Blue Cross and Blue Shield of Alabama Prescription Drug Guide

Transcription

1 April 08 Blue Cross and Blue Shield of Alabama Prescription Drug Guide Please consider talking to your doctor about prescribing preferred generic and brand 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. For questions about the Blue Cross and Blue Shield of Alabama 08 Prescription Drug Guide, call the customer service number on the back of your Blue Cross ID card or visit AlabamaBlue.com/pharmacy. The Prescription Drug Guide is regularly updated. Please visit AlabamaBlue.com/pharmacy for the most up-to-date information. Contents Introduction... I Member Prescription Benefit... I Pharmacy and Therapeutics (P&T) Committee... I Brand Drugs and Generic Drugs... II Classification... II Generic Substitution... II Drugs... II Compound Drugs... II Contraceptives... III Utilization Management... III... III... III... III Notice... III Key... IV Therapeutic Class Drug List Anti-Infective Drugs... Cancer Drugs... 7 Hormones, Diabetes and Related Drugs... Heart and Circulatory Drugs... 9 Respiratory Agents... 8 Gastrointestinal Drugs... 3 Genitourinary Drugs Central Nervous System Drugs Pain Relief Drugs Neuromuscular Drugs Supplements Blood Modifying Drugs Topical Drugs... 5 Miscellaneous Categories Index... 6 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. Prime Therapeutics LLC, an independent company, provides pharmacy benefit management services for Blue Cross and Blue Shield of Alabama, an independent licensee of the Blue Cross and Blue Shield Association. 457 AL Prime Therapeutics LLC 04/8

2 Introduction Blue Cross and Blue Shield of Alabama is pleased to present the January 08 Prescription Drug Guide. The Prescription Drug Guide includes all Preferred Brand drugs and a partial listing of Generic drugs. Brand name drugs not listed in this Prescription Drug Guide are Non-Preferred Brands. Blue Cross may choose to not add a drug to the Preferred Brand tier for reasons including safety or effectiveness, or because a similar, more cost-effective drug is already available as a Preferred Brand or Generic drug. Physicians are encouraged to prescribe drugs listed in this Prescription Drug Guide. Members are encouraged to show this Prescription Drug Guide to their physician and pharmacist. Member Prescription Benefit The Blue Cross prescription benefit is multi-tiered, placing prescription drugs into one of the following copayment levels. Tier Lowest copayment Generic drugs and select Preferred Brand drugs listed and unlisted generic drugs Tier Middle copayment Preferred Brand drugs all shown in the Prescription Drug Guide Tier 3 Highest copayment Non-Preferred Brand drugs unlisted Tier 4 (if applicable) Coverage is limited to prescription products approved by the Food and Drug Administration (FDA) as evidenced by a New Drug Application (NDA), Abbreviated New Drug Application (ANDA), or Biologics License Application (BLA) on file. Any legal requirements or group specific benefits for coverage will supersede this (e.g., preventive drugs per the Affordable Care Act). The drug benefit includes most prescription drugs, although some restrictions and exclusions apply. Investigational drugs and drugs indicated for cosmetic purposes (e.g., Propecia for hair growth) are not covered. Coverage and copayment levels vary depending on the plan. Drugs that require,, or that have are noted in the Prescription Drug Guide. Pharmacy and Therapeutics (P&T) Committee The P&T Committee is comprised of independent practicing physicians and pharmacists. The Committee meets at least quarterly. Newly marketed prescription drugs may not be covered until the P&T Committee has had an opportunity to review the drug, to determine whether the drug will be covered and if so, which tier will apply based on safety, efficacy, and the availability of other products within that class of drugs. If your physician feels that a new drug is medically necessary prior to P&T Committee evaluation, a non-formulary exception request for coverage may be submitted. Members and physicians can view the most up-to-date version of the Prescription Drug Guide at AlabamaBlue.com/pharmacy. Blue Cross and Blue Shield of Alabama Prescription Drug Guide, April 08 I

3 Brand Drugs and Generic Drugs Classification Prescription drugs are classified as either a Brand drug or a Generic drug. Blue Cross uses the Brand or Generic status provided by a nationally recognized company providing drug product information. The Brand/Generic status for a specific drug/specific marketer can sometimes change over the life of a product in the marketplace and change from Brand to Generic (or Generic to Brand). Such changes might change your copayment share. Brand drug or Generic drug status is never based upon a product having a trade name. Generic drugs often have trade names. Generic Substitution Blue Cross encourages generic utilization as a way to provide high quality drugs at a reduced cost. Generic drugs are as safe and effective as their brand counterparts, but are usually less expensive. Generic drugs are manufactured under the same strict requirements of FDA s current Good Manufacturing Practice regulations required for Brand drugs and cover the manufacturing, and identity, strength, purity and quality. An FDA-approved Generic drug may be substituted for the Brand counterpart when it: Contains the same active ingredient(s) as the brand drug Is identical in strength, dosage form, and route of administration Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile. To encourage use of Generic drugs, Tier Preferred Brand drugs typically move to Tier 3 after an equivalent generic version becomes available. Drugs drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and rheumatoid arthritis. drugs may be oral or injectable medications that can either be self-administered or administered by a health care professional. Some Blue Cross members must obtain their specialty drugs from the Pharmacy Select Network as the preferred provider. If the preferred provider is not utilized you may be responsible for up to 00 percent of the drug cost. Your plan may have a different coverage level for self-administered specialty drugs. If you have questions about your coverage for specialty drugs or your prescription drug benefit, call the number on the back of your ID card. A complete listing of specialty drugs is also available at AlabamaBlue.com/pharmacy. Compound Drugs Compound drugs are defined as a drug product made or modified to have characteristics that are specifically prescribed for an individual patient when commercial drug products are not available or appropriate. To be eligible for coverage, compounded drugs must contain at least one FDA-approved prescription ingredient and must not be a copy of a commercially available product. All compounded drugs are subject to review and may require prior authorization. Drugs used in compounded drugs may be subject to additional coverage criteria and utilization management edits. Compounds are covered only when medically necessary. Compound drugs are always classified as the highest cost-sharing non-specialty drug Tier. Blue Cross and Blue Shield of Alabama Prescription Drug Guide, April 08 II

4 Contraceptives Some or all of the contraceptive methods or prescription drugs listed in this Prescription Drug Guide may not be covered under your plan because of your employer s religious beliefs. To find out if contraceptive methods and prescription drugs are excluded, you may find this information in the exclusions section of your benefit booklet or you may contact your group administrator. Utilization Management Blue Cross is committed to supporting proper selection and use of drugs for its members. To help assure these goals are met, several programs have been developed to promote drug selection that encourages both effectiveness and safety. Detailed coverage criteria can be found at AlabamaBlue.com/pharmacy. Preferred generic or brand drugs requiring or, or drugs with will be noted in the Therapeutic Class Drug List portion of the Prescription Drug Guide. Some drugs require (PA) because of their high potential for misuse or overuse. Drugs selected for may require that specific clinical criteria are met before the drugs will be covered under a member s prescription benefit. Approval is required for claims to process at network pharmacies. (DL) identify gender or age restrictions, and/or the maximum quantity that can be dispensed over a specific period of time. Limits are in place to encourage appropriate drug utilization, enhance member outcomes, and reduce drug benefit costs. Limits are typically developed based upon FDA-approved drug labeling. (ST) programs help manage the cost of expensive drugs by redirecting members to safe, effective and less expensive alternatives. Drugs included in the program require a more cost-effective prerequisite drug be tried before the drug will be approved for coverage. If the member meets the prerequisite requirement, the requested drug will be covered automatically without requiring review. If prerequisite drugs are not found in the claims history, may be required. Drugs and drug categories included in the program are subject to change. Notice The purpose of the Blue Cross Prescription Drug Guide is to provide a guide to coverage. The Prescription Drug Guide is not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients. Neither this Prescription Drug Guide, nor the successful adjudication of a pharmacy claim, is guarantee of payment. Blue Cross and Blue Shield of Alabama Prescription Drug Guide, April 08 III

5 Key cap... capsules chew... chewable conc... concentrate cr... controlled release dr... delayed release ec... enteric coated effe... effervescent equiv... equivalent er... extended release inhal... inhalation inj... injection liq... liquid lotn... lotion nebu... nebulizer odt.... orally disintegrating tabs oint... ointment ophth... ophthalmic osm... osmotic release powd... powder sa... sustained action sl... sublingual soln... solution sr... sustained release suppos... suppositories susp... suspension tab... tablets td... transdermal Blue Cross and Blue Shield of Alabama Prescription Drug Guide, April 08 IV

6 08 ANTI-INFECTIVE DRUGS PENICILLINS amoxicillin (trihydrate) cap 50 amoxicillin (trihydrate) cap 500 amoxicillin (trihydrate) for susp 5 /5ml amoxicillin (trihydrate) for susp 00 /5ml amoxicillin (trihydrate) for susp 50 /5ml amoxicillin (trihydrate) for susp 400 /5ml amoxicillin (trihydrate) tab 500 amoxicillin (trihydrate) tab 875 amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (Augmentin) amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (Augmentin es-600) amoxicillin & k clavulanate tab er hr (Augmentin xr) amoxicillin & k clavulanate tab 50-5 amoxicillin & k clavulanate tab (Augmentin) amoxicillin & k clavulanate tab (Augmentin) dicloxacillin sodium cap 50 dicloxacillin sodium cap 500 penicillin v potassium tab 50 penicillin v potassium tab 500 CEPHALOSPORINS cefaclor cap 50 cefaclor cap 500 cefadroxil cap 500 cefadroxil for susp 50 /5ml cefadroxil for susp 500 /5ml cefadroxil tab gm cefdinir cap 300 cefdinir for susp 5 /5ml cefdinir for susp 50 /5ml cefixime for susp 00 /5ml (Suprax) cefixime for susp 00 /5ml (Suprax) cefpodoxime proxetil for susp 50 /5ml cefpodoxime proxetil for susp 00 /5ml cefpodoxime proxetil tab 00 cefpodoxime proxetil tab 00 cefprozil for susp 5 /5ml cefprozil for susp 50 /5ml cefprozil tab 50 cefprozil tab 500 ceftriaxone sodium for inj 50 ceftriaxone sodium for inj 500 (Rocephin) ceftriaxone sodium for inj gm (Rocephin) ceftriaxone sodium for inj gm cefuroxime axetil tab 50 (Ceftin) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide

7 08 cefuroxime axetil tab 500 (Ceftin) cephalexin cap 50 (Keflex) cephalexin cap 500 (Keflex) cephalexin for susp 5 /5ml cephalexin for susp 50 /5ml SUPRAX cefixime cap 400 SUPRAX cefixime chew tab 00 SUPRAX cefixime chew tab 00 SUPRAX cefixime for susp 00 /5ml SUPRAX cefixime for susp 00 /5ml SUPRAX cefixime for susp 500 /5ml MACROLIDES azithromycin for susp 00 /5ml (Zithromax) azithromycin for susp 00 /5ml (Zithromax) azithromycin tab 50 (Zithromax) azithromycin tab 500 (Zithromax) azithromycin tab 600 (Zithromax) clarithromycin tab er 4hr 500 clarithromycin tab 50 (Biaxin) clarithromycin tab 500 (Biaxin) TETRACYCLINES demeclocycline hcl tab 50 demeclocycline hcl tab 300 doxycycline hyclate cap 50 doxycycline hyclate cap 00 (Vibramycin) doxycycline hyclate tab 0 doxycycline hyclate tab 00 doxycycline monohydrate cap 50 doxycycline monohydrate cap 75 (Monodox) doxycycline monohydrate cap 00 (Monodox) doxycycline monohydrate cap 50 (Adoxa) doxycycline monohydrate tab 50 (Adoxa) doxycycline monohydrate tab 75 (Adoxa) doxycycline monohydrate tab 00 (Adoxa pak /00) doxycycline monohydrate tab 50 (Adoxa pak /50) minocycline hcl cap 50 (Minocin) minocycline hcl cap 75 (Minocin) minocycline hcl cap 00 (Minocin) minocycline hcl tab 50 minocycline hcl tab 75 minocycline hcl tab 00 tetracycline hcl cap 50 (Tetracycline hcl) tetracycline hcl cap 500 (Tetracycline hcl) FLUOROQUINOLONES ciprofloxacin for oral susp 500 /5ml (0%) (0 gm/00ml) (Cipro) ciprofloxacin hcl tab 50 (base equiv) (Cipro) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide

8 08 ciprofloxacin hcl tab 500 (base equiv) (Cipro) ciprofloxacin hcl tab 750 (base equiv) ciprofloxacin-ciprofloxacin hcl tab er 4hr 500 (base eq) (Cipro xr) ciprofloxacin-ciprofloxacin hcl tab er 4hr 000 (base eq) (Cipro xr) levofloxacin tab 50 (Levaquin) levofloxacin tab 500 (Levaquin) levofloxacin tab 750 (Levaquin) ofloxacin tab 400 AMINOGLYCOSIDES neomycin sulfate tab 500 paromomycin sulfate cap 50 tobramycin nebu soln 300 /5ml (Tobi) TUBERCULOSIS ethambutol hcl tab 00 (Myambutol) ethambutol hcl tab 400 (Myambutol) isoniazid tab 00 isoniazid tab 300 PRIFTIN rifapentine tab 50 pyrazinamide tab 500 rifabutin cap 50 (Mycobutin) rifampin cap 50 (Rifadin) rifampin cap 300 (Rifadin) FUNGAL INFECTIONS fluconazole for susp 0 /ml (Diflucan) fluconazole for susp 40 /ml (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) flucytosine cap 50 (Ancobon) flucytosine cap 500 (Ancobon) griseofulvin microsize susp 5 /5ml griseofulvin microsize tab 500 (Grifulvin v) itraconazole cap 00 (Sporanox) NOXAFIL posaconazole tab delayed release 00 NOXAFIL posaconazole susp 40 /ml nystatin tab unit terbinafine hcl tab 50 (Lamisil) voriconazole for susp 40 /ml (Vfend) voriconazole tab 50 (Vfend) voriconazole tab 00 (Vfend) VIRAL INFECTIONS Cytomegalovirus valganciclovir hcl for soln 50 /ml (base equiv) (Valcyte) valganciclovir hcl tab 450 (base equivalent) (Valcyte) Hepatitis adefovir dipivoxil tab 0 (Hepsera) BARACLUDE entecavir oral soln 0.05 /ml Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 3

9 08 entecavir tab 0.5 (Baraclude) entecavir tab (Baraclude) EPCLUSA sofosbuvirvelpatasvir tab HARVONI ledipasvirsofosbuvir tab lamivudine tab 00 (hbv) (Epivir hbv) MAVYRET glecaprevirpibrentasvir tab PEGASYS peginterferon alfa-a inj 80 mcg/ml PEGASYS peginterferon alfa-a inj 80 mcg/0.5ml PEGASYS PROCLICK peginterferon alfa-a inj 35 mcg/0.5ml PEGASYS PROCLICK peginterferon alfa-a inj 80 mcg/0.5ml ribavirin cap 00 (Rebetol) ribavirin tab 00 (Copegus) SOVALDI sofosbuvir tab 400 VOSEVI sofosbuvirvelpatasvir-voxilaprevir tab Herpes acyclovir cap 00 (Zovirax) acyclovir susp 00 /5ml (Zovirax) acyclovir tab 400 (Zovirax) acyclovir tab 800 (Zovirax) famciclovir tab 5 (Famvir) famciclovir tab 50 (Famvir) famciclovir tab 500 (Famvir) valacyclovir hcl tab 500 (Valtrex) valacyclovir hcl tab gm (Valtrex) HIV/AIDS abacavir sulfate soln 0 /ml (base equiv) (Ziagen) abacavir sulfate tab 300 (base equiv) (Ziagen) abacavir sulfate-lamivudine tab (Epzicom) abacavir sulfate-lamivudinezidovudine tab (Trizivir) atazanavir sulfate cap 50 (base equiv) (Reyataz) atazanavir sulfate cap 00 (base equiv) (Reyataz) atazanavir sulfate cap 300 (base equiv) (Reyataz) ATRIPLA efavirenzemtricitabine-tenofovir df tab COMPLERA emtricitabinerilpivirine-tenofovir df tab DESCOVY emtricitabinetenofovir alafenamide fumarate tab 00-5 didanosine delayed release capsule 00 (Videx ec) didanosine delayed release capsule 50 (Videx ec) didanosine delayed release capsule 400 (Videx ec) efavirenz cap 50 (Sustiva) efavirenz cap 00 (Sustiva) efavirenz tab 600 (Sustiva) EVOTAZ atazanavir sulfatecobicistat tab (base equiv) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 4

10 08 GENVOYA elvitegrav-cobicemtricitab-tenofov af tab INTELENCE etravirine tab 5 INTELENCE etravirine tab 00 INTELENCE etravirine tab 00 ISENTRESS raltegravir potassium packet for susp 00 (base equiv) ISENTRESS raltegravir potassium tab 400 (base equiv) ISENTRESS raltegravir potassium chew tab 5 (base equiv) ISENTRESS raltegravir potassium chew tab 00 (base equiv) ISENTRESS HD raltegravir potassium tab 600 (base equiv) KALETRA lopinavir-ritonavir tab 00-5 KALETRA lopinavir-ritonavir tab lamivudine oral soln 0 /ml (Epivir) lamivudine tab 50 (Epivir) lamivudine tab 300 (Epivir) lamivudine-zidovudine tab (Combivir) lopinavir-ritonavir soln /5ml (80-0 /ml) (Kaletra) nevirapine tab er 4hr 00 (Viramune xr) nevirapine tab er 4hr 400 (Viramune xr) nevirapine tab 00 (Viramune) NORVIR ritonavir tab 00 NORVIR ritonavir oral soln 80 /ml ODEFSEY emtricitabinerilpivirine-tenofovir af tab PREZCOBIX darunavircobicistat tab PREZISTA darunavir ethanolate susp 00 /ml (base equiv) PREZISTA darunavir ethanolate tab 75 (base equiv) PREZISTA darunavir ethanolate tab 50 (base equiv) PREZISTA darunavir ethanolate tab 600 (base equiv) PREZISTA darunavir ethanolate tab 800 (base equiv) REYATAZ atazanavir sulfate cap 50 (base equiv) REYATAZ atazanavir sulfate cap 00 (base equiv) REYATAZ atazanavir sulfate cap 300 (base equiv) stavudine cap 5 (Zerit) stavudine cap 0 (Zerit) stavudine cap 30 (Zerit) stavudine cap 40 (Zerit) STRIBILD elvitegrav-cobicemtricitab-tenofovdf tab SUSTIVA efavirenz tab 600 tenofovir disoproxil fumarate tab 300 (Viread) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 5

11 08 TIVICAY dolutegravir sodium tab 0 (base equiv) TIVICAY dolutegravir sodium tab 5 (base equiv) TIVICAY dolutegravir sodium tab 50 (base equiv) TRIUMEQ abacavirdolutegravir-lamivudine tab TRUVADA emtricitabinetenofovir disoproxil fumarate tab TRUVADA emtricitabinetenofovir disoproxil fumarate tab TRUVADA emtricitabinetenofovir disoproxil fumarate tab TRUVADA emtricitabinetenofovir disoproxil fumarate tab VIDEX didanosine for soln gm VIDEX didanosine for soln 4 gm VIRAMUNE nevirapine susp 50 /5ml VIREAD tenofovir disoproxil fumarate oral powder 40 / gm VIREAD tenofovir disoproxil fumarate tab 50 VIREAD tenofovir disoproxil fumarate tab 00 VIREAD tenofovir disoproxil fumarate tab 50 VIREAD tenofovir disoproxil fumarate tab 300 zidovudine cap 00 (Retrovir) zidovudine syrup 0 /ml (Retrovir) zidovudine tab 300 Influenza oseltamivir phosphate cap 30 (base equiv) (Tamiflu) oseltamivir phosphate cap 45 (base equiv) (Tamiflu) oseltamivir phosphate cap 75 (base equiv) (Tamiflu) oseltamivir phosphate for susp 6 /ml (base equiv) (Tamiflu) TAMIFLU oseltamivir phosphate for susp 6 /ml (base equiv) MALARIA atovaquone-proguanil hcl tab (Malarone) atovaquone-proguanil hcl tab (Malarone) chloroquine phosphate tab 500 (Aralen) DARAPRIM pyrimethamine tab 5 hydroxychloroquine sulfate tab 00 (Plaquenil) PRIMAQUINE PHOSPHATE primaquine phosphate tab 6.3 (5 base) WORM INFECTIONS ALBENZA albendazole tab 00 BENZNIDAZOLE benznidazole tab.5 BENZNIDAZOLE benznidazole tab 00 BILTRICIDE praziquantel tab 600 ivermectin tab 3 (Stromectol) OTHER ANTI-INFECTIVES clindamycin hcl cap 75 (Cleocin) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 6

12 08 clindamycin hcl cap 50 (Cleocin) clindamycin hcl cap 300 (Cleocin) clindamycin palmitate hcl for soln 75 /5ml (base equiv) (Cleocin pediatric gr) dapsone tab 5 dapsone tab 00 IMPAVIDO miltefosine cap 50 linezolid for susp 00 /5ml (Zyvox) linezolid tab 600 (Zyvox) metronidazole tab 50 (Flagyl) metronidazole tab 500 (Flagyl) SULFADIAZINE sulfadiazine tab 500 sulfamethoxazole-trimethoprim susp /5ml sulfamethoxazole-trimethoprim tab (Bactrim) sulfamethoxazole-trimethoprim tab (Bactrim ds) trimethoprim tab 00 vancomycin hcl cap 5 (Vancocin hcl) vancomycin hcl cap 50 (Vancocin hcl) XIFAXAN rifaximin tab 550 CANCER DRUGS ACTIMMUNE interferon gamma-b inj 00 mcg/0.5ml ( unit/0.5ml) AFINITOR everolimus tab.5 AFINITOR everolimus tab 5 AFINITOR everolimus tab 7.5 AFINITOR everolimus tab 0 AFINITOR DISPERZ everolimus tab for oral susp AFINITOR DISPERZ everolimus tab for oral susp 3 AFINITOR DISPERZ everolimus tab for oral susp 5 ALECENSA alectinib hcl cap 50 (base equivalent) ALUNBRIG brigatinib tab initiation therapy pack 90 & 80 ALUNBRIG brigatinib tab 30 ALUNBRIG brigatinib tab 90 ALUNBRIG brigatinib tab 80 anastrozole tab (Arimidex) bexarotene cap 75 (Targretin) bicalutamide tab 50 (Casodex) BOSULIF bosutinib tab 00 BOSULIF bosutinib tab 400 BOSULIF bosutinib tab 500 capecitabine tab 50 (Xeloda) capecitabine tab 500 (Xeloda) CAPRELSA vandetanib tab 00 CAPRELSA vandetanib tab 300 COMETRIQ cabozantinib s- malate cap 3 x 0 (60 dose) kit COMETRIQ cabozantinib s-mal cap x 80 & x 0 (00 dose) kit Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 7

13 08 COMETRIQ cabozantinib s-mal cap x 80 & 3 x 0 (40 dose) kit COTELLIC cobimetinib fumarate tab 0 (base equivalent) CYCLOPHOSPHAMIDE cyclophosphamide cap 5 CYCLOPHOSPHAMIDE cyclophosphamide cap 50 EMCYT estramustine phosphate sodium cap 40 ERIVEDGE vismodegib cap 50 ETOPOSIDE etoposide cap 50 exemestane tab 5 (Aromasin) FARESTON toremifene citrate tab 60 (base equivalent) FARYDAK panobinostat lactate cap 0 (base equivalent) FARYDAK panobinostat lactate cap 5 (base equivalent) FARYDAK panobinostat lactate cap 0 (base equivalent) flutamide cap 5 GILOTRIF afatinib dimaleate tab 0 (base equivalent) GILOTRIF afatinib dimaleate tab 30 (base equivalent) GILOTRIF afatinib dimaleate tab 40 (base equivalent) GLEOSTINE lomustine cap 5 GLEOSTINE lomustine cap 0 GLEOSTINE lomustine cap 40 GLEOSTINE lomustine cap 00 HEXALEN altretamine cap 50 HYCAMTIN topotecan hcl cap 0.5 (base equiv) HYCAMTIN topotecan hcl cap (base equiv) hydroxyurea cap 500 (Hydrea) IBRANCE palbociclib cap 75 IBRANCE palbociclib cap 00 IBRANCE palbociclib cap 5 ICLUSIG ponatinib hcl tab 5 (base equiv) ICLUSIG ponatinib hcl tab 45 (base equiv) imatinib mesylate tab 00 (base equivalent) (Gleevec) imatinib mesylate tab 400 (base equivalent) (Gleevec) IMBRUVICA ibrutinib cap 40 INLYTA axitinib tab INLYTA axitinib tab 5 IRESSA gefitinib tab 50 JAKAFI ruxolitinib phosphate tab 5 (base equivalent) JAKAFI ruxolitinib phosphate tab 0 (base equivalent) JAKAFI ruxolitinib phosphate tab 5 (base equivalent) JAKAFI ruxolitinib phosphate tab 0 (base equivalent) JAKAFI ruxolitinib phosphate tab 5 (base equivalent) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 8

14 08 KISQALI ribociclib succinate tab 00 (base equiv) KISQALI FEMARA 00 DOSE ribociclib tab 00 & letrozole tab.5 therapy pack KISQALI FEMARA 400 DOSE ribociclib tab 00 & letrozole tab.5 therapy pack KISQALI FEMARA 600 DOSE ribociclib tab 00 & letrozole tab.5 therapy pack LENVIMA 0 MG DAILY DOSE lenvatinib cap therapy pack 0 (0 daily dose) LENVIMA 4 MG DAILY DOSE lenvatinib cap therapy pack 0 & 4 (4 daily dose) LENVIMA 8 MG DAILY DOSE lenvatinib cap therapy pack 0 & 4 () (8 daily dose) LENVIMA 0 MG DAILY DOSE lenvatinib cap therapy pack 0 () (0 daily dose) LENVIMA 4 MG DAILY DOSE lenvatinib cap therapy pack 0 () & 4 (4 daily dose) LENVIMA 8 MG DAILY DOSE lenvatinib cap therapy pack 4 () (8 daily dose) letrozole tab.5 (Femara) LEUCOVORIN CALCIUM leucovorin calcium tab 0 LEUCOVORIN CALCIUM leucovorin calcium tab 5 leucovorin calcium tab 5 leucovorin calcium tab 5 LEUKERAN chlorambucil tab LONSURF trifluridine-tipiracil tab LONSURF trifluridine-tipiracil tab LYNPARZA olaparib cap 50 LYNPARZA olaparib tab 00 LYNPARZA olaparib tab 50 LYSODREN mitotane tab 500 MATULANE procarbazine hcl cap 50 megestrol acetate susp 40 /ml (Megace oral) megestrol acetate tab 0 megestrol acetate tab 40 MEKINIST trametinib dimethyl sulfoxide tab 0.5 (base equivalent) MEKINIST trametinib dimethyl sulfoxide tab (base equivalent) melphalan tab (Alkeran) mercaptopurine tab 50 (Purinethol) methotrexate sodium tab.5 (base equiv) MYLERAN busulfan tab NEXAVAR sorafenib tosylate tab 00 (base equivalent) nilutamide tab 50 (Nilandron) NINLARO ixazomib citrate cap.3 (base equivalent) NINLARO ixazomib citrate cap 3 (base equivalent) NINLARO ixazomib citrate cap 4 (base equivalent) ODOMZO sonidegib phosphate cap 00 (base equivalent) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 9

15 08 POMALYST pomalidomide cap POMALYST pomalidomide cap POMALYST pomalidomide cap 3 POMALYST pomalidomide cap 4 PURIXAN mercaptopurine susp 000 /00ml (0 /ml) RYDAPT midostaurin cap 5 SPRYCEL dasatinib tab 0 SPRYCEL dasatinib tab 50 SPRYCEL dasatinib tab 70 SPRYCEL dasatinib tab 80 SPRYCEL dasatinib tab 00 SPRYCEL dasatinib tab 40 STIVARGA regorafenib tab 40 SUTENT sunitinib malate cap.5 (base equivalent) SUTENT sunitinib malate cap 5 (base equivalent) SUTENT sunitinib malate cap 37.5 (base equivalent) SUTENT sunitinib malate cap 50 (base equivalent) SYLATRON peginterferon alfa-b for inj kit 00 mcg SYLATRON peginterferon alfa-b for inj kit 300 mcg SYLATRON peginterferon alfa-b for inj kit 600 mcg TABLOID thioguanine tab 40 TAFINLAR dabrafenib mesylate cap 50 (base equivalent) TAFINLAR dabrafenib mesylate cap 75 (base equivalent) TAGRISSO osimertinib mesylate tab 40 (base equivalent) TAGRISSO osimertinib mesylate tab 80 (base equivalent) tamoxifen citrate tab 0 (base equivalent) tamoxifen citrate tab 0 (base equivalent) TARCEVA erlotinib hcl tab 5 (base equivalent) TARCEVA erlotinib hcl tab 00 (base equivalent) TARCEVA erlotinib hcl tab 50 (base equivalent) TASIGNA nilotinib hcl cap 50 (base equivalent) TASIGNA nilotinib hcl cap 00 (base equivalent) temozolomide cap 5 (Temodar) temozolomide cap 0 (Temodar) temozolomide cap 00 (Temodar) temozolomide cap 40 (Temodar) temozolomide cap 80 (Temodar) temozolomide cap 50 (Temodar) tretinoin cap 0 TYKERB lapatinib ditosylate tab 50 (base equiv) VOTRIENT pazopanib hcl tab 00 (base equiv) XALKORI crizotinib cap 00 Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 0

16 08 XALKORI crizotinib cap 50 XTANDI enzalutamide cap 40 ZELBORAF vemurafenib tab 40 ZOLINZA vorinostat cap 00 ZYDELIG idelalisib tab 00 ZYDELIG idelalisib tab 50 ZYKADIA ceritinib cap 50 ZYTIGA abiraterone acetate tab 50 ZYTIGA abiraterone acetate tab 500 HORMONES, DIABETES AND RELATED DRUGS CORTICOSTEROIDS budesonide delayed release particles cap 3 (Entocort ec) CORTISONE ACETATE cortisone acetate tab 5 dexamethasone elixir 0.5 /5ml dexamethasone tab 0.5 dexamethasone tab 0.75 dexamethasone tab.5 dexamethasone tab 4 dexamethasone tab 6 fludrocortisone acetate tab 0. hydrocortisone tab 5 (Cortef) hydrocortisone tab 0 (Cortef) hydrocortisone tab 0 (Cortef) methylprednisolone tab therapy pack 4 () (Medrol dosepak) methylprednisolone tab 4 (Medrol) methylprednisolone tab 8 (Medrol) methylprednisolone tab 6 (Medrol) methylprednisolone tab 3 (Medrol) prednisolone sod phosph oral soln 6.7 /5ml (5 /5ml base) (Pediapred) prednisolone sod phosphate oral soln 5 /5ml (base equiv) prednisolone syrup 5 /5ml (usp solution equivalent) (Prelone) prednisone tab prednisone tab.5 prednisone tab 5 prednisone tab 0 prednisone tab 0 MALE HORMONES ANDROGEL testosterone td gel 0.5 /.5gm (.6%) ANDROGEL testosterone td gel 40.5 /.5gm (.6%) ANDROGEL PUMP testosterone td gel 0.5 / act (.6%) danazol cap 50 danazol cap 00 danazol cap 00 testosterone cypionate im inj in oil 00 /ml (Depotestosterone) testosterone cypionate im inj in oil 00 /ml (Depotestosterone) testosterone enanthate im inj in oil 00 /ml Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide

17 08 testosterone td gel 5 /.5gm (%) (Androgel) testosterone td gel 50 /5gm (%) (Androgel) testosterone td gel.5 /act (%) (Androgel pump) testosterone td soln 30 /act (Axiron) ESTROGENS CLIMARA PRO estradiollevonorgestrel td patch weekly /day DIVIGEL estradiol td gel 0.5 /0.5gm (0.%) DIVIGEL estradiol td gel 0.5 /0.5gm (0.%) DIVIGEL estradiol td gel / gm (0.%) estradiol & norethindrone acetate tab (Activella) estradiol & norethindrone acetate tab -0.5 (Activella) estradiol tab 0.5 (Estrace) estradiol tab (Estrace) estradiol tab (Estrace) estradiol td patch twice weekly 0.05 /4hr (Vivelle-dot) estradiol td patch twice weekly /4hr (Vivelle-dot) estradiol td patch twice weekly 0.05 /4hr (Vivelle-dot) estradiol td patch twice weekly /4hr (Vivelle-dot) estradiol td patch twice weekly 0. /4hr (Vivelle-dot) estradiol td patch weekly 0.05 /4hr (Climara) estradiol td patch weekly /4hr (37.5 mcg/4hr) (Climara) estradiol td patch weekly 0.05 /4hr (Climara) estradiol td patch weekly 0.06 /4hr (Climara) estradiol td patch weekly /4hr (Climara) estradiol td patch weekly 0. /4hr (Climara) norethindrone acetate-ethinyl estradiol tab mcg (Femhrt low dose) norethindrone acetate-ethinyl estradiol tab -5 mcg PREMARIN estrogens, conjugated tab 0.3 PREMARIN estrogens, conjugated tab 0.45 PREMARIN estrogens, conjugated tab 0.65 PREMARIN estrogens, conjugated tab 0.9 PREMARIN estrogens, conjugated tab.5 PREMPHASE conj est 0.65(4)/conj est-medroxypro ac tab (4) PREMPRO conjugated estrogen-medroxyprogest acetate tab PREMPRO conjugated estrogen-medroxyprogest acetate tab PREMPRO conjugated estrogen-medroxyprogest acetate tab PREMPRO conjugated estrogen-medroxyprogest acetate tab Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide

18 08 PROGESTINS medroxyprogesterone acetate tab.5 (Provera) medroxyprogesterone acetate tab 5 (Provera) medroxyprogesterone acetate tab 0 (Provera) norethindrone acetate tab 5 (Aygestin) progesterone micronized cap 00 (Prometrium) progesterone micronized cap 00 (Prometrium) BIRTH CONTROL desogest-eth estrad & eth estrad tab /0.0 (/5) (Mircette) desogest-ethin est tab / / (Cyclessa) desogestrel & ethinyl estradiol tab mcg (Desogen) drospirenone-ethinyl estradiol tab (Yaz) drospirenone-ethinyl estradiol tab (Yasmin 8) ELLA ulipristal acetate tab 30 ethynodiol diacetate & ethinyl estradiol tab -35 mcg ethynodiol diacetate & ethinyl estradiol tab -50 mcg (Zovia /50e) levonorg-eth est tab (84) & eth est tab 0.0(7) (Loseasonique) levonorg-eth est tab (84) & eth est tab 0.0(7) (Seasonique) levonorgestrel & ethinyl estradiol (9-day) tab levonorgestrel & ethinyl estradiol tab mcg levonorgestrel & ethinyl estradiol tab mcg levonorgestrel-eth estra tab / /0.5-30mcg medroxyprogesterone acetate im susp prefilled syr 50 /ml (Depo-provera contrac) medroxyprogesterone acetate im susp 50 /ml (Depo-provera contrac) norethindrone & ethinyl estradiol tab mcg (Ovcon-35) norethindrone & ethinyl estradiol tab mcg (Brevicon-8) norethindrone & ethinyl estradiol tab -35 mcg (Norinyl +35) norethindrone & ethinyl estradiol-fe chew tab mcg (Femcon fe) norethindrone ac-ethinyl estradfe tab -0/-30/-35 -mcg (Estrostep fe) norethindrone ace & ethinyl estradiol tab -0 mcg (Loestrin /0-) norethindrone ace & ethinyl estradiol tab.5-30 mcg (Loestrin.5/30-) norethindrone ace & ethinyl estradiol-fe tab -0 mcg (Loestrin fe /0) norethindrone ace & ethinyl estradiol-fe tab.5-30 mcg (Loestrin fe.5/30) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 3

19 08 norethindrone tab 0.35 (Norqd) norethindrone-eth estradiol tab / /-35 -mcg (Ortho-novum 7/7/7) norethindrone-eth estradiol tab /-35/ mcg (Trinorinyl 8) norgestimate & ethinyl estradiol tab mcg (Orthocyclen) norgestimate-eth estrad tab 0.8-5/0.5-5/0.5-5 mcg (Ortho tri-cyclen lo) norgestimate-eth estrad tab /0.5-35/ mcg (Ortho tri-cyclen) norgestrel & ethinyl estradiol tab mcg NUVARING etonogestrelethinyl estradiol va ring /4hr INFERTILITY FOLLISTIM AQ follitropin beta inj 300 unit/0.36ml FOLLISTIM AQ follitropin beta inj 600 unit/0.7ml FOLLISTIM AQ follitropin beta inj 900 unit/.08ml LUPRON DEPOT-PED (-MONTH leuprolide acetate for inj pediatric kit 7.5 LUPRON DEPOT-PED (-MONTH leuprolide acetate for inj pediatric kit.5 LUPRON DEPOT-PED (-MONTH leuprolide acetate for inj pediatric kit 5 LUPRON DEPOT-PED (3-MONTH leuprolide acetate (3 month) for inj pediatric kit.5 LUPRON DEPOT-PED (3-MONTH leuprolide acetate (3 month) for inj pediatric kit 30 PREGNYL W/DILUENT BENZYL chorionic gonadotropin for im inj 0000 unit SYNAREL nafarelin acetate nasal soln /ml (00 mcg/ act) (base eq) DIABETES acarbose tab 5 (Precose) acarbose tab 50 (Precose) acarbose tab 00 (Precose) BYDUREON exenatide for inj extended release susp BYDUREON BCISE exenatide extended release susp autoinjector /0.85ml BYDUREON PEN exenatide extended release for susp peninjector BYETTA exenatide soln peninjector 5 mcg/0.0ml BYETTA exenatide soln peninjector 0 mcg/0.04ml glimepiride tab (Amaryl) glimepiride tab (Amaryl) glimepiride tab 4 (Amaryl) glipizide tab er 4hr.5 (Glucotrol xl) glipizide tab er 4hr 5 (Glucotrol xl) glipizide tab er 4hr 0 (Glucotrol xl) glipizide tab 5 (Glucotrol) glipizide tab 0 (Glucotrol) glipizide-metformin hcl tab.5-50 glipizide-metformin hcl tab Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 4

20 08 glipizide-metformin hcl tab GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit glyburide micronized tab.5 (Glynase) glyburide micronized tab 3 (Glynase) glyburide micronized tab 6 (Glynase) glyburide tab.5 glyburide tab.5 glyburide tab 5 glyburide-metformin tab.5-50 (Glucovance) glyburide-metformin tab (Glucovance) glyburide-metformin tab (Glucovance) INVOKAMET canagliflozinmetformin hcl tab INVOKAMET canagliflozinmetformin hcl tab INVOKAMET canagliflozinmetformin hcl tab INVOKAMET canagliflozinmetformin hcl tab INVOKAMET XR canagliflozinmetformin hcl tab er 4hr INVOKAMET XR canagliflozinmetformin hcl tab er 4hr INVOKAMET XR canagliflozinmetformin hcl tab er 4hr INVOKAMET XR canagliflozinmetformin hcl tab er 4hr INVOKANA canagliflozin tab 00 INVOKANA canagliflozin tab 300 JANUMET sitagliptinmetformin hcl tab JANUMET sitagliptinmetformin hcl tab JANUMET XR sitagliptinmetformin hcl tab er 4hr JANUMET XR sitagliptinmetformin hcl tab er 4hr JANUMET XR sitagliptinmetformin hcl tab er 4hr JANUVIA sitagliptin phosphate tab 5 (base equiv) JANUVIA sitagliptin phosphate tab 50 (base equiv) JANUVIA sitagliptin phosphate tab 00 (base equiv) JARDIANCE empagliflozin tab 0 JARDIANCE empagliflozin tab 5 KOMBIGLYZE XR saxagliptinmetformin hcl tab er 4hr KOMBIGLYZE XR saxagliptinmetformin hcl tab er 4hr KOMBIGLYZE XR saxagliptinmetformin hcl tab er 4hr metformin hcl tab er 4hr 500 (Glucophage xr) metformin hcl tab er 4hr 750 (Glucophage xr) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 5

21 08 metformin hcl tab 500 (Glucophage) metformin hcl tab 850 (Glucophage) metformin hcl tab 000 (Glucophage) nateglinide tab 60 (Starlix) nateglinide tab 0 (Starlix) ONGLYZA saxagliptin hcl tab.5 (base equiv) ONGLYZA saxagliptin hcl tab 5 (base equiv) pioglitazone hcl tab 5 (base equiv) (Actos) pioglitazone hcl tab 30 (base equiv) (Actos) pioglitazone hcl tab 45 (base equiv) (Actos) pioglitazone hcl-metformin hcl tab (Actoplus met) pioglitazone hcl-metformin hcl tab (Actoplus met) repaglinide tab 0.5 (Prandin) repaglinide tab (Prandin) repaglinide tab (Prandin) SYNJARDY empagliflozinmetformin hcl tab SYNJARDY empagliflozinmetformin hcl tab SYNJARDY empagliflozinmetformin hcl tab SYNJARDY empagliflozinmetformin hcl tab SYNJARDY XR empagliflozinmetformin hcl tab er 4hr SYNJARDY XR empagliflozinmetformin hcl tab er 4hr SYNJARDY XR empagliflozinmetformin hcl tab er 4hr SYNJARDY XR empagliflozinmetformin hcl tab er 4hr VICTOZA liraglutide soln peninjector 8 /3ml (6 /ml) DIABETES - INSULINS Rapid-Acting Insulins FIASP insulin aspart inj 00 unit/ml FIASP FLEXTOUCH insulin aspart soln pen-injector 00 unit/ml NOVOLOG insulin aspart inj 00 unit/ml NOVOLOG FLEXPEN insulin aspart soln pen-injector 00 unit/ml NOVOLOG PENFILL insulin aspart soln cartridge 00 unit/ ml Short-Acting Insulins HUMULIN R U-500 (CONCENTR insulin regular (human) inj 500 unit/ml HUMULIN R U-500 KWIKPEN insulin regular (human) soln pen-injector 500 unit/ml NOVOLIN R insulin regular (human) inj 00 unit/ml Intermediate-Acting Insulins NOVOLIN N insulin nph (human) (isophane) inj 00 unit/ml NOVOLIN 70/30 insulin nph isophane & regular human inj 00 unit/ml (70-30) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 6

22 08 NOVOLOG MIX 70/30 insulin aspart prot & aspart (human) inj 00 unit/ml (70-30) NOVOLOG MIX 70/30 PREFILL insulin aspart prot & aspart sus pen-inj 00 unit/ml (70-30) Basal Insulins LANTUS insulin glargine inj 00 unit/ml LANTUS SOLOSTAR insulin glargine soln pen-injector 00 unit/ml LEVEMIR insulin detemir inj 00 unit/ml LEVEMIR FLEXTOUCH insulin detemir soln pen-injector 00 unit/ml TOUJEO SOLOSTAR insulin glargine soln pen-injector 300 unit/ml TRESIBA FLEXTOUCH insulin degludec soln pen-injector 00 unit/ml TRESIBA FLEXTOUCH insulin degludec soln pen-injector 00 unit/ml THYROID REGULATION levothyroxine sodium tab 5 mcg (Synthroid) levothyroxine sodium tab 50 mcg (Synthroid) levothyroxine sodium tab 75 mcg (Synthroid) levothyroxine sodium tab 88 mcg (Synthroid) levothyroxine sodium tab 00 mcg (Synthroid) levothyroxine sodium tab mcg (Synthroid) levothyroxine sodium tab 5 mcg (Synthroid) levothyroxine sodium tab 37 mcg (Synthroid) levothyroxine sodium tab 50 mcg (Synthroid) levothyroxine sodium tab 75 mcg (Synthroid) levothyroxine sodium tab 00 mcg (Synthroid) levothyroxine sodium tab 300 mcg (Synthroid) liothyronine sodium tab 5 mcg (Cytomel) liothyronine sodium tab 5 mcg (Cytomel) liothyronine sodium tab 50 mcg (Cytomel) methimazole tab 5 (Tapazole) methimazole tab 0 (Tapazole) propylthiouracil tab 50 SYNTHROID levothyroxine sodium tab 5 mcg SYNTHROID levothyroxine sodium tab 50 mcg SYNTHROID levothyroxine sodium tab 75 mcg SYNTHROID levothyroxine sodium tab 88 mcg SYNTHROID levothyroxine sodium tab 00 mcg SYNTHROID levothyroxine sodium tab mcg SYNTHROID levothyroxine sodium tab 5 mcg SYNTHROID levothyroxine sodium tab 37 mcg SYNTHROID levothyroxine sodium tab 50 mcg SYNTHROID levothyroxine sodium tab 75 mcg Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 7

23 08 SYNTHROID levothyroxine sodium tab 00 mcg SYNTHROID levothyroxine sodium tab 300 mcg GROWTH HORMONE INCRELEX mecasermin inj 40 /4ml (0 /ml) OMNITROPE somatropin for inj 5.8 OMNITROPE somatropin inj 5 /.5ml OMNITROPE somatropin inj 0 /.5ml OTHER HORMONES AND RELATED DRUGS alendronate sodium tab 5 alendronate sodium tab 0 alendronate sodium tab 35 alendronate sodium tab 70 (Fosamax) cabergoline tab 0.5 calcitonin (salmon) nasal soln 00 unit/act (Miacalcin) calcitriol cap 0.5 mcg (Rocaltrol) calcitriol cap 0.5 mcg (Rocaltrol) calcitriol oral soln mcg/ml (Rocaltrol) desmopressin acetate inj 4 mcg/ ml (Ddavp) desmopressin acetate nasal soln 0.0% (refrigerated) (Ddavp) desmopressin acetate nasal spray soln 0.0% (Ddavp) desmopressin acetate nasal spray soln 0.0% (refrigerated) desmopressin acetate tab 0. (Ddavp) desmopressin acetate tab 0. (Ddavp) ibandronate sodium tab 50 (base equivalent) (Boniva) levocarnitine oral soln gm/0ml (0%) (Carnitor) levocarnitine tab 330 (Carnitor) LUPRON DEPOT-PED (-MONTH leuprolide acetate for inj pediatric kit 7.5 LUPRON DEPOT-PED (-MONTH leuprolide acetate for inj pediatric kit.5 LUPRON DEPOT-PED (-MONTH leuprolide acetate for inj pediatric kit 5 NITYR nitisinone tab NITYR nitisinone tab 5 NITYR nitisinone tab 0 octreotide acetate inj 50 mcg/ml (0.05 /ml) (Sandostatin) octreotide acetate inj 00 mcg/ml (0. /ml) (Sandostatin) octreotide acetate inj 00 mcg/ml (0. /ml) (Sandostatin) octreotide acetate inj 500 mcg/ml (0.5 /ml) (Sandostatin) octreotide acetate inj 000 mcg/ ml ( /ml) (Sandostatin) ORFADIN nitisinone susp 4 /ml ORFADIN nitisinone cap ORFADIN nitisinone cap 5 ORFADIN nitisinone cap 0 ORFADIN nitisinone cap 0 paricalcitol cap mcg (Zemplar) paricalcitol cap mcg (Zemplar) paricalcitol cap 4 mcg (Zemplar) raloxifene hcl tab 60 (Evista) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 8

24 08 risedronate sodium tab 5 (Actonel) risedronate sodium tab 30 (Actonel) risedronate sodium tab 35 (Actonel) risedronate sodium tab 50 (Actonel) SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 0 SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 0 SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 30 SENSIPAR cinacalcet hcl tab 30 (base equiv) SENSIPAR cinacalcet hcl tab 60 (base equiv) SENSIPAR cinacalcet hcl tab 90 (base equiv) STIMATE desmopressin acetate nasal soln.5 /ml STRENSIQ asfotase alfa subcutaneous inj 8 /0.45ml STRENSIQ asfotase alfa subcutaneous inj 8 /0.7ml STRENSIQ asfotase alfa subcutaneous inj 40 /ml STRENSIQ asfotase alfa subcutaneous inj 80 /0.8ml TYMLOS abaloparatide subcutaneous soln peninjector 30 mcg/.56ml HEART AND CIRCULATORY DRUGS ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATI benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab 0-.5 (Lotensin hct) benazepril & hydrochlorothiazide tab 0-.5 (Lotensin hct) benazepril & hydrochlorothiazide tab 0-5 (Lotensin hct) benazepril hcl tab 5 benazepril hcl tab 0 (Lotensin) benazepril hcl tab 0 (Lotensin) benazepril hcl tab 40 (Lotensin) captopril tab.5 captopril tab 5 captopril tab 50 captopril tab 00 enalapril maleate & hydrochlorothiazide tab 5-.5 enalapril maleate & hydrochlorothiazide tab 0-5 (Vaseretic) enalapril maleate tab.5 (Vasotec) enalapril maleate tab 5 (Vasotec) enalapril maleate tab 0 (Vasotec) enalapril maleate tab 0 (Vasotec) fosinopril sodium & hydrochlorothiazide tab 0-.5 Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 9

25 08 fosinopril sodium & hydrochlorothiazide tab 0-.5 fosinopril sodium tab 0 fosinopril sodium tab 0 fosinopril sodium tab 40 lisinopril & hydrochlorothiazide tab 0-.5 (Zestoretic) lisinopril & hydrochlorothiazide tab 0-.5 (Zestoretic) lisinopril & hydrochlorothiazide tab 0-5 (Zestoretic) lisinopril tab.5 (Zestril) lisinopril tab 5 (Prinivil) lisinopril tab 0 (Prinivil) lisinopril tab 0 (Prinivil) lisinopril tab 30 (Zestril) lisinopril tab 40 (Zestril) moexipril hcl tab 7.5 (Univasc) moexipril hcl tab 5 (Univasc) moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab 5-.5 (Uniretic) moexipril-hydrochlorothiazide tab 5-5 perindopril erbumine tab perindopril erbumine tab 4 (Aceon) perindopril erbumine tab 8 (Aceon) quinapril hcl tab 5 (Accupril) quinapril hcl tab 0 (Accupril) quinapril hcl tab 0 (Accupril) quinapril hcl tab 40 (Accupril) quinapril-hydrochlorothiazide tab 0-.5 (Accuretic) quinapril-hydrochlorothiazide tab 0-.5 (Accuretic) quinapril-hydrochlorothiazide tab 0-5 (Accuretic) ramipril cap.5 (Altace) ramipril cap.5 (Altace) ramipril cap 5 (Altace) ramipril cap 0 (Altace) trandolapril tab (Mavik) trandolapril tab (Mavik) trandolapril tab 4 (Mavik) ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS amlodipine-valsartanhydrochlorothiazide tab (Exforge hct) amlodipine-valsartanhydrochlorothiazide tab (Exforge hct) amlodipine-valsartanhydrochlorothiazide tab (Exforge hct) amlodipine-valsartanhydrochlorothiazide tab (Exforge hct) amlodipine-valsartanhydrochlorothiazide tab (Exforge hct) candesartan cilexetil tab 4 (Atacand) candesartan cilexetil tab 8 (Atacand) candesartan cilexetil tab 6 (Atacand) candesartan cilexetil tab 3 (Atacand) candesartan cilexetilhydrochlorothiazide tab 6-.5 (Atacand hct) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 0

26 08 candesartan cilexetilhydrochlorothiazide tab 3-.5 (Atacand hct) candesartan cilexetilhydrochlorothiazide tab 3-5 (Atacand hct) irbesartan tab 75 (Avapro) irbesartan tab 50 (Avapro) irbesartan tab 300 (Avapro) irbesartan-hydrochlorothiazide tab (Avalide) irbesartan-hydrochlorothiazide tab (Avalide) losartan potassium & hydrochlorothiazide tab (Hyzaar) losartan potassium & hydrochlorothiazide tab (Hyzaar) losartan potassium & hydrochlorothiazide tab 00-5 (Hyzaar) losartan potassium tab 5 (Cozaar) losartan potassium tab 50 (Cozaar) losartan potassium tab 00 (Cozaar) olmesartan medoxomil tab 5 (Benicar) olmesartan medoxomil tab 0 (Benicar) olmesartan medoxomil tab 40 (Benicar) olmesartan medoxomilhydrochlorothiazide tab 0-.5 (Benicar hct) olmesartan medoxomilhydrochlorothiazide tab (Benicar hct) olmesartan medoxomilhydrochlorothiazide tab 40-5 (Benicar hct) telmisartan tab 0 (Micardis) telmisartan tab 40 (Micardis) telmisartan tab 80 (Micardis) telmisartan-hydrochlorothiazide tab (Micardis hct) telmisartan-hydrochlorothiazide tab (Micardis hct) telmisartan-hydrochlorothiazide tab 80-5 (Micardis hct) valsartan tab 40 (Diovan) valsartan tab 80 (Diovan) valsartan tab 60 (Diovan) valsartan tab 30 (Diovan) valsartan-hydrochlorothiazide tab (Diovan hct) valsartan-hydrochlorothiazide tab (Diovan hct) valsartan-hydrochlorothiazide tab 60-5 (Diovan hct) valsartan-hydrochlorothiazide tab (Diovan hct) valsartan-hydrochlorothiazide tab 30-5 (Diovan hct) BETA BLOCKERS AND COMBINATIONS acebutolol hcl cap 00 (Sectral) acebutolol hcl cap 400 (Sectral) atenolol & chlorthalidone tab 50-5 (Tenoretic 50) atenolol & chlorthalidone tab 00-5 (Tenoretic 00) atenolol tab 5 (Tenormin) atenolol tab 50 (Tenormin) atenolol tab 00 (Tenormin) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide

27 08 bisoprolol & hydrochlorothiazide tab (Ziac) bisoprolol & hydrochlorothiazide tab (Ziac) bisoprolol & hydrochlorothiazide tab (Ziac) bisoprolol fumarate tab 5 (Zebeta) bisoprolol fumarate tab 0 (Zebeta) carvedilol tab 3.5 (Coreg) carvedilol tab 6.5 (Coreg) carvedilol tab.5 (Coreg) carvedilol tab 5 (Coreg) labetalol hcl tab 00 (Trandate) labetalol hcl tab 00 (Trandate) labetalol hcl tab 300 (Trandate) metoprolol & hydrochlorothiazide tab 50-5 (Lopressor hct) metoprolol & hydrochlorothiazide tab 00-5 (Lopressor hct) metoprolol succinate tab er 4hr 5 (tartrate equiv) (Toprol xl) metoprolol succinate tab er 4hr 50 (tartrate equiv) (Toprol xl) metoprolol succinate tab er 4hr 00 (tartrate equiv) (Toprol xl) metoprolol succinate tab er 4hr 00 (tartrate equiv) (Toprol xl) metoprolol tartrate tab 5 metoprolol tartrate tab 50 (Lopressor) metoprolol tartrate tab 00 (Lopressor) nadolol tab 0 (Corgard) nadolol tab 40 (Corgard) nadolol tab 80 (Corgard) pindolol tab 5 pindolol tab 0 propranolol hcl cap er 4hr 60 (Inderal la) propranolol hcl cap er 4hr 80 (Inderal la) propranolol hcl cap er 4hr 0 (Inderal la) propranolol hcl cap er 4hr 60 (Inderal la) propranolol hcl tab 0 propranolol hcl tab 0 propranolol hcl tab 40 propranolol hcl tab 60 propranolol hcl tab 80 CALCIUM CHANNEL BLOCKERS AND COMBINATIONS amlodipine besylate tab.5 (Norvasc) amlodipine besylate tab 5 (Norvasc) amlodipine besylate tab 0 (Norvasc) amlodipine besylate-atorvastatin calcium tab.5-0 (Caduet) amlodipine besylate-atorvastatin calcium tab.5-0 (Caduet) amlodipine besylate-atorvastatin calcium tab.5-40 (Caduet) amlodipine besylate-atorvastatin calcium tab 5-0 (Caduet) amlodipine besylate-atorvastatin calcium tab 5-0 (Caduet) Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide

28 08 amlodipine besylate-atorvastatin calcium tab 5-40 (Caduet) amlodipine besylate-atorvastatin calcium tab 5-80 (Caduet) amlodipine besylate-atorvastatin calcium tab 0-0 (Caduet) amlodipine besylate-atorvastatin calcium tab 0-0 (Caduet) amlodipine besylate-atorvastatin calcium tab 0-40 (Caduet) amlodipine besylate-atorvastatin calcium tab 0-80 (Caduet) amlodipine besylate-benazepril hcl cap.5-0 (Lotrel) amlodipine besylate-benazepril hcl cap 5-0 (Lotrel) amlodipine besylate-benazepril hcl cap 5-0 (Lotrel) amlodipine besylate-benazepril hcl cap 5-40 (Lotrel) amlodipine besylate-benazepril hcl cap 0-0 (Lotrel) amlodipine besylate-benazepril hcl cap 0-40 (Lotrel) amlodipine besylate-valsartan tab 5-60 (Exforge) amlodipine besylate-valsartan tab 5-30 (Exforge) amlodipine besylate-valsartan tab 0-60 (Exforge) amlodipine besylate-valsartan tab 0-30 (Exforge) diltiazem hcl cap er 4hr 0 diltiazem hcl cap er 4hr 80 diltiazem hcl cap er 4hr 40 diltiazem hcl coated beads cap er 4hr 0 (Cardizem cd) diltiazem hcl coated beads cap er 4hr 80 (Cardizem cd) diltiazem hcl coated beads cap er 4hr 40 (Cardizem cd) diltiazem hcl coated beads cap er 4hr 300 diltiazem hcl coated beads cap er 4hr 360 (Cardizem cd) diltiazem hcl extended release beads cap er 4hr 0 (Tiazac) diltiazem hcl extended release beads cap er 4hr 80 (Tiazac) diltiazem hcl extended release beads cap er 4hr 40 (Tiazac) diltiazem hcl extended release beads cap er 4hr 300 (Tiazac) diltiazem hcl extended release beads cap er 4hr 360 (Tiazac) diltiazem hcl extended release beads cap er 4hr 40 (Tiazac) diltiazem hcl tab 30 (Cardizem) diltiazem hcl tab 60 (Cardizem) diltiazem hcl tab 90 diltiazem hcl tab 0 (Cardizem) ENTRESTO sacubitril-valsartan tab 4-6 ENTRESTO sacubitril-valsartan tab 49-5 ENTRESTO sacubitril-valsartan tab felodipine tab er 4hr.5 felodipine tab er 4hr 5 felodipine tab er 4hr 0 Blue Cross and Blue Shield of Alabama April 08 Prescription Drug Guide 3