Prescription Drug Listing - Horizon NJ Health

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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-

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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

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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*

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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@*

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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*

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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

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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*

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April 2018

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