level 1 and 2 medication list 2.4 - azbluelevel 1 generic and level 2 medication list the...

Level 1 Generic and Level 2 Medication List 2/04/20

The medications listed in blue are available at the Level 1 copayment (the lowest cost sharing amount) and the medications listed in black are available at the Level 2 copayment. Not all generic medications are listed in this Guide.

Some medications are available at a retail copay level but will still require specialty distribution limited to a maximum of a 30 day supply. BCBSAZ has selected Optum Specialty Pharmacy as the exclusive Specialty Pharmacy. The medications followed by “SP” may be obtained through Optum Specialty Pharmacy. Please contact Optum Specialty Pharmacy directly at (866) 618-6741 to establish service with them. If you are currently obtaining a Specialty Medication from a Specialty Pharmacy and need to receive that medication from a retail pharmacy instead, please contact the Pharmacy Benefit Customer Service number listed on your BCBSAZ member identification card. BCBSAZ and/or the PBM will decide whether you are eligible to receive the Specialty Medication from a retail pharmacy instead of a Specialty Pharmacy.

The Level 2 Medication List includes the specific medications available at the Level 2 copayment. For example, if Adderall XR is listed, but Adderall is not, Adderall may only be available at Level 3 or Level 4.

The medications followed by “PL” have Prescription Limitations as stated in your benefit plan booklet. To learn more about Prescription Limitations, please click here.

ANDROGENS TESTOSTERONE REPLACEMENT Level 1 testosterone (generic for Testim, Androgel, Vogelxol) gel: 1% testosterone enanthate (PL) (generic for D elatestryl) Inj: 200mg/ml

ANTI-INFECTIVE

ANTI-FUNGALS Level 1 itraconazole (generic for Sporonoxl)

capsule: 100mg ketoconazole (generic for N izoral) tablet: 200mg oxiconazole (generic for Ox istat) cream: 1% voriconazole (generic for Vfend) tablet: 50mg, 200mg oral susp: 40mg/ml Linezolid Tabs Linezolid oral susp ANTI-FUNGALS, MOUTH/THROAT Level 1 nystatin (generic for M ycostatin, Nystatin)

tablet: 500,000u suspension: 100,000u/ml oral powder : 50miu, 150miu, 500miu, 2biu

ANTI-FUNGALS, VAGINAL Level 1 fluconazole (generic for D iflucan) tablet: 100mg, 150mg, 200mg ANTI-TUBERCULOSIS Level 2

*Coverage may vary by benefit plan

Dapsone Sirturo ANTI-PARASITICS Level 2 Atovaquone suspension Mepron suspension ANTI-VIRALS, (CMV) Level 1 ganciclovir (generic for C ytovene) capsule: 250mg, 500mg ANTI-VIRALS, (EENT) Level 1 trifluridine ophthalmic solution 1% (generic for Viroptic) ANTI-VIRALS, HEPATITIS Level 1 ANTI-VIRALS, HIV Level 1 abacavir sulfate-lamivudine-zidovudine (generic for Trizivir) tablet: 300-150-300mg abacavir sulfate (generic for Ziagen) tablets: 300mg oral solution: 20mg/ml didanosine (SP) (generic for Videx EC) capsule: 125mg, 200mg, 250mg, 400mg lamivudine-zidovudine (generic for C ombivir) tablet: 150-300mg lamivudine (generic for Epivir) tablet: 150mg, 300mg nevirapine (generic for Viramune) tablet: 200mg susp: 50mg/5ml nevirapine ER (generic for Viramune XR) tablet:: 100mg, 400mg stavudine (generic for Zerit)

capsule: 15mg, 20mg, 30mg, 40mg oral solution: 1mg/ml valacyclovir (generic for Valtrex) tablet: 500mg, 1000mg zidovudine (generic for R etrovir) capsule: 100mg tablets: 300mg syrup: 50mg/5ml Level 2 Aptivus Atazanavir caps (PL) Atripla (PL) Cimduo (PL) Complera Crixivan Edurant (PL) Efavirenz (PL) Emtriva (PL) Fosamprenavir Tabs Genvoya Intelence Isentress Isentress HD Invirase Kaletra Lexiva Nevirapine susp Norvir Caps/Sol Norvir Tabs Norvir Powder P acket Odefsey Tabs Prezista (PL) Reyataz (PL) Ritonavir Tabs Selzentry Stribild Symfi (PL) Symfi Lo (PL) Temixys tablet (PL) Tenofovir (PL) Tivicay Truvada (PL) Videx Viracept Viramune suspension

https://www.azblue.com/~/media/azblue/files/pharmacy-forms-mastery-directory/standard-pharmacy-plans/other-forms-and-resources/retail-and-mail-order-medications-and-vaccines-with-limitations-and-precertification-requirements.pdf

Level 1 Generic and Level 2 Medication List

The medications followed by "PL" have Prescription Limitations as stated in your benefit plan booklet. To learn more about Prescription Limitations, please click here.

Viread (PL) Vitekta ANTI-VIRALS, OTHERS Level 1 acyclovir (generic for Zovirax)

capsule: 200mg tablet: 400mg, 800mg suspension: 200mg/5ml

oseltamivir (generic for Tamiflu) (PL)

capsule: 30mg, 45mg, 75mg suspension: 6mg/ml

CEPHALOSPORINS, 1ST GENERATION Level 1 cephalexin (generic for Keflex)

capsule: 250mg, 500mg capsule: 750mg* suspension: 125mg/5ml, 250mg/5ml

cefadroxil (generic Duricef, Ultracef

capsule: 250mg, 500mg tablets: 1 gm suspension: 250mg/5ml, 500mg/5ml

CEPHALOSPORINS, 2ND GENERATION Level 1 cefaclor (generic for C eclor) capsule: 250mg, 500mg cefuroxime (generic for C eftin) tablet: 250mg, 500mg cefprozil (generic for C efzil) tablets: 250mg, 500mg

suspension: 125mg/5ml, 250mg/5ml

CEPHALOSPORINS, 3RDGENERATION Level 1 cefdinir generic for Omnicef) capsules: 300mg suspension: 125mg/5ml, 250mg/5ml cefpodoxime proxetil generic for Vantin) tablets: 100mg, 200mg suspension: 50mg/5ml, 100mg/5ml MACROLIDES Level 1 azithromycin (generic for Zithromax) tablet: 250mg, 500mg, 600mg suspension: 100mg/5ml, 200mg/5ml clarithromycin (generic for Biaxin)

tablet: 250mg, 500mg suspension: 125mg/5ml, 250mg/5ml

clarithromycin SR (generic for Biaxin XL)

tablet: 500mg

OTHER ANTI-INFECTIVES Level 1 Nitrofurantoin monohydrate macrocrystalline (generic for M acrobid)

capsules: 100mg Chlorhexidine gluconate, Periogard (generic for P eridex)

solution: 0.12% Level 2 Nebupent Pentamidiine SP OTHER ANTIMICROBIALS Level 1 clindamycin (generic for C leocin) capsule: 150mg, 300mg swab: 1% metronidazole (generic for Flagyl) tablet: 250mg, 500mg PENICILLINS Level 1 amoxicillin (generic for Amoxil)

capsule: 250mg, 500mg chewable tablet: 250mg suspension: 125mg/5ml, 200mg/5ml, 250mg/5ml, 400mg/5ml

amoxicillin/clavulanic potassium (generic for Augmentin)

tablet: 500mg/125mg, 875mg/125mg

suspension: 200-28.5mg/5ml, 250-

62.5mg/5ml, 400-57mg/5ml, 600-42.9mg/5ml dicloxacillin (generic for D ynapen, Pathocil)

capsule: 250mg, 500mg penicillin V potassium (generic for Penicillin VK) tablet: 250mg, 500mg QUINOLONES (FLURO) Level 1 ciprofloxacin HCL

(generic for C ipro) tablet: 250mg, 500mg, 750mg levofloxacin (PL) (generic for L evaquin) tablet: 250mg, 500mg, 750mg moxifloxacin

(generic for A velox) tablet: 400mg ofloxacin (PL) (generic for Floxin) tablet: 300mg, 400mg

SULFONAMIDES/MACROLIDES Level 1 erythromycin/sulfasoxazole (generic for Pediazole)

suspension: 200mg/600mg/5ml SULFONAMIDES Level 1 trimethoprim/sulfamethoxazole (generic for Bactrim)

tablet: 80mg/400mg trimethoprim/sulfamethoxazole (generic for Bactrim DS)

tablet: 160mg/800mgkit trimethoprim/sulfamethoxazole (generic for Septra) suspension: 40mg/200mg/5ml TETRACYCLINES Level 1 doxycycline Hyclate, morgidox (generic for Vibramycin)

capsule: 50mg, 100mg doxycycline hyclate (generic for Vibratab)

tablet:100mg doxycycline hyclate delayed release (generic for D oryx) (PL)

tablet:100mg doxycycline hyclate (generic for Periostat)

tablet: 20mg doxycycline monohydrate, Okebo, Mondoxyne NL* (generic for M onodox) capsule: 50mg,75mg, 100mg doxycycline monohydrate (generic for Adoxa) tablet: 50mg,75mg, 100mg minocycline (generic for M inocin)

capsule: 50mg, 75mg, 100mg tetracycline hcl (generic for Achromycin V)

capsule: 250mg, 500mg

ANTINEOPLASTIC ALKYLATING AGENTS Level 1 Alecensa-tab (PL) SP Alkeran-tab SP Cyclophosphamide-cap SP Empliciti-inj Gleostine-cap Hexalen-cap SP Leukeran-tab SP Melphalan-tab (generic for Alkeran) tablet: 2mg Myleran-tab SP Temodar-cap SP (PL) Temozolomide SP (generic for Temodar)

capsule: 5mg ,20mg, 100mg, 140mg,180mg, 250mg

Verzenio-tab SP (PL) ANTIMETABOLITES Level 1 Capecitabine SP (generic for X eloda) tablet: 150mg, 500mg Purinethol-tab Purixan (PL)-susp Tabloid-tab Trexall-tab

*Coverage may vary by benefit plan 2




Xeloda-tab SP ANTI-RHEUMATICS, PSORIASIS ANTIMETABOLITES Level 1 methotrexate tablet: 2.5mg

injection: 25mg/ml, 1gm oral solution: 2.5mg/ml

HORMONAL AGENTS Level 1 Abiraterone 250mg tab (PL) SP Anastrozole (PL)-tab (generic for Arimidex) tablet: 1mg Arimidex (PL)-tab Aromasin (PL)-tab Bicalutamide-tab (generic for Casodex) tablet: 50mg Daurismo (PL) tablet: 25mg, 100mg Eligard Kit (PL)-inj SP Emcyt-cap SP Exemestane (PL)-tab (generic for Aromasin) tablet: 25mg Fareston (PL)-tab Faslodex-inj SP (PL) Femara (PL)-tab Firmagon-inj SP Fulvestrant-inj SP (PL) Iressa Letrozole (PL)-tab Leuprolide Acetate 5mg-inj (PL) SP Lupron Depot 22.5mg inj (PL) SP Lupron Depot 30mg inj (PL) SP Lupron Depot 45mg inj (PL) SP Lysodren-tab SP Megace-oral susp Megestrol Acetate (generic for M egace) suspension: 40mg/ml Nilandron (PL)-tab Nilutamide (PL)-tab (generic for N ilandron) tablet: 150mg Soltamox-sol raloxifene (PL) (generic for E vista)

tablet: 60mg tamoxifen (generic for N olvadex) tablet: 10mg, 20mg Trelstar-susp SP Vantas-inj SP Xospata (PL) Xtandi-cap SP Yonsa-tab (PL) Zoladex-implant SP Zytiga-tab SP (PL) IMMUNOMODULATORS Level 1 Pomalyst-cap SP Thalomid-cap SP Imiquimod-cream

ENZYME INHIBITORS Level 1 Afinitor (PL)-tab/oral susp SP Alecensa (PL) SP Alunbrig tab (PL) SP Alunbrig Pak (PL) SP Bosulif-tab SP Braftovi cap (PL) Cabometyx-tab (PL) SP Calquence-cap (PL) Caprelsa-tab SP Cometriq-cap SP Cotellic-tab (PL) SP Erlotinib hcl SP Farydak-cap Gilotrif-tab SP Gleevec (PL)-tab SP Ibrance (PL)-cap SP Iclusig-tab SP Idhifa-(PL)-tab SP Imatinib tab (PL) SP Imbruvica (PL)-cap/tab SP Inrebic- (PL) cap Inlyta-tab SP Jakafi-tab SP Kisqali-(PL) tab SP Lenvima-cap SP Lorbrena tab Lynparza (PL)-cap SP Lynparza –(PL)-tab SP Mekinist (PL)-tab SP Mektovi cap (PL) Nexavar (PL)-tab SP Nerlynx- (PL)-tab SP Ninlaro-cap (PL) SP Rubraca-tab (PL) SP Rozlytrek-cap (PL) Rydapt-cap (PL) SP Sprycel (PL)-tab SP Stivarga-tab SP Sutent (PL)-cap SP Tafinlar-cap SP Tagrisso-tab SP Talzenna-cap (PL) Tarceva-tab SP Tasigna-cap SP Tazverik- tab (PL) Tykerb (PL)-tab SP Votrient-tab SP Xalkori (PL)-cap SP Zelboraf (PL)-tab SP Zolinza (PL)-cap SP Zydelig-tab (PL) SP Zykadia (PL)-cap, tab SP PREMALIGNANT LESION AGENTS Level 1 bexarotene cap SP (generic for Targretin) cap: 75mg carac cream 0.5% (PL) diclofenac Sodium soln (PL) (generic for Pennsaid) soln: 1.5% diclofenac Sodium gel (PL) (generic for Solaraze) gel: 3% Efudex-cream SP (PL) Fluorac-cream

Fluoroplex 1%-cream SP (PL) fluorouracil SP (generic for Efudex) cream: 5% Fluorouracil cream 0.5% (PL) Fluorouracil solution 2%, %5 Metvixia-cream Panretin-gel (PL) SP Picato-gel (PL) Solaraze gel (PL) Targretin cap SP Targretin gel (PL) SP Tibsovo tab (PL) Tolak-cream 4% Valchlor (PL)-gel SP OTHER ONCOLOGICS Level 1 Actimmune-inj SP Ayvakit- tab (PL) Bavencio-IV SP Balversa Tab SP Bendeka-inj SP Brukinsa Cap – (PL) Copiktra- cap (PL) Etoposide-cap SP Erivedge-cap SP Erleada- tab (PL) Hycamtin-cap SP Hydrea-cap Intron-A-inj SP Lartruvo-inj-SP Lonsurf-(PL)-tab SP Matulane-cap SP Mitoxantrone HCL-IV SP (PL) Mylotarg-IV-SP (PL) Nubeqa tab SP Odomzo (PL)-cap SP Piqray (PL) t ab Revlimid (PL)-cap SP Synribo-inj SP Tretinoin-cap SP (PL) Turalio-cap SP (PL) Venclexta-tab (PL) SP Vitrakvi (PL) Vizimpro- tab (PL) Xatmep –oral sol (PL) SP Xpovio Pak (PL) SP Zejula-cap-(PL) SP

AUTONOMIC & CENTRAL NERVOUS SYSTEM

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) Level 1 amphetamine-dextroamphetamine (generic for Adderall)

tablet: 5mg, 7.5mg, 10mg,12.5mg, 15mg 20mg, 30mg

atomoxetine hcl (generic for Strattera)

capsule: 10mg,18mg, 25mg, 40mg, 60mg, 80mg, 100mg

dextroamphetamine sulfate (generic for Zenzedi) (PL)

tablet: 5mg, 10mg





dextroamphetamine

(generic for D exedrine) (PL) capsule: 5mg, 10mg, 20mg

dextroamphetamine (generic for D extrostat) tablet: 5mg,10mg

guanfacine hcl ER/SR (PL) (generic for Intiniv)

tablet: 1mg, 2mg, 3mg, 4mg methamphetamine

(generic for D esoxyn) (PL) tablet: 5mg

everolimus (PL) (generic for Afinitor) tablet: 2.5mg, 5mg, 7.5mg methylphenidate ER (OSM)

(generic for C oncerta) (PL) tablet: 18mg, 27mg, 36mg. 54mg

methylphenidate (generic for R italin) (PL) tablet: 5mg,10mg, 20mg

methylphenidate 24hrER/SR (generic for R italin LA) (PL) capsules: 10mg,20mg, 30mg, 40mg methylphenidate CR (generic for M etadate CD) (PL)

capsules: 10mg, 20mg, 30mg, 40mg,50mg, 60mg

methylphenidate (generic for, Ritalin SR) tablets extended release: 20mg

methylphenidate OSM 72mg tablet methylphenidate

(generic for Qu illichew) (PL) tablet: 20mg,30mg, 40mg

methylphenidate SOL (generic for M ethylin) (PL) solt: 5mg/5ml, 10mg/5ml

methylphenidate hcl ER (PL) tablet: extended release 27mg, 36mg, 54mg Relexxii OSM 72mg tablet Level 2 Adderall XR (PL) Vyvanse capsule (PL) Vyvanse chew tablet (PL) ANTI-CONVULSANTS Level 1 carbamazepine (generic for Tegretol)

chewable tablet: 100mg tablet: 200mg

carbamazepine ER/SR (generic for Tegretol XR)

tablet: 100mg, 200mg, 400mg divalproex (generic for D epakote Delayed Release)

tablet: 125mg, 250mg, 500mg ethosuximide (generic for Zarontin)

capsule: 250 mg syrup: 250 mg/5ml

gabapentin (generic for N eurontin) capsule: 100mg, 300mg, 400mg tablet: 100mg, 300mg, 400mg, 600mg oral solution: 250mg/ml lamotrigine

(generic for L amictal, Lamictal XR, Lamictal ODT) tablet: 25mg, 100mg, 150mg, 200mg chewable tablet: 5mg, 25mg

extended release: 25mg, 50mg, 100mg, 200mg, 250mg, 300mg

levetiracetam, roweepra (generic for Keppra) tablet: 250mg, 500mg, 750mg, 1000mg oral solution: 100mg/ml levetiracetam (PL) (generic for Keppra XR) tablet: 500mg, 750mg lorazepam (generic for Ativan) tablet: 0.5mg, 1mg, 2mg oral concentrate: 2mg/ml phenobarbital

tablet: multiple strengths(not all L1 copay) elixir: 20mg/5ml

phenytoin sodium (generic for D ilantin)

capsule: 100mg pregabalin (PL)

(generic for Lyrica) capsule: 25mg, 50mg, 75mg. 100mg, 150mg, 200mg, 225mg solution: 20mg/ml primidone (generic for M ysoline) tablet 50mg, 250mg topirmate (PL) (generic for Top amax) tablet 25mg, 50mg, 100mg, 200mg zonisamide (generic for Zon egran) tablet 25mg, 50mg, 100mg

Level 2 Carbatrol Depakote ER Depakote Sprinkles Dilantin Fycompa (PL) Phenytek (PL) Tegretol Tegretol XR Topiramate ER Sprinkles (PL) Vigabatrin powder p ack (PL) Vimpat ANTIDEPRESSANTS Level 1 bupropion (generic for Wellbutrin) tablet: 75mg, 100mg bupropion SR (PL) (generic for Wellbutrin SR)

sustained-release tablet: 100mg, 150mg, 200mg

bupropion SR 24 hour (PL) (generic for Wellbutrin XL)

sustained-release tablet: 150mg, 300mg duloxetine (generic for C ymbalta) (PL)

capsule: 20mg, 30mg, 60mg venlafaxine ER 24HR (generic for Venlafaxine HCL ER)

tablet: 37.5mg, 75mg, 150mg, 225mg

venlafaxine (generic for Effexor)

tablet: 25mg. 37.5mg, 50mg, 75mg, 100mg venlafaxine SR/ER 24 hr (generic for Effexor XR)

capsules: 37.5mg, 75mg, 150mg ANTIDEPRESSANTS, OTHER Level 1 mirtazapine (PL) (generic for R emeron)

tablet: 7.5mg, 15mg, 30mg, 45mg mirtazapine ODT (PL) (generic for R emeron Soltab) tablet: 15mg, 30mg, 45mg trazodone (generic for D esyrel)

tablet: 50mg, 100mg, 150mg

ANTI-PARKINSON AGENTS Level 1 amantadine (generic for Symmetrel)

capsule: 100mg tablet: 100mg benztropine (generic for C ogentin)

tablet: 0.5mg, 1mg, 2mg bromocriptine (generic for Parlodel)

tablet: 2.5mg carbidopa/levodopa (generic for Sinemet, Sinemet CR)

tablet: 10/100mg, 25/100mg, 25/250mg sustained-release tablet: 25/100mg, 50/200mg

selegiline (generic for Eldepryl)

tablet: 5mg capsule: 5mg

tolcapone (generic for Tasmar)

tablet: 100mg Level 2 Pramipexole ER ANTIPSYCHOTICS, ATYPICAL Level 1 aripirazole (generic for Abilify) tablet: 2mg. 5mg, 10mg, 15mg, 20mg, 30mg oral sol: 1mg/ml clozapine (generic for C lozaril) tablet: 25mg, 100mg risperidone (generic for R isperdal) tablet: 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg oral solution: 1mg/ml olanzapine (PL) (generic for Zyprexa ) tablet: 2. 5mg, 5mg,7.5mg,10mg, 15mg, 20mg olanzapine odt (PL) (generic for Zyprexa Zydis) tablet: 5mg, 10mg, 15mg, 20mg quetiapine (PL) (generic for Seroquel)





tablets: 25mg, 50mg, 100mg, 150mg, 200mg, 300mg, 400mg

ziprasidone (PL) (generic for Ge odon) capsules: 20mg, 40mg, 60mg, 80mg ANTIPSYCHOTICS, TYPICAL Level 1 chlorpromazine (generic for Thorazine)

tablet: 10mg, 25mg, 50mg, 100mg, 200mg haloperidol (generic for H aldol)

tablet: 0.5mg, 1mg, 2mg, 5mg oral solution: 2mg/ml

thioridazine (generic for M ellaril) tablet: 10mg, 25mg, 50mg, 100mg ANTIPSYCHOTICS, MISCELLANEOUS Level 2 Pimozide ANXIOLYTIC/HYPNOTIC, NON BENZODIAZEPINE Level 1 buspirone (PL) (generic for Buspar)

tablet: 5mg, 10mg, 15mg eszopiclone (generic for L unesta)

tablet: 1mg, 2 mg, 3mg zolpidem tartrate (generic for Ambien)

tablet: 5mg, 10mg zolpidem tartrate ER (generic for Ambien CR)

tablet: 6.25mg, 12.5mg BENZODIAZEPINES 1, SHORT ACTING Level 1 alprazolam

(generic for X anax, Niravam) (PL) tablet: 0.25mg, 0.5mg, 1mg, 2mg ODT: 0.25mg, 0.5mg, 1mg, 2mg

alprazolam (generic for X anax Xr) (PL) tablet: 0.5mg, 1mg, 2mg, 3mg

midazolam (generic for v ersed) SYR: 2mg/ml (PL) oxazepam (generic for Serax) (PL)

capsule: 10mg,15mg triazolam (generic for H alcion) (PL)

tablet: 0.25mg BENZODIAZEPINES 2, MID-ACTING Level 1 Estazolam (PL) (generic for ProSom)

tablet: 1mg, 2mg temazepam (PL) (generic for R estoril)

capsule: 15mg, 30mg BENZODIAZEPINES 3, LONG ACTING Level 1

alprazolam ER (generic for X anax XR)

tablet: 0.5mg, 1mg, 2mg, 3mg alprazolam XR (generic for X anax XR)

tablet: 0.5mg, 1mg, 2mg, 3mg clonazepam (generic for Klonopin) (PL)

tablet: 0.5mg, 1mg, 2mg chlordiazepoxide (generic for L ibrium) (PL)

capsule: 5mg, 10mg, 25mg clorazepate dipotassium (PL) (generic for tranxene t) tablet: 3.75mg, 7.5mg, 15mg diazepam (generic for Valium) (PL)

tablet: 2mg, 5mg, 10mg IMMUNOMODULATORY AGENTS Level 2 Tecfidera (PL) Tecfidera Starter K it (PL) MANIA/BIPOLAR Level 1 divalproex (generic for D epakote Delayed Release)

tablet: 125mg, 250mg, 500mg lithium carbonate (generic for Eskalith) capsule: 300mg lithium carbonate CR (generic for Eskalith CR) controlled-release tablet: 450mg lithium carbonate CR (generic for L ithobid SR) controlled-release tablet: 300mg valproic acid (generic for D epakene) capsule: 250mg syrup: 250mg/5ml Level 2 Depakote ER Depakote Sprinkles MIGRAINE Level 1 eletriptan (generic for R elpax)

tablet: 20mg, 40mg frovatriptan (PL) (generic for Frova)

tablet: 2.5mg divalproex (generic for D epakote Delayed Release)

tablet: 125mg, 250mg, 500mg naratriptan (PL) (generic for Amerge)

tables: 1mg, 2.5mg sumatriptan (generic for Imitrex)

tablets: 25mg,50mg, 100mg (PL) vial: 6mg/0.5ml (PL) nasal spray: 5mg, 20mg (PL)

rizatriptan benzoate (PL) (generic for M axalt, Maxalt MLT)

tablets: 5mg, 10mg

orally disintegrating: 5mg, 10mg zolmitriptan (PL) (generic for Zomig)

tablets: 2.5mg, 5mg zolmitriptan ODT (PL) (generic for Zomig ZMT)

ODT: 2.5mg, 5mg Level 2 Depakote ER Depakote Sprinkles Zomig Nasal Spray (PL)

MUSCLE RELAXANTS Level 1 baclofen (generic for L ioresal)

tablet: 10mg, 20mg carisoprodol (generic for Soma)

tablet: 350mg cyclobenzaprine (generic for Flexeril)

tablet: 10mg methocarbamol (generic for R obaxin)

tablet: 500mg, 750mg tizanidine (generic for Zanaflex)

tablet: 2mg, 4 mg

Level 2 Dantrolene NARCOTICS Level 1 buprenorphine (generic for Butrans)

patch weekly: 5mcg, 7.5mcg, 10mcg, 15mcg, 20mcg

buprenorphine (generic for Subutex)

SL tab: 2mg, 8mg fentanyl td (PL) (generic for D uragesic)

patch 72-hour: 12.5mcg, 25mcg, 50mcg, 75mcg, 100mcg

morphine sulfate (generic for M S Contin)

sustained-release tablet: 15mg, 30mg, 60mg, 100mg, 200mg

morphine sulfate (generic for R oxanol)

oral solution: 20mg/ml morphine sulfate immediate release oral solution: 10mg/5ml, 20mg/5ml roxicodone (generic for R oxicodone, Dazidox, Oxyir)

tablet: 5mg, 10mg 15mg, 20mg, 30mg capsule: 5mg

Level 2 Hysingla ER (PL)

NARCOTICS, COMBOS Level 1 acetaminophen/codeine





(generic for Tylenol/codeine)

tablet: 300mg/15mg, 300mg/30mg, 300mg/60mg elixir: 120mg/12mg/5ml

acetaminophen/hydrocodone (generic for L orcet, Lorcet Plus)

tablet: 7.5mg/650mg, 10mg/650mg acetaminophen/hydrocodone, Lorcet HD (generic for N orco)

tablet: 5mg/325mg, 7.5mg/325mg, 10mg/325mg

acetaminophen/hydrocodone (generic for Vicodin, Vicodin ES)

tablet: 5mg/500mg, 7.5mg/500mg acetaminophen/oxycodone, roxicet, endocet (generic for Percocet)

tablet: 2.5mg/325mg, 5mg/325mg, 7.5mg/325mg, 10mg/325mg, 7.5mg/500mg 10mg/650mg solution: 5-325mg/5ml

acetaminophen/oxycodone (generic for Tylox)

capsule: 5mg/500mg acetaminophen/propoxyphene HCL (generic for Wygesic)

tablet: 65mg/650mg acetaminophen/propoxyphene-N (generic for D arvocet-N 100)

tablet: 100mg/650mg aspirin/oxycodone (generic for Percodan)

tablet: 5mg/325mg ibuprofen-hydrocodone (generic for Vicoprofen)

tablet: 7.5-200mg NAUSEA/VOMITING Level 1 Promethazine, promethegan (generic for Phenergan)

tablet: 25mg, 50mg syrup: 6.25mg/5ml rectal suppository: 12.5mg, 25mg, 50mg

Promethegan rectal suppository: 50mg prochlorperazine

tablet: 5mg, 10mg rectal suppository: 25mg

NEUROMUSCULAR DISORDERS Level 1 riluzole (generic for R ilutek)

tablet: 50mg NON STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) Level 1 diclofenac sodium (generic for Voltaren)

tablet: 25mg, 50mg, 75mg ibuprofen (generic for M otrin)

tablet: 400mg, 600mg, 800mg indomethacin (generic for Indocin)

capsule: 25mg, 50mg

nabumetone (generic for R elafen) tablet: 500mg, 750mg naproxen (generic for N aprosyn)

tablet: 250mg, 375mg, 500mg oxaprozin (generic for D aypro) tablet: 600mg

NON STEROIDAL ANTI-INFLAMMATORY DRUGS (OTHER) Level 1 ketorolac tromethamine (PL) (generic for Toradol) tablets: 10mg ketoprofen (generic for Or udis) capsules: 50mg, 75mg profeno (generic for N alfon) tablets: 600mg meloxicam (generic for M obic) tablets: 7.5mg, 15mg Level 2 Diclofenac 1.5% transdermal

GOUT Level 1 allopurinol (generic for Zyloprim)

tablet: 100mg, 300mg probenecid

tablet: 500mg OTHER ANALGESICS Level 1 butalbital/acetaminophen/caffeine, phrenilin forte (generic for Fioricet)

tablet: 50mg/325mg/40mg butalbital/acetaminophen/caffeine (generic for Esgic)

capsule: 50mg/40mg/325mg butalbital/aspirin/caffeine (generic for Fiorinal)

capsule: 50mg/40mg/325mg tramadol (generic for U ltram) (PL)

tablet: 50mg tramadol HCL SR 24 hour (generic for U ltram ER) (PL)


Level 2 Zubsolv SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI) Level 1 citalopram (PL) (generic for C elexa) tablet: 10mg, 20mg, 40mg desvenlafax er (PL) (generic for Pristiq) tablet: 25mg, 50mg, 100mg escitalopram (PL)

(generic for L exapro) tablet: 5mg, 10mg, 20mg solution: 5mg/5ml fluoxetine (PL) (generic for Prozac,Rapiflux)

capsule: 10mg, 20mg, 40mg tablets: 10mg, 20mg

paroxetine HCL (PL) (generic for Paxil) tablet: 10mg, 20mg, 30mg, 40mg sertraline (generic for Zoloft) tablet: 25mg, 50mg,100mg TRICYCLIC ANTIDEPRESSANTS (TCA) Level 1 amitriptyline (generic for Elavil)

tablet: 10mg, 25mg, 50mg, 75mg, 100mg, 150mg

doxepin (generic for Sinequan)

capsule: 10mg, 25mg, 50mg, 75mg, 100mg, 150mg oral concentrate: 10mg/ml

imipramine (generic for Tofranil, Tofranil PM)

tablet: 10mg, 25mg, 50mg capsule: 75mg, 100mg, 125mg, 150mg (PL)

nortriptyline (generic for Pamelor)

capsule: 10mg, 25mg, 50mg, 75mg ANTI-DEMENTIA AGENTS Level 1 donepezil hydrochloride (PL) (generic for Aricept)

tablet: 5mg, 10mg, 23mg ODT: 5mg, 10mg

galantamine hydrobromide (PL) (generic for R azadyne)

tablet: 4mg, 8mg, 12mg galantamine hydrobromide SR 24 HR (PL) (generic for R azadyne ER)

tablet: 8mg,16mg, 24mg rivastigmin tartrate (PL) (generic for Exelon)

capsule: 1.5mg, 3mg, 4.5mg, 6mg Level 2 Exelon Patch (PL) Exelon oral solution Memantine ER Rivastigmine Patch (PL)

CARDIOVASCULAR/HEART

ANGIOTENSIN-CONVERTING ENZYME INHIBITORS (ACEI) Level 1 Acetazolamide (generic for D iamox) tablet: 125mg benazepril (generic for L otensin) tablet: 5mg, 10mg, 20mg, 40mg captopril (generic for C apoten)





tablet: 12.5mg, 25mg, 50mg, 100mg

enalapril (generic for Vasotec)

tablet: 2.5mg, 5mg, 10mg, 20mg fosinopril (generic for M onopril)

tablet: 10mg, 20mg, 40mg lisinopril (generic for Prinivil/Zestril)

tablet: 2.5mg, 5mg, 10mg, 20mg, 30mg, 40mg

quinapril HCL (generic for Accupril) tablet: 5mg, 10mg, 20mg, 40mg quinapril-hctz (generic for Accuretic) tablet: 10-12.5mg, 20-12.5mg, 20-25mg ramipril (generic for Altace) capsules: 1.25, 2.5mg, 5mg, 10mg trandolapril (generic for M avik) tablet: 1mg, 2mg, 4mg ANGIOTENSIN II RECEPTOR BLOCKERS (A2RB) Level 1 amlodipine/besylate/valsartan (PL) (generic for E xforge)

tablet: 5-160mg, 10-160mg, 5-320mg, 10-320mg

amlodipine/valsartan/hydrochlorothiazide (PL) (generic for E xforge HCT)

tablet: 5-160-12.5mg, 5-160-25mg, 10-160-12.5mg, 10-160-25mg, 10-320-25mg

candesa/hctz (PL) (generic for Atacand HCT)

Tablets: 16-12.5 mg, 32-12.5 mg, 32-25mg, 16-12.5 mg, 32-12.5 mg

losartan (generic for C ozaar) tablet: 25mg, 50mg, 100mg losartan/hydrochlorothiazide (generic for H yzaar) tablet: 50/12.5mg, 100/12.5mg, 100/25mg telmisartan-hydrochlorothiazide (generic for M icardis HCT) (PL)

tablet: 80-12.5mg, 80-25mg, 40-12.5mg telmisartan (generic for M icardis)

tablet: 20mg, 40mg, 80mg valsartan (PL) (generic for D iovan) tablet: 40mg, 80mg, 160mg, 320mg valsartan-hydrochlorothiazide (generic for D iovan HCT) (PL)

tablet: 80-12.5mg, 160-12.5mg, 320-12.5mg, 160-25mg, 320-25mg

ANTI-ARRHYTHMICS Level 1 amiodarone, pacerone (generic for C ordarone) tablet: 200mg amiodarone, pacerone tablet: 100mg diltiazem HCL (generic for C ardizem)

tablet: 30mg, 60mg, 90mg, 120mg

procainamide (generic for Pronestyl)

capsule: 250mg sustained-release tablet: 500mg

Level 2 Multaq (PL) Tikosyn (PL) ANTI-PLATELETS Level 1 anagrelide (generic for Agrylin) capsule: 0.5mg, 1mg aspirin/dipyridamole SR (generic for Aggrenox) capsules: 25-200mg cilostazol (generic for Pletal) tablet: 50mg, 100mg clopidogrel (generic for Plavix) (PL) tablet: 75mg, 300mg dipyridamole (generic for Persantine) tablet: 25mg, 50mg, 75mg pentoxifylline ER, pentoxil CR (generic for Trental) tablet: 400mg prasugrel (generic for Effient) (PL) tablet: 5mg, 10mg ticlopidine (generic for Ticlid) tablet: 250mg Level 2 Aggrenox Asa/Dipyridamole Brilinta Ticlopidine Zontivity (PL)

BETA BLOCKERS Level 1 atenolol (generic for Tenormin)

tablet: 25mg, 50mg, 100mg carvedilol (generic for C oreg)

tablet: 3.125mg, 6.25mg, 12.5mg, 25mg metoprolol (generic for L opressor)

tablet: 25mg, 37.5mg, 75mg, 50mg, 100mg metoprolol er (generic for Toprol XL) tablet: 25mg, 50mg, 100mg, 200mg propranolol (generic for Inderal)

tablet: 10mg, 20mg, 40mg, 60mg, 80mg, 90mg

propranolol HCL ER 24 hr (generic for Inderal LA*)

capsule: 60mg, 80mg, 120mg, 160mg Level 2 Bystolic

BETA BLOCKERS, COMBOS Level 1 Atenolol/chlorthalidone (generic for Tenoretic) tablet: 50-25mg, 100-25mg Metoprolol Hydrochlorothiazide tablet: 100-50mg BENIGN PROSTATIC HYPERTROPHY (BPH) Level 1 doxazosin (generic for C ardura)

tablet: 1mg, 2mg, 4mg, 8mg dutasteride (generic for Avodart) (PL)

capsule: 0.5mg finasteride (PL) (generic for Proscar) tablet: 5mg tamsulosin (generic for Flomax)

capsule: 0.4mg terazosin (generic for H ytrin)

capsule: 1mg, 2mg, 5mg, 10mg CALCIUM CHANNEL BLOCKERS (CCB) Level 1 amlodipine (generic for N orvasc)

tablet: 2.5mg, 5mg, 10mg amlodipine besylate/benazepril (generic for L otrel)

capsule: 2.5-10mg, 5-20mg, 5-20mg, 5-40mg, 10-20mg, 10-40mg,

dilt-xr extended-release capsule: 120mg, 180mg, 240mg diltiazem ER (generic for Tiazac)

extended-release capsule: 120mg, 180mg, 240mg, 300mg

nifedipine ER, afeditab, nifediac CC (generic for Adalat CC)

extended-release tablet: 30mg, 60mg, 90mg nifedical XL (generic for Procardia XL) tablet: 30mg, 60mg nifedipine (generic for Procardia)

capsule:10, 20mg verapamil (generic for C alan, Isoptin)

tablet: 40mg, 80mg, 120mg verapamil SR (generic for C alan SR, Isoptin SR)

sustained-release tablet: 120mg, 180mg, 240mg

verapamil capsule HCL ER 24hr: 100 MG, 200MG

300MG Level 2 Cardene SR CHOLESTEROL LOWERING Level 1 atorvastatin (generic for L ipitor) (PL)





tablet: 10mg, 20mg, 40mg, 80mg

cholestyramine (generic for Qu estran, Questran Lite)

can: 4gm, bulk can only colesevelam (generic for Welchol) (PL) tablet:625mg colestipol (generic for C olestid) tablet: 1gm granules & packets: 5gm ezetimibe (generic for Zetia) (PL)

tablets: 10mg ezetimibe-Simvastatin (generic for Vytorin) (PL)

tablets: 10-10mg,10-20mg, 10-40mg, 10-80mg

fenofibrate (generic for L ofibra, Triglide, Tricor) (PL)

tablet: 48mg, 54mg, 145mg, 160mg capsules: 67mg, 134mg, 200mg fluvastatin (generic for L escol) (PL)

capsules: 20mg, 40mg gemfibrozil (generic for L opid)

tablet: 600mg lovastatin (generic for M evacor)

tablet: 10mg, 20mg, 40mg (PL) pravastatin (generic for Pravachol)

tablet: 10mg, 20mg, 40mg (PL) rosuvastatin (generic for Crestor)

tablet: 5gm. 10mg, 20mg, 40mg (PL)

simvastatin (generic for Zocor)

tablet: 5mg, 10mg, 20mg, 40mg, 80mg (PL) omega 3 acid ethyl esters, Triklo (generic for Lovaza)

capsule: 1gm (PL)

Level 2 Niacin ER (PL) Colesevelam pak SUSP 3.75gm (PL) Welchol (PL) DIRECT RENIN INHIBITORS Level 2 Amturnide Aliskiren fumarate (generic for Tekturna) (PL)

tablet: 150mg,300mg Tekamlo Tekturna (PL) Tekturna HCT (PL) Valturna DIURETICS 1, LOOP Level 1 bumetanide (generic for Bumex)

tablet: 0.5mg, 1mg, 2mg furosemide (generic for L asix)


oral solution: 10mg/ml DIURETICS 2, THIAZIDE Level 1 benazepril/HCTZ (generic for L otensin HCT)

tablet: 5mg/6.25mg, 10mg/12.5mg, 20mg/12.5mg, 20mg/25mg

chlorthalidone (generic for Hygroton)

tablet: 50mg enalapril/HCTZ (generic for Vaseretic)

tablet: 5mg/12.5mg, 10mg/25mg hydrochlorothiazide (HCTZ) (generic for H ydrodiuril)

tablet: 12.5mg, 25mg, 50mg hydrochlorothiazide (HCTZ) (generic for M icrozide)

capsules: 12.5mg indapamide (generic for L ozol)

tablet: 1.25mg, 2.5mg lisinopril/HCTZ (generic for Zestoretic/Prinzide)

tablet: 10mg/12.5mg, 20mg/12.5mg, 20mg/25mg

metolazone (generic for Zaroxolyn)

tablet: 2.5mg, 5mg, 10mg DIURETICS 3, OTHERS Level 1 triamterene/HCTZ (generic for D yazide)

capsule: 37.5mg/25mg triamterene/HCTZ (generic for M axzide) tablet: 37.5mg/25mg, 75mg/50mg spironolactone/HCTZ (generic for Aldactazide) tablet: 25mg/25mg spironolactone (generic for Aldactone) tablet: 25mg, 50mg, 100mg INOTROPES/PRESSORS Level 1 digoxin (generic for L anoxin)

tablet: 0.125mg, 0.25mg midodrine (generic for ProAmatine)

tablet: 2.5mg, 5mg, 10mg

Level 2 Lanoxin OTHER ANTI-HYPERTENSION Level 1 clonidine (generic for C atapress)

tablet: 0.1mg, 0.2mg, 0.3mg hydralazine (generic for Apresoline)

tablet: 10mg, 25mg, 50mg, 100mg prazosin (generic for M inipress)

capsule: 1mg, 2mg, 5mg

NITRATES Level 1 isosorbide dinitrate (generic for Isordil,, Isordil SR)

tablet: 5mg, 10mg, 20mg isosorbide mononitrate (generic for Imdur)

extended-release tablet: 30mg, 60mg, 120mg isosorbide mononitrate (generic for Ismo)

tablet: 20mg nitroglycerin (generic for N itro-Bid)

capsule: 2.5mg, 6.5mg, 9mg nitroglycerin (generic for N itrostat)

tablet: 0.3mg, 0.4mg, 0.6mg Level 2 Nitromist (PL) Nitroglycerin Lingual 400mcg spray (PL) OTHER CARDIOVASCULAR Level 2 Ranolazine ER (PL) (generic for Ranexa) tablet: 500mg, 1000mg Ranexa (PL)

DERMATOLOGIC/ SKIN

ACNE Level 1 adapalene (generic for D ifferin)

gel: 0.3%* benzoyl peroxide (generic for Benzefoamultra)

foam: 9.8% clindamycin (generic for C leocin-T)

gel: 1% lotion: 1% pad/swab 1% solution: 1%

clindamycin/benzoyl peroxide (generic for BenzaClin, Duac)

gel: 1%/5% gel: 1.2-5%

erythromycin (generic for T-Stat)

solution: 2% erythromycin (generic for Erygel)

gel: 2% metronidazole (generic for M etrocream, Metrogel, Metrolotion)

cream, gel, lotion: 0.75%, 0.1% tretinoin (generic for R etin-A)

cream: 0.025%, 0.05%, 0.1% gel: 0.01%, 0.025%

tretinoin





(generic for Atralin) gel: 0.05%

sulfacetamide sodium with sulfur* (generic for Sumadan, Plexion, Sumaxin Wash, Sumaxin TS) cleanser: 9.8-4.8% cream: 9.8-4.8%

wash: 9-4.5%, 9-4% suspension: 8-4% lotion: 9.8-4.8%

Level 2 Adapalene gel 0.1% Adapalene lotion * Adapalene cream * AMINOGLYCOSIDES Level 1 gentamicin 0.01% (generic for Ga ramycin)

cream: 0.1%, 15gm paromycin sulfate capsule: 250mg

ANESTHETICS Level 1 -prilocaine (generic for Emla)

cream: 2.5%

ANTI-BACTERIALS, DERM Level 1 mupirocin (generic for Bactroban) ointment: 2% Level 2 Bactroban NS ointment ANTIFUNGALS Level 1 ketoconazole (generic for N izoral)

cream: 2% shampoo: 2% tablets: 200mg

naftifine (generic for N aftin)

cream: 1%, 2% nystatin (generic for M ycostatin)

cream: 100,000u/g ointment: 100,000u/g

terbinafine (generic for L amisil)

tablet: 250mg ANTI-VIRALS Level 1 Podofilox solution (generic for C ondylox solution)

solution: 0.5% Level 2 Condylox gel OTHER DERMATOLOGICS Level 2

8-Mop Oxsoralen lotion PSORIASIS Level 1 calcipotriene solution (generic for D ovonex)

solution: 0.005% ceam: 0.005%

tazarotene (generic for Tazorac)

cream: 0.1% STEROIDS, HIGHEST POTENCY Level 1 clobetasol propionate (generic for Temovate)

cream: 0.05% ointment: 0.05%

halobetasol proprionate (PL) (generic for U ltravate) cream: 0.05% ointment: 0.05% STEROIDS, MEDIUM TO MEDIUM HIGH POTENCY Level 1 betamethasone dipropionate (generic for D iprosone)


Clotrimazole w/betamethasone (generic for L otrisone) cream: 1-0.05% lotion: 1-0.05% fluocinonide (generic for L idex, Lidex-E)

cream: 0.05% ointment: 0.05% gel: 0.05%

mometasone furoate (generic for Elocon) cream: 0.1% ointment: 0.1%

lotion 0.1% STEROIDS, LOW POTENCY Level 1 augmented betamethasone dipropionate

gel: 0.05% betamethasone valerate (generic for Valisone) cream: 0.1% lotion: 0.1% ointment: 0.1% desonide (generic for D esOwen)


fluocinolone acetonide (generic for Synalar)


triamcinolone acetonide (generic for Kenalog)

cream: 0.025%, 0.1% ointment: 0.025%, 0.1% lotion: 0.025%, 0.1%

STEROIDS, LOWEST POTENCY Level 1 Hydrocortisone, ala-cort (generic for H ytone)

cream: 0.5%, 1%, 2.5% ointment: 0.5%, 1%, 2.5% lotion: 1%, 2.5%

OTIC/ EAR

OTICS Level 1 ofloxacin (generic for Floxin Otic) solution: 3% 5ml, 3% 10ml fluocinolone acetonide (PL) (generic for D ermotic oil) oil: 0.01% neomycin-polymyxin-HC (generic for C ortisporinl) solution: 1% suspension: 3.5mg/ml-10000 unit/ml-1% Level 2 Ciprodex (PL)

NOSE NASAL SPRAYS Level 1 azelastine hcl NS (generic for Astepro NS) solution: 0.1%, 0.15% ipratropium bromide NS (generic for Atrovent NS) solution: 0.03%, 0.06% (PL) mometasone furoate NS (generic for Nasonex) Suspension: 50mcg/act

ENDOCRINE/ METABOLIC CALCIUM METABOLISM Level 1 alendronate (generic for Fosamax)

tablet: 5mg, 10mg,35mg, 70mg calcitonin (generic for M iacalcin/Fortical) (PL)

nasal spray: 200 units/act ergocalciferol (generic for D risdol) capsule: 50mg raloxifene (PL) ($0 copay) (generic for E vista)

tablet: 60mg risedronate (PL) (generic for Actonel) tablet: 5mg, 30mg, 35mg, 150mg risedronate delayed release (PL)* (generic for Atelvia) tablet: 35mg CORTICOSTEROIDS Level 1 dexamethasone, baycadron (generic for D ecadron, Hexadrol)

tablet, 0.5mg, 0.75mg,1mg, 1.5mg, 2mg, 4mg, 6mg





elixir: 0.5mg/5ml, 1mg/ml solution: 0.5mg/5ml

fludrocortisone acetate (generic for Florinef)

tablet: 0.1mg hydrocortisone (generic for C ortef)

tablet: 5mg, 10mg. 20mg methylprednisolone (generic for M edrol)

tablet: 4mg methylprednisolone, asmalp (generic for Or apred)

solution: 15mg/5ml prednisone (generic for D eltasone)

tablet: 1mg, 2.5mg, 5mg, 10mg, 20mg, 50mgprednisone pak: 5mg, 10mg Level 2 Orapred Orapred ODT

DIABETES MELLITUS Level 1 acarbose (generic for Precose)

tablet:25mg, 50mg, 100mg glimepiride (PL) (generic for Amaryl)

tablet: 1mg, 2mg. 4mg glipizide (generic for G lucotrol)

tablet: 5mg, 10mg glipizide ER (generic for G lucotrol XL)

extended-release tablet: 2.5mg, 5mg, 10mg glipizide-metformin (PL) (generic for M etaglip) tablet: 2.5-250mg, 2.5-500mg, 5mg-500mg glyburide (generic for D iabeta, Micronase)

tablet: 1.25mg, 2.5mg, 5mg glyburide micronized (generic for G lynase)

tablet: 1.5mg, 3mg, 6mg glyburide-metformin (generic for G lucovance)

tablet: 1,25-250mg, 2.5-500mg, 5-500mg Humalog Mix Vial (PL) Humalog vial (PL) Humulin vial (PL) Humulin R vial (PL) Humulin N vial Humulin 70/30 vial (PL) Insulin syringe Ketocare (acetone urine test strips) Lancets Lantus insulin vial (PL) Lifescan One Touch (glucose test strips) (PL) Lifescan One Touch Glucometer* (PL) (*No charge, any style One Touch meter i s available by calling Lifescan’s toll-free number 1-888-887-6299 or 1 -888-233-3282 Code 257BCA001) metformin (generic for G lucophage)


metformin ER/SR (generic for G lucophage XR)

extended-release tablet: 500mg, 750mg metformin ER/SR Osmotic (PL) (generic for Fortamet)

sustained release tablet: 500mg, 1000mg miglitol (generic for G lyset)

Tablet: 25mg, 50mg, 100mg nateglinide (PL) (generic for Starlix) tablet: 60mg, 120mg pen needles pioglitazone (PL) (generic for Actos)

tablet: 15mg, 30mg, 45mg pioglitazone-metformin (PL) (generic for Actoplus Met) tablet: 15-500mg, 15-850mg pioglitazone-glimepiride(PL) (generic for D uetact) tablet: 30-2mg, 30-4mg repaglinide (generic for Prandin) tablet: 1mg, 2mg Level 2 Actoplus Met XR Avandia (PL) Byetta (PL) Bydureon (PL) Bydureon Pen (PL) Bydureon Bcise Farxiga (PL) Freestyle Libre (PL) Glyset Humalog Cartridge Humalog Junior Kwikpen Humalog Mix Kwikpen Humulin Kwikpen Humulin N Kwikpen Humulin R U-500 Kwikpen Humulin R U-500 Concentrated vial (PL) Humulin 70/30 Kwikpen Invokana Invokamet Invokamet XR Janumet (PL) Janumet XR Januvia (PL) Kombiglyze XR Lantus Solostar Onglyza (PL) Prandin 0.5mg Repaglinide-Metformin Soliqua (PL) Symlin Pen (PL) Toujeo Solostar Pen Trulicity (PL) Victoza (PL) Xigduo XR ESTROGENS Level 1 estradiol, yuvafem (generic for Vagifem)

tablet: 10mcg estradiol (generic for Estrace)

tablet: 0.5mg, 1mg, 2mg estr adiol transdermal (PL) (generic for C limara)

weekly patch: 0.025 mg/24hr, 0.0375 mg/24hr, 0.05mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1mg/24hr

estr adiol transderma, dottil (PL) (generic for Vivelle Dot, Alora, Minivelle)

twice weekly patch: 0.025 mg, 0.0375 mg, 0.05mg, 0.075mg, 0.100mg

estropipate (generic for Og en, Ortho-Est)

tablet: 0.625mg, 0.75mg, .25mg,1.5mg, 2.5mg

Level 2 Cenestin (PL) Premarin ESTROGEN/PROGESTIN COMBO Level 1 Estradiol-norethindron acetate, Mimvey, Lopreeza, Amabelz (PL) (generic for Activella) tablet 1-0.05mg, 0.5-0.1mg Norethindrone acetate-ethinyl estradiol, Jevantique Lo, Fyavolv (PL) (generic for Femhrt) tablet 1-0.5mg-2.5mg Level 2 Premphase (PL) Prempro (PL) ORAL CONTRACEPTIVE, MONOPHASIC Level 1 Amethia, Ashlyna, Camrese, Daysee, Jaimess, Levonorgestrel/Ethinyl Estradiol, Simpesse (PL) (generic for Seasonique) tablet 0.15-0.03mg-0.01mg Amethia Lo, Comrese LoJaimess,, LoLevonorgestrel/Ethinyl Estradiol (91-day), (PL) (generic for L oSeasonique) tablet 0.1-0.02mg- 0.01mg Aurovela 1/20 Fayosim, Rivelsa, Levonorgestrel/Ethinyl Estradiol (PL) (generic for Qu artette)

tablet: 0.15-0.02/0.25/0.03mg & eth est 0.01mg

Apri, Cyred, Cyred EQ, Desogestrel/Ethinyl Estradiol, Emoquette, Enskyce, Isibloom, Juleber, Kalliga, Reclipsen, Solia (PL) (generic for D esogen-28) tablet 0.15mg/30mcg Drospirenone-Ethinyl Estradiol, Gianvi, Jasmiel, Lo-Zumandimine, Loryna, Nikki, Vestura (PL) (generic for Yaz) tablet 3-0.02mg Introvale, Jolessa, Levonorgestrel/Ethinyl Estradiol, Quasense, Setlakin, (PL) (generic for Seasonale) tablet: 0.15-0.03mg Afirmelle, Aubra, Aubra EQ, Aviane, Delyla, Falmina, Larissia, Lessina, Levonorgestrel/Ethinyl Estradiol, Lutera, Orsythia, Sronyx, Vienva (PL) (generic for Alesse, Levlite) tablet: 0.1mg/20mcg





Altavera, Ayuna, Chateal, Chateal EQ, Kurvelo, Levonorgestrel-Ethinyl Estradiol, Levora-28, Lillow, Marlissa, Portia-28 (PL) (generic for N ordette) tablet: 0.15mg/30mcg Nortrel, Wera (PL) (generic for Brevicon)

tablet: 0.5mg/35mcg, Alyacen, Cyclafem, Dasetta, Necon, Nortrel, Pirmella (generic for Or tho Novum) (PL) tablet: 1mg/35mcg Aurovela 21 1/20, Junel 21 1/20, Larin 21 1/20, Microgestin 21 1/20, Norethindrone Acetate/Ethinyl Estradiol 21 1/20 (PL) (generic for L oestrin 21 1/20) tablet: 1mg/20mcg, Aurovela 21 1.5/30, Hailey 21 1.5/30, Junel 21 1.5/30, Larin 21 1.5/30, Microgestin 21 1.5/30, Norethindrone Acetate/Ethinyl Estradiol 21 1.5/30(generic for L oestrin 21 1.5/30) (PL) tablet: 21 1.5mg/30mcg Aurovela FE 1/20, Blisovi FE 1/20, Gildess FE 1/20, Junel FE 1/20, Larin FE 1/20, Microgestin FE 1/20, Norethindrone Acetate/Ethinyl Estradiol FE 1/20 (PL) (generic for L oestrin Fe) tablet: 1mg/20mcg Aurovela FE 1.5/30, Blisovi FE 1.5/30, Gildess FE1.5/30, Junel FE 1.5/30, Larin FE 1.5/30, Microgestin FE 1.5/30 (generic for L oestrin FE 1.5/30) (PL) tablet: 1.5mg/30mcg Ocella, Syeda, Zarah, Zumandimine (PL) (generic for Yasmin 28) tablet: 3-0.03mg Estarylla, Mono-Linyah, Mononessa, Norgestimate/Ethinyl Estradiol, Previfem, Sprintec-28, Vylibra (PL) (generic for Or tho-Cyclen) tablet: 0.25-35mcg Ethynodiol Diacetate/Ethinyl Estradiol 1-35, Kelnor 1 /35, Zovia 1/35 (PL) (generic for D emulen) tablet: 1mg-35mcg Balziva, Briellyn, Gildagia, Philith, Vyfemla Zenchent (PL) (generic for Ov con 35) tablet: 0.4mg-35mcg Norethindrone/Ethinyl Estradiol FE, Wymzya FE (PL) (generic for Femcon Fe) tablet: 0.4 mg-35 mcg Cryselle-28, Elinest, Low-Ogestrel (PL) (generic for L o/Ovral-28) tablet: 0.3mg-30mcg ORAL CONTRACEPTIVE, BIPHASIC Level 1 Amethyst, Levonogestrel-Ethinyl Estradiol (PL) (generic for Lybrel) tablet: 90-20mcg) ORAL CONTRACEPTIVE, TRIPHASIC Level 1 Caziant Pak, Cesia Pak, Velivet Pak (PL)

(generic for C yclessa Pak) tablet: 0.1-0.025/0.125-0.025/0.15-.025mg

Alyacen 7/7/7, Cyclafem 7/7/7, Dasetta 7/7/7, Necon 7/7/7, Nortrel 7/7/7, Pirmella 7/7/7 (PL) (generic for Or tho-Novum 7/7/7)

tablet: 0.5-35/0.75-35/1-35 Enpresse 28, Levonorgestrel/Ethinyl Estradiol, Myzilra, Trivora 28 (PL) (generic for Triphasi 28)

tablet:0.05-30/0.075-40/0.125-30 Aranelle, Leena (PL) (generic for Tri-Norinyl)

tablet: 0.5-35/1-35/0.5-35mg Tilia FE, Tri-Legest FE (PL) (generic for Estrostep FE)

tablet: 1-20/1-30/1-35mg-mcg Norgestimate/Ethinyl Estradiol, Tri Femynor, Tri-Estarylla, Tri-Linyah, Tri-Mili, Trinessa, Tri-Previfem, Tri-Sprintec, Tri-Vylibra (PL) (generic for Or tho Tri-Cyclen)

tablet:0.18-35/0.215-35/0.25-35 ORAL CONTRACEPTIVE, PROGESTINS Level 1 Camila, Deblitane, Errin, Heather, Incassia, Jencycla, Jolivette, Lyza, Nora-BE, Norethindrone, Norlyda, Norlyroc, Sharobel, Tulana (PL) (generic for Or tho-Micronor) tablet: 0.35mg Slynd (PL) tablet: 4mg ORAL CONTRACEPTIVE, OTHER Level 1 Azurette, Bekyree, Desogestrel/Ethinyl Estradiol, Kariva, Kimidess, Pimtrea, Simliya, Viorele,Volnea (PL) (generic for M ircette) tablet: 0.15-0.02-0.02/0.01mg Level 2 Mircette (PL) Nuvaring (PL) OTHER ENDOCRINE/METABOLIC ANAPHYLAXIS Level 2 Mylan Epinephrine pen (PL) Baqsimi (PL) Glucagen Glucagon (PL) Symjepi (PL) PROGESTINS Level 1 medroxyprogesterone (generic for Provera)

tablet: 2.5mg, 5mg, 10mg medroxyprogesterone (generic for D epo-Provera)

injection: 150mg norethindrone acetate (PL) (generic for Aygestin) tablets: 5mg progesterone micronized (PL) (generic for Prometrium)

capsules: 100mg, 200mg THYROID Level 1 Armour Thy roid NP Thyroid, Levothyroxine/Liothyronine (generic for Armour Thy roid)

tablet: 15mg, 30mg, 60mg, 90mg, 120mg, 180mg, 240mg, 300mg

liothyronine (generic for C ytomel)

tablet: 5mcg, 25mcg, 50mcg levoxyl, levothyroxine, levothroid, unithroid, unithroid direct, Levo-T, euthyrox (generic for Synthroid)

tablet: 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg

Level 2 Synthroid Thyrolar


GASTROINTESTINAL/ STOMACH

ANTI-SPASMODICS Level 1 dicyclomine (generic for Bentyl) capsules: 10mg

tablet: 20mg hyoscyamine sulfate (generic for L evsin, Levsin SL)

tablet: 0.125mg sublingual tablet: 0.125mg

Methscopalamine Bromide tablet: 2.5mg (PL), 5mg PROTON PUMP INHIBITORS (PPI) Level 1 esomeprazole magnesium (generic for N exium) (PL)

delayed-release capsule: 20mg, 40mg lansoprazole (generic for Prevacid)

delayed-release capsule: 15mg, 30mg omeprazole (generic for Prilosec) delayed-release capsule: 10mg, 20mg, 40mg pantoprazole (generic for Protonix) (PL) tablet: 20mg, 40mg rabeprazole (generic for Aciphex)

tablet: 20mg

H2 BLOCKERS Level 1 cimetidine (generic for Tagamet)

tablet: 300mg, 400mg, 800mg famotidine (generic for Pepcid)

tablet: 40mg ranitidine (generic for Zantac)




tablet: 300mg capsule: 150mg syrup: 75mg/5ml

LAXITIVES Level 1 lactulose solution 10gm/15ml, 20gm/30ml Level 2 Nizatidine

GASTROINTESTINAL (GI), OTHER Level 1 azathioprine (generic for Imuran)

tablet: 50mg hydrocortisone cream, proctosol HC, proctozone,proctocare, procto-med (generic for H ytone/Anusol HC cream)

cream: 2.5% hydrocort AC, hemmorex-HC, (generic for Protocort AC)

suppository: 30mg mesalamine (generic for R owasa)

enema: 4gm mesalamine DR (generic for Asacol HD)

tablet: 800mg sucralfate (generic for C arafate)

tablets: 1gm Level 2 Asacol HD Canasa suppository (PL) mesalamine (generic for C anasa) (PL) suppos: 1000mg Carafate suspension Creon Delzicol Dipentum (PL) Linzess Mesalamine DR 400mg Capsule Pancrelipase Pentasa Zenpep NAUSEA/VOMITING Level 1 metoclopramide (generic for R eglan)

tablet: 5mg, 10mg syrup: 5mg/5ml

promethazine (generic for Phenergan)

tablet: 25mg, 50mg syrup: 6.25mg/5ml rectal suppository: 12.5mg, 25mg, 50mg

IMMUNOLOGIC

ANTI-RHEUMATICS Level 1 methotrexate

tablet: 2.5mg

injection: 25mg/ml, 1gm

Level 2 Cuprimine Penicillamine cap 250mg ANTI-MALARIALS Level 1 hydroxychloroquine (generic for Plaquenil)

tablet: 200mg atovaquone/proguanil (generic for M alaronel)

tablet: 62.5-25mg, 250/100mg IMMUNOSUPPRESSANTS Level 1 tacrolimus (generic for Prograf) capsules: 0.5mg, 1mg, 5mg tacrolimus (PL) (generic for Protopic) ointment: 0.3mg, 0.1mg mycophenolate mofetil (generic for C ellCept) capsules: 250mg tablets: 500mg oral solution: 200mg/ml mycophenolate sodium DR (generic for M yfortic) tablets: 180mg, 360mg Level 2 Sandimmune

NUTRIENTS & BLOOD MODIFIERS

ANTICOAGULANTS/THROMBOLYTICS Level 1 Jantoven, Warfarin (generic for C oumadin)

tablet: 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg

Level 2 Coumadin Eliquis Pradaxa Xarelto Xarelto Starter Pack

CALCIUM METABOLISM Level 1 Calcium Acetate (generic for Eliphos)

tablet: 667mg ELECTROLYTES, ACID BASE Level 1 Kaon, EdK+10 (generic for K-Tab)

tablet: 10mEq Klor-con (generic for K-Dur, K-Tab)

tablet: 10mEq, 20mEq Klor-con Micro Crys ER

tablet: 20mEq potassium chloride Micro Crys ER (generic for K-Dur)

tablet: 20mEq potassium chloride (generic for C ena-K)

solution: 10% potassium chloride (generic for Klor-Con powder)

powder p acket: 20mEq potassium chloride, Klor-con 8meq, K-Tab 8meq (generic for K-Dur, K, Slow K)

tablet: 8mEq, 10mEq, 20mEq capsule : 10 mEq

potassium chloride tablet: 25mEq

OPIATE ANTAGONIST

Level 2 Narcan NS (PL)

OPHTHALMIC/ EYE

ANTI-BACTERIALS, OPTHALMIC Level 1 erythromycin (generic for Ilotycin)

ointment: 5mg/gm gentamicin (generic for Ga ramycin)

ointment: 0.3% solution: 0.3%

sulfacetamide (generic for Sodium Sulamyd) solution: 10% Level 2 Restasis emulsion Restasis Multidose emulsion Tobrex ointment ANTI-BACTERIALS W/ STEROIDS Level 1 neomycin/polymyxin B/dexamethasone (generic for M axitrol)

ointment: 0.1% suspension: 0.1%

sulfacetamide, prednisolone (generic for Blephamide, Vasocidin)

ointment suspension

tobramycin-dexamethasone (generic forTobradex)

suspension 0.03-0.1%

CORTICOSTEROIDS, OPTHALMIC prednisolone acetate. pred forte (generic for O mnipred) suspension: 1% GLAUCOMA Level 1 brimonidine tartrate (generic for Alphagan)

solution: 2%





brimonidine tartrate (generic for Alphagan P)

solution: 0.15% carteolol (generic for O cupress)

solution: 1% dorzolamide hcl (generic for Trusopt)

solution: 2% dorzol/timolol (generic for C osopt) solution:2%-0.5% latanoprost (generic for X alatan)

solution: 0.005% levobunolol (generic for Betagan)

solution: 0.5% pilocarpine (generic for Isopto Carpine, Pilocar)

solution: 0.5%, 1%, 2%, 3%, 4%, 6% timolol opthalmic (generic Timoptic)

bottled solution: 0.25%, 5% Level 2 Alphagan P 0.01% Bimatoprost sol 0.03% (PL) Combigan Lumigan Pred Mild Susp 0.12% Travatan Z travoprost dro (generic for Travatan Z)

ophthalmic solution: 0.004% NON STEROIDAL ANTI-INFLAMMATORY DRUGS, OPTHALMIC (NSAIDS) Level 1 bacitracin-polymyxin-neomycin-HC (generic for C ortisporin) ophthalmic ointment: 1% ketorolac tromethamine (generic for Acular)

ophthalmic solution: 0.5% ketorolac tromethamine (generic for Acular LS)

ophthalmic solution: 0.4% Level 2 Bromfenac 0.9% Base Equiivalent (PL) Bromfenac 0.9% Once Daily Cequa (cyclosporine) SOLN 0.09% (PL) OPTHALMIC, OTHER Level 1 Flurbiprofen sodium (generic for O cufen)

sol: 0.03% Level 2 Cyclopentolate 0.5% Epinastine HCL 0.05%

RESPIRATORY

ANTIHISTAMINES, SEDATING Level 1 cyproheptadine (generic for Periactin)

tablet: 4mg hydroxyzine HCL (generic for Atarax)

tablet: 10mg, 25mg, 50mg hydroxyzine pamoate (generic for Vistaril)

capsule: 25mg, 50mg

ANTIHISTAMINES, OTHER Level 1 Carbinoxamine maleate (generic for Palgic) tablet: 4mg solution: 4mg/5ml ANTITUSSIVES/EXPECTORANTS Level 1 benzonatate softgels (generic for Tessalon Perles)

capsule: 100mg hydrocodone/homatropine (generic for H ycodan, Tussigon)

tablet: 5mg/1.5mg syrup: 5mg/1.5mg/5ml

promethazine/codeine (generic for Phenergan/codeine)

syrup: 6.25mg/10mg/5 promethazine/DM (generic for Phenergan DM)

syrup: 6.25mg/15mg/5ml promethazine/PE/codeine

syrup: 6.25-5mg/5ml 6.25-5-10mg/5ml

BRONCHODILATORS Level 1 albuterol (generic for Proventil) nebulizer: 0.083%

tablet: 2mg, 4mg syrup: 2mg/5ml

levalbuterol (generic for X openex) concentrated nebulizer: 1.25mg/0.5ml nebulizer: 0.31mg, 0.63mg, 1.25mg/3ml

Level 2 Anoro Ellipta Atrovent HFA (PL) Incruse Ellipta ProAir HFA ProAir Respiclick Serevent Diskus (PL) Stiolto Respimat (PL) Ventolin HFA BRONCHODILATORS, INHALED STEROIDS Level 1 Fluticasone propionate/salmeterol (generic for Airduo)

Inhaler: 113-14mcg/act, 232-14mcg/act, 55-14mcg/act

Level 2

Advair (PL) Advair HFA (PL) Symbicort ASTHMA, OTHER Level 1 dyphyllin-gg, DG 200, COPD, dyflex G (generic for L ufyllin GG)

Elixir: 100-100mg tablet: 200-200mg

difil-g fort liquid 100-100 difil g 400 tablet dilex-g liquid 100-100 dy-G liquid 100-100 dyphylline tab gg es (generic for D ifil G) tablets: 200-300mg

Ipratropium/albuterol (generic for D uoneb) nebulizer s olution: 0.5-2.5mg/3ml montelukast (PL) (generic for Singluair) chewable tablet: 4mg, 5mg granules: 4mg tablets: 10mg zafirlukast (PL) (generic for Accolate) tablet: 10mg, 20mg budesonide suspension (generic for Pulmicort Respules) (PL) tablet: 0.25mg, 0.5mg Level 2 Advair (PL) Alvesco (PL) Arnuity Ellipta Asmanex Asmanex HFA Flovent Diskus Flovent HFA Fluticasone-Salmeterol Aer (PL) Pulmicort respules 1mg (PL) Pulmicort flexhaler (PL) Qvar (PL) Qvar d ose counter (PL) Qvar R edihaler Theo-24 Trelegy Ellipta Wixela (PL) OTHER PULMONARY Level 1 Spacer/Aerosol-Holding Chambers – Device (PL) Spacer/Aerosol-Holding Chambers – Supplies Bags (PL) Spacer/Aerosol-Holding Chambers – Masks (PL) Level 2 Bethkis Breo Ellipta THEOPHYLLINES Level 1 Theochron ER 12HR theophylline solution (generic for Slo-phyllin) solution: 80mg/15ml theophylline SR 12 HR (generic for Theo-Dur)





sustained-release tablet:100mg, 200mg, 300mg

theophylline SR 24 HR (generic for U niphyl)

sustained-release tablet:400mg, 600mg

UROLOGIC ANTI-SPASMODICS, GENIT0-URINARY (GU) Level 1 oxybutynin chloride (generic for D itropan)

tablet: 5mg syrup: 5mg/5ml

oxybutynin chloride ER/SR (generic for D itropan XL)

tablet: 5mg, 10mg, 15mg flavoxatate HCL (generic for U rispas) tablet: 100mg tolterodine (generic for D etrol) tablet: 1mg, 2mg tolterodine SR/ER * (generic for D etrol LA) capsule: 2mg, 4mg trospium (generic for Sanctura) tablet: 20mg, 2mg foltrospium ER/SR (PL) (generic for Sanctura XR) capsule: 60mg Level 2 Darifenacin Hydrobromide SR/ER (PL) Myrbetriq Solifenacin succinate (PL) (generic for Vesicare)

Tablet: 5mg, 10mg Vesicare (PL) MINERALS Level 2 K-Phos Original

VAGINAL PREPARATIONS

ANTIMICROBIAL Level 1 clindamycin (PL) (generic for C leocin (PL)

cream: 2% ANTI-FUNGAL Level 1 terconazole (PL) (generic for Terazol 3)

cream: 0.8% suppository: 80mg

metronidazole vaginal gel (PL) (generic for M etrogel Vaginal Gel)

vaginal gel: 0.75% VAGINAL, OTHER

Level 1 estradiol vaginal cream (PL) (generic for Estrace vaginal creaml)

vaginal cream: 0.01% Level 2 Estrace cream (PL) Premarin cream (PL



Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call 602-864-4884 for Spanish and 877-475-4799 for all other languages and other aids and services.

If you believe that BCBSAZ 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: BCBSAZ’s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ 85002-3466, 602-864-2288, TTY/TDD 602-864-4823, [email protected]. You can file a grievance in person or by mail or email. If you need help filing a grievance BCBSAZ’s Civil Rights Coordinator 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, DC 20201, 1-800- 368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

mailto:[email protected]

http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Multi-language Interpreter Services

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