MOST COMMONLY PRESCRIBED FORMULARY …

1 October 2013. COMMONLY PRESCRIBED STANDARD FORMULARY MEDICATIONS. This list is a sample of COMMONLY PRESCRIBED generic and FORMULARY brand drugs. Refer to the Blue Cross and Blue Shield of Illinois Prescription Drug FORMULARY at for a more comprehensive and up-to-date list. The online FORMULARY is updated after new generic drugs become available and also on a regular basis. The FORMULARY may contain medications not covered under your prescription drug benefit plan. In addition, prescription versions of over-the-counter (OTC) medications may not be covered based on your prescription drug benefit plan. If you have questions about your prescription drug benefit, call the Pharmacy Program number on the back of your ID card. CARDIOVASCULAR Dipeptidyl Peptidase 4 Inhibitors MIGRAINE Cough and Cold ACE Inhibitors/Combinations JANUMET/JANUMET XR Triptans All generically available cough/.

2 Amlodipine/benazepril JANUVIA naratriptan cold medications that require a benazepril/benazepril HCT JUVISYNC rizatriptan prescription are on the FORMULARY . captopril/captopril HCT KOMBIGLYZE XR sumatriptan enalapril/enalapril HCT ONGLYZA zolmitriptan Miscellaneous fosinopril/fosinopril HCT ATROVENT HFA. irbesartan/irbesartan HCT Sulfonylureas OPHTHALMIC COMBIVENT. lisinopril/lisinopril HCT glimepiride Antibacterial COMBIVENT RESPIMAT. quinapril/quinapril HCT glipizide/XL ofloxacin ophth soln ipratropium/albuterol sulfate ramipril glyburide/glyburide micronized polymyxin B/trimethoprim SPIRIVA HANDIHALER. trandolopril tobramycin Insulin Products VIGAMOX SLEEP AIDS. Angiotensin II Receptor Blockers HUMALOG/HUMULIN zaleplon candesartan LANTUS Glaucoma zolpidem/ER.

3 Losartan/losartan HCT LEVEMIR brimonidine , valsartan HCT NOVOLIN/NOVOLOG dorzolamide soln THYROID REPLACEMENT. BENICAR/BENICAR HCT latanoprost levothyroxine includes Levoxyl*. Monitoring Kits/Strips & Syringes timolol maleate soln Beta-Blockers ACCU-CHEK STRIPS & KITS ALPHAGAN P UROLOGIC DISORDERS. acebutolol ACCU-CHEK LANCETS AZOPT Benign Prostatic Hypertrophy atenolol BAYER BREEZE STRIPS LUMIGAN doxazosin bisprolol/bisprolol HCT BAYER CONTOUR STRIPS TRAVATAN Z tamsulosin carvedilol BAYER MICROLET LANCETS terazosin labetalol BD NEEDLES/SYRINGES Other Eye Products metoprolol/metoprolol ER CHEMSTRIP BG STRIPS & KITS azelastine soln Urinary Incontinence propranolol diclofenac soln oxybutynin/ext-release INNOPRAN XL GASTROINTESTINAL ketorolac soln , tolterodine H2 Receptor Antagonists tobramycin/dexamethasone susp DETROL LA.

4 Calcium Channel Blockers cimetidine PATADAY VESICARE. amlodipine famotidine TOBRADEX OINT. diltiazem/XR/SR ranitidine ZYLET Others nifedipine ER finasteride verapamil/SR/ER Proton Pump Inhibitors PAIN/ARTHRITIS AVODART. lansoprazole/ODT Anti-inflammatory Agents Cholesterol Lowering Drugs omeprazole diclofenac WOMEN'S HEALTH. atorvastatin omeprazole/sodium bicarbonate etodolac Contraceptives cholestyramine pantoprazole ibuprofen Monophasic colestipol pkt NEXIUM indomethacin EE/desogestrel (Apri*). fenofibrate meloxicam EE/drospirenone (Gianvi*, Ocella*, gemfibrozil ANTI-INFECTIVE AGENTS nabumetone Zarah*). lovastatin Antibacterials naproxen EE/levonorgestrel (Aviane*, pravastatin amoxicillin oxaprozin Levora*). simvastatin amoxicillin/clavulanate sulindac EE/norethindrone (Necon*, CRESTOR ampicillin CELEBREX Necon 1/35*, Nortrel*, Nortrel 1/35*).

5 NIASPAN azithromycin tabs/susp HUMIRA EE/norgestimate (Mononessa*, TRILIPIX cefaclor Sprintec*). WELCHOL cefadroxil RESPIRATORY EE/norgestrel (Low-Ogestrel*). cefdinir Allergy Drugs DEPRESSION cefprozil All generically available Biphasic SSRIs cefuroxime antihistamine/decongestant EE/desogestrel (Kariva*). citalopram cephalexin combinations that require a EE/norethindrone (Necon 10/11*). escitalopram ciprofloxacin prescription are on the FORMULARY . fluoxetine doxycycline Triphasic paroxetine EES/sulfisoxazole azelastine EE/desogestrel (Velivet*). sertraline erythromycin fexofenadine EE/levonorgestrel (Trivora*). levofloxacin fluticasone EE/norethindrone (Necon 7/7/7*, Other Antidepressants penicillin VK levocetirizine Nortrel 7/7/7*).

6 Amitriptyline tetracycline triamcinolone EE/norgestimate (Tri-Sprintec*, bupropion/SR/XL tmp-smz DS ASTEPRO Trinessa*). bupropion ext-release 24hr NASONEX. mirtazapine/ODT Antifungals/Onychomycosis Progestin Only nefazodone terbinafine Asthma Drugs norethindrone (Errin*, Jolivette*). trazodone voriconazole montelukast venlafaxine/ER zafirlukast Others Antiviral/Herpes ADVAIR DISKUS/ADVAIR HFA levonorgestrel mg DIABETES acyclovir ASMANEX NUVARING. acarbose valacyclovir DULERA ORTHO EVRA. metformin/XR FLOVENT DISKUS/FLOVENT HFA. metformin/glyburide LOW MOLECULAR WEIGHT FORADIL AEROLIZER. repaglinide HEPARIN PROAIR HFA. PRANDIN enoxaparin QVAR (continued). VICTOZA SYMBICORT. VENTOLIN HFA. FORMULARY brand drugs are noted with names in UPPERCASE.

7 Certain generic drug products are listed by their proprietary name, and are indicated with an asterisk (*). EE = ethinyl estradiol Drug trademarks and servicemarks are the property of their respective third-party owners. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association October 2013. COMMONLY PRESCRIBED STANDARD FORMULARY MEDICATIONS. Hormone Therapy estradiol estradiol/norethindrone acetate estropipate medoxyprogesterone norethindrone progesterone micronized ESTRADERM. VIVELLE DOT. Miscellaneous alendronate ibandronate ACTONEL. EVISTA. ZEMPLAR. FORMULARY brand drugs are noted with names in UPPERCASE. Certain generic drug products are listed by their proprietary name, and are indicated with an asterisk (*).

8 EE = ethinyl estradiol Drug trademarks and servicemarks are the property of their respective third-party owners. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Associatio