B Lu E Cro Ss O F Id Ah O S Standard Three-Tier .
Blue Cross of Idaho’sStandard Three-Tier PrescriptionDrug FormularyThis document is a searchable PDF. On your keyboard press Ctrl F (Command F for Mac) and asearch field will open. Type in the name of the drug you are looking for in the search field, pressenter and it will locate the name of the drug in the document. 2021 Blue Cross of Idaho is an Independent Licensee of the Blue Cross and Blue Shield Association
Things to know about Blue Cross of Idaho’sStandard Three-Tier Prescription Drug FormularyThe Blue Cross of Idaho formulary is a list of drugs approved by Blue Cross of Idaho’s Pharmacy andTherapeutics Committee for coverage under your pharmacy benefit. The formulary includes brand name as wellas generic drugs that have undergone rigorous testing and are approved by the Food and Drug Administration(FDA). Not all drugs approved by the FDA are covered under the Blue Cross of Idaho formulary.Please Note:Your specific prescription benefit plan may not cover certain products or categories, regardless of their appearancein this document. Your copayment amounts may vary based on the structure of your prescription benefits. Productsrecently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market.The Multi-Tier FormularyIn most cases you will be responsible for a portion of the cost of each prescription you have filled, and dependingon the drug prescribed, your cost can vary. The Blue Cross of Idaho formulary has three tiers, with the first tiercosting you the least and the third tier costing you the most. Asking your doctor to prescribe drugs listed in thefirst or second tier of the formulary can save you money.TierDescriptionGeneric Drugs are equivalent to brand-namedrugs in dosage, safety, strength, method of administration,performance characteristics and intended use and Blue Cross ofIdaho has rated as preferred due to their quality and costeffectiveness.2Preferred Brand-Name Drugs are drugs that Blue Cross ofIdaho has rated as preferred due to their quality and costeffectiveness.Preferred Specialty Drugs aremedications used to treat complex conditions and Blue Cross ofIdaho has rated as preferred due to their quality and costeffectiveness3Non-Preferred Brand-Name Drugs are clinically effectivemedications, but come with an excessive cost compared toother alternatives within the same drug class.Non-Preferred Specialty Drugs are medications used treatcomplex conditions, but come with an excessive compared to otheralternatives within the same drug class.Affordable Care Act Drugs are drugs prescribed for coveredpreventive services that may be available at no cost to membersunder the regulations of the Affordable Care Act. Some plansgrandfathered under the Affordable Care Act may not be eligiblefor the ACA preventive drugs at no cost.1ACAThis formulary is not an all-inclusive listing, and is subject to change as new products andinformation become available.If you have questions about any of your medications, please discuss them with your doctor or pharmacist. Youcan also refer to your group’s contract provisions for more information about the terms and conditions of yourprescription drug benefit.
If you cannot find a drug you are using on this formulary, call the Blue Cross of Idaho Rx number on the back ofyour member ID card or log onto members.bcidaho.com using your unique login and password.Reading the FormularyOn the following pages, you’ll find a list of prescription drugs and columns that list the tier they each belong toand any specific requirements or limitations.Column NameDrugReferenceTierNotesWhat you will find in each column:Name of covered prescription drugsBrand name of the covered generic drug listed in the Drug column.*Please see information below regarding Mandatory Generic SubstitutionThe tier assignment for the prescription drug listed in the Drug columnRequirements and limitations, as well as indicating if drugs are part of thePreventive Drug List for HSA Plans. See Abbreviation Dictionary on the next pagefor definitions and more information about the abbreviations.Mandatory Generic SubstitutionSome Blue Cross of Idaho prescription drug plans include a mandatory generic substitution requirement. When adrug has both brand and generic forms available, the generic drug is listed under the Drug column as thecovered option with the brand or trademark name listed under the Reference column. When you or yourphysician choose the brand name drug, in addition to any applicable cost share(deductible/coinsurance/copayments) for the brand name medication, you will pay the cost difference betweenthe contracted cost of the generic drug and brand name drug. These cost difference amounts do not apply toyour annual out of pocket maximum. Reference Specialty Drugs, designated by an SP in the Notes column, will apply a Tier 2 and 3 cost shareprior to the cost difference calculationNewly Approved Prescription DrugsAny newly FDA approved prescription drug, biological agent, or other agent is excluded from coverage by BlueCross of Idaho until it has been reviewed and approved by Blue Cross of Idaho’s Pharmacy and TherapeuticsCommittee. The Blue Cross of Idaho Pharmacy and Therapeutics Committee meets quarterly to review newlyapproved drugs and older medications for coverage recommendations. The committee is comprised of practicingboard-certified physicians and licensed pharmacists from across the state of Idaho.
Abbreviation DictionaryPA - Prior authorizationMedications that list PA need prior authorization from Blue Cross of Idaho before we will cover thedrug. Your provider must provide documentation showing that the prescription is medically necessary.If prior authorization is not obtained, you may be held responsible for the entire cost of the drug.Please refer to your policy (also called a member contract) for more information about priorauthorization. You can find a copy of your policy and detailed information on the prior authorizationprocess online by logging into members.bcidaho.com.PREV - Preventive Drugs for HSA PlansSome preventive drugs may be available at no cost to members of High Deductible Health Plans,also known as HSA plans. Preventive medications are prescribed for the prevention of conditions orillnesses when individuals may be at high risk.QL - Quantity LimitsSome formulary drugs can only be filled in limited quantities. These prescriptions have been found tobe less effective or even dangerous when taken at higher than normal doses. The limits on QL drugs arein line with manufacturer’s recommendations regarding safety and effectiveness.SP - Specialty Drug ProgramSpecialty medications are generally prescribed for treatment of complex, on-going medical conditions.These medications are generally high cost, and have specific handling requirements. All specialty drugs arelimited to a 30 day supply per fill.ST - Step TherapyYou may need to use one or more alternative medications before Blue Cross of Idaho can authorize benefitsfor the use of another medication. Blue Cross of Idaho wants to ensure providers are trying equally or moreeffective, low-cost options before recommending effective, but higher cost treatments.AL - Age LimitationSome drugs may be only be safe or recommended for certain age groups. Blue Cross of Idaho places agelimitations to ensure drugs are not prescribed to individuals who are not of the recommended age.
orexiants**Adhd Agent - Selective Alpha Adrenergic Agonists***Tierclonidine hcl erKapvay1guanfacine hcl erIntuniv1Notes*Adhd Agent - Selective Norepinephrine Reuptake Inhibitor***atomoxetine hclStratteraQELBREE13ST; QL*Amphetamine Mixtures***amphetamine-dextroamphet erAdderall ines***ADZENYS XR-ODT3dextroamphetamine sulfate erDexedrine1dextroamphetamine sulfate oralsolutionProCentra1dextroamphetamine sulfate oral tablet10 mg, 5 mgZenzedi1DYANAVEL XR3methamphetamine hclDesoxynQL1VYVANSE2ZENZEDI ORAL TABLET 15 MG, 20MG, 30 MG1ZENZEDI ORAL TABLET 2.5 MG, 7.5MG1*Dopamine And Norepinephrine Reuptake Inhibitors (Dnris)***SUNOSI3PAStandard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/20211
DrugReference*Histamine H3-Receptor Antagonist/Inverse Agonists***WAKIXTierNotes3PA; SP1QL*Stimulants - ate hclFocalin1dexmethylphenidate hcl erFocalin XR1METADATE ER ORAL TABLETEXTENDED RELEASE 20 MG1methylphenidate hcl er (cd)1methylphenidate hcl er (la)1methylphenidate hcl er oral tabletextended release 10 mg, 20 mg1methylphenidate hcl er oral tabletextended release 18 mg, 27 mg, 36 mg,54 mgConcerta1methylphenidate hcl er oral tabletextended release 24 hour1methylphenidate hcl oral1modafinilProvigil1QLQUILLICHEW ER3QLQUILLIVANT XR ORAL SUSPENSIONRECONSTITUTED ER2*Alternative Medicines**Alternative Medicine - Eu***ISCAR MALI SUBCUTANEOUSINJECTABLE 5 3SPneomycin sulfate in sulfate oralHumatin1Standard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/20212
DrugReferenceTierNotes2SP; QL1SPRINVOQ2PA; SPXELJANZ2PA; SPXELJANZ XR2PA; SPTOBI PODHALERtobramycin inhalation nebulizationsolution 300 mg/5mlKitabis Pak*Analgesics - Anti-Inflammatory**Antirheumatic - Janus Kinase (Jak) Inhibitors****Antirheumatic Antimetabolites***RHEUMATREX ORAL TABLET 2.5MG3*Anti-Tnf-Alpha - Monoclonal Antibodies***HUMIRA PEDIATRIC CROHNSSTART SUBCUTANEOUS PREFILLEDSYRINGE KIT 40 MG/0.8ML, 80MG/0.8ML, 80 MG/0.8ML &40MG/0.4ML2PA; SPHUMIRA PEN SUBCUTANEOUS PENINJECTOR KIT 40 MG/0.4ML, 40MG/0.8ML2PA; SPHUMIRA PEN-CD/UC/HS STARTER2PA; SPHUMIRA PEN-PS/UV/ADOL HSSTART SUBCUTANEOUS PENINJECTOR KIT 40 MG/0.8ML2PA; SPHUMIRA SUBCUTANEOUSPREFILLED SYRINGE KIT 10MG/0.1ML, 20 MG/0.2ML, 40MG/0.4ML, 40 MG/0.8ML2PA; SP1QL*Cyclooxygenase 2 (Cox-2) Inhibitors***celecoxib oralCeleBREX*Gold Compounds***RIDAURA2*Interleukin-1 Blockers***ARCALYST3PA; SP3PA; SP*Interleukin-1Beta Blockers***ILARIS SUBCUTANEOUS SOLUTIONStandard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/20213
DrugReference*Interleukin-6 Receptor Inhibitors***KEVZARATierNotes2PA; SP*Nonsteroidal Anti-Inflammatory Agent Combinations***diclofenac-misoprostol oral tabletdelayed releaseArthrotec1*Nonsteroidal Anti-Inflammatory Agents (Nsaids)***diclofenac potassium oral tablet 50 mgCataflam1diclofenac sodium er1diclofenac sodium oral1EC-NAPROSYN ORAL TABLETDELAYED RELEASE 375 MG1ec-naproxenEC-Naprosyn1etodolac er1etodolac oral1flurbiprofen oral1ibuprofen oral tablet 400 mg, 600 mg,800 mgIBU1indomethacin er1indomethacin oral capsule 25 mg, 50 mg1ketoprofen er1ketoprofen oral capsule 50 mg, 75 mg1ketorolac tromethamine oral1meclofenamate sodium oral1mefenamic acid oral1meloxicam oral suspension1meloxicam oral tabletMobic1nabumetone oralRelafen1naproxen drEC-Naprosyn1naproxen oral tablet1naproxen sodium oral tablet 275 mg1naproxen sodium oral tablet 550 mgAnaprox DS1oxaprozinDaypro1piroxicam oralFeldene1sulindac oral1tolmetin sodium1Standard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/20214QL
DrugReference*Phosphodiesterase 4 (Pde4) Inhibitors***TierNotesOTEZLA ORAL TABLET2PA; SPOTEZLA ORAL TABLET THERAPYPACK2PA; SP1QLENBREL MINI2PA; SPENBREL SUBCUTANEOUSSOLUTION 25 MG/0.5ML2PA; SPENBREL SUBCUTANEOUSSOLUTION PREFILLED SYRINGE2PA; SPENBREL SUBCUTANEOUSSOLUTION RECONSTITUTED2PA; SPENBREL SURECLICKSUBCUTANEOUS SOLUTION AUTOINJECTOR2PA; SP*Pyrimidine Synthesis Inhibitors***leflunomide oralArava*Soluble Tumor Necrosis Factor Receptor Agents****Analgesics - Nonnarcotic**Analgesic Combinations***duraxin1LEVACET3*Salicylate Combinations***choline-mag trisalicylate1*Salicylates***adult aspirin ec low strengthAspir-LowACAAL; QLaspirin 81 oral tablet delayed releaseAspir-LowACAAL; QLaspirin adult low doseAspir-LowACAAL; QLaspirin adult low strength oral tabletchewableBayer Low DoseACAAL; QLaspirin childrensBayer Low DoseACAAL; QLaspirin low dose oral tablet chewableBayer Low DoseACAAL; QLaspirin oral tablet delayed release 81mgAspir-LowACAAL; QLASPIR-LOWACAAL; QLBAYER ASPIRIN EC LOW DOSEACAAL; QLStandard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/20215
DrugReferenceBAYER LOW DOSETierNotesACAAL; QLchildrens aspirinBayer Low DoseACAAL; QLchildrens aspirin low strengthBayer Low DoseACAAL; QLdiflunisal oral1ECOTRIN LOW STRENGTHACAAL; QLeq childrens aspirinBayer Low DoseACAAL; QLgnp adult aspirin low strength oraltablet chewableBayer Low DoseACAAL; QLgnp aspirin oral tablet delayed release81 mgAspir-LowACAAL; QLgoodsense aspirin oral tablet chewableBayer Low DoseACAAL; QLkls aspirin low doseAspir-LowACAAL; QLkp aspirinAspir-LowACAAL; QLACAAL; QLMINIPRIN LOW DOSEpx aspirin oral tablet chewableBayer Low DoseACAAL; QLpx enteric aspirin oral tablet delayedrelease 81 mgAspir-LowACAAL; QLqc childrens aspirinBayer Low DoseACAAL; QLra aspirin adult low strength oral tabletBayer Low DosechewableACAAL; QLra aspirin ec adult low stAspir-LowACAAL; QLra aspirin ec oral tablet delayed releaseAspir-Low81 mgACAAL; QLra childrens aspirinBayer Low DoseACAAL; QLsb childrens aspirinBayer Low DoseACAAL; QLST JOSEPH LOW DOSE ORALTABLET CHEWABLEACAAL; QLtgt aspirin low dose oral tablet delayedAspir-LowreleaseACAAL; QLtgt aspirin oral tablet chewableBayer Low DoseACAAL; QLtgt aspirin oral tablet delayed releaseAspir-LowACAAL; QLtgt childrens aspirinBayer Low DoseACAAL; QLacetaminophen-codeine1AL; QLacetaminophen-codeine #21AL; QL*Analgesics - Opioid**Codeine Combinations***Standard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/20216
DrugReferenceTierNotesacetaminophen-codeine #31AL; QLacetaminophen-codeine #41AL; QLCAPITAL/CODEINE3*Dihydrocodeine odone Combinations***hydrocodone-acetaminophen oralsolution 10-325 mg/15ml3QLhydrocodone-acetaminophen oralsolution 7.5-325 mg/15ml1QLhydrocodone-acetaminophen oral tablet10-300 mg, 10-325 mg, 5-325 mg, 7.5300 mg, 7.5-325 mg1QLhydrocodone-acetaminophen oral tabletXodol5-300 mg1QLhydrocodone-ibuprofen oral tablet 10200 mg, 5-200 mg, 7.5-200 mg1QLIBUDONE1QLLORCET1QLLORCET HD1QLLORCET PLUS ORAL TABLET 7.5-325MG1QLLORTAB ORAL ELIXIR 10-300MG/15ML3QLLORTAB ORAL TABLET 10-325 MG,5-325 MG, 7.5-325 MG1QLREPREXAIN ORAL TABLET 10-200MG1QLVICODIN ES ORAL TABLET 7.5-300MG1QLVICODIN HP ORAL TABLET 10-300MG1QLVICODIN ORAL TABLET 5-300 MG1QLXYLON1QLABSTRAL3PA; ST; QLARYMO ER3PA; QL*Opioid Agonists***Standard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/20217
DrugReferenceTierNotescodeine sulfate oral tablet 15 mg, 60 mg3AL; QLcodeine sulfate oral tablet 30 mg1AL; QLEMBEDA3PA; QL1PA; ST; QLfentanyl transdermal patch 72 hour 100mcg/hr, 12 mcg/hr, 25 mcg/hr, 50mcg/hr, 75 mcg/hr1PA; ST; QLFENTORA BUCCAL TABLET 100MCG, 200 MCG, 400 MCG, 600 MCG,800 MCG3PA; ST; QLhydromorphone hcl injection solution 4mg/ml1QL1QLKADIAN ORAL CAPSULEEXTENDED RELEASE 24 HOUR 200MG3PA; QLlevorphanol tartrate oral1PA; QLmeperidine hcl oral1QLmethadone hcl oral1PA; QLMETHADOSE ORAL TABLETSOLUBLE1PA; QLMORPHABOND ER3PA; QLmorphine sulfate (concentrate) oralsolution 100 mg/5ml1QLmorphine sulfate er beads1PA; QLmorphine sulfate er oral capsuleextended release 24 hour1PA; QLmorphine sulfate er oral tablet extendedMS Continrelease1PA; QLmorphine sulfate oral1QLNUCYNTA3QLNUCYNTA ER3PA; QLOPANA ER ORAL TABLET ER 12HOUR ABUSE-DETERRENT 10 MG, 15MG3fentanyl citrate buccal lozenge on ahandlehydromorphone hcl oralActiqDilaudidStandard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/20218
DrugReferenceTierNotesOPANA ER ORAL TABLET ER 12HOUR ABUSE-DETERRENT 20 MG, 30MG, 40 MG, 5 MG, 7.5 MG3PAoxycodone hcl er oral tablet er 12 hourOxyCONTINabuse-deterrent1PA; QLoxycodone hcl oral capsule1QLoxycodone hcl oral concentrate 100mg/5ml1QLoxycodone hcl oral solution1QLoxycodone hcl oral tablet1QLOXYCONTIN ORAL TABLET ER 12HOUR ABUSE-DETERRENT 15 MG, 20MG, 30 MG, 40 MG, 60 MG, 80 MG2PA; QLoxymorphone hcl1QLoxymorphone hcl er1PA; QLtramadol hcl er oral tablet extendedrelease 24 hour1PA; QL1AL; QL3PA; QLENDOCET ORAL TABLET 10-325 MG,2.5-325 MG, 5-325 MG, 7.5-325 MG1QLoxycodone-acetaminophen oral solution5-325 mg/5ml1tramadol hcl oral tablet 50 mgUltramXTAMPZA ER*Opioid Combinations***oxycodone-acetaminophen oral tablet10-325 mg, 2.5-325 mg, 5-325 mg, 7.5325 mgEndocet1QLoxycodone-aspirin oral tablet 4.8355325 e hcl sublingual1QL*Opioid Partial Agonists***buprenorphine hcl-naloxone hclSuboxone1QLbuprenorphine transdermalButrans1PA; QLbutorphanol tartrate nasal1QLpentazocine-naloxone hcl1QLStandard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/20219
DrugReferenceSUBLOCADETierNotes3QL1AL; QL*Tramadol ogens-Anabolic**Anabolic Steroids***ANADROL-503oxandrolone oral1*Androgens***ANDRODERM TRANSDERMALPATCH 24 HOUR2ANDROXY2danazol oral1methitest3methyltestosterone oral1STRIANT3testosterone cypionate intramuscularsolution 100 mg/ml, 200 mg/mlDepo-Testosteronetestosterone enanthate intramuscularsolution11testosterone transdermal gel 10 mg/act(2%)Fortesta1testosterone transdermal gel 12.5mg/act (1%)Vogelxo Pump1testosterone transdermal gel 25mg/2.5gm (1%), 50 mg/5gm (1%)AndroGel1testosterone transdermal solution1*Anorectal And Related Products**Intrarectal Steroids***COLOCORT1CORTIFOAM EXTERNAL2hydrocortisone rectal enemaCortenema1*Nitrate Vasodilating Agents***RECTIV3Standard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/202110
Drug*Rectal Anesthetic/Steroids***ReferenceTierhydrocortisone ace-pramoxine externalAnalpram-HCcream 1-1 %1pramcort external1Analpram-HCPROCTOFOAM HC EXTERNALNotes3*Rectal Steroids***hydrocortisone (perianal) externalcream 2.5 %Procto-Med HC1PROCTO-MED HC EXTERNAL1PROCTO-PAK EXTERNAL1PROCTOSOL HC EXTERNAL1PROCTOZONE-HC le oralAlbenza1QLbenznidazole oral tablet 100 mg3PAbenznidazole oral tablet 12.5 mg3EMVERM3ivermectin oralStromectol1praziquantel oralBiltricide1QLQL*Antianginal LATRATE-SR3isosorbide dinitrate er1isosorbide dinitrate oralIsordil Titradose1isosorbide mononitrate1isosorbide mononitrate er1MINITRAN1NITRO-BID3NITRO-DUR TRANSDERMAL PATCH24 HOUR 0.3 MG/HR, 0.8 MG/HR3nitroglycerin sublingualNitrostat1Standard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/202111
DrugReferencenitroglycerin transdermal patch 24hourNitro-Dur1nitroglycerin translingualNitroMist1NITRO-TIMETier1*Antianxiety Agents**Antianxiety Agents - Misc.***buspirone hcl oral1hydroxyzine hcl oral syrup1hydroxyzine hcl oral tablet1hydroxyzine pamoate oral1meprobamate1*Benzodiazepines***ALPRAZOLAM INTENSOL2alprazolam oral1chlordiazepoxide hcl1clorazepate dipotassium1DIAZEPAM INTENSOL1diazepam oral concentrateDiazepam Intensoldiazepam oral solution 5 mg/5mldiazepam oral tablet1ValiumLORAZEPAM INTENSOLlorazepam oral hythmics Type I-A***disopyramide phosphate oralNorpace1NORPACE CR3quinidine gluconate er1quinidine sulfate er1quinidine sulfate oral1*Antiarrhythmics Type I-B***mexiletine hcl oral1*Antiarrhythmics Type I-C***flecainide acetate1Standard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/202112Notes
DrugReferencepropafenone hclpropafenone hcl erTierNotes1Rythmol SR1amiodarone hcl oralPacerone1dofetilideTikosyn1*Antiarrhythmics Type Iii***MULTAQ3PACERONE ORAL TABLET 200 MG,400 MG1SP*Antiasthmatic And Bronchodilator Agents**5-Lipoxygenase Inhibitors***zileuton er1*Adrenergic Combinations***ADVAIR HFA2ANORO ELLIPTA2BREO ELLIPTA2BREZTRI AEROSPHERE3ST1PREVCOMBIVENT RESPIMAT2PREVDULERA3budesonide-formoterol fumaratefluticasone-salmeterolSymbicortWixela InhubPREV1PREVipratropium-albuterol1PREVSTIOLTO RESPIMAT INHALATIONAEROSOL SOLUTION 2.5-2.5MCG/ACT2SYMBICORT2PREVTRELEGY ELLIPTA3STWIXELA INHUB1PREV2PA; SP1PREV*Anti-Ige Monoclonal Antibodies***XOLAIR*Anti-Inflammatory Agents***cromolyn sodium inhalation*Beta Adrenergics***albuterol sulfate er1albuterol sulfate hfa inhalation aerosolProAir HFA1solution 108 (90 base) mcg/actStandard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/202113
DrugReferenceTieralbuterol sulfate inhalation nebulizationsolution (2.5 mg/3ml) 0.083%, 0.63mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml1albuterol sulfate oral1arformoterol tartrateBrovana1formoterol fumarate inhalationPerforomist1Noteslevalbuterol hcl inhalation nebulizationsolution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 Xopenexmg/3ml1PREVlevalbuterol hcl inhalation nebulizationXopenex Concentratesolution 1.25 mg/0.5ml1PREVlevalbuterol tartrate1Xopenex HFAmetaproterenol sulfate oral1PROAIR RESPICLICK3SEREVENT DISKUS2PREVterbutaline sulfate oral1PREV*Bronchodilators - Anticholinergics***ATROVENT HFA2ipratropium bromide inhalation1LONHALA MAGNAIR STARTER KIT3SEEBRI NEOHALER3PASPIRIVA HANDIHALER2PREVSPIRIVA RESPIMAT INHALATIONAEROSOL SOLUTION 1.25 MCG/ACT,2.5 MCG/ACT2PREVFASENRA2PA; SPFASENRA PEN2PA; SPNUCALA3PA; SPPREV*Interleukin-5 Antagonists (Igg1 Kappa)****Leukotriene Receptor Antagonists***montelukast sodium ve Phosphodiesterase 4 (Pde4) Inhibitors***DALIRESP3Standard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/202114
Drug*Steroid Inhalants***ReferenceTierNotesbudesonide inhalationPulmicort1PREVFLOVENT DISKUS2PREVFLOVENT HFA2PREVPULMICORT FLEXHALER2PREVQVAR INHALATION AEROSOLSOLUTION2PREVQVAR REDIHALER2PREV*Xanthine-Expectorants***DIFIL-G FORTE1*Xanthines***ELIXOPHYLLIN3THEO-242THEOCHRON ORAL TABLETEXTENDED RELEASE 12 HOUR 100MG, 200 MG1PREVtheophylline1PREVtheophylline er1PREVCOUMADIN in Anticoagulants***warfarin sodium oralJantoven*Direct Factor Xa Inhibitors***ELIQUIS2XARELTO2XARELTO STARTER PACK2*Heparins And Heparinoid-Like Agents***heparin (porcine) in nacl intravenoussolution 1000-0.9 ut/500ml-%1heparin (porcine) in nacl intravenoussolution 25000-0.45 ut/500ml-%3*Low Molecular Weight Heparins***enoxaparin sodiumLovenox1Standard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/202115
DrugReferenceFRAGMIN SUBCUTANEOUSSOLUTION 10000 UNIT/ML, 12500UNIT/0.5ML, 15000 UNIT/0.6ML, 18000UNT/0.72ML, 2500 UNIT/0.2ML, 5000UNIT/0.2ML, 7500 UNIT/0.3ML, 95000UNIT/3.8MLTierNotes3*Synthetic Heparinoid-Like Agents***fondaparinux sodiumArixtra1*Anticonvulsants**Ampa Glutamate Receptor Antagonists***FYCOMPA3PA*Anticonvulsants - Benzodiazepines***clobazamOnficlonazepam oral11diazepam rectalDiastat AcuDial1NAYZILAM3PASYMPAZAN3PAVALTOCO 10 MG DOSE3QLVALTOCO 15 MG DOSE3QLVALTOCO 20 MG DOSE3QLVALTOCO 5 MG DOSE3QLAPTIOM3PABRIVIACT ORAL3PA*Anticonvulsants - Misc.***carbamazepine erCarbatrol1carbamazepine oralTEGretol1DIACOMIT3PA; SPEPIDIOLEX3PA; SPEPITOL1FINTEPLA3gabapentin oralNeurontin1lamotrigine erLaMICtal XR1lamotrigine oral kit 21 x 25 mg & 7 x 50mg, 25 & 50 & 100 mg, 42 x 50 mg &LaMICtal ODT14x100 mg1Standard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/202116PA; SP
DrugReferenceTierlamotrigine oral tabletLaMICtal1lamotrigine oral tablet chewableLaMICtal1lamotrigine oral tablet dispersibleLaMICtal ODT1lamotrigine starter kit-blueLaMICtal Starter1lamotrigine starter kit-greenLaMICtal Starter1lamotrigine starter kit-orangeLaMICtal Starter1levetiracetam erKeppra XR1levetiracetam oralKeppra1oxcarbazepineTrileptal1OXTELLAR XR3POTIGA3pregabalin oralLyrica1primidone oralMysoline1ROWEEPRA ORAL TABLET 500 MGrufinamide1Banzel1SPRITAM3TEGRETOL ORAL SUSPENSION3TEGRETOL ORAL TABLET3TEGRETOL-XR ORAL TABLETEXTENDED RELEASE 12 HOUR 200MG, 400 MG3TOPAMAX3TOPAMAX SPRINKLE3topiramate oralNotesTopamaxVIMPAT ORAL13zonisamide I3PAXCOPRI (250 MG DAILY DOSE)3PAXCOPRI (350 MG DAILY DOSE)3PA*Gaba Modulators***tiagabine hclGabitril1vigabatrinSabril1PA; SPStandard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/202117
Drug*Hydantoins***ReferenceTierDILANTIN INFATABS3DILANTIN ORAL CAPSULE 100 MG3DILANTIN ORAL CAPSULE 30 MG2DILANTIN ORAL SUSPENSION3PEGANONE3PHENYTEK3phenytoin oral suspension 125 mg/5mlDilantin1phenytoin oral tablet chewableDilantin Infatabs1phenytoin sodium mide oralZarontin1Depakote ER1*Valproic Acid***divalproex sodium er oral tabletextended release 24 hourdivalproex sodium oral capsule delayedDepakote Sprinklesrelease sprinkle1divalproex sodium oral tablet delayedrelease1Depakotevalproic acid oral capsule1valproic acid oral solution1*Antidepressants**Alpha-2 Receptor Antagonists (Tetracyclics)***mirtazapine oralRemeron SolTab1*Antidepressants - Misc.***APLENZIN3bupropion hcl er (sr)Wellbutrin SR1bupropion hcl er (xl)Forfivo XL1bupropion hcl oral1maprotiline hcl1*Monoamine Oxidase Inhibitors (Maois)***EMSAM3MARPLAN3Standard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/202118Notes
DrugReferenceTierphenelzine sulfate oralNardil1tranylcypromine sulfateParnate1Notes*N-Methyl-D-Aspartic Acid (Nmda) Receptor Antagonists***SPRAVATO (56 MG DOSE)3PA; SPSPRAVATO (84 MG DOSE)3PA; SP*Selective Serotonin Reuptake Inhibitors (Ssris)***citalopram hydrobromide oral solutioncitalopram hydrobromide oral tablet1CeleXAescitalopram oxalate oral solution1PREV1escitalopram oxalate oral tabletLexapro1PREVfluoxetine hcl oral capsulePROzac1PREVfluoxetine hcl oral capsule delayedrelease1QLfluoxetine hcl oral solution1fluoxetine hcl oral tablet1fluvoxamine maleate1fluvoxamine maleate er1paroxetine hcl erPaxil CR1paroxetine hcl oral suspensionPaxil1paroxetine hcl oral tabletPaxil1PEXEVAPREV3sertraline hcl oral concentrateZoloft1sertraline hcl oral tabletZoloft1PREV*Serotonin Modulators***nefazodone hcl1trazodone hcl oral1TRINTELLIX3PAVIIBRYD3ST; QLVIIBRYD STARTER PACK3ST; QL*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)***desvenlafaxine er1desvenlafaxine fumarate er3desvenlafaxine succinate erduloxetine hcl oralPristiq11Standard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/202119
DrugReferenceTierNotesvenlafaxine hcl1PREVvenlafaxine hcl er1*Tricyclic Agents***amitriptyline hcl oral1amoxapine1clomipramine hcl oralAnafranil1desipramine hcl oral1doxepin hcl oral capsule1doxepin hcl oral concentrate1imipramine hcl oral1imipramine pamoate1nortriptyline hcl oral1protriptyline hcl1trimipramine maleate oral1*Antidiabetics**Alpha-Glucosidase Inhibitors***acarbose oralPrecosemiglitol1PREV1*Antidiabetic - Amylin Analogs***SYMLINPEN 120 SUBCUTANEOUSSOLUTION PEN-INJECTOR3PREVSYMLINPEN 60 SUBCUTANEOUSSOLUTION PEN-INJECTOR3PREVmetformin hcl er1PREVmetformin hcl oral tablet1PREV*Biguanides****Diabetic Other***BAQSIMI TWO PACKdiazoxide oral2Proglycem1glucagon emergency injection kit1glucagon emergency injection solutionreconstituted2GVOKE HYPOPEN 1-PACK2GVOKE PFS2Standard 3-Tier FormularyAL Age Limitation PA Prior AuthorizationPREV Preventive Drugs for HSA Plans SP Specialty MedicationST Step Therapy QL Quantity LimitsEffective as of 12/1/202120
UMET XR2ST*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors***JANUVIA*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations****Dopamine Receptor Agonists - Ergot Derivatives***CYCLOSET3*Human Insulin***FIASP2PREVFIASP FLEXTOUCH2PREVHUMULIN R U-500(CONCENTRATED)2PREVHUMULIN R U-500 KWIKPENSUBCUTANEOUS SOLUTION PENINJECTOR2PREVinsulin aspartNovoLOG2PREVinsulin aspart flexpenNovoLOG FlexPen2PREVinsulin aspart penfillNovoLOG PenFill2PREVinsulin aspart prot & aspartNovoLOG Mix 70/302PREVLANTUS2PREVLANTUS SOLOSTARSUBCUTANEOUS SOLUTION PENINJECTOR2PREVLEVEMIR2PREVLEVEMIR FLEXTOUCH2PREVNOVOLIN 70/302PREVNOVOLIN 70/30 FLEXPEN2PREVNOVOLIN N2PREVNOVOLIN N FLEXPEN2PREVNOVO
EXTENDED RELEASE 20 MG. 1: methylphenidate hcl er (cd) 1: methylphenidate hcl er (la) Ritalin LA: 1. methylphenidate hcl er oral tablet extended release 10 mg, 20 mg: 1. methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 mg, 54 mg: Concerta. 1: methylphenidate hcl er oral tablet extended release 24 hour. 1: methylphenidate hcl .
cruciaal. Issues met betrekking tot de uitvoering van de studie door de CRO bereikten niet altijd (tijdig) de verrichter. Het bijhouden van de (e)TMF vaak gedelegeerd aan CRO » Controle op volledigheid (e)TMF door CRO (maar ook verrichter) onvoldoende geborgd » Vertraging tussen beschikbaar zijn en uploaden van documenten in eTMF.
the vendor -how do you know you are choosing a 'qualified' CRO/vendor? 02. Inadequate control - transfer of regulatory obligations 03. 04. Changes in CRO - Vendor scope of work without changes in the contract 05. 06. REGULATOR COMMUNICATIONS CRO - Vendor Selection Criteria, Selection, Qualification Mergers, Acquisitions Due Diligence
Additionally , cro wd segmentation is a necessary preprocessing step that precedes a higher level task, such as counting (or , more generally , estimating) the number of indi viduals in cro wd, or analyzing their beha vioural dynamics and interac-tion. The areas to which cro wd
je partner povinen uhradit ČRo vzniklou škodu v plném rozsahu. 12. V případě, že ČRo vyrábí obchodní sdělení, pak prohlašuje, že je výrobcem zvukového záznamu a má právo záznam užít v rozsahu určeném mediaplánem dle této smlouvy. Partner není oprávněn poskytnout obchodní sdělení třetí osobě bez souhlasu ČRo.
partner povinen nahradit ČRo škodu v plném rozsahu. Partner poskytuje ČRo podlicenci k užití těchto výtvorů formou vysílání a streamu v neomezeném rozsahu. Partner se zavazuje, že znění obchodního sdělení bude v souladu s platnými právními předpisy ČR. Konečná textová i zvukova podoba podléhá schválení ČRo.
3 www.understandquran.com ‡m wQwb‡q †bq, †K‡o †bq (ف ط خ) rُ sَ _ْ یَ hLbB َ 9 آُ Zviv P‡j, nv‡U (ي ش م) اْ \َ َ hLb .:اذَإِ AÜKvi nq (م ل ظ) َ9َmْ أَ Zviv uvovj اْ ُ Kَ hw ْ َ Pvb (ء ي ش) ءَ Cﺵَ mewKQy ءٍ ْdﺵَ bِّ آُ kw³kvjx, ¶gZvevb ٌ یْ"ِKَ i“Kz- 3
Collectively make tawbah to Allāh S so that you may acquire falāḥ [of this world and the Hereafter]. (24:31) The one who repents also becomes the beloved of Allāh S, Âَْ Èِﺑاﻮَّﺘﻟاَّﺐُّ ßُِ çﻪَّٰﻠﻟانَّاِ Verily, Allāh S loves those who are most repenting. (2:22
DBT CEV - Parc Horizon 2000 - 62117 BREBIERES www.dbtcev.fr 12.2015. DOTc260 ind A/CRO Registrirani modeli i crteži – Ovaj dokument je vlasništvo DBT-CEV I TEB Inženjeringa, koji zadržavaju pravo da ga modificiraju u bilo koje vrijeme bez prethodne obavijesti. Kopiranje nije dozvoljeno bez dozvole vlasnika. 5. DC CHAdeMO konektor za punjenje
