Blue Cross & Blue Shield
of Rhode Island
2009-2010 Preferred Drug List
Effective October 2009–March 2010
Three Tier Commercial Formulary Guide
444 Westminster Street • Providence, RI 02903 • www.BCBSRI.com
Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association
2009-2010 Preferred Drug List
DRUG CATEGORY GENERICS PREFERRED BRANDS/2nd TIER NON-PREFERRED BRANDS/3rd TIER
Anti-infective
Anti-Flu (quantity limits for some plans) amantadine, rimantadine Relenza, Tamiflu
Anti-Fungals ciclopirox 8% soln, fluconazole, griseofulvin micro, Ancobon, Ertaczo, Grifulvin V 500mg, Gris-Peg,
itraconazole^, ketoconazole, nystatin, terbinafine^ Lamisil^, Noxafil, Penlac, Sporanox^, Vfend
Anti-Malarials chloroquine, hydroxychloroquine Daraprim, Malarone, Primaquine Aralen, Lariam, Plaquenil
Anti-Viral (quantity limits for some plans) acyclovir, famciclovir, ganciclovir Valtrex Famvir, Zovirax
Cephalosporins, 1st Generation cefadroxil, cephalexin Keflex
Cephalosporins, 2nd Generation cefaclor/ER, cefdinir, cefuroxime, cefprozil Ceftin, Cefzil
(quantity limits for some plans)
Cephalosporins, 3rd Generation cefpodoxime Suprax Cedax, Omnicef, Spectracef, Vantin
Hepatitis, Oral Agents Epivir HBV, Hepsera Baraclude, Tyzeka
Macrolides (quantity limits for some plans) azithromycin, clarithromycin/ER, Biaxin/XL, Zithromax/ZMAX
erythromycin/stearate EES
Penicillins (quantity limits for some plans) amoxicillin, amoxicillin/clavulanate, penicillin-VK Augmentin ES/XR, Moxatag
Quinolones (quantity limits for some plans) ciprofloxacin/ER, ofloxacin Levaquin Avelox, Cipro XR, Factive, Noroxin, Proquin XR
Tetracyclines declomycin, doxycycline/monohydrate, Adoxa^, Dynacin^, Doryx^, Minocin^, Periostat^,
minocycline, tetracycline Solodyn^, Vibramycin^
Vaginal Preparations acidic vaginal, clindamax, metronidazole, Gynazole-1 Cleocin, Monistat 3, Terazol 3/7#
miconazole, miconazole 3, nystatin, terconazole
cArdiovAsculAr
Ace Inhibitors benazepril, captopril, enalapril, fosinopril, lisinopril, Accupril, Aceon, Altace, Capoten, Lotensin,
moexipril, quinapril, ramipril, trandolopril Mavik, Monopril, Prinivil, Univasc, Vasotec
ACE/CCB Combinations amlodipine/benazepril Lotrel, Tarka
ACE/HCT Combinations benazepril HCT, captopril HCT, enalapril HCT, Accuretic, Capozide, Lotensin HCT, Monopril HCT,
fosinopril HCT, lisinopril HCT, quinapril HCT Prinzide, Uniretic, Vaseretic
Aldosterone Blockers spironolactone, eplerenone Inspra
Angiotensin II Receptor Blockers Avapro^, Diovan^ Atacand^, Benicar^, Cozaar^, Micardis^, Teveten^
(quantity limits for some plans)
Angiotensin II Receptor Blocker Combinations Avalide^, Diovan HCT^ Atacand HCT^, Azor, Benicar HCT^, Exforge,
(quantity limits for some plans) Hyzaar^, Micardis HCT^, Teveten HCT^
Beta Blockers atenolol, betaxolol, bisoprolol, carvediol, Bystolic, Coreg, Coreg CR, Inderal LA,
metoprolol, propranolol/LA Innopran XL, Levatol, Toprol XL
Bile Salt Sequestrants cholestyramine Welchol Colestid, Questran
Calcium Channel Blockers – Dihydropyridines amlodipine, felodipine, nicardipine, nifedipine XL, Sular Cardene SR, Dynacirc CR, Norvasc
nisoldipine
Calcium Channel Blockers – Diphenylalkylamine verapamil, verapamil SR Covera HS, Verelan PM
Calcium Channel Blockers – Diltiazems Cardizem LA
Fibric Acid Derivatives/Niacin fenofibrate, gemfibrozil Niaspan Antara^, Tricor^, Triglide^, Trilipix^
HMG CoA’s (quantity limits for some plans) lovastatin, pravastatin, simvastatin Crestor, Lipitor Altoprev, Lescol/XL, Mevacor, Pravachol, Zocor
HMG combinations (quantity limits for some plans) Advicor, Caduet, Vytorin
Miscellaneous Cardiovascular Agents Zetia Lovaza
(quantity limits for some plans)
Renin Inhibitor (quantity limits for some plans) Tekturna^, Tekturna HCT^
Vasodilators, Coronary isosorbide dinitrate/mononitrate, nitrek patch, Dilatrate – SR, Nitro-BID, Nitro-Dur, Nitrolingual Imdur, Isordil
(quantity limits for some plans) nitroglycerin
cns
Alcohol Dependence Campral
Alzheimer’s galantamine Aricept, Aricept ODT, Exelon patch, Namenda Cognex, Razadyne
Anticonvulsants clonazepam, carbamazepine, gabapentin, lamotrigine, Carbatrol, Dilantin, Phenytek, Topamax Felbatol, Keppra, Klonopin, Lyrica^, Trileptal,
levetiracetam, oxcarbazepine, phenytoin, zonisamide Zonegran
Anti-Depressants bupropion, citalopram, fluoxetine, mirtazapine, Celexa^, Cymbalta^, Effexor XR^, Lexapro^,
(quantity limits for some plans) paroxetine, trazodone Pristiq^, Savella^, Wellbutrin XL
Anti-Depressant/Anti-Psychotic Comb. Symbyax
Anti-Emetics dexamethasone, granisetron, ondansetron, Anzemet, Cesamet, Emend, Kytril, Zofran,
(quantity limits for some plans) prochlorperazine Sancuso
Anti-Migraine (quantity limits for some plans) sumatriptan Maxalt, Relpax Amerge^, Axert^, Frova^, Imitrex^, Treximet^,
Zomig^
Anti-Parkinsonian carbidopa/levodopa, pergolide, ropinirole, Apokyn, Mirapex Azilect, Eldepryl, Parcopa, Requip/XL
selegiline
Anti-Psychotic clozapine, risperidone, ziprasidone Abilify, Geodon, Seroquel/XR, Zyprexa, ZyprexaZydis Fazaclo, Invega
Benzodiazepines (quantity limits for some plans) alprazolam, lorazepam, oxazepam Doral, Niravam, Xanax XR
Miscellaneous (quantity limits for some plans) Xyrem
Sedative/Hypnotics/Melatonin Receptor zaleplon, zolpidem Ambien^, Ambien CR^, Edluar^, Lunesta^,
Agonists (quantity limits for some plans) Restoril, Rozerem^, Sonata^
Stimulants/ADHD amphetamine salt combo, dexmethylphenidate, Concerta, Focalin XR, Provigil, Strattera Adderall/XR, Daytrana, Focalin, Metadate CD,
(quantity limits for some plans) dextroamphetamine sulfate, melthylphenidate/ER Methylin soln, Nuvigil^, Ritalin/SR/LA, Vyvanse
OTC – Over the Counter; may not be covered by your prescription drug benefit. ^ – May require authorization for Managed Plan
2009-2010 Preferred Drug List
DRUG CATEGORY GENERICS PREFERRED BRANDS/2nd TIER NON-PREFERRED BRANDS/3rd TIER
cough, cold, Allergy
Antihistamines cetirizine (OTC), fexofenadine^, loratadine (OTC) Allegra^, Clarinex^, Palgic^, Xyzal^
(quantity limits for some plans)
Antihistamines – Decongestants cetirizine D (OTC), fexofenadine-D^, Allegra-D^, Clarinex-D^
(quantity limits for some plans) loratadine D (OTC)
dermAtologicAl
Acne/Rosacea Products, Anti-infective benzoyl peroxide, clindamycin, erythromycin, Akne-Mycin, Azelex cream, Benzashave, Brevoxyl,
metronidazole lotion Clinac, Evoclin foam, Finacea gel, Metro-Cream,
Metro-Gel, MetroLotion, Noritate, Triaz
Acne Products, Combination Products benzoyl peroxide/erythromycin Benzaclin, Benzamycin, Duac CS, Vanoxide HC,
(quantity limits for some plans) Ziana
Acne Products, Retinoids tretinoin Differin, Retin A Microgel, Tazorac
(quantity limits for some plans)
Anti-Fungals econazole cr, ciclopirox cr, ciclopirox susp, Exelderm cr/soln, Lamisil Spray, Metrogel, Avar Gel, Loprox, Mentax, Plexion
(quantity limits for some plans) ketoconazole cr, metronidazole Naftinl, Oxistat
Anti-infectives bacitracin Altabax
Anti-Psoriatic/Eczema hydrocortisone, clobetasol, fluocinonide, Elidel, Protopic Salex, Vanos
salicylic acid
Anti-Psoriatic Biologic/Systemic, oral Oxsoralen Ultra, 8-MOP Soriatane CK
Keratolytics/Immunomodulators podofilox soln Aldara, Condylox gel Condylox soln
(quantity limits for some plans)
Topical Steroids alclometasone dip, amcinonide, betamethasone Ala-Scalp, Capex, Clobex, Cloderm, Cordran,
(quantity limits for some plans) dip/val/augmented, clobetasol propionate, Cutivate cr/oint/lotion, Derma–Smoothe,
desonide, desoximetasone, diflorasone diacetate, Dermatop, DesOwen cr/lot/oin, Desonate,
fluocinolone aetonide, fluocinonide, fluticasone, Diprolene, Diprosone cr/oint, Elocon cr/oint,
halobetasol propionate, hydrocortisone/val, Halog, Kenalog spray, Locoid, Luxiq, Olux,
mometasone furoate, prednicarbate oint/cr, Pandel, Temovate cr/oint/soln, Vanos
triamcinolone acetonide
diAbetes
Biguanides metformin/ER Fortamet, Glucophage/XR, Glumetza, Riomet
Biguanides Combinations metformin/glipizide, metformin/glyburide Glucovance, Metaglip
DPP4 Inhibitors (quantity limits for some plans) Janumet, Januvia
Insulin Apidra, Humalog, Humalog Mix 50/50,
Humalog Mix 75/25, Humulin 50/50, Humulin
70/30, Humulin N/L/R, Lantus, Levemir, Novolin
70/30, Novolin N/R, Novolog, Novolog Mix 70/30
Alpha-Glucosidase Inhibitors, Meglitinides acarbose Glyset, Prandin Precose, Starlix
Miscellaneous (quantity limits for some plans) Byetta Prandimet, Symlin
Sulfonylureas glimepiride, glipizide, glipizide glyburide, Amaryl, Diabeta, Glucotrol/XL, Glynase
glyburide micronized
Supply Preferred Strips will take Tier 1 copay
ACCU-CHEK AVIVA, ACCU-CHEK COMFORT, ACCU-CHEK COMPACT ONE TOUCH TEST STRIPS,
ONE TOUCH ULTRASMART, ONE TOUCH ULTRA 2 TEST STRIPS, ONE TOUCH ULTRAMINI, ONE TOUCH ULTRA
TZDs (quantity limits for some plans) Actos, Avandia
TZD Combinations ACTOplus MET, Avandaryl, Avandamet, Duetact
(quantity limits for some plans)
gAstrointestinAl
Bile Salts ursodiol Urso/Forte Actigall
Electrolyte Depleters calcium acetate, sodium polystyrene Fosrenol, PhosLo, Renagel, Renvela Kayexalate
H-2 Antagonists cimetidine, famotidine, nizatidine, ranitidine Axid, Pepcid, Zantac
Hemorrhoidal Preparations Proctofoam HC
Inflammatory Bowel Disease balsalazide, hydrocortisone enema, mesalamine Asacol, Canasa, Entocort EC, Lialda, Pentasa Azulfidine, Azulfidine EN-tab, Colazal, Cortifoam,
enema, sulfasalazine, sulfasalazine EC Dipentum, Rowasa
Pancreatic Enzymes Creon, Pancrease MT, Ultrase, Ultrase MT,
Viokase
Proton Pump Inhibitors omeprazole, pantoprazole^ Aciphex^, Nexium^, Prevacid^, Protonix^, Zegerid^
(Prior Authorization may apply)
(quantity limits for some plans)
genitourinAry
Alpha-Blockers/BPH doxazosin, finasteride, terazosin Flomax Avodart, Cardura XL, Proscar, Uroxatral
Anti-Cholinergics oxybutynin/ER Detrol, Detrol LA, Vesicare Enablex, Ditropan XL, Oxytrol, Sanctura
hemAtologicAl
Anti-Platelet Agents cilostazol, dipyridamole, ticlopidine Aggrenox, Plavix Persantine, Ticlid
(quantity limits for some plans)
Miscellaneous Hematologic Agents Nascobal
hormones
Androgens (quantity limits for some plans) Androderm, Androgel, Testim Striant
Calcium Regulators alendronate Evista, Miacalcin Nasal Spray Actonel^, Actonel w/Calcium^, Boniva^,
(quantity limits for some plans) Fosamax/Fosamax-D^
OTC – Over the Counter; may not be covered by your prescription drug benefit. ^ – May require authorization for Managed Plan
2009-2010 Preferred Drug List
DRUG CATEGORY GENERICS PREFERRED BRANDS/2nd TIER NON-PREFERRED BRANDS/3rd TIER
Contraceptives Monophasic apri, kariva, levora, low-ogestrel, necon, ocella, Ortho-Evra , Yaz
^ ^
Femcon FE^, Loestrin 24 FE^, Nor-Q-D^,
(quantity limits for some plans) sprintec, zovia 1/35 Ovcon 50^, Seasonale^/Seasonique^
(3 copayments apply), Yasmin^
Contraceptives Triphasic necon 7/7/7, tri-sprintec, trinessa, trivora OrthoTriCyclen Lo^ Cyclessa^, Estrostep FE^, OrthoTriCyclen^,
(quantity limits for some plans) Tri-Norinyl^
Contraceptives Vaginal Nuvaring (3 copayments apply)
(quantity limits for some plans)
Epinephrine Epipen, Epipen JR
Estrogens & Estrogen/ estradiol, estradiol-norethindrone, estropipate, Cenestin, Enjuvia, FemHRT, Femtrace, Menest, Activella, Estrace, Ogen
Progesterone Combinations, Oral gynodiol Prefest, Premarin, Premphase, Prempro
(quantity limits for some plans)
Estrogens, Topical estradiol Climara Pro, Vivelle-DOT Climara, Elestrin, Estrasorb, Estraderm, Estrogel
(quantity limits for some plans) (2 copayments), Menostar
Estrogens, Vaginal Estring, Premarin cream, Vagifem supp Femring
(quantity limits for some plans)
Thyroid levothroid, levothyroxine, Levoxyl Synthroid Armour Thyroid, Nature-Throid
musculoskeletAl
COX 2s/NSAIDS diclofenac, etodolac, ibuprofen, indomethacin, Arthrotec, Celebrex^, Flector, Mobic
(quantity limits for some plans) meloxicam, nabumetone, naproxen, piroxicam,
salsalate, sulindac
DMARDs hydroxychloroquine, leflunomide, methotrexate Arava, Plaquenil
Muscle Relaxants carisoprodol, chloroxazone, cyclobenzaprine, Skelaxin Amrix, Fexmid, Flexeril, Zanaflex
metaxalone, methocarbamol, orphenadrine,
tizanidine
Narcotics & Analgesics hydrocodone & acetaminophen, ibuprofen Actiq, Avinza, Combunox, Darvocet A500,
(quantity limits for some plans) & oxycodone, morphine sulfate, oxycodone, Darvon-N, Dilaudid, Duragesic, Kadian, Lortab,
oxycodone & acetaminophen, propoxyphene/ MS Contin, Oxycontin, Reprexain, Synalgos-DC,
acetaminophen, transdermal fentanyl Ultram ER, Zydone
Topical Analgesics, non-narcotic Lidoderm, Synera
ophthAlmics
Allergy (quantity limits for some plans) cromolyn, ketotifen Pataday, Patanol Alamast, Alocril, Alomide, Crolom, Elestat,
Emadine, Optivar
Antibiotics (quantity limits for some plans) bacitracin oint, baci-poly oint, ciprofloxacin soln, Ciloxan oint, Tobrex oint Azasite, Ciloxan soln, Neosporin soln/oint,
erythromycin oint, gentamycin oint/soln, Ocuflox, Polysporin soln/oint, Polytrim, Tobradex,
neo-baci-poly oint, neo-poly-gram soln, ofloxacin Tobrex soln
soln, polymixin-TMP soln, tobramycin soln
Anti-Infective, Quinolone ciprofloxacin, ofloxacin Vigamox Quixin, Zylet, Zymar
Anti-Imflammatory dexamethasone, diclofenac, fluorometholone, Acular LS, Alrex, FML S.O.P. oint, FML Forte soln, Acular/PF, Flarex, FML soln, Ocufen, Vexol,
(quantity limits for some plans) flurbiprofen, prednisolone Lotemax, Maxidex, Nevanac, Pred Mild Voltaren, Xibrom
Anti-Viral (quantity limits for some plans) trifluridine Viroptic
Beta-Blockers (quantity limits for some plans) betaxolol, cateolol, levobunolol, timolol Betimol, Betoptic S Betagan, Istalol, Timoptic/XE
Carbonic Anhydrase Inhibitors & CAI-BB timolol/dorzolamide Azopt, Trusopt Cosopt
Combinations (quantity limits for some plans)
Immunomodulator Restasis
Miotics acetazolamide Diamox Sequel, Isopto Carbachol
Prostaglandins (quantity limits for some plans) Travatan/Z, Xalatan Latisse, Lumigan
otic
Anti-Infective/Anti-Inflammatory ofloxacin, neomycin/polymixin/HC Ciprodex Cipro HC, Cortisporin TC, Floxin
respirAtory
Anticholenergics ipratropium soln Atrovent HFA, Spiriva
(quantity limits for some plans)
Beta-Agonists albuterol/ipratropium Combivent, Foradil, Proair HFA, Proventil HFA, Duoneb, AccuNeb, Brovana, Maxair,
(quantity limits for some plans) Serevent Ventolin HFA, Xopenex HFA
Inhalation Assist Devices Aerochamber, Easivent
Inhaled Steroids Advair, Asmanex, Azmacort, Flovent, Pulmicort, Aerobid/Aerobid M, Alvesco
(quantity limits for some plans) QVAR, Symbicort
Nasal Antihistamines Astelin Astepro
(quantity limits for some plans)
Nasal Steroids flunisolide, fluticasone Nasonex Beconase AQ, Flonase, Nasacort AQ, Nasarel,
(quantity limits for some plans) Patanase, Rhinocort Aqua, Veramyst
Selective Leukotriene Receptor Antagonists Accolate^, Singulair^
(quantity limits for some plans)
Xanthines aminophylline, theophylline/ER/SA Lufyllin, Theo-24 Uniphyl
vitAmins
Prenatal Vitamins generics (exs. Prenatal Plus, Prenatal RX, Brands (exs. Duet DHA Stuartnatal, Precare
Prenatabs, Vinate GT) Premier, Prenate Elite, Primacare One)
OTC – Over the Counter; may not be covered by your prescription drug benefit. ^ – May require authorization for Managed Plan
2009-2010 Specialty Drug List
The following is the Specialty Drug List, many of the drugs are oral tablets or self administered while some drugs (in bold type)
are typically provided within a physician office setting with coverage under the medical benefit.
For members with a specialty benefit, coverage for drugs listed in bold type will not be provided under the medical benefit.
Providers must obtain these products through a preferred specialty vendor. Medications noted with a ^ below may require prior
authorization. Medications with a # may be subject to quantity limits. Please refer to www.bcbsri.com for more detailed program
benefit information.
DRUG CATEGORY SPECIALTY MEDICATION/HIGHEST TIER DRUG CATEGORY SPECIALTY MEDICATION/HIGHEST TIER
Anti-infective Hemophilia, Factor IX Alphanine
Antivirals, Hepatitis C Infergen (interferon alfacon-1) Bebulin
Intron A (interferon alfa 2b) Benefix
Pegasys (peginterferon alfa 2a)^# Mononine
Peg-Intron (peginterferon alfa 2b)^ Profilnine
Peg-Intron Redipen (peginterferon alfa 2b)^ Proplex
Rebetron (interferon alfa 2b/ribavirin) Hemophilia, Factor VIIa Novoseven
Roferon-A (interferon alfa 2a) Hemophilia, Factor VIII Advate
HIV, AIDS Fuzeon# (enfuvirtide) Alphanate
dermAtology Bioclate
Psoriasis Humira (adalimumab)^# Helixate
Amevive (alefacept)^ Hemofil M
Remicade (infliximab) ^ Humate P
endocrine Koate DVI
Growth Hormone Products Genotropin (somatropin) ^# Kogenate FS
Geref (sermorelin)^# Monarc M
Humatrope (somatropin)^# Monoclate P
Increlex (mecasermin)^# Novoseven RT
Norditropin (somatropin)^# Recombinate
Norditropin Nordiflex (somatropin)^# Refacto
Nutropin (somatropin)^# Xyntha
Nutropin AQ (somatropin)^# Immune Globulins Baygam^
Nutropin Depot (somatropin)^# Carimune^
Omnitrope (somatropin)^# Cytogam^
Saizen (somatropin)^# Flebogamma^
Serostem (somatropin)^# Gamastan^
Tev-tropin (somatropin)^# Gammagard^
Zorbtive (somatropin)^# Gamunex^
Miscellaneous Endocrine H.P. Acthar gel (corticotrophin)^ Iveegam^
Sandostatin LAR Depot (octreotide acetate)
Octagam^
Somatuline Depot
Polygam^
Somavert (pegvisomant)
Previgen^
Supprelin (histrelin acetate)
Vivaglobin^
Disorders Supprelin LA (histrelin acetate)
Thrombocytopenia Neumega (oprelvekin)^
Osteoporosis Boniva IV formulation only (ibandronate)^
WBC Deficiencies Leukine (sargramostim)
Forteo (teriparatide)^#
Neulasta (pegfilgrastim)#
Reclast (zoledronic acid)^
Neupogen (filgrastim)
gAstroenterology
Crohns, UC Cimzia (certolizumab)#^ immunomodulAtor
Cryopyrin-Associated Arcalyst (rilonacept)
Humira (adalimumab) ^
Periodic Syndromes Ilaris (canakinumab)
Tysabri (natalizumab)^ Cimzia (certolizumab)#^
Rheumatoid Arthritis
Remicade (infliximab)^ Enbrel (etanercept)^#
hemAtologicAl Humira (adalimumab)^
Anemia Aranesp (darbopoetin alfa)^ Kineret (anakinra)^
Epogen (epoetin alfa)^ Orencia (abatacept)^
Procrit (epoetin alfa)^ Remicade (infliximab)^
Fibrinogen Deficiency RiaSTAP (human fibrinogen concentrate) Rituxan (rituximab)^
Hemophilia FEIBA Simponi (galimumab)^
# – Quantity Limits for some plans. OTC – Over the Counter; may not be covered by your prescription drug benefit. ^ – May require authorization for Managed Plan
2009-2010 Specialty Drug List
DRUG CATEGORY SPECIALTY MEDICATION/HIGHEST TIER DRUG CATEGORY SPECIALTY MEDICATION/HIGHEST TIER
Transplant Drugs, Transplant Cellcept (mycophenolate mofetil)/ Oral Agents Afinitor (everolimus)^
Mycophenolate mofetil (generic) Gleevec (imatinib)^
Cyclosporine Iressa (gefitinib)
Gengraf (cyclosporine) Nexavar (sorafenib)^
Neoral (cyclosporine) Promacta (eltrombopag olamine)*
Prograf (tacrolimus) Revlimid (lenalidomine)^#
Rapamune (sirolimus) Sprycel (dasatinib)^
Sandimmune (cyclosporine) Sutent (sunitinib)^
Tacrolimus Tarceva (erlotinib)^
infertility Tasigna (nilotinib)^
Follitropins Follistim AQ (follitropin beta) Temodar (temozolomide)^
Gonal-F (follitropin alpha) Thalomid (thalidomide)^
GnRH Antagonists Cetrotide (cetrorelix acetate) Tykerb (lapatinib)^
Ganirelix acetate Xeloda (capecitabine)^
HCG Chorionic gonadotropin Zolinza (vorinostat)^
Novarel (chorionic gonadotropins) Prostate Cancer Degarelix (degarelix)
Eligard (leuprolide acetate)
Ovidrel (choriogonadotropin alpha)
Lupron Depot (leuprolide acetate)
Pregnyl (chorionic gonadotropins)
Plenaxis (abarelix)
Profasi (chorionic gonadotropin)
Trelstar Depot (triptorelin pamoate)
LHRH Factrel (gonadorelin hydrochloride)
Trelstar LA (triptorelin pamoate)
Lutrepulse (gonadorelin acetate)
Vantas (histrelin acetate)
Lutropin Luveris (lutropin alfa)
Viadur (leuprolide acetate)
Menotropins Menopur (gonadotropins/menotropins)
Zoladex (goserelin acetate)
Repronex (gonadotropins/menotropins)
pulmonAry
Urofollitropins Bravelle (urofollitropin)
Asthma Xolair (omalizumab)^
Fertinex (urofollitropin)
Cystic Fibrosis Pulmozyme (dornase alfa inhaled)
miscellAneous
TOBI (tobramycin inhaled)
Enzyme Replacements Aldurazyme (laronidase)
Pulmonary Hypertension Adcirca (tadalafil)
Aralast (alpha1 proteinase inhibitor)
epoprostenol
Ceredase (alglucerase)
Flolan (epoprostenol)
Cerezyme (imiglucerase)
Letairis (ambrisentan)
Cinryze (human C1 inhibitor)
Remodulin (treprostinil)
Elaprase (idursulfase)
Revatio (sildenifil)
Fabrazyme (agalsidase beta)
Tracleer (bosentan)
Kuvar (sapropterin)
Ventavis (iloprost inhaled)
Myozyme (alglucosidase alpha)
RSV Synagis (palivizumab)^
Naglazyme (galsulfase)
Prolastin (alpha1 proteinase inhibitor) # – Quantity Limits for some plans. OTC – Over the Counter; may not be covered by your
prescription drug benefit. ^ – May require authorization for Managed Plan
Zavesca (miglustat)^
Zemaira (alpha1 proteinase inhibitor)
Iron Overload Exjade (deferasirox)
Macular Degeneration Lucentis (ranibizumab)^
Macugen (pegaptanib)^
Muscle Disorder Botox (botulism toxin)^ Preferred Specialty Vendors
Myobloc (botulism toxin)^ VILLAGE FERTILITY PHARMACY: Toll Free 1-877-334-1610
neuromusculAr
CAREMARK CONNECT
Huntington’s Xenazine (tetrabenazine)^ Toll free 1-866-278-6634 • Web site www.CAREMARK.com
Multiple Sclerosis Avonex (interferon beta 1a)
Resource Information for Physicians/Providers
Betaseron (interferon beta 1b)
Copaxone (glatiramer) BLUE CROSS & BLUE SHIELD OF RHODE ISLAND
Local (401) 459-1000 • Toll free 1-800-637-3718
Rebif (interferon beta 1a) Web site www.BCBSRI.com
Tysabri (natalizumab)^
PATIENT HEALTH EDUCATION PROGRAMS: Local (401) 459-5625
oncology/hemAtology
Hematology NPlate (romiplostim)^ PHYSICIAN AND PROVIDER SERVICE
Promacta (eltrombopag olamine)^ Local (401) 274-4848 • Toll free 1-800-230-9050
Mozobil (plerixafor) ZN REV 7/09