Closed Formulary Medication Guide

Transcription

1 January Closed Formulary Medication Guide Click to search for a drug name in this document Contents Introduction... I Closed Formulary... II Changes to the formulary... II Pharmacy benefit... III Pharmacy options... III Formulary exception process... IV Generic drugs... IV Contraceptive coverage... IV Responsible RX programs... IV Mail Order Pharmacy... VII Preventive Medications... VII Immunizations... VII Women s preventive services... VII Pharmacy medications... VIII Using the Medication Guide... X Abbreviation/acronym key... XI Drugs not covered... Anti-Infective Drugs... 2 Immunizing Agents... 4 Cancer Drugs... 4 Hormones, Diabetes and Related Drugs... 5 Heart and Circulatory Drugs... 7 Respiratory Drugs... 0 Gastrointestinal Drugs... Genitourinary Drugs... 2 Central Nervous System Drugs... 2 Pain Relief Drugs... 4 Neuromuscular Drugs... 5 Supplements... 6 Blood Modifying Drugs... 6 Topical Products... 7 Miscellaneous Categories Index... 2 Please consider talking to your doctor about prescribing formulary medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you. The drug formulary is regularly updated. Please visit for the most up-to-date information. 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 J FL Prime Therapeutics LLC 0/5

2 Introduction Florida Blue is pleased to present the Closed Formulary Medication Guide. The Guide will provide helpful tips on how to make the most of your pharmacy benefits and details on the various coverage programs that are designed to provide safe and appropriate medication when you need it. Please refer to your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement for complete coverage details. The Closed Formulary Medication Guide also includes an abbreviated listing of Generic, and a complete listing of Brand Prescription Drugs (the formulary) that are covered under your plan. Changes in the formulary can occur over time and the most up-to-date listing can always be found by viewing the Closed Formulary Medication Guide online at or by calling the customer service number listed on your member ID card. For the hearing impaired, call Florida TTY Relay Service 7. Si desea hablar sobre esta guía en español con uno de nuestros representantes, por favor llame al número de atención al cliente indicado en su tarjeta de asegurado y pida ser transferido a un representante bilingüe. We reserve the right to add or remove or change the tier of any prescription medication in this Medication Guide at any time. Note: The decision concerning whether a prescription medication should be prescribed must be made by you and your physician. Any and all decisions that require or pertain to independent professional medical judgments or training, or the need for, and dosage of, a prescription medication, must be made solely by you and your treating physician in accordance with the patient/physician relationship. Key Tips and Coverage Guidelines By following these simple guidelines, you will be assured that you are getting the maximum benefit from your plan. When you have your prescriptions filled, ask your pharmacist if a Generic equivalent is available. Generic Prescription Drugs are usually less expensive and are covered unless specifically excluded under your Pharmacy Program Endorsement. You can check your Schedule of Benefits to determine your copay amount. Select Brand Name Prescription Drugs are included in the formulary and are therefore available to you through your plan. The Closed Formulary List includes all covered Brand Name Prescription Drugs. You can determine your out-of-pocket amount for Brand Name Prescription Drugs by reviewing your Schedule of Benefits. Brand Name Prescription Drugs not listed in the Closed Formulary List are not covered. If you are currently taking a medication, take a moment to review the formulary to determine if it is covered. If not, check with your doctor to understand available options and review the PHARMACY BENEFIT section of this Guide for exception procedures. If you or your provider request a covered Brand Name Prescription Drug when there is a Generic Prescription Drug available; you will be responsible for: () the difference in cost between the Generic Prescription Drug and the Brand Name Prescription Drug; and (2) the cost share applicable to Brand Name Prescription Drugs, as indicated on your Schedule of Benefits Take this Guide with you when you visit your doctor or health care provider so that he or she is aware of the drugs listed in the Closed Formulary and cost impacts when you discuss medication options. Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. I January Closed Formulary Medication Guide

3 Preface Closed Formulary The Closed Formulary Medication Guide includes the Closed Formulary list and reflects the current recommendations of Florida Blue and is developed in conjunction with Prime Therapeutics National Pharmacy & Therapeutics Committee. Florida Blue reserves the right to add or remove or change the tier of any prescription drug in this Medication Guide at any time. All Generic Prescription Drugs are covered unless specifically excluded by your plan. Brand Name Prescription Drugs are covered only if they are included in the Closed Formulary list. For your out-of-pocket expenses to be as low as possible, please consider asking your doctor to prescribe Generic drugs, or if necessary, Brand Name Prescription Drugs that are included on the Closed Formulary List. This will help ensure that your covered prescription drugs are allowed and reimbursed under your plan. In addition, consider using a participating pharmacy to obtain your covered prescription drugs because your out-of-pocket expenses should be lower than if you used a nonparticipating pharmacy. To save the most money on prescription drugs, share this Medication Guide with your doctor or health care provider at each visit. When you have your prescriptions filled, ask your pharmacist if a Generic Drug is available. Generic Drugs save you the most money. Changes to the formulary The Closed Formulary List is subject to change at any time. It is reviewed quarterly to examine new medications and new information about medications that are already on the market concerning safety, effectiveness and current use in therapy. The most up to date information about modifications to the medications listed in this Closed Formulary Medication Guide can be found by: Going to Click on the Members tab Click on the Login Now button and either Login or Register Once Logged in, click on My Plan, then select Pharmacy from the drop down menu Under Medication Guide/Approved Drug Lists, click Closed Formulary Medication Guide or Closed Formulary Medication Guide Updates Medication Guides are posted every January and July, and Medication Guide Updates are posted January, April, July and October. Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. January Closed Formulary Medication Guide II

4 Pharmacy benefit The pharmacy benefit has two parts/components, called Tiers. This means that covered Prescription Drugs must be included in one of the following Tiers: Tier : Generic Prescription Drugs whether listed in the Closed Formulary List or not. Tier 2: Only those Brand Name Prescription drugs listed in the Closed Formulary List. Medications: Covered Medications as indicated in the Medication List Condition Care Rx* Value/HSA Preventive Prescription Medications * Refer to the Condition Care Rx Program section of this Medication Guide for a description of the program Brand Name Drugs not listed in the Closed Formulary List are not covered. If you and your doctor or health care provider think that your condition cannot be treated by any of the medication(s) listed on the Closed Formulary List, your doctor may submit a request for an exception. If your exception request is approved, coverage will be available for the approved medication. Pharmacy options There are two different types of pharmacies for you to be aware of as you decide where to get your prescriptions filled retail pharmacies and specialty pharmacies. To save the most money, before you get a prescription filled, you should confirm which pharmacy is considered in-network for that particular medication. Retail Pharmacy Network Non- Generic medications and Brand Name medications listed in the Medication Guide can be filled at these pharmacies at a lower cost to you than other pharmacies in your area. If you go to a non-participating pharmacy, your prescription will cost you more. Pharmacy Network We have identified certain drugs as specialty drugs due to requirements such as special handling, storage, training, distribution, and management of the therapy. These drugs are listed as a Drug in this Medication Guide. To be covered under your pharmacy program at the in-network cost share, they must be purchased at a preferred Pharmacy. These pharmacies are different than the retail pharmacies and are identified in both the Provider Directory and this Medication Guide. Using an innetwork Pharmacy to provide these Drugs lowers the amount you pay for these medications. Non-Participating Pharmacy If your plan offers out-of-network pharmacy coverage, choosing a non-participating pharmacy will cost you more money. You may have to pay the full cost of the medication and then file a claim to be reimbursed. Our payment will be based on our Non-Participating Pharmacy Allowance minus your cost share. You will be responsible for your cost share and the difference between our Allowance and the cost of the medication. Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. III January Closed Formulary Medication Guide

5 Formulary exception process A formulary exception process is provided to allow for cases where the Closed Formulary List may not accommodate the unique medical needs of a member (e.g. documented allergy, ineffectiveness, or intolerable adverse effects from drugs on the formulary).the formulary exception form is available at Click on the Providers tab Click Pharmacy Info & Resources then click Medication Guides Click Formulary Exception Physician Fax Form Florida Blue is not obligated to approve any exception or continue a previously approved exception. Generic drugs Florida Blue encourages the use of Generic Drugs as a way to provide high-quality medications at a reduced cost. Generic Drugs are as safe and effective as their Brand Name counterparts, and are usually less expensive. A Food and Drug Administration (FDA) approved Generic Drug may be substituted for its Brand name counterpart because it: Contains the same active ingredient(s) as the Brand Name Drug Is identical in strength, dosage form, and route of administration Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile Check with your doctor or health care provider to determine if switching to a Generic Drug is appropriate for you. Contraceptive coverage If your pharmacy plan includes contraceptives at no cost, as a result of the expanded PPACA Preventive Services benefits, only generic contraceptive medications or devices (e.g., oral contraceptives, emergency contraceptive, and diaphragms) are covered at no cost share when purchased at a participating pharmacy. Note: Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement to determine if this benefit applies to your plan. Coverage details are also available to you by calling the customer service number listed on your member ID card. Responsible Rx programs Some covered medications may have additional requirements or limits on coverage. These requirements and limits may include: Program The Program encourages the appropriate, safe and cost-effective use of medication. If you are currently taking or are prescribed a medication that is included in the Program list of medications, your physician will need to submit a request in order for your prescription to be considered for coverage. If you do not request and/or receive prior approval, the medication will not be covered. A current listing of drugs requiring may be found at: Program Information and Forms Florida Blue reserves the right to change the medications that require at any time and for any reason. Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. January Closed Formulary Medication Guide IV

6 Program Information and Obtaining Prior Coverage Authorization Information about and forms for how to obtain a approval can be found here: Program Information and Forms NOTE: Your provider is required to complete and submit the form in order for a coverage determination to be made.. Once a decision is made, you and/or your doctor will be informed of the decision. 2. If the decision is made to authorize coverage, the medication(s) and/or supplies may be obtained from a participating pharmacy or at the appropriate location if the medication(s) will be administered by a health professional. approval does not waive your financial responsibility. 3. If a decision is made to deny authorization, you are free to purchase the prescription medication, supplies or over-the-counter (OTC) medication, but you will have to pay the full cost of the medication and will not be entitled to reimbursement under your plan. NOTE: You have the right to request an appeal if coverage authorization is denied. Please refer to the How to Appeal an Adverse Benefit Determination subsection of the Claims Processing or Appeal and Grievance Process section in your current Benefit Booklet, Certificate of Coverage, Contract or Member Handbook for information on how to file an appeal. Responsible Quantity Program The Responsible Quantity Program encourages the appropriate, safe and cost-effective use of medication by setting a maximum quantity per month for a medication or supply. The quantity limitations are based on the Food and Drug Administration guidelines and the manufacturer s dosing recommendations. Florida Blue reserves the right to change the Drugs and the quantity limits subject to the Responsible Quantity Program at any time and for any reason. In cases where a larger quantity of a Responsible Quantity Drug is medically required, your doctor or health care provider can request an override. A list of current drugs included in the Responsible Quantity Program may be found here: Responsible Quantity Program Information Program The Program promotes the appropriate, safe, and effective use of medications and helps you save on prescriptions. is based on nationally recognized therapeutic guidelines, clinical evidence, and research. For certain prescription medications, you are required to try designated or prerequisite medication(s) prior to trying a medication subject to the Program. A list of current drugs included in the Program may be found here: Program Information (Medical Pharmacy) Program Certain physician-administered prescription drugs which are rendered in a physician s office may be included in the for Medical Pharmacy Program. If you are taking a medication in the Program, please contact your physician/provider to discuss what medication options are best for you. Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. V January Closed Formulary Medication Guide

7 If, due to medical reasons, you cannot use the prerequisite drug and require the Medication, your doctor or health care provider may request prior authorization for an override. If the override request is approved, coverage will be provided for the Medication. Florida Blue reserves the right to change the drugs subject to the Program at any time and for any reason. A list of current drugs included in the Program may be found here: for Medical Pharmacy Program Information. Exception Requests If, for medical reasons, you require a quantity of medication outside the Responsible Quantity Program limits or you cannot use one of the alternative medications and require the medication listed in the or for Medical Pharmacy Programs, or you require a tier exception for an oral contraceptive drug, your physician may submit an exception request by completing one of the forms below Formulary Exception Request Forms Responsible Quantity Authorization Form Program Information and Authorization Forms for Medical Pharmacy Information and Authorization Forms Oral Contraceptives Tier Exception Request Form Drugs That Are Not Covered Your pharmacy benefit may not cover select medications. Some of the reasons a medication may not be covered are: The medication has been shown to have excessive adverse effects and/or safer alternatives The medication has a preferred formulary alternative or over-the-counter (OTC) alternative The medication is no longer marketed The medication has a widely available/distributed AB rated generic equivalent formulation The medication has not been approved by the FDA The medication has been repackaged a pharmaceutical product that is removed from the original manufacturer container (Brand Originator) and repackaged by another manufacturer with a different NDC. A list of medications that are not covered may be found at Medications Not Covered Select Generic and Brand Name drugs are not covered because of safety or effectiveness concerns. Covered Over-the-Counter (OTC) Products Your pharmacy benefit may provide coverage for certain OTC Drugs, if your doctor or health care provider prescribes them. However, only those OTC Drugs designated on the Closed Formulary List with OTC following the product name are eligible for coverage. Florida Blue reserves the right to change the OTC Drugs covered under the Closed Formulary Listat any time and for any reason. Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. January Closed Formulary Medication Guide VI

8 Mail Order Pharmacy Obtaining prescription medications through the Mail Order Pharmacy may reduce the cost you pay for your prescription medications. Members who have pharmacy benefits through Florida Blue can access and print out the Mail Order Pharmacy Form on our website, Note: If the original prescription was filled at a pharmacy other than the Mail Order Pharmacy, you must submit a new prescription with a quantity of up to a three-month supply and not less than a two-month supply along with the Registration and Prescription Order Form. Prescriptions may not be transferred from a retail pharmacy to the Mail Order Pharmacy. Note: Medications listed in the Self-Administered Drug List are not available through mail order. Self-Administered Injectables Self-administered injectable medications are designated in the Medication List with inj following the medication name (e.g., enoxaparin inj). No other Self-administered injectables will be covered unless such injectable is identified as a Drug in this Medication Guide. Self-administered injectables will be subject to the Brand or Generic cost share, as described in your Schedule of Benefits. Florida Blue reserves the right to change the Self-administered injectables covered through the Closed Formulary List at any time and for any reason. Patient Protection Affordable Care Act (PPACA) Mandated Coverage Preventive medications The Patient Protection and Affordable Care Act (PPACA) provides for members to receive coverage for certain preventive care services, medications, and immunizations at no out-of-pocket costs based on recommendations from the U.S. Preventive Services Task Force (USPSTF). These USPSTF recommendations include services that have been shown to be important in preventing disease as well as providing for additional women s services such as FDA-approved contraception. A list of drugs covered under our Preventive Medications Program may be found at: Preventive Medications List Immunizations Certain vaccines which are covered under your preventive benefit can be administered by Pharmacists that are certified. Not all pharmacies provide services for vaccine administration. It is important to contact the pharmacy prior to your visit to ensure availability and administration of the vaccine. A list of vaccines that are covered under your pharmacy benefits may be found at: Pharmacy Benefit Vaccines List Women s preventive services As a result of the expanded PPACA Preventive Services benefits for women s services, certain generic contraceptive medications or devices (e.g., oral contraceptives, emergency contraceptive, and diaphragms) are covered at no cost share when purchased at a participating pharmacy. A list of medications and devices covered under this benefit may be found at: Women s Preventive Services List Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. VII January Closed Formulary Medication Guide

9 Oral Chemotherapy Drugs Oral chemotherapy drugs are drugs prescribed by a physician to kill or slow the growth of cancerous cells in a manner consistent with the national accepted standards of practice. A list of these drugs can be found at: Oral Chemotherapy Drug List Condition Care Rx Program The Condition Care Rx Program is designed to help manage the cost of medications used to treat certain chronic conditions and encourage medication adherence. Members who have the Condition Care Rx Program as part of their benefits are eligible to receive medications from the Condition Care Rx Program Value/Health Savings Account Preventive List at a reduced cost. A list of medications that are part of the Condition Care Rx Value Program may be found at: Condition Care Rx Program Value List A list of medications that are part of the Condition Care Rx Program for Health Savings Account (HSA) compatible plans may be found at: Condition Care Rx Program HSA Preventive List Note: Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement to determine if the Condition Care Rx Program applies to your plan and the cost share. Coverage details may also be available to you by logging into the member section of or by calling the customer service number listed on your member ID card. Pharmacy medications Pharmacy medications are high-cost injectable, infused, oral or inhaled medications that generally require close supervision and monitoring of the patient s therapy. NOTE: Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement for information on how Pharmacy medications are covered on your plan. Coverage details are also available by calling the customer service number listed on your member ID card. Medications are divided into two categories: Self-Administered Patients self-administer these Pharmacy medications themselves. Because these medications are intended to be self-administered, these medications may not be covered if administered in a physician s office. If these medications are not obtained from a participating Pharmacy, out-of-network cost shares will apply (where out-of-network coverage is available). A current listing of Self-Administered Medications can be found here Provider-Administered These medications require the administration to be performed by a physician. The Pharmacy medications are ordered by a provider and administered in an office or outpatient setting. Provider-administered Pharmacy medications are covered under your medical benefit. A current listing of Provider-Administered Medications can be found here Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. January Closed Formulary Medication Guide VIII

10 Participating Pharmacy Provider If you are currently taking a Pharmacy medication, then your network for Pharmacies is limited to the following participating Pharmacy providers. Unless indicated below, any other pharmacy is considered a nonparticipating Pharmacy even if it participates in Florida Blue s networks for non- Pharmacy medications. Caremark Pharmacy Services All Products Phone: Fax: Caremark Pharmacy Caremark Hemophilia Services Hemophilia Products Telephone: (Mon-Fri., 9:00 a.m. to 7:30 p.m. EST) Fax: Caremark Hemophilia Prime Therapeutics Pharmacy (Prime Pharmacy) Telephone: (MEDS) 6337 Fax: TTY 7 Prime Pharmacy Prime Therapeutics Pharmacy (Prime Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC. Note: Pharmacy medications are not covered when purchased through the Mail Order Pharmacy. Self-administered specialty medications as classified by Florida Blue outside of the state of Florida may be obtained by a member with a written prescription through the preferred specialty pharmacy providers Prime Pharmacy or Caremark. If a member resides or is traveling outsides the state of Florida and needs to receive a provider-administered specialty medication, the prescribing physician should coordinate with the participating specialty pharmacy provider for their area or contact the local BlueCross and BlueShield Plan. This coordination can help ensure members receive their medications at the in-network cost share. Members that receive a written prescription directly from their provider for a provider-administered specialty medication should contact customer service for further assistance. Notice This Closed Formulary Medication Guide shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions, limitations, or conditions contained in the Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement. In the event of any inconsistencies between the Closed Formulary Medication Guide and the provisions contained in the Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement, the provisions contained in the Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement shall control to the extent necessary to effectuate the intent of Florida Blue. Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. IX January Closed Formulary Medication Guide

11 Using the Medication Guide The Medication List is organized into broad categories (e.g., Antibacterials). The first column of the chart lists the medication name. Generic medications are listed in lowercase boldface (e.g., metformin) Brand Name medications are capitalized (e.g., CRESTOR) Separate medication entries are required for some dosage forms or routes of administration including extended-release, delayed-release, rectal, injectable, otic, ophthalmic, vaginal, nasal, orally disintegrating, patches, and topical products. Note: Self-administered injectable medications are designated in the Medication List with inj following the medication name (e.g., enoxaparin inj). The second column indicates the Tier level: (Lowest Cost): Covered Generic Prescription Medications 2 (Higher Cost): Covered Preferred Brand Prescription Medications 3 (Highest Cost): Covered Non-Preferred Brand Prescription Medications and are not listed The third column indicates if the medication is a Self-Administered * medication. * If your Pharmacy plan has a separate cost share for medications, then all medications will apply that cost share regardless of the Tier level displayed in the Medication List. Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement to determine how coverage of Self-Administered medications applies to your plan. The remaining columns indicate the Responsible Rx Pharmacy Program(s) that apply to the prescription medication (e.g.,, Responsible Quantity and ). If an indicator is present in the column(s), then the Responsible Rx Program applies. An asterisk (*) next to a drug name signifies that this drug may not be covered. Please refer to your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement. Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. January Closed Formulary Medication Guide X

12 Abbreviation/acronym key caps... capsules chew tabs... chewable tablets conc... concentrate crm... cream ext-release... extended-release inhal... inhalation inj... injection lotn... lotion NP... non-preferred ODT... orally disintegrating tablets OSM... osmotic-release OTC... over-the-counter drug oint... ointment PA... Prior Coverage Authorization required QL... Responsible Quantity Program quantity limit applies RS.. Program prerequisite drug required SI...Self-Administered Injectable SL... sublingual SP... Self-Administered Pharmacy soln... solution supp... suppositories susp... suspension tabs... tablets Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. XI January Closed Formulary Medication Guide

13 Selected generic and brand name drugs are not covered because of safety or effectiveness concerns. This list is subject to change. acetaminophen/salicylamide/phenyltoloxamine Ala Quin Alcortin A Amoxapine Armour Thyroid Avandamet Avandaryl Avandia benzphetamine Bontril PDM Butisol Carisoprodol 250 mg carisoprodol 350 mg carisoprodol/aspirin carisoprodol/aspirin/codeine chlordiazepoxide/clidinium Demerol tabs Didrex diethylpropion Diethylpropion diethylpropion ext-release Donnatal Donnatal Extentabs Epifoam Equagesic ergoloid mesylates esterified estrogens/methyltestosterone flavoxate Halcion hydrocortisone/iodoquinol isoxsuprine 0 mg Isoxsuprine 20 mg Ketek ketoconazole tabs Librax Meperidine oral soln meperidine tabs meprobamate Nature-Throid nefazodone 250 mg Nefazodone 50 mg, 00 mg, 50 mg, 200 mg Novacort Omontys Opium Tincture opium tincture % pentazocine/naloxone phendimetrazine Phendimetrazine ext-release Phospholine Iodide Pramosone pramoxine pramoxine/hydrocortisone topical Regimex Reserpine Seconal sodium thiosulfate/salicylic acid lotn, 25-% Soma thioridazine thyroid tabs, 30 mg, 60 mg, 90 mg Thyrolar ticlopidine triazolam Westhroid WP Thyroid Zyflo Zyflo CR Florida Blue January Closed Medication Drug Guide

14 ANTI-INFECTIVE DRUGS PENICILLINS AMOXICILLIN chew tabs, 250 mg 2 amoxicillin/potassium clavulanate (Augmentin) amoxicillin/potassium clavulanate extrelease (Augmentin XR) amoxicillin, NP = chew tabs, 25 mg ampicillin caps AMPICILLIN susp 2 AUGMENTIN susp, 25 mg/5 ml 2 dicloxacillin penicillin v potassium CEPHALOSPORINS cefaclor caps cefadroxil cefdinir cefpodoxime cefprozil cefuroxime (Ceftin) cephalexin, NP = tabs (Keflex) MACROLIDES azithromycin susp, tabs (Zithromax) clarithromycin (Biaxin) clarithromycin ext-release (Biaxin XL) ERY-TAB 2 ERYTHROMYCIN BASE 2 erythromycin delayed-release caps ERYTHROMYCIN ETHYLSUCCINATE ZITHROMAX packets 2 TETRACYCLINES demeclocycline doxycycline hyclate caps (Vibramycin) doxycycline hyclate tabs doxycycline monohydrate (Adoxa, Monodox) minocycline (Dynacin, Minocin) TETRACYCLINE 2 FLUOROQUINOLONES ciprofloxacin (Cipro) ciprofloxacin ext-release (Cipro XR) levofloxacin (Levaquin) ofloxacin 200 mg, 300 mg SULFONAMIDES SULFADIAZINE 2 2 AMINOGLYCOSIDES BETHKIS 2 X neomycin sulfate paromomycin TOBI PODHALER 2 X tobramycin (Tobi) X TUBERCULOSIS ethambutol (Myambutol) ISONIAZID syrup 2 isoniazid tabs PRIFTIN 2 pyrazinamide rifabutin (Mycobutin) Tier KEY = Covered Generic Drugs = Responsible Rx Program X = Self-Administered Medication 2 = Preferred Brand Drugs * = May not be covered see endorsement 2 Florida Blue January Closed Medication Drug Guide

15 RIFAMATE 2 rifampin (Rifadin) FUNGAL INFECTIONS fluconazole (Diflucan) flucytosine (Ancobon) griseofulvin microsize (Grifulvin V) itraconazole (Sporanox) NOXAFIL 2 nystatin oral SPORANOX soln 2 terbinafine (Lamisil) voriconazole (Vfend) VIRAL INFECTIONS Cytomegalovirus VALCYTE 2 Hepatitis adefovir (Hepsera) BARACLUDE soln 2 entecavir (Baraclude) EPIVIR HBV soln 2 INTRON-A 2 X lamivudine (Epivir HBV) OLYSIO 2 X PEGASYS 2 X RIBATAB 2 X ribavirin (Copegus, Rebetol) X SOVALDI 2 X Herpes acyclovir (Zovirax) famciclovir (Famvir) valacyclovir (Valtrex) HIV/AIDS abacavir (Ziagen) abacavir/lamivudine/ zidovudine (Trizivir) APTIVUS 2 ATRIPLA 2 COMPLERA 2 CRIXIVAN 2 didanosine delayedrelease (Videx EC) EDURANT 2 EMTRIVA 2 EPIVIR soln 2 EPZICOM 2 FUZEON 2 X INTELENCE 2 INVIRASE 2 ISENTRESS 2 KALETRA 2 lamivudine (Epivir) lamivudine/zidovudine (Combivir) LEXIVA 2 NEVIRAPINE susp 2 nevirapine tabs (Viramune) nevirapine ext-release (Viramune XR) NORVIR 2 PREZISTA tabs 2 RESCRIPTOR 2 REYATAZ 2 SELZENTRY 2 stavudine (Zerit) Tier KEY = Covered Generic Drugs = Responsible Rx Program X = Self-Administered Medication 2 = Preferred Brand Drugs * = May not be covered see endorsement Florida Blue January Closed Medication Drug Guide 3

16 STRIBILD 2 SUSTIVA 2 TIVICAY 2 TRUVADA 2 VIDEX 2 VIRACEPT 2 VIRAMUNE susp 2 VIRAMUNE XR 00 mg 2 VIREAD 2 ZIAGEN soln 2 zidovudine (Retrovir) Influenza TAMIFLU 2 MALARIA atovaquone/proguanil (Malarone) chloroquine phosphate (Aralen) DARAPRIM 2 hydroxychloroquine (Plaquenil) mefloquine PRIMAQUINE 2 WORM INFECTIONS ALBENZA 2 BILTRICIDE 2 ivermectin (Stromectol) OTHER ANTI-INFECTIVES ALINIA 2 CAYSTON 2 clindamycin (Cleocin, Cleocin Pediatric) colistimethate (Coly-Mycin M) DAPSONE 2 erythromycin/sulfisoxazole metronidazole oral (Flagyl) NEBUPENT 2 PRIMSOL 2 SIVEXTRO tabs 2 sulfamethoxazole/ trimethoprim (Bactrim) trimethoprim vancomycin (Vancocin) XIFAXAN 550 mg 2 YODOXIN 2 ZYVOX 2 IMMUNIZING AGENTS FLU VACCINES, NP = FLUBLOK 2 GAMMAGARD LIQUID 2 X GAMMAKED 2 X GAMUNEX-C 2 X HIZENTRA 2 X MENACTRA 2 MENOMUNE-A/C/Y/W-35 2 MENVEO 2 PNEUMOVAX 23 2 PREVNAR 3 2 ZOSTAVAX 2 CANCER DRUGS ACTIMMUNE 2 X AFINITOR 2 X AFINITOR DISPERZ 2 X ALKERAN tabs 2 anastrozole (Arimidex) bicalutamide (Casodex) BOSULIF 2 X capecitabine (Xeloda) X Tier KEY = Covered Generic Drugs = Responsible Rx Program X = Self-Administered Medication 2 = Preferred Brand Drugs * = May not be covered see endorsement 4 Florida Blue January Closed Medication Drug Guide

17 CAPRELSA 2 X COMETRIQ 2 X CYCLOPHOSPHAMIDE tabs 2 EMCYT 2 ERIVEDGE 2 X ETOPOSIDE caps 2 exemestane (Aromasin) FARESTON 2 flutamide GILOTRIF 2 X GLEEVEC 2 X HEXALEN 2 X HYCAMTIN caps 2 X hydroxyurea (Hydrea) ICLUSIG 2 X IMBRUVICA 2 X INLYTA 2 X JAKAFI 2 X letrozole (Femara) LEUCOVORIN CALCIUM tabs, 0 mg, 5 mg leucovorin calcium tabs, 5 mg, 25 mg LEUKERAN 2 leuprolide acetate X LOMUSTINE 2 LYSODREN 2 X MATULANE 2 X megestrol (Megace) MEKINIST 2 X mercaptopurine (Purinethol) MESNEX tabs 2 2 methotrexate MYLERAN 2 NEXAVAR 2 X NILANDRON 2 POMALYST 2 X PURIXAN 2 X SPRYCEL 2 X STIVARGA 2 X SUTENT 2 X SYLATRON 2 X TABLOID 2 TAFINLAR 2 X tamoxifen TARCEVA 2 X TARGRETIN caps 2 X TASIGNA 2 X temozolomide (Temodar) X tretinoin caps X TYKERB 2 X VOTRIENT 2 X XALKORI 2 X XTANDI 2 X ZELBORAF 2 X ZOLINZA 2 X ZYDELIG 2 X ZYKADIA 2 X ZYTIGA 2 X HORMONES, DIABETES AND RELATED DRUGS CORTICOSTEROIDS budesonide ext-release (Entocort EC) CORTISONE 2 Tier KEY = Covered Generic Drugs = Responsible Rx Program X = Self-Administered Medication 2 = Preferred Brand Drugs * = May not be covered see endorsement Florida Blue January Closed Medication Drug Guide 5

18 dexamethasone elixir; tabs, 0.5 mg, 0.75 mg,.5 mg, 4 mg, 6 mg DEXAMETHASONE soln; tabs, 2 mg, 2 mg fludrocortisone hydrocortisone (Cortef) methylprednisolone (Medrol) prednisolone (Prelone) prednisolone sodium phosphate (Orapred) prednisolone sodium phosphate soln, 5 mg/5 ml PREDNISONE soln, 5 mg/5 ml; tabs, 50 mg; NP = dose packs prednisone tabs, mg, 2.5 mg, 5 mg, 0 mg, 20 mg MALE HORMONES ANDRODERM 2 ANDROGEL 2 danazol ESTROGENS CLIMARA PRO 2 DIVIGEL 2 estradiol patches (Climara) estradiol tabs (Estrace) estradiol/norethindrone acetate (Activella) estropipate 0.75 mg,.5 mg MENEST 2 PREMARIN 2 PREMPHASE 2 PREMPRO 2 PROGESTINS 2 medroxyprogesterone acetate tabs (Provera) norethindrone acetate (Aygestin) progesterone micronized (Prometrium) BIRTH CONTROL ELLA 2 levonorgestrel (Plan B, Plan B One-Step) norelgestromin/ethinyl estradiol (Ortho Evra) oral contraceptives all generics DIABETES acarbose (Precose) BYDUREON 2 BYETTA inj 2 glimepiride (Amaryl) glipizide (Glucotrol) glipizide ext-release (Glucotrol XL) glipizide/metformin GLUCAGON EMERGENCY inj kit 2 glyburide (Micronase) glyburide micronized (Glynase) glyburide/metformin (Glucovance) GLYBURIDE, distributor of Diabeta 2 INVOKAMET 2 INVOKANA 2 JANUMET 2 JANUMET XR 2 JANUVIA 2 KOMBIGLYZE XR 2 metformin (Glucophage) Tier KEY = Covered Generic Drugs = Responsible Rx Program X = Self-Administered Medication 2 = Preferred Brand Drugs * = May not be covered see endorsement 6 Florida Blue January Closed Medication Drug Guide

19 metformin extrelease (Glucophage XR) metformin ext-release OSM (Fortamet) nateglinide (Starlix) ONGLYZA 2 pioglitazone (Actos) pioglitazone/metformin (Actoplus Met) PROGLYCEM 2 repaglinide (Prandin) SYMLINPEN inj 2 Insulins Rapid-Acting Insulins NOVOLOG inj 2 Short-Acting Insulins NOVOLIN R inj 2 RELION R inj 2 Intermediate-Acting Insulins NOVOLIN N inj 2 NOVOLIN 70/30 inj 2 NOVOLOG MIX 70/30 inj 2 Basal Insulins LANTUS inj 2 LEVEMIR inj 2 THYROID REGULATION levothyroxine (Synthroid) liothyronine (Cytomel) methimazole (Tapazole) propylthiouracil SYNTHROID 2 GROWTH HORMONE INCRELEX 2 X NORDITROPIN 2 X OTHER HORMONES AND RELATED DRUGS alendronate tabs, 5 mg, 0 mg, 35 mg, 70 mg (Fosamax) cabergoline calcitonin-salmon (Miacalcin) calcitriol (Rocaltrol) desmopressin inj, nasal, tabs (DDAVP) ibandronate (Boniva) levocarnitine (Carnitor) methylergonovine octreotide (Sandostatin) X ORFADIN 2 X paricalcitol (Zemplar) raloxifene (Evista) risedronate (Actonel) SENSIPAR 2 SOMAVERT 2 X STIMATE 2 SYNAREL 2 X HEART AND CIRCULATORY DRUGS ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS benazepril (Lotensin) benazepril/ hydrochlorothiazide (Lotensin HCT) captopril CAPTOPRIL/ HYDROCHLOROTHIAZIDE 25-5 mg, 50-5 mg 2 Tier KEY = Covered Generic Drugs = Responsible Rx Program X = Self-Administered Medication 2 = Preferred Brand Drugs * = May not be covered see endorsement Florida Blue January Closed Medication Drug Guide 7

20 enalapril (Vasotec) enalapril/ hydrochlorothiazide (Vaseretic) fosinopril fosinopril/hydrochlorothiazide lisinopril (Prinivil, Zestril) lisinopril/ hydrochlorothiazide (Prinzide, Zestoretic) moexipril (Univasc) moexipril/ hydrochlorothiazide (Uniretic) perindopril (Aceon) quinapril (Accupril) quinapril/ hydrochlorothiazide (Accuretic) ramipril (Altace) trandolapril (Mavik) ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS irbesartan (Avapro) irbesartan/ hydrochlorothiazide (Avalide) losartan (Cozaar) losartan/ hydrochlorothiazide (Hyzaar) valsartan (Diovan) valsartan/ hydrochlorothiazide (Diovan HCT) BETA BLOCKERS AND COMBINATIONS acebutolol (Sectral) atenolol (Tenormin) atenolol/ chlorthalidone (Tenoretic) bisoprolol (Zebeta) bisoprolol/ hydrochlorothiazide (Ziac) carvedilol (Coreg) labetalol (Trandate) metoprolol succinate extrelease (Toprol XL) metoprolol tartrate (Lopressor) nadolol (Corgard) pindolol propranolol ext-release (Inderal LA) PROPRANOLOL soln, 20 mg/5 ml 2 propranolol tabs PROPRANOLOL/ 2 HYDROCHLOROTHIAZIDE mg TIMOLOL tabs 2 CALCIUM CHANNEL BLOCKERS AND COMBINATIONS amlodipine (Norvasc) amlodipine/benazepril (Lotrel) amlodipine/valsartan (Exforge) diltiazem (Cardizem) diltiazem ext-release (Cardizem CD, Tiazac) felodipine ext-release ISRADIPINE caps, 2.5 mg 2 nifedipine ext-release (Adalat CC, Procardia XL) NISOLDIPINE ext-release 25.5 mg 2 VERAPAMIL 40 mg 2 Tier KEY = Covered Generic Drugs = Responsible Rx Program X = Self-Administered Medication 2 = Preferred Brand Drugs * = May not be covered see endorsement 8 Florida Blue January Closed Medication Drug Guide

21 verapamil 80 mg, 20 mg (Calan) verapamil ext-release (Calan SR, Isoptin SR, Verelan, Verelan PM) CHEST PAIN ISOSORBIDE DINITRATE tabs, 2 30 mg isosorbide dinitrate tabs, 5 mg, 0 mg, 20 mg (Isordil) isosorbide mononitrate (Monoket) isosorbide mononitrate extrelease (Imdur) NITRO-BID 2 nitroglycerin 0. mg/hr, 0.2 mg/ hr, 0.4 mg/hr, 0.6 mg/hr (Nitro- Dur) NITROSTAT 2 CHOLESTEROL LOWERING atorvastatin (Lipitor) cholestyramine (Questran, Questran Light) colestipol (Colestid) CRESTOR 2 fenofibrate (Lofibra, Tricor) fenofibrate micronized (Lofibra) fenofibric acid delayedrelease (Trilipix) gemfibrozil (Lopid) lovastatin (Mevacor) niacin ext-release (Niaspan) pravastatin (Pravachol) simvastatin (Zocor) WELCHOL 2 FLUID RETENTION ACETAZOLAMIDE 25 mg 2 acetazolamide 250 mg acetazolamide extrelease (Diamox Sequels) amiloride amiloride/hydrochlorothiazide bumetanide chlorothiazide 500 mg CHLORTHALIDONE 25 mg, 50 mg 2 furosemide, NP = soln, 8 mg/ ml (Lasix) hydrochlorothiazide caps (Microzide) hydrochlorothiazide tabs indapamide methazolamide (Neptazane) metolazone (Zaroxolyn) spironolactone (Aldactone) spironolactone/ hydrochlorothiazide (Aldactazide) torsemide (Demadex) triamterene/hydrochlorothiazide, NP = caps, mg (Dyazide, Maxzide, Maxzide-25) HEART RHYTHM amiodarone (Cordarone) disopyramide (Norpace) flecainide mexiletine propafenone (Rythmol) propafenone ext-release (Rythmol SR) quinidine gluconate ext-release QUINIDINE SULFATE ext-release 2 Tier KEY = Covered Generic Drugs = Responsible Rx Program X = Self-Administered Medication 2 = Preferred Brand Drugs * = May not be covered see endorsement Florida Blue January Closed Medication Drug Guide 9

22 QUINIDINE SULFATE 200 mg 2 quinidine sulfate 300 mg sotalol (Betapace, Betapace AF) OTHER HEART RELATED DRUGS amlodipine/atorvastatin (Caduet) clonidine (Catapres, Catapres- TTS) DIGOXIN soln 2 digoxin tabs (Lanoxin) doxazosin (Cardura) eplerenone (Inspra) guanfacine (Tenex) hydralazine LETAIRIS 2 X methyldopa midodrine (Proamatine) minoxidil OPSUMIT 2 X prazosin (Minipress) sildenafil (Revatio) X terazosin TRACLEER 2 X VENTAVIS 2 X ERECTILE DYSFUNCTION LEVITRA* 2 ALLERGIC REACTION KITS EPIPEN inj 2 EPIPEN-JR inj 2 RESPIRATORY DRUGS ANTIHISTAMINES cyproheptadine loratadine (Claritin OTC) promethazine NASAL PRODUCTS azelastine (Astepro) flunisolide 25 mcg/ spray (Flunisolide) fluticasone propionate (Flonase) ipratropium (Atrovent) triamcinolone (Nasacort AQ) COUGH/COLD/ALLERGY acetylcysteine loratadine/ pseudoephedrine (Claritin-D OTC) ASTHMA/COPD albuterol ATROVENT HFA 2 budesonide (Pulmicort Respules) COMBIVENT RESPIMAT 2 cromolyn sodium inhal soln DULERA 2 FORADIL AEROLIZER 2 ipratropium inhal soln ipratropium/albuterol (Duoneb) levalbuterol, NP =.25 mg/0.5 ml (Xopenex) montelukast (Singulair) PROAIR HFA 2 PULMICORT FLEXHALER 2 PULMICORT RESPULES 2 mg/2 ml QVAR 2 SPIRIVA HANDIHALER 2 SPIRIVA RESPIMAT 2 Tier KEY = Covered Generic Drugs = Responsible Rx Program X = Self-Administered Medication 2 = Preferred Brand Drugs * = May not be covered see endorsement 0 Florida Blue January Closed Medication Drug Guide

23 SYMBICORT 2 terbutaline theophylline ext-release VENTOLIN HFA 2 zafirlukast (Accolate) OTHER RESPIRATORY DRUGS KALYDECO 2 X PULMOZYME 2 X GASTROINTESTINAL DRUGS LAXATIVES lactulose PEG electrolytes for soln (Colyte, Golytely, Nulytely) ULCER/GERD CARAFATE susp 2 cimetidine dicyclomine caps, tabs (Bentyl) famotidine (Pepcid) glycopyrrolate (Robinul) hyoscyamine (Anaspaz, Levsin, Levsin/SL) hyoscyamine ext-release (Levbid) lansoprazole delayedrelease (Prevacid) methscopolamine (Pamine, Pamine Forte) misoprostol (Cytotec) OMEPRAZOLE (Prilosec OTC) 2 omeprazole delayedrelease (Prilosec) pantoprazole delayedrelease (Protonix) PROPANTHELINE 5 mg 2 ranitidine (Zantac) sucralfate (Carafate) SYMAX DUOTAB 2 NAUSEA AND VOMITING EMEND caps, therapy pack 2 granisetron meclizine ondansetron (Zofran, Zofran ODT) ondansetron tabs, 24 mg trimethobenzamide (Tigan) DIGESTIVE ENZYMES Pancreatic enzyme products: CREON 2 ZENPEP 2 OTHER GASTROINTESTINAL DRUGS ASACOL HD 2 balsalazide (Colazal) calcium acetate (Eliphos, Phoslo) CANASA 2 CHENODAL 2 DELZICOL 2 diphenoxylate/atropine tabs (Lomotil) lactulose LIALDA 2 loperamide mesalamine metoclopramide (Reglan) PENTASA 2 RENVELA 2 sulfasalazine (Azulfidine) Tier KEY = Covered Generic Drugs = Responsible Rx Program X = Self-Administered Medication 2 = Preferred Brand Drugs * = May not be covered see endorsement Florida Blue January Closed Medication Drug Guide

24 sulfasalazine delayedrelease (Azulfidine EN-Tabs) ursodiol (Actigall, Urso 250, Urso Forte) GENITOURINARY DRUGS URINARY TRACT INFECTIONS nitrofurantoin (Furadantin) nitrofurantoin macrocrystalline (Macrodantin) nitrofurantoin monohydrate/ macrocrystalline (Macrobid) URINARY TRACT SPASMS oxybutynin oxybutynin ext-release (Ditropan XL) tolterodine (Detrol) tolterodine ext-release (Detrol LA) VESICARE 2 VAGINAL PRODUCTS AVC 2 CLEOCIN supp 2 clindamycin (Cleocin) metronidazole (MetroGel-Vaginal) PREMARIN 2 terconazole (Terazol) VAGIFEM 2 OTHER GENITOURINARY DRUGS alfuzosin ext-release (Uroxatral) CYSTAGON 2 finasteride (Proscar) K-PHOS NO. 2 2 potassium citrate extrelease (Urocit-K) potassium citrate/citric acid (Polycitra-K) sodium citrate/citric acid (Shohl's) tamsulosin (Flomax) CENTRAL NERVOUS SYSTEM DRUGS ANXIETY alprazolam (Xanax) alprazolam ext-release (Xanax XR) buspirone DIAZEPAM oral soln, mg/ml 2 diazepam tabs (Valium) hydroxyzine hcl hydroxyzine pamoate 25 mg, 50 mg (Vistaril) lorazepam (Ativan) lorazepam conc (Lorazepam Intensol) DEPRESSION amitriptyline bupropion (Wellbutrin) bupropion ext-release (Wellbutrin SR, Wellbutrin XL) citalopram (Celexa) clomipramine (Anafranil) desipramine (Norpramin) doxepin DOXEPIN 75 mg 2 duloxetine delayedrelease (Cymbalta) escitalopram (Lexapro) fluoxetine, 60 mg not covered (Prozac) Tier KEY = Covered Generic Drugs = Responsible Rx Program X = Self-Administered Medication 2 = Preferred Brand Drugs * = May not be covered see endorsement 2 Florida Blue January Closed Medication Drug Guide

25 fluvoxamine imipramine hcl (Tofranil) mirtazapine (Remeron, Remeron SolTab) nortriptyline caps (Pamelor) paroxetine hcl (Paxil) paroxetine hcl ext-release (Paxil CR) PAXIL susp 2 phenelzine (Nardil) sertraline (Zoloft) tranylcypromine (Parnate) trazodone venlafaxine venlafaxine ext-release caps (Effexor XR) VENLAFAXINE ext-release tabs, 225 mg venlafaxine ext-release tabs, 37.5 mg, 75 mg, 50 mg 2 PSYCHOTIC AND BIPOLAR DISORDERS chlorpromazine clozapine (Clozaril) fluphenazine hcl tabs haloperidol lactate oral soln haloperidol tabs LITHIUM soln 2 lithium carbonate LITHIUM CARBONATE caps, 600 mg lithium carbonate ext-release 300 mg (Lithobid) lithium carbonate ext-release 450 mg 2 loxapine (Loxitane) olanzapine (Zyprexa, Zyprexa Zydis) perphenazine prochlorperazine quetiapine (Seroquel) risperidone (Risperdal, Risperdal M-Tab) SEROQUEL XR 2 thiothixene trifluoperazine ziprasidone (Geodon) SLEEP AIDS estazolam phenobarbital soln; tabs, 6.2 mg, 32.4 mg PHENOBARBITAL tabs, 5 mg, 30 mg, 60 mg, 64.8 mg, 00 mg; NP = 97.2 mg temazepam (Restoril) zaleplon (Sonata) zolpidem (Ambien) zolpidem ext-release (Ambien CR) HYPERACTIVITY/NARCOLEPSY amphetamine/ dextroamphetamine (Adderall) amphetamine/ dextroamphetamine extrelease (Adderall XR) caffeine citrate (Cafcit) 2 dextroamphetamine dextroamphetamine extrelease (Dexedrine Spansule) methylphenidate tabs (Ritalin) Tier KEY = Covered Generic Drugs = Responsible Rx Program X = Self-Administered Medication 2 = Preferred Brand Drugs * = May not be covered see endorsement Florida Blue January Closed Medication Drug Guide 3