS – prenatal vit w/ fe
fumarate-fa tab 27-1 mg
EFFER-K – potassium
bicarbonate-citric acid effer tab
10 meq
4
1
VOL-TAB RX – prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
4
4
VP CH ULTRA – prenat w/o a w/
fe fum-fe cbn-dss-fa-dha cap
27-1-260 mg
4
EFFER-K – potassium
bicarbonate-citric acid effer tab
20 meq
4
VP-CH PLUS – prenatal w/o a w/fe
cbn-dss-fa-dha cap 29-1-265 mg
4
K-PHOS NEUTRAL – pot phos
monobasic w/sod phos di &
monobas tab 155-852-130mg
4
VP-CH-PNV – prenatal w/o vit a w/
fe cbn-dss-fa-dha cap 30-1-260
mg
4
K-TAB – potassium chloride tab cr
10 meq
K-TAB – potassium chloride tab cr
20 meq (1500 mg)
4
VP-GGR-B6 PRENATAL –
prenatal w/ calcium-vit b6-faginger tab 1.2 mg
4
LURIDE – sodium fluoride chew
tab 0.25 mg f (from 0.55 mg naf)
4
VP-HEME OB – prenat vit-fe poly
cmplx-fe heme poly-fa tab 28-6-1
mg
LURIDE – sodium fluoride chew
tab 0.5 mg f (from 1.1 mg naf)
4
4
LURIDE – sodium fluoride chew
tab 1 mg f (from 2.2 mg naf)
4
VP-HEME OB + DHA – prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
4
LURIDE – sodium fluoride soln 0.5
mg/ml f (from 1.1 mg/ml naf)
4
VP-HEME ONE – prenat-fe poly
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
4
VP-PNV-DHA – prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-215.8
mg
4
ZATEAN-CH – prenatal w/o a w/fe
cbn-dss-fa-dha cap 27-1-250 mg
4
ZATEAN-PN – prenatal vit w/
fe fum-methylfolate-fa tab
27-0.6-0.4 mg
4
92
MICRO-K – potassium chloride cap 4
cr 8 meq
MICRO-K – potassium chloride cap 4
cr 10 meq
2
pot bicarbonate & chloride effer
tab 25 meq
1
pot phos monobasic w/sod
phos di & monobas tab
155-852-130mg (K-phos neutral)
1
potassium bicarbonate effer tab
25 meq
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
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Drug Tier
2015
potassium chloride cap cr 10
meq (Micro-k)
1
ANIMI-3 – folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg
4
potassium chloride cap cr 8 meq
(Micro-k)
1
5
•
POTASSIUM CHLORIDE ER –
potassium chloride tab cr 20 meq
(1500 mg)
4
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 25 mcg/ml
5
•
potassium chloride
microencapsulated crys cr tab
10 meq
1
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 25 mcg/0.42ml
5
•
potassium chloride
microencapsulated crys cr tab
20 meq
1
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 40 mcg/ml
5
•
potassium chloride oral liq 10%
(20 meq/15ml)
1
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 40 mcg/0.4ml
5
•
potassium chloride oral liq 20%
(40 meq/15ml)
1
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 60 mcg/ml
potassium chloride powder
packet 20 meq
1
5
•
potassium chloride tab cr 10
meq (K-tab)
1
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 60 mcg/0.3ml
5
•
potassium chloride tab cr 8 meq
(600 mg)
1
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 100 mcg/ml
1
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 100 mcg/0.5ml
5
SODIUM FLUORIDE – sodium
fluoride tab 1 mg f (from 2.2 mg
naf)
•
1
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 150 mcg/0.75ml
5
sodium fluoride chew tab
0.25 mg f (from 0.55 mg naf)
(Luride)
•
1
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 150 mcg/0.3ml
5
sodium fluoride chew tab 0.5 mg
f (from 1.1 mg naf) (Luride)
•
sodium fluoride chew tab 1 mg f
(from 2.2 mg naf) (Luride)
1
5
•
sodium fluoride soln 0.125 mg/
drop f (0.275 mg/drop naf)
2
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 200 mcg/ml
5
•
sodium fluoride soln 0.5 mg/ml f
(from 1.1 mg/ml naf) (Luride)
1
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 200 mcg/0.4ml
zinc sulfate cap 220 mg (50 mg
elemental zn)
1
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 300 mcg/ml
5
•
HEMATOLOGICAL AGENTS
Quantity Limits
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Quantity Limits
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Drug Name
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2015
HEMATOPOIETIC AGENTS
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
93
5
3
FOLTRATE – cobalamine
combination tab
3
B-6 FOLIC ACID – cobalamine
combination cap
2
GRANIX – tbo-filgrastim soln
prefilled syringe 300 mcg/0.5ml
5
BP VIT 3 – folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg
•
4
GRANIX – tbo-filgrastim soln
prefilled syringe 480 mcg/0.8ml
5
CORVITE 150 – iron-folic acid-vit
c-vit b6-vit b12-zinc tab 150-1.25
mg
•
4
cyanocobalamin inj 1000 mcg/ml
1
DROXIA – hydroxyurea cap 200
mg
3
•
HEMATRON-AF – iron-docusateb12-folic acid-c-e-cu-biotin tab
150-1 mg
4
DROXIA – hydroxyurea cap 300
mg
3
•
ICAR-C PLUS – iron-vit c-vit b12folic acid tab 100-250-0.025-1
mg
3
•
iron-docusate-b12-folic acidc-e-cu-biotin tab 150-1 mg
(Hematron-af)
1
DROXIA – hydroxyurea cap 400
mg
EPOGEN – epoetin alfa inj 2000
unit/ml
5
•
1
EPOGEN – epoetin alfa inj 3000
unit/ml
5
•
iron-folic acid-vit c-vit b6-vit b12zinc tab 150-1.25 mg (Corvite
150)
EPOGEN – epoetin alfa inj 4000
unit/ml
5
EPOGEN – epoetin alfa inj 10000
unit/ml
5
EPOGEN – epoetin alfa inj 20000
unit/ml
5
fe fum-iron polysacch complexfa-b cmplx-c-zn-mn-cu cap
(Tandem plus)
1
fe fumarate w/ b12-vit c-fa-ifc
cap 110-0.015-75-0.5-240 mg
1
fe fumarate-vit c-vit b12-fa cap
460 (151 fe)-60-0.01-1 mg
1
ferrous fumarate-folic acid tab
324-1 mg
1
FOLGARD RX – folic acid-vitamin
b6-vitamin b12 tab 2.2-25-1 mg
4
94
•
•
1
folic acid-vitamin b6-vitamin b12
tab 2.2-25-0.5 mg
1
folic acid-vitamin b6-vitamin b12
tab 2.2-25-1 mg (Folgard rx)
1
1
iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg (Icar-c plus)
5
NEULASTA – pegfilgrastim inj 6
mg/0.6ml
5
NEULASTA DELIVERY KIT –
pegfilgrastim inj 6 mg/0.6ml
5
NEUPOGEN – filgrastim inj 300
mcg/ml
5
NEUPOGEN – filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
5
NEUPOGEN – filgrastim inj 300
mcg/0.5ml (600 mcg/ml)
5
NEUPOGEN – filgrastim inj 480
mcg/0.8ml (600 mcg/ml)
5
PROCRIT – epoetin alfa inj 2000
unit/ml
5
PROCRIT – epoetin alfa inj 3000
unit/ml
•
•
•
•
•
•
•
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 500 mcg/ml
•
folic acid tab 1 mg
Restricted Access
•
Prior Review
5
•
Drug Name
Specialty
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 300 mcg/0.6ml
Drug Name
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
2
PROCRIT – epoetin alfa inj 10000
unit/ml
5
•
enoxaparin sodium inj
120 mg/0.8ml (Lovenox)
2
PROCRIT – epoetin alfa inj 20000
unit/ml
5
•
enoxaparin sodium inj 150 mg/
ml (Lovenox)
2
PROCRIT – epoetin alfa inj 40000
unit/ml
5
•
enoxaparin sodium inj
30 mg/0.3ml (Lovenox)
2
TANDEM PLUS – fe fum-iron
polysacch complex-fa-b cmplx-czn-mn-cu cap
4
enoxaparin sodium inj
300 mg/3ml (Lovenox)
2
enoxaparin sodium inj
40 mg/0.4ml (Lovenox)
2
ANTICOAGULANTS
ARIXTRA – fondaparinux sodium
inj 2.5 mg/0.5ml
5
enoxaparin sodium inj
60 mg/0.6ml (Lovenox)
2
ARIXTRA – fondaparinux sodium
inj 5 mg/0.4ml
5
enoxaparin sodium inj
80 mg/0.8ml (Lovenox)
2
ARIXTRA – fondaparinux sodium
inj 7.5 mg/0.6ml
5
fondaparinux sodium inj
10 mg/0.8ml (Arixtra)
2
ARIXTRA – fondaparinux sodium
inj 10 mg/0.8ml
5
fondaparinux sodium inj
2.5 mg/0.5ml (Arixtra)
2
COUMADIN – warfarin sodium tab
1 mg
4
fondaparinux sodium inj
5 mg/0.4ml (Arixtra)
2
COUMADIN – warfarin sodium tab
2 mg
4
fondaparinux sodium inj
7.5 mg/0.6ml (Arixtra)
2
COUMADIN – warfarin sodium tab
2.5 mg
4
HEPARIN SODIUM – heparin
sodium (porcine) inj 2500 unit/ml
1
COUMADIN – warfarin sodium tab
3 mg
4
heparin sodium (porcine) inj
1000 unit/ml
1
COUMADIN – warfarin sodium tab
4 mg
4
heparin sodium (porcine) inj
10000 unit/ml
1
COUMADIN – warfarin sodium tab
5 mg
4
heparin sodium (porcine) inj
20000 unit/ml
1
COUMADIN – warfarin sodium tab
6 mg
4
heparin sodium (porcine) inj
5000 unit/ml
1
COUMADIN – warfarin sodium tab
7.5 mg
4
heparin sodium (porcine) pf inj
5000 unit/0.5ml
1
COUMADIN – warfarin sodium tab
10 mg
4
1
ELIQUIS – apixaban tab 2.5 mg
4
heparin sodium (porcine) 100
unit/ml in d5w (Heparin sodium/
d5w)
ELIQUIS – apixaban tab 5 mg
4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
enoxaparin sodium inj 100 mg/
ml (Lovenox)
Restricted Access
•
Prior Review
5
Drug Name
Specialty
PROCRIT – epoetin alfa inj 4000
unit/ml
Drug Name
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
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95
heparin sodium (porcine) 2 unit/
ml in sodium chloride 0.9%
(Heparin sodium/sodiu)
1
warfarin sodium tab 10 mg
(Coumadin)
1
heparin sodium (porcine) 40
unit/ml in d5w
warfarin sodium tab 2 mg
(Coumadin)
1
1
heparin sodium (porcine) 50
unit/ml in d5w (Heparin sodium/
d5w)
warfarin sodium tab 2.5 mg
(Coumadin)
1
1
warfarin sodium tab 3 mg
(Coumadin)
1
warfarin sodium tab 4 mg
(Coumadin)
1
warfarin sodium tab 5 mg
(Coumadin)
1
warfarin sodium tab 6 mg
(Coumadin)
1
warfarin sodium tab 7.5 mg
(Coumadin)
1
HEPARIN SODIUM/D5W – heparin 4
sodium (porcine) 50 unit/ml in
d5w
HEPARIN SODIUM/D5W – heparin 4
sodium (porcine) 100 unit/ml in
d5w
4
HEPARIN SODIUM/SODIUM CHL
– heparin sodium (porcine) 2
unit/ml in sodium chloride 0.9%
LOVENOX – enoxaparin sodium inj 4
30 mg/0.3ml
LOVENOX – enoxaparin sodium inj 4
40 mg/0.4ml
LOVENOX – enoxaparin sodium inj 4
60 mg/0.6ml
LOVENOX – enoxaparin sodium inj 4
80 mg/0.8ml
LOVENOX – enoxaparin sodium inj 4
100 mg/ml
LOVENOX – enoxaparin sodium inj 4
120 mg/0.8ml
LOVENOX – enoxaparin sodium inj 4
150 mg/ml
LOVENOX – enoxaparin sodium inj 4
300 mg/3ml
4
PRADAXA – dabigatran etexilate
mesylate cap 75 mg (etexilate
base eq)
4
PRADAXA – dabigatran etexilate
mesylate cap 150 mg (etexilate
base eq)
1
warfarin sodium tab 1 mg
(Coumadin)
96
XARELTO – rivaroxaban tab 10 mg 3
XARELTO – rivaroxaban tab 15 mg 3
XARELTO – rivaroxaban tab 20 mg 3
3
XARELTO STARTER PACK –
rivaroxaban tab starter therapy
pack 15 mg & 20 mg
HEMOSTATICS
AMICAR – aminocaproic acid tab
500 mg
4
AMICAR – aminocaproic acid tab
1000 mg
4
AMICAR – aminocaproic acid
syrup 25%
4
AMINOCAPROIC ACID –
aminocaproic acid tab 1000 mg
4
aminocaproic acid syrup 25%
(Amicar)
2
aminocaproic acid tab 500 mg
(Amicar)
2
tranexamic acid tab 650 mg
(Lysteda)
2
HEMATOLOGICAL AGENTS - MISC.
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
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2015
4
AGRYLIN – anagrelide hcl cap 0.5
mg
4
anagrelide hcl cap 0.5 mg
(Agrylin)
1
anagrelide hcl cap 1 mg
1
BRILINTA – ticagrelor tab 90 mg
4
cilostazol tab 100 mg (Pletal)
1
cilostazol tab 50 mg (Pletal)
1
clopidogrel bisulfate tab 300 mg
(base equiv) (Plavix)
1
clopidogrel bisulfate tab 75 mg
(base equiv) (Plavix)
1
dipyridamole tab 25 mg
(Persantine)
1
dipyridamole tab 50 mg
(Persantine)
1
dipyridamole tab 75 mg
(Persantine)
1
EFFIENT – prasugrel hcl tab 5 mg
(base equiv)
4
1
Quantity Limits
ticlopidine hcl tab 250 mg
Restricted Access
4
Prior Review
PLETAL – cilostazol tab 100 mg
Specialty
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Tier
AGGRENOX – aspirindipyridamole cap sr 12hr 25-200
mg
Specialty
Drug Name
Drug Tier
2015
TOPICAL PRODUCTS
OPHTHALMIC AGENTS
EFFIENT – prasugrel hcl tab 10 mg 4
(base equiv)
FIRAZYR – icatibant acetate inj 30 5
mg/3ml (base equivalent)
1
pentoxifylline tab cr 400 mg
• •
ACULAR – ketorolac tromethamine 4
ophth soln 0.5%
4
ACULAR LS – ketorolac
tromethamine ophth soln 0.4%
ALCAINE – proparacaine hcl ophth 4
soln 0.5%
4
ALPHAGAN P – brimonidine
tartrate ophth soln 0.1%
4
ALPHAGAN P – brimonidine
tartrate ophth soln 0.15%
2
apraclonidine hcl ophth soln
0.5% (base equivalent)
(Iopidine)
1
atropine sulfate ophth soln 1%
(Isopto atropine)
2
azelastine hcl ophth soln 0.05%
(Optivar)
1
BACITRACIN – bacitracin ophth
oint 500 unit/gm
1
bacitracin-polymyxin b ophth
oint
1
bacitracin-polymyxin-neomycinhc ophth oint 1%
BETAGAN – levobunolol hcl ophth 4
soln 0.5%
1
betaxolol hcl ophth soln 0.5%
PERSANTINE – dipyridamole tab
25 mg
4
PERSANTINE – dipyridamole tab
50 mg
4
BLEPH-10 – sulfacetamide sodium
ophth soln 10%
4
PERSANTINE – dipyridamole tab
75 mg
4
brimonidine tartrate ophth soln
0.15% (Alphagan p)
2
PLAVIX – clopidogrel bisulfate tab
75 mg (base equiv)
4
brimonidine tartrate ophth soln
0.2%
1
PLAVIX – clopidogrel bisulfate tab
300 mg (base equiv)
4
carteolol hcl ophth soln 1%
1
PLETAL – cilostazol tab 50 mg
CELLUGEL – hypromellose
intraocular soln 2%
4
4
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
97
CILOXAN – ciprofloxacin hcl ophth
soln 0.3%
4
FML LIQUIFILM – fluorometholone
ophth susp 0.1%
4
ciprofloxacin hcl ophth soln
0.3% (Ciloxan)
1
GARAMYCIN – gentamicin sulfate
ophth soln 0.3%
4
COMBIGAN – brimonidine tartratetimolol maleate ophth soln
0.2-0.5%
4
gatifloxacin ophth soln 0.5%
(Zymaxid)
2
4
gentamicin sulfate ophth oint
0.3%
1
COSOPT – dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8 mg/
ml
gentamicin sulfate ophth soln
0.3% (Garamycin)
1
cromolyn sodium ophth soln 4%
1
CYCLOGYL – cyclopentolate hcl
ophth soln 1%
homatropine hbr ophth soln 5%
(Isopto homatropine)
1
4
CYCLOGYL – cyclopentolate hcl
ophth soln 2%
hypromellose intraocular soln
2% (Cellugel)
1
4
4
cyclopentolate hcl ophth soln
1% (Cyclogyl)
1
IOPIDINE – apraclonidine
hcl ophth soln 0.5% (base
equivalent)
cyclopentolate hcl ophth soln
2% (Cyclogyl)
2
ISOPTO ATROPINE – atropine
sulfate ophth soln 1%
4
CYSTARAN – cysteamine
hcl ophth soln 0.44% (base
equivalent)
4
ISOPTO CARPINE – pilocarpine
hcl ophth soln 1%
4
dexamethasone sodium
phosphate ophth soln 0.1%
ISOPTO CARPINE – pilocarpine
hcl ophth soln 2%
4
1
diclofenac sodium ophth soln
0.1%
ISOPTO CARPINE – pilocarpine
hcl ophth soln 4%
4
1
1
ISOPTO HOMATROPINE –
homatropine hbr ophth soln 5%
4
dorzolamide hcl ophth soln 2%
(Trusopt)
1
ISOPTO HYOSCINE –
scopolamine hbr ophth soln
0.25%
3
dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml
(Cosopt)
ELESTAT – epinastine hcl ophth
soln 0.05%
ketorolac tromethamine ophth
soln 0.4% (Acular ls)
1
4
epinastine hcl ophth soln 0.05%
(Elestat)
ketorolac tromethamine ophth
soln 0.5% (Acular)
1
2
1
latanoprost ophth soln 0.005%
(Xalatan)
1
erythromycin ophth oint 5 mg/
gm
1
LEVOBUNOLOL HCL –
levobunolol hcl ophth soln 0.25%
1
fluorometholone ophth susp
0.1% (Fml liquifilm)
flurbiprofen sodium ophth soln
0.03% (Ocufen)
levobunolol hcl ophth soln 0.5%
(Betagan)
1
1
98
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
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Quantity Limits
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Drug Name
Specialty
Drug Tier
2015
MAXITROL – neomycin-polymyxin- 4
dexamethasone ophth susp 0.1%
MAXITROL – neomycin-polymyxin- 4
dexamethasone ophth oint 0.1%
2
METIPRANOLOL – metipranolol
ophth soln 0.3%
4
MYDRIACYL – tropicamide ophth
soln 1%
1
NAPHAZOLINE HCL –
naphazoline hcl ophth soln 0.1%
1
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op
oin
1
neomycin-polymy-gramicid op
sol 1.75-10000-0.025mg-untmg/ml (Neosporin)
1
neomycin-polymyxindexamethasone ophth oint
0.1% (Maxitrol)
1
neomycin-polymyxindexamethasone ophth susp
0.1% (Maxitrol)
1
NEOMYCIN/POLYMYXIN/
HYDROC – neomycin-polymyxinhc ophth susp
4
NEOSPORIN – neomycinpolymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
4
OCUFEN – flurbiprofen sodium
ophth soln 0.03%
4
OCUFLOX – ofloxacin ophth soln
0.3%
1
ofloxacin ophth soln 0.3%
(Ocuflox)
4
OMNIPRED – prednisolone
acetate ophth susp 1%
2
phenylephrine hcl ophth soln
10%
• •
phenylephrine hcl ophth soln
2.5%
2
pilocarpine hcl ophth soln 1%
(Isopto carpine)
1
pilocarpine hcl ophth soln 2%
(Isopto carpine)
1
pilocarpine hcl ophth soln 4%
(Isopto carpine)
1
polymyxin b-trimethoprim
ophth soln 10000 unit/ml-0.1%
(Polytrim)
1
POLYTRIM – polymyxin btrimethoprim ophth soln 10000
unit/ml-0.1%
4
PRED FORTE – prednisolone
acetate ophth susp 1%
4
PRED MILD – prednisolone
acetate ophth susp 0.12%
3
PRED-G – gentamicinprednisolone ace ophth susp
0.3-1%
2
prednisolone acetate ophth susp
1% (Pred forte)
1
PREDNISOLONE SODIUM
PHOSP – prednisolone sodium
phosphate ophth soln 1%
1
proparacaine hcl ophth soln
0.5% (Alcaine)
1
SIMBRINZA – brinzolamidebrimonidine tartrate ophth susp
1-0.2%
3
SULFACETAMIDE SODIUM –
sulfacetamide sodium ophth oint
10%
2
sulfacetamide sodium ophth
soln 10% (Bleph-10)
2
sulfacetamide sodiumprednisolone ophth soln
10-0.23(0.25)%
1
tetracaine hcl ophth soln 0.5%
1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
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3
Quantity Limits
LOTEMAX – loteprednol etabonate
ophth gel 0.5%
Restricted Access
2
Prior Review
levofloxacin ophth soln 0.5%
Specialty
Drug Name
Drug Tier
2015
• •
99
timolol maleate ophth gel
forming soln 0.25% (Timopticxe)
1
timolol maleate ophth gel
forming soln 0.5% (Timoptic-xe)
1
timolol maleate ophth soln
0.25% (Timoptic)
1
timolol maleate ophth soln 0.5%
(Timoptic)
1
TIMOPTIC – timolol maleate ophth
soln 0.25%
4
TIMOPTIC – timolol maleate ophth
soln 0.5%
4
TIMOPTIC-XE – timolol maleate
ophth gel forming soln 0.25%
4
TIMOPTIC-XE – timolol maleate
ophth gel forming soln 0.5%
4
TOBRADEX – tobramycindexamethasone ophth susp
0.3-0.1%
tobramycin ophth soln 0.3%
(Tobrex)
4
ZYMAXID – gatifloxacin ophth soln
0.5%
4
1
ACETIC ACID/ALUMINUM ACET
– acetic acid 2% in aluminum
acetate otic soln
2
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
1
antipyrine-benzocainepolycosanol otic sol
5.4-1.4-0.0097% (Treagan otic)
2
ANTIPYRINE/BENZOCAINE –
antipyrine-benzocaine otic soln
55-14 mg/ml (5.5-1.4%)
2
4
AURALGAN – antipyrinebenzocaine otic soln 55-14 mg/
ml (5.5-1.4%)
4
1
CETRAXAL – ciprofloxacin hcl otic
soln 0.2% (base equivalent)
4
CIPROFLOXACIN – ciprofloxacin
hcl otic soln 0.2% (base
equivalent)
4
CORTANE-B AQUEOUS –
pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml
4
CORTANE-B-OTIC – pramoxinehc-chloroxylenol otic soln
10-10-1 mg/ml
4
CORTISPORIN – neomycinpolymyxin-hc otic soln 1%
4
DERMOTIC – fluocinolone
acetonide (otic) oil 0.01%
4
fluocinolone acetonide (otic) oil
0.01% (Dermotic)
1
neomycin-polymyxin-hc otic
soln 1% (Cortisporin)
1
2
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Prior Review
Specialty
Quantity Limits
Restricted Access
Drug Tier
XALATAN – latanoprost ophth soln
0.005%
acetic acid otic soln 2%
TRUSOPT – dorzolamide hcl ophth 4
soln 2%
VIGAMOX – moxifloxacin hcl ophth 4
soln 0.5% (base equiv)
4
VIROPTIC – trifluridine ophth soln
1%
100
Drug Name
OTIC AGENTS
2
tobramycin-dexamethasone
ophth susp 0.3-0.1% (Tobradex)
4
TOBREX – tobramycin sulfate
ophth soln 0.3%
TRAVOPROST – travoprost ophth 4
soln 0.004%
2
trifluridine ophth soln 1%
(Viroptic)
2
tropicamide ophth soln 0.5%
tropicamide ophth soln 1%
(Mydriacyl)
Prior Review
Drug Name
Specialty
Drug Tier
2015
neomycin-polymyxin-hc otic
susp 3.5 mg/ml-10000 unit/
ml-1%
1
ofloxacin otic soln 0.3%
1
OTICIN HC NR – pramoxine-hcchloroxylenol otic soln 10-10-1
mg/ml
4
PRAMOTIC – pramoxinechloroxylenol otic liquid 1-0.1%
4
pramoxine-chloroxylenol otic
liquid 1-0.1% (Pramotic)
PREVIDENT FLUORIDE – sodium
fluoride gel 1.1% (0.5% f)
4
PREVIDENT 5000 BOOSTER –
sodium fluoride paste 1.1%
4
PREVIDENT 5000 DRY MOUTH –
sodium fluoride gel 1.1% (0.5% f)
4
PREVIDENT 5000 ENAMEL PRO
– sodium fluoride-potassium
nitrate paste 1.1-5%
4
2
PREVIDENT 5000 PLUS – sodium
fluoride cream 1.1%
4
pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/
ml (Cortane-b aqueous)
1
PREVIDENT 5000 SENSITIVE –
sodium fluoride-potassium nitrate
paste 1.1-5%
4
pramoxine-hc-chloroxylenol otic
soln 10-10-1 mg/ml (Cortane-botic)
1
SALAGEN – pilocarpine hcl tab 5
mg
4
4
SALAGEN – pilocarpine hcl tab 7.5
mg
4
TREAGAN OTIC – antipyrinebenzocaine-polycosanol otic sol
5.4-1.4-0.0097%
sodium fluoride cream 1.1%
(Prevident 5000 plus)
1
sodium fluoride gel 1.1% (0.5% f)
(Prevident fluoride)
1
sodium fluoride paste 1.1%
(Prevident 5000 boost)
1
MOUTH/THROAT/DENTAL AGENTS
1
chlorhexidine gluconate soln
0.12% (Peridex)
1
clotrimazole troche 10 mg
GEL-KAM ORAL CARE RINSE –
stannous fluoride conc 0.63%
4
sodium fluoride rinse 0.2%
(Prevident)
1
lidocaine hcl laryngotracheal
soln 4% (Lta 360 kit)
1
1
lidocaine hcl viscous soln 2%
1
sodium fluoride-potassium
nitrate paste 1.1-5% (Prevident
5000 sensi)
NUMOISYN – artificial saliva lozenge
4
stannous fluoride conc 0.63%
(Gel-kam oral care ri)
1
nystatin susp 100000 unit/ml
1
4
PERIDEX – chlorhexidine
gluconate soln 0.12%
4
THERA-FLUR-N – sodium fluoride
gel 1.1% (0.5% f)
1
pilocarpine hcl tab 5 mg
(Salagen)
2
triamcinolone acetonide dental
paste 0.1%
pilocarpine hcl tab 7.5 mg
(Salagen)
2
PREVIDENT – sodium fluoride
rinse 0.2%
4
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
ANORECTAL AGENTS
ANALPRAM E – hc-pramoxine
emol cream 2.5-1% & pramoxine
wipe 1% kit
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
4
101
ANALPRAM-HC – hydrocortisone
acetate w/ pramoxine rectal
cream 1-1%
4
ANALPRAM-HC – hydrocortisone
acetate w/ pramoxine rectal
cream 2.5-1%
4
ANALPRAM-HC SINGLES –
hydrocortisone acetate w/
pramoxine rectal cream 1-1%
4
ANALPRAM-HC SINGLES –
hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%
4
ANUSOL-HC – hydrocortisone
rectal cream 2.5%
4
ANUSOL-HC – hydrocortisone
acetate suppos 25 mg
4
CORTENEMA – hydrocortisone
enema 100 mg/60ml
4
CORTIFOAM – hydrocortisone
acetate rectal foam 90 mg/dose
3
hc-pramoxine emol cream
2.5-1% & pramoxine wipe 1%
kit (Analpram e)
2
hydrocortisone acetate suppos
25 mg (Anusol-hc)
1
hydrocortisone acetate suppos
30 mg (Proctocort)
lidocaine-hydrocortisone acetate
rectal cream kit 3-1%
2
lidocaine-hydrocortisone acetate
rectal cream 3-0.5%
2
lidocaine-hydrocortisone acetate
rectal gel kit 3-2.5%
2
PROCTOCORT – hydrocortisone
rectal cream 1%
4
PROCTOCORT – hydrocortisone
acetate suppos 30 mg
4
PROCTOFOAM HC –
hydrocortisone acetate w/
pramoxine rectal foam 1-1%
3
2
acitretin cap 17.5 mg (Soriatane)
2
acitretin cap 25 mg (Soriatane)
2
ACLOVATE – alclometasone
dipropionate cream 0.05%
4
acyclovir oint 5% (Zovirax)
2
ACZONE – dapsone gel 5%
4
adapalene cream 0.1% (Differin)
2
adapalene gel 0.1% (Differin)
2
1
adapalene gel 0.3% (Differin)
2
1
hydrocortisone acetate w/
pramoxine rectal cream 1-1%
(Analpram-hc)
2
alclometasone dipropionate
cream 0.05% (Aclovate)
alclometasone dipropionate oint
0.05%
1
hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%
(Analpram-hc)
2
ALDARA – imiquimod cream 5%
4
1
hydrocortisone enema
100 mg/60ml (Cortenema)
2
aluminum chloride soln 20%
(Drysol)
ALUVEA – urea cream 39%
4
hydrocortisone rectal cream 1%
(Proctocort)
1
hydrocortisone rectal cream
2.5% (Anusol-hc)
1
lidocaine-hydrocortisone acetate
rectal cream kit 3-0.5%
2
• •
AMCINONIDE – amcinonide cream 2
0.1%
AMCINONIDE – amcinonide lotion 2
0.1%
2
AMCINONIDE – amcinonide oint
0.1%
• •
•
•
•
• •
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
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• •
DERMATOLOGICALS
acitretin cap 10 mg (Soriatane)
102
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
ARZOL SILVER NITRATE APP –
silver nitrate-potassium nitrate
applicator 75-25%
4
BACTROBAN – mupirocin oint 2%
4
BACTROBAN – mupirocin calcium
cream 2%
4
BENZAC AC WASH – benzoyl
peroxide liq 5%
betamethasone dipropionate
augmented gel 0.05%
2
betamethasone dipropionate
augmented lotion 0.05%
(Diprolene)
2
2
4
betamethasone dipropionate
augmented oint 0.05%
(Diprolene)
BENZAC W WASH – benzoyl
peroxide liq 5%
4
betamethasone dipropionate
cream 0.05%
2
BENZACLIN – clindamycin
phosphate-benzoyl peroxide gel
1-5%
4
betamethasone dipropionate
lotion 0.05%
2
2
BENZACLIN WITH PUMP –
clindamycin phosphate-benzoyl
peroxide gel 1-5%
4
betamethasone dipropionate
oint 0.05%
betamethasone valerate aerosol
foam 0.12% (Luxiq)
2
BENZAMYCIN – benzoyl peroxideerythromycin gel 5-3%
4
betamethasone valerate cream
0.1%
1
BENZEFOAM – benzoyl peroxide
foam 5.3%
4
betamethasone valerate lotion
0.1%
1
BENZEFOAMULTRA – benzoyl
peroxide foam 9.8%
4
betamethasone valerate oint
0.1%
1
benzoyl peroxide creamy wash
4% & cleanser lotion kit
2
BPO 3% FOAMING CLOTHS –
benzoyl peroxide cloth 3%
2
• •
benzoyl peroxide creamy wash
8% & cleanser lotion kit
2
BPO 6% FOAMING CLOTHS –
benzoyl peroxide cloth 6%
2
• •
benzoyl peroxide foam 5.3%
(Benzefoam)
2
BPO 9% FOAMING CLOTHS –
benzoyl peroxide cloth 9%
2
• •
benzoyl peroxide foam 9.8%
(Benzefoamultra)
2
calcipotriene cream 0.005%
(Dovonex)
2
benzoyl peroxide gel 10%
2
calcipotriene oint 0.005%
2
benzoyl peroxide liq 2.5%
2
2
benzoyl peroxide liq 7%
2
calcipotriene soln 0.005%
(50 mcg/ml)
benzoyl peroxide lotion 6%
2
2
benzoyl peroxideerythromycin gel 5-3%
(Benzamycin)
2
calcipotriene-betamethasone
dipropionate oint 0.005-0.064%
(Taclonex)
4
betamethasone dipropionate
augmented cream 0.05%
(Diprolene af)
2
CALCITRIOL – calcitriol oint 3
mcg/gm
CENTANY – mupirocin oint 2%
1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
• •
103
CICLODAN SOLUTION KIT –
ciclopirox solution kit 8%
4
clobetasol propionate cream
0.05% (Temovate)
ciclopirox gel 0.77%
2
ciclopirox olamine cream 0.77%
(base equiv)
2
ciclopirox olamine susp 0.77%
(base equiv)
2
ciclopirox shampoo 1% (Loprox
shampoo)
2
ciclopirox solution kit 8%
(Ciclodan solution ki)
2
ciclopirox solution 8% (Penlac
Nail Lacquer)
2
CLARAVIS – isotretinoin cap 30
mg
2
CLARIFOAM EF – sulfacetamide
sodium w/ sulfur foam 10-5%
4
CLEOCIN-T – clindamycin
phosphate soln 1%
4
CLEOCIN-T – clindamycin
phosphate gel 1%
4
CLEOCIN-T – clindamycin
phosphate lotion 1%
4
CLEOCIN-T – clindamycin
phosphate swab 1%
4
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
2
clindamycin phosphate foam 1%
(Evoclin)
2
clindamycin phosphate gel 1%
(Cleocin-t)
1
1
clobetasol propionate emollient
base cream 0.05% (Temovate e)
2
clobetasol propionate emulsion
foam 0.05% (Olux-e)
2
clobetasol propionate foam
0.05% (Olux)
1
clobetasol propionate gel 0.05%
(Temovate)
2
clobetasol propionate lotion
0.05% (Clobex)
clobetasol propionate oint 0.05% 1
(Temovate)
2
clobetasol propionate shampoo
0.05% (Clobex)
1
clobetasol propionate soln
0.05% (Temovate)
2
clobetasol propionate spray
0.05% (Clobex)
4
CLOBEX – clobetasol propionate
spray 0.05%
4
CLOBEX – clobetasol propionate
lotion 0.05%
4
CLOBEX – clobetasol propionate
shampoo 0.05%
2
clotrimazole w/ betamethasone
cream 1-0.05% (Lotrisone)
2
clotrimazole w/ betamethasone
lotion 1-0.05%
CONDYLOX – podofilox soln 0.5% 4
clindamycin phosphate lotion
1% (Cleocin-t)
CUTIVATE – fluticasone
propionate cream 0.05%
4
1
4
clindamycin phosphate soln 1%
(Cleocin-t)
1
CUTIVATE – fluticasone
propionate lotion 0.05%
DENAVIR – penciclovir cream 1%
4
clindamycin phosphate swab 1%
(Cleocin-t)
1
4
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
2
DERMA-SMOOTHE/FS BODY –
fluocinolone acetonide oil 0.01%
(body oil)
104
1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
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Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
DERMA-SMOOTHE/FS BODY
OIL – fluocinolone acetonide oil
0.01% (body oil)
4
DIPROLENE – betamethasone
dipropionate augmented oint
0.05%
4
DERMA-SMOOTHE/FS SCALP –
fluocinolone acetonide oil 0.01%
(scalp oil)
4
DIPROLENE AF – betamethasone
dipropionate augmented cream
0.05%
4
DERMA-SMOOTHE/FS SCALP
OI – fluocinolone acetonide oil
0.01% (scalp oil)
4
DOVONEX – calcipotriene cream
0.005%
4
4
DRYSOL – aluminum chloride soln
20%
4
DERMATOP – prednicarbate
cream 0.1%
DERMATOP – prednicarbate oint
0.1%
DUAC – clindamycin phosphbenzoyl peroxide (refrig) gel 1.2
(1)-5%
4
4
desonide cream 0.05%
(Desowen)
1
econazole nitrate cream 1%
1
EFUDEX – fluorouracil cream 5%
4
ELOCON – mometasone furoate
solution 0.1% (lotion)
4
desonide lotion 0.05% (Desowen) 2
1
desonide oint 0.05% (Desowen)
DESOWEN – desonide cream
0.05%
4
ELOCON – mometasone furoate
cream 0.1%
4
DESOWEN – desonide lotion
0.05%
4
ELOCON – mometasone furoate
oint 0.1%
4
DESOWEN – desonide oint 0.05%
4
erythromycin pads 2%
2
DESOXIMETASONE –
desoximetasone cream 0.05%
2
erythromycin soln 2%
1
EURAX – crotamiton cream 10%
4
desoximetasone cream 0.25%
(Topicort)
2
EURAX – crotamiton lotion 10%
4
desoximetasone gel 0.05%
(Topicort)
2
desoximetasone oint 0.25%
(Topicort)
2
DIFFERIN – adapalene cream
0.1%
4
DIFFERIN – adapalene gel 0.1%
4
DIFLORASONE DIACETATE –
diflorasone diacetate cream
0.05%
2
diflorasone diacetate oint 0.05%
2
DIPROLENE – betamethasone
dipropionate augmented lotion
0.05%
4
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
EVOCLIN – clindamycin phosphate 4
foam 1%
4
EXTINA – ketoconazole foam 2%
FINACEA – azelaic acid gel 15%
4
• •
fluocinolone acetonide cream
0.01%
1
• •
fluocinolone acetonide cream
0.025% (Synalar)
1
fluocinolone acetonide oil 0.01%
(body oil) (Derma-smoothe/fs
bod)
1
fluocinolone acetonide oil 0.01%
(scalp oil) (Derma-smoothe/fs
sca)
1
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
• •
105
fluocinolone acetonide oint
0.025% (Synalar)
1
hydrocortisone butyrate soln
0.1% (Locoid)
2
fluocinolone acetonide soln
0.01% (Synalar)
1
hydrocortisone cream 1%
1
hydrocortisone cream 2.5%
1
fluocinonide cream 0.05%
1
hydrocortisone lotion 2.5%
2
fluocinonide cream 0.1% (Vanos)
1
1
hydrocortisone valerate cream
0.2%
2
fluocinonide emulsified base
cream 0.05%
1
hydrocortisone valerate oint
0.2% (Westcort)
2
fluocinonide gel 0.05%
fluocinonide oint 0.05%
1
imiquimod cream 5% (Aldara)
2
fluocinonide soln 0.05%
1
iodoquinol-hc cream 1%
1
fluorouracil cream 5% (Efudex)
2
isotretinoin cap 10 mg
2
fluorouracil soln 2%
2
isotretinoin cap 20 mg
2
fluorouracil soln 5%
2
isotretinoin cap 40 mg
2
fluticasone propionate cream
0.05% (Cutivate)
1
KERALYT – salicylic acid gel 6%
4
ketoconazole cream 2%
1
fluticasone propionate lotion
0.05% (Cutivate)
1
ketoconazole foam 2% (Extina)
2
1
ketoconazole shampoo 2%
(Nizoral)
1
fluticasone propionate oint
0.005% (Cutivate)
1
KLARON – sulfacetamide sodium
lotion 10% (acne)
4
GENTAMICIN SULFATE –
gentamicin sulfate cream 0.1%
1
LAC-HYDRIN – lactic acid
(ammonium lactate) cream 12%
4
GENTAMICIN SULFATE –
gentamicin sulfate oint 0.1%
4
LAC-HYDRIN – lactic acid
(ammonium lactate) lotion 12%
4
GRANULEX – trypsin w/ castor oil
& peruvian balsam spray
2
lactic acid (ammonium lactate)
cream 12% (Lac-hydrin)
2
halobetasol prop oint 0.05% &
ammonium lactate lot 12% kit
2
lactic acid (ammonium lactate)
lotion 10%
2
halobetasol propionate cream
0.05% (Ultravate)
2
lactic acid (ammonium lactate)
lotion 12% (Lac-hydrin)
2
halobetasol propionate oint
0.05% (Ultravate)
4
lactic acid w/ vitamin e cream
10%-3500 unit/30gm
2
HYDRO 35 – urea in lactic acid
vehicle foam 35%
2
lidocaine hcl cream 3%
2
hydrocortisone butyrate cream
0.1% (Locoid)
lidocaine hcl gel 2%
1
hydrocortisone butyrate oint
0.1% (Locoid)
2
lidocaine hcl soln 4% (Xylocaine)
1
lidocaine oint 5%
1
lidocaine patch 5% (Lidoderm)
2
106
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
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Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
•
4
LIDODERM – lidocaine patch 5%
lindane lotion 1%
2
nystatin cream 100000 unit/gm
1
lindane shampoo 1%
2
nystatin oint 100000 unit/gm
1
LOCOID – hydrocortisone butyrate
soln 0.1%
4
nystatin topical powder
1
4
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
1
LOCOID – hydrocortisone butyrate
cream 0.1%
LOCOID – hydrocortisone butyrate
oint 0.1%
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
1
4
LOPROX SHAMPOO – ciclopirox
shampoo 1%
OLUX – clobetasol propionate
foam 0.05%
4
4
LOTRISONE – clotrimazole w/
betamethasone cream 1-0.05%
OLUX-E – clobetasol propionate
emulsion foam 0.05%
4
4
2
OVACE PLUS WASH –
sulfacetamide sodium liquid 10%
4
mafenide acetate packet for
topical soln 5% (50 gm)
(Sulfamylon)
OVACE WASH – sulfacetamide
sodium liquid 10%
4
malathion lotion 0.5% (Ovide)
2
OVIDE – malathion lotion 0.5%
4
METROCREAM – metronidazole
cream 0.75%
4
PENLAC NAIL LACQUER –
ciclopirox solution 8%
4
METROGEL – metronidazole gel
1%
4
permethrin cream 5% (Elimite)
2
4
podofilox soln 0.5% (Condylox)
2
METROLOTION – metronidazole
lotion 0.75%
4
metronidazole cream 0.75%
(Metrocream)
2
PRAMOSONE – pramoxine-hc
cream 1-1%
4
metronidazole gel 0.75%
2
PRAMOSONE – pramoxine-hc
cream 1-2.5%
2
pramoxine-hc cream 1-2.5%
(Pramosone)
2
metronidazole gel 1% (Metrogel)
metronidazole lotion 0.75%
(Metrolotion)
2
prednicarbate cream 0.1%
(Dermatop)
1
mometasone furoate cream 0.1%
(Elocon)
1
prednicarbate oint 0.1%
(Dermatop)
1
mometasone furoate oint 0.1%
(Elocon)
1
PROTOPIC – tacrolimus oint
0.03%
4
mometasone furoate solution
0.1% (lotion) (Elocon)
1
PROTOPIC – tacrolimus oint 0.1%
4
2
RETIN-A – tretinoin cream 0.025%
4
mupirocin calcium cream 2%
(Bactroban)
RETIN-A – tretinoin cream 0.05%
4
•
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
NIZORAL – ketoconazole
shampoo 2%
4
Restricted Access
1
1
Prior Review
mupirocin oint 2% (Bactroban)
lidocaine-prilocaine cream
2.5-2.5% (Emla)
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
• •
• •
107
Quantity Limits
Restricted Access
SALEX – salicylic acid shampoo
6%
Prior Review
4
Specialty
RETIN-A – tretinoin gel 0.025%
Drug Name
Drug Tier
4
• •
• •
• •
Quantity Limits
RETIN-A – tretinoin gel 0.01%
Restricted Access
4
Prior Review
RETIN-A – tretinoin cream 0.1%
Specialty
Drug Name
Drug Tier
2015
SORIATANE – acitretin cap 17.5
mg
4
SORIATANE – acitretin cap 25 mg
4
4
STELARA – ustekinumab soln
prefilled syringe 45 mg/0.5ml
5
• •
•
SALEX CREAM – salicylic acid
cream 6% & cleanser liqd kit
4
STELARA – ustekinumab soln
prefilled syringe 90 mg/ml
5
• •
•
SALEX LOTION – salicylic acid
lotion 6% & cleanser liqd kit
4
sulfacetamide sodium liquid 10%
(Ovace wash)
2
SALICYLIC ACID – salicylic acid
soln 26%
2
sulfacetamide sodium lotion
10% (acne) (Klaron)
2
salicylic acid cream 6%
2
2
salicylic acid cream 6% &
cleanser liqd kit (Salex cream)
2
sulfacetamide sodium w/ sulfur
cleansing pad 10-4% (Sumaxin)
2
salicylic acid film forming liquid
27.5% (Virasal)
2
sulfacetamide sodium w/ sulfur
cream 10-5%
2
salicylic acid foam 6% (Salvax)
2
sulfacetamide sodium w/ sulfur
emulsion 10-1%
2
sulfacetamide sodium w/ sulfur
emulsion 10-5%
2
salicylic acid gel 6% (Keralyt)
salicylic acid lotion 6%
2
salicylic acid lotion 6% &
cleanser liqd kit (Salex lotion)
sulfacetamide sodium w/ sulfur
foam 10-5% (Clarifoam ef)
2
2
salicylic acid shampoo 6%
(Salex)
sulfacetamide sodium w/ sulfur
lotion 10-5%
2
2
2
SALVAX – salicylic acid foam 6%
4
sulfacetamide sodium w/ sulfur
susp 8-4% (Sumaxin ts)
SELENIUM SULFIDE – selenium
sulfide-pyrithione zinc in urea
shampoo 2.25%
1
sulfacetamide sodium w/ sulfur
wash 9-4.5% (Sumadan wash)
2
selenium sulfide lotion 2.5%
sulfacetamide sodium w/ sulfur
wash 9-4% (Sumaxin wash)
2
1
SILVADENE – silver sulfadiazine
cream 1%
4
sulfacetamide sodium-sulfur in
urea emulsion 10-4%
2
silver nitrate-potassium nitrate
applicator 75-25% (Arzol silver
nitrate)
2
sulfacetamide sodium-sulfur w/
sunscreens cream 10-5%
2
4
silver sulfadiazine cream 1%
(Silvadene)
1
SULFAMYLON – mafenide acetate
packet for topical soln 5% (50
gm)
sodium thiosulfate-salicylic acid
lotion 25-1%
2
SUMADAN WASH – sulfacetamide
sodium w/ sulfur wash 9-4.5%
4
SORIATANE – acitretin cap 10 mg
4
SUMAXIN – sulfacetamide sodium
w/ sulfur cleansing pad 10-4%
4
108
• •
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
SUMAXIN TS – sulfacetamide
sodium w/ sulfur susp 8-4%
4
TOPICORT – desoximetasone oint
0.25%
4
SUMAXIN WASH – sulfacetamide
sodium w/ sulfur wash 9-4%
4
tretinoin cream 0.025% (Retin-a)
2
tretinoin cream 0.05% (Retin-a)
2
SYNALAR – fluocinolone
acetonide cream 0.025%
4
tretinoin cream 0.1% (Retin-a)
2
4
tretinoin gel 0.01% (Retin-a)
2
SYNALAR – fluocinolone
acetonide oint 0.025%
tretinoin gel 0.025% (Retin-a)
2
TACLONEX – calcipotrienebetamethasone dipropionate
susp 0.005-0.064%
4
TRIAMCINOLONE ACETONIDE
– triamcinolone acetonide oint
0.5%
1
TACLONEX – calcipotrienebetamethasone dipropionate oint
0.005-0.064%
4
triamcinolone acetonide cream
0.025%
1
1
tacrolimus oint 0.03% (Protopic)
2
triamcinolone acetonide cream
0.1%
tacrolimus oint 0.1% (Protopic)
2
1
TARGRETIN – bexarotene gel 1%
5
4
triamcinolone acetonide lotion
0.025%
1
TAZORAC – tazarotene cream
0.05%
• •
• •
triamcinolone acetonide cream
0.5%
4
• •
triamcinolone acetonide lotion
0.1%
1
TAZORAC – tazarotene cream
0.1%
4
triamcinolone acetonide oint
0.025%
TAZORAC – tazarotene gel 0.1%
4
• •
• •
1
TAZORAC – tazarotene gel 0.05%
TEMOVATE – clobetasol
propionate soln 0.05%
triamcinolone acetonide oint
0.1%
1
4
4
TRIANEX – triamcinolone
acetonide oint 0.05%
4
TEMOVATE – clobetasol
propionate cream 0.05%
TEMOVATE – clobetasol
propionate gel 0.05%
trypsin w/ castor oil & peruvian
balsam oint (Xenaderm)
1
4
TEMOVATE – clobetasol
propionate oint 0.05%
trypsin w/ castor oil & peruvian
balsam spray (Granulex)
1
4
TEMOVATE E – clobetasol
propionate emollient base cream
0.05%
ULTRAVATE – halobetasol
propionate cream 0.05%
4
4
ULTRAVATE – halobetasol
propionate oint 0.05%
4
TOPICORT – desoximetasone
cream 0.05%
2
URAMAXIN – urea cream 45%
4
4
URAMAXIN – urea gel 45%
4
TOPICORT – desoximetasone
cream 0.25%
URAMAXIN – urea lotion 45%
4
TOPICORT – desoximetasone gel
0.05%
4
urea cream 39% (Aluvea)
2
urea cream 40%
2
• •
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
•
•
•
•
•
109
urea gel 45% (Uramaxin)
2
urea in lactic acid vehicle foam
35% (Hydro 35)
2
urea lotion 40%
2
urea lotion 45% (Uramaxin)
2
VECTICAL – calcitriol oint 3 mcg/
gm
4
VIRASAL – salicylic acid film
forming liquid 27.5%
4
VOLTAREN – diclofenac sodium
gel 1%
3
WESTCORT – hydrocortisone
valerate oint 0.2%
4
ONETOUCH ULTRA TEST STRIP
– glucose blood test strip
XENADERM – trypsin w/ castor oil
& peruvian balsam oint
4
ONETOUCH VERIO TEST STRIP
– glucose blood test strip
XYLOCAINE – lidocaine hcl soln
4%
4
SURESTEP PRO TEST STRIPS –
glucose blood test strip
ZOVIRAX – acyclovir oint 5%
4
MISCELLANEOUS PRODUCTS
THYROGEN – thyrotropin alfa for
inj 1.1 mg
ANTISEPTICS & DISINFECTANTS
MEDICAL DEVICES
formaldehyde solution 10%
ASCENSIA AUTODISC TEST ST –
glucose blood test disk
BAYER BREEZE 2 TEST DISC –
glucose blood test disk
BAYER CONTOUR BLOOD
GLUCO – glucose blood test
strip
BAYER CONTOUR NEXT BLOOD
– glucose blood test strip
• •
LANCETS – VARIOUS
MANUFACTURERS
•
1
ANTIDOTES
EVZIO – naloxone hcl solution
auto-injector 0.4 mg/0.4ml
4
EXJADE – deferasirox tab for oral
susp 125 mg
5
• •
EXJADE – deferasirox tab for oral
susp 250 mg
5
• •
EXJADE – deferasirox tab for oral
susp 500 mg
5
naltrexone hcl tab 50 mg (Revia)
1
REVIA – naltrexone hcl tab 50 mg
5
• •
DIAGNOSTIC PRODUCTS
All Brand Diabetic Supplies 25% coinsurance
110
•
GLUCOSE BLOOD TEST STRIPS
– VARIOUS
ONETOUCH ULTRA BLUE –
glucose blood test strip
5
OMNIFLEX DIAPHRAGM –
diaphragms
3
ORTHO DIAPHRAGM COIL SPRI
– diaphragm coil spring kit 50
mm
3
ORTHO DIAPHRAGM COIL SPRI
– diaphragm coil spring kit 100
mm
3
ORTHO DIAPHRAGM COIL SPRI
– diaphragm coil spring kit 105
mm
3
ORTHO DIAPHRAGM FLAT SPRI
– diaphragm flat spring kit 55 mm
3
ORTHO DIAPHRAGM FLAT SPRI
– diaphragm flat spring kit 60 mm
3
ORTHO DIAPHRAGM FLAT SPRI
– diaphragm flat spring kit 65 mm
3
• •
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
2
Restricted Access
urea gel 40%
Prior Review
urea cream 50%
2
Specialty
2
Drug Name
Drug Tier
Quantity Limits
Restricted Access
urea cream 45% (Uramaxin)
Specialty
Drug Name
Drug Tier
Prior Review
2015
•
ORTHO DIAPHRAGM FLAT SPRI
– diaphragm flat spring kit 75 mm
3
CELLCEPT – mycophenolate
mofetil tab 500 mg
4
•
ORTHO DIAPHRAGM FLAT SPRI
– diaphragm flat spring kit 80 mm
3
CELLCEPT – mycophenolate
mofetil for oral susp 200 mg/ml
4
•
ORTHO DIAPHRAGM FLAT SPRI
– diaphragm flat spring kit 85 mm
3
CUPRIMINE – penicillamine cap
250 mg
5
ORTHO DIAPHRAGM FLAT SPRI
– diaphragm flat spring kit 90 mm
3
cyclosporine cap 100 mg
(Sandimmune)
2
•
ORTHO DIAPHRAGM FLAT SPRI
– diaphragm flat spring kit 95 mm
3
cyclosporine cap 25 mg
(Sandimmune)
2
•
WIDE-SEAL SILICONE DIAPHR –
diaphragm wide seal 60 mm
3
CYCLOSPORINE MODIFIED –
cyclosporine modified cap 50 mg
2
•
WIDE-SEAL SILICONE DIAPHR –
diaphragm wide seal 65 mm
3
cyclosporine modified cap
100 mg (Neoral)
2
•
WIDE-SEAL SILICONE DIAPHR –
diaphragm wide seal 70 mm
3
cyclosporine modified cap
25 mg (Neoral)
2
•
WIDE-SEAL SILICONE DIAPHR –
diaphragm wide seal 75 mm
3
cyclosporine modified oral soln
100 mg/ml (Neoral)
2
•
WIDE-SEAL SILICONE DIAPHR –
diaphragm wide seal 80 mm
3
DEPEN TITRATABS –
penicillamine tab 250 mg
4
WIDE-SEAL SILICONE DIAPHR –
diaphragm wide seal 85 mm
3
IMURAN – azathioprine tab 50 mg
4
4
WIDE-SEAL SILICONE DIAPHR –
diaphragm wide seal 90 mm
3
KAYEXALATE – sodium
polystyrene sulfonate powder
•
3
mycophenolate mofetil cap
250 mg (Cellcept)
2
WIDE-SEAL SILICONE DIAPHR –
diaphragm wide seal 95 mm
mycophenolate mofetil for oral
susp 200 mg/ml (Cellcept)
2
•
ASSORTED CLASSES
ASTAGRAF XL – tacrolimus cap sr
24hr 0.5 mg
5
•
mycophenolate mofetil tab
500 mg (Cellcept)
2
•
ASTAGRAF XL – tacrolimus cap sr
24hr 1 mg
5
•
NEORAL – cyclosporine modified
cap 25 mg
4
•
ASTAGRAF XL – tacrolimus cap sr
24hr 5 mg
5
•
NEORAL – cyclosporine modified
cap 100 mg
4
•
AZASAN – azathioprine tab 75 mg
4
4
•
AZASAN – azathioprine tab 100
mg
4
NEORAL – cyclosporine modified
oral soln 100 mg/ml
4
•
azathioprine tab 50 mg (Imuran)
1
PROGRAF – tacrolimus cap 0.5
mg
PROGRAF – tacrolimus cap 1 mg
4
•
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
4
Restricted Access
Specialty
CELLCEPT – mycophenolate
mofetil cap 250 mg
Drug Name
Prior Review
Drug Tier
Quantity Limits
Restricted Access
Prior Review
3
Specialty
ORTHO DIAPHRAGM FLAT SPRI
– diaphragm flat spring kit 70 mm
Drug Name
Drug Tier
2015
111
RAPAMUNE – sirolimus tab 2 mg
4
RAPAMUNE – sirolimus oral soln 1 4
mg/ml
REVLIMID – lenalidomide caps 2.5 5
mg
5
REVLIMID – lenalidomide cap 5
mg
5
REVLIMID – lenalidomide cap 10
mg
5
REVLIMID – lenalidomide cap 15
mg
5
REVLIMID – lenalidomide cap 20
mg
5
REVLIMID – lenalidomide cap 25
mg
SANDIMMUNE – cyclosporine cap 4
25 mg
SANDIMMUNE – cyclosporine cap 4
100 mg
SANDIMMUNE – cyclosporine oral 4
soln 100 mg/ml
sirolimus tab 0.5 mg (Rapamune) 2
• •
THALOMID – thalidomide cap 200
mg
5
• •
• •
• •
• •
• •
• •
•
•
•
•
•
•
2
sirolimus tab 2 mg (Rapamune)
2
sodium polystyrene sulfonate
powder (Kayexalate)
2
SPS – sodium polystyrene
sulfonate oral susp 15 gm/60ml
4
tacrolimus cap 0.5 mg (Prograf)
2
tacrolimus cap 1 mg (Prograf)
2
tacrolimus cap 5 mg (Prograf)
2
THALOMID – thalidomide cap 50
mg
5
•
•
•
• •
THALOMID – thalidomide cap 100
mg
5
• •
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
Quantity Limits
5
Restricted Access
Prior Review
THALOMID – thalidomide cap 150
mg
Drug Name
• •
sirolimus tab 1 mg (Rapamune)
112
Specialty
RAPAMUNE – sirolimus tab 0.5 mg 4
4
RAPAMUNE – sirolimus tab 1 mg
Drug Tier
•
•
•
•
•
Quantity Limits
4
Restricted Access
Specialty
PROGRAF – tacrolimus cap 5 mg
Prior Review
Drug Name
Drug Tier
2015
2015
INDEX
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir).................................................6
abacavir sulfate tab 300 mg (base equiv) (Ziagen).........6
ABILIFY – aripiprazole oral solution 1 mg/ml.................... 60
ABILIFY – aripiprazole tab 10 mg.....................................60
ABILIFY – aripiprazole tab 15 mg.....................................60
ABILIFY – aripiprazole tab 20 mg.....................................60
ABILIFY – aripiprazole tab 2 mg.......................................60
ABILIFY – aripiprazole tab 30 mg.....................................60
ABILIFY – aripiprazole tab 5 mg.......................................60
acamprosate calcium tab delayed release 333 mg
(Campral)........................................................................ 66
acarbose tab 100 mg (Precose)..................................... 20
acarbose tab 25 mg (Precose)....................................... 20
acarbose tab 50 mg (Precose)....................................... 20
ACCOLATE – zafirlukast tab 10 mg................................. 47
ACCOLATE – zafirlukast tab 20 mg................................. 47
ACCUPRIL – quinapril hcl tab 10 mg............................... 34
ACCUPRIL – quinapril hcl tab 20 mg............................... 34
ACCUPRIL – quinapril hcl tab 40 mg............................... 34
ACCUPRIL – quinapril hcl tab 5 mg................................. 34
ACCURETIC – quinapril-hydrochlorothiazide tab 10-12.5
mg.................................................................................... 34
ACCURETIC – quinapril-hydrochlorothiazide tab 20-12.5
mg.................................................................................... 34
ACCURETIC – quinapril-hydrochlorothiazide tab 20-25
mg.................................................................................... 34
acebutolol hcl cap 200 mg (Sectral)..............................29
acebutolol hcl cap 400 mg (Sectral)..............................29
ACEON – perindopril erbumine tab 4 mg......................... 34
ACEON – perindopril erbumine tab 8 mg......................... 34
acetaminophen-isometheptene-caffeine tab 325-65-20
mg (Prodrin)................................................................... 75
acetaminophen-isometheptene-dichloral cap
325-65-100 mg................................................................ 75
acetaminophen w/ codeine soln 120-12 mg/5ml...........68
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).......................................................................... 68
acetaminophen w/ codeine tab 300-30 mg (Tylenol/
codeine #3).....................................................................68
acetaminophen w/ codeine tab 300-60 mg (Tylenol/
codeine #4).....................................................................68
ACETAZOLAMIDE – acetazolamide tab 125 mg.............. 41
acetazolamide cap sr 12hr 500 mg (Diamox)................41
acetazolamide sodium for inj 500 mg........................... 41
acetazolamide tab 250 mg..............................................41
ACETIC ACID/ALUMINUM ACET – acetic acid 2% in
aluminum acetate otic soln............................................100
acetic acid otic soln 2%............................................... 100
acetylcysteine inhal soln 10%........................................46
acetylcysteine inhal soln 20%........................................46
ACIPHEX – rabeprazole sodium ec tab 20 mg................. 50
acitretin cap 10 mg (Soriatane)....................................102
acitretin cap 17.5 mg (Soriatane).................................102
acitretin cap 25 mg (Soriatane)....................................102
ACLOVATE – alclometasone dipropionate cream
0.05%.............................................................................102
ACTIGALL – ursodiol cap 300 mg.................................... 52
ACTIQ – fentanyl citrate lollipop 1200 mcg.......................69
ACTIQ – fentanyl citrate lollipop 1600 mcg.......................69
ACTIQ – fentanyl citrate lollipop 200 mcg.........................68
ACTIQ – fentanyl citrate lollipop 400 mcg.........................68
ACTIQ – fentanyl citrate lollipop 600 mcg.........................68
ACTIQ – fentanyl citrate lollipop 800 mcg.........................69
ACTIVELLA – estradiol & norethindrone acetate tab
0.5-0.1 mg....................................................................... 16
ACTIVELLA – estradiol & norethindrone acetate tab 1-0.5
mg.................................................................................... 16
ACTIVE OB – prenatal w/o a w/fe cbn-fa-dha cap
20-1-320 mg.................................................................... 84
ACTONEL – risedronate sodium tab 150 mg....................25
ACTOPLUS MET – pioglitazone hcl-metformin hcl tab
15-500 mg....................................................................... 20
ACTOPLUS MET – pioglitazone hcl-metformin hcl tab
15-850 mg....................................................................... 20
ACTOS – pioglitazone hcl tab 15 mg (base equiv)........... 20
ACTOS – pioglitazone hcl tab 30 mg (base equiv)........... 20
ACTOS – pioglitazone hcl tab 45 mg (base equiv)........... 20
ACULAR – ketorolac tromethamine ophth soln 0.5%........97
ACULAR LS – ketorolac tromethamine ophth soln
0.4%.................................................................................97
acyclovir cap 200 mg (Zovirax)........................................6
acyclovir oint 5% (Zovirax)...........................................102
acyclovir susp 200 mg/5ml (Zovirax).............................. 6
acyclovir tab 400 mg (Zovirax)........................................ 6
acyclovir tab 800 mg (Zovirax)........................................ 6
ACZONE – dapsone gel 5%........................................... 102
ADALAT CC – nifedipine tab sr 24hr 30 mg..................... 31
ADALAT CC – nifedipine tab sr 24hr 60 mg..................... 31
ADALAT CC – nifedipine tab sr 24hr 90 mg..................... 31
adapalene cream 0.1% (Differin).................................. 102
adapalene gel 0.1% (Differin)....................................... 102
adapalene gel 0.3% (Differin)....................................... 102
ADDERALL – amphetamine-dextroamphetamine tab 10
mg.................................................................................... 64
ADDERALL – amphetamine-dextroamphetamine tab 12.5
mg.................................................................................... 64
ADDERALL – amphetamine-dextroamphetamine tab 15
mg.................................................................................... 64
ADDERALL – amphetamine-dextroamphetamine tab 20
mg.................................................................................... 64
ADDERALL – amphetamine-dextroamphetamine tab 30
mg.................................................................................... 64
ADDERALL – amphetamine-dextroamphetamine tab 5
mg.................................................................................... 64
ADDERALL – amphetamine-dextroamphetamine tab 7.5
mg.................................................................................... 64
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
113
2015
ADDERALL XR – amphetamine-dextroamphetamine cap
sr 24hr 10 mg..................................................................64
ADDERALL XR – amphetamine-dextroamphetamine cap
sr 24hr 15 mg..................................................................64
ADDERALL XR – amphetamine-dextroamphetamine cap
sr 24hr 20 mg..................................................................64
ADDERALL XR – amphetamine-dextroamphetamine cap
sr 24hr 25 mg..................................................................64
ADDERALL XR – amphetamine-dextroamphetamine cap
sr 24hr 30 mg..................................................................64
ADDERALL XR – amphetamine-dextroamphetamine cap
sr 24hr 5 mg....................................................................64
adefovir dipivoxil tab 10 mg (Hepsera)........................... 6
ADRENALIN – epinephrine inj 1 mg/ml (1:1000).............. 42
ADRENALIN – epinephrine inj 30 mg/30ml (1 mg/ml)
(1:1000)............................................................................42
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................. 47
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
250-50 mcg/dose............................................................. 47
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
500-50 mcg/dose............................................................. 47
ADVAIR HFA – fluticasone-salmeterol inhal aerosol
115-21 mcg/act................................................................ 47
ADVAIR HFA – fluticasone-salmeterol inhal aerosol
230-21 mcg/act................................................................ 47
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................ 47
AFINITOR DISPERZ – everolimus tab for oral susp 2
mg.................................................................................... 11
AFINITOR DISPERZ – everolimus tab for oral susp 3
mg.................................................................................... 11
AFINITOR DISPERZ – everolimus tab for oral susp 5
mg.................................................................................... 11
AFINITOR – everolimus tab 10 mg...................................11
AFINITOR – everolimus tab 2.5 mg..................................11
AFINITOR – everolimus tab 5 mg.....................................11
AFINITOR – everolimus tab 7.5 mg..................................11
AGGRENOX – aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................... 97
AGRYLIN – anagrelide hcl cap 0.5 mg............................. 97
ALBENZA – albendazole tab 200 mg............................... 10
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........47
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 47
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 47
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 47
albuterol sulfate syrup 2 mg/5ml................................... 47
albuterol sulfate tab 2 mg.............................................. 47
albuterol sulfate tab 4 mg.............................................. 47
albuterol sulfate tab sr 12hr 4 mg (Vospire er).............47
albuterol sulfate tab sr 12hr 8 mg (Vospire er).............47
ALCAINE – proparacaine hcl ophth soln 0.5%..................97
alclometasone dipropionate cream 0.05%
(Aclovate)......................................................................102
114
alclometasone dipropionate oint 0.05%...................... 102
ALDACTAZIDE – spironolactone & hydrochlorothiazide
tab 25-25 mg................................................................... 41
ALDACTAZIDE – spironolactone & hydrochlorothiazide
tab 50-50 mg................................................................... 41
ALDACTONE – spironolactone tab 100 mg...................... 41
ALDACTONE – spironolactone tab 25 mg........................41
ALDACTONE – spironolactone tab 50 mg........................41
ALDARA – imiquimod cream 5%.................................... 102
ALENDRONATE SODIUM – alendronate sodium oral soln
70 mg/75ml......................................................................25
ALENDRONATE SODIUM – alendronate sodium tab 40
mg.................................................................................... 25
alendronate sodium tab 10 mg...................................... 25
alendronate sodium tab 35 mg...................................... 25
alendronate sodium tab 5 mg........................................ 26
alendronate sodium tab 70 mg (Fosamax)................... 26
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 55
ALKERAN – melphalan tab 2 mg..................................... 11
allopurinol tab 100 mg (Zyloprim)................................. 76
allopurinol tab 300 mg (Zyloprim)................................. 76
ALORA – estradiol td patch biweekly 0.025 mg/24hr........ 16
ALORA – estradiol td patch biweekly 0.05 mg/24hr.......... 16
ALORA – estradiol td patch biweekly 0.075 mg/24hr........ 16
ALORA – estradiol td patch biweekly 0.1 mg/24hr............ 16
ALPHAGAN P – brimonidine tartrate ophth soln 0.1%...... 97
ALPHAGAN P – brimonidine tartrate ophth soln
0.15%...............................................................................97
alprazolam orally disintegrating tab 0.25 mg
(Niravam)........................................................................ 56
alprazolam orally disintegrating tab 0.5 mg................. 56
alprazolam orally disintegrating tab 1 mg.................... 56
alprazolam orally disintegrating tab 2 mg.................... 56
alprazolam tab 0.25 mg (Xanax).................................... 56
alprazolam tab 0.5 mg (Xanax)...................................... 56
alprazolam tab 1 mg (Xanax)......................................... 56
alprazolam tab 2 mg (Xanax)......................................... 56
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 56
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 56
alprazolam tab sr 24hr 2 mg (Xanax xr)........................ 56
alprazolam tab sr 24hr 3 mg (Xanax xr)........................ 56
ALTACE – ramipril cap 1.25 mg....................................... 34
ALTACE – ramipril cap 10 mg.......................................... 34
ALTACE – ramipril cap 2.5 mg......................................... 34
ALTACE – ramipril cap 5 mg............................................ 34
aluminum chloride soln 20% (Drysol)......................... 102
ALUVEA – urea cream 39%........................................... 102
AMANTADINE HCL – amantadine hcl tab 100 mg........... 81
amantadine hcl cap 100 mg........................................... 81
amantadine hcl syrup 50 mg/5ml...................................81
AMARYL – glimepiride tab 1 mg.......................................20
AMARYL – glimepiride tab 2 mg.......................................20
AMARYL – glimepiride tab 4 mg.......................................20
AMBIEN CR – zolpidem tartrate tab cr 12.5 mg............... 63
AMBIEN CR – zolpidem tartrate tab cr 6.25 mg............... 63
AMBIEN – zolpidem tartrate tab 10 mg............................ 63
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
AMBIEN – zolpidem tartrate tab 5 mg.............................. 63
AMCINONIDE – amcinonide cream 0.1%.......................102
AMCINONIDE – amcinonide lotion 0.1%........................ 102
AMCINONIDE – amcinonide oint 0.1%........................... 102
AMERGE – naratriptan hcl tab 1 mg (base equiv)............ 75
AMERGE – naratriptan hcl tab 2.5 mg (base equiv)......... 75
AMICAR – aminocaproic acid syrup 25%......................... 96
AMICAR – aminocaproic acid tab 1000 mg...................... 96
AMICAR – aminocaproic acid tab 500 mg........................ 96
amiloride & hydrochlorothiazide tab 5-50 mg...............41
amiloride hcl tab 5 mg....................................................41
AMINOCAPROIC ACID – aminocaproic acid tab 1000
mg.................................................................................... 96
aminocaproic acid syrup 25% (Amicar)........................ 96
aminocaproic acid tab 500 mg (Amicar)....................... 96
amiodarone hcl tab 100 mg........................................... 33
amiodarone hcl tab 200 mg (Cordarone)...................... 33
amiodarone hcl tab 400 mg........................................... 33
amiodarone hcl tab 400 mg........................................... 33
amitriptyline hcl tab 100 mg...........................................57
amitriptyline hcl tab 10 mg............................................ 57
amitriptyline hcl tab 150 mg...........................................57
amitriptyline hcl tab 25 mg............................................ 57
amitriptyline hcl tab 50 mg............................................ 57
amitriptyline hcl tab 75 mg............................................ 57
amlodipine besylate-atorvastatin calcium tab 10-10 mg
(Caduet).......................................................................... 44
amlodipine besylate-atorvastatin calcium tab 10-20 mg
(Caduet).......................................................................... 44
amlodipine besylate-atorvastatin calcium tab 10-40 mg
(Caduet).......................................................................... 44
amlodipine besylate-atorvastatin calcium tab 10-80 mg
(Caduet).......................................................................... 44
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)....................................................................44
amlodipine besylate-atorvastatin calcium tab 2.5-20
mg (Caduet)....................................................................44
amlodipine besylate-atorvastatin calcium tab 2.5-40
mg (Caduet)....................................................................44
amlodipine besylate-atorvastatin calcium tab 5-10 mg
(Caduet).......................................................................... 44
amlodipine besylate-atorvastatin calcium tab 5-20 mg
(Caduet).......................................................................... 44
amlodipine besylate-atorvastatin calcium tab 5-40 mg
(Caduet).......................................................................... 44
amlodipine besylate-atorvastatin calcium tab 5-80 mg
(Caduet).......................................................................... 44
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel).............................................................................34
amlodipine besylate-benazepril hcl cap 10-40 mg
(Lotrel).............................................................................34
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel).............................................................................34
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel).............................................................................34
amlodipine besylate-benazepril hcl cap 5-20 mg
(Lotrel).............................................................................34
amlodipine besylate-benazepril hcl cap 5-40 mg
(Lotrel).............................................................................34
amlodipine besylate tab 10 mg (Norvasc).....................31
amlodipine besylate tab 2.5 mg (Norvasc)....................31
amlodipine besylate tab 5 mg (Norvasc)...................... 31
amlodipine besylate-valsartan tab 10-160 mg
(Exforge)......................................................................... 34
amlodipine besylate-valsartan tab 10-320 mg
(Exforge)......................................................................... 34
amlodipine besylate-valsartan tab 5-160 mg
(Exforge)......................................................................... 34
amlodipine besylate-valsartan tab 5-320 mg
(Exforge)......................................................................... 34
amlodipine-valsartan-hydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)....................................... 35
amlodipine-valsartan-hydrochlorothiazide tab
10-160-25 mg (Exforge hct).......................................... 35
amlodipine-valsartan-hydrochlorothiazide tab
10-320-25 mg (Exforge hct).......................................... 35
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)......................................... 35
amlodipine-valsartan-hydrochlorothiazide tab 5-160-25
mg (Exforge hct)............................................................35
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml.................. 1
amoxicillin (trihydrate) for susp 200 mg/5ml.................. 1
amoxicillin (trihydrate) for susp 250 mg/5ml.................. 1
amoxicillin (trihydrate) for susp 400 mg/5ml.................. 1
amoxicillin (trihydrate) tab 500 mg..................................1
amoxicillin (trihydrate) tab 875 mg..................................1
amoxicillin & k clavulanate chew tab 200-28.5 mg.........1
amoxicillin & k clavulanate chew tab 400-57 mg............1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.............................................................................. 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)......................................................................1
amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)......................................................... 1
amoxicillin & k clavulanate tab 250-125 mg................... 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)......................................................................1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)......................................................................1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................. 1
AMOXICILLIN – amoxicillin (trihydrate) chew tab 125
mg...................................................................................... 1
AMOXICILLIN – amoxicillin (trihydrate) chew tab 250
mg...................................................................................... 1
amoxicillin cap-clarithro tab-lansopraz cap dr therapy
pack (Prevpac)............................................................... 50
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
115
2015
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)................................................................... 64
amphetamine-dextroamphetamine cap sr 24hr 15 mg
(Adderall xr)................................................................... 64
amphetamine-dextroamphetamine cap sr 24hr 20 mg
(Adderall xr)................................................................... 64
amphetamine-dextroamphetamine cap sr 24hr 25 mg
(Adderall xr)................................................................... 64
amphetamine-dextroamphetamine cap sr 24hr 30 mg
(Adderall xr)................................................................... 64
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(Adderall xr)................................................................... 64
amphetamine-dextroamphetamine tab 10 mg
(Adderall)........................................................................ 64
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)........................................................................ 64
amphetamine-dextroamphetamine tab 15 mg
(Adderall)........................................................................ 64
amphetamine-dextroamphetamine tab 20 mg
(Adderall)........................................................................ 64
amphetamine-dextroamphetamine tab 30 mg
(Adderall)........................................................................ 65
amphetamine-dextroamphetamine tab 5 mg
(Adderall)........................................................................ 65
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................ 65
AMPICILLIN – ampicillin for susp 125 mg/5ml.................... 1
AMPICILLIN – ampicillin for susp 250 mg/5ml.................... 1
ampicillin cap 250 mg.......................................................1
ampicillin cap 500 mg.......................................................1
AMPYRA – dalfampridine tab sr 12hr 10 mg.................... 66
ANAFRANIL – clomipramine hcl cap 25 mg..................... 57
ANAFRANIL – clomipramine hcl cap 50 mg..................... 57
ANAFRANIL – clomipramine hcl cap 75 mg..................... 57
anagrelide hcl cap 0.5 mg (Agrylin).............................. 97
anagrelide hcl cap 1 mg................................................. 97
ANALPRAM E – hc-pramoxine emol cream 2.5-1% &
pramoxine wipe 1% kit.................................................. 101
ANALPRAM-HC – hydrocortisone acetate w/ pramoxine
rectal cream 1-1%......................................................... 102
ANALPRAM-HC – hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1%...................................................... 102
ANALPRAM-HC SINGLES – hydrocortisone acetate w/
pramoxine rectal cream 1-1%....................................... 102
ANALPRAM-HC SINGLES – hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%.................................... 102
ANAPROX DS – naproxen sodium tab 550 mg................ 73
ANAPROX – naproxen sodium tab 275 mg...................... 73
ANASPAZ – hyoscyamine sulfate tab disp 0.125 mg........50
anastrozole tab 1 mg (Arimidex)................................... 11
ANCOBON – flucytosine cap 250 mg................................. 5
ANCOBON – flucytosine cap 500 mg................................. 5
ANDRODERM – testosterone td patch 24hr 2
mg/24hr............................................................................16
ANDRODERM – testosterone td patch 24hr 4
mg/24hr............................................................................16
116
ANDROGEL PUMP – testosterone td gel 12.5 mg/act
(1%)................................................................................. 16
ANDROGEL PUMP – testosterone td gel 20.25 mg/act
(1.62%)............................................................................ 16
ANDROGEL – testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................ 16
ANDROGEL – testosterone td gel 25 mg/2.5gm (1%)...... 16
ANDROGEL – testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................ 16
ANDROGEL – testosterone td gel 50 mg/5gm (1%)......... 16
ANDROID – methyltestosterone cap 10 mg......................16
ANIMI-3 – folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg......................................................................... 93
ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh............................................................... 47
ANTABUSE – disulfiram tab 250 mg................................ 66
ANTABUSE – disulfiram tab 500 mg................................ 66
ANTARA – fenofibrate micronized cap 30 mg...................42
ANTARA – fenofibrate micronized cap 90 mg...................42
ANTIPYRINE/BENZOCAINE – antipyrine-benzocaine otic
soln 55-14 mg/ml (5.5-1.4%)......................................... 100
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)...................................................................... 100
antipyrine-benzocaine-polycosanol otic sol
5.4-1.4-0.0097% (Treagan otic)................................... 100
ANUSOL-HC – hydrocortisone acetate suppos 25
mg.................................................................................. 102
ANUSOL-HC – hydrocortisone rectal cream 2.5%..........102
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine).........................................................................97
APTIVUS – tipranavir cap 250 mg......................................6
APTIVUS – tipranavir oral soln 100 mg/ml......................... 6
ARALEN – chloroquine phosphate tab 500 mg.................10
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 100 mcg/0.5ml............................ 93
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 100 mcg/ml.................................93
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 150 mcg/0.3ml............................ 93
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 150 mcg/0.75ml.......................... 93
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 200 mcg/0.4ml............................ 93
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 200 mcg/ml.................................93
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 25 mcg/0.42ml............................ 93
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 25 mcg/ml...................................93
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 300 mcg/0.6ml............................ 94
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 300 mcg/ml.................................93
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 40 mcg/0.4ml.............................. 93
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 40 mcg/ml...................................93
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 500 mcg/ml.................................94
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 60 mcg/0.3ml.............................. 93
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 60 mcg/ml...................................93
ARAVA – leflunomide tab 10 mg...................................... 73
ARAVA – leflunomide tab 20 mg...................................... 73
ARICEPT – donepezil hydrochloride tab 10 mg................66
ARICEPT – donepezil hydrochloride tab 23 mg................66
ARICEPT – donepezil hydrochloride tab 5 mg..................66
ARICEPT ODT – donepezil hydrochloride orally
disintegrating tab 10 mg..................................................66
ARIMIDEX – anastrozole tab 1 mg................................... 11
ARIXTRA – fondaparinux sodium inj 10 mg/0.8ml............ 95
ARIXTRA – fondaparinux sodium inj 2.5 mg/0.5ml........... 95
ARIXTRA – fondaparinux sodium inj 5 mg/0.4ml.............. 95
ARIXTRA – fondaparinux sodium inj 7.5 mg/0.6ml........... 95
ARMOUR THYROID – thyroid tab 120 mg (2 grain)......... 23
ARMOUR THYROID – thyroid tab 15 mg (1/4 grain)........ 23
ARMOUR THYROID – thyroid tab 180 mg (3 grain)......... 23
ARMOUR THYROID – thyroid tab 240 mg (4 grain)......... 23
ARMOUR THYROID – thyroid tab 300 mg (5 grain)......... 23
ARMOUR THYROID – thyroid tab 30 mg (1/2 grain)........ 23
ARMOUR THYROID – thyroid tab 60 mg (1 grain)........... 23
ARMOUR THYROID – thyroid tab 90 mg (1 1/2 grain)..... 23
AROMASIN – exemestane tab 25 mg.............................. 11
ARTHROTEC 50 – diclofenac w/ misoprostol tab delayed
release 50-0.2 mg........................................................... 73
ARTHROTEC 75 – diclofenac w/ misoprostol tab delayed
release 75-0.2 mg........................................................... 73
ARZOL SILVER NITRATE APP – silver nitrate-potassium
nitrate applicator 75-25%...............................................103
ASCENSIA AUTODISC TEST ST – glucose blood test
disk.................................................................................110
ASMANEX HFA – mometasone furoate inhal aerosol
suspension 100 mcg/act..................................................47
ASMANEX HFA – mometasone furoate inhal aerosol
suspension 200 mcg/act..................................................47
ASMANEX TWISTHALER 120 ME – mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................47
ASMANEX TWISTHALER 14 MET – mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................47
ASMANEX TWISTHALER 30 ME – mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................47
ASMANEX TWISTHALER 30 MET – mometasone furoate
inhal powd 110 mcg/inh (breath activated)......................47
ASMANEX TWISTHALER 60 MET – mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................47
ASMANEX TWISTHALER 7 METE – mometasone furoate
inhal powd 110 mcg/inh (breath activated)......................47
ASTAGRAF XL – tacrolimus cap sr 24hr 0.5 mg............ 111
ASTAGRAF XL – tacrolimus cap sr 24hr 1 mg............... 111
ASTAGRAF XL – tacrolimus cap sr 24hr 5 mg............... 111
ATABEX EC – prenatal vit w/ dss-iron carbonyl-fa tab dr
29-1 mg........................................................................... 84
ATABEX PRENATAL – prenatal vit w/ iron carbonyl-fa tab
65-1 mg........................................................................... 84
ATACAND – candesartan cilexetil tab 16 mg................... 35
ATACAND – candesartan cilexetil tab 32 mg................... 35
ATACAND – candesartan cilexetil tab 4 mg..................... 35
ATACAND – candesartan cilexetil tab 8 mg..................... 35
ATACAND HCT – candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg................................ 35
ATACAND HCT – candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg................................ 35
ATACAND HCT – candesartan cilexetilhydrochlorothiazide tab 32-25 mg................................... 35
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100)..................................................................................35
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50)....................................................................................35
atenolol tab 100 mg (Tenormin).....................................29
atenolol tab 25 mg (Tenormin).......................................29
atenolol tab 50 mg (Tenormin).......................................29
ATIVAN – lorazepam tab 0.5 mg...................................... 56
ATIVAN – lorazepam tab 1 mg......................................... 56
ATIVAN – lorazepam tab 2 mg......................................... 56
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 42
atorvastatin calcium tab 20 mg (base equivalent)
(Lipitor)........................................................................... 42
atorvastatin calcium tab 40 mg (base equivalent)
(Lipitor)........................................................................... 42
atorvastatin calcium tab 80 mg (base equivalent)
(Lipitor)........................................................................... 42
atovaquone-proguanil hcl tab 250-100 mg
(Malarone).......................................................................10
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone).......................................................................10
ATRIPLA – efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................ 6
atropine sulfate ophth soln 1% (Isopto atropine)......... 97
ATROVENT – ipratropium bromide nasal soln 0.03% (21
mcg/spray)....................................................................... 46
ATROVENT – ipratropium bromide nasal soln 0.06% (42
mcg/spray)....................................................................... 46
AUGMENTIN – amoxicillin & k clavulanate for susp
125-31.25 mg/5ml..............................................................1
AUGMENTIN – amoxicillin & k clavulanate for susp
250-62.5 mg/5ml................................................................1
AUGMENTIN – amoxicillin & k clavulanate tab 500-125
mg...................................................................................... 1
AUGMENTIN – amoxicillin & k clavulanate tab 875-125
mg...................................................................................... 1
AUGMENTIN XR – amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg.................................................................... 1
AURALGAN – antipyrine-benzocaine otic soln 55-14 mg/
ml (5.5-1.4%)................................................................. 100
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
117
2015
AVALIDE – irbesartan-hydrochlorothiazide tab 150-12.5
mg.................................................................................... 35
AVALIDE – irbesartan-hydrochlorothiazide tab 300-12.5
mg.................................................................................... 35
AVAPRO – irbesartan tab 150 mg.................................... 35
AVAPRO – irbesartan tab 300 mg.................................... 35
AVAPRO – irbesartan tab 75 mg......................................35
AXID – nizatidine cap 300 mg.......................................... 50
AXID – nizatidine oral soln 15 mg/ml................................50
AYGESTIN – norethindrone acetate tab 5 mg.................. 20
azacitidine for inj 100 mg (Vidaza)................................ 11
AZASAN – azathioprine tab 100 mg............................... 111
AZASAN – azathioprine tab 75 mg................................. 111
azathioprine tab 50 mg (Imuran)..................................111
azelastine hcl nasal spray 137 mcg/spray (1 mg/
ml)....................................................................................46
azelastine hcl ophth soln 0.05% (Optivar).................... 97
AZILECT – rasagiline mesylate tab 0.5 mg (base
equiv)............................................................................... 81
AZILECT – rasagiline mesylate tab 1 mg (base equiv)..... 81
AZITHROMYCIN – azithromycin powd pack for susp 1
gm...................................................................................... 2
azithromycin for susp 100 mg/5ml (Zithromax)..............2
azithromycin for susp 200 mg/5ml (Zithromax)..............2
azithromycin tab 250 mg (Zithromax)............................. 2
azithromycin tab 500 mg (Zithromax)............................. 2
azithromycin tab 600 mg (Zithromax)............................. 2
AZULFIDINE EN-TABS – sulfasalazine tab delayed
release 500 mg................................................................53
AZULFIDINE – sulfasalazine tab 500 mg......................... 53
B
B-6 FOLIC ACID – cobalamine combination cap.............. 94
BACITRACIN – bacitracin ophth oint 500 unit/gm.............97
bacitracin-polymyxin b ophth oint.................................97
bacitracin-polymyxin-neomycin-hc ophth oint 1%.......97
baclofen tab 10 mg......................................................... 83
baclofen tab 20 mg......................................................... 83
BACTRIM DS – sulfamethoxazole-trimethoprim tab
800-160 mg..................................................................... 10
BACTRIM – sulfamethoxazole-trimethoprim tab 400-80
mg.................................................................................... 10
BACTROBAN – mupirocin calcium cream 2%................ 103
BACTROBAN – mupirocin oint 2%................................. 103
BAL-CARE DHA – prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg...................................................... 84
balsalazide disodium cap 750 mg (Colazal)..................53
BARACLUDE – entecavir oral soln 0.05 mg/ml.................. 6
BARACLUDE – entecavir tab 0.5 mg................................. 6
BARACLUDE – entecavir tab 1 mg.................................... 6
BAYER BREEZE 2 TEST DISC – glucose blood test
disk.................................................................................110
BAYER CONTOUR BLOOD GLUCO – glucose blood test
strip................................................................................ 110
BAYER CONTOUR NEXT BLOOD – glucose blood test
strip................................................................................ 110
118
b-complex w/ c & folic acid cap 1 mg
(Nephrocaps)..................................................................84
b-complex w/ c & folic acid tab..................................... 84
b-complex w/ c & folic acid tab 1 mg (Nephro-vite
rx).................................................................................... 84
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................. 35
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................. 35
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................. 35
benazepril & hydrochlorothiazide tab 5-6.25 mg..........35
benazepril hcl tab 10 mg (Lotensin).............................. 35
benazepril hcl tab 20 mg (Lotensin).............................. 35
benazepril hcl tab 40 mg (Lotensin).............................. 35
benazepril hcl tab 5 mg.................................................. 35
BENTYL – dicyclomine hcl cap 10 mg..............................50
BENTYL – dicyclomine hcl tab 20 mg.............................. 50
BENZAC AC WASH – benzoyl peroxide liq 5%.............. 103
BENZACLIN – clindamycin phosphate-benzoyl peroxide
gel 1-5%........................................................................ 103
BENZACLIN WITH PUMP – clindamycin phosphatebenzoyl peroxide gel 1-5%............................................ 103
BENZAC W WASH – benzoyl peroxide liq 5%................103
BENZAMYCIN – benzoyl peroxide-erythromycin gel
5-3%...............................................................................103
BENZEFOAM – benzoyl peroxide foam 5.3%.................103
BENZEFOAMULTRA – benzoyl peroxide foam 9.8%..... 103
benzonatate cap 100 mg (Tessalon perles).................. 46
benzonatate cap 200 mg................................................ 46
benzoyl peroxide creamy wash 4% & cleanser lotion
kit...................................................................................103
benzoyl peroxide creamy wash 8% & cleanser lotion
kit...................................................................................103
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)................................................................103
benzoyl peroxide foam 5.3% (Benzefoam)..................103
benzoyl peroxide foam 9.8% (Benzefoamultra).......... 103
benzoyl peroxide gel 10%............................................ 103
benzoyl peroxide liq 2.5%............................................ 103
benzoyl peroxide liq 7%............................................... 103
benzoyl peroxide lotion 6%..........................................103
benztropine mesylate tab 0.5 mg...................................81
benztropine mesylate tab 1 mg..................................... 81
benztropine mesylate tab 2 mg..................................... 81
BETAGAN – levobunolol hcl ophth soln 0.5%...................97
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)............................................................... 103
betamethasone dipropionate augmented gel
0.05%.............................................................................103
betamethasone dipropionate augmented lotion 0.05%
(Diprolene).................................................................... 103
betamethasone dipropionate augmented oint 0.05%
(Diprolene).................................................................... 103
betamethasone dipropionate cream 0.05%.................103
betamethasone dipropionate lotion 0.05%................. 103
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
betamethasone dipropionate oint 0.05%.....................103
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 103
betamethasone valerate cream 0.1%...........................103
betamethasone valerate lotion 0.1%........................... 103
betamethasone valerate oint 0.1%...............................103
BETAPACE AF – sotalol hcl (afib/afl) tab 120 mg.............29
BETAPACE AF – sotalol hcl (afib/afl) tab 160 mg.............29
BETAPACE AF – sotalol hcl (afib/afl) tab 80 mg...............29
BETAPACE – sotalol hcl tab 120 mg................................29
BETAPACE – sotalol hcl tab 160 mg................................29
BETAPACE – sotalol hcl tab 80 mg..................................29
BETASERON – interferon beta-1b for inj kit 0.3 mg..........66
betaxolol hcl ophth soln 0.5%....................................... 97
betaxolol hcl tab 10 mg (Kerlone)................................. 29
betaxolol hcl tab 20 mg (Kerlone)................................. 29
bethanechol chloride tab 10 mg (Urecholine)...............54
bethanechol chloride tab 25 mg (Urecholine)...............54
bethanechol chloride tab 50 mg (Urecholine)...............54
bethanechol chloride tab 5 mg (Urecholine)................ 54
BETHKIS – tobramycin nebu soln 300 mg/4ml................... 4
BIAXIN – clarithromycin for susp 250 mg/5ml.....................2
BIAXIN – clarithromycin tab 250 mg................................... 2
BIAXIN – clarithromycin tab 500 mg................................... 2
BIAXIN XL – clarithromycin tab sr 24hr 500 mg..................2
BIAXIN XL PAC – clarithromycin tab sr 24hr 500 mg..........2
bicalutamide tab 50 mg (Casodex)................................ 11
BIDIL – isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 45
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 35
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 35
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 35
bisoprolol fumarate tab 10 mg (Zebeta)........................29
bisoprolol fumarate tab 5 mg (Zebeta)..........................29
BLEPH-10 – sulfacetamide sodium ophth soln 10%......... 97
B-NEXA – prenatal w/ calcium-vit b6-fa-ginger tab 1.22
mg.................................................................................... 84
BONIVA – ibandronate sodium tab 150 mg (base
equivalent)....................................................................... 26
BP FOLINATAL PLUS B – prenatal w/ calcium carbonateb6-b12-fa tab 1 mg..........................................................84
BP MULTINATAL PLUS – prenatal w/o a vit w/ fe
fumarate-fa tab 30-1 mg..................................................84
BP MULTINATAL PLUS – prenatal w/o a vit w/ fe fum-fa
tab chew 40-1 mg........................................................... 84
BPO 3% FOAMING CLOTHS – benzoyl peroxide cloth
3%..................................................................................103
BPO 6% FOAMING CLOTHS – benzoyl peroxide cloth
6%..................................................................................103
BPO 9% FOAMING CLOTHS – benzoyl peroxide cloth
9%..................................................................................103
BP VIT 3 – folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg......................................................................... 94
BRAVELLE – Benefit Limits may apply – urofollitropin
purified for inj 75 unit...................................................... 26
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh...........................................................48
BREVICON-28 – norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg.......................................................................18
BRILINTA – ticagrelor tab 90 mg......................................97
brimonidine tartrate ophth soln 0.15% (Alphagan
p)......................................................................................97
brimonidine tartrate ophth soln 0.2%............................97
bromocriptine mesylate cap 5 mg (Parlodel)................81
bromocriptine mesylate tab 2.5 mg...............................81
brompheniramine maleate tab sr 12hr 6 mg.................45
budesonide cap sr 24hr 3 mg (Entocort ec)................. 14
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)...................................................................... 48
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)...................................................................... 48
budesonide nasal susp 32 mcg/act (Rhinocort
aqua)............................................................................... 46
bumetanide tab 0.5 mg................................................... 41
bumetanide tab 1 mg...................................................... 41
bumetanide tab 2 mg...................................................... 41
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv).............................................................................. 69
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv).............................................................................. 69
buprenorphine hcl sl tab 2 mg (base equiv)................. 69
buprenorphine hcl sl tab 8 mg (base equiv)................. 69
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 66
bupropion hcl tab 100 mg (Wellbutrin)......................... 57
bupropion hcl tab 75 mg (Wellbutrin)........................... 57
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 57
bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr)........ 57
bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)........ 57
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl).........57
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl).........57
buspirone hcl tab 10 mg................................................ 56
buspirone hcl tab 15 mg................................................ 56
buspirone hcl tab 30 mg................................................ 56
buspirone hcl tab 5 mg.................................................. 56
buspirone hcl tab 7.5 mg............................................... 56
butalbital-acetaminophen-caffeine cap 50-325-40
mg....................................................................................68
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)............................................................................. 68
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30
mg (Fioricet/codeine).................................................... 69
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
mg....................................................................................69
butalbital-acetaminophen tab 50-325 mg...................... 68
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)..........................................................................68
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)......................................................69
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
119
2015
butorphanol tartrate nasal soln 10 mg/ml.....................69
C
cabergoline tab 0.5 mg................................................... 26
CADUET – amlodipine besylate-atorvastatin calcium tab
10-10 mg......................................................................... 45
CADUET – amlodipine besylate-atorvastatin calcium tab
10-20 mg......................................................................... 45
CADUET – amlodipine besylate-atorvastatin calcium tab
10-40 mg......................................................................... 45
CADUET – amlodipine besylate-atorvastatin calcium tab
10-80 mg......................................................................... 45
CADUET – amlodipine besylate-atorvastatin calcium tab
2.5-10 mg........................................................................ 45
CADUET – amlodipine besylate-atorvastatin calcium tab
2.5-20 mg........................................................................ 45
CADUET – amlodipine besylate-atorvastatin calcium tab
2.5-40 mg........................................................................ 45
CADUET – amlodipine besylate-atorvastatin calcium tab
5-10 mg........................................................................... 45
CADUET – amlodipine besylate-atorvastatin calcium tab
5-20 mg........................................................................... 45
CADUET – amlodipine besylate-atorvastatin calcium tab
5-40 mg........................................................................... 45
CADUET – amlodipine besylate-atorvastatin calcium tab
5-80 mg........................................................................... 45
CALAN SR – verapamil hcl tab cr 120 mg........................31
CALAN SR – verapamil hcl tab cr 180 mg........................31
CALAN SR – verapamil hcl tab cr 240 mg........................31
CALAN – verapamil hcl tab 120 mg..................................31
CALAN – verapamil hcl tab 80 mg....................................31
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)............................................. 103
calcipotriene cream 0.005% (Dovonex)....................... 103
calcipotriene oint 0.005%............................................. 103
calcipotriene soln 0.005% (50 mcg/ml)........................103
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)...................................................................... 26
CALCITRIOL – calcitriol oint 3 mcg/gm.......................... 103
calcitriol cap 0.25 mcg (Rocaltrol).................................26
calcitriol cap 0.5 mcg (Rocaltrol)...................................26
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................26
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................. 53
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)..........................................................................53
CALCIUM PNV – prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg............................................................. 84
CANASA – mesalamine suppos 1000 mg........................ 53
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct)........................................................... 35
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct)........................................................... 36
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct)........................................................... 36
candesartan cilexetil tab 16 mg (Atacand)....................35
120
candesartan cilexetil tab 32 mg (Atacand)....................35
candesartan cilexetil tab 4 mg (Atacand)......................35
candesartan cilexetil tab 8 mg (Atacand)......................35
capecitabine tab 150 mg (Xeloda)................................. 11
capecitabine tab 500 mg (Xeloda)................................. 11
CAPRELSA – vandetanib tab 100 mg.............................. 12
CAPRELSA – vandetanib tab 300 mg.............................. 12
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 25-15 mg................................... 36
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 25-25 mg................................... 36
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 50-15 mg................................... 36
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 50-25 mg................................... 36
captopril tab 100 mg....................................................... 36
captopril tab 12.5 mg...................................................... 36
captopril tab 25 mg......................................................... 36
captopril tab 50 mg......................................................... 36
CARAFATE – sucralfate susp 1 gm/10ml......................... 50
CARAFATE – sucralfate tab 1 gm.................................... 50
CARBAGLU – carglumic acid tab 200 mg........................ 26
carbamazepine cap sr 12hr 100 mg (Carbatrol)............77
carbamazepine cap sr 12hr 200 mg (Carbatrol)............77
carbamazepine cap sr 12hr 300 mg (Carbatrol)............77
carbamazepine chew tab 100 mg.................................. 77
carbamazepine susp 100 mg/5ml (Tegretol)................. 77
carbamazepine tab 200 mg (Tegretol)........................... 77
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)..........77
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)..........77
CARBATROL – carbamazepine cap sr 12hr 100 mg........ 77
CARBATROL – carbamazepine cap sr 12hr 200 mg........ 77
CARBATROL – carbamazepine cap sr 12hr 300 mg........ 77
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 12.5-50-200 mg.................... 81
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 18.75-75-200 mg.................. 81
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 25-100-200 mg..................... 81
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 31.25-125-200 mg................ 81
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 37.5-150-200 mg.................. 81
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 50-200-200 mg..................... 81
carbidopa & levodopa tab 10-100 mg (Sinemet)...........81
carbidopa & levodopa tab 25-100 mg (Sinemet)...........81
carbidopa & levodopa tab 25-250 mg (Sinemet)...........81
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................... 81
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................... 81
carbidopa tab 25 mg (Lodosyn).....................................81
carbinoxamine maleate soln 4 mg/5ml..........................45
carbinoxamine maleate tab 4 mg...................................45
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr
120 mg.............................................................................31
CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr
180 mg.............................................................................31
CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr
240 mg.............................................................................31
CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr
300 mg.............................................................................31
CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr
360 mg.............................................................................31
CARDIZEM – diltiazem hcl tab 120 mg............................ 31
CARDIZEM – diltiazem hcl tab 30 mg.............................. 31
CARDIZEM – diltiazem hcl tab 60 mg.............................. 31
CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr
120 mg.............................................................................31
CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr
180 mg.............................................................................31
CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr
240 mg.............................................................................31
CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr
300 mg.............................................................................31
CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr
360 mg.............................................................................31
CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr
420 mg.............................................................................31
CARDURA – doxazosin mesylate tab 1 mg......................36
CARDURA – doxazosin mesylate tab 2 mg......................36
CARDURA – doxazosin mesylate tab 4 mg......................36
CARDURA – doxazosin mesylate tab 8 mg......................36
carisoprodol tab 350 mg (Soma)................................... 83
CARNITOR – levocarnitine oral soln 1 gm/10ml (10%).....26
CARNITOR – levocarnitine tab 330 mg............................ 26
CARNITOR SF – levocarnitine oral soln 1 gm/10ml
(10%)............................................................................... 26
carteolol hcl ophth soln 1%........................................... 97
carvedilol tab 12.5 mg (Coreg).......................................29
carvedilol tab 25 mg (Coreg)..........................................29
carvedilol tab 3.125 mg (Coreg).....................................29
carvedilol tab 6.25 mg (Coreg).......................................29
CASODEX – bicalutamide tab 50 mg............................... 12
CATAPRES – clonidine hcl tab 0.1 mg.............................36
CATAPRES – clonidine hcl tab 0.2 mg.............................36
CATAPRES – clonidine hcl tab 0.3 mg.............................36
CATAPRES-TTS-1 – clonidine hcl td patch weekly 0.1
mg/24hr............................................................................36
CATAPRES-TTS-2 – clonidine hcl td patch weekly 0.2
mg/24hr............................................................................36
CATAPRES-TTS-3 – clonidine hcl td patch weekly 0.3
mg/24hr............................................................................36
CAYSTON – aztreonam lysine for inhal soln 75 mg (base
equivalent)....................................................................... 10
cefaclor cap 250 mg......................................................... 2
cefaclor cap 500 mg......................................................... 2
CEFACLOR – cefaclor for susp 125 mg/5ml...................... 1
CEFACLOR – cefaclor for susp 250 mg/5ml...................... 1
CEFACLOR – cefaclor for susp 375 mg/5ml...................... 2
cefadroxil cap 500 mg...................................................... 2
cefadroxil for susp 250 mg/5ml....................................... 2
cefadroxil for susp 500 mg/5ml....................................... 2
cefadroxil tab 1 gm........................................................... 2
cefdinir cap 300 mg.......................................................... 2
cefdinir for susp 125 mg/5ml........................................... 2
cefdinir for susp 250 mg/5ml........................................... 2
cefpodoxime proxetil for susp 100 mg/5ml.................... 2
cefpodoxime proxetil for susp 50 mg/5ml...................... 2
cefpodoxime proxetil tab 100 mg.................................... 2
cefpodoxime proxetil tab 200 mg.................................... 2
cefprozil for susp 125 mg/5ml......................................... 2
cefprozil for susp 250 mg/5ml......................................... 2
cefprozil tab 250 mg......................................................... 2
cefprozil tab 500 mg......................................................... 2
CEFTIBUTEN – ceftibuten cap 400 mg.............................. 2
CEFTIBUTEN – ceftibuten for susp 180 mg/5ml.................2
CEFTIN – cefuroxime axetil for susp 125 mg/5ml...............2
CEFTIN – cefuroxime axetil for susp 250 mg/5ml...............2
CEFTIN – cefuroxime axetil tab 250 mg............................. 2
CEFTIN – cefuroxime axetil tab 500 mg............................. 2
cefuroxime axetil for susp 125 mg/5ml (Ceftin)..............2
cefuroxime axetil tab 250 mg (Ceftin)............................. 2
cefuroxime axetil tab 500 mg (Ceftin)............................. 2
CELEBREX – celecoxib cap 100 mg................................ 73
CELEBREX – celecoxib cap 200 mg................................ 73
CELEBREX – celecoxib cap 400 mg................................ 73
CELEBREX – celecoxib cap 50 mg.................................. 73
celecoxib cap 100 mg (Celebrex).................................. 73
celecoxib cap 200 mg (Celebrex).................................. 73
celecoxib cap 400 mg (Celebrex).................................. 73
celecoxib cap 50 mg (Celebrex).................................... 73
CELEXA – citalopram hydrobromide tab 10 mg (base
equiv)............................................................................... 57
CELEXA – citalopram hydrobromide tab 20 mg (base
equiv)............................................................................... 57
CELEXA – citalopram hydrobromide tab 40 mg (base
equiv)............................................................................... 57
CELLCEPT – mycophenolate mofetil cap 250 mg.......... 111
CELLCEPT – mycophenolate mofetil for oral susp 200 mg/
ml................................................................................... 111
CELLCEPT – mycophenolate mofetil tab 500 mg........... 111
CELLUGEL – hypromellose intraocular soln 2%...............97
CENTANY – mupirocin oint 2%...................................... 103
cephalexin cap 250 mg (Keflex).......................................2
cephalexin cap 500 mg (Keflex).......................................2
cephalexin cap 750 mg (Keflex).......................................2
cephalexin for susp 125 mg/5ml......................................2
cephalexin for susp 250 mg/5ml......................................2
CETRAXAL – ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 100
CETROTIDE – Benefit Limits may apply – cetrorelix
acetate for inj kit 0.25 mg................................................26
CHANTIX CONTINUING MONTH – varenicline tartrate tab
1 mg (base equiv)........................................................... 66
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
121
2015
CHANTIX STARTING MONTH PA – varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 66
CHANTIX – varenicline tartrate tab 0.5 mg (base
equiv)............................................................................... 66
CHANTIX – varenicline tartrate tab 1 mg (base equiv)......66
chlordiazepoxide hcl cap 10 mg.................................... 56
chlordiazepoxide hcl cap 25 mg.................................... 56
chlordiazepoxide hcl cap 5 mg......................................56
chlorhexidine gluconate soln 0.12% (Peridex)........... 101
chloroquine phosphate tab 250 mg...............................10
chloroquine phosphate tab 500 mg (Aralen)................ 10
CHLOROTHIAZIDE – chlorothiazide tab 250 mg..............41
chlorothiazide tab 500 mg.............................................. 41
chlorpromazine hcl tab 100 mg..................................... 61
chlorpromazine hcl tab 10 mg....................................... 60
chlorpromazine hcl tab 200 mg..................................... 61
chlorpromazine hcl tab 25 mg....................................... 61
chlorpromazine hcl tab 50 mg....................................... 61
CHLORTHALIDONE – chlorthalidone tab 100 mg............ 41
CHLORTHALIDONE – chlorthalidone tab 25 mg.............. 41
CHLORTHALIDONE – chlorthalidone tab 50 mg.............. 41
chlorzoxazone tab 500 mg (Parafon forte dsc).............83
CHOICE-OB+DHA – prenatal mv w/fe poly-fa chw 29-1
mg & dha cap 250 mg pak ............................................ 84
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................ 43
cholestyramine light powder packets 4 gm..................43
cholestyramine powder 4 gm/dose (Questran)............ 43
cholestyramine powder packets 4 gm (Questran)........43
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix)............................................................... 43
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix)............................................................... 43
chorionic gonadotropin for inj 10000 unit – Benefit
Limits may apply........................................................... 26
CICLODAN SOLUTION KIT – ciclopirox solution kit
8%..................................................................................104
ciclopirox gel 0.77%......................................................104
ciclopirox olamine cream 0.77% (base equiv)............ 104
ciclopirox olamine susp 0.77% (base equiv).............. 104
ciclopirox shampoo 1% (Loprox shampoo)................104
ciclopirox solution 8% (Penlac Nail Lacquer).............104
ciclopirox solution kit 8% (Ciclodan solution ki)........104
cilostazol tab 100 mg (Pletal).........................................97
cilostazol tab 50 mg (Pletal)...........................................97
CILOXAN – ciprofloxacin hcl ophth soln 0.3%.................. 98
cimetidine hcl soln 300 mg/5ml..................................... 50
cimetidine tab 200 mg.................................................... 50
cimetidine tab 300 mg.................................................... 50
cimetidine tab 400 mg.................................................... 50
cimetidine tab 800 mg.................................................... 50
CIPRO – ciprofloxacin hcl tab 250 mg (base equiv)............4
CIPRO – ciprofloxacin hcl tab 500 mg (base equiv)............4
CIPROFLOXACIN – ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 100
122
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)....................................................4
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)......................................................... 4
CIPROFLOXACIN HCL – ciprofloxacin hcl tab 100 mg
(base equiv).......................................................................4
ciprofloxacin hcl ophth soln 0.3% (Ciloxan).................98
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 4
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 4
ciprofloxacin hcl tab 750 mg (base equiv)......................4
CIPRO XR – ciprofloxacin-ciprofloxacin hcl tab sr 24hr
1000 mg(base eq)............................................................. 4
CIPRO XR – ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500
mg (base eq)..................................................................... 4
citalopram hydrobromide oral soln 10 mg/5ml.............57
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 57
citalopram hydrobromide tab 20 mg (base equiv)
(Celexa)........................................................................... 57
citalopram hydrobromide tab 40 mg (base equiv)
(Celexa)........................................................................... 57
CITRANATAL 90 DHA – prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak........................................... 84
CITRANATAL ASSURE – prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack............................................84
CITRANATAL B-CALM – prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak.................................................84
CITRANATAL DHA – prenat w/o a w/fecbn-fegl-dss-fa tab
& dha cap 250 mg pack.................................................. 84
CITRANATAL HARMONY – prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg..................................................84
CITRANATAL HARMONY – prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg........................................... 84
CITRANATAL HARMONY – prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg........................................... 84
CITRANATAL RX – prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg........................................................... 84
CLARAVIS – isotretinoin cap 30 mg............................... 104
CLARIFOAM EF – sulfacetamide sodium w/ sulfur foam
10-5%.............................................................................104
CLARINEX – desloratadine tab 5 mg............................... 45
CLARINEX REDITABS – desloratadine tab orally
disintegrating 2.5 mg....................................................... 45
CLARINEX REDITABS – desloratadine tab orally
disintegrating 5 mg.......................................................... 45
clarithromycin for susp 125 mg/5ml................................3
clarithromycin for susp 250 mg/5ml (Biaxin)..................3
clarithromycin tab 250 mg (Biaxin)................................. 3
clarithromycin tab 500 mg (Biaxin)................................. 3
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)..........3
CLEOCIN – clindamycin hcl cap 150 mg..........................11
CLEOCIN – clindamycin hcl cap 300 mg..........................11
CLEOCIN – clindamycin hcl cap 75 mg............................11
CLEOCIN – clindamycin phosphate vaginal cream 2%.....55
CLEOCIN PEDIATRIC GRANULE – clindamycin palmitate
hcl for soln 75 mg/5ml (base equiv)................................ 11
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
CLEOCIN-T – clindamycin phosphate gel 1%................ 104
CLEOCIN-T – clindamycin phosphate lotion 1%.............104
CLEOCIN-T – clindamycin phosphate soln 1%...............104
CLEOCIN-T – clindamycin phosphate swab 1%............. 104
clidinium & chlordiazepoxide cap 2.5-5 mg
(Librax)............................................................................50
CLIMARA – estradiol td patch weekly 0.025 mg/24hr....... 16
CLIMARA – estradiol td patch weekly 0.0375 mg/24hr
(37.5 mcg/24hr)............................................................... 16
CLIMARA – estradiol td patch weekly 0.05 mg/24hr......... 16
CLIMARA – estradiol td patch weekly 0.06 mg/24hr......... 16
CLIMARA – estradiol td patch weekly 0.075 mg/24hr....... 16
CLIMARA – estradiol td patch weekly 0.1 mg/24hr........... 16
clindamycin hcl cap 150 mg (Cleocin).......................... 11
clindamycin hcl cap 300 mg (Cleocin).......................... 11
clindamycin hcl cap 75 mg (Cleocin)............................ 11
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr).........................................11
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)....................................................................104
clindamycin phosphate foam 1% (Evoclin).................104
clindamycin phosphate gel 1% (Cleocin-t)................. 104
clindamycin phosphate lotion 1% (Cleocin-t).............104
clindamycin phosphate soln 1% (Cleocin-t)............... 104
clindamycin phosphate swab 1% (Cleocin-t)..............104
clindamycin phosphate vaginal cream 2%
(Cleocin)..........................................................................55
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)................................................................104
clobetasol propionate cream 0.05% (Temovate)........ 104
clobetasol propionate emollient base cream 0.05%
(Temovate e)................................................................ 104
clobetasol propionate emulsion foam 0.05% (Oluxe)....................................................................................104
clobetasol propionate foam 0.05% (Olux)................... 104
clobetasol propionate gel 0.05% (Temovate)..............104
clobetasol propionate lotion 0.05% (Clobex)..............104
clobetasol propionate oint 0.05% (Temovate)............ 104
clobetasol propionate shampoo 0.05% (Clobex)........104
clobetasol propionate soln 0.05% (Temovate)........... 104
clobetasol propionate spray 0.05% (Clobex).............. 104
CLOBEX – clobetasol propionate lotion 0.05%............... 104
CLOBEX – clobetasol propionate shampoo 0.05%.........104
CLOBEX – clobetasol propionate spray 0.05%...............104
clomiphene citrate tab 50 mg – Benefit Limits may
apply................................................................................26
clomipramine hcl cap 25 mg (Anafranil)....................... 57
clomipramine hcl cap 50 mg (Anafranil)....................... 57
clomipramine hcl cap 75 mg (Anafranil)....................... 57
clonazepam orally disintegrating tab 0.125 mg............77
clonazepam orally disintegrating tab 0.25 mg..............77
clonazepam orally disintegrating tab 0.5 mg................77
clonazepam orally disintegrating tab 1 mg...................77
clonazepam orally disintegrating tab 2 mg...................77
clonazepam tab 0.5 mg (Klonopin)................................77
clonazepam tab 1 mg (Klonopin)...................................77
clonazepam tab 2 mg (Klonopin)...................................77
clonidine hcl tab 0.1 mg (Catapres).............................. 36
clonidine hcl tab 0.2 mg (Catapres).............................. 36
clonidine hcl tab 0.3 mg (Catapres).............................. 36
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................... 65
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 36
clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2)................................................................................ 36
clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3)................................................................................ 36
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix)............................................................................ 97
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix)............................................................................ 97
clorazepate dipotassium tab 15 mg (Tranxene t)......... 56
clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 56
clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 56
clotrimazole troche 10 mg............................................101
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).................................................................... 104
clotrimazole w/ betamethasone lotion 1-0.05%.......... 104
clozapine tab 100 mg (Clozaril)..................................... 61
clozapine tab 200 mg......................................................61
clozapine tab 25 mg (Clozaril)....................................... 61
clozapine tab 50 mg........................................................61
CLOZARIL – clozapine tab 100 mg.................................. 61
CLOZARIL – clozapine tab 25 mg.................................... 61
C-NATE DHA – prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................... 84
COARTEM – artemether-lumefantrine tab 20-120 mg...... 10
CODEINE SULFATE – codeine sulfate tab 15 mg............69
CODEINE SULFATE – codeine sulfate tab 30 mg............69
CODEINE SULFATE – codeine sulfate tab 60 mg............69
codeine sulfate tab 15 mg (Codeine sulfate)................ 69
codeine sulfate tab 30 mg..............................................69
codeine sulfate tab 60 mg..............................................69
COLAZAL – balsalazide disodium cap 750 mg.................53
COLCHICINE – colchicine tab 0.6 mg.............................. 76
colchicine w/ probenecid tab 0.5-500 mg......................76
COLCRYS – colchicine tab 0.6 mg...................................76
COLESTID – colestipol hcl granule packets 5 gm............ 43
COLESTID – colestipol hcl granules 5 gm........................43
COLESTID – colestipol hcl tab 1 gm................................ 43
COLESTID FLAVORED – colestipol hcl granule packets 5
gm.................................................................................... 43
COLESTID FLAVORED – colestipol hcl granules 5
gm.................................................................................... 43
colestipol hcl granule packets 5 gm (Colestid
flavored)..........................................................................43
colestipol hcl granules 5 gm (Colestid flavored)..........43
colestipol hcl tab 1 gm (Colestid)..................................43
COLYTE-FLAVOR PACKS – peg 3350-kcl-na bicarb-naclna sulfate for soln 227.1 gm............................................49
COLYTE-FLAVOR PACKS – peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm.............................................. 49
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
123
2015
COMBIGAN – brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%...................................................................98
COMBIVENT RESPIMAT – ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act........................................... 48
COMBIVIR – lamivudine-zidovudine tab 150-300 mg......... 6
COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60
mg dose) kit.....................................................................12
COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit............................................................ 12
COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit............................................................ 12
COMPLERA – emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................. 6
COMPLETE NATAL DHA – prenat-fe bis-fe prot succ-faca tab & omega 3 cap 250 pk.........................................84
COMPLETENATE – prenatal vit w/ fe fumarate-fa chew
tab 29-1 mg..................................................................... 84
COMTAN – entacapone tab 200 mg.................................81
CO-NATAL FA – prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................... 84
CONCEPT DHA – prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg............................................................ 84
CONCEPT OB – prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg................................................................. 84
CONCERTA – methylphenidate hcl tab sa osm 18 mg..... 65
CONCERTA – methylphenidate hcl tab sa osm 27 mg..... 65
CONCERTA – methylphenidate hcl tab sa osm 36 mg..... 65
CONCERTA – methylphenidate hcl tab sa osm 54 mg..... 65
CONDYLOX – podofilox soln 0.5%.................................104
COPAXONE – glatiramer acetate inj kit 20 mg/ml............ 66
COPAXONE – glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................... 66
COPEGUS – ribavirin tab 200 mg...................................... 6
CORDARONE – amiodarone hcl tab 200 mg................... 33
COREG – carvedilol tab 12.5 mg..................................... 29
COREG – carvedilol tab 25 mg........................................ 29
COREG – carvedilol tab 3.125 mg................................... 29
COREG – carvedilol tab 6.25 mg..................................... 29
CORGARD – nadolol tab 20 mg.......................................29
CORGARD – nadolol tab 40 mg.......................................29
CORGARD – nadolol tab 80 mg.......................................29
CORTANE-B AQUEOUS – pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml.................................. 100
CORTANE-B-OTIC – pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml............................................................... 100
CORTEF – hydrocortisone tab 10 mg...............................14
CORTEF – hydrocortisone tab 20 mg...............................14
CORTEF – hydrocortisone tab 5 mg.................................14
CORTENEMA – hydrocortisone enema 100
mg/60ml......................................................................... 102
CORTIFOAM – hydrocortisone acetate rectal foam 90 mg/
dose............................................................................... 102
CORTISONE ACETATE – cortisone acetate tab 25
mg.................................................................................... 14
CORTISPORIN – neomycin-polymyxin-hc otic soln
1%..................................................................................100
124
CORVITE 150 – iron-folic acid-vit c-vit b6-vit b12-zinc tab
150-1.25 mg.................................................................... 94
CORZIDE – nadolol & bendroflumethiazide tab 40-5
mg.................................................................................... 36
CORZIDE – nadolol & bendroflumethiazide tab 80-5
mg.................................................................................... 36
COSOPT – dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml.................................................................98
COUMADIN – warfarin sodium tab 10 mg........................ 95
COUMADIN – warfarin sodium tab 1 mg.......................... 95
COUMADIN – warfarin sodium tab 2.5 mg....................... 95
COUMADIN – warfarin sodium tab 2 mg.......................... 95
COUMADIN – warfarin sodium tab 3 mg.......................... 95
COUMADIN – warfarin sodium tab 4 mg.......................... 95
COUMADIN – warfarin sodium tab 5 mg.......................... 95
COUMADIN – warfarin sodium tab 6 mg.......................... 95
COUMADIN – warfarin sodium tab 7.5 mg....................... 95
COZAAR – losartan potassium tab 100 mg...................... 36
COZAAR – losartan potassium tab 25 mg........................ 36
COZAAR – losartan potassium tab 50 mg........................ 36
CRESTOR – rosuvastatin calcium tab 10 mg................... 43
CRESTOR – rosuvastatin calcium tab 20 mg................... 43
CRESTOR – rosuvastatin calcium tab 40 mg................... 43
CRESTOR – rosuvastatin calcium tab 5 mg..................... 43
CRINONE – progesterone vaginal gel 4%........................ 55
CRINONE – progesterone vaginal gel 8%........................ 55
CRIXIVAN – indinavir sulfate cap 200 mg.......................... 6
CRIXIVAN – indinavir sulfate cap 400 mg.......................... 6
CROMOLYN SODIUM – cromolyn sodium soln nebu 20
mg/2ml............................................................................. 48
cromolyn sodium ophth soln 4%...................................98
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom).................................................................. 53
CUPRIMINE – penicillamine cap 250 mg....................... 111
CUTIVATE – fluticasone propionate cream 0.05%......... 104
CUTIVATE – fluticasone propionate lotion 0.05%...........104
cyanocobalamin inj 1000 mcg/ml.................................. 94
CYCLESSA – desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg........................ 18
cyclobenzaprine hcl tab 10 mg......................................83
cyclobenzaprine hcl tab 5 mg........................................83
cyclobenzaprine hcl tab 7.5 mg (Fexmid)..................... 83
CYCLOGYL – cyclopentolate hcl ophth soln 1%.............. 98
CYCLOGYL – cyclopentolate hcl ophth soln 2%.............. 98
cyclopentolate hcl ophth soln 1% (Cyclogyl)............... 98
cyclopentolate hcl ophth soln 2% (Cyclogyl)............... 98
CYCLOPHOSPHAMIDE – cyclophosphamide cap 25
mg.................................................................................... 12
CYCLOPHOSPHAMIDE – cyclophosphamide cap 50
mg.................................................................................... 12
cyclosporine cap 100 mg (Sandimmune)....................111
cyclosporine cap 25 mg (Sandimmune)......................111
cyclosporine modified cap 100 mg (Neoral)............... 111
cyclosporine modified cap 25 mg (Neoral)................. 111
CYCLOSPORINE MODIFIED – cyclosporine modified cap
50 mg.............................................................................111
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
cyclosporine modified oral soln 100 mg/ml
(Neoral)......................................................................... 111
CYMBALTA – duloxetine hcl enteric coated pellets cap 20
mg.................................................................................... 57
CYMBALTA – duloxetine hcl enteric coated pellets cap 30
mg.................................................................................... 57
CYMBALTA – duloxetine hcl enteric coated pellets cap 60
mg.................................................................................... 57
cyproheptadine hcl syrup 2 mg/5ml..............................45
cyproheptadine hcl tab 4 mg......................................... 45
CYSTARAN – cysteamine hcl ophth soln 0.44% (base
equivalent)....................................................................... 98
CYTOMEL – liothyronine sodium tab 25 mcg................... 23
CYTOMEL – liothyronine sodium tab 50 mcg................... 23
CYTOMEL – liothyronine sodium tab 5 mcg..................... 23
CYTOTEC – misoprostol tab 100 mcg..............................50
CYTOTEC – misoprostol tab 200 mcg..............................50
D
D.H.E. 45 – dihydroergotamine mesylate inj 1 mg/ml....... 75
DALIRESP – roflumilast tab 500 mcg............................... 48
danazol cap 100 mg........................................................ 16
danazol cap 200 mg........................................................ 16
danazol cap 50 mg..........................................................16
DANTRIUM – dantrolene sodium cap 100 mg.................. 83
DANTRIUM – dantrolene sodium cap 25 mg.................... 83
DANTRIUM – dantrolene sodium cap 50 mg.................... 83
dantrolene sodium cap 25 mg (Dantrium).................... 83
dantrolene sodium cap 50 mg (Dantrium).................... 83
DANTROLENE SODIUM – dantrolene sodium cap 100
mg.................................................................................... 83
DAPSONE – dapsone tab 100 mg................................... 11
DAPSONE – dapsone tab 25 mg..................................... 11
DARAPRIM – pyrimethamine tab 25 mg...........................10
DAYPRO – oxaprozin tab 600 mg.................................... 73
DDAVP – desmopressin acetate nasal soln 0.01%
(refrigerated).................................................................... 26
DDAVP – desmopressin acetate nasal spray soln
0.01%...............................................................................26
DDAVP – desmopressin acetate tab 0.1 mg.....................26
DDAVP – desmopressin acetate tab 0.2 mg.....................26
DELESTROGEN – estradiol valerate im in oil 10 mg/
ml..................................................................................... 17
DELESTROGEN – estradiol valerate im in oil 20 mg/
ml..................................................................................... 17
DELESTROGEN – estradiol valerate im in oil 40 mg/
ml..................................................................................... 17
DELZICOL – mesalamine cap dr 400 mg......................... 53
DEMADEX – torsemide tab 100 mg................................. 41
DEMADEX – torsemide tab 10 mg................................... 41
DEMADEX – torsemide tab 20 mg................................... 41
DEMADEX – torsemide tab 5 mg..................................... 41
demeclocycline hcl tab 150 mg....................................... 3
demeclocycline hcl tab 300 mg....................................... 3
DEMEROL – meperidine hcl tab 100 mg..........................69
DEMEROL – meperidine hcl tab 50 mg............................69
DENAVIR – penciclovir cream 1%.................................. 104
DEPAKENE – valproate sodium syrup 250 mg/5ml (base
equiv)............................................................................... 77
DEPAKENE – valproic acid cap 250 mg...........................77
DEPAKOTE – divalproex sodium tab delayed release 125
mg.................................................................................... 77
DEPAKOTE – divalproex sodium tab delayed release 250
mg.................................................................................... 77
DEPAKOTE – divalproex sodium tab delayed release 500
mg.................................................................................... 77
DEPAKOTE ER – divalproex sodium tab sr 24 hr 250
mg.................................................................................... 77
DEPAKOTE ER – divalproex sodium tab sr 24 hr 500
mg.................................................................................... 77
DEPAKOTE SPRINKLES – divalproex sodium cap
sprinkle 125 mg............................................................... 77
DEPEN TITRATABS – penicillamine tab 250 mg............111
DEPO-PROVERA CONTRACEPTIV –
medroxyprogesterone acetate im susp 150 mg/ml.......... 18
DEPO-TESTOSTERONE – testosterone cypionate im inj
in oil 100 mg/ml...............................................................16
DEPO-TESTOSTERONE – testosterone cypionate im inj
in oil 200 mg/ml...............................................................16
DERMA-SMOOTHE/FS BODY – fluocinolone acetonide
oil 0.01% (body oil)........................................................104
DERMA-SMOOTHE/FS BODY OIL – fluocinolone
acetonide oil 0.01% (body oil)....................................... 105
DERMA-SMOOTHE/FS SCALP – fluocinolone acetonide
oil 0.01% (scalp oil)....................................................... 105
DERMA-SMOOTHE/FS SCALP OI – fluocinolone
acetonide oil 0.01% (scalp oil)...................................... 105
DERMATOP – prednicarbate cream 0.1%......................105
DERMATOP – prednicarbate oint 0.1%.......................... 105
DERMOTIC – fluocinolone acetonide (otic) oil 0.01%..... 100
desipramine hcl tab 100 mg (Norpramin)......................57
desipramine hcl tab 10 mg (Norpramin)....................... 57
desipramine hcl tab 150 mg (Norpramin)......................57
desipramine hcl tab 25 mg (Norpramin)....................... 58
desipramine hcl tab 50 mg (Norpramin)....................... 58
desipramine hcl tab 75 mg (Norpramin)....................... 58
desloratadine tab 5 mg (Clarinex)................................. 45
desloratadine tab orally disintegrating 2.5 mg
(Clarinex reditabs)......................................................... 45
desloratadine tab orally disintegrating 5 mg (Clarinex
reditabs)..........................................................................45
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)............................................................................26
desmopressin acetate nasal spray soln 0.01%
(Ddavp)............................................................................26
desmopressin acetate nasal spray soln 0.01%
(refrigerated)...................................................................26
desmopressin acetate tab 0.1 mg (Ddavp)................... 26
desmopressin acetate tab 0.2 mg (Ddavp)................... 26
DESOGEN – desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg.......................................................................18
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
125
2015
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette).........................................................18
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
(Cyclessa)....................................................................... 18
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)....................................................................... 18
desonide cream 0.05% (Desowen)...............................105
desonide lotion 0.05% (Desowen)............................... 105
desonide oint 0.05% (Desowen).................................. 105
DESOWEN – desonide cream 0.05%.............................105
DESOWEN – desonide lotion 0.05%.............................. 105
DESOWEN – desonide oint 0.05%................................. 105
desoximetasone cream 0.25% (Topicort)....................105
DESOXIMETASONE – desoximetasone cream
0.05%.............................................................................105
desoximetasone gel 0.05% (Topicort)......................... 105
desoximetasone oint 0.25% (Topicort)........................105
DETROL – tolterodine tartrate tab 1 mg........................... 54
DETROL – tolterodine tartrate tab 2 mg........................... 54
DEX4 GLUCOSE – glucose oral liquid 15 gm/59ml.......... 20
DEXAMETHASONE – dexamethasone soln 0.5
mg/5ml............................................................................. 14
DEXAMETHASONE – dexamethasone tab 1 mg............. 14
DEXAMETHASONE – dexamethasone tab 2 mg............. 14
dexamethasone elixir 0.5 mg/5ml.................................. 15
DEXAMETHASONE INTENSOL – dexamethasone conc 1
mg/ml............................................................................... 15
dexamethasone sodium phosphate ophth soln
0.1%.................................................................................98
dexamethasone tab 0.5 mg............................................ 15
dexamethasone tab 0.75 mg.......................................... 15
dexamethasone tab 1.5 mg............................................ 15
dexamethasone tab 4 mg............................................... 15
dexamethasone tab 6 mg............................................... 15
DEXEDRINE – dextroamphetamine sulfate cap sr 24hr 10
mg.................................................................................... 65
DEXEDRINE – dextroamphetamine sulfate cap sr 24hr 15
mg.................................................................................... 65
DEXEDRINE – dextroamphetamine sulfate cap sr 24hr 5
mg.................................................................................... 65
dexmethylphenidate hcl tab 10 mg (Focalin)................65
dexmethylphenidate hcl tab 2.5 mg (Focalin)...............65
dexmethylphenidate hcl tab 5 mg (Focalin)..................65
DEXPAK 10 DAY – dexamethasone tab 1.5 mg taper
pack................................................................................. 15
DEXPAK 13 DAY – dexamethasone tab 1.5 mg taper
pack................................................................................. 15
DEXPAK 6 DAY – dexamethasone tab 1.5 mg taper
pack................................................................................. 15
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)..................................................................... 65
dextroamphetamine sulfate cap sr 24hr 15 mg
(Dexedrine)..................................................................... 65
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)..................................................................... 65
126
dextroamphetamine sulfate tab 10 mg..........................65
dextroamphetamine sulfate tab 5 mg............................65
DIAMOX – acetazolamide cap sr 12hr 500 mg................. 41
DIASTAT ACUDIAL – diazepam rectal gel delivery system
10 mg...............................................................................77
DIASTAT ACUDIAL – diazepam rectal gel delivery system
20 mg...............................................................................77
DIASTAT PEDIATRIC – diazepam rectal gel delivery
system 2.5 mg................................................................. 77
DIAZEPAM – diazepam rectal gel delivery system 10
mg.................................................................................... 77
DIAZEPAM – diazepam rectal gel delivery system 2.5
mg.................................................................................... 77
DIAZEPAM – diazepam rectal gel delivery system 20
mg.................................................................................... 77
diazepam tab 10 mg (Valium).........................................56
diazepam tab 2 mg (Valium)...........................................56
diazepam tab 5 mg (Valium)...........................................56
diclofenac potassium tab 50 mg (Cataflam)................. 74
diclofenac sodium ophth soln 0.1%.............................. 98
diclofenac sodium tab delayed release 25 mg............. 74
diclofenac sodium tab delayed release 50 mg............. 74
diclofenac sodium tab delayed release 75 mg............. 74
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................... 74
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50).......................................................... 74
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75).......................................................... 74
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 50
dicyclomine hcl tab 20 mg (Bentyl)...............................50
didanosine delayed release capsule 125 mg (Videx
ec)......................................................................................6
didanosine delayed release capsule 200 mg (Videx
ec)......................................................................................6
didanosine delayed release capsule 250 mg (Videx
ec)......................................................................................6
didanosine delayed release capsule 400 mg (Videx
ec)......................................................................................6
DIFFERIN – adapalene cream 0.1%...............................105
DIFFERIN – adapalene gel 0.1%....................................105
DIFICID – fidaxomicin tab 200 mg......................................3
DIFLORASONE DIACETATE – diflorasone diacetate
cream 0.05%................................................................. 105
diflorasone diacetate oint 0.05%................................. 105
DIFLUCAN – fluconazole for susp 10 mg/ml...................... 5
DIFLUCAN – fluconazole for susp 40 mg/ml...................... 5
DIFLUCAN – fluconazole tab 100 mg.................................5
DIFLUCAN – fluconazole tab 150 mg.................................5
DIFLUCAN – fluconazole tab 200 mg.................................5
DIFLUCAN – fluconazole tab 50 mg...................................5
diflunisal tab 500 mg...................................................... 68
digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................28
digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................28
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45)....................................................................................75
DILANTIN INFATABS – phenytoin chew tab 50 mg..........77
DILANTIN – phenytoin sodium extended cap 100 mg.......77
DILANTIN – phenytoin sodium extended cap 30 mg........ 77
DILANTIN – phenytoin susp 125 mg/5ml..........................77
DILAUDID – hydromorphone hcl tab 2 mg........................69
DILAUDID – hydromorphone hcl tab 4 mg........................69
DILAUDID – hydromorphone hcl tab 8 mg........................69
diltiazem hcl cap sr 12hr 120 mg...................................31
diltiazem hcl cap sr 12hr 60 mg.................................... 31
diltiazem hcl cap sr 12hr 90 mg.................................... 31
diltiazem hcl cap sr 24hr 120 mg...................................31
diltiazem hcl cap sr 24hr 180 mg...................................31
diltiazem hcl cap sr 24hr 240 mg...................................31
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................. 31
diltiazem hcl coated beads cap sr 24hr 180 mg
(Cardizem cd)................................................................. 31
diltiazem hcl coated beads cap sr 24hr 240 mg
(Cardizem cd)................................................................. 31
diltiazem hcl coated beads cap sr 24hr 300 mg
(Cardizem cd)................................................................. 31
diltiazem hcl coated beads cap sr 24hr 360 mg
(Cardizem cd)................................................................. 31
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la).................................................................. 31
diltiazem hcl coated beads tab sr 24hr 240 mg
(Cardizem la).................................................................. 31
diltiazem hcl coated beads tab sr 24hr 300 mg
(Cardizem la).................................................................. 31
diltiazem hcl coated beads tab sr 24hr 360 mg
(Cardizem la).................................................................. 31
diltiazem hcl coated beads tab sr 24hr 420 mg
(Cardizem la).................................................................. 31
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).....................................................................32
diltiazem hcl extended release beads cap sr 24hr 180
mg (Tiazac).....................................................................32
diltiazem hcl extended release beads cap sr 24hr 240
mg (Tiazac).....................................................................32
diltiazem hcl extended release beads cap sr 24hr 300
mg (Tiazac).....................................................................32
diltiazem hcl extended release beads cap sr 24hr 360
mg (Tiazac).....................................................................32
diltiazem hcl extended release beads cap sr 24hr 420
mg (Tiazac).....................................................................32
diltiazem hcl tab 120 mg (Cardizem)............................. 32
diltiazem hcl tab 30 mg (Cardizem)............................... 32
diltiazem hcl tab 60 mg (Cardizem)............................... 32
diltiazem hcl tab 90 mg.................................................. 32
DIOVAN HCT – valsartan-hydrochlorothiazide tab
160-12.5 mg.................................................................... 36
DIOVAN HCT – valsartan-hydrochlorothiazide tab 160-25
mg.................................................................................... 37
DIOVAN HCT – valsartan-hydrochlorothiazide tab
320-12.5 mg.................................................................... 37
DIOVAN HCT – valsartan-hydrochlorothiazide tab 320-25
mg.................................................................................... 37
DIOVAN HCT – valsartan-hydrochlorothiazide tab 80-12.5
mg.................................................................................... 36
DIOVAN – valsartan tab 160 mg...................................... 36
DIOVAN – valsartan tab 320 mg...................................... 36
DIOVAN – valsartan tab 40 mg........................................ 36
DIOVAN – valsartan tab 80 mg........................................ 36
DIPENTUM – olsalazine sodium cap 250 mg................... 53
DIPHENOXYLATE/ATROPINE – diphenoxylate w/
atropine liq 2.5-0.025 mg/5ml..........................................49
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)..........................................................................49
DIPROLENE AF – betamethasone dipropionate
augmented cream 0.05%.............................................. 105
DIPROLENE – betamethasone dipropionate augmented
lotion 0.05%...................................................................105
DIPROLENE – betamethasone dipropionate augmented
oint 0.05%......................................................................105
dipyridamole tab 25 mg (Persantine)............................ 97
dipyridamole tab 50 mg (Persantine)............................ 97
dipyridamole tab 75 mg (Persantine)............................ 97
disopyramide phosphate cap 100 mg (Norpace)..........33
disopyramide phosphate cap 150 mg (Norpace)..........33
disulfiram tab 250 mg (Antabuse)................................. 66
disulfiram tab 500 mg (Antabuse)................................. 66
DITROPAN XL – oxybutynin chloride tab sr 24hr 10
mg.................................................................................... 54
DITROPAN XL – oxybutynin chloride tab sr 24hr 15
mg.................................................................................... 54
DITROPAN XL – oxybutynin chloride tab sr 24hr 5 mg.....54
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles)........................................................................ 77
divalproex sodium tab delayed release 125 mg
(Depakote)...................................................................... 77
divalproex sodium tab delayed release 250 mg
(Depakote)...................................................................... 77
divalproex sodium tab delayed release 500 mg
(Depakote)...................................................................... 78
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................... 78
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................... 78
DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%).......... 17
DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%).............. 17
DIVIGEL – estradiol td gel 1 mg/gm (0.1%)...................... 17
DOLOPHINE HCL – methadone hcl tab 5 mg.................. 69
DOLOPHINE – methadone hcl tab 10 mg........................ 69
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt).............................................................67
donepezil hydrochloride orally disintegrating tab 5
mg....................................................................................67
donepezil hydrochloride tab 10 mg (Aricept)............... 67
donepezil hydrochloride tab 23 mg (Aricept)............... 67
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
127
2015
donepezil hydrochloride tab 5 mg (Aricept)................. 67
DONNATAL – pb-hyoscy-atrop-scopol elix
16.2-0.1037-0.0194-0.0065 mg/5ml................................ 50
DONNATAL – pb-hyoscy-atrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg....................................... 50
dorzolamide hcl ophth soln 2% (Trusopt).....................98
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt).............................................................. 98
DOVONEX – calcipotriene cream 0.005%...................... 105
doxazosin mesylate tab 1 mg (Cardura)....................... 37
doxazosin mesylate tab 2 mg (Cardura)....................... 37
doxazosin mesylate tab 4 mg (Cardura)....................... 37
doxazosin mesylate tab 8 mg (Cardura)....................... 37
doxepin hcl cap 100 mg................................................. 58
doxepin hcl cap 10 mg................................................... 58
doxepin hcl cap 150 mg................................................. 58
doxepin hcl cap 25 mg................................................... 58
doxepin hcl cap 50 mg................................................... 58
doxepin hcl conc 10 mg/ml............................................ 58
DOXEPIN HCL – doxepin hcl cap 75 mg..........................58
doxycycline hyclate cap 100 mg (Vibramycin)............... 3
doxycycline hyclate cap 50 mg....................................... 3
doxycycline hyclate tab 100 mg...................................... 3
doxycycline hyclate tab 20 mg........................................ 3
doxycycline hyclate tab delayed release 100 mg........... 3
doxycycline hyclate tab delayed release 150 mg
(Doryx).............................................................................. 3
doxycycline hyclate tab delayed release 75 mg............. 3
doxycycline monohydrate cap 100 mg (Monodox)........ 3
doxycycline monohydrate cap 150 mg (Adoxa)............. 3
doxycycline monohydrate cap 50 mg............................. 3
doxycycline monohydrate cap 75 mg (Monodox).......... 3
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)..................................................................... 3
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100).................................................................................3
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150).................................................................................3
doxycycline monohydrate tab 50 mg (Adoxa)................ 3
doxycycline monohydrate tab 75 mg (Adoxa)................ 4
DRISDOL – ergocalciferol cap 50000 unit........................ 84
dronabinol cap 10 mg (Marinol).....................................52
dronabinol cap 2.5 mg (Marinol)....................................52
dronabinol cap 5 mg (Marinol).......................................52
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 18
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28)....................................................................................18
DROXIA – hydroxyurea cap 200 mg.................................94
DROXIA – hydroxyurea cap 300 mg.................................94
DROXIA – hydroxyurea cap 400 mg.................................94
DRYSOL – aluminum chloride soln 20%........................ 105
DUAC – clindamycin phosph-benzoyl peroxide (refrig) gel
1.2 (1)-5%......................................................................105
DUETACT – pioglitazone hcl-glimepiride tab 30-2 mg...... 20
DUETACT – pioglitazone hcl-glimepiride tab 30-4 mg...... 20
128
DUET DHA 400 – prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg......................................................... 85
DUET DHA BALANCED – prenat w/fe poly-na fered-fa tab
25-1 & omega cap 267 mg............................................. 85
DUET DHA BALANCED – prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 380mg.......................................... 85
DUET DHA – prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg......................................................... 84
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 58
duloxetine hcl enteric coated pellets cap 30 mg
(Cymbalta)...................................................................... 58
duloxetine hcl enteric coated pellets cap 60 mg
(Cymbalta)...................................................................... 58
DURAGESIC – fentanyl td patch 72hr 100 mcg/hr............69
DURAGESIC – fentanyl td patch 72hr 12 mcg/hr............. 69
DURAGESIC – fentanyl td patch 72hr 25 mcg/hr............. 69
DURAGESIC – fentanyl td patch 72hr 50 mcg/hr............. 69
DURAGESIC – fentanyl td patch 72hr 75 mcg/hr............. 69
DUTOPROL – metoprolol & hydrochlorothiazide tab sr
24hr 100-12.5 mg............................................................ 37
DUTOPROL – metoprolol & hydrochlorothiazide tab sr
24hr 25-12.5 mg.............................................................. 37
DUTOPROL – metoprolol & hydrochlorothiazide tab sr
24hr 50-12.5 mg.............................................................. 37
DYAZIDE – triamterene & hydrochlorothiazide cap 37.5-25
mg.................................................................................... 41
DYMISTA – azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act................................................................ 46
DYRENIUM – triamterene cap 100 mg............................. 41
DYRENIUM – triamterene cap 50 mg...............................41
E
E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg........ 3
EC-NAPROSYN – naproxen tab ec 375 mg..................... 74
EC-NAPROSYN – naproxen tab ec 500 mg..................... 74
econazole nitrate cream 1%......................................... 105
EDURANT – rilpivirine hcl tab 25 mg (base equivalent)...... 6
EFFER-K – potassium bicarbonate-citric acid effer tab 10
meq.................................................................................. 92
EFFER-K – potassium bicarbonate-citric acid effer tab 20
meq.................................................................................. 92
EFFEXOR XR – venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)....................................................................... 58
EFFEXOR XR – venlafaxine hcl cap sr 24hr 37.5 mg
(base equivalent)............................................................. 58
EFFEXOR XR – venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)....................................................................... 58
EFFIENT – prasugrel hcl tab 10 mg (base equiv)............. 97
EFFIENT – prasugrel hcl tab 5 mg (base equiv)............... 97
EFUDEX – fluorouracil cream 5%...................................105
ELDEPRYL – selegiline hcl cap 5 mg...............................81
ELESTAT – epinastine hcl ophth soln 0.05%................... 98
ELIGARD – leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg................................................................... 12
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
ELIGARD – leuprolide acetate (4 month) for subcutaneous
inj kit 30 mg.....................................................................12
ELIGARD – leuprolide acetate (6 month) for subcutaneous
inj kit 45 mg.....................................................................12
ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5
mg.................................................................................... 12
ELIPHOS – calcium acetate (phosphate binder) tab 667
mg.................................................................................... 53
ELIQUIS – apixaban tab 2.5 mg....................................... 95
ELIQUIS – apixaban tab 5 mg.......................................... 95
ELITE-OB – prenatal vit w/ iron carbonyl-fa tab 50-1.25
mg.................................................................................... 85
ELIXOPHYLLIN – theophylline elixir 80 mg/15ml..............48
ELLA – ulipristal acetate tab 30 mg.................................. 18
ELMIRON – pentosan polysulfate sodium caps 100
mg.................................................................................... 55
ELOCON – mometasone furoate cream 0.1%................ 105
ELOCON – mometasone furoate oint 0.1%.................... 105
ELOCON – mometasone furoate solution 0.1%
(lotion)............................................................................ 105
EMCYT – estramustine phosphate sodium cap 140
mg.................................................................................... 12
EMEND – aprepitant capsule 125 mg...............................52
EMEND – aprepitant capsule 40 mg.................................52
EMEND – aprepitant capsule 80 mg.................................52
EMEND – aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 52
EMTRIVA – emtricitabine caps 200 mg.............................. 6
EMTRIVA – emtricitabine soln 10 mg/ml............................ 6
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic).......................................................................37
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg....................................................................................37
enalapril maleate tab 10 mg (Vasotec).......................... 37
enalapril maleate tab 2.5 mg (Vasotec)......................... 37
enalapril maleate tab 20 mg (Vasotec).......................... 37
enalapril maleate tab 5 mg (Vasotec)............................ 37
ENBREL – etanercept for subcutaneous inj kit 25 mg...... 74
ENBREL – etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml.....................................................................74
ENBREL – etanercept subcutaneous soln prefilled syringe
50 mg/ml..........................................................................74
ENBREL SURECLICK – etanercept subcutaneous
solution auto-injector 50 mg/ml....................................... 74
ENDOMETRIN – progesterone vaginal insert 100 mg...... 55
enoxaparin sodium inj 100 mg/ml (Lovenox)............... 95
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)...........95
enoxaparin sodium inj 150 mg/ml (Lovenox)............... 95
enoxaparin sodium inj 300 mg/3ml (Lovenox)..............95
enoxaparin sodium inj 30 mg/0.3ml (Lovenox).............95
enoxaparin sodium inj 40 mg/0.4ml (Lovenox).............95
enoxaparin sodium inj 60 mg/0.6ml (Lovenox).............95
enoxaparin sodium inj 80 mg/0.8ml (Lovenox).............95
entacapone tab 200 mg (Comtan)..................................81
entecavir tab 0.5 mg (Baraclude).....................................6
entecavir tab 1 mg (Baraclude)........................................6
ENTEREG – alvimopan cap 12 mg.................................. 53
ENTOCORT EC – budesonide cap sr 24hr 3 mg..............15
epinastine hcl ophth soln 0.05% (Elestat).....................98
EPINEPHRINE – epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)..........................................................42
EPINEPHRINE – epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................42
EPIPEN 2-PAK – epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................42
EPIPEN-JR 2-PAK – epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000)................................................... 42
EPIVIR HBV – lamivudine oral soln 5 mg/ml...................... 6
EPIVIR HBV – lamivudine tab 100 mg............................... 6
EPIVIR – lamivudine oral soln 10 mg/ml.............................6
EPIVIR – lamivudine tab 150 mg........................................6
EPIVIR – lamivudine tab 300 mg........................................6
eplerenone tab 25 mg (Inspra).......................................37
eplerenone tab 50 mg (Inspra).......................................37
EPOGEN – epoetin alfa inj 10000 unit/ml......................... 94
EPOGEN – epoetin alfa inj 20000 unit/ml......................... 94
EPOGEN – epoetin alfa inj 2000 unit/ml...........................94
EPOGEN – epoetin alfa inj 3000 unit/ml...........................94
EPOGEN – epoetin alfa inj 4000 unit/ml...........................94
eprosartan mesylate tab 600 mg (Teveten)...................37
EPZICOM – abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 6
ergocalciferol cap 50000 unit (Drisdol)......................... 84
ERIVEDGE – vismodegib cap 150 mg............................. 12
ERY-TAB – erythromycin tab delayed release 250 mg....... 3
ERY-TAB – erythromycin tab delayed release 333 mg....... 3
ERY-TAB – erythromycin tab delayed release 500 mg....... 3
ERYTHROCIN STEARATE – erythromycin stearate tab
250 mg...............................................................................3
ERYTHROMYCIN BASE – erythromycin tab 250 mg......... 3
ERYTHROMYCIN BASE – erythromycin tab 500 mg......... 3
ERYTHROMYCIN ETHYLSUCCINA – erythromycin
ethylsuccinate tab 400 mg................................................ 3
erythromycin ophth oint 5 mg/gm................................. 98
erythromycin pads 2%.................................................. 105
erythromycin soln 2%...................................................105
erythromycin w/ delayed release particles cap 250
mg......................................................................................3
ESCAVITE LQ – pediatric multiple vitamins w/ fl-fe drops
0.25-6 mg/ml....................................................................85
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro).........................................................................58
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro).........................................................................58
escitalopram oxalate tab 20 mg (base equiv)
(Lexapro).........................................................................58
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro).........................................................................58
ESGIC – butalbital-acetaminophen-caffeine tab 50-325-40
mg.................................................................................... 68
estazolam tab 1 mg.........................................................63
estazolam tab 2 mg.........................................................63
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
129
2015
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................. 17
esterified estrogens & methyltestosterone tab 1.25-2.5
mg....................................................................................17
ESTRACE – estradiol tab 0.5 mg..................................... 17
ESTRACE – estradiol tab 1 mg........................................ 17
ESTRACE – estradiol tab 2 mg........................................ 17
ESTRACE – estradiol vaginal cream 0.1 mg/gm.............. 55
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)........................................................................17
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)........................................................................17
estradiol tab 0.5 mg (Estrace)........................................17
estradiol tab 1 mg (Estrace)...........................................17
estradiol tab 2 mg (Estrace)...........................................17
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 17
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot).................................................................... 17
estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot).................................................................................. 17
estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot).................................................................................. 17
estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot).................................................................................. 17
estradiol td patch weekly 0.025 mg/24hr (Climara)...... 17
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)....................................................... 17
estradiol td patch weekly 0.05 mg/24hr (Climara)........ 17
estradiol td patch weekly 0.06 mg/24hr (Climara)........ 17
estradiol td patch weekly 0.075 mg/24hr (Climara)...... 17
estradiol td patch weekly 0.1 mg/24hr (Climara).......... 17
estradiol valerate im in oil 20 mg/ml (Delestrogen)......17
estradiol valerate im in oil 40 mg/ml (Delestrogen)......17
ESTRING – estradiol vaginal ring 2 mg (7.5
mcg/24hrs)....................................................................... 55
ESTROPIPATE – estropipate tab 3 mg............................ 17
estropipate tab 0.75 mg..................................................17
estropipate tab 1.5 mg....................................................17
ESTROSTEP FE – norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg................................................... 18
eszopiclone tab 1 mg (Lunesta).................................... 63
eszopiclone tab 2 mg (Lunesta).................................... 63
eszopiclone tab 3 mg (Lunesta).................................... 63
ethambutol hcl tab 100 mg (Myambutol)........................ 5
ethambutol hcl tab 400 mg (Myambutol)........................ 5
ethosuximide cap 250 mg (Zarontin).............................78
ethosuximide soln 250 mg/5ml (Zarontin).................... 78
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg..................................................................................18
ETIDRONATE DISODIUM – etidronate disodium tab 400
mg.................................................................................... 26
etodolac cap 200 mg.......................................................74
etodolac cap 300 mg.......................................................74
etodolac tab 400 mg....................................................... 74
etodolac tab 500 mg....................................................... 74
130
etodolac tab sr 24hr 400 mg.......................................... 74
etodolac tab sr 24hr 500 mg.......................................... 74
etodolac tab sr 24hr 600 mg.......................................... 74
ETOPOSIDE – etoposide cap 50 mg................................12
EURAX – crotamiton cream 10%....................................105
EURAX – crotamiton lotion 10%..................................... 105
EVISTA – raloxifene hcl tab 60 mg...................................26
EVOCLIN – clindamycin phosphate foam 1%.................105
EVZIO – naloxone hcl solution auto-injector 0.4
mg/0.4ml........................................................................ 110
EXELON – rivastigmine tartrate cap 1.5 mg..................... 67
EXELON – rivastigmine tartrate cap 3 mg........................ 67
EXELON – rivastigmine tartrate cap 4.5 mg..................... 67
EXELON – rivastigmine tartrate cap 6 mg........................ 67
exemestane tab 25 mg (Aromasin)................................12
EXFORGE – amlodipine besylate-valsartan tab 10-160
mg.................................................................................... 37
EXFORGE – amlodipine besylate-valsartan tab 10-320
mg.................................................................................... 37
EXFORGE – amlodipine besylate-valsartan tab 5-160
mg.................................................................................... 37
EXFORGE – amlodipine besylate-valsartan tab 5-320
mg.................................................................................... 37
EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg......................... 37
EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg............................ 37
EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg............................ 37
EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg........................... 37
EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg.............................. 37
EXJADE – deferasirox tab for oral susp 125 mg.............110
EXJADE – deferasirox tab for oral susp 250 mg.............110
EXJADE – deferasirox tab for oral susp 500 mg.............110
EXTINA – ketoconazole foam 2%...................................105
EXTRA-VIRT PLUS DHA – prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg...................................... 85
F
famciclovir tab 125 mg (Famvir)...................................... 6
famciclovir tab 250 mg (Famvir)...................................... 7
famciclovir tab 500 mg (Famvir)...................................... 7
famotidine for susp 40 mg/5ml (Pepcid)....................... 50
famotidine tab 20 mg (Pepcid).......................................50
famotidine tab 40 mg (Pepcid).......................................50
FAMVIR – famciclovir tab 125 mg...................................... 7
FAMVIR – famciclovir tab 250 mg...................................... 7
FAMVIR – famciclovir tab 500 mg...................................... 7
FARESTON – toremifene citrate tab 60 mg (base
equivalent)....................................................................... 12
FASLODEX – fulvestrant inj 250 mg/5ml.......................... 12
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
mg....................................................................................94
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg....................................................................................94
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu
cap (Tandem plus).........................................................94
felbamate susp 600 mg/5ml (Felbatol).......................... 78
felbamate tab 400 mg (Felbatol).................................... 78
felbamate tab 600 mg (Felbatol).................................... 78
FELBATOL – felbamate susp 600 mg/5ml........................78
FELBATOL – felbamate tab 400 mg.................................78
FELBATOL – felbamate tab 600 mg.................................78
FELDENE – piroxicam cap 10 mg.................................... 74
FELDENE – piroxicam cap 20 mg.................................... 74
felodipine tab sr 24hr 10 mg.......................................... 32
felodipine tab sr 24hr 2.5 mg......................................... 32
felodipine tab sr 24hr 5 mg............................................32
FEMARA – letrozole tab 2.5 mg....................................... 12
FEMCON FE – norethindrone & ethinyl estradiol-fe chew
tab 0.4 mg-35 mcg.......................................................... 18
FEMHRT LOW DOSE – norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg...........................................17
fenofibrate micronized cap 130 mg............................... 43
fenofibrate micronized cap 134 mg (Lofibra)................43
fenofibrate micronized cap 200 mg (Lofibra)................43
fenofibrate micronized cap 43 mg................................. 43
fenofibrate micronized cap 67 mg (Lofibra)..................43
fenofibrate tab 145 mg (Tricor)...................................... 43
fenofibrate tab 160 mg (Lofibra).................................... 43
fenofibrate tab 48 mg (Tricor)........................................ 43
fenofibrate tab 54 mg (Lofibra)...................................... 43
fentanyl citrate lollipop 1200 mcg (Actiq)..................... 69
fentanyl citrate lollipop 1600 mcg (Actiq)..................... 69
fentanyl citrate lollipop 200 mcg (Actiq)....................... 69
fentanyl citrate lollipop 400 mcg (Actiq)....................... 69
fentanyl citrate lollipop 600 mcg (Actiq)....................... 69
fentanyl citrate lollipop 800 mcg (Actiq)....................... 69
fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 69
fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 69
fentanyl td patch 72hr 25 mcg/hr (Duragesic).............. 69
fentanyl td patch 72hr 50 mcg/hr (Duragesic).............. 69
fentanyl td patch 72hr 75 mcg/hr (Duragesic).............. 69
ferrous fumarate-folic acid tab 324-1 mg...................... 94
FEXMID – cyclobenzaprine hcl tab 7.5 mg....................... 83
FINACEA – azelaic acid gel 15%................................... 105
finasteride tab 5 mg (Proscar)....................................... 55
FIORICET/CODEINE – butalbital-acetaminophen-caff w/
cod cap 50-300-40-30 mg............................................... 70
FIORICET/CODEINE – butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg............................................... 70
FIORICET – butalbital-acetaminophen-caffeine tab
50-325-40 mg.................................................................. 68
FIORINAL/CODEINE #3 – butalbital-aspirin-caff w/
codeine cap 50-325-40-30 mg........................................ 70
FIORINAL – butalbital-aspirin-caffeine cap 50-325-40
mg.................................................................................... 68
FIRAZYR – icatibant acetate inj 30 mg/3ml (base
equivalent)....................................................................... 97
FLAGYL – metronidazole cap 375 mg..............................11
FLAGYL – metronidazole tab 250 mg...............................11
FLAGYL – metronidazole tab 500 mg...............................11
flavoxate hcl tab 100 mg................................................ 54
flecainide acetate tab 100 mg........................................ 33
flecainide acetate tab 150 mg........................................ 33
flecainide acetate tab 50 mg.......................................... 33
FLOMAX – tamsulosin hcl cap 0.4 mg..............................55
FLONASE – fluticasone propionate nasal susp 50 mcg/
act.................................................................................... 46
FLOVENT DISKUS – fluticasone propionate aer pow ba
100 mcg/blister................................................................ 48
FLOVENT DISKUS – fluticasone propionate aer pow ba
250 mcg/blister................................................................ 48
FLOVENT DISKUS – fluticasone propionate aer pow ba
50 mcg/blister.................................................................. 48
FLOVENT HFA – fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)......................................................... 48
FLOVENT HFA – fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)......................................................... 48
FLOVENT HFA – fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)........................................................... 48
fluconazole for susp 10 mg/ml (Diflucan)....................... 5
fluconazole for susp 40 mg/ml (Diflucan)....................... 5
fluconazole tab 100 mg (Diflucan)................................... 5
fluconazole tab 150 mg (Diflucan)................................... 5
fluconazole tab 200 mg (Diflucan)................................... 5
fluconazole tab 50 mg (Diflucan).....................................5
flucytosine cap 250 mg (Ancobon)..................................5
flucytosine cap 500 mg (Ancobon)..................................5
fludrocortisone acetate tab 0.1 mg................................15
FLUMADINE – rimantadine hydrochloride tab 100 mg....... 7
FLUNISOLIDE – flunisolide nasal soln 25 mcg/act
(0.025%).......................................................................... 46
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)....................................................................46
fluocinolone acetonide (otic) oil 0.01%
(Dermotic)..................................................................... 100
fluocinolone acetonide cream 0.01%.......................... 105
fluocinolone acetonide cream 0.025% (Synalar)........ 105
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod)...........................................................105
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)........................................................... 105
fluocinolone acetonide oint 0.025% (Synalar)............ 106
fluocinolone acetonide soln 0.01% (Synalar)............. 106
fluocinonide cream 0.05%............................................ 106
fluocinonide cream 0.1% (Vanos)................................ 106
fluocinonide emulsified base cream 0.05%................ 106
fluocinonide gel 0.05%................................................. 106
fluocinonide oint 0.05%................................................ 106
fluocinonide soln 0.05%............................................... 106
fluorometholone ophth susp 0.1% (Fml liquifilm)........ 98
fluorouracil cream 5% (Efudex)................................... 106
fluorouracil soln 2%......................................................106
fluorouracil soln 5%......................................................106
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
131
2015
fluoxetine hcl (pmdd) cap 10 mg................................... 67
fluoxetine hcl (pmdd) cap 20 mg................................... 67
fluoxetine hcl cap 10 mg (Prozac)................................. 58
fluoxetine hcl cap 20 mg (Prozac)................................. 58
fluoxetine hcl cap 40 mg (Prozac)................................. 58
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly)............................................................................ 58
FLUOXETINE HCL – fluoxetine hcl tab 60 mg................. 58
fluoxetine hcl solution 20 mg/5ml................................. 58
fluoxetine hcl tab 10 mg.................................................58
fluoxetine hcl tab 20 mg.................................................58
fluphenazine hcl tab 10 mg............................................ 61
fluphenazine hcl tab 1 mg..............................................61
fluphenazine hcl tab 2.5 mg........................................... 61
fluphenazine hcl tab 5 mg..............................................61
FLURAZEPAM HCL – flurazepam hcl cap 15 mg............. 63
FLURAZEPAM HCL – flurazepam hcl cap 30 mg............. 63
flurbiprofen sodium ophth soln 0.03% (Ocufen).......... 98
flurbiprofen tab 100 mg.................................................. 74
flurbiprofen tab 50 mg.................................................... 74
flutamide cap 125 mg..................................................... 12
fluticasone propionate cream 0.05% (Cutivate)..........106
fluticasone propionate lotion 0.05% (Cutivate).......... 106
fluticasone propionate nasal susp 50 mcg/act
(Flonase)......................................................................... 46
fluticasone propionate oint 0.005% (Cutivate)............106
fluvastatin sodium cap 20 mg (Lescol)......................... 43
fluvastatin sodium cap 40 mg (Lescol)......................... 43
fluvoxamine maleate tab 100 mg................................... 58
fluvoxamine maleate tab 25 mg.....................................58
fluvoxamine maleate tab 50 mg.....................................58
FML LIQUIFILM – fluorometholone ophth susp 0.1%....... 98
FOCALGIN-B – prenatal w/ calcium-vit b6-fa-ginger tab
1.22 mg............................................................................85
FOCALIN – dexmethylphenidate hcl tab 10 mg................ 65
FOCALIN – dexmethylphenidate hcl tab 2.5 mg............... 65
FOCALIN – dexmethylphenidate hcl tab 5 mg.................. 65
FOLBECAL – prenatal w/ calcium carbonate-b6-b12-fa tab
1 mg.................................................................................85
FOLCAL DHA – prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg........................................................ 85
FOLCAPS OMEGA 3 – prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg.................................................. 85
FOLET DHA – prenat w/fecbn-bisg-methylf-dss tab dr &
dha cap pak.....................................................................85
FOLET ONE – prenat w/o a w/fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg............................................................. 85
FOLGARD RX – folic acid-vitamin b6-vitamin b12 tab
2.2-25-1 mg..................................................................... 94
folic acid tab 1 mg.......................................................... 94
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg..... 94
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg
(Folgard rx).....................................................................94
FOLIVANE-OB – prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg................................................................. 85
132
FOLIVANE-PRX DHA NF – prenatal w/o vit a w/fe fumdss-fa-dha cap 30-1.24-265 mg...................................... 85
FOLLISTIM AQ – Benefit Limits may apply – follitropin
beta inj 150 unit/0.5ml..................................................... 26
FOLLISTIM AQ – Benefit Limits may apply – follitropin
beta inj 300 unit/0.36ml................................................... 26
FOLLISTIM AQ – Benefit Limits may apply – follitropin
beta inj 600 unit/0.72ml................................................... 26
FOLLISTIM AQ – Benefit Limits may apply – follitropin
beta inj 75 unit/0.5ml....................................................... 26
FOLLISTIM AQ – Benefit Limits may apply – follitropin
beta inj 900 unit/1.08ml................................................... 26
FOLTRATE – cobalamine combination tab.......................94
fondaparinux sodium inj 10 mg/0.8ml (Arixtra)............ 95
fondaparinux sodium inj 2.5 mg/0.5ml (Arixtra)........... 95
fondaparinux sodium inj 5 mg/0.4ml (Arixtra).............. 95
fondaparinux sodium inj 7.5 mg/0.6ml (Arixtra)........... 95
FORADIL AEROLIZER – formoterol fumarate inhal cap 12
mcg.................................................................................. 48
formaldehyde solution 10%..........................................110
FORTAMET – metformin hcl tab sr 24hr osmotic 1000
mg.................................................................................... 20
FORTAMET – metformin hcl tab sr 24hr osmotic 500
mg.................................................................................... 20
FORTEO – teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 26
FORTICAL – calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 26
FOSAMAX – alendronate sodium tab 70 mg.................... 26
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg....................................................................................37
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg....................................................................................37
fosinopril sodium tab 10 mg.......................................... 37
fosinopril sodium tab 20 mg.......................................... 37
fosinopril sodium tab 40 mg.......................................... 37
FURADANTIN – nitrofurantoin susp 25 mg/5ml................ 54
FUROSEMIDE – furosemide oral soln 8 mg/ml................ 41
furosemide oral soln 10 mg/ml...................................... 41
furosemide tab 20 mg (Lasix)........................................ 41
furosemide tab 40 mg (Lasix)........................................ 41
furosemide tab 80 mg (Lasix)........................................ 41
FUZEON – enfuvirtide for inj 90 mg....................................7
G
gabapentin cap 100 mg (Neurontin).............................. 78
gabapentin cap 300 mg (Neurontin).............................. 78
gabapentin cap 400 mg (Neurontin).............................. 78
gabapentin oral soln 250 mg/5ml (Neurontin).............. 78
gabapentin tab 600 mg (Neurontin)...............................78
gabapentin tab 800 mg (Neurontin)...............................78
GABITRIL – tiagabine hcl tab 2 mg.................................. 78
GABITRIL – tiagabine hcl tab 4 mg.................................. 78
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)................................................................. 67
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
galantamine hydrobromide cap sr 24hr 24 mg
(Razadyne er)................................................................. 67
galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne er)................................................................. 67
GALANTAMINE HYDROBROMIDE – galantamine
hydrobromide oral soln 4 mg/ml...................................... 67
galantamine hydrobromide tab 12 mg (Razadyne).......67
galantamine hydrobromide tab 4 mg (Razadyne)........ 67
galantamine hydrobromide tab 8 mg (Razadyne)........ 67
GANIRELIX ACETATE – Benefit Limits may apply –
ganirelix acetate inj 250 mcg/0.5ml................................. 26
GARAMYCIN – gentamicin sulfate ophth soln 0.3%......... 98
GASTRINEX NF – hyoscyamine-phenyltoloxamine cap
0.0625-15 mg.................................................................. 50
GASTROCROM – cromolyn sodium oral conc 100
mg/5ml............................................................................. 53
gatifloxacin ophth soln 0.5% (Zymaxid)........................98
GEL-KAM ORAL CARE RINSE – stannous fluoride conc
0.63%.............................................................................101
gemfibrozil tab 600 mg (Lopid)......................................43
GENTAMICIN SULFATE – gentamicin sulfate cream
0.1%...............................................................................106
GENTAMICIN SULFATE – gentamicin sulfate oint
0.1%...............................................................................106
gentamicin sulfate ophth oint 0.3%...............................98
gentamicin sulfate ophth soln 0.3% (Garamycin)........ 98
GEODON – ziprasidone hcl cap 20 mg............................ 61
GEODON – ziprasidone hcl cap 40 mg............................ 61
GEODON – ziprasidone hcl cap 60 mg............................ 61
GEODON – ziprasidone hcl cap 80 mg............................ 61
GESTICARE DHA – prenatal w/fe fum-fa tab dr 27-1 mg &
dha cap 250 mg pack .................................................... 85
GILOTRIF – afatinib dimaleate tab 20 mg (base
equivalent)....................................................................... 12
GILOTRIF – afatinib dimaleate tab 30 mg (base
equivalent)....................................................................... 12
GILOTRIF – afatinib dimaleate tab 40 mg (base
equivalent)....................................................................... 12
GLEEVEC – imatinib mesylate tab 100 mg (base
equivalent)....................................................................... 12
GLEEVEC – imatinib mesylate tab 400 mg (base
equivalent)....................................................................... 12
glimepiride tab 1 mg (Amaryl)....................................... 21
glimepiride tab 2 mg (Amaryl)....................................... 21
glimepiride tab 4 mg (Amaryl)....................................... 21
glipizide-metformin hcl tab 2.5-250 mg......................... 21
glipizide-metformin hcl tab 2.5-500 mg......................... 21
glipizide-metformin hcl tab 5-500 mg............................ 21
glipizide tab 10 mg (Glucotrol)...................................... 21
glipizide tab 5 mg (Glucotrol)........................................ 21
glipizide tab sr 24hr 10 mg (Glucotrol xl)......................21
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).....................21
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 21
GLUCAGEN – glucagon hcl (rdna) for inj 1 mg (base
equiv)............................................................................... 21
GLUCAGEN HYPOKIT – glucagon hcl (rdna) for inj 1 mg
(base equiv).....................................................................21
GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj
kit 1 mg............................................................................21
GLUCOPHAGE – metformin hcl tab 1000 mg.................. 21
GLUCOPHAGE – metformin hcl tab 500 mg.................... 21
GLUCOPHAGE – metformin hcl tab 850 mg.................... 21
GLUCOPHAGE XR – metformin hcl tab sr 24hr 500
mg.................................................................................... 21
GLUCOPHAGE XR – metformin hcl tab sr 24hr 750
mg.................................................................................... 21
GLUCOSE BLOOD TEST STRIPS – VARIOUS............. 110
glucose gel 40%.............................................................. 21
glucose oral liquid 15 gm/59ml......................................21
GLUCOTROL – glipizide tab 10 mg..................................21
GLUCOTROL – glipizide tab 5 mg....................................21
GLUCOTROL XL – glipizide tab sr 24hr 10 mg................ 21
GLUCOTROL XL – glipizide tab sr 24hr 2.5 mg............... 21
GLUCOTROL XL – glipizide tab sr 24hr 5 mg.................. 21
GLUCOVANCE – glyburide-metformin tab 1.25-250
mg.................................................................................... 21
GLUCOVANCE – glyburide-metformin tab 2.5-500 mg.....21
GLUCOVANCE – glyburide-metformin tab 5-500 mg........21
GLYBURIDE – glyburide tab 1.25 mg...............................21
GLYBURIDE – glyburide tab 2.5 mg.................................21
GLYBURIDE – glyburide tab 5 mg................................... 21
glyburide-metformin tab 1.25-250 mg
(Glucovance).................................................................. 21
glyburide-metformin tab 2.5-500 mg (Glucovance)...... 21
glyburide-metformin tab 5-500 mg (Glucovance)......... 21
glyburide micronized tab 1.5 mg (Glynase).................. 21
glyburide micronized tab 3 mg (Glynase)..................... 21
glyburide micronized tab 6 mg (Glynase)..................... 21
glyburide tab 1.25 mg..................................................... 21
glyburide tab 2.5 mg....................................................... 21
glyburide tab 5 mg..........................................................21
glycopyrrolate tab 1 mg (Robinul).................................50
glycopyrrolate tab 2 mg (Robinul forte)........................50
GLYNASE – glyburide micronized tab 1.5 mg.................. 21
GLYNASE – glyburide micronized tab 3 mg..................... 21
GLYNASE – glyburide micronized tab 6 mg..................... 21
GOLYTELY – peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm.....................................................................49
GOLYTELY – peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm..............................................................49
GONAL-F – Benefit Limits may apply – follitropin alfa for
inj 1050 unit..................................................................... 27
GONAL-F – Benefit Limits may apply – follitropin alfa for
inj 450 unit.......................................................................26
GONAL-F RFF – Benefit Limits may apply – follitropin alfa
for inj 75 unit................................................................... 27
GONAL-F RFF PEN – Benefit Limits may apply –
follitropin alfa inj 300 unit/0.5ml.......................................27
GONAL-F RFF PEN – Benefit Limits may apply –
follitropin alfa inj 450 unit/0.75ml..................................... 27
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
133
2015
GONAL-F RFF PEN – Benefit Limits may apply –
follitropin alfa inj 900 unit/1.5ml.......................................27
GONAL-F RFF REDIJECT – Benefit Limits may apply –
follitropin alfa inj 300 unit/0.5ml.......................................27
GONAL-F RFF REDIJECT – Benefit Limits may apply –
follitropin alfa inj 450 unit/0.75ml..................................... 27
GONAL-F RFF REDIJECT – Benefit Limits may apply –
follitropin alfa inj 900 unit/1.5ml.......................................27
GRANIX – tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml........................................................................ 94
GRANIX – tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml........................................................................ 94
GRANULEX – trypsin w/ castor oil & peruvian balsam
spray.............................................................................. 106
GRIFULVIN V – griseofulvin microsize tab 500 mg............ 5
griseofulvin microsize susp 125 mg/5ml........................ 5
griseofulvin microsize tab 500 mg (Grifulvin v)............. 5
griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 5
griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 5
GRIS-PEG – griseofulvin ultramicrosize tab 125 mg...........5
GRIS-PEG – griseofulvin ultramicrosize tab 250 mg...........5
guanfacine hcl tab 1 mg (Tenex)................................... 37
guanfacine hcl tab 2 mg (Tenex)................................... 37
H
HALCION – triazolam tab 0.25 mg................................... 63
halobetasol propionate cream 0.05% (Ultravate)........106
halobetasol propionate oint 0.05% (Ultravate)........... 106
halobetasol prop oint 0.05% & ammonium lactate lot
12% kit.......................................................................... 106
haloperidol lactate oral conc 2 mg/ml...........................61
haloperidol tab 0.5 mg....................................................61
haloperidol tab 10 mg.....................................................61
haloperidol tab 1 mg.......................................................61
haloperidol tab 20 mg.....................................................61
haloperidol tab 2 mg.......................................................61
haloperidol tab 5 mg.......................................................61
HARVONI – ledipasvir-sofosbuvir tab 90-400 mg............... 7
hc-pramoxine emol cream 2.5-1% & pramoxine wipe
1% kit (Analpram e).....................................................102
HEMATRON-AF – iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg......................................................... 94
HEMENATAL OB + DHA – prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck....................................... 85
HEMENATAL OB – prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg..............................................................85
HEPARIN SODIUM/D5W – heparin sodium (porcine) 100
unit/ml in d5w.................................................................. 96
HEPARIN SODIUM/D5W – heparin sodium (porcine) 50
unit/ml in d5w.................................................................. 96
HEPARIN SODIUM/SODIUM CHL – heparin sodium
(porcine) 2 unit/ml in sodium chloride 0.9%.................... 96
heparin sodium (porcine) 100 unit/ml in d5w (Heparin
sodium/d5w)................................................................... 95
heparin sodium (porcine) 2 unit/ml in sodium chloride
0.9% (Heparin sodium/sodiu)....................................... 96
134
heparin sodium (porcine) 40 unit/ml in d5w................. 96
heparin sodium (porcine) 50 unit/ml in d5w (Heparin
sodium/d5w)................................................................... 96
heparin sodium (porcine) inj 10000 unit/ml.................. 95
heparin sodium (porcine) inj 1000 unit/ml.................... 95
heparin sodium (porcine) inj 20000 unit/ml.................. 95
heparin sodium (porcine) inj 5000 unit/ml.................... 95
heparin sodium (porcine) pf inj 5000 unit/0.5ml........... 95
HEPARIN SODIUM – heparin sodium (porcine) inj 2500
unit/ml.............................................................................. 95
HEPSERA – adefovir dipivoxil tab 10 mg........................... 7
HEXALEN – altretamine cap 50 mg..................................12
HIPREX – methenamine hippurate tab 1 gm.................... 54
homatropine hbr ophth soln 5% (Isopto
homatropine).................................................................. 98
HUMIRA – adalimumab inj kit 20 mg/0.4ml...................... 74
HUMIRA – adalimumab inj kit 40 mg/0.8ml (50 mg/ml).....74
HUMIRA – adalimumab prefilled syringe kit 10
mg/0.2ml.......................................................................... 74
HUMIRA PEDIATRIC CROHNS D – adalimumab inj kit 40
mg/0.8ml (50 mg/ml)....................................................... 74
HUMIRA PEN – adalimumab inj kit 40 mg/0.8ml (50 mg/
ml).................................................................................... 74
HUMIRA PEN-CROHNS DISEASE – adalimumab inj kit
40 mg/0.8ml (50 mg/ml).................................................. 74
HUMIRA PEN-PSORIASIS STAR – adalimumab inj kit 40
mg/0.8ml (50 mg/ml)....................................................... 74
HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv)..... 12
HYCAMTIN – topotecan hcl cap 1 mg (base equiv)..........12
HYCET – hydrocodone-acetaminophen soln 7.5-325
mg/15ml........................................................................... 70
hydralazine hcl tab 100 mg............................................ 37
hydralazine hcl tab 10 mg.............................................. 37
hydralazine hcl tab 25 mg.............................................. 37
hydralazine hcl tab 50 mg.............................................. 38
HYDREA – hydroxyurea cap 500 mg............................... 12
HYDRO 35 – urea in lactic acid vehicle foam 35%......... 106
hydrochlorothiazide cap 12.5 mg (Microzide)...............41
hydrochlorothiazide tab 12.5 mg................................... 41
hydrochlorothiazide tab 25 mg...................................... 41
hydrochlorothiazide tab 50 mg...................................... 41
HYDROCODONE/ACETAMINOPHEN – hydrocodoneacetaminophen soln 7.5-500 mg/15ml............................ 70
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet).............................................................................70
hydrocodone-acetaminophen tab 10-300 mg
(Xodol).............................................................................70
hydrocodone-acetaminophen tab 10-325 mg
(Norco)............................................................................ 70
hydrocodone-acetaminophen tab 5-300 mg
(Xodol).............................................................................70
hydrocodone-acetaminophen tab 5-325 mg
(Norco)............................................................................ 70
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol).............................................................................70
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco)............................................................................ 70
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........70
hydrocodone-ibuprofen tab 2.5-200 mg
(Reprexain)..................................................................... 70
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)...... 70
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)....................................................................70
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml.......46
hydrocodone w/ homatropine tab 5-1.5 mg.................. 46
hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml
(Tussionex pennkineti)..................................................46
hydrocortisone acetate suppos 25 mg (Anusolhc)..................................................................................102
hydrocortisone acetate suppos 30 mg
(Proctocort).................................................................. 102
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc)..................................................... 102
hydrocortisone acetate w/ pramoxine rectal cream
2.5-1% (Analpram-hc).................................................. 102
hydrocortisone butyrate cream 0.1% (Locoid)........... 106
hydrocortisone butyrate oint 0.1% (Locoid)............... 106
hydrocortisone butyrate soln 0.1% (Locoid).............. 106
hydrocortisone cream 1%............................................ 106
hydrocortisone cream 2.5%......................................... 106
hydrocortisone enema 100 mg/60ml (Cortenema)..... 102
hydrocortisone lotion 2.5%.......................................... 106
hydrocortisone rectal cream 1% (Proctocort)............ 102
hydrocortisone rectal cream 2.5% (Anusol-hc).......... 102
hydrocortisone tab 10 mg (Cortef)................................ 15
hydrocortisone tab 20 mg (Cortef)................................ 15
hydrocortisone tab 5 mg (Cortef).................................. 15
hydrocortisone valerate cream 0.2%...........................106
hydrocortisone valerate oint 0.2% (Westcort)............ 106
HYDROMORPHONE HCL – hydromorphone hcl suppos 3
mg.................................................................................... 70
hydromorphone hcl tab 2 mg (Dilaudid)....................... 70
hydromorphone hcl tab 4 mg (Dilaudid)....................... 70
hydromorphone hcl tab 8 mg (Dilaudid)....................... 70
hydroxychloroquine sulfate tab 200 mg
(Plaquenil).......................................................................10
hydroxyurea cap 500 mg (Hydrea)................................ 12
hydroxyzine hcl syrup 10 mg/5ml..................................56
hydroxyzine hcl tab 10 mg.............................................56
hydroxyzine hcl tab 25 mg............................................. 56
hydroxyzine hcl tab 50 mg.............................................56
hydroxyzine pamoate cap 25 mg (Vistaril)....................56
hydroxyzine pamoate cap 50 mg (Vistaril)....................56
HYDROXYZINE PAMOATE – hydroxyzine pamoate cap
100 mg.............................................................................56
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 50
hyoscyamine sulfate soln 0.125 mg/ml......................... 50
hyoscyamine sulfate tab 0.125 mg (Levsin)................. 50
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 50
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)..........50
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid).....50
HYPERSAL – sodium chloride soln nebu 7%................... 46
HYPER-SAL – sodium chloride soln nebu 7%.................. 46
hypromellose intraocular soln 2% (Cellugel)................98
HYZAAR – losartan potassium & hydrochlorothiazide tab
100-12.5 mg.................................................................... 38
HYZAAR – losartan potassium & hydrochlorothiazide tab
100-25 mg....................................................................... 38
HYZAAR – losartan potassium & hydrochlorothiazide tab
50-12.5 mg...................................................................... 38
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)...........................................................................27
IBUDONE – hydrocodone-ibuprofen tab 10-200 mg......... 70
ibuprofen tab 400 mg......................................................74
ibuprofen tab 600 mg......................................................74
ibuprofen tab 800 mg......................................................74
ICAR-C PLUS – iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg........................................................ 94
ICLUSIG – ponatinib hcl tab 15 mg (base equiv).............. 12
ICLUSIG – ponatinib hcl tab 45 mg (base equiv).............. 12
imipramine hcl tab 10 mg (Tofranil).............................. 58
imipramine hcl tab 25 mg (Tofranil).............................. 58
imipramine hcl tab 50 mg (Tofranil).............................. 58
imiquimod cream 5% (Aldara)......................................106
IMITREX STATDOSE REFILL – sumatriptan succinate
solution cartridge 4 mg/0.5ml.......................................... 75
IMITREX STATDOSE REFILL – sumatriptan succinate
solution cartridge 6 mg/0.5ml.......................................... 76
IMITREX STATDOSE SYSTEM – sumatriptan succinate
solution auto-injector 4 mg/0.5ml.................................... 76
IMITREX STATDOSE SYSTEM – sumatriptan succinate
solution auto-injector 6 mg/0.5ml.................................... 76
IMITREX – sumatriptan nasal spray 20 mg/act.................75
IMITREX – sumatriptan nasal spray 5 mg/act...................75
IMITREX – sumatriptan succinate inj 6 mg/0.5ml............. 75
IMITREX – sumatriptan succinate tab 100 mg..................75
IMITREX – sumatriptan succinate tab 25 mg....................75
IMITREX – sumatriptan succinate tab 50 mg....................75
IMURAN – azathioprine tab 50 mg................................. 111
INATAL ADVANCE – prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg..................................................................... 85
INATAL GT – prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg.................................................................................... 85
INATAL ULTRA – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 85
indapamide tab 1.25 mg................................................. 41
indapamide tab 2.5 mg................................................... 42
INDERAL LA – propranolol hcl cap sr 24hr 120 mg.......... 29
INDERAL LA – propranolol hcl cap sr 24hr 160 mg.......... 29
INDERAL LA – propranolol hcl cap sr 24hr 60 mg............29
INDERAL LA – propranolol hcl cap sr 24hr 80 mg............29
indomethacin cap 25 mg................................................ 74
indomethacin cap 50 mg................................................ 74
indomethacin cap cr 75 mg........................................... 74
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
135
2015
INFANATE BALANCE – prenatal w/o a w/fe cbn-dss-fadha cap 29-1-265 mg...................................................... 85
INFANATE PLUS – prenat w/o a w/fe fum-fe cbn-dss-fadha cap 27-1-260 mg...................................................... 85
INLYTA – axitinib tab 1 mg...............................................12
INLYTA – axitinib tab 5 mg...............................................12
INSPRA – eplerenone tab 25 mg..................................... 38
INSPRA – eplerenone tab 50 mg..................................... 38
INSTA-GLUCOSE – glucose gel 77.4%........................... 21
INTELENCE – etravirine tab 100 mg.................................. 7
INTELENCE – etravirine tab 200 mg.................................. 7
INTELENCE – etravirine tab 25 mg.................................... 7
INVIRASE – saquinavir mesylate cap 200 mg.................... 7
INVIRASE – saquinavir mesylate tab 500 mg.....................7
INVOKAMET – canagliflozin-metformin hcl tab 150-1000
mg.................................................................................... 22
INVOKAMET – canagliflozin-metformin hcl tab 150-500
mg.................................................................................... 22
INVOKAMET – canagliflozin-metformin hcl tab 50-1000
mg.................................................................................... 22
INVOKAMET – canagliflozin-metformin hcl tab 50-500
mg.................................................................................... 22
INVOKANA – canagliflozin tab 100 mg.............................22
INVOKANA – canagliflozin tab 300 mg.............................22
iodoquinol-hc cream 1%...............................................106
IOPIDINE – apraclonidine hcl ophth soln 0.5% (base
equivalent)....................................................................... 98
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml...... 48
ipratropium bromide inhal soln 0.02%.......................... 48
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)........................................................................46
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)........................................................................46
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................38
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................38
irbesartan tab 150 mg (Avapro)..................................... 38
irbesartan tab 300 mg (Avapro)..................................... 38
irbesartan tab 75 mg (Avapro)....................................... 38
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1
mg (Hematron-af)...........................................................94
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Corvite 150)...................................................................94
iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg
(Icar-c plus).................................................................... 94
ISENTRESS – raltegravir potassium chew tab 100 mg
(base equiv).......................................................................7
ISENTRESS – raltegravir potassium chew tab 25 mg
(base equiv).......................................................................7
ISENTRESS – raltegravir potassium packet for susp 100
mg (base equiv).................................................................7
ISENTRESS – raltegravir potassium tab 400 mg (base
equiv)................................................................................. 7
isoniazid tab 100 mg.........................................................5
isoniazid tab 300 mg.........................................................5
136
ISOPTIN SR – verapamil hcl tab cr 120 mg..................... 32
ISOPTIN SR – verapamil hcl tab cr 180 mg..................... 32
ISOPTIN SR – verapamil hcl tab cr 240 mg..................... 32
ISOPTO ATROPINE – atropine sulfate ophth soln 1%..... 98
ISOPTO CARPINE – pilocarpine hcl ophth soln 1%......... 98
ISOPTO CARPINE – pilocarpine hcl ophth soln 2%......... 98
ISOPTO CARPINE – pilocarpine hcl ophth soln 4%......... 98
ISOPTO HOMATROPINE – homatropine hbr ophth soln
5%....................................................................................98
ISOPTO HYOSCINE – scopolamine hbr ophth soln
0.25%...............................................................................98
ISORDIL TITRADOSE – isosorbide dinitrate tab 40
mg.................................................................................... 28
ISORDIL TITRADOSE – isosorbide dinitrate tab 5 mg......28
ISOSORBIDE DINITRATE – isosorbide dinitrate tab 30
mg.................................................................................... 28
isosorbide dinitrate tab 10 mg.......................................28
isosorbide dinitrate tab 20 mg.......................................28
isosorbide dinitrate tab 5 mg (Isordil titradose)........... 28
isosorbide dinitrate tab cr 40 mg.................................. 28
isosorbide mononitrate tab 10 mg................................ 28
isosorbide mononitrate tab 20 mg................................ 28
isosorbide mononitrate tab sr 24hr 120 mg (Imdur).....28
isosorbide mononitrate tab sr 24hr 30 mg (Imdur).......28
isosorbide mononitrate tab sr 24hr 60 mg (Imdur).......28
isotretinoin cap 10 mg..................................................106
isotretinoin cap 20 mg..................................................106
isotretinoin cap 40 mg..................................................106
itraconazole cap 100 mg (Sporanox)...............................5
ivermectin tab 3 mg (Stromectol).................................. 10
J
JAKAFI – ruxolitinib phosphate tab 10 mg (base
equivalent)....................................................................... 12
JAKAFI – ruxolitinib phosphate tab 15 mg (base
equivalent)....................................................................... 12
JAKAFI – ruxolitinib phosphate tab 20 mg (base
equivalent)....................................................................... 12
JAKAFI – ruxolitinib phosphate tab 25 mg (base
equivalent)....................................................................... 12
JAKAFI – ruxolitinib phosphate tab 5 mg (base
equivalent)....................................................................... 12
JINTELI – norethindrone acetate-ethinyl estradiol tab 1
mg-5 mcg.........................................................................17
K
KADIAN – morphine sulfate cap sr 24hr 100 mg.............. 70
KADIAN – morphine sulfate cap sr 24hr 10 mg................ 70
KADIAN – morphine sulfate cap sr 24hr 200 mg.............. 70
KADIAN – morphine sulfate cap sr 24hr 20 mg................ 70
KADIAN – morphine sulfate cap sr 24hr 30 mg................ 70
KADIAN – morphine sulfate cap sr 24hr 50 mg................ 70
KADIAN – morphine sulfate cap sr 24hr 60 mg................ 70
KADIAN – morphine sulfate cap sr 24hr 80 mg................ 70
KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml
(80-20 mg/ml).................................................................... 7
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
KALETRA – lopinavir-ritonavir tab 100-25 mg.................... 7
KALETRA – lopinavir-ritonavir tab 200-50 mg.................... 7
KAPVAY – clonidine hcl tab sr 12hr 0.1 mg......................65
KAYEXALATE – sodium polystyrene sulfonate
powder........................................................................... 111
KEFLEX – cephalexin cap 250 mg..................................... 2
KEFLEX – cephalexin cap 500 mg..................................... 2
KEPPRA – levetiracetam oral soln 100 mg/ml.................. 78
KEPPRA – levetiracetam tab 1000 mg............................. 78
KEPPRA – levetiracetam tab 250 mg............................... 78
KEPPRA – levetiracetam tab 500 mg............................... 78
KEPPRA – levetiracetam tab 750 mg............................... 78
KEPPRA XR – levetiracetam tab sr 24hr 500 mg............. 78
KEPPRA XR – levetiracetam tab sr 24hr 750 mg............. 78
KERALYT – salicylic acid gel 6%....................................106
KERLONE – betaxolol hcl tab 10 mg................................29
KERLONE – betaxolol hcl tab 20 mg................................30
ketoconazole cream 2%................................................106
ketoconazole foam 2% (Extina)................................... 106
ketoconazole shampoo 2% (Nizoral)........................... 106
ketoconazole tab 200 mg................................................. 5
ketoprofen cap 50 mg.....................................................74
ketoprofen cap 75 mg.....................................................74
ketorolac tromethamine im inj 60 mg/2ml (30 mg/
ml)....................................................................................74
ketorolac tromethamine ophth soln 0.4% (Acular
ls).....................................................................................98
ketorolac tromethamine ophth soln 0.5% (Acular).......98
ketorolac tromethamine tab 10 mg................................74
KITABIS PAK – tobramycin nebu soln 300 mg/5ml............ 4
KLARON – sulfacetamide sodium lotion 10% (acne)...... 106
KLONOPIN – clonazepam tab 0.5 mg.............................. 78
KLONOPIN – clonazepam tab 1 mg................................. 78
KLONOPIN – clonazepam tab 2 mg................................. 78
KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 22
KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 22
KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr
5-500 mg......................................................................... 22
K-PHOS NEUTRAL – pot phos monobasic w/sod phos di
& monobas tab 155-852-130mg......................................92
K-TAB – potassium chloride tab cr 10 meq...................... 92
K-TAB – potassium chloride tab cr 20 meq (1500 mg)......92
L
labetalol hcl tab 100 mg (Trandate)...............................30
labetalol hcl tab 200 mg (Trandate)...............................30
labetalol hcl tab 300 mg (Trandate)...............................30
LAC-HYDRIN – lactic acid (ammonium lactate) cream
12%................................................................................106
LAC-HYDRIN – lactic acid (ammonium lactate) lotion
12%................................................................................106
lactic acid (ammonium lactate) cream 12% (Lachydrin)...........................................................................106
lactic acid (ammonium lactate) lotion 10%................. 106
lactic acid (ammonium lactate) lotion 12% (Lachydrin)...........................................................................106
lactic acid w/ vitamin e cream 10%-3500
unit/30gm...................................................................... 106
lactulose (encephalopathy) solution 10 gm/15ml.........53
lactulose solution 10 gm/15ml....................................... 49
LAMICTAL CHEWABLE DISPERS – lamotrigine tab
chewable dispersible 25 mg............................................ 78
LAMICTAL CHEWABLE DISPERS – lamotrigine tab
chewable dispersible 5 mg.............................................. 78
LAMICTAL – lamotrigine tab 100 mg................................78
LAMICTAL – lamotrigine tab 150 mg................................78
LAMICTAL – lamotrigine tab 200 mg................................78
LAMICTAL – lamotrigine tab 25 mg..................................78
LAMICTAL ODT – lamotrigine orally disintegrating tab 100
mg.................................................................................... 78
LAMICTAL ODT – lamotrigine orally disintegrating tab 200
mg.................................................................................... 78
LAMICTAL ODT – lamotrigine orally disintegrating tab 25
mg.................................................................................... 78
LAMICTAL ODT – lamotrigine orally disintegrating tab 50
mg.................................................................................... 78
LAMICTAL STARTER/NOT TAKI – lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit............................................78
LAMICTAL STARTER/TAKING C – lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit..........................................78
LAMICTAL STARTER/TAKING V – lamotrigine tab 25 mg
(35) starter kit.................................................................. 79
LAMICTAL XR – lamotrigine tab sr 24hr 100 mg.............. 79
LAMICTAL XR – lamotrigine tab sr 24hr 200 mg.............. 79
LAMICTAL XR – lamotrigine tab sr 24hr 250 mg.............. 79
LAMICTAL XR – lamotrigine tab sr 24hr 25 mg................ 79
LAMICTAL XR – lamotrigine tab sr 24hr 300 mg.............. 79
LAMICTAL XR – lamotrigine tab sr 24hr 50 mg................ 79
LAMISIL – terbinafine hcl tab 250 mg.................................5
lamivudine oral soln 10 mg/ml (Epivir)........................... 7
lamivudine tab 100 mg (Epivir hbv).................................7
lamivudine tab 150 mg (Epivir)........................................ 7
lamivudine tab 300 mg (Epivir)........................................ 7
lamivudine-zidovudine tab 150-300 mg (Combivir)........ 7
lamotrigine orally disintegrating tab 100 mg (Lamictal
odt).................................................................................. 79
lamotrigine orally disintegrating tab 200 mg (Lamictal
odt).................................................................................. 79
lamotrigine orally disintegrating tab 25 mg (Lamictal
odt).................................................................................. 79
lamotrigine orally disintegrating tab 50 mg (Lamictal
odt).................................................................................. 79
lamotrigine tab 100 mg (Lamictal)................................. 79
lamotrigine tab 150 mg (Lamictal)................................. 79
lamotrigine tab 200 mg (Lamictal)................................. 79
lamotrigine tab 25 mg (Lamictal)................................... 79
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................... 79
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................... 79
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
137
2015
lamotrigine tab sr 24hr 100 mg (Lamictal xr)................79
lamotrigine tab sr 24hr 200 mg (Lamictal xr)................79
lamotrigine tab sr 24hr 250 mg (Lamictal xr)................79
lamotrigine tab sr 24hr 25 mg (Lamictal xr)..................79
lamotrigine tab sr 24hr 300 mg (Lamictal xr)................79
lamotrigine tab sr 24hr 50 mg (Lamictal xr)..................79
LANCETS – VARIOUS MANUFACTURERS.................. 110
LANOXIN – digoxin tab 125 mcg (0.125 mg)....................28
LANOXIN – digoxin tab 187.5 mcg (0.1875 mg)............... 28
LANOXIN – digoxin tab 250 mcg (0.25 mg)......................28
LANOXIN – digoxin tab 62.5 mcg (0.0625 mg)................. 28
lansoprazole cap delayed release 15 mg
(Prevacid)........................................................................50
lansoprazole cap delayed release 30 mg
(Prevacid)........................................................................50
LANTUS – insulin glargine inj 100 unit/ml.........................23
LANTUS SOLOSTAR – insulin glargine soln pen-injector
100 unit/ml....................................................................... 23
LASIX – furosemide tab 20 mg.........................................42
LASIX – furosemide tab 40 mg.........................................42
LASIX – furosemide tab 80 mg.........................................42
latanoprost ophth soln 0.005% (Xalatan)...................... 98
LATUDA – lurasidone hcl tab 60 mg................................ 61
leflunomide tab 10 mg (Arava).......................................74
leflunomide tab 20 mg (Arava).......................................74
LESCOL – fluvastatin sodium cap 20 mg......................... 43
LESCOL – fluvastatin sodium cap 40 mg......................... 43
letrozole tab 2.5 mg (Femara)........................................ 13
LEUCOVORIN CALCIUM – leucovorin calcium tab 10
mg.................................................................................... 13
LEUCOVORIN CALCIUM – leucovorin calcium tab 15
mg.................................................................................... 13
leucovorin calcium tab 25 mg........................................13
leucovorin calcium tab 5 mg..........................................13
LEUKERAN – chlorambucil tab 2 mg............................... 13
leuprolide acetate inj kit 5 mg/ml.................................. 13
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)........................................................................48
levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)
(Xopenex)........................................................................48
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)
(Xopenex)........................................................................48
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv) (Xopenex concentrate)...................................... 48
LEVAQUIN – levofloxacin oral soln 25 mg/ml.....................4
LEVAQUIN – levofloxacin tab 250 mg................................ 4
LEVAQUIN – levofloxacin tab 500 mg................................ 4
LEVAQUIN – levofloxacin tab 750 mg................................ 4
LEVBID – hyoscyamine sulfate tab sr 12hr 0.375 mg....... 50
levetiracetam oral soln 100 mg/ml (Keppra)................. 79
levetiracetam tab 1000 mg (Keppra)..............................79
levetiracetam tab 250 mg (Keppra)................................79
levetiracetam tab 500 mg (Keppra)................................79
levetiracetam tab 750 mg (Keppra)................................79
levetiracetam tab sr 24hr 500 mg (Keppra xr).............. 79
levetiracetam tab sr 24hr 750 mg (Keppra xr).............. 79
138
LEVOBUNOLOL HCL – levobunolol hcl ophth soln
0.25%...............................................................................98
levobunolol hcl ophth soln 0.5% (Betagan)..................98
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 27
levocarnitine tab 330 mg (Carnitor)...............................27
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5
mg/ml) (Xyzal)................................................................ 45
levocetirizine dihydrochloride tab 5 mg (Xyzal)........... 45
levofloxacin ophth soln 0.5%.........................................99
levofloxacin oral soln 25 mg/ml (Levaquin)....................4
levofloxacin tab 250 mg (Levaquin)................................ 4
levofloxacin tab 500 mg (Levaquin)................................ 4
levofloxacin tab 750 mg (Levaquin)................................ 4
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg................................................................... 18
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg..................................................................................18
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg..................................................................................18
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg................................ 18
levonorgestrel tab 0.75 mg (Plan b).............................. 18
levonorgestrel tab 1.5 mg (Plan b one-step).................18
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)............................................ 18
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)................................................ 18
levothyroxine sodium tab 100 mcg (Synthroid)........... 23
levothyroxine sodium tab 112 mcg (Synthroid)........... 23
levothyroxine sodium tab 125 mcg (Synthroid)........... 23
levothyroxine sodium tab 137 mcg (Synthroid)........... 23
levothyroxine sodium tab 150 mcg (Synthroid)........... 23
levothyroxine sodium tab 175 mcg (Synthroid)........... 23
levothyroxine sodium tab 200 mcg (Synthroid)........... 23
levothyroxine sodium tab 25 mcg (Synthroid)............. 23
levothyroxine sodium tab 300 mcg (Synthroid)........... 23
levothyroxine sodium tab 50 mcg (Synthroid)............. 24
levothyroxine sodium tab 75 mcg (Synthroid)............. 24
levothyroxine sodium tab 88 mcg (Synthroid)............. 24
LEVSIN/SL – hyoscyamine sulfate tab sl 0.125 mg.......... 50
LEVSIN – hyoscyamine sulfate tab 0.125 mg................... 50
LEXAPRO – escitalopram oxalate soln 5 mg/5ml (base
equiv)............................................................................... 58
LEXAPRO – escitalopram oxalate tab 10 mg (base
equiv)............................................................................... 58
LEXAPRO – escitalopram oxalate tab 20 mg (base
equiv)............................................................................... 58
LEXAPRO – escitalopram oxalate tab 5 mg (base
equiv)............................................................................... 58
LEXIVA – fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................. 7
LEXIVA – fosamprenavir calcium tab 700 mg (base
equiv)................................................................................. 7
LIALDA – mesalamine tab delayed release 1.2 gm.......... 53
LIBRAX – clidinium & chlordiazepoxide cap 2.5-5 mg.......50
lidocaine hcl cream 3%................................................ 106
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
lidocaine hcl gel 2%......................................................106
lidocaine hcl laryngotracheal soln 4% (Lta 360
kit)..................................................................................101
lidocaine hcl soln 4% (Xylocaine)................................106
lidocaine hcl viscous soln 2%..................................... 101
lidocaine-hydrocortisone acetate rectal cream
3-0.5%............................................................................102
lidocaine-hydrocortisone acetate rectal cream kit
3-0.5%............................................................................102
lidocaine-hydrocortisone acetate rectal cream kit
3-1%...............................................................................102
lidocaine-hydrocortisone acetate rectal gel kit
3-2.5%............................................................................102
lidocaine oint 5%...........................................................106
lidocaine patch 5% (Lidoderm).................................... 106
lidocaine-prilocaine cream 2.5-2.5% (Emla)................107
LIDODERM – lidocaine patch 5%................................... 107
lindane lotion 1%...........................................................107
lindane shampoo 1%.................................................... 107
LINZESS – linaclotide cap 145 mcg................................. 53
LINZESS – linaclotide cap 290 mcg................................. 53
liothyronine sodium tab 25 mcg (Cytomel)...................24
liothyronine sodium tab 50 mcg (Cytomel)...................24
liothyronine sodium tab 5 mcg (Cytomel).....................24
LIPITOR – atorvastatin calcium tab 10 mg (base
equivalent)....................................................................... 43
LIPITOR – atorvastatin calcium tab 20 mg (base
equivalent)....................................................................... 43
LIPITOR – atorvastatin calcium tab 40 mg (base
equivalent)....................................................................... 43
LIPITOR – atorvastatin calcium tab 80 mg (base
equivalent)....................................................................... 43
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 38
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 38
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 38
lisinopril tab 10 mg (Prinivil)..........................................38
lisinopril tab 2.5 mg (Zestril).......................................... 38
lisinopril tab 20 mg (Prinivil)..........................................38
lisinopril tab 30 mg (Zestril)........................................... 38
lisinopril tab 40 mg (Zestril)........................................... 38
lisinopril tab 5 mg (Prinivil)............................................38
lithium carbonate cap 150 mg (Lithium carbonate)......61
lithium carbonate cap 300 mg....................................... 61
lithium carbonate cap 600 mg (Lithium carbonate)......61
LITHIUM CARBONATE – lithium carbonate cap 150
mg.................................................................................... 61
LITHIUM CARBONATE – lithium carbonate cap 600
mg.................................................................................... 61
lithium carbonate tab 300 mg........................................ 61
lithium carbonate tab cr 300 mg (Lithobid)...................61
lithium carbonate tab cr 450 mg....................................61
LITHIUM – lithium oral solution 8 meq/5ml....................... 61
LITHOBID – lithium carbonate tab cr 300 mg................... 61
L-METHYLFOLATE PNV DHA – prenat w/fe fum-l
methylfolate-fa-dha cap 27-1.13-0.4 mg..........................85
LOCOID – hydrocortisone butyrate cream 0.1%............. 107
LOCOID – hydrocortisone butyrate oint 0.1%................. 107
LOCOID – hydrocortisone butyrate soln 0.1%................ 107
LODOSYN – carbidopa tab 25 mg................................... 81
LOESTRIN 1/20-21 – norethindrone ace & ethinyl
estradiol tab 1 mg-20 mcg.............................................. 19
LOESTRIN 1.5/30-21 – norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg............................................19
LOESTRIN FE 1/20 – norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg.......................................... 18
LOESTRIN FE 1.5/30 – norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg....................................... 18
LOFIBRA – fenofibrate micronized cap 134 mg................43
LOFIBRA – fenofibrate micronized cap 200 mg................43
LOFIBRA – fenofibrate micronized cap 67 mg..................43
LOFIBRA – fenofibrate tab 160 mg...................................43
LOFIBRA – fenofibrate tab 54 mg.................................... 43
LOMOTIL – diphenoxylate w/ atropine tab 2.5-0.025
mg.................................................................................... 49
LOMUSTINE – lomustine cap 100 mg..............................13
LOMUSTINE – lomustine cap 10 mg................................13
LOMUSTINE – lomustine cap 40 mg................................13
loperamide hcl cap 2 mg................................................50
LOPID – gemfibrozil tab 600 mg.......................................43
LOPRESSOR HCT – metoprolol & hydrochlorothiazide tab
100-25 mg....................................................................... 38
LOPRESSOR HCT – metoprolol & hydrochlorothiazide tab
50-25 mg......................................................................... 38
LOPRESSOR – metoprolol tartrate tab 100 mg................30
LOPRESSOR – metoprolol tartrate tab 50 mg..................30
LOPROX SHAMPOO – ciclopirox shampoo 1%............. 107
LORAZEPAM INTENSOL – lorazepam conc 2 mg/ml...... 56
lorazepam tab 0.5 mg (Ativan)....................................... 56
lorazepam tab 1 mg (Ativan).......................................... 56
lorazepam tab 2 mg (Ativan).......................................... 56
losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).....................................................38
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar).................................................................... 38
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar).................................................................... 38
losartan potassium tab 100 mg (Cozaar)...................... 38
losartan potassium tab 25 mg (Cozaar)........................ 38
losartan potassium tab 50 mg (Cozaar)........................ 38
LOSEASONIQUE – levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)...................................................... 19
LOTEMAX – loteprednol etabonate ophth gel 0.5%..........99
LOTENSIN – benazepril hcl tab 10 mg.............................38
LOTENSIN – benazepril hcl tab 20 mg.............................38
LOTENSIN – benazepril hcl tab 40 mg.............................38
LOTENSIN HCT – benazepril & hydrochlorothiazide tab
10-12.5 mg...................................................................... 38
LOTENSIN HCT – benazepril & hydrochlorothiazide tab
20-12.5 mg...................................................................... 38
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
139
2015
LOTENSIN HCT – benazepril & hydrochlorothiazide tab
20-25 mg......................................................................... 38
LOTREL – amlodipine besylate-benazepril hcl cap 10-20
mg.................................................................................... 38
LOTREL – amlodipine besylate-benazepril hcl cap 10-40
mg.................................................................................... 38
LOTREL – amlodipine besylate-benazepril hcl cap 2.5-10
mg.................................................................................... 38
LOTREL – amlodipine besylate-benazepril hcl cap 5-10
mg.................................................................................... 38
LOTREL – amlodipine besylate-benazepril hcl cap 5-20
mg.................................................................................... 38
LOTREL – amlodipine besylate-benazepril hcl cap 5-40
mg.................................................................................... 38
LOTRISONE – clotrimazole w/ betamethasone cream
1-0.05%..........................................................................107
LOTRONEX – alosetron hcl tab 0.5 mg (base equiv)........53
LOTRONEX – alosetron hcl tab 1 mg (base equiv)...........53
lovastatin tab 10 mg....................................................... 43
lovastatin tab 20 mg (Mevacor)..................................... 44
lovastatin tab 40 mg (Mevacor)..................................... 44
LOVENOX – enoxaparin sodium inj 100 mg/ml................ 96
LOVENOX – enoxaparin sodium inj 120 mg/0.8ml........... 96
LOVENOX – enoxaparin sodium inj 150 mg/ml................ 96
LOVENOX – enoxaparin sodium inj 300 mg/3ml.............. 96
LOVENOX – enoxaparin sodium inj 30 mg/0.3ml............. 96
LOVENOX – enoxaparin sodium inj 40 mg/0.4ml............. 96
LOVENOX – enoxaparin sodium inj 60 mg/0.6ml............. 96
LOVENOX – enoxaparin sodium inj 80 mg/0.8ml............. 96
loxapine succinate cap 10 mg....................................... 61
loxapine succinate cap 25 mg....................................... 61
loxapine succinate cap 50 mg....................................... 61
loxapine succinate cap 5 mg......................................... 61
LUNESTA – eszopiclone tab 1 mg................................... 63
LUNESTA – eszopiclone tab 2 mg................................... 63
LUNESTA – eszopiclone tab 3 mg................................... 63
LUPRON DEPOT – leuprolide acetate (3 month) for inj kit
11.25 mg..........................................................................13
LUPRON DEPOT – leuprolide acetate (3 month) for inj kit
22.5 mg............................................................................13
LUPRON DEPOT – leuprolide acetate (4 month) for inj kit
30 mg...............................................................................13
LUPRON DEPOT – leuprolide acetate (6 month) for inj kit
45 mg...............................................................................13
LUPRON DEPOT – leuprolide acetate for inj kit 3.75
mg.................................................................................... 13
LUPRON DEPOT – leuprolide acetate for inj kit 7.5
mg.................................................................................... 13
LUPRON DEPOT-PED – leuprolide acetate (3 month) for
inj pediatric kit 11.25 mg................................................. 27
LUPRON DEPOT-PED – leuprolide acetate (3 month) for
inj pediatric kit 30 mg...................................................... 27
LUPRON DEPOT-PED – leuprolide acetate for inj
pediatric kit 11.25 mg...................................................... 27
LUPRON DEPOT-PED – leuprolide acetate for inj
pediatric kit 15 mg........................................................... 27
140
LUPRON DEPOT-PED – leuprolide acetate for inj
pediatric kit 7.5 mg.......................................................... 27
LURIDE – sodium fluoride chew tab 0.25 mg f (from 0.55
mg naf)............................................................................ 92
LURIDE – sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf)...................................................................................92
LURIDE – sodium fluoride chew tab 1 mg f (from 2.2 mg
naf)...................................................................................92
LURIDE – sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/
ml naf)..............................................................................92
LYRICA – pregabalin cap 100 mg.................................... 79
LYRICA – pregabalin cap 150 mg.................................... 79
LYRICA – pregabalin cap 200 mg.................................... 79
LYRICA – pregabalin cap 225 mg.................................... 79
LYRICA – pregabalin cap 25 mg...................................... 79
LYRICA – pregabalin cap 300 mg.................................... 79
LYRICA – pregabalin cap 50 mg...................................... 79
LYRICA – pregabalin cap 75 mg...................................... 79
LYRICA – pregabalin soln 20 mg/ml.................................79
LYSODREN – mitotane tab 500 mg................................. 13
M
MACNATAL CN DHA – prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg...................................................... 85
MACROBID – nitrofurantoin monohydrate macrocrystalline
cap 100 mg..................................................................... 54
MACRODANTIN – nitrofurantoin macrocrystalline cap 100
mg.................................................................................... 54
MACRODANTIN – nitrofurantoin macrocrystalline cap 25
mg.................................................................................... 54
MACRODANTIN – nitrofurantoin macrocrystalline cap 50
mg.................................................................................... 54
mafenide acetate packet for topical soln 5% (50 gm)
(Sulfamylon)................................................................. 107
MALARONE – atovaquone-proguanil hcl tab 250-100
mg.................................................................................... 10
MALARONE – atovaquone-proguanil hcl tab 62.5-25
mg.................................................................................... 10
malathion lotion 0.5% (Ovide)......................................107
MARINOL – dronabinol cap 10 mg................................... 52
MARINOL – dronabinol cap 2.5 mg.................................. 52
MARINOL – dronabinol cap 5 mg.....................................52
MARNATAL-F – prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg.................................................................... 85
MATULANE – procarbazine hcl cap 50 mg...................... 13
MAVIK – trandolapril tab 1 mg..........................................38
MAVIK – trandolapril tab 2 mg..........................................38
MAVIK – trandolapril tab 4 mg..........................................39
MAXALT-MLT – rizatriptan benzoate orally disintegrating
tab 10 mg........................................................................ 76
MAXALT-MLT – rizatriptan benzoate orally disintegrating
tab 5 mg.......................................................................... 76
MAXALT – rizatriptan benzoate tab 10 mg....................... 76
MAXALT – rizatriptan benzoate tab 5 mg......................... 76
MAXITROL – neomycin-polymyxin-dexamethasone ophth
oint 0.1%..........................................................................99
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
MAXITROL – neomycin-polymyxin-dexamethasone ophth
susp 0.1%........................................................................99
MAXZIDE-25 – triamterene & hydrochlorothiazide tab
37.5-25 mg...................................................................... 42
MAXZIDE – triamterene & hydrochlorothiazide tab 75-50
mg.................................................................................... 42
meclizine hcl tab 12.5 mg...............................................52
meclizine hcl tab 25 mg..................................................52
meclizine hcl tab 32 mg..................................................52
MEDROL DOSEPAK – methylprednisolone tab 4 mg dose
pack................................................................................. 15
MEDROL – methylprednisolone tab 16 mg.......................15
MEDROL – methylprednisolone tab 2 mg.........................15
MEDROL – methylprednisolone tab 32 mg.......................15
MEDROL – methylprednisolone tab 4 mg.........................15
MEDROL – methylprednisolone tab 8 mg.........................15
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................. 19
medroxyprogesterone acetate tab 10 mg (Provera).....20
medroxyprogesterone acetate tab 2.5 mg
(Provera)......................................................................... 20
medroxyprogesterone acetate tab 5 mg (Provera).......20
mefloquine hcl tab 250 mg.............................................10
MEGACE ORAL – megestrol acetate susp 40 mg/ml....... 13
megestrol acetate susp 40 mg/ml (Megace oral)..........13
megestrol acetate tab 20 mg..........................................13
megestrol acetate tab 40 mg..........................................13
MELOXICAM – meloxicam susp 7.5 mg/5ml.................... 74
meloxicam tab 15 mg (Mobic)........................................74
meloxicam tab 7.5 mg (Mobic).......................................74
MENOPUR – Benefit Limits may apply – menotropins for
subcutaneous inj 75 unit................................................. 27
meperidine hcl tab 100 mg (Demerol)........................... 70
meperidine hcl tab 50 mg (Demerol)............................. 70
MEPHYTON – phytonadione tab 5 mg............................. 84
meprobamate tab 200 mg...............................................56
meprobamate tab 400 mg...............................................56
mercaptopurine tab 50 mg (Purinethol)........................ 13
mesalamine enema 4 gm................................................53
mesalamine rectal enema 4 gm & cleanser wipe kit
(Rowasa)......................................................................... 53
MESNEX – mesna tab 400 mg.........................................13
MESTINON – pyridostigmine bromide tab 60 mg............. 83
METAPROTERENOL SULFATE – metaproterenol sulfate
syrup 10 mg/5ml..............................................................48
METAPROTERENOL SULFATE – metaproterenol sulfate
tab 10 mg........................................................................ 48
METAPROTERENOL SULFATE – metaproterenol sulfate
tab 20 mg........................................................................ 48
metaxalone tab 800 mg (Skelaxin).................................83
metformin hcl tab 1000 mg (Glucophage).....................22
metformin hcl tab 500 mg (Glucophage)...................... 22
metformin hcl tab 850 mg (Glucophage)...................... 22
metformin hcl tab sr 24hr 500 mg (Glucophage xr)......22
metformin hcl tab sr 24hr 750 mg (Glucophage xr)......22
metformin hcl tab sr 24hr osmotic 1000 mg
(Fortamet)....................................................................... 22
metformin hcl tab sr 24hr osmotic 500 mg
(Fortamet)....................................................................... 22
methadone hcl conc 10 mg/ml (Methadose).................70
METHADONE HCL – methadone hcl soln 10 mg/5ml.......70
METHADONE HCL – methadone hcl soln 5 mg/5ml........ 70
methadone hcl tab 10 mg (Dolophine).......................... 70
methadone hcl tab 5 mg (Dolophine hcl)......................70
methadone hcl tab for oral susp 40 mg........................ 70
METHADOSE – methadone hcl conc 10 mg/ml................71
METHADOSE SUGAR-FREE – methadone hcl conc 10
mg/ml............................................................................... 71
methazolamide tab 25 mg (Neptazane)......................... 42
methazolamide tab 50 mg (Neptazane)......................... 42
methenamine hippurate tab 1 gm (Hiprex)................... 54
methenamine-hyosc-meth blue-benz acid-phenyl sal
tab 81.6mg (Prosed/ds)................................................. 54
methenamine-hyos-meth blue-sod phos-phen sal tab
81.6 mg ..........................................................................54
METHENAMINE MANDELATE – methenamine mandelate
tab 0.5 gm....................................................................... 54
methenamine mandelate tab 1 gm................................ 54
methimazole tab 10 mg (Tapazole)................................24
methimazole tab 5 mg (Tapazole)..................................24
methocarbamol tab 500 mg (Robaxin).......................... 83
methocarbamol tab 750 mg (Robaxin-750)................... 83
methotrexate sodium inj 25 mg/ml................................ 13
methotrexate sodium inj pf 25 mg/ml............................13
methotrexate sodium tab 2.5 mg (base equiv)............. 13
methscopolamine bromide tab 2.5 mg (Pamine)..........50
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................50
METHYLDOPA/HYDROCHLOROTHI – methyldopa &
hydrochlorothiazide tab 250-15 mg................................. 39
METHYLDOPA/HYDROCHLOROTHI – methyldopa &
hydrochlorothiazide tab 250-25 mg................................. 39
methyldopa tab 250 mg.................................................. 39
methyldopa tab 500 mg.................................................. 39
methylergonovine maleate tab 0.2 mg.......................... 25
METHYLIN – methylphenidate hcl soln 10 mg/5ml........... 65
METHYLIN – methylphenidate hcl soln 5 mg/5ml............. 65
methylphenidate hcl cap sr 24hr 20 mg (Ritalin la)...... 65
methylphenidate hcl cap sr 24hr 30 mg (Ritalin la)...... 65
methylphenidate hcl cap sr 24hr 40 mg (Ritalin la)...... 65
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
cr 10 mg.......................................................................... 65
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 18 mg................................................................. 65
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 27 mg................................................................. 65
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 36 mg................................................................. 65
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 54 mg................................................................. 65
methylphenidate hcl soln 10 mg/5ml (Methylin)...........65
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
141
2015
methylphenidate hcl soln 5 mg/5ml (Methylin).............65
methylphenidate hcl tab 10 mg (Ritalin)....................... 66
methylphenidate hcl tab 20 mg (Ritalin)....................... 66
methylphenidate hcl tab 5 mg (Ritalin)......................... 66
methylphenidate hcl tab cr 20 mg (Ritalin sr)...............66
methylprednisolone tab 16 mg (Medrol)....................... 15
methylprednisolone tab 32 mg (Medrol)....................... 15
methylprednisolone tab 4 mg (Medrol)......................... 15
methylprednisolone tab 4 mg dose pack (Medrol
dosepak)......................................................................... 15
methylprednisolone tab 8 mg (Medrol)......................... 15
METIPRANOLOL – metipranolol ophth soln 0.3%............ 99
metoclopramide hcl inj 5 mg/ml.................................... 53
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml).........53
metoclopramide hcl tab 10 mg (Reglan)....................... 53
metoclopramide hcl tab 5 mg (Reglan)......................... 53
metolazone tab 10 mg.................................................... 42
metolazone tab 2.5 mg (Zaroxolyn)............................... 42
metolazone tab 5 mg (Zaroxolyn).................................. 42
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct).............................................................. 39
metoprolol & hydrochlorothiazide tab 100-50 mg........ 39
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct).............................................................. 39
metoprolol succinate tab sr 24hr 100 mg (Toprol
xl).....................................................................................30
metoprolol succinate tab sr 24hr 200 mg (Toprol
xl).....................................................................................30
metoprolol succinate tab sr 24hr 25 mg (Toprol xl)..... 30
metoprolol succinate tab sr 24hr 50 mg (Toprol xl)..... 30
metoprolol tartrate tab 100 mg (Lopressor)..................30
metoprolol tartrate tab 25 mg........................................ 30
metoprolol tartrate tab 50 mg (Lopressor)....................30
METROCREAM – metronidazole cream 0.75%..............107
METROGEL – metronidazole gel 1%............................. 107
METROGEL-VAGINAL – metronidazole vaginal gel
0.75%...............................................................................55
METROLOTION – metronidazole lotion 0.75%...............107
metronidazole cap 375 mg (Flagyl)............................... 11
metronidazole cream 0.75% (Metrocream)..................107
metronidazole gel 0.75%...............................................107
metronidazole gel 1% (Metrogel)................................. 107
metronidazole lotion 0.75% (Metrolotion)................... 107
metronidazole tab 250 mg (Flagyl)................................ 11
metronidazole tab 500 mg (Flagyl)................................ 11
metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 55
MEVACOR – lovastatin tab 40 mg................................... 44
mexiletine hcl cap 150 mg............................................. 33
mexiletine hcl cap 200 mg............................................. 33
mexiletine hcl cap 250 mg............................................. 33
MIACALCIN – calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 27
MICARDIS HCT – telmisartan-hydrochlorothiazide tab
40-12.5 mg...................................................................... 39
142
MICARDIS HCT – telmisartan-hydrochlorothiazide tab
80-12.5 mg...................................................................... 39
MICARDIS HCT – telmisartan-hydrochlorothiazide tab
80-25 mg......................................................................... 39
MICARDIS – telmisartan tab 20 mg..................................39
MICARDIS – telmisartan tab 40 mg..................................39
MICARDIS – telmisartan tab 80 mg..................................39
MICRO-K – potassium chloride cap cr 10 meq................. 92
MICRO-K – potassium chloride cap cr 8 meq...................92
MICROZIDE – hydrochlorothiazide cap 12.5 mg.............. 42
midazolam hcl syrup 2 mg/ml (base equivalent).......... 63
midodrine hcl tab 10 mg................................................ 42
midodrine hcl tab 2.5 mg............................................... 42
midodrine hcl tab 5 mg.................................................. 42
MILLIPRED DP – prednisolone tab 5 mg dose pack.........15
MILLIPRED – prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)........................................................15
MILLIPRED – prednisolone tab 5 mg............................... 15
MINIPRESS – prazosin hcl cap 1 mg............................... 39
MINIPRESS – prazosin hcl cap 2 mg............................... 39
MINIPRESS – prazosin hcl cap 5 mg............................... 39
MINOCIN – minocycline hcl cap 100 mg............................ 4
MINOCIN – minocycline hcl cap 50 mg.............................. 4
MINOCIN – minocycline hcl cap 75 mg.............................. 4
minocycline hcl cap 100 mg (Minocin)............................4
minocycline hcl cap 50 mg (Minocin)............................. 4
minocycline hcl cap 75 mg (Minocin)............................. 4
minocycline hcl tab 100 mg............................................. 4
minocycline hcl tab 50 mg............................................... 4
minocycline hcl tab 75 mg............................................... 4
minocycline hcl tab sr 24hr 135 mg................................ 4
minocycline hcl tab sr 24hr 45 mg.................................. 4
minocycline hcl tab sr 24hr 90 mg.................................. 4
minoxidil tab 10 mg........................................................ 39
minoxidil tab 2.5 mg....................................................... 39
MIRAPEX – pramipexole dihydrochloride tab 0.125
mg.................................................................................... 81
MIRAPEX – pramipexole dihydrochloride tab 0.25 mg......81
MIRAPEX – pramipexole dihydrochloride tab 0.5 mg....... 81
MIRAPEX – pramipexole dihydrochloride tab 0.75 mg......81
MIRAPEX – pramipexole dihydrochloride tab 1.5 mg....... 81
MIRAPEX – pramipexole dihydrochloride tab 1 mg.......... 81
MIRCETTE – desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5).................................................. 19
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)............................................................................. 58
mirtazapine orally disintegrating tab 30 mg (Remeron
soltab)............................................................................. 58
mirtazapine orally disintegrating tab 45 mg (Remeron
soltab)............................................................................. 58
mirtazapine tab 15 mg (Remeron)................................. 58
mirtazapine tab 30 mg (Remeron)................................. 58
mirtazapine tab 45 mg (Remeron)................................. 58
mirtazapine tab 7.5 mg................................................... 58
misoprostol tab 100 mcg (Cytotec)............................... 51
misoprostol tab 200 mcg (Cytotec)............................... 51
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
MOBIC – meloxicam susp 7.5 mg/5ml..............................75
MOBIC – meloxicam tab 15 mg........................................75
MOBIC – meloxicam tab 7.5 mg.......................................74
modafinil tab 100 mg (Provigil)......................................66
modafinil tab 200 mg (Provigil)......................................66
MODERIBA 1200 DOSE PACK – ribavirin tab 600 mg....... 7
MODERIBA 800 DOSE PACK – ribavirin tab 400 mg.........7
MODERIBA – ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.......................................................................... 7
MODICON – norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg.......................................................................19
moexipril hcl tab 15 mg (Univasc).................................39
moexipril hcl tab 7.5 mg (Univasc)................................39
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)......................................................................... 39
moexipril-hydrochlorothiazide tab 15-25 mg................ 39
moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ 39
mometasone furoate cream 0.1% (Elocon)................. 107
mometasone furoate oint 0.1% (Elocon).....................107
mometasone furoate solution 0.1% (lotion)
(Elocon).........................................................................107
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)....................................................................... 48
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)....................................................................... 48
montelukast sodium tab 10 mg (base equiv)
(Singulair)....................................................................... 48
morphine sulfate (concentrate) oral soln 20 mg/ml..... 71
morphine sulfate cap sr 24hr 100 mg (Kadian)............ 71
morphine sulfate cap sr 24hr 10 mg (Kadian).............. 71
morphine sulfate cap sr 24hr 20 mg (Kadian).............. 71
morphine sulfate cap sr 24hr 30 mg (Kadian).............. 71
morphine sulfate cap sr 24hr 50 mg (Kadian).............. 71
morphine sulfate cap sr 24hr 60 mg (Kadian).............. 71
morphine sulfate cap sr 24hr 80 mg (Kadian).............. 71
MORPHINE SULFATE – morphine sulfate suppos 10
mg.................................................................................... 71
MORPHINE SULFATE – morphine sulfate suppos 20
mg.................................................................................... 71
MORPHINE SULFATE – morphine sulfate suppos 30
mg.................................................................................... 71
MORPHINE SULFATE – morphine sulfate suppos 5
mg.................................................................................... 71
MORPHINE SULFATE – morphine sulfate tab 15 mg.......71
MORPHINE SULFATE – morphine sulfate tab 30 mg.......71
morphine sulfate oral soln 10 mg/5ml...........................71
morphine sulfate oral soln 20 mg/5ml...........................71
morphine sulfate tab cr 100 mg (Ms contin)................. 71
morphine sulfate tab cr 15 mg (Ms contin)...................71
morphine sulfate tab cr 200 mg (Ms contin)................. 71
morphine sulfate tab cr 30 mg (Ms contin)...................71
morphine sulfate tab cr 60 mg (Ms contin)...................71
MS CONTIN – morphine sulfate tab cr 100 mg................ 71
MS CONTIN – morphine sulfate tab cr 15 mg.................. 71
MS CONTIN – morphine sulfate tab cr 200 mg................ 71
MS CONTIN – morphine sulfate tab cr 30 mg.................. 71
MS CONTIN – morphine sulfate tab cr 60 mg.................. 71
MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab
27-0.8 mg........................................................................ 85
mupirocin calcium cream 2% (Bactroban)..................107
mupirocin oint 2% (Bactroban).................................... 107
M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg........... 85
MYAMBUTOL – ethambutol hcl tab 100 mg....................... 5
MYAMBUTOL – ethambutol hcl tab 400 mg....................... 5
mycophenolate mofetil cap 250 mg (Cellcept)........... 111
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept).......................................................................111
mycophenolate mofetil tab 500 mg (Cellcept)............ 111
MYDRIACYL – tropicamide ophth soln 1%....................... 99
MYLERAN – busulfan tab 2 mg........................................13
MYNATAL ADVANCE – prenatal vit w/ dss-iron carbonylfa tab 90-1 mg.................................................................85
MYNATAL PLUS – prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................... 85
MYNATAL – prenatal multivitamins & minerals w/ iron & fa
cap 1 mg......................................................................... 85
MYNATAL ULTRACAPLET – prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg.................................................. 86
MYNATAL-Z – prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................... 86
MYNATE 90 PLUS – prenatal vit w/ dss-fe fumarate-fa tab
cr 90-1 mg....................................................................... 86
MYSOLINE – primidone tab 250 mg.................................79
MYSOLINE – primidone tab 50 mg...................................79
N
nabumetone tab 500 mg.................................................75
nabumetone tab 750 mg.................................................75
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)......................................................................... 39
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)......................................................................... 39
nadolol tab 20 mg (Corgard).......................................... 30
nadolol tab 40 mg (Corgard).......................................... 30
nadolol tab 80 mg (Corgard).......................................... 30
naltrexone hcl tab 50 mg (Revia).................................110
NAPHAZOLINE HCL – naphazoline hcl ophth soln
0.1%.................................................................................99
NAPROSYN – naproxen susp 125 mg/5ml.......................75
NAPROSYN – naproxen tab 250 mg................................75
NAPROSYN – naproxen tab 375 mg................................75
NAPROSYN – naproxen tab 500 mg................................75
naproxen sodium tab 275 mg (Anaprox)...................... 75
naproxen sodium tab 550 mg (Anaprox ds)................. 75
naproxen susp 125 mg/5ml (Naprosyn)........................ 75
naproxen tab 250 mg (Naprosyn).................................. 75
naproxen tab 375 mg (Naprosyn).................................. 75
naproxen tab 500 mg (Naprosyn).................................. 75
naproxen tab ec 375 mg (Ec-naprosyn)........................ 75
naproxen tab ec 500 mg (Ec-naprosyn)........................ 75
naratriptan hcl tab 1 mg (base equiv) (Amerge)........... 76
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)........ 76
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
143
2015
NARDIL – phenelzine sulfate tab 15 mg...........................58
NASACORT AQ – triamcinolone acetonide nasal aerosol
suspension 55 mcg/act....................................................46
NASONEX – mometasone furoate nasal susp 50 mcg/
act.................................................................................... 46
NATACHEW – prenatal vit w/ fe fum-fe bisglycin-fa chew
tab 28-1 mg..................................................................... 86
NATALVIRT 90 DHA – prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak........................................... 86
NATALVIRT CA – prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack..................................................... 86
NATALVIT – prenatal vit w/ fe fumarate-fa tab 75-1
mg.................................................................................... 86
NATAL-V RX – prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................... 86
nateglinide tab 120 mg (Starlix).....................................22
nateglinide tab 60 mg (Starlix).......................................22
NATELLE ONE – prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg............................................................. 86
NATURE-THROID NT-2.5 – thyroid tab 162.5 mg (2 1/2
grain)................................................................................24
NATURE-THROID – thyroid tab 113.75 mg......................24
NATURE-THROID – thyroid tab 130 mg...........................24
NATURE-THROID – thyroid tab 146.25 mg......................24
NATURE-THROID – thyroid tab 16.25 mg........................24
NATURE-THROID – thyroid tab 195 mg...........................24
NATURE-THROID – thyroid tab 260 mg...........................24
NATURE-THROID – thyroid tab 32.5 mg..........................24
NATURE-THROID – thyroid tab 325 mg (5 grain)............ 24
NATURE-THROID – thyroid tab 48.75 mg (3/4 grain).......24
NATURE-THROID – thyroid tab 65 mg.............................24
NATURE-THROID – thyroid tab 81.25 mg........................24
NATURE-THROID – thyroid tab 97.5 mg..........................24
NEEVO DHA – prenat w/o a w/fefum-methylfol-omegas
cap 27-1.13 mg............................................................... 86
NEOMYCIN/POLYMYXIN/HYDROC – neomycinpolymyxin-hc ophth susp................................................. 99
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin.................................99
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)............... 99
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol).........................................................................99
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol)............................................................... 99
neomycin-polymyxin-hc otic soln 1%
(Cortisporin)................................................................. 100
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.....................................................................101
neomycin sulfate tab 500 mg...........................................4
NEORAL – cyclosporine modified cap 100 mg............... 111
NEORAL – cyclosporine modified cap 25 mg................. 111
NEORAL – cyclosporine modified oral soln 100 mg/
ml................................................................................... 111
NEOSPORIN – neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml...................................... 99
144
NEPHROCAPS – b-complex w/ c & folic acid cap 1
mg.................................................................................... 86
NEPHRO-VITE RX – b-complex w/ c & folic acid tab 1
mg.................................................................................... 86
NEPTAZANE – methazolamide tab 25 mg....................... 42
NEPTAZANE – methazolamide tab 50 mg....................... 42
NESTABS ABC – prenatal w/o vit a w/fe polysac-fa-ca tab
& omega 3 cap................................................................86
NESTABS DHA – prenat w/o a w/ fe bisglyc-fa tab 32-1
mg & omega cap pack.................................................... 86
NESTABS – prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg........................................................................... 86
NEULASTA DELIVERY KIT – pegfilgrastim inj 6
mg/0.6ml.......................................................................... 94
NEULASTA – pegfilgrastim inj 6 mg/0.6ml....................... 94
NEUPOGEN – filgrastim inj 300 mcg/0.5ml (600 mcg/
ml).................................................................................... 94
NEUPOGEN – filgrastim inj 300 mcg/ml........................... 94
NEUPOGEN – filgrastim inj 480 mcg/0.8ml (600 mcg/
ml).................................................................................... 94
NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/
ml).................................................................................... 94
NEURONTIN – gabapentin cap 100 mg........................... 79
NEURONTIN – gabapentin cap 300 mg........................... 79
NEURONTIN – gabapentin cap 400 mg........................... 79
NEURONTIN – gabapentin oral soln 250 mg/5ml............. 80
NEURONTIN – gabapentin tab 600 mg............................ 80
NEURONTIN – gabapentin tab 800 mg............................ 80
NEVIRAPINE – nevirapine susp 50 mg/5ml....................... 7
nevirapine tab 200 mg (Viramune)...................................7
nevirapine tab sr 24hr 400 mg (Viramune xr)................. 7
NEWGEN – prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg........................................................................... 86
NEXA PLUS – prenatal w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg............................................................... 86
NEXAVAR – sorafenib tosylate tab 200 mg (base
equivalent)....................................................................... 13
NEXIUM – esomeprazole magnesium cap delayed release
20 mg...............................................................................51
NEXIUM – esomeprazole magnesium cap delayed release
40 mg...............................................................................51
NEXIUM – esomeprazole magnesium for delayed release
susp pack 2.5 mg............................................................51
NEXIUM – esomeprazole magnesium for delayed release
susp packet 10 mg.......................................................... 51
NEXIUM – esomeprazole magnesium for delayed release
susp packet 20 mg.......................................................... 51
NEXIUM – esomeprazole magnesium for delayed release
susp packet 40 mg.......................................................... 51
NEXIUM – esomeprazole magnesium for delayed release
susp packet 5 mg............................................................51
niacin tab cr 1000 mg (antihyperlipidemic)
(Niaspan).........................................................................44
niacin tab cr 500 mg (antihyperlipidemic)
(Niaspan).........................................................................44
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
niacin tab cr 750 mg (antihyperlipidemic)
(Niaspan).........................................................................44
NIACOR – niacin (antihyperlipidemic) tab 500 mg............ 44
NIASPAN – niacin tab cr 1000 mg
(antihyperlipidemic)..........................................................44
NIASPAN – niacin tab cr 500 mg (antihyperlipidemic)...... 44
NIASPAN – niacin tab cr 750 mg (antihyperlipidemic)...... 44
nicardipine hcl cap 20 mg..............................................32
nicardipine hcl cap 30 mg..............................................32
NICOTROL INHALER – nicotine inhaler system 10 mg (4
mg delivered)...................................................................67
NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/
spray)............................................................................... 67
nifedipine cap 10 mg (Procardia)...................................32
nifedipine cap 20 mg...................................................... 32
nifedipine tab sr 24hr 30 mg (Adalat cc).......................32
nifedipine tab sr 24hr 60 mg (Adalat cc).......................32
nifedipine tab sr 24hr 90 mg (Adalat cc).......................32
nifedipine tab sr 24hr osmotic 30 mg (Procardia
xl).....................................................................................32
nifedipine tab sr 24hr osmotic 60 mg (Procardia
xl).....................................................................................32
nifedipine tab sr 24hr osmotic 90 mg (Procardia
xl).....................................................................................32
NILANDRON – nilutamide tab 150 mg............................. 13
nimodipine cap 30 mg.................................................... 32
NIRAVAM – alprazolam orally disintegrating tab 0.25
mg.................................................................................... 56
NISOLDIPINE – nisoldipine tab sr 24hr 40 mg................. 32
nisoldipine tab sr 24hr 17 mg (Sular)............................32
nisoldipine tab sr 24hr 34 mg (Sular)............................32
nisoldipine tab sr 24hr 8.5 mg (Sular)...........................32
NITRO-BID – nitroglycerin oint 2%................................... 28
NITRO-DUR – nitroglycerin td patch 24hr 0.1 mg/hr.........28
NITRO-DUR – nitroglycerin td patch 24hr 0.2 mg/hr.........28
NITRO-DUR – nitroglycerin td patch 24hr 0.3 mg/hr.........29
NITRO-DUR – nitroglycerin td patch 24hr 0.4 mg/hr.........29
NITRO-DUR – nitroglycerin td patch 24hr 0.6 mg/hr.........29
NITRO-DUR – nitroglycerin td patch 24hr 0.8 mg/hr.........29
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin)................................................................. 54
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin)................................................................. 54
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)................................................................ 54
nitrofurantoin susp 25 mg/5ml (Furadantin)................. 54
nitroglycerin cap cr 2.5 mg............................................ 29
nitroglycerin cap cr 6.5 mg............................................ 29
nitroglycerin cap cr 9 mg............................................... 29
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 29
nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)......... 29
nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)......... 29
nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)......... 29
NITROSTAT – nitroglycerin sl tab 0.3 mg.........................29
NITROSTAT – nitroglycerin sl tab 0.4 mg.........................29
NITROSTAT – nitroglycerin sl tab 0.6 mg.........................29
nizatidine cap 150 mg.....................................................51
nizatidine cap 300 mg (Axid)..........................................51
nizatidine oral soln 15 mg/ml (Axid)..............................51
NIZORAL – ketoconazole shampoo 2%..........................107
NORCO – hydrocodone-acetaminophen tab 10-325
mg.................................................................................... 71
NORCO – hydrocodone-acetaminophen tab 5-325 mg.....71
NORCO – hydrocodone-acetaminophen tab 7.5-325
mg.................................................................................... 71
norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr (Ortho evra)................................................... 19
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg (Femcon fe)................................................ 19
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
(Ovcon-35)...................................................................... 19
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
(Brevicon-28).................................................................. 19
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
(Norinyl 1+35).................................................................19
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)................................................ 19
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg (Loestrin fe 1/20)................................................... 19
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg (Loestrin 1.5/30-21)............................................... 19
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)........................................................... 19
norethindrone acetate tab 5 mg (Aygestin).................. 20
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg (Estrostep fe).................................................. 19
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg (Ortho-novum 7/7/7)....................................... 19
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28).......................................................19
norethindrone tab 0.35 mg (Nor-qd)..............................19
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
(Ortho-cyclen)................................................................ 19
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg (Ortho tri-cyclen)............................................ 19
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 19
NORINYL 1+35 – norethindrone & ethinyl estradiol tab 1
mg-35 mcg.......................................................................19
NORPACE – disopyramide phosphate cap 100 mg..........33
NORPACE – disopyramide phosphate cap 150 mg..........34
NORPRAMIN – desipramine hcl tab 100 mg.................... 59
NORPRAMIN – desipramine hcl tab 10 mg...................... 59
NORPRAMIN – desipramine hcl tab 150 mg.................... 59
NORPRAMIN – desipramine hcl tab 25 mg...................... 59
NORPRAMIN – desipramine hcl tab 50 mg...................... 59
NORPRAMIN – desipramine hcl tab 75 mg...................... 59
NOR-QD – norethindrone tab 0.35 mg............................. 19
nortriptyline hcl cap 10 mg (Pamelor)...........................59
nortriptyline hcl cap 25 mg (Pamelor)...........................59
nortriptyline hcl cap 50 mg (Pamelor)...........................59
nortriptyline hcl cap 75 mg (Pamelor)...........................59
NORVASC – amlodipine besylate tab 10 mg....................32
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
145
2015
NORVASC – amlodipine besylate tab 2.5 mg...................32
NORVASC – amlodipine besylate tab 5 mg......................32
NORVIR – ritonavir cap 100 mg......................................... 7
NORVIR – ritonavir oral soln 80 mg/ml...............................7
NORVIR – ritonavir tab 100 mg.......................................... 7
NOVOLIN 70/30 – insulin isophane & regular (human) inj
100 unit/ml (70-30).......................................................... 23
NOVOLIN 70/30 RELION – insulin isophane & regular
(human) inj 100 unit/ml (70-30)....................................... 23
NOVOLIN N – insulin isophane (human) inj 100 unit/
ml..................................................................................... 23
NOVOLIN N RELION – insulin isophane (human) inj 100
unit/ml.............................................................................. 23
NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 23
NOVOLIN R RELION – insulin regular (human) inj 100
unit/ml.............................................................................. 23
NOVOLOG FLEXPEN – insulin aspart soln pen-injector
100 unit/ml....................................................................... 23
NOVOLOG – insulin aspart inj 100 unit/ml........................23
NOVOLOG MIX 70/30 – insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)....................................... 23
NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30).............................23
NOVOLOG PENFILL – insulin aspart inj 100 unit/ml........ 23
NOVOLOG PENFILL – insulin aspart soln cartridge 100
unit/ml.............................................................................. 23
NOXAFIL – posaconazole susp 40 mg/ml.......................... 5
NOXAFIL – posaconazole tab delayed release 100 mg......5
NUCYNTA ER – tapentadol hcl tab sr 12hr 100 mg..........71
NUCYNTA ER – tapentadol hcl tab sr 12hr 150 mg..........71
NUCYNTA ER – tapentadol hcl tab sr 12hr 200 mg..........71
NUCYNTA ER – tapentadol hcl tab sr 12hr 250 mg..........71
NUCYNTA ER – tapentadol hcl tab sr 12hr 50 mg........... 71
NUCYNTA – tapentadol hcl tab 100 mg........................... 71
NUCYNTA – tapentadol hcl tab 50 mg............................. 71
NUCYNTA – tapentadol hcl tab 75 mg............................. 71
NULYTELY/FLAVOR PACKS – peg 3350-kcl-sod bicarbnacl for soln 420 gm....................................................... 49
NUMOISYN – artificial saliva - lozenge...........................101
NUTRI-TAB OB + DHA – prenat w/o a w/ fe bisglyc-fa tab
32-1 mg & omega cap pack............................................ 86
NUTRI-TAB OB – prenatal vit w/o vit a w/ fe bisglycinatefa tab 32-1 mg.................................................................86
NUVARING – etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr....................................................... 19
NYMALIZE – nimodipine oral soln 60 mg/20ml.................32
nystatin cream 100000 unit/gm....................................107
nystatin oint 100000 unit/gm........................................107
nystatin oral powder......................................................... 6
nystatin susp 100000 unit/ml....................................... 101
nystatin tab 500000 unit................................................... 6
nystatin topical powder ...............................................107
nystatin-triamcinolone cream 100000-0.1 unit/gm%....................................................................................107
nystatin-triamcinolone oint 100000-0.1 unit/gm-%..... 107
146
O
OB COMPLETE/DHA – prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg............................................ 86
OB COMPLETE ONE – prenatal w/o a w/fecbn-fe asp
glyc-fa-fish cap 50-1-476 mg...........................................86
OB COMPLETE PETITE – prenat w/o a w/fecbnfeaspglyc-fa-omega cap 35-5-1-200 mg..........................86
OB COMPLETE PREMIER – prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg.................................................... 86
OB COMPLETE – prenatal vit w/ iron carbonyl-fa tab
50-1.25 mg...................................................................... 86
OB-NATAL ONE – prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg...................................................... 86
OBSTETRIX DHA – prenat w/fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak............................................... 86
OBSTETRIX EC – prenatal vit w/ dss-iron carbonyl-fa tab
29-1 mg........................................................................... 86
O-CAL FA – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 86
O-CAL PRENATAL – prenatal vit w/ fe fumarate-fa tab
15-1 mg........................................................................... 86
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin).................................................................. 27
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin).................................................................. 27
octreotide acetate inj 200 mcg/ml (0.2 mg/ml)
(Sandostatin).................................................................. 27
octreotide acetate inj 500 mcg/ml (0.5 mg/ml)
(Sandostatin).................................................................. 27
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
(Sandostatin).................................................................. 27
OCUFEN – flurbiprofen sodium ophth soln 0.03%............ 99
OCUFLOX – ofloxacin ophth soln 0.3%............................99
OFLOXACIN – ofloxacin tab 400 mg.................................. 4
ofloxacin ophth soln 0.3% (Ocuflox)............................. 99
ofloxacin otic soln 0.3%............................................... 101
olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax).....67
olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax).....67
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax).......67
olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax).......67
olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax).......67
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)...............................................................................61
olanzapine orally disintegrating tab 15 mg (Zyprexa
zydis)...............................................................................61
olanzapine orally disintegrating tab 20 mg (Zyprexa
zydis)...............................................................................61
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis)...............................................................................61
olanzapine tab 10 mg (Zyprexa).................................... 61
olanzapine tab 15 mg (Zyprexa).................................... 61
olanzapine tab 2.5 mg (Zyprexa)................................... 61
olanzapine tab 20 mg (Zyprexa).................................... 61
olanzapine tab 5 mg (Zyprexa)...................................... 61
olanzapine tab 7.5 mg (Zyprexa)................................... 61
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
OLUX – clobetasol propionate foam 0.05%.................... 107
OLUX-E – clobetasol propionate emulsion foam
0.05%.............................................................................107
OLYSIO – simeprevir sodium cap 150 mg (base
equivalent)......................................................................... 7
omeprazole cap delayed release 10 mg (Prilosec)....... 51
omeprazole cap delayed release 20 mg (Prilosec)....... 51
omeprazole cap delayed release 40 mg (Prilosec)....... 51
OMNARIS – ciclesonide nasal susp 50 mcg/act............... 46
OMNIFLEX DIAPHRAGM – diaphragms........................ 110
OMNIPRED – prednisolone acetate ophth susp 1%......... 99
OMNITROPE – somatropin for inj 5.8 mg.........................27
OMNITROPE – somatropin inj 10 mg/1.5ml..................... 27
OMNITROPE – somatropin inj 5 mg/1.5ml....................... 27
ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 52
ondansetron hcl tab 24 mg............................................ 52
ondansetron hcl tab 4 mg (Zofran)................................52
ondansetron hcl tab 8 mg (Zofran)................................52
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................. 52
ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................. 52
ONETOUCH ULTRA BLUE – glucose blood test
strip................................................................................ 110
ONETOUCH ULTRA TEST STRIP – glucose blood test
strip................................................................................ 110
ONETOUCH VERIO TEST STRIP – glucose blood test
strip................................................................................ 110
ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv)........ 22
ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)........... 22
OPANA – oxymorphone hcl tab 10 mg............................. 72
OPANA – oxymorphone hcl tab 5 mg............................... 71
OPSUMIT – macitentan tab 10 mg................................... 45
orphenadrine citrate tab sr 12hr 100 mg.......................83
ORTHO-CEPT – desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg.......................................................................19
ORTHO-CYCLEN – norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg.............................................................. 19
ORTHO DIAPHRAGM COIL SPRI – diaphragm coil spring
kit 100 mm.....................................................................110
ORTHO DIAPHRAGM COIL SPRI – diaphragm coil spring
kit 105 mm.....................................................................110
ORTHO DIAPHRAGM COIL SPRI – diaphragm coil spring
kit 50 mm.......................................................................110
ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring
kit 55 mm.......................................................................110
ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring
kit 60 mm.......................................................................110
ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring
kit 65 mm.......................................................................110
ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring
kit 70 mm.......................................................................111
ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring
kit 75 mm.......................................................................111
ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring
kit 80 mm.......................................................................111
ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring
kit 85 mm.......................................................................111
ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring
kit 90 mm.......................................................................111
ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring
kit 95 mm.......................................................................111
ORTHO EVRA – norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr............................................................. 19
ORTHO MICRONOR – norethindrone tab 0.35 mg.......... 19
ORTHO-NOVUM 1/35 – norethindrone & ethinyl estradiol
tab 1 mg-35 mcg............................................................. 20
ORTHO-NOVUM 7/7/7 – norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg........................................... 20
ORTHO TRI-CYCLEN – norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg.................................. 19
OTICIN HC NR – pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml............................................................... 101
OVACE PLUS WASH – sulfacetamide sodium liquid
10%................................................................................107
OVACE WASH – sulfacetamide sodium liquid 10%........ 107
OVCON-35 – norethindrone & ethinyl estradiol tab 0.4
mg-35 mcg.......................................................................20
OVIDE – malathion lotion 0.5%...................................... 107
OVIDREL – Benefit Limits may apply –
choriogonadotropin alfa inj 250 mcg/0.5ml......................27
OXANDRIN – oxandrolone tab 10 mg.............................. 16
OXANDRIN – oxandrolone tab 2.5 mg............................. 16
oxandrolone tab 10 mg (Oxandrin)................................16
oxandrolone tab 2.5 mg (Oxandrin)...............................16
oxaprozin tab 600 mg (Daypro)..................................... 75
oxazepam cap 10 mg...................................................... 56
oxazepam cap 15 mg...................................................... 56
oxazepam cap 30 mg...................................................... 56
oxcarbazepine tab 150 mg (Trileptal)............................ 80
oxcarbazepine tab 300 mg (Trileptal)............................ 80
oxcarbazepine tab 600 mg (Trileptal)............................ 80
oxybutynin chloride syrup 5 mg/5ml.............................54
oxybutynin chloride tab 5 mg........................................ 54
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl).....................................................................................54
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl).....................................................................................54
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)......54
oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 72
oxycodone hcl cap 5 mg................................................ 72
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl).............................................................72
OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter
10 mg...............................................................................72
OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter
20 mg...............................................................................72
OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter
40 mg...............................................................................72
OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter
80 mg...............................................................................72
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
147
2015
OXYCODONE HCL – oxycodone hcl conc 100 mg/5ml (20
mg/ml).............................................................................. 72
OXYCODONE HCL – oxycodone hcl soln 5 mg/5ml.........72
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)........... 72
oxycodone hcl tab 10 mg...............................................72
oxycodone hcl tab 15 mg (Roxicodone)....................... 72
oxycodone hcl tab 20 mg...............................................72
oxycodone hcl tab 30 mg (Roxicodone)....................... 72
oxycodone hcl tab 5 mg (Roxicodone)......................... 72
oxycodone-ibuprofen tab 5-400 mg...............................72
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)....................................................................... 72
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)....................................................................... 72
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)....................................................................... 72
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)....................................................................... 72
OXYCONTIN – oxycodone hcl tab er 12hr deter 10
mg.................................................................................... 72
OXYCONTIN – oxycodone hcl tab er 12hr deter 15
mg.................................................................................... 72
OXYCONTIN – oxycodone hcl tab er 12hr deter 20
mg.................................................................................... 72
OXYCONTIN – oxycodone hcl tab er 12hr deter 30
mg.................................................................................... 72
OXYCONTIN – oxycodone hcl tab er 12hr deter 40
mg.................................................................................... 72
OXYCONTIN – oxycodone hcl tab er 12hr deter 60
mg.................................................................................... 72
OXYCONTIN – oxycodone hcl tab er 12hr deter 80
mg.................................................................................... 72
oxymorphone hcl tab 10 mg (Opana)............................72
oxymorphone hcl tab 5 mg (Opana)..............................72
P
PAIRE OB – prenat w/ fe poly cmplx-fe asp-fe gly-fa tab &
dha cap pak.....................................................................86
PAMELOR – nortriptyline hcl cap 10 mg.......................... 59
PAMELOR – nortriptyline hcl cap 25 mg.......................... 59
PAMELOR – nortriptyline hcl cap 50 mg.......................... 59
PAMELOR – nortriptyline hcl cap 75 mg.......................... 59
PAMINE FORTE – methscopolamine bromide tab 5
mg.................................................................................... 51
PAMINE – methscopolamine bromide tab 2.5 mg.............51
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................ 51
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................ 51
PARAFON FORTE DSC – chlorzoxazone tab 500 mg..... 83
paricalcitol cap 1 mcg (Zemplar)................................... 27
paricalcitol cap 2 mcg (Zemplar)................................... 27
paricalcitol cap 4 mcg (Zemplar)................................... 27
PARLODEL – bromocriptine mesylate cap 5 mg.............. 81
PARNATE – tranylcypromine sulfate tab 10 mg............... 59
paromomycin sulfate cap 250 mg................................... 5
148
paroxetine hcl tab 10 mg (Paxil).................................... 59
paroxetine hcl tab 20 mg (Paxil).................................... 59
paroxetine hcl tab 30 mg (Paxil).................................... 59
paroxetine hcl tab 40 mg (Paxil).................................... 59
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 59
paroxetine hcl tab sr 24hr 25 mg (Paxil cr)...................59
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 59
PAXIL CR – paroxetine hcl tab sr 24hr 12.5 mg............... 59
PAXIL CR – paroxetine hcl tab sr 24hr 25 mg.................. 59
PAXIL CR – paroxetine hcl tab sr 24hr 37.5 mg............... 59
PAXIL – paroxetine hcl tab 10 mg.................................... 59
PAXIL – paroxetine hcl tab 20 mg.................................... 59
PAXIL – paroxetine hcl tab 30 mg.................................... 59
PAXIL – paroxetine hcl tab 40 mg.................................... 59
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/
ml ................................................................................... 86
pediatric multiple vitamins w/ fluoride chew tab 0.25
mg .................................................................................. 86
pediatric multiple vitamins w/ fluoride chew tab 1 mg
......................................................................................... 87
pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml
......................................................................................... 87
pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml
......................................................................................... 87
pediatric vitamins acd w/ fluoride soln 0.25 mg/ml ..... 87
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml ....... 87
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely)........................................................................ 49
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
(Colyte-flavor packs)..................................................... 49
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack).................................................... 49
PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml......... 8
PEGASYS – peginterferon alfa-2a inj 180 mcg/ml.............. 8
PEGASYS PROCLICK – peginterferon alfa-2a inj 135
mcg/0.5ml.......................................................................... 8
PEGASYS PROCLICK – peginterferon alfa-2a inj 180
mcg/0.5ml.......................................................................... 8
PEGINTRON – peginterferon alfa-2b for inj kit 120
mcg/0.5ml.......................................................................... 8
PEG-INTRON – peginterferon alfa-2b for inj kit 120
mcg/0.5ml.......................................................................... 7
PEGINTRON – peginterferon alfa-2b for inj kit 150
mcg/0.5ml.......................................................................... 8
PEG-INTRON – peginterferon alfa-2b for inj kit 150
mcg/0.5ml.......................................................................... 7
PEGINTRON – peginterferon alfa-2b for inj kit 50
mcg/0.5ml.......................................................................... 8
PEG-INTRON – peginterferon alfa-2b for inj kit 50
mcg/0.5ml.......................................................................... 7
PEGINTRON – peginterferon alfa-2b for inj kit 80
mcg/0.5ml.......................................................................... 8
PEG-INTRON – peginterferon alfa-2b for inj kit 80
mcg/0.5ml.......................................................................... 7
PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for
inj kit 120 mcg/0.5ml......................................................... 8
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for
inj kit 150 mcg/0.5ml......................................................... 8
PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for
inj kit 50 mcg/0.5ml........................................................... 8
PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for
inj kit 80 mcg/0.5ml........................................................... 8
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
120 mcg/0.5ml................................................................... 8
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
150 mcg/0.5ml................................................................... 8
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
50 mcg/0.5ml..................................................................... 7
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
80 mcg/0.5ml..................................................................... 8
penicillin v potassium for soln 125 mg/5ml.................... 1
penicillin v potassium for soln 250 mg/5ml.................... 1
penicillin v potassium tab 250 mg...................................1
penicillin v potassium tab 500 mg...................................1
PENLAC NAIL LACQUER – ciclopirox solution 8%........ 107
PENTASA – mesalamine cap cr 250 mg.......................... 53
PENTASA – mesalamine cap cr 500 mg.......................... 53
pentazocine w/ naloxone tab 50-0.5 mg........................72
pentoxifylline tab cr 400 mg...........................................97
PEPCID – famotidine for susp 40 mg/5ml.........................51
PEPCID – famotidine tab 20 mg.......................................51
PEPCID – famotidine tab 40 mg.......................................51
PERCOCET – oxycodone w/ acetaminophen tab 10-325
mg.................................................................................... 72
PERCOCET – oxycodone w/ acetaminophen tab 2.5-325
mg.................................................................................... 72
PERCOCET – oxycodone w/ acetaminophen tab 5-325
mg.................................................................................... 72
PERCOCET – oxycodone w/ acetaminophen tab 7.5-325
mg.................................................................................... 72
PERCODAN – oxycodone-aspirin tab 4.8355-325 mg...... 72
PERIDEX – chlorhexidine gluconate soln 0.12%............ 101
perindopril erbumine tab 2 mg...................................... 39
perindopril erbumine tab 4 mg (Aceon)........................ 39
perindopril erbumine tab 8 mg (Aceon)........................ 39
permethrin cream 5% (Elimite).................................... 107
perphenazine tab 16 mg................................................. 61
perphenazine tab 2 mg................................................... 61
perphenazine tab 4 mg................................................... 61
perphenazine tab 8 mg................................................... 61
PERSANTINE – dipyridamole tab 25 mg..........................97
PERSANTINE – dipyridamole tab 50 mg..........................97
PERSANTINE – dipyridamole tab 75 mg..........................97
phenazopyridine hcl tab 100 mg (Pyridium)................. 55
phenazopyridine hcl tab 200 mg (Pyridium)................. 55
phenelzine sulfate tab 15 mg (Nardil)............................59
phenobarbital elixir 20 mg/5ml...................................... 63
PHENOBARBITAL – phenobarbital tab 100 mg............... 63
PHENOBARBITAL – phenobarbital tab 15 mg................. 63
PHENOBARBITAL – phenobarbital tab 30 mg................. 63
PHENOBARBITAL – phenobarbital tab 60 mg................. 63
phenobarbital tab 16.2 mg............................................. 63
phenobarbital tab 32.4 mg............................................. 63
phenobarbital tab 64.8 mg............................................. 63
phenobarbital tab 97.2 mg............................................. 63
phenylephrine hcl ophth soln 10%................................99
phenylephrine hcl ophth soln 2.5%...............................99
PHENYTEK – phenytoin sodium extended cap 200
mg.................................................................................... 80
PHENYTEK – phenytoin sodium extended cap 300
mg.................................................................................... 80
phenytoin chew tab 50 mg (Dilantin infatabs).............. 80
phenytoin sodium extended cap 100 mg (Dilantin)......80
phenytoin sodium extended cap 200 mg
(Phenytek).......................................................................80
phenytoin sodium extended cap 300 mg
(Phenytek).......................................................................80
phenytoin susp 125 mg/5ml (Dilantin).......................... 80
PHOSLO – calcium acetate (phosphate binder) cap 667
mg (169 mg ca)...............................................................53
pilocarpine hcl ophth soln 1% (Isopto carpine)............99
pilocarpine hcl ophth soln 2% (Isopto carpine)............99
pilocarpine hcl ophth soln 4% (Isopto carpine)............99
pilocarpine hcl tab 5 mg (Salagen)..............................101
pilocarpine hcl tab 7.5 mg (Salagen)...........................101
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)......22
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)......22
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)............................................................... 22
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)............................................................... 22
pioglitazone hcl tab 15 mg (base equiv) (Actos).......... 22
pioglitazone hcl tab 30 mg (base equiv) (Actos).......... 22
pioglitazone hcl tab 45 mg (base equiv) (Actos).......... 22
piroxicam cap 10 mg (Feldene)..................................... 75
piroxicam cap 20 mg (Feldene)..................................... 75
PLAN B – levonorgestrel tab 0.75 mg.............................. 20
PLAN B ONE-STEP – levonorgestrel tab 1.5 mg..............20
PLAQUENIL – hydroxychloroquine sulfate tab 200 mg.....10
PLAVIX – clopidogrel bisulfate tab 300 mg (base
equiv)............................................................................... 97
PLAVIX – clopidogrel bisulfate tab 75 mg (base equiv).....97
PLEGRIDY – peginterferon beta-1a soln pen-injector 125
mcg/0.5ml........................................................................ 67
PLEGRIDY – peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml................................................................. 67
PLEGRIDY STARTER PACK – peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack......................................67
PLEGRIDY STARTER PACK – peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack.................................... 67
PLETAL – cilostazol tab 100 mg.......................................97
PLETAL – cilostazol tab 50 mg.........................................97
PNV-DHA+DOCUSATE – prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg............................................. 87
PNV-DHA – prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg........................................................... 87
PNV FERROUS FUMARATE/DOCU – prenatal vit w/ dssfe fumarate-fa tab 29-1 mg............................................. 87
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
149
2015
PNV-FIRST – prenatal mv w/ fe polysac cmplx-fa-dha cap
29-1-200 mg.................................................................... 87
PNV FOLIC ACID + IRON MUL – prenatal vit w/ fe
fumarate-fa tab 27-1 mg..................................................87
PNV-OB/DHA – prenatal mv w/fe fum-fa tab 65-1 mg &
dha cap 250 mg pack .................................................... 87
PNV OB+DHA – prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack..................................................... 87
PNV-OMEGA – prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................... 87
PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fe
fumarate-fa tab 27-1 mg..................................................87
PNV-SELECT – prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg.................................................................. 87
PNV TABS 29-1 – prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................... 87
PNV-TOTAL – prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg..................................................................... 87
PNV-VP-U – prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg...................................................................... 87
podofilox soln 0.5% (Condylox)...................................107
polyethylene glycol 3350 oral packet............................49
polyethylene glycol 3350 oral powder.......................... 49
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)......................................................... 99
POLYTRIM – polymyxin b-trimethoprim ophth soln 10000
unit/ml-0.1%..................................................................... 99
potassium bicarbonate effer tab 25 meq...................... 92
potassium chloride cap cr 10 meq (Micro-k)................ 93
potassium chloride cap cr 8 meq (Micro-k).................. 93
POTASSIUM CHLORIDE ER – potassium chloride tab cr
20 meq (1500 mg)...........................................................93
potassium chloride microencapsulated crys cr tab 10
meq..................................................................................93
potassium chloride microencapsulated crys cr tab 20
meq..................................................................................93
potassium chloride oral liq 10% (20 meq/15ml)............93
potassium chloride oral liq 20% (40 meq/15ml)............93
potassium chloride powder packet 20 meq..................93
potassium chloride tab cr 10 meq (K-tab).................... 93
potassium chloride tab cr 8 meq (600 mg)................... 93
potassium citrate & citric acid powder pack 3300-1002
mg....................................................................................55
potassium citrate tab cr 10 meq (1080 mg) (Urocit-k
10)....................................................................................55
potassium citrate tab cr 15 meq (1620 mg) (Urocit-k
15)....................................................................................55
potassium citrate tab cr 5 meq (540 mg) (Urocit-k
5)......................................................................................55
pot bicarbonate & chloride effer tab 25 meq................ 92
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral).................................. 92
PRADAXA – dabigatran etexilate mesylate cap 150 mg
(etexilate base eq)...........................................................96
PRADAXA – dabigatran etexilate mesylate cap 75 mg
(etexilate base eq)...........................................................96
150
pramipexole dihydrochloride tab 0.125 mg
(Mirapex)......................................................................... 81
pramipexole dihydrochloride tab 0.25 mg
(Mirapex)......................................................................... 81
pramipexole dihydrochloride tab 0.5 mg (Mirapex)......81
pramipexole dihydrochloride tab 0.75 mg
(Mirapex)......................................................................... 81
pramipexole dihydrochloride tab 1.5 mg (Mirapex)......82
pramipexole dihydrochloride tab 1 mg (Mirapex)........ 81
PRAMOSONE – pramoxine-hc cream 1-1%................... 107
PRAMOSONE – pramoxine-hc cream 1-2.5%................ 107
PRAMOTIC – pramoxine-chloroxylenol otic liquid
1-0.1%............................................................................101
pramoxine-chloroxylenol otic liquid 1-0.1%
(Pramotic)..................................................................... 101
pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1
mg/ml (Cortane-b aqueous)........................................101
pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml
(Cortane-b-otic)............................................................ 101
pramoxine-hc cream 1-2.5% (Pramosone).................. 107
PRANDIN – repaglinide tab 0.5 mg.................................. 22
PRANDIN – repaglinide tab 1 mg..................................... 22
PRANDIN – repaglinide tab 2 mg..................................... 22
PRAVACHOL – pravastatin sodium tab 20 mg................. 44
PRAVACHOL – pravastatin sodium tab 40 mg................. 44
PRAVACHOL – pravastatin sodium tab 80 mg................. 44
pravastatin sodium tab 10 mg....................................... 44
pravastatin sodium tab 20 mg (Pravachol)................... 44
pravastatin sodium tab 40 mg (Pravachol)................... 44
pravastatin sodium tab 80 mg (Pravachol)................... 44
prazosin hcl cap 1 mg (Minipress)................................ 39
prazosin hcl cap 2 mg (Minipress)................................ 39
prazosin hcl cap 5 mg (Minipress)................................ 39
PRECOSE – acarbose tab 100 mg...................................22
PRECOSE – acarbose tab 25 mg.................................... 22
PRECOSE – acarbose tab 50 mg.................................... 22
PRED FORTE – prednisolone acetate ophth susp 1%..... 99
PRED-G – gentamicin-prednisolone ace ophth susp
0.3-1%..............................................................................99
PRED MILD – prednisolone acetate ophth susp
0.12%...............................................................................99
prednicarbate cream 0.1% (Dermatop)........................107
prednicarbate oint 0.1% (Dermatop)............................107
prednisolone acetate ophth susp 1% (Pred forte)........99
PREDNISOLONE SODIUM PHOSP – prednisolone
sodium phosphate ophth soln 1%................................... 99
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)....................................................................15
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred).............................................15
prednisolone syrup 15 mg/5ml (usp solution
equivalent) (Prelone)..................................................... 15
PREDNISONE INTENSOL – prednisone conc 5 mg/
ml..................................................................................... 15
PREDNISONE – prednisone oral soln 5 mg/5ml.............. 15
PREDNISONE – prednisone tab 10 mg dose pack...........15
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
PREDNISONE – prednisone tab 50 mg............................15
PREDNISONE – prednisone tab 5 mg dose pack............ 15
prednisone tab 10 mg.....................................................15
prednisone tab 1 mg.......................................................15
prednisone tab 2.5 mg....................................................15
prednisone tab 20 mg.....................................................15
prednisone tab 5 mg.......................................................15
PREFERA OB + DHA – prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck....................................... 87
PREFERAOB ONE – prenat-fe poly cmplx-fe heme polyfa-dha cap 22-6-1-200 mg...............................................87
PREFERA OB – prenat vit-fe poly cmplx-fe heme poly-fa
tab 28-6-1 mg.................................................................. 87
PREFOL-DHA – prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 26-1.2-300 mg.......................................................... 87
PRELONE – prednisolone syrup 15 mg/5ml (usp solution
equivalent)....................................................................... 16
PREMARIN – estrogens, conjugated tab 0.3 mg.............. 17
PREMARIN – estrogens, conjugated tab 0.45 mg............ 17
PREMARIN – estrogens, conjugated tab 0.625 mg.......... 17
PREMARIN – estrogens, conjugated tab 0.9 mg.............. 17
PREMARIN – estrogens, conjugated tab 1.25 mg............ 17
PREMARIN – estrogens, conjugated vaginal cream 0.625
mg/gm.............................................................................. 55
PREMPHASE – conj est 0.625(14)/conj est-medroxypro
ac tab 0.625-5mg(14)...................................................... 17
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.3-1.5 mg.................................................... 18
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.45-1.5 mg.................................................. 18
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.625-2.5 mg................................................ 18
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.625-5 mg................................................... 18
PRENA1/QUATREFOLIC – prenat w/o a w/fefum-methfolfa-dha cap 30-0.6-0.4-200 mg.........................................89
PRENA1 CHEW – prenat w/ b2-b6-b12-d3-folic acid chew
tab 1.4 mg....................................................................... 89
PRENA1 PEARL – prenat w/oa w/fefum-na fered-fa-dha
cap cr 30-1.4-200 mg...................................................... 89
PRENA1 PLUS/QUATREFOLIC – prenat w/o a w/ fe
chelate-l methylfol-fa tab & dha cap pk........................... 89
PRENAISSANCE 90 DHA – prenat w/o a w/fecbn-fegldss-fa tab 90 &dha cap 300mg pak................................ 88
PRENAISSANCE BALANCE – prenatal w/o vit a w/ fe
cbn-dss-fa-dha cap 30-1-260 mg.................................... 87
PRENAISSANCE DHA – prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 250 mg pack............................................87
PRENAISSANCE HARMONY DHA – prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr 380mg....................... 87
PRENAISSANCE NEXT-B – prenatal w/ calcium-vit b6-faginger tab 1.22 mg.......................................................... 88
PRENAISSANCE NEXT – prenatal w/ calcium-vit b6-faginger tab 1.2 mg............................................................ 88
PRENAISSANCE PLUS – prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg...................................................... 88
PRENAISSANCE – prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg........................................................ 87
PRENAISSANCE PROMISE – prenat w/o a w/fecbn-fegldss-fa tab & dha cap 300 mg pack................................. 88
PRENAPLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 88
PRENATABS FA – prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................... 88
PRENATABS RX – prenatal vit w/ iron carbonyl-fa tab
29-1 mg........................................................................... 88
PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab
29-1 mg........................................................................... 88
PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab
29-1 mg........................................................................... 88
PRENATAL AD – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 88
PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa
tab 27-0.8 mg.................................................................. 88
PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa
tab 27-1 mg..................................................................... 88
PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fa
tab 27-0.8 mg.................................................................. 88
PRENATAL PLUS IRON – prenatal vit w/ iron carbonyl-fa
tab 29-1 mg..................................................................... 88
PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 88
PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8
mg.................................................................................... 88
PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 88
PRENATAL-U – prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg...................................................................... 88
PRENATAL VITAMINS PLUS – prenatal vit w/ fe
fumarate-fa tab 27-1 mg..................................................88
PRENATE AM – prenatal w/ calcium-vit b6-vit b12-faginger tab 1 mg............................................................... 88
PRENATE DHA – prenat w/o a w/feaspg-methfol-fa-dha
cap 18-0.6-0.4-300 mg.................................................... 88
PRENATE DHA – prenat w/o a w/fefum-methfol-fa-dha
cap 28-0.6-0.4-300 mg.................................................... 88
PRENATE ELITE – prenatal vit w/ fe fum-methylfolate-fa
tab 26-0.6-0.4 mg............................................................ 88
PRENATE ELITE – prenatal w/ fe asp gly-l methylfol-fa
tab 20-0.6-0.4 mg............................................................ 88
PRENATE ENHANCE – prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg............................................. 88
PRENATE ESSENTIAL – prenat w/o a w/feaspg-methfolfa-dha cap 18-0.6-0.4-300 mg.........................................88
PRENATE ESSENTIAL – prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg.......................................... 88
PRENATE MINI – prenat w/oa w/fecb-feasp-meth-fa-dha
cap 18-0.6-0.4-350 mg.................................................... 88
PRENATE PIXIE – prenat w/o a w/feaspg-methfol-fa-dha
cap 10-0.6-0.4-200 mg.................................................... 88
PRENATE – prenat mv & min w/ l-methylfolate-fa chew
tab 0.6-0.4 mg................................................................. 88
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
151
2015
PRENATE RESTORE – prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg............................................. 89
PRENATE STAR – prenatal vit w/ fe asparto glycinate-fa
tab 20-1 mg..................................................................... 89
PRENEXA – prenatal w/o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg............................................................... 89
PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 89
PREQUE 10 – prenatal mv w/fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg.............................................................. 89
PRETAB – prenatal vit w/ fe fumarate-fa tab 29-1 mg...... 89
PREVACID – lansoprazole cap delayed release 15
mg.................................................................................... 51
PREVACID – lansoprazole cap delayed release 30
mg.................................................................................... 51
PREVIDENT 5000 BOOSTER – sodium fluoride paste
1.1%...............................................................................101
PREVIDENT 5000 DRY MOUTH – sodium fluoride gel
1.1% (0.5% f).................................................................101
PREVIDENT 5000 ENAMEL PRO – sodium fluoridepotassium nitrate paste 1.1-5%..................................... 101
PREVIDENT 5000 PLUS – sodium fluoride cream
1.1%...............................................................................101
PREVIDENT 5000 SENSITIVE – sodium fluoridepotassium nitrate paste 1.1-5%..................................... 101
PREVIDENT FLUORIDE – sodium fluoride gel 1.1%
(0.5% f).......................................................................... 101
PREVIDENT – sodium fluoride rinse 0.2%..................... 101
PREVPAC – amoxicillin cap-clarithro tab-lansopraz cap dr
therapy pack.................................................................... 51
PREZISTA – darunavir ethanolate susp 100 mg/ml (base
equiv)................................................................................. 8
PREZISTA – darunavir ethanolate tab 150 mg (base
equiv)................................................................................. 8
PREZISTA – darunavir ethanolate tab 600 mg (base
equiv)................................................................................. 8
PREZISTA – darunavir ethanolate tab 75 mg (base
equiv)................................................................................. 8
PREZISTA – darunavir ethanolate tab 800 mg (base
equiv)................................................................................. 8
PRILOSEC – omeprazole cap delayed release 10 mg......51
PRILOSEC – omeprazole cap delayed release 20 mg......51
PRILOSEC – omeprazole cap delayed release 40 mg......51
PRIMAQUINE PHOSPHATE – primaquine phosphate tab
26.3 mg............................................................................10
primidone tab 250 mg (Mysoline).................................. 80
primidone tab 50 mg (Mysoline).................................... 80
PRINIVIL – lisinopril tab 10 mg.........................................39
PRINIVIL – lisinopril tab 20 mg.........................................39
PRINIVIL – lisinopril tab 5 mg...........................................39
PR NATAL 400 EC – prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk...................................................... 87
PR NATAL 400 – prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk....................................................... 87
PR NATAL 430 EC – prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk...................................................... 87
152
PR NATAL 430 – prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 430 pk....................................................... 87
PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).........................................................48
probenecid tab 500 mg...................................................76
PROCARDIA – nifedipine cap 10 mg............................... 32
PROCARDIA XL – nifedipine tab sr 24hr osmotic 30
mg.................................................................................... 32
PROCARDIA XL – nifedipine tab sr 24hr osmotic 60
mg.................................................................................... 32
PROCARDIA XL – nifedipine tab sr 24hr osmotic 90
mg.................................................................................... 32
prochlorperazine maleate tab 10 mg (Compazine).......61
prochlorperazine maleate tab 5 mg (Compazine).........62
prochlorperazine suppos 25 mg....................................62
PROCRIT – epoetin alfa inj 10000 unit/ml........................ 95
PROCRIT – epoetin alfa inj 20000 unit/ml........................ 95
PROCRIT – epoetin alfa inj 2000 unit/ml.......................... 94
PROCRIT – epoetin alfa inj 3000 unit/ml.......................... 94
PROCRIT – epoetin alfa inj 40000 unit/ml........................ 95
PROCRIT – epoetin alfa inj 4000 unit/ml.......................... 95
PROCTOCORT – hydrocortisone acetate suppos 30
mg.................................................................................. 102
PROCTOCORT – hydrocortisone rectal cream 1%........ 102
PROCTOFOAM HC – hydrocortisone acetate w/
pramoxine rectal foam 1-1%......................................... 102
PRODRIN – acetaminophen-isometheptene-caffeine tab
325-65-20 mg.................................................................. 76
progesterone im in oil 50 mg/ml....................................20
progesterone micronized cap 100 mg
(Prometrium).................................................................. 20
progesterone micronized cap 200 mg
(Prometrium).................................................................. 20
PROGRAF – tacrolimus cap 0.5 mg............................... 111
PROGRAF – tacrolimus cap 1 mg.................................. 111
PROGRAF – tacrolimus cap 5 mg.................................. 112
promethazine-dm syrup 6.25-15 mg/5ml....................... 47
promethazine hcl suppos 12.5 mg................................ 45
promethazine hcl suppos 25 mg................................... 45
promethazine hcl suppos 50 mg................................... 45
promethazine hcl syrup 6.25 mg/5ml............................ 46
promethazine hcl tab 12.5 mg........................................46
promethazine hcl tab 25 mg...........................................46
promethazine hcl tab 50 mg...........................................46
PROMETHAZINE VC/CODEINE – phenylephrinepromethazine w/ codeine syrup 5-6.25-10 mg/5ml.......... 46
PROMETHAZINE VC PLAIN – promethazine &
phenylephrine syrup 6.25-5 mg/5ml................................ 46
promethazine w/ codeine syrup 6.25-10 mg/5ml.......... 47
PROMETRIUM – progesterone micronized cap 100
mg.................................................................................... 20
PROMETRIUM – progesterone micronized cap 200
mg.................................................................................... 20
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 34
propafenone hcl cap sr 12hr 325 mg (Rythmol sr)....... 34
propafenone hcl cap sr 12hr 425 mg (Rythmol sr)....... 34
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
propafenone hcl tab 150 mg (Rythmol).........................34
propafenone hcl tab 225 mg (Rythmol).........................34
propafenone hcl tab 300 mg.......................................... 34
proparacaine hcl ophth soln 0.5% (Alcaine).................99
PROPRANOLOL/HYDROCHLOROTH – propranolol &
hydrochlorothiazide tab 40-25 mg................................... 39
PROPRANOLOL/HYDROCHLOROTH – propranolol &
hydrochlorothiazide tab 80-25 mg................................... 39
propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 30
propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 30
propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 30
propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 30
propranolol hcl tab 10 mg..............................................30
propranolol hcl tab 20 mg..............................................30
propranolol hcl tab 40 mg..............................................30
propranolol hcl tab 60 mg..............................................30
propranolol hcl tab 80 mg..............................................30
propylthiouracil tab 50 mg............................................. 24
PROSCAR – finasteride tab 5 mg.................................... 55
PROSED/DS – methenamine-hyosc-meth blue-benz acidphenyl sal tab 81.6mg..................................................... 54
PROTONIX – pantoprazole sodium ec tab 20 mg (base
equiv)............................................................................... 51
PROTONIX – pantoprazole sodium ec tab 40 mg (base
equiv)............................................................................... 51
PROTOPIC – tacrolimus oint 0.03%............................... 107
PROTOPIC – tacrolimus oint 0.1%................................. 107
protriptyline hcl tab 10 mg (Vivactil)............................. 59
protriptyline hcl tab 5 mg (Vivactil)............................... 59
PROVERA – medroxyprogesterone acetate tab 10
mg.................................................................................... 20
PROVERA – medroxyprogesterone acetate tab 2.5
mg.................................................................................... 20
PROVERA – medroxyprogesterone acetate tab 5 mg...... 20
PROVIDA OB – prenatal w/o a w/fe fum-fe poly-fa cap
20-20-1.25 mg................................................................. 89
PROVIGIL – modafinil tab 100 mg................................... 66
PROVIGIL – modafinil tab 200 mg................................... 66
PROZAC – fluoxetine hcl cap 10 mg................................ 59
PROZAC – fluoxetine hcl cap 20 mg................................ 59
PROZAC – fluoxetine hcl cap 40 mg................................ 59
PROZAC WEEKLY – fluoxetine hcl cap delayed release
90 mg...............................................................................59
PULMICORT – budesonide inhalation susp 0.25
mg/2ml............................................................................. 48
PULMICORT – budesonide inhalation susp 0.5
mg/2ml............................................................................. 48
PULMOZYME – dornase alfa inhal soln 1 mg/ml..............49
PUREFE OB PLUS – prenatal w/o a w/fe fum-fe poly-fa
cap 162.115.2-1 mg........................................................ 89
PURINETHOL – mercaptopurine tab 50 mg..................... 13
pyrazinamide tab 500 mg................................................. 5
PYRIDIUM – phenazopyridine hcl tab 100 mg..................55
PYRIDIUM – phenazopyridine hcl tab 200 mg..................55
pyridostigmine bromide tab 60 mg (Mestinon).............83
Q
QNASL – beclomethasone dipropionate nasal aerosol 80
mcg/act............................................................................ 46
QNASL CHILDRENS – beclomethasone dipropionate
nasal aerosol 40 mcg/act................................................ 46
QUARTETTE – levonor-eth est tab 0.15-0.02/0.025/0.03
mg &eth est 0.01 mg.......................................................20
QUESTRAN – cholestyramine powder 4 gm/dose............44
QUESTRAN – cholestyramine powder packets 4 gm....... 44
QUESTRAN LIGHT – cholestyramine light powder 4 gm/
dose................................................................................. 44
quetiapine fumarate tab 100 mg (Seroquel)..................62
quetiapine fumarate tab 200 mg (Seroquel)..................62
quetiapine fumarate tab 25 mg (Seroquel)....................62
quetiapine fumarate tab 300 mg (Seroquel)..................62
quetiapine fumarate tab 400 mg (Seroquel)..................62
quetiapine fumarate tab 50 mg (Seroquel)....................62
QUFLORA PEDIATRIC – pediatric multiple vitamins w/
fluoride chew tab 0.25 mg...............................................89
QUFLORA PEDIATRIC – pediatric multiple vitamins w/
fluoride chew tab 1 mg....................................................89
QUFLORA PEDIATRIC – pediatric multiple vitamins w/
fluoride soln 0.25 mg/ml.................................................. 89
QUFLORA PEDIATRIC – pediatric multiple vitamins w/
fluoride soln 0.5 mg/ml.................................................... 89
quinapril hcl tab 10 mg (Accupril)................................. 39
quinapril hcl tab 20 mg (Accupril)................................. 39
quinapril hcl tab 40 mg (Accupril)................................. 39
quinapril hcl tab 5 mg (Accupril)................................... 39
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)...................................................................... 39
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)...................................................................... 40
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)...................................................................... 40
quinidine gluconate tab cr 324 mg................................34
QUINIDINE SULFATE – quinidine sulfate tab 200 mg...... 34
quinidine sulfate tab 300 mg..........................................34
R
rabeprazole sodium ec tab 20 mg (Aciphex)................ 51
raloxifene hcl tab 60 mg (Evista)................................... 27
ramipril cap 1.25 mg (Altace)......................................... 40
ramipril cap 10 mg (Altace)............................................ 40
ramipril cap 2.5 mg (Altace)........................................... 40
ramipril cap 5 mg (Altace)..............................................40
RANEXA – ranolazine tab sr 12hr 1000 mg......................29
RANEXA – ranolazine tab sr 12hr 500 mg....................... 29
ranitidine hcl cap 150 mg...............................................51
ranitidine hcl cap 300 mg...............................................51
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 51
ranitidine hcl tab 150 mg (Zantac).................................51
ranitidine hcl tab 300 mg (Zantac).................................51
RAPAMUNE – sirolimus oral soln 1 mg/ml..................... 112
RAPAMUNE – sirolimus tab 0.5 mg............................... 112
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
153
2015
RAPAMUNE – sirolimus tab 1 mg.................................. 112
RAPAMUNE – sirolimus tab 2 mg.................................. 112
RAZADYNE ER – galantamine hydrobromide cap sr 24hr
16 mg...............................................................................67
RAZADYNE ER – galantamine hydrobromide cap sr 24hr
24 mg...............................................................................67
RAZADYNE ER – galantamine hydrobromide cap sr 24hr
8 mg.................................................................................67
RAZADYNE – galantamine hydrobromide oral soln 4 mg/
ml..................................................................................... 67
RAZADYNE – galantamine hydrobromide tab 12 mg....... 67
RAZADYNE – galantamine hydrobromide tab 4 mg......... 67
RAZADYNE – galantamine hydrobromide tab 8 mg......... 67
REAPHIRM – prenatal mv w/ fe polysac cmplx-fa-dha cap
29-1-200 mg.................................................................... 89
REBETOL – ribavirin cap 200 mg.......................................8
REBIF – interferon beta-1a inj 22 mcg/0.5ml (12mu/ml)
(44 mcg/ml)......................................................................67
REBIF – interferon beta-1a inj 44 mcg/0.5ml (24mu/ml)
(88 mcg/ml)......................................................................68
REBIF REBIDOSE – interferon beta-1a inj 22 mcg/0.5ml
(12mu/ml) (44 mcg/ml).................................................... 68
REBIF REBIDOSE – interferon beta-1a inj 44 mcg/0.5ml
(24mu/ml) (88 mcg/ml).................................................... 68
REBIF REBIDOSE TITRATION – interferon beta-1a inj 6 x
8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml..................................68
REBIF TITRATION PACK – interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml........................................68
REGLAN – metoclopramide hcl tab 10 mg....................... 53
REGLAN – metoclopramide hcl tab 5 mg......................... 53
RELION R – insulin regular (human) inj 100 unit/ml..........23
RELNATE DHA – prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................... 89
REMERON – mirtazapine tab 15 mg................................ 59
REMERON – mirtazapine tab 30 mg................................ 59
REMERON – mirtazapine tab 45 mg................................ 59
REMERON SOLTAB – mirtazapine orally disintegrating
tab 15 mg........................................................................ 59
REMERON SOLTAB – mirtazapine orally disintegrating
tab 30 mg........................................................................ 59
REMERON SOLTAB – mirtazapine orally disintegrating
tab 45 mg........................................................................ 59
RENAGEL – sevelamer hcl tab 400 mg............................53
RENAGEL – sevelamer hcl tab 800 mg............................53
RENVELA – sevelamer carbonate packet 0.8 gm.............53
RENVELA – sevelamer carbonate packet 2.4 gm.............53
RENVELA – sevelamer carbonate tab 800 mg................. 53
repaglinide tab 0.5 mg (Prandin)................................... 22
repaglinide tab 1 mg (Prandin)...................................... 22
repaglinide tab 2 mg (Prandin)...................................... 22
REPREXAIN – hydrocodone-ibuprofen tab 2.5-200
mg.................................................................................... 72
REPREXAIN – hydrocodone-ibuprofen tab 5-200 mg.......72
REPRONEX – Benefit Limits may apply – menotropins for
inj 75 unit.........................................................................27
REQUIP – ropinirole hydrochloride tab 0.25 mg............... 82
154
REQUIP – ropinirole hydrochloride tab 0.5 mg................. 82
REQUIP – ropinirole hydrochloride tab 1 mg.................... 82
REQUIP – ropinirole hydrochloride tab 2 mg.................... 82
REQUIP – ropinirole hydrochloride tab 3 mg.................... 82
REQUIP – ropinirole hydrochloride tab 4 mg.................... 82
REQUIP – ropinirole hydrochloride tab 5 mg.................... 82
REQUIP XL – ropinirole hydrochloride tab sr 24hr 12 mg
(base equivalent)............................................................. 82
REQUIP XL – ropinirole hydrochloride tab sr 24hr 2 mg
(base equivalent)............................................................. 82
REQUIP XL – ropinirole hydrochloride tab sr 24hr 4 mg
(base equivalent)............................................................. 82
REQUIP XL – ropinirole hydrochloride tab sr 24hr 6 mg
(base equivalent)............................................................. 82
REQUIP XL – ropinirole hydrochloride tab sr 24hr 8 mg
(base equivalent)............................................................. 82
RESCRIPTOR – delavirdine mesylate tab 100 mg............. 8
RESCRIPTOR – delavirdine mesylate tab 200 mg............. 8
RESERPINE – reserpine tab 0.1 mg................................ 40
RESERPINE – reserpine tab 0.25 mg.............................. 40
RESTORIL – temazepam cap 15 mg............................... 63
RESTORIL – temazepam cap 22.5 mg............................ 63
RESTORIL – temazepam cap 30 mg............................... 63
RESTORIL – temazepam cap 7.5 mg.............................. 63
RETIN-A – tretinoin cream 0.025%.................................107
RETIN-A – tretinoin cream 0.05%...................................107
RETIN-A – tretinoin cream 0.1%.....................................108
RETIN-A – tretinoin gel 0.01%........................................108
RETIN-A – tretinoin gel 0.025%......................................108
RETROVIR – zidovudine cap 100 mg................................ 8
RETROVIR – zidovudine syrup 10 mg/ml...........................8
REVATIO – sildenafil citrate tab 20 mg............................ 45
REVIA – naltrexone hcl tab 50 mg..................................110
REVLIMID – lenalidomide cap 10 mg............................. 112
REVLIMID – lenalidomide cap 15 mg............................. 112
REVLIMID – lenalidomide cap 20 mg............................. 112
REVLIMID – lenalidomide cap 25 mg............................. 112
REVLIMID – lenalidomide cap 5 mg............................... 112
REVLIMID – lenalidomide caps 2.5 mg.......................... 112
REYATAZ – atazanavir sulfate cap 150 mg (base
equiv)................................................................................. 8
REYATAZ – atazanavir sulfate cap 200 mg (base
equiv)................................................................................. 8
REYATAZ – atazanavir sulfate cap 300 mg (base
equiv)................................................................................. 8
REYATAZ – atazanavir sulfate oral powder packet 50 mg
(base equiv).......................................................................8
RHINOCORT AQUA – budesonide nasal susp 32 mcg/
act.................................................................................... 46
RIBASPHERE RIBAPAK – ribavirin tab 400 mg................. 8
RIBASPHERE RIBAPAK – ribavirin tab 400 mg & ribavirin
tab 600 mg dose pack...................................................... 8
RIBASPHERE RIBAPAK – ribavirin tab 600 mg................. 8
RIBASPHERE – ribavirin tab 400 mg................................. 8
RIBASPHERE – ribavirin tab 600 mg................................. 8
RIBATAB – ribavirin tab 400 mg.........................................8
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
RIBATAB – ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.......................................................................... 9
RIBATAB – ribavirin tab 600 mg.........................................8
ribavirin cap 200 mg (Rebetol).........................................9
ribavirin tab 200 mg (Copegus)....................................... 9
RIFADIN – rifampin cap 150 mg.........................................5
RIFADIN – rifampin cap 300 mg.........................................5
RIFAMATE – isoniazid & rifampin cap 150-300 mg............ 5
rifampin cap 150 mg (Rifadin)..........................................5
rifampin cap 300 mg (Rifadin)..........................................5
RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fa
tab 27-0.8 mg.................................................................. 89
RILUTEK – riluzole tab 50 mg.......................................... 83
riluzole tab 50 mg (Rilutek)............................................ 83
rimantadine hydrochloride tab 100 mg (Flumadine)...... 9
RIOMET – metformin hcl oral soln 500 mg/5ml................ 22
risedronate sodium tab 150 mg (Actonel).....................27
RISPERDAL M-TAB – risperidone orally disintegrating tab
0.5 mg..............................................................................62
RISPERDAL M-TAB – risperidone orally disintegrating tab
1 mg.................................................................................62
RISPERDAL M-TAB – risperidone orally disintegrating tab
2 mg.................................................................................62
RISPERDAL M-TAB – risperidone orally disintegrating tab
3 mg.................................................................................62
RISPERDAL M-TAB – risperidone orally disintegrating tab
4 mg.................................................................................62
RISPERDAL – risperidone soln 1 mg/ml...........................62
RISPERDAL – risperidone tab 0.25 mg............................ 62
RISPERDAL – risperidone tab 0.5 mg..............................62
RISPERDAL – risperidone tab 1 mg.................................62
RISPERDAL – risperidone tab 2 mg.................................62
RISPERDAL – risperidone tab 3 mg.................................62
RISPERDAL – risperidone tab 4 mg.................................62
risperidone orally disintegrating tab 0.25 mg...............62
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab).............................................................................. 62
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab).............................................................................. 62
risperidone orally disintegrating tab 2 mg (Risperdal
m-tab).............................................................................. 62
risperidone orally disintegrating tab 3 mg (Risperdal
m-tab).............................................................................. 62
risperidone orally disintegrating tab 4 mg (Risperdal
m-tab).............................................................................. 62
risperidone soln 1 mg/ml (Risperdal)............................62
risperidone tab 0.25 mg (Risperdal).............................. 62
risperidone tab 0.5 mg (Risperdal)................................ 62
risperidone tab 1 mg (Risperdal)................................... 62
risperidone tab 2 mg (Risperdal)................................... 62
risperidone tab 3 mg (Risperdal)................................... 62
risperidone tab 4 mg (Risperdal)................................... 62
RITALIN LA – methylphenidate hcl cap sr 24hr 10 mg......66
RITALIN LA – methylphenidate hcl cap sr 24hr 20 mg......66
RITALIN LA – methylphenidate hcl cap sr 24hr 30 mg......66
RITALIN LA – methylphenidate hcl cap sr 24hr 40 mg......66
RITALIN – methylphenidate hcl tab 10 mg....................... 66
RITALIN – methylphenidate hcl tab 20 mg....................... 66
RITALIN – methylphenidate hcl tab 5 mg......................... 66
rivastigmine tartrate cap 1.5 mg (Exelon)..................... 68
rivastigmine tartrate cap 3 mg (Exelon)........................68
rivastigmine tartrate cap 4.5 mg (Exelon)..................... 68
rivastigmine tartrate cap 6 mg (Exelon)........................68
rizatriptan benzoate orally disintegrating tab 10 mg
(Maxalt-mlt).....................................................................76
rizatriptan benzoate orally disintegrating tab 5 mg
(Maxalt-mlt).....................................................................76
rizatriptan benzoate tab 10 mg (Maxalt)........................76
rizatriptan benzoate tab 5 mg (Maxalt)..........................76
R-NATAL OB – prenatal w/o a w/fe cbn-fa-dha cap
20-1-320 mg.................................................................... 89
ROBAXIN-750 – methocarbamol tab 750 mg................... 83
ROBAXIN – methocarbamol tab 500 mg.......................... 83
ROBINUL FORTE – glycopyrrolate tab 2 mg....................51
ROBINUL – glycopyrrolate tab 1 mg.................................51
ROCALTROL – calcitriol cap 0.25 mcg.............................27
ROCALTROL – calcitriol cap 0.5 mcg.............................. 27
ROCALTROL – calcitriol oral soln 1 mcg/ml..................... 28
ropinirole hydrochloride tab 0.25 mg (Requip).............82
ropinirole hydrochloride tab 0.5 mg (Requip)...............82
ropinirole hydrochloride tab 1 mg (Requip)................. 82
ropinirole hydrochloride tab 2 mg (Requip)................. 82
ropinirole hydrochloride tab 3 mg (Requip)................. 82
ropinirole hydrochloride tab 4 mg (Requip)................. 82
ropinirole hydrochloride tab 5 mg (Requip)................. 82
ropinirole hydrochloride tab sr 24hr 12 mg (base
equivalent) (Requip xl).................................................. 82
ropinirole hydrochloride tab sr 24hr 2 mg (base
equivalent) (Requip xl).................................................. 82
ropinirole hydrochloride tab sr 24hr 4 mg (base
equivalent) (Requip xl).................................................. 82
ropinirole hydrochloride tab sr 24hr 6 mg (base
equivalent) (Requip xl).................................................. 82
ropinirole hydrochloride tab sr 24hr 8 mg (base
equivalent) (Requip xl).................................................. 82
ROWASA – mesalamine rectal enema 4 gm & cleanser
wipe kit.............................................................................53
ROXICODONE – oxycodone hcl tab 15 mg......................73
ROXICODONE – oxycodone hcl tab 30 mg......................73
ROXICODONE – oxycodone hcl tab 5 mg........................72
RYTHMOL – propafenone hcl tab 150 mg........................34
RYTHMOL – propafenone hcl tab 225 mg........................34
RYTHMOL SR – propafenone hcl cap sr 12hr 225 mg..... 34
RYTHMOL SR – propafenone hcl cap sr 12hr 325 mg..... 34
RYTHMOL SR – propafenone hcl cap sr 12hr 425 mg..... 34
S
SALAGEN – pilocarpine hcl tab 5 mg............................. 101
SALAGEN – pilocarpine hcl tab 7.5 mg.......................... 101
SALEX CREAM – salicylic acid cream 6% & cleanser liqd
kit................................................................................... 108
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
155
2015
SALEX LOTION – salicylic acid lotion 6% & cleanser liqd
kit................................................................................... 108
SALEX – salicylic acid shampoo 6%.............................. 108
salicylic acid cream 6%................................................ 108
salicylic acid cream 6% & cleanser liqd kit (Salex
cream)........................................................................... 108
salicylic acid film forming liquid 27.5% (Virasal)........108
salicylic acid foam 6% (Salvax)................................... 108
salicylic acid gel 6% (Keralyt)......................................108
salicylic acid lotion 6%.................................................108
salicylic acid lotion 6% & cleanser liqd kit (Salex
lotion)............................................................................ 108
SALICYLIC ACID – salicylic acid soln 26%.................... 108
salicylic acid shampoo 6% (Salex).............................. 108
salsalate tab 500 mg....................................................... 68
salsalate tab 750 mg....................................................... 68
SALVAX – salicylic acid foam 6%...................................108
SAMSCA – tolvaptan tab 15 mg....................................... 28
SAMSCA – tolvaptan tab 30 mg....................................... 28
SANDIMMUNE – cyclosporine cap 100 mg.................... 112
SANDIMMUNE – cyclosporine cap 25 mg...................... 112
SANDIMMUNE – cyclosporine oral soln 100 mg/ml........112
SANDOSTATIN – octreotide acetate inj 1000 mcg/ml (1
mg/ml).............................................................................. 28
SANDOSTATIN – octreotide acetate inj 100 mcg/ml (0.1
mg/ml).............................................................................. 28
SANDOSTATIN – octreotide acetate inj 200 mcg/ml (0.2
mg/ml).............................................................................. 28
SANDOSTATIN – octreotide acetate inj 500 mcg/ml (0.5
mg/ml).............................................................................. 28
SANDOSTATIN – octreotide acetate inj 50 mcg/ml (0.05
mg/ml).............................................................................. 28
SEASONIQUE – levonorg-eth est tab 0.15-0.03mg(84) &
eth est tab 0.01mg(7)...................................................... 20
SECTRAL – acebutolol hcl cap 200 mg............................30
SECTRAL – acebutolol hcl cap 400 mg............................30
SELECT-OB+DHA – prenatal mv w/fe poly-fa chw 29-1
mg & dha cap 250 mg pak ............................................ 89
SELECT-OB – prenatal vit w/ fe polysac cmplx-fa chew
tab 29-1 mg..................................................................... 89
SELECT-OB – prenat w/ fepolycmplx-methylfol-fa chew
tab 29-0.6-0.4 mg............................................................ 89
selegiline hcl cap 5 mg (Eldepryl)................................. 82
selegiline hcl tab 5 mg................................................... 82
selenium sulfide lotion 2.5%........................................ 108
SELENIUM SULFIDE – selenium sulfide-pyrithione zinc in
urea shampoo 2.25%.................................................... 108
SELZENTRY – maraviroc tab 150 mg................................ 9
SELZENTRY – maraviroc tab 300 mg................................ 9
SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................... 89
SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab
29-1 mg........................................................................... 89
SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)......... 28
SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)......... 28
SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)......... 28
156
SEREVENT DISKUS – salmeterol xinafoate aer pow ba
50 mcg/dose (base equiv)............................................... 48
SEROQUEL – quetiapine fumarate tab 100 mg................62
SEROQUEL – quetiapine fumarate tab 200 mg................62
SEROQUEL – quetiapine fumarate tab 25 mg..................62
SEROQUEL – quetiapine fumarate tab 300 mg................62
SEROQUEL – quetiapine fumarate tab 400 mg................62
SEROQUEL – quetiapine fumarate tab 50 mg..................62
sertraline hcl oral conc 20 mg/ml (Zoloft).....................59
sertraline hcl tab 100 mg (Zoloft).................................. 59
sertraline hcl tab 25 mg (Zoloft).................................... 60
sertraline hcl tab 50 mg (Zoloft).................................... 60
SE-TAN DHA – prenatal w/fe fum-fe poly -fa-omega 3 cap
15-15-1 mg...................................................................... 89
SETON ET-EC – prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk...................................................... 89
SETONET – prenat-fe bis-fe prot succ-fa-ca tab & omega
3 cap 430 pk................................................................... 89
SHOHLS SOLUTION MODIFIED – sodium citrate & citric
acid soln 500-334 mg/5ml............................................... 55
SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (base
equiv)............................................................................... 28
SIGNIFOR – pasireotide diaspartate inj 0.6 mg/ml (base
equiv)............................................................................... 28
SIGNIFOR – pasireotide diaspartate inj 0.9 mg/ml (base
equiv)............................................................................... 28
sildenafil citrate tab 20 mg (Revatio).............................45
SILVADENE – silver sulfadiazine cream 1%...................108
silver nitrate-potassium nitrate applicator 75-25%
(Arzol silver nitrate).....................................................108
silver sulfadiazine cream 1% (Silvadene)................... 108
SIMBRINZA – brinzolamide-brimonidine tartrate ophth
susp 1-0.2%.....................................................................99
SIMPONI – golimumab subcutaneous soln auto-injector
100 mg/ml........................................................................75
SIMPONI – golimumab subcutaneous soln auto-injector
50 mg/0.5ml.....................................................................75
SIMPONI – golimumab subcutaneous soln prefilled
syringe 100 mg/ml........................................................... 75
SIMPONI – golimumab subcutaneous soln prefilled
syringe 50 mg/0.5ml........................................................ 75
simvastatin tab 10 mg (Zocor)....................................... 44
simvastatin tab 20 mg (Zocor)....................................... 44
simvastatin tab 40 mg (Zocor)....................................... 44
simvastatin tab 5 mg (Zocor)......................................... 44
simvastatin tab 80 mg (Zocor)....................................... 44
SINEMET – carbidopa & levodopa tab 10-100 mg............82
SINEMET – carbidopa & levodopa tab 25-100 mg............82
SINEMET – carbidopa & levodopa tab 25-250 mg............82
SINEMET CR – carbidopa & levodopa tab cr 25-100
mg.................................................................................... 82
SINEMET CR – carbidopa & levodopa tab cr 50-200
mg.................................................................................... 82
SINGULAIR – montelukast sodium chew tab 4 mg (base
equiv)............................................................................... 48
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
SINGULAIR – montelukast sodium chew tab 5 mg (base
equiv)............................................................................... 49
SINGULAIR – montelukast sodium tab 10 mg (base
equiv)............................................................................... 48
sirolimus tab 0.5 mg (Rapamune)................................112
sirolimus tab 1 mg (Rapamune)...................................112
sirolimus tab 2 mg (Rapamune)...................................112
SKELAXIN – metaxalone tab 800 mg...............................83
sodium chloride irrigation soln 0.9%............................ 55
sodium chloride soln nebu 0.9%................................... 47
sodium chloride soln nebu 3%...................................... 47
sodium chloride soln nebu 7% (Hyper-sal)...................47
sodium citrate & citric acid soln 500-334 mg/5ml
(Shohls solution modi)..................................................55
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride)............................................................................93
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride)............................................................................93
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride)............................................................................93
sodium fluoride cream 1.1% (Prevident 5000
plus).............................................................................. 101
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride).........................................................................101
sodium fluoride paste 1.1% (Prevident 5000
boost)............................................................................ 101
sodium fluoride-potassium nitrate paste 1.1-5%
(Prevident 5000 sensi).................................................101
sodium fluoride rinse 0.2% (Prevident).......................101
SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from
2.2 mg naf)...................................................................... 93
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf).................................................................................. 93
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride)............................................................................93
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl)...................................................................... 28
sodium polystyrene sulfonate powder
(Kayexalate)..................................................................112
sodium thiosulfate-salicylic acid lotion 25-1%........... 108
SOMA – carisoprodol tab 350 mg.....................................83
SONATA – zaleplon cap 10 mg........................................63
SONATA – zaleplon cap 5 mg..........................................63
SORIATANE – acitretin cap 10 mg.................................108
SORIATANE – acitretin cap 17.5 mg..............................108
SORIATANE – acitretin cap 25 mg.................................108
sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 30
sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 30
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 30
sotalol hcl tab 120 mg (Betapace)................................. 30
sotalol hcl tab 160 mg (Betapace)................................. 30
sotalol hcl tab 240 mg.................................................... 30
sotalol hcl tab 80 mg (Betapace)................................... 30
SOVALDI – sofosbuvir tab 400 mg.....................................9
SPIRIVA HANDIHALER – tiotropium bromide
monohydrate inhal cap 18 mcg (base equiv)...................49
SPIRIVA RESPIMAT – tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act................................................ 49
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide)...................................................................42
spironolactone tab 100 mg (Aldactone)........................ 42
spironolactone tab 25 mg (Aldactone).......................... 42
spironolactone tab 50 mg (Aldactone).......................... 42
SPORANOX – itraconazole cap 100 mg.............................6
SPORANOX PULSEPAK – itraconazole cap 100 mg......... 6
SPRYCEL – dasatinib tab 100 mg....................................13
SPRYCEL – dasatinib tab 140 mg....................................13
SPRYCEL – dasatinib tab 20 mg......................................13
SPRYCEL – dasatinib tab 50 mg......................................13
SPRYCEL – dasatinib tab 70 mg......................................13
SPRYCEL – dasatinib tab 80 mg......................................13
SPS – sodium polystyrene sulfonate oral susp 15
gm/60ml......................................................................... 112
STALEVO 100 – carbidopa-levodopa-entacapone tabs
25-100-200 mg................................................................ 82
STALEVO 125 – carbidopa-levodopa-entacapone tabs
31.25-125-200 mg........................................................... 82
STALEVO 150 – carbidopa-levodopa-entacapone tabs
37.5-150-200 mg............................................................. 82
STALEVO 200 – carbidopa-levodopa-entacapone tabs
50-200-200 mg................................................................ 83
STALEVO 50 – carbidopa-levodopa-entacapone tabs
12.5-50-200 mg............................................................... 83
STALEVO 75 – carbidopa-levodopa-entacapone tabs
18.75-75-200 mg............................................................. 83
stannous fluoride conc 0.63% (Gel-kam oral care
ri)................................................................................... 101
STARLIX – nateglinide tab 120 mg...................................22
STARLIX – nateglinide tab 60 mg.................................... 22
stavudine cap 15 mg (Zerit)............................................. 9
stavudine cap 20 mg (Zerit)............................................. 9
stavudine cap 30 mg (Zerit)............................................. 9
stavudine cap 40 mg (Zerit)............................................. 9
stavudine for oral soln 1 mg/ml (Zerit)............................9
STELARA – ustekinumab soln prefilled syringe 45
mg/0.5ml........................................................................ 108
STELARA – ustekinumab soln prefilled syringe 90 mg/
ml................................................................................... 108
STRIBILD – elvitegrav-cobicis-emtricitab-tenofov tab
150-150-200-300 mg......................................................... 9
STROMECTOL – ivermectin tab 3 mg..............................10
STROVITE – b-complex w/ c & folic acid tab....................89
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3
mg (base equiv)...............................................................73
SUBOXONE – buprenorphine hcl-naloxone hcl sl film
2-0.5 mg (base equiv)..................................................... 73
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv)...............................................................73
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2
mg (base equiv)...............................................................73
sucralfate tab 1 gm (Carafate)....................................... 51
SULAR – nisoldipine tab sr 24hr 17 mg............................32
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
157
2015
SULAR – nisoldipine tab sr 24hr 34 mg............................33
SULAR – nisoldipine tab sr 24hr 8.5 mg...........................32
sulfacetamide sodium liquid 10% (Ovace wash)........ 108
sulfacetamide sodium lotion 10% (acne) (Klaron)......108
sulfacetamide sodium ophth soln 10% (Bleph-10).......99
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%................................................................ 99
SULFACETAMIDE SODIUM – sulfacetamide sodium
ophth oint 10%................................................................ 99
sulfacetamide sodium-sulfur in urea emulsion
10-4%.............................................................................108
sulfacetamide sodium-sulfur w/ sunscreens cream
10-5% ........................................................................... 108
sulfacetamide sodium w/ sulfur cleansing pad 10-4%
(Sumaxin)......................................................................108
sulfacetamide sodium w/ sulfur cream 10-5%............ 108
sulfacetamide sodium w/ sulfur emulsion 10-1%....... 108
sulfacetamide sodium w/ sulfur emulsion 10-5%....... 108
sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam
ef)...................................................................................108
sulfacetamide sodium w/ sulfur lotion 10-5%.............108
sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin
ts)...................................................................................108
sulfacetamide sodium w/ sulfur wash 9-4.5%
(Sumadan wash).......................................................... 108
sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin
wash).............................................................................108
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml............................................................................ 11
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)......................................................................... 11
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds)....................................................................11
SULFAMYLON – mafenide acetate packet for topical soln
5% (50 gm)....................................................................108
sulfasalazine tab 500 mg (Azulfidine)........................... 53
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 53
sulindac tab 150 mg........................................................75
sulindac tab 200 mg........................................................75
SUMADAN WASH – sulfacetamide sodium w/ sulfur wash
9-4.5%............................................................................108
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............ 76
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)................................... 76
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)................................... 76
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref)..................................................... 76
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref)..................................................... 76
SUMATRIPTAN SUCCINATE – sumatriptan succinate inj
4 mg/0.5ml.......................................................................76
SUMATRIPTAN SUCCINATE – sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml............................... 76
sumatriptan succinate tab 100 mg (Imitrex)................. 76
158
sumatriptan succinate tab 25 mg (Imitrex)................... 76
sumatriptan succinate tab 50 mg (Imitrex)................... 76
SUMATRIPTAN – sumatriptan nasal spray 20 mg/act...... 76
SUMATRIPTAN – sumatriptan nasal spray 5 mg/act........ 76
SUMAXIN – sulfacetamide sodium w/ sulfur cleansing pad
10-4%.............................................................................108
SUMAXIN TS – sulfacetamide sodium w/ sulfur susp
8-4%...............................................................................109
SUMAXIN WASH – sulfacetamide sodium w/ sulfur wash
9-4%...............................................................................109
SUPRAX – cefixime cap 400 mg........................................ 2
SUPRAX – cefixime for susp 100 mg/5ml.......................... 2
SUPRAX – cefixime for susp 200 mg/5ml.......................... 2
SUPRAX – cefixime for susp 500 mg/5ml.......................... 2
SURESTEP PRO TEST STRIPS – glucose blood test
strip................................................................................ 110
SUSTIVA – efavirenz cap 200 mg...................................... 9
SUSTIVA – efavirenz cap 50 mg........................................ 9
SUSTIVA – efavirenz tab 600 mg.......................................9
SUTENT – sunitinib malate cap 12.5 mg (base
equivalent)....................................................................... 13
SUTENT – sunitinib malate cap 25 mg (base
equivalent)....................................................................... 13
SUTENT – sunitinib malate cap 37.5 mg (base
equivalent)....................................................................... 13
SUTENT – sunitinib malate cap 50 mg (base
equivalent)....................................................................... 13
SYLATRON – peginterferon alfa-2b for inj kit 296 mcg..... 13
SYLATRON – peginterferon alfa-2b for inj kit 444 mcg..... 13
SYLATRON – peginterferon alfa-2b for inj kit 4 x 296
mcg.................................................................................. 13
SYLATRON – peginterferon alfa-2b for inj kit 4 x 444
mcg.................................................................................. 14
SYLATRON – peginterferon alfa-2b for inj kit 888 mcg..... 13
SYMAX DUOTAB – hyoscyamine sulfate tab cr 0.375 mg
(0.125 mg ir/0.25 mg cr)..................................................52
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act.................................................. 49
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act.................................................... 49
SYMBYAX – olanzapine-fluoxetine hcl cap 12-25 mg.......68
SYMBYAX – olanzapine-fluoxetine hcl cap 12-50 mg.......68
SYMBYAX – olanzapine-fluoxetine hcl cap 3-25 mg.........68
SYMBYAX – olanzapine-fluoxetine hcl cap 6-25 mg.........68
SYMBYAX – olanzapine-fluoxetine hcl cap 6-50 mg.........68
SYNALAR – fluocinolone acetonide cream 0.025%........ 109
SYNALAR – fluocinolone acetonide oint 0.025%............ 109
SYNTHROID – levothyroxine sodium tab 100 mcg...........24
SYNTHROID – levothyroxine sodium tab 112 mcg...........24
SYNTHROID – levothyroxine sodium tab 125 mcg...........24
SYNTHROID – levothyroxine sodium tab 137 mcg...........24
SYNTHROID – levothyroxine sodium tab 150 mcg...........24
SYNTHROID – levothyroxine sodium tab 175 mcg...........24
SYNTHROID – levothyroxine sodium tab 200 mcg...........24
SYNTHROID – levothyroxine sodium tab 25 mcg.............24
SYNTHROID – levothyroxine sodium tab 300 mcg...........24
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
SYNTHROID – levothyroxine sodium tab 50 mcg.............24
SYNTHROID – levothyroxine sodium tab 75 mcg.............24
SYNTHROID – levothyroxine sodium tab 88 mcg.............24
T
TABLOID – thioguanine tab 40 mg................................... 14
TACLONEX – calcipotriene-betamethasone dipropionate
oint 0.005-0.064%..........................................................109
TACLONEX – calcipotriene-betamethasone dipropionate
susp 0.005-0.064%........................................................109
tacrolimus cap 0.5 mg (Prograf).................................. 112
tacrolimus cap 1 mg (Prograf)..................................... 112
tacrolimus cap 5 mg (Prograf)..................................... 112
tacrolimus oint 0.03% (Protopic)................................. 109
tacrolimus oint 0.1% (Protopic)................................... 109
TAMIFLU – oseltamivir phosphate cap 30 mg (base
equiv)................................................................................. 9
TAMIFLU – oseltamivir phosphate cap 45 mg (base
equiv)................................................................................. 9
TAMIFLU – oseltamivir phosphate cap 75 mg (base
equiv)................................................................................. 9
TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base
equiv)................................................................................. 9
tamoxifen citrate tab 10 mg (base equivalent)............. 14
tamoxifen citrate tab 20 mg (base equivalent)............. 14
tamsulosin hcl cap 0.4 mg (Flomax)............................. 55
TANDEM PLUS – fe fum-iron polysacch complex-fa-b
cmplx-c-zn-mn-cu cap..................................................... 95
TAPAZOLE – methimazole tab 10 mg..............................24
TAPAZOLE – methimazole tab 5 mg................................24
TARCEVA – erlotinib hcl tab 100 mg (base
equivalent)....................................................................... 14
TARCEVA – erlotinib hcl tab 150 mg (base
equivalent)....................................................................... 14
TARCEVA – erlotinib hcl tab 25 mg (base equivalent)...... 14
TARGRETIN – bexarotene cap 75 mg............................. 14
TARGRETIN – bexarotene gel 1%................................. 109
TARON-BC – prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit
b6 tab pak....................................................................... 89
TARON-C DHA – prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg............................................................ 90
TARON-DUO EC – prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk...................................................... 90
TARON-PREX – prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 30-1.2-265 mg.......................................................... 90
TASIGNA – nilotinib hcl cap 150 mg (base equivalent).....14
TASIGNA – nilotinib hcl cap 200 mg (base equivalent).....14
TAZORAC – tazarotene cream 0.05%............................109
TAZORAC – tazarotene cream 0.1%..............................109
TAZORAC – tazarotene gel 0.05%................................. 109
TAZORAC – tazarotene gel 0.1%................................... 109
TECFIDERA – dimethyl fumarate capsule delayed release
120 mg.............................................................................68
TECFIDERA – dimethyl fumarate capsule delayed release
240 mg.............................................................................68
TECFIDERA STARTER PACK – dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg...................... 68
TEGRETOL – carbamazepine susp 100 mg/5ml.............. 80
TEGRETOL – carbamazepine tab 200 mg....................... 80
TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg..... 80
TEGRETOL-XR – carbamazepine tab sr 12hr 200 mg..... 80
TEGRETOL-XR – carbamazepine tab sr 12hr 400 mg..... 80
telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 40
telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 40
telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 40
telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 40
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)................................................................. 40
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)................................................................. 40
telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)................................................................. 40
telmisartan tab 20 mg (Micardis)................................... 40
telmisartan tab 40 mg (Micardis)................................... 40
telmisartan tab 80 mg (Micardis)................................... 40
temazepam cap 15 mg (Restoril)................................... 63
temazepam cap 22.5 mg (Restoril)................................ 64
temazepam cap 30 mg (Restoril)................................... 64
temazepam cap 7.5 mg (Restoril).................................. 64
TEMODAR – temozolomide cap 100 mg.......................... 14
TEMODAR – temozolomide cap 140 mg.......................... 14
TEMODAR – temozolomide cap 180 mg.......................... 14
TEMODAR – temozolomide cap 20 mg............................ 14
TEMODAR – temozolomide cap 250 mg.......................... 14
TEMODAR – temozolomide cap 5 mg.............................. 14
TEMOVATE – clobetasol propionate cream 0.05%........ 109
TEMOVATE – clobetasol propionate gel 0.05%..............109
TEMOVATE – clobetasol propionate oint 0.05%.............109
TEMOVATE – clobetasol propionate soln 0.05%............109
TEMOVATE E – clobetasol propionate emollient base
cream 0.05%................................................................. 109
temozolomide cap 100 mg (Temodar)........................... 14
temozolomide cap 140 mg (Temodar)........................... 14
temozolomide cap 180 mg (Temodar)........................... 14
temozolomide cap 20 mg (Temodar).............................14
temozolomide cap 250 mg (Temodar)........................... 14
temozolomide cap 5 mg (Temodar)...............................14
TENEX – guanfacine hcl tab 1 mg....................................40
TENEX – guanfacine hcl tab 2 mg....................................40
TENORETIC 100 – atenolol & chlorthalidone tab 100-25
mg.................................................................................... 40
TENORETIC 50 – atenolol & chlorthalidone tab 50-25
mg.................................................................................... 40
TENORMIN – atenolol tab 100 mg................................... 30
TENORMIN – atenolol tab 25 mg..................................... 30
TENORMIN – atenolol tab 50 mg..................................... 30
TERAZOL 3 – terconazole vaginal cream 0.8%................55
TERAZOL 7 – terconazole vaginal cream 0.4%................55
terazosin hcl cap 10 mg................................................. 40
terazosin hcl cap 1 mg................................................... 40
terazosin hcl cap 2 mg................................................... 40
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
159
2015
terazosin hcl cap 5 mg................................................... 40
terbinafine hcl tab 250 mg (Lamisil)................................6
terbutaline sulfate tab 2.5 mg........................................ 49
terbutaline sulfate tab 5 mg........................................... 49
terconazole vaginal cream 0.4% (Terazol 7)................. 55
terconazole vaginal cream 0.8% (Terazol 3)................. 55
terconazole vaginal suppos 80 mg................................55
TESSALON PERLES – benzonatate cap 100 mg.............47
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................. 16
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................. 16
testosterone enanthate im inj in oil 200 mg/ml............ 16
TESTRED – methyltestosterone cap 10 mg..................... 16
tetracaine hcl ophth soln 0.5%...................................... 99
TETRACYCLINE HCL – tetracycline hcl cap 250 mg......... 4
TETRACYCLINE HCL – tetracycline hcl cap 500 mg......... 4
THALOMID – thalidomide cap 100 mg........................... 112
THALOMID – thalidomide cap 150 mg........................... 112
THALOMID – thalidomide cap 200 mg........................... 112
THALOMID – thalidomide cap 50 mg............................. 112
theophylline soln 80 mg/15ml........................................ 49
theophylline tab sr 12hr 100 mg.................................... 49
theophylline tab sr 12hr 200 mg.................................... 49
theophylline tab sr 12hr 300 mg.................................... 49
theophylline tab sr 12hr 450 mg.................................... 49
theophylline tab sr 24hr 400 mg.................................... 49
theophylline tab sr 24hr 600 mg.................................... 49
THERA-FLUR-N – sodium fluoride gel 1.1% (0.5% f)..... 101
THERANATAL CORE NUTRITION – prenatal vit w/ fe
fumarate-fa tab 27-1 mg..................................................90
thioridazine hcl tab 100 mg............................................62
thioridazine hcl tab 10 mg..............................................62
thioridazine hcl tab 25 mg..............................................62
thioridazine hcl tab 50 mg..............................................62
thiothixene cap 10 mg.................................................... 63
thiothixene cap 1 mg...................................................... 62
thiothixene cap 2 mg...................................................... 63
thiothixene cap 5 mg...................................................... 63
THYROGEN – thyrotropin alfa for inj 1.1 mg.................. 110
thyroid tab 30 mg (1/2 grain) (Armour thyroid).............24
thyroid tab 60 mg (1 grain) (Armour thyroid)................24
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)..........24
tiagabine hcl tab 2 mg (Gabitril).................................... 80
tiagabine hcl tab 4 mg (Gabitril).................................... 80
TIAZAC – diltiazem hcl extended release beads cap sr
24hr 120 mg.................................................................... 33
TIAZAC – diltiazem hcl extended release beads cap sr
24hr 180 mg.................................................................... 33
TIAZAC – diltiazem hcl extended release beads cap sr
24hr 240 mg.................................................................... 33
TIAZAC – diltiazem hcl extended release beads cap sr
24hr 300 mg.................................................................... 33
TIAZAC – diltiazem hcl extended release beads cap sr
24hr 360 mg.................................................................... 33
160
TIAZAC – diltiazem hcl extended release beads cap sr
24hr 420 mg.................................................................... 33
ticlopidine hcl tab 250 mg..............................................97
TIGAN – trimethobenzamide hcl cap 300 mg................... 52
TIKOSYN – dofetilide cap 125 mcg (0.125 mg)................ 34
TIKOSYN – dofetilide cap 250 mcg (0.25 mg).................. 34
TIKOSYN – dofetilide cap 500 mcg (0.5 mg).................... 34
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe)................................................................ 100
timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe)................................................................ 100
timolol maleate ophth soln 0.25% (Timoptic)............. 100
timolol maleate ophth soln 0.5% (Timoptic)............... 100
TIMOPTIC – timolol maleate ophth soln 0.25%.............. 100
TIMOPTIC – timolol maleate ophth soln 0.5%................ 100
TIMOPTIC-XE – timolol maleate ophth gel forming soln
0.25%.............................................................................100
TIMOPTIC-XE – timolol maleate ophth gel forming soln
0.5%...............................................................................100
TINDAMAX – tinidazole tab 250 mg................................. 11
TINDAMAX – tinidazole tab 500 mg................................. 11
tinidazole tab 250 mg (Tindamax)..................................11
tinidazole tab 500 mg (Tindamax)..................................11
TIROSINT – levothyroxine sodium cap 100 mcg.............. 25
TIROSINT – levothyroxine sodium cap 112 mcg.............. 25
TIROSINT – levothyroxine sodium cap 125 mcg.............. 25
TIROSINT – levothyroxine sodium cap 137 mcg.............. 25
TIROSINT – levothyroxine sodium cap 13 mcg................ 24
TIROSINT – levothyroxine sodium cap 150 mcg.............. 25
TIROSINT – levothyroxine sodium cap 25 mcg................ 25
TIROSINT – levothyroxine sodium cap 50 mcg................ 25
TIROSINT – levothyroxine sodium cap 75 mcg................ 25
TIROSINT – levothyroxine sodium cap 88 mcg................ 25
TIVICAY – dolutegravir sodium tab 50 mg (base equiv)......9
tizanidine hcl cap 2 mg (Zanaflex).................................83
tizanidine hcl cap 4 mg (Zanaflex).................................83
tizanidine hcl cap 6 mg (Zanaflex).................................83
tizanidine hcl tab 2 mg................................................... 83
tizanidine hcl tab 4 mg (Zanaflex)................................. 83
TL-CARE DHA – prenatal w/fe fumarate-fa-dss-fish oil cap
27-1-500 mg.................................................................... 90
TL FOLATE – prenatal vit w/ fe fum-methylfolate-fa tab
27-0.5-0.5 mg.................................................................. 90
TL-SELECT DHA – prenatal w/o vit a w/ fe fum-doc-fa-dha
cap 29-1.25-350 mg........................................................ 90
TL-SELECT – prenatal w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg............................................................... 90
TOBI PODHALER – tobramycin inhal cap 28 mg............... 5
TOBI – tobramycin nebu soln 300 mg/5ml..........................5
TOBRADEX – tobramycin-dexamethasone ophth susp
0.3-0.1%.........................................................................100
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex).................................................................... 100
tobramycin nebu soln 300 mg/5ml (Tobi)....................... 5
tobramycin ophth soln 0.3% (Tobrex)......................... 100
TOBREX – tobramycin sulfate ophth soln 0.3%..............100
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
TOFRANIL – imipramine hcl tab 10 mg............................ 60
TOFRANIL – imipramine hcl tab 25 mg............................ 60
TOFRANIL – imipramine hcl tab 50 mg............................ 60
tolazamide tab 250 mg....................................................22
TOLAZAMIDE – tolazamide tab 500 mg...........................22
TOLBUTAMIDE – tolbutamide tab 500 mg....................... 22
tolmetin sodium cap 400 mg..........................................75
tolterodine tartrate tab 1 mg (Detrol).............................54
tolterodine tartrate tab 2 mg (Detrol).............................54
TOPAMAX SPRINKLE – topiramate sprinkle cap 15
mg.................................................................................... 80
TOPAMAX SPRINKLE – topiramate sprinkle cap 25
mg.................................................................................... 80
TOPAMAX – topiramate tab 100 mg................................ 80
TOPAMAX – topiramate tab 200 mg................................ 80
TOPAMAX – topiramate tab 25 mg.................................. 80
TOPAMAX – topiramate tab 50 mg.................................. 80
TOPICORT – desoximetasone cream 0.05%................. 109
TOPICORT – desoximetasone cream 0.25%................. 109
TOPICORT – desoximetasone gel 0.05%.......................109
TOPICORT – desoximetasone oint 0.25%......................109
topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 80
topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 80
topiramate tab 100 mg (Topamax).................................80
topiramate tab 200 mg (Topamax).................................80
topiramate tab 25 mg (Topamax)...................................80
topiramate tab 50 mg (Topamax)...................................80
TOPROL XL – metoprolol succinate tab sr 24hr 100
mg.................................................................................... 30
TOPROL XL – metoprolol succinate tab sr 24hr 200
mg.................................................................................... 30
TOPROL XL – metoprolol succinate tab sr 24hr 25
mg.................................................................................... 30
TOPROL XL – metoprolol succinate tab sr 24hr 50
mg.................................................................................... 30
torsemide tab 100 mg (Demadex)..................................42
torsemide tab 10 mg (Demadex)....................................42
torsemide tab 20 mg (Demadex)....................................42
torsemide tab 5 mg (Demadex)......................................42
TRACLEER – bosentan tab 125 mg................................. 45
TRACLEER – bosentan tab 62.5 mg................................ 45
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)......................................................................... 73
tramadol hcl tab 50 mg (Ultram).................................... 73
tramadol hcl tab sr 24hr 100 mg (Ultram er).................73
tramadol hcl tab sr 24hr 200 mg (Ultram er).................73
tramadol hcl tab sr 24hr 300 mg (Ultram er).................73
tramadol hcl tab sr 24hr biphasic release 200 mg....... 73
tramadol hcl tab sr 24hr biphasic release 300 mg....... 73
TRANDATE – labetalol hcl tab 100 mg.............................30
TRANDATE – labetalol hcl tab 200 mg.............................30
TRANDATE – labetalol hcl tab 300 mg.............................30
trandolapril tab 1 mg (Mavik)......................................... 40
trandolapril tab 2 mg (Mavik)......................................... 40
trandolapril tab 4 mg (Mavik)......................................... 40
tranexamic acid tab 650 mg (Lysteda).......................... 96
TRANSDERM-SCOP – scopolamine td patch 72hr 1.5
mg.................................................................................... 52
TRANXENE T – clorazepate dipotassium tab 15 mg........ 56
TRANXENE T – clorazepate dipotassium tab 3.75 mg..... 56
TRANXENE T – clorazepate dipotassium tab 7.5 mg....... 56
tranylcypromine sulfate tab 10 mg (Parnate)............... 60
TRAVOPROST – travoprost ophth soln 0.004%............. 100
trazodone hcl tab 100 mg...............................................60
trazodone hcl tab 150 mg...............................................60
trazodone hcl tab 300 mg...............................................60
trazodone hcl tab 50 mg.................................................60
TREAGAN OTIC – antipyrine-benzocaine-polycosanol otic
sol 5.4-1.4-0.0097%.......................................................101
tretinoin cap 10 mg......................................................... 14
tretinoin cream 0.025% (Retin-a)................................. 109
tretinoin cream 0.05% (Retin-a)................................... 109
tretinoin cream 0.1% (Retin-a)..................................... 109
tretinoin gel 0.01% (Retin-a).........................................109
tretinoin gel 0.025% (Retin-a).......................................109
TRIADVANCE – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 90
triamcinolone acetonide cream 0.025%...................... 109
triamcinolone acetonide cream 0.1%.......................... 109
triamcinolone acetonide cream 0.5%.......................... 109
triamcinolone acetonide dental paste 0.1%................ 101
triamcinolone acetonide lotion 0.025%....................... 109
triamcinolone acetonide lotion 0.1%........................... 109
triamcinolone acetonide nasal aerosol suspension 55
mcg/act (Nasacort aq)................................................... 46
triamcinolone acetonide oint 0.025%.......................... 109
triamcinolone acetonide oint 0.1%.............................. 109
TRIAMCINOLONE ACETONIDE – triamcinolone
acetonide oint 0.5%.......................................................109
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide)......................................................................... 42
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)................................................................... 42
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide).........................................................................42
TRIANEX – triamcinolone acetonide oint 0.05%............. 109
triazolam tab 0.125 mg................................................... 64
triazolam tab 0.25 mg (Halcion)..................................... 64
TRICARE PRENATAL COMPLEAT – prenat w/o a fefumfa tab 27-1 mg & fish oil chew cap pak........................... 90
TRICARE PRENATAL DHA ONE – prenatal w/fe
fumarate-fa-dss-fish oil cap 27-1-500 mg........................90
TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg..... 90
TRICOR – fenofibrate tab 145 mg.................................... 44
TRICOR – fenofibrate tab 48 mg...................................... 44
trifluoperazine hcl tab 10 mg......................................... 63
trifluoperazine hcl tab 1 mg........................................... 63
trifluoperazine hcl tab 2 mg........................................... 63
trifluoperazine hcl tab 5 mg........................................... 63
trifluridine ophth soln 1% (Viroptic)............................ 100
trihexyphenidyl hcl elixir 0.4 mg/ml.............................. 83
trihexyphenidyl hcl tab 2 mg......................................... 83
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
161
2015
trihexyphenidyl hcl tab 5 mg......................................... 83
TRILEPTAL – oxcarbazepine tab 150 mg.........................80
TRILEPTAL – oxcarbazepine tab 300 mg.........................80
TRILEPTAL – oxcarbazepine tab 600 mg.........................80
TRILIPIX – choline fenofibrate cap dr 135 mg (fenofibric
acid equiv)....................................................................... 44
TRILIPIX – choline fenofibrate cap dr 45 mg (fenofibric
acid equiv)....................................................................... 44
trimethobenzamide hcl cap 300 mg (Tigan)..................52
trimethoprim tab 100 mg................................................ 11
TRINATAL GT – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 90
TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................... 90
TRINATAL ULTRA – prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg..................................................................... 90
TRINATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg......90
TRI-NORINYL 28 – norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg............................................. 20
TRI-TABS DHA – prenat w/o a w/ fe bisglyc-fa tab 32-1
mg & omega cap pack.................................................... 90
TRIVEEN-DUO DHA – prenat-fe bis-fe prot succ-fa-ca tab
& omega 3 cap 400 pk....................................................90
TRIVEEN-PRX RNF – prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg................................................... 90
TRIZIVIR – abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg................................................................ 9
tropicamide ophth soln 0.5%....................................... 100
tropicamide ophth soln 1% (Mydriacyl)...................... 100
trospium chloride cap sr 24hr 60 mg............................ 54
trospium chloride tab 20 mg..........................................54
TRUSOPT – dorzolamide hcl ophth soln 2%.................. 100
TRUVADA – emtricitabine-tenofovir disoproxil fumarate
tab 200-300 mg................................................................. 9
trypsin w/ castor oil & peruvian balsam oint
(Xenaderm)................................................................... 109
trypsin w/ castor oil & peruvian balsam spray
(Granulex)..................................................................... 109
TUSSIONEX PENNKINETIC EXT – hydrocod polstchlorphen polst cr susp 10-8 mg/5ml.............................. 47
TWYNSTA – telmisartan-amlodipine tab 40-10 mg...........40
TWYNSTA – telmisartan-amlodipine tab 40-5 mg.............40
TWYNSTA – telmisartan-amlodipine tab 80-10 mg...........40
TWYNSTA – telmisartan-amlodipine tab 80-5 mg.............40
TYBOST – cobicistat tab 150 mg....................................... 9
TYKERB – lapatinib ditosylate tab 250 mg (base
equiv)............................................................................... 14
TYLENOL/CODEINE #3 – acetaminophen w/ codeine tab
300-30 mg....................................................................... 73
TYLENOL/CODEINE #4 – acetaminophen w/ codeine tab
300-60 mg....................................................................... 73
TYLENOL/CODEINE – acetaminophen w/ codeine tab
300-15 mg....................................................................... 73
TYZEKA – telbivudine tab 600 mg......................................9
162
U
ULTIMATECARE ONE NF – prenatal w/fe cbnyl-fe asp
glyc-fa-dss-omega cap 20-7-1 mg...................................90
ULTIMATECARE ONE – prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg.................................................. 90
ULTIMATE OB DHA – prenat w/ fe poly cmplx-fe asp-fe
gly-fa tab & dha cap pak................................................. 90
ULTRACET – tramadol-acetaminophen tab 37.5-325
mg.................................................................................... 73
ULTRAM ER – tramadol hcl tab sr 24hr 100 mg...............73
ULTRAM ER – tramadol hcl tab sr 24hr 200 mg...............73
ULTRAM ER – tramadol hcl tab sr 24hr 300 mg...............73
ULTRAM – tramadol hcl tab 50 mg.................................. 73
ULTRA TABS – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 90
ULTRAVATE – halobetasol propionate cream 0.05%..... 109
ULTRAVATE – halobetasol propionate oint 0.05%......... 109
URAMAXIN – urea cream 45%.......................................109
URAMAXIN – urea gel 45%............................................109
URAMAXIN – urea lotion 45%........................................ 109
urea cream 39% (Aluvea)............................................. 109
urea cream 40%.............................................................109
urea cream 45% (Uramaxin)......................................... 110
urea cream 50%.............................................................110
urea gel 40%.................................................................. 110
urea gel 45% (Uramaxin).............................................. 110
urea in lactic acid vehicle foam 35% (Hydro 35).........110
urea lotion 40%..............................................................110
urea lotion 45% (Uramaxin)..........................................110
URECHOLINE – bethanechol chloride tab 10 mg.............55
URECHOLINE – bethanechol chloride tab 25 mg.............55
URECHOLINE – bethanechol chloride tab 50 mg.............55
URECHOLINE – bethanechol chloride tab 5 mg...............54
UREX – methenamine hippurate tab 1 gm....................... 54
UROCIT-K 10 – potassium citrate tab cr 10 meq (1080
mg)...................................................................................55
UROCIT-K 15 – potassium citrate tab cr 15 meq (1620
mg)...................................................................................55
UROCIT-K 5 – potassium citrate tab cr 5 meq (540
mg)...................................................................................55
UROXATRAL – alfuzosin hcl tab sr 24hr 10 mg............... 56
URSO 250 – ursodiol tab 250 mg.....................................53
ursodiol cap 300 mg (Actigall).......................................53
ursodiol tab 250 mg (Urso 250)..................................... 53
ursodiol tab 500 mg (Urso forte)................................... 54
URSO FORTE – ursodiol tab 500 mg...............................53
V
valacyclovir hcl tab 1 gm (Valtrex).................................. 9
valacyclovir hcl tab 500 mg (Valtrex).............................. 9
VALCYTE – valganciclovir hcl for soln 50 mg/ml (base
equiv)................................................................................. 9
VALCYTE – valganciclovir hcl tab 450 mg......................... 9
valganciclovir hcl tab 450 mg (Valcyte).......................... 9
VALIUM – diazepam tab 10 mg........................................57
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
VALIUM – diazepam tab 2 mg..........................................56
VALIUM – diazepam tab 5 mg..........................................56
valproate sodium syrup 250 mg/5ml (base equiv)
(Depakene)......................................................................80
valproic acid cap 250 mg (Depakene)........................... 80
valsartan-hydrochlorothiazide tab 160-12.5 mg
(Diovan hct)....................................................................40
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct).................................................................................. 40
valsartan-hydrochlorothiazide tab 320-12.5 mg
(Diovan hct).................................................................... 40
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct).................................................................................. 40
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct).................................................................................. 40
valsartan tab 160 mg (Diovan)....................................... 40
valsartan tab 320 mg (Diovan)....................................... 40
valsartan tab 40 mg (Diovan)......................................... 40
valsartan tab 80 mg (Diovan)......................................... 40
VALTREX – valacyclovir hcl tab 1 gm................................ 9
VALTREX – valacyclovir hcl tab 500 mg............................ 9
VANCOCIN HCL – vancomycin hcl cap 125 mg...............11
VANCOCIN HCL – vancomycin hcl cap 250 mg...............11
vancomycin hcl cap 125 mg (Vancocin hcl)................. 11
vancomycin hcl cap 250 mg (Vancocin hcl)................. 11
VASERETIC – enalapril maleate & hydrochlorothiazide tab
10-25 mg......................................................................... 40
VASOTEC – enalapril maleate tab 10 mg........................ 40
VASOTEC – enalapril maleate tab 2.5 mg........................40
VASOTEC – enalapril maleate tab 20 mg........................ 40
VASOTEC – enalapril maleate tab 5 mg.......................... 40
VECTICAL – calcitriol oint 3 mcg/gm.............................. 110
VEMAVITE-PRX 2 – prenatal w/o vit a w/ fe fum-dss-fadha cap 27-1.25-300 mg................................................. 90
VENA-BAL DHA – prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg...................................................... 90
VENATAL-FA – prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................... 90
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)..................................................................... 60
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)..................................................................... 60
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)..................................................................... 60
VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 150
mg (base equivalent).......................................................60
VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 225
mg (base equivalent).......................................................60
VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 37.5
mg (base equivalent).......................................................60
VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 75
mg (base equivalent).......................................................60
venlafaxine hcl tab 100 mg............................................ 60
venlafaxine hcl tab 25 mg.............................................. 60
venlafaxine hcl tab 37.5 mg........................................... 60
venlafaxine hcl tab 50 mg.............................................. 60
venlafaxine hcl tab 75 mg.............................................. 60
venlafaxine hcl tab sr 24hr 150 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 60
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 60
venlafaxine hcl tab sr 24hr 75 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 60
VERAMYST – fluticasone furoate nasal susp 27.5 mcg/
spray................................................................................ 46
verapamil hcl cap sr 24hr 100 mg (Verelan pm)........... 33
verapamil hcl cap sr 24hr 120 mg (Verelan)................. 33
verapamil hcl cap sr 24hr 180 mg (Verelan)................. 33
verapamil hcl cap sr 24hr 200 mg (Verelan pm)........... 33
verapamil hcl cap sr 24hr 240 mg (Verelan)................. 33
verapamil hcl cap sr 24hr 300 mg (Verelan pm)........... 33
verapamil hcl cap sr 24hr 360 mg (Verelan)................. 33
verapamil hcl tab 120 mg (Calan).................................. 33
verapamil hcl tab 80 mg (Calan).................................... 33
verapamil hcl tab cr 120 mg (Calan sr)......................... 33
verapamil hcl tab cr 180 mg (Calan sr)......................... 33
verapamil hcl tab cr 240 mg (Calan sr)......................... 33
VERAPAMIL HCL – verapamil hcl tab 40 mg................... 33
VERELAN PM – verapamil hcl cap sr 24hr 100 mg.......... 33
VERELAN PM – verapamil hcl cap sr 24hr 200 mg.......... 33
VERELAN PM – verapamil hcl cap sr 24hr 300 mg.......... 33
VERELAN – verapamil hcl cap sr 24hr 120 mg................ 33
VERELAN – verapamil hcl cap sr 24hr 180 mg................ 33
VERELAN – verapamil hcl cap sr 24hr 240 mg................ 33
VERELAN – verapamil hcl cap sr 24hr 360 mg................ 33
VERIPRED 20 – prednisolone sod phosphate oral soln 20
mg/5ml (base equiv)........................................................16
VFEND – voriconazole for susp 40 mg/ml.......................... 6
VFEND – voriconazole tab 200 mg.................................... 6
VFEND – voriconazole tab 50 mg...................................... 6
VIAGRA – Benefit Limits may apply – sildenafil citrate tab
100 mg.............................................................................45
VIAGRA – Benefit Limits may apply – sildenafil citrate tab
25 mg...............................................................................45
VIAGRA – Benefit Limits may apply – sildenafil citrate tab
50 mg...............................................................................45
VICOPROFEN – hydrocodone-ibuprofen tab 7.5-200
mg.................................................................................... 73
VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml).................................................................................... 22
VICTRELIS – boceprevir cap 200 mg.................................9
VIDEX – didanosine for soln 2 gm......................................9
VIDEX – didanosine for soln 4 gm......................................9
VIDEX EC – didanosine delayed release capsule 125
mg...................................................................................... 9
VIDEX EC – didanosine delayed release capsule 200
mg...................................................................................... 9
VIDEX EC – didanosine delayed release capsule 250
mg...................................................................................... 9
VIDEX EC – didanosine delayed release capsule 400
mg...................................................................................... 9
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
163
2015
VIEKIRA PAK – ombitas-paritapre-riton & dasab tab pak
12.5-75-50 & 250 mg........................................................ 9
VIGAMOX – moxifloxacin hcl ophth soln 0.5% (base
equiv)............................................................................. 100
VINACAL B – prenat w/o a w/fecbn-feglu-fa tab 20-1 mg &
vit b6 tab pak...................................................................90
VINACAL – prenatal w/o a w/ fe carbonyl-fe gluc-dss-fa
tab 27-1mg...................................................................... 90
VINATE AZ EXTRA – prenatal vit w/ fe bisglycinate
chelate-fa tab 29-1 mg.................................................... 91
VINATE CALCIUM – prenatal vit w/ iron carbonyl-fe glucfa tab 27-1 mg.................................................................91
VINATE CARE – prenatal w/o a vit w/ fe fum-fa tab chew
40-1 mg........................................................................... 91
VINATE C – prenatal w/o a vit w/ fe fumarate-fa tab 30-1
mg.................................................................................... 91
VINATE DHA RF – prenat w/o a w/fefum-methylfolomegas cap 27-1.13 mg................................................. 91
VINATE GT – prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg.................................................................................... 91
VINATE IC – prenatal w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg............................................................... 91
VINATE II – prenatal vit w/ fe bisglycinate chelate-fa tab
29-1 mg........................................................................... 91
VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1
mg.................................................................................... 91
VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................... 91
VINATE ULTRA – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 91
VIRACEPT – nelfinavir mesylate tab 250 mg..................... 9
VIRACEPT – nelfinavir mesylate tab 625 mg..................... 9
VIRAMUNE – nevirapine susp 50 mg/5ml.......................... 9
VIRAMUNE – nevirapine tab 200 mg................................. 9
VIRAMUNE XR – nevirapine tab sr 24hr 100 mg..............10
VIRAMUNE XR – nevirapine tab sr 24hr 400 mg..............10
VIRASAL – salicylic acid film forming liquid 27.5%......... 110
VIREAD – tenofovir disoproxil fumarate oral powder 40
mg/gm.............................................................................. 10
VIREAD – tenofovir disoproxil fumarate tab 150 mg......... 10
VIREAD – tenofovir disoproxil fumarate tab 200 mg......... 10
VIREAD – tenofovir disoproxil fumarate tab 250 mg......... 10
VIREAD – tenofovir disoproxil fumarate tab 300 mg......... 10
VIROPTIC – trifluridine ophth soln 1%............................100
VIRT-ADVANCE – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 91
VIRT-BAL DHA PLUS – prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 380mg.......................................... 91
VIRT-CARE ONE – prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg...................................................... 91
VIRT-C DHA – prenatal w/fe fum-fe poly -fa-omega 3 cap
53.5-38-1 mg................................................................... 91
VIRT NATE – prenatal vit w/ fe fumarate-fa tab 28-1
mg.................................................................................... 91
VIRT-PN DHA – prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg........................................................... 91
164
VIRT-PN PLUS – prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap........................................... 91
VIRT-PN – prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg.................................................................. 91
VIRTPREX – prenatal w/o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg................................................................. 91
VIRT-SELECT – prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg........................................................ 91
VIRT-VITE GT – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 91
VISTARIL – hydroxyzine pamoate cap 25 mg.................. 57
VISTARIL – hydroxyzine pamoate cap 50 mg.................. 57
VITAFOL-NANO – prenatal w/o a w/ fefum-l methylfol-fa
tab 18-0.6-0.4 mg............................................................ 91
VITAFOL-OB+DHA – prenatal mv w/fe fum-fa tab 65-1 mg
& dha cap 250 mg pack .................................................91
VITAFOL-OB – prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................... 91
VITAFOL-ONE – prenatal mv w/ fe polysac cmplx-fa-dha
cap 29-1-200 mg............................................................. 91
VITAFOL-PN – prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................... 91
VITAFOL ULTRA – prenat w/fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg........................................................... 91
VITAMEDMD ONE RX/QUATREFO – prenat w/o a w/
fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg.................. 91
VITAMEDMD PLUS RX/QUATRE – prenat w/o a w/ fe
chelate-l methylfol-fa tab & dha cap pk........................... 91
VITAMEDMD REDICHEW RX – prenat w/ b2-b6-b12-d3folic acid chew tab 1.4 mg.............................................. 92
VITAPEARL – prenat w/oa w/fefum-na fered-fa-dha cap cr
30-1.4-200 mg................................................................. 92
VITA-PREN – prenatal vit w/ docusate-iron-fa tab 65-1
mg.................................................................................... 91
VIVA DHA – prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................... 92
VIVELLE-DOT – estradiol td patch biweekly 0.025
mg/24hr............................................................................18
VIVELLE-DOT – estradiol td patch biweekly 0.0375
mg/24hr............................................................................18
VIVELLE-DOT – estradiol td patch biweekly 0.05
mg/24hr............................................................................18
VIVELLE-DOT – estradiol td patch biweekly 0.075
mg/24hr............................................................................18
VIVELLE-DOT – estradiol td patch biweekly 0.1
mg/24hr............................................................................18
V-NATAL DHA – prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack.......................................................... 90
V-NATAL – prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg........................................................................... 90
VOL-NATE – prenatal vit w/ fe fumarate-fa tab 28-1
mg.................................................................................... 92
VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 92
VOL-TAB RX – prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................... 92
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
VOLTAREN – diclofenac sodium gel 1%........................ 110
VOLTAREN-XR – diclofenac sodium tab sr 24hr 100
mg.................................................................................... 75
voriconazole for susp 40 mg/ml (Vfend)......................... 6
voriconazole tab 200 mg (Vfend).....................................6
voriconazole tab 50 mg (Vfend).......................................6
VOSPIRE ER – albuterol sulfate tab sr 12hr 4 mg............49
VOSPIRE ER – albuterol sulfate tab sr 12hr 8 mg............49
VOTRIENT – pazopanib hcl tab 200 mg (base equiv).......14
VP-CH PLUS – prenatal w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg.................................................................... 92
VP-CH-PNV – prenatal w/o vit a w/ fe cbn-dss-fa-dha cap
30-1-260 mg.................................................................... 92
VP CH ULTRA – prenat w/o a w/fe fum-fe cbn-dss-fa-dha
cap 27-1-260 mg............................................................. 92
VP-GGR-B6 PRENATAL – prenatal w/ calcium-vit b6-faginger tab 1.2 mg............................................................ 92
VP-HEME OB + DHA – prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck....................................... 92
VP-HEME OB – prenat vit-fe poly cmplx-fe heme poly-fa
tab 28-6-1 mg.................................................................. 92
VP-HEME ONE – prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg...................................................92
VP-PNV-DHA – prenatal vit w/ fe fum-fa-omega 3 cap
28-1-215.8 mg................................................................. 92
VYVANSE – lisdexamfetamine dimesylate cap 10 mg......66
VYVANSE – lisdexamfetamine dimesylate cap 20 mg......66
VYVANSE – lisdexamfetamine dimesylate cap 30 mg......66
VYVANSE – lisdexamfetamine dimesylate cap 40 mg......66
VYVANSE – lisdexamfetamine dimesylate cap 50 mg......66
VYVANSE – lisdexamfetamine dimesylate cap 60 mg......66
VYVANSE – lisdexamfetamine dimesylate cap 70 mg......66
W
warfarin sodium tab 10 mg (Coumadin)........................96
warfarin sodium tab 1 mg (Coumadin)..........................96
warfarin sodium tab 2.5 mg (Coumadin).......................96
warfarin sodium tab 2 mg (Coumadin)..........................96
warfarin sodium tab 3 mg (Coumadin)..........................96
warfarin sodium tab 4 mg (Coumadin)..........................96
warfarin sodium tab 5 mg (Coumadin)..........................96
warfarin sodium tab 6 mg (Coumadin)..........................96
warfarin sodium tab 7.5 mg (Coumadin).......................96
WELLBUTRIN – bupropion hcl tab 100 mg...................... 60
WELLBUTRIN – bupropion hcl tab 75 mg........................ 60
WELLBUTRIN SR – bupropion hcl tab sr 12hr 100 mg.....60
WELLBUTRIN SR – bupropion hcl tab sr 12hr 150 mg.....60
WELLBUTRIN SR – bupropion hcl tab sr 12hr 200 mg.....60
WELLBUTRIN XL – bupropion hcl tab sr 24hr 150 mg..... 60
WELLBUTRIN XL – bupropion hcl tab sr 24hr 300 mg..... 60
WESTCORT – hydrocortisone valerate oint 0.2%...........110
WESTHROID-P – thyroid tab 130 mg...............................25
WESTHROID-P – thyroid tab 16.25 mg............................25
WESTHROID-P – thyroid tab 32.5 mg..............................25
WESTHROID-P – thyroid tab 48.75 mg (3/4 grain)...........25
WESTHROID-P – thyroid tab 65 mg.................................25
WESTHROID-P – thyroid tab 97.5 mg..............................25
WESTHROID – thyroid tab 113.75 mg............................. 25
WESTHROID – thyroid tab 130 mg.................................. 25
WESTHROID – thyroid tab 146.25 mg............................. 25
WESTHROID – thyroid tab 16.25 mg............................... 25
WESTHROID – thyroid tab 162.5 mg (2 1/2 grain)........... 25
WESTHROID – thyroid tab 195 mg.................................. 25
WESTHROID – thyroid tab 260 mg.................................. 25
WESTHROID – thyroid tab 32.5 mg................................. 25
WESTHROID – thyroid tab 325 mg (5 grain).................... 25
WESTHROID – thyroid tab 48.75 mg (3/4 grain).............. 25
WESTHROID – thyroid tab 65 mg.................................... 25
WESTHROID – thyroid tab 81.25 mg............................... 25
WESTHROID – thyroid tab 97.5 mg................................. 25
WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal
60 mm............................................................................111
WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal
65 mm............................................................................111
WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal
70 mm............................................................................111
WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal
75 mm............................................................................111
WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal
80 mm............................................................................111
WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal
85 mm............................................................................111
WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal
90 mm............................................................................111
WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal
95 mm............................................................................111
WP THYROID – thyroid tab 113.75 mg............................ 25
WP THYROID – thyroid tab 130 mg................................. 25
WP THYROID – thyroid tab 16.25 mg.............................. 25
WP THYROID – thyroid tab 32.5 mg................................ 25
WP THYROID – thyroid tab 48.75 mg (3/4 grain)............. 25
WP THYROID – thyroid tab 65 mg................................... 25
WP THYROID – thyroid tab 81.25 mg.............................. 25
WP THYROID – thyroid tab 97.5 mg................................ 25
X
XALATAN – latanoprost ophth soln 0.005%................... 100
XALKORI – crizotinib cap 200 mg.................................... 14
XALKORI – crizotinib cap 250 mg.................................... 14
XANAX – alprazolam tab 0.25 mg.................................... 57
XANAX – alprazolam tab 0.5 mg...................................... 57
XANAX – alprazolam tab 1 mg......................................... 57
XANAX – alprazolam tab 2 mg......................................... 57
XANAX XR – alprazolam tab sr 24hr 0.5 mg.................... 57
XANAX XR – alprazolam tab sr 24hr 1 mg....................... 57
XANAX XR – alprazolam tab sr 24hr 2 mg....................... 57
XANAX XR – alprazolam tab sr 24hr 3 mg....................... 57
XARELTO – rivaroxaban tab 10 mg................................. 96
XARELTO – rivaroxaban tab 15 mg................................. 96
XARELTO – rivaroxaban tab 20 mg................................. 96
XARELTO STARTER PACK – rivaroxaban tab starter
therapy pack 15 mg & 20 mg..........................................96
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
165
2015
XELJANZ – tofacitinib citrate tab 5 mg (base
equivalent)....................................................................... 75
XELODA – capecitabine tab 150 mg................................ 14
XELODA – capecitabine tab 500 mg................................ 14
XENADERM – trypsin w/ castor oil & peruvian balsam
oint................................................................................. 110
XIFAXAN – rifaximin tab 200 mg...................................... 11
XIFAXAN – rifaximin tab 550 mg...................................... 11
XODOL – hydrocodone-acetaminophen tab 10-300
mg.................................................................................... 73
XODOL – hydrocodone-acetaminophen tab 5-300 mg..... 73
XODOL – hydrocodone-acetaminophen tab 7.5-300
mg.................................................................................... 73
XOPENEX CONCENTRATE – levalbuterol hcl soln nebu
conc 1.25 mg/0.5ml (base equiv).................................... 49
XOPENEX – levalbuterol hcl soln nebu 0.31 mg/3ml (base
equiv)............................................................................... 49
XOPENEX – levalbuterol hcl soln nebu 0.63 mg/3ml (base
equiv)............................................................................... 49
XOPENEX – levalbuterol hcl soln nebu 1.25 mg/3ml (base
equiv)............................................................................... 49
XTANDI – enzalutamide cap 40 mg..................................14
XYLOCAINE – lidocaine hcl soln 4%..............................110
XYREM – sodium oxybate oral solution 500 mg/ml.......... 68
XYZAL – levocetirizine dihydrochloride soln 2.5 mg/5ml
(0.5 mg/ml)...................................................................... 46
XYZAL – levocetirizine dihydrochloride tab 5 mg.............. 46
Y
YASMIN 28 – drospirenone-ethinyl estradiol tab 3-0.03
mg.................................................................................... 20
YAZ – drospirenone-ethinyl estradiol tab 3-0.02 mg......... 20
YODOXIN – iodoquinol tab 210 mg.................................. 10
YODOXIN – iodoquinol tab 650 mg.................................. 10
Z
zafirlukast tab 10 mg (Accolate).................................... 49
zafirlukast tab 20 mg (Accolate).................................... 49
zaleplon cap 10 mg (Sonata)..........................................64
zaleplon cap 5 mg (Sonata)........................................... 64
ZANAFLEX – tizanidine hcl cap 2 mg...............................83
ZANAFLEX – tizanidine hcl cap 4 mg...............................83
ZANAFLEX – tizanidine hcl cap 6 mg...............................83
ZANAFLEX – tizanidine hcl tab 4 mg............................... 83
ZANTAC – ranitidine hcl tab 150 mg................................ 52
ZANTAC – ranitidine hcl tab 300 mg................................ 52
ZARONTIN – ethosuximide cap 250 mg...........................80
ZARONTIN – ethosuximide soln 250 mg/5ml................... 80
ZATEAN-CH – prenatal w/o a w/fe cbn-dss-fa-dha cap
27-1-250 mg.................................................................... 92
ZATEAN-PN DHA – prenat w/o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg.................................................... 92
ZATEAN-PN PLUS – prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap........................................... 92
ZATEAN-PN – prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg.................................................................. 92
166
ZEBETA – bisoprolol fumarate tab 10 mg........................ 30
ZEBETA – bisoprolol fumarate tab 5 mg.......................... 30
ZELBORAF – vemurafenib tab 240 mg (base
equivalent)....................................................................... 14
ZEMPLAR – paricalcitol cap 1 mcg.................................. 28
ZEMPLAR – paricalcitol cap 2 mcg.................................. 28
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
10000-34000-55000 unit..................................................52
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
15000-51000-82000 unit..................................................52
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
20000-68000-109000 unit................................................52
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
25000-85000-136000 unit................................................52
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit....................................................52
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
40000-136000-218000 unit..............................................52
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit....................................................52
ZERIT – stavudine cap 15 mg.......................................... 10
ZERIT – stavudine cap 20 mg.......................................... 10
ZERIT – stavudine cap 30 mg.......................................... 10
ZERIT – stavudine cap 40 mg.......................................... 10
ZERIT – stavudine for oral soln 1 mg/ml...........................10
ZESTORETIC – lisinopril & hydrochlorothiazide tab
10-12.5 mg...................................................................... 40
ZESTORETIC – lisinopril & hydrochlorothiazide tab
20-12.5 mg...................................................................... 41
ZESTORETIC – lisinopril & hydrochlorothiazide tab 20-25
mg.................................................................................... 41
ZESTRIL – lisinopril tab 10 mg......................................... 41
ZESTRIL – lisinopril tab 2.5 mg........................................ 41
ZESTRIL – lisinopril tab 20 mg......................................... 41
ZESTRIL – lisinopril tab 30 mg......................................... 41
ZESTRIL – lisinopril tab 40 mg......................................... 41
ZESTRIL – lisinopril tab 5 mg........................................... 41
ZETIA – ezetimibe tab 10 mg........................................... 44
ZETONNA – ciclesonide nasal aerosol soln 37 mcg/act
(50 mcg/valve)................................................................. 46
ZIAC – bisoprolol & hydrochlorothiazide tab 10-6.25
mg.................................................................................... 41
ZIAC – bisoprolol & hydrochlorothiazide tab 2.5-6.25
mg.................................................................................... 41
ZIAC – bisoprolol & hydrochlorothiazide tab 5-6.25
mg.................................................................................... 41
ZIAGEN – abacavir sulfate soln 20 mg/ml (base
equiv)............................................................................... 10
ZIAGEN – abacavir sulfate tab 300 mg (base equiv)........ 10
zidovudine cap 100 mg (Retrovir)..................................10
zidovudine syrup 10 mg/ml (Retrovir)........................... 10
zidovudine tab 300 mg................................................... 10
zinc sulfate cap 220 mg (50 mg elemental zn)..............93
ZINGIBER – prenatal w/ calcium-vit b6-fa-ginger tab 1.2
mg.................................................................................... 92
ziprasidone hcl cap 20 mg (Geodon)............................ 63
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
2015
ziprasidone hcl cap 40 mg (Geodon)............................ 63
ziprasidone hcl cap 60 mg (Geodon)............................ 63
ziprasidone hcl cap 80 mg (Geodon)............................ 63
ZITHROMAX – azithromycin for susp 100 mg/5ml............. 3
ZITHROMAX – azithromycin for susp 200 mg/5ml............. 3
ZITHROMAX – azithromycin powd pack for susp 1 gm...... 3
ZITHROMAX – azithromycin tab 250 mg............................3
ZITHROMAX – azithromycin tab 500 mg............................3
ZITHROMAX – azithromycin tab 600 mg............................3
ZITHROMAX TRI-PAK – azithromycin tab 500 mg............. 3
ZITHROMAX Z-PAK – azithromycin tab 250 mg................ 3
ZOCOR – simvastatin tab 10 mg......................................44
ZOCOR – simvastatin tab 20 mg......................................44
ZOCOR – simvastatin tab 40 mg......................................44
ZOCOR – simvastatin tab 5 mg........................................44
ZOCOR – simvastatin tab 80 mg......................................44
ZOFRAN ODT – ondansetron orally disintegrating tab 4
mg.................................................................................... 52
ZOFRAN ODT – ondansetron orally disintegrating tab 8
mg.................................................................................... 52
ZOFRAN – ondansetron hcl oral soln 4 mg/5ml................52
ZOFRAN – ondansetron hcl tab 4 mg.............................. 52
ZOFRAN – ondansetron hcl tab 8 mg.............................. 52
ZOLINZA – vorinostat cap 100 mg................................... 14
ZOLOFT – sertraline hcl oral conc 20 mg/ml.................... 60
ZOLOFT – sertraline hcl tab 100 mg................................ 60
ZOLOFT – sertraline hcl tab 25 mg.................................. 60
ZOLOFT – sertraline hcl tab 50 mg.................................. 60
zolpidem tartrate tab 10 mg (Ambien)...........................64
zolpidem tartrate tab 5 mg (Ambien).............................64
zolpidem tartrate tab cr 12.5 mg (Ambien cr)............... 64
zolpidem tartrate tab cr 6.25 mg (Ambien cr)............... 64
ZONATUSS – benzonatate cap 150 mg........................... 47
ZONEGRAN – zonisamide cap 100 mg............................80
ZONEGRAN – zonisamide cap 25 mg..............................80
zonisamide cap 100 mg (Zonegran).............................. 80
zonisamide cap 25 mg (Zonegran)................................ 81
zonisamide cap 50 mg....................................................81
ZOVIRAX – acyclovir cap 200 mg.................................... 10
ZOVIRAX – acyclovir oint 5%......................................... 110
ZOVIRAX – acyclovir susp 200 mg/5ml............................ 10
ZOVIRAX – acyclovir tab 400 mg..................................... 10
ZOVIRAX – acyclovir tab 800 mg..................................... 10
ZYBAN – bupropion hcl (smoking deterrent) tab sr 12hr
150 mg.............................................................................68
ZYLOPRIM – allopurinol tab 100 mg................................ 76
ZYLOPRIM – allopurinol tab 300 mg................................ 76
ZYMAXID – gatifloxacin ophth soln 0.5%....................... 100
ZYPREXA – olanzapine tab 10 mg...................................63
ZYPREXA – olanzapine tab 15 mg...................................63
ZYPREXA – olanzapine tab 2.5 mg..................................63
ZYPREXA – olanzapine tab 20 mg...................................63
ZYPREXA – olanzapine tab 5 mg.....................................63
ZYPREXA – olanzapine tab 7.5 mg..................................63
ZYPREXA ZYDIS – olanzapine orally disintegrating tab 10
mg.................................................................................... 63
ZYPREXA ZYDIS – olanzapine orally disintegrating tab 15
mg.................................................................................... 63
ZYPREXA ZYDIS – olanzapine orally disintegrating tab 20
mg.................................................................................... 63
ZYTIGA – abiraterone acetate tab 250 mg....................... 14
ZYVOX – linezolid tab 600 mg..........................................11
Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary
167