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_1101_.pdf

PREFERRED DRUG LIST
CONVERSION TABLE
January 2002
BOLD TYPEFACE indicates product is available at the preferred generic copayment tier.
CAPS indicates product is available at the preferred brand copayment tier.
NON-PREFERRED DRUG
PREFERRED ALTERNATIVE
Ranitidine 300mg
Cimetidine 800mg
Famotidine 40mg
Cardiovascular Agents – Calcium Channel Blockers Diltiazem
PLENDIL
Nifedipine
Verapamil

Fluoxetine (error on original document)
Erythromycin
Amoxicillin
Ibuprofen
Diclofenac Sodium
Naproxen
Salsalate
Ketoprofen
COMPLETE PREFERRED DRUG LIST
BOLD TYPEFACE indicates product is available at the preferred generic copayment tier.
CAPS indicates product is available at the preferred brand copayment tier.
Amylase/Lipase/Protease
Alprazolam
/Pancreatin
APAP/Dichloralphenazone/
Acebutolol
lsometheptene
Acetaminophen/Codeine2
Amantadine
Acetaminophen/Hydrocodone2 AGENERASE
Bacitracin
Acetazolamide
Albuterol
Amiloride/HCTZ
Baclofen
Acetic Acid/ Hydrocortisone ALDARA
Amiodarone
Amitriptyline
Atenolol
Amoxicillin
Atenolol/Chlorthalidone
Acyclovir Oral
Ampicillin
Atropine
Belladonna/Phenobarbital
Allopurinol
Amylase/Lipase/Protease
Atropine Sulfate
THE BLUEGRASS FAMILY HEALTH PREFERRED DRUG LIST HAS BEEN COMPILED TO RESPOND TO THE CONSTANTLY CHANGING NATURE OF DRUG
THERAPY. THE LIST IS DYNAMIC AND IT IS SUBJECT TO CHANGE. YOU WILL BE NOTIFIED AT LEAST 30 DAYS IN ADVANCE OF ALL CHANGES. EVERY
EFFORT HAS BEEN MADE TO INSURE THE ACCURACY OF THIS DOCUMENT. WE APOLOGIZE FOR ANY INCONVENIENCE ERRORS MAY CAUSE.
PDL 11/01
Benzocaine/Antipyrine Otic
Cyclopentolate
Metronidazole
Benzonatate
Cyclophosphamide
Benztropine Mesylate
Cyproheptadine
Minocycline (Susp. Not
Betamethasone Dipropionate CYTOMEL
Covered at Generic Tier) 3
Betamethasone Valerate
Isoniazid
Minoxidil
Betaxolol
Bethanechol
Fenoprofen
Isosorbide Dinitrate
Famotidine
Isosorbide Mononitrate
Morphine2
Bromocriptine
Ketoconazole
Bumetanide
Desipramine
Fluocinolone
Ketoprofen
Bupropion
Desmopressin
Fluocinolone Acetonide
Ketorolac Tromethamine
Butoconazole
Dexamethasone
Fluocinonide
Labetalol
Captopril
Dexamethasone/Neomycin
Fluoride/Polyvitamins; /FE
Lactulose
Nabumetone
Captopril/HCTZ
Dexameth/Poly/Neomycin
Fluoride/Vitamin A, D, C; /FE LAMICTAL
Carbachol
Dexchlorpheniramine
Fluorometholone
Naphazoline
Carbamazepine
Dextroamphetamine3
Fluphenazine
Naproxen
Carbidopa/Levodopa
Diabetic Lancets - All
Flurazepam
Naproxen Sodium
Carisoprodol
DIABETIC TEST STRIPS – ALL Flurbiprofen Sodium
Diazepam
Leucovorin
Folic Acid
Cefaclor
Diclofenac Sodium
Cefadroxil
Dicloxacillin
Dicyclomine
Levobunolol
Diflunisal
Furosemide
Cephalexin
Levothyroxine
Neomycin Sulfate
Cephradine
Diltiazem
Gemfibrozil
Lidocaine Viscous
Neomycin/Gramicidin
Chloral Hydrate
Diltiazem SA Caps
Gentamicin
/Polymyxin
Chlordiazepoxide
Diltiazem SR
Gentamicin Sulfate
Neomycin/Polymyxin/HC
Lithium Carbonate (All Forms) NEORAL
Chloroquine Phosphate
Glipizide
Chlorpromazine
Diphenoxylate/Atropine
Chlorpropamide
Dipivefrin
Nicardipine
Chlorthalidone
Glyburide
Lorazepam
Cholestyramine
Nifedipine
Choline Mag. Trisalicylate
Dipyridamole
Nifedipine SR
Cimetidine
Disopyramide
Griseofulvin Ultramicrosize
Low-Ogestrel
Disopyramide CR
Guaifenesin
Loxapine
Nitrofurantoin
Clemastine
Doxazosin Mesylate
Guaifenesin/Codeine
Nitrofurantoin Macrocrystals
Guaifenesin/Codeine/ PSE
Nitroglycerin Ointment
Doxycycline (Tabs, Caps
Guaifenesin/Pseudoephedrine Maprotiline
Nitroglycerin Patches
Clindamycin
Guanabenz
Nitroglycerin Sublingual
Clindamycin Solution
Guenfacine
Clobetasol
Haloperidol
Nortriptyline
Clofibrate
Mebendazole
Clonazepam
Meclofenamate
Clonidine
Medroxyprogesterone
Clorazepate
Homatropine
Megestrol
Nystatin (Oral Powder Not
Codeine/Aspirin
Meperidine2
Covered)
Codeine/CPM/ PSE
Enalapril
Mephobarbital
Colchicine
Epinephrine
Hydralazine
Ogestrel
Hydrochlorothiazide (HCTZ) METAPREL
Hydrocodone/Homatropine
Metaproterenol Oral
Hydrocortisone
Metformin
Hydrocortisone Rectal
Methadone2
Hydrocortisone/Pramox
Methazolamide
Orphenadrine Citrate
Ergotamine Tartrate
Hydromorphone
Methimazole
Orphenadrine/Aspirin/Caffeine
Ergotamine/Caffeine/Bella/ Pb Hydroxychloroquine
Methocarbamol
Erlotamine/Caffeine
Hydroxyurea
Methotrexate
Erythromycin
Hydroxyzine
Methyldopa
Esterified Estrogens
Hyoscyamine Sulfate
Methylphenidate3
Cromolyn Ophthalmic Solution Estradiol
Ibuprofen
Methylprednisolone
Estradiol Patches
Imipramine
Methyltestosterone
Metoclopramide
Oxazepam
Estropipate
Indapamide
Metoprolol Tartrate
Cyclobenzaprine
Indomethacin
Indomethacin SR
Oxybutynin
THE BLUEGRASS FAMILY HEALTH PREFERRED DRUG LIST HAS BEEN COMPILED TO RESPOND TO THE CONSTANTLY CHANGING NATURE OF DRUG THERAPY. THE LIST IS
DYNAMIC AND IT IS SUBJECT TO CHANGE. YOU WILL BE NOTIFIED AT LEAST 30 DAYS IN ADVANCE OF ALL CHANGES. EVERY EFFORT HAS BEEN MADE TO INSURE THE
ACCURACY OF THIS DOCUMENT. WE APOLOGIZE FOR ANY INCONVENIENCE ERRORS MAY CAUSE.
PDL 11/01
Oxycodone/Acetaminophen2 PREMARIN
Rifampin
Oxycodone/Aspirin2
Tetracycline
Papavarine CR
Theophylline
Ursodiol
Salsalate
Theophylline SR
Valproic Acid
Thiethylperazine
Primidone
Pemoline
Probenecid
Thioridazine
Penicillin VK
Procainamide
Selegiline
Thiothixene
Verapamil
Procainamide SR
Selenium Sulfide 2.5%
Thyroid, Desiccated
Verapamil LA Tablets
Pentoxifylline
Prochlorperazine Maleate
Perphenazine
Promethazine
Phenazopyridine
Promethazine/Codeine
Silver Sulfadiazine
PHENERGAN 12.5MG, 25MG Promethazine DM
Tobramycin Drops
Promethazine/Codeine/PE
Phenobarbital
Propafenone
Tolazamide
Phenyleph/Pyril
Propoxyphene
Sodium Chloride
Tolbutamide
Warfarin Sodium
Phenylephrine
Propoxyphene-N/APAP
Sodium Polystyrene Sulfonate Tolmetin
Phenylephrine/Hydrocodone/ Propoxyphene/ASA/Caffeine SORIATANE
Propranolol
Phenylephrine/Promethazine Propranolol LA
Spironolactone
Trazodone
Phenytoin
Propranolol/HCTZ
Spironolactone/HCTZ
Tretinoin3– Limited to Acne
Propylthiouracil
Triamcinolone
Pilocarpine
Sucralfate
Triamcinolone/Nystatin
Pindolol
PSE/Carbinox.
Triamterene/HCTZ
Piroxicam
Sulfacetamide/Prednisolone Triazolam
P-tlox/Phenir/Pyril
Trifluoperazine
Sulfasalazine
Trifluridine
Sulfisoxazole
Trihexyphenidyl
Polymixin B Sulgate/TMP
Pyrazinamide
Sulfonylureas
Tri-Levlen
Zovia
Polymyxin B/Bacitracin
Quinidine Gluconate
Sulindac
Trimethobenzamide
Potassium Chloride 10mEq
Quinidine Sulfate
Trimethoprim
Potassium Iodide
Quinidine Sulfate SR
Pramoxine/Hydrocortisone
Prazosin
Ranitidine
Prednisolone
Tamoxifen Citrate
Triple Sulfa Vaginal
Prednisolone Acetate
Temazepam
Prednisolone Phosphate
Terazosin
Tropicamide
Prednisone
Terbutaline Sulfate
1 Available via Step Therapy (online prior authorization) 2 Quantity Limits Apply 3 Prior Authorization Required 4 Limited to Specialist Use Only
If a drug you are looking for is not on this list, it may be available at your non-preferred drug
copayment. Any medications prescribed for the treatment of diagnoses excluded from coverage
will not be covered at any copayment tier
.


EXCEPTIONS POLICY – Most covered non-preferred medications are available upon payment of the third tier prescription copayment.
However, there are certain drugs that, due to the nature of the medication, require prior authorization before the plan will cover them at any
copayment tier. Only physicians may request prior authorizations as they are based on medical history. In addition, the plan will not cover
in any way certain categories of drugs because they are plan exclusions. Examples include, but are not limited to, drugs used for smoking
cessation, weight loss, sexual dysfunction and cosmetic purposes. Prior authorizations are based on established clinical guidelines and
the patient’s medical history and only physicians may request medication approvals.
THE BLUEGRASS FAMILY HEALTH PREFERRED DRUG LIST HAS BEEN COMPILED TO RESPOND TO THE CONSTANTLY CHANGING NATURE OF DRUG THERAPY. THE LIST IS
DYNAMIC AND IT IS SUBJECT TO CHANGE. YOU WILL BE NOTIFIED AT LEAST 30 DAYS IN ADVANCE OF ALL CHANGES. EVERY EFFORT HAS BEEN MADE TO INSURE THE
ACCURACY OF THIS DOCUMENT. WE APOLOGIZE FOR ANY INCONVENIENCE ERRORS MAY CAUSE.
PDL 11/01

Source: http://www.bgfh.com/pdf/2002_PDL.pdf

Microsoft word - 42878927-2d9b-08c4a1.doc

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