BCBSM and BCN Custom Drug List (Formulary) July 2013
Table of contents
BCBSM and BCN Custom Drug List (Formulary) introduction
5
Blue Care Network Prior authorization and step therapy guidelines
8
Blue Cross Blue Shield of Michigan Prior authorization and step therapy criteria
26
BCBSM/BCN Preferred alternatives 59
Generic substitution and Preferred alternatives 59
Dose optimization and quantity limits 68
Anti-infectives
1A 69Penicillins
1B 69Cephalosporins
1C 70Tetracyclines
1D 70Macrolides
1G 71Urinary Tract Agents
1F 71Sulfonamides and Combinations
1E 71Quinolones
1H 72Antifungals
1I 72Antivirals
1J 73Antiretrovirals
1K 74Antimalarials
1L 74Antituberculars
1N 75Miscellaneous Anti-infectives
1M 75Antiparasitics/Anthelmintics
Cardiovascular, hypertension, cholesterol
2A 76Lipid-lowering Agents
2B 77Beta Blockers and Combinations
2C 78ACE-Inhibitors and Combinations
2D 79Angiotensin II Receptor Blockers and Combinations
2E 80Calcium Channel Blockers and Combinations
2F 81Diuretics
2G 81Cardiovascular Treatment
2I 82Anticoagulants and Hemostasis Agents
2H 82Nitrates and Combinations
2K 83Miscellaneous Antihypertensives
2J 83Alpha-adrenergic Agents
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Central nervous system
3A 84Antidepressants
3C 85Anxiolytics
3B 85Antipsychotics
3D 86Sedative/Hypnotics
3E 86CNS Stimulants
3G 87Salicylates
3F 87Nonsteroidal Anti-inflammatory Drugs
3H 88Narcotics
3J 89Narcotic Mixed Agonist/Antagonist
3I 89Narcotic/Analgesic Combinations
3K 90Narcotic Antagonists
3M 90Migraine Therapy
3O 91Parkinsons Disease and Related Disorders
3P 92Anticonvulsants
3Q 93Skeletal Muscle Relaxants
3R 93Myesthenia Gravis
3S 94Miscellaneous CNS
Gastrointestinal agents
4A 95H2-Receptor Antagonists
4B 95Proton Pump Inhibitors
4C 95Other Ulcer Therapy
4E 96Antiemetics
4D 96Antidiarrheals and Antispasmodics
4G 97Digestive Enzymes
4F 97Bile Acids
4H 98Miscellaneous Gastrointestinal Agents
Obstetrics and gynecology
5A 99Contraceptives-Monophasic
5B 99Contraceptives-Biphasic
5E 100Contraceptives-Postcoital
5D 100Contraceptives-Misc.
5C 100Contraceptives-Triphasic
5G 101Estrogens
5F 101Progestins
5H 102Estrogen/Progestin Combinations
5J 102Infertility Treatment
5L 103Miscellaneous OB-GYN
5K 103Vaginal Anti-infective/Antifungal
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Rheumatology and musculoskeletal
6A 104Salicylates
6B 104Gout Therapy
6C 104Corticosteroids
6D 105Miscellaneous Rheumatologic Agents
6E 105Osteoporosis/Hormonal Treatment
6F 106Osteoporosis/Bone Resorption
Endocrinology
7B 107Thyroid Hormones
7C 107Corticosteroids
7A 107Antithyroid Agents
7D 108Androgens
7E 109Miscellaneous Endocrine
7F 110Insulins
7G 111Non-insulin Hypoglycemic Agents
7H 112Growth Hormone and Related Products
Antineoplastics and immunosuppresants
8B 113Antimetabolites
8A 113Alkylating Agents
8D 114Hormonal Agents
8C 114Immunomodulators
8E 115Miscellaneous Antineoplastic Agents
8F 115Adjuvant Therapy
8G 116Kinase Inhibitors and Molecular Target Inhibitors
Immunology and hematology
9A 117Immunoglobulins
9B 117Hematopoietic Agents
9C 118Interferons and MS Therapy
Dermatology
10B 119High Potency Corticosteroids
10A 119Very High Potency Corticosteriods
10C 120Medium Potency Corticosteroids
10D 120Low Potency Corticosteroids
10E 120Topical Anesthetics
10F 121Acne Treatment
10I 122Topical Antivirals
10H 122Topical Antifungals
10G 122Topical Antibacterials
10J 123Wound and Burn Therapy
10K 123Antipsoriatic/Antiseborrheic
10L 123Scabicides/Pediculicides
10M 124Miscellaneous Dermatologicals
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Ophthalmology
11B 125Other Glaucoma Agents
11A 125Ophthalmic Beta Blockers
11C 126Cycloplegic Mydriatics
11D 126Ophthalmic Anti-inflammatory Agents
11F 127Ophthalmic Steroids
11E 127Ophthalmic Anti-infectives
11G 128Ophthalmic Anti-infective/Steroid Combinations
11H 128Miscellaneous Ophthalmic Agents
Otic and nasal preparations
12A 129Nasal Preparations
12B 129Otic Preparations
Respiratory, cough and cold
13B 130Antihistamine/Decongestant Combinations
13A 130Antihistamines
13C 130Antitussive combinations
13F 131Oral Beta-Agonists
13G 131Inhaled Beta-Agonists
13D 131Expectorant combinations
13J 132Theophyllines
13H 132Inhaled Steroids
13I 132Intranasal Steroids
13L 133Miscellaneous Pulmonary Agents
13K 133Epinephrine
Urology
14B 134Miscellaneous Urologicals
14A 134Urinary Antispasmodics
14C 135BPH Treatment
Vitamins and supplements
15A 136Vitamins and Minerals
15B 136Potassium Replacement
Diagnostic and other miscellaneous
16A 137Diagnostics and Other Miscellaneous
Lifestyle modification
17C 138Smoking Cessation
17A 138Impotence
17B 138Weight Loss Preparations
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*Most generic drugs and some brand-name drugs are Tier 1 at BCN. **Applies to members with a 3-Tier + Specialty Drugs Rx benefit. Page 5
Introduction The BCBSM and BCN Custom Drug List (Formulary) (July 2013 update) is a useful reference and educational tool for prescribers, pharmacists and members. We regularly update the list of medications approved by the U.S. Food and Drug Administration and reviewed by the BCBSM and BCN Pharmacy and Therapeutics Committee. That means the list represents the clinical judgment of Michigan physicians, pharmacists and other experts in the diagnosis and treatment of disease and the promotion of health. These medications are selected based on safety, clinical effectiveness and opportunity for cost savings. It’s why we can say that the BCBSM and BCN Custom Drug List will help in maintaining the quality of care for our members and containing costs for our clients. Physicians, pharmacists and members should regularly refer to the BCBSM and BCN Custom Drug List for information regarding drug coverage and therapeutic options for BCBSM and BCN members. Physicians are encouraged to prescribe preferred medications whenever possible. The BCBSM and BCN Custom Drug List is divided into major therapeutic categories by chapter for easy use. Products approved for more than one therapeutic indication may be included in more than one chapter. Within each chapter, drugs are identified according to whether they’re generics (Tier 1*), preferred brand (Tier 2), or nonpreferred brand (Tier 3).
Tier 1*: These drugs have a proven record of safety and effectiveness and offer the best value for members. Because they’re Tier 1, they require the lowest copayment, making them your most cost-effective option for treatment. All generic drugs at BCBSM are Tier 1.
Tier 2: Our Tier 2 drugs also have a record of safety and effectiveness, but, because more cost-effective therapies or generic alternatives to these drugs are usually available, most Tier 2 drugs require a higher copayment.
Tier 3: Tier 3 drugs may not have a proven record for safety or their clinical value may not be as high as the drugs in tiers 1 and 2. Depending on the member’s drug coverage, the member may pay a higher copayment or even the entire cost of these drugs.
Specialty — Preferred**: This tier applies to generic and brand-name specialty drugs typically found in Tier 1 and Tier 2.
Specialty — Nonpreferred**: This tier applies to nonpreferred (nonformulary) specialty drugs typically found in Tier 3.
NOTE: When a generic version of a Tier 2 or Tier 3 drug becomes available, the generic version is generally added to Tier 1. The status of the original branded version will be Tier 3 for BCBSM. For all BCN members and some BCBSM members, depending on their plan, there may be a mandatory maximum allowable cost requirement. This means that if a member fills a brand-name drug when a generic version is available, he or she must pay the applicable brand copay as well as pay the difference in cost between the brand-name and generic drug.
BCBSM and BCN respect the judgment of the dispensing pharmacists and expect them to contact the prescriber when a prescription for a drug or dose may not be appropriate for a patient. We also encourage pharmacists to contact the prescriber to suggest an alternative when a BCBSM or BCN member’s prescription is written for a Tier 3 (nonpreferred or non-covered) drug. Drug coverage Coverage and applicable copayment amounts for drugs on the BCBSM and BCN Custom Drug List are based on a member’s drug plan. Not all drugs included in the BCBSM and BCN Custom Drug List are
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necessarily covered by each patient’s plan. Most BCN members don’t have coverage for Tier 3 drugs unless a BCN-affiliated provider certifies that the prescription is medically necessary and BCN agrees. Similarly, BCBSM members with a closed Rx benefit lack coverage for nonpreferred drugs. Some BCBSM and BCN plans may require a different copayment amount or may not cover certain lifestyle drugs. These may include weight-loss products and drugs to treat sexual dysfunction or infertility. BCN’s coverage for drugs used to treat infertility is based on the member’s BCN medical plan. Members should consult their prescription drug benefit packet or contact a customer service representative to determine their specific coverage. Approved medications In general, only FDA-approved prescription medications are eligible for coverage under a member’s policy. When a drug is available in the identical strength and dosage in either a prescription or a nonprescription medication, the prescription medication is usually not covered. In these cases, prescribers should refer the patient to the equivalent over-the-counter product. Certain OTC products, such as loratadine (Claritin®), are covered for BCN members and for some BCBSM members with a prescription. Other exceptions are identified in this document.
Certain medications may be excluded from a BCBSM and BCN member’s pharmacy benefits, but may be covered under their medical benefit. Such medications include serums, vaccines and other medications that are generally administered in a physician’s office under the supervision of appropriate health care personnel and not normally dispensed to the patient for self-administration. Prior approval and step therapy Prior approval may be necessary for coverage of certain medications. In these cases, clinical criteria must be met based on current medical information and approved by the BCBSM and BCN Pharmacy and Therapeutics Committee, or other information must be provided before coverage is approved. Drugs subject to step therapy may require previous treatment with one or more preferred drugs before coverage is approved. The Blue Care Network Prior Authorization and Step Therapy (PA/ST) Guidelines (Pages 8-25) and the BCBSM Prior Authorization and Step-Therapy (PA/ST) Program (Pages 26-58) provide a list of drugs that require prior approval or must meet step-therapy requirements prior to coverage. A description of the BCN PA/ST Guidelines and the BCBSM PA/ST Program are included in this document. To view the most recent version, please go to bcbsm.com/RxInfo. For BCBSM members: Members should consult their prescription drug benefit packet for information on how to obtain prior approval, or call the Customer Service number on the back of their Blues member ID card for additional information. For Physicians: Physicians can access the medication request forms on the web at bcbsm.com, Provider Secured Services - Login. Select the button titled Medication Prior Authorization. The prescribing physician can complete a form online and submit it to us electronically. Prescribers can also look up the status of an electronically submitted request for prior approval of a drug. Call the number below if you have questions about prior approval, prefer to conduct a review over the phone or want hard-copy medication request forms. Web - Provider Secured Services - Login
bcbsm.com/index.html Select Medication Prior Authorization
Call 1-800-437-3803 Fax 1-866-601-4425
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Write Blue Cross Blue Shield of Michigan Pharmacy Services P.O. BOX 2320 Detroit, MI 48231-2320
Alternatively, physicians can download the medication request forms on web-DENIS in BCBSM Provider Publications and Resources. Print the electronic form, complete it and submit it to us by fax or mail. For BCN members Members new to BCN can obtain a “Transition Fill” — a one-time, 30-day courtesy fill of a prescription that normally requires prior authorization or step-therapy. Prior authorization is required to continue coverage. To request approval for a drug that requires prior authorization or step-therapy, physicians should contact the BCN Pharmacy Help Desk at 1-800-437-3803. This is the preferred and most efficient method to generate a medication coverage request. You will need to provide your NPI number and the member’s contract number or enrollee ID to access the member’s account information. To avoid delays in processing, it’s important to enter the information as accurately and completely as possible. This will ensure that your call is routed to the correct call center. Post this number in a convenient location in your office for future use. Alternatively, physicians can download the medication request forms through web-DENIS in BCN Provider Publications and Resources. Be sure to identify urgent requests, and return completed request forms to the Pharmacy Services Clinical Help Desk for review. We will notify the physician of approved requests and process the member’s claim accordingly. If a request isn’t approved, we‘ll notify the member and physician in writing. The notification includes the reason for the denial and an explanation of the appeal rights and the appeals process. As part of our 2013 focus on efficient service, drugs are listed alphabetically within each tier. This document is current at the time of publication (January and July) and is subject to change.
Page 9Blue Care Network - Prior Authorization and Step-Therapy Guidelines
Blue Care NetworkPrior Authorization and Step-Therapy Guidelines
July 2013
Blue Care Network’s Prior Approval and Step-Therapy Guidelines help ensure that safe, high-quality cost-effective drugs are prescribed prior to the use of more expensive agents that may not have proven value over current preferred (formulary) medications. Our prior authorization and step-therapy criteria are based on current medical information and have been approved by the BCBSM/BCN Pharmacy and Therapeutics Committee. These guidelines apply to all members with a BCN commercial drug rider.
PRIOR APPROVAL (PA): Drugs requiring PA are covered only if the member meets specific criteria. STEP THERAPY (ST): Drugs subject to ST require previous treatment with one or more preferred
agents prior to coverage.
OTHER UTILIZATION MANAGEMENT TOOLS: • Quantity Limits (QL) and mandatory generic dispensing are applied to all BCN commercial drug
riders. • Specialty drugs <s> are limited to a maximum 30-day supply per fill and are available through
Walgreens Specialty Pharmacy and most retail pharmacies. Some specialty drugs require a 15-day first fill.
• Most BCN members do not have coverage for nonpreferred (nonformulary) drugs. Requests for coverage of nonpreferred drugs are considered when the member meets BCN’s criteria and the member has tried and failed to respond to an adequate trial of the available preferred agents from the same drug class, or the available preferred agents would pose unnecessary risk to the member.
Please visit us online at BCBSM.com/RxInfo for more information.
This information applies to members with a BCN commercial drug benefit. Criteria for BCN AdvantageSM and Blue Cross Complete of Michigan members can be viewed on our Web site: MiBCN.com.
(g)=generic available ANTI-INFECTIVESAnti-Fungals Approval duration: up to 3 monthsNonpreferred:Lamisil® Granules
Requires documentation that the member has experienced treatment failure of or intolerance to at least three months of treatment with griseofulvin (Grifulvin V(g)) suspension.
Miscellaneous Anti-infectives Approval duration: up to 3 monthsNonpreferred: Cayston®
Coverage is provided for the treatment of pneumonia in patients with cystic fibrosis.
Quinolones Approval duration: up to 1 monthPreferred: Cipro®XR(g) (ciprofloxacin-extended release)
Preferred agents:Cipro XR(g): Approved only for uncomplicated urinary tract infection (cystitis). Alternatives include Cipro(g) 100-250mg BID x 3 days and Bactrim DS®(g) BID x 3-5 days.
Antituberculars Approval duration: up to 2 yearsSirturo™ (bedaquiline) Sirturo: Approved for members > 18 years old with pulmonary multi-drug resistant tuberculosis
(MDR-TB).
Page 10Blue Care Network - Prior Authorization and Step-Therapy Guidelines
ANTI-INFECTIVES (Cont.)Tetracyclines Approval duration: up to 1 yearPreferred:Adoxa®(g) (doxycyline),Doryx®(g) (doxycyline),Monodox® 75mg(g) caps (doxycycline monohydrate),Solodyn®(g) (minocycline),
Nonpreferred: Oracea®, Solodyn 55, 65, 80, 105, 115mg; XiminoTM
Preferred agents*:Adoxa(g): Requires documentation that the member has experienced treatment failure of or intolerance to generic doxycycline monohydrate (Monodox (g)).Doryx(g), Monodox 75mg(g): Requires documentation that the member has experienced treatment failure of or intolerance to generic immediate release doxycycline hyclate (Periostat(g), Vibramycin (g), Vibratabs (g))
Nonpreferred agents*:Oracea: Requires documentation that the member has experienced treatment failure of or intolerance to generic doxycycline monohydrate (Monodox (g)).Solodyn 55, 65, 80, 105, 115mg, Ximino: Requires documentation that the member has experienced treatment failure of or intolerance to generic minocycline immediate release (Minocin (g), Dynacin (g)).*Approved if above criteria are met, and a copy of the completed MedWatch form (that has been submitted to the FDA) has been submitted to the plan to document treatment failure of or intolerance to a preferred agent.
ANTINEOPLASTICS & IMMUNOSUPPRESSANTSHormonal Agents Approval duration: up to 1 yearPreferred:Arimidex® (g) (anastrozole), Aromasin® (g) (exemestane), Femara® (g) (letrozole)
PA required for males: Approved only for ER-positive breast cancer treatment.
Immunomodulators Approval duration: up to 1 yearPreferred:Arcalyst™ (rilonacept)
Nonpreferred:Revlimid®
Preferred agents:Arcalyst: Approved for the treatment of cryopyrin-associated periodic syndrome in members ≥12 years of age.
Nonpreferred agents:Revlimid: Approved for treatment of transfusion-dependent anemia due to low or intermediate-1 risk myelodysplastic syndromes (MDS) with deletion 5q abnormality; multiple myeloma, or members with documentation of enrollment in a Phase II-IV investigative study approved by an appropriate Investigational Review Board (IRB). MDS must be confirmed by FISH analysis or other genetic testing.
Kinase Inhibitors & Molecular Target Inhibitors Approval duration: up to 1 yearPreferred:Afinitor, Disperz® (everolimus), Bosulif® (bosutinib),Caprelsa® (vandetanib),Cometriq™ (cabozantinib s-malate),Hycamtin® (topotecan), Iclusig® (ponatinib),Inlyta® (axitinib),Iressa® (gefitinib),Nexavar® (sorafenib),Sprycel® (dasatinib),Stivarga ® (regorafenib), Sutent® (sunitinib),Tarceva® (erlotinib), Tasigna® (nilotinib),Tykerb® (lapatinib),Votrient® (pazopanib),
Cont. next page...
Preferred agents*:Afinitor, Disperz; Bosulif, Caprelsa, Cometriq, Hycamtin, Iclusig, Inlyta, Iressa, Nexavar, Sprycel, Stivarga, Sutent, Tarceva, Tasigna, Tykerb, Votrient:Approved for FDA indication, or requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB. Trial or failure of a preferred therapy may be required before coverage will authorized.
Page 10 Page 11Blue Care Network - Prior Authorization and Step-Therapy Guidelines
ANTINEOPLASTICS & IMMUNOSUPPRESSANTS (Cont.) Kinase Inhibitors & Molecular Target Inhibitors (cont.) Approval duration: up to 1 yearPreferred:Xalkori® (crizotinib),Zelboraf® (vemurafenib)
Nonpreferred:Xtandi®,Zytiga®
Preferred agents*:Xalkori, Zelboraf:Approved for FDA indication, or requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB. Trial or failure of a preferred therapy may be required before coverage will authorized.
Nonpreferred agents*:Xtandi, Zytiga: Requires a diagnosis of metastatic castration-resistant prostate cancer (CRPC) in patients who have previously received chemotherapy treatment with docetaxel. Also requires members to receive concurrent therapy with oral prednisone.
*Approved for FDA indication, or requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB.
Miscellaneous Antineoplastic Agents Approval duration: up to 1 yearPreferred:Erivedge™ (vismodegib),Jakafi® (ruxolitinib) , Zolinza® (vorinostat)
Preferred:Erivedge, Jakafi, Zolinza:Approved for FDA indication, or requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB. Trial or failure of a preferred therapy may be required before coverage will authorized.
CARDIOVASCULAR, HYPERTENSION, CHOLESTEROLAlpha-adrenergic Agents Approval duration: up to 10 yearsNonpreferred:NexiclonTM XR
Requires documentation that member has experienced failure of or intolerance to Catapres(g) or Catapres-TTS(g).
Angiotensin II Receptor Blockers (ARBS) Approval duration: up to 10 yearsPreferred:Atacand® (g) (candesartan), HCT(g), Benicar® (olmesartan medoxomil), HCT; Diovan® HCT(g) (valsartan/hctz)
Nonpreferred:Azor®, Diovan, Edarbi®, Edarbyclor®, Exforge®, HCT; Micardis®, HCT; Teveten® HCT; TribenzorTM, Twynsta®
Preferred agents:Atacand(g), HCT(g); Benicar, HCT; Diovan HCT(g): Requires documentation that the member has experienced intolerance to a generic ARB (Cozaar(g), Hyzaar(g), or Teveten 600mg(g)).
Nonpreferred agents:Diovan, Edarbi, Edarbyclor, Micardis, HCT; Teveten HCT: Requires documentation that the member has experienced treatment failure of or intolerance to two of the following a preferred arb’s: Atacand (g), HCT (g); Avapro (g), Avalide (g), Cozaar(g), Diovan HCT (g), Hyzaar(g), AND Benicar, HCT. Azor, Exforge, HCT; Tribenzor, Twynsta: Requires successful treatment of at least three months of therapy with the individual agents contained in the requested medication at the prescribed dosage.
Beta Blockers Approval duration: up to 10 yearsNonpreferred:Bystolic®, Coreg CR™
Nonpreferred agents:Bystolic: Requires documentation that the member has experienced treatment failure of or intolerance to at least two unique preferred beta blockers, such as betaxolol, atenolol, acebutolol, metoprolol, or bisoprolol. Coreg CR: Requires documentation that the member experienced treatment failure of or intolerance to both carvedilol immediate-release (Coreg(g)) AND metoprolol succinate (Toprol XL(g)).
Cardiovascular Treatment Approval duration: up to 10 yearsNonpreferred:Ranexa®
Ranexa: Requires documentation that the member has experienced treatment failure of or intolerance to both a beta-blocker and a nitrate. The member must have no history of or high risk for cancer.
Page 12Blue Care Network - Prior Authorization and Step-Therapy Guidelines
CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL (Cont.)Cholesterol-Lowering Agents Approval duration: up to 10 yearsPreferred:Kynamro (mipomersen sodium)®
Nonpreferred:Advicor® , Altoprev®, Crestor®, Juvisync™, Juxtapid™, Livalo®, Simcor®, Trilipix®, Vytorin®, Vascepa®
Kynamro: Requires documentation that the member has homozygous familial hypercholesterolemia (HoFH), and member is receiving optimal adjunctive treatment with other therapies including a low-fat diet and other oral lipid lowering treatments. Approval Duration: up to 1 year.
Nonpreferred agents:Altoprev, Crestor, Livalo, Vytorin: Requires documentation that member has experienced failure of or intolerance to two generic statins one of which must be high dose (>=40mg) Lipitor(g).Advicor, Juvisync, Simcor: Requires successful treatment of at least three months of therapy with the individual agents contained in the requested medication at the prescribed dosage.Juxtapid: Requires documentation that the member has homozygous familial hypercholesterolemia (HoFH), and member is receiving optimal adjunctive treatmetn with other therapies including a low-fat diet and other oral lipid lowering treatments. Approval Duration: up to 1 year.Trilipix: Requires documentation that the member has experienced treatment failure of or intolerance to ALL generic fenofibrates, such as Lofibra(g) and Lopid(g), and Tricor(g) AND an explanation why Trilipix is expected to work when generic fenofibrates have not. Concomitant use of a statin does not satisfy criteria.Vascepa: Requires documentation that the member has experienced treatment failure of or intolerance to three of the following: Lopid(g), an OTC Omega 3, and a generic fenofibrate (i.e. Antara(g), Lofibra(g) , or Tricor(g)), AND triglyceride levels >500mg/dl.
Miscellaneous Antihypertensives Approval duration: up to 10 yearsNonpreferred:Amturnide®,TekamloTM,Tekturna®, HCT
Amturnide, Tekamlo: Requires successful treatment of at least three months of therapy with the individual agents contained in the requested medication at the prescribed dosage.Tekturna, HCT: Approved for the treatment of hypertension AND requires documentation that the member has experienced treatment failure of or intolerance to ALL of the following drug classes: diuretics, beta-blockers, ACE inhibitors, and angiotensin II receptor blockers (ARBS).
CENTRAL NERVOUS SYSTEMAnticonvulsants Approval duration: up to 10 yearsNonpreferred:GraliseTM,Lyrica®
Nonpreferred:Gralise: Requires documentation that the member has:• Diagnosis of neuropathic pain associated with post-herpetic neuralgia AND the member has
experienced treatment failure of or intolerance to:o Members ≥ 65 years of age: gabapentin 1200 mg per dayo Members < 65 years: gabapentin 1200 mg per day AND a tricyclic antidepressant.
• An explanation why gabepentin extended release is expected to work if gabepentin immediate release has not.
Lyrica: Requires documentation that the member has at least one of the three listed diagnoses: • Seizure disorder that is being treated concurrently with other anticonvulsants • Neuropathic pain associated with either diabetic peripheral neuropathy or post-herpetic
neuralgia or spinal cord injury AND the member has experienced treatment failure of or intolerance to:o Members ≥ 65 years of age: gabapentin 1200 mg per dayo Members < 65 years: gabapentin 1200 mg per day, AND a tricyclic antidepressant.
• Fibromyalgia and documentation that the member has experienced intolerance to gabapentin or inadequate relief from gabapentin 1200 mg per day, AND treatment failure of or intolerance to at least three of the following: a tricyclic antidepressant, an SSRI, an SNRI, cyclobenzaprine, or tramadol.
Additional criteria:• Approvals are granted only at the specific strength requested.• Approved dosage is limited to < 300 mg per day for initial treatment and will not exceed 600 mg per day if 300 mg/day is tolerated.
• Any previous authorizations are discontinued when a new strength is approved.
Page 12 Page 13Blue Care Network - Prior Authorization and Step-Therapy Guidelines
CENTRAL NERVOUS SYSTEM (Cont.)Antidepressants Approval duration: up to 10 yearsPreferred:Luvox CR® (g) (fluvoxamine maleate),Serzone® (g) (nefazodone)
Nonpreferred:AplenzinTM, Cymbalta®, Desvenlafaxine ER, Forvifo XL®, OleptroTM, Pexeva®, Pristiq®, Savella®, ViibrydTM
Preferred agents: Luvox CR(g): Requires documentation that the member has experienced treatment failure of or intolerance to at least three generic antidepressants AND documentation that continued use of Luvox(g) will adversely affect the member’s mental health.Serzone(g): Requires documentation that member has experienced treatment failure of or intolerance to at least three of the following antidepressants (Prozac(g), Celexa(g), Paxil/CR(g) Luvox(g), Zoloft(g), Effexor, XR(g), or Wellbutrin SR, XL(g)).
Nonpreferred agents: Aplenzin, Forvifo XL: Requires documentation that the member has experienced treatment failure of or intolerance to at least three generic antidepressants AND documentation that continued use of Wellbutrin SR/XL(g) will adversely affect the member’s mental health. Forfivo XL: documentation that continued use of Wellbutrin XL(g) will adversely affect the member’s mental health.Cymbalta: •Depressionand/oranxiety: Requires documentation that the member has experienced
treatment failure of or intolerance to at least two generic SSRI’s, and one generic SNRI. •Post-herpeticneuralgiaordiabeticperipheralneuropathy: If older than 65
years, requires treatment failure of or intolerance to gabapentin 1200 mg per day. If under 65 years, requires treatment failure of or intolerance to gabapentin 1200 mg per day and a tricyclic antidepressant.
•Fibromyalgia: Documentation is required to show that the member has experienced intolerance to gabapentin OR inadequate relief from gabapentin 1200 mg per day AND treatment failure of or intolerance to at least three of the following: a tricyclic antidepressant, an SSRI, an SNRI, Flexeril(g), or Ultram(g).
• Chronic musculoskeletal pain: Requires documentation of treatment failure or intolerance of two generic preferred medications from any three drug classes (NSAID, centrally acting analgesics, or antidepressants).
Oleptro: Approved for major depressive disorder in members who have experienced treatment failure of or intolerance to at least three preferred antidepressants one of which is Desyrel®(g) AND documentation that continued use of Desyrel(g) will adversely affect the member’s mental health.Pexeva: Requires documentation that the member has experienced treatment failure of or intolerance to at least three generic antidepressants AND documentation that continued use of Paxil(g) will adversely affect the member’s mental health.Desvenlafaxine ER, Pristiq: Requires documentation that the member has experienced treatment failure of or intolerance to at least three generic antidepressants, one of which is a generic SNRI, AND documentation that continued use of Effexor(g) or Effexor XR(g) will adversely affect the member’s mental health.Savella: Approved for treatment of fibromyalgia AND requires documentation that the member has experienced intolerance to gabapentin or inadequate relief from gabapentin 1200 mg per day and treatment failure of or intolerance to at least three of the following: a tricyclic antidepressant, an SSRI, an SNRI, cyclobenzaprine, or tramadol.Viibryd: Requires documentation that the member has experienced treatment failure of or intolerance to at least three generic antidepressants.
Antipsychotics Approval duration: up to 10 yearsPreferred:Abilify®, Discmelt (aripiprazole), Fazaclo (clozapine),
Nonpreferred: Fanapt®, Fazaclo, Invega®, Latuda®, Saphris®,
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Preferred agents:Abilify, Fazaclo 12.5, 25, 100mg(g): Requires treatment failure of or intolerance to one of the following 2nd generation preferred antipsycotics: Geodon(g), Risperdal(g), Seroquel(g), Zyprexa(g).
Nonpreferred agents:Fanapt, Fazaclo 150, 200mg, Latuda, Saphris: Requires treatment failure of or intolerance to one of the following 2nd generation antipsycotics: Geodon(g), Risperdal(g), Seroquel(g), Zyprexa(g) AND Abilify.
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CENTRAL NERVOUS SYSTEM (Cont.)Antipsychotics (cont.) Approval duration: up to 10 yearsNonpreferred: Invega®, Seroquel XR®
Nonpreferred agents:Invega: Requires documentation that the member has experienced treatment failure of or intolerance Risperdal(g). Maximum dose of Invega is limited to 12 mg per day.Seroquel XR: Requires documentation that the member has experienced treatment failure of or intolerance to Seroquel(g).
CNS Stimulants Approval duration: up to 5 yearsPreferred:Adderall XR® (amphet asp/amphet/d-amphet)(g), Procentra™ (dextroamphetamine), Provigil® (modafinil) (g)
Nonpreferred:Nuvigil®, Quillivant™ XR,Strattera™, Vyvanse™, Xyrem®
Preferred agents:Adderall XR(g): Requires documentation that member has experienced treatment failure of or intolerance to brand name Adderall XR.Procentra: Requires documentation that member has experienced treatment failure of or intolerance to both Metadate CD and Adderall XR; both of which may be sprinkled on food.Provigil(g): Approved only for members with narcolepsy, or obstructive sleep apnea. Dosage limited to a maximum of 400mg per day. Shift-work sleep disorder is not covered since treatment is not medically necessary. Approval duration: up to 10 years
Nonpreferred agents:Nuvigil: Approved for treatment of narcolepsy or obstructive sleep apnea and requires documentation that member has experienced treatment failure of or intolerance to Provigil (g).Approval duration: up to 10 yearsQuivillant XR: Approved for members ≥ 6 years of age who have been diagnosed with ADHD and has completed both a generic formulary methylphenidate and a generic amphetamine product, one of which must be a generic long acting formulation, AND physician provides documentation that the member cannot swallow tablets/capsules and has tried and failed one of the agents that can be opened and sprinkled on apple sauce (e.g. Metadate CD (g) and Adderall XR).Strattera: Approvable when stimulants are contraindicated by medical history OR the following criteria by age:•ForBCNmembersage5to20: Requires documentation that the member has
experienced treatment failure of or intolerance to both a methylphenidate (such as Ritalin(g) or Concerta(g)) AND an amphetamine (such as Adderall(g)).
•ForBCNmembersage21andolder: Requires documentation that the member has experienced treatment failure of or intolerance to either a methylphenidate OR an amphetamine.
•Note: The use of Strattera in members ≤ 4 years of age is not recommended or supported by literature.
Vyvanse: Requires documentation that the member has experienced treatment failure of or intolerance to both a methylphenidate (such as Ritalin(g) or Concerta(g)) AND an amphetamine (such as Adderall(g)).Xyrem: Approved members with a diagnosis of narcolepsy with cataplexy. For members with a diagnosis of narcolepsy with excessive day time sleepiness, requires documentation that member has experienced treatment failure of or intolerance to either methylphenidate or amphetamine AND Provigil(g).Approval duration: up to 1 year
Migraine Therapy Approval duration: up to 10 yearsPreferred:Alsuma® (g) (sumatriptan),Amerge® (g) (naratriptan),Maxalt®, MLT® (g) (rizatriptan),Zomig®, ZMT® (g) (zolmitriptan) Cont. next page...
Preferred agents:Alsuma(g), Amerge(g), Maxalt, MLT(g) Zomig ZMT(g): Requires documentation that member has experienced treatment failure of or intolerance to sumatriptan (Imitrex(g)).
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CENTRAL NERVOUS SYSTEM (Cont.)Migraine Therapy (cont.) Approval duration: up to 10 yearsNonpreferred:Axert®, CambiaTM, Frova®, Relpax®, Treximet®, ZecuityTM, Zomig nasal spray;
Nonpreferred agents:Alsuma, Axert, Frova, Relpax, Zomig nasal spray, Zecuity: Requires documentation that member has experienced failure of or intolerance to both sumatriptan (Imitrex(g)), and Maxalt, MLT(g).Cambia: Requires documentation that member has experienced failure of or intolerance to diclofenac (oral) and one oral generic NSAID.Approval duration: up to 1 yearTreximet: Requires documentation that the member has experienced treatment failure of or intolerance to a combination of sumatriptan (Imitrex(g)) or Maxalt(g) AND naproxen. Documentation as to why sumatriptan (Imitrex(g)) or Maxalt(g) and naproxen as individual agents do not work for and/or may be harmful to the member must be provided.
Miscellaneous CNS Approval duration: up to 1 yearPreferred: Nuedexta® (dextromethorphan/quinidine),Zanaflex® tablets (tizanadine) (g)Zanaflex capsules (tizanadine) (g)
Nonpreferred:Aricept® 23mg
Preferred agents:Nuedexta: Requires documentation that member has a diagnosis of pseudobulbar affect.Zanaflex tablets(g): Requires patient has had trial failure of or intolerance to baclofen and Flexeril(g).Zanaflex capsules(g): Requires patient has had trial failure of or intolerance to the following: baclofen and Flexeril(g), and Zanaflex tablets(g).
Nonpreferred agents:Aricept 23mg: Requires documentation for a progressive-type dementia AND requires successful treatment with Aricept 10mg for three months.Aricept 23mg: Requires documentation for a progressive-type dementia AND requires successful treatment with Aricept 10mg for three months.Intuniv, Kapvay: Approved for treatment of ADHD and requires documentation that the member has experienced treatment failure of or intolerance to both a methylphenidate (such as Ritalin(g) or Concerta(g)), an amphetamine (such as Adderall(g)), Tenex(g), and Catapres(g).Approval duration: up to 5 years
Narcotics Approval duration: up to 1 yearPreferred:Actiq® (fentanyl citrate) (g), Opana® (oxymorphone) (g), Opana ER (oxymorphone) 7.5, 15mg (g)
Nonpreferred:AbstralTM, ButransTM, Fentora®, Lazanda®, Onsolis®, SubsysTM
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Preferred agents:Actiq(g): Approved for the treatment of breakthrough cancer pain in members that are tolerant of high dose narcotics and is currently receiving a long-acting narcotic. The member must also have experienced treatment failure of or intolerance to the use of other oral immediate-release narcotics for the management of breakthrough pain.Opana(g): Requires documentation that the member has experienced treatment failure of or intolerance to morphine sulfate 20mg/mL (Roxanol(g)) or morphine sulfate immediate-release (MSIR(g)).Opana ER 7.5, 15mg(g): Requires documentation that the member has experienced treatment failure of or intolerance to ALL of the following long-acting Preferred agents: methadone, morphine sulfate extended-release (Oramorph(g), MS Contin(g)), and fentanyl transdermal patch (Duragesic(g)).
Nonpreferred agents:Abstral, Fentora, Lazanda, Onsolis Subsys: Approved for the treatment of breakthrough cancer pain in members that are tolerant of high dose narcotics and who are currently receiving a long-acting narcotic. The member must also have experienced treatment failure of or intolerance to the use of Actiq(g) and other oral immediate-release narcotics for the management of breakthrough pain. Lazanda and Subsys also require treatment failure of or intolerance to a buccal fentanyl product.Butrans: Coverage is provided for a diagnosis of moderate to severe chronic pain AND documentation that the member has experienced treatment failure of or intolerance to methadone, Duragesic(g) AND morphine sulfate (MS Contin(g) or Oramorph SR(g)).
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CENTRAL NERVOUS SYSTEM (Cont.)Narcotics (cont.) Approval duration: up to 1 yearNonpreferred:ExalgoTM, Nucynta®, Soln, ER; Onsolis®, Opana ER, Oxycontin®, Oxecta®
Nonpreferred agents:Exalgo: Coverage is provided for the management of moderate to severe pain in opioid tolerant patients requiring continuous around the clock analgesia for an extended period of time AND requires documentation that the member has experienced treatment failure of or intolerance to ALL of the following long-acting Preferred agents: methadone, morphine sulfate extended-release (Oramorph(g), MS Contin(g)), and fentanyl transdermal patch (Duragesic(g)).Nucynta, Soln: Requires documentation that member has experienced treatment failure of or intolerance to Ultram(g), ER(g); or Ultracet(g) AND three preferred immediate-release narcotics. If use is to exceed 30 days, Nucynta must be used in combination with a long-acting narcotic, such as methadone, morphine sulfate extended-release (Oramorph(g), MS Contin(g)), and fentanyl transdermal patch (Duragesic(g)).Nucynta ER: Requires documentation that member has experienced treatment failure of or intolerance to Ultram ER(g) AND two of the following preferred alternatives: morphine sulfate extended-release (Oramorph(g), MS Contin(g)), fentanyl transdermal patch (Duragesic(g)) OR methadone.• Post-herpetic neuralgia or diabetic peripheral neuropathy: If older than 65
years, requires treatment failure of or intolerance to gabapentin 1200 mg per day. If under 65 years, requires treatment failure of or intolerance to gabapentin 1200 mg per day and a tricyclic antidepressant.
Opana ER, Oxycontin: Requires documentation that the member has experienced treatment failure of or intolerance to ALL of the following long-acting Preferred agents: methadone, morphine sulfate extended-release (Oramorph(g), MS Contin(g)), and fentanyl transdermal patch (Duragesic(g)).Oxecta: Requires documentation that the member has experienced treatment failure of or intolerance to at least three of the following immediate-release narcotics MS-IR(g), Opana IR(g), oxycodone IR. If use is to exceed 30 days, Oxecta must be used in combination with a long-acting narcotic, such as methadone, Oramorph(g), or MS Contin(g), and Duragesic(g).
Narcotic Mixed Agonist/Antagonist Approval duration: up to 1 yearNonpreferred: Rybix® ODT
Nonpreferred agents:Rybix ODT: Requires documentation that the member cannot swallow ANY oral tramadol tablets OR the member has exhibited intolerance to at least two different manufacturer’s brands of Ultram(g).
Non-Steroidal Anti-Inflammatory Drugs Approval duration: up to 10 yearsPreferred:Arthrotec® (g)
Nonpreferred:Celebrex®, Flector® Patch,
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Preferred agents: Arthrotec(g): Approved for members >60 years of age, receiving anticoagulant or antiplatelet therapy, receiving chronic treatment with oral corticosteroids (≥ 60 days duration), or a history of or current diagnosis of peptic ulcer disease, clinically significant gastrointestinal bleeding, and/or alcoholism.
Nonpreferred agents:Celebrex: Approvedformembers>60yearsofage who are not at high risk for cardiovascular events, and do not have a previous history of stroke, myocardial infarction (MI), coronary heart disease, or blood clots. The member must not be receiving concomitant anticoagulant or an antiplatelet therapy. Approvedformembers≤60yearsofage who are receiving chronic treatment with oral corticosteroids (≥ 60 days duration) or have a history of or current diagnosis of peptic ulcer disease, clinically significant gastrointestinal bleeding, and/or alcoholism AND experience treatment failure of or intolerance to Mobig(g) or Lodine(g). The member must not be receiving concomitant anticoagulant or antiplatelet therapy AND have no previous history or evidence of cardiovascular and thromboembolic disease. Note: Lodine®(g) is more selective than Celebrex for the COX-2 enzyme.Flector Patch: Approved only for the treatment of acute sprains AND requires treatment failure of or intolerance to Voltaren(g)/XR(g) tablets AND an OTC topical analgesic (Myoflex OR Aspercreme).Approval duration: up to 1 month
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CENTRAL NERVOUS SYSTEM (Cont.)Non-Steroidal Anti-Inflammatory Drugs (cont.) Approval duration: up to 10 yearsNonpreferred:Celebrex®, Flector® Patch, PennsaidTM, VimovoTM, Voltaren® Gel
Nonpreferred agents:Pennsaid, Voltaren Gel: Requires documentation of treatment failure of or intolerance to Voltaren(g)/XR(g) tablets AND an OTC topical analgesic (Myoflex OR Aspercreme).Approval duration: up to 3 monthsVimovo: Requires documentation that member has had treatment failure of or intolerance to Prilosec(g), Protonix(g) and Prevacid(g) AND meets any one of the following criteria:• Greater than 60 years of age• Receiving anticoagulant or antiplatelet therapy• Receiving chronic treatment with oral corticosteroids (>= 60 days duration)• A history or peptic ulcer disease, clinically significant gastrointestinal bleeding, and/or
alcoholism.Parkinson’s Disease and Related Disorders Approval duration: up to 10 yearsNonpreferred: HorizantTM , Mirapex ER®, Neupro®
Horizant: RestlessLegsSyndrome(RLS): Requires a diagnosis of and treatment failure or intolerance to Requip(g), XL(g); Mirapex(g), and Neurontin(g), and an explanation why gabepentin extended release is expected to work if gabepentin immediate release has not.•Post-herpeticneuralgia• If older than 65 years, requires treatment failure of or intolerance to gabapentin 1200 mg per
day. If under 65 years, requires treatment failure of or intolerance to gabapentin 1200 mg per day and a tricyclic antidepressant.
Mirapex ER: Requires a diagnosis of Parkinson’s Disease and treatment failure or intolerance to Mirapex IR(g) AND documentation that the continued use will adversely affect the member’s condition.Neupro: Requires a diagnosis of Parkinson’s Disease or restless leg syndrome, and treatment failure of or intolerance to Mirapex(g), ER AND Requip(g), XL(g). • Restless leg syndrome: also requires treatment failure of or intolerance to
Neurontin(g).Sedatives/Hypnotics Approval duration: up to 1 yearPreferred:Ambien CR® (g) (zolpidem)
Nonpreferred: EdluarTM, Intermezzo®, Lunesta®, Rozerem®, SilenorTM, ZolpiMistTM
Preferred agents:Requires documentation that member has experienced treatment failure of or intolerance to an adequate trial of both Ambien®(g) and Sonata®(g).
Nonpreferred agents: Edluar, Intermezzo, Lunesta, Rozerem, ZolpiMist: Requires documentation that member has been diagnosed with middle of the night waking and experienced treatment failure of or intolerance to Ambien(g), AND Sonata(g), coverage is not provided in combination with other sedatives.Silenor: Requires documentation that member has experienced treatment failure of or intolerance to Sinequan®(g), Ambien(g), Sonata(g) AND Desyrel®(g).
DERMATOLOGYAcne Treatment Approval duration: up to 1 yearNonpreferred:Veltin™ gel, Ziana® gel
Requires documentation of medical necessity to identify why individual agents [Cleocin-T®(g) plus Retin-A®(g)] cannot be used.
Antipsoriatic/Antiseborrheic Approval duration: up to 1 yearPreferred:Enbrel® (etanercept), Humira® (adalimumab)
Preferred agents: Enbrel, Humira: Moderate to Severe Psoriasis: Requires 3 months of previous treatment with topical corticosteroids and 3 months treatment with PUVA.
Antipsoriatic/Antiseborrheic Approval duration: up to 10 yearsNonpreferred:Taclonex, Scalp®
Nonpreferred agents:Taclonex: Requires documentation that the member has experienced treatment failure of or intolerance to at least 30 days of treatment with the combination of a very high potency corticosteroid [Diprolene ointment(g), Temovate(g), Psorcon(g)] AND Dovonex(g)].
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DERMATOLOGY (Cont.)Miscellaneous Dermatologicals (cont.) Approval duration: up to 1 yearNonpreferred:Protopic®, Solaraze®
Nonpreferred agents:Protopic: Approved for members ≥2 years of age with a diagnosis of atopic dermatitis or eczema and documentation that the member has experienced treatment failure of or intolerance to Elidel®. For members ages 2 to 15, only the 0.03% strength may be used.Solaraze: Approved for members with a diagnosis of actinic keratosis how have experience treatment failure with cryotherapy or phototherapy and TWO other medications such as Efudex(g), Aldara(g), or Retin-A(g).
Wound & Burn Therapy Approval duration: up to 1 yearNonpreferred:Regranex®
Requires documentation that the member has a diagnosis of lower extremity diabetic neuropathic ulcers that have an adequate blood supply and extend into the subcutaneous tissue or beyond (must be a full thickness – for example, Stage III to the muscle or Stage IV to the bone). Members must be participating in a comprehensive wound care program which includes treatment such as surgical removal of tissue, pressure relief (for example, non-weight bearing), and infection control.
DIAGNOSTICS & OTHER MISCELLANEOUSDiagnostic & Other Miscellaneous Fomulary:Kalydeco™ (ivacaftor),Kuvan® (sapropterin dihydrochloride),Xenazine® (tetrabenazine)
Nonpreferred:Campral®, Exjade® , Ferriprox®, Firazyr®, Korlym™
Preferred agents:Kalydeco: Requires documentation that the member has a confirmed diagnosis of cystic fibrosis with the G551D mutation confirmed by genetic testKuvan: Requires documentation that member has a diagnosis of phenylketonuria (PKU) and will be following a phenylalanine-restricted diet in conjunction with Kuvan.Approval duration: up to 1 yearXenazine: Requires documentation that member has a diagnosis of chorea associated with Huntington’s disease.Approval duration: up to 10 years
Nonpreferred agents:Campral: Approved for the treatment of alcohol dependence, to maintain abstinence from alcohol in members who have been abstinent at treatment initiation for at least 5 days post-detoxification. Members must be enrolled in a comprehensive alcohol management program that includes psychosocial support.Approval duration: up to 1 yearExjade: Approved for members ≥2 years of age with a diagnosis of chronic iron overload due to blood transfusions (transfusional hemosiderosis) or transfusional iron overload due to thalssemia syndromes and documentation that the member has experienced treatment failure of or intolerance to Desferal®(g).Ferriprox: Requires treatment failure of or intolerance to Desferal(g) and Exjade for members with transfusional iron overload. Approval duration: up to 1 yearFirazyr: Approved for members ≥18 years of for the treatment of acute attacks of hereditary angioedema (HAE).Approval duration: up to 1 yearKorlym: Requires documentation that the member has a diagnosis of: a) Hypercortisolism as a result of endogenous Cushing’s syndromeb) Failure of or intolerance to ketoconazole or mitotane, unless contraindicated or not tolerated.b) Diagnosis of type II diabetes mellitus or glucose intolerancec) Surgical treatment has been ineffective or are not candidates for surgeryNote: Also requires enrollment in REMS program
Approval duration: up to 1 year
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ENDOCRINOLOGYGrowth Hormone & Related ProductsPreferred:Genotropin® (somatropin),Nutropin®, AQ (somatropin)
Nonpreferred:Humatrope®, Norditropin®, Omnitrope®, Saizen® , Serostim®, Tev-Tropin®, Valtropin®, Zorbtive™, Increlex™
Preferred agents:Children (<18 years of age): Requires a diagnosis of growth hormone deficiency, growth failure secondary to chronic renal failure/insufficiency in children who have not received a renal transplant, growth failure in children small for gestational age or with intrauterine growth retardation, Turner’s Syndrome, Noonan’s Syndrome, Prader-Willi Syndrome, SHOX deficiency, or for treatment of severe burns covering >40% of the total body surface area. The member’s current height and weight must be provided. The member must also have open epiphyses.Initial treatment: For growth hormone deficiency, two growth hormone stimulation tests OR one GH stimulation test along with a subnormal IGF-1 level and IGFBP-3 level must be provided. The member’s height must be below the 5th percentile.To continue: The member must achieve a growth velocity of > 4.5 cm/year while receivingtherapy over the past year. Treatment may continue until final height or epiphyseal closure hasbeen documented.Approval duration: up to 1 yearAdults (≥18 years of age): Approved for treatment of growth hormone deficiency, AIDS wasting cachexia, Turner’s Syndrome, and Short Bowel Syndrome (SBS). The diagnosis must be made by an endocrinologist or a nephrologist. Initial diagnosis must be based on two growth hormone stimulation tests, three or more pituitary hormone deficiencies with an IGF-1 below 80ng/ml OR one growth hormone and at least one pituitary hormone deficiencyApproval duration: up to 10 years (exception SBS 1 month)
Nonpreferred agents: Also requires documentation that the member has experiencedtreatment failure of or intolerance to preferred agents.Increlex: Approved for treatment of severe IGF-1 deficiency, growth hormone gene deletion,and Laron’s syndrome in members <18 years of age, with open epiphyses, and height below the 3rd percentile. Member must have a normal or elevated growth hormone level with an IGF-1 level 3 or more standard deviations below normal. The prescriber must be a pediatric endocrinologist.Approval duration: Initial approval is granted for 1 year and renewal can be obtained if member has clinical response with therapy, as demonstrated by an annual growth velocity of ≥ 2.5 cm
Non-Insulin Hypoglycemic Agents Approval duration: up to 10 yearsNonpreferred:Actoplus MET® XR, Avandamet®, Avandaryl®, Avandia®, Byetta®, BydureonTM, Cycloset®, Janumet®, XR; Januvia®, Jentadueto™, Juvisync®, Kazano®, Kombiglyze™ XR, Nesina®, Oseni®, Onglyza™, Prandimet®, Tradjenta™, Symlin®, Victoza®
Nonpreferred agents:Actosplus MET XR, Avandamet, Avandaryl, Janumet, XR; Jentadueto, Juvisync, Kazano, Kombiglyze XR, Oseni, Prandimet: Requires documentation that the member has experienced successful treatment with at least three months of therapy with the individual agents that are in the combination product. Avandamet, Avandaryl: also requires enrollment in REMS program.Avandia: Requires documentation that the member has had treatment failure of or intolerance to both Glucophage(g) and Actos. Coverage is subject to enrollment in REMS. Byetta, Bydureon, Victoza: Approved for members with a diagnosis of ype 2 diabetes where members have failed to achieve a hemoglobin A1C of <7, and have experienced treatment failure or or intolerance to two oral agents (one of which is metformin), and insulin.Cyclocet, Januvia, Onglyza, Nesina, Tradjenta: Requires documentation that member has experienced treatment failure of or intolerance to the use of three of the following: metformin, basal insulin, sulfonylurea, and a TZD. Symlin: Approved for members ≥18 years of age for the treatment of type 1 or 2 diabetes who are receiving insulin therapy and has not achieved desired glucose control (Hgb A1C >7%) despite good compliance with optimal insulin therapy.
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ENDOCRINOLOGY (cont.)Miscellaneous Preferred:Signaior®
Nonpreferred:Egrifta®, Gattex®,Uceris™,
Preferred:Signifor: Approved for members > 18 years who meet the following criteria:a) Hypercortisolism as a result of endogenous Cushing’s syndrome.b) Surgical treatment has been ineffective or are not candidates for surgery.c) Treatment failure of or intolerance to Nizoral(g) or Lysodren.
Inital approval length up to 3 months, renewal up to 6 months
Nonpreferred: Egrifta: Approved for members > 18 years of age for the reduction of excess abdominal fat in HIV-associated lipodystrophy, receiving antiretroviral therapy, with gender-specific measures when other weight loss efforts have been ineffective and there is functional impairment in activities of daily living. Renewal coverage is provided for the reduction of excess abdominal fat in HIV-associated lipodystrophy when clinical documentation is provided indicating a decrease in waist circumference and continuation of functional impairment in activities of daily living. Approval duration: Initial approval length up to 6 months, renewal up to 1 year.Gattex: Approved for members > 18 years of age with a diagnosis of Short Bowel Syndrome (SBS) AND dependence on parenteral support > 12 months.Uceris: Approved for the treatment of active, mild to moderate ulcerative colitis a trial and failure or intolerance to an oral 5-ASA AND two oral, locally active corticosteroids one of which is Entocort EC(g)
GASTROINTESTINAL AGENTSAntiemetics Approval duration: up to 1 yearNonpreferred:Sancuso®, Zuplenz®
Requires documentation that the member has experienced treatment failure of or intolerance to oral granisetron (Kytril(g)) AND ondansetron (Zofran(g), ODT(g)).
Hematopoietic Agents Preferred:Procrit® (epoetin alfa),Promacta® (eltrombopag)
Nonpreferred: Aranesp®, Epogen®
Preferred:Procrit: Requires documentation that the member has one of the following conditions: anemia secondary to chronic renal failure, chronic renal insufficiency, HIV infection, HIV therapy, chemotherapy, myelodysplasia, or chronic hepatitis C therapy, OR prophylaxis prior to surgery to reduce need for allogenic blood transfusions. A Hgb level of less than 10 g/dL is required for initial therapy. For continued coverage dose adjustments are required to maintain Hgb between 10 to 12 g/dL. Duration of approval is dependent on the indication.Approval duration: Initial approval up to 6 months to 1 yearPromacta: Approved for treatment of thrombocytopenia with chronic immune thrombocytopenic purpura or chronic hepatitis C infection associated thrombocytopenia, and has a platelet count of <400 x 109/L if continuing therapy, and inadequate response to, intolerance to, or is not a candidate for standard first-line treatments, such as corticosteroids, immunoglobulins, or splenectomy.Approval duration: up to 6 months
Nonpreferred agents:Also requires documentation that member has experienced failure of or intolerance to preferred epoetin alfa (Procrit).Approval duration: up to 6 months to 1 year
Miscellaneous Gastrointestinal Agents Approval duration: up to 1 yearPreferred:Relistor® (methylnaltrexone)
Preferred agents:Relistor: Approved for the treatment of opioid-induced constipation in members with advanced illness whom are receiving palliative care and requires documentation that the member has experienced inadequate response to at least 3 of the following laxatives: bulk laxatives (polycarbophil, psyllium, methylcellulose), saline laxatives (milk of magnesia/magnesium hydroxide), osmotic laxatives (Miralax(g)), or stimulant (Dulcolax(g), Senna(g)).
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GASTROINTESTINAL AGENTS (Cont.)Miscellaneous Gastrointestinal Agents (cont.) Approval duration: up to 1 yearNonpreferred:Amitiza®, ChenodalTM, GiazoTM, Cimzia®, FulyzaqTM, LiznessTM, Lotronex®, Xifaxan 550®
Nonpreferred agents:Amitiza, Linzess: Approved for the treatment of chronic idiopathic constipation (fewer than 3 bowel movements/week) or constipation predominant IBS in female members 18 to 65 years of age whom have tried and failed ALL of the following: dietary advice, trials of bulk laxatives, stool softeners, and a short course of stimulant laxatives and are NOT taking medications causing constipation. A total of 12 weeks can be approved, with renewal, only if improvement in bowel frequency is seen with initial trial. Linzess: Also requires treatment failure of or intolerance to Amitiza.Chenodal: Approved for dissolution of gallstones only in patients where surgery is not appropriate. In addition, member must have experience treatment failure of or have an intolerance to Actigall(g). Member cannot have history of hepatocellular disease.Approval duration: up to 2 yearsCimzia: Approved for the treatment of Crohn’s disease in members ≥18 years of age whom have experienced treatment failure of or intolerance to both Enbrel, and Humira.Approval duration: up to 10 yearsFulyzaq: Approved for members with HIV/AIDS who are currently on antiretroviral therapy for the treatment of symtomatic relief of non-infectious diarrhea. Gaizo: Approved for the treatment of mild to moderate active ulcerative colitis in male pts ≥18 who have experienced treatment failure of or intolerance to Colazal(g) AND Azulfidine(g). Approval duration: up to 10 yearsLotronex: Approved for the treatment of severe, diarrhea-predominant irritable bowel syndrome in women at least 18 years of age who have failed to respond to conventional diarrhea therapy including one OTC product (loperamide, bismuth subsalicylate) and one prescription agent (diphenoxylate/atropine (Lomotil(g)).Xifaxan 550: Requires diagnosis of hepatic encephalopathy AND documentation that the member has had treatment failure of or intolerance to lactulose.
Proton Pump Inhibitors Approval duration: up to 10 yearsPreferred:Prevacid®(g) capsule (lansoprazole), Prevacid SolutabTM, Zegerid®(g) capsule (omeprazole/sodium bicarbonate)
Nonpreferred: Aciphex®, Sprinkles; DexilantTM, Nexium®, Prilosec suspension, Protonix suspension, VimovoTM,
Zegarid Packet
Preferred agents:Prevacid(g), Solutab: Requires documentation that the member has experienced failure of or intolerance to Prilosec® OTC(g) or Prilosec(g), AND Protonix(g).Zegerid(g): Requires documentation that member has experienced failure of or intolerance to Prilosec OTC(g) or Prilosec(g) AND Protonix(g), AND Prevacid(g) or Prevacid Solutab.
Nonpreferred agents:Aciphex, Sprinkles; Zegerid Packet: Requires documentation that the member has experienced treatment failure of or intolerance to Prilosec OTC or Prilosec(g) AND Protonix(g), AND Prevacid(g) or Prevacid Solutab. Dexilant, Nexium: Requires documentation that the member has experienced treatment failure of or intolerance to all BCN preferred alternatives [either Prilosec OTC or Prilosec(g), Protonix(g), AND Prevacid(g)], one of which is at a twice daily, high dose regimen.Prilosec suspension, Protonix suspension: Requires documentation that member has experienced treatment failure of or intolerance to Prevacid Solutab. Vimovo: Requires documentation that member has had treatment failure of or intolerance to Prilosec(g), Protonix(g) and Prevacid(g) AND meets any one of the following criteria:•Greater than 60 years of age•Receiving anticoagulant or antiplatelet therapy•Receiving chronic treatment with oral corticosteroids (>= 60 days duration)•A history or peptic ulcer disease, clinically significant gastrointestinal bleeding, and/or alcoholism.Approval duration: up to 10 years
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IMMUNOLOGY & HEMATOLOGYHepatitis B & C TherapyPreferred:IncivekTM (telaprevir), Infergen (interferon alfacon-1), Intron-A (interferon alfa-2B),Pegasys (peginterferon alfa 2-A), Peg-Intron (peginterferon alfa-2B), RibavirinVictrelisTM (boceprevir)
Preferred agents:Incivek: Requires a diagnosis of Hepatitis C genotype 1. Patients taking Incivek must be receiving triple therapy along with a peg interferon and ribavirin for the appropriate duration of the treatment. Approval duration: Initial approval: up to 6 weeks. Renewal: up to 6 weeks if viral load is 1000 IU/mL or less at treatment week 4.Infergen: Approved for the treatment of Hepatitis B. Approval duration: up to 1 yearIntron-A: Approved for the treatment of Hepatitis B, condyloma acuminate, essential thrombocythemia, hairy cell leukemia, Kaposi’s sarcoma, malignant melanoma, multiple myeloma, non-Hodgkin’s lymphoma, Philadelphia chromosome (Ph) positive chronic phase myelogenous leukemia (CML), and renal cell carcinoma. Approval duration: up to 1 yearPeg-Intron, Pegasys: Approved for the treatment of Hepatitis B and Hepatitis C. For hepatitis C, approved for members naïve to pegylated interferon therapy only. Genotype, HIV status, previous therapy and duration must also be provided. The member must receive peglylated interferon in combination with ribavirin unless contraindicated. Approval duration: • For genotypes 2, 3: Approval is for a total of 24 weeks duration. • For non-genotypes 2,3 receiving dual therapy with ribavirin:Initial approval
is 16 weeks, renewal is 32 weeks if the members achieves >_ 2 log decrease in viral load after 12 weeks of treatment.
• For genotype 1 receiving triple therapy: Initial and renewal approval durations depend on patient’s viral loads at all futility points and treatment duration as indicated in the prescribing information.
Ribavirin: Approved for the treatment of Hepatitis C. Genotype, HIV status, previous therapy and duration must also be provided.Victrelis: Requires a diagnosis of Hepatitis C genotype 1, and treatment failure of or intolerance to Incivek. Patients taking Victrelis must be receiving triple therapy along with a peg interferon and ribavirin for the appropriate duration of the treatment.Approval duration: Initial and renewal approval durations depend on patient’s viral loads at all futility points and treatment duration as indicated in the prescribing information.
Interferons and MS Therapy Nonpreferred: AmpyraTM, AubagioTM, Betaseron®, GilenyaTM
Nonpreferred:Ampyra: Initial treatment: Requires a diagnosis of multiple sclerosis and documentation of difficulty walking resulting in significant limitations of instrumental activities of daily living. Also requires two timed 25-foot walk (T25FW) measurements that must be within 10% variability and demonstrates that the patient is able to walk 25 feet in 8-45 seconds. To continue: Requires documentation of improvement in walking speed by at least 10% as assessed by the T25FW AND that limitations of instrumental activities of daily living has improved as a result of increased walking speed within the first 2 months of therapy. Coverage thereafter will be provided there is documentation that the member has maintained or experienced improved walking speed from the previous measurement.Approval duration: initial approval is 2 months, renewal up to 12 monthsAubagio, Gilenya: Approved for members 18 and older who have a diagnosis of a relapsing form of multiple sclerosis, where member has experienced treatement failure of or intolerance to an interferon beta product (for example, Avonex®, Extavia® or Rebif®) AND Copaxone®. Treatment failure is defined as documented relapse or the presence of new and/or newly enlarged MRI lesions in the previous year.Approval duration: up to 1 yearBetaseron: Requires documentation that member has experienced failure of or intolerance to Extavia®. Approval duration: up to 10 years
Page 22 Page 23Blue Care Network - Prior Authorization and Step-Therapy Guidelines
LIFESTYLE MODIFICATION PRODUCTSImpotence Approval duration: up to 1 yearPreferred:Caverject® (alprostadil), Cialis® (tadalafil), Muse® (alprostadil), Viagra® (sildenafil citrate)
Nonpreferred:Edex®, Levitra®, Staxyn®, StendraTM
For men under the age of 18, and for women; not coveredFor men 18 to 34 years old: requires a diagnosis of erectile dysfunction (ED) secondary to a medical cause such as multiple sclerosis, spinal cord injury, Parkinson’s disease, radiation for prostate or bladder cancer, and other indications deemed appropriate. The member must not be using nitrates concomitantly and avoid use of alpha blockers with oral ED agents. Maximum of 6 doses per 28 days.For men over the age of 34: requires a diagnosis of ED.
Weight Loss Products Approval duration: up to 1 yearPreferred:phentermine and related products
Nonpreferred: Belviq®, QsymiaTM, SuprenzaTM ODT, Xenical®
Preferred agents: Requires verification that member’s Body Mass Index (BMI) is ≥30 kg/m2 or >27 kg/m2 with co-morbidities, and concurrent lifestyle modification plan. Coverage for all anorexiants and related drugs is limited to 3 months. Additional coverage requires documentation of weight loss of at least 2 pounds per month. Maximum benefit is 12 months of treatment per lifetime.
Nonpreferred agents:Requires verification that member’s Body Mass Index (BMI) is ≥30 kg/m2 or >27 kg/m2 with co-morbidities, and concurrent lifestyle modification plan. Coverage for all anorexiants and related drugs is initally limited to 3 months. Additional coverage requires documentation of weight loss of at least 2 pounds per month. Belviq, Qsymia, Suprenza ODT: also requires documentation as to why continued use of generic phenteramine will adversely affect the member’s health. Maximum benefit is 12 months of treatment per lifetime; 24 months of treatment per lifetime for Xenical.
MISCELLANEOUSCompounds Coverage criteria include all the below:
• The compound is medically necessary for the member’s condition • The compound contains only FDA-approved drugs.• There are no appropriate FDA-approved commercial formulations of the compound available.U6W’s (bulk powders) are not covered.Approval duration: up to 6 months
OBSTETRICS AND GYNECOLOGYInfertility treatment Approval duration: up to 1 yearPreferred:Bravelle® (urofollitropin), Cetrotide® (cetrorelix acetate), FertinexTM (urofollitropin), Ganirelix acetate® (ganirelix acetate), Gonal-F®, RFF (follitropin alfa, recomb), Ovidrel® (HCG alfa, recomb), Novarel®/Pregnyl®/Profasi® (gonadotropin, chorionic, human), Repronex® (menotropins)
Nonpreferred:Follistim® AQ, Luveris®, Menopur®
Coverage is provided for most BCN female members with an infertility benefit and also in accordance with generally accepted medical practice. BCN does not provide coverage for infertility drugs to be used as part of assisted reproductive technology treatment, such as in-vitro fertilization (IVF), zygote in vitro fertilization transfer (ZIFT), gamete in vitro fertilization transfer (GIFT). Authorization will be provided for one year. Additional coverage will be based on documentation that the member is being treated according to accepted medical practice. Requests are not consider ed for men.
Nonpreferred: Also Requires treatment failure of or intolerance to preferred agents.
OPTHALMIC AGENTSMiscellaneous Approval duration: up to 1 yearPreferred:Cystaran™
Preferred: Approved for members with a diagnosis of cystanosis who are also taking oral cysteamine.
Page 24Blue Care Network - Prior Authorization and Step-Therapy Guidelines
OTIC & NASAL PREPARATIONSIntranasal Steroids Approval duration: up to 10 yearsPreferred:Nasacort AQ® (g) (triamcinolone acetonide)
Nonpreferred:Beconase AQ®, Dymista™, Nasonex®, Omnaris™, Qnasl®,Rhinocort Aqua®, Veramyst™, Zetonna™
Preferred agents:Nasacort AQ(g): Requires documentation that member has experienced treatment failure of or intolerance to fluticasone (Flonase(g)) or flunisolide (Nasalide(g)/Nasarel(g)).
Nonpreferred agents: Requires documentation that member has experienced treatment failure of or intolerance to fluticasone (Flonase(g)) or flunisolide (Nasalide(g)/Nasarel(g)) AND Nasacort AQ(g).
RESPIRATORY COUGH & COLDAntihistamines and Combinations Approval duration: up to 10 yearsPreferred:Clarinex® (g) (desloratadine), Xyzal® (g) (levocetirizine)
Nonpreferred:Clarinex-D®, Clarinex, Syrup®, Semprex-D®
Requires documentation that the member has experienced treatment failure of or intolerance to OTC loratadine and OTC cetirizine.
Inhaled Beta-Agonists Approval duration: up to 10 yearsNonpreferred:Arcapta® Neohaler, Brovana®, Perforomist™
Requires documentation that the member has experienced treatment failure of or intolerance to both Serevent® and Foradil®.
Miscellaneous Approval duration: up to 10 yearsNonpreferred:DalirespTM
Daliresp: Requires documentation that the member has a diagnosis of severe chronic obstructive pulmonary disorder (COPD) associated with chronic bronchitis and a history of exacerbations despite therapy with a long acting beta agonist, an anticholinergic and a preferred inhaled steroid.
Pulmonary Arterial Hypertension Approval duration: up to 1 yearPreferred:Letairis™ (ambrisentan), Revatio®(g) (sildenafil), Soln; Tracleer® (bosentan), TyvasoTM (treprostinil), Ventavis® (iloprost)
Nonpreferred:Adcirca™
Preferred agents: Letairis, Revatio(g), Revatio Soln; Tracleer, Tyvaso, Ventavis: Approved for the treatment of pulmonary arterial hypertension (PAH) WHO Class III or IV symptoms.
Nonpreferred agents:Adcirca: Approved for the treatment of pulmonary arterial hypertension (PAH), WHO Class III or IV symptoms AND requires documentation that member has experienced treatment failure of or intolerance to Revatio(g).
RHEUMATOLOGY & MUSCULOSKELETALGout Therapy Approval duration: up to 10 yearsPreferred:Uloric® (febuxostat)
Requires successful treatment of at least one month with allopurinol prior to apprroval of Uloric.
Miscellaneous Rheumatologic Agents Approval duration: up to 10 yearsPreferred:Enbrel®(etanercept), Humira® (adalimumab)
Cont. next page...
Preferred agents: Enbrel, Humira: Requires a three month trial with two concurrent oral disease modifying antirheumatic drugs (one must be methotrexate unless contraindicated). Examples of DMARDs include: methotrexate, sulfasalazine, azathioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine.
Page 24 Page 25Blue Care Network - Prior Authorization and Step-Therapy Guidelines
RHEUMATOLOGY & MUSCULOSKELETAL (Cont.)Miscellaneous Rheumatologic Agents (cont.) Approval duration: up to 10 yearsNonpreferred:Cimzia®, Kineret®, Orencia® SC, RayosTM, SimponiTM, Xeljanz®
Nonpreferred agents:Cimzia, Kineret, Orencia SC, Simponi, Xeljanz: Requires that the member has experienced treatment failure of or intolerance to Enbrel and Humira.Rayos: Member must have a diagnosis of rheumatoid arthritis and documentation of trial or intolerance of two generic oral corticosteroids, one of which must be prednisone and an explanation why delayed release is expected to work if prednisone immediate release has not.
Osteoporosis/Bone Resorption Inhibitors Approval duration: up to 10 yearsPreferred:Actonel® (risedronate), Boniva® (ibandronate) (g)
Nonpreferred:AtelviaTM, BinostoTM, Fosamax D™, ForteoTM
Preferred agents: Boniva(g): Requires documentation that member has experienced treatment failure of or intolerance to alendronate (Fosamax(g)).Actonel: Requires documentation that member has experienced treatment failure of or intolerance to alendronate (Fosamax(g)) or Boniva(g).
Nonpreferred agents: Atelvia, Binosto, Fosamax D: Requires documentation that member has experienced treatment failure of or intolerance to both alendronate (Fosamax(g)) and Actonel.Forteo: Approved for the treatment of osteoporosis (T-score <= -2.5) AND requires documentation that the member has a contraindication to or experienced treatment failure of or intolerance to a bisphosphonate.Approval duration: up to 2 years
UROLOGYBladder Control Approval duration: up to 10 yearsNonpreferred:Myrbetriq®
Myrbetriq: Approved when the member has experience treatment failure of or intolerance to at least 2 of the following generics (Detrol(g), Ditropan(g), XL(g); Sanctura(g), XR(g)) and Detrol LA.
BPH Treatment Approval duration: up to 10 yearsPreferred:Cialis® (tadalafil), JalynTM (dutasteride/tamsulosin)
Cialis: Approved for BPHwhen the member has experience treatment failure of or intolerance to both an alpha blocker, 5-alpha reductase inhibitor, and that the member has an IPSS score >13.Jalyn: Requires successful treatment of at least one month of therapy of either an alpha blocker, 5-alpha-reductase inhibitor or Jalyn.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 27
Blue Cross Blue Shield of MI Prior Authorization/Step Therapy Program
Custom Drug List (Formulary) July 2013
BCBSM monitors the use of certain medications to ensure our members receive the most appropriate and cost-effective drug therapy. Prior authorization (PA) for these drugs means that certain clinical criteria must be met before coverage is provided. In the case of drugs requiring step therapy (ST), for example, previous treatment with one or more generic or preferred drug may be required. Drugs that must meet clinical criteria are identified in the drug list with (PA) or (ST). Your physician can contact our pharmacy help desk to request prior authorization for these drugs. The criteria for authorization are based on current medical information and the recommendations of the Blues’ Pharmacy and Therapeutics Committee, a group of physicians, pharmacists and other experts. You may be required to pay the full cost of the drug if your physician does not obtain prior authorization. When your doctor prescribes a brand-name drug that’s nonpreferred, requires prior authorization or is not covered under your drug rider, it may not be a covered benefit. BCBSM reviews all physician and member requests to determine if the drug is medically necessary and that there aren’t equally effective alternative drugs on the drug list. Please call the Customer Service number on the back of your BCBSM identification card if you have questions about your drug coverage, a drug claim or filing a benefit exception.
Prior Authorization/Step Therapy Drug Categories
CUSTOM DRUG LIST (FORMULARY)
ANTI-INFECTIVES
1C - Tetracyclines
Adoxa® (g) (doxycycline)
Requires documentation that the member had a trial of generic doxycycline monohydrate (Monodox®) or generic doxycycline hyclate immediate release (Vibramycin®).
Adoxa® Pak (doxycycline) Nonpreferred
Requires documentation that the member had a trial of generic doxycycline monohydrate (Monodox®) or generic doxycycline hyclate immediate release (Vibramycin®).
Doryx® (g) (doxycycline)
Requires documentation that the member had a trial of generic doxycycline monohydrate (Monodox®) or generic doxycycline hyclate immediate release (Vibramycin®).
Doryx® 200mg (doxycycline) Nonpreferred
Requires documentation that the member had a trial of generic doxycycline monohydrate (Monodox®) or generic doxycycline hyclate immediate release (Vibramycin®).
Oracea® (doxycycline) Nonpreferred
Requires documentation that the member had a trial of generic doxycycline monohydrate (Monodox®) or generic doxycycline hyclate immediate release (Vibramycin®).
Solodyn® (minocycline) Nonpreferred
Requires documentation that the member had a trial of generic minocycline immediate release capsules (Minocin®).
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 28
Solodyn® (g) (minocycline)
Requires documentation that the member had a trial of generic minocycline immediate release capsules (Minocin®).
Ximino™ (minocycline) Nonpreferred
Requires documentation that the member had a trial of generic minocycline immediate release capsules (Minocin®).
1I - Antivirals
Incivek® (telaprevir)
Coverage will be provided for adult patients (18 years or older) with Chronic hepatitis C genotype 1 infection AND
1. Compensated liver disease (including cirrhosis) AND with recent HCV-RNA level. 2. Used in combination with peg interferon alfa (PegIntron or Pegasys) and ribavirin
(Rebetol, Copegus). **Renewal criteria for Incivek® requires updated viral load**
Sitavig® (acyclovir buccal tablet) Nonpreferred
Coverage requires trial and failure of generic acyclovir and generic valacyclovir.
Victrelis® (boceprevir)
Coverage will be provided for adult patients (18 years or older) with Chronic hepatitis C genotype 1 infection AND
1. Compensated liver disease (including cirrhosis) AND with recent HCV-RNA level 2. Used in combination with peg interferon alfa (PegIntron or Pegasys) and ribavirin
(Rebetol, Copegus) AND 3. Therapy must be initiated for 4 weeks with peg interferon alfa and ribavirin (Victrelis
therapy starts at treatment week 5 ) AND 4. Treatment with telaprevir (Incivek®) is contraindicated or not recommended:
1. History of severe skin reactions or dermatologic conditions 2. Moderate to severe hepatic impairment (Child-Pugh B or C)
**Renewal criteria for Victrelis® requires updated viral load**
1L - Antituberculars
Sirturo™ (bedaquiline tablet)
For FDA approved indications only: As part of combination therapy in adults (18 years and older) with pulmonary multidrug-resistant tuberculosis (MDR-TB).
1N - Miscellaneous Anti-infectives
Bethkis® (tobramycin inhalation) Nonpreferred
Coverage is provided when the member has cystic fibrosis and is infected with Pseudomonas aeruginosa.
Cayston® (aztreonam lysine) Nonpreferred
Covered for the improvement of respiratory symptoms in cystic fibrosis patients with Pseudomonas aeruginosa.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 29
CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL
2A - Lipid-lowering Agents
Advicor® (lovastatin/niacin ER) Nonpreferred
Requires documentation that member has had at least 3 months of treatment with lovastatin and niacin extended release as individual agents when used concomitantly.
Altoprev® (lovastatin ER) Nonpreferred
Requires documentation that the member has experienced treatment failure of or intolerance to at least two generic statins one of which is Lipitor (g) and one of which is high dose (≥ 40 mg).
Crestor® (rosuvastatin) Nonpreferred
Requires documentation that the member has experienced treatment failure of or intolerance to at least two generic statins one of which is Lipitor (g) and one of which is high dose (≥ 40 mg).
Juxtapid™ (lomitapide) Nonpreferred
Coverage will be provided for the treatment of patients with diagnosis of homozygous familial hypercholesterolemia (HoFH) confirmed by genetic testing OR by both of the following: untreated LDL > 500 mg/dL AND family history (in both parents) supporting a diagnosis of familial hypercholesterolemia based on genetic testing and/or laboratory values. Patient will be receiving optimal adjunctive treatment with other therapies that includes: a low-fat diet and other lipid lowering treatments including apheresis (if available). Patients must have experienced treatment failure or intolerance to the preferred drug to treat HoFH. Therapy is considered investigational for all other conditions such as but not limited to: heterozygous familial hypercholesterolemia or hyperlipidemia. Authorization will be reviewed annually to confirm that current criteria are met and that the medication is effective.
Kynamro™ (mipomersen)
Coverage will be provided for the treatment of patients with diagnosis of homozygous familial hypercholesterolemia (HoFH) confirmed by genetic testing OR by both of the following: untreated LDL > 500 mg/dL AND family history (in both parents) supporting a diagnosis of familial hypercholesterolemia based on genetic testing and/or laboratory values. Patient will be receiving optimal adjunctive treatment with other therapies that includes: a low-fat diet and other lipid lowering treatments. Patients must have experienced treatment failure or intolerance to the preferred drug to treat HoFH. Therapy is considered investigational for all other conditions such as but not limited to: heterozygous familial hypercholesterolemia or hyperlipidemia. Authorization will be reviewed annually to confirm that current criteria are met and that the medication is effective.
Lescol XL® (fluvastatin) Nonpreferred
Requires documentation that the member has experienced treatment failure of or intolerance to at least two generic statins one of which is Lipitor (g) and one of which is high dose (≥ 40 mg).
Livalo® (pitavastatin) Nonpreferred
Requires documentation that the member has experienced treatment failure of or intolerance to at least two generic statins one of which is Lipitor (g) and one of which is high dose (≥ 40 mg).
Simcor® (simvastatin/ niacin ER) Nonpreferred
Requires documentation that member has had at least 3 months of treatment with simvastatin and niacin extended release as individual agents when used concomitantly.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 30
Trilipix® (fenofibric acid) Nonpreferred
Requires trial and failure of gemfibrozil (g) AND fenofibrate (g).
Vascepa® (icosapent ethyl) Nonpreferred
Coverage is provided when all the following criteria are met: a) Triglyceride (TG) levels ≥ 500 mg/dl AND b) Trial of generic gemfibrozil AND c) Trial of generic fenofibrate or Niaspan (niacin)
Vytorin® (simvastatin/ezetimibe) Nonpreferred
Requires documentation that the member has experienced treatment failure of or intolerance to at least two generic statins one of which is Lipitor (g) and one of which is high dose (≥ 40 mg).
2D - Angiotensin II Receptor Blockers and Combinations
Benicar® /HCT (olmesartan)
Requires documentation that the member has experienced failure of or intolerance to a generic Angiotensin II Receptor Blocker (ARB).
Diovan® (valsartan) Nonpreferred
Requires documentation that the member has experienced failure of or intolerance to a generic Angiotensin II Receptor Blocker (ARB) AND Benicar®/HCT (olmesartan).
Edarbi™ (azilsartan medoxomil) Nonpreferred
Requires documentation that the member has experienced failure of or intolerance to a generic Angiotensin II Receptor Blocker (ARB) AND Benicar®/HCT (olmesartan).
Micardis® /HCT (telmisartan) Nonpreferred
Requires documentation that the member has experienced failure of or intolerance to a generic Angiotensin II Receptor Blocker (ARB) AND Benicar®/HCT (olmesartan).
Teveten® HCT (eprosartan/ hydrochlorothiazide) Nonpreferred
Requires documentation that the member has experienced failure of or intolerance to a generic Angiotensin II Receptor Blocker (ARB) AND Benicar®/HCT (olmesartan).
2K - Miscellaneous Antihypertensives
Tekturna® (aliskiren) Nonpreferred
Requires documentation that the member has tried standard effective doses and not reached therapeutic goals or could not tolerate therapy with ALL of the following drug classes:
1. Diuretic 2. Beta-blocker 3. ACE-Inhibitor 4. Angiotension II Receptor Blocker (ARB)
CENTRAL NERVOUS SYSTEM
3A - Antidepressants
Aplenzin® (bupropion hydrobromide) Nonpreferred
Requires trial/failure of at least two generic or preferred antidepressant agents, one of which must be generic bupropion.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 31
Cymbalta® (duloxetine) Nonpreferred
Coverage for Cymbalta® will be provided for: Treatment of major depression Approval requires trial and failure with two generic or preferred antidepressants. OR Treatment of diabetic neuropathic pain If patient equal to or greater than 65 years of age: After a 30-day trial of gabapentin. If patient less than 65 years of age: After a 30-day trial of gabapentin AND a tricyclic antidepressant, such as amitriptyline, desipramine or imipramine. OR Treatment of Fibromyalgia Fibromyalgia characterized by pain in all 4 body quadrants, for at least 3 months, with or without fatigue and sleep disturbance AND the patient has tried and experienced intolerance to gabapentin OR had inadequate pain relief at doses of 1200 mg or above AND has tried and experienced intolerance or inadequate pain relief to three of the following: tricyclic antidepressant, SSRI, SNRI, cyclobenzaprine and tramadol. OR Treatment of Chronic Musculoskeletal Pain Approval requires failure or intolerance of two generic alternatives from any of the following three drug classes: antidepressants, NSAIDs and centrally acting analgesics. Examples of centrally acting analgesics include: codeine, hydrocodone, morphine, meperidine, oxycodone and tramadol. OR Treatment of Generalized Anxiety Disorder Approval requires trial and failure of two generic or preferred antidepressants.
Desvenlafaxine ER® (desvenlafaxine) Nonpreferred
Requires trial/failure of at least two generic or preferred antidepressant agents, one of which must be Effexor® (g), Effexor XR® (g) or venlafaxine ER.
Forfivo XL® (bupropion hydrochloride) Nonpreferred
Requires trial/failure of at least two generic or preferred antidepressant agents, one of which must be generic bupropion.
Oleptro™ (trazodone ER) Nonpreferred
Coverage approved for the treatment of major depressive disorder. Requires trial and failure of Desyrel (g) and documentation why the long acting would be more efficacious.
Pexeva® (paroxetine) Nonpreferred
Requires trial/failure of at least two generic or preferred antidepressant agents, one of which must be generic paroxetine.
Pristiq® (desvenlafaxine) Nonpreferred
Requires trial/failure of at least two generic or preferred antidepressant agents, one of which must be Effexor® (g), Effexor XR® (g) or venlafaxine ER.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 32
Viibryd® (vilazodone) Nonpreferred
Requires trial/failure of at least two generic or preferred antidepressant agents.
3B - Antipsychotics
Abilify® (aripiprazole)
Requires a trial of a generic antipsychotic (clozapine, risperidone, quetiapine, olanzapine, ziprasidone) For a diagnosis of Major Depressive Disorder, requires trial/failure of an antidepressant, and documentation that Abilify will be used adjunctively with an antidepressant.
Fanapt® (iloperidone) Nonpreferred
Requires a trial of a generic antipsychotic (clozapine, risperidone, quetiapine, olanzapine, ziprasidone) AND Abilify®.
Invega® (paliperidone) Nonpreferred
Requires trial of generic risperidone (Risperdal®) AND Abilify®.
Latuda® (lurasidone) Nonpreferred
Requires a trial of a generic antipsychotic (clozapine, risperidone, quetiapine, olanzapine, ziprasidone) AND Abilify®
Saphris® (asenapine) Nonpreferred
Requires a trial of a generic antipsychotic (clozapine, risperidone, quetiapine, olanzapine, ziprasidone) AND Abilify®
Seroquel XR® (quetiapine fumarate) Nonpreferred
Requires trial of generic quetiapine (Seroquel®) AND Abilify® For a diagnosis of Major Depressive Disorder, requires trial/failure of an antidepressant AND Abilify®, and documentation that Seroquel XR will be used adjunctively with an antidepressant.
Versacloz™ (clozapine oral suspension) Nonpreferred
Requires treatment failure or intolerance to clozapine tablets and clozapine ODT unless the member is unable to take both formulations.
3D - Sedative/Hypnotics
Edluar® (zolpidem tartrate SL) Nonpreferred
Requires trial and failure, or intolerance, to the generic alternatives Ambien® (zolpidem) AND Sonata® (zaleplon) AND documentation of medical necessity.
Intermezzo® (zolpidem tartrate SL) Nonpreferred
Requires trial and failure, or intolerance, to the generic alternatives Ambien CR® (zolpidem extended release) AND Sonata® (zaleplon). Also, coverage will not be approved for combination therapy with other sedative hypnotics.
Silenor® (doxepin) Nonpreferred
Requires trial and failure of the generic alternatives Ambien (g) AND Sonata (g).
Zolpimist® (zolpidem tartrate) Nonpreferred
Requires trial and failure, or intolerance, to the generic alternatives Ambien® (zolpidem) AND Sonata® (zaleplon) AND documentation of medical necessity.
3E - CNS Stimulants
Nuvigil® (armodafinil) Nonpreferred
Requires treatment failure or intolerance to generic Provigil.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 33
Quillivant XR™ (methylphenidate hydrochloride extended release) Nonpreferred
Coverage of the requested drug is provided when all the below criteria are met: a) The member is ≥ 6 years of age and diagnosed with ADHD. b) AND has tried and failed both a generic methylphenidate and a generic amphetamine product, one of which must be a generic long acting formulation. c) AND physician provides documentation that the member cannot swallow tablets/capsules and has tried and failed one of the agents that can be opened and sprinkled on apple sauce (e.g. Metadate CD (g) and Adderall XR (g)).
Vyvanse® (lisdexamfetamine) Nonpreferred
Covered for members 6 years of age and older with the appropriate diagnosis who have experienced therapeutic failure or intolerance to BOTH an amphetamine-type product AND a methylphenidate product. Maximum dose approved per day will be 70 mg.
3F - Nonsteroidal Anti-inflammatory Drugs
Cambia™ (diclofenac potassium) Nonpreferred
Approval requires documentation that the patient has tried and failed or is intolerant to generic oral diclofenac AND one oral generic NSAID (Non-steroidal anti-inflammatory drug).
Celebrex® (celecoxib) Nonpreferred
Requires one of the following: • Age > 60 OR • Concomitant use of anticoagulants or oral steroids OR • Risk of GI bleed (history of PUD, previous GI bleed, alcoholism).
Duexis® (ibuprofen/famotidine) Nonpreferred
Requires trial and failure of individual generic agents ibuprofen and famotidine taken concurrently AND explanation of why the combination product is expected to work if the individual agents have not.
Flector® (diclofenac patch) Nonpreferred
For FDA approved indications only. Member must have tried and failed or demonstrated intolerance to oral diclofenac AND at least two other oral, traditional NSAIDs unless the patient is unable to take any oral medications.
AND Coverage will NOT be provided in the presence of concurrent therapy with oral NSAIDs or a COX II inhibitor.
Pennsaid® (diclofenac sodium) Nonpreferred
For FDA approved indications only. Member must have tried and failed or demonstrated intolerance to oral diclofenac AND at least two other oral, traditional NSAIDs unless the patient is unable to take any oral medications.
AND Coverage will NOT be provided in the presence of concurrent therapy with oral NSAIDs or a COX II inhibitor.
Vimovo® (naproxen/esomeprazole) Nonpreferred
Approval requires trial and failure of Prilosec (g) AND Protonix (g) AND Prevacid (g) AND one of the following criteria: Member is > 60 years of age or Receiving anticoagulant or antiplatelet therapy or Receiving chronic treatment with oral corticosteroids (>60 days duration) or Has a history of or current diagnosis of peptic ulcer disease, clinically significant gastrointestinal bleeding and/or alcoholism.
Voltaren Gel® (diclofenac) Nonpreferred
For FDA approved indications only. Member must have tried and failed or demonstrated intolerance to oral diclofenac AND at least two other oral, traditional NSAIDs unless the patient is unable to take any oral medications.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 34
AND Coverage will NOT be provided in the presence of concurrent therapy with oral NSAIDs or a COX II inhibitor.
3H - Narcotics
Abstral® (fentanyl citrate) Nonpreferred
Requires a diagnosis for the treatment of breakthrough cancer pain in members that are tolerant to high dose narcotics and who are currently receiving a long-acting narcotic. The member must also have experienced treatment failure of or intolerance to oral immediate-release narcotics AND generic short acting fentanyl products.
Actiq® (g) (fentanyl citrate)
Requires a diagnosis for the treatment of breakthrough cancer pain in members that are tolerant to high dose narcotics and who are currently receiving a long-acting narcotic. The member must also have experienced treatment failure of or intolerance to oral immediate-release narcotics.
Exalgo® (hydromorphone ER) Nonpreferred
Coverage will be provided for management of moderate to severe pain in opioid tolerant patients requiring continuous, around the clock opioid analgesia for an extended period of time. Criteria also require trial and failure or intolerance of TWO of the following: extended release morphine, fentanyl patch or methadone. Coverage will not be provided for use as an “as needed” analgesic or for acute pain or postoperative pain.
Fentora® (fentanyl citrate) Nonpreferred
Requires a diagnosis for the treatment of breakthrough cancer pain in members that are tolerant to high dose narcotics and who are currently receiving a long-acting narcotic. The member must also have experienced treatment failure of or intolerance to oral immediate-release narcotics AND generic short acting fentanyl products.
Lazanda® (fentanyl citrate) Nonpreferred
Requires a diagnosis for the treatment of breakthrough cancer pain in members that are tolerant to high dose narcotics and who are currently receiving a long-acting narcotic. The member must also have experienced treatment failure of or intolerance to oral immediate-release narcotics AND must have experienced treatment failure of or intolerance to fentanyl citrate buccal lollipop AND fentanyl buccal tablet.
Nucynta® ER (tapentadol) Nonpreferred
Requires documented trial and failure or intolerance to Ultram® ER (g) AND trial and failure of TWO of the following generic alternatives: extended-release morphine, fentanyl patch or methadone. Covered for the treatment of Diabetic Peripheral Neuropathy (DPN) with the following criteria: If the member is equal to or greater than 65 years of age: The member must experience trial and failure of gabapentin AND Cymbalta. If the member is less than 65 years of age: The member must experience trial and failure of gabapentin AND Cymbalta AND a tricyclic antidepressant such as amitriptyline, desipramine, nortriptyline or imipramine.
Nucynta® Immediate-Release tablets and oral solution (tapentadol) Nonpreferred
Requires documentation that the patient has experienced treatment failure of or intolerance to generic immediate-release tramadol or tramadol/acetaminophen AND TWO generic immediate-release narcotics: MS-IR (g), Opana IR (g), or oxycodone IR (g). If use is to exceed 30 days, Nucynta must be used in combination with a long-acting narcotic, such as methadone, morphine sulfate extended-release (Oramorph (g), MS Contin (g)), or fentanyl transdermal patch (Duragesic (g)).
Onsolis® (fentanyl citrate) Nonpreferred
Requires a diagnosis for the treatment of breakthrough cancer pain in members that are tolerant to high dose narcotics and who are currently receiving a long-acting narcotic. The member must also have experienced treatment failure of or intolerance to oral immediate-release narcotics AND generic short acting fentanyl products.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 35
Opana® ER (oxymorphone HCl) Nonpreferred
Requires documentation that the member has experienced treatment failure of or intolerance to two of the following long-acting generic agents: methadone, morphine sulfate extended-release, fentanyl transdermal patch.
Oxycontin® (oxycodone HCl) Nonpreferred
Requires documentation that the member has experienced treatment failure of or intolerance to two of the following long-acting generic agents: methadone, morphine sulfate extended-release, fentanyl transdermal patch.
Subsys® (fentanyl citrate) Nonpreferred
Requires a diagnosis for the treatment of breakthrough cancer pain in members that are tolerant to high dose narcotics and who are currently receiving a long-acting narcotic. The member must also have experienced treatment failure of or intolerance to oral immediate-release narcotics AND must have experienced treatment failure of or intolerance to fentanyl citrate buccal lollipop AND fentanyl buccal tablet.
3J - Narcotic Mixed Agonist/Antagonist
Butrans® (buprenorphine) Nonpreferred
Coverage will be provided for the management of moderate to severe chronic pain in patients requiring around the clock opioid analgesia for an extended period of time. Butrans® also requires trial and failure or intolerance of TWO of the following: extended release morphine, fentanyl patch, tramadol extended release, or methadone. Coverage will not be provided for use as an “as needed” analgesic or for acute pain or postoperative pain.
3M - Migraine Therapy
Axert® (almotriptan) Nonpreferred
Requires trial and failure of both options Imitrex® (g) AND Maxalt® (g).
Cambia™ (diclofenac potassium) Nonpreferred
Requires documentation that the patient has tried and failed or is intolerant to generic oral diclofenac AND one oral generic NSAID (Non-steroidal anti-inflammatory drug).
Frova® (frovatriptan) Nonpreferred
Requires trial and failure of both options Imitrex® (g) AND Maxalt® (g).
Relpax® (eletriptan) Nonpreferred
Requires trial and failure of both options Imitrex® (g) AND Maxalt® (g).
Sumavel® DosePro (sumatriptan injection) Nonpreferred
Requires trial and failure of both options Imitrex® (g) injection AND Maxalt MLT® (g).
Treximet® (sumatriptan /naproxen sodium) Nonpreferred
Requires prior use of Imitrex® (g) and Naprosyn® (g) in combination AND documentation indicating why use of the individual agents is harmful to the member AND documentation of trial and failure of Maxalt® (g).
Zecuity™ (sumatriptan iontophoretic transdermal system) Nonpreferred
Requires trial and failure of both options Imitrex® (g) AND Maxalt® (g).
Zomig® (g) / Zomig® ZMT (g) (zolmitriptan)
Requires trial and failure of both options Imitrex® (g) AND Maxalt® (g).
Zomig® Nasal Spray (zolmitriptan) Nonpreferred
Requires trial and failure of both options Imitrex® (g) AND Maxalt® (g).
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 36
3O - Parkinsons Disease and Related Disorders
Mirapex® ER (pramipexole ER) Nonpreferred
Coverage approved for the treatment of Parkinson's. Requires trial and failure of Mirapex® (g).
Neupro® (rotigotine transdermal system) Nonpreferred
For the treatment of the signs and symptoms of Parkinson's disease and documented treatment failure, intolerance or contraindication of Mirapex® (g) and Requip® (g) unless the member is unable to take an oral formulation. OR For the treatment of moderate-to-severe primary restless legs syndrome (RLS) and documented treatment failure, intolerance or contraindication of Mirapex® (g), Requip® (g) and Neurontin® (g) unless the member is unable to take an oral formulation.
3P - Anticonvulsants
Fycompa™ (perampanel) Nonpreferred
Coverage of the requested drug is provided when all the below criteria are met: a) Member is ≥ 12 years of age b) Adjunctive therapy in partial-onset seizures for patients with epilepsy c) Member has experienced treatment failure of or intolerance to at least 3 generic alternatives for the treatment of partial-onset seizures. OR d) Member is currently stable on treatment with perampanel.
Gralise® (gabapentin CR) Nonpreferred
Covered for the treatment of post-herpetic neuralgia with the following criteria: If patient equal to or greater than 65 years of age: After a 30-day trial of gabapentin. If patient less than 65 years of age: After a 30-day trial of gabapentin AND a tricyclic antidepressant, such as amitriptyline, desipramine or imipramine.
Lyrica® (pregabalin) Nonpreferred
Coverage of Lyrica® will be provided for: Adjunctive treatment for adult patients with partial onset of seizures
OR Treatment of diabetic neuropathic pain, post-herpetic neuralgia or neuropathic pain associated with spinal cord injury If patient equal to or greater than 65 years of age: After a 30-day trial of gabapentin. If patient less than 65 years of age: After a 30-day trial of gabapentin AND a tricyclic antidepressant, such as amitriptyline, desipramine or imipramine.
OR Treatment of Fibromyalgia Fibromyalgia characterized by pain in all 4 body quadrants for at least 3 months with or without fatigue and sleep disturbance AND the patient has tried and experienced intolerance to gabapentin OR had inadequate pain relief at doses of 1200 mg or above AND has tried and experienced intolerance or inadequate pain relief to three of the following: tricyclic antidepressant, SSRI, SNRI, cyclobenzaprine, tramadol.
Onfi® tablet and oral suspension (clobazam) Nonpreferred
For the adjunctive treatment of seizures associated with Lennox-Gastaut syndrome in patients 2 years and older.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 37
Oxtellar XR™ (oxcarbazepine xr) Nonpreferred
Coverage of the requested drug is provided when all the below criteria are met: a) Member is ≥ 6 years of age b) Adjunctive therapy in partial-onset seizures for patients with epilepsy c) Member has experienced treatment failure of or intolerance to at least 3 generic alternatives for the treatment of partial-onset seizures, one of which must be Trileptal (g).
3Q - Skeletal Muscle Relaxants
Amrix® (g) (cyclobenzaprine)
Approval requires previous trial and failure of generic immediate-release cyclobenzaprine.
3S - Miscellaneous CNS
Aricept® 23 mg (donepezil) Nonpreferred
Requires 3 month trial of Aricept® (g) (donepezil) 10 mg tablets within the last year.
Horizant® (gabapentin er) Nonpreferred
Treatment of moderate to severe Restless Leg Syndrome (RLS) in adults: Approval requires treatment failure of or intolerance to all three alternatives: generic Mirapex®, generic Neurontin® AND generic Requip®. OR Treatment of Postherpetic Neuralgia (PHN): Approval requires treatment failure of or intolerance to generic or preferred alternatives: - If the patient is equal to or greater than 65 years of age: After a 30 day trial of gabapentin at a dose of 1200mg per day - If the patient is less than 65 years of age: After a 30 day trial of gabapentin at a dose of 1200mg per day and a tricyclic antidepressant such as amitriptyline, desipramine, or imipramine
Intuniv® (guanfacine extended-release) Nonpreferred
Covered for the members 6 years of age and older with the appropriate diagnosis who have experienced therapeutic failure or intolerance to BOTH an amphetamine-type product AND a methylphenidate product.
Kapvay® (clonidine ER) Nonpreferred
Covered for the members 6 years of age and older with the appropriate diagnosis who have experienced therapeutic failure or intolerance to BOTH an amphetamine-type product AND a methylphenidate product.
Nuedexta® (dextromethorphan/quinidine)
Requires appropriate diagnosis for coverage. Coverage approved for the treatment of PBA (pseudobulbar affect) secondary to ALS and/or MS.
Savella® (milnacipran) Nonpreferred
Requires diagnosis of fibromyalgia characterized by pain in all 4 body quadrants for at least 3 months with or without fatigue and sleep disturbance AND the patient has tried and experienced intolerance to gabapentin OR had inadequate pain relief at doses of 1200 mg or above AND has tried and experienced intolerance or inadequate pain relief to three of the following: tricyclic antidepressant, SSRI, SNRI, cyclobenzaprine, tramadol.
Xyrem® (sodium oxybate) Nonpreferred
Requires a diagnosis of narcolepsy and A OR B: A. Cataplexy demonstrated by supporting chart documentation or sleep studies
OR B. Excessive daytime sleepiness demonstrated by supporting chart documentation or sleep studies when (1 AND 2):
1. Modafinil in doses up to 400 mg daily has been ineffective, not tolerated or contraindicated.
AND 2. At least one other generic or preferred treatment, such as methylphenidate or
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 38
dextroamphetamine, has been ineffective, not tolerated or is contraindicated.
Xyrem® will NOT be approved if: 1. Patient is being treated with sedative hypnotic agents, other CNS depressants or
using alcohol 2. Patient has a history of drug abuse 3. Patient has succinic semialdehyde dehydrogenase deficiency
GASTROINTESTINAL AGENTS
4B - Proton Pump Inhibitors
Aciphex® (rabeprazole) Nonpreferred
Requires failure of or intolerance to all generic alternatives: Prilosec® (g) AND Protonix® (g) AND Prevacid®/Prevacid® SoluTab™ (g)
Aciphex® Sprinkle™ (rabeprazole) Nonpreferred
Requires failure of or intolerance to ranitidine syrup, omeprazole and lansoprazole.
Dexilant™ (dexlansoprazole) Nonpreferred
Requires failure of or intolerance to all generic alternatives: Prilosec® (g) AND Protonix® (g) AND Prevacid®/Prevacid® SoluTab™ (g).
Nexium® (esomeprazole) Nonpreferred
Requires failure of or intolerance to all generic alternatives: Prilosec® (g) AND Protonix® (g) AND Prevacid®/Prevacid® SoluTab™ (g).
Vimovo® (naproxen/esomeprazole) Nonpreferred
Approval requires trial and failure of Prilosec (g) AND Protonix (g) AND Prevacid (g) AND one of the following criteria: Member is > 60 years of age or Receiving anticoagulant or antiplatelet therapy or Receiving chronic treatment with oral corticosteroids (>60 days duration) or Has a history of or current diagnosis of peptic ulcer disease, clinically significant gastrointestinal bleeding and/or alcoholism.
Zegerid® powder for oral suspension (omeprazole/ sodium bicarbonate) Nonpreferred
Requires failure of or intolerance to all generic alternatives: Prilosec® (g) AND Protonix® (g) AND Prevacid®/Prevacid® SoluTab™ (g).
4D - Antidiarrheals and Antispasmodics
Fulyzaq™ (crofelemer delayed release)
FDA approved indications only. Require the prescriber to confirm the diarrhea is non-infectious or related to anything other than antiviral therapy.
4E - Antiemetics
Diclegis® (doxylamine succinate and pyridoxine hcl) Nonpreferred
For FDA approved indications and trial and failure of the individual agents (doxylamine and pyridoxine) in combination.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 39
Sancuso® (granisetron) Nonpreferred
Coverage will be provided for: 1. Indication of prevention and/or treatment of nausea/vomiting associated with
chemotherapy and/or radiation therapy AND
2. Documented treatment/failure with generic ondansetron (Zofran®) AND generic granisetron (Kytril®)
Zuplenz® oral soluble film (ondansetron) Nonpreferred
Requires documentation that the member has experienced treatment failure or intolerance to Zofran ODT (g) AND oral Kytril (g). Documentation must be provided as to why continued use of Zofran ODT will harm the patient.
4F - Bile Acids
Chenodal™ (chenodeoxycholic acid) Nonpreferred
Coverage approved for patients with radiolucent stones in well-opacifying gallbladders in whom selective surgery would be undertaken except for the presence of increased surgical risk because of systemic disease or age. Requires:
1. Trial and failure or intolerance of ursodiol 2. Patient is not a candidate for surgery 3. Patient has no history of hepatocellular disease 4. If the patient is a woman, required that they are not pregnant and may not become
pregnant. Coverage is limited to 24 months total of ursodiol plus Chenodal™.
4H - Miscellaneous Gastrointestinal Agents
Amitiza® (lubiprostone) Nonpreferred
Patient must be 18 years or older and have a diagnosis of constipation predominant Irritable Bowel Syndrome (IBS) OR Chronic idiopathic constipation with documented failure with one fiber laxative and either a stimulant or osmotic laxative.
Cimzia® (certolizumab pegol) Nonpreferred
The following criteria are used in reviewing medical exceptions for Cimzia® Age 18 or older and for the treatment of acute exacerbation of moderate to severe Crohn’s disease when the following criteria are met (1 AND 2):
1. Treatment with an adequate course of systemic corticosteroids has been ineffective or is contraindicated or patient has been unable to taper or patient is experiencing breakthrough disease while stabilized on an immunomodulatory medication for at least 2 months. AND
2. Previous trial/failure/contraindication of Humira®. OR Age 18 or older and for the treatment of rheumatoid arthritis when the following criteria are met (1 AND 2)
1. Treatment failure with a three month trial with two concurrent DMARDs (one must be methotrexate unless contraindicated) AND
2. Treatment failure or documented intolerance to Adalimumab (Humira®) and Etanercept (Enbrel®)
Gattex® (teduglutide)
Coverage will be provided for the treatment of Short Bowel Syndrome in patients with dependence on parenteral support for at least 12 months. Authorization will be reviewed annually to confirm that current criteria are met and if treatment is successful (defined as a reduction in at least 20% weekly parenteral or IV nutrition volume).
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 40
Giazo® (balsalazide disodium) Nonpreferred
Coverage will be provided for the treatment of mildly to moderately active ulcerative colitis in patients 18 years of age and older who have had trial and failure or intolerance of generic Colazal® and generic Azulfidine®.
Humira® (adalimumab)
Coverage will be provided for the following: o Rheumatoid arthritis, juvenile RA or psoriatic arthritis: Requires three-month
trial with two concurrent DMARDs (one must be methotrexate unless contraindicated). Examples of DMARDs include: methotrexate, sulfasalazine, azothioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine.
o Ankylosing spondylitis: requires therapy is being supervised by a Rheumatologist.
o Moderate to severe psoriasis: Requires 3 months of previous treatment with topical corticosteroids AND 3 months treatment with phototherapy or photochemotherapy (unless contraindicated) AND therapy must be supervised by a Dermatologist.
o Crohn’s Disease/Ulcerative Colitis: Coverage for patients age 18 years and older with a diagnosis of moderately to severely active Crohn’s disease/Ulcerative Colitis with a history of inadequate response to conventional therapy.
Linzess™ (linaclotide) Nonpreferred
Patient must be 18 years or older and have a diagnosis of constipation predominant Irritable Bowel Syndrome (IBS) OR Chronic idiopathic constipation with documented failure with one fiber laxative and either a stimulant or osmotic laxative. Drug induced constipation must also be ruled out.
Lotronex® (alosetron hydrochloride) Nonpreferred
Approved for treatment of women > 18 years old with severe, diarrhea-predominant Irritable Bowel Syndrome (IBS) who have failed to respond to conventional IBS therapy.
Relistor® (methylnaltrexone bromide)
Coverage will be provided for: 1. The treatment of opioid-induced constipation in patients with advanced illnesses who
are receiving palliative care when response to laxative therapy has not been sufficient. 2. Patients shall be on stable doses of opioids for greater than 2 weeks. 3. Duration of methylnaltrexone therapy shall be limited to 3 months. 4. Previous history of treatment for constipation shall include fluids, stool softeners, bulk
laxatives, saline laxatives and osmotic laxatives. Laxatives trials shall be of at least 5 days duration.
5. Maximum initial regimen shall be 1 box (7 doses). 6. Monthly doses shall not exceed 14.
Patients experiencing withdrawal symptoms while taking methylnaltrexone should consider using an alternate form of therapy.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 41
OBSTETRICS AND GYNECOLOGY
5J - Infertility Treatment
Novarel® (chorionic gonadotropin)
Coverage will be provided in accordance with infertility benefit and policy for both males and females and for FDA approved indications.
Pregnyl® (chorionic gonadotropin)
Coverage will be provided in accordance with infertility benefit and policy for both males and females and for FDA approved indications.
5L - Miscellaneous OB-GYN
Diclegis® (doxylamine succinate and pyridoxine hcl) Nonpreferred
For FDA approved indications and trial and failure of the individual agents (doxylamine and pyridoxine) in combination.
RHEUMATOLOGY AND MUSCULOSKELETAL
6B - Gout Therapy
Uloric® (febuxostat)
Requires treatment failure, intolerance or contraindication with generic allopurinol.
6D - Miscellaneous Rheumatologic Agents
Cimzia® (certolizumab pegol) Nonpreferred
The following criteria are used in reviewing medical exceptions for Cimzia® Age 18 or older and for the treatment of acute exacerbation of moderate to severe Crohn’s disease when the following criteria are met (1 AND 2):
1. Treatment with an adequate course of systemic corticosteroids has been ineffective or is contraindicated or patient has been unable to taper or patient is experiencing breakthrough disease while stabilized on an immunomodulatory medication for at least 2 months. AND
2. Previous trial/failure/contraindication of Humira®. OR Age 18 or older and for the treatment of rheumatoid arthritis when the following criteria are met (1 AND 2)
1. Treatment failure with a three month trial with two concurrent DMARDs (one must be methotrexate unless contraindicated) AND
2. Treatment failure or documented intolerance to Adalimumab (Humira®) and Etanercept (Enbrel®)
Enbrel® (etanercept)
Coverage will be provided for the following: • Rheumatoid arthritis, juvenile RA or psoriatic arthritis: Requires three-month trial with
two concurrent DMARDs (one must be methotrexate unless contraindicated). Examples of DMARDs include: methotrexate, sulfasalazine, azothioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine.
• Ankylosing spondylitis: requires therapy is being supervised by a Rheumatologist. • Moderate to severe psoriasis: Requires 3 months of previous treatment with topical
corticosteroids AND 3 months treatment with phototherapy or photochemotherapy (unless contraindicated) AND therapy must be supervised by a Dermatologist.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 42
Humira® (adalimumab)
Coverage will be provided for the following: o Rheumatoid arthritis, juvenile RA or psoriatic arthritis: Requires three-month
trial with two concurrent DMARDs (one must be methotrexate unless contraindicated). Examples of DMARDs include: methotrexate, sulfasalazine, azothioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine.
o Ankylosing spondylitis: requires therapy is being supervised by a Rheumatologist.
o Moderate to severe psoriasis: Requires 3 months of previous treatment with topical corticosteroids AND 3 months treatment with phototherapy or photochemotherapy (unless contraindicated) AND therapy must be supervised by a Dermatologist.
o Crohn’s Disease/Ulcerative Colitis: Coverage for patients age 18 years and older with a diagnosis of moderately to severely active Crohn’s disease/Ulcerative Colitis with a history of inadequate response to conventional therapy.
Kineret® (anakinra) Nonpreferred
Coverage will be provided for adults with Rheumatoid arthritis. Requires three-month trial with two concurrent DMARDs (one must be methotrexate unless contraindicated) AND treatment failure or intolerance to Enbrel® and Humira®. Examples of DMARDs include: methotrexate, sulfasalazine, azothioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine. OR Requires a diagnosis of Neonatal-onset multisystem inflammatory disease. Continued authorization shall be reviewed at least annually, and documentation indicating that there is disease stability or improvement must be provided.
Orencia® SC (abatacept) Nonpreferred
Coverage will be provided for adults with Rheumatoid Arthritis after a three-month trial with two concurrent DMARDs (one must be methotrexate unless contraindicated) AND treatment failure or intolerance to Enbrel® and Humira®. Examples of DMARDs include: methotrexate, sulfasalazine, azothioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine.
Simponi® (golimumab) Nonpreferred
Coverage will be provided for members 18 years of age or older with the following: Rheumatoid arthritis and psoriatic arthritis: Requires a 3-month trial on two concurrent Disease Modifying Anti-Rheumatic Drugs (DMARDs), one of which must be methotrexate unless contraindicated, AND treatment failure or contraindication to both Enbrel® AND Humira®.
OR Ankylosing spondylitis: Requires a treatment failure or contraindication to both Enbrel® AND Humira®.
Xeljanz® (tofacitinib) Nonpreferred
Coverage will be provided for adults with Rheumatoid Arthritis after a three-month trial with two concurrent DMARDs (one must be methotrexate unless contraindicated) AND treatment failure or intolerance to Enbrel® AND Humira®. Examples of DMARDs include: methotrexate, sulfasalazine, azothioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine. Coverage may be renewed annually thereafter when clinical notes document positive clinical response.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 43
6E - Osteoporosis/Hormonal Treatment
Forteo® (teriparatide) Nonpreferred
Coverage will be provided for the following guidelines: 1. For patients with a history of fracture. OR 2. For the treatment of postmenopausal women with osteoporosis who are at high risk of fracture or men with primary or hypogonadal osteoporosis who are at high risk for fracture and meet the following criteria (a and b):
a) Have a bone mineral density (BMD) that is 2.5 standard deviations or more below the mean (T-score at or below -2.5).
b) Patient has tried and failed a bisphosphonate (generic or preferred agents include Fosamax® (g), Boniva® (g) and Actonel®) for a 24 month period except when: 1. Contraindication to a bisphosphonate (such as a stricture or achalasia, inability to
stand or sit upright for at least 30 minutes and increased risk of aspiration). OR
2. Documented intolerance to a bisphosphonate Forteo will be approved for a maximum of two years.
6F - Osteoporosis/Bone Resorption
Actonel® (risedronate)
Requires documentation that the member has tried and failed/not tolerated treatment with Fosamax® (g) or Boniva® (g).
Atelvia® (risedronate) Nonpreferred
Requires documentation that the member has tried and failed/not tolerated treatment with Fosamax® (g) and Actonel® (risendronate).
Binosto™ (alendronate sodium effervescent) Nonpreferred
Requires documentation that the member has experienced treatment failure or intolerance, or has a contraindication to alendronate (Fosamax®), ibandronate (Boniva®) and Actonel®.
Fosamax Plus D® (alendronate / vitamin D3) Nonpreferred
Requires documentation that the member has tried and failed/not tolerated treatment with both Fosamax® (g) AND Actonel® (risedronate).
ENDOCRINOLOGY
7C - Corticosteroids
Rayos® (prednisone delayed release) Nonpreferred
Requires documentation of a diagnosis of rheumatoid arthritis and documentation of a trial or intolerance of two systemically absorbed generic oral corticosteroids, one of which must be prednisone and an explanation why delayed release is expected to work if prednisone immediate release has not.
Uceris™ (budesonide extended release) Nonpreferred
Coverage of the requested drug is provided when all the below criteria are met: 1.For the induction of remission in patients with active mild to moderate ulcerative colitis AND 2. History of inadequate response to two different conventional therapies for active disease. -Duration of therapy: 8 weeks
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 44
7D - Androgens
Anadrol-50® (oxymetholone) Nonpreferred
Approved for the treatment of clinically diagnosed anemia (documentation must support the trial of standard supportive measures for treating anemia including: transfusion, correction of iron, folic acid, vitamin B12, or pyridoxine deficiency, antibacterial therapy and the appropriate use of corticosteroids) OR for the treatment of HIV-associated wasting OR if prophylactic therapy is needed in patients with hereditary angioedema.
Oxandrin® (g) (oxandrolone)
Approved when used as an adjunct therapy to promote weight gain in patients who have had extensive surgery, chronic infection, or severe trauma OR for therapy to offset protein catabolism associated with prolonged use of corticosteroids OR for bone pain associated with osteoporosis OR if prophylactic therapy is needed in patients with hereditary angioedema.
7E - Miscellaneous Endocrine
Carbaglu® (carglumic acid)
Covered for the treatment of acute hyperammonemia due to the deficiency of the hepatic enzyme N-acetylglutamate synthase (NAGS).
Egrifta® (tesamorelin) Nonpreferred
Coverage will be provided for the FDA approved indication only. The reduction of excess abdominal fat in HIV-infected patients with lipodystrophy AND supporting documentation will be required for the following criteria:
A. Patient is infected with human immunodeficiency virus (HIV). B. Patient is receiving antiretroviral therapy (ART). C. Weight loss efforts (dietary modification and exercise) have been ineffective in
reducing the excess abdominal fat due to lipodystrophy. D. Documentation of the medical complication(s) caused by excess abdominal fat. E. The medical complication(s) due to excess abdominal fat are unresponsive to
conventional therapy. Initial approval is for 6 months. Coverage may be renewed for 12 months when the following criteria are met:
A. Clinical documentation indicating a decrease in waist circumference (decrease in lipodystrophy).
B. Reduction of complication(s) provided in the initial request caused by excess abdominal fat.
Coverage is NOT provided for weight loss management in patients with HIV infection. H.P. Acthar Gel® (repository corticotropin) Nonpreferred
Coverage will be provided for the treatment of infantile spasms for children less than 2 years old.
Korlym™ (mifepristone)
Coverage requires documentation of ALL the following: 1. Diagnosis of hypercortisolism as a result of endogenous Cushing’s syndrome 2. Diagnosis of type II diabetes mellitus or glucose intolerance 3. Surgical treatment has been ineffective or not a candidate for surgery 4. Treatment failure to ketoconazole or mitotane, unless contraindicated or not tolerated
Initial approval = 6 months. Renewal of coverage requires documentation of ≥ 25% reduction in HbA1c from baseline. Coverage may be renewed for 6 months based on response. Coverage will NOT be provided for all other conditions.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 45
Procysbi™ (cysteamine bitartrate) Nonpreferred
Coverage will be provided for the treatment of nephropathic cystinosis, in patients who have had a positive response to therapy with oral cysteamine (Cystagon®) but have experienced intolerable side effects. Documentation must support request.
Ravicti™ (glycerol phenylbutyrate) Nonpreferred
Coverage will be provided for the management of patients with urea cycle disorders who cannot be managed by dietary protein restriction and /or amino acid supplementation alone. Therapy is considered investigational for all other conditions such as but not limited: N-acetylglutamate synthase (NAGS) deficiency.
Sandostatin LAR® Approval requires member to have previously tried, responded and tolerated immediate-release octreotide injection in addition to the diagnosis requirement listed for Sandostatin(g).
Sandostatin® (g) (octreotide)
Approval requires one of the following (1, 2 or 3): 1. Clinically diagnosed acromegaly AND one of the following (a, b or c)
a) Failure to respond to surgery or radiation OR b) Not a candidate for surgery or radiation OR c) Use to shrink tumor prior to surgery
2. Diagnosis of metastatic carcinoid tumor 3. Diagnosis of vasoactive intestinal peptide tumors (VIPomas)
Signifor® (pasireotide)
Coverage will be provided for the treatment of adults with hypercortisolism as a result of endogenous Cushings syndrome for whom pituitary surgery is not an option, or has not been curative. Patients must also have documented a treatment failure to ketoconazole or mitotane, unless it is contraindicated. Authorization will be reviewed annually to confirm that current criteria are met and that the medication is effective.
Somavert® (pegvisomant)
For the treatment of acromegaly in patients who have had an inadequate response to surgery and/or radiation therapy and/or other medical therapies or for whom these therapies are not appropriate.
7G - Non-insulin Hypoglycemic Agents
Bydureon® (exenatide extended-release) Nonpreferred
Approved as adjunctive therapy in combination with at least one of the following medications: metformin, sulfonylurea or a thiazolidinedione AND being used to improve glycemic control in patients who have a diagnosis of type II diabetes mellitus AND have tried at least 2 of the following: metformin, a sulfonylurea or a thiazolidinedione (unless contraindicated) AND documentation that the member failed to achieve desired glucose control evidenced by a Hgb A1c greater than 7%. Bydureon® is NOT covered for the primary indication of weight loss in patients with or without diabetes.
Byetta® (exenatide) Nonpreferred
Approved as adjunctive therapy in combination with at least one of the following medications: metformin, sulfonylurea or a thiazolidinedione AND being used to improve glycemic control in patients who have a diagnosis of type II diabetes mellitus AND have tried at least 2 of the following: metformin, a sulfonylurea or a thiazolidinedione (unless contraindicated) AND documentation that the member failed to achieve desired glucose control evidenced by a Hgb A1c greater than 7%. Byetta® is NOT covered for the primary indication of weight loss in patients with or without diabetes.
Cycloset® (bromocriptine) Nonpreferred
Approved as adjunctive therapy in combination with at least one of the following medications: metformin, sulfonylurea or a thiazolidinedione AND being used to improve glycemic control in patients who have a diagnosis of type II diabetes mellitus AND have tried at least 2 of the following: metformin, a sulfonylurea or a thiazolidinedione (unless contraindicated) AND
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 46
documentation that the member failed to achieve desired glucose control evidenced by a Hgb A1c greater than 7%. Cycloset® is NOT covered for the primary indication of weight loss in patients with or without diabetes.
Invokana™ (canagliflozin) Nonpreferred
Requires trial of metformin and another preferred antidiabetic medication prior to approval.
Jentadueto® (linagliptin/metformin) Nonpreferred
Requires successful treatment of linagliptin and metformin as individual agents for at least 3 months.
Kazano® (alogliptin and metformin) Nonpreferred
Requires trial and failure of Januvia® AND Onglyza®
Nesina® (alogliptin) Nonpreferred
Requires trial and failure of Januvia® AND Onglyza®
Oseni® (alogliptin and pioglitazone) Nonpreferred
Requires trial and failure of Januvia® AND Onglyza®
Tradjenta® (linagliptin) Nonpreferred
Requires trial and failure of Januvia® AND Onglyza®
Victoza® (liraglutide)
Nonpreferred
Approved as adjunctive therapy in combination with at least one of the following medications: metformin, sulfonylurea or a thiazolidinedione AND being used to improve glycemic control in patients who have a diagnosis of type II diabetes mellitus AND have tried at least 2 of the following: metformin, a sulfonylurea or a thiazolidinedione (unless contraindicated) AND documentation that the member failed to achieve desired glucose control evidenced by a Hgb A1c greater than 7%. Victoza® is NOT covered for the primary indication of weight loss in patients with or without diabetes.
7H - Growth Hormone and Related Products
Genotropin®
(somatropin) Nutropin®/Nutropin® AQ (somatropin) Nonpreferred: Humatrope® Norditropin® Omnitrope® Saizen® Serostim® Tev-Tropin® Zorbtive™
Coverage will be provided for: Pediatric Growth Hormone Deficiency Children (M < 16 years old, F < 15 years old):
Initial Treatment: Req. > 6 months of initial height measurements, Ht < 5th percentile for age (based on initial evaluation), abnormal growth velocity based on > 6 mo. of measurement, < 50th percentile for age with growth hormone therapy, initial subnormal blood test for growth hormone. To continue treatment: must have a documented growth velocity of > 2.5 cm/year during the first 6 mo. of therapy & documented growth of > 4.5 cm/year for each succeeding 6 month review period. Treatment may continue until final height or epiphyseal closure has been documented or patient has reached age 16 years (M) or 15 years (F).
Adults: Diagnosis of growth hormone deficiency confirmed by laboratory testing (e.g. provocative stimulation), known indication for pituitary disease and multiple pituitary hormone deficiencies. Multiple stimulation tests may be required in certain clinical circumstances. May
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 47
be approved for AIDS-wasting cachexia and Turner’s Syndrome. Growth hormone therapy is NOT covered for anti-aging, obesity or athletic enhancement.
Nonpreferred agents require that the member has experienced treatment failure of or intolerance to preferred agents.
Gattex® (teduglutide)
Coverage will be provided for the treatment of Short Bowel Syndrome in patients with dependence on parenteral support for at least 12 months. Authorization will be reviewed annually to confirm that current criteria are met and if treatment is successful (defined as a reduction in at least 20% weekly parenteral or IV nutrition volume).
Increlex® (mecasermin) Nonpreferred
Approval will require all of the following (1, 2, 3, 4, 5 and 6): 1. Medication to be prescribed by a pediatric endocrinologist 2. Diagnosis of one of the following:
• Severe primary IGF-1 deficiency or growth hormone gene deletion or • genetic mutation of growth hormone receptor (Laron Syndrome)
3. Current height measurement at less than 3rd percentile for age and sex 4. IGF-1 level greater than or equal to 3 standard deviations below normal 5. Normal or elevated growth hormone levels based on at least one growth hormone
stimulation test 6. Open growth plates Authorizations shall be reviewed at least annually to confirm that current medical necessity criteria are met and that the medication is effective. Continued authorization in children may be given for up to 12 months until any one of the following conditions occurs:
1. Growth velocity is less than 2.5 cm/year OR 2. Bone age in males exceeds 16 0/12 years of age OR 3. Bone age in females exceeds 14 0/12 years of age
ANTINEOPLASTICS AND IMMUNOSUPPRESANTS
8C - Immunomodulators
Arcalyst® (rilonacept)
Only FDA-approved for treatment of Cryopyrin-Associated Periodic Syndromes (CAPS), including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS) in adults and children 12 years and older.
Kineret® (anakinra) Nonpreferred
Coverage will be provided for adults with Rheumatoid arthritis. Requires three-month trial with two concurrent DMARDs (one must be methotrexate unless contraindicated) AND treatment failure or intolerance to Enbrel® and Humira®. Examples of DMARDs include: methotrexate, sulfasalazine, azothioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine. OR Requires a diagnosis of Neonatal-onset multisystem inflammatory disease. Continued authorization shall be reviewed at least annually, and documentation indicating that there is disease stability or improvement must be provided.
Pomalyst® (pomalidomide) Nonpreferred
Coverage will be provided for patients with multiple myeloma who have received at least 2 prior therapies including lenalidomide and bortezomib and have demonstrated disease progression on or within 60 days of completion of last therapy.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 48
Rayos® (prednisone delayed release) Nonpreferred
Requires documentation of a diagnosis of rheumatoid arthritis and documentation of a trial or intolerance of two systemically absorbed generic oral corticosteroids, one of which must be prednisone and an explanation why delayed release is expected to work if prednisone immediate release has not.
8D - Hormonal Agents
Arimidex® (g) (anastrozole)
Coverage review required for males only. Approved only for ER-positive breast cancer treatment and other literature supported cancer therapies.
Aromasin® (g) (exemestane)
Coverage review required for males only. Approved only for ER-positive breast cancer treatment and other literature supported cancer therapies.
Femara® (g) (letrozole)
Coverage review required for males only. Approved only for ER-positive breast cancer treatment and other literature supported cancer therapies.
Xtandi® (enzalutamide)
Coverage for Xtandi® is provided when all of the following are met: a. Diagnosis of metastatic castration-resistant prostate cancer b. Prior treatment with docetaxel Authorization will be reviewed annually to assess treatment response
8E - Miscellaneous Antineoplastic Agents
Erivedge™ (vismodegib)
Coverage will be provided for the following: 1. Prescriber is an oncologist or dermatologist
AND 2) Diagnosis of metastatic Basal Cell Carcinoma (mBCC)
OR 3) Diagnosis of locally advanced Basal Cell Carcinoma (laBCC)
a) That has recurred following surgery OR b) Who are not candidates for surgery AND who are not candidates for radiation
Coverage will be reviewed to assess disease progression and intolerance. Coverage will NOT be provided for all other conditions. Initial coverage approval = 6 months.
Jakafi® (ruxolitinib)
Coverage requires chart notes documenting ALL of the following: 1. Diagnosis of intermediate or high risk myelofibrosis 2. Refractory or not a candidate to hydroxyurea 3. Prescribing physician is an oncologist/hematologist 4. Imaging tests documenting spleen enlargement and measurement 5. Bone marrow testing documenting fibrosis 6. Documentation of disease symptoms (for example: abdominal discomfort, pain under
left rib, night sweats, itching, bone/ muscle pain, and early satiety) 7. CBC and platelet count prior to initiation of therapy
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 49
8. Requested dose appropriate for platelet count and renal or hepatic impairment Initial approval = 6 months Renewal of therapy requires documentation of at least a 35% reduction in spleen volume OR a 50% reduction in palpable spleen length AND at least a 50% improvement of symptoms compared to score assessed prior to treatment measured by the MFSAF diary. Coverage may be renewed for 6 months based on response.
Sandostatin LAR®
Approval requires member to have previously tried, responded and tolerated immediate-release octreotide injection in addition to the diagnosis requirement listed for Sandostatin(g).
Sandostatin® (g) (octreotide)
Approval requires one of the following (1, 2 or 3): 1. Clinically diagnosed acromegaly AND one of the following (a, b or c)
a) Failure to respond to surgery or radiation OR b) Not a candidate for surgery or radiation OR c) Use to shrink tumor prior to surgery
2. Diagnosis of metastatic carcinoid tumor 3. Diagnosis of vasoactive intestinal peptide tumors (VIPomas)
Targretin® capsules (bexarotene) Nonpreferred
Coverage will be provided for the FDA approved indication only: Targretin (bexarotene) capsules are indicated for the treatment of cutaneous manifestations of cutaneous T-cell lymphoma (CTCL) in patients who are refractory to at least one prior systemic therapy. Initial approval = 12 months. Coverage may be renewed for 12 months based on response. Coverage will NOT be provided for Alzheimer’s disease.
8F - Adjuvant Therapy
Aranesp® (darbepoetin alfa) Nonpreferred
Information may need to be submitted describing the use and setting of the drug to make the determination. Approved for use in members with hemoglobin less than 12 g/dL and one of the following conditions: anemia secondary to chronic renal failure, chronic renal insufficiency, HIV infection, HIV therapy, chemotherapy, myelodysplasia or chronic hepatitis C therapy OR prophylaxis prior to major surgery. Duration of approval is dependent on the indication. Coverage for nonpreferred agents also requires documentation that the member has experienced failure of or intolerance to the preferred agent epoetin alfa (Procrit®). Coverage duration = 3 months
Epogen® (epoetin alfa) Nonpreferred
Information may need to be submitted describing the use and setting of the drug to make the determination. Approved for use in members with hemoglobin less than 12 g/dL and one of the following conditions: anemia secondary to chronic renal failure, chronic renal insufficiency, HIV infection, HIV therapy, chemotherapy, myelodysplasia or chronic hepatitis C therapy OR prophylaxis prior to major surgery. Duration of approval is dependent on the indication. Coverage for nonpreferred agents also requires documentation that the member has
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 50
experienced failure of or intolerance to the preferred agent epoetin alfa (Procrit®). Coverage duration = 3 months
Procrit® (epoetin alfa)
Information may need to be submitted describing the use and setting of the drug to make the determination. Approved for use in members with hemoglobin less than 12 g/dL and one of the following conditions: anemia secondary to chronic renal failure, chronic renal insufficiency, HIV infection, HIV therapy, chemotherapy, myelodysplasia or chronic hepatitis C therapy OR prophylaxis prior to major surgery. Duration of approval is dependent on the indication. Coverage duration = 3 months
8G - Kinase Inhibitors and Molecular Target Inhibitors
Bosulif® (bosutinib)
Coverage will be provided when all of the following are met: a) The patient has Philadelphia-positive chromosome Chronic Myelogenous Leukemia (Ph+ CML) b) The patient had a documented trial and failure or intolerance to i. imatinib (Gleevec®) AND ii. either dasatanib (Sprycel®) or nilotinib (Tasigna®) Initial authorization: 3 months Renewal: Patient has a good response to the medication
Cometriq™ (cabozantinib)
Coverage will be provided for the treatment of patients with progressive, metastatic medullary thyroid cancer. Therapy is considered investigational for all other conditions. Authorization will be reviewed annually to confirm that current criteria are met and that the medication is effective and to assess for disease progression and intolerance.
Iclusig™ (ponatinib)
Coverage will be provided for: The treatment Philadelphia chromosome positive acute lymphoblastic (Ph+ALL) OR Philadelphia chromosome positive chronic myelogenous leukemia (Ph+CML) AND Documented T315I mutation OR documented resistance or intolerance to preferred agents (i.e., imatinib etc) Authorization will be reviewed annually to confirm that current criteria are met and that the medication is effective (improvement in test results) and to assess for disease progression and intolerance.
Inlyta® (axitinib)
Coverage will be provided for patients with a documented diagnosis of Advanced Renal Cell Carcinoma (RCC) AND documented trial of one prior systemic treatment showing ineffective, not tolerated or contraindicated. Coverage will not be provided for all other conditions.
Stivarga® (regorafenib)
Coverage of the requested drug is provided when the below criteria are met: Diagnosis of metastatic or unresectable gastrointestinal stromal tumors AND disease progression or intolerance to treatment with imatinib AND sunitinib. Authorization will be reviewed annually to confirm that current criteria are met and that the medication is effective. OR Diagnosis of metastatic colorectal cancer (mCRC) AND prior treatment with fluoropyrimidine-, oxaliplatin- and irinotecan-based chemotherapy, an anti- VEGF therapy, and, if KRAS wild type, an anti-EGFR therapy Continuation of treatment requires a lack of disease progression or unacceptable toxicity documented in chart notes.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 51
Xalkori® (crizotinib)
Coverage will be provided for patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (ALK)-positive as detected by a FDA approved test.
Zelboraf® (vemurafenib)
Coverage will be provided for patients with unresectable or metastatic melanoma with BRAFV600E mutation as detected by an FDA-approved test.
IMMUNOLOGY AND HEMATOLOGY
9A - Immunoglobulins
Gammagard™ Gammaked™ Gamunex-C®
Hizentra®
Nonpreferred
Requires appropriate diagnosis for coverage, subcutaneous administration and other criteria may apply depending on diagnosis.
9B - Hematopoietic Agents
Aranesp® (darbepoetin alfa) Nonpreferred
Information may need to be submitted describing the use and setting of the drug to make the determination. Approved for use in members with hemoglobin less than 12 g/dL and one of the following conditions: anemia secondary to chronic renal failure, chronic renal insufficiency, HIV infection, HIV therapy, chemotherapy, myelodysplasia or chronic hepatitis C therapy OR prophylaxis prior to major surgery. Duration of approval is dependent on the indication. Coverage for nonpreferred agents also requires documentation that the member has experienced failure of or intolerance to the preferred agent epoetin alfa (Procrit®). Coverage duration = 3 months
Epogen® (epoetin alfa) Nonpreferred
Information may need to be submitted describing the use and setting of the drug to make the determination. Approved for use in members with hemoglobin less than 12 g/dL and one of the following conditions: anemia secondary to chronic renal failure, chronic renal insufficiency, HIV infection, HIV therapy, chemotherapy, myelodysplasia or chronic hepatitis C therapy OR prophylaxis prior to major surgery. Duration of approval is dependent on the indication. Coverage for nonpreferred agents also requires documentation that the member has experienced failure of or intolerance to the preferred agent epoetin alfa (Procrit®). Coverage duration = 3 months
Procrit® (epoetin alfa)
Information may need to be submitted describing the use and setting of the drug to make the determination. Approved for use in members with hemoglobin less than 12 g/dL and one of the following conditions: anemia secondary to chronic renal failure, chronic renal insufficiency, HIV infection, HIV therapy, chemotherapy, myelodysplasia or chronic hepatitis C therapy OR prophylaxis prior to major surgery. Duration of approval is dependent on the indication. Coverage duration = 3 months
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 52
Promacta® (eltrombopag)
Approval for coverage requires either A OR B: A. Diagnosis of chronic immune thrombocytopenia (ITP) and persistent thrombocytopenia (platelet count < 150,000 mcL) for > 2 months and requires all of the following:
1. Age greater than 18 years old 2. Prescribed by a hematologist or in consultation with a hematologist 3. Inadequate response or patient must not be a candidate for corticosteroids,
immunoglobulins or splenectomy 4. Current platelet count is < 50, 000 mcL 5. Dose is < 75 mg/day
Renewal for Promacta® requires recent platelet count of 30,000-150, 000 mcL AND dose is < 75 mg/day. OR B. Diagnosis of thrombocytopenia with chronic hepatitis C and requires all of the following:
1. ≥18 years of age 2. Platelets <75,000 mcL 3. Initiating antiviral therapy with pegylated interferon and ribavirin.
Renewal for Promacta® requires recent platelet count of 30,000-150,000 mcL and dose is < 100 mg/day -Authorization period 1. Initial duration of approval will be 3 months. 2. Continuation of therapy will be approved for 12 months.
9C - Interferons and MS Therapy
Ampyra® (dalfampridine) Nonpreferred
Coverage may be provided in patients ≥ 18 years of age when the criteria below are met: • Diagnosis of multiple sclerosis. • Prescribing physician is a neurologist. • Patient has documented difficulty walking, resulting in significant limitations of
instrumental activities of daily living. • Clinical notes are provided documenting two measurements with variability within 10%
demonstrating the patient is able to walk 25 feet in 8-45 seconds. The faster time of the two measurements will serve as the baseline value. Ambulatory function assessed with the timed 25-foot walk (T25FW).
• Patient does not have a history of seizure. • Patient does not have moderate to severe renal impairment (CrCl ≤ 50 ml/min). • Patient does not have prior treatment and failure with Ampyra.
Initial approval length is for 3 months Coverage may be renewed for 12 months when the following criteria are met:
• Clinical notes are provided documenting improvement in walking speed by at least 10% as assessed by the timed 25-foot walk.
• Indication that the significant limitations of instrumental activities of daily living have improved/resolved as a result of increased speed of ambulation.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 53
• Renewal will not be authorized if there is failure to demonstrate benefit after the initial 3 month trial period while on medication. Continuation and future coverage of Ampyra will not be authorized for patients who have been identified as non-responders.
Coverage may be renewed annually thereafter (12 month intervals) when clinical notes document no deterioration in walking speed, compared to the previous walking speed measured for renewal of therapy, as assessed by the timed 25-foot walk.
Aubagio® (teriflunomide) Nonpreferred
Approval requires (1,2,3, 4 and 5): 1. That the patient is 18 years of age or older with a relapsing form of multiple sclerosis 2. The prescribing physician must be a neurologist 3. Trial of at least one interferon beta product (e.g. Avonex®, Betaseron®, Extavia®, Rebif®)
OR Copaxone® has demonstrated clinical failure or intolerance, unless all products are contraindicated based on clinical documentation • Treatment failure is demonstrated by the following:
- Documented clinical relapse - The presence of new and/or newly enlarged MRI lesions in the previous year
4. Will not be used in combination with other disease-modifying treatments of multiple sclerosis
5. Patient does not have contraindication to Aubagio®.
Renewal Requests Only: Coverage will be provided at 12 month intervals. Authorization will be reviewed annually to confirm that current medical necessity criteria are met and that the medication is effective based on relapse events or MRI data.
Betaseron® (interferon beta-1b) Nonpreferred
Requires trial and failure or intolerance of Extavia®
Gilenya™ (fingolimod) Nonpreferred
Approval requires (1,2,3, 4 and 5): 1. That the patient is 18 years of age or older with a relapsing form of multiple sclerosis. 2. The prescribing physician must be a neurologist 3. Trial of at least one interferon beta product (e.g. Avonex®, Betaseron®, Extavia®, Rebif®)
OR Copaxone® has demonstrated clinical failure or intolerance, unless all products are contraindicated based on clinical documentation • Treatment failure is demonstrated by the following:
- Documented clinical relapse - The presence of new and/or newly enlarged MRI lesions in the previous year
4. Will not be used in combination with other disease-modifying treatments of multiple sclerosis
5. Patient does not have contraindication to Gilenya™ Renewal Requests Only: Coverage will be provided at 12 month intervals. Authorization will be reviewed annually to confirm that current medical necessity criteria are met and that the medication is effective based on relapse events or MRI data.
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 54
Tecfidera™ (dimethyl fumarate delayed-release) Nonpreferred
Approval requires (1,2,3, 4 and 5): 1. That the patient is 18 years of age or older with a relapsing form of multiple sclerosis. 2. The prescribing physician must be a neurologist 3. Trial of at least one interferon beta product (e.g. Avonex®, Betaseron®, Extavia®, Rebif®) OR Copaxone® has demonstrated clinical failure or intolerance, unless all products are contraindicated based on clinical documentation • Treatment failure is demonstrated by the following: - Documented clinical relapse - The presence of new and/or newly enlarged MRI lesions in the previous year 4. Will not be used in combination with other disease-modifying treatments of multiple sclerosis 5. Patient does not have contraindication to Tecfidera™
Renewal Requests Only: Coverage will be provided at 12 month intervals. Authorization will be reviewed annually to confirm that current medical necessity criteria are met and that the medication is effective based on relapse events or MRI data.
DERMATOLOGY
10K - Antipsoriatic/Antiseborrheic
Enbrel® (etanercept)
Coverage will be provided for the following: • Rheumatoid arthritis, juvenile RA or psoriatic arthritis: Requires three-month trial with
two concurrent DMARDs (one must be methotrexate unless contraindicated). Examples of DMARDs include: methotrexate, sulfasalazine, azothioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine.
• Ankylosing spondylitis: requires therapy is being supervised by a Rheumatologist. • Moderate to severe psoriasis: Requires 3 months of previous treatment with topical
corticosteroids AND 3 months treatment with phototherapy or photochemotherapy (unless contraindicated) AND therapy must be supervised by a Dermatologist.
Humira® (adalimumab)
Coverage will be provided for the following: • Rheumatoid arthritis, juvenile RA or psoriatic arthritis: Requires three-month trial with
two concurrent DMARDs (one must be methotrexate unless contraindicated). Examples of DMARDs include: methotrexate, sulfasalazine, azothioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine.
• Ankylosing spondylitis: requires therapy is being supervised by a Rheumatologist. • Moderate to severe psoriasis: Requires 3 months of previous treatment with topical
corticosteroids AND 3 months treatment with phototherapy or photochemotherapy (unless contraindicated) AND therapy must be supervised by a Dermatologist.
• Crohn’s Disease/Ulcerative Colitis: Coverage for patients age 18 years and older with a diagnosis of moderately to severely active Crohn’s disease/Ulcerative Colitis with a history of inadequate response to conventional therapy.
10M - Miscellaneous Dermatologicals
Picato® (ingenol mebutate) Nonpreferred
Coverage for Picato® will be provided after ALL the following criteria have been met:
1. Chart notes showing diagnosis of actinic keratosis 2. Member has not responded to, or has been intolerant to 3 different treatment courses
using cryotherapy or phototherapy
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 55
3. Trial of two generic or preferred agents, which may include Efudex(g), Aldara(g) or Retin- A(g).
Solaraze® (diclofenac) Nonpreferred
Requires documentation of diagnosis of actinic keratosis and that the member has not responded to, or has been intolerant of 3 different treatment courses using cryotherapy or phototherapy, plus 2 generic or preferred agents, which may include Efudex(g), Aldara(g) and Retin-A(g).
OPHTHALMOLOGY
11H - Miscellaneous Ophthalmic Agents
Cystaran™ (cysteamine)
Coverage will be provided for the treatment of corneal cystine crystal accumulation in patients with cystinosis, when taking in combination with oral Cystagon®.
OTIC AND NASAL PREPARATIONS
12A - Nasal Preparations
Beconase® AQ (beclomethasone) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®).
Dymista® (azelastine/fluticasone) Nonpreferred
Requires documentation that the member has experienced treatment failure of or intolerance to 2 generic intranasal steroid products one of which must be intranasal fluticasone used in combination with intranasal azelastine for a 3 month trial.
Nasonex® (mometasone) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®).
Omnaris® (ciclesonide) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®).
Qnasl® (beclomethasone) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®).
Rhinocort AQ® (budesonide) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®).
Veramyst® (fluticasone) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®).
Zetonna® (ciclesonide) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®).
RESPIRATORY, COUGH AND COLD
13A - Antihistamines
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 56
Karbinal™ ER (carbinoxamine maleate extended-release oral suspension) Nonpreferred
Coverage approved after trial and failure of generic carbinoxamine and two other generic antihistamines.
13I - Intranasal Steroids
Beconase® AQ (beclomethasone) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®).
Dymista® (azelastine/fluticasone) Nonpreferred
Requires documentation that the member has experienced treatment failure of or intolerance to 2 generic intranasal steroid products one of which must be intranasal fluticasone used in combination with intranasal azelastine for a 3 month trial.
Nasonex® (mometasone) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®).
Omnaris® (ciclesonide) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®).
Qnasl® (beclomethasone) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®).
Rhinocort AQ® (budesonide) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®)
Veramyst® (fluticasone) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®).
Zetonna® (ciclesonide) Nonpreferred
Requires trial and failure/intolerance of 2 of the following intranasal steroids: generic fluticasone (Flonase®), generic flunisolide (Nasarel®) or generic triamcinolone (Nasacort AQ®).
13L - Miscellaneous Pulmonary Agents
Adcirca® (tadalafil) Nonpreferred
Approved for members with documentation of a diagnosis of Pulmonary Arterial Hypertension (PAH). Coverage is NOT provided for Adcirca® in situations where the patient is receiving nitrate therapy.
Daliresp® (roflumilast) Nonpreferred
Coverage will be approved for use in patients with severe COPD associated with chronic bronchitis AND a history of exacerbations despite maximal therapy with a LABA (long-acting beta agonist), an anticholinergic and an inhaled corticosteroid. Supporting documentation will be required for processing.
Kalydeco™ (ivacaftor)
Coverage will be provided for patients with a documented diagnosis of cystic fibrosis (CF) with the specific G551D mutation confirmed by a genetic test. Coverage will NOT be provided for all other conditions such as but not limited to: other
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 57
mutations aside from G551D mutation, heterozygous F508-del CFTR mutation. Initial approval = 12 months. Authorization may be reviewed at least annually to assess treatment response.
Revatio® tablet (g) and oral suspension (sildenafil citrate)
Approved for members with documentation of a diagnosis of Pulmonary Arterial Hypertension (PAH). Coverage is NOT provided for sildenafil (Revatio®) in situations where patients are receiving nitrate therapy.
UROLOGY
14A - Urinary Antispasmodics
Myrbetriq® (mirabegron extended release) Nonpreferred
Coverage will be provided when the following are met: Treatment failure or intolerance to at least two generic OAB (Overactive Bladder) therapies AND documentation of no hypertension, or documentation of controlled hypertension via treatment, based on 3 most recent blood pressure readings.
14B - Miscellaneous Urologicals
Procysbi™ (cysteamine bitartrate) Nonpreferred
Coverage will be provided for the treatment of nephropathic cystinosis, in patients who have had a positive response to therapy with oral cysteamine (Cystagon®) but have experienced intolerable side effects. Documentation must support request.
14C - BPH Treatment
Cialis® (tadalafil)
Requires diagnosis of Benign Prostatic Hyperplasia (BPH) AND trial and failure or intolerance of an alpha-blocker AND a 5-alpha reductase inhibitor. May be covered for the diagnosis of erectile dysfunction dependent on the plan’s benefit with quantity limit restrictions.
DIAGNOSTIC AND OTHER MISCELLANEOUS
16A - Diagnostics and Other Miscellaneous
Ferriprox® (deferiprone) Nonpreferred
Coverage will be provided for patients with a diagnosis of transfusional iron overload due to thalassemia syndromes when current chelation therapy is inadequate AND monitoring Absolute Neutrophilic Count (ANC) and serum ferritin level prior to and during therapy AND documented previous trial of both Exjade® and Desferal®. Coverage will not be provided for all other indications. Initial approval = 12 months. Coverage may be renewed for 12 months with documentation of >20% decline in serum ferritin within one year of baseline level.
Firazyr® (icatibant) Nonpreferred
Coverage will be provided for a diagnosis of hereditary angioedema (HAE) established by an immunologist or hematologist. Supporting documentation will be required for processing.
Xenazine® (tetrabenazine)
Approval will require diagnosis of chorea associated with Huntington’s disease AND, for doses above 50 mg per day, documentation of the CYP2D6 genotype of the patient will be required. Tetrabenazine is considered investigational when used for all other conditions, including, but not limited to: Chorea not associated with Huntington’s disease, Tardive dyskinesia, Dystonia,
(g)= generic available Please refer to the Custom Drug List Book for further clarification and descriptions of drugs.
BCBSM Prior Authorization Criteria and Step Therapy (Custom Drug List) 58
tics and other dyskinesias, Hyperkinetic or involuntary movement disorders, Tourette’s syndrome, Athetoid cerebral palsy.
LIFESTYLE MODIFICATION
17B - Weight Loss Preparations
Belviq® (lorcaserin) Nonpreferred
Initial coverage (up to 3 months) may be authorized for members who meet one of the following criteria:
1. Documentation is provided that the member’s BMI is ≥ 30 kg/m2 2. Documentation is provided that the member’s BMI is ≥ 27 kg/m2 AND has at
least one weight-related co-morbid condition, (e.g., hypertension, dyslipidemia, type 2 diabetes)
AND all of the following: o Documentation of a concurrent lifestyle modification program o The member is ≥ 18 years
Continued coverage (up to 12 months) may be authorized for members who provide documentation of weight loss of at least 5% during the first 12 weeks of treatment. Continued coverage of Belviq may be provided if the member has maintained at least a 5% weight loss from baseline.
Qsymia® (phentermine and topiramate) Nonpreferred
Initial coverage (up to 6 months) may be authorized for members who meet one of the following criteria:
1. Documentation is provided that the member’s BMI is ≥ 30 kg/m2
2. Documentation is provided that the member’s BMI is ≥ 27 kg/m2 AND has at least one weight-related co-morbid condition, (e.g., hypertension, dyslipidemia, type 2 diabetes)
AND all of the following: o Documentation of a concurrent lifestyle modification program o The member is ≥ 18 years o If female, the member must have a negative pregnancy test each month and
use effective contraception during Qsymia® therapy. o Trial and failure of generic phentermine for Qsymia®
Continued coverage may be authorized for members who provide documentation of weight loss of at least 5% during the first 6 months of treatment. Continued coverage of Qsymia® will be reviewed annually and may be provided if the member has maintained at least a 5% weight loss from baseline.
Suprenza™ (phentermine HCL) Nonpreferred
Coverage requires trial and failure of generic phentermine AND explanation of why Suprenza™ is expected to work if generic phentermine has not.
Page 59
Generic substitution and preferred brand-name alternatives
Generic drug substitution Generic drug substitution occurs when a generic equivalent is dispensed rather than the brand-name product. Products designated in the drug list with a “(g)” after the name are available as generics approved by the U.S. Food and Drug Administration. BCN members are required to use generic substitution. For BCN members, if a brand-name drug is requested when a generic version is available, members will pay their Tier 2 copayment plus the difference in cost between the brand and generic versions. Prescribers may request authorization for the brand-name version, based on medical necessity. A completed MedWatch form is required. BCBSM members are encouraged to receive the generic equivalent, if available, or they may be required to pay the difference in cost between the brand dispensed and the generic equivalent, in addition to the applicable copay. The maximum allowable cost or MAC list sets ceiling prices for reimbursement of certain generic prescription drugs. The drugs on the MAC list are commonly prescribed and dispensed, and have undergone the FDA’s review and approval process, which ensures that:
• Generic drugs contain the same active ingredients and are the same strengths and dosage forms as their brand-name counterparts.
• The FDA has given the generics an “A” rating and has determined they are the equivalent of their
brand-name counterparts. Or the BCBSM and BCN Pharmacy and Therapeutics Committee has reviewed the products and found them to be acceptable generic substitutes.
When the above two criteria are met, generics can be substituted with the full expectation that they’ll produce the same clinical effects and have the same safety profiles as the prescribed brand-name products. Possible brand alternatives There are some medications that are identical in strength and formulation, that are produced by multiple manufacturers, but are marketed as brand-name products with different brand names. We encourage prescribers to select Tier 1 or Tier 2 products to help patients save on their out-of-pocket costs.
Possible brand alternatives Tier 3 Preferred Alternatives Epogen® Procrit® Follistim® Gonal-F® Humatrope®, Norditropin® , Omnitrope®, Saizen®, Serostim®, Tev-Tropin®, Zorbtive®
Genotropin®, Nutropin®
Possible therapeutic alternatives The BCBSM/BCN Preferred Alternatives — July 2013 list represents possible alternatives to Tier 3 drugs. These alternative medications can generally be prescribed without approval from BCBSM or BCN, and can be dispensed with lesser copayments for members. Therapeutic alternatives may represent a different drug class, contain different ingredients or may be available in strengths or dosage forms that differ from the prescribed branded products. Pharmacists must obtain authorization from a patient’s physician to dispense an alternative product. Listed below are examples of the therapeutic alternatives a patient’s physician should consider when determining appropriate treatment for the patient. The physician should consider individual drug product characteristics and patient factors such as coexisting disease states, contraindications, therapeutic history, concurrent medications and other relevant circumstances. This list is also available at bcbsm.com/RxInfo.
BCBSM/BCN Preferred Alternatives - July 2013
Tier 3 Preferred Alternatives Tier 3 Preferred Alternatives
ABSORICA (REQ DERM CONSULT)
Accutane(g) (REQ DERM CONSULT)*
ABSTRAL Actiq(g)*, MSIR(g), MS Contin(g), Opana IR(g), Roxanol(g)
ACANYA Individual Agents (BPO and Clindamycin)
ACIPHEX, SPRINKLE
Prilosec(g)/Prilosec OTC**; Prevacid(g)*, Solutab*; Protonix(g), Zegerid(g)*, Zantac(g)
ACTOPLUS MET XR
Glucophage(g), XR(g); plus Actos(g), or Actoplus met(g)
ACUVAIL Acular, LS(g); Voltaren(g)
ACZONE Topical OTC benzoyl peroxide, clindamycin, erythromycin
ADCIRCA Revatio(g)*
ADVICOR Lescol(g), Lipitor(g), Mevacor(g), Pravachol(g), Zocor(g); plus Niaspan
AEROSPAN Alvesco, Asmanex, Azmacort, Flovent, Pulmicort, QVAR
AGGRENOX Plavix(g); Persantine(g) plus ASA OTC
AKNE-MYCIN Erythromycin topical solution & gel(g)
ALAMAST Alomide, Patanol, Zaditor OTC(g)
ALREX Decadron ophth(g), Pred Forte(g), Pred Mild
ALTABAX Triple Antibiotic OTC, Bactroban(g)
ALTACE TABLETS Altace capsules(g), Lotensin(g), Zestril(g), Vasotec(g)
ALTOPREV Lescol(g), Lipitor(g), Mevacor(g), Pravachol(g), Zocor(g), Zetia
AMITIZA OTC laxatives and stool softeners, OTC Fiber, OTC Stimulant, Gycolax(g), Lactulose(g)
AMTURNIDE Lotrel(g), Generic ACE Inhibitor (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g) and HCTZ
ANADROL-50 Androgel, 1.62%; Androxy(g), Depo-testosterone(g), Androderm, Delatestryl
ANGELIQ FemHRT, Prempro/Premphase, or Estradiol plus Progestin
ANTUROL Ditropan(g), XL(g); Detrol(g), Detrol LA, Sanctura(g), XR(g)
ANZEMET Kytril(g); Zofran(g), ODT(g)
APHTHASOL Kenalog in Orabase(g)
APLENZIN Generic SSRI/SNRI (Celexa(g), Prozac(g), Zoloft(g), Effexor(g), XR(g); Wellbutrin, SR, XL(g), etc.)
APRISO Azulfidine(g), Azulfidine En-Tab(g), Asacol, HD; Delzicol, Pentasa
ARANESP Procrit*
ARCAPTA NEOHALER
Foradil, Serevent, Spiriva
ARICEPT 23MG Aricept(g)
ARMOUR THYROID Synthroid(g)
ATELVIA Fosamax(g), Actonel*, Boniva(g)*
AUBAGIO Avonex, Copaxone, Extavia, Rebif
AUVI-Q Epi-pen, Epi-pen Jr.
AVANDAMET ActoPlus Met(g), Glucophage(g), Actos(g)
AVANDARYL Duetact, Actos(g), Amaryl(g)
AVANDIA Glucophage(g); Insulin or a sulfonylurea (Glucotrol, XL(g);Micronase(g), Amaryl(g)), Actos(g)
AVC Diflucan(g) oral, Terazol(g) vaginal
AVINZA Duragesic(g), Methadone(g), MSIR(g), MS Contin(g), Oramorph SR(g)
AXERT Amerge(g)*, Imitrex(g); Maxalt(g)*, MLT(g)*, Zomig(g)*, ZMT(g)*
AXIRON Androgel, 1.62%; Androderm
AZASITE Ciloxan(g), Ocuflox(g), Vigamox(g)
AZELEX Retin-A(g)
AZOR Generic ACE (lisinopril, benazepril, etc.) or ARB (Atacand(g)* Avapro(g), Cozaar(g)*, Teveten(g), or Benicar*) PLUS Norvasc(g)
BECONASE AQ Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ(g)*
BELVIQ Alli OTC, Bontril(g)*, Didrex(g)*, Phentermine(g)*, Tenuate(g)*
BEPREVE Zaditor OTC(g), Patanol
BESIVANCE Ciloxan(g), Ocuflox(g), Vigamox
BETASERON Avonex, Copaxone, Rebif
BETHKIS Tobi
BETIMOL Betagan(g), Betoptic(g), Timoptic(g)
BEYAZ Yasmin(g), Yaz(g) PLUS Folic Acid 1MG
BINOSTO Boniva(g)*, Fosamax(g), Actonel*
BIO-T-GEL Androgel, 1.62%; Androderm
BROMDAY Acular(g), Bromfenac(g), Voltaren(g), Ocufen(g)
BROVANA Foradil, Serevent Diskus
* Prior Approval (Authorization) or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 60
Tier 3 Preferred Alternatives Tier 3 Preferred Alternatives
BUTISOL SODIUM Ambien(g), Prosom(g), Restoril(g), Sonata(g)
BUTRANS Duragesic(g), Methadone(g), MS Contin(g), Oramorph(g), Ryzolt(g), Ultram ER(g)
BYDUREON Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g)
BYETTA Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g)
BYSTOLIC Lopressor(g), Tenormin(g), Toprol XL(g), etc.
CAMBIA Voltaren Oral(g), Generic NSAIDs (Lodine(g), Mobic(g), Motrin(g), Naprosyn(g), Voltaren(g))
CAMPRAL Revia(g), Antabuse(g)
CANTIL Bentyl(g), Donnatal(g), Robinul(g)
CARAC Efudex(g)
CARDENE SR Cardene(g), Norvasc(g), Procardia XL(g)
CARDURA XL Cardura(g), Flomax(g), Hytrin(g), Avodart, Jalyn*, Uroxatral(g)
CARMOL HC Hydrocortisone plus Aquaphor OTC, Hydrocortisone plus Eucerin OTC
CAYSTON Tobi
CEDAX Ceclor(g), Ceftin(g), Duricef(g), Keflex(g), Omnicef(g)
CELEBREX Lodine(g), Mobic(g), Motrin(g), Naprosyn(g), Voltaren(g), etc.
CENESTIN Estrace(g), Ogen(g), Enjuvia, Premarin
CESAMET Kytril(g); Zofran(g), ODT(g)
CHENODAL Actigall(g), Urso(g)
CIMZIA SYRINGE Enbrel*, Humira*, methotrexate
CLARINEX (ALL) Claritin OTC(g)**, Zyrtec OTC(g)**, Astelin(g), Xyzal(g)*
CLEOCIN VAGINAL OVULES
Cleocin Vaginal Cream(g)
CLIMARA PRO Climara(g), Vivelle-DOT, or Estraderm plus a progestin
CLINDESSE Cleocin vaginal cream(g)
CLOBEX SPRAY Diprolene(g), Psorcon(g), Temovate(g), Ultravate(g)
COGNEX Razadyne, ER(g); Aricept(g), ODT(g); Namenda
COLESTID FLAVORED
Colestid(g), Questran(g), Light(g)
COLY-MYCIN S Cortisporin(g), Floxin(g) Otic, Cipro HC
COMBIPATCH Climara(g), Vivelle-DOT, Estraderm plus Progestin
CONZIP Ultram(g), ER(g); Ryzolt(g)
COREG CR Coreg(g), Toprol XL(g)
CORTISPORIN-TC Cortisporin(g), Floxin(g) Otic, Cipro Otic HC
COSOPT PF Cosopt(g)
CRESTOR Lescol(g), Lipitor(g), Mevacor(g), Pravachol(g), Zocor(g), Zetia
CYCLOSET Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g)
CYMBALTA Generic SSRI/SNRI (Celexa(g), Effexor(g), XR(g); Prozac(g), Zoloft(g), etc.)
DALIRESP Advair, Foradil, Serevent, Spiriva, Symbicort
DAYTRANA Adderall(g), XR(brand BCN only); Concerta(g), Focalin(g), Metadate CD(g), Ritalin, LA(g); SR(g);
DENAVIR Zovirax 5% cream, ointment(g)
DEPEN Cuprimine
DESONATE Elocon(g), Locoid(g), Synalar solution(g), Capex
DESVENLAFAXINE ER
Celexa(g), Prozac(g), Zoloft(g), Effexor(g), Effexor XR(g)
DEXILANT Prilosec(g)/Prilosec OTC**; Prevacid(g)*, Solutab*; Protonix(g), Zegerid(g)*
DIFICID Flagyl(g), Vancocin
DIOVAN Avapro(g), Cozaar(g), Hyzaar(g), Benicar*
DIPENTUM Azulfidine(g), Azulfidine En-Tab(g), Asacol, HD; Delzicol, Pentasa
DONNATAL EXTENTABS
Bentyl(g), Donnatal(g), Robinul(g)
DORAL Ambien(g), Halcion(g), Prosom(g), Restoril(g), Sonata(g)
DORYX Minocin(g), Monodox(g)*, Vibramycin(g)
DUEXIS Motrin(g), Pepcid(g)
DUREZOL Decadron ophth(g); Inflamase, Forte(g); Pred Forte(g), etc.
DUTOPROL Toprol XL(g), HydroDiuril(g)
DYMISTA Astelin(g), Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ(g)*
DYNACIRC CR Cardene(g), Dynacirc(g), Norvasc(g), Procardia XL(g)
* Prior Approval (Authorization) or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 61
Tier 3 Preferred Alternatives Tier 3 Preferred Alternatives
EDARBI Avapro(g), Avalide(g), Cozaar(g), Hyzaar(g), Benicar*, HCT*; Atacand(g)*
EDARBYCLOR Avapro(g), Avalide(g), Cozaar(g), Hyzaar(g), Benicar*, HCT*; Atacand HCT(g)*, Diovan HCT(g)*, chlorthalidone
EDEX Caverject*, Cialis*, Muse*, Viagra*
EDLUAR Ambien(g), Sonata(g)
EFUDEX OCCLUSION
Efudex(g)
ELESTRIN Climara(g), Estrace(g), Ogen(g), Vivelle-DOT, Estraderm
ELIGARD Lupron, Depot;Trelstar, Depot
ELLA Plan B(g), One-step(g)
EMADINE Zaditor OTC(g), Alomide, Patanol
EMBEDA Duragesic(g), Methadone(g), MSIR(g), MS Contin(g), Oramorph SR(g)
EMSAM Celexa(g), Effexor(g), XR(g); Paxil(g), Prozac(g), Wellbutrin, SR, XL(g); Lexapro(g)
ENABLEX Ditropan(g), XL(g); Detrol(g), Detrol LA, Sanctura(g), XR(g)
EPIDUO, PUMP Individual agents: Differin(g) plus OTC BPO
EPOGEN Procrit*
EQUETRO Tegretol(g), XR(g)
ERTACZO Lamisil AT(g) OTC; Lotrimin(g), Ultra OTC; Monistat-Derm(g), Nizoral cream(g), Spectazole(g)
ESTRACE VAGINAL CREAM
Premarin Vaginal Cream, Vagifem
ESTRASORB Climara(g), Estrace(g), Ogen(g), Estraderm, Vivelle-DOT
ESTROGEL Climara(g), Estrace(g), Ogen(g), Estraderm, Vivelle-DOT
EVAMIST Climara(g), Estrace(g), Ogen(g), Estraderm, Vivelle-DOT
EXALGO Duragesic(g), Methadone(g), MS Contin(g), Oramorph(g)
EXFORGE Lotrel(g), Generic ACE Inhibitor (lisinopril, benazepril, etc.), Atacand(g)*, Avapro(g), Benicar*, or Cozaar(g) PLUS Norvasc(g)
EXFORGE HCT Avalide(g), Atacand HCT(g)*, Benicar HCT*, Diovan HCT(g)*, Hyzaar(g), Lotrel(g) plus HCTZ(g)
EXJADE Desferal(g)
EXTAVIA Avonex, Betaseron, Copaxone, Rebif
FACTIVE Erythromycin(g), Vibramycin(g), Zithromax(g), Avelox
FANAPT Clozaril(g), Risperdal(g), Abilify*, Geodon(g), Seroquel(g), Zyprexa(g)
FAZACLO Clozaril(g), Risperdal(g), Abilify*, Geodon(g), Seroquel(g), Zyprexa(g)
FEMCON FE Loestrin Fe(g) [NOT 24], Estrostep Fe(g)
FEMRING Estring
FEMTRACE Estrace(g), Ogen(g), Enjuvia, Premarin
FENOGLIDE Antara(g), Lofibra(g), Lopid(g), Tricor(g)
FENTORA Actiq(g)*, Duragesic(g), MSIR(g), MS Contin(g), Opana IR(g), Roxanol(g)
FERRIPROX Desferal(g)
FEXMID Flexeril(g)
FINACEA, PLUS Metrogel topical(g), Metrolotion(g), Retin-A(g)
FLECTOR PATCH Topical OTC analgesic balms, i.e. trolamine salicylate; Voltaren oral(g), Mobic(g), Motrin(g), Lodine(g) , Naprosyn(g)
FOCALIN XR Adderall(g), XR(brand BCN only); Focalin(g); Ritalin, LA(g), SR(g); Concerta(g), Metadate CD(g)
FOLLISTIM AQ Gonal-F, Gonal RFF
FORFIVO XL Generic SSRI/SNRI (Celexa(g), Prozac(g), Zoloft(g), Effexor(g), XR(g); Wellbutrin, SR, XL(g), etc.)
FORTEO Fosamax(g), Miacalcin(g), Actonel*, Boniva(g)*
FORTESTA Androgel, 1.62%; AndroDerm
FOSAMAX PLUS D Actonel, Boniva(g)*, Fosamax(g) plus OTC Vitamin D
FOSRENOL Tums OTC, Phoslo(g), Renagel, Renvela, 2.4g packet;
FRAGMIN Lovenox(g)
FROVA Amerge(g)*, Imitrex(g); Maxalt(g)*, MLT(g)*, Zomig(g)*, ZMT(g)*
FYCOMPA Depakote, Depakote ER, gabapentin, Topamax(g), Lamictal(g), Trileptal(g), Tegretol(g)
GALZIN OTC zinc supplements
GELNIQUE Ditropan(g), XL(g); Detrol(g), Detrol LA, Sanctura(g), XR(g)
GIAZO Azulfidine(g), Asacol, Delzicol, Pentasa
GILENYA Avonex, Copaxone, Extavia, Rebif
GLUMETZA Glucophage(g), Glucophage XR(g)
* Prior Approval (Authorization) or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 62
Tier 3 Preferred Alternatives Tier 3 Preferred Alternatives
GLYSET Precose(g)
GRALISE Neurontin(g), TCA's(g), Ultram(g)
GYNAZOLE-1, 2 Lotrimin OTC, Monistat OTC, Diflucan 150mg(g), Terazol(g)
HALFLYTELY Colyte(g), or Golytely PLUS bisacodyl OTC
HECTOROL Rocaltrol(g)
HORIZANT Mirapex(g), Neurontin(g), or a tricyclic antidepressant, Requip(g)
HUMATROPE Genotropin*; Nutropin*, AQ*
ILEVRO Ocufen(g), Voltaren ophth(g)
INNOPRAN XL Inderal(g), Inderal LA(g), Inderide(g)
INTERMEZZO Ambien(g), Ambein CR(g)*, Sonata(g)
INTUNIV Adderall(g), XR(brand BCN only); Catapres(g), Concerta(g), Ritalin, LA(g), Tenex(g)
INVEGA Clozaril(g), Risperdal(g), Abilify*, Geodon(g), Seroquel(g), Zyprexa(g)
IOPIDINE Alphagan(g), Alphagan P 0.15%(g), 0.1%
IQUIX Ciloxan(g), Ocuflox(g), Vigamox
JANUMET, XR (BCN ONLY)
Glucophage(g), XR(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g), Actoplus Met(g)
JANUVIA (BCN ONLY)
Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g)
JENTADUETO Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g), Actoplus Met(g)
JUVISYNC Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g), Plus Lescol(g), Zocor(g)
JUXTAPID Kynamro
KADIAN Duragesic(g), Methadone(g), MSIR(g), MS Contin(g), Oramorph SR(g)
KAOCHLOR-EFF Potassium Chloride(g) liquid, capsules or tablets
KAPVAY Adderall(g), XR(brand BCN only); Catapres(g); Guanfacine(g), Ritalin, LA(g), Strattera*
KARBINAL ER Claritin OTC(g)**, Clarinex(g)*, Zyrtec OTC(g)**, Astelin(g), Xyzal(g)*
KAZANO Glucophage(g), XR(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g), Actoplus Met(g)
KETEK Erythromycin(g), Zithromax(g)
KINERET Enbrel*, Humira*, methotrexate
KOMBIGLYZE XR (BCN Only)
Glucophage(g), XR(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g)
KORLYM Ketoconazole, Lysodren
LAMICTAL ODT Lamictal(g), Disper tabs(g), Tegretol(g)
LAMISIL GRANULES
Lamisil(g)
LASTACAFT Patanol, Alomide
LATUDA Risperdal(g), Abilify*, Geodon(g), Seroquel(g), Zyprexa(g)
LAZANDA Actiq(g)*, MSIR(g), Opana IR(g), Roxanol(g)
LESCOL XL Lescol(g), Lipitor(g), Mevacor(g), Pravachol(g), Zocor(g), Zetia
LEVATOL Inderal(g), Inderal LA(g), Lopressor(g), Sectral(g), Tenormin(g), Toprol XL(g)
LEVITRA Cialis*, Viagra*
LIALDA Azulfidine(g); Asacol, HD; Delzicol, Pentasa
LIDODERM PATCH Topical lidocaine, EMLA(g)
LINZESS OTC laxatives and stool softeners, OTC Fiber, OTC Stimulant, Gycolax(g), Lactulose(g)
LIPOFEN Antara(g), Lofibra(g), Lopid(g), Tricor(g)
LIPTRUZET Lescol(g), Lipitor(g), Mevacor(g), Pravachol(g), Zocor(g); plus Zetia
LIVALO Lescol(g), Lipitor(g), Mevacor(g), Pravachol(g), Zocor(g), Zetia
LO LOESTRIN FE Generic biphasic contraceptives
LOCOID LIPOCREAM
Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g)
LOESTRIN 24 FE Loestrin(g), Loestrin Fe(g)
LORZONE Parafon Forte(g)
LOTEMAX Decadron ophth(g), Pred Forte(g), Pred Mild
LOTRONEX OTC Anti-diarrheals; Levbid(g); Levsin, SL(g); Levsinex(g); Lomotil(g)
LOVAZA Antara(g), Lofibra(g), Lopid(g), OTC Omega products, Tricor(g)
LUNESTA Ambien(g), CR(g)*, Halcion(g), Prosom(g), Restoril(g), Sonata(g)
LUVERIS Repronex
LUVOX CR Luvox(g) immediate release, Celexa(g), Prozac(g), Paxil(g), Zoloft(g)
* Prior Approval (Authorization) or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 63
Tier 3 Preferred Alternatives Tier 3 Preferred Alternatives
LUXIQ Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g), Valisone(g)
LYRICA Effexor(g), XR(g); Flexeril(g), Neurontin(g), SSRI's(g), TCA's(g), Ultram(g)
MAGNACET Percocet(g), Tylox(g)
MARPLAN Parnate(g), Nardil
MAXAIR Albuterol(g); Proair HFA, Ventolin HFA
MAXIDEX Decadron ophth(g)
MEGACE ES Megace(g)
MENEST Estradiol (various), Ogen(g)
MENOPUR Repronex
MENOSTAR Climara(g), Estrace(g), Ogen(g), Vivelle-DOT, Estraderm
MENTAX Lamisil AT(g), OTC; Lotrimin(g), Ultra OTC; Monistat-Derm(g), Nizoral cream(g), Spectazole(g)
METHITEST Androgel, 1.62%; Androxy(g), Depo- Testosterone(g), Oxandrin(g), Androderm, Delatestryl
METHYLIN CHEW Adderall(g), XR(brand BCN only); Metadate CD(g), (Both of which may be "sprinkled" on food), Methylin Solution(g)
METOZOLV ODT Reglan(g)
MICARDIS, HCT Avapro(g), Avalide(g), Cozaar(g), Hyzaar(g), Benicar*, HCT*; Atacand, HCT(g)*, Diovan HCT(g)*, Teveten(g)
MINIVELLE Climara(g), Vivelle(g), Alora, Vivelle-DOT
MIRAPEX ER Mirapex(g)
MONUROL Bactrim(g), DS(g); Macrobid(g), Cipro(g), Levaquin(g)
MOVIPREP Colyte(g), Nulytely(g)
MOXATAG Amoxil capsules(g)
MYFORTIC Cellcept(g)
MYRBETRIQ Ditropan(g), XL(g); Detrol(g), Detrol LA, Sanctura(g), XR(g)
MYTELASE Mestinon(g), Prostigmin
NAFTIN Lotrimin(g), Monistat(g), Nizoral CR(g), Nystatin(g)
NAMENDA XR Namenda; Aricept(g), ODT(g)
NAPRELAN Mobic(g); Motrin(g); Naprosyn, EC(g); etc*
NASCOBAL SPRAY Cyanocobalamin tabs OTC, Cyanocobalamin injection
NASONEX Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*(g)
NATAZIA Yasmin(g), Yaz(g)
NESINA Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g)
NEULASTA Neupogen
NEUPRO Mirapex(g), Neurontin(g), Requip(g)
NEVANAC Ocufen(g), Voltaren ophth(g)
NEXICLON XR Catapres-TTS(g), Catapres(g)
NEXIUM Prilosec(g)/Prilosec OTC**; Prevacid(g)*, Solutab*; Protonix(g)
NICOTROL, NS Nicotine gum(g)**, lozenge(g), patch(g)**
NORDITROPIN, NORDIFLEX
Genotropin*; Nutropin*, AQ*
NORITATE MetroCream(g)
NOROXIN Bactrim DS/Septra DS(g); Cipro(g), XR(g)*, Levaquin(g)
NUCYNTA, ER, SOLN
Methadone, Ultram(g), ER(g); MSIR(g), oxycodone IR(g)
NUVARING Depo-Provera(g), Oral contraceptives, Ortho Evra
NUVIGIL Provigil(g)*
OLEPTRO Desyrel(g)
OLUX-E Diprolene(g), Psorcon(g), Temovate(g), Ultravate(g)
OMECLAMOX-PAK Prilosec(g), Prilosec OTC, Omeprazole OTC, Biaxin, Amoxil capsules(g)
OMNARIS Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*(g)
OMNITROPE Genotropin*, Nutropin*, AQ*
ONFI Klonopin(g), Topamax (g), Valproic acid(g)
ONGLYZA (BCN ONLY)
Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g)
ONMEL Sporonax(g), Lamisil(g)
ONSOLIS Actiq(g)*, MSIR(g), MS Contin(g), Opana IR(g), Roxanol(g)
OPANA ER Duragesic(g), Methadone(g), Morphine(g), MS Contin(g), Oramorph SR(g)
ORACEA Monodox(g)*, Vibramycin(g)
ORAPRED ODT Orapred(g)
ORAXYL Vibramycin(g)
ORENCIA SC Humira*, Enbrel*, Methotrexate(g)
ORTHO-PREFEST Use FemHRT(g), 2.5MCG-0.5; Prempro/Premphase, or Estradiol plus progestin
* Prior Approval (Authorization) or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 64
Tier 3 Preferred Alternatives Tier 3 Preferred Alternatives
OSENI Glucophage(g), XR(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g), Actoplus Met(g)
OSMOPREP Colyte(g), Nulytely(g)
OSPHENA Evista, Estring, Vagifem
OVCON-50, FE Modicon(g), Ortho-Cyclen(g), Ortho-Novum(g), Ovcon-35(g)
OXECTA Duragesic(g), Methadone(g), MS Contin(g), Oramorph(g)
OXISTAT Lamisil AT(g), OTC; Lotrimin(g), Ultra OTC; Monistat-Derm(g), Nizoral cream(g), Spectazole(g)
OXTELLAR XR Depakote, Depakote ER, gabapentin, Topamax(g), Lamictal(g), Trileptal(g), Tegretol, XR(g)
OXYCONTIN Duragesic(g), Methadone(g), MS Contin(g), Oramorph(g)
OXYTROL Ditropan(g), XL(g); Detrol(g), Detrol LA, Sanctura(g), XR(g)
PANDEL Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g), Cloderm, Cordran
PAREMYD Atropine(g), Cyclogyl(g), Mydriacyl(g)
PATADAY Zaditor OTC(g), Alocril, Alomide, Patanol
PATANASE Astelin(g), Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*(g)
PCE Biaxin(g), Erythromycin(g), Zithromax(g)
PENNSAID Topical OTC analgesic balms, i.e. trolamine salicylate; Voltaren oral(g), Mobic(g), Motrin(g), Lodine(g) , Naproxen(g)
PERANEX HC Anusol HC(g), Proctocream HC(g)
PERFOROMIST Serevent Diskus, Foradil MDI
PERTZYE Creon, Pancrease MT, Ultrase MT, Viokase
PEXEVA Generic SSRI/SNRI (Celexa(g), Prozac(g), Paxil(g), Zoloft(g), etc.)
PHOSLYRA Phoslo(g), Renagel, Renvela, 2.4g packet;
PICATO Aldara(g), Efudex(g)
PLIAGLIS Emla(g), lidocaine
POTIGA Valium(g), Diastat(g), Dilantin(g)
PRANDIMET Individual agents: Prandin and Glucophage(g)
PRED-G Garamycin(g), Pred Forte(g)
PREPOPIK Colyte(g), Nulytely(g)
PRILOSEC SUSPENSION
Prilosec(g)/Prilosec OTC**; Prevacid(g)*, Solutab*; Protonix(g)
PRISTIQ Generic SSRI/SNRI (Celexa(g), Prozac(g), Zoloft(g), Effexor(g), XR(g); etc.)
PROLENSA Acular(g), Bromfenac(g), Voltaren(g), Ocufen(g)
PROTONIX SUSP Prilosec(g)/Prilosec OTC**; Prevacid(g)*, Solutab*; Protonix(g)
PROTOPIC Topical corticosteroids, Elidel*
PROVENTIL HFA Proair HFA, Ventolin HFA
PYLERA Use Tetracycline(g) plus Flagyl(g) plus Bismuth; or Helidac or PREVPAC
QNASL Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*(g)
QSYMIA Alli OTC, Bontril(g)*, Didrex(g)*, Phentermine(g)*, Tenuate(g)*
QUILLIVANT XR Adderall XR(brand BCN only), Metadate CD(g) (Both of which may be "sprinkled" on food), Methylin Solution(g)
QUIXIN Ciloxan(g), Vigamox
RANEXA Long-acting nitrate, plus a beta-blocker or calcium channel blocker
RANICLOR Ceclor(g), Ceftin(g), Duricef(g), Keflex(g), Omnicef(g)
RAPAFLO Cardura(g), Flomax(g), Hytrin(g), Avodart, Uroxatral(g), Jalyn*
RAVICTI Buphenyl
RAYOS Prednisone, Prednisolone, Cortisone, Medrol(g), etc
RECTIV Nitroglycerin Ointment
REGRANEX Ethezyme(g), Granulex(g)
RELPAX Amerge(g)*, Imitrex(g); Maxalt(g)*, MLT(g)*, Zomig(g)*, ZMT(g)*
RESCULA Alphagan(g), Cosopt(g), Lumigan, Travatan(g), Z;
REVLIMID Thalomid
RHINOCORT AQUA Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ(g)*
RIOMET Glucophage(g)
RITALIN LA 10MG Adderall(g), XR(brand BCN only); Ritalin, LA(g), Concerta(g), Metadate CD(g)
ROZEREM Ambien(g), Halcion(g), Prosom(g), Restoril(g), Sonata(g)
RYBIX ODT Ultram(g)
SAFYRAL Generic tri-cyclic birth control plus an OTC vitamin
* Prior Approval (Authorization) or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 65
Tier 3 Preferred Alternatives Tier 3 Preferred Alternatives
SAIZEN Genotropin*; Nutropin*, AQ*
SANCUSO PATCH Kytril(g); Zofran(g), ODT(g)
SAPHRIS Clozaril(g), Risperdal(g), Abilify*, Geodon(g), Seroquel(g), Zyprexa(g)
SARAFEM TABLET Fluoxetine capsule(g)
SAVELLA Effexor(g), XR(g); Flexeril(g), Neurontin(g), SSRI(g), TCA's(g), Ultram(g)
SEMPREX D Claritin-D OTC(g)**, Zyrtec-D OTC(g)**, Xyzal(g)*, Astelin(g)
SEROQUEL XR Clozaril(g), Risperdal(g), Abilify*, Geodon(g), Zyprexa(g), Seroquel(g) (IR)
SEROSTIM Genotropin*, Nutropin*, AQ*
SILENOR Ambien(g), Desyrel(g), Silenor(g), Sonata(g)
SIMBRINZA Alphagan(g), Cosopt(g), Lumigan, Travatan(g), Z;Travatan Z, Trusopt(g), Xalatan(g)
SIMCOR Individual agents (Zocor(g) PLUS Niaspan)
SIMPONI Enbrel*, Humira*, methotrexate
SITAVIG Famvir(g), Valtrex(g), Zovirax(g)
SKLICE Elimite(g), Lindane(g), Eurax
SOLARAZE Aldara(g), Efudex(g)
SOLODYN Minocyn(g), Monodox(g)*, Vibramycin(g)
SOLTAMOX Tamoxifen
SORILUX Dovonex(g)
STAXYN Cialis*, Viagra*
STENDRA Cialis*, Viagra*
STRATTERA Adderall(g), XR(brand BCN only); Focalin(g), Ritalin, LA(g), Concerta(g), Metadate CD(g)
STRIANT Androgel, 1.62%; Androderm, Androxy(g), Depo-testosterone(g), Oxandrin(g), Delatestryl
SUBSYS Actiq(g)*, MSIR(g), MS Contin(g), Opana IR(g), Roxanol(g)
SUCLEAR Colyte(g), Nulytely(g)
SUMAVEL DOSEPRO
Amerge(g)*, Imitrex(g); Maxalt(g)*, MLT(g)*, Zomig(g)*, ZMT(g)*
SUPRAX Ceclor(g), Ceftin(g), Duricef(g), Keflex(g), Omnicef(g)
SUPRAX, SUSP Omnicef(g), Vantin(g)
SUPRENZA ODT Alli OTC, Bontril(g)*, Didrex(g)*, Phentermine(g)*, Tenuate(g)*
SUPREP Colyte(g), Nulytely(g)
SYMLIN Insulin
TACLONEX, SCALP Use Dovonex(g) plus Diprosone/Diprolene(g)
TASMAR Comtan(g)
TEKAMLO Lotrel(g), Generic ACE Inhibitor (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g)
TEKTURNA, HCT Generic ACE (lisinopril, benazepril, etc.) or ARB (Atacand, HCT(g)*; Avapro(g), Avalide(g); Cozaar(g), Diovan HCT(g)*, Hyzaar(g), Teveten(g), or Benicar*, HCT*)
TESTIM Androgel, 1.62%; Androderm
TESTRED, ANDROID
Androgel, 1.62%; Androxy(g), Depo- Testosterone(g), Oxandrin(g), Androderm, Delatestryl
TEVETEN HCT Avapro(g), Avalide(g), Atacand HCT(g)*, Cozaar(g), Hyzaar(g), Benicar*, HCT*; Teveten(g) PLUS HydroDiuril(g)
TEV-TROPIN Genotropin*; Nutropin*, AQ*
TIROSINT Synthroid(g)
TOBRADEX ST Tobradex(g)
TOVIAZ (BCBSM ONLY)
Ditropan(g), XL(g); Detrol(g), Detrol LA, Sanctura(g), XR(g)
TRADJENTA Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g), (Januvia*, Onglyza*, Kombiglyze XR* BCBSM Only)
TRANXENE SD Ativan(g), Buspar(g), Serax(g), Tranxene(g), Valium(g), Xanax(g)
TREXIMET Individual agents (Imitrex(g) PLUS naproxen); Amerge(g)*; Maxalt(g), MLT(g)*, Zomig(g)*, ZMT(g)*
TRIBENZOR Atacand(g)*, Avapro(g), Avalide(g), Benicar/HCT*, Cozaar(g), HCTZ(g), Hyzaar(g) PLUS Norvasc(g)
TRIGLIDE Antara(g), Lofibra(g), Lopid(g), Tricor(g)
TRILIPIX Antara(g), Lofibra(g), Lopid(g), Tricor(g)
TUDORZA PRESSAIR
Foradil, Serevent, Spiriva
TWYNSTA Lotrel(g), Generic ACE Inhibitor (lisinopril, benazepril, etc.), Atacand(g)*, Avapro(g), Benicar*, or Cozaar(g) PLUS Norvasc(g)
TYZEKA Baraclude, Epivir HBV, Hepsera
UCERIS Entocort EC(g), mesalamine, prednisone, Prednisolone, sulfasalazine
* Prior Approval (Authorization) or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 66
Tier 3 Preferred Alternatives Tier 3 Preferred Alternatives
VANOS 0.1% CR Diprolene(g), Psorcon(g), Temovate(g), Ultravate(g)
VASCEPA Antara(g), Lofibra(g), Lopid(g), OTC Omega products, Tricor(g)
VECTICAL Dovonex(g)
VERAMYST Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*(g)
VERDESO Elocon(g), Locoid(g), Synalar solution(g), Capex
VEREGEN Condylox Solution(g), Gel
VERSACLOZ Clozaril(g), Fazaclo(g)*
VESICARE Ditropan(g), XL(g); Detrol(g), Detrol LA, Sanctura(g), XR(g)
VICTOZA Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos(g)
VIIBRYD Generic SSRI/SNRI (Celexa(g), Prozac(g), Zoloft(g), Effexor(g), XR(g); Wellbutrin, SR, XL(g), etc.)
VIMOVO Generic PPI's (Prilosec(g), Protonix(g), Prevacid(g)*), Plus Naprosyn(g)
VIRAMUNE XR Viramune(g)
VISICOL Colyte(g), Nulytely(g)
VITUZ SOLN Tussionex(g), Hycodan(g)
VOLTAREN GEL Topical OTC analgesic balms, i.e. trolamine salicylate; Voltaren oral(g), Mobic(g), Motrin(g), Lodine(g) , Naproxen(g)
VUSION OTC diaper rash products
VYTORIN Lescol(g), Lipitor(g), Mevacor(g), Pravachol(g), Zocor(g); plus Zetia
VYVANSE Adderall(g), XR(brand BCN only); Ritalin, LA(g), SR(g); Concerta(g), Metadate CD(g)
XELJANZ Enbrel*, Humira*, methotrexate
XENICAL Alli OTC, Bontril(g)*, Didrex(g)*, Phentermine(g)*, Tenuate(g)*
XERESE Acyclovir cream, Zovirax cream PLUS Hydrocortisone cream
XIFAXAN 220MG Bactrim DS(g), Vibramycin(g)
XIFAXAN 550MG Lactulose
XIMINO Minocin(g), Monodox(g)*, Vibramycin(g)
XOLEGEL Nizoral(g)
XOPENEX HFA Albuterol(g); Proair HFA, Ventolin, HFA, Xopenex(g)
XTANDI Casodex(g), docetaxel
XYREM Provigil(g), Concerta(g), Metadate(g), Adderall(g), Adderall XR(brand BCN only)
ZANTAC EFFERDOSE
Zantac(g) (RX only); Pepcid(g)
ZAVESCA Ceredase, Cerezyme (medical benefit)
ZECUITY Amerge(g)*, Imitrex(g); Maxalt(g)*, MLT(g)*, Zomig(g)*, ZMT(g)*
ZEGERID PACKET Prilosec(g)/Prilosec OTC**; Prevacid(g)*, Solutab*; Protonix(g), Zegerid(g)*
ZELAPAR Eldepryl(g)
ZEMPLAR Rocaltrol(g)
ZETONNA Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*(g)
ZIANA GEL Individual agents: Cleocin topical(g) and Retin-A(g)*
ZIOPTAN Alphagan(g), Cosopt(g), Lumigan, Travatan(g); Z, Trusopt(g), Xalatan(g)
ZIPSOR Mobic(g), Motrin(g), Naprosyn, EC(g); Voltaren(g), etc*
ZMAX Zithromax(g)
ZOLPIMIST Ambien(g), Sonata(g)
ZOMIG NASAL SPRAY
Amerge(g)*, Imitrex(g); Maxalt(g)*, MLT(g)*, Zomig(g)*, ZMT(g)*
ZORBTIVE Genotropin*; Nutropin*, AQ*
ZUPLENZ Kytril(g); Zofran(g), ODT(g)
ZYCLARA Aldara(g)
ZYDONE Lortab(g), Tylenol with Codeine(g), Vicodin(g)
ZYFLO CR Accolate(g), Inhaled Steroids, Singulair(g)
ZYLET Maxitrol(g), Tobradex(g), Vasocidin(g)
ZYMAR Ciloxan(g), Vigamox
ZYMAXID Ciloxan(g), Ocuflox(g)
* Prior Approval (Authorization) or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 67
Page 68
Dose optimization and quantity limits The Blue Cross Blue Shield of Michigan and Blue Care Network dose optimization programs encourage appropriate prescribing of medications intended for once-daily administration. Quantities of these medications are limited to single daily doses of appropriate strengths. Michigan Blues pharmacists work closely with physicians and community pharmacists to achieve this goal, which promotes patient compliance and more cost-effective therapy. Examples of some drugs include certain cholesterol-lowering, diabetes, antidepressant and anti-hypertensive medications. Quantity limits also apply to both BCBSM and BCN for other medications, based on manufacturer recommendations, available package size and other criteria. These drugs are identified with a quantity limit (#) indicator. A complete list of medications subject to quantity limits is available at: bcbsm.com/RxInfo. Copayments A member’s benefit plan design determines applicable copayments for covered prescriptions. Symbols used throughout the document
(g) Generic equivalent covered. Brand not covered or requires higher copay. (#) Quantity limits may apply [PA] Prior authorization required for some members [ST] Step therapy required prior to use for some members <s> Specialty drug BE Drugs offered a Tier 0 copayment for BCN Blue EssentialsSM Rx benefit
Editor’s note: Please send us your comments and suggestions regarding the BCBSM and BCN Custom Drug List. Your input is vital to its continued success. We review and consider all responses. Please send your comments to:
Drug Information Services — Mail Code 512C Blue Cross Blue Shield of Michigan 600 E. Lafayette Boulevard Detroit, MI 48226-2998 or Pharmacy Services — Mail Code C303 Blue Care Network of Michigan 20500 Civic Center Drive Southfield, MI 48076-5043
1. ANTI-INFECTIVES
1A. Penicillins
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
AMOXICILLIN TRIHYDRATEAMOXIL (g)
AMPICILLIN TRIHYDRATEAMPICILLIN (g)
AMOX TR/POTASSIUM CLAVULANATEAUGMENTIN, ES, XR (g)
DICLOXACILLIN SODIUMDICLOXACILLIN (g)
PENICILLIN V POTASSIUMPENICILLIN VK (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
AMOXICILLIN TRIHYDRATEMOXATAG
1B. Cephalosporins
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CEFACLORCECLOR (g)
CEFACLORCECLOR ER (g)
CEFUROXIME AXETILCEFTIN (g)
CEFPROZILCEFZIL (g)
CEFADROXIL HYDRATEDURICEF (g)
CEPHALEXIN MONOHYDRATEKEFLEX (g)
CEFDINIROMNICEF (g)
CEFDITOREN PIVOXILSPECTRACEF (g) [QL]
CEFPODOXIME PROXETILVANTIN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
CEFUROXIME AXETILCEFTIN 250MG/5ML
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
CEFTIBUTEN DIHYDRATECEDAX
CEFACLORRANICLOR
CEFIXIMESUPRAX, SUSP
(g) Generic equivalent covered. Brand not covered or requires higher copay.
Page 69BE – Drugs offered at a zero dollar copayment with the BCN “Blue Essentials” Rx benefit
<s> Specialty Drug
[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
1C. Tetracyclines
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
DOXYCYCLINE MONOHYDRATEADOXA (g) [PA]
DOXYCYCLINE HYCLATEDORYX (g) [PA] [QL]
MINOCYCLINE HCLMINOCIN, DYNACIN (g)
DOXYCYCLINE MONOHYDRATEMONODOX (g) [PA] [QL]
DOXYCYCLINE HYCLATEPERIOSTAT (g)
MINOCYCLINE HCLSOLODYN 45, 90, 135MG (g) [PA]
TETRACYCLINE HCLTETRACYCLINE (g)
DOXYCYCLINE HYCLATEVIBRAMYCIN, VIBRATABS (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
DOXYCYCLINE HYCLATEDORYX [PA]
DOXYCYCLINE MONOHYDRATEORACEA [PA]
DOXYCYCLINE HYCLATEORAXYL
MINOCYCLINE HCLSOLODYN 55, 65, 80, 105, 115MG [PA]
1D. Macrolides
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CLARITHROMYCINBIAXIN, XL (g)
ERYTHROMYCINERY-TAB (g)
ERYTHROMYCIN ETHYLSUCCINATEERYTHROMYCIN (g)
ERYTHROMYCIN STEARATEERYTHROMYCIN STEARATE (g)
ERY E-SUCC/SULFISOXAZOLEPEDIAZOLE (g)
AZITHROMYCINZITHROMAX (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ERYTHROMYCINERY-TAB 500MG (TIER 3 BCBSM Only)
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
FIDAXOMICINDIFICID [QL]
TELITHROMYCINKETEK
ERYTHROMYCIN BASEPCE
AZITHROMYCINZMAX
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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1E. Quinolones
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CIPROFLOXACIN HCLCIPRO (g)
CIPROFLOXACIN HCL-BETAINE COMBCIPRO XR (g) [PA] [QL]
OFLOXACINFLOXIN (g)
LEVOFLOXACINLEVAQUIN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
MOXIFLOXACIN HCLAVELOX, ABC
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
GEMIFLOXACIN MESYLATEFACTIVE
NORFLOXACINNOROXIN
1F. Sulfonamides and Combinations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
SULFAMETHOXAZOLE/TRIMETHOPRIMBACTRIM, DS, SEPTRA, DS (g)
ERY E-SUCC/SULFISOXAZOLEPEDIAZOLE (g)
SULFADIAZINESULFADIAZINE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
1G. Urinary Tract Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
METHENAMINE HIPPURATEHIPREX/UREX (g)
NITROFURANTOINMACROBID (g)
NITROFURANTOIN MACROCRYSTALMACRODANTIN (g)
METHENAMINE MANDELATEMANDELAMINE (g)
PHENAZOPYRIDINE HCLPYRIDIUM (g)
TRIMETHOPRIMTRIMETHOPRIM (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NITROFURANTOIN MACROCRYSTALMACRODANTIN 25MG (TIER 3 BCBSM ONLY)
TRIMETHOPRIMPRIMSOL (TIER 3 BCBSM ONLY)
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
FOSFOMYCIN TROMETHAMINEMONUROL
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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1H. Antifungals
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
FLUCYTOSINEANCOBON (g)
FLUCONAZOLEDIFLUCAN (g)
GRISEOFULVIN,MICROSIZEGRIFULVIN V, SUSP (g)
GRISEOFULVIN ULTRAMICROSIZEGRIS PEG (g)
TERBINAFINE HCLLAMISIL TABLETS (g)
CLOTRIMAZOLEMYCELEX TROCHE (g)
KETOCONAZOLENIZORAL (g)
NYSTATINNYSTATIN (g)
ITRACONAZOLESPORANOX CAPS (g)
VORICONAZOLEVFEND (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
POSACONAZOLENOXAFIL
ITRACONAZOLESPORANOX SOLN
VORICONAZOLEVFEND SUSP
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
TERBINAFINE HCLLAMISIL GRANULES [PA]
ITRACONAZOLEONMEL [ST] [QL]
MICONAZOLEORAVIG [QL]
1I. Antivirals
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
RIBAVIRINCOPEGUS (g) [PA] <s>
GANCICLOVIRCYTOVENE (g)
FAMCICLOVIRFAMVIR (g) [QL]
RIMANTADINE HCLFLUMADINE (g)
RIBAVIRINREBETOL (g) [PA] <s>
RIBAVIRINRIBAPAK (g) <s>
RIBAVIRINRIBASPHERE (g) <s>
RIBAVIRINRIBATAB (g) <s>
AMANTADINE HCLSYMMETREL (g)
VALACYCLOVIR HCLVALTREX (g) [QL]
ACYCLOVIRZOVIRAX (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ENTECAVIRBARACLUDE <s>
LAMIVUDINEEPIVIR HBV
ADEFOVIR DIPIVOXILHEPSERA <s>
TELAPREVIRINCIVEK [PA] [QL] <s>
RIBAVIRINREBETOL SOLUTION [PA] <s>
ZANAMIVIRRELENZA [QL]
OSELTAMIVIR PHOSPHATETAMIFLU CAP, SUSP [QL]
VALGANCICLOVIR HYDROCHLORIDEVALCYTE
BOCEPREVIRVICTRELIS [PA] [ST] [QL] <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
ACYCLOVIRSITAVIG [PA] [QL]
TELBIVUDINETYZEKA <s>
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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1J. Antiretrovirals
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
LAMIVUDINE/ZIDOVUDINECOMBIVIR (g)
LAMIVUDINEEPIVIR (g)
ZIDOVUDINERETROVIR (g)
DIDANOSINEVIDEX EC (g)
NEVIRAPINEVIRAMUNE (g)
STAVUDINEZERIT (g)
ABACAVIR SULFATEZIAGEN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
TIPRANAVIRAPTIVUS(MUST BE USED WITH NORVIR)
EFAVIRENZ/EMTRICITAB/TENOFOVIRATRIPLA
EMTRICITAB/RILPIVIRINE/TENOFOVCOMPLERA [QL]
INDINAVIR SULFATECRIXIVAN
RILPIVIRINE HYDROCHLORIDEEDURANT [QL]
EMTRICITABINEEMTRIVA
LAMIVUDINEEPIVIR 10MG/ML
ABACAVIR SULFATE/LAMIVUDINEEPZICOM
ENFUVIRTIDEFUZEON <s>
ETRAVIRINEINTELENCE
SAQUINAVIR MESYLATEINVIRASE
RALTEGRAVIR POTASSIUMISENTRESS
RITONAVIR/LOPINAVIRKALETRA
FOSAMPRENAVIR CALCIUMLEXIVA
RITONAVIRNORVIR
DARUNAVIR ETHANOLATEPREZISTA, SUSP
DELAVIRDINE MESYLATERESCRIPTOR
ATAZANAVIR SULFATEREYATAZ
MARAVIROCSELZENTRY
ELVITEGR/COBICIST/EMTRIC/TENOFSTRIBILD [QL]
EFAVIRENZSUSTIVA
ABACAVIR/LAMIVUDINE/ZIDOVUDINETRIZIVIR
EMTRICITABINE/TENOFOVIRTRUVADA
DIDANOSINEVIDEX
NELFINAVIR MESYLATEVIRACEPT
TENOFOVIR DISOPROXIL FUMARATEVIREAD
ABACAVIR SULFATEZIAGEN SOLN
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
FOSAMPRENAVIR CALCIUMLEXIVA SUSP
NEVIRAPINEVIRAMUNE XR
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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1K. Antimalarials
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CHLOROQUINE PHOSPHATEARALEN (g)
MEFLOQUINE HCLLARIAM (g)
ATOVAQUONE/PROGUANIL HCLMALARONE (g)
HYDROXYCHLOROQUINE SULFATEPLAQUENIL (g)
QUININE SULFATEQUALAQUIN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ARTEMETHER/LUMEFANTRINECOARTEM [QL]
PYRIMETHAMINEDARAPRIM
PRIMAQUINE PHOSPHATEPRIMAQUINE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
1L. Antituberculars
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ETHAMBUTOL HCLETHAMBUTOL (g)
ISONIAZIDISONIAZID (g)
PYRAZINAMIDEPYRAZINAMIDE (g)
RIFAMPINRIFADIN (g)
RIFAMPIN/ISONIAZIDRIFAMATE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
DAPSONEDAPSONE
RIFABUTINMYCOBUTIN
CYCLOSERINESEROMYCIN
BEDAQUILINE FUMARATESIRTURO [PA] [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
RIFAPENTINEPRIFTIN
RIFAMPIN/INH/PYRAZINAMIDERIFATER
ETHIONAMIDETRECATOR
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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1M. Antiparasitics/Anthelmintics
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
METRONIDAZOLEFLAGYL (g)
PAROMOMYCIN SULFATEHUMATIN (g)
TINIDAZOLETINDAMAX (g) [QL]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NITAZOXANIDEALINIA
PRAZIQUANTELBILTRICIDE
METRONIDAZOLEFLAGYL ER
ATOVAQUONEMEPRON
PENTAMIDINE ISETHIONATENEBUPENT AEROSOL
IVERMECTINSTROMECTROL - SINGLE DOSE [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
ALBENDAZOLEALBENZA
1N. Miscellaneous Anti-infectives
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CLINDAMYCIN HCLCLEOCIN (g)
NEOMYCIN SULFATENEOMYCIN (g)
VANCOMYCIN HCLVANCOMYCIN HCL (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NEOMYCIN SULFATENEO-FRADIN (TIER 3 BCBSM Only)
TOBRAMYCIN/0.25 NORMAL SALINETOBI [QL] <s>
LINEZOLIDZYVOX
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
TOBRAMYCINBETHKIS [PA] [QL] <s>
AZTREONAM LYSINECAYSTON [PA] [QL] <s>
RIFAXIMINXIFAXAN 200MG [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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2. CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL
2A. Lipid-lowering Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
FENOFIBRATE,MICRONIZEDANTARA (g)
AMLODIPINE/ATORVASTATIN CALCADUET (g) [QL]
COLESTIPOL HCLCOLESTID (g)
FENOFIBRIC ACIDFIBRICOR (g)
FLUVASTATIN SODIUMLESCOL (g) [QL]
ATORVASTATIN CALCIUMLIPITOR (g) [QL]
FENOFIBRATE,MICRONIZEDLOFIBRA (g) BE
GEMFIBROZILLOPID (g) BE
LOVASTATINMEVACOR (g) [QL] BE
PRAVASTATIN SODIUMPRAVACHOL (g) [QL] BE
CHOLESTYRAMINEQUESTRAN, LIGHT (g)
FENOFIBRATE NANOCRYSTALLIZEDTRICOR (g) [QL]
SIMVASTATINZOCOR (g) [QL] BE
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
MIPOMERSEN SODIUMKYNAMRO [PA] [QL] <s>
NIACINNIASPAN BE
COLESEVELAM HCLWELCHOL
EZETIMIBEZETIA [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NIACIN/LOVASTATINADVICOR [PA] [QL]
LOVASTATINALTOPREV [PA] [QL]
COLESTIPOL HCLCOLESTID PACKET
ROSUVASTATIN CALCIUMCRESTOR [ST] [QL]
FENOFIBRATEFENOGLIDE
SITAGLIPTIN/SIMVASTATINJUVISYNC [PA] [QL]
LOMITAPIDE MESYLATEJUXTAPID [PA] [QL] <s>
FLUVASTATIN SODIUMLESCOL XL [PA] [QL]
FENOFIBRATELIPOFEN [QL]
EZETIMIBE/ATORVASTATIN CALCIUMLIPTRUZET [ST] [QL]
PITAVASTATIN CALCIUMLIVALO [ST] [QL]
OMEGA-3 ACID ETHYL ESTERSLOVAZA
NIACIN/SIMVASTATINSIMCOR [ST]
FENOFIBRATE NANOCRYSTALLIZEDTRIGLIDE
FENOFIBRIC ACIDTRILIPIX [PA] [QL]
ICOSAPENT ETHYLVASCEPA [PA] [QL]
EZETIMIBE/SIMVASTATINVYTORIN [PA] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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2B. Beta Blockers and Combinations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
SOTALOL HCLBETAPACE, AF (g) BE
TIMOLOL MALEATEBLOCADREN (g) BE
CARVEDILOLCOREG (g) BE
NADOLOLCORGARD (g) BE
NADOLOL/BENDROFLUMETHIAZIDECORZIDE (g) BE
PROPRANOLOL HCLINDERAL (g) BE
PROPRANOLOL HCLINDERAL LA (g) [QL] BE
PROPRANOLOL/HYDROCHLOROTHIAZIDEINDERIDE (g) BE
BETAXOLOL HCLKERLONE (g) BE
METOPROLOL TARTRATELOPRESSOR (g) BE
METOPROLOL/HYDROCHLOROTHIAZIDELOPRESSOR HCT (g) BE
LABETALOL HCLNORMODYNE (g) BE
PINDOLOLPINDOLOL (g) BE
ACEBUTOLOL HCLSECTRAL (g) BE
ATENOLOL/CHLORTHALIDONETENORETIC (g) BE
ATENOLOLTENORMIN (g) BE
METOPROLOL SUCCINATETOPROL XL (g) BE
LABETALOL HCLTRANDATE (g)
BISOPROLOL FUMARATEZEBETA (g) BE
BISOPROL/HYDROCHLOROTHIAZIDEZIAC (g) BE
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NEBIVOLOL HCLBYSTOLIC [ST] [QL]
CARVEDILOL PHOSPHATECOREG CR [PA] [QL]
METOPROLOL SUCCINATE/HCTZDUTOPROL [PA] [QL]
PROPRANOLOL HCLINNOPRAN XL
PENBUTOLOL SULFATELEVATOL
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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2C. ACE-Inhibitors and Combinations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
QUINAPRIL HCLACCUPRIL (g) BE
QUINAPRIL/HYDROCHLOROTHIAZIDEACCURETIC (g) BE
PERINDOPRIL ERBUMINEACEON (g)
RAMIPRILALTACE CAPSULE (g) BE
CAPTOPRILCAPOTEN (g) BE
CAPTOPRIL/HYDROCHLOROTHIAZIDECAPOZIDE (g) BE
BENAZEPRIL HCLLOTENSIN (g) BE
BENAZEPRIL/HYDROCHLOROTHIAZIDELOTENSIN HCT (g) BE
AMLODIPINE BESYLATE/BENAZEPRILLOTREL (g) BE
AMLODIPINE BESYLATE/BENAZEPRILLOTREL 5/40, 10/40MG (g) [QL]
TRANDOLAPRILMAVIK (g) BE
FOSINOPRIL SODIUMMONOPRIL (g) BE
FOSINOPRIL/HYDROCHLOROTHIAZIDEMONOPRIL HCT (g) BE
LISINOPRILPRINIVIL, ZESTRIL (g) BE
LISINOPRIL/HYDROCHLOROTHIAZIDEPRINZIDE, ZESTORETIC (g) BE
TRANDOLAPRIL/VERAPAMIL HCLTARKA (g) [QL]
MOEXIPRIL/HYDROCHLOROTHIAZIDEUNIRETIC (g) BE
MOEXIPRIL HCLUNIVASC (g) BE
ENALAPRIL/HYDROCHLOROTHIAZIDEVASERETIC (g) BE
ENALAPRIL MALEATEVASOTEC (g) BE
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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2D. Angiotensin II Receptor Blockers and Combinations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CANDESARTAN CILEXETILATACAND (g) [PA] [QL]
CANDESARTAN/HYDROCHLOROTHIAZIDATACAND HCT (g) [PA]
IRBESARTAN/HYDROCHLOROTHIAZIDEAVALIDE (g) [QL]
IRBESARTANAVAPRO (g) [QL]
LOSARTAN POTASSIUMCOZAAR (g) [QL] BE
VALSARTAN/HYDROCHLOROTHIAZIDEDIOVAN HCT (g) [PA] [QL]
LOSARTAN/HYDROCHLOROTHIAZIDEHYZAAR (g) [QL] BE
EPROSARTAN MESYLATETEVETEN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
OLMESARTAN MEDOXOMILBENICAR [ST] [QL]
OLMESARTAN/HYDROCHLOROTHIAZIDEBENICAR HCT [ST] [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
AMLODIPINE BES/OLMESARTAN MEDAZOR [PA] [QL]
VALSARTANDIOVAN [PA]
AZILSARTAN MEDOXOMILEDARBI [PA] [QL]
AZILSARTAN MED/CHLORTHALIDONEEDARBYCLOR [PA] [QL]
AMLODIPINE/VALSARTANEXFORGE [PA]
AMLODIPINE/VALSARTAN/HCTZEXFORGE HCT [PA] [QL]
TELMISARTANMICARDIS [PA] [QL]
TELMISARTAN/HYDROCHLOROTHIAZIDMICARDIS HCT [PA] [QL]
EPROSARTAN MESYLATETEVETEN 400MG [PA]
EPROSARTAN/HYDROCHLOROTHIAZIDETEVETEN HCT [PA]
OLMESARTAN MED/AMLODIPINE/HCTZTRIBENZOR [ST] [QL]
TELMISARTAN/AMLODIPINETWYNSTA [PA] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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2E. Calcium Channel Blockers and Combinations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
AMLODIPINE/ATORVASTATIN CALCADUET (g) [QL]
VERAPAMIL HCLCALAN SR/ISOPTIN SR (g)
NICARDIPINE HCLCARDENE (g)
DILTIAZEM HCLCARDIZEM, SR, CD, LA (g)
ISRADIPINEDYNACIRC (g)
AMLODIPINE BESYLATE/BENAZEPRILLOTREL (g) BE
AMLODIPINE BESYLATE/BENAZEPRILLOTREL 5/40, 10/40MG (g) [QL]
AMLODIPINE BESYLATENORVASC (g) BE
FELODIPINEPLENDIL (g)
NIFEDIPINEPROCARDIA, XL;ADALAT CC (g) [QL]
NISOLDIPINESULAR (g)
TRANDOLAPRIL/VERAPAMIL HCLTARKA (g) [QL]
DILTIAZEM HCLTIAZAC (g)
VERAPAMIL HCLVERELAN (g)
VERAPAMIL HCLVERELAN PM (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
AMLODIPINE BES/OLMESARTAN MEDAZOR [PA] [QL]
NICARDIPINE HCLCARDENE SR
DILTIAZEM HCLCARDIZEM LA 120MG
ISRADIPINEDYNACIRC CR
AMLODIPINE/VALSARTANEXFORGE [PA]
AMLODIPINE/VALSARTAN/HCTZEXFORGE HCT [PA] [QL]
ALISKIREN/AMLODIPINETEKAMLO [ST] [QL]
OLMESARTAN MED/AMLODIPINE/HCTZTRIBENZOR [ST] [QL]
TELMISARTAN/AMLODIPINETWYNSTA [PA] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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2F. Diuretics
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
SPIRONOLACT/HYDROCHLOROTHIAZIDALDACTAZIDE (g) BE
SPIRONOLACTONEALDACTONE (g) BE
BUMETANIDEBUMEX (g) BE
TORSEMIDEDEMADEX (g) BE
ACETAZOLAMIDEDIAMOX (g)
ACETAZOLAMIDEDIAMOX SEQUELS (g)
CHLOROTHIAZIDEDIURIL (g) BE
HYDROCHLOROTHIAZIDEHYDRODIURIL, MICROZIDE (g) BE
CHLORTHALIDONEHYGROTON, THALITONE (g) BE
EPLERENONEINSPRA (g) BE
FUROSEMIDELASIX (g) BE
INDAPAMIDELOZOL (g) BE
TRIAMTERENE/HYDROCHLOROTHIAZIDMAXZIDE, DYAZIDE (g) BE
AMILORIDE HCLMIDAMOR (g) BE
AMILORIDE/HYDROCHLOROTHIAZIDEMODURETIC (g) BE
METOLAZONEZAROXOLYN (g) BE
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
TRIAMTERENEDYRENIUM
ETHACRYNIC ACIDEDECRIN
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
METOPROLOL SUCCINATE/HCTZDUTOPROL [PA] [QL]
AZILSARTAN MED/CHLORTHALIDONEEDARBYCLOR [PA] [QL]
2G. Cardiovascular Treatment
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
SOTALOL HCLBETAPACE, AF (g) BE
AMIODARONE HCLCORDARONE (g)
DIGOXINDIGOXIN (g)
MEXILETINE HCLMEXITIL (g)
DISOPYRAMIDE PHOSPHATENORPACE (g)
MIDODRINE HCLPROAMATINE (g)
QUINIDINE SULFATEQUINIDEX (g)
QUINIDINE GLUCONATEQUINIDINE GLUCONATE SA (g)
PROPAFENONE HCLRYTHMOL, SR (g)
FLECAINIDE ACETATETAMBOCOR (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
DRONEDARONE HYDROCHLORIDEMULTAQ [QL]
DISOPYRAMIDE PHOSPHATENORPACE CR
DOFETILIDETIKOSYN
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
RANOLAZINERANEXA [PA]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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2H. Nitrates and Combinations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ISOSORBIDE MONONITRATEIMDUR (g)
ISOSORBIDE MONONITRATEISMO, MONOKET (g)
ISOSORBIDE DINITRATEISORDIL (g)
NITROGLYCERINNITRO-BID OINTMENT (g)
NITROGLYCERINNITROGLYCERIN PATCH (g)
NITROGLYCERINNITROGLYCERIN SA CAP (g)
NITROGLYCERINNITROGLYCERIN SPRAY [QL]
NITROGLYCERINNITROMIST (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ISOSORBIDE DINITRATEDILATRATE-SR
NITROGLYCERINNITRO-DUR (TIER 3 BCBSM Only)
NITROGLYCERINNITROSTAT
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONENONE
2I. Anticoagulants and Hemostasis Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ANAGRELIDE HCLAGRYLIN (g)
AMINOCAPROIC ACIDAMICAR (g)
FONDAPARINUX SODIUMARIXTRA (g) <s>
WARFARIN SODIUMCOUMADIN (g) BE
HEPARIN SODIUM,PORCINEHEPARIN (g) <s>
ENOXAPARIN SODIUMLOVENOX (g) <s>
DIPYRIDAMOLEPERSANTINE (g)
CLOPIDOGREL BISULFATEPLAVIX (g) BE
CILOSTAZOLPLETAL (g)
TICLOPIDINE HCLTICLID (g)
PENTOXIFYLLINETRENTAL (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
TICAGRELORBRILINTA [QL]
PRASUGREL HYDROCHLORIDEEFFIENT [QL]
APIXABANELIQUIS [QL]
PHYTONADIONEMEPHYTON
DABIGATRAN ETEXILATE MESYLATEPRADAXA [QL]
RIVAROXABANXARELTO [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
ASPIRIN/DIPYRIDAMOLEAGGRENOX
DALTEPARIN SODIUM,PORCINEFRAGMIN <s>
TINZAPARIN SODIUM,PORCINEINNOHEP <s>
DESIRUDIN INJECTIONIPRIVASK <s>
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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<s> Specialty Drug
[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
2J. Alpha-adrenergic Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
METHYLDOPAALDOMET (g)
METHYLDOPA/HYDROCHLOROTHIAZIDEALDORIL (g)
DOXAZOSIN MESYLATECARDURA (g)
CLONIDINE HCLCATAPRES, TTS (g)
TERAZOSIN HCLHYTRIN (g)
PRAZOSIN HCLMINIPRESS (g)
RESERPINERESERPINE (g)
GUANFACINE HCLTENEX (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
CLONIDINE HCLNEXICLON XR [PA] [QL]
2K. Miscellaneous Antihypertensives
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
HYDRALAZINE HCLAPRESOLINE (g)
MINOXIDILLONITEN (g)
PAPAVERINE HCLPAPAVERINE CAPS (g)
ISOXSUPRINE HCLVASODILAN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
ALISKIREN/AMLODIPINE/HCTZAMTURNIDE [ST] [QL]
ALISKIREN/AMLODIPINETEKAMLO [ST] [QL]
ALISKIREN HEMIFUMARATETEKTURNA [PA]
ALISKIREN/HYDROCHLOROTHIAZIDETEKTURNA HCT [PA]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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<s> Specialty Drug
[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
3. CENTRAL NERVOUS SYSTEM
3A. Antidepressants
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CLOMIPRAMINE HCLANAFRANIL (g) BE
AMOXAPINEASENDIN (g)
CITALOPRAM HYDROBROMIDECELEXA (g) BE
TRAZODONE HCLDESYREL (g) BE
VENLAFAXINE HCLEFFEXOR (g) BE
VENLAFAXINE HCLEFFEXOR XR (g) [QL] BE
AMITRIPTYLINE HCLELAVIL (g) BE
AMITRIPTYLINE HCL/PERPHENAZINEETRAFON (g)
FLUVOXAMINE MALEATEFLUVOXAMINE MALEATE (g) BE
ESCITALOPRAM OXALATELEXAPRO (g) [QL]
AMITRIP HCL/CHLORDIAZEPOXIDELIMBITROL, DS (g)
FLUVOXAMINE MALEATELUVOX CR (g) [PA]
MAPROTILINE HCLMAPROTILINE HCL (g) BE
PHENELZINE SULFATENARDIL (g)
DESIPRAMINE HCLNORPRAMIN (g) BE
NORTRIPTYLINE HCLPAMELOR, AVENTYL (g) BE
TRANYLCYPROMINE SULFATEPARNATE (g)
PAROXETINE HCLPAXIL (g) BE
PAROXETINE HCLPAXIL CR (g) [QL]
FLUOXETINE HCLPROZAC WEEKLY (g) [QL]
FLUOXETINE HCLPROZAC, SARAFEM CAPSULES (g) BE
MIRTAZAPINEREMERON, SOLTAB (g) BE
NEFAZODONE HCLSERZONE (g) [PA]
DOXEPIN HCLSINEQUAN, ADAPIN (g) BE
TRIMIPRAMINE MALEATESURMONTIL (g)
IMIPRAMINE HCLTOFRANIL (g) BE
IMIPRAMINE PAMOATETOFRANIL-PM (g)
VENLAFAXINE HCLVENLAFAXINE HCL ER (g) [QL] BE
PROTRIPTYLINE HCLVIVACTIL (g)
BUPROPION HCLWELLBUTRIN XL (g) [QL]
BUPROPION HCLWELLBUTRIN, SR (g) BE
SERTRALINE HCLZOLOFT (g) BE
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
BUPROPRION HBRAPLENZIN [PA]
DULOXETINE HCLCYMBALTA [PA] [QL]
DESVENLAFAXINEDESVENLAFAXINE ER [ST] [QL]
SELEGILINEEMSAM [QL]
FLUOXETINE HCLFLUOXETINE 60MG [QL]
BUPROPION HYDROCHLORIDE ERFORFIVO XL [PA] [QL]
ISOCARBOXAZIDMARPLAN
TRAZODONE HCLOLEPTRO [PA] [QL]
PAROXETINE MESYLATEPEXEVA [PA] [QL]
DESVENLAFAXINE SUCCINATEPRISTIQ [ST] [QL]
FLUOXETINE HCLSARAFEM TABLET
VILAZODONE HYDROCHLORIDEVIIBRYD [PA] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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<s> Specialty Drug
[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
3B. Antipsychotics
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CLOZAPINEFAZACLO 12.5, 25, 100MG (g) [ST]
ZIPRASIDONE HCLGEODON (g)
HALOPERIDOLHALDOL (g) BE
LOXAPINE SUCCINATELOXITANE (g)
THIORIDAZINE HCLMELLARIL (g) BE
THIOTHIXENENAVANE (g)
PERPHENAZINEPERPHENAZINE (g)
FLUPHENAZINE HCLPROLIXIN (g) BE
RISPERIDONERISPERDAL M-TAB (g) BE
RISPERIDONERISPERDAL(g) (TIER 0-BCN ONLY) BE
QUETIAPINE FUMARATESEROQUEL (g)
TRIFLUOPERAZINE HCLSTELAZINE (g) BE
OLANZAPINE/FLUOXETINE HCLSYMBYAX (g)
CHLORPROMAZINE HCLTHORAZINE (g) BE
OLANZAPINEZYPREXA, ZYDIS (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ARIPIPRAZOLEABILIFY DISCMELT (Tier 3 - BCBSM Only) [ST]
ARIPIPRAZOLEABILIFY, SOLUTION [ST]
PIMOZIDEORAP
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
ILOPERIDONEFANAPT [ST]
CLOZAPINEFAZACLO [ST]
PALIPERIDONEINVEGA [PA] [QL]
LURASIDONE HCLLATUDA [ST]
ASENAPINESAPHRIS [PA] [QL]
QUETIAPINE FUMARATESEROQUEL XR [PA] [QL]
3C. Anxiolytics
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
LORAZEPAMATIVAN (g)
BUSPIRONE HCLBUSPAR (g)
CHLORDIAZEPOXIDE HCLLIBRIUM (g)
MEPROBAMATEMILTOWN, EQUANIL (g)
ALPRAZOLAMNIRAVAM (g)
OXAZEPAMSERAX (g)
CLORAZEPATE DIPOTASSIUMTRANXENE (g)
DIAZEPAMVALIUM (g)
ALPRAZOLAMXANAX, XR (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
CLORAZEPATE DIPOTASSIUMTRANXENE SD
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
3D. Sedative/Hypnotics
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ZOLPIDEM TARTRATEAMBIEN (g) [QL]
ZOLPIDEM TARTRATEAMBIEN CR (g) [PA] [QL]
CHLORAL HYDRATECHLORAL HYDRATE (g)
FLURAZEPAM HCLDALMANE (g) [QL]
TRIAZOLAMHALCION (g) [QL]
ESTAZOLAMPROSOM (g) [QL]
TEMAZEPAMRESTORIL (g) [QL]
ZALEPLONSONATA (g) [QL]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
BUTABARBITAL SODIUMBUTISOL SODIUM
QUAZEPAMDORAL [QL]
ZOLPIDEM TARTRATEEDLUAR [PA] [QL]
ZOLPIDEM TARTRATEINTERMEZZO [PA] [QL]
ESZOPICLONELUNESTA [PA] [QL]
RAMELTEONROZEREM [PA] [QL]
DOXEPIN HCLSILENOR [PA] [QL]
ZOLPIDEM TARTRATEZOLPIMIST [PA] [QL]
3E. CNS Stimulants
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
AMPHET ASP/AMPHET/D-AMPHETADDERALL (g) [QL]
AMPHET ASP/AMPHET/D-AMPHETADDERALL XR (BRAND BCN-ONLY) [QL]
AMPHET ASP/AMPHET/D-AMPHETADDERALL XR (g) [PA] [QL]
METHYLPHENIDATE HCLCONCERTA (g) [QL]
METHAMPHETAMINE HCLDESOXYN (g) [QL]
D-AMPHETAMINE SULFATEDEXEDRINE (g) [QL]
DEXMETHYLPHENIDATE HCLFOCALIN (g) [QL]
METHYLPHENIDATE HCLMETADATE CD (g) [QL]
METHYLPHENIDATE HCLMETHYLIN SOLN (g) [QL]
D-AMPHETAMINE SULFATEPROCENTRA (g) [PA]
MODAFINILPROVIGIL (g) [PA] [QL]
METHYLPHENIDATE HCLRITALIN LA(g) 20, 30, 40MG [QL]
METHYLPHENIDATE HCLRITALIN, SR; METHYLIN, ER (g) [QL]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
METHYLPHENIDATEDAYTRANA [QL]
DEXMETHYLPHENIDATE HCLFOCALIN XR [QL]
METHYLPHENIDATE HCLMETHYLIN CHEW [QL]
ARMODAFINILNUVIGIL [PA] [QL]
METHYLPHENIDATE HCLQUILLIVANT XR
METHYLPHENIDATE HCLRITALIN LA 10MG [QL]
ATOMOXETINE HCLSTRATTERA [PA] [QL]
LISDEXAMFETAMINE DIMESYLATEVYVANSE [PA] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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<s> Specialty Drug
[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
3F. Nonsteroidal Anti-inflammatory Drugs
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NAPROXEN SODIUMANAPROX, DS (g)
FLURBIPROFENANSAID (g)
DICLOFENAC SODIUM/MISOPROSTOLARTHROTEC (g) [PA] [QL]
DICLOFENAC POTASSIUMCATAFLAM (g)
SULINDACCLINORIL (g)
OXAPROZINDAYPRO (g)
NAPROXENEC-NAPROSYN (g)
PIROXICAMFELDENE (g)
INDOMETHACININDOCIN, SR (g)
KETOPROFENKETOPROFEN (g)
ETODOLACLODINE, XL (g)
MECLOFENAMATE SODIUMMECLOMEN (g)
MELOXICAMMOBIC (g)
IBUPROFENMOTRIN (g)
NAPROXENNAPROSYN (g)
MEFENAMIC ACIDPONSTEL (g)
NABUMETONERELAFEN (g)
TOLMETIN SODIUMTOLECTIN, DS (g)
KETOROLAC TROMETHAMINETORADOL (g) [QL]
DICLOFENAC SODIUMVOLTAREN, XR (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
INDOMETHACININDOCIN SUPPOSITORY
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
DICLOFENAC POTASSIUMCAMBIA [PA] [QL]
CELECOXIBCELEBREX [PA] [QL]
IBUPROFEN/FAMOTIDINEDUEXIS [PA] [QL]
DICLOFENAC EPOLAMINEFLECTOR PATCH [PA] [QL]
NAPROXEN SODIUMNAPRELAN
DICLOFENAC SODIUMPENNSAID [PA] [QL]
KETOROLAC TROMETHAMINESPRIX [QL]
NAPROXEN/ESOMEPRAZOLE MAGVIMOVO [PA] [QL]
DICLOFENAC SODIUMVOLTAREN GEL [PA] [QL]
DICLOFENAC POTASSIUMZIPSOR
3G. Salicylates
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
SALSALATEDISALCID, SALFLEX (g)
DIFLUNISALDOLOBID (g)
CHOLINE MAGNESIUM TRISALICYLATETRILISATE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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<s> Specialty Drug
[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
3H. Narcotics
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
FENTANYL CITRATEACTIQ (g) [PA] [QL]
CODEINE SULFATE(g)CODEINE SULFATE (g) [QL]
MEPERIDINE HCLDEMEROL (g)
HYDROMORPHONE HCLDILAUDID (g)
FENTANYLDURAGESIC (g) [QL]
MORPHINE SULFATEKADIAN (g)
METHADONE HCLMETHADONE (g)
MORPHINE SULFATEMS CONTIN/ORAMORPH SR (g)
MORPHINE SULFATEMSIR (g)
OXYMORPHONE HCLOPANA (g) [PA] [QL]
OXYMORPHONE HCLOPANA ER 7.5, 15MG (g) [PA] [QL]
OXYCODONE HCLOXYCODONE IMMEDIATE RELEASE (g)
MORPHINE SULFATERMS SUPPOSITORY (g)
MORPHINE SULFATEROXANOL (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
FENTANYL CITRATEABSTRAL [PA] [QL]
MORPHINE SULFATEAVINZA [QL]
MORPHINE SULFATE/NALTREXONEEMBEDA [QL]
HYDROMORPHONE HCLEXALGO [PA] [QL]
FENTANYL CITRATEFENTORA [PA] [QL]
MORPHINE SULFATEKADIAN 10,70, 130, 150, 200MG
FENTANYL CITRATELAZANDA [PA] [QL]
TAPENTADOL HYDROCHLORIDENUCYNTA, ER, SOLN [PA] [QL]
FENTANYL CITRATEONSOLIS [PA] [QL]
OXYMORPHONE HCLOPANA ER [PA] [QL]
OXYCODONE HCLOXECTA [PA] [QL]
OXYCODONE HCLOXYCONTIN [PA] [QL]
FENTANYLSUBSYS [PA] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
3I. Narcotic/Analgesic Combinations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CODEINE PHOS/ASPIRINASPIRIN W/CODEINE (g)
CODEINE/BUTALBUT/ACETAMIN/CAFFFIORICET W/CODEINE (g)
BUTALB/ACETAMINOPHEN/CAFFEINEFIORICET; ESGIC, PLUS (g)
BUTALBITAL/ASPIRIN/CAFFEINEFIORINAL (g)
CODEINE/BUTALBITAL/ASA/CAFFEINFIORINAL W/CODEINE (g)
OXYCODONE HCL/ACETAMINOPHENPERCOCET (g) [QL]
OXYCODONE HCL/ASPIRINPERCODAN (g)
BUTALBITAL/ACETAMINOPHENPHRENILIN (g)
CODEINE PHOS/ACETAMINOPHENTYLENOL W/CODEINE (g) [QL]
OXYCODONE HCL/ACETAMINOPHENTYLOX (g) [QL]
HYDROCODONE BIT/ACETAMINOPHENVICODIN, LORTAB (g) [QL]
HYDROCODONE/IBUPROFENVICOPROFEN (g)
HYDROCODONE BIT/ACETAMINOPHENXODOL (g) [QL]
BUTALB/ACETAMINOPHEN/CAFFEINEZEBUTAL (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
BUTALBITAL/ACETAMINOPHENPHRENILIN FORTE (TIER 3 - BCBSM Only)
DIHYDROCODEINE/ASPIRIN/CAFFEINSYNALGOS-DC
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
OXYCODONE HCL/ACETAMINOPHENMAGNACET [QL]
HYDROCODONE BIT/ACETAMINOPHENZYDONE [QL]
3J. Narcotic Mixed Agonist/Antagonist
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
TRAMADOL HCLRYZOLT (g) [QL]
BUTORPHANOL TARTRATESTADOL NS (g)
BUPRENORPHINE HCL/NALOXONE HCLSUBOXONE (g)
PENTAZOCINE HCL/ACETAMINOPHENTALACEN (g)
PENTAZOCINE HCL/NALOXONE HCLTALWIN NX (g)
TRAMADOL HCL/ACETAMINOPHENULTRACET (g)
TRAMADOL HCLULTRAM, ER (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
BUPRENORPHINE HCL/NALOXONE HCLSUBOXONE FILM
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
BUPRENORPHINEBUTRANS [PA] [QL]
TRAMADOL HCLCONZIP [QL]
TRAMADOL HCLRYBIX ODT [PA] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
3K. Narcotic Antagonists
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NALTREXONE HCLREVIA (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
METHYLNALTREXONERELISTOR [PA] [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
3M. Migraine Therapy
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
SUMATRIPTAN SUCCINATEALSUMA (g) [ST] [QL]
NARATRIPTAN HCLAMERGE (g) [ST] [QL]
BUTALBITAL/ACETAMINOPHENBUPAP (g)
DIHYDROERGOTAMINE MESYLATED.H.E.45 (g) [QL]
BUTALB/ACETAMINOPHEN/CAFFEINEFIORICET; ESGIC, PLUS (g)
BUTALBITAL/ASPIRIN/CAFFEINEFIORINAL (g)
CODEINE/BUTALBITAL/ASA/CAFFEINFIORINAL W/CODEINE (g)
SUMATRIPTAN SUCCINATEIMITREX (ALL FORMS) (g) [QL]
RIZATRIPTAN BENZOATEMAXALT, MLT (g) [QL]
ISOMETHEPTENE/APAP/DICHLPHENMIDRIN (g)
DIHYDROERGOTAMINE MESYLATEMIGRANAL (g) [QL]
BUTALBITAL/ACETAMINOPHENPHRENILIN (g)
BUTORPHANOL TARTRATESTADOL NS (g)
BUTALB/ACETAMINOPHEN/CAFFEINEZEBUTAL (g)
ZOLMITRIPTANZOMIG(g), ZMT (g) [ST] [QL]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ERGOTAMINE TARTRATE/CAFFEINECAFERGOT [QL]
ERGOTAMINE TARTRATEERGOMAR [QL]
BUTALBITAL/ACETAMINOPHENPHRENILIN FORTE (TIER 3 - BCBSM Only)
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
ALMOTRIPTAN MALATEAXERT [ST] [QL]
DICLOFENAC POTASSIUMCAMBIA [PA] [QL]
FROVATRIPTAN SUCCINATEFROVA [ST] [QL]
ELETRIPTAN HYDROBROMIDERELPAX [ST] [QL]
SUMATRIPTAN SUCCINATESUMAVEL DOSEPRO [PA] [QL]
SUMATRIPTAN SUCC/NAPROXEN SODTREXIMET [PA] [QL]
SUMATRIPTAN IONTOPHORETICZECUITY [ST] [QL]
ZOLMITRIPTANZOMIG NASAL SPRAY [ST] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
3O. Parkinsons Disease and Related Disorders
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
TRIHEXYPHENIDYL HCLARTANE (g)
BENZTROPINE MESYLATECOGENTIN (g)
ENTACAPONECOMTAN (g)
CABERGOLINEDOSTINEX (g)
SELEGILINE HCLELDEPRYL (g)
PRAMIPEXOLE DI-HCLMIRAPEX (g)
CARBIDOPA/LEVODOPAPARCOPA (g)
BROMOCRIPTINE MESYLATEPARLODEL (g)
ROPINIROLE HCLREQUIP (g)
ROPINIROLE HCLREQUIP XL (g) [QL]
CARBIDOPA/LEVODOPASINEMET, CR (g)
CARBIDOPA/LEVODOPA/ENTACAPONESTALEVO (g)
AMANTADINE HCLSYMMETREL (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
APOMORPHINE HCLAPOKYN <s>
RASAGILINE MESYLATEAZILECT
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
PRAMIPEXOLE DI-HCLMIRAPEX ER [PA] [QL]
ROTIGOTINENEUPRO [PA] [QL]
TOLCAPONETASMAR
SELEGILINE HCLZELAPAR [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
3P. Anticonvulsants
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CARBAMAZEPINECARBATROL (g)
VALPROATE SODIUMDEPAKENE (g)
DIVALPROEX SODIUMDEPAKOTE, ER, SPRINKLES (g)
ACETAZOLAMIDEDIAMOX (g)
DIAZEPAMDIASTAT 2.5MG (g)
PHENYTOIN SODIUM EXTENDEDDILANTIN (g)
PHENYTOINDILANTIN CHEW TABS (g)
FELBAMATEFELBATOL (g)
TIAGABINE HCLGABITRIL 2, 4MG (g)
LEVETIRACETAMKEPPRA, XR (g)
CLONAZEPAMKLONOPIN, WAFER (g)
LAMOTRIGINELAMICTAL TABS, DISPERTABS (g)
LAMOTRIGINELAMICTAL XR (g) [QL]
MEPHOBARBITALMEBARAL (g)
PRIMIDONEMYSOLINE (g)
GABAPENTINNEURONTIN (g)
PHENOBARBITALPHENOBARBITAL (g)
CARBAMAZEPINETEGRETOL, XR (g)
TOPIRAMATETOPAMAX, SPRINKLE (g)
OXCARBAZEPINETRILEPTAL, SUSP (g)
ETHOSUXIMIDEZARONTIN (g)
ZONISAMIDEZONEGRAN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
RUFINAMIDEBANZEL
METHSUXIMIDECELONTIN
DIAZEPAMDIASTAT
PHENYTOINDILANTIN 30MG
TIAGABINE HCLGABITRIL
ETHOTOINPEGANONE
VIGABATRINSABRIL <s>
CARBAMAZEPINETEGRETOL XR 100MG
LACOSAMIDEVIMPAT
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
CARBAMAZEPINEEQUETRO
PERAMPANELFYCOMPA [PA] [QL]
GABAPENTINGRALISE [PA] [QL]
LAMOTRIGINELAMICTAL ODT [QL]
PREGABALINLYRICA [PA] [QL]
CLOBAZAMONFI [PA] [QL]
OXCARBAZEPINEOXTELLAR XR [ST] [QL]
EZOGABINEPOTIGA
VALPROIC ACIDSTAVZOR
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
3Q. Skeletal Muscle Relaxants
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
BACLOFENBACLOFEN, LIORESAL (g)
DANTROLENE SODIUMDANTRIUM (g)
CYCLOBENZAPRINE HCLFEXMID (g)
CYCLOBENZAPRINE HCLFLEXERIL (g)
CHLORZOXAZONELORZONE
ORPHENADRINE CITRATENORFLEX (g)
ORPHENADRINE/ASPIRIN/CAFFEINENORGESIC, FORTE (g)
CHLORZOXAZONEPARAFLEX, PARAFON FORTE DSC (g)
METHOCARBAMOLROBAXIN (g)
METAXALONESKELAXIN (g)
CARISOPRODOLSOMA (g)
CARISOPRODOL/ASPIRINSOMA COMPOUND (g)
CODEINE PHOS/CARISOPRODOL/ASASOMA COMPOUND W/CODEINE (g)
DIAZEPAMVALIUM (g)
TIZANIDINE HCLZANAFLEX (g) [PA]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
CYCLOBENZAPRINE HCLAMRIX [PA] [QL]
3R. Myesthenia Gravis
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
PYRIDOSTIGMINE BROMIDEMESTINON (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
PYRIDOSTIGMINE BROMIDEMESTINON TIMESPAN, SYRUP
NEOSTIGMINE BROMIDEPROSTIGMIN
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
AMBENONIUM CHLORIDEMYTELASE
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
3S. Miscellaneous CNS
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
DONEPEZIL HCLARICEPT, ODT (g)
LITHIUM CARBONATEESKALITH, CR (g)
RIVASTIGMINE TARTRATEEXELON (g) [QL]
LITHIUM CITRATELITHIUM CITRATE (g)
LITHIUM CARBONATELITHOBID (g)
NIMODIPINENIMOTOP (g)
GALANTAMINE HYDROBROMIDERAZADYNE, ER, SOLUTION (g)
RILUZOLERILUTEK (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
RIVASTIGMINE TARTRATEEXELON PATCH, SOLN [QL]
MEMANTINE HCLNAMENDA, SOLN
DEXTROMETHORPHAN HBR/QUINIDINENUEDEXTA [PA] [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
DONEPEZIL HCLARICEPT 23MG [ST] [QL]
GABAPENTIN ENACARBILHORIZANT [PA] [QL]
GUANFACINE HCLINTUNIV [PA] [QL]
CLONIDINE HCLKAPVAY [PA] [QL]
MEMANTINE HCLNAMENDA XR [ST] [QL]
MILNACIPRAN HCLSAVELLA [PA] [QL]
SODIUM OXYBATEXYREM [PA] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
4. GASTROINTESTINAL AGENTS
4A. H2-Receptor Antagonists
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NIZATIDINEAXID (RX ONLY) (g)
FAMOTIDINEPEPCID (RX ONLY) (g)
CIMETIDINETAGAMET (RX ONLY) (g)
RANITIDINE HCLZANTAC (RX ONLY) (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
4B. Proton Pump Inhibitors
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
OMEPRAZOLEOMEPRAZOLE OTC (g)
LANSOPRAZOLEPREVACID (g) [ST]
OMEPRAZOLEPRILOSEC (g)
OMEPRAZOLE MAGNESIUMPRILOSEC OTC
PANTOPRAZOLE SODIUMPROTONIX (g)
OMEPRAZOLE/SODIUM BICARBONATEZEGERID RX (g) [PA]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
LANSOPRAZOLEPREVACID SOLUTAB [PA]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
RABEPRAZOLE SODIUMACIPHEX, SPRINKLE [PA] [QL]
DEXLANSOPRAZOLEDEXILANT [ST] [QL]
ESOMEPRAZOLE MAG TRIHYDRATENEXIUM [PA]
OMEPRAZOLE MAGNESIUMPRILOSEC SUSPENSION [PA]
PANTOPRAZOLE SODIUMPROTONIX SUSPENSION [ST]
NAPROXEN/ESOMEPRAZOLE MAGVIMOVO [PA] [QL]
OMEPRAZOLE/SODIUM BICARBONATEZEGERID PACKET [PA] [QL]
4C. Other Ulcer Therapy
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
SUCRALFATECARAFATE, SUSP (g)
MISOPROSTOLCYTOTEC (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
TETRACYC HCL/BIS SS/METRONIDHELIDAC
LANSOPRAZOLE/AMOX TR/CLARITHPREVPAC
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
OMEPRAZOLE/AMOX TR/CLARITHOMECLAMOX-PAK
BISMUTH/METRONID/TETRACYCLINEPYLERA
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
4D. Antidiarrheals and Antispasmodics
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ERGOTAMINE TART/BELLAD ALK/PBBELLAMINE/BELLASPAS (g)
DICYCLOMINE HCLBENTYL (g)
BELLADONNA ALKALOIDS/PHENOBARBDONNATAL (g)
HYOSCYAMINE SULFATELEVBID (g)
HYOSCYAMINE SULFATELEVSIN, SL (g)
HYOSCYAMINE SULFATELEVSINEX (g)
CLIDINIUM BR/CHLORDIAZEPOXIDELIBRAX (g)
DIPHENOXYLATE HCL/ATROP SULFLOMOTIL (g)
PAREGORICPAREGORIC (g)
PROPANTHELINE BROMIDEPRO-BANTHINE 15MG (g)
GLYCOPYRROLATEROBINUL, FORTE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
CROFELEMERFULYZAQ [PA] [QL] <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
MEPENZOLATE BROMIDECANTIL
BELLADONNA ALKALOIDS/PHENOBARBDONNATAL EXTENTABS
4E. Antiemetics
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
MECLIZINE HCLANTIVERT (g)
PROCHLORPERAZINE MALEATECOMPAZINE (g)
GRANISETRON HCLGRANISOL (g)
GRANISETRON HCLKYTRIL (g) [QL]
DRONABINOLMARINOL (g) [QL]
PROMETHAZINE HCLPHENERGAN (g)
TRIMETHOBENZAMIDE HCLTIGAN (g)
ONDANSETRONZOFRAN, ODT (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
APREPITANTEMEND 80,125MG CAPSULES [QL]
SCOPOLAMINE HYDROBROMIDETRANSDERM-SCOP
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
DOLASETRON MESYLATEANZEMET [QL]
NABILONECESAMET
GRANISETRONSANCUSO [ST] [QL]
ONDANSETRONZUPLENZ [ST] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
4F. Bile Acids
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
URSODIOLACTIGALL (g)
URSODIOLURSO, URSO FORTE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
CHENODIOLCHENODAL [PA]
4G. Digestive Enzymes
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
AMYLASE/LIPASE/PROTEASEDYGASE (g)
AMYLASE/LIPASE/PROTEASELAPASE (g)
LIPASE/PROTEASE/AMYLASEPANCREASE MT 10, 16, 20 (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
AMYLASE/LIPASE/PROTEASECREON
AMYLASE/LIPASE/PROTEASELIPRAM-UL20
LIPASE/PROTEASE/AMYLASEPANCREASE MT 4
LIPASE/PROTEASE/AMYLASEPANCREAZE
AMYLASE/LIPASE/PROTEASEPANGESTYME UL 12
AMYLASE/LIPASE/PROTEASEULTRASE
AMYLASE/LIPASE/PROTEASEULTRESA
LIPASE/PROTEASE/AMYLASEVIOKACE
AMYLASE/LIPASE/PROTEASEVIOKASE
AMYLASE/LIPASE/PROTEASEZENPEP
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
AMYLASE/LIPASE/PROTEASEPERTZYE
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
4H. Miscellaneous Gastrointestinal Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
HYDROCORTISONE/PRAMOXINE HCLANALPRAM HC (g)
LIDOCAINE HCL/HCANAMANTLE HC (g)
HYDROCORTISONEANUSOL HC, PROCTOCREAM HC (g)
SULFASALAZINEAZULFIDINE, EN-TAB (g)
BALSALAZIDE DISODIUMCOLAZAL (g)
HYDROCORTISONE ACETATECORTENEMA (g)
POLYETHYLENE GLYCOL 3350GLYCOLAX (g)
HC ACETATE/PRAMOXINE HCLHC ACETATE/PRAMOXINE HCL
LACTULOSELACTULOSE (g)
HYDROCORTISONE ACETATEPROCTOCORT SUPPOSITORY (g)
METOCLOPRAMIDE HCLREGLAN TAB, SOLUTION (g)
MESALAMINEROWASA ENEMA (g)
MESALAMINESFROWASA ENEMA (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
MESALAMINEASACOL
MESALAMINEASACOL HD
MESALAMINECANASA
HYDROCORTISONE ACETATECORTIFOAM
MESALAMINEDELZICOL
TEDUGLUTIDEGATTEX [PA] [QL] <s>
MESALAMINEPENTASA
METHYLNALTREXONERELISTOR [PA] [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
LUBIPROSTONEAMITIZA [PA] [QL]
MESALAMINEAPRISO
CERTOLIZUMABCIMZIA SYRINGE [PA] [QL] <s>
GLYCOPYRROLATECUVPOSA
OLSALAZINE SODIUMDIPENTUM
BALSALAZIDE DISODIUMGIAZO [PA] [QL]
MESALAMINELIALDA [QL]
LINACLOTIDELINZESS [PA] [QL]
ALOSETRON HCLLOTRONEX [PA] [QL]
METOCLOPRAMIDE HCLMETOZOLV ODT
HC ACETATE/LIDOCAINE HCLPERANEX HC
HC ACETATE/PRAMOXINE HCLPRAMOSONE
NITROGLYCERINRECTIV [QL]
RIFAXIMINXIFAXAN 550MG [PA] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
5. OBSTETRICS AND GYNECOLOGY
5A. Contraceptives-Monophasic
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
LEVONORGESTREL-ETH ESTRAALESSE (g), LEVLITE (g)
ETHYNODIOL D-ETHINYL ESTRADIOLDEMULEN (g)
DESOGESTREL-ETHINYL ESTRADIOLDESOGEN (g), ORTHO-CEPT (g)
NORETH-ETHINYL ESTRADIOL/IRONFEMCON FE (g)
NORGESTREL-ETHINYL ESTRADIOLLO/OVRAL (g)
NORETH A-ET ESTRA/FE FUMARATELOESTRIN, FE (g)
LEVONORGESTREL-ETH ESTRALYBREL (g)
NORETHINDRONE-ETHINYL ESTRADMODICON (g)
LEVONORGESTREL-ETH ESTRANORDETTE, LEVLEN (g)
NORETHINDRONE-MESTRANOLNORINYL 1/35 (g), ORTHO-NOVUM 1/35 (g)
NORETHINDRONE-ETHINYL ESTRADNORINYL 1/50 (g), ORTHO-NOVUM 1/50 (g)
NORGESTIMATE-ETHINYL ESTRADIOLORTHO-CYCLEN (g)
NORETHINDRONE-ETHINYL ESTRADOVCON 35 (g)
NORGESTREL-ETHINYL ESTRADIOLOVRAL (g)
LEVONORGESTREL-ETH ESTRASEASONALE (g) [QL]
ETHINYL ESTRADIOL/DROSPIRENONEYASMIN 28 (g)
ETHINYL ESTRADIOL/DROSPIRENONEYASMIN 28 (g)
ETHINYL ESTRADIOL/DROSPIRENONEYAZ (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NORETH A-ET ESTRA/FE FUMARATELOESTRIN 24 FE
ESTRADIOL VALERATE/DIENOGESTNATAZIA
NORETHINDRONE-ETHINYL ESTRADOVCON-50, FE
5B. Contraceptives-Biphasic
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
L-NORGEST-ETH ESTR/ETHIN ESTRALOSEASONIQUE (g) [QL]
DESOG-ET ESTRA/ETHIN ESTRAMIRCETTE (g)
NORETHINDRONE-ETHINYL ESTRADNECON 10/11 (g)
L-NORGEST-ETH ESTR/ETHIN ESTRASEASONIQUE (g) [QL]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NORETH A-ET ESTRA/FE FUMARATELO LOESTRIN FE
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
5C. Contraceptives-Triphasic
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
DESOGESTREL-ETHINYL ESTRADIOLCYCLESSA (g)
NORETH A-ET ESTRA/FE FUMARATEESTROSTEP FE (g)
NORGESTIMATE-ETHINYL ESTRADIOLORTHO TRI-CYCLEN (g)
NORETHINDRONE-ETHINYL ESTRADORTHO-NOVUM 7/7/7 (g)
NORETHINDRONE-ETHINYL ESTRADTRI-NORINYL (g)
LEVONORGESTREL-ETH ESTRATRIPHASIL, TRILEVLEN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NORGESTIMATE-ETHINYL ESTRADIOLORTHO TRI-CYCLEN LO
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
5D. Contraceptives-Misc.
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NORETHINDRONEORTHO MICRONOR (g), NOR-QD (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ETHINYL ESTRADIOL/NORELGESTORTHO EVRA [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
DROSPIR/ETH ESTRA/LEVOMEFOL CABEYAZ
ETONOGESTREL/ETHINYL ESTRADIOLNUVARING [QL]
DROSPIR/ETH ESTRA/LEVOMEFOL CASAFYRAL
5E. Contraceptives-Postcoital
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
LEVONORGESTRELPLAN B, ONE-STEP (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
ULIPRISTAL ACETATEELLA [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
5F. Progestins
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NORETHINDRONE ACETATEAYGESTIN (g)
MEDROXYPROGESTERONE ACETDEPO-PROVERA 150MG (g)
PROGESTERONEPROGESTERONE IN OIL (INJ) (g)
PROGESTERONE,MICRONIZEDPROMETRIUM (g)
MEDROXYPROGESTERONE ACETPROVERA (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
PROGESTERONE,MICRONIZEDCRINONE [PA]
MEDROXYPROGESTERONE ACETDEPO-SUBQ PROVERA 104
PROGESTERONE, MICRONIZEDENDOMETRIN [PA]
PROGESTERONE,MICRONIZEDPROCHIEVE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
5G. Estrogens
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ESTRADIOLCLIMARA (g) [QL]
ESTRADIOLESTRACE (g)
ESTROPIPATEOGEN, ORTHO-EST (g)
ESTRADIOLVIVELLE (g) [QL]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ESTRADIOLALORA [QL]
ESTROGENS,CONJ.,SYNTHETIC BENJUVIA [QL]
ESTRADIOLESTRADERM [QL]
ESTRADIOLESTRING [QL]
ESTROGENS,CONJUGATEDPREMARIN CREAM
ESTROGENS,CONJUGATEDPREMARIN, PREMARIN LOW DOSE
ESTRADIOLVAGIFEM [QL]
ESTRADIOLVIVELLE-DOT [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
ESTROGENS,CONJ.,SYNTHETIC ACENESTIN
ESTRADIOLDIVIGEL [QL]
ESTRADIOLELESTRIN [QL]
ESTRADIOLESTRACE VAGINAL CREAM
ESTRADIOLESTRASORB [QL]
ESTRADIOLESTROGEL [QL]
ESTRADIOL TRANSDERMAL SPRAYEVAMIST [QL]
ESTRADIOL ACETATEFEMRING [QL]
ESTRADIOL ACETATEFEMTRACE
ESTROGENS,ESTERIFIEDMENEST
ESTRADIOLMENOSTAR [QL]
ESTRADIOLMINIVELLE [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
5H. Estrogen/Progestin Combinations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ESTRADIOL/NORETH ACACTIVELLA (g)
ESTROGEN,ESTER/ME-TESTOSTERONEESTRATEST, H.S. (g)
ETHINYL ESTRADIOL/NORETH ACFEMHRT (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ETHINYL ESTRADIOL/NORETH ACFEMHRT 0.5MG-2.5MCG
ESTROGEN,CON/M-PROGEST ACETPREMPRO, LOW DOSE/PREMPHASE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
ESTRADIOL/DROSPIRENONEANGELIQ [QL]
ESTRADIOL/LEVONORGESTRELCLIMARA PRO [QL]
ESTRADIOL/NORETH ACCOMBIPATCH [QL]
ESTRADIOL/NORGESTIMATEORTHO-PREFEST
5J. Infertility Treatment
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CLOMIPHENE CITRATECLOMID (g)
LEUPROLIDE ACETATELUPRON (g) <s>
CHORIONIC GONADOTROPIN, HUMANNOVAREL, PREGNYL, PROFASI (g) [PA] <s>
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
UROFOLLITROPIN (FSH)BRAVELLE [PA] <s>
CETRORELIX ACETATECETROTIDE [PA] <s>
UROFOLLITROPIN (FSH)FERTINEX [PA] <s>
GANIRELIX ACETATEGANIRELIX ACETATE [PA] <s>
FOLLITROPIN ALPHA,RECOMBGONAL-F, RFF [PA] <s>
HCG ALPHA,RECOMBINANTOVIDREL [PA] <s>
MENOTROPINSREPRONEX [PA] <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
FOLLITROPIN BETA,RECOMBFOLLISTIM AQ [PA] <s>
LUTROPIN ALPHALUVERIS [PA] <s>
MENOTROPINSMENOPUR [PA] <s>
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
5K. Vaginal Anti-infective/Antifungal
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CLINDAMYCIN PHOSPHATECLEOCIN VAG CREAM (g)
FLUCONAZOLEDIFLUCAN (g)
METRONIDAZOLEMETROGEL-VAGINAL (g)
NYSTATINNYSTATIN (g)
TERCONAZOLETERAZOL- 3, 7 (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
SULFANILAMIDEAVC
CLINDAMYCIN PHOSPHATECLEOCIN VAGINAL OVULES
CLINDAMYCIN PHOSPHATECLINDESSE
BUTOCONAZOLE NITRATEGYNAZOLE-2
5L. Miscellaneous OB-GYN
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
TRANEXAMIC ACIDLYSTEDA (g) [QL]
METHYLERGONOVINE MALEATEMETHERGINE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
LEUPROLIDE ACETATELUPRON DEPOT <s>
NAFARELIN ACETATESYNAREL
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
OSPEMIFENEOSPHENA
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
6. RHEUMATOLOGY AND MUSCULOSKELETAL
6A. Salicylates
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
SEE CHAPTERS 3F & 3GSALICYLATES AND NSAIDS
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
6B. Gout Therapy
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
COLCHICINE/PROBENECIDCOLBENEMID (g)
PROBENECIDPROBENECID (g)
ALLOPURINOLZYLOPRIM (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
COLCHICINECOLCRYS
FEBUXOSTATULORIC [ST] [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
6C. Corticosteroids
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
SEE CHAPTER 7CCORTICOSTEROIDS
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
6D. Miscellaneous Rheumatologic Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
LEFLUNOMIDEARAVA (g) [QL]
SULFASALAZINEAZULFIDINE, EN-TAB (g)
AZATHIOPRINEIMURAN (g)
METHOTREXATE SODIUMMETHOTREXATE (g)
HYDROXYCHLOROQUINE SULFATEPLAQUENIL (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
PENICILLAMINECUPRIMINE [QL]
ETANERCEPTENBREL [PA] [QL] <s>
ADALIMUMABHUMIRA [PA] [QL] <s>
METHOTREXATE SODIUMRHEUMATREX, TREXALL
AURANOFINRIDAURA
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
AZATHIOPRINEAZASAN
CERTOLIZUMABCIMZIA SYRINGE [PA] [QL] <s>
PENICILLAMINEDEPEN
ANAKINRAKINERET [PA] [QL] <s>
ABATACEPTORENCIA SC [PA] [QL] <s>
GOLIMUMABSIMPONI [PA] [QL] <s>
TOFACITINIB CITRATEXELJANZ [PA]
6E. Osteoporosis/Hormonal Treatment
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ESTRADIOLCLIMARA (g) [QL]
ESTRADIOLESTRACE (g)
ESTROGEN,ESTER/ME-TESTOSTERONEESTRATEST, H.S. (g)
ETHINYL ESTRADIOL/NORETH ACFEMHRT (g)
ESTROPIPATEOGEN, ORTHO-EST (g)
ESTRADIOLVIVELLE (g) [QL]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ESTRADIOLALORA [QL]
ESTROGENS,CONJ.,SYNTHETIC BENJUVIA [QL]
ESTRADIOLESTRADERM [QL]
ETHINYL ESTRADIOL/NORETH ACFEMHRT 0.5MG-2.5MCG
ESTROGENS,CONJUGATEDPREMARIN CREAM
ESTROGENS,CONJUGATEDPREMARIN, PREMARIN LOW DOSE
ESTROGEN,CON/M-PROGEST ACETPREMPRO, LOW DOSE/PREMPHASE
ESTRADIOLVIVELLE-DOT [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
ESTROGENS,CONJ.,SYNTHETIC ACENESTIN
TERIPARATIDEFORTEO [PA] [QL] <s>
ESTROGENS,ESTERIFIEDMENEST
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
6F. Osteoporosis/Bone Resorption
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
IBANDRONATE SODIUMBONIVA (g) [ST] [QL]
ETIDRONATE DISODIUMDIDRONEL (g) [QL]
FIRST-LINE THERAPY WHEN APPROPRIATEESTROGENS
ALENDRONATE SODIUMFOSAMAX, WEEKLY (g) [QL] BE
CALCITONIN,SALMON,SYNTHETICMIACALCIN NASAL SPRAY (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
RISEDRONATE SODIUMACTONEL, WEEKLY, 150MG [ST] [QL]
RALOXIFENE HCLEVISTA
CALCITONIN,SALMON,SYNTHETICMIACALCIN INJECTION
TILUDRONATE DISODIUMSKELID [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
RISEDRONATE SODIUMATELVIA [PA] [QL]
ALENDRONATEBINOSTO [ST] [QL]
ALENDRONATE SODIUM/VITAMIN D3FOSAMAX PLUS D [ST] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
7. ENDOCRINOLOGY
7A. Antithyroid Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
PROPYLTHIOURACILPROPYLTHIOURACIL (g)
METHIMAZOLETAPAZOLE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
POTASSIUM IODIDESSKI
7B. Thyroid Hormones
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
LIOTHYRONINE SODIUMCYTOMEL (g)
LEVOTHYROXINE SODIUMSYNTHROID (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
LIOTRIXTHYROLAR
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
THYROIDARMOUR THYROID
LEVOTHYROXINE SODIUMTIROSINT
7C. Corticosteroids
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
HYDROCORTISONECORTEF, HYDROCORTISONE (g)
CORTISONE ACETATECORTISONE ACETATE (g)
DEXAMETHASONEDECADRON (g)
BUDESONIDEENTOCORT EC (g)
FLUDROCORTISONE ACETATEFLORINEF (g)
METHYLPREDNISOLONEMEDROL, DOSEPAK (g)
PREDNISOLONE SOD PHOSPHATEORAPRED (g)
PREDNISOLONEPREDNISOLONE, TABS, SYRUP (g)
PREDNISONEPREDNISONE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
PREDNISOLONE SOD PHOSPHATEORAPRED ODT
PREDNISONERAYOS [PA] [QL]
BUDESONIDEUCERIS [PA] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
7D. Androgens
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
FLUOXYMESTERONEANDROXY 10MG (g)
DANAZOLDANOCRINE (g)
TESTOSTERONE ENANTHATEDELATESTRYL (g)
TESTOSTERONE CYPIONATEDEPO-TESTOSTERONE (g)
OXANDROLONEOXANDRIN (g) [PA]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
TESTOSTERONEANDRODERM [QL]
TESTOSTERONEANDROGEL, 1.62% [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
OXYMETHOLONEANADROL-50 [QL]
TESTOSTERONEAXIRON [PA] [QL]
TESTOSTERONEBIO-T-GEL [PA] [QL]
TESTOSTERONEFORTESTA [PA] [QL]
METHYLTESTOSTERONEMETHITEST
TESTOSTERONESTRIANT [PA] [QL]
TESTOSTERONETESTIM [PA] [QL]
METHYLTESTOSTERONETESTRED, ANDROID [PA]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
7E. Miscellaneous Endocrine
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
SODIUM PHENYLBUTYRATEBUPHENYL (g)
ERGOCALCIFEROLCALCIFEROL (g)
DESMOPRESSIN ACETATEDDAVP TABS, SPRAY (g)
CABERGOLINEDOSTINEX (g)
CALCITONIN,SALMON,SYNTHETICMIACALCIN NASAL SPRAY (g)
FINASTERIDEPROSCAR (g)
CALCITRIOLROCALTROL (g)
OCTREOTIDE ACETATESANDOSTATIN (g) [PA] <s>
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
SODIUM PHENYLBUTYRATEBUPHENYL
CARGLUMIC ACIDCARBAGLU [PA] <s>
CYSTEAMINE BITARTRATECYSTAGON
GLUCAGON,HUMAN RECOMBINANTGLUCAGON EMERGENCY KIT
MIFEPRISTONEKORLYM [PA] [QL] <s>
LEUPROLIDE ACETATELUPRON DEPOT-PED <s>
CALCITONIN,SALMON,SYNTHETICMIACALCIN INJECTION
OCTREOTIDE ACETATESANDOSTATIN LAR [PA] <s>
CINACALCET HCLSENSIPAR <s>
PASIREOTIDE DIASPARTATESIGNIFOR [PA] [QL] <s>
LANREOTIDE ACETATESOMATULINE DEPOT <s>
PEGVISOMANTSOMAVERT [PA] <s>
DESMOPRESSIN ACETATESTIMATE
NAFARELIN ACETATESYNAREL
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
TESAMORELIN ACETATEEGRIFTA [PA] [QL] <s>
DOXERCALCIFEROLHECTOROL
GLYCEROL PHENYLBUTYRATERAVICTI [PA] [QL] <s>
MIGLUSTATZAVESCA
PARICALCITOLZEMPLAR
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
7F. Insulins
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NONE
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
INSULIN GLULISINEAPIDRA (PEN/CARTRIDGE)
INSULIN GLULISINEAPIDRA (VIAL)
INSULIN LISPRO,HUMAN REC.ANLOGHUMALOG, MIX (PEN/CARTRIDGE)
INSULIN NPL/INSULIN LISPROHUMALOG, MIX (VIAL) BE
HUMULINHUMULIN 70/30 (PEN/CARTRIDGE)
HUMULINHUMULIN 70/30 (VIAL) BE
NPH, HUMAN INSULIN ISOPHANEHUMULIN N (PEN/CARTRIDGE)
NPH, HUMAN INSULIN ISOPHANEHUMULIN N (VIAL) BE
INSULIN REGULAR HUMAN RECHUMULIN R (VIAL) BE
INSULIN GLARGINE,HUM.REC.ANLOGLANTUS (PEN/CARTRIDGE)
INSULIN GLARGINE,HUM.REC.ANLOGLANTUS (VIAL)
INSULIN DETEMIRLEVEMIR (PEN)
INSULIN DETEMIRLEVEMIR (VIAL)
INSULIN REGULAR HUMAN RECNOVOLIN (PEN/CARTRIDGE)
INSULIN REGULAR HUMAN RECNOVOLIN (VIAL) BE
INSULIN ASPARTNOVOLOG (PEN/CARTRIDGE)
INSULIN ASPARTNOVOLOG (VIAL) BE
INSULN ASP PRT/INSULIN ASPARTNOVOLOG MIX (PEN/VIAL)
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
7G. Non-insulin Hypoglycemic Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
PIOGLITAZONE HCL/METFORMIN HCLACTOPLUS MET (g) [QL]
PIOGLITAZONE HCLACTOS (g) [QL]
GLIMEPIRIDEAMARYL (g) BE
GLYBURIDEDIABETA, MICRONASE (g) BE
CHLORPROPAMIDEDIABINESE (g) BE
PIOGLITAZONE/GLIMEPIRIDEDUETACT (g) [QL]
METFORMIN HCLFORTAMET (g)
METFORMIN HCLGLUCOPHAGE, XR (g) BE
GLIPIZIDEGLUCOTROL, XL (g) BE
GLYBURIDE/METFORMIN HCLGLUCOVANCE (g) BE
GLYBURIDE,MICRONIZEDGLYNASE (g) BE
GLIPIZIDE/METFORMIN HCLMETAGLIP (g) BE
TOLBUTAMIDEORINASE (g)
ACARBOSEPRECOSE (g)
NATEGLINIDESTARLIX (g)
TOLAZAMIDETOLINASE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
SITAGLIPTIN PHOS/METFORMIN HCLJANUMET (TIER 3 - BCN ONLY) [PA] [QL]
SITAGLIPTIN PHOS/METFORMIN HCLJANUMET XR (TIER 3 - BCN ONLY) [PA] [QL]
SITAGLIPTIN PHOSPHATEJANUVIA (TIER 3 - BCN ONLY) [PA] [QL]
SAXAGLIPTIN HCL/METFORMIN HCLKOMBIGLYZE XR (TIER 3 - BCN ONLY) [ST] [QL]
SAXAGLIPTIN HYDROCHLORIDEONGLYZA (TIER 3 - BCN ONLY) [PA] [QL]
REPAGLINIDEPRANDIN
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
PIOGLITAZONE HCL/METFORMIN HCLACTOPLUS MET XR [ST] [QL]
ROSIGLITAZONE/METFORMIN HCLAVANDAMET [ST] [QL]
ROSIGLITAZONE MALEATE/GLIMEPIRAVANDARYL [ST]
ROSIGLITAZONE MALEATEAVANDIA [ST] [QL]
EXENATIDE MICROSPHERESBYDUREON [PA] [QL]
EXENATIDEBYETTA [PA] [QL]
BROMOCRIPTINE MESYLATECYCLOSET [PA] [QL]
METFORMIN HCLGLUMETZA
MIGLITOLGLYSET
LINAGLIPTIN/METFORMIN HCLJENTADUETO [PA] [QL]
SITAGLIPTIN/SIMVASTATINJUVISYNC [PA] [QL]
ALOGLIPTIN BENZ/METFORMIN HCLKAZANO [ST] [QL]
ALOGLIPTIN BENZOATENESINA [ST] [QL]
ALOGLIPTIN BENZ/PIOGLITZONEOSENI [ST] [QL]
REPAGLINIDE/METFORMIN HCLPRANDIMET [PA]
METFORMIN HCLRIOMET
PRAMLINTIDE ACETATESYMLIN [ST] [QL]
LINAGLIPTINTRADJENTA [PA] [QL]
LIRAGLUTIDEVICTOZA [PA] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
7H. Growth Hormone and Related Products
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NONE
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
TEDUGLUTIDEGATTEX [PA] [QL] <s>
SOMATROPINGENOTROPIN [PA] <s>
SOMATROPINNUTROPIN [PA] <s>
SOMATROPINNUTROPIN AQ [PA] <s>
SOMATROPINNUTROPIN AQ NUSPIN [PA] <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
SOMATROPINHUMATROPE [PA] <s>
MECASERMININCRELEX [PA] <s>
SOMATROPINNORDITROPIN (ALL) [PA] <s>
SOMATROPINOMNITROPE [PA] <s>
SOMATROPINSAIZEN [PA] <s>
SOMATROPINSEROSTIM [PA] <s>
SOMATROPINTEV-TROPIN [PA] <s>
SOMATROPINZORBTIVE [PA] <s>
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
8. ANTINEOPLASTICS AND IMMUNOSUPPRESANTS
8A. Alkylating Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CYCLOPHOSPHAMIDECYTOXAN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
MELPHALANALKERAN
LOMUSTINECEENU
CHLORAMBUCILLEUKERAN
BUSULFANMYLERAN
TEMOZOLOMIDETEMODAR <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
8B. Antimetabolites
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
METHOTREXATE SODIUMMETHOTREXATE TABS (g)
MERCAPTOPURINEPURINETHOL (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
FLUDARABINE PHOSPHATEOFORTA [QL] <s>
THIOGUANINETABLOID
CAPECITABINEXELODA <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
8C. Immunomodulators
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
MYCOPHENOLATE MOFETILCELLCEPT (g) <s>
CYCLOSPORINE, MODIFIEDGENGRAF, NEORAL (g) <s>
AZATHIOPRINEIMURAN (g)
PREDNISONEPREDNISONE (g)
TACROLIMUS ANHYDROUSPROGRAF (g) <s>
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
RILONACEPTARCALYST [PA] <s>
MYCOPHENOLATE MOFETILCELLCEPT SUSPENSION <s>
SIROLIMUSRAPAMUNE TABS, SOLUTION <s>
CYCLOSPORINESANDIMMUNE <s>
THALIDOMIDETHALOMID <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
AZATHIOPRINEAZASAN
ANAKINRAKINERET [PA] [QL] <s>
MYCOPHENOLATE SODIUMMYFORTIC <s>
PREDNISONERAYOS [PA] [QL]
LENALIDOMIDEREVLIMID [PA] [QL] <s>
8D. Hormonal Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ANASTROZOLEARIMIDEX (g) [PA]
EXEMESTANEAROMASIN (g) [PA]
BICALUTAMIDECASODEX (g)
FLUTAMIDEEULEXIN (g)
LETROZOLEFEMARA (g) [PA]
LEUPROLIDE ACETATELUPRON (g) <s>
MEGESTROL ACETATEMEGACE (g)
TAMOXIFEN CITRATETAMOXIFEN CITRATE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
MEDROXYPROGESTERONE ACETDEPO-PROVERA 400MG
TOREMIFENE CITRATEFARESTON
LEUPROLIDE ACETATELUPRON DEPOT <s>
NILUTAMIDENILANDRON
TRIPTORELIN PAMOATETRELSTAR DEPOT, LA <s>
ENZALUTAMIDEXTANDI [PA] [QL] <s>
GOSERELIN ACETATEZOLADEX [QL] <s>
ABIRATERONE ACETATEZYTIGA [PA] [QL] <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
LEUPROLIDE ACETATEELIGARD <s>
FULVESTRANTFASLODEX
MEGESTROL ACETATEMEGACE ES
TAMOXIFEN CITRATESOLTAMOX [PA] [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
8E. Miscellaneous Antineoplastic Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
HYDROXYUREAHYDREA (g)
OCTREOTIDE ACETATESANDOSTATIN (g) [PA] <s>
ETOPOSIDEVEPESID (g)
TRETINOINVESANOID (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
HYDROXYUREADROXIA
ESTRAMUSTINE PHOSPHATE SODIUMEMCYT
VISMODEGIBERIVEDGE [PA] [QL] <s>
ALTRETAMINEHEXALEN
TOPOTECAN HCLHYCAMTIN [PA] <s>
RUXOLITINIBJAKAFI [PA] [QL] <s>
MITOTANELYSODREN
PROCARBAZINE HCLMATULANE
OCTREOTIDE ACETATESANDOSTATIN LAR [PA] <s>
VORINOSTATZOLINZA [PA] <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
PEGINTERFERON ALFA-2BSYLATRON [PA] <s>
BEXAROTENETARGRETIN ORAL [PA] <s>
8F. Adjuvant Therapy
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
LEUCOVORIN CALCIUMLEUCOVORIN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
SARGRAMOSTIMLEUKINE <s>
MESNAMESNEX TABS
FILGRASTIMNEUPOGEN <s>
EPOETIN ALFAPROCRIT [PA] <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
DARBEPOETIN ALFA IN ALBUMN SOLARANESP [PA] <s>
EPOETIN ALFAEPOGEN [PA] <s>
PEGFILGRASTIMNEULASTA [QL] <s>
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
8G. Kinase Inhibitors and Molecular Target Inhibitors
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NONE
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
EVEROLIMUSAFINITOR, DISPERZ [PA] [QL] <s>
BOSUTINIBBOSULIF [PA] [QL] <s>
VANDETANIBCAPRELSA [PA] [QL] <s>
CABOZANTINIB S-MALATECOMETRIQ [PA] [QL] <s>
IMATINIB MESYLATEGLEEVEC <s>
PONATINIB HCLICLUSIG [PA] [QL] <s>
AXITINIBINLYTA [PA] [QL] <s>
GEFITINIBIRESSA [PA] <s>
SORAFENIB TOSYLATENEXAVAR [PA] [QL] <s>
DASATINIBSPRYCEL [PA] [QL] <s>
REGORAFENIBSTIVARGA [PA] [QL] <s>
SUNITINIB MALATESUTENT [PA] [QL] <s>
ERLOTINIB HCLTARCEVA [PA] <s>
NILOTINIB HYDROCHLORIDETASIGNA [PA] <s>
LAPATINIB DITOSYLATETYKERB [PA] <s>
PAZOPANIB HYDROCHLORIDEVOTRIENT [PA] <s>
RIVAROXABANXALKORI [PA] [QL] <s>
VEMURAFENIBZELBORAF [PA] [QL] <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
EVEROLIMUSZORTRESS [QL] <s>
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
9. IMMUNOLOGY AND HEMATOLOGY
9A. Immunoglobulins
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NONE
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
IMMUNE GLOBULINGAMUNEX-C SQ (BCBSM ONLY) [PA] <s>
IMMUNE GLOBULINHIZENTRA (BCBSM ONLY) [PA] <s>
9B. Hematopoietic Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NONE
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
SARGRAMOSTIMLEUKINE <s>
OPRELVEKINNEUMEGA <s>
FILGRASTIMNEUPOGEN <s>
EPOETIN ALFAPROCRIT [PA] <s>
ELTROMBOPAG OLAMINEPROMACTA [PA] [QL] <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
DARBEPOETIN ALFA IN ALBUMN SOLARANESP [PA] <s>
EPOETIN ALFAEPOGEN [PA] <s>
PEGFILGRASTIMNEULASTA [QL] <s>
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
9C. Interferons and MS Therapy
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
RIBAVIRINREBETOL (g) [PA] <s>
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
INTERFERON GAMMA-1B,RECOMB.ACTIMMUNE <s>
INTERFERON ALFA-N3ALFERON N
INTERFERON BETA-1AAVONEX <s>
GLATIRAMER ACETATECOPAXONE <s>
INTERFERON ALFACON-1INFERGEN [PA] <s>
INTERFERON ALFA-2B,RECOMB.INTRON A [PA] <s>
PEGINTERFERON ALFA-2APEGASYS [PA] [QL] <s>
PEGINTERFERON ALFA-2BPEG-INTRON, REDIPEN [PA] [QL] <s>
INTERFERON BETA-1A/ALBUMINREBIF, REBIDOSE <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
FAMPRIDINE (4-AMINOPYRIDINE)AMPYRA [PA] [QL] <s>
TERIFLUNOMIDEAUBAGIO [PA] [QL] <s>
INTERFERON BETA-1BBETASERON [PA] <s>
INTERFERON BETA-1BEXTAVIA <s>
FINGOLIMOD HYDROCHLORIDEGILENYA [PA] [QL] <s>
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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[PA] Prior approval may be required [QL] Quantity limits may apply[ST] Step therapy may be required
10. DERMATOLOGY
10A. Very High Potency Corticosteriods
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CLOBETASOL PROPIONATECLOBEX SHAMPOO, LOTION (g)
BETAMET DIPROP/PROP GLYDIPROLENE OINTMENT (g)
CLOBETASOL PROPIONATE/EMOLLOLUX-E (g)
DIFLORASONE DIACETATEPSORCON, FLORONE (g)
CLOBETASOL PROPIONATETEMOVATE (g), CLOBEVATE (g)
HALOBETASOL PROPIONATEULTRAVATE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
CLOBETASOL PROPIONATECLOBEX SPRAY
FLUOCINONIDEVANOS 0.1% CR
10B. High Potency Corticosteroids
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
TRIAMCINOLONE ACETONIDEARISTOCORT, KENALOG 0.5% CR (g)
AMCINONIDECYCLOCORT (g)
BETAMET DIPROP/PROP GLYDIPROLENE AF, GEL, CR, LOT (g)
BETAMETHASONE DIPROPIONATEDIPROSONE (g), MAXIVATE (g)
FLUOCINONIDELIDEX, E (g)
DIFLORASONE DIACETATEPSORCON, FLORONE (g)
DESOXIMETASONETOPICORT CR, GEL, OINT (g)
BETAMETHASONE VALERATEVALISONE CR, LOTION, OINT (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
DIFLORASONE DIACETATE/EMOLLAPEXICON E
HALCINONIDEHALOG
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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10C. Medium Potency Corticosteroids
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
TRIAMCINOLONE ACETONIDEARISTOCORT, KENALOG (g)
FLUTICASONE PROPIONATECUTIVATE (g)
PREDNICARBATEDERMATOP (g)
MOMETASONE FUROATEELOCON (g)
HYDROCORTISONE BUTYRATELOCOID CR, OINT, SOLN (g)
HYDROCORTISONE BUTYRATE/EMOLLLOCOID LIPOCREAM (g)
BETAMETHASONE VALERATELUXIQ (g)
FLUOCINOLONE ACETONIDESYNALAR 0.025% CREAM, OINT (g)
DESOXIMETASONETOPICORT LP (g)
BETAMETHASONE VALERATEVALISONE CR, LOTION, OINT (g)
HYDROCORTISONE VALERATEWESTCORT (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
CLOCORTOLONE PIVALATECLODERM
FLURANDRENOLIDECORDRAN, TAPE, SP
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
HYDROCORTISONE BUTYRATELOCOID LOTION
HYDROCORTISONE PROBUTATEPANDEL
DESOXIMETASONETOPICORT
10D. Low Potency Corticosteroids
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ALCLOMETASONE DIPROPIONATEACLOVATE (g)
HYDROCORTISONEDERMACORT, HYTONE (Rx Only) (g)
FLUOCINOLONE ACETONIDEDERMA-SMOOTHE/FS (g)
DESONIDEDESOWEN, TRIDESILON (g)
FLUOCINOLONE ACETONIDESYNALAR CREAM, SOLN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
FLUOCINOLONE ACETONIDECAPEX SHAMPOO
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
DESONIDEDESONATE [ST]
DESONIDEVERDESO [ST]
10E. Topical Anesthetics
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
LIDOCAINE/PRILOCAINEEMLA (g)
LIDOCAINE HCLXYLOCAINE (Rx Only) (g)
LIDOCAINE HCLXYLOCAINE VISCOUS (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
LIDOCAINELIDODERM PATCH
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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10F. Acne Treatment
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ISOTRETINOINACCUTANE (g) (REQ DERM CONSULT)
DOXYCYCLINE MONOHYDRATEADOXA (g) [PA]
CLINDAMYCIN PHOS/BENZOYL PEROXBENZACLIN (g)
ERYTHROMYCIN BASE/BENZ PERBENZAMYCIN (g)
BENZOYL PEROXIDEBENZOYL PEROXIDE-RX (g)
BENZOYL PEROXIDEBREVOXYL GEL (g)
CLINDAMYCIN PHOSPHATECLEOCIN T (g)
ADAPALENEDIFFERIN 0.1% CREAM, GEL (g)
DOXYCYCLINE HYCLATEDORYX (g) [PA] [QL]
CLINDAMYCIN PHOSPHATE/BENZ PERDUAC (g)
ERYTHROMYCIN BASE/ETHANOLERYTHROMYCIN TOPICAL SOLN, GEL (g)
CLINDAMYCIN PHOSPHATEEVOCLIN FOAM (g)
METRONIDAZOLEMETROCREAM, GEL, LOTION (g)
MINOCYCLINE HCLMINOCIN, DYNACIN (g)
DOXYCYCLINE MONOHYDRATEMONODOX (g) [PA] [QL]
DOXYCYCLINE HYCLATEPERIOSTAT (g)
SULFACETAMIDE SODIUM/SULFURPLEXION, TS (g)
TRETINOIN MICROSPHERESRETIN-A MICRO, PUMP (g)
TRETINOINRETIN-A, AVITA (g)
SULFACETAMIDE SOD/SULFUR/UREAROSULA CLEANSER (g)
MINOCYCLINE HCLSOLODYN 45, 90, 135MG (g) [PA]
SULFACETAMIDE SODIUM/SULFURSULFACET-R (g)
DOXYCYCLINE HYCLATEVIBRAMYCIN, VIBRATABS (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ADAPALENEDIFFERIN 0.3% GEL, PUMP
METRONIDAZOLEMETROGEL TOPICAL 1%, PUMP
TAZAROTENETAZORAC
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
ISOTRETINOINABSORICA (REQ DERM CONSULT)
CLINDAMYCIN PHOS/BENZOYL PEROXACANYA
DAPSONEACZONE [QL]
ERYTHROMYCIN BASEAKNE-MYCIN
RETAPAMULINALTABAX
AZELAIC ACIDAZELEX
BENZOYL PEROXIDECLINAC BPO
ADAPALENEDIFFERIN 0.1% LOTION
ADAPALENE/BENZOYL PEROXIDEEPIDUO, PUMP
AZELAIC ACIDFINACEA
METRONIDAZOLENORITATE
DOXYCYCLINE MONOHYDRATEORACEA [PA]
DOXYCYCLINE HYCLATEORAXYL
SULFACETAMIDE SODIUM/SULFURROSULA FOAM
MINOCYCLINE HCLSOLODYN 55, 65, 80, 105, 115MG [PA]
MINOCYCLINE HCLXIMINO [PA]
CLINDAMYCIN/TRETINOINZIANA GEL [PA]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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10G. Topical Antibacterials
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
MUPIROCIN CALCIUMBACTROBAN (g)
GENTAMICIN SULFATEGENTAMICIN CR, OINT (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
MUPIROCIN CALCIUMBACTROBAN NASAL
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
RETAPAMULINALTABAX
10H. Topical Antifungals
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
KETOCONAZOLEEXTINA (g)
CICLOPIROX OLAMINELOPROX CR, LOTIONg)
CICLOPIROXLOPROX GEL, SHAMPOO (g)
CLOTRIMAZOLELOTRIMIN (g)
CLOTRIMAZOLE/BETAMET DIPROPLOTRISONE CR, LOTION (g)
MICONAZOLE NITRATEMONISTAT-DERM (g)
NYSTATINMYCOSTATIN (g)
KETOCONAZOLENIZORAL CR, SHAMPOO 2% (g)
NYSTATIN/TRIAMCINNYSTATIN W/TRIAMCINOLONE (g)
CICLOPIROXPENLAC (g)
ECONAZOLE NITRATESPECTAZOLE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
BUTENAFINE HCLMENTAX
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
SERTACONAZOLE NITRATEERTACZO
SULCONAZOLE NITRATEEXELDERM SOLN, CR
NAFTIFINE HCLNAFTIN
OXICONAZOLE NITRATEOXISTAT
MICONAZOLE NITRATE/ZINC OXIDEVUSION
KETOCONAZOLEXOLEGEL
10I. Scabicides/Pediculicides
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ACYCLOVIRZOVIRAX OINT (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ACYCLOVIRZOVIRAX CREAM
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
PENCICLOVIRDENAVIR
ACYCLOVIR/HYDROCORTISONEXERESE
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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10J. Wound and Burn Therapy
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
PAPAIN/UREAACCUZYME, ETHEZYME, GLADASE (g)
TRYPSIN/BALSAM PERU/CASTOR OILGRANULEX (g)
SILVER SULFADIAZINESILVADENE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
COLLAGENASESANTYL
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
BECAPLERMINREGRANEX [PA]
10K. Antipsoriatic/Antiseborrheic
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CALCIPOTRIENEDOVONEX (g)
ANTHRALINDRITHOCREME HP (g)
SELENIUM SULFIDESELSUN RX (g)
CALCITRIOLVECTICAL (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ANTHRALINDRITHO-SCALP
ETANERCEPTENBREL [PA] [QL] <s>
ADALIMUMABHUMIRA [PA] [QL] <s>
METHOXSALEN, RAPIDOXSORALEN, ULTRA
ACITRETINSORIATANE [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
CALCIPOTRIENESORILUX
BETAMET DIPROP/CALCIPOTRIENETACLONEX, SCALP [PA]
10L. Scabicides/Pediculicides
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
PERMETHRINELIMITE (g)
LINDANELINDANE (g)
SPINOSADNATROBA (g)
MALATHIONOVIDE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
CROTAMITONEURAX
CROTAMITONEURAX Lotion (TIER 3 BCBSM only)
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
IVERMECTINSKLICE [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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10M. Miscellaneous Dermatologicals
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
IMIQUIMODALDARA (g) [QL]
PODOFILOXCONDYLOX SOLN (g)
ALUMINUM CHLORIDEDRYSOL (g)
FLUOROURACILEFUDEX (g)
DOXEPIN HCLZONALON (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
PODOFILOXCONDYLOX GEL
PIMECROLIMUSELIDEL
ALITRETINOINPANRETIN
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
FLUOROURACILCARAC
HYDROCORTISONE ACETATE/UREACARMOL HC
FLUOROURACIL/ADHESIVE BANDAGEEFUDEX OCCLUSION
INGENOL MEBUTATEPICATO [PA] [QL]
TACROLIMUSPROTOPIC [ST]
DICLOFENAC SODIUMSOLARAZE [PA]
BEXAROTENETARGRETIN GEL <s>
SINECATECHINSVEREGEN
IMIQUIMODZYCLARA [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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11. OPHTHALMOLOGY
11A. Ophthalmic Beta Blockers
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
LEVOBUNOLOL HCLBETAGAN (g)
BETAXOLOL HCLBETOPTIC SOLN (g)
CARTEOLOL HCLOCUPRESS (g)
METIPRANOLOLOPTIPRANOLOL (g)
TIMOLOL MALEATETIMOPTIC - XE (g)
TIMOLOL MALEATETIMOPTIC (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
BETAXOLOL HCLBETOPTIC S
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
TIMOLOLBETIMOL
TIMOLOL MALEATEISTALOL
TIMOLOL MALEATETIMOPTIC PF
11B. Other Glaucoma Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
BRIMONIDINE TARTRATEALPHAGAN, P 0.15% (g)
TIMOLOL MALEATE/DORZOLAM HCLCOSOPT (g)
APRACLONIDINE HCLIOPIDINE DROPS (g)
PILOCARPINE HCLPILOCAR, ISOPTO-CARPINE (g)
TRAVOPROST (BENZALKONIUM)TRAVATAN (g)
DORZOLAMIDE HCLTRUSOPT (g)
LATANOPROSTXALATAN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
BRIMONIDINE TARTRATEALPHAGAN P 0.1%
BRINZOLAMIDEAZOPT
CARBACHOLISOPTO CARBACHOL
BIMATOPROSTLUMIGAN
ECHOTHIOPHATE IODIDEPHOSPHOLINE IODIDE
PILOCARPINE HCLPILOPINE HS
TRAVOPROSTTRAVATAN Z
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
BRIMONIDINE TARTRATE/TIMOLOLCOMBIGAN
DORZOLAMIDE/TIMOLOL/PFCOSOPT PF
APRACLONIDINE HCLIOPIDINE DROPERETTE
UNOPROSTONE ISOPROPYLRESCULA [ST]
BRINZOLAMIDE/BRIMONID TARTSIMBRINZA
TAFLUPROST/PFZIOPTAN [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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11C. Cycloplegic Mydriatics
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CYCLOPENTOLATE HCLCYCLOGYL (g)
ATROPINE SULFATEISOPTO ATROPINE (g)
HOMATROPINE HBRISOPTO HOMATROPINE (g)
TROPICAMIDEMYDRIACYL (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
SCOPOLAMINE HYDROBROMIDEISOPTO HYOSCINE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
HYDROXYAMPHETAMINE/TROPICAMIDEPAREMYD
11D. Ophthalmic Anti-inflammatory Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
KETOROLAC TROMETHAMINEACULAR, LS (g)
FLURBIPROFEN SODIUMOCUFEN (g)
DICLOFENAC SODIUMVOLTAREN (g)
BROMFENAC SODIUMXIBROM (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
KETOROLAC TROMETHAMINEACUVAIL
BROMFENAC SODIUMBROMDAY
NEPAFENACILEVRO
NEPAFENACNEVANAC
BROMFENAC SODIUMPROLENSA
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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11E. Ophthalmic Anti-infectives
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
BACITRACINBACITRACIN (g)
SULFACETAMIDE SODIUMBLEPH-10, SODIUM SULAMYDE (g)
CIPROFLOXACIN HCLCILOXAN DROPS (g)
GENTAMICIN SULFATEGARAMYCIN (g)
ERYTHROMYCIN BASEILOTYCIN (g)
NEOMYCIN/GRAMICIDIN/POLYMYXN BNEOSPORIN OPHTH SOLN (g)
NEOMY SULF/BACITRA/POLYMYXIN BNEOSPORIN OPTH OINT (g)
OFLOXACINOCUFLOX (g)
BACITRACIN/POLYMYXIN B SULFATEPOLYSPORIN (g)
POLYMYXIN B SULFATE/TMPPOLYTRIM (g)
LEVOFLOXACINQUIXIN (g)
TOBRAMYCIN SULFATETOBREX (g)
TRIFLURIDINEVIROPTIC (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
CIPROFLOXACIN HCLCILOXAN OINT
MOXIFLOXACIN HCLMOXEZA
NATAMYCINNATACYN
MOXIFLOXACIN HCLVIGAMOX
GANCICLOVIRZIRGAN
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
AZITHROMYCINAZASITE
BESIFLOXACIN HYDROCHLORIDEBESIVANCE
LEVOFLOXACINIQUIX
GATIFLOXACINZYMAXID
11F. Ophthalmic Steroids
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
DEXAMETHASONE SOD PHOSPHATEDECADRON OPTH (g)
FLUOROMETHOLONEFML (g)
PREDNISOLONE SOD PHOSPHATEINFLAMASE, FORTE (g)
PREDNISOLONE ACETATEPRED FORTE (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
FLUOROMETHOLONEFML FORTE, S.O.P.
PREDNISOLONE ACETATEPRED MILD
RIMEXOLONEVEXOL
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
LOTEPREDNOL ETABONATEALREX
DIFLUPREDNATEDUREZOL
LOTEPREDNOL ETABONATELOTEMAX
DEXAMETHASONEMAXIDEX
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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11G. Ophthalmic Anti-infective/Steroid Combinations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NEOMY SULF/POLYMYX B SULF/HCCORTISPORIN (g)
NEO/POLYMYX B SULF/DEXAMETHMAXITROL (g)
TOBRAMYCIN SULFATE/DEXAMETHTOBRADEX SUSP (g)
NA SULFACETM/PREDNIS SPVASOCIDIN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NA SULFACETM/PREDNISOL ACBLEPHAMIDE DROPS, OINT
NEOMY SULF/POLYMYX B SULF/PREDPOLY-PRED
TOBRAMYCIN SULFATE/DEXAMETHTOBRADEX OINT
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
GENTAMICIN/PREDNISOL ACPRED-G
TOBRAMYCIN/DEXAMETHASONETOBRADEX ST
TOBRAMYCIN/LOTEPRED ETABZYLET
11H. Miscellaneous Ophthalmic Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NAPHAZOLINE HCLALBALON (g)
EPINASTINE HCLELESTAT (g)
PHENYLEPHRINE HCLNEO-SYNEPHRINE (g)
CROMOLYN SODIUMOPTICROM (g)
AZELASTINE HCLOPTIVAR (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NEDOCROMIL SODIUMALOCRIL
LODOXAMIDE TROMETHAMINEALOMIDE
CYSTEAMINE HYDROCHLORIDECYSTARAN [PA] [QL] <s>
HYDROXYPROPYL CELLULOSELACRISERT
OLOPATADINE HCLPATANOL
CYCLOSPORINERESTASIS
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
PEMIROLAST POTASSIUMALAMAST
BEPOTASTINE BESILATEBEPREVE
EMEDASTINE DIFUMARATEEMADINE
ALCAFTADINELASTACAFT
OLOPATADINE HCLPATADAY
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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12. OTIC & NASAL PREPARATIONS
12A. Nasal Preparations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
AZELASTINE HCLASTELIN NASAL SPRAY (g) [QL]
IPRATROPIUM BROMIDEATROVENT NASAL SPRAY (g) [QL]
FLUTICASONE PROPIONATEFLONASE (g) [QL]
TRIAMCINOLONE ACETONIDENASACORT AQ (g) [ST] [QL]
FLUNISOLIDE 0.025% SPRAYNASALIDE (g) [QL]
FLUNISOLIDENASAREL (g) [QL]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
AZELASTINE HCLASTEPRO NASAL SPRAY [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
BECLOMETHASONE DIPROPIONATEBECONASE AQ [ST] [QL]
FLUTICASONE PROPIONATE/AZELASTINE HCLDYMISTA [ST] [QL]
MOMETASONE FUROATENASONEX [ST] [QL]
CICLESONIDEOMNARIS [ST] [QL]
OLOPATADINE HCLPATANASE [QL]
BECLOMETHASONE DIPROPIONATEQNASL [ST] [QL]
BUDESONIDERHINOCORT AQUA [ST] [QL]
FLUTICASONE FUROATEVERAMYST [ST] [QL]
CICLESONIDEZETONNA [ST] [QL]
12B. Otic Preparations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ACETIC ACID/HYDROCORTISONEACETASOL, HC/VOSOL, HC (g)
AA/ANTPY/BCAINE/POLICO/AL ACETAURALGAN (g)
CIPROFLOXACIN HCLCETREXAL (g)
NEOMY SULF/POLYMYX B SULF/HCCORTISPORIN (g)
ACETIC ACID/ALUMINUM ACETATEDOMEBORO OTIC (g)
OFLOXACINFLOXIN OTIC (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
CIPROFLOXACIN HCL/HCCIPRO HC
CIPROFLOXACIN HCL/DEXAMETHCIPRODEX
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NEOMYCIN SULFATE/COLIST SUL/HCCOLY-MYCIN S
NEOMY SULF/COLIST SUL/HC/THONZCORTISPORIN-TC
OFLOXACINFLOXIN OTIC SINGLES
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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13. RESPIRATORY, COUGH & COLD
13A. Antihistamines
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
AZELASTINE HCLASTELIN NASAL SPRAY (g) [QL]
HYDROXYZINEATARAX, VISTARIL (g)
DIPHENHYDRAMINE HCLBENADRYL (g)
DESLORATADINECLARINEX 2.5, 5mg (g) [ST] [QL]
LORATADINECLARITIN, ALAVERT (OTC) (g)
CYPROHEPTADINE HCLPERIACTIN (g)
PROMETHAZINE HCLPHENERGAN (g)
DEXCHLORPHENIRAMINE MALEATEPOLARAMINE (g)
LEVOCETIRIZINE DIHYDROCHLORIDEXYZAL (g) [ST] [QL]
CETIRIZINE HCLZYRTEC (OTC) (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
AZELASTINE HCLASTEPRO NASAL SPRAY [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
DESLORATADINECLARINEX SYRUP [PA] [QL]
CARBINOXAMINE MALEATE ERKARBINAL ER [PA] [QL]
OLOPATADINE HCLPATANASE [QL]
13B. Antihistamine/Decongestant Combinations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
P-EPHED SUL/LORATADINECLARITIN-D 12HR, 24HR (OTC) (g)
P-EPHED HCL/CETIRIZINE HCLZYRTEC-D (OTC) (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
P-EPHED SUL/DESLORATADINECLARINEX-D [PA] [QL]
PSEUDOEPHEDRINE HCL/ACRIVASSEMPREX-D [ST]
13C. Antitussive combinations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
D-METHORPHAN HB/PROMETH HCLPHENERGAN DM (g)
CODEINE/PROMETHAZINE HCLPHENERGAN W/CODEINE (g)
BENZONATATETESSALON, PERLES (g)
HYDROCODONE/CHLORPHEN POLISTUSSIONEX (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
HYDROCODONE/CHLORPHEN POLISTUSSICAPS
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
HYDROCODONE AND PSEUDOEPHEDRINEREZIRA [QL]
HYDROCODONE BIT/CHLOR-MALVITUZ [QL]
CHLORPHENIRAMINE, HYDROCODONE/PSEneZUTRIPRO [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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13D. Expectorant combinations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
PHENYLEPHRINE HCL/PROMETH HCLPHENERGAN VC (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
13F. Oral Beta-Agonists
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
METAPROTERENOL SULFATEALUPENT (g)
TERBUTALINE SULFATEBRETHINE (g)
ALBUTEROL SULFATEPROVENTIL SOLUTION (g)
ALBUTEROL SULFATEVOSPIRE ER (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
13G. Inhaled Beta-Agonists
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ALBUTEROL SULFATEACCUNEB (g)
ALBUTEROL SULFATEALBUTEROL NEBULIZER SOLN (g)
METAPROTERENOL SULFATEMETAPROTERENOL SOLN (g)
LEVALBUTEROL HCLXOPENEX (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
FORMOTEROL FUMARATEFORADIL [QL]
ALBUTEROLPROAIR HFA, VENTOLIN HFA [QL]
SALMETEROL XINAFOATESEREVENT DISKUS [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
INDACATEROL MALEATEARCAPTA NEOHALER [QL]
ARFORMOTEROL TARTRATEBROVANA [PA] [QL]
PIRBUTEROL ACETATEMAXAIR AUTOHALER [QL]
FORMOTEROL FUMARATEPERFOROMIST [PA] [QL]
ALBUTEROLPROVENTIL HFA [QL]
LEVALBUTEROL TARTRATEXOPENEX HFA [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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13H. Inhaled Steroids
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
BUDESONIDEPULMICORT 0.25MG, 0.5MG/2ML (g) [QL] BE
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
CICLESONIDEALVESCO (TIER 1-BCN ONLY) [QL] BE
MOMETASONE FUROATEASMANEX (TIER 1-BCN ONLY) [QL] BE
FLUTICASONE PROPIONATEFLOVENT HFA, DISKUS (TIER 1-BCN ONLY) [QL] BE
BUDESONIDEPULMICORT 1MG/2ML (TIER 1-BCN ONLY) [QL] BE
BUDESONIDEPULMICORT INH (TIER 1-BCN ONLY) [QL]
BECLOMETHASONE DIPROPIONATEQVAR (TIER 1-BCN ONLY) [QL] BE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
FLUNISOLIDEAEROSPAN [QL]
13I. Intranasal Steroids
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
FLUTICASONE PROPIONATEFLONASE (g) [QL]
TRIAMCINOLONE ACETONIDENASACORT AQ (g) [ST] [QL]
FLUNISOLIDE 0.025% SPRAYNASALIDE (g) [QL]
FLUNISOLIDENASAREL (g) [QL]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
BECLOMETHASONE DIPROPIONATEBECONASE AQ [ST] [QL]
MOMETASONE FUROATENASONEX [ST] [QL]
CICLESONIDEOMNARIS [ST] [QL]
BECLOMETHASONE DIPROPIONATEQNASL [ST] [QL]
BUDESONIDERHINOCORT AQUA [ST] [QL]
FLUTICASONE FUROATEVERAMYST [ST] [QL]
CICLESONIDEZETONNA [ST] [QL]
13J. Theophyllines
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
THEOPHYLLINE ANHYDROUSTHEOPHYLLINE ANHYDROUS (g)
THEOPHYLLINE ANHYDROUSUNIPHYL (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
THEOPHYLLINE ANHYDROUSTHEO-24
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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13K. Epinephrine
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NONE
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
EPINEPHRINEEPIPEN, JR [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
EPINEPHRINEAUVI-Q [QL]
13L. Miscellaneous Pulmonary Agents
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ZAFIRLUKASTACCOLATE (g) [QL]
IPRATROPIUM BROMIDEATROVENT NASAL SPRAY (g) [QL]
IPRATROPIUM BROMIDEATROVENT SOLN (g)
IPRATROPIUM/ALBUTEROL SULFATEDUONEB (g)
CROMOLYN SODIUMINTAL SOLUTION (g)
ACETYLCYSTEINEMUCOMYST (g)
SILDENAFIL CITRATEREVATIO (g) [PA] [QL] <s>
MONTELUKAST SODIUMSINGULAIR (g) [QL]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
FLUTICASONE/SALMETEROLADVAIR [QL]
IPRATROPIUM BROMIDEATROVENT INHALER [QL]
IPRATROPIUM/ALBUTEROL SULFATECOMBIVENT, RESPIMAT [QL]
MOMETASONE/FORMOTEROLDULERA [QL]
IVACAFTORKALYDECO [PA] [QL] <s>
AMBRISENTANLETAIRIS [PA] [QL] <s>
DORNASE ALFAPULMOZYME <s>
SILDENAFIL CITRATEREVATIO SUSP [PA] [QL] <s>
TIOTROPIUM BROMIDESPIRIVA [QL]
BUDESONIDE/FORMOTEROL FUMARATESYMBICORT [QL]
BOSENTANTRACLEER [PA] <s>
TREPROSTINILTYVASO [PA] [QL] <s>
ILOPROSTVENTAVIS [PA] [QL] <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
TADALAFILADCIRCA [PA] [QL] <s>
ROFLUMILASTDALIRESP [PA] [QL]
ACLIDINIUM BROMIDETUDORZA PRESSAIR [PA] [QL]
ZILEUTONZYFLO, CR [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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14. UROLOGY
14A. Urinary Antispasmodics
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
DICYCLOMINE HCLBENTYL (g)
TOLTERODINE TARTRATEDETROL (g)
OXYBUTYNIN CHLORIDEDITROPAN, XL (g)
HYOSCYAMINE SULFATELEVBID (g)
HYOSCYAMINE SULFATELEVSIN, SL (g)
HYOSCYAMINE SULFATELEVSINEX (g)
PROPANTHELINE BROMIDEPRO-BANTHINE 15MG (g)
TROSPIUM CHLORIDESANCTURA (g)
TROSPIUM CHLORIDESANCTURA XR (g) [QL]
FLAVOXATE HCLURISPAS (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
TOLTERODINE TARTRATEDETROL LA
FESOTERODINE FUMARATETOVIAZ (TIER 3 - BCBSM ONLY) [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
OXYBUTYNINANTUROL [QL]
DARIFENACIN HYDROBROMIDEENABLEX
OXYBUTYNIN CHLORIDEGELNIQUE, PUMP [QL]
MIRABEGRONMYRBETRIQ [PA] [QL]
OXYBUTYNINOXYTROL [QL]
SOLIFENACIN SUCCINATEVESICARE
14B. Miscellaneous Urologicals
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
CITRIC ACID/POTASSIUM CITRATECYTRA-2, 3, K (g)
PHOSPHORUS #1K-PHOS NEUTRAL (g)
SOD/POTASS/K CIT/SOD CIT/CAPOLYCITRA (g)
PHENAZOPYRIDINE HCLPYRIDIUM (g)
BETHANECHOL CHLORIDEURECHOLINE (g)
POTASSIUM CITRATEUROCIT-K (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
PENTOSAN POLYSULFATE SODIUMELMIRON
MAG CARB/CITRIC ACID/G-LACTONERENACIDIN
MTH/ME BLUE/BA/SALICY/ATP/HYOSURETRON D-S
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NONE
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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14C. BPH Treatment
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
DOXAZOSIN MESYLATECARDURA (g)
TAMSULOSIN HCLFLOMAX (g)
TERAZOSIN HCLHYTRIN (g)
FINASTERIDEPROSCAR (g)
ALFUZOSIN HCLUROXATRAL (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
DUTASTERIDEAVODART
TADALAFILCIALIS 2.5, 5MG [PA] [QL]
DUTASTERIDE/TAMSULOSIN HCLJALYN [ST] [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
DOXAZOSIN MESYLATECARDURA XL
SILODOSINRAPAFLO [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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15. VITAMINS AND SUPPLEMENTS
15A. Vitamins and Minerals
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
ERGOCALCIFEROLCALCIFEROL (g)
CYANOCOBALAMINCYANOCOBALAMIN INJ (g)
FOLIC ACIDFOLVITE (g)
SODIUM FLUORIDELURIDE (g)
FLUORIDE ION/MULTIVITAMINSPOLY-VI-FLOR (g)
PRENATAL VIT/IRON,CARB/DOSS/FAPRENATAL VITS (g)
SODIUM FLUORIDEPREVIDENT (g)
CALCITRIOLROCALTROL (g)
FLUORIDE ION/VIT A,C&DTRI-VI-FLOR (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
PHYTONADIONEMEPHYTON
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
ZINC ACETATEGALZIN
DOXERCALCIFEROLHECTOROL
CYANOCOBALAMINNASCOBAL SPRAY
IRON ASPGLY&PS/C/B12/FA/CA/SUCNIFEREX GOLD
LYSINE HCL/VIT B COMP/FA/ZINCSUPERVITE
PARICALCITOLZEMPLAR
15B. Potassium Replacement
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
POTASSIUM CHLORIDEKAYCIEL, KAON-CL, KAON LIQUID (g)
POTASSIUM CHLORIDEK-LOR, KLOR-CON (g)
POTASSIUM BICARBONATE/CIT ACK-LYTE, KLOR-CON/EF (g)
POTASSIUM CHLORIDEK-TAB, K-DUR, SLOW-K, KAON CL (g)
POTASSIUM CHLORIDEMICRO-K (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
NONE
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
POTASSIUM CHLORIDE/POT BICARBKAOCHLOR-EFF
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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16. DIAGNOSTIC AND OTHER MISCELLANEOUS
16A. Diagnostics and Other Miscellaneous
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
DISULFIRAMANTABUSE (g)
LEVOCARNITINECARNITOR (g)
SOD SULF/SOD/NAHCO3/KCL/PEG'SCOLYTE (g)
DEFEROXAMINE MESYLATEDESFERAL (g)
CEVIMELINE HCLEVOXAC (g)
PEG 3350/NA SULF,BICARB,CL/KCLGOLYTELY (g)
SODIUM POLYSTYRENE SULFONATEKAYEXALATE (g)
SOD SULF/SOD/NAHCO3/KCL/PEG'SNULYTELY (g)
CHLORHEXIDINE GLUCONATEPERIDEX (g)
CALCIUM ACETATEPHOSLO (g)
NALTREXONE HCLREVIA (g)
PILOCARPINE HCLSALAGEN (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
PENICILLAMINECUPRIMINE [QL]
PEG 3350/NA SULF,BICARB,CL/KCLGOLYTELY PACKET
SAPROPTERIN DIHYDROCHLORIDEKUVAN [PA] <s>
PRUSSIAN BLUERADIOGARDASE [QL]
SEVELAMER HCLRENAGEL
SEVELAMER CARBONATERENVELA PACKET 2.4G
SEVELAMER CARBONATERENVELA TABLET
TOLVAPTANSAMSCA <s>
TETRABENAZINEXENAZINE [PA] [QL] <s>
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
AMLEXANOXAPHTHASOL
ACAMPROSATE CALCIUMCAMPRAL [PA]
DEFERASIROXEXJADE [PA] <s>
DEFERIPRONEFERRIPROX [PA] [QL] <s>
ICATIBANT ACETATEFIRAZYR [PA] [QL] <s>
LANTHANUM CARBONATEFOSRENOL
BISAC/NACL/NAHCO3/KCL/PEG 3350HALFLYTELY [QL]
PEG3350/SOD SUL/NACL/ASB/C/KCLMOVIPREP
NITISINONEORFADIN <s>
NAPHOS M-B M-H/NA PHOS,DI-BAOSMOPREP, VISICOL
CALCIUM ACETATEPHOSLYRA
SOD PICOSULF/MAG OX/CITRIC ACPREPOPIK
SEVELAMER CARBONATERENVELA PACKET 0.8G
PEG 3350-BOWEL 2,TWO PART PREPSUCLEAR [QL]
SODIUM,POTASSIUM,&MAG SULFATESSUPREP
TRIENTINE HCLSYPRINE <s>
MIGLUSTATZAVESCA
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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17. LIFESTYLE MODIFICATION
17A. Impotence
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
YOHIMBINE HCLYOHIMBINE HCL (g)
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
ALPROSTADILCAVERJECT [PA] [QL]
TADALAFILCIALIS [PA] [QL]
ALPROSTADILMUSE [PA] [QL]
SILDENAFIL CITRATEVIAGRA [PA] [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
ALPROSTADILEDEX [PA] [QL]
VARDENAFIL HCLLEVITRA [PA] [QL]
OSPEMIFENEOSPHENA
VARDENAFIL HCLSTAXYN [PA] [QL]
AVANAFILSTENDRA [PA] [QL]
17B. Weight Loss Preparations
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
PHENTERMINE HCLADIPEX-P (g) [PA] [QL]
PHENDIMETRAZINE TARTRATEBONTRIL (g) [PA] [QL]
BENZPHETAMINE HCLDIDREX (g) [PA] [QL]
DIETHYLPROPION HCLTENUATE (g) [PA] [QL]
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
PHENTERMINE RESINIONAMIN [PA] [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
LORCASERIN HCLBELVIQ [PA] [QL]
PHENTERMINE/TOPIRAMATEQSYMIA [PA] [QL]
PHENTERMINE HCLSUPRENZA ODT [PA] [QL]
ORLISTATXENICAL [PA] [QL]
17C. Smoking Cessation
TIER 1 - (Generics)Generic NameTrade Name Utilization Management
NICOTINE POLACRILEXCOMMIT LOZENGE OTC (g) (BCN ONLY) [QL] BE
NICOTINE POLACRILEXNICOTINE GUM, NICORETTE (g) (BCN ONLY) [QL] BE
NICOTINENICOTINE PATCH (g) (BCN ONLY) [QL] BE
BUPROPION HCLZYBAN (g) BE
TIER 2 - (Preferred Brands)Generic NameTrade Name Utilization Management
VARENICLINE TARTRATECHANTIX [QL]
TIER 3 - (Nonpreferred Brands)Generic NameTrade Name Utilization Management
NICOTINENICOTROL, NS [QL]
(g) Generic equivalent covered. Brand not covered or requires higher copay.
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Index
Trade Name Page Trade Name PageABILIFY DISCMELT (Tier 3 - BCBSM Only) 85
ABILIFY, SOLUTION 85
ABSORICA 121
ABSTRAL 88
ACANYA 121
ACCOLATE (g) 133
ACCUNEB(g) 131
ACCUPRIL(g) 78
ACCURETIC(g) 78
ACCUTANE (g) 121
ACCUZYME, ETHEZYME, GLADASE(g) 123
ACEON(g) 78
ACETASOL, HC/VOSOL, HC(g) 129
ACIPHEX, SPRINKLE 95
ACLOVATE(g) 120
ACTIGALL(g) 97
ACTIMMUNE 118
ACTIQ(g) 88
ACTIVELLA(g) 102
ACTONEL, WEEKLY, 150MG 106
ACTOPLUS MET (g) 111
ACTOPLUS MET XR 111
ACTOS (g) 111
ACULAR, LS(g) 126
ACUVAIL 126
ACZONE 121
ADCIRCA 133
ADDERALL XR (BRAND BCN-ONLY) 86
ADDERALL XR(g) 86
ADDERALL(g) 86
ADIPEX-P(g) 138
ADOXA(g) 70
ADOXA(g) 121
ADVAIR 133
ADVICOR 76
AEROSPAN 132
AFINITOR, DISPERZ 116
AGGRENOX 82
AGRYLIN(g) 82
AKNE-MYCIN 121
ALAMAST 128
ALBALON(g) 128
ALBENZA 75
ALBUTEROL NEBULIZER SOLN(g) 131
ALDACTAZIDE(g) 81
ALDACTONE(g) 81
ALDARA(g) 124
ALDOMET(g) 83
ALDORIL(g) 83
ALESSE(g), LEVLITE(g) 99
ALFERON N 118
ALINIA 75
ALKERAN 113
ALOCRIL 128
ALOMIDE 128
ALORA 101
ALORA 105
ALPHAGAN P 0.1% 125
ALPHAGAN, P 0.15%(g) 125
ALREX 127
ALSUMA(g) 90
ALTABAX 121
ALTABAX 122
ALTACE CAPSULE(g) 78
ALTOPREV 76
ALUPENT(g) 131
ALVESCO (TIER 1-BCN ONLY) 132
AMARYL(g) 111
AMBIEN CR(g) 86
AMBIEN(g) 86
AMERGE(g) 90
AMICAR(g) 82
AMITIZA 98
AMOXIL(g) 69
AMPICILLIN(g) 69
AMPYRA 118
AMRIX 93
AMTURNIDE 83
ANADROL-50 108
ANAFRANIL(g) 84
ANALPRAM HC(g) 98
ANAMANTLE HC(g) 98
ANAPROX, DS(g) 87
ANCOBON(g) 72
ANDRODERM 108
ANDROGEL, 1.62% 108
ANDROXY 10MG(g) 108
ANGELIQ 102
ANSAID(g) 87
ANTABUSE(g) 137
ANTARA (g) 76
ANTIVERT(g) 96
ANTUROL 134
ANUSOL HC, PROCTOCREAM HC(g) 98
ANZEMET 96
APEXICON E 119
APHTHASOL 137
APIDRA (PEN/CARTRIDGE) 110
APIDRA (VIAL) 110
APLENZIN 84
APOKYN 91
APRESOLINE(g) 83
APRISO 98
APTIVUS(MUST BE USED WITH NORVIR) 73
ARALEN(g) 74
ARANESP 115
ARANESP 117
ARAVA(g) 105
ARCALYST 114
ARCAPTA NEOHALER 131
ARICEPT 23MG 94
ARICEPT, ODT (g) 94
ARIMIDEX(g) 114
ARISTOCORT, KENALOG 0.5% CR(g) 119
ARISTOCORT, KENALOG(g) 120
ARIXTRA (g) 82
Trade Name Page Trade Name PageARMOUR THYROID 107
AROMASIN(g) 114
ARTANE(g) 91
ARTHROTEC (g) 87
ASACOL 98
ASACOL HD 98
ASENDIN(g) 84
ASMANEX (TIER 1-BCN ONLY) 132
ASPIRIN W/CODEINE(g) 89
ASTELIN NASAL SPRAY(g) 129
ASTELIN NASAL SPRAY(g) 130
ASTEPRO NASAL SPRAY 129
ASTEPRO NASAL SPRAY 130
ATACAND (g) 79
ATACAND HCT (g) 79
ATARAX, VISTARIL(g) 130
ATELVIA 106
ATIVAN(g) 85
ATRIPLA 73
ATROVENT NASAL SPRAY(g) 129
ATROVENT NASAL SPRAY(g) 133
ATROVENT INHALER 133
ATROVENT SOLN (g) 133
AUBAGIO 118
AUGMENTIN, ES, XR(g) 69
AURALGAN(g) 129
AUVI-Q 133
AVALIDE (g) 79
AVANDAMET 111
AVANDARYL 111
AVANDIA 111
AVAPRO (g) 79
AVC 103
AVELOX, ABC 71
AVINZA 88
AVODART 135
AVONEX 118
AXERT 90
AXID (RX ONLY)(g) 95
AXIRON 108
AYGESTIN(g) 101
AZASAN 105
AZASAN 114
AZASITE 127
AZELEX 121
AZILECT 91
AZOPT 125
AZOR 79
AZOR 80
AZULFIDINE, EN-TAB(g) 98
AZULFIDINE, EN-TAB(g) 105
BACITRACIN(g) 127
BACLOFEN, LIORESAL(g) 93
BACTRIM, DS, SEPTRA, DS(g) 71
BACTROBAN (g) 122
BACTROBAN NASAL 122
BANZEL 92
BARACLUDE 72
BECONASE AQ 129
BECONASE AQ 132
BELLAMINE/BELLASPAS(g) 96
BELVIQ 138
BENADRYL(g) 130
BENICAR 79
BENICAR HCT 79
BENTYL(g) 96
BENTYL(g) 134
BENZACLIN (g) 121
BENZAMYCIN(g) 121
BENZOYL PEROXIDE-RX(g) 121
BEPREVE 128
BESIVANCE 127
BETAGAN(g) 125
BETAPACE, AF(g) 77
BETAPACE, AF(g) 81
BETASERON 118
BETHKIS 75
BETIMOL 125
BETOPTIC S 125
BETOPTIC SOLN(g) 125
BEYAZ 100
BIAXIN, XL(g) 70
BILTRICIDE 75
BINOSTO 106
BIO-T-GEL 108
BLEPH-10, SODIUM SULAMYDE(g) 127
BLEPHAMIDE DROPS, OINT 128
BLOCADREN(g) 77
BONIVA (g) 106
BONTRIL(g) 138
BOSULIF 116
BRAVELLE 102
BRETHINE(g) 131
BREVOXYL GEL(g) 121
BRILINTA 82
BROMDAY 126
BROVANA 131
BUMEX(g) 81
BUPAP(g) 90
BUPHENYL 109
BUPHENYL (g) 109
BUSPAR(g) 85
BUTISOL SODIUM 86
BUTRANS 89
BYDUREON 111
BYETTA 111
BYSTOLIC 77
CADUET(g) 76
CADUET(g) 80
CAFERGOT 90
CALAN SR/ISOPTIN SR(g) 80
CALCIFEROL(g) 109
CALCIFEROL(g) 136
CAMBIA 87
CAMBIA 90
CAMPRAL 137
CANASA 98
CANTIL 96
Trade Name Page Trade Name PageCAPEX SHAMPOO 120
CAPOTEN(g) 78
CAPOZIDE(g) 78
CAPRELSA 116
CARAC 124
CARAFATE, SUSP(g) 95
CARBAGLU 109
CARBATROL(g) 92
CARDENE SR 80
CARDENE(g) 80
CARDIZEM LA 120MG 80
CARDIZEM, SR, CD, LA(g) 80
CARDURA XL 135
CARDURA(g) 83
CARDURA(g) 135
CARMOL HC 124
CARNITOR(g) 137
CASODEX(g) 114
CATAFLAM(g) 87
CATAPRES, TTS(g) 83
CAVERJECT 138
CAYSTON 75
CECLOR ER(g) 69
CECLOR(g) 69
CEDAX 69
CEENU 113
CEFTIN 250MG/5ML 69
CEFTIN(g) 69
CEFZIL(g) 69
CELEBREX 87
CELEXA(g) 84
CELLCEPT SUSPENSION 114
CELLCEPT(g) 114
CELONTIN 92
CENESTIN 101
CENESTIN 105
CESAMET 96
CETREXAL (g) 129
CETROTIDE 102
CHANTIX 138
CHENODAL 97
CHLORAL HYDRATE(g) 86
CIALIS 138
CIALIS 2.5, 5MG 135
CILOXAN DROPS(g) 127
CILOXAN OINT 127
CIMZIA SYRINGE 98
CIMZIA SYRINGE 105
CIPRO HC 129
CIPRO XR(g) 71
CIPRO(g) 71
CIPRODEX 129
CLARINEX 2.5, 5mg (g) 130
CLARINEX SYRUP 130
CLARINEX-D 130
CLARITIN, ALAVERT (OTC)(g) 130
CLARITIN-D 12HR, 24HR (OTC)(g) 130
CLEOCIN T(g) 121
CLEOCIN VAG CREAM(g) 103
CLEOCIN VAGINAL OVULES 103
CLEOCIN(g) 75
CLIMARA PRO 102
CLIMARA(g) 101
CLIMARA(g) 105
CLINAC BPO 121
CLINDESSE 103
CLINORIL(g) 87
CLOBEX SHAMPOO, LOTION(g) 119
CLOBEX SPRAY 119
CLODERM 120
CLOMID(g) 102
COARTEM 74
CODEINE SULFATE(g) 88
COGENTIN(g) 91
COLAZAL(g) 98
COLBENEMID(g) 104
COLCRYS 104
COLESTID PACKET 76
COLESTID(g) 76
COLY-MYCIN S 129
COLYTE(g) 137
COMBIGAN 125
COMBIPATCH 102
COMBIVENT RESPIMAT 133
COMBIVENT, RESPIMAT 133
COMBIVIR(g) 73
COMETRIQ 116
COMMIT LOZENGE OTC (g) (BCN ONLY) 138
COMPAZINE(g) 96
COMPLERA 73
COMTAN (g) 91
CONCERTA(g) 86
CONDYLOX GEL 124
CONDYLOX SOLN(g) 124
CONZIP 89
COPAXONE 118
COPEGUS(g) 72
CORDARONE(g) 81
CORDRAN, TAPE, SP 120
COREG CR 77
COREG(g) 77
CORGARD(g) 77
CORTEF, HYDROCORTISONE(g) 107
CORTENEMA(g) 98
CORTICOSTEROIDS 104
CORTIFOAM 98
CORTISONE ACETATE(g) 107
CORTISPORIN(g) 128
CORTISPORIN(g) 129
CORTISPORIN-TC 129
CORZIDE(g) 77
COSOPT PF 125
COSOPT(g) 125
COUMADIN(g) 82
COZAAR(g) 79
CREON 97
CRESTOR 76
CRINONE 101
Trade Name Page Trade Name PageCRIXIVAN 73
CUPRIMINE 105
CUPRIMINE 137
CUTIVATE(g) 120
CUVPOSA 98
CYANOCOBALAMIN INJ(g) 136
CYCLESSA(g) 100
CYCLOCORT(g) 119
CYCLOGYL(g) 126
CYCLOSET 111
CYMBALTA 84
CYSTAGON 109
CYSTARAN 128
CYTOMEL(g) 107
CYTOTEC(g) 95
CYTOVENE(g) 72
CYTOXAN(g) 113
CYTRA-2, 3, K(g) 134
D.H.E.45(g) 90
DALIRESP 133
DALMANE(g) 86
DANOCRINE(g) 108
DANTRIUM(g) 93
DAPSONE 74
DARAPRIM 74
DAYPRO(g) 87
DAYTRANA 86
DDAVP SOLN 109
DDAVP TABS, SPRAY(g) 109
DECADRON OPTH(g) 127
DECADRON(g) 107
DELATESTRYL(g) 108
DELZICOL 98
DEMADEX(g) 81
DEMEROL(g) 88
DEMULEN(g) 99
DENAVIR 122
DEPAKENE(g) 92
DEPAKOTE, ER, SPRINKLES(g) 92
DEPEN 105
DEPO-PROVERA 150MG(g) 101
DEPO-PROVERA 400MG 114
DEPO-SUBQ PROVERA 104 101
DEPO-TESTOSTERONE(g) 108
DERMACORT, HYTONE (Rx Only)(g) 120
DERMA-SMOOTHE/FS(g) 120
DERMATOP(g) 120
DESFERAL(g) 137
DESOGEN(g), ORTHO-CEPT(g) 99
DESONATE 120
DESOWEN, TRIDESILON(g) 120
DESOXYN(g) 86
DESVENLAFAXINE ER 84
DESYREL(g) 84
DETROL (g) 134
DETROL LA 134
DEXEDRINE(g) 86
DEXILANT 95
DIABETA, MICRONASE(g) 111
DIABINESE(g) 111
DIAMOX SEQUELS(g) 81
DIAMOX(g) 81
DIAMOX(g) 92
DIASTAT 92
DIASTAT 2.5MG(g) 92
DICLEGIS 96
DICLEGIS 103
DICLOXACILLIN(g) 69
DIDREX(g) 138
DIDRONEL(g) 106
DIFFERIN 0.1% CREAM, GEL(g) 121
DIFFERIN 0.1% LOTION 121
DIFFERIN 0.3% GEL, PUMP 121
DIFICID 70
DIFLUCAN(g) 72
DIFLUCAN(g) 103
DIGOXIN(g) 81
DILANTIN 30MG 92
DILANTIN CHEW TABS (g) 92
DILANTIN(g) 92
DILATRATE-SR 82
DILAUDID(g) 88
DIOVAN 79
DIOVAN HCT (g) 79
DIPENTUM 98
DIPROLENE AF, GEL, CR, LOT(g) 119
DIPROLENE OINTMENT(g) 119
DIPROSONE(g), MAXIVATE(g) 119
DISALCID, SALFLEX(g) 87
DITROPAN, XL(g) 134
DIURIL(g) 81
DIVIGEL 101
DOLOBID(g) 87
DOMEBORO OTIC(g) 129
DONNATAL EXTENTABS 96
DONNATAL(g) 96
DORAL 86
DORYX 70
DORYX(g) 70
DORYX(g) 121
DOSTINEX(g) 91
DOSTINEX(g) 109
DOVONEX (g) 123
DRITHOCREME HP(g) 123
DRITHO-SCALP 123
DROXIA 115
DRYSOL(g) 124
DUAC (g) 121
DUETACT (g) 111
DUEXIS 87
DULERA 133
DUONEB(g) 133
DURAGESIC(g) 88
DUREZOL 127
DURICEF(g) 69
DUTOPROL 77
DUTOPROL 81
DYGASE(g) 97
Trade Name Page Trade Name PageDYMISTA 129
DYNACIRC CR 80
DYNACIRC(g) 80
DYRENIUM 81
EC-NAPROSYN(g) 87
EDARBI 79
EDARBYCLOR 79
EDARBYCLOR 81
EDECRIN 81
EDEX 138
EDLUAR 86
EDURANT 73
EFFEXOR XR(g) 84
EFFEXOR(g) 84
EFFIENT 82
EFUDEX OCCLUSION 124
EFUDEX(g) 124
EGRIFTA 109
ELAVIL(g) 84
ELDEPRYL (g) 91
ELESTAT(g) 128
ELESTRIN 101
ELIDEL 124
ELIGARD 114
ELIMITE(g) 123
ELIQUIS 82
ELLA 100
ELMIRON 134
ELOCON(g) 120
EMADINE 128
EMBEDA 88
EMCYT 115
EMEND 80,125MG CAPSULES 96
EMLA(g) 120
EMSAM 84
EMTRIVA 73
ENABLEX 134
ENBREL 105
ENBREL 123
ENDOMETRIN 101
ENJUVIA 101
ENJUVIA 105
ENTOCORT EC(g) 107
EPIDUO, PUMP 121
EPIPEN, JR 133
EPIVIR 10MG/ML 73
EPIVIR HBV 72
EPIVIR(g) 73
EPOGEN 115
EPOGEN 117
EPZICOM 73
EQUETRO 92
ERGOMAR 90
ERIVEDGE 115
ERTACZO 122
ERY-TAB 500MG (TIER 3 BCBSM Only) 70
ERY-TAB(g) 70
ERYTHROMYCIN STEARATE(g) 70
ERYTHROMYCIN TOPICAL SOLN, GEL(g) 121
ERYTHROMYCIN(g) 70
ESKALITH, CR(g) 94
ESTRACE VAGINAL CREAM 101
ESTRACE(g) 101
ESTRACE(g) 105
ESTRADERM 101
ESTRADERM 105
ESTRASORB 101
ESTRATEST, H.S.(g) 102
ESTRATEST, H.S.(g) 105
ESTRING 101
ESTROGEL 101
ESTROGENS 106
ESTROSTEP FE(g) 100
ETHAMBUTOL(g) 74
ETRAFON(g) 84
EULEXIN(g) 114
EURAX 123
EURAX Lotion (TIER 3 BCBSM only) 123
EVAMIST 101
EVISTA 106
EVOCLIN FOAM(g) 121
EVOXAC (g) 137
EXALGO 88
EXELDERM SOLN, CR 122
EXELON PATCH, SOLN 94
EXELON(g) 94
EXFORGE 79
EXFORGE 80
EXFORGE HCT 79
EXFORGE HCT 80
EXJADE 137
EXTAVIA 118
EXTINA (g) 122
FACTIVE 71
FAMVIR(g) 72
FANAPT 85
FARESTON 114
FASLODEX 114
FAZACLO 85
FAZACLO 12.5, 25, 100MG (g) 85
FELBATOL(g) 92
FELDENE(g) 87
FEMARA(g) 114
FEMCON FE(g) 99
FEMHRT 0.5MG-2.5MCG 102
FEMHRT 0.5MG-2.5MCG 105
FEMHRT(g) 102
FEMHRT(g) 105
FEMRING 101
FEMTRACE 101
FENOGLIDE 76
FENTORA 88
FERRIPROX 137
FERTINEX 102
FEXMID (g) 93
FIBRICOR(g) 76
FINACEA 121
FIORICET W/CODEINE(g) 89
Trade Name Page Trade Name PageFIORICET; ESGIC, PLUS(g) 89
FIORICET; ESGIC, PLUS(g) 90
FIORINAL W/CODEINE(g) 89
FIORINAL W/CODEINE(g) 90
FIORINAL(g) 89
FIORINAL(g) 90
FIRAZYR 137
FLAGYL ER 75
FLAGYL(g) 75
FLECTOR PATCH 87
FLEXERIL(g) 93
FLOMAX(g) 135
FLONASE(g) 129
FLONASE(g) 132
FLORINEF(g) 107
FLOVENT HFA, DISKUS (TIER 1-BCN ONLY) 132
FLOXIN OTIC SINGLES 129
FLOXIN OTIC(g) 129
FLOXIN(g) 71
FLUMADINE(g) 72
FLUOXETINE 60MG 84
FLUVOXAMINE MALEATE(g) 84
FML FORTE, S.O.P. 127
FML(g) 127
FOCALIN XR 86
FOCALIN(g) 86
FOLLISTIM AQ 102
FOLVITE(g) 136
FORADIL 131
FORFIVO XL 84
FORTAMET (g) 111
FORTEO 105
FORTESTA 108
FOSAMAX PLUS D 106
FOSAMAX, WEEKLY(g) 106
FOSRENOL 137
FRAGMIN 82
FROVA 90
FULYZAQ 96
FUZEON 73
FYCOMPA 92
GABITRIL 92
GABITRIL 2, 4MG (g) 92
GALZIN 136
GAMMAKED LIQUID (BCBSM ONLY) 117
GAMUNEX-C SQ (BCBSM ONLY) 117
GANIRELIX ACETATE 102
GARAMYCIN(g) 127
GATTEX 98
GATTEX 112
GELNIQUE, PUMP 134
GENGRAF, NEORAL(g) 114
GENOTROPIN 112
GENTAMICIN CR, OINT(g) 122
GEODON (g) 85
GIAZO 98
GILENYA 118
GLEEVEC 116
GLUCAGON EMERGENCY KIT 109
GLUCOPHAGE, XR(g) 111
GLUCOTROL, XL(g) 111
GLUCOVANCE(g) 111
GLUMETZA 111
GLYCOLAX(g) 98
GLYNASE(g) 111
GLYSET 111
GOLYTELY PACKET 137
GOLYTELY(g) 137
GONAL-F, RFF 102
GRALISE 92
GRANISOL (g) 96
GRANULEX(g) 123
GRIFULVIN V, SUSP(g) 72
GRIS PEG(g) 72
GYNAZOLE-2 103
HALCION(g) 86
HALDOL(g) 85
HALFLYTELY 137
HALOG 119
HC ACETATE/PRAMOXINE HCL 98
HECTOROL 109
HECTOROL 136
HELIDAC 95
HEPARIN(g) 82
HEPSERA 72
HEXALEN 115
HIPREX/UREX(g) 71
HIZENTRA (BCBSM ONLY) 117
HORIZANT 94
HUMALOG, MIX (PEN/CARTRIDGE) 110
HUMALOG, MIX (VIAL) 110
HUMATIN(g) 75
HUMATROPE 112
HUMIRA 105
HUMIRA 123
HUMULIN 70/30 (PEN/CARTRIDGE) 110
HUMULIN 70/30 (VIAL) 110
HUMULIN N (PEN/CARTRIDGE) 110
HUMULIN N (VIAL) 110
HUMULIN R (VIAL) 110
HYCAMTIN 115
HYDREA(g) 115
HYDRODIURIL, MICROZIDE(g) 81
HYGROTON, THALITONE(g) 81
HYTRIN(g) 83
HYTRIN(g) 135
HYZAAR(g) 79
ICLUSIG 116
ILEVRO 126
ILOTYCIN(g) 127
IMDUR(g) 82
IMITREX (ALL FORMS)(g) 90
IMURAN(g) 105
IMURAN(g) 114
INCIVEK 72
INCRELEX 112
INDERAL LA(g) 77
INDERAL(g) 77
Trade Name Page Trade Name PageINDERIDE(g) 77
INDOCIN SUPPOSITORY 87
INDOCIN, SR(g) 87
INFERGEN 118
INFLAMASE, FORTE(g) 127
INLYTA 116
INNOHEP 82
INNOPRAN XL 77
INSPRA(g) 81
INTAL SOLUTION(g) 133
INTELENCE 73
INTERMEZZO 86
INTRON A 118
INTUNIV 94
INVEGA 85
INVIRASE 73
INVOKANA 111
IONAMIN 138
IOPIDINE DROPERETTE 125
IOPIDINE DROPS(g) 125
IPRIVASK 82
IQUIX 127
IRESSA 116
ISENTRESS 73
ISMO, MONOKET(g) 82
ISONIAZID(g) 74
ISOPTO ATROPINE(g) 126
ISOPTO CARBACHOL 125
ISOPTO HOMATROPINE(g) 126
ISOPTO HYOSCINE 126
ISORDIL(g) 82
ISTALOL 125
JAKAFI 115
JALYN 135
JANUMET (TIER 3 - BCN ONLY) 111
JANUMET XR (TIER 3 - BCN ONLY) 111
JANUVIA (TIER 3 - BCN ONLY) 111
JENTADUETO 111
JUVISYNC 76
JUVISYNC 111
JUXTAPID 76
KADIAN 10,70, 130, 150, 200MG 88
KADIAN(g) 88
KALETRA 73
KALYDECO 133
KAOCHLOR-EFF 136
KAPVAY 94
KARBINAL 130
KAYCIEL, KAON-CL, KAON LIQUID(g) 136
KAYEXALATE(g) 137
KAZANO 111
KEFLEX(g) 69
KEPPRA, XR(g) 92
KERLONE(g) 77
KETEK 70
KETOPROFEN(g) 87
KINERET 105
KINERET 114
KLONOPIN, WAFER(g) 92
K-LOR, KLOR-CON(g) 136
K-LYTE, KLOR-CON/EF(g) 136
KOMBIGLYZE XR (TIER 3 - BCN ONLY) 111
KORLYM 109
K-PHOS NEUTRAL(g) 134
K-TAB, K-DUR, SLOW-K, KAON CL(g) 136
KUVAN 137
KYNAMRO 76
KYTRIL(g) 96
LACRISERT 128
LACTULOSE(g) 98
LAMICTAL ODT 92
LAMICTAL TABS, DISPERTABS(g) 92
LAMICTAL XR (g) 92
LAMISIL GRANULES 72
LAMISIL TABLETS(g) 72
LANTUS (PEN/CARTRIDGE) 110
LANTUS (VIAL) 110
LAPASE(g) 97
LARIAM(g) 74
LASIX(g) 81
LASTACAFT 128
LATUDA 85
LAZANDA 88
LESCOL (g) 76
LESCOL XL 76
LETAIRIS 133
LEUCOVORIN(g) 115
LEUKERAN 113
LEUKINE 115
LEUKINE 117
LEVAQUIN(g) 71
LEVATOL 77
LEVBID(g) 96
LEVBID(g) 134
LEVEMIR (PEN) 110
LEVEMIR (VIAL) 110
LEVITRA 138
LEVSIN, SL(g) 96
LEVSIN, SL(g) 134
LEVSINEX(g) 96
LEVSINEX(g) 134
LEXAPRO (g) 84
LEXIVA 73
LEXIVA SUSP 73
LIALDA 98
LIBRAX(g) 96
LIBRIUM(g) 85
LIDEX, E(g) 119
LIDODERM PATCH 120
LIMBITROL, DS(g) 84
LINDANE(g) 123
LINZESS 98
LIPITOR(g) 76
LIPOFEN 76
LIPRAM-UL20 97
LIPTRUZET 76
LITHIUM CITRATE(g) 94
LITHOBID(g) 94
Trade Name Page Trade Name PageLIVALO 76
LO LOESTRIN FE 99
LO/OVRAL(g) 99
LOCOID CR, OINT, SOLN(g) 120
LOCOID LIPOCREAM(g) 120
LOCOID LOTION 120
LODINE, XL(g) 87
LOESTRIN 24 FE 99
LOESTRIN, FE(g) 99
LOFIBRA(g) 76
LOMOTIL(g) 96
LONITEN(g) 83
LOPID(g) 76
LOPRESSOR HCT(g) 77
LOPRESSOR(g) 77
LOPROX CR, LOTIONg) 122
LOPROX GEL, SHAMPOO(g) 122
LORZONE 93
LOSEASONIQUE(g) 99
LOTEMAX 127
LOTENSIN HCT(g) 78
LOTENSIN(g) 78
LOTREL 5/40, 10/40MG(g) 78
LOTREL 5/40, 10/40MG(g) 80
LOTREL(g) 78
LOTREL(g) 80
LOTRIMIN(g) 122
LOTRISONE CR, LOTION(g) 122
LOTRONEX 98
LOVAZA 76
LOVENOX(g) 82
LOXITANE(g) 85
LOZOL(g) 81
LUMIGAN 125
LUNESTA 86
LUPRON DEPOT 103
LUPRON DEPOT 114
LUPRON DEPOT-PED 109
LUPRON(g) 102
LUPRON(g) 114
LURIDE(g) 136
LUVERIS 102
LUVOX CR (g) 84
LUXIQ (g) 120
LYBREL(g) 99
LYRICA 92
LYSODREN 115
LYSTEDA (g) 103
MACROBID(g) 71
MACRODANTIN 25MG (TIER 3 BCBSM ONLY 71
MACRODANTIN(g) 71
MAGNACET 89
MALARONE(g) 74
MANDELAMINE(g) 71
MAPROTILINE HCL(g) 84
MARINOL(g) 96
MARPLAN 84
MATULANE 115
MAVIK(g) 78
MAXAIR AUTOHALER 131
MAXALT, MLT (g) 90
MAXIDEX 127
MAXITROL(g) 128
MAXZIDE, DYAZIDE(g) 81
MEBARAL(g) 92
MECLOMEN(g) 87
MEDROL, DOSEPAK(g) 107
MEGACE ES 114
MEGACE(g) 114
MELLARIL(g) 85
MENEST 101
MENEST 105
MENOPUR 102
MENOSTAR 101
MENTAX 122
MEPHYTON 82
MEPHYTON 136
MEPRON 75
MESNEX TABS 115
MESTINON TIMESPAN, SYRUP 93
MESTINON(g) 93
METADATE CD (g) 86
METAGLIP(g) 111
METAPROTERENOL SOLN(g) 131
METHADONE(g) 88
METHERGINE(g) 103
METHITEST 108
METHOTREXATE TABS(g) 113
METHOTREXATE(g) 105
METHYLIN CHEW 86
METHYLIN SOLN(g) 86
METOZOLV ODT 98
METROCREAM, GEL, LOTION(g) 121
METROGEL TOPICAL 1%, PUMP 121
METROGEL-VAGINAL(g) 103
MEVACOR(g) 76
MEXITIL(g) 81
MIACALCIN INJECTION 106
MIACALCIN INJECTION 109
MIACALCIN NASAL SPRAY(g) 106
MIACALCIN NASAL SPRAY(g) 109
MICARDIS 79
MICARDIS HCT 79
MICRO-K(g) 136
MIDAMOR(g) 81
MIDRIN(g) 90
MIGRANAL (g) 90
MILTOWN, EQUANIL(g) 85
MINIPRESS(g) 83
MINIVELLE 101
MINOCIN, DYNACIN(g) 70
MINOCIN, DYNACIN(g) 121
MIRAPEX ER 91
MIRAPEX(g) 91
MIRCETTE(g) 99
MOBIC(g) 87
MODICON(g) 99
MODURETIC(g) 81
Trade Name Page Trade Name PageMONISTAT-DERM(g) 122
MONODOX(g) 70
MONODOX(g) 121
MONOPRIL HCT(g) 78
MONOPRIL(g) 78
MONUROL 71
MOTRIN(g) 87
MOVIPREP 137
MOXATAG 69
MOXEZA 127
MS CONTIN/ORAMORPH SR(g) 88
MSIR(g) 88
MUCOMYST(g) 133
MULTAQ 81
MUSE 138
MYCELEX TROCHE(g) 72
MYCOBUTIN 74
MYCOSTATIN(g) 122
MYDRIACYL(g) 126
MYFORTIC 114
MYLERAN 113
MYRBETRIQ 134
MYSOLINE(g) 92
MYTELASE 93
NAFTIN 122
NAMENDA XR 94
NAMENDA, SOLN 94
NAPRELAN 87
NAPROSYN(g) 87
NARDIL(g) 84
NASACORT AQ(g) 129
NASACORT AQ(g) 132
NASALIDE(g) 129
NASALIDE(g) 132
NASAREL(g) 129
NASAREL(g) 132
NASCOBAL SPRAY 136
NASONEX 129
NASONEX 132
NATACYN 127
NATAZIA 99
NATROBA (g) 123
NAVANE(g) 85
NEBUPENT AEROSOL 75
NECON 10/11(g) 99
NEO-FRADIN (TIER 3 BCBSM Only) 75
NEOMYCIN(g) 75
NEOSPORIN OPHTH SOLN(g) 127
NEOSPORIN OPTH OINT(g) 127
NEO-SYNEPHRINE(g) 128
NESINA 111
NEULASTA 115
NEULASTA 117
NEUMEGA 117
NEUPOGEN 115
NEUPOGEN 117
NEUPRO 91
NEURONTIN(g) 92
NEVANAC 126
NEXAVAR 116
NEXICLON XR 83
NEXIUM 95
NIASPAN 76
NICOTINE GUM, NICORETTE (g) (BCN ONLY 138
NICOTINE PATCH (g) (BCN ONLY) 138
NICOTROL, NS 138
NIFEREX GOLD 136
NILANDRON 114
NIMOTOP(g) 94
NIRAVAM(g) 85
NITRO-BID OINTMENT(g) 82
NITRO-DUR (TIER 3 BCBSM Only) 82
NITROGLYCERIN PATCH(g) 82
NITROGLYCERIN SA CAP(g) 82
NITROGLYCERIN SPRAY 82
NITROMIST(g) 82
NITROSTAT 82
NIZORAL CR, SHAMPOO 2%(g) 122
NIZORAL(g) 72
NORDETTE, LEVLEN(g) 99
NORDITROPIN (ALL) 112
NORFLEX(g) 93
NORGESIC, FORTE(g) 93
NORINYL 1/35(g), ORTHO-NOVUM 1/35(g) 99
NORINYL 1/50(g), ORTHO-NOVUM 1/50(g) 99
NORITATE 121
NORMODYNE(g) 77
NOROXIN 71
NORPACE CR 81
NORPACE(g) 81
NORPRAMIN(g) 84
NORVASC(g) 80
NORVIR 73
NOVAREL, PREGNYL, PROFASI (g) 102
NOVOLIN (PEN/CARTRIDGE) 110
NOVOLIN (VIAL) 110
NOVOLOG (PEN/CARTRIDGE) 110
NOVOLOG (VIAL) 110
NOVOLOG MIX (PEN/VIAL) 110
NOXAFIL 72
NUCYNTA, ER, SOLN 88
NUEDEXTA 94
NULYTELY(g) 137
NUTROPIN 112
NUTROPIN AQ 112
NUTROPIN AQ NUSPIN 112
NUVARING 100
NUVIGIL 86
NYSTATIN W/TRIAMCINOLONE(g) 122
NYSTATIN(g) 72
NYSTATIN(g) 103
OCUFEN(g) 126
OCUFLOX(g) 127
OCUPRESS(g) 125
OFORTA 113
OGEN, ORTHO-EST(g) 101
OGEN, ORTHO-EST(g) 105
OLEPTRO 84
Trade Name Page Trade Name PageOLUX-E (g) 119
OMECLAMOX-PAK 95
OMEPRAZOLE OTC(g) 95
OMNARIS 129
OMNARIS 132
OMNICEF(g) 69
OMNITROPE 112
ONFI 92
ONGLYZA (TIER 3 - BCN ONLY) 111
ONMEL 72
ONSOLIS 88
OPANA ER 88
OPANA ER 7.5, 15MG(g) 88
OPANA(g) 88
OPTICROM(g) 128
OPTIPRANOLOL(g) 125
OPTIVAR(g) 128
ORACEA 70
ORACEA 121
ORAP 85
ORAPRED ODT 107
ORAPRED(g) 107
ORAVIG 72
ORAXYL 70
ORAXYL 121
ORENCIA SC 105
ORFADIN 137
ORINASE(g) 111
ORTHO EVRA 100
ORTHO MICRONOR(g), NOR-QD(g) 100
ORTHO TRI-CYCLEN LO 100
ORTHO TRI-CYCLEN(g) 100
ORTHO-CYCLEN(g) 99
ORTHO-NOVUM 7/7/7(g) 100
ORTHO-PREFEST 102
OSENI 111
OSMOPREP, VISICOL 137
OSPHENA 103
OSPHENA 138
OVCON 35(g) 99
OVCON-50, FE 99
OVIDE(g) 123
OVIDREL 102
OVRAL(g) 99
OXANDRIN(g) 108
OXECTA 88
OXISTAT 122
OXSORALEN, ULTRA 123
OXTELLAR XR 92
OXYCODONE IMMEDIATE RELEASE(g) 88
OXYCONTIN 88
OXYTROL 134
PAMELOR, AVENTYL(g) 84
PANCREASE MT 10, 16, 20(g) 97
PANCREASE MT 4 97
PANCREAZE 97
PANDEL 120
PANGESTYME UL 12 97
PANRETIN 124
PAPAVERINE CAPS(g) 83
PARAFLEX, PARAFON FORTE DSC(g) 93
PARCOPA(g) 91
PAREGORIC(g) 96
PAREMYD 126
PARLODEL(g) 91
PARNATE(g) 84
PATADAY 128
PATANASE 129
PATANASE 130
PATANOL 128
PAXIL CR(g) 84
PAXIL(g) 84
PCE 70
PEDIAZOLE(g) 70
PEDIAZOLE(g) 71
PEGANONE 92
PEGASYS 118
PEG-INTRON, REDIPEN 118
PENICILLIN VK(g) 69
PENLAC(g) 122
PENNSAID 87
PENTASA 98
PEPCID (RX ONLY)(g) 95
PERANEX HC 98
PERCOCET(g) 89
PERCODAN(g) 89
PERFOROMIST 131
PERIACTIN(g) 130
PERIDEX(g) 137
PERIOSTAT(g) 70
PERIOSTAT(g) 121
PERPHENAZINE(g) 85
PERSANTINE(g) 82
PERTZYE 97
PEXEVA 84
PHENERGAN DM(g) 130
PHENERGAN VC(g) 131
PHENERGAN W/CODEINE(g) 130
PHENERGAN(g) 96
PHENERGAN(g) 130
PHENOBARBITAL(g) 92
PHOSLO(g) 137
PHOSLYRA 137
PHOSPHOLINE IODIDE 125
PHRENILIN FORTE (TIER 3 - BCBSM Only) 89
PHRENILIN FORTE (TIER 3 - BCBSM Only) 90
PHRENILIN(g) 89
PHRENILIN(g) 90
PICATO 124
PILOCAR, ISOPTO-CARPINE(g) 125
PILOPINE HS 125
PINDOLOL(g) 77
PLAN B, ONE-STEP (g) 100
PLAQUENIL(g) 74
PLAQUENIL(g) 105
PLAVIX (g) 82
PLENDIL(g) 80
PLETAL(g) 82
Trade Name Page Trade Name PagePLEXION, TS(g) 121
POLARAMINE(g) 130
POLYCITRA(g) 134
POLY-PRED 128
POLYSPORIN(g) 127
POLYTRIM(g) 127
POLY-VI-FLOR(g) 136
POMALYST 114
PONSTEL (g) 87
POTIGA 92
PRADAXA 82
PRAMOSONE 98
PRANDIMET 111
PRANDIN 111
PRAVACHOL(g) 76
PRECOSE(g) 111
PRED FORTE(g) 127
PRED MILD 127
PRED-G 128
PREDNISOLONE, TABS, SYRUP(g) 107
PREDNISONE(g) 107
PREDNISONE(g) 114
PREMARIN CREAM 101
PREMARIN CREAM 105
PREMARIN, PREMARIN LOW DOSE 101
PREMARIN, PREMARIN LOW DOSE 105
PREMPRO, LOW DOSE/PREMPHASE 102
PREMPRO, LOW DOSE/PREMPHASE 105
PRENATAL VITS(g) 136
PREPOPIK 137
PREVACID SOLUTAB 95
PREVACID(g) 95
PREVIDENT(g) 136
PREVPAC 95
PREZISTA, SUSP 73
PRIFTIN 74
PRILOSEC OTC 95
PRILOSEC SUSPENSION 95
PRILOSEC(g) 95
PRIMAQUINE 74
PRIMSOL (TIER 3 BCBSM ONLY) 71
PRINIVIL, ZESTRIL(g) 78
PRINZIDE, ZESTORETIC(g) 78
PRISTIQ 84
PROAIR HFA, VENTOLIN HFA 131
PROAMATINE(g) 81
PRO-BANTHINE 15MG(g) 96
PRO-BANTHINE 15MG(g) 134
PROBENECID(g) 104
PROCARDIA, XL;ADALAT CC(g) 80
PROCENTRA (g) 86
PROCHIEVE 101
PROCRIT 115
PROCRIT 117
PROCTOCORT SUPPOSITORY(g) 98
PROGESTERONE IN OIL (INJ)(g) 101
PROGRAF(g) 114
PROLENSA 125
PROLENSA 126
PROLIXIN(g) 85
PROMACTA 117
PROMETRIUM (g) 101
PROPYLTHIOURACIL(g) 107
PROSCAR(g) 109
PROSCAR(g) 135
PROSOM(g) 86
PROSTIGMIN 93
PROTONIX SUSPENSION 95
PROTONIX(g) 95
PROTOPIC 124
PROVENTIL HFA 131
PROVENTIL SOLUTION(g) 131
PROVERA(g) 101
PROVIGIL (g) 86
PROZAC WEEKLY(g) 84
PROZAC, SARAFEM CAPSULES(g) 84
PSORCON, FLORONE(g) 119
PSORCON, FLORONE(g) 119
PULMICORT 0.25MG, 0.5MG/2ML(g) 132
PULMICORT 1MG/2ML (TIER 1-BCN ONLY) 132
PULMICORT INH (TIER 1-BCN ONLY) 132
PULMOZYME 133
PURINETHOL(g) 113
PYLERA 95
PYRAZINAMIDE(g) 74
PYRIDIUM(g) 71
PYRIDIUM(g) 134
QNASL 129
QNASL 132
QSYMIA 138
QUALAQUIN (g) 74
QUESTRAN, LIGHT(g) 76
QUILLIVANT XR 86
QUINIDEX(g) 81
QUINIDINE GLUCONATE SA(g) 81
QUIXIN(g) 127
QVAR (TIER 1-BCN ONLY) 132
RADIOGARDASE 137
RANEXA 81
RANICLOR 69
RAPAFLO 135
RAPAMUNE TABS, SOLUTION 114
RAVICTI 109
RAYOS 107
RAYOS 114
RAZADYNE, ER, SOLUTION(g) 94
REBETOL SOLUTION 72
REBETOL(g) 72
REBETOL(g) 118
REBIF, REBIDOSE 118
RECTIV 98
REGLAN TAB, SOLUTION(g) 98
REGRANEX 123
RELAFEN(g) 87
RELENZA 72
RELISTOR 90
RELISTOR 98
RELPAX 90
Trade Name Page Trade Name PageREMERON, SOLTAB(g) 84
RENACIDIN 134
RENAGEL 137
RENVELA PACKET 0.8G 137
RENVELA PACKET 2.4G 137
RENVELA TABLET 137
REPRONEX 102
REQUIP XL (g) 91
REQUIP(g) 91
RESCRIPTOR 73
RESCULA 125
RESERPINE(g) 83
RESTASIS 128
RESTORIL(g) 86
RETIN-A MICRO, PUMP (g) 121
RETIN-A, AVITA(g) 121
RETROVIR(g) 73
REVATIO (g) 133
REVATIO SUSP 133
REVIA(g) 90
REVIA(g) 137
REVLIMID 114
REYATAZ 73
REZIRA 130
RHEUMATREX, TREXALL 105
RHINOCORT AQUA 129
RHINOCORT AQUA 132
RIBAPAK(g) 72
RIBASPHERE (g) 72
RIBATAB(g) 72
RIDAURA 105
RIFADIN(g) 74
RIFAMATE(g) 74
RIFATER 74
RILUTEK(g) 94
RIOMET 111
RISPERDAL M-TAB(g) 85
RISPERDAL(g) (TIER 0-BCN ONLY) 85
RITALIN LA 10MG 86
RITALIN LA(g) 20, 30, 40MG 86
RITALIN, SR; METHYLIN, ER(g) 86
RMS SUPPOSITORY(g) 88
ROBAXIN(g) 93
ROBINUL, FORTE(g) 96
ROCALTROL(g) 109
ROCALTROL(g) 136
ROSULA CLEANSER(g) 121
ROSULA FOAM 121
ROWASA ENEMA(g) 98
ROXANOL(g) 88
ROZEREM 86
RYBIX ODT 89
RYTHMOL, SR(g) 81
RYZOLT(g) 89
SABRIL 92
SAFYRAL 100
SAIZEN 112
SALAGEN(g) 137
SALICYLATES AND NSAIDS 104
SAMSCA 137
SANCTURA XR (g) 134
SANCTURA(g) 134
SANCUSO 96
SANDIMMUNE 114
SANDOSTATIN LAR 109
SANDOSTATIN LAR 115
SANDOSTATIN(g) 109
SANDOSTATIN(g) 115
SANTYL 123
SAPHRIS 85
SARAFEM TABLET 84
SAVELLA 94
SEASONALE(g) 99
SEASONIQUE(g) 99
SECTRAL(g) 77
SELSUN RX(g) 123
SELZENTRY 73
SEMPREX-D 130
SENSIPAR 109
SERAX(g) 85
SEREVENT DISKUS 131
SEROMYCIN 74
SEROQUEL (g) 85
SEROQUEL XR 85
SEROSTIM 112
SERZONE(g) 84
SFROWASA ENEMA(g) 98
SIGNIFOR 109
SILENOR 86
SILVADENE(g) 123
SIMBRINZA 125
SIMCOR 76
SIMPONI 105
SINEMET, CR(g) 91
SINEQUAN, ADAPIN(g) 84
SINGULAIR (g) 133
SIRTURO 74
SITAVIG 72
SKELAXIN(g) 93
SKELID 106
SKLICE 123
SOLARAZE 124
SOLODYN 45, 90, 135MG(g) 70
SOLODYN 45, 90, 135MG(g) 121
SOLODYN 55, 65, 80, 105, 115MG 70
SOLODYN 55, 65, 80, 105, 115MG 121
SOLTAMOX 114
SOMA COMPOUND W/CODEINE(g) 93
SOMA COMPOUND(g) 93
SOMA(g) 93
SOMATULINE DEPOT 109
SOMAVERT 109
SONATA(g) 86
SORIATANE 123
SORILUX 123
SPECTAZOLE(g) 122
SPECTRACEF(g) 69
SPIRIVA 133
Trade Name Page Trade Name PageSPORANOX CAPS(g) 72
SPORANOX SOLN 72
SPRIX 87
SPRYCEL 116
SSKI 107
STADOL NS(g) 89
STADOL NS(g) 90
STALEVO (g) 91
STARLIX(g) 111
STAVZOR 92
STAXYN 138
STELAZINE(g) 85
STENDRA 138
STIMATE 109
STIVARGA 116
STRATTERA 86
STRIANT 108
STRIBILD 73
STROMECTROL - SINGLE DOSE 75
SUBOXONE (g) 89
SUBOXONE FILM 89
SUBSYS 88
SUCLEAR 137
SULAR(g) 80
SULFACET-R(g) 121
SULFADIAZINE(g) 71
SUMAVEL DOSEPRO 90
SUPERVITE 136
SUPRAX, SUSP 69
SUPRENZA ODT 138
SUPREP 137
SURMONTIL(g) 84
SUSTIVA 73
SUTENT 116
SYMBICORT 133
SYMBYAX (g) 85
SYMLIN 111
SYMMETREL(g) 72
SYMMETREL(g) 91
SYNALAR 0.025% CREAM, OINT(g) 120
SYNALAR CREAM, SOLN(g) 120
SYNALGOS-DC 89
SYNAREL 103
SYNAREL 109
SYNTHROID (g) 107
SYPRINE 137
TABLOID 113
TACLONEX, SCALP 123
TAGAMET (RX ONLY)(g) 95
TALACEN(g) 89
TALWIN NX(g) 89
TAMBOCOR(g) 81
TAMIFLU CAP, SUSP 72
TAMOXIFEN CITRATE(g) 114
TAPAZOLE(g) 107
TARCEVA 116
TARGRETIN GEL 124
TARGRETIN ORAL 115
TARKA(g) 78
TARKA(g) 80
TASIGNA 116
TASMAR 91
TAZORAC 121
TECFIDERA 118
TEGRETOL XR 100MG 92
TEGRETOL, XR(g) 92
TEKAMLO 80
TEKAMLO 83
TEKTURNA 83
TEKTURNA HCT 83
TEMODAR 113
TEMOVATE(g), CLOBEVATE(g) 119
TENEX(g) 83
TENORETIC(g) 77
TENORMIN(g) 77
TENUATE(g) 138
TERAZOL- 3, 7(g) 103
TESSALON, PERLES(g) 130
TESTIM 108
TESTRED, ANDROID 108
TETRACYCLINE(g) 70
TEVETEN 400MG 79
TEVETEN HCT 79
TEVETEN(g) 79
TEV-TROPIN 112
THALOMID 114
THEO-24 132
THEOPHYLLINE ANHYDROUS(g) 132
THORAZINE(g) 85
THYROLAR 107
TIAZAC(g) 80
TICLID(g) 82
TIGAN(g) 96
TIKOSYN 81
TIMOPTIC - XE(g) 125
TIMOPTIC PF 125
TIMOPTIC(g) 125
TINDAMAX (g) 75
TIROSINT 107
TOBI 75
TOBI PODHALER 75
TOBRADEX OINT 128
TOBRADEX ST 128
TOBRADEX SUSP(g) 128
TOBREX(g) 127
TOFRANIL(g) 84
TOFRANIL-PM(g) 84
TOLECTIN, DS(g) 87
TOLINASE(g) 111
TOPAMAX, SPRINKLE(g) 92
TOPICORT 120
TOPICORT CR, GEL, OINT(g) 119
TOPICORT LP(g) 120
TOPROL XL(g) 77
TORADOL(g) 87
TOVIAZ (TIER 3 - BCBSM ONLY) 134
TRACLEER 133
TRADJENTA 111
Trade Name Page Trade Name PageTRANDATE(g) 77
TRANSDERM-SCOP 96
TRANXENE SD 85
TRANXENE(g) 85
TRAVATAN (g) 125
TRAVATAN Z 125
TRECATOR 74
TRELSTAR DEPOT, LA 114
TRENTAL(g) 82
TREXIMET 90
TRIBENZOR 79
TRIBENZOR 80
TRICOR (g) 76
TRIGLIDE 76
TRILEPTAL, SUSP(g) 92
TRILIPIX 76
TRILISATE(g) 87
TRIMETHOPRIM(g) 71
TRI-NORINYL(g) 100
TRIPHASIL, TRILEVLEN(g) 100
TRI-VI-FLOR(g) 136
TRIZIVIR 73
TRUSOPT(g) 125
TRUVADA 73
TUDORZA PRESSAIR 133
TUSSICAPS 130
TUSSIONEX(g) 130
TWYNSTA 79
TWYNSTA 80
TYKERB 116
TYLENOL W/CODEINE(g) 89
TYLOX(g) 89
TYVASO 133
TYZEKA 72
UCERIS 107
ULORIC 104
ULTRACET(g) 89
ULTRAM, ER(g) 89
ULTRASE 97
ULTRAVATE(g) 119
ULTRESA 97
UNIPHYL(g) 132
UNIRETIC(g) 78
UNIVASC(g) 78
URECHOLINE(g) 134
URETRON D-S 134
URISPAS(g) 134
UROCIT-K(g) 134
UROXATRAL(g) 135
URSO, URSO FORTE(g) 97
VAGIFEM 101
VALCYTE 72
VALISONE CR, LOTION, OINT(g) 119
VALISONE CR, LOTION, OINT(g) 120
VALIUM(g) 85
VALIUM(g) 93
VALTREX(g) 72
VANCOMYCIN HCL (g) 75
VANOS 0.1% CR 119
VANTIN(g) 69
VASCEPA 76
VASERETIC(g) 78
VASOCIDIN(g) 128
VASODILAN(g) 83
VASOTEC(g) 78
VECAMYL 81
VECTICAL(g) 123
VENLAFAXINE HCL ER(g) 84
VENTAVIS 133
VEPESID(g) 115
VERAMYST 129
VERAMYST 132
VERDESO 120
VEREGEN 124
VERELAN PM(g) 80
VERELAN(g) 80
VESANOID(g) 115
VESICARE 134
VEXOL 127
VFEND SUSP 72
VFEND(g) 72
VIAGRA 138
VIBRAMYCIN, VIBRATABS(g) 70
VIBRAMYCIN, VIBRATABS(g) 121
VICODIN, LORTAB(g) 89
VICOPROFEN(g) 89
VICTOZA 111
VICTRELIS 72
VIDEX 73
VIDEX EC(g) 73
VIGAMOX 127
VIIBRYD 84
VIMOVO 87
VIMOVO 95
VIMPAT 92
VIOKACE 97
VIOKASE 97
VIRACEPT 73
VIRAMUNE (g) 73
VIRAMUNE XR 73
VIREAD 73
VIROPTIC(g) 127
VITUZ 130
VIVACTIL(g) 84
VIVELLE(g) 101
VIVELLE(g) 105
VIVELLE-DOT 101
VIVELLE-DOT 105
VOLTAREN GEL 87
VOLTAREN(g) 126
VOLTAREN, XR(g) 87
VOSPIRE ER(g) 131
VOTRIENT 116
VUSION 122
VYTORIN 76
VYVANSE 86
WELCHOL 76
WELLBUTRIN XL (g) 84
Trade Name Page Trade Name PageWELLBUTRIN, SR(g) 84
WESTCORT(g) 120
XALATAN(g) 125
XALKORI 116
XANAX, XR(g) 85
XARELTO 82
XELJANZ 105
XELODA 113
XENAZINE 137
XENICAL 138
XERESE 122
XIBROM(g) 126
XIFAXAN 200MG 75
XIFAXAN 550MG 98
XIMINO 121
XODOL(g) 89
XOLEGEL 122
XOPENEX (g) 131
XOPENEX HFA 131
XTANDI 114
XYLOCAINE (Rx Only)(g) 120
XYLOCAINE VISCOUS(g) 120
XYREM 94
XYZAL(g) 130
YASMIN 28(g) 99
YAZ(g) 99
YOHIMBINE HCL(g) 138
ZANAFLEX (g) 93
ZANTAC (RX ONLY)(g) 95
ZARONTIN(g) 92
ZAROXOLYN(g) 81
ZAVESCA 109
ZAVESCA 137
ZEBETA(g) 77
ZEBUTAL(g) 89
ZEBUTAL(g) 90
ZECUITY 90
ZEGERID PACKET 95
ZEGERID RX(g) 95
ZELAPAR 91
ZELBORAF 116
ZEMPLAR 109
ZEMPLAR 136
ZENPEP 97
ZERIT(g) 73
ZETIA 76
ZETONNA 129
ZETONNA 132
ZIAC(g) 77
ZIAGEN (g) 73
ZIAGEN SOLN 73
ZIANA GEL 121
ZIOPTAN 125
ZIPSOR 87
ZIRGAN 127
ZITHROMAX(g) 70
ZMAX 70
ZOCOR(g) 76
ZOFRAN, ODT(g) 96
ZOLADEX 114
ZOLINZA 115
ZOLOFT(g) 84
ZOLPIMIST 86
ZOMIG NASAL SPRAY 90
ZOMIG(g), ZMT (g) 90
ZONALON(g) 124
ZONEGRAN(g) 92
ZORBTIVE 112
ZORTRESS 116
ZOVIRAX CREAM 122
ZOVIRAX OINT (g) 123
ZOVIRAX(g) 72
ZUPLENZ 96
ZUTRIPRO 130
ZYBAN(g) 138
ZYCLARA 124
ZYDONE 89
ZYFLO, CR 133
ZYLET 128
ZYLOPRIM(g) 104
ZYMAXID 127
ZYPREXA, ZYDIS(g) 85
ZYRTEC (OTC)(g) 130
ZYRTEC-D (OTC)(g) 130
ZYTIGA 114
ZYVOX 75
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