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$: BCBSM/BCN Custom Drug List - Kalamazoo RESA · BCBSM and BCN Custom 'UXJ /LVW 2013 JXO\ Formulary Table of contents BCBSM and BCN Custom Drug List (Formulary) introduction 5 Blue$
Blue Cross Blue Shield of Michigan and

Blue Care Network

Custom Drug List (Formulary)

JULY 2013

BCBSM and BCN Custom Drug List (Formulary)

July 2013

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

Page 3

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

Page 4

*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

Page 6

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

http://www.bcbsm.com/RxInfo

http://www.bcbsm.com/

Page 7

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 8

Blue Care Network

Prior Approval and Step Therapy Guidelines

July 2013

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).


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.


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.


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.


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)).


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)).


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


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)].


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


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.


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)).


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


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


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.


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.


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.

Page 26

Blue Cross Blue Shield of Michigan Prior Authorization and Step Therapy Program

July 2013

(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


Doryx® (g) (doxycycline)


Doryx® 200mg (doxycycline) Nonpreferred


Oracea® (doxycycline) Nonpreferred


Solodyn® (minocycline) Nonpreferred

Requires documentation that the member had a trial of generic minocycline immediate release capsules (Minocin®).



Solodyn® (g) (minocycline)


Ximino™ (minocycline) Nonpreferred


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.



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


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


Livalo® (pitavastatin) Nonpreferred


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.



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


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


Micardis® /HCT (telmisartan) Nonpreferred


Teveten® HCT (eprosartan/ hydrochlorothiazide) Nonpreferred


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.



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.



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.



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



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





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


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




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


Relpax® (eletriptan) Nonpreferred


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


Zomig® (g) / Zomig® ZMT (g) (zolmitriptan)


Zomig® Nasal Spray (zolmitriptan) Nonpreferred




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.



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



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


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


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.



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).



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.



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.




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.



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



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.



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



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


Oseni® (alogliptin and pioglitazone) Nonpreferred


Tradjenta® (linagliptin) Nonpreferred


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



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.



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)


Femara® (g) (letrozole)


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



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



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.



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


Epogen® (epoetin alfa) Nonpreferred


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



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.



• 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.



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)










• 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



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


Omnaris® (ciclesonide) Nonpreferred


Qnasl® (beclomethasone) Nonpreferred


Rhinocort AQ® (budesonide) Nonpreferred


Veramyst® (fluticasone) Nonpreferred


Zetonna® (ciclesonide) Nonpreferred


RESPIRATORY, COUGH AND COLD

13A - Antihistamines



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


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


Omnaris® (ciclesonide) Nonpreferred


Qnasl® (beclomethasone) Nonpreferred


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


Zetonna® (ciclesonide) Nonpreferred


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



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,



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


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)




Page 61


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)




Page 62


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)




Page 63


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




Page 64


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




Page 65


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




Page 66


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)




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

http://www.bcbsm.com/RxInfo

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


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)


CEFUROXIME AXETILCEFTIN 250MG/5ML


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


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)


NONE


DOXYCYCLINE HYCLATEDORYX [PA]

DOXYCYCLINE MONOHYDRATEORACEA [PA]

DOXYCYCLINE HYCLATEORAXYL

MINOCYCLINE HCLSOLODYN 55, 65, 80, 105, 115MG [PA]

1D. Macrolides


CLARITHROMYCINBIAXIN, XL (g)

ERYTHROMYCINERY-TAB (g)

ERYTHROMYCIN ETHYLSUCCINATEERYTHROMYCIN (g)

ERYTHROMYCIN STEARATEERYTHROMYCIN STEARATE (g)

ERY E-SUCC/SULFISOXAZOLEPEDIAZOLE (g)

AZITHROMYCINZITHROMAX (g)


ERYTHROMYCINERY-TAB 500MG (TIER 3 BCBSM Only)


FIDAXOMICINDIFICID [QL]

TELITHROMYCINKETEK

ERYTHROMYCIN BASEPCE

AZITHROMYCINZMAX



<s> Specialty Drug


1E. Quinolones


CIPROFLOXACIN HCLCIPRO (g)

CIPROFLOXACIN HCL-BETAINE COMBCIPRO XR (g) [PA] [QL]

OFLOXACINFLOXIN (g)

LEVOFLOXACINLEVAQUIN (g)


MOXIFLOXACIN HCLAVELOX, ABC


GEMIFLOXACIN MESYLATEFACTIVE

NORFLOXACINNOROXIN

1F. Sulfonamides and Combinations


SULFAMETHOXAZOLE/TRIMETHOPRIMBACTRIM, DS, SEPTRA, DS (g)

ERY E-SUCC/SULFISOXAZOLEPEDIAZOLE (g)

SULFADIAZINESULFADIAZINE (g)


NONE


NONE

1G. Urinary Tract Agents


METHENAMINE HIPPURATEHIPREX/UREX (g)

NITROFURANTOINMACROBID (g)

NITROFURANTOIN MACROCRYSTALMACRODANTIN (g)

METHENAMINE MANDELATEMANDELAMINE (g)

PHENAZOPYRIDINE HCLPYRIDIUM (g)

TRIMETHOPRIMTRIMETHOPRIM (g)


NITROFURANTOIN MACROCRYSTALMACRODANTIN 25MG (TIER 3 BCBSM ONLY)

TRIMETHOPRIMPRIMSOL (TIER 3 BCBSM ONLY)


FOSFOMYCIN TROMETHAMINEMONUROL



<s> Specialty Drug


1H. Antifungals


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)


POSACONAZOLENOXAFIL

ITRACONAZOLESPORANOX SOLN

VORICONAZOLEVFEND SUSP


TERBINAFINE HCLLAMISIL GRANULES [PA]

ITRACONAZOLEONMEL [ST] [QL]

MICONAZOLEORAVIG [QL]

1I. Antivirals


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)


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>


ACYCLOVIRSITAVIG [PA] [QL]

TELBIVUDINETYZEKA <s>



<s> Specialty Drug


1J. Antiretrovirals


LAMIVUDINE/ZIDOVUDINECOMBIVIR (g)

LAMIVUDINEEPIVIR (g)

ZIDOVUDINERETROVIR (g)

DIDANOSINEVIDEX EC (g)

NEVIRAPINEVIRAMUNE (g)

STAVUDINEZERIT (g)

ABACAVIR SULFATEZIAGEN (g)


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


FOSAMPRENAVIR CALCIUMLEXIVA SUSP

NEVIRAPINEVIRAMUNE XR



<s> Specialty Drug


1K. Antimalarials


CHLOROQUINE PHOSPHATEARALEN (g)

MEFLOQUINE HCLLARIAM (g)

ATOVAQUONE/PROGUANIL HCLMALARONE (g)

HYDROXYCHLOROQUINE SULFATEPLAQUENIL (g)

QUININE SULFATEQUALAQUIN (g)


ARTEMETHER/LUMEFANTRINECOARTEM [QL]

PYRIMETHAMINEDARAPRIM

PRIMAQUINE PHOSPHATEPRIMAQUINE


NONE

1L. Antituberculars


ETHAMBUTOL HCLETHAMBUTOL (g)

ISONIAZIDISONIAZID (g)

PYRAZINAMIDEPYRAZINAMIDE (g)

RIFAMPINRIFADIN (g)

RIFAMPIN/ISONIAZIDRIFAMATE (g)


DAPSONEDAPSONE

RIFABUTINMYCOBUTIN

CYCLOSERINESEROMYCIN

BEDAQUILINE FUMARATESIRTURO [PA] [QL]


RIFAPENTINEPRIFTIN

RIFAMPIN/INH/PYRAZINAMIDERIFATER

ETHIONAMIDETRECATOR



<s> Specialty Drug


1M. Antiparasitics/Anthelmintics


METRONIDAZOLEFLAGYL (g)

PAROMOMYCIN SULFATEHUMATIN (g)

TINIDAZOLETINDAMAX (g) [QL]


NITAZOXANIDEALINIA

PRAZIQUANTELBILTRICIDE

METRONIDAZOLEFLAGYL ER

ATOVAQUONEMEPRON

PENTAMIDINE ISETHIONATENEBUPENT AEROSOL

IVERMECTINSTROMECTROL - SINGLE DOSE [QL]


ALBENDAZOLEALBENZA

1N. Miscellaneous Anti-infectives


CLINDAMYCIN HCLCLEOCIN (g)

NEOMYCIN SULFATENEOMYCIN (g)

VANCOMYCIN HCLVANCOMYCIN HCL (g)


NEOMYCIN SULFATENEO-FRADIN (TIER 3 BCBSM Only)

TOBRAMYCIN/0.25 NORMAL SALINETOBI [QL] <s>

LINEZOLIDZYVOX


TOBRAMYCINBETHKIS [PA] [QL] <s>

AZTREONAM LYSINECAYSTON [PA] [QL] <s>

RIFAXIMINXIFAXAN 200MG [QL]



<s> Specialty Drug


2. CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL

2A. Lipid-lowering Agents


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


MIPOMERSEN SODIUMKYNAMRO [PA] [QL] <s>

NIACINNIASPAN BE

COLESEVELAM HCLWELCHOL

EZETIMIBEZETIA [QL]


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]



<s> Specialty Drug


2B. Beta Blockers and Combinations


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


NONE


NEBIVOLOL HCLBYSTOLIC [ST] [QL]

CARVEDILOL PHOSPHATECOREG CR [PA] [QL]

METOPROLOL SUCCINATE/HCTZDUTOPROL [PA] [QL]

PROPRANOLOL HCLINNOPRAN XL

PENBUTOLOL SULFATELEVATOL



<s> Specialty Drug


2C. ACE-Inhibitors and Combinations


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


NONE



<s> Specialty Drug


2D. Angiotensin II Receptor Blockers and Combinations


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)


OLMESARTAN MEDOXOMILBENICAR [ST] [QL]

OLMESARTAN/HYDROCHLOROTHIAZIDEBENICAR HCT [ST] [QL]


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]



<s> Specialty Drug


2E. Calcium Channel Blockers and Combinations


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)


NONE


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]



<s> Specialty Drug


2F. Diuretics


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


TRIAMTERENEDYRENIUM

ETHACRYNIC ACIDEDECRIN


METOPROLOL SUCCINATE/HCTZDUTOPROL [PA] [QL]

AZILSARTAN MED/CHLORTHALIDONEEDARBYCLOR [PA] [QL]

2G. Cardiovascular Treatment


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)


DRONEDARONE HYDROCHLORIDEMULTAQ [QL]

DISOPYRAMIDE PHOSPHATENORPACE CR

DOFETILIDETIKOSYN


RANOLAZINERANEXA [PA]



<s> Specialty Drug


2H. Nitrates and Combinations


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)


ISOSORBIDE DINITRATEDILATRATE-SR

NITROGLYCERINNITRO-DUR (TIER 3 BCBSM Only)

NITROGLYCERINNITROSTAT


NONENONE

2I. Anticoagulants and Hemostasis Agents


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)


TICAGRELORBRILINTA [QL]

PRASUGREL HYDROCHLORIDEEFFIENT [QL]

APIXABANELIQUIS [QL]

PHYTONADIONEMEPHYTON

DABIGATRAN ETEXILATE MESYLATEPRADAXA [QL]

RIVAROXABANXARELTO [QL]


ASPIRIN/DIPYRIDAMOLEAGGRENOX

DALTEPARIN SODIUM,PORCINEFRAGMIN <s>

TINZAPARIN SODIUM,PORCINEINNOHEP <s>

DESIRUDIN INJECTIONIPRIVASK <s>



<s> Specialty Drug


2J. Alpha-adrenergic Agents


METHYLDOPAALDOMET (g)

METHYLDOPA/HYDROCHLOROTHIAZIDEALDORIL (g)

DOXAZOSIN MESYLATECARDURA (g)

CLONIDINE HCLCATAPRES, TTS (g)

TERAZOSIN HCLHYTRIN (g)

PRAZOSIN HCLMINIPRESS (g)

RESERPINERESERPINE (g)

GUANFACINE HCLTENEX (g)


NONE


CLONIDINE HCLNEXICLON XR [PA] [QL]

2K. Miscellaneous Antihypertensives


HYDRALAZINE HCLAPRESOLINE (g)

MINOXIDILLONITEN (g)

PAPAVERINE HCLPAPAVERINE CAPS (g)

ISOXSUPRINE HCLVASODILAN (g)


NONE


ALISKIREN/AMLODIPINE/HCTZAMTURNIDE [ST] [QL]

ALISKIREN/AMLODIPINETEKAMLO [ST] [QL]

ALISKIREN HEMIFUMARATETEKTURNA [PA]

ALISKIREN/HYDROCHLOROTHIAZIDETEKTURNA HCT [PA]



<s> Specialty Drug


3. CENTRAL NERVOUS SYSTEM

3A. Antidepressants


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


NONE


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]



<s> Specialty Drug


3B. Antipsychotics


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)


ARIPIPRAZOLEABILIFY DISCMELT (Tier 3 - BCBSM Only) [ST]

ARIPIPRAZOLEABILIFY, SOLUTION [ST]

PIMOZIDEORAP


ILOPERIDONEFANAPT [ST]

CLOZAPINEFAZACLO [ST]

PALIPERIDONEINVEGA [PA] [QL]

LURASIDONE HCLLATUDA [ST]

ASENAPINESAPHRIS [PA] [QL]

QUETIAPINE FUMARATESEROQUEL XR [PA] [QL]

3C. Anxiolytics


LORAZEPAMATIVAN (g)

BUSPIRONE HCLBUSPAR (g)

CHLORDIAZEPOXIDE HCLLIBRIUM (g)

MEPROBAMATEMILTOWN, EQUANIL (g)

ALPRAZOLAMNIRAVAM (g)

OXAZEPAMSERAX (g)

CLORAZEPATE DIPOTASSIUMTRANXENE (g)

DIAZEPAMVALIUM (g)

ALPRAZOLAMXANAX, XR (g)


NONE


CLORAZEPATE DIPOTASSIUMTRANXENE SD



<s> Specialty Drug


3D. Sedative/Hypnotics


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]


NONE


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


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]


NONE


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]



<s> Specialty Drug


3F. Nonsteroidal Anti-inflammatory Drugs


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)


INDOMETHACININDOCIN SUPPOSITORY


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


SALSALATEDISALCID, SALFLEX (g)

DIFLUNISALDOLOBID (g)

CHOLINE MAGNESIUM TRISALICYLATETRILISATE (g)


NONE


NONE



<s> Specialty Drug


3H. Narcotics


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)


NONE


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]



<s> Specialty Drug


3I. Narcotic/Analgesic Combinations


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)


BUTALBITAL/ACETAMINOPHENPHRENILIN FORTE (TIER 3 - BCBSM Only)

DIHYDROCODEINE/ASPIRIN/CAFFEINSYNALGOS-DC


OXYCODONE HCL/ACETAMINOPHENMAGNACET [QL]

HYDROCODONE BIT/ACETAMINOPHENZYDONE [QL]

3J. Narcotic Mixed Agonist/Antagonist


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)


BUPRENORPHINE HCL/NALOXONE HCLSUBOXONE FILM


BUPRENORPHINEBUTRANS [PA] [QL]

TRAMADOL HCLCONZIP [QL]

TRAMADOL HCLRYBIX ODT [PA] [QL]



<s> Specialty Drug


3K. Narcotic Antagonists


NALTREXONE HCLREVIA (g)


METHYLNALTREXONERELISTOR [PA] [QL]


NONE

3M. Migraine Therapy


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]


ERGOTAMINE TARTRATE/CAFFEINECAFERGOT [QL]

ERGOTAMINE TARTRATEERGOMAR [QL]

BUTALBITAL/ACETAMINOPHENPHRENILIN FORTE (TIER 3 - BCBSM Only)


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]



<s> Specialty Drug


3O. Parkinsons Disease and Related Disorders


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)


APOMORPHINE HCLAPOKYN <s>

RASAGILINE MESYLATEAZILECT


PRAMIPEXOLE DI-HCLMIRAPEX ER [PA] [QL]

ROTIGOTINENEUPRO [PA] [QL]

TOLCAPONETASMAR

SELEGILINE HCLZELAPAR [QL]



<s> Specialty Drug


3P. Anticonvulsants


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)


RUFINAMIDEBANZEL

METHSUXIMIDECELONTIN

DIAZEPAMDIASTAT

PHENYTOINDILANTIN 30MG

TIAGABINE HCLGABITRIL

ETHOTOINPEGANONE

VIGABATRINSABRIL <s>

CARBAMAZEPINETEGRETOL XR 100MG

LACOSAMIDEVIMPAT


CARBAMAZEPINEEQUETRO

PERAMPANELFYCOMPA [PA] [QL]

GABAPENTINGRALISE [PA] [QL]

LAMOTRIGINELAMICTAL ODT [QL]

PREGABALINLYRICA [PA] [QL]

CLOBAZAMONFI [PA] [QL]

OXCARBAZEPINEOXTELLAR XR [ST] [QL]

EZOGABINEPOTIGA

VALPROIC ACIDSTAVZOR



<s> Specialty Drug


3Q. Skeletal Muscle Relaxants


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]


NONE


CYCLOBENZAPRINE HCLAMRIX [PA] [QL]

3R. Myesthenia Gravis


PYRIDOSTIGMINE BROMIDEMESTINON (g)


PYRIDOSTIGMINE BROMIDEMESTINON TIMESPAN, SYRUP

NEOSTIGMINE BROMIDEPROSTIGMIN


AMBENONIUM CHLORIDEMYTELASE



<s> Specialty Drug


3S. Miscellaneous CNS


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)


RIVASTIGMINE TARTRATEEXELON PATCH, SOLN [QL]

MEMANTINE HCLNAMENDA, SOLN

DEXTROMETHORPHAN HBR/QUINIDINENUEDEXTA [PA] [QL]


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]



<s> Specialty Drug


4. GASTROINTESTINAL AGENTS

4A. H2-Receptor Antagonists


NIZATIDINEAXID (RX ONLY) (g)

FAMOTIDINEPEPCID (RX ONLY) (g)

CIMETIDINETAGAMET (RX ONLY) (g)

RANITIDINE HCLZANTAC (RX ONLY) (g)


NONE

4B. Proton Pump Inhibitors


OMEPRAZOLEOMEPRAZOLE OTC (g)

LANSOPRAZOLEPREVACID (g) [ST]

OMEPRAZOLEPRILOSEC (g)

OMEPRAZOLE MAGNESIUMPRILOSEC OTC

PANTOPRAZOLE SODIUMPROTONIX (g)

OMEPRAZOLE/SODIUM BICARBONATEZEGERID RX (g) [PA]


LANSOPRAZOLEPREVACID SOLUTAB [PA]


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


SUCRALFATECARAFATE, SUSP (g)

MISOPROSTOLCYTOTEC (g)


TETRACYC HCL/BIS SS/METRONIDHELIDAC

LANSOPRAZOLE/AMOX TR/CLARITHPREVPAC


OMEPRAZOLE/AMOX TR/CLARITHOMECLAMOX-PAK

BISMUTH/METRONID/TETRACYCLINEPYLERA



<s> Specialty Drug


4D. Antidiarrheals and Antispasmodics


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)


CROFELEMERFULYZAQ [PA] [QL] <s>


MEPENZOLATE BROMIDECANTIL

BELLADONNA ALKALOIDS/PHENOBARBDONNATAL EXTENTABS

4E. Antiemetics


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)


APREPITANTEMEND 80,125MG CAPSULES [QL]

SCOPOLAMINE HYDROBROMIDETRANSDERM-SCOP


DOLASETRON MESYLATEANZEMET [QL]

NABILONECESAMET

GRANISETRONSANCUSO [ST] [QL]

ONDANSETRONZUPLENZ [ST] [QL]



<s> Specialty Drug


4F. Bile Acids


URSODIOLACTIGALL (g)

URSODIOLURSO, URSO FORTE (g)


NONE


CHENODIOLCHENODAL [PA]

4G. Digestive Enzymes


AMYLASE/LIPASE/PROTEASEDYGASE (g)

AMYLASE/LIPASE/PROTEASELAPASE (g)

LIPASE/PROTEASE/AMYLASEPANCREASE MT 10, 16, 20 (g)


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


AMYLASE/LIPASE/PROTEASEPERTZYE



<s> Specialty Drug


4H. Miscellaneous Gastrointestinal Agents


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)


MESALAMINEASACOL

MESALAMINEASACOL HD

MESALAMINECANASA

HYDROCORTISONE ACETATECORTIFOAM

MESALAMINEDELZICOL

TEDUGLUTIDEGATTEX [PA] [QL] <s>

MESALAMINEPENTASA

METHYLNALTREXONERELISTOR [PA] [QL]


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]



<s> Specialty Drug


5. OBSTETRICS AND GYNECOLOGY

5A. Contraceptives-Monophasic


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)


NONE


NORETH A-ET ESTRA/FE FUMARATELOESTRIN 24 FE

ESTRADIOL VALERATE/DIENOGESTNATAZIA

NORETHINDRONE-ETHINYL ESTRADOVCON-50, FE

5B. Contraceptives-Biphasic


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]


NONE


NORETH A-ET ESTRA/FE FUMARATELO LOESTRIN FE



<s> Specialty Drug


5C. Contraceptives-Triphasic


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)


NORGESTIMATE-ETHINYL ESTRADIOLORTHO TRI-CYCLEN LO


NONE

5D. Contraceptives-Misc.


NORETHINDRONEORTHO MICRONOR (g), NOR-QD (g)


ETHINYL ESTRADIOL/NORELGESTORTHO EVRA [QL]


DROSPIR/ETH ESTRA/LEVOMEFOL CABEYAZ

ETONOGESTREL/ETHINYL ESTRADIOLNUVARING [QL]

DROSPIR/ETH ESTRA/LEVOMEFOL CASAFYRAL

5E. Contraceptives-Postcoital


LEVONORGESTRELPLAN B, ONE-STEP (g)


NONE


ULIPRISTAL ACETATEELLA [QL]



<s> Specialty Drug


5F. Progestins


NORETHINDRONE ACETATEAYGESTIN (g)

MEDROXYPROGESTERONE ACETDEPO-PROVERA 150MG (g)

PROGESTERONEPROGESTERONE IN OIL (INJ) (g)

PROGESTERONE,MICRONIZEDPROMETRIUM (g)

MEDROXYPROGESTERONE ACETPROVERA (g)


PROGESTERONE,MICRONIZEDCRINONE [PA]

MEDROXYPROGESTERONE ACETDEPO-SUBQ PROVERA 104

PROGESTERONE, MICRONIZEDENDOMETRIN [PA]

PROGESTERONE,MICRONIZEDPROCHIEVE


NONE

5G. Estrogens


ESTRADIOLCLIMARA (g) [QL]

ESTRADIOLESTRACE (g)

ESTROPIPATEOGEN, ORTHO-EST (g)

ESTRADIOLVIVELLE (g) [QL]


ESTRADIOLALORA [QL]

ESTROGENS,CONJ.,SYNTHETIC BENJUVIA [QL]

ESTRADIOLESTRADERM [QL]

ESTRADIOLESTRING [QL]

ESTROGENS,CONJUGATEDPREMARIN CREAM

ESTROGENS,CONJUGATEDPREMARIN, PREMARIN LOW DOSE

ESTRADIOLVAGIFEM [QL]

ESTRADIOLVIVELLE-DOT [QL]


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]



<s> Specialty Drug


5H. Estrogen/Progestin Combinations


ESTRADIOL/NORETH ACACTIVELLA (g)

ESTROGEN,ESTER/ME-TESTOSTERONEESTRATEST, H.S. (g)

ETHINYL ESTRADIOL/NORETH ACFEMHRT (g)


ETHINYL ESTRADIOL/NORETH ACFEMHRT 0.5MG-2.5MCG

ESTROGEN,CON/M-PROGEST ACETPREMPRO, LOW DOSE/PREMPHASE


ESTRADIOL/DROSPIRENONEANGELIQ [QL]

ESTRADIOL/LEVONORGESTRELCLIMARA PRO [QL]

ESTRADIOL/NORETH ACCOMBIPATCH [QL]

ESTRADIOL/NORGESTIMATEORTHO-PREFEST

5J. Infertility Treatment


CLOMIPHENE CITRATECLOMID (g)

LEUPROLIDE ACETATELUPRON (g) <s>

CHORIONIC GONADOTROPIN, HUMANNOVAREL, PREGNYL, PROFASI (g) [PA] <s>


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>


FOLLITROPIN BETA,RECOMBFOLLISTIM AQ [PA] <s>

LUTROPIN ALPHALUVERIS [PA] <s>

MENOTROPINSMENOPUR [PA] <s>



<s> Specialty Drug


5K. Vaginal Anti-infective/Antifungal


CLINDAMYCIN PHOSPHATECLEOCIN VAG CREAM (g)

FLUCONAZOLEDIFLUCAN (g)

METRONIDAZOLEMETROGEL-VAGINAL (g)

NYSTATINNYSTATIN (g)

TERCONAZOLETERAZOL- 3, 7 (g)


NONE


SULFANILAMIDEAVC

CLINDAMYCIN PHOSPHATECLEOCIN VAGINAL OVULES

CLINDAMYCIN PHOSPHATECLINDESSE

BUTOCONAZOLE NITRATEGYNAZOLE-2

5L. Miscellaneous OB-GYN


TRANEXAMIC ACIDLYSTEDA (g) [QL]

METHYLERGONOVINE MALEATEMETHERGINE (g)


LEUPROLIDE ACETATELUPRON DEPOT <s>

NAFARELIN ACETATESYNAREL


OSPEMIFENEOSPHENA



<s> Specialty Drug


6. RHEUMATOLOGY AND MUSCULOSKELETAL

6A. Salicylates


SEE CHAPTERS 3F & 3GSALICYLATES AND NSAIDS


NONE


NONE

6B. Gout Therapy


COLCHICINE/PROBENECIDCOLBENEMID (g)

PROBENECIDPROBENECID (g)

ALLOPURINOLZYLOPRIM (g)


COLCHICINECOLCRYS

FEBUXOSTATULORIC [ST] [QL]


NONE

6C. Corticosteroids


SEE CHAPTER 7CCORTICOSTEROIDS


NONE


NONE



<s> Specialty Drug


6D. Miscellaneous Rheumatologic Agents


LEFLUNOMIDEARAVA (g) [QL]

SULFASALAZINEAZULFIDINE, EN-TAB (g)

AZATHIOPRINEIMURAN (g)

METHOTREXATE SODIUMMETHOTREXATE (g)

HYDROXYCHLOROQUINE SULFATEPLAQUENIL (g)


PENICILLAMINECUPRIMINE [QL]

ETANERCEPTENBREL [PA] [QL] <s>

ADALIMUMABHUMIRA [PA] [QL] <s>

METHOTREXATE SODIUMRHEUMATREX, TREXALL

AURANOFINRIDAURA


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


ESTRADIOLCLIMARA (g) [QL]

ESTRADIOLESTRACE (g)

ESTROGEN,ESTER/ME-TESTOSTERONEESTRATEST, H.S. (g)

ETHINYL ESTRADIOL/NORETH ACFEMHRT (g)

ESTROPIPATEOGEN, ORTHO-EST (g)

ESTRADIOLVIVELLE (g) [QL]


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]


ESTROGENS,CONJ.,SYNTHETIC ACENESTIN

TERIPARATIDEFORTEO [PA] [QL] <s>

ESTROGENS,ESTERIFIEDMENEST



<s> Specialty Drug


6F. Osteoporosis/Bone Resorption


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)


RISEDRONATE SODIUMACTONEL, WEEKLY, 150MG [ST] [QL]

RALOXIFENE HCLEVISTA

CALCITONIN,SALMON,SYNTHETICMIACALCIN INJECTION

TILUDRONATE DISODIUMSKELID [QL]


RISEDRONATE SODIUMATELVIA [PA] [QL]

ALENDRONATEBINOSTO [ST] [QL]

ALENDRONATE SODIUM/VITAMIN D3FOSAMAX PLUS D [ST] [QL]



<s> Specialty Drug


7. ENDOCRINOLOGY

7A. Antithyroid Agents


PROPYLTHIOURACILPROPYLTHIOURACIL (g)

METHIMAZOLETAPAZOLE (g)


NONE


POTASSIUM IODIDESSKI

7B. Thyroid Hormones


LIOTHYRONINE SODIUMCYTOMEL (g)

LEVOTHYROXINE SODIUMSYNTHROID (g)


LIOTRIXTHYROLAR


THYROIDARMOUR THYROID

LEVOTHYROXINE SODIUMTIROSINT

7C. Corticosteroids


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)


NONE


PREDNISOLONE SOD PHOSPHATEORAPRED ODT

PREDNISONERAYOS [PA] [QL]

BUDESONIDEUCERIS [PA] [QL]



<s> Specialty Drug


7D. Androgens


FLUOXYMESTERONEANDROXY 10MG (g)

DANAZOLDANOCRINE (g)

TESTOSTERONE ENANTHATEDELATESTRYL (g)

TESTOSTERONE CYPIONATEDEPO-TESTOSTERONE (g)

OXANDROLONEOXANDRIN (g) [PA]


TESTOSTERONEANDRODERM [QL]

TESTOSTERONEANDROGEL, 1.62% [QL]


OXYMETHOLONEANADROL-50 [QL]

TESTOSTERONEAXIRON [PA] [QL]

TESTOSTERONEBIO-T-GEL [PA] [QL]

TESTOSTERONEFORTESTA [PA] [QL]

METHYLTESTOSTERONEMETHITEST

TESTOSTERONESTRIANT [PA] [QL]

TESTOSTERONETESTIM [PA] [QL]

METHYLTESTOSTERONETESTRED, ANDROID [PA]



<s> Specialty Drug


7E. Miscellaneous Endocrine


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>


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


TESAMORELIN ACETATEEGRIFTA [PA] [QL] <s>

DOXERCALCIFEROLHECTOROL

GLYCEROL PHENYLBUTYRATERAVICTI [PA] [QL] <s>

MIGLUSTATZAVESCA

PARICALCITOLZEMPLAR



<s> Specialty Drug


7F. Insulins


NONE


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)


NONE



<s> Specialty Drug


7G. Non-insulin Hypoglycemic Agents


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)


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


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]



<s> Specialty Drug


7H. Growth Hormone and Related Products


NONE


TEDUGLUTIDEGATTEX [PA] [QL] <s>

SOMATROPINGENOTROPIN [PA] <s>

SOMATROPINNUTROPIN [PA] <s>

SOMATROPINNUTROPIN AQ [PA] <s>

SOMATROPINNUTROPIN AQ NUSPIN [PA] <s>


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>



<s> Specialty Drug


8. ANTINEOPLASTICS AND IMMUNOSUPPRESANTS

8A. Alkylating Agents


CYCLOPHOSPHAMIDECYTOXAN (g)


MELPHALANALKERAN

LOMUSTINECEENU

CHLORAMBUCILLEUKERAN

BUSULFANMYLERAN

TEMOZOLOMIDETEMODAR <s>


NONE

8B. Antimetabolites


METHOTREXATE SODIUMMETHOTREXATE TABS (g)

MERCAPTOPURINEPURINETHOL (g)


FLUDARABINE PHOSPHATEOFORTA [QL] <s>

THIOGUANINETABLOID

CAPECITABINEXELODA <s>


NONE



<s> Specialty Drug


8C. Immunomodulators


MYCOPHENOLATE MOFETILCELLCEPT (g) <s>

CYCLOSPORINE, MODIFIEDGENGRAF, NEORAL (g) <s>

AZATHIOPRINEIMURAN (g)

PREDNISONEPREDNISONE (g)

TACROLIMUS ANHYDROUSPROGRAF (g) <s>


RILONACEPTARCALYST [PA] <s>

MYCOPHENOLATE MOFETILCELLCEPT SUSPENSION <s>

SIROLIMUSRAPAMUNE TABS, SOLUTION <s>

CYCLOSPORINESANDIMMUNE <s>

THALIDOMIDETHALOMID <s>


AZATHIOPRINEAZASAN

ANAKINRAKINERET [PA] [QL] <s>

MYCOPHENOLATE SODIUMMYFORTIC <s>

PREDNISONERAYOS [PA] [QL]

LENALIDOMIDEREVLIMID [PA] [QL] <s>

8D. Hormonal Agents


ANASTROZOLEARIMIDEX (g) [PA]

EXEMESTANEAROMASIN (g) [PA]

BICALUTAMIDECASODEX (g)

FLUTAMIDEEULEXIN (g)

LETROZOLEFEMARA (g) [PA]

LEUPROLIDE ACETATELUPRON (g) <s>

MEGESTROL ACETATEMEGACE (g)

TAMOXIFEN CITRATETAMOXIFEN CITRATE (g)


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>


LEUPROLIDE ACETATEELIGARD <s>

FULVESTRANTFASLODEX

MEGESTROL ACETATEMEGACE ES

TAMOXIFEN CITRATESOLTAMOX [PA] [QL]



<s> Specialty Drug


8E. Miscellaneous Antineoplastic Agents


HYDROXYUREAHYDREA (g)

OCTREOTIDE ACETATESANDOSTATIN (g) [PA] <s>

ETOPOSIDEVEPESID (g)

TRETINOINVESANOID (g)


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>


PEGINTERFERON ALFA-2BSYLATRON [PA] <s>

BEXAROTENETARGRETIN ORAL [PA] <s>

8F. Adjuvant Therapy


LEUCOVORIN CALCIUMLEUCOVORIN (g)


SARGRAMOSTIMLEUKINE <s>

MESNAMESNEX TABS

FILGRASTIMNEUPOGEN <s>

EPOETIN ALFAPROCRIT [PA] <s>


DARBEPOETIN ALFA IN ALBUMN SOLARANESP [PA] <s>

EPOETIN ALFAEPOGEN [PA] <s>

PEGFILGRASTIMNEULASTA [QL] <s>



<s> Specialty Drug


8G. Kinase Inhibitors and Molecular Target Inhibitors


NONE


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>


EVEROLIMUSZORTRESS [QL] <s>



<s> Specialty Drug


9. IMMUNOLOGY AND HEMATOLOGY

9A. Immunoglobulins


NONE


NONE


IMMUNE GLOBULINGAMUNEX-C SQ (BCBSM ONLY) [PA] <s>

IMMUNE GLOBULINHIZENTRA (BCBSM ONLY) [PA] <s>

9B. Hematopoietic Agents


NONE


SARGRAMOSTIMLEUKINE <s>

OPRELVEKINNEUMEGA <s>

FILGRASTIMNEUPOGEN <s>

EPOETIN ALFAPROCRIT [PA] <s>

ELTROMBOPAG OLAMINEPROMACTA [PA] [QL] <s>


DARBEPOETIN ALFA IN ALBUMN SOLARANESP [PA] <s>

EPOETIN ALFAEPOGEN [PA] <s>

PEGFILGRASTIMNEULASTA [QL] <s>



<s> Specialty Drug


9C. Interferons and MS Therapy


RIBAVIRINREBETOL (g) [PA] <s>


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>


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>



<s> Specialty Drug


10. DERMATOLOGY

10A. Very High Potency Corticosteriods


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)


NONE


CLOBETASOL PROPIONATECLOBEX SPRAY

FLUOCINONIDEVANOS 0.1% CR

10B. High Potency Corticosteroids


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)


NONE


DIFLORASONE DIACETATE/EMOLLAPEXICON E

HALCINONIDEHALOG



<s> Specialty Drug


10C. Medium Potency Corticosteroids


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)


CLOCORTOLONE PIVALATECLODERM

FLURANDRENOLIDECORDRAN, TAPE, SP


HYDROCORTISONE BUTYRATELOCOID LOTION

HYDROCORTISONE PROBUTATEPANDEL

DESOXIMETASONETOPICORT

10D. Low Potency Corticosteroids


ALCLOMETASONE DIPROPIONATEACLOVATE (g)

HYDROCORTISONEDERMACORT, HYTONE (Rx Only) (g)

FLUOCINOLONE ACETONIDEDERMA-SMOOTHE/FS (g)

DESONIDEDESOWEN, TRIDESILON (g)

FLUOCINOLONE ACETONIDESYNALAR CREAM, SOLN (g)


FLUOCINOLONE ACETONIDECAPEX SHAMPOO


DESONIDEDESONATE [ST]

DESONIDEVERDESO [ST]

10E. Topical Anesthetics


LIDOCAINE/PRILOCAINEEMLA (g)

LIDOCAINE HCLXYLOCAINE (Rx Only) (g)

LIDOCAINE HCLXYLOCAINE VISCOUS (g)


NONE


LIDOCAINELIDODERM PATCH



<s> Specialty Drug


10F. Acne Treatment


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)


ADAPALENEDIFFERIN 0.3% GEL, PUMP

METRONIDAZOLEMETROGEL TOPICAL 1%, PUMP

TAZAROTENETAZORAC


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]



<s> Specialty Drug


10G. Topical Antibacterials


MUPIROCIN CALCIUMBACTROBAN (g)

GENTAMICIN SULFATEGENTAMICIN CR, OINT (g)


MUPIROCIN CALCIUMBACTROBAN NASAL


RETAPAMULINALTABAX

10H. Topical Antifungals


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)


BUTENAFINE HCLMENTAX


SERTACONAZOLE NITRATEERTACZO

SULCONAZOLE NITRATEEXELDERM SOLN, CR

NAFTIFINE HCLNAFTIN

OXICONAZOLE NITRATEOXISTAT

MICONAZOLE NITRATE/ZINC OXIDEVUSION

KETOCONAZOLEXOLEGEL

10I. Scabicides/Pediculicides


ACYCLOVIRZOVIRAX OINT (g)


ACYCLOVIRZOVIRAX CREAM


PENCICLOVIRDENAVIR

ACYCLOVIR/HYDROCORTISONEXERESE



<s> Specialty Drug


10J. Wound and Burn Therapy


PAPAIN/UREAACCUZYME, ETHEZYME, GLADASE (g)

TRYPSIN/BALSAM PERU/CASTOR OILGRANULEX (g)

SILVER SULFADIAZINESILVADENE (g)


COLLAGENASESANTYL


BECAPLERMINREGRANEX [PA]

10K. Antipsoriatic/Antiseborrheic


CALCIPOTRIENEDOVONEX (g)

ANTHRALINDRITHOCREME HP (g)

SELENIUM SULFIDESELSUN RX (g)

CALCITRIOLVECTICAL (g)


ANTHRALINDRITHO-SCALP

ETANERCEPTENBREL [PA] [QL] <s>

ADALIMUMABHUMIRA [PA] [QL] <s>

METHOXSALEN, RAPIDOXSORALEN, ULTRA

ACITRETINSORIATANE [QL]


CALCIPOTRIENESORILUX

BETAMET DIPROP/CALCIPOTRIENETACLONEX, SCALP [PA]

10L. Scabicides/Pediculicides


PERMETHRINELIMITE (g)

LINDANELINDANE (g)

SPINOSADNATROBA (g)

MALATHIONOVIDE (g)


CROTAMITONEURAX

CROTAMITONEURAX Lotion (TIER 3 BCBSM only)


IVERMECTINSKLICE [QL]



<s> Specialty Drug


10M. Miscellaneous Dermatologicals


IMIQUIMODALDARA (g) [QL]

PODOFILOXCONDYLOX SOLN (g)

ALUMINUM CHLORIDEDRYSOL (g)

FLUOROURACILEFUDEX (g)

DOXEPIN HCLZONALON (g)


PODOFILOXCONDYLOX GEL

PIMECROLIMUSELIDEL

ALITRETINOINPANRETIN


FLUOROURACILCARAC

HYDROCORTISONE ACETATE/UREACARMOL HC

FLUOROURACIL/ADHESIVE BANDAGEEFUDEX OCCLUSION

INGENOL MEBUTATEPICATO [PA] [QL]

TACROLIMUSPROTOPIC [ST]

DICLOFENAC SODIUMSOLARAZE [PA]

BEXAROTENETARGRETIN GEL <s>

SINECATECHINSVEREGEN

IMIQUIMODZYCLARA [QL]



<s> Specialty Drug


11. OPHTHALMOLOGY

11A. Ophthalmic Beta Blockers


LEVOBUNOLOL HCLBETAGAN (g)

BETAXOLOL HCLBETOPTIC SOLN (g)

CARTEOLOL HCLOCUPRESS (g)

METIPRANOLOLOPTIPRANOLOL (g)

TIMOLOL MALEATETIMOPTIC - XE (g)

TIMOLOL MALEATETIMOPTIC (g)


BETAXOLOL HCLBETOPTIC S


TIMOLOLBETIMOL

TIMOLOL MALEATEISTALOL

TIMOLOL MALEATETIMOPTIC PF

11B. Other Glaucoma Agents


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)


BRIMONIDINE TARTRATEALPHAGAN P 0.1%

BRINZOLAMIDEAZOPT

CARBACHOLISOPTO CARBACHOL

BIMATOPROSTLUMIGAN

ECHOTHIOPHATE IODIDEPHOSPHOLINE IODIDE

PILOCARPINE HCLPILOPINE HS

TRAVOPROSTTRAVATAN Z


BRIMONIDINE TARTRATE/TIMOLOLCOMBIGAN

DORZOLAMIDE/TIMOLOL/PFCOSOPT PF

APRACLONIDINE HCLIOPIDINE DROPERETTE

UNOPROSTONE ISOPROPYLRESCULA [ST]

BRINZOLAMIDE/BRIMONID TARTSIMBRINZA

TAFLUPROST/PFZIOPTAN [QL]



<s> Specialty Drug


11C. Cycloplegic Mydriatics


CYCLOPENTOLATE HCLCYCLOGYL (g)

ATROPINE SULFATEISOPTO ATROPINE (g)

HOMATROPINE HBRISOPTO HOMATROPINE (g)

TROPICAMIDEMYDRIACYL (g)


SCOPOLAMINE HYDROBROMIDEISOPTO HYOSCINE


HYDROXYAMPHETAMINE/TROPICAMIDEPAREMYD

11D. Ophthalmic Anti-inflammatory Agents


KETOROLAC TROMETHAMINEACULAR, LS (g)

FLURBIPROFEN SODIUMOCUFEN (g)

DICLOFENAC SODIUMVOLTAREN (g)

BROMFENAC SODIUMXIBROM (g)


NONE


KETOROLAC TROMETHAMINEACUVAIL

BROMFENAC SODIUMBROMDAY

NEPAFENACILEVRO

NEPAFENACNEVANAC

BROMFENAC SODIUMPROLENSA



<s> Specialty Drug


11E. Ophthalmic Anti-infectives


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)


CIPROFLOXACIN HCLCILOXAN OINT

MOXIFLOXACIN HCLMOXEZA

NATAMYCINNATACYN

MOXIFLOXACIN HCLVIGAMOX

GANCICLOVIRZIRGAN


AZITHROMYCINAZASITE

BESIFLOXACIN HYDROCHLORIDEBESIVANCE

LEVOFLOXACINIQUIX

GATIFLOXACINZYMAXID

11F. Ophthalmic Steroids


DEXAMETHASONE SOD PHOSPHATEDECADRON OPTH (g)

FLUOROMETHOLONEFML (g)

PREDNISOLONE SOD PHOSPHATEINFLAMASE, FORTE (g)

PREDNISOLONE ACETATEPRED FORTE (g)


FLUOROMETHOLONEFML FORTE, S.O.P.

PREDNISOLONE ACETATEPRED MILD

RIMEXOLONEVEXOL


LOTEPREDNOL ETABONATEALREX

DIFLUPREDNATEDUREZOL

LOTEPREDNOL ETABONATELOTEMAX

DEXAMETHASONEMAXIDEX



<s> Specialty Drug


11G. Ophthalmic Anti-infective/Steroid Combinations


NEOMY SULF/POLYMYX B SULF/HCCORTISPORIN (g)

NEO/POLYMYX B SULF/DEXAMETHMAXITROL (g)

TOBRAMYCIN SULFATE/DEXAMETHTOBRADEX SUSP (g)

NA SULFACETM/PREDNIS SPVASOCIDIN (g)


NA SULFACETM/PREDNISOL ACBLEPHAMIDE DROPS, OINT

NEOMY SULF/POLYMYX B SULF/PREDPOLY-PRED

TOBRAMYCIN SULFATE/DEXAMETHTOBRADEX OINT


GENTAMICIN/PREDNISOL ACPRED-G

TOBRAMYCIN/DEXAMETHASONETOBRADEX ST

TOBRAMYCIN/LOTEPRED ETABZYLET

11H. Miscellaneous Ophthalmic Agents


NAPHAZOLINE HCLALBALON (g)

EPINASTINE HCLELESTAT (g)

PHENYLEPHRINE HCLNEO-SYNEPHRINE (g)

CROMOLYN SODIUMOPTICROM (g)

AZELASTINE HCLOPTIVAR (g)


NEDOCROMIL SODIUMALOCRIL

LODOXAMIDE TROMETHAMINEALOMIDE

CYSTEAMINE HYDROCHLORIDECYSTARAN [PA] [QL] <s>

HYDROXYPROPYL CELLULOSELACRISERT

OLOPATADINE HCLPATANOL

CYCLOSPORINERESTASIS


PEMIROLAST POTASSIUMALAMAST

BEPOTASTINE BESILATEBEPREVE

EMEDASTINE DIFUMARATEEMADINE

ALCAFTADINELASTACAFT

OLOPATADINE HCLPATADAY



<s> Specialty Drug


12. OTIC & NASAL PREPARATIONS

12A. Nasal Preparations


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]


AZELASTINE HCLASTEPRO NASAL SPRAY [QL]


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


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)


CIPROFLOXACIN HCL/HCCIPRO HC

CIPROFLOXACIN HCL/DEXAMETHCIPRODEX


NEOMYCIN SULFATE/COLIST SUL/HCCOLY-MYCIN S

NEOMY SULF/COLIST SUL/HC/THONZCORTISPORIN-TC

OFLOXACINFLOXIN OTIC SINGLES



<s> Specialty Drug


13. RESPIRATORY, COUGH & COLD

13A. Antihistamines


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)


AZELASTINE HCLASTEPRO NASAL SPRAY [QL]


DESLORATADINECLARINEX SYRUP [PA] [QL]

CARBINOXAMINE MALEATE ERKARBINAL ER [PA] [QL]

OLOPATADINE HCLPATANASE [QL]

13B. Antihistamine/Decongestant Combinations


P-EPHED SUL/LORATADINECLARITIN-D 12HR, 24HR (OTC) (g)

P-EPHED HCL/CETIRIZINE HCLZYRTEC-D (OTC) (g)


NONE


P-EPHED SUL/DESLORATADINECLARINEX-D [PA] [QL]

PSEUDOEPHEDRINE HCL/ACRIVASSEMPREX-D [ST]

13C. Antitussive combinations


D-METHORPHAN HB/PROMETH HCLPHENERGAN DM (g)

CODEINE/PROMETHAZINE HCLPHENERGAN W/CODEINE (g)

BENZONATATETESSALON, PERLES (g)

HYDROCODONE/CHLORPHEN POLISTUSSIONEX (g)


HYDROCODONE/CHLORPHEN POLISTUSSICAPS


HYDROCODONE AND PSEUDOEPHEDRINEREZIRA [QL]

HYDROCODONE BIT/CHLOR-MALVITUZ [QL]

CHLORPHENIRAMINE, HYDROCODONE/PSEneZUTRIPRO [QL]



<s> Specialty Drug


13D. Expectorant combinations


PHENYLEPHRINE HCL/PROMETH HCLPHENERGAN VC (g)


NONE


NONE

13F. Oral Beta-Agonists


METAPROTERENOL SULFATEALUPENT (g)

TERBUTALINE SULFATEBRETHINE (g)

ALBUTEROL SULFATEPROVENTIL SOLUTION (g)

ALBUTEROL SULFATEVOSPIRE ER (g)


NONE


NONE

13G. Inhaled Beta-Agonists


ALBUTEROL SULFATEACCUNEB (g)

ALBUTEROL SULFATEALBUTEROL NEBULIZER SOLN (g)

METAPROTERENOL SULFATEMETAPROTERENOL SOLN (g)

LEVALBUTEROL HCLXOPENEX (g)


FORMOTEROL FUMARATEFORADIL [QL]

ALBUTEROLPROAIR HFA, VENTOLIN HFA [QL]

SALMETEROL XINAFOATESEREVENT DISKUS [QL]


INDACATEROL MALEATEARCAPTA NEOHALER [QL]

ARFORMOTEROL TARTRATEBROVANA [PA] [QL]

PIRBUTEROL ACETATEMAXAIR AUTOHALER [QL]

FORMOTEROL FUMARATEPERFOROMIST [PA] [QL]

ALBUTEROLPROVENTIL HFA [QL]

LEVALBUTEROL TARTRATEXOPENEX HFA [QL]



<s> Specialty Drug


13H. Inhaled Steroids


BUDESONIDEPULMICORT 0.25MG, 0.5MG/2ML (g) [QL] BE


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


FLUNISOLIDEAEROSPAN [QL]

13I. Intranasal Steroids


FLUTICASONE PROPIONATEFLONASE (g) [QL]

TRIAMCINOLONE ACETONIDENASACORT AQ (g) [ST] [QL]

FLUNISOLIDE 0.025% SPRAYNASALIDE (g) [QL]

FLUNISOLIDENASAREL (g) [QL]


NONE


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


THEOPHYLLINE ANHYDROUSTHEOPHYLLINE ANHYDROUS (g)

THEOPHYLLINE ANHYDROUSUNIPHYL (g)


THEOPHYLLINE ANHYDROUSTHEO-24


NONE



<s> Specialty Drug


13K. Epinephrine


NONE


EPINEPHRINEEPIPEN, JR [QL]


EPINEPHRINEAUVI-Q [QL]

13L. Miscellaneous Pulmonary Agents


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]


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>


TADALAFILADCIRCA [PA] [QL] <s>

ROFLUMILASTDALIRESP [PA] [QL]

ACLIDINIUM BROMIDETUDORZA PRESSAIR [PA] [QL]

ZILEUTONZYFLO, CR [QL]



<s> Specialty Drug


14. UROLOGY

14A. Urinary Antispasmodics


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)


TOLTERODINE TARTRATEDETROL LA

FESOTERODINE FUMARATETOVIAZ (TIER 3 - BCBSM ONLY) [QL]


OXYBUTYNINANTUROL [QL]

DARIFENACIN HYDROBROMIDEENABLEX

OXYBUTYNIN CHLORIDEGELNIQUE, PUMP [QL]

MIRABEGRONMYRBETRIQ [PA] [QL]

OXYBUTYNINOXYTROL [QL]

SOLIFENACIN SUCCINATEVESICARE

14B. Miscellaneous Urologicals


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)


PENTOSAN POLYSULFATE SODIUMELMIRON

MAG CARB/CITRIC ACID/G-LACTONERENACIDIN

MTH/ME BLUE/BA/SALICY/ATP/HYOSURETRON D-S


NONE



<s> Specialty Drug


14C. BPH Treatment


DOXAZOSIN MESYLATECARDURA (g)

TAMSULOSIN HCLFLOMAX (g)

TERAZOSIN HCLHYTRIN (g)

FINASTERIDEPROSCAR (g)

ALFUZOSIN HCLUROXATRAL (g)


DUTASTERIDEAVODART

TADALAFILCIALIS 2.5, 5MG [PA] [QL]

DUTASTERIDE/TAMSULOSIN HCLJALYN [ST] [QL]


DOXAZOSIN MESYLATECARDURA XL

SILODOSINRAPAFLO [QL]



<s> Specialty Drug


15. VITAMINS AND SUPPLEMENTS

15A. Vitamins and Minerals


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)


PHYTONADIONEMEPHYTON


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


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)


NONE


POTASSIUM CHLORIDE/POT BICARBKAOCHLOR-EFF



<s> Specialty Drug


16. DIAGNOSTIC AND OTHER MISCELLANEOUS

16A. Diagnostics and Other Miscellaneous


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)


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>


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



<s> Specialty Drug


17. LIFESTYLE MODIFICATION

17A. Impotence


YOHIMBINE HCLYOHIMBINE HCL (g)


ALPROSTADILCAVERJECT [PA] [QL]

TADALAFILCIALIS [PA] [QL]

ALPROSTADILMUSE [PA] [QL]

SILDENAFIL CITRATEVIAGRA [PA] [QL]


ALPROSTADILEDEX [PA] [QL]

VARDENAFIL HCLLEVITRA [PA] [QL]

OSPEMIFENEOSPHENA

VARDENAFIL HCLSTAXYN [PA] [QL]

AVANAFILSTENDRA [PA] [QL]

17B. Weight Loss Preparations


PHENTERMINE HCLADIPEX-P (g) [PA] [QL]

PHENDIMETRAZINE TARTRATEBONTRIL (g) [PA] [QL]

BENZPHETAMINE HCLDIDREX (g) [PA] [QL]

DIETHYLPROPION HCLTENUATE (g) [PA] [QL]


PHENTERMINE RESINIONAMIN [PA] [QL]


LORCASERIN HCLBELVIQ [PA] [QL]

PHENTERMINE/TOPIRAMATEQSYMIA [PA] [QL]

PHENTERMINE HCLSUPRENZA ODT [PA] [QL]

ORLISTATXENICAL [PA] [QL]

17C. Smoking Cessation


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


VARENICLINE TARTRATECHANTIX [QL]


NICOTINENICOTROL, NS [QL]



<s> Specialty Drug


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

CB 2870 JUL 13 R017446

bcbsm/bcn custom drug list - kalamazoo resa · bcbsm and bcn custom 'uxj /lvw 2013 jxo\...

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