Generics Plus Formulary - Blue Cross Blue Shield of Illinois
Generics Plus Formulary - Blue Cross Blue Shield of Illinois
Generics Plus Formulary - Blue Cross Blue Shield of Illinois
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Drug Name Specialty<br />
potassium phosphate/sodium<br />
phosphates (K-Phos Neutral – brand<br />
is NP)<br />
sodium fluoride, NP = tabs (Luride –<br />
brand is NP)<br />
BLOOD MODIFYING DRUGS<br />
ADVATE<br />
ALPHANATE<br />
ALPHANINE SD<br />
anagrelide (Agrylin – brand is NP)<br />
BEBULIN<br />
BEBULIN VH<br />
BENEFIX<br />
CEREZYME<br />
cilostazol (Pletal – brand is NP)<br />
clopidogrel (Plavix – brand is NP)<br />
CORIFACT<br />
cyanocobalamin inj<br />
dipyridamole (Persantine – brand is<br />
NP)<br />
enoxaparin (Lovenox – brand is NP)<br />
FEIBA NF<br />
FEIBA VH<br />
folic acid tabs, 1 mg<br />
HELIXATE FS<br />
HEMOFIL M<br />
KOATE-DVI<br />
KOGENATE FS<br />
MONOCLATE-P<br />
MONONINE<br />
NEUPOGEN<br />
NOVOSEVEN RT<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
Prior Authorization<br />
pentoxifylline ext-release (Trental –<br />
brand is NP)<br />
PROCRIT • •<br />
PROFILNINE SD<br />
•<br />
Dispensing Limits<br />
•<br />
Step Therapy<br />
Drug Name Specialty<br />
RECOMBINATE<br />
SOLIRIS<br />
warfarin (Coumadin – brand is NP)<br />
WILATE<br />
XYNTHA<br />
XYNTHA SOLOFUSE<br />
TOPICAL DRUGS<br />
2013<br />
<strong>Blue</strong> <strong>Cross</strong> and <strong>Blue</strong> <strong>Shield</strong> <strong>Generics</strong> <strong>Plus</strong> July 2013 Drug <strong>Formulary</strong> 13<br />
EYE<br />
Anti-infectives<br />
BACITRACIN oint<br />
bacitracin/polymyxin B oint<br />
cipr<strong>of</strong>loxacin soln (Ciloxan – brand is<br />
NP)<br />
erythromycin oint<br />
gentamicin oint, soln (Garamycin –<br />
brand is NP)<br />
NATACYN<br />
neomycin/polymyxin B/bacitracin<br />
oint<br />
neomycin/polymyxin B/gramicidin<br />
soln (Neosporin – brand is NP)<br />
<strong>of</strong>loxacin soln (Ocuflox – brand is NP)<br />
polymyxin B/trimethoprim<br />
soln (Polytrim – brand is NP)<br />
sulfacetamide sodium soln (Bleph-10<br />
– brand is NP)<br />
tobramycin soln (Tobrex – brand is<br />
NP)<br />
trifluridine soln (Viroptic – brand is NP)<br />
Steroids and Combination Products<br />
dexamethasone sodium phosphate<br />
soln<br />
fluorometholone susp, 0.1% (FML<br />
Liquifilm – brand is NP)<br />
neomycin/polymyxin B/bacitracin/<br />
hydrocortisone oint<br />
•<br />
•<br />
•<br />
•<br />
•<br />
Prior Authorization<br />
Dispensing Limits<br />
Step Therapy
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