BCBSM/BCN Formulary Alternatives - January 2007 NonFormulary Formulary Alternative NonFormulary Formulary Alternative
NONFORMULARY OTC preparations (various)BENZ PEROXIDE
Lotensin(g), Prinivil/Zestril(g), Vasotec(g), Univasc
Prilosec OTC (covered for BCN members with a prescription),
Asmanex, Azmacort, Flovent inhaler, Pulmicort, QVAR
Mevacor(g), Zocor(g), Pravachol(g), Crestor (ST*); plus Norvasc
Lotensin(g), Prinivil/Zestril(g), Vasotec(g), Univasc
members with a prescription), Allegra(g) (ST*), Allegra-D (ST*)
Use FemHRT, Prempro/Premphase, or Estradiol
(PA*), (ST*) - Prior Authorization or Step Therapy may be required. Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives. The BCBSM/BCN Custom Formulary can be downloaded onto your PDA. Visit www.epocrates.com for details. NonFormulary Formulary Alternative NonFormulary Formulary Alternative
Lotrimin(g) (OTC), Lotrimin Ultra (OTC), Monistat-Derm(g), Nizoral
COMBUNOX TABS Use oxycodone plus ibuprofen
Inderide(g), Tenoretic(g), Lopressor HCT(g), Timolide
Ritalin(g), Adderall(g), Concerta, Metadate CD, Adderall XR
Benicar, HCT, Cozaar, Hyzaar (ST for all*)
Restoril(g), Halcion(g), Prosom(g), Ambien
Clozaril(g), Seroquel, Risperdal, Zyprexa
Use generic albuterol plus Atrovent(g) solution
Celexa(g), Effexor(g), Paxil(g), Lexapro (ST*), Effexor XR (ST*)
(PA*), (ST*) - Prior Authorization or Step Therapy may be required. Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives. The BCBSM/BCN Custom Formulary can be downloaded onto your PDA. Visit www.epocrates.com for details. NonFormulary Formulary Alternative NonFormulary Formulary Alternative
Motrin(g), Naprosyn(g), Voltaren(g), Lodine(g), etc.
Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g), Cloderm,
Prempro/Premphase, or Estradiol plus progestin
Lotensin(g), Prinivil/Zestril(g), Vasotec(g), Univasc
Androxy(g), Androderm, Delatestryl, Depo-testosterone
Synalar(g), Topicort(g), Cloderm, Cordran
Lotrimin(g) (OTC), Lotrimin Ultra (OTC), Monistat-Derm(g), Nizoral
(PA*), (ST*) - Prior Authorization or Step Therapy may be required. Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives. The BCBSM/BCN Custom Formulary can be downloaded onto your PDA. Visit www.epocrates.com for details. NonFormulary Formulary Alternative NonFormulary Formulary Alternative
Prilosec(g), or Prevacid (ST*) plus Naprosyn(g)
Prilosec OTC (covered for BCN members with a prescription),
Diprosone(g), Lidex(g), Topicort(g), Synalar(g)
Ativan(g), Valium(g), Xanax(g), Serax(g), Tranxene(g), Buspar(g)
Effexor(g), Wellbutrin, SR(g), Lexapro (ST*), Effexor XR (ST*)
Wellbutrin, SR(g), Prozac(g), Celexa(g), Effexor(g), Paxil(g),
Effexor(g), Wellbutrin, SR(g), Lexapro (ST*), Effexor XR (ST*)
Bontril(g), Phentermine(g), Tenuate(g), Didrex, Ionamin (PA*
Keflex(g), Ceclor(g), Duricef(g), Ceftin(g), Omnicef
(PA*), (ST*) - Prior Authorization or Step Therapy may be required. Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives. The BCBSM/BCN Custom Formulary can be downloaded onto your PDA. Visit www.epocrates.com for details. NonFormulary Formulary Alternative NonFormulary Formulary Alternative
Restoril(g), Halcion(g), Prosom(g), Ambien
Ceredase, Cerezyme (Both are medical benefits at BCN)
Prilosec OTC (covered for BCN members with a prescription), Prilosec(g), Prevacid (ST*)
Claritin/Alavert(g) (OTC covered for members with a prescription), Allegra(g) (ST*), Allegra-D (ST*)
(PA*), (ST*) - Prior Authorization or Step Therapy may be required. Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives. The BCBSM/BCN Custom Formulary can be downloaded onto your PDA. Visit www.epocrates.com for details.
Assessment and Evaluation Client Number and Name: #1221 John Smith* Assessment Date: February 5 Assessed By: Sue, Aging Wisely Care Manager Demographics Current Living Arrangement: Own home Phone: (727)555-5555 Address: 275 West Dr., Clearwater, FL 33761 DOB: 2/1/29 Social Security #: 222-22-1111 Marital Status: Widow US Citizen: Y