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Regence BlueShieldEssential FormularyRegence BlueShield1800 9th AvenueSeattle, WA 98101Regence BlueShield serves select counties in Washington and is an independent licensee of the Blue Cross and Blue Shield Association.
Prescription drug benefits from Regence BlueShieldYou want to get the most from your benefits. You also want the information you need to make smart decisionsabout prescription drugs. We’re here to help you do that. We’ll give you and your doctor the latest and bestinformation about effective, quality drugs that also cost less.Regence BlueShield prescription drug programYour plan covers drugs listed on the Regence BlueShield Essential Formulary. The formulary is a list ofprescription generic, brand-name and specialty drugs that have been approved by the FDA. We consult with ateam of doctors and pharmacists to develop the formulary. It can help you and your doctor choose effectivedrugs that can save you money. You can buy formulary drugs at participating retail, mail-order and specialtypharmacies. Our formulary is available on Regence.com. Your plan doesn’t cover drugs not listed on theformulary.Changes to the formularyOur Pharmacy & Therapeutics Committee (made up of doctors and pharmacists from right here in ourcommunity) reviews the latest drug information. Their goal is to find ways to help you get the treatment youneed for the most affordable price. Generally, if you’re currently taking a formulary drug, its formulary statuswon’t change during the year unless: The same drug becomes available as a generic, orSafety or effectiveness concerns are raised, orThe Pharmacy & Therapeutics Committee determines that changes to the formulary would overall bebest for our members. We’ll send you a letter if a change means more out-of-pocket costs for you.What is the Essential Formulary prescription drug benefit?With an Essential Formulary benefit, prescription drugs fall into one of four categories or “tiers.” Each tier has adifferent cost share.*Tier 1— Generic and select brand-name insulinTier 2—Category 1 brand-nameTier 3—Category 2 brand-nameTier 4—Specialty medicationsLowest cost share.Generic drugs are as effective, safe and highquality as their brand-name counterparts, yet lessexpensive.Because of their value and effectiveness, these areconsidered to be preferred when there is nogeneric.These drugs may be more expensive and are lesspreferred than their alternatives in Tier 1 or Tier 2.These are used to treat complex medical conditionsand are available through our designated specialtypharmacy. They may require more involvementwith your doctor and require special storage andhandling.*“Cost share” is a deductible, flat-dollar copay or coinsurance/percentage.
What are your cost shares for Tier 1, 2, 3 or 4 drugs?You can find your cost shares in your benefit booklet or when you log in to Regence.com. Of course, you canalways call Customer Service at the number listed on the back of your member card.About prescription drugsPreventive drugsPreventive care benefits are an important part of a plan that covers preventive drugs. Under some plans, youmay not need to pay a copay or coinsurance, or meet your deductible for preventive drugs.Preventive drugs prevent a disease or condition for people who have risk factors. They can also be used toprevent the recurrence of a disease or condition for those who have recovered. They don’t include drugs thattreat an existing illness, injury or condition.See your benefit booklet or online summary to find out if your plan covers preventive drugs. To view thecovered PPACA Preventive Care Medication List, go to Regence.com.Advantages of generic drugsConsumer Reports says, “Generics are every bit as pure, potent, and safe as brands.”1 That’s because theFDA makes sure that generic drugs are just as strong, effective and pure as brand-names. By law, all genericsmust have the same active ingredients as their brand-named equivalent. Generic equivalent: The same active ingredient, strength and dosage as the brand-nameGeneric alternative: A different chemical that has a similar effect as the brand-nameGeneric drugs generally cost less than brand-name drugs because the makers of generic drugs aren’tspending as much money on research, development and marketing. Talk with your doctor to see whether ageneric is right for you.About specialty drugsMany people with complex conditions, such as, but not limited to, multiple sclerosis, rheumatoid arthritis andcancer, need special medications. These drugs are available through our designated specialty pharmacy andmay require special handling.We created the Specialty Select Pharmacy Program for specialty drugs. It includes: Educational materials, counseling and product information24-hour access to pharmacists and nursesRefill remindersFree delivery and suppliesConvenient delivery in unmarked packaging to ensure privacyYou’ll be able to get your first prescription filled at a retail pharmacy if the medication is available. Then you’llget a letter explaining that you’ll need to use one of our contracted specialty pharmacies for all future fills. Formore information on the Specialty Pharmacy Program, see Regence.com.
Tips for getting your prescription filledFilling your prescription at a retail pharmacyRegenceRx provides our participating pharmacy network. It’s a nationwide network of over 65,000 pharmacies.To have your drugs covered, you need to use a participating network pharmacy and show your member cardbefore purchasing your prescription. This way you’ll pay the correct cost share, and the pharmacist can seeyour prescription history.Most pharmacies in your area are part of the network. If you need a prescription filled while you’re traveling,you’ll find network pharmacies throughout the United States. Simply go Regence.com.If you go to a pharmacy not in the network, your medication won’t be covered.Your plan usually covers a 30-day supply of medication at a retail pharmacy. See your benefit booklet orbenefit summary online for your benefit limit.If you get less than a 30-day supply, you’ll still have to pay the full copay.Save time and money with prescriptions by mailIf you take a maintenance medication, you can receive your medicine by mail from Walgreens Mail ServicePharmacy . You save time with fewer trips to the local pharmacy, and you save money with discounted pricesand lower cost shares.You can get prescriptions up to the maximum supply allowed by your plan—typically 90 days, but it may vary—for less than you would pay for the same amount at a retail pharmacy. See your benefit booklet for details.How to receive your prescription by mail from the Walgreens Mail Service PharmacyGetting started is easy!1. Since it takes about two weeks to receive your prescription, ask your doctor to write two separate prescriptions(be sure that your doctor indicates if refills are allowed):a. One for a 30-day supply that you can fill right away at a retail pharmacyb. One for a 90-day supply, or the most your plan allows, that you can mail or fax to Walgreens Mail Servicewithin two weeks of your medicine running out2. Complete a Mail Service Registration Form, which you can download from Regence.com.3. Send your prescription(s), order form and payment to the address or fax number on the order form. You can paywith a personal check or credit card.You’ll get your prescriptions by mail in about two weeks.Make it even easierOrdering new prescriptions and refills is easier once you have an account with the Walgreens Mail ServicePharmacy. Simply log in to Walgreens.com/MailService and follow the instructions. Or order your refills bycalling Walgreens Customer Care at 888-832-5462.
Quality drug therapy with the Prior Authorization ProgramUsing your medications correctly is important. Our Prior Authorization Program helps you make decisionsabout your care and prescription drugs. It aims to improve the quality of your drug therapy by: Promoting the appropriate use of your medicationsChecking the appropriate length of your drug therapyHow the program worksWhen you fill your prescription, it’s checked to see if it meets recommended guidelines: If it meets the guidelines, your prescription is filled without interruption.If it doesn’t meet the guidelines, your prescription won’t be filled until it has been reviewed.Review processThe prior authorization process is simple. Your doctor or pharmacist can go to Regence.com, call 800-6435918, or fax 888-437-1510.The review process takes one to two business days. If your prescription is approved, then it’s covered and canbe filled the same day.Medications subject to the Prior Authorization ProgramDrugs tagged with PA in the formulary must receive prior authorization. For an updated list of medications thatrequire prior authorization, visit Regence.com.
Frequently asked questionsQ. What are my cost-share amounts?A. Check your benefit booklet to see what your cost share is for each tier.Q. What if I want to take a brand-name drug, even if there is a generic available?A. It’s your choice. In some cases, if you stay on a brand-name drug when a generic is available, you mayhave to pay more or up to the full price for your medication.Q. Are the drugs on the formulary just the ones that are the cheapest?A. No. All of the drugs on our formulary must be approved by the FDA. Also, our Pharmacy & TherapeuticsCommittee needs to determine that they are safe and effective. When several drugs are similar in safety andeffectiveness, one or more of the lower-cost ones are selected for our formulary.Q. I’ve heard that some people can’t take generic drugs. Why not?A. A brand-name drug and its generic equivalent have the same active ingredients. But different manufacturerscan use different inactive ingredients. Some people may have an allergic reaction to the inactive ingredients.This type of reaction is rare and can happen just as often with a brand-name drug.Q. What if there is no generic drug available to substitute for my brand-name drug?A. Even if there isn’t a generic equivalent yet, there may be another generic available within the same class ofdrugs that will work just as well. Talk to your doctor to learn more.Q. What if my doctor says I have to take a drug not included on the formulary?A. Your plan doesn’t cover non-formulary medications. If you choose to use a non-formulary medication, you’llbe responsible for the full price.However, if your doctor feels that a non-formulary medication is medically necessary, you may be able to getan exception and have it covered. You or your doctor will need to request prior authorization so that we candetermine medical necessity. See your benefit booklet for more information.Q. Are there any excluded categories of drugs?A. Yes. Common exclusions include drugs for obesity, infertility and sexual dysfunction. Certain drugs thathave a generic or an over-the-counter alternative are not covered. See your benefit booklet for your plan’sexclusions.Q. What does it mean when my drug is covered under the medical benefit?A. Drugs covered under the medical benefit are often injected or infused and typically are administered by ahealth care professional. These drugs and their related services are covered under your medical benefitinstead of the prescription drug benefit. See your benefit contract, log in to see your benefits on Regence.comor call Customer Service for coverage details specific to your plan.Q. Can I use any pharmacy I want?A. No. You need to use a network pharmacy to have your drugs covered. If you go to a pharmacy not in thenetwork, your medications won’t be covered.Specialty drugs are covered only when purchased through our specialty pharmacy. See your benefit bookletfor details about the Specialty Select Pharmacy Program and coverage at a non-network pharmacy.Q. How do I find a network pharmacy near my home or when I am away?A. Most pharmacies in your area are probably in the network. There are also network pharmacies throughoutthe United States. Use Regence.com to find a network pharmacy near you.
Q. How do I enroll in the Specialty Pharmacy Program?A. You can fill your first specialty prescription at a retail pharmacy. Then you’ll get a letter explaining that in thefuture you’ll need to use one of our contracted specialty pharmacies for your drug to be covered. CallCustomer Service for more information.Q. Is there more drug information available to members?A. Visit Regence.com to learn more.
Essential *adderall xr oral capsule extended release 24hourTier 1amphetamine-dextroamphetamine oral tabletTier 1*Amphetamines**-*Amphetamines***dextroamphetamine sulfate er oral capsuleextended release 24 hourTier 1dextroamphetamine sulfate oral tabletTier 1methamphetamine hcl oral tabletTier 1VYVANSE ORAL CAPSULE 20 MG, 30 MG,40 MG, 50 MG, 60 MG, 70 MGTier 2zenzedi oral tablet 10 mg, 2.5 mg, 5 mg, 7.5mgTier 1*Analeptics**-*Analeptics***caffeine citrate oral solution 20 mg/mlTier hetamine***diethylpropion hcl er oral tablet extendedrelease 24 hr*Tier 1diethylpropion hcl oral tabletTier 1phendimetrazine tartrate er oral capsuleextended release 24 hourTier 1phendimetrazine tartrate oral tabletTier 1*Attention-Deficit/Hyperactivity Disorder(Adhd) Agents**-*Adhd Agent - SelectiveAlpha Adrenergic Agonists***clonidine hcl er oral tablet extended release12 hr*Tier 1guanfacine hcl er oral tablet extendedrelease 24 hr*Tier 11
DrugTierNotes*Attention-Deficit/Hyperactivity Disorder(Adhd) Agents**-*Adhd Agent - SelectiveNorepinephrine Reuptake Inhibitor***STRATTERA ORAL CAPSULETier 3*Stimulants - Misc.**-*Stimulants - Misc.***DAYTRANA TRANSDERMAL PATCHTier 3dexmethylphenidate hcl er oral capsuleextended release 24 hourTier 1dexmethylphenidate hcl oral tabletTier 1metadate er oral tablet extendedrelease*Tier 1methylphenidate hcl er (cd) oral capsuleextended release*Tier 1methylphenidate hcl er (la) oral capsuleextended release 24 hour 20 mg, 30 mg, 40mgTier 1methylphenidate hcl er oral tabletextendedrelease*Tier 1methylphenidate hcl oral solutionTier 1methylphenidate hcl oral tabletTier 1modafinil oral tabletTier 1PA; QL (30 EA per 30 Days)NUVIGIL ORAL TABLETTier 3PA; QL (30 EA per 30 IN ORAL TABLETTier des***neomycin sulfate oral tabletTier 1paromomycin sulfate oral capsuleTier 1Tobramycin INHALATION NEBULIZATIONSOLUTIONTier 4SPTier 4PA; SP; QL (60 EA per 30Days)*Analgesics - Anti-Inflammatory**Antirheumatic - EnzymeInhibitors**-*Antirheumatic - Janus Kinase(Jak) Inhibitors***Xeljanz ORAL icAntimetabolites***RHEUMATREX ORAL TABLET2Tier 3
DrugTierNotesHumira Pen-Crohns StarterSUBCUTANEOUS* KITTier 4PA; SPHumira SUBCUTANEOUS* 10 MG/0.2MLTier 4PA; SPHumira SUBCUTANEOUS* KITTier 4PA; SPSimponi SUBCUTANEOUS*Tier 4PA; SP*Anti-Tnf-Alpha - MonoclonalAntibodies**-*Anti-Tnf-Alpha - MonoclonalAntibodies****Gold Compounds**-*Gold Compounds***RIDAURA ORAL CAPSULETier 2*Interleukin-1 Blockers**-*Interleukin-1Blockers***Arcalyst SUBCUTANEOUS* SOLUTIONRECONSTITUTEDTier 4PA; SP; QL (4 EA per 30 Days)Tier 4PA; SPTier 4PA; SP*Interleukin-1 Receptor Antagonist(Il-1Ra)**-*Interleukin-1 ReceptorAntagonist (Il-1Ra)***Kineret SUBCUTANEOUS**Interleukin-6 ReceptorInhibitors**-*Interleukin-6 ReceptorInhibitors***Actemra SUBCUTANEOUS**Nonsteroidal Anti-Inflammatory Agents(Nsaids)**-*Cyclooxygenase 2 (Cox-2)Inhibitors***CeleBREX ORAL CAPSULE 100 MG, 200MG, 50 MGNFPA; QL (60 EA per 30 Days)CeleBREX ORAL CAPSULE 400 MGNFPA; QL (30 EA per 30 Days)celecoxib oral capsuleTier 1PATier 3PA*Nonsteroidal Anti-Inflammatory Agents(Nsaids)**-*NonsteroidalAnti-Inflammatory Agent Combinations***VIMOVO ORAL TABLET DELAYEDRELEASE*Nonsteroidal Anti-Inflammatory Agents(Nsaids)**-*NonsteroidalAnti-Inflammatory Agents (Nsaids)***diclofenac potassium oral tabletTier 1diclofenac sodium er oral tablet extendedrelease 24 hr*Tier 1diclofenac sodium oral tablet delayed releaseTier 1etodolac er oral tablet extended release 24hr*Tier 13
DrugTieretodolac oral capsuleTier 1etodolac oral tabletTier 1fenoprofen calcium oral tabletTier 1flurbiprofen oral tabletTier 1ibuprofen oral tablet 400 mg, 600 mg, 800mgTier 1indomethacin er oral capsule extendedrelease*Tier 1indomethacin oral capsuleTier 1ketoprofen er oral capsule extended release24 hourTier 1ketoprofen oral capsuleTier 1ketorolac tromethamine oral tabletTier 1meclofenamate sodium oral capsuleTier 1mefenamic acid oral capsuleTier 1meloxicam oral tabletTier 1nabumetone oral tabletTier 1NALFON ORAL CAPSULE 400 MGTier 3naproxen dr oral tablet delayed releaseTier 1naproxen oral suspensionTier 1naproxen oral tabletTier 1naproxen sodium oral tablet 275 mg, 550 mgTier 1oxaprozin oral tabletTier 1piroxicam oral capsuleTier 1sulindac oral tabletTier 1tolmetin sodium oral capsuleTier 1tolmetin sodium oral tabletTier 1Notes*Pyrimidine SynthesisInhibitors**-*Pyrimidine SynthesisInhibitors***leflunomide oral tabletTier 1*Selective CostimulationModulators**-*Selective CostimulationModulators***Orencia SUBCUTANEOUS*Tier 4PA; SPEnbrel SUBCUTANEOUS* 25 MG/0.5ML, 50MG/MLTier 4PA; SPEnbrel SUBCUTANEOUS* KITTier 4PA; SP; QL (8 EA per 30 Days)*Soluble Tumor Necrosis Factor ReceptorAgents**-*Soluble Tumor Necrosis FactorReceptor Agents***4
DrugTierNotesEnbrel SureClick SUBCUTANEOUS*Tier 4PA; SP*Analgesics - Nonnarcotic**Analgesic Combinations**-*AnalgesicCombinations***duraxin oral capsuleTier 1ed-flex oral capsuleTier butalbital-acetaminophen oral tabletTier 1butalbital-apap-caffeine oral capsuleTier 1butalbital-apap-caffeine oral tablet 50-325-40mgTier 1butalbital-asa-caffeine oral capsuleTier 1capacet oral capsuleTier 1margesic oral capsuleTier 1marten-tab oral tabletTier 1*Salicylates**-*Salicylate Combinations***choline & mag trisalicylate oral tablet 1000mgTier 1choline-mag trisalicylate oral liquid†Tier 1*Salicylates**-*Salicylates***aspirin low dose oral tabletTier 1diflunisal oral tabletTier 1salsalate oral tabletTier 11 (Preventative Medication);OTC*Analgesics - Opioid**Opioid Agonists**-*Opioid Agonists***codeine sulfate oral solution 30 mg/5mlTier 1codeine sulfate oral tabletTier 1EMBEDA ORAL CAPSULE EXTENDEDRELEASE*Tier 3PAfentanyl citrate buccal lollipopTier 1PA; QL (90 EA per 30 Days)fentanyl transdermal patch 72 hrTier 1hydromorphone hcl oral liquid†Tier 1hydromorphone hcl oral tabletTier 1hydromorphone hcl suppositoryTier 1levorphanol tartrate oral tabletTier 1meperidine hcl oral solutionTier 1meperidine hcl oral tabletTier 1methadone hcl oral concentrateTier 15
DrugTiermethadone hcl oral solutionTier 1methadone hcl oral tabletTier 1methadone hcl oral tablet solubleTier 1methadose oral concentrateTier 1methadose oral tablet solubleTier 1morphine sulfate (concentrate) oral solution20 mg/mlTier 1morphine sulfate er oral tabletextendedrelease*Tier 1morphine sulfate oral solutionTier 1morphine sulfate oral tabletTier 1morphine sulfate suppositoryTier 1NUCYNTA ER ORAL TABLET EXTENDEDRELEASE 12 HR*Tier 3NUCYNTA ORAL TABLETTier 3OPANA ER ORAL 10 MG, 15 MG, 20 MG,30 MG, 40 MG, 5 MG, 7.5 MGTier 3oxycodone hcl oral capsuleTier 1oxycodone hcl oral concentrateTier 1oxycodone hcl oral solutionTier 1oxycodone hcl oral tabletTier 1OXYCONTIN ORALTier 3oxymorphone hcl oral tabletTier 1tramadol hcl oral tabletTier 1*Opioid n-codeine #2 oral tabletTier 1acetaminophen-codeine #3 oral tabletTier 1acetaminophen-codeine #4 oral tabletTier 1acetaminophen-codeine oral solutionTier 1ascomp-codeine oral capsuleTier 1butalbital-apap-caff-cod oral capsuleTier 1butalbital-asa-caff-codeine oral capsuleTier 1*Opioid one-acetaminophen oral solution7.5-325 mg/15mlTier 1hydrocodone-acetaminophen oral tablet10-300 mg, 10-325 mg, 2.5-325 mg, 5-300mg, 5-325 mg, 7.5-300 mg, 7.5-325 mgTier 16NotesPAPA; QL (60 EA per 30 Days)PA
DrugTierhydrocodone-ibuprofen oral tabletTier 1ibudone oral tablet 5-200 mgTier 1reprexain oral tablet 10-200 mgTier 1vicodin es oral tablet 7.5-300 mgTier 1vicodin hp oral tablet 10-300 mgTier 1vicodin oral tablet 5-300 mgTier 1xylon oral tabletTier 1Notes*Opioid Combinations**-*OpioidCombinations***endocet oral tablet 10-325 mg, 5-325 mg,7.5-325 mgTier 1endodan oral tabletTier 1oxycodone-acetaminophen oral tablet 10-325mg, 2.5-325 mg, 5-325 mg, 7.5-325 mgTier 1oxycodone-aspirin oral tablet 4.8355-325 mgTier 1oxycodone-ibuprofen oral tabletTier 1roxicet oral tablet 5-325 mgTier 1*Opioid etaminophen oral tabletTier 1*Opioid Partial Agonists**-*Opioid PartialAgonists***buprenorphine hcl sublingual tabletsublingualTier 1buprenorphine hcl-naloxone hcl sublingualtablet sublingualTier 1butorphanol tartrate nasal solutionTier 1BUTRANS TRANSDERMAL PATCHWEEKLYTier 3pentazocine-naloxone hcl oral tabletTier 1SUBOXONE SUBLINGUAL FILMTier 2PA*Androgens-Anabolic**Anabolic Steroids**-*Anabolic Steroids***ANADROL-50 ORAL TABLETTier 3oxandrolone oral tabletTier 1*Androgens**-*Androgens***ANDRODERM TRANSDERMAL PATCH 24HR 2 MG/24HR, 4 MG/24HRTier 3PA; QL (60 EA per 30 Days)ANDROGEL PUMP TRANSDERMAL 12.5MG/ACT (1%)Tier 2PA; QL (300 GM per 30 Days)7
DrugTierNotesANDROGEL PUMP TRANSDERMAL 20.25MG/ACT (1.62%)Tier 2PA; QL (150 GM per 30 Days)ANDROGEL TRANSDERMAL 20.25MG/1.25GM (1.62%), 40.5 MG/2.5GM(1.62%)Tier 2PA; QL (150 GM per 30 Days)ANDROGEL TRANSDERMAL 25MG/2.5GM, 50 MG/5GMTier 2PA; QL (300 GM per 30 Days)AXIRON TRANSDERMAL SOLUTIONTier 3PA; QL (180 ML per 30 Days)danazol oral capsuleTier 1DEPO-TESTOSTERONEINTRAMUSCULAR* SOLUTIONTier 3FORTESTA TRANSDERMALTier 3METHITEST ORAL TABLETTier 2testosterone cypionate intramuscular*solutionTier 1SItestosterone enanthate intramuscular*solutionTier 1SI*Anorectal Agents**Intrarectal Steroids**-*IntrarectalSteroids***colocort enemaTier 1CORTIFOAM FOAMTier 3hydrocortisone enemaTier 1*Rectal am-hc lotionTier 1hydrocortisone ace-pramoxine creamTier 1hydrocortisone ace-pramoxine kitTier 1lidocaine-hydrocortisone ace 2.8-0.55 %Tier 1lidocaine-hydrocortisone ace creamTier 1lidocaine-hydrocortisone ace kit 2-2 %, 3-1%, 3-2.5 %Tier 1PROCTOFOAM HC FOAMTier 3*Rectal Steroids**-*Rectal Steroids***anucort-hc suppositoryTier 1hydrocortisone acetate suppositoryTier 1proctosol hc creamTier 1proctozone-hc creamTier 1*Vasodilating Agents**-*NitrateVasodilating Agents***RECTIV OINTMENT8Tier 3PA; QL (120 GM per 30 Days)
elmintics***ALBENZA ORAL TABLETTier 2BILTRICIDE ORAL TABLETTier 2ivermectin oral tabletTier 1*Antianginal *RANEXA ORAL TABLET EXTENDEDRELEASE 12 HR*Tier 3*Nitrates**-*Nitrates***isoditrate er oral tablet extendedrelease*Tier 1isosorbide dinitrate er oral tabletextendedrelease*Tier 1isosorbide dinitrate oral tabletTier 1isosorbide mononitrate er oral tabletextended release 24 hr*Tier 1isosorbide mononitrate oral tabletTier 1minitran transdermal patch 24 hrTier 1NITRO-BID TRANSDERMAL OINTMENTTier 3NITRO-DUR TRANSDERMAL PATCH 24HR 0.3 MG/HR, 0.8 MG/HRTier 3nitroglycerin er oral capsule extendedrelease*Tier 1nitroglycerin transdermal patch 24 hrTier 1nitroglycerin translingual solutionTier 1NITROSTAT SUBLINGUAL TABLETSUBLINGUALTier 3*Antianxiety Agents**Antianxiety Agents - Misc.**-*AntianxietyAgents - Misc.***buspirone hcl oral tabletTier 1hydroxyzine hcl oral syrupTier 1hydroxyzine hcl oral tabletTier 1hydroxyzine pamoate oral capsuleTier 1meprobamate oral tabletTier 1*Benzodiazepines**-*Benzodiazepines***alprazolam er oral tablet extended release 24hr*Tier 1alprazolam oral tabletTier 19
DrugTieralprazolam oral tablet dispersibleTier 1chlordiazepoxide hcl oral capsuleTier 1clorazepate dipotassium oral tabletTier 1diazepam oral solution 1 mg/mlTier 1diazepam oral tabletTier 1lorazepam oral concentrateTier 1lorazepam oral tabletTier 1oxazepam oral capsuleTier 1*Antiarrhythmics**Antiarrhythmics TypeI-A**-*Antiarrhythmics Type I-A***disopyramide phosphate oral capsuleTier 1NORPACE CR ORAL CAPSULEEXTENDED RELEASE 12 HOUR 100 MGTier 3quinidine gluconate er oral tabletextendedrelease*Tier 1quinidine sulfate er oral tabletextendedrelease*Tier 1quinidine sulfate oral tabletTier 1*Antiarrhythmics TypeI-B**-*Antiarrhythmics Type I-B***mexiletine hcl oral capsuleTier 1*Antiarrhythmics TypeI-C**-*Antiarrhythmics Type I-C***flecainide acetate oral tabletTier 1propafenone hcl er oral capsule extendedrelease 12 hourTier 1propafenone hcl oral tabletTier 1*Antiarrhythmics TypeIii**-*Antiarrhythmics Type Iii***amiodarone hcl oral tabletTier 1MULTAQ ORAL TABLETTier 3pacerone oral tabletTier 1TIKOSYN ORAL CAPSULETier 3*Antiasthmatic And nti-Inflammatory Agents***cromolyn sodium inhalation nebulizationsolution10Tier 1Notes
DrugTierNotes*Asthma And Bronchodilator -g forte oral liquid†Tier 1*Bronchodilators Anticholinergics**-*Bronchodilators Anticholinergics***ATROVENT HFA INHALATION AEROSOL,SOLUTIONTier 2ipratropium bromide inhalation solutionTier 1SPIRIVA HANDIHALER INHALATIONCAPSULETier 2SPIRIVA RESPIMAT INHALATIONAEROSOL, SOLUTIONTier 2TUDORZA PRESSAIR INHALATIONAEROSOL POWDER, BREATH ACTIVATEDTier s***ZYFLO CR ORAL TABLET EXTENDEDRELEASE 12 HR*Tier 3ZYFLO ORAL TABLETTier 3*Leukotriene Modulators**-*LeukotrieneReceptor Antagonists***montelukast sodium oral packetTier 1montelukast sodium oral tabletTier 1montelukast sodium oral tablet chewableTier 1zafirlukast oral tabletTier 1*Selective Phosphodiesterase 4 (Pde4)Inhibitors**-*Selective Phosphodiesterase4 (Pde4) Inhibitors***DALIRESP ORAL TABLETTier 3*Steroid Inhalants**-*Steroid Inhalants***ALVESCO INHALATION AEROSOL,SOLUTIONTier 3ASMANEX 120 METERED DOSESINHALATION AEROSOL POWDER,BREATH ACTIVATEDTier 2ASMANEX 14 METERED DOSESINHALATION AEROSOL POWDER,BREATH ACTIVATEDTier 2PA11
DrugTierNotesASMANEX 30 METERED DOSESINHALATION AEROSOL POWDER,BREATH ACTIVATEDTier 2ASMANEX 60 METERED DOSESINHALATION AEROSOL POWDER,BREATH ACTIVATEDTier 2ASMANEX 7 METERED DOSESINHALATION AEROSOL POWDER,BREATH ACTIVATEDTier 2ASMANEX HFA INHALATION AEROSOL†Tier 2budesonide inhalation suspensionTier 1FLOVENT DISKUS INHALATION AEROSOLPOWDER, BREATH ACTIVATEDTier 3PAFLOVENT HFA INHALATION AEROSOL†Tier 3PAPULMICORT FLEXHALER INHALATIONAEROSOL POWDER, BREATH ACTIVATEDTier 2PULMICORT INHALATION SUSPENSION 1MG/2MLTier 2QVAR INHALATION AEROSOL, SOLUTIONTier AIR DISKUS INHALATION AEROSOLPOWDER, BREATH ACTIVATEDTier 3PAADVAIR HFA INHALATION AEROSOL†Tier 3PACOMBIVENT RESPIMAT INHALATIONAEROSOL, SOLUTIONTier 2DULERA INHALATION AEROSOL†Tier 2ipratropium-albuterol inhalation solutionTier 1SYMBICORT INHALATION AEROSOL†Tier 2*Sympathomimetics**-*BetaAdrenergics***albuterol sulfate er oral tablet extendedrelease 12 hr*Tier 1albuterol sulfate inhalation nebulizationsolutionTier 1albuterol sulfate oral syrupTier 1albuterol sulfate oral tabletTier 1ARCAPTA NEOHALER INHALATIONCAPSULETier 3BROVANA INHALATION NEBULIZATIONSOLUTIONTier 3FORADIL AEROLIZER INHALATIONCAPSULETier 212
DrugTierlevalbuterol hcl inhalation nebulizationsolutionTier 1metaproterenol sulfate oral syrupTier 1metaproterenol sulfate oral tabletTier 1PERFOROMIST INHALATIONNEBULIZATION SOLUTIONTier 3PROAIR HFA INHALATION AEROSOL,SOLUTIONTier 2PROVENTIL HFA INHALATION AEROSOL,SOLUTIONTier 3SEREVENT DISKUS INHALATIONAEROSOL POWDER, BREATH ACTIVATEDTier 2terbutaline sulfate oral tabletTier 1VENTOLIN HFA INHALATION AEROSOL,SOLUTIONTier 2XOPENEX HFA INHALATION AEROSOL†Tier 3Notes*Xanthines**-*Xanthines***elixophyllin oral elixirTier 1LUFYLLIN ORAL TABLET 200 MGTier 3theochron oral tablet extended release 12 hr*Tier 1theophylline er oral tablet extended release12 hr*Tier 1theophylline er oral tablet extended release24 hr*Tier 1theophylline oral solutionTier 1*Anticoagulants**Coumarin N ORAL TABLETTier 2jantoven oral tabletTier 1warfarin sodium oral tabletTier 1*Direct Factor Xa Inhibitors**-*DirectFactor Xa Inhibitors***ELIQUIS ORAL TABLETTier 2XARELTO ORAL TABLETTier 2XARELTO STARTER PACK ORALTier 2QL (60 EA per 30 Days)*Heparins And Heparinoid-LikeAgents**-*Heparins And Heparinoid-LikeAgents***heparin (porcine) lock flush intravenous*solutionTier 113
DrugTierheparin lock flush intravenous* solutionTier 1monoject flush syr/hep lock intravenous*solution 100 unit/mlTier 1Notes*Heparins And Heparinoid-LikeAgents**-*Low Molecular WeightHeparins***enoxaparin sodium injection solutionTier 1enoxaparin sodium subcutaneous* solutionTier 1FRAGMIN SUBCUTANEOUS* SOLUTION10000 UNIT/ML, 12500 UNIT/0.5ML, 15000UNIT/0.6ML, 18000 UNT/0.72ML, 2500UNIT/0.2ML, 5000 UNIT/0.2ML, 7500UNIT/0.3MLTier 3*Heparins And Heparinoid-LikeAgents**-*Synthetic Heparinoid-LikeAgents***fondaparinux sodium subcutaneous* solutionTier 1*Thrombin Inhibitors**-*ThrombinInhibitors - Selective Direct &Reversible***PRADAXA ORAL CAPSULETier 2*Anticonvulsants**Anticonvulsants Benzodiazepines**-*Anticonvulsants Benzodiazepines***clonazepam oral tabletTier 1clonazepam oral tablet dispersibleTier 1DIASTAT ACUDIALTier 2DIASTAT PEDIATRICTier 2DIAZEPAM 10 MG, 2.5 MG, 20 MGTier 2*Anticonvulsants Misc.**-*Anticonvulsants - Misc.***BANZEL ORAL SUSPENSIONTier 3BANZEL ORAL TABLETTier 3carbamazepine er oral capsule extendedrelease 12 hourTier 1carbamazepine er oral tablet extendedrelease 12 hr*Tier 1carbamazepine oral suspensionTier 1carbamazepine oral tabletTier 1carbamazepine oral tablet chewableTier 1epitol oral tabletTier 114PA; QL (60 EA per 30 Days)
Your plan covers drugs listed on the Regence BlueShield Essential Formulary. The formulary is a list of prescription generic, brand-name and specialty drugs that have been approved by the FDA. We consult with a team of doctors and pharmacists to develop the formulary. It can help you and your doctor choose effective drugs that can save you money.
