Craneisd.com

MOST COMMONLY PRESCRIBED DRUGS
(Preferred Drug List)
EFFECTIVE jaNUaRY 1, 2007
The Blue Cross and Blue Shield of Texas most commonly If you are currently taking a drug that is not shown on this list, prescribed preferred drugs are listed below. This list does not
cal Customer Service at the number located on the back of your include all of the preferred drugs that are included in your
BCBSTX member ID card. They can tel you what your copayment prescription benefit.
wil be. If you are taking one of the brand-name drugs shown in parentheses, tel your pharmacist that you would like the generic The drugs listed below are grouped into broad categories. Each version. Generic drugs are just as safe and effective as brand- category includes two alphabetical lists of drugs.
name drugs, and you may wish to consider using the generic • The first list shows generic drugs in bold, lower-case
version since you wil usual y pay the lowest copayment for them. type, fol owed (in parentheses) by their most common brand-name(s). The brand-name drugs (in parentheses) are This list has been updated for 2007, however, this list may not usual y non-preferred, and are shown for information only.
reflect the preferred drug list that was finalized on your plan’s start date and updated as of your anniversary date. Prescription • The second list shows brand-name drugs in all benefit information is available on the Blue Cross and Blue Shield of Texas web site, www.bcbstx.com.
In most cases, generic drugs – whether included on this list or This list was current at the time of printing and is subject
not – are available at the lowest copayment. The brand-name to change.
drugs (shown in al CAPITAL LETTERS) are available at the middle copayment. Non-preferred brand-name drugs require the highest Drug coverage is dependent on individual plan benefits.
copayment. Some are shown in parentheses, others are not listed.
a N T I - I N F E C T I V E D R U G S
acyclovir (Zovirax)
amoxicillin
amoxicillin/potassium clavulanate –
12 hour dosing (Augmentin)
ampicillin
azithromycin (Zithromax)
D I a B E T E S , H O R M O N E S
a N D R E L aT E D D R U G S *
cefadroxil (Duricef)
calcitonin-salmon nasal – Fortical
cefprozil (Cefzil)
desmopressin (DDVAP)
cefuroxime axetil tablets (Ceftin)
dexamethasone (Decadron)
cephalexin (Keflex)
esterified estrogens/methyltestosterone
ciprofloxacin tablets (Cipro)
clindamycin (Cleocin)
estradiol patches (Climara)
doxycycline hyclate
estradiol tablets (Estrace)
erythromycin delayed-release (Eryc)
estropipate (Ogen)
erythromycin ethylsuccinate
glimepiride (Amaryl)
fluconazole (Diflucan)
glipizide (Glucotrol)
griseofulvin microsize suspension
glipizide extended-release (Glucotrol XL)
glyburide (Diabeta, Micronase)
hydroxychloroquine (Plaquenil)
glyburide/metformin (Glucovance)
itraconazole capsules (Sporanox)
hydrocortisone tablets, 20 mg (Cortef)
ketoconazole (Nizoral)
levothyroxine – includes Levoxyl
metronidazole (Flagyl)
minocycline capsules, tablets
medroxyprogesterone acetate (Provera)
metformin (Glucophage)
nitrofurantoin monohydrate/macrocrystals
metformin extended-release (Glucophage XR)
penicillin v potassium
methylprednisolone (Medrol)
ribavirin capsules (Rebetol)
norethindrone acetate (Aygestin)
ribavirin tablets (Copegus)
oral contraceptives – all generics
tetracycline
trimethoprim/sulfamethoxazole
prednisone
prednisolone sodium phosphate solution
H E a R T a N D C I R C U L aT O R Y
thyroid (Armour Thyroid)
amiodarone (Cordarone)
atenolol (Tenormin)
* Standardly not covered for fully insured business. Some exceptions may apply. Please check your specific plan documents.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of Blue Cross and Blue Shield Association.
atenolol/chlorthalidone (Tenoretic)
benazepril (Lotensin)
benazepril/hydrochlorothiazide
bisoprolol/hydrochlorothiazide (Ziac)
bumetanide (Bumex)
captopril (Capoten)
captopril/hydrochlorothiazide (Capozide)
a L L E R G I E S , a S T H M a ,
chlorthalidone tablets, 25 mg, 50 mg
C O P D D R U G S
cholestyramine (Questran, Questran Light)
albuterol inhaler (Proventil)
clonidine (Catapres)
codeine/guaifenesin solution, syrup, tablets
digoxin (Lanoxin)
cyproheptadine
G E N I T O U R I N a R Y D R U G S
diltiazem extended-release
fexofenadine (Allegra)
clindamycin vaginal cream (Cleocin)
flunisolide nasal spray
finasteride (Proscar)
doxazosin (Cardura)
fluticasone (Flonase)
metrogel vaginal gel (Metrogel Vaginal)
enalapril (Vasotec)
ipratropium bromide nebulization solution
oxybutynin (Ditropan)
enalapril/hydrochlorothiazide (Vaseretic)
promethazine syrup, tablets (Phenergan)
terconazole (Terazol 3, 7)
flecainide (Tambocor)
promethazine suppositories (Phenergan)
furosemide (Lasix)
theophylline extended-release
gemfibrozil (Lopid)
guanfacine (Tenex)
hydrochlorothiazide
indapamide (Lozol)
isosorbide mononitrate extended-release
a L Z H E I M E R’S D I S E a S E ;
E M O T I O N a L , M E N Ta L a N D
labetalol (Trandate)
N E R V O U S C O N D I T I O N S ,
lisinopril (Prinivil, Zestril)
a N D S L E E P
lisinopril/hydrochlorothiazide
alprazolam (Xanax)
amitriptyline
lovastatin (Mevacor)
amphetamine/dextroamphetamine mixed
metoprolol (Lopressor)
salts (Adderall)
nadolol (Corgard)
bupropion (Wellbutrin)
nifedipine extended-release
bupropion extended-release
nitroglycerin sublingual tablets, patches
buspirone (Buspar)
citalopram (Celexa)
pravastatin (Pravachol)
clozapine tablets 25 mg, 100 mg (Clozaril)
prazosin (Minipress)
G a S T R O I N T E S T I N a L
dextroamphetamine (Dexedrine)
propranolol (Inderal)
dextroamphetamine extended-release
quinapril (Accupril)
cimetidine (Tagamet), 200 mg not covered
quinapril/hydrochlorothiazide (Accuretic)
dicyclomine (Bentyl)
diazepam (Valium)
simvastatin (Zocor)
famotidine (Pepcid), 20 mg not covered
doxepin (Sinequan)
sotalol (Betapace, Betapace AF)
hyoscyamine (Levsin)
fluoxetine (Prozac)
spironolactone (Aldactone)
hyoscyamine extended-release
hydroxyzine hcl (Atarax)
spironolactone/hydrochlorothiazide
hydroxyzine pamoate (Vistaril)
lactulose
imipramine hcl (Tofranil)
terazosin (Hytrin)
mesalamine enema (Rowasa)
lithium carbonate capsules
triamterene/hydrochlorothiazide
metoclopramide (Reglan)
misoprostol (Cytotec)
lithium carbonate extended-release
verapamil (Calan)
omeprazole delayed-release (Prilosec),
lorazepam (Ativan)
verapamil extended-release
polyethylene glycol 3350 (Miralax)
methylphenidate (Ritalin)
ranitidine (Zantac), 150 mg not covered
methylphenidate extended-release
sucralfate tablets (Carafate)
mirtazapine (Remeron)
sulfasalazine (Azulfidine)
nortriptyline (Pamelor)
paroxetine hcl (Paxil)
phenobarbital
prochlorperazine suppositories, 25 mg;
tablets (Compazine)
sertraline (Zoloft)
temazepam (Restoril)
trazodone (Desyrel)
* Standardly not covered for fully insured business. Some exceptions may apply. Please check your specific plan documents.
venlafaxine (Effexor)
benztropine
bromocriptine (Parlodel)
carbamazepine (Tegretol)
carbidopa/levodopa (Sinemet)
carbidopa/levodopa extended-release
clonazepam (Klonopin)
E a R , M O U T H , T H R O aT,
a N D S K I N D R U G S *
cyclobenzaprine (Flexeril)
benzocaine/antipyrine ear soln
gabapentin capsules, tablets (Neurontin)
betamethasone dipropionate, augmented,
gabapentin tablets (Gabarone)
cream, gel, ointment (Diprolene)
lamotigine (Lamictal)
betamethasone dipropionate (Diprosone)
methocarbamol (Robaxin)
clindamycin (Cleocin T)
phenytoin sodium extended (Dilantin)
clobetasol (Temovate)
primidone (Mysoline)
desonide (DesOwen)
tizanidine (Zanaflex)
desoximetasone (Topicort)
valproic acid (Depakene)
a R T H R I T I S a N D P a I N
econazole (Spectazole)
R E L I E F D R U G S
zonisamide (Zonegran)
erythromycin gel (Erygel)
acetaminophen/codeine
fluocinonide (Lidex)
halobetasol (Ultravate)
acetaminophen/isometheptene/
hydrocortisone valerate (Westcort)
dichloralphenazone (Midrin)
ketoconazole cream
allopurinol (Zyloprim)
lidocaine viscous
butalbital/acetaminophen/caffeine
metronidazole cream, 0.75% (Metrocream)
mometasone (Elocon)
butalbital/aspirin/caffeine (Fiorinal)
mupirocin ointment (Bactroban)
butalbital/aspirin/caffeine/codeine
S U P P L E M E N T S
neomycin/polymyxin B/hydrocortisone ear
potassium chloride extended-release
diclofenac sodium delayed-release (Voltaren)
prenatal multivitamins with 1 mg folic acid
nystatin cream, ointment, powder
etodolac (Lodine)
nystatin/triamcinolone
fentanyl patches (Duragesic)
B L O O D M O D I F Y I N G
silver sulfadiazine (Silvadene)
hydrocodone/acetaminophen
tretinoin (Retin-A)
cilostazol (Pletal)
triamcinolone acetonide (Kenalog)
ibuprofen, suspension (Motrin), 100 mg/5
folic acid
pentoxifylline extended-release (Trental)
indomethacin capsules (Indocin)
warfarin (Coumadin)
meloxicam (Mobic)
methotrexate
morphine sulfate extended-release
E Y E D R U G S
nabumetone (Relafen)
ciprofloxacin solution (Ciloxan)
naproxen (Naprosyn)
gentamicin ointment, solution
naproxen sodium (Anaprox)
ketoprofen fumarate (Zaditor)
oxycodone (Roxicodone)
polymyxin B/trimethoprim solution (Polytrim)
oxycodone extended-release (Oxycontin)
prednisolone acetate suspension
oxycodone/acetaminophen (Percocet)
piroxicam (Feldene)
sulfacetamide sodium (Bleph-10)
propoxyphene napsylate/acetaminophen
timolol maleate gel-forming solution
timolol maleate solution (Timoptic)
tobramycin solution (Tobrex)
D I a B E T I C S U P P L I E S *
ACCU-CHEK TEST STRIPS
P a R K I N S O N ’ S D I S E a S E ;
N E U R O M U S C U L a R a N D
S E I Z U R E D R U G S
amantadine (Symmetrel)
baclofen
* Standardly not covered for fully insured business. Some exceptions may apply. Please check your specific plan documents.
Prime Therapeutics LLC is the pharmacy benefit manager for Blue Cross and Blue Shield of Texas.
4 6 8 4 9 - 0 9 0 6 P R I M E T H E R A P E U T I C S L LC

Source: http://www.craneisd.com/employee_info/1-1-07%20Preferred%20Drug%20List.pdf