Condition Care Rx Program Drug List - Florida Blue
Condition Care Rx Program Drug List - Florida Blue
Condition Care Rx Program Drug List - Florida Blue
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<strong>Condition</strong> <strong>Care</strong> <strong>Rx</strong> <strong>Program</strong> <strong>Drug</strong> <strong>List</strong><br />
Effective 1/1/15<br />
<strong>Drug</strong>s not on your formulary may or may not have lower copays. To find out which value drug categories are<br />
included in your plan design, please consult your member contract materials. Below is a list of medications that<br />
MAY be available under your plan. Generic drugs are available for many of the brand-name drugs noted on this<br />
list. Standard utilization management programs may still apply to certain drugs.<br />
DEPRESSION<br />
amitriptyline<br />
bupropion (generic Wellbutrin)<br />
bupropion ext-release (generic<br />
Wellbutrin ext-release)<br />
citalopram<br />
desipramine<br />
DOXEPIN 150 mg<br />
doxepin caps, 10, 25, 50, 75,<br />
100 mg; conc<br />
duloxetine<br />
escitalopram<br />
fluoxetine<br />
fluoxetine delayed-release<br />
imipramine hcl<br />
imipramine pamoate<br />
mirtazapine<br />
mirtazapine ODT<br />
nortriptyline<br />
paroxetine hcl<br />
paroxetine hcl ext-release<br />
phenelzine<br />
protriptyline<br />
sertraline<br />
tranylcypromine<br />
trazodone<br />
trimipramine<br />
venlafaxine<br />
venlafaxine ext-release caps<br />
VENLAFAXINE ext-release tabs,<br />
225 mg<br />
venlafaxine ext-release tabs, 37.5,<br />
75, 150 mg<br />
DIABETES<br />
acarbose<br />
BYDUREON<br />
BYETTA<br />
chlorpropamide<br />
glimepiride<br />
glipizide<br />
glipizide ext-release<br />
GLUCAGON EMERGENCY KIT<br />
glyburide micronized<br />
GLYBURIDE, distributor of Diabeta<br />
glyburide, generics of Micronase<br />
glyburide/metformin<br />
GLYSET<br />
INVOKAMET<br />
DIABETES (continued)<br />
INVOKANA<br />
JANUMET<br />
JANUMET XR<br />
JANUVIA<br />
JUVISYNC<br />
KOMBIGLYZE XR<br />
LANTUS<br />
LEVEMIR<br />
metformin<br />
metformin ext-release<br />
nateglinide<br />
NOVOLIN<br />
NOVOLOG<br />
ONGLYZA<br />
pioglitazone HCL<br />
pioglitazone HCL-glimepiride<br />
pioglitazone HCL/metformin HCL<br />
PROGLYCEM<br />
repaglinide<br />
SYMLINPEN<br />
VICTOZA<br />
DIABETIC SUPPLIES<br />
Diabetic Supplies – Preferred Blood<br />
Glucose Monitoring Kits, Insulin<br />
Syringes, Lancets, Lancet Devices,<br />
Pen Needles, Preferred Test Strips<br />
HIGH BLOOD PRESSURE<br />
acebutolol<br />
acetazolamide<br />
acetazolamide ext-release<br />
amiloride<br />
amiloride/hydrochlorothiazide<br />
amlodipine<br />
amlodipine/benazepril<br />
atenolol<br />
atenolol/chlorthalidone<br />
benazepril<br />
benazepril/hydrochlorothiazide<br />
betaxolol<br />
bisoprolol<br />
bisoprolol/hydrochlorothiazide<br />
bumetanide<br />
captopril<br />
CAPTOPRIL/<br />
HYDROCHLOROTHIAZIDE<br />
Generic <strong>Drug</strong>s = lower case Brand <strong>Drug</strong>s = CAPITAL LETTERS (Mandatory generic may apply)<br />
This list may not be all inclusive and is subject to change due to market availability of drugs<br />
<strong>Florida</strong> <strong>Blue</strong> is an Independent Licensee of the <strong>Blue</strong> Cross and <strong>Blue</strong> Shield Association<br />
<strong>Florida</strong> <strong>Blue</strong> is an Independent Licensee of the <strong>Blue</strong> Cross and <strong>Blue</strong> Shield Association<br />
HIGH BLOOD PRESSURE<br />
(continued)<br />
captopril/hydrochlorothiazide<br />
carvedilol<br />
chlorothiazide<br />
CHLORTHALIDONE 25, 50 mg<br />
clonidine<br />
diltiazem<br />
diltiazem ext-release<br />
doxazosin<br />
enalapril<br />
enalapril/hydrochlorothiazide<br />
eplerenone<br />
eprosartan<br />
felodipine ext-release<br />
fosinopril<br />
fosinopril/hydrochlorothiazide<br />
furosemide soln, 10 mg/mL; tabs<br />
guanfacine<br />
hydralazine<br />
hydrochlorothiazide caps; tabs,<br />
12.5, 25, 50 mg<br />
indapamide<br />
INNOPRAN XL<br />
irbesartan<br />
irbesartan/hydrochlorothiazide<br />
ISRADIPINE<br />
labetalol<br />
lisinopril<br />
lisinopril/hydrochlorothiazide<br />
losartan<br />
losartan/hydrochlorothiazide<br />
methazolamide<br />
methyldopa<br />
metolazone<br />
metoprolol succinate ext-release<br />
metoprolol tartrate<br />
metoprolol/hydrochlorothiazide<br />
minoxidil<br />
moexipril<br />
moexipril/hydrochlorothiazide<br />
nadolol<br />
nadolol/bendroflumethiazide<br />
Page 1 of 2
HIGH BLOOD PRESSURE<br />
(continued)<br />
nicardipine<br />
nifedipine<br />
nifedipine ext-release<br />
nimodipine<br />
nisoldipine ext release 8.5, 17,<br />
34 mg<br />
NISOLDIPINE ext-release 20, 25.5,<br />
30, 40 mg<br />
perindopril<br />
pindolol<br />
prazosin<br />
propranolol ext-release<br />
PROPRANOLOL soln<br />
propranolol tabs<br />
PROPRANOLOL/HYDROCHLORO<br />
-THIAZIDE<br />
quinapril<br />
quinapril/hydrochlorothiazide<br />
ramipril<br />
spironolactone<br />
spironolactone/hydrochlorothiazide<br />
telmisartan<br />
terazosin<br />
TIMOLOL tabs<br />
torsemide<br />
trandolapril<br />
triamterene/hydrochlorothiazide<br />
valsartan<br />
verapamil<br />
verapamil ext-release<br />
HIGH CHOLESTEROL<br />
atorvastatin<br />
cholestyramine<br />
cholestyramine light<br />
colestipol<br />
CRESTOR<br />
fenofibrate<br />
fenofibrate micronized<br />
fluvastatin<br />
gemfibrozil<br />
lovastatin<br />
niacin ER<br />
omega-3 acid ethyl esters<br />
pravastatin<br />
simvastatin<br />
WELCHOL<br />
ZETIA<br />
RESPIRATORY<br />
acetylcysteine inhal soln<br />
ADVAIR DISKUS<br />
ADVAIR HFA<br />
albuterol<br />
albuterol ext-release<br />
ANORO ELLIPTA<br />
ASMANEX<br />
ATROVENT HFA<br />
BREO ELLIPTA<br />
budesonide inhal susp, 0.25,<br />
0.5 mg/2 mL<br />
COMBIVENT<br />
COMBIVENT RESPIMAT<br />
cromolyn sodium inhal soln<br />
DULERA<br />
dyphylline/guaifenesin<br />
FLOVENT DISKUS<br />
FLOVENT HFA<br />
FORADIL AEROLIZER<br />
ipratropium inhal soln<br />
ipratropium/albuterol inhal soln<br />
levalbuterol<br />
levalbuterol HCL<br />
montelukast sodium<br />
PROAIR HFA<br />
PULMICORT RESPULES 1mg/2mL<br />
QVAR<br />
SPIRIVA HANDIHALER<br />
SPIRIVA RESPIMAT<br />
SYMBICORT<br />
terbutaline<br />
theophylline ext-release<br />
VENTOLIN HFA<br />
zafirlukast<br />
TOBACCO CESSATION –<br />
(<strong>Program</strong> Category Only-<br />
Not a Standard Benefit)<br />
NICOTROL INHALER (<strong>Rx</strong>)<br />
NICOTROL NS (<strong>Rx</strong>)<br />
Generic <strong>Drug</strong>s = lower case Brand <strong>Drug</strong>s = CAPITAL LETTERS (Mandatory generic may apply)<br />
This list may not be all inclusive and is subject to change due to market availability of drugs<br />
<strong>Florida</strong> <strong>Blue</strong> is an Independent Licensee of the <strong>Blue</strong> Cross and <strong>Blue</strong> Shield Association Page 2 of 2
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