Prescription Drug Listing - Horizon NJ Health
Prescription Drug Listing
Horizon NJ Health wants to make sure you are getting the health care you need. Very often, that health care may include prescription drugs.
Most prescription and non-prescription (over-thecounter) drugs are covered at no cost, or low cost to you, as long as your doctor orders them and they are listed on our Formulary. A committee of doctors and pharmacists reviews the list of drugs on our formulary to make sure that the drugs are safe and effective. If your doctor decides
that you must have a drug that is not included in the Prescription Drug List (Formulary) or your
drug needs pre-approval, including a brand name medication exception, he or she can call and ask for special permission for you to get the drug. Your doctor can call the Horizon NJ Health Pharmacy Department at 1-800-682-9094.
For a pharmacy near you, visit our Provider Directory at or call Member Services toll free at 1-800-682-9090. People with hearing or speech difficulties can call our TTY/TDD service at 711.
Symbol
Meaning
CAPS @ YO *
Brand name drugs Needs pre-approval or other limitations apply Means "years old" Limitations apply (quantity, age) Subject to Step Therapy of first-line agents
Some members may have their HIV/AIDS medications covered through the AIDS Drug Distribution Program (ADDP).
Vitamin A derivatives are considered noncovered pharmacy benefits for members 35 years of age and older.
? A Formulary is alist of approved medications covered by Horizon NJ Health ? You can have prescriptions filled at any participating pharmacy.
Please note that Horizon NJ Health maximum days supply limit is 30 days.
Products and policies provided by Horizon NJ Health and services provided by Horizon Blue Cross Blue Shield of New Jersey, each an independent licensee of the Blue Cross and Blue Shield Association. Communications may be issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all of its companies. ? 2018 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.
A abacavir@* abacavir/
lamivudine@* ABILIFY
MAINTENA* ABREVA* acarbose@* acebutolol* acetasol acetasol hc acetazolamide acetic acid acetylcysteine acid jelly ACTHAR HP @ acyclovir capsule,
tablet, oral suspension, powder, vial* acyclovir ointment @* ADACEL @* ADCIRCA@* ADVIL COLD
AND SINUS AGGRENOX* AGRYLIN AIRDUO* (generic
only) AKINETON AKNE-MYCIN alavert* ALAWAY* ALBENZA albuterol* alclometasone* alendronate* alfuzosin* ALKERAN allopurinol ALOCRIL alogliptin@* alogliptin/
metformin* alogliptin/
pioglitazone@* alprazolam amantadine AMBISOME@ amidrine amiloride amiloride/
hydrochloro-
Page 1 of 7
thiazide aminocaproic
acid aminophylline* amiodarone AMITIZA @* amitriptyline amlodipine* amlodipine/
benazepril* ammonium lactate* amoxapine* amoxicillin* amoxicillin/
clavulanate* amoxicillin/
clavulanate ER* amphetamine-
dextroamphetamine, ER@* amphotericin ampicillin AMPYRA* ANA-KIT ANADROL-50 anastrozole @* antipyrene/ benzocaine acetaminophen/ codeine* apri* apraclonidine APRISO ER* APTIVUS@* aquatab d ARCALYST @* ARICEPT 5mg/10mg* aripiprazole* aripiprazole ODT* ARIXTRA* aspercreme 4% cream* aspirin/codeine* aspirin ASMANEX TWISTHALER/HFA* ASSESS* atenolol/chlorthalidone atomoxetine* atorvastatin* ATRIPLA@* atropine sulfate ATROVENT HFA*
atovaquone/progua nil augmented
betamethasone cream* aurodex* AVANDARYL@* AVANDIA@* AVANDAMET* AVC aviane* AVONEX @* AXID AR (OTC)* aygestin* AZACTAM @ azathioprine azelastine nasal spray* azithromycin*
B b-c/folic b-complex bacitracin/neomyci n/
polymyxin* bacitracin baclofen BASAGLAR
KWIKPEN* belladonna/opium bellamine-s bencort BENLYSTA@ benzonatate(11
YO)*
benzoyl peroxide cream, lotion*
benztropine* BERINERT @ betamethasone* betamethasone
dipropionate ointment* betamethasone valerate* BETASERON @* betaxolol* bethanechol BETOPTIC-S bicalutamide @* BIDIL* BICILLIN BILTRICIDE
bisoprolol/ hydrochlorothiazide
bisoprolol bleomycin bleph-10 BLEPHAMIDE BOOSTRIX @* BOTOX @* brimonidine
0.2%* bromanate bromfenex bromocriptine* budesonide
nebulizer solution (8YO)* bumetanide buprenorphine @* buprenorphine/ naloxone tablets@* bupropion, SR* bupropion XL* buspirone butalbital/acetaminophen/caffeine* butalbital/aspirin/ caffeine* butorphanol* BYDUREON@*
C cabergoline CAFCIT calcipotriene* calcitriol calcitonin* calcium acetate CALDEROL CAMPRAL* CANASA capecitabine @* CAPITROL CARBAGLU carbidopa* carbdopa/
levodopa, CR* carbidopa/levodopa
/entacapone* carbamazepine,
ER CARBATROL
April 2018
CARBILEV carboplatin CARDEC CARDEC DM carisoprodol* CARMOL 40 CARMOL SCALP CARMOL-HC cartia xt CATAPRES-TTS* carvedilol* CAYSTON* cefaclor, ER cefadroxil cefdinir* cefpodoxime* cefprozil* ceftriaxone cefuroxime celecoxib* CENESTIN cephalexin CEREZYME @ CETACAINE cetirizine (OTC)* cetirizine/
pseudoephedrine (OTC)* cevimeline CHEMET chemstrip bg CHILDREN'S ADVIL chlorpheniramine chloral hydrate chlordiazepoxide chloroquin chlorothiazide chlorpromazine chlorthalidone chlorzoxazone cholestyramine, light chromagen ciclopirox 8%* ciclopirox 0.77% cream* cilostazol* CILOXAN ointment* CINRYZE @* CIPRO HC* CIPRODEX* ciprofloxacin
(1YO)*
ciprofloxacin ER
(18YO)*
ciprofloxacin eye drops*
ciprofloxacin otic* cisplatin citalopram* citric acid clarithromycin, SR clemastine CLEOCIN
VAGINAL clindamycin cream/
solution/capsule* CLINDESSE* clindets clobetasol 0.05%
cream* clobetasol E 0.05%
cream* clomipramine* clonazepam clonidine* clopidogrel* clorazepate clotrimazole* clotrimazole/
betamethasone cream clozapine* clozapine ODT* COARTEM* codeine sulfate colchicine capsule* colestipol colocort COLY-MYCIN colyte colyte flavored COMBIPATCH COMBIVENT* COMPLERA@* COMTAN* constulose COPAXONE 20mg/mL* cormax cortic CORTIFOAM cortisone CORTISPORIN* CORZIDE COUMADIN CREON CRIXIVAN@* cromolyn* CUVPOSA* cyanocobalamine
Page 2 of 7
tablets, capsules, injection cyclobenzaprine cyclopentolate cyclophosphamide @* cyclosporine cyproheptadine CYSTARAN@* cytarabine CYTOMEL CYTOVENE cytra k cytra-2 cytra-3
D danazol dantrolene DAPSONE DARAPRIM darifenacin ER* daunorubicin DELATESTRYL@ demeclocycline*
DENAVIR @*
DEPEN* DEPOPROVERA* desipramine* desogestrel/ethin estradiol* desonide cream* desmopressin* desoximetasone gel,
0.25% ointment, 0.25% cream* dexamethason/
neomycin/polymyxi n dexamethasone* dexchloropheniramine DEXFERRUM @ dexmethylphenidate* dextroamphetamine dextroamphetamine
/amphetamine dextroamphetamine
/amphetamine XR* DHT diazepam DIBENZYLINE diclofenac 1% gel*
diclofenac tablet dicloxacillin dicyclomine* didanosine@* DIFFERIN OTC 0.1%
gel*
(Not covered if 35 YO)
DIFICID* diflunisal digitek digoxin diltia xt diltiazem DIMETAPP DIPENTUM* diphenhydramine diphenoxylate/
atropine dipyridamole disopyramide disulfiram* divalproex sodium DIURIL dorzolamide dorzolamide
hydrochloride/ timolol maleate doxazosin* doxepin* doxorubicin @* dextromethorphan doxycycline* dronabinol @ duloxetine* DURICEF dutasteride* dyphyllin* DYRENIUM
E ear-gesic* EASIVENT econazole* ECONOPRED EDURANT@* EFUDEX* EGRIFTA* ELELYSO @ ELIGARD @* ELIQUIS* ELLA* ELMIRON ELOXATIN @
April 2018
EMEND@* EMSAM* EMTRIVA@* enalapril* enalapril/
hydrochlorothiazide* ENBREL @* endodan ENGERIX-B @* enoxaparin entecavir* entex pse epinephrine* epinephrine jr* epitol EPIVIR HBV* epoprostenol @ ERBITUX @ ergotamine/ caffeine tablets erythromycin topical solution ESBRIET@* escitalopram* ESCLIM ESKALITH CR estazolam ESTINYL ESTRACE estradiol* estradiol/ norethindrone* estradiol patch* estradiol valerate injection ESTRING ESTROGEL estrogen/methyltestosterone estropipate ethambutol ethosuximide ethyl chloride etidronate etoposide @* EUFLEXXA @* EURAX* EXELON, patch* exemestane @* EYLEA*
ezetimibe*
F famotidine* FAMVIR*
Page 3 of 7
FARESTON@* felbamate felodipine ER FEMRING fenofibrate* fentanyl patches@* fentanyl citrate, oral
transmucosal@* FERAHEME @ FERRLECIT @ ferrous sulfate* fexofenadine
180mg, 30mg/5 ml * fexofenadine/ pseudoephedrine (OTC)* finasteride* FIRAZYR@* FIRMAGON FLAREX flecainide FLOVENT* fluconazole* flucytosine fludrocortisone fluocinolone cream/ointment* fluocinolone otic oil* fluocinonide cream, gel, ointment* fluoritab fluorometholone eye drops* FLUOROPLEX fluorouracil @* fluoxetine capsule* fluphenazine* flurazepam flurbiprofen flutamide fluticasone* fluticasone/ salmeterol* fluvoxamine* FML FORTE FML S.O.P.* folic acid FORADIL* FOSAMAX PLUS D* fosinopril, hydrochlorothiazide* FOSRENOL
FRAGMIN FULVICIN UF FUNGOID FURADANTIN furosemide FUZEON@*
G gabapentin* GABITRIL galantamine* GARDASIL@* GASTROCROM* GATTEX@ gavilyte-N* gemcitabine @* gemfibrozil GENEDEL gentak gentamicin GENVOYA@* GILENYA* GLASSIA glimepiride@* glipizide@* glipizide er@* GLUCAGON glyburide@* glyburide/metformin* glycopyrrolate griseofulvin guaifenesin guanfacine, ER*
GYNAZOLE*
H Haloperidol HAVRIX @* HECTOROL HEMANGEOL* hemril hep-lock heparin sodium HEPSERA HERCEPTIN* HIPREX HIZENTRA homatropine* HUMALOG
100U/mL vial* (only
3mL vial for LTC) HUMATROPE @
HUMIRA @* HUMULIN
100U/mL vial*(only 3mL vial for LTC) hydralazine hydralazine/ hydrochlorothiazide hydrochlorothiazide hydrocodone / acetaminophen 325mg* hydrocodone / ibuprofen* hydrocortisone* hydrocortisone/ pramoxine* hydromorphone hydroxychloroquine hydroxyurea hydroxyzine
I ibuprofen ILARIS @ imatinib @* IMBRUVICA@* imipramine* imiquimod
cream@* INCRELEX indapamide indomethacin INFED @ INGREZZA@* INNOHEP INSPRA* INSPIREASE* insulin syringes* INTAL
INHALER* INTELENCE@* INTRON-A @ INVEGA
SUSTENNA* INVIRASE@* iophen nr iophen c-nr iophen dm-nr IPLEX* ipratropium* ipratropium/
albuterol* IPRIVASK*
April 2018
irbesartan* irbesartan/
hydrochlorothiazide* IRESSA* irinotecan @* iron complex* ISENTRESS@* isoniazid isosorbide dinitrate isosorbide mononitrate isotretinoin itraconazole*
J JARDIANCE@* JUXTAPID@*
K KALBITOR @ KALYDECO@* KALETRA@* kariva* KERALAC
NAILSTICK* ketoconazole* ketoconazole
shampoo* ketoprofen ketorolac* ketorolac eye
drops* KORLYM @* KRISTALOSE KYNAMRO@*
L labetalol lactic acid* lactulose* LAMISIL AT* lamivudine@* lamivudine-
zidovudine@* lamotrigine* LANOXICAPS lansoprazole
capsules* larin* latanoprost* leflunomide LETAIRIS@*
Page 4 of 7
letrozole @* leucovorin @* LEUKERAN leuprolide@* levetiracetam, ER* levobunolol levocarnitine levocetirizine 5mg* levofloxacin* levofloxacin eye drops* levora* levororgestrel /
ethinyl estradoil* levothyroxine* LEVOXYL* LEXIVA@* lidocaine/
hydrocortisone acetate cream*
lidocaine patch@*
linezolid liquibid lisinopril* lisinopril/
hydrochlorothiazide* lithium carbonate lithium citrate LITHOBID loperamide* loratadine (otc)* loratadine/pseudoephedrine* lorazepam losartan* losartan/hydrochlorothiazide* LOTRONEX* lovastatin* low-ogestrol* loxapine LUCENTIS* LUNELLE LUPRON DEPOT-PED@* LUPRON DEPOT@*
M MACUGEN* MAKENA*
malathion@*
maprotiline* marten-tab
MATULANE@* MAVYRET@* MAXIDEX MAXIPIME mebendazol meclizine medroxy-
progesterone* mefloquine* megestrol* meloxicam* memantine IR* MENACTRA @* MENEST MENOSTAR* meperidine MEPHYTON meprobamate MEPRON mercaptopurine @* metformin, xr* metforminglipizide* methadone@ methazolam methenamine METHERGINE methimazole methocarbamol methotrexate methyldopa methylphenidate
CD* methylphenidate,
ER* methyl-
prednisolone* metipranol metoclopramide metolazone metoprolol metoprolol ER* metronidazole tablets* mexiletine miconazole cream, OTC
suppository* microgestin* midodrine miglitol@* minitran minocycline capsule mirtazapine* misoprostol
MOBAN modafinil@* moexipril* moexipril/
hydrochlorothiazide * mometasone* MONISTAT 7* mononessa* montelukast* MONUROL morphine sulfate morphine sulfate
ER@* MOTOFEN moxifloxacin* MOZOBIL* MULTAQ* mupirocin* MYALEPT@* MYCOBUTIN mycophenolate
mofetil MYOBLOC @
N nabumetone* nadolol nafcillin nalbuphine naldelate naltrexone* naphazolin* naproxen* naratriptan* NARCAN* NARDIL* NASACORT
ALLERGY 24HR* nateglinide@* NATPARA@* nebulizer* NEBUPENT* necon* neomycin/ bacitracin/ polymyxin* neomycin NEPHRON FA* NEULASTA@* nevirapine@* NEXIUM 24HR OTC*
April 2018
next choice one dose*
niacin niacin ER* nicardipine* nicotine chewing gum
(18YO)* nicotine lozenge
(18YO)* nicotine transdermal
(18YO)* nifedical nifedipine* NILANDRON nimodipine* nitrofurantoin nitroglycerin nitrolingual NITYR@* nizatidine oral
solution* nizatidine capsule* NIZORAL A-D* nor-qd* norgestimate /
ethinyl estradiol* norethinedrone /
ethinyl estradiol* norlyroc* nortrel* nortriptyline* NORVIR@* NPLATE @ NUCALA@* NUEDEXTA@* nupercainal NUPLAZID@* NYMALIZE@* nystatin/
triamcinolone nystatin*
O octreotide* ODEFSEY@* ODOMZO@* OFEV@* ofloxacin eye
drops* ofloxacin otic* ogestrel* olanzapine* olanzapine orally
disintegrating tablets*
olanzapine/ fluoxetine*
omeprazole* omeprazole OTC* ondansetron* ondansetron
ODT* ONE TOUCH* OPTICHAMBER* OPTIHALER* OPTIONHOME
COMPRESSOR (Respironics)* ORAP ORKAMBI* orphenadrine ortho-est* oseltamivir* OTC omeprazole-
magnesium* oticaine* oxaliplatin @* oxandrolone oxazepam oxcarbazepine oxybutynin, SR* oxycodone/
acetaminophen* oxycodone/aspirin* oxycodone tablet oxycodone er @* OXYCONTIN @* oxymorphone IR OXYTROL (OTC)*
P paclitaxel @* paliperidone* pantoprazole* paromomycin paroxetine* paroxetine cr* peg 3350 PEG-INTRON @ PEG-INTRON
REDIPEN @ PEGASYS @* pen needle* penicillin pentazocine pentazocin/
acetaminophen* pentoxifylline perindopril*
Page 5 of 7
periogard permetherin perphenazine phenazopyradine* phenobarbitol PHENYTEK phenytoin phos-flur phospholine pilocarpine pimtrea* pindolol pioglitazone@* pioglitazone/glimep
iride@* pioglitazone/
metformin* poly-vit* poly-vit/fluoride* poly-vitamin* polyethylene glycol potassium chloride potassium citrate PRADAXA* pramipexole* pramoxine* pravastatin* prazosin PRED MILD PRED-G prednicarbate
ointment* prednisolone* prednisone PREMARIN
tablets* PREMPHASE PREMPRO PREVACID
24HR OTC*
PREVIDENT* previfem* PREZISTA@* PRIMAQUINE primidone PRIMSOL probenecid/colchici ne probenecid procainamide prochlorperazine PROCRIT @ proctocream proctosol proctozone progesterone
PROMACTA* prometh vc (2YO)* promethazine/
codeine(2YO)* promethazine
(2YO)*
PROMETRIUM propafenone propantheline propoxyphene* propoxyphene/
acetaminophen* propranolol, cr* propranolol/
hydrochlorothiazide propylthiouracil protriptyline PULMOZYME* pyrazinamide pyridostigmine
Q quetiapine* quinapril* quinapril/
hydrochlorothiazide * quinidine QVAR*
R rabeprazole 20mg* raloxifene ramipril* ranitidine OTC* ranitidine syrup* ranitidine tablets* RAPAMUNE RECOMBIVAX HB@* REBIF* RECTIV* REGRANEX* RELENZA (5YO)
@* REMODULIN@ RENAGEL RENAX renal caps repaglinide@* REPATHA@* RESCRIPTOR@* reserpine
April 2018
REYATAZ@* ribavirin @* RIDAURA* rifampin* RILUTEK rimantadine RIMSO-50 RIOMET* risedronate 5mg,
30mg, 35mg* RISPERDAL
CONSTA* risperidone* RITUXAN @ rizatriptan,
MLT*
ROBITUSSIN ROFERON-A ropinirole, ER* rosuvastatin* ROWASA* RUCONEST@*
S SABRIL POWDER salicylic acid* salsalate
SAVELLA* Selegiline* selenium sulfide* sevelamer
carbonate tablet* SELZENTRY@* SEREVENT
DISK* SEROSTIM @* sertraline* SIGNIFOR@* sildenafil 20mg
tablet@* silver nitrate silver sulfadiazine simvastatin* SIRTURO@* sulfamethoxazole/
trimethoprim* sulfamethoxazole/
trimethoprim DS* sodium fluoride* sodium polysterene sulfonate sodium chloride SOMATULINE
Page 6 of 7
DEPOT* sotalol hc SPECTRACEF* spironolactone spironolactone/
hydrochlorothiazide SPIRIVA HANDIHALER* sprintec* stavudine@* STRENSIQ@* STRIANT@* STRIBILD@* STROMECTOL sucralfate sulfacetamide sodium/ sulfur 10-5% emulsion* sulfadiazine sulfasalazine sulindac sumatriptan* SUSTIVA@* SYMLIN@* SYNAGIS @* SYNAREL @* SYNJARDY*
T TABLOID@* tacrolimus
immediaterelease tacrolimus ointment@* TAFINLAR@* tamoxifen @* tamsulosin TAXOTERE TECFIDERA* temazepam temozolomide @* terazosin terbinafine tablets* terbutaline
terconazole cream*
TERRAMYCIN testosterone
cypionate@* testosterone gel 1% @* testosterone
propionate@
tetracycline THALITONE THALOMID* THEO-24* theochron theophylline* THIOGUANINE thiothixene thyroid THYROLAR-2 tiagabine ticlopidine TIKOSYN tilia fe* timolol maleate* TIVICAY@* tizanidine* TOBRADEX
OINTMENT* tobramycin* tobramycin/
dexamethasone* tobramycin inhaled
solution* TOBREX
OINTMENT* tolmetin sodium tolnaftate* tolterodine, ER* topiramate* topotecan @* torsemide TRACLEER@* tramadol* tramadol/
acetaminophen* tramadol er* trandolapril* trandolapril /
verapamil* transdermal
nitroglycerin tranylcypromine* trazodone* tri-legest fe* tri-sprintec* tri-vit/iron* tri-vit/flluoride* tri-vita/fluoride* tri-vite/fluoride* triamcinolone
cream/ointment* triamterene/
hydrochlorothiazide triazolam
tricosal trifluoperazine trifluridine trihexyphenidyl trimethobenzamide trimethoprim trimipramine* TRINATE* trinessa* trinessa lo* trivora-28* TRIZIVIR@* tropicamide trospium* TRUVADA@* TUDORZA* tussigon TWINRIX @* TYVASO@*
U undecylinic acid* unithroid uroquid acid ursodiol
V VAGIFEM* valacyclovir* VALCYTE* valproic acid valsartan* valsartan/
hydrochlorothiazide* vancomycin* VAQTA @* VELCADE venlafaxine* venlafaxine ER* VENOFER @ VENTAVIS@* VENTOLIN HFA* verapamil VEXOL VICKS 44M vicodin hp* VICTOZA@* VIDEX@* vincristine vinorelbine VIRACEPT@* VIRAMUNE XR@*
April 2018
VIREAD@* VIROPTIC* VISICOL VISTOGARD@* vitamin d VITEKTA@* VIVAGLOBIN VIVITROL @*
W warfarin WELCHOL*
X XENAZINE * XERAC-AC XARELTO* XGEVA* XOLAIR @ XURIDEN@*
Y YODOXIN
Z ZADITOR OTC* zaleplon* ZARXIO@* ZEGERID OTC* ZEMPLAR* ZENPEP zidovudine@* zinc sulfate ziprasidone* ZOLADEX @* zolpidem* ZOMACTON@
ZOMETA* zonisamide* ZORBTIVE @* ZORTRESS ZOSTAVAX @* zovia 1/35* zovia 1/50* ZYBAN (18YO)* ZYPREXA
RELPEVV*
Page 7 of 7
April 2018
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