Select Drug List - Empire Blue Cross Blue Shield

EpidrinEpinastine eye drops QLEpitolEprosartan QLErgocalciferol (Vit D2)capsEry-Tab 250mg,333mg tabErythromcyin eye oint.Erythromycin 2% gel,topical soln.Erythromycinethylsuccinate400mg filmtabErythromycin filmtab,250mg capErythromycin stearateErythromycin/benzoylperoxide gelErythromycin/sulfisoxazoleEscitalopram QL DOEstradiol patch QLEstradiol tabEstrogen/methyltestosteroneEstropipateEthambutolEthosuximideEtodolac, ERFamciclovirFamotidine tab, oral soln.FelbamateFelodipine ER QL DOFenofibrateFenofibric acidFenoprofenFinasteride 5mg tab PAFlavoxateFluconazole tab,oral soln.FlucytosineFludrocortisoneFlunisolidenasal spray ST QLFluocinolone body oil,scalp oilFluocinolone cream,topical soln., oint.,ear dropFluocinonideFluorometholoneeye dropsFluorouracil cream,topical soln.Fluoxetine, DR (except60mg) QL DOFluphenazine tab,oral soln. PAFlurbiprofen eye dropFlurbiprofen tabFluticasonenasal spray QLFluticasone topicalFluvastatin QL DOFluvoxamine QL DOFolic acid 1mgFosinoprilFosinopril/HCTZFurosemide tab, oral soln.Garamycin eye dropsGemfibrozilGentamycineye drops, oint.GlimepirideGlipizide, ER, XLGlipizide/metforminGlyburideGlyburide/metforminGriseofulvinGuaifenesin/codeinesyrup (generic version)GuanfacineGuanidineHalacHalobetasol propionateHaloperidol tab PAHydralazine tabHydrochlorothiazideHydrocodone/acetaminophen QLHydrocortisone tabHydrocortisone 2.5%cream, lotion, oint.Hydrocortisone acetate2% gelHydrocortisone acetatesuppositoryHydrocortisone butyrate0.1% cream, oint., soln.Hydrocortisone enemaHydrocortisone valerate0.2% cream, ointmentHydrocortisone/aceticacid ear dropsHydrocortisone/pramoxine cream,ointmentHydromorphonesuppositoryHydromorphone tab,oral soln. QLHydroxychloroquineHydroxyzine HCL tab,oral soln.Hydroxyzine pamoateIbandronate QLIbuprofenImipramine HCL tabImiquimod cream PA QLIndapamideIndomethacin , ER capIpratropium bromide nebsoln. QLIrbesartan QL DOIrbesartan/HCTZ QL DOIsometheptene/acetaminophen/caffeineIsometheptene/acetaminophen/dichloralphenazoneIsonarifIsoniazid tab, oral soln.Isosorbide dinitrate,ER tabIsosorbide mononitrate,ER tabsIsradipineKetoconazoleKetoprofen, ERKetorolac eye dropsKetorolac tab QLKlor-Con tabLabetolol tabLactuloseLamotrigine tab(immediate release)Lansoprazole PA QLLatanoprostLevobunolol eye dropsLevofloxacin tab QLLevonorgestrel tab QLLevothroidLevothyroxine tabLevoxylLidocaine viscous soln.Lidocaine/hydrocortisone3/0.5% creamLidocaine/prilocaineLindaneLiothyronine tabLisinoprilLisinopril/HCTZLithium carbonate, ERLithium citrate oral soln.Losartan QL DOLosartan/HCTZ QL DOLovastatin QL DOLoxapine PAMalathionMaprotilineMatzim LA QL DOMebendazoleMeclizine tabMeclofenamate capMedroxyprogesteronetabMefenamic acidMefloquineMegestrolMeloxicam oralsuspensionMeloxicam tab QLMeperidine tab,oral soln. QLMeprobamate QLMetadate ER PA QLMetaproterenolMetaxaloneMetformin, ERMethadone tab,oral soln. QLMethamphetamine PA QLMethanamine MDMethazolamideMethimazoleMethocarbamolMethscopolaminebromideMethyclothiazideMethyldopaMethyldopa/HCTZMethylergonovine tabMethylphenidate, CD, ER,SR PA QLMethylprednisolone tabMetipranolol eye dropsMetoclopramide tab,oral soln.Metoprolol tab, ERMetoprolol/HCTZMetronidazole 0.75% gelMetronidazole tab,capsule, cream, lotionMiconazole 200mgvaginal suppositoryMinocyclineMinocycline ER PAMinoxidil tabMirtazapineMisoprostol PAModafinil PA QLMoexiprilMoexipril/HCTZMometasone cream, oint,topical soln.Montelukast QLMorgidox caps PAMorphine sulfate IRtab QLMorphine sulfateoral soln. QLMorphine sulfatesuppositoryMupirocin oint.NabumetoneNadololNadolol/bendroflumethiazideNaltrexoneNaphazoline eye dropsNaproxen, DRNaratriptan QLNature-ThroidNefazodoneNeomycin tabNeomycin/polymixin/bacitracin eye oint.Neomycin/polymixin/bacitracin/hydrocortisone eye oint.Neomycin/polymixin/dexamethasoneeye drops, oint.Neomycin/polymixin/gramicidin eye dropsNeomycin/polymixin/hydrocortisone ear andeye dropsNicardipine capsNifedipine capNifedipine tab ER, XLQL DONisoldipine ER QL DONitro-Bid oint.NitrofurantoinNitroglycerin, ER, SRNizatidineNorethindroneNortriptylineNP ThyroidNystatin cream, oint.,powder, tab, susp.Nystatin/triamcinoloneOfloxacin ear andeye dropsOfloxacin tab QLOmeprazole caps QLOrphenadrine EROxaprozinOxcarbazepineOxybutynin, EROxycodone QLOxycodone/acetaminophen tab,cap QLOxycodone/aspirin QLOxymorphoneOxymorphone ER QLPancrelipaseParamomycinParoxetine, CR, ER QL DOPenicillin VKPentoxifylline, ERPerindoprilPermethrin creamPerphenazine PAPhenazopyridinePhenelzinePhenobarbital tab,oral soln.Phenytoin ext. capPilocarpine eye dropsPindololPioglitazone QLPiroxicamPodofiloxPolymixin/trimethoprimeye dropsPotassium chloride ERtab, ER capPotassium citrate ER TabPramipexolePravastatin QL DOPrazosin3

PrednicarbatePrednisolone eye dropsPrednisolone oral soln.PrednisonePrenatal Vitamins(all generic covered)PrimidoneProbenecidProbenecid/colchicineProcentra QLProchlorperazine tabProgesterone,micronized capPromethazine tab,suppository, syrupPromethazine VC syrupPromethazine VC syrupwith codeinePromethazine/codeine syrupPromethazine-DM syrupPropranolol ERPropranolol tab, oral soln.Propranolol/HCTZPropylthiouracilProtriptylinePyrazinamideQuetiapine PAQuinaprilQuinapril/HCTZQuinidine sulfate, ERQuinine sulfate PA QLRamiprilRanitidine 150mg,300mg tab, capRanitidine oral soln.RifampinRimantadineRisperidone, ODT,oral soln. PARizatriptan, ODT QLRopinirole, ERRosadan cream and gelRoxicet tab, caplet QLSelegilineSelenium sulfide 2.5%lotion, shampooSertraline QL DOSilver sulfadiazine creamSimvastatin 80mg PA QLSimvastatin QL DOSodium polystyrenesulfate 30gm/120mlenemaSodium polystyrenesulfate powderSodium polystyrenesulfonateSodiumsulfacetamide/sulfurSodium sulfacetamide/sulfur/ureaSpinosadSpironolactoneSucralfateSulfacetamideeye drops, oint.Sulfacetamide sodiumSulfacetamide sodium/prednisolone eye dropsSulfacetamidesodium/sulfurSulfacetamide sodium/sulfur/ureaSulfacetamidesodium/ureaSulfamethoxazole/trimethoprim, DSSulfasalazineSulindacSumatriptan tab QLTamsulosinTaztia XT QL DOTerazosinTerbinafine tab PATerbutaline tabTerconazoleTetracycline capsTheochron ERTheophylline ER,oral soln.Thioridazine PAThiothixene PATiclopidineTimolol eye drops, gelTimolol tabTizanidineTobramycin eye dropsTobramycin/dexamethasoneeye dropsTolazamideTolbutamideTolmetinTolterodineTopiramate PATorsemide tabTramadol ER 100mg,200mg, 300mg tabs QLTramadol QLTrandolaprilTranexamic acid 650mgTranylcypromineTrazodoneTretinoin cream, gel PATriamcinolone cream,lotion, oint.Triamcinolonenasal spray QLTriamcinolone pasteTriamterene/HCTZTrifluoperazine PATrifluridine eye dropsTrihexyphenidylTrimethobenzamide capTrimethoprimTrimipramineTropicamide eye dropsUnithroidValacyclovirValproid acid cap,oral soln.Valsartan/HCTZ QL DOVenlafaxineVenlafaxine ER QL DOVerapamil tab, ER PMQL DOVerapamil tab,ER tab, capVicodin, ES, HP QLWarfarinWesthroidZafirlukastZaleplon QLZenatane PAZenzedi 5mg, 10mgPA QLZiprasidone PAZolmitriptan QLZolpidem(immediate release) QLTier 2AcamprosateAccu-Chek Product LineAcitretinAdvair Diskus, HFA QLAnaspaz ODTAsmanex Twisthaler QLBethanechol tabBromfenac eye dropsBudesonide ECBuprenorphinesyringe, vialCalcitonin nasal spray QLCalcium acetate tabCefpodoximeCevimelineCilostazolClozapine, ODT PADanazolDantroleneDemeclocyclineDesipramineDihydroergotaminenasal spray QLDulera QLEliphosEntacaponeEpipen, Jr.EplerenoneErgoloidEvistaFentanyl patch ST QLFlecainideFlovent HFA QLFlovent QLFortical nasal spray QLGabapentinGalantamine, ER QLGlucagenGranisetron tab QLHumalogHumalog MixHumulin N, R, 70-30Itraconazole PAKetorolac inj. QLLantusLantus SolostarLeflunomideLevalbuterol neb soln.LevemirLevemir FlexpenLevetiracetamLevetiracetam ER PA QLLevocarnitine tab,oral soln.Levorphanol tab QLMafenide acetatepowder packMethenamine hippurateMexiletineMorphine sulfate ER QLNateglinide PANimodipineNitroglycerin sprayNitrostatNovolinNovologNovolog MixOlanzapine tab, ODT PAOndansetron tab, ODT,oral soln. QLOne Touch Product LineOxandrolone PAPantoprazole QLPilocarpine tabsProair HFA QLPropafenonePrudoxinPulmicort 1mg/2mLrespules QLPulmicort Flexhaler QLQvar QLRelenza QLRepaglinide PARivastigmine QLSerevent Diskus QLSorineSotalol tab, AF tabSulfadiazineSumatriptan inj QLSymbicort QLTamiflu QLTiagabineTranexamic acid1000mg/10mLTrospium chloride ERUrsodiolVancomycin caps PAZenpepZonisamideTier 3AbacavirAbilify tab PAAciphex QLActonel ST QLAczoneAdcirca PAAdefovirAfinitor DisperzAfinitor PAAggrenox QLAlamast PAAlbenzaAliniaAlkeran tabAlocril PA QLAlomide PA QLAltabaxAmevive PAAmitizaAmpyra PA QLAnadrol-50AnagrelideAnastrazole tab PAAndrogel PA QLAntivert 50mgAnzemet tablet QLApidra, Solostar STApriso ERAptivusAranesp PAArestinAtacand† QL DOAtriplaAubagio PA QLAvodartAxert ST QLAzathioprine tabAzelex PAAzilectAzoptBaraclude PABenicar QL DOBepreve PA QLBesivanceBeyazBicalutamideBiltricideBosulif PABrilinta QLBrovana QLBuphenyl tablet PABydureon ST QLBystolicCambia QL4

Campral†CantilCaprelsa PACarbaglu PACedaxCeeNUCelebrex ST QLCelontinCenestinCesamet STChemetCialis 2.5mg, 5mg PACiclodan kitCimzia PA QLCipro HC ear dropsCiprodex ear drops PAClindacin kitClodermCoartemColcrys PA QLColy-Mycin ear dropsCombiganCometriq PACordran, SPCortisporin cream, oint.Crestor ST QL DOCresylateCrixivanCuprimineCyclophosphamide tabCyclosporine cap, soln.Cymbalta PA QL DODaliresp QLDapsoneDaraprimDexilant ST QLDibenzylineDidanosine DRDifferin 0.1% lotion,0.3% gelDificid PADiovan QL DODipentumDroxiaDurezol QLDyreniumEdarbi QL DOEdecrinEdurantEffient QL DOElidel PAEllaElmironEmadine PA QLEmcyt PAEmsam QLEmtrivaEnablex STEnbrel PA QLEnjuviaEnoxaparin PAEpiduoEpivir HBV soln. PAEpzicomErivedge PAErtaczoEstringEtoposide capsEuraxExalgo ER ST QLExeldermExemestane PAExjade PAExtavia PAFactive QLFanapt PAFarestonFemtraceFerriprox PAFinaceaFlector STFluoroplexFlutamideFML S.O.PFocalin XR PA QLFondaparinux PAForteo PA QLFosamax Plus D ST QLFosrenol PAFragmin PAFrova ST QLFuzeonGeneress FeGengrafGilotrifGleevec PAGlysetHalogHepsera†HexalenHorizant PAHumira PA QLHycamtin capsHydroxyureaIclusig PAIncrelex PAInfergenInlyta PAInnohep PAIntelenceIntron A PAIntuniv ER PAInvega tab PAInviraseIsentressJakafi PAJanumet, XR QLJanuvia ST QLKaletraKapvay, ER PAKetekKineret PALacrisertLamuvidineLamuvidine/zidovudineLanoxin tabLatuda PALetairis PALetrozoleLeucovorin tabLeukeranLeuprolide PALevatolLexivaLivalo ST QL DOLo Loestrin FeLo Minastrin FeLodosyn STLoestrin 24 FeLomustineLotemaxLotronexLovazaLumiganLunesta PA QLLyrica PA QLLysodrenMarplanMatulaneMaxair QLMaxalt, MLT† QLMekinist PAMenestMentaxMepronMepron PAMercaptopurineMethitestMethotrexate tabMicardis QL DOMigranal nasal spray† QLMinastrin 24 FEMorgidox kit PAMotofenMoviprepMultaqMycobutinMycophenolateMyleranNaftinNamenda QLNatacynNataziaNeulasta PA QLNeupogen PANevanacNevirapineNexavar PANexium PA QLNiaspan ERNilandronNoroxin QLNorvirNucynta, ER QLNuedextaNuoxNuvaringNuvigil PA QLOfortaOmnaris ST QLOnglyza ST QLOraceaOrap PAOrfadinOrtho EvraOrtho Tri-cyclen LoOxistatOxsoralen-Ultra PAOxycontin ST QLPanretinPataday PA QLPatanase QLPatanol PA QLPeganonePegasys PA QLPegintron PAPerforomist QLPhisohexPhospholine iodidePomalystPradaxa QLPrandin† PAPred-GPred-G S.O.P.Premarin creamPremarin tabPremphasePremproPrevident 5000Booster PlusPrezistaPrimaquinePrimsolPristiq QL DOProcrit PAProglycemProlia PAPromacta PAProquin XRProtopic PAProventil HFA QLQuartetteRanexaRapafloRapamuneRebif PARebif Rebidose PAReclast†RectivRegranexRelistor PARelpax ST QLRemicade PARemodulin PARenvela PARescriptorRestasisRevlimid PA QLReyatazRibavirin PARidauraRifaterRilutek†RiluzoleRituxan PARosadan kitRozerem ST QLSabrilSafyralSamsca PASantylSaphris PASavella QLSelzentrySensiparSeroquel XR PASildenafil 20mg tab PASilenorSimponi Aria PA QLSimponi PA QLSkelidSolaraze PA QLSomatulineSoriatane†Spiriva QLSprycel PAStavudineStelara PA QLStivarga PAStrattera PA QLStromectolSuboxone Film PA QLSulfamylon creamSulfamylon powderpacket†Suprax cap, tab, susp.SustivaSutent PASymlin PASynarel PASyneraSyprineTabloidTaclonexTacrolimusTafinlarTamoxifenTarceva PATargretin PATasigna PA5

For more information, please visit empireblue.com.}}If you have additional questions about your prescription benefits,please call the Member Services number on your ID card.}}Speech and hearing impaired (TDD/TTY users) should call800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m., ET.}}For the most current version of this Select Drug List,please visit empireblue.com.Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.40625NYMENEBS Effective 1/14