Enhanced Formulary - BCBST
EnhancedFormularyH7917 12 MetFORMMetropolitan Government ofNashville and Davidson County
2012 Medicare EGWPEnhanced Alternative Benefit DesignAll Drugs Listed are on Tier 3 – Non-Preferred BrandBrand NameGeneric AvailableDose/Dosage FormUtilization RequirementsErectile Dysfunction AgentsEdex/CaverjectNo10 mcg injection kitQuantity Limit6 units every 25 days20 mcg injection kit40 mcg injection kitMuseNo125 mcg urethral suppository250 mcg urethral suppository500 mcg urethral suppository1,000 mcg urethral suppositoryViagraNo25 mg tabletQuantity Limit6 tablets every 25 daysCialis 2.5mg and 5mg also subjectto Prior Authorization50 mg tablet100 mg tabletCialisNo2.5 mg tablet5 mg tablet10 mg tablet20 mg tabletLevitraNo2.5 mg tablet5 mg tablet10 mg tablet20 mg tabletBenzodiazepinesXanaxYes - alprazolam0.25 mg tabletQuantity Limit60 tablets or 30 mL oralconcentrate every 25 days0.5 mg tablet1 mg tablet2 mg tablet1 mg/mL oral concentration0.25 mg tablet - rapiddisintegrating0.5 mg tablet - rapid disintegrating1 mg tablet - rapid disintegrating2 mg tablet - rapid disintegratingThis is not a complete list of drugs covered by the Part D plan. For a complete listing, please call Members Servicesat 1-800-818-0962. TTY/TDD users call: 1-888-423-9490. You may call Member Services from 8:00 a.m. to9:00 p.m. Eastern Time, 7 days a week. From February 15 to October 14, you may be required to leave a message. 1Your call will be returned the next business day. You may also log onto www.bcbst-medicare.com.
Brand NameXanax XRGeneric AvailableYes - alprazolam ERDose/Dosage Form0.5 mg tablet - sustained releaseUtilization RequirementsQuantity Limit30 tablets every 25 days1 mg tablet - sustained release2 mg tablet - sustained releaseLibriumYes - chlordiazepoxide5 mg capsuleQuantity Limit60 tablets every 25 daysStep Therapy /PriorAuthorizationMust first try one of the following:alprazolam, lorazepam, oxazepam,clonazepam, temazepam,triazolam, quazepam, or estazolam10 mg capsuleTranxeneYes - clorazepate dipotassium3.75 mg tabletQuantity Limit60 tablets every 25 daysStep Therapy /PriorAuthorizationMust first try one of the following:alprazolam, lorazepam, oxazepam,clonazepam, temazepam,triazolam, quazepam, or estazolam7.5 mg tablet15 mg tabletValiumYes - diazepam2 mg tabletQuantity Limit60 tablets or 500 mL solution or30 mL oral concentrate every 25days),Step Therapy /PriorAuthorizationMust first try one of the following:alprazolam, lorazepam, oxazepam,clonazepam, temazepam,triazolam, quazepam, or estazolam5 mg tablet10 mg tablet5 mg/mL oral concentration5 mg/5 mL solution5 mg/mL injection syringe2None
Brand NameAtivanGeneric AvailableYes - lorazepamDose/Dosage Form0.5 mg tabletUtilization RequirementsQuantity Limit60 tablets or 30 mL oralconcentrate every 25 days1 mg tablet2 mg tablet2 mg/mL oral concentrate2 mg/mL injection vialNone4 mg/mL injection solutionSerexYes - oxazepam15 mg capsule15 mg capsuleQuantity Limit60 tablets every 25 days30 mg capsuleKlonopinYes - clonazepam0.125 mg tabletQuantity Limit60 tablets every 25 days0.25 mg tablet0.5 mg tablet1 mg tablet2 mg tabletDiastatYes - diazepam2.5 mg rectal kitNone5 mg rectal kit10 mg rectal kit15 mg rectal kit20 mg rectal kitDalmaneYes- flurazepam15 mg capsuleQuantity Limit15 tablets every 25 daysStep Therapy /Prior AuthorizationMust first try one of the following:alprazolam, lorazepam,oxazepam, clonazepam,temazepam, triazolam, quazepam,or estazolam3
Brand NameRestorilGeneric AvailableYes - temazepamDose/Dosage Form7.5 mg capsuleUtilization RequirementsQuantity Limit15 capsules every 25 days15 mg capsule22.5 mg capsule30 mg capsuleHalcionYes - triazolam0.125 mg tabletQuantity Limit10 tablets every 25 days0.25mg tabletBarbituratesButisolYes - butabarbital sodium15 mgNone30 mg50 mg100 mg30 mg/5 mL elixirMebaralYes - mephobarbital32 mgNone50 mgLuminalYes - phenobarbital15 mg30 mg60 mg100 mg15 mg/5mL elixir20 mg/5mL elixir30 mg/mL injection60 mg/mL injection65 mg/mL injection130 mg/mL injection4None
Brand NameCephadynGeneric AvailableYes - butalbital/acetaminophenDose/Dosage Form50 mg/325 mg tabletUtilization RequirementsQuantity Limit240 tablets every 365 days50 mg/650 mg tablet50 mg/325 mg tablet50 mg/650 mg tabletFioricetYes -butalbital/acetaminophen/caffeine50 mg/300 mg/40 mg tabletQuantity Limit240 tablets every 365 days50 mg/325 mg/40 mg tablet50 mg/500 mg/40 mg tablet50 mg/750 mg/40 mg tablet50 mg/325 mg/15 mg tabletYes - butalbital/aspirin/caffeine50 mg/325 mg/40 mg tabletQuantity Limit240 tablets every 365 daysTessalon /phenylephrine/ /promethazinesyrupC-Phen DMdextromethorphan/phenylephrine/ chlorpheniraminesyrupCarbofed yrupGanidin NRguaifenesinsolutionCheratussin ACguaifenesin/codeine phosphatesyrupGuiatuss done/homatropinesyrupTussionex iorinalCough and Cold Agents5
Brand NameGeneric AvailableDose/Dosage FormBpm Pseudo 6-45 Mg SRpseudoephedrine/brompheniraminetabletCheratussin azine xallcarbetapentane/guaifenesinliquidPoly-Hist nCPM-PSE Jr (chlorpheniramine/phenylephrinesustained release tabletM-END eliquidM-END on RequirementsNone
Prescription Vitamin/Mineral ProductsDIALYVITE 3,000 TABLET - Folic acid, Vitamin B complex with C and zincAscorbic Acid (Vitamin C) 100mg, Biotin 300mcg, Calcium Pantothenate (Vitamin B5) 10mg, D-Alpha Tocopheryl Succinate (Vitamin E) 30IU,Folic Acid (Vitamin B9) 3mg, Mecobalamin 1mg, Niacinamide 20mg, Pyridoxine (Vitamin B6) 10mg, Riboflavin (Vitamin B2) 1.7mg, SeleniumAnimo Acid Chelate 70mcg, Thiamine Mononitrate (Vitamin B1) 1.5mg, Zinc Citrate 15mgREOCYTE PLUS CAPSULE -Multivitamin/MineralsCalcium Pantothenate (Vitamin B5) 10mg, Cupric Sulfate 0.8mg, Cyanocobalamin (Vitamin B12) 15mcg, Ferrous Fumarate 324mg, Folic Acid(Vitamin B9) 1000mcg, Magnesium Sulfate 6.9mg, Manganese Sulfate 1.3mg, Niacinamide 30mg, Pyridoxine (Vitamin B6) 5mg, Riboflavin(Vitamin B2) 6mg, Sodium Ascorbate 200mg, Thiamine Mononitrate (Vitamin B1) 10mg, Zinc Sulfate 18.FOLTRIN CAPSULE - Iron with Vitamin B12, C, folic acid, and intrinsic factorAscorbic Acid (Vitamin C) 75mg, Cyanocobalamin (Vitamin B12) 15mcg, Folic Acid Vitamin B9) 0.5mg, Iron 110mg [Ferrous Fumarate ], LiverStomach Concentrate 240mgRENAL CAPS SOFTGEL - Folic acid, Vitamin B complex with CAscorbic Acid (Vitamin C) 100mg, Biotin 150mcg, Cyanocobalamin (Vitamin B12) 6mcg, Folic Acid (Vitamin B9) 1mg, Niacin (Vitamin B3) 20mg,Pantothenic Acid (Vitamin B5) 5mg, Pyridoxine (Vitamin B6) 10mg, Riboflavin (Vitamin B2) 1.7mg, Thiamine (Vitamin B1) 1.5mgREPLIVA 21-7 TABLET - Folic acid, multiple Vitamins with ironAscorbic Acid (Vitamin C) 140mg, Calcium Ascorbate with ascorbic acid metabolites (Vitamin C) 60mg, Cyanocobalamin (Vitamin B12) 10mcg,Ferrous Asparto Glycinate 70mg, Ferrous Fumarate 81mg, Folic Acid (Vitamin B9) 1mg, Succinic acid 150mgCHROMAGEN CAPLET Vitamin B complex with C and iron Ascorbic Acid (Vitamin C) 150mg [Calcium Ascorbate ], Cyanocobalamin (VitaminB12) 10mcg, Iron 70mg [Ferrous Asparto Glycinate ], Liver Stomach Concentrate 50mg, Succinic acid 75mg, Threonic acid 2mg [CalciumThreonate ]FERREX 150 FORTE PLUS CAPSULE - Folic acid, Vitamin B complex with Vitamin C and ironAscorbic Acid (Vitamin C) 60mg [Calcium Ascorbate ], Cyanocobalamin (Vitamin B12) 25mcg, Ferrous Asparto Glycinate 50mg, Folic Acid(Vitamin B9) 1mg, Polysaccharide-Iron Complex 100mg, Succinic acid 50mg, Threonic acid 0.8mg [Calcium Threonate]CHROMAGEN FORTE CAPLET - Folic acid, Vitamin B complex with C and ironAscorbic Acid (Vitamin C) 60mg [Calcium Ascorbate ], Cyanocobalamin (Vitamin B12) 10mcg, Ferrous Asparto Glycinate 50mg, FerrousFumarate 101mg, Folic Acid (Vitamin B9) 1mg, Succinic acid 50mg, Threonic acid 0.8mg [Calcium Threonate]FERREX 150 FORTE CAPSULE - Folic acid, Vitamin B complex and ironCyanocobalamin (Vitamin B12) 25mcg, Folic Acid (Vitamin B9) 1mg, Iron 150mg, Polysaccharide-Iron Complex 150mgHEMATINIC-VITAMIN-MINERAL TAB - Ferrous fumarate and folic acid Vitamin B complexCalcium Pantothenate (Vitamin B5), Cupric Oxide, Cyanocobalamin (Vitamin B12), Ferrous Fumarate, Folic Acid (VitaminB9), Magnesium, Manganese, Niacinamide, Pyridoxine (Vitamin B6), Riboflavin (Vitamin B2), Sodium Ascorbate, ThiamineMononitrate (Vitamin B1), Zinc Oxide Oral tabletMETANX TABLET - Vitamin B complexL-methylfolate calcium 3mg, Mecobalamin 2mg, Pyridoxal-5-Phosphate (Vitamin B6) 35mgRE DUALVIT PLUS CAPSULE - Minerals, ferrous fumarate , folic acid and Polysaccharide iron complexCalcium Pantothenate (Vitamin B5) 10mg, Cupric Sulfate 0.8mg, Cyanocobalamin (Vitamin B12) 15mcg, Ferrous Fumarate 162mg, Folic Acid(Vitamin B9) 1000mcg, Manganese Sulfate 1.3mg, Niacinamide 30mg, Polysaccharide-Iron Complex 115.2mg, Pyridoxine (Vitamin B6) 5mg,Riboflavin (Vitamin B2) 6mg, Sodium Ascorbate 200mg, Thiamine Mononitrate (Vitamin B1) 10mg, Zinc Sulfate 18.2mg7
CEREFOLIN TABLET - Folic acid & Vitamin B complexCyanocobalamin (Vitamin B12) 1mg, L-methylfolate 5.635mg, Pyridoxine (Vitamin B6) 50mg, Riboflavin (Vitamin B2) 5mgCEREFOLIN NAC CAPLETAcetylcysteine 600mg, L-methylfolate calcium 6mg, Mecobalamin 2mgVITAMIN C ascorbic acid 500 mg tabletCYANOCOBALAMIN INJECTION cyanocobalamin 500 mcg/1mLNASCOBAL cyanocobalamin nasal spray 500 mcg/0.1 mLFOLTX TABLET cyanocobalamin/folic acid/pyridoxineVITAMIN D ergocalciferol 50,000 units softgelFERROUS SULFATE ferrous sulfate 325 mg tabletFOLIC ACID folic acid 1 mg tabletV-C FORTE CAPSULE - folic acid/multiple vitamins/mineralsAscorbic Acid (Vitamin C) 150mg, Calcium Pantothenate (Vitamin B5) 10mg, Cyanocobalamin (Vitamin B12) 10mcg, Folic Acid (Vitamin B9)1mg, Magnesium Sulfate 70mg, Manganese 4mg, Niacinamide 25mg, Pyridoxine (Vitamin B6) 2mg, Riboflavin (Vitamin B2) 5mg, ThiamineMononitrate (Vitamin B1) 10mg, Vitamin A 8000IU, Vitamin E 50IU, Zinc Sulfate 80mgPOLY-IRON iron polysaccharides complex 150 mg capsuleDEPLIN TABLET l-methylfolate calcium 7.5 mg and 15 mgMEPHYTON TABLET phytonadione 5 mg8
BlueCross BlueShield of TennesseeP.O. Box 180205 Chattanooga, TN 37402bcbst-medicare.comA health plan with a Medicare contract.BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield AssociationThis document has been classified as public information
CEREFOLIN TABLET - Folic acid & Vitamin B complex Cyanocobalamin (Vitamin B12) 1mg, L-methylfolate 5.635mg, Pyridoxine (Vitamin B6) 50mg, Riboflavin (Vitamin B2) 5mg CEREFOLIN NAC CAPLET Acetylcysteine 600mg, L-methylfolate calcium 6mg, Mecobalamin 2mg VITAMIN C ascorbic acid 500 mg t
MDwise Formulary Introduction – Hoosier Healthwise (HHW) HHW members must use MDwise network pharmacies to access their prescription drug benefit. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition Drugs in this formulary are grouped into categories depending on the type of medical
Articulate with concept of Drug Formulary Understand the importance of drug formulary Describe how to read d rug formulary Understand the purpose of maintaining drug formulary Describe the concept of Current Index of Medical Specialties (CIMS) Know i mportance and u se of CIMS
Blue Cross Blue Shield of North Dakota Drug Formulary . January 2021 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.
You must generally use network pharmacies to use your prescription drug beneft. Benefts, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year. WHAT IS THE MEDICAREBLUE RX FORMULARY? A formulary is a list of covered drugs selected by MedicareBlue Rx in consultation with a
The Formulary Tiers tab of the RX Drug Template (screen shot above) tells us a lot about the Formulary IDs. For example, we can see that Formulary ID WAF002 uses Drug List 1 (purple circle), covered drugs are separated into 7 tiers (blue circle), each tier
Nov 01, 2019 · Anthem Blue MedicareRx Standard (PDP)’s Formulary?” Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and pr
2016, and from time to time during the year. Page 1 of 98 What is the Aetna Medicare Comprehensive Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of . Aetna Formulary The compreh
Hoosier Healthwise members must use MDwise network pharmacies to access their prescription drug benefit. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition Drugs in this formulary are grouped into categories depending on
