Download PDL_2011_rev 2011_0105.xlsx - Arkansas Blue Cross and Blue

2011 Preferred Drug List
Value Formulary
ADHD
amphetamine salts / ER
dextroamphetamine
methylphenidate / ER
Strattera
Vyvanse
ALZHEIMER'S DISEASE
galantamine / ER
rivastigmine
CARDIOVASCULAR
Renin Angiotensin
Aldosterone System
(STEP THERAPY)
AZOR (step)
benazepril / HCTZ
Benicar / HCT (step)
enalapril / HCTZ
fosinopril / HCTZ
lisinopril / HCTZ
losartan / HCTZ
quinapril / quinaretic
ramipril
Tribenzor (step)
Alpha Blockers/BPH
doxazosin
finasteride
prazosin
tamsulosin
terazosin
Calcium Channel Blockers
diltiazem/ext-rel
felodipine
nicardipine
nifedipine/ext-rel
nisolodipine
verapamil/ext-rel
DEPRESSION
SSRI's (STEP THERAPY)
citalopram
fluoxetine
Lexapro (step)
paroxetine
sertraline
Other Antidepressants
amitriptyline
bupropion / SR / XL
doxepin
imipramine
mirtazapine
trazodone
venlafaxine / XR
DIABETES
Actos / Actoplus Met / XR
Byetta
DuetAct
glimepiride
glipizide / ext-rel
glipizide/metformin
glyburide
glyburide/metformin
Humulin / Humalog
Januvia / Janumet
Lantus
Levemir
metformin / ext-rel
Novolin / Novolog
Symlin
GASTROINTESTINAL
Amitiza
cimetidine
famotidine
nizatidine
ranitidine
HEPATITIS C
Cholesterol Lowering Agents
Statins (STEP THERAPY)
Lipitor (step)
lovastatin
pravastatin
simvastatin
Other
fenofibrate
Niaspan
Simcor
Tricor (Tier 3)
Trilipix
Pegasys (Tier 3) / **
ribavirin
INFECTION
Antimicrobials
amoxicillin
amoxicillin/clavulanate
ampicillin
azithromycin
cefaclor
INFECTION (cont.)
Antimicrobials (cont.)
cefadroxil
cephalexin
ciprofloxacin
clarithromycin
clindamycin
dicloxacillin
doxycycline
erythromycin
minocycline
ofloxacin
penicillin
SMZ-TMP
tetracycline
OPHTHALMICS (cont.)
levobunolol
Nevanac
metipranolol
ofloxacin
Pataday / Patanol
pilocarpine
polymixin B/trimethoprim
prednisolone
timolol
tobramycin
Travatan / Travatan Z
Vigamox
Xalatan
MIGRAINE
triptans (STEP THERAPY)
naratriptan
sumatriptan
MISCELLANEOUS
Androgel
Alvesco (Tier 3)
Avonex
Ciprodex
Copaxone
Enbrel (Tier 3) / **
Follistim AQ (Tier 3) / **
Nitrolingual Pump Spray
Norditropin (Tier 3) / **
Orapred ODT
Ranexa
Savella
Twinject
Ulesfia
Uloric
OPHTHALMICS
betaxolol
carteolol
cromolyn sodium
dexamethasone
dorzolamide
dorzolamide / timolol
erythromycin
gentamicin sulfate
THYROID
REPLACEMENT
levothyroxine sodium
thyroid
TOPICAL PRODUCTS
PAIN
trimethoprim
Antivirals
acyclovir
valacyclovir
SEDATIVE/HYPNOTICS
(STEP THERAPY)
chloral hydrate
estazolam
flurazepam
temazepam
zalepon
zolpidem
NSAIDs (STEP THERAPY)
Celebrex (Tier 3) (step)
diclofenac
etodolac/ext-rel
ibuprofen
indomethacin
meloxicam
naproxen
oxaprozin
piroxicam
salsalate
sulindac
RESPIRATORY
Nasal Antihistamines
Astepro
azelastine
amcinonide
betamethasone
clobetasol
desonide
desoximetasone
diflorasone
fluocinonide
fluticasone
halobetasol
hydrocortisone
mometasone
nystatin
triamcinolone
WOMEN'S HEALTH (cont.)
Hormone Replacement Therapy
Cenestin
Enjuvia
estradiol
estropipate
Evamist
Contraceptives
all oral generics
LoSeasonique (3 copays)
Nuvaring
Seasonique (3 copays)
Anti-infectives
Clindesse
Gynazole-1
terconazole
Prescription Vitamins
all generics
Prenate DHA
Prenate Elite
Prenate Essential
URINARY INCONTINENCE
flavoxate
Vesicare
oxybutynin
This is not a comprehensive
list of covered medications
LEGEND
Boldface denotes generic
Nasal Corticosteriods
(STEP THERAPY)
flunisolide
fluticasone
WOMEN'S HEALTH
Osteoporosis / bisphosphonates
(STEP THERAPY)
alendronate
Boniva (step)
**May require Prior Authorization
Osteoporosis / miscellaneous
calcitonin
Evista
Forteo (Tier 3) / **
fortical
There may be nonpreferred brand name
medications that require step therapy
that are not listed.
(Tier 3) - 3rd tier copay if applicable
(Step) - Requires Step Therapy
Beta-2 Agonists
Advair / Advair HFA
albuterol
Foradil
ProAir HFA
Corticosteriod Inhalers
Flovent / Flovent HFA
Miscellaneous Agents
ipratropium bromide
Singulair
Spiriva
PLEASE NOTE: When a generic
equivalent becomes available the Brand
will automatically move to non coverage
or subject to 100% copay.
Tier placement is subject to change.
revised January 4, 2011