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BNSF Prescription ProgramPreventive Therapy Drug List(07/01/22)ANTI-INFECTIVESANTIRETROVIRAL AGENTSemtricitabine/tenofovir disoproxilfumarate 200/300 mgAPRETUDEDESCOVY(TRUVADA 200/300 RAGMINLOVENOX(PRADAXA)(SAVAYSA)XARELTOPLATELET AGGREGATION INHIBITORSaspirin 81 mgclopidogreldipyridamoledipyridamole ext-rel/aspirinprasugrel(ASPIRIN/OMEPRAZOLE LA)(ZONTIVITY)Over-the-Counter (OTC) products require a prescription.Coverage may vary by plan.ANTICONVULSANTScarbamazepinecarbamazepine ext-relclobazamclonazepamdivalproex sodium delayed-reldivalproex sodium amotrigine ext-rellevetiracetamlevetiracetam n sodium iramate ext-rel)valproic CARBATROLCELONTINDEPAKOTEDEPAKOTE ERDIACOMITDILANTIN(ELEPSIA LKEPPRAKEPPRA XRKLONOPINLAMICTALLAMICTAL XRMYSOLINE(ONFI)OXTELLAR XRPHENYTEKQUDEXY TALTROKENDI XRVIMPATXCOPRIZARONTIN(ZONEGRAN)CARDIOVASCULAR CONDITIONS OTHERANTIARRHYTHMIC opafenonepropafenone ext-relsotalolsotalol AFPacerone(BETAPACE)(BETAPACE AF)MULTAQ(NORPACE)NORPACE CRRYTHMOL SRSORINESOTYLIZETIKOSYNORAL ANTIANGINAL AGENTSisosorbide dinitrateisosorbide mononitrate(Isosorbide mononitrate ext-rel)ISORDILSublingual and chewable formulations are not includedon this list.TRANSDERMAL/TOPICAL ANTIANGINALAGENTSnitroglycerin transdermalNITRO-BIDNITRO-DURCORONARY ARTERY ric acidfenofibric acid delayed-relfluvastatinfluvastatin ext-relgemfibrozilicosapent ethyllovastatinniacin revalite(ALTOPREV)ANTARACOLESTID(CRESTOR)(EZALLOR SPRINKLE)(FENOFIBRIC ACID)FENOGLIDE – except for 120mg tabFIBRICOR(FLOLIPID(LESCOL XL)LIPITORLIPOFEN(LIVALO)LOPID* Products are not covered by BNSF Prescription Program but are covered by BNSF Medical Program.( ) CVS Caremark Formulary Exclusions – require trial and failure of preferred, covered options or approval via prior authorization to be covered. Please refer to the CVSCaremark Performance Drug List for preferred medication options that are available.Some strengths or dosage forms may not be included in the BNSF Prescription Program Preventative Therapy Drug List.Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.
NIASPANPRALUENTQUESTRAN/QUESTRAN OL(ZETIA)ZOCOR(ZYPITAMAG)COMBINATION YTORINDIABETESDIAGNOSTIC AGENTS AND SUPPLIESBLOOD GLUCOSE MONITORS –Accu-Chek & One TouchBLOOD GLUCOSE STRIPS –Accu-Chek & One TouchCONTROL SOLUTIONSINSULIN DELIVERY DEVICES –Plan restrictions may applyINSULIN SYRINGES, INFUSION SETS,AND NEEDLES – Plan restrictionsmay applyKETONE BLOOD TEST STRIPS - ALLLANCETS, LANCET DEVICESURINE TESTING STRIPS - ALLOver-the-Counter (OTC) products require a prescription.Coverage may vary by plan.INHALED DIABETES AGENTS(AFREZZA)INJECTABLE DIABETES AGENTS(ADLYXIN)(ADMELOG)(APIDRA)BASAGLAR KWIKPEN(BYDUREON BCISE)(BYETTA)FIASP(HUMALOG)(HUMULIN)(INSULIN ASPART)(INSULIN ASPART 70/30)(INSULIN GLARGINE)(INSULIN EOTRESIBATRULICITYVICTOZAXULTOPHYOver-the-Counter (OTC) products require a prescription.Coverage may vary by plan.ORAL DIABETES de ext-relglipizide/metforminmetforminmetformin LUS METACTOPLUS MET XR(ACTOS)AMARYLDUETACTFARXIGAGLUCOTROL XL(GLUMETZA – and its generics)GLYXAMBI(INVOKAMET)(INVOKAMET XR)(INVOKANA)JANUMETJANUMET XRJANUVIAJARDIANCE(JENTADUETO)(JENTADUETO XR)(KAZANO)(KOMBIGLYZE YNJARDYSYNJARDY XR(TRADJENTA)(TRIJARDY XR)XIGDUO XRHEMATOLOGIC AGENTSADVATEADYNOVATEAFSTYLAALPHANATEALPHANINE T(FEIBA)HEMOFIL MHUMATE-PIDELVIONIXINITYJIVIKOATE-DVIKOGENATE ISTRETTENXYNTHAHYPERTENSIONACE INHIBITORS/ANGIOTENSIN II RECEPTORANTAGONISTS AND COMBINATION rothiazidetrandolapriltrandolapril/verapamil RILACCURETICALTACE(ATACAND)(ATACAND HCT)AVALIDEAVAPRO(BENICAR)* Products are not covered by BNSF Prescription Program but are covered by BNSF Medical Program.( ) CVS Caremark Formulary Exclusions – require trial and failure of preferred, covered options or approval via prior authorization to be covered. Please refer to the CVSCaremark Performance Drug List for preferred medication options that are available.Some strengths or dosage forms may not be included in the BNSF Prescription Program Preventative Therapy Drug List.Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.
(BENICAR HCT)(COZAAR)(DIOVAN)(DIOVAN NSIN HCTLOTREL(MICARDIS)(MICARDIS HCT)(PRESTALIA)QBRELISTRANDOLAPRIL/VERAPAMIL ERVASERETICVASOTEC(ZESTORETIC)ZESTRILBETA-BLOCKERS AND othiazidecarvedilolcarvedilol phosphate ext-rellabetalolmetoprololmetoprolol succinate lolpindololpropranololpropranolol ext-reltimolol maleateBYSTOLICCOREG(COREG CR)CORGARD(DUTOPROL)(INDERAL PROL-XL)TRANDATEZIACCALCIUM CHANNEL BLOCKERS ANDCOMBINATION AGENTSamlodipinediltiazem(diltiazem ext-rel)diltiazem XRfelodipine ext-relisradipinenicardipinenifedipinenifedipine ext-relnisoldipine ext-relverapamilverapamil ext-relCartia XTDilt-XR(Matzim LA)Nifediac CCTaztia XTCALAN SR(CARDIZEM)(CARDIZEM CD)(CARDIZEM LA)CONJUPRIISOPTIN SR(KATERZIA)NORLIQVA(NORVASC)PROCARDIA XLSULARTIAZACVERELANVERELAN DACTAZIDEDIURILMAXZIDE(THALITONE)OTHER ANTIHYPERTENSIVE misartanclonidineclonidine (EXFORGE)(EXFORGE HCT)METHYLDOPATEKTURNATEKTURNA HCTTRIBENZORIMMUNIZING AGENTSALLERGENIC EXTRACTSALLERGENIC EXTRACTS*IMMUNIZATIONSVACCINES *MENTAL onbupropion ext-relcitalopramdesipraminedesvenlafaxine ext-reldoxepinduloxetine delayed-relescitalopramfluoxetinefluoxetine delayed-relimipramine HClimipramine pamoatemirtazapinenortriptylineparoxetine HClparoxetine HCl ominetrazodonetrimipraminevenlafaxinevenlafaxine ENLAFAXINE ER(DRIZALMA SPRINKLE)(EFFEXOR XR)EMSAMFETZIMAFLUOXETINE 60 mgFORFIVO ARNATE(PAXIL)(PAXIL CR)(PEXEVA)(PRISTIQ)(PROZAC)REMERON(SERTRALINE CAP)TRINTELLIX(VIIBRYD)WELLBUTRIN SRWELLBUTRIN promazineclozapinefluphenazinefluphenazine decanoatehaloperidolloxapineolanzapine* Products are not covered by BNSF Prescription Program but are covered by BNSF Medical Program.( ) CVS Caremark Formulary Exclusions – require trial and failure of preferred, covered options or approval via prior authorization to be covered. Please refer to the CVSCaremark Performance Drug List for preferred medication options that are available.Some strengths or dosage forms may not be included in the BNSF Prescription Program Preventative Therapy Drug List.Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.
olanzapine orally disintegrating tabspaliperidoneperphenazinequetiapinequetiapine razineziprasidone(ABILIFY)(ABILIFY MAINTENA)(ABILIFY DONHALDOL DECANOATEINVEGAINVEGA SUSTENNA(INVEGA TRINZA)LATUDA(LYBALVI)REXULTIRISPERDALRISPERDAL CONSTASAPHRIS(SECUADO)SEROQUEL(SEROQUEL XR)VERSACLOZVRAYLARZYPREXAZYPREXA ZYDISOBSESSIVE COMPULSIVE DISORDERclomipraminefluvoxaminefluvoxamine /salmonibandronateraloxifenerisedronatezoledronic acid 5 mg/100 mLACTONELATELVIABINOSTOBONIVABONIVA INJECTION(EVENITY)EVISTAFORTEOFOSAMAXFOSAMAX PLUS D(MIACALCIN NASAL SPRAY)PROLIARECLAST(TERIPARATIDE)TYMLOSPREVENTIVE CARE SERVICESAGENTS FOR CHEMICAL DEPENDENCYacamprosate calciumbuprenorphine sublingualbuprenorphine/naloxone BOXONE FILM)VIVITROLZUBSOLVANTI-OBESITY AGENTSbenzphetaminediethylpropiondiethylpropion )(LOMAIRA)(PHENDIMETRAZINE ER)QSYMIASAXENDAWEGOVY(XENICAL)BOWEL PREPARATIONSpeg P)NULYTELY(OSMOPREP)(PLENVU)(SUPREP)(SUTAB)SMOKING DETERRENTSbupropion ext-relnicotine polacrilexnicotine transdermalvareniclineCHANTIXNICODERM CQNICORETTE GUMNICORETTE LOZENGENICOTROL INHALERNICOTROL NSOver-the-Counter (OTC) products require a prescription.Coverage may vary by plan.MISCELLANEOUScholecalciferol (D3)Over-the-Counter (OTC) products require a prescription.Coverage may vary by plan.RESPIRATORY DISORDERSRESPIRATORY AGENTSbudesonide suspension(budesonide/formoterol)cromolyn sodium nebulizer st(zileuton ext-rel)(Wixela Inhub)ACCOLATEADVAIRADVAIR HFA(AIRDUO RESPICLICK)(ALVESCO)ARNUITY ELLIPTA(ASMANEX)(ASMANEX HFA)BREO ELLIPTA(CINQAIR)(DULERA)FASENRAFLOVENT DISKUSFLOVENT HFAFLUTICASONE FUROATE/VILANTEROL ELLIPTAFLUTICASONE PROPIONATE HFANUCALAPULMICORTPULMICORT FLEXHALERQVAR REDIHALER(SINGULAIR)SPIRIVA RESPIMAT 1.25 mcgSYMBICORTSYNAGISTEZSPIRETRELEGY ELLIPTAXOLAIRZYFLOSUPPLIES (Plan restrictions may apply)PEAK FLOW METERSSPACER DEVICESSPACER SUPPLIESVARIOUS CONDITIONSANTI-MALARIAL maquine(ARAKODA)MALARONEPRIMAQUINEDENTAL CARIES PREVENTIONsodium fluoridePEDIATRIC MULTIVITAMINS WITHFLUORIDE – Plan restrictions mayapplyHEREDITARY ANGIOEDEMA UPPRESSIVE AGENTScyclosporine capseverolimus* Products are not covered by BNSF Prescription Program but are covered by BNSF Medical Program.( ) CVS Caremark Formulary Exclusions – require trial and failure of preferred, covered options or approval via prior authorization to be covered. Please refer to the CVSCaremark Performance Drug List for preferred medication options that are available.Some strengths or dosage forms may not be included in the BNSF Prescription Program Preventative Therapy Drug List.Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.
mycophenolate mofetilmycophenolate sodium delayed-relsirolimustacrolimusGengraf(ASTAGRAF XL)(CELLCEPT)(ENVARSUS MMUNE(ZORTRESS)MULTIPLE SCLEROSIS AGENTSdimethyl fumarate IDERA)TYSABRIVUMERITY(ZEPOSIA)WOMEN'S HEALTHANTIESTROGENStamoxifenSOLTAMOXAROMATASE OMASINFEMARACONTRACEPTIVESCONTRACEPTIVES - ALLPRESCRIPTION FORMULATIONSLimitations on brand-name productsmay applyOver-the-Counter (OTC) emergency contraceptiveproducts require a prescription. Coverage may vary byplan.PRENATAL VITAMINSfolic acidPRENATAL VITAMINS – Planrestrictions may applyOver-the-Counter (OTC) products require a prescription.Coverage may vary by plan.* Products are not covered by BNSF Prescription Program but are covered by BNSF Medical Program.( ) CVS Caremark Formulary Exclusions – require trial and failure of preferred, covered options or approval via prior authorization to be covered. Please refer to the CVSCaremark Performance Drug List for preferred medication options that are available.Some strengths or dosage forms may not be included in the BNSF Prescription Program Preventative Therapy Drug List.Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.
* Products are not covered by BNSF Prescription Program but are covered by BNSF Medical Program. ( ) CVS Caremark Formulary Exclusions - require trial and failure of preferred, covered options or approval via prior authorization to be covered. Please refer to the CVS Caremark
