Excluded Drug Name. Tablet Delayed Release. Lozenge on a Handle
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- Buddy Tate
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1 Abilify Absorica Abstral Acanya Accolate Aciphex Aciphex Sprinkle Acticlate Actiq Actonel Actos Adapalene Adderall Adderall XR Adrenaclick Page 1 of 9 Sublingual Delayed Release Sprinkle Lozenge on a Handle Extended Release 24 Auto-injector Aerospan Aerosol Alcortin A Almotriptan Malate Alomide Altabax Ointment Altoprev Extended Release 24 Alvesco Aerosol Amcinonide Lotion Extended Release 24 Amrix Anafranil Apexicon E Ointment Apidra Aplenzin Extended Release 24 Arava Arthrotec (diclofenac & misoprostel) Delayed Release Asacol HD Delayed Release Atacand Atacand HCT Auvi-Q Auto-injector Avalide Avapro Avar Avar Cleanser Emulsion Avar LS Cleanser (sulfur 2%/ sulfacetamide Liquid 10%) Avar-e Emollient Azor Beconase AQ
2 Benicar Benicar HCT Bepreve Betamethasone Valerate Betapace Betapace AF Budesonide Butalbital-acetaminophen-caffeine Bydureon Pen-injector Byetta Pen Pen-injector Cafergot Cambia powder Packet Carac Extended Release 12 Carbatrol Cardizem Cardizem CD Cardizem LA Carisoprodol **250mg** Celexa Cetirizine HCl Ciclopirox Ciclopirox Shampoo Ciclopirox Olamine Clarinex Climara Patch Weekly Clindagel Clindamycin Phos-Benzoyl Perox ***1%/5%**** Clindamycin Phosphate Clindamycin-Tretinoin Clobetasol Propionate Liquid Clobex Spray Liquid Clocortolone Pivalate Clotrimazole-Betamethasone Colazal Extended Release 24 ConZip Cordran Lotion Cordran Tape Coreg Extended Release 24 Coreg CR Cozaar Crestor Cyclobenzaprine HCl ***7.5mg*** Page 2 of 9
3 Cymbalta Page 3 of 9 Delayed Release Particles Daklinza Darifenacin Extended Release 24 Delzicol Delayed Release Demerol Desloratadine Desonide Desoximetasone Detrol Extended Release 24 Detrol LA Dexilant Delayed Release Extended Release 24 Dexmethylphenidate HCl ER Dexpak Therapy Pack Diclofenac-Misoprostol Delayed Release Differin Dilaudid Diovan Diovan HCT Ditropan XL Extended Release 24 Divigel Dolophine Doryx Delayed Release Doryx MPC Delayed Release Doxycycline Delayed Release Duexis (ibuprofen + famotidine) Dutoprol Extended Release 24 Dyrenium E.E.S. Granules Reconstituted Ecoza Edarbi Edarbyclor Extended Release 24 Effexor XR ***CAPSULES*** Elavil Enablex Extended Release 24 Epiduo Epiduo Forte eprosartan mesylate EryPed 200 Reconstituted EryPed 400 Reconstituted Esomeprazole Magnesium Delayed Release Estrace Estrace
4 Evamist Exforge Exforge HCT Extavia Kit Page 4 of 9 Fanapt Farxiga Fentora Fexofenadine HCl Fioricet Flunisolide Fluocinonide ***0.1%*** FLUoxetine HCl ***60mg *** FLUoxetine HCl ***90mg*** Delayed Release Flurandrenolide Lotion Fluticasone Propionate Fluvastatin Sodium Fluvastatin Sodium ER Extended Release 24 FML Ointment Focalin Extended Release 24 Focalin XR Forfivo XL Extended Release 24 Fortamet Extended Release 24 Fortesta Fosrenol Frovatriptan Succinate nique Genotropin Reconstituted Gleevec Glucophage Glucophage XR Extended Release 24 Glumetza Extended Release 24 Gralise Halog Hycet Hydrocodone-Acetaminophen **10/300** Hydrocodone-Acetaminophen **2.5/325** Hydrocodone-Acetaminophen **5/300** Hydrocodone-Acetaminophen **7.5/300** Hydrocortisone Butyr Lipo Base Hydrocortisone Butyrate Hydrocortisone Valerate Hyzaar
5 Incruse Ellipta Aerosol Powder Breath Activated Intermezzo Sublingual Intuniv Extended Release 24 Jalyn Jublia Kazano Keppra Keppra XR Extended Release 24 Kerydin Ketoconazole Kombiglyze XR Extended Release 24 LaMICtal LamICtal ODT Disintegrating LamICtal XR Extended Release 24 Lanoxin Lansoprazole Delayed Release Lastacaft Lescol XL Extended Release 24 Levitra Levocetirizine Dihydrochloride Lipitor Locoid Lotion Loprox Shampoo Loratadine Lortab Lorzone ***750mg*** Lumigan Lunesta Luzu Macrodantin Matzim LA Extended Release 24 Menostar Patch Weekly Metadate CD Extended Release Metadate ER Extended Release MetFORMIN HCl ER (MOD) Extended Release 24 MetFORMIN HCl ER (OSM) Extended Release 24 Methylin Mevacor Miacalcin Injection Miacalcin Nasal Spray Micardis Millipred Page 5 of 9
6 Minivelle Minocin Page 6 of 9 Patch Twice Weekly Minocycline HCl ***TABS*** Mometasone Furoate MS Contin Extended Release Myrbetriq Extended Release 24 Naftifine HCl Naftin Extended Release 24 Namenda XR Naprelan Extended Release 24 Nasonex Natesto Nesina Neupogen Neurontin NexIUM Nilandron Norco Noritate Norpramin Norvasc Novacort Novolin/Novolog Nutropin AQ NuSpin Nuvigil Nystatin-Triamcinolone Oleptro Extended Release 24 Olux-E Olysio Omeprazole-Sodium Bicarbonate Omnaris Onexton Onglyza Opsumit Oracea Delayed Release OrthoVisc Prefilled Syringe Oseni Oxiconazole Nitrate Oxistat Lotion OxyCODONE HCl ***CAPS*** Oxytrol Patch Twice Weekly Pamelor
7 Pataday Page 7 of 9 Paxil Paxil CR Extended Release 24 Pazeo Pennsaid Pexeva Plavix Plexion Cleanser Liquid Pradaxa Pred Forte Pred Mild Prevacid Delayed Release Prevacid SoluTab Disintegrating Prilosec Pristiq Extended Release 24 Promethazine-DM Syrup Protonix Proventil HFA Aerosol PROzac Prozac weekly Delayed Release Qnasl Aerosol Qnasl Childrens Aerosol Extended Release 24 Qsymia RABEprazole Sodium Delayed Release Rayos Delayed Release Relistor Relpax Rhinocort Allergy Rhinocort Aqua Ritalin Extended Release 24 Ritalin LA Roxicodone Rozerem Saizen Reconstituted Sernivo Emulsion Silenor Singulair Solodyn Extended Release 24 Spritam Disintegrating Soluble Sulfacetamide Sodium-Sulfur Sumavel DosePro Jet-injector Surmontil
8 Symbicort Aerosol Technivie TEGretol TEGretol-XR Extended Release 12 Telmisartan-HCTZ Terbinafine HCl Testim Testosterone Tetracycline HCl Teveten Teveten HCT TiZANidine HCl CAPS Tofranil Tofranil PM Topamax Topamax ER ER 24 Sprinkle Topamax Sprinkle Sprinkle Topicort Spray Liquid Toviaz Extended Release 24 Extended Release 24 Tramadol HCL ER ***CAP*** Tretinoin ***0.05% gel*** Trexall Treximet Tri-Luma Triamcinolone Acetonide Aerosol Trianex Ointment Tricor Trileptal Extended Release 24 Trokendi XR Tudorza Pressair Aerosol Powder Breath Activated Ultram Ultram ER Extended Release 24 Ultravate Lotion Uroxatral Extended Release 24 Valcyte Valtrex Vanoxide-HC Lotion Veltin Venlafaxine HCl ER ***TABS*** Extended Release 24 Veramyst Verdeso Verdrocet Page 8 of 9
9 VESIcare Vicodin Vicodin ES Vicodin HP Vicoprofen Viekara Pak Therapy Pack Vimovo Delayed Release Vivelle-Dot Patch Twice Weekly Vogelxo Vogelxo Pump Voltaren Wellbutrin SR Extended Release 12 Wellbutrin XL Extended Release 24 Xalatan Xigduo & XR Xiidra Xodol Xolegel Xopenex HFA Aerosol Xylon Xyzal Zamicet Zegerid Zepatier Zetonna Aerosol Ziana Zioptan Zocor Zoloft Zolpidem Tartrate Sublingual Zolpidem Tartrate ER Extended Release Zonegran Zovirax Zubsolv Sublingual Zyclara Page 9 of 9
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Alert Warfarin Ordered without INR CPOE, Nursing and Pharmacy 10/13/14 S B A R Prescribers currently do NOT get a warning if warfarin is actively ordered and there has not been an INR result in the past
BLUE SHIELD OF CALIFORNIA MARCH 2016 STANDARD DRUG FORMULARY CHANGES
BLUE SHIELD OF CALIFORNIA MARCH 2016 STANDARD DRUG FORMULARY CHANGES Blue Shield is committed to covering safe, effective and affordable medications, so we regularly review and update our drug formularies.
The Medical Letter. on Drugs and Therapeutics
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U T I L I Z A T I O N E D I T S
I N D I A N A H E A L T H C O V E R A G E P R O G R A M S U T I L I Z A T I O N E D I T S A P R I L 1 9, 2 0 1 2 s for s Refer to Provider Bulletin BT200709 for additional information regarding the Mental
Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70 mg Fosamax Arthritis
AGGRENOX. Products Affected. Details. Open 1 Last Updated: 12/01/2018. Aggrenox
Open 1 Last Updated: 12/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 18066: version 17 1 ANTICONVULSANTS
2013 Quantity Level Limits (QLL) Criteria
Certain drugs covered through your EmblemHealth Medicare PDP Medicare Plan are covered for only a limited quantity. We do this to ensure compliance with the US Food and Drug Administration and manufacturer
STEP THERAPY. Cigna Pharmacy Management. What is Step Therapy?
STEP THERAPY Cigna Pharmacy Management What is Step Therapy? Prescription medications cost a lot of money. At Cigna, we get that. That s why we ve created a program that helps save you money and stay healthy.
Avoid paying too much for your prescriptions
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Rx Step Program Medicine List Avoid paying too much for your prescriptions It s important to try to
Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
School Corp Formulary Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70
ABBREVIATED FORMULARY As of January 1, 2018
ABBREVIATED FORMULARY As of January 1, 2018 fepblue.org Review this abbreviated formulary to learn how to get the most from your pharmacy benefit such as: n Understanding the Formulary n How to use the