Class Listing

Key to Symbols

*=Generic forms of this drug are covered at Tier 1 copay. Brand equivalents are Tier 3. Please ask your doctor or practitioner and pharmacist to prescribe/dispense the generic form.
May require prior authorization=Point of Sale Intervention Program drug; may require prior authorization
=This drug is not in the POS Program; however, it may require prior approval in some cases. For approval, call Customer or Member Services.
=This drug is commonly excluded from coverage by contracts that exclude certain classes of drugs. See benefit brochure or applicable contract language for details.

Therapeutic Class Listing

Chapter 1: Anti-Infectives
Chapter 2: Antineoplastics and Immunosuppressants
Chapter 3: Autonomic and CNS Drugs
Chapter 4: Cardiovascular Drugs
Chapter 5: Dermatology
Chapter 6: Ear, Nose and Throat Drugs
Chapter 7: Endocrine and Diabetes Drugs
Chapter 8: Gastroenterology
Chapter 9: Immunology, Vaccines and Biotechnology
Chapter 10: Musculoskeletal and Rheumatology
Chapter 11: Obstetrics and Gynecology
Chapter 12: Ophthalmology
Chapter 13: Respiratory and Allergy
Chapter 14: Urology
Chapter 15: Vitamins and Electrolytes
Chapter 16: Miscellaneous

Chapter 1: Anti-Infectives[TOP]
 1.1Penicillins
   *amoxicillin1
   *ampicillin1
   *dicloxacillin (Liquid is Tier 2) 1
   *penicillin 1
    AUGMENTIN amoxicillin/clavulanic acid2
 1.2Tetracyclines
   *doxycycline 1
   *tetracycline 1
 1.3Cephalosporins
  1.3.1Cephalosporins, First Generation
   *cephalexin 1
  1.3.2Cephalosporins, Second Generation
    CEFTIN cefuroxime2
    CEFZIL SUSPENSION cefprozil 2
    OMNICEF SUSPENSION cefdinir 2
    SUPRAX SUSPENSION cefixime 2
    SUPRAX TABLETS cefixime tablets (Qty limited to single dose) 3
 1.4Macrolides
   *erythromycin (All generic forms) 1
   *erythromycin/sulfisoxazole 1
    BIAXIN clarithromycin (Including XL) 2
    ZITHROMAX azithromycin2
 1.5Quinolones
    CIPRO ciprofloxacin2
    FLOXIN ofloxacin 2
    TEQUIN gatifloxacin2
 1.6Sulfas and Related Agents
   *sulfadiazine 1
   *sulfisoxazole (Liquid is Tier 2) 1
   *trimethoprim/sulfamethoxazole 1
    GANTANOL sulfamethoxazole2
 1.7Urinary Tract Agents
   *nitrofurantoin macro 1
    FURADANTIN nitrofurantoin 2
    MACROBID nitrofurantoin monohydrate macro 2
 1.8Antivirals
  1.8.1Antivirals, Misc
   *acyclovir1
   *amantadine 1
    CYTOVENE ganciclovir2
    FAMVIR famciclovir2
    VALTREX valacyclovir2
  1.8.2Antivirals, HIV/AIDS
    AGENERASE amprenavir2
    COMBIVIR lamivudine/zidovudine2
    CRIXIVAN indinavir 2
    EPIVIR lamivudine 2
    FORTOVASE saquinavir 2
    HIVID zalcitabine 2
    KALETRA lopinavir/ritonavir2
    NORVIR ritonavir 2
    RESCRIPTOR delavirdine2
    RETROVIR zidovudine2
    SUSTIVA efavirenz 2
    TRIZIVIR abacavir/zidovudine/lamivudine2
    VIDEX didanosine2
    VIRACEPT nelfinavir 2
    VIRAMUNE nevirapine 2
    ZERIT stavudine 2
    ZIAGEN abacavir 2
 1.9Antifungal Agents
   *griseofulvin microsize 1
   *griseofulvin ultramicrosize 1
   *nystatin 1
    ANCOBON flucytosine2
    DIFLUCAN fluconazole2
    LAMISIL terbinafine2
    MYCELEX clotrimazole2
 1.10Vancomycin
    VANCOCIN vancomycin2
 1.11Anti-Infectives, Misc
  1.11.1Anti-Infectives, Misc
   *clindamycin (150mg) 1
   *neomycin1
    DAPSONE dapsone 2
    TOBI tobramycin nebulized 2
  1.11.2Antiparasitics
   *iodoquinol 1
   *mebendazole 1
   *metronidazole (375mg is Tier 3)1
   *paromomycin 1
   *pentamidine injection 1
    BILTRICIDE praziquantel2
    FUROXONE furazolidone2
    MEPRON atovaquone2
    MINTEZOL thiabendazole 2
    NEBUPENT pentamidine nebulized 2
    STROMECTOL ivermectin 2
  1.11.3Antimalarials
   *chloroquine 1
   *hydroxychloroquine 1
   *primaquine 1
   *quinine 1
    DARAPRIM pyrimethamine 2
    FANSIDAR pyrimethamine/sulfadoxine2
    LARIAM mefloquine2
  1.11.4Antimycobacterials
   *isoniazid1
   *pyrazinamide 1
   *rifampin 1
   *streptomycin 1
    LAMPRENE clofazimine2
    MYAMBUTOL ethambutol2
    MYCOBUTIN rifabutin 2
    SEROMYCIN cycloserine2
Chapter 2: Antineoplastics and Immunosuppressants[TOP]
 2.1Antineoplastic and Immunosuppressant Drugs
  2.1.1Alkylating Agents
    ALKERAN melphalan 2
    CEENU lomustine 2
    CYTOXAN cyclophosphamide 2
    LEUKERAN chlorambucil2
    MYLERAN busulfan 2
  2.1.2Antimetabolites
   *methotrexate 1
    FLUDARA fludarabine2
    PURINETHOL mercaptopurine2
    THIOGUANINE thioguanine2
    XELODA capecitabine2
  2.1.3Hormones and Related Drugs
   *megestrol 1
    ARIMIDEX anastrozole2
    CASODEX bicalutamide2
    EULEXIN flutamide 2
    FARESTON toremifene2
    FEMARA letrozole 2
    NILANDRON nilutamide 2
    NOLVADEX tamoxifen (Tamoxifen is Tier 2)2
  2.1.5Immunosuppressant Drugs
   *azathioprine 1
   *cyclosporine microemulsion 1
    CELLCEPT mycophenolate 2
    PROGRAF tacrolimus 2
    SANDIMMUNE cyclosporine2
  2.1.6Miscellaneous Antineoplastic Drugs
    EMCYT estramustine2
    ERGAMISOL levamisole 2
    HEXALEN altretamine2
    HYDREA hydroxyurea2
    LUPRON leuprolide 2
    LYSODREN mitotane 2
    MATULANE procarbazine 2
    VEPESID etoposide 2
    VESANOID tretinoin2
 2.2Adjunctive Agents
   *leucovorin 1
Chapter 3: Autonomic and CNS[TOP]
 3.1Narcotic Analgesics
  3.1.1Narcotic Analgesics
   *codeine 1
   *hydromorphone 1
   *meperidine 1
   *methadone 1
   *morphine sulfate 1
   *morphine sulfate sr1
    DURAGESIC fentanyl transdermal2
    MS CONTIN morphine sulfate sr 2
    RMS morphine (Suppository) 2
  3.1.2 Narcotic Analgesic Combinations
   *acetaminophen/codeine (Liquid is Tier 2) 1
   *acetaminophen/hydrocodone (Liquid is Tier 2) 1
   *acetaminophen/oxycodone 1
   *aspirin/codeine 1
   *aspirin/oxycodone1
 3.2Propoxyphene
  3.2 Narcotic Partial Agonist/Antagonists
   *propoxyphene (All generic combinations are Tier 1) 1
   May require prior authorizationSTADOL butorphanol (Max 3 cannisters/30 days)2
    TALWIN NX pentazocine/naloxone2
 3.3Non-Narcotic Analgesics
  3.3.1NSAIDs
   *diclofenac 1
   *etodolac1
   *ibuprofen1
   *indomethacin 1
   *meclofenamate 1
   *naproxen1
   *naproxen sodium1
   *piroxicam1
   *sulindac 1
   *tolmetin 1
   May require prior authorizationCELEBREX celecoxib (Reserve for pts at high-risk of NSAID gastropathy - step therapy to be implemented in 2002)2
   May require prior authorizationVIOXX rofecoxib (Reserve for pts at high-risk of NSAID gastropathy - step therapy to be implemented in 2002)2
  3.3.2Salicylates
   *choline/mag salicylates 1
   *diflunisal1
   *salsalate1
 3.4Headache and Antiemetic Therpay
  3.4.1Headache Drugs
   *acetaminophen/butalbital 1
   *acetaminophen/butalbital/caffeine1
   *acetaminophen/butalbital/caffeine/codeine 1
   *aspirin/butalbital/caffeine 1
   *aspirin/butalbital/caffeine/codeine1
   *ergotamine/caff/belladonna/phenobarbital 1
   *ergotamine/caffeine 1
   *isometheptene/dichloralphenazone/apap 1
   May require prior authorizationAMERGE naratriptan (Max 23 mg/30 days)2
   May require prior authorizationIMITREX sumatriptan (Max 1200 mg/30 days: 4 inj kits, 12 nasal sprays, or 24 (50mg) tablets)2
   May require prior authorizationMAXALT rizatriptan (Max 120 mg/30 days)2
   May require prior authorizationMIGRANAL dihydroergotamine (Max 8 amps/30 days)2
    ERGOMAR ergotamine2
  3.4.2Antiemetic and Antivertigo Drugs
   *meclizine1
   *prochlorperazine 1
   *promethazine1
    KYTRIL granisetron2
    TRANSDERM-SCOP scopolamine 2
    ZOFRAN ondansetron2
 3.5Antiparkinson Agents
   *amantadine 1
   *benztropine 1
   *bromocriptine1
   *levodopa/carbidopa (Including CR) 1
   *selegiline1
   *trihexyphenidyl 1
    COMTAN entacapone2
    DOPAR levodopa 2
    MIRAPEX pramipexole2
    REQUIP ropinirole 2
 3.6Anticonvulsants
   *acetazolamide (500mg Sequels are Tier 2) 1
   *clonazepam 1
   *ethosuximide 1
   *mephobarbital1
   *phenobarbital1
   *phenytoin 1
   *primidone1
    DEPAKENE valproic acid2
    DEPAKOTE divalproex 2
    DIASTAT diazepam rectal2
    DILANTIN phenytoin 2
    FELBATOL felbamate 2
    GABITRIL tiagabine 2
    KEPPRA levetiracetam 2
    LAMICTAL lamotrigine2
    NEURONTIN gabapentin2
    TEGRETOL carbamazepine (Including XR) 2
    TOPAMAX topiramate 2
    ZONEGRAN zonisamide2
 3.7Misc Neurological Therapy
    ARICEPT donepezil 2
    COPAXONE glatiramer 2
    EXELON rivastigmine2
    NIMOTOP nimodipine 2
 3.8Muscle Relaxants and Antispasmodics
  3.8.1Muscle Relaxants
   *baclofen1
   *carisoprodol 1
   *cyclobenzaprine 1
   *methocarbamol 1
    DANTRIUM dantrolene2
  3.8.2Myasthenia Gravis
   *pyridostigmine1
    MESTINON SR pyridostigmine sr2
    PROSTIGMIN neostigmine2
 3.9Psychotherapeutic Drugs
  3.9.3Antipsychotics
   This drug is commonly excluded from coverage*chlorpromazine 1
   This drug is commonly excluded from coverage*clozapine1
   This drug is commonly excluded from coverage*fluphenazine 1
   This drug is commonly excluded from coverage*haloperidol 1
   This drug is commonly excluded from coverage*loxapine 1
   This drug is commonly excluded from coverage*perphenazine1
   This drug is commonly excluded from coverage*thiothixene 1
   This drug is commonly excluded from coverage*trifluoperazine1
   This drug is commonly excluded from coverageGEODON ziprasidone2
   This drug is commonly excluded from coverageMOBAN molindone 2
   This drug is commonly excluded from coverageRISPERDAL risperidone (Liquid not covered)2
   This drug is commonly excluded from coverageSEROQUEL quetiapine 2
   This drug is commonly excluded from coverageZYPREXA olanzapine2
  3.9.4Psychotherapeutics, Misc
   *dextroamphetamine (Spansule is Tier 2) 1
   This drug is commonly excluded from coverage*ergoloid mesylates 1
   This drug is commonly excluded from coverage*lithium carbonate (Eskalith CR is Tier 2)1
   This drug is commonly excluded from coverage*lithium citrate 1
   *methylphenidate (Including generic SR) 1
    ADDERALL amphetamine/dextroamphetamine (Including XR) 2
    CYLERT pemoline 2
  3.9.5Anxiolytics/Hypnotics
   This drug is commonly excluded from coverage*alprazolam 1
   This drug is commonly excluded from coverage*chloral hydrate 1
   This drug is commonly excluded from coverage*diazepam1
   This drug is commonly excluded from coverage*lorazepam 1
   This drug is commonly excluded from coverage*temazepam 1
   This drug is commonly excluded from coverage*triazolam1
   This drug is commonly excluded from coverageSECONAL secobarbital2
 3.10Antidepressants
  3.10.1Cyclic Antidepressants
   This drug is commonly excluded from coverage*amitriptyline 1
   This drug is commonly excluded from coverage*amoxapine 1
   This drug is commonly excluded from coverage*clomipramine 1
   This drug is commonly excluded from coverage*desipramine 1
   This drug is commonly excluded from coverage*doxepin 1
   This drug is commonly excluded from coverage*imipramine 1
   This drug is commonly excluded from coverage*maprotiline 1
   This drug is commonly excluded from coverage*nortriptyline 1
   This drug is commonly excluded from coverage*protriptyline 1
  3.10.2SSRIs
   This drug is commonly excluded from coverage*fluoxetine 2
   This drug is commonly excluded from coverageCELEXA citalopram 2
   This drug is commonly excluded from coveragePAXIL paroxetine2
   This drug is commonly excluded from coverageZOLOFT sertraline 2
  3.10.3Other Antidepressants
   This drug is commonly excluded from coverage*bupropion 1
   This drug is commonly excluded from coverage*trazodone 1
   This drug is commonly excluded from coverageEFFEXOR venlafaxine (Including XR) 2
   This drug is commonly excluded from coverageSERZONE nefazodone2
   This drug is commonly excluded from coverageWELLBUTRIN SR bupropion sr2
  3.10.4MAO Inhibitors
   This drug is commonly excluded from coverageNARDIL phenelzine2
   This drug is commonly excluded from coveragePARNATE tranylcypromine2
Chapter 4: Cardiovascular[TOP]
 4.1Antiarrhythmics
   *amiodarone 1
   *disopyramide (Including CR) 1
   *mexiletine 1
   *propafenone (300mg is Tier 2)1
   *quinidine (Brand-only forms are Tier 2) 1
   *sotalol 1
    ETHMOZINE moricizine 2
    PROCANBID procainamide (All generics are Tier 1) 2
    TAMBOCOR flecainide 2
 4.2 Cardiac Glycosides
    LANOXIN digoxin (0.5mg not covered) 2
 4.3Nitrates
   *isosorbide dinitrate1
   *isosorbide mononitrate 1
   *isosorbide mononitrate sr 1
   *isosorbide mononitrate sr 1
   *nitroglycerin oral 1
   *nitroglycerin transdermal1
    NITROSTAT nitroglycerin sl 2
 4.4Coagulation Therapy
  4.4.1Anticoagulants
    COUMADIN warfarin 2
  4.4.2Antiplatelet Drugs
   *dipyridamole 1
   *sulfinpyrazone 1
    PLAVIX clopidogrel2
    TICLID ticlopidine 2
  4.4.3Heparins
   *heparin 1
    FRAGMIN dalteparin 2
    LOVENOX enoxaparin2
  4.4.4Vitamin K
    MEPHYTON phytonadione 2
  4.4.5Hemostatics
    AMICAR aminocaproic acid 2
  4.4.6Misc Coagulation Agents
   *pentoxifylline 1
 4.5Antihypertensives
  4.5.1Diuretics
   *amiloride1
   *amiloride/hctz1
   *bumetanide 1
   *chlorothiazide1
   *chlorthalidone1
   *furosemide 1
   *hydrochlorothiazide 1
   *indapamide 1
   *methylclothiazide 1
   *spironolactone 1
   *spironolactone/hctz 1
   *triamterene/hydrochlorothiazide 1
    ZAROXOLYN metolazone2
  4.5.2Beta Blockers
   *atenolol 1
   *labetalol 1
   *metoprolol 1
   *nadolol 1
   *pindolol 1
   *propranolol (Including LA) 1
   *timolol 1
    COREG carvedilol 2
    TOPROL XL metoprolol succinate 2
  4.5.3Calcium Channel Blockers
   *diltiazem (XT and CD are Tier 2) 1
   *nifedipine1
   *nifedipine cc 1
   *verapamil (Including SR) 1
    COVERA HS verapamil chronobiol la2
    TIAZAC diltiazem cr2
    VERELAN PM verapamil chronobiol la2
  4.5.4ACE Inhibitors
   *captopril1
   *enalapril 1
    ACCUPRIL quinapril 2
    ALTACE ramipril 2
    LOTENSIN benazepril 2
    MAVIK trandolapril2
    MONOPRIL fosinopril 2
    PRINIVIL lisinopril2
    UNIVASC moexipril 2
    ZESTRIL lisinopril2
  4.5.5Adrenergic Antagonists & Related Drugs
   *clonidine1
   *doxazosin 1
   *guanabenz 1
   *guanfacine 1
   *methyldopa 1
   *prazosin1
   *reserpine1
   *terazosin1
  4.5.6Agents for Pheochromocytoma
    DEMSER metyrosine2
    DIBENZYLINE phenoxybenzamine 2
    REGITINE phentolamine mesylate 2
  4.5.7Vasodilators
   *hydralazine 1
   *minoxidil 1
  4.5.8Other Antihypertensive Combinations
   *atenolol/chlorthalidone 1
   *bisoprolol/hctz1
   *captopril/hctz1
   *clonidine/chlorthalidone1
   *propranolol/hctz 1
    DIOVAN HCT valsartan/hctz 2
    LOTENSIN HCT benazepril/hctz 2
    LOTREL benazepril/amlodipine2
    MICARDIS HCT telmisartan/hctz2
    MONOPRIL HCT fosinopril/hctz 2
    PRINZIDE lisinopril/hctz2
    UNIRETIC moexipril/hctz 2
    ZESTORETIC lisinopril/hctz2
  4.5.9Angiontensin Receptor Blockers
    DIOVAN valsartan 2
    MICARDIS telmisartan2
 4.6Lipid Lowering Agents
   *cholestyramine 1
   *cholestyramine light 1
   *gemfibrozil 1
   *lovastatin1
    COLESTID colestipol 2
    LESCOL fluvastatin (Including XR) 2
    LIPITOR atorvastatin2
    NIASPAN niacin sr2
    PRAVACHOL pravastatin2
    TRICOR fenofibrate2
Chapter 5: Dermatology[TOP]
 5.1Topical Corticosteroids
  5.1.1Topical Corticosteroids, Group I (Very High Potency)
    DIPROLENE betamethasone dipropionate augmented2
  5.1.2Topical Corticosteroids, Group II (High Potency)
   *betamethasone dipropionate1
   *betamethasone valerate 1
   *desoximetasone 1
   *fluocinonide 1
    DIPROLENE AF betamethasone dipropionate augmented2
  5.1.4Topical Corticosteroids, Group IV (Medium Potency)
   *fluocinolone 1
   *triamcinolone 1
    ELOCON mometasone2
  5.1.6Topical Corticosteroids, Group VI (Low Potency)
   *desonide1
  5.1.7Topical Corticosteroids, Group VII (Least Potency)
   *hydrocortisone (2.5% only) 1
 5.2Topical Anesthetics
   *lidocaine1
    DYCLONE dyclonine 2
 5.3Acne Therapy
   *azelaic acid 1
   *clindamycin topical 1
   *erythromycin topical 1
   *sulfacetamide/sulfur 1
   This drug is not in the POS Program; however, it may require prior approval in some cases.tretinoin (Microsphere is Tier 2; authorization required for patients older than 39 years; no initial 30-day authorization given) 2
    ACCUTANE isotretinoin (Oral)2
    BENZAMYCIN benzoyl peroxide/erythromycin2
    MECLAN meclocycline sulfosalicylate 2
    METROGEL metronidazole gel2
    TAZORAC tazarotene2
 5.4Topical Antibacterials
   *gentamicin 1
    BACTROBAN mupirocin 2
 5.5Topical Antifungals
   *clotrimazole 1% (BHP only)
   *nystatin 1
   *nystatin/triamcinolone 1
     nystatin topical powder (BHP only)
    EXELDERM sulconazole nitrate 2
    LOPROX ciclopirox 2
 5.6Topical Antivirals
    DENAVIR penciclovir cream2
    ZOVIRAX acyclovir ointment 2
 5.7Burn Therapy
   *silver sulfadiazine1
 5.8Topical Enzymes
    GRANULEX trypsin2
 5.9Keratolytics
    KERALYT salicylic acid2
 5.10Antipsoriatic/Antiseborrheic
   *selenium sulfide 1
    CAPITROL chloroxine 2
    DOVONEX calcipotriene2
    DRITHOCREME anthralin 2
    SEBIZON sulfacetamide 2
    SORIATANE acitretin2
 5.11Scabicides/Pediculosides
   *lindane 1
   *permethrin 1
    EURAX crotamiton 2
 5.12Dermatologicals, Misc
   *ammonium lactate 1
    ACTINEX masoprocol2
    CARMOL 40 urea 40% 2
    CONDYLOX podofilox 2
    DRYSOL aluminum chloride2
    EFUDEX fluorouracil2
    FLUOROPLEX fluorouracil2
    OXSORALEN methoxsalen2
    TRISORALEN trioxsalen 2
Chapter 6: Ear, Nose and Throat[TOP]
 6.1Intranasal Steroids
    BECONASE beclomethasone nasal (Including AQ) 2
    FLONASE fluticasone nasal2
    NASACORT triamcinolone nasal (Including AQ) 2
    RHINOCORT budesonide nasal (Including AQ) 2
    VANCENASE beclomethasone nasal (Including AQ) 2
 6.2Otic Preparations, Misc
   *acetic acid 1
   *acetic acid/aluminum acetate otic (Generic equivalent of Domeboro Otic) 1
   *acetic acid/hydrocortisone liquid 1
   *benzocaine/antipyrine liquid1
   *chloramphenicol 1
    CERUMENEX triethanolamine 2
    FLOXIN OTIC ofloxacin 2
 6.3Otic Steroid/Antibiotic
   *neomycin/polymyxin/hc otic 1
 6.4Misc ENT Agents
   *chlorhexidine 1
   *lidocaine1
   *triamcinolone in orabase 1
    NASALCROM cromolyn nasal 3
Chapter 7: Endocrine and Diabetes[TOP]
 7.1Antithyroid Agents
   *methimazole 1
   *potassium iodide 1
   *propylthiouracil 1
 7.2Thyroid Hormones
    CYTOMEL liothyronine2
    LEVOTHROID levothyroxine 2
    LEVOXYL levothyroxine 2
    SYNTHROID levothyroxine 2
    THYROID thyroid2
    THYROLAR liotrix 2
 7.3Adrenal Hormones
   *dexamethasone 1
   *hydrocortisone tablet 1
   *methylprednisolone 1
   *prednisolone 1
   *prednisone 1
    ARISTOCORT triamcinolone oral2
    FLORINEF fludrocortisone 2
    PEDIAPRED prednisolone2
 7.4Hormones, Misc
  7.4.1Androgens
   *danazol 1
   *fluoxymesterone 1
   *methyltestosterone1
    ANDRODERM testosterone transdermal2
    TESLAC testolactone 50mg 2
    TESTODERM testosterone transdermal2
  7.4.3Hormones, Misc
   *calcitonin injection 1
   *desmopressin nasal 1
    CEREDASE alglucerase2
    CYTADREN aminoglutethimide2
    DDAVP TABLET desmopressin tablet 2
    DOSTINEX cabergoline2
    SANDOSTATIN octreotide 2
    SYNAREL nafarelin 2
 7.5Diabetes Therapy
  7.5.1Insulins (All Insulins are Tier 2.)
    HUMALOG insulin lispro2
    HUMULIN insulin, human2
    LANTUS insulin glargine2
    NOVOLIN insulin, human 2
    NOVOLOG insulin aspart 2
  7.5.2Oral Hypoglycemic Agents
   *glipizide (Including XL) 1
   *glyburide1
   *tolazamide 1
    ACTOS pioglitazone2
    AVANDIA rosiglitazone2
    GLUCOPHAGE metformin (XR is Tier 3)2
    GLUCOVANCE metformin/glyburide 2
  7.5.3Glucose Elevating Agents
   *glucagon1
  7.5.4Insulin Syringes
   *insulin syringes and needles†
  7.5.5Glucose Monitoring Supplies
   *diabetic blood testing strips†
   *diabetic urine testing products †
   *lancets †
Chapter 8: Gastroenterology[TOP]
 8.1Ulcer Therapy
  8.1.1H2 Antagonists
   *cimetidine 1
   *famotidine 1
   *ranitidine1
  8.1.2Prostaglandins
    CYTOTEC misoprostol2
  8.1.3Other Ulcer Drugs
   *sucralfate 1
  8.1.4Proton Pump Inhibitors (PA required for all.)
   May require prior authorizationPRILOSEC omeprazole (PA required for > 90-day Rx)2
   May require prior authorizationPROTONIX pantoprazole (PA required for > 90-day Rx)2
 8.2Antidiarrheals and Antispasmodics
  8.2Antidiarrheals/Antispasmodics
   *belladonna /phenobarbital 1
   *clidinium/chlordiazepoxide 1
   *dicyclomine 1
   *diphenoxylate/atropine 1
   *hyoscyamine 1
   *paregoric1
   *propantheline1
 8.3Gastrointestinal, Misc
  8.3.1Bile Acids
   *ursodiol 1
  8.3.2Digestive Enzymes
   *lipase/amylase/protease1
   *pancrelipase 1
  8.3.3Gastrointestinal, Misc
   *hydrocortisone anorectal cream 1
   *hydrocortisone/pramoxine 1
   *lactulose liquid1
   *metoclopramide 1
   *sulfasalazine 1
    ASACOL mesalamine2
    AZULFIDINE EN-TABS sulfasalazine ec2
    CORTENEMA hydrocortisone enema2
    CORTIFOAM hydrocortisone foam 2
    PENTASA mesalamine2
    PROPULSID cisapride (Limited access program by mfr; see http://us.janssen.com for
    ROWASA mesalamine (Enema, suppository)2
  8.3.5Bowel Evacuants
   *peg electrolyte bowel prep 1
Chapter 9: Immunology, Vaccines and Biotechnology[TOP]
 9.1Biotechnology Drugs
   This drug is not in the POS Program; however, it may require prior approval in some cases.ACTIMMUNE interferon gamma-1b2
   This drug is not in the POS Program; however, it may require prior approval in some cases.ALFERON-N interferon alfa-n32
   This drug is not in the POS Program; however, it may require prior approval in some cases.AVONEX interferon beta-1a 2
   This drug is not in the POS Program; however, it may require prior approval in some cases.BETASERON interferon beta-1b 2
   This drug is not in the POS Program; however, it may require prior approval in some cases.INTRON-A interferon alfa-2b2
   This drug is not in the POS Program; however, it may require prior approval in some cases.LEUKINE sargramostim 2
   This drug is not in the POS Program; however, it may require prior approval in some cases.NEUMEGA oprelvekin 2
   This drug is not in the POS Program; however, it may require prior approval in some cases.NEUPOGEN filgrastim 2
   This drug is not in the POS Program; however, it may require prior approval in some cases.PROCRIT erythropoietin (Epogen is non-preferred) 2
   This drug is not in the POS Program; however, it may require prior approval in some cases.REBETRON interferon alfa-2b/ribavirin2
Chapter 10: Musculoskeletal and Rheumatology[TOP]
 10.2Gout Therapy
  10.2Gout Therapy
   *allopurinol 1
   *colchicine 1
   *probenecid 1
 10.3Rheumatological Agents
  10.3.2Rheumatological Agents
   *azathioprine2
   *hydroxychloroquine 1
   *methotrexate 1
   *sulfasalazine 1
    AZULFIDINE EN-TABS sulfasalazine 2
    CUPRIMINE penicillamine2
    MYOCHRYSINE gold sodium thiomalate 1
    RIDAURA auranofin 2
    SOLGANAL aurothioglucose2
 10.4Osteoporosis Therapy
  10.4Osteoporosis Therapy
    ACTONEL risedronate2
    DIDRONEL etidronate 2
    EVISTA raloxifene 2
    FOSAMAX alendronate2
    MIACALCIN calcitonin nasal 2
Chapter 11: Obstetrics and Gynecology[TOP]
 11.1Oral Contraceptives
  11.1.1Oral Contraceptives, Monophasic
   *ethinyl estradiol/norethindrone (Ortho Novum is Tier 2) 1
   *generic oral contraceptives (All) 1
    ALESSE ethinyl estradiol/levonorgestrel 2
    DEMULEN estradiol/ethynodiol 2
    DESOGEN ethinyl estradiol/desogestrel2
    LOESTRIN, LOESTRIN FE estradiol/norethindrone 2
    LOOVRAL ethinyl estradiol/norgestrel 1
    ORTHO NOVUM ethinyl estradiol/norethindrone 2
    ORTHO-CYCLEN ethinyl estradiol/norgestimate 2
    OVCON ethinyl estradiol/norethindrone 2
    OVRAL ethinyl estradiol/norgestrel 1
  11.1.2Oral Contraceptives, Biphasic
   *ethinyl estradiol/norethindrone 10/11 1
    ORTHO NOVUM 10/11 ethinyl estradiol/norethindrone 2
  11.1.3Oral Contraceptives, Triphasic
   *ethinyl estradiol/levonorgestrel 7/7/7 (Triphasil is Tier 2) 1
    ORTHO NOVUM 7/7/7 ethinyl estradiol/norethindrone 2
    ORTHO-TRICYCLEN ethinyl estradiol/norgestimate 2
    TRIPHASIL ethinyl estradiol/levonorgestrel 2
  11.1.4Oral Contraceptives, Progestin Only
    MICRONOR norethindrone 2
    NOR-QD norethindrone 2
 11.2Oxytocics
    METHERGINE methylergonovine2
 11.3Estrogens and Progestins
  11.3.1Progestins
   *hydroxyprogesterone 1
   *medroxyprogesterone 1
   *progesterone injection 1
    AYGESTIN norethindrone 2
    PROMETRIUM progesterone micronized2
  11.3.2Estrogens
   *esterified estrogen 2
   *estradiol micronized (Includes vaginal cream)1
   *estradiol transdermal patch 1
   *estropipate 1
    ALORA estradiol transdermal patch 2
    CLIMARA estradiol transdermal patch 2
    ESTRADERM estradiol transdermal patch 2
    ESTRING estradiol vaginal ring 2
    ORTHO-DIENESTROL dienestrol vaginal cream2
    PREMARIN conjugated estrogens (Includes vaginal cream) 2
    VIVELLE estradiol transdermal patch 2
  11.3.3Estrogen Combinations
    ESTRATEST esterified estrogens/methyltestosterone2
    FEMHRT ethinyl estradiol/norethindrone 2
    PREMPRO, PREMPHASE conjugated estrogens/medroxyprogesterone 2
 11.4Misc OB/GYN Agents
  11.4.2Vaginal Antiinfectives
   *acetic acid/oxyquin/ricin/glycerin 1
   *triple sulfa vaginal cream 1
    AVC sulfanilamide vaginal gel2
    CLEOCIN clindamycin vaginal gel2
    METROGEL VAGINAL metronidazole vaginal gel2
  11.4.3Vaginal Antifungals
   *nystatin vaginal 1
    DIFLUCAN VC fluconazole 150mg oral single-dose2
    MYCELEX-7 clotrimazole vaginal cream (BHP only)
    MYCELEX-G clotrimazole vaginal suppository1
    TERAZOL 7 terconazole vaginal cream2
  11.4.4Specialized OB/GYN Drugs
   *isoxsuprine 1
    BRETHINE terbutaline 2
    BRICANYL terbutaline 2
    SYNAREL nafarelin 2
Chapter 12: Ophthalmology[TOP]
 12.1Beta Blockers
   *levobunolol liquid 1
   *timolol ophthalmic 1
    BETOPTIC, BETOPTIC-S betaxolol ophthalmic2
    OPTIPRANOLOL metipranolol2
 12.2Cholinesterase Inhibitors
    PHOSPHOLINE IODIDE echothiophate ophthalmic2
 12.3Direct Acting Miotics
   *pilocarpine ophthalmic 1
 12.4Glaucoma Drugs, Other Ophthalmic
   *carbachol ophthalmic 1
   *dipivefrin ophthalmic 1
   *epinephrine ophthalmic 1
   *pilocarpine/epinephrine ophthalmic 1
    ALPHAGAN brimonidine2
    AZOPT brinzolamide2
    COSOPT dorzolamide/timolol 2
    EPPY-N epinephryl borate2
    ESERINE physostigmine 2
    HUMORSOL demecarium2
    IOPIDINE apraclonidine 2
    LUMIGAN bimatoprost2
    TRAVATAN travoprost 2
    TRUSOPT dorzolamide2
    XALATAN latanoprost2
 12.5Glaucoma Drugs, Oral
   *acetazolamide (500mg Sequels are Tier 2) 1
   *methazolamide 1
    DARANIDE dichlorphenamide2
    OSMOGLYN glycerin2
 12.6Cycloplegic Mydriatics
   *atropine ophthalmic 1
   *cyclopentolate1
   *homatropine ophthalmic 1
   *tropicamide 1
 12.7Opthalmic NSAIDs
   *diclofenac ophthalmic 1
   *flurbiprofen 1
    PROFENAL suprofen 2
 12.8Vasoconstrictor Decongestants
   *naphazoline 1
   *phenylephrine1
 12.9Ophthalmic Antibiotics
   *bacitracin ophthalmic 1
   *erythromycin ophthalmic 1
   *gentamicin ophthalmic 1
   *neomycin/polymyxin/bacitracin ophthalmic 1
   *neomycin/polymyxin/gramicidin ophthalmic 1
   *sulfacetamide ophthalmic 1
   *tobramycin ophthalmic 1
   *trimethoprim/polymixin b 1
    CHIBROXIN norfloxacin2
    CILOXIN ciprofloxacin ophthalmic2
    OCUFLOX ofloxacin 2
 12.11Ophthalmic Steroids
   *dexamethasone ophthalmic (Maxidex is Tier 2) 1
   *prednisolone ophthalmic 1
 12.12Ophthalmic Steroid/Antibiotics
   *fluorometholone ophthalmic (FML is Tier 2) 1
   *neomycin/bacitracin/polymyxin/hc ophthalmic 1
   *neomycin/dexamethasone ophthalmic 1
   *neomycin/polymyxin/dexamethasone ophthalmic1
   *neomycin/polymyxin/hc ophthalmic 1
   *sulfacetamide/prednisolone ophthalmic 1
    POLY-PRED neomycin/polymyxin/pred ophthalmic2
    TOBRADEX tobramycin/dexamethasone ophthalmic 2
 12.13Ophthalmic Steroid/Sulfonamides
    HMS medrysone ophthalmic2
 12.15Ophthalmics, Misc
    ALOMIDE lodoxamide2
    LACRISERT artificial tear insert 2
    LIVOSTIN levocabastine 2
    PATANOL olopatadine2
 12.16Ophthalmic Antivirals
    HERPLEX idoxuridine2
    VIRA-A vidarabine ophthalmic2
    VIROPTIC trifluridine ophthalmic2
Chapter 13: Respiratory and Allergy[TOP]
 13.1Antihistamine and Antiallergic Agents
  13.1.1Antihistamines
   *cyproheptadine 1
   *diphenhydramine (BHP only)
   *hydroxyzine 1
    ALLEGRA fexofenadine 2
    POLYHISTINE pheniramine/pyrilamine/phenyltoloxamine (Liquid) 2
    ZYRTEC cetirizine 2
  13.1.2Adrenergics
    ANA-KIT epinephrine allergy kit2
    EPI-PEN epinephrine syringe 2
 13.2Cough and Cold Therapy
  13.2.1Antitussive Combinations
   *guaifenesin/codeine liquid 1
   *guaifenesin/hydrocodone liquid 1
   *phenylephrine/chlorpheniramine/hydrocodone liquid 1
   *promethazine/codeine syrup1
   *promethazine/dextromethorphan liquid 1
   *promethazine/pe/codeine syrup 1
  13.2.2Expectorant Combinations
   *pseudoephedrine/guaifenesin la 1
  13.2.3Decongestant/Antihistamines
   *pseudoephedrine/chlorpheniramine 1
 13.3Pulmonary Agents
  13.3.1Xanthines
   *aminophylline 1
   *theophylline 1
    SLO-BID theophylline sr 2
    THEO-DUR theophylline sr 2
  13.3.2Beta Antagonists
   *albuterol metered dose inhaler 1
   *albuterol nebulized 1
   *albuterol tablet & oral liquid 1
    BRETHINE terbutaline 2
    BRICANYL terbutaline 2
    FORADIL formoterol 2
    SEREVENT salmeterol (Including Diskus)2
  13.3.4Corticosteroids, Inhaled
    AEROBID, AEROBID-M flunisolide oral inhaler2
    AZMACORT triamcinolone oral inhaler2
    BECLOVENT beclomethasone oral inhaler2
    FLOVENT fluticasone oral inhaler and diskhaler 2
    PULMICORT budesonide oral inhaler2
    PULMICORT RESPULES budesonide inhalation suspension2
    VANCERIL beclomethasone oral inhaler (Including DS) 2
  13.3.6Pulmonary Agents, Misc
   *acetylcysteine1
   *cromolyn inhaled (All forms are covered) 1
    ACCOLATE zafirlukast 2
    ATROVENT ipratropium metered dose inhaler2
    COMBIVENT ipratropium/albuterol metered dose inhaler2
    PULMOZYME dornase alfa2
    SINGULAIR montelukast2
    TILADE nedocromil (All forms are covered) 2
Chapter 14: Urology[TOP]
 14.1Cholinergic Agents
   *bethanechol 1
 14.2Anticholinergics and Antispasmodics
   *oxybutynin (XL is Tier 3) 1
    DETROL tolterodine 2
 14.3Urinary Anesthetics
   *phenazopyridine 1
 14.4Urologicals, Misc
    ELMIRON pentosan polysulfate sodium 2
    RENACIDIN citric acid/gluconic acid2
    UROCIT-K potassium citrate2
 14.5BPH Therapy
   *doxazosin 2
   *terazosin1
    FLOMAX tamsulosin2
    PROSCAR finasteride2
Chapter 15: Vitamins and Electrolytes[TOP]
 15.1Vitamins and Minerals
   *ergocalciferol1
   *fluoride 1
   *folic acid 1mg1
   *multivitamin/fluoride chew or liquid1
   *multivitamin/fluoride/iron chew or liquid 1
   *niacin 500mg, otc (BHP only)
   *prenatal vitamins 1
   *vitamin a1
   *vitamins acd/fluoride/iron chew or liquid 1
    CARNITOR levocarnitine2
    NASCOBAL cyanocobalamin nasal 2
    ROCALTROL calcitriol 2
 15.3Electrolytes
   *potassium (All generics) 1
 15.4Misc Vits and Electrolytes
   *sodium polystyrene sulfonate liquid 1
Chapter 16: Miscellaneous[TOP]
 16.1Miscellaneous Agents
   *disulfiram1
    CHEMET succimer 2
    PRO-AMITINE midodrine 2
    RILUTEK riluzole 2
    SALAGEN pilocarpine2
    THALOMID thalidomide2
 16.2Smoking Cessation
   This drug is commonly excluded from coverageNICOTROL NS nicotine nasal spray2
   This drug is commonly excluded from coverageZYBAN bupropion 2