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Blue Cross & Blue Shield
of Rhode Island
Preferred Drug List
Effective October 2011 - March 2012
Three Tier Commercial Premier Formulary Guide
500 Exchange Street  Providence, RI 02903-2699  www.BCBSRI.com
Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association
Preferred Drug List
DRUG CATEGORY
ANTI-INFECTIVE
Anti-Flu #
ciclopirox 8% soln, fluconazole, flucytosine, Ertaczo, Grifulvin V 500 mg, Gris-Peg, Noxafil, griseofulvin micro, itraconazole^, ketoconazole, Cephalosporins, 2nd Generation # cefaclor/ER, cefprozil, cefuroxime amoxicillin, amoxicillin/clavulanate, penicillin VK ciprofloxacin/ER, levofloxacin, ofloxacin Avelox, Factive, Levaquin, Noroxin, Proquin XR doxycycline hyclate/monohydrate, minocycline ER metronidazole, miconazole, miconazole 3, nystatin, CARDIOVASCULAR
ACE Inhibitors
benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, benazepril/HCTZ, captopril/HCTZ, enalapril/HCTZ, fosinopril/HCTZ, lisinopril/HCTZ, moexipril/HCTZ, Angiotensin II Receptor Blockers # losartan Angiotensin II Receptor Blocker Combinations # losartan/HCTZ Atacand HCT^, Azor^, Benicar HCT^, Exforge^, Micardis HCT^, Teveten HCT^, Tribenzor^, atenolol, betaxolol, bisoprolol, carvedilol, Calcium Channel Blockers - Dihydropyridines Diphenylalkylamines Fibric Acid Derivatives/Niacin Amturnide^, Tekamlo^, Tekturna^, Tekturna HCT^, nitroglycerin oral spray, nitroglycerin transdermal CNS
Alcohol/Opioid Dependence #
Carbatrol, Depakote^/Depakote ER^, Dilantin, divalproex sodium/ER, felbamate, gabapentin, Felbatol, Keppra^, Lamictal^, Lyrica^, Phenytek^, lamotrigine, levetiracetam, oxcarbazepine, Tegretol-XR^, Topamax^, Trileptal^, Zonegran Anti-Depressants # bupropion/ER, citalopram, fluoxetine, mirtazapine, venlafaxine ER caps/tabs (generic) Anti-Emetics # dexamethasone, granisetron, metoclopramide, carbidopa/levodopa, pramipexole, ropinirole, clozapine, risperidone, ziprasidone Geodon, Abilify^, Fanapt, Fazaclo^, Invega, Saphris # - Quantity Limits for some plans OTC - Over the Counter; may not be covered by your prescription drug benefit. ^ - May require authorization for Managed Plan This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. Preferred Drug List
DRUG CATEGORY
CNS (continued)
Smoking Cessation
bupropion, nicotine patch/gum/lozenge (OTC) Stimulants/ADHD # dexmethylphenidate, dextroamphetamine, Adderall XR, Concerta, Daytrana, Metadate CD, COUGH, COLD, ALLERGY
Antihistamines #
Antihistamines - Decongestants # cetirizine D (OTC), loratadine D (OTC) DERMATOLOGICAL
Acne/Rosacea Products, Anti-infective #
Anti-Fungals # ciclopirox cream/susp, econazole cream, Exelderm cream/soln, Lamisil Spray, Naftin, Anti-Psoriatic Biologic/Systemic, oral # Keratolytics/Immunomodulators # podofilox soln Topical Steroids # alclometasone, amcinonide, betamethasone, Capex, Cloderm, Cordran, Cutivate lotion, Derma-Smoothe/FS, DesOwen cream/lotion/oint, diflorasone, fluocinolone, fluocinonide, Desonate, Kenalog spray, Locoid lotion/lipo cream, fluticasone, halobetasol, hydrocortisone, DIABETES
Biguanides
metformin/glipizide, metformin/glyburide Apidra, Humalog, Humalog Mix, Humulin 70/30, Novolin 70/30^, Novolin N/R^, Novolog^, Alpha-Glucosidase Inhibitors, Meglitinides LifeScan products: OneTouch, OneTouch Ultra, GASTROINTESTINAL
Bile Salts
calcium acetate, sodium polystyrene sulfonate cimetidine, famotidine, nizatidine, ranitidine Asacol, Asacol HD, Canasa, Lialda, Pentasa Proton Pump Inhibitors # omeprazole Dexilant GENITOURINARY
Alpha-Blockers/BPH
alfuzosin ER, doxazosin, finasteride, tamsulosin, Avodart, HEMATOLOGICAL
Anti-Platelet Agents #
HORMONES
Androgens #
Calcium Regulators # alendronate, calcitonin nasal spray Actonel^, Atelvia^, Boniva^, Fosamax Plus D^ Contraceptives Monophasic # Amethia (3 copayments apply), Apri, Balziva, Camrese (3 copayments apply), Kariva, Levora, Low-Ogestrel, Necon, Ocella, Sprintec, Zenchent, # - Quantity Limits for some plans OTC - Over the Counter; may not be covered by your prescription drug benefit. ^ - May require authorization for Managed Plan This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. Preferred Drug List
DRUG CATEGORY
HORMONES (continued)
Contraceptives Triphasic # Necon 7/7/7, Trinessa, Tri-Sprintec, Trivora
estradiol, estradiol/norethindrone, estropipate, Cenestin, Enjuvia, FemHRT 0.5 mg/2.5 mcg, Armour Thyroid, Nature-Throid, Synthroid MUSCULOSKELETAL
COX 2s/NSAIDs # diclofenac, etodolac, ibuprofen, indomethacin,
Arthrotec, Celebrex^, Flector^, Pennsaid^ meloxicam, nabumetone, naproxen, piroxicam, carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine, Narcotics & Analgesics # hydrocodone/acetaminophen, hydromorphone, Abstral^, Avinza, Fentora^, Kadian, Onsolis^, ibuprofen/oxycodone, morphine sulfate/ER, OPHTHALMICS
Allergy #
azelastine, cromolyn, epinastine, ketotifen Alamast, Alocril, Alomide, Emadine, Lastacaft, bacitracin oint, ciprofloxacin soln, erythromycin oint, Blephamide, Ciloxan oint, Tobrex oint gentamicin oint/soln, neomycin/polymyxin B/ bacitracin oint, neomycin/polymyxin B/gramicidin soln, ofloxacin soln, polymyxin B/bacitracin oint, polymixin B/trimethoprim soln, tobramycin soln, Anti-Inflammatory # dexamethasone, diclofenac, fluorometholone, betaxolol, carteolol, levobunolol, timolol Carbonic Anhydrase Inhibitors & CAI-BB OTIC
Anti-Infective/Anti-Inflammatory ofloxacin,
neomycin/polymixin B/hydrocortisone Ciprodex RESPIRATORY
Anticholinergics # ipratropium soln
Brovana, Maxair, Proventil HFA, Ventolin HFA, Advair, Asmanex, budesonide soln, Flovent, Nasal Steroids # flunisolide, fluticasone Selective Leukotriene Receptor Antagonists # zafirlukast VITAMINS
Miscellaneous
generics (e.g., Prenatabs, Prenatal Plus) # - Quantity Limits for some plans OTC - Over the Counter; may not be covered by your prescription drug benefit. ^ - May require authorization for Managed Plan This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. Specialty Drug List
The following is the Specialty Drug List, many of the drugs are oral tablets or self administered while some drugs
(in bold type) are typically provided within a physician office setting with coverage under the medical benefit.
For members with a specialty benefit, coverage for drugs listed in bold type will not be provided under the
medical benefit. Providers must obtain these products through a preferred specialty vendor. Medications noted with
a ^ below may require prior authorization. Medications with a # may be subject to quantity limits. Please refer to
www.bcbsri.com for more detailed program benefit information.
DRUG CATEGORY
SPECIALTY MEDICATION / HIGHEST TIER
DRUG CATEGORY
SPECIALTY MEDICATION / HIGHEST TIER
ANTI-INFECTIVE
Hemophilia, Factor VIIa
Antivirals, Hepatitis C
Hemophilia, Factor VII
PegIntron Redipen (peginterferon alfa 2b)^ HIV, AIDS
DERMATOLOGY
Psoriasis
Amevive (alefacept)^
Immune Globulins
Flebogamma^
Gamastan^
Gammagard^
Remicade (infliximab)^
Gamunex^ PREFERRED, Gamunex-C^ PREFERRED
Stelara (ustekinumab)^
Hizentra^
ENDOCRINE
Privigen^
Growth Hormone Products
Vivaglobin^
Miscellaneous Mozobil
(plerixafor)
Thrombocytopenia
WBC Deficiencies
IMMUNOMODULATOR
Cryopyrin-Associated
Periodic Syndromes
Lupus Erythematosus
Rheumatoid Arthritis
Actemra (tocilizumab)^
Miscellaneous Endocrine Disorders
Sandostatin LAR Depot (octreotide acetate)
Somatuline Depot (lanreotide acetate)
Supprelin LA (histrelin acetate)
Orencia (abatacept)^ #
Osteoporosis
Boniva IV formulation only (ibandronate)^
Remicade (infliximab)^
Rituxan (rituximab)^
Prolia (denosumab)^
Reclast (zoledronic acid)^
IMMUNOSUPPRESSIVE
GASTROENTEROLOGY
Transplant Drugs
Crohns, UC
INFERTILITY
Follitropins
Follistim AQ (follitropin beta) PREFERRED Remicade (infliximab)^
Tysabri (natalizumab)^
GnRH Antagonists
HEMATOLOGICAL
Fibrinogen Deficiency
Hemophilia
Hemophilia, Factor IX
Lutropin
Menotropins
SD Urofollitropins
# - Quantity Limits for some plans OTC - Over the Counter; may not be covered by your prescription drug benefit. ^ - May require authorization for Managed Plan. PREFERRED - These medications are preferred within their class. This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. Specialty Drug List
DRUG CATEGORY
SPECIALTY MEDICATION / HIGHEST TIER
DRUG CATEGORY
SPECIALTY MEDICATION / HIGHEST TIER
MISCELLANEOUS
Topical Agents
Anticonvulsants
Injectable Agents
Eligard (leuprolide acetate)
Firmagon
(degarelix)
Chronic Gout
Krystexxa (pegloticase)^
Lupron Depot (leuprolide acetate)
Enzyme Replacements
Aldurazyme (laronidase)
Plenaxis (abarelix)
Aralast (alpha1 proteinase inhibitor)
Trelstar Depot (triptorelin pamoate)
Ceredase (alglucerase)
Trelstar LA (triptorelin pamoate)
Cerezyme (imiglucerase)
Vantas (histrelin acetate)
Cinryze (human C1 inhibitor)
Elaprase (idursulfase)
Zoladex (goserelin acetate)
Fabrazyme (agalsidase beta)
PULMONARY
Glassia (alpha1 proteinase inhibitor)
Asthma Xolair
(omalizumab)^
Lumizyme (alglucosidase alfa)^
Cystic Fibrosis
Myozyme (alglucosidase alfa)^
Naglazyme (galsulfase)
Prolastin (alpha1 proteinase inhibitor)
Pulmonary Hypertension
Vpriv (velaglucerase)^
epoprostenol (generic)
(epoprostenol)
Zemaira (alpha1 proteinase inhibitor)
Iron Overload
Remodulin (treprostinil)
Macular Degeneration
Lucentis (ranibizumab)^
(pegaptanib)^
NEUROMUSCULAR
Huntington's
RSV Synagis
(palivizumab)^
Multiple Sclerosis
Tysabri (natalizumab)^
Muscle Disorder
Botox (botulinum toxin type A)^
Dysport (botulinum toxin type A)^
Myobloc (botulinum toxin type B)^
Xeomin (botulinum toxin type A)^
ONCOLOGY/HEMATOLOGY
Hematology
NPlate (romiplostim)^
Oral Agents
Preferred Specialty Vendors
VILLAGE FERTILITY PHARMACY: TOLL FREE 1-877-334-1610
CAREMARK CONNECT
TOLL FREE 1-866-278-6634 • WEBSITE www.CAREMARK.com Resource Information for Physicians/Providers
BLUE CROSS & BLUE SHIELD OF RHODE ISLAND
LOCAL (401) 459-1000 • TOLL FREE 1-800-637-3718 PATIENT HEALTH EDUCATION PROGRAMS:
PHYSICIAN AND PROVIDER SERVICE
LOCAL (401) 274-4848 • TOLL FREE 1-800-230-9050 # - Quantity Limits for some plans OTC - Over the Counter; may not be covered by your prescription drug benefit. ^ - May require authorization for Managed Plan. PREFERRED - These medications are preferred within their class. This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage.

Source: https://www.bcbsri.com/sites/default/files/documents/Preferred_Drug_List_pdf.pdf