October 30, 2017 | Author: Anonymous | Category: N/A
for the most up-to-date information. Contents. Prime Therapeutics Blue Cross and Blue Shield of Kansas ......
October 2017 (2016 Plan Year)
Blue Cross and Blue Shield of Kansas Formulary for BlueCareSM Products
The Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products is regularly updated. Please visit www.bcbsks.com or Prime Therapeutics website at www.MyPrime.com for the most up-to-date information.
Contents
Therapeutic Class Drug List
Introduction ...................................................................... I
Anti-Infective Agents........................................................1
How Formulary Drugs Are Selected for
Biologicals .....................................................................18
BlueCare Products ....................................................... I
Antineoplastic Agents ....................................................24
Tiers ................................................................................. I
Endocrine and Metabolic Drugs ....................................32
Affordable Care Act ......................................................... I
Cardiovascular Agents ..................................................60
Specialty Products .......................................................... II
Respiratory Agents ........................................................86
Step Therapy .................................................................. II
Gastrointestinal Agents .................................................95
Prior Authorization .......................................................... II
Genitourinary Agents ...................................................104
Quantity Limits ................................................................ II
Central Nervous System Drugs ...................................109
Excluded Drugs .............................................................. II
Analgesics and Anesthetics ........................................135
Key ................................................................................. III
Neuromuscular Drugs .................................................157 Nutritional Products .....................................................170 Hematological Agents .................................................179 Topical Products ..........................................................188 Miscellaneous Products ..............................................217 Index ............................................................................279
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. Blue Cross and Blue Shield of Kansas and BlueCross BlueShield Kansas Solutions are independent licensees of the Blue Cross Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. AllianceRx Walgreens Prime provides pharmacy benefits and is not affiliated with Blue Cross and Blue Shield of Kansas or BlueCross BlueShield Kansas Solutions.
5-103-D KS HIM © Prime Therapeutics 10/17
Introduction The attached Formulary for BlueCare Products shows covered drugs for a broad range of diseases. Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Brand prescription drugs are shown in capital letters followed by the generic name. The Formulary for BlueCare Products is organized into broad categories (e.g. Anti-Infective Agents). Within most categories, drugs are sub-grouped by drug class (e.g. Penicillins) or by use for a specific medical condition (e.g. Diabetes). Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However, decisions regarding therapy and treatment are always between members and their physician. The current version of the Formulary for BlueCare Products is available at the BCBSKS website at www.bcbsks.com or by calling BCBSKS customer service at 1.800.432.3990. Online pharmacy tools are available through the Prime Therapeutics website at www.MyPrime.com. You can find drug cost estimates or check if a particular drug is on the Formulary for BlueCare Products..
How Formulary Drugs Are Selected for BlueCare Products Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. Both drugs that are newly approved by the U.S. Food and Drug Administration (FDA) as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list.
Tiers This prescription benefit is multi-tiered, placing prescription drugs into one of five copay/coinsurance levels: • Generic Drugs (Tier 1) • Preferred Brand Drugs (Tier 2) • Non-Preferred Brand Drugs (Tier 3) • Preferred Specialty Drugs (Tier 4) • Non-Preferred Specialty Drugs (Tier 5) • Drugs Subject to Medical Benefit (M) • Drugs that may be covered if criteria for $0 copay under the Affordable Care Act are met (A)
Affordable Care Act (ACA) Preventive Drugs marked in the ACA column are covered at $0 cost share when meeting the conditions outlined under the Affordable Care Act. Examples of categories of drugs that may be subject to $0 cost share include aspirin, breast cancer preventive,fluoride supplements, folic acid supplements, iron supplements, tobacco cessation, vitamin D supplements, and FDA approved contraceptive methods. If you do not find the drug you are searching for, contact BCBSKS to find out if the drug is available over the counter or is covered under your medical benefit.
Blue Cross and Blue Shield of Kansas Formulary for BlueCareSM Products October 2017 (2016 Plan Year)
I
Specialty Products Specialty drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral or injectable medications that can either be self-administered or administered by a health care professional. Drugs marked as “Limited Distribution” have restrictions on where you may obtain the drug. Your prescription drug benefit may require you to use AllianceRx Walgreens Prime to be eligible for in-network benefits. If you have questions about your specialty pharmacy benefit, please call the phone number on the back of your ID card. Oral oncology drugs subject to the medical benefit are listed as drug tier M.
Step Therapy Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. If a step therapy is required for a medication listed in this document, it will be noted next to the medication with a dot under the step therapy column.
Prior Authorization Your benefit plan may require prior authorization for certain drugs that are high-cost or have the potential for misuse. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. If a prior authorization is required for a medication listed in this document, it will be noted next to the medication with a dot under the prior authorization column.
Quantity Limits Drug quantity limits help encourage medication use as intended by the FDA. Quantity limits are placed on medications in certain drug categories. For the medications listed in this document, if a quantity limit applies, it will be noted next to the medication with a dot under the quantity limits column. Limits may include: quantity of covered medication per prescription and/or quantity of covered medication in a given time period. If your doctor prescribes a greater quantity of medication than what the quantity limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows. There may also be limits for members within a certain age range, and coverage only for members of a specific gender.
Excluded Drugs Drugs not found listed in this Formulary may be excluded from coverage. Drugs excluded from coverage will be allowed if certain exception criteria are met.
Blue Cross and Blue Shield of Kansas Formulary for BlueCareSM Products October 2017 (2016 Plan Year)
II
Key cap ...................................................................... capsules odt ............................................. orally disintegrating tabs chew .................................................................. chewable oint ..................................................................... ointment conc ............................................................. concentrate ophth ............................................................... ophthalmic cr ..........................................................controlled-release osm.......................................................... osmotic-release dr .............................................................delayed-release powd..................................................................... powder ec ................................................................enteric coated sa ............................................................ sustained-action effe................................................................. effervescent sl ...................................................................... sublingual equiv ................................................................ equivalent soln ....................................................................... solution er .......................................................... extended-release sr .......................................................... sustained-release inhal................................................................... inhalation suppos ........................................................ suppositories inj ......................................................................... injection susp................................................................ suspension liq .............................................................................. liquid tab...........................................................................tablets lotn ........................................................................... lotion td ................................................................... transdermal nebu ................................................................... nebulizer
Blue Cross and Blue Shield of Kansas Formulary for BlueCareSM Products October 2017 (2016 Plan Year)
III
This information is being furnished in compliance with applicable federal regulations. This Notice has important information. This notice has important information about your application or coverage through Blue Cross and Blue Shield of Kansas. Look for key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Please call 1-800-432-3990. Discrimination is against the law. Blue Cross and Blue Shield of Kansas (BCBSKS) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. BCBSKS does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Kansas: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Holly Graves. If you believe that BCBSKS has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Holly Graves, Director, Internal Sales and Customer Service, 1133 S.W. Topeka Blvd., Topeka, KS 66629-0001, 785-291-4375, TTY: 1-800-430-1270, Fax: 785-290-0785,
[email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Holly Graves is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Este Aviso contiene información importante. Este aviso contiene información importante acerca de su solicitud o cobertura a través de Cruz Azul y Escudo Azul de Kansas. Preste atención a las fechas clave que contiene este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al 1-800-432-3990. Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng bàn về đơn nộp hoặc hợp đồng bảo hiểm qua chương trình Blue Cross và Blue Shield ở Kansas. Xin xem ngày then chốt trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ trúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Vui lòng gọi đến số 1-800-432-3990. 本通知有重要的訊息。本通知有關於您透過堪薩斯州的 Blue Cross 和 Blue Shield 提交的申請或保險的重要訊息。請留意本通知內的重 要日期。您可能需要在截止日期之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母語得到本訊息和幫助。請撥打 1-800-432-3990。 Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält wichtige Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Blaues Kreuz und Blaues Schild von Kansas. Suchen Sie nach wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter 1-800-432-3990. 본 통지서에는 중요한 정보가 들어 있습니다. 즉 이 통지서는 귀하의 신청에 관하여 그리고 캔사스의 Blue Cross와 Blue Shield를 통한 커버리지에 관한 정보를 포함하고 있습니다. 본 통지서에서 핵심이 되는 날짜들을 찾으십시오. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다. 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 1-800-432-3990으로 전화하십시오.
ແຈ້ງການນມ ີ້ ຂ ີ ມ ໍ້ ູນສ �ຳຄັນ. ແ ຈ້ງການນມ ີ້ ຂ ີ ມ ໍ້ ູນສ �ຳຄັນກ ່ຽວກັບຄ �ຳຮ້ອງສະໝັກ ຫຼື ຄວາມຄຸ້ມຄ ອງປະກັນໄ ພຂອງທ່ານຜ່ານ Blue Cross ແ ລະ Blue Shield ລັດKansas. ຈົ່ງກ ວດເບິ່ງວ ັນທີສ�ຳຄັນຕ ່າງໆໃນແຈ້ງການນີ້. ທ່ານອາດຈະຈ�ຳເປັນຕ້ອງດ�ຳເນີນກ ານຕາມກ�ຳນົດເ ວລາສະເພາະຕ່າງໆ ເພື່ອຮ ັກສາຄວາມຄຸ້ມຄ ອງປະກັນສ ຸຂະພາບຂອງທ່ານ ຫຼື ການຊ່ວຍເຫຼືອເລື່ອງຄ່າໃ ຊ້ຈ່າຍຕ່າງໆ. ທ່ານມສ ີ ິດໄ ດ້ຮ ັບຂມ ໍ້ ູນນ ີ້ ແ ລະ ຄວາມຊ່ວຍເຫຼືອ ເປັນພາສາຂອງທ່ານໂດຍບໍ່ເສຍຄ່າ. ກະລຸນາໂທຫາ 1-800-432-3990. 29-100 09/16
يحوي هذا االشعار معلومات مهمة بخصوص طلبك للحصول عىل التغطية من خالل بلو كروس آند بلو شيلد أوف.يحوي هذا االشعار معلومات هامة قد تحتاج التخاذ اجراء يف تواريخ معينة للحفاظ عىل تغطيتك الصحية او للمساعدة يف دفع. ابحث عن التواريخ الهامة يف هذا االشعار.كانساس .1 -800-432-3990 اتصل بالرقم. لك الحق يف الحصور عىل املعلومات واملساعدة بلغتك من دون أي تكلفة.التكاليف Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Asul na Krus at Asul na Kalasag ng Kansas. Tingnan ang mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Mangyaring tumawag sa 1-800-432-3990.
ဤသတိေပးခ်က္တြင္ အေရးၾကီးေသာ အခ်က္အလက္မ်ား ပါရွိပါသည္။ ဤသတိေပးခ်က္တြင္ သင့္ အပလီေကးရွင္း သို႔မဟုတ္ ဘလူး ခေရာ့စ္ (Blue Cross) ႏွင့္ ကန္ဆက္(Kansas) ျပည္နယ္၏ ဘလူးရွီးဒ္(Blue Shield) မွ အခြင့္အေရးအေၾကာင္း အေရးၾကီးသည့္ အခ်က္အလက္မ်ား ပါရွိပါသည္။ ဤအသိေပးခ်က္တြင္ အဓိကေန႔ရက္မ်ားကို ရွာေဖြပါ။ သင့္က်န္းမာေရး ေစာင့္ေရွာက္မႈ အခြင့္အေရးကို ရရွရ ိ န္ သိမ ႔ု ဟုတ္ ေငြကန ု ေ ္ ၾကးက်ခံ၍ ကူညမ ီ က ႈ ုိ ရရွႏ ိ င ုိ ရ ္ န္ သတ္မတ ွ ရ ္ က္အတိင ု း္ လုပေ ္ ဆာင္ရန္ လိအ ု ပ္ပါသည္။ သင္တ ့ င ြ ္ ဤအခ်က္အလက္မ်ားကို ရရွရ ိ န္ ႏွင့္ သင္ဘ ့ ာသာစကားျဖင့္ ကုနက ္ ်စရိတမ ္ ရွဘ ိ ဲ အကူအညီရပိင ု ခ ္ င ြ ့္ ရွပ ိ ါသည္။ ေက်းဇူးျပဳ၍ 1-800-432-3990 ကို ေခၚဆိပ ု ါ။ Cet avis fournit des informations importantes. Cet avis fournit des informations importantes sur votre demande ou sur votre assurance auprès de Croix bleue et bouclier bleu du Kansas. Recherchez les dates clés dans le présent avis. Vous devrez peut-être prendre des mesures avant une certaine échéance pour conserver votre assurance santé, faute de quoi vous devrez financer les coûts. Vous êtes autorisé à bénéficier gratuitement de ces informations et de cette aide dans votre langue. Veuillez appeler le 1-800-432-3990. この通知には重要な情報が含まれています。この通知には、カンザス州の健康保険組合および医療保険組合の申請または補償範囲に 関する重要な情報が含まれています。この通知に記載されている重要な日付をご確認ください。健康保険や有料サポートを維持する には、特定の期日までに行動を取らなければならない場合があります。ご希望の言語による情報とサポートが無料で提供されます。 1-800-432-3990 までお電話ください。 Настоящее уведомление содержит важную информацию. Это уведомление содержит важную информацию о вашем заявлении или страховом покрытии через Синий крест и Синий щит Канзаса. Посмотрите на ключевые даты в настоящем уведомлении. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по номеру 1-800-432-3990. Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv thov kev pab los yog koj qhov kev pab cuam los ntawm Blue Cross thiab Blue Shield ntawm Kansas. Saib cov caij nyoog los yog tej hnub tseem ceeb uas sau rau hauv daim ntawv no kom zoo. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau ua koj hom lus pub dawb rau koj. Thov hu rau tus xov tooj 1-800-432-3990.
بە تاريخ. این اطالعیه حاوی اطالعات مهمی در مورد فرم تقاضا یا پوشش بیمه ای شام توسط صلیب آبی و سپر آبی کانزاس می باشد.این اطالعیه حاوی اطالعات مهمی است ممکن است نیاز داشته باشید تا قبل از تاریخ خاصی اقدامی انجام دهید تا پوشش سالمت خود را نگه دارید یا در مورد هزینه ها کمک.های مهم در اين اطالعیه توجە مناييد . متاس بگیرید1 -800-432-3990 لطفاً با شامره تلفن. این حق شامست تا این اطالعات و کمک را برای زبان خود و به رایگان دریافت کنید.دریافت کنید Ilani hii ina Taarifa Muhimu. Ilani hii ina taarifa muhimu kuhusu maombi yako au chanjo kupitia Msalaba wa Samawati na Ngao ya Samawati ya Kansas. Angalia kwa ajili ya tarehe muhimu katika ilani hii. Waweza pia hitajika kuchukua hatua katika muda ulio pangwa fulani ili uweze ku hifadhi bima yako ya afya au msaada wa gharama zake. Una haki ya kupata habari hii na msaada kwa lugha yako bila gharama. Tafadhali piga nambari kwa 1-800-432-3990.
ANTI-INFECTIVE AGENTS PENICILLINS AMOXICILLIN - amoxicillin (trihydrate) chew tab 125 mg
2
AMOXICILLIN - amoxicillin (trihydrate) chew tab 250 mg
2
amoxicillin (trihydrate) cap 250 mg
1
amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg amoxicillin & k clavulanate for susp 200-28.5 mg/5ml
1 1 1 1 1 1 1 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 tab 875-125 mg (Augmentin)
1
AMOXICILLIN TRIHYDRATE amoxicillin (trihydrate) powder
3
AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab 200-28.5 mg
3
AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab 400-57 mg
3
ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm (Unasyn)
1
ampicillin & sulbactam sodium for inj 3 (2-1) gm (Unasyn)
1
ampicillin & sulbactam sodium for inj 15 (10-5) gm (Unasyn bulk pack)
1
ampicillin cap 500 mg
1
AMPICILLIN SODIUM ampicillin sodium for inj 125 mg
3
ampicillin sodium for inj 250 mg
1
ampicillin sodium for inj 500 mg
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)
1
amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg (Augmentin xr)
1
amoxicillin & k clavulanate tab 250-125 mg
1
ampicillin sodium for inj 10 gm
1
ampicillin sodium for iv soln 2 gm
amoxicillin & k clavulanate tab 500-125 mg (Augmentin)
ampicillin sodium for inj 1 gm ampicillin sodium for inj 2 gm
AUGMENTIN - amoxicillin & k clavulanate for susp 125-31.25 mg/5ml SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1 2
Products October (2016 Plan Year)
1
AUGMENTIN - amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
3
AUGMENTIN - amoxicillin & k clavulanate tab 500-125 mg
3
penicillin g potassium for inj 5000000 unit (Pfizerpen-g)
AUGMENTIN - amoxicillin & k clavulanate tab 875-125 mg
3
penicillin g potassium for inj 20000000 unit (Pfizerpen-g)
AUGMENTIN ES-600 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
3
AUGMENTIN XR - amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg
oxacillin sodium for inj 10 gm
PENICILLIN G SODIUM penicillin g sodium for inj 5000000 unit
3
BICILLIN C-R - penicillin g benzathine & procaine inj susp 1200000 unit/2ml
3
penicillin v potassium for soln 125 mg/5ml
1
BICILLIN C-R - penicillin g benzathine & procaine inj 900000-300000 unt/2ml
3
BICILLIN L-A - penicillin g benzathine intramuscular susp 600000 unit/ml
3
BICILLIN L-A - penicillin g benzathine intramuscular susp 1200000 unit/2ml
3
BICILLIN L-A - penicillin g benzathine intramuscular susp 2400000 unit/4ml
3
dicloxacillin sodium cap 250 mg
1
dicloxacillin sodium cap 500 mg
1
3
UNASYN - ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm
3
3
3
nafcillin sodium for inj 1 gm
1
UNASYN BULK PACK ampicillin & sulbactam sodium for inj 15 (10-5) gm
1
CEPHALOSPORINS
oxacillin sodium for inj 1 gm oxacillin sodium for inj 2 gm
1 1 1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
1
PFIZERPEN-G - penicillin g potassium for inj 20000000 unit
3
nafcillin sodium for inj 10 gm
1
3
MOXATAG - amoxicillin (trihydrate) tab er 24hr 775 mg nafcillin sodium for inj 2 gm
1
PFIZERPEN-G - penicillin g potassium for inj 5000000 unit
UNASYN - ampicillin & sulbactam sodium for inj 3 (2-1) gm
ACA
1
3
penicillin v potassium tab 500 mg
Dispensing Limits
1
3
penicillin v potassium tab 250 mg
Step Therapy
1
PENICILLIN G PROCAINE penicillin g procaine intramuscular susp 600000 unit/ml
penicillin v potassium for soln 250 mg/5ml
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
CEDAX - ceftibuten cap 400 mg
3
CEDAX - ceftibuten for susp 180 mg/5ml
3
Products October (2016 Plan Year)
2
CEFACLOR - cefaclor for susp 125 mg/5ml
3
CEFACLOR - cefaclor for susp 250 mg/5ml
3
3
CEFDITOREN PIVOXIL cefditoren pivoxil tab 400 mg (base equivalent)
1
CEFACLOR - cefaclor for susp 375 mg/5ml
3
cefepime hcl for inj 1 gm (Maxipime)
1
cefaclor cap 250 mg
1
cefepime hcl for inj 2 gm (Maxipime) cefixime for susp 100 mg/5ml (Suprax)
1
cefaclor cap 500 mg
1
CEFACLOR ER - cefaclor monohydrate tab er 12hr 500 mg
3
cefadroxil cap 500 mg
1
cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm
1 1 3
CEFAZOLIN SODIUM cefazolin sodium (bulk) for inj 300 gm
3
CEFAZOLIN SODIUM cefazolin sodium for inj 20 gm
3
cefazolin sodium for inj 500 mg
1
cefazolin sodium for inj 10 gm cefdinir cap 300 mg cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml CEFDITOREN PIVOXIL cefditoren pivoxil tab 200 mg (base equivalent)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
CEFOTAN - cefotetan disodium 3 for inj 1 gm CEFOTAN - cefotetan disodium 3 for inj 2 gm 3 CEFOTAXIME SODIUM cefotaxime sodium for inj 500 mg 3 CEFOTAXIME SODIUM cefotaxime sodium for inj 1 gm 3 CEFOTAXIME SODIUM cefotaxime sodium for inj 2 gm 3 CEFOTAXIME SODIUM cefotaxime sodium for inj 10 gm 3 CEFOTETAN - cefotetan disodium for inj 10 gm 1 cefotetan disodium for inj 1 gm (Cefotan) 1 cefotetan disodium for inj 2 gm (Cefotan) 1 cefoxitin sodium for inj 10 gm 1 cefpodoxime proxetil for susp 50 mg/5ml 1 cefpodoxime proxetil for susp 100 mg/5ml 1 cefpodoxime proxetil tab 100 mg
1
CEFAZOLIN SODIUM cefazolin sodium (bulk) for inj 100 gm
cefazolin sodium for inj 1 gm
cefixime for susp 200 mg/5ml (Suprax)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1 3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
3
cefpodoxime proxetil tab 200 mg cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg cefprozil tab 500 mg
1
cefuroxime sodium for inj 1.5 gm (Zinacef)
1
cefuroxime sodium for inj 7.5 gm (Zinacef)
1 1 1
CEPHALEXIN - cephalexin tab 250 mg
3
CEPHALEXIN - cephalexin tab 500 mg
3
cephalexin cap 250 mg (Keflex)
1
ceftazidime for inj 2 gm (Fortaz)
1
cephalexin cap 500 mg (Keflex)
1
ceftazidime for inj 6 gm (Fortaz)
1
cephalexin cap 750 mg (Keflex)
1
CEFTIBUTEN - ceftibuten cap 400 mg
3
cephalexin for susp 125 mg/5ml
1
CEFTIBUTEN - ceftibuten for susp 180 mg/5ml
3
cephalexin for susp 250 mg/5ml
CEFTIN - cefuroxime axetil for susp 125 mg/5ml
2
FORTAZ - ceftazidime for inj 500 mg
3
CEFTIN - cefuroxime axetil for susp 250 mg/5ml
3
FORTAZ - ceftazidime for inj 1 gm
3
CEFTRIAXONE SODIUM ceftriaxone sodium (bulk) for inj 100 gm
3
FORTAZ - ceftazidime for inj 2 gm
3 3
ceftriaxone sodium for inj 250 mg
1
FORTAZ - ceftazidime for inj 6 gm
3
1
KEFLEX - cephalexin cap 250 mg
3
1
KEFLEX - cephalexin cap 500 mg
3
1
KEFLEX - cephalexin cap 750 mg
3
cefuroxime axetil tab 250 mg (Ceftin)
1
MAXIPIME - cefepime hcl for inj 1 gm
3
cefuroxime axetil tab 500 mg (Ceftin)
1
MAXIPIME - cefepime hcl for inj 2 gm
3
cefuroxime sodium for inj 750 mg (Zinacef)
1
SPECTRACEF - cefditoren pivoxil tab 400 mg (base equivalent)
ceftriaxone sodium for inj 2 gm
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
1
1
ceftriaxone sodium for inj 1 gm (Rocephin)
Step Therapy
1
ceftazidime for inj 1 gm (Fortaz)
ceftriaxone sodium for inj 500 mg (Rocephin)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
Products October (2016 Plan Year)
4
SUPRAX - cefixime cap 400 mg
2
clarithromycin tab 500 mg (Biaxin)
1
SUPRAX - cefixime chew tab 100 mg
2
DIFICID - fidaxomicin tab 200 mg
3
SUPRAX - cefixime chew tab 200 mg
2
3
SUPRAX - cefixime for susp 100 mg/5ml
3
E.E.S. GRANULES erythromycin ethylsuccinate for susp 200 mg/5ml
3
SUPRAX - cefixime for susp 200 mg/5ml
3
E.E.S. 400 - erythromycin ethylsuccinate tab 400 mg
3
SUPRAX - cefixime for susp 500 mg/5ml
2
ERY-TAB - erythromycin tab delayed release 250 mg
3
ZINACEF - cefuroxime sodium for inj 750 mg
3
ERY-TAB - erythromycin tab delayed release 333 mg
3
ZINACEF - cefuroxime sodium for inj 1.5 gm
3
ERY-TAB - erythromycin tab delayed release 500 mg
3
ZINACEF - cefuroxime sodium for inj 7.5 gm
3
ERYPED 200 - erythromycin ethylsuccinate for susp 200 mg/5ml ERYPED 400 - erythromycin ethylsuccinate for susp 400 mg/5ml
3
ERYTHROCIN STEARATE erythromycin stearate tab 250 mg
3
1
ERYTHROMYCIN erythromycin powder
3
azithromycin tab 250 mg (Zithromax)
1
ERYTHROMYCIN BASE erythromycin tab 250 mg
3
azithromycin tab 500 mg (Zithromax)
1
ERYTHROMYCIN BASE erythromycin tab 500 mg
3
azithromycin tab 600 mg (Zithromax)
1
3
clarithromycin for susp 125 mg/5ml
1
ERYTHROMYCIN ETHYLSUCCINA erythromycin ethylsuccinate powder ERYTHROMYCIN ETHYLSUCCINA erythromycin ethylsuccinate tab 400 mg
3
MACROLIDES AZITHROMYCIN azithromycin powd pack for susp 1 gm
2
azithromycin for susp 100 mg/5ml (Zithromax)
1
azithromycin for susp 200 mg/5ml (Zithromax)
clarithromycin for susp 250 mg/5ml (Biaxin) clarithromycin tab er 24hr 500 mg clarithromycin tab 250 mg (Biaxin)
1 1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
erythromycin ethylsuccinate 1 for susp 200 mg/5ml (E.e.s. granules)
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
5
erythromycin w/ delayed release particles cap 250 mg
1
doxycycline hyclate tab 75 mg (Acticlate)
PCE - erythromycin w/ enteric coated particles tab 333 mg PCE - erythromycin w/ enteric coated particles tab 500 mg
3
doxycycline hyclate tab 150 mg (Acticlate)
ZITHROMAX - azithromycin for susp 100 mg/5ml
3
doxycycline monohydrate cap 50 mg
ZITHROMAX - azithromycin for susp 200 mg/5ml
3
doxycycline monohydrate cap 75 mg (Monodox)
ZITHROMAX - azithromycin powd pack for susp 1 gm
3
doxycycline monohydrate cap 100 mg (Monodox)
ZITHROMAX - azithromycin tab 250 mg
3
doxycycline monohydrate cap 150 mg (Adoxa)
ZITHROMAX - azithromycin tab 500 mg
3
doxycycline monohydrate tab 50 mg (Adoxa)
ZITHROMAX - azithromycin tab 600 mg
3
doxycycline monohydrate tab 75 mg (Adoxa) doxycycline monohydrate tab 100 mg (Adoxa pak 1/100)
1
ZITHROMAX TRI-PAK azithromycin tab 500 mg
3
ZITHROMAX Z-PAK azithromycin tab 250 mg
3
1
ZMAX - azithromycin extended release for oral susp 2 gm
3
doxycycline monohydrate tab 150 mg (Adoxa pak 1/150) MINOCYCLINE HCL minocycline hcl powder
3
minocycline hcl cap 50 mg (Minocin)
1
minocycline hcl cap 75 mg (Minocin)
1
minocycline hcl cap 100 mg (Minocin)
1
MINOCYCLINE HCL ER minocycline hcl tab er 24hr 45 mg
3
minocycline hcl tab er 24hr 90 mg
1
minocycline hcl tab er 24hr 135 mg minocycline hcl tab 50 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
1
doxycycline hyclate tab 100 mg
CHLORTETRACYCLINE HCL - 3 chlortetracycline hcl powder 3 DEMECLOCYCLINE HCL demeclocycline hcl powder 1 demeclocycline hcl tab 150 mg 1 demeclocycline hcl tab 300 mg 1 doxycycline hyclate cap 50 mg 1 doxycycline hyclate cap 100 mg (Vibramycin) 1 doxycycline hyclate tab 20 mg
Step Therapy
1
3
TETRACYCLINES
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1 1 1
1 1
Products October (2016 Plan Year)
6
minocycline hcl tab 75 mg minocycline hcl tab 100 mg
TETRACYCLINE HCL tetracycline hcl cap 250 mg
3
TETRACYCLINE HCL tetracycline hcl cap 500 mg
3
tetracycline hcl cap 250 mg (Tetracycline hcl)
1
tetracycline hcl cap 500 mg (Tetracycline hcl)
1
VIBRAMYCIN - doxycycline calcium syrup 50 mg/5ml
3
AVELOX - moxifloxacin hcl tab 400 mg (base equiv)
3
CIPRO - ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)
3
CIPRO - ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml)
3
CIPRO - ciprofloxacin hcl tab 250 mg (base equiv)
3
CIPRO - ciprofloxacin hcl tab 500 mg (base equiv)
3
CIPRO XR - ciprofloxacinciprofloxacin hcl tab er 24hr 500 mg (base eq)
3
CIPRO XR - ciprofloxacinciprofloxacin hcl tab er 24hr 1000 mg(base eq)
3
ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro)
1
CIPROFLOXACIN HCL ciprofloxacin hcl tab 100 mg (base equiv)
3
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)
1
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) ciprofloxacin hcl tab 750 mg (base equiv) ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq) (Cipro xr)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1 3
ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro)
Drug Name
1
OXYTETRACYCLINE HCL oxytetracycline hcl powder
FLUOROQUINOLONES
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1
1 ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq) (Cipro xr) 3 FACTIVE - gemifloxacin mesylate tab 320 mg (base equiv) 3 LEVAQUIN - levofloxacin tab 250 mg 3 LEVAQUIN - levofloxacin tab 500 mg 3 LEVAQUIN - levofloxacin tab 750 mg LEVOFLOXACIN - levofloxacin 3 oral soln 25 mg/ml 1 levofloxacin tab 250 mg (Levaquin) 1 levofloxacin tab 500 mg (Levaquin) 1 levofloxacin tab 750 mg (Levaquin) 1 moxifloxacin hcl tab 400 mg (base equiv) (Avelox) 3 OFLOXACIN - ofloxacin tab 300 mg 1 ofloxacin tab 400 mg
1
AMINOGLYCOSIDES AMIKACIN SULFATE amikacin sulfate powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
3
Products October (2016 Plan Year)
7
amikacin sulfate inj 500 mg/2ml (250 mg/ml) amikacin sulfate inj 1 gm/4ml (250 mg/ml)
1
tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv)
1
tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv)
•
gentamicin sulfate inj 10 mg/ ml
1
SULFONAMIDES
3
1
SULFADIAZINE - sulfadiazine powder
2
KITABIS PAK - tobramycin nebu soln 300 mg/5ml
5
SULFADIAZINE - sulfadiazine tab 500 mg
3
neomycin sulfate tab 500 mg
1
SULFADIAZINE SODIUM sulfadiazine sodium powder
1
SULFAMETHOXAZOLE sulfamethoxazole powder
3
STREPTOMYCIN SULFATE streptomycin sulfate for inj 1 gm
3
SULFAMETHOXAZOLE MICRO - sulfamethoxazole powder
3
STREPTOMYCIN SULFATE streptomycin sulfate powder
3
SULFAPYRIDINE sulfapyridine powder
3
TOBI - tobramycin nebu soln 300 mg/5ml
5
•
SULFATHIAZOLE sulfathiazole powder
3
TOBI PODHALER - tobramycin inhal cap 28 mg
5
•
SULFISOXIZOLE sulfisoxazole crystals
3
TOBRAMYCIN - tobramycin nebu soln 300 mg/5ml
5
•
tobramycin nebu soln 300 mg/5ml (Tobi)
4
•
ANTIMYCOBACTERIAL AGENTS 3 AMINOSALICYLIC ACID aminosalicylic acid powder 3 CAPASTAT SULFATE capreomycin sulfate for inj 1 gm 3 CYCLOSERINE - cycloserine cap 250 mg 3 ETHAMBUTOL HCL ethambutol hcl powder 1 ethambutol hcl tab 100 mg (Myambutol) 1 ethambutol hcl tab 400 mg (Myambutol) 3 ISONIAZID - isoniazid inj 100 mg/ml
paromomycin sulfate cap 250 mg
TOBRAMYCIN SULFATE tobramycin sulfate inj 10 mg/ ml (base equivalent)
3
TOBRAMYCIN SULFATE tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv)
3
TOBRAMYCIN SULFATE tobramycin sulfate powder
3
tobramycin sulfate for inj 1.2 gm
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
1
5
•
Step Therapy
1
BETHKIS - tobramycin nebu soln 300 mg/4ml
gentamicin sulfate inj 40 mg/ ml
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
8
ISONIAZID - isoniazid powder
3
ISONIAZID - isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg
3
2
ANCOBON - flucytosine cap 250 mg
3
1
ANCOBON - flucytosine cap 500 mg BIO-STATIN - nystatin cap 500000 unit
3
BIO-STATIN - nystatin cap 1000000 unit
3
CRESEMBA isavuconazonium sulfate cap 186 mg
3
1
MYAMBUTOL - ethambutol hcl tab 100 mg
3
MYAMBUTOL - ethambutol hcl tab 400 mg
3
MYCOBUTIN - rifabutin cap 150 mg
3
PASER - aminosalicylic acid er granules packet 4 gm
3
DIFLUCAN - fluconazole for susp 10 mg/ml
3
PRIFTIN - rifapentine tab 150 mg
2
DIFLUCAN - fluconazole for susp 40 mg/ml
3
pyrazinamide tab 500 mg
1
rifabutin cap 150 mg (Mycobutin)
1
RIFADIN - rifampin cap 150 mg
3
RIFAMATE - isoniazid & rifampin cap 150-300 mg
3
RIFAMPIN - rifampin powder
3
3
RIFATER - isoniazid-rifampin w/ pyrazinamide tab 50-120-300 mg
3
SIRTURO - bedaquiline fumarate tab 100 mg (base equiv)
3
TRECATOR - ethionamide tab 250 mg
3
ANTIFUNGALS AMPHOTERICIN B amphotericin b for inj 50 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
DIFLUCAN - fluconazole tab 50 3 mg 3 DIFLUCAN - fluconazole tab 100 mg 3 DIFLUCAN - fluconazole tab 150 mg 3 DIFLUCAN - fluconazole tab 200 mg 1 fluconazole for susp 10 mg/ ml (Diflucan) 1 fluconazole for susp 40 mg/ ml (Diflucan) 1 fluconazole tab 50 mg (Diflucan) 1 fluconazole tab 100 mg (Diflucan) 1 fluconazole tab 150 mg (Diflucan) 1 fluconazole tab 200 mg (Diflucan) 1 flucytosine cap 250 mg (Ancobon) 1 flucytosine cap 500 mg (Ancobon)
rifampin cap 150 mg (Rifadin) 1 rifampin cap 300 mg (Rifadin) 1 RIFAMPIN/SYRSPEND SF PH4 - rifampin susp 25 mg/ ml (compound kit)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
9
GRIS-PEG - griseofulvin ultramicrosize tab 125 mg
3
VFEND - voriconazole tab 200 mg
3
GRIS-PEG - griseofulvin ultramicrosize tab 250 mg
3
1
griseofulvin microsize susp 125 mg/5ml
1
voriconazole for susp 40 mg/ml (Vfend) voriconazole tab 50 mg (Vfend)
1
1
voriconazole tab 200 mg (Vfend)
1
1
ANTIVIRALS
1
abacavir sulfate tab 300 mg (base equiv) (Ziagen)
itraconazole cap 100 mg (Sporanox)
1
abacavir sulfate-lamivudine tab 600-300 mg (Epzicom)
ketoconazole tab 200 mg
1
griseofulvin microsize tab 500 mg (Grifulvin v) griseofulvin ultramicrosize tab 125 mg (Gris-peg) griseofulvin ultramicrosize tab 250 mg (Gris-peg)
1
MICONAZOLE - miconazole powder
3
acyclovir cap 200 mg (Zovirax)
1
NOXAFIL - posaconazole susp 40 mg/ml
2
acyclovir susp 200 mg/5ml (Zovirax)
1
NOXAFIL - posaconazole tab delayed release 100 mg
2
acyclovir tab 400 mg (Zovirax)
1
nystatin oral powder
1
acyclovir tab 800 mg (Zovirax) adefovir dipivoxil tab 10 mg (Hepsera)
1
APTIVUS - tipranavir cap 250 mg
3
APTIVUS - tipranavir oral soln 100 mg/ml
3
ATRIPLA - efavirenzemtricitabine-tenofovir df tab 600-200-300 mg
2
ONMEL - itraconazole tab 200 mg
3
SPORANOX - itraconazole cap 100 mg
3
SPORANOX - itraconazole oral soln 10 mg/ml
2
SPORANOX PULSEPAK itraconazole cap 100 mg
3
terbinafine hcl tab 250 mg (Lamisil)
1
BARACLUDE - entecavir oral soln 0.05 mg/ml
2
VFEND - voriconazole for susp 40 mg/ml
3
BARACLUDE - entecavir tab 0.5 mg
3
VFEND - voriconazole tab 50 mg
3
BARACLUDE - entecavir tab 1 mg
3
SM
Limited Distribution
ACA
1
3
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Dispensing Limits
1
LAMISIL - terbinafine hcl tab 250 mg
1
Step Therapy
1
abacavir sulfatelamivudine-zidovudine tab 300-150-300 mg (Trizivir)
nystatin tab 500000 unit
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
10
COMBIVIR - lamivudinezidovudine tab 150-300 mg
3
EPCLUSA - sofosbuvirvelpatasvir tab 400-100 mg
4
COMPLERA - emtricitabinerilpivirine-tenofovir df tab 200-25-300 mg
2
EPIVIR - lamivudine oral soln 10 mg/ml
3
EPIVIR - lamivudine tab 150 mg
3
COPEGUS - ribavirin tab 200 mg
5 3
EPIVIR - lamivudine tab 300 mg
3
CRIXIVAN - indinavir sulfate cap 200 mg
EPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv)
2
CRIXIVAN - indinavir sulfate cap 400 mg
3
EPIVIR HBV - lamivudine tab 100 mg (hbv)
3
DAKLINZA - daclatasvir dihydrochloride tab 30 mg (base equivalent)
5
3
DAKLINZA - daclatasvir dihydrochloride tab 60 mg (base equivalent)
5
•
•
EPZICOM - abacavir sulfatelamivudine tab 600-300 mg
2
DAKLINZA - daclatasvir dihydrochloride tab 90 mg (base equivalent)
5
•
•
EVOTAZ - atazanavir sulfatecobicistat tab 300-150 mg (base equiv) famciclovir tab 125 mg (Famvir)
1
DESCOVY - emtricitabinetenofovir alafenamide fumarate tab 200-25 mg
2
famciclovir tab 250 mg (Famvir)
1 1
didanosine delayed release capsule 125 mg (Videx ec)
1
famciclovir tab 500 mg (Famvir) FLUMADINE - rimantadine hydrochloride tab 100 mg
3
FUZEON - enfuvirtide for inj 90 mg
5
GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab 150-150-200-10 mg
2
didanosine delayed release capsule 200 mg (Videx ec) didanosine delayed release capsule 250 mg (Videx ec) didanosine delayed release capsule 400 mg (Videx ec)
•
•
•
1 1 1
EDURANT - rilpivirine hcl tab 25 mg (base equivalent)
3
HARVONI - ledipasvirsofosbuvir tab 90-400 mg
4
EMTRIVA - emtricitabine caps 200 mg
3
HEPSERA - adefovir dipivoxil tab 10 mg
3
EMTRIVA - emtricitabine soln 10 mg/ml
3
INTELENCE - etravirine tab 25 mg
2
entecavir tab 0.5 mg (Baraclude)
1
INTELENCE - etravirine tab 100 mg
2
entecavir tab 1 mg (Baraclude)
1
INTELENCE - etravirine tab 200 mg
2
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
11
INVIRASE - saquinavir mesylate cap 200 mg
3
INVIRASE - saquinavir mesylate tab 500 mg
3
ISENTRESS - raltegravir potassium chew tab 25 mg (base equiv)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
LEXIVA - fosamprenavir calcium tab 700 mg (base equiv)
3
1
2
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ ml) (Kaletra)
5
•
ISENTRESS - raltegravir potassium chew tab 100 mg (base equiv)
2
MODERIBA - ribavirin tab 200 mg & ribavirin tab 400 mg dose pack
5
•
ISENTRESS - raltegravir potassium packet for susp 100 mg (base equiv)
2
MODERIBA - ribavirin tab 400 mg & ribavirin tab 600 mg dose pack
5
•
ISENTRESS - raltegravir potassium tab 400 mg (base equiv)
2
MODERIBA 1200 DOSE PACK - ribavirin tab 600 mg
•
ISENTRESS HD - raltegravir potassium tab 600 mg (base equiv)
2
KALETRA - lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)
3
KALETRA - lopinavir-ritonavir tab 100-25 mg
2
MODERIBA 800 DOSE PACK - 5 ribavirin tab 400 mg 1 nevirapine tab er 24hr 100 mg (Viramune xr) 1 nevirapine tab er 24hr 400 mg (Viramune xr) 1 nevirapine tab 200 mg (Viramune) NORVIR - ritonavir cap 100 mg 3
KALETRA - lopinavir-ritonavir tab 200-50 mg
2
lamivudine oral soln 10 mg/ ml (Epivir)
1
lamivudine tab 100 mg (hbv) (Epivir hbv)
1
lamivudine tab 150 mg (Epivir)
1
lamivudine tab 300 mg (Epivir)
1
lamivudine-zidovudine tab 150-300 mg (Combivir)
1
LEXIVA - fosamprenavir calcium susp 50 mg/ml (base equiv)
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
NORVIR - ritonavir oral soln 80 mg/ml
2
NORVIR - ritonavir tab 100 mg
2
ODEFSEY - emtricitabinerilpivirine-tenofovir af tab 200-25-25 mg
2
OLYSIO - simeprevir sodium cap 150 mg (base equivalent)
5
oseltamivir phosphate cap 30 mg (base equiv) (Tamiflu)
1
oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu)
1
oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu)
1
Products October (2016 Plan Year)
•
•
12
•
•
PEGASYS PROCLICK peginterferon alfa-2a inj 135 mcg/0.5ml
4
•
•
PEGASYS PROCLICK peginterferon alfa-2a inj 180 mcg/0.5ml
4
•
•
PEGINTRON - peginterferon alfa-2b for inj kit 50 mcg/0.5ml
5
•
•
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
PREZCOBIX - darunavircobicistat tab 800-150 mg
2
PREZISTA - darunavir ethanolate susp 100 mg/ml (base equiv)
2
PREZISTA - darunavir ethanolate tab 75 mg (base equiv)
2
PREZISTA - darunavir ethanolate tab 150 mg (base equiv)
2
PREZISTA - darunavir ethanolate tab 600 mg (base equiv)
2
PREZISTA - darunavir ethanolate tab 800 mg (base equiv)
2
REBETOL - ribavirin cap 200 mg
5
•
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
4
ACA
PEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml
•
•
Dispensing Limits
•
Step Therapy
4
Prior Authorization
PEGASYS - peginterferon alfa-2a inj 180 mcg/ml
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
REBETOL - ribavirin soln 40 mg/ml
5
RELENZA DISKHALER zanamivir aero powder breath activated 5 mg/blister
3
RESCRIPTOR - delavirdine mesylate tab 100 mg
3
RESCRIPTOR - delavirdine mesylate tab 200 mg
3
RETROVIR - zidovudine cap 100 mg
3
RETROVIR - zidovudine syrup 10 mg/ml
3
REYATAZ - atazanavir sulfate cap 150 mg (base equiv)
2
REYATAZ - atazanavir sulfate cap 200 mg (base equiv)
2
REYATAZ - atazanavir sulfate cap 300 mg (base equiv)
2
REYATAZ - atazanavir sulfate oral powder packet 50 mg (base equiv)
3
RIBASPHERE - ribavirin tab 400 mg
5
•
RIBASPHERE - ribavirin tab 600 mg
5
•
RIBASPHERE RIBAPAK ribavirin tab 400 mg
5
•
RIBASPHERE RIBAPAK ribavirin tab 600 mg
5
•
RIBASPHERE RIBAPAK ribavirin tab 200 mg & ribavirin tab 400 mg dose pack
5
•
RIBASPHERE RIBAPAK ribavirin tab 400 mg & ribavirin tab 600 mg dose pack
5
•
ribavirin cap 200 mg (Rebetol)
4
•
Products October (2016 Plan Year)
13
ribavirin for inhal soln 6 gm (Virazole)
1
ribavirin tab 200 mg (Copegus)
4
rimantadine hydrochloride tab 100 mg (Flumadine)
1
SELZENTRY - maraviroc oral soln 20 mg/ml
3
SELZENTRY - maraviroc tab 25 mg
3
SELZENTRY - maraviroc tab 75 mg
3
SELZENTRY - maraviroc tab 150 mg
3
SELZENTRY - maraviroc tab 300 mg
3
SITAVIG - acyclovir buccal tab 50 mg
3
SOVALDI - sofosbuvir tab 400 mg
4
stavudine cap 15 mg (Zerit)
1
stavudine cap 20 mg (Zerit) stavudine cap 30 mg (Zerit) stavudine cap 40 mg (Zerit)
•
•
•
1 1 1
STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab 150-150-200-300 mg
2
SUSTIVA - efavirenz cap 50 mg
2
SUSTIVA - efavirenz cap 200 mg
2
SUSTIVA - efavirenz tab 600 mg
2
TAMIFLU - oseltamivir phosphate cap 30 mg (base equiv)
3
TAMIFLU - oseltamivir phosphate cap 45 mg (base equiv)
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
TAMIFLU - oseltamivir phosphate cap 75 mg (base equiv)
3
TAMIFLU - oseltamivir phosphate for susp 6 mg/ml (base equiv)
2
TECHNIVIE - ombitasvirparitaprevir-ritonavir tab 12.5-75-50 mg
5
TIVICAY - dolutegravir sodium tab 10 mg (base equiv)
2
TIVICAY - dolutegravir sodium tab 25 mg (base equiv)
2
TIVICAY - dolutegravir sodium tab 50 mg (base equiv)
2
TRIUMEQ - abacavirdolutegravir-lamivudine tab 600-50-300 mg
2
TRIZIVIR - abacavir sulfatelamivudine-zidovudine tab 300-150-300 mg
3
TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 100-150 mg
2
TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 133-200 mg
2
TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 167-250 mg
2
TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 200-300 mg
2
TYBOST - cobicistat tab 150 mg
3
valacyclovir hcl tab 500 mg (Valtrex)
1
valacyclovir hcl tab 1 gm (Valtrex)
1
VALCYTE - valganciclovir hcl for soln 50 mg/ml (base equiv)
3
Products October (2016 Plan Year)
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
14
VALCYTE - valganciclovir hcl tab 450 mg (base equivalent)
3
valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte)
1
valganciclovir hcl tab 450 mg (base equivalent) (Valcyte)
1
VALTREX - valacyclovir hcl tab 500 mg
3
VALTREX - valacyclovir hcl tab 1 gm
3
VIDEX - didanosine for soln 2 gm
2
VIDEX - didanosine for soln 4 gm
2
VIDEX EC - didanosine delayed release capsule 125 mg
3
VIDEX EC - didanosine delayed release capsule 200 mg
3
VIDEX EC - didanosine delayed release capsule 250 mg
3
VIDEX EC - didanosine delayed release capsule 400 mg
3
VIEKIRA PAK - ombitasparitapre-riton & dasab tab pak 12.5-75-50 & 250 mg
5
VIEKIRA XR - dasab-ombitparitap-riton tab er 24hr 200-8.33-50-33.33 mg
5
VIRACEPT - nelfinavir mesylate tab 250 mg
VIRAMUNE - nevirapine tab 200 mg
3
VIRAMUNE XR - nevirapine tab er 24hr 100 mg
3
VIRAMUNE XR - nevirapine tab er 24hr 400 mg
3
VIRAZOLE - ribavirin for inhal soln 6 gm
3
VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/ gm
2
VIREAD - tenofovir disoproxil fumarate tab 150 mg
2
VIREAD - tenofovir disoproxil fumarate tab 200 mg
2
VIREAD - tenofovir disoproxil fumarate tab 250 mg
2
VIREAD - tenofovir disoproxil fumarate tab 300 mg
2
ZEPATIER - elbasvirgrazoprevir tab 50-100 mg
5
ZERIT - stavudine cap 15 mg
3
ZERIT - stavudine cap 20 mg
3
ZERIT - stavudine cap 30 mg
3
ZERIT - stavudine cap 40 mg
3
ZERIT - stavudine for oral soln 1 mg/ml
2
ZIAGEN - abacavir sulfate soln 20 mg/ml (base equiv)
2
ZIAGEN - abacavir sulfate tab 300 mg (base equiv)
3
zidovudine cap 100 mg (Retrovir)
1
3
zidovudine syrup 10 mg/ml (Retrovir)
1
VIRACEPT - nelfinavir mesylate tab 625 mg
3
zidovudine tab 300 mg
1 3
VIRAMUNE - nevirapine susp 50 mg/5ml
2
ZOVIRAX - acyclovir cap 200 mg ZOVIRAX - acyclovir susp 200 mg/5ml
3
• •
• •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
15
ZOVIRAX - acyclovir tab 400 mg
3
quinine sulfate cap 324 mg (Qualaquin)
ZOVIRAX - acyclovir tab 800 mg
3
3 QUININE SULFATE DIHYDRATE - quinine sulfate powder
1
AMEBICIDES
1
IODOQUINOL - iodoquinol powder
ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg (Malarone) atovaquone-proguanil hcl tab 250-100 mg (Malarone) CHLOROQUINE PHOSPHATE - chloroquine phosphate powder
3
CHLOROQUINE PHOSPHATE - chloroquine phosphate tab 250 mg
3
chloroquine phosphate tab 500 mg (Aralen)
1
COARTEM - artemetherlumefantrine tab 20-120 mg
2
DARAPRIM - pyrimethamine tab 25 mg
2
hydroxychloroquine sulfate tab 200 mg (Plaquenil)
1
MALARONE - atovaquoneproguanil hcl tab 62.5-25 mg
3
MALARONE - atovaquoneproguanil hcl tab 250-100 mg
3
mefloquine hcl tab 250 mg
1
PLAQUENIL hydroxychloroquine sulfate tab 200 mg
3
PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3 mg
2
QUALAQUIN - quinine sulfate cap 324 mg
3
QUINACRINE HCL quinacrine hcl powder
3
QUININE SULFATE - quinine sulfate powder
3
ANTHELMINTICS
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
3
ALBENZA - albendazole tab 200 mg
2
BILTRICIDE - praziquantel tab 600 mg
2
EMVERM - mebendazole chew tab 100 mg
3
ivermectin tab 3 mg (Stromectol)
1
MEBENDAZOLE mebendazole powder
3
STROMECTOL - ivermectin tab 3 mg
3
THIABENDAZOLE thiabendazole powder
3
ANTI-INFECTIVE AGENTS - MISC. ALINIA - nitazoxanide for susp 3 100 mg/5ml 3 ALINIA - nitazoxanide tab 500 mg 1 atovaquone susp 750 mg/5ml (Mepron) AZACTAM - aztreonam for inj 1 3 gm AZACTAM - aztreonam for inj 2 3 gm 1 aztreonam for inj 1 gm (Azactam) 1 aztreonam for inj 2 gm (Azactam) 1 bacitracin intramuscular for soln 50000 unit (Bacitracin) SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
16
BACTRIM - sulfamethoxazoletrimethoprim tab 400-80 mg
3
BACTRIM DS sulfamethoxazoletrimethoprim tab 800-160 mg
3
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr)
1
CAYSTON - aztreonam lysine for inhal soln 75 mg (base equivalent)
5
clindamycin phosphate inj 300 mg/2ml (Cleocin phosphate)
1
CHLORAMPHENICOL chloramphenicol powder
3
clindamycin phosphate inj 600 mg/4ml (Cleocin phosphate) clindamycin phosphate inj 900 mg/6ml (Cleocin phosphate)
1
clindamycin phosphate inj 9 gm/60ml (Cleocin phosphate)
1
colistimethate sodium for inj 150 mg (Coly-Mycin M)
1
•
CLEOCIN - clindamycin hcl cap 3 75 mg CLEOCIN - clindamycin hcl cap 3 150 mg CLEOCIN - clindamycin hcl cap 3 300 mg 3 CLEOCIN PEDIATRIC GRANULE - clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) 3 CLEOCIN PHOSPHATE clindamycin phosphate inj 300 mg/2ml 3 CLEOCIN PHOSPHATE clindamycin phosphate inj 600 mg/4ml 3 CLEOCIN PHOSPHATE clindamycin phosphate inj 900 mg/6ml 3 CLEOCIN PHOSPHATE clindamycin phosphate inj 9 gm/60ml 3 CLIN SINGLE USE KIT clindamycin phosphate inj 300 mg/2ml kit 1 clindamycin hcl cap 75 mg (Cleocin) 1 clindamycin hcl cap 150 mg (Cleocin) 1 clindamycin hcl cap 300 mg (Cleocin)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
COLY-MYCIN M colistimethate sodium for inj 150 mg
3
dapsone tab 25 mg
1
dapsone tab 100 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
FIRST-METRONIDAZOLE 100 - metronidazole benzoate for susp 100 mg/ ml (cmpd kit)
3
FIRST-METRONIDAZOLE 50 metronidazole benzoate for susp 50 mg/ml (cmpd kit)
3
FIRST-VANCOMYCIN 25 vancomycin hcl oral soln 25 mg/ml (compound kit)
3
FIRST-VANCOMYCIN 50 vancomycin hcl oral soln 50 mg/ml (compound kit)
3
FLAGYL - metronidazole cap 375 mg
3
FLAGYL - metronidazole tab 250 mg
3
FLAGYL - metronidazole tab 500 mg
3
Products October (2016 Plan Year)
17
IMPAVIDO - miltefosine cap 50 mg
2
INVANZ - ertapenem sodium for inj 1 gm (base equivalent)
3
sulfamethoxazoletrimethoprim tab 400-80 mg (Bactrim)
LINCOCIN - lincomycin hcl inj 300 mg/ml
3
sulfamethoxazoletrimethoprim tab 800-160 mg (Bactrim ds)
3
lincomycin hcl inj 300 mg/ml (Lincocin)
1
TINDAMAX - tinidazole tab 500 mg
1
linezolid for susp 100 mg/5ml (Zyvox)
1
tinidazole tab 250 mg (Tindamax)
1
1
tinidazole tab 500 mg (Tindamax)
linezolid tab 600 mg (Zyvox)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
MEPRON - atovaquone susp 750 mg/5ml
3
TRIMETHOPRIM trimethoprim powder
3
METRONIDAZOLE BENZOATE/SY metronidazole benzoate for susp 50 mg/ml (cmpd kit)
3
trimethoprim tab 100 mg
1
metronidazole cap 375 mg (Flagyl)
VANCOCIN HCL - vancomycin hcl cap 125 mg
3
1
VANCOCIN HCL - vancomycin hcl cap 250 mg
3
VANCOMYCIN HCL vancomycin hcl powder
3
metronidazole tab 250 mg (Flagyl)
1
NEBUPENT - pentamidine isethionate for nebulization soln 300 mg
2
VANCOMYCIN HCL + SYRSPEND - vancomycin hcl oral susp 50 mg/ml (compound kit)
3
metronidazole tab 500 mg (Flagyl)
1
vancomycin hcl cap 125 mg (Vancocin hcl)
1
PENTAM 300 - pentamidine isethionate for soln 300 mg
3
vancomycin hcl cap 250 mg (Vancocin hcl)
1
POLYMYXIN B SULFATE polymyxin b sulfate powder
3
XIFAXAN - rifaximin tab 200 mg
3
polymyxin b sulfate for inj 500000 unit
1
XIFAXAN - rifaximin tab 550 mg
2
PRIMSOL - trimethoprim hcl oral soln 50 mg/5ml (base equiv)
3
ZYVOX - linezolid for susp 100 mg/5ml
3
2
ZYVOX - linezolid tab 600 mg
3
SIVEXTRO - tedizolid phosphate tab 200 mg sulfamethoxazoletrimethoprim susp 200-40 mg/5ml
1
BIOLOGICALS VACCINES
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
18
ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml
A
•
ENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml
A
•
AFLURIA PF 2016-2017 influenza virus vaccine split pf susp pref syringe 0.5 ml
A
•
ENGERIX-B - hepatitis b vaccine (recombinant) 10 mcg/0.5ml
A
•
AFLURIA PF 2017-2018 influenza virus vaccine split pf susp pref syringe 0.5 ml
A
•
ENGERIX-B - hepatitis b vaccine (recombinant) 20 mcg/ml
A
•
AFLURIA QUADRIVALENT 2016 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
•
FLUAD 2016-2017 - influenza vac type a&b surface ant adj susp pref syr 0.5 ml
A
•
AFLURIA QUADRIVALENT 2017 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
•
FLUAD 2017-2018 - influenza vac type a&b surface ant adj susp pref syr 0.5 ml
A
•
A
•
•
FLUARIX QUADRIVALENT 2015 - influenza virus vac split quadrivalent susp pref syr 0.5ml
AFLURIA QUADRIVALENT 2017 - influenza virus vaccine split quadrivalent im inj
A
A
•
•
FLUARIX QUADRIVALENT 2016 - influenza virus vac split quadrivalent susp pref syr 0.5ml
AFLURIA 2015-2016 influenza virus vaccine split im susp
A
AFLURIA 2016-2017 influenza virus vaccine split im susp
A
FLUARIX QUADRIVALENT 2017 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
•
•
AFLURIA 2017-2018 influenza virus vaccine split im susp
A
•
FLUARIX 2014-2015 influenza virus vaccine split pf susp pref syringe 0.5 ml
A
•
BEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilled syringe
A
•
FLUBLOK QUADRIVALENT 2017 - influenza vac recomb ha quad pf soln pref syr 0.5 ml
2
CERVARIX - human papillomavirus (hpv) bival (type 16, 18) recmb vac inj
A
•
FLUBLOK 2015-2016 influenza virus vac recombinant hemagglutinin (ha) inj
A
COMVAX - haemophilus b polysac conj-hepatitis b (recomb) vac im susp
A
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
•
ACA
A
Dispensing Limits
AFLURIA PF 2015-2016 influenza virus vaccine split pf susp pref syringe 0.5 ml
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
ACTHIB - haemophilus b polysaccharide conjugate vaccine for inj
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
19
FLUVIRIN 2016-2017 influenza vac type a&b surface antigen susp pref syr 0.5 ml
A
•
FLUVIRIN 2016-2017 influenza virus vaccine types a & b surface antigen im susp
A
•
FLUCELVAX QUADRIVALENT 20 - influenza vac tiss-cult subunt quad susp pref syr 0.5 ml
A
•
FLUVIRIN 2017-2018 influenza vac type a&b surface antigen susp pref syr 0.5 ml
A
•
FLUCELVAX QUADRIVALENT 20 - influenza vac tissuecultured subunit quadrivalent im susp
2
FLUVIRIN 2017-2018 influenza virus vaccine types a & b surface antigen im susp
A
•
FLUCELVAX 2015-2016 influenza virus vac tiss-cult subunit susp pref syr 0.5 ml
A
•
FLUZONE HIGH-DOSE PF 2015 - influenza virus vac split high-dose pf susp pref syr 0.5ml
A
•
FLULAVAL QUADRIVALENT 201 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
•
FLUZONE HIGH-DOSE PF 2016 - influenza virus vac split high-dose pf susp pref syr 0.5ml
A
•
FLULAVAL QUADRIVALENT 201 - influenza virus vaccine split quadrivalent im inj
A
FLUZONE HIGH-DOSE PF 2017 - influenza virus vac split high-dose pf susp pref syr 0.5ml
A
•
FLUMIST QUADRIVALENT influenza virus vaccine live quadrivalent intranasal susp
A
FLUZONE INTRADERMAL QUADR - influenza virus vac split quad intradermal pen 9 mcg/strain
A
•
FLUVIRIN PF 2014-2015 influenza virus vac types a & b pf susp prefilled syr 0.5 ml
A
•
FLUVIRIN 2015-2016 influenza vac type a&b surface antigen susp pref syr 0.5 ml
A
•
FLUZONE QUADRIVALENT 2015 - influenza virus vac split quadrivalent susp pref syr 0.25 ml
A
•
FLUVIRIN 2015-2016 influenza virus vaccine types a & b surface antigen im susp
A
•
FLUZONE QUADRIVALENT 2015 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
•
FLUZONE QUADRIVALENT 2015 - influenza virus vaccine split quadrivalent im inj
A
•
• •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
•
ACA
A
Dispensing Limits
FLUBLOK 2017-2018 influenza virus vac recombinant hemagglutinin (ha) inj
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
FLUBLOK 2016-2017 influenza virus vac recombinant hemagglutinin (ha) inj
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
20
GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac susp pref syr
A
•
HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml
A
•
HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml
A
•
HIBERIX - haemophilus b polysaccharide conjugate vac for inj 10 mcg
A
•
IMOVAX RABIES (H.D.C.V.) rabies virus vaccine, hdc inj
A
•
IPOL INACTIVATED IPV poliovirus vaccine, ipv injection
A
•
M-M-R II - measles, mumps & rubella virus vaccines for inj
A
•
MENACTRA - meningococcal (a, c, y, and w-135) conjugate vaccine inj
A
•
MENHIBRIX - meningococcal (c & y)-haemophilus b tet tox conj vac for inj
A
•
MENOMUNE-A/C/Y/W-135 meningococcal vaccine a, c, y, and w-135 inj
A
•
MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj
A
•
A
•
•
PEDVAX HIB - haemophilus b polysaccharide conj vac im susp 7.5 mcg/0.5 ml
A
•
•
PNEUMOVAX 23 pneumococcal vaccine polyvalent inj 25 mcg/0.5ml PNEUMOVAX 23/1 DOSE pneumococcal vaccine polyvalent inj 25 mcg/0.5ml
A
•
PREVNAR 13 - pneumococcal 13-valent conjugate vaccine inj
A
•
FLUZONE QUADRIVALENT 2015 - influenza virus vaccine split quadrivalent inj 0.5 ml
A
FLUZONE QUADRIVALENT 2016 - influenza virus vac split quadrivalent susp pref syr 0.25 ml
A
FLUZONE QUADRIVALENT 2016 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
FLUZONE QUADRIVALENT 2016 - influenza virus vaccine split quadrivalent im inj
A
•
FLUZONE QUADRIVALENT 2016 - influenza virus vaccine split quadrivalent inj 0.5 ml
A
•
FLUZONE QUADRIVALENT 2017 - influenza virus vac split quadrivalent susp pref syr 0.25 ml
A
FLUZONE QUADRIVALENT 2017 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
•
FLUZONE QUADRIVALENT 2017 - influenza virus vaccine split quadrivalent im inj
A
•
FLUZONE SPLIT 2015-2016 influenza virus vaccine split im susp
A
GARDASIL - human papillomavirus (hpv) quadrivalent recombinant vac inj
A
GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac im susp
A
• •
•
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
21
DAPTACEL - diph, acellular pert & tet tox inj 15 lf-10 mcg-5 lf/0.5ml
A
•
DIPHTHERIA/TETANUS TOXOID - diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml
A
•
RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml
A
• •
INFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml
A
•
RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 10 mcg/ml
A
•
KINRIX - diph-tetanus tox adacell pert & polio virus, ipv vac inj
A
•
RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 40 mcg/ml
A
•
A
•
A
PEDIARIX - diph-tetanus toxacell pert-hepatitis b-polio ipv vac inj
ROTARIX - rotavirus vaccine, live for oral susp ROTATEQ - rotavirus vaccine, live oral pentavalent soln
A
•
A
•
TRUMENBA - meningococcal group b vac (recomb) im susp prefilled syr
A
•
PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp
A
•
TWINRIX - hepatitis a (inact)hep b (recomb) vac inj 720-20 elu-mcg/ml
A
•
QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj TENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu
A
•
VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml
A
•
A
•
VAQTA - hepatitis a vaccine inj susp 50 unit/ml
A
•
TETANUS/DIPHTHERIA TOXOID - tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml
VARIVAX - varicella virus vac live for subcutaneous inj 1350 pfu/0.5ml
A
•
ZOSTAVAX - zoster vaccine live for subcutaneous susp 19400 unit/0.65ml
A
•
TOXOIDS ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml
A
BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lfmcg/0.5ml
A
PASSIVE IMMUNIZING AGENTS 3 ANTIVENIN LATRODECTUS MAC - antivenin latrodectus mactans inj kit 3 GAMASTAN S/D - immune globulin (human) im inj 3 GAMMAGARD LIQUID immune globulin (human) iv or subcutaneous soln 1 gm/10ml 3 GAMMAGARD LIQUID immune globulin (human) iv or subcutaneous soln 2.5 gm/25ml
• •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
•
ACA
A
Dispensing Limits
RABAVERT - rabies vaccine, pcec for inj
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
PROQUAD - measles-mumpsrubella-varicella virus vaccines for inj
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • •
22
GAMMAGARD LIQUID immune globulin (human) iv or subcutaneous soln 30 gm/300ml
3
•
GAMMAKED - immune globulin 3 (human) iv or subcutaneous soln 1 gm/10ml GAMMAKED - immune globulin 3 (human) iv or subcutaneous soln 2.5 gm/25ml GAMMAKED - immune globulin 3 (human) iv or subcutaneous soln 5 gm/50ml GAMMAKED - immune globulin 3 (human) iv or subcutaneous soln 10 gm/100ml GAMMAKED - immune globulin 3 (human) iv or subcutaneous soln 20 gm/200ml 3 GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 1 gm/10ml 3 GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 2.5 gm/25ml 3 GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 5 gm/50ml
Limited Distribution
•
ACA
3
Dispensing Limits
GAMMAGARD LIQUID immune globulin (human) iv or subcutaneous soln 20 gm/200ml
Step Therapy
•
Prior Authorization
3
Drug Name
Drug Tier
GAMMAGARD LIQUID immune globulin (human) iv or subcutaneous soln 10 gm/100ml
Limited Distribution
•
ACA
3
Dispensing Limits
GAMMAGARD LIQUID immune globulin (human) iv or subcutaneous soln 5 gm/50ml
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 10 gm/100ml
3
•
GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 20 gm/200ml
3
•
GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 40 gm/400ml
3
•
HEPAGAM B - hepatitis b immune globulin (human) inj soln
3
•
HIZENTRA - immune globulin (human) subcutaneous inj 1 gm/5ml
3
•
•
•
HIZENTRA - immune globulin (human) subcutaneous inj 2 gm/10ml
3
•
•
•
HIZENTRA - immune globulin (human) subcutaneous inj 4 gm/20ml
3
•
•
•
HIZENTRA - immune globulin (human) subcutaneous inj 10 gm/50ml
3
•
•
•
HYPERHEP B S/D - hepatitis b immune globulin (human) im inj soln
3
•
HYPERRAB S/D - rabies immune globulin (human) inj 150 unit/ml
3
3
•
HYPERRHO S/D - rho d immune globulin im soln pref syr 1500 unit (300mcg)
3
•
HYPERRHO S/D MINI-DOSE rho d immune globulin im soln pref syr 250 unit (50 mcg) HYPERTET S/D - tetanus immune globulin (human) inj 250 unit/ml
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
23
3
•
•
HYQVIA - immun glob inj 10 gm/100ml-hyaluron inj 800 unt/5 ml kit
3
•
•
HYQVIA - immun glob inj 20 gm/200ml-hyaluron inj 1600 unt/10 ml kit
3
•
•
HYQVIA - immun glob inj 30 gm/300ml-hyaluron inj 2400 unt/15 ml kit
3
IMOGAM RABIES-HT - rabies immune globulin (human) inj 150 unit/ml
3
MICRHOGAM ULTRAFILTERED - rho d immune globulin im soln pref syr 250 unit (50 mcg)
3
NABI-HB - hepatitis b immune globulin (human) im inj soln
3
RHOGAM ULTRA-FILTERED PLU - rho d immune globulin im soln pref syr 1500 unit (300mcg)
3
RHOPHYLAC - rho d immune globulin sol pref syr 1500 unt/2ml (300mcg/2ml)
3
SYNAGIS - palivizumab im soln 50 mg/0.5ml
4
SYNAGIS - palivizumab im soln 100 mg/ml
4
3
WINRHO SDF - rho d immune globulin (human) inj 1500 unit/1.3ml
3
WINRHO SDF - rho d immune globulin (human) inj 15000 unit/13ml
3
BIOLOGICALS MISC
•
ADAGEN - pegademase bovine inj 250 unit/ml
3
GRASTEK - timothy grass pollen allergen ext tab sl 2800 bau
3
•
•
ORALAIR - grass mixed pollen ext tab sl 300 ir (index of reactivity)
3
•
•
RAGWITEK - short ragweed pollen allergen extract tab sl 12 amb a 1-u
3
•
•
ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml)
4
•
AFINITOR - everolimus tab 2.5 mg
M
•
AFINITOR - everolimus tab 5 mg
M
•
AFINITOR - everolimus tab 7.5 mg
M
•
M
•
VARIZIG - varicella-zoster immune glob (human) im inj 125 unit/1.2ml
3
AFINITOR - everolimus tab 10 mg
M
•
WINRHO SDF - rho d immune globulin (human) inj 2500 unit/2.2ml
3
AFINITOR DISPERZ everolimus tab for oral susp 2 mg AFINITOR DISPERZ everolimus tab for oral susp 3 mg
M
•
•
•
Limited Distribution
HYQVIA - immun glob inj 5 gm/50ml-hyaluron inj 400 unt/2.5 ml kit
WINRHO SDF - rho d immune globulin (human) inj 5000 unit/4.4ml
ACA
•
Dispensing Limits
•
Step Therapy
3
Prior Authorization
HYQVIA - immun glob inj 2.5 gm/25ml-hyaluron inj 200 unt/1.25 ml kit
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
ANTINEOPLASTIC AGENTS ANTINEOPLASTICS
•
•
•
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
•
24
capecitabine tab 150 mg (Xeloda)
M
•
ALFERON N - interferon alfan3 inj 5000000 unit/ml
5
capecitabine tab 500 mg (Xeloda)
M
•
ALKERAN - melphalan tab 2 mg
M
CAPRELSA - vandetanib tab 100 mg
M
•
ALUNBRIG - brigatinib tab 30 mg
M
CAPRELSA - vandetanib tab 300 mg
M
•
anastrozole tab 1 mg (Arimidex)
M
CASODEX - bicalutamide tab 50 mg
M
ARIMIDEX - anastrozole tab 1 mg
M
M
•
AROMASIN - exemestane tab 25 mg
M
COMETRIQ - cabozantinib smal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit
M
•
azacitidine for inj 100 mg (Vidaza)
1
COMETRIQ - cabozantinib smal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit
bexarotene cap 75 mg (Targretin)
M
M
•
bicalutamide tab 50 mg (Casodex)
M
COMETRIQ - cabozantinib smalate cap 3 x 20 mg (60 mg dose) kit
M
•
BLEO 15K - bleomycin sulf for inj 15 usp unit(15000 international unit)
3
COTELLIC - cobimetinib fumarate tab 20 mg (base equivalent)
M
bleomycin sulfate for inj 15 unit
1
CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg
M
cyclophosphamide for inj 500 mg
1
bleomycin sulfate for inj 30 unit
•
•
•
1
BOSULIF - bosutinib tab 100 mg
M
•
BOSULIF - bosutinib tab 500 mg
M
•
CABOMETYX - cabozantinib s-malate tab 20 mg (base equivalent)
M
•
CABOMETYX - cabozantinib s-malate tab 40 mg (base equivalent)
M
•
cyclophosphamide for inj 1 gm cyclophosphamide for inj 2 gm
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1 1
CYTARABINE - cytarabine inj 20 mg/ml
3
cytarabine inj pf 20 mg/ml
1
cytarabine inj pf 100 mg/ml
Limited Distribution
•
ACA
M
Dispensing Limits
CABOMETYX - cabozantinib s-malate tab 60 mg (base equivalent)
Step Therapy
•
Prior Authorization
M
Drug Name
Drug Tier
ALECENSA - alectinib hcl cap 150 mg (base equivalent)
Limited Distribution
•
ACA
M
Dispensing Limits
AFINITOR DISPERZ everolimus tab for oral susp 5 mg
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
Products October (2016 Plan Year)
25
DEPO-PROVERA medroxyprogesterone acetate im susp 400 mg/ml
2
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
•
ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg
5
•
• •
FIRMAGON - degarelix acetate for inj 120 mg (base equiv)
4
•
FLOXURIDINE - floxuridine for inj 0.5 gm
3
flutamide cap 125 mg
M
GILOTRIF - afatinib dimaleate tab 30 mg (base equivalent)
M
•
GILOTRIF - afatinib dimaleate tab 40 mg (base equivalent)
M
•
M
•
EMCYT - estramustine phosphate sodium cap 140 mg
M
GLEEVEC - imatinib mesylate tab 100 mg (base equivalent)
M
M
•
ERIVEDGE - vismodegib cap 150 mg
GLEEVEC - imatinib mesylate tab 400 mg (base equivalent)
ERWINAZE - asparaginase erwinia chrysanthemi for inj 10000 unit
2
GLEOSTINE - lomustine cap 5 mg
M M
ETOPOSIDE - etoposide cap 50 mg
M
GLEOSTINE - lomustine cap 10 mg
M
exemestane tab 25 mg (Aromasin)
M
GLEOSTINE - lomustine cap 40 mg GLEOSTINE - lomustine cap 100 mg
M
GLIADEL WAFER - carmustine in polifeprosan intracranial implant wafer 7.7 mg
2
•
HEXALEN - altretamine cap 50 M mg HYCAMTIN - topotecan hcl cap M 0.25 mg (base equiv) HYCAMTIN - topotecan hcl cap M 1 mg (base equiv) M HYDREA - hydroxyurea cap 500 mg
• • •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
•
•
FARESTON - toremifene citrate M tab 60 mg (base equivalent) M FARYDAK - panobinostat lactate cap 10 mg (base equivalent) M FARYDAK - panobinostat lactate cap 15 mg (base equivalent) M FARYDAK - panobinostat lactate cap 20 mg (base equivalent) FASLODEX - fulvestrant inj 250 2 mg/5ml FEMARA - letrozole tab 2.5 mg M
ACA
4
M
•
Dispensing Limits
FIRMAGON - degarelix acetate for inj 80 mg (base equiv)
GILOTRIF - afatinib dimaleate tab 20 mg (base equivalent)
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
• • •
26
HYDROXYPROGESTERONE CAPRO hydroxyprogesterone caproate im in oil 1.25 gm/5ml
5
hydroxyurea cap 500 mg (Hydrea)
M
IBRANCE - palbociclib cap 75 mg
M
•
IBRANCE - palbociclib cap 100 M mg IBRANCE - palbociclib cap 125 M mg ICLUSIG - ponatinib hcl tab 15 M mg (base equiv) ICLUSIG - ponatinib hcl tab 45 M mg (base equiv) M imatinib mesylate tab 100 mg (base equivalent) (Gleevec) M imatinib mesylate tab 400 mg (base equivalent) (Gleevec) IMBRUVICA - ibrutinib cap 140 M mg M INLYTA - axitinib tab 1 mg
• • • • • • • • •
INLYTA - axitinib tab 5 mg
M
INTRON A - interferon alfa-2b inj 6000000 unit/ml
4
•
INTRON A - interferon alfa-2b inj 10000000 unit/ml
4
•
INTRON A - interferon alfa-2b for inj 10000000 unit
4
•
INTRON A - interferon alfa-2b for inj 18000000 unit
4
•
INTRON A - interferon alfa-2b for inj 50000000 unit
4
•
INTRON A W/DILUENT interferon alfa-2b for inj 10000000 unit
4
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
INTRON A W/DILUENT interferon alfa-2b for inj 18000000 unit
4
•
INTRON A W/DILUENT interferon alfa-2b for inj 50000000 unit
4
•
IRESSA - gefitinib tab 250 mg
M
JAKAFI - ruxolitinib phosphate tab 5 mg (base equivalent)
M
• •
JAKAFI - ruxolitinib phosphate tab 10 mg (base equivalent)
M
•
JAKAFI - ruxolitinib phosphate tab 15 mg (base equivalent)
M
•
JAKAFI - ruxolitinib phosphate tab 20 mg (base equivalent)
M
•
JAKAFI - ruxolitinib phosphate tab 25 mg (base equivalent)
M
•
KISQALI - ribociclib succinate tab 200 mg (base equiv)
M
•
KISQALI FEMARA 200 DOSE - M ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack KISQALI FEMARA 400 DOSE - M ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack KISQALI FEMARA 600 DOSE - M ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack M LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack 10 mg (10 mg daily dose) M LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose)
•
Products October (2016 Plan Year)
• • • •
27
LENVIMA 18 MG DAILY DOSE - lenvatinib cap therapy pack 10 & 4 (2) mg (18 mg daily dose)
M
LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose)
M
LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose)
M
LENVIMA 8 MG DAILY DOSE - M lenvatinib cap therapy pack 4 (2) mg (8 mg daily dose) letrozole tab 2.5 mg (Femara) M LEUCOVORIN CALCIUM leucovorin calcium for inj 500 mg
2
LEUCOVORIN CALCIUM leucovorin calcium tab 10 mg
2
LEUCOVORIN CALCIUM leucovorin calcium tab 15 mg
2
leucovorin calcium for inj 50 mg
1
leucovorin calcium for inj 100 mg leucovorin calcium for inj 200 mg leucovorin calcium for inj 350 mg leucovorin calcium tab 5 mg leucovorin calcium tab 25 mg
•
•
1 1 1 1 1
LEUKERAN - chlorambucil tab 2 mg
M
leuprolide acetate inj kit 5 mg/ml
4
LEVAMISOLE HCL levamisole hcl powder
3
LONSURF - trifluridine-tipiracil tab 15-6.14 mg
M
•
LONSURF - trifluridine-tipiracil tab 20-8.19 mg
M
•
LUPRON DEPOT (1-MONTH) - 4 leuprolide acetate for inj kit 3.75 mg LUPRON DEPOT (1-MONTH) - 4 leuprolide acetate for inj kit 7.5 mg LUPRON DEPOT (3-MONTH) - 4 leuprolide acetate (3 month) for inj kit 11.25 mg LUPRON DEPOT (3-MONTH) - 4 leuprolide acetate (3 month) for inj kit 22.5 mg LUPRON DEPOT (4-MONTH) - 4 leuprolide acetate (4 month) for inj kit 30 mg LUPRON DEPOT (6-MONTH) - 4 leuprolide acetate (6 month) for inj kit 45 mg M LYNPARZA - olaparib cap 50 mg LYSODREN - mitotane tab 500 M mg MATULANE - procarbazine hcl M cap 50 mg 3 MEGESTROL ACETATE megestrol acetate powder 1 megestrol acetate susp 40 mg/ml (Megace oral) megestrol acetate tab 20 mg 1
•
megestrol acetate tab 40 mg
1
MEKINIST - trametinib dimethyl M sulfoxide tab 0.5 mg (base equivalent)
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • • • • • • • •
•
28
•
mercaptopurine tab 50 mg (Purinethol)
M
•
MESNEX - mesna tab 400 mg
2
NINLARO - ixazomib citrate cap 4 mg (base equivalent)
METHOTREXATE methotrexate powder
3
M
•
METHOTREXATE SODIUM methotrexate sodium inj 250 mg/10ml (25 mg/ml)
3
ODOMZO - sonidegib phosphate cap 200 mg (base equivalent) ONCASPAR - pegaspargase inj 750 unit/ml
2
methotrexate sodium for inj 1 gm
1
POMALYST - pomalidomide cap 1 mg
M
•
1
POMALYST - pomalidomide cap 2 mg
M
•
1
POMALYST - pomalidomide cap 3 mg
M
•
1
POMALYST - pomalidomide cap 4 mg
M
•
1
PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)
M
RUBRACA - rucaparib camsylate tab 200 mg (base equivalent)
M
•
RUBRACA - rucaparib camsylate tab 250 mg (base equivalent)
M
•
RUBRACA - rucaparib camsylate tab 300 mg (base equivalent)
M
•
RYDAPT - midostaurin cap 25 mg
M
•
M
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) methotrexate sodium inj 50 mg/2ml (25 mg/ml) methotrexate sodium tab 2.5 mg (base equiv)
1 1 1
MUSTARGEN mechlorethamine hcl for inj 10 mg
2
MYLERAN - busulfan tab 2 mg
M
NEXAVAR - sorafenib tosylate tab 200 mg (base equivalent)
M
NILANDRON - nilutamide tab 150 mg
M
SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml (base equivalent)
M
SPRYCEL - dasatinib tab 20 mg
M
nilutamide tab 150 mg (Nilandron)
•
SPRYCEL - dasatinib tab 50 mg
M
•
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
M
M
NINLARO - ixazomib citrate cap 3 mg (base equivalent)
ACA
•
Dispensing Limits
M
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Drug Name NINLARO - ixazomib citrate cap 2.3 mg (base equivalent)
MEKINIST - trametinib dimethyl M sulfoxide tab 2 mg (base equivalent) melphalan tab 2 mg (Alkeran) M
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
29
SPRYCEL - dasatinib tab 140 mg
M
•
STIVARGA - regorafenib tab 40 M mg SUTENT - sunitinib malate cap M 12.5 mg (base equivalent) SUTENT - sunitinib malate cap M 25 mg (base equivalent) SUTENT - sunitinib malate cap M 37.5 mg (base equivalent) SUTENT - sunitinib malate cap M 50 mg (base equivalent) 4 SYLATRON - peginterferon alfa-2b for inj kit 296 mcg 4 SYLATRON - peginterferon alfa-2b for inj kit 444 mcg 4 SYLATRON - peginterferon alfa-2b for inj kit 888 mcg 4 SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg TABLOID - thioguanine tab 40 M mg M TAFINLAR - dabrafenib mesylate cap 50 mg (base equivalent) M TAFINLAR - dabrafenib mesylate cap 75 mg (base equivalent) M TAGRISSO - osimertinib mesylate tab 40 mg (base equivalent) M TAGRISSO - osimertinib mesylate tab 80 mg (base equivalent)
• • • • • •
•
•
•
•
• •
• • • •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
M
•
M
•
TARCEVA - erlotinib hcl tab 25 mg (base equivalent)
M
•
TARCEVA - erlotinib hcl tab 100 mg (base equivalent)
M
•
TARCEVA - erlotinib hcl tab 150 mg (base equivalent)
M
•
TARGRETIN - bexarotene cap 75 mg
M
•
TASIGNA - nilotinib hcl cap 150 M mg (base equivalent) TASIGNA - nilotinib hcl cap 200 M mg (base equivalent) TEMODAR - temozolomide cap M 5 mg TEMODAR - temozolomide cap M 20 mg TEMODAR - temozolomide cap M 100 mg TEMODAR - temozolomide cap M 140 mg TEMODAR - temozolomide cap M 180 mg TEMODAR - temozolomide cap M 250 mg M temozolomide cap 5 mg (Temodar) M temozolomide cap 20 mg (Temodar) M temozolomide cap 100 mg (Temodar) M temozolomide cap 140 mg (Temodar) M temozolomide cap 180 mg (Temodar) M temozolomide cap 250 mg (Temodar)
•
Products October (2016 Plan Year)
Limited Distribution
•
ACA
M
Dispensing Limits
SPRYCEL - dasatinib tab 100 mg
tamoxifen citrate tab 20 mg (base equivalent)
Step Therapy
•
tamoxifen citrate tab 10 mg (base equivalent)
Prior Authorization
M
Drug Name
Drug Tier
SPRYCEL - dasatinib tab 80 mg
Limited Distribution
•
ACA
M
Dispensing Limits
SPRYCEL - dasatinib tab 70 mg
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • • • • • • • • • • • •
30
THERACYS - bcg live intravesical for susp 81 mg/ vial
2
TICE BCG - bcg live intravesical for susp 50 mg
2
TRELSTAR MIXJECT triptorelin pamoate for im susp 3.75 mg
4
TRELSTAR MIXJECT triptorelin pamoate for im susp 11.25 mg
4
•
TRELSTAR MIXJECT triptorelin pamoate for im susp 22.5 mg
4
•
tretinoin cap 10 mg
M
•
TREXALL - methotrexate sodium tab 5 mg (base equiv) TREXALL - methotrexate sodium tab 7.5 mg (base equiv)
M
TREXALL - methotrexate sodium tab 10 mg (base equiv)
M
TREXALL - methotrexate sodium tab 15 mg (base equiv)
M
TYKERB - lapatinib ditosylate tab 250 mg (base equiv)
M
UVADEX - methoxsalen (photopheresis) soln 20 mcg/ml
2
VALSTAR - valrubicin soln for intravesical instillation 40 mg/ml
2
VANTAS - histrelin acetate implant kit 50 mg
3
VENCLEXTA - venetoclax tab 10 mg
M
•
VENCLEXTA - venetoclax tab 50 mg
M
•
M
•
VIDAZA - azacitidine for inj 100 mg
3
•
• •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
VENCLEXTA STARTING PACK - venetoclax tab therapy starter pack 10 & 50 & 100 mg
ACA
•
Dispensing Limits
M
Step Therapy
VENCLEXTA - venetoclax tab 100 mg
VOTRIENT - pazopanib hcl tab M 200 mg (base equiv) M XALKORI - crizotinib cap 200 mg M XALKORI - crizotinib cap 250 mg M XELODA - capecitabine tab 150 mg M XELODA - capecitabine tab 500 mg XTANDI - enzalutamide cap 40 M mg M ZEJULA - niraparib tosylate cap 100 mg (base equivalent) ZELBORAF - vemurafenib tab M 240 mg 3 ZOLADEX - goserelin acetate implant 3.6 mg 3 ZOLADEX - goserelin acetate implant 10.8 mg ZOLINZA - vorinostat cap 100 M mg M ZYDELIG - idelalisib tab 100 mg M ZYDELIG - idelalisib tab 150 mg M ZYKADIA - ceritinib cap 150 mg M ZYTIGA - abiraterone acetate tab 250 mg M ZYTIGA - abiraterone acetate tab 500 mg
•
M
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • • • • • • • • • • • • • • • 31
ENDOCRINE AND METABOLIC DRUGS CORTICOSTEROIDS
3 ACTIVE INJECTION KIT BLM- - betameth na pho&ace inj 6 mg/ml & bupiv 0.25% & lido1% kit 3 ACTIVE INJECTION KIT BM betamethasone sod phos & ace inj 6 mg/ml & bupiv 0.25% kit 3 ACTIVE INJECTION KIT D dexamethasone sodium phosphate pf inj 10 mg/ml kit 3 ACTIVE INJECTION KIT DL dexamethasone sod phos pf inj 10 mg/ml & lidocaine 1% kit ACTIVE INJECTION KIT DLM - 3 dexamethasone pf inj 10 mg/ ml & bupiv 0.25% & lido 1% kit ACTIVE INJECTION KIT KL-3 - 3 triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit 3 ACTIVE INJECTION KIT KM triamcinolone inj 40 mg/ml & bupivacaine hcl inj 0.5% kit 3 ACTIVE INJECTION KIT L methylprednisolone inj 40 mg/ml & lidocaine inj 1% kit 3 ACTIVE INJECTION KIT LMD - methylprednisolone inj 80 mg/ml & bupiv 0.25% &lido 1% kit ACTIVE INJECTION KIT M-1 - 3 dexamethasone sod phos pf inj 10 mg/ml & bupiv 0.25% kit 3 ARZE-JECT-A - triamcinolone acetonide inj kit 3 x 40 mg/ ml
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
BETA 1 KIT - betamethasone sod phos & acet inj kit 30 mg/5 ml (6 mg/ml)
3
BETALIDO - betamethasone sod phos & ace inj 6 mg/ml & lido inj 1% kit
3
betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml (Celestone-soluspan)
1
BETAMETHASONE SODIUM PHOS - betamethasone sodium phosphate powder
3
BT INJECTION KIT triamcinolone inj 40 mg/ml & bupivacaine hcl inj 0.5% kit
3
budesonide delayed release particles cap 3 mg (Entocort ec)
1
BUPIVILOG KIT triamcinolone inj 40 mg/ml & bupivacaine hcl inj 0.5% kit
3
CELESTONE-SOLUSPAN betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml
3
CORTEF - hydrocortisone tab 5 mg
3
CORTEF - hydrocortisone tab 10 mg
3
CORTEF - hydrocortisone tab 20 mg
3
CORTISONE ACETATE cortisone acetate powder
3
CORTISONE ACETATE cortisone acetate tab 25 mg
2
DEPO-MEDROL methylprednisolone acetate inj susp 20 mg/ml
3
DEPO-MEDROL methylprednisolone acetate inj susp 40 mg/ml
3
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
32
DEPO-MEDROL methylprednisolone acetate inj susp 80 mg/ml
3
DERMACINRX CINLONE-I CPI - triamcinolone inj 40 mg/ ml & lido-prilo cr 2.5-2.5% kit
3
DEXAMETHASONE dexamethasone powder
3
DEXAMETHASONE dexamethasone soln 0.5 mg/5ml
2
DEXAMETHASONE dexamethasone tab 1 mg
2
DEXAMETHASONE dexamethasone tab 2 mg
2
DEXAMETHASONE ACETATE - dexamethasone acetate powder
3
DEXAMETHASONE ACETATE ANH dexamethasone acetate powder
3
DEXAMETHASONE BASE dexamethasone powder
3
dexamethasone elixir 0.5 mg/5ml
1
dexamethasone sodium phosphate inj 20 mg/5ml dexamethasone sodium phosphate inj 120 mg/30ml dexamethasone sodium phosphate inj 100 mg/10ml dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1.5 mg dexamethasone tab 4 mg dexamethasone tab 6 mg
Limited Distribution
ACA
Dispensing Limits
1 1 1 1 1 1 1
DEXLIDO - dexamethasone sod phos pf inj 10 mg/ml & lidocaine 1% kit
3
DEXLIDO-M - dexamethasone pf inj 10 mg/ml & bupiv 0.25% & lido 1% kit
3
DEXPAK 10 DAY dexamethasone tab therapy pack 1.5 mg (35)
3
DEXPAK 13 DAY dexamethasone tab therapy pack 1.5 mg (51)
3
3
DEXAMETHASONE INTENSOL - dexamethasone conc 1 mg/ml
2
3
DEXAMETHASONE SODIUM PHOS - dexamethasone sod phosphate preservative free inj 10 mg/ml
3
DOUBLEDEX dexamethasone sodium phosphate pf inj 10 mg/ml kit
3
DEXAMETHASONE SODIUM PHOS - dexamethasone sodium phosphate inj 10 mg/ ml
3
DYURAL-L methylprednisolone inj 40 mg/ml & lidocaine inj 1% kit
3
DEXAMETHASONE SODIUM PHOS - dexamethasone sodium phosphate powder
3
DYURAL-LM methylprednisolone inj 40 mg/ml & bupiv 0.25% &lido 1% kit
3
dexamethasone sodium phosphate inj 4 mg/ml
1
DYURAL-40 methylprednisolone inj 40 mg/ml & bupiv 0.25% &lido 1% kit
SM
Step Therapy
1
DEXPAK 6 DAY dexamethasone tab therapy pack 1.5 mg (21)
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
33
DYURAL-80 methylprednisolone inj 80 mg/ml & bupiv 0.25% &lido 1% kit
3
ENTOCORT EC - budesonide delayed release particles cap 3 mg
3
FLUDROCORTISONE ACETATE - fludrocortisone acetate powder
3
fludrocortisone acetate tab 0.1 mg
MARDEX-25 - dexamethasone sod phos pf inj 10 mg/ml & bupiv 0.25% kit
3
MEDROL - methylprednisolone tab 2 mg
3
MEDROL - methylprednisolone tab 4 mg
3
MEDROL - methylprednisolone tab 8 mg
3
1
MEDROL - methylprednisolone tab 16 mg
3
hydrocortisone tab 5 mg (Cortef)
1
MEDROL - methylprednisolone tab 32 mg
3
hydrocortisone tab 10 mg (Cortef)
1
3
hydrocortisone tab 20 mg (Cortef)
1
MEDROL DOSEPAK methylprednisolone tab therapy pack 4 mg (21)
3
INTERARTICULAR JOINT KIT - triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit
3
METHYLPREDNISOLONE methylprednisolone powder
3
JTT PHYSICIANS KIT triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit
3
METHYLPREDNISOLONE ACETAT methylprednisolone acetate powder methylprednisolone acetate inj susp 40 mg/ml (Depomedrol)
1
KENALOG-10 - triamcinolone acetonide inj susp 10 mg/ml
3
1
KENALOG-40 - triamcinolone acetonide inj susp 40 mg/ml
3
methylprednisolone acetate inj susp 80 mg/ml (Depomedrol)
1
LIDOLOG KIT - triamcinolone inj 40 mg/ml & lidocaine hcl inj 2% kit
3
methylprednisolone sodium succinate for inj 40 mg (Solu-medrol)
1
LT INJECTION KIT triamcinolone inj 40 mg/ml & lidocaine hcl inj 2% kit
3
methylprednisolone sodium succinate for inj 125 mg (Solu-medrol)
1
MARBETA-L - betameth na pho&ace inj 6 mg/ml & bupiv 0.25% & lido1% kit
3
methylprednisolone sodium succinate for inj 1000 mg (Solu-medrol) methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak)
1
methylprednisolone tab 4 mg (Medrol)
1
MARBETA-25 - betamethasone 3 sod phos & ace inj 6 mg/ml & bupiv 0.25% kit
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
34
methylprednisolone tab 8 mg (Medrol) methylprednisolone tab 16 mg (Medrol) methylprednisolone tab 32 mg (Medrol)
1
1 3
MILLIPRED - prednisolone tab 5 mg
3
MILLIPRED DP - prednisolone tab therapy pack 5 mg (21)
3
MILLIPRED DP - prednisolone tab therapy pack 5 mg (48)
3
MLK F1 KIT - triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit
3
MLK F2 KIT - triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit
3
MLK F3 KIT - triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit
3
MLK F4 KIT - triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit
3
MLP A-1 - triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit
3
MLP A-2 - triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit
3
MULTI-SPECIALTY KIT methylprednisolone inj 40 mg/ml & lidocaine inj 1% kit
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
ORAPRED ODT - prednisolone 3 sod phos orally disintegr tab 30 mg (base eq) 3 P-CARE D40 methylprednisolone acetate inj susp 40 mg/ml kit 3 P-CARE D40MX methylprednisolone inj 40 mg/ml & bupiv 0.5% &lido 1% kit 3 P-CARE D80 methylprednisolone acetate inj susp 40 mg/ml kit 3 P-CARE D80MX methylprednisolone inj 40 mg/ml & bupiv 0.5% &lido 1% kit 3 P-CARE K40 - triamcinolone acetonide inj kit 40 mg/ml 3 P-CARE K40MX triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 1% kit 3 P-CARE K80 - triamcinolone acetonide inj kit 2 x 40 mg/ ml 3 P-CARE K80MX triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 1% kit 3 PEDIAPRED - prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) 3 PHYSICIANS EZ USE JOINT T - triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit 3 PHYSICIANS EZ USE MPRED - methylprednisolone ace 40 mg/ml & bupivacaine inj 0.5% kit 3 POD-CARE 100C betamethasone sod phos & acet inj kit 30 mg/5 ml (6 mg/ ml)
1
MILLIPRED - prednisolone sod phosphate oral soln 10 mg/5ml (base equiv)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ORAPRED ODT - prednisolone 3 sod phos orally disintegr tab 10 mg (base eq) ORAPRED ODT - prednisolone 3 sod phos orally disintegr tab 15 mg (base eq) SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
35
POD-CARE 100CMX betameth na pho&ace inj 6 mg/ml & bupiv 0.5% & lido1% kit
3
PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate powder
3
prednisolone syrup 15 mg/5ml (usp solution equivalent) (Prelone)
1
POD-CARE 100K triamcinolone acetonide inj kit 40 mg/ml
3
3
PREDNISONE - prednisone oral soln 5 mg/5ml
2
POD-CARE 100KMX triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 1% kit
3
PREDNISOLONE prednisolone powder
3
PREDNISONE - prednisone powder
3
PREDNISOLONE ACETATE prednisolone acetate powder
3
PREDNISONE - prednisone tab therapy pack 5 mg (21)
3
PREDNISOLONE ANHYDROUS - prednisolone powder
3
PREDNISONE - prednisone tab therapy pack 5 mg (48) PREDNISONE - prednisone tab therapy pack 10 mg (21)
3
prednisolone sod phos orally disintegr tab 10 mg (base eq) (Orapred odt)
1
PREDNISONE - prednisone tab therapy pack 10 mg (48)
3
PREDNISONE - prednisone tab 50 mg
2
PREDNISONE INTENSOL prednisone conc 5 mg/ml
3
prednisone tab 1 mg
1
prednisolone sod phos orally disintegr tab 15 mg (base eq) (Orapred odt) prednisolone sod phos orally disintegr tab 30 mg (base eq) (Orapred odt)
1
1
prednisone tab 2.5 mg
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred)
1
prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) prednisolone sod phosphate oral soln 10 mg/5ml (base equiv) (Millipred) prednisolone sod phosphate oral soln 20 mg/5ml (base equiv) (Veripred 20) PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate oral soln 25 mg/5ml (base eq)
prednisone tab 5 mg prednisone tab 10 mg prednisone tab 20 mg
Limited Distribution
1
3
1
PRO-C-DURE 6 KIT triamcinolone acetonide inj kit 3 x 40 mg/ml READYSHARP ANESTHETICS + - betameth na pho&ace inj 6 mg/ml & bupiv 0.5% & lido1% kit
3
READYSHARP ANESTHETICS + dexamethasone inj 10 mg/ml & bupiv 0.5% & lido 1% kit
3
SM
ACA
1
1
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Dispensing Limits
1
3
3
Step Therapy
1
PRO-C-DURE 5 KIT triamcinolone acetonide inj kit 2 x 40 mg/ml
1
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
36
READYSHARP ANESTHETICS + methylprednisolone inj 80 mg/ml & bupiv 0.5% &lido 1% kit
3
READYSHARP BETAMETHASONE betamethasone sod phos & acet inj kit 30 mg/5 ml (6 mg/ ml)
3
READYSHARP DEXAMETHASONE dexamethasone sodium phosphate inj 10 mg/ml kit
3
READYSHARP METHYLPREDNISO methylprednisolone acetate inj susp 80 mg/ml kit
3
READYSHARP TRIAMCINOLONE triamcinolone acetonide inj kit 40 mg/ml
3
READYSHARP-K triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 1% kit
3
SOLU-CORTEF hydrocortisone sodium succinate pf for inj 100 mg
3
SOLU-CORTEF hydrocortisone sodium succinate pf for inj 250 mg
3
SOLU-CORTEF hydrocortisone sodium succinate pf for inj 500 mg
3
SOLU-CORTEF hydrocortisone sodium succinate pf for inj 1000 mg
SOLU-MEDROL methylprednisolone sodium succinate for inj 500 mg
3
SOLU-MEDROL methylprednisolone sodium succinate for inj 1000 mg
3
SOLU-MEDROL methylprednisolone sodium succinate for inj 2000 mg
3
TRIAMCINOLONE DIACETATE - triamcinolone diacetate micronized powder
3
TRIAMCINOLONE DIACETATE M triamcinolone diacetate micronized powder
3
UCERIS - budesonide tab er 24hr 9 mg
3
VERIPRED 20 - prednisolone sod phosphate oral soln 20 mg/5ml (base equiv)
3
ANDROGEN-ANABOLIC ANADROL-50 - oxymetholone tab 50 mg
3
•
ANDRODERM - testosterone td patch 24hr 2 mg/24hr
3
•
•
ANDRODERM - testosterone td patch 24hr 4 mg/24hr
3
•
•
ANDROGEL - testosterone td gel 25 mg/2.5gm (1%)
3
•
•
ANDROGEL - testosterone td gel 50 mg/5gm (1%)
3
•
•
3
ANDROGEL - testosterone td gel 20.25 mg/1.25gm (1.62%)
2
•
•
SOLU-MEDROL methylprednisolone sodium succinate for inj 40 mg
3
ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%)
2
•
•
2
•
•
SOLU-MEDROL methylprednisolone sodium succinate for inj 125 mg
3
ANDROGEL PUMP testosterone td gel 20.25 mg/act (1.62%)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
37
ANDROID - methyltestosterone 3 cap 10 mg 2 ANDROXY - fluoxymesterone tab 10 mg 3 AVEED - testosterone undecanoate im inj in oil 750 mg/3ml (250mg/ml) AXIRON - testosterone td soln 3 30 mg/act 3 DANAZOL - danazol powder danazol cap 50 mg danazol cap 100 mg danazol cap 200 mg
1 1 1
• •
•
•
•
• • • •
•
•
METHITEST methyltestosterone oral tab 10 mg
3
METHYLTESTOSTERONE methyltestosterone powder
3
methyltestosterone cap 10 mg (Testred)
1
•
NATESTO - testosterone nasal gel 5.5 mg/act
3
•
OXANDRIN - oxandrolone tab 2.5 mg
3
•
OXANDRIN - oxandrolone tab 10 mg
3
•
oxandrolone tab 2.5 mg (Oxandrin)
1
•
oxandrolone tab 10 mg (Oxandrin)
1
•
STRIANT - testosterone buccal mucoadhesive system 30 mg
3
•
•
TESTIM - testosterone td gel 50 mg/5gm (1%)
3
•
•
3
DEPO-TESTOSTERONE testosterone cypionate im inj in oil 200 mg/ml
3
EC-RX TESTOSTERONE 0.2% - testosterone cream 0.2% (compounding kit)
3
EC-RX TESTOSTERONE 0.4% - testosterone cream 0.4% (compounding kit)
3
TESTOPEL - testosterone implant pellets 75 mg
3
•
•
3
•
•
EC-RX TESTOSTERONE 10% - testosterone cream 10% (compounding kit)
3
TESTOSTERONE testosterone td gel 25 mg/2.5gm (1%)
3
•
•
EC-RX TESTOSTERONE 20% - testosterone cream 20% (compounding kit)
3
TESTOSTERONE testosterone td gel 50 mg/5gm (1%)
3
•
•
FIRST-TESTOSTERONE testosterone propionate td ointment 2% (cmpd kit)
3
TESTOSTERONE testosterone td gel 10mg/act (2%)
1
•
•
FIRST-TESTOSTERONE MC COM - testosterone propionate td cream 2% (cmpd kit)
3
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone)
1
•
•
FORTESTA - testosterone td gel 10mg/act (2%)
3
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone) testosterone enanthate im inj in oil 200 mg/ml
1
•
•
•
•
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
•
DEPO-TESTOSTERONE testosterone cypionate im inj in oil 100 mg/ml
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
38
testosterone td gel 50 mg/5gm (1%) (Androgel)
1
•
•
1
•
•
•
testosterone td soln 30 mg/ act (Axiron)
1
TESTRED - methyltestosterone 3 cap 10 mg VOGELXO - testosterone td gel 3 50 mg/5gm (1%) 3 VOGELXO PUMP testosterone td gel 12.5 mg/ act (1%) ESTROGENS
CLIMARA - estradiol td patch weekly 0.025 mg/24hr
3
CLIMARA - estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)
3
•
CLIMARA - estradiol td patch weekly 0.05 mg/24hr
3
CLIMARA - estradiol td patch weekly 0.06 mg/24hr
3
•
•
CLIMARA - estradiol td patch weekly 0.075 mg/24hr
3
•
•
CLIMARA - estradiol td patch weekly 0.1 mg/24hr
3
CLIMARA PRO - estradiollevonorgestrel td patch weekly 0.045-0.015 mg/day
2
•
ACTIVELLA - estradiol & norethindrone acetate tab 0.5-0.1 mg
3
COMBIPATCH - estradiolnorethindrone ace td pttw 0.05-0.14 mg/day
3
ACTIVELLA - estradiol & norethindrone acetate tab 1-0.5 mg
3
COMBIPATCH - estradiolnorethindrone ace td pttw 0.05-0.25 mg/day
3
ALORA - estradiol td patch biweekly 0.025 mg/24hr
3
DELESTROGEN - estradiol valerate im in oil 10 mg/ml
3
ALORA - estradiol td patch biweekly 0.05 mg/24hr
3
DELESTROGEN - estradiol valerate im in oil 20 mg/ml
3
ALORA - estradiol td patch biweekly 0.075 mg/24hr
3
DELESTROGEN - estradiol valerate im in oil 40 mg/ml
3
ALORA - estradiol td patch biweekly 0.1 mg/24hr
3
DEPO-ESTRADIOL - estradiol cypionate im in oil 5 mg/ml
3
ANGELIQ - drospirenoneestradiol tab 0.25-0.5 mg
3
DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)
2
ANGELIQ - drospirenoneestradiol tab 0.5-1 mg
3
DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)
2
DIVIGEL - estradiol td gel 1 mg/gm (0.1%)
2
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
•
ACA
•
3
Dispensing Limits
1
BIEST/PROGESTERONE estradiol-estriolprogesterone micronized cream (cmpd kit)
Step Therapy
testosterone td gel 25 mg/2.5gm (1%) (Androgel)
testosterone td gel 12.5 mg/ act (1%) (Androgel pump)
•
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
TESTOSTERONE PUMP testosterone td gel 12.5 mg/ act (1%)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
39
DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mg
3
estradiol td patch twice weekly 0.075 mg/24hr (Vivelle-dot)
1
EC-RX ESTRADIOL 0.4% estradiol micronized cream 0.4% (compounding kit)
3
estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-dot)
1
EC-RX ESTRADIOL 0.6% estradiol micronized cream 0.6% (compounding kit)
3
estradiol td patch weekly 0.025 mg/24hr (Climara)
1
ELESTRIN - estradiol gel 0.06% (0.52 mg/0.87 gm metered-dose pump)
3
estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara)
esterified estrogens & methyltestosterone tab 0.625-1.25 mg
1
estradiol td patch weekly 0.05 mg/24hr (Climara)
esterified estrogens & methyltestosterone tab 1.25-2.5 mg
estradiol td patch weekly 0.06 mg/24hr (Climara)
1
estradiol td patch weekly 0.075 mg/24hr (Climara)
ESTRACE - estradiol tab 0.5 mg
3
estradiol td patch weekly 0.1 mg/24hr (Climara)
ESTRACE - estradiol tab 1 mg
3
ESTRACE - estradiol tab 2 mg
3
estradiol valerate im in oil 20 mg/ml (Delestrogen)
ESTRADIOL - estradiol powder
3
estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella)
1
estradiol & norethindrone acetate tab 1-0.5 mg (Activella)
1
estradiol valerate im in oil 40 mg/ml (Delestrogen)
estradiol tab 0.5 mg (Estrace) 1 1 estradiol tab 1 mg (Estrace) estradiol tab 2 mg (Estrace)
1
estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot)
1
estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot)
1
estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot)
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1 1 1 1 1 1
ESTRIOL - estriol micronized powder
3
ESTROGEL - estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump)
2
ESTRONE - estrone powder
3
ESTROPIPATE - estropipate tab 0.75 mg
3
ESTROPIPATE - estropipate tab 1.5 mg
3
ESTROPIPATE - estropipate tab 3 mg
2
ETHINYL ESTRADIOL - ethinyl 3 estradiol powder 3 EVAMIST - estradiol transdermal spray 1.53 mg/ spray
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
40
FEMHRT LOW DOSE norethindrone acetateethinyl estradiol tab 0.5 mg-2.5 mcg
3
MENEST - esterified estrogens tab 0.3 mg
3
MENEST - esterified estrogens tab 0.625 mg
3
MENEST - esterified estrogens tab 1.25 mg
3
MENOSTAR - estradiol td patch weekly 14 mcg/24hr
3
MINIVELLE - estradiol td patch biweekly 0.0375 mg/24hr
3
MINIVELLE - estradiol td patch biweekly 0.05 mg/24hr
3
MINIVELLE - estradiol td patch biweekly 0.075 mg/24hr
3
MINIVELLE - estradiol td patch biweekly 0.1 mg/24hr
3
MINIVELLE - estradiol td patch twice weekly 0.025 mg/24hr
3
1 norethindrone acetateethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt low dose) 1 norethindrone acetateethinyl estradiol tab 1 mg-5 mcg 3 PREFEST - estradiol tab 1 mg(15)/estrad-norgestimate tab 1-0.09mg(15) 3 PREMARIN - estrogens, conjugated for inj 25 mg 2 PREMARIN - estrogens, conjugated tab 0.3 mg 2 PREMARIN - estrogens, conjugated tab 0.45 mg 2 PREMARIN - estrogens, conjugated tab 0.625 mg
PREMARIN - estrogens, conjugated tab 0.9 mg
2
PREMARIN - estrogens, conjugated tab 1.25 mg
2
PREMPHASE - conj est 0.625(14)/conj estmedroxypro ac tab 0.625-5mg(14)
2
PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg
2
PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.45-1.5 mg
2
PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.625-2.5 mg
2
PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.625-5 mg
2
VIVELLE-DOT - estradiol td patch twice weekly 0.025 mg/24hr
3
VIVELLE-DOT - estradiol td patch twice weekly 0.0375 mg/24hr
3
VIVELLE-DOT - estradiol td patch twice weekly 0.05 mg/24hr
3
VIVELLE-DOT - estradiol td patch twice weekly 0.075 mg/24hr
3
VIVELLE-DOT - estradiol td patch twice weekly 0.1 mg/24hr
3
CONTRACEPTIVES
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
BEYAZ - drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg
3
BREVICON-28 - norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
3
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
41
3 CYCLESSA - desogestethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mgmg A DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp prefilled syr 150 mg/ml A DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml A DEPO-SUBQ PROVERA 104 - medroxyprogesterone acetate susp pref syr 104 mg/0.65ml 3 DESOGEN - desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg A desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette) A desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa) A desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) A drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg (Beyaz) A drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz) A drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28) ELLA - ulipristal acetate tab 30 A mg
•
3
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg
A
•
A
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
ESTROSTEP FE norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg
ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg (Zovia 1/50e)
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
FALESSA - levonorgest-eth estrad tab 0.1 mg-20 mcg & fa tab 1 mg kit
3
GENERESS FE norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg
3
IMPLANON - etonogestrel subdermal implant 68 mg
A
• •
•
levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg (Quartette)
A
•
•
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique)
A
•
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique)
A
•
A
•
A
•
A
•
•
• •
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg
•
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg
•
levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg
•
LEVONORGESTREL AND ETHINY - levonorgestrelethinyl estradiol (continuous) tab 90-20 mcg SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
3
Products October (2016 Plan Year)
42
• •
• •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
A levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mgmcg A levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg 3 LILETTA - levonorgestrel releasing iud 18.6 mcg/day (52 mg total) 3 LO LOESTRIN FE - norethineth estradiol-fe tab 1 mg-10 mcg (24)/10 mcg (2) 3 LOESTRIN FE 1.5/30 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg 3 LOESTRIN FE 1/20 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg 3 LOESTRIN 1.5/30-21 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg 3 LOESTRIN 1/20-21 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 3 LOSEASONIQUE - levonorgeth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) A medroxyprogesterone acetate im susp prefilled syr 150 mg/ml (Depoprovera contrac) A medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac) 3 MINASTRIN 24 FE norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24)
Prior Authorization
•
Drug Name
Drug Tier
A
levonorgestrel tab 1.5 mg (Plan b one-step)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
MIRCETTE - desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)
3
MIRENA - levonorgestrel releasing iud 20 mcg/day (52 mg total)
A
NATAZIA - estradiol valeratedienogest tab 3 mg /2-2 mg/2-3 mg/1 mg
3
NECON 1/50-28 norethindrone & mestranol tab 1 mg-50 mcg
2
NEXPLANON - etonogestrel subdermal implant 68 mg
A
• •
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (Ovcon-35)
A
•
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28)
A
•
norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35)
A
•
norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (Femcon fe)
A
•
norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg (Generess fe)
A
•
norethindrone acethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe)
A
•
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21)
A
•
norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21)
A
•
Products October (2016 Plan Year)
• •
43
A norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24) (Minastrin 24 fe) A norethindrone aceethinyl estradiol-fe tab 1 mg-20 mcg (24) (Lomedia 24 fe) A norethindrone tab 0.35 mg (Nor-qd) A norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mgmcg (Ortho-novum 7/7/7) A norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28) A norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Orthocyclen) A norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mgmcg (Ortho tri-cyclen lo) A norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mgmcg (Ortho tri-cyclen) A norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg A NUVARING - etonogestrelethinyl estradiol va ring 0.120-0.015 mg/24hr 2 OGESTREL - norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg
ORTHO MICRONOR norethindrone tab 0.35 mg
3 3
•
ORTHO TRI-CYCLEN norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg
3
•
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg
3
•
ORTHO-CYCLEN norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg ORTHO-NOVUM 1/35 norethindrone & ethinyl estradiol tab 1 mg-35 mcg
3
3
•
ORTHO-NOVUM 7/7/7 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mgmcg PARAGARD INTRAUTERINE COP - copper iud
3
•
PLAN B ONE-STEP levonorgestrel tab 1.5 mg
A 3
•
QUARTETTE - levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg
3
•
SAFYRAL - drospirenoneethinyl estrad-levomefolate tab 3-0.03-0.451 mg
3
•
SEASONIQUE - levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) SKYLA - levonorgestrel releasing iud 14 mcg/day (13.5 mg total)
2
• •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
•
Limited Distribution
•
ACA
A
A
Dispensing Limits
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30)
ORTHO EVRA norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• •
•
44
TAYTULLA - norethindrone ace-ethinyl estradiol-fe cap 1 mg-20 mcg (24)
3
NORETHINDRONE ACETATE - norethindrone acetate powder
3
TRI-NORINYL 28 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg
3
norethindrone acetate tab 5 mg (Aygestin)
1
XULANE - norelgestrominethinyl estradiol td ptwk 150-35 mcg/24hr
A
YASMIN 28 - drospirenoneethinyl estradiol tab 3-0.03 mg
3
YAZ - drospirenone-ethinyl estradiol tab 3-0.02 mg
3
PROGESTINS AYGESTIN - norethindrone acetate tab 5 mg
3
EC-RX PROGESTERONE 10% - progesterone micronized td cream 10% (cmpd kit)
3
EC-RX PROGESTERONE 20% - progesterone micronized td cream 20% (cmpd kit)
3
MAKENA hydroxyprogesterone caproate im in oil 250 mg/ml
4
medroxyprogesterone acetate tab 2.5 mg (Provera)
1
medroxyprogesterone acetate tab 5 mg (Provera)
1
progesterone im in oil 50 mg/ml
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
3 PROGESTERONE MICRONIZED - progesterone micronized powder 1 progesterone micronized cap 100 mg (Prometrium) 1 progesterone micronized cap 200 mg (Prometrium) 3 PROGESTERONE MILLED progesterone powder 3 PROGESTERONE WETTABLE - progesterone powder 3 PROGESTERONE 10% KIT progesterone micronized td cream 10% (cmpd kit) PROMETRIUM - progesterone 3 micronized cap 100 mg PROMETRIUM - progesterone 3 micronized cap 200 mg 3 PROVERA medroxyprogesterone acetate tab 2.5 mg 3 PROVERA medroxyprogesterone acetate tab 5 mg 3 PROVERA medroxyprogesterone acetate tab 10 mg
•
1 medroxyprogesterone acetate tab 10 mg (Provera) 3 MEGACE ES - megestrol acetate susp 625 mg/5ml 1 megestrol acetate susp 625 mg/5ml (Megace es)
ANTIDIABETICS Antidiabetics
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
acarbose tab 25 mg (Precose)
1
acarbose tab 50 mg (Precose)
1
Products October (2016 Plan Year)
45
acarbose tab 100 mg (Precose)
1
ACTOPLUS MET - pioglitazone 3 hcl-metformin hcl tab 15-500 mg ACTOPLUS MET - pioglitazone 3 hcl-metformin hcl tab 15-850 mg 3 ACTOPLUS MET XR pioglitazone hcl-metformin hcl tab er 24hr 15-1000 mg 3 ACTOPLUS MET XR pioglitazone hcl-metformin hcl tab er 24hr 30-1000 mg 3 ACTOS - pioglitazone hcl tab 15 mg (base equiv) 3 ACTOS - pioglitazone hcl tab 30 mg (base equiv) 3 ACTOS - pioglitazone hcl tab 45 mg (base equiv) 3 ALOGLIPTIN - alogliptin benzoate tab 6.25 mg (base equiv) 3 ALOGLIPTIN - alogliptin benzoate tab 12.5 mg (base equiv) 3 ALOGLIPTIN - alogliptin benzoate tab 25 mg (base equiv) 3 ALOGLIPTIN/METFORMIN HCL - alogliptin-metformin hcl tab 12.5-500 mg 3 ALOGLIPTIN/METFORMIN HCL - alogliptin-metformin hcl tab 12.5-1000 mg 3 ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 12.5-15 mg 3 ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 12.5-30 mg
ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 12.5-45 mg
3
ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 25-15 mg
3
ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 25-30 mg
3
ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 25-45 mg
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
AMARYL - glimepiride tab 1 mg 3 AMARYL - glimepiride tab 2 mg 3 AMARYL - glimepiride tab 4 mg 3 3 AVANDIA - rosiglitazone maleate tab 2 mg (base equiv) 3 AVANDIA - rosiglitazone maleate tab 4 mg (base equiv) BYDUREON - exenatide for inj 2 extended release susp 2 mg 2 BYDUREON PEN - exenatide extended release for susp pen-injector 2 mg BYETTA - exenatide soln pen- 2 injector 5 mcg/0.02ml BYETTA - exenatide soln pen- 2 injector 10 mcg/0.04ml 3 CHLORPROPAMIDE chlorpropamide tab 100 mg 3 CHLORPROPAMIDE chlorpropamide tab 250 mg 3 CYCLOSET - bromocriptine mesylate tab 0.8 mg (base equivalent) 3 DUETACT - pioglitazone hclglimepiride tab 30-2 mg 3 DUETACT - pioglitazone hclglimepiride tab 30-4 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
46
FARXIGA - dapagliflozin propanediol tab 5 mg (base equivalent)
3
FARXIGA - dapagliflozin propanediol tab 10 mg (base equivalent)
3
1
glipizide tab er 24hr 5 mg (Glucotrol xl)
1
glipizide tab er 24hr 10 mg (Glucotrol xl)
1
glipizide tab 5 mg (Glucotrol)
1
glipizide tab 10 mg (Glucotrol)
1
glipizide-metformin hcl tab 2.5-250 mg
1
glipizide-metformin hcl tab 2.5-500 mg glipizide-metformin hcl tab 5-500 mg
1 1
GLUCAGEN HYPOKIT glucagon hcl (rdna) for inj 1 mg (base equiv)
3
GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
GLUCOPHAGE - metformin hcl 3 tab 850 mg GLUCOPHAGE - metformin hcl 3 tab 1000 mg 3 GLUCOPHAGE XR metformin hcl tab er 24hr 500 mg 3 GLUCOPHAGE XR metformin hcl tab er 24hr 750 mg 3 GLUCOTROL - glipizide tab 5 mg GLUCOTROL - glipizide tab 10 3 mg GLUCOTROL XL - glipizide tab 3 er 24hr 2.5 mg GLUCOTROL XL - glipizide tab 3 er 24hr 5 mg GLUCOTROL XL - glipizide tab 3 er 24hr 10 mg 3 GLUCOVANCE - glyburidemetformin tab 2.5-500 mg 3 GLUCOVANCE - glyburidemetformin tab 5-500 mg 3 GLYBURIDE - glyburide powder 1 glyburide micronized tab 1.5 mg (Glynase) 1 glyburide micronized tab 3 mg (Glynase) 1 glyburide micronized tab 6 mg (Glynase) 1 glyburide tab 1.25 mg
FORTAMET - metformin hcl tab 3 er 24hr osmotic 500 mg FORTAMET - metformin hcl tab 3 er 24hr osmotic 1000 mg 1 glimepiride tab 1 mg (Amaryl) 1 glimepiride tab 2 mg (Amaryl) 1 glimepiride tab 4 mg (Amaryl) 3 GLIPIZIDE - glipizide powder glipizide tab er 24hr 2.5 mg (Glucotrol xl)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
glyburide tab 2.5 mg glyburide tab 5 mg glyburide-metformin tab 1.25-250 mg (Glucovance) glyburide-metformin tab 2.5-500 mg (Glucovance)
GLUCOPHAGE - metformin hcl 3 tab 500 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1 1 1 1
Products October (2016 Plan Year)
47
1
INVOKANA - canagliflozin tab 300 mg
2
GLYNASE - glyburide micronized tab 1.5 mg
3
JANUMET - sitagliptinmetformin hcl tab 50-500 mg
2
GLYNASE - glyburide micronized tab 3 mg
3
2
GLYNASE - glyburide micronized tab 6 mg
3
JANUMET - sitagliptinmetformin hcl tab 50-1000 mg
2
GLYSET - miglitol tab 25 mg
3
GLYSET - miglitol tab 50 mg
3
JANUMET XR - sitagliptinmetformin hcl tab er 24hr 50-500 mg
GLYSET - miglitol tab 100 mg
3
2
GLYXAMBI - empagliflozinlinagliptin tab 10-5 mg
3
JANUMET XR - sitagliptinmetformin hcl tab er 24hr 50-1000 mg JANUMET XR - sitagliptinmetformin hcl tab er 24hr 100-1000 mg
2
GLYXAMBI - empagliflozinlinagliptin tab 25-5 mg
3
INVOKAMET - canagliflozinmetformin hcl tab 50-500 mg
2
2
INVOKAMET - canagliflozinmetformin hcl tab 50-1000 mg
2
JANUVIA - sitagliptin phosphate tab 25 mg (base equiv)
2
INVOKAMET - canagliflozinmetformin hcl tab 150-500 mg
2
JANUVIA - sitagliptin phosphate tab 50 mg (base equiv)
2
INVOKAMET - canagliflozinmetformin hcl tab 150-1000 mg
2
JANUVIA - sitagliptin phosphate tab 100 mg (base equiv) JARDIANCE - empagliflozin tab 10 mg
2
INVOKAMET XR canagliflozin-metformin hcl tab er 24hr 50-500 mg
2
JARDIANCE - empagliflozin tab 25 mg
2
JENTADUETO - linagliptinmetformin hcl tab 2.5-500 mg
3
INVOKAMET XR canagliflozin-metformin hcl tab er 24hr 50-1000 mg
2
JENTADUETO - linagliptinmetformin hcl tab 2.5-850 mg
3
INVOKAMET XR canagliflozin-metformin hcl tab er 24hr 150-500 mg
2
2
3
INVOKAMET XR canagliflozin-metformin hcl tab er 24hr 150-1000 mg
JENTADUETO - linagliptinmetformin hcl tab 2.5-1000 mg JENTADUETO XR - linagliptinmetformin hcl tab er 24hr 2.5-1000 mg
3
INVOKANA - canagliflozin tab 100 mg
2
glyburide-metformin tab 5-500 mg (Glucovance)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
48
JENTADUETO XR - linagliptinmetformin hcl tab er 24hr 5-1000 mg
3
NESINA - alogliptin benzoate tab 6.25 mg (base equiv)
3
NESINA - alogliptin benzoate tab 12.5 mg (base equiv)
3
KAZANO - alogliptin-metformin hcl tab 12.5-500 mg
3
NESINA - alogliptin benzoate tab 25 mg (base equiv)
3
KAZANO - alogliptin-metformin hcl tab 12.5-1000 mg
3 2
ONGLYZA - saxagliptin hcl tab 2.5 mg (base equiv)
2
KOMBIGLYZE XR saxagliptin-metformin hcl tab er 24hr 2.5-1000 mg
2
KOMBIGLYZE XR saxagliptin-metformin hcl tab er 24hr 5-500 mg
2
ONGLYZA - saxagliptin hcl tab 5 mg (base equiv) OSENI - alogliptin-pioglitazone tab 12.5-15 mg
3
KOMBIGLYZE XR saxagliptin-metformin hcl tab er 24hr 5-1000 mg
2
OSENI - alogliptin-pioglitazone tab 12.5-30 mg
3 3
KORLYM - mifepristone tab 300 mg
5
OSENI - alogliptin-pioglitazone tab 12.5-45 mg
3
metformin hcl tab er 24hr 500 mg (Glucophage xr)
1
OSENI - alogliptin-pioglitazone tab 25-15 mg OSENI - alogliptin-pioglitazone tab 25-30 mg
3
OSENI - alogliptin-pioglitazone tab 25-45 mg
3
pioglitazone hcl tab 15 mg (base equiv) (Actos)
1
metformin hcl tab er 24hr 750 mg (Glucophage xr) metformin hcl tab er 24hr osmotic 500 mg (Fortamet)
•
1 1
metformin hcl tab er 24hr osmotic 1000 mg (Fortamet)
1
metformin hcl tab 500 mg (Glucophage)
1
pioglitazone hcl tab 45 mg (base equiv) (Actos)
metformin hcl tab 850 mg (Glucophage)
1
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)
metformin hcl tab 1000 mg (Glucophage)
1
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)
miglitol tab 25 mg (Glyset)
1
miglitol tab 50 mg (Glyset) miglitol tab 100 mg (Glyset)
pioglitazone hcl tab 30 mg (base equiv) (Actos)
1 1
nateglinide tab 120 mg (Starlix)
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1 1 1 1
1 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met) 1 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met) 3 PRANDIN - repaglinide tab 1 mg
1
nateglinide tab 60 mg (Starlix)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
49
PRANDIN - repaglinide tab 2 mg
3
PRECOSE - acarbose tab 25 mg
3
PRECOSE - acarbose tab 50 mg
3
PRECOSE - acarbose tab 100 mg
3
PROGLYCEM - diazoxide susp 50 mg/ml
3
repaglinide tab 0.5 mg (Prandin)
1
repaglinide tab 1 mg (Prandin)
1
repaglinide tab 2 mg (Prandin)
1
REPAGLINIDE/METFORMIN HYD - repaglinide-metformin hcl tab 1-500 mg
3
REPAGLINIDE/METFORMIN HYD - repaglinide-metformin hcl tab 2-500 mg
3
RIOMET - metformin hcl oral soln 500 mg/5ml
3
STARLIX - nateglinide tab 60 mg
3
STARLIX - nateglinide tab 120 mg
3
SYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml (1000 mcg/ml)
3
SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml (1000 mcg/ml)
SYNJARDY - empagliflozinmetformin hcl tab 12.5-1000 mg
2
SYNJARDY XR empagliflozin-metformin hcl tab er 24hr 5-1000 mg
2
SYNJARDY XR empagliflozin-metformin hcl tab er 24hr 10-1000 mg
2
SYNJARDY XR empagliflozin-metformin hcl tab er 24hr 12.5-1000 mg
2
SYNJARDY XR empagliflozin-metformin hcl tab er 24hr 25-1000 mg
2
TANZEUM - albiglutide for soln pen-injector 30 mg
3
TANZEUM - albiglutide for soln pen-injector 50 mg
3
TOLAZAMIDE - tolazamide tab 250 mg
3
TOLAZAMIDE - tolazamide tab 500 mg
3
TOLBUTAMIDE - tolbutamide tab 500 mg
3
TRADJENTA - linagliptin tab 5 mg
3
TRULICITY - dulaglutide soln pen-injector 0.75 mg/0.5ml
3
TRULICITY - dulaglutide soln pen-injector 1.5 mg/0.5ml
3
3
VICTOZA - liraglutide soln peninjector 18 mg/3ml (6 mg/ml)
2 3
SYNJARDY - empagliflozinmetformin hcl tab 5-500 mg
2
XIGDUO XR - dapagliflozinmetformin hcl tab er 24hr 5-500 mg
SYNJARDY - empagliflozinmetformin hcl tab 5-1000 mg
2
3
SYNJARDY - empagliflozinmetformin hcl tab 12.5-500 mg
2
XIGDUO XR - dapagliflozinmetformin hcl tab er 24hr 5-1000 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
50
3
AFREZZA - insulin regular (human) inhal powd 4 (60) & 8 (30) unit/cart
3
•
XIGDUO XR - dapagliflozinmetformin hcl tab er 24hr 10-1000 mg
3
AFREZZA - insulin regular (human) inhal powd 4 (90) & 8 (90) unit/cart
3
•
•
AFREZZA - insulin regular (human) inhalation powder 4 unit/cartridge
3
•
•
Rapid-Acting Insulins
•
APIDRA - insulin glulisine inj 100 unit/ml
3
•
APIDRA SOLOSTAR - insulin glulisine soln pen-injector inj 100 unit/ml
3
•
AFREZZA - insulin regular (human) inhalation powder 8 unit/cartridge
3
•
•
HUMALOG - insulin lispro inj 100 unit/ml
3
•
3
•
•
HUMALOG - insulin lispro soln cartridge 100 unit/ml
3
•
AFREZZA - insulin regular (human) inhalation powder 12 unit/cartridge
3
•
HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml
3
•
HUMULIN R - insulin regular (human) inj 100 unit/ml
HUMALOG KWIKPEN - insulin lispro soln pen-injector 200 unit/ml
3
•
NOVOLOG - insulin aspart inj 100 unit/ml
2
NOVOLOG FLEXPEN - insulin aspart soln pen-injector 100 unit/ml
2
NOVOLOG PENFILL - insulin aspart soln cartridge 100 unit/ml
2
Short-Acting Insulins
Limited Distribution
XIGDUO XR - dapagliflozinmetformin hcl tab er 24hr 10-500 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 HUMULIN R U-500 (CONCENTR - insulin regular (human) inj 500 unit/ml 2 HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500 unit/ml 2 NOVOLIN R - insulin regular (human) inj 100 unit/ml 2 NOVOLIN R RELION - insulin regular (human) inj 100 unit/ ml 2 RELION R - insulin regular (human) inj 100 unit/ml
AFREZZA - insulin regular (human) inh powd 8 (60) & 12 (30) unit/cart
3
•
•
AFREZZA - insulin regular (human) inh powd 4 & 8 & 12 unit/cart (60)
3
•
•
AFREZZA - insulin regular (human) inhal powd 4 (30) & 8 (60) unit/cart
3
•
•
Intermediate-Acting Insulins
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100 unit/ml (50-50)
3
•
HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro sus pen-inj 100 unit/ ml (50-50)
3
•
HUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml (75-25)
3
•
Products October (2016 Plan Year)
51
3
HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml
3
HUMULIN N KWIKPEN insulin nph (human) (isophane) susp pen-injector 100 unit/ml
3
HUMULIN 70/30 - insulin nph isophane & regular human inj 100 unit/ml (70-30)
3
•
HUMULIN 70/30 KWIKPEN insulin nph & regular susp pen-inj 100 unit/ml (70-30)
3
•
NOVOLIN N - insulin nph (human) (isophane) inj 100 unit/ml
2
NOVOLIN N RELION - insulin nph (human) (isophane) inj 100 unit/ml
2
NOVOLIN 70/30 - insulin nph isophane & regular human inj 100 unit/ml (70-30)
2
NOVOLIN 70/30 RELION insulin nph isophane & regular human inj 100 unit/ ml (70-30)
2
NOVOLOG MIX 70/30 - insulin aspart prot & aspart (human) inj 100 unit/ml (70-30)
2
NOVOLOG MIX 70/30 PREFILL - insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30)
2
Basal Insulins LANTUS - insulin glargine inj 100 unit/ml
2
LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml
2
LEVEMIR - insulin detemir inj 100 unit/ml
2 2
•
LEVEMIR FLEXTOUCH insulin detemir soln peninjector 100 unit/ml
2
•
TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml TRESIBA FLEXTOUCH insulin degludec soln peninjector 100 unit/ml
2
TRESIBA FLEXTOUCH insulin degludec soln peninjector 200 unit/ml
2
THYROID AGENTS ARMOUR THYROID - thyroid tab 15 mg (1/4 grain)
3
ARMOUR THYROID - thyroid tab 30 mg (1/2 grain)
3
ARMOUR THYROID - thyroid tab 60 mg (1 grain)
3
ARMOUR THYROID - thyroid tab 90 mg (1 1/2 grain)
3
ARMOUR THYROID - thyroid tab 120 mg (2 grain)
3
ARMOUR THYROID - thyroid tab 180 mg (3 grain)
3
ARMOUR THYROID - thyroid tab 240 mg (4 grain)
3
ARMOUR THYROID - thyroid tab 300 mg (5 grain)
3
CYTOMEL - liothyronine sodium tab 5 mcg
3
CYTOMEL - liothyronine sodium tab 25 mcg
3
CYTOMEL - liothyronine sodium tab 50 mcg
3
levothyroxine sodium tab 25 mcg (Synthroid)
1
levothyroxine sodium tab 50 mcg (Synthroid) SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro sus pen-inj 100 unit/ ml (75-25)
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
Products October (2016 Plan Year)
52
levothyroxine sodium tab 75 mcg (Synthroid) levothyroxine sodium tab 88 mcg (Synthroid) levothyroxine sodium tab 100 mcg (Synthroid) levothyroxine sodium tab 112 mcg (Synthroid) levothyroxine sodium tab 125 mcg (Synthroid) levothyroxine sodium tab 137 mcg (Synthroid) levothyroxine sodium tab 150 mcg (Synthroid) levothyroxine sodium tab 175 mcg (Synthroid) levothyroxine sodium tab 200 mcg (Synthroid) levothyroxine sodium tab 300 mcg (Synthroid)
1
NATURE-THROID - thyroid tab 65 mg
3
1
NATURE-THROID - thyroid tab 81.25 mg
3
1
NATURE-THROID - thyroid tab 97.5 mg
3
1
NATURE-THROID - thyroid tab 113.75 mg
3
1
NATURE-THROID - thyroid tab 130 mg
3
1
NATURE-THROID - thyroid tab 195 mg
3
1
NATURE-THROID - thyroid tab 260 mg
3
1
NATURE-THROID - thyroid tab 325 mg (5 grain)
3
1
NATURE-THROID - thyroid tab 146.25 mg
3
1
NATURE-THROID NT-2.5 thyroid tab 162.5 mg (2 1/2 grain)
3
3
1
LIOTHYRONINE SODIUM liothyronine sodium powder
3
liothyronine sodium tab 5 mcg (Cytomel)
1
PCCA T3 SODIUM DILUTION - liothyronine sodium powder
1
propylthiouracil tab 50 mg
3
1
SYNTHROID - levothyroxine sodium tab 25 mcg
3
METHIMAZOLE - methimazole powder
3
SYNTHROID - levothyroxine sodium tab 50 mcg
3
methimazole tab 5 mg (Tapazole)
1
SYNTHROID - levothyroxine sodium tab 75 mcg
3
methimazole tab 10 mg (Tapazole)
1
SYNTHROID - levothyroxine sodium tab 88 mcg
3
NATURE-THROID - thyroid tab 16.25 mg
3
SYNTHROID - levothyroxine sodium tab 100 mcg
3
NATURE-THROID - thyroid tab 32.5 mg
3
SYNTHROID - levothyroxine sodium tab 112 mcg
3
NATURE-THROID - thyroid tab 48.75 mg (3/4 grain)
3
SYNTHROID - levothyroxine sodium tab 125 mcg
liothyronine sodium tab 25 mcg (Cytomel) liothyronine sodium tab 50 mcg (Cytomel)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
53
SYNTHROID - levothyroxine sodium tab 137 mcg
3
TIROSINT - levothyroxine sodium cap 25 mcg
3
SYNTHROID - levothyroxine sodium tab 150 mcg
3
TIROSINT - levothyroxine sodium cap 50 mcg
3
SYNTHROID - levothyroxine sodium tab 175 mcg
3
TIROSINT - levothyroxine sodium cap 75 mcg
3
SYNTHROID - levothyroxine sodium tab 200 mcg
3
TIROSINT - levothyroxine sodium cap 88 mcg
3
SYNTHROID - levothyroxine sodium tab 300 mcg
3
TIROSINT - levothyroxine sodium cap 100 mcg
3
TAPAZOLE - methimazole tab 5 mg
3
TIROSINT - levothyroxine sodium cap 112 mcg
3
TAPAZOLE - methimazole tab 10 mg
3
TIROSINT - levothyroxine sodium cap 125 mcg
3
THYROID - thyroid powder
3
3
THYROID PORCINE - thyroid powder
3
TIROSINT - levothyroxine sodium cap 137 mcg
3
thyroid tab 15 mg (1/4 grain) (Armour thyroid)
1
TIROSINT - levothyroxine sodium cap 150 mcg
3
thyroid tab 30 mg (1/2 grain) (Armour thyroid)
1
TRIIODO-L-THYRONINE liothyronine sodium powder
3
thyroid tab 60 mg (1 grain) (Armour thyroid)
1
WESTHROID - thyroid tab 32.5 mg
3
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)
1
WESTHROID - thyroid tab 65 mg
3
thyroid tab 120 mg (2 grain) (Armour thyroid)
1
WESTHROID - thyroid tab 97.5 mg
3
THYROLAR-1 - liotrix (t3-t4) tab 60 mg (12.5-50 mcg)
3
WESTHROID - thyroid tab 130 mg
3
THYROLAR-1/2 - liotrix (t3-t4) tab 30 mg (6.25-25 mcg)
3
WESTHROID - thyroid tab 195 mg
3
THYROLAR-1/4 - liotrix (t3-t4) tab 15 mg (3.1-12.5 mcg)
3
WP THYROID - thyroid tab 16.25 mg
3
THYROLAR-2 - liotrix (t3-t4) tab 120 mg (25-100 mcg)
3
WP THYROID - thyroid tab 32.5 mg
3
THYROLAR-3 - liotrix (t3-t4) tab 180 mg (37.5-150 mcg)
3
WP THYROID - thyroid tab 48.75 mg (3/4 grain)
3
TIROSINT - levothyroxine sodium cap 13 mcg
3
WP THYROID - thyroid tab 65 mg WP THYROID - thyroid tab 81.25 mg
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
54
WP THYROID - thyroid tab 97.5 mg
3
WP THYROID - thyroid tab 113.75 mg
3
WP THYROID - thyroid tab 130 mg
3
OXYTOCICS
alendronate sodium tab 5 mg alendronate sodium tab 10 mg alendronate sodium tab 35 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1
CERVIDIL - dinoprostone vaginal inserts 10 mg
3
alendronate sodium tab 70 mg (Fosamax)
3
HEMABATE - carboprost tromethamine im soln 250 mcg/ml
3
ATELVIA - risedronate sodium tab delayed release 35 mg
3
METHERGINE methylergonovine maleate tab 0.2 mg
3
BINOSTO - alendronate sodium effervescent tab 70 mg
3
methylergonovine maleate inj 0.2 mg/ml
1
BONIVA - ibandronate sodium tab 150 mg (base equivalent)
5
•
•
•
•
oxytocin inj 10 unit/ml (Pitocin)
1
BUPHENYL - sodium phenylbutyrate oral powder 3 gm/teaspoonful
PITOCIN - oxytocin inj 10 unit/ ml
3
BUPHENYL - sodium phenylbutyrate tab 500 mg
5
PREPIDIL - dinoprostone cervical gel 0.5 mg/3gm
3
cabergoline tab 0.5 mg
1 1
PROSTIN E2 - dinoprostone vaginal suppos 20 mg
3
calcitonin (salmon) nasal soln 200 unit/act (Miacalcin) calcitriol cap 0.25 mcg (Rocaltrol)
1
calcitriol cap 0.5 mcg (Rocaltrol)
1
calcitriol oral soln 1 mcg/ml (Rocaltrol)
1
CARBAGLU - carglumic acid tab 200 mg
5
CARNITOR - levocarnitine oral soln 1 gm/10ml (10%)
3
CARNITOR - levocarnitine tab 330 mg
3
CARNITOR SF - levocarnitine oral soln 1 gm/10ml (10%)
3
ENDOCRINE and METABOLIC AGENTS - MISC. 3 ACTONEL - risedronate sodium tab 5 mg 3 ACTONEL - risedronate sodium tab 30 mg 3 ACTONEL - risedronate sodium tab 35 mg 3 ACTONEL - risedronate sodium tab 150 mg 3 ALENDRONATE SODIUM alendronate sodium oral soln 70 mg/75ml 2 ALENDRONATE SODIUM alendronate sodium tab 40 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
•
55
5 CHORIONIC GONADOTROPIN - chorionic gonadotropin for inj 10000 unit CYSTADANE - betaine powder 3 for oral solution 3 DDAVP - desmopressin acetate inj 4 mcg/ml 3 DDAVP - desmopressin acetate nasal soln 0.01% (refrigerated) 3 DDAVP - desmopressin acetate nasal spray soln 0.01% 3 DDAVP - desmopressin acetate tab 0.1 mg 3 DDAVP - desmopressin acetate tab 0.2 mg 1 desmopressin acetate inj 4 mcg/ml (Ddavp) 1 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp) 1 desmopressin acetate nasal spray soln 0.01% (Ddavp) 1 desmopressin acetate nasal spray soln 0.01% (refrigerated) 1 desmopressin acetate tab 0.1 mg (Ddavp) 1 desmopressin acetate tab 0.2 mg (Ddavp) 1 doxercalciferol cap 0.5 mcg (Hectorol) 1 doxercalciferol cap 1 mcg (Hectorol) 1 doxercalciferol cap 2.5 mcg (Hectorol) 3 ETIDRONATE DISODIUM etidronate disodium tab 200 mg
•
ETIDRONATE DISODIUM etidronate disodium tab 400 mg
3
EVISTA - raloxifene hcl tab 60 mg
A
FORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml
5
FOSAMAX - alendronate sodium tab 70 mg
3
FOSAMAX PLUS D alendronate sodiumcholecalciferol tab 70-2800 mg-unit
3
FOSAMAX PLUS D alendronate sodiumcholecalciferol tab 70-5600 mg-unit
3
GENOTROPIN - somatropin for 5 inj 12 mg (13.8 mg overfill) GENOTROPIN - somatropin for 5 subcutaneous inj 5 mg 5 GENOTROPIN MINIQUICK somatropin for inj 0.2 mg 5 GENOTROPIN MINIQUICK somatropin for inj 0.4 mg 5 GENOTROPIN MINIQUICK somatropin for inj 0.6 mg 5 GENOTROPIN MINIQUICK somatropin for inj 0.8 mg 5 GENOTROPIN MINIQUICK somatropin for inj 1 mg 5 GENOTROPIN MINIQUICK somatropin for inj 1.2 mg 5 GENOTROPIN MINIQUICK somatropin for inj 1.4 mg 5 GENOTROPIN MINIQUICK somatropin for inj 1.6 mg 5 GENOTROPIN MINIQUICK somatropin for inj 1.8 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
56
•
HECTOROL - doxercalciferol cap 0.5 mcg
3
HECTOROL - doxercalciferol cap 1 mcg
3
HECTOROL - doxercalciferol cap 2.5 mcg
3
HUMATROPE - somatropin for inj 6 mg (18 unit)
5
•
•
HUMATROPE - somatropin for inj 12 mg (36 unit)
5
•
•
HUMATROPE - somatropin for inj 24 mg
5
•
•
•
•
•
• • • •
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
5
ACA
H.P. ACTHAR - corticotropin inj gel 80 unit/ml
HUMATROPE COMBO PACK - 5 somatropin for inj 5 mg 1 ibandronate sodium tab 150 mg (base equivalent) (Boniva) INCRELEX - mecasermin inj 40 4 mg/4ml (10 mg/ml) 5 KUVAN - sapropterin dihydrochloride powder packet 100 mg 5 KUVAN - sapropterin dihydrochloride powder packet 500 mg 5 KUVAN - sapropterin dihydrochloride soluble tab 100 mg 1 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) 1 levocarnitine tab 330 mg (Carnitor) 5 LUPANETA PACK - leuprolide (1 mon) inj 3.75 mg & norethindrone tab 5 mg kit
•
Dispensing Limits
•
Step Therapy
5
Prior Authorization
GENOTROPIN MINIQUICK somatropin for inj 2 mg
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
LUPANETA PACK - leuprolide (3 mon) inj 11.25 mg & norethindrone tab 5 mg kit
5
•
LUPRON DEPOT-PED (1MONTH - leuprolide acetate for inj pediatric kit 7.5 mg
4
•
LUPRON DEPOT-PED (1MONTH - leuprolide acetate for inj pediatric kit 11.25 mg
4
•
LUPRON DEPOT-PED (1MONTH - leuprolide acetate for inj pediatric kit 15 mg
4
•
LUPRON DEPOT-PED (3MONTH - leuprolide acetate (3 month) for inj pediatric kit 11.25 mg
4
•
LUPRON DEPOT-PED (3MONTH - leuprolide acetate (3 month) for inj pediatric kit 30 mg
4
•
MIACALCIN - calcitonin (salmon) inj 200 unit/ml
3
MYALEPT - metreleptin for subcutaneous inj 11.3 mg
5
NATPARA - parathyroid hormone (recombinant) for inj cartridge 25 mcg
5
•
•
•
NATPARA - parathyroid hormone (recombinant) for inj cartridge 50 mcg
5
•
•
•
NATPARA - parathyroid hormone (recombinant) for inj cartridge 75 mcg
5
•
•
•
NATPARA - parathyroid hormone (recombinant) for inj cartridge 100 mcg
5
•
•
•
NORDITROPIN FLEXPRO somatropin inj 5 mg/1.5ml
5
•
•
NORDITROPIN FLEXPRO somatropin inj 10 mg/1.5ml
5
•
•
NORDITROPIN FLEXPRO somatropin inj 15 mg/1.5ml
5
•
•
Products October (2016 Plan Year)
•
57
5
NOVAREL - chorionic gonadotropin for inj 10000 unit
5
NUTROPIN AQ NUSPIN 10 somatropin inj 10 mg/2ml
5
•
•
NUTROPIN AQ NUSPIN 20 somatropin inj 20 mg/2ml
5
•
•
NUTROPIN AQ NUSPIN 5 somatropin inj 5 mg/2ml
5
•
•
octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin)
4
•
octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin)
4
•
octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin)
4
•
octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin)
4
•
octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin)
4
•
OMNITROPE - somatropin for inj 5.8 mg
4
•
•
OMNITROPE - somatropin inj 5 4 mg/1.5ml 4 OMNITROPE - somatropin inj 10 mg/1.5ml ORFADIN - nitisinone cap 2 mg 4
•
•
•
•
OSPHENA - ospemifene tab 60 3 mg 1 paricalcitol cap 1 mcg (Zemplar) 1 paricalcitol cap 2 mcg (Zemplar) 1 paricalcitol cap 4 mcg (Zemplar) 5 PREGNYL W/DILUENT BENZYL - chorionic gonadotropin for inj 10000 unit 2 PROLIA - denosumab inj 60 mg/ml A raloxifene hcl tab 60 mg (Evista) 5 RAVICTI - glycerol phenylbutyrate liquid 1.1 gm/ ml 1 risedronate sodium tab delayed release 35 mg (Atelvia) risedronate sodium tab 5 mg 1 (Actonel) 1 risedronate sodium tab 30 mg (Actonel) 1 risedronate sodium tab 35 mg (Actonel) 1 risedronate sodium tab 150 mg (Actonel) 3 ROCALTROL - calcitriol cap 0.25 mcg 3 ROCALTROL - calcitriol cap 0.5 mcg 3 ROCALTROL - calcitriol oral soln 1 mcg/ml 5 SAIZEN - somatropin (nonrefrigerated) for inj 5 mg 5 SAIZEN - somatropin (nonrefrigerated) for inj 8.8 mg
•
• • • • •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
NORDITROPIN FLEXPRO somatropin inj 30 mg/3ml
ORFADIN - nitisinone cap 5 mg 4 4 ORFADIN - nitisinone cap 10 mg 4 ORFADIN - nitisinone cap 20 mg 4 ORFADIN - nitisinone susp 4 mg/ml
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • • •
•
•
•
•
•
58
5
•
SAMSCA - tolvaptan tab 15 mg
5
SAMSCA - tolvaptan tab 30 mg
5
SANDOSTATIN - octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
5
• • •
SANDOSTATIN - octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
5
SANDOSTATIN - octreotide acetate inj 200 mcg/ml (0.2 mg/ml)
Limited Distribution
SAIZENPREP RECONSTITUTION somatropin (nonrefrigerated) for inj 8.8 mg
ACA
SEROSTIM - somatropin (non-refrigerated) for subcutaneous inj 5 mg
5
•
SEROSTIM - somatropin (non-refrigerated) for subcutaneous inj 6 mg
5
•
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
•
5
•
SIGNIFOR LAR - pasireotide pamoate for im er susp 20 mg (base equiv)
5
•
SANDOSTATIN - octreotide acetate inj 500 mcg/ml (0.5 mg/ml)
5
•
SIGNIFOR LAR - pasireotide pamoate for im er susp 40 mg (base equiv)
5
•
SANDOSTATIN - octreotide acetate inj 1000 mcg/ml (1 mg/ml)
5
•
SIGNIFOR LAR - pasireotide pamoate for im er susp 60 mg (base equiv)
5
•
SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 10 mg
4
•
sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl)
4
SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 20 mg
4
•
SOMATULINE DEPOT lanreotide acetate extended release inj 60 mg/0.2ml
5
•
SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 30 mg
4
•
SOMATULINE DEPOT lanreotide acetate extended release inj 90 mg/0.3ml
5
•
SENSIPAR - cinacalcet hcl tab 30 mg (base equiv)
2
5
•
SENSIPAR - cinacalcet hcl tab 60 mg (base equiv)
2
SOMATULINE DEPOT lanreotide acetate extended release inj 120 mg/0.5ml
5
•
SENSIPAR - cinacalcet hcl tab 90 mg (base equiv)
2
SOMAVERT - pegvisomant for inj 10 mg (as protein)
5
•
SEROSTIM - somatropin (non-refrigerated) for subcutaneous inj 4 mg
5
SOMAVERT - pegvisomant for inj 15 mg (as protein) SOMAVERT - pegvisomant for inj 20 mg (as protein)
5
•
•
•
Dispensing Limits
•
Step Therapy
5
Prior Authorization
SAIZEN CLICK.EASY somatropin (nonrefrigerated) for inj 8.8 mg
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
•
• •
•
59
•
STIMATE - desmopressin acetate nasal soln 1.5 mg/ml
2
STRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml
4
•
•
STRENSIQ - asfotase alfa subcutaneous inj 28 mg/0.7ml
4
•
•
STRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml
4
•
•
STRENSIQ - asfotase alfa subcutaneous inj 80 mg/0.8ml
4
•
•
SUPPRELIN LA - histrelin acetate (cpp) implant kit 50 mg
3
SYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) (base eq)
3
TYMLOS - abaloparatide subcutaneous soln peninjector 3120 mcg/1.56ml
4
XGEVA - denosumab inj 120 mg/1.7ml
5
XURIDEN - uridine triacetate oral granules packet 2 gm
5
ZEMPLAR - paricalcitol cap 1 mcg
3
ZEMPLAR - paricalcitol cap 2 mcg
3
ZOMACTON - somatropin for inj 10 mg
5
•
•
ZOMACTON - somatropin for subcutaneous inj 5 mg
5
•
•
ZORBTIVE - somatropin (non-refrigerated) for subcutaneous inj 8.8 mg
5
•
•
CARDIOVASCULAR AGENTS CARDIOTONICS DIGOXIN - digoxin oral soln 0.05 mg/ml
2
digoxin inj 0.25 mg/ml (Lanoxin)
1
digoxin tab 125 mcg (0.125 mg) (Lanoxin)
1
digoxin tab 250 mcg (0.25 mg) (Lanoxin)
•
1
LANOXIN - digoxin inj 0.25 mg/ ml
3
LANOXIN - digoxin tab 62.5 mcg (0.0625 mg)
3
LANOXIN - digoxin tab 125 mcg (0.125 mg)
3
LANOXIN - digoxin tab 187.5 mcg (0.1875 mg)
3
LANOXIN - digoxin tab 250 mcg (0.25 mg)
3
LANOXIN PEDIATRIC - digoxin 3 inj 0.1 mg/ml
• •
Limited Distribution
5
ACA
SOMAVERT - pegvisomant for inj 30 mg (as protein)
Dispensing Limits
•
Step Therapy
5
Prior Authorization
SOMAVERT - pegvisomant for inj 25 mg (as protein)
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ANTIANGINAL AGENTS
• •
DILATRATE SR - isosorbide dinitrate cap er 40 mg
3
ISORDIL TITRADOSE isosorbide dinitrate tab 5 mg
3
ISORDIL TITRADOSE isosorbide dinitrate tab 40 mg
3
ISOSORBIDE DINITRATE ER - 3 isosorbide dinitrate tab er 40 mg isosorbide dinitrate tab 5 mg 1 (Isordil titradose) 1 isosorbide dinitrate tab 10 mg 1 isosorbide dinitrate tab 20 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
60
isosorbide dinitrate tab 30 mg isosorbide mononitrate tab er 24hr 30 mg isosorbide mononitrate tab er 24hr 60 mg isosorbide mononitrate tab er 24hr 120 mg isosorbide mononitrate tab 10 mg isosorbide mononitrate tab 20 mg
1
nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)
1
nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)
1
nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)
1 1 1
1
NITROLINGUAL PUMPSPRAY - nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
3
NITROMIST - nitroglycerin lingual aerosol 400 mcg/ spray
3
NITRO-DUR - nitroglycerin td patch 24hr 0.1 mg/hr
3
NITRO-DUR - nitroglycerin td patch 24hr 0.2 mg/hr
3
NITROSTAT - nitroglycerin sl tab 0.3 mg
3
NITRO-DUR - nitroglycerin td patch 24hr 0.3 mg/hr
3
NITROSTAT - nitroglycerin sl tab 0.4 mg
3
NITRO-DUR - nitroglycerin td patch 24hr 0.4 mg/hr
3
NITROSTAT - nitroglycerin sl tab 0.6 mg
3
NITRO-DUR - nitroglycerin td patch 24hr 0.6 mg/hr
3
RANEXA - ranolazine tab er 12hr 500 mg
3
NITRO-DUR - nitroglycerin td patch 24hr 0.8 mg/hr
3
RANEXA - ranolazine tab er 12hr 1000 mg
3
nitroglycerin cap er 2.5 mg
1
nitroglycerin cap er 9 mg
1
ACEBUTOLOL HCL acebutolol hcl powder
3
acebutolol hcl cap 200 mg (Sectral)
1
acebutolol hcl cap 400 mg (Sectral)
1
ATENOLOL - atenolol powder
3
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400 mcg/spray
3
nitroglycerin sl tab 0.3 mg (Nitrostat)
1
nitroglycerin sl tab 0.4 mg (Nitrostat)
1
atenolol tab 25 mg (Tenormin)
1
nitroglycerin sl tab 0.6 mg (Nitrostat)
1
atenolol tab 50 mg (Tenormin)
1
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)
1
atenolol tab 100 mg (Tenormin)
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
1
2
1
Dispensing Limits
1
NITRO-BID - nitroglycerin oint 2%
nitroglycerin cap er 6.5 mg
Step Therapy
1
nitroglycerin tl soln 0.4 mg/ spray (400 mcg/spray) (Nitrolingual pumpspr)
BETA BLOCKERS
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
61
ATENOLOL/SYRSPEND SF PH4 - atenolol oral suspension 1 mg/ml (cmpd kit)
3
BETAPACE - sotalol hcl tab 80 mg
3
BETAPACE - sotalol hcl tab 120 mg
3
BETAPACE - sotalol hcl tab 160 mg
3
BETAPACE AF - sotalol hcl (afib/afl) tab 80 mg
3
BETAPACE AF - sotalol hcl (afib/afl) tab 120 mg
3
BETAPACE AF - sotalol hcl (afib/afl) tab 160 mg
3
betaxolol hcl tab 10 mg (Kerlone)
1
betaxolol hcl tab 20 mg (Kerlone)
1
bisoprolol fumarate tab 5 mg (Zebeta)
1
bisoprolol fumarate tab 10 mg (Zebeta)
1
BYSTOLIC - nebivolol hcl tab 2.5 mg (base equivalent)
3
BYSTOLIC - nebivolol hcl tab 5 mg (base equivalent)
3
BYSTOLIC - nebivolol hcl tab 10 mg (base equivalent)
3
BYSTOLIC - nebivolol hcl tab 20 mg (base equivalent)
3
carvedilol tab 3.125 mg (Coreg)
1
carvedilol tab 6.25 mg (Coreg)
1
carvedilol tab 12.5 mg (Coreg)
1
carvedilol tab 25 mg (Coreg)
1
COREG - carvedilol tab 3.125 mg
3
COREG - carvedilol tab 6.25 mg
3
COREG - carvedilol tab 12.5 mg
3
COREG - carvedilol tab 25 mg
3
COREG CR - carvedilol phosphate cap er 24hr 10 mg
3
COREG CR - carvedilol phosphate cap er 24hr 20 mg
3
COREG CR - carvedilol phosphate cap er 24hr 40 mg
3
COREG CR - carvedilol phosphate cap er 24hr 80 mg
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
CORGARD - nadolol tab 20 mg 3 CORGARD - nadolol tab 40 mg 3 CORGARD - nadolol tab 80 mg 3 HEMANGEOL - propranolol hcl 3 oral soln 4.28 mg/ml (3.75 mg/ml base equiv) 3 INDERAL LA - propranolol hcl cap er 24hr 60 mg 3 INDERAL LA - propranolol hcl cap er 24hr 80 mg 3 INDERAL LA - propranolol hcl cap er 24hr 120 mg 3 INDERAL LA - propranolol hcl cap er 24hr 160 mg 3 INDERAL XL - propranolol hcl sustained-release beads cap er 24hr 80 mg 3 INDERAL XL - propranolol hcl sustained-release beads cap er 24hr 120 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
•
62
INNOPRAN XL - propranolol hcl sustained-release beads cap er 24hr 80 mg
3
INNOPRAN XL - propranolol hcl sustained-release beads cap er 24hr 120 mg
3
labetalol hcl tab 100 mg (Trandate)
1
labetalol hcl tab 200 mg (Trandate)
1
labetalol hcl tab 300 mg (Trandate)
1
LOPRESSOR - metoprolol tartrate tab 50 mg
NADOLOL - nadolol powder
3
nadolol tab 20 mg (Corgard)
1
nadolol tab 40 mg (Corgard) nadolol tab 80 mg (Corgard) pindolol tab 5 mg pindolol tab 10 mg
3
3
LOPRESSOR - metoprolol tartrate tab 100 mg
3
PROPRANOLOL HCL propranolol hcl powder
1
metoprolol succinate tab er 24hr 25 mg (tartrate equiv) (Toprol xl)
1
propranolol hcl cap er 24hr 60 mg (Inderal la)
metoprolol succinate tab er 24hr 50 mg (tartrate equiv) (Toprol xl)
1
metoprolol succinate tab er 24hr 100 mg (tartrate equiv) (Toprol xl)
1
metoprolol succinate tab er 24hr 200 mg (tartrate equiv) (Toprol xl) METOPROLOL TARTRATE metoprolol tartrate powder
3
METOPROLOL TARTRATE metoprolol tartrate tab 37.5 mg
3
METOPROLOL TARTRATE metoprolol tartrate tab 75 mg
3
metoprolol tartrate tab 25 mg
1
metoprolol tartrate tab 50 mg (Lopressor) metoprolol tartrate tab 100 mg (Lopressor)
propranolol hcl tab 20 mg
1
propranolol hcl tab 40 mg propranolol hcl tab 60 mg propranolol hcl tab 80 mg sotalol hcl (afib/afl) tab 80 mg (Betapace af) sotalol hcl (afib/afl) tab 120 mg (Betapace af) sotalol hcl (afib/afl) tab 160 mg (Betapace af)
1 1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
1
2
propranolol hcl tab 10 mg
ACA
1
PROPRANOLOL HCL propranolol hcl oral soln 40 mg/5ml
propranolol hcl cap er 24hr 160 mg (Inderal la)
Dispensing Limits
1
2
propranolol hcl cap er 24hr 120 mg (Inderal la)
Step Therapy
1
PROPRANOLOL HCL propranolol hcl oral soln 20 mg/5ml
propranolol hcl cap er 24hr 80 mg (Inderal la)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1 1 1 1 1 1 1
sotalol hcl tab 80 mg (Betapace)
1
sotalol hcl tab 120 mg (Betapace)
1
sotalol hcl tab 160 mg (Betapace)
1
Products October (2016 Plan Year)
63
sotalol hcl tab 240 mg
1
SOTYLIZE - sotalol hcl oral solution 5 mg/ml
3
TENORMIN - atenolol tab 25 mg
3
TENORMIN - atenolol tab 50 mg
3
TENORMIN - atenolol tab 100 mg
3
TIMOLOL MALEATE - timolol maleate powder
3
TIMOLOL MALEATE - timolol maleate tab 5 mg
2
TIMOLOL MALEATE - timolol maleate tab 10 mg
2
TIMOLOL MALEATE - timolol maleate tab 20 mg
2
TOPROL XL - metoprolol succinate tab er 24hr 25 mg (tartrate equiv)
3
TOPROL XL - metoprolol succinate tab er 24hr 50 mg (tartrate equiv)
3
TOPROL XL - metoprolol succinate tab er 24hr 100 mg (tartrate equiv)
3
TOPROL XL - metoprolol succinate tab er 24hr 200 mg (tartrate equiv)
3
amlodipine besylate tab 10 mg (Norvasc)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
3 AMLODIPINE BESYLATE/ SYRSP - amlodipine besylate oral susp 1 mg/ml (cmpd kit) 3 CALAN - verapamil hcl tab 80 mg CALAN - verapamil hcl tab 120 3 mg CALAN SR - verapamil hcl tab 3 er 120 mg CALAN SR - verapamil hcl tab 3 er 180 mg CALAN SR - verapamil hcl tab 3 er 240 mg 3 CARDIZEM - diltiazem hcl tab 30 mg 3 CARDIZEM - diltiazem hcl tab 60 mg 3 CARDIZEM - diltiazem hcl tab 120 mg 3 CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 120 mg 3 CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 180 mg 3 CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 240 mg 3 CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 360 mg 3 CARDIZEM LA - diltiazem hcl coated beads tab er 24hr 120 mg 3 CARDIZEM LA - diltiazem hcl coated beads tab er 24hr 180 mg
CALCIUM CHANNEL BLOCKERS ADALAT CC - nifedipine tab er 3 24hr 30 mg ADALAT CC - nifedipine tab er 3 24hr 60 mg ADALAT CC - nifedipine tab er 3 24hr 90 mg 1 amlodipine besylate tab 2.5 mg (Norvasc) 1 amlodipine besylate tab 5 mg (Norvasc)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
64
CARDIZEM LA - diltiazem hcl coated beads tab er 24hr 240 mg
3
diltiazem hcl coated beads tab er 24hr 240 mg (Cardizem la)
1
CARDIZEM LA - diltiazem hcl coated beads tab er 24hr 300 mg
3
diltiazem hcl coated beads tab er 24hr 300 mg (Cardizem la)
1
CARDIZEM LA - diltiazem hcl coated beads tab er 24hr 360 mg
3
diltiazem hcl coated beads tab er 24hr 360 mg (Cardizem la)
1
CARDIZEM LA - diltiazem hcl coated beads tab er 24hr 420 mg
3
diltiazem hcl coated beads tab er 24hr 420 mg (Cardizem la)
1
diltiazem hcl cap er 12hr 60 mg
1
diltiazem hcl extended release beads cap er 24hr 120 mg (Tiazac)
1
diltiazem hcl cap er 12hr 90 mg diltiazem hcl cap er 12hr 120 mg diltiazem hcl cap er 24hr 120 mg diltiazem hcl cap er 24hr 180 mg diltiazem hcl cap er 24hr 240 mg
1
diltiazem hcl extended release beads cap er 24hr 180 mg (Tiazac)
1
diltiazem hcl extended release beads cap er 24hr 240 mg (Tiazac)
1 1
diltiazem hcl extended release beads cap er 24hr 300 mg (Tiazac)
1
diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem cd)
1
diltiazem hcl coated beads cap er 24hr 180 mg (Cardizem cd)
1
diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem cd)
1
diltiazem hcl coated beads cap er 24hr 300 mg
1
diltiazem hcl coated beads cap er 24hr 360 mg (Cardizem cd)
1
diltiazem hcl coated beads tab er 24hr 180 mg (Cardizem la)
1
diltiazem hcl extended release beads cap er 24hr 360 mg (Tiazac) diltiazem hcl extended release beads cap er 24hr 420 mg (Tiazac)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
1
1
diltiazem hcl tab 60 mg (Cardizem)
1
diltiazem hcl tab 90 mg
1
diltiazem hcl tab 120 mg (Cardizem)
1
felodipine tab er 24hr 2.5 mg
1
isradipine cap 2.5 mg
SM
1
1
felodipine tab er 24hr 10 mg
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1
diltiazem hcl tab 30 mg (Cardizem)
felodipine tab er 24hr 5 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1
Products October (2016 Plan Year)
65
isradipine cap 5 mg nicardipine hcl cap 20 mg nicardipine hcl cap 30 mg
1 1 1
NIFEDIPINE - nifedipine powder
3
nifedipine cap 10 mg (Procardia)
1
nifedipine cap 20 mg
1
NORVASC - amlodipine besylate tab 5 mg
3
NORVASC - amlodipine besylate tab 10 mg
3
NYMALIZE - nimodipine oral soln 60 mg/20ml
3
PROCARDIA - nifedipine cap 10 mg
3
PROCARDIA XL - nifedipine tab er 24hr osmotic release 30 mg
3
PROCARDIA XL - nifedipine tab er 24hr osmotic release 60 mg
3
3
nifedipine tab er 24hr 30 mg (Adalat cc)
1
nifedipine tab er 24hr 60 mg (Adalat cc)
1
nifedipine tab er 24hr 90 mg (Adalat cc)
1
nifedipine tab er 24hr osmotic release 30 mg (Procardia xl)
1
PROCARDIA XL - nifedipine tab er 24hr osmotic release 90 mg
1
SULAR - nisoldipine tab er 24hr 8.5 mg
3
nifedipine tab er 24hr osmotic release 60 mg (Procardia xl)
3
nifedipine tab er 24hr osmotic release 90 mg (Procardia xl)
1
SULAR - nisoldipine tab er 24hr 17 mg SULAR - nisoldipine tab er 24hr 34 mg
3
nimodipine cap 30 mg
1
TIAZAC - diltiazem hcl extended release beads cap er 24hr 120 mg
3
TIAZAC - diltiazem hcl extended release beads cap er 24hr 180 mg
3
TIAZAC - diltiazem hcl extended release beads cap er 24hr 240 mg
3
TIAZAC - diltiazem hcl extended release beads cap er 24hr 300 mg
3
TIAZAC - diltiazem hcl extended release beads cap er 24hr 360 mg
3
TIAZAC - diltiazem hcl extended release beads cap er 24hr 420 mg
3
NISOLDIPINE ER - nisoldipine tab er 24hr 20 mg
3
NISOLDIPINE ER - nisoldipine tab er 24hr 25.5 mg
3
NISOLDIPINE ER - nisoldipine tab er 24hr 30 mg
3
NISOLDIPINE ER - nisoldipine tab er 24hr 40 mg
3
nisoldipine tab er 24hr 8.5 mg (Sular)
1
nisoldipine tab er 24hr 17 mg (Sular) nisoldipine tab er 24hr 34 mg (Sular) NORVASC - amlodipine besylate tab 2.5 mg
1 1 3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
66
VERAPAMIL HCL - verapamil hcl powder
3
VERELAN PM - verapamil hcl cap er 24hr 200 mg
3
verapamil hcl cap er 24hr 100 mg (Verelan pm)
1
VERELAN PM - verapamil hcl cap er 24hr 300 mg
3
1
ANTIARRHYTHMICS
verapamil hcl cap er 24hr 120 mg (Verelan) verapamil hcl cap er 24hr 180 mg (Verelan) verapamil hcl cap er 24hr 200 mg (Verelan pm)
amiodarone hcl tab 100 mg
1 1
1
amiodarone hcl tab 400 mg
1
disopyramide phosphate cap 100 mg (Norpace)
1
disopyramide phosphate cap 150 mg (Norpace)
1
dofetilide cap 125 mcg (0.125 mg) (Tikosyn)
verapamil hcl tab er 120 mg (Calan sr)
1
dofetilide cap 250 mcg (0.25 mg) (Tikosyn)
verapamil hcl tab er 180 mg (Calan sr)
1
dofetilide cap 500 mcg (0.5 mg) (Tikosyn)
verapamil hcl tab er 240 mg (Calan sr)
1
verapamil hcl tab 40 mg
1
verapamil hcl cap er 24hr 300 mg (Verelan pm) verapamil hcl cap er 24hr 360 mg (Verelan)
flecainide acetate tab 50 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg
verapamil hcl tab 80 mg (Calan)
1
verapamil hcl tab 120 mg (Calan)
1
mexiletine hcl cap 150 mg
VERAPAMIL HYDROCHLORIDE verapamil hcl powder
3
mexiletine hcl cap 250 mg
VERELAN - verapamil hcl cap er 24hr 120 mg
3
VERELAN - verapamil hcl cap er 24hr 180 mg
3
VERELAN - verapamil hcl cap er 24hr 240 mg
3
VERELAN - verapamil hcl cap er 24hr 360 mg
3
VERELAN PM - verapamil hcl cap er 24hr 100 mg
3
mexiletine hcl cap 200 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
amiodarone hcl tab 200 mg (Cordarone)
1
verapamil hcl cap er 24hr 240 mg (Verelan)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1 1 1 1 1 1 1
MULTAQ - dronedarone hcl tab 400 mg (base equivalent)
2
NORPACE - disopyramide phosphate cap 100 mg
3
NORPACE - disopyramide phosphate cap 150 mg
3
NORPACE CR - disopyramide phosphate cap er 12hr 100 mg
3
NORPACE CR - disopyramide phosphate cap er 12hr 150 mg
3
Products October (2016 Plan Year)
67
PROCAINAMIDE HCL procainamide hcl inj 100 mg/ ml
3
PROCAINAMIDE HCL procainamide hcl inj 500 mg/ ml
3
PROCAINAMIDE HCL procainamide hcl powder propafenone hcl cap er 12hr 225 mg (Rythmol sr) propafenone hcl cap er 12hr 325 mg (Rythmol sr) propafenone hcl cap er 12hr 425 mg (Rythmol sr)
ANTIHYPERTENSIVES ACCUPRIL - quinapril hcl tab 5 mg
3
ACCUPRIL - quinapril hcl tab 10 mg
3
3
ACCUPRIL - quinapril hcl tab 20 mg
3
1
ACCUPRIL - quinapril hcl tab 40 mg
3
ACCURETIC - quinaprilhydrochlorothiazide tab 10-12.5 mg
3
ACCURETIC - quinaprilhydrochlorothiazide tab 20-12.5 mg
3
ACCURETIC - quinaprilhydrochlorothiazide tab 20-25 mg
3
ACEON - perindopril erbumine tab 4 mg
3
ACEON - perindopril erbumine tab 8 mg
3
ALTACE - ramipril cap 1.25 mg
3
ALTACE - ramipril cap 2.5 mg
3
ALTACE - ramipril cap 5 mg
3
ALTACE - ramipril cap 10 mg
3
amlodipine besylatebenazepril hcl cap 2.5-10 mg (Lotrel)
1
1 1
propafenone hcl tab 150 mg (Rythmol)
1
propafenone hcl tab 225 mg (Rythmol)
1
propafenone hcl tab 300 mg
1
QUINIDINE GLUCONATE quinidine gluconate inj 80 mg/ml
3
quinidine gluconate tab er 324 mg
1
QUINIDINE SULFATE quinidine sulfate tab 200 mg
3
QUINIDINE SULFATE quinidine sulfate tab 300 mg
3
RYTHMOL SR - propafenone hcl cap er 12hr 225 mg
3
RYTHMOL SR - propafenone hcl cap er 12hr 325 mg
3
RYTHMOL SR - propafenone hcl cap er 12hr 425 mg
3
TIKOSYN - dofetilide cap 125 mcg (0.125 mg)
3
TIKOSYN - dofetilide cap 250 mcg (0.25 mg)
3
TIKOSYN - dofetilide cap 500 mcg (0.5 mg)
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
amlodipine besylatebenazepril hcl cap 5-10 mg (Lotrel)
1
amlodipine besylatebenazepril hcl cap 5-20 mg (Lotrel)
1
amlodipine besylatebenazepril hcl cap 5-40 mg (Lotrel)
1
amlodipine besylatebenazepril hcl cap 10-20 mg (Lotrel)
1
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
68
amlodipine besylatebenazepril hcl cap 10-40 mg (Lotrel) amlodipine besylateolmesartan medoxomil tab 5-20 mg (Azor) amlodipine besylateolmesartan medoxomil tab 5-40 mg (Azor) amlodipine besylateolmesartan medoxomil tab 10-20 mg (Azor) amlodipine besylateolmesartan medoxomil tab 10-40 mg (Azor)
1
1
1
1
1
amlodipine besylatevalsartan tab 5-320 mg (Exforge)
1
amlodipine besylatevalsartan tab 10-160 mg (Exforge)
1
amlodipine besylatevalsartan tab 10-320 mg (Exforge)
1
amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg (Exforge hct)
1
1
•
ATACAND - candesartan cilexetil tab 16 mg
3
•
ATACAND - candesartan cilexetil tab 32 mg
3
•
ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg
3
•
ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg
3
•
ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab 32-25 mg
3
•
atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)
1
atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100)
1
AVALIDE - irbesartanhydrochlorothiazide tab 150-12.5 mg
3
•
AVALIDE - irbesartanhydrochlorothiazide tab 300-12.5 mg
3
•
AVAPRO - irbesartan tab 75 mg
3
•
AVAPRO - irbesartan tab 150 mg
3
•
AVAPRO - irbesartan tab 300 mg
3
•
3
•
3
•
amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg (Exforge hct)
1
1
AZOR - amlodipine besylateolmesartan medoxomil tab 5-40 mg
Products October (2016 Plan Year)
Limited Distribution
3
ACA
ATACAND - candesartan cilexetil tab 8 mg
Dispensing Limits
•
AZOR - amlodipine besylateolmesartan medoxomil tab 5-20 mg
SM
Step Therapy
3
1
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Prior Authorization
ATACAND - candesartan cilexetil tab 4 mg
amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg (Exforge hct)
amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg (Exforge hct)
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Drug Name
1
amlodipine besylatevalsartan tab 5-160 mg (Exforge)
amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg (Exforge hct)
Prior Authorization
Drug Name
Drug Tier
2016
69
benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) benazepril hcl tab 5 mg
1
1
1
bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)
1
bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac)
1
benazepril hcl tab 10 mg (Lotensin)
1
benazepril hcl tab 20 mg (Lotensin)
1
benazepril hcl tab 40 mg (Lotensin)
1
BENICAR - olmesartan medoxomil tab 5 mg
3
BENICAR - olmesartan medoxomil tab 20 mg
3
•
BENICAR - olmesartan medoxomil tab 40 mg
3
•
BENICAR HCT olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg
3
•
BENICAR HCT olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg
3
candesartan cilexetil tab 4 mg (Atacand)
1
candesartan cilexetil tab 32 mg (Atacand) candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg (Atacand hct) candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg (Atacand hct) candesartan cilexetilhydrochlorothiazide tab 32-25 mg (Atacand hct) captopril tab 12.5 mg captopril tab 25 mg captopril tab 50 mg
•
captopril tab 100 mg CAPTOPRIL/ HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 25-15 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
1
3
candesartan cilexetil tab 16 mg (Atacand)
•
1
BYVALSON - nebivololvalsartan tab 5-80 mg
candesartan cilexetil tab 8 mg (Atacand)
1
ACA
benazepril & hydrochlorothiazide tab 5-6.25 mg
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac)
•
Dispensing Limits
•
3
Step Therapy
3
BENICAR HCT olmesartan medoxomilhydrochlorothiazide tab 40-25 mg
Prior Authorization
AZOR - amlodipine besylateolmesartan medoxomil tab 10-40 mg
Drug Name
Drug Tier
•
Limited Distribution
3
ACA
AZOR - amlodipine besylateolmesartan medoxomil tab 10-20 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
1 1 1 1
1
1
1 1 1 1 2
Products October (2016 Plan Year)
70
CAPTOPRIL/ HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 25-25 mg
2
CAPTOPRIL/ HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 50-15 mg
2
CAPTOPRIL/ HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 50-25 mg
2
CARDURA - doxazosin mesylate tab 1 mg
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)
1
clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2)
1
clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3)
1
3
3
CLORPRES - clonidine & chlorthalidone tab 0.1-15 mg
3
CARDURA - doxazosin mesylate tab 2 mg
3
CLORPRES - clonidine & chlorthalidone tab 0.2-15 mg
3
CARDURA - doxazosin mesylate tab 4 mg
3
CLORPRES - clonidine & chlorthalidone tab 0.3-15 mg
3
CARDURA - doxazosin mesylate tab 8 mg
3
CORZIDE - nadolol & bendroflumethiazide tab 40-5 mg
CATAPRES - clonidine hcl tab 0.1 mg
3
3
CATAPRES - clonidine hcl tab 0.2 mg
3
CORZIDE - nadolol & bendroflumethiazide tab 80-5 mg
3
•
CATAPRES - clonidine hcl tab 0.3 mg
3
COZAAR - losartan potassium tab 25 mg
3
•
CATAPRES-TTS-1 - clonidine hcl td patch weekly 0.1 mg/24hr
3
COZAAR - losartan potassium tab 50 mg COZAAR - losartan potassium tab 100 mg
3
•
CATAPRES-TTS-2 - clonidine hcl td patch weekly 0.2 mg/24hr
3
DEMSER - metyrosine cap 250 mg
3 3
CATAPRES-TTS-3 - clonidine hcl td patch weekly 0.3 mg/24hr
3
DIAZOXIDE - diazoxide powder
3
CLONIDINE HCL - clonidine hcl powder
3
DIBENZYLINE phenoxybenzamine hcl cap 10 mg
3
clonidine hcl tab 0.1 mg (Catapres)
1
DIOVAN - valsartan tab 40 mg DIOVAN - valsartan tab 80 mg
3
DIOVAN - valsartan tab 160 mg 3 SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • • 71
DIOVAN - valsartan tab 320 mg 3 3 DIOVAN HCT - valsartanhydrochlorothiazide tab 80-12.5 mg 3 DIOVAN HCT - valsartanhydrochlorothiazide tab 160-12.5 mg 3 DIOVAN HCT - valsartanhydrochlorothiazide tab 160-25 mg 3 DIOVAN HCT - valsartanhydrochlorothiazide tab 320-12.5 mg 3 DIOVAN HCT - valsartanhydrochlorothiazide tab 320-25 mg 1 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) 3 DUTOPROL - metoprolol & hydrochlorothiazide tab er 24hr 25-12.5 mg 3 DUTOPROL - metoprolol & hydrochlorothiazide tab er 24hr 50-12.5 mg 3 DUTOPROL - metoprolol & hydrochlorothiazide tab er 24hr 100-12.5 mg EDARBI - azilsartan medoxomil 3 tab 40 mg EDARBI - azilsartan medoxomil 3 tab 80 mg 3 EDARBYCLOR - azilsartan medoxomil-chlorthalidone tab 40-12.5 mg
EDARBYCLOR - azilsartan medoxomil-chlorthalidone tab 40-25 mg
3
•
enalapril maleate & hydrochlorothiazide tab 5-12.5 mg
1
•
enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic)
• •
• • •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
• •
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
enalapril maleate tab 2.5 mg (Vasotec)
1
enalapril maleate tab 5 mg (Vasotec)
1
enalapril maleate tab 10 mg (Vasotec)
1
enalapril maleate tab 20 mg (Vasotec)
1
EPANED - enalapril maleate oral soln 1 mg/ml
3
eplerenone tab 25 mg (Inspra)
1
eplerenone tab 50 mg (Inspra)
1
EPROSARTAN MESYLATE eprosartan mesylate tab 600 mg
3
•
EXFORGE - amlodipine besylate-valsartan tab 5-160 mg
3
•
EXFORGE - amlodipine besylate-valsartan tab 5-320 mg
3
•
EXFORGE - amlodipine besylate-valsartan tab 10-160 mg
3
•
EXFORGE - amlodipine besylate-valsartan tab 10-320 mg
3
•
EXFORGE HCT amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg
3
•
Products October (2016 Plan Year)
72
EXFORGE HCT amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg
3
EXFORGE HCT amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg
3
EXFORGE HCT amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg
3
EXFORGE HCT amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg
3
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg fosinopril sodium tab 10 mg fosinopril sodium tab 20 mg fosinopril sodium tab 40 mg
INSPRA - eplerenone tab 50 mg
3
irbesartan tab 75 mg (Avapro)
1
irbesartan tab 150 mg (Avapro)
1
irbesartan tab 300 mg (Avapro)
1 1
1
irbesartanhydrochlorothiazide tab 150-12.5 mg (Avalide)
1
irbesartanhydrochlorothiazide tab 300-12.5 mg (Avalide)
1
lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic)
• • •
lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic)
1 1
hydralazine hcl inj 20 mg/ml
1
lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) lisinopril tab 2.5 mg (Zestril) lisinopril tab 5 mg (Prinivil)
1
lisinopril tab 10 mg (Prinivil)
1
lisinopril tab 20 mg (Prinivil)
1 1
lisinopril tab 30 mg (Zestril)
HYZAAR - losartan potassium & hydrochlorothiazide tab 50-12.5 mg
3
•
HYZAAR - losartan potassium & hydrochlorothiazide tab 100-12.5 mg
3
•
lisinopril tab 40 mg (Zestril)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
3
1
hydralazine hcl tab 100 mg
Dispensing Limits
INSPRA - eplerenone tab 25 mg
guanfacine hcl tab 2 mg (Tenex)
hydralazine hcl tab 50 mg
Step Therapy
3
1
hydralazine hcl tab 25 mg
•
Drug Name HYZAAR - losartan potassium & hydrochlorothiazide tab 100-25 mg
guanfacine hcl tab 1 mg (Tenex)
hydralazine hcl tab 10 mg
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
1
1 1 1 1 1 1
LOPRESSOR HCT metoprolol & hydrochlorothiazide tab 50-25 mg
3
losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar)
1
Products October (2016 Plan Year)
73
losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar) losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar) losartan potassium tab 25 mg (Cozaar) losartan potassium tab 50 mg (Cozaar) losartan potassium tab 100 mg (Cozaar)
1
1
1
1 3
LOTENSIN - benazepril hcl tab 40 mg
3
LOTENSIN HCT - benazepril & hydrochlorothiazide tab 10-12.5 mg
3
LOTENSIN HCT - benazepril & hydrochlorothiazide tab 20-12.5 mg
3
LOTENSIN HCT - benazepril & hydrochlorothiazide tab 20-25 mg
3
LOTREL - amlodipine besylate- 3 benazepril hcl cap 5-10 mg LOTREL - amlodipine besylate- 3 benazepril hcl cap 5-20 mg LOTREL - amlodipine besylate- 3 benazepril hcl cap 10-20 mg LOTREL - amlodipine besylate- 3 benazepril hcl cap 10-40 mg 1 methyldopa tab 250 mg methyldopa tab 500 mg METHYLDOPA/ HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab 250-15 mg
3
metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct)
1
metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct)
1
LOTENSIN - benazepril hcl tab 20 mg
METHYLDOPA/ HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab 250-25 mg
1 3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
METOPROLOL SUCCINATE ER/H - metoprolol & hydrochlorothiazide tab er 24hr 25-12.5 mg
3
METOPROLOL SUCCINATE ER/H - metoprolol & hydrochlorothiazide tab er 24hr 50-12.5 mg
3
METOPROLOL SUCCINATE ER/H - metoprolol & hydrochlorothiazide tab er 24hr 100-12.5 mg
3
METOPROLOL/ HYDROCHLOROTHI metoprolol & hydrochlorothiazide tab 100-50 mg
3
MICARDIS - telmisartan tab 20 mg
3
•
MICARDIS - telmisartan tab 40 mg
3
•
MICARDIS - telmisartan tab 80 mg
3
•
MICARDIS HCT - telmisartanhydrochlorothiazide tab 40-12.5 mg
3
•
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-12.5 mg
3
•
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-25 mg
3
•
Products October (2016 Plan Year)
74
MINIPRESS - prazosin hcl cap 1 mg
3
MINIPRESS - prazosin hcl cap 2 mg
3
MINIPRESS - prazosin hcl cap 5 mg
3
minoxidil tab 2.5 mg
1
minoxidil tab 10 mg
olmesartan medoxomilhydrochlorothiazide tab 40-25 mg (Benicar hct) olmesartan-amlodipinehydrochlorothiazide tab 20-5-12.5 mg (Tribenzor) olmesartan-amlodipinehydrochlorothiazide tab 40-5-12.5 mg (Tribenzor)
1
moexipril hcl tab 7.5 mg (Univasc)
1
moexipril hcl tab 15 mg (Univasc)
1
moexiprilhydrochlorothiazide tab 7.5-12.5 mg
1
olmesartan-amlodipinehydrochlorothiazide tab 40-10-12.5 mg (Tribenzor)
1
olmesartan-amlodipinehydrochlorothiazide tab 40-10-25 mg (Tribenzor)
1
perindopril erbumine tab 2 mg
moexiprilhydrochlorothiazide tab 15-12.5 mg (Uniretic) moexiprilhydrochlorothiazide tab 15-25 mg nadolol & bendroflumethiazide tab 40-5 mg (Corzide) nadolol & bendroflumethiazide tab 80-5 mg (Corzide) olmesartan medoxomil tab 5 mg (Benicar) olmesartan medoxomil tab 20 mg (Benicar) olmesartan medoxomil tab 40 mg (Benicar) olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg (Benicar hct) olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg (Benicar hct)
olmesartan-amlodipinehydrochlorothiazide tab 40-5-25 mg (Tribenzor)
perindopril erbumine tab 4 mg (Aceon)
1
perindopril erbumine tab 8 mg (Aceon) phenoxybenzamine hcl cap 10 mg (Dibenzyline)
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
1
1
1
1 1 1 1
PHENTOLAMINE MESYLATE - 3 phentolamine mesylate for inj 5 mg PRAZOSIN HCL - prazosin hcl 3 powder 1 prazosin hcl cap 1 mg (Minipress) 1 prazosin hcl cap 2 mg (Minipress) 1 prazosin hcl cap 5 mg (Minipress) 3 PRAZOSIN HYDROCHLORIDE prazosin hcl powder
1 1 1 1
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
75
PRESTALIA - perindopril arginine-amlodipine besylate tab 3.5-2.5 mg
3
PRESTALIA - perindopril arginine-amlodipine besylate tab 7-5 mg
3
ramipril cap 5 mg (Altace)
3
PRESTALIA - perindopril arginine-amlodipine besylate tab 14-10 mg
3
RESERPINE - reserpine powder
3
PRINIVIL - lisinopril tab 5 mg
3
TARKA - trandolapril-verapamil hcl tab er 1-240 mg
3
PRINIVIL - lisinopril tab 10 mg
3
TARKA - trandolapril-verapamil hcl tab er 2-180 mg
PRINIVIL - lisinopril tab 20 mg
3
3
PROPRANOLOL/ HYDROCHLOROTH propranolol & hydrochlorothiazide tab 40-25 mg
2
TARKA - trandolapril-verapamil hcl tab er 2-240 mg TARKA - trandolapril-verapamil hcl tab er 4-240 mg
3 3
•
PROPRANOLOL/ HYDROCHLOROTH propranolol & hydrochlorothiazide tab 80-25 mg
2
TEKTURNA - aliskiren fumarate tab 150 mg (base equivalent) TEKTURNA - aliskiren fumarate tab 300 mg (base equivalent)
3
• •
quinapril hcl tab 5 mg (Accupril)
1
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-12.5 mg
3
QBRELIS - lisinopril oral soln 1 mg/ml
3
3
•
quinapril hcl tab 10 mg (Accupril)
1
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-25 mg
3
1
•
quinapril hcl tab 20 mg (Accupril)
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-12.5 mg
quinapril hcl tab 40 mg (Accupril)
1
3
•
quinaprilhydrochlorothiazide tab 10-12.5 mg (Accuretic)
1
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-25 mg telmisartan tab 20 mg (Micardis)
1
telmisartan tab 40 mg (Micardis)
1
telmisartan tab 80 mg (Micardis)
1
telmisartan-amlodipine tab 40-5 mg (Twynsta)
1
quinaprilhydrochlorothiazide tab 20-12.5 mg (Accuretic) quinaprilhydrochlorothiazide tab 20-25 mg (Accuretic)
ramipril cap 1.25 mg (Altace) ramipril cap 2.5 mg (Altace) ramipril cap 10 mg (Altace)
1
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1
Products October (2016 Plan Year)
76
telmisartan-amlodipine tab 40-10 mg (Twynsta) telmisartan-amlodipine tab 80-5 mg (Twynsta) telmisartan-amlodipine tab 80-10 mg (Twynsta) telmisartanhydrochlorothiazide tab 40-12.5 mg (Micardis hct) telmisartanhydrochlorothiazide tab 80-12.5 mg (Micardis hct) telmisartanhydrochlorothiazide tab 80-25 mg (Micardis hct)
1 1 1 1
1
1
•
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab 40-5-25 mg
3
•
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab 40-10-12.5 mg
3
•
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab 40-10-25 mg
3
•
TWYNSTA - telmisartanamlodipine tab 40-5 mg
3
•
TENORETIC 100 - atenolol & chlorthalidone tab 100-25 mg
3
TENORETIC 50 - atenolol & chlorthalidone tab 50-25 mg
3
TWYNSTA - telmisartanamlodipine tab 40-10 mg
3
•
terazosin hcl cap 1 mg
1
TWYNSTA - telmisartanamlodipine tab 80-5 mg
3
•
1
TWYNSTA - telmisartanamlodipine tab 80-10 mg
3
•
1
valsartan tab 40 mg (Diovan)
1
1
valsartan tab 80 mg (Diovan)
1
valsartan tab 160 mg (Diovan)
1
1
valsartan tab 320 mg (Diovan)
1
1
valsartanhydrochlorothiazide tab 80-12.5 mg (Diovan hct)
1
terazosin hcl cap 2 mg terazosin hcl cap 5 mg terazosin hcl cap 10 mg trandolapril tab 1 mg (Mavik) trandolapril tab 2 mg (Mavik) trandolapril tab 4 mg (Mavik) trandolapril-verapamil hcl tab er 1-240 mg (Tarka) trandolapril-verapamil hcl tab er 2-180 mg (Tarka) trandolapril-verapamil hcl tab er 2-240 mg (Tarka) trandolapril-verapamil hcl tab er 4-240 mg (Tarka) TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab 20-5-12.5 mg
1
1
1
valsartanhydrochlorothiazide tab 160-12.5 mg (Diovan hct)
1 3
valsartanhydrochlorothiazide tab 160-25 mg (Diovan hct)
•
valsartanhydrochlorothiazide tab 320-12.5 mg (Diovan hct) SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
3
ACA
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab 40-5-12.5 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
1
Products October (2016 Plan Year)
77
valsartanhydrochlorothiazide tab 320-25 mg (Diovan hct)
1
DIURETICS acetazolamide cap er 12hr 500 mg (Diamox)
3
VASOTEC - enalapril maleate tab 2.5 mg
3
acetazolamide tab 250 mg
3
VASOTEC - enalapril maleate tab 5 mg
3
VASOTEC - enalapril maleate tab 10 mg
3
ALDACTAZIDE spironolactone & hydrochlorothiazide tab 25-25 mg
3
VASOTEC - enalapril maleate tab 20 mg
3
ALDACTAZIDE spironolactone & hydrochlorothiazide tab 50-50 mg ALDACTONE - spironolactone tab 25 mg
3
ALDACTONE - spironolactone tab 50 mg
3
ALDACTONE - spironolactone tab 100 mg
3
amiloride & hydrochlorothiazide tab 5-50 mg
1
acetazolamide tab 125 mg
VECAMYL - mecamylamine hcl 3 tab 2.5 mg 3 ZESTORETIC - lisinopril & hydrochlorothiazide tab 10-12.5 mg 3 ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-12.5 mg 3 ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-25 mg ZESTRIL - lisinopril tab 2.5 mg 3 ZESTRIL - lisinopril tab 5 mg
3
ZESTRIL - lisinopril tab 10 mg
3
ZESTRIL - lisinopril tab 20 mg
3
ZESTRIL - lisinopril tab 30 mg
3
ZESTRIL - lisinopril tab 40 mg
3
ZIAC - bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
3
ZIAC - bisoprolol & hydrochlorothiazide tab 5-6.25 mg
3
ZIAC - bisoprolol & hydrochlorothiazide tab 10-6.25 mg
3
•
1
bumetanide tab 2 mg
Limited Distribution
ACA
1 1 1 1
BUMEX - bumetanide tab 0.5 mg
3
BUMEX - bumetanide tab 1 mg
3
BUMEX - bumetanide tab 2 mg
3
CHLOROTHIAZIDE chlorothiazide tab 250 mg
3
chlorothiazide tab 500 mg
1
chlorthalidone tab 25 mg
Dispensing Limits
1
amiloride hcl tab 5 mg
bumetanide tab 1 mg
SM
1
3
bumetanide tab 0.5 mg
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1
AMILORIDE HCL - amiloride hcl powder bumetanide inj 0.25 mg/ml
Step Therapy
1
VASERETIC enalapril maleate & hydrochlorothiazide tab 10-25 mg
acetazolamide sodium for inj 500 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
Products October (2016 Plan Year)
78
chlorthalidone tab 50 mg
1
DEMADEX - torsemide tab 10 mg
3
DEMADEX - torsemide tab 20 mg
3
DIAMOX - acetazolamide cap er 12hr 500 mg
3
DIURIL - chlorothiazide susp 250 mg/5ml
3
DYAZIDE - triamterene & hydrochlorothiazide cap 37.5-25 mg
3
DYRENIUM - triamterene cap 50 mg
3
DYRENIUM - triamterene cap 100 mg
indapamide tab 1.25 mg indapamide tab 2.5 mg
1 3
LASIX - furosemide tab 20 mg
3
LASIX - furosemide tab 40 mg
3
LASIX - furosemide tab 80 mg
3
MAXZIDE - triamterene & hydrochlorothiazide tab 75-50 mg
3
MAXZIDE-25 - triamterene & hydrochlorothiazide tab 37.5-25 mg
3
3
METHAZOLAMIDE methazolamide powder
3
EDECRIN - ethacrynic acid tab 25 mg
3
methazolamide tab 25 mg (Neptazane)
1
ethacrynic acid tab 25 mg
1
methazolamide tab 50 mg (Neptazane)
1
METHYCLOTHIAZIDE methyclothiazide powder
3
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
3
1
metolazone tab 2.5 mg (Zaroxolyn)
1
1
metolazone tab 5 mg (Zaroxolyn)
1
1
metolazone tab 10 mg
1
3
FUROSEMIDE - furosemide powder
3
furosemide inj 10 mg/ml
1
furosemide oral soln 10 mg/ ml furosemide tab 20 mg (Lasix) furosemide tab 40 mg (Lasix) furosemide tab 80 mg (Lasix)
1
3
HYDROCHLOROTHIAZIDE hydrochlorothiazide powder
3
MICROZIDE hydrochlorothiazide cap 12.5 mg
hydrochlorothiazide cap 12.5 mg (Microzide)
1
NEPTAZANE - methazolamide tab 25 mg
3
1
NEPTAZANE - methazolamide tab 50 mg
3
1
SPIRONOLACTONE spironolactone powder
3
1
spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide)
1
hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
KEVEYIS - dichlorphenamide tab 50 mg
FUROSEMIDE - furosemide oral soln 8 mg/ml
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
•
79
spironolactone tab 25 mg (Aldactone)
1
spironolactone tab 50 mg (Aldactone)
3
1
ADYPHREN AMP KIT epinephrine inj kit 1 mg/ml (1:1000)
3
spironolactone tab 100 mg (Aldactone)
1
ADYPHREN II - epinephrine inj kit 1 mg/ml (1:1000)
3
torsemide tab 5 mg (Demadex)
1
ADYPHREN KIT - epinephrine inj kit 1 mg/ml (1:1000)
1
torsemide tab 10 mg (Demadex)
1
ephedrine sulfate inj 50 mg/ ml
torsemide tab 20 mg (Demadex)
1
torsemide tab 100 mg (Demadex)
1
TRIAMTERENE - triamterene powder
3
triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide)
1
triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) TRIAMTERENE/ HYDROCHLOROTH triamterene & hydrochlorothiazide cap 50-25 mg
EPINEPHRINE AUTHORIZED GENERIC TO EPIPEN - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)
1
EPINEPHRINE AUTHORIZED GENERIC TO EPIPEN JR - epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)
1
1
EPINEPHRINESNAP-V epinephrine inj kit 1 mg/ml (1:1000)
3
1
EPIPEN 2-PAK - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)
2
EPIPEN-JR 2-PAK epinephrine solution autoinjector 0.15 mg/0.3ml (1:2000)
2
EPISNAP - epinephrine inj kit 1 mg/ml (1:1000)
3
LEVOPHED - norepinephrine bitartrate inj 1 mg/ml
3
midodrine hcl tab 2.5 mg
1
3
VASOPRESSORS
ADRENALIN - epinephrine inj 1 3 mg/ml (1:1000) 3 ADRENALIN - epinephrine inj 30 mg/30ml (1 mg/ml) (1:1000) 3 ADYPHREN AMP II KIT epinephrine inj kit 1 mg/ml (1:1000)
midodrine hcl tab 5 mg midodrine hcl tab 10 mg norepinephrine bitartrate inj 1 mg/ml (Levophed) NORTHERA - droxidopa cap 100 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 3
Products October (2016 Plan Year)
•
80
•
PHENYLEPHRINE HCL phenylephrine hcl inj 10 mg/ ml
3
ANTIHYPERLIPIDEMICS
•
1
COLESTID - colestipol hcl granule packets 5 gm
3
COLESTID - colestipol hcl granules 5 gm
3
COLESTID - colestipol hcl tab 1 gm
3 3
ALTOPREV - lovastatin tab er 24hr 20 mg
3
ALTOPREV - lovastatin tab er 24hr 40 mg
3
•
COLESTID FLAVORED colestipol hcl granule packets 5 gm
ALTOPREV - lovastatin tab er 24hr 60 mg
3
•
COLESTID FLAVORED colestipol hcl granules 5 gm
3
ANTARA - fenofibrate micronized cap 30 mg
3
1
ANTARA - fenofibrate micronized cap 90 mg
3
colestipol hcl granule packets 5 gm (Colestid flavored)
1
atorvastatin calcium tab 10 mg (base equivalent) (Lipitor)
1
colestipol hcl granules 5 gm (Colestid flavored) colestipol hcl tab 1 gm (Colestid)
1
atorvastatin calcium tab 20 mg (base equivalent) (Lipitor)
1
CRESTOR - rosuvastatin calcium tab 5 mg
3
•
3
•
atorvastatin calcium tab 40 mg (base equivalent) (Lipitor)
1
CRESTOR - rosuvastatin calcium tab 10 mg CRESTOR - rosuvastatin calcium tab 20 mg
3
•
atorvastatin calcium tab 80 mg (base equivalent) (Lipitor)
1
CRESTOR - rosuvastatin calcium tab 40 mg
3
•
ezetimibe tab 10 mg (Zetia)
1
cholestyramine light powder packets 4 gm
1
cholestyramine light powder 4 gm/dose (Questran light) cholestyramine powder packets 4 gm (Questran) cholestyramine powder 4 gm/dose (Questran) choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix)
ezetimibe-simvastatin tab 10-10 mg (Vytorin)
1
ezetimibe-simvastatin tab 10-20 mg (Vytorin)
1
ezetimibe-simvastatin tab 10-40 mg (Vytorin)
1
ezetimibe-simvastatin tab 10-80 mg (Vytorin)
1
FENOFIBRATE - fenofibrate cap 50 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
3
ACA
NORTHERA - droxidopa cap 300 mg
choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix)
Dispensing Limits
•
Step Therapy
3
Prior Authorization
NORTHERA - droxidopa cap 200 mg
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 3
Products October (2016 Plan Year)
81
FENOFIBRATE - fenofibrate cap 150 mg
3
fenofibrate micronized cap 43 mg
1
fenofibrate micronized cap 67 mg (Lofibra) fenofibrate micronized cap 130 mg fenofibrate micronized cap 134 mg (Lofibra) fenofibrate micronized cap 200 mg (Lofibra)
fluvastatin sodium tab er 24 hr 80 mg (Lescol xl)
Limited Distribution
ACA
1
GEMFIBROZIL - gemfibrozil powder
3
1
gemfibrozil tab 600 mg (Lopid)
1
1
JUXTAPID - lomitapide mesylate cap 5 mg (base equiv)
5
•
JUXTAPID - lomitapide mesylate cap 10 mg (base equiv)
5
•
JUXTAPID - lomitapide mesylate cap 20 mg (base equiv)
5
•
JUXTAPID - lomitapide mesylate cap 30 mg (base equiv)
5
•
JUXTAPID - lomitapide mesylate cap 40 mg (base equiv)
5
•
JUXTAPID - lomitapide mesylate cap 60 mg (base equiv)
5
•
5
•
1 1
fenofibrate tab 40 mg (Fenoglide)
1
fenofibrate tab 48 mg (Tricor)
1
fenofibrate tab 54 mg (Lofibra)
1
fenofibrate tab 120 mg (Fenoglide)
1
fenofibrate tab 145 mg (Tricor)
1
fenofibrate tab 160 mg (Lofibra)
1
FENOFIBRIC ACID - fenofibric acid tab 35 mg
3
FENOFIBRIC ACID - fenofibric acid tab 105 mg
3
KYNAMRO - mipomersen sodium soln prefilled syringe 200 mg/ml
3
FENOGLIDE - fenofibrate tab 40 mg
3
LESCOL XL - fluvastatin sodium tab er 24 hr 80 mg
3
FENOGLIDE - fenofibrate tab 120 mg
3
LIPOFEN - fenofibrate cap 50 mg
3
FIBRICOR - fenofibric acid tab 35 mg
3
LIPOFEN - fenofibrate cap 150 mg
3
•
FIBRICOR - fenofibric acid tab 105 mg
3
LIVALO - pitavastatin calcium tab 1 mg (base equiv)
3
•
fluvastatin sodium cap 20 mg (Lescol)
1
LIVALO - pitavastatin calcium tab 2 mg (base equiv)
3
•
1
LIVALO - pitavastatin calcium tab 4 mg (base equiv) LOFIBRA - fenofibrate micronized cap 67 mg
3
fluvastatin sodium cap 40 mg (Lescol)
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
•
82
LOFIBRA - fenofibrate micronized cap 134 mg
3
LOFIBRA - fenofibrate micronized cap 200 mg
3
LOFIBRA - fenofibrate tab 54 mg
3
pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg (Pravachol) pravastatin sodium tab 40 mg (Pravachol)
LOPID - gemfibrozil tab 600 mg 3 1 lovastatin tab 10 mg
pravastatin sodium tab 80 mg (Pravachol)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1
lovastatin tab 20 mg (Mevacor)
1
QUESTRAN - cholestyramine powder packets 4 gm
3
lovastatin tab 40 mg (Mevacor)
1
QUESTRAN - cholestyramine powder 4 gm/dose
3
LOVAZA - omega-3-acid ethyl esters cap 1 gm
3
3
niacin tab er 500 mg (antihyperlipidemic) (Niaspan)
1
QUESTRAN LIGHT cholestyramine light powder 4 gm/dose
4
•
•
•
niacin tab er 750 mg (antihyperlipidemic) (Niaspan)
1
REPATHA - evolocumab subcutaneous soln prefilled syringe 140 mg/ml
4
•
•
•
niacin tab er 1000 mg (antihyperlipidemic) (Niaspan)
1
REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneous soln cartridge/ infusor 420 mg/3.5ml
4
•
•
•
NIACOR - niacin (antihyperlipidemic) tab 500 mg
3
REPATHA SURECLICK evolocumab subcutaneous soln auto-injector 140 mg/ml
1
NIASPAN - niacin tab er 500 mg (antihyperlipidemic)
3
rosuvastatin calcium tab 5 mg (Crestor)
NIASPAN - niacin tab er 750 mg (antihyperlipidemic)
3
NIASPAN - niacin tab er 1000 mg (antihyperlipidemic)
3
omega-3-acid ethyl esters cap 1 gm (Lovaza)
1
PRALUENT - alirocumab subcutaneous soln peninjector 75 mg/ml
4
PRALUENT - alirocumab subcutaneous soln peninjector 150 mg/ml
4
rosuvastatin calcium tab 10 mg (Crestor) rosuvastatin calcium tab 20 mg (Crestor) rosuvastatin calcium tab 40 mg (Crestor) simvastatin tab 5 mg (Zocor)
• •
• •
• •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1 1 1 1
simvastatin tab 10 mg (Zocor)
1
simvastatin tab 20 mg (Zocor)
1
simvastatin tab 40 mg (Zocor)
1
Products October (2016 Plan Year)
83
simvastatin tab 80 mg (Zocor)
1
ADEMPAS - riociguat tab 2.5 mg
5
TRICOR - fenofibrate tab 48 mg
3
1
TRICOR - fenofibrate tab 145 mg
3
amlodipine besylateatorvastatin calcium tab 2.5-10 mg (Caduet)
TRIGLIDE - fenofibrate tab 160 mg
3
TRILIPIX - choline fenofibrate cap dr 45 mg (fenofibric acid equiv)
3
amlodipine besylateatorvastatin calcium tab 2.5-40 mg (Caduet)
TRILIPIX - choline fenofibrate cap dr 135 mg (fenofibric acid equiv)
3
amlodipine besylateatorvastatin calcium tab 5-10 mg (Caduet)
VASCEPA - icosapent ethyl cap 2 0.5 gm VASCEPA - icosapent ethyl cap 2 1 gm 3 VYTORIN - ezetimibesimvastatin tab 10-10 mg 3 VYTORIN - ezetimibesimvastatin tab 10-20 mg 3 VYTORIN - ezetimibesimvastatin tab 10-40 mg 3 VYTORIN - ezetimibesimvastatin tab 10-80 mg 2 WELCHOL - colesevelam hcl packet for susp 3.75 gm 2 WELCHOL - colesevelam hcl tab 625 mg 3 ZETIA - ezetimibe tab 10 mg
amlodipine besylateatorvastatin calcium tab 5-20 mg (Caduet)
CARDIOVASCULAR AGENTS - MISC. ADCIRCA - tadalafil tab 20 mg 4 (pah) 5 ADEMPAS - riociguat tab 0.5 mg ADEMPAS - riociguat tab 1 mg 5
amlodipine besylateatorvastatin calcium tab 2.5-20 mg (Caduet)
amlodipine besylateatorvastatin calcium tab 5-40 mg (Caduet)
•
amlodipine besylateatorvastatin calcium tab 5-80 mg (Caduet)
• •
amlodipine besylateatorvastatin calcium tab 10-10 mg (Caduet)
•
amlodipine besylateatorvastatin calcium tab 10-20 mg (Caduet) amlodipine besylateatorvastatin calcium tab 10-40 mg (Caduet) amlodipine besylateatorvastatin calcium tab 10-80 mg (Caduet)
• •
ADEMPAS - riociguat tab 1.5 mg
5
• •
ADEMPAS - riociguat tab 2 mg
5
• SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
1
1
1
1
1
1
1
1
1
1
BIDIL - isosorbide dinitratehydralazine hcl tab 20-37.5 mg
3
CADUET - amlodipine besylate-atorvastatin calcium tab 5-10 mg
3
Products October (2016 Plan Year)
84
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
CADUET - amlodipine besylate-atorvastatin calcium tab 5-20 mg
3
NYLIDRIN HYDROCHLORIDE - nylidrin hcl powder
3
CADUET - amlodipine besylate-atorvastatin calcium tab 5-40 mg
3
OPSUMIT - macitentan tab 10 mg
4
•
3
5
CADUET - amlodipine besylate-atorvastatin calcium tab 5-80 mg
ORENITRAM - treprostinil diolamine tab er 0.125 mg (base equiv)
•
3
ORENITRAM - treprostinil diolamine tab er 0.25 mg (base equiv)
5
CADUET - amlodipine besylate-atorvastatin calcium tab 10-10 mg
•
ORENITRAM - treprostinil diolamine tab er 1 mg (base equiv)
5
CADUET - amlodipine besylate-atorvastatin calcium tab 10-20 mg
3
•
ORENITRAM - treprostinil diolamine tab er 2.5 mg (base equiv)
5
CADUET - amlodipine besylate-atorvastatin calcium tab 10-40 mg
3
•
3
ORENITRAM - treprostinil diolamine tab er 5 mg (base equiv)
5
CADUET - amlodipine besylate-atorvastatin calcium tab 10-80 mg
•
papaverine hcl inj 30 mg/ml
1
cardioplegic soln (Plegisol)
1
• •
PLEGISOL - cardioplegic soln
3
REMODULIN - treprostinil sodium inj 1 mg/ml (base equiv)
5
•
REMODULIN - treprostinil sodium inj 2.5 mg/ml (base equiv)
5
•
REMODULIN - treprostinil sodium inj 5 mg/ml (base equiv)
5
•
REMODULIN - treprostinil sodium inj 10 mg/ml (base equiv)
5
•
CIALIS - tadalafil tab 2.5 mg
2
CIALIS - tadalafil tab 5 mg
2
CORLANOR - ivabradine hcl tab 5 mg (base equiv)
3
CORLANOR - ivabradine hcl tab 7.5 mg (base equiv)
3
ENTRESTO - sacubitrilvalsartan tab 24-26 mg
2
•
•
ENTRESTO - sacubitrilvalsartan tab 49-51 mg
2
•
•
ENTRESTO - sacubitrilvalsartan tab 97-103 mg
2
•
•
ISOXSUPRINE HCL isoxsuprine hcl tab 20 mg
3
REVATIO - sildenafil citrate for suspension 10 mg/ml
5
•
isoxsuprine hcl tab 10 mg
1
REVATIO - sildenafil citrate tab 20 mg
5
•
sildenafil citrate tab 20 mg (Revatio)
4
•
LETAIRIS - ambrisentan tab 5 mg
4
•
LETAIRIS - ambrisentan tab 10 mg
4
• SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
85
ERECTILE DYSFUNCTION CIALIS - tadalafil tab 2.5 mg
2
CIALIS - tadalafil tab 5 mg
2
•
brompheniramine maleate tab sr 12hr 6 mg
1
•
BROMPHENIRAMINE TANNATE brompheniramine tannate chew tab 12 mg
3
carbinoxamine maleate soln 4 mg/5ml
1
• •
carbinoxamine maleate tab 4 mg
1
DESLORATADINE ODT desloratadine tab orally disintegrating 2.5 mg
3
DESLORATADINE ODT desloratadine tab orally disintegrating 5 mg
3
desloratadine tab 5 mg (Clarinex)
1
DICOPANOL FUSEPAQ diphenhydramine hcl for oral susp 5 mg/ml (compound kit)
3
DICOPANOL RAPIDPAQ diphenhydramine hcl for oral susp 5 mg/ml (compound kit)
3
DIPHENHYDRAMINE HCL diphenhydramine hcl powder
3
Limited Distribution
ACA
•
3
Dispensing Limits
TRACLEER - bosentan tab 125 4 mg 5 TYVASO - treprostinil inhalation solution 0.6 mg/ml 5 TYVASO REFILL - treprostinil inhalation solution 0.6 mg/ml 5 TYVASO STARTER treprostinil inhalation solution 0.6 mg/ml 4 UPTRAVI - selexipag tab therapy pack 200 mcg (140) & 800 mcg (60) 4 UPTRAVI - selexipag tab 200 mcg 4 UPTRAVI - selexipag tab 400 mcg 4 UPTRAVI - selexipag tab 600 mcg 4 UPTRAVI - selexipag tab 800 mcg UPTRAVI - selexipag tab 1000 4 mcg UPTRAVI - selexipag tab 1200 4 mcg UPTRAVI - selexipag tab 1400 4 mcg UPTRAVI - selexipag tab 1600 4 mcg VENTAVIS - iloprost inhalation 5 solution 10 mcg/ml VENTAVIS - iloprost inhalation 5 solution 20 mcg/ml
BROMPHENIRAMINE MALEATE brompheniramine maleate powder
Step Therapy
•
Prior Authorization
4
TRACLEER - bosentan tab 62.5 mg
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3 CHLORPHENIRAMINE MALEATE - chlorpheniramine maleate powder 3 CLEMASTINE FUMARATE clemastine fumarate powder 3 CLEMASTINE FUMARATE clemastine fumarate tab 2.68 mg 1 cyproheptadine hcl syrup 2 mg/5ml cyproheptadine hcl tab 4 mg 1
• • • • • • • • • • • •
RESPIRATORY AGENTS ANTIHISTAMINES
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
86
diphenhydramine hcl cap 50 mg diphenhydramine hcl elixir 12.5 mg/5ml diphenhydramine hcl inj 50 mg/ml DOXYLAMINE SUCCINATE doxylamine succinate powder
PYRILAMINE MALEATE pyrilamine maleate crystals
3
1
PYRILAMINE MALEATE pyrilamine maleate powder
3
1
TRIPELENNAMINE HCL tripelennamine hcl powder
3
3
NASAL AGENTS - SYSTEMIC and TOPICAL 3 ADRENALIN - epinephrine hcl nasal soln 0.1% ALZAIR ALLERGY BLOCKER 3 NA - hypromellose nasal powder 3 ASTEPRO - azelastine hcl nasal spray 0.15% (205.5 mcg/spray) 1 azelastine hcl nasal spray 137 mcg/spray (1 mg/ml) 1 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro) 2 BACTROBAN NASAL mupirocin calcium nasal oint 2% 1 budesonide nasal susp 32 mcg/act (Rhinocort aqua) 3 DYMISTA - azelastine hclfluticasone prop nasal spray 137-50 mcg/act 3 FLUNISOLIDE - flunisolide nasal soln 25 mcg/act (0.025%) fluticasone propionate nasal 1 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)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
KARBINAL ER - carbinoxamine 3 maleate extended release susp 4 mg/5ml 1 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal) 1 levocetirizine dihydrochloride tab 5 mg (Xyzal) 3 PHENERGAN - promethazine hcl inj 25 mg/ml 3 PHENERGAN - promethazine hcl inj 50 mg/ml 3 PROMETHAZINE HCL promethazine hcl powder 1 promethazine hcl inj 25 mg/ ml (Phenergan) 1 promethazine hcl inj 50 mg/ ml (Phenergan) 1 promethazine hcl suppos 12.5 mg 1 promethazine hcl suppos 25 mg 1 promethazine hcl suppos 50 mg 1 promethazine hcl syrup 6.25 mg/5ml 1 promethazine hcl tab 12.5 mg 1 promethazine hcl tab 25 mg promethazine hcl tab 50 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
87
mometasone furoate nasal susp 50 mcg/act (Nasonex) olopatadine hcl nasal soln 0.6% (Patanase)
1 1
PATANASE - olopatadine hcl nasal soln 0.6%
3
PHENYLEPHRINE HCL phenylephrine hcl crystals
3
PHENYLEPHRINE HCL phenylephrine hcl powder
3
PHENYLPROPANOLAMINE HYDRO phenylpropanolamine hcl powder
3
PSEUDOEPHEDRINE HCL pseudoephedrine hcl powder
3
triamcinolone acetonide nasal aerosol suspension 55 mcg/act (Nasacort aq)
1
DECON-A - brompheniramine & phenylephrine elixir 2-5 mg/5ml
3
DECON-G - phenylephrinebrompheniramineguaifenesin liqd 2-1-40 mg/ ml
3
DEXTROMETHORPHAN HBR - dextromethorphan hbr powder
3
DEXTROMETHORPHAN HBR MONO - dextromethorphan hbr crystals
3
DEXTROMETHORPHAN HBR MONO - dextromethorphan hbr powder
3
EXACTUSS - phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml
3
3
ACETYLCYSTEINE acetylcysteine powder
3
FLOWTUSS - hydrocodoneguaifenesin soln 2.5-200 mg/5ml GILPHEX TR - phenylephrineguaifenesin tab 10-388 mg
3
acetylcysteine inhal soln 10%
1 1
GILTUSS - phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml
3
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 20% benzonatate cap 100 mg (Tessalon perles)
1
GILTUSS TR - phenylephrine w/ dm-gg tab 10-28-388 mg
3
benzonatate cap 200 mg
1
3 1
BROMHEXINE HCL bromhexine hcl powder
3
GUAIFENESIN - guaifenesin powder
brompheniramine & pseudoephedrine tab sr 12hr 6-45 mg
1
guaifenesin-codeine soln 100-10 mg/5ml
CARBAPHEN 12 - phenylephchlorphen-carbetapentane liqd 10-4-27.5 mg/5ml
3
CARBAPHEN 12 PED phenyleph-chlorphencarbetapentane susp 2.5-1.25-7.5 mg/ml
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
HYCOFENIX pseudoephedrine w/ hydrocodone-gg soln 30-2.5-200 mg/5ml
3
hydrocod polst-chlorphen polst er susp 10-8 mg/5ml (Tussionex pennkineti)
1
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
88
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml hydrocodone w/ homatropine tab 5-1.5 mg
1
promethazine & phenylephrine syrup 6.25-5 mg/5ml
1
promethazine w/ codeine syrup 6.25-10 mg/5ml
HYPERSAL - sodium chloride soln nebu 3.5%
3
HYPERSAL - sodium chloride soln nebu 7%
3
N-ACETYL-L-CYSTEINE acetylcysteine powder
3
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml (Zutripro)
NEBUSAL - sodium chloride soln nebu 6%
3
pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml
NEOTUSS PLUS phenylephrine-chlorphen-dm liquid 7.5-4-30 mg/5ml
3
RELHIST - bromphen tanphenyleph tan chew tab 6-15 mg
3
NORTUSS-EX dextromethorphanguaifenesin liquid 20-200 mg/5ml
3
REZIRA - pseudoephedrine w/ hydrocodone soln 60-5 mg/5ml
3
3
OBREDON - hydrocodoneguaifenesin soln 2.5-200 mg/5ml
3
SEMPREX-D - acrivastine & pseudoephedrine cap 8-60 mg
1
PANATUSS DXP phenylephrinedexbromphen-dm-gg liquid 5-1-15-100 mg/5ml
3
sodium chloride soln nebu 0.9%
phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml
1
sodium chloride soln nebu 7% (Hyper-sal)
1
sodium chloride soln nebu 10%
1
TERPIN HYDRATE - terpin hydrate powder
3
3
TERPIN HYDRATE MONOHYDRAT - terpin hydrate powder
3
TESSALON PERLES benzonatate cap 100 mg
3
phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml PHENYLEPHRINE/ GUAIFENESIN phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml)
sodium chloride soln nebu 3%
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
1
3
promethazinephenylephrine-codeine syrup 6.25-5-10 mg/5ml
Step Therapy
1
HYPER-SAL - sodium chloride soln nebu 7%
promethazine-dm syrup 6.25-15 mg/5ml
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1
1
1
1 1 1
Products October (2016 Plan Year)
89
TGQ 15DM/5PEH/2CPM phenylephrine-chlorphen-dm syrup 5-2-15 mg/5ml
3
ADVAIR HFA - fluticasonesalmeterol inhal aerosol 45-21 mcg/act
2
TGQ 30PSE/150GFN/15DM pseudoephedrine w/ dm-gg syrup 30-15-150 mg/5ml
3
ADVAIR HFA - fluticasonesalmeterol inhal aerosol 115-21 mcg/act
2
TGQ 30PSE/3BRM/15DM pseudoephed-bromphen-dm syrup 30-3-15 mg/5ml
3
ADVAIR HFA - fluticasonesalmeterol inhal aerosol 230-21 mcg/act
2
TUSSICAPS - hydrocod polstchlorphen polst cap er 12hr 5-4 mg
3
AEROSPAN - flunisolide hfa inhal aerosol 80 mcg/act
3
ALBUTEROL SULFATE albuterol sulfate powder
3
TUSSICAPS - hydrocod polstchlorphen polst cap er 12hr 10-8 mg
3
1
TUSSIONEX PENNKINETIC EXT - hydrocod polstchlorphen polst er susp 10-8 mg/5ml
3
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)
TUZISTRA XR - codeine polistchlorphen polist er susp 14.7-2.8 mg/5ml
3
VITUZ - hydrocodonechlorpheniramine soln 5-4 mg/5ml
3
ZUTRIPRO - pseudoephchlorphen w/ hydrocodone soln 60-4-5 mg/5ml
3
albuterol sulfate soln nebu 0.5% (5 mg/ml) albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) albuterol sulfate syrup 2 mg/5ml albuterol sulfate tab er 12hr 4 mg (Vospire er) albuterol sulfate tab er 12hr 8 mg (Vospire er)
ANTIASTHMATIC and BRONCHODILATOR AGENTS ACCOLATE - zafirlukast tab 10 3 mg ACCOLATE - zafirlukast tab 20 3 mg ADVAIR DISKUS - fluticasone- 2 salmeterol aer powder ba 100-50 mcg/dose ADVAIR DISKUS - fluticasone- 2 salmeterol aer powder ba 250-50 mcg/dose ADVAIR DISKUS - fluticasone- 2 salmeterol aer powder ba 500-50 mcg/dose
albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1 1 1 1
ALVESCO - ciclesonide inhal aerosol 80 mcg/act
3
ALVESCO - ciclesonide inhal aerosol 160 mcg/act
3
AMINOPHYLLINE ANHYDROUS aminophylline powder
3
ANORO ELLIPTA umeclidinium-vilanterol aero powd ba 62.5-25 mcg/inh
2
Products October (2016 Plan Year)
90
ARCAPTA NEOHALER indacaterol maleate inhal powder cap 75 mcg (base equiv)
3
ARNUITY ELLIPTA fluticasone furoate aerosol powder breath activ 100 mcg/act
2
ARNUITY ELLIPTA fluticasone furoate aerosol powder breath activ 200 mcg/act
2
ASMANEX HFA - mometasone furoate inhal aerosol suspension 100 mcg/act
ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act
2
BEVESPI AEROSPHERE glycopyrrolate-formoterol fumarate aerosol 9-4.8 mcg/ act
3
BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh
2
2
2
BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba 200-25 mcg/inh
3
ASMANEX HFA - mometasone furoate inhal aerosol suspension 200 mcg/act
2
BROVANA - arformoterol tartrate soln nebu 15 mcg/2ml (base equiv)
1
ASMANEX TWISTHALER 120 ME - mometasone furoate inhal powd 220 mcg/inh (breath activated)
2
budesonide inhalation susp 0.25 mg/2ml (Pulmicort)
ASMANEX TWISTHALER 14 MET - mometasone furoate inhal powd 220 mcg/inh (breath activated)
2
ASMANEX TWISTHALER 30 MET - mometasone furoate inhal powd 110 mcg/inh (breath activated)
2
ASMANEX TWISTHALER 30 MET - mometasone furoate inhal powd 220 mcg/inh (breath activated)
2
ASMANEX TWISTHALER 60 MET - mometasone furoate inhal powd 220 mcg/inh (breath activated)
2
ASMANEX TWISTHALER 7 METE - mometasone furoate inhal powd 110 mcg/inh (breath activated)
2
budesonide inhalation susp 0.5 mg/2ml (Pulmicort) budesonide inhalation susp 1 mg/2ml (Pulmicort)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1
COMBIVENT RESPIMAT ipratropium-albuterol inhal aerosol soln 20-100 mcg/act
2
CROMOLYN SODIUM cromolyn sodium powder
3
CROMOLYN SODIUM cromolyn sodium soln nebu 20 mg/2ml
3
DALIRESP - roflumilast tab 500 3 mcg 2 DULERA - mometasone furoate-formoterol fumarate aerosol 100-5 mcg/act 2 DULERA - mometasone furoate-formoterol fumarate aerosol 200-5 mcg/act 1 dyphylline-guaifenesin liqd 100-100 mg/5ml 3 ELIXOPHYLLIN - theophylline elixir 80 mg/15ml SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
91
EPHEDRINE HCL - ephedrine hcl powder
3
EPHEDRINE SULFATE ephedrine sulfate powder
3
epinephrine hcl inj 1 mg/ml
1
epinephrine hcl soln prefilled syringe 0.1 mg/ml
1
INCRUSE ELLIPTA umeclidinium br aero powd breath act 62.5 mcg/inh (base eq)
2
IPRATROPIUM BROMIDE ipratropium bromide powder
3
ipratropium bromide inhal soln 0.02%
1
FLOVENT DISKUS fluticasone propionate aer pow ba 50 mcg/blister
2
FLOVENT DISKUS fluticasone propionate aer pow ba 100 mcg/blister
2
FLOVENT DISKUS fluticasone propionate aer pow ba 250 mcg/blister
2
ISUPREL - isoproterenol hcl inj 0.2 mg/ml
3 1
FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act (50/valve)
2
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenex concentrate)
FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act (125/valve)
2
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex)
1
FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act (250/valve)
2
levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex)
1
FLUNISOLIDE - flunisolide powder
3
1
FLUNISOLIDE ANHYDROUS flunisolide powder
3
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex)
3
FLUTICASONE PROPIONATE/SA fluticasone-salmeterol aer powder ba 55-14 mcg/act
1
LEVALBUTEROL TARTRATE HFA - levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv)
3
FLUTICASONE PROPIONATE/SA fluticasone-salmeterol aer powder ba 113-14 mcg/act
1
METAPROTERENOL SULFATE - metaproterenol sulfate powder
3
FLUTICASONE PROPIONATE/SA fluticasone-salmeterol aer powder ba 232-14 mcg/act
1
METAPROTERENOL SULFATE - metaproterenol sulfate syrup 10 mg/5ml METAPROTERENOL SULFATE - metaproterenol sulfate tab 10 mg
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
IPRATROPIUM BROMIDE MONOH - ipratropium bromide powder
3
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
1
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
92
METAPROTERENOL SULFATE - metaproterenol sulfate tab 20 mg
3
montelukast sodium chew tab 4 mg (base equiv) (Singulair)
3
1
PULMICORT FLEXHALER budesonide inhal aero powd 180 mcg/act (breath activated)
2
montelukast sodium chew tab 5 mg (base equiv) (Singulair)
1
QVAR - beclomethasone diprop inhal aero soln 40 mcg/act (50/valve)
2
montelukast sodium oral granules packet 4 mg (base equiv) (Singulair)
1
QVAR - beclomethasone diprop inhal aero soln 80 mcg/act (100/valve) SEREVENT DISKUS salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv)
2
SINGULAIR - montelukast sodium chew tab 4 mg (base equiv)
3
montelukast sodium tab 10 mg (base equiv) (Singulair)
1
NUCALA - mepolizumab for inj 100 mg
5
PERFOROMIST - formoterol fumarate soln nebu 20 mcg/2ml
3
SINGULAIR - montelukast sodium chew tab 5 mg (base equiv)
3
PROAIR HFA - albuterol sulfate 2 inhal aero 108 mcg/act (90mcg base equiv) 2 PROAIR RESPICLICK albuterol sulfate aer pow ba 108 mcg/act (90 mcg base equiv) 3 PROVENTIL HFA - albuterol sulfate inhal aero 108 mcg/ act (90mcg base equiv) 3 PULMICORT - budesonide inhalation susp 0.25 mg/2ml 3 PULMICORT - budesonide inhalation susp 0.5 mg/2ml 3 PULMICORT - budesonide inhalation susp 1 mg/2ml 3 PULMICORT FLEXHALER budesonide inhal aero powd 90 mcg/act (breath activated)
SINGULAIR - montelukast sodium oral granules packet 4 mg (base equiv)
3
SINGULAIR - montelukast sodium tab 10 mg (base equiv)
3
SPIRIVA HANDIHALER tiotropium bromide monohydrate inhal cap 18 mcg (base equiv)
2
SPIRIVA RESPIMAT tiotropium bromide monohydrate inhal aerosol 1.25 mcg/act
2
SPIRIVA RESPIMAT tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act
2
STIOLTO RESPIMAT tiotropium br-olodaterol inhal aero soln 2.5-2.5 mcg/act
2
•
•
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
93
STRIVERDI RESPIMAT olodaterol hcl inhal aerosol soln 2.5 mcg/act (base equiv)
3
TUDORZA PRESSAIR aclidinium bromide aerosol powd breath activated 400 mcg/act
3
SYMBICORT - budesonideformoterol fumarate dihyd aerosol 80-4.5 mcg/act
2
UTIBRON NEOHALER indacaterol-glycopyrrolate inhal cap 27.5-15.6 mcg
3
SYMBICORT - budesonideformoterol fumarate dihyd aerosol 160-4.5 mcg/act
2
VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/ act (90mcg base equiv)
2
TERBUTALINE SULFATE terbutaline sulfate powder
3
VOSPIRE ER - albuterol sulfate tab er 12hr 4 mg
3
terbutaline sulfate inj 1 mg/ ml
1
VOSPIRE ER - albuterol sulfate tab er 12hr 8 mg
3
1
XOLAIR - omalizumab for inj 150 mg
5
1
XOPENEX - levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
3
XOPENEX - levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)
3
XOPENEX - levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)
3
XOPENEX CONCENTRATE levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv)
3
XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv)
3
1
zafirlukast tab 10 mg (Accolate)
1
1
zafirlukast tab 20 mg (Accolate)
1
1
zileuton tab er 12hr 600 mg (Zyflo cr)
1
1
ZYFLO - zileuton tab 600 mg
3
ZYFLO CR - zileuton tab er 12hr 600 mg
3
terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg THEO-24 - theophylline cap er 24hr 100 mg
3
THEO-24 - theophylline cap er 24hr 200 mg
3
THEO-24 - theophylline cap er 24hr 300 mg
3
THEO-24 - theophylline cap er 24hr 400 mg
3
theophylline soln 80 mg/15ml
1
theophylline tab er 12hr 100 mg theophylline tab er 12hr 200 mg theophylline tab er 12hr 300 mg theophylline tab er 12hr 450 mg theophylline tab er 24hr 400 mg theophylline tab er 24hr 600 mg
1 1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
94
RESPIRATORY AGENTS - MISC. 3 CUROSURF - poractant alfa intratracheal susp 120 mg/1.5ml 3 CUROSURF - poractant alfa intratracheal susp 240 mg/3ml ESBRIET - pirfenidone cap 267 5 mg ESBRIET - pirfenidone tab 267 5 mg ESBRIET - pirfenidone tab 801 5 mg 3 INFASURF - calfactant in nacl 0.9% intratracheal susp 35 mg/ml 4 KALYDECO - ivacaftor packet 50 mg 4 KALYDECO - ivacaftor packet 75 mg KALYDECO - ivacaftor tab 150 4 mg OFEV - nintedanib esylate cap 5 100 mg (base equivalent) OFEV - nintedanib esylate cap 5 150 mg (base equivalent) 5 ORKAMBI - lumacaftorivacaftor tab 100-125 mg 5 ORKAMBI - lumacaftorivacaftor tab 200-125 mg 4 PULMOZYME - dornase alfa inhal soln 1 mg/ml 3 SCLEROSOL INTRAPLEURAL - talc intrapleural aerosol powder 4 gm (0.4 gm/second) 3 STERILE TALC POWDER talc intrapleural powder for susp 5 gm
SURVANTA INTRATRACHEAL beractant in nacl 0.9% intratracheal susp 25 mg/ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3
GASTROINTESTINAL AGENTS LAXATIVES
•
•
•
BISACODYL - bisacodyl powder
3
•
•
•
1
•
•
•
bisacodyl tab & peg 3350kcl-sod bicarb-nacl for soln kit
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• •
CASCARA SAGRADA cascara sagrada fl ext 1 gm/ ml
3
COLYTE-FLAVOR PACKS peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm
3
DOCUSATE SODIUM docusate sodium powder
3
GIALAX - polyethylene glycol 3350 - kit
3
GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate packet 227.1 gm
3
GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
3
KRISTALOSE - lactulose oral crystal packet 10 gm
3
KRISTALOSE - lactulose oral crystal packet 20 gm
3
lactulose solution 10 gm/15ml
1
MAGNESIUM SULFATE magnesium sulfate powder
3
MAGNESIUM SULFATE HEPTAHY - magnesium sulfate powder
3
mineral oil
1
MINERAL OIL - mineral oil (bulk)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
3
Products October (2016 Plan Year)
95
MINERAL OIL HEAVY mineral oil (bulk)
3
MINERAL OIL LIGHT - mineral oil light (bulk)
3
MOVIPREP - peg 3350-kclnacl-na sulfate-na acorbatec for soln 100 gm
3
MURI-LUBE - mineral oil light (bulk)
diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)
2
KAOLIN - kaolin powder
3
3
LOMOTIL - diphenoxylate w/ atropine tab 2.5-0.025 mg
3
NULYTELY/FLAVOR PACKS peg 3350-kcl-sod bicarb-nacl for soln 420 gm
3
LOPERAMIDE HCL loperamide hcl powder
3
loperamide hcl cap 2 mg
1
OSMOPREP - sod phos mono-sod phos di tabs 1.102-0.398 gm(1.5gm na phos)
3
PCP 100 - mag citbisacodyl-petrolat-pegmetoclopramide-electrol kit
3
peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/ flavor pack)
1
PAREGORIC - paregoric tincture 2 mg/5ml (morphine equivalent)
3
peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm (Golytely)
1
PECTIN - pectin powder
3 3
peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm (Colyte-flavor packs)
1
RESTORA RX - lactobacillus casei-folic acid cap 60-1.25 mg
3
polyethylene glycol 3350 oral packet
1
RESTORA SPRINKLES lactobacillus casei-folic acid packet 15-0.25 mg
3
1
VSL#3 DS - probiotic product packet
PREPOPIK - sod picosulfatemg oxide-citric acid pack 10 mg-3.5 gm-12 gm
3
SUPREP BOWEL PREP KIT sodium sulfate-potassium sulfate-magnesium sulfate oral soln
3
ANTIDIARRHEALS BISMUTH SUBGALLATE bismuth subgallate powder
MOTOFEN - difenoxin w/ atropine tab 1-0.025 mg
3
MYTESI - crofelemer tab delayed release 125 mg
3
opium tincture 1% (10 mg/ ml) (morphine equiv)
1
ANTACIDS
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
DIPHENOXYLATE/ ATROPINE - diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml
polyethylene glycol 3350 oral powder
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
MAGNESIUM OXIDE HEAVY magnesium oxide powder
3
MAGNESIUM OXIDE LIGHT magnesium oxide powder
3
MAGNESIUM TRISILICATE magnesium trisilicate powder
3
MAGNESIUM TRISILICATE ANH - magnesium trisilicate powder
3
Products October (2016 Plan Year)
96
MAGNESIUM TRISILICATE HYD - magnesium trisilicate powder
3
BELLADONNA & OPIUM belladonna alkaloids & opium suppos 16.2-30 mg
3
SODIUM BICARBONATE sodium bicarbonate powder
3
3
1
BELLADONNA ALKALOIDS & OP - belladonna alkaloids & opium suppos 16.2-60 mg
3
ULCER DRUGS amoxicillin cap-clarithro tablansopraz cap dr therapy pack (Prevpac)
atropine sulfate soln prefill syr 1 mg/10ml (0.1 mg/ml)
ANASPAZ - hyoscyamine sulfate tab disint 0.125 mg
3
3
ATROPEN - atropine sulfate im soln auto-injector 0.25 mg/0.3ml
3
BENTYL - dicyclomine hcl inj 10 mg/ml CARAFATE - sucralfate susp 1 gm/10ml
2
ATROPEN - atropine sulfate im soln auto-injector 0.5 mg/0.7ml
3
CARAFATE - sucralfate tab 1 gm
3
3
CIMETIDINE - cimetidine powder
3
ATROPEN - atropine sulfate im soln auto-injector 1 mg/0.7ml
cimetidine hcl soln 300 mg/5ml
1
ATROPEN - atropine sulfate im soln auto-injector 2 mg/0.7ml
3
ATROPINE SULFATE atropine sulfate inj 0.4 mg/ml
3
ATROPINE SULFATE atropine sulfate monohydrate powder
3
ATROPINE SULFATE atropine sulfate powder
3
ATROPINE SULFATE atropine sulfate soln prefill syr 0.25 mg/5ml (0.05 mg/ ml)
3
ATROPINE SULFATE atropine sulfate soln prefill syr 0.5 mg/5ml (0.1 mg/ml)
3
atropine sulfate inj 1 mg/ml
1
atropine sulfate inj 8 mg/20ml (0.4 mg/ml) ATROPINE SULFATE MONOHYDR - atropine sulfate monohydrate powder
cimetidine tab 300 mg cimetidine tab 400 mg cimetidine tab 800 mg clidinium & chlordiazepoxide cap 2.5-5 mg (Librax)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
BENTYL - dicyclomine hcl cap 10 mg
cimetidine tab 200 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1
CUVPOSA - glycopyrrolate oral 3 soln 1 mg/5ml 3 CYTOTEC - misoprostol tab 100 mcg 3 CYTOTEC - misoprostol tab 200 mcg 3 DEPRIZINE FUSEPAQ ranitidine hcl for oral susp 22.4 mg/ml (compound kit) 3 DEPRIZINE RAPIDPAQ ranitidine hcl for oral susp 22.4 mg/ml (compound kit)
1 3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
97
dicyclomine hcl cap 10 mg (Bentyl)
1
dicyclomine hcl inj 10 mg/ml (Bentyl)
1
dicyclomine hcl oral soln 10 mg/5ml
1
dicyclomine hcl tab 20 mg (Bentyl)
1
DONNATAL - pb-hyoscyatrop-scopol elix 16.2-0.1037-0.0194-0.0065 mg/5ml
3
DONNATAL - pb-hyoscyatrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg
3
famotidine for susp 40 mg/5ml (Pepcid)
1
famotidine tab 20 mg (Pepcid)
1
famotidine tab 40 mg (Pepcid)
1
glycopyrrolate inj 0.2 mg/ml (Robinul)
1
glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) (Robinul)
1
glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) (Robinul)
1
glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) (Robinul)
hyoscyamine sulfate tab disint 0.125 mg (Anaspaz) hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid) hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl) hyoscyamine sulfate tab 0.125 mg (Levsin)
1
glycopyrrolate tab 2 mg (Robinul forte)
1
HYOSCYAMINE SULFATE hyoscyamine sulfate powder
3
hyoscyamine sulfate elixir 0.125 mg/5ml
1
Limited Distribution
ACA
1 1
lansoprazole cap delayed release 15 mg (Prevacid)
1 1
LEVBID - hyoscyamine sulfate tab er 12hr 0.375 mg
3
LEVSIN - hyoscyamine sulfate inj 0.5 mg/ml
3
LEVSIN - hyoscyamine sulfate tab 0.125 mg
3
LEVSIN/SL - hyoscyamine sulfate tab sl 0.125 mg
3
LIBRAX - clidinium & chlordiazepoxide cap 2.5-5 mg
3
methscopolamine bromide tab 2.5 mg (Pamine)
1 1
misoprostol tab 100 mcg (Cytotec)
1
misoprostol tab 200 mcg (Cytotec)
1
NIZATIDINE - nizatidine oral soln 15 mg/ml
3
nizatidine cap 150 mg
1
nizatidine cap 300 mg (Axid)
Dispensing Limits
1
3
methscopolamine bromide tab 5 mg (Pamine forte)
Step Therapy
1
ISOPROPAMIDE IODIDE isopropamide iodide powder
lansoprazole cap delayed release 30 mg (Prevacid)
Prior Authorization
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Drug Name
1
glycopyrrolate tab 1 mg (Robinul)
hyoscyamine sulfate soln 0.125 mg/ml
Prior Authorization
Drug Name
Drug Tier
2016
1
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
98
OMECLAMOX-PAK amoxicillin cap-clarithro tab w/ omepraz cap dr therapy pack
3
omeprazole cap delayed release 10 mg (Prilosec)
1
omeprazole cap delayed release 20 mg (Prilosec) omeprazole cap delayed release 40 mg (Prilosec) omeprazole-sodium bicarbonate cap 20-1100 mg (Zegerid) omeprazole-sodium bicarbonate cap 40-1100 mg (Zegerid) omeprazole-sodium bicarbonate powd pack for susp 20-1680 mg (Zegerid) omeprazole-sodium bicarbonate powd pack for susp 40-1680 mg (Zegerid)
PREVPAC - amoxicillin capclarithro tab-lansopraz cap dr therapy pack
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3
PROPANTHELINE BROMIDE - 3 propantheline bromide powder PROPANTHELINE BROMIDE - 2 propantheline bromide tab 15 mg 2 PROTONIX - pantoprazole sodium for delayed release susp packet 40 mg 3 PYLERA - bismuth subcitmetronidazole-tetracycline cap 140-125-125 mg 1 rabeprazole sodium ec tab 20 mg (Aciphex) 1 ranitidine hcl cap 150 mg
1 1 1
1
1
ranitidine hcl cap 300 mg
1
ranitidine hcl inj 50 mg/2ml (25 mg/ml) (Zantac)
PAMINE - methscopolamine bromide tab 2.5 mg
3
ranitidine hcl inj 150 mg/6ml (25 mg/ml) (Zantac)
PAMINE FORTE methscopolamine bromide tab 5 mg
3
ranitidine hcl syrup 15 mg/ ml (75 mg/5ml)
pantoprazole sodium ec tab 20 mg (base equiv) (Protonix)
1
pantoprazole sodium ec tab 40 mg (base equiv) (Protonix)
1
1 pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg (Donnatal) 3 PEPCID - famotidine for susp 40 mg/5ml PEPCID - famotidine tab 20 mg 3 PEPCID - famotidine tab 40 mg 3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1 1 1 1
ranitidine hcl tab 150 mg (Zantac)
1
ranitidine hcl tab 300 mg (Zantac)
1
ROBINUL - glycopyrrolate inj 0.2 mg/ml
3
ROBINUL - glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml)
3
ROBINUL - glycopyrrolate inj 1 mg/5ml (0.2 mg/ml)
3
ROBINUL - glycopyrrolate inj 4 mg/20ml (0.2 mg/ml)
3
ROBINUL - glycopyrrolate tab 1 mg
3
ROBINUL FORTE glycopyrrolate tab 2 mg
3
Products October (2016 Plan Year)
99
SCOPOLAMINE HBR scopolamine hbr powder
3
dronabinol cap 2.5 mg (Marinol)
1
SUCRALFATE - sucralfate powder
3
dronabinol cap 5 mg (Marinol)
1
sucralfate tab 1 gm (Carafate)
1
dronabinol cap 10 mg (Marinol)
1
SYMAX DUOTAB hyoscyamine sulfate tab er 0.375 mg (0.125 mg ir/0.25 mg er)
3
EMEND - aprepitant capsule 40 mg
2 3
ZANTAC - ranitidine hcl inj 50 mg/2ml (25 mg/ml)
3
EMEND - aprepitant capsule 80 mg
2
ZANTAC - ranitidine hcl inj 150 mg/6ml (25 mg/ml)
3
EMEND - aprepitant capsule 125 mg
2
ZANTAC - ranitidine hcl inj 1000 mg/40ml (25 mg/ml)
2
EMEND - aprepitant for oral susp 125 mg (125 mg/5ml)
3
ZANTAC - ranitidine hcl tab 150 mg
3
EMEND TRIPACK - aprepitant capsule therapy pack 80 & 125 mg
3
granisetron hcl tab 1 mg
1
ZANTAC - ranitidine hcl tab 300 mg ANTIEMETICS AKYNZEO - netupitantpalonosetron cap 300-0.5 mg
3
ANZEMET - dolasetron mesylate tab 50 mg
3
ANZEMET - dolasetron mesylate tab 100 mg
3
aprepitant capsule therapy pack 80 & 125 mg (Emend)
1
aprepitant capsule 40 mg (Emend)
1
aprepitant capsule 80 mg (Emend)
1
aprepitant capsule 125 mg (Emend)
1
CESAMET - nabilone cap 1 mg
3
DIMENHYDRINATE dimenhydrinate inj 50 mg/ml
3
MARINOL - dronabinol cap 2.5 mg
3
MARINOL - dronabinol cap 5 mg
3
MARINOL - dronabinol cap 10 mg
3
MECLIZINE HCL - meclizine hcl powder
3
MECLIZINE HCL MONOHYDRATE - meclizine hcl powder
3
meclizine hcl tab 12.5 mg
1
meclizine hcl tab 25 mg ondansetron hcl inj 4 mg/2ml (2 mg/ml)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1 1
ondansetron hcl inj 40 mg/20ml (2 mg/ml) (Zofran)
1
ondansetron hcl oral soln 4 mg/5ml (Zofran)
1
ondansetron hcl tab 4 mg (Zofran)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
Products October (2016 Plan Year)
100
ondansetron hcl tab 8 mg (Zofran)
1
ondansetron hcl tab 24 mg
1
CREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit
2
ondansetron orally disintegrating tab 4 mg (Zofran odt)
1
CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit
2
ondansetron orally disintegrating tab 8 mg (Zofran odt)
1
CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit
2
SANCUSO - granisetron td patch 3.1 mg/24hr (contains 34.3 mg)
3
CREON - pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit
2
scopolamine td patch 72hr 1 mg/3days (Transdermscop)
1
CREON - pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit
2
L-GLUTAMIC ACID HCL glutamic acid hcl powder
3
PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 2600-6200-10850 unit
3
PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 4200-14200-24600 unit
3
PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 10500-35500-61500 unit
3
PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 16800-56800-98400 unit
3
PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 21000-54700-83900 unit
3
PEPSIN - pepsin powder
3
PERTZYE - pancrelipase (lip-prot-amyl) dr cap 4000-14375-15125 unit
3
PERTZYE - pancrelipase (lip-prot-amyl) dr cap 8000-28750-30250 unit
3
PERTZYE - pancrelipase (lip-prot-amyl) dr cap 16000-57500-60500 unit
3
TIGAN - trimethobenzamide hcl 3 cap 300 mg TIGAN - trimethobenzamide hcl 3 inj 100 mg/ml 3 TRANSDERM-SCOP scopolamine td patch 72hr 1.5 mg 1 trimethobenzamide hcl cap 300 mg (Tigan) 3 VARUBI - rolapitant hcl tab 90 mg (base equiv) 3 ZOFRAN - ondansetron hcl oral soln 4 mg/5ml ZOFRAN - ondansetron hcl tab 3 4 mg ZOFRAN - ondansetron hcl tab 3 8 mg 3 ZOFRAN ODT - ondansetron orally disintegrating tab 4 mg 3 ZOFRAN ODT - ondansetron orally disintegrating tab 8 mg 3 ZUPLENZ - ondansetron oral soluble film 4 mg 3 ZUPLENZ - ondansetron oral soluble film 8 mg
•
DIGESTIVE AIDS SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
101
PERTZYE - pancrelipase (lip-prot-amyl) dr cap 24000-86250-90750 unit
3
SUCRAID - sacrosidase soln 8500 unit/ml
5
VIOKACE - pancrelipase (lip-prot-amyl) tab 10440-39150-39150 unit
3
VIOKACE - pancrelipase (lip-prot-amyl) tab 20880-78300-78300 unit
3
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit
2
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit
2
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit
2
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit
2
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit
2
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit
2
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 40000-136000-218000 unit
2
•
AMITIZA - lubiprostone cap 24 mcg
3
APRISO - mesalamine cap er 24hr 0.375 gm
3
ASACOL HD - mesalamine tab delayed release 800 mg
2
AURYXIA - ferric citrate tab 1 gm (210 mg ferric iron)
3
AZULFIDINE - sulfasalazine tab 500 mg
3
AZULFIDINE EN-TABS sulfasalazine tab delayed release 500 mg
3
balsalazide disodium cap 750 mg (Colazal)
1
calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo)
GASTROINTESTINAL AGENTS- MISC. 3 ACTIGALL - ursodiol cap 300 mg 1 alosetron hcl tab 0.5 mg (base equiv) (Lotronex) alosetron hcl tab 1 mg (base 1 equiv) (Lotronex) 3 AMITIZA - lubiprostone cap 8 mcg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
calcium acetate (phosphate binder) tab 667 mg (Eliphos)
1
CANASA - mesalamine suppos 1000 mg
2
CHENODAL - chenodiol tab 250 mg
4
•
CHOLBAM - cholic acid cap 50 mg
5
•
CHOLBAM - cholic acid cap 250 mg
5
•
CIMZIA - certolizumab pegol for inj kit 2 x 200 mg
5
•
•
•
CIMZIA - certolizumab pegol inj 5 kit 2 x 200 mg/ml 5 CIMZIA STARTER KIT certolizumab pegol inj kit 6 x 200 mg/ml 3 COLAZAL - balsalazide disodium cap 750 mg 1 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom)
•
•
•
•
•
•
Products October (2016 Plan Year)
102
DELZICOL - mesalamine cap dr 400 mg
2
LOTRONEX - alosetron hcl tab 0.5 mg (base equiv)
3
DIPENTUM - olsalazine sodium cap 250 mg
3
LOTRONEX - alosetron hcl tab 1 mg (base equiv)
3
ELIPHOS - calcium acetate (phosphate binder) tab 667 mg
3
MESALAMINE - mesalamine powder
3
3
MESALAMINE DR mesalamine tab delayed release 800 mg
3
ENTEREG - alvimopan cap 12 mg FOSRENOL - lanthanum carbonate chew tab 500 mg (elemental)
3
mesalamine enema 4 gm
1
FOSRENOL - lanthanum carbonate chew tab 750 mg (elemental)
3
FOSRENOL - lanthanum carbonate chew tab 1000 mg (elemental)
3
FOSRENOL - lanthanum carbonate oral powder pack 750 mg (elemental)
3
FOSRENOL - lanthanum carbonate oral powder pack 1000 mg (elemental)
3
GASTROCROM - cromolyn sodium oral conc 100 mg/5ml
3
metoclopramide hcl tab 10 mg (Reglan)
3
GATTEX - teduglutide (rdna) for inj kit 5 mg
5
METOCLOPRAMIDE ODT metoclopramide hcl orally disintegrating tab 5 mg
GIAZO - balsalazide disodium tab 1.1 gm
3
3
lactulose (encephalopathy) solution 10 gm/15ml
1
METOCLOPRAMIDE ODT metoclopramide hcl orally disintegrating tab 10 mg MOVANTIK - naloxegol oxalate tab 12.5 mg (base equivalent)
3
mesalamine tab delayed release 1.2 gm (Lialda)
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
METOCLOPRAMIDE HCL metoclopramide hcl powder
3
metoclopramide hcl inj 5 mg/ml
1
METOCLOPRAMIDE HCL MONOHY - metoclopramide hcl monohydrate powder
3
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)
1
metoclopramide hcl tab 5 mg (Reglan)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1
LIALDA - mesalamine tab delayed release 1.2 gm
2
LINZESS - linaclotide cap 72 mcg
2
MOVANTIK - naloxegol oxalate tab 25 mg (base equivalent)
3
LINZESS - linaclotide cap 145 mcg
2
OCALIVA - obeticholic acid tab 5 mg
5
•
•
•
LINZESS - linaclotide cap 290 mcg
2
OCALIVA - obeticholic acid tab 10 mg
5
•
•
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
103
PENTASA - mesalamine cap er 2 250 mg PENTASA - mesalamine cap er 2 500 mg 3 PHOSLYRA - calcium acetate (phosphate binder) oral soln 667 mg/5ml REGLAN - metoclopramide hcl 3 tab 5 mg REGLAN - metoclopramide hcl 3 tab 10 mg RELISTOR - methylnaltrexone 3 bromide inj 8 mg/0.4ml (20 mg/ml) RELISTOR - methylnaltrexone 3 bromide inj 12 mg/0.6ml (20 mg/ml) RENAGEL - sevelamer hcl tab 3 400 mg RENAGEL - sevelamer hcl tab 3 800 mg 2 RENVELA - sevelamer carbonate packet 0.8 gm 2 RENVELA - sevelamer carbonate packet 2.4 gm 2 RENVELA - sevelamer carbonate tab 800 mg 1 sevelamer carbonate packet 0.8 gm (Renvela) 1 sevelamer carbonate packet 2.4 gm (Renvela) 1 sevelamer carbonate tab 800 mg (Renvela) 3 SFROWASA - mesalamine sulfite-free (sf) enema 4 gm/60ml 3 SIMETHICONE - simethicone liquid 3 SULFASALAZINE sulfasalazine powder
sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)
1
sulfasalazine tab 500 mg (Azulfidine)
1
TRULANCE - plecanatide tab 3 mg
3
URSO FORTE - ursodiol tab 500 mg
3
URSO 250 - ursodiol tab 250 mg
3
ursodiol cap 300 mg (Actigall)
1
ursodiol tab 250 mg (Urso 250)
1
ursodiol tab 500 mg (Urso forte)
1
3 URSODIOL/SYRSPEND SF PH4 - ursodiol susp 30 mg/ml (compound kit) 2 VELPHORO - sucroferric oxyhydroxide chew tab 500 mg 2 VIBERZI - eluxadoline tab 75 mg VIBERZI - eluxadoline tab 100 2 mg XERMELO - telotristat etiprate 5 tab 250 mg (telotristat ethyl equiv) 3 5-AMINOSALICYLIC ACID mesalamine powder
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
GENITOURINARY AGENTS URINARY ANTI-INFECTIVES
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
FURADANTIN - nitrofurantoin susp 25 mg/5ml
3
HIPREX - methenamine hippurate tab 1 gm
3
MACROBID - nitrofurantoin monohydrate macrocrystalline cap 100 mg
3
Products October (2016 Plan Year)
104
MACRODANTIN nitrofurantoin macrocrystalline cap 25 mg
3
MACRODANTIN nitrofurantoin macrocrystalline cap 50 mg
3
3
NITROFURANTOIN MACROCRYST nitrofurantoin macrocrystal powder
1
MACRODANTIN nitrofurantoin macrocrystalline cap 100 mg
3
nitrofurantoin macrocrystalline cap 25 mg (Macrodantin)
methenamine hippurate tab 1 gm (Hiprex)
1
nitrofurantoin macrocrystalline cap 50 mg (Macrodantin)
3
methenamine mandelate tab 1 gm
1
nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)
1
nitrofurantoin susp 25 mg/5ml (Furadantin)
3
1
URIMAR-T - methenaminehyosc-meth blue-sod phosphen sal tab 120 mg
3
1
UROGESIC-BLUE methenamine-hyoscaminemeth blue-sod phos tab 81.6 mg
1
URINARY ANTISPASMODICS
methenamine-hyosc-meth blue-sod phos-phen sal cap 118 mg methenamine-hyosc-meth blue-sod phos-phen sal cap 120 mg methenamine-hyosc-meth blue-sod phos-phen sal tab 81 mg methenamine-hyoscaminemeth blue-sod phos cap 120 mg methenamine-hyoscaminemeth blue-sod phos tab 81.6 mg (Urogesic-blue)
1
MONUROL - fosfomycin tromethamine powd pack 3 gm (base equivalent)
3
NALIDIXIC ACID - nalidixic acid powder
3
bethanechol chloride tab 5 mg (Urecholine)
1
bethanechol chloride tab 50 mg (Urecholine) darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv) (Enablex) darifenacin hydrobromide tab er 24hr 15 mg (base equiv) (Enablex) SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
1
3
bethanechol chloride tab 25 mg (Urecholine)
1
1
BETHANECHOL CHLORIDE bethanechol chloride powder
bethanechol chloride tab 10 mg (Urecholine)
1
Dispensing Limits
1
METHENAMINE MANDELATE - methenamine mandelate tab 0.5 gm
methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6mg (Prosed/ds)
Step Therapy
1
nitrofurantoin macrocrystalline cap 100 mg (Macrodantin)
methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1
1
Products October (2016 Plan Year)
105
DETROL - tolterodine tartrate tab 1 mg
3
DETROL - tolterodine tartrate tab 2 mg
3
DETROL LA - tolterodine tartrate cap er 24hr 2 mg
3
DETROL LA - tolterodine tartrate cap er 24hr 4 mg
3
DITROPAN XL - oxybutynin chloride tab er 24hr 5 mg
3
DITROPAN XL - oxybutynin chloride tab er 24hr 10 mg
oxybutynin chloride tab 5 mg
3
tolterodine tartrate cap er 24hr 2 mg (Detrol la)
1
1
3
tolterodine tartrate tab 2 mg (Detrol)
1
DITROPAN XL - oxybutynin chloride tab er 24hr 15 mg
3
TOVIAZ - fesoterodine fumarate tab er 24hr 4 mg
3
ENABLEX - darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv)
3
TOVIAZ - fesoterodine fumarate tab er 24hr 8 mg
3
3
trospium chloride cap er 24hr 60 mg
1
ENABLEX - darifenacin hydrobromide tab er 24hr 15 mg (base equiv) flavoxate hcl tab 100 mg
1
GELNIQUE - oxybutynin chloride td gel 10%
3
GELNIQUE PUMP - oxybutynin 3 chloride td gel 10% MYRBETRIQ - mirabegron tab 2 er 24 hr 25 mg MYRBETRIQ - mirabegron tab 2 er 24 hr 50 mg 3 OXYBUTININ CHLORIDE oxybutynin chloride powder 1 oxybutynin chloride syrup 5 mg/5ml 1 oxybutynin chloride tab er 24hr 5 mg (Ditropan xl) 1 oxybutynin chloride tab er 24hr 10 mg (Ditropan xl) 1 oxybutynin chloride tab er 24hr 15 mg (Ditropan xl)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
1
URECHOLINE - bethanechol chloride tab 5 mg
3
URECHOLINE - bethanechol chloride tab 10 mg
3
URECHOLINE - bethanechol chloride tab 25 mg
3
URECHOLINE - bethanechol chloride tab 50 mg
3
VESICARE - solifenacin succinate tab 5 mg
2
VESICARE - solifenacin succinate tab 10 mg
2
VAGINAL PRODUCTS
Dispensing Limits
1
tolterodine tartrate tab 1 mg (Detrol)
trospium chloride tab 20 mg
Step Therapy
1
OXYTROL - oxybutynin td patch biweekly 3.9 mg/24hr
tolterodine tartrate cap er 24hr 4 mg (Detrol la)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
AVC - sulfanilamide vaginal cream 15%
3
CLEOCIN - clindamycin phosphate vaginal cream 2%
3
CLEOCIN - clindamycin phosphate vaginal suppos 100 mg
2
Products October (2016 Plan Year)
106
clindamycin phosphate vaginal cream 2% (Cleocin)
1
MICONAZOLE 3 - miconazole nitrate vaginal suppos 200 mg
3
nonoxynol-9 gel 4%
A
CLINDESSE - clindamycin phosphate (one dose) vaginal cream 2%
3
CRINONE - progesterone vaginal gel 4%
3
NUVESSA - metronidazole vaginal gel 1.3%
3
3
OPTIONS CONCEPTROL VAGINA - nonoxynol-9 gel 4%
A
CRINONE - progesterone vaginal gel 8%
•
OPTIONS GYNOL II VAGINAL - nonoxynol-9 gel 3%
A
•
PREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm
3
RELAGARD - acetic acidoxyquinoline vaginal gel 0.9-0.025%
3
SHUR-SEAL - nonoxynol-9 gel 2%
A
TERAZOL 7 - terconazole vaginal cream 0.4%
3
terconazole vaginal cream 0.4% (Terazol 7)
1
ENCARE - nonoxynol-9 vaginal A suppos 100 mg ENDOMETRIN - progesterone 3 vaginal insert 100 mg 2 ESTRACE - estradiol vaginal cream 0.1 mg/gm 3 ESTRING - estradiol vaginal ring 2 mg (7.5 mcg/24hrs) 3 FEM PH - acetic acidoxyquinoline vaginal gel 0.9-0.025% 3 FEMRING - estradiol acetate vaginal ring 0.05 mg/24hr 3 FEMRING - estradiol acetate vaginal ring 0.1 mg/24hr 3 FIRST-PROGESTERONE VGS 10 - progesterone vaginal suppository 100 mg 3 FIRST-PROGESTERONE VGS 20 - progesterone vaginal suppository 200 mg 3 GYNAZOLE-1 - butoconazole nitrate (one dose) vaginal cream 2% 3 METROGEL-VAGINAL metronidazole vaginal gel 0.75% 1 metronidazole vaginal gel 0.75% (Metrogel-vaginal) 1 miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit
•
terconazole vaginal cream 0.8% (Terazol 3) terconazole vaginal suppos 80 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
1 1
•
TODAY SPONGE nonoxynol-9 vaginal sponge 1000 mg
A
VAGIFEM - estradiol vaginal tab 10 mcg
1
VCF VAGINAL CONTRACEPTIVE nonoxynol-9 film 28%
A
•
VCF VAGINAL CONTRACEPTIVE nonoxynol-9 foam 12.5%
A
•
GENITOURINARY AGENTS - MISC.
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
107
acetic acid irrigation soln 0.25% alfuzosin hcl tab er 24hr 10 mg (Uroxatral)
1 1
NEOSPORIN GU IRRIGANT neomycin-polymyxin b gu irrigation soln
3
3
AVODART - dutasteride cap 0.5 mg
3
ORACIT - sodium citrate & citric acid soln 490-640 mg/5ml
CARDURA XL - doxazosin mesylate tab er 24 hr 4 mg (base equiv)
3
PHENAZOPYRIDINE HCL phenazopyridine hcl powder
3 1
CARDURA XL - doxazosin mesylate tab er 24 hr 8 mg (base equiv)
3
phenazopyridine hcl tab 100 mg (Pyridium)
CYSTAGON - cysteamine bitartrate cap 50 mg
4
•
CYSTAGON - cysteamine bitartrate cap 150 mg
4
•
dutasteride cap 0.5 mg (Avodart)
1
dutasteride-tamsulosin hcl cap 0.5-0.4 mg (JALYN)
phenazopyridine hcl tab 200 mg (Pyridium) pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1
POTASSIUM CITRATE potassium citrate powder
3 1
1
potassium citrate & citric acid powder pack 3300-1002 mg
ELMIRON - pentosan polysulfate sodium caps 100 mg
3
potassium citrate & citric acid soln 1100-334 mg/5ml
3
finasteride tab 5 mg (Proscar)
1
POTASSIUM CITRATE MONOHYD - potassium citrate granules
1
FLOMAX - tamsulosin hcl cap 0.4 mg
3
potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)
GLYCINE - glycine powder
3
GLYCINE (L) - glycine powder
3
glycine irrigation soln 1.5%
1
RAPAFLO - silodosin cap 8 mg
3
RENACIDIN - citric acidgluconolactone-magnesium carbonate soln
3
1
1 potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10) 1 potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15) 3 PROSCAR - finasteride tab 5 mg 3 PYRIDIUM - phenazopyridine hcl tab 100 mg 3 PYRIDIUM - phenazopyridine hcl tab 200 mg RAPAFLO - silodosin cap 4 mg 3
JALYN - dutasteride-tamsulosin 3 hcl cap 0.5-0.4 mg 2 K-PHOS NO 2 - potassium & sodium acid phosphates tab 305-700 mg LITHOSTAT - acetohydroxamic 3 acid tab 250 mg 1 neomycin-polymyxin b gu irrigation soln (Neosporin gu irrigan)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
108
RIMSO-50 - dimethyl sulfoxide soln 50%
3
alprazolam orally disintegrating tab 0.25 mg (Niravam)
1
SHOHLS SOLUTION MODIFIED - sodium citrate & citric acid soln 500-334 mg/5ml
3
alprazolam orally disintegrating tab 0.5 mg
1
sodium chloride irrigation soln 0.9%
1
alprazolam orally disintegrating tab 1 mg
SODIUM CITRATE - sodium citrate crystals
3
alprazolam orally disintegrating tab 2 mg
sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi)
1
alprazolam tab er 24hr 0.5 mg (Xanax xr)
SODIUM CITRATE ANHYDROUS - sodium citrate powder
3
SORBITOL - sorbitol irrigation soln 3%
1
3
alprazolam tab er 24hr 3 mg (Xanax xr)
1
SORBITOL - sorbitol irrigation soln 3.3%
3
alprazolam tab 0.25 mg (Xanax)
1
SORBITOL-MANNITOL sorbitol-mannitol irrigation soln 2.7-0.54 gm/100ml
3
alprazolam tab 0.5 mg (Xanax)
1
alprazolam tab 1 mg (Xanax)
1
tamsulosin hcl cap 0.4 mg
1
UROCIT-K 10 - potassium citrate tab er 10 meq (1080 mg)
3
UROCIT-K 15 - potassium citrate tab er 15 meq (1620 mg)
3
UROCIT-K 5 - potassium citrate tab er 5 meq (540 mg)
3
UROXATRAL - alfuzosin hcl tab er 24hr 10 mg
3
•
Limited Distribution
1
ATIVAN - lorazepam inj 2 mg/ ml
3
ATIVAN - lorazepam inj 4 mg/ ml
3
ATIVAN - lorazepam tab 0.5 mg 3 3 ATIVAN - lorazepam tab 1 mg ATIVAN - lorazepam tab 2 mg
3
buspirone hcl tab 5 mg
1
buspirone hcl tab 7.5 mg buspirone hcl tab 10 mg buspirone hcl tab 15 mg
CENTRAL NERVOUS SYSTEM DRUGS
buspirone hcl tab 30 mg
ANTIANXIETY AGENTS
chlordiazepoxide hcl cap 5 mg
ALPRAZOLAM INTENSOL alprazolam conc 1 mg/ml
ACA
1
alprazolam tab er 24hr 2 mg (Xanax xr)
3
Dispensing Limits
1
1
THIOLA - tiopronin tab 100 mg
Step Therapy
1
alprazolam tab er 24hr 1 mg (Xanax xr)
alprazolam tab 2 mg (Xanax)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3
chlordiazepoxide hcl cap 10 mg SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1 1 1 1 1 1
Products October (2016 Plan Year)
109
chlordiazepoxide hcl cap 25 mg
1
hydroxyzine pamoate cap 50 mg (Vistaril)
1
1
lorazepam inj 2 mg/ml (Ativan)
1
1
lorazepam inj 4 mg/ml (Ativan)
1
DIAZEPAM - diazepam im solution auto-inj 10 mg/2ml
3
lorazepam tab 0.5 mg (Ativan)
1
DIAZEPAM - diazepam inj 5 mg/ml
3
lorazepam tab 1 mg (Ativan)
1
DIAZEPAM - diazepam oral soln 1 mg/ml
2
diazepam conc 5 mg/ml
1
clorazepate dipotassium tab 7.5 mg (Tranxene t) clorazepate dipotassium tab 15 mg (Tranxene t)
diazepam tab 2 mg (Valium) diazepam tab 5 mg (Valium) diazepam tab 10 mg (Valium)
1
lorazepam tab 2 mg (Ativan) meprobamate tab 200 mg meprobamate tab 400 mg oxazepam cap 10 mg
1
oxazepam cap 15 mg
1
oxazepam cap 30 mg
1
DROPERIDOL - droperidol powder
3
droperidol inj 2.5 mg/ml
1
1 1 1
TRANXENE T - clorazepate dipotassium tab 7.5 mg
3
VALIUM - diazepam tab 2 mg
3
VALIUM - diazepam tab 5 mg
3
VALIUM - diazepam tab 10 mg
3 3
hydroxyzine hcl im soln 50 mg/ml
1
3
1
VISTARIL - hydroxyzine pamoate cap 50 mg
3
1
XANAX - alprazolam tab 0.25 mg XANAX - alprazolam tab 0.5 mg
3
XANAX - alprazolam tab 1 mg
3
XANAX - alprazolam tab 2 mg
3
XANAX XR - alprazolam tab er 24hr 0.5 mg
3
XANAX XR - alprazolam tab er 24hr 1 mg
3
XANAX XR - alprazolam tab er 24hr 2 mg
3
hydroxyzine hcl tab 50 mg
1 1
HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100 mg
2
HYDROXYZINE PAMOATE hydroxyzine pamoate powder
3
hydroxyzine pamoate cap 25 mg (Vistaril)
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
1
VISTARIL - hydroxyzine pamoate cap 25 mg
hydroxyzine hcl tab 25 mg
ACA
1
3
hydroxyzine hcl tab 10 mg
Dispensing Limits
1
HYDROXYZINE HCL hydroxyzine hcl im soln 25 mg/ml
hydroxyzine hcl syrup 10 mg/5ml
Step Therapy
1
lorazepam conc 2 mg/ml (Lorazepam intensol)
clorazepate dipotassium tab 3.75 mg (Tranxene t)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
110
XANAX XR - alprazolam tab er 24hr 3 mg ANTIDEPRESSANTS
3
bupropion hcl tab er 24hr 300 mg (Wellbutrin xl)
1
AMITRIPTYLINE HCL amitriptyline hcl powder
3
1
amitriptyline hcl tab 10 mg
1
bupropion hcl tab 100 mg (Wellbutrin) CELEXA - citalopram hydrobromide tab 10 mg (base equiv)
3
•
CELEXA - citalopram hydrobromide tab 20 mg (base equiv)
3
•
CELEXA - citalopram hydrobromide tab 40 mg (base equiv)
3
•
citalopram hydrobromide oral soln 10 mg/5ml
1
amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg
1 1 1 1 1
AMOXAPINE - amoxapine tab 25 mg
3
AMOXAPINE - amoxapine tab 50 mg
3
AMOXAPINE - amoxapine tab 100 mg
3
AMOXAPINE - amoxapine tab 150 mg
3
ANAFRANIL - clomipramine hcl 3 cap 25 mg ANAFRANIL - clomipramine hcl 3 cap 50 mg ANAFRANIL - clomipramine hcl 3 cap 75 mg APLENZIN - bupropion hbr tab 3 er 24hr 174 mg APLENZIN - bupropion hbr tab 3 er 24hr 348 mg APLENZIN - bupropion hbr tab 3 er 24hr 522 mg 1 bupropion hcl tab er 12hr 100 mg (Wellbutrin sr) 1 bupropion hcl tab er 12hr 150 mg (Wellbutrin sr) 1 bupropion hcl tab er 12hr 200 mg (Wellbutrin sr) 1 bupropion hcl tab er 24hr 150 mg (Wellbutrin xl)
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
•
clomipramine hcl cap 50 mg (Anafranil)
1
•
clomipramine hcl cap 75 mg (Anafranil)
1
CYMBALTA - duloxetine hcl enteric coated pellets cap 20 mg
3
•
CYMBALTA - duloxetine hcl enteric coated pellets cap 30 mg
3
•
CYMBALTA - duloxetine hcl enteric coated pellets cap 60 mg
3
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
1
bupropion hcl tab 75 mg (Wellbutrin)
amitriptyline hcl tab 25 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
111
DESIPRAMINE HCL desipramine hcl powder
3
desipramine hcl tab 10 mg (Norpramin)
1
desipramine hcl tab 25 mg (Norpramin)
1
desipramine hcl tab 50 mg (Norpramin)
1
desipramine hcl tab 75 mg (Norpramin)
1
desipramine hcl tab 100 mg (Norpramin)
1
desipramine hcl tab 150 mg (Norpramin)
1
DESVENLAFAXINE ER desvenlafaxine tab er 24hr 50 mg
3
•
DESVENLAFAXINE ER desvenlafaxine tab er 24hr 100 mg
3
•
desvenlafaxine succinate tab er 24hr 25 mg (base equiv) (Pristiq)
1
desvenlafaxine succinate tab er 24hr 50 mg (base equiv) (Pristiq) desvenlafaxine succinate tab er 24hr 100 mg (base equiv) (Pristiq)
DOXEPIN HCL - doxepin hcl powder
3
doxepin hcl cap 10 mg
1
doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl conc 10 mg/ml
1 1 1 1 1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
3
duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta)
1
duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta)
1
duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta)
1
EFFEXOR XR - venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)
3
•
EFFEXOR XR - venlafaxine hcl cap er 24hr 75 mg (base equivalent)
3
•
EFFEXOR XR - venlafaxine hcl cap er 24hr 150 mg (base equivalent)
3
•
ELAVIL - amitriptyline hcl tab 25 mg
3
EMSAM - selegiline td patch 24hr 6 mg/24hr
3
EMSAM - selegiline td patch 24hr 9 mg/24hr
3
EMSAM - selegiline td patch 24hr 12 mg/24hr
3
escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro)
1
escitalopram oxalate tab 5 mg (base equiv) (Lexapro)
1
escitalopram oxalate tab 10 mg (base equiv) (Lexapro)
1
escitalopram oxalate tab 20 mg (base equiv) (Lexapro)
1
Products October (2016 Plan Year)
Limited Distribution
ACA
•
DULOXETINE HCL duloxetine hcl enteric coated pellets cap 40 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
1
2
doxepin hcl cap 50 mg
Drug Name
1
DOXEPIN HCL - doxepin hcl cap 75 mg
doxepin hcl cap 25 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
112
3
FETZIMA - levomilnacipran hcl cap er 24hr 40 mg (base equivalent)
3
•
FETZIMA - levomilnacipran hcl cap er 24hr 80 mg (base equivalent)
3
•
FETZIMA - levomilnacipran hcl cap er 24hr 120 mg (base equivalent)
3
•
FETZIMA TITRATION PACK levomilnacipran hcl cap er 24hr 20 & 40 mg therapy pack
3
•
FLUOXETINE DR - fluoxetine hcl cap delayed release 90 mg
3
•
FLUOXETINE HCL - fluoxetine hcl tab 60 mg
3
•
fluoxetine hcl cap 10 mg (Prozac)
1
fluoxetine hcl cap 20 mg (Prozac)
1
fluoxetine hcl cap 40 mg (Prozac)
1
fluoxetine hcl solution 20 mg/5ml
1
fluoxetine hcl tab 10 mg fluoxetine hcl tab 20 mg fluvoxamine maleate cap er 24hr 100 mg fluvoxamine maleate cap er 24hr 150 mg fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg fluvoxamine maleate tab 100 mg
FORFIVO XL - bupropion hcl tab er 24hr 450 mg
3
IMIPRAMINE HCL - imipramine 3 hcl powder 1 imipramine hcl tab 10 mg (Tofranil) 1 imipramine hcl tab 25 mg (Tofranil) 1 imipramine hcl tab 50 mg (Tofranil) 1 imipramine pamoate cap 75 mg (Tofranil-pm) 1 imipramine pamoate cap 100 mg (Tofranil-pm) 1 imipramine pamoate cap 125 mg (Tofranil-pm) 1 imipramine pamoate cap 150 mg (Tofranil-pm) 3 KHEDEZLA - desvenlafaxine tab er 24hr 50 mg 3 KHEDEZLA - desvenlafaxine tab er 24hr 100 mg 3 LEXAPRO - escitalopram oxalate tab 5 mg (base equiv) 3 LEXAPRO - escitalopram oxalate tab 10 mg (base equiv) 3 LEXAPRO - escitalopram oxalate tab 20 mg (base equiv) 3 MAPROTILINE HCL maprotiline hcl tab 25 mg 3 MAPROTILINE HCL maprotiline hcl tab 50 mg 3 MAPROTILINE HCL maprotiline hcl tab 75 mg MARPLAN - isocarboxazid tab 3 10 mg
1 1 1 1 1 1 1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
•
FETZIMA - levomilnacipran hcl cap er 24hr 20 mg (base equivalent)
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • • • • • • •
113
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 7.5 mg
1
mirtazapine tab 15 mg (Remeron)
1
mirtazapine tab 30 mg (Remeron)
1
mirtazapine tab 45 mg (Remeron)
1
NARDIL - phenelzine sulfate tab 15 mg
3
NEFAZODONE HCL nefazodone hcl tab 100 mg
3
NEFAZODONE HCL nefazodone hcl tab 150 mg
3
NEFAZODONE HCL nefazodone hcl tab 200 mg
3
nefazodone hcl tab 50 mg
1
nefazodone hcl tab 250 mg
nortriptyline hcl cap 50 mg (Pamelor)
1
nortriptyline hcl cap 75 mg (Pamelor)
1
PAMELOR - nortriptyline hcl cap 10 mg
3
PAMELOR - nortriptyline hcl cap 25 mg
3
PAMELOR - nortriptyline hcl cap 50 mg
3
PAMELOR - nortriptyline hcl cap 75 mg
3
PARNATE - tranylcypromine sulfate tab 10 mg
3
paroxetine hcl tab er 24hr 12.5 mg (Paxil cr)
1
paroxetine hcl tab er 24hr 25 mg (Paxil cr) paroxetine hcl tab er 24hr 37.5 mg (Paxil cr)
1
NORPRAMIN - desipramine hcl 3 tab 10 mg NORPRAMIN - desipramine hcl 3 tab 25 mg 3 NORTRIPTYLINE HCL nortriptyline hcl powder 2 NORTRIPTYLINE HCL nortriptyline hcl soln 10 mg/5ml 1 nortriptyline hcl cap 10 mg (Pamelor) 1 nortriptyline hcl cap 25 mg (Pamelor)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1
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
PAXIL - paroxetine hcl oral susp 10 mg/5ml (base equiv)
3
•
PAXIL - paroxetine hcl tab 10 mg
3
•
PAXIL - paroxetine hcl tab 20 mg
3
•
PAXIL - paroxetine hcl tab 30 mg
3
•
PAXIL - paroxetine hcl tab 40 mg
3
•
PAXIL CR - paroxetine hcl tab er 24hr 12.5 mg
3
•
Products October (2016 Plan Year)
114
PEXEVA - paroxetine mesylate tab 20 mg (base equiv)
3
•
PEXEVA - paroxetine mesylate tab 30 mg (base equiv)
3
•
PEXEVA - paroxetine mesylate tab 40 mg (base equiv)
3
•
phenelzine sulfate tab 15 mg (Nardil)
1
PRISTIQ - desvenlafaxine succinate tab er 24hr 25 mg (base equiv)
3
•
PRISTIQ - desvenlafaxine succinate tab er 24hr 50 mg (base equiv)
3
•
PRISTIQ - desvenlafaxine succinate tab er 24hr 100 mg (base equiv)
3
protriptyline hcl tab 5 mg (Vivactil)
1
protriptyline hcl tab 10 mg (Vivactil)
1
PROZAC - fluoxetine hcl cap 10 mg
3
•
PROZAC - fluoxetine hcl cap 20 mg
3
•
PROZAC - fluoxetine hcl cap 40 mg
3
•
REMERON - mirtazapine tab 15 mg
3
•
REMERON - mirtazapine tab 30 mg
3
•
REMERON - mirtazapine tab 45 mg
3
•
•
•
REMERON SOLTAB mirtazapine orally disintegrating tab 30 mg
3
•
REMERON SOLTAB mirtazapine orally disintegrating tab 45 mg
3
•
sertraline hcl oral conc 20 mg/ml (Zoloft)
1
sertraline hcl tab 25 mg (Zoloft)
1
sertraline hcl tab 50 mg (Zoloft)
1
sertraline hcl tab 100 mg (Zoloft)
1
SURMONTIL - trimipramine maleate cap 25 mg
3
SURMONTIL - trimipramine maleate cap 50 mg
3
SURMONTIL - trimipramine maleate cap 100 mg
3
Limited Distribution
•
3
ACA
PEXEVA - paroxetine mesylate tab 10 mg (base equiv)
3
REMERON SOLTAB mirtazapine orally disintegrating tab 15 mg
Dispensing Limits
•
Step Therapy
3
Prior Authorization
PAXIL CR - paroxetine hcl tab er 24hr 37.5 mg
Drug Name
Drug Tier
•
Limited Distribution
3
ACA
PAXIL CR - paroxetine hcl tab er 24hr 25 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
TOFRANIL - imipramine hcl tab 3 10 mg TOFRANIL - imipramine hcl tab 3 25 mg TOFRANIL - imipramine hcl tab 3 50 mg 1 tranylcypromine sulfate tab 10 mg (Parnate) TRAZODONE HCL - trazodone 3 hcl powder 1 trazodone hcl tab 50 mg trazodone hcl tab 100 mg trazodone hcl tab 150 mg trazodone hcl tab 300 mg TRIMIPRAMINE MALEATE trimipramine maleate powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1 1 1 3
Products October (2016 Plan Year)
115
trimipramine maleate cap 25 mg (Surmontil) trimipramine maleate cap 50 mg (Surmontil) trimipramine maleate cap 100 mg (Surmontil)
1
venlafaxine hcl tab 25 mg venlafaxine hcl tab 37.5 mg
1
venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg
1
venlafaxine hcl tab 100 mg
1 1 1
•
VIIBRYD - vilazodone hcl tab 10 mg
3
•
TRINTELLIX - vortioxetine hbr tab 10 mg (base equiv)
3
•
VIIBRYD - vilazodone hcl tab 20 mg
3
•
TRINTELLIX - vortioxetine hbr tab 20 mg (base equiv)
3
•
VIIBRYD - vilazodone hcl tab 40 mg
3
•
venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) (Effexor xr)
1
VIIBRYD STARTER PACK vilazodone hcl tab starter kit 10 (7) & 20 (23) mg
3
•
venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr)
1
WELLBUTRIN SR - bupropion hcl tab er 12hr 100 mg
3
•
3
1
•
venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Effexor xr)
WELLBUTRIN SR - bupropion hcl tab er 12hr 150 mg
3
•
VENLAFAXINE HCL ER venlafaxine hcl tab er 24hr 37.5 mg (base equivalent)
3
WELLBUTRIN SR - bupropion hcl tab er 12hr 200 mg WELLBUTRIN XL - bupropion hcl tab er 24hr 150 mg
3
•
WELLBUTRIN XL - bupropion hcl tab er 24hr 300 mg
3
VENLAFAXINE HCL ER venlafaxine hcl tab er 24hr 75 mg (base equivalent)
3
•
3
•
VENLAFAXINE HCL ER venlafaxine hcl tab er 24hr 150 mg (base equivalent)
3
ZOLOFT - sertraline hcl oral conc 20 mg/ml ZOLOFT - sertraline hcl tab 25 mg
3
•
venlafaxine hcl tab er 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er)
1
ZOLOFT - sertraline hcl tab 50 mg
3
•
3
•
venlafaxine hcl tab er 24hr 75 mg (base equivalent) (Venlafaxine hcl er)
1
ZOLOFT - sertraline hcl tab 100 mg
venlafaxine hcl tab er 24hr 150 mg (base equivalent) (Venlafaxine hcl er)
1
venlafaxine hcl tab er 24hr 225 mg (base equivalent)
1
•
Limited Distribution
1
3
•
ACA
1
TRINTELLIX - vortioxetine hbr tab 5 mg (base equiv)
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ANTIPSYCHOTICS
ABILIFY - aripiprazole tab 2 mg 3 ABILIFY - aripiprazole tab 5 mg 3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
ABILIFY - aripiprazole tab 10 mg
3
ABILIFY - aripiprazole tab 15 mg
3
Products October (2016 Plan Year)
116
ABILIFY - aripiprazole tab 20 mg
3
ABILIFY - aripiprazole tab 30 mg
3
ABILIFY MAINTENA aripiprazole im for extended release susp 300 mg
3
ABILIFY MAINTENA aripiprazole im for extended release susp 400 mg
3
ADASUVE - loxapine aerosol powder breath activated 10 mg
3
aripiprazole oral solution 1 mg/ml
1
chlorpromazine hcl tab 50 mg
1
chlorpromazine hcl tab 100 mg
1
chlorpromazine hcl tab 200 mg
1
CLOZAPINE ODT - clozapine orally disintegrating tab 12.5 mg
3
CLOZAPINE ODT - clozapine orally disintegrating tab 150 mg
3
CLOZAPINE ODT - clozapine orally disintegrating tab 200 mg
3
clozapine orally disintegrating tab 25 mg (Fazaclo)
1
clozapine orally disintegrating tab 100 mg (Fazaclo)
1
clozapine tab 25 mg (Clozaril)
1
clozapine tab 50 mg
1
aripiprazole orally disintegrating tab 10 mg aripiprazole orally disintegrating tab 15 mg aripiprazole tab 2 mg (Abilify) aripiprazole tab 5 mg (Abilify)
1
aripiprazole tab 15 mg (Abilify)
1
aripiprazole tab 20 mg (Abilify)
1
aripiprazole tab 30 mg (Abilify)
1
ARISTADA - aripiprazole lauroxil im er susp prefilled syr 441 mg/1.6ml
3
ARISTADA - aripiprazole lauroxil im er susp prefilled syr 662 mg/2.4ml
3
ARISTADA - aripiprazole lauroxil im er susp prefilled syr 882 mg/3.2ml
3
ARISTADA - aripiprazole lauroxil im er susp prefilled syr 1064 mg/3.9ml
3
3
CHLORPROMAZINE HCL chlorpromazine hcl inj 50 mg/2ml
3
CHLORPROMAZINE HCL chlorpromazine hcl powder
3
chlorpromazine hcl tab 10 mg
1
chlorpromazine hcl tab 25 mg
1
aripiprazole tab 10 mg (Abilify)
CHLORPROMAZINE HCL chlorpromazine hcl inj 25 mg/ml
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1 1 1 1
clozapine tab 100 mg (Clozaril)
1
clozapine tab 200 mg
1
CLOZARIL - clozapine tab 25 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3
Products October (2016 Plan Year)
117
CLOZARIL - clozapine tab 100 mg
3
EQUETRO - carbamazepine (antipsychotic) cap er 12hr 100 mg
3
3
FLUPHENAZINE HCL fluphenazine hcl inj 2.5 mg/ ml
2
EQUETRO - carbamazepine (antipsychotic) cap er 12hr 200 mg
3
FLUPHENAZINE HCL fluphenazine hcl oral conc 5 mg/ml fluphenazine hcl tab 1 mg
1
EQUETRO - carbamazepine (antipsychotic) cap er 12hr 300 mg
3
FANAPT - iloperidone tab 1 mg
3
FANAPT - iloperidone tab 2 mg
3
FANAPT - iloperidone tab 4 mg
3
FANAPT - iloperidone tab 6 mg
3
FANAPT - iloperidone tab 8 mg
3
FANAPT - iloperidone tab 10 mg
fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg fluphenazine hcl tab 10 mg
3
GEODON - ziprasidone hcl cap 60 mg
3
3
GEODON - ziprasidone hcl cap 80 mg
3
FANAPT - iloperidone tab 12 mg
3
3
FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg & 4 mg & 6 mg titration pak
3
GEODON - ziprasidone mesylate for inj 20 mg (base equivalent) HALDOL - haloperidol lactate inj 5 mg/ml
3
FAZACLO - clozapine orally disintegrating tab 12.5 mg
3
3
FAZACLO - clozapine orally disintegrating tab 25 mg
3
HALDOL DECANOATE 100 haloperidol decanoate im soln 100 mg/ml
3
FAZACLO - clozapine orally disintegrating tab 100 mg
3
HALDOL DECANOATE 50 haloperidol decanoate im soln 50 mg/ml
FAZACLO - clozapine orally disintegrating tab 150 mg
3
HALOPERIDOL - haloperidol powder
3
FAZACLO - clozapine orally disintegrating tab 200 mg
3
1
fluphenazine decanoate inj 25 mg/ml
1
haloperidol decanoate im soln 50 mg/ml (Haldol decanoate 50) haloperidol decanoate im soln 100 mg/ml (Haldol decanoate 100)
1
haloperidol lactate inj 5 mg/ ml (Haldol)
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
1
GEODON - ziprasidone hcl cap 40 mg
haloperidol lactate oral conc 2 mg/ml
Dispensing Limits
1 3
2
Step Therapy
1
GEODON - ziprasidone hcl cap 20 mg
FLUPHENAZINE HCL fluphenazine hcl elixir 2.5 mg/5ml
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
Products October (2016 Plan Year)
118
haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 2 mg haloperidol tab 5 mg haloperidol tab 10 mg haloperidol tab 20 mg
1 1 1 1 1 3
INVEGA - paliperidone tab er 24hr 3 mg
3
INVEGA - paliperidone tab er 24hr 6 mg
3
INVEGA - paliperidone tab er 24hr 9 mg
3
INVEGA SUSTENNA paliperidone palmitate im extend-release susp 117 mg/0.75ml
3
INVEGA SUSTENNA paliperidone palmitate im extended-release susp 39 mg/0.25ml
3
INVEGA SUSTENNA paliperidone palmitate im extended-release susp 78 mg/0.5ml
3
INVEGA SUSTENNA paliperidone palmitate im extended-release susp 156 mg/ml
3
INVEGA SUSTENNA paliperidone palmitate im extended-release susp 234 mg/1.5ml
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
INVEGA TRINZA - paliperidone 3 palmitate im extend-release susp 546 mg/1.75ml INVEGA TRINZA - paliperidone 3 palmitate im extend-release susp 819 mg/2.625ml LATUDA - lurasidone hcl tab 20 3 mg LATUDA - lurasidone hcl tab 40 3 mg LATUDA - lurasidone hcl tab 60 3 mg LATUDA - lurasidone hcl tab 80 3 mg 3 LATUDA - lurasidone hcl tab 120 mg LITHIUM - lithium oral solution 2 8 meq/5ml 2 LITHIUM CARBONATE lithium carbonate cap 150 mg 3 LITHIUM CARBONATE lithium carbonate cap 600 mg 3 LITHIUM CARBONATE lithium carbonate powder 1 lithium carbonate cap 150 mg (Lithium carbonate) 1 lithium carbonate cap 300 mg 1 lithium carbonate cap 600 mg (Lithium carbonate) 1 lithium carbonate tab er 300 mg (Lithobid) 1 lithium carbonate tab er 450 mg 1 lithium carbonate tab 300 mg 3 LITHOBID - lithium carbonate tab er 300 mg loxapine succinate cap 5 mg 1
1
INVEGA - paliperidone tab er 24hr 1.5 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
INVEGA TRINZA - paliperidone 3 palmitate im extend-release susp 273 mg/0.875ml INVEGA TRINZA - paliperidone 3 palmitate im extend-release susp 410 mg/1.315ml
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
119
loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 50 mg
1
paliperidone tab er 24hr 9 mg (Invega)
1
perphenazine tab 2 mg perphenazine tab 4 mg
1
perphenazine tab 8 mg
•
•
perphenazine tab 16 mg
•
NUPLAZID - pimavanserin tartrate tab 17 mg (base equivalent)
3
olanzapine for im inj 10 mg (Zyprexa)
1
olanzapine orally disintegrating tab 5 mg (Zyprexa zydis)
1
olanzapine orally disintegrating tab 10 mg (Zyprexa zydis)
1
olanzapine orally disintegrating tab 15 mg (Zyprexa zydis)
1
olanzapine orally disintegrating tab 20 mg (Zyprexa zydis)
1
olanzapine tab 2.5 mg (Zyprexa)
1
quetiapine fumarate tab er 24hr 200 mg (Seroquel xr)
olanzapine tab 5 mg (Zyprexa)
1
quetiapine fumarate tab er 24hr 300 mg (Seroquel xr)
olanzapine tab 7.5 mg (Zyprexa)
1
quetiapine fumarate tab er 24hr 400 mg (Seroquel xr)
olanzapine tab 10 mg (Zyprexa)
1
quetiapine fumarate tab 25 mg (Seroquel)
olanzapine tab 15 mg (Zyprexa)
1
quetiapine fumarate tab 50 mg (Seroquel)
olanzapine tab 20 mg (Zyprexa)
1
quetiapine fumarate tab 100 mg (Seroquel)
paliperidone tab er 24hr 1.5 mg (Invega)
1
quetiapine fumarate tab 200 mg (Seroquel)
1
quetiapine fumarate tab 300 mg (Seroquel)
1
quetiapine fumarate tab 400 mg (Seroquel)
paliperidone tab er 24hr 3 mg (Invega) paliperidone tab er 24hr 6 mg (Invega)
prochlorperazine edisylate inj 5 mg/ml
Limited Distribution
ACA
Dispensing Limits
1 1 1
1
quetiapine fumarate tab er 24hr 150 mg (Seroquel xr)
Step Therapy
1
prochlorperazine maleate tab 5 mg (Compazine)
quetiapine fumarate tab er 24hr 50 mg (Seroquel xr)
SM
1
3
prochlorperazine suppos 25 mg
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1
PROCHLORPERAZINE MALEATE - prochlorperazine maleate powder
prochlorperazine maleate tab 10 mg (Compazine)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1 1 1 1 1 1 1 1 1
Products October (2016 Plan Year)
120
REXULTI - brexpiprazole tab 0.25 mg
3
REXULTI - brexpiprazole tab 0.5 mg
3
REXULTI - brexpiprazole tab 1 mg
3
REXULTI - brexpiprazole tab 2 mg
3
REXULTI - brexpiprazole tab 3 mg
3
REXULTI - brexpiprazole tab 4 mg
3
RISPERDAL - risperidone soln 1 mg/ml
3
RISPERDAL - risperidone tab 0.25 mg
3
RISPERDAL - risperidone tab 0.5 mg
3
RISPERDAL - risperidone tab 1 3 mg RISPERDAL - risperidone tab 2 3 mg RISPERDAL - risperidone tab 3 3 mg RISPERDAL - risperidone tab 4 3 mg 3 RISPERDAL CONSTA risperidone microspheres for inj 12.5 mg 3 RISPERDAL CONSTA risperidone microspheres for inj 25 mg 3 RISPERDAL CONSTA risperidone microspheres for inj 37.5 mg 3 RISPERDAL CONSTA risperidone microspheres for inj 50 mg 3 RISPERDAL M-TAB risperidone orally disintegrating tab 0.5 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
RISPERDAL M-TAB risperidone orally disintegrating tab 1 mg
3
RISPERDAL M-TAB risperidone orally disintegrating tab 2 mg
3
RISPERDAL M-TAB risperidone orally disintegrating tab 3 mg
3
RISPERDAL M-TAB risperidone orally disintegrating tab 4 mg
3
risperidone orally disintegrating tab 0.25 mg
1
risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab)
1
risperidone orally disintegrating tab 1 mg (Risperdal m-tab)
1
risperidone orally disintegrating tab 2 mg (Risperdal m-tab)
1
risperidone orally disintegrating tab 3 mg (Risperdal m-tab)
1
risperidone orally disintegrating tab 4 mg (Risperdal m-tab)
1
risperidone soln 1 mg/ml (Risperdal)
1
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
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
121
risperidone tab 4 mg (Risperdal)
1
SAPHRIS - asenapine maleate sl tab 2.5 mg (base equiv)
3
SAPHRIS - asenapine maleate sl tab 5 mg (base equiv)
3
SAPHRIS - asenapine maleate sl tab 10 mg (base equiv)
3
SEROQUEL - quetiapine fumarate tab 25 mg
3
SEROQUEL - quetiapine fumarate tab 50 mg
3
SEROQUEL - quetiapine fumarate tab 100 mg
3
SEROQUEL - quetiapine fumarate tab 200 mg
3
SEROQUEL - quetiapine fumarate tab 300 mg
3
SEROQUEL - quetiapine fumarate tab 400 mg
3
SEROQUEL XR - quetiapine fumarate tab er 24hr 50 mg
3
SEROQUEL XR - quetiapine fumarate tab er 24hr 150 mg
3
SEROQUEL XR - quetiapine fumarate tab er 24hr 200 mg
3
SEROQUEL XR - quetiapine fumarate tab er 24hr 300 mg
3
SEROQUEL XR - quetiapine fumarate tab er 24hr 400 mg
3
thioridazine hcl tab 10 mg
1
thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg thioridazine hcl tab 100 mg thiothixene cap 1 mg thiothixene cap 2 mg thiothixene cap 5 mg thiothixene cap 10 mg trifluoperazine hcl tab 1 mg
trifluoperazine hcl tab 2 mg trifluoperazine hcl tab 5 mg trifluoperazine hcl tab 10 mg
1 1 1 1 1 1 1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1
VERSACLOZ - clozapine susp 50 mg/ml
3
VRAYLAR - cariprazine hcl cap therapy pack 1.5 mg (1) & 3 mg (6)
3
VRAYLAR - cariprazine hcl cap 1.5 mg (base equivalent)
3
VRAYLAR - cariprazine hcl cap 3 mg (base equivalent)
3
VRAYLAR - cariprazine hcl cap 4.5 mg (base equivalent)
3
VRAYLAR - cariprazine hcl cap 6 mg (base equivalent)
3
ziprasidone hcl cap 20 mg (Geodon)
1
ziprasidone hcl cap 40 mg (Geodon)
1
ziprasidone hcl cap 60 mg (Geodon)
1
ziprasidone hcl cap 80 mg (Geodon)
1
ZYPREXA - olanzapine for im inj 10 mg
3
ZYPREXA - olanzapine tab 2.5 mg
3
ZYPREXA - olanzapine tab 5 mg
3
ZYPREXA - olanzapine tab 7.5 mg
3
ZYPREXA - olanzapine tab 10 mg
3
ZYPREXA - olanzapine tab 15 mg
3
ZYPREXA - olanzapine tab 20 mg
3
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
122
ZYPREXA RELPREVV olanzapine pamoate for extended rel im susp 210 mg (base eq)
3
ZYPREXA RELPREVV olanzapine pamoate for extended rel im susp 300 mg (base eq)
3
ZYPREXA RELPREVV olanzapine pamoate for extended rel im susp 405 mg (base eq)
3
ZYPREXA ZYDIS - olanzapine orally disintegrating tab 5 mg
3
ZYPREXA ZYDIS - olanzapine orally disintegrating tab 10 mg
3
ZYPREXA ZYDIS - olanzapine orally disintegrating tab 15 mg
3
ZYPREXA ZYDIS - olanzapine orally disintegrating tab 20 mg
3
HYPNOTICS
BELSOMRA - suvorexant tab 20 mg
3
BUTISOL SODIUM butabarbital sodium tab 30 mg
3
CHLORAL HYDRATE - chloral hydrate crystals
3
DORAL - quazepam tab 15 mg
3
EDLUAR - zolpidem tartrate sl tab 5 mg
3
EDLUAR - zolpidem tartrate sl tab 10 mg
3
estazolam tab 1 mg
1
estazolam tab 2 mg eszopiclone tab 1 mg (Lunesta)
1
eszopiclone tab 2 mg (Lunesta)
1
eszopiclone tab 3 mg (Lunesta)
1
FLURAZEPAM HCL flurazepam hcl cap 15 mg
3
3
FLURAZEPAM HCL flurazepam hcl cap 30 mg
3
AMBIEN - zolpidem tartrate tab 10 mg
3
HALCION - triazolam tab 0.25 mg
3
AMBIEN CR - zolpidem tartrate tab er 6.25 mg
3
AMBIEN CR - zolpidem tartrate tab er 12.5 mg
3
AMYTAL SODIUM amobarbital sodium for inj 500 mg
3
BELSOMRA - suvorexant tab 5 mg
3
BELSOMRA - suvorexant tab 10 mg
3
BELSOMRA - suvorexant tab 15 mg
3
HETLIOZ - tasimelteon capsule 3 20 mg 3 INTERMEZZO - zolpidem tartrate sl tab 1.75 mg 3 INTERMEZZO - zolpidem tartrate sl tab 3.5 mg 3 LUNESTA - eszopiclone tab 1 mg 3 LUNESTA - eszopiclone tab 2 mg 3 LUNESTA - eszopiclone tab 3 mg
SM
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
AMBIEN - zolpidem tartrate tab 5 mg
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
•
•
•
123
NEMBUTAL SODIUM pentobarbital sodium inj 50 mg/ml
3
RESTORIL - temazepam cap 22.5 mg
3
RESTORIL - temazepam cap 30 mg
3
PENTOBARBITAL SODIUM pentobarbital sodium powder
3
ROZEREM - ramelteon tab 8 mg
3
pentobarbital sodium inj 50 mg/ml (Nembutal sodium)
1
3
PHENOBARBITAL phenobarbital powder
3
SECONAL SODIUM secobarbital sodium cap 100 mg SILENOR - doxepin hcl (sleep) tab 3 mg (base equiv)
3
PHENOBARBITAL phenobarbital tab 15 mg
3
SILENOR - doxepin hcl (sleep) tab 6 mg (base equiv)
3
PHENOBARBITAL phenobarbital tab 30 mg
3
SONATA - zaleplon cap 5 mg
3
PHENOBARBITAL phenobarbital tab 60 mg
3
SONATA - zaleplon cap 10 mg
3
PHENOBARBITAL phenobarbital tab 100 mg
3
temazepam cap 7.5 mg (Restoril)
1
phenobarbital elixir 20 mg/5ml
1
temazepam cap 15 mg (Restoril)
1
PHENOBARBITAL SODIUM phenobarbital sodium inj 65 mg/ml
3
temazepam cap 22.5 mg (Restoril)
1 1
PHENOBARBITAL SODIUM phenobarbital sodium inj 130 mg/ml
3
temazepam cap 30 mg (Restoril) TRIAZOLAM - triazolam tab 0.125 mg
3
PHENOBARBITAL SODIUM phenobarbital sodium powder
3
triazolam tab 0.25 mg (Halcion)
1 1
phenobarbital tab 16.2 mg
1
zaleplon cap 5 mg (Sonata)
phenobarbital tab 32.4 mg phenobarbital tab 64.8 mg phenobarbital tab 97.2 mg
zaleplon cap 10 mg (Sonata)
1
zolpidem tartrate sl tab 1.75 mg (Intermezzo)
1
zolpidem tartrate sl tab 3.5 mg (Intermezzo)
1
QUAZEPAM - quazepam tab 15 mg
3
RESTORIL - temazepam cap 7.5 mg
3
RESTORIL - temazepam cap 15 mg
3
zolpidem tartrate tab er 6.25 mg (Ambien cr) zolpidem tartrate tab er 12.5 mg (Ambien cr) zolpidem tartrate tab 5 mg (Ambien)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1 1
Products October (2016 Plan Year)
124
zolpidem tartrate tab 10 mg (Ambien)
1
ZOLPIMIST - zolpidem tartrate oral spray 5 mg/act
3
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ ANOREXIANTS 3 ADDERALL - amphetaminedextroamphetamine tab 5 mg 3 ADDERALL - amphetaminedextroamphetamine tab 7.5 mg 3 ADDERALL - amphetaminedextroamphetamine tab 10 mg 3 ADDERALL - amphetaminedextroamphetamine tab 12.5 mg 3 ADDERALL - amphetaminedextroamphetamine tab 15 mg 3 ADDERALL - amphetaminedextroamphetamine tab 20 mg 3 ADDERALL - amphetaminedextroamphetamine tab 30 mg 3 ADDERALL XR amphetaminedextroamphetamine cap er 24hr 5 mg 3 ADDERALL XR amphetaminedextroamphetamine cap er 24hr 10 mg 3 ADDERALL XR amphetaminedextroamphetamine cap er 24hr 15 mg 3 ADDERALL XR amphetaminedextroamphetamine cap er 24hr 20 mg
ADDERALL XR amphetaminedextroamphetamine cap er 24hr 25 mg
3
ADDERALL XR amphetaminedextroamphetamine cap er 24hr 30 mg
3
ADZENYS XR-ODT amphetamine tab extended release disintegrating 3.1 mg
3
ADZENYS XR-ODT amphetamine tab extended release disintegrating 6.3 mg
3
ADZENYS XR-ODT amphetamine tab extended release disintegrating 9.4 mg
3
ADZENYS XR-ODT amphetamine tab extended release disintegrating 12.5 mg
3
ADZENYS XR-ODT amphetamine tab extended release disintegrating 15.7 mg
3
ADZENYS XR-ODT amphetamine tab extended release disintegrating 18.8 mg
3
amphetaminedextroamphetamine cap er 24hr 5 mg (Adderall xr)
1
amphetaminedextroamphetamine cap er 24hr 10 mg (Adderall xr) amphetaminedextroamphetamine cap er 24hr 15 mg (Adderall xr) amphetaminedextroamphetamine cap er 24hr 20 mg (Adderall xr)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
Products October (2016 Plan Year)
125
amphetaminedextroamphetamine cap er 24hr 25 mg (Adderall xr) amphetaminedextroamphetamine cap er 24hr 30 mg (Adderall xr) amphetaminedextroamphetamine tab 5 mg (Adderall) amphetaminedextroamphetamine tab 7.5 mg (Adderall) amphetaminedextroamphetamine tab 10 mg (Adderall) amphetaminedextroamphetamine tab 12.5 mg (Adderall) amphetaminedextroamphetamine tab 15 mg (Adderall) amphetaminedextroamphetamine tab 20 mg (Adderall) amphetaminedextroamphetamine tab 30 mg (Adderall)
1
APTENSIO XR methylphenidate hcl cap er 24hr 50 mg (xr)
3
1
APTENSIO XR methylphenidate hcl cap er 24hr 60 mg (xr)
3
1
armodafinil tab 50 mg (Nuvigil)
1
armodafinil tab 150 mg (Nuvigil)
1
armodafinil tab 200 mg (Nuvigil)
1
armodafinil tab 250 mg (Nuvigil)
1
atomoxetine hcl cap 10 mg (base equiv) (Strattera)
1
1
1
1
atomoxetine hcl cap 18 mg (base equiv) (Strattera)
1
atomoxetine hcl cap 25 mg (base equiv) (Strattera) atomoxetine hcl cap 40 mg (base equiv) (Strattera)
1
atomoxetine hcl cap 60 mg (base equiv) (Strattera)
1
atomoxetine hcl cap 80 mg (base equiv) (Strattera)
Limited Distribution
ACA
1 1 1
3
CAFFEINE ANHYDROUS caffeine powder
3
APTENSIO XR methylphenidate hcl cap er 24hr 15 mg (xr)
1
APTENSIO XR methylphenidate hcl cap er 24hr 20 mg (xr)
3
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) (Cafcit)
APTENSIO XR methylphenidate hcl cap er 24hr 30 mg (xr)
3
APTENSIO XR methylphenidate hcl cap er 24hr 40 mg (xr)
3
SM
Dispensing Limits
1
3
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Step Therapy
1
APTENSIO XR methylphenidate hcl cap er 24hr 10 mg (xr)
atomoxetine hcl cap 100 mg (base equiv) (Strattera)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
CAFFEINE CITRATED caffeine citrate powder
3
CAFFEINE/SODIUM BENZOATE - caffeine & sodium benzoate inj 125-125 mg/ml (500 mg/2ml)
3
clonidine hcl tab er 12hr 0.1 mg (Kapvay)
1
Products October (2016 Plan Year)
126
CONCERTA - methylphenidate hcl tab er osmotic release (osm) 18 mg
3
CONCERTA - methylphenidate hcl tab er osmotic release (osm) 27 mg
3
CONCERTA - methylphenidate hcl tab er osmotic release (osm) 36 mg
3
CONCERTA - methylphenidate hcl tab er osmotic release (osm) 54 mg
3
DAYTRANA - methylphenidate td patch 10 mg/9hr
3
DAYTRANA - methylphenidate td patch 15 mg/9hr
3
DAYTRANA - methylphenidate td patch 20 mg/9hr
3
DAYTRANA - methylphenidate td patch 30 mg/9hr
3
DESOXYN methamphetamine hcl tab 5 mg
3
DEXEDRINE dextroamphetamine sulfate cap er 24hr 5 mg
3
DEXEDRINE dextroamphetamine sulfate cap er 24hr 10 mg
3
DEXEDRINE dextroamphetamine sulfate cap er 24hr 15 mg
3
dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr)
1
dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin xr) dexmethylphenidate hcl cap er 24 hr 15 mg (Focalin xr) dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin xr)
dexmethylphenidate hcl cap er 24 hr 25 mg (Focalin xr) dexmethylphenidate hcl cap er 24 hr 30 mg (Focalin xr) dexmethylphenidate hcl cap er 24 hr 35 mg (Focalin xr) dexmethylphenidate hcl cap er 24 hr 40 mg (Focalin xr) dexmethylphenidate hcl tab 2.5 mg (Focalin) dexmethylphenidate hcl tab 5 mg (Focalin) dexmethylphenidate hcl tab 10 mg (Focalin)
Limited Distribution
1 1 1 1 1
dextroamphetamine sulfate cap er 24hr 10 mg (Dexedrine)
1
dextroamphetamine sulfate cap er 24hr 15 mg (Dexedrine)
1
dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra)
1
dextroamphetamine sulfate tab 5 mg
1 1
1
EVEKEO - amphetamine sulfate tab 5 mg
3
1
EVEKEO - amphetamine sulfate tab 10 mg
3
FOCALIN dexmethylphenidate hcl tab 2.5 mg
3
SM
ACA
1
3
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Dispensing Limits
1
DYANAVEL XR - amphetamine extended release susp 2.5 mg/ml
1
Step Therapy
1
dextroamphetamine sulfate cap er 24hr 5 mg (Dexedrine)
dextroamphetamine sulfate tab 10 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
127
FOCALIN dexmethylphenidate hcl tab 5 mg
3
FOCALIN dexmethylphenidate hcl tab 10 mg
3
FOCALIN XR dexmethylphenidate hcl cap er 24 hr 5 mg
3
FOCALIN XR dexmethylphenidate hcl cap er 24 hr 10 mg
3
FOCALIN XR dexmethylphenidate hcl cap er 24 hr 15 mg
3
FOCALIN XR dexmethylphenidate hcl cap er 24 hr 20 mg
3
FOCALIN XR dexmethylphenidate hcl cap er 24 hr 25 mg
3
FOCALIN XR dexmethylphenidate hcl cap er 24 hr 30 mg
3
FOCALIN XR dexmethylphenidate hcl cap er 24 hr 35 mg
3
FOCALIN XR dexmethylphenidate hcl cap er 24 hr 40 mg
3
guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv)
1
guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv) guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv) guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv)
3
3
KAPVAY - clonidine hcl tab er 12hr 0.1 mg
3
methamphetamine hcl tab 5 mg (Desoxyn)
1
METHYLIN - methylphenidate hcl soln 5 mg/5ml
3
METHYLIN - methylphenidate hcl soln 10 mg/5ml
3
METHYLPHENIDATE HCL methylphenidate hcl chew tab 2.5 mg
3
METHYLPHENIDATE HCL methylphenidate hcl chew tab 5 mg
3
METHYLPHENIDATE HCL methylphenidate hcl chew tab 10 mg
3
methylphenidate hcl cap er 10 mg (cd)
1
methylphenidate hcl cap er 40 mg (cd) methylphenidate hcl cap er 50 mg (cd) methylphenidate hcl cap er 60 mg (cd) methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin la)
1
INTUNIV - guanfacine hcl tab er 24hr 2 mg (base equiv)
INTUNIV - guanfacine hcl tab er 24hr 4 mg (base equiv)
methylphenidate hcl cap er 30 mg (cd)
1
3
3
methylphenidate hcl cap er 20 mg (cd)
1
INTUNIV - guanfacine hcl tab er 24hr 1 mg (base equiv)
INTUNIV - guanfacine hcl tab er 24hr 3 mg (base equiv)
methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin la) methylphenidate hcl cap er 24hr 40 mg (la) (Ritalin la)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1 1 1 1
Products October (2016 Plan Year)
128
METHYLPHENIDATE HCL ER - methylphenidate hcl tab er 24hr 18 mg
3
METHYLPHENIDATE HCL ER - methylphenidate hcl tab er 24hr 27 mg
3
METHYLPHENIDATE HCL ER - methylphenidate hcl tab er 24hr 36 mg
3
METHYLPHENIDATE HCL ER - methylphenidate hcl tab er 24hr 54 mg
3
METHYLPHENIDATE HCL ER (L - methylphenidate hcl cap er 24hr 60 mg (la)
3
methylphenidate hcl soln 5 mg/5ml (Methylin)
1
methylphenidate hcl soln 10 mg/5ml (Methylin) methylphenidate hcl tab er osmotic release (osm) 18 mg (Concerta) methylphenidate hcl tab er osmotic release (osm) 27 mg (Concerta) methylphenidate hcl tab er osmotic release (osm) 36 mg (Concerta) methylphenidate hcl tab er osmotic release (osm) 54 mg (Concerta) methylphenidate hcl tab er 10 mg methylphenidate hcl tab er 20 mg methylphenidate hcl tab 5 mg (Ritalin) methylphenidate hcl tab 10 mg (Ritalin) methylphenidate hcl tab 20 mg (Ritalin)
1 1
1
1
1
1 1 1 1 1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
modafinil tab 100 mg (Provigil)
1
modafinil tab 200 mg (Provigil)
1
NUVIGIL - armodafinil tab 50 mg
3
NUVIGIL - armodafinil tab 150 mg
3
NUVIGIL - armodafinil tab 200 mg
3
NUVIGIL - armodafinil tab 250 mg
3
PROCENTRA dextroamphetamine sulfate oral solution 5 mg/5ml
3
PROVIGIL - modafinil tab 100 mg
3
PROVIGIL - modafinil tab 200 mg
3
QUILLICHEW ER methylphenidate hcl chew tab extended release 20 mg
3
QUILLICHEW ER methylphenidate hcl chew tab extended release 30 mg
3
QUILLICHEW ER methylphenidate hcl chew tab extended release 40 mg
3
QUILLIVANT XR methylphenidate hcl for er susp 25 mg/5ml (5 mg/ml)
3
RITALIN - methylphenidate hcl tab 5 mg
3
RITALIN - methylphenidate hcl tab 10 mg
3
RITALIN - methylphenidate hcl tab 20 mg
3
RITALIN LA - methylphenidate hcl cap er 24hr 10 mg (la)
3
RITALIN LA - methylphenidate hcl cap er 24hr 20 mg (la)
3
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
129
RITALIN LA - methylphenidate hcl cap er 24hr 30 mg (la)
3
VYVANSE - lisdexamfetamine dimesylate chew tab 50 mg
2
RITALIN LA - methylphenidate hcl cap er 24hr 40 mg (la)
3
VYVANSE - lisdexamfetamine dimesylate chew tab 60 mg
2
STRATTERA - atomoxetine hcl cap 10 mg (base equiv)
3
STRATTERA - atomoxetine hcl cap 18 mg (base equiv)
3
STRATTERA - atomoxetine hcl cap 25 mg (base equiv)
3
STRATTERA - atomoxetine hcl cap 40 mg (base equiv)
3
STRATTERA - atomoxetine hcl cap 60 mg (base equiv)
3
ZENZEDI - dextroamphetamine 3 sulfate tab 2.5 mg ZENZEDI - dextroamphetamine 3 sulfate tab 7.5 mg ZENZEDI - dextroamphetamine 3 sulfate tab 15 mg ZENZEDI - dextroamphetamine 3 sulfate tab 20 mg ZENZEDI - dextroamphetamine 3 sulfate tab 30 mg
STRATTERA - atomoxetine hcl cap 80 mg (base equiv)
3
STRATTERA - atomoxetine hcl cap 100 mg (base equiv)
3
VYVANSE - lisdexamfetamine dimesylate cap 10 mg
2
VYVANSE - lisdexamfetamine dimesylate cap 20 mg
2
VYVANSE - lisdexamfetamine dimesylate cap 30 mg
2
VYVANSE - lisdexamfetamine dimesylate cap 40 mg
2
VYVANSE - lisdexamfetamine dimesylate cap 50 mg
2
VYVANSE - lisdexamfetamine dimesylate cap 60 mg
2
VYVANSE - lisdexamfetamine dimesylate cap 70 mg
2
VYVANSE - lisdexamfetamine dimesylate chew tab 10 mg
2
VYVANSE - lisdexamfetamine dimesylate chew tab 20 mg
2
VYVANSE - lisdexamfetamine dimesylate chew tab 30 mg
2
VYVANSE - lisdexamfetamine dimesylate chew tab 40 mg
2
PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS - MISC. 1 acamprosate calcium tab delayed release 333 mg (Campral) • AMPYRA - dalfampridine tab er 5 • 12hr 10 mg 3 ANTABUSE - disulfiram tab 250 mg 3 ANTABUSE - disulfiram tab 500 mg 3 ARICEPT - donepezil hydrochloride tab 5 mg 3 ARICEPT - donepezil hydrochloride tab 10 mg 3 ARICEPT - donepezil hydrochloride tab 23 mg • AUBAGIO - teriflunomide tab 7 4 • mg 4 • • AUBAGIO - teriflunomide tab 14 mg AUSTEDO - deutetrabenazine 5 tab 6 mg AUSTEDO - deutetrabenazine 5 tab 9 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
• • • •
130
AUSTEDO - deutetrabenazine tab 12 mg
5
AVONEX - interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial)
4
AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml
4
AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml
COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml
4
•
•
•
disulfiram tab 250 mg (Antabuse)
1
disulfiram tab 500 mg (Antabuse)
1
donepezil hydrochloride orally disintegrating tab 5 mg
1
•
•
•
•
•
•
4
•
•
•
BETASERON - interferon beta-1b for inj kit 0.3 mg
4
•
•
•
BRISDELLE - paroxetine mesylate cap 7.5 mg (base equiv)
3
bupropion hcl (smoking deterrent) tab er 12hr 150 mg (Zyban)
A
•
CHANTIX - varenicline tartrate tab 0.5 mg (base equiv)
A
•
donepezil hydrochloride tab 10 mg (Aricept)
CHANTIX - varenicline tartrate tab 1 mg (base equiv)
A
•
donepezil hydrochloride tab 23 mg (Aricept)
•
ERGOLOID MESYLATES ergoloid mesylates tab 1 mg
3
CHANTIX CONTINUING MONTH - varenicline tartrate tab 1 mg (base equiv)
A
3
CHANTIX STARTING MONTH PA - varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack
A
EXELON - rivastigmine td patch 24hr 4.6 mg/24hr EXELON - rivastigmine td patch 24hr 9.5 mg/24hr
3 3
CHLORDIAZEPOXIDE/ AMITRIPT chlordiazepoxideamitriptyline tab 5-12.5 mg
3
EXELON - rivastigmine td patch 24hr 13.3 mg/24hr EXTAVIA - interferon beta-1b for inj kit 0.3 mg
5 3
CHLORDIAZEPOXIDE/ AMITRIPT chlordiazepoxideamitriptyline tab 10-25 mg
3
FLUOXETINE - fluoxetine hcl (pmdd) cap 10 mg FLUOXETINE - fluoxetine hcl (pmdd) cap 20 mg
3
A
•
fluoxetine hcl (pmdd) tab 10 mg (Sarafem)
1
COMMIT - nicotine polacrilex lozenge 2 mg COMMIT - nicotine polacrilex lozenge 4 mg
A
•
fluoxetine hcl (pmdd) tab 20 mg (Sarafem)
donepezil hydrochloride orally disintegrating tab 10 mg (Aricept odt) donepezil hydrochloride tab 5 mg (Aricept)
SM
Limited Distribution
•
•
•
ACA
4
•
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Dispensing Limits
COPAXONE - glatiramer acetate soln prefilled syringe 20 mg/ml
•
•
Step Therapy
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
1
1 1 1
1
Products October (2016 Plan Year)
131
GALANTAMINE HYDROBROMIDE galantamine hydrobromide oral soln 4 mg/ml
3
galantamine hydrobromide cap er 24hr 8 mg (Razadyne er)
1
galantamine hydrobromide cap er 24hr 16 mg (Razadyne er)
1
galantamine hydrobromide cap er 24hr 24 mg (Razadyne er)
1
galantamine hydrobromide tab 4 mg (Razadyne)
1
galantamine hydrobromide tab 8 mg (Razadyne) galantamine hydrobromide tab 12 mg (Razadyne)
1 4
•
•
•
glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone)
4
•
•
•
INGREZZA - valbenazine tosylate cap 40 mg (base equiv)
5
•
•
•
memantine hcl oral solution 2 mg/ml (Namenda)
1
memantine hcl tab 5 mg (Namenda)
1
memantine hcl tab 10 mg (Namenda)
1
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak (Namenda titration pa)
1
NAMENDA - memantine hcl tab 5 mg
3
NAMENDA - memantine hcl tab 10 mg
3
3
NAMENDA XR - memantine hcl cap er 24hr 7 mg
3
NAMENDA XR - memantine hcl cap er 24hr 14 mg
3
NAMENDA XR - memantine hcl cap er 24hr 21 mg
3
NAMENDA XR - memantine hcl cap er 24hr 28 mg
3
3 NAMENDA XR TITRATION PACK - memantine hcl cap er 24hr 7 mg & 14 mg & 21 mg & 28 mg pack 3 NAMZARIC - memantine hcldonepezil hcl cap er 24hr 7-10 mg 3 NAMZARIC - memantine hcldonepezil hcl cap er 24hr 14-10 mg 3 NAMZARIC - memantine hcldonepezil hcl cap er 24hr 21-10 mg 3 NAMZARIC - memantine hcldonepezil hcl cap er 24hr 28-10 mg 3 NAMZARIC - memantinedonepezil cap er 24hr 7 & 14 & 21 & 28-10 mg pack A NICODERM CQ - nicotine td patch 24hr 7 mg/24hr A NICODERM CQ - nicotine td patch 24hr 14 mg/24hr A NICODERM CQ - nicotine td patch 24hr 21 mg/24hr A NICORETTE - nicotine polacrilex gum 2 mg A NICORETTE - nicotine polacrilex gum 4 mg
1
GILENYA - fingolimod hcl cap 0.5 mg (base equiv)
NAMENDA TITRATION PAK memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • • • •
132
NICORETTE MINI - nicotine polacrilex lozenge 2 mg
A
•
NICORETTE MINI - nicotine polacrilex lozenge 4 mg
A
•
NICORETTE STARTER KIT nicotine polacrilex gum 2 mg
A
•
NICORETTE STARTER KIT nicotine polacrilex gum 4 mg
A
•
nicotine polacrilex gum 2 mg
A
•
A
•
A
•
A
•
A
•
A
•
A
•
NICOTINE TRANSDERMAL SYST - nicotine td patch 24 hr kit 21-14-7 mg/24hr
A
•
NICOTROL INHALER nicotine inhaler system 10 mg (4 mg delivered)
A
•
NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/ spray)
A
NUEDEXTA dextromethorphan hbrquinidine sulfate cap 20-10 mg
2
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)
1
nicotine polacrilex gum 4 mg nicotine polacrilex lozenge 2 mg nicotine polacrilex lozenge 4 mg nicotine td patch 24hr 7 mg/24hr nicotine td patch 24hr 14 mg/24hr nicotine td patch 24hr 21 mg/24hr
olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax) olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax) olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1 1 1 1
ORAP - pimozide tab 1 mg
3
ORAP - pimozide tab 2 mg
3
PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 2-10 mg
3
PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 2-25 mg
3
PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 4-10 mg
3
PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 4-25 mg
3
PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 4-50 mg
3
pimozide tab 1 mg (Orap)
1
pimozide tab 2 mg (Orap)
Limited Distribution
•
ACA
A
Dispensing Limits
NICORETTE - nicotine polacrilex lozenge 4 mg
olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
NICORETTE - nicotine polacrilex lozenge 2 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml
4
•
•
•
PLEGRIDY - peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml
4
•
•
•
PLEGRIDY STARTER PACK peginterferon beta-1a soln pen-inj 63 & 94 mcg/0.5ml pack
4
•
•
•
Products October (2016 Plan Year)
133
PLEGRIDY STARTER PACK peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack
4
RAZADYNE - galantamine hydrobromide tab 4 mg
3
RAZADYNE - galantamine hydrobromide tab 8 mg
3
RAZADYNE - galantamine hydrobromide tab 12 mg
3
RAZADYNE ER - galantamine hydrobromide cap er 24hr 8 mg
3
RAZADYNE ER - galantamine hydrobromide cap er 24hr 16 mg
3
RAZADYNE ER - galantamine hydrobromide cap er 24hr 24 mg
3
REBIF - interferon beta-1a soln pref syr 22 mcg/0.5ml (12mu/ml)
4
REBIF - interferon beta-1a soln pref syr 44 mcg/0.5ml (24mu/ml)
4
REBIF REBIDOSE - interferon beta-1a soln auto-inj 22 mcg/0.5ml (12mu/ml)
rivastigmine tartrate cap 3 mg (Exelon) rivastigmine tartrate cap 4.5 mg (Exelon) rivastigmine tartrate cap 6 mg (Exelon) rivastigmine td patch 24hr 4.6 mg/24hr (Exelon) rivastigmine td patch 24hr 9.5 mg/24hr (Exelon) rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)
•
•
•
•
•
•
4
•
•
•
REBIF REBIDOSE - interferon beta-1a soln auto-inj 44 mcg/0.5ml (24mu/ml)
4
•
•
•
REBIF REBIDOSE TITRATION - interferon beta-1a auto-inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml
4
•
•
•
REBIF TITRATION PACK interferon beta-1a pref syr 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml
4
rivastigmine tartrate cap 1.5 mg (Exelon)
1
•
•
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1 1
SARAFEM - fluoxetine hcl (pmdd) tab 10 mg
3
SARAFEM - fluoxetine hcl (pmdd) tab 20 mg
3
SAVELLA - milnacipran hcl tab 12.5 mg
3
SAVELLA - milnacipran hcl tab 25 mg
3
SAVELLA - milnacipran hcl tab 50 mg
3
SAVELLA - milnacipran hcl tab 100 mg
3
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak
3
SYMBYAX - olanzapinefluoxetine hcl cap 3-25 mg
3
SYMBYAX - olanzapinefluoxetine hcl cap 6-25 mg
3
SYMBYAX - olanzapinefluoxetine hcl cap 6-50 mg
3
SYMBYAX - olanzapinefluoxetine hcl cap 12-25 mg
3
SYMBYAX - olanzapinefluoxetine hcl cap 12-50 mg
3
TECFIDERA - dimethyl fumarate capsule delayed release 120 mg
4
Products October (2016 Plan Year)
•
•
•
134
BUFFERIN - aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg
A
•
BUFFERIN LOW DOSE aspirin buffered (ca carb-mg carb-mg ox) tab 81 mg
A
•
•
butalbital-acetaminophen tab 50-300 mg
1
4
•
butalbital-acetaminophen tab 50-325 mg
•
XENAZINE - tetrabenazine tab 25 mg
5
•
butalbital-acetaminophencaffeine cap 50-300-40 mg (Fioricet)
1
XENAZINE - tetrabenazine tab 12.5 mg
5
1
XYREM - sodium oxybate oral solution 500 mg/ml
5
•
•
•
butalbital-acetaminophencaffeine cap 50-325-40 mg
ZINBRYTA - daclizumab soln prefilled syringe 150 mg/ml
5
•
•
•
ZYBAN - bupropion hcl (smoking deterrent) tab er 12hr 150 mg
A
•
•
•
ANALGESICS AND ANESTHETICS ANALGESICS - NON-NARCOTIC 3 ACETYL SALICYLIC ACID aspirin powder 3 ALLZITAL - butalbitalacetaminophen tab 25-325 mg 3 ASPIRIN - aspirin powder aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg aspirin chew tab 81 mg aspirin tab delayed release 81 mg aspirin tab delayed release 325 mg aspirin tab 325 mg
1
butalbital-acetaminophencaffeine tab 50-325-40 mg (Esgic)
1
butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)
1
BUTALBITAL/ASPIRIN/ CAFFEI - butalbital-aspirincaffeine tab 50-325-40 mg
3
choline & magnesium salicylates liq 500 mg/5ml
1
clonidine hcl inj (for epidural infusion) 100 mcg/ml (Duraclon)
1
clonidine hcl inj (for epidural infusion) 500 mcg/ml (Duraclon)
1
diflunisal tab 500 mg
1
A
•
A
• •
DURACLON - clonidine hcl inj (for epidural infusion) 100 mcg/ml
3
A
•
3
A
•
DURACLON - clonidine hcl inj (for epidural infusion) 500 mcg/ml DURAXIN - acetaminophensalicylamidephenyltoloxamine cap 300-200-20mg
3
A
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
tetrabenazine tab 25 mg (Xenazine)
ACA
4
Dispensing Limits
tetrabenazine tab 12.5 mg (Xenazine)
Step Therapy
•
•
Prior Authorization
4
Drug Name
Drug Tier
TECFIDERA STARTER PACK - dimethyl fumarate capsule dr starter pack 120 mg & 240 mg
•
Limited Distribution
•
ACA
4
Dispensing Limits
TECFIDERA - dimethyl fumarate capsule delayed release 240 mg
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
135
ECOTRIN REGULAR STRENGTH - aspirin tab delayed release 325 mg
A
ESGIC - butalbitalacetaminophen-caffeine tab 50-325-40 mg
3
FIORICET - butalbitalacetaminophen-caffeine cap 50-300-40 mg
3
FIORINAL - butalbital-aspirincaffeine cap 50-325-40 mg
3
LEVACET - aspirin-apapsalicylamide-caffeine tab 500-250-150-32.5 mg
3
PRIALT - ziconotide acetate intrathecal inj 500 mcg/20ml (25 mcg/ml)
3
PRIALT - ziconotide acetate intrathecal inj 100 mcg/ml
3
PRIALT - ziconotide acetate intrathecal inj 500 mcg/5ml
3
salsalate tab 500 mg
1
salsalate tab 750 mg
3
SODIUM SALICYLATE sodium salicylate powder
3
TENCON - butalbitalacetaminophen tab 50-325 mg
3
VANATOL LQ - butalbitalacetaminophen-caffeine soln 50-325-40 mg/15ml
3
VANATOL S - butalbitalacetaminophen-caffeine soln 50-325-40 mg/15ml
3
ABSTRAL - fentanyl citrate sl tab 300 mcg (base equiv)
3
ABSTRAL - fentanyl citrate sl tab 400 mcg (base equiv)
3
ABSTRAL - fentanyl citrate sl tab 600 mcg (base equiv)
3
ABSTRAL - fentanyl citrate sl tab 800 mcg (base equiv)
3
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
ACETAMINOPHEN/ CAFFEINE/DI acetaminophen-caffeinedihydrocodeine cap 320.5-30-16 mg
3
ACETAMINOPHEN/ CAFFEINE/DI acetaminophen-caffeinedihydrocodeine tab 325-30-16 mg
3
ACTIQ - fentanyl citrate lollipop 200 mcg
3
ACTIQ - fentanyl citrate lollipop 400 mcg
3
ACTIQ - fentanyl citrate lollipop 600 mcg
3
ACTIQ - fentanyl citrate lollipop 800 mcg
3
ABSTRAL - fentanyl citrate sl tab 100 mcg (base equiv)
3
ACTIQ - fentanyl citrate lollipop 1200 mcg
3
ABSTRAL - fentanyl citrate sl tab 200 mcg (base equiv)
3
ACTIQ - fentanyl citrate lollipop 1600 mcg
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
Drug Name
1
SODIUM SALICYLATE sodium salicylate crystals
ANALGESICS - NARCOTIC
Prior Authorization
Drug Name
Drug Tier
2016
136
3
•
BUPRENORPHINE buprenorphine td patch weekly 20 mcg/hr
3
•
buprenorphine hcl inj 0.3 mg/ml (base equiv) (Buprenex)
1
buprenorphine hcl sl tab 2 mg (base equiv)
1
ASPIRIN-CAFFEINEDIHYDROC - aspirincaffeine-dihydrocodeine cap 356.4-30-16 mg
3
BELBUCA - buprenorphine hcl buccal film 75 mcg (base equivalent)
3
BELBUCA - buprenorphine hcl buccal film 150 mcg (base equivalent)
3
BELBUCA - buprenorphine hcl buccal film 300 mcg (base equivalent)
3
•
BELBUCA - buprenorphine hcl buccal film 750 mcg (base equivalent)
3
•
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)
BELBUCA - buprenorphine hcl buccal film 900 mcg (base equivalent)
3
•
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)
BUNAVAIL - buprenorphinenaloxone buccal film 2.1-0.3 mg (base equiv)
3
BUNAVAIL - buprenorphinenaloxone buccal film 4.2-0.7 mg (base equiv)
3
BUNAVAIL - buprenorphinenaloxone buccal film 6.3-1 mg (base equiv)
3
BUPRENEX - buprenorphine hcl inj 0.3 mg/ml (base equiv)
buprenorphine hcl sl tab 8 mg (base equiv)
1 1
1
butalbital-acetaminophencaff w/ cod cap 50-300-40-30 mg (Fioricet/ codeine)
1
butalbital-acetaminophencaff w/ cod cap 50-325-40-30 mg
1
1
3
butalbital-aspirincaff w/ codeine cap 50-325-40-30 mg (Fiorinal/ codeine #3)
3
BUPRENORPHINE buprenorphine td patch weekly 5 mcg/hr
3
BUTORPHANOL TARTRATE butorphanol tartrate inj 1 mg/ ml
1
BUPRENORPHINE buprenorphine td patch weekly 7.5 mcg/hr
3
butorphanol tartrate inj 2 mg/ml
•
butorphanol tartrate nasal soln 10 mg/ml BUTRANS - buprenorphine td patch weekly 5 mcg/hr
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
BUPRENORPHINE buprenorphine td patch weekly 15 mcg/hr
1
ACA
•
alfentanil inj 500 mcg/ml (Alfenta)
•
Dispensing Limits
3
3
•
Step Therapy
BUPRENORPHINE buprenorphine td patch weekly 10 mcg/hr
ALFENTANIL HCL - alfentanil inj 500 mcg/ml
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
•
3
•
Products October (2016 Plan Year)
137
3
•
BUTRANS - buprenorphine td patch weekly 20 mcg/hr
3
•
CODEINE PHOSPHATE codeine phosphate powder
3
CODEINE SULFATE - codeine sulfate tab 15 mg
3
CODEINE SULFATE - codeine sulfate tab 30 mg
3
CODEINE SULFATE - codeine sulfate tab 60 mg
3
codeine sulfate tab 15 mg (Codeine sulfate)
1
codeine sulfate tab 30 mg
1
codeine sulfate tab 60 mg
1
CONZIP - tramadol hcl cap er 24hr biphasic release 100 mg
3
•
CONZIP - tramadol hcl cap er 24hr biphasic release 200 mg
3
•
CONZIP - tramadol hcl cap er 24hr biphasic release 300 mg
3
•
DEMEROL - meperidine hcl inj 25 mg/ml
3
DEMEROL - meperidine hcl inj 25 mg/0.5ml (50 mg/ml)
3
DEMEROL - meperidine hcl inj 50 mg/ml
3
DEMEROL - meperidine hcl inj 75 mg/1.5ml (50 mg/ml)
3
DEMEROL - meperidine hcl inj 100 mg/2ml (50 mg/ml)
3
3
DEMEROL - meperidine hcl tab 3 100 mg 3 DILAUDID - hydromorphone hcl inj 1 mg/ml 3 DILAUDID - hydromorphone hcl inj 2 mg/ml 3 DILAUDID - hydromorphone hcl inj 4 mg/ml 3 DILAUDID - hydromorphone hcl liqd 1 mg/ml 3 DILAUDID - hydromorphone hcl tab 2 mg 3 DILAUDID - hydromorphone hcl tab 4 mg 3 DILAUDID - hydromorphone hcl tab 8 mg 3 DOLOPHINE - methadone hcl tab 5 mg 3 DOLOPHINE - methadone hcl tab 10 mg 3 DURAGESIC - fentanyl td patch 72hr 12 mcg/hr 3 DURAGESIC - fentanyl td patch 72hr 25 mcg/hr 3 DURAGESIC - fentanyl td patch 72hr 50 mcg/hr 3 DURAGESIC - fentanyl td patch 72hr 75 mcg/hr 3 DURAGESIC - fentanyl td patch 72hr 100 mcg/hr 3 EMBEDA - morphinenaltrexone cap er 20-0.8 mg 3 EMBEDA - morphinenaltrexone cap er 30-1.2 mg 3 EMBEDA - morphinenaltrexone cap er 50-2 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
BUTRANS - buprenorphine td patch weekly 15 mcg/hr
DEMEROL - meperidine hcl inj 100 mg/ml
ACA
•
Dispensing Limits
3
3
Step Therapy
BUTRANS - buprenorphine td patch weekly 10 mcg/hr
DEMEROL - meperidine hcl inj 75 mg/ml
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
BUTRANS - buprenorphine td patch weekly 7.5 mcg/hr
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • • • • • • •
138
3
•
EXALGO - hydromorphone hcl tab er 24hr deter 8 mg
3
•
EXALGO - hydromorphone hcl tab er 24hr deter 12 mg
3
•
EXALGO - hydromorphone hcl tab er 24hr deter 16 mg
3
•
EXALGO - hydromorphone hcl tab er 24hr deter 32 mg
3
•
FENTANYL - fentanyl td patch 72hr 37.5 mcg/hr
3
•
FENTANYL - fentanyl td patch 72hr 62.5 mcg/hr
3
•
FENTANYL - fentanyl td patch 72hr 87.5 mcg/hr
3
•
FENTANYL CITRATE - fentanyl 3 citrate powder 1 fentanyl citrate lollipop 200 mcg (Actiq) 1 fentanyl citrate lollipop 400 mcg (Actiq) 1 fentanyl citrate lollipop 600 mcg (Actiq) 1 fentanyl citrate lollipop 800 mcg (Actiq) 1 fentanyl citrate lollipop 1200 mcg (Actiq) 1 fentanyl citrate lollipop 1600 mcg (Actiq) 1 fentanyl td patch 72hr 12 mcg/hr (Duragesic) 1 fentanyl td patch 72hr 25 mcg/hr (Duragesic) 1 fentanyl td patch 72hr 50 mcg/hr (Duragesic)
FENTORA - fentanyl citrate buccal tab 200 mcg (base equiv)
3
FENTORA - fentanyl citrate buccal tab 400 mcg (base equiv)
3
FENTORA - fentanyl citrate buccal tab 600 mcg (base equiv)
3
FENTORA - fentanyl citrate buccal tab 800 mcg (base equiv)
3
FIORICET/CODEINE butalbital-acetaminophencaff w/ cod cap 50-300-40-30 mg
3
FIORINAL/CODEINE #3 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
3
HYCET - hydrocodoneacetaminophen soln 7.5-325 mg/15ml
3
hydrocodoneacetaminophen soln 7.5-325 mg/15ml (Hycet)
1
hydrocodoneacetaminophen tab 5-300 mg (Xodol)
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
•
3
hydrocodoneacetaminophen tab 10-325 mg (Norco)
•
1
FENTORA - fentanyl citrate buccal tab 100 mcg (base equiv)
hydrocodoneacetaminophen tab 2.5-325 mg
•
•
Limited Distribution
EMBEDA - morphinenaltrexone cap er 100-4 mg
fentanyl td patch 72hr 100 mcg/hr (Duragesic)
1
ACA
•
Dispensing Limits
3
Step Therapy
EMBEDA - morphinenaltrexone cap er 80-3.2 mg
fentanyl td patch 72hr 75 mcg/hr (Duragesic)
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
EMBEDA - morphinenaltrexone cap er 60-2.4 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
Products October (2016 Plan Year)
139
hydrocodoneacetaminophen tab 7.5-300 mg (Xodol) hydrocodoneacetaminophen tab 5-325 mg (Norco) hydrocodoneacetaminophen tab 7.5-325 mg (Norco) hydrocodoneacetaminophen tab 10-300 mg (Xodol) hydrocodone-ibuprofen tab 5-200 mg (Reprexain) hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen) hydrocodone-ibuprofen tab 10-200 mg (Ibudone)
1
hydromorphone hcl tab er 24hr deter 32 mg (Exalgo) hydromorphone hcl tab 2 mg (Dilaudid)
1
hydromorphone hcl tab 4 mg (Dilaudid)
1
hydromorphone hcl tab 8 mg (Dilaudid)
1
1 1 1
1 1 1 1
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 20 mg
3
•
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 30 mg
3
•
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 40 mg
3
•
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 60 mg
3
•
HYDROMORPHONE HCL hydromorphone hcl powder
3
HYDROMORPHONE HCL hydromorphone hcl suppos 3 mg
2
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 80 mg
3
•
hydromorphone hcl inj 1 mg/ ml
1
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 100 mg
3
•
3
•
1
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 120 mg
1
IBUDONE - hydrocodoneibuprofen tab 10-200 mg
3
1
INFUMORPH 200 - morphine sulfate for microinfusion inj 200 mg/20ml (10mg/ml)
3
INFUMORPH 500 - morphine sulfate for microinfusion inj 500 mg/20ml (25mg/ml)
3
IONSYS - fentanyl hcl iontophoretic td system 40 mcg/act (base equiv)
3
KADIAN - morphine sulfate cap er 24hr 10 mg
3
hydromorphone hcl inj 2 mg/ ml hydromorphone hcl inj 4 mg/ ml hydromorphone hcl liqd 1 mg/ml (Dilaudid) hydromorphone hcl preservative free (pf) inj 10 mg/ml (Dilaudid-hp) hydromorphone hcl tab er 24hr deter 8 mg (Exalgo) hydromorphone hcl tab er 24hr deter 12 mg (Exalgo) hydromorphone hcl tab er 24hr deter 16 mg (Exalgo)
1
1
•
1
•
1
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
• 140
3
•
KADIAN - morphine sulfate cap er 24hr 50 mg
3
•
KADIAN - morphine sulfate cap er 24hr 60 mg
3
•
KADIAN - morphine sulfate cap er 24hr 80 mg
3
KADIAN - morphine sulfate cap er 24hr 100 mg
1
meperidine hcl tab 100 mg (Demerol)
1
MEPERIDINE HCL/ PROMETHAZI - meperidine w/ promethazine cap 50-25 mg
3
•
METHADONE HCL methadone hcl inj 10 mg/ml
3
3
•
METHADONE HCL methadone hcl powder
3
KADIAN - morphine sulfate cap er 24hr 200 mg
3
•
3
LAZANDA - fentanyl citrate nasal spray 100 mcg/act (base equiv)
3
METHADONE HCL methadone hcl soln 5 mg/5ml
3
LAZANDA - fentanyl citrate nasal spray 300 mcg/act (base equiv)
3
METHADONE HCL methadone hcl soln 10 mg/5ml methadone hcl conc 10 mg/ ml (Methadose)
1
LAZANDA - fentanyl citrate nasal spray 400 mcg/act (base equiv)
3
LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg
3
methadone hcl soln 10 mg/5ml (Methadone hcl)
LORTAB - hydrocodoneacetaminophen soln 10-300 mg/15ml
3
methadone hcl tab for oral susp 40 mg
MEPERIDINE HCL meperidine hcl inj 10 mg/ml
methadone hcl soln 5 mg/5ml (Methadone hcl)
1 1 1
methadone hcl tab 5 mg (Dolophine hcl)
1
3
methadone hcl tab 10 mg (Dolophine)
1
MEPERIDINE HCL meperidine hcl oral soln 50 mg/5ml
3
METHADOSE - methadone hcl conc 10 mg/ml
3
3
3
MEPERIDINE HCL meperidine hcl powder
METHADOSE SUGAR-FREE methadone hcl conc 10 mg/ ml
meperidine hcl inj 25 mg/ml (Demerol)
1
3
meperidine hcl inj 50 mg/ml (Demerol)
1
MORPHINE SULFATE morphine sulfate im inj device 10 mg/0.7ml
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
KADIAN - morphine sulfate cap er 24hr 40 mg
meperidine hcl tab 50 mg (Demerol)
ACA
•
Dispensing Limits
3
1
Step Therapy
KADIAN - morphine sulfate cap er 24hr 30 mg
meperidine hcl inj 100 mg/ml (Demerol)
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
KADIAN - morphine sulfate cap er 24hr 20 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
141
•
MORPHINE SULFATE ER morphine sulfate beads cap er 24hr 30 mg
3
•
MORPHINE SULFATE ER morphine sulfate beads cap er 24hr 45 mg
3
•
3
MORPHINE SULFATE ER morphine sulfate beads cap er 24hr 60 mg
3
•
MORPHINE SULFATE morphine sulfate powder
3
3
•
MORPHINE SULFATE morphine sulfate suppos 5 mg
2
MORPHINE SULFATE ER morphine sulfate beads cap er 24hr 75 mg
3
•
MORPHINE SULFATE morphine sulfate suppos 10 mg
2
MORPHINE SULFATE ER morphine sulfate beads cap er 24hr 90 mg
3
•
MORPHINE SULFATE morphine sulfate suppos 20 mg
2
MORPHINE SULFATE ER morphine sulfate beads cap er 24hr 120 mg morphine sulfate inj pf 0.5 mg/ml
1
MORPHINE SULFATE morphine sulfate suppos 30 mg
2
MORPHINE SULFATE morphine sulfate tab 15 mg
2
morphine sulfate oral soln 10 mg/5ml
MORPHINE SULFATE morphine sulfate tab 30 mg
2
morphine sulfate oral soln 20 mg/5ml
morphine sulfate cap er 24hr 10 mg (Kadian)
1
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)
3
MORPHINE SULFATE morphine sulfate inj 4 mg/ml
3
MORPHINE SULFATE morphine sulfate inj 5 mg/ml
3
MORPHINE SULFATE morphine sulfate inj 8 mg/ml
1
MORPHINE SULFATE morphine sulfate inj 10 mg/ ml
morphine sulfate cap er 24hr 20 mg (Kadian) morphine sulfate cap er 24hr 30 mg (Kadian) morphine sulfate cap er 24hr 50 mg (Kadian) morphine sulfate cap er 24hr 60 mg (Kadian) morphine sulfate cap er 24hr 80 mg (Kadian)
1 1 1 1 1
morphine sulfate cap er 24hr 100 mg (Kadian)
morphine sulfate inj pf 1 mg/ ml
•
morphine sulfate tab er 15 mg (Ms contin)
•
morphine sulfate tab er 30 mg (Ms contin)
•
morphine sulfate tab er 60 mg (Ms contin)
•
morphine sulfate tab er 100 mg (Ms contin)
•
morphine sulfate tab er 200 mg (Ms contin)
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
1
MORPHINE SULFATE morphine sulfate inj 2 mg/ml
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1
•
1
•
1
•
1
•
1
•
Products October (2016 Plan Year)
142
3
•
MS CONTIN - morphine sulfate tab er 100 mg
3
•
MS CONTIN - morphine sulfate tab er 200 mg
3
nalbuphine hcl inj 10 mg/ml
1
nalbuphine hcl inj 20 mg/ml
•
1
3
OPANA - oxymorphone hcl tab 10 mg
3
OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 5 mg
3
•
OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 7.5 mg
3
•
OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 10 mg
3
•
OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 15 mg
3
•
OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 20 mg
3
•
OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 30 mg
3
•
3
•
NORCO - hydrocodoneacetaminophen tab 10-325 mg
3
NORCO - hydrocodoneacetaminophen tab 5-325 mg
3
NORCO - hydrocodoneacetaminophen tab 7.5-325 mg
3
NUCYNTA - tapentadol hcl tab 50 mg
3
NUCYNTA - tapentadol hcl tab 75 mg
3
OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 40 mg
3
3
NUCYNTA - tapentadol hcl tab 100 mg
OXAYDO - oxycodone hcl tab abuse deter 5 mg
2
•
OXAYDO - oxycodone hcl tab abuse deter 7.5 mg
3
NUCYNTA ER - tapentadol hcl tab er 12hr 50 mg
•
OXYCODONE HCL oxycodone hcl powder
3
NUCYNTA ER - tapentadol hcl tab er 12hr 100 mg
2
•
oxycodone hcl cap 5 mg
1
NUCYNTA ER - tapentadol hcl tab er 12hr 150 mg
2
NUCYNTA ER - tapentadol hcl tab er 12hr 200 mg
2
•
NUCYNTA ER - tapentadol hcl tab er 12hr 250 mg
2
OPANA - oxymorphone hcl inj 1 mg/ml
3
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl)
1
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 10 mg
3
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 15 mg
3
•
Products October (2016 Plan Year)
Limited Distribution
MS CONTIN - morphine sulfate tab er 60 mg
OPANA - oxymorphone hcl tab 5 mg
ACA
•
Dispensing Limits
3
Step Therapy
MS CONTIN - morphine sulfate tab er 30 mg
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
MS CONTIN - morphine sulfate tab er 15 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
143
3
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 60 mg
3
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 80 mg
3
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)
3
OXYCODONE/IBUPROFEN oxycodone-ibuprofen tab 5-400 mg
3
OXYCONTIN - oxycodone hcl tab er 12hr deter 10 mg
2
•
OXYCONTIN - oxycodone hcl tab er 12hr deter 15 mg
2
•
OXYCONTIN - oxycodone hcl tab er 12hr deter 20 mg
2
•
1
OXYCONTIN - oxycodone hcl tab er 12hr deter 30 mg
2
•
1
OXYCONTIN - oxycodone hcl tab er 12hr deter 40 mg
2
oxycodone hcl tab 5 mg (Roxicodone)
•
1
OXYCONTIN - oxycodone hcl tab er 12hr deter 60 mg
2
oxycodone hcl tab 10 mg
• •
• • •
oxycodone hcl tab 15 mg (Roxicodone)
1
OXYCONTIN - oxycodone hcl tab er 12hr deter 80 mg
2
oxycodone hcl tab 20 mg
1
1
oxycodone hcl tab 30 mg (Roxicodone)
1
oxymorphone hcl tab 5 mg (Opana)
1
oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet)
1
oxymorphone hcl tab 10 mg (Opana) OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab er 12hr 5 mg
3
•
OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab er 12hr 7.5 mg
3
•
OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab er 12hr 10 mg
3
•
OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab er 12hr 15 mg
3
•
oxycodone w/ acetaminophen tab 5-325 mg (Percocet) oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) oxycodone w/ acetaminophen tab 10-325 mg (Percocet) oxycodone-aspirin tab 4.8355-325 mg (Percodan)
1
1
1
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 40 mg
OXYCODONE/ ACETAMINOPHEN oxycodone w/ acetaminophen soln 5-325 mg/5ml
ACA
•
Dispensing Limits
3
Step Therapy
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 30 mg
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 20 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
144
OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab er 12hr 20 mg
3
OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab er 12hr 30 mg
3
OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab er 12hr 40 mg
3
pentazocine w/ naloxone tab 50-0.5 mg
1
• •
ROXICODONE - oxycodone hcl tab 30 mg
3
SUBOXONE - buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)
2
SUBOXONE - buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)
2
SUBOXONE - buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv)
2
SUBOXONE - buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv)
2
SUBSYS - fentanyl sublingual spray 100 mcg
3
SUBSYS - fentanyl sublingual spray 200 mcg
3
SUBSYS - fentanyl sublingual spray 400 mcg
3
SUBSYS - fentanyl sublingual spray 600 mcg
3
PERCOCET - oxycodone w/ acetaminophen tab 2.5-325 mg
3
PERCOCET - oxycodone w/ acetaminophen tab 5-325 mg
3
PERCOCET - oxycodone w/ acetaminophen tab 7.5-325 mg
3
PERCOCET - oxycodone w/ acetaminophen tab 10-325 mg
3
SUBSYS - fentanyl sublingual spray 800 mcg
3 3
PRIMLEV - oxycodone w/ acetaminophen tab 5-300 mg
3
SUBSYS - fentanyl sublingual spray 1200 mcg (600 mcg x 2)
3
PRIMLEV - oxycodone w/ acetaminophen tab 7.5-300 mg
3
SUBSYS - fentanyl sublingual spray 1600 mcg (800 mcg x 2)
3
PRIMLEV - oxycodone w/ acetaminophen tab 10-300 mg
3
SYNALGOS-DC - aspirincaffeine-dihydrocodeine cap 356.4-30-16 mg
3
PROBUPHINE IMPLANT KIT - buprenorphine hcl subdermal implant 74.2 mg (base equiv)
3
SYNAPRYN FUSEPAQ tramadol hcl for oral susp 10 mg/ml (compound kit)
3
ROXICODONE - oxycodone hcl tab 5 mg
3
TALWIN - pentazocine lactate inj 30 mg/ml
3
ROXICODONE - oxycodone hcl tab 15 mg
3
TRAMADOL HCL ER tramadol hcl cap er 24hr biphasic release 100 mg
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
145
TRAMADOL HCL ER tramadol hcl cap er 24hr biphasic release 150 mg
3
TRAMADOL HCL ER tramadol hcl cap er 24hr biphasic release 200 mg
3
TRAMADOL HCL ER tramadol hcl cap er 24hr biphasic release 300 mg tramadol hcl tab er 24hr 100 mg tramadol hcl tab er 24hr 200 mg tramadol hcl tab er 24hr 300 mg tramadol hcl tab er 24hr biphasic release 100 mg tramadol hcl tab er 24hr biphasic release 200 mg tramadol hcl tab er 24hr biphasic release 300 mg
ULTRAM - tramadol hcl tab 50 mg
3
•
XODOL - hydrocodoneacetaminophen tab 5-300 mg
3
3
•
XODOL - hydrocodoneacetaminophen tab 7.5-300 mg
3
1
•
3
1
•
XODOL - hydrocodoneacetaminophen tab 10-300 mg
1
•
1
•
1
•
1
•
tramadol hcl tab 50 mg (Ultram)
1
tramadol-acetaminophen tab 37.5-325 mg (Ultracet)
1
TREZIX - acetaminophencaffeine-dihydrocodeine cap 320.5-30-16 mg
3
TYLENOL/CODEINE acetaminophen w/ codeine tab 300-15 mg
3
TYLENOL/CODEINE #3 acetaminophen w/ codeine tab 300-30 mg
3
TYLENOL/CODEINE #4 acetaminophen w/ codeine tab 300-60 mg
3
ULTRACET - tramadolacetaminophen tab 37.5-325 mg
3
XTAMPZA ER - oxycodone cap 3 er 12hr abuse-deterrent 9 mg XTAMPZA ER - oxycodone cap 3 er 12hr abuse-deterrent 13.5 mg XTAMPZA ER - oxycodone cap 3 er 12hr abuse-deterrent 18 mg XTAMPZA ER - oxycodone cap 3 er 12hr abuse-deterrent 27 mg XTAMPZA ER - oxycodone cap 3 er 12hr abuse-deterrent 36 mg 3 ZAMICET - hydrocodoneacetaminophen soln 10-325 mg/15ml 3 ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abusedeterrent 10 mg 3 ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abusedeterrent 15 mg 3 ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abusedeterrent 20 mg 3 ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abusedeterrent 30 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • • • •
• • • •
146
3
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 1.4-0.36 mg (base eq)
3
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 2.9-0.71 mg (base eq)
3
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 5.7-1.4 mg (base eq)
3
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 8.6-2.1 mg (base eq)
3
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 11.4-2.9 mg (base eq)
3
ANALGESICS - ANTI-INFLAMMATORY 5 • ACTEMRA - tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9ml 3 ACTIVE INJECTION KIT KET- - ketorolac trometh inj 30 mg/ml & lidocaine hcl 1% kit 3 ACTIVE INJECTION KIT KETM - ketorolac inj 30 mg/ ml & bupivacaine 0.25% & lido 1% kit 3 ANAPROX DS - naproxen sodium tab 550 mg ARAVA - leflunomide tab 10 mg 3 ARAVA - leflunomide tab 20 mg 3 5 ARCALYST - rilonacept for inj 220 mg
3
celecoxib cap 50 mg (Celebrex)
1
celecoxib cap 100 mg (Celebrex)
1
celecoxib cap 200 mg (Celebrex)
1
celecoxib cap 400 mg (Celebrex)
1
DAYPRO - oxaprozin tab 600 mg
3
diclofenac potassium tab 50 mg (Cataflam)
1
diclofenac sodium tab delayed release 25 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg
•
•
diclofenac sodium tab er 24hr 100 mg diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50) diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75)
• SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 0.7-0.18 mg (base eq)
ARTHROTEC 75 - diclofenac w/ misoprostol tab delayed release 75-0.2 mg
ACA
•
Dispensing Limits
3
3
Step Therapy
ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abusedeterrent 50 mg
ARTHROTEC 50 - diclofenac w/ misoprostol tab delayed release 50-0.2 mg
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abusedeterrent 40 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1
1
EC-NAPROSYN - naproxen tab ec 375 mg
3
EC-NAPROSYN - naproxen tab ec 500 mg
3
ENBREL - etanercept for subcutaneous inj 25 mg
4
•
•
•
ENBREL - etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml
4
•
•
•
Products October (2016 Plan Year)
147
Limited Distribution
HUMIRA PEN-CROHNS DISEASE - adalimumab peninjector kit 40 mg/0.8ml
4
•
•
•
HUMIRA PEN-PSORIASIS STAR - adalimumab peninjector kit 40 mg/0.8ml
4
•
•
•
3
1
IBUPROFEN - ibuprofen powder
1
ibuprofen susp 100 mg/5ml
1
1
ibuprofen tab 400 mg
1
ibuprofen tab 600 mg
1
ibuprofen tab 800 mg
FELDENE - piroxicam cap 10 mg
3
ILARIS - canakinumab for inj 180 mg
4
•
FELDENE - piroxicam cap 20 mg
3
ILARIS - canakinumab subcutaneous inj 150 mg/ml
4
•
FENOPROFEN CALCIUM fenoprofen calcium powder
3
INDOCIN - indomethacin suppos 50 mg
3
FENOPROFEN CALCIUM fenoprofen calcium tab 600 mg
3
INDOCIN - indomethacin susp 25 mg/5ml
3 3
FLURBIPROFEN - flurbiprofen powder
3
INDOMETHACIN indomethacin powder
1
flurbiprofen tab 50 mg
1
indomethacin cap er 75 mg
ENBREL SURECLICK etanercept subcutaneous solution auto-injector 50 mg/ ml etodolac cap 200 mg
1
etodolac cap 300 mg etodolac tab er 24hr 400 mg etodolac tab er 24hr 500 mg etodolac tab er 24hr 600 mg etodolac tab 400 mg etodolac tab 500 mg
flurbiprofen tab 100 mg
•
•
•
1
1
HUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml
4
HUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml
4
HUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml
4
HUMIRA PEDIATRIC CROHNS D - adalimumab prefilled syringe kit 40 mg/0.8ml
4
indomethacin cap 25 mg
• • • •
• • • •
indomethacin cap 50 mg
• •
1 1
1 1 3
ketoprofen cap 50 mg
1 1 3
•
KETOPROFEN ER ketoprofen cap er 24hr 200 mg
3
•
KETOPROFEN MICRONIZED - ketoprofen powder KETOPROFEN ULTRA MICRONIZ - ketoprofen powder
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
•
1
KETOPROFEN - ketoprofen powder ketoprofen cap 75 mg
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
4
•
Drug Tier
Limited Distribution
ACA
Dispensing Limits
4
4
•
Drug Name HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml
ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
148
KETOROCAINE-L - ketorolac trometh inj 30 mg/ml & lidocaine hcl 1% kit
3
KETOROCAINE-LM - ketorolac 3 inj 30 mg/ml & bupivacaine 0.25% & lido 1% kit 3 KETOROLAC TROMETHAMINE - ketorolac tromethamine inj 60 mg/2ml (30 mg/ml) 1 ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml) 1 ketorolac tromethamine inj 15 mg/ml 1 ketorolac tromethamine inj 30 mg/ml 1 ketorolac tromethamine tab 10 mg 5 KINERET - anakinra subcutaneous soln prefilled syringe 100 mg/0.67ml 1 leflunomide tab 10 mg (Arava) 1 leflunomide tab 20 mg (Arava) LODINE - etodolac tab 400 mg 3 MECLOFENAMATE SODIUM meclofenamate sodium cap 50 mg
3
MECLOFENAMATE SODIUM meclofenamate sodium cap 100 mg
3
MECLOFENAMATE SODIUM meclofenamate sodium powder
3
MEFENAMIC ACID mefenamic acid powder
3
mefenamic acid cap 250 mg (Ponstel)
1
meloxicam tab 7.5 mg (Mobic)
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
meloxicam tab 15 mg (Mobic) 1 MOBIC - meloxicam tab 7.5 mg 3 MOBIC - meloxicam tab 15 mg
3
nabumetone tab 500 mg
1
nabumetone tab 750 mg
•
•
1
NAPRELAN - naproxen sodium 3 tab er 24hr 375 mg (base equiv) NAPRELAN - naproxen sodium 3 tab er 24hr 500 mg (base equiv) NAPRELAN - naproxen sodium 3 tab er 24hr 750 mg (base equiv) 3 NAPROSYN - naproxen susp 125 mg/5ml 3 NAPROSYN - naproxen tab 500 mg 3 NAPROXEN - naproxen powder 3 NAPROXEN SODIUM naproxen sodium powder 1 naproxen sodium tab er 24hr 375 mg (base equiv) (Naprelan) 1 naproxen sodium tab er 24hr 500 mg (base equiv) (Naprelan) 1 naproxen sodium tab 275 mg (Anaprox) 1 naproxen sodium tab 550 mg (Anaprox ds) 1 naproxen susp 125 mg/5ml (Naprosyn) naproxen tab ec 375 mg (Ec- 1 naprosyn) naproxen tab ec 500 mg (Ec- 1 naprosyn) 1 naproxen tab 250 mg (Naprosyn)
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
149
naproxen tab 375 mg (Naprosyn)
1
PHENYLBUTAZONE phenylbutazone powder
3
naproxen tab 500 mg (Naprosyn)
1
3
ORENCIA - abatacept subcutaneous soln prefilled syringe 50 mg/0.4ml
5
•
•
•
PIROXICAM - piroxicam powder piroxicam cap 10 mg (Feldene)
1
5
•
•
•
piroxicam cap 20 mg (Feldene)
1
ORENCIA - abatacept subcutaneous soln prefilled syringe 87.5 mg/0.7ml
3
ORENCIA - abatacept subcutaneous soln prefilled syringe 125 mg/ml
5
•
•
•
PONSTEL - mefenamic acid cap 250 mg
3
ORENCIA CLICKJECT abatacept subcutaneous soln auto-injector 125 mg/ml
5
•
•
•
RASUVO - methotrexate soln pf auto-injector 7.5 mg/0.15ml RASUVO - methotrexate soln pf auto-injector 10 mg/0.2ml
3
OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg & 30 mg
4
•
•
•
RASUVO - methotrexate soln pf auto-injector 12.5 mg/0.25ml
3
OTEZLA - apremilast tab 30 mg
4
•
•
•
RASUVO - methotrexate soln pf auto-injector 15 mg/0.3ml
3
OTREXUP - methotrexate soln pf auto-injector 10mg/0.4ml
3
3
OTREXUP - methotrexate soln pf auto-injector 12.5 mg/0.4ml
3
RASUVO - methotrexate soln pf auto-injector 17.5 mg/0.35ml RASUVO - methotrexate soln pf auto-injector 20 mg/0.4ml
3
OTREXUP - methotrexate soln pf auto-injector 15mg/0.4ml
3
3
OTREXUP - methotrexate soln pf auto-injector 17.5 mg/0.4ml
3
RASUVO - methotrexate soln pf auto-injector 22.5 mg/0.45ml RASUVO - methotrexate soln pf auto-injector 25 mg/0.5ml
3
OTREXUP - methotrexate soln pf auto-injector 20mg/0.4ml
3
RASUVO - methotrexate soln pf auto-injector 30 mg/0.6ml
3
OTREXUP - methotrexate soln pf auto-injector 22.5 mg/0.4ml
3
3
OTREXUP - methotrexate soln pf auto-injector 25mg/0.4ml
3
READYSHARP ANESTHETICS + - ketorolac inj 15 mg/ml & bupivacaine 0.5% & lido 1% kit
oxaprozin tab 600 mg (Daypro)
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
READYSHARP KETOROLAC - 3 ketorolac tromethamine inj 15 mg/ml kit RIDAURA - auranofin cap 3 mg 3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
150
4
SIMPONI - golimumab subcutaneous soln autoinjector 100 mg/ml
4
SIMPONI - golimumab subcutaneous soln prefilled syringe 50 mg/0.5ml
4
•
•
•
SIMPONI - golimumab subcutaneous soln prefilled syringe 100 mg/ml
4
•
•
•
SPRIX - ketorolac tromethamine nasal spray 15.75 mg/spray
3
SULINDAC - sulindac powder
3
sulindac tab 150 mg
1
sulindac tab 200 mg
•
•
1
3
•
AXERT - almotriptan malate tab 12.5 mg
3
•
CAFERGOT - ergotamine w/ caffeine tab 1-100 mg
3
CAMBIA - diclofenac potassium packet 50 mg
3
D.H.E. 45 - dihydroergotamine mesylate inj 1 mg/ml
3
DIHYDROERGOTAMINE MESYLAT dihydroergotamine mesylate nasal spray 4 mg/ml
3
DIHYDROERGOTAMINE MESYLAT dihydroergotamine mesylate powder
3
1
3
dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45)
TOLMETIN SODIUM - tolmetin sodium tab 600 mg
3
ERGOMAR - ergotamine tartrate sl tab 2 mg
3
XELJANZ - tofacitinib citrate tab 5 mg (base equivalent)
5
•
•
•
ERGOTAMINE TARTRATE ergotamine tartrate powder
3
XELJANZ XR - tofacitinib citrate tab er 24hr 11 mg (base equivalent)
5
•
•
•
ergotamine w/ caffeine tab 1-100 mg (Cafergot)
1
almotriptan malate tab 6.25 mg (Axert) almotriptan malate tab 12.5 mg (Axert) AMERGE - naratriptan hcl tab 1 mg (base equiv)
1
•
•
FROVA - frovatriptan succinate tab 2.5 mg (base equivalent)
3
•
frovatriptan succinate tab 2.5 mg (base equivalent) (Frova)
1
•
IMITREX - sumatriptan nasal spray 5 mg/act
3
•
1
•
IMITREX - sumatriptan nasal spray 20 mg/act
3
•
1
•
IMITREX - sumatriptan succinate inj 6 mg/0.5ml
3
•
3
•
IMITREX - sumatriptan succinate tab 25 mg
3
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
AXERT - almotriptan malate tab 6.25 mg
ACA
•
TOLMETIN SODIUM - tolmetin sodium tab 200 mg
acetaminophenisometheptene-caffeine tab 325-65-20 mg (Prodrin)
Dispensing Limits
3
3
MIGRAINE PRODUCTS
Step Therapy
AMERGE - naratriptan hcl tab 2.5 mg (base equiv)
TOLMETIN SODIUM - tolmetin sodium cap 400 mg
ZIPSOR - diclofenac potassium 3 cap 25 mg
Prior Authorization
•
SIMPONI - golimumab subcutaneous soln autoinjector 50 mg/0.5ml
•
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
151
3
•
IMITREX STATDOSE REFILL sumatriptan succinate solution cartridge 6 mg/0.5ml
3
IMITREX STATDOSE SYSTEM - sumatriptan succinate solution autoinjector 4 mg/0.5ml
3
IMITREX STATDOSE SYSTEM - sumatriptan succinate solution autoinjector 6 mg/0.5ml
3
isometheptene-dichloralacetaminophen cap 65-100-325 mg
1
• • •
MAXALT - rizatriptan benzoate tab 5 mg (base equivalent)
3
•
MAXALT - rizatriptan benzoate tab 10 mg (base equivalent)
3
•
MAXALT-MLT - rizatriptan benzoate oral disintegrating tab 5 mg (base eq)
3
•
MAXALT-MLT - rizatriptan benzoate oral disintegrating tab 10 mg (base eq)
3
•
MIGERGOT - ergotamine w/ caffeine suppos 2-100 mg
3
MIGRANAL dihydroergotamine mesylate nasal spray 4 mg/ml
2
•
naratriptan hcl tab 1 mg (base equiv) (Amerge)
1
•
1
•
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
IMITREX STATDOSE REFILL sumatriptan succinate solution cartridge 4 mg/0.5ml
•
ACA
•
Dispensing Limits
3
Step Therapy
IMITREX - sumatriptan succinate tab 100 mg
ONZETRA XSAIL - sumatriptan 3 succinate exhaler powder 11 mg/nosepiece 3 PRODRIN - acetaminophenisometheptene-caffeine tab 325-65-20 mg 1 RELPAX - eletriptan hydrobromide tab 20 mg (base equivalent) 1 RELPAX - eletriptan hydrobromide tab 40 mg (base equivalent) 1 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) (Maxalt-mlt) 1 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt) 1 rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt) 1 rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) 1 sumatriptan nasal spray 5 mg/act (Imitrex) 1 sumatriptan nasal spray 20 mg/act (Imitrex) SUMATRIPTAN SUCCINATE - 3 sumatriptan succinate solution prefilled syringe 6 mg/0.5ml 1 sumatriptan succinate inj 6 mg/0.5ml (Imitrex) 1 sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdose sys) 1 sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys)
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
IMITREX - sumatriptan succinate tab 50 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • • • • • • • • • • •
152
1 sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref) 1 sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref) 1 sumatriptan succinate tab 25 mg (Imitrex) 1 sumatriptan succinate tab 50 mg (Imitrex) 1 sumatriptan succinate tab 100 mg (Imitrex) 3 SUMAVEL DOSEPRO sumatriptan succinate solution jet-injector 4 mg/0.5ml 3 SUMAVEL DOSEPRO sumatriptan succinate solution jet-injector 6 mg/0.5ml 3 TREXIMET - sumatriptannaproxen sodium tab 10-60 mg 3 TREXIMET - sumatriptannaproxen sodium tab 85-500 mg 3 ZEMBRACE SYMTOUCH sumatriptan succinate solution auto-injector 3 mg/0.5ml 1 zolmitriptan orally disintegrating tab 2.5 mg (Zomig zmt) 1 zolmitriptan orally disintegrating tab 5 mg (Zomig zmt) 1 zolmitriptan tab 2.5 mg (Zomig) 1 zolmitriptan tab 5 mg (Zomig)
• • • •
• • • • •
•
ZOMIG - zolmitriptan nasal spray 5 mg/spray unit
2
•
ZOMIG - zolmitriptan tab 2.5 mg
3
•
ZOMIG - zolmitriptan tab 5 mg
3
ZOMIG ZMT - zolmitriptan orally disintegrating tab 2.5 mg
3
• •
ZOMIG ZMT - zolmitriptan orally disintegrating tab 5 mg
3
•
allopurinol tab 100 mg (Zyloprim)
1
allopurinol tab 300 mg (Zyloprim)
1
COLCHICINE - colchicine cap 0.6 mg
3
COLCHICINE - colchicine powder
3
COLCHICINE - colchicine tab 0.6 mg
3
colchicine w/ probenecid tab 0.5-500 mg
1
COLCRYS - colchicine tab 0.6 mg
2
MITIGARE - colchicine cap 0.6 mg
3
probenecid tab 500 mg
1
ZYLOPRIM - allopurinol tab 100 mg
3
ZYLOPRIM - allopurinol tab 300 mg
3
Limited Distribution
2
ACA
Dispensing Limits
Step Therapy
ZOMIG - zolmitriptan nasal spray 2.5 mg/spray unit
GOUT AGENTS
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ULORIC - febuxostat tab 40 mg 3 ULORIC - febuxostat tab 80 mg 3
• •
LOCAL ANESTHETICS - PARENTERAL 3 ACTIVE INJECTION KIT LM-2 - lidocaine hcl inj 1% & bupivacaine hcl inj 0.25% kit
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
153
ARTICADENT DENTAL articaine-epinephrine inj 4%-1:200000
3
ARTICADENT DENTAL articaine-epinephrine inj 4%-1:100000
1
3
bupivacaine inj 0.5% w/ epinephrine preservative free (pf) (Marcaine/ epinephrine)
1
BD PUDENDAL/LOCAL BLOCK - lidocaine hcl local inj kit 1%
3
bupivacaine 0.75% in dextrose inj 8.25% (Marcaine spinal) CARBOCAINE - mepivacaine hcl inj 1%
3
BL INJECTION KIT - bupiv pf inj 0.5% & lido pf inj 2% & povi-iod swab kit
3
CARBOCAINE - mepivacaine hcl inj 1.5%
3
CARBOCAINE - mepivacaine hcl inj 2%
3
BUPIVACAINE HCL bupivacaine hcl powder
3
CARBOCAINE - mepivacaine hcl preservative free (pf) inj 1%
3
bupivacaine hcl inj 0.25% (Marcaine)
1
bupivacaine hcl inj 0.5% (Marcaine)
1
3
BUPIVACAINE HCL MONOHYDRA - bupivacaine hcl powder
3
CARBOCAINE - mepivacaine hcl preservative free (pf) inj 2%
3
bupivacaine hcl preservative free (pf) inj 0.25% (Marcaine)
1
CITANEST FORTE DENTAL prilocaine inj 4% w/ epinephrine 1:200000 CITANEST PLAIN DENTAL prilocaine hcl inj 4%
3
D-CARE 100X - lidocaine 1% w/ epinephrine-1:200000 pf inj kit
3
DURASAFE SPINAL/ EPIDURAL - lidocaine hcl local inj kit 1%
3
EXPAREL - bupivacaine liposome inj 1.3% (13.3 mg/ ml)
3
LETS KIT - lidocaine & tetracaine w/ epineph kit (compounding kit)
3
lidocaine hcl local inj 0.5% (Xylocaine)
1
lidocaine hcl local inj 1% (Xylocaine)
1
lidocaine hcl local inj 1.5% (Xylocaine-mpf)
1
bupivacaine hcl preservative 1 free (pf) inj 0.5% (Marcaine) bupivacaine hcl preservative 1 free (pf) inj 0.75% (Marcaine w/o epi) 1 bupivacaine inj 0.25% w/ epinephrine (Marcaine/ epinephrine) 1 bupivacaine inj 0.25% w/ epinephrine preservative free (pf) (Marcaine/ epinephrine) 1 bupivacaine inj 0.5% w/ epinephrine (Marcaine/ epinephrine)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
154
lidocaine hcl local inj 2% (Xylocaine)
1
lidocaine hcl local preservative free (pf) inj 0.5% (Xylocaine-mpf)
3
1
MARCAINE - bupivacaine hcl preservative free (pf) inj 0.75%
3
1
MARCAINE SPINAL bupivacaine 0.75% in dextrose inj 8.25%
3
1
MARCAINE/EPINEPHRINE bupivacaine inj 0.25% w/ epinephrine 1:200000
3
1
MARCAINE/EPINEPHRINE bupivacaine inj 0.25% w/ epinephrine 1:200000 (pf)
3
lidocaine inj 0.5% w/ epinephrine-1:200000 (Xylocaine/epinephrin)
1
MARCAINE/EPINEPHRINE bupivacaine inj 0.5% w/ epinephrine 1:200000
3
lidocaine inj 1% w/ epinephrine-1:100000 (Xylocaine/epinephrin)
1
MARCAINE/EPINEPHRINE bupivacaine inj 0.5% w/ epinephrine 1:200000 (pf)
3
lidocaine inj 1.5% w/ epinephrine-1:200000 (Xylocaine-mpf/epinep)
1
MARLIDO KIT - lidocaine hcl inj 2% & bupivacaine hcl inj 0.5% kit
3
lidocaine inj 2% w/ epinephrine-1:200000 (Xylocaine-mpf/epinep)
1
MARLIDO-25 - lidocaine hcl inj 1% & bupivacaine hcl inj 0.25% kit MEPIVACAINE HCL mepivacaine hcl powder
3
lidocaine inj 2% w/ epinephrine-1:100000 (Xylocaine/epinephrin)
1
mepivacaine hcl inj 1% (Carbocaine)
1
1
mepivacaine hcl inj 1.5% (Carbocaine)
1
lidocaine inj 2% w/ epinephrine-1:50000
mepivacaine hcl inj 2% (Carbocaine)
1
MARCAINE - bupivacaine hcl inj 0.25%
3
MARCAINE - bupivacaine hcl preservative free (pf) inj 0.25%
3
mepivacaine hcl preservative free (pf) inj 1% (Carbocaine)
1
MARCAINE - bupivacaine hcl inj 0.5%
3
MARCAINE - bupivacaine hcl preservative free (pf) inj 0.5%
3
lidocaine hcl local preservative free (pf) inj 1% (Xylocaine-mpf) lidocaine hcl local preservative free (pf) inj 2% (Xylocaine-mpf) lidocaine hcl local preservative free (pf) inj 4% (Xylocaine-mpf)
mepivacaine hcl preservative free (pf) inj 2% (Carbocaine) MLD KIT - lidocaine inj 2% & bupivacaine inj 0.5% & dextose 50% kit
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
3
Products October (2016 Plan Year)
155
MONOJECT BONE MARROW BIOP - lidocaine hcl local inj kit 1%
3
ropivacaine hcl inj 2 mg/ml (Naropin)
1
ropivacaine hcl inj 5 mg/ml (Naropin)
1
NAROPIN - ropivacaine hcl inj 2 mg/ml
3
ropivacaine hcl inj 7.5 mg/ml (Naropin)
1
NAROPIN - ropivacaine hcl inj 5 mg/ml
3 3
ropivacaine hcl inj 10 mg/ml (Naropin)
1
NAROPIN - ropivacaine hcl inj 7.5 mg/ml
NESACAINE - chloroprocaine hcl inj 1%
3
SENSORCAINE-MPF/ EPINEPHRI - bupivacaine inj 0.75% w/ epinephrine 1:200000 (pf)
3
NAROPIN - ropivacaine hcl inj 10 mg/ml
3
3
NESACAINE - chloroprocaine hcl inj 2%
3
TETRACAINE HCL - tetracaine hcl inj 1%
3
NESACAINE-MPF chloroprocaine hcl preservative free (pf) inj 2%
3
TETRACAINE HCL - tetracaine hcl powder
3
NESACAINE-MPF chloroprocaine hcl preservative free (pf) inj 3%
3
TURKEL PARACENTESIS PROCE - lidocaine hcl local inj kit 1% XYLOCAINE - lidocaine hcl local inj 0.5%
3
XYLOCAINE - lidocaine hcl local inj 1%
3
XYLOCAINE - lidocaine hcl local inj 2%
3
XYLOCAINE-MPF - lidocaine hcl local inj 1.5%
3
XYLOCAINE-MPF - lidocaine hcl local preservative free (pf) inj 0.5%
3
XYLOCAINE-MPF - lidocaine hcl local preservative free (pf) inj 1%
3
XYLOCAINE-MPF - lidocaine hcl local preservative free (pf) inj 2%
3
XYLOCAINE-MPF - lidocaine hcl local preservative free (pf) inj 4%
3
P-CARE M - bupivacaine hcl inj 3 kit 0.5% P-CARE X - lidocaine hcl local 3 inj kit 1% P-CARE 100MX - lidocaine hcl 3 inj 1% & bupivacaine hcl inj 0.5% kit PRILOCAINE HCL - prilocaine 3 hcl powder PROCAINE HCL - procaine hcl 3 crystals 3 READYSHARP BUPIVACAINE - bupivacaine hcl preservative free (pf) inj kit 0.5% 3 READYSHARP LIDOCAINE lidocaine hcl local inj kit 1% 3 READYSHARP-A - lidocaine hcl inj 1% & bupivacaine hcl inj 0.5% kit
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
156
XYLOCAINE-MPF/ EPINEPHRINE - lidocaine inj 1% w/ epinephrine-1:200000
3
XYLOCAINE-MPF/ EPINEPHRINE lidocaine inj 1.5% w/ epinephrine-1:200000
3
XYLOCAINE-MPF/ EPINEPHRINE - lidocaine inj 2% w/ epinephrine-1:200000
3
XYLOCAINE/EPINEPHRINE lidocaine inj 0.5% w/ epinephrine-1:200000
3
XYLOCAINE/EPINEPHRINE lidocaine inj 1% w/ epinephrine-1:100000
3
XYLOCAINE/EPINEPHRINE lidocaine inj 2% w/ epinephrine-1:100000
3
ZINGO - lidocaine hcl powder for intradermal jet-injector 0.5 mg
3
3
BRIVIACT - brivaracetam tab 25 mg
3
BRIVIACT - brivaracetam tab 50 mg
3
BRIVIACT - brivaracetam tab 75 mg
3
BRIVIACT - brivaracetam tab 100 mg
3
CARBAMAZEPINE carbamazepine powder
3
carbamazepine cap er 12hr 100 mg (Carbatrol)
1
carbamazepine cap er 12hr 200 mg (Carbatrol) carbamazepine cap er 12hr 300 mg (Carbatrol) carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml (Tegretol)
NEUROMUSCULAR DRUGS ANTICONVULSANTS
BRIVIACT - brivaracetam tab 10 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1
APTIOM - eslicarbazepine acetate tab 200 mg
3
carbamazepine tab er 12hr 100 mg (Tegretol-xr)
APTIOM - eslicarbazepine acetate tab 400 mg
3
carbamazepine tab er 12hr 200 mg (Tegretol-xr)
APTIOM - eslicarbazepine acetate tab 600 mg
3
carbamazepine tab er 12hr 400 mg (Tegretol-xr)
1
APTIOM - eslicarbazepine acetate tab 800 mg
3
carbamazepine tab 200 mg (Tegretol)
3
BANZEL - rufinamide susp 40 mg/ml
2
CARBATROL - carbamazepine cap er 12hr 100 mg
3
BANZEL - rufinamide tab 200 mg
2
CARBATROL - carbamazepine cap er 12hr 200 mg
3
BANZEL - rufinamide tab 400 mg
2
CARBATROL - carbamazepine cap er 12hr 300 mg
BRIVIACT - brivaracetam oral soln 10 mg/ml
3
1 1
CELONTIN - methsuximide cap 2 300 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
157
CEREBYX - fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv)
3
CEREBYX - fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv)
3
clonazepam orally disintegrating tab 0.125 mg
1
clonazepam orally disintegrating tab 0.25 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 1 mg clonazepam orally disintegrating tab 2 mg
DEPAKOTE SPRINKLES divalproex sodium cap delayed release sprinkle 125 mg
1 1 1 1
clonazepam tab 1 mg (Klonopin)
1
clonazepam tab 2 mg (Klonopin)
1
DEPAKENE - valproate sodium oral soln 250 mg/5ml (base equiv)
3
DEPAKENE - valproic acid cap 250 mg
3
DEPAKOTE - divalproex sodium tab delayed release 125 mg
3
DEPAKOTE - divalproex sodium tab delayed release 250 mg
3
DEPAKOTE - divalproex sodium tab delayed release 500 mg
3
DEPAKOTE ER - divalproex sodium tab er 24 hr 250 mg
3
DEPAKOTE ER - divalproex sodium tab er 24 hr 500 mg
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
3
DIASTAT ACUDIAL - diazepam 2 rectal gel delivery system 10 mg DIASTAT ACUDIAL - diazepam 2 rectal gel delivery system 20 mg 2 DIASTAT PEDIATRIC diazepam rectal gel delivery system 2.5 mg 2 DILANTIN - phenytoin sodium extended cap 30 mg 2 DILANTIN - phenytoin sodium extended cap 100 mg 3 DILANTIN INFATABS phenytoin chew tab 50 mg 2 DILANTIN-125 - phenytoin susp 125 mg/5ml 1 divalproex sodium cap delayed release sprinkle 125 mg (Depakote sprinkles) 1 divalproex sodium tab delayed release 125 mg (Depakote) 1 divalproex sodium tab delayed release 250 mg (Depakote) 1 divalproex sodium tab delayed release 500 mg (Depakote) 1 divalproex sodium tab er 24 hr 250 mg (Depakote er) 1 divalproex sodium tab er 24 hr 500 mg (Depakote er) 1 ethosuximide cap 250 mg (Zarontin) 1 ethosuximide soln 250 mg/5ml (Zarontin)
1
clonazepam tab 0.5 mg (Klonopin)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
158
FANATREX FUSEPAQ gabapentin oral susp 25 mg/ ml (cmpd kit)
3
gabapentin tab 600 mg (Neurontin)
1
felbamate susp 600 mg/5ml (Felbatol)
1
gabapentin tab 800 mg (Neurontin)
1
felbamate tab 400 mg (Felbatol)
1 1
GABITRIL - tiagabine hcl tab 2 mg
3
felbamate tab 600 mg (Felbatol)
GABITRIL - tiagabine hcl tab 4 mg
3
FELBATOL - felbamate susp 600 mg/5ml
3
GABITRIL - tiagabine hcl tab 12 mg
3
GABITRIL - tiagabine hcl tab 16 mg
3
KEPPRA - levetiracetam oral soln 100 mg/ml
3
KEPPRA - levetiracetam tab 250 mg
3
KEPPRA - levetiracetam tab 500 mg
3
KEPPRA - levetiracetam tab 750 mg
3
KEPPRA - levetiracetam tab 1000 mg
3
KEPPRA XR - levetiracetam tab er 24hr 500 mg
3
KEPPRA XR - levetiracetam tab er 24hr 750 mg
3
KLONOPIN - clonazepam tab 0.5 mg
3
gabapentin oral soln 250 mg/5ml (Neurontin)
FELBATOL - felbamate tab 400 3 mg FELBATOL - felbamate tab 600 3 mg 1 fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) (Cerebyx) 1 fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) (Cerebyx) FYCOMPA - perampanel susp 3 0.5 mg/ml FYCOMPA - perampanel tab 2 3 mg FYCOMPA - perampanel tab 4 3 mg FYCOMPA - perampanel tab 6 3 mg FYCOMPA - perampanel tab 8 3 mg 3 FYCOMPA - perampanel tab 10 mg 3 FYCOMPA - perampanel tab 12 mg 1 gabapentin cap 100 mg (Neurontin) 1 gabapentin cap 300 mg (Neurontin) 1 gabapentin cap 400 mg (Neurontin)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
KLONOPIN - clonazepam tab 1 3 mg KLONOPIN - clonazepam tab 2 3 mg LAMICTAL - lamotrigine tab 25 3 mg 3 LAMICTAL - lamotrigine tab 100 mg 3 LAMICTAL - lamotrigine tab 150 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
159
LAMICTAL - lamotrigine tab 200 mg
3
LAMICTAL CHEWABLE DISPERS - lamotrigine tab chewable dispersible 5 mg
3
LAMICTAL CHEWABLE DISPERS - lamotrigine tab chewable dispersible 25 mg
3
LAMICTAL ODT - lamotrigine orally disintegrating tab 25 mg
3
LAMICTAL ODT - lamotrigine orally disintegrating tab 50 mg
3
LAMICTAL ODT - lamotrigine orally disintegrating tab 100 mg
3
LAMICTAL ODT - lamotrigine orally disintegrating tab 200 mg
3
LAMICTAL ODT - lamotrigine tab disint 25 mg (21) & 50 mg (7) titration kit
3
LAMICTAL ODT - lamotrigine tab disint 50 mg (42)- 100 mg(14) titration kit
3
LAMICTAL ODT - lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7) kit
3
LAMICTAL STARTER/NOT TAKI - lamotrigine tab 25 mg (42) & 100 mg (7) starter kit
3
LAMICTAL STARTER/TAKING C - lamotrigine tab 25 mg (84) & 100 mg (14) starter kit
3
LAMICTAL STARTER/TAKING V - lamotrigine tab 25 mg (35) starter kit
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
LAMICTAL XR - lamotrigine tab 3 er 24hr 25 (14) & 50 mg (14) & 100 mg(7) kit 3 LAMICTAL XR - lamotrigine tab er 24hr 50 (14) & 100 mg(14) & 200 mg(7) kit LAMICTAL XR - lamotrigine tab 3 er 24hr 25 mg LAMICTAL XR - lamotrigine tab 3 er 24hr 50 mg LAMICTAL XR - lamotrigine tab 3 er 24hr 100 mg LAMICTAL XR - lamotrigine tab 3 er 24hr 200 mg LAMICTAL XR - lamotrigine tab 3 er 24hr 250 mg LAMICTAL XR - lamotrigine tab 3 er 24hr 300 mg 1 lamotrigine orally disintegrating tab 25 mg (Lamictal odt) 1 lamotrigine orally disintegrating tab 50 mg (Lamictal odt) 1 lamotrigine orally disintegrating tab 100 mg (Lamictal odt) 1 lamotrigine orally disintegrating tab 200 mg (Lamictal odt) 1 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) 1 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di) 1 lamotrigine tab disint 25 mg (21) & 50 mg (7) titration kit (Lamictal odt) 1 lamotrigine tab disint 50 mg (42)- 100 mg(14) titration kit (Lamictal odt)
LAMICTAL XR - lamotrigine tab 3 er 24hr 25 mg (21) & 50 mg (7) titration kit
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
160
LYRICA - pregabalin cap 50 mg
2
1
LYRICA - pregabalin cap 75 mg
2
1
LYRICA - pregabalin cap 100 mg
2
1
LYRICA - pregabalin cap 150 mg
2
1
LYRICA - pregabalin cap 200 mg
2
1
LYRICA - pregabalin cap 225 mg
2
1
LYRICA - pregabalin cap 300 mg
2
1
2
lamotrigine tab 25 mg (Lamictal)
LYRICA - pregabalin soln 20 mg/ml
1
MYSOLINE - primidone tab 50 mg
3
lamotrigine tab 100 mg (Lamictal)
MYSOLINE - primidone tab 250 mg
3
lamotrigine tab 150 mg (Lamictal)
1
NEURONTIN - gabapentin cap 100 mg
3
lamotrigine tab 200 mg (Lamictal)
1
NEURONTIN - gabapentin cap 300 mg
3
levetiracetam oral soln 100 mg/ml (Keppra)
1 1
NEURONTIN - gabapentin cap 400 mg
3
1
NEURONTIN - gabapentin oral soln 250 mg/5ml
3
NEURONTIN - gabapentin tab 600 mg
3
levetiracetam tab 250 mg (Keppra)
1
NEURONTIN - gabapentin tab 800 mg
3
levetiracetam tab 500 mg (Keppra)
1
ONFI - clobazam suspension 2.5 mg/ml
3
levetiracetam tab 750 mg (Keppra)
1 1
ONFI - clobazam tab 10 mg
3
levetiracetam tab 1000 mg (Keppra)
ONFI - clobazam tab 20 mg
3
LYRICA - pregabalin cap 25 mg
2
oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)
1
lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7) kit (Lamictal odt) lamotrigine tab er 24hr 25 mg (Lamictal xr) lamotrigine tab er 24hr 50 mg (Lamictal xr) lamotrigine tab er 24hr 100 mg (Lamictal xr) lamotrigine tab er 24hr 200 mg (Lamictal xr) lamotrigine tab er 24hr 250 mg (Lamictal xr) lamotrigine tab er 24hr 300 mg (Lamictal xr)
levetiracetam tab er 24hr 500 mg (Keppra xr) levetiracetam tab er 24hr 750 mg (Keppra xr)
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
161
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
oxcarbazepine tab 150 mg (Trileptal)
1
QUDEXY XR - topiramate cap er 24hr sprinkle 25 mg
3
oxcarbazepine tab 300 mg (Trileptal)
1
QUDEXY XR - topiramate cap er 24hr sprinkle 50 mg
3
oxcarbazepine tab 600 mg (Trileptal)
1
QUDEXY XR - topiramate cap er 24hr sprinkle 100 mg
3
OXTELLAR XR oxcarbazepine tab er 24hr 150 mg
3
QUDEXY XR - topiramate cap er 24hr sprinkle 150 mg
3
QUDEXY XR - topiramate cap er 24hr sprinkle 200 mg
3
OXTELLAR XR oxcarbazepine tab er 24hr 300 mg
3
2
•
OXTELLAR XR oxcarbazepine tab er 24hr 600 mg
3
SABRIL - vigabatrin powd pack 500 mg SABRIL - vigabatrin tab 500 mg
2
•
PEGANONE - ethotoin tab 250 mg
3
3
PHENYTEK - phenytoin sodium extended cap 200 mg
3
SPRITAM - levetiracetam tab disintegrating soluble 250 mg
3
PHENYTEK - phenytoin sodium extended cap 300 mg
3
SPRITAM - levetiracetam tab disintegrating soluble 500 mg
3
phenytoin chew tab 50 mg (Dilantin infatabs)
1
SPRITAM - levetiracetam tab disintegrating soluble 750 mg
3
PHENYTOIN SODIUM phenytoin sodium powder
3
SPRITAM - levetiracetam tab disintegrating soluble 1000 mg
1
TEGRETOL - carbamazepine susp 100 mg/5ml
3
phenytoin sodium extended cap 100 mg (Dilantin)
1
TEGRETOL - carbamazepine tab 200 mg
3
1
TEGRETOL-XR carbamazepine tab er 12hr 100 mg
3
TEGRETOL-XR carbamazepine tab er 12hr 200 mg
3
3
1
phenytoin sodium extended cap 200 mg (Phenytek) phenytoin sodium extended cap 300 mg (Phenytek) phenytoin sodium inj 50 mg/ ml
1
phenytoin susp 125 mg/5ml (Dilantin)
1
primidone tab 50 mg (Mysoline)
1
TEGRETOL-XR carbamazepine tab er 12hr 400 mg
primidone tab 250 mg (Mysoline)
1
tiagabine hcl tab 2 mg (Gabitril)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
162
tiagabine hcl tab 4 mg (Gabitril)
1
TRILEPTAL - oxcarbazepine tab 150 mg
3
TOPAMAX - topiramate tab 25 mg
3
TRILEPTAL - oxcarbazepine tab 300 mg
3
TOPAMAX - topiramate tab 50 mg
3
TRILEPTAL - oxcarbazepine tab 600 mg
3
TOPAMAX - topiramate tab 100 3 mg TOPAMAX - topiramate tab 200 3 mg 3 TOPAMAX SPRINKLE topiramate sprinkle cap 15 mg 3 TOPAMAX SPRINKLE topiramate sprinkle cap 25 mg TOPIRAMATE ER - topiramate 3 cap er 24hr sprinkle 25 mg TOPIRAMATE ER - topiramate 3 cap er 24hr sprinkle 50 mg TOPIRAMATE ER - topiramate 3 cap er 24hr sprinkle 100 mg TOPIRAMATE ER - topiramate 3 cap er 24hr sprinkle 150 mg TOPIRAMATE ER - topiramate 3 cap er 24hr sprinkle 200 mg 1 topiramate sprinkle cap 15 mg (Topamax sprinkle) 1 topiramate sprinkle cap 25 mg (Topamax sprinkle) 1 topiramate tab 25 mg (Topamax) 1 topiramate tab 50 mg (Topamax) 1 topiramate tab 100 mg (Topamax) 1 topiramate tab 200 mg (Topamax) 3 TRILEPTAL - oxcarbazepine susp 300 mg/5ml (60 mg/ml)
TROKENDI XR - topiramate cap er 24hr 25 mg
3
TROKENDI XR - topiramate cap er 24hr 50 mg
3
TROKENDI XR - topiramate cap er 24hr 100 mg
3
TROKENDI XR - topiramate cap er 24hr 200 mg
3
valproate sodium oral soln 250 mg/5ml (base equiv) (Depakene)
1
valproic acid cap 250 mg (Depakene)
1
VIMPAT - lacosamide oral solution 10 mg/ml
3
VIMPAT - lacosamide tab 50 mg
3
VIMPAT - lacosamide tab 100 mg
3
VIMPAT - lacosamide tab 150 mg
3
VIMPAT - lacosamide tab 200 mg
3
ZARONTIN - ethosuximide cap 250 mg
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ZARONTIN - ethosuximide soln 3 250 mg/5ml ZONEGRAN - zonisamide cap 3 25 mg ZONEGRAN - zonisamide cap 3 100 mg 1 zonisamide cap 25 mg (Zonegran) 1 zonisamide cap 50 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
163
zonisamide cap 100 mg (Zonegran) ANTIPARKINSON AGENTS amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml amantadine hcl tab 100 mg
1
carbidopa & levodopa orally disintegrating tab 25-250 mg
1
carbidopa & levodopa tab er 25-100 mg (Sinemet cr)
1 1
carbidopa & levodopa tab er 50-200 mg (Sinemet cr) carbidopa & levodopa tab 10-100 mg (Sinemet)
•
carbidopa & levodopa tab 25-100 mg (Sinemet)
AZILECT - rasagiline mesylate tab 1 mg (base equiv)
3
carbidopa & levodopa tab 25-250 mg (Sinemet)
BENZTROPINE MESYLATE benztropine mesylate powder
3
carbidopa tab 25 mg (Lodosyn)
1 2
benztropine mesylate inj 1 mg/ml (Cogentin)
1
CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 12.5-50-200 mg CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 18.75-75-200 mg
2
CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 25-100-200 mg
2
CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 31.25-125-200 mg
2
CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 37.5-150-200 mg
2
CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 50-200-200 mg
2
COGENTIN - benztropine mesylate inj 1 mg/ml
3
benztropine mesylate tab 2 mg
1
BROMOCRIPTINE MESYLATE - bromocriptine mesylate powder
3
bromocriptine mesylate cap 5 mg (base equivalent) (Parlodel)
1
bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel)
1
carbidopa & levodopa orally disintegrating tab 10-100 mg
1
carbidopa & levodopa orally disintegrating tab 25-100 mg
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
1
3
1
ACA
1
AZILECT - rasagiline mesylate tab 0.5 mg (base equiv)
benztropine mesylate tab 1 mg
Dispensing Limits
1
5
1
Step Therapy
1
APOKYN - apomorphine hcl soln cartridge 30 mg/3ml
benztropine mesylate tab 0.5 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1
Products October (2016 Plan Year)
164
COMTAN - entacapone tab 200 3 mg 3 DUOPA - carbidopa-levodopa enteral susp 4.63-20 mg/ml ELDEPRYL - selegiline hcl cap 3 5 mg 1 entacapone tab 200 mg (Comtan) LEVODOPA - levodopa powder 3
•
MIRAPEX ER - pramipexole dihydrochloride tab er 24hr 3.75 mg
3
MIRAPEX ER - pramipexole dihydrochloride tab er 24hr 4.5 mg
3
NEUPRO - rotigotine td patch 24hr 1 mg/24hr
3
NEUPRO - rotigotine td patch 24hr 2 mg/24hr
3
NEUPRO - rotigotine td patch 24hr 3 mg/24hr
3
NEUPRO - rotigotine td patch 24hr 4 mg/24hr
3
LODOSYN - carbidopa tab 25 mg
3
MIRAPEX - pramipexole dihydrochloride tab 0.125 mg
3
MIRAPEX - pramipexole dihydrochloride tab 0.25 mg
3
NEUPRO - rotigotine td patch 24hr 6 mg/24hr
3
MIRAPEX - pramipexole dihydrochloride tab 0.5 mg
3
NEUPRO - rotigotine td patch 24hr 8 mg/24hr
3
MIRAPEX - pramipexole dihydrochloride tab 0.75 mg
3
3
MIRAPEX - pramipexole dihydrochloride tab 1 mg
3
PARLODEL - bromocriptine mesylate cap 5 mg (base equivalent)
3
MIRAPEX - pramipexole dihydrochloride tab 1.5 mg
3
PARLODEL - bromocriptine mesylate tab 2.5 mg (base equivalent)
MIRAPEX ER - pramipexole dihydrochloride tab er 24hr 0.375 mg
3
pramipexole dihydrochloride tab er 24hr 0.375 mg (Mirapex er)
1
MIRAPEX ER - pramipexole dihydrochloride tab er 24hr 0.75 mg
3
pramipexole dihydrochloride tab er 24hr 0.75 mg (Mirapex er)
1
MIRAPEX ER - pramipexole dihydrochloride tab er 24hr 1.5 mg
3
pramipexole dihydrochloride tab er 24hr 1.5 mg (Mirapex er)
1
MIRAPEX ER - pramipexole dihydrochloride tab er 24hr 2.25 mg
3
pramipexole dihydrochloride tab er 24hr 2.25 mg (Mirapex er)
1
MIRAPEX ER - pramipexole dihydrochloride tab er 24hr 3 mg
3
pramipexole dihydrochloride tab er 24hr 3 mg (Mirapex er)
1
pramipexole dihydrochloride tab er 24hr 3.75 mg (Mirapex er)
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
165
pramipexole dihydrochloride tab er 24hr 4.5 mg (Mirapex er)
1
REQUIP XL - ropinirole hydrochloride tab er 24hr 6 mg (base equivalent)
3
pramipexole dihydrochloride tab 0.125 mg (Mirapex)
1
REQUIP XL - ropinirole hydrochloride tab er 24hr 8 mg (base equivalent)
3
REQUIP XL - ropinirole hydrochloride tab er 24hr 12 mg (base equivalent)
3
ropinirole hydrochloride tab er 24hr 2 mg (base equivalent) (Requip xl)
1
pramipexole dihydrochloride tab 0.25 mg (Mirapex) pramipexole dihydrochloride tab 0.5 mg (Mirapex) pramipexole dihydrochloride tab 0.75 mg (Mirapex) pramipexole dihydrochloride tab 1 mg (Mirapex) pramipexole dihydrochloride tab 1.5 mg (Mirapex)
1 1 1 1
ropinirole hydrochloride tab er 24hr 4 mg (base equivalent) (Requip xl)
1
rasagiline mesylate tab 0.5 mg (base equiv) (Azilect)
1
rasagiline mesylate tab 1 mg (base equiv) (Azilect)
1
ropinirole hydrochloride tab er 24hr 6 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab er 24hr 8 mg (base equivalent) (Requip xl)
REQUIP - ropinirole hydrochloride tab 0.25 mg
3
REQUIP - ropinirole hydrochloride tab 0.5 mg
3
ropinirole hydrochloride tab er 24hr 12 mg (base equivalent) (Requip xl)
REQUIP - ropinirole hydrochloride tab 1 mg
3
ropinirole hydrochloride tab 0.25 mg (Requip)
REQUIP - ropinirole hydrochloride tab 2 mg
3
ropinirole hydrochloride tab 0.5 mg (Requip)
REQUIP - ropinirole hydrochloride tab 3 mg
3
ropinirole hydrochloride tab 1 mg (Requip)
REQUIP - ropinirole hydrochloride tab 4 mg
3
ropinirole hydrochloride tab 2 mg (Requip)
REQUIP - ropinirole hydrochloride tab 5 mg
3
ropinirole hydrochloride tab 3 mg (Requip)
REQUIP XL - ropinirole hydrochloride tab er 24hr 2 mg (base equivalent)
3
ropinirole hydrochloride tab 4 mg (Requip)
REQUIP XL - ropinirole hydrochloride tab er 24hr 4 mg (base equivalent)
3
ropinirole hydrochloride tab 5 mg (Requip) RYTARY - carbidopa & levodopa cap er 23.75-95 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
1
1 1 1 1 1 1 1 3
Products October (2016 Plan Year)
166
RYTARY - carbidopa & levodopa cap er 36.25-145 mg
3
STALEVO 75 - carbidopalevodopa-entacapone tabs 18.75-75-200 mg
3
RYTARY - carbidopa & levodopa cap er 48.75-195 mg
3
TASMAR - tolcapone tab 100 mg
3
3
1
RYTARY - carbidopa & levodopa cap er 61.25-245 mg
tolcapone tab 100 mg (Tasmar)
1
SELEGILINE HCL - selegiline hcl powder
3
trihexyphenidyl hcl elixir 0.4 mg/ml
selegiline hcl cap 5 mg (Eldepryl)
1
selegiline hcl tab 5 mg
1
SINEMET - carbidopa & levodopa tab 10-100 mg
3
SINEMET - carbidopa & levodopa tab 25-100 mg
3
SINEMET - carbidopa & levodopa tab 25-250 mg
3
SINEMET CR - carbidopa & levodopa tab er 25-100 mg
3
SINEMET CR - carbidopa & levodopa tab er 50-200 mg
3
STALEVO 100 - carbidopalevodopa-entacapone tabs 25-100-200 mg
3
STALEVO 125 - carbidopalevodopa-entacapone tabs 31.25-125-200 mg
3
STALEVO 150 - carbidopalevodopa-entacapone tabs 37.5-150-200 mg
3
STALEVO 200 - carbidopalevodopa-entacapone tabs 50-200-200 mg
3
STALEVO 50 - carbidopalevodopa-entacapone tabs 12.5-50-200 mg
3
trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg NEUROMUSCULAR AGENTS
SM
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1 1
ANECTINE - succinylcholine chloride inj 20 mg/ml
3
BOTOX - onabotulinumtoxina for inj 100 unit
3
BOTOX - onabotulinumtoxina for inj 200 unit
3
DYSPORT abobotulinumtoxina for im inj 300 unit
3
•
DYSPORT abobotulinumtoxina for im inj 500 unit
3
•
MYOBLOC rimabotulinumtoxinb im inj 2500 unit/0.5ml
3
MYOBLOC rimabotulinumtoxinb im inj 5000 unit/ml
3
MYOBLOC rimabotulinumtoxinb im inj 10000 unit/2ml
3
QUELICIN - succinylcholine chloride inj 20 mg/ml
3
RILUTEK - riluzole tab 50 mg
3
riluzole tab 50 mg (Rilutek)
1
XEOMIN - incobotulinumtoxina for im inj 50 unit
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3
Products October (2016 Plan Year)
•
167
XEOMIN - incobotulinumtoxina for im inj 100 unit
3
XEOMIN - incobotulinumtoxina for im inj 200 unit
3
MUSCULOSKELETAL THERAPY AGENTS 3 ACTIVECYCLOBENZAPRINE KI cyclobenzaprine hcl td cream 5% (compound kit) 3 AMRIX - cyclobenzaprine hcl cap er 24hr 15 mg 3 AMRIX - cyclobenzaprine hcl cap er 24hr 30 mg BACLOFEN - baclofen powder 3 baclofen tab 10 mg baclofen tab 20 mg
carisoprodol tab 250 mg (Soma)
1
carisoprodol tab 350 mg (Soma)
1
carisoprodol w/ aspirin & codeine tab 200-325-16 mg
1
carisoprodol w/ aspirin tab 200-325 mg
DANTRIUM - dantrolene sodium cap 50 mg
3
dantrolene sodium cap 25 mg (Dantrium)
1
dantrolene sodium cap 100 mg
1 3
3
dantrolene sodium cap 50 mg (Dantrium)
1
CARISOPRODOL carisoprodol powder
DANTRIUM - dantrolene sodium cap 25 mg
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1
ENOVARXCYCLOBENZAPRINE H cyclobenzaprine hcl td cream 20 mg/gm (compound kit)
3
FEXMID - cyclobenzaprine hcl tab 7.5 mg
3
FIRST-BACLOFEN 1 baclofen oral susp 1 mg/ml (cmpd kit)
3
FIRST-BACLOFEN 5 baclofen oral susp 5 mg/ml (cmpd kit)
3
GABLOFEN - baclofen intrathecal soln prefilled syringe 50 mcg/ml
3
3
CARTICEL - autologous cultured chondrocytes for implantation
3
GABLOFEN - baclofen intrathecal soln prefilled syringe 10000 mcg/20ml
3
chlorzoxazone tab 500 mg (Parafon forte dsc)
1
GABLOFEN - baclofen intrathecal soln prefilled syringe 20000 mcg/20ml
cyclobenzaprine hcl tab 5 mg
1
GABLOFEN - baclofen intrathecal soln prefilled syringe 40000 mcg/20ml
3
LIORESAL INTRATHECAL baclofen intrathecal inj 0.05 mg/ml (50 mcg/ml)
3
•
LIORESAL INTRATHECAL baclofen intrathecal inj 10 mg/20ml (500 mcg/ml)
3
•
cyclobenzaprine hcl tab 7.5 mg (Fexmid) cyclobenzaprine hcl tab 10 mg CYCLOPHENE RAPIDPAQ cyclobenzaprine hcl td cream 5% (compound kit)
1 1 3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
168
LIORESAL INTRATHECAL baclofen intrathecal inj 10 mg/5ml (2000 mcg/ml)
3
LIORESAL INTRATHECAL baclofen intrathecal inj 40 mg/20ml (2000 mcg/ml)
3
LORZONE - chlorzoxazone tab 375 mg
3
LORZONE - chlorzoxazone tab 750 mg
3
MACI - autologous cultured chondrocyte on collagen membrane sheet
SOMA - carisoprodol tab 350 mg
3
TABRADOL FUSEPAQ cyclobenzaprine hcl w/ msm oral susp 1 mg/ml (cmpd kit)
3
TABRADOL RAPIDPAQ cyclobenzaprine hcl w/ msm oral susp 1 mg/ml (cmpd kit)
3
1
3
tizanidine hcl cap 2 mg (base equivalent) (Zanaflex)
1
METAXALONE - metaxalone tab 400 mg
3
tizanidine hcl cap 4 mg (base equivalent) (Zanaflex)
1
metaxalone tab 800 mg (Skelaxin)
1
tizanidine hcl cap 6 mg (base equivalent) (Zanaflex)
methocarbamol inj 1000 mg/10ml (Robaxin)
1
tizanidine hcl tab 2 mg (base equivalent)
1
methocarbamol tab 500 mg (Robaxin)
1
tizanidine hcl tab 4 mg (base equivalent) (Zanaflex)
methocarbamol tab 750 mg (Robaxin-750)
1
ZANAFLEX - tizanidine hcl cap 2 mg (base equivalent)
3
ORPHENADRINE CITRATE orphenadrine citrate powder
3
ZANAFLEX - tizanidine hcl cap 4 mg (base equivalent)
3
orphenadrine citrate inj 30 mg/ml (Norflex)
1
ZANAFLEX - tizanidine hcl cap 6 mg (base equivalent)
3
1
ZANAFLEX - tizanidine hcl tab 4 mg (base equivalent)
3
PARAFON FORTE DSC chlorzoxazone tab 500 mg
3
ANTIMYASTHENIC AGENTS
ROBAXIN - methocarbamol inj 1000 mg/10ml
3
orphenadrine citrate tab er 12hr 100 mg
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
ENLON - edrophonium chloride 3 inj 10 mg/ml 3 GUANIDINE HCL - guanidine hcl tab 125 mg 3 MESTINON - pyridostigmine bromide syrup 60 mg/5ml 3 MESTINON - pyridostigmine bromide tab 60 mg 3 MESTINON TIMESPAN pyridostigmine bromide tab er 180 mg
ROBAXIN - methocarbamol tab 3 500 mg 3 ROBAXIN-750 methocarbamol tab 750 mg 3 SKELAXIN - metaxalone tab 800 mg 3 SOMA - carisoprodol tab 250 mg SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
169
pyridostigmine bromide tab er 180 mg (Mestinon timespan)
1
pyridostigmine bromide tab 60 mg (Mestinon) REGONOL - pyridostigmine bromide iv soln 10 mg/2ml (5 mg/ml)
ERGOCALCIFEROL ergocalciferol powder
3
1
ergocalciferol cap 50000 unit (Drisdol)
1
3
MEPHYTON - phytonadione tab 5 mg
2
NIACIN - niacin oral powder
3
NIACIN - niacin powder
3
NIACINAMIDE - niacinamide powder
3
NICOTINAMIDE - niacinamide powder
3
NUTRITIONAL PRODUCTS VITAMINS AMINOBENZOATE POTASSIUM - potassium aminobenzoate packet 2 gm
3
AMINOBENZOIC ACID - paraaminobenzoic acid powder
3
AQUASOL A PARENTERAL vitamin a inj 50000 unit/ml
3
ascorbic acid inj 500 mg/ml
1
BABY DDROPS cholecalciferol drops 400 unit/0.03ml (per drop)
A
BIOTIN - biotin powder
3
CALCIUM ASCORBATE DIHYDRA - calcium ascorbate powder
3
CALCIUM PANTOTHENATE calcium pantothenate powder
3
cholecalciferol cap 400 unit
A
cholecalciferol chew tab 400 unit cholecalciferol drops 400 unit/0.03ml (per drop) cholecalciferol oral liquid 400 unit/ml cholecalciferol tab 400 unit
•
3
SODIUM ASCORBATE sodium ascorbate powder
3
•
sodium ascorbate inj 250 mg/ml
1
A
•
THIAMINE HCL - thiamine hcl powder
3
A
• •
thiamine hcl inj 100 mg/ml
1
A
D-VI-SOL - cholecalciferol oral liquid 400 unit/ml
A
ERGOCAL - ergocalciferol cap 2500 unit
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
PARA-AMINOBENZOIC ACID - 3 para-aminobenzoic acid powder phytonadione inj 1 mg/0.5ml 1 (2 mg/ml) 3 POTABA - potassium aminobenzoate cap 500 mg 3 POTASSIUM PAMINOBENZOATE potassium aminobenzoate powder PYRIDOXINE HCL - pyridoxine 3 hcl powder 1 pyridoxine hcl inj 100 mg/ml SODIUM ASCORBATE sodium ascorbate granules
A
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
THIAMINE HYDROCHLORIDE thiamine hcl powder
3
VITAMIN D2 - ergocalciferol tab 400 unit
A
Products October (2016 Plan Year)
•
170
VITAMIN D3 - cholecalciferol oral liquid 1200 unit/15ml
A
VITAMIN E ACETATE - vitamin e powder
3
3
DIALYVITE 5000 - b-complex w/ c-biotin-e-minerals & folic acid tab 5 mg
3
VITAMIN K1 - phytonadione inj 10 mg/ml
3
DIALYVITE/ZINC - b-complex w/ c-zn & folic acid tab 1 mg
3
WHEAT GERM - wheat germ oil
3
ESCAVITE - pediatric multiple vitamins w/ fl-fe chew tab 0.25-7.5 mg
4-AMINOBENZOIC ACID POTAS - potassium aminobenzoate powder
3
ESCAVITE D - pediatric multiple vitamins w/ fl-fe chew tab 0.25-6 mg
3
ESCAVITE LQ - pediatric multiple vitamins w/ fl-fe drops 0.25-6 mg/ml
3
FLORIVA - ped multiple vitamins & minerals w/ fl chew tab 0.25 mg
3
FLORIVA - ped multiple vitamins & minerals w/ fl chew tab 0.5 mg
3
FLORIVA - ped multiple vitamins & minerals w/ fl chew tab 1 mg
3
FLORIVA PLUS - pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml
3
MULTIVITAMINS ADRENAL C FORMULA bioflavonoid products tab
3
ADVANCED AM/PM - multiple vitamins w/ calcium therapy pack
3
AP-ZEL - multiple vitamins w/ minerals tab
3
b-complex vitamin inj
1
b-complex w/ c & folic acid cap 1 mg (Nephrocaps) b-complex w/ c & folic acid tab b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) b-complex w/ c & folic acid tab 5 mg
1 1 1
3
COD LIVER OIL - cod liver oil
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
FOLBEE PLUS CZ - b-complex 3 w/ c-biotin-minerals & folic acid tab 5 mg FOLGARD OS - multiple vit w/ 3 min & calcium-folic acid tab 500-1.1 mg 3 FORTAVIT - multiple vitamins w/ minerals cap 1 multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite) 1 multiple vitamins w/ minerals cap 1 multiple vitamins w/ minerals tab (Strovite forte)
1
BACMIN - multiple vitamins w/ minerals tab
Prior Authorization
Drug Name
Drug Tier
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
CORVITE - multiple vitamins w/ 3 minerals & fa tab 1.25 mg 3 DIALYVITE SUPREME D multiple vitamins w/ minerals & fa tab 3 mg 3 DIALYVITE 3000 - b-complex w/ c-biotin-e-minerals & folic acid tab 3 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
171
MULTIVITAMIN WITH FLUORID - multiple vit & fluoride-folic acid chew tab 0.25-0.3 mg
3
MULTIVITAMIN WITH FLUORID - multiple vit & fluoride-folic acid chew tab 0.5-0.3 mg
3
MULTIVITAMIN WITH FLUORID - multiple vit & fluoride-folic acid chew tab 1-0.3 mg
3
MULTIVITAMIN/FLUORIDE pediatric multiple vitamins w/ fluoride chew tab 0.25 mg
3
MULTIVITAMIN/FLUORIDE pediatric multiple vitamins w/ fluoride chew tab 0.5 mg
3
MULTIVITAMIN/FLUORIDE pediatric multiple vitamins w/ fluoride chew tab 1 mg
3
MYKIDZ IRON FL - pediatric vitamins acd fluoride & fe susp 0.25-10 mg/2ml
3
NEPHPLEX RX - b-complex w/ c-zn & folic acid tab 1 mg
3
NICOMIDE - niacinamide w/ zn-cu-methylfolate tab 750-25-1.5-0.5 mg
3
NUTRICAP - multiple vitamins w/ minerals tab
3
NUTRIVIT - b-complex w/ lysine-min-fe & fa liqd 800-15-1 mg/15ml
3
OCUVEL - multiple vitamins w/ minerals & fa cap 0.5 mg
3
pediatric multiple vitamin w/ minerals & c drops 45 mg/ ml
1
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ ml pediatric multiple vitamins w/ fluoride chew tab 0.25 mg pediatric multiple vitamins w/ fluoride chew tab 0.5 mg pediatric multiple vitamins w/ fluoride chew tab 1 mg pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml
NEPHRO-VITE RX - b-complex 3 w/ c & folic acid tab 1 mg NEPHROCAPS - b-complex w/ 3 c & folic acid cap 1 mg 3 NICADAN - multiple vitamins w/ minerals tab 3 NICADAN ZX - multiple vitamins w/ minerals tab NICAZEL - multiple vitamins w/ 3 minerals tab 3 NICAZEL FORTE - multiple vitamins w/ minerals tab 3 NICOMIDE - niacinamide w/ zn-cu-methylfol-se-cr tab 750-27-2-0.5 mg
pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml pediatric vitamins acd w/ fluoride soln 0.25 mg/ml pediatric vitamins acd w/ fluoride soln 0.5 mg/ml
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
1 1 1 1 1
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 0.25 mg
3
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 0.5 mg
3
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 1 mg
3
Products October (2016 Plan Year)
172
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic susp 0.25 mg/ml
3
QUFLORA PEDIATRIC pediatric multiple vitamins w/ fluoride chew tab 0.5 mg
3
POLY-VI-FLOR FS - pediatric multiple vit w/ fluoride oral strip 0.25 mg
3
QUFLORA PEDIATRIC pediatric multiple vitamins w/ fluoride chew tab 1 mg
3
POLY-VI-FLOR FS - pediatric multiple vit w/ fluoride oral strip 0.5 mg
3
QUFLORA PEDIATRIC pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml
3
POLY-VI-FLOR FS - pediatric multiple vitamins w/ fluoride oral strip 1 mg
3
QUFLORA PEDIATRIC pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml
3
POLY-VI-FLOR/IRON - ped multiple vit w/ fl-fe biphasic chew tab 0.5-10 mg
3
RENATABS - b-complex w/ cbiotin-vit e & folic acid tab 1 mg
3
POLY-VI-FLOR/IRON - ped multiple vitamin w/ fl-fe biphasic susp 0.25-7 mg/ml
3
3
PRENATABS RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg
2
RENATABS WITH IRON - b complex-c-biotin-e-fa tab 1mg & fe cbn tab 100 mg pack REQ 49+ - multiple vitamins w/ minerals tab
3
PRENATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg
2
PRENATAL 19 - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg
2
PRENATAL-U - prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg
2
PROTECT PLUS - multiple vitamins w/ minerals cap
3
QUFLORA FE - multi vit w/ min & fluoride-iron-fa chew tab 0.25 mg
3
QUFLORA FE PEDIATRIC pediatric multiple vitamins w/ fl-fe drops 0.25-9.5 mg/ml
3
QUFLORA PEDIATRIC pediatric multiple vitamins w/ fluoride chew tab 0.25 mg
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
SIDEROL - multiple vitamins w/ 3 minerals tab 1 speciality vitamin product tab 3 STROVITE FORTE - multiple vitamins w/ minerals & fa syrup 1 mg/15ml 3 STROVITE FORTE - multiple vitamins w/ minerals tab 3 STROVITE ONE - multiple vitamins w/ minerals tab 3 SUPERVITE - b-complex w/ lysine-zn & folic acid liquid 3 SUPPORT - multiple vitamins w/ minerals liquid 3 SUPPORT-500 - speciality vitamin product cap 3 SYNAGEX - multiple vitamins w/ minerals & fa cap 1.25 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
173
SYNATEK - multiple vitamins w/ minerals & fa cap 1.25 mg
3
TEXAVITE LQ - pediatric multivitamins w/fl-fe-zn drops 0.25-7-3 mg/ml
3
TL G-FOL OS - multiple vit w/ min & calcium-folic acid tab 500-1.1 mg
3
TL-FLUORIVITE - pediatric multiple vitamins w/ fl-fe chew tab 0.25-7.5 mg
3
TRI-VI-FLOR - ped vit acd & lmethylfol w/ fl biphasic susp 0.25 mg/ml
3
TRI-VI-FLOR - ped vit acd & lmethylfol w/ fl biphasic susp 0.5 mg/ml
3
TRI-VI-FLORO - ped vit acd & l-methylfol w/ fl biphasic susp 0.25 mg/ml
3
TRI-VI-FLORO - ped vit acd & l-methylfol w/ fl biphasic susp 0.5 mg/ml
3
TRI-VIT/FLUORIDE/IRON pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml
2
TRINATE - prenatal vit w/ fe fumarate-fa tab 28-1 mg
2
UDAMIN SP - multiple vitamins w/ minerals & fa tab 1 mg
3
VITA-RX DIABETIC VITAMIN speciality vitamin product cap
3
VITAFOL - iron w/ vitamin tab
3
VITAJECT - b-complex w/ c inj
3
VITAL-D RX - b-complex w/ cbiotin-d-zinc & folic acid tab 1 mg
3
VITAROCA PLUS - multiple vitamins w/ minerals tab
3
VP-ZEL - multiple vitamins w/ minerals tab
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3
MINERALS and ELECTROLYTES CALCIFOL - ca carb-folic acid- 3 vit d-b6-b12-boron-mag wafer 1342-1.6 mg 3 CALCIUM CARBONATE calcium carbonate powder 3 CALCIUM CARBONATE HEAVY - calcium carbonate powder 3 CALCIUM CARBONATE LIGHT - calcium carbonate powder 3 CALCIUM CHLORIDE ANHYDROU - calcium chloride (dihydrate) granules 3 CALCIUM CHLORIDE DIHYDRAT - calcium chloride (dihydrate) granules 3 CALCIUM CHLORIDE DIHYDRAT - calcium chloride (dihydrate) powder 3 CALCIUM GLUCONATE ANHYDRO - calcium gluconate powder 3 CALCIUM GLUCONATE MONOHYD - calcium gluconate powder 3 CALCIUM LACTATE PENTAHYDR - calcium lactate pentahydrate powder 3 CALCIUM PHOSPHATE DIBASIC - calcium phosphate, dibasic powder 3 CALCIUM PHOSPHATE TRIBASI - calcium phosphate, tribasic powder 3 CALCIUM-FOLIC ACID PLUS D - ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
174
CUPRIC SULFATE - cupric sulfate powder
3
IODOPEN - sodium iodide inj 100 mcg/ml
3
CUPRIC SULFATE PENTAHYDRA - cupric sulfate granules
3
K-PHOS - potassium phosphate monobasic tab 500 mg
2
EFFER-K - potassium bicarbonate-citric acid effer tab 10 meq
3
3
EFFER-K - potassium bicarbonate-citric acid effer tab 20 meq
3
K-PHOS NEUTRAL - pot phos monobasic w/sod phos di & monobas tab 155-852-130mg K-TAB - potassium chloride tab er 8 meq (600 mg)
3
ELLIOTTS B - intrathecal electrolytes w/ dextrose
3
3
FLORICAL - sodium fluoride w/ calcium carb cap 8.3-364 mg
A
•
K-TAB - potassium chloride tab er 10 meq
3
FLORICAL - sodium fluoride w/ calcium carb tab 8.3-364 mg
A
•
K-TAB - potassium chloride tab er 20 meq (1500 mg)
3
FLORIVA - sodium fluoridevitamin d liqd drops 0.25 mg/ ml-400 unit/ml
3
•
KLOR-CON M15 - potassium chloride microencapsulated crys er tab 15 meq
3
FLUOR-A-DAY - sodium fluoride-xylitol chew tab 0.55 (0.25 mg f)-236.79 mg
2
LOZI-FLUR - sodium fluoride lozenge 1 mg f (from 2.2 mg naf)
3
FLUOR-A-DAY - sodium fluoride-xylitol chew tab 2.2 (1 mg f)-236.79 mg
2
MAGNEBIND 400 magnesium-calcium-folic acid tab 400-200-1 mg
3
FLUORABON - sodium fluoride soln 0.25 mg/0.6ml (from 0.55 mg/0.6ml naf)
3
MAGNESIUM CARBONATE HEAVY - magnesium carbonate powder
3
FLURA-DROPS - sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf)
2
MAGNESIUM CARBONATE LIGHT - magnesium carbonate powder MAGNESIUM CHLORIDE magnesium chloride powder
3
GALZIN - zinc acetate cap 25 mg (elemental zinc)
3
3
GALZIN - zinc acetate cap 50 mg (elemental zinc)
3
MAGNESIUM CHLORIDE HEXAHY - magnesium chloride crystals
1
GNP VITAMIN D-400 - calcium carbonate-cholecalciferol tab 90 mg-400 unit
3
magnesium chloride inj 200 mg/ml
IODINE STRONG - iodine solution strong 5% (lugol's)
3
MAGNESIUM SULFATE magnesium sulfate iv soln 2 gm/50ml (40 mg/ml)
• • • •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
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Drug Name
Drug Tier
2016
•
3
Products October (2016 Plan Year)
175
MAGNESIUM SULFATE magnesium sulfate iv soln 4 gm/100ml (40 mg/ml)
3
POTASSIUM BICARBONATE potassium bicarbonate granules
3
MAGNESIUM SULFATE magnesium sulfate iv soln 20 gm/500ml (40 mg/ml)
3
POTASSIUM BICARBONATE potassium bicarbonate powder
3
MAGNESIUM SULFATE magnesium sulfate iv soln 40 gm/1000ml (40 mg/ml)
3
potassium bicarbonate effer tab 25 meq
1
3
POTASSIUM CHLORIDE potassium chloride granules
3
MAGNESIUM SULFATE magnesium sulfate iv soln 4 gm/50ml (80 mg/ml)
3
magnesium sulfate inj 50%
1
POTASSIUM CHLORIDE potassium chloride oral soln 20% (40 meq/15ml)
magnesium sulfate iv soln 2 gm/50ml (40 mg/ml) (Magnesium sulfate)
1
POTASSIUM CHLORIDE potassium chloride powder (for compounding)
3
magnesium sulfate iv soln 4 gm/100ml (40 mg/ml) (Magnesium sulfate)
1
potassium chloride cap er 8 meq (Micro-k)
1
magnesium sulfate iv soln 20 gm/500ml (40 mg/ml) (Magnesium sulfate)
1
potassium chloride cap er 10 meq (Micro-k)
3
magnesium sulfate iv soln 40 gm/1000ml (40 mg/ml) (Magnesium sulfate)
1
POTASSIUM CHLORIDE ER potassium chloride tab er 8 meq (600 mg)
3
magnesium sulfate iv soln 4 gm/50ml (80 mg/ml) (Magnesium sulfate)
1
POTASSIUM CHLORIDE ER potassium chloride tab er 20 meq (1500 mg)
1
MICRO-K - potassium chloride cap er 8 meq
3
potassium chloride microencapsulated crys er tab 10 meq
MICRO-K - potassium chloride cap er 10 meq
3
MONOCAL - sodium monofluorophosphatecalcium carb tab 22.75-625 mg
A
pot bicarbonate & chloride effer tab 25 meq
1
pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-phos neutral)
potassium chloride microencapsulated crys er tab 20 meq
•
potassium chloride oral soln 10% (20 meq/15ml) potassium chloride powder packet 20 meq potassium chloride tab er 8 meq (600 mg)
1
potassium chloride tab er 10 meq (K-tab)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
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Limited Distribution
ACA
Dispensing Limits
Step Therapy
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Drug Name
Drug Tier
2016
1
1
1 1 1 1
Products October (2016 Plan Year)
176
SODIUM ACETATE ANHYDROUS - sodium acetate crystals
3
SSKI - potassium iodide soln 1 gm/ml
2
ZINC SULFATE - zinc sulfate powder
3
SODIUM ACETATE ANHYDROUS - sodium acetate powder
3
3
SODIUM ACETATE TRIHYDRATE - sodium acetate granules
3
ZINC SULFATE HEPTAHYDRATE - zinc sulfate granules
3
SODIUM CHLORIDE - sodium chloride granules
3
ZINC SULFATE HEPTAHYDRATE - zinc sulfate powder ZINC SULFATE MONOHYDRATE - zinc sulfate powder
3
SODIUM CHLORIDE - sodium chloride powder
3
sodium chloride flush iv soln 0.9%
1
NUTRIENTS
sodium chloride inj 0.9% sodium chloride inj 2.5 meq/ ml (14.6%) sodium chloride iv soln 0.9%
acetylcysteine cap 600 mg
1 1 1
SODIUM FLUORIDE - sodium fluoride tab 0.5 mg f (from 1.1 mg naf)
2
SODIUM FLUORIDE - sodium fluoride tab 1 mg f (from 2.2 mg naf)
2
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride)
1
• • •
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride)
1
•
sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride)
1
•
sodium fluoride soln 0.125 mg/drop f (0.275 mg/ drop naf)
1
sodium fluoride soln 0.5 mg/ ml f (from 1.1 mg/ml naf) (Luride)
1
• •
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
ALANINE - alanine powder
3
amino acids cap
1
CARDIOVID PLUS - dha-epavit b6-b12-folic acid cap 240-360-20-0.5-0.8 mg
3
CHOLINE BITARTRATE choline bitartrate powder
3
DEXTROSE - dextrose powder
3
DEXTROSE ANHYDROUS dextrose powder
3
DL-ALANINE - alanine powder
3
DL-LEUCINE - leucine powder
3
DL-METHIONINE - methionine powder
3
DL-PHENYLALANINE phenylalanine powder
3
FRUCTOSE - fructose granules
3
FRUCTOSE - fructose powder
3
GLUTAMINE - glutamine powder (bulk)
3
GLUTATHIONE-L - glutathione bulk powder
3
GLUTATHIONE-L REDUCED glutathione bulk powder
3
Products October (2016 Plan Year)
177
L-ALANINE - alanine powder
3
L-ARGININE - arginine powder
3
L-ARGININE BASE - arginine powder
3
L-CYSTINE - cystine powder
3
L-GLUTAMIC ACID - glutamic acid powder
3
L-GLUTAMINE - glutamine crystals
3
L-GLUTAMINE - glutamine powder (bulk)
3
L-HISTIDINE - histidine powder 3 3 L-HISTIDINE MONOHYDROCHLO histidine hcl crystals 3 L-HISTIDINE MONOHYDROCHLO histidine hcl powder 3 L-ISOLEUCINE - isoleucine powder 3 L-LEUCINE - leucine powder L-METHIONINE - methionine powder
3
L-PHENYLALANINE phenylalanine powder
3
L-PROLINE - proline powder
3
L-THREONINE - threonine crystals
3
L-TRYPTOPHAN - tryptophan powder
3
3
LECITHIN - lecithin (bulk) granules
3
LECITHIN - lecithin granules
3
METHIONINE - methionine powder
3
3
NEOKE MCT70 - medium chain triglycerides oral powder 70 gm/100gm
3
NUTRESTORE - glutamine powd pack 5 gm
3
TAURINE - taurine liquid (bulk)
3
TAURINE - taurine powder
3
THREONINE - threonine powder
3
TRYPTOPHAN - tryptophan cap 500 mg
3
TRYPTOPHAN - tryptophan powder
3
VALINE - valine powder
3
DIETARY PRODUCTS
L-TYROSINE - tyrosine powder 3 3 L-VALINE - valine crystals L-VALINE - valine powder
NEOKE ALCAR acetylcarnitine oral powder
APP SLIM RMS - nutritional supplement - diet aids cap
3
ASPARTAME - aspartame powder (for compounding)
3
ASPARTAME (NUTRASWEET) aspartame powder (for compounding)
3
CAMINO PRO 15PE nutritional supplement liquid
3
FIBERSOURCE HN nutritional supplement liquid
3
GLYTACTIN BETTERMILK DE-L - nutritional supplement pack
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
GLYTACTIN BETTERMILK 15 - 3 nutritional supplement pack 3 GLYTACTIN BUILD 10PE nutritional supplement pack 3 GLYTACTIN COMPLETE 10PE - nutritional supplement bar
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
178
GLYTACTIN RESTORE LITE 10 - nutritional supplement pack
3
TYLACTIN RESTORE 10 nutritional supplement liquid
3
TYLACTIN RESTORE 5PE nutritional supplement pack
3
GLYTACTIN RESTORE 5 nutritional supplement pack
3
TYLACTIN RTD 15 - nutritional supplement liquid
3
GLYTACTIN RTD 10 nutritional supplement liquid
3 3
VILACTIN AA PLUS nutritional supplement liquid
3
GLYTACTIN RTD 15 nutritional supplement liquid HOMACTIN AA PLUS nutritional supplement liquid
3
XYZBAC - dietary management 3 product - tabs
ISOVACTIN AA PLUS nutritional supplement liquid
3
KETOVIE - nutritional supplement liquid
3
KETOVIE PEPTIDE nutritional supplement liquid
3
NOURISH - nutritional supplement liquid
3
nutritional supplement liquid
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
HEMATOLOGICAL AGENTS HEMATOPOIETIC AGENTS ABANEU-SL cyanocobalaminmethylcobalamin tab sl 600-600 mcg
3
ACTIVE FE - fe carbonyl-fab complex-a-c-d-e-min tab 75-1.25 mg
3
ANIMI-3 - folic acid-b6-b12-domega 3-phytosterols cap 1 mg
3
PHENACTIN AA PLUS nutritional supplement liquid
3
PKU EASY MICROTABS nutritional supplement tabs delayed release
3
ANIMI-3/VITAMIN D - folic acid-b6-b12-d-omega 3phytosterols cap 1 mg
3
PROMACTIN AA PLUS nutritional supplement liquid
3
4
•
PROMACTIN AA PLUS 20PE nutritional supplement susp
3
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 25 mcg/ml
4
•
SACCHARIN - saccharin powder
3
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 40 mcg/ml
SACCHARIN SODIUM sodium saccharin granules
3
4
•
SACCHARIN SODIUM sodium saccharin powder
3
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 60 mcg/ml
4
•
THRIVACIN DETOX nutritional supplement liquid
3
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 100 mcg/ml
3
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 200 mcg/ml
4
THRIVACIN 30 - nutritional supplement liquid
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
179
4
ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe 10 mcg/0.4ml
4
ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe 25 mcg/0.42ml
4
ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe 40 mcg/0.4ml
4
•
ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe 60 mcg/0.3ml
4
•
ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 100 mcg/0.5ml
4
•
ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 150 mcg/0.3ml
4
•
ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 200 mcg/0.4ml
4
ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 300 mcg/0.6ml
4
ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 500 mcg/ml
4
B-12 COMPLIANCE INJECTION cyanocobalamin inj kit 1000 mcg/ml
3
• •
• • •
B-6 FOLIC ACID - cobalamine combination cap
3
BIFERARX - polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg
3
BP VIT 3 - folic acid-vit b6-vit b12-omega 3-phytosterols cap 1 mg
3
carbonyl iron susp 15 mg/1.25ml (elemental iron)
A
CENFOL - folic acid-vitamin b6-vitamin b12 tab 2.3-24.5-2 mg
3
CENTRATEX - ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg
3
CERDELGA - eliglustat tartrate cap 84 mg (base equivalent)
5
CIFEREX - folic acidcholecalciferol cap 1 mg-3775 unit
3
CIFRAZOL - folic acidcholecalciferol cap 1 mg-3775 unit
3
CORVITE FE - iron combination tab
3
CORVITE 150 - iron combination tab
3
CORVITE 150 - iron-folic acidvit c-vit b6-vit b12-zinc tab 150-1.25 mg
3
CYANOCOBALAMIN cyanocobalamin crystals
3
CYANOCOBALAMIN cyanocobalamin powder (for compounding)
3
cyanocobalamin inj 1000 mcg/ml
1
CYFOLEX - fa-d3-ca carbcollagen bovine cap 1 mg-800 unt-50 mg-300 mg SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 300 mcg/ml
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
3
Products October (2016 Plan Year)
180
DERMACINRX PUREFOLIX folic acid-cholecalciferol tab 1 mg-5000 unit
3
FERIVA 21/7 - fe asparto glyb12-fa-c-dss-succinic acidzn tab 75-1 mg
3
DIVISTA - folic acid-vit b6-vit b12-omega 3-biotin-cr cap 1 mg
3
FERIVAFA - iron-c-fa-b12biotin-copper-docusate cap 110-1 mg
3
DROXIA - hydroxyurea cap 200 mg
3
3
DROXIA - hydroxyurea cap 300 mg
3
FERRALET 90 - fe carbonyl-fe gluconate-fa-vit b12-vit c-dss tab 90-1 mg
3
DROXIA - hydroxyurea cap 400 mg
3
FERRAPLUS 90 - iron-folic acid-vit b12-vit c-docusate sod tab 90-1 mg
DURACHOL - folic acidcholecalciferol cap 1 mg-3775 unit
3
FERRETTS CHEWABLE IRON - carbonyl iron chew tab 18 mg (elemental iron)
A
EPOGEN - epoetin alfa inj 2000 unit/ml
5
•
3
EPOGEN - epoetin alfa inj 3000 unit/ml
5
•
FERRO-PLEX HEMATINIC - fe fum-dss-vit c-vit e-vit b12-iffa tab 115-1 mg
3
EPOGEN - epoetin alfa inj 4000 unit/ml
5
•
FERROTRIN - iron w/ b12-vit c-fa-ifc cap 36-0.015-75-0.5-240 mg
EPOGEN - epoetin alfa inj 10000 unit/ml
5
•
1
EPOGEN - epoetin alfa inj 20000 unit/ml
5
•
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg
fe fum-iron polysacch complex-fa-b cmplx-c-znmn-cu cap (Tandem plus)
1
fe fumarate w/ b12vit c-fa-ifc cap 110-0.015-75-0.5-240 mg fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg
ferrous fumarate-folic acid tab 324-1 mg
1
1
FER-IN-SOL - ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)
A
FERIVA - fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap 75-1 mg
3
•
SM
Limited Distribution
Dispensing Limits
Step Therapy
ACA
•
1
FERROUS SULFATE - ferrous sulfate liquid 220 mg/5ml (44 mg/5ml elemental fe)
A
•
FERROUS SULFATE - ferrous sulfate syrup 300 mg/5ml (60 mg/5ml elemental fe)
A
•
FERROUS SULFATE ANHYDROUS - ferrous sulfate powder
3
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe)
A
FERROUS SULFATE HEPTAHYDR - ferrous sulfate granules
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
3
Products October (2016 Plan Year)
181
ferrous sulfate soln 75 mg/ ml (15 mg/ml elemental fe)
A
4
FOLGARD RX - folic acidvitamin b6-vitamin b12 tab 2.2-25-1 mg
3
GRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml
3
FOLIC ACID - folic acid inj 5 mg/ml
3
HEMATOGEN FA - fe fumarate-vit c-vit b12-fa cap 200-250-0.01-1 mg HEMATRON-AF - irondocusate-b12-folic acid-c-ecu-biotin tab 150-1 mg
3
HEMETAB - polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg
3
3
1
HEMOCYTE PLUS - ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx)
1
HEMOCYTE-F - iron combination elixir
3 3
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg
1
HYDROXOCOBALAMIN hydroxocobalamin inj 1000 mcg/ml ICAR PEDIATRIC - carbonyl iron susp 15 mg/1.25ml (elemental iron)
A
ICAR-C PLUS - iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg
3
INFED - iron dextran inj 50 mg/ ml (elemental iron)
3
INTEGRA F - fe fumfe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe)
3
folic acid tab 800 mcg folic acid tab 1 mg folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg
A A 1
FOLIVANE-F - fe fumfe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe)
3
FOLIVANE-PLUS - fe fumiron polysacch complex-fa-b complex-c-biotin cap
3
FOLIXAPURE - folic acidcholecalciferol tab 1 mg-5000 unit
3
FOLTRATE - cobalamine combination tab
3
FUSION PLUS - fe fum-iron poly cmplx-fa-b cmplx-cbiotin-probiotic cap
3
INTEGRA PLUS - fe fum-iron polysacch complex-fa-b complex-c-biotin cap
3
FUSION SPRINKLES - fe fumfe polys cmplx-fa-c-probiotic pack 7-0.25-50-5 mg
3
IRON CHEWS PEDIATRIC carbonyl iron chew tab 15 mg (elemental iron)
A
iron combination cap
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
•
3
folic acid tab 400 mcg
Dispensing Limits
•
FOCALGIN DSS - fe carbonylfe gluconate-fa-vit b12-vit cdss tab 90-1 mg
• • •
Step Therapy
4
GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml
FOLIC ACID - folic acid powder 3 A folic acid cap 0.8 mg
Prior Authorization
Drug Name
Drug Tier
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
•
•
182
iron polysacch complex-vit b12-fa cap 150-0.025-1 mg
1
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
iron-docusate-b12-folic acidc-e-cu-biotin tab 150-1 mg (Hematron-af)
1
MULTIGEN FOLIC - fe asparto gly-succinic acd-vit cthreonic acd-b12-fa tab
3
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite 150)
1
MULTIGEN PLUS - fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab MYKIDZ IRON 10 - iron susp 15 mg/1.5ml
A
IROSPAN 24/6 - fe bisglyc-fe polys-succ acd-b cmplx-cca-fa tab ther pk
3
NASCOBAL - cyanocobalamin nasal spray 500 mcg/0.1ml
3
NEPHRON FA - ferrous fumarate w/ fa-dss-b complex-vit c tab
3
IS 24/6 - fe bisglyc-fe polyssucc acd-b cmplx-c-ca-fa tab ther pk
3
NEULASTA - pegfilgrastim soln prefilled syringe 6 mg/0.6ml
4
MAXFE - iron-fa-vit b12-biotinvit c-docusate-mg-zn tab 160-1 mg
3
•
4
•
MIRCERA - methoxy pegepoetin beta soln prefilled syr 30 mcg/0.3ml
3
NEULASTA ONPRO KIT pegfilgrastim soln prefilled syringe kit 6 mg/0.6ml
4
•
MIRCERA - methoxy pegepoetin beta soln prefilled syr 50 mcg/0.3ml
3
NEUPOGEN - filgrastim inj 300 mcg/ml NEUPOGEN - filgrastim inj 480 mcg/1.6ml (300 mcg/ml)
4
•
MIRCERA - methoxy pegepoetin beta soln prefilled syr 75 mcg/0.3ml
3
NEUPOGEN - filgrastim soln prefilled syringe 300 mcg/0.5ml
4
•
MIRCERA - methoxy pegepoetin beta soln prefilled syr 100 mcg/0.3ml
3
NEUPOGEN - filgrastim soln prefilled syringe 480 mcg/0.8ml (600 mcg/ml)
4
•
MIRCERA - methoxy pegepoetin beta soln prefilled syr 150 mcg/0.3ml
3
NEURIN-SL - cyanocobalaminmethylcobalamin tab sl 600-600 mcg
3
MIRCERA - methoxy pegepoetin beta soln prefilled syr 200 mcg/0.3ml
3
NIFEREX - iron combination tab
3 3
MOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml)
5
NOXIFOL-D - folic acidcholecalciferol tab 1 mg-2500 unit
5
•
MULTIGEN - fe asparto glysucc acd-c-threonic acdb12-des stom tab
3
NPLATE - romiplostim for inj 250 mcg NPLATE - romiplostim for inj 500 mcg
5
•
•
•
NUFERA - iron combination tab 3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
183
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ORTHO D - folic acidcholecalciferol cap 1 mg-3775 unit
3
REVESTA - folic acidcholecalciferol cap 1 mg-5750 unit
3
PHYSICIANS EZ USE B-12 CO - cyanocobalamin inj kit 1000 mcg/ml
3
ROXIFOL-D - folic acidcholecalciferol tab 1 mg-500 unit
3
PRE-FOLIC - folic acid-vitamin c tab 1-100 mg
3
3
PROCRIT - epoetin alfa inj 2000 unit/ml
4
TANDEM F - ferrous fumiron polysacch-fa cap 162-115.2-1 mg (106 mg fe)
4
•
3
PROCRIT - epoetin alfa inj 3000 unit/ml
TANDEM PLUS - fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap
PROCRIT - epoetin alfa inj 4000 unit/ml
4
•
3
PROCRIT - epoetin alfa inj 10000 unit/ml
4
•
TARON FORTE - fe bisglycinate-fe polysacch-vit c-vit b12-fa cap
3
PROCRIT - epoetin alfa inj 20000 unit/ml
4
•
VITAMIN DEFICIENCY INJECT - cyanocobalamin inj kit 1000 mcg/ml
PROCRIT - epoetin alfa inj 40000 unit/ml
4
•
4
•
PROFERRIN-FORTE - iron heme polypeptide-folic acid tab 12-1 mg (fe equiv)
3
ZARXIO - filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml
4
•
PROMACTA - eltrombopag olamine tab 12.5 mg (base equiv)
5
•
ZARXIO - filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml
3
PROMACTA - eltrombopag olamine tab 25 mg (base equiv)
5
•
ZAVARA - folic acidcholecalciferol cap 1 mg-5750 unit ZAVESCA - miglustat cap 100 mg
5
PROMACTA - eltrombopag olamine tab 50 mg (base equiv)
5
•
ZOLATE - folic acidcholecalciferol cap 1 mg-3775 unit
3
PROMACTA - eltrombopag olamine tab 75 mg (base equiv)
5
•
ANTICOAGULANTS
PROTECTIRON - iron polysacch-fa-b complex-vit c-e & minerals tab 60-1 mg
3
PUREFE PLUS - ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg
3
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
ACD FORMULA A anticoagulant citrate dextrose solution a
3
ACD FORMULA B anticoagulant citrate dextrose solution b
3
ACD-A NOCLOT-50 anticoagulant citrate dextrose solution a
3
Products October (2016 Plan Year)
•
•
•
184
ANTICOAGULANT CITRATE DEX - anticoagulant citrate dextrose solution a
3
ANTICOAGULANT CITRATE PHO - anticoagulant citrate phosphate dextrose soln
3
ANTICOAGULANT SODIUM CITR - anticoagulant sodium citrate soln 4%
3
ARIXTRA - fondaparinux sodium inj 2.5 mg/0.5ml
3
enoxaparin sodium inj 100 mg/ml (Lovenox)
ARIXTRA - fondaparinux sodium subcutaneous inj 5 mg/0.4ml
3
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)
ARIXTRA - fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
3
ARIXTRA - fondaparinux sodium subcutaneous inj 10 mg/0.8ml
3
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml (Arixtra)
COUMADIN - warfarin sodium tab 1 mg
3
COUMADIN - warfarin sodium tab 2 mg
3
fondaparinux sodium subcutaneous inj 5 mg/0.4ml (Arixtra)
COUMADIN - warfarin sodium tab 2.5 mg
3
COUMADIN - warfarin sodium tab 3 mg
3
COUMADIN - warfarin sodium tab 4 mg
3
COUMADIN - warfarin sodium tab 5 mg
3
COUMADIN - warfarin sodium tab 6 mg
3
COUMADIN - warfarin sodium tab 7.5 mg
3
COUMADIN - warfarin sodium tab 10 mg
3
ELIQUIS - apixaban tab 2.5 mg
2
ELIQUIS - apixaban tab 5 mg
2
enoxaparin sodium inj 30 mg/0.3ml (Lovenox) enoxaparin sodium inj 40 mg/0.4ml (Lovenox) enoxaparin sodium inj 60 mg/0.6ml (Lovenox) enoxaparin sodium inj 80 mg/0.8ml (Lovenox)
enoxaparin sodium inj 150 mg/ml (Lovenox) enoxaparin sodium inj 300 mg/3ml (Lovenox)
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml (Arixtra) fondaparinux sodium subcutaneous inj 10 mg/0.8ml (Arixtra)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1 1 1 1 1
1
1
1
FRAGMIN - dalteparin sodium inj 10000 unit/ml
3
FRAGMIN - dalteparin sodium inj 2500 unit/0.2ml
3
FRAGMIN - dalteparin sodium inj 5000 unit/0.2ml
3
FRAGMIN - dalteparin sodium inj 7500 unit/0.3ml
3
FRAGMIN - dalteparin sodium inj 12500 unit/0.5ml
3
FRAGMIN - dalteparin sodium inj 15000 unit/0.6ml
3
Products October (2016 Plan Year)
185
FRAGMIN - dalteparin sodium inj 18000 unit/0.72ml
3
LOVENOX - enoxaparin sodium inj 100 mg/ml
3
FRAGMIN - dalteparin sodium inj 95000 unit/3.8ml
3
LOVENOX - enoxaparin sodium inj 120 mg/0.8ml
3
heparin sodium (porcine) inj 1000 unit/ml
1
LOVENOX - enoxaparin sodium inj 150 mg/ml
3
1
LOVENOX - enoxaparin sodium inj 300 mg/3ml
3
1
PRADAXA - dabigatran etexilate mesylate cap 75 mg (etexilate base eq)
3
PRADAXA - dabigatran etexilate mesylate cap 110 mg (etexilate base eq)
3
PRADAXA - dabigatran etexilate mesylate cap 150 mg (etexilate base eq)
3
SAVAYSA - edoxaban tosylate tab 15 mg (base equivalent)
3
SAVAYSA - edoxaban tosylate tab 30 mg (base equivalent)
3
SAVAYSA - edoxaban tosylate tab 60 mg (base equivalent)
3
TRICITRASOL - anticoagulant sodium citrate concentrate 46.7%
3
WARFARIN SODIUM CLATHRATE - warfarin sodium powder
3
warfarin sodium tab 1 mg (Coumadin)
1
heparin sodium (porcine) inj 5000 unit/ml heparin sodium (porcine) inj 10000 unit/ml heparin sodium (porcine) inj 20000 unit/ml heparin sodium (porcine) pf inj 5000 unit/0.5ml
1 1
heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9% (Heparin sodium/ sodiu)
1
HEPARIN SODIUM/NACL 0.45% - heparin sodium (porcine) 50 unit/ml in sodium chloride 0.45%
3
HEPARIN SODIUM/NACL 0.45% - heparin sodium (porcine) 100 unt/ml in sodium chloride 0.45%
3
HEPARIN SODIUM/SODIUM CHL - heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9%
3
IPRIVASK - desirudin for inj 15 mg
5
LOVENOX - enoxaparin sodium inj 30 mg/0.3ml
3
warfarin sodium tab 2 mg (Coumadin)
1
LOVENOX - enoxaparin sodium inj 40 mg/0.4ml
3
warfarin sodium tab 2.5 mg (Coumadin)
1
LOVENOX - enoxaparin sodium inj 60 mg/0.6ml
3
warfarin sodium tab 3 mg (Coumadin)
1
LOVENOX - enoxaparin sodium inj 80 mg/0.8ml
3
warfarin sodium tab 4 mg (Coumadin)
1
warfarin sodium tab 5 mg (Coumadin)
1
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
186
warfarin sodium tab 6 mg (Coumadin)
1
warfarin sodium tab 7.5 mg (Coumadin)
1
warfarin sodium tab 10 mg (Coumadin)
RECOTHROM - thrombin (recombinant) for soln 20000 unit
3
3
1
RECOTHROM SPRAY KIT thrombin (recombinant) for soln 20000 unit
XARELTO - rivaroxaban tab 10 mg
2
THROMBIN-JMI DILUENT thrombin for soln 5000 unit
3
XARELTO - rivaroxaban tab 15 mg
2
THROMBIN-JMI DILUENT thrombin for soln 20000 unit
3
XARELTO - rivaroxaban tab 20 mg
2
3
XARELTO STARTER PACK rivaroxaban tab starter therapy pack 15 mg & 20 mg
2
THROMBIN-JMI EPISTAXIS thrombin for soln kit 5000 unit THROMBIN-JMI SYRINGE SPRA - thrombin for soln kit 5000 unit
3
THROMBIN-JMI SYRINGE SPRA - thrombin for soln kit 20000 unit
3
3
HEMOSTATICS AMICAR - aminocaproic acid oral soln 0.25 gm/ml
3
AMICAR - aminocaproic acid tab 500 mg
2
AMICAR - aminocaproic acid tab 1000 mg
3
THROMBIN-JMI W/DIL SPRAY - thrombin for soln kit 20000 unit THROMBOGEN - thrombin for soln kit 10000 unit
3
ARTISS - fibrin sealant component solution
3 3
3
EVICEL - fibrin sealant component kit 2 ml
THROMBOGEN - thrombin for soln 1000 unit
3
THROMBOGEN - thrombin for soln 10000 unit
3
EVICEL - fibrin sealant component kit 5 ml
TISSEEL - fibrin sealant component solution
3
EVITHROM - thrombin (human) topical soln 800-1200 unit/ml
3
3
LYSTEDA - tranexamic acid tab 650 mg
3
TISSEEL VH - fibrin sealant component kit 2 ml
3
MONSELS FERRIC SUBSULFATE - ferric subsulfate soln
3
TISSEEL VH - fibrin sealant component kit 4 ml TISSEEL VH - fibrin sealant component kit 10 ml
3
RAPLIXA - fibrinogen-thrombin powder 79-699 mg-unit/gm
3
tranexamic acid tab 650 mg (Lysteda)
1
RECOTHROM - thrombin (recombinant) for soln 5000 unit
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
HEMATOLOGICAL AGENTS - MISC.
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
187
AGGRENOX - aspirindipyridamole cap er 12hr 25-200 mg
3
PLAVIX - clopidogrel bisulfate tab 75 mg (base equiv)
3
PLAVIX - clopidogrel bisulfate tab 300 mg (base equiv)
3
AGRYLIN - anagrelide hcl cap 0.5 mg
3
prasugrel hcl tab 5 mg (base equiv) (Effient)
1
anagrelide hcl cap 0.5 mg (Agrylin)
1
anagrelide hcl cap 1 mg
1
prasugrel hcl tab 10 mg (base equiv) (Effient)
aspirin-dipyridamole cap er 12hr 25-200 mg (Aggrenox)
1
BRILINTA - ticagrelor tab 60 mg
2
BRILINTA - ticagrelor tab 90 mg
2
CATHFLO ACTIVASE alteplase for inj 2 mg
3
cilostazol tab 50 mg (Pletal)
1
cilostazol tab 100 mg (Pletal) clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)
ZONTIVITY - vorapaxar sulfate tab 2.08 mg (base equivalent)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 3
TOPICAL PRODUCTS OPHTHALMIC AGENTS
1 1
ACULAR - ketorolac tromethamine ophth soln 0.5%
3
ACULAR LS - ketorolac tromethamine ophth soln 0.4%
3
ACUVAIL - ketorolac tromethamine ophth soln 0.45%
3
AKTEN - lidocaine hcl ophth gel 3.5%
3
ALOCRIL - nedocromil sodium ophth soln 2%
3
ALOMIDE - lodoxamide tromethamine ophth soln 0.1%
3
clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)
1
dipyridamole tab 25 mg (Persantine)
1
dipyridamole tab 50 mg (Persantine)
1
dipyridamole tab 75 mg (Persantine)
1
DURLAZA - aspirin capsule er 24hr 162.5 mg
3
ALPHAGAN P - brimonidine tartrate ophth soln 0.1%
3
EFFIENT - prasugrel hcl tab 5 mg (base equiv)
2
ALPHAGAN P - brimonidine tartrate ophth soln 0.15%
3
EFFIENT - prasugrel hcl tab 10 mg (base equiv)
2
ALREX - loteprednol etabonate ophth susp 0.2%
2
FIRAZYR - icatibant acetate inj 30 mg/3ml (base equivalent)
4
•
•
•
AMVISC - sodium hyaluronate intraocular inj 12 mg/ml
3
KALBITOR - ecallantide inj 10 mg/ml
5
•
•
•
3
pentoxifylline tab er 400 mg
1
AMVISC PLUS - sodium hyaluronate intraocular inj 16 mg/ml
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
188
apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine)
1
BIMATOPROST - bimatoprost ophth soln 0.03%
3
BLEPH-10 - sulfacetamide sodium ophth soln 10%
3
ATROPINE SULFATE atropine sulfate ophth oint 1%
2
3
ATROPINE SULFATE atropine sulfate ophth soln 1%
3
BLEPHAMIDE - sulfacetamide sodium-prednisolone ophth susp 10-0.2%
3
AZASITE - azithromycin ophth soln 1%
3
BLEPHAMIDE S.O.P. sulfacetamide sodiumprednisolone ophth oint 10-0.2%
azelastine hcl ophth soln 0.05% (Optivar)
1
brimonidine tartrate ophth soln 0.15% (Alphagan p)
1
AZOPT - brinzolamide ophth susp 1%
3
brimonidine tartrate ophth soln 0.2%
BACITRACIN - bacitracin ophth 2 oint 500 unit/gm 1 bacitracin-polymyxin b ophth oint 1 bacitracin-polymyxinneomycin-hc ophth oint 1% 3 BEPREVE - bepotastine besilate ophth soln 1.5% 3 BESIVANCE - besifloxacin hcl ophth susp 0.6% (base equiv) 3 BETADINE OPHTHALMIC PREP - povidone-iodine ophth soln 5% 3 BETAGAN - levobunolol hcl ophth soln 0.5% 1 betaxolol hcl ophth soln 0.5% 3 BETIMOL - timolol ophth soln 0.25% 3 BETIMOL - timolol ophth soln 0.5% 3 BETOPTIC-S - betaxolol hcl ophth susp 0.25%
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
BROMFENAC - bromfenac sodium ophth soln 0.09% (base equivalent)
3
bromfenac sodium ophth soln 0.09% (base equiv) (once-daily)
1
carteolol hcl ophth soln 1%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
CILOXAN - ciprofloxacin hcl ophth oint 0.3%
2
CILOXAN - ciprofloxacin hcl ophth soln 0.3%
3
ciprofloxacin hcl ophth soln 0.3% (Ciloxan)
1
COMBIGAN - brimonidine tartrate-timolol maleate ophth soln 0.2-0.5%
3
COSOPT - dorzolamide hcltimolol maleate ophth soln 22.3-6.8 mg/ml
3
COSOPT PF - dorzolamide hcl- 3 timolol maleate ophth sol 22.3-6.8 mg/ml pf cromolyn sodium ophth soln 1 4% 3 CYCLOGYL - cyclopentolate hcl ophth soln 0.5%
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
189
CYCLOGYL - cyclopentolate hcl ophth soln 1%
3
CYCLOGYL - cyclopentolate hcl ophth soln 2%
3
CYCLOMYDRIL cyclopentolate w/ phenylephrine ophth soln 0.2-1%
3
cyclopentolate hcl ophth soln 0.5% (Cyclogyl)
1
cyclopentolate hcl ophth soln 1% (Cyclogyl) cyclopentolate hcl ophth soln 2% (Cyclogyl)
DEXAMETHASONE SODIUM PHOS - dexamethasone sodium phosphate ophth soln 0.1%
3
diclofenac sodium ophth soln 0.1%
1 1 1
5
FLAREX - fluorometholone acetate ophth susp 0.1%
3
fluorometholone ophth susp 0.1% (Fml liquifilm)
1
FML - fluorometholone ophth oint 0.1%
3
FML FORTE - fluorometholone ophth susp 0.25%
3
FML LIQUIFILM fluorometholone ophth susp 0.1%
3
gatifloxacin ophth soln 0.5% (Zymaxid)
1
GELFILM OP - gelatin adsorbable ophth film
3
GENTAK - gentamicin sulfate ophth oint 0.3%
1
gentamicin sulfate ophth soln 0.3% (Garamycin)
1
HEALON - sodium hyaluronate intraocular inj 10 mg/ml
3
3
HEALON GV - sodium hyaluronate intraocular inj 14 mg/ml
3
DUREZOL - difluprednate ophth emulsion 0.05%
3
3
ELESTAT - epinastine hcl ophth soln 0.05%
3
HEALON5 - sodium hyaluronate intraocular inj 23 mg/ml
1
EMADINE - emedastine difumarate ophth soln 0.05% (base equiv)
3
homatropine hbr ophth soln 5% (Isopto homatropine)
epinastine hcl ophth soln 0.05% (Elestat)
1
SM
ACA
Dispensing Limits
Step Therapy
Limited Distribution
•
1
DOUBLE PM - prednisolonemoxifloxacin opth for soln 1-0.5% (cmpd kit)
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Prior Authorization
1
EYLEA - aflibercept intravitreal inj 2 mg/0.05ml (40 mg/ml)
flurbiprofen sodium ophth soln 0.03% (Ocufen)
•
Drug Tier
ACA
Dispensing Limits
Step Therapy
Limited Distribution
erythromycin ophth oint 5 mg/gm
1 5
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt)
Drug Name
1
CYSTARAN - cysteamine hcl ophth soln 0.44% (base equivalent)
dorzolamide hcl ophth soln 2% (Trusopt)
Prior Authorization
Drug Name
Drug Tier
2016
ILEVRO - nepafenac ophth susp 0.3%
3
ILUVIEN - fluocinolone acetonide intravitreal implant 0.19 mg
3
Products October (2016 Plan Year)
•
190
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
IOPIDINE - apraclonidine hcl ophth soln 0.5% (base equivalent)
3
LUCENTIS - ranibizumab intravitreal inj 0.3 mg/0.05ml (6 mg/ml)
5
•
IOPIDINE - apraclonidine hcl ophth soln 1% (base equivalent)
3
LUCENTIS - ranibizumab intravitreal inj 0.5 mg/0.05ml (10 mg/ml)
5
•
ISOPTO CARPINE pilocarpine hcl ophth soln 1%
3
LUCENTIS - ranibizumab intravitreal soln pref syr 0.5 mg/0.05ml
5
•
ISOPTO CARPINE pilocarpine hcl ophth soln 2%
3
LUMIGAN - bimatoprost ophth soln 0.01%
2
MACUGEN - pegaptanib sodium intravitreous inj 0.3 mg/90 microliter
5
ISOPTO CARPINE pilocarpine hcl ophth soln 4%
3
MAXIDEX - dexamethasone ophth susp 0.1%
3
ISTALOL - timolol maleate ophth soln 0.5% (once-daily)
3 5
MAXITROL - neomycinpolymyxin-dexamethasone ophth oint 0.1%
3
JETREA - ocriplasmin intravitreal inj 0.5 mg/0.2ml (2.5 mg/ml)
MAXITROL - neomycinpolymyxin-dexamethasone ophth susp 0.1%
3
ketorolac tromethamine ophth soln 0.4% (Acular ls)
1
METIPRANOLOL metipranolol ophth soln 0.3%
3
3
ketorolac tromethamine ophth soln 0.5% (Acular)
•
1
LACRISERT - artificial tear ophth insert
3
LASTACAFT - alcaftadine ophth soln 0.25%
3
MIOCHOL-E - acetylcholine chloride intraocular for soln 20 mg (1:100)
latanoprost ophth soln 0.005% (Xalatan)
1
MIOSTAT - carbachol intraocular inj 0.01%
3
1
MITOSOL - mitomycin for ophth soln kit 0.2 mg
3
1
MOXEZA - moxifloxacin hcl ophth soln 0.5% (base eq) (2 times daily)
2
moxifloxacin hcl ophth soln 0.5% (base equiv) (Vigamox)
1
NATACYN - natamycin ophth susp 5%
2
levobunolol hcl ophth soln 0.5% (Betagan) levofloxacin ophth soln 0.5% LOTEMAX - loteprednol etabonate ophth gel 0.5%
2
LOTEMAX - loteprednol etabonate ophth oint 0.5%
2
LOTEMAX - loteprednol etabonate ophth susp 0.5%
2
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
•
191
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin neomycin-polymygramicid op sol 1.75-10000-0.025mg-untmg/ml (Neosporin) neomycin-polymyxindexamethasone ophth oint 0.1% (Maxitrol) neomycin-polymyxindexamethasone ophth susp 0.1% (Maxitrol)
1
1
1
PATADAY - olopatadine hcl ophth soln 0.2% (base equivalent)
2
PATANOL - olopatadine hcl ophth soln 0.1% (base equivalent)
3
PAZEO - olopatadine hcl ophth soln 0.7% (base equivalent)
2
phenylephrine hcl ophth soln 2.5%
1
phenylephrine hcl ophth soln 10%
1
3
1
3
NEOSPORIN - neomycinpolymy-gramicid op sol 1.75-10000-0.025mg-untmg/ml
3
pilocarpine hcl ophth soln 1% (Isopto carpine)
NEVANAC - nepafenac ophth susp 0.1%
3
pilocarpine hcl ophth soln 4% (Isopto carpine)
OCUFLOX - ofloxacin ophth soln 0.3%
3
ofloxacin ophth soln 0.3% (Ocuflox)
1
olopatadine hcl ophth soln 0.1% (base equivalent) (Patanol)
1
olopatadine hcl ophth soln 0.2% (base equivalent) (Pataday)
pilocarpine hcl ophth soln 2% (Isopto carpine)
polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1% (Polytrim)
Limited Distribution
1
PRED FORTE - prednisolone acetate ophth susp 1%
3
1
PRED MILD - prednisolone acetate ophth susp 0.12%
3 3
OMNIPRED - prednisolone acetate ophth susp 1%
3
PRED-G - gentamicinprednisolone ace ophth susp 0.3-1%
ophthalmic irrigation solution - intraocular (Bss plus)
1
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint 0.3-0.6%
3
OZURDEX - dexamethasone intravitreal implant 0.7 mg
3
prednisolone acetate ophth susp 1% (Pred forte)
1
SM
ACA
1
3
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Dispensing Limits
1
POLYTRIM - polymyxin btrimethoprim ophth soln 10000 unit/ml-0.1%
•
Step Therapy
1
PHOSPHOLINE IODIDE echothiophate iodide ophth for soln 0.125%
NEOMYCIN/POLYMYXIN/ HYDROC - neomycinpolymyxin-hc ophth susp
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
192
PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate ophth soln 1%
3
PREDNISOLONE/ MOXIFLOXACIN prednisolone-moxifloxacin opth soln 1-0.5%
3
PREDNISOLONE/ MOXIFLOXACIN prednisolone-moxifloxacinbromfenac opth sol 1-0.5-0.09%
3
PREDNISOLONE/ MOXIFLOXACIN prednisolone-moxifloxacinketorolac opth sol 1-0.5-0.5%
3
PROLENSA - bromfenac sodium ophth soln 0.07% (base equivalent)
3
proparacaine hcl ophth soln 0.5% (Alcaine)
1
SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint 10%
3
sulfacetamide sodium ophth soln 10% (Bleph-10)
1
sulfacetamide sodiumprednisolone ophth soln 10-0.23(0.25)% tetracaine hcl ophth soln 0.5%
1
timolol maleate ophth gel forming soln 0.5% (Timoptic-xe)
1
timolol maleate ophth soln 0.25% (Timoptic)
1
TIMOPTIC - timolol maleate ophth soln 0.25%
3
TIMOPTIC - timolol maleate ophth soln 0.5%
3
TIMOPTIC OCUDOSE - timolol maleate preservative free ophth soln 0.25%
3
3
RESCULA - unoprostone isopropyl ophth soln 0.15%
3
RESTASIS - cyclosporine (ophth) emulsion 0.05%
3
RESTASIS MULTIDOSE cyclosporine (ophth) emulsion 0.05%
3
TIMOPTIC OCUDOSE - timolol maleate preservative free ophth soln 0.5%
3
RETISERT - fluocinolone acetonide intravitreal implant 0.59 mg
3
TIMOPTIC-XE - timolol maleate ophth gel forming soln 0.25%
3
SHELLGEL - sodium hyaluronate intraocular inj 12 mg/ml
3
TIMOPTIC-XE - timolol maleate ophth gel forming soln 0.5%
3
SIMBRINZA - brinzolamidebrimonidine tartrate ophth susp 1-0.2%
2
TOBRADEX - tobramycindexamethasone ophth oint 0.3-0.1% TOBRADEX - tobramycindexamethasone ophth susp 0.3-0.1%
3
SM
Limited Distribution
ACA
1
3
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Dispensing Limits
1
PROVISC - sodium hyaluronate intraocular inj 10 mg/ml
•
Step Therapy
1
timolol maleate ophth gel forming soln 0.25% (Timoptic-xe)
timolol maleate ophth soln 0.5% (Timoptic)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
193
TOBRADEX ST - tobramycindexamethasone ophth susp 0.3-0.05%
3
tobramycin ophth soln 0.3% (Tobrex)
1
tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex)
1
TOBREX - tobramycin ophth oint 0.3%
3
TOBREX - tobramycin ophth soln 0.3%
3
TRAVATAN Z - travoprost ophth soln 0.004% (benzalkonium free) (bak free)
2
TRIESENCE - triamcinolone acetonide ophth inj 40 mg/ml
3
trifluridine ophth soln 1% (Viroptic)
1
TRIPLE PMB - prednisolmoxiflox-bromfen for sol 1-0.5-0.09% (cmpd kit)
3
TRIPLE PMK - prednisolmoxiflox-ketorolac for sol 1-0.5-0.5% (cmpd kit)
3
TROPICAMIDE - tropicamide powder
3
tropicamide ophth soln 1% (Mydriacyl)
1
TRUSOPT - dorzolamide hcl ophth soln 2%
3
VIGAMOX - moxifloxacin hcl ophth soln 0.5% (base equiv)
3
VIROPTIC - trifluridine ophth soln 1%
3
XALATAN - latanoprost ophth soln 0.005%
3
XIIDRA - lifitegrast ophth soln 5%
3
ZIOPTAN - tafluprost ophth soln 0.0015%
3
ZIRGAN - ganciclovir ophth gel 0.15%
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ZYLET - loteprednol etabonate- 2 tobramycin ophth susp 0.5-0.3% 3 ZYMAXID - gatifloxacin ophth soln 0.5% OTIC AGENTS acetic acid otic soln 2% CETRAXAL - ciprofloxacin hcl otic soln 0.2% (base equivalent)
3
CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1%
3
CIPRODEX - ciprofloxacindexamethasone otic susp 0.3-0.1%
3
CIPROFLOXACIN ciprofloxacin hcl otic soln 0.2% (base equivalent)
3
COLY-MYCIN S - neomycincolistin-hc-thonzonium otic susp 3.3-3-10-0.5 mg/ml
3
DERMOTIC - fluocinolone acetonide (otic) oil 0.01%
3
FLOXIN OTIC - ofloxacin otic soln 0.3%
3
fluocinolone acetonide (otic) oil 0.01% (Dermotic)
1
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol hc)
1
neomycin-polymyxin-hc otic soln 1% (Cortisporin)
1
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ ml-1% ofloxacin otic soln 0.3%
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1
1
1
Products October (2016 Plan Year)
194
OTOVEL - ciprofloxacinfluocinolone aceton (pf) otic soln 0.3-0.025%
3
MOUTH/THROAT/DENTAL AGENTS 3 AMPHOTERICIN B amphotericin b powder 3 AQUORAL - artificial saliva solution 3 ARESTIN - minocycline hcl subgingival powder cartridge 1 mg 1 benzocaine mouth/throat aerosol 20% 3 BOCASAL - artificial saliva packet 3 CAPHOSOL - artificial saliva solution 1 cevimeline hcl cap 30 mg (Evoxac) 1 chlorhexidine gluconate soln 0.12% (Peridex) 1 clotrimazole troche 10 mg
MUCOTROL - oral wound care products - wafer
3
NAFRINSE DAILY/ ACIDULATED - sodium fluoride-phosphoric acid for soln 1 mg/5ml (f equiv)
3
NAFRINSE DAILY/NEUTRAL sodium fluoride for soln rinse 0.05%
3
NAFRINSE WEEKLY - sodium fluoride for soln rinse 0.2%
3
NEUTRASAL - artificial saliva packet
3
NUMOISYN - artificial saliva lozenge
3
NUMOISYN - artificial saliva solution
3
nystatin susp 100000 unit/ml
1
ORAFATE - sucralfate-malate paste 10%
3
ORAMAGICRX - oral wound care products - for susp rinse
3
ORAVIG - miconazole buccal tab 50 mg (mouth-throat)
3
DEBACTEROL - sulfuric acidsulfonated phenolics soln 30-50%
3
EVOXAC - cevimeline hcl cap 30 mg
3
PERIDEX - chlorhexidine gluconate soln 0.12%
3
FIRST-MOUTHWASH BLM diphenhyd-lido-al hydrox-mg hydrox-simeth susp (cmpd kit)
3
pilocarpine hcl tab 5 mg (Salagen)
1
pilocarpine hcl tab 7.5 mg (Salagen)
1
GEL-KAM ORAL CARE RINSE - stannous fluoride conc 0.63%
3
PREVIDENT FLUORIDE sodium fluoride gel 1.1% (0.5% f)
3
GELCLAIR - povidone-sodium hyaluronate-glycyrrhetinic acid gel
3
LIDOCAINE HCL - lidocaine hcl laryngotracheal soln 4%
3
PREVIDENT 5000 BOOSTER - 3 sodium fluoride paste 1.1% 3 PREVIDENT 5000 BOOSTER PL - sodium fluoride paste 1.1%
lidocaine hcl viscous soln 2%
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
195
PREVIDENT 5000 DRY MOUTH - sodium fluoride gel 1.1% (0.5% f)
3
PREVIDENT 5000 ENAMEL PRO - sodium fluoridepotassium nitrate paste 1.1-5%
3
PREVIDENT 5000 PLUS sodium fluoride cream 1.1%
3
PREVIDENT 5000 SENSITIVE - sodium fluoride-potassium nitrate paste 1.1-5%
3
PROTHELIAL - sucralfatemalate paste 10%
3
SALAGEN - pilocarpine hcl tab 5 mg
3
SALAGEN - pilocarpine hcl tab 7.5 mg
3
SALICEPT - oral wound care products - for susp rinse SALIVAMAX - artificial saliva packet
triamcinolone acetonide dental paste 0.1% ZINC ACETATE - zinc acetate crystals ANORECTAL AGENTS
ANALPRAM HC SINGLES hydrocortisone acetate w/ pramoxine rectal cream 2.5-1%
3
ANALPRAM-HC hydrocortisone acetate w/ pramoxine rectal cream 1-1%
3
3
3
ANALPRAM-HC hydrocortisone acetate w/ pramoxine rectal lotn 2.5-1%
3
3
ANUSOL-HC - hydrocortisone rectal cream 2.5% CORTENEMA - hydrocortisone enema 100 mg/60ml
3
CORTIFOAM - hydrocortisone acetate rectal foam 10% (90 mg/dose)
2
hydrocortisone acetate suppos 25 mg (Anusol-hc)
1
hydrocortisone acetate suppos 30 mg (Proctocort) hydrocortisone acetate w/ pramoxine rectal cream 1-1% (Analpram-hc) hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% (Analpram-hc) hydrocortisone enema 100 mg/60ml (Cortenema) hydrocortisone rectal cream 1% (Proctocort)
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
3
3
SALIVATE RX - artificial saliva - 3 packet 1 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 sodium fluoride rinse 0.2% (Prevident) 1 sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 sensi) 1 stannous fluoride conc 0.63% (Gel-kam oral care ri) 1 stannous fluoride gel 0.4% THERA-FLUR-N - sodium fluoride gel 1.1% (0.5% f)
1
ANALPRAM HC hydrocortisone acetate w/ pramoxine rectal cream 2.5-1%
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1
1
1 1
Products October (2016 Plan Year)
196
1
ABSORICA - isotretinoin cap 40 mg
3
LIDOCAINE HCLHYDROCORTIS - lidocainehydrocortisone acetate rectal gel 2.8-0.55%
3
ACANYA - clindamycin phosphate-benzoyl peroxide gel 1.2-2.5%
3
1
1
lidocaine-hydrocortisone acetate rectal cream 3-0.5%
acitretin cap 10 mg (Soriatane) acitretin cap 17.5 mg (Soriatane)
1
acitretin cap 25 mg (Soriatane)
1
ACTICOAT ABSORBENT ANTIMI - wound dressings pads
3
ACTICOAT ANTIMICROBIAL DR - wound dressings - pads
3
ACTICOAT FLEX 3 BARRIER D - wound dressings - pads
3
ACTICOAT 7 2"X2" - wound dressings - pads
3
hydrocortisone rectal cream 2.5% (Anusol-hc)
PROCORT - hydrocortisone acetate w/ pramoxine rectal cream 1.85-1.15%
3
PROCTOCORT hydrocortisone acetate suppos 30 mg
3
PROCTOCORT hydrocortisone rectal cream 1%
3
PROCTOFOAM HC hydrocortisone acetate w/ pramoxine rectal foam 1-1%
3
RECTIV - nitroglycerin oint 0.4%
3
ACTICOAT 7 4"X5" - wound dressings - pads
3
UCERIS - budesonide rectal foam 2 mg/act
3
ACTIVE-KETOPROFEN KIT - ketoprofen cream 5% (compound kit)
3
ACTIVE-PREP KIT I flurbiprofen-cyclobenzaprine cream (cmpd kit)
3
ACTIVE-PREP KIT II ketoprofen-baclofengabapentin cream (cmpd kit)
3
ACTIVE-PREP KIT III ketoprofen-lidocainegabapentin cream (cmpd kit)
3
ACTIVE-PREP KIT IV tramadol-gabapentinmenthol-camphor cream (cmpd kit)
3
ACTIVE-PREP KIT V itraconazole-phenytoin sodium cream (cmpd kit)
3
DERMATOLOGICALS A.A.G.C. KIT IN TERODERM amantad-amitript-gabacycloben cream 8-4-10-4% (cmpd kit)
3
ABSORICA - isotretinoin cap 10 mg
3
ABSORICA - isotretinoin cap 20 mg
3
ABSORICA - isotretinoin cap 25 mg
3
ABSORICA - isotretinoin cap 30 mg
3
ABSORICA - isotretinoin cap 35 mg
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
197
ACTIVE-TRAMADOL KIT tramadol hcl cream 8% (compound kit)
3
ALEVICYN ANTIPRURITIC SG - dermatological products misc - liquid
3
ACUICYN DAILY EYELID & EY - eyelid cleansers - liquid
3
ALEVICYN DERMAL SPRAY wound dressings - soln
3
acyclovir oint 5% (Zovirax)
1
ALLEVYN AG ADHESIVE wound dressings - pads
3
ALLEVYN AG GENTLE BORDER - wound dressings - pads
3
ALLEVYN AG NONADHESIVE - wound dressings - pads
3
ALLEVYN AG SACRUM wound dressings - pads
3
1
ALLEVYN GENTLE - wound dressings - pads
3
AIF #2 DRUG PREPARATION flurbiprofen-gabapentcycloben-lido-dexameth cr (cmp kit)
3
ALLO-PAX - levocetirizineloratadine cream 5-5% (cmpd kit)
3
3
AIF #3 DRUG PREPARATION K - flurbiprofen-baclofencycloben-lido cream (cmp kit)
3
ALOQUIN - iodoquinol-aloe polysaccharides gel 1.25-1% ALTABAX - retapamulin oint 1%
3 3
AKTIPAK - benzoyl peroxideerythromycin gel pack 5-3%
3
ALUMINUM CHLORIDE ANHYDRO - aluminum chloride powder
ALA SCALP - hydrocortisone lotion 2%
3
3
ALA-QUIN - clioquinol-hc cream 3-0.5%
3
ALUMINUM CHLORIDE HEXAHYD - aluminum chloride crystals
3
alclometasone dipropionate cream 0.05% (Aclovate)
1
ALUMINUM CHLORIDE HEXAHYD - aluminum chloride powder
1
AMCINONIDE - amcinonide cream 0.1%
3
3
3
ALDARA - imiquimod cream 5%
AMCINONIDE - amcinonide lotion 0.1%
3
AMCINONIDE - amcinonide oint 0.1%
3
ALEVICYN ANTIPRURITIC GEL - wound dressings - gel
ACZONE - dapsone gel 5%
3
ACZONE - dapsone gel 7.5%
3
ADAPALENE - adapalene lotion 0.1%
3
•
adapalene cream 0.1% (Differin)
1
•
adapalene gel 0.1% (Differin)
1
• •
adapalene gel 0.3% (Differin) adapalene-benzoyl peroxide gel 0.1-2.5%
alclometasone dipropionate oint 0.05%
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ANTHRALIN - anthralin powder 3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
198
APEXICON E - diflorasone diacetate emollient base cream 0.05%
3
AVO CREAM - wound dressings - emulsion
3
AZELEX - azelaic acid cream 20%
3
ARNICA FLOWER - arnica tincture
3
BACITRACIN - bacitracin powder
3
ARZOL SILVER NITRATE APP - silver nitratepotassium nitrate applicator 75-25%
3
BACITRACIN ZINC - bacitracin zinc powder
3
ASTERO - lidocaine hcl gel 4%
3
3
ATOPICLAIR - dermatological products misc - cream
3
BACLOFEN - baclofen cream 2% (cmpd kit)
3
ATRALIN - tretinoin gel 0.05%
3
BACTROBAN - mupirocin calcium cream 2% BEAU RX - scar treatment products - gel
3
ATRAPRO ANTIPRURITIC HYDR - wound dressings gel
3
3
ATRAPRO CP - wound dressings - kit
3
BENSAL HP - salicylic acid & benzoic acid oint 3-6%
3
ATRAPRO DERMAL SPRAY wound cleansers - liquid
3
BENZAC AC WASH - benzoyl peroxide liq 5%
3
AUGMENTED BETAMETHASONE D betamethasone dipropionate augmented gel 0.05%
3
BENZACLIN - clindamycin phosphate-benzoyl peroxide gel 1-5%
3
AVAR - sulfacetamide sodium w/ sulfur cleansing pad 9.5-5%
3
BENZACLIN WITH PUMP clindamycin phosphatebenzoyl peroxide gel 1-5%
3
AVAR - sulfacetamide sodium w/ sulfur foam 9.5-5%
3
BENZAMYCIN - benzoyl peroxide-erythromycin gel 5-3%
3
AVAR LS - sulfacetamide sodium w/ sulfur cleansing pad 10-2%
3
BENZEFOAM - benzoyl peroxide foam 5.3% BENZEFOAM ULTRA benzoyl peroxide foam 9.8%
3
AVAR LS - sulfacetamide sodium w/ sulfur foam 10-2%
3
BENZIQ - benzoyl peroxide gel 5.25 %
3 3
AVAR LS CLEANSER sulfacetamide sodium w/ sulfur cleanser 10-2%
3
BENZIQ LS - benzoyl peroxide gel 2.75% BENZIQ WASH - benzoyl peroxide liq 5.25%
3
AVAR-E LS - sulfacetamide sodium w/ sulfur cream 10-2%
3
BENZOCAINE - benzocaine powder
3
BENZOIC ACID - benzoic acid crystals
3
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
199
BENZOIC ACID - benzoic acid powder
3
benzoin compound tincture
1
betamethasone dipropionate oint 0.05%
BENZOIN TINCTURE benzoin tincture
3
BETAMETHASONE VALERATE - betamethasone valerate powder
BENZOYL PEROXIDE benzoyl peroxide powder
3
betamethasone valerate aerosol foam 0.12% (Luxiq)
benzoyl peroxide cloth 6%
1
betamethasone valerate cream 0.1%
benzoyl peroxide foam 5.3% (Benzefoam)
1
benzoyl peroxide foam 9.8% (Benzefoamultra)
1
benzoyl peroxide gel 10%
1
betamethasone valerate lotion 0.1% betamethasone valerate oint 0.1%
3
1
3
1
BP CLEANSING WASH sulfacetamide sodium-sulfur in urea emulsion 10-4%
1
CALAMINE - calamine powder
3
benzoyl peroxideerythromycin gel 5-3% (Benzamycin)
1
calcipotriene cream 0.005% (Dovonex)
1
3
1
BETAMETHASONE DIPROPIONAT betamethasone dipropionate powder
calcipotriene oint 0.005%
betamethasone dipropionate augmented cream 0.05% (Diprolene af)
1
betamethasone dipropionate augmented lotion 0.05% (Diprolene)
1
betamethasone dipropionate augmented oint 0.05% (Diprolene)
1
betamethasone dipropionate cream 0.05%
1
benzoyl peroxide liq 7% benzoyl peroxide liq 10% benzoyl peroxide lotion 6%
betamethasone dipropionate lotion 0.05%
1
calcipotriene soln 0.005% (50 mcg/ml)
Limited Distribution
1
3
1
ACA
1
BORIC ACID - boric acid granules
benzoyl peroxide liq 2.5%
Dispensing Limits
1
3
3
Step Therapy
1
BIAFINE - wound dressings emulsion
BENZOYL PEROXIDE HYDROUS - benzoyl peroxide powder
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
CALCITRIOL - calcitriol oint 3 mcg/gm
3
CAMPHOR - camphor crystals
3
CAMPHOR - camphor granules 3 3 CANTHARIDIN - cantharidin powder 3 CAPEX - fluocinolone acetonide shampoo 0.01% CAPSAICIN - capsaicin powder 3
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
CARAC - fluorouracil cream 0.5%
2
CARRASYN HYDROGEL WOUND D - wound dressings - gel
3
Products October (2016 Plan Year)
200
CELACYN POSTPROCEDURE PA - wound dressings - kit
3
CEM-UREA - urea soln 45%
3
CENTANY - mupirocin oint 2%
3
CERACADE - dermatological products misc - emulsion
3
CHLOROACETIC ACID monochloroacetic acid powder ciclopirox gel 0.77%
1
1
CLINOIN - clindamycintretinoin-cholesty crm 1.25-0.025-1% (cmp kit)
3
CLIOQUINOL - clioquinol powder
3
1
ciclopirox solution 8% (Penlac Nail Lacquer)
1
CLEOCIN-T - clindamycin phosphate gel 1%
3
CLEOCIN-T - clindamycin phosphate lotion 1%
3
CLEOCIN-T - clindamycin phosphate soln 1%
3
CLEOCIN-T - clindamycin phosphate swab 1%
3
CLINDAGEL - clindamycin phosphate gel 1%
3
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
CLOBETASOL PROPIONATE - 3 clobetasol propionate powder clobetasol propionate cream 1 0.05% (Temovate) 1 clobetasol propionate emollient base cream 0.05% (Temovate e) 1 clobetasol propionate emulsion foam 0.05% (Olux-e) 1 clobetasol propionate foam 0.05% (Olux) 1 clobetasol propionate gel 0.05% (Temovate) 1 clobetasol propionate lotion 0.05% (Clobex) 3 CLOBETASOL PROPIONATE MIC - clobetasol propionate powder 1 clobetasol propionate oint 0.05% (Temovate) 1 clobetasol propionate shampoo 0.05% (Clobex) 1 clobetasol propionate soln 0.05% (Temovate)
1
ciclopirox shampoo 1% (Loprox shampoo)
Prior Authorization
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Drug Tier 1
clindamycin phosphatetretinoin gel 1.2-0.025% (Ziana)
1
clindamycin phosphate lotion 1% (Cleocin-t)
clindamycin phosphate swab 1% (Cleocin-t)
1
3
ciclopirox olamine cream 0.77% (base equiv)
clindamycin phosphate gel 1% (Cleocin-t)
clindamycin phosphate soln 1% (Cleocin-t)
1
3
clindamycin phosphate foam 1% (Evoclin)
Drug Name
clindamycin phosphatebenzoyl peroxide gel 1-5% (Benzaclin)
CICLOPIROX OLAMINE ciclopirox olamine powder
ciclopirox olamine susp 0.77% (base equiv)
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
201
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
CONDYLOX - podofilox gel 0.5%
3
CLOBETASOL 17 PROPIONATE - clobetasol propionate powder
3
COPASIL - emollient - gel
3 3
CLOBEX - clobetasol propionate lotion 0.05%
3
CORDRAN - flurandrenolide cream 0.05%
3
CLOBEX - clobetasol propionate shampoo 0.05%
3
CORDRAN - flurandrenolide lotion 0.05%
3
CLOBEX - clobetasol propionate spray 0.05%
3
CORDRAN - flurandrenolide oint 0.05%
3
CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1%
3
CORDRAN - flurandrenolide tape 4 mcg/sqcm
3
CLOCORTOLONE PIVALATE PUM - clocortolone pivalate cream 0.1%
3
CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot 10-10-1mg/ml
3
CLODERM - clocortolone pivalate cream 0.1%
3
CORTISPORIN - bacitracinpolymyxin-neomycin hc oint 1%
3
CLODERM PUMP clocortolone pivalate cream 0.1%
3
CORTISPORIN - neomycinpolymyxin-hc crm 3.5 mg/ gm-10000 unt/gm-0.5% COSENTYX - secukinumab subcutaneous soln prefilled syringe 150 mg/ml
5
•
•
•
COSENTYX SENSOREADY PEN - secukinumab subcutaneous soln autoinjector 150 mg/ml
5
•
•
•
CURITY HYPERTONIC SODIUM - wound dressings misc
3
CURITY SODIUM CHLORIDE DR - wound dressings - pads
3
CUTIVATE - fluticasone propionate cream 0.05%
3
CUTIVATE - fluticasone propionate lotion 0.05%
3
DENAVIR - penciclovir cream 1%
3
clobetasol propionate spray 0.05% (Clobex)
CLOTRIMAZOLE - clotrimazole 3 crystals CLOTRIMAZOLE - clotrimazole 3 powder 1 clotrimazole cream 1% clotrimazole soln 1% clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) clotrimazole w/ betamethasone lotion 1-0.05%
1 1
1
COAL TAR - coal tar soln 20%
3
COCAINE HCL - cocaine hcl powder
3
COCAINE HCL - cocaine hcl soln 4%
3
COLLAGENASE - collagenase powder
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
202
DERMA-SMOOTHE/FS BODY - fluocinolone acetonide oil 0.01% (body oil)
3
DERMA-SMOOTHE/FS SCALP - fluocinolone acetonide oil 0.01% (scalp oil)
3
DERMATOP - prednicarbate cream 0.1%
3
DERMATOP - prednicarbate oint 0.1%
3
DESONATE - desonide gel 0.05%
3
DESONIDE - desonide powder
3
desonide cream 0.05% (Desowen)
1
desonide lotion 0.05% (Desowen)
1
desonide oint 0.05% (Desowen)
1
DESOWEN - desonide cream 0.05%
3
DESOWEN - desonide lotion 0.05%
3
desoximetasone cream 0.05% (Topicort)
1
desoximetasone cream 0.25% (Topicort)
1
desoximetasone gel 0.05% (Topicort)
1
desoximetasone oint 0.05% (Topicort)
1
desoximetasone oint 0.25% (Topicort)
1
DEXERYL - dermatological products misc - cream
3
DIAB - wound dressings - gel
3
DIAB F.D.G. FREEZE-DRIED wound dressings - gel
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
DIBUCAINE HCL - dibucaine hcl powder
3
DICLOFENAC SODIUM diclofenac sodium cream 3%
3
diclofenac sodium gel 1% (Voltaren)
1
diclofenac sodium soln 1.5% (Pennsaid)
1
DIFFERIN - adapalene cream 0.1%
3
•
DIFFERIN - adapalene gel 0.1%
3
•
DIFFERIN - adapalene gel 0.3%
3
•
DIFFERIN - adapalene lotion 0.1%
3
•
DIFLORASONE DIACETATE diflorasone diacetate cream 0.05%
2
DIFLORASONE DIACETATE diflorasone diacetate oint 0.05%
3
DIPENTOCAINE - diclofenacgabapentin-lidocaine hcl cream 5-5-2% (cmp kit)
3
DIPROLENE - betamethasone dipropionate augmented lotion 0.05%
3
DIPROLENE - betamethasone dipropionate augmented oint 0.05%
3
DIPROLENE AF betamethasone dipropionate augmented cream 0.05%
3
DOVONEX - calcipotriene cream 0.005%
3
DRITHO-CREME HP anthralin cream 1%
3
DRYSOL - aluminum chloride soln 20%
2
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
203
DUAC - clindamycin phosphbenzoyl peroxide (refrig) gel 1.2 (1)-5%
3
ENOVARX-LIDOCAINE HCL lidocaine hcl cream 10% (compound kit)
3
ECONAZOLE NITRATE econazole nitrate powder
3
3
econazole nitrate cream 1%
1
ENOVARX-NAPROXEN naproxen cream 10% (compound kit) ENOVARX-TRAMADOL tramadol hcl cream 5% (compound kit)
3
ENSTILAR - calcipotrienebetamethasone dipropionate foam 0.005-0.064%
2
ENTTY SPRAY EMULSION dermatological products misc - emulsion
3
ECOZA - econazole nitrate foam 1%
3
EFUDEX - fluorouracil cream 5%
3
ELETONE - dermatological products misc - cream
3
ELETONE TWINPACK dermatological products misc - cream
3
ELIDEL - pimecrolimus cream 1%
2
EPICERAM - dermatological products misc - emulsion
3
ELIMITE - permethrin cream 5%
3
EPIDUO - adapalene-benzoyl peroxide gel 0.1-2.5%
3
ELOCON - mometasone furoate cream 0.1%
3
3
ELOCON - mometasone furoate oint 0.1%
3
EPIDUO FORTE - adapalenebenzoyl peroxide gel 0.3-2.5%
3
EMULSION SB dermatological products misc - emulsion
3
EPIFOAM - pramoxine-hc aerosol foam 1-1%
3
ENOVARX-BACLOFEN baclofen cream 1% (compound kit)
3
EQUIPTO-BACLOFEN baclofen cream 2% (cmpd kit)
3
ENOVARX-DICLOFENAC SODIU - diclofenac sodium cream 2.5% (compounding kit)
3
EQUIPTO-NAPROXEN naproxen cream 10% (compound kit) ERTACZO - sertaconazole nitrate cream 2%
3
ENOVARX-IBUPROFEN ibuprofen cream 10% (compounding kit)
3
ENOVARX-LIDOCAINE HCL lidocaine hcl cream 5% (compound kit)
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ERYGEL - erythromycin gel 2% 3 erythromycin gel 2% (Erygel) 1 erythromycin pads 2% erythromycin soln 2%
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1 1
ESSENTRA WIPES 9X9" CLEAN - isopropyl alcohol wipes 70%
3
EURAX - crotamiton cream 10%
3
Products October (2016 Plan Year)
204
EURAX - crotamiton lotion 10% 3 3 EVOCLIN - clindamycin phosphate foam 1% 3 EXELDERM - sulconazole nitrate cream 1% 3 EXELDERM - sulconazole nitrate solution 1% 3 EXODERM - sodium thiosulfate-salicylic acid lotion 25-1% 3 EXTINA - ketoconazole foam 2% 3 FABIOR - tazarotene (acne) foam 0.1% FBL KIT - flurbiprofen-baclofen- 3 lidocaine cream 15-4-5% (cmpd kit) 2 FINACEA - azelaic acid foam 15% 2 FINACEA - azelaic acid gel 15% 3 FIRST-HYDROCORTISONE hydrocortisone gel 10% (cmpd kit) 3 FLECTOR - diclofenac epolamine patch 1.3% 3 FLUOCINOLONE ACETONIDE - fluocinolone acetonide powder 1 fluocinolone acetonide cream 0.01% 1 fluocinolone acetonide cream 0.025% (Synalar) 1 fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod) 1 fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca) 1 fluocinolone acetonide oint 0.025% (Synalar)
fluocinolone acetonide soln 0.01% (Synalar)
3
fluocinonide cream 0.05%
1
fluocinonide gel 0.05% fluocinonide oint 0.05% fluocinonide soln 0.05%
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1 1 1 2
FLUOROURACIL - fluorouracil cream 0.5%
3
FLUOROURACIL - fluorouracil soln 2%
3
FLUOROURACIL - fluorouracil soln 5%
3
fluorouracil cream 5% (Efudex)
1
flurandrenolide cream 0.05%
1
flurandrenolide lotion 0.05% (Cordran)
1
flurandrenolide oint 0.05% (Cordran)
1
fluticasone propionate cream 0.05% (Cutivate)
1
fluticasone propionate oint 0.005% (Cutivate)
SM
1
FLUOROPLEX - fluorouracil cream 1%
fluticasone propionate lotion 0.05% (Cutivate)
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1
FLUOCINONIDE - fluocinonide powder fluocinonide emulsified base cream 0.05%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1
GENADUR - dermatological products misc - liquid
3
GENTAMICIN SULFATE gentamicin sulfate oint 0.1%
2
GENTAMICIN SULFATE gentamicin sulfate powder
3
gentamicin sulfate cream 0.1%
1
Products October (2016 Plan Year)
205
GENTAMICIN SULFATE MICRON - gentamicin sulfate powder
3
HYDRO 40 FOAM - urea foam 40%
3
HYDROCORTISONE hydrocortisone powder
3
GENTIAN VIOLET - gentian violet crystals
3
HYDROCORTISONE ACETATE - hydrocortisone acetate powder
3
GENTIAN VIOLET - gentian violet powder
3
HYDROCORTISONE ACETATE MI hydrocortisone acetate powder
3
hydrocortisone butyrate cream 0.1% (Locoid)
1
GLYCOLIC ACID - glycolic acid 3 soln 70% 3 GLYCOLIC ACID 70% HIGH PU - glycolic acid soln 70% GORDOFILM - salicylic & lactic 3 acids soln 16.7-16.7% 3 GORDONS UREA - urea ointment 40% 1 halobetasol propionate cream 0.05% (Ultravate) 1 halobetasol propionate oint 0.05% (Ultravate) 3 HALOG - halcinonide cream 0.1% HALOG - halcinonide oint 0.1% 3 HALOTIN - haloprogin cream 1%
3
HPR - dermatological products, misc. - aerosol foam
3
HPR PLUS - dermatological products misc - cream
3
HPR PLUS - dermatological products, misc. - aerosol foam
3
HYALUCIL-0.5 - sodium hyaluronate-fluorouracil cream 2-0.5% (cmpd kit)
3
HYALUCIL-4 - sodium hyaluronate-fluorouracil cream 2-4% (cmpd kit)
3
hydrocortisone butyrate hydrophilic lipo base cream 0.1% (Locoid lipocream)
1
hydrocortisone butyrate oint 0.1% (Locoid)
1
hydrocortisone butyrate soln 0.1% (Locoid) hydrocortisone cream 1% hydrocortisone cream 2.5%
1
HYDROCORTISONE MICRONIZED hydrocortisone micronized powder
3
hydrocortisone oint 1%
1
HYDROFERA BLUE FOAM DRESS - wound dressings pads
SM
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
hydrocortisone lotion 2.5%
hydrocortisone valerate oint 0.2% (Westcort)
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1 1
hydrocortisone valerate cream 0.2%
1 hyaluronate sodium (emollient) gel 0.2% (Hylira) HYDRO 35 - urea in lactic acid 3 vehicle foam 35%
1
hydrocortisone lotion 2% (Ala scalp)
hydrocortisone oint 2.5%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 3
Products October (2016 Plan Year)
206
HYDROFERA BLUE HEAVY DRAI - wound dressings pads
3
KAMDOY - dermatological products misc - emulsion
3
KENALOG - triamcinolone acetonide aerosol soln 0.147 mg/gm
3
HYDROFERA BLUE READY FOAM - wound dressings pads
3
3
3
HYDROFERA BLUE 4"X4" wound dressings - pads
KENDALL AMORPHOUS HYDROGE - wound dressings - gel
HYDROQUINONE hydroquinone powder
3
3
HYLATOPIC PLUS dermatological products misc - cream
3
KENDALL HYDROGEL IMPREGNA - hydroactive (sterile) dressing
3
HYLATOPIC PLUS dermatological products misc - lotion
3
KENDALL HYDROGEL WOUND DR - hydroactive (sterile) dressing
3
HYLATOPIC PLUS dermatological products, misc. - aerosol foam
3
KENDALL ZINC CALCIUM ALGI - wound dressings misc
3
HYLIRA - hyaluronate sodium (emollient) gel 0.2%
3
KENDALL ZINC CALCIUM ALGI - wound dressings pads
3
HYLIRA - hyaluronate sodium (emollient) lotion 0.1%
3
KERAGEL - wound dressings gel
3
ICHTHAMMOL - ichthammol powder
3
KERAGELT - wound dressings - gel KERALAC - urea cream 47%
3
imiquimod cream 5% (Aldara)
1
KERALYT - salicylic acid gel 6%
3
iodoquinol-hydrocortisone in aloe vehicle cream 1-1.9% (Vytone)
1
KERAMATRIX REPLICINE 10CM - wound dressings sheet
3
1
KERAMATRIX REPLICINE 5CMX - wound dressings sheet
3
KERYDIN - tavaborole soln 5%
3
ketoconazole cream 2%
1
isotretinoin cap 10 mg isotretinoin cap 20 mg isotretinoin cap 30 mg isotretinoin cap 40 mg
1 1 1
JUBLIA - efinaconazole soln 10%
3
K.B.G.L. IN TERODERM CREA - ketoprofenbaclofen-gabapent-lido crm 15-4-10-2% (cmp kit)
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
ketoconazole foam 2% (Extina)
1
ketoconazole shampoo 2% (Nizoral)
1
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
207
KETOPHENE RAPIDPAQ ketoprofen cream 20% (compound kit)
3
LIDODERM - lidocaine patch 5%
3
KETOROLAC 2% GEL ketorolac tromethamine gel 2% (cmpd kit) (base equiv)
3
3
KLARON - sulfacetamide sodium lotion 10% (acne)
3
LIDOPROFEN - ketoprofenketamine-lidocaine cream 5-5-2% (compound kit)
3
LINDANE - lindane shampoo 1%
3
LAC-HYDRIN - lactic acid (ammonium lactate) cream 12%
3
LAC-HYDRIN - lactic acid (ammonium lactate) lotion 12%
3
LOCOID - hydrocortisone butyrate cream 0.1% LOCOID - hydrocortisone butyrate lotion 0.1%
3
lactic acid (ammonium lactate) cream 12% (Lachydrin)
1
LOCOID - hydrocortisone butyrate oint 0.1%
3 3
lactic acid (ammonium lactate) lotion 10%
1
LOCOID - hydrocortisone butyrate soln 0.1%
3
lidocaine-prilocaine cream 2.5-2.5% (Emla)
lactic acid (ammonium lactate) lotion 12% (Lachydrin)
1
lactic acid w/ vitamin e cream 10%-3500 unit/30gm
1
LOPROX - ciclopirox olamine cream 0.77% (base equiv)
3
LATRIX XM - urea in zinc undecylenate-lactic acid vehicle emulsion 45%
3
LOPROX - ciclopirox olamine susp 0.77% (base equiv)
3 3
LAVARE WOUND WASH wound cleansers - gel
3
LOPROX SHAMPOO ciclopirox shampoo 1%
3
LEVULAN KERASTICK aminolevulinic acid hcl for soln 20% (stick applicator)
3
LOTRISONE - clotrimazole w/ betamethasone cream 1-0.05%
3
LIDOCAINE - lidocaine powder
3
LOUTREX - antiseborrheic products misc - cream
lidocaine hcl gel 2%
1 3
lidocaine hcl soln 4% (Xylocaine)
1
lidocaine patch 5% (Lidoderm)
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
LOCOID LIPOCREAM hydrocortisone butyrate hydrophilic lipo base cream 0.1%
LIDOCAINE HCL MONOHYDRATE - lidocaine hcl powder
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
LUXAMEND - wound dressings 3 - cream 3 LUXIQ - betamethasone valerate aerosol foam 0.12% LUZU - luliconazole cream 1% 3 malathion lotion 0.5% (Ovide)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1
Products October (2016 Plan Year)
208
MEDIHONEY CALCIUM ALGINAT - wound dressings - pads
3
MEDIHONEY WOUND & BURN DR - wound dressings - pads
3
MICROCYN - wound cleansers - liquid
3
MICROCYN SKIN AND WOUND H - wound cleansers - gel
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
MIRVASO - brimonidine tartrate 3 gel 0.33% (base equivalent) 1 mometasone furoate cream 0.1% (Elocon) 1 mometasone furoate oint 0.1% (Elocon) 1 mometasone furoate solution 0.1% (lotion) (Elocon) 1 mupirocin calcium cream 2% (Bactroban) 1 mupirocin oint 2% (Bactroban) 1 naftifine hcl cream 1%
MEDIHONEY WOUND/BURN - 3 wound dressings - pads 3 MENTAX - butenafine hcl cream 1% 3 METHOXSALEN methoxsalen crystals 3 METHOXSALEN methoxsalen powder 1 methoxsalen rapid cap 10 mg (Oxsoralen ultra) 3 METHYL SALICYLATE methyl salicylate liquid 3 METROCREAM metronidazole cream 0.75% 3 METROGEL - metronidazole gel 1% 3 METROLOTION metronidazole lotion 0.75% 3 METRONIDAZOLE BENZOATE - metronidazole benzoate powder 1 metronidazole cream 0.75% (Metrocream) 1 metronidazole gel 0.75%
naftifine hcl cream 2% (Naftin)
1
NAFTIN - naftifine hcl cream 2%
3
NAFTIN - naftifine hcl gel 1%
3
NAFTIN - naftifine hcl gel 2%
3
NAPRO 15% COMPOUNDING KIT naproxen cream 15%
3
NATROBA - spinosad susp 0.9%
3 3
metronidazole gel 1% (Metrogel)
1
metronidazole lotion 0.75% (Metrolotion)
1
NEO-SYNALAR - neomycin sulfate-fluocinolone acetonide cream 0.5-0.025%
3
3
MICONAZOLE NITRATE miconazole nitrate powder
NEOMYCIN SULFATE neomycin sulfate powder
3
NEOSALUS - dermatological products misc - cream
3
MICORT-HC - hydrocortisone acetate cream 2.5%
NEOSALUS - dermatological products, misc. - aerosol foam
3
MICROCYN - wound cleansers - gel
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
209
NEOSALUS - emollient - lotion
3
NEOSALUS CP dermatological products misc - cream
3
3
OLUX-E - clobetasol propionate emulsion foam 0.05%
3
NITROFURAZONE nitrofurazone powder
3
ONEXTON - clindamycin phosphate-benzoyl peroxide gel 1.2-3.75%
NIVATOPIC PLUS dermatological products misc - cream
3
OVACE PLUS - sulfacetamide sodium cream 10%
3 3
NIZORAL - ketoconazole shampoo 2%
3
OVACE PLUS - sulfacetamide sodium foam 9.8%
3
NORITATE - metronidazole cream 1%
3
OVACE PLUS - sulfacetamide sodium lotion 9.8%
3
NOVACORT - pramoxine-hc gel 1-2%
3
OVACE PLUS - sulfacetamide sodium shampoo 10%
3
NOXIFINE WOUND DRESSING - wound dressings - emulsion
3
OVACE PLUS WASH sulfacetamide sodium cleansing gel 10%
3
NP #2 DRUG PREPARATION KI - tramadol-flurbip-amitripgaba-clonidine-lido crm (cmp kit)
3
OVACE PLUS WASH sulfacetamide sodium liquid 10% OVACE WASH - sulfacetamide sodium liquid 10%
3
NUCORT - hydrocortisone acetate lotion 2%
3
OVIDE - malathion lotion 0.5%
3
oxiconazole nitrate cream 1% (Oxistat)
1
NUTRASEB - emollient - cream 3 3 NUVAIL - dermatological products misc - solution 1 nystatin cream 100000 unit/ gm nystatin oint 100000 unit/gm 1 nystatin topical powder 100000 unit/gm nystatin-triamcinolone cream 100000-0.1 unit/gm% nystatin-triamcinolone oint 100000-0.1 unit/gm-% OLUX - clobetasol propionate foam 0.05%
OXISTAT - oxiconazole nitrate cream 1%
3
OXISTAT - oxiconazole nitrate lotion 1%
3 3
1
OXSORALEN ULTRA methoxsalen rapid cap 10 mg
1
PANDEL - hydrocortisone probutate cream 0.1%
3 3
1
PANRETIN - alitretinoin gel 0.1%
3
3
PENLAC NAIL LACQUER ciclopirox solution 8% permethrin cream 5% (Elimite)
1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
210
PHLAG SPRAY dermatological products misc - emulsion
3
PRAMOSONE - pramoxine-hc oint 1-1%
3
PRAMOSONE - pramoxine-hc oint 1-2.5%
3
PICATO - ingenol mebutate gel 0.015%
2
PRAMOSONE E - pramoxinehc emollient base cream 1-2.5%
3
PICATO - ingenol mebutate gel 0.05%
2
PICO SINGLE USE NEGATIVE - wound dressings - kit
3
PRAMOXINE HCL - pramoxine hcl powder
3
pramoxine-hc cream 1-2.5% (Pramosone)
1
PLEXION - sulfacetamide sodium w/ sulfur cream 9.8-4.8%
3
1
PLEXION - sulfacetamide sodium w/ sulfur lotion 9.8-4.8%
3
prednicarbate cream 0.1% (Dermatop) prednicarbate oint 0.1% (Dermatop)
1
PLEXION CLEANSER sulfacetamide sodium w/ sulfur cleanser 9.8-4.8%
3
PRESERA - dermatological products, misc. - aerosol foam
3
PLEXION CLEANSING CLOTHS - sulfacetamide sodium w/ sulfur cleansing cloth 9.8-4.8%
3
PROMISEB - antiseborrheic products misc - cream
3
PROTOPIC - tacrolimus oint 0.03%
3
PROTOPIC - tacrolimus oint 0.1%
3
PRUCLAIR - dermatological products misc - cream
3
PRUMYX - dermatological products misc - cream
3
PRUTECT - wound dressings emulsion
3
PSORCON - diflorasone diacetate cream 0.05%
3
PYROGALLIC ACID pyrogallol-chlorobutanol oint 25-2%
3
QUINJA - iodoquinol-aloe polysaccharides gel 1.25-1%
3
RADIAGEL - wound dressings - gel
3
RADIAPLEXRX - wound dressings - gel
3
PLIAGLIS - lidocaine-tetracaine 3 cream 7-7% 3 PODOCON 25 IN BENZOIN TIN - podophyllum resin soln 25% 1 podofilox soln 0.5% (Condylox) 3 PODOPHYLLUM RESIN podophyllum resin powder PRAMOSONE - pramoxine-hc 3 cream 1-1% PRAMOSONE - pramoxine-hc 3 cream 1-2.5% PRAMOSONE - pramoxine-hc 3 lotion 1-1% PRAMOSONE - pramoxine-hc 3 lotion 1-2.5%
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
211
RECEDO - scar treatment products - gel
3
RETINOIC ACID-ALL TRANS tretinoin powder
3
RECURA - antifungal combination products misc cream
3
REXAPHENAC - diclofenac sodium cream 1%
3
RIAX - benzoyl peroxide foam 5.5%
3
REGENECARE - lidocaine hclcollagen-aloe vera gel 2%
3 3
RIAX - benzoyl peroxide foam 9.5%
3
REGRANEX - becaplermin gel 0.01%
RTD WOUND CARE DRESSING - wound dressings - pads
3
RESTORE SILVER DRESSING 2 - wound dressings - pads
3
RYNODERM - urea cream 37.5%
3
RESTORE SILVER DRESSING 4 - wound dressings - pads
3
3
RESTORE SILVER DRESSING 6 - wound dressings - pads
3
SALEX - salicylic acid shampoo 6% SALICYLIC ACID - salicylic acid crystals
3
RETIN-A - tretinoin cream 0.025%
3
•
SALICYLIC ACID - salicylic acid powder
3
RETIN-A - tretinoin cream 0.05%
3
•
salicylic acid cream 6%
1
RETIN-A - tretinoin cream 0.1%
3
•
RETIN-A - tretinoin gel 0.01%
3
RETIN-A - tretinoin gel 0.025%
3
RETIN-A MICRO - tretinoin microsphere gel 0.04%
3
• • •
RETIN-A MICRO - tretinoin microsphere gel 0.1%
3
•
RETIN-A MICRO PUMP tretinoin microsphere gel 0.04%
3
•
RETIN-A MICRO PUMP tretinoin microsphere gel 0.08%
3
•
RETIN-A MICRO PUMP tretinoin microsphere gel 0.1%
3
•
RETINOIC ACID - tretinoin powder
3
salicylic acid er film-forming soln 28.5% (Ultrasal-er) salicylic acid film forming liquid 27.5% (Virasal) salicylic acid foam 6% (Salvax)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1
salicylic acid gel 6% (Keralyt) 1 1 salicylic acid lotion 6% salicylic acid shampoo 6% (Salex)
1
salicylic acid soln 26%
1
SALISOL - salicylic acid soln 23%
3
SALITECH - salicylic acid lotion 3 5% 3 SALVAX - salicylic acid foam 6% SANTYL - collagenase oint 250 3 unit/gm
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
212
scar treatment products - gel
1
SEBUDERM - dermatological products misc - gel
3
selenium sulfide lotion 2.5%
1
SELENIUM SULFIDE SHAMPOO - selenium sulfide lotion 2.25%
3
selenium sulfide-pyrithione zinc in urea shampoo 2.25%
1
SELRX - selenium sulfidepyrithione zinc in urea shampoo 2.3%
3
SERNIVO - betamethasone dipropionate spray emulsion 0.05% (base equiv)
3
SILVADENE - silver sulfadiazine cream 1%
3
skin protectants misc cream
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
SKLICE - ivermectin lotion 0.5%
3
SODIUM SULFACETAMIDE WASH - sulfacetamide sodium in bakuchiol vehicle wash 10%
3
3 SODIUM SULFACETAMIDE/ SULF - sulfacetamide sodium w/ sulfur lotion 10-5% 2 SODIUM SULFACETAMIDE/ SULF - sulfacetamide sodium w/ sulfur susp 10-5% 3 SODIUM SULFACETAMIDE/ SULF - sulfacetamide sodium-sulfur in urea emulsion 10-5% 3 SODIUM SULFACETAMIDE/ SULF - sulfacetamide sodium-sulfur in urea gel 10-5% SONAFINE - wound dressings 3 - emulsion 2 SOOLANTRA - ivermectin cream 1% 3 SORIATANE - acitretin cap 10 mg 3 SORIATANE - acitretin cap 17.5 mg 3 SORIATANE - acitretin cap 25 mg 3 SORILUX - calcipotriene foam 0.005% 3 SP ANTIPRURITIC - wound dressings - gel 3 SP SCAR MANAGEMENT scar treatment products - gel 3 SPECTRAGEL - wound dressings - gel
SILVASORB - wound dressings 3 - gel 3 SILVER NITRATE - silver nitrate crystals 3 SILVER NITRATE - silver nitrate oint 10% 3 SILVER NITRATE - silver nitrate soln 0.5% 3 SILVER NITRATE - silver nitrate soln 10% 3 SILVER NITRATE - silver nitrate soln 25% 3 SILVER NITRATE - silver nitrate soln 50% silver sulfadiazine cream 1% 1 (Silvadene) 3 SILVERSEAL HYDROGEL DRESS - silver - pad 2"x3" 3 SILVERSEAL HYDROGEL DRESS - silver - pad 4"x5" 3 SILVRSTAT WOUND DRESSING - silver - gel SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
213
SPINOSAD - spinosad susp 0.9%
3
SSS 10-5 - sulfacetamide sodium w/ sulfur foam 10-5%
3
STELARA - ustekinumab inj 45 mg/0.5ml
4
•
•
•
STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml
4
•
•
•
STELARA - ustekinumab soln prefilled syringe 90 mg/ml
4
•
•
•
SULFACETAMIDE SODIUM sulfacetamide sodium powder
sulfacetamide sodium w/ sulfur emulsion 10-1% sulfacetamide sodium w/ sulfur emulsion 10-5%
sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts)
1
1
3
sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash)
1
sulfacetamide sodium cleansing gel 10% (Ovace plus wash)
1
sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash)
3
sulfacetamide sodium liquid 10% (Ovace wash)
1
SULFAMYLON - mafenide acetate cream 85 mg/gm
2
1
SULFAMYLON - mafenide acetate packet for topical soln 5% (50 gm)
1
SULFURATED LIME sulfurated lime solution
3
sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% (Plexion cleanser)
1
SUMADAN WASH sulfacetamide sodium w/ sulfur wash 9-4.5%
3
sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls cleanser)
1
SUMAXIN - sulfacetamide sodium w/ sulfur cleansing pad 10-4%
3
sulfacetamide sodium w/ sulfur cleansing pad 10-4% (Sumaxin)
1
SUMAXIN TS - sulfacetamide sodium w/ sulfur susp 8-4%
3 3
sulfacetamide sodium w/ sulfur cream 9.8-4.8% (Plexion)
1
SUMAXIN WASH sulfacetamide sodium w/ sulfur wash 9-4%
3
sulfacetamide sodium w/ sulfur cream 10-2% (Avare ls)
1
SYNALAR - fluocinolone acetonide cream 0.025% SYNALAR - fluocinolone acetonide oint 0.025%
3
sulfacetamide sodium w/ sulfur cream 10-5%
1
SYNALAR - fluocinolone acetonide soln 0.01%
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
1 1
sulfacetamide sodium shampoo 10% (Ovace plus)
Step Therapy
1
sulfacetamide sodium w/ sulfur lotion 9.8-4.8% (Plexion)
sulfacetamide sodium lotion 10% (acne) (Klaron)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
214
SYNERA - lidocaine-tetracaine topical patch 70-70 mg
3
TETRIX - dermatological products misc - cream
3
tacrolimus oint 0.03% (Protopic)
1
TEXACORT - hydrocortisone soln 2.5%
3
tacrolimus oint 0.1% (Protopic)
1
THERAHONEY - wound dressings - gel
3
TALTZ - ixekizumab subcutaneous soln autoinjector 80 mg/ml
5
TOLAK - fluorouracil cream 4%
3 3
TALTZ - ixekizumab subcutaneous soln prefilled syringe 80 mg/ml
5
TOLNAFTATE - tolnaftate powder (compounding) TOPICORT - desoximetasone cream 0.05%
3
TANNIC ACID - tannic acid powder
3
TOPICORT - desoximetasone cream 0.25%
3
TARGRETIN - bexarotene gel 1%
5
TOPICORT - desoximetasone gel 0.05%
3
tazarotene cream 0.1% (Tazorac)
1
TOPICORT - desoximetasone oint 0.05%
3
TAZORAC - tazarotene cream 0.05%
2
TOPICORT - desoximetasone oint 0.25%
3
TAZORAC - tazarotene cream 0.1%
3
TOPICORT - desoximetasone spray 0.25%
3
TAZORAC - tazarotene gel 0.05%
2
TRETIN-X - tretinoin cream 0.075%
3
TAZORAC - tazarotene gel 0.1%
2
TRETINOIN - tretinoin powder
3 3
TBC - trypsin w/ castor oil & peruvian balsam spray
3
TRETINOIN (ALL-TRANS RETI - tretinoin powder
1
•
TEGADERM AG MESH DRESSING - wound dressings - pads
3
tretinoin cream 0.025% (Retin-a) tretinoin cream 0.05% (Retina)
1
•
TEMOVATE - clobetasol propionate cream 0.05%
3
tretinoin cream 0.1% (Retina)
1
•
TEMOVATE - clobetasol propionate gel 0.05%
3
tretinoin gel 0.01% (Retin-a)
1
TEMOVATE - clobetasol propionate oint 0.05%
3 3
tretinoin microsphere gel 0.04% (Retin-a micro)
1
TEMOVATE - clobetasol propionate soln 0.05%
• • • •
tretinoin microsphere gel 0.1% (Retin-a micro)
1
TETRACYCLINE HCL tetracycline hcl powder
3
•
• •
• •
• •
•
tretinoin gel 0.025% (Retin-a) tretinoin gel 0.05% (Atralin)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1 1
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
215
TRI-CHLOR - trichloroacetic acid liqd 80%
3
ULTRAVATE - halobetasol propionate lotion 0.05%
3
TRIAMCINOLONE ACETONIDE - triamcinolone acetonide powder
3
ULTRAVATE - halobetasol propionate oint 0.05%
3
URAMAXIN - urea cream 45%
3
triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog)
1
URAMAXIN - urea gel 45%
3 3
triamcinolone acetonide cream 0.025%
1
URAMAXIN - urea in ammonium lactate vehicle foam 20% URAMAXIN - urea lotion 45%
3
URAMAXIN GT - urea gel 45%
3
urea cream 39% (Aluvea)
1
triamcinolone acetonide cream 0.1% triamcinolone acetonide cream 0.5% triamcinolone acetonide lotion 0.025% triamcinolone acetonide lotion 0.1% triamcinolone acetonide oint 0.025% triamcinolone acetonide oint 0.1% triamcinolone acetonide oint 0.5%
1 1
urea cream 40%
1
urea cream 45% (Uramaxin) urea cream 47% (Keralac)
1
urea cream 50%
urea gel 45% (Uramaxin)
1
3
TRICHLOROACETIC ACID trichloroacetic acid crystals
3
urea in zinc undecylenatelactic acid vehicle emulsion 50%
TRICHLOROACETIC ACID trichloroacetic acid powder
3
urea lotion 40% urea lotion 45% (Uramaxin)
TRIDESILON - desonide cream 3 0.05% 3 TURPENTINE SPIRITS turpentine spirit 3 ULESFIA - benzyl alcohol lotion 5% 3 ULTRASAL-ER - salicylic acid er film-forming soln 28.5% 3 ULTRAVATE - halobetasol propionate cream 0.05%
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
1
1
TRIANEX - triamcinolone acetonide oint 0.05%
ACA
1 1
urea in lactic acid-salicylic acid vehicle susp 50%
Dispensing Limits
1
urea foam 40% (Hydro 40 foam)
1
Step Therapy
1
1
urea in lactic acid vehicle foam 35% (Hydro 35)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1
1 1
UREA NAIL - urea in zinc undecylenate-lactic acid vehicle stick 50%
3
urea suspension 40% (Umecta)
1
UREVAZ - urea cream 44%
3
UTOPIC - urea cream 41%
3
VACUSTIM BLACK - wound dressings - kit
3
VACUSTIM SILVER - wound dressings - kit
3
Products October (2016 Plan Year)
216
VALCHLOR - mechlorethamine hcl gel 0.016% (base equivalent)
4
VANOXIDE-HC - benzoyl peroxide-hc lotion 5-0.5%
3
VASCUDERM HYDROGEL WOUND - wound dressings gel
3
VECTICAL - calcitriol oint 3 mcg/gm
3
VELTIN - clindamycin phosphate-tretinoin gel 1.2-0.025%
3
VENELEX - balsam perucastor oil oint
3
VERDESO - desonide foam 0.05%
3
VEREGEN - sinecatechins oint 15%
3
VIRASAL - salicylic acid film forming liquid 27.5%
3
VOLTAREN - diclofenac sodium gel 1%
3
VOPAC GB - ketoprofenlidocaine-gabapentin cream 5-2-5% (cmpd kit)
3
VOPAC KT - ketoprofenketamine-lidocaine cream 5-5-2% (compound kit)
3
VUSION - miconazole-zinc oxide-white petrolatum oint 0.25-15-81.35%
3
VYTONE - iodoquinolhydrocortisone in aloe vehicle cream 1-1.9%
3
WESTCORT - hydrocortisone valerate oint 0.2%
XERESE - acyclovirhydrocortisone cream 5-1%
3
XEROFORM NONOCCLUSIVE OI - bismuth tribromophenate-petrolatum dressing - misc
3
XEROFORM NONOCCLUSIVE OI - bismuth tribromophenate-petrolatum dressing pads
3
XEROFORM OCCLUSIVE PETROL - bismuth tribromophenate-petrolatum dressing - misc
3
XEROFORM OCCLUSIVE PETROL - bismuth tribromophenate-petrolatum dressing pads
3
XOLEGEL - ketoconazole gel 2%
3
XYLOCAINE - lidocaine hcl soln 4%
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ZACLIR CLEANSING - benzoyl 3 peroxide lotion 8% 3 ZANABIN ANTIPRURITIC HYDR - wound dressings gel 3 ZIANA - clindamycin phosphate-tretinoin gel 1.2-0.025% 3 ZITHRANOL - anthralin shampoo 1% ZOVIRAX - acyclovir cream 5% 3 ZOVIRAX - acyclovir oint 5%
3 2
3
ZYCLARA - imiquimod cream 3.75%
2
WOUND DEBRIDEMENT wound dressings - kit
3
ZYCLARA PUMP - imiquimod cream 2.5%
2
XERALUX - dermatological products misc - cream
3
ZYCLARA PUMP - imiquimod cream 3.75% MISCELLANEOUS PRODUCTS
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
217
ANTISEPTICS & DISINFECTANTS 3 ANASEPT - sodium hypochlorite liquid 0.057% BENZALKONIUM CHLORIDE - 3 benzalkonium chloride soln BENZALKONIUM CHLORIDE - 3 benzalkonium chloride soln 50% 3 BUCALSEP - antiseptic products misc - liquid 3 BUCALSEP - antiseptic products misc - solution 3 CETYLCIDE-G - glutaral conc
POTASSIUM PERMANGANATE potassium permanganate crystals
3
SILVER PROTEIN MILD silver protein mild powder
3
TRIPLE DYE - triple dye solution
3
UNI-SOLVE - antiseptic products misc - pads
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
UNI-SOLVE WIPES - antiseptic 3 products misc - pads ANTIDOTES
CHLORHEXIDINE GLUCONATE - chlorhexidine gluconate soln 20%
3
BAL IN OIL - dimercaprol inj 100 mg/ml
3 3
FORMA-RAY - formaldehyde solution 20%
3
FORMALDEHYDE formaldehyde solution 37%
3
CALCIUM DISODIUM VERSENAT - edetate calcium disodium inj 1 gm/5ml (200 mg/ml)
3
formaldehyde solution 10%
1
CETYLEV - acetylcysteine effervescent tab 500 mg
GLUTARALDEHYDE - glutaral soln 25%
3
CETYLEV - acetylcysteine effervescent tab 2.5 gm
3
HYDROGEN PEROXIDE hydrogen peroxide soln 30%
3
CHARCOAL ACTIVATED charcoal activated powder
3
IODINE TINCTURE - iodine tincture
3
CHEMET - succimer cap 100 mg
2
IV PREP WIPES - antiseptic products misc - pads
3
deferoxamine mesylate for inj 500 mg (Desferal)
1
KERR TRIPLE DYE - triple dye swabs
3
deferoxamine mesylate for inj 2 gm (Desferal)
LUGOLS STRONG IODINE iodine solution
3
DESFERAL - deferoxamine mesylate for inj 500 mg
3
MICROCLENS WIPES antiseptic products misc pads
3
DUODOTE - atropine 2.1 mg/0.7ml-pralidoxime cl 600 mg/2ml im auto-inj
3
PHENOL - phenol crystals
3
3
PHENOL - phenol liquid (bulk)
3
EDETATE CALCIUM DISODIUM - edetate calcium disodium powder EXJADE - deferasirox tab for oral susp 125 mg
5
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
1
Products October (2016 Plan Year)
• 218
•
FERRIPROX - deferiprone oral soln 100 mg/ml
5
FERRIPROX - deferiprone tab 500 mg
5
•
JADENU - deferasirox tab 90 mg
5
•
JADENU - deferasirox tab 180 mg
5
•
JADENU - deferasirox tab 360 mg
5
•
JADENU SPRINKLE deferasirox granules packet 90 mg
5
•
JADENU SPRINKLE deferasirox granules packet 180 mg
5
•
JADENU SPRINKLE deferasirox granules packet 360 mg
5
•
METHYLENE BLUE methylene blue inj 1%
3
NALOXONE HCL - naloxone hcl soln cartridge 0.4 mg/ml
3
NALOXONE HCL - naloxone hcl soln prefilled syringe 2 mg/2ml
3
naloxone hcl inj 0.4 mg/ml
1
naloxone hcl inj 4 mg/10ml
•
1
NARCAN - naloxone hcl nasal spray 4 mg/0.1ml
2
PHYSOSTIGMINE SALICYLATE physostigmine salicylate inj 1 mg/ml
3
PRALIDOXIME CHLORIDE pralidoxime chloride im soln auto-injector 600 mg/2ml
3
RADIOGARDASE - prussian blue insoluble cap 0.5 gm
3
VISTOGARD - uridine triacetate oral granules packet 10 gm
5
•
VIVITROL - naltrexone for im extended release susp 380 mg
5
•
DIAGNOSTIC PRODUCTS BAYER BREEZE 2 TEST DISC - glucose blood test disk
2
BAYER CONTOUR BLOOD GLUCO - glucose blood test strip
2
BAYER CONTOUR NEXT BLOOD - glucose blood test strip
2
BD 3ML LL SYR/PREFILL LIT - 3 arterial blood gas kit 3 DRIHEP ARTERIAL LINE SAMP - arterial blood gas kit 3 DRIHEP PLUS 3ML LL PREFIL - arterial blood gas kit 3 DRIHEP PLUS 3ML PREFILLED - arterial blood gas kit 3 GLUCAGEN DIAGNOSTIC glucagon hcl (rdna) diagnostic for inj 1 mg (base equiv) 3 LIQUIHEP BD 3ML PREFIL SY - arterial blood gas kit 3 LIQUIHEP BD 3ML PREFILLED - arterial blood gas kit LIQUIHEP II BD 3ML LL SYR - 3 arterial blood gas kit
1
naltrexone hcl tab 50 mg (Revia)
Limited Distribution
5
ACA
EXJADE - deferasirox tab for oral susp 500 mg
Dispensing Limits
•
Step Therapy
5
Prior Authorization
EXJADE - deferasirox tab for oral susp 250 mg
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
219
LIQUIHEP II BD 3ML PREFIL arterial blood gas kit
3
RESERVAPAK PLUS KIT resveratrol oral syrup (cmpd kit)
METHACHOLINE CHLORIDE - 3 methacholine chloride crystals METHACHOLINE CHLORIDE - 3 methacholine chloride powder 3 PRESET 1ML LS SYR/ PREFILL - arterial blood gas kit 3 PRESET 3ML LL SYR/ PREFILL - arterial blood gas kit 3 PRESET 3ML SYR/PREFILL LY - arterial blood gas kit 3 PRESET 3ML SYR/ PREFILLED - arterial blood gas kit 3 3ML GLASS SYR KIT/1ML NA - arterial blood gas kit 3 5ML GLASS SYR KIT/1ML NA - arterial blood gas kit ALTERNATIVE MEDICINES
CHEMICALS A-LIPOIC ACID (DL-THIOCTI alpha-lipoic acid (bulk) powder
3
AC DERMAPEPTIDE saccharomyces cerevisiae extract liquid
3
ACEPROMAZINE MALEATE acepromazine maleate (bulk) powder
3
ACESULFAME POTASSIUM acesulfame potassium (bulk) powder
3
ACETAMINOPHEN acetaminophen (bulk) granules
3
ACETAMINOPHEN acetaminophen powder
3
ACETAMINOPHEN CRYSTAL 60 - acetaminophen (bulk) crystals
3
ACETARSONE - acetarsone (bulk) powder
3
ACETAZOLAMIDE acetazolamide (bulk) powder
3
ACETIC ACID - acetic acid soln 5%
3
3
CO-BALAMIN - ubiquinolvit b12-resveratrol-fa cap 200-5-400-0.8 mg
3
CO-VERATROL - ubiquinolvit b12-resveratrol-fa cap 200-5-400-0.8 mg
3
ACETIC ACID GLACIAL acetic acid (glacial) soln 99%
3
NEOKE RA LIPOIC - alphalipoic acid (thioctic acid) oral powder 800 mg/gm
3
ACETIC ACID GLACIAL acetic acid soln
3
3
3
QUINZYME - coenzyme q10 tab disint 90 mg
ACETONE - acetone soln
3
RESERVAPAK KIT resveratrol oral syrup (cmpd kit)
3
ACETYL DIPEPTIDE-1 CETYL - acetyl dipeptide-1 cetyl ester (bulk) solution
SM
Limited Distribution
ACA
Dispensing Limits
Step Therapy
3
CITRUS BERGAMOT - citrus bergamot oral powder 250 mg/0.25 gm
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Products October (2016 Plan Year)
220
ACETYL HEXAPEPTIDE-8 acetyl hexapeptide-8 (bulk) powder
3
ACETYL HEXAPEPTIDE-8 acetyl hexapeptide-8 (bulk) solution
3
3
ADRENOCHROME SEMICARBAZO carbazochrome (bulk) powder
3
ACETYL-D-GLUCOSAMINE acetyl-d-glucosamine powder
3
ADRENOCORTICOTROPHIC HORM - corticotropin (bulk) powder AGAR - agar granules
3
3
AGAR - agar powder
3
ACETYL-L-CARNITINE HYDROC - acetylcarnitine hcl (bulk) powder
3
ACETYLCHOLINE CHLORIDE - acetylcholine chloride powder
3
ALASKAN RED ALGAE alaskan red algae (bulk) powder ALBENDAZOLE - albendazole (bulk) powder
3
ACIDOPHILUS LACTOBACILLUS lactobacillus acidophilus powder
3
ALCOHOL - alcohol, usp 95%
3
ALDOSTERONE - aldosterone (bulk) powder
3 3
ACRIFLAVINE NEUTRAL acriflavine powder
3
ALGINIC ACID - alginic acid powder
3
ACTIPHYTE OF ALGAE GL algae extract (bulk) liquid
3
ALKYL BENZOATE C12-15 c12-15 alkyl benzoate (bulk) liquid ALLANTOIN - allantoin powder
3
ALLOPURINOL - allopurinol (bulk) powder
3
ALMOND OIL - almond oil (sweet)
3
ALMOND OIL SWEET almond oil (sweet)
3
ALOE VERA - aloe vera oil
3
ALOE VERA - aloe vera powder
3
ALOE VERA FREEZE DRIED aloe vera powder
3
ALOE VERA LEAF - aloe vera powder
3
ALPHA KETOGLUTARIC ACID - alpha-ketoglutaric acid (bulk) powder
3
ACTIPHYTE OF CUCUMBER - 3 cucumber extract (bulk) liquid 3 ACTIPHYTE OF IVY - hedera helix (ivy) extract (bulk) liquid 3 ACTIPHYTE OF LEMONGRASS - lemongrass (bulk) liquid 3 ACYCLOVIR - acyclovir (bulk) powder 3 ADEMETIONINE DISULFATE TO - ademetionine disulfate tosylate (bulk) powder 3 ADENOSINE - adenosine powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
221
ALPHA LIPOIC ACID - alphalipoic acid (bulk) powder
3
ALPHA-GPC 50% glycerylphosphorylcholine (bulk) powder
3
ALPHA-KETOGLUTARIC ACID - alpha-ketoglutaric acid (bulk) powder
3
ALPHA-TOCOPHEROL vitamin e (bulk) liquid
3
ALPRAZOLAM - alprazolam (bulk) powder
3
ALTRENOGEST - altrenogest (bulk) powder
3
ALUM AMMONIUM - alum (ammonium) powder
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
AMINOLEVULINIC ACID HCL - 3 methyl aminolevulinate hcl (bulk) powder 3 AMITRIPTYLINE HCL amitriptyline hcl (bulk) powder 3 AMLODIPINE BESYLATE amlodipine besylate (bulk) powder AMMONIUM BICARBONATE - 3 ammonium bicarbonate powder 3 AMMONIUM BROMIDE ammonium bromide granules 3 AMMONIUM CHLORIDE ammonium chloride granules 3 AMMONIUM HYDROXIDE ammonia solution, strong 3 AMMONIUM LACTATE ammonium lactate solution 70% 3 AMMONIUM LAURYL SULFATE - ammonium lauryl sulfate (bulk) liquid 28% 3 AMMONIUM MOLYBDATE TETRAH - ammonium molybdate tetrahydrate (bulk) powder 3 AMMONIUM SULFATE ammonium sulfate granules 3 AMMONIUM TETRATHIOMOLYBDA ammonium molybdate tetrahydrate (bulk) powder AMOXICILLIN/CLAVULANATE 3 P - amoxicillin-potassium clavulanate 4:1 (bulk) powder ANASTROZOLE - anastrozole 3 (bulk) powder
ALUMINUM ACETATE BASIC - 3 aluminum subacetate (bulk) powder 3 ALUMINUM CHLOROHYDRATE aluminum chlorohydrate (bulk) powder 3 ALUMINUM HYDROXIDE DRIED - aluminum hydroxide gel powder 3 ALUMINUM POTASSIUM SULFAT - alum (potassium) powder 3 ALUMINUM SULFATE aluminum sulfate granules 3 ALUMINUM SULFATE HYDRATE - aluminum sulfate granules 3 AMANTADINE HCL amantadine hcl (bulk) powder 3 AMINOCAPROIC ACID aminocaproic acid (bulk) powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
222
ANDROSTENEDIONE androstenedione (bulk) powder
3
ASPARAGINE MONOHYDRATE asparagine (bulk) powder
3
ANISINDIONE - anisindione (bulk) powder
3
3
ANTIMONY TRICHLORIDE antimony trichloride (bulk) crystals
3
ATORVASTATIN CALCIUM atorvastatin calcium (bulk) powder ATOVAQUONE - atovaquone (bulk) powder
3
ANTIMONY TRISULFIDE antimony trisulfide (bulk) powder
3
ATTAPULGITE ACTIVATED COL - attapulgite (bulk) powder
3
AVICEL PH 101 MICROCRYSTA - cellulose (bulk) powder
3
AVICEL PH 105 MICROCRYSTA - cellulose (bulk) powder
3
AVIPTADIL ACETATE aviptadil acetate (bulk) powder
3
AVOCADO OIL - avocado oil (bulk)
3
AZELAIC ACID - azelaic acid (bulk) flakes
3
AZELASTINE HCL - azelastine hcl (bulk) powder
3
AZITHROMYCIN azithromycin (bulk) powder
3
AZITHROMYCIN DIHYDRATE - azithromycin (bulk) powder
3
BACITRACIN MICRONIZED bacitracin micronized (bulk) powder
3
BASE G ALMOND OIL SWEET - almond oil (sweet)
3
BASIC FUCHSIN HCL - basic fuchsin hcl powder
3
BECLOMETHASONE DIPROPIONA beclomethasone dipropionate (bulk) powder
3
ANTIPYRINE - antipyrine (bulk) 3 crystals ANTIPYRINE - antipyrine (bulk) 3 powder 3 APOMORPHINE HCL apomorphine hcl (bulk) powder 3 APOMORPHINE HCL HEMIHYDRA - apomorphine hcl (bulk) powder 3 ARBUTIN ALPHA - arbutin alpha (bulk) powder 3 ARGININE HCL - arginine hcl (bulk) powder 3 ARLACEL 165 - glyceryl stearate-peg 100 stearate (bulk) powder 3 ARNICA LG - arnica (bulk) liquid ARSENIC TRIOXIDE - arsenic 3 trioxide (bulk) powder 3 ASCORBIC ACID - ascorbic acid (bulk) granules 3 ASCORBIC ACID - ascorbic acid (bulk) powder ASCORBIC ACID CASSAVE - 3 ascorbic acid (bulk) powder 3 ASCORBYL PALMITATE ascorbyl palmitate (bulk) powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
223
BELLADONNA - belladonna (bulk) tincture
3
BELLADONNA EXTRACT belladonna (bulk) powder
3
BENACTYZINE HYDROCHLORIDE benactyzine hcl (bulk) powder
3
BENAZEPRIL HCL - benazepril 3 hcl (bulk) powder 3 BENFOTIAMINE benfotiamine (bulk) powder 3 BENZETHONIUM CHLORIDE - benzethonium chloride powder BENZOIN GUM - benzoin gum 3 (bulk) powder 3 BENZOQUINONE (PARA) 1,4-benzoquinone (bulk) crystals 3 BENZYL BENZOATE - benzyl benzoate liquid 3 BETA CAROTENE - beta carotene (bulk) beadlets 10% BETA CYCLODEXTRIN - beta 3 cyclodextrin (bulk) powder 3 BETA GLUCAN - beta glucan (bulk) powder 3 BETAHISTINE DIHYDROCHLORI betahistine hydrochloride (bulk) powder 3 BETAHISTINE HCL betahistine hydrochloride (bulk) powder 3 BETAINE ANHYDROUS betaine (bulk) powder 3 BETAINE HCL - betaine hcl powder
BETAMETHASONE ACETATE - betamethasone acetate (bulk) powder
3
BETAMETHASONE ACETATE MIC - betamethasone acetate (bulk) powder
3
BETANAPHTHOL betanaphthol (bulk) powder
3
BETHANECHOL CHLORIDE bethanechol chloride (bulk) powder
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
BHA - butylated hydroxyanisole 3 flakes BHT - butylated hydroxytoluene 3 granules 3 BIMATOPROST - bimatoprost (bulk) powder 3 BIORE HYDRATING MOISTURIZ - fragrances (bulk) - liquid 3 BISABOLOL ALPHA-L bisabolol, alpha-l (bulk) liquid 3 BISMUTH CITRATE - bismuth citrate powder BISMUTH SUBCARBONATE - 3 bismuth subcarbonate powder 3 BISMUTH SUBNITRATE bismuth subnitrate powder BISMUTH SUBSALICYLATE - 3 bismuth subsalicylate powder 3 BITTER ORANGE - bitter orange (citrus aurantium amara) (bulk) powder 3 BLUE AGAVE ORGANIC agave tequilana (blue agave) liquid 3 BORIC ACID - boric acid crystals
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
224
BORIC ACID - boric acid powder
3
BORON AMORPHOUS FINE boron (bulk) powder BORON CITRATE - boron citrate (bulk) powder 5%
3
3
BUTORPHANOL TARTRATE butorphanol tartrate (bulk) powder
3
3
BUTYL ALCOHOL - butyl alcohol (bulk) liquid BUTYLATED HYDROXYANISOLE butylated hydroxyanisole powder
3
BUTYLATED HYDROXYTOLUENE butylated hydroxytoluene granules
3
BUTYLATED HYDROXYTOLUENE butylated hydroxytoluene powder
3
BUTYLENE GLYCOL butylene glycol (bulk) liquid
3
C INDICUM EXTRACT/ C SINES - c indicum & c sinesis leaf extract liquid
3
CALCIPOTRIENE calcipotriene (bulk) powder
3
CALCIPOTRIENE MONOHYDRATE calcipotriene hydrate (bulk) powder
3
CALCIPOTRIOL - calcipotriene (bulk) powder
3
CALCITRIOL - calcitriol (bulk) powder
3
CALCITRIOL IN ALMOND OIL - calcitriol in almond oil (bulk) 1000 nanogram/ml
3
CALCIUM ACETATE - calcium acetate (bulk) powder
3
3 BOSWELLIA SERRATA EXTRACT - boswellia serrata extract (bulk) powder BRIJ 35 - polyoxyethylene (23) 3 lauryl ether (bulk) wax 3 BRIJ 700 - polyoxyethylene (100) stearyl ether (bulk) wax 3 BRIJ 93 - polyoxyethylene (2) oleyl ether (bulk) liquid 3 BRILLIANT GREEN - brilliant green (bulk) powder 3 BRIMONIDINE TARTRATE brimonidine tartrate (bulk) powder 3 BROMFENAC SODIUM bromfenac sodium (bulk) powder 3 BUDESONIDE - budesonide (bulk) powder 3 BUFLOMEDIL HCL buflomedil hcl (bulk) powder 3 BUPRENORPHINE HCL buprenorphine hcl (bulk) powder BUPROPION HCL - bupropion 3 hcl (bulk) powder 3 BUPROPION HYDROCHLORIDE bupropion hcl (bulk) powder BUSPIRONE HCL - buspirone 3 hcl powder BUTALBITAL - butalbital (bulk) 3 powder
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
CALCIUM ALGINATE - calcium 3 alginate (bulk) powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
225
CALCIUM AMINO ACID CHELAT - calcium amino acid chelate (bulk) granules 30%
3
CALCIUM SULFATE HEMIHYDRA - calcium sulfate powder (plaster of paris)
3
CALCIUM CHLORIDE ANHYDROU - calcium chloride anhydrous (bulk) powder
3
CALCIUM THIOGLYCOLATE TRI - calcium thioglycolate (bulk) powder
3
3
CAMPHOR OIL - bulk chemicals - liquid
3
CALCIUM CITRATE - calcium citrate tetrahydrate (bulk) powder
3
CALCIUM CITRATE TETRAHYDR - calcium citrate tetrahydrate (bulk) powder
3
CANADIAN BALSAM canadian balsam (bulk) liquid CAPRYLIC ACID - caprylic acid (bulk) liquid
3
CALCIUM FOLINATE leucovorin calcium powder
3
3
CALCIUM GLUBIONATE calcium glubionate (bulk) powder
3
CAPRYLIC/CAPRIC TRIGLYCER - caprylic capric triglyceride (bulk) liquid
3
CALCIUM GLUBIONATE MONOHY - calcium glubionate (bulk) powder
3
CAPSAICIN PALMITATE capsaicin palmitate (bulk) powder CAPSICUM OLEORESIN capsicum oleoresin liquid
3
CALCIUM HYDROXIDE calcium hydroxide powder
3
CAPTOPRIL - captopril (bulk) powder
3
CALCIUM HYDROXYAPATITE durapatite (hydroxyapatite) (bulk) powder
3
CARBACHOL - carbachol (bulk) powder
3 3
CALCIUM LEVULINATE DIHYDR - calcium levulinate dihydrate (bulk) powder
3
CARBAMIDE PEROXIDE carbamide peroxide (bulk) powder
3
CALCIUM PYRUVATE calcium pyruvate (bulk) powder
3
CARBAZOCHROME carbazochrome (bulk) powder CARBIDOPA - carbidopa powder
3
CALCIUM SACCHARIN saccharin calcium (bulk) crystals
3
CARBIDOPA ANHYDROUS carbidopa powder
3 3
CALCIUM SULFATE ANHYDROUS - calcium sulfate powder (plaster of paris)
3
CARBIMAZOLE - carbimazole (bulk) powder CARBOMER 934P - carbomer powder
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
226
CARBOMER 934P RESIN carbomer powder
3
CARBOMER 940 - carbomer powder
3
CARBOPOL 940 - carbomer powder
3
CARBOPOL 940 NF carbomer powder
3
CARBOXYMETHYLCELLULOSE 3 SO - carboxymethylcellulose sodium granules CARBOXYMETHYLCELLULOSE 3 SO - carboxymethylcellulose sodium powder 3 CARNAUBA WAX - carnauba wax (bulk) flakes 3 CARNITINE (L) - levocarnitine (bulk) powder 3 CARNOSINE L - carnosine (bulk) powder 3 CASTOR OIL - castor oil
CELLULOSE MICROCRYSTALLIN cellulose (bulk) powder
3
CELLULOSE PARTIALLY DEPOL - cellulose (bulk) powder
3
CELLULOSE/CMC NA MICROCRY - cellulose carmellose sodium (bulk) powder
3
CERAPHYL SLK - isodecyl neopentanoate (bulk) liquid
3
CERESIN WAX - ceresin wax (bulk) flakes
3
CESIUM CHLORIDE - cesium chloride (bulk) powder
3
CETEARYL ALCOHOL/ CETEARET - cetearyl alcohol-ceteareth 20 (bulk) powder
3
CETYL ESTERS WAX spermaceti wax (bulk)
3
CETYL MYRISTOLEATE cetyl myristoleate (bulk) oil 40%
3
CETYL MYRISTOLEATE cetyl myristoleate (bulk) powder
3
3
CEDAR LEAF OIL - cedar leaf oil
3
CEFTAZIDIME - ceftazidime (bulk) powder
3
CEFTAZIDIME/SODIUM CARBON - ceftazidime with sodium carbonate (bulk) powder
3
CEFTRIAXONE SODIUM ceftriaxone sodium (bulk) powder
3
CETYL MYRISTOLEATE cetyl myristoleate (bulk) powder 20%
3
CELECOXIB - celecoxib (bulk) powder
3
CETYL MYRISTOLEATE cetyl myristoleate (bulk) wax 40% CETYLPYRIDINIUM CHLORIDE - cetylpyridinium chloride crystals
3
CELLULASE - cellulase (bulk) powder
3
CELLULOSE MICROCRYSTALLIN cellulose (bulk) crystals
3
CHICKEN PROTEIN - chicken protein (bulk) powder
3
CHLORAMBUCIL chlorambucil (bulk) powder
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
227
CHLORAMPHENICOL PALMITATE chloramphenicol palmitate (bulk) powder
3
CHLORHEXIDINE DIACETATE H chlorhexidine acetate (bulk) powder
3
CHLORHEXIDINE GLUCONATE - chlorhexidine gluconate solution
3
CHLOROFORM - chloroform soln
3
CHLOROPHYLLIN SODIUM COPP - chlorophyllin copper complex sodium (bulk) powder
3
CHLOROXINE - chloroxine (bulk) powder
3
CHLOROXYLENOL chloroxylenol (bulk) powder
3
CHOLECALCIFEROL cholecalciferol (bulk) powder
3
CHOLECALCIFEROL cholecalciferol crystals
3
CHOLESTEROL - cholesterol flakes
3
CIDOFOVIR ANHYDROUS cidofovir (bulk) powder
3
CHOLESTEROL - cholesterol powder
3
CIDOFOVIR DIHYDRATE cidofovir (bulk) powder
3
CHOLESTYRAMINE cholestyramine (bulk) powder
3
CINNAMON BARK CASSIA cinnamon bark (bulk) powder
3
CHOLESTYRAMINE RESIN cholestyramine (bulk) powder
3
CIPROFLOXACIN ciprofloxacin (bulk) powder
3
CIPROFLOXACIN HCL ciprofloxacin hcl (bulk) powder
3
CIPROFLOXACIN HCL MONOHYD - ciprofloxacin hcl (bulk) powder
3
CHONDROITIN SULFATE SODIU - chondroitin sulfate sodium (bulk) powder
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3
3 CHORIONIC GONADOTROPIN - chorionic gonadotropin (bulk) powder 3 CHROMIUM CHLORIDE chromic chloride (bulk) powder 3 CHROMIUM CHLORIDE HEXAHYD - chromic chloride (bulk) crystals 3 CHROMIUM PICOLINATE chromium picolinate (bulk) powder 3 CHROMIUM POLYNICOTINATE chromium polynicotinate (bulk) powder 3 CHROMIUM POTASSIUM SULFAT - chromium potassium sulfate dodecahydrate (bulk) crystals 3 CHRYSIN - chrysin powder
CHOLINE CHLORIDE - choline 3 chloride (bulk) powder 3 CHOLINE MAGNESIUM TRISALI - choline magnesium trisalicylate (bulk) powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
228
CISAPRIDE MONOHYDRATE - cisapride (bulk) powder
3
CLOMIPRAMINE HCL clomipramine hcl (bulk) powder
3
CITRIC ACID - citric acid powder
3
CLONAZEPAM - clonazepam (bulk) powder
3
CITRIC ACID ANHYDROUS citric acid granules
3
3
CITRIC ACID ANHYDROUS citric acid powder
3
CLOPIDOGREL BISULFATE clopidogrel bisulfate (bulk) powder
3
CITRIC ACID MONOHYDRATE - citric acid monohydrate granules
3
CLORSULON - clorsulon (bulk) powder CLOVE OIL - clove oil
3
COAL TAR - coal tar (crude) solution
3
CITRIC ACID MONOHYDRATE - citric acid monohydrate powder
3
CITRONELLA OIL - citronella oil
3
CITRULLINE(L) - citrulline (bulk) powder
3
CITRUS BIOFLAVONOIDS citrus bioflavonoids (bulk) powder 13%
3
CLARITHROMYCIN clarithromycin (bulk) powder
3
COENZYME Q-10 - coenzyme q10 powder
3
CLEMIZOLE HCL - clemizole hcl (bulk) powder
3
COENZYME Q10 - coenzyme q10 powder
3
CLIDINIUM BROMIDE clidinium bromide (bulk) powder
3
COLHIBIN - colhibin solution
3 3
CLINDAMYCIN HCL clindamycin hcl (bulk) powder
3
COLISTIMETHATE SODIUM colistimethate sodium (bulk) powder
3
CLINDAMYCIN HCL MONOHYDRA - clindamycin hcl (bulk) powder
3
COLLAGEN HYDROLYSATE collagen hydrolysate (bovine) (bulk) powder
3
CLINDAMYCIN PHOSPHATE clindamycin phosphate (bulk) powder
3
COLLOIDAL ACTIVATED ATTAP - attapulgite (bulk) powder COPASIL - silicone (bulk) gel
3
3
COPPER GLUCONATE copper gluconate (bulk) powder
3
CLOFAZIMINE - clofazimine (bulk) powder
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
COAL TAR - coal tar (crude) tar 3 COBALT GLUCONATE - cobalt 3 gluconate (bulk) powder COBAMAMIDE - cobamamide 3 (bulk) powder 3 COCAMIDE DEA - cocamide dea (bulk) liquid 3 COCONUT OIL - coconut oil
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
229
COPPER GLYCINATE - cupric glycinate (bulk) powder
3
COPPER PEPTIDE - copper peptide (bulk) powder
3
CORAL CALCIUM - coral calcium (bulk) powder
3
CORN OIL - corn oil (bulk)
3
CORN STARCH - starch powder
3
CORTICOTROPHIN corticotropin (bulk) powder
3
COSMOCIL CQ polyaminopropyl biguanide (bulk) liquid
3
COTTONSEED OIL cottonseed oil
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
3 CUPRIC CHLORIDE DIHYDRATE - cupric chloride crystals CUPUACU BUTTER - cupuacu 3 butter (bulk) 3 CURCUMIN - turmeric (curcuma longa) (bulk) powder 3 CURCUMIN EXTRACT turmeric (curcuma longa) (bulk) powder 3 CYCLANDELATE cyclandelate (bulk) powder 3 CYCLOBENZAPRINE cyclobenzaprine (bulk) powder 3 CYCLOBENZAPRINE HCL cyclobenzaprine (bulk) powder 3 CYCLOBENZAPRINE HCL cyclobenzaprine hcl (bulk) powder 3 CYCLOMETHICONE cyclomethicone (bulk) liquid 3 CYCLOPENTASILOXANE/ PEG/PP cyclopentasiloxane-peg/ ppg-18/18 dimethicone liquid 3 CYCLOPENTOLATE HCL cyclopentolate hcl (bulk) powder 3 CYCLOPHOSPHAMIDE cyclophosphamide (bulk) powder 3 CYCLOSERINE - cycloserine (bulk) powder 3 CYCLOSPORINE cyclosporine (bulk) powder 3 CYCLOSPORINE A cyclosporine (bulk) powder
COUMARIN - coumarin powder 3 3 CRANBERRY - cranberry (vaccinium macrocarpon) (bulk) powder 3 CREATINE - creatine (bulk) powder 3 CREATINE ANHYDROUS creatine (bulk) powder CREATINE MONOHYDRATE - 3 creatine monohydrate (bulk) powder CREATININE - creatinine (bulk) 3 powder 3 CRESOL - cresol (bulk) liquid CROTAMITON - crotamiton (bulk) liquid
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3
CROTON OIL - croton oil (bulk) 3 oil 3 CRYOSERV - dimethyl sulfoxide - solution 3 CUCUMBER MELON fragrances (bulk) - liquid
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
230
CYPROHEPTADINE HCL cyproheptadine hcl (bulk) powder
3
DESOXYCORTICOSTERONE ACET - desoxycorticosterone acetate (bulk) powder
3
CYSTEAMINE HCL cysteamine hcl (bulk) powder
3
DEVILS CLAW - devil's claw (harpagophytum procumbens) (bulk) powder
3
D-MANNOSE - d-mannose (bulk) powder
3
3
D-RIBOSE - d-ribose (bulk) powder
3
DEXAMETHASONE ISONICOTINA dexamethasone isonicotinate (bulk) powder
DANTROLENE SODIUM dantrolene sodium (bulk) powder
3
DEXPANTHENOL dexpanthenol (bulk) liquid
3 3
DAPIPRAZOLE HCL dapiprazole hcl (bulk) powder
3
DEXPANTHENOL dexpanthenol (bulk) powder DHEA - prasterone powder
3
3
3
DAPSONE - dapsone (bulk) powder
DHEA MICRONIZED prasterone micronized powder DIAMINOPYRIDINE diaminopyridine (bulk) powder
3
DIAZEPAM - diazepam (bulk) powder
3
DIAZOXIDE - diazoxide (bulk) powder
3
DIBUCAINE HCL - dibucaine hcl powder
3
DEHYDROEPIANDROSTERONE3prasterone powder 3 DEMECARIUM BROMIDE demecarium bromide (bulk) powder 3 DEOXYCHOLIC ACID deoxycholic acid (bulk) powder 3 DEOXYCHOLIC ACID SODIUM - sodium deoxycholate (bulk) powder 3 DERMACINRX ETHOXY DIGLYCO - carbitol liquid 3 DESICCATED BEEF LIVER desiccated beef liver (bulk) powder DESMOPRESSIN ACETATE - 3 desmopressin acetate (bulk) powder 3 DESOXIMETASONE desoximetasone (bulk) powder
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
DIBUTYL SQUARATE - squaric 3 acid dibutylester liquid 3 DICHLORALPHENAZONE dichloralphenazone (bulk) powder 3 DICHLOROACETIC ACID dichloracetic acid (bulk) liquid 3 DICLAZURIL - diclazuril (bulk) powder 3 DICLOFENAC SODIUM diclofenac sodium (bulk) powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
231
DICUMAROL - dicumarol (bulk) 3 powder 3 DICYCLOMINE HYDROCHLORIDE dicyclomine hydrochloride (bulk) powder 3 DIETHANOLAMINE diethanolamine (bulk) liquid 3 DIETHYL-M-TOLUAMIDE diethyltoluamide (bulk) liquid 3 DIETHYLCARBAMAZINE CITRAT - diethylcarbamazine citrate (bulk) powder 3 DIETHYLENE GLYCOL MONOETH - carbitol liquid 3 DIETHYLPROPION HYDROCHLOR diethylpropion hydrochloride (bulk) powder 3 DIETHYLSTILBESTROL diethylstilbestrol (bulk) powder 3 DIHYDROCODEINE BITARTRATE dihydrocodeine bitartrate (bulk) powder 3 DIHYDROXYACETONE (1,3) DI - dihydroxyacetone (1,3) dimer (bulk) powder 3 DIINDOLYLMETHANE diindolylmethane (bulk) powder 3 DIIODO-L-THYRONINE 3,5 3,5-diiodothyronine (bulk) powder DILTIAZEM HCL - diltiazem hcl 3 (bulk) powder 3 DIMENHYDRINATE dimenhydrinate powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
DIMERCAPTO-1PROPANESULFO dimercaptopropanesulfonate (2,3) sodium (dmps) powder
3
DIMERCAPTOPROPANESULFONA dimercaptopropanesulfonate (2,3) sodium (dmps) powder
3
DIMERCAPTOSUCCINIC ACID - succimer (bulk) crystals
3
DIMERCAPTOSUCCINIC ACID - succimer (bulk) powder
3
DIMETHYL FUMARATE dimethyl fumarate (bulk) powder
3
DIMETHYL SILOXANE HYDROXY - dimethyl siloxane hydroxyalkylterminated liquid
3
DIMETHYL SULFONE methylsulfonylmethane (bulk) powder
3
DIMETHYL SULFOXIDE dimethyl sulfoxide - solution
3
DIMETHYLACETAMIDE dimethylacetamide (bulk) liquid
3
DIMETHYLAMINOETHANOL (DEA - deanol (bulk) liquid
3
DIMETHYLGLYCINE HCL dimethylglycine hcl (bulk) powder
3
DINITROCHLOROBENZENE dinitrochlorobenzene crystals
3
DIOSGENIN - diosgenin (bulk) powder
3
DIOSMIN - diosmin (bulk) powder
3
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
232
DIOXYBENZONE dioxybenzone (bulk) powder
3
DIPHENIDOL HYDROCHLORIDE diphenidol hcl (bulk) powder
3
DIPHENYLCYCLOPROPENONE 3diphenylcyclopropenone (bulk) powder 3 DIPYRIDAMOLE dipyridamole (bulk) powder 3 DISOPHENOL - disophenol (2.6-diiodo-4-nitrophenol) powder 97% DISULFIRAM - disulfiram (bulk) 3 powder 3 DL-ALPHA LIPOIC ACID alpha-lipoic acid (bulk) powder 3 DL-MALIC ACID - malic acid powder 3 DL-PANTHENOL - panthenol (bulk) powder 3 DL-3-HYDROXYBUTYRIC ACID - sodium 3hydroxybutyrate (bulk) powder 3 DMAE BITARTRATE - deanol bitartrate (bulk) powder 3 DOCOSANOL - docosanol (bulk) powder 3 DOCUSATE SODIUM/ SODIUM BE - docusate sodium-sodium benzoate powder 85-15% 3 DOPAMINE HYDROCHLORIDE dopamine hcl (bulk) powder DOW CORNING 1501 FLUID - 3 decamethylcyclopentasiloxane (bulk) liquid DOW CORNING 200 - silicone 3 (bulk) liquid
DOXYCYCLINE MONOHYDRATE doxycycline monohydrate (bulk) powder
3
DRAKKAR NOIR - fragrances (bulk) - liquid
3
DULOXETINE HCL duloxetine hcl (bulk) powder
3
DYCLONINE HCL - dyclonine hcl (bulk) powder
3
DYPHYLLINE - dyphylline (bulk) powder
3
ECONAZOLE NITRATE econazole nitrate powder
3
EDETATE ACID - edetic acid powder
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
EDETATE DISODIUM - edetate 3 disodium powder 3 EDETATE DISODIUM DIHYDRAT - edetate disodium powder 3 EDETATE TETRASODIUM TETRA - edetate sodium (bulk) powder EDROPHONIUM CHLORIDE - 3 edrophonium chloride (bulk) powder 3 EGCG - green tea (camillia sinensis) (bulk) powder 3 EMU OIL - emu oil (bulk)
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
ENALAPRIL MALEATE enalapril maleate (bulk) powder
3
ENOVARX-AMITRIPTYLINE amitriptyline hcl cream 2% kit (compounding kit)
3
ENROFLOXACIN enrofloxacin (bulk) powder
3
EPINEPHRINE - epinephrine powder
3
Products October (2016 Plan Year)
233
EPINEPHRINE BASE epinephrine powder
3
EPINEPHRINE BITARTRATE epinephrine bitartrate (bulk) powder
3
EQUIPTO-AMITRIPTYLINE amitriptyline cream 2% (compounding kit)
3
ERGOLOID MESYLATES ergoloid mesylates (bulk) powder
3
ERYTHROMYCIN ESTOLATE - erythromycin estolate (bulk) powder
3
ESTRADIOL - estradiol (bulk) powder
ESTRIOL ULTRA MICRONIZED - estriol micronized (bulk) powder
3
ESTRONE - estrone (bulk) crystals
3
ESTRONE - estrone (bulk) powder
3
ESTRONE CONCENTRATE estrone (bulk) cream 1%
3
ETHER - ether (solvent grade) soln
3
ETHOSUXIMIDE ethosuximide (bulk) powder
3
3
ETHOXY DIGLYCOL - carbitol liquid
3
ESTRADIOL - estradiol micronized (bulk) powder
3
ETHYL ALCOHOL - alcohol, usp 95%
3
ESTRADIOL BENZOATE estradiol benzoate (bulk) powder
3
ETHYL ALCOHOL 190 PROOF - alcohol, usp 95%
3 3
ESTRADIOL CONCENTRATE - estradiol (bulk) cream 10%
3
ETHYL OLEATE - ethyl oleate (bulk) liquid
3
ESTRADIOL CYPIONATE estradiol cypionate (bulk) powder
3
ETHYLENEDIAMINE ethylenediamine liquid 99% (bulk) ETOMIDATE - etomidate (bulk) powder
3
ESTRADIOL MICRONIZED estradiol micronized (bulk) powder
3
ETOPOSIDE - etoposide (bulk) powder
3 3
ESTRADIOL VALERATE estradiol valerate (bulk) powder
3
EUCALYPTOL - eucalyptol (bulk) liquid
3
ESTRIOL - estriol micronized (bulk) powder
3
EUCALYPTUS OIL eucalyptus oil EUGENOL - eugenol
3
FAMCICLOVIR - famciclovir (bulk) powder
3
ESTRIOL CONCENTRATE estriol (bulk) cream 10%
3 3
FAMOTIDINE - famotidine (bulk) powder
3
ESTRIOL MICRONIZED estriol micronized (bulk) powder
FENBENDAZOLE fenbendazole (bulk) powder
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
234
FENOFIBRATE - fenofibrate (bulk) powder
3
FLIBANSERIN - flibanserin (bulk) powder
3
FERRIC AMMONIUM CITRATE - ferric ammonium citrate (bulk) powder
3
FLOXURIDINE - floxuridine (bulk) powder
3
FLUCONAZOLE - fluconazole (bulk) powder
3
FERRIC CHLORIDE HEXAHYDRA - ferric chloride lump
3
3
FERRIC PYROPHOSPHATE bulk chemicals - powder
3
FLUCYTOSINE - flucytosine (bulk) powder
3
FERRIC SUBSULFATE - ferric subsulfate (bulk) soln
3
FLUMAZENIL - flumazenil (bulk) powder FLUNIXIN MEGLUMINE flunixin meglumine (bulk) powder
3
FLUORESCEIN - fluorescein (bulk) powder
3
FLUORESCEIN SODIUM fluorescein sodium powder
3
FLUOROURACIL - fluorouracil (bulk) powder
3
FLUOXETINE HCL - fluoxetine hcl (bulk) powder
3
FLUPHENAZINE DECANOATE - fluphenazine decanoate (bulk) liquid
3
FLUPHENAZINE DECANOATE - fluphenazine decanoate (bulk) powder
3
FLUTICASONE PROPIONATE - fluticasone propionate (bulk) powder
3
FORMOTEROL FUMARATE formoterol fumarate (bulk) powder
3
FORMOTEROL FUMARATE formoterol fumarate dihydrate (bulk) powder
3
FORSKOLIN - forskolin (bulk) powder
3
FREEDOM ESTERDERM cetearyl ethylhexanoate (bulk) liquid
3
FERRIC SULFATE HYDRATE - 3 ferric sulfate (bulk) powder 3 FERROUS BISGLYCINATE CHEL - ferrous bisglycinate chelate (bulk) powder 3 FERROUS FUMARATE ferrous fumarate (bulk) powder 3 FERROUS GLUCONATE ferrous gluconate (bulk) powder 3 FERROUS GLUCONATE DIHYDRA - ferrous gluconate (bulk) granules 3 FERROUS GLUCONATE DIHYDRA - ferrous gluconate (bulk) powder 3 FERULIC ACID - ferulic acid (bulk) powder 3 FEVERFEW - feverfew (bulk) powder 3 FEXOFENADINE HCL fexofenadine hcl (bulk) powder 3 FINASTERIDE - finasteride (bulk) crystals 3 FINASTERIDE - finasteride (bulk) powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
235
FRESH LINEN FRAGRANCE fragrances (bulk) - liquid
3
FULLERS EARTH - fullers earth powder
3
FUMARIC ACID - fumaric acid (bulk) powder
3
FURAZOLIDONE furazolidone (bulk) powder
3
GABAPENTIN - gabapentin powder
3
GALACTOSE - galactose (bulk) powder
3
GAPEAM BUDIBAC - bulk chemical compound kit cream (cmpd kit)
3
GARDENIA FRAGRANCE gardenia fragrance (bulk) oil
3
GATIFLOXACIN SESQUIHYDRAT gatifloxacin (bulk) powder
3
GENISTEIN - genistein (bulk) powder
GLUCOSAMINE HYDROCHLORIDE glucosamine hydrochloride (bulk) powder
3
GLUCOSAMINE SULFATE glucosamine sulfate (bulk) powder
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3 GLUCOSAMINE SULFATE POTAS - glucosamine sulfate potassium (bulk) powder 3 GLUCOSAMINE SULFATE SODIU - glucosamine sulfate sodium chloride (bulk) powder 3 GLUTARALDEHYDE IN WATER - glutaral (bulk) liquid 50% 3 GLYCERIN - glycerin liquid GLYCERIN - glycerin soln
3
GLYCERINE - glycerin liquid
3
3
GLYCEROL FORMAL glycerin liquid
3
GERANIUM NATURAL geranium oil
3
3
GERMALL PLUS - diazolidinyl urea-iodopropynyl butylcarbamate liquid
3
GLYCEROL MONOOLEATE glycerol monooleate (bulk) powder GLYCERYL MONOSTEARATE - glyceryl monostearate flakes
3
GLYCINE SOYA PROTEIN soybean protein (bulk) solution
3
GLYCOFUROL - glycofurol (bulk) liquid
3
GERMANIUM SESQUIOXIDE - 3 germanium sesquioxide powder 3 GINGER ROOT - ginger root powder 3 GINSENG (AMERICAN) american ginseng (panax quinquefolium) (bulk) powder 3 GINSENG ROOT - ginseng root (panax ginseng) (bulk) powder 3 GLUCONOLACTONE gluconolactone powder
GLYCOLIC ACID - glycolic acid 3 crystals GLYCOLIC ACID - glycolic acid 3 granules 3 GLYCOPYRROLATE glycopyrrolate (bulk) powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
236
GLYCOSAMINOGLYCANS glycosaminoglycans (bulk) liquid
3
GYMNEMA SYLVESTRIS LEAF - gymnema sylvestric leaf (bulk) powder
3
GLYCYRRHIZIC ACID glycyrrhizin (bulk) powder
3
HALOPERIDOL - haloperidol (bulk) powder
3
GOLD SODIUM THIOMALATE - gold sodium thiomalate (bulk) powder
3
HALOPERIDOL DECANOATE - haloperidol decanoate (bulk) powder
3
GRAMICIDIN D - gramicidin d powder
3
3
GRAPE SEED - grape seed (bulk) oil
3
HAWTHORN BERRY hawthorn berry (bulk) powder
3
GRAPESEED - grape seed (bulk) oil
3
HEMATOXYLIN - hematoxylin (bulk) powder
3
GREEN SOAP - green soap (bulk) emulsion
3
HEPARIN SODIUM - heparin sodium (porcine) powder HEPES - hepes (bulk) powder
3
GREEN TEA - epigallocatechin gallate (bulk) powder 95%
3
HEPTAMINOL - heptaminol (bulk) powder
3
GREEN TEA - green tea (camillia sinensis) (bulk) powder
3
HISTAMINE DIPHOSPHATE histamine phosphate crystals
3
GREEN TEA OIL FRAGRANCE - green tea oil fragrance (bulk) oil
3
HISTAMINE PHOSPHATE histamine phosphate crystals
3
GRISEOFULVIN - griseofulvin micronized (bulk) powder
3
3
GUAIACOL - guaiacol solution
3
GUANABENZ ACETATE guanabenz acetate (bulk) powder
3
HOMATROPINE METHYLBROMIDE homatropine methylbromide powder
3
GUANETHIDINE HEMISULFATE guanethidine sulfate (bulk) powder
3
HONEY ALMOND FRAGRANCE - honey almond fragrance (bulk) liquid
3
GUANIDINEACETIC ACID glycocyamine (bulk) powder
3
HUMAN CHORIONIC GONADOTRO - chorionic gonadotropin (bulk) powder
3
GUAR GUM - guar gum powder
3
HUPERZINE SERRATE A huperzine serrate a (bulk) powder 1%
GUARANA SEED EXTRACT guarana (bulk) powder
3
HYALURONATE SODIUM hyaluronate sodium (bulk) powder
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
237
HYALURONIC ACID HYDROLYZE - hyaluronic acid (bulk) powder
3
HYALURONIC ACID SODIUM - 3 hyaluronate sodium (bulk) powder HYALURONIC ACID SODIUM 3 SA - hyaluronate sodium (bulk) powder 3 HYALURONIDASE hyaluronidase (bulk) powder 3 HYALURONIDASE BOVINE hyaluronidase bovine (bulk) lyophilized powder 3 HYDRALAZINE HCL hydralazine hcl (bulk) powder 3 HYDRAZINE SULFATE hydrazine sulfate (bulk) crystals 3 HYDROCHLORIC ACID hydrochloric acid liquid 3 HYDROCHLORIC ACID hydrochloric acid liq 10% 3 HYDROCHLORIC ACID hydrochloric acid liq 37% 3 HYDROCODONE BITARTRATE - hydrocodone bitartrate (bulk) crystals 3 HYDROCODONE BITARTRATE - hydrocodone bitartrate (bulk) powder 3 HYDROCORTISONE HEMISUCCIN hydrocortisone hemisuccinate (bulk) powder 3 HYDROFLUORIC ACID hydrofluoric acid (bulk) liquid 48% 3 HYDROXOCOBALAMIN hydroxocobalamin (bulk) powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
HYDROXOCOBALAMIN HYDROCHL hydroxocobalamin hcl (bulk) powder
3
HYDROXYAMPHETAMINE HYDROB hydroxyamphetamine hbr (bulk) powder
3
HYDROXYCHLOROQUINE SULFAT hydroxychloroquine sulfate (bulk) powder
3
HYDROXYETHYL CELLULOSE - hydroxyethyl cellulose (bulk) powder
3
HYDROXYETHYL CELLULOSE 10 hydroxyethyl cellulose (bulk) powder
3
HYDROXYETHYL CELLULOSE 45 hydroxyethyl cellulose (bulk) powder
3
HYDROXYETHYL CELLULOSE 50 hydroxyethyl cellulose (bulk) powder
3
HYDROXYETHYL METHACRYLATE hydroxyethyl methacrylate (bulk) powder 96%
3
HYDROXYPROGESTERONE CAPRO hydroxyprogesterone caproate (bulk) powder
3
HYDROXYPROPYL CELLULOSE - hydroxypropyl cellulose powder
3
HYDROXYPROPYL CELLULOSE 1 hydroxypropyl cellulose powder
3
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
238
HYDROXYPROPYL CELLULOSE 4 hydroxypropyl cellulose powder
3
HYDROXYPROPYL CELLULOSE 7 hydroxypropyl cellulose powder
3
HYDROXYPROPYL METHYLCELLU hypromellose (bulk) powder
3
HYDROXYPROPYL-BETACYCLOD - hydroxypropylbeta-cyclodextrin (bulk) powder
3
HYDROXYQUINOLINE SULFATE - oxyquinoline sulfate (bulk) powder
3
HYDROXYTRYPTOPHAN hydroxytryptophan powder
3
HYDROXYTRYPTOPHAN L-5 - hydroxytryptophan powder
3
HYDROXYUREA hydroxyurea (bulk) powder
3
HYDROXYZINE HCL hydroxyzine hcl (bulk) powder
3
HYPROMELLOSE METHOCEL K1 hypromellose (bulk) powder
3
HYPROMELLOSE 100000CPS - hypromellose (bulk) powder
3
HYPROMELLOSE 4000 MPAS - hypromellose (bulk) powder
3
HYPROMELLOSE 4000CPS hypromellose (bulk) powder
3
IDEBENONE - idebenone (bulk) powder
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
IDOXURIDINE - bulk chemicals 3 - crystals 3 IDOXURIDINE - idoxuridine (bulk) powder 3 IMIDUREA - imidurea (bulk) powder IMIQUIMOD - imiquimod (bulk) 3 powder 3 INDOCYANINE GREEN indocyanine green (bulk) powder 3 INDOLE-3-CARBINOL indole-3-carbinol powder 3 INOSITOL - inositol (bulk) powder 3 INOSITOL HEXANICOTINATE - inositol niacinate (bulk) powder 3 IODINE - iodine flakes
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
IODINE RESUBLIMED - iodine granules
3
IODINE STRONG - iodine solution strong (lugol's) (bulk)
3
IODOFORM - iodoform powder
3
IOPANOIC ACID - iopanoic acid (bulk) powder
3
ISOMETHEPTENE MUCATE isometheptene mucate (bulk) powder
3
ISOPROPANOL - isopropyl alcohol 70%
3
ISOPROPYL ALCOHOL isopropyl alcohol
3
ISOPROPYL ALCOHOL isopropyl alcohol 70%
3
ISOPROPYL ALCOHOL isopropyl alcohol 99%
3
ISOPROPYL MYRISTATE isopropyl myristate (bulk) solution
3
Products October (2016 Plan Year)
239
ISOPROPYL PALMITATE isopropyl palmitate liquid
3
KINETIN - kinetin (bulk) powder
3
ISOPROTERENOL HCL isoproterenol hcl (bulk) powder
3
KIWI FRAGRANCE - kiwi fragrance (bulk) liquid
3
KOJIC ACID - kojic acid powder
3
ISOSORBIDE - isosorbide (bulk) powder
3 3
KUDZU ROOT - kudzu (bulk) powder
3
ISOTRETINOIN - isotretinoin (bulk) powder ISOXSUPRINE HCL isoxsuprine hcl (bulk) powder
3
ITRACONAZOLE itraconazole powder
3
IVERMECTIN - ivermectin (bulk) powder
3
JASMINE FRAGRANCE jasmine fragrance (bulk) liquid
3
JOJOBA OIL - jojoba oil (bulk)
3
JUNIPER TAR - juniper tar oil
3
KANAMYCIN SULFATE kanamycin sulfate (bulk) powder
3
KETAMINE HCL - ketamine hcl (bulk) powder
3
KETOCONAZOLE ketoconazole powder
3
KETOPROFEN 10% CREAM BASE - ketoprofen (bulk) cream 10%
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
L-ARGININE HCL - arginine hcl 3 (bulk) powder 3 L-ASPARAGINE MONOHYDRATE - bulk chemicals - powder 3 L-ASPARTIC ACID - aspartic acid powder 3 L-CARNITINE - levocarnitine (bulk) powder 3 L-CARNOSINE - carnosine (bulk) powder 3 L-CITRULLINE - citrulline (bulk) powder 3 L-CYSTEINE - cysteine (bulk) powder 3 L-CYSTEINE HCL MONOHYDRAT - cysteine hcl powder 3 L-GLUTAMIC ACID MONOSODIU - monosodium glutamate (bulk) powder 3 L-LYSINE HCL - lysine hcl powder 3 L-LYSINE MONOHYDROCHLORID lysine hcl powder L-MENTHOL - menthol crystals 3
3 KETOROLAC TROMETHAMINE - ketorolac tromethamine (bulk) powder 3 KETOTIFEN FUMARATE ketotifen fumarate (bulk) powder 3 KETOTIFEN HYDROGEN FUMARA - ketotifen fumarate (bulk) powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
L-METHYLFOLATE CALCIUM - levomefolate calcium (bulk) powder
3
L-ORNITHINE HYDROCHLORIDE ornithine hcl (bulk) powder
3
Products October (2016 Plan Year)
240
L-SELENOMETHIONINE l-selenomethionine (bulk) powder
3
L-SELENOMETHIONINE BLEND - l-selenomethionine (bulk) powder
3
L-SERINE - serine (bulk) powder
3
L-THYROXINE SODIUM levothyroxine sodium (bulk) powder
3
3 L-5METHYLTETRAHYDROFOLIC levomefolate calcium (bulk) powder 3 LABETALOL HCL - labetalol hcl (bulk) powder LACTASE 5000 - lactase (bulk) 3 powder LACTIC ACID - lactic acid soln 3 LACTIC ACID RACEMIC lactic acid soln
3
LAMOTRIGINE - lamotrigine (bulk) powder
3
LANSOPRAZOLE lansoprazole (bulk) powder
3
LATANOPROST - latanoprost (bulk) powder
3
LAURETH-9 POLIDOCANOL laureth-9 (bulk) liquid
3
LAURIC ACID - lauric acid (bulk) powder
3
LAVENDER OIL FRAGRANCE - lavender oil
3
LAVENDER OIL NATURAL lavender oil
3
LEAD ACETATE TRIHYDRATE - lead acetate trihydrate powder
3
LEAD TETROXIDE - lead tetroxide (bulk) powder 99%
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
LECITHIN - soybean lecithin (bulk) granules
3
LECITHIN SOYA - soybean lecithin (bulk) granules
3
LECITHIN SOYA - soybean lecithin (bulk) powder
3
LEFLUNOMIDE - leflunomide (bulk) powder
3
LEMONGRASS OIL lemongrass oil
3
LETROZOLE - letrozole (bulk) powder
3
LEUCOVORIN CALCIUM leucovorin calcium powder
3
LEUPROLIDE ACETATE leuprolide acetate (bulk) powder
3
LEVALBUTEROL HCL levalbuterol hcl (bulk) powder
3
LEVETIRACETAM levetiracetam (bulk) powder
3
LEVOCARNITINE levocarnitine (bulk) powder
3
LEVOCETIRIZINE DIHYDROCHL levocetirizine dihydrochloride (bulk) powder
3
LEVOFLOXACIN HEMIHYDRATE levofloxacin (bulk) powder
3
LEVOFLOXACIN HEMIHYDRATE levofloxacin hemihydrate (bulk) powder
3
LEVOMEFOLATE CALCIUM levomefolate calcium (bulk) powder
3
LEVORPHANOL TARTRATE levorphanol tartrate (bulk) powder
3
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
241
LEVOTHYROXINE SODIUM levothyroxine sodium (bulk) powder
3
LOCUST BEAN GUM - carob (locust bean gum) (bulk) powder
3
LICORICE DEGLYCYRRHIZINAT licorice, deglycyrrhizinated (bulk) powder
3
LORATADINE - loratadine (bulk) powder
3 3
LICORICE ROOT - licorice (glycyrrhiza) powder
3
LORAZEPAM - lorazepam (bulk) powder
3
LIDOCAINE - lidocaine (bulk) crystals
3
LUGOLS - iodine solution strong (lugol's) (bulk)
3
LIDOCAINE - lidocaine (bulk) powder
3
LUTEIN - lutein (bulk) beads 5%
3
LIDOCAINE BASE - lidocaine (bulk) powder
3
LUTEIN - lutein (bulk) powder 5%
3
LIDOCAINE HCL - lidocaine hcl (bulk) powder
3
LYSINE HCL - lysine hcl (bulk) granules
3
LIDOCAINE HCL MONOHYDRATE - lidocaine hcl (bulk) powder
3
MACA ROOT - maca root (lepidium meyenii) (bulk) powder
3
LIME OIL - lime oil
3
MACADAMIA NUT OIL macadamian nut oil MAFENIDE ACETATE mafenide acetate (bulk) powder
3
LIMONENE - limonene (bulk) liquid
3
LINCOMYCIN HCL lincomycin hcl (bulk) powder
3
3
LINOLEIC ACID - linoleic acid (bulk) liquid
3
MAGNASWEET 110 ammonium glycyrrhizinate (bulk) liquid
3
LINSEED OIL RAW - flaxseed oil (linseed oil)
3
MAGNASWEET 135 ammonium glycyrrhizinate (bulk) powder
LIOTHYRONINE - liothyronine (bulk) powder
3
3
LIPACTIVE INCA INCHI WO - inca inchi (plukenetia volubilis) seed (bulk) liquid
3
MAGNESIUM ALUMINUM SILICA - magnesium aluminum silicate (bulk) powder MAGNESIUM AMINO ACID CHEL - magnesium amino acid chelate (bulk) powder 20%
3
MAGNESIUM ASCORBATE magnesium ascorbate (bulk) powder
3
LIPOIC ACID - alpha-lipoic acid 3 (bulk) powder 3 LISINOPRIL - lisinopril (bulk) powder 3 LITHIUM CITRATE TETRAHYDR - lithium citrate tetrahydrate (bulk) powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
242
MAGNESIUM BISGLYCINATE CH - magnesium glycinate (bulk) powder
3
MANGANESE GLUCONATE manganese gluconate (bulk) powder
3
MAGNESIUM BISGLYCINATE DI - magnesium bisglycinate dihydrate (bulk) powder
3
MANGANESE SULFATE manganese sulfate (bulk) powder
3
MAGNESIUM CITRATE magnesium citrate (bulk) powder
3
MANNITOL - mannitol powder
3 3
MAGNESIUM CITRATE TRIBASI - magnesium citrate (bulk) powder
3
MECAMYLAMINE HCL mecamylamine hcl (bulk) powder
3
MAGNESIUM GLUCONATE magnesium gluconate (bulk) powder
3
MECHLORETHAMINE HCL mechlorethamine hcl (bulk) powder
3
MAGNESIUM GLYCINATE magnesium glycinate (bulk) powder
3
MECLOFENOXATE HYDROCHLORI meclofenoxate hcl (bulk) powder
3
MEDIUM CHAIN TRIGLYCERIDE - medium chain triglycerides (bulk) liquid
3
MAGNESIUM HYDROXIDE magnesium hydroxide (bulk) powder MAGNESIUM MALATE magnesium malate (bulk) powder
3
3
MAGNESIUM PHOSPHATE DIBAS - magnesium phosphate dibasic trihydrate (bulk) powder
3
MEDROXYPROGESTERONE ACETA medroxyprogesterone acetate (bulk) powder
3
MALEIC ACID - maleic acid (bulk) powder
3
MEDROXYPROGESTERONE ACETA medroxyprogesterone acetate micronized (bulk) powder
MALIC ACID - malic acid powder
3
3
MALTODEXTRIN maltodextrin (bulk) powder
3
MEDROXYPROGESTERONE MICRO medroxyprogesterone micronized powder
MANDELIC ACID - mandelic acid (bulk) powder
3
MEGLUMINE - meglumine (bulk) powder
3
MANGANESE CHLORIDE TETRAH - manganese chloride tetrahydrate (bulk) powder
3
MELATONIN - melatonin powder
3
MELOXICAM - meloxicam (bulk) powder
3
MEMANTINE HYDROCHLORIDE memantine hcl (bulk) powder
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
243
MENADIONE - menadione (bulk) powder
3
METHOCEL E4M PREMIUM hypromellose (bulk) powder
3
MENADIONE SODIUM BISULFIT - menadione sodium bisulfite crystals
3
METHOCEL K100M PREMIUM - hypromellose (bulk) powder
3
MENTHOL - menthol crystals
3
3
MEQUINOL - mequinol (bulk) powder
3
METHOXYETHANOL methoxyethanol (bulk) liquid
3
MERCAPTOPURINE - bulk chemicals - powder
3
MERCAPTOPURINE mercaptopurine (bulk) powder
3
METHSCOPOLAMINE BROMIDE methscopolamine bromide (bulk) powder
3
MERCAPTOPURINE mercaptopurine monohydrate (bulk) powder
3
METHSCOPOLAMINE NITRATE - methscopolamine nitrate (bulk) powder
3
MERCAPTOPURINE MONOHYDRAT mercaptopurine monohydrate (bulk) powder
3
METHYL FOLATE - 5methyltetrahydrofolate (bulk) powder
3
METACRESOL ACETATE metacresol acetate (bulk) liquid
3
METHYL METHACRYLATE CROSS - methyl methacrylate crosspolymer (bulk) powder
3
METFORMIN HCL - metformin hcl (bulk) powder
3
METHYL SULFONE methylsulfonylmethane (bulk) crystals
3
METHACRYLIC ACID COPOLYME - methacrylic acid copolymer (type a) powder
3
METHYLCOBALAMIN methylcobalamin powder METHYLENE BLUE methylene blue powder
3 3
METHANESULFONIC ACID methanesulfonic acid (bulk) liquid
3
METHYLENE BLUE TRIHYDRATE - methylene blue powder
3
METHANOL - methyl alcohol
3
METHENAMINE methenamine powder
3
METHYLENE CHLORIDE methylene chloride (bulk) liquid
3
METHENAMINE MANDELATE - methenamine mandelate (bulk) powder
3
METHOCARBAMOL methocarbamol (bulk) powder
3
METHYLMETHACRYLATE CROSSP methylmethacrylate crosspolymer (310) (bulk) powder METHYLPHENIDATE HCL methylphenidate hcl powder
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
244
METHYLSULFONYLMETHANE - 3 methylsulfonylmethane (bulk) powder METHYSERGIDE MALEATE - 3 methysergide maleate powder 3 METRONIDAZOLE metronidazole powder 3 MEXILETINE HYDROCHLORIDE mexiletine hcl (bulk) powder 3 MIDAZOLAM - midazolam (bulk) powder 3 MILK THISTLE - milk thistle seed (bulk) powder MINOXIDIL - minoxidil powder 3
MOXIFLOXACIN HCL moxifloxacin hcl (bulk) powder
3
MOXISYLYTE HCL moxisylyte hcl (bulk) powder
3
MUPIROCIN - mupirocin (bulk) powder
3
NABUMETONE - nabumetone (bulk) powder
3
NADH - nicotinamide adenine dinucleotide, disodium trihydr powder
3
NALBUPHINE HCL nalbuphine hcl (bulk) powder
3
NALOXONE HCL - naloxone hcl (bulk) powder
3
NALOXONE HCL DIHYDRATE - naloxone hcl (bulk) powder
3
NALTREXONE - naltrexone (bulk) powder
3
MISOPROSTOL - misoprostol (bulk) powder 1%
3
MISOPROSTOL-HPMC misoprostol (bulk) powder 1%
3
MITOMYCIN - mitomycin (bulk) powder
3
NALTREXONE HCL naltrexone hcl (bulk) powder
3
MITOTANE - mitotane (bulk) powder
3
3
MOLYBDENUM - molybdenum (bulk) powder
3
NANDROLONE DECANOATE - nandrolone decanoate (bulk) powder
3
MOMETASONE FUROATE mometasone furoate (bulk) powder
3
NATAPRES - bulk chemicals liquid
3
MONOBENZONE monobenzone (bulk) powder
3
NATURAL MIXED TOCOPHEROLS tocopherols (bulk) powder 30%
MONOETHANOLAMINE monoethanolamine (bulk) liquid
3
3
MONTELUKAST SODIUM montelukast sodium (bulk) powder
3
NEOSTIGMINE METHYLSULFATE neostigmine methylsulfate (bulk) powder NEPAFENAC - nepafenac (bulk) powder
3
MORANTEL TARTRATE morantel tartrate (bulk) powder
3
NETTLE LEAF - nettle leaf (bulk) powder
3
NIAOULI - niaouli oil
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
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Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
245
NICLOSAMIDE - niclosamide (bulk) powder
3
NICOTINAMIDE ADENINE DINU - nadide powder
3
3
ONDANSETRON HCL DIHYDRATE - ondansetron hcl (bulk) powder
3
NICOTINE POLACRILEX nicotine polacrilex powder
3
ORIGANUM - origanum oil (bulk)
3
NICOTINE TARTRATE nicotine tartrate (bulk) powder
3
ORNITHINE HYDROCHLORIDE ornithine hcl (bulk) powder
3
NIMODIPINE - nimodipine (bulk) powder
3
OXALIC ACID DIHYDRATE oxalic acid dihydrate (bulk) powder
NITRIC ACID - nitric acid liquid
3
3
NITROFURANTOIN nitrofurantoin (bulk) powder
3
OXANDROLONE oxandrolone (bulk) powder OXYBENZONE - oxybenzone powder
3
OXYBUTININ CHLORIDE oxybutynin chloride (bulk) powder
3
OXYBUTYNIN CHLORIDE oxybutynin chloride (bulk) powder
3
OXYMETAZOLINE HCL oxymetazoline hcl (bulk) powder
3
OXYTETRACYCLINE DIHYDRATE oxytetracycline dihydrate (bulk) powder
3
OXYTOCIN - oxytocin (bulk) powder
3
PALMAROSA OIL - palmarosa oil (bulk)
3
PALMITAMIDE MEA (PMEA) palmidrol (bulk) powder
3
PALMITOYL PENTAPEPTIDE-3 palmitoyl pentapeptide-3 (bulk) gel
3
PALMITOYL TRIPEPTIDE-3 palmitoyl tripeptide-3 (bulk) solution
3
3 NITROFURANTOIN ANHYDROUS - nitrofurantoin (bulk) powder 3 NOREPINEPHRINE BITARTRATE norepinephrine bitartrate (bulk) powder 3 NORETHINDRONE norethindrone (bulk) powder 3 NOURISIL - silicone (bulk) gel NYSTATIN - nystatin (bulk) powder
3
NYSTATIN FOREIGN - nystatin 3 (bulk) powder 3 OCTINOXATE - octinoxate (bulk) liquid 3 OCTYL STEARATE - octyl stearate (bulk) liquid 3 OLIVE OIL - olive oil OLMESARTAN MEDOXOMIL olmesartan medoxomil (bulk) powder
3
OMEPRAZOLE - omeprazole (bulk) powder
3
ONDANSETRON HCL ondansetron hcl (bulk) powder
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
246
PANCREATIN - pancreatin (bulk) powder
3
PERFLUORODECALIN perfluorodecalin (bulk) liquid
3
PANTHENOL - panthenol (bulk) powder
3
3
PANTOPRAZOLE SODIUM pantoprazole sodium (bulk) powder
3
PERGOLIDE MESYLATE pergolide mesylate (bulk) powder PERMETHRIN TECHNICAL permethrin (bulk) liquid
3
PAPAIN - papain powder
3
3
PARACHLOROPHENOL parachlorophenol (bulk) powder
3
PERPHENAZINE perphenazine (bulk) powder PERUVIAN BALSAM peruvian balsam
3
PARAFORMALDEHYDE paraformaldehyde powder
3
PERUVIAN BALSAM peruvian balsam powder
3
PAROMOMYCIN SULFATE paromomycin sulfate (bulk) powder
3
3
PCCA DMAE COMPLEX deanol (bulk) liquid
3
PEUCEDANUM OSTRUTHIUM EXT peucedanum ostruthium extract (masterwort) solution
3
PCCA T4 SODIUM DILUTION - levothyroxine sodium (bulk) powder
3
PHENELZINE SULFATE phenelzine sulfate (bulk) powder
3
PEANUT OIL - peanut oil
3
PHENINDIONE - phenindione (bulk) powder
PEG 400 MONOSTEARATE peg 400 monostearate powder
3
PHENOLSULFONIC ACID phenolsulfonic acid (bulk) liquid
3
PEG-40 CASTOR OIL - peg-40 castor oil (bulk)
3
3
PENNYROYAL OIL pennyroyal oil (bulk)
3
PHENOXYBENZAMINE HCL phenoxybenzamine hcl (bulk) powder
3
PENTOSAN POLYSULFATE SODI - pentosan polysulfate sodium (bulk) powder
3
PHENOXYETHANOL phenoxyethanol (bulk) liquid
3
PENTOXIFYLLINE pentoxifylline (bulk) powder
3
PHENTERMINE HYDROCHLORIDE phentermine hcl (bulk) powder
PENTYLENE GLYCOL pentylene glycol (bulk) liquid
3
PENTYLENETETRAZOLE pentylenetetrazol (bulk) crystals
3
PEPPERMINT OIL peppermint oil
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
PHENTOLAMINE MESYLATE - 3 phentolamine mesylate (bulk) powder 3 PHENYL SALICYLATE phenyl salicylate crystals 3 PHENYLETHYL ALCOHOL phenylethyl alcohol (bulk) liquid SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
247
PHENYLETHYLAMINE HCL phenylethylamine hcl (bulk) powder
3
PHENYLMERCURIC ACETATE - phenylmercuric acetate powder
3
PHENYLMERCURIC NITRATE - phenylmercuric nitrate (bulk) powder
3
PHENYLTOLOXAMINE DIHYDROG phenyltoloxamine citrate (bulk) powder
3
PHENYTOIN - phenytoin (bulk) powder
PINE NEEDLE OIL - pine needle oil (bulk)
3
PINE OIL - pine oil
3
PINE TAR - pine tar
3
PINEAPPLE EXTRACT pineapple extract (bulk) liquid
3
PINENE (L-ALPHA) - l-alpha pinene (bulk) powder
3
PIPERINE - piperine (bulk) powder
3 3
3
PIRACETAM - piracetam (bulk) powder
3
PHOSPHATIDYLCHOLINE phosphatidylcholine (bulk) powder
3
PMX-1184 SILICONE - silicone (bulk) liquid
3
PHOSPHATIDYLSERINE soybean lecithin (bulk) powder 40%
3
PODOFILOX - podofilox (bulk) powder POLYETHYLENE GLYCOL 600 - bulk chemicals - liquid
3
PHYTIC ACID IN WATER phytic acid (bulk) liquid 50%
3
POLYHEXAMETHYLENE BIGUANI - polyaminopropyl biguanide (bulk) solution 20%
3
PHOSPHORIC ACID phosphoric acid soln 85%
3
3
PHYTONADIONE phytonadione (bulk) crystals
3
POLYOX WSR-301 - bulk chemicals - powder
3
PHYTONADIONE phytonadione (bulk) liquid
3
POLYOXYL 40 STEARATE bulk chemicals - misc.
3
PILOCARPINE HCL pilocarpine hydrochloride powder
3
POLYSORBATE 20 polysorbate 20 soln
3
PILOCARPINE NITRATE pilocarpine nitrate (bulk) powder
3
POLYSORBATE 40 polysorbate 40 soln POLYSORBATE 60 polysorbate 60 liq
3
POLYSORBATE 80 polysorbate 80 liq
3
PILOCARPINE NITRATE pilocarpine nitrate crystals
3 3
PINE BARK EXTRACT - pine bark extract (bulk) powder 95%
3
POLYVINYL ALCOHOL polyvinyl alcohol (bulk) powder
3
PIMOBENDAN - pimobendan (bulk) powder
POLYVINYLPYRROLIDONE K-30 - povidone (bulk) powder
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
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Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
248
POLYVINYLPYRROLIDONE K-90 - povidone (bulk) powder
3
POTASSIUM HYDROXIDE potassium hydroxide solution 45%
3
POMEGRANATE SEED pomegranate seed (bulk) oil 80%
3
POTASSIUM IODIDE potassium iodide (bulk) crystals
3
PONAZURIL - ponazuril (bulk) powder
3
3
POTASH SULFURATED LUMP - potash, sulfurated lump
3
POTASSIUM IODIDE potassium iodide (bulk) granules
3
POTASSIUM ACETATE potassium acetate (bulk) powder
3
POTASSIUM IODIDE potassium iodide (bulk) powder
3
POTASSIUM ACETATE potassium acetate crystals
3
POTASSIUM METABISULFITE potassium metabisulfite (bulk) crystals
POTASSIUM ACETATE potassium acetate granules
3
3
POTASSIUM ASPARTATE potassium aspartate (bulk) powder
3
POTASSIUM METABISULFITE potassium metabisulfite (bulk) powder POTASSIUM NITRATE potassium nitrate crystals
3
POTASSIUM NITRATE potassium nitrate powder
3
POTASSIUM PERCHLORATE - potassium perchlorate crystals
3
POTASSIUM PERMANGANATE potassium permanganate (bulk) granules
3
POTASSIUM PHOSPHATE DIBAS - potassium phosphate dibasic granules
3
POTASSIUM PHOSPHATE MONOB - potassium phosphate monobasic crystals
3
POTASSIUM SULFATE potassium sulfate (bulk) powder
3
POVIDONE - povidone (bulk) powder
3
3 POTASSIUM AZELAOYL DIGLYC - potassium azelaoyl diglycinate (bulk) liquid 3 POTASSIUM BITARTRATE potassium bitartrate powder 3 POTASSIUM BROMIDE potassium bromide crystals 3 POTASSIUM BROMIDE potassium bromide granules 3 POTASSIUM BROMIDE potassium bromide powder 3 POTASSIUM GLUCONATE ANHYD - potassium gluconate powder 3 POTASSIUM HYDROXIDE potassium hydroxide pellets 3 POTASSIUM HYDROXIDE potassium hydroxide solution 5%
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
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Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
249
POVIDONE K-30 - povidone (bulk) powder
3
POVIDONE-IODINE povidone-iodine (bulk) flakes
3
POVIDONE-IODINE povidone-iodine (bulk) powder
3
PROGESTERONE CONCENTRATE progesterone (bulk) cream 40%
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3
3 PROGESTERONE MICRONIZED - progesterone micronized (bulk) powder 3 PROGESTERONE MICRONIZED ( progesterone micronized (bulk) powder 3 PROGESTERONE MICRONIZED P progesterone micronized (bulk) powder 3 PROGESTERONE MILLED progesterone (bulk) powder 3 PROGESTERONE ULTRA MICRON - progesterone micronized (bulk) powder 3 PROGESTERONE WETTABLE - progesterone (bulk) powder 3 PROGESTERONE WETTABLE (YA progesterone (bulk) powder PROMAZINE HCL - promazine 3 hcl (bulk) powder 3 PROMETHAZINE HCL promethazine hcl (bulk) powder 3 PROPANEDIOL - propanediol (bulk) liquid 3 PROPARACAINE HCL proparacaine hcl (bulk) powder 3 PROPYL GALLATE - propyl gallate (bulk) powder 3 PROPYLENE GLYCOL propylene glycol liquid
3 POWDER SCENT FRAGRANCE - powder scent fragrance (bulk) liquid 3 PRALIDOXIME CHLORIDE pralidoxime chloride (bulk) powder PRAZIQUANTEL - praziquantel 3 (bulk) powder 3 PREGABALIN - pregabalin (bulk) powder 3 PREGNENOLONE pregnenolone powder 3 PREGNENOLONE MICRONIZED pregnenolone (micronized) powder PRILOCAINE - prilocaine (bulk) 3 powder PRILOCAINE HCL - prilocaine 3 hcl (bulk) powder PRIMIDONE - primidone (bulk) 3 powder 3 PROCARBAZINE HCL procarbazine hcl (bulk) powder 3 PROCHLORPERAZINE EDISYLAT - prochlorperazine edisylate (bulk) powder PROFLAVINE HEMISULFATE - 3 proflavine hemisulfate (bulk) powder 3 PROGESTERONE progesterone (bulk) powder
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Products October (2016 Plan Year)
250
PROPYLENE GLYCOL MONOSTEA - propylene glycol monostearate (bulk) beads
3
PROPYLTHIOURACIL propylthiouracil (bulk) powder
QUATERNIUM-15 quaternium-15 (bulk) powder
3 3
3
QUERCETIN DIHYDRATE quercetin dihydrate (bulk) powder
3
PROSTAGLANDIN E2 dinoprostone (bulk) powder
3
QUINIDINE SULFATE quinidine sulfate (bulk) powder
3
QUINIDINE SULFATE DIHYDRA - quinidine sulfate crystals
3
PROTAMINE SULFATE protamine sulfate (bulk) powder
QUININE HCL - quinine hcl dihydrate crystals
3
PROTIRELIN - protirelin (bulk) powder
3
RACEPINEPHRINE HCL racepinephrine hcl (bulk) powder
3
PSYLLIUM HUSK - psyllium husk (bulk) powder
3
PULLULAN - pullulan (bulk) powder
3
RANITIDINE HCL - ranitidine hcl (bulk) powder
3
PUMICE (FLOUR) - pumice stone powder
3
RAPESEED OIL - rapeseed oil (bulk)
3
PYRANTEL PAMOATE pyrantel pamoate (bulk) powder
3
RASAGILINE MESYLATE rasagiline mesylate (bulk) powder
3
PYRAZINAMIDE pyrazinamide (bulk) powder
3
3
PYRIDOSTIGMINE BROMIDE - pyridostigmine bromide (bulk) powder
3
RAUWOLFIA SERPENTINA rauwolfia serpentina (bulk) powder RED YEAST RICE - red yeast rice extract (bulk) powder
3
RENOVAGE - teprenonecaprylic capric triglyceride (bulk) liquid
3
RESORCINOL - resorcinol crystals
3
RESORCINOL - resorcinol powder
3
RETINALDEHYDE - retinal (bulk) powder
3
3 PYRIDOXAL-5-PHOSPHATE MON - pyridoxal-5 phosphate (bulk) powder 3 PYRIMETHAMINE pyrimethamine (bulk) powder 3 PYROGALLOL - pyrogallol crystals 3 PYRUVIC ACID - pyruvic acid liquid 3 PYRUVIC ACID - pyruvic acid powder
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
RETINOL MOLECULAR FILM - 3 vitamin a oil 0.3% 3 RIBAVIRIN - ribavirin (bulk) powder
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Products October (2016 Plan Year)
251
RIBOFLAVIN - riboflavin (bulk) powder
3
RIBOFLAVIN-5-PHOSPHATE SO - riboflavin 5-phosphate sodium (bulk) powder
3
3
SECRETIN-MANNITOL secretin-mannitol (bulk) powder 1-99%
3
RIBOSE (D) - d-ribose (bulk) powder
3
SELENIUM SULFIDE selenium sulfide (bulk) powder
3
RIFAXIMIN - rifaximin (bulk) powder
3
SELENIUM YEAST - selenium yeast (bulk) powder
3
ROCURONIUM BROMIDE rocuronium bromide (bulk) powder
3
SENNA - senna fluid extract (bulk)
3
RONIDAZOLE - ronidazole (bulk) powder
3
SEPICALM VG - white water lilly flower-sodium palmitoyl proline liqd
3
ROPIVACAINE HCL ropivacaine hcl (bulk) powder
3
SERMORELIN ACETATE sermorelin acetate (bulk) powder
3
ROSE BENGAL B - rose bengal b (bulk) powder
3
SEROTONIN HCL - serotonin hcl (bulk) powder
3
ROSE OIL - rose oil
3
SERTRALINE HCL - sertraline hcl (bulk) powder SESAME OIL - sesame oil
3
SHARK CARTILAGE - shark cartilage (bulk) powder
3
SHOWER FRESH FRAGRANCE - shower fresh fragrance (bulk) liquid
3
ROSEMARY OIL - rosemary oil 3 3 ROSIN LUMP - rosin lump RUBIDIUM CHLORIDE rubidium chloride (bulk) powder
3
RUTIN - rutin (bulk) powder
3
SAFFLOWER OIL - safflower oil
3
SAGE LEAF - sage leaf (bulk) powder
3
SALICYLIC ACID - salicylic acid (bulk) solution 50%
3
SALSALATE - salsalate (bulk) powder
3
SASSAFRAS OIL - sassafras oil
3
SAW PALMETTO BERRY saw palmetto (bulk) powder
3
SCARLET RED - scarlet red (bulk) powder
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
SIBERIAN GINSENG - siberian 3 ginseng (bulk) powder 3 SILDENAFIL CITRATE sildenafil citrate (bulk) powder 3 SILICA GEL - silica gel
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
SILICA GEL ULTRAMICRONIZE - silica gel
3
SILICON DIOXIDE - silica (bulk) powder
3
SILICONE BLEND CUSTOM silicone (bulk) paste
3
SILICONE ELASTOMER BLEND - silicone (bulk) gel
3
Products October (2016 Plan Year)
252
SILICONE FLUID 556 - silicone 3 (bulk) liquid 3 SILVER SULFADIAZINE silver sulfadiazine (bulk) powder 3 SIMVASTATIN - simvastatin (bulk) powder 3 SINCALIDE IN MANNITOL sincalide in mannitol (bulk) powder 100 mcg/gm 3 SIROLIMUS - sirolimus (bulk) powder 3 SODIUM ACETATE TRIHYDRATE - sodium acetate trihydrate (bulk) powder 3 SODIUM ALGINATE - sodium alginate powder 3 SODIUM BICARBONATE sodium bicarbonate (bulk) powder SODIUM BISULFITE - sodium 3 bisulfite granules 3 SODIUM BITARTRATE MONOHYD - sodium bitartrate monohydrate (bulk) powder 3 SODIUM BORATE DECAHYDRATE - sodium borate powder 3 SODIUM BROMIDE - sodium bromide granules SODIUM BUTYRATE - sodium 3 butyrate powder 3 SODIUM CACODYLATE sodium cacodylate powder 3 SODIUM CAPRATE - sodium caprate (bulk) powder 3 SODIUM CAPYRLATE FOOD GRA - sodium caprylate (bulk) powder
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
SODIUM CARBONATE ANHYDROU - sodium carbonate powder
3
SODIUM CARBONATE MONOHYDR - sodium carbonate monohydrate powder
3
SODIUM CARBOXYMETHYLCELLU carboxymethylcellulose sodium powder
3
SODIUM CHLORIDE/SODIUM BI - sodium bicarbonatesodium chloride powder
3
SODIUM CHLORITE - sodium chlorite (bulk) flakes
3
SODIUM CITRATE DIHYDRATE - sodium citrate dihydrate powder
3
SODIUM COCOYL GLUTAMATE - sodium cocoyl glutamate (bulk) liquid
3
SODIUM DEHYDROACETATE sodium dehydroacetate(bulk) powder
3
SODIUM DEOXYCHOLATE sodium deoxycholate (bulk) powder
3
SODIUM DICHLOROACETATE sodium dichloroacetate (bulk) powder
3
SODIUM FLUORIDE - sodium fluoride (bulk) powder
3
SODIUM FLUOROPHOSPHATE sodium monofluorophosphate (bulk) powder
3
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
253
SODIUM GLUCONATE sodium gluconate (bulk) powder
3
SODIUM NITRITE - sodium nitrite granules
3
SODIUM OLEATE - sodium oleate (bulk) powder
3
SODIUM HYALURONATE hyaluronate sodium (bulk) powder
3
3
SODIUM HYALURONATE (INJEC - hyaluronate sodium (bulk) powder
3
SODIUM PERBORATE TETRAHYD - sodium perborate powder
3
SODIUM HYDROXIDE sodium hydroxide pellets
3
SODIUM PHENYLBUTYRATE sodium phenylbutyrate (bulk) powder
SODIUM HYDROXIDE sodium hydroxide solution 10%
3
SODIUM IODIDE - sodium iodide (bulk) granules
3
SODIUM L-ASPARTATE sodium aspartate monohydrate (bulk) powder
3
SODIUM LACTATE - sodium lactate soln 60%
3
SODIUM LAURETH SULFATE - sodium laureth sulfate (bulk) liquid
3
SODIUM METABISULFITE sodium metabisulfite granules
3
SODIUM METABISULFITE sodium metabisulfite powder
3
SODIUM METABISULFITE ANHY - sodium metabisulfite granules
3
SODIUM MOLYBDATE sodium molybdate (bulk) powder
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3 SODIUM PHOSPHATE DIBASIC - sodium phosphate dibasic (bulk) crystals 3 SODIUM PHOSPHATE DIBASIC - sodium phosphate dibasic (bulk) granules 3 SODIUM PHOSPHATE DIBASIC - sodium phosphate dibasic (bulk) powder 3 SODIUM PHOSPHATE MONOBASI - sodium phosphate monobasic (bulk) granules 3 SODIUM PHOSPHATE MONOBASI - sodium phosphate monobasic (bulk) powder 3 SODIUM PHOSPHATE TRIBASIC - sodium phosphate tribasic (bulk) crystals 3 SODIUM POLYSTYRENE SULFON - sodium polystyrene sulfonate (bulk) powder 3 SODIUM PROPIONATE sodium propionate powder 3 SODIUM PYROPHOSPHATE ANHY - bulk chemicals powder
3 SODIUM MONOFLUOROPHOSPHAT sodium monofluorophosphate (bulk) powder 3 SODIUM NITRATE ACS sodium nitrate (bulk) powder
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Products October (2016 Plan Year)
254
SODIUM PYRROLIDONE CARBOX - sodium pidolate (bulk) liquid
3
SORBITAN MONOOLEATE sorbitan monooleate (bulk) liquid
3
SODIUM SELENITE - sodium selenite (bulk) powder
3
3
SODIUM STEARATE - sodium stearate (bulk) powder
3
SORBITAN MONOPALMITATE - sorbitan monopalmitate (bulk) powder
SODIUM STEARYL FUMARATE - sodium stearyl fumarate (bulk) powder
3
SORBITAN MONOPALMITATE BA - sorbitan monopalmitate (bulk) powder
3
SODIUM SUCCINATE sodium succinate powder
3
SORBITOL - sorbitol powder
3 3
SODIUM SULFATE - sodium sulfate powder
3
SOYABEAN CASEIN DIGEST ME - soyabean casein digest medium (bulk) powder
SODIUM SULFITE ANHYDROUS - sodium sulfite powder
3
SOYBEAN OIL - soybean oil
3
SPEARMINT OIL - spearmint oil
3
SODIUM TARTRATE DIHYDRATE - sodium tartrate (bulk) powder
3
SPIRULINA - spirulina (bulk) powder
3
SQUALANE - squalane (bulk) liquid
3
SODIUM TETRADECYL SULFATE - sodium tetradecyl sulfate (bulk) powder
3
SQUALANE - squalane (bulk) oil
3
SQUARIC ACID - squaric acid (bulk) powder
3
ST JOHNS WORT - st john's wort (hypericum perforatum) (bulk) powder
3
STANNOUS CHLORIDE DIHYDRA - stannous chloride (bulk) crystals
3
STANNOUS FLUORIDE stannous fluoride (bulk) powder
3
STANOZOLOL - stanozolol (bulk) powder
3
STEVIA EXTRACT - stevia (bulk) powder
3
STEVIOL GLYCOSIDES steviol glycosides (bulk) powder 95%
3
3 SODIUM TETRADECYL SULFATE - sodium tetradecyl sulfate (bulk) solution 27% 3 SODIUM VALPROATE valproate sodium (bulk) powder 3 SODIUM 4AMINOSALICYLATE aminosalicylate sodium (bulk) powder 3 SODIUM-L-ASCORBYL-2PHOSP - sodium ascorbyl phosphate dihydrate (bulk) powder SORBITAN MONOLAURATE - 3 sorbitan monolaurate (bulk) liquid
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
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Prior Authorization
Drug Name
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Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
255
STEVIOSIDE - stevioside (bulk) fluid extract 15%
3
SULFUR PRECIPITATED sulfur (bulk) powder
3
STRONTIUM CHLORIDE strontium chloride (bulk) crystals
3
SULFUR SUBLIMED - sulfur (bulk) powder
3
SULFURIC ACID - sulfuric acid soln
3
STRONTIUM CHLORIDE strontium chloride (bulk) powder
3
3
STRONTIUM NITRATE strontium nitrate (bulk) crystals
3
SULPIRIDE - sulpiride (bulk) powder SUMATRIPTAN - sumatriptan (bulk) powder
3
SUCCIMER DMSA - succimer (bulk) powder
3
3
SUCCINIC ACID - succinic acid crystals
3
SUMATRIPTAN SUCCINATE sumatriptan succinate (bulk) powder
3
SUCCINYLCHOLINE CHLORIDE - succinylcholine chloride (bulk) powder
3
SUPEROXIDE DISMUTASE superoxide dismutase (bulk) powder
3
SUCROSE - sucrose powder
3
SUPEROXIDE DISMUTASE superoxide dismutase (bulk) solution SYN-AKE - dipeptide diaminobutylroyl benzylamide diacetate liqd
3
TACROLIMUS - tacrolimus (bulk) powder
3
TACROLIMUS MONOHYDRATE tacrolimus (bulk) powder
3
TALC - talc powder
3
TAMOXIFEN CITRATE tamoxifen citrate (bulk) powder
3
TARTARIC ACID - tartaric acid granules
3
TARTARIC ACID - tartaric acid powder
3
TAZAROTENE - tazarotene (bulk) powder
3
TEA COCOYL GLUTAMINE triethanolamine cocoyl glutamate (bulk) soln
3
3 SUCROSE CONFECTIONERS - sucrose powder 3 SUCROSE OCTAACETATE sucrose octaacetate crystals 3 SUCROSE POWDERED CONFECTI - sucrose powder 3 SUFENTANIL CITRATE sufentanil citrate powder 3 SULFACETAMIDE sulfacetamide (bulk) powder 3 SULFADIMETHOXINE sulfadimethoxine (bulk) powder 3 SULFAMERAZINE sulfamerazine (bulk) powder 3 SULFANILAMIDE sulfanilamide powder 3 SULFOSALICYLIC ACID DIHYD - sulfosalicylic acid dihydrate (bulk) powder SULFUR - sulfur (bulk) powder 3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
256
TEA TREE OIL - tea tree oil (bulk)
3
TERBINAFINE HCL terbinafine hcl (bulk) powder
3
TESTOSTERONE testosterone (bulk) powder
3
TESTOSTERONE CONCENTRATE testosterone (bulk) cream 20%
3
TESTOSTERONE CYPIONATE - testosterone cypionate (bulk) powder
3
TESTOSTERONE ENANTHATE - testosterone enanthate (bulk) powder
TETRAHYDROBIOPTERIN DIHYD - tetrahydrobiopterin dihydrochloride (bulk) powder
3
TETRAHYDROBIOPTERIN HYDRO - tetrahydrobiopterin dihydrochloride (bulk) powder
3
TETRAHYDROZOLINE HCL tetrahydrozoline hcl (bulk) powder
3
THEANINE - theanine (bulk) powder
3
3
THEOBROMINE - theobromine (bulk) powder
3 3
TESTOSTERONE MICRONIZED - testosterone micronized (bulk) powder
3
THEOPHYLLINE ANHYDROUS - theophylline powder
3
TESTOSTERONE MICRONIZED ( testosterone micronized (bulk) powder
3
THIOGUANINE - thioguanine (bulk) powder THIORIDAZINE HCL thioridazine hcl (bulk) powder
3
TESTOSTERONE MICRONIZED S testosterone (bulk) powder
3
THIOSALICYLIC ACID SODIUM - sodium thiosalicylate (bulk) powder
3
TESTOSTERONE MICRONIZED Y testosterone micronized (bulk) crystals
3
THIOTEPA - thiotepa (bulk) powder
3
THYMOL - thymol crystals
3
TESTOSTERONE NONMICRONIZ - testosterone (bulk) powder
3
THYMOL IODIDE - thymol iodide powder
3 3
TESTOSTERONE PROPIONATE - testosterone propionate (bulk) powder
3
THYROID - thyroid (porcine) (bulk) powder
3
TETRACAINE - tetracaine (bulk) powder
3
TICARCILLIN DISODIUM/ CLAV - ticarcillin-pot clavulanate (bulk) powder 30:1
TETRAHYDRO-L-BIOPTERIN DI - tetrahydrobiopterin dihydrochloride (bulk) powder
3
TINIDAZOLE - tinidazole powder
3
TINOGARD TL - benzotriazolyl dodecyl p-cresol (bulk) liquid
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
257
TIOPRONIN - tiopronin (bulk) powder
3
TITANIUM DIOXIDE - titanium dioxide liquid 30%
3
3
TRICHLORMETHIAZIDE trichlormethiazide (bulk) powder
3
TITANIUM DIOXIDE - titanium dioxide powder
3
TRICLOSAN - triclosan (bulk) powder
3
TIZANIDINE HCL - tizanidine hcl (bulk) powder
3
TRIETHANOLAMINE LAURYL SU - triethanolamine lauryl sulfate (bulk) liquid
TOBRAMYCIN - tobramycin (bulk) powder
3
TRIFLURIDINE - trifluridine (bulk) powder
3
TOCOPHERYL ACID SUCCINATE - vitamin e succinate (bulk) powder
3
TOCOTRIENOLS - tocotrienols (bulk) susp 50%
3
TOLAZOLINE HYDROCHLORIDE tolazoline hydrochloride (bulk) powder
3
TOLTRAZURIL - toltrazuril (bulk) powder
3
TRILOSTANE - trilostane (bulk) 3 powder TRIMEPRAZINE TARTRATE - 3 trimeprazine tartrate (bulk) powder TRIMETHOBENZAMIDE HCL - 3 trimethobenzamide hcl (bulk) powder 3 TRIOXSALEN - trioxsalen (bulk) powder 3 TRIPROLIDINE HCL triprolidine hcl crystals 3 TRITON X-100 - octoxynol liquid 3 TROMETHAMINE tromethamine (bulk) powder 3 TROPOLONE - tropolone (bulk) powder 3 TRYPSIN - trypsin powder
TOLUIDINE BLUE O - tolonium 3 chloride powder 3 TOPIRAMATE - topiramate (bulk) powder 3 TRAMADOL HCL - tramadol hcl (bulk) powder 3 TRANEXAMIC ACID tranexamic acid (bulk) powder 3 TRANILAST - tranilast (bulk) powder 3 TRIACETIN - triacetin (bulk) liquid 3 TRIAMCINOLONE triamcinolone (bulk) powder 3 TRIAMCINOLONE HEXACETONID triamcinolone hexacetonide (bulk) powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
TURMERIC - turmeric (curcuma longa) (bulk) powder
3
TURMERIC ROOT - turmeric (curcuma longa) (bulk) powder
3
TYLOSIN TARTRATE - tylosin tartrate (bulk) powder
3
TYLOXAPOL - tyloxapol (bulk) liquid
3
UBIDECARENONE coenzyme q10 powder
3
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
258
UBIQUINOL - ubiquinol (bulk) powder
3
VITAMIN A - vitamin a (bulk) powder
3
UBIQUINOL - ubiquinol (bulk) powder 30%
3
VITAMIN A ACETATE - vitamin a acetate (bulk) beadlets
3
UNDECYLENIC ACID undecylenic acid liquid
3
3
UREA - urea powder
3
VITAMIN A PALMITATE vitamin a palmitate (bulk) liquid
URIDINE - uridine (bulk) powder
3
VITAMIN D3 - cholecalciferol (bulk) powder
3
URSODIOL - ursodiol (bulk) powder
3
VITAMIN D3 - cholecalciferol liquid
3
VALACYCLOVIR HCL valacyclovir hcl (bulk) powder
3
VITAMIN D3 - cholecalciferol powder 100000 unit/gm
3 3
VALERIAN ROOT - valerian root (bulk) powder
3
VITAMIN E - vitamin e (bulk) liquid
3
VALPROATE SODIUM valproate sodium (bulk) powder
3
VITAMIN E ACETATE - vitamin e acetate (bulk) liquid
3
VANADIUM - vanadium (bulk) powder
3
VITAMIN E SUCCINATE vitamin e succinate (bulk) powder
3
VANADYL SULFATE HYDRATE - vanadyl sulfate (bulk) crystals
3
VITAMIN K2 - menaquinone-7 (bulk) powder VORICONAZOLE voriconazole (bulk) powder
3
VARDENAFIL HYDROCHLORIDE vardenafil hcl (bulk) powder
3
WHEY PROTEIN ISOLATE INST - whey protein (bulk) powder
3
VECURONIUM BROMIDE vecuronium bromide (bulk) powder
3
WHITE KIDNEY BEAN EXTRACT - white kidney bean extract (bulk) powder
3
WHITE WILLOW BARK willow bark (bulk) powder
3
WITCH HAZEL - hamamelis leaf (witch hazel) fluid extract
3
XYLAZINE HYDROCHLORIDE xylazine hcl (bulk) powder
3
XYLITOL - xylitol (bulk) powder
3
3 VICTORIAS SECRET VANILLA - fragrances (bulk) liquid 3 VIDARABINE - vidarabine (bulk) powder 3 VINBLASTINE SULFATE vinblastine sulfate (bulk) powder 3 VINPOCETINE - vinpocetine (bulk) powder
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
259
XYLOMETAZOLINE HCL xylometazoline hcl (bulk) powder
3
2-METHOXYESTRADIOL 2-methoxyestradiol (bulk) powder
3
YEAST EXTRACT - yeast extract (bulk) liquid
3
2,3-DIMERCAPTOSUCCINIC AC - succimer (bulk) powder
3
YLANG-YLANG OIL FRAGRANCE - cananga oil fragrance (bulk)
3
4-AMINOBUTYRIC ACID gamma-aminobutyric acid (bulk) crystals
3
ZEAXANTHIN - zeaxanthin (bulk) powder
3
4-AMINOPYRIDINE dalfampridine powder
3
ZINC ACETATE - zinc acetate (bulk) powder
3
4-METHYLPYRAZOLE fomepizole (bulk) liquid
3
ZINC CHLORIDE - zinc chloride granules
3
5-FLUOROURACIL fluorouracil (bulk) powder
3
ZINC CITRATE DIHYDRATE zinc citrate (bulk) powder
3
5-HTP - hydroxytryptophan powder
3
ZINC GLUCONATE - zinc gluconate (bulk) powder
3
3
ZINC MONOMETHIONINE zinc monomethionine (bulk) powder
3
5-HYDROXY-LTRYPTOPHAN hydroxytryptophan powder
ZINC OXIDE - zinc oxide (bulk) powder
3
ZINC PICOLINATE - zinc picolinate (bulk) powder
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3 5METHYLTETRAHYDROFOLATE 5-methyltetrahydrofolate calcium powder 3 5METHYLTETRAHYDROFOLIC A - levomefolate glucosamine (bulk) powder 3 6-AMINOCAPROIC ACID aminocaproic acid (bulk) powder 3 7-KETO DHEA - 7ketodehydroepiandrosterone (7-keto dhea) powder 3 9-AMINOACRIDINE HCL 9-aminoacridine hcl (bulk) powder
ZINC PYRITHIONE - pyrithione 3 zinc (bulk) liquid 48% 3 ZINC UNDECYLENATE - zinc undecylenate powder 3 ZIRCONIUM OXIDE zirconium oxide (bulk) powder 3 ZOLMITRIPTAN - zolmitriptan (bulk) powder 3 ZONISAMIDE - zonisamide (bulk) powder 3 2-DEOXY-D-GLUCOSE - 2deoxy-d-glucose powder 3 2-DEOXY-D-GLUCOSE REAGANT - 2-deoxy-dglucose powder
MEDICAL DEVICES
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
ALCOH-GLOVE CONTOURED WIP - alcohol swabs
3
ALCOH-WIPE 12" X 12" alcohol swabs
3
Products October (2016 Plan Year)
260
AMIELLE RESTORE VAGINAL E - misc. devices
3
BAYER BREEZE 2 HIGH CONTR - blood glucose calibration - liquid - high
2
BAYER BREEZE 2 LOW CONTRO - blood glucose calibration - liquid - low
2
BAYER BREEZE 2 NORMAL CON - blood glucose calibration - liquid - normal
2
BAYER CONTOUR HIGH CONTRO - blood glucose calibration - liquid - high
HURRISEAL - dental desensitizing product solution
3
INSULIN PEN NEEDLES – VARIOUS
2
INSULIN SYRINGES – VARIOUS
2
LANCET DEVICES-VARIOUS
2
LANCETS – VARIOUS
2
MI PASTE - dentifrices - paste
3
2
MI PASTE PLUS - dentifrices paste
3 3
BAYER CONTOUR LOW CONTROL - blood glucose calibration - liquid - low
2
Q-CARE Q2 ORAL CLEANSING/ - oral hygiene products - kit
3
BAYER CONTOUR NEXT CONTRO - blood glucose calibration - liquid - low
2
Q-CARE Q4 ORAL CLEANSING/ - oral hygiene products - kit
3
BAYER CONTOUR NEXT CONTRO - blood glucose calibration - liquid - normal
2
RAPPORT RING LOADING SYST - impotence aid device - kit
3
BAYER CONTOUR NORMAL CONT - blood glucose calibration - liquid - normal
2
RAPPORT VACUUM THERAPY DE - impotence aid device - kit
3
ERECAID CLASSIC impotence aid device - kit
3
REMESENSE - dental desensitizing product - misc
3
ERECAID ESTEEM impotence aid device - kit
3
EROS-CTD - clitoral vacuum device
3
SIDEKICK BLOOD GLUCOSE SY - blood glucose meter disposable device with test strips
3
FC FEMALE CONDOM condoms - female
A
•
SURE-T INFUSION SET 18" subcutaneous infusion set
3
FC2 FEMALE CONDOM condoms - female
A
•
SURE-T INFUSION SET 23" subcutaneous infusion set
3
FEMCAP - cervical cap 22 mm
3
SURE-T INFUSION SET 32" subcutaneous infusion set
FEMCAP - cervical cap 26 mm
3
FEMCAP - cervical cap 30 mm
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
3 SURE-T INFUSION SET 6MM - subcutaneous infusion set
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
261
3 SURE-T INFUSION SET 8MM - subcutaneous infusion set
APOTHESIL - cream base
3 3
PHARMACEUTICAL ADJUVANTS 3 ACACIA - acacia powder
APPLE FLAVOR - flavoring agent - liquid APPLE FLAVOR - flavoring agent - powder
3
ADA SHAMPOO - external vehicles - shampoo
3
APRICOT FLAVOR - flavoring agent - liquid
3
ADVANCED BASE PLUS cream base
3
APRICOT FLAVOR - flavoring agent - powder
3
ALBA-DERM - cream base
3
3
ALCOHOL BASE GEL alcohol gel base
3
ASTRAGALUS ROOT tragacanth powder
3
ALCOHOL DEHYDRATED ethyl alcohol 100%
3
AUXIPRO VANISHING CREAM - cream base
3
ALFALFA FLAVOR - flavoring agent - powder
3
BACOCALMINE pharmaceutical excipients (bulk) liquid
ALMOND OIL BITTER FLAVOR - flavoring agent liquid
3
BACON FLAVOR - flavoring agent - liquid
3 3
ALPAWASH - polyethylene glycol ointment
3
BACTERIOSTATIC WATER FOR - water for inject, bacteriostatic benzyl alcohol
ALTADERM CREAM BASE cream base
3
3
ANHYDROUS BASE anhydrous ointment base
3
BACTERIOSTATIC WATER PARA - water for inject, bacteriostatic parabens
3
ANHYDROUS CREAM BASE anhydrous cream base
3
BANANA CONCENTRATE flavoring agent - liquid
3
ANHYDROUS GEL BASE - gel base - gel
3
BANANA CREAM FLAVOR flavoring agent - liquid
3
ANISE EXTRACT - flavoring agent - liquid
3
BANANA CREME FLAVOR flavoring agent - liquid
3
ANISE FLAVOR - flavoring agent - oil
3
BANANA FLAVOR - flavoring agent - liquid
3
APOTHEDERM - transdermal base cream
3
BASE A POLYETHYLENE GLYCO - polyethylene glycol 1450 powder
APOTHESAR - transdermal base cream
3
3
APOTHESAR PLUS - cream base
3
BASE C POLYETHYLENE GLYCO - polyethylene glycol 300 liquid
3
APOTHESAR 2 - cream base
3
BASE CREAM WITH LIPOSOME - cream base liposomic
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
262
BASE D POLYETHYLENE GLYCO - polyethylene glycol 4500 powder
3
BASE GELATIN GUMMY TROCHE - gummy gel base gel
3
BASE W301 - cream base
3
BASE X - hydrogenated vegetable oil flakes
3
BEEF FLAVOR - flavoring agent - liquid
BLACKBERRY FLAVOR flavoring agent - liquid
3
BLUEBERRY FLAVOR flavoring agent - liquid
3
BRILLIANT BLUE G - c.i. acid blue 90 powder
3
BUBBLE GUM CONCENTRATE - flavoring agent - liquid
3
3
BUBBLE GUM FLAVOR flavoring agent - liquid
3
BEEF FLAVOR - flavoring agent - powder
3
BUTTER FLAVOR - flavoring agent - liquid
3
BEEF TYPE FLAVOR NATURAL - flavoring agent liquid
3
BUTTER RUM FLAVOR flavoring agent - liquid
3
3
BUTTERSCOTCH FLAVOR flavoring agent - liquid
3
BEEF-ADE - flavoring agent powder
3
CAPSUBLEND-H - excipient filler powder
3
BEES WAX - wax, white BEESWAX - wax, yellow
3
3
BEESWAX - wax, white
3
CAPSUBLEND-P - excipient filler powder
BENTONITE - bentonite powder
3
CAPSUBLEND-S - excipient filler powder
3
BENZYL ALCOHOL - benzyl alcohol
3
CARAMEL FLAVOR - flavoring agent - liquid
3
BHRT BASE - hormone cream base
3
CARBOGEL 940 - carbomer gel base
3
BITTER DRUG POWDER bitter drug base powder
3
CARBOHOL 940 - carbomer gel base
3
BITTER STOP FLAVOR flavoring agent - liquid
3
BITTERNESS MASK FLAVOR - flavoring agent liquid
3
BITTERNESS REDUCING AGENT - flavoring agent powder
3
CARBOMER GEL AQUEOUS - 3 carbomer gel base 3 CARBOMER GEL HYDROALCOHOL carbomer gel base 3 CARRAGEENAN carrageenan (bulk) powder 3 CELA BASE - cream base
3 BITTERNESS SUPRESSOR FLAV - flavoring agent - liquid
CETYL ALCOHOL - cetyl alcohol flakes
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
3
Products October (2016 Plan Year)
263
CETYL ALCOHOL - cetyl alcohol powder
3
CHRYSADERM DAY - cream base
3
CHEESE-ADE FLAVOR flavoring agent - powder
3
CHRYSADERM NIGHT cream base
3
CHEESECAKE FLAVOR flavoring agent - liquid
3
CINNAMON FLAVOR flavoring agent - oil
3
CHEMSIL K-12 - paste base paste
3
CLOVAGEL - gel base - gel
3
3
COCOA BUTTER - cocoa butter
3
CHEMSIL K-51 - gel base - gel CHERRY FLAVOR - flavoring agent - liquid
3
CHERRY SYRUP - cherry syrup
3
CHERRY-ADE FLAVOR flavoring agent - powder
3
CHEW-HESIVE - gelatin ointment base
3
CHICKEN BROTH FLAVOR SPRA - flavoring agent powder
3
CHICKEN FLAVOR - flavoring agent - powder
3
3 COCOA BUTTER DEODORIZED - cocoa butter COCONUT FLAVOR - flavoring 3 agent - liquid 3 COFFEE FLAVOR - flavoring agent - liquid 3 COLA FLAVOR - flavoring agent - liquid 3 COLLASIL OSA pharmaceutical excipients (bulk) powder 3 COLLODION - collodion COLLODION FLEXIBLE collodion flexible
3
CHICKEN FLAVOR OIL SOLUBL - flavoring agent liquid
3
3
CHICKEN FLAVOR WATER MISC - flavoring agent liquid
3
CORIANDER OIL - coriander oil CORN SYRUP - corn syrup
3 3
CHLOROBUTANOL chlorobutanol powder
3
COTTON CANDY FLAVOR flavoring agent - liquid
3
CHLOROBUTANOL ANHYDROUS chlorobutanol powder
3
CRAN-RASPBERRY FLAVOR - flavoring agent liquid CREAM BASE - cream base
3
CHOCOLATE FLAVOR flavoring agent - liquid
3
CREAM CONCENTRATE cream base
3
CHOCOLATE FLAVOR flavoring agent - powder
3
3
CHOCOLATE HAZELNUT FLAVOR - flavoring agent liquid
3
CREME DE MENTHE FLAVOR - flavoring agent liquid CREME DEMENTHE FLAVOR - flavoring agent liquid
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
264
CUSTOM LIPOTHENE 110 gel base - gel
3
EUCALYPTUS FLAVOR flavoring agent - oil
3
CUSTOM LIPOTHENE 133 gel base - gel
3
EUGENOL FLAVOR - flavoring agent - liquid
3
CUSTOM POLYGLYCOL TROCHE - troche base flakes
3
EVANS BLUE - evans blue powder
3
3
EXYDERM - transdermal patch
3
CUSTOM POLYGLYCOL TROCHE - troche base wax
3
CUTIS PLUS - cream base
3
F-MELT - rapid dissolve tablet base powder FAGRON CAPFILL PRO excipient filler powder
3
C10-C30 ALKYL ACRYLATE CR - pharmaceutical excipients (bulk) powder
3
3
DELIVRA SR - transdermal base cream
3
FAGRON DISPERSAPRO excipient filler powder
3
DERMACINRX TOPICAL SOLUTI - external vehicles solution
3
FAGRON LS PLUS - cream base FAGRON NATURAL CREAM cream base
3
EFFERVESCENT effervescent base (bulk) powder
3
EMOLIVAN - cream base
3
EMOLLIENT CREAM - cream base
3
EMULGADE CM - emulsifying base - liquid
3
EMULSIFYING WAX emulsifying wax
3
EMULSION CONCENTRATE emulsifying base - liquid
3
ENGLISH TOFFEE FLAVOR flavoring agent - liquid
3
ESPUMIL - foam base - foam
3
ETHYL ACETATE - ethyl acetate soln
3
ETHYL ALCOHOL - ethyl alcohol 100%
3
ETHYL ALCOHOL 200 PROOF - ethyl alcohol 100%
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
FAGRON SUPREME CREAM - 3 cream base FD&C YELLOW #5 - tartrazine 3 (fd&c yellow #5) powder 3 FD&C YELLOW #6 ALUMINUM L - fd&c yellow #6 aluminum lake powder 3 FDC BLUE 1 - dye fdc blue 1 (brilliant blue fcf) - powder 3 FDC BLUE 2 - fd&c blue #2 (indigotine) powder 3 FDC GREEN #3 - dye fdc green 3 powder 3 FDC RED #3 - dye fdc red 3 (erythrosine) powder 3 FDC RED 40 - dye fdc red 40 (allura red) - powder 3 FDC YELLOW 6 - dye fdc yellow 6 (sunset yellow) powder FISH FLAVOR - flavoring agent 3 - liquid 3 FITALITE - cream base
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
265
FIZZMIX BASE - effervescent base (bulk) powder
3
FLAVOR BLEND - oral vehicles 3 - susp 3 FLAVOR CONCENTRATE/ CHLORH - flavoring agent concentrate 3 FLAVOR PLUS - oral vehicles FLAVOR SWEET - oral vehicles - syrup
3
FLAVOR SWEET-SF - oral vehicles - syrup
3
FOAMIL - external vehicles liquid
3
FOOD COLOR BLACK - food color black - powder
3
FOOD COLOR BLUE - dye fdc blue 1 (brilliant blue fcf) liquid
3
FOOD COLOR BLUE - dye fdc blue 1 aluminum lake powder
3
FOOD COLOR BROWN - food color brown - powder
3
FOOD COLOR GREEN - food color green - liquid
3
FOOD COLOR GREEN - food color green - powder
3
FOOD COLOR LIME GREEN food color lime green powder
3
FOOD COLOR ORANGE - dye fdc yellow 6 (sunset yellow) powder
3
FOOD COLOR PINK - food color pink - liquid
3
FOOD COLOR RED - dye fdc red 40 (allura red) - powder
3
FOOD COLOR RED - food color red - liquid
3
FOOD COLOR VIOLET - food color violet - powder
3
FOOD COLOR WHITE - food color white - liquid
3
FOOD COLOR YELLOW fd&c yellow #5 aluminum lake powder
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
FOOD COLOR YELLOW - food 3 color yellow - liquid 3 FREEDOM ADAPTADERM cream base 3 FREEDOM ADAPTADERM gel base - gel 3 FREEDOM CEPAPRO - gel base - gel 3 FREEDOM DERMA SERUM cream base FREEDOM DERMA-D - cream 3 base FREEDOM DERMA-N - cream 3 base FREEDOM LOLLIPOP BASE - 3 sorbitol lollipop base miscellaneous FREEDOM ODT BASE - rapid 3 dissolve tablet base powder 3 FREEDOM PEG TROCHE BASE - troche base powder 3 FREEDOM SILOMAC ANHYDROUS - gel base gel 3 FREEDOM SIMPLECAP POWDER - excipient filler powder 3 GELATIN - gelatin (bulk) powder 3 GELATIN TYPE A - gelatin (bulk) powder 3 GRAPE FLAVOR - flavoring agent - liquid
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
266
GRAPEFRUIT FLAVOR PINK flavoring agent - oil
3
KRIS-ESTER 236 - kris-ester 236 liquid
3
GUAVA FLAVOR - flavoring agent - liquid
3
KRISGEL 100 - krisgel 100 gel
3
LACTOSE - lactose powder
3
LACTOSE ANHYDROUS lactose powder
3
GUM ARABIC SPRAY-DRIED - 3 acacia powder GUM BASE GELATIN - gummy 3 gel base - gel HAM FLAVOR - flavoring agent 3 - liquid 3 HONEY FLAVOR - flavoring agent - liquid 3 HORMONE CREAM BASE hormone cream base 3 HORMONE CREAM BASE BOTANI - hormone cream base 3 HRT BASE - hormone cream base 3 HRT BASE BOTANICAL hormone cream base 3 HRT BASE FOR MEN hormone gel base HRT BASE HEAVY - hormone 3 cream base HRT CREAM BASE - hormone 3 cream base HRT CREAM BASE WOMEN - 3 hormone cream base 3 HRT NATURAL LOTION hormone lotion base 3 HSA STERILE DILUENT human serum albumin diluent for injection 3 HYDROGEL - carbomer gel base H20 GEL BASE - gel base - gel 3 KAHLUA FLAVOR - flavoring agent - liquid
3
KARAYA GUM - karaya gum
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
LACTOSE HYDROUS - lactose 3 powder 3 LACTOSE MONOHYDRATE lactose monohydrate powder 3 LACTOSE MONOHYDRATE SPRAY - lactose monohydrate powder 1 lanolin LANOLIN - lanolin anhydrous oil
3
LANOLIN ALCOHOL - lanolin alcohol wax
3
LANOLIN ANHYDROUS lanolin anhydrous
3
LECITHIN ISOPROPYL PALMIT - lecithin-isopropyl palmitate solution
3
LECITHIN ORGANOGEL premium lecithin organogel base gel
3
LEMON EXTRACT - flavoring agent - liquid
3
LEMON FLAVOR - flavoring agent - oil
3
LEMONADE FLAVOR flavoring agent - oil
3
LICORICE FLAVOR - flavoring agent - liquid
3
LIME FLAVOR - flavoring agent 3 - oil 3 LIPMAX - lecithin-isopropyl palmitate solution 3 LIPO CREAM BASE - cream base
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
267
LIPOFOAM RX - foam base foam
3
MAPLE FLAVOR - flavoring agent - liquid
3
LIPOGEL CR BASE - gel base - gel
3
MARSHMALLOW FLAVOR flavoring agent - liquid
3
LIPOPEN ABSORPTION ENHANC - cream base
3
MEDI-RDT BASE - rapid dissolve tablet base powder
3
LIPOPEN ANHYDROUS lotion base - lotion
3
MEDI-RDT KIT - rapid dissolve tablet base powder kit
3
LIPOPEN ULTRA BASE cream base
3
LIPOSOMAL HEAVY - cream base
3
LIPOSOMAL REGULAR cream base
3
MEDI-RDT KIT (MULTIDOSE) - 3 rapid dissolve tablet base powder kit 3 MEDIBASE C - polyethylene glycol 300 liquid 3 MEDIDERM - cream base
LIPOZYME - cream base liposomic
3
MEDIHOL BASE - alcohol gel base
3
LIQUIGEL COMPLEX emulsifying base - liquid
3
3
LISSAMINE GREEN B lissamine green b powder
3
METER BUFFER PH 10 buffer reference standard solution ph 10
3
LIVER FLAVOR - flavoring agent - liquid
3
METER BUFFER PH 4 - buffer reference standard solution ph 4
LIVER FLAVOR - flavoring agent - powder
3
3
LOLLIPOP BASE - isomalt lollipop base powder
3
METER BUFFER PH 7 - buffer reference standard solution ph 7
3
LOXORAL BASE - excipient filler powder
3
METHYLCELLULOSE methylcellulose powder
3
LOZIBASE S - lozibase misc
3
METHYLPARABEN methylparaben powder
LUBRAJEL NP - gel base - gel
3
3
MAGNESIUM STEARATE magnesium stearate powder
3
MINT CHOCOLATE CHIP FLAVO - flavoring agent liquid MOLASSES FLAVOR flavoring agent - powder
3
MANGO FLAVOR - flavoring agent - liquid
3 3
3
MANGO FLAVOR - flavoring agent - powder
MUCOLOX - pharmaceutical excipients (bulk) liquid
3
MULTIUSE BASE - cream base
3
MANGO FLAVOR SWEETENED - flavoring agent - powder
MYRJ 53 - polyoxyl 40 stearate powder
3
NOURILITE - cream base
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
268
NOURIVAN ANTIOX CREAM BAS - cream base
3
PCCA ANHYDROUS BASE anhydrous ointment base
3
NOXI-K - cream base
3
3
OCCLUVAN - hydrophilic ointment
3
PCCA ANHYDROUS LIPODERM B - cream base
3
OINTMENT BASE EMULSIFYING - emulsifying ointment
3
PCCA BIOPEPTIDE BASE cream base PCCA COBASE #1 - cobase #1 ointment base
3
OLEABASE PLASTICIZED plastibase ointment
3
PCCA COSMETIC HRT BASE - cream base
3
OLEIC ACID - oleic acid soln
3
3
ORA-BLEND - oral vehicles susp
3
PCCA CUSTOM LIPO-MAX cream base liposomic
3
ORA-BLEND SF - oral vehicles - susp
3
PCCA EMULSIFIX-205 BASE emulsifying base - liquid
3
ORA-PLUS - oral vehicles
3
ORA-SWEET - oral vehicles syrup
3
PCCA FIXED OIL BASE - fixed oil suspension vehicle liquid
ORA-SWEET SF - oral vehicles - syrup
3
ORANGE CREAM FLAVOR flavoring agent - liquid
3
ORANGE FLAVOR - flavoring agent - liquid
3
ORANGE FLAVOR - flavoring agent - powder
3
ORANGE OIL FLAVOR flavoring agent - liquid
3
P-SILOXAN DS - cream base
3
PARAFFIN - paraffin wax
3
PASSION FRUIT FLAVOR flavoring agent - powder
3
PASSION FRUIT FLAVOR SWEE - flavoring agent powder
3
PCCA ACACIA SYRUP BASE - acacia syrup
3
PCCA ALADERM BASE cream base
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
PCCA GELATIN BASE - gelatin 3 ointment base PCCA LECITHIN ISOPROPYL 3 P - lecithin-isopropyl palmitate solution 3 PCCA LIPODERM BASE cream base 3 PCCA LIPODERM CUSTOM BASE - cream base 3 PCCA LIPODERM HMW - gel base - gel 3 PCCA LIPOSOMIC BASE FOR D - cream base liposomic 3 PCCA LIPOSOMIC BASE FOR N - cream base liposomic 3 PCCA LIPOSOMIC BASE FOR O - cream base liposomic 3 PCCA LIPOSOMIC BASE FOR S - cream base liposomic
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
269
PCCA LOXASPERSE BASE poloxamer-xylitol powder
3
PCCA VANISHING CREAM/ LOTI - cream base
3
PCCA MVC BASE - cream base
3
PCCA VANPEN BASE - cream base
3
PCCA NATACREAM - cream base
3
PCCA XYLIFOS BASE poloxamer-xylitol powder
3
PCCA OCCLUSADERM - gel base - gel
3
PCCA-PLUS - oral vehicles susp
3
PCCA PLASTICIZED BASE plastibase ointment
3
PEACH FLAVOR - flavoring agent - liquid
3
PCCA PLURONIC F127 BASE - pluronic f127 base gel 30%
3
PEANUT BUTTER FLAVOR flavoring agent - liquid
3
PEG 300 - polyethylene glycol 300 liquid
3
PCCA POLOXAMER 407 pluronic f127 base gel 20%
3 3
3
PCCA POLYGLYCOL TROCHE - troche base powder
PENCREAM - cream base PENDERM - cream base
3 3
PCCA POLYPEG BASE polyethylene glycol ointment
3
PENTAPHENE BASE - cream base
3
PCCA PRACAMAC BASE - oil base - oil
3
PEPPERMINT FLAVOR flavoring agent - oil
3
PCCA PRACASIL TM-PLUS BAS - cream base
3
PETROLATUM WHITE - white petrolatum ointment
3
PCCA RAPID DISSOLVE TABLE - rapid dissolve tablet base powder
3
PH 10 BUFFER - buffer reference standard solution ph 10
3
PCCA SORBITOL LOLLIPOP BA - sorbitol lollipop base flakes
3
PH 4 BUFFER - buffer reference standard solution ph 4
3
PCCA SPIRA-WASH BASE gel base - gel
3
PH 7 BUFFER - buffer reference standard solution ph 7
PCCA SWEET-SF - oral vehicles - syrup
3
PHARMABASE COSMETIC cream base
3
PHARMABASE HEAVY cream base
3
PHYTOBASE - cream base
3
PINA COLADA FLAVOR flavoring agent - liquid
3
PINEAPPLE FLAVOR flavoring agent - liquid
3
3 PCCA SWEETNESS ENHANCER - flavoring agent - liquid PCCA SYRUP VEHICLE - oral 3 vehicles - syrup 3 PCCA VANISHING CREAM LIGH - cream base
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
270
PLACEBO #00 - placebo - cap
3
PLASTIBASE - plastibase ointment
3
PLASTICIZED BASE plastibase ointment
3
PLO GEL - MEDIFLO KIT premium lecithin organogel base kit
3
PLO GEL - MEDIFLO PREMIX - premium lecithin organogel base gel
3
PLO TRANSDERMAL CREAM - transdermal base cream
3
PLO20 BASE - premium lecithin organogel base gel
3
PLURONIC - poloxamer gel 20%
3
PLURONIC - poloxamer gel 30%
3
PLURONIC F127 - pluronic f127 base gel 20%
3
PLURONIC F127 - pluronic f127 base gel 30%
3
PLURONIC F127 - poloxamer powder
3
PLURONIC L64 - poloxamer liquid
POLYETHYLENE GLYCOL 300 - polyethylene glycol 300 liquid
3
POLYETHYLENE GLYCOL 3350 - polyethylene glycol 3350 (bulk) granules
3
POLYETHYLENE GLYCOL 3350 - polyethylene glycol 3350 powder
3
POLYETHYLENE GLYCOL 400 - polyethylene glycol 400 liquid
3
POLYETHYLENE GLYCOL 4500 - polyethylene glycol 4500 powder
3
POLYETHYLENE GLYCOL 600 - polyethylene glycol 600 liquid
3
POLYETHYLENE GLYCOL 8000 - polyethylene glycol 8000 granules
3
POLYETHYLENE GLYCOL 8000 - polyethylene glycol 8000 oint
3
POLYETHYLENE GLYCOL 8000 - polyethylene glycol 8000 powder
3
3
POLYOXYL 40 STEARATE polyoxyl 40 stearate pellet
3
POLOXAMER 188 - poloxamer powder
3
POLYOXYL 40 STEARATE polyoxyl 40 stearate powder
3
POLOXAMER 407 - poloxamer powder
3
POLYPEG SUPPOSITORY BASE - suppository base
3
POLYETHYLENE GLYCOL NF - polyethylene glycol 1450 powder
3
POTASSIUM SORBATE potassium sorbate granules
3
3
3
POLYETHYLENE GLYCOL 1450 - polyethylene glycol 1450 liquid
POTASSIUM SORBATE potassium sorbate powder
3
POLYETHYLENE GLYCOL 1450 - polyethylene glycol 1450 powder
3
PRALINES AND CREAM FLAVOR - flavoring agent liquid PROPYLENE GLYCOL propylene glycol
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
271
PROPYLPARABEN propylparaben powder
3
SANARE SCAR THERAPY cream base
3
PUMPKIN FLAVOR - flavoring agent - liquid
3
SA3 DERM - cream base
3
SEDANARE - cream base
3
PURIFIED WATER - distilled water
3
3
QUINIZARIN GREEN SS - dc green 6 (quinizarin green ss) powder
3
SEPINEO P 600 - emulsifying base - liquid SERAQUA - serum base liquid
3
RASPBERRY CONCENTRATE - flavoring agent - concentrate
3
SHEA BUTTER - shea butter
3
SHEA BUTTER ORGANIC shea butter
3
RASPBERRY FLAVOR flavoring agent - liquid
3
SHRIMP FLAVOR - flavoring agent - liquid
3
RASPBERRY FLAVOR flavoring agent - powder
3
SILOSOME TRANSDERMAL transdermal base cream
3
RASPBERRY SYRUP raspberry syrup
3
SILPROTEX PLUS - cream base
3
RDT-PLUS - pharmaceutical excipients (bulk) powder
3
SIMPLE SYRUP - simple syrup
3
REGENT ALCOHOL - ethyl alcohol 100%
3
SIMPLGEL 30 - gel base - gel
3 3
REJUVACARE PLUS - cream base
3
SKYY DERM - cream base
3
RHEOSPRAY - external vehicles - liquid
3
SODIUM BENZOATE - sodium benzoate powder
3
ROOT BEER FLAVOR flavoring agent - liquid
3
SODIUM CHLORIDE BACTERIOS - saline injection w/ benzyl alcohol
3
saline injection bacteriostatic
1
SODIUM LAURYL SULFATE sodium lauryl sulfate powder
3
SALINE/PHENOL - saline w/ phenol inj
3
SODIUM THIOSULFATE sodium thiosulfate powder
3
SALT DURABLE CREAM cream base
3
SODIUM THIOSULFATE PENTAH - sodium thiosulfate crystals
SALT STABLE LO - cream base
3
SOLU-K GEL - gel base - gel
3 3
SALT STABLE LS ADVANCED - cream base
3
SOLVATECH PLUS - oral vehicles - susp
3
SANARE ADVANCED SCAR THER - cream base
3
SOLVATECH SWEET SF - oral vehicles - syrup SOLYDRA - oil base - liquid
3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
272
SORBIC ACID - sorbic acid powder
3
SYRSPEND SF - oral vehicles
3
SYRSPEND SF PH4 - oral vehicles for susp
3
SORBITOL - sorbitol solution (bulk)
3
SYRUP VEHICLE - oral vehicles - syrup
3
SORBITOL CANDY BASE sorbitol candy base crystals
3 3
SYRUP VEHICLE SF - oral vehicles - syrup
3
SPEARMINT FLAVOR flavoring agent - oil
3
TANGERINE FLAVOR flavoring agent - oil
3
SPG SUPPOSI-BASE suppository base - pellets STEARIC ACID - stearic acid flakes
3
STEARIC ACID - stearic acid powder
3
STEARIC ACID TRIPLE PRESS - stearic acid powder
3
STEARYL ALCOHOL - stearyl alcohol flakes
3
STEARYL ALCOHOL - stearyl alcohol powder
3
3 TANGERINE FLAVOR SWEETENE - flavoring agent - powder 3 TDC MAX CREAM transdermal base cream 3 TDM SOLUTION - external vehicles - solution 3 TEABERRY FLAVOR flavoring agent - oil 3 TERODERM - cream base TERODERM-PLUS - cream base
3
STERA BASE - cream base
3
STEVIA GLYCERITE LIQUID E - flavoring agent - liquid
3
TIGHTENING BASE - cream base
3
STRAWBERRY FLAVOR flavoring agent - liquid
3
TOMMY GEL - gel base - gel
3
3
TRAGACANTH - tragacanth powder
3
SULPHAN BLUE - isosulfan blue (bulk) powder
3
TRANSDERMAL PAIN BASE transdermal base cream
3
SUPER SYNERSWEET FLAVOR - flavoring agent powder
3
SUSPENSION VEHICLE - oral vehicles - susp
3
TROCHE BASE - troche base powder TROLAMINE - trolamine liquid
3
SWEET CORN FLAVOR CONCENT - flavoring agent concentrate
3
TROPICAL PUNCH FLAVOR flavoring agent - liquid
3 3
SYNAPSIN - pharmaceutical excipients (bulk) powder
3
TRYPAN BLUE - trypan blue powder
3
SYRPALTA - oral vehicles syrup
3
TUNA FLAVOR - flavoring agent - powder
3
SYRPALTA - simple - syrup
3
TUTTI FRUTTI FLAVOR flavoring agent - liquid
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
273
TUTTI-FRUTTI FLAVOR flavoring agent - liquid
3
VERSAPRO - lotion base lotion
3
U-MILD SHAMPOO - external vehicles - shampoo
3
VERSAPRO SHAMPOO external vehicles - shampoo
3
UCARE POLYMER JR-400 pharmaceutical excipients (bulk) powder
3
VERSATILE CREAM BASE cream base
3
3
VERSATILE RICH CREAM BASE - cream base
3
ULTRADERM - cream base UNIVERSAL WATER GEL alcohol gel base
3
WATER BASE GEL - alcohol gel base
3
VANILLA BUTTERNUT FLAVOR - flavoring agent liquid
3
water for injection
1
VANILLA FLAVOR - flavoring agent - liquid
3
WATERMELON FLAVOR flavoring agent - liquid
3
VANILLIN FLAVOR - flavoring agent - powder
3
WHITE BEES WAX - wax, white
3
VANISH-PEN - cream base
3
3
VANISHING CREAM - cream base
3
WHITE PETROLATUM - white petrolatum ointment white petrolatum gel
1
VANISHING CREAM BOTANICAL - cream base
3
VERSABASE - versabase cream
3
VERSABASE - versabase gel
3
VERSABASE - versabase lotion
3
VERSABASE - versabase shampoo
3
VERSABASE FOAM versabase foam
3
VERSAFREE - oral vehicles syrup
3
VERSAPLUS - oral vehicles syrup
3
VERSAPRO - cream base
3
VERSAPRO - foam base foam
3
VERSAPRO - gel base - gel
3
water for iv injection
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
WHITE WAX - wax, white
3
WILD CHERRY FLAVOR flavoring agent - liquid
3
3 WILEY BASIC ELEMENTS BHRT - hormone cream base 3 WITEPSOL - hydrogenated vegetable oil wax 3 WITEPSOL H15 BASE F hydrogenated vegetable oil pellets 3 WOUND WASH BASE - gel base - gel 3 XANTHAN GUM - xanthan gum powder XEMATOP BASE - cream base 3
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
YELLOW PETROLATUM petrolatum ointment
3
ZOE SCRIPTS IDEALBASE cream base
3
ZOSIL - paste base - paste
3
Products October (2016 Plan Year)
274
3
CUPRIMINE - penicillamine cap 250 mg
5
ADENOSINE-5MONOPHOSPHATE adenosine phosphate powder
3
cyclosporine cap 25 mg (Sandimmune)
1
cyclosporine cap 100 mg (Sandimmune)
1
ADENOSINE-5TRIPHOSPHATE adenosine phosphate powder
3
CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg
3
cyclosporine modified cap 25 mg (Neoral)
1
alprostadil inj 500 mcg/ml (Prostin vr pediatric)
1
cyclosporine modified cap 50 mg (Cyclosporine modifie)
1
AMPHADASE - hyaluronidase bovine inj 150 unit/ml
3
ASTAGRAF XL - tacrolimus cap er 24hr 0.5 mg
3
1
ASTAGRAF XL - tacrolimus cap er 24hr 1 mg
3
cyclosporine modified cap 100 mg (Neoral)
ASTAGRAF XL - tacrolimus cap er 24hr 5 mg
3
AZASAN - azathioprine tab 75 mg
3
1ST BASE - cream base ASSORTED CLASSES
cyclosporine modified oral soln 100 mg/ml (Neoral)
AZASAN - azathioprine tab 100 3 mg AZATHIOPRINE - azathioprine 3 powder AZATHIOPRINE - azathioprine 3 sodium for inj 100 mg 1 azathioprine tab 50 mg (Imuran) 3 BROMELAIN - bromelains powder 3 CELLCEPT - mycophenolate mofetil cap 250 mg 3 CELLCEPT - mycophenolate mofetil for oral susp 200 mg/ ml 3 CELLCEPT - mycophenolate mofetil tab 500 mg 3 CHYMOTRYPSIN ALPHA chymotrypsin powder SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
1
DELFLEX-LC/1.5% DEXTROSE - peritoneal dialysis solutions 346 mosm/ l
3
DELFLEX-LC/2.5% DEXTROSE - peritoneal dialysis solutions 394 mosm/ l
3
DELFLEX-LC/4.25% DEXTROSE - peritoneal dialysis solutions 483 mosm/ l
3
DELFLEX-SM/1.5% DEXTROSE - peritoneal dialysis solutions 347 mosm/ l
3
DELFLEX-SM/2.5% DEXTROSE - peritoneal dialysis solutions 398 mosm/ l
3
DEPEN TITRATABS penicillamine tab 250 mg
4
Products October (2016 Plan Year)
•
275
DIANEAL LOW CALCIUM/1.5% - peritoneal dialysis solutions 344 mosm/ l
3
DIANEAL LOW CALCIUM/2.5% - peritoneal dialysis solutions 395 mosm/ l
3
DIANEAL LOW CALCIUM/4.25% - peritoneal dialysis solutions 483 mosm/ l
3
DIANEAL PD-2/1.5% DEXTROS - peritoneal dialysis solutions 346 mosm/ l
3
DIANEAL PD-2/2.5% DEXTROS - peritoneal dialysis solutions 396 mosm/ l
3
DIANEAL PD-2/4.25% DEXTRO - peritoneal dialysis solutions 485 mosm/l
3
ENVARSUS XR - tacrolimus tab er 24hr 0.75 mg
mycophenolate mofetil for oral susp 200 mg/ml (Cellcept)
1
mycophenolate mofetil tab 500 mg (Cellcept)
1
mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic)
Limited Distribution
ACA
Dispensing Limits
1
3
MYFORTIC - mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)
3
NEORAL - cyclosporine modified cap 25 mg
3
NEORAL - cyclosporine modified cap 100 mg
3 3
3
NEORAL - cyclosporine modified oral soln 100 mg/ml
3
ENVARSUS XR - tacrolimus tab er 24hr 1 mg
3
NEXAVIR - liver derivative complex inj 25.5 mg/ml
3
ENVARSUS XR - tacrolimus tab er 24hr 4 mg
3
PENICILLAMINE penicillamine powder
EXTRANEAL - icodextrinelectrolytes solution 7.5%
3
HYLENEX - hyaluronidase human inj 150 unit/ml
3
IMURAN - azathioprine tab 50 mg
3
irrigation solution, physiological
1
mycophenolate mofetil cap 250 mg (Cellcept)
Step Therapy
1
MYFORTIC - mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)
lactated ringer's for irrigation
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
PROGRAF - tacrolimus cap 0.5 3 mg 3 PROGRAF - tacrolimus cap 1 mg 3 PROGRAF - tacrolimus cap 5 mg 3 PROSTIN VR PEDIATRIC alprostadil inj 500 mcg/ml 2 RAPAMUNE - sirolimus oral soln 1 mg/ml RAPAMUNE - sirolimus tab 0.5 3 mg 3 RAPAMUNE - sirolimus tab 1 mg
1 1
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
276
RAPAMUNE - sirolimus tab 2 mg
3
REVLIMID - lenalidomide caps 2.5 mg
M
•
REVLIMID - lenalidomide cap 5 M mg M REVLIMID - lenalidomide cap 10 mg M REVLIMID - lenalidomide cap 15 mg M REVLIMID - lenalidomide cap 20 mg M REVLIMID - lenalidomide cap 25 mg 1 ringer's solution for irrigation 3 SANDIMMUNE - cyclosporine cap 25 mg 3 SANDIMMUNE - cyclosporine cap 100 mg 3 SANDIMMUNE - cyclosporine oral soln 100 mg/ml 3 SARAPIN - misc natural products inj 1 sirolimus tab 0.5 mg (Rapamune) 1 sirolimus tab 1 mg (Rapamune) 1 sirolimus tab 2 mg (Rapamune) 1 sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps) 1 sodium polystyrene sulfonate powder (Kayexalate) 1 sodium polystyrene sulfonate rectal susp 30 gm/120ml 5 SYPRINE - trientine hcl cap 250 mg
• • • • •
• SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
tacrolimus cap 0.5 mg (Prograf)
1
tacrolimus cap 1 mg (Prograf)
1
tacrolimus cap 5 mg (Prograf)
1
THALOMID - thalidomide cap 50 mg
M
•
THALOMID - thalidomide cap 100 mg
M
•
THALOMID - thalidomide cap 150 mg
M
•
THALOMID - thalidomide cap 200 mg
M
•
ULTRABAG/DIANEAL LOW CALC - peritoneal dialysis solutions 344 mosm/l
3
ULTRABAG/DIANEAL LOW CALC - peritoneal dialysis solutions 395 mosm/l
3
ULTRABAG/DIANEAL LOW CALC - peritoneal dialysis solutions 483 mosm/l
3
ULTRABAG/DIANEAL PD-2/1.5 - peritoneal dialysis solutions 346 mosm/l
3
ULTRABAG/DIANEAL PD-2/2.5 - peritoneal dialysis solutions 396 mosm/l
3
ULTRABAG/DIANEAL PD-2/4.2 - peritoneal dialysis solutions 485 mosm/l
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
VELTASSA - patiromer sorbitex 3 calcium for susp packet 8.4 gm (base eq) VELTASSA - patiromer sorbitex 3 calcium for susp packet 16.8 gm (base eq) VELTASSA - patiromer sorbitex 3 calcium for susp packet 25.2 gm (base eq)
•
Products October (2016 Plan Year)
277
• •
VIASPAN - organ preservation solution
3
VITRASE - hyaluronidase ovine inj 200 unit/ml
3
water for irrigation, sterile irrigation soln
1
XIAFLEX - collagenase clostridium histolyticum for inj 0.9 mg
5
ZORTRESS - everolimus tab 0.25 mg
2
ZORTRESS - everolimus tab 0.5 mg
2
ZORTRESS - everolimus tab 0.75 mg
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
278
2016 ACCUPRIL -quinapril hcl tab 20 mg................................. 68 ACCUPRIL -quinapril hcl tab 40 mg................................. 68 ACCURETIC -quinapril-hydrochlorothiazide tab 10-12.5 mg.................................................................................... 68 ACCURETIC -quinapril-hydrochlorothiazide tab 20-12.5 mg.................................................................................... 68 ACCURETIC -quinapril-hydrochlorothiazide tab 20-25 mg.................................................................................... 68 ACD-A NOCLOT-50 -anticoagulant citrate dextrose solution a....................................................................... 184 AC DERMAPEPTIDE -saccharomyces cerevisiae extract liquid.............................................................................. 220 ACD FORMULA A -anticoagulant citrate dextrose solution a..................................................................................... 184 ACD FORMULA B -anticoagulant citrate dextrose solution b..................................................................................... 184 ACEBUTOLOL HCL -acebutolol hcl powder..................... 61 acebutolol hcl cap 200 mg (Sectral).............................. 61 acebutolol hcl cap 400 mg (Sectral).............................. 61 ACEON -perindopril erbumine tab 4 mg........................... 68 ACEON -perindopril erbumine tab 8 mg........................... 68 ACEPROMAZINE MALEATE -acepromazine maleate (bulk) powder................................................................ 220 ACESULFAME POTASSIUM -acesulfame potassium (bulk) powder................................................................ 220 ACETAMINOPHEN/CAFFEINE/DI -acetaminophencaffeine-dihydrocodeine cap 320.5-30-16 mg............. 136 ACETAMINOPHEN/CAFFEINE/DI -acetaminophencaffeine-dihydrocodeine tab 325-30-16 mg................. 136 ACETAMINOPHEN -acetaminophen (bulk) granules..... 220 ACETAMINOPHEN -acetaminophen powder................. 220 ACETAMINOPHEN CRYSTAL 60 -acetaminophen (bulk) crystals.......................................................................... 220 acetaminophen-isometheptene-caffeine tab 325-65-20 mg (Prodrin)................................................................ 151 acetaminophen w/ codeine soln 120-12 mg/5ml........ 136 acetaminophen w/ codeine tab 300-15 mg (Tylenol/ codeine)........................................................................ 136 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ codeine #3).................................................................. 136 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ codeine #4).................................................................. 136 ACETARSONE -acetarsone (bulk) powder..................... 220 ACETAZOLAMIDE -acetazolamide (bulk) powder.......... 220 acetazolamide cap er 12hr 500 mg (Diamox)............... 78 acetazolamide sodium for inj 500 mg........................... 78 acetazolamide tab 125 mg.............................................. 78 acetazolamide tab 250 mg.............................................. 78 ACETIC ACID -acetic acid soln 5%................................ 220 ACETIC ACID GLACIAL -acetic acid (glacial) soln 99%................................................................................220 ACETIC ACID GLACIAL -acetic acid soln...................... 220 acetic acid irrigation soln 0.25%................................. 108 acetic acid otic soln 2%................................................ 194 ACETONE -acetone soln................................................. 220
INDEX 2,3-DIMERCAPTOSUCCINIC AC -succimer (bulk) powder........................................................................... 260 A A.A.G.C. KIT IN TERODERM -amantad-amitript-gabacycloben cream 8-4-10-4% (cmpd kit)......................... 197 abacavir sulfate-lamivudine tab 600-300 mg (Epzicom)....................................................................... 10 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg (Trizivir)..............................................10 abacavir sulfate tab 300 mg (base equiv) (Ziagen)...... 10 ABANEU-SL -cyanocobalamin-methylcobalamin tab sl 600-600 mcg................................................................. 179 ABILIFY -aripiprazole tab 2 mg....................................... 116 ABILIFY -aripiprazole tab 5 mg....................................... 116 ABILIFY -aripiprazole tab 10 mg..................................... 116 ABILIFY -aripiprazole tab 15 mg..................................... 116 ABILIFY -aripiprazole tab 20 mg..................................... 117 ABILIFY -aripiprazole tab 30 mg..................................... 117 ABILIFY MAINTENA -aripiprazole im for extended release susp 300 mg................................................................. 117 ABILIFY MAINTENA -aripiprazole im for extended release susp 400 mg................................................................. 117 ABSORICA -isotretinoin cap 10 mg................................ 197 ABSORICA -isotretinoin cap 20 mg................................ 197 ABSORICA -isotretinoin cap 25 mg................................ 197 ABSORICA -isotretinoin cap 30 mg................................ 197 ABSORICA -isotretinoin cap 35 mg................................ 197 ABSORICA -isotretinoin cap 40 mg................................ 197 ABSTRAL -fentanyl citrate sl tab 100 mcg (base equiv)............................................................................. 136 ABSTRAL -fentanyl citrate sl tab 200 mcg (base equiv)............................................................................. 136 ABSTRAL -fentanyl citrate sl tab 300 mcg (base equiv)............................................................................. 136 ABSTRAL -fentanyl citrate sl tab 400 mcg (base equiv)............................................................................. 136 ABSTRAL -fentanyl citrate sl tab 600 mcg (base equiv)............................................................................. 136 ABSTRAL -fentanyl citrate sl tab 800 mcg (base equiv)............................................................................. 136 ACACIA -acacia powder.................................................. 262 acamprosate calcium tab delayed release 333 mg (Campral)...................................................................... 130 ACANYA -clindamycin phosphate-benzoyl peroxide gel 1.2-2.5%........................................................................ 197 acarbose tab 25 mg (Precose)....................................... 45 acarbose tab 50 mg (Precose)....................................... 45 acarbose tab 100 mg (Precose)..................................... 46 ACCOLATE -zafirlukast tab 10 mg....................................90 ACCOLATE -zafirlukast tab 20 mg....................................90 ACCUPRIL -quinapril hcl tab 5 mg................................... 68 ACCUPRIL -quinapril hcl tab 10 mg................................. 68
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
279
2016 ACETYLCHOLINE CHLORIDE -acetylcholine chloride powder........................................................................... 221 ACETYLCYSTEINE -acetylcysteine powder.....................88 acetylcysteine cap 600 mg........................................... 177 acetylcysteine inhal soln 10%........................................ 88 acetylcysteine inhal soln 20%........................................ 88 ACETYL-D-GLUCOSAMINE -acetyl-d-glucosamine powder........................................................................... 221 ACETYL DIPEPTIDE-1 CETYL -acetyl dipeptide-1 cetyl ester (bulk) solution...................................................... 220 ACETYL HEXAPEPTIDE-8 -acetyl hexapeptide-8 (bulk) powder........................................................................... 221 ACETYL HEXAPEPTIDE-8 -acetyl hexapeptide-8 (bulk) solution.......................................................................... 221 ACETYL-L-CARNITINE HYDROC -acetylcarnitine hcl (bulk) powder................................................................ 221 ACETYL SALICYLIC ACID -aspirin powder................... 135 ACIDOPHILUS LACTOBACILLUS -lactobacillus acidophilus powder....................................................... 221 acitretin cap 10 mg (Soriatane).................................... 197 acitretin cap 17.5 mg (Soriatane)................................. 197 acitretin cap 25 mg (Soriatane).................................... 197 ACRIFLAVINE NEUTRAL -acriflavine powder................ 221 ACTEMRA -tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9ml................................................... 147 ACTHIB -haemophilus b polysaccharide conjugate vaccine for inj.................................................................. 19 ACTICOAT 7 2"X2" -wound dressings - pads................. 197 ACTICOAT 7 4"X5" -wound dressings - pads................. 197 ACTICOAT ABSORBENT ANTIMI -wound dressings pads............................................................................... 197 ACTICOAT ANTIMICROBIAL DR -wound dressings pads............................................................................... 197 ACTICOAT FLEX 3 BARRIER D -wound dressings pads............................................................................... 197 ACTIGALL -ursodiol cap 300 mg.................................... 102 ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml)....................................................... 24 ACTIPHYTE OF ALGAE GL -algae extract (bulk) liquid.............................................................................. 221 ACTIPHYTE OF CUCUMBER -cucumber extract (bulk) liquid.............................................................................. 221 ACTIPHYTE OF IVY -hedera helix (ivy) extract (bulk) liquid.............................................................................. 221 ACTIPHYTE OF LEMONGRASS -lemongrass (bulk) liquid.............................................................................. 221 ACTIQ -fentanyl citrate lollipop 200 mcg........................ 136 ACTIQ -fentanyl citrate lollipop 400 mcg........................ 136 ACTIQ -fentanyl citrate lollipop 600 mcg........................ 136 ACTIQ -fentanyl citrate lollipop 800 mcg........................ 136 ACTIQ -fentanyl citrate lollipop 1200 mcg...................... 136 ACTIQ -fentanyl citrate lollipop 1600 mcg...................... 136 ACTIVE-CYCLOBENZAPRINE KI -cyclobenzaprine hcl td cream 5% (compound kit)............................................ 168
ACTIVE FE -fe carbonyl-fa-b complex-a-c-d-e-min tab 75-1.25 mg.................................................................... 179 ACTIVE INJECTION KIT BLM- -betameth na pho&ace inj 6 mg/ml & bupiv 0.25% & lido1% kit.............................. 32 ACTIVE INJECTION KIT BM -betamethasone sod phos & ace inj 6 mg/ml & bupiv 0.25% kit................................. 32 ACTIVE INJECTION KIT D -dexamethasone sodium phosphate pf inj 10 mg/ml kit......................................... 32 ACTIVE INJECTION KIT DL -dexamethasone sod phos pf inj 10 mg/ml & lidocaine 1% kit..................................32 ACTIVE INJECTION KIT DLM -dexamethasone pf inj 10 mg/ml & bupiv 0.25% & lido 1% kit................................ 32 ACTIVE INJECTION KIT KET- -ketorolac trometh inj 30 mg/ml & lidocaine hcl 1% kit........................................ 147 ACTIVE INJECTION KIT KETM -ketorolac inj 30 mg/ml & bupivacaine 0.25% & lido 1% kit..................................147 ACTIVE INJECTION KIT KL-3 -triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit................................. 32 ACTIVE INJECTION KIT KM -triamcinolone inj 40 mg/ml & bupivacaine hcl inj 0.5% kit........................................ 32 ACTIVE INJECTION KIT LM-D -methylprednisolone inj 80 mg/ml & bupiv 0.25% &lido 1% kit................................. 32 ACTIVE INJECTION KIT L -methylprednisolone inj 40 mg/ml & lidocaine inj 1% kit........................................... 32 ACTIVE INJECTION KIT LM-2 -lidocaine hcl inj 1% & bupivacaine hcl inj 0.25% kit........................................ 153 ACTIVE INJECTION KIT M-1 -dexamethasone sod phos pf inj 10 mg/ml & bupiv 0.25% kit.................................. 32 ACTIVE-KETOPROFEN KIT -ketoprofen cream 5% (compound kit).............................................................. 197 ACTIVELLA -estradiol & norethindrone acetate tab 0.5-0.1 mg....................................................................... 39 ACTIVELLA -estradiol & norethindrone acetate tab 1-0.5 mg.................................................................................... 39 ACTIVE-PREP KIT I -flurbiprofen-cyclobenzaprine cream (cmpd kit)...................................................................... 197 ACTIVE-PREP KIT III -ketoprofen-lidocaine-gabapentin cream (cmpd kit)........................................................... 197 ACTIVE-PREP KIT II -ketoprofen-baclofen-gabapentin cream (cmpd kit)........................................................... 197 ACTIVE-PREP KIT IV -tramadol-gabapentin-mentholcamphor cream (cmpd kit)........................................... 197 ACTIVE-PREP KIT V -itraconazole-phenytoin sodium cream (cmpd kit)........................................................... 197 ACTIVE-TRAMADOL KIT -tramadol hcl cream 8% (compound kit).............................................................. 198 ACTONEL -risedronate sodium tab 5 mg......................... 55 ACTONEL -risedronate sodium tab 30 mg....................... 55 ACTONEL -risedronate sodium tab 35 mg....................... 55 ACTONEL -risedronate sodium tab 150 mg..................... 55 ACTOPLUS MET -pioglitazone hcl-metformin hcl tab 15-500 mg....................................................................... 46 ACTOPLUS MET -pioglitazone hcl-metformin hcl tab 15-850 mg....................................................................... 46
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
280
2016 ADDERALL XR -amphetamine-dextroamphetamine cap er 24hr 15 mg............................................................... 125 ADDERALL XR -amphetamine-dextroamphetamine cap er 24hr 20 mg............................................................... 125 ADDERALL XR -amphetamine-dextroamphetamine cap er 24hr 25 mg............................................................... 125 ADDERALL XR -amphetamine-dextroamphetamine cap er 24hr 30 mg............................................................... 125 adefovir dipivoxil tab 10 mg (Hepsera)......................... 10 ADEMETIONINE DISULFATE TO -ademetionine disulfate tosylate (bulk) powder.................................................. 221 ADEMPAS -riociguat tab 0.5 mg....................................... 84 ADEMPAS -riociguat tab 1 mg.......................................... 84 ADEMPAS -riociguat tab 1.5 mg....................................... 84 ADEMPAS -riociguat tab 2 mg.......................................... 84 ADEMPAS -riociguat tab 2.5 mg....................................... 84 ADENOSINE -adenosine powder.................................... 221 ADENOSINE-5-MONOPHOSPHATE -adenosine phosphate powder........................................................ 275 ADENOSINE-5-TRIPHOSPHATE -adenosine phosphate powder........................................................................... 275 ADRENAL C FORMULA -bioflavonoid products tab.......171 ADRENALIN -epinephrine hcl nasal soln 0.1%................ 87 ADRENALIN -epinephrine inj 1 mg/ml (1:1000)................80 ADRENALIN -epinephrine inj 30 mg/30ml (1 mg/ml) (1:1000)........................................................................... 80 ADRENOCHROME SEMICARBAZO -carbazochrome (bulk) powder................................................................ 221 ADRENOCORTICOTROPHIC HORM -corticotropin (bulk) powder........................................................................... 221 ADVAIR DISKUS -fluticasone-salmeterol aer powder ba 100-50 mcg/dose............................................................ 90 ADVAIR DISKUS -fluticasone-salmeterol aer powder ba 250-50 mcg/dose............................................................ 90 ADVAIR DISKUS -fluticasone-salmeterol aer powder ba 500-50 mcg/dose............................................................ 90 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21 mcg/act............................................................................ 90 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21 mcg/act............................................................................ 90 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 230-21 mcg/act............................................................................ 90 ADVANCED AM/PM -multiple vitamins w/ calcium therapy pack............................................................................... 171 ADVANCED BASE PLUS -cream base.......................... 262 ADYPHREN AMP II KIT -epinephrine inj kit 1 mg/ml (1:1000)........................................................................... 80 ADYPHREN AMP KIT -epinephrine inj kit 1 mg/ml (1:1000)........................................................................... 80 ADYPHREN II -epinephrine inj kit 1 mg/ml (1:1000).........80 ADYPHREN KIT -epinephrine inj kit 1 mg/ml (1:1000)..... 80 ADZENYS XR-ODT -amphetamine tab extended release disintegrating 3.1 mg.................................................... 125 ADZENYS XR-ODT -amphetamine tab extended release disintegrating 6.3 mg.................................................... 125
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab er 24hr 15-1000 mg........................................................ 46 ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab er 24hr 30-1000 mg........................................................ 46 ACTOS -pioglitazone hcl tab 15 mg (base equiv)............. 46 ACTOS -pioglitazone hcl tab 30 mg (base equiv)............. 46 ACTOS -pioglitazone hcl tab 45 mg (base equiv)............. 46 ACUICYN DAILY EYELID & EY -eyelid cleansers liquid.............................................................................. 198 ACULAR -ketorolac tromethamine ophth soln 0.5%....... 188 ACULAR LS -ketorolac tromethamine ophth soln 0.4%...............................................................................188 ACUVAIL -ketorolac tromethamine ophth soln 0.45%.............................................................................188 ACYCLOVIR -acyclovir (bulk) powder............................ 221 acyclovir cap 200 mg (Zovirax)...................................... 10 acyclovir oint 5% (Zovirax)........................................... 198 acyclovir susp 200 mg/5ml (Zovirax)............................ 10 acyclovir tab 400 mg (Zovirax)...................................... 10 acyclovir tab 800 mg (Zovirax)...................................... 10 ACZONE -dapsone gel 5%............................................. 198 ACZONE -dapsone gel 7.5%.......................................... 198 ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml........................................................................ 22 ADAGEN -pegademase bovine inj 250 unit/ml................. 24 ADALAT CC -nifedipine tab er 24hr 30 mg....................... 64 ADALAT CC -nifedipine tab er 24hr 60 mg....................... 64 ADALAT CC -nifedipine tab er 24hr 90 mg....................... 64 ADAPALENE -adapalene lotion 0.1%............................. 198 adapalene-benzoyl peroxide gel 0.1-2.5%.................. 198 adapalene cream 0.1% (Differin).................................. 198 adapalene gel 0.1% (Differin)....................................... 198 adapalene gel 0.3% (Differin)....................................... 198 ADA SHAMPOO -external vehicles - shampoo.............. 262 ADASUVE -loxapine aerosol powder breath activated 10 mg.................................................................................. 117 ADCIRCA -tadalafil tab 20 mg (pah)................................. 84 ADDERALL -amphetamine-dextroamphetamine tab 5 mg.................................................................................. 125 ADDERALL -amphetamine-dextroamphetamine tab 7.5 mg.................................................................................. 125 ADDERALL -amphetamine-dextroamphetamine tab 10 mg.................................................................................. 125 ADDERALL -amphetamine-dextroamphetamine tab 12.5 mg.................................................................................. 125 ADDERALL -amphetamine-dextroamphetamine tab 15 mg.................................................................................. 125 ADDERALL -amphetamine-dextroamphetamine tab 20 mg.................................................................................. 125 ADDERALL -amphetamine-dextroamphetamine tab 30 mg.................................................................................. 125 ADDERALL XR -amphetamine-dextroamphetamine cap er 24hr 5 mg................................................................. 125 ADDERALL XR -amphetamine-dextroamphetamine cap er 24hr 10 mg............................................................... 125
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
281
2016 AGGRENOX -aspirin-dipyridamole cap er 12hr 25-200 mg.................................................................................. 188 AGRYLIN -anagrelide hcl cap 0.5 mg............................. 188 AIF #2 DRUG PREPARATION -flurbiprofen-gabapentcycloben-lido-dexameth cr (cmp kit)............................ 198 AIF #3 DRUG PREPARATION K -flurbiprofen-baclofencycloben-lido cream (cmp kit)...................................... 198 AKTEN -lidocaine hcl ophth gel 3.5%............................. 188 AKTIPAK -benzoyl peroxide-erythromycin gel pack 5-3%.............................................................................. 198 AKYNZEO -netupitant-palonosetron cap 300-0.5 mg..... 100 ALANINE -alanine powder...............................................177 ALA-QUIN -clioquinol-hc cream 3-0.5%..........................198 ALA SCALP -hydrocortisone lotion 2%........................... 198 ALASKAN RED ALGAE -alaskan red algae (bulk) powder........................................................................... 221 ALBA-DERM -cream base...............................................262 ALBENDAZOLE -albendazole (bulk) powder................. 221 ALBENZA -albendazole tab 200 mg................................. 16 ALBUTEROL SULFATE -albuterol sulfate powder........... 90 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)......... 90 albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 90 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv).............................................................................. 90 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv).............................................................................. 90 albuterol sulfate syrup 2 mg/5ml................................... 90 albuterol sulfate tab er 12hr 4 mg (Vospire er)............ 90 albuterol sulfate tab er 12hr 8 mg (Vospire er)............ 90 albuterol sulfate tab 2 mg...............................................90 albuterol sulfate tab 4 mg...............................................90 alclometasone dipropionate cream 0.05% (Aclovate)..................................................................... 198 alclometasone dipropionate oint 0.05%......................198 ALCOH-GLOVE CONTOURED WIP -alcohol swabs..... 260 ALCOHOL -alcohol, usp 95%......................................... 221 ALCOHOL BASE GEL -alcohol gel base........................ 262 ALCOHOL DEHYDRATED -ethyl alcohol 100%............. 262 ALCOH-WIPE 12" X 12" -alcohol swabs........................ 260 ALDACTAZIDE -spironolactone & hydrochlorothiazide tab 25-25 mg......................................................................... 78 ALDACTAZIDE -spironolactone & hydrochlorothiazide tab 50-50 mg......................................................................... 78 ALDACTONE -spironolactone tab 25 mg......................... 78 ALDACTONE -spironolactone tab 50 mg......................... 78 ALDACTONE -spironolactone tab 100 mg....................... 78 ALDARA -imiquimod cream 5%...................................... 198 ALDOSTERONE -aldosterone (bulk) powder................. 221 ALECENSA -alectinib hcl cap 150 mg (base equivalent)....................................................................... 25 ALENDRONATE SODIUM -alendronate sodium oral soln 70 mg/75ml..................................................................... 55 ALENDRONATE SODIUM -alendronate sodium tab 40 mg.................................................................................... 55 alendronate sodium tab 5 mg........................................ 55
ADZENYS XR-ODT -amphetamine tab extended release disintegrating 9.4 mg.................................................... 125 ADZENYS XR-ODT -amphetamine tab extended release disintegrating 12.5 mg.................................................. 125 ADZENYS XR-ODT -amphetamine tab extended release disintegrating 15.7 mg.................................................. 125 ADZENYS XR-ODT -amphetamine tab extended release disintegrating 18.8 mg.................................................. 125 AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act...... 90 AFINITOR DISPERZ -everolimus tab for oral susp 2 mg.................................................................................... 24 AFINITOR DISPERZ -everolimus tab for oral susp 3 mg.................................................................................... 24 AFINITOR DISPERZ -everolimus tab for oral susp 5 mg.................................................................................... 25 AFINITOR -everolimus tab 2.5 mg.................................... 24 AFINITOR -everolimus tab 5 mg....................................... 24 AFINITOR -everolimus tab 7.5 mg.................................... 24 AFINITOR -everolimus tab 10 mg..................................... 24 AFLURIA 2015-2016 -influenza virus vaccine split im susp................................................................................. 19 AFLURIA 2016-2017 -influenza virus vaccine split im susp................................................................................. 19 AFLURIA 2017-2018 -influenza virus vaccine split im susp................................................................................. 19 AFLURIA PF 2015-2016 -influenza virus vaccine split pf susp pref syringe 0.5 ml................................................. 19 AFLURIA PF 2016-2017 -influenza virus vaccine split pf susp pref syringe 0.5 ml................................................. 19 AFLURIA PF 2017-2018 -influenza virus vaccine split pf susp pref syringe 0.5 ml................................................. 19 AFLURIA QUADRIVALENT 2017 -influenza virus vaccine split quadrivalent im inj................................................... 19 AFLURIA QUADRIVALENT 2016 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 19 AFLURIA QUADRIVALENT 2017 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 19 AFREZZA -insulin regular (human) inhalation powder 4 unit/cartridge.................................................................... 51 AFREZZA -insulin regular (human) inhalation powder 8 unit/cartridge.................................................................... 51 AFREZZA -insulin regular (human) inhalation powder 12 unit/cartridge.................................................................... 51 AFREZZA -insulin regular (human) inhal powd 4 (30) & 8 (60) unit/cart.................................................................... 51 AFREZZA -insulin regular (human) inhal powd 4 (60) & 8 (30) unit/cart.................................................................... 51 AFREZZA -insulin regular (human) inhal powd 4 (90) & 8 (90) unit/cart.................................................................... 51 AFREZZA -insulin regular (human) inh powd 4 & 8 & 12 unit/cart (60).................................................................... 51 AFREZZA -insulin regular (human) inh powd 8 (60) & 12 (30) unit/cart.................................................................... 51 AGAR -agar granules...................................................... 221 AGAR -agar powder........................................................ 221
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
282
2016 alendronate sodium tab 10 mg...................................... 55 alendronate sodium tab 35 mg...................................... 55 alendronate sodium tab 70 mg (Fosamax)................... 55 ALEVICYN ANTIPRURITIC GEL -wound dressings gel.................................................................................. 198 ALEVICYN ANTIPRURITIC SG -dermatological products misc - liquid................................................................... 198 ALEVICYN DERMAL SPRAY -wound dressings soln................................................................................ 198 ALFALFA FLAVOR -flavoring agent - powder................. 262 ALFENTANIL HCL -alfentanil inj 500 mcg/ml................. 137 alfentanil inj 500 mcg/ml (Alfenta)............................... 137 ALFERON N -interferon alfa-n3 inj 5000000 unit/ml......... 25 alfuzosin hcl tab er 24hr 10 mg (Uroxatral)................ 108 ALGINIC ACID -alginic acid powder............................... 221 ALINIA -nitazoxanide for susp 100 mg/5ml.......................16 ALINIA -nitazoxanide tab 500 mg..................................... 16 A-LIPOIC ACID (DL-THIOCTI -alpha-lipoic acid (bulk) powder........................................................................... 220 ALKERAN -melphalan tab 2 mg....................................... 25 ALKYL BENZOATE C12-15 -c12-15 alkyl benzoate (bulk) liquid.............................................................................. 221 ALLANTOIN -allantoin powder........................................ 221 ALLEVYN AG ADHESIVE -wound dressings - pads...... 198 ALLEVYN AG GENTLE BORDER -wound dressings pads............................................................................... 198 ALLEVYN AG NON-ADHESIVE -wound dressings pads............................................................................... 198 ALLEVYN AG SACRUM -wound dressings - pads......... 198 ALLEVYN GENTLE -wound dressings - pads................ 198 ALLO-PAX -levocetirizine-loratadine cream 5-5% (cmpd kit).................................................................................. 198 ALLOPURINOL -allopurinol (bulk) powder..................... 221 allopurinol tab 100 mg (Zyloprim)............................... 153 allopurinol tab 300 mg (Zyloprim)............................... 153 ALLZITAL -butalbital-acetaminophen tab 25-325 mg..... 135 ALMOND OIL -almond oil (sweet).................................. 221 ALMOND OIL BITTER FLAVOR -flavoring agent liquid.............................................................................. 262 ALMOND OIL SWEET -almond oil (sweet).....................221 almotriptan malate tab 6.25 mg (Axert).......................151 almotriptan malate tab 12.5 mg (Axert).......................151 ALOCRIL -nedocromil sodium ophth soln 2%................ 188 ALOE VERA -aloe vera oil.............................................. 221 ALOE VERA -aloe vera powder...................................... 221 ALOE VERA FREEZE DRIED -aloe vera powder.......... 221 ALOE VERA LEAF -aloe vera powder............................ 221 ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl tab 12.5-500 mg............................................................. 46 ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl tab 12.5-1000 mg........................................................... 46 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 12.5-15 mg...................................................................... 46 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 12.5-30 mg...................................................................... 46
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 12.5-45 mg...................................................................... 46 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 25-15 mg......................................................................... 46 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 25-30 mg......................................................................... 46 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 25-45 mg......................................................................... 46 ALOGLIPTIN -alogliptin benzoate tab 6.25 mg (base equiv)............................................................................... 46 ALOGLIPTIN -alogliptin benzoate tab 12.5 mg (base equiv)............................................................................... 46 ALOGLIPTIN -alogliptin benzoate tab 25 mg (base equiv)............................................................................... 46 ALOMIDE -lodoxamide tromethamine ophth soln 0.1%...............................................................................188 ALOQUIN -iodoquinol-aloe polysaccharides gel 1.25-1%......................................................................... 198 ALORA -estradiol td patch biweekly 0.025 mg/24hr......... 39 ALORA -estradiol td patch biweekly 0.05 mg/24hr........... 39 ALORA -estradiol td patch biweekly 0.075 mg/24hr......... 39 ALORA -estradiol td patch biweekly 0.1 mg/24hr............. 39 alosetron hcl tab 0.5 mg (base equiv) (Lotronex)...... 102 alosetron hcl tab 1 mg (base equiv) (Lotronex)......... 102 ALPAWASH -polyethylene glycol ointment..................... 262 ALPHAGAN P -brimonidine tartrate ophth soln 0.1%..... 188 ALPHAGAN P -brimonidine tartrate ophth soln 0.15%.............................................................................188 ALPHA-GPC 50% -glycerylphosphorylcholine (bulk) powder........................................................................... 222 ALPHA-KETOGLUTARIC ACID -alpha-ketoglutaric acid (bulk) powder................................................................ 222 ALPHA KETOGLUTARIC ACID -alpha-ketoglutaric acid (bulk) powder................................................................ 221 ALPHA LIPOIC ACID -alpha-lipoic acid (bulk) powder........................................................................... 222 ALPHA-TOCOPHEROL -vitamin e (bulk) liquid.............. 222 ALPRAZOLAM -alprazolam (bulk) powder..................... 222 ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/ ml................................................................................... 109 alprazolam orally disintegrating tab 0.5 mg............... 109 alprazolam orally disintegrating tab 1 mg.................. 109 alprazolam orally disintegrating tab 2 mg.................. 109 alprazolam orally disintegrating tab 0.25 mg (Niravam)...................................................................... 109 alprazolam tab er 24hr 0.5 mg (Xanax xr)................... 109 alprazolam tab er 24hr 1 mg (Xanax xr)...................... 109 alprazolam tab er 24hr 2 mg (Xanax xr)...................... 109 alprazolam tab er 24hr 3 mg (Xanax xr)...................... 109 alprazolam tab 0.25 mg (Xanax).................................. 109 alprazolam tab 0.5 mg (Xanax).................................... 109 alprazolam tab 1 mg (Xanax)....................................... 109 alprazolam tab 2 mg (Xanax)....................................... 109 alprostadil inj 500 mcg/ml (Prostin vr pediatric)........ 275 ALREX -loteprednol etabonate ophth susp 0.2%........... 188
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
283
2016 amikacin sulfate inj 500 mg/2ml (250 mg/ml)................. 8 amiloride & hydrochlorothiazide tab 5-50 mg.............. 78 AMILORIDE HCL -amiloride hcl powder........................... 78 amiloride hcl tab 5 mg.................................................... 78 amino acids cap............................................................. 177 9-AMINOACRIDINE HCL -9-aminoacridine hcl (bulk) powder........................................................................... 260 AMINOBENZOATE POTASSIUM -potassium aminobenzoate packet 2 gm........................................ 170 AMINOBENZOIC ACID -para-aminobenzoic acid powder........................................................................... 170 4-AMINOBENZOIC ACID POTAS -potassium aminobenzoate powder................................................ 171 4-AMINOBUTYRIC ACID -gamma-aminobutyric acid (bulk) crystals................................................................ 260 AMINOCAPROIC ACID -aminocaproic acid (bulk) powder........................................................................... 222 6-AMINOCAPROIC ACID -aminocaproic acid (bulk) powder........................................................................... 260 AMINOLEVULINIC ACID HCL -methyl aminolevulinate hcl (bulk) powder.......................................................... 222 AMINOPHYLLINE ANHYDROUS -aminophylline powder............................................................................. 90 4-AMINOPYRIDINE -dalfampridine powder....................260 AMINOSALICYLIC ACID -aminosalicylic acid powder....... 8 5-AMINOSALICYLIC ACID -mesalamine powder...........104 amiodarone hcl tab 100 mg............................................ 67 amiodarone hcl tab 400 mg............................................ 67 amiodarone hcl tab 200 mg (Cordarone)...................... 67 AMITIZA -lubiprostone cap 8 mcg.................................. 102 AMITIZA -lubiprostone cap 24 mcg................................ 102 AMITRIPTYLINE HCL -amitriptyline hcl (bulk) powder........................................................................... 222 AMITRIPTYLINE HCL -amitriptyline hcl powder............. 111 amitriptyline hcl tab 10 mg........................................... 111 amitriptyline hcl tab 25 mg........................................... 111 amitriptyline hcl tab 50 mg........................................... 111 amitriptyline hcl tab 75 mg........................................... 111 amitriptyline hcl tab 100 mg......................................... 111 amitriptyline hcl tab 150 mg......................................... 111 AMLODIPINE BESYLATE/SYRSP -amlodipine besylate oral susp 1 mg/ml (cmpd kit)..........................................64 AMLODIPINE BESYLATE -amlodipine besylate (bulk) powder........................................................................... 222 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg (Caduet)................................................................... 84 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg (Caduet)................................................................... 84 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg (Caduet)................................................................... 84 amlodipine besylate-atorvastatin calcium tab 5-10 mg (Caduet).......................................................................... 84 amlodipine besylate-atorvastatin calcium tab 5-20 mg (Caduet).......................................................................... 84
ALTABAX -retapamulin oint 1%.......................................198 ALTACE -ramipril cap 1.25 mg.......................................... 68 ALTACE -ramipril cap 2.5 mg............................................ 68 ALTACE -ramipril cap 5 mg............................................... 68 ALTACE -ramipril cap 10 mg............................................. 68 ALTADERM CREAM BASE -cream base....................... 262 ALTOPREV -lovastatin tab er 24hr 20 mg........................ 81 ALTOPREV -lovastatin tab er 24hr 40 mg........................ 81 ALTOPREV -lovastatin tab er 24hr 60 mg........................ 81 ALTRENOGEST -altrenogest (bulk) powder................... 222 ALUM AMMONIUM -alum (ammonium) powder.............222 ALUMINUM ACETATE BASIC -aluminum subacetate (bulk) powder................................................................ 222 ALUMINUM CHLORIDE ANHYDRO -aluminum chloride powder........................................................................... 198 ALUMINUM CHLORIDE HEXAHYD -aluminum chloride crystals.......................................................................... 198 ALUMINUM CHLORIDE HEXAHYD -aluminum chloride powder........................................................................... 198 ALUMINUM CHLOROHYDRATE -aluminum chlorohydrate (bulk) powder......................................... 222 ALUMINUM HYDROXIDE DRIED -aluminum hydroxide gel powder.....................................................................222 ALUMINUM POTASSIUM SULFAT -alum (potassium) powder........................................................................... 222 ALUMINUM SULFATE -aluminum sulfate granules........ 222 ALUMINUM SULFATE HYDRATE -aluminum sulfate granules......................................................................... 222 ALUNBRIG -brigatinib tab 30 mg...................................... 25 ALVESCO -ciclesonide inhal aerosol 80 mcg/act............. 90 ALVESCO -ciclesonide inhal aerosol 160 mcg/act........... 90 ALZAIR ALLERGY BLOCKER NA -hypromellose nasal powder............................................................................. 87 AMANTADINE HCL -amantadine hcl (bulk) powder....... 222 amantadine hcl cap 100 mg......................................... 164 amantadine hcl syrup 50 mg/5ml................................ 164 amantadine hcl tab 100 mg.......................................... 164 AMARYL -glimepiride tab 1 mg......................................... 46 AMARYL -glimepiride tab 2 mg......................................... 46 AMARYL -glimepiride tab 4 mg......................................... 46 AMBIEN CR -zolpidem tartrate tab er 6.25 mg............... 123 AMBIEN CR -zolpidem tartrate tab er 12.5 mg............... 123 AMBIEN -zolpidem tartrate tab 5 mg.............................. 123 AMBIEN -zolpidem tartrate tab 10 mg............................ 123 AMCINONIDE -amcinonide cream 0.1%........................ 198 AMCINONIDE -amcinonide lotion 0.1%.......................... 198 AMCINONIDE -amcinonide oint 0.1%.............................198 AMERGE -naratriptan hcl tab 1 mg (base equiv)........... 151 AMERGE -naratriptan hcl tab 2.5 mg (base equiv)........ 151 AMICAR -aminocaproic acid oral soln 0.25 gm/ml......... 187 AMICAR -aminocaproic acid tab 500 mg........................ 187 AMICAR -aminocaproic acid tab 1000 mg...................... 187 AMIELLE RESTORE VAGINAL E -misc. devices........... 261 AMIKACIN SULFATE -amikacin sulfate powder................. 7 amikacin sulfate inj 1 gm/4ml (250 mg/ml)..................... 8
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
284
2016 amlodipine besylate-atorvastatin calcium tab 5-40 mg (Caduet).......................................................................... 84 amlodipine besylate-atorvastatin calcium tab 5-80 mg (Caduet).......................................................................... 84 amlodipine besylate-atorvastatin calcium tab 10-10 mg (Caduet)................................................................... 84 amlodipine besylate-atorvastatin calcium tab 10-20 mg (Caduet)................................................................... 84 amlodipine besylate-atorvastatin calcium tab 10-40 mg (Caduet)................................................................... 84 amlodipine besylate-atorvastatin calcium tab 10-80 mg (Caduet)................................................................... 84 amlodipine besylate-benazepril hcl cap 2.5-10 mg (Lotrel)............................................................................ 68 amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel)............................................................................ 68 amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel)............................................................................ 68 amlodipine besylate-benazepril hcl cap 5-40 mg (Lotrel)............................................................................ 68 amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel)............................................................................ 68 amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel)............................................................................ 69 amlodipine besylate-olmesartan medoxomil tab 5-20 mg (Azor)....................................................................... 69 amlodipine besylate-olmesartan medoxomil tab 5-40 mg (Azor)....................................................................... 69 amlodipine besylate-olmesartan medoxomil tab 10-20 mg (Azor)....................................................................... 69 amlodipine besylate-olmesartan medoxomil tab 10-40 mg (Azor)....................................................................... 69 amlodipine besylate tab 2.5 mg (Norvasc)................... 64 amlodipine besylate tab 5 mg (Norvasc)...................... 64 amlodipine besylate tab 10 mg (Norvasc).................... 64 amlodipine besylate-valsartan tab 5-160 mg (Exforge)......................................................................... 69 amlodipine besylate-valsartan tab 5-320 mg (Exforge)......................................................................... 69 amlodipine besylate-valsartan tab 10-160 mg (Exforge)......................................................................... 69 amlodipine besylate-valsartan tab 10-320 mg (Exforge)......................................................................... 69 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg (Exforge hct)........................................ 69 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg (Exforge hct)........................................... 69 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg (Exforge hct)...................................... 69 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg (Exforge hct)......................................... 69 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg (Exforge hct)......................................... 69 AMMONIUM BICARBONATE -ammonium bicarbonate powder........................................................................... 222
AMMONIUM BROMIDE -ammonium bromide granules......................................................................... 222 AMMONIUM CHLORIDE -ammonium chloride granules......................................................................... 222 AMMONIUM HYDROXIDE -ammonia solution, strong............................................................................. 222 AMMONIUM LACTATE -ammonium lactate solution 70%................................................................................222 AMMONIUM LAURYL SULFATE -ammonium lauryl sulfate (bulk) liquid 28%............................................... 222 AMMONIUM MOLYBDATE TETRAH -ammonium molybdate tetrahydrate (bulk) powder......................... 222 AMMONIUM SULFATE -ammonium sulfate granules......................................................................... 222 AMMONIUM TETRATHIOMOLYBDA -ammonium molybdate tetrahydrate (bulk) powder......................... 222 AMOXAPINE -amoxapine tab 25 mg.............................. 111 AMOXAPINE -amoxapine tab 50 mg.............................. 111 AMOXAPINE -amoxapine tab 100 mg............................ 111 AMOXAPINE -amoxapine tab 150 mg............................ 111 AMOXICILLIN/CLAVULANATE P -amoxicillin & k clavulanate chew tab 200-28.5 mg.................................. 1 AMOXICILLIN/CLAVULANATE P -amoxicillin & k clavulanate chew tab 400-57 mg..................................... 1 AMOXICILLIN/CLAVULANATE P -amoxicillin-potassium clavulanate 4:1 (bulk) powder...................................... 222 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml.............................................................................. 1 amoxicillin & k clavulanate for susp 400-57 mg/5ml..... 1 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin)..................................................................... 1 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)........................................................ 1 amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg (Augmentin xr)................................................................ 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 -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).............................................................. 97 AMOXICILLIN TRIHYDRATE -amoxicillin (trihydrate) powder............................................................................... 1 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
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
285
2016 amoxicillin (trihydrate) tab 875 mg.................................. 1 AMPHADASE -hyaluronidase bovine inj 150 unit/ml...... 275 amphetamine-dextroamphetamine cap er 24hr 5 mg (Adderall xr)................................................................. 125 amphetamine-dextroamphetamine cap er 24hr 10 mg (Adderall xr)................................................................. 125 amphetamine-dextroamphetamine cap er 24hr 15 mg (Adderall xr)................................................................. 125 amphetamine-dextroamphetamine cap er 24hr 20 mg (Adderall xr)................................................................. 125 amphetamine-dextroamphetamine cap er 24hr 25 mg (Adderall xr)................................................................. 126 amphetamine-dextroamphetamine cap er 24hr 30 mg (Adderall xr)................................................................. 126 amphetamine-dextroamphetamine tab 5 mg (Adderall)...................................................................... 126 amphetamine-dextroamphetamine tab 7.5 mg (Adderall)...................................................................... 126 amphetamine-dextroamphetamine tab 10 mg (Adderall)...................................................................... 126 amphetamine-dextroamphetamine tab 12.5 mg (Adderall)...................................................................... 126 amphetamine-dextroamphetamine tab 15 mg (Adderall)...................................................................... 126 amphetamine-dextroamphetamine tab 20 mg (Adderall)...................................................................... 126 amphetamine-dextroamphetamine tab 30 mg (Adderall)...................................................................... 126 AMPHOTERICIN B -amphotericin b for inj 50 mg.............. 9 AMPHOTERICIN B -amphotericin b powder.................. 195 ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm (Unasyn)........................................................................... 1 ampicillin & sulbactam sodium for inj 3 (2-1) gm (Unasyn)........................................................................... 1 ampicillin & sulbactam sodium for inj 15 (10-5) gm (Unasyn bulk pack).........................................................1 ampicillin cap 500 mg....................................................... 1 AMPICILLIN SODIUM -ampicillin sodium for inj 125 mg...................................................................................... 1 ampicillin sodium for inj 1 gm......................................... 1 ampicillin sodium for inj 2 gm......................................... 1 ampicillin sodium for inj 10 gm....................................... 1 ampicillin sodium for inj 250 mg..................................... 1 ampicillin sodium for inj 500 mg..................................... 1 ampicillin sodium for iv soln 2 gm.................................. 1 AMPYRA -dalfampridine tab er 12hr 10 mg................... 130 AMRIX -cyclobenzaprine hcl cap er 24hr 15 mg............ 168 AMRIX -cyclobenzaprine hcl cap er 24hr 30 mg............ 168 AMVISC PLUS -sodium hyaluronate intraocular inj 16 mg/ ml................................................................................... 188 AMVISC -sodium hyaluronate intraocular inj 12 mg/ ml................................................................................... 188 AMYTAL SODIUM -amobarbital sodium for inj 500 mg.................................................................................. 123 ANADROL-50 -oxymetholone tab 50 mg.......................... 37
ANAFRANIL -clomipramine hcl cap 25 mg..................... 111 ANAFRANIL -clomipramine hcl cap 50 mg..................... 111 ANAFRANIL -clomipramine hcl cap 75 mg..................... 111 anagrelide hcl cap 1 mg............................................... 188 anagrelide hcl cap 0.5 mg (Agrylin)............................ 188 ANALPRAM-HC -hydrocortisone acetate w/ pramoxine rectal cream 1-1%........................................................ 196 ANALPRAM HC -hydrocortisone acetate w/ pramoxine rectal cream 2.5-1%..................................................... 196 ANALPRAM-HC -hydrocortisone acetate w/ pramoxine rectal lotn 2.5-1%..........................................................196 ANALPRAM HC SINGLES -hydrocortisone acetate w/ pramoxine rectal cream 2.5-1%................................... 196 ANAPROX DS -naproxen sodium tab 550 mg............... 147 ANASEPT -sodium hypochlorite liquid 0.057%.............. 218 ANASPAZ -hyoscyamine sulfate tab disint 0.125 mg....... 97 ANASTROZOLE -anastrozole (bulk) powder.................. 222 anastrozole tab 1 mg (Arimidex)................................... 25 ANCOBON -flucytosine cap 250 mg................................... 9 ANCOBON -flucytosine cap 500 mg................................... 9 ANDRODERM -testosterone td patch 24hr 2 mg/24hr..... 37 ANDRODERM -testosterone td patch 24hr 4 mg/24hr..... 37 ANDROGEL PUMP -testosterone td gel 20.25 mg/act (1.62%)............................................................................ 37 ANDROGEL -testosterone td gel 25 mg/2.5gm (1%)....... 37 ANDROGEL -testosterone td gel 50 mg/5gm (1%).......... 37 ANDROGEL -testosterone td gel 20.25 mg/1.25gm (1.62%)............................................................................ 37 ANDROGEL -testosterone td gel 40.5 mg/2.5gm (1.62%)............................................................................ 37 ANDROID -methyltestosterone cap 10 mg....................... 38 ANDROSTENEDIONE -androstenedione (bulk) powder........................................................................... 223 ANDROXY -fluoxymesterone tab 10 mg........................... 38 ANECTINE -succinylcholine chloride inj 20 mg/ml......... 167 ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg.......... 39 ANGELIQ -drospirenone-estradiol tab 0.5-1 mg............... 39 ANHYDROUS BASE -anhydrous ointment base............ 262 ANHYDROUS CREAM BASE -anhydrous cream base............................................................................... 262 ANHYDROUS GEL BASE -gel base - gel...................... 262 ANIMI-3/VITAMIN D -folic acid-b6-b12-d-omega 3phytosterols cap 1 mg.................................................. 179 ANIMI-3 -folic acid-b6-b12-d-omega 3-phytosterols cap 1 mg.................................................................................. 179 ANISE EXTRACT -flavoring agent - liquid...................... 262 ANISE FLAVOR -flavoring agent - oil............................. 262 ANISINDIONE -anisindione (bulk) powder......................223 ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba 62.5-25 mcg/inh.............................................................. 90 ANTABUSE -disulfiram tab 250 mg................................ 130 ANTABUSE -disulfiram tab 500 mg................................ 130 ANTARA -fenofibrate micronized cap 30 mg.................... 81 ANTARA -fenofibrate micronized cap 90 mg.................... 81 ANTHRALIN -anthralin powder....................................... 198
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
286
2016 ANTICOAGULANT CITRATE DEX -anticoagulant citrate dextrose solution a....................................................... 185 ANTICOAGULANT CITRATE PHO -anticoagulant citrate phosphate dextrose soln.............................................. 185 ANTICOAGULANT SODIUM CITR -anticoagulant sodium citrate soln 4%.............................................................. 185 ANTIMONY TRICHLORIDE -antimony trichloride (bulk) crystals.......................................................................... 223 ANTIMONY TRISULFIDE -antimony trisulfide (bulk) powder........................................................................... 223 ANTIPYRINE -antipyrine (bulk) crystals..........................223 ANTIPYRINE -antipyrine (bulk) powder.......................... 223 ANTIVENIN LATRODECTUS MAC -antivenin latrodectus mactans inj kit................................................................. 22 ANUSOL-HC -hydrocortisone rectal cream 2.5%........... 196 ANZEMET -dolasetron mesylate tab 50 mg................... 100 ANZEMET -dolasetron mesylate tab 100 mg................. 100 APEXICON E -diflorasone diacetate emollient base cream 0.05%................................................................. 199 APIDRA -insulin glulisine inj 100 unit/ml........................... 51 APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj 100 unit/ml.......................................................................51 APLENZIN -bupropion hbr tab er 24hr 174 mg.............. 111 APLENZIN -bupropion hbr tab er 24hr 348 mg.............. 111 APLENZIN -bupropion hbr tab er 24hr 522 mg.............. 111 APOKYN -apomorphine hcl soln cartridge 30 mg/3ml........................................................................... 164 APOMORPHINE HCL -apomorphine hcl (bulk) powder........................................................................... 223 APOMORPHINE HCL HEMIHYDRA -apomorphine hcl (bulk) powder................................................................ 223 APOTHEDERM -transdermal base cream...................... 262 APOTHESAR 2 -cream base.......................................... 262 APOTHESAR PLUS -cream base................................... 262 APOTHESAR -transdermal base cream......................... 262 APOTHESIL -cream base............................................... 262 APPLE FLAVOR -flavoring agent - liquid........................ 262 APPLE FLAVOR -flavoring agent - powder.................... 262 APP SLIM RMS -nutritional supplement - diet aids cap................................................................................. 178 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine)...................................................................... 189 aprepitant capsule 40 mg (Emend)............................. 100 aprepitant capsule 80 mg (Emend)............................. 100 aprepitant capsule 125 mg (Emend)........................... 100 aprepitant capsule therapy pack 80 & 125 mg (Emend)........................................................................ 100 APRICOT FLAVOR -flavoring agent - liquid................... 262 APRICOT FLAVOR -flavoring agent - powder................ 262 APRISO -mesalamine cap er 24hr 0.375 gm................. 102 APTENSIO XR -methylphenidate hcl cap er 24hr 10 mg (xr)................................................................................. 126 APTENSIO XR -methylphenidate hcl cap er 24hr 15 mg (xr)................................................................................. 126
APTENSIO XR -methylphenidate hcl cap er 24hr 20 mg (xr)................................................................................. 126 APTENSIO XR -methylphenidate hcl cap er 24hr 30 mg (xr)................................................................................. 126 APTENSIO XR -methylphenidate hcl cap er 24hr 40 mg (xr)................................................................................. 126 APTENSIO XR -methylphenidate hcl cap er 24hr 50 mg (xr)................................................................................. 126 APTENSIO XR -methylphenidate hcl cap er 24hr 60 mg (xr)................................................................................. 126 APTIOM -eslicarbazepine acetate tab 200 mg............... 157 APTIOM -eslicarbazepine acetate tab 400 mg............... 157 APTIOM -eslicarbazepine acetate tab 600 mg............... 157 APTIOM -eslicarbazepine acetate tab 800 mg............... 157 APTIVUS -tipranavir cap 250 mg...................................... 10 APTIVUS -tipranavir oral soln 100 mg/ml......................... 10 AP-ZEL -multiple vitamins w/ minerals tab..................... 171 AQUASOL A PARENTERAL -vitamin a inj 50000 unit/ ml................................................................................... 170 AQUORAL -artificial saliva - solution.............................. 195 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 25 mcg/ml........................................................................... 179 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 40 mcg/ml........................................................................... 179 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 60 mcg/ml........................................................................... 179 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 100 mcg/ml........................................................................... 179 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 200 mcg/ml........................................................................... 179 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 300 mcg/ml........................................................................... 180 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 10 mcg/0.4ml..................................... 180 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 25 mcg/0.42ml................................... 180 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 40 mcg/0.4ml..................................... 180 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 60 mcg/0.3ml..................................... 180 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 100 mcg/0.5ml................................... 180 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 150 mcg/0.3ml................................... 180 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 200 mcg/0.4ml................................... 180 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 300 mcg/0.6ml................................... 180 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 500 mcg/ml........................................ 180 ARAVA -leflunomide tab 10 mg....................................... 147 ARAVA -leflunomide tab 20 mg....................................... 147 ARBUTIN ALPHA -arbutin alpha (bulk) powder..............223 ARCALYST -rilonacept for inj 220 mg.............................147
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
287
2016 ARTHROTEC 50 -diclofenac w/ misoprostol tab delayed release 50-0.2 mg.........................................................147 ARTHROTEC 75 -diclofenac w/ misoprostol tab delayed release 75-0.2 mg.........................................................147 ARTICADENT DENTAL -articaine-epinephrine inj 4%-1:200000................................................................. 154 ARTICADENT DENTAL -articaine-epinephrine inj 4%-1:100000................................................................. 154 ARTISS -fibrin sealant component solution.................... 187 ARZE-JECT-A -triamcinolone acetonide inj kit 3 x 40 mg/ ml..................................................................................... 32 ARZOL SILVER NITRATE APP -silver nitrate-potassium nitrate applicator 75-25%............................................. 199 ASACOL HD -mesalamine tab delayed release 800 mg.................................................................................. 102 ASCORBIC ACID -ascorbic acid (bulk) granules............223 ASCORBIC ACID -ascorbic acid (bulk) powder..............223 ASCORBIC ACID CASSAVE -ascorbic acid (bulk) powder........................................................................... 223 ascorbic acid inj 500 mg/ml......................................... 170 ASCORBYL PALMITATE -ascorbyl palmitate (bulk) powder........................................................................... 223 ASMANEX HFA -mometasone furoate inhal aerosol suspension 100 mcg/act................................................. 91 ASMANEX HFA -mometasone furoate inhal aerosol suspension 200 mcg/act................................................. 91 ASMANEX TWISTHALER 120 ME -mometasone furoate inhal powd 220 mcg/inh (breath activated).................... 91 ASMANEX TWISTHALER 7 METE -mometasone furoate inhal powd 110 mcg/inh (breath activated).................... 91 ASMANEX TWISTHALER 14 MET -mometasone furoate inhal powd 220 mcg/inh (breath activated).................... 91 ASMANEX TWISTHALER 30 MET -mometasone furoate inhal powd 110 mcg/inh (breath activated).................... 91 ASMANEX TWISTHALER 30 MET -mometasone furoate inhal powd 220 mcg/inh (breath activated).................... 91 ASMANEX TWISTHALER 60 MET -mometasone furoate inhal powd 220 mcg/inh (breath activated).................... 91 ASPARAGINE MONOHYDRATE -asparagine (bulk) powder........................................................................... 223 ASPARTAME -aspartame powder (for compounding)................................................................178 ASPARTAME (NUTRASWEET) -aspartame powder (for compounding)................................................................178 ASPIRIN -aspirin powder................................................. 135 aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg................................................................................. 135 ASPIRIN-CAFFEINE-DIHYDROC -aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg........................... 137 aspirin chew tab 81 mg.................................................135 aspirin-dipyridamole cap er 12hr 25-200 mg (Aggrenox)................................................................... 188 aspirin tab delayed release 81 mg...............................135 aspirin tab delayed release 325 mg.............................135 aspirin tab 325 mg......................................................... 135
ARCAPTA NEOHALER -indacaterol maleate inhal powder cap 75 mcg (base equiv)................................................91 ARESTIN -minocycline hcl subgingival powder cartridge 1 mg.................................................................................. 195 ARGININE HCL -arginine hcl (bulk) powder................... 223 ARICEPT -donepezil hydrochloride tab 5 mg................. 130 ARICEPT -donepezil hydrochloride tab 10 mg............... 130 ARICEPT -donepezil hydrochloride tab 23 mg............... 130 ARIMIDEX -anastrozole tab 1 mg..................................... 25 aripiprazole orally disintegrating tab 10 mg...............117 aripiprazole orally disintegrating tab 15 mg...............117 aripiprazole oral solution 1 mg/ml............................... 117 aripiprazole tab 2 mg (Abilify)...................................... 117 aripiprazole tab 5 mg (Abilify)...................................... 117 aripiprazole tab 10 mg (Abilify).................................... 117 aripiprazole tab 15 mg (Abilify).................................... 117 aripiprazole tab 20 mg (Abilify).................................... 117 aripiprazole tab 30 mg (Abilify).................................... 117 ARISTADA -aripiprazole lauroxil im er susp prefilled syr 441 mg/1.6ml................................................................ 117 ARISTADA -aripiprazole lauroxil im er susp prefilled syr 662 mg/2.4ml................................................................ 117 ARISTADA -aripiprazole lauroxil im er susp prefilled syr 882 mg/3.2ml................................................................ 117 ARISTADA -aripiprazole lauroxil im er susp prefilled syr 1064 mg/3.9ml.............................................................. 117 ARIXTRA -fondaparinux sodium inj 2.5 mg/0.5ml.......... 185 ARIXTRA -fondaparinux sodium subcutaneous inj 5 mg/0.4ml........................................................................ 185 ARIXTRA -fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml........................................................................ 185 ARIXTRA -fondaparinux sodium subcutaneous inj 10 mg/0.8ml........................................................................ 185 ARLACEL 165 -glyceryl stearate-peg 100 stearate (bulk) powder........................................................................... 223 armodafinil tab 50 mg (Nuvigil)................................... 126 armodafinil tab 150 mg (Nuvigil)................................. 126 armodafinil tab 200 mg (Nuvigil)................................. 126 armodafinil tab 250 mg (Nuvigil)................................. 126 ARMOUR THYROID -thyroid tab 15 mg (1/4 grain)......... 52 ARMOUR THYROID -thyroid tab 30 mg (1/2 grain)......... 52 ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)...... 52 ARMOUR THYROID -thyroid tab 60 mg (1 grain)............ 52 ARMOUR THYROID -thyroid tab 120 mg (2 grain).......... 52 ARMOUR THYROID -thyroid tab 180 mg (3 grain).......... 52 ARMOUR THYROID -thyroid tab 240 mg (4 grain).......... 52 ARMOUR THYROID -thyroid tab 300 mg (5 grain).......... 52 ARNICA FLOWER -arnica - tincture............................... 199 ARNICA LG -arnica (bulk) liquid..................................... 223 ARNUITY ELLIPTA -fluticasone furoate aerosol powder breath activ 100 mcg/act................................................ 91 ARNUITY ELLIPTA -fluticasone furoate aerosol powder breath activ 200 mcg/act................................................ 91 AROMASIN -exemestane tab 25 mg................................ 25 ARSENIC TRIOXIDE -arsenic trioxide (bulk) powder..... 223
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
288
2016 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor)........................................................................... 81 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor)........................................................................... 81 ATOVAQUONE -atovaquone (bulk) powder................... 223 atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)...................................................................... 16 atovaquone-proguanil hcl tab 250-100 mg (Malarone)...................................................................... 16 atovaquone susp 750 mg/5ml (Mepron)....................... 16 ATRALIN -tretinoin gel 0.05%......................................... 199 ATRAPRO ANTIPRURITIC HYDR -wound dressings gel.................................................................................. 199 ATRAPRO CP -wound dressings - kit............................. 199 ATRAPRO DERMAL SPRAY -wound cleansers liquid.............................................................................. 199 ATRIPLA -efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg..............................................................10 ATROPEN -atropine sulfate im soln auto-injector 0.25 mg/0.3ml.......................................................................... 97 ATROPEN -atropine sulfate im soln auto-injector 0.5 mg/0.7ml.......................................................................... 97 ATROPEN -atropine sulfate im soln auto-injector 1 mg/0.7ml.......................................................................... 97 ATROPEN -atropine sulfate im soln auto-injector 2 mg/0.7ml.......................................................................... 97 ATROPINE SULFATE -atropine sulfate inj 0.4 mg/ml....... 97 ATROPINE SULFATE -atropine sulfate monohydrate powder............................................................................. 97 ATROPINE SULFATE -atropine sulfate ophth oint 1%.................................................................................. 189 ATROPINE SULFATE -atropine sulfate ophth soln 1%.................................................................................. 189 ATROPINE SULFATE -atropine sulfate powder................97 ATROPINE SULFATE -atropine sulfate soln prefill syr 0.25 mg/5ml (0.05 mg/ml).............................................. 97 ATROPINE SULFATE -atropine sulfate soln prefill syr 0.5 mg/5ml (0.1 mg/ml).........................................................97 atropine sulfate inj 1 mg/ml............................................97 atropine sulfate inj 8 mg/20ml (0.4 mg/ml)................... 97 ATROPINE SULFATE MONOHYDR -atropine sulfate monohydrate powder...................................................... 97 atropine sulfate soln prefill syr 1 mg/10ml (0.1 mg/ ml)................................................................................... 97 ATROVENT HFA -ipratropium bromide hfa inhal aerosol 17 mcg/act.......................................................................91 ATTAPULGITE ACTIVATED COL -attapulgite (bulk) powder........................................................................... 223 AUBAGIO -teriflunomide tab 7 mg.................................. 130 AUBAGIO -teriflunomide tab 14 mg................................ 130 AUGMENTED BETAMETHASONE D -betamethasone dipropionate augmented gel 0.05%............................. 199 AUGMENTIN -amoxicillin & k clavulanate for susp 125-31.25 mg/5ml............................................................. 1
ASTAGRAF XL -tacrolimus cap er 24hr 0.5 mg..............275 ASTAGRAF XL -tacrolimus cap er 24hr 1 mg................ 275 ASTAGRAF XL -tacrolimus cap er 24hr 5 mg................ 275 ASTEPRO -azelastine hcl nasal spray 0.15% (205.5 mcg/ spray)............................................................................... 87 ASTERO -lidocaine hcl gel 4%....................................... 199 ASTRAGALUS ROOT -tragacanth powder.....................262 ATACAND -candesartan cilexetil tab 4 mg....................... 69 ATACAND -candesartan cilexetil tab 8 mg....................... 69 ATACAND -candesartan cilexetil tab 16 mg..................... 69 ATACAND -candesartan cilexetil tab 32 mg..................... 69 ATACAND HCT -candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg............................................................... 69 ATACAND HCT -candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg............................................................... 69 ATACAND HCT -candesartan cilexetil-hydrochlorothiazide tab 32-25 mg...................................................................69 ATELVIA -risedronate sodium tab delayed release 35 mg.................................................................................... 55 ATENOLOL/SYRSPEND SF PH4 -atenolol oral suspension 1 mg/ml (cmpd kit)...................................... 62 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50).................................................................................... 69 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100).................................................................................. 69 ATENOLOL -atenolol powder............................................ 61 atenolol tab 25 mg (Tenormin)....................................... 61 atenolol tab 50 mg (Tenormin)....................................... 61 atenolol tab 100 mg (Tenormin)..................................... 61 ATIVAN -lorazepam inj 2 mg/ml...................................... 109 ATIVAN -lorazepam inj 4 mg/ml...................................... 109 ATIVAN -lorazepam tab 0.5 mg....................................... 109 ATIVAN -lorazepam tab 1 mg.......................................... 109 ATIVAN -lorazepam tab 2 mg.......................................... 109 atomoxetine hcl cap 10 mg (base equiv) (Strattera)..................................................................... 126 atomoxetine hcl cap 18 mg (base equiv) (Strattera)..................................................................... 126 atomoxetine hcl cap 25 mg (base equiv) (Strattera)..................................................................... 126 atomoxetine hcl cap 40 mg (base equiv) (Strattera)..................................................................... 126 atomoxetine hcl cap 60 mg (base equiv) (Strattera)..................................................................... 126 atomoxetine hcl cap 80 mg (base equiv) (Strattera)..................................................................... 126 atomoxetine hcl cap 100 mg (base equiv) (Strattera)..................................................................... 126 ATOPICLAIR -dermatological products misc - cream..... 199 ATORVASTATIN CALCIUM -atorvastatin calcium (bulk) powder........................................................................... 223 atorvastatin calcium tab 10 mg (base equivalent) (Lipitor)........................................................................... 81 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor)........................................................................... 81
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
289
2016 AUGMENTIN -amoxicillin & k clavulanate for susp 250-62.5 mg/5ml............................................................... 2 AUGMENTIN -amoxicillin & k clavulanate tab 500-125 mg...................................................................................... 2 AUGMENTIN -amoxicillin & k clavulanate tab 875-125 mg...................................................................................... 2 AUGMENTIN ES-600 -amoxicillin & k clavulanate for susp 600-42.9 mg/5ml...................................................... 2 AUGMENTIN XR -amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg.................................................................... 2 AURYXIA -ferric citrate tab 1 gm (210 mg ferric iron)..... 102 AUSTEDO -deutetrabenazine tab 6 mg.......................... 130 AUSTEDO -deutetrabenazine tab 9 mg.......................... 130 AUSTEDO -deutetrabenazine tab 12 mg........................131 AUXIPRO VANISHING CREAM -cream base................ 262 AVALIDE -irbesartan-hydrochlorothiazide tab 150-12.5 mg.................................................................................... 69 AVALIDE -irbesartan-hydrochlorothiazide tab 300-12.5 mg.................................................................................... 69 AVANDIA -rosiglitazone maleate tab 2 mg (base equiv)............................................................................... 46 AVANDIA -rosiglitazone maleate tab 4 mg (base equiv)............................................................................... 46 AVAPRO -irbesartan tab 75 mg........................................ 69 AVAPRO -irbesartan tab 150 mg...................................... 69 AVAPRO -irbesartan tab 300 mg...................................... 69 AVAR-E LS -sulfacetamide sodium w/ sulfur cream 10-2%............................................................................ 199 AVAR LS CLEANSER -sulfacetamide sodium w/ sulfur cleanser 10-2%............................................................. 199 AVAR LS -sulfacetamide sodium w/ sulfur cleansing pad 10-2%............................................................................ 199 AVAR LS -sulfacetamide sodium w/ sulfur foam 10-2%............................................................................ 199 AVAR -sulfacetamide sodium w/ sulfur cleansing pad 9.5-5%........................................................................... 199 AVAR -sulfacetamide sodium w/ sulfur foam 9.5-5%...... 199 AVC -sulfanilamide vaginal cream 15%.......................... 106 AVEED -testosterone undecanoate im inj in oil 750 mg/3ml (250mg/ml)......................................................... 38 AVELOX -moxifloxacin hcl tab 400 mg (base equiv).......... 7 AVICEL PH 101 MICROCRYSTA -cellulose (bulk) powder........................................................................... 223 AVICEL PH 105 MICROCRYSTA -cellulose (bulk) powder........................................................................... 223 AVIPTADIL ACETATE -aviptadil acetate (bulk) powder........................................................................... 223 AVOCADO OIL -avocado oil (bulk)................................. 223 AVO CREAM -wound dressings - emulsion.................... 199 AVODART -dutasteride cap 0.5 mg................................ 108 AVONEX -interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial)..................................................... 131 AVONEX -interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml...................................................................... 131
AVONEX PEN -interferon beta-1a im auto-injector kit 30 mcg/0.5ml...................................................................... 131 AXERT -almotriptan malate tab 6.25 mg........................ 151 AXERT -almotriptan malate tab 12.5 mg........................ 151 AXIRON -testosterone td soln 30 mg/act.......................... 38 AYGESTIN -norethindrone acetate tab 5 mg.................... 45 azacitidine for inj 100 mg (Vidaza)................................ 25 AZACTAM -aztreonam for inj 1 gm................................... 16 AZACTAM -aztreonam for inj 2 gm................................... 16 AZASAN -azathioprine tab 75 mg................................... 275 AZASAN -azathioprine tab 100 mg................................. 275 AZASITE -azithromycin ophth soln 1%........................... 189 AZATHIOPRINE -azathioprine powder........................... 275 AZATHIOPRINE -azathioprine sodium for inj 100 mg.................................................................................. 275 azathioprine tab 50 mg (Imuran).................................. 275 AZELAIC ACID -azelaic acid (bulk) flakes...................... 223 AZELASTINE HCL -azelastine hcl (bulk) powder........... 223 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro).........................................................................87 azelastine hcl nasal spray 137 mcg/spray (1 mg/ ml)................................................................................... 87 azelastine hcl ophth soln 0.05% (Optivar).................. 189 AZELEX -azelaic acid cream 20%.................................. 199 AZILECT -rasagiline mesylate tab 0.5 mg (base equiv)............................................................................. 164 AZILECT -rasagiline mesylate tab 1 mg (base equiv)............................................................................. 164 AZITHROMYCIN -azithromycin (bulk) powder............... 223 AZITHROMYCIN -azithromycin powd pack for susp 1 gm...................................................................................... 5 AZITHROMYCIN DIHYDRATE -azithromycin (bulk) powder........................................................................... 223 azithromycin for susp 100 mg/5ml (Zithromax)............. 5 azithromycin for susp 200 mg/5ml (Zithromax)............. 5 azithromycin tab 250 mg (Zithromax)............................. 5 azithromycin tab 500 mg (Zithromax)............................. 5 azithromycin tab 600 mg (Zithromax)............................. 5 AZOPT -brinzolamide ophth susp 1%............................. 189 AZOR -amlodipine besylate-olmesartan medoxomil tab 5-20 mg........................................................................... 69 AZOR -amlodipine besylate-olmesartan medoxomil tab 5-40 mg........................................................................... 69 AZOR -amlodipine besylate-olmesartan medoxomil tab 10-20 mg......................................................................... 70 AZOR -amlodipine besylate-olmesartan medoxomil tab 10-40 mg......................................................................... 70 aztreonam for inj 1 gm (Azactam)................................. 16 aztreonam for inj 2 gm (Azactam)................................. 16 AZULFIDINE EN-TABS -sulfasalazine tab delayed release 500 mg............................................................. 102 AZULFIDINE -sulfasalazine tab 500 mg......................... 102 B BABY DDROPS -cholecalciferol drops 400 unit/0.03ml (per drop)...................................................................... 170 SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
290
2016 BAYER BREEZE 2 HIGH CONTR -blood glucose calibration - liquid - high............................................... 261 BAYER BREEZE 2 LOW CONTRO -blood glucose calibration - liquid - low................................................ 261 BAYER BREEZE 2 NORMAL CON -blood glucose calibration - liquid - normal........................................... 261 BAYER BREEZE 2 TEST DISC -glucose blood test disk................................................................................ 219 BAYER CONTOUR BLOOD GLUCO -glucose blood test strip................................................................................ 219 BAYER CONTOUR HIGH CONTRO -blood glucose calibration - liquid - high............................................... 261 BAYER CONTOUR LOW CONTROL -blood glucose calibration - liquid - low................................................ 261 BAYER CONTOUR NEXT BLOOD -glucose blood test strip................................................................................ 219 BAYER CONTOUR NEXT CONTRO -blood glucose calibration - liquid - low................................................ 261 BAYER CONTOUR NEXT CONTRO -blood glucose calibration - liquid - normal........................................... 261 BAYER CONTOUR NORMAL CONT -blood glucose calibration - liquid - normal........................................... 261 b-complex vitamin inj.................................................... 171 b-complex w/ c & folic acid cap 1 mg (Nephrocaps)............................................................... 171 b-complex w/ c & folic acid tab................................... 171 b-complex w/ c & folic acid tab 5 mg.......................... 171 b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx).................................................................................. 171 B-12 COMPLIANCE INJECTION -cyanocobalamin inj kit 1000 mcg/ml................................................................. 180 BD 3ML LL SYR/PREFILL LIT -arterial blood gas kit..... 219 BD PUDENDAL/LOCAL BLOCK -lidocaine hcl local inj kit 1%.................................................................................. 154 BEAU RX -scar treatment products - gel........................ 199 BECLOMETHASONE DIPROPIONA -beclomethasone dipropionate (bulk) powder........................................... 223 BEEF-ADE -flavoring agent - powder............................. 263 BEEF FLAVOR -flavoring agent - liquid.......................... 263 BEEF FLAVOR -flavoring agent - powder.......................263 BEEF TYPE FLAVOR NATURAL -flavoring agent liquid.............................................................................. 263 BEESWAX -wax, white.................................................... 263 BEES WAX -wax, white................................................... 263 BEESWAX -wax, yellow.................................................. 263 BELBUCA -buprenorphine hcl buccal film 75 mcg (base equivalent)..................................................................... 137 BELBUCA -buprenorphine hcl buccal film 150 mcg (base equivalent)..................................................................... 137 BELBUCA -buprenorphine hcl buccal film 300 mcg (base equivalent)..................................................................... 137 BELBUCA -buprenorphine hcl buccal film 750 mcg (base equivalent)..................................................................... 137 BELBUCA -buprenorphine hcl buccal film 900 mcg (base equivalent)..................................................................... 137
BACITRACIN -bacitracin ophth oint 500 unit/gm............ 189 BACITRACIN -bacitracin powder.................................... 199 bacitracin intramuscular for soln 50000 unit (Bacitracin)..................................................................... 16 BACITRACIN MICRONIZED -bacitracin micronized (bulk) powder........................................................................... 223 bacitracin-polymyxin b ophth oint.............................. 189 bacitracin-polymyxin-neomycin-hc ophth oint 1%.................................................................................. 189 BACITRACIN ZINC -bacitracin zinc powder................... 199 BACLOFEN -baclofen cream 2% (cmpd kit)................... 199 BACLOFEN -baclofen powder........................................ 168 baclofen tab 10 mg........................................................ 168 baclofen tab 20 mg........................................................ 168 BACMIN -multiple vitamins w/ minerals tab.................... 171 BACOCALMINE -pharmaceutical excipients (bulk) liquid.............................................................................. 262 BACON FLAVOR -flavoring agent - liquid.......................262 BACTERIOSTATIC WATER FOR -water for inject, bacteriostatic benzyl alcohol........................................ 262 BACTERIOSTATIC WATER PARA -water for inject, bacteriostatic parabens................................................ 262 BACTRIM DS -sulfamethoxazole-trimethoprim tab 800-160 mg..................................................................... 17 BACTRIM -sulfamethoxazole-trimethoprim tab 400-80 mg.................................................................................... 17 BACTROBAN -mupirocin calcium cream 2%................. 199 BACTROBAN NASAL -mupirocin calcium nasal oint 2%.................................................................................... 87 BAL IN OIL -dimercaprol inj 100 mg/ml.......................... 218 balsalazide disodium cap 750 mg (Colazal)............... 102 BANANA CONCENTRATE -flavoring agent - liquid........ 262 BANANA CREAM FLAVOR -flavoring agent - liquid....... 262 BANANA CREME FLAVOR -flavoring agent - liquid....... 262 BANANA FLAVOR -flavoring agent - liquid.....................262 BANZEL -rufinamide susp 40 mg/ml............................... 157 BANZEL -rufinamide tab 200 mg.................................... 157 BANZEL -rufinamide tab 400 mg.................................... 157 BARACLUDE -entecavir oral soln 0.05 mg/ml.................. 10 BARACLUDE -entecavir tab 0.5 mg................................. 10 BARACLUDE -entecavir tab 1 mg.................................... 10 BASE A POLYETHYLENE GLYCO -polyethylene glycol 1450 powder................................................................. 262 BASE C POLYETHYLENE GLYCO -polyethylene glycol 300 liquid....................................................................... 262 BASE CREAM WITH LIPOSOME -cream base liposomic........................................................................262 BASE D POLYETHYLENE GLYCO -polyethylene glycol 4500 powder................................................................. 263 BASE G ALMOND OIL SWEET -almond oil (sweet)...... 223 BASE GELATIN GUMMY TROCHE -gummy gel base gel.................................................................................. 263 BASE W301 -cream base............................................... 263 BASE X -hydrogenated vegetable oil flakes................... 263 BASIC FUCHSIN HCL -basic fuchsin hcl powder...........223
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
291
2016 BENZIQ LS -benzoyl peroxide gel 2.75%....................... 199 BENZIQ WASH -benzoyl peroxide liq 5.25%.................. 199 BENZOCAINE -benzocaine powder................................199 benzocaine mouth/throat aerosol 20%....................... 195 BENZOIC ACID -benzoic acid crystals........................... 199 BENZOIC ACID -benzoic acid powder........................... 200 benzoin compound tincture......................................... 200 BENZOIN GUM -benzoin gum (bulk) powder................. 224 BENZOIN TINCTURE -benzoin tincture......................... 200 benzonatate cap 200 mg................................................. 88 benzonatate cap 100 mg (Tessalon perles).................. 88 BENZOQUINONE (PARA) -1,4-benzoquinone (bulk) crystals.......................................................................... 224 BENZOYL PEROXIDE -benzoyl peroxide powder......... 200 benzoyl peroxide cloth 6%........................................... 200 benzoyl peroxide-erythromycin gel 5-3% (Benzamycin)............................................................... 200 benzoyl peroxide foam 5.3% (Benzefoam)................. 200 benzoyl peroxide foam 9.8% (Benzefoamultra)......... 200 benzoyl peroxide gel 10%.............................................200 BENZOYL PEROXIDE HYDROUS -benzoyl peroxide powder........................................................................... 200 benzoyl peroxide liq 2.5%.............................................200 benzoyl peroxide liq 7%................................................200 benzoyl peroxide liq 10%..............................................200 benzoyl peroxide lotion 6%.......................................... 200 BENZTROPINE MESYLATE -benztropine mesylate powder........................................................................... 164 benztropine mesylate inj 1 mg/ml (Cogentin)............ 164 benztropine mesylate tab 0.5 mg................................ 164 benztropine mesylate tab 1 mg................................... 164 benztropine mesylate tab 2 mg................................... 164 BENZYL ALCOHOL -benzyl alcohol............................... 263 BENZYL BENZOATE -benzyl benzoate liquid................ 224 BEPREVE -bepotastine besilate ophth soln 1.5%.......... 189 BESIVANCE -besifloxacin hcl ophth susp 0.6% (base equiv)............................................................................. 189 BETA CAROTENE -beta carotene (bulk) beadlets 10%................................................................................224 BETA CYCLODEXTRIN -beta cyclodextrin (bulk) powder........................................................................... 224 BETADINE OPHTHALMIC PREP -povidone-iodine ophth soln 5%......................................................................... 189 BETAGAN -levobunolol hcl ophth soln 0.5%.................. 189 BETA GLUCAN -beta glucan (bulk) powder................... 224 BETAHISTINE DIHYDROCHLORI -betahistine hydrochloride (bulk) powder......................................... 224 BETAHISTINE HCL -betahistine hydrochloride (bulk) powder........................................................................... 224 BETAINE ANHYDROUS -betaine (bulk) powder............ 224 BETAINE HCL -betaine hcl powder................................ 224 BETA 1 KIT -betamethasone sod phos & acet inj kit 30 mg/5 ml (6 mg/ml).......................................................... 32 BETALIDO -betamethasone sod phos & ace inj 6 mg/ml & lido inj 1% kit.................................................................. 32
BELLADONNA & OPIUM -belladonna alkaloids & opium suppos 16.2-30 mg......................................................... 97 BELLADONNA ALKALOIDS & OP -belladonna alkaloids & opium suppos 16.2-60 mg.......................................... 97 BELLADONNA -belladonna (bulk) tincture..................... 224 BELLADONNA EXTRACT -belladonna (bulk) powder........................................................................... 224 BELSOMRA -suvorexant tab 5 mg................................. 123 BELSOMRA -suvorexant tab 10 mg............................... 123 BELSOMRA -suvorexant tab 15 mg............................... 123 BELSOMRA -suvorexant tab 20 mg............................... 123 BENACTYZINE HYDROCHLORIDE -benactyzine hcl (bulk) powder................................................................ 224 benazepril & hydrochlorothiazide tab 5-6.25 mg......... 70 benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct)................................................................ 70 benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct)................................................................ 70 benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct)................................................................ 70 BENAZEPRIL HCL -benazepril hcl (bulk) powder.......... 224 benazepril hcl tab 5 mg.................................................. 70 benazepril hcl tab 10 mg (Lotensin).............................. 70 benazepril hcl tab 20 mg (Lotensin).............................. 70 benazepril hcl tab 40 mg (Lotensin).............................. 70 BENFOTIAMINE -benfotiamine (bulk) powder............... 224 BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg...............................70 BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg...............................70 BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-25 mg.................................. 70 BENICAR -olmesartan medoxomil tab 5 mg.....................70 BENICAR -olmesartan medoxomil tab 20 mg...................70 BENICAR -olmesartan medoxomil tab 40 mg...................70 BENSAL HP -salicylic acid & benzoic acid oint 3-6%..... 199 BENTONITE -bentonite powder...................................... 263 BENTYL -dicyclomine hcl cap 10 mg............................... 97 BENTYL -dicyclomine hcl inj 10 mg/ml............................. 97 BENZAC AC WASH -benzoyl peroxide liq 5%............... 199 BENZACLIN -clindamycin phosphate-benzoyl peroxide gel 1-5%........................................................................ 199 BENZACLIN WITH PUMP -clindamycin phosphatebenzoyl peroxide gel 1-5%........................................... 199 BENZALKONIUM CHLORIDE -benzalkonium chloride soln................................................................................ 218 BENZALKONIUM CHLORIDE -benzalkonium chloride soln 50%....................................................................... 218 BENZAMYCIN -benzoyl peroxide-erythromycin gel 5-3%.............................................................................. 199 BENZEFOAM -benzoyl peroxide foam 5.3%.................. 199 BENZEFOAM ULTRA -benzoyl peroxide foam 9.8%..... 199 BENZETHONIUM CHLORIDE -benzethonium chloride powder........................................................................... 224 BENZIQ -benzoyl peroxide gel 5.25 %........................... 199
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
292
2016 BETAMETHASONE ACETATE -betamethasone acetate (bulk) powder................................................................ 224 BETAMETHASONE ACETATE MIC -betamethasone acetate (bulk) powder................................................... 224 BETAMETHASONE DIPROPIONAT -betamethasone dipropionate powder..................................................... 200 betamethasone dipropionate augmented cream 0.05% (Diprolene af)............................................................... 200 betamethasone dipropionate augmented lotion 0.05% (Diprolene)................................................................... 200 betamethasone dipropionate augmented oint 0.05% (Diprolene)................................................................... 200 betamethasone dipropionate cream 0.05%................ 200 betamethasone dipropionate lotion 0.05%................. 200 betamethasone dipropionate oint 0.05%.................... 200 BETAMETHASONE SODIUM PHOS -betamethasone sodium phosphate powder............................................. 32 betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml (Celestone-soluspan).............................. 32 betamethasone valerate aerosol foam 0.12% (Luxiq)........................................................................... 200 BETAMETHASONE VALERATE -betamethasone valerate powder........................................................................... 200 betamethasone valerate cream 0.1%.......................... 200 betamethasone valerate lotion 0.1%........................... 200 betamethasone valerate oint 0.1%.............................. 200 BETANAPHTHOL -betanaphthol (bulk) powder............. 224 BETAPACE AF -sotalol hcl (afib/afl) tab 80 mg................ 62 BETAPACE AF -sotalol hcl (afib/afl) tab 120 mg.............. 62 BETAPACE AF -sotalol hcl (afib/afl) tab 160 mg.............. 62 BETAPACE -sotalol hcl tab 80 mg.................................... 62 BETAPACE -sotalol hcl tab 120 mg.................................. 62 BETAPACE -sotalol hcl tab 160 mg.................................. 62 BETASERON -interferon beta-1b for inj kit 0.3 mg......... 131 betaxolol hcl ophth soln 0.5%......................................189 betaxolol hcl tab 10 mg (Kerlone)................................. 62 betaxolol hcl tab 20 mg (Kerlone)................................. 62 BETHANECHOL CHLORIDE -bethanechol chloride (bulk) powder........................................................................... 224 BETHANECHOL CHLORIDE -bethanechol chloride powder........................................................................... 105 bethanechol chloride tab 5 mg (Urecholine).............. 105 bethanechol chloride tab 10 mg (Urecholine)............ 105 bethanechol chloride tab 25 mg (Urecholine)............ 105 bethanechol chloride tab 50 mg (Urecholine)............ 105 BETHKIS -tobramycin nebu soln 300 mg/4ml.................... 8 BETIMOL -timolol ophth soln 0.25%............................... 189 BETIMOL -timolol ophth soln 0.5%................................. 189 BETOPTIC-S -betaxolol hcl ophth susp 0.25%.............. 189 BEVESPI AEROSPHERE -glycopyrrolate-formoterol fumarate aerosol 9-4.8 mcg/act..................................... 91 bexarotene cap 75 mg (Targretin)..................................25 BEXSERO -meningococcal vac b (recomb omv adjuv) inj prefilled syringe............................................................... 19
BEYAZ -drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg..............................................................41 B-6 FOLIC ACID -cobalamine combination cap............. 180 BHA -butylated hydroxyanisole flakes.............................224 BHRT BASE -hormone cream base................................263 BHT -butylated hydroxytoluene granules........................ 224 BIAFINE -wound dressings - emulsion........................... 200 bicalutamide tab 50 mg (Casodex)................................ 25 BICILLIN C-R -penicillin g benzathine & procaine inj susp 1200000 unit/2ml.............................................................. 2 BICILLIN C-R -penicillin g benzathine & procaine inj 900000-300000 unt/2ml.................................................... 2 BICILLIN L-A -penicillin g benzathine intramuscular susp 600000 unit/ml.................................................................. 2 BICILLIN L-A -penicillin g benzathine intramuscular susp 1200000 unit/2ml.............................................................. 2 BICILLIN L-A -penicillin g benzathine intramuscular susp 2400000 unit/4ml.............................................................. 2 BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg.................................................................................... 84 BIEST/PROGESTERONE -estradiol-estriol-progesterone micronized cream (cmpd kit).......................................... 39 BIFERARX -polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg........................................................... 180 BILTRICIDE -praziquantel tab 600 mg.............................. 16 BIMATOPROST -bimatoprost (bulk) powder.................. 224 BIMATOPROST -bimatoprost ophth soln 0.03%............ 189 BINOSTO -alendronate sodium effervescent tab 70 mg.................................................................................... 55 BIORE HYDRATING MOISTURIZ -fragrances (bulk) liquid.............................................................................. 224 BIO-STATIN -nystatin cap 500000 unit............................... 9 BIO-STATIN -nystatin cap 1000000 unit............................. 9 BIOTIN -biotin powder..................................................... 170 BISABOLOL ALPHA-L -bisabolol, alpha-l (bulk) liquid.............................................................................. 224 BISACODYL -bisacodyl powder........................................ 95 bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit..................................................................................... 95 BISMUTH CITRATE -bismuth citrate powder................. 224 BISMUTH SUBCARBONATE -bismuth subcarbonate powder........................................................................... 224 BISMUTH SUBGALLATE -bismuth subgallate powder............................................................................. 96 BISMUTH SUBNITRATE -bismuth subnitrate powder........................................................................... 224 BISMUTH SUBSALICYLATE -bismuth subsalicylate powder........................................................................... 224 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac)............................................................................... 70 bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)............................................................................... 70 bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac)............................................................................... 70 bisoprolol fumarate tab 5 mg (Zebeta)..........................62
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
293
2016 bisoprolol fumarate tab 10 mg (Zebeta)........................62 BITTER DRUG POWDER -bitter drug base powder...... 263 BITTERNESS MASK FLAVOR -flavoring agent liquid.............................................................................. 263 BITTERNESS REDUCING AGENT -flavoring agent powder........................................................................... 263 BITTERNESS SUPRESSOR FLAV -flavoring agent liquid.............................................................................. 263 BITTER ORANGE -bitter orange (citrus aurantium amara) (bulk) powder................................................................ 224 BITTER STOP FLAVOR -flavoring agent - liquid............ 263 BLACKBERRY FLAVOR -flavoring agent - liquid........... 263 BLEO 15K -bleomycin sulf for inj 15 usp unit(15000 international unit)............................................................ 25 bleomycin sulfate for inj 15 unit.................................... 25 bleomycin sulfate for inj 30 unit.................................... 25 BLEPHAMIDE S.O.P. -sulfacetamide sodiumprednisolone ophth oint 10-0.2%................................. 189 BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth susp 10-0.2%................................................................ 189 BLEPH-10 -sulfacetamide sodium ophth soln 10%........ 189 BL INJECTION KIT -bupiv pf inj 0.5% & lido pf inj 2% & povi-iod swab kit........................................................... 154 BLUE AGAVE ORGANIC -agave tequilana (blue agave) liquid.............................................................................. 224 BLUEBERRY FLAVOR -flavoring agent - liquid.............. 263 BOCASAL -artificial saliva - packet................................. 195 BONIVA -ibandronate sodium tab 150 mg (base equivalent)....................................................................... 55 BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lflf-mcg/0.5ml..................................................................... 22 BORIC ACID -boric acid crystals.................................... 224 BORIC ACID -boric acid granules................................... 200 BORIC ACID -boric acid powder..................................... 225 BORON AMORPHOUS FINE -boron (bulk) powder....... 225 BORON CITRATE -boron citrate (bulk) powder 5%....... 225 BOSULIF -bosutinib tab 100 mg....................................... 25 BOSULIF -bosutinib tab 500 mg....................................... 25 BOSWELLIA SERRATA EXTRACT -boswellia serrata extract (bulk) powder.................................................... 225 BOTOX -onabotulinumtoxina for inj 100 unit.................. 167 BOTOX -onabotulinumtoxina for inj 200 unit.................. 167 BP CLEANSING WASH -sulfacetamide sodium-sulfur in urea emulsion 10-4%................................................... 200 BP VIT 3 -folic acid-vit b6-vit b12-omega 3-phytosterols cap 1 mg....................................................................... 180 BREO ELLIPTA -fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh.......................................................... 91 BREO ELLIPTA -fluticasone furoate-vilanterol aero powd ba 200-25 mcg/inh.......................................................... 91 BREVICON-28 -norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg...................................................................... 41 BRIJ 35 -polyoxyethylene (23) lauryl ether (bulk) wax................................................................................ 225 BRIJ 93 -polyoxyethylene (2) oleyl ether (bulk) liquid..... 225
BRIJ 700 -polyoxyethylene (100) stearyl ether (bulk) wax................................................................................ 225 BRILINTA -ticagrelor tab 60 mg...................................... 188 BRILINTA -ticagrelor tab 90 mg...................................... 188 BRILLIANT BLUE G -c.i. acid blue 90 powder............... 263 BRILLIANT GREEN -brilliant green (bulk) powder......... 225 BRIMONIDINE TARTRATE -brimonidine tartrate (bulk) powder........................................................................... 225 brimonidine tartrate ophth soln 0.2%......................... 189 brimonidine tartrate ophth soln 0.15% (Alphagan p)................................................................................... 189 BRISDELLE -paroxetine mesylate cap 7.5 mg (base equiv)............................................................................. 131 BRIVIACT -brivaracetam oral soln 10 mg/ml.................. 157 BRIVIACT -brivaracetam tab 10 mg............................... 157 BRIVIACT -brivaracetam tab 25 mg............................... 157 BRIVIACT -brivaracetam tab 50 mg............................... 157 BRIVIACT -brivaracetam tab 75 mg............................... 157 BRIVIACT -brivaracetam tab 100 mg............................. 157 BROMELAIN -bromelains powder...................................275 BROMFENAC -bromfenac sodium ophth soln 0.09% (base equivalent).......................................................... 189 BROMFENAC SODIUM -bromfenac sodium (bulk) powder........................................................................... 225 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily).................................................................. 189 BROMHEXINE HCL -bromhexine hcl powder.................. 88 BROMOCRIPTINE MESYLATE -bromocriptine mesylate powder........................................................................... 164 bromocriptine mesylate cap 5 mg (base equivalent) (Parlodel)...................................................................... 164 bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel)...................................................................... 164 brompheniramine & pseudoephedrine tab sr 12hr 6-45 mg........................................................................... 88 BROMPHENIRAMINE MALEATE -brompheniramine maleate powder.............................................................. 86 brompheniramine maleate tab sr 12hr 6 mg................ 86 BROMPHENIRAMINE TANNATE -brompheniramine tannate chew tab 12 mg.................................................86 BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml (base equiv).................................................................... 91 BT INJECTION KIT -triamcinolone inj 40 mg/ml & bupivacaine hcl inj 0.5% kit............................................ 32 BUBBLE GUM CONCENTRATE -flavoring agent liquid.............................................................................. 263 BUBBLE GUM FLAVOR -flavoring agent - liquid............ 263 BUCALSEP -antiseptic products misc - liquid.................218 BUCALSEP -antiseptic products misc - solution.............218 BUDESONIDE -budesonide (bulk) powder..................... 225 budesonide delayed release particles cap 3 mg (Entocort ec).................................................................. 32 budesonide inhalation susp 0.25 mg/2ml (Pulmicort)......................................................................91
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
294
2016 budesonide inhalation susp 0.5 mg/2ml (Pulmicort)......................................................................91 budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 91 budesonide nasal susp 32 mcg/act (Rhinocort aqua)............................................................................... 87 BUFFERIN -aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg.......................................................................... 135 BUFFERIN LOW DOSE -aspirin buffered (ca carb-mg carb-mg ox) tab 81 mg................................................. 135 BUFLOMEDIL HCL -buflomedil hcl (bulk) powder.......... 225 bumetanide inj 0.25 mg/ml............................................. 78 bumetanide tab 0.5 mg................................................... 78 bumetanide tab 1 mg...................................................... 78 bumetanide tab 2 mg...................................................... 78 BUMEX -bumetanide tab 0.5 mg...................................... 78 BUMEX -bumetanide tab 1 mg......................................... 78 BUMEX -bumetanide tab 2 mg......................................... 78 BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3 mg (base equiv)............................................................ 137 BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7 mg (base equiv)............................................................ 137 BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg (base equiv).................................................................. 137 BUPHENYL -sodium phenylbutyrate oral powder 3 gm/ teaspoonful...................................................................... 55 BUPHENYL -sodium phenylbutyrate tab 500 mg............. 55 BUPIVACAINE HCL -bupivacaine hcl powder................ 154 bupivacaine hcl inj 0.25% (Marcaine).......................... 154 bupivacaine hcl inj 0.5% (Marcaine)............................ 154 BUPIVACAINE HCL MONOHYDRA -bupivacaine hcl powder........................................................................... 154 bupivacaine hcl preservative free (pf) inj 0.25% (Marcaine).................................................................... 154 bupivacaine hcl preservative free (pf) inj 0.5% (Marcaine).................................................................... 154 bupivacaine hcl preservative free (pf) inj 0.75% (Marcaine w/o epi)...................................................... 154 bupivacaine 0.75% in dextrose inj 8.25% (Marcaine spinal)........................................................................... 154 bupivacaine inj 0.25% w/ epinephrine (Marcaine/ epinephrine)................................................................. 154 bupivacaine inj 0.5% w/ epinephrine (Marcaine/ epinephrine)................................................................. 154 bupivacaine inj 0.25% w/ epinephrine preservative free (pf) (Marcaine/epinephrine)............................... 154 bupivacaine inj 0.5% w/ epinephrine preservative free (pf) (Marcaine/epinephrine)....................................... 154 BUPIVILOG KIT -triamcinolone inj 40 mg/ml & bupivacaine hcl inj 0.5% kit............................................ 32 BUPRENEX -buprenorphine hcl inj 0.3 mg/ml (base equiv)............................................................................. 137 BUPRENORPHINE -buprenorphine td patch weekly 5 mcg/hr............................................................................ 137 BUPRENORPHINE -buprenorphine td patch weekly 7.5 mcg/hr............................................................................ 137
BUPRENORPHINE -buprenorphine td patch weekly 10 mcg/hr............................................................................ 137 BUPRENORPHINE -buprenorphine td patch weekly 15 mcg/hr............................................................................ 137 BUPRENORPHINE -buprenorphine td patch weekly 20 mcg/hr............................................................................ 137 BUPRENORPHINE HCL -buprenorphine hcl (bulk) powder........................................................................... 225 buprenorphine hcl inj 0.3 mg/ml (base equiv) (Buprenex)................................................................... 137 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)............................................................................ 137 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)............................................................................ 137 buprenorphine hcl sl tab 2 mg (base equiv).............. 137 buprenorphine hcl sl tab 8 mg (base equiv).............. 137 BUPROPION HCL -bupropion hcl (bulk) powder............225 bupropion hcl (smoking deterrent) tab er 12hr 150 mg (Zyban).......................................................................... 131 bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)...... 111 bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)...... 111 bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)...... 111 bupropion hcl tab er 24hr 150 mg (Wellbutrin xl)...... 111 bupropion hcl tab er 24hr 300 mg (Wellbutrin xl)...... 111 bupropion hcl tab 75 mg (Wellbutrin)......................... 111 bupropion hcl tab 100 mg (Wellbutrin)....................... 111 BUPROPION HYDROCHLORIDE -bupropion hcl (bulk) powder........................................................................... 225 BUSPIRONE HCL -buspirone hcl powder...................... 225 buspirone hcl tab 5 mg................................................. 109 buspirone hcl tab 7.5 mg.............................................. 109 buspirone hcl tab 10 mg............................................... 109 buspirone hcl tab 15 mg............................................... 109 buspirone hcl tab 30 mg............................................... 109 BUTALBITAL/ASPIRIN/CAFFEI -butalbital-aspirin-caffeine tab 50-325-40 mg......................................................... 135 butalbital-acetaminophen-caffeine cap 50-325-40 mg................................................................................. 135 butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet)....................................................................... 135 butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic)........................................................................... 135 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg.......................................................... 137 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg (Fioricet/codeine).......................... 137 butalbital-acetaminophen tab 50-300 mg....................135 butalbital-acetaminophen tab 50-325 mg....................135 butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)....................................................................... 135 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine #3)................................................... 137 BUTALBITAL -butalbital (bulk) powder............................ 225 BUTISOL SODIUM -butabarbital sodium tab 30 mg.......123
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
295
2016 CADUET -amlodipine besylate-atorvastatin calcium tab 5-80 mg........................................................................... 85 CADUET -amlodipine besylate-atorvastatin calcium tab 10-10 mg......................................................................... 85 CADUET -amlodipine besylate-atorvastatin calcium tab 10-20 mg......................................................................... 85 CADUET -amlodipine besylate-atorvastatin calcium tab 10-40 mg......................................................................... 85 CADUET -amlodipine besylate-atorvastatin calcium tab 10-80 mg......................................................................... 85 CAFERGOT -ergotamine w/ caffeine tab 1-100 mg....... 151 CAFFEINE/SODIUM BENZOATE -caffeine & sodium benzoate inj 125-125 mg/ml (500 mg/2ml).................. 126 CAFFEINE ANHYDROUS -caffeine powder................... 126 CAFFEINE CITRATED -caffeine citrate powder............. 126 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) (Cafcit).............................................................. 126 CALAMINE -calamine powder......................................... 200 CALAN SR -verapamil hcl tab er 120 mg......................... 64 CALAN SR -verapamil hcl tab er 180 mg......................... 64 CALAN SR -verapamil hcl tab er 240 mg......................... 64 CALAN -verapamil hcl tab 80 mg..................................... 64 CALAN -verapamil hcl tab 120 mg................................... 64 CALCIFOL -ca carb-folic acid-vit d-b6-b12-boron-mag wafer 1342-1.6 mg........................................................174 CALCIPOTRIENE -calcipotriene (bulk) powder.............. 225 calcipotriene cream 0.005% (Dovonex).......................200 CALCIPOTRIENE MONOHYDRATE -calcipotriene hydrate (bulk) powder................................................... 225 calcipotriene oint 0.005%..............................................200 calcipotriene soln 0.005% (50 mcg/ml)....................... 200 CALCIPOTRIOL -calcipotriene (bulk) powder................ 225 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin)...................................................................... 55 CALCITRIOL -calcitriol (bulk) powder............................. 225 CALCITRIOL -calcitriol oint 3 mcg/gm............................ 200 calcitriol cap 0.25 mcg (Rocaltrol)................................. 55 calcitriol cap 0.5 mcg (Rocaltrol)................................... 55 CALCITRIOL IN ALMOND OIL -calcitriol in almond oil (bulk) 1000 nanogram/ml............................................. 225 calcitriol oral soln 1 mcg/ml (Rocaltrol)........................55 CALCIUM ACETATE -calcium acetate (bulk) powder..... 225 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo)........................................................... 102 calcium acetate (phosphate binder) tab 667 mg (Eliphos)....................................................................... 102 CALCIUM ALGINATE -calcium alginate (bulk) powder........................................................................... 225 CALCIUM AMINO ACID CHELAT -calcium amino acid chelate (bulk) granules 30%.........................................226 CALCIUM ASCORBATE DIHYDRA -calcium ascorbate powder........................................................................... 170 CALCIUM CARBONATE -calcium carbonate powder........................................................................... 174
BUTORPHANOL TARTRATE -butorphanol tartrate (bulk) powder........................................................................... 225 BUTORPHANOL TARTRATE -butorphanol tartrate inj 1 mg/ml............................................................................. 137 butorphanol tartrate inj 2 mg/ml.................................. 137 butorphanol tartrate nasal soln 10 mg/ml.................. 137 BUTRANS -buprenorphine td patch weekly 5 mcg/ hr.................................................................................... 137 BUTRANS -buprenorphine td patch weekly 7.5 mcg/ hr.................................................................................... 138 BUTRANS -buprenorphine td patch weekly 10 mcg/ hr.................................................................................... 138 BUTRANS -buprenorphine td patch weekly 15 mcg/ hr.................................................................................... 138 BUTRANS -buprenorphine td patch weekly 20 mcg/ hr.................................................................................... 138 BUTTER FLAVOR -flavoring agent - liquid..................... 263 BUTTER RUM FLAVOR -flavoring agent - liquid............ 263 BUTTERSCOTCH FLAVOR -flavoring agent - liquid...... 263 BUTYL ALCOHOL -butyl alcohol (bulk) liquid.................225 BUTYLATED HYDROXYANISOLE -butylated hydroxyanisole powder................................................. 225 BUTYLATED HYDROXYTOLUENE -butylated hydroxytoluene granules.............................................. 225 BUTYLATED HYDROXYTOLUENE -butylated hydroxytoluene powder................................................ 225 BUTYLENE GLYCOL -butylene glycol (bulk) liquid........ 225 BYDUREON -exenatide for inj extended release susp 2 mg.................................................................................... 46 BYDUREON PEN -exenatide extended release for susp pen-injector 2 mg............................................................ 46 BYETTA -exenatide soln pen-injector 5 mcg/0.02ml........ 46 BYETTA -exenatide soln pen-injector 10 mcg/0.04ml...... 46 BYSTOLIC -nebivolol hcl tab 2.5 mg (base equivalent)....................................................................... 62 BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent).......62 BYSTOLIC -nebivolol hcl tab 10 mg (base equivalent)....................................................................... 62 BYSTOLIC -nebivolol hcl tab 20 mg (base equivalent)....................................................................... 62 BYVALSON -nebivolol-valsartan tab 5-80 mg.................. 70 C cabergoline tab 0.5 mg................................................... 55 CABOMETYX -cabozantinib s-malate tab 20 mg (base equivalent)....................................................................... 25 CABOMETYX -cabozantinib s-malate tab 40 mg (base equivalent)....................................................................... 25 CABOMETYX -cabozantinib s-malate tab 60 mg (base equivalent)....................................................................... 25 CADUET -amlodipine besylate-atorvastatin calcium tab 5-10 mg........................................................................... 84 CADUET -amlodipine besylate-atorvastatin calcium tab 5-20 mg........................................................................... 85 CADUET -amlodipine besylate-atorvastatin calcium tab 5-40 mg........................................................................... 85
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
296
2016 CAMPHOR -camphor granules....................................... 200 CAMPHOR OIL -bulk chemicals - liquid......................... 226 CANADIAN BALSAM -canadian balsam (bulk) liquid..... 226 CANASA -mesalamine suppos 1000 mg........................ 102 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg (Atacand hct).......................................................... 70 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg (Atacand hct).......................................................... 70 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg (Atacand hct).......................................................... 70 candesartan cilexetil tab 4 mg (Atacand)..................... 70 candesartan cilexetil tab 8 mg (Atacand)..................... 70 candesartan cilexetil tab 16 mg (Atacand)................... 70 candesartan cilexetil tab 32 mg (Atacand)................... 70 CANTHARIDIN -cantharidin powder............................... 200 CAPASTAT SULFATE -capreomycin sulfate for inj 1 gm...................................................................................... 8 capecitabine tab 150 mg (Xeloda)................................. 25 capecitabine tab 500 mg (Xeloda)................................. 25 CAPEX -fluocinolone acetonide shampoo 0.01%........... 200 CAPHOSOL -artificial saliva - solution............................ 195 CAPRELSA -vandetanib tab 100 mg................................ 25 CAPRELSA -vandetanib tab 300 mg................................ 25 CAPRYLIC/CAPRIC TRIGLYCER -caprylic capric triglyceride (bulk) liquid................................................. 226 CAPRYLIC ACID -caprylic acid (bulk) liquid................... 226 CAPSAICIN -capsaicin powder....................................... 200 CAPSAICIN PALMITATE -capsaicin palmitate (bulk) powder........................................................................... 226 CAPSICUM OLEORESIN -capsicum oleoresin liquid.............................................................................. 226 CAPSUBLEND-H -excipient filler powder....................... 263 CAPSUBLEND-P -excipient filler powder....................... 263 CAPSUBLEND-S -excipient filler powder....................... 263 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 25-15 mg.................................. 70 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 25-25 mg.................................. 71 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 50-15 mg.................................. 71 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 50-25 mg.................................. 71 CAPTOPRIL -captopril (bulk) powder............................. 226 captopril tab 12.5 mg...................................................... 70 captopril tab 25 mg......................................................... 70 captopril tab 50 mg......................................................... 70 captopril tab 100 mg....................................................... 70 CARAC -fluorouracil cream 0.5%.................................... 200 CARAFATE -sucralfate susp 1 gm/10ml........................... 97 CARAFATE -sucralfate tab 1 gm.......................................97 CARAMEL FLAVOR -flavoring agent - liquid.................. 263 CARBACHOL -carbachol (bulk) powder......................... 226 CARBAGLU -carglumic acid tab 200 mg.......................... 55 carbamazepine cap er 12hr 100 mg (Carbatrol)......... 157 carbamazepine cap er 12hr 200 mg (Carbatrol)......... 157
CALCIUM CARBONATE HEAVY -calcium carbonate powder........................................................................... 174 CALCIUM CARBONATE LIGHT -calcium carbonate powder........................................................................... 174 CALCIUM CHLORIDE ANHYDROU -calcium chloride anhydrous (bulk) powder.............................................. 226 CALCIUM CHLORIDE ANHYDROU -calcium chloride (dihydrate) granules...................................................... 174 CALCIUM CHLORIDE DIHYDRAT -calcium chloride (dihydrate) granules...................................................... 174 CALCIUM CHLORIDE DIHYDRAT -calcium chloride (dihydrate) powder........................................................ 174 CALCIUM CITRATE -calcium citrate tetrahydrate (bulk) powder........................................................................... 226 CALCIUM CITRATE TETRAHYDR -calcium citrate tetrahydrate (bulk) powder........................................... 226 CALCIUM DISODIUM VERSENAT -edetate calcium disodium inj 1 gm/5ml (200 mg/ml).............................. 218 CALCIUM-FOLIC ACID PLUS D -ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg........................... 174 CALCIUM FOLINATE -leucovorin calcium powder......... 226 CALCIUM GLUBIONATE -calcium glubionate (bulk) powder........................................................................... 226 CALCIUM GLUBIONATE MONOHY -calcium glubionate (bulk) powder................................................................ 226 CALCIUM GLUCONATE ANHYDRO -calcium gluconate powder........................................................................... 174 CALCIUM GLUCONATE MONOHYD -calcium gluconate powder........................................................................... 174 CALCIUM HYDROXIDE -calcium hydroxide powder......226 CALCIUM HYDROXYAPATITE -durapatite (hydroxyapatite) (bulk) powder..................................... 226 CALCIUM LACTATE PENTAHYDR -calcium lactate pentahydrate powder.................................................... 174 CALCIUM LEVULINATE DIHYDR -calcium levulinate dihydrate (bulk) powder................................................ 226 CALCIUM PANTOTHENATE -calcium pantothenate powder........................................................................... 170 CALCIUM PHOSPHATE DIBASIC -calcium phosphate, dibasic powder.............................................................. 174 CALCIUM PHOSPHATE TRIBASI -calcium phosphate, tribasic powder.............................................................. 174 CALCIUM PYRUVATE -calcium pyruvate (bulk) powder........................................................................... 226 CALCIUM SACCHARIN -saccharin calcium (bulk) crystals.......................................................................... 226 CALCIUM SULFATE ANHYDROUS -calcium sulfate powder (plaster of paris).............................................. 226 CALCIUM SULFATE HEMIHYDRA -calcium sulfate powder (plaster of paris).............................................. 226 CALCIUM THIOGLYCOLATE TRI -calcium thioglycolate (bulk) powder................................................................ 226 CAMBIA -diclofenac potassium packet 50 mg................ 151 CAMINO PRO 15PE -nutritional supplement liquid........ 178 CAMPHOR -camphor crystals......................................... 200
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
297
2016 carbamazepine cap er 12hr 300 mg (Carbatrol)......... 157 CARBAMAZEPINE -carbamazepine powder.................. 157 carbamazepine chew tab 100 mg................................ 157 carbamazepine susp 100 mg/5ml (Tegretol)............... 157 carbamazepine tab er 12hr 100 mg (Tegretol-xr)....... 157 carbamazepine tab er 12hr 200 mg (Tegretol-xr)....... 157 carbamazepine tab er 12hr 400 mg (Tegretol-xr)....... 157 carbamazepine tab 200 mg (Tegretol)......................... 157 CARBAMIDE PEROXIDE -carbamide peroxide (bulk) powder........................................................................... 226 CARBAPHEN 12 PED -phenyleph-chlorphencarbetapentane susp 2.5-1.25-7.5 mg/ml...................... 88 CARBAPHEN 12 -phenyleph-chlorphen-carbetapentane liqd 10-4-27.5 mg/5ml..................................................... 88 CARBATROL -carbamazepine cap er 12hr 100 mg....... 157 CARBATROL -carbamazepine cap er 12hr 200 mg....... 157 CARBATROL -carbamazepine cap er 12hr 300 mg....... 157 CARBAZOCHROME -carbazochrome (bulk) powder..... 226 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg................................ 164 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg.............................. 164 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg................................. 164 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg............................ 164 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg.............................. 164 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg................................. 164 carbidopa & levodopa orally disintegrating tab 10-100 mg................................................................................. 164 carbidopa & levodopa orally disintegrating tab 25-100 mg................................................................................. 164 carbidopa & levodopa orally disintegrating tab 25-250 mg................................................................................. 164 carbidopa & levodopa tab er 25-100 mg (Sinemet cr).................................................................................. 164 carbidopa & levodopa tab er 50-200 mg (Sinemet cr).................................................................................. 164 carbidopa & levodopa tab 10-100 mg (Sinemet)........ 164 carbidopa & levodopa tab 25-100 mg (Sinemet)........ 164 carbidopa & levodopa tab 25-250 mg (Sinemet)........ 164 CARBIDOPA ANHYDROUS -carbidopa powder............ 226 CARBIDOPA -carbidopa powder..................................... 226 carbidopa tab 25 mg (Lodosyn)................................... 164 CARBIMAZOLE -carbimazole (bulk) powder.................. 226 carbinoxamine maleate soln 4 mg/5ml......................... 86 carbinoxamine maleate tab 4 mg.................................. 86 CARBOCAINE -mepivacaine hcl inj 1%......................... 154 CARBOCAINE -mepivacaine hcl inj 1.5%...................... 154 CARBOCAINE -mepivacaine hcl inj 2%......................... 154 CARBOCAINE -mepivacaine hcl preservative free (pf) inj 1%.................................................................................. 154
CARBOCAINE -mepivacaine hcl preservative free (pf) inj 2%.................................................................................. 154 CARBOGEL 940 -carbomer gel base............................. 263 CARBOHOL 940 -carbomer gel base............................. 263 CARBOMER 940 -carbomer powder.............................. 227 CARBOMER GEL AQUEOUS -carbomer gel base........ 263 CARBOMER GEL HYDROALCOHOL -carbomer gel base............................................................................... 263 CARBOMER 934P -carbomer powder............................ 226 CARBOMER 934P RESIN -carbomer powder................227 carbonyl iron susp 15 mg/1.25ml (elemental iron)............................................................................... 180 CARBOPOL 940 -carbomer powder............................... 227 CARBOPOL 940 NF -carbomer powder......................... 227 CARBOXYMETHYLCELLULOSE SO carboxymethylcellulose sodium granules.................... 227 CARBOXYMETHYLCELLULOSE SO carboxymethylcellulose sodium powder...................... 227 cardioplegic soln (Plegisol)............................................ 85 CARDIOVID PLUS -dha-epa-vit b6-b12-folic acid cap 240-360-20-0.5-0.8 mg................................................. 177 CARDIZEM CD -diltiazem hcl coated beads cap er 24hr 120 mg............................................................................ 64 CARDIZEM CD -diltiazem hcl coated beads cap er 24hr 180 mg............................................................................ 64 CARDIZEM CD -diltiazem hcl coated beads cap er 24hr 240 mg............................................................................ 64 CARDIZEM CD -diltiazem hcl coated beads cap er 24hr 360 mg............................................................................ 64 CARDIZEM -diltiazem hcl tab 30 mg................................ 64 CARDIZEM -diltiazem hcl tab 60 mg................................ 64 CARDIZEM -diltiazem hcl tab 120 mg.............................. 64 CARDIZEM LA -diltiazem hcl coated beads tab er 24hr 120 mg............................................................................ 64 CARDIZEM LA -diltiazem hcl coated beads tab er 24hr 180 mg............................................................................ 64 CARDIZEM LA -diltiazem hcl coated beads tab er 24hr 240 mg............................................................................ 65 CARDIZEM LA -diltiazem hcl coated beads tab er 24hr 300 mg............................................................................ 65 CARDIZEM LA -diltiazem hcl coated beads tab er 24hr 360 mg............................................................................ 65 CARDIZEM LA -diltiazem hcl coated beads tab er 24hr 420 mg............................................................................ 65 CARDURA -doxazosin mesylate tab 1 mg....................... 71 CARDURA -doxazosin mesylate tab 2 mg....................... 71 CARDURA -doxazosin mesylate tab 4 mg....................... 71 CARDURA -doxazosin mesylate tab 8 mg....................... 71 CARDURA XL -doxazosin mesylate tab er 24 hr 4 mg (base equiv).................................................................. 108 CARDURA XL -doxazosin mesylate tab er 24 hr 8 mg (base equiv).................................................................. 108 CARISOPRODOL -carisoprodol powder......................... 168 carisoprodol tab 250 mg (Soma)................................. 168 carisoprodol tab 350 mg (Soma)................................. 168
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
298
2016 carisoprodol w/ aspirin & codeine tab 200-325-16 mg................................................................................. 168 carisoprodol w/ aspirin tab 200-325 mg......................168 CARNAUBA WAX -carnauba wax (bulk) flakes.............. 227 CARNITINE (L) -levocarnitine (bulk) powder.................. 227 CARNITOR -levocarnitine oral soln 1 gm/10ml (10%)...... 55 CARNITOR -levocarnitine tab 330 mg.............................. 55 CARNITOR SF -levocarnitine oral soln 1 gm/10ml (10%)............................................................................... 55 CARNOSINE L -carnosine (bulk) powder....................... 227 CARRAGEENAN -carrageenan (bulk) powder............... 263 CARRASYN HYDROGEL WOUND D -wound dressings gel.................................................................................. 200 carteolol hcl ophth soln 1%......................................... 189 CARTICEL -autologous cultured chondrocytes for implantation................................................................... 168 carvedilol tab 3.125 mg (Coreg)..................................... 62 carvedilol tab 6.25 mg (Coreg)....................................... 62 carvedilol tab 12.5 mg (Coreg)....................................... 62 carvedilol tab 25 mg (Coreg).......................................... 62 CASCARA SAGRADA -cascara sagrada fl ext 1 gm/ ml..................................................................................... 95 CASODEX -bicalutamide tab 50 mg................................. 25 CASTOR OIL -castor oil.................................................. 227 CATAPRES -clonidine hcl tab 0.1 mg............................... 71 CATAPRES -clonidine hcl tab 0.2 mg............................... 71 CATAPRES -clonidine hcl tab 0.3 mg............................... 71 CATAPRES-TTS-1 -clonidine hcl td patch weekly 0.1 mg/24hr........................................................................... 71 CATAPRES-TTS-2 -clonidine hcl td patch weekly 0.2 mg/24hr........................................................................... 71 CATAPRES-TTS-3 -clonidine hcl td patch weekly 0.3 mg/24hr........................................................................... 71 CATHFLO ACTIVASE -alteplase for inj 2 mg................. 188 CAYSTON -aztreonam lysine for inhal soln 75 mg (base equivalent)....................................................................... 17 C10-C30 ALKYL ACRYLATE CR -pharmaceutical excipients (bulk) powder...............................................265 CEDAR LEAF OIL -cedar leaf oil.................................... 227 CEDAX -ceftibuten cap 400 mg.......................................... 2 CEDAX -ceftibuten for susp 180 mg/5ml............................ 2 cefaclor cap 250 mg.......................................................... 3 cefaclor cap 500 mg.......................................................... 3 CEFACLOR -cefaclor for susp 125 mg/5ml........................ 3 CEFACLOR -cefaclor for susp 250 mg/5ml........................ 3 CEFACLOR -cefaclor for susp 375 mg/5ml........................ 3 CEFACLOR ER -cefaclor monohydrate tab er 12hr 500 mg...................................................................................... 3 cefadroxil cap 500 mg....................................................... 3 cefadroxil for susp 250 mg/5ml....................................... 3 cefadroxil for susp 500 mg/5ml....................................... 3 cefadroxil tab 1 gm............................................................ 3 CEFAZOLIN SODIUM -cefazolin sodium (bulk) for inj 100 gm...................................................................................... 3
CEFAZOLIN SODIUM -cefazolin sodium (bulk) for inj 300 gm...................................................................................... 3 CEFAZOLIN SODIUM -cefazolin sodium for inj 20 gm....... 3 cefazolin sodium for inj 1 gm.......................................... 3 cefazolin sodium for inj 10 gm........................................ 3 cefazolin sodium for inj 500 mg...................................... 3 cefdinir cap 300 mg........................................................... 3 cefdinir for susp 125 mg/5ml........................................... 3 cefdinir for susp 250 mg/5ml........................................... 3 CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg (base equivalent).............................................................. 3 CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg (base equivalent).............................................................. 3 cefepime hcl for inj 1 gm (Maxipime).............................. 3 cefepime hcl for inj 2 gm (Maxipime).............................. 3 cefixime for susp 100 mg/5ml (Suprax).......................... 3 cefixime for susp 200 mg/5ml (Suprax).......................... 3 CEFOTAN -cefotetan disodium for inj 1 gm........................ 3 CEFOTAN -cefotetan disodium for inj 2 gm........................ 3 CEFOTAXIME SODIUM -cefotaxime sodium for inj 1 gm...................................................................................... 3 CEFOTAXIME SODIUM -cefotaxime sodium for inj 2 gm...................................................................................... 3 CEFOTAXIME SODIUM -cefotaxime sodium for inj 10 gm...................................................................................... 3 CEFOTAXIME SODIUM -cefotaxime sodium for inj 500 mg...................................................................................... 3 CEFOTETAN -cefotetan disodium for inj 10 gm................. 3 cefotetan disodium for inj 1 gm (Cefotan)...................... 3 cefotetan disodium for inj 2 gm (Cefotan)...................... 3 cefoxitin sodium for inj 10 gm......................................... 3 cefpodoxime proxetil for susp 50 mg/5ml...................... 3 cefpodoxime proxetil for susp 100 mg/5ml.................... 3 cefpodoxime proxetil tab 100 mg.................................... 3 cefpodoxime proxetil tab 200 mg.................................... 4 cefprozil for susp 125 mg/5ml..........................................4 cefprozil for susp 250 mg/5ml..........................................4 cefprozil tab 250 mg.......................................................... 4 cefprozil tab 500 mg.......................................................... 4 CEFTAZIDIME/SODIUM CARBON -ceftazidime with sodium carbonate (bulk) powder.................................. 227 CEFTAZIDIME -ceftazidime (bulk) powder..................... 227 ceftazidime for inj 1 gm (Fortaz)...................................... 4 ceftazidime for inj 2 gm (Fortaz)...................................... 4 ceftazidime for inj 6 gm (Fortaz)...................................... 4 CEFTIBUTEN -ceftibuten cap 400 mg................................ 4 CEFTIBUTEN -ceftibuten for susp 180 mg/5ml.................. 4 CEFTIN -cefuroxime axetil for susp 125 mg/5ml................ 4 CEFTIN -cefuroxime axetil for susp 250 mg/5ml................ 4 CEFTRIAXONE SODIUM -ceftriaxone sodium (bulk) for inj 100 gm......................................................................... 4 CEFTRIAXONE SODIUM -ceftriaxone sodium (bulk) powder........................................................................... 227 ceftriaxone sodium for inj 2 gm.......................................4 ceftriaxone sodium for inj 1 gm (Rocephin)................... 4
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
299
2016 ceftriaxone sodium for inj 250 mg...................................4 ceftriaxone sodium for inj 500 mg (Rocephin)............... 4 cefuroxime axetil tab 250 mg (Ceftin)............................. 4 cefuroxime axetil tab 500 mg (Ceftin)............................. 4 cefuroxime sodium for inj 1.5 gm (Zinacef)................... 4 cefuroxime sodium for inj 7.5 gm (Zinacef)................... 4 cefuroxime sodium for inj 750 mg (Zinacef).................. 4 CELA BASE -cream base............................................... 263 CELACYN POST-PROCEDURE PA -wound dressings kit................................................................................... 201 celecoxib cap 50 mg (Celebrex).................................. 147 celecoxib cap 100 mg (Celebrex)................................ 147 celecoxib cap 200 mg (Celebrex)................................ 147 celecoxib cap 400 mg (Celebrex)................................ 147 CELECOXIB -celecoxib (bulk) powder............................227 CELESTONE-SOLUSPAN -betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml.................. 32 CELEXA -citalopram hydrobromide tab 10 mg (base equiv)............................................................................. 111 CELEXA -citalopram hydrobromide tab 20 mg (base equiv)............................................................................. 111 CELEXA -citalopram hydrobromide tab 40 mg (base equiv)............................................................................. 111 CELLCEPT -mycophenolate mofetil cap 250 mg........... 275 CELLCEPT -mycophenolate mofetil for oral susp 200 mg/ ml................................................................................... 275 CELLCEPT -mycophenolate mofetil tab 500 mg............ 275 CELLULASE -cellulase (bulk) powder............................ 227 CELLULOSE/CMC NA MICROCRY -cellulose carmellose sodium (bulk) powder................................................... 227 CELLULOSE MICROCRYSTALLIN -cellulose (bulk) crystals.......................................................................... 227 CELLULOSE MICROCRYSTALLIN -cellulose (bulk) powder........................................................................... 227 CELLULOSE PARTIALLY DEPOL -cellulose (bulk) powder........................................................................... 227 CELONTIN -methsuximide cap 300 mg.......................... 157 CEM-UREA -urea soln 45%............................................ 201 CENFOL -folic acid-vitamin b6-vitamin b12 tab 2.3-24.5-2 mg.................................................................................. 180 CENTANY -mupirocin oint 2%.........................................201 CENTRATEX -ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg.................................................... 180 cephalexin cap 250 mg (Keflex)....................................... 4 cephalexin cap 500 mg (Keflex)....................................... 4 cephalexin cap 750 mg (Keflex)....................................... 4 CEPHALEXIN -cephalexin tab 250 mg............................... 4 CEPHALEXIN -cephalexin tab 500 mg............................... 4 cephalexin for susp 125 mg/5ml...................................... 4 cephalexin for susp 250 mg/5ml...................................... 4 CERACADE -dermatological products misc emulsion........................................................................ 201 CERAPHYL SLK -isodecyl neopentanoate (bulk) liquid.............................................................................. 227
CERDELGA -eliglustat tartrate cap 84 mg (base equivalent)..................................................................... 180 CEREBYX -fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv).......................................................... 158 CEREBYX -fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv).......................................................... 158 CERESIN WAX -ceresin wax (bulk) flakes..................... 227 CERVARIX -human papillomavirus (hpv) bival (type 16, 18) recmb vac inj............................................................ 19 CERVIDIL -dinoprostone vaginal inserts 10 mg............... 55 CESAMET -nabilone cap 1 mg....................................... 100 CESIUM CHLORIDE -cesium chloride (bulk) powder........................................................................... 227 CETEARYL ALCOHOL/CETEARET -cetearyl alcoholceteareth 20 (bulk) powder.......................................... 227 CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base equivalent)..................................................................... 194 CETYL ALCOHOL -cetyl alcohol flakes.......................... 263 CETYL ALCOHOL -cetyl alcohol powder....................... 264 CETYLCIDE-G -glutaral conc.......................................... 218 CETYL ESTERS WAX -spermaceti wax (bulk)............... 227 CETYLEV -acetylcysteine effervescent tab 2.5 gm........ 218 CETYLEV -acetylcysteine effervescent tab 500 mg....... 218 CETYL MYRISTOLEATE -cetyl myristoleate (bulk) oil 40%................................................................................227 CETYL MYRISTOLEATE -cetyl myristoleate (bulk) powder........................................................................... 227 CETYL MYRISTOLEATE -cetyl myristoleate (bulk) powder 20%.................................................................. 227 CETYL MYRISTOLEATE -cetyl myristoleate (bulk) wax 40%................................................................................227 CETYLPYRIDINIUM CHLORIDE -cetylpyridinium chloride crystals.......................................................................... 227 cevimeline hcl cap 30 mg (Evoxac)............................. 195 CHANTIX CONTINUING MONTH -varenicline tartrate tab 1 mg (base equiv)........................................................ 131 CHANTIX STARTING MONTH PA -varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack............................... 131 CHANTIX -varenicline tartrate tab 0.5 mg (base equiv)............................................................................. 131 CHANTIX -varenicline tartrate tab 1 mg (base equiv)............................................................................. 131 CHARCOAL ACTIVATED -charcoal activated powder........................................................................... 218 CHEESE-ADE FLAVOR -flavoring agent - powder......... 264 CHEESECAKE FLAVOR -flavoring agent - liquid........... 264 CHEMET -succimer cap 100 mg.................................... 218 CHEMSIL K-51 -gel base - gel....................................... 264 CHEMSIL K-12 -paste base - paste............................... 264 CHENODAL -chenodiol tab 250 mg............................... 102 CHERRY-ADE FLAVOR -flavoring agent - powder........ 264 CHERRY FLAVOR -flavoring agent - liquid.................... 264 CHERRY SYRUP -cherry syrup...................................... 264 CHEW-HESIVE -gelatin ointment base.......................... 264
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
300
2016 chlorpromazine hcl tab 100 mg................................... 117 chlorpromazine hcl tab 200 mg................................... 117 CHLORPROPAMIDE -chlorpropamide tab 100 mg.......... 46 CHLORPROPAMIDE -chlorpropamide tab 250 mg.......... 46 CHLORTETRACYCLINE HCL -chlortetracycline hcl powder............................................................................... 6 chlorthalidone tab 25 mg................................................ 78 chlorthalidone tab 50 mg................................................ 79 chlorzoxazone tab 500 mg (Parafon forte dsc).......... 168 CHOCOLATE FLAVOR -flavoring agent - liquid............. 264 CHOCOLATE FLAVOR -flavoring agent - powder.......... 264 CHOCOLATE HAZELNUT FLAVOR -flavoring agent liquid.............................................................................. 264 CHOLBAM -cholic acid cap 50 mg................................. 102 CHOLBAM -cholic acid cap 250 mg............................... 102 cholecalciferol cap 400 unit......................................... 170 cholecalciferol chew tab 400 unit................................ 170 CHOLECALCIFEROL -cholecalciferol (bulk) powder..... 228 CHOLECALCIFEROL -cholecalciferol crystals............... 228 cholecalciferol drops 400 unit/0.03ml (per drop)....... 170 cholecalciferol oral liquid 400 unit/ml......................... 170 cholecalciferol tab 400 unit.......................................... 170 CHOLESTEROL -cholesterol flakes................................228 CHOLESTEROL -cholesterol powder............................. 228 CHOLESTYRAMINE -cholestyramine (bulk) powder..... 228 cholestyramine light powder 4 gm/dose (Questran light)................................................................................ 81 cholestyramine light powder packets 4 gm................. 81 cholestyramine powder 4 gm/dose (Questran)............ 81 cholestyramine powder packets 4 gm (Questran)....... 81 CHOLESTYRAMINE RESIN -cholestyramine (bulk) powder........................................................................... 228 choline & magnesium salicylates liq 500 mg/5ml...... 135 CHOLINE BITARTRATE -choline bitartrate powder........177 CHOLINE CHLORIDE -choline chloride (bulk) powder........................................................................... 228 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix).............................................................. 81 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix).............................................................. 81 CHOLINE MAGNESIUM TRISALI -choline magnesium trisalicylate (bulk) powder............................................. 228 CHONDROITIN SULFATE SODIU -chondroitin sulfate sodium (bulk) powder................................................... 228 CHORIONIC GONADOTROPIN -chorionic gonadotropin (bulk) powder................................................................ 228 CHORIONIC GONADOTROPIN -chorionic gonadotropin for inj 10000 unit............................................................. 56 CHROMIUM CHLORIDE -chromic chloride (bulk) powder........................................................................... 228 CHROMIUM CHLORIDE HEXAHYD -chromic chloride (bulk) crystals................................................................ 228 CHROMIUM PICOLINATE -chromium picolinate (bulk) powder........................................................................... 228
CHICKEN BROTH FLAVOR SPRA -flavoring agent powder........................................................................... 264 CHICKEN FLAVOR -flavoring agent - powder................ 264 CHICKEN FLAVOR OIL SOLUBL -flavoring agent liquid.............................................................................. 264 CHICKEN FLAVOR WATER MISC -flavoring agent liquid.............................................................................. 264 CHICKEN PROTEIN -chicken protein (bulk) powder......227 CHLORAL HYDRATE -chloral hydrate crystals.............. 123 CHLORAMBUCIL -chlorambucil (bulk) powder.............. 227 CHLORAMPHENICOL -chloramphenicol powder............ 17 CHLORAMPHENICOL PALMITATE -chloramphenicol palmitate (bulk) powder................................................ 228 CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg........................................... 131 CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg............................................ 131 chlordiazepoxide hcl cap 5 mg.................................... 109 chlordiazepoxide hcl cap 10 mg.................................. 109 chlordiazepoxide hcl cap 25 mg.................................. 110 CHLORHEXIDINE DIACETATE H -chlorhexidine acetate (bulk) powder................................................................ 228 CHLORHEXIDINE GLUCONATE -chlorhexidine gluconate soln 20%...................................................... 218 CHLORHEXIDINE GLUCONATE -chlorhexidine gluconate solution......................................................... 228 chlorhexidine gluconate soln 0.12% (Peridex)...........195 CHLOROACETIC ACID -monochloroacetic acid powder........................................................................... 201 CHLOROBUTANOL ANHYDROUS -chlorobutanol powder........................................................................... 264 CHLOROBUTANOL -chlorobutanol powder................... 264 CHLOROFORM -chloroform soln.................................... 228 CHLOROPHYLLIN SODIUM COPP -chlorophyllin copper complex sodium (bulk) powder.................................... 228 CHLOROQUINE PHOSPHATE -chloroquine phosphate powder............................................................................. 16 CHLOROQUINE PHOSPHATE -chloroquine phosphate tab 250 mg...................................................................... 16 chloroquine phosphate tab 500 mg (Aralen)................ 16 CHLOROTHIAZIDE -chlorothiazide tab 250 mg............... 78 chlorothiazide tab 500 mg.............................................. 78 CHLOROXINE -chloroxine (bulk) powder....................... 228 CHLOROXYLENOL -chloroxylenol (bulk) powder.......... 228 CHLORPHENIRAMINE MALEATE -chlorpheniramine maleate powder.............................................................. 86 CHLORPROMAZINE HCL -chlorpromazine hcl inj 25 mg/ ml................................................................................... 117 CHLORPROMAZINE HCL -chlorpromazine hcl inj 50 mg/2ml........................................................................... 117 CHLORPROMAZINE HCL -chlorpromazine hcl powder........................................................................... 117 chlorpromazine hcl tab 10 mg..................................... 117 chlorpromazine hcl tab 25 mg..................................... 117 chlorpromazine hcl tab 50 mg..................................... 117
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
301
2016 ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq) (Cipro xr)........................................................ 7 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro)........................................................... 7 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro)........................................................... 7 CIPROFLOXACIN HCL -ciprofloxacin hcl (bulk) powder........................................................................... 228 CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg (base equiv)...................................................................... 7 CIPROFLOXACIN HCL MONOHYD -ciprofloxacin hcl (bulk) powder................................................................ 228 ciprofloxacin hcl ophth soln 0.3% (Ciloxan).............. 189 ciprofloxacin hcl tab 750 mg (base equiv)..................... 7 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 7 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 7 CIPRO HC -ciprofloxacin-hydrocortisone otic susp 0.2-1%........................................................................... 194 CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq)............................................................ 7 CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq).....................................................................7 CISAPRIDE MONOHYDRATE -cisapride (bulk) powder........................................................................... 229 citalopram hydrobromide oral soln 10 mg/5ml.......... 111 citalopram hydrobromide tab 10 mg (base equiv) (Celexa).........................................................................111 citalopram hydrobromide tab 20 mg (base equiv) (Celexa).........................................................................111 citalopram hydrobromide tab 40 mg (base equiv) (Celexa).........................................................................111 CITANEST FORTE DENTAL -prilocaine inj 4% w/ epinephrine 1:200000................................................... 154 CITANEST PLAIN DENTAL -prilocaine hcl inj 4%.......... 154 CITRIC ACID ANHYDROUS -citric acid granules.......... 229 CITRIC ACID ANHYDROUS -citric acid powder............ 229 CITRIC ACID -citric acid powder.................................... 229 CITRIC ACID MONOHYDRATE -citric acid monohydrate granules......................................................................... 229 CITRIC ACID MONOHYDRATE -citric acid monohydrate powder........................................................................... 229 CITRONELLA OIL -citronella oil...................................... 229 CITRULLINE(L) -citrulline (bulk) powder.........................229 CITRUS BERGAMOT -citrus bergamot oral powder 250 mg/0.25 gm................................................................... 220 CITRUS BIOFLAVONOIDS -citrus bioflavonoids (bulk) powder 13%.................................................................. 229 CLARITHROMYCIN -clarithromycin (bulk) powder........ 229 clarithromycin for susp 125 mg/5ml............................... 5 clarithromycin for susp 250 mg/5ml (Biaxin)................. 5 clarithromycin tab er 24hr 500 mg.................................. 5 clarithromycin tab 250 mg (Biaxin)................................. 5 clarithromycin tab 500 mg (Biaxin)................................. 5 CLEMASTINE FUMARATE -clemastine fumarate powder............................................................................. 86
CHROMIUM POLYNICOTINATE -chromium polynicotinate (bulk) powder.........................................228 CHROMIUM POTASSIUM SULFAT -chromium potassium sulfate dodecahydrate (bulk) crystals.......................... 228 CHRYSADERM DAY -cream base..................................264 CHRYSADERM NIGHT -cream base............................. 264 CHRYSIN -chrysin powder.............................................. 228 CHYMOTRYPSIN ALPHA -chymotrypsin powder.......... 275 CIALIS -tadalafil tab 2.5 mg......................................... 85,86 CIALIS -tadalafil tab 5 mg............................................ 85,86 ciclopirox gel 0.77%...................................................... 201 CICLOPIROX OLAMINE -ciclopirox olamine powder..... 201 ciclopirox olamine cream 0.77% (base equiv)............201 ciclopirox olamine susp 0.77% (base equiv).............. 201 ciclopirox shampoo 1% (Loprox shampoo)............... 201 ciclopirox solution 8% (Penlac Nail Lacquer)............ 201 CIDOFOVIR ANHYDROUS -cidofovir (bulk) powder......228 CIDOFOVIR DIHYDRATE -cidofovir (bulk) powder........ 228 CIFEREX -folic acid-cholecalciferol cap 1 mg-3775 unit................................................................................. 180 CIFRAZOL -folic acid-cholecalciferol cap 1 mg-3775 unit................................................................................. 180 cilostazol tab 50 mg (Pletal)......................................... 188 cilostazol tab 100 mg (Pletal)....................................... 188 CILOXAN -ciprofloxacin hcl ophth oint 0.3%.................. 189 CILOXAN -ciprofloxacin hcl ophth soln 0.3%..................189 CIMETIDINE -cimetidine powder...................................... 97 cimetidine hcl soln 300 mg/5ml..................................... 97 cimetidine tab 200 mg..................................................... 97 cimetidine tab 300 mg..................................................... 97 cimetidine tab 400 mg..................................................... 97 cimetidine tab 800 mg..................................................... 97 CIMZIA -certolizumab pegol for inj kit 2 x 200 mg.......... 102 CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml.......... 102 CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200 mg/ml............................................................................. 102 C INDICUM EXTRACT/C SINES -c indicum & c sinesis leaf extract liquid...........................................................225 CINNAMON BARK CASSIA -cinnamon bark (bulk) powder........................................................................... 228 CINNAMON FLAVOR -flavoring agent - oil.....................264 CIPRO -ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml).......................................................................... 7 CIPRO -ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml).......................................................................... 7 CIPRO -ciprofloxacin hcl tab 250 mg (base equiv)............. 7 CIPRO -ciprofloxacin hcl tab 500 mg (base equiv)............. 7 CIPRODEX -ciprofloxacin-dexamethasone otic susp 0.3-0.1%........................................................................ 194 CIPROFLOXACIN -ciprofloxacin (bulk) powder.............. 228 CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base equivalent)..................................................................... 194 ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq) (Cipro xr)................................................... 7
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
302
2016 clindamycin phosphate inj 300 mg/2ml (Cleocin phosphate)..................................................................... 17 clindamycin phosphate inj 600 mg/4ml (Cleocin phosphate)..................................................................... 17 clindamycin phosphate inj 900 mg/6ml (Cleocin phosphate)..................................................................... 17 clindamycin phosphate lotion 1% (Cleocin-t)............ 201 clindamycin phosphate soln 1% (Cleocin-t)............... 201 clindamycin phosphate swab 1% (Cleocin-t)............. 201 clindamycin phosphate-tretinoin gel 1.2-0.025% (Ziana)........................................................................... 201 clindamycin phosphate vaginal cream 2% (Cleocin)....................................................................... 107 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)............................................................... 201 CLINDESSE -clindamycin phosphate (one dose) vaginal cream 2%...................................................................... 107 CLINOIN -clindamycin-tretinoin-cholesty crm 1.25-0.025-1% (cmp kit)............................................... 201 CLIN SINGLE USE KIT -clindamycin phosphate inj 300 mg/2ml kit........................................................................ 17 CLIOQUINOL -clioquinol powder.................................... 201 CLOBETASOL PROPIONATE -clobetasol propionate powder........................................................................... 201 CLOBETASOL 17 PROPIONATE -clobetasol propionate powder........................................................................... 202 clobetasol propionate cream 0.05% (Temovate)........ 201 clobetasol propionate emollient base cream 0.05% (Temovate e)................................................................ 201 clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 201 clobetasol propionate foam 0.05% (Olux).................. 201 clobetasol propionate gel 0.05% (Temovate)............. 201 clobetasol propionate lotion 0.05% (Clobex)............. 201 CLOBETASOL PROPIONATE MIC -clobetasol propionate powder........................................................................... 201 clobetasol propionate oint 0.05% (Temovate)............ 201 clobetasol propionate shampoo 0.05% (Clobex)....... 201 clobetasol propionate soln 0.05% (Temovate)........... 201 clobetasol propionate spray 0.05% (Clobex)............. 202 CLOBEX -clobetasol propionate lotion 0.05%................ 202 CLOBEX -clobetasol propionate shampoo 0.05%.......... 202 CLOBEX -clobetasol propionate spray 0.05%................ 202 CLOCORTOLONE PIVALATE -clocortolone pivalate cream 0.1%................................................................... 202 CLOCORTOLONE PIVALATE PUM -clocortolone pivalate cream 0.1%................................................................... 202 CLODERM -clocortolone pivalate cream 0.1%............... 202 CLODERM PUMP -clocortolone pivalate cream 0.1%...............................................................................202 CLOFAZIMINE -clofazimine (bulk) powder..................... 229 clomipramine hcl cap 25 mg (Anafranil)..................... 111 clomipramine hcl cap 50 mg (Anafranil)..................... 111 clomipramine hcl cap 75 mg (Anafranil)..................... 111
CLEMASTINE FUMARATE -clemastine fumarate tab 2.68 mg.................................................................................... 86 CLEMIZOLE HCL -clemizole hcl (bulk) powder.............. 229 CLEOCIN -clindamycin hcl cap 75 mg............................. 17 CLEOCIN -clindamycin hcl cap 150 mg........................... 17 CLEOCIN -clindamycin hcl cap 300 mg........................... 17 CLEOCIN -clindamycin phosphate vaginal cream 2%.................................................................................. 106 CLEOCIN -clindamycin phosphate vaginal suppos 100 mg.................................................................................. 106 CLEOCIN PEDIATRIC GRANULE -clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)...............................17 CLEOCIN PHOSPHATE -clindamycin phosphate inj 9 gm/60ml........................................................................... 17 CLEOCIN PHOSPHATE -clindamycin phosphate inj 300 mg/2ml............................................................................. 17 CLEOCIN PHOSPHATE -clindamycin phosphate inj 600 mg/4ml............................................................................. 17 CLEOCIN PHOSPHATE -clindamycin phosphate inj 900 mg/6ml............................................................................. 17 CLEOCIN-T -clindamycin phosphate gel 1%.................. 201 CLEOCIN-T -clindamycin phosphate lotion 1%.............. 201 CLEOCIN-T -clindamycin phosphate soln 1%................ 201 CLEOCIN-T -clindamycin phosphate swab 1%.............. 201 clidinium & chlordiazepoxide cap 2.5-5 mg (Librax)........................................................................... 97 CLIDINIUM BROMIDE -clidinium bromide (bulk) powder........................................................................... 229 CLIMARA -estradiol td patch weekly 0.025 mg/24hr........ 39 CLIMARA -estradiol td patch weekly 0.05 mg/24hr.......... 39 CLIMARA -estradiol td patch weekly 0.06 mg/24hr.......... 39 CLIMARA -estradiol td patch weekly 0.075 mg/24hr........ 39 CLIMARA -estradiol td patch weekly 0.1 mg/24hr............ 39 CLIMARA -estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)...............................................................39 CLIMARA PRO -estradiol-levonorgestrel td patch weekly 0.045-0.015 mg/day........................................................ 39 CLINDAGEL -clindamycin phosphate gel 1%................. 201 clindamycin hcl cap 75 mg (Cleocin)............................ 17 clindamycin hcl cap 150 mg (Cleocin).......................... 17 clindamycin hcl cap 300 mg (Cleocin).......................... 17 CLINDAMYCIN HCL -clindamycin hcl (bulk) powder......229 CLINDAMYCIN HCL MONOHYDRA -clindamycin hcl (bulk) powder................................................................ 229 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr)........................................17 clindamycin phosphate-benzoyl peroxide gel 1-5% (Benzaclin)................................................................... 201 CLINDAMYCIN PHOSPHATE -clindamycin phosphate (bulk) powder................................................................ 229 clindamycin phosphate foam 1% (Evoclin)................ 201 clindamycin phosphate gel 1% (Cleocin-t)................. 201 clindamycin phosphate inj 9 gm/60ml (Cleocin phosphate)..................................................................... 17
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
303
2016 CLOZAPINE ODT -clozapine orally disintegrating tab 150 mg.................................................................................. 117 CLOZAPINE ODT -clozapine orally disintegrating tab 200 mg.................................................................................. 117 clozapine orally disintegrating tab 25 mg (Fazaclo)....................................................................... 117 clozapine orally disintegrating tab 100 mg (Fazaclo)....................................................................... 117 clozapine tab 50 mg...................................................... 117 clozapine tab 200 mg.................................................... 117 clozapine tab 25 mg (Clozaril)..................................... 117 clozapine tab 100 mg (Clozaril)................................... 117 CLOZARIL -clozapine tab 25 mg.................................... 117 CLOZARIL -clozapine tab 100 mg.................................. 118 COAL TAR -coal tar (crude) solution.............................. 229 COAL TAR -coal tar (crude) tar.......................................229 COAL TAR -coal tar soln 20%........................................ 202 COARTEM -artemether-lumefantrine tab 20-120 mg....... 16 CO-BALAMIN -ubiquinol-vit b12-resveratrol-fa cap 200-5-400-0.8 mg......................................................... 220 COBALT GLUCONATE -cobalt gluconate (bulk) powder........................................................................... 229 COBAMAMIDE -cobamamide (bulk) powder.................. 229 COCAINE HCL -cocaine hcl powder.............................. 202 COCAINE HCL -cocaine hcl soln 4%............................. 202 COCAMIDE DEA -cocamide dea (bulk) liquid................ 229 COCOA BUTTER -cocoa butter...................................... 264 COCOA BUTTER DEODORIZED -cocoa butter............ 264 COCONUT FLAVOR -flavoring agent - liquid................. 264 COCONUT OIL -coconut oil............................................ 229 CODEINE PHOSPHATE -codeine phosphate powder........................................................................... 138 CODEINE SULFATE -codeine sulfate tab 15 mg........... 138 CODEINE SULFATE -codeine sulfate tab 30 mg........... 138 CODEINE SULFATE -codeine sulfate tab 60 mg........... 138 codeine sulfate tab 30 mg............................................ 138 codeine sulfate tab 60 mg............................................ 138 codeine sulfate tab 15 mg (Codeine sulfate).............. 138 COD LIVER OIL -cod liver oil......................................... 171 COENZYME Q-10 -coenzyme q10 powder.................... 229 COENZYME Q10 -coenzyme q10 powder..................... 229 COFFEE FLAVOR -flavoring agent - liquid..................... 264 COGENTIN -benztropine mesylate inj 1 mg/ml.............. 164 COLA FLAVOR -flavoring agent - liquid..........................264 COLAZAL -balsalazide disodium cap 750 mg................ 102 COLCHICINE -colchicine cap 0.6 mg............................. 153 COLCHICINE -colchicine powder................................... 153 COLCHICINE -colchicine tab 0.6 mg.............................. 153 colchicine w/ probenecid tab 0.5-500 mg................... 153 COLCRYS -colchicine tab 0.6 mg................................... 153 COLESTID -colestipol hcl granule packets 5 gm.............. 81 COLESTID -colestipol hcl granules 5 gm......................... 81 COLESTID -colestipol hcl tab 1 gm.................................. 81 COLESTID FLAVORED -colestipol hcl granule packets 5 gm.................................................................................... 81
CLOMIPRAMINE HCL -clomipramine hcl (bulk) powder........................................................................... 229 CLONAZEPAM -clonazepam (bulk) powder................... 229 clonazepam orally disintegrating tab 0.125 mg......... 158 clonazepam orally disintegrating tab 0.25 mg........... 158 clonazepam orally disintegrating tab 0.5 mg............. 158 clonazepam orally disintegrating tab 1 mg................ 158 clonazepam orally disintegrating tab 2 mg................ 158 clonazepam tab 0.5 mg (Klonopin).............................. 158 clonazepam tab 1 mg (Klonopin)................................. 158 clonazepam tab 2 mg (Klonopin)................................. 158 CLONIDINE HCL -clonidine hcl powder........................... 71 clonidine hcl inj (for epidural infusion) 100 mcg/ml (Duraclon).....................................................................135 clonidine hcl inj (for epidural infusion) 500 mcg/ml (Duraclon).....................................................................135 clonidine hcl tab er 12hr 0.1 mg (Kapvay).................. 126 clonidine hcl tab 0.1 mg (Catapres).............................. 71 clonidine hcl tab 0.2 mg (Catapres).............................. 71 clonidine hcl tab 0.3 mg (Catapres).............................. 71 clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 71 clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2)................................................................................ 71 clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3)................................................................................ 71 CLOPIDOGREL BISULFATE -clopidogrel bisulfate (bulk) powder........................................................................... 229 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix).......................................................................... 188 clopidogrel bisulfate tab 300 mg (base equiv) (Plavix).......................................................................... 188 clorazepate dipotassium tab 3.75 mg (Tranxene t).....................................................................................110 clorazepate dipotassium tab 7.5 mg (Tranxene t)...... 110 clorazepate dipotassium tab 15 mg (Tranxene t)....... 110 CLORPRES -clonidine & chlorthalidone tab 0.1-15 mg.................................................................................... 71 CLORPRES -clonidine & chlorthalidone tab 0.2-15 mg.................................................................................... 71 CLORPRES -clonidine & chlorthalidone tab 0.3-15 mg.................................................................................... 71 CLORSULON -clorsulon (bulk) powder.......................... 229 CLOTRIMAZOLE -clotrimazole crystals.......................... 202 CLOTRIMAZOLE -clotrimazole powder.......................... 202 clotrimazole cream 1%.................................................. 202 clotrimazole soln 1%..................................................... 202 clotrimazole troche 10 mg............................................ 195 clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone).................................................................... 202 clotrimazole w/ betamethasone lotion 1-0.05%..........202 CLOVAGEL -gel base - gel............................................. 264 CLOVE OIL -clove oil...................................................... 229 CLOZAPINE ODT -clozapine orally disintegrating tab 12.5 mg.................................................................................. 117
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
304
2016 CONDYLOX -podofilox gel 0.5%.................................... 202 CONZIP -tramadol hcl cap er 24hr biphasic release 100 mg.................................................................................. 138 CONZIP -tramadol hcl cap er 24hr biphasic release 200 mg.................................................................................. 138 CONZIP -tramadol hcl cap er 24hr biphasic release 300 mg.................................................................................. 138 COPASIL -emollient - gel................................................ 202 COPASIL -silicone (bulk) gel........................................... 229 COPAXONE -glatiramer acetate soln prefilled syringe 20 mg/ml............................................................................. 131 COPAXONE -glatiramer acetate soln prefilled syringe 40 mg/ml............................................................................. 131 COPEGUS -ribavirin tab 200 mg...................................... 11 COPPER GLUCONATE -copper gluconate (bulk) powder........................................................................... 229 COPPER GLYCINATE -cupric glycinate (bulk) powder........................................................................... 230 COPPER PEPTIDE -copper peptide (bulk) powder........230 CORAL CALCIUM -coral calcium (bulk) powder............ 230 CORDRAN -flurandrenolide cream 0.05%...................... 202 CORDRAN -flurandrenolide lotion 0.05%....................... 202 CORDRAN -flurandrenolide oint 0.05%.......................... 202 CORDRAN -flurandrenolide tape 4 mcg/sqcm............... 202 COREG -carvedilol tab 3.125 mg..................................... 62 COREG -carvedilol tab 6.25 mg....................................... 62 COREG -carvedilol tab 12.5 mg....................................... 62 COREG -carvedilol tab 25 mg.......................................... 62 COREG CR -carvedilol phosphate cap er 24hr 10 mg..... 62 COREG CR -carvedilol phosphate cap er 24hr 20 mg..... 62 COREG CR -carvedilol phosphate cap er 24hr 40 mg..... 62 COREG CR -carvedilol phosphate cap er 24hr 80 mg..... 62 CORGARD -nadolol tab 20 mg......................................... 62 CORGARD -nadolol tab 40 mg......................................... 62 CORGARD -nadolol tab 80 mg......................................... 62 CORIANDER OIL -coriander oil...................................... 264 CORLANOR -ivabradine hcl tab 5 mg (base equiv)......... 85 CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)...... 85 CORN OIL -corn oil (bulk)............................................... 230 CORN STARCH -starch powder..................................... 230 CORN SYRUP -corn syrup............................................. 264 CORTANE-B -hydrocortisone-pramoxine-chloroxylenol lot 10-10-1mg/ml................................................................ 202 CORTEF -hydrocortisone tab 5 mg...................................32 CORTEF -hydrocortisone tab 10 mg.................................32 CORTEF -hydrocortisone tab 20 mg.................................32 CORTENEMA -hydrocortisone enema 100 mg/60ml..... 196 CORTICOTROPHIN -corticotropin (bulk) powder........... 230 CORTIFOAM -hydrocortisone acetate rectal foam 10% (90 mg/dose)................................................................. 196 CORTISONE ACETATE -cortisone acetate powder......... 32 CORTISONE ACETATE -cortisone acetate tab 25 mg..... 32 CORTISPORIN -bacitracin-polymyxin-neomycin hc oint 1%.................................................................................. 202
COLESTID FLAVORED -colestipol hcl granules 5 gm..... 81 colestipol hcl granule packets 5 gm (Colestid flavored)......................................................................... 81 colestipol hcl granules 5 gm (Colestid flavored)......... 81 colestipol hcl tab 1 gm (Colestid)..................................81 COLHIBIN -colhibin solution............................................ 229 COLISTIMETHATE SODIUM -colistimethate sodium (bulk) powder................................................................ 229 colistimethate sodium for inj 150 mg (Coly-Mycin M)..................................................................................... 17 COLLAGENASE -collagenase powder........................... 202 COLLAGEN HYDROLYSATE -collagen hydrolysate (bovine) (bulk) powder.................................................. 229 COLLASIL OSA -pharmaceutical excipients (bulk) powder........................................................................... 264 COLLODION -collodion................................................... 264 COLLODION FLEXIBLE -collodion flexible.....................264 COLLOIDAL ACTIVATED ATTAP -attapulgite (bulk) powder........................................................................... 229 COLY-MYCIN M -colistimethate sodium for inj 150 mg.................................................................................... 17 COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic susp 3.3-3-10-0.5 mg/ml.............................................. 194 COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm............................................. 95 COMBIGAN -brimonidine tartrate-timolol maleate ophth soln 0.2-0.5%................................................................ 189 COMBIPATCH -estradiol-norethindrone ace td pttw 0.05-0.14 mg/day............................................................ 39 COMBIPATCH -estradiol-norethindrone ace td pttw 0.05-0.25 mg/day............................................................ 39 COMBIVENT RESPIMAT -ipratropium-albuterol inhal aerosol soln 20-100 mcg/act.......................................... 91 COMBIVIR -lamivudine-zidovudine tab 150-300 mg........ 11 COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg dose) kit........................................................................... 25 COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit............................................................25 COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit............................................................25 COMMIT -nicotine polacrilex lozenge 2 mg.................... 131 COMMIT -nicotine polacrilex lozenge 4 mg.................... 131 COMPLERA -emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg................................................................11 COMTAN -entacapone tab 200 mg................................. 165 COMVAX -haemophilus b polysac conj-hepatitis b (recomb) vac im susp..................................................... 19 CONCERTA -methylphenidate hcl tab er osmotic release (osm) 18 mg..................................................................127 CONCERTA -methylphenidate hcl tab er osmotic release (osm) 27 mg..................................................................127 CONCERTA -methylphenidate hcl tab er osmotic release (osm) 36 mg..................................................................127 CONCERTA -methylphenidate hcl tab er osmotic release (osm) 54 mg..................................................................127
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
305
2016 CORTISPORIN -neomycin-polymyxin-hc crm 3.5 mg/ gm-10000 unt/gm-0.5%................................................ 202 CORVITE FE -iron combination tab................................ 180 CORVITE 150 -iron combination tab...............................180 CORVITE 150 -iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg.................................................................. 180 CORVITE -multiple vitamins w/ minerals & fa tab 1.25 mg.................................................................................. 171 CORZIDE -nadolol & bendroflumethiazide tab 40-5 mg.................................................................................... 71 CORZIDE -nadolol & bendroflumethiazide tab 80-5 mg.................................................................................... 71 COSENTYX -secukinumab subcutaneous soln prefilled syringe 150 mg/ml........................................................ 202 COSENTYX SENSOREADY PEN -secukinumab subcutaneous soln auto-injector 150 mg/ml................ 202 COSMOCIL CQ -polyaminopropyl biguanide (bulk) liquid.............................................................................. 230 COSOPT -dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml.............................................................. 189 COSOPT PF -dorzolamide hcl-timolol maleate ophth sol 22.3-6.8 mg/ml pf..........................................................189 COTELLIC -cobimetinib fumarate tab 20 mg (base equivalent)....................................................................... 25 COTTON CANDY FLAVOR -flavoring agent - liquid....... 264 COTTONSEED OIL -cottonseed oil................................ 230 COUMADIN -warfarin sodium tab 1 mg.......................... 185 COUMADIN -warfarin sodium tab 2 mg.......................... 185 COUMADIN -warfarin sodium tab 2.5 mg....................... 185 COUMADIN -warfarin sodium tab 3 mg.......................... 185 COUMADIN -warfarin sodium tab 4 mg.......................... 185 COUMADIN -warfarin sodium tab 5 mg.......................... 185 COUMADIN -warfarin sodium tab 6 mg.......................... 185 COUMADIN -warfarin sodium tab 7.5 mg....................... 185 COUMADIN -warfarin sodium tab 10 mg........................ 185 COUMARIN -coumarin powder....................................... 230 CO-VERATROL -ubiquinol-vit b12-resveratrol-fa cap 200-5-400-0.8 mg......................................................... 220 COZAAR -losartan potassium tab 25 mg..........................71 COZAAR -losartan potassium tab 50 mg..........................71 COZAAR -losartan potassium tab 100 mg........................71 CRANBERRY -cranberry (vaccinium macrocarpon) (bulk) powder........................................................................... 230 CRAN-RASPBERRY FLAVOR -flavoring agent liquid.............................................................................. 264 CREAM BASE -cream base............................................ 264 CREAM CONCENTRATE -cream base.......................... 264 CREATINE ANHYDROUS -creatine (bulk) powder........ 230 CREATINE -creatine (bulk) powder................................ 230 CREATINE MONOHYDRATE -creatine monohydrate (bulk) powder................................................................ 230 CREATININE -creatinine (bulk) powder.......................... 230 CREME DEMENTHE FLAVOR -flavoring agent liquid.............................................................................. 264
CREME DE MENTHE FLAVOR -flavoring agent liquid.............................................................................. 264 CREON -pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit...................................................101 CREON -pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit................................................ 101 CREON -pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit.............................................. 101 CREON -pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit............................................ 101 CREON -pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit........................................... 101 CRESEMBA -isavuconazonium sulfate cap 186 mg.......... 9 CRESOL -cresol (bulk) liquid.......................................... 230 CRESTOR -rosuvastatin calcium tab 5 mg.......................81 CRESTOR -rosuvastatin calcium tab 10 mg.....................81 CRESTOR -rosuvastatin calcium tab 20 mg.....................81 CRESTOR -rosuvastatin calcium tab 40 mg.....................81 CRINONE -progesterone vaginal gel 4%........................107 CRINONE -progesterone vaginal gel 8%........................107 CRIXIVAN -indinavir sulfate cap 200 mg.......................... 11 CRIXIVAN -indinavir sulfate cap 400 mg.......................... 11 CROMOLYN SODIUM -cromolyn sodium powder............ 91 CROMOLYN SODIUM -cromolyn sodium soln nebu 20 mg/2ml............................................................................. 91 cromolyn sodium ophth soln 4%................................ 189 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom)................................................................102 CROTAMITON -crotamiton (bulk) liquid.......................... 230 CROTON OIL -croton oil (bulk) oil.................................. 230 CRYOSERV -dimethyl sulfoxide - solution......................230 CUCUMBER MELON -fragrances (bulk) - liquid.............230 CUPRIC CHLORIDE DIHYDRATE -cupric chloride crystals.......................................................................... 230 CUPRIC SULFATE -cupric sulfate powder..................... 175 CUPRIC SULFATE PENTAHYDRA -cupric sulfate granules......................................................................... 175 CUPRIMINE -penicillamine cap 250 mg......................... 275 CUPUACU BUTTER -cupuacu butter (bulk)................... 230 CURCUMIN EXTRACT -turmeric (curcuma longa) (bulk) powder........................................................................... 230 CURCUMIN -turmeric (curcuma longa) (bulk) powder........................................................................... 230 CURITY HYPERTONIC SODIUM -wound dressings misc............................................................................... 202 CURITY SODIUM CHLORIDE DR -wound dressings pads............................................................................... 202 CUROSURF -poractant alfa intratracheal susp 120 mg/1.5ml.......................................................................... 95 CUROSURF -poractant alfa intratracheal susp 240 mg/3ml............................................................................. 95 CUSTOM LIPOTHENE 110 -gel base - gel.................... 265 CUSTOM LIPOTHENE 133 -gel base - gel.................... 265 CUSTOM POLYGLYCOL TROCHE -troche base flakes............................................................................. 265
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
306
2016 cyclosporine modified cap 50 mg (Cyclosporine modifie)......................................................................... 275 cyclosporine modified cap 25 mg (Neoral).................275 cyclosporine modified cap 100 mg (Neoral)...............275 CYCLOSPORINE MODIFIED -cyclosporine modified cap 50 mg............................................................................ 275 cyclosporine modified oral soln 100 mg/ml (Neoral)......................................................................... 275 CYFOLEX -fa-d3-ca carb-collagen bovine cap 1 mg-800 unt-50 mg-300 mg........................................................ 180 CYMBALTA -duloxetine hcl enteric coated pellets cap 20 mg.................................................................................. 111 CYMBALTA -duloxetine hcl enteric coated pellets cap 30 mg.................................................................................. 111 CYMBALTA -duloxetine hcl enteric coated pellets cap 60 mg.................................................................................. 111 CYPROHEPTADINE HCL -cyproheptadine hcl (bulk) powder........................................................................... 231 cyproheptadine hcl syrup 2 mg/5ml.............................. 86 cyproheptadine hcl tab 4 mg......................................... 86 CYSTADANE -betaine powder for oral solution................ 56 CYSTAGON -cysteamine bitartrate cap 50 mg...............108 CYSTAGON -cysteamine bitartrate cap 150 mg.............108 CYSTARAN -cysteamine hcl ophth soln 0.44% (base equivalent)..................................................................... 190 CYSTEAMINE HCL -cysteamine hcl (bulk) powder........231 CYTARABINE -cytarabine inj 20 mg/ml............................ 25 cytarabine inj pf 20 mg/ml.............................................. 25 cytarabine inj pf 100 mg/ml............................................ 25 CYTOMEL -liothyronine sodium tab 5 mcg.......................52 CYTOMEL -liothyronine sodium tab 25 mcg.....................52 CYTOMEL -liothyronine sodium tab 50 mcg.....................52 CYTOTEC -misoprostol tab 100 mcg................................97 CYTOTEC -misoprostol tab 200 mcg................................97
CUSTOM POLYGLYCOL TROCHE -troche base wax................................................................................ 265 CUTIS PLUS -cream base.............................................. 265 CUTIVATE -fluticasone propionate cream 0.05%........... 202 CUTIVATE -fluticasone propionate lotion 0.05%.............202 CUVPOSA -glycopyrrolate oral soln 1 mg/5ml................. 97 CYANOCOBALAMIN -cyanocobalamin crystals............. 180 CYANOCOBALAMIN -cyanocobalamin powder (for compounding)................................................................180 cyanocobalamin inj 1000 mcg/ml................................ 180 CYCLANDELATE -cyclandelate (bulk) powder............... 230 CYCLESSA -desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg...................... 42 CYCLOBENZAPRINE -cyclobenzaprine (bulk) powder........................................................................... 230 CYCLOBENZAPRINE HCL -cyclobenzaprine (bulk) powder........................................................................... 230 CYCLOBENZAPRINE HCL -cyclobenzaprine hcl (bulk) powder........................................................................... 230 cyclobenzaprine hcl tab 5 mg...................................... 168 cyclobenzaprine hcl tab 10 mg.................................... 168 cyclobenzaprine hcl tab 7.5 mg (Fexmid)................... 168 CYCLOGYL -cyclopentolate hcl ophth soln 0.5%........... 189 CYCLOGYL -cyclopentolate hcl ophth soln 1%.............. 190 CYCLOGYL -cyclopentolate hcl ophth soln 2%.............. 190 CYCLOMETHICONE -cyclomethicone (bulk) liquid........230 CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth soln 0.2-1%................................................................... 190 CYCLOPENTASILOXANE/PEG/PP -cyclopentasiloxanepeg/ppg-18/18 dimethicone liquid................................ 230 CYCLOPENTOLATE HCL -cyclopentolate hcl (bulk) powder........................................................................... 230 cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..........190 cyclopentolate hcl ophth soln 1% (Cyclogyl).............190 cyclopentolate hcl ophth soln 2% (Cyclogyl).............190 CYCLOPHENE RAPIDPAQ -cyclobenzaprine hcl td cream 5% (compound kit)............................................ 168 CYCLOPHOSPHAMIDE -cyclophosphamide (bulk) powder........................................................................... 230 CYCLOPHOSPHAMIDE -cyclophosphamide cap 25 mg.................................................................................... 25 CYCLOPHOSPHAMIDE -cyclophosphamide cap 50 mg.................................................................................... 25 cyclophosphamide for inj 1 gm..................................... 25 cyclophosphamide for inj 2 gm..................................... 25 cyclophosphamide for inj 500 mg................................. 25 CYCLOSERINE -cycloserine (bulk) powder................... 230 CYCLOSERINE -cycloserine cap 250 mg.......................... 8 CYCLOSET -bromocriptine mesylate tab 0.8 mg (base equivalent)....................................................................... 46 CYCLOSPORINE A -cyclosporine (bulk) powder........... 230 cyclosporine cap 25 mg (Sandimmune)..................... 275 cyclosporine cap 100 mg (Sandimmune)................... 275 CYCLOSPORINE -cyclosporine (bulk) powder.............. 230
D DAKLINZA -daclatasvir dihydrochloride tab 30 mg (base equivalent)....................................................................... 11 DAKLINZA -daclatasvir dihydrochloride tab 60 mg (base equivalent)....................................................................... 11 DAKLINZA -daclatasvir dihydrochloride tab 90 mg (base equivalent)....................................................................... 11 DALIRESP -roflumilast tab 500 mcg................................. 91 danazol cap 50 mg.......................................................... 38 danazol cap 100 mg........................................................ 38 danazol cap 200 mg........................................................ 38 DANAZOL -danazol powder.............................................. 38 DANTRIUM -dantrolene sodium cap 25 mg................... 168 DANTRIUM -dantrolene sodium cap 50 mg................... 168 dantrolene sodium cap 100 mg................................... 168 dantrolene sodium cap 25 mg (Dantrium).................. 168 dantrolene sodium cap 50 mg (Dantrium).................. 168 DANTROLENE SODIUM -dantrolene sodium (bulk) powder........................................................................... 231 DAPIPRAZOLE HCL -dapiprazole hcl (bulk) powder..... 231 DAPSONE -dapsone (bulk) powder................................ 231 SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
307
2016 dapsone tab 25 mg.......................................................... 17 dapsone tab 100 mg........................................................ 17 DAPTACEL -diph, acellular pert & tet tox inj 15 lf-10 mcg-5 lf/0.5ml................................................................. 22 DARAPRIM -pyrimethamine tab 25 mg............................ 16 darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv) (Enablex).......................................................... 105 darifenacin hydrobromide tab er 24hr 15 mg (base equiv) (Enablex).......................................................... 105 DAYPRO -oxaprozin tab 600 mg.................................... 147 DAYTRANA -methylphenidate td patch 10 mg/9hr......... 127 DAYTRANA -methylphenidate td patch 15 mg/9hr......... 127 DAYTRANA -methylphenidate td patch 20 mg/9hr......... 127 DAYTRANA -methylphenidate td patch 30 mg/9hr......... 127 D-CARE 100X -lidocaine 1% w/ epinephrine-1:200000 pf inj kit.............................................................................. 154 DDAVP -desmopressin acetate inj 4 mcg/ml.................... 56 DDAVP -desmopressin acetate nasal soln 0.01% (refrigerated).................................................................... 56 DDAVP -desmopressin acetate nasal spray soln 0.01%...............................................................................56 DDAVP -desmopressin acetate tab 0.1 mg...................... 56 DDAVP -desmopressin acetate tab 0.2 mg...................... 56 DEBACTEROL -sulfuric acid-sulfonated phenolics soln 30-50%.......................................................................... 195 DECON-A -brompheniramine & phenylephrine elixir 2-5 mg/5ml............................................................................. 88 DECON-G -phenylephrine-brompheniramine-guaifenesin liqd 2-1-40 mg/ml............................................................ 88 deferoxamine mesylate for inj 2 gm (Desferal).......... 218 deferoxamine mesylate for inj 500 mg (Desferal)...... 218 DEHYDROEPIANDROSTERONE -prasterone powder........................................................................... 231 DELESTROGEN -estradiol valerate im in oil 10 mg/ ml..................................................................................... 39 DELESTROGEN -estradiol valerate im in oil 20 mg/ ml..................................................................................... 39 DELESTROGEN -estradiol valerate im in oil 40 mg/ ml..................................................................................... 39 DELFLEX-LC/1.5% DEXTROSE -peritoneal dialysis solutions 346 mosm/l.................................................... 275 DELFLEX-LC/2.5% DEXTROSE -peritoneal dialysis solutions 394 mosm/l.................................................... 275 DELFLEX-LC/4.25% DEXTROSE -peritoneal dialysis solutions 483 mosm/l.................................................... 275 DELFLEX-SM/1.5% DEXTROSE -peritoneal dialysis solutions 347 mosm/l.................................................... 275 DELFLEX-SM/2.5% DEXTROSE -peritoneal dialysis solutions 398 mosm/l.................................................... 275 DELIVRA SR -transdermal base cream.......................... 265 DELZICOL -mesalamine cap dr 400 mg......................... 103 DEMADEX -torsemide tab 10 mg..................................... 79 DEMADEX -torsemide tab 20 mg..................................... 79 DEMECARIUM BROMIDE -demecarium bromide (bulk) powder........................................................................... 231
DEMECLOCYCLINE HCL -demeclocycline hcl powder..... 6 demeclocycline hcl tab 150 mg....................................... 6 demeclocycline hcl tab 300 mg....................................... 6 DEMEROL -meperidine hcl inj 25 mg/ml........................ 138 DEMEROL -meperidine hcl inj 50 mg/ml........................ 138 DEMEROL -meperidine hcl inj 75 mg/ml........................ 138 DEMEROL -meperidine hcl inj 100 mg/ml...................... 138 DEMEROL -meperidine hcl inj 25 mg/0.5ml (50 mg/ ml).................................................................................. 138 DEMEROL -meperidine hcl inj 75 mg/1.5ml (50 mg/ ml).................................................................................. 138 DEMEROL -meperidine hcl inj 100 mg/2ml (50 mg/ ml).................................................................................. 138 DEMEROL -meperidine hcl tab 100 mg......................... 138 DEMSER -metyrosine cap 250 mg................................... 71 DENAVIR -penciclovir cream 1%.................................... 202 DEOXYCHOLIC ACID -deoxycholic acid (bulk) powder........................................................................... 231 DEOXYCHOLIC ACID SODIUM -sodium deoxycholate (bulk) powder................................................................ 231 2-DEOXY-D-GLUCOSE -2-deoxy-d-glucose powder..... 260 2-DEOXY-D-GLUCOSE REAGANT -2-deoxy-d-glucose powder........................................................................... 260 DEPAKENE -valproate sodium oral soln 250 mg/5ml (base equiv).................................................................. 158 DEPAKENE -valproic acid cap 250 mg...........................158 DEPAKOTE -divalproex sodium tab delayed release 125 mg.................................................................................. 158 DEPAKOTE -divalproex sodium tab delayed release 250 mg.................................................................................. 158 DEPAKOTE -divalproex sodium tab delayed release 500 mg.................................................................................. 158 DEPAKOTE ER -divalproex sodium tab er 24 hr 250 mg.................................................................................. 158 DEPAKOTE ER -divalproex sodium tab er 24 hr 500 mg.................................................................................. 158 DEPAKOTE SPRINKLES -divalproex sodium cap delayed release sprinkle 125 mg............................................... 158 DEPEN TITRATABS -penicillamine tab 250 mg............. 275 DEPO-ESTRADIOL -estradiol cypionate im in oil 5 mg/ ml..................................................................................... 39 DEPO-MEDROL -methylprednisolone acetate inj susp 20 mg/ml............................................................................... 32 DEPO-MEDROL -methylprednisolone acetate inj susp 40 mg/ml............................................................................... 32 DEPO-MEDROL -methylprednisolone acetate inj susp 80 mg/ml............................................................................... 33 DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml........ 42 DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp prefilled syr 150 mg/ml............................................................................... 42 DEPO-PROVERA -medroxyprogesterone acetate im susp 400 mg/ml....................................................................... 26
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
308
2016 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette)........................................................ 42 desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa).......................................................................42 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen)....................................................................... 42 DESONATE -desonide gel 0.05%................................... 203 desonide cream 0.05% (Desowen).............................. 203 DESONIDE -desonide powder........................................ 203 desonide lotion 0.05% (Desowen)............................... 203 desonide oint 0.05% (Desowen).................................. 203 DESOWEN -desonide cream 0.05%...............................203 DESOWEN -desonide lotion 0.05%................................ 203 desoximetasone cream 0.05% (Topicort)....................203 desoximetasone cream 0.25% (Topicort)....................203 DESOXIMETASONE -desoximetasone (bulk) powder........................................................................... 231 desoximetasone gel 0.05% (Topicort)......................... 203 desoximetasone oint 0.05% (Topicort)........................ 203 desoximetasone oint 0.25% (Topicort)........................ 203 DESOXYCORTICOSTERONE ACET desoxycorticosterone acetate (bulk) powder............... 231 DESOXYN -methamphetamine hcl tab 5 mg.................. 127 DESVENLAFAXINE ER -desvenlafaxine tab er 24hr 50 mg.................................................................................. 112 DESVENLAFAXINE ER -desvenlafaxine tab er 24hr 100 mg.................................................................................. 112 desvenlafaxine succinate tab er 24hr 25 mg (base equiv) (Pristiq)............................................................. 112 desvenlafaxine succinate tab er 24hr 50 mg (base equiv) (Pristiq)............................................................. 112 desvenlafaxine succinate tab er 24hr 100 mg (base equiv) (Pristiq)............................................................. 112 DETROL LA -tolterodine tartrate cap er 24hr 2 mg........ 106 DETROL LA -tolterodine tartrate cap er 24hr 4 mg........ 106 DETROL -tolterodine tartrate tab 1 mg........................... 106 DETROL -tolterodine tartrate tab 2 mg........................... 106 DEVILS CLAW -devil's claw (harpagophytum procumbens) (bulk) powder..........................................231 DEXAMETHASONE ACETATE ANH -dexamethasone acetate powder............................................................... 33 DEXAMETHASONE ACETATE -dexamethasone acetate powder............................................................................. 33 DEXAMETHASONE BASE -dexamethasone powder...... 33 DEXAMETHASONE -dexamethasone powder................. 33 DEXAMETHASONE -dexamethasone soln 0.5 mg/5ml............................................................................. 33 DEXAMETHASONE -dexamethasone tab 1 mg...............33 DEXAMETHASONE -dexamethasone tab 2 mg...............33 dexamethasone elixir 0.5 mg/5ml.................................. 33 DEXAMETHASONE INTENSOL -dexamethasone conc 1 mg/ml............................................................................... 33 DEXAMETHASONE ISONICOTINA -dexamethasone isonicotinate (bulk) powder...........................................231
DEPO-SUBQ PROVERA 104 -medroxyprogesterone acetate susp pref syr 104 mg/0.65ml.............................42 DEPO-TESTOSTERONE -testosterone cypionate im inj in oil 100 mg/ml.................................................................. 38 DEPO-TESTOSTERONE -testosterone cypionate im inj in oil 200 mg/ml.................................................................. 38 DEPRIZINE FUSEPAQ -ranitidine hcl for oral susp 22.4 mg/ml (compound kit)..................................................... 97 DEPRIZINE RAPIDPAQ -ranitidine hcl for oral susp 22.4 mg/ml (compound kit)..................................................... 97 DERMACINRX CINLONE-I CPI -triamcinolone inj 40 mg/ ml & lido-prilo cr 2.5-2.5% kit......................................... 33 DERMACINRX ETHOXY DIGLYCO -carbitol liquid........ 231 DERMACINRX PUREFOLIX -folic acid-cholecalciferol tab 1 mg-5000 unit.............................................................. 181 DERMACINRX TOPICAL SOLUTI -external vehicles solution.......................................................................... 265 DERMA-SMOOTHE/FS BODY -fluocinolone acetonide oil 0.01% (body oil)............................................................ 203 DERMA-SMOOTHE/FS SCALP -fluocinolone acetonide oil 0.01% (scalp oil)...................................................... 203 DERMATOP -prednicarbate cream 0.1%........................ 203 DERMATOP -prednicarbate oint 0.1%............................ 203 DERMOTIC -fluocinolone acetonide (otic) oil 0.01%...... 194 DESCOVY -emtricitabine-tenofovir alafenamide fumarate tab 200-25 mg................................................................ 11 DESFERAL -deferoxamine mesylate for inj 500 mg....... 218 DESICCATED BEEF LIVER -desiccated beef liver (bulk) powder........................................................................... 231 DESIPRAMINE HCL -desipramine hcl powder............... 112 desipramine hcl tab 10 mg (Norpramin)..................... 112 desipramine hcl tab 25 mg (Norpramin)..................... 112 desipramine hcl tab 50 mg (Norpramin)..................... 112 desipramine hcl tab 75 mg (Norpramin)..................... 112 desipramine hcl tab 100 mg (Norpramin)................... 112 desipramine hcl tab 150 mg (Norpramin)................... 112 DESLORATADINE ODT -desloratadine tab orally disintegrating 2.5 mg...................................................... 86 DESLORATADINE ODT -desloratadine tab orally disintegrating 5 mg......................................................... 86 desloratadine tab 5 mg (Clarinex)................................. 86 DESMOPRESSIN ACETATE -desmopressin acetate (bulk) powder................................................................ 231 desmopressin acetate inj 4 mcg/ml (Ddavp)................ 56 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp)........................................................................... 56 desmopressin acetate nasal spray soln 0.01% (Ddavp)........................................................................... 56 desmopressin acetate nasal spray soln 0.01% (refrigerated).................................................................. 56 desmopressin acetate tab 0.1 mg (Ddavp)................... 56 desmopressin acetate tab 0.2 mg (Ddavp)................... 56 DESOGEN -desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg...................................................................... 42
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
309
2016 DEXPANTHENOL -dexpanthenol (bulk) liquid................ 231 DEXPANTHENOL -dexpanthenol (bulk) powder............ 231 dextroamphetamine sulfate cap er 24hr 5 mg (Dexedrine)................................................................... 127 dextroamphetamine sulfate cap er 24hr 10 mg (Dexedrine)................................................................... 127 dextroamphetamine sulfate cap er 24hr 15 mg (Dexedrine)................................................................... 127 dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra)................................................................... 127 dextroamphetamine sulfate tab 5 mg......................... 127 dextroamphetamine sulfate tab 10 mg....................... 127 DEXTROMETHORPHAN HBR -dextromethorphan hbr powder............................................................................. 88 DEXTROMETHORPHAN HBR MONO dextromethorphan hbr crystals....................................... 88 DEXTROMETHORPHAN HBR MONO dextromethorphan hbr powder....................................... 88 DEXTROSE ANHYDROUS -dextrose powder............... 177 DEXTROSE -dextrose powder........................................ 177 DHEA MICRONIZED -prasterone micronized powder........................................................................... 231 DHEA -prasterone powder.............................................. 231 D.H.E. 45 -dihydroergotamine mesylate inj 1 mg/ml.......151 DIAB F.D.G. FREEZE-DRIED -wound dressings gel.................................................................................. 203 DIAB -wound dressings - gel.......................................... 203 DIALYVITE/ZINC -b-complex w/ c-zn & folic acid tab 1 mg.................................................................................. 171 DIALYVITE 3000 -b-complex w/ c-biotin-e-minerals & folic acid tab 3 mg................................................................ 171 DIALYVITE 5000 -b-complex w/ c-biotin-e-minerals & folic acid tab 5 mg................................................................ 171 DIALYVITE SUPREME D -multiple vitamins w/ minerals & fa tab 3 mg................................................................... 171 DIAMINOPYRIDINE -diaminopyridine (bulk) powder..... 231 DIAMOX -acetazolamide cap er 12hr 500 mg.................. 79 DIANEAL LOW CALCIUM/1.5% -peritoneal dialysis solutions 344 mosm/l.................................................... 276 DIANEAL LOW CALCIUM/2.5% -peritoneal dialysis solutions 395 mosm/l.................................................... 276 DIANEAL LOW CALCIUM/4.25% -peritoneal dialysis solutions 483 mosm/l.................................................... 276 DIANEAL PD-2/4.25% DEXTRO -peritoneal dialysis solutions 485 mosm/l.................................................... 276 DIANEAL PD-2/1.5% DEXTROS -peritoneal dialysis solutions 346 mosm/l.................................................... 276 DIANEAL PD-2/2.5% DEXTROS -peritoneal dialysis solutions 396 mosm/l.................................................... 276 DIASTAT ACUDIAL -diazepam rectal gel delivery system 10 mg............................................................................ 158 DIASTAT ACUDIAL -diazepam rectal gel delivery system 20 mg............................................................................ 158 DIASTAT PEDIATRIC -diazepam rectal gel delivery system 2.5 mg.............................................................. 158
DEXAMETHASONE SODIUM PHOS -dexamethasone sodium phosphate inj 10 mg/ml..................................... 33 DEXAMETHASONE SODIUM PHOS -dexamethasone sodium phosphate ophth soln 0.1%............................. 190 DEXAMETHASONE SODIUM PHOS -dexamethasone sodium phosphate powder............................................. 33 DEXAMETHASONE SODIUM PHOS -dexamethasone sod phosphate preservative free inj 10 mg/ml............... 33 dexamethasone sodium phosphate inj 4 mg/ml.......... 33 dexamethasone sodium phosphate inj 20 mg/5ml...... 33 dexamethasone sodium phosphate inj 120 mg/30ml.......................................................................... 33 dexamethasone sodium phosphate inj 100 mg/10ml.......................................................................... 33 dexamethasone tab 0.5 mg............................................ 33 dexamethasone tab 0.75 mg.......................................... 33 dexamethasone tab 1.5 mg............................................ 33 dexamethasone tab 4 mg............................................... 33 dexamethasone tab 6 mg............................................... 33 DEXEDRINE -dextroamphetamine sulfate cap er 24hr 5 mg.................................................................................. 127 DEXEDRINE -dextroamphetamine sulfate cap er 24hr 10 mg.................................................................................. 127 DEXEDRINE -dextroamphetamine sulfate cap er 24hr 15 mg.................................................................................. 127 DEXERYL -dermatological products misc - cream......... 203 DEXLIDO -dexamethasone sod phos pf inj 10 mg/ml & lidocaine 1% kit............................................................... 33 DEXLIDO-M -dexamethasone pf inj 10 mg/ml & bupiv 0.25% & lido 1% kit........................................................ 33 dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr).................................................................................. 127 dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin xr).................................................................................. 127 dexmethylphenidate hcl cap er 24 hr 15 mg (Focalin xr).................................................................................. 127 dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin xr).................................................................................. 127 dexmethylphenidate hcl cap er 24 hr 25 mg (Focalin xr).................................................................................. 127 dexmethylphenidate hcl cap er 24 hr 30 mg (Focalin xr).................................................................................. 127 dexmethylphenidate hcl cap er 24 hr 35 mg (Focalin xr).................................................................................. 127 dexmethylphenidate hcl cap er 24 hr 40 mg (Focalin xr).................................................................................. 127 dexmethylphenidate hcl tab 2.5 mg (Focalin)............ 127 dexmethylphenidate hcl tab 5 mg (Focalin)............... 127 dexmethylphenidate hcl tab 10 mg (Focalin)............. 127 DEXPAK 10 DAY -dexamethasone tab therapy pack 1.5 mg (35)............................................................................ 33 DEXPAK 13 DAY -dexamethasone tab therapy pack 1.5 mg (51)............................................................................ 33 DEXPAK 6 DAY -dexamethasone tab therapy pack 1.5 mg (21)............................................................................ 33
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
310
2016 didanosine delayed release capsule 400 mg (Videx ec).................................................................................... 11 DIETHANOLAMINE -diethanolamine (bulk) liquid.......... 232 DIETHYLCARBAMAZINE CITRAT -diethylcarbamazine citrate (bulk) powder..................................................... 232 DIETHYLENE GLYCOL MONOETH -carbitol liquid....... 232 DIETHYL-M-TOLUAMIDE -diethyltoluamide (bulk) liquid.............................................................................. 232 DIETHYLPROPION HYDROCHLOR -diethylpropion hydrochloride (bulk) powder......................................... 232 DIETHYLSTILBESTROL -diethylstilbestrol (bulk) powder........................................................................... 232 DIFFERIN -adapalene cream 0.1%................................ 203 DIFFERIN -adapalene gel 0.1%...................................... 203 DIFFERIN -adapalene gel 0.3%...................................... 203 DIFFERIN -adapalene lotion 0.1%.................................. 203 DIFICID -fidaxomicin tab 200 mg........................................ 5 DIFLORASONE DIACETATE -diflorasone diacetate cream 0.05%................................................................. 203 DIFLORASONE DIACETATE -diflorasone diacetate oint 0.05%.............................................................................203 DIFLUCAN -fluconazole for susp 10 mg/ml........................ 9 DIFLUCAN -fluconazole for susp 40 mg/ml........................ 9 DIFLUCAN -fluconazole tab 50 mg..................................... 9 DIFLUCAN -fluconazole tab 100 mg................................... 9 DIFLUCAN -fluconazole tab 150 mg................................... 9 DIFLUCAN -fluconazole tab 200 mg................................... 9 diflunisal tab 500 mg..................................................... 135 DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 60 digoxin inj 0.25 mg/ml (Lanoxin)................................... 60 digoxin tab 125 mcg (0.125 mg) (Lanoxin)................... 60 digoxin tab 250 mcg (0.25 mg) (Lanoxin)..................... 60 DIHYDROCODEINE BITARTRATE -dihydrocodeine bitartrate (bulk) powder................................................ 232 DIHYDROERGOTAMINE MESYLAT -dihydroergotamine mesylate nasal spray 4 mg/ml..................................... 151 DIHYDROERGOTAMINE MESYLAT -dihydroergotamine mesylate powder........................................................... 151 dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45).................................................................................. 151 DIHYDROXYACETONE (1,3) DI -dihydroxyacetone (1,3) dimer (bulk) powder...................................................... 232 DIINDOLYLMETHANE -diindolylmethane (bulk) powder........................................................................... 232 DIIODO-L-THYRONINE 3,5 -3,5-diiodothyronine (bulk) powder........................................................................... 232 DILANTIN INFATABS -phenytoin chew tab 50 mg......... 158 DILANTIN -phenytoin sodium extended cap 30 mg........158 DILANTIN -phenytoin sodium extended cap 100 mg......158 DILANTIN-125 -phenytoin susp 125 mg/5ml.................. 158 DILATRATE SR -isosorbide dinitrate cap er 40 mg.......... 60 DILAUDID -hydromorphone hcl inj 1 mg/ml.................... 138 DILAUDID -hydromorphone hcl inj 2 mg/ml.................... 138 DILAUDID -hydromorphone hcl inj 4 mg/ml.................... 138 DILAUDID -hydromorphone hcl liqd 1 mg/ml.................. 138
diazepam conc 5 mg/ml................................................ 110 DIAZEPAM -diazepam (bulk) powder............................. 231 DIAZEPAM -diazepam im solution auto-inj 10 mg/2ml........................................................................... 110 DIAZEPAM -diazepam inj 5 mg/ml.................................. 110 DIAZEPAM -diazepam oral soln 1 mg/ml........................110 diazepam tab 2 mg (Valium)......................................... 110 diazepam tab 5 mg (Valium)......................................... 110 diazepam tab 10 mg (Valium)....................................... 110 DIAZOXIDE -diazoxide (bulk) powder.............................231 DIAZOXIDE -diazoxide powder......................................... 71 DIBENZYLINE -phenoxybenzamine hcl cap 10 mg..........71 DIBUCAINE HCL -dibucaine hcl powder................. 203,231 DIBUTYL SQUARATE -squaric acid dibutylester liquid.............................................................................. 231 DICHLORALPHENAZONE -dichloralphenazone (bulk) powder........................................................................... 231 DICHLOROACETIC ACID -dichloracetic acid (bulk) liquid.............................................................................. 231 DICLAZURIL -diclazuril (bulk) powder............................ 231 diclofenac potassium tab 50 mg (Cataflam)............... 147 DICLOFENAC SODIUM -diclofenac sodium (bulk) powder........................................................................... 231 DICLOFENAC SODIUM -diclofenac sodium cream 3%.................................................................................. 203 diclofenac sodium gel 1% (Voltaren)...........................203 diclofenac sodium ophth soln 0.1%............................ 190 diclofenac sodium soln 1.5% (Pennsaid)................... 203 diclofenac sodium tab delayed release 25 mg........... 147 diclofenac sodium tab delayed release 50 mg........... 147 diclofenac sodium tab delayed release 75 mg........... 147 diclofenac sodium tab er 24hr 100 mg....................... 147 diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50)........................................................147 diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75)........................................................147 dicloxacillin sodium cap 250 mg..................................... 2 dicloxacillin sodium cap 500 mg..................................... 2 DICOPANOL FUSEPAQ -diphenhydramine hcl for oral susp 5 mg/ml (compound kit)......................................... 86 DICOPANOL RAPIDPAQ -diphenhydramine hcl for oral susp 5 mg/ml (compound kit)......................................... 86 DICUMAROL -dicumarol (bulk) powder.......................... 232 dicyclomine hcl cap 10 mg (Bentyl).............................. 98 dicyclomine hcl inj 10 mg/ml (Bentyl)........................... 98 dicyclomine hcl oral soln 10 mg/5ml............................ 98 dicyclomine hcl tab 20 mg (Bentyl)............................... 98 DICYCLOMINE HYDROCHLORIDE -dicyclomine hydrochloride (bulk) powder......................................... 232 didanosine delayed release capsule 125 mg (Videx ec).................................................................................... 11 didanosine delayed release capsule 200 mg (Videx ec).................................................................................... 11 didanosine delayed release capsule 250 mg (Videx ec).................................................................................... 11
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
311
2016 DILAUDID -hydromorphone hcl tab 2 mg....................... 138 DILAUDID -hydromorphone hcl tab 4 mg....................... 138 DILAUDID -hydromorphone hcl tab 8 mg....................... 138 diltiazem hcl cap er 12hr 60 mg.....................................65 diltiazem hcl cap er 12hr 90 mg.....................................65 diltiazem hcl cap er 12hr 120 mg...................................65 diltiazem hcl cap er 24hr 120 mg...................................65 diltiazem hcl cap er 24hr 180 mg...................................65 diltiazem hcl cap er 24hr 240 mg...................................65 diltiazem hcl coated beads cap er 24hr 300 mg........... 65 diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem cd)................................................................ 65 diltiazem hcl coated beads cap er 24hr 180 mg (Cardizem cd)................................................................ 65 diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem cd)................................................................ 65 diltiazem hcl coated beads cap er 24hr 360 mg (Cardizem cd)................................................................ 65 diltiazem hcl coated beads tab er 24hr 180 mg (Cardizem la)................................................................. 65 diltiazem hcl coated beads tab er 24hr 240 mg (Cardizem la)................................................................. 65 diltiazem hcl coated beads tab er 24hr 300 mg (Cardizem la)................................................................. 65 diltiazem hcl coated beads tab er 24hr 360 mg (Cardizem la)................................................................. 65 diltiazem hcl coated beads tab er 24hr 420 mg (Cardizem la)................................................................. 65 DILTIAZEM HCL -diltiazem hcl (bulk) powder................ 232 diltiazem hcl extended release beads cap er 24hr 120 mg (Tiazac).................................................................... 65 diltiazem hcl extended release beads cap er 24hr 180 mg (Tiazac).................................................................... 65 diltiazem hcl extended release beads cap er 24hr 240 mg (Tiazac).................................................................... 65 diltiazem hcl extended release beads cap er 24hr 300 mg (Tiazac).................................................................... 65 diltiazem hcl extended release beads cap er 24hr 360 mg (Tiazac).................................................................... 65 diltiazem hcl extended release beads cap er 24hr 420 mg (Tiazac).................................................................... 65 diltiazem hcl tab 90 mg................................................... 65 diltiazem hcl tab 30 mg (Cardizem)............................... 65 diltiazem hcl tab 60 mg (Cardizem)............................... 65 diltiazem hcl tab 120 mg (Cardizem)............................. 65 DIMENHYDRINATE -dimenhydrinate inj 50 mg/ml......... 100 DIMENHYDRINATE -dimenhydrinate powder................ 232 DIMERCAPTO-1-PROPANESULFO -dimercaptopropanesulfonate (2,3) sodium (dmps) powder........................ 232 DIMERCAPTOPROPANE-SULFONA dimercaptopropane-sulfonate (2,3) sodium (dmps) powder........................................................................... 232 DIMERCAPTOSUCCINIC ACID -succimer (bulk) crystals.......................................................................... 232
DIMERCAPTOSUCCINIC ACID -succimer (bulk) powder........................................................................... 232 DIMETHYLACETAMIDE -dimethylacetamide (bulk) liquid.............................................................................. 232 DIMETHYLAMINOETHANOL (DEA -deanol (bulk) liquid.............................................................................. 232 DIMETHYL FUMARATE -dimethyl fumarate (bulk) powder........................................................................... 232 DIMETHYLGLYCINE HCL -dimethylglycine hcl (bulk) powder........................................................................... 232 DIMETHYL SILOXANE HYDROXY -dimethyl siloxane hydroxyalkyl-terminated liquid...................................... 232 DIMETHYL SULFONE -methylsulfonylmethane (bulk) powder........................................................................... 232 DIMETHYL SULFOXIDE -dimethyl sulfoxide solution.......................................................................... 232 DINITROCHLOROBENZENE -dinitrochlorobenzene crystals.......................................................................... 232 DIOSGENIN -diosgenin (bulk) powder............................232 DIOSMIN -diosmin (bulk) powder................................... 232 DIOVAN HCT -valsartan-hydrochlorothiazide tab 80-12.5 mg.................................................................................... 72 DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-12.5 mg.................................................................................... 72 DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-25 mg.................................................................................... 72 DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-12.5 mg.................................................................................... 72 DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-25 mg.................................................................................... 72 DIOVAN -valsartan tab 40 mg........................................... 71 DIOVAN -valsartan tab 80 mg........................................... 71 DIOVAN -valsartan tab 160 mg......................................... 71 DIOVAN -valsartan tab 320 mg......................................... 72 DIOXYBENZONE -dioxybenzone (bulk) powder............ 233 DIPENTOCAINE -diclofenac-gabapentin-lidocaine hcl cream 5-5-2% (cmp kit)................................................ 203 DIPENTUM -olsalazine sodium cap 250 mg...................103 diphenhydramine hcl cap 50 mg................................... 87 DIPHENHYDRAMINE HCL -diphenhydramine hcl powder............................................................................. 86 diphenhydramine hcl elixir 12.5 mg/5ml....................... 87 diphenhydramine hcl inj 50 mg/ml................................ 87 DIPHENIDOL HYDROCHLORIDE -diphenidol hcl (bulk) powder........................................................................... 233 DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml....................................................... 96 diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)......................................................................... 96 DIPHENYLCYCLOPROPENONE diphenylcyclopropenone (bulk) powder....................... 233 DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml............................... 22 DIPROLENE AF -betamethasone dipropionate augmented cream 0.05%............................................. 203
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
312
2016 DOCUSATE SODIUM -docusate sodium powder............. 95 dofetilide cap 125 mcg (0.125 mg) (Tikosyn)................67 dofetilide cap 250 mcg (0.25 mg) (Tikosyn)..................67 dofetilide cap 500 mcg (0.5 mg) (Tikosyn)....................67 DOLOPHINE -methadone hcl tab 5 mg.......................... 138 DOLOPHINE -methadone hcl tab 10 mg........................ 138 donepezil hydrochloride orally disintegrating tab 5 mg................................................................................. 131 donepezil hydrochloride orally disintegrating tab 10 mg (Aricept odt).......................................................... 131 donepezil hydrochloride tab 5 mg (Aricept)............... 131 donepezil hydrochloride tab 10 mg (Aricept)............. 131 donepezil hydrochloride tab 23 mg (Aricept)............. 131 DONNATAL -pb-hyoscy-atrop-scopol elix 16.2-0.1037-0.0194-0.0065 mg/5ml............................... 98 DONNATAL -pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg...................................... 98 DOPAMINE HYDROCHLORIDE -dopamine hcl (bulk) powder........................................................................... 233 DORAL -quazepam tab 15 mg........................................ 123 dorzolamide hcl ophth soln 2% (Trusopt).................. 190 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt)............................................................190 DOUBLEDEX -dexamethasone sodium phosphate pf inj 10 mg/ml kit.................................................................... 33 DOUBLE PM -prednisolone-moxifloxacin opth for soln 1-0.5% (cmpd kit)......................................................... 190 DOVONEX -calcipotriene cream 0.005%........................203 DOW CORNING 1501 FLUID decamethylcyclopentasiloxane (bulk) liquid................. 233 DOW CORNING 200 -silicone (bulk) liquid.....................233 doxazosin mesylate tab 1 mg (Cardura)....................... 72 doxazosin mesylate tab 2 mg (Cardura)....................... 72 doxazosin mesylate tab 4 mg (Cardura)....................... 72 doxazosin mesylate tab 8 mg (Cardura)....................... 72 doxepin hcl cap 10 mg..................................................112 doxepin hcl cap 25 mg..................................................112 doxepin hcl cap 50 mg..................................................112 doxepin hcl cap 100 mg................................................112 doxepin hcl cap 150 mg................................................112 doxepin hcl conc 10 mg/ml.......................................... 112 DOXEPIN HCL -doxepin hcl cap 75 mg......................... 112 DOXEPIN HCL -doxepin hcl powder.............................. 112 doxercalciferol cap 0.5 mcg (Hectorol)......................... 56 doxercalciferol cap 1 mcg (Hectorol)............................ 56 doxercalciferol cap 2.5 mcg (Hectorol)......................... 56 doxycycline hyclate cap 50 mg....................................... 6 doxycycline hyclate cap 100 mg (Vibramycin)...............6 doxycycline hyclate tab 20 mg........................................ 6 doxycycline hyclate tab 100 mg...................................... 6 doxycycline hyclate tab 75 mg (Acticlate)...................... 6 doxycycline hyclate tab 150 mg (Acticlate).................... 6 doxycycline monohydrate cap 50 mg............................. 6 doxycycline monohydrate cap 150 mg (Adoxa).............6 doxycycline monohydrate cap 75 mg (Monodox)..........6
DIPROLENE -betamethasone dipropionate augmented lotion 0.05%.................................................................. 203 DIPROLENE -betamethasone dipropionate augmented oint 0.05%..................................................................... 203 DIPYRIDAMOLE -dipyridamole (bulk) powder............... 233 dipyridamole tab 25 mg (Persantine).......................... 188 dipyridamole tab 50 mg (Persantine).......................... 188 dipyridamole tab 75 mg (Persantine).......................... 188 DISOPHENOL -disophenol (2.6-diiodo-4-nitrophenol) powder 97%.................................................................. 233 disopyramide phosphate cap 100 mg (Norpace)......... 67 disopyramide phosphate cap 150 mg (Norpace)......... 67 DISULFIRAM -disulfiram (bulk) powder.......................... 233 disulfiram tab 250 mg (Antabuse)............................... 131 disulfiram tab 500 mg (Antabuse)............................... 131 DITROPAN XL -oxybutynin chloride tab er 24hr 5 mg.................................................................................. 106 DITROPAN XL -oxybutynin chloride tab er 24hr 10 mg.................................................................................. 106 DITROPAN XL -oxybutynin chloride tab er 24hr 15 mg.................................................................................. 106 DIURIL -chlorothiazide susp 250 mg/5ml......................... 79 divalproex sodium cap delayed release sprinkle 125 mg (Depakote sprinkles)............................................158 divalproex sodium tab delayed release 125 mg (Depakote).................................................................... 158 divalproex sodium tab delayed release 250 mg (Depakote).................................................................... 158 divalproex sodium tab delayed release 500 mg (Depakote).................................................................... 158 divalproex sodium tab er 24 hr 250 mg (Depakote er).................................................................................. 158 divalproex sodium tab er 24 hr 500 mg (Depakote er).................................................................................. 158 DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)........... 39 DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)............... 39 DIVIGEL -estradiol td gel 1 mg/gm (0.1%)....................... 39 DIVISTA -folic acid-vit b6-vit b12-omega 3-biotin-cr cap 1 mg.................................................................................. 181 DL-ALANINE -alanine powder......................................... 177 DL-ALPHA LIPOIC ACID -alpha-lipoic acid (bulk) powder........................................................................... 233 DL-3-HYDROXYBUTYRIC ACID -sodium 3hydroxybutyrate (bulk) powder..................................... 233 DL-LEUCINE -leucine powder......................................... 177 DL-MALIC ACID -malic acid powder............................... 233 DL-METHIONINE -methionine powder........................... 177 DL-PANTHENOL -panthenol (bulk) powder.................... 233 DL-PHENYLALANINE -phenylalanine powder............... 177 DMAE BITARTRATE -deanol bitartrate (bulk) powder........................................................................... 233 D-MANNOSE -d-mannose (bulk) powder....................... 231 DOCOSANOL -docosanol (bulk) powder........................ 233 DOCUSATE SODIUM/SODIUM BE -docusate sodiumsodium benzoate powder 85-15%............................... 233
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
313
2016 doxycycline monohydrate cap 100 mg (Monodox)........6 DOXYCYCLINE MONOHYDRATE -doxycycline monohydrate (bulk) powder..........................................233 doxycycline monohydrate tab 50 mg (Adoxa)............... 6 doxycycline monohydrate tab 75 mg (Adoxa)............... 6 doxycycline monohydrate tab 100 mg (Adoxa pak 1/100)................................................................................. 6 doxycycline monohydrate tab 150 mg (Adoxa pak 1/150)................................................................................. 6 DOXYLAMINE SUCCINATE -doxylamine succinate powder............................................................................. 87 DRAKKAR NOIR -fragrances (bulk) - liquid.................... 233 D-RIBOSE -d-ribose (bulk) powder................................. 231 DRIHEP ARTERIAL LINE SAMP -arterial blood gas kit................................................................................... 219 DRIHEP PLUS 3ML LL PREFIL -arterial blood gas kit................................................................................... 219 DRIHEP PLUS 3ML PREFILLED -arterial blood gas kit................................................................................... 219 DRITHO-CREME HP -anthralin cream 1%..................... 203 dronabinol cap 2.5 mg (Marinol).................................. 100 dronabinol cap 5 mg (Marinol)..................................... 100 dronabinol cap 10 mg (Marinol)................................... 100 DROPERIDOL -droperidol powder..................................110 droperidol inj 2.5 mg/ml................................................ 110 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28).................................................................................... 42 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 42 drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg (Beyaz)............................................... 42 DROXIA -hydroxyurea cap 200 mg................................ 181 DROXIA -hydroxyurea cap 300 mg................................ 181 DROXIA -hydroxyurea cap 400 mg................................ 181 DRYSOL -aluminum chloride soln 20%.......................... 203 DUAC -clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%..................................................................... 204 DUAVEE -conjugated estrogens-bazedoxifene tab 0.45-20 mg...................................................................... 40 DUETACT -pioglitazone hcl-glimepiride tab 30-2 mg....... 46 DUETACT -pioglitazone hcl-glimepiride tab 30-4 mg....... 46 DULERA -mometasone furoate-formoterol fumarate aerosol 100-5 mcg/act.................................................... 91 DULERA -mometasone furoate-formoterol fumarate aerosol 200-5 mcg/act.................................................... 91 DULOXETINE HCL -duloxetine hcl (bulk) powder.......... 233 DULOXETINE HCL -duloxetine hcl enteric coated pellets cap 40 mg..................................................................... 112 duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta).................................................................... 112 duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta).................................................................... 112 duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta).................................................................... 112 DUODOTE -atropine 2.1 mg/0.7ml-pralidoxime cl 600 mg/2ml im auto-inj........................................................ 218
DUOPA -carbidopa-levodopa enteral susp 4.63-20 mg/ ml................................................................................... 165 DURACHOL -folic acid-cholecalciferol cap 1 mg-3775 unit................................................................................. 181 DURACLON -clonidine hcl inj (for epidural infusion) 100 mcg/ml........................................................................... 135 DURACLON -clonidine hcl inj (for epidural infusion) 500 mcg/ml........................................................................... 135 DURAGESIC -fentanyl td patch 72hr 12 mcg/hr............. 138 DURAGESIC -fentanyl td patch 72hr 25 mcg/hr............. 138 DURAGESIC -fentanyl td patch 72hr 50 mcg/hr............. 138 DURAGESIC -fentanyl td patch 72hr 75 mcg/hr............. 138 DURAGESIC -fentanyl td patch 72hr 100 mcg/hr........... 138 DURASAFE SPINAL/EPIDURAL -lidocaine hcl local inj kit 1%.................................................................................. 154 DURAXIN -acetaminophen-salicylamidephenyltoloxamine cap 300-200-20mg.......................... 135 DUREZOL -difluprednate ophth emulsion 0.05%........... 190 DURLAZA -aspirin capsule er 24hr 162.5 mg................ 188 dutasteride cap 0.5 mg (Avodart)................................ 108 dutasteride-tamsulosin hcl cap 0.5-0.4 mg (JALYN)......................................................................... 108 DUTOPROL -metoprolol & hydrochlorothiazide tab er 24hr 25-12.5 mg............................................................. 72 DUTOPROL -metoprolol & hydrochlorothiazide tab er 24hr 50-12.5 mg............................................................. 72 DUTOPROL -metoprolol & hydrochlorothiazide tab er 24hr 100-12.5 mg........................................................... 72 D-VI-SOL -cholecalciferol oral liquid 400 unit/ml............ 170 DYANAVEL XR -amphetamine extended release susp 2.5 mg/ml............................................................................. 127 DYAZIDE -triamterene & hydrochlorothiazide cap 37.5-25 mg.................................................................................... 79 DYCLONINE HCL -dyclonine hcl (bulk) powder............. 233 DYMISTA -azelastine hcl-fluticasone prop nasal spray 137-50 mcg/act............................................................... 87 DYPHYLLINE -dyphylline (bulk) powder......................... 233 dyphylline-guaifenesin liqd 100-100 mg/5ml................ 91 DYRENIUM -triamterene cap 50 mg................................. 79 DYRENIUM -triamterene cap 100 mg............................... 79 DYSPORT -abobotulinumtoxina for im inj 300 unit......... 167 DYSPORT -abobotulinumtoxina for im inj 500 unit......... 167 DYURAL-L -methylprednisolone inj 40 mg/ml & lidocaine inj 1% kit......................................................................... 33 DYURAL-LM -methylprednisolone inj 40 mg/ml & bupiv 0.25% &lido 1% kit......................................................... 33 DYURAL-40 -methylprednisolone inj 40 mg/ml & bupiv 0.25% &lido 1% kit......................................................... 33 DYURAL-80 -methylprednisolone inj 80 mg/ml & bupiv 0.25% &lido 1% kit......................................................... 34 E EC-NAPROSYN -naproxen tab ec 375 mg.....................147 EC-NAPROSYN -naproxen tab ec 500 mg.....................147 econazole nitrate cream 1%......................................... 204
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
314
2016 EFFIENT -prasugrel hcl tab 5 mg (base equiv).............. 188 EFFIENT -prasugrel hcl tab 10 mg (base equiv)............ 188 EFUDEX -fluorouracil cream 5%..................................... 204 EGCG -green tea (camillia sinensis) (bulk) powder........ 233 ELAVIL -amitriptyline hcl tab 25 mg................................ 112 ELDEPRYL -selegiline hcl cap 5 mg...............................165 ELESTAT -epinastine hcl ophth soln 0.05%................... 190 ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm metered-dose pump)...................................................... 40 ELETONE -dermatological products misc - cream......... 204 ELETONE TWINPACK -dermatological products misc cream............................................................................. 204 ELIDEL -pimecrolimus cream 1%................................... 204 ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5 mg.................................................................................... 26 ELIGARD -leuprolide acetate (3 month) for subcutaneous inj kit 22.5mg...................................................................26 ELIGARD -leuprolide acetate (4 month) for subcutaneous inj kit 30 mg.................................................................... 26 ELIGARD -leuprolide acetate (6 month) for subcutaneous inj kit 45 mg.................................................................... 26 ELIMITE -permethrin cream 5%...................................... 204 ELIPHOS -calcium acetate (phosphate binder) tab 667 mg.................................................................................. 103 ELIQUIS -apixaban tab 2.5 mg....................................... 185 ELIQUIS -apixaban tab 5 mg.......................................... 185 ELIXOPHYLLIN -theophylline elixir 80 mg/15ml............... 91 ELLA -ulipristal acetate tab 30 mg.................................... 42 ELLIOTTS B -intrathecal electrolytes w/ dextrose.......... 175 ELMIRON -pentosan polysulfate sodium caps 100 mg.................................................................................. 108 ELOCON -mometasone furoate cream 0.1%................. 204 ELOCON -mometasone furoate oint 0.1%......................204 EMADINE -emedastine difumarate ophth soln 0.05% (base equiv).................................................................. 190 EMBEDA -morphine-naltrexone cap er 20-0.8 mg......... 138 EMBEDA -morphine-naltrexone cap er 30-1.2 mg......... 138 EMBEDA -morphine-naltrexone cap er 50-2 mg............ 138 EMBEDA -morphine-naltrexone cap er 60-2.4 mg......... 139 EMBEDA -morphine-naltrexone cap er 80-3.2 mg......... 139 EMBEDA -morphine-naltrexone cap er 100-4 mg.......... 139 EMCYT -estramustine phosphate sodium cap 140 mg.................................................................................... 26 EMEND -aprepitant capsule 40 mg................................ 100 EMEND -aprepitant capsule 80 mg................................ 100 EMEND -aprepitant capsule 125 mg.............................. 100 EMEND -aprepitant for oral susp 125 mg (125 mg/5ml).......................................................................... 100 EMEND TRIPACK -aprepitant capsule therapy pack 80 & 125 mg.......................................................................... 100 EMOLIVAN -cream base................................................. 265 EMOLLIENT CREAM -cream base................................. 265 EMSAM -selegiline td patch 24hr 6 mg/24hr.................. 112 EMSAM -selegiline td patch 24hr 9 mg/24hr.................. 112 EMSAM -selegiline td patch 24hr 12 mg/24hr................ 112
ECONAZOLE NITRATE -econazole nitrate powder.................................................................... 204,233 ECOTRIN REGULAR STRENGTH -aspirin tab delayed release 325 mg............................................................. 136 ECOZA -econazole nitrate foam 1%............................... 204 EC-RX ESTRADIOL 0.4% -estradiol micronized cream 0.4% (compounding kit).................................................. 40 EC-RX ESTRADIOL 0.6% -estradiol micronized cream 0.6% (compounding kit).................................................. 40 EC-RX PROGESTERONE 10% -progesterone micronized td cream 10% (cmpd kit)............................. 45 EC-RX PROGESTERONE 20% -progesterone micronized td cream 20% (cmpd kit)............................. 45 EC-RX TESTOSTERONE 0.2% -testosterone cream 0.2% (compounding kit).................................................. 38 EC-RX TESTOSTERONE 0.4% -testosterone cream 0.4% (compounding kit).................................................. 38 EC-RX TESTOSTERONE 10% -testosterone cream 10% (compounding kit)........................................................... 38 EC-RX TESTOSTERONE 20% -testosterone cream 20% (compounding kit)........................................................... 38 EDARBI -azilsartan medoxomil tab 40 mg........................72 EDARBI -azilsartan medoxomil tab 80 mg........................72 EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab 40-12.5 mg...................................................................... 72 EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab 40-25 mg......................................................................... 72 EDECRIN -ethacrynic acid tab 25 mg.............................. 79 EDETATE ACID -edetic acid powder.............................. 233 EDETATE CALCIUM DISODIUM -edetate calcium disodium powder........................................................... 218 EDETATE DISODIUM DIHYDRAT -edetate disodium powder........................................................................... 233 EDETATE DISODIUM -edetate disodium powder...........233 EDETATE TETRASODIUM TETRA -edetate sodium (bulk) powder................................................................ 233 EDLUAR -zolpidem tartrate sl tab 5 mg..........................123 EDLUAR -zolpidem tartrate sl tab 10 mg........................123 EDROPHONIUM CHLORIDE -edrophonium chloride (bulk) powder................................................................ 233 EDURANT -rilpivirine hcl tab 25 mg (base equivalent)..... 11 E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg......... 5 E.E.S. GRANULES -erythromycin ethylsuccinate for susp 200 mg/5ml....................................................................... 5 EFFER-K -potassium bicarbonate-citric acid effer tab 10 meq................................................................................ 175 EFFER-K -potassium bicarbonate-citric acid effer tab 20 meq................................................................................ 175 EFFERVESCENT -effervescent base (bulk) powder...... 265 EFFEXOR XR -venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)..................................................................... 112 EFFEXOR XR -venlafaxine hcl cap er 24hr 75 mg (base equivalent)..................................................................... 112 EFFEXOR XR -venlafaxine hcl cap er 24hr 150 mg (base equivalent)..................................................................... 112
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
315
2016 EMTRIVA -emtricitabine caps 200 mg.............................. 11 EMTRIVA -emtricitabine soln 10 mg/ml............................ 11 EMULGADE CM -emulsifying base - liquid.....................265 EMULSIFYING WAX -emulsifying wax........................... 265 EMULSION CONCENTRATE -emulsifying base liquid.............................................................................. 265 EMULSION SB -dermatological products misc emulsion........................................................................ 204 EMU OIL -emu oil (bulk)..................................................233 EMVERM -mebendazole chew tab 100 mg...................... 16 ENABLEX -darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv).................................................................. 106 ENABLEX -darifenacin hydrobromide tab er 24hr 15 mg (base equiv).................................................................. 106 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg................................................................................... 72 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic)...................................................................... 72 ENALAPRIL MALEATE -enalapril maleate (bulk) powder........................................................................... 233 enalapril maleate tab 2.5 mg (Vasotec)......................... 72 enalapril maleate tab 5 mg (Vasotec)............................ 72 enalapril maleate tab 10 mg (Vasotec).......................... 72 enalapril maleate tab 20 mg (Vasotec).......................... 72 ENBREL -etanercept for subcutaneous inj 25 mg.......... 147 ENBREL -etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml.................................................................. 147 ENBREL -etanercept subcutaneous soln prefilled syringe 50 mg/ml....................................................................... 148 ENBREL SURECLICK -etanercept subcutaneous solution auto-injector 50 mg/ml.................................................. 148 ENCARE -nonoxynol-9 vaginal suppos 100 mg............. 107 ENDOMETRIN -progesterone vaginal insert 100 mg..... 107 ENGERIX-B -hepatitis b vaccine (recombinant) 10 mcg/0.5ml........................................................................ 19 ENGERIX-B -hepatitis b vaccine (recombinant) 20 mcg/ ml..................................................................................... 19 ENGERIX-B -hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml........................................................................ 19 ENGERIX-B -hepatitis b vaccine (recombinant) susp 20 mcg/ml............................................................................. 19 ENGLISH TOFFEE FLAVOR -flavoring agent liquid.............................................................................. 265 ENLON -edrophonium chloride inj 10 mg/ml.................. 169 ENOVARX-AMITRIPTYLINE -amitriptyline hcl cream 2% kit (compounding kit).................................................... 233 ENOVARX-BACLOFEN -baclofen cream 1% (compound kit).................................................................................. 204 ENOVARX-CYCLOBENZAPRINE H -cyclobenzaprine hcl td cream 20 mg/gm (compound kit)............................. 168 ENOVARX-DICLOFENAC SODIU -diclofenac sodium cream 2.5% (compounding kit).................................... 204 ENOVARX-IBUPROFEN -ibuprofen cream 10% (compounding kit)......................................................... 204
ENOVARX-LIDOCAINE HCL -lidocaine hcl cream 5% (compound kit).............................................................. 204 ENOVARX-LIDOCAINE HCL -lidocaine hcl cream 10% (compound kit).............................................................. 204 ENOVARX-NAPROXEN -naproxen cream 10% (compound kit).............................................................. 204 ENOVARX-TRAMADOL -tramadol hcl cream 5% (compound kit).............................................................. 204 enoxaparin sodium inj 30 mg/0.3ml (Lovenox).......... 185 enoxaparin sodium inj 40 mg/0.4ml (Lovenox).......... 185 enoxaparin sodium inj 60 mg/0.6ml (Lovenox).......... 185 enoxaparin sodium inj 80 mg/0.8ml (Lovenox).......... 185 enoxaparin sodium inj 100 mg/ml (Lovenox)............. 185 enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........ 185 enoxaparin sodium inj 150 mg/ml (Lovenox)............. 185 enoxaparin sodium inj 300 mg/3ml (Lovenox)........... 185 ENROFLOXACIN -enrofloxacin (bulk) powder............... 233 ENSTILAR -calcipotriene-betamethasone dipropionate foam 0.005-0.064%...................................................... 204 entacapone tab 200 mg (Comtan)............................... 165 entecavir tab 0.5 mg (Baraclude)................................... 11 entecavir tab 1 mg (Baraclude)...................................... 11 ENTEREG -alvimopan cap 12 mg.................................. 103 ENTOCORT EC -budesonide delayed release particles cap 3 mg......................................................................... 34 ENTRESTO -sacubitril-valsartan tab 24-26 mg................ 85 ENTRESTO -sacubitril-valsartan tab 49-51 mg................ 85 ENTRESTO -sacubitril-valsartan tab 97-103 mg.............. 85 ENTTY SPRAY EMULSION -dermatological products misc - emulsion............................................................. 204 ENVARSUS XR -tacrolimus tab er 24hr 0.75 mg........... 276 ENVARSUS XR -tacrolimus tab er 24hr 1 mg................ 276 ENVARSUS XR -tacrolimus tab er 24hr 4 mg................ 276 EPANED -enalapril maleate oral soln 1 mg/ml................. 72 EPCLUSA -sofosbuvir-velpatasvir tab 400-100 mg.......... 11 EPHEDRINE HCL -ephedrine hcl powder........................ 92 EPHEDRINE SULFATE -ephedrine sulfate powder.......... 92 ephedrine sulfate inj 50 mg/ml.......................................80 EPICERAM -dermatological products misc emulsion........................................................................ 204 EPIDUO -adapalene-benzoyl peroxide gel 0.1-2.5%......204 EPIDUO FORTE -adapalene-benzoyl peroxide gel 0.3-2.5%........................................................................ 204 EPIFOAM -pramoxine-hc aerosol foam 1-1%.................204 epinastine hcl ophth soln 0.05% (Elestat).................. 190 EPINEPHRINE - AUTHORIZED GENERIC TO EPIPEN -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)........................................................................... 80 EPINEPHRINE - AUTHORIZED GENERIC TO EPIPEN JR -epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)........................................................................... 80 EPINEPHRINE BASE -epinephrine powder................... 234 EPINEPHRINE BITARTRATE -epinephrine bitartrate (bulk) powder................................................................ 234 EPINEPHRINE -epinephrine powder.............................. 233
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
316
2016 epinephrine hcl inj 1 mg/ml............................................ 92 epinephrine hcl soln prefilled syringe 0.1 mg/ml.........92 EPINEPHRINESNAP-V -epinephrine inj kit 1 mg/ml (1:1000)........................................................................... 80 EPIPEN-JR 2-PAK -epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000).................................................. 80 EPIPEN 2-PAK -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)........................................................... 80 EPISNAP -epinephrine inj kit 1 mg/ml (1:1000)................ 80 EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)............. 11 EPIVIR HBV -lamivudine tab 100 mg (hbv)...................... 11 EPIVIR -lamivudine oral soln 10 mg/ml............................ 11 EPIVIR -lamivudine tab 150 mg........................................ 11 EPIVIR -lamivudine tab 300 mg........................................ 11 eplerenone tab 25 mg (Inspra)....................................... 72 eplerenone tab 50 mg (Inspra)....................................... 72 EPOGEN -epoetin alfa inj 2000 unit/ml...........................181 EPOGEN -epoetin alfa inj 3000 unit/ml...........................181 EPOGEN -epoetin alfa inj 4000 unit/ml...........................181 EPOGEN -epoetin alfa inj 10000 unit/ml.........................181 EPOGEN -epoetin alfa inj 20000 unit/ml.........................181 EPROSARTAN MESYLATE -eprosartan mesylate tab 600 mg.................................................................................... 72 EPZICOM -abacavir sulfate-lamivudine tab 600-300 mg.................................................................................... 11 EQUETRO -carbamazepine (antipsychotic) cap er 12hr 100 mg.......................................................................... 118 EQUETRO -carbamazepine (antipsychotic) cap er 12hr 200 mg.......................................................................... 118 EQUETRO -carbamazepine (antipsychotic) cap er 12hr 300 mg.......................................................................... 118 EQUIPTO-AMITRIPTYLINE -amitriptyline cream 2% (compounding kit)......................................................... 234 EQUIPTO-BACLOFEN -baclofen cream 2% (cmpd kit).................................................................................. 204 EQUIPTO-NAPROXEN -naproxen cream 10% (compound kit).............................................................. 204 ERECAID CLASSIC -impotence aid device - kit............. 261 ERECAID ESTEEM -impotence aid device - kit............. 261 ergocalciferol cap 50000 unit (Drisdol)....................... 170 ERGOCALCIFEROL -ergocalciferol powder...................170 ERGOCAL -ergocalciferol cap 2500 unit........................ 170 ERGOLOID MESYLATES -ergoloid mesylates (bulk) powder........................................................................... 234 ERGOLOID MESYLATES -ergoloid mesylates tab 1 mg.................................................................................. 131 ERGOMAR -ergotamine tartrate sl tab 2 mg.................. 151 ERGOTAMINE TARTRATE -ergotamine tartrate powder........................................................................... 151 ergotamine w/ caffeine tab 1-100 mg (Cafergot)........ 151 ERIVEDGE -vismodegib cap 150 mg............................... 26 EROS-CTD -clitoral vacuum device................................ 261 ERTACZO -sertaconazole nitrate cream 2%.................. 204 ERWINAZE -asparaginase erwinia chrysanthemi for inj 10000 unit....................................................................... 26
ERYGEL -erythromycin gel 2%....................................... 204 ERYPED 200 -erythromycin ethylsuccinate for susp 200 mg/5ml............................................................................... 5 ERYPED 400 -erythromycin ethylsuccinate for susp 400 mg/5ml............................................................................... 5 ERY-TAB -erythromycin tab delayed release 250 mg........ 5 ERY-TAB -erythromycin tab delayed release 333 mg........ 5 ERY-TAB -erythromycin tab delayed release 500 mg........ 5 ERYTHROCIN STEARATE -erythromycin stearate tab 250 mg.............................................................................. 5 ERYTHROMYCIN BASE -erythromycin tab 250 mg.......... 5 ERYTHROMYCIN BASE -erythromycin tab 500 mg.......... 5 ERYTHROMYCIN -erythromycin powder............................5 ERYTHROMYCIN ESTOLATE -erythromycin estolate (bulk) powder................................................................ 234 ERYTHROMYCIN ETHYLSUCCINA -erythromycin ethylsuccinate powder...................................................... 5 ERYTHROMYCIN ETHYLSUCCINA -erythromycin ethylsuccinate tab 400 mg............................................... 5 erythromycin ethylsuccinate for susp 200 mg/5ml (E.e.s. granules).............................................................. 5 erythromycin gel 2% (Erygel)....................................... 204 erythromycin ophth oint 5 mg/gm............................... 190 erythromycin pads 2%.................................................. 204 erythromycin soln 2%................................................... 204 erythromycin w/ delayed release particles cap 250 mg......................................................................................6 ESBRIET -pirfenidone cap 267 mg................................... 95 ESBRIET -pirfenidone tab 267 mg.................................... 95 ESBRIET -pirfenidone tab 801 mg.................................... 95 ESCAVITE D -pediatric multiple vitamins w/ fl-fe chew tab 0.25-6 mg...................................................................... 171 ESCAVITE LQ -pediatric multiple vitamins w/ fl-fe drops 0.25-6 mg/ml................................................................. 171 ESCAVITE -pediatric multiple vitamins w/ fl-fe chew tab 0.25-7.5 mg................................................................... 171 escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro)...................................................................... 112 escitalopram oxalate tab 5 mg (base equiv) (Lexapro)...................................................................... 112 escitalopram oxalate tab 10 mg (base equiv) (Lexapro)...................................................................... 112 escitalopram oxalate tab 20 mg (base equiv) (Lexapro)...................................................................... 112 ESGIC -butalbital-acetaminophen-caffeine tab 50-325-40 mg.................................................................................. 136 ESPUMIL -foam base - foam.......................................... 265 ESSENTRA WIPES 9X9" CLEAN -isopropyl alcohol wipes 70%..................................................................... 204 estazolam tab 1 mg....................................................... 123 estazolam tab 2 mg....................................................... 123 esterified estrogens & methyltestosterone tab 0.625-1.25 mg................................................................ 40 esterified estrogens & methyltestosterone tab 1.25-2.5 mg.....................................................................40
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
317
2016 ESTRONE CONCENTRATE -estrone (bulk) cream 1%.................................................................................. 234 ESTRONE -estrone (bulk) crystals................................. 234 ESTRONE -estrone (bulk) powder.................................. 234 ESTRONE -estrone powder.............................................. 40 ESTROPIPATE -estropipate tab 0.75 mg......................... 40 ESTROPIPATE -estropipate tab 1.5 mg........................... 40 ESTROPIPATE -estropipate tab 3 mg.............................. 40 ESTROSTEP FE -norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg.................................................. 42 eszopiclone tab 1 mg (Lunesta).................................. 123 eszopiclone tab 2 mg (Lunesta).................................. 123 eszopiclone tab 3 mg (Lunesta).................................. 123 ethacrynic acid tab 25 mg.............................................. 79 ETHAMBUTOL HCL -ethambutol hcl powder..................... 8 ethambutol hcl tab 100 mg (Myambutol)........................ 8 ethambutol hcl tab 400 mg (Myambutol)........................ 8 ETHER -ether (solvent grade) soln................................. 234 ETHINYL ESTRADIOL -ethinyl estradiol powder............. 40 ethosuximide cap 250 mg (Zarontin).......................... 158 ETHOSUXIMIDE -ethosuximide (bulk) powder.............. 234 ethosuximide soln 250 mg/5ml (Zarontin).................. 158 ETHOXY DIGLYCOL -carbitol liquid............................... 234 ETHYL ACETATE -ethyl acetate soln............................. 265 ETHYL ALCOHOL -alcohol, usp 95%............................. 234 ETHYL ALCOHOL -ethyl alcohol 100%.......................... 265 ETHYL ALCOHOL 190 PROOF -alcohol, usp 95%........ 234 ETHYL ALCOHOL 200 PROOF -ethyl alcohol 100%..... 265 ETHYLENEDIAMINE -ethylenediamine liquid 99% (bulk).............................................................................. 234 ETHYL OLEATE -ethyl oleate (bulk) liquid..................... 234 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg................................................................................. 42 ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg (Zovia 1/50e)......................................................... 42 ETIDRONATE DISODIUM -etidronate disodium tab 200 mg.................................................................................... 56 ETIDRONATE DISODIUM -etidronate disodium tab 400 mg.................................................................................... 56 etodolac cap 200 mg..................................................... 148 etodolac cap 300 mg..................................................... 148 etodolac tab er 24hr 400 mg........................................ 148 etodolac tab er 24hr 500 mg........................................ 148 etodolac tab er 24hr 600 mg........................................ 148 etodolac tab 400 mg...................................................... 148 etodolac tab 500 mg...................................................... 148 ETOMIDATE -etomidate (bulk) powder........................... 234 ETOPOSIDE -etoposide (bulk) powder........................... 234 ETOPOSIDE -etoposide cap 50 mg..................................26 EUCALYPTOL -eucalyptol (bulk) liquid........................... 234 EUCALYPTUS FLAVOR -flavoring agent - oil................ 265 EUCALYPTUS OIL -eucalyptus oil.................................. 234 EUGENOL -eugenol........................................................ 234 EUGENOL FLAVOR -flavoring agent - liquid.................. 265 EURAX -crotamiton cream 10%...................................... 204
ESTRACE -estradiol tab 0.5 mg....................................... 40 ESTRACE -estradiol tab 1 mg.......................................... 40 ESTRACE -estradiol tab 2 mg.......................................... 40 ESTRACE -estradiol vaginal cream 0.1 mg/gm.............. 107 estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella)....................................................................... 40 estradiol & norethindrone acetate tab 1-0.5 mg (Activella)....................................................................... 40 ESTRADIOL BENZOATE -estradiol benzoate (bulk) powder........................................................................... 234 ESTRADIOL CONCENTRATE -estradiol (bulk) cream 10%................................................................................234 ESTRADIOL CYPIONATE -estradiol cypionate (bulk) powder........................................................................... 234 ESTRADIOL -estradiol (bulk) powder............................. 234 ESTRADIOL -estradiol micronized (bulk) powder...........234 ESTRADIOL -estradiol powder..........................................40 ESTRADIOL MICRONIZED -estradiol micronized (bulk) powder........................................................................... 234 estradiol tab 0.5 mg (Estrace)........................................ 40 estradiol tab 1 mg (Estrace)........................................... 40 estradiol tab 2 mg (Estrace)........................................... 40 estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 40 estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot).................................................................... 40 estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot).................................................................................. 40 estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot).................................................................................. 40 estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot).................................................................................. 40 estradiol td patch weekly 0.025 mg/24hr (Climara)......40 estradiol td patch weekly 0.05 mg/24hr (Climara)........40 estradiol td patch weekly 0.06 mg/24hr (Climara)........40 estradiol td patch weekly 0.075 mg/24hr (Climara)......40 estradiol td patch weekly 0.1 mg/24hr (Climara)..........40 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara)...................................................... 40 ESTRADIOL VALERATE -estradiol valerate (bulk) powder........................................................................... 234 estradiol valerate im in oil 20 mg/ml (Delestrogen)..... 40 estradiol valerate im in oil 40 mg/ml (Delestrogen)..... 40 ESTRING -estradiol vaginal ring 2 mg (7.5 mcg/24hrs).................................................................... 107 ESTRIOL CONCENTRATE -estriol (bulk) cream 10%................................................................................234 ESTRIOL -estriol micronized (bulk) powder....................234 ESTRIOL -estriol micronized powder................................ 40 ESTRIOL MICRONIZED -estriol micronized (bulk) powder........................................................................... 234 ESTRIOL ULTRA MICRONIZED -estriol micronized (bulk) powder........................................................................... 234 ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump)...................................................... 40
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
318
2016 EXTAVIA -interferon beta-1b for inj kit 0.3 mg................ 131 EXTINA -ketoconazole foam 2%..................................... 205 EXTRANEAL -icodextrin-electrolytes solution 7.5%....... 276 EXYDERM -transdermal patch........................................ 265 EYLEA -aflibercept intravitreal inj 2 mg/0.05ml (40 mg/ ml).................................................................................. 190 ezetimibe-simvastatin tab 10-10 mg (Vytorin).............. 81 ezetimibe-simvastatin tab 10-20 mg (Vytorin).............. 81 ezetimibe-simvastatin tab 10-40 mg (Vytorin).............. 81 ezetimibe-simvastatin tab 10-80 mg (Vytorin).............. 81 ezetimibe tab 10 mg (Zetia)............................................ 81
EURAX -crotamiton lotion 10%....................................... 205 EVAMIST -estradiol transdermal spray 1.53 mg/spray..... 40 EVANS BLUE -evans blue powder................................. 265 EVEKEO -amphetamine sulfate tab 5 mg.......................127 EVEKEO -amphetamine sulfate tab 10 mg.....................127 EVICEL -fibrin sealant component kit 2 ml..................... 187 EVICEL -fibrin sealant component kit 5 ml..................... 187 EVISTA -raloxifene hcl tab 60 mg..................................... 56 EVITHROM -thrombin (human) topical soln 800-1200 unit/ml............................................................................ 187 EVOCLIN -clindamycin phosphate foam 1%.................. 205 EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg (base equiv).................................................................... 11 EVOXAC -cevimeline hcl cap 30 mg.............................. 195 EXACTUSS -phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml............................................................................. 88 EXALGO -hydromorphone hcl tab er 24hr deter 8 mg.................................................................................. 139 EXALGO -hydromorphone hcl tab er 24hr deter 12 mg.................................................................................. 139 EXALGO -hydromorphone hcl tab er 24hr deter 16 mg.................................................................................. 139 EXALGO -hydromorphone hcl tab er 24hr deter 32 mg.................................................................................. 139 EXELDERM -sulconazole nitrate cream 1%................... 205 EXELDERM -sulconazole nitrate solution 1%................ 205 EXELON -rivastigmine td patch 24hr 4.6 mg/24hr.......... 131 EXELON -rivastigmine td patch 24hr 9.5 mg/24hr.......... 131 EXELON -rivastigmine td patch 24hr 13.3 mg/24hr........ 131 exemestane tab 25 mg (Aromasin)................................ 26 EXFORGE -amlodipine besylate-valsartan tab 5-160 mg.................................................................................... 72 EXFORGE -amlodipine besylate-valsartan tab 5-320 mg.................................................................................... 72 EXFORGE -amlodipine besylate-valsartan tab 10-160 mg.................................................................................... 72 EXFORGE -amlodipine besylate-valsartan tab 10-320 mg.................................................................................... 72 EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg......................... 72 EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg............................ 73 EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg....................... 73 EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg.......................... 73 EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg.......................... 73 EXJADE -deferasirox tab for oral susp 125 mg.............. 218 EXJADE -deferasirox tab for oral susp 250 mg.............. 219 EXJADE -deferasirox tab for oral susp 500 mg.............. 219 EXODERM -sodium thiosulfate-salicylic acid lotion 25-1%............................................................................ 205 EXPAREL -bupivacaine liposome inj 1.3% (13.3 mg/ ml).................................................................................. 154
F FABIOR -tazarotene (acne) foam 0.1%.......................... 205 FACTIVE -gemifloxacin mesylate tab 320 mg (base equiv)................................................................................. 7 FAGRON CAPFILL PRO -excipient filler powder............265 FAGRON DISPERSAPRO -excipient filler powder......... 265 FAGRON LS PLUS -cream base.................................... 265 FAGRON NATURAL CREAM -cream base.................... 265 FAGRON SUPREME CREAM -cream base................... 265 FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa tab 1 mg kit..................................................................... 42 FAMCICLOVIR -famciclovir (bulk) powder...................... 234 famciclovir tab 125 mg (Famvir).................................... 11 famciclovir tab 250 mg (Famvir).................................... 11 famciclovir tab 500 mg (Famvir).................................... 11 FAMOTIDINE -famotidine (bulk) powder.........................234 famotidine for susp 40 mg/5ml (Pepcid)....................... 98 famotidine tab 20 mg (Pepcid)....................................... 98 famotidine tab 40 mg (Pepcid)....................................... 98 FANAPT -iloperidone tab 1 mg....................................... 118 FANAPT -iloperidone tab 2 mg....................................... 118 FANAPT -iloperidone tab 4 mg....................................... 118 FANAPT -iloperidone tab 6 mg....................................... 118 FANAPT -iloperidone tab 8 mg....................................... 118 FANAPT -iloperidone tab 10 mg..................................... 118 FANAPT -iloperidone tab 12 mg..................................... 118 FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg & 4 mg & 6 mg titration pak......................................... 118 FANATREX FUSEPAQ -gabapentin oral susp 25 mg/ml (cmpd kit)...................................................................... 159 FARESTON -toremifene citrate tab 60 mg (base equivalent)....................................................................... 26 FARXIGA -dapagliflozin propanediol tab 5 mg (base equivalent)....................................................................... 47 FARXIGA -dapagliflozin propanediol tab 10 mg (base equivalent)....................................................................... 47 FARYDAK -panobinostat lactate cap 10 mg (base equivalent)....................................................................... 26 FARYDAK -panobinostat lactate cap 15 mg (base equivalent)....................................................................... 26 FARYDAK -panobinostat lactate cap 20 mg (base equivalent)....................................................................... 26 FASLODEX -fulvestrant inj 250 mg/5ml............................ 26
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
319
2016 FENOFIBRATE -fenofibrate (bulk) powder..................... 235 FENOFIBRATE -fenofibrate cap 50 mg............................ 81 FENOFIBRATE -fenofibrate cap 150 mg.......................... 82 fenofibrate micronized cap 43 mg................................. 82 fenofibrate micronized cap 130 mg............................... 82 fenofibrate micronized cap 67 mg (Lofibra)................. 82 fenofibrate micronized cap 134 mg (Lofibra)............... 82 fenofibrate micronized cap 200 mg (Lofibra)............... 82 fenofibrate tab 40 mg (Fenoglide)................................. 82 fenofibrate tab 120 mg (Fenoglide)............................... 82 fenofibrate tab 54 mg (Lofibra)...................................... 82 fenofibrate tab 160 mg (Lofibra).................................... 82 fenofibrate tab 48 mg (Tricor)........................................ 82 fenofibrate tab 145 mg (Tricor)...................................... 82 FENOFIBRIC ACID -fenofibric acid tab 35 mg................. 82 FENOFIBRIC ACID -fenofibric acid tab 105 mg............... 82 FENOGLIDE -fenofibrate tab 40 mg................................. 82 FENOGLIDE -fenofibrate tab 120 mg............................... 82 FENOPROFEN CALCIUM -fenoprofen calcium powder........................................................................... 148 FENOPROFEN CALCIUM -fenoprofen calcium tab 600 mg.................................................................................. 148 FENTANYL CITRATE -fentanyl citrate powder............... 139 fentanyl citrate lollipop 200 mcg (Actiq)..................... 139 fentanyl citrate lollipop 400 mcg (Actiq)..................... 139 fentanyl citrate lollipop 600 mcg (Actiq)..................... 139 fentanyl citrate lollipop 800 mcg (Actiq)..................... 139 fentanyl citrate lollipop 1200 mcg (Actiq)................... 139 fentanyl citrate lollipop 1600 mcg (Actiq)................... 139 FENTANYL -fentanyl td patch 72hr 37.5 mcg/hr.............139 FENTANYL -fentanyl td patch 72hr 62.5 mcg/hr.............139 FENTANYL -fentanyl td patch 72hr 87.5 mcg/hr.............139 fentanyl td patch 72hr 12 mcg/hr (Duragesic)............ 139 fentanyl td patch 72hr 25 mcg/hr (Duragesic)............ 139 fentanyl td patch 72hr 50 mcg/hr (Duragesic)............ 139 fentanyl td patch 72hr 75 mcg/hr (Duragesic)............ 139 fentanyl td patch 72hr 100 mcg/hr (Duragesic).......... 139 FENTORA -fentanyl citrate buccal tab 100 mcg (base equiv)............................................................................. 139 FENTORA -fentanyl citrate buccal tab 200 mcg (base equiv)............................................................................. 139 FENTORA -fentanyl citrate buccal tab 400 mcg (base equiv)............................................................................. 139 FENTORA -fentanyl citrate buccal tab 600 mcg (base equiv)............................................................................. 139 FENTORA -fentanyl citrate buccal tab 800 mcg (base equiv)............................................................................. 139 FER-IN-SOL -ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)................................................................. 181 FERIVA 21/7 -fe asparto gly-b12-fa-c-dss-succinic acid-zn tab 75-1 mg...................................................................181 FERIVAFA -iron-c-fa-b12-biotin-copper-docusate cap 110-1 mg....................................................................... 181 FERIVA -fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap 75-1 mg......................................................................... 181
FAZACLO -clozapine orally disintegrating tab 12.5 mg.................................................................................. 118 FAZACLO -clozapine orally disintegrating tab 25 mg..... 118 FAZACLO -clozapine orally disintegrating tab 100 mg.................................................................................. 118 FAZACLO -clozapine orally disintegrating tab 150 mg.................................................................................. 118 FAZACLO -clozapine orally disintegrating tab 200 mg.................................................................................. 118 FBL KIT -flurbiprofen-baclofen-lidocaine cream 15-4-5% (cmpd kit)...................................................................... 205 FC FEMALE CONDOM -condoms - female....................261 FC2 FEMALE CONDOM -condoms - female..................261 FD&C YELLOW #6 ALUMINUM L -fd&c yellow #6 aluminum lake powder................................................. 265 FD&C YELLOW #5 -tartrazine (fd&c yellow #5) powder........................................................................... 265 FDC BLUE 1 -dye fdc blue 1 (brilliant blue fcf) powder........................................................................... 265 FDC BLUE 2 -fd&c blue #2 (indigotine) powder............. 265 FDC GREEN #3 -dye fdc green 3 powder...................... 265 FDC RED #3 -dye fdc red 3 (erythrosine) powder.......... 265 FDC RED 40 -dye fdc red 40 (allura red) - powder........ 265 FDC YELLOW 6 -dye fdc yellow 6 (sunset yellow) powder........................................................................... 265 fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg................................................................................. 181 fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg................................................................................. 181 fe fum-iron polysacch complex-fa-b cmplx-c-zn-mncu cap (Tandem plus)................................................ 181 felbamate susp 600 mg/5ml (Felbatol)........................ 159 felbamate tab 400 mg (Felbatol).................................. 159 felbamate tab 600 mg (Felbatol).................................. 159 FELBATOL -felbamate susp 600 mg/5ml........................159 FELBATOL -felbamate tab 400 mg................................. 159 FELBATOL -felbamate tab 600 mg................................. 159 FELDENE -piroxicam cap 10 mg.................................... 148 FELDENE -piroxicam cap 20 mg.................................... 148 felodipine tab er 24hr 2.5 mg......................................... 65 felodipine tab er 24hr 5 mg............................................ 65 felodipine tab er 24hr 10 mg.......................................... 65 FEMARA -letrozole tab 2.5 mg......................................... 26 FEMCAP -cervical cap 22 mm........................................ 261 FEMCAP -cervical cap 26 mm........................................ 261 FEMCAP -cervical cap 30 mm........................................ 261 FEMHRT LOW DOSE -norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg......................................... 41 FEM PH -acetic acid-oxyquinoline vaginal gel 0.9-0.025%.................................................................... 107 FEMRING -estradiol acetate vaginal ring 0.05 mg/24hr......................................................................... 107 FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr......................................................................... 107 FENBENDAZOLE -fenbendazole (bulk) powder............ 234
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
320
2016 FETZIMA TITRATION PACK -levomilnacipran hcl cap er 24hr 20 & 40 mg therapy pack.................................... 113 FEVERFEW -feverfew (bulk) powder..............................235 FEXMID -cyclobenzaprine hcl tab 7.5 mg.......................168 FEXOFENADINE HCL -fexofenadine hcl (bulk) powder........................................................................... 235 FIBERSOURCE HN -nutritional supplement liquid......... 178 FIBRICOR -fenofibric acid tab 35 mg............................... 82 FIBRICOR -fenofibric acid tab 105 mg............................. 82 FINACEA -azelaic acid foam 15%.................................. 205 FINACEA -azelaic acid gel 15%..................................... 205 FINASTERIDE -finasteride (bulk) crystals...................... 235 FINASTERIDE -finasteride (bulk) powder....................... 235 finasteride tab 5 mg (Proscar)..................................... 108 FIORICET/CODEINE -butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg............................................ 139 FIORICET -butalbital-acetaminophen-caffeine cap 50-300-40 mg................................................................136 FIORINAL/CODEINE #3 -butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg................................................... 139 FIORINAL -butalbital-aspirin-caffeine cap 50-325-40 mg.................................................................................. 136 FIRAZYR -icatibant acetate inj 30 mg/3ml (base equivalent)..................................................................... 188 FIRMAGON -degarelix acetate for inj 80 mg (base equiv)............................................................................... 26 FIRMAGON -degarelix acetate for inj 120 mg (base equiv)............................................................................... 26 FIRST-BACLOFEN 1 -baclofen oral susp 1 mg/ml (cmpd kit).................................................................................. 168 FIRST-BACLOFEN 5 -baclofen oral susp 5 mg/ml (cmpd kit).................................................................................. 168 FIRST-HYDROCORTISONE -hydrocortisone gel 10% (cmpd kit)...................................................................... 205 FIRST-METRONIDAZOLE 100 -metronidazole benzoate for susp 100 mg/ml (cmpd kit)....................................... 17 FIRST-METRONIDAZOLE 50 -metronidazole benzoate for susp 50 mg/ml (cmpd kit)......................................... 17 FIRST-MOUTHWASH BLM -diphenhyd-lido-al hydrox-mg hydrox-simeth susp (cmpd kit)..................................... 195 FIRST-PROGESTERONE VGS 10 -progesterone vaginal suppository 100 mg...................................................... 107 FIRST-PROGESTERONE VGS 20 -progesterone vaginal suppository 200 mg...................................................... 107 FIRST-TESTOSTERONE MC COM -testosterone propionate td cream 2% (cmpd kit)................................ 38 FIRST-TESTOSTERONE -testosterone propionate td ointment 2% (cmpd kit).................................................. 38 FIRST-VANCOMYCIN 25 -vancomycin hcl oral soln 25 mg/ml (compound kit)..................................................... 17 FIRST-VANCOMYCIN 50 -vancomycin hcl oral soln 50 mg/ml (compound kit)..................................................... 17 FISH FLAVOR -flavoring agent - liquid........................... 265 FITALITE -cream base.....................................................265 FIZZMIX BASE -effervescent base (bulk) powder.......... 266
FERRALET 90 -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg........................................................... 181 FERRAPLUS 90 -iron-folic acid-vit b12-vit c-docusate sod tab 90-1 mg...................................................................181 FERRETTS CHEWABLE IRON -carbonyl iron chew tab 18 mg (elemental iron)................................................. 181 FERRIC AMMONIUM CITRATE -ferric ammonium citrate (bulk) powder................................................................ 235 FERRIC CHLORIDE HEXAHYDRA -ferric chloride lump............................................................................... 235 FERRIC PYROPHOSPHATE -bulk chemicals powder........................................................................... 235 FERRIC SUBSULFATE -ferric subsulfate (bulk) soln..... 235 FERRIC SULFATE HYDRATE -ferric sulfate (bulk) powder........................................................................... 235 FERRIPROX -deferiprone oral soln 100 mg/ml.............. 219 FERRIPROX -deferiprone tab 500 mg............................ 219 FERRO-PLEX HEMATINIC -fe fum-dss-vit c-vit e-vit b12if-fa tab 115-1 mg......................................................... 181 FERROTRIN -iron w/ b12-vit c-fa-ifc cap 36-0.015-75-0.5-240 mg............................................... 181 FERROUS BISGLYCINATE CHEL -ferrous bisglycinate chelate (bulk) powder................................................... 235 ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg.......................................................................181 FERROUS FUMARATE -ferrous fumarate (bulk) powder........................................................................... 235 ferrous fumarate-folic acid tab 324-1 mg....................181 FERROUS GLUCONATE DIHYDRA -ferrous gluconate (bulk) granules.............................................................. 235 FERROUS GLUCONATE DIHYDRA -ferrous gluconate (bulk) powder................................................................ 235 FERROUS GLUCONATE -ferrous gluconate (bulk) powder........................................................................... 235 FERROUS SULFATE ANHYDROUS -ferrous sulfate powder........................................................................... 181 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe).................................................................................. 181 FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml (44 mg/5ml elemental fe)............................................. 181 FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml (60 mg/5ml elemental fe)............................................. 181 FERROUS SULFATE HEPTAHYDR -ferrous sulfate granules......................................................................... 181 ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe).................................................................................. 182 FERULIC ACID -ferulic acid (bulk) powder..................... 235 FETZIMA -levomilnacipran hcl cap er 24hr 20 mg (base equivalent)..................................................................... 113 FETZIMA -levomilnacipran hcl cap er 24hr 40 mg (base equivalent)..................................................................... 113 FETZIMA -levomilnacipran hcl cap er 24hr 80 mg (base equivalent)..................................................................... 113 FETZIMA -levomilnacipran hcl cap er 24hr 120 mg (base equivalent)..................................................................... 113
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
321
2016 FLAGYL -metronidazole cap 375 mg................................ 17 FLAGYL -metronidazole tab 250 mg................................ 17 FLAGYL -metronidazole tab 500 mg................................ 17 FLAREX -fluorometholone acetate ophth susp 0.1%..... 190 FLAVOR BLEND -oral vehicles - susp............................ 266 FLAVOR CONCENTRATE/CHLORH -flavoring agent concentrate.................................................................... 266 FLAVOR PLUS -oral vehicles..........................................266 FLAVOR SWEET -oral vehicles - syrup.......................... 266 FLAVOR SWEET-SF -oral vehicles - syrup.................... 266 flavoxate hcl tab 100 mg...............................................106 flecainide acetate tab 50 mg.......................................... 67 flecainide acetate tab 100 mg........................................ 67 flecainide acetate tab 150 mg........................................ 67 FLECTOR -diclofenac epolamine patch 1.3%................ 205 FLIBANSERIN -flibanserin (bulk) powder....................... 235 FLOMAX -tamsulosin hcl cap 0.4 mg............................. 108 FLORICAL -sodium fluoride w/ calcium carb cap 8.3-364 mg.................................................................................. 175 FLORICAL -sodium fluoride w/ calcium carb tab 8.3-364 mg.................................................................................. 175 FLORIVA -ped multiple vitamins & minerals w/ fl chew tab 0.25 mg......................................................................... 171 FLORIVA -ped multiple vitamins & minerals w/ fl chew tab 0.5 mg........................................................................... 171 FLORIVA -ped multiple vitamins & minerals w/ fl chew tab 1 mg.............................................................................. 171 FLORIVA PLUS -pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml............................................................ 171 FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/ ml-400 unit/ml............................................................... 175 FLOVENT DISKUS -fluticasone propionate aer pow ba 50 mcg/blister....................................................................... 92 FLOVENT DISKUS -fluticasone propionate aer pow ba 100 mcg/blister................................................................ 92 FLOVENT DISKUS -fluticasone propionate aer pow ba 250 mcg/blister................................................................ 92 FLOVENT HFA -fluticasone propionate hfa inhal aer 110 mcg/act (125/valve)........................................................ 92 FLOVENT HFA -fluticasone propionate hfa inhal aer 220 mcg/act (250/valve)........................................................ 92 FLOVENT HFA -fluticasone propionate hfa inhal aero 44 mcg/act (50/valve)...........................................................92 FLOWTUSS -hydrocodone-guaifenesin soln 2.5-200 mg/5ml............................................................................. 88 FLOXIN OTIC -ofloxacin otic soln 0.3%..........................194 FLOXURIDINE -floxuridine (bulk) powder.......................235 FLOXURIDINE -floxuridine for inj 0.5 gm......................... 26 FLUAD 2016-2017 -influenza vac type a&b surface ant adj susp pref syr 0.5 ml................................................. 19 FLUAD 2017-2018 -influenza vac type a&b surface ant adj susp pref syr 0.5 ml................................................. 19 FLUARIX 2014-2015 -influenza virus vaccine split pf susp pref syringe 0.5 ml.......................................................... 19
FLUARIX QUADRIVALENT 2015 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 19 FLUARIX QUADRIVALENT 2016 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 19 FLUARIX QUADRIVALENT 2017 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 19 FLUBLOK 2015-2016 -influenza virus vac recombinant hemagglutinin (ha) inj..................................................... 19 FLUBLOK 2016-2017 -influenza virus vac recombinant hemagglutinin (ha) inj..................................................... 20 FLUBLOK 2017-2018 -influenza virus vac recombinant hemagglutinin (ha) inj..................................................... 20 FLUBLOK QUADRIVALENT 2017 -influenza vac recomb ha quad pf soln pref syr 0.5 ml...................................... 19 FLUCELVAX 2015-2016 -influenza virus vac tiss-cult subunit susp pref syr 0.5 ml........................................... 20 FLUCELVAX QUADRIVALENT 20 -influenza vac tiss-cult subunt quad susp pref syr 0.5 ml.................................. 20 FLUCELVAX QUADRIVALENT 20 -influenza vac tissuecultured subunit quadrivalent im susp........................... 20 FLUCONAZOLE -fluconazole (bulk) powder.................. 235 fluconazole for susp 10 mg/ml (Diflucan)....................... 9 fluconazole for susp 40 mg/ml (Diflucan)....................... 9 fluconazole tab 50 mg (Diflucan)..................................... 9 fluconazole tab 100 mg (Diflucan)................................... 9 fluconazole tab 150 mg (Diflucan)................................... 9 fluconazole tab 200 mg (Diflucan)................................... 9 flucytosine cap 250 mg (Ancobon)................................. 9 flucytosine cap 500 mg (Ancobon)................................. 9 FLUCYTOSINE -flucytosine (bulk) powder..................... 235 FLUDROCORTISONE ACETATE -fludrocortisone acetate powder............................................................................. 34 fludrocortisone acetate tab 0.1 mg............................... 34 FLULAVAL QUADRIVALENT 201 -influenza virus vaccine split quadrivalent im inj................................................... 20 FLULAVAL QUADRIVALENT 201 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 20 FLUMADINE -rimantadine hydrochloride tab 100 mg.......11 FLUMAZENIL -flumazenil (bulk) powder.........................235 FLUMIST QUADRIVALENT -influenza virus vaccine live quadrivalent intranasal susp...........................................20 FLUNISOLIDE ANHYDROUS -flunisolide powder........... 92 FLUNISOLIDE -flunisolide nasal soln 25 mcg/act (0.025%).......................................................................... 87 FLUNISOLIDE -flunisolide powder.................................... 92 FLUNIXIN MEGLUMINE -flunixin meglumine (bulk) powder........................................................................... 235 fluocinolone acetonide cream 0.01%.......................... 205 fluocinolone acetonide cream 0.025% (Synalar)........205 FLUOCINOLONE ACETONIDE -fluocinolone acetonide powder........................................................................... 205 fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).......................................................... 205 fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)...........................................................205
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
322
2016 fluphenazine hcl tab 10 mg.......................................... 118 FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf)............................................... 175 flurandrenolide cream 0.05%....................................... 205 flurandrenolide lotion 0.05% (Cordran).......................205 flurandrenolide oint 0.05% (Cordran).......................... 205 FLURAZEPAM HCL -flurazepam hcl cap 15 mg............ 123 FLURAZEPAM HCL -flurazepam hcl cap 30 mg............ 123 FLURBIPROFEN -flurbiprofen powder............................148 flurbiprofen sodium ophth soln 0.03% (Ocufen)........190 flurbiprofen tab 50 mg.................................................. 148 flurbiprofen tab 100 mg................................................ 148 flutamide cap 125 mg...................................................... 26 FLUTICASONE PROPIONATE/SA -fluticasone-salmeterol aer powder ba 55-14 mcg/act........................................ 92 FLUTICASONE PROPIONATE/SA -fluticasone-salmeterol aer powder ba 113-14 mcg/act...................................... 92 FLUTICASONE PROPIONATE/SA -fluticasone-salmeterol aer powder ba 232-14 mcg/act...................................... 92 fluticasone propionate cream 0.05% (Cutivate)......... 205 FLUTICASONE PROPIONATE -fluticasone propionate (bulk) powder................................................................ 235 fluticasone propionate lotion 0.05% (Cutivate).......... 205 fluticasone propionate nasal susp 50 mcg/act (Flonase)......................................................................... 87 fluticasone propionate oint 0.005% (Cutivate)........... 205 fluvastatin sodium cap 20 mg (Lescol)......................... 82 fluvastatin sodium cap 40 mg (Lescol)......................... 82 fluvastatin sodium tab er 24 hr 80 mg (Lescol xl)........82 FLUVIRIN 2015-2016 -influenza vac type a&b surface antigen susp pref syr 0.5 ml...........................................20 FLUVIRIN 2016-2017 -influenza vac type a&b surface antigen susp pref syr 0.5 ml...........................................20 FLUVIRIN 2017-2018 -influenza vac type a&b surface antigen susp pref syr 0.5 ml...........................................20 FLUVIRIN 2015-2016 -influenza virus vaccine types a & b surface antigen im susp................................................. 20 FLUVIRIN 2016-2017 -influenza virus vaccine types a & b surface antigen im susp................................................. 20 FLUVIRIN 2017-2018 -influenza virus vaccine types a & b surface antigen im susp................................................. 20 FLUVIRIN PF 2014-2015 -influenza virus vac types a & b pf susp prefilled syr 0.5 ml............................................. 20 fluvoxamine maleate cap er 24hr 100 mg................... 113 fluvoxamine maleate cap er 24hr 150 mg................... 113 fluvoxamine maleate tab 25 mg................................... 113 fluvoxamine maleate tab 50 mg................................... 113 fluvoxamine maleate tab 100 mg................................. 113 FLUZONE HIGH-DOSE PF 2015 -influenza virus vac split high-dose pf susp pref syr 0.5ml....................................20 FLUZONE HIGH-DOSE PF 2016 -influenza virus vac split high-dose pf susp pref syr 0.5ml....................................20 FLUZONE HIGH-DOSE PF 2017 -influenza virus vac split high-dose pf susp pref syr 0.5ml....................................20
fluocinolone acetonide oint 0.025% (Synalar)............ 205 fluocinolone acetonide (otic) oil 0.01% (Dermotic).................................................................... 194 fluocinolone acetonide soln 0.01% (Synalar)............. 205 fluocinonide cream 0.05%............................................ 205 fluocinonide emulsified base cream 0.05%................ 205 FLUOCINONIDE -fluocinonide powder........................... 205 fluocinonide gel 0.05%.................................................. 205 fluocinonide oint 0.05%................................................ 205 fluocinonide soln 0.05%................................................ 205 FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from 0.55 mg/0.6ml naf)........................................................175 FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55 (0.25 mg f)-236.79 mg..................................................175 FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg f)-236.79 mg.................................................................. 175 FLUORESCEIN -fluorescein (bulk) powder.................... 235 FLUORESCEIN SODIUM -fluorescein sodium powder........................................................................... 235 fluorometholone ophth susp 0.1% (Fml liquifilm)..... 190 FLUOROPLEX -fluorouracil cream 1%........................... 205 fluorouracil cream 5% (Efudex)................................... 205 FLUOROURACIL -fluorouracil (bulk) powder................. 235 5-FLUOROURACIL -fluorouracil (bulk) powder.............. 260 FLUOROURACIL -fluorouracil cream 0.5%.................... 205 FLUOROURACIL -fluorouracil soln 2%.......................... 205 FLUOROURACIL -fluorouracil soln 5%.......................... 205 FLUOXETINE DR -fluoxetine hcl cap delayed release 90 mg.................................................................................. 113 FLUOXETINE -fluoxetine hcl (pmdd) cap 10 mg............ 131 FLUOXETINE -fluoxetine hcl (pmdd) cap 20 mg............ 131 fluoxetine hcl cap 10 mg (Prozac)............................... 113 fluoxetine hcl cap 20 mg (Prozac)............................... 113 fluoxetine hcl cap 40 mg (Prozac)............................... 113 FLUOXETINE HCL -fluoxetine hcl (bulk) powder........... 235 FLUOXETINE HCL -fluoxetine hcl tab 60 mg................. 113 fluoxetine hcl (pmdd) tab 10 mg (Sarafem)................ 131 fluoxetine hcl (pmdd) tab 20 mg (Sarafem)................ 131 fluoxetine hcl solution 20 mg/5ml............................... 113 fluoxetine hcl tab 10 mg............................................... 113 fluoxetine hcl tab 20 mg............................................... 113 FLUPHENAZINE DECANOATE -fluphenazine decanoate (bulk) liquid.................................................................... 235 FLUPHENAZINE DECANOATE -fluphenazine decanoate (bulk) powder................................................................ 235 fluphenazine decanoate inj 25 mg/ml......................... 118 FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5 mg/5ml........................................................................... 118 FLUPHENAZINE HCL -fluphenazine hcl inj 2.5 mg/ ml................................................................................... 118 FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/ ml................................................................................... 118 fluphenazine hcl tab 1 mg............................................ 118 fluphenazine hcl tab 2.5 mg......................................... 118 fluphenazine hcl tab 5 mg............................................ 118
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
323
2016 FLUZONE INTRADERMAL QUADR -influenza virus vac split quad intradermal pen 9 mcg/strain......................... 20 FLUZONE QUADRIVALENT 2015 -influenza virus vaccine split quadrivalent im inj..................................... 20 FLUZONE QUADRIVALENT 2016 -influenza virus vaccine split quadrivalent im inj..................................... 21 FLUZONE QUADRIVALENT 2017 -influenza virus vaccine split quadrivalent im inj..................................... 21 FLUZONE QUADRIVALENT 2015 -influenza virus vaccine split quadrivalent inj 0.5 ml............................... 21 FLUZONE QUADRIVALENT 2016 -influenza virus vaccine split quadrivalent inj 0.5 ml............................... 21 FLUZONE QUADRIVALENT 2015 -influenza virus vac split quadrivalent susp pref syr 0.25 ml......................... 20 FLUZONE QUADRIVALENT 2015 -influenza virus vac split quadrivalent susp pref syr 0.5ml............................ 20 FLUZONE QUADRIVALENT 2016 -influenza virus vac split quadrivalent susp pref syr 0.25 ml......................... 21 FLUZONE QUADRIVALENT 2016 -influenza virus vac split quadrivalent susp pref syr 0.5ml............................ 21 FLUZONE QUADRIVALENT 2017 -influenza virus vac split quadrivalent susp pref syr 0.25 ml......................... 21 FLUZONE QUADRIVALENT 2017 -influenza virus vac split quadrivalent susp pref syr 0.5ml............................ 21 FLUZONE SPLIT 2015-2016 -influenza virus vaccine split im susp............................................................................ 21 F-MELT -rapid dissolve tablet base powder....................265 FML -fluorometholone ophth oint 0.1%........................... 190 FML FORTE -fluorometholone ophth susp 0.25%.......... 190 FML LIQUIFILM -fluorometholone ophth susp 0.1%...... 190 FOAMIL -external vehicles - liquid.................................. 266 FOCALGIN DSS -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg........................................................... 182 FOCALIN -dexmethylphenidate hcl tab 2.5 mg.............. 127 FOCALIN -dexmethylphenidate hcl tab 5 mg................. 128 FOCALIN -dexmethylphenidate hcl tab 10 mg............... 128 FOCALIN XR -dexmethylphenidate hcl cap er 24 hr 5 mg.................................................................................. 128 FOCALIN XR -dexmethylphenidate hcl cap er 24 hr 10 mg.................................................................................. 128 FOCALIN XR -dexmethylphenidate hcl cap er 24 hr 15 mg.................................................................................. 128 FOCALIN XR -dexmethylphenidate hcl cap er 24 hr 20 mg.................................................................................. 128 FOCALIN XR -dexmethylphenidate hcl cap er 24 hr 25 mg.................................................................................. 128 FOCALIN XR -dexmethylphenidate hcl cap er 24 hr 30 mg.................................................................................. 128 FOCALIN XR -dexmethylphenidate hcl cap er 24 hr 35 mg.................................................................................. 128 FOCALIN XR -dexmethylphenidate hcl cap er 24 hr 40 mg.................................................................................. 128 FOLBEE PLUS CZ -b-complex w/ c-biotin-minerals & folic acid tab 5 mg................................................................ 171
FOLGARD OS -multiple vit w/ min & calcium-folic acid tab 500-1.1 mg.................................................................... 171 FOLGARD RX -folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg................................................................... 182 folic acid cap 0.8 mg..................................................... 182 FOLIC ACID -folic acid inj 5 mg/ml................................. 182 FOLIC ACID -folic acid powder....................................... 182 folic acid tab 400 mcg................................................... 182 folic acid tab 800 mcg................................................... 182 folic acid tab 1 mg......................................................... 182 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg................................................................................. 182 folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg..... 182 folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx).................................................................. 182 FOLIVANE-F -fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe)................................... 182 FOLIVANE-PLUS -fe fum-iron polysacch complex-fa-b complex-c-biotin cap..................................................... 182 FOLIXAPURE -folic acid-cholecalciferol tab 1 mg-5000 unit................................................................................. 182 FOLTRATE -cobalamine combination tab....................... 182 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml (Arixtra).........................................................................185 fondaparinux sodium subcutaneous inj 5 mg/0.4ml (Arixtra).........................................................................185 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml (Arixtra).........................................................................185 fondaparinux sodium subcutaneous inj 10 mg/0.8ml (Arixtra).........................................................................185 FOOD COLOR BLACK -food color black - powder.........266 FOOD COLOR BLUE -dye fdc blue 1 aluminum lake powder........................................................................... 266 FOOD COLOR BLUE -dye fdc blue 1 (brilliant blue fcf) liquid.............................................................................. 266 FOOD COLOR BROWN -food color brown - powder..... 266 FOOD COLOR GREEN -food color green - liquid.......... 266 FOOD COLOR GREEN -food color green - powder....... 266 FOOD COLOR LIME GREEN -food color lime green powder........................................................................... 266 FOOD COLOR ORANGE -dye fdc yellow 6 (sunset yellow) - powder........................................................... 266 FOOD COLOR PINK -food color pink - liquid................. 266 FOOD COLOR RED -dye fdc red 40 (allura red) powder........................................................................... 266 FOOD COLOR RED -food color red - liquid................... 266 FOOD COLOR VIOLET -food color violet - powder........266 FOOD COLOR WHITE -food color white - liquid............ 266 FOOD COLOR YELLOW -fd&c yellow #5 aluminum lake powder........................................................................... 266 FOOD COLOR YELLOW -food color yellow - liquid....... 266 FORFIVO XL -bupropion hcl tab er 24hr 450 mg........... 113 FORMALDEHYDE -formaldehyde solution 37%............ 218 formaldehyde solution 10%.......................................... 218 FORMA-RAY -formaldehyde solution 20%..................... 218
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
324
2016 FREEDOM DERMA-N -cream base............................... 266 FREEDOM DERMA SERUM -cream base..................... 266 FREEDOM ESTERDERM -cetearyl ethylhexanoate (bulk) liquid.............................................................................. 235 FREEDOM LOLLIPOP BASE -sorbitol lollipop base miscellaneous................................................................266 FREEDOM ODT BASE -rapid dissolve tablet base powder........................................................................... 266 FREEDOM PEG TROCHE BASE -troche base powder........................................................................... 266 FREEDOM SILOMAC ANHYDROUS -gel base - gel..... 266 FREEDOM SIMPLECAP POWDER -excipient filler powder........................................................................... 266 FRESH LINEN FRAGRANCE -fragrances (bulk) liquid.............................................................................. 236 FROVA -frovatriptan succinate tab 2.5 mg (base equivalent)..................................................................... 151 frovatriptan succinate tab 2.5 mg (base equivalent) (Frova).......................................................................... 151 FRUCTOSE -fructose granules....................................... 177 FRUCTOSE -fructose powder......................................... 177 FULLERS EARTH -fullers earth powder......................... 236 FUMARIC ACID -fumaric acid (bulk) powder..................236 FURADANTIN -nitrofurantoin susp 25 mg/5ml............... 104 FURAZOLIDONE -furazolidone (bulk) powder............... 236 FUROSEMIDE -furosemide oral soln 8 mg/ml..................79 FUROSEMIDE -furosemide powder..................................79 furosemide inj 10 mg/ml................................................. 79 furosemide oral soln 10 mg/ml...................................... 79 furosemide tab 20 mg (Lasix)........................................ 79 furosemide tab 40 mg (Lasix)........................................ 79 furosemide tab 80 mg (Lasix)........................................ 79 FUSION PLUS -fe fum-iron poly cmplx-fa-b cmplx-cbiotin-probiotic cap........................................................ 182 FUSION SPRINKLES -fe fum-fe polys cmplx-fa-cprobiotic pack 7-0.25-50-5 mg..................................... 182 FUZEON -enfuvirtide for inj 90 mg................................... 11 FYCOMPA -perampanel susp 0.5 mg/ml........................ 159 FYCOMPA -perampanel tab 2 mg.................................. 159 FYCOMPA -perampanel tab 4 mg.................................. 159 FYCOMPA -perampanel tab 6 mg.................................. 159 FYCOMPA -perampanel tab 8 mg.................................. 159 FYCOMPA -perampanel tab 10 mg................................ 159 FYCOMPA -perampanel tab 12 mg................................ 159
FORMOTEROL FUMARATE -formoterol fumarate (bulk) powder........................................................................... 235 FORMOTEROL FUMARATE -formoterol fumarate dihydrate (bulk) powder................................................ 235 FORSKOLIN -forskolin (bulk) powder............................. 235 FORTAMET -metformin hcl tab er 24hr osmotic 500 mg.................................................................................... 47 FORTAMET -metformin hcl tab er 24hr osmotic 1000 mg.................................................................................... 47 FORTAVIT -multiple vitamins w/ minerals cap................ 171 FORTAZ -ceftazidime for inj 1 gm....................................... 4 FORTAZ -ceftazidime for inj 2 gm....................................... 4 FORTAZ -ceftazidime for inj 6 gm....................................... 4 FORTAZ -ceftazidime for inj 500 mg................................... 4 FORTEO -teriparatide (recombinant) inj 600 mcg/2.4ml........................................................................ 56 FORTESTA -testosterone td gel 10mg/act (2%)............... 38 FOSAMAX -alendronate sodium tab 70 mg......................56 FOSAMAX PLUS D -alendronate sodium-cholecalciferol tab 70-2800 mg-unit....................................................... 56 FOSAMAX PLUS D -alendronate sodium-cholecalciferol tab 70-5600 mg-unit....................................................... 56 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg................................................................................... 73 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg................................................................................... 73 fosinopril sodium tab 10 mg.......................................... 73 fosinopril sodium tab 20 mg.......................................... 73 fosinopril sodium tab 40 mg.......................................... 73 fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) (Cerebyx).......................................................... 159 fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) (Cerebyx).......................................................... 159 FOSRENOL -lanthanum carbonate chew tab 500 mg (elemental).................................................................... 103 FOSRENOL -lanthanum carbonate chew tab 750 mg (elemental).................................................................... 103 FOSRENOL -lanthanum carbonate chew tab 1000 mg (elemental).................................................................... 103 FOSRENOL -lanthanum carbonate oral powder pack 750 mg (elemental).............................................................. 103 FOSRENOL -lanthanum carbonate oral powder pack 1000 mg (elemental).....................................................103 FRAGMIN -dalteparin sodium inj 10000 unit/ml..............185 FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml...........185 FRAGMIN -dalteparin sodium inj 5000 unit/0.2ml...........185 FRAGMIN -dalteparin sodium inj 7500 unit/0.3ml...........185 FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml.........185 FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml.........185 FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml.......186 FRAGMIN -dalteparin sodium inj 95000 unit/3.8ml.........186 FREEDOM ADAPTADERM -cream base....................... 266 FREEDOM ADAPTADERM -gel base - gel.................... 266 FREEDOM CEPAPRO -gel base - gel............................ 266 FREEDOM DERMA-D -cream base............................... 266
G gabapentin cap 100 mg (Neurontin)............................ 159 gabapentin cap 300 mg (Neurontin)............................ 159 gabapentin cap 400 mg (Neurontin)............................ 159 GABAPENTIN -gabapentin powder................................ 236 gabapentin oral soln 250 mg/5ml (Neurontin)............ 159 gabapentin tab 600 mg (Neurontin)............................. 159 gabapentin tab 800 mg (Neurontin)............................. 159 GABITRIL -tiagabine hcl tab 2 mg.................................. 159 GABITRIL -tiagabine hcl tab 4 mg.................................. 159 GABITRIL -tiagabine hcl tab 12 mg................................ 159 SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
325
2016 GAMUNEX-C -immune globulin (human) iv or subcutaneous soln 20 gm/200ml................................... 23 GAMUNEX-C -immune globulin (human) iv or subcutaneous soln 40 gm/400ml................................... 23 GAPEAM BUDIBAC -bulk chemical compound kit - cream (cmpd kit)...................................................................... 236 GARDASIL -human papillomavirus (hpv) quadrivalent recombinant vac inj.........................................................21 GARDASIL 9 -human papillomavirus (hpv) 9-valent recomb vac im susp....................................................... 21 GARDASIL 9 -human papillomavirus (hpv) 9-valent recomb vac susp pref syr............................................... 21 GARDENIA FRAGRANCE -gardenia fragrance (bulk) oil................................................................................... 236 GASTROCROM -cromolyn sodium oral conc 100 mg/5ml........................................................................... 103 gatifloxacin ophth soln 0.5% (Zymaxid)..................... 190 GATIFLOXACIN SESQUIHYDRAT -gatifloxacin (bulk) powder........................................................................... 236 GATTEX -teduglutide (rdna) for inj kit 5 mg.................... 103 GELATIN -gelatin (bulk) powder......................................266 GELATIN TYPE A -gelatin (bulk) powder....................... 266 GELCLAIR -povidone-sodium hyaluronate-glycyrrhetinic acid gel.......................................................................... 195 GELFILM OP -gelatin adsorbable ophth film.................. 190 GEL-KAM ORAL CARE RINSE -stannous fluoride conc 0.63%.............................................................................195 GELNIQUE -oxybutynin chloride td gel 10%.................. 106 GELNIQUE PUMP -oxybutynin chloride td gel 10%....... 106 GEMFIBROZIL -gemfibrozil powder..................................82 gemfibrozil tab 600 mg (Lopid)...................................... 82 GENADUR -dermatological products misc - liquid..........205 GENERESS FE -norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg................................................42 GENISTEIN -genistein (bulk) powder............................. 236 GENOTROPIN MINIQUICK -somatropin for inj 0.2 mg.................................................................................... 56 GENOTROPIN MINIQUICK -somatropin for inj 0.4 mg.................................................................................... 56 GENOTROPIN MINIQUICK -somatropin for inj 0.6 mg.................................................................................... 56 GENOTROPIN MINIQUICK -somatropin for inj 0.8 mg.................................................................................... 56 GENOTROPIN MINIQUICK -somatropin for inj 1 mg....... 56 GENOTROPIN MINIQUICK -somatropin for inj 1.2 mg.................................................................................... 56 GENOTROPIN MINIQUICK -somatropin for inj 1.4 mg.................................................................................... 56 GENOTROPIN MINIQUICK -somatropin for inj 1.6 mg.................................................................................... 56 GENOTROPIN MINIQUICK -somatropin for inj 1.8 mg.................................................................................... 56 GENOTROPIN MINIQUICK -somatropin for inj 2 mg....... 57 GENOTROPIN -somatropin for inj 12 mg (13.8 mg overfill)............................................................................. 56
GABITRIL -tiagabine hcl tab 16 mg................................ 159 GABLOFEN -baclofen intrathecal soln prefilled syringe 50 mcg/ml........................................................................... 168 GABLOFEN -baclofen intrathecal soln prefilled syringe 10000 mcg/20ml........................................................... 168 GABLOFEN -baclofen intrathecal soln prefilled syringe 20000 mcg/20ml........................................................... 168 GABLOFEN -baclofen intrathecal soln prefilled syringe 40000 mcg/20ml........................................................... 168 GALACTOSE -galactose (bulk) powder.......................... 236 galantamine hydrobromide cap er 24hr 8 mg (Razadyne er).............................................................. 132 galantamine hydrobromide cap er 24hr 16 mg (Razadyne er).............................................................. 132 galantamine hydrobromide cap er 24hr 24 mg (Razadyne er).............................................................. 132 GALANTAMINE HYDROBROMIDE -galantamine hydrobromide oral soln 4 mg/ml.................................. 132 galantamine hydrobromide tab 4 mg (Razadyne)...... 132 galantamine hydrobromide tab 8 mg (Razadyne)...... 132 galantamine hydrobromide tab 12 mg (Razadyne)................................................................... 132 GALZIN -zinc acetate cap 25 mg (elemental zinc)......... 175 GALZIN -zinc acetate cap 50 mg (elemental zinc)......... 175 GAMASTAN S/D -immune globulin (human) im inj........... 22 GAMMAGARD LIQUID -immune globulin (human) iv or subcutaneous soln 1 gm/10ml....................................... 22 GAMMAGARD LIQUID -immune globulin (human) iv or subcutaneous soln 2.5 gm/25ml.................................... 22 GAMMAGARD LIQUID -immune globulin (human) iv or subcutaneous soln 5 gm/50ml....................................... 23 GAMMAGARD LIQUID -immune globulin (human) iv or subcutaneous soln 10 gm/100ml................................... 23 GAMMAGARD LIQUID -immune globulin (human) iv or subcutaneous soln 20 gm/200ml................................... 23 GAMMAGARD LIQUID -immune globulin (human) iv or subcutaneous soln 30 gm/300ml................................... 23 GAMMAKED -immune globulin (human) iv or subcutaneous soln 1 gm/10ml....................................... 23 GAMMAKED -immune globulin (human) iv or subcutaneous soln 2.5 gm/25ml.................................... 23 GAMMAKED -immune globulin (human) iv or subcutaneous soln 5 gm/50ml....................................... 23 GAMMAKED -immune globulin (human) iv or subcutaneous soln 10 gm/100ml................................... 23 GAMMAKED -immune globulin (human) iv or subcutaneous soln 20 gm/200ml................................... 23 GAMUNEX-C -immune globulin (human) iv or subcutaneous soln 1 gm/10ml....................................... 23 GAMUNEX-C -immune globulin (human) iv or subcutaneous soln 2.5 gm/25ml.................................... 23 GAMUNEX-C -immune globulin (human) iv or subcutaneous soln 5 gm/50ml....................................... 23 GAMUNEX-C -immune globulin (human) iv or subcutaneous soln 10 gm/100ml................................... 23
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
326
2016 GLEOSTINE -lomustine cap 40 mg.................................. 26 GLEOSTINE -lomustine cap 100 mg................................ 26 GLIADEL WAFER -carmustine in polifeprosan intracranial implant wafer 7.7 mg...................................................... 26 glimepiride tab 1 mg (Amaryl)........................................47 glimepiride tab 2 mg (Amaryl)........................................47 glimepiride tab 4 mg (Amaryl)........................................47 GLIPIZIDE -glipizide powder............................................. 47 glipizide-metformin hcl tab 2.5-250 mg......................... 47 glipizide-metformin hcl tab 2.5-500 mg......................... 47 glipizide-metformin hcl tab 5-500 mg............................ 47 glipizide tab er 24hr 2.5 mg (Glucotrol xl).................... 47 glipizide tab er 24hr 5 mg (Glucotrol xl)....................... 47 glipizide tab er 24hr 10 mg (Glucotrol xl)..................... 47 glipizide tab 5 mg (Glucotrol).........................................47 glipizide tab 10 mg (Glucotrol).......................................47 GLUCAGEN DIAGNOSTIC -glucagon hcl (rdna) diagnostic for inj 1 mg (base equiv)............................. 219 GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg (base equiv).................................................................... 47 GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj kit 1 mg........................................................................... 47 GLUCONOLACTONE -gluconolactone powder.............. 236 GLUCOPHAGE -metformin hcl tab 500 mg...................... 47 GLUCOPHAGE -metformin hcl tab 850 mg...................... 47 GLUCOPHAGE -metformin hcl tab 1000 mg.................... 47 GLUCOPHAGE XR -metformin hcl tab er 24hr 500 mg.................................................................................... 47 GLUCOPHAGE XR -metformin hcl tab er 24hr 750 mg.................................................................................... 47 GLUCOSAMINE HYDROCHLORIDE -glucosamine hydrochloride (bulk) powder......................................... 236 GLUCOSAMINE SULFATE -glucosamine sulfate (bulk) powder........................................................................... 236 GLUCOSAMINE SULFATE POTAS -glucosamine sulfate potassium (bulk) powder.............................................. 236 GLUCOSAMINE SULFATE SODIU -glucosamine sulfate sodium chloride (bulk) powder..................................... 236 GLUCOTROL -glipizide tab 5 mg..................................... 47 GLUCOTROL -glipizide tab 10 mg................................... 47 GLUCOTROL XL -glipizide tab er 24hr 2.5 mg................ 47 GLUCOTROL XL -glipizide tab er 24hr 5 mg................... 47 GLUCOTROL XL -glipizide tab er 24hr 10 mg................. 47 GLUCOVANCE -glyburide-metformin tab 2.5-500 mg...... 47 GLUCOVANCE -glyburide-metformin tab 5-500 mg......... 47 GLUTAMINE -glutamine powder (bulk)........................... 177 GLUTARALDEHYDE -glutaral soln 25%.........................218 GLUTARALDEHYDE IN WATER -glutaral (bulk) liquid 50%................................................................................236 GLUTATHIONE-L -glutathione bulk powder.................... 177 GLUTATHIONE-L REDUCED -glutathione bulk powder........................................................................... 177 GLYBURIDE -glyburide powder........................................ 47 glyburide-metformin tab 1.25-250 mg (Glucovance).................................................................. 47
GENOTROPIN -somatropin for subcutaneous inj 5 mg.................................................................................... 56 GENTAK -gentamicin sulfate ophth oint 0.3%................ 190 gentamicin sulfate cream 0.1%.................................... 205 GENTAMICIN SULFATE -gentamicin sulfate oint 0.1%...............................................................................205 GENTAMICIN SULFATE -gentamicin sulfate powder..... 205 gentamicin sulfate inj 10 mg/ml....................................... 8 gentamicin sulfate inj 40 mg/ml....................................... 8 GENTAMICIN SULFATE MICRON -gentamicin sulfate powder........................................................................... 206 gentamicin sulfate ophth soln 0.3% (Garamycin)...... 190 GENTIAN VIOLET -gentian violet crystals...................... 206 GENTIAN VIOLET -gentian violet powder...................... 206 GENVOYA -elvitegrav-cobic-emtricitab-tenofov af tab 150-150-200-10 mg........................................................ 11 GEODON -ziprasidone hcl cap 20 mg............................ 118 GEODON -ziprasidone hcl cap 40 mg............................ 118 GEODON -ziprasidone hcl cap 60 mg............................ 118 GEODON -ziprasidone hcl cap 80 mg............................ 118 GEODON -ziprasidone mesylate for inj 20 mg (base equivalent)..................................................................... 118 GERANIUM NATURAL -geranium oil............................. 236 GERMALL PLUS -diazolidinyl urea-iodopropynyl butylcarbamate liquid.................................................... 236 GERMANIUM SESQUIOXIDE -germanium sesquioxide powder........................................................................... 236 GIALAX -polyethylene glycol 3350 - kit............................ 95 GIAZO -balsalazide disodium tab 1.1 gm....................... 103 GILENYA -fingolimod hcl cap 0.5 mg (base equiv)......... 132 GILOTRIF -afatinib dimaleate tab 20 mg (base equivalent)....................................................................... 26 GILOTRIF -afatinib dimaleate tab 30 mg (base equivalent)....................................................................... 26 GILOTRIF -afatinib dimaleate tab 40 mg (base equivalent)....................................................................... 26 GILPHEX TR -phenylephrine-guaifenesin tab 10-388 mg.................................................................................... 88 GILTUSS -phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml............................................................................. 88 GILTUSS TR -phenylephrine w/ dm-gg tab 10-28-388 mg.................................................................................... 88 GINGER ROOT -ginger root powder.............................. 236 GINSENG (AMERICAN) -american ginseng (panax quinquefolium) (bulk) powder....................................... 236 GINSENG ROOT -ginseng root (panax ginseng) (bulk) powder........................................................................... 236 glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone)................................................................... 132 GLEEVEC -imatinib mesylate tab 100 mg (base equivalent)....................................................................... 26 GLEEVEC -imatinib mesylate tab 400 mg (base equivalent)....................................................................... 26 GLEOSTINE -lomustine cap 5 mg.................................... 26 GLEOSTINE -lomustine cap 10 mg.................................. 26
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
327
2016 glyburide-metformin tab 2.5-500 mg (Glucovance)..... 47 glyburide-metformin tab 5-500 mg (Glucovance)........ 48 glyburide micronized tab 1.5 mg (Glynase)..................47 glyburide micronized tab 3 mg (Glynase).....................47 glyburide micronized tab 6 mg (Glynase).....................47 glyburide tab 1.25 mg..................................................... 47 glyburide tab 2.5 mg....................................................... 47 glyburide tab 5 mg.......................................................... 47 GLYCERINE -glycerin liquid............................................ 236 GLYCERIN -glycerin liquid.............................................. 236 GLYCERIN -glycerin soln................................................ 236 GLYCEROL FORMAL -glycerin liquid............................. 236 GLYCEROL MONOOLEATE -glycerol monooleate (bulk) powder........................................................................... 236 GLYCERYL MONOSTEARATE -glyceryl monostearate flakes............................................................................. 236 GLYCINE -glycine powder............................................... 108 glycine irrigation soln 1.5%.......................................... 108 GLYCINE (L) -glycine powder......................................... 108 GLYCINE SOYA PROTEIN -soybean protein (bulk) solution.......................................................................... 236 GLYCOFUROL -glycofurol (bulk) liquid........................... 236 GLYCOLIC ACID -glycolic acid crystals.......................... 236 GLYCOLIC ACID -glycolic acid granules........................ 236 GLYCOLIC ACID -glycolic acid soln 70%....................... 206 GLYCOLIC ACID 70% HIGH PU -glycolic acid soln 70%................................................................................206 GLYCOPYRROLATE -glycopyrrolate (bulk) powder....... 236 glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) (Robinul)......................................................................... 98 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) (Robinul).......98 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) (Robinul)......................................................................... 98 glycopyrrolate inj 0.2 mg/ml (Robinul).......................... 98 glycopyrrolate tab 1 mg (Robinul)................................. 98 glycopyrrolate tab 2 mg (Robinul forte)........................98 GLYCOSAMINOGLYCANS -glycosaminoglycans (bulk) liquid.............................................................................. 237 GLYCYRRHIZIC ACID -glycyrrhizin (bulk) powder......... 237 GLYNASE -glyburide micronized tab 1.5 mg.................... 48 GLYNASE -glyburide micronized tab 3 mg....................... 48 GLYNASE -glyburide micronized tab 6 mg....................... 48 GLYSET -miglitol tab 25 mg.............................................. 48 GLYSET -miglitol tab 50 mg.............................................. 48 GLYSET -miglitol tab 100 mg............................................ 48 GLYTACTIN BETTERMILK DE-L -nutritional supplement pack............................................................................... 178 GLYTACTIN BETTERMILK 15 -nutritional supplement pack............................................................................... 178 GLYTACTIN BUILD 10PE -nutritional supplement pack............................................................................... 178 GLYTACTIN COMPLETE 10PE -nutritional supplement bar.................................................................................. 178 GLYTACTIN RESTORE LITE 10 -nutritional supplement pack............................................................................... 179
GLYTACTIN RESTORE 5 -nutritional supplement pack............................................................................... 179 GLYTACTIN RTD 10 -nutritional supplement liquid........ 179 GLYTACTIN RTD 15 -nutritional supplement liquid........ 179 GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............ 48 GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............ 48 GNP VITAMIN D-400 -calcium carbonate-cholecalciferol tab 90 mg-400 unit....................................................... 175 GOLD SODIUM THIOMALATE -gold sodium thiomalate (bulk) powder................................................................ 237 GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm.................................................................... 95 GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate packet 227.1 gm............................................................. 95 GORDOFILM -salicylic & lactic acids soln 16.7-16.7%.................................................................... 206 GORDONS UREA -urea ointment 40%.......................... 206 GRAMICIDIN D -gramicidin d powder............................ 237 granisetron hcl tab 1 mg.............................................. 100 GRANIX -tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml...................................................................... 182 GRANIX -tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml...................................................................... 182 GRAPE FLAVOR -flavoring agent - liquid....................... 266 GRAPEFRUIT FLAVOR PINK -flavoring agent - oil........ 267 GRAPESEED -grape seed (bulk) oil............................... 237 GRAPE SEED -grape seed (bulk) oil.............................. 237 GRASTEK -timothy grass pollen allergen ext tab sl 2800 bau................................................................................... 24 GREEN SOAP -green soap (bulk) emulsion...................237 GREEN TEA -epigallocatechin gallate (bulk) powder 95%................................................................................237 GREEN TEA -green tea (camillia sinensis) (bulk) powder........................................................................... 237 GREEN TEA OIL FRAGRANCE -green tea oil fragrance (bulk) oil......................................................................... 237 GRISEOFULVIN -griseofulvin micronized (bulk) powder........................................................................... 237 griseofulvin microsize susp 125 mg/5ml...................... 10 griseofulvin microsize tab 500 mg (Grifulvin v)........... 10 griseofulvin ultramicrosize tab 125 mg (Gris-peg)...... 10 griseofulvin ultramicrosize tab 250 mg (Gris-peg)...... 10 GRIS-PEG -griseofulvin ultramicrosize tab 125 mg.......... 10 GRIS-PEG -griseofulvin ultramicrosize tab 250 mg.......... 10 GUAIACOL -guaiacol solution......................................... 237 guaifenesin-codeine soln 100-10 mg/5ml..................... 88 GUAIFENESIN -guaifenesin powder.................................88 GUANABENZ ACETATE -guanabenz acetate (bulk) powder........................................................................... 237 GUANETHIDINE HEMISULFATE -guanethidine sulfate (bulk) powder................................................................ 237 guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv)........................................................................ 128 guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv)........................................................................ 128
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
328
2016 guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv)........................................................................ 128 guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv)........................................................................ 128 guanfacine hcl tab 1 mg (Tenex)................................... 73 guanfacine hcl tab 2 mg (Tenex)................................... 73 GUANIDINEACETIC ACID -glycocyamine (bulk) powder........................................................................... 237 GUANIDINE HCL -guanidine hcl tab 125 mg................. 169 GUARANA SEED EXTRACT -guarana (bulk) powder........................................................................... 237 GUAR GUM -guar gum powder...................................... 237 GUAVA FLAVOR -flavoring agent - liquid....................... 267 GUM ARABIC SPRAY-DRIED -acacia powder.............. 267 GUM BASE GELATIN -gummy gel base - gel................ 267 GYMNEMA SYLVESTRIS LEAF -gymnema sylvestric leaf (bulk) powder................................................................ 237 GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal cream 2%...................................................................... 107
HEALON GV -sodium hyaluronate intraocular inj 14 mg/ ml................................................................................... 190 HEALON -sodium hyaluronate intraocular inj 10 mg/ ml................................................................................... 190 HEALON5 -sodium hyaluronate intraocular inj 23 mg/ ml................................................................................... 190 HECTOROL -doxercalciferol cap 0.5 mcg........................ 57 HECTOROL -doxercalciferol cap 1 mcg........................... 57 HECTOROL -doxercalciferol cap 2.5 mcg........................ 57 HEMABATE -carboprost tromethamine im soln 250 mcg/ ml..................................................................................... 55 HEMANGEOL -propranolol hcl oral soln 4.28 mg/ml (3.75 mg/ml base equiv).......................................................... 62 HEMATOGEN FA -fe fumarate-vit c-vit b12-fa cap 200-250-0.01-1 mg....................................................... 182 HEMATOXYLIN -hematoxylin (bulk) powder.................. 237 HEMATRON-AF -iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg...................................................... 182 HEMETAB -polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg........................................................... 182 HEMOCYTE-F -iron combination elixir........................... 182 HEMOCYTE PLUS -ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg.............................................. 182 HEPAGAM B -hepatitis b immune globulin (human) inj soln.................................................................................. 23 HEPARIN SODIUM/NACL 0.45% -heparin sodium (porcine) 50 unit/ml in sodium chloride 0.45%............. 186 HEPARIN SODIUM/NACL 0.45% -heparin sodium (porcine) 100 unt/ml in sodium chloride 0.45%............186 HEPARIN SODIUM/SODIUM CHL -heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9%................. 186 HEPARIN SODIUM -heparin sodium (porcine) powder........................................................................... 237 heparin sodium (porcine) inj 1000 unit/ml.................. 186 heparin sodium (porcine) inj 5000 unit/ml.................. 186 heparin sodium (porcine) inj 10000 unit/ml................ 186 heparin sodium (porcine) inj 20000 unit/ml................ 186 heparin sodium (porcine) pf inj 5000 unit/0.5ml........ 186 heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9% (Heparin sodium/sodiu).................................... 186 HEPES -hepes (bulk) powder......................................... 237 HEPSERA -adefovir dipivoxil tab 10 mg........................... 11 HEPTAMINOL -heptaminol (bulk) powder...................... 237 HETLIOZ -tasimelteon capsule 20 mg............................ 123 HEXALEN -altretamine cap 50 mg................................... 26 H20 GEL BASE -gel base - gel...................................... 267 HIBERIX -haemophilus b polysaccharide conjugate vac for inj 10 mcg.................................................................. 21 HIPREX -methenamine hippurate tab 1 gm....................104 HISTAMINE DIPHOSPHATE -histamine phosphate crystals.......................................................................... 237 HISTAMINE PHOSPHATE -histamine phosphate crystals.......................................................................... 237 HIZENTRA -immune globulin (human) subcutaneous inj 1 gm/5ml............................................................................. 23
H HALCION -triazolam tab 0.25 mg................................... 123 HALDOL DECANOATE 100 -haloperidol decanoate im soln 100 mg/ml............................................................. 118 HALDOL DECANOATE 50 -haloperidol decanoate im soln 50 mg/ml....................................................................... 118 HALDOL -haloperidol lactate inj 5 mg/ml........................ 118 halobetasol propionate cream 0.05% (Ultravate)....... 206 halobetasol propionate oint 0.05% (Ultravate)........... 206 HALOG -halcinonide cream 0.1%................................... 206 HALOG -halcinonide oint 0.1%....................................... 206 HALOPERIDOL DECANOATE -haloperidol decanoate (bulk) powder................................................................ 237 haloperidol decanoate im soln 50 mg/ml (Haldol decanoate 50).............................................................. 118 haloperidol decanoate im soln 100 mg/ml (Haldol decanoate 100)............................................................ 118 HALOPERIDOL -haloperidol (bulk) powder.................... 237 HALOPERIDOL -haloperidol powder.............................. 118 haloperidol lactate inj 5 mg/ml (Haldol)...................... 118 haloperidol lactate oral conc 2 mg/ml.........................118 haloperidol tab 0.5 mg.................................................. 119 haloperidol tab 1 mg..................................................... 119 haloperidol tab 2 mg..................................................... 119 haloperidol tab 5 mg..................................................... 119 haloperidol tab 10 mg................................................... 119 haloperidol tab 20 mg................................................... 119 HALOTIN -haloprogin cream 1%.................................... 206 HAM FLAVOR -flavoring agent - liquid........................... 267 HARVONI -ledipasvir-sofosbuvir tab 90-400 mg.............. 11 HAVRIX -hepatitis a vaccine inj susp 720 el unit/0.5ml......................................................................... 21 HAVRIX -hepatitis a vaccine inj susp 1440 el unit/ml....... 21 HAWTHORN BERRY -hawthorn berry (bulk) powder........................................................................... 237
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
329
2016 HUMIRA -adalimumab prefilled syringe kit 20 mg/0.4ml........................................................................ 148 HUMIRA -adalimumab prefilled syringe kit 40 mg/0.8ml........................................................................ 148 HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled syringe kit 40 mg/0.8ml................................................ 148 HUMIRA PEN -adalimumab pen-injector kit 40 mg/0.8ml........................................................................ 148 HUMIRA PEN-CROHNS DISEASE -adalimumab peninjector kit 40 mg/0.8ml................................................ 148 HUMIRA PEN-PSORIASIS STAR -adalimumab peninjector kit 40 mg/0.8ml................................................ 148 HUMULIN 70/30 -insulin nph isophane & regular human inj 100 unit/ml (70-30).................................................... 52 HUMULIN 70/30 KWIKPEN -insulin nph & regular susp pen-inj 100 unit/ml (70-30)............................................. 52 HUMULIN N -insulin nph (human) (isophane) inj 100 unit/ ml..................................................................................... 52 HUMULIN N KWIKPEN -insulin nph (human) (isophane) susp pen-injector 100 unit/ml......................................... 52 HUMULIN R -insulin regular (human) inj 100 unit/ml........ 51 HUMULIN R U-500 (CONCENTR -insulin regular (human) inj 500 unit/ml..................................................................51 HUMULIN R U-500 KWIKPEN -insulin regular (human) soln pen-injector 500 unit/ml.......................................... 51 HUPERZINE SERRATE A -huperzine serrate a (bulk) powder 1%.................................................................... 237 HURRISEAL -dental desensitizing product - solution..... 261 HYALUCIL-0.5 -sodium hyaluronate-fluorouracil cream 2-0.5% (cmpd kit)......................................................... 206 HYALUCIL-4 -sodium hyaluronate-fluorouracil cream 2-4% (cmpd kit)............................................................ 206 hyaluronate sodium (emollient) gel 0.2% (Hylira)...... 206 HYALURONATE SODIUM -hyaluronate sodium (bulk) powder........................................................................... 237 HYALURONIC ACID HYDROLYZE -hyaluronic acid (bulk) powder........................................................................... 238 HYALURONIC ACID SODIUM -hyaluronate sodium (bulk) powder........................................................................... 238 HYALURONIC ACID SODIUM SA -hyaluronate sodium (bulk) powder................................................................ 238 HYALURONIDASE BOVINE -hyaluronidase bovine (bulk) lyophilized powder........................................................ 238 HYALURONIDASE -hyaluronidase (bulk) powder.......... 238 HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)...... 26 HYCAMTIN -topotecan hcl cap 1 mg (base equiv)........... 26 HYCET -hydrocodone-acetaminophen soln 7.5-325 mg/15ml......................................................................... 139 HYCOFENIX -pseudoephedrine w/ hydrocodone-gg soln 30-2.5-200 mg/5ml.......................................................... 88 HYDRALAZINE HCL -hydralazine hcl (bulk) powder......238 hydralazine hcl inj 20 mg/ml.......................................... 73 hydralazine hcl tab 10 mg.............................................. 73 hydralazine hcl tab 25 mg.............................................. 73 hydralazine hcl tab 50 mg.............................................. 73
HIZENTRA -immune globulin (human) subcutaneous inj 2 gm/10ml........................................................................... 23 HIZENTRA -immune globulin (human) subcutaneous inj 4 gm/20ml........................................................................... 23 HIZENTRA -immune globulin (human) subcutaneous inj 10 gm/50ml..................................................................... 23 HOMACTIN AA PLUS -nutritional supplement liquid...... 179 homatropine hbr ophth soln 5% (Isopto homatropine)............................................................... 190 HOMATROPINE METHYLBROMIDE -homatropine methylbromide powder................................................. 237 HONEY ALMOND FRAGRANCE -honey almond fragrance (bulk) liquid................................................... 237 HONEY FLAVOR -flavoring agent - liquid.......................267 HORMONE CREAM BASE BOTANI -hormone cream base............................................................................... 267 HORMONE CREAM BASE -hormone cream base........ 267 H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 57 HPR -dermatological products, misc. - aerosol foam......206 HPR PLUS -dermatological products, misc. - aerosol foam............................................................................... 206 HPR PLUS -dermatological products misc - cream........ 206 HRT BASE BOTANICAL -hormone cream base............. 267 HRT BASE FOR MEN -hormone gel base..................... 267 HRT BASE HEAVY -hormone cream base..................... 267 HRT BASE -hormone cream base.................................. 267 HRT CREAM BASE -hormone cream base.................... 267 HRT CREAM BASE WOMEN -hormone cream base..... 267 HRT NATURAL LOTION -hormone lotion base.............. 267 HSA STERILE DILUENT -human serum albumin diluent for injection.................................................................... 267 5-HTP -hydroxytryptophan powder................................. 260 HUMALOG -insulin lispro inj 100 unit/ml...........................51 HUMALOG -insulin lispro soln cartridge 100 unit/ml.........51 HUMALOG KWIKPEN -insulin lispro soln pen-injector 100 unit/ml.............................................................................. 51 HUMALOG KWIKPEN -insulin lispro soln pen-injector 200 unit/ml.............................................................................. 51 HUMALOG MIX 75/25 -insulin lispro prot & lispro inj 100 unit/ml (75-25)................................................................. 51 HUMALOG MIX 50/50 -insulin lispro protamine & lispro inj 100 unit/ml (50-50)......................................................... 51 HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot & lispro sus pen-inj 100 unit/ml (50-50).............................51 HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25).............................52 HUMAN CHORIONIC GONADOTRO -chorionic gonadotropin (bulk) powder..........................................237 HUMATROPE COMBO PACK -somatropin for inj 5 mg.................................................................................... 57 HUMATROPE -somatropin for inj 24 mg.......................... 57 HUMATROPE -somatropin for inj 6 mg (18 unit).............. 57 HUMATROPE -somatropin for inj 12 mg (36 unit)............ 57 HUMIRA -adalimumab prefilled syringe kit 10 mg/0.2ml........................................................................ 148
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
330
2016 hydralazine hcl tab 100 mg............................................ 73 HYDRAZINE SULFATE -hydrazine sulfate (bulk) crystals.......................................................................... 238 HYDREA -hydroxyurea cap 500 mg................................. 26 HYDROCHLORIC ACID -hydrochloric acid liq 10%....... 238 HYDROCHLORIC ACID -hydrochloric acid liq 37%....... 238 HYDROCHLORIC ACID -hydrochloric acid liquid...........238 hydrochlorothiazide cap 12.5 mg (Microzide).............. 79 HYDROCHLOROTHIAZIDE -hydrochlorothiazide powder............................................................................. 79 hydrochlorothiazide tab 12.5 mg................................... 79 hydrochlorothiazide tab 25 mg...................................... 79 hydrochlorothiazide tab 50 mg...................................... 79 hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet).......................................................................... 139 hydrocodone-acetaminophen tab 2.5-325 mg............ 139 hydrocodone-acetaminophen tab 7.5-325 mg (Norco).......................................................................... 140 hydrocodone-acetaminophen tab 5-325 mg (Norco).......................................................................... 140 hydrocodone-acetaminophen tab 10-325 mg (Norco).......................................................................... 139 hydrocodone-acetaminophen tab 7.5-300 mg (Xodol).......................................................................... 140 hydrocodone-acetaminophen tab 5-300 mg (Xodol).......................................................................... 139 hydrocodone-acetaminophen tab 10-300 mg (Xodol).......................................................................... 140 HYDROCODONE BITARTRATE -hydrocodone bitartrate (bulk) crystals................................................................ 238 HYDROCODONE BITARTRATE -hydrocodone bitartrate (bulk) powder................................................................ 238 hydrocodone-ibuprofen tab 10-200 mg (Ibudone)..... 140 hydrocodone-ibuprofen tab 5-200 mg (Reprexain)................................................................... 140 hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen)................................................................. 140 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml...... 89 hydrocodone w/ homatropine tab 5-1.5 mg..................89 hydrocod polst-chlorphen polst er susp 10-8 mg/5ml (Tussionex pennkineti)................................................. 88 HYDROCORTISONE ACETATE -hydrocortisone acetate powder........................................................................... 206 HYDROCORTISONE ACETATE MI -hydrocortisone acetate powder............................................................. 206 hydrocortisone acetate suppos 25 mg (Anusolhc)................................................................................. 196 hydrocortisone acetate suppos 30 mg (Proctocort).................................................................. 196 hydrocortisone acetate w/ pramoxine rectal cream 1-1% (Analpram-hc).................................................... 196 hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% (Analpram-hc)................................................. 196 hydrocortisone butyrate cream 0.1% (Locoid)...........206
hydrocortisone butyrate hydrophilic lipo base cream 0.1% (Locoid lipocream)............................................ 206 hydrocortisone butyrate oint 0.1% (Locoid)............... 206 hydrocortisone butyrate soln 0.1% (Locoid).............. 206 hydrocortisone cream 1%.............................................206 hydrocortisone cream 2.5%..........................................206 hydrocortisone enema 100 mg/60ml (Cortenema)................................................................. 196 HYDROCORTISONE HEMISUCCIN -hydrocortisone hemisuccinate (bulk) powder....................................... 238 HYDROCORTISONE -hydrocortisone powder............... 206 hydrocortisone lotion 2.5%.......................................... 206 hydrocortisone lotion 2% (Ala scalp).......................... 206 HYDROCORTISONE MICRONIZED -hydrocortisone micronized powder........................................................ 206 hydrocortisone oint 1%................................................. 206 hydrocortisone oint 2.5%..............................................206 hydrocortisone rectal cream 2.5% (Anusol-hc)......... 197 hydrocortisone rectal cream 1% (Proctocort)............ 196 hydrocortisone tab 5 mg (Cortef).................................. 34 hydrocortisone tab 10 mg (Cortef)................................ 34 hydrocortisone tab 20 mg (Cortef)................................ 34 hydrocortisone valerate cream 0.2%...........................206 hydrocortisone valerate oint 0.2% (Westcort)............ 206 hydrocortisone w/ acetic acid otic soln 1-2% (Vosol hc)................................................................................. 194 HYDROFERA BLUE 4"X4" -wound dressings - pads..... 207 HYDROFERA BLUE FOAM DRESS -wound dressings pads............................................................................... 206 HYDROFERA BLUE HEAVY DRAI -wound dressings pads............................................................................... 207 HYDROFERA BLUE READY FOAM -wound dressings pads............................................................................... 207 HYDROFLUORIC ACID -hydrofluoric acid (bulk) liquid 48%................................................................................238 HYDRO 40 FOAM -urea foam 40%................................ 206 HYDROGEL -carbomer gel base.................................... 267 HYDROGEN PEROXIDE -hydrogen peroxide soln 30%................................................................................218 HYDROMORPHONE HCL -hydromorphone hcl powder........................................................................... 140 HYDROMORPHONE HCL -hydromorphone hcl suppos 3 mg.................................................................................. 140 hydromorphone hcl inj 1 mg/ml...................................140 hydromorphone hcl inj 2 mg/ml...................................140 hydromorphone hcl inj 4 mg/ml...................................140 hydromorphone hcl liqd 1 mg/ml (Dilaudid)...............140 hydromorphone hcl preservative free (pf) inj 10 mg/ml (Dilaudid-hp)................................................................ 140 hydromorphone hcl tab er 24hr deter 8 mg (Exalgo)........................................................................ 140 hydromorphone hcl tab er 24hr deter 12 mg (Exalgo)........................................................................ 140 hydromorphone hcl tab er 24hr deter 16 mg (Exalgo)........................................................................ 140
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
331
2016 hydromorphone hcl tab er 24hr deter 32 mg (Exalgo)........................................................................ 140 hydromorphone hcl tab 2 mg (Dilaudid)..................... 140 hydromorphone hcl tab 4 mg (Dilaudid)..................... 140 hydromorphone hcl tab 8 mg (Dilaudid)..................... 140 HYDROQUINONE -hydroquinone powder......................207 HYDRO 35 -urea in lactic acid vehicle foam 35%.......... 206 HYDROXOCOBALAMIN HYDROCHL -hydroxocobalamin hcl (bulk) powder.......................................................... 238 HYDROXOCOBALAMIN -hydroxocobalamin (bulk) powder........................................................................... 238 HYDROXOCOBALAMIN -hydroxocobalamin inj 1000 mcg/ml........................................................................... 182 HYDROXYAMPHETAMINE HYDROB hydroxyamphetamine hbr (bulk) powder......................238 hydroxychloroquine sulfate tab 200 mg (Plaquenil)...................................................................... 16 HYDROXYCHLOROQUINE SULFAT -hydroxychloroquine sulfate (bulk) powder.................................................... 238 HYDROXYETHYL CELLULOSE -hydroxyethyl cellulose (bulk) powder................................................................ 238 HYDROXYETHYL CELLULOSE 10 -hydroxyethyl cellulose (bulk) powder................................................. 238 HYDROXYETHYL CELLULOSE 45 -hydroxyethyl cellulose (bulk) powder................................................. 238 HYDROXYETHYL CELLULOSE 50 -hydroxyethyl cellulose (bulk) powder................................................. 238 HYDROXYETHYL METHACRYLATE -hydroxyethyl methacrylate (bulk) powder 96%................................. 238 5-HYDROXY-L-TRYPTOPHAN -hydroxytryptophan powder........................................................................... 260 HYDROXYPROGESTERONE CAPRO hydroxyprogesterone caproate (bulk) powder............. 238 HYDROXYPROGESTERONE CAPRO hydroxyprogesterone caproate im in oil 1.25 gm/5ml............................................................................. 27 HYDROXYPROPYL-BETA-CYCLOD -hydroxypropylbeta-cyclodextrin (bulk) powder................................... 239 HYDROXYPROPYL CELLULOSE -hydroxypropyl cellulose powder........................................................... 238 HYDROXYPROPYL CELLULOSE 1 -hydroxypropyl cellulose powder........................................................... 238 HYDROXYPROPYL CELLULOSE 4 -hydroxypropyl cellulose powder........................................................... 239 HYDROXYPROPYL CELLULOSE 7 -hydroxypropyl cellulose powder........................................................... 239 HYDROXYPROPYL METHYLCELLU -hypromellose (bulk) powder................................................................ 239 HYDROXYQUINOLINE SULFATE -oxyquinoline sulfate (bulk) powder................................................................ 239 HYDROXYTRYPTOPHAN -hydroxytryptophan powder........................................................................... 239 HYDROXYTRYPTOPHAN L-5 -hydroxytryptophan powder........................................................................... 239 hydroxyurea cap 500 mg (Hydrea)................................ 27
HYDROXYUREA -hydroxyurea (bulk) powder............... 239 HYDROXYZINE HCL -hydroxyzine hcl (bulk) powder........................................................................... 239 HYDROXYZINE HCL -hydroxyzine hcl im soln 25 mg/ ml................................................................................... 110 hydroxyzine hcl im soln 50 mg/ml...............................110 hydroxyzine hcl syrup 10 mg/5ml............................... 110 hydroxyzine hcl tab 10 mg........................................... 110 hydroxyzine hcl tab 25 mg........................................... 110 hydroxyzine hcl tab 50 mg........................................... 110 hydroxyzine pamoate cap 25 mg (Vistaril)................. 110 hydroxyzine pamoate cap 50 mg (Vistaril)................. 110 HYDROXYZINE PAMOATE -hydroxyzine pamoate cap 100 mg.......................................................................... 110 HYDROXYZINE PAMOATE -hydroxyzine pamoate powder........................................................................... 110 HYLATOPIC PLUS -dermatological products, misc. aerosol foam................................................................. 207 HYLATOPIC PLUS -dermatological products misc cream............................................................................. 207 HYLATOPIC PLUS -dermatological products misc lotion.............................................................................. 207 HYLENEX -hyaluronidase human inj 150 unit/ml........... 276 HYLIRA -hyaluronate sodium (emollient) gel 0.2%.........207 HYLIRA -hyaluronate sodium (emollient) lotion 0.1%..... 207 hyoscyamine sulfate elixir 0.125 mg/5ml...................... 98 HYOSCYAMINE SULFATE -hyoscyamine sulfate powder............................................................................. 98 hyoscyamine sulfate soln 0.125 mg/ml......................... 98 hyoscyamine sulfate tab disint 0.125 mg (Anaspaz)....................................................................... 98 hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid)........................................................................... 98 hyoscyamine sulfate tab 0.125 mg (Levsin)................. 98 hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)......... 98 HYPERHEP B S/D -hepatitis b immune globulin (human) im inj soln........................................................................ 23 HYPERRAB S/D -rabies immune globulin (human) inj 150 unit/ml.............................................................................. 23 HYPERRHO S/D MINI-DOSE -rho d immune globulin im soln pref syr 250 unit (50 mcg)...................................... 23 HYPERRHO S/D -rho d immune globulin im soln pref syr 1500 unit (300mcg).........................................................23 HYPERSAL -sodium chloride soln nebu 3.5%..................89 HYPER-SAL -sodium chloride soln nebu 7%................... 89 HYPERSAL -sodium chloride soln nebu 7%.....................89 HYPERTET S/D -tetanus immune globulin (human) inj 250 unit/ml.......................................................................23 HYPROMELLOSE 4000CPS -hypromellose (bulk) powder........................................................................... 239 HYPROMELLOSE 100000CPS -hypromellose (bulk) powder........................................................................... 239 HYPROMELLOSE METHOCEL K1 -hypromellose (bulk) powder........................................................................... 239
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
332
2016 ILARIS -canakinumab subcutaneous inj 150 mg/ml....... 148 ILEVRO -nepafenac ophth susp 0.3%............................ 190 ILUVIEN -fluocinolone acetonide intravitreal implant 0.19 mg.................................................................................. 190 imatinib mesylate tab 100 mg (base equivalent) (Gleevec)........................................................................ 27 imatinib mesylate tab 400 mg (base equivalent) (Gleevec)........................................................................ 27 IMBRUVICA -ibrutinib cap 140 mg................................... 27 IMIDUREA -imidurea (bulk) powder................................ 239 IMIPRAMINE HCL -imipramine hcl powder.................... 113 imipramine hcl tab 10 mg (Tofranil)............................ 113 imipramine hcl tab 25 mg (Tofranil)............................ 113 imipramine hcl tab 50 mg (Tofranil)............................ 113 imipramine pamoate cap 75 mg (Tofranil-pm)........... 113 imipramine pamoate cap 100 mg (Tofranil-pm)......... 113 imipramine pamoate cap 125 mg (Tofranil-pm)......... 113 imipramine pamoate cap 150 mg (Tofranil-pm)......... 113 imiquimod cream 5% (Aldara)...................................... 207 IMIQUIMOD -imiquimod (bulk) powder........................... 239 IMITREX STATDOSE REFILL -sumatriptan succinate solution cartridge 4 mg/0.5ml....................................... 152 IMITREX STATDOSE REFILL -sumatriptan succinate solution cartridge 6 mg/0.5ml....................................... 152 IMITREX STATDOSE SYSTEM -sumatriptan succinate solution auto-injector 4 mg/0.5ml................................. 152 IMITREX STATDOSE SYSTEM -sumatriptan succinate solution auto-injector 6 mg/0.5ml................................. 152 IMITREX -sumatriptan nasal spray 5 mg/act.................. 151 IMITREX -sumatriptan nasal spray 20 mg/act................ 151 IMITREX -sumatriptan succinate inj 6 mg/0.5ml............. 151 IMITREX -sumatriptan succinate tab 25 mg................... 151 IMITREX -sumatriptan succinate tab 50 mg................... 152 IMITREX -sumatriptan succinate tab 100 mg................. 152 IMOGAM RABIES-HT -rabies immune globulin (human) inj 150 unit/ml..................................................................24 IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc inj..................................................................................... 21 IMPAVIDO -miltefosine cap 50 mg.................................... 18 IMPLANON -etonogestrel subdermal implant 68 mg........ 42 IMURAN -azathioprine tab 50 mg................................... 276 INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)..........57 INCRUSE ELLIPTA -umeclidinium br aero powd breath act 62.5 mcg/inh (base eq)............................................ 92 indapamide tab 1.25 mg..................................................79 indapamide tab 2.5 mg.................................................... 79 INDERAL LA -propranolol hcl cap er 24hr 60 mg............. 62 INDERAL LA -propranolol hcl cap er 24hr 80 mg............. 62 INDERAL LA -propranolol hcl cap er 24hr 120 mg........... 62 INDERAL LA -propranolol hcl cap er 24hr 160 mg........... 62 INDERAL XL -propranolol hcl sustained-release beads cap er 24hr 80 mg.......................................................... 62 INDERAL XL -propranolol hcl sustained-release beads cap er 24hr 120 mg........................................................ 62 INDOCIN -indomethacin suppos 50 mg..........................148
HYPROMELLOSE 4000 MPA-S -hypromellose (bulk) powder........................................................................... 239 HYQVIA -immun glob inj 2.5 gm/25ml-hyaluron inj 200 unt/1.25 ml kit................................................................. 24 HYQVIA -immun glob inj 5 gm/50ml-hyaluron inj 400 unt/2.5 ml kit................................................................... 24 HYQVIA -immun glob inj 10 gm/100ml-hyaluron inj 800 unt/5 ml kit...................................................................... 24 HYQVIA -immun glob inj 20 gm/200ml-hyaluron inj 1600 unt/10 ml kit.................................................................... 24 HYQVIA -immun glob inj 30 gm/300ml-hyaluron inj 2400 unt/15 ml kit.................................................................... 24 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 20 mg............................................................................ 140 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 30 mg............................................................................ 140 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 40 mg............................................................................ 140 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 60 mg............................................................................ 140 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 80 mg............................................................................ 140 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 100 mg.......................................................................... 140 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 120 mg.......................................................................... 140 HYZAAR -losartan potassium & hydrochlorothiazide tab 50-12.5 mg...................................................................... 73 HYZAAR -losartan potassium & hydrochlorothiazide tab 100-12.5 mg.................................................................... 73 HYZAAR -losartan potassium & hydrochlorothiazide tab 100-25 mg....................................................................... 73 I ibandronate sodium tab 150 mg (base equivalent) (Boniva).......................................................................... 57 IBRANCE -palbociclib cap 75 mg..................................... 27 IBRANCE -palbociclib cap 100 mg................................... 27 IBRANCE -palbociclib cap 125 mg................................... 27 IBUDONE -hydrocodone-ibuprofen tab 10-200 mg........ 140 IBUPROFEN -ibuprofen powder..................................... 148 ibuprofen susp 100 mg/5ml.......................................... 148 ibuprofen tab 400 mg.................................................... 148 ibuprofen tab 600 mg.................................................... 148 ibuprofen tab 800 mg.................................................... 148 ICAR-C PLUS -iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg..................................................... 182 ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml (elemental iron)............................................................. 182 ICHTHAMMOL -ichthammol powder............................... 207 ICLUSIG -ponatinib hcl tab 15 mg (base equiv)............... 27 ICLUSIG -ponatinib hcl tab 45 mg (base equiv)............... 27 IDEBENONE -idebenone (bulk) powder......................... 239 IDOXURIDINE -bulk chemicals - crystals....................... 239 IDOXURIDINE -idoxuridine (bulk) powder...................... 239 ILARIS -canakinumab for inj 180 mg.............................. 148
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
333
2016 INDOCIN -indomethacin susp 25 mg/5ml....................... 148 INDOCYANINE GREEN -indocyanine green (bulk) powder........................................................................... 239 INDOLE-3-CARBINOL -indole-3-carbinol powder.......... 239 indomethacin cap er 75 mg.......................................... 148 indomethacin cap 25 mg.............................................. 148 indomethacin cap 50 mg.............................................. 148 INDOMETHACIN -indomethacin powder........................ 148 INFANRIX -diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml............................................................... 22 INFASURF -calfactant in nacl 0.9% intratracheal susp 35 mg/ml............................................................................... 95 INFED -iron dextran inj 50 mg/ml (elemental iron)......... 182 INFUMORPH 200 -morphine sulfate for microinfusion inj 200 mg/20ml (10mg/ml)............................................... 140 INFUMORPH 500 -morphine sulfate for microinfusion inj 500 mg/20ml (25mg/ml)............................................... 140 INGREZZA -valbenazine tosylate cap 40 mg (base equiv)............................................................................. 132 INLYTA -axitinib tab 1 mg.................................................. 27 INLYTA -axitinib tab 5 mg.................................................. 27 INNOPRAN XL -propranolol hcl sustained-release beads cap er 24hr 80 mg.......................................................... 63 INNOPRAN XL -propranolol hcl sustained-release beads cap er 24hr 120 mg........................................................ 63 INOSITOL HEXANICOTINATE -inositol niacinate (bulk) powder........................................................................... 239 INOSITOL -inositol (bulk) powder................................... 239 INSPRA -eplerenone tab 25 mg....................................... 73 INSPRA -eplerenone tab 50 mg....................................... 73 INSULIN PEN NEEDLES – VARIOUS............................ 261 INSULIN SYRINGES – VARIOUS...................................261 INTEGRA F -fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe)................................... 182 INTEGRA PLUS -fe fum-iron polysacch complex-fa-b complex-c-biotin cap..................................................... 182 INTELENCE -etravirine tab 25 mg.................................... 11 INTELENCE -etravirine tab 100 mg.................................. 11 INTELENCE -etravirine tab 200 mg.................................. 11 INTERARTICULAR JOINT KIT -triamcinolone inj 40 mg/ ml & lidocaine 1% & ammonia inh kit............................ 34 INTERMEZZO -zolpidem tartrate sl tab 1.75 mg............ 123 INTERMEZZO -zolpidem tartrate sl tab 3.5 mg.............. 123 INTRON A -interferon alfa-2b for inj 10000000 unit.......... 27 INTRON A -interferon alfa-2b for inj 18000000 unit.......... 27 INTRON A -interferon alfa-2b for inj 50000000 unit.......... 27 INTRON A -interferon alfa-2b inj 6000000 unit/ml............ 27 INTRON A -interferon alfa-2b inj 10000000 unit/ml.......... 27 INTRON A W/DILUENT -interferon alfa-2b for inj 10000000 unit................................................................. 27 INTRON A W/DILUENT -interferon alfa-2b for inj 18000000 unit................................................................. 27 INTRON A W/DILUENT -interferon alfa-2b for inj 50000000 unit................................................................. 27
INTUNIV -guanfacine hcl tab er 24hr 1 mg (base equiv)............................................................................. 128 INTUNIV -guanfacine hcl tab er 24hr 2 mg (base equiv)............................................................................. 128 INTUNIV -guanfacine hcl tab er 24hr 3 mg (base equiv)............................................................................. 128 INTUNIV -guanfacine hcl tab er 24hr 4 mg (base equiv)............................................................................. 128 INVANZ -ertapenem sodium for inj 1 gm (base equivalent)....................................................................... 18 INVEGA -paliperidone tab er 24hr 1.5 mg...................... 119 INVEGA -paliperidone tab er 24hr 3 mg......................... 119 INVEGA -paliperidone tab er 24hr 6 mg......................... 119 INVEGA -paliperidone tab er 24hr 9 mg......................... 119 INVEGA SUSTENNA -paliperidone palmitate im extended-release susp 39 mg/0.25ml.......................... 119 INVEGA SUSTENNA -paliperidone palmitate im extended-release susp 78 mg/0.5ml............................ 119 INVEGA SUSTENNA -paliperidone palmitate im extended-release susp 156 mg/ml............................... 119 INVEGA SUSTENNA -paliperidone palmitate im extended-release susp 234 mg/1.5ml.......................... 119 INVEGA SUSTENNA -paliperidone palmitate im extendrelease susp 117 mg/0.75ml........................................ 119 INVEGA TRINZA -paliperidone palmitate im extendrelease susp 273 mg/0.875ml...................................... 119 INVEGA TRINZA -paliperidone palmitate im extendrelease susp 410 mg/1.315ml...................................... 119 INVEGA TRINZA -paliperidone palmitate im extendrelease susp 546 mg/1.75ml........................................ 119 INVEGA TRINZA -paliperidone palmitate im extendrelease susp 819 mg/2.625ml...................................... 119 INVIRASE -saquinavir mesylate cap 200 mg................... 12 INVIRASE -saquinavir mesylate tab 500 mg.................... 12 INVOKAMET -canagliflozin-metformin hcl tab 50-500 mg.................................................................................... 48 INVOKAMET -canagliflozin-metformin hcl tab 150-500 mg.................................................................................... 48 INVOKAMET -canagliflozin-metformin hcl tab 50-1000 mg.................................................................................... 48 INVOKAMET -canagliflozin-metformin hcl tab 150-1000 mg.................................................................................... 48 INVOKAMET XR -canagliflozin-metformin hcl tab er 24hr 50-500 mg....................................................................... 48 INVOKAMET XR -canagliflozin-metformin hcl tab er 24hr 50-1000 mg..................................................................... 48 INVOKAMET XR -canagliflozin-metformin hcl tab er 24hr 150-500 mg..................................................................... 48 INVOKAMET XR -canagliflozin-metformin hcl tab er 24hr 150-1000 mg................................................................... 48 INVOKANA -canagliflozin tab 100 mg.............................. 48 INVOKANA -canagliflozin tab 300 mg.............................. 48 IODINE -iodine flakes...................................................... 239 IODINE RESUBLIMED -iodine granules......................... 239
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
334
2016 IODINE STRONG -iodine solution strong 5% (lugol's).......................................................................... 175 IODINE STRONG -iodine solution strong (lugol's) (bulk).............................................................................. 239 IODINE TINCTURE -iodine tincture................................ 218 IODOFORM -iodoform powder........................................ 239 IODOPEN -sodium iodide inj 100 mcg/ml....................... 175 iodoquinol-hydrocortisone in aloe vehicle cream 1-1.9% (Vytone)........................................................... 207 IODOQUINOL -iodoquinol powder.................................... 16 IONSYS -fentanyl hcl iontophoretic td system 40 mcg/act (base equiv).................................................................. 140 IOPANOIC ACID -iopanoic acid (bulk) powder............... 239 IOPIDINE -apraclonidine hcl ophth soln 0.5% (base equivalent)..................................................................... 191 IOPIDINE -apraclonidine hcl ophth soln 1% (base equivalent)..................................................................... 191 IPOL INACTIVATED IPV -poliovirus vaccine, ipv injection........................................................................... 21 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 92 ipratropium bromide inhal soln 0.02%.......................... 92 IPRATROPIUM BROMIDE -ipratropium bromide powder............................................................................. 92 IPRATROPIUM BROMIDE MONOH -ipratropium bromide powder............................................................................. 92 ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent)....................................................................... 87 ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent)....................................................................... 87 IPRIVASK -desirudin for inj 15 mg.................................. 186 irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide)..........................................................................73 irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide)..........................................................................73 irbesartan tab 75 mg (Avapro)....................................... 73 irbesartan tab 150 mg (Avapro)..................................... 73 irbesartan tab 300 mg (Avapro)..................................... 73 IRESSA -gefitinib tab 250 mg........................................... 27 IRON CHEWS PEDIATRIC -carbonyl iron chew tab 15 mg (elemental iron)............................................................. 182 iron combination cap.................................................... 182 iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg (Hematron-af)........................................................ 183 iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite 150)................................................................ 183 iron polysacch complex-vit b12-fa cap 150-0.025-1 mg................................................................................. 183 IROSPAN 24/6 -fe bisglyc-fe polys-succ acd-b cmplx-cca-fa tab ther pk........................................................... 183 irrigation solution, physiological................................. 276 IS 24/6 -fe bisglyc-fe polys-succ acd-b cmplx-c-ca-fa tab ther pk........................................................................... 183 ISENTRESS HD -raltegravir potassium tab 600 mg (base equiv)............................................................................... 12
ISENTRESS -raltegravir potassium chew tab 25 mg (base equiv)............................................................................... 12 ISENTRESS -raltegravir potassium chew tab 100 mg (base equiv).................................................................... 12 ISENTRESS -raltegravir potassium packet for susp 100 mg (base equiv).............................................................. 12 ISENTRESS -raltegravir potassium tab 400 mg (base equiv)............................................................................... 12 isometheptene-dichloral-acetaminophen cap 65-100-325 mg............................................................. 152 ISOMETHEPTENE MUCATE -isometheptene mucate (bulk) powder................................................................ 239 ISONIAZID -isoniazid inj 100 mg/ml................................... 8 ISONIAZID -isoniazid powder..............................................9 ISONIAZID -isoniazid syrup 50 mg/5ml.............................. 9 isoniazid tab 100 mg......................................................... 9 isoniazid tab 300 mg......................................................... 9 ISOPROPAMIDE IODIDE -isopropamide iodide powder............................................................................. 98 ISOPROPANOL -isopropyl alcohol 70%......................... 239 ISOPROPYL ALCOHOL -isopropyl alcohol.................... 239 ISOPROPYL ALCOHOL -isopropyl alcohol 70%............ 239 ISOPROPYL ALCOHOL -isopropyl alcohol 99%............ 239 ISOPROPYL MYRISTATE -isopropyl myristate (bulk) solution.......................................................................... 239 ISOPROPYL PALMITATE -isopropyl palmitate liquid..... 240 ISOPROTERENOL HCL -isoproterenol hcl (bulk) powder........................................................................... 240 ISOPTO CARPINE -pilocarpine hcl ophth soln 1%........ 191 ISOPTO CARPINE -pilocarpine hcl ophth soln 2%........ 191 ISOPTO CARPINE -pilocarpine hcl ophth soln 4%........ 191 ISORDIL TITRADOSE -isosorbide dinitrate tab 5 mg.......60 ISORDIL TITRADOSE -isosorbide dinitrate tab 40 mg.................................................................................... 60 ISOSORBIDE DINITRATE ER -isosorbide dinitrate tab er 40 mg.............................................................................. 60 isosorbide dinitrate tab 10 mg....................................... 60 isosorbide dinitrate tab 20 mg....................................... 60 isosorbide dinitrate tab 30 mg....................................... 61 isosorbide dinitrate tab 5 mg (Isordil titradose).......... 60 ISOSORBIDE -isosorbide (bulk) powder........................ 240 isosorbide mononitrate tab er 24hr 30 mg................... 61 isosorbide mononitrate tab er 24hr 60 mg................... 61 isosorbide mononitrate tab er 24hr 120 mg................. 61 isosorbide mononitrate tab 10 mg................................ 61 isosorbide mononitrate tab 20 mg................................ 61 isotretinoin cap 10 mg.................................................. 207 isotretinoin cap 20 mg.................................................. 207 isotretinoin cap 30 mg.................................................. 207 isotretinoin cap 40 mg.................................................. 207 ISOTRETINOIN -isotretinoin (bulk) powder.................... 240 ISOVACTIN AA PLUS -nutritional supplement liquid...... 179 ISOXSUPRINE HCL -isoxsuprine hcl (bulk) powder...... 240 ISOXSUPRINE HCL -isoxsuprine hcl tab 20 mg.............. 85 isoxsuprine hcl tab 10 mg.............................................. 85
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
335
2016 isradipine cap 2.5 mg...................................................... 65 isradipine cap 5 mg......................................................... 66 ISTALOL -timolol maleate ophth soln 0.5% (oncedaily).............................................................................. 191 ISUPREL -isoproterenol hcl inj 0.2 mg/ml.........................92 itraconazole cap 100 mg (Sporanox)............................ 10 ITRACONAZOLE -itraconazole powder.......................... 240 IVERMECTIN -ivermectin (bulk) powder.........................240 ivermectin tab 3 mg (Stromectol).................................. 16 IV PREP WIPES -antiseptic products misc - pads..........218
JENTADUETO XR -linagliptin-metformin hcl tab er 24hr 2.5-1000 mg.................................................................... 48 JENTADUETO XR -linagliptin-metformin hcl tab er 24hr 5-1000 mg....................................................................... 49 JETREA -ocriplasmin intravitreal inj 0.5 mg/0.2ml (2.5 mg/ ml).................................................................................. 191 JOJOBA OIL -jojoba oil (bulk)......................................... 240 JTT PHYSICIANS KIT -triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit..................................... 34 JUBLIA -efinaconazole soln 10%.................................... 207 JUNIPER TAR -juniper tar oil.......................................... 240 JUXTAPID -lomitapide mesylate cap 5 mg (base equiv)............................................................................... 82 JUXTAPID -lomitapide mesylate cap 10 mg (base equiv)............................................................................... 82 JUXTAPID -lomitapide mesylate cap 20 mg (base equiv)............................................................................... 82 JUXTAPID -lomitapide mesylate cap 30 mg (base equiv)............................................................................... 82 JUXTAPID -lomitapide mesylate cap 40 mg (base equiv)............................................................................... 82 JUXTAPID -lomitapide mesylate cap 60 mg (base equiv)............................................................................... 82
J JADENU -deferasirox tab 90 mg..................................... 219 JADENU -deferasirox tab 180 mg................................... 219 JADENU -deferasirox tab 360 mg................................... 219 JADENU SPRINKLE -deferasirox granules packet 90 mg.................................................................................. 219 JADENU SPRINKLE -deferasirox granules packet 180 mg.................................................................................. 219 JADENU SPRINKLE -deferasirox granules packet 360 mg.................................................................................. 219 JAKAFI -ruxolitinib phosphate tab 5 mg (base equivalent)....................................................................... 27 JAKAFI -ruxolitinib phosphate tab 10 mg (base equivalent)....................................................................... 27 JAKAFI -ruxolitinib phosphate tab 15 mg (base equivalent)....................................................................... 27 JAKAFI -ruxolitinib phosphate tab 20 mg (base equivalent)....................................................................... 27 JAKAFI -ruxolitinib phosphate tab 25 mg (base equivalent)....................................................................... 27 JALYN -dutasteride-tamsulosin hcl cap 0.5-0.4 mg........ 108 JANUMET -sitagliptin-metformin hcl tab 50-500 mg......... 48 JANUMET -sitagliptin-metformin hcl tab 50-1000 mg....... 48 JANUMET XR -sitagliptin-metformin hcl tab er 24hr 50-500 mg....................................................................... 48 JANUMET XR -sitagliptin-metformin hcl tab er 24hr 50-1000 mg..................................................................... 48 JANUMET XR -sitagliptin-metformin hcl tab er 24hr 100-1000 mg................................................................... 48 JANUVIA -sitagliptin phosphate tab 25 mg (base equiv)............................................................................... 48 JANUVIA -sitagliptin phosphate tab 50 mg (base equiv)............................................................................... 48 JANUVIA -sitagliptin phosphate tab 100 mg (base equiv)............................................................................... 48 JARDIANCE -empagliflozin tab 10 mg............................. 48 JARDIANCE -empagliflozin tab 25 mg............................. 48 JASMINE FRAGRANCE -jasmine fragrance (bulk) liquid.............................................................................. 240 JENTADUETO -linagliptin-metformin hcl tab 2.5-1000 mg.................................................................................... 48 JENTADUETO -linagliptin-metformin hcl tab 2.5-500 mg.................................................................................... 48 JENTADUETO -linagliptin-metformin hcl tab 2.5-850 mg.................................................................................... 48
K KADIAN -morphine sulfate cap er 24hr 10 mg............... 140 KADIAN -morphine sulfate cap er 24hr 20 mg............... 141 KADIAN -morphine sulfate cap er 24hr 30 mg............... 141 KADIAN -morphine sulfate cap er 24hr 40 mg............... 141 KADIAN -morphine sulfate cap er 24hr 50 mg............... 141 KADIAN -morphine sulfate cap er 24hr 60 mg............... 141 KADIAN -morphine sulfate cap er 24hr 80 mg............... 141 KADIAN -morphine sulfate cap er 24hr 100 mg............. 141 KADIAN -morphine sulfate cap er 24hr 200 mg............. 141 KAHLUA FLAVOR -flavoring agent - liquid..................... 267 KALBITOR -ecallantide inj 10 mg/ml...............................188 KALETRA -lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml).............................................................................. 12 KALETRA -lopinavir-ritonavir tab 100-25 mg.................... 12 KALETRA -lopinavir-ritonavir tab 200-50 mg.................... 12 KALYDECO -ivacaftor packet 50 mg................................ 95 KALYDECO -ivacaftor packet 75 mg................................ 95 KALYDECO -ivacaftor tab 150 mg.................................... 95 KAMDOY -dermatological products misc - emulsion...... 207 KANAMYCIN SULFATE -kanamycin sulfate (bulk) powder........................................................................... 240 KAOLIN -kaolin powder..................................................... 96 KAPVAY -clonidine hcl tab er 12hr 0.1 mg..................... 128 KARAYA GUM -karaya gum............................................ 267 KARBINAL ER -carbinoxamine maleate extended release susp 4 mg/5ml................................................................ 87 KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg....... 49 KAZANO -alogliptin-metformin hcl tab 12.5-500 mg......... 49 K.B.G.L. IN TERODERM CREA -ketoprofen-baclofengabapent-lido crm 15-4-10-2% (cmp kit)..................... 207 KEFLEX -cephalexin cap 250 mg....................................... 4 SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
336
2016 KEFLEX -cephalexin cap 500 mg....................................... 4 KEFLEX -cephalexin cap 750 mg....................................... 4 KENALOG -triamcinolone acetonide aerosol soln 0.147 mg/gm............................................................................ 207 KENALOG-10 -triamcinolone acetonide inj susp 10 mg/ ml..................................................................................... 34 KENALOG-40 -triamcinolone acetonide inj susp 40 mg/ ml..................................................................................... 34 KENDALL AMORPHOUS HYDROGE -wound dressings gel.................................................................................. 207 KENDALL HYDROGEL IMPREGNA -hydroactive (sterile) dressing......................................................................... 207 KENDALL HYDROGEL WOUND DR -hydroactive (sterile) dressing......................................................................... 207 KENDALL ZINC CALCIUM ALGI -wound dressings misc............................................................................... 207 KENDALL ZINC CALCIUM ALGI -wound dressings pads............................................................................... 207 KEPPRA -levetiracetam oral soln 100 mg/ml................. 159 KEPPRA -levetiracetam tab 250 mg............................... 159 KEPPRA -levetiracetam tab 500 mg............................... 159 KEPPRA -levetiracetam tab 750 mg............................... 159 KEPPRA -levetiracetam tab 1000 mg............................. 159 KEPPRA XR -levetiracetam tab er 24hr 500 mg............ 159 KEPPRA XR -levetiracetam tab er 24hr 750 mg............ 159 KERAGELT -wound dressings - gel................................ 207 KERAGEL -wound dressings - gel.................................. 207 KERALAC -urea cream 47%........................................... 207 KERALYT -salicylic acid gel 6%...................................... 207 KERAMATRIX REPLICINE 10CM -wound dressings sheet.............................................................................. 207 KERAMATRIX REPLICINE 5CMX -wound dressings sheet.............................................................................. 207 KERR TRIPLE DYE -triple dye swabs............................ 218 KERYDIN -tavaborole soln 5%........................................207 KETAMINE HCL -ketamine hcl (bulk) powder................ 240 ketoconazole cream 2%................................................ 207 ketoconazole foam 2% (Extina)................................... 207 KETOCONAZOLE -ketoconazole powder...................... 240 ketoconazole shampoo 2% (Nizoral)........................... 207 ketoconazole tab 200 mg................................................ 10 7-KETO DHEA -7-ketodehydroepiandrosterone (7-keto dhea) powder................................................................ 260 KETOPHENE RAPIDPAQ -ketoprofen cream 20% (compound kit).............................................................. 208 ketoprofen cap 50 mg................................................... 148 ketoprofen cap 75 mg................................................... 148 KETOPROFEN 10% CREAM BASE -ketoprofen (bulk) cream 10%.................................................................... 240 KETOPROFEN ER -ketoprofen cap er 24hr 200 mg...... 148 KETOPROFEN -ketoprofen powder................................ 148 KETOPROFEN MICRONIZED -ketoprofen powder....... 148 KETOPROFEN ULTRA MICRONIZ -ketoprofen powder........................................................................... 148
KETOROCAINE-L -ketorolac trometh inj 30 mg/ml & lidocaine hcl 1% kit....................................................... 149 KETOROCAINE-LM -ketorolac inj 30 mg/ml & bupivacaine 0.25% & lido 1% kit..................................149 KETOROLAC 2% GEL -ketorolac tromethamine gel 2% (cmpd kit) (base equiv).................................................208 ketorolac tromethamine im inj 60 mg/2ml (30 mg/ ml)................................................................................. 149 ketorolac tromethamine inj 15 mg/ml......................... 149 ketorolac tromethamine inj 30 mg/ml......................... 149 KETOROLAC TROMETHAMINE -ketorolac tromethamine (bulk) powder................................................................ 240 KETOROLAC TROMETHAMINE -ketorolac tromethamine inj 60 mg/2ml (30 mg/ml)............................................. 149 ketorolac tromethamine ophth soln 0.5% (Acular)......................................................................... 191 ketorolac tromethamine ophth soln 0.4% (Acular ls)................................................................................... 191 ketorolac tromethamine tab 10 mg............................. 149 KETOTIFEN FUMARATE -ketotifen fumarate (bulk) powder........................................................................... 240 KETOTIFEN HYDROGEN FUMARA -ketotifen fumarate (bulk) powder................................................................ 240 KETOVIE -nutritional supplement liquid.......................... 179 KETOVIE PEPTIDE -nutritional supplement liquid......... 179 KEVEYIS -dichlorphenamide tab 50 mg........................... 79 KHEDEZLA -desvenlafaxine tab er 24hr 50 mg............. 113 KHEDEZLA -desvenlafaxine tab er 24hr 100 mg........... 113 KINERET -anakinra subcutaneous soln prefilled syringe 100 mg/0.67ml.............................................................. 149 KINETIN -kinetin (bulk) powder....................................... 240 KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv vac inj.............................................................................. 22 KISQALI FEMARA 200 DOSE -ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack..................................27 KISQALI FEMARA 400 DOSE -ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack..................................27 KISQALI FEMARA 600 DOSE -ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack..................................27 KISQALI -ribociclib succinate tab 200 mg (base equiv)............................................................................... 27 KITABIS PAK -tobramycin nebu soln 300 mg/5ml.............. 8 KIWI FRAGRANCE -kiwi fragrance (bulk) liquid............. 240 KLARON -sulfacetamide sodium lotion 10% (acne)....... 208 KLONOPIN -clonazepam tab 0.5 mg.............................. 159 KLONOPIN -clonazepam tab 1 mg................................. 159 KLONOPIN -clonazepam tab 2 mg................................. 159 KLOR-CON M15 -potassium chloride microencapsulated crys er tab 15 meq....................................................... 175 KOJIC ACID -kojic acid powder...................................... 240 KOMBIGLYZE XR -saxagliptin-metformin hcl tab er 24hr 2.5-1000 mg.................................................................... 49 KOMBIGLYZE XR -saxagliptin-metformin hcl tab er 24hr 5-500 mg......................................................................... 49
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
337
2016 L-ALANINE -alanine powder........................................... 178 LAMICTAL CHEWABLE DISPERS -lamotrigine tab chewable dispersible 5 mg........................................... 160 LAMICTAL CHEWABLE DISPERS -lamotrigine tab chewable dispersible 25 mg......................................... 160 LAMICTAL -lamotrigine tab 25 mg.................................. 159 LAMICTAL -lamotrigine tab 100 mg................................ 159 LAMICTAL -lamotrigine tab 150 mg................................ 159 LAMICTAL -lamotrigine tab 200 mg................................ 160 LAMICTAL ODT -lamotrigine orally disintegrating tab 25 mg.................................................................................. 160 LAMICTAL ODT -lamotrigine orally disintegrating tab 50 mg.................................................................................. 160 LAMICTAL ODT -lamotrigine orally disintegrating tab 100 mg.................................................................................. 160 LAMICTAL ODT -lamotrigine orally disintegrating tab 200 mg.................................................................................. 160 LAMICTAL ODT -lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7) kit.................................................... 160 LAMICTAL ODT -lamotrigine tab disint 25 mg (21) & 50 mg (7) titration kit......................................................... 160 LAMICTAL ODT -lamotrigine tab disint 50 mg (42)- 100 mg(14) titration kit......................................................... 160 LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg (42) & 100 mg (7) starter kit.........................................160 LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg (84) & 100 mg (14) starter kit.......................................160 LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg (35) starter kit............................................................... 160 LAMICTAL XR -lamotrigine tab er 24hr 25 (14) & 50 mg (14) & 100 mg(7) kit..................................................... 160 LAMICTAL XR -lamotrigine tab er 24hr 50 (14) & 100 mg(14) & 200 mg(7) kit................................................ 160 LAMICTAL XR -lamotrigine tab er 24hr 25 mg............... 160 LAMICTAL XR -lamotrigine tab er 24hr 50 mg............... 160 LAMICTAL XR -lamotrigine tab er 24hr 100 mg............. 160 LAMICTAL XR -lamotrigine tab er 24hr 200 mg............. 160 LAMICTAL XR -lamotrigine tab er 24hr 250 mg............. 160 LAMICTAL XR -lamotrigine tab er 24hr 300 mg............. 160 LAMICTAL XR -lamotrigine tab er 24hr 25 mg (21) & 50 mg (7) titration kit......................................................... 160 LAMISIL -terbinafine hcl tab 250 mg................................ 10 lamivudine oral soln 10 mg/ml (Epivir)......................... 12 lamivudine tab 150 mg (Epivir)...................................... 12 lamivudine tab 300 mg (Epivir)...................................... 12 lamivudine tab 100 mg (hbv) (Epivir hbv)..................... 12 lamivudine-zidovudine tab 150-300 mg (Combivir)..... 12 LAMOTRIGINE -lamotrigine (bulk) powder..................... 241 lamotrigine orally disintegrating tab 25 mg (Lamictal odt)................................................................................ 160 lamotrigine orally disintegrating tab 50 mg (Lamictal odt)................................................................................ 160 lamotrigine orally disintegrating tab 100 mg (Lamictal odt)................................................................................ 160
KOMBIGLYZE XR -saxagliptin-metformin hcl tab er 24hr 5-1000 mg....................................................................... 49 KORLYM -mifepristone tab 300 mg.................................. 49 K-PHOS NEUTRAL -pot phos monobasic w/sod phos di & monobas tab 155-852-130mg...................................... 175 K-PHOS NO 2 -potassium & sodium acid phosphates tab 305-700 mg................................................................... 108 K-PHOS -potassium phosphate monobasic tab 500 mg.................................................................................. 175 KRIS-ESTER 236 -kris-ester 236 liquid.......................... 267 KRISGEL 100 -krisgel 100 gel........................................ 267 KRISTALOSE -lactulose oral crystal packet 10 gm.......... 95 KRISTALOSE -lactulose oral crystal packet 20 gm.......... 95 K-TAB -potassium chloride tab er 10 meq...................... 175 K-TAB -potassium chloride tab er 8 meq (600 mg)......... 175 K-TAB -potassium chloride tab er 20 meq (1500 mg)..... 175 KUDZU ROOT -kudzu (bulk) powder.............................. 240 KUVAN -sapropterin dihydrochloride powder packet 100 mg.................................................................................... 57 KUVAN -sapropterin dihydrochloride powder packet 500 mg.................................................................................... 57 KUVAN -sapropterin dihydrochloride soluble tab 100 mg.................................................................................... 57 KYNAMRO -mipomersen sodium soln prefilled syringe 200 mg/ml....................................................................... 82 L LABETALOL HCL -labetalol hcl (bulk) powder............... 241 labetalol hcl tab 100 mg (Trandate)............................... 63 labetalol hcl tab 200 mg (Trandate)............................... 63 labetalol hcl tab 300 mg (Trandate)............................... 63 LAC-HYDRIN -lactic acid (ammonium lactate) cream 12%................................................................................208 LAC-HYDRIN -lactic acid (ammonium lactate) lotion 12%................................................................................208 LACRISERT -artificial tear ophth insert...........................191 LACTASE 5000 -lactase (bulk) powder.......................... 241 lactated ringer's for irrigation...................................... 276 lactic acid (ammonium lactate) cream 12% (Lachydrin).......................................................................... 208 lactic acid (ammonium lactate) lotion 10%.................208 lactic acid (ammonium lactate) lotion 12% (Lachydrin).......................................................................... 208 LACTIC ACID -lactic acid soln........................................ 241 LACTIC ACID RACEMIC -lactic acid soln...................... 241 lactic acid w/ vitamin e cream 10%-3500 unit/30gm......................................................................208 LACTOSE ANHYDROUS -lactose powder..................... 267 LACTOSE HYDROUS -lactose powder.......................... 267 LACTOSE -lactose powder............................................. 267 LACTOSE MONOHYDRATE -lactose monohydrate powder........................................................................... 267 LACTOSE MONOHYDRATE SPRAY -lactose monohydrate powder.................................................... 267 lactulose (encephalopathy) solution 10 gm/15ml...... 103 lactulose solution 10 gm/15ml....................................... 95
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
338
2016 lamotrigine orally disintegrating tab 200 mg (Lamictal odt)................................................................................ 160 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di)................................................................ 160 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di)................................................................ 160 lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7) kit (Lamictal odt)................................................... 161 lamotrigine tab disint 25 mg (21) & 50 mg (7) titration kit (Lamictal odt)......................................................... 160 lamotrigine tab disint 50 mg (42)- 100 mg(14) titration kit (Lamictal odt)......................................................... 160 lamotrigine tab er 24hr 25 mg (Lamictal xr)............... 161 lamotrigine tab er 24hr 50 mg (Lamictal xr)............... 161 lamotrigine tab er 24hr 100 mg (Lamictal xr)............. 161 lamotrigine tab er 24hr 200 mg (Lamictal xr)............. 161 lamotrigine tab er 24hr 250 mg (Lamictal xr)............. 161 lamotrigine tab er 24hr 300 mg (Lamictal xr)............. 161 lamotrigine tab 25 mg (Lamictal)................................. 161 lamotrigine tab 100 mg (Lamictal)............................... 161 lamotrigine tab 150 mg (Lamictal)............................... 161 lamotrigine tab 200 mg (Lamictal)............................... 161 LANCET DEVICES-VARIOUS.........................................261 LANCETS – VARIOUS.................................................... 261 lanolin.............................................................................. 267 LANOLIN ALCOHOL -lanolin alcohol wax...................... 267 LANOLIN ANHYDROUS -lanolin anhydrous.................. 267 LANOLIN -lanolin anhydrous oil...................................... 267 LANOXIN -digoxin inj 0.25 mg/ml..................................... 60 LANOXIN -digoxin tab 62.5 mcg (0.0625 mg).................. 60 LANOXIN -digoxin tab 125 mcg (0.125 mg)..................... 60 LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................ 60 LANOXIN -digoxin tab 250 mcg (0.25 mg)....................... 60 LANOXIN PEDIATRIC -digoxin inj 0.1 mg/ml................... 60 lansoprazole cap delayed release 15 mg (Prevacid)....................................................................... 98 lansoprazole cap delayed release 30 mg (Prevacid)....................................................................... 98 LANSOPRAZOLE -lansoprazole (bulk) powder.............. 241 LANTUS -insulin glargine inj 100 unit/ml.......................... 52 LANTUS SOLOSTAR -insulin glargine soln pen-injector 100 unit/ml.......................................................................52 L-ARGININE -arginine powder........................................ 178 L-ARGININE BASE -arginine powder............................. 178 L-ARGININE HCL -arginine hcl (bulk) powder................ 240 LASIX -furosemide tab 20 mg........................................... 79 LASIX -furosemide tab 40 mg........................................... 79 LASIX -furosemide tab 80 mg........................................... 79 L-ASPARAGINE MONOHYDRATE -bulk chemicals powder........................................................................... 240 L-ASPARTIC ACID -aspartic acid powder...................... 240 LASTACAFT -alcaftadine ophth soln 0.25%................... 191 LATANOPROST -latanoprost (bulk) powder................... 241 latanoprost ophth soln 0.005% (Xalatan).................... 191
LATRIX XM -urea in zinc undecylenate-lactic acid vehicle emulsion 45%............................................................... 208 LATUDA -lurasidone hcl tab 20 mg.................................119 LATUDA -lurasidone hcl tab 40 mg.................................119 LATUDA -lurasidone hcl tab 60 mg.................................119 LATUDA -lurasidone hcl tab 80 mg.................................119 LATUDA -lurasidone hcl tab 120 mg...............................119 LAURETH-9 POLIDOCANOL -laureth-9 (bulk) liquid..... 241 LAURIC ACID -lauric acid (bulk) powder........................ 241 LAVARE WOUND WASH -wound cleansers - gel.......... 208 LAVENDER OIL FRAGRANCE -lavender oil.................. 241 LAVENDER OIL NATURAL -lavender oil........................ 241 LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base equiv)............................................................................. 141 LAZANDA -fentanyl citrate nasal spray 300 mcg/act (base equiv)............................................................................. 141 LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base equiv)............................................................................. 141 L-CARNITINE -levocarnitine (bulk) powder.................... 240 L-CARNOSINE -carnosine (bulk) powder....................... 240 L-CITRULLINE -citrulline (bulk) powder.......................... 240 L-CYSTEINE -cysteine (bulk) powder............................. 240 L-CYSTEINE HCL MONOHYDRAT -cysteine hcl powder........................................................................... 240 L-CYSTINE -cystine powder............................................178 LEAD ACETATE TRIHYDRATE -lead acetate trihydrate powder........................................................................... 241 LEAD TETROXIDE -lead tetroxide (bulk) powder 99%................................................................................241 LECITHIN ISOPROPYL PALMIT -lecithin-isopropyl palmitate solution.......................................................... 267 LECITHIN -lecithin (bulk) granules.................................. 178 LECITHIN -lecithin granules............................................ 178 LECITHIN ORGANOGEL -premium lecithin organogel base gel.........................................................................267 LECITHIN SOYA -soybean lecithin (bulk) granules........ 241 LECITHIN SOYA -soybean lecithin (bulk) powder.......... 241 LECITHIN -soybean lecithin (bulk) granules................... 241 LEFLUNOMIDE -leflunomide (bulk) powder................... 241 leflunomide tab 10 mg (Arava)..................................... 149 leflunomide tab 20 mg (Arava)..................................... 149 LEMONADE FLAVOR -flavoring agent - oil.................... 267 LEMON EXTRACT -flavoring agent - liquid.................... 267 LEMON FLAVOR -flavoring agent - oil........................... 267 LEMONGRASS OIL -lemongrass oil...............................241 LENVIMA 14 MG DAILY DOSE -lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose)............................... 27 LENVIMA 18 MG DAILY DOSE -lenvatinib cap therapy pack 10 & 4 (2) mg (18 mg daily dose)......................... 28 LENVIMA 24 MG DAILY DOSE -lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose)......................... 28 LENVIMA 10 MG DAILY DOSE -lenvatinib cap therapy pack 10 mg (10 mg daily dose)..................................... 27 LENVIMA 20 MG DAILY DOSE -lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose)................................ 28
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
339
2016 levetiracetam tab 750 mg (Keppra)............................. 161 levetiracetam tab 1000 mg (Keppra)........................... 161 levobunolol hcl ophth soln 0.5% (Betagan)............... 191 LEVOCARNITINE -levocarnitine (bulk) powder.............. 241 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 57 levocarnitine tab 330 mg (Carnitor)............................... 57 LEVOCETIRIZINE DIHYDROCHL -levocetirizine dihydrochloride (bulk) powder...................................... 241 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal)................................................................ 87 levocetirizine dihydrochloride tab 5 mg (Xyzal)...........87 LEVODOPA -levodopa powder....................................... 165 LEVOFLOXACIN HEMIHYDRATE -levofloxacin (bulk) powder........................................................................... 241 LEVOFLOXACIN HEMIHYDRATE -levofloxacin hemihydrate (bulk) powder........................................... 241 LEVOFLOXACIN -levofloxacin oral soln 25 mg/ml............. 7 levofloxacin ophth soln 0.5%....................................... 191 levofloxacin tab 250 mg (Levaquin)................................ 7 levofloxacin tab 500 mg (Levaquin)................................ 7 levofloxacin tab 750 mg (Levaquin)................................ 7 LEVOMEFOLATE CALCIUM -levomefolate calcium (bulk) powder........................................................................... 241 levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg (Quartette)....................................................... 42 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg.................................................................. 42 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg................................................................................. 42 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg................................................................................. 42 LEVONORGESTREL AND ETHINY -levonorgestrelethinyl estradiol (continuous) tab 90-20 mcg................. 42 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg............................... 43 levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg.......................................................................43 levonorgestrel tab 1.5 mg (Plan b one-step)................ 43 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique)........................................... 42 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique)............................................... 42 LEVOPHED -norepinephrine bitartrate inj 1 mg/ml...........80 LEVORPHANOL TARTRATE -levorphanol tartrate (bulk) powder........................................................................... 241 LEVORPHANOL TARTRATE -levorphanol tartrate tab 2 mg.................................................................................. 141 LEVOTHYROXINE SODIUM -levothyroxine sodium (bulk) powder........................................................................... 242 levothyroxine sodium tab 25 mcg (Synthroid)............. 52 levothyroxine sodium tab 50 mcg (Synthroid)............. 52 levothyroxine sodium tab 75 mcg (Synthroid)............. 53 levothyroxine sodium tab 88 mcg (Synthroid)............. 53 levothyroxine sodium tab 100 mcg (Synthroid)........... 53 levothyroxine sodium tab 112 mcg (Synthroid)........... 53
LENVIMA 8 MG DAILY DOSE -lenvatinib cap therapy pack 4 (2) mg (8 mg daily dose).................................... 28 LESCOL XL -fluvastatin sodium tab er 24 hr 80 mg......... 82 LETAIRIS -ambrisentan tab 5 mg..................................... 85 LETAIRIS -ambrisentan tab 10 mg................................... 85 LETROZOLE -letrozole (bulk) powder............................ 241 letrozole tab 2.5 mg (Femara)........................................ 28 LETS KIT -lidocaine & tetracaine w/ epineph kit (compounding kit)......................................................... 154 leucovorin calcium for inj 50 mg................................... 28 leucovorin calcium for inj 100 mg................................. 28 leucovorin calcium for inj 200 mg................................. 28 leucovorin calcium for inj 350 mg................................. 28 LEUCOVORIN CALCIUM -leucovorin calcium for inj 500 mg.................................................................................... 28 LEUCOVORIN CALCIUM -leucovorin calcium powder........................................................................... 241 LEUCOVORIN CALCIUM -leucovorin calcium tab 10 mg.................................................................................... 28 LEUCOVORIN CALCIUM -leucovorin calcium tab 15 mg.................................................................................... 28 leucovorin calcium tab 5 mg.......................................... 28 leucovorin calcium tab 25 mg........................................ 28 LEUKERAN -chlorambucil tab 2 mg................................. 28 leuprolide acetate inj kit 5 mg/ml.................................. 28 LEUPROLIDE ACETATE -leuprolide acetate (bulk) powder........................................................................... 241 LEVACET -aspirin-apap-salicylamide-caffeine tab 500-250-150-32.5 mg................................................... 136 LEVALBUTEROL HCL -levalbuterol hcl (bulk) powder........................................................................... 241 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenex concentrate)..................................... 92 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex)....................................................................... 92 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex)....................................................................... 92 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex)....................................................................... 92 LEVALBUTEROL TARTRATE HFA -levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv)........................... 92 LEVAMISOLE HCL -levamisole hcl powder...................... 28 LEVAQUIN -levofloxacin tab 250 mg.................................. 7 LEVAQUIN -levofloxacin tab 500 mg.................................. 7 LEVAQUIN -levofloxacin tab 750 mg.................................. 7 LEVBID -hyoscyamine sulfate tab er 12hr 0.375 mg........ 98 LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector 100 unit/ml.......................................................................52 LEVEMIR -insulin detemir inj 100 unit/ml..........................52 LEVETIRACETAM -levetiracetam (bulk) powder............ 241 levetiracetam oral soln 100 mg/ml (Keppra)...............161 levetiracetam tab er 24hr 500 mg (Keppra xr)............ 161 levetiracetam tab er 24hr 750 mg (Keppra xr)............ 161 levetiracetam tab 250 mg (Keppra)............................. 161 levetiracetam tab 500 mg (Keppra)............................. 161
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
340
2016 lidocaine hcl local preservative free (pf) inj 4% (Xylocaine-mpf)........................................................... 155 LIDOCAINE HCL MONOHYDRATE -lidocaine hcl (bulk) powder........................................................................... 242 LIDOCAINE HCL MONOHYDRATE -lidocaine hcl powder........................................................................... 208 lidocaine hcl soln 4% (Xylocaine)............................... 208 lidocaine hcl viscous soln 2%..................................... 195 lidocaine-hydrocortisone acetate rectal cream 3-0.5%........................................................................... 197 lidocaine inj 2% w/ epinephrine-1:50000.................... 155 lidocaine inj 0.5% w/ epinephrine-1:200000 (Xylocaine/epinephrin)............................................... 155 lidocaine inj 1% w/ epinephrine-1:100000 (Xylocaine/ epinephrin)................................................................... 155 lidocaine inj 2% w/ epinephrine-1:100000 (Xylocaine/ epinephrin)................................................................... 155 lidocaine inj 1.5% w/ epinephrine-1:200000 (Xylocaine-mpf/epinep).............................................. 155 lidocaine inj 2% w/ epinephrine-1:200000 (Xylocainempf/epinep).................................................................. 155 LIDOCAINE -lidocaine (bulk) crystals............................. 242 LIDOCAINE -lidocaine (bulk) powder..............................242 LIDOCAINE -lidocaine powder........................................ 208 lidocaine patch 5% (Lidoderm).................................... 208 lidocaine-prilocaine cream 2.5-2.5% (Emla)............... 208 LIDODERM -lidocaine patch 5%..................................... 208 LIDOLOG KIT -triamcinolone inj 40 mg/ml & lidocaine hcl inj 2% kit......................................................................... 34 LIDOPROFEN -ketoprofen-ketamine-lidocaine cream 5-5-2% (compound kit)................................................. 208 LILETTA -levonorgestrel releasing iud 18.6 mcg/day (52 mg total).......................................................................... 43 LIME FLAVOR -flavoring agent - oil................................ 267 LIME OIL -lime oil............................................................ 242 LIMONENE -limonene (bulk) liquid................................. 242 LINCOCIN -lincomycin hcl inj 300 mg/ml.......................... 18 lincomycin hcl inj 300 mg/ml (Lincocin)....................... 18 LINCOMYCIN HCL -lincomycin hcl (bulk) powder.......... 242 LINDANE -lindane shampoo 1%..................................... 208 linezolid for susp 100 mg/5ml (Zyvox).......................... 18 linezolid tab 600 mg (Zyvox).......................................... 18 LINOLEIC ACID -linoleic acid (bulk) liquid...................... 242 LINSEED OIL RAW -flaxseed oil (linseed oil)................. 242 LINZESS -linaclotide cap 72 mcg................................... 103 LINZESS -linaclotide cap 145 mcg................................. 103 LINZESS -linaclotide cap 290 mcg................................. 103 LIORESAL INTRATHECAL -baclofen intrathecal inj 0.05 mg/ml (50 mcg/ml)........................................................ 168 LIORESAL INTRATHECAL -baclofen intrathecal inj 10 mg/20ml (500 mcg/ml).................................................. 168 LIORESAL INTRATHECAL -baclofen intrathecal inj 10 mg/5ml (2000 mcg/ml).................................................. 169 LIORESAL INTRATHECAL -baclofen intrathecal inj 40 mg/20ml (2000 mcg/ml)................................................ 169
levothyroxine sodium tab 125 mcg (Synthroid)........... 53 levothyroxine sodium tab 137 mcg (Synthroid)........... 53 levothyroxine sodium tab 150 mcg (Synthroid)........... 53 levothyroxine sodium tab 175 mcg (Synthroid)........... 53 levothyroxine sodium tab 200 mcg (Synthroid)........... 53 levothyroxine sodium tab 300 mcg (Synthroid)........... 53 LEVSIN/SL -hyoscyamine sulfate tab sl 0.125 mg........... 98 LEVSIN -hyoscyamine sulfate inj 0.5 mg/ml..................... 98 LEVSIN -hyoscyamine sulfate tab 0.125 mg.................... 98 LEVULAN KERASTICK -aminolevulinic acid hcl for soln 20% (stick applicator)................................................... 208 LEXAPRO -escitalopram oxalate tab 5 mg (base equiv)............................................................................. 113 LEXAPRO -escitalopram oxalate tab 10 mg (base equiv)............................................................................. 113 LEXAPRO -escitalopram oxalate tab 20 mg (base equiv)............................................................................. 113 LEXIVA -fosamprenavir calcium susp 50 mg/ml (base equiv)............................................................................... 12 LEXIVA -fosamprenavir calcium tab 700 mg (base equiv)............................................................................... 12 L-GLUTAMIC ACID -glutamic acid powder..................... 178 L-GLUTAMIC ACID HCL -glutamic acid hcl powder....... 101 L-GLUTAMIC ACID MONOSODIU -monosodium glutamate (bulk) powder............................................... 240 L-GLUTAMINE -glutamine crystals................................. 178 L-GLUTAMINE -glutamine powder (bulk)........................178 L-HISTIDINE -histidine powder....................................... 178 L-HISTIDINE MONOHYDROCHLO -histidine hcl crystals.......................................................................... 178 L-HISTIDINE MONOHYDROCHLO -histidine hcl powder........................................................................... 178 LIALDA -mesalamine tab delayed release 1.2 gm......... 103 LIBRAX -clidinium & chlordiazepoxide cap 2.5-5 mg........98 LICORICE DEGLYCYRRHIZINAT -licorice, deglycyrrhizinated (bulk) powder................................. 242 LICORICE FLAVOR -flavoring agent - liquid.................. 267 LICORICE ROOT -licorice (glycyrrhiza) powder............. 242 LIDOCAINE BASE -lidocaine (bulk) powder................... 242 lidocaine hcl gel 2%...................................................... 208 LIDOCAINE HCL-HYDROCORTIS -lidocainehydrocortisone acetate rectal gel 2.8-0.55%............... 197 LIDOCAINE HCL -lidocaine hcl (bulk) powder................242 LIDOCAINE HCL -lidocaine hcl laryngotracheal soln 4%.................................................................................. 195 lidocaine hcl local inj 0.5% (Xylocaine)...................... 154 lidocaine hcl local inj 1% (Xylocaine)......................... 154 lidocaine hcl local inj 2% (Xylocaine)......................... 155 lidocaine hcl local inj 1.5% (Xylocaine-mpf)...............154 lidocaine hcl local preservative free (pf) inj 0.5% (Xylocaine-mpf)........................................................... 155 lidocaine hcl local preservative free (pf) inj 1% (Xylocaine-mpf)........................................................... 155 lidocaine hcl local preservative free (pf) inj 2% (Xylocaine-mpf)........................................................... 155
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
341
2016 lithium carbonate tab 300 mg...................................... 119 LITHIUM CITRATE TETRAHYDR -lithium citrate tetrahydrate (bulk) powder........................................... 242 LITHIUM -lithium oral solution 8 meq/5ml....................... 119 LITHOBID -lithium carbonate tab er 300 mg.................. 119 LITHOSTAT -acetohydroxamic acid tab 250 mg............. 108 LIVALO -pitavastatin calcium tab 1 mg (base equiv)........ 82 LIVALO -pitavastatin calcium tab 2 mg (base equiv)........ 82 LIVALO -pitavastatin calcium tab 4 mg (base equiv)........ 82 LIVER FLAVOR -flavoring agent - liquid......................... 268 LIVER FLAVOR -flavoring agent - powder......................268 L-LEUCINE -leucine powder........................................... 178 L-LYSINE HCL -lysine hcl powder.................................. 240 L-LYSINE MONOHYDROCHLORID -lysine hcl powder........................................................................... 240 L-MENTHOL -menthol crystals....................................... 240 L-METHIONINE -methionine powder.............................. 178 L-METHYLFOLATE CALCIUM -levomefolate calcium (bulk) powder................................................................ 240 L-5-METHYLTETRAHYDROFOLIC -levomefolate calcium (bulk) powder................................................................ 241 LOCOID -hydrocortisone butyrate cream 0.1%.............. 208 LOCOID -hydrocortisone butyrate lotion 0.1%................208 LOCOID -hydrocortisone butyrate oint 0.1%.................. 208 LOCOID -hydrocortisone butyrate soln 0.1%..................208 LOCOID LIPOCREAM -hydrocortisone butyrate hydrophilic lipo base cream 0.1%................................ 208 LOCUST BEAN GUM -carob (locust bean gum) (bulk) powder........................................................................... 242 LODINE -etodolac tab 400 mg........................................ 149 LODOSYN -carbidopa tab 25 mg................................... 165 LOESTRIN 1.5/30-21 -norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg.......................................... 43 LOESTRIN 1/20-21 -norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg............................................................ 43 LOESTRIN FE 1.5/30 -norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg...................................... 43 LOESTRIN FE 1/20 -norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg......................................... 43 LOFIBRA -fenofibrate micronized cap 67 mg................... 82 LOFIBRA -fenofibrate micronized cap 134 mg................. 83 LOFIBRA -fenofibrate micronized cap 200 mg................. 83 LOFIBRA -fenofibrate tab 54 mg...................................... 83 LOLLIPOP BASE -isomalt lollipop base powder.............268 LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10 mcg (24)/10 mcg (2)....................................................... 43 LOMOTIL -diphenoxylate w/ atropine tab 2.5-0.025 mg.................................................................................... 96 LONSURF -trifluridine-tipiracil tab 15-6.14 mg................. 28 LONSURF -trifluridine-tipiracil tab 20-8.19 mg................. 28 loperamide hcl cap 2 mg................................................ 96 LOPERAMIDE HCL -loperamide hcl powder.................... 96 LOPID -gemfibrozil tab 600 mg......................................... 83 lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra).......................................................................... 12
LIOTHYRONINE -liothyronine (bulk) powder.................. 242 LIOTHYRONINE SODIUM -liothyronine sodium powder............................................................................. 53 liothyronine sodium tab 5 mcg (Cytomel).................... 53 liothyronine sodium tab 25 mcg (Cytomel).................. 53 liothyronine sodium tab 50 mcg (Cytomel).................. 53 LIPACTIVE INCA INCHI WO -inca inchi (plukenetia volubilis) seed (bulk) liquid........................................... 242 LIPMAX -lecithin-isopropyl palmitate solution................. 267 LIPO CREAM BASE -cream base.................................. 267 LIPOFEN -fenofibrate cap 50 mg...................................... 82 LIPOFEN -fenofibrate cap 150 mg.................................... 82 LIPOFOAM RX -foam base - foam................................. 268 LIPOGEL CR BASE -gel base - gel................................ 268 LIPOIC ACID -alpha-lipoic acid (bulk) powder................ 242 LIPOPEN ABSORPTION ENHANC -cream base...........268 LIPOPEN ANHYDROUS -lotion base - lotion................. 268 LIPOPEN ULTRA BASE -cream base............................ 268 LIPOSOMAL HEAVY -cream base................................. 268 LIPOSOMAL REGULAR -cream base............................ 268 LIPOZYME -cream base liposomic................................. 268 LIQUIGEL COMPLEX -emulsifying base - liquid............ 268 LIQUIHEP BD 3ML PREFILLED -arterial blood gas kit................................................................................... 219 LIQUIHEP BD 3ML PREFIL SY -arterial blood gas kit................................................................................... 219 LIQUIHEP II BD 3ML LL SYR -arterial blood gas kit...... 219 LIQUIHEP II BD 3ML PREFIL -arterial blood gas kit...... 220 lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic)..................................................................... 73 lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic)..................................................................... 73 lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic)..................................................................... 73 LISINOPRIL -lisinopril (bulk) powder.............................. 242 lisinopril tab 5 mg (Prinivil)............................................ 73 lisinopril tab 10 mg (Prinivil).......................................... 73 lisinopril tab 20 mg (Prinivil).......................................... 73 lisinopril tab 2.5 mg (Zestril).......................................... 73 lisinopril tab 30 mg (Zestril)........................................... 73 lisinopril tab 40 mg (Zestril)........................................... 73 L-ISOLEUCINE -isoleucine powder................................ 178 LISSAMINE GREEN B -lissamine green b powder........ 268 lithium carbonate cap 300 mg..................................... 119 lithium carbonate cap 150 mg (Lithium carbonate).................................................................... 119 lithium carbonate cap 600 mg (Lithium carbonate).................................................................... 119 LITHIUM CARBONATE -lithium carbonate cap 150 mg.................................................................................. 119 LITHIUM CARBONATE -lithium carbonate cap 600 mg.................................................................................. 119 LITHIUM CARBONATE -lithium carbonate powder........ 119 lithium carbonate tab er 450 mg.................................. 119 lithium carbonate tab er 300 mg (Lithobid)................ 119
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
342
2016 LOTRONEX -alosetron hcl tab 0.5 mg (base equiv)....... 103 LOTRONEX -alosetron hcl tab 1 mg (base equiv).......... 103 LOUTREX -antiseborrheic products misc - cream.......... 208 lovastatin tab 10 mg........................................................ 83 lovastatin tab 20 mg (Mevacor)..................................... 83 lovastatin tab 40 mg (Mevacor)..................................... 83 LOVAZA -omega-3-acid ethyl esters cap 1 gm.................83 LOVENOX -enoxaparin sodium inj 30 mg/0.3ml.............186 LOVENOX -enoxaparin sodium inj 40 mg/0.4ml.............186 LOVENOX -enoxaparin sodium inj 60 mg/0.6ml.............186 LOVENOX -enoxaparin sodium inj 80 mg/0.8ml.............186 LOVENOX -enoxaparin sodium inj 100 mg/ml................186 LOVENOX -enoxaparin sodium inj 120 mg/0.8ml...........186 LOVENOX -enoxaparin sodium inj 150 mg/ml................186 LOVENOX -enoxaparin sodium inj 300 mg/3ml..............186 loxapine succinate cap 5 mg....................................... 119 loxapine succinate cap 10 mg..................................... 120 loxapine succinate cap 25 mg..................................... 120 loxapine succinate cap 50 mg..................................... 120 LOXORAL BASE -excipient filler powder........................ 268 LOZIBASE S -lozibase misc............................................268 LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg naf)................................................................................. 175 L-PHENYLALANINE -phenylalanine powder.................. 178 L-PROLINE -proline powder............................................ 178 L-SELENOMETHIONINE BLEND -l-selenomethionine (bulk) powder................................................................ 241 L-SELENOMETHIONINE -l-selenomethionine (bulk) powder........................................................................... 241 L-SERINE -serine (bulk) powder..................................... 241 L-THREONINE -threonine crystals..................................178 L-THYROXINE SODIUM -levothyroxine sodium (bulk) powder........................................................................... 241 LT INJECTION KIT -triamcinolone inj 40 mg/ml & lidocaine hcl inj 2% kit.................................................... 34 L-TRYPTOPHAN -tryptophan powder............................. 178 L-TYROSINE -tyrosine powder....................................... 178 LUBRAJEL NP -gel base - gel........................................ 268 LUCENTIS -ranibizumab intravitreal inj 0.3 mg/0.05ml (6 mg/ml)............................................................................ 191 LUCENTIS -ranibizumab intravitreal inj 0.5 mg/0.05ml (10 mg/ml)............................................................................ 191 LUCENTIS -ranibizumab intravitreal soln pref syr 0.5 mg/0.05ml...................................................................... 191 LUGOLS -iodine solution strong (lugol's) (bulk).............. 242 LUGOLS STRONG IODINE -iodine solution.................. 218 LUMIGAN -bimatoprost ophth soln 0.01%...................... 191 LUNESTA -eszopiclone tab 1 mg....................................123 LUNESTA -eszopiclone tab 2 mg....................................123 LUNESTA -eszopiclone tab 3 mg....................................123 LUPANETA PACK -leuprolide (1 mon) inj 3.75 mg & norethindrone tab 5 mg kit............................................. 57 LUPANETA PACK -leuprolide (3 mon) inj 11.25 mg & norethindrone tab 5 mg kit............................................. 57
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab 50-25 mg......................................................................... 73 LOPRESSOR -metoprolol tartrate tab 50 mg................... 63 LOPRESSOR -metoprolol tartrate tab 100 mg................. 63 LOPROX -ciclopirox olamine cream 0.77% (base equiv)............................................................................. 208 LOPROX -ciclopirox olamine susp 0.77% (base equiv)............................................................................. 208 LOPROX SHAMPOO -ciclopirox shampoo 1%.............. 208 LORATADINE -loratadine (bulk) powder......................... 242 lorazepam conc 2 mg/ml (Lorazepam intensol)......... 110 lorazepam inj 2 mg/ml (Ativan).................................... 110 lorazepam inj 4 mg/ml (Ativan).................................... 110 LORAZEPAM -lorazepam (bulk) powder........................ 242 lorazepam tab 0.5 mg (Ativan)..................................... 110 lorazepam tab 1 mg (Ativan)........................................ 110 lorazepam tab 2 mg (Ativan)........................................ 110 L-ORNITHINE HYDROCHLORIDE -ornithine hcl (bulk) powder........................................................................... 240 LORTAB -hydrocodone-acetaminophen soln 10-300 mg/15ml......................................................................... 141 LORZONE -chlorzoxazone tab 375 mg.......................... 169 LORZONE -chlorzoxazone tab 750 mg.......................... 169 losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar)....................................................................73 losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar).................................................... 74 losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar)....................................................................74 losartan potassium tab 25 mg (Cozaar)........................ 74 losartan potassium tab 50 mg (Cozaar)........................ 74 losartan potassium tab 100 mg (Cozaar)...................... 74 LOSEASONIQUE -levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)..................................................... 43 LOTEMAX -loteprednol etabonate ophth gel 0.5%......... 191 LOTEMAX -loteprednol etabonate ophth oint 0.5%........ 191 LOTEMAX -loteprednol etabonate ophth susp 0.5%...... 191 LOTENSIN -benazepril hcl tab 20 mg.............................. 74 LOTENSIN -benazepril hcl tab 40 mg.............................. 74 LOTENSIN HCT -benazepril & hydrochlorothiazide tab 10-12.5 mg...................................................................... 74 LOTENSIN HCT -benazepril & hydrochlorothiazide tab 20-12.5 mg...................................................................... 74 LOTENSIN HCT -benazepril & hydrochlorothiazide tab 20-25 mg......................................................................... 74 LOTREL -amlodipine besylate-benazepril hcl cap 5-10 mg.................................................................................... 74 LOTREL -amlodipine besylate-benazepril hcl cap 5-20 mg.................................................................................... 74 LOTREL -amlodipine besylate-benazepril hcl cap 10-20 mg.................................................................................... 74 LOTREL -amlodipine besylate-benazepril hcl cap 10-40 mg.................................................................................... 74 LOTRISONE -clotrimazole w/ betamethasone cream 1-0.05%......................................................................... 208
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
343
2016 MACRODANTIN -nitrofurantoin macrocrystalline cap 100 mg.................................................................................. 105 MACUGEN -pegaptanib sodium intravitreous inj 0.3 mg/90 microliter............................................................ 191 MAFENIDE ACETATE -mafenide acetate (bulk) powder........................................................................... 242 MAGNASWEET 110 -ammonium glycyrrhizinate (bulk) liquid.............................................................................. 242 MAGNASWEET 135 -ammonium glycyrrhizinate (bulk) powder........................................................................... 242 MAGNEBIND 400 -magnesium-calcium-folic acid tab 400-200-1 mg................................................................175 MAGNESIUM ALUMINUM SILICA -magnesium aluminum silicate (bulk) powder.................................................... 242 MAGNESIUM AMINO ACID CHEL -magnesium amino acid chelate (bulk) powder 20%................................... 242 MAGNESIUM ASCORBATE -magnesium ascorbate (bulk) powder................................................................ 242 MAGNESIUM BISGLYCINATE CH -magnesium glycinate (bulk) powder................................................................ 243 MAGNESIUM BISGLYCINATE DI -magnesium bisglycinate dihydrate (bulk) powder............................243 MAGNESIUM CARBONATE HEAVY -magnesium carbonate powder......................................................... 175 MAGNESIUM CARBONATE LIGHT -magnesium carbonate powder......................................................... 175 MAGNESIUM CHLORIDE HEXAHY -magnesium chloride crystals.......................................................................... 175 magnesium chloride inj 200 mg/ml............................. 175 MAGNESIUM CHLORIDE -magnesium chloride powder........................................................................... 175 MAGNESIUM CITRATE -magnesium citrate (bulk) powder........................................................................... 243 MAGNESIUM CITRATE TRIBASI -magnesium citrate (bulk) powder................................................................ 243 MAGNESIUM GLUCONATE -magnesium gluconate (bulk) powder................................................................ 243 MAGNESIUM GLYCINATE -magnesium glycinate (bulk) powder........................................................................... 243 MAGNESIUM HYDROXIDE -magnesium hydroxide (bulk) powder........................................................................... 243 MAGNESIUM MALATE -magnesium malate (bulk) powder........................................................................... 243 MAGNESIUM OXIDE HEAVY -magnesium oxide powder............................................................................. 96 MAGNESIUM OXIDE LIGHT -magnesium oxide powder............................................................................. 96 MAGNESIUM PHOSPHATE DIBAS -magnesium phosphate dibasic trihydrate (bulk) powder................. 243 MAGNESIUM STEARATE -magnesium stearate powder........................................................................... 268 MAGNESIUM SULFATE HEPTAHY -magnesium sulfate powder............................................................................. 95 magnesium sulfate inj 50%.......................................... 176
LUPRON DEPOT (1-MONTH) -leuprolide acetate for inj kit 3.75 mg...................................................................... 28 LUPRON DEPOT (1-MONTH) -leuprolide acetate for inj kit 7.5 mg........................................................................ 28 LUPRON DEPOT (3-MONTH) -leuprolide acetate (3 month) for inj kit 11.25 mg............................................. 28 LUPRON DEPOT (3-MONTH) -leuprolide acetate (3 month) for inj kit 22.5 mg............................................... 28 LUPRON DEPOT (4-MONTH) -leuprolide acetate (4 month) for inj kit 30 mg.................................................. 28 LUPRON DEPOT (6-MONTH) -leuprolide acetate (6 month) for inj kit 45 mg.................................................. 28 LUPRON DEPOT-PED (1-MONTH -leuprolide acetate for inj pediatric kit 7.5 mg.................................................... 57 LUPRON DEPOT-PED (1-MONTH -leuprolide acetate for inj pediatric kit 11.25 mg................................................ 57 LUPRON DEPOT-PED (1-MONTH -leuprolide acetate for inj pediatric kit 15 mg..................................................... 57 LUPRON DEPOT-PED (3-MONTH -leuprolide acetate (3 month) for inj pediatric kit 11.25 mg............................... 57 LUPRON DEPOT-PED (3-MONTH -leuprolide acetate (3 month) for inj pediatric kit 30 mg................................... 57 LUTEIN -lutein (bulk) beads 5%..................................... 242 LUTEIN -lutein (bulk) powder 5%................................... 242 LUXAMEND -wound dressings - cream.......................... 208 LUXIQ -betamethasone valerate aerosol foam 0.12%.............................................................................208 LUZU -luliconazole cream 1%......................................... 208 L-VALINE -valine crystals................................................ 178 L-VALINE -valine powder................................................ 178 LYNPARZA -olaparib cap 50 mg....................................... 28 LYRICA -pregabalin cap 25 mg.......................................161 LYRICA -pregabalin cap 50 mg.......................................161 LYRICA -pregabalin cap 75 mg.......................................161 LYRICA -pregabalin cap 100 mg.....................................161 LYRICA -pregabalin cap 150 mg.....................................161 LYRICA -pregabalin cap 200 mg.....................................161 LYRICA -pregabalin cap 225 mg.....................................161 LYRICA -pregabalin cap 300 mg.....................................161 LYRICA -pregabalin soln 20 mg/ml................................. 161 LYSINE HCL -lysine hcl (bulk) granules......................... 242 LYSODREN -mitotane tab 500 mg....................................28 LYSTEDA -tranexamic acid tab 650 mg......................... 187 M MACADAMIA NUT OIL -macadamian nut oil..................242 MACA ROOT -maca root (lepidium meyenii) (bulk) powder........................................................................... 242 MACI -autologous cultured chondrocyte on collagen membrane sheet........................................................... 169 MACROBID -nitrofurantoin monohydrate macrocrystalline cap 100 mg................................................................... 104 MACRODANTIN -nitrofurantoin macrocrystalline cap 25 mg.................................................................................. 105 MACRODANTIN -nitrofurantoin macrocrystalline cap 50 mg.................................................................................. 105
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
344
2016 magnesium sulfate iv soln 2 gm/50ml (40 mg/ml) (Magnesium sulfate)................................................... 176 magnesium sulfate iv soln 4 gm/100ml (40 mg/ml) (Magnesium sulfate)................................................... 176 magnesium sulfate iv soln 20 gm/500ml (40 mg/ml) (Magnesium sulfate)................................................... 176 magnesium sulfate iv soln 40 gm/1000ml (40 mg/ml) (Magnesium sulfate)................................................... 176 magnesium sulfate iv soln 4 gm/50ml (80 mg/ml) (Magnesium sulfate)................................................... 176 MAGNESIUM SULFATE -magnesium sulfate iv soln 2 gm/50ml (40 mg/ml)......................................................175 MAGNESIUM SULFATE -magnesium sulfate iv soln 4 gm/100ml (40 mg/ml)................................................... 176 MAGNESIUM SULFATE -magnesium sulfate iv soln 20 gm/500ml (40 mg/ml)................................................... 176 MAGNESIUM SULFATE -magnesium sulfate iv soln 40 gm/1000ml (40 mg/ml)................................................. 176 MAGNESIUM SULFATE -magnesium sulfate iv soln 4 gm/50ml (80 mg/ml)......................................................176 MAGNESIUM SULFATE -magnesium sulfate powder...... 95 MAGNESIUM TRISILICATE ANH -magnesium trisilicate powder............................................................................. 96 MAGNESIUM TRISILICATE HYD -magnesium trisilicate powder............................................................................. 97 MAGNESIUM TRISILICATE -magnesium trisilicate powder............................................................................. 96 MAKENA -hydroxyprogesterone caproate im in oil 250 mg/ml............................................................................... 45 MALARONE -atovaquone-proguanil hcl tab 62.5-25 mg.................................................................................... 16 MALARONE -atovaquone-proguanil hcl tab 250-100 mg.................................................................................... 16 malathion lotion 0.5% (Ovide)...................................... 208 MALEIC ACID -maleic acid (bulk) powder...................... 243 MALIC ACID -malic acid powder.................................... 243 MALTODEXTRIN -maltodextrin (bulk) powder................243 MANDELIC ACID -mandelic acid (bulk) powder............. 243 MANGANESE CHLORIDE TETRAH -manganese chloride tetrahydrate (bulk) powder............................. 243 MANGANESE GLUCONATE -manganese gluconate (bulk) powder................................................................ 243 MANGANESE SULFATE -manganese sulfate (bulk) powder........................................................................... 243 MANGO FLAVOR -flavoring agent - liquid...................... 268 MANGO FLAVOR -flavoring agent - powder.................. 268 MANGO FLAVOR SWEETENED -flavoring agent powder........................................................................... 268 MANNITOL -mannitol powder......................................... 243 MAPLE FLAVOR -flavoring agent - liquid....................... 268 MAPROTILINE HCL -maprotiline hcl tab 25 mg............. 113 MAPROTILINE HCL -maprotiline hcl tab 50 mg............. 113 MAPROTILINE HCL -maprotiline hcl tab 75 mg............. 113 MARBETA-25 -betamethasone sod phos & ace inj 6 mg/ ml & bupiv 0.25% kit...................................................... 34
MARBETA-L -betameth na pho&ace inj 6 mg/ml & bupiv 0.25% & lido1% kit......................................................... 34 MARCAINE/EPINEPHRINE -bupivacaine inj 0.25% w/ epinephrine 1:200000................................................... 155 MARCAINE/EPINEPHRINE -bupivacaine inj 0.5% w/ epinephrine 1:200000................................................... 155 MARCAINE/EPINEPHRINE -bupivacaine inj 0.25% w/ epinephrine 1:200000 (pf)............................................ 155 MARCAINE/EPINEPHRINE -bupivacaine inj 0.5% w/ epinephrine 1:200000 (pf)............................................ 155 MARCAINE -bupivacaine hcl inj 0.25%.......................... 155 MARCAINE -bupivacaine hcl inj 0.5%............................ 155 MARCAINE -bupivacaine hcl preservative free (pf) inj 0.25%.............................................................................155 MARCAINE -bupivacaine hcl preservative free (pf) inj 0.5%...............................................................................155 MARCAINE -bupivacaine hcl preservative free (pf) inj 0.75%.............................................................................155 MARCAINE SPINAL -bupivacaine 0.75% in dextrose inj 8.25%.............................................................................155 MARDEX-25 -dexamethasone sod phos pf inj 10 mg/ml & bupiv 0.25% kit............................................................... 34 MARINOL -dronabinol cap 2.5 mg.................................. 100 MARINOL -dronabinol cap 5 mg..................................... 100 MARINOL -dronabinol cap 10 mg................................... 100 MARLIDO KIT -lidocaine hcl inj 2% & bupivacaine hcl inj 0.5% kit......................................................................... 155 MARLIDO-25 -lidocaine hcl inj 1% & bupivacaine hcl inj 0.25% kit....................................................................... 155 MARPLAN -isocarboxazid tab 10 mg............................. 113 MARSHMALLOW FLAVOR -flavoring agent - liquid....... 268 MATULANE -procarbazine hcl cap 50 mg........................ 28 MAXALT-MLT -rizatriptan benzoate oral disintegrating tab 5 mg (base eq)............................................................. 152 MAXALT-MLT -rizatriptan benzoate oral disintegrating tab 10 mg (base eq)........................................................... 152 MAXALT -rizatriptan benzoate tab 5 mg (base equivalent)..................................................................... 152 MAXALT -rizatriptan benzoate tab 10 mg (base equivalent)..................................................................... 152 MAXFE -iron-fa-vit b12-biotin-vit c-docusate-mg-zn tab 160-1 mg....................................................................... 183 MAXIDEX -dexamethasone ophth susp 0.1%................ 191 MAXIPIME -cefepime hcl for inj 1 gm................................. 4 MAXIPIME -cefepime hcl for inj 2 gm................................. 4 MAXITROL -neomycin-polymyxin-dexamethasone ophth oint 0.1%....................................................................... 191 MAXITROL -neomycin-polymyxin-dexamethasone ophth susp 0.1%..................................................................... 191 MAXZIDE -triamterene & hydrochlorothiazide tab 75-50 mg.................................................................................... 79 MAXZIDE-25 -triamterene & hydrochlorothiazide tab 37.5-25 mg...................................................................... 79 MEBENDAZOLE -mebendazole powder.......................... 16
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
345
2016 MEDROXYPROGESTERONE MICRO medroxyprogesterone micronized powder................... 243 mefenamic acid cap 250 mg (Ponstel)........................ 149 MEFENAMIC ACID -mefenamic acid powder.................149 mefloquine hcl tab 250 mg............................................. 16 MEGACE ES -megestrol acetate susp 625 mg/5ml......... 45 MEGESTROL ACETATE -megestrol acetate powder....... 28 megestrol acetate susp 625 mg/5ml (Megace es)........ 45 megestrol acetate susp 40 mg/ml (Megace oral)......... 28 megestrol acetate tab 20 mg.......................................... 28 megestrol acetate tab 40 mg.......................................... 28 MEGLUMINE -meglumine (bulk) powder........................ 243 MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent)............................................................ 28 MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base equivalent)....................................................................... 29 MELATONIN -melatonin powder..................................... 243 MELOXICAM -meloxicam (bulk) powder........................ 243 meloxicam tab 7.5 mg (Mobic)..................................... 149 meloxicam tab 15 mg (Mobic)...................................... 149 melphalan tab 2 mg (Alkeran)........................................ 29 memantine hcl oral solution 2 mg/ml (Namenda)...... 132 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak (Namenda titration pa)............................................... 132 memantine hcl tab 5 mg (Namenda)........................... 132 memantine hcl tab 10 mg (Namenda)......................... 132 MEMANTINE HYDROCHLORIDE -memantine hcl (bulk) powder........................................................................... 243 MENACTRA -meningococcal (a, c, y, and w-135) conjugate vaccine inj...................................................... 21 MENADIONE -menadione (bulk) powder........................244 MENADIONE SODIUM BISULFIT -menadione sodium bisulfite crystals.............................................................244 MENEST -esterified estrogens tab 0.3 mg....................... 41 MENEST -esterified estrogens tab 0.625 mg................... 41 MENEST -esterified estrogens tab 1.25 mg..................... 41 MENHIBRIX -meningococcal (c & y)-haemophilus b tet tox conj vac for inj.......................................................... 21 MENOMUNE-A/C/Y/W-135 -meningococcal vaccine a, c, y, and w-135 inj.............................................................. 21 MENOSTAR -estradiol td patch weekly 14 mcg/24hr....... 41 MENTAX -butenafine hcl cream 1%................................209 MENTHOL -menthol crystals........................................... 244 MENVEO -meningococcal (a, c, y, and w-135) oligo conj vac for inj........................................................................ 21 MEPERIDINE HCL/PROMETHAZI -meperidine w/ promethazine cap 50-25 mg........................................ 141 meperidine hcl inj 25 mg/ml (Demerol)....................... 141 meperidine hcl inj 50 mg/ml (Demerol)....................... 141 meperidine hcl inj 100 mg/ml (Demerol)..................... 141 MEPERIDINE HCL -meperidine hcl inj 10 mg/ml........... 141 MEPERIDINE HCL -meperidine hcl oral soln 50 mg/5ml........................................................................... 141 MEPERIDINE HCL -meperidine hcl powder................... 141 meperidine hcl tab 50 mg (Demerol)........................... 141
MECAMYLAMINE HCL -mecamylamine hcl (bulk) powder........................................................................... 243 MECHLORETHAMINE HCL -mechlorethamine hcl (bulk) powder........................................................................... 243 MECLIZINE HCL -meclizine hcl powder......................... 100 MECLIZINE HCL MONOHYDRATE -meclizine hcl powder........................................................................... 100 meclizine hcl tab 12.5 mg............................................. 100 meclizine hcl tab 25 mg................................................ 100 MECLOFENAMATE SODIUM -meclofenamate sodium cap 50 mg..................................................................... 149 MECLOFENAMATE SODIUM -meclofenamate sodium cap 100 mg................................................................... 149 MECLOFENAMATE SODIUM -meclofenamate sodium powder........................................................................... 149 MECLOFENOXATE HYDROCHLORI -meclofenoxate hcl (bulk) powder................................................................ 243 MEDIBASE C -polyethylene glycol 300 liquid................. 268 MEDIDERM -cream base................................................ 268 MEDIHOL BASE -alcohol gel base................................. 268 MEDIHONEY CALCIUM ALGINAT -wound dressings pads............................................................................... 209 MEDIHONEY WOUND/BURN -wound dressings pads............................................................................... 209 MEDIHONEY WOUND & BURN DR -wound dressings pads............................................................................... 209 MEDI-RDT BASE -rapid dissolve tablet base powder........................................................................... 268 MEDI-RDT KIT (MULTIDOSE) -rapid dissolve tablet base powder kit...................................................................... 268 MEDI-RDT KIT -rapid dissolve tablet base powder kit................................................................................... 268 MEDIUM CHAIN TRIGLYCERIDE -medium chain triglycerides (bulk) liquid............................................... 243 MEDROL DOSEPAK -methylprednisolone tab therapy pack 4 mg (21)............................................................... 34 MEDROL -methylprednisolone tab 2 mg.......................... 34 MEDROL -methylprednisolone tab 4 mg.......................... 34 MEDROL -methylprednisolone tab 8 mg.......................... 34 MEDROL -methylprednisolone tab 16 mg........................ 34 MEDROL -methylprednisolone tab 32 mg........................ 34 MEDROXYPROGESTERONE ACETA medroxyprogesterone acetate (bulk) powder.............. 243 MEDROXYPROGESTERONE ACETA medroxyprogesterone acetate micronized (bulk) powder........................................................................... 243 medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac)................................................ 43 medroxyprogesterone acetate im susp prefilled syr 150 mg/ml (Depo-provera contrac)............................. 43 medroxyprogesterone acetate tab 2.5 mg (Provera)......................................................................... 45 medroxyprogesterone acetate tab 5 mg (Provera)...... 45 medroxyprogesterone acetate tab 10 mg (Provera)......................................................................... 45
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
346
2016 meperidine hcl tab 100 mg (Demerol)......................... 141 MEPHYTON -phytonadione tab 5 mg............................. 170 mepivacaine hcl inj 1% (Carbocaine).......................... 155 mepivacaine hcl inj 1.5% (Carbocaine)....................... 155 mepivacaine hcl inj 2% (Carbocaine).......................... 155 MEPIVACAINE HCL -mepivacaine hcl powder............... 155 mepivacaine hcl preservative free (pf) inj 1% (Carbocaine)................................................................ 155 mepivacaine hcl preservative free (pf) inj 2% (Carbocaine)................................................................ 155 meprobamate tab 200 mg............................................. 110 meprobamate tab 400 mg............................................. 110 MEPRON -atovaquone susp 750 mg/5ml......................... 18 MEQUINOL -mequinol (bulk) powder............................. 244 MERCAPTOPURINE -bulk chemicals - powder............. 244 MERCAPTOPURINE -mercaptopurine (bulk) powder........................................................................... 244 MERCAPTOPURINE -mercaptopurine monohydrate (bulk) powder................................................................ 244 MERCAPTOPURINE MONOHYDRAT -mercaptopurine monohydrate (bulk) powder..........................................244 mercaptopurine tab 50 mg (Purinethol)........................ 29 MESALAMINE DR -mesalamine tab delayed release 800 mg.................................................................................. 103 mesalamine enema 4 gm.............................................. 103 MESALAMINE -mesalamine powder.............................. 103 mesalamine tab delayed release 1.2 gm (Lialda)....... 103 MESNEX -mesna tab 400 mg........................................... 29 MESTINON -pyridostigmine bromide syrup 60 mg/5ml........................................................................... 169 MESTINON -pyridostigmine bromide tab 60 mg.............169 MESTINON TIMESPAN -pyridostigmine bromide tab er 180 mg.......................................................................... 169 METACRESOL ACETATE -metacresol acetate (bulk) liquid.............................................................................. 244 METAPROTERENOL SULFATE -metaproterenol sulfate powder............................................................................. 92 METAPROTERENOL SULFATE -metaproterenol sulfate syrup 10 mg/5ml............................................................. 92 METAPROTERENOL SULFATE -metaproterenol sulfate tab 10 mg........................................................................ 92 METAPROTERENOL SULFATE -metaproterenol sulfate tab 20 mg........................................................................ 93 METAXALONE -metaxalone tab 400 mg........................ 169 metaxalone tab 800 mg (Skelaxin).............................. 169 METER BUFFER PH 10 -buffer reference standard solution ph 10............................................................... 268 METER BUFFER PH 4 -buffer reference standard solution ph 4................................................................. 268 METER BUFFER PH 7 -buffer reference standard solution ph 7................................................................. 268 METFORMIN HCL -metformin hcl (bulk) powder........... 244 metformin hcl tab er 24hr 500 mg (Glucophage xr)..... 49 metformin hcl tab er 24hr 750 mg (Glucophage xr)..... 49
metformin hcl tab er 24hr osmotic 500 mg (Fortamet)....................................................................... 49 metformin hcl tab er 24hr osmotic 1000 mg (Fortamet)....................................................................... 49 metformin hcl tab 500 mg (Glucophage)...................... 49 metformin hcl tab 850 mg (Glucophage)...................... 49 metformin hcl tab 1000 mg (Glucophage).................... 49 METHACHOLINE CHLORIDE -methacholine chloride crystals.......................................................................... 220 METHACHOLINE CHLORIDE -methacholine chloride powder........................................................................... 220 METHACRYLIC ACID COPOLYME -methacrylic acid copolymer (type a) powder...........................................244 methadone hcl conc 10 mg/ml (Methadose).............. 141 METHADONE HCL -methadone hcl inj 10 mg/ml...........141 METHADONE HCL -methadone hcl powder.................. 141 METHADONE HCL -methadone hcl soln 5 mg/5ml........141 METHADONE HCL -methadone hcl soln 10 mg/5ml......141 methadone hcl soln 5 mg/5ml (Methadone hcl)......... 141 methadone hcl soln 10 mg/5ml (Methadone hcl)....... 141 methadone hcl tab for oral susp 40 mg...................... 141 methadone hcl tab 10 mg (Dolophine)........................ 141 methadone hcl tab 5 mg (Dolophine hcl)................... 141 METHADOSE -methadone hcl conc 10 mg/ml............... 141 METHADOSE SUGAR-FREE -methadone hcl conc 10 mg/ml............................................................................. 141 methamphetamine hcl tab 5 mg (Desoxyn)................ 128 METHANESULFONIC ACID -methanesulfonic acid (bulk) liquid.............................................................................. 244 METHANOL -methyl alcohol........................................... 244 METHAZOLAMIDE -methazolamide powder.................... 79 methazolamide tab 25 mg (Neptazane)......................... 79 methazolamide tab 50 mg (Neptazane)......................... 79 methenamine hippurate tab 1 gm (Hiprex)................. 105 methenamine-hyoscamine-meth blue-sod phos cap 120 mg.......................................................................... 105 methenamine-hyoscamine-meth blue-sod phos tab 81.6 mg (Urogesic-blue).............................................105 methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6mg (Prosed/ds).............................................. 105 methenamine-hyosc-meth blue-sod phos-phen sal cap 118 mg.................................................................. 105 methenamine-hyosc-meth blue-sod phos-phen sal cap 120 mg.................................................................. 105 methenamine-hyosc-meth blue-sod phos-phen sal tab 81 mg............................................................................ 105 methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg......................................................................... 105 METHENAMINE MANDELATE -methenamine mandelate (bulk) powder................................................................ 244 METHENAMINE MANDELATE -methenamine mandelate tab 0.5 gm..................................................................... 105 methenamine mandelate tab 1 gm.............................. 105 METHENAMINE -methenamine powder......................... 244
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
347
2016 METHYLENE BLUE TRIHYDRATE -methylene blue powder........................................................................... 244 METHYLENE CHLORIDE -methylene chloride (bulk) liquid.............................................................................. 244 methylergonovine maleate inj 0.2 mg/ml...................... 55 METHYL FOLATE -5-methyltetrahydrofolate (bulk) powder........................................................................... 244 METHYLIN -methylphenidate hcl soln 5 mg/5ml............ 128 METHYLIN -methylphenidate hcl soln 10 mg/5ml.......... 128 METHYL METHACRYLATE CROSS -methyl methacrylate crosspolymer (bulk) powder................... 244 METHYLMETHACRYLATE CROSSP methylmethacrylate crosspolymer (310) (bulk) powder........................................................................... 244 METHYLPARABEN -methylparaben powder.................. 268 methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin la)................................................................................... 128 methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin la)................................................................................... 128 methylphenidate hcl cap er 24hr 40 mg (la) (Ritalin la)................................................................................... 128 methylphenidate hcl cap er 10 mg (cd)...................... 128 methylphenidate hcl cap er 20 mg (cd)...................... 128 methylphenidate hcl cap er 30 mg (cd)...................... 128 methylphenidate hcl cap er 40 mg (cd)...................... 128 methylphenidate hcl cap er 50 mg (cd)...................... 128 methylphenidate hcl cap er 60 mg (cd)...................... 128 METHYLPHENIDATE HCL ER (L -methylphenidate hcl cap er 24hr 60 mg (la)................................................. 129 METHYLPHENIDATE HCL ER -methylphenidate hcl tab er 24hr 18 mg............................................................... 129 METHYLPHENIDATE HCL ER -methylphenidate hcl tab er 24hr 27 mg............................................................... 129 METHYLPHENIDATE HCL ER -methylphenidate hcl tab er 24hr 36 mg............................................................... 129 METHYLPHENIDATE HCL ER -methylphenidate hcl tab er 24hr 54 mg............................................................... 129 METHYLPHENIDATE HCL -methylphenidate hcl chew tab 2.5 mg..................................................................... 128 METHYLPHENIDATE HCL -methylphenidate hcl chew tab 5 mg........................................................................ 128 METHYLPHENIDATE HCL -methylphenidate hcl chew tab 10 mg...................................................................... 128 METHYLPHENIDATE HCL -methylphenidate hcl powder........................................................................... 244 methylphenidate hcl soln 5 mg/5ml (Methylin).......... 129 methylphenidate hcl soln 10 mg/5ml (Methylin)........ 129 methylphenidate hcl tab er 10 mg............................... 129 methylphenidate hcl tab er 20 mg............................... 129 methylphenidate hcl tab er osmotic release (osm) 18 mg (Concerta)..............................................................129 methylphenidate hcl tab er osmotic release (osm) 27 mg (Concerta)..............................................................129 methylphenidate hcl tab er osmotic release (osm) 36 mg (Concerta)..............................................................129
METHERGINE -methylergonovine maleate tab 0.2 mg.................................................................................... 55 METHIMAZOLE -methimazole powder............................. 53 methimazole tab 5 mg (Tapazole).................................. 53 methimazole tab 10 mg (Tapazole)................................ 53 METHIONINE -methionine powder................................. 178 METHITEST -methyltestosterone oral tab 10 mg............. 38 methocarbamol inj 1000 mg/10ml (Robaxin).............. 169 METHOCARBAMOL -methocarbamol (bulk) powder..... 244 methocarbamol tab 750 mg (Robaxin-750).................169 methocarbamol tab 500 mg (Robaxin)........................ 169 METHOCEL E4M PREMIUM -hypromellose (bulk) powder........................................................................... 244 METHOCEL K100M PREMIUM -hypromellose (bulk) powder........................................................................... 244 METHOTREXATE -methotrexate powder......................... 29 methotrexate sodium for inj 1 gm................................. 29 methotrexate sodium inj 50 mg/2ml (25 mg/ml)........... 29 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)...... 29 methotrexate sodium inj pf 100 mg/4ml (25 mg/ ml)................................................................................... 29 methotrexate sodium inj pf 200 mg/8ml (25 mg/ ml)................................................................................... 29 methotrexate sodium inj pf 250 mg/10ml (25 mg/ ml)................................................................................... 29 methotrexate sodium inj pf 1000 mg/40ml (25 mg/ ml)................................................................................... 29 METHOTREXATE SODIUM -methotrexate sodium inj 250 mg/10ml (25 mg/ml)........................................................29 methotrexate sodium tab 2.5 mg (base equiv)............. 29 METHOXSALEN -methoxsalen crystals......................... 209 METHOXSALEN -methoxsalen powder.......................... 209 methoxsalen rapid cap 10 mg (Oxsoralen ultra)........ 209 2-METHOXYESTRADIOL -2-methoxyestradiol (bulk) powder........................................................................... 260 METHOXYETHANOL -methoxyethanol (bulk) liquid...... 244 METHSCOPOLAMINE BROMIDE -methscopolamine bromide (bulk) powder.................................................. 244 methscopolamine bromide tab 2.5 mg (Pamine)......... 98 methscopolamine bromide tab 5 mg (Pamine forte)................................................................................98 METHSCOPOLAMINE NITRATE -methscopolamine nitrate (bulk) powder..................................................... 244 METHYCLOTHIAZIDE -methyclothiazide powder............ 79 METHYCLOTHIAZIDE -methyclothiazide tab 5 mg..........79 METHYLCELLULOSE -methylcellulose powder............. 268 METHYLCOBALAMIN -methylcobalamin powder.......... 244 METHYLDOPA/HYDROCHLOROTHI -methyldopa & hydrochlorothiazide tab 250-15 mg................................ 74 METHYLDOPA/HYDROCHLOROTHI -methyldopa & hydrochlorothiazide tab 250-25 mg................................ 74 methyldopa tab 250 mg.................................................. 74 methyldopa tab 500 mg.................................................. 74 METHYLENE BLUE -methylene blue inj 1%.................. 219 METHYLENE BLUE -methylene blue powder................ 244
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
348
2016 metolazone tab 5 mg (Zaroxolyn).................................. 79 METOPROLOL/HYDROCHLOROTHI -metoprolol & hydrochlorothiazide tab 100-50 mg................................ 74 metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct)..............................................................74 metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct)..............................................................74 METOPROLOL SUCCINATE ER/H -metoprolol & hydrochlorothiazide tab er 24hr 25-12.5 mg.................. 74 METOPROLOL SUCCINATE ER/H -metoprolol & hydrochlorothiazide tab er 24hr 50-12.5 mg.................. 74 METOPROLOL SUCCINATE ER/H -metoprolol & hydrochlorothiazide tab er 24hr 100-12.5 mg................ 74 metoprolol succinate tab er 24hr 25 mg (tartrate equiv) (Toprol xl)........................................................... 63 metoprolol succinate tab er 24hr 50 mg (tartrate equiv) (Toprol xl)........................................................... 63 metoprolol succinate tab er 24hr 100 mg (tartrate equiv) (Toprol xl)........................................................... 63 metoprolol succinate tab er 24hr 200 mg (tartrate equiv) (Toprol xl)........................................................... 63 METOPROLOL TARTRATE -metoprolol tartrate powder............................................................................. 63 METOPROLOL TARTRATE -metoprolol tartrate tab 37.5 mg.................................................................................... 63 METOPROLOL TARTRATE -metoprolol tartrate tab 75 mg.................................................................................... 63 metoprolol tartrate tab 25 mg........................................ 63 metoprolol tartrate tab 50 mg (Lopressor)................... 63 metoprolol tartrate tab 100 mg (Lopressor)................. 63 METROCREAM -metronidazole cream 0.75%............... 209 METROGEL -metronidazole gel 1%............................... 209 METROGEL-VAGINAL -metronidazole vaginal gel 0.75%.............................................................................107 METROLOTION -metronidazole lotion 0.75%................ 209 METRONIDAZOLE BENZOATE/SY -metronidazole benzoate for susp 50 mg/ml (cmpd kit)......................... 18 METRONIDAZOLE BENZOATE -metronidazole benzoate powder........................................................................... 209 metronidazole cap 375 mg (Flagyl)............................... 18 metronidazole cream 0.75% (Metrocream)................. 209 metronidazole gel 0.75%............................................... 209 metronidazole gel 1% (Metrogel)................................. 209 metronidazole lotion 0.75% (Metrolotion)................... 209 METRONIDAZOLE -metronidazole powder....................245 metronidazole tab 250 mg (Flagyl)................................ 18 metronidazole tab 500 mg (Flagyl)................................ 18 metronidazole vaginal gel 0.75% (Metrogelvaginal)......................................................................... 107 mexiletine hcl cap 150 mg.............................................. 67 mexiletine hcl cap 200 mg.............................................. 67 mexiletine hcl cap 250 mg.............................................. 67 MEXILETINE HYDROCHLORIDE -mexiletine hcl (bulk) powder........................................................................... 245 MIACALCIN -calcitonin (salmon) inj 200 unit/ml............... 57
methylphenidate hcl tab er osmotic release (osm) 54 mg (Concerta)..............................................................129 methylphenidate hcl tab 5 mg (Ritalin)....................... 129 methylphenidate hcl tab 10 mg (Ritalin)..................... 129 methylphenidate hcl tab 20 mg (Ritalin)..................... 129 methylprednisolone acetate inj susp 40 mg/ml (Depomedrol)........................................................................... 34 methylprednisolone acetate inj susp 80 mg/ml (Depomedrol)........................................................................... 34 METHYLPREDNISOLONE ACETAT -methylprednisolone acetate powder............................................................... 34 METHYLPREDNISOLONE -methylprednisolone powder............................................................................. 34 methylprednisolone sodium succinate for inj 40 mg (Solu-medrol)................................................................. 34 methylprednisolone sodium succinate for inj 125 mg (Solu-medrol)................................................................. 34 methylprednisolone sodium succinate for inj 1000 mg (Solu-medrol)................................................................. 34 methylprednisolone tab 4 mg (Medrol)......................... 34 methylprednisolone tab 8 mg (Medrol)......................... 35 methylprednisolone tab 16 mg (Medrol)....................... 35 methylprednisolone tab 32 mg (Medrol)....................... 35 methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak).......................................................... 34 4-METHYLPYRAZOLE -fomepizole (bulk) liquid............ 260 METHYL SALICYLATE -methyl salicylate liquid............. 209 METHYL SULFONE -methylsulfonylmethane (bulk) crystals.......................................................................... 244 METHYLSULFONYLMETHANE -methylsulfonylmethane (bulk) powder................................................................ 245 methyltestosterone cap 10 mg (Testred)...................... 38 METHYLTESTOSTERONE -methyltestosterone powder............................................................................. 38 5-METHYLTETRAHYDROFOLATE -5methyltetrahydrofolate calcium powder....................... 260 5-METHYLTETRAHYDROFOLIC A -levomefolate glucosamine (bulk) powder.......................................... 260 METHYSERGIDE MALEATE -methysergide maleate powder........................................................................... 245 METIPRANOLOL -metipranolol ophth soln 0.3%........... 191 metoclopramide hcl inj 5 mg/ml.................................. 103 METOCLOPRAMIDE HCL -metoclopramide hcl powder........................................................................... 103 METOCLOPRAMIDE HCL MONOHY -metoclopramide hcl monohydrate powder.............................................. 103 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)...... 103 metoclopramide hcl tab 5 mg (Reglan)....................... 103 metoclopramide hcl tab 10 mg (Reglan)..................... 103 METOCLOPRAMIDE ODT -metoclopramide hcl orally disintegrating tab 5 mg................................................. 103 METOCLOPRAMIDE ODT -metoclopramide hcl orally disintegrating tab 10 mg............................................... 103 metolazone tab 10 mg..................................................... 79 metolazone tab 2.5 mg (Zaroxolyn)............................... 79
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
349
2016 MINIPRESS -prazosin hcl cap 5 mg................................. 75 MINIVELLE -estradiol td patch biweekly 0.0375 mg/24hr........................................................................... 41 MINIVELLE -estradiol td patch biweekly 0.05 mg/24hr........................................................................... 41 MINIVELLE -estradiol td patch biweekly 0.075 mg/24hr........................................................................... 41 MINIVELLE -estradiol td patch biweekly 0.1 mg/24hr.......41 MINIVELLE -estradiol td patch twice weekly 0.025 mg/24hr........................................................................... 41 minocycline hcl cap 50 mg (Minocin)............................. 6 minocycline hcl cap 75 mg (Minocin)............................. 6 minocycline hcl cap 100 mg (Minocin)........................... 6 MINOCYCLINE HCL ER -minocycline hcl tab er 24hr 45 mg...................................................................................... 6 MINOCYCLINE HCL -minocycline hcl powder................... 6 minocycline hcl tab er 24hr 90 mg.................................. 6 minocycline hcl tab er 24hr 135 mg................................ 6 minocycline hcl tab 50 mg............................................... 6 minocycline hcl tab 75 mg............................................... 7 minocycline hcl tab 100 mg............................................. 7 MINOXIDIL -minoxidil powder......................................... 245 minoxidil tab 2.5 mg........................................................ 75 minoxidil tab 10 mg......................................................... 75 MINT CHOCOLATE CHIP FLAVO -flavoring agent liquid.............................................................................. 268 MIOCHOL-E -acetylcholine chloride intraocular for soln 20 mg (1:100)............................................................... 191 MIOSTAT -carbachol intraocular inj 0.01%..................... 191 MI PASTE -dentifrices - paste......................................... 261 MI PASTE PLUS -dentifrices - paste.............................. 261 MIRAPEX ER -pramipexole dihydrochloride tab er 24hr 0.375 mg....................................................................... 165 MIRAPEX ER -pramipexole dihydrochloride tab er 24hr 0.75 mg......................................................................... 165 MIRAPEX ER -pramipexole dihydrochloride tab er 24hr 1.5 mg........................................................................... 165 MIRAPEX ER -pramipexole dihydrochloride tab er 24hr 2.25 mg......................................................................... 165 MIRAPEX ER -pramipexole dihydrochloride tab er 24hr 3 mg.................................................................................. 165 MIRAPEX ER -pramipexole dihydrochloride tab er 24hr 3.75 mg......................................................................... 165 MIRAPEX ER -pramipexole dihydrochloride tab er 24hr 4.5 mg........................................................................... 165 MIRAPEX -pramipexole dihydrochloride tab 0.125 mg.................................................................................. 165 MIRAPEX -pramipexole dihydrochloride tab 0.25 mg.................................................................................. 165 MIRAPEX -pramipexole dihydrochloride tab 0.5 mg.......165 MIRAPEX -pramipexole dihydrochloride tab 0.75 mg.................................................................................. 165 MIRAPEX -pramipexole dihydrochloride tab 1 mg..........165 MIRAPEX -pramipexole dihydrochloride tab 1.5 mg.......165
MICARDIS HCT -telmisartan-hydrochlorothiazide tab 40-12.5 mg...................................................................... 74 MICARDIS HCT -telmisartan-hydrochlorothiazide tab 80-12.5 mg...................................................................... 74 MICARDIS HCT -telmisartan-hydrochlorothiazide tab 80-25 mg......................................................................... 74 MICARDIS -telmisartan tab 20 mg.................................... 74 MICARDIS -telmisartan tab 40 mg.................................... 74 MICARDIS -telmisartan tab 80 mg.................................... 74 MICONAZOLE 3 -miconazole nitrate vaginal suppos 200 mg.................................................................................. 107 MICONAZOLE -miconazole powder................................. 10 MICONAZOLE NITRATE -miconazole nitrate powder........................................................................... 209 miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit............................................................................ 107 MICORT-HC -hydrocortisone acetate cream 2.5%......... 209 MICRHOGAM ULTRA-FILTERED -rho d immune globulin im soln pref syr 250 unit (50 mcg)................................. 24 MICROCLENS WIPES -antiseptic products misc pads............................................................................... 218 MICROCYN SKIN AND WOUND H -wound cleansers gel.................................................................................. 209 MICROCYN -wound cleansers - gel............................... 209 MICROCYN -wound cleansers - liquid............................ 209 MICRO-K -potassium chloride cap er 8 meq.................. 176 MICRO-K -potassium chloride cap er 10 meq................ 176 MICROZIDE -hydrochlorothiazide cap 12.5 mg................79 MIDAZOLAM -midazolam (bulk) powder........................ 245 midodrine hcl tab 2.5 mg................................................ 80 midodrine hcl tab 5 mg................................................... 80 midodrine hcl tab 10 mg................................................. 80 MIGERGOT -ergotamine w/ caffeine suppos 2-100 mg.................................................................................. 152 miglitol tab 25 mg (Glyset)............................................. 49 miglitol tab 50 mg (Glyset)............................................. 49 miglitol tab 100 mg (Glyset)........................................... 49 MIGRANAL -dihydroergotamine mesylate nasal spray 4 mg/ml............................................................................. 152 MILK THISTLE -milk thistle seed (bulk) powder............. 245 MILLIPRED DP -prednisolone tab therapy pack 5 mg (21).................................................................................. 35 MILLIPRED DP -prednisolone tab therapy pack 5 mg (48).................................................................................. 35 MILLIPRED -prednisolone sod phosphate oral soln 10 mg/5ml (base equiv)....................................................... 35 MILLIPRED -prednisolone tab 5 mg................................. 35 MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24)........................................... 43 mineral oil......................................................................... 95 MINERAL OIL HEAVY -mineral oil (bulk)..........................96 MINERAL OIL LIGHT -mineral oil light (bulk)................... 96 MINERAL OIL -mineral oil (bulk)....................................... 95 MINIPRESS -prazosin hcl cap 1 mg................................. 75 MINIPRESS -prazosin hcl cap 2 mg................................. 75
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
350
2016 M-M-R II -measles, mumps & rubella virus vaccines for inj..................................................................................... 21 MOBIC -meloxicam tab 7.5 mg....................................... 149 MOBIC -meloxicam tab 15 mg........................................ 149 modafinil tab 100 mg (Provigil).................................... 129 modafinil tab 200 mg (Provigil).................................... 129 MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg...... 12 MODERIBA 800 DOSE PACK -ribavirin tab 400 mg........ 12 MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg dose pack........................................................................ 12 MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg dose pack........................................................................ 12 moexipril hcl tab 7.5 mg (Univasc)................................ 75 moexipril hcl tab 15 mg (Univasc)................................. 75 moexipril-hydrochlorothiazide tab 7.5-12.5 mg........... 75 moexipril-hydrochlorothiazide tab 15-25 mg............... 75 moexipril-hydrochlorothiazide tab 15-12.5 mg (Uniretic)......................................................................... 75 MOLASSES FLAVOR -flavoring agent - powder............ 268 MOLYBDENUM -molybdenum (bulk) powder................. 245 mometasone furoate cream 0.1% (Elocon)................ 209 MOMETASONE FUROATE -mometasone furoate (bulk) powder........................................................................... 245 mometasone furoate nasal susp 50 mcg/act (Nasonex)....................................................................... 88 mometasone furoate oint 0.1% (Elocon).................... 209 mometasone furoate solution 0.1% (lotion) (Elocon)........................................................................ 209 MONOBENZONE -monobenzone (bulk) powder............245 MONOCAL -sodium monofluorophosphate-calcium carb tab 22.75-625 mg......................................................... 176 MONOETHANOLAMINE -monoethanolamine (bulk) liquid.............................................................................. 245 MONOJECT BONE MARROW BIOP -lidocaine hcl local inj kit 1%....................................................................... 156 MONSELS FERRIC SUBSULFATE -ferric subsulfate soln................................................................................ 187 montelukast sodium chew tab 4 mg (base equiv) (Singulair)....................................................................... 93 montelukast sodium chew tab 5 mg (base equiv) (Singulair)....................................................................... 93 MONTELUKAST SODIUM -montelukast sodium (bulk) powder........................................................................... 245 montelukast sodium oral granules packet 4 mg (base equiv) (Singulair)...........................................................93 montelukast sodium tab 10 mg (base equiv) (Singulair)....................................................................... 93 MONUROL -fosfomycin tromethamine powd pack 3 gm (base equivalent).......................................................... 105 MORANTEL TARTRATE -morantel tartrate (bulk) powder........................................................................... 245 morphine sulfate cap er 24hr 10 mg (Kadian)............ 142 morphine sulfate cap er 24hr 20 mg (Kadian)............ 142 morphine sulfate cap er 24hr 30 mg (Kadian)............ 142 morphine sulfate cap er 24hr 50 mg (Kadian)............ 142
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 30 mcg/0.3ml...................................................................... 183 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 50 mcg/0.3ml...................................................................... 183 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 75 mcg/0.3ml...................................................................... 183 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 100 mcg/0.3ml.............................................................. 183 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 150 mcg/0.3ml.............................................................. 183 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 200 mcg/0.3ml.............................................................. 183 MIRCETTE -desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)................................................. 43 MIRENA -levonorgestrel releasing iud 20 mcg/day (52 mg total)................................................................................. 43 mirtazapine orally disintegrating tab 15 mg (Remeron soltab)........................................................................... 114 mirtazapine orally disintegrating tab 30 mg (Remeron soltab)........................................................................... 114 mirtazapine orally disintegrating tab 45 mg (Remeron soltab)........................................................................... 114 mirtazapine tab 7.5 mg..................................................114 mirtazapine tab 15 mg (Remeron)............................... 114 mirtazapine tab 30 mg (Remeron)............................... 114 mirtazapine tab 45 mg (Remeron)............................... 114 MIRVASO -brimonidine tartrate gel 0.33% (base equivalent)..................................................................... 209 MISOPROSTOL-HPMC -misoprostol (bulk) powder 1%.................................................................................. 245 MISOPROSTOL -misoprostol (bulk) powder 1%............ 245 misoprostol tab 100 mcg (Cytotec)............................... 98 misoprostol tab 200 mcg (Cytotec)............................... 98 MITIGARE -colchicine cap 0.6 mg.................................. 153 MITOMYCIN -mitomycin (bulk) powder.......................... 245 MITOSOL -mitomycin for ophth soln kit 0.2 mg.............. 191 MITOTANE -mitotane (bulk) powder............................... 245 MLD KIT -lidocaine inj 2% & bupivacaine inj 0.5% & dextose 50% kit............................................................ 155 3ML GLASS SYR KIT/1ML NA -arterial blood gas kit................................................................................... 220 5ML GLASS SYR KIT/1ML NA -arterial blood gas kit................................................................................... 220 MLK F1 KIT -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit....................................................................... 35 MLK F2 KIT -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit....................................................................... 35 MLK F3 KIT -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit....................................................................... 35 MLK F4 KIT -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit....................................................................... 35 MLP A-1 -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit...............................................................................35 MLP A-2 -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit...............................................................................35
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
351
2016 morphine sulfate cap er 24hr 60 mg (Kadian)............ 142 morphine sulfate cap er 24hr 80 mg (Kadian)............ 142 morphine sulfate cap er 24hr 100 mg (Kadian).......... 142 MORPHINE SULFATE ER -morphine sulfate beads cap er 24hr 30 mg............................................................... 142 MORPHINE SULFATE ER -morphine sulfate beads cap er 24hr 45 mg............................................................... 142 MORPHINE SULFATE ER -morphine sulfate beads cap er 24hr 60 mg............................................................... 142 MORPHINE SULFATE ER -morphine sulfate beads cap er 24hr 75 mg............................................................... 142 MORPHINE SULFATE ER -morphine sulfate beads cap er 24hr 90 mg............................................................... 142 MORPHINE SULFATE ER -morphine sulfate beads cap er 24hr 120 mg............................................................. 142 morphine sulfate inj pf 0.5 mg/ml................................ 142 morphine sulfate inj pf 1 mg/ml................................... 142 MORPHINE SULFATE -morphine sulfate im inj device 10 mg/0.7ml........................................................................ 141 MORPHINE SULFATE -morphine sulfate inj 2 mg/ml..... 142 MORPHINE SULFATE -morphine sulfate inj 4 mg/ml..... 142 MORPHINE SULFATE -morphine sulfate inj 5 mg/ml..... 142 MORPHINE SULFATE -morphine sulfate inj 8 mg/ml..... 142 MORPHINE SULFATE -morphine sulfate inj 10 mg/ ml................................................................................... 142 MORPHINE SULFATE -morphine sulfate powder.......... 142 MORPHINE SULFATE -morphine sulfate suppos 5 mg.................................................................................. 142 MORPHINE SULFATE -morphine sulfate suppos 10 mg.................................................................................. 142 MORPHINE SULFATE -morphine sulfate suppos 20 mg.................................................................................. 142 MORPHINE SULFATE -morphine sulfate suppos 30 mg.................................................................................. 142 MORPHINE SULFATE -morphine sulfate tab 15 mg...... 142 MORPHINE SULFATE -morphine sulfate tab 30 mg...... 142 morphine sulfate oral soln 10 mg/5ml........................ 142 morphine sulfate oral soln 20 mg/5ml........................ 142 morphine sulfate oral soln 100 mg/5ml (20 mg/ ml)................................................................................. 142 morphine sulfate tab er 15 mg (Ms contin)................ 142 morphine sulfate tab er 30 mg (Ms contin)................ 142 morphine sulfate tab er 60 mg (Ms contin)................ 142 morphine sulfate tab er 100 mg (Ms contin).............. 142 morphine sulfate tab er 200 mg (Ms contin).............. 142 MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............96 MOVANTIK -naloxegol oxalate tab 12.5 mg (base equivalent)..................................................................... 103 MOVANTIK -naloxegol oxalate tab 25 mg (base equivalent)..................................................................... 103 MOVIPREP -peg 3350-kcl-nacl-na sulfate-na acorbate-c for soln 100 gm...............................................................96 MOXATAG -amoxicillin (trihydrate) tab er 24hr 775 mg...... 2 MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2 times daily).................................................................... 191
MOXIFLOXACIN HCL -moxifloxacin hcl (bulk) powder........................................................................... 245 moxifloxacin hcl ophth soln 0.5% (base equiv) (Vigamox)..................................................................... 191 moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 7 MOXISYLYTE HCL -moxisylyte hcl (bulk) powder..........245 MOZOBIL -plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml)............................................................................ 183 MS CONTIN -morphine sulfate tab er 15 mg..................143 MS CONTIN -morphine sulfate tab er 30 mg..................143 MS CONTIN -morphine sulfate tab er 60 mg..................143 MS CONTIN -morphine sulfate tab er 100 mg................143 MS CONTIN -morphine sulfate tab er 200 mg................143 MUCOLOX -pharmaceutical excipients (bulk) liquid....... 268 MUCOTROL -oral wound care products - wafer............. 195 MULTAQ -dronedarone hcl tab 400 mg (base equivalent)....................................................................... 67 MULTIGEN -fe asparto gly-succ acd-c-threonic acd-b12des stom tab................................................................. 183 MULTIGEN FOLIC -fe asparto gly-succinic acd-vit cthreonic acd-b12-fa tab................................................ 183 MULTIGEN PLUS -fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab................................................ 183 multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite)........................................................................ 171 multiple vitamins w/ minerals cap............................... 171 multiple vitamins w/ minerals tab (Strovite forte)...... 171 MULTI-SPECIALTY KIT -methylprednisolone inj 40 mg/ml & lidocaine inj 1% kit...................................................... 35 MULTIUSE BASE -cream base....................................... 268 MULTIVITAMIN/FLUORIDE -pediatric multiple vitamins w/ fluoride chew tab 0.25 mg............................................ 172 MULTIVITAMIN/FLUORIDE -pediatric multiple vitamins w/ fluoride chew tab 0.5 mg.............................................. 172 MULTIVITAMIN/FLUORIDE -pediatric multiple vitamins w/ fluoride chew tab 1 mg................................................. 172 MULTIVITAMIN WITH FLUORID -multiple vit & fluoridefolic acid chew tab 0.25-0.3 mg................................... 172 MULTIVITAMIN WITH FLUORID -multiple vit & fluoridefolic acid chew tab 0.5-0.3 mg..................................... 172 MULTIVITAMIN WITH FLUORID -multiple vit & fluoridefolic acid chew tab 1-0.3 mg........................................ 172 mupirocin calcium cream 2% (Bactroban)................. 209 MUPIROCIN -mupirocin (bulk) powder........................... 245 mupirocin oint 2% (Bactroban).................................... 209 MURI-LUBE -mineral oil light (bulk).................................. 96 MUSTARGEN -mechlorethamine hcl for inj 10 mg........... 29 MYALEPT -metreleptin for subcutaneous inj 11.3 mg...... 57 MYAMBUTOL -ethambutol hcl tab 100 mg......................... 9 MYAMBUTOL -ethambutol hcl tab 400 mg......................... 9 MYCOBUTIN -rifabutin cap 150 mg.................................... 9 mycophenolate mofetil cap 250 mg (Cellcept)........... 276 mycophenolate mofetil for oral susp 200 mg/ml (Cellcept)...................................................................... 276 mycophenolate mofetil tab 500 mg (Cellcept)............276
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
352
2016 nalbuphine hcl inj 20 mg/ml......................................... 143 NALBUPHINE HCL -nalbuphine hcl (bulk) powder.........245 NALIDIXIC ACID -nalidixic acid powder......................... 105 NALOXONE HCL DIHYDRATE -naloxone hcl (bulk) powder........................................................................... 245 naloxone hcl inj 0.4 mg/ml........................................... 219 naloxone hcl inj 4 mg/10ml.......................................... 219 NALOXONE HCL -naloxone hcl (bulk) powder...............245 NALOXONE HCL -naloxone hcl soln cartridge 0.4 mg/ ml................................................................................... 219 NALOXONE HCL -naloxone hcl soln prefilled syringe 2 mg/2ml........................................................................... 219 NALTREXONE HCL -naltrexone hcl (bulk) powder........ 245 naltrexone hcl tab 50 mg (Revia)................................. 219 NALTREXONE -naltrexone (bulk) powder...................... 245 NAMENDA -memantine hcl tab 5 mg............................. 132 NAMENDA -memantine hcl tab 10 mg........................... 132 NAMENDA TITRATION PAK -memantine hcl tab 5 mg (28) & 10 mg (21) titration pak..................................... 132 NAMENDA XR -memantine hcl cap er 24hr 7 mg.......... 132 NAMENDA XR -memantine hcl cap er 24hr 14 mg........ 132 NAMENDA XR -memantine hcl cap er 24hr 21 mg........ 132 NAMENDA XR -memantine hcl cap er 24hr 28 mg........ 132 NAMENDA XR TITRATION PACK -memantine hcl cap er 24hr 7 mg & 14 mg & 21 mg & 28 mg pack................ 132 NAMZARIC -memantine-donepezil cap er 24hr 7 & 14 & 21 & 28-10 mg pack..................................................... 132 NAMZARIC -memantine hcl-donepezil hcl cap er 24hr 7-10 mg......................................................................... 132 NAMZARIC -memantine hcl-donepezil hcl cap er 24hr 14-10 mg....................................................................... 132 NAMZARIC -memantine hcl-donepezil hcl cap er 24hr 21-10 mg....................................................................... 132 NAMZARIC -memantine hcl-donepezil hcl cap er 24hr 28-10 mg....................................................................... 132 NANDROLONE DECANOATE -nandrolone decanoate (bulk) powder................................................................ 245 NAPRELAN -naproxen sodium tab er 24hr 375 mg (base equiv)............................................................................. 149 NAPRELAN -naproxen sodium tab er 24hr 500 mg (base equiv)............................................................................. 149 NAPRELAN -naproxen sodium tab er 24hr 750 mg (base equiv)............................................................................. 149 NAPRO 15% COMPOUNDING KIT -naproxen cream 15%................................................................................209 NAPROSYN -naproxen susp 125 mg/5ml...................... 149 NAPROSYN -naproxen tab 500 mg................................ 149 NAPROXEN -naproxen powder...................................... 149 NAPROXEN SODIUM -naproxen sodium powder.......... 149 naproxen sodium tab er 24hr 375 mg (base equiv) (Naprelan)..................................................................... 149 naproxen sodium tab er 24hr 500 mg (base equiv) (Naprelan)..................................................................... 149 naproxen sodium tab 275 mg (Anaprox).................... 149 naproxen sodium tab 550 mg (Anaprox ds)............... 149
mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic)................................................. 276 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic)................................................. 276 MYFORTIC -mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)............................................ 276 MYFORTIC -mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)............................................ 276 MYKIDZ IRON FL -pediatric vitamins acd fluoride & fe susp 0.25-10 mg/2ml.................................................... 172 MYKIDZ IRON 10 -iron susp 15 mg/1.5ml...................... 183 MYLERAN -busulfan tab 2 mg.......................................... 29 MYOBLOC -rimabotulinumtoxinb im inj 2500 unit/0.5ml....................................................................... 167 MYOBLOC -rimabotulinumtoxinb im inj 5000 unit/ml......167 MYOBLOC -rimabotulinumtoxinb im inj 10000 unit/2ml.......................................................................... 167 MYRBETRIQ -mirabegron tab er 24 hr 25 mg................106 MYRBETRIQ -mirabegron tab er 24 hr 50 mg................106 MYRJ 53 -polyoxyl 40 stearate powder.......................... 268 MYSOLINE -primidone tab 50 mg.................................. 161 MYSOLINE -primidone tab 250 mg................................ 161 MYTESI -crofelemer tab delayed release 125 mg............ 96 N NABI-HB -hepatitis b immune globulin (human) im inj soln.................................................................................. 24 NABUMETONE -nabumetone (bulk) powder.................. 245 nabumetone tab 500 mg............................................... 149 nabumetone tab 750 mg............................................... 149 N-ACETYL-L-CYSTEINE -acetylcysteine powder............ 89 NADH -nicotinamide adenine dinucleotide, disodium trihydr powder............................................................... 245 nadolol & bendroflumethiazide tab 40-5 mg (Corzide)......................................................................... 75 nadolol & bendroflumethiazide tab 80-5 mg (Corzide)......................................................................... 75 NADOLOL -nadolol powder............................................... 63 nadolol tab 20 mg (Corgard).......................................... 63 nadolol tab 40 mg (Corgard).......................................... 63 nadolol tab 80 mg (Corgard).......................................... 63 nafcillin sodium for inj 1 gm............................................ 2 nafcillin sodium for inj 2 gm............................................ 2 nafcillin sodium for inj 10 gm.......................................... 2 NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................. 195 NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln rinse 0.05%................................................................... 195 NAFRINSE WEEKLY -sodium fluoride for soln rinse 0.2%...............................................................................195 naftifine hcl cream 1%.................................................. 209 naftifine hcl cream 2% (Naftin).................................... 209 NAFTIN -naftifine hcl cream 2%..................................... 209 NAFTIN -naftifine hcl gel 1%........................................... 209 NAFTIN -naftifine hcl gel 2%........................................... 209 nalbuphine hcl inj 10 mg/ml......................................... 143
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
353
2016 naproxen susp 125 mg/5ml (Naprosyn)...................... 149 naproxen tab ec 375 mg (Ec-naprosyn)...................... 149 naproxen tab ec 500 mg (Ec-naprosyn)...................... 149 naproxen tab 250 mg (Naprosyn)................................ 149 naproxen tab 375 mg (Naprosyn)................................ 150 naproxen tab 500 mg (Naprosyn)................................ 150 naratriptan hcl tab 1 mg (base equiv) (Amerge)........ 152 naratriptan hcl tab 2.5 mg (base equiv) (Amerge)..... 152 NARCAN -naloxone hcl nasal spray 4 mg/0.1ml............ 219 NARDIL -phenelzine sulfate tab 15 mg.......................... 114 NAROPIN -ropivacaine hcl inj 2 mg/ml........................... 156 NAROPIN -ropivacaine hcl inj 5 mg/ml........................... 156 NAROPIN -ropivacaine hcl inj 7.5 mg/ml........................ 156 NAROPIN -ropivacaine hcl inj 10 mg/ml......................... 156 NASCOBAL -cyanocobalamin nasal spray 500 mcg/0.1ml...................................................................... 183 NATACYN -natamycin ophth susp 5%............................ 191 NATAPRES -bulk chemicals - liquid................................ 245 NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2 mg/2-3 mg/1 mg............................................................. 43 nateglinide tab 60 mg (Starlix)....................................... 49 nateglinide tab 120 mg (Starlix)..................................... 49 NATESTO -testosterone nasal gel 5.5 mg/act.................. 38 NATPARA -parathyroid hormone (recombinant) for inj cartridge 25 mcg............................................................. 57 NATPARA -parathyroid hormone (recombinant) for inj cartridge 50 mcg............................................................. 57 NATPARA -parathyroid hormone (recombinant) for inj cartridge 75 mcg............................................................. 57 NATPARA -parathyroid hormone (recombinant) for inj cartridge 100 mcg........................................................... 57 NATROBA -spinosad susp 0.9%..................................... 209 NATURAL MIXED TOCOPHEROLS -tocopherols (bulk) powder 30%.................................................................. 245 NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2 grain)................................................................................53 NATURE-THROID -thyroid tab 16.25 mg..........................53 NATURE-THROID -thyroid tab 32.5 mg............................53 NATURE-THROID -thyroid tab 65 mg...............................53 NATURE-THROID -thyroid tab 81.25 mg..........................53 NATURE-THROID -thyroid tab 97.5 mg............................53 NATURE-THROID -thyroid tab 113.75 mg........................ 53 NATURE-THROID -thyroid tab 130 mg.............................53 NATURE-THROID -thyroid tab 146.25 mg....................... 53 NATURE-THROID -thyroid tab 195 mg.............................53 NATURE-THROID -thyroid tab 260 mg.............................53 NATURE-THROID -thyroid tab 48.75 mg (3/4 grain)........ 53 NATURE-THROID -thyroid tab 325 mg (5 grain).............. 53 NEBUPENT -pentamidine isethionate for nebulization soln 300 mg.................................................................... 18 NEBUSAL -sodium chloride soln nebu 6%....................... 89 NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50 mcg.................................................................................. 43 NEFAZODONE HCL -nefazodone hcl tab 100 mg......... 114 NEFAZODONE HCL -nefazodone hcl tab 150 mg......... 114
NEFAZODONE HCL -nefazodone hcl tab 200 mg......... 114 nefazodone hcl tab 50 mg............................................ 114 nefazodone hcl tab 250 mg.......................................... 114 NEMBUTAL SODIUM -pentobarbital sodium inj 50 mg/ ml................................................................................... 124 NEOKE ALCAR -acetylcarnitine oral powder................. 178 NEOKE MCT70 -medium chain triglycerides oral powder 70 gm/100gm................................................................ 178 NEOKE RA LIPOIC -alpha-lipoic acid (thioctic acid) oral powder 800 mg/gm....................................................... 220 NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp.............................................. 192 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin............................. 192 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin)........... 192 neomycin-polymyxin b gu irrigation soln (Neosporin gu irrigan).................................................................... 108 neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol)...................................................................... 192 neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol).............................................................192 neomycin-polymyxin-hc otic soln 1% (Cortisporin).................................................................194 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%.................................................................... 194 NEOMYCIN SULFATE -neomycin sulfate powder.......... 209 neomycin sulfate tab 500 mg........................................... 8 NEORAL -cyclosporine modified cap 25 mg...................276 NEORAL -cyclosporine modified cap 100 mg.................276 NEORAL -cyclosporine modified oral soln 100 mg/ ml................................................................................... 276 NEOSALUS CP -dermatological products misc cream............................................................................. 210 NEOSALUS -dermatological products, misc. - aerosol foam............................................................................... 209 NEOSALUS -dermatological products misc - cream...... 209 NEOSALUS -emollient - lotion........................................ 210 NEOSPORIN GU IRRIGANT -neomycin-polymyxin b gu irrigation soln................................................................. 108 NEOSPORIN -neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml................................... 192 NEOSTIGMINE METHYLSULFATE -neostigmine methylsulfate (bulk) powder......................................... 245 NEO-SYNALAR -neomycin sulfate-fluocinolone acetonide cream 0.5-0.025%........................................................ 209 NEOTUSS PLUS -phenylephrine-chlorphen-dm liquid 7.5-4-30 mg/5ml.............................................................. 89 NEPAFENAC -nepafenac (bulk) powder.........................245 NEPHPLEX RX -b-complex w/ c-zn & folic acid tab 1 mg.................................................................................. 172 NEPHROCAPS -b-complex w/ c & folic acid cap 1 mg.................................................................................. 172 NEPHRON FA -ferrous fumarate w/ fa-dss-b complex-vit c tab...............................................................................183
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
354
2016 niacin tab er 500 mg (antihyperlipidemic) (Niaspan)........................................................................ 83 niacin tab er 750 mg (antihyperlipidemic) (Niaspan)........................................................................ 83 niacin tab er 1000 mg (antihyperlipidemic) (Niaspan)........................................................................ 83 NIACOR -niacin (antihyperlipidemic) tab 500 mg............. 83 NIAOULI -niaouli oil......................................................... 245 NIASPAN -niacin tab er 500 mg (antihyperlipidemic)....... 83 NIASPAN -niacin tab er 750 mg (antihyperlipidemic)....... 83 NIASPAN -niacin tab er 1000 mg (antihyperlipidemic)..... 83 NICADAN -multiple vitamins w/ minerals tab.................. 172 NICADAN ZX -multiple vitamins w/ minerals tab............ 172 nicardipine hcl cap 20 mg.............................................. 66 nicardipine hcl cap 30 mg.............................................. 66 NICAZEL FORTE -multiple vitamins w/ minerals tab...... 172 NICAZEL -multiple vitamins w/ minerals tab................... 172 NICLOSAMIDE -niclosamide (bulk) powder................... 246 NICODERM CQ -nicotine td patch 24hr 7 mg/24hr........ 132 NICODERM CQ -nicotine td patch 24hr 14 mg/24hr...... 132 NICODERM CQ -nicotine td patch 24hr 21 mg/24hr...... 132 NICOMIDE -niacinamide w/ zn-cu-methylfolate tab 750-25-1.5-0.5 mg........................................................ 172 NICOMIDE -niacinamide w/ zn-cu-methylfol-se-cr tab 750-27-2-0.5 mg........................................................... 172 NICORETTE MINI -nicotine polacrilex lozenge 2 mg..... 133 NICORETTE MINI -nicotine polacrilex lozenge 4 mg..... 133 NICORETTE -nicotine polacrilex gum 2 mg................... 132 NICORETTE -nicotine polacrilex gum 4 mg................... 132 NICORETTE -nicotine polacrilex lozenge 2 mg.............. 133 NICORETTE -nicotine polacrilex lozenge 4 mg.............. 133 NICORETTE STARTER KIT -nicotine polacrilex gum 2 mg.................................................................................. 133 NICORETTE STARTER KIT -nicotine polacrilex gum 4 mg.................................................................................. 133 NICOTINAMIDE ADENINE DINU -nadide powder......... 246 NICOTINAMIDE -niacinamide powder............................ 170 nicotine polacrilex gum 2 mg.......................................133 nicotine polacrilex gum 4 mg.......................................133 nicotine polacrilex lozenge 2 mg................................. 133 nicotine polacrilex lozenge 4 mg................................. 133 NICOTINE POLACRILEX -nicotine polacrilex powder........................................................................... 246 NICOTINE TARTRATE -nicotine tartrate (bulk) powder........................................................................... 246 nicotine td patch 24hr 7 mg/24hr.................................133 nicotine td patch 24hr 14 mg/24hr...............................133 nicotine td patch 24hr 21 mg/24hr...............................133 NICOTINE TRANSDERMAL SYST -nicotine td patch 24 hr kit 21-14-7 mg/24hr.................................................. 133 NICOTROL INHALER -nicotine inhaler system 10 mg (4 mg delivered)................................................................ 133 NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/ spray)............................................................................. 133 nifedipine cap 20 mg....................................................... 66
NEPHRO-VITE RX -b-complex w/ c & folic acid tab 1 mg.................................................................................. 172 NEPTAZANE -methazolamide tab 25 mg......................... 79 NEPTAZANE -methazolamide tab 50 mg......................... 79 NESACAINE -chloroprocaine hcl inj 1%......................... 156 NESACAINE -chloroprocaine hcl inj 2%......................... 156 NESACAINE-MPF -chloroprocaine hcl preservative free (pf) inj 2%......................................................................156 NESACAINE-MPF -chloroprocaine hcl preservative free (pf) inj 3%......................................................................156 NESINA -alogliptin benzoate tab 6.25 mg (base equiv)............................................................................... 49 NESINA -alogliptin benzoate tab 12.5 mg (base equiv)............................................................................... 49 NESINA -alogliptin benzoate tab 25 mg (base equiv).......49 NETTLE LEAF -nettle leaf (bulk) powder........................245 NEULASTA ONPRO KIT -pegfilgrastim soln prefilled syringe kit 6 mg/0.6ml.................................................. 183 NEULASTA -pegfilgrastim soln prefilled syringe 6 mg/0.6ml........................................................................ 183 NEUPOGEN -filgrastim inj 300 mcg/ml........................... 183 NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/ ml).................................................................................. 183 NEUPOGEN -filgrastim soln prefilled syringe 300 mcg/0.5ml...................................................................... 183 NEUPOGEN -filgrastim soln prefilled syringe 480 mcg/0.8ml (600 mcg/ml)............................................... 183 NEUPRO -rotigotine td patch 24hr 1 mg/24hr................ 165 NEUPRO -rotigotine td patch 24hr 2 mg/24hr................ 165 NEUPRO -rotigotine td patch 24hr 3 mg/24hr................ 165 NEUPRO -rotigotine td patch 24hr 4 mg/24hr................ 165 NEUPRO -rotigotine td patch 24hr 6 mg/24hr................ 165 NEUPRO -rotigotine td patch 24hr 8 mg/24hr................ 165 NEURIN-SL -cyanocobalamin-methylcobalamin tab sl 600-600 mcg................................................................. 183 NEURONTIN -gabapentin cap 100 mg........................... 161 NEURONTIN -gabapentin cap 300 mg........................... 161 NEURONTIN -gabapentin cap 400 mg........................... 161 NEURONTIN -gabapentin oral soln 250 mg/5ml............ 161 NEURONTIN -gabapentin tab 600 mg............................ 161 NEURONTIN -gabapentin tab 800 mg............................ 161 NEUTRASAL -artificial saliva - packet............................ 195 NEVANAC -nepafenac ophth susp 0.1%........................ 192 nevirapine tab er 24hr 100 mg (Viramune xr)............... 12 nevirapine tab er 24hr 400 mg (Viramune xr)............... 12 nevirapine tab 200 mg (Viramune).................................12 NEXAVAR -sorafenib tosylate tab 200 mg (base equivalent)....................................................................... 29 NEXAVIR -liver derivative complex inj 25.5 mg/ml......... 276 NEXPLANON -etonogestrel subdermal implant 68 mg.................................................................................... 43 NIACINAMIDE -niacinamide powder...............................170 NIACIN -niacin oral powder............................................. 170 NIACIN -niacin powder.................................................... 170
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
355
2016 nifedipine cap 10 mg (Procardia).................................. 66 NIFEDIPINE -nifedipine powder........................................ 66 nifedipine tab er 24hr 30 mg (Adalat cc).......................66 nifedipine tab er 24hr 60 mg (Adalat cc).......................66 nifedipine tab er 24hr 90 mg (Adalat cc).......................66 nifedipine tab er 24hr osmotic release 30 mg (Procardia xl)................................................................. 66 nifedipine tab er 24hr osmotic release 60 mg (Procardia xl)................................................................. 66 nifedipine tab er 24hr osmotic release 90 mg (Procardia xl)................................................................. 66 NIFEREX -iron combination tab...................................... 183 NILANDRON -nilutamide tab 150 mg............................... 29 nilutamide tab 150 mg (Nilandron)................................ 29 nimodipine cap 30 mg..................................................... 66 NIMODIPINE -nimodipine (bulk) powder........................ 246 NINLARO -ixazomib citrate cap 2.3 mg (base equivalent)....................................................................... 29 NINLARO -ixazomib citrate cap 3 mg (base equivalent)....................................................................... 29 NINLARO -ixazomib citrate cap 4 mg (base equivalent)....................................................................... 29 NISOLDIPINE ER -nisoldipine tab er 24hr 20 mg............ 66 NISOLDIPINE ER -nisoldipine tab er 24hr 25.5 mg......... 66 NISOLDIPINE ER -nisoldipine tab er 24hr 30 mg............ 66 NISOLDIPINE ER -nisoldipine tab er 24hr 40 mg............ 66 nisoldipine tab er 24hr 8.5 mg (Sular)........................... 66 nisoldipine tab er 24hr 17 mg (Sular)............................66 nisoldipine tab er 24hr 34 mg (Sular)............................66 NITRIC ACID -nitric acid liquid........................................ 246 NITRO-BID -nitroglycerin oint 2%..................................... 61 NITRO-DUR -nitroglycerin td patch 24hr 0.1 mg/hr.......... 61 NITRO-DUR -nitroglycerin td patch 24hr 0.2 mg/hr.......... 61 NITRO-DUR -nitroglycerin td patch 24hr 0.3 mg/hr.......... 61 NITRO-DUR -nitroglycerin td patch 24hr 0.4 mg/hr.......... 61 NITRO-DUR -nitroglycerin td patch 24hr 0.6 mg/hr.......... 61 NITRO-DUR -nitroglycerin td patch 24hr 0.8 mg/hr.......... 61 NITROFURANTOIN ANHYDROUS -nitrofurantoin (bulk) powder........................................................................... 246 nitrofurantoin macrocrystalline cap 25 mg (Macrodantin)...............................................................105 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin)...............................................................105 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin)...............................................................105 NITROFURANTOIN MACROCRYST -nitrofurantoin macrocrystal powder.....................................................105 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)............................................................. 105 NITROFURANTOIN -nitrofurantoin (bulk) powder.......... 246 nitrofurantoin susp 25 mg/5ml (Furadantin).............. 105 NITROFURAZONE -nitrofurazone powder..................... 210 nitroglycerin cap er 2.5 mg............................................ 61 nitroglycerin cap er 6.5 mg............................................ 61 nitroglycerin cap er 9 mg............................................... 61
NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol 400 mcg/spray................................................................ 61 nitroglycerin sl tab 0.3 mg (Nitrostat)........................... 61 nitroglycerin sl tab 0.4 mg (Nitrostat)........................... 61 nitroglycerin sl tab 0.6 mg (Nitrostat)........................... 61 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 61 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)......... 61 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)......... 61 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)......... 61 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) (Nitrolingual pumpspr)................................................. 61 NITROLINGUAL PUMPSPRAY -nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)..............................................61 NITROMIST -nitroglycerin lingual aerosol 400 mcg/ spray................................................................................ 61 NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 61 NITROSTAT -nitroglycerin sl tab 0.4 mg........................... 61 NITROSTAT -nitroglycerin sl tab 0.6 mg........................... 61 NIVATOPIC PLUS -dermatological products misc cream............................................................................. 210 nizatidine cap 150 mg..................................................... 98 nizatidine cap 300 mg (Axid).......................................... 98 NIZATIDINE -nizatidine oral soln 15 mg/ml...................... 98 NIZORAL -ketoconazole shampoo 2%........................... 210 nonoxynol-9 gel 4%....................................................... 107 NORCO -hydrocodone-acetaminophen tab 7.5-325 mg.................................................................................. 143 NORCO -hydrocodone-acetaminophen tab 5-325 mg.................................................................................. 143 NORCO -hydrocodone-acetaminophen tab 10-325 mg.................................................................................. 143 NORDITROPIN FLEXPRO -somatropin inj 5 mg/1.5ml.......................................................................... 57 NORDITROPIN FLEXPRO -somatropin inj 10 mg/1.5ml.......................................................................... 57 NORDITROPIN FLEXPRO -somatropin inj 15 mg/1.5ml.......................................................................... 57 NORDITROPIN FLEXPRO -somatropin inj 30 mg/3ml............................................................................. 58 norepinephrine bitartrate inj 1 mg/ml (Levophed)....... 80 NOREPINEPHRINE BITARTRATE -norepinephrine bitartrate (bulk) powder................................................ 246 norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (Femcon fe)............................................... 43 norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg (Generess fe)............................................ 43 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28)................................................................. 43 norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35)................................................................ 43 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (Ovcon-35)...................................................................... 43 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20).................................................. 44
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
356
2016 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30)............................................... 44 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21)................................................. 43 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21).............................................. 43 norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24) (Minastrin 24 fe)............................................44 norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) (Lomedia 24 fe)............................................. 44 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg................................................................................. 41 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt low dose)................................................ 41 NORETHINDRONE ACETATE -norethindrone acetate powder............................................................................. 45 norethindrone acetate tab 5 mg (Aygestin).................. 45 norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe)................................................. 43 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7)...................................... 44 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)...................................................... 44 NORETHINDRONE -norethindrone (bulk) powder......... 246 norethindrone tab 0.35 mg (Nor-qd).............................. 44 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-cyclen)................................................................ 44 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen)........................................... 44 norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg (Ortho tri-cyclen lo)....................................... 44 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 44 NORITATE -metronidazole cream 1%.............................210 NORPACE CR -disopyramide phosphate cap er 12hr 100 mg.................................................................................... 67 NORPACE CR -disopyramide phosphate cap er 12hr 150 mg.................................................................................... 67 NORPACE -disopyramide phosphate cap 100 mg........... 67 NORPACE -disopyramide phosphate cap 150 mg........... 67 NORPRAMIN -desipramine hcl tab 10 mg......................114 NORPRAMIN -desipramine hcl tab 25 mg......................114 NORTHERA -droxidopa cap 100 mg................................ 80 NORTHERA -droxidopa cap 200 mg................................ 81 NORTHERA -droxidopa cap 300 mg................................ 81 nortriptyline hcl cap 10 mg (Pamelor).........................114 nortriptyline hcl cap 25 mg (Pamelor).........................114 nortriptyline hcl cap 50 mg (Pamelor).........................114 nortriptyline hcl cap 75 mg (Pamelor).........................114 NORTRIPTYLINE HCL -nortriptyline hcl powder............ 114 NORTRIPTYLINE HCL -nortriptyline hcl soln 10 mg/5ml........................................................................... 114 NORTUSS-EX -dextromethorphan-guaifenesin liquid 20-200 mg/5ml................................................................ 89 NORVASC -amlodipine besylate tab 2.5 mg.................... 66 NORVASC -amlodipine besylate tab 5 mg....................... 66
NORVASC -amlodipine besylate tab 10 mg..................... 66 NORVIR -ritonavir cap 100 mg......................................... 12 NORVIR -ritonavir oral soln 80 mg/ml...............................12 NORVIR -ritonavir tab 100 mg.......................................... 12 NOURILITE -cream base................................................ 268 NOURISH -nutritional supplement liquid......................... 179 NOURISIL -silicone (bulk) gel......................................... 246 NOURIVAN ANTIOX CREAM BAS -cream base............ 269 NOVACORT -pramoxine-hc gel 1-2%............................. 210 NOVAREL -chorionic gonadotropin for inj 10000 unit....... 58 NOVOLIN 70/30 -insulin nph isophane & regular human inj 100 unit/ml (70-30).................................................... 52 NOVOLIN 70/30 RELION -insulin nph isophane & regular human inj 100 unit/ml (70-30)........................................ 52 NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/ ml..................................................................................... 52 NOVOLIN N RELION -insulin nph (human) (isophane) inj 100 unit/ml.......................................................................52 NOVOLIN R -insulin regular (human) inj 100 unit/ml........ 51 NOVOLIN R RELION -insulin regular (human) inj 100 unit/ml.............................................................................. 51 NOVOLOG FLEXPEN -insulin aspart soln pen-injector 100 unit/ml.......................................................................51 NOVOLOG -insulin aspart inj 100 unit/ml......................... 51 NOVOLOG MIX 70/30 -insulin aspart prot & aspart (human) inj 100 unit/ml (70-30)...................................... 52 NOVOLOG MIX 70/30 PREFILL -insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30)........................... 52 NOVOLOG PENFILL -insulin aspart soln cartridge 100 unit/ml.............................................................................. 51 NOXAFIL -posaconazole susp 40 mg/ml.......................... 10 NOXAFIL -posaconazole tab delayed release 100 mg..... 10 NOXIFINE WOUND DRESSING -wound dressings emulsion........................................................................ 210 NOXIFOL-D -folic acid-cholecalciferol tab 1 mg-2500 unit................................................................................. 183 NOXI-K -cream base....................................................... 269 NP #2 DRUG PREPARATION KI -tramadol-flurbipamitrip-gaba-clonidine-lido crm (cmp kit)..................... 210 NPLATE -romiplostim for inj 250 mcg............................. 183 NPLATE -romiplostim for inj 500 mcg............................. 183 NUCALA -mepolizumab for inj 100 mg............................. 93 NUCORT -hydrocortisone acetate lotion 2%.................. 210 NUCYNTA ER -tapentadol hcl tab er 12hr 50 mg........... 143 NUCYNTA ER -tapentadol hcl tab er 12hr 100 mg......... 143 NUCYNTA ER -tapentadol hcl tab er 12hr 150 mg......... 143 NUCYNTA ER -tapentadol hcl tab er 12hr 200 mg......... 143 NUCYNTA ER -tapentadol hcl tab er 12hr 250 mg......... 143 NUCYNTA -tapentadol hcl tab 50 mg............................. 143 NUCYNTA -tapentadol hcl tab 75 mg............................. 143 NUCYNTA -tapentadol hcl tab 100 mg........................... 143 NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap 20-10 mg....................................................................... 133 NUFERA -iron combination tab....................................... 183
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
357
2016 octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin)................................................................. 58 OCTYL STEARATE -octyl stearate (bulk) liquid............. 246 OCUFLOX -ofloxacin ophth soln 0.3%........................... 192 OCUVEL -multiple vitamins w/ minerals & fa cap 0.5 mg.................................................................................. 172 ODEFSEY -emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg.................................................................. 12 ODOMZO -sonidegib phosphate cap 200 mg (base equivalent)....................................................................... 29 OFEV -nintedanib esylate cap 100 mg (base equivalent)....................................................................... 95 OFEV -nintedanib esylate cap 150 mg (base equivalent)....................................................................... 95 OFLOXACIN -ofloxacin tab 300 mg.................................... 7 ofloxacin ophth soln 0.3% (Ocuflox)........................... 192 ofloxacin otic soln 0.3%................................................194 ofloxacin tab 400 mg......................................................... 7 OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg.................................................................................. 44 OINTMENT BASE EMULSIFYING -emulsifying ointment......................................................................... 269 olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax).................................................................... 133 olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax).................................................................... 133 olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax).................................................................... 133 olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax).................................................................... 133 olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax).................................................................... 133 olanzapine for im inj 10 mg (Zyprexa)........................ 120 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis).............................................................................120 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis).............................................................................120 olanzapine orally disintegrating tab 15 mg (Zyprexa zydis).............................................................................120 olanzapine orally disintegrating tab 20 mg (Zyprexa zydis).............................................................................120 olanzapine tab 2.5 mg (Zyprexa)................................. 120 olanzapine tab 5 mg (Zyprexa).................................... 120 olanzapine tab 7.5 mg (Zyprexa)................................. 120 olanzapine tab 10 mg (Zyprexa).................................. 120 olanzapine tab 15 mg (Zyprexa).................................. 120 olanzapine tab 20 mg (Zyprexa).................................. 120 OLEABASE PLASTICIZED -plastibase ointment........... 269 OLEIC ACID -oleic acid soln........................................... 269 OLIVE OIL -olive oil......................................................... 246 olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg (Tribenzor).............................................. 75 olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg (Tribenzor).............................................. 75
NULYTELY/FLAVOR PACKS -peg 3350-kcl-sod bicarbnacl for soln 420 gm.......................................................96 NUMOISYN -artificial saliva - lozenge............................ 195 NUMOISYN -artificial saliva - solution............................ 195 NUPLAZID -pimavanserin tartrate tab 17 mg (base equivalent)..................................................................... 120 NUTRASEB -emollient - cream....................................... 210 NUTRESTORE -glutamine powd pack 5 gm.................. 178 NUTRICAP -multiple vitamins w/ minerals tab................172 nutritional supplement liquid....................................... 179 NUTRIVIT -b-complex w/ lysine-min-fe & fa liqd 800-15-1 mg/15ml......................................................................... 172 NUTROPIN AQ NUSPIN 10 -somatropin inj 10 mg/2ml............................................................................. 58 NUTROPIN AQ NUSPIN 20 -somatropin inj 20 mg/2ml............................................................................. 58 NUTROPIN AQ NUSPIN 5 -somatropin inj 5 mg/2ml....... 58 NUVAIL -dermatological products misc - solution........... 210 NUVARING -etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr...................................................... 44 NUVESSA -metronidazole vaginal gel 1.3%...................107 NUVIGIL -armodafinil tab 50 mg..................................... 129 NUVIGIL -armodafinil tab 150 mg................................... 129 NUVIGIL -armodafinil tab 200 mg................................... 129 NUVIGIL -armodafinil tab 250 mg................................... 129 NYLIDRIN HYDROCHLORIDE -nylidrin hcl powder.........85 NYMALIZE -nimodipine oral soln 60 mg/20ml.................. 66 nystatin cream 100000 unit/gm.................................... 210 NYSTATIN FOREIGN -nystatin (bulk) powder................ 246 NYSTATIN -nystatin (bulk) powder..................................246 nystatin oint 100000 unit/gm........................................ 210 nystatin oral powder........................................................10 nystatin susp 100000 unit/ml....................................... 195 nystatin tab 500000 unit..................................................10 nystatin topical powder 100000 unit/gm..................... 210 nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 210 nystatin-triamcinolone oint 100000-0.1 unit/gm%.................................................................................... 210 O OBREDON -hydrocodone-guaifenesin soln 2.5-200 mg/5ml............................................................................. 89 OCALIVA -obeticholic acid tab 5 mg............................... 103 OCALIVA -obeticholic acid tab 10 mg............................. 103 OCCLUVAN -hydrophilic ointment.................................. 269 OCTINOXATE -octinoxate (bulk) liquid........................... 246 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin)................................................................. 58 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin)................................................................. 58 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin)................................................................. 58 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin)................................................................. 58
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
358
2016 ondansetron hcl tab 24 mg.......................................... 101 ondansetron hcl tab 4 mg (Zofran)..............................100 ondansetron hcl tab 8 mg (Zofran)..............................101 ondansetron orally disintegrating tab 4 mg (Zofran odt)................................................................................ 101 ondansetron orally disintegrating tab 8 mg (Zofran odt)................................................................................ 101 ONEXTON -clindamycin phosphate-benzoyl peroxide gel 1.2-3.75%...................................................................... 210 ONFI -clobazam suspension 2.5 mg/ml.......................... 161 ONFI -clobazam tab 10 mg............................................. 161 ONFI -clobazam tab 20 mg............................................. 161 ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv)......... 49 ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............ 49 ONMEL -itraconazole tab 200 mg..................................... 10 ONZETRA XSAIL -sumatriptan succinate exhaler powder 11 mg/nosepiece........................................................... 152 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 5 mg....................................................... 143 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 7.5 mg.................................................... 143 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 10 mg..................................................... 143 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 15 mg..................................................... 143 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 20 mg..................................................... 143 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 30 mg..................................................... 143 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 40 mg..................................................... 143 OPANA -oxymorphone hcl inj 1 mg/ml............................143 OPANA -oxymorphone hcl tab 5 mg............................... 143 OPANA -oxymorphone hcl tab 10 mg............................. 143 ophthalmic irrigation solution - intraocular (Bss plus).............................................................................. 192 opium tincture 1% (10 mg/ml) (morphine equiv)..........96 OPSUMIT -macitentan tab 10 mg..................................... 85 OPTIONS CONCEPTROL VAGINA -nonoxynol-9 gel 4%.................................................................................. 107 OPTIONS GYNOL II VAGINAL -nonoxynol-9 gel 3%..... 107 ORA-BLEND -oral vehicles - susp.................................. 269 ORA-BLEND SF -oral vehicles - susp............................ 269 ORACIT -sodium citrate & citric acid soln 490-640 mg/5ml........................................................................... 108 ORAFATE -sucralfate-malate paste 10%........................ 195 ORALAIR -grass mixed pollen ext tab sl 300 ir (index of reactivity)......................................................................... 24 ORAMAGICRX -oral wound care products - for susp rinse............................................................................... 195 ORANGE CREAM FLAVOR -flavoring agent - liquid...... 269 ORANGE FLAVOR -flavoring agent - liquid.................... 269 ORANGE FLAVOR -flavoring agent - powder................ 269 ORANGE OIL FLAVOR -flavoring agent - liquid............. 269 ORA-PLUS -oral vehicles................................................ 269
olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg (Tribenzor)................................................. 75 olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg (Tribenzor)............................................ 75 olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg (Tribenzor)............................................... 75 olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg (Benicar hct)..............................................75 olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg (Benicar hct)..............................................75 olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg (Benicar hct)........................................................... 75 OLMESARTAN MEDOXOMIL -olmesartan medoxomil (bulk) powder................................................................ 246 olmesartan medoxomil tab 5 mg (Benicar).................. 75 olmesartan medoxomil tab 20 mg (Benicar)................ 75 olmesartan medoxomil tab 40 mg (Benicar)................ 75 olopatadine hcl nasal soln 0.6% (Patanase).................88 olopatadine hcl ophth soln 0.2% (base equivalent) (Pataday)...................................................................... 192 olopatadine hcl ophth soln 0.1% (base equivalent) (Patanol)....................................................................... 192 OLUX -clobetasol propionate foam 0.05%......................210 OLUX-E -clobetasol propionate emulsion foam 0.05%.............................................................................210 OLYSIO -simeprevir sodium cap 150 mg (base equivalent)....................................................................... 12 OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/ omepraz cap dr therapy pack........................................ 99 omega-3-acid ethyl esters cap 1 gm (Lovaza)............. 83 omeprazole cap delayed release 10 mg (Prilosec)...... 99 omeprazole cap delayed release 20 mg (Prilosec)...... 99 omeprazole cap delayed release 40 mg (Prilosec)...... 99 OMEPRAZOLE -omeprazole (bulk) powder................... 246 omeprazole-sodium bicarbonate cap 20-1100 mg (Zegerid)......................................................................... 99 omeprazole-sodium bicarbonate cap 40-1100 mg (Zegerid)......................................................................... 99 omeprazole-sodium bicarbonate powd pack for susp 20-1680 mg (Zegerid)....................................................99 omeprazole-sodium bicarbonate powd pack for susp 40-1680 mg (Zegerid)....................................................99 OMNIPRED -prednisolone acetate ophth susp 1%........ 192 OMNITROPE -somatropin for inj 5.8 mg.......................... 58 OMNITROPE -somatropin inj 5 mg/1.5ml......................... 58 OMNITROPE -somatropin inj 10 mg/1.5ml....................... 58 ONCASPAR -pegaspargase inj 750 unit/ml...................... 29 ONDANSETRON HCL DIHYDRATE -ondansetron hcl (bulk) powder................................................................ 246 ondansetron hcl inj 4 mg/2ml (2 mg/ml)..................... 100 ondansetron hcl inj 40 mg/20ml (2 mg/ml) (Zofran)......................................................................... 100 ONDANSETRON HCL -ondansetron hcl (bulk) powder........................................................................... 246 ondansetron hcl oral soln 4 mg/5ml (Zofran)............. 100
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
359
2016 ORAP -pimozide tab 1 mg.............................................. 133 ORAP -pimozide tab 2 mg.............................................. 133 ORAPRED ODT -prednisolone sod phos orally disintegr tab 10 mg (base eq)....................................................... 35 ORAPRED ODT -prednisolone sod phos orally disintegr tab 15 mg (base eq)....................................................... 35 ORAPRED ODT -prednisolone sod phos orally disintegr tab 30 mg (base eq)....................................................... 35 ORA-SWEET -oral vehicles - syrup................................ 269 ORA-SWEET SF -oral vehicles - syrup.......................... 269 ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................ 195 ORENCIA -abatacept subcutaneous soln prefilled syringe 50 mg/0.4ml.................................................................. 150 ORENCIA -abatacept subcutaneous soln prefilled syringe 87.5 mg/0.7ml............................................................... 150 ORENCIA -abatacept subcutaneous soln prefilled syringe 125 mg/ml..................................................................... 150 ORENCIA CLICKJECT -abatacept subcutaneous soln auto-injector 125 mg/ml................................................ 150 ORENITRAM -treprostinil diolamine tab er 0.125 mg (base equiv).................................................................... 85 ORENITRAM -treprostinil diolamine tab er 0.25 mg (base equiv)............................................................................... 85 ORENITRAM -treprostinil diolamine tab er 1 mg (base equiv)............................................................................... 85 ORENITRAM -treprostinil diolamine tab er 2.5 mg (base equiv)............................................................................... 85 ORENITRAM -treprostinil diolamine tab er 5 mg (base equiv)............................................................................... 85 ORFADIN -nitisinone cap 2 mg......................................... 58 ORFADIN -nitisinone cap 5 mg......................................... 58 ORFADIN -nitisinone cap 10 mg....................................... 58 ORFADIN -nitisinone cap 20 mg....................................... 58 ORFADIN -nitisinone susp 4 mg/ml.................................. 58 ORIGANUM -origanum oil (bulk)..................................... 246 ORKAMBI -lumacaftor-ivacaftor tab 100-125 mg............. 95 ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg............. 95 ORNITHINE HYDROCHLORIDE -ornithine hcl (bulk) powder........................................................................... 246 orphenadrine citrate inj 30 mg/ml (Norflex)................169 ORPHENADRINE CITRATE -orphenadrine citrate powder........................................................................... 169 orphenadrine citrate tab er 12hr 100 mg.................... 169 ORTHO-CYCLEN -norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg.............................................................. 44 ORTHO D -folic acid-cholecalciferol cap 1 mg-3775 unit................................................................................. 184 ORTHO EVRA -norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr............................................................. 44 ORTHO MICRONOR -norethindrone tab 0.35 mg............44 ORTHO-NOVUM 7/7/7 -norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg.......................................... 44 ORTHO-NOVUM 1/35 -norethindrone & ethinyl estradiol tab 1 mg-35 mcg............................................................ 44
ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg................................. 44 ORTHO TRI-CYCLEN -norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg................................. 44 oseltamivir phosphate cap 30 mg (base equiv) (Tamiflu).......................................................................... 12 oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu).......................................................................... 12 oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu).......................................................................... 12 OSENI -alogliptin-pioglitazone tab 12.5-15 mg................. 49 OSENI -alogliptin-pioglitazone tab 12.5-30 mg................. 49 OSENI -alogliptin-pioglitazone tab 12.5-45 mg................. 49 OSENI -alogliptin-pioglitazone tab 25-15 mg.................... 49 OSENI -alogliptin-pioglitazone tab 25-30 mg.................... 49 OSENI -alogliptin-pioglitazone tab 25-45 mg.................... 49 OSMOPREP -sod phos mono-sod phos di tabs 1.102-0.398 gm(1.5gm na phos).................................... 96 OSPHENA -ospemifene tab 60 mg................................... 58 OTEZLA -apremilast tab 30 mg...................................... 150 OTEZLA -apremilast tab starter therapy pack 10 mg & 20 mg & 30 mg.................................................................. 150 OTOVEL -ciprofloxacin-fluocinolone aceton (pf) otic soln 0.3-0.025%.................................................................... 195 OTREXUP -methotrexate soln pf auto-injector 10mg/0.4ml.................................................................... 150 OTREXUP -methotrexate soln pf auto-injector 12.5 mg/0.4ml........................................................................ 150 OTREXUP -methotrexate soln pf auto-injector 15mg/0.4ml.................................................................... 150 OTREXUP -methotrexate soln pf auto-injector 17.5 mg/0.4ml........................................................................ 150 OTREXUP -methotrexate soln pf auto-injector 20mg/0.4ml.................................................................... 150 OTREXUP -methotrexate soln pf auto-injector 22.5 mg/0.4ml........................................................................ 150 OTREXUP -methotrexate soln pf auto-injector 25mg/0.4ml.................................................................... 150 OVACE PLUS -sulfacetamide sodium cream 10%......... 210 OVACE PLUS -sulfacetamide sodium foam 9.8%.......... 210 OVACE PLUS -sulfacetamide sodium lotion 9.8%......... 210 OVACE PLUS -sulfacetamide sodium shampoo 10%................................................................................210 OVACE PLUS WASH -sulfacetamide sodium cleansing gel 10%......................................................................... 210 OVACE PLUS WASH -sulfacetamide sodium liquid 10%................................................................................210 OVACE WASH -sulfacetamide sodium liquid 10%......... 210 OVIDE -malathion lotion 0.5%........................................ 210 oxacillin sodium for inj 1 gm........................................... 2 oxacillin sodium for inj 2 gm........................................... 2 oxacillin sodium for inj 10 gm......................................... 2 OXALIC ACID DIHYDRATE -oxalic acid dihydrate (bulk) powder........................................................................... 246 OXANDRIN -oxandrolone tab 2.5 mg............................... 38
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
360
2016 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 40 mg............................................................................ 144 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 60 mg............................................................................ 144 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 80 mg............................................................................ 144 OXYCODONE HCL -oxycodone hcl powder.................. 143 oxycodone hcl soln 5 mg/5ml (Oxycodone hcl).........144 oxycodone hcl tab 10 mg............................................. 144 oxycodone hcl tab 20 mg............................................. 144 oxycodone hcl tab 5 mg (Roxicodone)....................... 144 oxycodone hcl tab 15 mg (Roxicodone)..................... 144 oxycodone hcl tab 30 mg (Roxicodone)..................... 144 oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet)..................................................................... 144 oxycodone w/ acetaminophen tab 5-325 mg (Percocet)..................................................................... 144 oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet)..................................................................... 144 oxycodone w/ acetaminophen tab 10-325 mg (Percocet)..................................................................... 144 OXYCONTIN -oxycodone hcl tab er 12hr deter 10 mg.................................................................................. 144 OXYCONTIN -oxycodone hcl tab er 12hr deter 15 mg.................................................................................. 144 OXYCONTIN -oxycodone hcl tab er 12hr deter 20 mg.................................................................................. 144 OXYCONTIN -oxycodone hcl tab er 12hr deter 30 mg.................................................................................. 144 OXYCONTIN -oxycodone hcl tab er 12hr deter 40 mg.................................................................................. 144 OXYCONTIN -oxycodone hcl tab er 12hr deter 60 mg.................................................................................. 144 OXYCONTIN -oxycodone hcl tab er 12hr deter 80 mg.................................................................................. 144 OXYMETAZOLINE HCL -oxymetazoline hcl (bulk) powder........................................................................... 246 oxymorphone hcl tab 5 mg (Opana)............................144 oxymorphone hcl tab 10 mg (Opana)..........................144 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab er 12hr 5 mg...........................................................144 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab er 12hr 7.5 mg........................................................144 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab er 12hr 10 mg.........................................................144 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab er 12hr 15 mg.........................................................144 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab er 12hr 20 mg.........................................................145 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab er 12hr 30 mg.........................................................145 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab er 12hr 40 mg.........................................................145 OXYTETRACYCLINE DIHYDRATE -oxytetracycline dihydrate (bulk) powder................................................ 246
OXANDRIN -oxandrolone tab 10 mg................................ 38 OXANDROLONE -oxandrolone (bulk) powder............... 246 oxandrolone tab 2.5 mg (Oxandrin).............................. 38 oxandrolone tab 10 mg (Oxandrin)............................... 38 oxaprozin tab 600 mg (Daypro)................................... 150 OXAYDO -oxycodone hcl tab abuse deter 5 mg............ 143 OXAYDO -oxycodone hcl tab abuse deter 7.5 mg..........143 oxazepam cap 10 mg.................................................... 110 oxazepam cap 15 mg.................................................... 110 oxazepam cap 30 mg.................................................... 110 oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)...................................................................... 161 oxcarbazepine tab 150 mg (Trileptal).......................... 162 oxcarbazepine tab 300 mg (Trileptal).......................... 162 oxcarbazepine tab 600 mg (Trileptal).......................... 162 oxiconazole nitrate cream 1% (Oxistat)...................... 210 OXISTAT -oxiconazole nitrate cream 1%........................ 210 OXISTAT -oxiconazole nitrate lotion 1%......................... 210 OXSORALEN ULTRA -methoxsalen rapid cap 10 mg.................................................................................. 210 OXTELLAR XR -oxcarbazepine tab er 24hr 150 mg...... 162 OXTELLAR XR -oxcarbazepine tab er 24hr 300 mg...... 162 OXTELLAR XR -oxcarbazepine tab er 24hr 600 mg...... 162 OXYBENZONE -oxybenzone powder............................. 246 OXYBUTININ CHLORIDE -oxybutynin chloride (bulk) powder........................................................................... 246 OXYBUTININ CHLORIDE -oxybutynin chloride powder........................................................................... 106 OXYBUTYNIN CHLORIDE -oxybutynin chloride (bulk) powder........................................................................... 246 oxybutynin chloride syrup 5 mg/5ml.......................... 106 oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)................................................................................... 106 oxybutynin chloride tab er 24hr 10 mg (Ditropan xl)................................................................................... 106 oxybutynin chloride tab er 24hr 15 mg (Ditropan xl)................................................................................... 106 oxybutynin chloride tab 5 mg...................................... 106 OXYCODONE/ACETAMINOPHEN -oxycodone w/ acetaminophen soln 5-325 mg/5ml.............................. 144 OXYCODONE/IBUPROFEN -oxycodone-ibuprofen tab 5-400 mg....................................................................... 144 oxycodone-aspirin tab 4.8355-325 mg (Percodan).................................................................... 144 oxycodone hcl cap 5 mg.............................................. 143 oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl).......................................................... 143 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 10 mg............................................................................ 143 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 15 mg............................................................................ 143 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 20 mg............................................................................ 144 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 30 mg............................................................................ 144
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
361
2016 PARAFFIN -paraffin wax..................................................269 PARAFON FORTE DSC -chlorzoxazone tab 500 mg..... 169 PARAFORMALDEHYDE -paraformaldehyde powder........................................................................... 247 PARAGARD INTRAUTERINE COP -copper iud............... 44 PAREGORIC -paregoric tincture 2 mg/5ml (morphine equivalent)....................................................................... 96 paricalcitol cap 1 mcg (Zemplar)................................... 58 paricalcitol cap 2 mcg (Zemplar)................................... 58 paricalcitol cap 4 mcg (Zemplar)................................... 58 PARLODEL -bromocriptine mesylate cap 5 mg (base equivalent)..................................................................... 165 PARLODEL -bromocriptine mesylate tab 2.5 mg (base equivalent)..................................................................... 165 PARNATE -tranylcypromine sulfate tab 10 mg............... 114 paromomycin sulfate cap 250 mg................................... 8 PAROMOMYCIN SULFATE -paromomycin sulfate (bulk) powder........................................................................... 247 paroxetine hcl tab er 24hr 12.5 mg (Paxil cr)............. 114 paroxetine hcl tab er 24hr 25 mg (Paxil cr)................ 114 paroxetine hcl tab er 24hr 37.5 mg (Paxil cr)............. 114 paroxetine hcl tab 10 mg (Paxil).................................. 114 paroxetine hcl tab 20 mg (Paxil).................................. 114 paroxetine hcl tab 30 mg (Paxil).................................. 114 paroxetine hcl tab 40 mg (Paxil).................................. 114 PASER -aminosalicylic acid er granules packet 4 gm........ 9 PASSION FRUIT FLAVOR -flavoring agent - powder..... 269 PASSION FRUIT FLAVOR SWEE -flavoring agent powder........................................................................... 269 PATADAY -olopatadine hcl ophth soln 0.2% (base equivalent)..................................................................... 192 PATANASE -olopatadine hcl nasal soln 0.6%................... 88 PATANOL -olopatadine hcl ophth soln 0.1% (base equivalent)..................................................................... 192 PAXIL CR -paroxetine hcl tab er 24hr 12.5 mg............... 114 PAXIL CR -paroxetine hcl tab er 24hr 25 mg..................115 PAXIL CR -paroxetine hcl tab er 24hr 37.5 mg............... 115 PAXIL -paroxetine hcl oral susp 10 mg/5ml (base equiv)............................................................................. 114 PAXIL -paroxetine hcl tab 10 mg.................................... 114 PAXIL -paroxetine hcl tab 20 mg.................................... 114 PAXIL -paroxetine hcl tab 30 mg.................................... 114 PAXIL -paroxetine hcl tab 40 mg.................................... 114 PAZEO -olopatadine hcl ophth soln 0.7% (base equivalent)..................................................................... 192 pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg (Donnatal)................................................................ 99 P-CARE D40 -methylprednisolone acetate inj susp 40 mg/ml kit.......................................................................... 35 P-CARE D80 -methylprednisolone acetate inj susp 40 mg/ml kit.......................................................................... 35 P-CARE D40MX -methylprednisolone inj 40 mg/ml & bupiv 0.5% &lido 1% kit................................................. 35 P-CARE D80MX -methylprednisolone inj 40 mg/ml & bupiv 0.5% &lido 1% kit................................................. 35
OXYTETRACYCLINE HCL -oxytetracycline hcl powder............................................................................... 7 oxytocin inj 10 unit/ml (Pitocin)..................................... 55 OXYTOCIN -oxytocin (bulk) powder............................... 246 OXYTROL -oxybutynin td patch biweekly 3.9 mg/24hr......................................................................... 106 OZURDEX -dexamethasone intravitreal implant 0.7 mg.................................................................................. 192 P paliperidone tab er 24hr 1.5 mg (Invega).................... 120 paliperidone tab er 24hr 3 mg (Invega)....................... 120 paliperidone tab er 24hr 6 mg (Invega)....................... 120 paliperidone tab er 24hr 9 mg (Invega)....................... 120 PALMAROSA OIL -palmarosa oil (bulk)......................... 246 PALMITAMIDE MEA (PMEA) -palmidrol (bulk) powder........................................................................... 246 PALMITOYL PENTAPEPTIDE-3 -palmitoyl pentapeptide-3 (bulk) gel..............................................246 PALMITOYL TRIPEPTIDE-3 -palmitoyl tripeptide-3 (bulk) solution.......................................................................... 246 PAMELOR -nortriptyline hcl cap 10 mg.......................... 114 PAMELOR -nortriptyline hcl cap 25 mg.......................... 114 PAMELOR -nortriptyline hcl cap 50 mg.......................... 114 PAMELOR -nortriptyline hcl cap 75 mg.......................... 114 PAMINE FORTE -methscopolamine bromide tab 5 mg.................................................................................... 99 PAMINE -methscopolamine bromide tab 2.5 mg.............. 99 PANATUSS DXP -phenylephrine-dexbromphen-dm-gg liquid 5-1-15-100 mg/5ml................................................ 89 PANCREATIN -pancreatin (bulk) powder........................ 247 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 2600-6200-10850 unit...................................................101 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 4200-14200-24600 unit................................................ 101 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 10500-35500-61500 unit.............................................. 101 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 16800-56800-98400 unit.............................................. 101 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 21000-54700-83900 unit.............................................. 101 PANDEL -hydrocortisone probutate cream 0.1%............ 210 PANRETIN -alitretinoin gel 0.1%..................................... 210 PANTHENOL -panthenol (bulk) powder..........................247 pantoprazole sodium ec tab 20 mg (base equiv) (Protonix)........................................................................99 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix)........................................................................99 PANTOPRAZOLE SODIUM -pantoprazole sodium (bulk) powder........................................................................... 247 PAPAIN -papain powder.................................................. 247 papaverine hcl inj 30 mg/ml........................................... 85 PARA-AMINOBENZOIC ACID -para-aminobenzoic acid powder........................................................................... 170 PARACHLOROPHENOL -parachlorophenol (bulk) powder........................................................................... 247
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
362
2016 PCCA PRACAMAC BASE -oil base - oil........................ 270 PCCA PRACASIL TM-PLUS BAS -cream base............. 270 PCCA RAPID DISSOLVE TABLE -rapid dissolve tablet base powder................................................................. 270 PCCA SORBITOL LOLLIPOP BA -sorbitol lollipop base flakes............................................................................. 270 PCCA SPIRA-WASH BASE -gel base - gel.................... 270 PCCA SWEETNESS ENHANCER -flavoring agent liquid.............................................................................. 270 PCCA SWEET-SF -oral vehicles - syrup........................ 270 PCCA SYRUP VEHICLE -oral vehicles - syrup.............. 270 PCCA T4 SODIUM DILUTION -levothyroxine sodium (bulk) powder................................................................ 247 PCCA T3 SODIUM DILUTION -liothyronine sodium powder............................................................................. 53 PCCA VANISHING CREAM/LOTI -cream base............. 270 PCCA VANISHING CREAM LIGH -cream base............. 270 PCCA VANPEN BASE -cream base............................... 270 PCCA XYLIFOS BASE -poloxamer-xylitol powder......... 270 PCE -erythromycin w/ enteric coated particles tab 333 mg...................................................................................... 6 PCE -erythromycin w/ enteric coated particles tab 500 mg...................................................................................... 6 PCP 100 -mag cit-bisacodyl-petrolat-pegmetoclopramide-electrol kit............................................. 96 PEACH FLAVOR -flavoring agent - liquid....................... 270 PEANUT BUTTER FLAVOR -flavoring agent - liquid..... 270 PEANUT OIL -peanut oil................................................. 247 PECTIN -pectin powder..................................................... 96 PEDIAPRED -prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)................................................ 35 PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj.............................................................................. 22 pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ ml................................................................................... 172 pediatric multiple vitamins w/ fluoride chew tab 0.25 mg................................................................................. 172 pediatric multiple vitamins w/ fluoride chew tab 0.5 mg................................................................................. 172 pediatric multiple vitamins w/ fluoride chew tab 1 mg................................................................................. 172 pediatric multiple vitamins w/ fluoride soln 0.25 mg/ ml................................................................................... 172 pediatric multiple vitamins w/ fluoride soln 0.5 mg/ ml................................................................................... 172 pediatric multiple vitamin w/ minerals & c drops 45 mg/ml............................................................................ 172 pediatric vitamins acd w/ fluoride soln 0.25 mg/ ml................................................................................... 172 pediatric vitamins acd w/ fluoride soln 0.5 mg/ml..... 172 PEDVAX HIB -haemophilus b polysaccharide conj vac im susp 7.5 mcg/0.5 ml....................................................... 21 PEGANONE -ethotoin tab 250 mg.................................. 162 PEGASYS -peginterferon alfa-2a inj 180 mcg/ml............. 13 PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml........ 13
P-CARE K40MX -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 1% kit.......................................................... 35 P-CARE K80MX -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 1% kit.......................................................... 35 P-CARE K40 -triamcinolone acetonide inj kit 40 mg/ ml..................................................................................... 35 P-CARE K80 -triamcinolone acetonide inj kit 2 x 40 mg/ ml..................................................................................... 35 P-CARE M -bupivacaine hcl inj kit 0.5%......................... 156 P-CARE 100MX -lidocaine hcl inj 1% & bupivacaine hcl inj 0.5% kit.................................................................... 156 P-CARE X -lidocaine hcl local inj kit 1%......................... 156 PCCA ACACIA SYRUP BASE -acacia syrup................. 269 PCCA ALADERM BASE -cream base............................ 269 PCCA ANHYDROUS BASE -anhydrous ointment base............................................................................... 269 PCCA ANHYDROUS LIPODERM B -cream base.......... 269 PCCA BIOPEPTIDE BASE -cream base........................ 269 PCCA COBASE #1 -cobase #1 ointment base.............. 269 PCCA COSMETIC HRT BASE -cream base.................. 269 PCCA CUSTOM LIPO-MAX -cream base liposomic...... 269 PCCA DMAE COMPLEX -deanol (bulk) liquid................247 PCCA EMULSIFIX-205 BASE -emulsifying base liquid.............................................................................. 269 PCCA FIXED OIL BASE -fixed oil suspension vehicle liquid.............................................................................. 269 PCCA GELATIN BASE -gelatin ointment base............... 269 PCCA LECITHIN ISOPROPYL P -lecithin-isopropyl palmitate solution.......................................................... 269 PCCA LIPODERM BASE -cream base........................... 269 PCCA LIPODERM CUSTOM BASE -cream base.......... 269 PCCA LIPODERM HMW -gel base - gel........................ 269 PCCA LIPOSOMIC BASE FOR D -cream base liposomic........................................................................269 PCCA LIPOSOMIC BASE FOR N -cream base liposomic........................................................................269 PCCA LIPOSOMIC BASE FOR O -cream base liposomic........................................................................269 PCCA LIPOSOMIC BASE FOR S -cream base liposomic........................................................................269 PCCA LOXASPERSE BASE -poloxamer-xylitol powder........................................................................... 270 PCCA MVC BASE -cream base..................................... 270 PCCA NATACREAM -cream base.................................. 270 PCCA OCCLUSADERM -gel base - gel......................... 270 PCCA PLASTICIZED BASE -plastibase ointment.......... 270 PCCA PLURONIC F127 BASE -pluronic f127 base gel 30%................................................................................270 PCCA-PLUS -oral vehicles - susp.................................. 270 PCCA POLOXAMER 407 -pluronic f127 base gel 20%................................................................................270 PCCA POLYGLYCOL TROCHE -troche base powder........................................................................... 270 PCCA POLYPEG BASE -polyethylene glycol ointment......................................................................... 270
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
363
2016 PENTYLENE GLYCOL -pentylene glycol (bulk) liquid.............................................................................. 247 PENTYLENETETRAZOLE -pentylenetetrazol (bulk) crystals.......................................................................... 247 PEPCID -famotidine for susp 40 mg/5ml.......................... 99 PEPCID -famotidine tab 20 mg......................................... 99 PEPCID -famotidine tab 40 mg......................................... 99 PEPPERMINT FLAVOR -flavoring agent - oil................. 270 PEPPERMINT OIL -peppermint oil................................. 247 PEPSIN -pepsin powder.................................................. 101 PERCOCET -oxycodone w/ acetaminophen tab 2.5-325 mg.................................................................................. 145 PERCOCET -oxycodone w/ acetaminophen tab 5-325 mg.................................................................................. 145 PERCOCET -oxycodone w/ acetaminophen tab 7.5-325 mg.................................................................................. 145 PERCOCET -oxycodone w/ acetaminophen tab 10-325 mg.................................................................................. 145 PERFLUORODECALIN -perfluorodecalin (bulk) liquid.............................................................................. 247 PERFOROMIST -formoterol fumarate soln nebu 20 mcg/2ml........................................................................... 93 PERGOLIDE MESYLATE -pergolide mesylate (bulk) powder........................................................................... 247 PERIDEX -chlorhexidine gluconate soln 0.12%............. 195 perindopril erbumine tab 2 mg...................................... 75 perindopril erbumine tab 4 mg (Aceon)........................ 75 perindopril erbumine tab 8 mg (Aceon)........................ 75 permethrin cream 5% (Elimite).................................... 210 PERMETHRIN TECHNICAL -permethrin (bulk) liquid.............................................................................. 247 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg.............................................. 133 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-25 mg.............................................. 133 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-10 mg.............................................. 133 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-25 mg.............................................. 133 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-50 mg.............................................. 133 PERPHENAZINE -perphenazine (bulk) powder............. 247 perphenazine tab 2 mg................................................. 120 perphenazine tab 4 mg................................................. 120 perphenazine tab 8 mg................................................. 120 perphenazine tab 16 mg............................................... 120 PERTZYE -pancrelipase (lip-prot-amyl) dr cap 4000-14375-15125 unit................................................ 101 PERTZYE -pancrelipase (lip-prot-amyl) dr cap 8000-28750-30250 unit................................................ 101 PERTZYE -pancrelipase (lip-prot-amyl) dr cap 16000-57500-60500 unit.............................................. 101 PERTZYE -pancrelipase (lip-prot-amyl) dr cap 24000-86250-90750 unit.............................................. 102 PERUVIAN BALSAM -peruvian balsam..........................247
PEGASYS PROCLICK -peginterferon alfa-2a inj 135 mcg/0.5ml........................................................................ 13 PEGASYS PROCLICK -peginterferon alfa-2a inj 180 mcg/0.5ml........................................................................ 13 PEG-40 CASTOR OIL -peg-40 castor oil (bulk)..............247 PEGINTRON -peginterferon alfa-2b for inj kit 50 mcg/0.5ml........................................................................ 13 PEGINTRON -peginterferon alfa-2b for inj kit 80 mcg/0.5ml........................................................................ 13 PEGINTRON -peginterferon alfa-2b for inj kit 120 mcg/0.5ml........................................................................ 13 PEGINTRON -peginterferon alfa-2b for inj kit 150 mcg/0.5ml........................................................................ 13 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-flavor packs)............................................. 96 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely)................................................................. 96 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack)................................................... 96 PEG 400 MONOSTEARATE -peg 400 monostearate powder........................................................................... 247 PEG 300 -polyethylene glycol 300 liquid........................ 270 PENCREAM -cream base............................................... 270 PENDERM -cream base.................................................. 270 PENICILLAMINE -penicillamine powder......................... 276 penicillin g potassium for inj 5000000 unit (Pfizerpeng)........................................................................................ 2 penicillin g potassium for inj 20000000 unit (Pfizerpen-g).....................................................................2 PENICILLIN G PROCAINE -penicillin g procaine intramuscular susp 600000 unit/ml.................................. 2 PENICILLIN G SODIUM -penicillin g sodium for inj 5000000 unit..................................................................... 2 penicillin v potassium for soln 125 mg/5ml................... 2 penicillin v potassium for soln 250 mg/5ml................... 2 penicillin v potassium tab 250 mg...................................2 penicillin v potassium tab 500 mg...................................2 PENLAC NAIL LACQUER -ciclopirox solution 8%......... 210 PENNYROYAL OIL -pennyroyal oil (bulk)...................... 247 PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp............................................................... 22 PENTAM 300 -pentamidine isethionate for soln 300 mg.................................................................................... 18 PENTAPHENE BASE -cream base................................ 270 PENTASA -mesalamine cap er 250 mg.......................... 104 PENTASA -mesalamine cap er 500 mg.......................... 104 pentazocine w/ naloxone tab 50-0.5 mg......................145 pentobarbital sodium inj 50 mg/ml (Nembutal sodium)......................................................................... 124 PENTOBARBITAL SODIUM -pentobarbital sodium powder........................................................................... 124 PENTOSAN POLYSULFATE SODI -pentosan polysulfate sodium (bulk) powder................................................... 247 PENTOXIFYLLINE -pentoxifylline (bulk) powder............ 247 pentoxifylline tab er 400 mg......................................... 188
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
364
2016 PERUVIAN BALSAM -peruvian balsam powder.............247 PETROLATUM WHITE -white petrolatum ointment........ 270 PEUCEDANUM OSTRUTHIUM EXT -peucedanum ostruthium extract (masterwort) solution...................... 247 PEXEVA -paroxetine mesylate tab 10 mg (base equiv)............................................................................. 115 PEXEVA -paroxetine mesylate tab 20 mg (base equiv)............................................................................. 115 PEXEVA -paroxetine mesylate tab 30 mg (base equiv)............................................................................. 115 PEXEVA -paroxetine mesylate tab 40 mg (base equiv)............................................................................. 115 PFIZERPEN-G -penicillin g potassium for inj 5000000 unit..................................................................................... 2 PFIZERPEN-G -penicillin g potassium for inj 20000000 unit..................................................................................... 2 PHARMABASE COSMETIC -cream base...................... 270 PHARMABASE HEAVY -cream base............................. 270 PH 10 BUFFER -buffer reference standard solution ph 10................................................................................... 270 PH 4 BUFFER -buffer reference standard solution ph 4..................................................................................... 270 PH 7 BUFFER -buffer reference standard solution ph 7..................................................................................... 270 PHENACTIN AA PLUS -nutritional supplement liquid.............................................................................. 179 PHENAZOPYRIDINE HCL -phenazopyridine hcl powder........................................................................... 108 phenazopyridine hcl tab 100 mg (Pyridium)...............108 phenazopyridine hcl tab 200 mg (Pyridium)...............108 PHENELZINE SULFATE -phenelzine sulfate (bulk) powder........................................................................... 247 phenelzine sulfate tab 15 mg (Nardil)......................... 115 PHENERGAN -promethazine hcl inj 25 mg/ml................. 87 PHENERGAN -promethazine hcl inj 50 mg/ml................. 87 PHENINDIONE -phenindione (bulk) powder.................. 247 phenobarbital elixir 20 mg/5ml.................................... 124 PHENOBARBITAL -phenobarbital powder..................... 124 PHENOBARBITAL -phenobarbital tab 15 mg................. 124 PHENOBARBITAL -phenobarbital tab 30 mg................. 124 PHENOBARBITAL -phenobarbital tab 60 mg................. 124 PHENOBARBITAL -phenobarbital tab 100 mg............... 124 PHENOBARBITAL SODIUM -phenobarbital sodium inj 65 mg/ml............................................................................. 124 PHENOBARBITAL SODIUM -phenobarbital sodium inj 130 mg/ml..................................................................... 124 PHENOBARBITAL SODIUM -phenobarbital sodium powder........................................................................... 124 phenobarbital tab 16.2 mg............................................ 124 phenobarbital tab 32.4 mg............................................ 124 phenobarbital tab 64.8 mg............................................ 124 phenobarbital tab 97.2 mg............................................ 124 PHENOL -phenol crystals................................................218 PHENOL -phenol liquid (bulk)......................................... 218
PHENOLSULFONIC ACID -phenolsulfonic acid (bulk) liquid.............................................................................. 247 phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 75 PHENOXYBENZAMINE HCL -phenoxybenzamine hcl (bulk) powder................................................................ 247 PHENOXYETHANOL -phenoxyethanol (bulk) liquid...... 247 PHENTERMINE HYDROCHLORIDE -phentermine hcl (bulk) powder................................................................ 247 PHENTOLAMINE MESYLATE -phentolamine mesylate (bulk) powder................................................................ 247 PHENTOLAMINE MESYLATE -phentolamine mesylate for inj 5 mg......................................................................75 PHENYLBUTAZONE -phenylbutazone powder.............. 150 PHENYLEPHRINE/GUAIFENESIN -phenylephrineguaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml)........... 89 phenylephrine hcl ophth soln 2.5%............................. 192 phenylephrine hcl ophth soln 10%.............................. 192 PHENYLEPHRINE HCL -phenylephrine hcl crystals........ 88 PHENYLEPHRINE HCL -phenylephrine hcl inj 10 mg/ ml..................................................................................... 81 PHENYLEPHRINE HCL -phenylephrine hcl powder........ 88 phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml.......... 89 phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml............... 89 phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml............ 89 PHENYLETHYL ALCOHOL -phenylethyl alcohol (bulk) liquid.............................................................................. 247 PHENYLETHYLAMINE HCL -phenylethylamine hcl (bulk) powder........................................................................... 248 PHENYLMERCURIC ACETATE -phenylmercuric acetate powder........................................................................... 248 PHENYLMERCURIC NITRATE -phenylmercuric nitrate (bulk) powder................................................................ 248 PHENYLPROPANOLAMINE HYDRO phenylpropanolamine hcl powder.................................. 88 PHENYL SALICYLATE -phenyl salicylate crystals......... 247 PHENYLTOLOXAMINE DIHYDROG -phenyltoloxamine citrate (bulk) powder..................................................... 248 PHENYTEK -phenytoin sodium extended cap 200 mg.................................................................................. 162 PHENYTEK -phenytoin sodium extended cap 300 mg.................................................................................. 162 phenytoin chew tab 50 mg (Dilantin infatabs)............162 PHENYTOIN -phenytoin (bulk) powder........................... 248 phenytoin sodium extended cap 100 mg (Dilantin)....................................................................... 162 phenytoin sodium extended cap 200 mg (Phenytek).................................................................... 162 phenytoin sodium extended cap 300 mg (Phenytek).................................................................... 162 phenytoin sodium inj 50 mg/ml................................... 162 PHENYTOIN SODIUM -phenytoin sodium powder........ 162 phenytoin susp 125 mg/5ml (Dilantin)........................ 162 PHLAG SPRAY -dermatological products misc emulsion........................................................................ 211
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
365
2016 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met)............................................................... 49 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met)............................................................... 49 pioglitazone hcl tab 15 mg (base equiv) (Actos)..........49 pioglitazone hcl tab 30 mg (base equiv) (Actos)..........49 pioglitazone hcl tab 45 mg (base equiv) (Actos)..........49 PIPERINE -piperine (bulk) powder.................................. 248 PIRACETAM -piracetam (bulk) powder........................... 248 piroxicam cap 10 mg (Feldene)................................... 150 piroxicam cap 20 mg (Feldene)................................... 150 PIROXICAM -piroxicam powder...................................... 150 PITOCIN -oxytocin inj 10 unit/ml....................................... 55 PKU EASY MICROTABS -nutritional supplement tabs delayed release.............................................................179 PLACEBO #00 -placebo - cap........................................ 271 PLAN B ONE-STEP -levonorgestrel tab 1.5 mg............... 44 PLAQUENIL -hydroxychloroquine sulfate tab 200 mg...... 16 PLASTIBASE -plastibase ointment................................. 271 PLASTICIZED BASE -plastibase ointment..................... 271 PLAVIX -clopidogrel bisulfate tab 75 mg (base equiv)............................................................................. 188 PLAVIX -clopidogrel bisulfate tab 300 mg (base equiv)............................................................................. 188 PLEGISOL -cardioplegic soln............................................ 85 PLEGRIDY -peginterferon beta-1a soln pen-injector 125 mcg/0.5ml...................................................................... 133 PLEGRIDY -peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml.............................................................. 133 PLEGRIDY STARTER PACK -peginterferon beta-1a soln pen-inj 63 & 94 mcg/0.5ml pack.................................. 133 PLEGRIDY STARTER PACK -peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack................................. 134 PLEXION CLEANSER -sulfacetamide sodium w/ sulfur cleanser 9.8-4.8%......................................................... 211 PLEXION CLEANSING CLOTHS -sulfacetamide sodium w/ sulfur cleansing cloth 9.8-4.8%............................... 211 PLEXION -sulfacetamide sodium w/ sulfur cream 9.8-4.8%........................................................................ 211 PLEXION -sulfacetamide sodium w/ sulfur lotion 9.8-4.8%........................................................................ 211 PLIAGLIS -lidocaine-tetracaine cream 7-7%.................. 211 PLO20 BASE -premium lecithin organogel base gel...... 271 PLO GEL - MEDIFLO KIT -premium lecithin organogel base kit.......................................................................... 271 PLO GEL - MEDIFLO PRE-MIX -premium lecithin organogel base gel....................................................... 271 PLO TRANSDERMAL CREAM -transdermal base cream............................................................................. 271 PLURONIC F127 -pluronic f127 base gel 20%.............. 271 PLURONIC F127 -pluronic f127 base gel 30%.............. 271 PLURONIC F127 -poloxamer powder.............................271 PLURONIC L64 -poloxamer liquid.................................. 271 PLURONIC -poloxamer gel 20%..................................... 271 PLURONIC -poloxamer gel 30%..................................... 271
PHOSLYRA -calcium acetate (phosphate binder) oral soln 667 mg/5ml................................................................... 104 PHOSPHATIDYLCHOLINE -phosphatidylcholine (bulk) powder........................................................................... 248 PHOSPHATIDYLSERINE -soybean lecithin (bulk) powder 40%................................................................................248 PHOSPHOLINE IODIDE -echothiophate iodide ophth for soln 0.125%.................................................................. 192 PHOSPHORIC ACID -phosphoric acid soln 85%........... 248 PHYSICIANS EZ USE B-12 CO -cyanocobalamin inj kit 1000 mcg/ml................................................................. 184 PHYSICIANS EZ USE JOINT T -triamcinolone inj 40 mg/ ml & lidocaine 1% & ammonia inh kit............................ 35 PHYSICIANS EZ USE M-PRED -methylprednisolone ace 40 mg/ml & bupivacaine inj 0.5% kit.............................. 35 PHYSOSTIGMINE SALICYLATE -physostigmine salicylate inj 1 mg/ml.................................................... 219 PHYTIC ACID IN WATER -phytic acid (bulk) liquid 50%................................................................................248 PHYTOBASE -cream base.............................................. 270 phytonadione inj 1 mg/0.5ml (2 mg/ml).......................170 PHYTONADIONE -phytonadione (bulk) crystals............ 248 PHYTONADIONE -phytonadione (bulk) liquid................ 248 PICATO -ingenol mebutate gel 0.015%.......................... 211 PICATO -ingenol mebutate gel 0.05%............................ 211 PICO SINGLE USE NEGATIVE -wound dressings kit................................................................................... 211 pilocarpine hcl ophth soln 1% (Isopto carpine)......... 192 pilocarpine hcl ophth soln 2% (Isopto carpine)......... 192 pilocarpine hcl ophth soln 4% (Isopto carpine)......... 192 PILOCARPINE HCL -pilocarpine hydrochloride powder........................................................................... 248 pilocarpine hcl tab 5 mg (Salagen)..............................195 pilocarpine hcl tab 7.5 mg (Salagen)...........................195 PILOCARPINE NITRATE -pilocarpine nitrate (bulk) powder........................................................................... 248 PILOCARPINE NITRATE -pilocarpine nitrate crystals.......................................................................... 248 PIMOBENDAN -pimobendan (bulk) powder................... 248 pimozide tab 1 mg (Orap)............................................. 133 pimozide tab 2 mg (Orap)............................................. 133 PINA COLADA FLAVOR -flavoring agent - liquid........... 270 pindolol tab 5 mg............................................................. 63 pindolol tab 10 mg........................................................... 63 PINEAPPLE EXTRACT -pineapple extract (bulk) liquid.............................................................................. 248 PINEAPPLE FLAVOR -flavoring agent - liquid............... 270 PINE BARK EXTRACT -pine bark extract (bulk) powder 95%................................................................................248 PINE NEEDLE OIL -pine needle oil (bulk)...................... 248 PINENE (L-ALPHA) -l-alpha pinene (bulk) powder.........248 PINE OIL -pine oil............................................................ 248 PINE TAR -pine tar.......................................................... 248 pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)..... 49 pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)..... 49
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
366
2016 polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1% (Polytrim)...................................................... 192 POLYOX WSR-301 -bulk chemicals - powder................ 248 POLYOXYL 40 STEARATE -bulk chemicals - misc........ 248 POLYOXYL 40 STEARATE -polyoxyl 40 stearate pellet.............................................................................. 271 POLYOXYL 40 STEARATE -polyoxyl 40 stearate powder........................................................................... 271 POLYPEG SUPPOSITORY BASE -suppository base............................................................................... 271 POLYSORBATE 60 -polysorbate 60 liq.......................... 248 POLYSORBATE 80 -polysorbate 80 liq.......................... 248 POLYSORBATE 20 -polysorbate 20 soln....................... 248 POLYSORBATE 40 -polysorbate 40 soln....................... 248 POLYTRIM -polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%.................................................................. 192 POLY-VI-FLOR/IRON -ped multiple vitamin w/ fl-fe biphasic susp 0.25-7 mg/ml......................................... 173 POLY-VI-FLOR/IRON -ped multiple vit w/ fl-fe biphasic chew tab 0.5-10 mg...................................................... 173 POLY-VI-FLOR FS -pediatric multiple vitamins w/ fluoride oral strip 1 mg...............................................................173 POLY-VI-FLOR FS -pediatric multiple vit w/ fluoride oral strip 0.25 mg................................................................. 173 POLY-VI-FLOR FS -pediatric multiple vit w/ fluoride oral strip 0.5 mg................................................................... 173 POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic chew tab 0.25 mg................................................................... 172 POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic chew tab 0.5 mg..................................................................... 172 POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic chew tab 1 mg........................................................................ 172 POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic susp 0.25 mg/ml.................................................................... 173 POLYVINYL ALCOHOL -polyvinyl alcohol (bulk) powder........................................................................... 248 POLYVINYLPYRROLIDONE K-30 -povidone (bulk) powder........................................................................... 248 POLYVINYLPYRROLIDONE K-90 -povidone (bulk) powder........................................................................... 249 POMALYST -pomalidomide cap 1 mg.............................. 29 POMALYST -pomalidomide cap 2 mg.............................. 29 POMALYST -pomalidomide cap 3 mg.............................. 29 POMALYST -pomalidomide cap 4 mg.............................. 29 POMEGRANATE SEED -pomegranate seed (bulk) oil 80%................................................................................249 PONAZURIL -ponazuril (bulk) powder............................ 249 PONSTEL -mefenamic acid cap 250 mg........................ 150 pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml.......................................................................... 108 POTABA -potassium aminobenzoate cap 500 mg..........170 POTASH SULFURATED LUMP -potash, sulfurated lump............................................................................... 249 POTASSIUM ACETATE -potassium acetate (bulk) powder........................................................................... 249
PMX-1184 SILICONE -silicone (bulk) liquid.................... 248 PNEUMOVAX 23/1 DOSE -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml............................................ 21 PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml.................................................................. 21 POD-CARE 100C -betamethasone sod phos & acet inj kit 30 mg/5 ml (6 mg/ml)..................................................... 35 POD-CARE 100CMX -betameth na pho&ace inj 6 mg/ml & bupiv 0.5% & lido1% kit.............................................. 36 POD-CARE 100KMX -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 1% kit.......................................................... 36 POD-CARE 100K -triamcinolone acetonide inj kit 40 mg/ ml..................................................................................... 36 PODOCON 25 IN BENZOIN TIN -podophyllum resin soln 25%................................................................................211 PODOFILOX -podofilox (bulk) powder............................ 248 podofilox soln 0.5% (Condylox)................................... 211 PODOPHYLLUM RESIN -podophyllum resin powder........................................................................... 211 POLOXAMER 188 -poloxamer powder...........................271 POLOXAMER 407 -poloxamer powder...........................271 POLYETHYLENE GLYCOL 600 -bulk chemicals liquid.............................................................................. 248 POLYETHYLENE GLYCOL NF -polyethylene glycol 1450 powder........................................................................... 271 polyethylene glycol 3350 oral packet............................ 96 polyethylene glycol 3350 oral powder.......................... 96 POLYETHYLENE GLYCOL 3350 -polyethylene glycol 3350 (bulk) granules..................................................... 271 POLYETHYLENE GLYCOL 8000 -polyethylene glycol 8000 granules............................................................... 271 POLYETHYLENE GLYCOL 1450 -polyethylene glycol 1450 liquid..................................................................... 271 POLYETHYLENE GLYCOL 300 -polyethylene glycol 300 liquid.............................................................................. 271 POLYETHYLENE GLYCOL 400 -polyethylene glycol 400 liquid.............................................................................. 271 POLYETHYLENE GLYCOL 600 -polyethylene glycol 600 liquid.............................................................................. 271 POLYETHYLENE GLYCOL 8000 -polyethylene glycol 8000 oint....................................................................... 271 POLYETHYLENE GLYCOL 1450 -polyethylene glycol 1450 powder................................................................. 271 POLYETHYLENE GLYCOL 3350 -polyethylene glycol 3350 powder................................................................. 271 POLYETHYLENE GLYCOL 4500 -polyethylene glycol 4500 powder................................................................. 271 POLYETHYLENE GLYCOL 8000 -polyethylene glycol 8000 powder................................................................. 271 POLYHEXAMETHYLENE BIGUANI -polyaminopropyl biguanide (bulk) solution 20%...................................... 248 polymyxin b sulfate for inj 500000 unit......................... 18 POLYMYXIN B SULFATE -polymyxin b sulfate powder............................................................................. 18
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
367
2016 POTASSIUM HYDROXIDE -potassium hydroxide pellets............................................................................ 249 POTASSIUM HYDROXIDE -potassium hydroxide solution 5%.................................................................................. 249 POTASSIUM HYDROXIDE -potassium hydroxide solution 45%................................................................................249 POTASSIUM IODIDE -potassium iodide (bulk) crystals.......................................................................... 249 POTASSIUM IODIDE -potassium iodide (bulk) granules......................................................................... 249 POTASSIUM IODIDE -potassium iodide (bulk) powder........................................................................... 249 POTASSIUM METABISULFITE -potassium metabisulfite (bulk) crystals................................................................ 249 POTASSIUM METABISULFITE -potassium metabisulfite (bulk) powder................................................................ 249 POTASSIUM NITRATE -potassium nitrate crystals........ 249 POTASSIUM NITRATE -potassium nitrate powder.........249 POTASSIUM P-AMINOBENZOATE -potassium aminobenzoate powder................................................ 170 POTASSIUM PERCHLORATE -potassium perchlorate crystals.......................................................................... 249 POTASSIUM PERMANGANATE -potassium permanganate (bulk) granules..................................... 249 POTASSIUM PERMANGANATE -potassium permanganate crystals................................................. 218 POTASSIUM PHOSPHATE DIBAS -potassium phosphate dibasic granules............................................................ 249 POTASSIUM PHOSPHATE MONOB -potassium phosphate monobasic crystals..................................... 249 POTASSIUM SORBATE -potassium sorbate granules......................................................................... 271 POTASSIUM SORBATE -potassium sorbate powder..... 271 POTASSIUM SULFATE -potassium sulfate (bulk) powder........................................................................... 249 pot bicarbonate & chloride effer tab 25 meq.............. 176 pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-phos neutral)...............................176 POVIDONE-IODINE -povidone-iodine (bulk) flakes....... 250 POVIDONE-IODINE -povidone-iodine (bulk) powder..... 250 POVIDONE K-30 -povidone (bulk) powder..................... 250 POVIDONE -povidone (bulk) powder..............................249 POWDER SCENT FRAGRANCE -powder scent fragrance (bulk) liquid................................................... 250 PRADAXA -dabigatran etexilate mesylate cap 75 mg (etexilate base eq)........................................................ 186 PRADAXA -dabigatran etexilate mesylate cap 110 mg (etexilate base eq)........................................................ 186 PRADAXA -dabigatran etexilate mesylate cap 150 mg (etexilate base eq)........................................................ 186 PRALIDOXIME CHLORIDE -pralidoxime chloride (bulk) powder........................................................................... 250 PRALIDOXIME CHLORIDE -pralidoxime chloride im soln auto-injector 600 mg/2ml.............................................. 219
POTASSIUM ACETATE -potassium acetate crystals..... 249 POTASSIUM ACETATE -potassium acetate granules......................................................................... 249 POTASSIUM ASPARTATE -potassium aspartate (bulk) powder........................................................................... 249 POTASSIUM AZELAOYL DIGLYC -potassium azelaoyl diglycinate (bulk) liquid................................................. 249 potassium bicarbonate effer tab 25 meq.................... 176 POTASSIUM BICARBONATE -potassium bicarbonate granules......................................................................... 176 POTASSIUM BICARBONATE -potassium bicarbonate powder........................................................................... 176 POTASSIUM BITARTRATE -potassium bitartrate powder........................................................................... 249 POTASSIUM BROMIDE -potassium bromide crystals.......................................................................... 249 POTASSIUM BROMIDE -potassium bromide granules......................................................................... 249 POTASSIUM BROMIDE -potassium bromide powder........................................................................... 249 potassium chloride cap er 8 meq (Micro-k)................ 176 potassium chloride cap er 10 meq (Micro-k).............. 176 POTASSIUM CHLORIDE ER -potassium chloride tab er 8 meq (600 mg)............................................................... 176 POTASSIUM CHLORIDE ER -potassium chloride tab er 20 meq (1500 mg)........................................................ 176 potassium chloride microencapsulated crys er tab 10 meq............................................................................... 176 potassium chloride microencapsulated crys er tab 20 meq............................................................................... 176 potassium chloride oral soln 10% (20 meq/15ml)...... 176 POTASSIUM CHLORIDE -potassium chloride granules......................................................................... 176 POTASSIUM CHLORIDE -potassium chloride oral soln 20% (40 meq/15ml)...................................................... 176 POTASSIUM CHLORIDE -potassium chloride powder (for compounding)................................................................176 potassium chloride powder packet 20 meq............... 176 potassium chloride tab er 10 meq (K-tab).................. 176 potassium chloride tab er 8 meq (600 mg)................. 176 potassium citrate & citric acid powder pack 3300-1002 mg................................................................................. 108 potassium citrate & citric acid soln 1100-334 mg/5ml.......................................................................... 108 POTASSIUM CITRATE MONOHYD -potassium citrate granules......................................................................... 108 POTASSIUM CITRATE -potassium citrate powder......... 108 potassium citrate tab er 5 meq (540 mg) (Urocit-k 5).................................................................................... 108 potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10).................................................................................. 108 potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15).................................................................................. 108 POTASSIUM GLUCONATE ANHYD -potassium gluconate powder......................................................... 249
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
368
2016 PRECOSE -acarbose tab 25 mg...................................... 50 PRECOSE -acarbose tab 50 mg...................................... 50 PRECOSE -acarbose tab 100 mg.................................... 50 PRED FORTE -prednisolone acetate ophth susp 1%.................................................................................. 192 PRED-G -gentamicin-prednisolone ace ophth susp 0.3-1%........................................................................... 192 PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint 0.3-0.6%........................................................................ 192 PRED MILD -prednisolone acetate ophth susp 0.12%.............................................................................192 prednicarbate cream 0.1% (Dermatop)....................... 211 prednicarbate oint 0.1% (Dermatop)........................... 211 PREDNISOLONE/MOXIFLOXACIN -prednisolonemoxifloxacin-bromfenac opth sol 1-0.5-0.09%............. 193 PREDNISOLONE/MOXIFLOXACIN -prednisolonemoxifloxacin-ketorolac opth sol 1-0.5-0.5%................. 193 PREDNISOLONE/MOXIFLOXACIN -prednisolonemoxifloxacin opth soln 1-0.5%..................................... 193 prednisolone acetate ophth susp 1% (Pred forte)..... 192 PREDNISOLONE ACETATE -prednisolone acetate powder............................................................................. 36 PREDNISOLONE ANHYDROUS -prednisolone powder............................................................................. 36 PREDNISOLONE -prednisolone powder.......................... 36 PREDNISOLONE SODIUM PHOSP -prednisolone sodium phosphate ophth soln 1%................................ 193 PREDNISOLONE SODIUM PHOSP -prednisolone sodium phosphate oral soln 25 mg/5ml (base eq)......... 36 PREDNISOLONE SODIUM PHOSP -prednisolone sodium phosphate powder............................................. 36 prednisolone sod phos orally disintegr tab 10 mg (base eq) (Orapred odt)............................................... 36 prednisolone sod phos orally disintegr tab 15 mg (base eq) (Orapred odt)............................................... 36 prednisolone sod phos orally disintegr tab 30 mg (base eq) (Orapred odt)............................................... 36 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)................................................................... 36 prednisolone sod phosphate oral soln 10 mg/5ml (base equiv) (Millipred)................................................ 36 prednisolone sod phosphate oral soln 20 mg/5ml (base equiv) (Veripred 20)........................................... 36 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred)............................................36 prednisolone syrup 15 mg/5ml (usp solution equivalent) (Prelone).................................................... 36 PREDNISONE INTENSOL -prednisone conc 5 mg/ml..... 36 PREDNISONE -prednisone oral soln 5 mg/5ml................ 36 PREDNISONE -prednisone powder.................................. 36 PREDNISONE -prednisone tab 50 mg............................. 36 PREDNISONE -prednisone tab therapy pack 5 mg (21).................................................................................. 36 PREDNISONE -prednisone tab therapy pack 5 mg (48).................................................................................. 36
PRALINES AND CREAM FLAVOR -flavoring agent liquid.............................................................................. 271 PRALUENT -alirocumab subcutaneous soln pen-injector 75 mg/ml......................................................................... 83 PRALUENT -alirocumab subcutaneous soln pen-injector 150 mg/ml....................................................................... 83 pramipexole dihydrochloride tab er 24hr 0.375 mg (Mirapex er).................................................................. 165 pramipexole dihydrochloride tab er 24hr 0.75 mg (Mirapex er).................................................................. 165 pramipexole dihydrochloride tab er 24hr 1.5 mg (Mirapex er).................................................................. 165 pramipexole dihydrochloride tab er 24hr 2.25 mg (Mirapex er).................................................................. 165 pramipexole dihydrochloride tab er 24hr 3 mg (Mirapex er).................................................................. 165 pramipexole dihydrochloride tab er 24hr 3.75 mg (Mirapex er).................................................................. 165 pramipexole dihydrochloride tab er 24hr 4.5 mg (Mirapex er).................................................................. 166 pramipexole dihydrochloride tab 0.125 mg (Mirapex).......................................................................166 pramipexole dihydrochloride tab 0.25 mg (Mirapex).......................................................................166 pramipexole dihydrochloride tab 0.5 mg (Mirapex).......................................................................166 pramipexole dihydrochloride tab 0.75 mg (Mirapex).......................................................................166 pramipexole dihydrochloride tab 1 mg (Mirapex)...... 166 pramipexole dihydrochloride tab 1.5 mg (Mirapex).......................................................................166 PRAMOSONE E -pramoxine-hc emollient base cream 1-2.5%........................................................................... 211 PRAMOSONE -pramoxine-hc cream 1-1%.................... 211 PRAMOSONE -pramoxine-hc cream 1-2.5%................. 211 PRAMOSONE -pramoxine-hc lotion 1-1%...................... 211 PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 211 PRAMOSONE -pramoxine-hc oint 1-1%.........................211 PRAMOSONE -pramoxine-hc oint 1-2.5%......................211 pramoxine-hc cream 1-2.5% (Pramosone)................. 211 PRAMOXINE HCL -pramoxine hcl powder..................... 211 PRANDIN -repaglinide tab 1 mg....................................... 49 PRANDIN -repaglinide tab 2 mg....................................... 50 prasugrel hcl tab 5 mg (base equiv) (Effient)............. 188 prasugrel hcl tab 10 mg (base equiv) (Effient)........... 188 pravastatin sodium tab 10 mg....................................... 83 pravastatin sodium tab 20 mg (Pravachol)...................83 pravastatin sodium tab 40 mg (Pravachol)...................83 pravastatin sodium tab 80 mg (Pravachol)...................83 PRAZIQUANTEL -praziquantel (bulk) powder................ 250 prazosin hcl cap 1 mg (Minipress)................................ 75 prazosin hcl cap 2 mg (Minipress)................................ 75 prazosin hcl cap 5 mg (Minipress)................................ 75 PRAZOSIN HCL -prazosin hcl powder............................. 75 PRAZOSIN HYDROCHLORIDE -prazosin hcl powder..... 75
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
369
2016 PRESET 3ML SYR/PREFILL LY -arterial blood gas kit................................................................................... 220 PRESTALIA -perindopril arginine-amlodipine besylate tab 3.5-2.5 mg....................................................................... 76 PRESTALIA -perindopril arginine-amlodipine besylate tab 7-5 mg............................................................................. 76 PRESTALIA -perindopril arginine-amlodipine besylate tab 14-10 mg......................................................................... 76 PREVIDENT 5000 BOOSTER PL -sodium fluoride paste 1.1%...............................................................................195 PREVIDENT 5000 BOOSTER -sodium fluoride paste 1.1%...............................................................................195 PREVIDENT 5000 DRY MOUTH -sodium fluoride gel 1.1% (0.5% f)................................................................ 196 PREVIDENT 5000 ENAMEL PRO -sodium fluoridepotassium nitrate paste 1.1-5%................................... 196 PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5% f)..................................................................................... 195 PREVIDENT 5000 PLUS -sodium fluoride cream 1.1%...............................................................................196 PREVIDENT 5000 SENSITIVE -sodium fluoridepotassium nitrate paste 1.1-5%................................... 196 PREVNAR 13 -pneumococcal 13-valent conjugate vaccine inj....................................................................... 21 PREVPAC -amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack................................................................... 99 PREZCOBIX -darunavir-cobicistat tab 800-150 mg..........13 PREZISTA -darunavir ethanolate susp 100 mg/ml (base equiv)............................................................................... 13 PREZISTA -darunavir ethanolate tab 75 mg (base equiv)............................................................................... 13 PREZISTA -darunavir ethanolate tab 150 mg (base equiv)............................................................................... 13 PREZISTA -darunavir ethanolate tab 600 mg (base equiv)............................................................................... 13 PREZISTA -darunavir ethanolate tab 800 mg (base equiv)............................................................................... 13 PRIALT -ziconotide acetate intrathecal inj 100 mcg/ ml................................................................................... 136 PRIALT -ziconotide acetate intrathecal inj 500 mcg/5ml......................................................................... 136 PRIALT -ziconotide acetate intrathecal inj 500 mcg/20ml (25 mcg/ml)................................................................... 136 PRIFTIN -rifapentine tab 150 mg........................................ 9 PRILOCAINE HCL -prilocaine hcl (bulk) powder............ 250 PRILOCAINE HCL -prilocaine hcl powder...................... 156 PRILOCAINE -prilocaine (bulk) powder.......................... 250 PRIMAQUINE PHOSPHATE -primaquine phosphate tab 26.3 mg........................................................................... 16 PRIMIDONE -primidone (bulk) powder........................... 250 primidone tab 50 mg (Mysoline).................................. 162 primidone tab 250 mg (Mysoline)................................ 162 PRIMLEV -oxycodone w/ acetaminophen tab 5-300 mg.................................................................................. 145
PREDNISONE -prednisone tab therapy pack 10 mg (21).................................................................................. 36 PREDNISONE -prednisone tab therapy pack 10 mg (48).................................................................................. 36 prednisone tab 1 mg....................................................... 36 prednisone tab 2.5 mg.................................................... 36 prednisone tab 5 mg....................................................... 36 prednisone tab 10 mg..................................................... 36 prednisone tab 20 mg..................................................... 36 PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate tab 1-0.09mg(15)............................................................ 41 PRE-FOLIC -folic acid-vitamin c tab 1-100 mg............... 184 PREGABALIN -pregabalin (bulk) powder....................... 250 PREGNENOLONE MICRONIZED -pregnenolone (micronized) powder..................................................... 250 PREGNENOLONE -pregnenolone powder..................... 250 PREGNYL W/DILUENT BENZYL -chorionic gonadotropin for inj 10000 unit............................................................. 58 PREMARIN -estrogens, conjugated for inj 25 mg............ 41 PREMARIN -estrogens, conjugated tab 0.3 mg............... 41 PREMARIN -estrogens, conjugated tab 0.45 mg............. 41 PREMARIN -estrogens, conjugated tab 0.625 mg........... 41 PREMARIN -estrogens, conjugated tab 0.9 mg............... 41 PREMARIN -estrogens, conjugated tab 1.25 mg............. 41 PREMARIN -estrogens, conjugated vaginal cream 0.625 mg/gm............................................................................ 107 PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac tab 0.625-5mg(14).......................................................... 41 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg................................................... 41 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.45-1.5 mg................................................. 41 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.625-2.5 mg............................................... 41 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.625-5 mg.................................................. 41 PRENATABS RX -prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................. 173 PRENATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg.................................................................................. 173 PRENATAL 19 -prenatal vit w/ fe fumarate-fa chew tab 29-1 mg......................................................................... 173 PRENATAL-U -prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg.................................................................... 173 PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm............55 PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10 mg-3.5 gm-12 gm........................................................... 96 PRESERA -dermatological products, misc. - aerosol foam............................................................................... 211 PRESET 3ML LL SYR/PREFILL -arterial blood gas kit................................................................................... 220 PRESET 1ML LS SYR/PREFILL -arterial blood gas kit................................................................................... 220 PRESET 3ML SYR/PREFILLED -arterial blood gas kit................................................................................... 220
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
370
2016 PROCRIT -epoetin alfa inj 3000 unit/ml.......................... 184 PROCRIT -epoetin alfa inj 4000 unit/ml.......................... 184 PROCRIT -epoetin alfa inj 10000 unit/ml........................ 184 PROCRIT -epoetin alfa inj 20000 unit/ml........................ 184 PROCRIT -epoetin alfa inj 40000 unit/ml........................ 184 PROCTOCORT -hydrocortisone acetate suppos 30 mg.................................................................................. 197 PROCTOCORT -hydrocortisone rectal cream 1%.......... 197 PROCTOFOAM HC -hydrocortisone acetate w/ pramoxine rectal foam 1-1%........................................ 197 PRODRIN -acetaminophen-isometheptene-caffeine tab 325-65-20 mg................................................................152 PROFERRIN-FORTE -iron heme polypeptide-folic acid tab 12-1 mg (fe equiv).................................................. 184 PROFLAVINE HEMISULFATE -proflavine hemisulfate (bulk) powder................................................................ 250 PROGESTERONE CONCENTRATE -progesterone (bulk) cream 40%.................................................................... 250 progesterone im in oil 50 mg/ml.................................... 45 PROGESTERONE 10% KIT -progesterone micronized td cream 10% (cmpd kit).................................................... 45 progesterone micronized cap 100 mg (Prometrium).................................................................. 45 progesterone micronized cap 200 mg (Prometrium).................................................................. 45 PROGESTERONE MICRONIZED P -progesterone micronized (bulk) powder............................................. 250 PROGESTERONE MICRONIZED -progesterone micronized (bulk) powder............................................. 250 PROGESTERONE MICRONIZED ( -progesterone micronized (bulk) powder............................................. 250 PROGESTERONE MICRONIZED -progesterone micronized powder.......................................................... 45 PROGESTERONE MILLED -progesterone (bulk) powder........................................................................... 250 PROGESTERONE MILLED -progesterone powder......... 45 PROGESTERONE -progesterone (bulk) powder........... 250 PROGESTERONE ULTRA MICRON -progesterone micronized (bulk) powder............................................. 250 PROGESTERONE WETTABLE -progesterone (bulk) powder........................................................................... 250 PROGESTERONE WETTABLE -progesterone powder............................................................................. 45 PROGESTERONE WETTABLE (YA -progesterone (bulk) powder........................................................................... 250 PROGLYCEM -diazoxide susp 50 mg/ml......................... 50 PROGRAF -tacrolimus cap 0.5 mg................................. 276 PROGRAF -tacrolimus cap 1 mg.................................... 276 PROGRAF -tacrolimus cap 5 mg.................................... 276 PROLENSA -bromfenac sodium ophth soln 0.07% (base equivalent)..................................................................... 193 PROLIA -denosumab inj 60 mg/ml................................... 58 PROMACTA -eltrombopag olamine tab 12.5 mg (base equiv)............................................................................. 184
PRIMLEV -oxycodone w/ acetaminophen tab 7.5-300 mg.................................................................................. 145 PRIMLEV -oxycodone w/ acetaminophen tab 10-300 mg.................................................................................. 145 PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base equiv)............................................................................... 18 PRINIVIL -lisinopril tab 5 mg............................................. 76 PRINIVIL -lisinopril tab 10 mg........................................... 76 PRINIVIL -lisinopril tab 20 mg........................................... 76 PRISTIQ -desvenlafaxine succinate tab er 24hr 25 mg (base equiv).................................................................. 115 PRISTIQ -desvenlafaxine succinate tab er 24hr 50 mg (base equiv).................................................................. 115 PRISTIQ -desvenlafaxine succinate tab er 24hr 100 mg (base equiv).................................................................. 115 PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)........................................................ 93 PROAIR RESPICLICK -albuterol sulfate aer pow ba 108 mcg/act (90 mcg base equiv)......................................... 93 probenecid tab 500 mg................................................. 153 PROBUPHINE IMPLANT KIT -buprenorphine hcl subdermal implant 74.2 mg (base equiv).....................145 PROCAINAMIDE HCL -procainamide hcl inj 100 mg/ ml..................................................................................... 68 PROCAINAMIDE HCL -procainamide hcl inj 500 mg/ ml..................................................................................... 68 PROCAINAMIDE HCL -procainamide hcl powder............ 68 PROCAINE HCL -procaine hcl crystals.......................... 156 PROCARBAZINE HCL -procarbazine hcl (bulk) powder........................................................................... 250 PROCARDIA -nifedipine cap 10 mg................................. 66 PROCARDIA XL -nifedipine tab er 24hr osmotic release 30 mg.............................................................................. 66 PROCARDIA XL -nifedipine tab er 24hr osmotic release 60 mg.............................................................................. 66 PROCARDIA XL -nifedipine tab er 24hr osmotic release 90 mg.............................................................................. 66 PRO-C-DURE 5 KIT -triamcinolone acetonide inj kit 2 x 40 mg/ml......................................................................... 36 PRO-C-DURE 6 KIT -triamcinolone acetonide inj kit 3 x 40 mg/ml......................................................................... 36 PROCENTRA -dextroamphetamine sulfate oral solution 5 mg/5ml........................................................................... 129 prochlorperazine edisylate inj 5 mg/ml....................... 120 PROCHLORPERAZINE EDISYLAT -prochlorperazine edisylate (bulk) powder................................................ 250 PROCHLORPERAZINE MALEATE -prochlorperazine maleate powder............................................................ 120 prochlorperazine maleate tab 5 mg (Compazine)...... 120 prochlorperazine maleate tab 10 mg (Compazine)................................................................. 120 prochlorperazine suppos 25 mg.................................. 120 PROCORT -hydrocortisone acetate w/ pramoxine rectal cream 1.85-1.15%........................................................ 197 PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 184
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
371
2016 propranolol hcl cap er 24hr 160 mg (Inderal la)........... 63 PROPRANOLOL HCL -propranolol hcl oral soln 20 mg/5ml............................................................................. 63 PROPRANOLOL HCL -propranolol hcl oral soln 40 mg/5ml............................................................................. 63 PROPRANOLOL HCL -propranolol hcl powder................ 63 propranolol hcl tab 10 mg.............................................. 63 propranolol hcl tab 20 mg.............................................. 63 propranolol hcl tab 40 mg.............................................. 63 propranolol hcl tab 60 mg.............................................. 63 propranolol hcl tab 80 mg.............................................. 63 PROPYLENE GLYCOL MONOSTEA -propylene glycol monostearate (bulk) beads...........................................251 PROPYLENE GLYCOL -propylene glycol.......................271 PROPYLENE GLYCOL -propylene glycol liquid............. 250 PROPYL GALLATE -propyl gallate (bulk) powder.......... 250 PROPYLPARABEN -propylparaben powder................... 272 PROPYLTHIOURACIL -propylthiouracil (bulk) powder........................................................................... 251 propylthiouracil tab 50 mg............................................. 53 PROQUAD -measles-mumps-rubella-varicella virus vaccines for inj................................................................ 22 PROSCAR -finasteride tab 5 mg.................................... 108 PROSTAGLANDIN E2 -dinoprostone (bulk) powder...... 251 PROSTIN E2 -dinoprostone vaginal suppos 20 mg......... 55 PROSTIN VR PEDIATRIC -alprostadil inj 500 mcg/ ml................................................................................... 276 PROTAMINE SULFATE -protamine sulfate (bulk) powder........................................................................... 251 PROTECTIRON -iron polysacch-fa-b complex-vit c-e & minerals tab 60-1 mg................................................... 184 PROTECT PLUS -multiple vitamins w/ minerals cap......173 PROTHELIAL -sucralfate-malate paste 10%.................. 196 PROTIRELIN -protirelin (bulk) powder............................ 251 PROTONIX -pantoprazole sodium for delayed release susp packet 40 mg......................................................... 99 PROTOPIC -tacrolimus oint 0.03%................................. 211 PROTOPIC -tacrolimus oint 0.1%................................... 211 protriptyline hcl tab 5 mg (Vivactil)............................. 115 protriptyline hcl tab 10 mg (Vivactil)........................... 115 PROVENTIL HFA -albuterol sulfate inhal aero 108 mcg/ act (90mcg base equiv).................................................. 93 PROVERA -medroxyprogesterone acetate tab 2.5 mg.................................................................................... 45 PROVERA -medroxyprogesterone acetate tab 5 mg....... 45 PROVERA -medroxyprogesterone acetate tab 10 mg..... 45 PROVIGIL -modafinil tab 100 mg................................... 129 PROVIGIL -modafinil tab 200 mg................................... 129 PROVISC -sodium hyaluronate intraocular inj 10 mg/ ml................................................................................... 193 PROZAC -fluoxetine hcl cap 10 mg................................ 115 PROZAC -fluoxetine hcl cap 20 mg................................ 115 PROZAC -fluoxetine hcl cap 40 mg................................ 115 PRUCLAIR -dermatological products misc - cream........ 211 PRUMYX -dermatological products misc - cream...........211
PROMACTA -eltrombopag olamine tab 25 mg (base equiv)............................................................................. 184 PROMACTA -eltrombopag olamine tab 50 mg (base equiv)............................................................................. 184 PROMACTA -eltrombopag olamine tab 75 mg (base equiv)............................................................................. 184 PROMACTIN AA PLUS -nutritional supplement liquid.............................................................................. 179 PROMACTIN AA PLUS 20PE -nutritional supplement susp............................................................................... 179 PROMAZINE HCL -promazine hcl (bulk) powder........... 250 promethazine & phenylephrine syrup 6.25-5 mg/5ml............................................................................ 89 promethazine-dm syrup 6.25-15 mg/5ml.......................89 promethazine hcl inj 25 mg/ml (Phenergan).................87 promethazine hcl inj 50 mg/ml (Phenergan).................87 PROMETHAZINE HCL -promethazine hcl (bulk) powder........................................................................... 250 PROMETHAZINE HCL -promethazine hcl powder........... 87 promethazine hcl suppos 12.5 mg................................ 87 promethazine hcl suppos 25 mg................................... 87 promethazine hcl suppos 50 mg................................... 87 promethazine hcl syrup 6.25 mg/5ml............................ 87 promethazine hcl tab 12.5 mg........................................ 87 promethazine hcl tab 25 mg........................................... 87 promethazine hcl tab 50 mg........................................... 87 promethazine-phenylephrine-codeine syrup 6.25-5-10 mg/5ml............................................................................ 89 promethazine w/ codeine syrup 6.25-10 mg/5ml..........89 PROMETRIUM -progesterone micronized cap 100 mg.................................................................................... 45 PROMETRIUM -progesterone micronized cap 200 mg.................................................................................... 45 PROMISEB -antiseborrheic products misc - cream........ 211 propafenone hcl cap er 12hr 225 mg (Rythmol sr)...... 68 propafenone hcl cap er 12hr 325 mg (Rythmol sr)...... 68 propafenone hcl cap er 12hr 425 mg (Rythmol sr)...... 68 propafenone hcl tab 300 mg.......................................... 68 propafenone hcl tab 150 mg (Rythmol)........................ 68 propafenone hcl tab 225 mg (Rythmol)........................ 68 PROPANEDIOL -propanediol (bulk) liquid...................... 250 PROPANTHELINE BROMIDE -propantheline bromide powder............................................................................. 99 PROPANTHELINE BROMIDE -propantheline bromide tab 15 mg.............................................................................. 99 proparacaine hcl ophth soln 0.5% (Alcaine).............. 193 PROPARACAINE HCL -proparacaine hcl (bulk) powder........................................................................... 250 PROPRANOLOL/HYDROCHLOROTH -propranolol & hydrochlorothiazide tab 40-25 mg.................................. 76 PROPRANOLOL/HYDROCHLOROTH -propranolol & hydrochlorothiazide tab 80-25 mg.................................. 76 propranolol hcl cap er 24hr 60 mg (Inderal la)............. 63 propranolol hcl cap er 24hr 80 mg (Inderal la)............. 63 propranolol hcl cap er 24hr 120 mg (Inderal la)........... 63
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
372
2016 Q-CARE Q2 ORAL CLEANSING/ -oral hygiene products kit................................................................................... 261 Q-CARE Q4 ORAL CLEANSING/ -oral hygiene products kit................................................................................... 261 QUADRACEL -diph-tetanus tox ad-acell pert & polio virus, ipv vac inj.............................................................. 22 QUALAQUIN -quinine sulfate cap 324 mg........................16 QUARTETTE -levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg...................................................... 44 QUATERNIUM-15 -quaternium-15 (bulk) powder........... 251 QUAZEPAM -quazepam tab 15 mg................................ 124 QUDEXY XR -topiramate cap er 24hr sprinkle 25 mg.................................................................................. 162 QUDEXY XR -topiramate cap er 24hr sprinkle 50 mg.................................................................................. 162 QUDEXY XR -topiramate cap er 24hr sprinkle 100 mg.................................................................................. 162 QUDEXY XR -topiramate cap er 24hr sprinkle 150 mg.................................................................................. 162 QUDEXY XR -topiramate cap er 24hr sprinkle 200 mg.................................................................................. 162 QUELICIN -succinylcholine chloride inj 20 mg/ml...........167 QUERCETIN DIHYDRATE -quercetin dihydrate (bulk) powder........................................................................... 251 QUESTRAN -cholestyramine powder 4 gm/dose............. 83 QUESTRAN -cholestyramine powder packets 4 gm........ 83 QUESTRAN LIGHT -cholestyramine light powder 4 gm/ dose................................................................................. 83 quetiapine fumarate tab er 24hr 50 mg (Seroquel xr).................................................................................. 120 quetiapine fumarate tab er 24hr 150 mg (Seroquel xr).................................................................................. 120 quetiapine fumarate tab er 24hr 200 mg (Seroquel xr).................................................................................. 120 quetiapine fumarate tab er 24hr 300 mg (Seroquel xr).................................................................................. 120 quetiapine fumarate tab er 24hr 400 mg (Seroquel xr).................................................................................. 120 quetiapine fumarate tab 25 mg (Seroquel)................. 120 quetiapine fumarate tab 50 mg (Seroquel)................. 120 quetiapine fumarate tab 100 mg (Seroquel)............... 120 quetiapine fumarate tab 200 mg (Seroquel)............... 120 quetiapine fumarate tab 300 mg (Seroquel)............... 120 quetiapine fumarate tab 400 mg (Seroquel)............... 120 QUFLORA FE -multi vit w/ min & fluoride-iron-fa chew tab 0.25 mg......................................................................... 173 QUFLORA FE PEDIATRIC -pediatric multiple vitamins w/ fl-fe drops 0.25-9.5 mg/ml............................................ 173 QUFLORA PEDIATRIC -pediatric multiple vitamins w/ fluoride chew tab 0.25 mg............................................ 173 QUFLORA PEDIATRIC -pediatric multiple vitamins w/ fluoride chew tab 0.5 mg.............................................. 173 QUFLORA PEDIATRIC -pediatric multiple vitamins w/ fluoride chew tab 1 mg................................................. 173
PRUTECT -wound dressings - emulsion........................ 211 pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml (Zutripro).......................................................... 89 pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml............................................................................ 89 PSEUDOEPHEDRINE HCL -pseudoephedrine hcl powder............................................................................. 88 P-SILOXAN DS -cream base.......................................... 269 PSORCON -diflorasone diacetate cream 0.05%............ 211 PSYLLIUM HUSK -psyllium husk (bulk) powder.............251 PULLULAN -pullulan (bulk) powder................................ 251 PULMICORT -budesonide inhalation susp 0.25 mg/2ml............................................................................. 93 PULMICORT -budesonide inhalation susp 0.5 mg/2ml............................................................................. 93 PULMICORT -budesonide inhalation susp 1 mg/2ml....... 93 PULMICORT FLEXHALER -budesonide inhal aero powd 90 mcg/act (breath activated).........................................93 PULMICORT FLEXHALER -budesonide inhal aero powd 180 mcg/act (breath activated)...................................... 93 PULMOZYME -dornase alfa inhal soln 1 mg/ml............... 95 PUMICE (FLOUR) -pumice stone powder...................... 251 PUMPKIN FLAVOR -flavoring agent - liquid................... 272 PUREFE PLUS -ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg.................................................... 184 PURIFIED WATER -distilled water.................................. 272 PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/ ml).................................................................................... 29 PYLERA -bismuth subcit-metronidazole-tetracycline cap 140-125-125 mg..............................................................99 PYRANTEL PAMOATE -pyrantel pamoate (bulk) powder........................................................................... 251 PYRAZINAMIDE -pyrazinamide (bulk) powder............... 251 pyrazinamide tab 500 mg..................................................9 PYRIDIUM -phenazopyridine hcl tab 100 mg................. 108 PYRIDIUM -phenazopyridine hcl tab 200 mg................. 108 PYRIDOSTIGMINE BROMIDE -pyridostigmine bromide (bulk) powder................................................................ 251 pyridostigmine bromide tab er 180 mg (Mestinon timespan)......................................................................170 pyridostigmine bromide tab 60 mg (Mestinon).......... 170 PYRIDOXAL-5-PHOSPHATE MON -pyridoxal-5 phosphate (bulk) powder.............................................. 251 pyridoxine hcl inj 100 mg/ml........................................ 170 PYRIDOXINE HCL -pyridoxine hcl powder.....................170 PYRILAMINE MALEATE -pyrilamine maleate crystals..... 87 PYRILAMINE MALEATE -pyrilamine maleate powder..... 87 PYRIMETHAMINE -pyrimethamine (bulk) powder......... 251 PYROGALLIC ACID -pyrogallol-chlorobutanol oint 25-2%............................................................................ 211 PYROGALLOL -pyrogallol crystals................................. 251 PYRUVIC ACID -pyruvic acid liquid................................ 251 PYRUVIC ACID -pyruvic acid powder............................ 251 Q QBRELIS -lisinopril oral soln 1 mg/ml............................... 76
SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
373
2016 RAGWITEK -short ragweed pollen allergen extract tab sl 12 amb a 1-u.................................................................. 24 raloxifene hcl tab 60 mg (Evista)................................... 58 ramipril cap 1.25 mg (Altace)......................................... 76 ramipril cap 2.5 mg (Altace)........................................... 76 ramipril cap 5 mg (Altace).............................................. 76 ramipril cap 10 mg (Altace)............................................ 76 RANEXA -ranolazine tab er 12hr 500 mg......................... 61 RANEXA -ranolazine tab er 12hr 1000 mg....................... 61 ranitidine hcl cap 150 mg............................................... 99 ranitidine hcl cap 300 mg............................................... 99 ranitidine hcl inj 50 mg/2ml (25 mg/ml) (Zantac).......... 99 ranitidine hcl inj 150 mg/6ml (25 mg/ml) (Zantac)........ 99 RANITIDINE HCL -ranitidine hcl (bulk) powder.............. 251 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 99 ranitidine hcl tab 150 mg (Zantac)................................. 99 ranitidine hcl tab 300 mg (Zantac)................................. 99 RAPAFLO -silodosin cap 4 mg........................................108 RAPAFLO -silodosin cap 8 mg........................................108 RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 276 RAPAMUNE -sirolimus tab 0.5 mg..................................276 RAPAMUNE -sirolimus tab 1 mg.....................................276 RAPAMUNE -sirolimus tab 2 mg.....................................277 RAPESEED OIL -rapeseed oil (bulk).............................. 251 RAPLIXA -fibrinogen-thrombin powder 79-699 mg-unit/ gm.................................................................................. 187 RAPPORT RING LOADING SYST -impotence aid device - kit.................................................................................261 RAPPORT VACUUM THERAPY DE -impotence aid device - kit.....................................................................261 RASAGILINE MESYLATE -rasagiline mesylate (bulk) powder........................................................................... 251 rasagiline mesylate tab 0.5 mg (base equiv) (Azilect).........................................................................166 rasagiline mesylate tab 1 mg (base equiv) (Azilect).........................................................................166 RASPBERRY CONCENTRATE -flavoring agent concentrate.................................................................... 272 RASPBERRY FLAVOR -flavoring agent - liquid............. 272 RASPBERRY FLAVOR -flavoring agent - powder.......... 272 RASPBERRY SYRUP -raspberry syrup......................... 272 RASUVO -methotrexate soln pf auto-injector 7.5 mg/0.15ml...................................................................... 150 RASUVO -methotrexate soln pf auto-injector 10 mg/0.2ml........................................................................ 150 RASUVO -methotrexate soln pf auto-injector 12.5 mg/0.25ml...................................................................... 150 RASUVO -methotrexate soln pf auto-injector 15 mg/0.3ml........................................................................ 150 RASUVO -methotrexate soln pf auto-injector 17.5 mg/0.35ml...................................................................... 150 RASUVO -methotrexate soln pf auto-injector 20 mg/0.4ml........................................................................ 150 RASUVO -methotrexate soln pf auto-injector 22.5 mg/0.45ml...................................................................... 150
QUFLORA PEDIATRIC -pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml............................................... 173 QUFLORA PEDIATRIC -pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml................................................. 173 QUILLICHEW ER -methylphenidate hcl chew tab extended release 20 mg...............................................129 QUILLICHEW ER -methylphenidate hcl chew tab extended release 30 mg...............................................129 QUILLICHEW ER -methylphenidate hcl chew tab extended release 40 mg...............................................129 QUILLIVANT XR -methylphenidate hcl for er susp 25 mg/5ml (5 mg/ml)..........................................................129 QUINACRINE HCL -quinacrine hcl powder...................... 16 quinapril hcl tab 5 mg (Accupril)................................... 76 quinapril hcl tab 10 mg (Accupril)................................. 76 quinapril hcl tab 20 mg (Accupril)................................. 76 quinapril hcl tab 40 mg (Accupril)................................. 76 quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic)...................................................................... 76 quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic)...................................................................... 76 quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic)...................................................................... 76 QUINIDINE GLUCONATE -quinidine gluconate inj 80 mg/ ml..................................................................................... 68 quinidine gluconate tab er 324 mg................................ 68 QUINIDINE SULFATE DIHYDRA -quinidine sulfate crystals.......................................................................... 251 QUINIDINE SULFATE -quinidine sulfate (bulk) powder........................................................................... 251 QUINIDINE SULFATE -quinidine sulfate tab 200 mg....... 68 QUINIDINE SULFATE -quinidine sulfate tab 300 mg....... 68 QUININE HCL -quinine hcl dihydrate crystals................ 251 quinine sulfate cap 324 mg (Qualaquin)....................... 16 QUININE SULFATE DIHYDRATE -quinine sulfate powder............................................................................. 16 QUININE SULFATE -quinine sulfate powder.................... 16 QUINIZARIN GREEN SS -dc green 6 (quinizarin green ss) powder.....................................................................272 QUINJA -iodoquinol-aloe polysaccharides gel 1.25-1%......................................................................... 211 QUINZYME -coenzyme q10 tab disint 90 mg................. 220 QVAR -beclomethasone diprop inhal aero soln 40 mcg/act (50/valve)......................................................................... 93 QVAR -beclomethasone diprop inhal aero soln 80 mcg/act (100/valve)....................................................................... 93 R RABAVERT -rabies vaccine, pcec for inj.......................... 22 rabeprazole sodium ec tab 20 mg (Aciphex)................ 99 RACEPINEPHRINE HCL -racepinephrine hcl (bulk) powder........................................................................... 251 RADIAGEL -wound dressings - gel................................. 211 RADIAPLEXRX -wound dressings - gel.......................... 211 RADIOGARDASE -prussian blue insoluble cap 0.5 gm.................................................................................. 219
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
374
2016 RASUVO -methotrexate soln pf auto-injector 25 mg/0.5ml........................................................................ 150 RASUVO -methotrexate soln pf auto-injector 30 mg/0.6ml........................................................................ 150 RAUWOLFIA SERPENTINA -rauwolfia serpentina (bulk) powder........................................................................... 251 RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml...........58 RAZADYNE ER -galantamine hydrobromide cap er 24hr 8 mg.............................................................................. 134 RAZADYNE ER -galantamine hydrobromide cap er 24hr 16 mg............................................................................ 134 RAZADYNE ER -galantamine hydrobromide cap er 24hr 24 mg............................................................................ 134 RAZADYNE -galantamine hydrobromide tab 4 mg.........134 RAZADYNE -galantamine hydrobromide tab 8 mg.........134 RAZADYNE -galantamine hydrobromide tab 12 mg.......134 RDT-PLUS -pharmaceutical excipients (bulk) powder........................................................................... 272 READYSHARP-A -lidocaine hcl inj 1% & bupivacaine hcl inj 0.5% kit.................................................................... 156 READYSHARP ANESTHETICS + -betameth na pho&ace inj 6 mg/ml & bupiv 0.5% & lido1% kit........................... 36 READYSHARP ANESTHETICS + -dexamethasone inj 10 mg/ml & bupiv 0.5% & lido 1% kit..................................36 READYSHARP ANESTHETICS + -ketorolac inj 15 mg/ml & bupivacaine 0.5% & lido 1% kit................................ 150 READYSHARP ANESTHETICS + -methylprednisolone inj 80 mg/ml & bupiv 0.5% &lido 1% kit.............................. 37 READYSHARP BETAMETHASONE -betamethasone sod phos & acet inj kit 30 mg/5 ml (6 mg/ml)....................... 37 READYSHARP BUPIVACAINE -bupivacaine hcl preservative free (pf) inj kit 0.5%................................. 156 READYSHARP DEXAMETHASONE -dexamethasone sodium phosphate inj 10 mg/ml kit................................ 37 READYSHARP KETOROLAC -ketorolac tromethamine inj 15 mg/ml kit.................................................................. 150 READYSHARP-K -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 1% kit.......................................................... 37 READYSHARP LIDOCAINE -lidocaine hcl local inj kit 1%.................................................................................. 156 READYSHARP METHYLPREDNISO methylprednisolone acetate inj susp 80 mg/ml kit......... 37 READYSHARP TRIAMCINOLONE -triamcinolone acetonide inj kit 40 mg/ml.............................................. 37 REBETOL -ribavirin cap 200 mg....................................... 13 REBETOL -ribavirin soln 40 mg/ml................................... 13 REBIF -interferon beta-1a soln pref syr 22 mcg/0.5ml (12mu/ml)...................................................................... 134 REBIF -interferon beta-1a soln pref syr 44 mcg/0.5ml (24mu/ml)...................................................................... 134 REBIF REBIDOSE -interferon beta-1a soln auto-inj 22 mcg/0.5ml (12mu/ml).................................................... 134 REBIF REBIDOSE -interferon beta-1a soln auto-inj 44 mcg/0.5ml (24mu/ml).................................................... 134
REBIF REBIDOSE TITRATION -interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml........................ 134 REBIF TITRATION PACK -interferon beta-1a pref syr 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................. 134 RECEDO -scar treatment products - gel.........................212 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml........................................................... 22 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 10 mcg/ml.............................................................. 22 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 40 mcg/ml.............................................................. 22 RECOTHROM SPRAY KIT -thrombin (recombinant) for soln 20000 unit............................................................. 187 RECOTHROM -thrombin (recombinant) for soln 5000 unit................................................................................. 187 RECOTHROM -thrombin (recombinant) for soln 20000 unit................................................................................. 187 RECTIV -nitroglycerin oint 0.4%..................................... 197 RECURA -antifungal combination products misc cream............................................................................. 212 RED YEAST RICE -red yeast rice extract (bulk) powder........................................................................... 251 REGENECARE -lidocaine hcl-collagen-aloe vera gel 2%.................................................................................. 212 REGENT ALCOHOL -ethyl alcohol 100%...................... 272 REGLAN -metoclopramide hcl tab 5 mg......................... 104 REGLAN -metoclopramide hcl tab 10 mg....................... 104 REGONOL -pyridostigmine bromide iv soln 10 mg/2ml (5 mg/ml)............................................................................ 170 REGRANEX -becaplermin gel 0.01%............................. 212 REJUVACARE PLUS -cream base................................. 272 RELAGARD -acetic acid-oxyquinoline vaginal gel 0.9-0.025%.................................................................... 107 RELENZA DISKHALER -zanamivir aero powder breath activated 5 mg/blister......................................................13 RELHIST -bromphen tan-phenyleph tan chew tab 6-15 mg.................................................................................... 89 RELION R -insulin regular (human) inj 100 unit/ml........... 51 RELISTOR -methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml)............................................................................ 104 RELISTOR -methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/ml)..................................................................... 104 RELPAX -eletriptan hydrobromide tab 20 mg (base equivalent)..................................................................... 152 RELPAX -eletriptan hydrobromide tab 40 mg (base equivalent)..................................................................... 152 REMERON -mirtazapine tab 15 mg................................ 115 REMERON -mirtazapine tab 30 mg................................ 115 REMERON -mirtazapine tab 45 mg................................ 115 REMERON SOLTAB -mirtazapine orally disintegrating tab 15 mg............................................................................ 115 REMERON SOLTAB -mirtazapine orally disintegrating tab 30 mg............................................................................ 115 REMERON SOLTAB -mirtazapine orally disintegrating tab 45 mg............................................................................ 115
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
375
2016 RESCULA -unoprostone isopropyl ophth soln 0.15%.............................................................................193 RESERPINE -reserpine powder........................................ 76 RESERVAPAK KIT -resveratrol oral syrup (cmpd kit)..... 220 RESERVAPAK PLUS KIT -resveratrol oral syrup (cmpd kit).................................................................................. 220 RESORCINOL -resorcinol crystals..................................251 RESORCINOL -resorcinol powder.................................. 251 RESTASIS -cyclosporine (ophth) emulsion 0.05%......... 193 RESTASIS MULTIDOSE -cyclosporine (ophth) emulsion 0.05%.............................................................................193 RESTORA RX -lactobacillus casei-folic acid cap 60-1.25 mg.................................................................................... 96 RESTORA SPRINKLES -lactobacillus casei-folic acid packet 15-0.25 mg.......................................................... 96 RESTORE SILVER DRESSING 2 -wound dressings pads............................................................................... 212 RESTORE SILVER DRESSING 4 -wound dressings pads............................................................................... 212 RESTORE SILVER DRESSING 6 -wound dressings pads............................................................................... 212 RESTORIL -temazepam cap 7.5 mg.............................. 124 RESTORIL -temazepam cap 15 mg............................... 124 RESTORIL -temazepam cap 22.5 mg............................ 124 RESTORIL -temazepam cap 30 mg............................... 124 RETINALDEHYDE -retinal (bulk) powder....................... 251 RETIN-A MICRO PUMP -tretinoin microsphere gel 0.04%.............................................................................212 RETIN-A MICRO PUMP -tretinoin microsphere gel 0.08%.............................................................................212 RETIN-A MICRO PUMP -tretinoin microsphere gel 0.1%...............................................................................212 RETIN-A MICRO -tretinoin microsphere gel 0.04%........ 212 RETIN-A MICRO -tretinoin microsphere gel 0.1%.......... 212 RETIN-A -tretinoin cream 0.025%................................... 212 RETIN-A -tretinoin cream 0.05%..................................... 212 RETIN-A -tretinoin cream 0.1%....................................... 212 RETIN-A -tretinoin gel 0.01%.......................................... 212 RETIN-A -tretinoin gel 0.025%........................................ 212 RETINOIC ACID-ALL TRANS -tretinoin powder.............212 RETINOIC ACID -tretinoin powder.................................. 212 RETINOL MOLECULAR FILM -vitamin a oil 0.3%......... 251 RETISERT -fluocinolone acetonide intravitreal implant 0.59 mg......................................................................... 193 RETROVIR -zidovudine cap 100 mg................................ 13 RETROVIR -zidovudine syrup 10 mg/ml.......................... 13 REVATIO -sildenafil citrate for suspension 10 mg/ml....... 85 REVATIO -sildenafil citrate tab 20 mg............................... 85 REVESTA -folic acid-cholecalciferol cap 1 mg-5750 unit................................................................................. 184 REVLIMID -lenalidomide cap 5 mg................................. 277 REVLIMID -lenalidomide cap 10 mg............................... 277 REVLIMID -lenalidomide cap 15 mg............................... 277 REVLIMID -lenalidomide cap 20 mg............................... 277 REVLIMID -lenalidomide cap 25 mg............................... 277
REMESENSE -dental desensitizing product - misc........ 261 REMODULIN -treprostinil sodium inj 1 mg/ml (base equiv)............................................................................... 85 REMODULIN -treprostinil sodium inj 2.5 mg/ml (base equiv)............................................................................... 85 REMODULIN -treprostinil sodium inj 5 mg/ml (base equiv)............................................................................... 85 REMODULIN -treprostinil sodium inj 10 mg/ml (base equiv)............................................................................... 85 RENACIDIN -citric acid-gluconolactone-magnesium carbonate soln.............................................................. 108 RENAGEL -sevelamer hcl tab 400 mg........................... 104 RENAGEL -sevelamer hcl tab 800 mg........................... 104 RENATABS -b-complex w/ c-biotin-vit e & folic acid tab 1 mg.................................................................................. 173 RENATABS WITH IRON -b complex-c-biotin-e-fa tab 1mg & fe cbn tab 100 mg pack............................................ 173 RENOVAGE -teprenone-caprylic capric triglyceride (bulk) liquid.............................................................................. 251 RENVELA -sevelamer carbonate packet 0.8 gm............ 104 RENVELA -sevelamer carbonate packet 2.4 gm............ 104 RENVELA -sevelamer carbonate tab 800 mg................ 104 REPAGLINIDE/METFORMIN HYD -repaglinide-metformin hcl tab 1-500 mg.............................................................50 REPAGLINIDE/METFORMIN HYD -repaglinide-metformin hcl tab 2-500 mg.............................................................50 repaglinide tab 0.5 mg (Prandin)................................... 50 repaglinide tab 1 mg (Prandin)...................................... 50 repaglinide tab 2 mg (Prandin)...................................... 50 REPATHA -evolocumab subcutaneous soln prefilled syringe 140 mg/ml.......................................................... 83 REPATHA PUSHTRONEX SYSTEM -evolocumab subcutaneous soln cartridge/infusor 420 mg/3.5ml....... 83 REPATHA SURECLICK -evolocumab subcutaneous soln auto-injector 140 mg/ml.................................................. 83 REQ 49+ -multiple vitamins w/ minerals tab................... 173 REQUIP -ropinirole hydrochloride tab 0.25 mg...............166 REQUIP -ropinirole hydrochloride tab 0.5 mg.................166 REQUIP -ropinirole hydrochloride tab 1 mg....................166 REQUIP -ropinirole hydrochloride tab 2 mg....................166 REQUIP -ropinirole hydrochloride tab 3 mg....................166 REQUIP -ropinirole hydrochloride tab 4 mg....................166 REQUIP -ropinirole hydrochloride tab 5 mg....................166 REQUIP XL -ropinirole hydrochloride tab er 24hr 2 mg (base equivalent).......................................................... 166 REQUIP XL -ropinirole hydrochloride tab er 24hr 4 mg (base equivalent).......................................................... 166 REQUIP XL -ropinirole hydrochloride tab er 24hr 6 mg (base equivalent).......................................................... 166 REQUIP XL -ropinirole hydrochloride tab er 24hr 8 mg (base equivalent).......................................................... 166 REQUIP XL -ropinirole hydrochloride tab er 24hr 12 mg (base equivalent).......................................................... 166 RESCRIPTOR -delavirdine mesylate tab 100 mg............ 13 RESCRIPTOR -delavirdine mesylate tab 200 mg............ 13
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
376
2016 rimantadine hydrochloride tab 100 mg (Flumadine).................................................................... 14 RIMSO-50 -dimethyl sulfoxide soln 50%........................ 109 ringer's solution for irrigation...................................... 277 RIOMET -metformin hcl oral soln 500 mg/5ml.................. 50 risedronate sodium tab delayed release 35 mg (Atelvia).......................................................................... 58 risedronate sodium tab 5 mg (Actonel)........................ 58 risedronate sodium tab 30 mg (Actonel)...................... 58 risedronate sodium tab 35 mg (Actonel)...................... 58 risedronate sodium tab 150 mg (Actonel).................... 58 RISPERDAL CONSTA -risperidone microspheres for inj 12.5 mg......................................................................... 121 RISPERDAL CONSTA -risperidone microspheres for inj 25 mg............................................................................ 121 RISPERDAL CONSTA -risperidone microspheres for inj 37.5 mg......................................................................... 121 RISPERDAL CONSTA -risperidone microspheres for inj 50 mg............................................................................ 121 RISPERDAL M-TAB -risperidone orally disintegrating tab 0.5 mg........................................................................... 121 RISPERDAL M-TAB -risperidone orally disintegrating tab 1 mg.............................................................................. 121 RISPERDAL M-TAB -risperidone orally disintegrating tab 2 mg.............................................................................. 121 RISPERDAL M-TAB -risperidone orally disintegrating tab 3 mg.............................................................................. 121 RISPERDAL M-TAB -risperidone orally disintegrating tab 4 mg.............................................................................. 121 RISPERDAL -risperidone soln 1 mg/ml.......................... 121 RISPERDAL -risperidone tab 0.25 mg............................ 121 RISPERDAL -risperidone tab 0.5 mg.............................. 121 RISPERDAL -risperidone tab 1 mg................................. 121 RISPERDAL -risperidone tab 2 mg................................. 121 RISPERDAL -risperidone tab 3 mg................................. 121 RISPERDAL -risperidone tab 4 mg................................. 121 risperidone orally disintegrating tab 0.25 mg............ 121 risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab)............................................................................ 121 risperidone orally disintegrating tab 1 mg (Risperdal m-tab)............................................................................ 121 risperidone orally disintegrating tab 2 mg (Risperdal m-tab)............................................................................ 121 risperidone orally disintegrating tab 3 mg (Risperdal m-tab)............................................................................ 121 risperidone orally disintegrating tab 4 mg (Risperdal m-tab)............................................................................ 121 risperidone soln 1 mg/ml (Risperdal).......................... 121 risperidone tab 0.25 mg (Risperdal)............................ 121 risperidone tab 0.5 mg (Risperdal).............................. 121 risperidone tab 1 mg (Risperdal)................................. 121 risperidone tab 2 mg (Risperdal)................................. 121 risperidone tab 3 mg (Risperdal)................................. 121 risperidone tab 4 mg (Risperdal)................................. 122
REVLIMID -lenalidomide caps 2.5 mg............................ 277 REXAPHENAC -diclofenac sodium cream 1%............... 212 REXULTI -brexpiprazole tab 0.25 mg............................. 121 REXULTI -brexpiprazole tab 0.5 mg............................... 121 REXULTI -brexpiprazole tab 1 mg.................................. 121 REXULTI -brexpiprazole tab 2 mg.................................. 121 REXULTI -brexpiprazole tab 3 mg.................................. 121 REXULTI -brexpiprazole tab 4 mg.................................. 121 REYATAZ -atazanavir sulfate cap 150 mg (base equiv)............................................................................... 13 REYATAZ -atazanavir sulfate cap 200 mg (base equiv)............................................................................... 13 REYATAZ -atazanavir sulfate cap 300 mg (base equiv)............................................................................... 13 REYATAZ -atazanavir sulfate oral powder packet 50 mg (base equiv).................................................................... 13 REZIRA -pseudoephedrine w/ hydrocodone soln 60-5 mg/5ml............................................................................. 89 RHEOSPRAY -external vehicles - liquid......................... 272 RHOGAM ULTRA-FILTERED PLU -rho d immune globulin im soln pref syr 1500 unit (300mcg)................. 24 RHOPHYLAC -rho d immune globulin sol pref syr 1500 unt/2ml (300mcg/2ml)..................................................... 24 RIAX -benzoyl peroxide foam 5.5%................................ 212 RIAX -benzoyl peroxide foam 9.5%................................ 212 RIBASPHERE RIBAPAK -ribavirin tab 400 mg................. 13 RIBASPHERE RIBAPAK -ribavirin tab 600 mg................. 13 RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin tab 400 mg dose pack....................................................13 RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin tab 600 mg dose pack....................................................13 RIBASPHERE -ribavirin tab 400 mg................................. 13 RIBASPHERE -ribavirin tab 600 mg................................. 13 ribavirin cap 200 mg (Rebetol)....................................... 13 ribavirin for inhal soln 6 gm (Virazole)......................... 14 RIBAVIRIN -ribavirin (bulk) powder................................. 251 ribavirin tab 200 mg (Copegus)..................................... 14 RIBOFLAVIN-5-PHOSPHATE SO -riboflavin 5-phosphate sodium (bulk) powder................................................... 252 RIBOFLAVIN -riboflavin (bulk) powder............................ 252 RIBOSE (D) -d-ribose (bulk) powder.............................. 252 RIDAURA -auranofin cap 3 mg....................................... 150 rifabutin cap 150 mg (Mycobutin).................................... 9 RIFADIN -rifampin cap 150 mg........................................... 9 RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 9 RIFAMPIN/SYRSPEND SF PH4 -rifampin susp 25 mg/ml (compound kit).................................................................. 9 rifampin cap 150 mg (Rifadin).......................................... 9 rifampin cap 300 mg (Rifadin).......................................... 9 RIFAMPIN -rifampin powder................................................ 9 RIFATER -isoniazid-rifampin w/ pyrazinamide tab 50-120-300 mg.................................................................. 9 RIFAXIMIN -rifaximin (bulk) powder................................ 252 RILUTEK -riluzole tab 50 mg.......................................... 167 riluzole tab 50 mg (Rilutek).......................................... 167
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
377
2016 ropinirole hydrochloride tab 2 mg (Requip)............... 166 ropinirole hydrochloride tab 3 mg (Requip)............... 166 ropinirole hydrochloride tab 4 mg (Requip)............... 166 ropinirole hydrochloride tab 5 mg (Requip)............... 166 ropivacaine hcl inj 2 mg/ml (Naropin)......................... 156 ropivacaine hcl inj 5 mg/ml (Naropin)......................... 156 ropivacaine hcl inj 7.5 mg/ml (Naropin)...................... 156 ropivacaine hcl inj 10 mg/ml (Naropin)....................... 156 ROPIVACAINE HCL -ropivacaine hcl (bulk) powder...... 252 ROSE BENGAL B -rose bengal b (bulk) powder............ 252 ROSEMARY OIL -rosemary oil....................................... 252 ROSE OIL -rose oil.......................................................... 252 ROSIN LUMP -rosin lump............................................... 252 rosuvastatin calcium tab 5 mg (Crestor)...................... 83 rosuvastatin calcium tab 10 mg (Crestor).................... 83 rosuvastatin calcium tab 20 mg (Crestor).................... 83 rosuvastatin calcium tab 40 mg (Crestor).................... 83 ROTARIX -rotavirus vaccine, live for oral susp................. 22 ROTATEQ -rotavirus vaccine, live oral pentavalent soln.................................................................................. 22 ROXICODONE -oxycodone hcl tab 5 mg....................... 145 ROXICODONE -oxycodone hcl tab 15 mg..................... 145 ROXICODONE -oxycodone hcl tab 30 mg..................... 145 ROXIFOL-D -folic acid-cholecalciferol tab 1 mg-500 unit................................................................................. 184 ROZEREM -ramelteon tab 8 mg..................................... 124 RTD WOUND CARE DRESSING -wound dressings pads............................................................................... 212 RUBIDIUM CHLORIDE -rubidium chloride (bulk) powder........................................................................... 252 RUBRACA -rucaparib camsylate tab 200 mg (base equivalent)....................................................................... 29 RUBRACA -rucaparib camsylate tab 250 mg (base equivalent)....................................................................... 29 RUBRACA -rucaparib camsylate tab 300 mg (base equivalent)....................................................................... 29 RUTIN -rutin (bulk) powder............................................. 252 RYDAPT -midostaurin cap 25 mg..................................... 29 RYNODERM -urea cream 37.5%.................................... 212 RYTARY -carbidopa & levodopa cap er 23.75-95 mg.................................................................................. 166 RYTARY -carbidopa & levodopa cap er 36.25-145 mg.................................................................................. 167 RYTARY -carbidopa & levodopa cap er 48.75-195 mg.................................................................................. 167 RYTARY -carbidopa & levodopa cap er 61.25-245 mg.................................................................................. 167 RYTHMOL SR -propafenone hcl cap er 12hr 225 mg...... 68 RYTHMOL SR -propafenone hcl cap er 12hr 325 mg...... 68 RYTHMOL SR -propafenone hcl cap er 12hr 425 mg...... 68
RITALIN LA -methylphenidate hcl cap er 24hr 10 mg (la).................................................................................. 129 RITALIN LA -methylphenidate hcl cap er 24hr 20 mg (la).................................................................................. 129 RITALIN LA -methylphenidate hcl cap er 24hr 30 mg (la).................................................................................. 130 RITALIN LA -methylphenidate hcl cap er 24hr 40 mg (la).................................................................................. 130 RITALIN -methylphenidate hcl tab 5 mg......................... 129 RITALIN -methylphenidate hcl tab 10 mg....................... 129 RITALIN -methylphenidate hcl tab 20 mg....................... 129 rivastigmine tartrate cap 1.5 mg (Exelon)...................134 rivastigmine tartrate cap 3 mg (Exelon)......................134 rivastigmine tartrate cap 4.5 mg (Exelon)...................134 rivastigmine tartrate cap 6 mg (Exelon)......................134 rivastigmine td patch 24hr 4.6 mg/24hr (Exelon)....... 134 rivastigmine td patch 24hr 9.5 mg/24hr (Exelon)....... 134 rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)..... 134 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) (Maxalt-mlt)........................................................... 152 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt)................................................ 152 rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt)......................................................................... 152 rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt)......................................................................... 152 ROBAXIN -methocarbamol inj 1000 mg/10ml................ 169 ROBAXIN-750 -methocarbamol tab 750 mg...................169 ROBAXIN -methocarbamol tab 500 mg.......................... 169 ROBINUL FORTE -glycopyrrolate tab 2 mg..................... 99 ROBINUL -glycopyrrolate inj 0.2 mg/ml............................ 99 ROBINUL -glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml)....... 99 ROBINUL -glycopyrrolate inj 1 mg/5ml (0.2 mg/ml).......... 99 ROBINUL -glycopyrrolate inj 4 mg/20ml (0.2 mg/ml)........ 99 ROBINUL -glycopyrrolate tab 1 mg.................................. 99 ROCALTROL -calcitriol cap 0.25 mcg...............................58 ROCALTROL -calcitriol cap 0.5 mcg.................................58 ROCALTROL -calcitriol oral soln 1 mcg/ml....................... 58 ROCURONIUM BROMIDE -rocuronium bromide (bulk) powder........................................................................... 252 RONIDAZOLE -ronidazole (bulk) powder....................... 252 ROOT BEER FLAVOR -flavoring agent - liquid.............. 272 ropinirole hydrochloride tab er 24hr 2 mg (base equivalent) (Requip xl)............................................... 166 ropinirole hydrochloride tab er 24hr 4 mg (base equivalent) (Requip xl)............................................... 166 ropinirole hydrochloride tab er 24hr 6 mg (base equivalent) (Requip xl)............................................... 166 ropinirole hydrochloride tab er 24hr 8 mg (base equivalent) (Requip xl)............................................... 166 ropinirole hydrochloride tab er 24hr 12 mg (base equivalent) (Requip xl)............................................... 166 ropinirole hydrochloride tab 0.25 mg (Requip).......... 166 ropinirole hydrochloride tab 0.5 mg (Requip)............ 166 ropinirole hydrochloride tab 1 mg (Requip)............... 166
S SABRIL -vigabatrin powd pack 500 mg.......................... 162 SABRIL -vigabatrin tab 500 mg...................................... 162 SACCHARIN -saccharin powder..................................... 179 SACCHARIN SODIUM -sodium saccharin granules...... 179 SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
378
2016 SANDOSTATIN LAR DEPOT -octreotide acetate for im inj kit 30 mg......................................................................... 59 SANDOSTATIN -octreotide acetate inj 50 mcg/ml (0.05 mg/ml).............................................................................. 59 SANDOSTATIN -octreotide acetate inj 100 mcg/ml (0.1 mg/ml).............................................................................. 59 SANDOSTATIN -octreotide acetate inj 200 mcg/ml (0.2 mg/ml).............................................................................. 59 SANDOSTATIN -octreotide acetate inj 500 mcg/ml (0.5 mg/ml).............................................................................. 59 SANDOSTATIN -octreotide acetate inj 1000 mcg/ml (1 mg/ml).............................................................................. 59 SANTYL -collagenase oint 250 unit/gm.......................... 212 SAPHRIS -asenapine maleate sl tab 2.5 mg (base equiv)............................................................................. 122 SAPHRIS -asenapine maleate sl tab 5 mg (base equiv)............................................................................. 122 SAPHRIS -asenapine maleate sl tab 10 mg (base equiv)............................................................................. 122 SARAFEM -fluoxetine hcl (pmdd) tab 10 mg.................. 134 SARAFEM -fluoxetine hcl (pmdd) tab 20 mg.................. 134 SARAPIN -misc natural products inj............................... 277 SASSAFRAS OIL -sassafras oil...................................... 252 SAVAYSA -edoxaban tosylate tab 15 mg (base equivalent)..................................................................... 186 SAVAYSA -edoxaban tosylate tab 30 mg (base equivalent)..................................................................... 186 SAVAYSA -edoxaban tosylate tab 60 mg (base equivalent)..................................................................... 186 SAVELLA -milnacipran hcl tab 12.5 mg.......................... 134 SAVELLA -milnacipran hcl tab 25 mg............................. 134 SAVELLA -milnacipran hcl tab 50 mg............................. 134 SAVELLA -milnacipran hcl tab 100 mg........................... 134 SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak............................... 134 SAW PALMETTO BERRY -saw palmetto (bulk) powder........................................................................... 252 SCARLET RED -scarlet red (bulk) powder..................... 252 scar treatment products - gel...................................... 213 SCLEROSOL INTRAPLEURAL -talc intrapleural aerosol powder 4 gm (0.4 gm/second)....................................... 95 SCOPOLAMINE HBR -scopolamine hbr powder............100 scopolamine td patch 72hr 1 mg/3days (Transdermscop)............................................................................. 101 SEASONIQUE -levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)..................................................... 44 SEBUDERM -dermatological products misc - gel........... 213 SECONAL SODIUM -secobarbital sodium cap 100 mg.................................................................................. 124 SECRETIN-MANNITOL -secretin-mannitol (bulk) powder 1-99%............................................................................ 252 SEDANARE -cream base................................................ 272 selegiline hcl cap 5 mg (Eldepryl)............................... 167 SELEGILINE HCL -selegiline hcl powder....................... 167 selegiline hcl tab 5 mg.................................................. 167
SACCHARIN SODIUM -sodium saccharin powder........ 179 SA3 DERM -cream base................................................. 272 SAFFLOWER OIL -safflower oil...................................... 252 SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg..............................................................44 SAGE LEAF -sage leaf (bulk) powder............................ 252 SAIZEN CLICK.EASY -somatropin (non-refrigerated) for inj 8.8 mg........................................................................ 59 SAIZENPREP RECONSTITUTION -somatropin (nonrefrigerated) for inj 8.8 mg..............................................59 SAIZEN -somatropin (non-refrigerated) for inj 5 mg......... 58 SAIZEN -somatropin (non-refrigerated) for inj 8.8 mg...... 58 SALAGEN -pilocarpine hcl tab 5 mg............................... 196 SALAGEN -pilocarpine hcl tab 7.5 mg............................ 196 SALEX -salicylic acid shampoo 6%................................ 212 SALICEPT -oral wound care products - for susp rinse............................................................................... 196 salicylic acid cream 6%................................................ 212 salicylic acid er film-forming soln 28.5% (Ultrasaler).................................................................................. 212 salicylic acid film forming liquid 27.5% (Virasal)....... 212 salicylic acid foam 6% (Salvax)................................... 212 salicylic acid gel 6% (Keralyt)...................................... 212 salicylic acid lotion 6%................................................. 212 SALICYLIC ACID -salicylic acid (bulk) solution 50%...... 252 SALICYLIC ACID -salicylic acid crystals......................... 212 SALICYLIC ACID -salicylic acid powder......................... 212 salicylic acid shampoo 6% (Salex).............................. 212 salicylic acid soln 26%..................................................212 SALINE/PHENOL -saline w/ phenol inj........................... 272 saline injection bacteriostatic...................................... 272 SALISOL -salicylic acid soln 23%................................... 212 SALITECH -salicylic acid lotion 5%................................ 212 SALIVAMAX -artificial saliva - packet..............................196 SALIVATE RX -artificial saliva - packet........................... 196 SALSALATE -salsalate (bulk) powder............................. 252 salsalate tab 500 mg..................................................... 136 salsalate tab 750 mg..................................................... 136 SALT DURABLE CREAM -cream base.......................... 272 SALT STABLE LO -cream base...................................... 272 SALT STABLE LS ADVANCED -cream base..................272 SALVAX -salicylic acid foam 6%..................................... 212 SAMSCA -tolvaptan tab 15 mg......................................... 59 SAMSCA -tolvaptan tab 30 mg......................................... 59 SANARE ADVANCED SCAR THER -cream base.......... 272 SANARE SCAR THERAPY -cream base....................... 272 SANCUSO -granisetron td patch 3.1 mg/24hr (contains 34.3 mg)........................................................................ 101 SANDIMMUNE -cyclosporine cap 25 mg....................... 277 SANDIMMUNE -cyclosporine cap 100 mg..................... 277 SANDIMMUNE -cyclosporine oral soln 100 mg/ml......... 277 SANDOSTATIN LAR DEPOT -octreotide acetate for im inj kit 10 mg......................................................................... 59 SANDOSTATIN LAR DEPOT -octreotide acetate for im inj kit 20 mg......................................................................... 59
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
379
2016 selenium sulfide lotion 2.5%........................................ 213 selenium sulfide-pyrithione zinc in urea shampoo 2.25%.............................................................................213 SELENIUM SULFIDE -selenium sulfide (bulk) powder........................................................................... 252 SELENIUM SULFIDE SHAMPOO -selenium sulfide lotion 2.25%.............................................................................213 SELENIUM YEAST -selenium yeast (bulk) powder........ 252 SELRX -selenium sulfide-pyrithione zinc in urea shampoo 2.3%...............................................................................213 SELZENTRY -maraviroc oral soln 20 mg/ml.................... 14 SELZENTRY -maraviroc tab 25 mg.................................. 14 SELZENTRY -maraviroc tab 75 mg.................................. 14 SELZENTRY -maraviroc tab 150 mg................................ 14 SELZENTRY -maraviroc tab 300 mg................................ 14 SEMPREX-D -acrivastine & pseudoephedrine cap 8-60 mg.................................................................................... 89 SENNA -senna fluid extract (bulk).................................. 252 SENSIPAR -cinacalcet hcl tab 30 mg (base equiv).......... 59 SENSIPAR -cinacalcet hcl tab 60 mg (base equiv).......... 59 SENSIPAR -cinacalcet hcl tab 90 mg (base equiv).......... 59 SENSORCAINE-MPF/EPINEPHRI -bupivacaine inj 0.75% w/ epinephrine 1:200000 (pf)............................ 156 SEPICALM VG -white water lilly flower-sodium palmitoyl proline liqd..................................................................... 252 SEPINEO P 600 -emulsifying base - liquid..................... 272 SERAQUA -serum base - liquid...................................... 272 SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv)................................................... 93 SERMORELIN ACETATE -sermorelin acetate (bulk) powder........................................................................... 252 SERNIVO -betamethasone dipropionate spray emulsion 0.05% (base equiv).......................................................213 SEROQUEL -quetiapine fumarate tab 25 mg................. 122 SEROQUEL -quetiapine fumarate tab 50 mg................. 122 SEROQUEL -quetiapine fumarate tab 100 mg............... 122 SEROQUEL -quetiapine fumarate tab 200 mg............... 122 SEROQUEL -quetiapine fumarate tab 300 mg............... 122 SEROQUEL -quetiapine fumarate tab 400 mg............... 122 SEROQUEL XR -quetiapine fumarate tab er 24hr 50 mg.................................................................................. 122 SEROQUEL XR -quetiapine fumarate tab er 24hr 150 mg.................................................................................. 122 SEROQUEL XR -quetiapine fumarate tab er 24hr 200 mg.................................................................................. 122 SEROQUEL XR -quetiapine fumarate tab er 24hr 300 mg.................................................................................. 122 SEROQUEL XR -quetiapine fumarate tab er 24hr 400 mg.................................................................................. 122 SEROSTIM -somatropin (non-refrigerated) for subcutaneous inj 4 mg................................................... 59 SEROSTIM -somatropin (non-refrigerated) for subcutaneous inj 5 mg................................................... 59 SEROSTIM -somatropin (non-refrigerated) for subcutaneous inj 6 mg................................................... 59
SEROTONIN HCL -serotonin hcl (bulk) powder............. 252 sertraline hcl oral conc 20 mg/ml (Zoloft).................. 115 SERTRALINE HCL -sertraline hcl (bulk) powder............ 252 sertraline hcl tab 25 mg (Zoloft).................................. 115 sertraline hcl tab 50 mg (Zoloft).................................. 115 sertraline hcl tab 100 mg (Zoloft)................................ 115 SESAME OIL -sesame oil............................................... 252 sevelamer carbonate packet 0.8 gm (Renvela).......... 104 sevelamer carbonate packet 2.4 gm (Renvela).......... 104 sevelamer carbonate tab 800 mg (Renvela)............... 104 SFROWASA -mesalamine sulfite-free (sf) enema 4 gm/60ml......................................................................... 104 SHARK CARTILAGE -shark cartilage (bulk) powder...... 252 SHEA BUTTER ORGANIC -shea butter......................... 272 SHEA BUTTER -shea butter........................................... 272 SHELLGEL -sodium hyaluronate intraocular inj 12 mg/ ml................................................................................... 193 SHOHLS SOLUTION MODIFIED -sodium citrate & citric acid soln 500-334 mg/5ml............................................ 109 SHOWER FRESH FRAGRANCE -shower fresh fragrance (bulk) liquid.................................................................... 252 SHRIMP FLAVOR -flavoring agent - liquid..................... 272 SHUR-SEAL -nonoxynol-9 gel 2%.................................. 107 SIBERIAN GINSENG -siberian ginseng (bulk) powder........................................................................... 252 SIDEKICK BLOOD GLUCOSE SY -blood glucose meter disposable device with test strips................................ 261 SIDEROL -multiple vitamins w/ minerals tab.................. 173 SIGNIFOR LAR -pasireotide pamoate for im er susp 20 mg (base equiv).............................................................. 59 SIGNIFOR LAR -pasireotide pamoate for im er susp 40 mg (base equiv).............................................................. 59 SIGNIFOR LAR -pasireotide pamoate for im er susp 60 mg (base equiv).............................................................. 59 SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base equiv)............................................................................... 59 SIGNIFOR -pasireotide diaspartate inj 0.6 mg/ml (base equiv)............................................................................... 59 SIGNIFOR -pasireotide diaspartate inj 0.9 mg/ml (base equiv)............................................................................... 59 SILDENAFIL CITRATE -sildenafil citrate (bulk) powder........................................................................... 252 sildenafil citrate tab 20 mg (Revatio)............................ 85 SILENOR -doxepin hcl (sleep) tab 3 mg (base equiv)............................................................................. 124 SILENOR -doxepin hcl (sleep) tab 6 mg (base equiv)............................................................................. 124 SILICA GEL -silica gel..................................................... 252 SILICA GEL ULTRAMICRONIZE -silica gel.................... 252 SILICON DIOXIDE -silica (bulk) powder......................... 252 SILICONE BLEND CUSTOM -silicone (bulk) paste........ 252 SILICONE ELASTOMER BLEND -silicone (bulk) gel..... 252 SILICONE FLUID 556 -silicone (bulk) liquid................... 253 SILOSOME TRANSDERMAL -transdermal base cream............................................................................. 272
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
380
2016 sirolimus tab 0.5 mg (Rapamune)............................... 277 sirolimus tab 1 mg (Rapamune).................................. 277 sirolimus tab 2 mg (Rapamune).................................. 277 SIRTURO -bedaquiline fumarate tab 100 mg (base equiv)................................................................................. 9 SITAVIG -acyclovir buccal tab 50 mg................................ 14 SIVEXTRO -tedizolid phosphate tab 200 mg....................18 SKELAXIN -metaxalone tab 800 mg............................... 169 skin protectants misc - cream..................................... 213 SKLICE -ivermectin lotion 0.5%...................................... 213 SKYLA -levonorgestrel releasing iud 14 mcg/day (13.5 mg total).......................................................................... 44 SKYY DERM -cream base.............................................. 272 SODIUM ACETATE ANHYDROUS -sodium acetate crystals.......................................................................... 177 SODIUM ACETATE ANHYDROUS -sodium acetate powder........................................................................... 177 SODIUM ACETATE TRIHYDRATE -sodium acetate granules......................................................................... 177 SODIUM ACETATE TRIHYDRATE -sodium acetate trihydrate (bulk) powder................................................ 253 SODIUM ALGINATE -sodium alginate powder............... 253 SODIUM 4-AMINOSALICYLATE -aminosalicylate sodium (bulk) powder................................................................ 255 sodium ascorbate inj 250 mg/ml................................. 170 SODIUM ASCORBATE -sodium ascorbate granules..... 170 SODIUM ASCORBATE -sodium ascorbate powder....... 170 SODIUM BENZOATE -sodium benzoate powder........... 272 SODIUM BICARBONATE -sodium bicarbonate (bulk) powder........................................................................... 253 SODIUM BICARBONATE -sodium bicarbonate powder............................................................................. 97 SODIUM BISULFITE -sodium bisulfite granules.............253 SODIUM BITARTRATE MONOHYD -sodium bitartrate monohydrate (bulk) powder..........................................253 SODIUM BORATE DECAHYDRATE -sodium borate powder........................................................................... 253 SODIUM BROMIDE -sodium bromide granules............. 253 SODIUM BUTYRATE -sodium butyrate powder............. 253 SODIUM CACODYLATE -sodium cacodylate powder........................................................................... 253 SODIUM CAPRATE -sodium caprate (bulk) powder...... 253 SODIUM CAPYRLATE FOOD GRA -sodium caprylate (bulk) powder................................................................ 253 SODIUM CARBONATE ANHYDROU -sodium carbonate powder........................................................................... 253 SODIUM CARBONATE MONOHYDR -sodium carbonate monohydrate powder.................................................... 253 SODIUM CARBOXYMETHYLCELLU carboxymethylcellulose sodium powder...................... 253 SODIUM CHLORIDE/SODIUM BI -sodium bicarbonatesodium chloride powder............................................... 253 SODIUM CHLORIDE BACTERIOS -saline injection w/ benzyl alcohol............................................................... 272 sodium chloride flush iv soln 0.9%............................. 177
SILPROTEX PLUS -cream base..................................... 272 SILVADENE -silver sulfadiazine cream 1%.....................213 SILVASORB -wound dressings - gel............................... 213 SILVER NITRATE -silver nitrate crystals.........................213 SILVER NITRATE -silver nitrate oint 10%....................... 213 SILVER NITRATE -silver nitrate soln 0.5%..................... 213 SILVER NITRATE -silver nitrate soln 10%...................... 213 SILVER NITRATE -silver nitrate soln 25%...................... 213 SILVER NITRATE -silver nitrate soln 50%...................... 213 SILVER PROTEIN MILD -silver protein mild powder...... 218 SILVERSEAL HYDROGEL DRESS -silver - pad 2"x3".............................................................................. 213 SILVERSEAL HYDROGEL DRESS -silver - pad 4"x5".............................................................................. 213 silver sulfadiazine cream 1% (Silvadene)................... 213 SILVER SULFADIAZINE -silver sulfadiazine (bulk) powder........................................................................... 253 SILVRSTAT WOUND DRESSING -silver - gel................ 213 SIMBRINZA -brinzolamide-brimonidine tartrate ophth susp 1-0.2%.................................................................. 193 SIMETHICONE -simethicone liquid.................................104 SIMPLE SYRUP -simple - syrup..................................... 272 SIMPLGEL 30 -gel base - gel......................................... 272 SIMPONI -golimumab subcutaneous soln auto-injector 50 mg/0.5ml........................................................................ 151 SIMPONI -golimumab subcutaneous soln auto-injector 100 mg/ml..................................................................... 151 SIMPONI -golimumab subcutaneous soln prefilled syringe 50 mg/0.5ml.................................................................. 151 SIMPONI -golimumab subcutaneous soln prefilled syringe 100 mg/ml..................................................................... 151 SIMVASTATIN -simvastatin (bulk) powder...................... 253 simvastatin tab 5 mg (Zocor)......................................... 83 simvastatin tab 10 mg (Zocor)....................................... 83 simvastatin tab 20 mg (Zocor)....................................... 83 simvastatin tab 40 mg (Zocor)....................................... 83 simvastatin tab 80 mg (Zocor)....................................... 84 SINCALIDE IN MANNITOL -sincalide in mannitol (bulk) powder 100 mcg/gm..................................................... 253 SINEMET -carbidopa & levodopa tab 10-100 mg........... 167 SINEMET -carbidopa & levodopa tab 25-100 mg........... 167 SINEMET -carbidopa & levodopa tab 25-250 mg........... 167 SINEMET CR -carbidopa & levodopa tab er 25-100 mg.................................................................................. 167 SINEMET CR -carbidopa & levodopa tab er 50-200 mg.................................................................................. 167 SINGULAIR -montelukast sodium chew tab 4 mg (base equiv)............................................................................... 93 SINGULAIR -montelukast sodium chew tab 5 mg (base equiv)............................................................................... 93 SINGULAIR -montelukast sodium oral granules packet 4 mg (base equiv).............................................................. 93 SINGULAIR -montelukast sodium tab 10 mg (base equiv)............................................................................... 93 SIROLIMUS -sirolimus (bulk) powder............................. 253
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
381
2016 sodium chloride inj 0.9%.............................................. 177 sodium chloride inj 2.5 meq/ml (14.6%)...................... 177 sodium chloride irrigation soln 0.9%.......................... 109 sodium chloride iv soln 0.9%....................................... 177 SODIUM CHLORIDE -sodium chloride granules............ 177 SODIUM CHLORIDE -sodium chloride powder.............. 177 sodium chloride soln nebu 0.9%................................... 89 sodium chloride soln nebu 3%...................................... 89 sodium chloride soln nebu 10%.................................... 89 sodium chloride soln nebu 7% (Hyper-sal).................. 89 SODIUM CHLORITE -sodium chlorite (bulk) flakes........253 sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi).............................................. 109 SODIUM CITRATE ANHYDROUS -sodium citrate powder........................................................................... 109 SODIUM CITRATE DIHYDRATE -sodium citrate dihydrate powder........................................................................... 253 SODIUM CITRATE -sodium citrate crystals.................... 109 SODIUM COCOYL GLUTAMATE -sodium cocoyl glutamate (bulk) liquid.................................................. 253 SODIUM DEHYDROACETATE -sodium dehydroacetate(bulk) powder....................................... 253 SODIUM DEOXYCHOLATE -sodium deoxycholate (bulk) powder........................................................................... 253 SODIUM DICHLOROACETATE -sodium dichloroacetate (bulk) powder................................................................ 253 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride)......................................................................... 177 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride)......................................................................... 177 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride)......................................................................... 177 sodium fluoride cream 1.1% (Prevident 5000 plus).............................................................................. 196 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)........................................................................ 196 sodium fluoride paste 1.1% (Prevident 5000 boost)............................................................................ 196 sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 sensi)............................................... 196 sodium fluoride rinse 0.2% (Prevident)...................... 196 SODIUM FLUORIDE -sodium fluoride (bulk) powder..... 253 SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from 1.1 mg naf)....................................................................177 SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from 2.2 mg naf)....................................................................177 sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf)................................................................................ 177 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride)......................................................................... 177 SODIUM FLUOROPHOSPHATE -sodium monofluorophosphate (bulk) powder............................253 SODIUM GLUCONATE -sodium gluconate (bulk) powder........................................................................... 254
SODIUM HYALURONATE -hyaluronate sodium (bulk) powder........................................................................... 254 SODIUM HYALURONATE (INJEC -hyaluronate sodium (bulk) powder................................................................ 254 SODIUM HYDROXIDE -sodium hydroxide pellets......... 254 SODIUM HYDROXIDE -sodium hydroxide solution 10%................................................................................254 SODIUM IODIDE -sodium iodide (bulk) granules........... 254 SODIUM LACTATE -sodium lactate soln 60%................ 254 SODIUM-L-ASCORBYL-2-PHOSP -sodium ascorbyl phosphate dihydrate (bulk) powder..............................255 SODIUM L-ASPARTATE -sodium aspartate monohydrate (bulk) powder................................................................ 254 SODIUM LAURETH SULFATE -sodium laureth sulfate (bulk) liquid.................................................................... 254 SODIUM LAURYL SULFATE -sodium lauryl sulfate powder........................................................................... 272 SODIUM METABISULFITE ANHY -sodium metabisulfite granules......................................................................... 254 SODIUM METABISULFITE -sodium metabisulfite granules......................................................................... 254 SODIUM METABISULFITE -sodium metabisulfite powder........................................................................... 254 SODIUM MOLYBDATE -sodium molybdate (bulk) powder........................................................................... 254 SODIUM MONOFLUOROPHOSPHAT -sodium monofluorophosphate (bulk) powder............................254 SODIUM NITRATE ACS -sodium nitrate (bulk) powder........................................................................... 254 SODIUM NITRITE -sodium nitrite granules.................... 254 SODIUM OLEATE -sodium oleate (bulk) powder........... 254 SODIUM PERBORATE TETRAHYD -sodium perborate powder........................................................................... 254 sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl)...................................................................... 59 SODIUM PHENYLBUTYRATE -sodium phenylbutyrate (bulk) powder................................................................ 254 SODIUM PHOSPHATE DIBASIC -sodium phosphate dibasic (bulk) crystals................................................... 254 SODIUM PHOSPHATE DIBASIC -sodium phosphate dibasic (bulk) granules................................................. 254 SODIUM PHOSPHATE DIBASIC -sodium phosphate dibasic (bulk) powder................................................... 254 SODIUM PHOSPHATE MONOBASI -sodium phosphate monobasic (bulk) granules........................................... 254 SODIUM PHOSPHATE MONOBASI -sodium phosphate monobasic (bulk) powder............................................. 254 SODIUM PHOSPHATE TRIBASIC -sodium phosphate tribasic (bulk) crystals................................................... 254 sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps).............................................................................. 277 sodium polystyrene sulfonate powder (Kayexalate)................................................................. 277 sodium polystyrene sulfonate rectal susp 30 gm/120ml...................................................................... 277
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
382
2016 SOLU-MEDROL -methylprednisolone sodium succinate for inj 500 mg..................................................................37 SOLU-MEDROL -methylprednisolone sodium succinate for inj 1000 mg................................................................37 SOLU-MEDROL -methylprednisolone sodium succinate for inj 2000 mg................................................................37 SOLVATECH PLUS -oral vehicles - susp........................272 SOLVATECH SWEET SF -oral vehicles - syrup............. 272 SOLYDRA -oil base - liquid............................................. 272 SOMA -carisoprodol tab 250 mg..................................... 169 SOMA -carisoprodol tab 350 mg..................................... 169 SOMATULINE DEPOT -lanreotide acetate extended release inj 60 mg/0.2ml.................................................. 59 SOMATULINE DEPOT -lanreotide acetate extended release inj 90 mg/0.3ml.................................................. 59 SOMATULINE DEPOT -lanreotide acetate extended release inj 120 mg/0.5ml................................................ 59 SOMAVERT -pegvisomant for inj 10 mg (as protein)....... 59 SOMAVERT -pegvisomant for inj 15 mg (as protein)....... 59 SOMAVERT -pegvisomant for inj 20 mg (as protein)....... 59 SOMAVERT -pegvisomant for inj 25 mg (as protein)....... 60 SOMAVERT -pegvisomant for inj 30 mg (as protein)....... 60 SONAFINE -wound dressings - emulsion....................... 213 SONATA -zaleplon cap 5 mg.......................................... 124 SONATA -zaleplon cap 10 mg........................................ 124 SOOLANTRA -ivermectin cream 1%.............................. 213 SORBIC ACID -sorbic acid powder................................ 273 SORBITAN MONOLAURATE -sorbitan monolaurate (bulk) liquid.................................................................... 255 SORBITAN MONOOLEATE -sorbitan monooleate (bulk) liquid.............................................................................. 255 SORBITAN MONOPALMITATE BA -sorbitan monopalmitate (bulk) powder....................................... 255 SORBITAN MONOPALMITATE -sorbitan monopalmitate (bulk) powder................................................................ 255 SORBITOL CANDY BASE -sorbitol candy base crystals.......................................................................... 273 SORBITOL-MANNITOL -sorbitol-mannitol irrigation soln 2.7-0.54 gm/100ml........................................................ 109 SORBITOL -sorbitol irrigation soln 3%............................109 SORBITOL -sorbitol irrigation soln 3.3%........................ 109 SORBITOL -sorbitol powder............................................ 255 SORBITOL -sorbitol solution (bulk)................................. 273 SORIATANE -acitretin cap 10 mg................................... 213 SORIATANE -acitretin cap 17.5 mg................................ 213 SORIATANE -acitretin cap 25 mg................................... 213 SORILUX -calcipotriene foam 0.005%............................ 213 sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 63 sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 63 sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 63 sotalol hcl tab 240 mg.....................................................64 sotalol hcl tab 80 mg (Betapace)................................... 63 sotalol hcl tab 120 mg (Betapace)................................. 63 sotalol hcl tab 160 mg (Betapace)................................. 63 SOTYLIZE -sotalol hcl oral solution 5 mg/ml.................... 64
SODIUM POLYSTYRENE SULFON -sodium polystyrene sulfonate (bulk) powder................................................ 254 SODIUM PROPIONATE -sodium propionate powder..... 254 SODIUM PYROPHOSPHATE ANHY -bulk chemicals powder........................................................................... 254 SODIUM PYRROLIDONE CARBOX -sodium pidolate (bulk) liquid.................................................................... 255 SODIUM SALICYLATE -sodium salicylate crystals........ 136 SODIUM SALICYLATE -sodium salicylate powder......... 136 SODIUM SELENITE -sodium selenite (bulk) powder..... 255 SODIUM STEARATE -sodium stearate (bulk) powder........................................................................... 255 SODIUM STEARYL FUMARATE -sodium stearyl fumarate (bulk) powder................................................ 255 SODIUM SUCCINATE -sodium succinate powder......... 255 SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium-sulfur in urea emulsion 10-5%........................ 213 SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium-sulfur in urea gel 10-5%.................................. 213 SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium w/ sulfur lotion 10-5%................................................... 213 SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium w/ sulfur susp 10-5%.................................................... 213 SODIUM SULFACETAMIDE WASH -sulfacetamide sodium in bakuchiol vehicle wash 10%....................... 213 SODIUM SULFATE -sodium sulfate powder................... 255 SODIUM SULFITE ANHYDROUS -sodium sulfite powder........................................................................... 255 SODIUM TARTRATE DIHYDRATE -sodium tartrate (bulk) powder........................................................................... 255 SODIUM TETRADECYL SULFATE -sodium tetradecyl sulfate (bulk) powder.................................................... 255 SODIUM TETRADECYL SULFATE -sodium tetradecyl sulfate (bulk) solution 27%........................................... 255 SODIUM THIOSULFATE PENTAH -sodium thiosulfate crystals.......................................................................... 272 SODIUM THIOSULFATE -sodium thiosulfate powder........................................................................... 272 SODIUM VALPROATE -valproate sodium (bulk) powder........................................................................... 255 SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base equivalent)....................................................................... 29 SOLU-CORTEF -hydrocortisone sodium succinate pf for inj 100 mg....................................................................... 37 SOLU-CORTEF -hydrocortisone sodium succinate pf for inj 250 mg....................................................................... 37 SOLU-CORTEF -hydrocortisone sodium succinate pf for inj 500 mg....................................................................... 37 SOLU-CORTEF -hydrocortisone sodium succinate pf for inj 1000 mg..................................................................... 37 SOLU-K GEL -gel base - gel.......................................... 272 SOLU-MEDROL -methylprednisolone sodium succinate for inj 40 mg....................................................................37 SOLU-MEDROL -methylprednisolone sodium succinate for inj 125 mg..................................................................37
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
383
2016 STALEVO 125 -carbidopa-levodopa-entacapone tabs 31.25-125-200 mg........................................................ 167 STALEVO 150 -carbidopa-levodopa-entacapone tabs 37.5-150-200 mg.......................................................... 167 STALEVO 200 -carbidopa-levodopa-entacapone tabs 50-200-200 mg..............................................................167 STALEVO 50 -carbidopa-levodopa-entacapone tabs 12.5-50-200 mg.............................................................167 STALEVO 75 -carbidopa-levodopa-entacapone tabs 18.75-75-200 mg.......................................................... 167 STANNOUS CHLORIDE DIHYDRA -stannous chloride (bulk) crystals................................................................ 255 stannous fluoride conc 0.63% (Gel-kam oral care ri)................................................................................... 196 stannous fluoride gel 0.4%........................................... 196 STANNOUS FLUORIDE -stannous fluoride (bulk) powder........................................................................... 255 STANOZOLOL -stanozolol (bulk) powder....................... 255 STARLIX -nateglinide tab 60 mg....................................... 50 STARLIX -nateglinide tab 120 mg..................................... 50 stavudine cap 15 mg (Zerit)............................................14 stavudine cap 20 mg (Zerit)............................................14 stavudine cap 30 mg (Zerit)............................................14 stavudine cap 40 mg (Zerit)............................................14 1ST BASE -cream base.................................................. 275 STEARIC ACID -stearic acid flakes................................ 273 STEARIC ACID -stearic acid powder.............................. 273 STEARIC ACID TRIPLE PRESS -stearic acid powder........................................................................... 273 STEARYL ALCOHOL -stearyl alcohol flakes.................. 273 STEARYL ALCOHOL -stearyl alcohol powder............... 273 STELARA -ustekinumab inj 45 mg/0.5ml........................ 214 STELARA -ustekinumab soln prefilled syringe 45 mg/0.5ml........................................................................ 214 STELARA -ustekinumab soln prefilled syringe 90 mg/ ml................................................................................... 214 STERA BASE -cream base............................................. 273 STERILE TALC POWDER -talc intrapleural powder for susp 5 gm....................................................................... 95 STEVIA EXTRACT -stevia (bulk) powder....................... 255 STEVIA GLYCERITE LIQUID E -flavoring agent liquid.............................................................................. 273 STEVIOL GLYCOSIDES -steviol glycosides (bulk) powder 95%................................................................................255 STEVIOSIDE -stevioside (bulk) fluid extract 15%...........256 STIMATE -desmopressin acetate nasal soln 1.5 mg/ ml..................................................................................... 60 STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aero soln 2.5-2.5 mcg/act....................................................... 93 STIVARGA -regorafenib tab 40 mg................................... 30 ST JOHNS WORT -st john's wort (hypericum perforatum) (bulk) powder................................................................ 255 STRATTERA -atomoxetine hcl cap 10 mg (base equiv)............................................................................. 130
SOVALDI -sofosbuvir tab 400 mg..................................... 14 SOYABEAN CASEIN DIGEST ME -soyabean casein digest medium (bulk) powder....................................... 255 SOYBEAN OIL -soybean oil............................................ 255 SP ANTIPRURITIC -wound dressings - gel.................... 213 SPEARMINT FLAVOR -flavoring agent - oil................... 273 SPEARMINT OIL -spearmint oil...................................... 255 speciality vitamin product tab..................................... 173 SPECTRACEF -cefditoren pivoxil tab 400 mg (base equivalent)......................................................................... 4 SPECTRAGEL -wound dressings - gel........................... 213 SPG SUPPOSI-BASE -suppository base - pellets..........273 SPINOSAD -spinosad susp 0.9%................................... 214 SPIRIVA HANDIHALER -tiotropium bromide monohydrate inhal cap 18 mcg (base equiv)....................................... 93 SPIRIVA RESPIMAT -tiotropium bromide monohydrate inhal aerosol 1.25 mcg/act............................................. 93 SPIRIVA RESPIMAT -tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act............................................... 93 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide).................................................................. 79 SPIRONOLACTONE -spironolactone powder.................. 79 spironolactone tab 25 mg (Aldactone).......................... 80 spironolactone tab 50 mg (Aldactone).......................... 80 spironolactone tab 100 mg (Aldactone)........................ 80 SPIRULINA -spirulina (bulk) powder............................... 255 SPORANOX -itraconazole cap 100 mg............................ 10 SPORANOX -itraconazole oral soln 10 mg/ml..................10 SPORANOX PULSEPAK -itraconazole cap 100 mg........ 10 SPRITAM -levetiracetam tab disintegrating soluble 250 mg.................................................................................. 162 SPRITAM -levetiracetam tab disintegrating soluble 500 mg.................................................................................. 162 SPRITAM -levetiracetam tab disintegrating soluble 750 mg.................................................................................. 162 SPRITAM -levetiracetam tab disintegrating soluble 1000 mg.................................................................................. 162 SPRIX -ketorolac tromethamine nasal spray 15.75 mg/ spray.............................................................................. 151 SPRYCEL -dasatinib tab 20 mg........................................ 29 SPRYCEL -dasatinib tab 50 mg........................................ 29 SPRYCEL -dasatinib tab 70 mg........................................ 30 SPRYCEL -dasatinib tab 80 mg........................................ 30 SPRYCEL -dasatinib tab 100 mg...................................... 30 SPRYCEL -dasatinib tab 140 mg...................................... 30 SP SCAR MANAGEMENT -scar treatment products gel.................................................................................. 213 SQUALANE -squalane (bulk) liquid................................ 255 SQUALANE -squalane (bulk) oil..................................... 255 SQUARIC ACID -squaric acid (bulk) powder.................. 255 SSKI -potassium iodide soln 1 gm/ml............................. 177 SSS 10-5 -sulfacetamide sodium w/ sulfur foam 10-5%............................................................................ 214 STALEVO 100 -carbidopa-levodopa-entacapone tabs 25-100-200 mg..............................................................167
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
384
2016 SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x 2).................................................................................... 145 SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x 2).................................................................................... 145 SUCCIMER DMSA -succimer (bulk) powder.................. 256 SUCCINIC ACID -succinic acid crystals......................... 256 SUCCINYLCHOLINE CHLORIDE -succinylcholine chloride (bulk) powder.................................................. 256 SUCRAID -sacrosidase soln 8500 unit/ml...................... 102 SUCRALFATE -sucralfate powder.................................. 100 sucralfate tab 1 gm (Carafate)..................................... 100 SUCROSE CONFECTIONERS -sucrose powder.......... 256 SUCROSE OCTAACETATE -sucrose octaacetate crystals.......................................................................... 256 SUCROSE POWDERED CONFECTI -sucrose powder........................................................................... 256 SUCROSE -sucrose powder........................................... 256 SUFENTANIL CITRATE -sufentanil citrate powder.........256 SULAR -nisoldipine tab er 24hr 8.5 mg............................ 66 SULAR -nisoldipine tab er 24hr 17 mg............................. 66 SULAR -nisoldipine tab er 24hr 34 mg............................. 66 sulfacetamide sodium cleansing gel 10% (Ovace plus wash).............................................................................214 sulfacetamide sodium liquid 10% (Ovace wash)....... 214 sulfacetamide sodium lotion 10% (acne) (Klaron)..... 214 sulfacetamide sodium ophth soln 10% (Bleph-10)..................................................................... 193 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%............................................................. 193 sulfacetamide sodium shampoo 10% (Ovace plus).............................................................................. 214 SULFACETAMIDE SODIUM -sulfacetamide sodium ophth oint 10%........................................................................ 193 SULFACETAMIDE SODIUM -sulfacetamide sodium powder........................................................................... 214 sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls cleanser).................................................................. 214 sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% (Plexion cleanser)....................................................... 214 sulfacetamide sodium w/ sulfur cleansing pad 10-4% (Sumaxin)..................................................................... 214 sulfacetamide sodium w/ sulfur cream 10-5%........... 214 sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e ls)................................................................................... 214 sulfacetamide sodium w/ sulfur cream 9.8-4.8% (Plexion)....................................................................... 214 sulfacetamide sodium w/ sulfur emulsion 10-1%...... 214 sulfacetamide sodium w/ sulfur emulsion 10-5%...... 214 sulfacetamide sodium w/ sulfur lotion 9.8-4.8% (Plexion)....................................................................... 214 sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts).................................................................................. 214 sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash)......................................................... 214
STRATTERA -atomoxetine hcl cap 18 mg (base equiv)............................................................................. 130 STRATTERA -atomoxetine hcl cap 25 mg (base equiv)............................................................................. 130 STRATTERA -atomoxetine hcl cap 40 mg (base equiv)............................................................................. 130 STRATTERA -atomoxetine hcl cap 60 mg (base equiv)............................................................................. 130 STRATTERA -atomoxetine hcl cap 80 mg (base equiv)............................................................................. 130 STRATTERA -atomoxetine hcl cap 100 mg (base equiv)............................................................................. 130 STRAWBERRY FLAVOR -flavoring agent - liquid.......... 273 STRENSIQ -asfotase alfa subcutaneous inj 18 mg/0.45ml........................................................................ 60 STRENSIQ -asfotase alfa subcutaneous inj 28 mg/0.7ml.......................................................................... 60 STRENSIQ -asfotase alfa subcutaneous inj 40 mg/ml..... 60 STRENSIQ -asfotase alfa subcutaneous inj 80 mg/0.8ml.......................................................................... 60 STREPTOMYCIN SULFATE -streptomycin sulfate for inj 1 gm...................................................................................... 8 STREPTOMYCIN SULFATE -streptomycin sulfate powder............................................................................... 8 STRIANT -testosterone buccal mucoadhesive system 30 mg.................................................................................... 38 STRIBILD -elvitegrav-cobic-emtricitab-tenofovdf tab 150-150-200-300 mg...................................................... 14 STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln 2.5 mcg/act (base equiv)................................................ 94 STROMECTOL -ivermectin tab 3 mg................................16 STRONTIUM CHLORIDE -strontium chloride (bulk) crystals.......................................................................... 256 STRONTIUM CHLORIDE -strontium chloride (bulk) powder........................................................................... 256 STRONTIUM NITRATE -strontium nitrate (bulk) crystals.......................................................................... 256 STROVITE FORTE -multiple vitamins w/ minerals & fa syrup 1 mg/15ml........................................................... 173 STROVITE FORTE -multiple vitamins w/ minerals tab.................................................................................. 173 STROVITE ONE -multiple vitamins w/ minerals tab....... 173 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)............................................................ 145 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)............................................................ 145 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv)............................................................ 145 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv)............................................................ 145 SUBSYS -fentanyl sublingual spray 100 mcg................. 145 SUBSYS -fentanyl sublingual spray 200 mcg................. 145 SUBSYS -fentanyl sublingual spray 400 mcg................. 145 SUBSYS -fentanyl sublingual spray 600 mcg................. 145 SUBSYS -fentanyl sublingual spray 800 mcg................. 145
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
385
2016 sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash).............................................................................214 SULFACETAMIDE -sulfacetamide (bulk) powder........... 256 SULFADIAZINE SODIUM -sulfadiazine sodium powder............................................................................... 8 SULFADIAZINE -sulfadiazine powder................................. 8 SULFADIAZINE -sulfadiazine tab 500 mg.......................... 8 SULFADIMETHOXINE -sulfadimethoxine (bulk) powder........................................................................... 256 SULFAMERAZINE -sulfamerazine (bulk) powder...........256 SULFAMETHOXAZOLE MICRO -sulfamethoxazole powder............................................................................... 8 SULFAMETHOXAZOLE -sulfamethoxazole powder.......... 8 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml............................................................................ 18 sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)......................................................................... 18 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds)................................................................... 18 SULFAMYLON -mafenide acetate cream 85 mg/gm...... 214 SULFAMYLON -mafenide acetate packet for topical soln 5% (50 gm)................................................................... 214 SULFANILAMIDE -sulfanilamide powder........................ 256 SULFAPYRIDINE -sulfapyridine powder............................. 8 SULFASALAZINE -sulfasalazine powder........................ 104 sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs).........................................................................104 sulfasalazine tab 500 mg (Azulfidine)......................... 104 SULFATHIAZOLE -sulfathiazole powder.............................8 SULFISOXIZOLE -sulfisoxazole crystals............................ 8 SULFOSALICYLIC ACID DIHYD -sulfosalicylic acid dihydrate (bulk) powder................................................ 256 SULFURATED LIME -sulfurated lime solution................ 214 SULFURIC ACID -sulfuric acid soln................................ 256 SULFUR PRECIPITATED -sulfur (bulk) powder............. 256 SULFUR SUBLIMED -sulfur (bulk) powder.................... 256 SULFUR -sulfur (bulk) powder........................................ 256 SULINDAC -sulindac powder.......................................... 151 sulindac tab 150 mg...................................................... 151 sulindac tab 200 mg...................................................... 151 SULPHAN BLUE -isosulfan blue (bulk) powder..............273 SULPIRIDE -sulpiride (bulk) powder............................... 256 SUMADAN WASH -sulfacetamide sodium w/ sulfur wash 9-4.5%........................................................................... 214 sumatriptan nasal spray 5 mg/act (Imitrex)................ 152 sumatriptan nasal spray 20 mg/act (Imitrex).............. 152 sumatriptan succinate inj 6 mg/0.5ml (Imitrex).......... 152 sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdose sys)............................... 152 sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys)............................... 152 sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref).................................................. 153 sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref).................................................. 153
SUMATRIPTAN SUCCINATE -sumatriptan succinate (bulk) powder................................................................ 256 SUMATRIPTAN SUCCINATE -sumatriptan succinate solution prefilled syringe 6 mg/0.5ml........................... 152 sumatriptan succinate tab 25 mg (Imitrex)................. 153 sumatriptan succinate tab 50 mg (Imitrex)................. 153 sumatriptan succinate tab 100 mg (Imitrex)............... 153 SUMATRIPTAN -sumatriptan (bulk) powder................... 256 SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 4 mg/0.5ml....................................................... 153 SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 6 mg/0.5ml....................................................... 153 SUMAXIN -sulfacetamide sodium w/ sulfur cleansing pad 10-4%............................................................................ 214 SUMAXIN TS -sulfacetamide sodium w/ sulfur susp 8-4%.............................................................................. 214 SUMAXIN WASH -sulfacetamide sodium w/ sulfur wash 9-4%.............................................................................. 214 SUPEROXIDE DISMUTASE -superoxide dismutase (bulk) powder........................................................................... 256 SUPEROXIDE DISMUTASE -superoxide dismutase (bulk) solution.......................................................................... 256 SUPER SYNERSWEET FLAVOR -flavoring agent powder........................................................................... 273 SUPERVITE -b-complex w/ lysine-zn & folic acid liquid.............................................................................. 173 SUPPORT -multiple vitamins w/ minerals liquid............. 173 SUPPORT-500 -speciality vitamin product cap.............. 173 SUPPRELIN LA -histrelin acetate (cpp) implant kit 50 mg.................................................................................... 60 SUPRAX -cefixime cap 400 mg.......................................... 5 SUPRAX -cefixime chew tab 100 mg................................. 5 SUPRAX -cefixime chew tab 200 mg................................. 5 SUPRAX -cefixime for susp 100 mg/5ml............................ 5 SUPRAX -cefixime for susp 200 mg/5ml............................ 5 SUPRAX -cefixime for susp 500 mg/5ml............................ 5 SUPREP BOWEL PREP KIT -sodium sulfate-potassium sulfate-magnesium sulfate oral soln.............................. 96 SURE-T INFUSION SET 18" -subcutaneous infusion set.................................................................................. 261 SURE-T INFUSION SET 23" -subcutaneous infusion set.................................................................................. 261 SURE-T INFUSION SET 32" -subcutaneous infusion set.................................................................................. 261 SURE-T INFUSION SET 6MM -subcutaneous infusion set.................................................................................. 261 SURE-T INFUSION SET 8MM -subcutaneous infusion set.................................................................................. 262 SURMONTIL -trimipramine maleate cap 25 mg............. 115 SURMONTIL -trimipramine maleate cap 50 mg............. 115 SURMONTIL -trimipramine maleate cap 100 mg........... 115 SURVANTA INTRATRACHEAL -beractant in nacl 0.9% intratracheal susp 25 mg/ml........................................... 95 SUSPENSION VEHICLE -oral vehicles - susp............... 273 SUSTIVA -efavirenz cap 50 mg........................................ 14
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
386
2016 SYNJARDY -empagliflozin-metformin hcl tab 5-500 mg.................................................................................... 50 SYNJARDY -empagliflozin-metformin hcl tab 5-1000 mg.................................................................................... 50 SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr 5-1000 mg....................................................................... 50 SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr 10-1000 mg..................................................................... 50 SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr 12.5-1000 mg.................................................................. 50 SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr 25-1000 mg..................................................................... 50 SYNRIBO -omacetaxine mepesuccinate for inj 3.5 mg.................................................................................... 30 SYNTHROID -levothyroxine sodium tab 25 mcg.............. 53 SYNTHROID -levothyroxine sodium tab 50 mcg.............. 53 SYNTHROID -levothyroxine sodium tab 75 mcg.............. 53 SYNTHROID -levothyroxine sodium tab 88 mcg.............. 53 SYNTHROID -levothyroxine sodium tab 100 mcg............ 53 SYNTHROID -levothyroxine sodium tab 112 mcg............ 53 SYNTHROID -levothyroxine sodium tab 125 mcg............ 53 SYNTHROID -levothyroxine sodium tab 137 mcg............ 54 SYNTHROID -levothyroxine sodium tab 150 mcg............ 54 SYNTHROID -levothyroxine sodium tab 175 mcg............ 54 SYNTHROID -levothyroxine sodium tab 200 mcg............ 54 SYNTHROID -levothyroxine sodium tab 300 mcg............ 54 SYPRINE -trientine hcl cap 250 mg................................ 277 SYRPALTA -oral vehicles - syrup.................................... 273 SYRPALTA -simple - syrup.............................................. 273 SYRSPEND SF -oral vehicles......................................... 273 SYRSPEND SF PH4 -oral vehicles for susp.................. 273 SYRUP VEHICLE -oral vehicles - syrup......................... 273 SYRUP VEHICLE SF -oral vehicles - syrup................... 273
SUSTIVA -efavirenz cap 200 mg...................................... 14 SUSTIVA -efavirenz tab 600 mg....................................... 14 SUTENT -sunitinib malate cap 12.5 mg (base equivalent)....................................................................... 30 SUTENT -sunitinib malate cap 25 mg (base equivalent)....................................................................... 30 SUTENT -sunitinib malate cap 37.5 mg (base equivalent)....................................................................... 30 SUTENT -sunitinib malate cap 50 mg (base equivalent)....................................................................... 30 SWEET CORN FLAVOR CONCENT -flavoring agent concentrate.................................................................... 273 SYLATRON -peginterferon alfa-2b for inj kit 296 mcg...... 30 SYLATRON -peginterferon alfa-2b for inj kit 444 mcg...... 30 SYLATRON -peginterferon alfa-2b for inj kit 888 mcg...... 30 SYMAX DUOTAB -hyoscyamine sulfate tab er 0.375 mg (0.125 mg ir/0.25 mg er).............................................. 100 SYMBICORT -budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act................................................... 94 SYMBICORT -budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/act................................................. 94 SYMBYAX -olanzapine-fluoxetine hcl cap 3-25 mg........ 134 SYMBYAX -olanzapine-fluoxetine hcl cap 6-25 mg........ 134 SYMBYAX -olanzapine-fluoxetine hcl cap 6-50 mg........ 134 SYMBYAX -olanzapine-fluoxetine hcl cap 12-25 mg...... 134 SYMBYAX -olanzapine-fluoxetine hcl cap 12-50 mg...... 134 SYMLINPEN 120 -pramlintide acetate pen-inj 2700 mcg/2.7ml (1000 mcg/ml)............................................... 50 SYMLINPEN 60 -pramlintide acetate pen-inj 1500 mcg/1.5ml (1000 mcg/ml)............................................... 50 SYNAGEX -multiple vitamins w/ minerals & fa cap 1.25 mg.................................................................................. 173 SYNAGIS -palivizumab im soln 50 mg/0.5ml....................24 SYNAGIS -palivizumab im soln 100 mg/ml.......................24 SYN-AKE -dipeptide diaminobutylroyl benzylamide diacetate liqd................................................................. 256 SYNALAR -fluocinolone acetonide cream 0.025%......... 214 SYNALAR -fluocinolone acetonide oint 0.025%............. 214 SYNALAR -fluocinolone acetonide soln 0.01%.............. 214 SYNALGOS-DC -aspirin-caffeine-dihydrocodeine cap 356.4-30-16 mg.............................................................145 SYNAPRYN FUSEPAQ -tramadol hcl for oral susp 10 mg/ ml (compound kit)......................................................... 145 SYNAPSIN -pharmaceutical excipients (bulk) powder........................................................................... 273 SYNAREL -nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) (base eq)..........................................................60 SYNATEK -multiple vitamins w/ minerals & fa cap 1.25 mg.................................................................................. 174 SYNERA -lidocaine-tetracaine topical patch 70-70 mg.................................................................................. 215 SYNJARDY -empagliflozin-metformin hcl tab 12.5-1000 mg.................................................................................... 50 SYNJARDY -empagliflozin-metformin hcl tab 12.5-500 mg.................................................................................... 50
T TABLOID -thioguanine tab 40 mg..................................... 30 TABRADOL FUSEPAQ -cyclobenzaprine hcl w/ msm oral susp 1 mg/ml (cmpd kit)............................................... 169 TABRADOL RAPIDPAQ -cyclobenzaprine hcl w/ msm oral susp 1 mg/ml (cmpd kit)........................................169 tacrolimus cap 0.5 mg (Prograf).................................. 277 tacrolimus cap 1 mg (Prograf)..................................... 277 tacrolimus cap 5 mg (Prograf)..................................... 277 TACROLIMUS MONOHYDRATE -tacrolimus (bulk) powder........................................................................... 256 tacrolimus oint 0.03% (Protopic)................................. 215 tacrolimus oint 0.1% (Protopic)................................... 215 TACROLIMUS -tacrolimus (bulk) powder....................... 256 TAFINLAR -dabrafenib mesylate cap 50 mg (base equivalent)....................................................................... 30 TAFINLAR -dabrafenib mesylate cap 75 mg (base equivalent)....................................................................... 30 TAGRISSO -osimertinib mesylate tab 40 mg (base equivalent)....................................................................... 30 TAGRISSO -osimertinib mesylate tab 80 mg (base equivalent)....................................................................... 30 SM
Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
387
2016 TAZORAC -tazarotene gel 0.05%................................... 215 TAZORAC -tazarotene gel 0.1%..................................... 215 TBC -trypsin w/ castor oil & peruvian balsam spray....... 215 TDC MAX CREAM -transdermal base cream................. 273 TDM SOLUTION -external vehicles - solution................ 273 TEABERRY FLAVOR -flavoring agent - oil..................... 273 TEA COCOYL GLUTAMINE -triethanolamine cocoyl glutamate (bulk) soln.................................................... 256 TEA TREE OIL -tea tree oil (bulk).................................. 257 TECFIDERA -dimethyl fumarate capsule delayed release 120 mg.......................................................................... 134 TECFIDERA -dimethyl fumarate capsule delayed release 240 mg.......................................................................... 135 TECFIDERA STARTER PACK -dimethyl fumarate capsule dr starter pack 120 mg & 240 mg................... 135 TECHNIVIE -ombitasvir-paritaprevir-ritonavir tab 12.5-75-50 mg................................................................. 14 TEGADERM AG MESH DRESSING -wound dressings pads............................................................................... 215 TEGRETOL -carbamazepine susp 100 mg/5ml............. 162 TEGRETOL -carbamazepine tab 200 mg....................... 162 TEGRETOL-XR -carbamazepine tab er 12hr 100 mg.................................................................................. 162 TEGRETOL-XR -carbamazepine tab er 12hr 200 mg.................................................................................. 162 TEGRETOL-XR -carbamazepine tab er 12hr 400 mg.................................................................................. 162 TEKTURNA -aliskiren fumarate tab 150 mg (base equivalent)....................................................................... 76 TEKTURNA -aliskiren fumarate tab 300 mg (base equivalent)....................................................................... 76 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 150-12.5 mg.................................................................... 76 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 150-25 mg....................................................................... 76 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 300-12.5 mg.................................................................... 76 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 300-25 mg....................................................................... 76 telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 76 telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 77 telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 77 telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 77 telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct)................................................................. 77 telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct)................................................................. 77 telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct)................................................................. 77 telmisartan tab 20 mg (Micardis)................................... 76 telmisartan tab 40 mg (Micardis)................................... 76 telmisartan tab 80 mg (Micardis)................................... 76 temazepam cap 7.5 mg (Restoril)................................ 124 temazepam cap 15 mg (Restoril)................................. 124 temazepam cap 22.5 mg (Restoril).............................. 124
TALC -talc powder........................................................... 256 TALTZ -ixekizumab subcutaneous soln auto-injector 80 mg/ml............................................................................. 215 TALTZ -ixekizumab subcutaneous soln prefilled syringe 80 mg/ml....................................................................... 215 TALWIN -pentazocine lactate inj 30 mg/ml..................... 145 TAMIFLU -oseltamivir phosphate cap 30 mg (base equiv)............................................................................... 14 TAMIFLU -oseltamivir phosphate cap 45 mg (base equiv)............................................................................... 14 TAMIFLU -oseltamivir phosphate cap 75 mg (base equiv)............................................................................... 14 TAMIFLU -oseltamivir phosphate for susp 6 mg/ml (base equiv)............................................................................... 14 tamoxifen citrate tab 10 mg (base equivalent)............. 30 tamoxifen citrate tab 20 mg (base equivalent)............. 30 TAMOXIFEN CITRATE -tamoxifen citrate (bulk) powder........................................................................... 256 tamsulosin hcl cap 0.4 mg........................................... 109 TANDEM F -ferrous fum-iron polysacch-fa cap 162-115.2-1 mg (106 mg fe)........................................ 184 TANDEM PLUS -fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap.................................................. 184 TANGERINE FLAVOR -flavoring agent - oil................... 273 TANGERINE FLAVOR SWEETENE -flavoring agent powder........................................................................... 273 TANNIC ACID -tannic acid powder................................. 215 TANZEUM -albiglutide for soln pen-injector 30 mg........... 50 TANZEUM -albiglutide for soln pen-injector 50 mg........... 50 TAPAZOLE -methimazole tab 5 mg.................................. 54 TAPAZOLE -methimazole tab 10 mg................................ 54 TARCEVA -erlotinib hcl tab 25 mg (base equivalent)....... 30 TARCEVA -erlotinib hcl tab 100 mg (base equivalent)..... 30 TARCEVA -erlotinib hcl tab 150 mg (base equivalent)..... 30 TARGRETIN -bexarotene cap 75 mg................................30 TARGRETIN -bexarotene gel 1%....................................215 TARKA -trandolapril-verapamil hcl tab er 1-240 mg......... 76 TARKA -trandolapril-verapamil hcl tab er 2-180 mg......... 76 TARKA -trandolapril-verapamil hcl tab er 2-240 mg......... 76 TARKA -trandolapril-verapamil hcl tab er 4-240 mg......... 76 TARON FORTE -fe bisglycinate-fe polysacch-vit c-vit b12fa cap............................................................................ 184 TARTARIC ACID -tartaric acid granules......................... 256 TARTARIC ACID -tartaric acid powder........................... 256 TASIGNA -nilotinib hcl cap 150 mg (base equivalent)...... 30 TASIGNA -nilotinib hcl cap 200 mg (base equivalent)...... 30 TASMAR -tolcapone tab 100 mg.....................................167 TAURINE -taurine liquid (bulk)........................................ 178 TAURINE -taurine powder............................................... 178 TAYTULLA -norethindrone ace-ethinyl estradiol-fe cap 1 mg-20 mcg (24).............................................................. 45 tazarotene cream 0.1% (Tazorac)................................. 215 TAZAROTENE -tazarotene (bulk) powder...................... 256 TAZORAC -tazarotene cream 0.05%.............................. 215 TAZORAC -tazarotene cream 0.1%................................ 215
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
388
2016 temazepam cap 30 mg (Restoril)................................. 124 TEMODAR -temozolomide cap 5 mg................................ 30 TEMODAR -temozolomide cap 20 mg.............................. 30 TEMODAR -temozolomide cap 100 mg............................ 30 TEMODAR -temozolomide cap 140 mg............................ 30 TEMODAR -temozolomide cap 180 mg............................ 30 TEMODAR -temozolomide cap 250 mg............................ 30 TEMOVATE -clobetasol propionate cream 0.05%.......... 215 TEMOVATE -clobetasol propionate gel 0.05%............... 215 TEMOVATE -clobetasol propionate oint 0.05%.............. 215 TEMOVATE -clobetasol propionate soln 0.05%..............215 temozolomide cap 5 mg (Temodar)............................... 30 temozolomide cap 20 mg (Temodar)............................. 30 temozolomide cap 100 mg (Temodar)........................... 30 temozolomide cap 140 mg (Temodar)........................... 30 temozolomide cap 180 mg (Temodar)........................... 30 temozolomide cap 250 mg (Temodar)........................... 30 TENCON -butalbital-acetaminophen tab 50-325 mg...... 136 TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu......... 22 TENORETIC 100 -atenolol & chlorthalidone tab 100-25 mg.................................................................................... 77 TENORETIC 50 -atenolol & chlorthalidone tab 50-25 mg.................................................................................... 77 TENORMIN -atenolol tab 25 mg....................................... 64 TENORMIN -atenolol tab 50 mg....................................... 64 TENORMIN -atenolol tab 100 mg..................................... 64 TERAZOL 7 -terconazole vaginal cream 0.4%............... 107 terazosin hcl cap 1 mg....................................................77 terazosin hcl cap 2 mg....................................................77 terazosin hcl cap 5 mg....................................................77 terazosin hcl cap 10 mg..................................................77 terbinafine hcl tab 250 mg (Lamisil).............................. 10 TERBINAFINE HCL -terbinafine hcl (bulk) powder.........257 terbutaline sulfate inj 1 mg/ml....................................... 94 terbutaline sulfate tab 2.5 mg........................................ 94 terbutaline sulfate tab 5 mg........................................... 94 TERBUTALINE SULFATE -terbutaline sulfate powder..... 94 terconazole vaginal cream 0.4% (Terazol 7)............... 107 terconazole vaginal cream 0.8% (Terazol 3)............... 107 terconazole vaginal suppos 80 mg............................. 107 TERODERM -cream base............................................... 273 TERODERM-PLUS -cream base.................................... 273 TERPIN HYDRATE MONOHYDRAT -terpin hydrate powder............................................................................. 89 TERPIN HYDRATE -terpin hydrate powder...................... 89 TESSALON PERLES -benzonatate cap 100 mg.............. 89 TESTIM -testosterone td gel 50 mg/5gm (1%)................. 38 TESTOPEL -testosterone implant pellets 75 mg.............. 38 TESTOSTERONE CONCENTRATE -testosterone (bulk) cream 20%.................................................................... 257 testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................. 38 testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................. 38
TESTOSTERONE CYPIONATE -testosterone cypionate (bulk) powder................................................................ 257 testosterone enanthate im inj in oil 200 mg/ml............ 38 TESTOSTERONE ENANTHATE -testosterone enanthate (bulk) powder................................................................ 257 TESTOSTERONE MICRONIZED S -testosterone (bulk) powder........................................................................... 257 TESTOSTERONE MICRONIZED -testosterone micronized (bulk) powder............................................. 257 TESTOSTERONE MICRONIZED ( -testosterone micronized (bulk) powder............................................. 257 TESTOSTERONE MICRONIZED Y -testosterone micronized (bulk) crystals............................................. 257 TESTOSTERONE NON-MICRONIZ -testosterone (bulk) powder........................................................................... 257 TESTOSTERONE PROPIONATE -testosterone propionate (bulk) powder..............................................257 TESTOSTERONE PUMP -testosterone td gel 12.5 mg/act (1%)................................................................................. 39 testosterone td gel 12.5 mg/act (1%) (Androgel pump).............................................................................. 39 testosterone td gel 25 mg/2.5gm (1%) (Androgel)....... 39 testosterone td gel 50 mg/5gm (1%) (Androgel).......... 39 testosterone td soln 30 mg/act (Axiron)....................... 39 TESTOSTERONE -testosterone (bulk) powder.............. 257 TESTOSTERONE -testosterone td gel 10mg/act (2%)................................................................................. 38 TESTOSTERONE -testosterone td gel 25 mg/2.5gm (1%)................................................................................. 38 TESTOSTERONE -testosterone td gel 50 mg/5gm (1%)................................................................................. 38 TESTRED -methyltestosterone cap 10 mg....................... 39 TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml.............................................. 22 tetrabenazine tab 12.5 mg (Xenazine)......................... 135 tetrabenazine tab 25 mg (Xenazine)............................ 135 tetracaine hcl ophth soln 0.5%.................................... 193 TETRACAINE HCL -tetracaine hcl inj 1%.......................156 TETRACAINE HCL -tetracaine hcl powder..................... 156 TETRACAINE -tetracaine (bulk) powder.........................257 tetracycline hcl cap 250 mg (Tetracycline hcl)............... 7 tetracycline hcl cap 500 mg (Tetracycline hcl)............... 7 TETRACYCLINE HCL -tetracycline hcl cap 250 mg...........7 TETRACYCLINE HCL -tetracycline hcl cap 500 mg...........7 TETRACYCLINE HCL -tetracycline hcl powder..............215 TETRAHYDROBIOPTERIN DIHYD -tetrahydrobiopterin dihydrochloride (bulk) powder...................................... 257 TETRAHYDROBIOPTERIN HYDRO -tetrahydrobiopterin dihydrochloride (bulk) powder...................................... 257 TETRAHYDRO-L-BIOPTERIN DI -tetrahydrobiopterin dihydrochloride (bulk) powder...................................... 257 TETRAHYDROZOLINE HCL -tetrahydrozoline hcl (bulk) powder........................................................................... 257 TETRIX -dermatological products misc - cream............. 215 TEXACORT -hydrocortisone soln 2.5%.......................... 215
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
389
2016 TEXAVITE LQ -pediatric multivitamins w/fl-fe-zn drops 0.25-7-3 mg/ml.............................................................. 174 TGQ 15DM/5PEH/2CPM -phenylephrine-chlorphen-dm syrup 5-2-15 mg/5ml.......................................................90 TGQ 30PSE/3BRM/15DM -pseudoephed-bromphen-dm syrup 30-3-15 mg/5ml.....................................................90 TGQ 30PSE/150GFN/15DM -pseudoephedrine w/ dm-gg syrup 30-15-150 mg/5ml................................................ 90 THALOMID -thalidomide cap 50 mg............................... 277 THALOMID -thalidomide cap 100 mg............................. 277 THALOMID -thalidomide cap 150 mg............................. 277 THALOMID -thalidomide cap 200 mg............................. 277 THEANINE -theanine (bulk) powder............................... 257 THEOBROMINE -theobromine (bulk) powder................ 257 THEOPHYLLINE ANHYDROUS -theophylline powder........................................................................... 257 theophylline soln 80 mg/15ml........................................ 94 theophylline tab er 12hr 100 mg.................................... 94 theophylline tab er 12hr 200 mg.................................... 94 theophylline tab er 12hr 300 mg.................................... 94 theophylline tab er 12hr 450 mg.................................... 94 theophylline tab er 24hr 400 mg.................................... 94 theophylline tab er 24hr 600 mg.................................... 94 THEO-24 -theophylline cap er 24hr 100 mg..................... 94 THEO-24 -theophylline cap er 24hr 200 mg..................... 94 THEO-24 -theophylline cap er 24hr 300 mg..................... 94 THEO-24 -theophylline cap er 24hr 400 mg..................... 94 THERACYS -bcg live intravesical for susp 81 mg/vial...... 31 THERA-FLUR-N -sodium fluoride gel 1.1% (0.5% f)...... 196 THERAHONEY -wound dressings - gel.......................... 215 THIABENDAZOLE -thiabendazole powder....................... 16 thiamine hcl inj 100 mg/ml........................................... 170 THIAMINE HCL -thiamine hcl powder............................ 170 THIAMINE HYDROCHLORIDE -thiamine hcl powder........................................................................... 170 THIOGUANINE -thioguanine (bulk) powder................... 257 THIOLA -tiopronin tab 100 mg........................................ 109 thioridazine hcl tab 10 mg............................................ 122 thioridazine hcl tab 25 mg............................................ 122 thioridazine hcl tab 50 mg............................................ 122 thioridazine hcl tab 100 mg.......................................... 122 THIORIDAZINE HCL -thioridazine hcl (bulk) powder..... 257 THIOSALICYLIC ACID SODIUM -sodium thiosalicylate (bulk) powder................................................................ 257 THIOTEPA -thiotepa (bulk) powder................................. 257 thiothixene cap 1 mg..................................................... 122 thiothixene cap 2 mg..................................................... 122 thiothixene cap 5 mg..................................................... 122 thiothixene cap 10 mg...................................................122 THREONINE -threonine powder..................................... 178 THRIVACIN DETOX -nutritional supplement liquid......... 179 THRIVACIN 30 -nutritional supplement liquid................. 179 THROMBIN-JMI DILUENT -thrombin for soln 5000 unit................................................................................. 187
THROMBIN-JMI DILUENT -thrombin for soln 20000 unit................................................................................. 187 THROMBIN-JMI EPISTAXIS -thrombin for soln kit 5000 unit................................................................................. 187 THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit 5000 unit....................................................................... 187 THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit 20000 unit..................................................................... 187 THROMBIN-JMI W/DIL SPRAY -thrombin for soln kit 20000 unit..................................................................... 187 THROMBOGEN -thrombin for soln kit 10000 unit.......... 187 THROMBOGEN -thrombin for soln 1000 unit................. 187 THROMBOGEN -thrombin for soln 10000 unit............... 187 THYMOL IODIDE -thymol iodide powder....................... 257 THYMOL -thymol crystals................................................257 THYROID PORCINE -thyroid powder............................... 54 thyroid tab 15 mg (1/4 grain) (Armour thyroid)............ 54 thyroid tab 30 mg (1/2 grain) (Armour thyroid)............ 54 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)......... 54 thyroid tab 60 mg (1 grain) (Armour thyroid)............... 54 thyroid tab 120 mg (2 grain) (Armour thyroid)............. 54 THYROID -thyroid (porcine) (bulk) powder..................... 257 THYROID -thyroid powder................................................. 54 THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25 mcg)................................................................................. 54 THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5 mcg)................................................................................. 54 THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg)......54 THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100 mcg)................................................................................. 54 THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150 mcg)................................................................................. 54 tiagabine hcl tab 2 mg (Gabitril).................................. 162 tiagabine hcl tab 4 mg (Gabitril).................................. 163 TIAZAC -diltiazem hcl extended release beads cap er 24hr 120 mg....................................................................66 TIAZAC -diltiazem hcl extended release beads cap er 24hr 180 mg....................................................................66 TIAZAC -diltiazem hcl extended release beads cap er 24hr 240 mg....................................................................66 TIAZAC -diltiazem hcl extended release beads cap er 24hr 300 mg....................................................................66 TIAZAC -diltiazem hcl extended release beads cap er 24hr 360 mg....................................................................66 TIAZAC -diltiazem hcl extended release beads cap er 24hr 420 mg....................................................................66 TICARCILLIN DISODIUM/CLAV -ticarcillin-pot clavulanate (bulk) powder 30:1........................................................ 257 TICE BCG -bcg live intravesical for susp 50 mg...............31 TIGAN -trimethobenzamide hcl cap 300 mg................... 101 TIGAN -trimethobenzamide hcl inj 100 mg/ml................ 101 TIGHTENING BASE -cream base.................................. 273 TIKOSYN -dofetilide cap 125 mcg (0.125 mg)................. 68 TIKOSYN -dofetilide cap 250 mcg (0.25 mg)................... 68 TIKOSYN -dofetilide cap 500 mcg (0.5 mg)..................... 68
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
390
2016 timolol maleate ophth gel forming soln 0.25% (Timoptic-xe)................................................................ 193 timolol maleate ophth gel forming soln 0.5% (Timoptic-xe)................................................................ 193 timolol maleate ophth soln 0.25% (Timoptic)............. 193 timolol maleate ophth soln 0.5% (Timoptic)............... 193 TIMOLOL MALEATE -timolol maleate powder................. 64 TIMOLOL MALEATE -timolol maleate tab 5 mg............... 64 TIMOLOL MALEATE -timolol maleate tab 10 mg............. 64 TIMOLOL MALEATE -timolol maleate tab 20 mg............. 64 TIMOPTIC OCUDOSE -timolol maleate preservative free ophth soln 0.25%.......................................................... 193 TIMOPTIC OCUDOSE -timolol maleate preservative free ophth soln 0.5%............................................................ 193 TIMOPTIC -timolol maleate ophth soln 0.25%................193 TIMOPTIC -timolol maleate ophth soln 0.5%..................193 TIMOPTIC-XE -timolol maleate ophth gel forming soln 0.25%.............................................................................193 TIMOPTIC-XE -timolol maleate ophth gel forming soln 0.5%...............................................................................193 TINDAMAX -tinidazole tab 500 mg................................... 18 tinidazole tab 250 mg (Tindamax)..................................18 tinidazole tab 500 mg (Tindamax)..................................18 TINIDAZOLE -tinidazole powder..................................... 257 TINOGARD TL -benzotriazolyl dodecyl p-cresol (bulk) liquid.............................................................................. 257 TIOPRONIN -tiopronin (bulk) powder............................. 258 TIROSINT -levothyroxine sodium cap 13 mcg..................54 TIROSINT -levothyroxine sodium cap 25 mcg..................54 TIROSINT -levothyroxine sodium cap 50 mcg..................54 TIROSINT -levothyroxine sodium cap 75 mcg..................54 TIROSINT -levothyroxine sodium cap 88 mcg..................54 TIROSINT -levothyroxine sodium cap 100 mcg................54 TIROSINT -levothyroxine sodium cap 112 mcg................ 54 TIROSINT -levothyroxine sodium cap 125 mcg................54 TIROSINT -levothyroxine sodium cap 137 mcg................54 TIROSINT -levothyroxine sodium cap 150 mcg................54 TISSEEL -fibrin sealant component solution.................. 187 TISSEEL VH -fibrin sealant component kit 2 ml............. 187 TISSEEL VH -fibrin sealant component kit 4 ml............. 187 TISSEEL VH -fibrin sealant component kit 10 ml........... 187 TITANIUM DIOXIDE -titanium dioxide liquid 30%........... 258 TITANIUM DIOXIDE -titanium dioxide powder............... 258 TIVICAY -dolutegravir sodium tab 10 mg (base equiv)..... 14 TIVICAY -dolutegravir sodium tab 25 mg (base equiv)..... 14 TIVICAY -dolutegravir sodium tab 50 mg (base equiv)..... 14 tizanidine hcl cap 2 mg (base equivalent) (Zanaflex)......................................................................169 tizanidine hcl cap 4 mg (base equivalent) (Zanaflex)......................................................................169 tizanidine hcl cap 6 mg (base equivalent) (Zanaflex)......................................................................169 tizanidine hcl tab 2 mg (base equivalent)................... 169 tizanidine hcl tab 4 mg (base equivalent) (Zanaflex)......................................................................169
TIZANIDINE HCL -tizanidine hcl (bulk) powder.............. 258 TL-FLUORIVITE -pediatric multiple vitamins w/ fl-fe chew tab 0.25-7.5 mg............................................................ 174 TL G-FOL OS -multiple vit w/ min & calcium-folic acid tab 500-1.1 mg.................................................................... 174 TOBI PODHALER -tobramycin inhal cap 28 mg.................8 TOBI -tobramycin nebu soln 300 mg/5ml........................... 8 TOBRADEX ST -tobramycin-dexamethasone ophth susp 0.3-0.05%...................................................................... 194 TOBRADEX -tobramycin-dexamethasone ophth oint 0.3-0.1%........................................................................ 193 TOBRADEX -tobramycin-dexamethasone ophth susp 0.3-0.1%........................................................................ 193 tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex).................................................................... 194 tobramycin nebu soln 300 mg/5ml (Tobi)....................... 8 tobramycin ophth soln 0.3% (Tobrex)......................... 194 tobramycin sulfate for inj 1.2 gm.....................................8 tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv)................................................................................ 8 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv)................................................................................ 8 TOBRAMYCIN SULFATE -tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv).................................... 8 TOBRAMYCIN SULFATE -tobramycin sulfate inj 10 mg/ml (base equivalent).............................................................. 8 TOBRAMYCIN SULFATE -tobramycin sulfate powder....... 8 TOBRAMYCIN -tobramycin (bulk) powder......................258 TOBRAMYCIN -tobramycin nebu soln 300 mg/5ml............ 8 TOBREX -tobramycin ophth oint 0.3%........................... 194 TOBREX -tobramycin ophth soln 0.3%........................... 194 TOCOPHERYL ACID SUCCINATE -vitamin e succinate (bulk) powder................................................................ 258 TOCOTRIENOLS -tocotrienols (bulk) susp 50%............ 258 TODAY SPONGE -nonoxynol-9 vaginal sponge 1000 mg.................................................................................. 107 TOFRANIL -imipramine hcl tab 10 mg............................ 115 TOFRANIL -imipramine hcl tab 25 mg............................ 115 TOFRANIL -imipramine hcl tab 50 mg............................ 115 TOLAK -fluorouracil cream 4%........................................215 TOLAZAMIDE -tolazamide tab 250 mg.............................50 TOLAZAMIDE -tolazamide tab 500 mg.............................50 TOLAZOLINE HYDROCHLORIDE -tolazoline hydrochloride (bulk) powder......................................... 258 TOLBUTAMIDE -tolbutamide tab 500 mg......................... 50 tolcapone tab 100 mg (Tasmar)................................... 167 TOLMETIN SODIUM -tolmetin sodium cap 400 mg....... 151 TOLMETIN SODIUM -tolmetin sodium tab 200 mg........ 151 TOLMETIN SODIUM -tolmetin sodium tab 600 mg........ 151 TOLNAFTATE -tolnaftate powder (compounding).......... 215 tolterodine tartrate cap er 24hr 2 mg (Detrol la)........ 106 tolterodine tartrate cap er 24hr 4 mg (Detrol la)........ 106 tolterodine tartrate tab 1 mg (Detrol).......................... 106 tolterodine tartrate tab 2 mg (Detrol).......................... 106 TOLTRAZURIL -toltrazuril (bulk) powder........................ 258
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
391
2016 tramadol-acetaminophen tab 37.5-325 mg (Ultracet)....................................................................... 146 TRAMADOL HCL ER -tramadol hcl cap er 24hr biphasic release 100 mg............................................................. 145 TRAMADOL HCL ER -tramadol hcl cap er 24hr biphasic release 150 mg............................................................. 146 TRAMADOL HCL ER -tramadol hcl cap er 24hr biphasic release 200 mg............................................................. 146 TRAMADOL HCL ER -tramadol hcl cap er 24hr biphasic release 300 mg............................................................. 146 tramadol hcl tab er 24hr biphasic release 100 mg..... 146 tramadol hcl tab er 24hr biphasic release 200 mg..... 146 tramadol hcl tab er 24hr biphasic release 300 mg..... 146 tramadol hcl tab er 24hr 100 mg..................................146 tramadol hcl tab er 24hr 200 mg..................................146 tramadol hcl tab er 24hr 300 mg..................................146 tramadol hcl tab 50 mg (Ultram).................................. 146 TRAMADOL HCL -tramadol hcl (bulk) powder............... 258 trandolapril tab 1 mg (Mavik)......................................... 77 trandolapril tab 2 mg (Mavik)......................................... 77 trandolapril tab 4 mg (Mavik)......................................... 77 trandolapril-verapamil hcl tab er 1-240 mg (Tarka)...... 77 trandolapril-verapamil hcl tab er 2-180 mg (Tarka)...... 77 trandolapril-verapamil hcl tab er 2-240 mg (Tarka)...... 77 trandolapril-verapamil hcl tab er 4-240 mg (Tarka)...... 77 tranexamic acid tab 650 mg (Lysteda)........................ 187 TRANEXAMIC ACID -tranexamic acid (bulk) powder........................................................................... 258 TRANILAST -tranilast (bulk) powder............................... 258 TRANSDERMAL PAIN BASE -transdermal base cream............................................................................. 273 TRANSDERM-SCOP -scopolamine td patch 72hr 1.5 mg.................................................................................. 101 TRANXENE T -clorazepate dipotassium tab 7.5 mg...... 110 tranylcypromine sulfate tab 10 mg (Parnate)............. 115 TRAVATAN Z -travoprost ophth soln 0.004% (benzalkonium free) (bak free)..................................... 194 trazodone hcl tab 50 mg............................................... 115 trazodone hcl tab 100 mg............................................. 115 trazodone hcl tab 150 mg............................................. 115 trazodone hcl tab 300 mg............................................. 115 TRAZODONE HCL -trazodone hcl powder.....................115 TRECATOR -ethionamide tab 250 mg................................ 9 TRELSTAR MIXJECT -triptorelin pamoate for im susp 3.75 mg........................................................................... 31 TRELSTAR MIXJECT -triptorelin pamoate for im susp 11.25 mg......................................................................... 31 TRELSTAR MIXJECT -triptorelin pamoate for im susp 22.5 mg........................................................................... 31 TRESIBA FLEXTOUCH -insulin degludec soln peninjector 100 unit/ml......................................................... 52 TRESIBA FLEXTOUCH -insulin degludec soln peninjector 200 unit/ml......................................................... 52 TRETINOIN (ALL-TRANS RETI -tretinoin powder..........215 tretinoin cap 10 mg......................................................... 31
TOLUIDINE BLUE O -tolonium chloride powder............ 258 TOMMY GEL -gel base - gel...........................................273 TOPAMAX SPRINKLE -topiramate sprinkle cap 15 mg.................................................................................. 163 TOPAMAX SPRINKLE -topiramate sprinkle cap 25 mg.................................................................................. 163 TOPAMAX -topiramate tab 25 mg...................................163 TOPAMAX -topiramate tab 50 mg...................................163 TOPAMAX -topiramate tab 100 mg.................................163 TOPAMAX -topiramate tab 200 mg.................................163 TOPICORT -desoximetasone cream 0.05%................... 215 TOPICORT -desoximetasone cream 0.25%................... 215 TOPICORT -desoximetasone gel 0.05%........................ 215 TOPICORT -desoximetasone oint 0.05%....................... 215 TOPICORT -desoximetasone oint 0.25%....................... 215 TOPICORT -desoximetasone spray 0.25%.................... 215 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25 mg.................................................................................. 163 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 50 mg.................................................................................. 163 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 100 mg.................................................................................. 163 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 150 mg.................................................................................. 163 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 200 mg.................................................................................. 163 topiramate sprinkle cap 15 mg (Topamax sprinkle)........................................................................163 topiramate sprinkle cap 25 mg (Topamax sprinkle)........................................................................163 topiramate tab 25 mg (Topamax)................................. 163 topiramate tab 50 mg (Topamax)................................. 163 topiramate tab 100 mg (Topamax)............................... 163 topiramate tab 200 mg (Topamax)............................... 163 TOPIRAMATE -topiramate (bulk) powder....................... 258 TOPROL XL -metoprolol succinate tab er 24hr 25 mg (tartrate equiv)................................................................. 64 TOPROL XL -metoprolol succinate tab er 24hr 50 mg (tartrate equiv)................................................................. 64 TOPROL XL -metoprolol succinate tab er 24hr 100 mg (tartrate equiv)................................................................. 64 TOPROL XL -metoprolol succinate tab er 24hr 200 mg (tartrate equiv)................................................................. 64 torsemide tab 5 mg (Demadex)...................................... 80 torsemide tab 10 mg (Demadex).................................... 80 torsemide tab 20 mg (Demadex).................................... 80 torsemide tab 100 mg (Demadex).................................. 80 TOUJEO SOLOSTAR -insulin glargine soln pen-injector 300 unit/ml.......................................................................52 TOVIAZ -fesoterodine fumarate tab er 24hr 4 mg.......... 106 TOVIAZ -fesoterodine fumarate tab er 24hr 8 mg.......... 106 TRACLEER -bosentan tab 62.5 mg.................................. 86 TRACLEER -bosentan tab 125 mg................................... 86 TRADJENTA -linagliptin tab 5 mg..................................... 50 TRAGACANTH -tragacanth powder................................273
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
392
2016 tretinoin cream 0.025% (Retin-a)................................. 215 tretinoin cream 0.05% (Retin-a)................................... 215 tretinoin cream 0.1% (Retin-a)..................................... 215 tretinoin gel 0.05% (Atralin).......................................... 215 tretinoin gel 0.01% (Retin-a)......................................... 215 tretinoin gel 0.025% (Retin-a)....................................... 215 tretinoin microsphere gel 0.04% (Retin-a micro)....... 215 tretinoin microsphere gel 0.1% (Retin-a micro)......... 215 TRETINOIN -tretinoin powder......................................... 215 TRETIN-X -tretinoin cream 0.075%................................ 215 TREXALL -methotrexate sodium tab 5 mg (base equiv)............................................................................... 31 TREXALL -methotrexate sodium tab 7.5 mg (base equiv)............................................................................... 31 TREXALL -methotrexate sodium tab 10 mg (base equiv)............................................................................... 31 TREXALL -methotrexate sodium tab 15 mg (base equiv)............................................................................... 31 TREXIMET -sumatriptan-naproxen sodium tab 10-60 mg.................................................................................. 153 TREXIMET -sumatriptan-naproxen sodium tab 85-500 mg.................................................................................. 153 TREZIX -acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg.............................................................146 TRIACETIN -triacetin (bulk) liquid................................... 258 triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog)...................................................................... 216 triamcinolone acetonide cream 0.025%...................... 216 triamcinolone acetonide cream 0.1%.......................... 216 triamcinolone acetonide cream 0.5%.......................... 216 triamcinolone acetonide dental paste 0.1%............... 196 triamcinolone acetonide lotion 0.025%....................... 216 triamcinolone acetonide lotion 0.1%........................... 216 triamcinolone acetonide nasal aerosol suspension 55 mcg/act (Nasacort aq).................................................. 88 triamcinolone acetonide oint 0.025%.......................... 216 triamcinolone acetonide oint 0.1%.............................. 216 triamcinolone acetonide oint 0.5%.............................. 216 TRIAMCINOLONE ACETONIDE -triamcinolone acetonide powder........................................................................... 216 TRIAMCINOLONE DIACETATE M -triamcinolone diacetate micronized powder..........................................37 TRIAMCINOLONE DIACETATE -triamcinolone diacetate micronized powder.......................................................... 37 TRIAMCINOLONE HEXACETONID -triamcinolone hexacetonide (bulk) powder......................................... 258 TRIAMCINOLONE -triamcinolone (bulk) powder............ 258 TRIAMTERENE/HYDROCHLOROTH -triamterene & hydrochlorothiazide cap 50-25 mg................................. 80 triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide).........................................................................80 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25)................................................................... 80 triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide)........................................................................ 80
TRIAMTERENE -triamterene powder............................... 80 TRIANEX -triamcinolone acetonide oint 0.05%.............. 216 triazolam tab 0.25 mg (Halcion)................................... 124 TRIAZOLAM -triazolam tab 0.125 mg............................. 124 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg............................................................ 77 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg............................................................ 77 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg............................................................... 77 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg.......................................................... 77 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg............................................................. 77 TRICHLORMETHIAZIDE -trichlormethiazide (bulk) powder........................................................................... 258 TRICHLOROACETIC ACID -trichloroacetic acid crystals.......................................................................... 216 TRICHLOROACETIC ACID -trichloroacetic acid powder........................................................................... 216 TRI-CHLOR -trichloroacetic acid liqd 80%......................216 TRICITRASOL -anticoagulant sodium citrate concentrate 46.7%.............................................................................186 TRICLOSAN -triclosan (bulk) powder............................. 258 TRICOR -fenofibrate tab 48 mg........................................ 84 TRICOR -fenofibrate tab 145 mg...................................... 84 TRIDESILON -desonide cream 0.05%............................216 TRIESENCE -triamcinolone acetonide ophth inj 40 mg/ ml................................................................................... 194 TRIETHANOLAMINE LAURYL SU -triethanolamine lauryl sulfate (bulk) liquid........................................................258 trifluoperazine hcl tab 1 mg......................................... 122 trifluoperazine hcl tab 2 mg......................................... 122 trifluoperazine hcl tab 5 mg......................................... 122 trifluoperazine hcl tab 10 mg....................................... 122 trifluridine ophth soln 1% (Viroptic)............................ 194 TRIFLURIDINE -trifluridine (bulk) powder....................... 258 TRIGLIDE -fenofibrate tab 160 mg................................... 84 trihexyphenidyl hcl elixir 0.4 mg/ml............................ 167 trihexyphenidyl hcl tab 2 mg........................................167 trihexyphenidyl hcl tab 5 mg........................................167 TRIIODO-L-THYRONINE -liothyronine sodium powder............................................................................. 54 TRILEPTAL -oxcarbazepine susp 300 mg/5ml (60 mg/ ml).................................................................................. 163 TRILEPTAL -oxcarbazepine tab 150 mg........................ 163 TRILEPTAL -oxcarbazepine tab 300 mg........................ 163 TRILEPTAL -oxcarbazepine tab 600 mg........................ 163 TRILIPIX -choline fenofibrate cap dr 45 mg (fenofibric acid equiv)....................................................................... 84 TRILIPIX -choline fenofibrate cap dr 135 mg (fenofibric acid equiv)....................................................................... 84 TRILOSTANE -trilostane (bulk) powder.......................... 258 TRIMEPRAZINE TARTRATE -trimeprazine tartrate (bulk) powder........................................................................... 258
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
393
2016 trimethobenzamide hcl cap 300 mg (Tigan)............... 101 TRIMETHOBENZAMIDE HCL -trimethobenzamide hcl (bulk) powder................................................................ 258 trimethoprim tab 100 mg................................................ 18 TRIMETHOPRIM -trimethoprim powder............................18 trimipramine maleate cap 25 mg (Surmontil)............. 116 trimipramine maleate cap 50 mg (Surmontil)............. 116 trimipramine maleate cap 100 mg (Surmontil)........... 116 TRIMIPRAMINE MALEATE -trimipramine maleate powder........................................................................... 115 TRINATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg..... 174 TRI-NORINYL 28 -norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg............................................ 45 TRINTELLIX -vortioxetine hbr tab 5 mg (base equiv)..... 116 TRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)............................................................................. 116 TRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)............................................................................. 116 TRIOXSALEN -trioxsalen (bulk) powder......................... 258 TRIPELENNAMINE HCL -tripelennamine hcl powder...... 87 TRIPLE DYE -triple dye solution..................................... 218 TRIPLE PMB -prednisol-moxiflox-bromfen for sol 1-0.5-0.09% (cmpd kit)................................................. 194 TRIPLE PMK -prednisol-moxiflox-ketorolac for sol 1-0.5-0.5% (cmpd kit)................................................... 194 TRIPROLIDINE HCL -triprolidine hcl crystals................. 258 TRITON X-100 -octoxynol liquid......................................258 TRIUMEQ -abacavir-dolutegravir-lamivudine tab 600-50-300 mg................................................................14 TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic susp 0.25 mg/ml........................................................... 174 TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic susp 0.5 mg/ml............................................................. 174 TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp 0.25 mg/ml.................................................................... 174 TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp 0.5 mg/ml...................................................................... 174 TRI-VIT/FLUORIDE/IRON -pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml.............................................174 TRIZIVIR -abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg..............................................................14 TROCHE BASE -troche base powder............................ 273 TROKENDI XR -topiramate cap er 24hr 25 mg.............. 163 TROKENDI XR -topiramate cap er 24hr 50 mg.............. 163 TROKENDI XR -topiramate cap er 24hr 100 mg............ 163 TROKENDI XR -topiramate cap er 24hr 200 mg............ 163 TROLAMINE -trolamine liquid......................................... 273 TROMETHAMINE -tromethamine (bulk) powder............ 258 TROPICAL PUNCH FLAVOR -flavoring agent liquid.............................................................................. 273 tropicamide ophth soln 1% (Mydriacyl)...................... 194 TROPICAMIDE -tropicamide powder.............................. 194 TROPOLONE -tropolone (bulk) powder..........................258 trospium chloride cap er 24hr 60 mg.......................... 106 trospium chloride tab 20 mg........................................ 106
TRULANCE -plecanatide tab 3 mg................................. 104 TRULICITY -dulaglutide soln pen-injector 0.75 mg/0.5ml.......................................................................... 50 TRULICITY -dulaglutide soln pen-injector 1.5 mg/0.5ml.......................................................................... 50 TRUMENBA -meningococcal group b vac (recomb) im susp prefilled syr............................................................. 22 TRUSOPT -dorzolamide hcl ophth soln 2%....................194 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg..................................................................... 14 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab 133-200 mg..................................................................... 14 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab 167-250 mg..................................................................... 14 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg..................................................................... 14 TRYPAN BLUE -trypan blue powder...............................273 TRYPSIN -trypsin powder............................................... 258 TRYPTOPHAN -tryptophan cap 500 mg.........................178 TRYPTOPHAN -tryptophan powder................................ 178 TUDORZA PRESSAIR -aclidinium bromide aerosol powd breath activated 400 mcg/act......................................... 94 TUNA FLAVOR -flavoring agent - powder...................... 273 TURKEL PARACENTESIS PROCE -lidocaine hcl local inj kit 1%............................................................................ 156 TURMERIC ROOT -turmeric (curcuma longa) (bulk) powder........................................................................... 258 TURMERIC -turmeric (curcuma longa) (bulk) powder........................................................................... 258 TURPENTINE SPIRITS -turpentine spirit....................... 216 TUSSICAPS -hydrocod polst-chlorphen polst cap er 12hr 5-4 mg............................................................................. 90 TUSSICAPS -hydrocod polst-chlorphen polst cap er 12hr 10-8 mg........................................................................... 90 TUSSIONEX PENNKINETIC EXT -hydrocod polstchlorphen polst er susp 10-8 mg/5ml.............................90 TUTTI-FRUTTI FLAVOR -flavoring agent - liquid........... 274 TUTTI FRUTTI FLAVOR -flavoring agent - liquid........... 273 TUZISTRA XR -codeine polist-chlorphen polist er susp 14.7-2.8 mg/5ml.............................................................. 90 TWINRIX -hepatitis a (inact)-hep b (recomb) vac inj 720-20 elu-mcg/ml.......................................................... 22 TWYNSTA -telmisartan-amlodipine tab 40-5 mg.............. 77 TWYNSTA -telmisartan-amlodipine tab 80-5 mg.............. 77 TWYNSTA -telmisartan-amlodipine tab 40-10 mg............ 77 TWYNSTA -telmisartan-amlodipine tab 80-10 mg............ 77 TYBOST -cobicistat tab 150 mg....................................... 14 TYKERB -lapatinib ditosylate tab 250 mg (base equiv)............................................................................... 31 TYLACTIN RESTORE 10 -nutritional supplement liquid.............................................................................. 179 TYLACTIN RESTORE 5PE -nutritional supplement pack............................................................................... 179 TYLACTIN RTD 15 -nutritional supplement liquid.......... 179
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
394
2016 TYLENOL/CODEINE #3 -acetaminophen w/ codeine tab 300-30 mg..................................................................... 146 TYLENOL/CODEINE #4 -acetaminophen w/ codeine tab 300-60 mg..................................................................... 146 TYLENOL/CODEINE -acetaminophen w/ codeine tab 300-15 mg..................................................................... 146 TYLOSIN TARTRATE -tylosin tartrate (bulk) powder......258 TYLOXAPOL -tyloxapol (bulk) liquid............................... 258 TYMLOS -abaloparatide subcutaneous soln pen-injector 3120 mcg/1.56ml............................................................ 60 TYVASO REFILL -treprostinil inhalation solution 0.6 mg/ ml..................................................................................... 86 TYVASO STARTER -treprostinil inhalation solution 0.6 mg/ml............................................................................... 86 TYVASO -treprostinil inhalation solution 0.6 mg/ml.......... 86
UNASYN BULK PACK -ampicillin & sulbactam sodium for inj 15 (10-5) gm................................................................ 2 UNDECYLENIC ACID -undecylenic acid liquid.............. 259 UNI-SOLVE -antiseptic products misc - pads................. 218 UNI-SOLVE WIPES -antiseptic products misc - pads..... 218 UNIVERSAL WATER GEL -alcohol gel base..................274 UPTRAVI -selexipag tab 200 mcg.....................................86 UPTRAVI -selexipag tab 400 mcg.....................................86 UPTRAVI -selexipag tab 600 mcg.....................................86 UPTRAVI -selexipag tab 800 mcg.....................................86 UPTRAVI -selexipag tab 1000 mcg...................................86 UPTRAVI -selexipag tab 1200 mcg...................................86 UPTRAVI -selexipag tab 1400 mcg...................................86 UPTRAVI -selexipag tab 1600 mcg...................................86 UPTRAVI -selexipag tab therapy pack 200 mcg (140) & 800 mcg (60)...................................................................86 URAMAXIN GT -urea gel 45%........................................ 216 URAMAXIN -urea cream 45%......................................... 216 URAMAXIN -urea gel 45%.............................................. 216 URAMAXIN -urea in ammonium lactate vehicle foam 20%................................................................................216 URAMAXIN -urea lotion 45%.......................................... 216 urea cream 40%............................................................. 216 urea cream 50%............................................................. 216 urea cream 39% (Aluvea).............................................. 216 urea cream 47% (Keralac).............................................216 urea cream 45% (Uramaxin)......................................... 216 urea foam 40% (Hydro 40 foam).................................. 216 urea gel 45% (Uramaxin)...............................................216 urea in lactic acid-salicylic acid vehicle susp 50%................................................................................216 urea in lactic acid vehicle foam 35% (Hydro 35)........ 216 urea in zinc undecylenate-lactic acid vehicle emulsion 50%................................................................................216 urea lotion 40%.............................................................. 216 urea lotion 45% (Uramaxin).......................................... 216 UREA NAIL -urea in zinc undecylenate-lactic acid vehicle stick 50%....................................................................... 216 urea suspension 40% (Umecta)................................... 216 UREA -urea powder.........................................................259 URECHOLINE -bethanechol chloride tab 5 mg.............. 106 URECHOLINE -bethanechol chloride tab 10 mg............ 106 URECHOLINE -bethanechol chloride tab 25 mg............ 106 URECHOLINE -bethanechol chloride tab 50 mg............ 106 UREVAZ -urea cream 44%............................................. 216 URIDINE -uridine (bulk) powder...................................... 259 URIMAR-T -methenamine-hyosc-meth blue-sod phosphen sal tab 120 mg.................................................... 105 UROCIT-K 10 -potassium citrate tab er 10 meq (1080 mg)................................................................................. 109 UROCIT-K 15 -potassium citrate tab er 15 meq (1620 mg)................................................................................. 109 UROCIT-K 5 -potassium citrate tab er 5 meq (540 mg)................................................................................. 109
U UBIDECARENONE -coenzyme q10 powder.................. 258 UBIQUINOL -ubiquinol (bulk) powder............................. 259 UBIQUINOL -ubiquinol (bulk) powder 30%.....................259 UCARE POLYMER JR-400 -pharmaceutical excipients (bulk) powder................................................................ 274 UCERIS -budesonide rectal foam 2 mg/act.................... 197 UCERIS -budesonide tab er 24hr 9 mg............................ 37 UDAMIN SP -multiple vitamins w/ minerals & fa tab 1 mg.................................................................................. 174 ULESFIA -benzyl alcohol lotion 5%................................ 216 ULORIC -febuxostat tab 40 mg....................................... 153 ULORIC -febuxostat tab 80 mg....................................... 153 ULTRABAG/DIANEAL LOW CALC -peritoneal dialysis solutions 344 mosm/l.................................................... 277 ULTRABAG/DIANEAL LOW CALC -peritoneal dialysis solutions 395 mosm/l.................................................... 277 ULTRABAG/DIANEAL LOW CALC -peritoneal dialysis solutions 483 mosm/l.................................................... 277 ULTRABAG/DIANEAL PD-2/1.5 -peritoneal dialysis solutions 346 mosm/l.................................................... 277 ULTRABAG/DIANEAL PD-2/2.5 -peritoneal dialysis solutions 396 mosm/l.................................................... 277 ULTRABAG/DIANEAL PD-2/4.2 -peritoneal dialysis solutions 485 mosm/l.................................................... 277 ULTRACET -tramadol-acetaminophen tab 37.5-325 mg.................................................................................. 146 ULTRADERM -cream base............................................. 274 ULTRAM -tramadol hcl tab 50 mg...................................146 ULTRASAL-ER -salicylic acid er film-forming soln 28.5%.............................................................................216 ULTRAVATE -halobetasol propionate cream 0.05%....... 216 ULTRAVATE -halobetasol propionate lotion 0.05%........ 216 ULTRAVATE -halobetasol propionate oint 0.05%........... 216 U-MILD SHAMPOO -external vehicles - shampoo......... 274 UNASYN -ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm.......................................................................... 2 UNASYN -ampicillin & sulbactam sodium for inj 3 (2-1) gm...................................................................................... 2
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
395
2016 valsartan tab 80 mg (Diovan)......................................... 77 valsartan tab 160 mg (Diovan)....................................... 77 valsartan tab 320 mg (Diovan)....................................... 77 VALSTAR -valrubicin soln for intravesical instillation 40 mg/ml............................................................................... 31 VALTREX -valacyclovir hcl tab 1 gm................................. 15 VALTREX -valacyclovir hcl tab 500 mg............................. 15 VANADIUM -vanadium (bulk) powder............................. 259 VANADYL SULFATE HYDRATE -vanadyl sulfate (bulk) crystals.......................................................................... 259 VANATOL LQ -butalbital-acetaminophen-caffeine soln 50-325-40 mg/15ml....................................................... 136 VANATOL S -butalbital-acetaminophen-caffeine soln 50-325-40 mg/15ml....................................................... 136 VANCOCIN HCL -vancomycin hcl cap 125 mg................ 18 VANCOCIN HCL -vancomycin hcl cap 250 mg................ 18 VANCOMYCIN HCL + SYRSPEND -vancomycin hcl oral susp 50 mg/ml (compound kit)....................................... 18 vancomycin hcl cap 125 mg (Vancocin hcl)................. 18 vancomycin hcl cap 250 mg (Vancocin hcl)................. 18 VANCOMYCIN HCL -vancomycin hcl powder.................. 18 VANILLA BUTTERNUT FLAVOR -flavoring agent liquid.............................................................................. 274 VANILLA FLAVOR -flavoring agent - liquid..................... 274 VANILLIN FLAVOR -flavoring agent - powder................ 274 VANISHING CREAM BOTANICAL -cream base............ 274 VANISHING CREAM -cream base.................................. 274 VANISH-PEN -cream base.............................................. 274 VANOXIDE-HC -benzoyl peroxide-hc lotion 5-0.5%....... 217 VANTAS -histrelin acetate implant kit 50 mg.................... 31 VAQTA -hepatitis a vaccine inj susp 25 unit/0.5ml............22 VAQTA -hepatitis a vaccine inj susp 50 unit/ml.................22 VARDENAFIL HYDROCHLORIDE -vardenafil hcl (bulk) powder........................................................................... 259 VARIVAX -varicella virus vac live for subcutaneous inj 1350 pfu/0.5ml................................................................ 22 VARIZIG -varicella-zoster immune glob (human) im inj 125 unit/1.2ml................................................................. 24 VARUBI -rolapitant hcl tab 90 mg (base equiv).............. 101 VASCEPA -icosapent ethyl cap 0.5 gm............................ 84 VASCEPA -icosapent ethyl cap 1 gm............................... 84 VASCUDERM HYDROGEL WOUND -wound dressings gel.................................................................................. 217 VASERETIC -enalapril maleate & hydrochlorothiazide tab 10-25 mg......................................................................... 78 VASOTEC -enalapril maleate tab 2.5 mg......................... 78 VASOTEC -enalapril maleate tab 5 mg............................ 78 VASOTEC -enalapril maleate tab 10 mg.......................... 78 VASOTEC -enalapril maleate tab 20 mg.......................... 78 VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 film 28%................................................................................107 VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 foam 12.5%.............................................................................107 VECAMYL -mecamylamine hcl tab 2.5 mg....................... 78 VECTICAL -calcitriol oint 3 mcg/gm................................ 217
UROGESIC-BLUE -methenamine-hyoscamine-meth bluesod phos tab 81.6 mg.................................................. 105 UROXATRAL -alfuzosin hcl tab er 24hr 10 mg............... 109 URSODIOL/SYRSPEND SF PH4 -ursodiol susp 30 mg/ml (compound kit).............................................................. 104 ursodiol cap 300 mg (Actigall)..................................... 104 ursodiol tab 250 mg (Urso 250)................................... 104 ursodiol tab 500 mg (Urso forte)................................. 104 URSODIOL -ursodiol (bulk) powder................................ 259 URSO FORTE -ursodiol tab 500 mg...............................104 URSO 250 -ursodiol tab 250 mg..................................... 104 UTIBRON NEOHALER -indacaterol-glycopyrrolate inhal cap 27.5-15.6 mcg.......................................................... 94 UTOPIC -urea cream 41%.............................................. 216 UVADEX -methoxsalen (photopheresis) soln 20 mcg/ ml..................................................................................... 31 V VACUSTIM BLACK -wound dressings - kit..................... 216 VACUSTIM SILVER -wound dressings - kit.................... 216 VAGIFEM -estradiol vaginal tab 10 mcg......................... 107 valacyclovir hcl tab 1 gm (Valtrex)................................ 14 valacyclovir hcl tab 500 mg (Valtrex)............................ 14 VALACYCLOVIR HCL -valacyclovir hcl (bulk) powder........................................................................... 259 VALCHLOR -mechlorethamine hcl gel 0.016% (base equivalent)..................................................................... 217 VALCYTE -valganciclovir hcl for soln 50 mg/ml (base equiv)............................................................................... 14 VALCYTE -valganciclovir hcl tab 450 mg (base equivalent)....................................................................... 15 VALERIAN ROOT -valerian root (bulk) powder.............. 259 valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte).......................................................................... 15 valganciclovir hcl tab 450 mg (base equivalent) (Valcyte).......................................................................... 15 VALINE -valine powder.................................................... 178 VALIUM -diazepam tab 2 mg.......................................... 110 VALIUM -diazepam tab 5 mg.......................................... 110 VALIUM -diazepam tab 10 mg........................................ 110 valproate sodium oral soln 250 mg/5ml (base equiv) (Depakene)................................................................... 163 VALPROATE SODIUM -valproate sodium (bulk) powder........................................................................... 259 valproic acid cap 250 mg (Depakene)......................... 163 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct).................................................................................. 77 valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct)................................................................... 77 valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct).................................................................................. 77 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct)................................................................... 77 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct).................................................................................. 78 valsartan tab 40 mg (Diovan)......................................... 77
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
396
2016 verapamil hcl tab er 180 mg (Calan sr)......................... 67 verapamil hcl tab er 240 mg (Calan sr)......................... 67 verapamil hcl tab 40 mg................................................. 67 verapamil hcl tab 80 mg (Calan).................................... 67 verapamil hcl tab 120 mg (Calan).................................. 67 VERAPAMIL HCL -verapamil hcl powder......................... 67 VERAPAMIL HYDROCHLORIDE -verapamil hcl powder............................................................................. 67 VERDESO -desonide foam 0.05%.................................. 217 VEREGEN -sinecatechins oint 15%................................217 VERELAN PM -verapamil hcl cap er 24hr 100 mg........... 67 VERELAN PM -verapamil hcl cap er 24hr 200 mg........... 67 VERELAN PM -verapamil hcl cap er 24hr 300 mg........... 67 VERELAN -verapamil hcl cap er 24hr 120 mg................. 67 VERELAN -verapamil hcl cap er 24hr 180 mg................. 67 VERELAN -verapamil hcl cap er 24hr 240 mg................. 67 VERELAN -verapamil hcl cap er 24hr 360 mg................. 67 VERIPRED 20 -prednisolone sod phosphate oral soln 20 mg/5ml (base equiv)....................................................... 37 VERSABASE FOAM -versabase foam........................... 274 VERSABASE -versabase cream..................................... 274 VERSABASE -versabase gel.......................................... 274 VERSABASE -versabase lotion...................................... 274 VERSABASE -versabase shampoo................................ 274 VERSACLOZ -clozapine susp 50 mg/ml........................ 122 VERSAFREE -oral vehicles - syrup................................ 274 VERSAPLUS -oral vehicles - syrup................................ 274 VERSAPRO -cream base................................................274 VERSAPRO -foam base - foam...................................... 274 VERSAPRO -gel base - gel............................................ 274 VERSAPRO -lotion base - lotion..................................... 274 VERSAPRO SHAMPOO -external vehicles shampoo........................................................................ 274 VERSATILE CREAM BASE -cream base....................... 274 VERSATILE RICH CREAM BASE -cream base............. 274 VESICARE -solifenacin succinate tab 5 mg................... 106 VESICARE -solifenacin succinate tab 10 mg................. 106 VFEND -voriconazole for susp 40 mg/ml.......................... 10 VFEND -voriconazole tab 50 mg...................................... 10 VFEND -voriconazole tab 200 mg.................................... 10 VIASPAN -organ preservation solution........................... 278 VIBERZI -eluxadoline tab 75 mg..................................... 104 VIBERZI -eluxadoline tab 100 mg................................... 104 VIBRAMYCIN -doxycycline calcium syrup 50 mg/5ml........ 7 VICTORIAS SECRET VANILLA -fragrances (bulk) liquid.............................................................................. 259 VICTOZA -liraglutide soln pen-injector 18 mg/3ml (6 mg/ ml).................................................................................... 50 VIDARABINE -vidarabine (bulk) powder......................... 259 VIDAZA -azacitidine for inj 100 mg................................... 31 VIDEX -didanosine for soln 2 gm...................................... 15 VIDEX -didanosine for soln 4 gm...................................... 15 VIDEX EC -didanosine delayed release capsule 125 mg.................................................................................... 15
VECURONIUM BROMIDE -vecuronium bromide (bulk) powder........................................................................... 259 VELPHORO -sucroferric oxyhydroxide chew tab 500 mg.................................................................................. 104 VELTASSA -patiromer sorbitex calcium for susp packet 8.4 gm (base eq).......................................................... 277 VELTASSA -patiromer sorbitex calcium for susp packet 16.8 gm (base eq)........................................................ 277 VELTASSA -patiromer sorbitex calcium for susp packet 25.2 gm (base eq)........................................................ 277 VELTIN -clindamycin phosphate-tretinoin gel 1.2-0.025%.................................................................... 217 VENCLEXTA STARTING PACK -venetoclax tab therapy starter pack 10 & 50 & 100 mg...................................... 31 VENCLEXTA -venetoclax tab 10 mg.................................31 VENCLEXTA -venetoclax tab 50 mg.................................31 VENCLEXTA -venetoclax tab 100 mg...............................31 VENELEX -balsam peru-castor oil oint........................... 217 venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) (Effexor xr)................................................................... 116 venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr)................................................................... 116 venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Effexor xr)................................................................... 116 VENLAFAXINE HCL ER -venlafaxine hcl tab er 24hr 37.5 mg (base equivalent).................................................... 116 VENLAFAXINE HCL ER -venlafaxine hcl tab er 24hr 75 mg (base equivalent).................................................... 116 VENLAFAXINE HCL ER -venlafaxine hcl tab er 24hr 150 mg (base equivalent).................................................... 116 venlafaxine hcl tab er 24hr 225 mg (base equivalent)................................................................... 116 venlafaxine hcl tab er 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er)..................................................... 116 venlafaxine hcl tab er 24hr 75 mg (base equivalent) (Venlafaxine hcl er)..................................................... 116 venlafaxine hcl tab er 24hr 150 mg (base equivalent) (Venlafaxine hcl er)..................................................... 116 venlafaxine hcl tab 25 mg.............................................116 venlafaxine hcl tab 37.5 mg......................................... 116 venlafaxine hcl tab 50 mg.............................................116 venlafaxine hcl tab 75 mg.............................................116 venlafaxine hcl tab 100 mg.......................................... 116 VENTAVIS -iloprost inhalation solution 10 mcg/ml........... 86 VENTAVIS -iloprost inhalation solution 20 mcg/ml........... 86 VENTOLIN HFA -albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)........................................................ 94 verapamil hcl cap er 24hr 120 mg (Verelan)................. 67 verapamil hcl cap er 24hr 180 mg (Verelan)................. 67 verapamil hcl cap er 24hr 240 mg (Verelan)................. 67 verapamil hcl cap er 24hr 360 mg (Verelan)................. 67 verapamil hcl cap er 24hr 100 mg (Verelan pm)........... 67 verapamil hcl cap er 24hr 200 mg (Verelan pm)........... 67 verapamil hcl cap er 24hr 300 mg (Verelan pm)........... 67 verapamil hcl tab er 120 mg (Calan sr)......................... 67
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
397
2016 VITAMIN A PALMITATE -vitamin a palmitate (bulk) liquid.............................................................................. 259 VITAMIN A -vitamin a (bulk) powder............................... 259 VITAMIN D3 -cholecalciferol (bulk) powder.................... 259 VITAMIN D3 -cholecalciferol liquid.................................. 259 VITAMIN D3 -cholecalciferol oral liquid 1200 unit/15ml........................................................................ 171 VITAMIN D3 -cholecalciferol powder 100000 unit/ gm.................................................................................. 259 VITAMIN DEFICIENCY INJECT -cyanocobalamin inj kit 1000 mcg/ml................................................................. 184 VITAMIN D2 -ergocalciferol tab 400 unit.........................170 VITAMIN E ACETATE -vitamin e acetate (bulk) liquid.............................................................................. 259 VITAMIN E ACETATE -vitamin e powder........................ 171 VITAMIN E SUCCINATE -vitamin e succinate (bulk) powder........................................................................... 259 VITAMIN E -vitamin e (bulk) liquid.................................. 259 VITAMIN K2 -menaquinone-7 (bulk) powder.................. 259 VITAMIN K1 -phytonadione inj 10 mg/ml........................ 171 VITAROCA PLUS -multiple vitamins w/ minerals tab..... 174 VITA-RX DIABETIC VITAMIN -speciality vitamin product cap................................................................................. 174 VITRASE -hyaluronidase ovine inj 200 unit/ml............... 278 VITUZ -hydrocodone-chlorpheniramine soln 5-4 mg/5ml............................................................................. 90 VIVELLE-DOT -estradiol td patch twice weekly 0.025 mg/24hr........................................................................... 41 VIVELLE-DOT -estradiol td patch twice weekly 0.0375 mg/24hr........................................................................... 41 VIVELLE-DOT -estradiol td patch twice weekly 0.05 mg/24hr........................................................................... 41 VIVELLE-DOT -estradiol td patch twice weekly 0.075 mg/24hr........................................................................... 41 VIVELLE-DOT -estradiol td patch twice weekly 0.1 mg/24hr........................................................................... 41 VIVITROL -naltrexone for im extended release susp 380 mg.................................................................................. 219 VOGELXO PUMP -testosterone td gel 12.5 mg/act (1%)................................................................................. 39 VOGELXO -testosterone td gel 50 mg/5gm (1%)............. 39 VOLTAREN -diclofenac sodium gel 1%.......................... 217 VOPAC GB -ketoprofen-lidocaine-gabapentin cream 5-2-5% (cmpd kit)......................................................... 217 VOPAC KT -ketoprofen-ketamine-lidocaine cream 5-5-2% (compound kit).............................................................. 217 voriconazole for susp 40 mg/ml (Vfend)....................... 10 voriconazole tab 50 mg (Vfend)..................................... 10 voriconazole tab 200 mg (Vfend)................................... 10 VORICONAZOLE -voriconazole (bulk) powder.............. 259 VOSPIRE ER -albuterol sulfate tab er 12hr 4 mg............. 94 VOSPIRE ER -albuterol sulfate tab er 12hr 8 mg............. 94 VOTRIENT -pazopanib hcl tab 200 mg (base equiv)....... 31 VP-ZEL -multiple vitamins w/ minerals tab..................... 174
VIDEX EC -didanosine delayed release capsule 200 mg.................................................................................... 15 VIDEX EC -didanosine delayed release capsule 250 mg.................................................................................... 15 VIDEX EC -didanosine delayed release capsule 400 mg.................................................................................... 15 VIEKIRA PAK -ombitas-paritapre-riton & dasab tab pak 12.5-75-50 & 250 mg..................................................... 15 VIEKIRA XR -dasab-ombit-paritap-riton tab er 24hr 200-8.33-50-33.33 mg.................................................... 15 VIGAMOX -moxifloxacin hcl ophth soln 0.5% (base equiv)............................................................................. 194 VIIBRYD STARTER PACK -vilazodone hcl tab starter kit 10 (7) & 20 (23) mg..................................................... 116 VIIBRYD -vilazodone hcl tab 10 mg................................116 VIIBRYD -vilazodone hcl tab 20 mg................................116 VIIBRYD -vilazodone hcl tab 40 mg................................116 VILACTIN AA PLUS -nutritional supplement liquid......... 179 VIMPAT -lacosamide oral solution 10 mg/ml.................. 163 VIMPAT -lacosamide tab 50 mg...................................... 163 VIMPAT -lacosamide tab 100 mg.................................... 163 VIMPAT -lacosamide tab 150 mg.................................... 163 VIMPAT -lacosamide tab 200 mg.................................... 163 VINBLASTINE SULFATE -vinblastine sulfate (bulk) powder........................................................................... 259 VINPOCETINE -vinpocetine (bulk) powder.................... 259 VIOKACE -pancrelipase (lip-prot-amyl) tab 10440-39150-39150 unit.............................................. 102 VIOKACE -pancrelipase (lip-prot-amyl) tab 20880-78300-78300 unit.............................................. 102 VIRACEPT -nelfinavir mesylate tab 250 mg..................... 15 VIRACEPT -nelfinavir mesylate tab 625 mg..................... 15 VIRAMUNE -nevirapine susp 50 mg/5ml.......................... 15 VIRAMUNE -nevirapine tab 200 mg................................. 15 VIRAMUNE XR -nevirapine tab er 24hr 100 mg...............15 VIRAMUNE XR -nevirapine tab er 24hr 400 mg...............15 VIRASAL -salicylic acid film forming liquid 27.5%.......... 217 VIRAZOLE -ribavirin for inhal soln 6 gm........................... 15 VIREAD -tenofovir disoproxil fumarate oral powder 40 mg/gm.............................................................................. 15 VIREAD -tenofovir disoproxil fumarate tab 150 mg.......... 15 VIREAD -tenofovir disoproxil fumarate tab 200 mg.......... 15 VIREAD -tenofovir disoproxil fumarate tab 250 mg.......... 15 VIREAD -tenofovir disoproxil fumarate tab 300 mg.......... 15 VIROPTIC -trifluridine ophth soln 1%............................. 194 VISTARIL -hydroxyzine pamoate cap 25 mg.................. 110 VISTARIL -hydroxyzine pamoate cap 50 mg.................. 110 VISTOGARD -uridine triacetate oral granules packet 10 gm.................................................................................. 219 VITAFOL -iron w/ vitamin tab.......................................... 174 VITAJECT -b-complex w/ c inj.........................................174 VITAL-D RX -b-complex w/ c-biotin-d-zinc & folic acid tab 1 mg.............................................................................. 174 VITAMIN A ACETATE -vitamin a acetate (bulk) beadlets......................................................................... 259
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
398
2016 WELCHOL -colesevelam hcl packet for susp 3.75 gm..... 84 WELCHOL -colesevelam hcl tab 625 mg......................... 84 WELLBUTRIN SR -bupropion hcl tab er 12hr 100 mg.................................................................................. 116 WELLBUTRIN SR -bupropion hcl tab er 12hr 150 mg.................................................................................. 116 WELLBUTRIN SR -bupropion hcl tab er 12hr 200 mg.................................................................................. 116 WELLBUTRIN XL -bupropion hcl tab er 24hr 150 mg.................................................................................. 116 WELLBUTRIN XL -bupropion hcl tab er 24hr 300 mg.................................................................................. 116 WESTCORT -hydrocortisone valerate oint 0.2%............ 217 WESTHROID -thyroid tab 32.5 mg................................... 54 WESTHROID -thyroid tab 65 mg...................................... 54 WESTHROID -thyroid tab 97.5 mg................................... 54 WESTHROID -thyroid tab 130 mg.................................... 54 WESTHROID -thyroid tab 195 mg.................................... 54 WHEAT GERM -wheat germ - oil....................................171 WHEY PROTEIN ISOLATE INST -whey protein (bulk) powder........................................................................... 259 WHITE BEES WAX -wax, white...................................... 274 WHITE KIDNEY BEAN EXTRACT -white kidney bean extract (bulk) powder.................................................... 259 white petrolatum gel...................................................... 274 WHITE PETROLATUM -white petrolatum ointment........ 274 WHITE WAX -wax, white................................................. 274 WHITE WILLOW BARK -willow bark (bulk) powder....... 259 WILD CHERRY FLAVOR -flavoring agent - liquid.......... 274 WILEY BASIC ELEMENTS BHRT -hormone cream base............................................................................... 274 WINRHO SDF -rho d immune globulin (human) inj 2500 unit/2.2ml......................................................................... 24 WINRHO SDF -rho d immune globulin (human) inj 5000 unit/4.4ml......................................................................... 24 WINRHO SDF -rho d immune globulin (human) inj 1500 unit/1.3ml......................................................................... 24 WINRHO SDF -rho d immune globulin (human) inj 15000 unit/13ml.......................................................................... 24 WITCH HAZEL -hamamelis leaf (witch hazel) fluid extract............................................................................ 259 WITEPSOL H15 BASE F -hydrogenated vegetable oil pellets............................................................................ 274 WITEPSOL -hydrogenated vegetable oil wax.................274 WOUND DEBRIDEMENT -wound dressings - kit........... 217 WOUND WASH BASE -gel base - gel............................ 274 WP THYROID -thyroid tab 16.25 mg................................ 54 WP THYROID -thyroid tab 32.5 mg.................................. 54 WP THYROID -thyroid tab 65 mg..................................... 54 WP THYROID -thyroid tab 81.25 mg................................ 54 WP THYROID -thyroid tab 97.5 mg.................................. 55 WP THYROID -thyroid tab 113.75 mg.............................. 55 WP THYROID -thyroid tab 130 mg................................... 55 WP THYROID -thyroid tab 48.75 mg (3/4 grain).............. 54
VRAYLAR -cariprazine hcl cap 1.5 mg (base equivalent)..................................................................... 122 VRAYLAR -cariprazine hcl cap 3 mg (base equivalent)..................................................................... 122 VRAYLAR -cariprazine hcl cap 4.5 mg (base equivalent)..................................................................... 122 VRAYLAR -cariprazine hcl cap 6 mg (base equivalent)..................................................................... 122 VRAYLAR -cariprazine hcl cap therapy pack 1.5 mg (1) & 3 mg (6)........................................................................ 122 VSL#3 DS -probiotic product - packet.............................. 96 VUSION -miconazole-zinc oxide-white petrolatum oint 0.25-15-81.35%............................................................. 217 VYTONE -iodoquinol-hydrocortisone in aloe vehicle cream 1-1.9%................................................................ 217 VYTORIN -ezetimibe-simvastatin tab 10-10 mg............... 84 VYTORIN -ezetimibe-simvastatin tab 10-20 mg............... 84 VYTORIN -ezetimibe-simvastatin tab 10-40 mg............... 84 VYTORIN -ezetimibe-simvastatin tab 10-80 mg............... 84 VYVANSE -lisdexamfetamine dimesylate cap 10 mg..... 130 VYVANSE -lisdexamfetamine dimesylate cap 20 mg..... 130 VYVANSE -lisdexamfetamine dimesylate cap 30 mg..... 130 VYVANSE -lisdexamfetamine dimesylate cap 40 mg..... 130 VYVANSE -lisdexamfetamine dimesylate cap 50 mg..... 130 VYVANSE -lisdexamfetamine dimesylate cap 60 mg..... 130 VYVANSE -lisdexamfetamine dimesylate cap 70 mg..... 130 VYVANSE -lisdexamfetamine dimesylate chew tab 10 mg.................................................................................. 130 VYVANSE -lisdexamfetamine dimesylate chew tab 20 mg.................................................................................. 130 VYVANSE -lisdexamfetamine dimesylate chew tab 30 mg.................................................................................. 130 VYVANSE -lisdexamfetamine dimesylate chew tab 40 mg.................................................................................. 130 VYVANSE -lisdexamfetamine dimesylate chew tab 50 mg.................................................................................. 130 VYVANSE -lisdexamfetamine dimesylate chew tab 60 mg.................................................................................. 130 W WARFARIN SODIUM CLATHRATE -warfarin sodium powder........................................................................... 186 warfarin sodium tab 1 mg (Coumadin)....................... 186 warfarin sodium tab 2 mg (Coumadin)....................... 186 warfarin sodium tab 2.5 mg (Coumadin).................... 186 warfarin sodium tab 3 mg (Coumadin)....................... 186 warfarin sodium tab 4 mg (Coumadin)....................... 186 warfarin sodium tab 5 mg (Coumadin)....................... 186 warfarin sodium tab 6 mg (Coumadin)....................... 187 warfarin sodium tab 7.5 mg (Coumadin).................... 187 warfarin sodium tab 10 mg (Coumadin)..................... 187 WATER BASE GEL -alcohol gel base............................ 274 water for injection.......................................................... 274 water for irrigation, sterile irrigation soln...................278 water for iv injection..................................................... 274 WATERMELON FLAVOR -flavoring agent - liquid.......... 274
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
399
2016 XIIDRA -lifitegrast ophth soln 5%.................................... 194 XODOL -hydrocodone-acetaminophen tab 7.5-300 mg.................................................................................. 146 XODOL -hydrocodone-acetaminophen tab 5-300 mg.................................................................................. 146 XODOL -hydrocodone-acetaminophen tab 10-300 mg.................................................................................. 146 XOLAIR -omalizumab for inj 150 mg................................ 94 XOLEGEL -ketoconazole gel 2%.................................... 217 XOPENEX CONCENTRATE -levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv)................................... 94 XOPENEX HFA -levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv)...................................................... 94 XOPENEX -levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)............................................................................... 94 XOPENEX -levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)............................................................................... 94 XOPENEX -levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)............................................................................... 94 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 9 mg.................................................................................. 146 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 13.5 mg......................................................................... 146 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 18 mg............................................................................ 146 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 27 mg............................................................................ 146 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 36 mg............................................................................ 146 XTANDI -enzalutamide cap 40 mg.................................... 31 XULANE -norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr.......................................................................... 45 XURIDEN -uridine triacetate oral granules packet 2 gm.................................................................................... 60 XYLAZINE HYDROCHLORIDE -xylazine hcl (bulk) powder........................................................................... 259 XYLITOL -xylitol (bulk) powder........................................259 XYLOCAINE/EPINEPHRINE -lidocaine inj 0.5% w/ epinephrine-1:200000................................................... 157 XYLOCAINE/EPINEPHRINE -lidocaine inj 1% w/ epinephrine-1:100000................................................... 157 XYLOCAINE/EPINEPHRINE -lidocaine inj 2% w/ epinephrine-1:100000................................................... 157 XYLOCAINE -lidocaine hcl local inj 0.5%....................... 156 XYLOCAINE -lidocaine hcl local inj 1%.......................... 156 XYLOCAINE -lidocaine hcl local inj 2%.......................... 156 XYLOCAINE -lidocaine hcl soln 4%................................ 217 XYLOCAINE-MPF/EPINEPHRINE -lidocaine inj 1% w/ epinephrine-1:200000................................................... 157 XYLOCAINE-MPF/EPINEPHRINE -lidocaine inj 1.5% w/ epinephrine-1:200000................................................... 157 XYLOCAINE-MPF/EPINEPHRINE -lidocaine inj 2% w/ epinephrine-1:200000................................................... 157 XYLOCAINE-MPF -lidocaine hcl local inj 1.5%.............. 156
X XALATAN -latanoprost ophth soln 0.005%..................... 194 XALKORI -crizotinib cap 200 mg...................................... 31 XALKORI -crizotinib cap 250 mg...................................... 31 XANAX -alprazolam tab 0.25 mg.................................... 110 XANAX -alprazolam tab 0.5 mg...................................... 110 XANAX -alprazolam tab 1 mg......................................... 110 XANAX -alprazolam tab 2 mg......................................... 110 XANAX XR -alprazolam tab er 24hr 0.5 mg................... 110 XANAX XR -alprazolam tab er 24hr 1 mg...................... 110 XANAX XR -alprazolam tab er 24hr 2 mg...................... 110 XANAX XR -alprazolam tab er 24hr 3 mg...................... 111 XANTHAN GUM -xanthan gum powder.......................... 274 XARELTO -rivaroxaban tab 10 mg..................................187 XARELTO -rivaroxaban tab 15 mg..................................187 XARELTO -rivaroxaban tab 20 mg..................................187 XARELTO STARTER PACK -rivaroxaban tab starter therapy pack 15 mg & 20 mg.......................................187 XELJANZ -tofacitinib citrate tab 5 mg (base equivalent)..................................................................... 151 XELJANZ XR -tofacitinib citrate tab er 24hr 11 mg (base equivalent)..................................................................... 151 XELODA -capecitabine tab 150 mg.................................. 31 XELODA -capecitabine tab 500 mg.................................. 31 XEMATOP BASE -cream base....................................... 274 XENAZINE -tetrabenazine tab 12.5 mg.......................... 135 XENAZINE -tetrabenazine tab 25 mg............................. 135 XEOMIN -incobotulinumtoxina for im inj 50 unit............. 167 XEOMIN -incobotulinumtoxina for im inj 100 unit........... 168 XEOMIN -incobotulinumtoxina for im inj 200 unit........... 168 XERALUX -dermatological products misc - cream......... 217 XERESE -acyclovir-hydrocortisone cream 5-1%............ 217 XERMELO -telotristat etiprate tab 250 mg (telotristat ethyl equiv)............................................................................. 104 XEROFORM NON-OCCLUSIVE OI -bismuth tribromophenate-petrolatum dressing - misc............... 217 XEROFORM NON-OCCLUSIVE OI -bismuth tribromophenate-petrolatum dressing pads................. 217 XEROFORM OCCLUSIVE PETROL -bismuth tribromophenate-petrolatum dressing - misc............... 217 XEROFORM OCCLUSIVE PETROL -bismuth tribromophenate-petrolatum dressing pads................. 217 XGEVA -denosumab inj 120 mg/1.7ml..............................60 XIAFLEX -collagenase clostridium histolyticum for inj 0.9 mg.................................................................................. 278 XIFAXAN -rifaximin tab 200 mg........................................ 18 XIFAXAN -rifaximin tab 550 mg........................................ 18 XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr 5-500 mg......................................................................... 50 XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr 5-1000 mg....................................................................... 50 XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr 10-500 mg....................................................................... 51 XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr 10-1000 mg..................................................................... 51
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
400
2016 ZEJULA -niraparib tosylate cap 100 mg (base equivalent)....................................................................... 31 ZELBORAF -vemurafenib tab 240 mg.............................. 31 ZEMBRACE SYMTOUCH -sumatriptan succinate solution auto-injector 3 mg/0.5ml............................................... 153 ZEMPLAR -paricalcitol cap 1 mcg.................................... 60 ZEMPLAR -paricalcitol cap 2 mcg.................................... 60 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit................................................ 102 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit................................................ 102 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit.............................................. 102 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit.............................................. 102 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit............................................ 102 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit............................................ 102 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 40000-136000-218000 unit.......................................... 102 ZENZEDI -dextroamphetamine sulfate tab 2.5 mg......... 130 ZENZEDI -dextroamphetamine sulfate tab 7.5 mg......... 130 ZENZEDI -dextroamphetamine sulfate tab 15 mg.......... 130 ZENZEDI -dextroamphetamine sulfate tab 20 mg.......... 130 ZENZEDI -dextroamphetamine sulfate tab 30 mg.......... 130 ZEPATIER -elbasvir-grazoprevir tab 50-100 mg............... 15 ZERIT -stavudine cap 15 mg............................................ 15 ZERIT -stavudine cap 20 mg............................................ 15 ZERIT -stavudine cap 30 mg............................................ 15 ZERIT -stavudine cap 40 mg............................................ 15 ZERIT -stavudine for oral soln 1 mg/ml............................ 15 ZESTORETIC -lisinopril & hydrochlorothiazide tab 10-12.5 mg...................................................................... 78 ZESTORETIC -lisinopril & hydrochlorothiazide tab 20-12.5 mg...................................................................... 78 ZESTORETIC -lisinopril & hydrochlorothiazide tab 20-25 mg.................................................................................... 78 ZESTRIL -lisinopril tab 2.5 mg.......................................... 78 ZESTRIL -lisinopril tab 5 mg............................................. 78 ZESTRIL -lisinopril tab 10 mg........................................... 78 ZESTRIL -lisinopril tab 20 mg........................................... 78 ZESTRIL -lisinopril tab 30 mg........................................... 78 ZESTRIL -lisinopril tab 40 mg........................................... 78 ZETIA -ezetimibe tab 10 mg............................................. 84 ZIAC -bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg.................................................................................... 78 ZIAC -bisoprolol & hydrochlorothiazide tab 5-6.25 mg..... 78 ZIAC -bisoprolol & hydrochlorothiazide tab 10-6.25 mg.................................................................................... 78 ZIAGEN -abacavir sulfate soln 20 mg/ml (base equiv)..... 15 ZIAGEN -abacavir sulfate tab 300 mg (base equiv)......... 15 ZIANA -clindamycin phosphate-tretinoin gel 1.2-0.025%.................................................................... 217 zidovudine cap 100 mg (Retrovir)................................. 15
XYLOCAINE-MPF -lidocaine hcl local preservative free (pf) inj 0.5%...................................................................156 XYLOCAINE-MPF -lidocaine hcl local preservative free (pf) inj 1%......................................................................156 XYLOCAINE-MPF -lidocaine hcl local preservative free (pf) inj 2%......................................................................156 XYLOCAINE-MPF -lidocaine hcl local preservative free (pf) inj 4%......................................................................156 XYLOMETAZOLINE HCL -xylometazoline hcl (bulk) powder........................................................................... 260 XYREM -sodium oxybate oral solution 500 mg/ml......... 135 XYZBAC -dietary management product - tabs................179 Y YASMIN 28 -drospirenone-ethinyl estradiol tab 3-0.03 mg.................................................................................... 45 YAZ -drospirenone-ethinyl estradiol tab 3-0.02 mg...........45 YEAST EXTRACT -yeast extract (bulk) liquid................ 260 YELLOW PETROLATUM -petrolatum ointment.............. 274 YLANG-YLANG OIL FRAGRANCE -cananga oil fragrance (bulk)............................................................. 260 Z ZACLIR CLEANSING -benzoyl peroxide lotion 8%........ 217 zafirlukast tab 10 mg (Accolate).................................... 94 zafirlukast tab 20 mg (Accolate).................................... 94 zaleplon cap 5 mg (Sonata).......................................... 124 zaleplon cap 10 mg (Sonata)........................................ 124 ZAMICET -hydrocodone-acetaminophen soln 10-325 mg/15ml......................................................................... 146 ZANABIN ANTIPRURITIC HYDR -wound dressings gel.................................................................................. 217 ZANAFLEX -tizanidine hcl cap 2 mg (base equivalent)..................................................................... 169 ZANAFLEX -tizanidine hcl cap 4 mg (base equivalent)..................................................................... 169 ZANAFLEX -tizanidine hcl cap 6 mg (base equivalent)..................................................................... 169 ZANAFLEX -tizanidine hcl tab 4 mg (base equivalent)..................................................................... 169 ZANTAC -ranitidine hcl inj 50 mg/2ml (25 mg/ml)........... 100 ZANTAC -ranitidine hcl inj 150 mg/6ml (25 mg/ml)......... 100 ZANTAC -ranitidine hcl inj 1000 mg/40ml (25 mg/ml)..... 100 ZANTAC -ranitidine hcl tab 150 mg................................ 100 ZANTAC -ranitidine hcl tab 300 mg................................ 100 ZARONTIN -ethosuximide cap 250 mg.......................... 163 ZARONTIN -ethosuximide soln 250 mg/5ml................... 163 ZARXIO -filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml...................................................................... 184 ZARXIO -filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml...................................................................... 184 ZAVARA -folic acid-cholecalciferol cap 1 mg-5750 unit................................................................................. 184 ZAVESCA -miglustat cap 100 mg................................... 184 ZEAXANTHIN -zeaxanthin (bulk) powder....................... 260
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
401
2016 zidovudine syrup 10 mg/ml (Retrovir)........................... 15 zidovudine tab 300 mg.................................................... 15 zileuton tab er 12hr 600 mg (Zyflo cr)........................... 94 ZINACEF -cefuroxime sodium for inj 1.5 gm...................... 5 ZINACEF -cefuroxime sodium for inj 7.5 gm...................... 5 ZINACEF -cefuroxime sodium for inj 750 mg..................... 5 ZINBRYTA -daclizumab soln prefilled syringe 150 mg/ ml................................................................................... 135 ZINC ACETATE -zinc acetate (bulk) powder.................. 260 ZINC ACETATE -zinc acetate crystals............................ 196 ZINC CHLORIDE -zinc chloride granules....................... 260 ZINC CITRATE DIHYDRATE -zinc citrate (bulk) powder........................................................................... 260 ZINC GLUCONATE -zinc gluconate (bulk) powder........ 260 ZINC MONOMETHIONINE -zinc monomethionine (bulk) powder........................................................................... 260 ZINC OXIDE -zinc oxide (bulk) powder.......................... 260 ZINC PICOLINATE -zinc picolinate (bulk) powder.......... 260 ZINC PYRITHIONE -pyrithione zinc (bulk) liquid 48%................................................................................260 ZINC SULFATE HEPTAHYDRATE -zinc sulfate granules......................................................................... 177 ZINC SULFATE HEPTAHYDRATE -zinc sulfate powder........................................................................... 177 ZINC SULFATE MONOHYDRATE -zinc sulfate powder........................................................................... 177 ZINC SULFATE -zinc sulfate powder.............................. 177 ZINC UNDECYLENATE -zinc undecylenate powder...... 260 ZINGO -lidocaine hcl powder for intradermal jet-injector 0.5 mg........................................................................... 157 ZIOPTAN -tafluprost ophth soln 0.0015%....................... 194 ziprasidone hcl cap 20 mg (Geodon).......................... 122 ziprasidone hcl cap 40 mg (Geodon).......................... 122 ziprasidone hcl cap 60 mg (Geodon).......................... 122 ziprasidone hcl cap 80 mg (Geodon).......................... 122 ZIPSOR -diclofenac potassium cap 25 mg..................... 151 ZIRCONIUM OXIDE -zirconium oxide (bulk) powder..... 260 ZIRGAN -ganciclovir ophth gel 0.15%............................ 194 ZITHRANOL -anthralin shampoo 1%.............................. 217 ZITHROMAX -azithromycin for susp 100 mg/5ml............... 6 ZITHROMAX -azithromycin for susp 200 mg/5ml............... 6 ZITHROMAX -azithromycin powd pack for susp 1 gm....... 6 ZITHROMAX -azithromycin tab 250 mg............................. 6 ZITHROMAX -azithromycin tab 500 mg............................. 6 ZITHROMAX -azithromycin tab 600 mg............................. 6 ZITHROMAX TRI-PAK -azithromycin tab 500 mg.............. 6 ZITHROMAX Z-PAK -azithromycin tab 250 mg.................. 6 ZMAX -azithromycin extended release for oral susp 2 gm...................................................................................... 6 ZOE SCRIPTS IDEALBASE -cream base...................... 274 ZOFRAN ODT -ondansetron orally disintegrating tab 4 mg.................................................................................. 101 ZOFRAN ODT -ondansetron orally disintegrating tab 8 mg.................................................................................. 101 ZOFRAN -ondansetron hcl oral soln 4 mg/5ml............... 101
ZOFRAN -ondansetron hcl tab 4 mg.............................. 101 ZOFRAN -ondansetron hcl tab 8 mg.............................. 101 ZOHYDRO ER -hydrocodone bitartrate cap er 12hr abuse-deterrent 10 mg................................................. 146 ZOHYDRO ER -hydrocodone bitartrate cap er 12hr abuse-deterrent 15 mg................................................. 146 ZOHYDRO ER -hydrocodone bitartrate cap er 12hr abuse-deterrent 20 mg................................................. 146 ZOHYDRO ER -hydrocodone bitartrate cap er 12hr abuse-deterrent 30 mg................................................. 146 ZOHYDRO ER -hydrocodone bitartrate cap er 12hr abuse-deterrent 40 mg................................................. 147 ZOHYDRO ER -hydrocodone bitartrate cap er 12hr abuse-deterrent 50 mg................................................. 147 ZOLADEX -goserelin acetate implant 3.6 mg................... 31 ZOLADEX -goserelin acetate implant 10.8 mg................. 31 ZOLATE -folic acid-cholecalciferol cap 1 mg-3775 unit................................................................................. 184 ZOLINZA -vorinostat cap 100 mg..................................... 31 zolmitriptan orally disintegrating tab 2.5 mg (Zomig zmt)............................................................................... 153 zolmitriptan orally disintegrating tab 5 mg (Zomig zmt)............................................................................... 153 zolmitriptan tab 2.5 mg (Zomig)................................... 153 zolmitriptan tab 5 mg (Zomig)...................................... 153 ZOLMITRIPTAN -zolmitriptan (bulk) powder...................260 ZOLOFT -sertraline hcl oral conc 20 mg/ml.................... 116 ZOLOFT -sertraline hcl tab 25 mg.................................. 116 ZOLOFT -sertraline hcl tab 50 mg.................................. 116 ZOLOFT -sertraline hcl tab 100 mg................................ 116 zolpidem tartrate sl tab 1.75 mg (Intermezzo)............ 124 zolpidem tartrate sl tab 3.5 mg (Intermezzo).............. 124 zolpidem tartrate tab er 6.25 mg (Ambien cr)............. 124 zolpidem tartrate tab er 12.5 mg (Ambien cr)............. 124 zolpidem tartrate tab 5 mg (Ambien)...........................124 zolpidem tartrate tab 10 mg (Ambien).........................125 ZOLPIMIST -zolpidem tartrate oral spray 5 mg/act........ 125 ZOMACTON -somatropin for inj 10 mg.............................60 ZOMACTON -somatropin for subcutaneous inj 5 mg....... 60 ZOMIG ZMT -zolmitriptan orally disintegrating tab 2.5 mg.................................................................................. 153 ZOMIG ZMT -zolmitriptan orally disintegrating tab 5 mg.................................................................................. 153 ZOMIG -zolmitriptan nasal spray 2.5 mg/spray unit........153 ZOMIG -zolmitriptan nasal spray 5 mg/spray unit...........153 ZOMIG -zolmitriptan tab 2.5 mg...................................... 153 ZOMIG -zolmitriptan tab 5 mg......................................... 153 ZONEGRAN -zonisamide cap 25 mg............................. 163 ZONEGRAN -zonisamide cap 100 mg........................... 163 zonisamide cap 50 mg.................................................. 163 zonisamide cap 25 mg (Zonegran).............................. 163 zonisamide cap 100 mg (Zonegran)............................ 164 ZONISAMIDE -zonisamide (bulk) powder.......................260 ZONTIVITY -vorapaxar sulfate tab 2.08 mg (base equivalent)..................................................................... 188
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
402
2016 ZORBTIVE -somatropin (non-refrigerated) for subcutaneous inj 8.8 mg................................................ 60 ZORTRESS -everolimus tab 0.25 mg............................. 278 ZORTRESS -everolimus tab 0.5 mg............................... 278 ZORTRESS -everolimus tab 0.75 mg............................. 278 ZOSIL -paste base - paste.............................................. 274 ZOSTAVAX -zoster vaccine live for subcutaneous susp 19400 unit/0.65ml........................................................... 22 ZOVIRAX -acyclovir cap 200 mg...................................... 15 ZOVIRAX -acyclovir cream 5%....................................... 217 ZOVIRAX -acyclovir oint 5%........................................... 217 ZOVIRAX -acyclovir susp 200 mg/5ml.............................. 15 ZOVIRAX -acyclovir tab 400 mg....................................... 16 ZOVIRAX -acyclovir tab 800 mg....................................... 16 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 0.7-0.18 mg (base eq).................................................. 147 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 1.4-0.36 mg (base eq).................................................. 147 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 2.9-0.71 mg (base eq).................................................. 147 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 5.7-1.4 mg (base eq)................................................................ 147 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 8.6-2.1 mg (base eq)................................................................ 147 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 11.4-2.9 mg (base eq)................................................................ 147 ZUPLENZ -ondansetron oral soluble film 4 mg.............. 101 ZUPLENZ -ondansetron oral soluble film 8 mg.............. 101 ZUTRIPRO -pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml................................................................. 90 ZYBAN -bupropion hcl (smoking deterrent) tab er 12hr 150 mg.......................................................................... 135 ZYCLARA -imiquimod cream 3.75%............................... 217 ZYCLARA PUMP -imiquimod cream 2.5%..................... 217 ZYCLARA PUMP -imiquimod cream 3.75%................... 217 ZYDELIG -idelalisib tab 100 mg........................................ 31 ZYDELIG -idelalisib tab 150 mg........................................ 31 ZYFLO CR -zileuton tab er 12hr 600 mg.......................... 94 ZYFLO -zileuton tab 600 mg............................................. 94 ZYKADIA -ceritinib cap 150 mg........................................ 31 ZYLET -loteprednol etabonate-tobramycin ophth susp 0.5-0.3%........................................................................ 194 ZYLOPRIM -allopurinol tab 100 mg................................ 153 ZYLOPRIM -allopurinol tab 300 mg................................ 153 ZYMAXID -gatifloxacin ophth soln 0.5%......................... 194 ZYPREXA -olanzapine for im inj 10 mg.......................... 122 ZYPREXA -olanzapine tab 2.5 mg.................................. 122 ZYPREXA -olanzapine tab 5 mg..................................... 122 ZYPREXA -olanzapine tab 7.5 mg.................................. 122 ZYPREXA -olanzapine tab 10 mg................................... 122 ZYPREXA -olanzapine tab 15 mg................................... 122 ZYPREXA -olanzapine tab 20 mg................................... 122 ZYPREXA RELPREVV -olanzapine pamoate for extended rel im susp 210 mg (base eq)...................... 123
ZYPREXA RELPREVV -olanzapine pamoate for extended rel im susp 300 mg (base eq)...................... 123 ZYPREXA RELPREVV -olanzapine pamoate for extended rel im susp 405 mg (base eq)...................... 123 ZYPREXA ZYDIS -olanzapine orally disintegrating tab 5 mg.................................................................................. 123 ZYPREXA ZYDIS -olanzapine orally disintegrating tab 10 mg.................................................................................. 123 ZYPREXA ZYDIS -olanzapine orally disintegrating tab 15 mg.................................................................................. 123 ZYPREXA ZYDIS -olanzapine orally disintegrating tab 20 mg.................................................................................. 123 ZYTIGA -abiraterone acetate tab 250 mg......................... 31 ZYTIGA -abiraterone acetate tab 500 mg......................... 31 ZYVOX -linezolid for susp 100 mg/5ml............................. 18 ZYVOX -linezolid tab 600 mg............................................ 18
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Blue Cross and Blue Shield of Kansas Formulary for BlueCare
Products October (2016 Plan Year)
403
