Adph.org

An Independent Licensee of the Blue Cross and Blue Shield Association 450 Riverchase Parkway East, Birmingham, AL 35244 Drug Class
Generic drugs
Preferred Brand drugs
Drugs not covered
amphetamine/dextroamphetamine (Adderall), amphetamine/dextroamphetamine ER (Adderall XR), dexmethylphenidate (Focalin), dextroamphetamine, ATTENTION-DEFICIT
ADDERALL,ADDERALL XR, AMPHETAMINE-DEXTROAMPHETAMINE 24HR, CONCERTA, DAYTRANA, DESOXYN, DEXEDRINE, FOCALIN, KAPVAY, METADATE HYPERACTIVITY
CD, METHYLIN, METHYLPHENIDATE ER, MODAFINIL, NUVIGIL, PROCENTRA, DISORDER (ADHD)
PROVIGIL, RITALIN, RITALIN LA, RITALIN SR, STRATTERA Methylin ER, methylphenidate (Methylin, Ritalin), methylphenidate ER (Ritalin LA, Ritalin SR) budesonide soln 0.25, 0.5 mg (Pulmicort Respules), ACCOLATE, ACCUNEB, AEROBID-M, ALVESCO, AMINOPHYLLINE,ARCAPTA, ATROVENT HFA, BRETHINE, BRONCOMAR, BROVANA, COMBIVENT, DUONEB, RESPIRATORY
ELIXOPHYLLIN, FLOVENT DISKUS, FLOVENT HFA, MAXAIR AUTOHALER, METAPROTERENOL TABS, PERFOROMIST, PROVENTIL HFA, PULMICORT FLEXHALER, PULMICORT 0.25MG AND 0.5MG RESPULES, QVAR, SEREVENT, SYMBICORT, THEO-24, VENTOLIN HFA, VOSPIRE ER, XOPENEX, XOPENEX HFA, acarbose (Precose), chlorpropamide, glimepiride (Amaryl), glipizide (Glucotrol), ACTOPLUS MET, ACTOPLUS MET XR, AMARYL, APIDRA, AVANDAMET, AVANDARYL, AVANDIA, BYETTA, BYDUREON, CYCLOSET, DIABETA, DUETACT, FORTAMET, GLUCAGEN HYPOKIT, GLUCOPHAGE, GLUCOPHAGE XR, GLUCOTROL, GLUCOTROL XL, GLUCOVANCE, GLUMETZA, GLYCRON 4.5MG, DIABETES – Rx Only
GLYNASE, GLYSET, HUMALOG, HUMULIN, JANUMET, JANUMET XR, JANUVIA, JENTADUETO, JUVISYNC, LEVEMIR, METAGLIP, PRANDIMET, PRANDIN, PRECOSE, RELION, RIOMET, STARLIX, SYMLIN, TOLAZAMIDE, TOLBUTAMIDE, metformin ext-release OSM (Fortamet), nateglinide (Starlix), pioglitazone (Actos), pioglitazone/metformin (Actoplus Met) * This list includes the most frequently prescribed drugs on the formulary. Go to www.bcbsal.com to see the complete Generics Plus Drug Guide. This list is subject to change. Drugs may be subject to utilization management (e.g., step therapy). Drug names are the property of their respective owners. Generics Plus Formulary Alternatives effective 10/1/12 Drug Class
Generic drugs
Preferred Brand drugs
Drugs not covered
budeprion SR, XL (Wellbutrin SR, XL), bupropion (Wellbutrin), bupropion ext-release (Wellbutrin SR, XL), citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), APLENZIN, CELEXA, CYMBALTA, EFFEXOR XR, LEXAPRO, LUVOX CR, MAPROTILINE, NEFAZODONE, OLEPTRO, PAXIL, PAXIL CR, PEXEVA, PRISTIQ, DEPRESSION
PROZAC, REMERON, VIIBRYD, WELLBUTRIN, WELLBUTRIN SR, WELLBUTRIN XL, paroxetine ext-release (Paxil CR), sertraline (Zoloft), trazodone, venlafaxine (Effexor), venlafaxine ext-release (Effexor XR) lansoprazole (Prevacid), omeprazole (Prilosec), ACIPHEX, DEXILANT, PREVACID, PREVACID SOLUTAB, PRILOSEC, PROTONIX, omeprazole/sodium bicarbonate (Zegerid), carbamazepine (Tegretol), carbamazepine ER (Carbatrol, Tegretol-XR), clonazepam (Klonopin), divalproex (Depakote, Depakote Sprinkles) divalproex ext-release (Depakote ER), ethosuximimide (Zarontin), felbamate (Felbatol), BANZEL, CARBATROL, CELONTIN, DEPAKENE, DEPAKOTE, DEPAKOTE ER, DEPAKOTE SPRINKLES, DILANTIN, FELBATOL, GABITRIL, GRALISE, HORIZANT, ANTICONVULSANTS
KEPPRA, KEPPRA XR, KLONOPIN, LAMICTAL, LAMICTAL XR, LYRICA, MYSOLINE, NEURONTIN, ONFI, PEGANONE, PHENYTEK, POTIGA, STAVZOR, TEGRETOL, TEGRETOL-XR, TOPAMAX, TRILEPTAL, VIMPAT, ZARONTIN, ZONEGRAN oxcarbazepine (Trileptal), phenytoin sodium ext-release (Dilantin), primidone (Mysoline), topiramate (Topamax), valproic acid (Depakene) zonisamide (Zonegran) * This list includes the most frequently prescribed drugs on the formulary. Go to www.bcbsal.com to see the complete Generics Plus Drug Guide. This list is subject to change. Drugs may be subject to utilization management (e.g., step therapy). Drug names are the property of their respective owners. Generics Plus Formulary Alternatives effective 10/1/12 Drug Class
Generic drugs
Preferred Brand drugs
Drugs not covered
adapalene (Differin), Amnesteen, Avita, benzoyl peroxide, Claravis, clindamycin (Cleocin-T, Evoclin), ACANYA, ACZONE, AKNE-MYCIN, ATRALIN, AZELEX, BENZACLIN, BENZAMYCIN, clindamycin/benzoyl peroxide (Benzaclin), BENZIQ, BPO 8%, BREVOXYL, CLEOCIN-T, CLINDACIN PAC, DIFFERIN, DUAC, EPIDUO, EVOCLIN, FINACEA PLUS, INOVA, METROCREAM, METROLOTION, erythromycin/benzoyl peroxide (Benzamycin), PLEXION, RETIN-A, SUMADAN, SUMAXIN, TRETIN-X, VANOXIDE-HC, VELTIN, metronidazole (Metrocream, Metrolotion), Myorisan, Sotret, sulfacetamide/sulfur (Plexion), tretinoin (Retin-A) levonorgestrel (Plan B), medroxyprogesterone acetate inj., CYCLESSA, DESOGEN, FEMCON FE, LOESTRIN, LO/OVRAL-28, LOSEASONIQUE, LYBREL, MIRCETTE, NORDETTE-28, NORINYL, NUVARING, OGESTREL, ORTHO- CONTRACEPTIVES
most generic oral contraceptives are Tier 1 CYCLEN, ORTHO-NOVUM, OVCON, PLAN B, SEASONALE, SEASONIQUE, YASMIN, (e.g., Apri, Aviane, Sprintec-28,Trinessa, Trisprintec) azelastine (Astelin), cetirizine syrup (Zyrtec), flunisolide, fluticasone (Flonase), ALLEGRA, ASTELIN, ASTEPRO, ATROVENT NASAL, BECONASE AQ, CLARINEX, FLONASE, NASACORT AQ, OMNARIS, PATANASE, QNASL, RHINOCORT AQUA, ipratropium nasal (Atrovent Nasal), levocetirizine (Xyzal), triamcinolone acetonide * This list includes the most frequently prescribed drugs on the formulary. Go to www.bcbsal.com to see the complete Generics Plus Drug Guide. This list is subject to change. Drugs may be subject to utilization management (e.g., step therapy). Drug names are the property of their respective owners. Generics Plus Formulary Alternatives effective 10/1/12

Source: http://www.adph.org/allkids/assets/pharmchart.82712.pdf