Printer Friendly Drug Formulary - CareFirst BlueCross BlueShield

BLOOD BLOOD MODIFIERS anagrelide NEUPOGEN^(P) pentoxifylline^(M) PROCRIT^(P) BLOOD THINNERS (ANTICOAGULANTS) ARIXTRA COUMADIN^(M) FRAGMIN LOVENOX warfarin^(M) STROKE PREVENTION PLAVIX^(M) ticlopidine^(M) CANCER DRUGS -ORAL (ANTINEOPLASTICS) CANCER DRUGS -ORAL (ANTINEOPLASTICS) AFINITOR^(P)	CANCER DRUGS -ORAL (ANTINEOPLASTICS) CANCER DRUGS -ORAL (ANTINEOPLASTICS) ARIMIDEX^(M) AROMASIN^(M) bicalutamide FEMARA^(M) GLEEVEC^(P) HYCAMTIN^(P) NEXAVAR^(P) REVLIMID^(P) SPRYCEL^(P) SUTENT^(P) TARCEVA^(P) TASIGNA^(P) TEMODAR^(P) THALOMID^(P) THIOGUANINE TYKERB^(P) VOTRIENT^(P) XELODA^(P) ZOLINZA^(P) CENTRAL NERVOUS SYSTEM ALZHEIMER'S DRUGS ARICEPT^(M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
CENTRAL NERVOUS SYSTEM ALZHEIMER'S DRUGS NAMENDA^(M) ANTI-PARKINSON DRUGS amantadine^(M) APOKYN^(M) benztropine^(M) bromocriptine ^(M) levodopa/carbidopa^(M) ropinirole^(M) selegiline^(M) ATTENTION DEFICIT DISORDER (ADD), NARCOLEPSY amphetamine/dextroamphetamine^(M) CONCERTA^(M) dexmethylphenidate^(M) dextroamphetamine^(M) methamphetamine^(M) methylphenidate sr^(M) methylphenidate^(M) SEIZURE MEDICATIONS (ANTICONVULSANTS) carbamazepine extended release^(M) carbamazepine^(M) clonazepam^(M) divalproex ^(M) divalproex sodium^(M)	CENTRAL NERVOUS SYSTEM SEIZURE MEDICATIONS (ANTICONVULSANTS) ethosuximide^(M) gabapentin^(M) lamotrigine^(M) levetiracetam^(M) phenobarbital^(M) phenytoin^(M) primidone^(M) topiramate^(M) valproic acid^(M) zonisamide^(M) SLEEP AIDS flurazepam temazepam zaleplon zolpidem CHEST PAIN & HEART DISEASE CHEST PAIN & HEART DISEASE isosorbide dinitrate^(M) isosorbide mononitrate^(M) nitroglycerin sl^(M) transdermal nitroglycerin^(M) DIABETES & HIGH BLOOD SUGAR ANTIDIABETIC DRUGS acarbose^(M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
DIABETES & HIGH BLOOD SUGAR ANTIDIABETIC DRUGS ACTOPLUS MET^(M) ACTOS^(M) AVANDAMET^(M) AVANDARYL^(M) AVANDIA^(M) BYETTA^(P,Q,M) DUETACT^(M) glimepiride^(M) glipizide extended release^(M) glipizide^(M) glyburide and metformin^(M) glyburide^(M) JANUMET^(M) JANUVIA^(M) LEVEMIR^(M) metformin xr^(M) metformin^(M) nateglinide^(M) NOVO INSULIN^(M) NOVOLOG^(M) PRANDIN^(M) BLOOD SUGAR TEST STRIPS ACCU-CHEK meter test strips^(Q,M) OneTouch meter test strips^(Q,M) DISEASES ARTHRITIS (RHEUMATOID) ENBREL^(P)	DISEASES ARTHRITIS (RHEUMATOID) hydroxychloroquine^(M) HUMIRA^(P) leflunomide^(M) methotrexate^(M) BONE DISEASE alendronate ^(M) calcitonin salmon nasal spray^(M) etidronate^(M) EVISTA^(M) GOUT allopurinol^(M) colchicine/probenecid^(M) colchicine^(M) probenecid^(M) HEPATITIS INTRON A^(M) PEGASYS^(P) ribavirin MULTIPLE SCLEROSIS DRUGS COPAXONE^(P,M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
DISEASES MULTIPLE SCLEROSIS DRUGS REBIF^(P,M) THYROID DISEASE levothyroxine^(M) liothyronine^(M) methimazole^(M) propylthiouracil^(M) ENT (EAR/NOSE/THROAT) ALLERGIES & COLDS (NASAL) ASTELIN flunisolide^(M) fluticasone propionate^(M) ALLERGIES (ORAL) fexofenadine/p-ephed^(M) fexofenadine^(M) COLDS WITH COUGHING guaifenesin/codeine hydrocodone/guaifenesin promethazine/codeine	ENT (EAR/NOSE/THROAT) COLDS/CONGESTION & ALLERGIES phenylephrine/brompheniramine pseudoephedrine/chlorpheniramine EAR DROPS acetic acid hydrocortisone/acetic acid hydrocortisone/neomycin/polymyxin b ofloxacin MISCELLANEOUS lidocaine viscous EYE ANTI-INFLAMMATORY DROPS prednisolone acetate COMBINATION EYE INFECTION DROPS dexamethasone/neomycin/polymyxin dexamethasone/tobramycin neomycin/bacitracin/polymyxin/hc prednisolone/sulfacetamide EYE INFECTION DROPS bacitracin
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
EYE EYE INFECTION DROPS ofloxacin polymyxin b/bacitracin polymyxin b/trimethoprim polymyxin/neomycin/bacitracin oint. polymyxin/neomycin/gramicidin sol. sodium sulfacetamide tobramycin drops trifluridine VIGAMOX GLAUCOMA DRUGS acetazolamide^(M) Alphagan P 0.1%^(M) AZOPT^(M) brimonidine 0.15%^(M) dipivefrin^(M) dorzolamide/timolol^(M) dorzolamide^(M) ISOPTO CARBACHOL^(M) levobunolol^(M) LUMIGAN^(M) methazolamide^(M) pilocarpine^(M) XALATAN^(M) MISCELLANEOUS DRUGS atropine flurbiprofen	EYE MISCELLANEOUS DRUGS ketoralac tromethamine, 0.4 % ketorolac tromethamine 0.5% RESTASIS^(M) HEART RHYTHM DISORDERS HEART RHYTHM DISORDERS acebutolol^(M) amiodarone^(M) digoxin^(M) disopyramide^(M) procainamide^(M) propafenone^(M) propranolol^(M) sotalol^(M) verapamil^(M) HIGH BLOOD PRESSURE & HEART DISEASE ACE INHIBITORS benazepril^(M) captopril^(M) enalapril^(M) fosinopril^(M) lisinopril^(M) moexipril^(M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
HIGH BLOOD PRESSURE & HEART DISEASE ACE INHIBITORS quinapril^(M) ramipril^(M) trandolapril^(M) ALPHA BETA BLOCKERS carvedilol^(M) COREG CR^(M) doxazosin^(M) labetalol^(M) prazosin^(M) ANGIOTENSIN II BLOCKERS AVAPRO^(M) DIOVAN^(M) BETA BLOCKERS acebutolol^(M) atenolol^(M) metoprolol xl^(M) metoprolol^(M) nadolol^(M) propranolol extended rel.^(M) propranolol^(M) CALCIUM CHANNEL BLOCKERS amlodipine^(M)	HIGH BLOOD PRESSURE & HEART DISEASE CALCIUM CHANNEL BLOCKERS diltiazem extended release^(M) diltiazem^(M) felodipine^(M) nifedipine extended release^(M) nifedipine sustained release^(M) verapamil extended release^(M) verapamil^(M) COMBINATION DRUGS amlodipine/benazepril^(M) atenolol/chlorthalidone^(M) AVALIDE^(M) bisoprolol/hctz^(M) captopril/hctz^(M) DIOVAN HCT^(M) enalapril/hctz^(M) lisinopril/hctz^(M) moexipril/hct^(M) SYMPATHOLYTICS clonidine^(M) guanfacine^(M) hydralazine^(M) methyldopa^(M) WATER PILLS OR DIURETICS bumetanide^(M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
HIGH BLOOD PRESSURE & HEART DISEASE WATER PILLS OR DIURETICS chlorthalidone^(M) furosemide^(M) hydrochlorothiazide^(M) indapamide^(M) metolazone^(M) spironolactone^(M) torsemide^(M) triamterene/hctz^(M) HIGH CHOLESTEROL DRUGS (ANTILIPEMICS) HIGH CHOLESTEROL DRUGS (ANTILIPEMICS) cholestyramine^(M) colestipol^(M) gemfibrozil^(M) lovastatin^(M) LIPITOR^(M) NIASPAN^(M) pravastatin^(M) simvastatin^(M) TRICOR^(M) HIV & AIDS MISCELLANEOUS ISENTRESS^(M)	HIV & AIDS MISCELLANEOUS SELZENTRY^(M) COMBINATION DRUGS COMBIVIR^(M) EPZICOM^(M) KALETRA^(M) TRIZIVIR^(M) TRUVADA^(M) NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS INTELENCE^(M) RESCRIPTOR^(M) SUSTIVA^(M) VIRAMUNE^(M) NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS didanosine^(M) EMTRIVA^(M) EPIVIR^(M) FUZEON^(M) HIVID^(M) stavudine^(M) VIDEX Powder^(M) VIREAD^(M) zidovudine capsules^(M) zidovudine tablets and syrup^(M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
HIV & AIDS NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS ZIAGEN^(M) PROTEASE INHIBITORS AGENERASE^(M) APTIVUS^(M) CRIXIVAN^(M) FORTOVASE, INVIRASE^(M) LEXIVA^(M) NORVIR^(M) PREZISTA^(M) REYATAZ^(M) VIRACEPT^(M) HORMONES GROWTH NORDITROPIN^(P) SEROSTIM^(P) HORMONE REPLACEMENT DRUGS esterified estrogens 0.625 mg/methyltestosterone 1.25 mg^(M) esterified estrogens 1.25 mg/methyltestosterone 2.5 mg^(M) FEMHRT^(M) PREMPHASE^(M) PREMPRO^(M)	HORMONES MALE ANDRODERM^(M) ANDROGEL^(M) methyltestosterone MISCELLANEOUS desmopressin acetate tablets^(M) despopressin acetate nasal spray^(M) STEROID REPLACEMENT MEDICATION hydrocortisone IMMUNE SYSTEM ANTI-REJECTION (IMMUNOSUPPRESSANTS) azathioprine^(M) cyclosporine^(M) mercaptopurine^(M) RAPAMUNE^(M) tacrolimus^(M) INFECTIONS BACTERIAL (CEPHALOSPORINS) cefaclor
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
INFECTIONS BACTERIAL (CEPHALOSPORINS) cefadroxil cefdinir cefpodoxime cefprozil cefuroxime cephalexin capsules BACTERIAL (COMBINATION ANTIBIOTICS) erythromycin/sulfisoxazole trimethoprim/sulfamethoxazole BACTERIAL (FLUROQUINOLONES) ciprofloxacin er^(Q) ciprofloxacin LEVAQUIN BACTERIAL (MACROLIDES) azithromycin suspension^(Q) azithromycin tablets^(Q) clarithromycin extended release clarithromycin suspension clarithromycin erythromycin delayed release pellets erythromycin ethylsuccinate erythromycin stearate BACTERIAL (MISCELLANEOUS ANTIBIOTICS) clindamycin	INFECTIONS BACTERIAL (MISCELLANEOUS ANTIBIOTICS) metronidazole BACTERIAL (PENICILLINS) amoxicillin/clavulanate amoxicillin/pot.clavulanate amoxicillin AUGMENTIN XR BACTERIAL (SULFONAMIDES) sulfisoxazole trimethoprim/sulfamethoxazole BACTERIAL (TETRACYCLINES) doxycycline monohydrate doxycycline minocycline tetracycline FUNGAL (ANTIFUNGAL DRUGS) clotrimazole fluconazole itraconazole ketoconazole nystatin
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
INFECTIONS FUNGAL (ANTIFUNGAL DRUGS) terbinafine MISCELLANEOUS ANTI-INFECTIVE DRUGS chloroquine phosphate DAPSONE hydroxychloroquine mefloquine ZYVOX TUBERCULOSIS (ANTITUBERCULOSIS DRUG) ethambutol^(M) isoniazid/rifampin^(M) isoniazid^(M) URINARY TRACT nitrofurantoin (macrocrystals) nitrofurantoin exten. rel. VIRAL (ANTIVIRAL DRUGS) acyclovir amantadine famciclovir VALCYTE VALTREX	LOW BLOOD PRESSURE LOW BLOOD PRESSURE midodrine^(M) MENTAL HEALTH ANTIDEPRESSANTS bupropion xl 150mg^(M) bupropion^(M) citalopram^(M) clomipramine^(M) desipramine^(M) doxepin^(M) EFFEXOR-XR^(M) fluoxetine^(M) imipramine^(M) LEXAPRO^(M) mirtapazine orally disintegrating^(M) mirtazapine^(M) nefazodone^(M) nortriptyline^(M) paroxetine controlled release^(M) paroxetine^(M) protriptyline^(M) sertraline^(M) tranylcypromine^(M) trazodone^(M) venlafaxine^(M) ANTIPSYCHOTIC DRUGS ABILIFY^(M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
MENTAL HEALTH ANTIPSYCHOTIC DRUGS chlorpromazine^(M) fluphenazine^(M) haloperidol^(M) perphenazine^(M) risperidone^(M) SEROQUEL^(M) thioridazine^(M) thiothixene^(M) trifluoperazine^(M) ANXIETY alprazolam buspirone diazepam lorazepam MANIC-DEPRESSION OR BIPOLAR DRUGS lithium carbonate ext. rel.^(M) valproic acid^(M) MUSCLE RELAXERS MUSCLE RELAXERS carisoprodol cyclobenzaprine	MUSCLE RELAXERS MUSCLE RELAXERS diazepam methocarbamol tizanidine OB-GYN BIRTH CONTROL PILLS (MONOPHASIC CONTRACEPTIVES) 0.03mg ethinyl estradiol/ 0.15mg levonorgestrel^(Q,M) 30 mcg ethinyl estradiol/0.15 mg levonorgestrel^(M) drospirenone/ethinylestradiol^(M) ethinyl estradiol/desogestrel^(M) ethinyl estradiol/levonorgestrel^(M) ethinyl estradiol/norethindrone^(M) ethinyl estradiol/norgestimate^(M) ethinylestradiol 30 mcg/desogestrel 0.15 mg^(M) low-ogestrel^(M) mestranol/norethindrone^(M) necon^(M) ogestrel^(M) zovia^(M) BIRTH CONTROL PILLS (PROGESTIN ONLY) medroxyprogesterone injection^(Q) norethindrone 0.35 mg^(M) BIRTH CONTROL PILLS (TRIPHASIC CONTRACEPTIVES) desogestrel/ethinylestradiol^(M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
OB-GYN BIRTH CONTROL PILLS (TRIPHASIC CONTRACEPTIVES) desogestril/ethinyl estradiol^(M) ethinyl estradiol+norethindrone^(M) ethinyl estradiol/levonorgestrel^(M) ethinyl estradiol/norethindrone acetate^(M) ethinyl estradiol/norethindrone^(M) norgestinate-ethinyl estradiol^(M) ORTHO TRI-CYCLEN LO^(M) BREAST CANCER (ANTI-ESTROGENS) FARESTON^(M) tamoxifen^(M) FEMALE HORMONES (ESTROGENS) estradiol patch^(M) estradiol tablets^(M) estradiol^(M) estropipate^(M) ESTRACE VAGINAL CREAM^(M) PREMARIN VAGINAL CREAM^(M) PREMARIN^(M) FEMALE HORMONES (PROGESTINS) medroxyprogesterone acetate^(M) PROMETRIUM^(M) FEMALE HORMONES (REPLACEMENT COMBINATIONS) esterified estrogens 0.625 mg/methyltestosterone 1.25 mg^(M)	OB-GYN FEMALE HORMONES (REPLACEMENT COMBINATIONS) esterified estrogens 1.25 mg/methyltestosterone 2.5 mg^(M) FEMHRT^(M) PREMPHASE^(M) PREMPRO^(M) FERTILITY BRAVELLE^(P) chorionic gonadotropin^(P) clomiphene CETROTIDE^(P) ganirelix acetate^(P) GONAL-F^(P) MENOPUR^(P) OVIDREL^(P) progesterone in oil^(P) REPRONEX^(P) PRENATAL VITAMINS prenatal vitamins^(M) prenatal vitamins UTERINE CONTRACTIONS & BLEEDING terbutaline YEAST OR BACTERIAL INFECTIONS clindamycin
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
OB-GYN YEAST OR BACTERIAL INFECTIONS metronidazole vaginal gel nystatin vaginal terconazole triple sulfa PAIN MANAGEMENT (ANALGESICS) PAIN MANAGEMENT (ANALGESICS) acetaminophen/codeine apap/dichloral-phenazone/isometheptene^(M) butalbital/apap butalbital/caffeine/apap butalbital/caffeine/aspirin butorphanol^(Q) codeine diclofenac sodium xr^(M) diclofenac sodium^(M) diflunisal^(M) dihydroergotamine mesylate^(M) etodolac xl^(M) etodolac^(M) fentanyl lozenge^(P) fentanyl transdermal hydrocodone/apap hydromorphone ibuprofen/hydrocodone^(M) ibuprofen^(M) indomethacin^(M) ketorolac^(Q,M)	PAIN MANAGEMENT (ANALGESICS) PAIN MANAGEMENT (ANALGESICS) meloxicam^(M) meperidine morphine sulfate morphine, sustained release nabumetone^(M) naproxen^(M) oxaprozin^(M) oxycodone, sustained release^(Q) oxycodone/apap oxycodone/aspirin piroxicam^(M) propoxyphene/apap salsalate^(M) sulindac^(M) sumatriptan^(Q) tramadol^(M) RESPIRATORY PROBLEMS ASTHMA & COPD (MISCELLANEOUS INHALERS) ADVAIR^(M) cromolyn sodium^(M) COMBIVENT^(M) ipratropium bromide^(M) SPIRIVA^(M) ASTHMA (BRONCHODILATORS) PROAIR HFA^(M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
RESPIRATORY PROBLEMS ASTHMA (BRONCHODILATORS) SEREVENT^(M) VENTOLIN HFA^(M) ASTHMA (METHYLXANTHINES) theophylline^(M) ASTHMA (ORAL BRONCHODILATORS) metaproterenol^(M) ASTHMA (ORAL STEROIDS) dexamethasone prednisone ASTHMA (STEROID INHALERS) AZMACORT^(M) FLOVENT HFA ^(M) PULMICORT^(M) MISCELLANEOUS DRUGS EPIPEN; EPIPEN JR.^(Q) SINGULAIR^(M) SKIN ACNE benzoyl peroxide/erythromycin	SKIN ACNE clindamycin phos/benzyl peroxide clindamycin erythromycin isotretinoin minocycline tretinoin cream and gel^(P) ANTI-INFLAMMATORY OR CORTICOSTEROIDS aug. betamethasone diprop. oint. betamethasone diprop. clobetasol propionate desonide fluocinolone acetonide oint, cream, sol. fluocinonide halobetasol propionate hydrocortisone valerate mometasone furoate triamcinolone acetonide cream, oint. DISEASES-ECZEMA & PSORIASIS methotrexate (oral) PROTOPIC TAZORAC^(P) GENITAL WARTS ALDARA
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
SKIN LICE AND SCABIES TREATMENT permethrin cream MISCELLANEOUS ciclopirox fluorouracil TOPICAL ANTIBIOTICS clindamycin topical erythromycin metronidazole topical gel mupirocin ointment silver sulfadiazine TOPICAL ANTIFUNGAL DRUGS clotrimazole/betamethasone econazole ketoconazole cream nystatin ZOVIRAX CREAM AND OINTMENT STEROIDS (ORAL ANTI-INFLAMMATORY DRUGS) STEROIDS (ORAL ANTI-INFLAMMATORY DRUGS) dexamethasone	STEROIDS (ORAL ANTI-INFLAMMATORY DRUGS) STEROIDS (ORAL ANTI-INFLAMMATORY DRUGS) methylprednisolone prednisolone sodium STOMACH & DIGESTIVE DISORDERS ACID & STOMACH ULCERS cimetidine^(M) famotidine 40 mg^(M) KAPIDEX^(M) lansoprazole^(M) misoprostol^(M) nizatidine^(M) omeprazole 10mg & 40mg^(P,M) pantoprazole^(M) PREVPAC ranitidine 300 mg^(M) sucralfate ANTI-DIARRHEAL DRUGS diphenoxylate/atropine ANTI-NAUSEA dronabinol EMEND^(Q) granisetron^(Q)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
STOMACH & DIGESTIVE DISORDERS ANTI-NAUSEA ondansetron prochlorperazine promethazine BOWEL & COLON DISEASE ASACOL^(M) ENTOCORT EC^(M) hydrocortisone/pramoxine^(M) hydrocortisone^(M) mesalamine rectal susp^(M) IRRITABLE BOWEL SYNDROME clidinium/chlordiazepoxide dicyclomine hyoscyamine MALABSORPTION DISEASE pancrelipase^(M) MISCELLANEOUS peg/electrolyte soln. sulfasalazine^(M) ursodiol^(M) SEVERE HEARTBURN & REFLUX metoclopramide^(M)	SUBSTANCE ABUSE ALCOHOL ABUSE disulfiram DRUG ADDICTION naltrexone QUIT SMOKING AIDS bupropion sr SUPPLEMENTS POTASSIUM (EFF. TABLET) potassium chlor. eff. tablet^(M) POTASSIUM (TABLETS) potassium chlor. tablet^(M) VITAMIN D calcitriol capsules^(M) calcitriol suspension^(M) HECTOROL^(M) UROLOGY BLADDER CONTROL (ANTISPASMODICS) DETROL LA^(M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
UROLOGY BLADDER CONTROL (ANTISPASMODICS) DETROL^(M) hyoscyamine^(M) oxybutynin sr^(M) oxybutynin^(M) BLADDER CONTROL (CHOLINERGIC AGENTS) bethanechol chloride^(M) IMPOTENCE (ERECTILE DYSFUNCTION) VIAGRA^(Q) PROSTATE DISEASE (BENIGN PROSTATIC HYPERTROPHY) AVODART^(M) doxazosin^(M) finasteride^(M) FLOMAX^(M) terazosin^(M) URINARY TRACT PAIN (ANESTHETICS) phenazopyridine

KEY:

Preferred Brand-Name Drugs (Tier 2) Generic Drug (Tier 1)

Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

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