Custom Drug List
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Confidence comes with Custom Drug List BCBSM and BCN Custom Drug List (Formulary) - January 2015 Table of contents BCBSM and BCN Custom Drug List (Formulary) Generic substitution and Preferred alternatives BCBSM/BCN Preferred alternatives introduction How to read the BCBSM/BCN Custom Drug List BCBSM/BCN Preferred Alternatives List 6 11 12 13 Appendix A Anti-infectives 1A 1B 1C 1D 1E 1F 1G 1H 1I 1J 1K 1L 1M 1N Antifungals Antimalarials Antiparasitics/Anthelmintics Antiretrovirals Antituberculars Antivirals Cephalosporins Macrolides Penicillins Quinolones Sulfonamides and Combinations Tetracyclines Urinary Tract Agents Miscellaneous Anti-infectives 14 14 14 15 16 16 17 17 17 17 18 18 18 18 Cardiovascular, hypertension, cholesterol 2A 2B 2C 2D 2E 2F 2G 2H 2I 2J 2K 2K ACE-Inhibitors and Combinations Alpha-adrenergic Agents Angiotensin II Receptor Blockers and Combinations Anticoagulants and Hemostasis Agents Beta Blockers and Combinations Calcium Channel Blockers and Combinations Cardiovascular Treatment Diuretics Lipid-lowering Agents Nitrates and Combinations Renin-inhibitors and Combinations Miscellaneous Antihypertensives 19 19 20 20 21 21 22 22 23 23 24 25 Page 1 Central nervous system 3A 3B 3C 3D 3E 3F 3G 3H 3I 3J 3K 3L 3M 3N 3O 3P 3Q 3R Alzheimer's therapy Anticonvulsants Antidepressants Antipsychotics Anxiolytics CNS Stimulants Migraine Therapy Myesthenia Gravis Narcotic Antagonists Narcotic Mixed Agonist/Antagonist Narcotic/Analgesic Combinations Narcotics Nonsteroidal Anti-inflammatory Drugs Parkinsons Disease and Related Disorders Salicylates Sedative/Hypnotics Skeletal Muscle Relaxants Miscellaneous CNS 25 26 27 28 28 29 29 30 30 30 30 31 32 33 33 34 34 35 Gastrointestinal agents 4A 4B 4C 4D 4E 4F 4G 4H 4I 4J 4K 4L 5-Aminosalicylic Acid (5-ASA) Agents Antidiarrheals and Antispasmodics Antiemetics Bile Acids Bowel Preparation and Cleansing Agents Digestive Enzymes H2-Receptor Antagonists Other Ulcer Therapy Proton Pump Inhibitors Topical Anti-Inflammatory Agents Tumor Necrosis Factor (TNF) Blocking Agents Miscellaneous Gastrointestinal Agents 36 36 36 37 37 37 37 37 38 38 38 39 Obstetrics and gynecology 5A 5B 5C 5D 5E 5F 5G 5H 5I 5J 5K Contraceptives-Biphasic Contraceptives-Misc. Contraceptives-Monophasic Contraceptives-Postcoital Contraceptives-Triphasic Estrogen/Progestin Combinations Estrogens Infertility Treatment Progestins Vaginal Anti-infective/Antifungal Miscellaneous OB-GYN 40 40 40 41 41 41 41 42 42 42 43 Page 2 Rheumatology and musculoskeletal 6A 6B 6C 6D 6E 6F 6G 6H Corticosteroids Gout Therapy Non-Tumor Necrosis Factor (TNF) Blocking Agents Osteoporosis/Bone Resorption Osteoporosis/Hormonal Treatment Salicylates Tumor Necrosis Factor (TNF) Blocking Agents Miscellaneous Rheumatologic Agents 44 44 44 44 45 45 45 45 Endocrinology 7A 7B 7C 7D 7E 7F 7G 7H 7I 7J 7K Androgens Antithyroid Agents Corticosteroids Growth Hormone and Related Products Insulins Non-insulin Hypoglycemic Agents Somatostatin Analogs Thyroid Hormones Urea Cycle Disorder Agents Vitamin D Analogs Miscellaneous Endocrine 46 46 46 47 47 48 49 49 49 49 49 Antineoplastics and immunossuppresants 8A 8B 8C 8D 8E 8F 8G Adjuvant Therapy Alkylating Agents Antimetabolites Hormonal Agents Immunomodulators Kinase Inhibitors and Molecular Target Inhibitors Miscellaneous Antineoplastic Agents 50 50 50 51 51 52 52 Immunology and hematology 9A 9B 9C 9D Hematopoietic Agents Immunoglobulins Interferons and MS Therapy Miscellaneous Immunology and Hepatology 53 53 53 53 Page 3 Dermatology 10A 10B 10C 10D 10E 10F 10G 10H 10I 10J 10K 10L 10M 10N Acne Treatment Antipsoriatic/Antiseborrheic Corticosteriods - Very High Potency Corticosteroids - High Potency Corticosteroids - Medium Potency Corticosteroids - Low Potency Scabicides/Pediculicides Topical Anesthetics Topical Antibacterials Topical Antifungals Topical Antineoplastic Agents and Immunomodulators Topical Antivirals Wound and Burn Therapy Miscellaneous Dermatologicals 54 55 55 55 56 56 56 56 57 57 57 57 58 58 Ophthalmology 11A 11B 11C 11D 11E 11F 11G 11H 11I Cycloplegic Mydriatics Ophthalmic Anti-Allergy Agents Ophthalmic Anti-infective/Steroid Combinations Ophthalmic Anti-infectives Ophthalmic Anti-inflammatory Agents Ophthalmic Beta Blockers Ophthalmic Steroids Other Glaucoma Agents Miscellaneous Ophthalmic Agents 59 59 59 60 60 60 61 61 61 Otic and nasal preparations 12A 12B Nasal Preparations Otic Preparations 62 62 Respiratory, cough and cold 13A 13B 13C 13D 13E 13F 13G 13H 13I 13J 13K 13L 13M 13N 13O Antihistamine/Decongestant Combinations Antihistamines Antitussives Cystic Fibrosis Agents Epinephrine Inhaled Anticholinergics Inhaled Beta-Agonist/Anticholinergic Combinations Inhaled Beta-Agonists Inhaled Steroid/Beta-Agonist Combinations Inhaled Steroids Intranasal Steroids Oral Beta-Agonists Pulmonary Hypertension Agents Theophyllines Miscellaneous Respiratory Agents 63 63 63 64 64 64 64 64 65 65 65 65 65 66 66 Page 4 Urology 14A 14B 14C BPH Treatment Urinary Antispasmodics Miscellaneous Urologicals 67 67 67 Vitamins and supplements 15A 15B Potassium Replacement Vitamins and Minerals 68 68 Diagnostic and other miscellaneous 16A 16B 16C Chelating Agents Ion-Removing Agents Diagnostics and Other Miscellaneous 69 69 69 Lifestyle modification 17A 17B 17C Impotence, Sexual Dysfunction Smoking Cessation Weight Loss Preparations 70 70 70 Page 5 Blue Cross and BCN Custom Drug List We regularly update this list with medications approved by the U.S. Food and Drug Administration and reviewed by the Blue Cross and BCN Pharmacy and Therapeutics Committee. 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. The committee selects medications based on safety, clinical effectiveness and opportunity for cost savings. This is how the Blue Cross and BCN Custom Drug List helps maintain quality of care and contain costs for our members. Tier descriptions Tier 1: Generics – lowest copayment Most drugs in this category are generic drugs. Members pay the lowest copay for these drugs, which make them the most cost-effective option for treatment. Tier 1 drugs are grouped into two tiers for some BCN pharmacy benefits: Tier 1A: Preferred Generics — lower generic drug copay This tier includes commonly prescribed generic drugs that treat chronic diseases such as depression, hypertension, cholesterol, diabetes, heart disease and congestive heart failure. Select brand-name drugs that treat chronic diseases such as asthma and diabetes are also included in this tier. Offering these drugs at the lowest copay makes these drugs more accessible to members and helps ensure that they continue to take these important drugs regularly as prescribed. Tier 1B: Generics — higher generic drug copay Tier 1B includes generic drugs that aren’t listed in Tier 1A. The Tier 1B copay is higher than the Tier 1A copay, but is still lower than the copay for brand-name drugs. Tiers 1A and 1B apply only to BCN members with a six-tier drug plan. Blue Cross considers all generic, nonspecialty drugs to be Tier 1. Tier 2: Preferred Brand — higher copay This tier includes preferred, brand-name drugs that don’t have a generic equivalent. These drugs are more expensive than generics and members pay a higher copay for them. Tier 3: Nonpreferred Brands — highest copay This tier includes brand-name drugs for which there is either a generic alternative or a more cost-effective preferred brand-name drug available. Members pay the highest copay for these drugs. Page 6 Tier 4: Preferred Specialty — lower specialty drug cost sharing Specialty drugs in Tier 4 are generally more effective and less expensive than nonpreferred specialty drugs in Tier 5. Tier 5: Nonpreferred Specialty — higher specialty drug cost sharing Members pay the highest copay for these specialty drugs because a more cost-effective generic or preferred brand-name drug is available. Some plans group specialty drugs into Tiers 4 and 5. If you don’t have this type of plan, you’ll find specialty drugs grouped under Tiers 1, 2 or 3. For more information on specialty drugs, see Specialty Drug Program Rx Benefit Member Guide. Specialty drugs are limited to a 30-day supply. Select specialty drugs are managed by the 15-Day Specialty Drug Limitation Program. Drugs included on this list are limited to a 15-day supply for all fills for Blue Cross PPO and BCN HMO drug plans. Members pay half their copay for a 15-day supply. For additional details visit bcbsm.com/pharmacy. Preventive drug coverage Under the Patient Protection and Affordable Care Act, also known as national health care reform, most health plans must cover certain preventive services and drugs with no cost sharing. For a complete list of preventive drugs refer to Preventive drug coverage or visit bcbsm.com/pharmacy. Members must meet plan requirements and have a prescription to be covered. For details, see How prior approval, step therapy and quantity limits work. What you should know Use this list to find information about drug coverage and therapeutic options for Blue Cross and BCN members. This list is divided into major drug classes or indication for use by chapter so it’s easy to use. Products approved for more than one use may be included in more than one chapter. Within each chapter, drugs are identified according to their tier placement (Tiers 1 through 5). We encourage physicians to prescribe preferred medications whenever possible. Blue Cross 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 the member. We also encourage pharmacists to contact the prescriber to suggest an alternative when a Blue Cross or BCN member’s prescription is written for a Tier 3 or Tier 5 (nonpreferred) drug that isn’t covered. Page 7 Coverage and applicable copay amounts for drugs on the Blue Cross and BCN Custom Drug List are based on a member’s drug plan. Not all drugs included in the drug list are necessarily covered by each member’s plan. Some medications excluded from a member’s pharmacy benefit may be covered under his or her medical benefit. Examples include serums, vaccines and other medications that are generally administered in a physician’s office under the supervision of appropriate health care personnel and aren’t normally dispensed to the member for self-administration. New generics: 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 Blue Cross and Tier 2 for BCN. All BCN members and some Blue Cross members, depending on their plan, may be required to pay the difference between the brand name drug and the generic drug, as well as the applicable brand-name copay. How prior approval, step therapy and quantity limits work The Blue Care Network Prior Authorization and Step Therapy Guidelines and the Blue Cross Prior Authorization and Step Therapy Guidelines provide a list of drugs that require approval or step-therapy prior to coverage. To view the current version, visit bcbsm.com/pharmacy. Prior approval Prior approval may be necessary for coverage of certain medications. In these cases, the member must meet clinical criteria or additional information must be provided before coverage is approved. Clinical criteria are based on current medical information and approved by the Blue Cross and BCN Pharmacy and Therapeutics Committee. Step therapy Drugs subject to step therapy may require previous treatment with one or more preferred drugs before coverage is approved. Quantity limits and dose optimization Blue Cross and BCN set quantity limits based on clinical appropriateness and manufacturerrecommended dosing for particular drugs. Blue Cross and BCN dose optimization programs encourage appropriate prescribing of medications that are intended for once-daily administration. For certain medications, physicians are encouraged to prescribe prescription drugs in once-daily dosage regimens, as opposed to using multiple lower doses of the same drug to help increase a member’s adherence the medication. Page 8 Obtaining prior approval or step therapy For members: Blue Cross Members should consult their prescription drug benefit packet for information on how to obtain approval or how to request a review for coverage of a drug that isn't included in your plan. Members can also call the Customer Service number on the back of their Blues ID card for additional information. Members who have a PPO plan and need a request taken care of right away can fill out an expedited request form on the web at bcbsm.com. Or write to: Blue Cross Blue Shield of Michigan Pharmacy Services P.O. BOX 2320 Detroit, MI 48231-2320 BCN To request approval for a drug, members can talk to their doctor. Members can also initiate the request by calling the Customer Service number on the back of their BCN ID card. For physicians: Blue Cross Physicians can request approval one of four ways: 1. Web - bcbsm.com a. Log in as a provider b. Select Medication Prior Authorization 2. Call - 1-800-437-3803 3. Fax - 1-866-601-4425 4. Write Blue Cross Blue Shield of Michigan Pharmacy Services P.O. BOX 2320 Detroit, MI 48231-2320 BCN Physicians can request approval one of three ways: 1. Call: 1-800-437-3803 a. Provide the member’s numeric contract number or enrollee ID. Do not use the alpha prefix b. Enter the requested information accurately and completely so your request is routed correctly. 2. Fax: 1-877-442-3778 3. Write: Blue Care Network Pharmacy Services Help Desk Mail Code C303 Southfield, MI 48076 Page 9 Physicians can download the medication request forms through web-DENIS under Blue Cross or BCN Provider Publications and Resources. Be sure to identify urgent requests, and return the completed request forms to the Pharmacy Services Clinical Help Desk for review. We 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. This document is current at the time of publication and is subject to change. Please go to bcbsm.com/pharmacy and click Drug Lists for the most up-to-date information regarding the Blue Cross and BCN Custom Drug List. Page 10 Generic drug substitution and possible therapeutic alternatives Generic drug substitution Generic drug substitution occurs when a pharmacist dispenses a generic equivalent rather than the brand-name product. Generics approved by the U.S. Food and Drug Administration are listed in the “Generic name” column to the right of the brand-name drug. Generic substitution is required for all BCN members and most Blue Cross members. If both the generic and brand names are listed, the tier number matches the available generic. The brand-name tier is always higher, reflecting the higher copayment when there’s an available generic. Blue Cross members 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. BCN members If a brand-name drug is requested when a generic version is available, members will pay their Tier 2 or Tier 4 copay 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. The maximum allowable cost, or MAC, list sets the highest 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’re the equivalent of their brand-name counterparts, or the Blue Cross 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 Some medications are identical in strength and formulation, and are produced by multiple manufacturers, but are marketed as brand-name products with different brand names. We encourage prescribers to select preferred (Tier 1 or Tier 2) products to help members save on their out-of-pocket costs. Nonpreferred drugs Epogen® Follistim® Possible brand alternatives Preferred alternatives Procrit® Gonal-F® Page 11 Humatrope®, Norditropin® , Omnitrope®, Saizen®, Serostim®, Zomacton®, Zorbtive® Genotropin®, Nutropin® Possible therapeutic alternatives The Blue Cross and BCN Preferred Alternatives — January 2016 list represents possible alternatives to nonpreferred drugs. These alternative medications can generally be prescribed without approval from Blue Cross or BCN, and can be dispensed with lower out-of-pocket costs 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. Appendix A, lists examples of the therapeutic alternatives a member’s physician should consider when determining appropriate treatment for the member. The physician should consider individual drug product characteristics and member factors such as coexisting disease states, contraindications, therapeutic history, concurrent medications and other relevant circumstances. This list is also available at bcbsm.com/pharmacy. Editor’s note: Please send us your comments and suggestions regarding the Blue Cross 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 Pharmacy Services — Mail Code C303 Blue Care Network of Michigan OR 20500 Civic Center Drive Southfield, MI 48076-5043 Page 12 How to read the Blue Cross and BCN Custom Drug List This drug list shows the drug’s copayment tier and whether the drug has special requirements for coverage. Drugs are listed alphabetically by brand name. If a generic version is available, the name is included in the “Generic Name” column next to the brand name and coverage is provided for the generic version. The brand name is included for informational purposes only, as the brandname drugs aren’t covered or may require a higher copay, depending on the member’s plan. If only a brand name is listed, there isn’t a generic version available. 9 7 11 12 13 10 8 11 12 13 1 2 3 4 5 6 1 2 3 4 5 6 Drugs are organized based on drug class or indication for use. 7 Custom: Applies to most Blue Cross and BCN members (with a two-tier closed or three-tier drug plan) Crestor® is a brand-name drug that requires a Tier 3 copay. Both Blue Cross and BCN require step therapy for coverage and quantity limits. Kynamro™ is a brand-name specialty drug (<s>). It’s listed under Tier 2 for most members and requires a Tier 4 copay with a five-tier or six-tier plan. Prior approval and quantity limits apply for both Blue Cross and BCN plans. The generic drug, atorvastatin calcium, requires a Tier 1 copay and a Tier 1A copay for BCN members with a six-tier drug plan. Quantity limits apply for both plans. The generic drug, fenofibric acid (choline), requires a Tier 1 copay and a Tier 1B copay for BCN members with a six-tier drug plan. Quantity limits apply for BCN plans. Zetia® is a brand-name drug that requires a Tier 2 copay. Quantity limits apply for both Blue Cross and BCN plans. Tiers: Five-tier: Applies to members with a five-tier, or three-tier + specialty drug plan. 8 9 10 11 12 13 BCN 6-Tier: Applies to BCN members with a six-tier drug plan. Blue Cross: Requirements for coverage include prior approval, step therapy and quantity limits. BCN: Requirements for coverage include prior authorization, step therapy and quantity limits. Prior approval: Approval from Blue Cross or BCN is required for coverage. Step therapy: Criteria must be met prior to coverage. Quantity limits: Prescriptions can’t exceed a specific quantity per fill. “Prevent” designates preventive drugs Page 13 1. ANTI-INFECTIVES 1A. Antifungals BCBSM/BCN BCBSM Trade name Ancobon Cresemba capsules Diflucan Grifulvin V Gris-PEG Lamisil granules Lamisil tablets Mycelex Troche Nizoral Noxafil suspension Noxafil tablet Nystatin Onmel Oravig Sporanox capsule Sporanox solution Vfend Generic name flucytosine fluconazole griseofulvin,microsize griseofulvin ultramicrosize terbinafine hcl clotrimazole ketoconazole nystatin itraconazole voriconazole 1B. Antimalarials Generic name chloroquine phosphate mefloquine hcl atovaquone/proguanil hcl hydroxychloroquine sulfate quinine sulfate 1C. Antiparasitics/Anthelmintics Trade name Albenza Alinia Biltricide Flagyl Flagyl ER Humatin Mepron Nebupent Aerosol Stromectol Tindamax PA - Prior approval may be required Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 2 1 1 1 3 1 1 1 2 2 1 3 3 1 2 1 1 2 1 1 1 3 1 1 1 2 2 1 3 3 1 2 1 1B 2 1B 1B 1B 3 1B 1B 1B 2 2 1B 3 3 1B 2 1B BCBSM/BCN BCBSM Trade name Aralen Coartem Daraprim <s> Lariam Malarone Plaquenil Primaquine Qualaquin BCN metronidazole paromomycin sulfate atovaquone ivermectin tinidazole ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 2 2 1 1 1 2 1 1 2 4 1 1 1 2 1 1B 2 4 1B 1B 1B 2 1B BCBSM/BCN BCBSM Generic name BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 2 1 2 1 1 2 1 1 2 2 2 1 2 1 1 2 1 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 2 2 2 1B 2 1B 1B 2 1B 1B <s> - Specialty Drug Page 14 1D. Antiretrovirals Trade name Aptivus Atripla Combivir Complera Crixivan Edurant Emtriva Epivir Epzicom Evotaz Fuzeon <s> Intelence Invirase Isentress Kaletra Lexiva Norvir Prezcobix Prezista (Must Be Used With Norvir) Rescriptor Retrovir Reyataz Selzentry Stribild Sustiva Tivicay Triumeq Trizivir Truvada Tybost Videx Videx EC Viracept Viramune XR 100mg Viramune, XR Viread Vitekta Zerit Ziagen solution Ziagen tablet PA - Prior approval may be required BCBSM/BCN BCBSM Generic name lamivudine/zidovudine lamivudine zidovudine abacavir/lamivudine/zidovudine didanosine nevirapine stavudine abacavir sulfate ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 1 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 1 2 2 2 1 2 3 1 2 2 1 2 1 2 2 1 2 2 2 2 1 2 2 4 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 1 2 2 2 1 2 3 1 2 2 1 2 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 2 2 1B 2 2 2 2 1B 2 2 4 2 2 2 2 2 2 2 2 2 1B 2 2 2 2 2 2 1B 2 2 2 1B 2 3 1B 2 2 1B 2 1B <s> - Specialty Drug Page 15 1E. Antituberculars BCBSM/BCN BCBSM Trade name Cycloserine Dapsone Ethambutol Isoniazid Mycobutin Paser (BCN tier 2 only) Priftin Pyrazinamide Rifadin Rifater Sirturo Trecator Generic name ethambutol hcl isoniazid rifabutin pyrazinamide rifampin 1F. Antivirals PA - Prior approval may be required Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 1 1 1 3 3 1 1 3 2 3 2 2 1 1 1 3 3 1 1 3 2 3 2 2 1B 1B 1B 2 3 1B 1B 3 2 3 BCBSM/BCN BCBSM Trade name Amantadine hcl Baraclude solution <s> Baraclude tablets <s> Copegus <s> Daklinza <s> Epivir HBV solution Epivir HBV tablets Famvir Flumadine Harvoni <s> Hepsera <s> Olysio <s> Rebetol capsule <s> Rebetol solution <s> Relenza Ribasphere, Ribapak <s> Ribatab <s> Sitavig Sovaldi <s> Tamiflu Technivie <s> Tyzeka <s> Valcyte solution Valcyte tablets Valtrex Viekira Pak <s> Zovirax BCN Generic name amantadine hcl entecavir ribavirin lamivudine famciclovir rimantadine hcl adefovir dipivoxil ribavirin ribavirin ribavirin valganciclovir hydrochloride valacyclovir hcl acyclovir ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 2 1 1 3 2 1 1 1 2 1 2 1 2 2 1 1 3 2 2 3 3 2 1 1 2 1 1 4 4 4 5 2 1 1 1 4 4 4 4 4 2 4 4 3 4 2 5 5 2 1 1 4 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 4 4 4 5 2 1B 1B 1B 4 4 4 4 4 2 4 4 3 4 2 5 5 2 1B 1B 4 1B <s> - Specialty Drug Page 16 1G. Cephalosporins BCBSM/BCN BCBSM Trade name Ceclor, ER Cedax Ceftin suspension Ceftin tablets Cefzil Duricef Keflex Omnicef Spectracef (28 Count) Spectracef Suprax chew, capsules, tablets Suprax suspension 100/5, 200mg/5ml Suprax suspension 500mg/5ml Vantin Generic name cefaclor ceftibuten dihydrate cefuroxime axetil cefprozil cefadroxil hydrate cephalexin monohydrate cefdinir cefditoren pivoxil cefixime cefpodoxime proxetil 1H. Macrolides Trade name Biaxin, XL Dificid E. E. S. tablet Ery-Tab Ery-Tab 500mg (Tier 2 BCN Only) Erythromycin base Erythromycin Stearate Ketek Pediazole Zithromax Zmax Trade name Generic name clarithromycin erythromycin ethylsuccinate erythromycin erythromycin base erythromycin stearate ery e-succ/sulfisoxazole azithromycin Trade name PA - Prior approval may be required 1 1 2 1 1 1 1 1 3 1 3 1 3 1 1 1 2 1 1 1 1 1 3 1 3 1 3 1 1B 1B 2 1B 1B 1B 1B 1B 3 1B 3 1B 3 1B Generic name amoxicillin trihydrate ampicillin trihydrate amox tr/potassium clavulanate dicloxacillin sodium penicillin v potassium Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 1 1 3 1 1 3 1 1 3 1 3 1 1 3 1 1 3 1 1 3 1B 3 1B 1B 2 1B 1B 3 1B 1B 3 Generic name ciprofloxacin hcl ciprofloxacin hcl-betaine comb ofloxacin levofloxacin ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 1 2 1 1 3 1 3 1 1 2 1 1 3 1 3 1B 1B 2 1B 1B 3 1B BCBSM/BCN BCBSM moxifloxacin hcl BCN BCBSM/BCN BCBSM 1J. Quinolones Avelox Avelox ABC Cipro Cipro XR Factive Floxin tablet Levaquin Custom 5-Tier PA ST QL 6-Tier PA ST QL BCBSM/BCN BCBSM 1I. Penicillins Amoxicillin ER Amoxil Ampicillin Augmentin 125mg-31.25mg/5ml Augmentin, ES, XR Dicloxacillin Moxatag Penicillin VK BCN BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 2 1 1 3 1 1 1 2 1 1 3 1 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 2 1B 1B 3 1B 1B <s> - Specialty Drug Page 17 1K. Sulfonamides and Combinations Trade name Bactrim, DS Pediazole Sulfadiazine Generic name sulfamethoxazole/trimethoprim ery e-succ/sulfisoxazole sulfadiazine 1L. Tetracyclines Generic name doxycycline monohydrate doxycycline monohydrate demeclocycline hcl doxycycline hyclate minocycline hcl doxycycline monohydrate doxycycline hyclate minocycline hcl tetracycline hcl doxycycline hyclate 1M. Urinary Tract Agents Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 1 1 1B 1B 1B BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 1 1 1 3 3 1 1 3 1 1 3 1 1 3 3 1 1 1 1 3 3 1 1 3 1 1 3 1 1 3 3 1B 1B 1B 1B 3 3 1B 1B 3 1B 1B 3 1B 1B 2 BCBSM/BCN BCBSM Trade name Furadantin Hiprex/Urex Macrobid Macrodantin Monurol Primsol (Tier 2 BCN Only) Pyridium (BCBSM only) Trimethoprim UTA (BCBSM only) BCN BCBSM/BCN BCBSM Trade name Acticlate Adoxa capsule Adoxa tablet Declomycin Doryx Doryx 50, 200mg Doxycycline IR-DR Minocin Monodox Oracea Periostat Solodyn Solodyn 55, 65, 80, 105, 115mg Tetracycline Vibramycin Vibramycin syrup (Tier 2 BCN only) BCBSM/BCN BCBSM Generic name nitrofurantoin methenamine hippurate nitrofurantoin nitrofurantoin macrocrystal phenazopyridine hcl trimethoprim BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 3 3 1 1 3 1 1 1 1 3 3 1 1 3 1B 1B 1B 1B 3 2 NC 1B NC NC - Not Covered for members with a BCN drug benefit 1N. Miscellaneous Anti-infectives Trade name Bethkis <s> Cayston <s> Cleocin Cleocin 75mg Neomycin Peridex Sivextro Tobi <s> Tobi Podhaler <s> Vancocin hcl Xifaxan 200mg Zyvox PA - Prior approval may be required BCBSM/BCN BCBSM Generic name clindamycin hcl neomycin sulfate chlorhexidine gluconate tobramycin/0.25 normal saline vancomycin hcl linezolid ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 1 2 1 1 2 1 3 1 3 1 5 5 1 2 1 1 2 4 5 1 3 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 5 5 1B 2 1B 1B 2 4 5 1B 3 1B <s> - Specialty Drug Page 18 2. CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL 2A. ACE-Inhibitors and Combinations Trade name Generic name Accupril Accuretic Aceon Altace Capoten Capozide Epaned Lotensin Lotensin HCT Lotrel Mavik Monopril Monopril HCT Prestalia Prinivil; Zestril Prinzide; Zestoretic Tarka Uniretic Univasc Vaseretic Vasotec quinapril hcl quinapril/hydrochlorothiazide perindopril erbumine ramipril captopril captopril/hydrochlorothiazide benazepril hcl benazepril/hydrochlorothiazide amlodipine besylate/benazepril trandolapril fosinopril sodium fosinopril/hydrochlorothiazide lisinopril lisinopril/hydrochlorothiazide trandolapril/verapamil hcl moexipril/hydrochlorothiazide moexipril hcl enalapril/hydrochlorothiazide enalapril maleate 2B. Alpha-adrenergic Agents Trade name Aldomet Aldoril Cardura Catapres Catapres TTS Clorpres Clorpres 0.3-15mg (Tier 2 - BCN Only) Dibenzyline Hytrin Minipress Reserpine Tenex PA - Prior approval may be required BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 1 1 3 1 1 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1 1 3 1 1 1 1 1 1 3 1 1 1 1 1 1 1 1A 1A 1B 1A 1A 1A 3 1A 1A 1A 1A 1A 1A 3 1A 1A 1B 1A 1A 1A 1A BCBSM/BCN BCBSM Generic name methyldopa methyldopa/hydrochlorothiazide doxazosin mesylate clonidine hcl clonidine hcl clonidine hcl/chlorthalidone phenoxybenzamine hcl terazosin hcl prazosin hcl reserpine guanfacine hcl ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 3 1 1 1 1 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 1B 1B 1A 1B 1B 2 1B 1B 1B 1B 1B <s> - Specialty Drug Page 19 2C. Angiotensin II Receptor Blockers and Trade name Atacand Atacand HCT Avalide Avapro Azor Benicar, HCT Cozaar Diovan Diovan HCT Edarbi Edarbyclor Entresto Exforge Exforge HCT Hyzaar Micardis Micardis HCT Teveten Tribenzor Twynsta Generic name candesartan cilexetil candesartan/hydrochlorothiazide irbesartan/hydrochlorothiazide irbesartan losartan potassium valsartan valsartan/hydrochlorothiazide amlodipine/valsartan amlodipine/valsartan/hctz losartan/hydrochlorothiazide telmisartan telmisartan/hydrochlorothiazide eprosartan mesylate telmisartan/amlodipine 2D. Anticoagulants and Hemostasis Agents Trade name Aggrenox Agrylin Amicar Amicar solution Arixtra <s> Brilinta Coumadin Effient Eliquis Fragmin <s> Heparin <s> Iprivask <s> Lovenox <s> Mephyton Persantine Plavix Pletal Pradaxa Savaysa Ticlid Trental Vitamin K Xarelto Zontivity PA - Prior approval may be required Generic name aspirin/dipyridamole anagrelide hcl aminocaproic acid fondaparinux sodium warfarin sodium heparin sodium,porcine enoxaparin sodium dipyridamole clopidogrel bisulfate cilostazol ticlopidine hcl pentoxifylline phytonadione ST - Step therapy may be required BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 3 2 1 1 1 3 3 3 1 1 1 1 1 1 3 1 1 1 1 1 3 2 1 1 1 3 3 3 1 1 1 1 1 1 3 1 1A 1A 1A 1A 3 2 1A 1B 1A 3 3 3 1B 1B 1A 1B 1B 1A 3 1B BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 2 1 1 2 1 2 2 3 1 3 1 2 1 1 1 2 3 1 1 1 2 3 1 1 2 1 4 2 1 2 2 5 4 5 4 2 1 1 1 2 3 1 1 1 2 3 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 1B 2 1B 4 2 1A 2 2 5 4 5 4 2 1B 1A 1B 2 3 1B 1B 1B 2 3 <s> - Specialty Drug Page 20 2E. Beta Blockers and Combinations Trade name Betapace, AF Blocadren Bystolic Bystolic 20mg Coreg CR Coreg immediate release Corgard Corzide Dutoprol Hemangeol Inderal XL Inderal, LA Inderide Innopran XL Kerlone Levatol Lopressor Lopressor HCT Normodyne; Trandate Pindolol Sectral Sotylize Tenoretic Tenormin Toprol XL Zebeta Ziac Generic name sotalol hcl timolol maleate carvedilol nadolol nadolol/bendroflumethiazide propranolol hcl propranolol/hydrochlorothiazide betaxolol hcl metoprolol tartrate metoprolol/hydrochlorothiazide labetalol hcl pindolol acebutolol hcl atenolol/chlorthalidone atenolol metoprolol succinate bisoprolol fumarate bisoprolol/hydrochlorothiazide 2F. Calcium Channel Blockers and Combinations Trade name Azor Caduet Calan SR; Isoptin SR Cardene Cardene SR Cardizem LA 120mg Cardizem, SR, CD, LA Dynacirc Exforge Exforge HCT Lotrel Norvasc Plendil Prestalia Procardia, XL; Adalat CC Sular Tarka Tiazac Tribenzor Twynsta Verelan PM PA - Prior approval may be required Generic name amlodipine/atorvastatin cal verapamil hcl nicardipine hcl diltiazem hcl isradipine amlodipine/valsartan amlodipine/valsartan/hctz amlodipine besylate/benazepril amlodipine besylate felodipine nifedipine nisoldipine trandolapril/verapamil hcl diltiazem hcl telmisartan/amlodipine verapamil hcl ST - Step therapy may be required BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 3 3 3 1 1 1 3 3 3 1 1 3 1 3 1 1 1 1 1 3 1 1 1 1 1 1 1 3 3 3 1 1 1 3 3 3 1 1 3 1 3 1 1 1 1 1 3 1 1 1 1 1 1A 1A 3 3 3 1A 1A 1A 3 3 3 1A 1A 3 1A 3 1A 1A 1A 1A 1A 3 1A 1A 1A 1A 1A BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 1 1 3 3 1 1 1 1 1 1 1 3 1 1 1 1 3 1 1 3 1 1 1 3 3 1 1 1 1 1 1 1 3 1 1 1 1 3 1 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 3 1B 1B 1B 3 3 1B 1B 1B 1B 1A 1A 1B 3 1B 1B 1B 1B 3 1B 1B <s> - Specialty Drug Page 21 2G. Cardiovascular Treatment BCBSM/BCN BCBSM Trade name Betapace, AF Cordarone Corlanor Lanoxin Lanoxin 62.5, 187.5mcg Mexitil Multaq Norpace Norpace CR Northera <s> Papaverine capsule Proamatine Quinidine gluconate Quinidine sulfate Ranexa Rythmol, SR Sotylize Tambocor Tikosyn Vasodilan (BCBSM only) Generic name sotalol hcl amiodarone hcl digoxin mexiletine hcl disopyramide phosphate papaverine hcl midodrine hcl quinidine gluconate quinidine sulfate propafenone hcl flecainide acetate isoxsuprine hcl BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 3 1 3 1 2 1 2 3 1 1 1 1 3 1 3 1 2 1 1 1 3 1 3 1 2 1 2 5 1 1 1 1 3 1 3 1 2 1 1A 1B 3 1B 3 1B 2 1B 2 5 1B 1B 1B 1B 3 1B 3 1B 2 NC NC - Not Covered for members with a BCN drug benefit 2H. Diuretics Trade name Aldactazide Aldactazide 50/50mg (Tier 2 BCN only) Aldactone Bumex Demadex Diamox, Sequels Diuril capsules, tablets Diuril suspension (Tier 2 BCN only) Dutoprol Dyazide, Maxzide Dyrenium Edecrin Furosemide solution (Tier 2 BCN only) Hydrodiuril; Microzide Hygroton; Thalitone Inspra Lasix Lozol Midamor Moduretic Zaroxolyn PA - Prior approval may be required BCBSM/BCN BCBSM Generic name spironolact/hydrochlorothiazid spironolactone bumetanide torsemide acetazolamide chlorothiazide triamterene/hydrochlorothiazide hydrochlorothiazide chlorthalidone eplerenone furosemide indapamide amiloride hcl amiloride/hydrochlorothiazide metolazone ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 1 1 1 1 1 3 3 1 2 2 3 1 1 1 1 1 1 1 1 1 3 1 1 1 1 1 3 3 1 2 2 3 1 1 1 1 1 1 1 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1A 2 1A 1A 1A 1B 1A 2 3 1A 2 2 2 1A 1A 1A 1A 1A 1A 1A 1A <s> - Specialty Drug Page 22 2I. Lipid-lowering Agents BCBSM/BCN BCBSM Trade name Advicor Altoprev Antara Antara 30, 90mg Caduet Colestid Colestid granules, packet Crestor Fenoglide; Fenofibrate Fibricor Juxtapid <s> Kynamro <s> Lescol Lescol XL Lipitor Lipofen Liptruzet Livalo Lofibra Lopid Lovaza Mevacor Niacor (Tier 2 BCN only) Niaspan Praluent <s> Pravachol Questran, Light Repatha <s> Simcor Tricor Triglide Trilipix Vascepa Vytorin Welchol Zetia Zocor Generic name fenofibrate,micronized amlodipine/atorvastatin cal colestipol hcl fenofibric acid fluvastatin sodium fluvastatin sodium atorvastatin calcium fenofibrate,micronized gemfibrozil omega-3 acid ethyl esters lovastatin niacin pravastatin sodium cholestyramine fenofibrate nanocrystallized fenofibric acid (choline) simvastatin 2J. Nitrates and Combinations Trade name BiDil Dilatrate-SR Imdur Isordil Isordil 40mg (Tier 2 BCN Only) Nitro-Bid ointment Nitro-Dur (Tier 2 BCN Only) Nitro-Dur 0.3mg, 0.8mg Nitroglycerin caps, patch, spray, tablet Nitrostat PA - Prior approval may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 1 3 1 1 3 3 3 1 3 2 1 1 1 3 3 3 1 1 1 1 3 1 3 1 1 3 3 1 3 1 3 3 2 2 1 3 3 1 3 1 1 3 3 3 1 5 4 1 1 1 3 3 3 1 1 1 1 3 1 5 1 1 5 3 1 3 1 3 3 2 2 1 3 3 1B 3 1B 1B 3 3 3 1B 5 4 1B 1B 1A 3 3 3 1A 1A 1B 1A 2 1B 5 1A 1B 5 3 1B 3 1B 3 3 2 2 1A BCBSM/BCN BCBSM Generic name isosorbide mononitrate isosorbide dinitrate nitroglycerin nitroglycerin ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 1 1 3 1 3 3 1 2 2 2 1 1 3 1 3 3 1 2 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 2 2 1A 1B 2 1B 2 3 1B 2 <s> - Specialty Drug Page 23 2K. Renin-inhibitors and Combinations Trade name Generic name Tekamlo Tekturna Tekturna HCT Trade name PA - Prior approval may be required Generic name hydralazine hcl minoxidil ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 3 2L. Miscellaneous Antihypertensives Apresoline Demser (Tier 2 BCN Only) Loniten Vecamyl BCBSM/BCN BCBSM 3 3 3 3 3 3 BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 1 3 1 3 1 3 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 2 1B 3 <s> - Specialty Drug Page 24 3. CENTRAL NERVOUS SYSTEM 3A. Alzheimer's therapy Trade name Aricept 23mg Aricept, ODT Exelon capsules Exelon patch Namenda Namenda dosepak Namenda XR Namzaric Razadyne, ER PA - Prior approval may be required BCBSM/BCN BCBSM Generic name donepezil hcl donepezil hcl rivastigmine tartrate rivastigmine memantine hcl galantamine hydrobromide BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 1 2 3 3 1 1 1 1 1 1 2 3 3 1 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 1B 1B 1B 1B 1B 2 3 3 1B <s> - Specialty Drug Page 25 3B. Anticonvulsants BCBSM/BCN BCBSM Trade name Generic name Acthar H.P. <s> Aptiom Banzel Banzel suspension (Tier 2 BCN only) Carbatrol Celontin Depakene Depakote, ER, Sprinkles Diamox, Sequels Diastat 2.5mg Kit Diastat Acudial Dilantin Dilantin 30mg Dilantin Chew Tabs Felbatol Fycompa Gabitril Gabitril 12, 16mg Keppra Keppra XR Klonopin, Wafer Lamictal dosepak Lamictal dosepak ODT Lamictal ODT, XR Lamictal tabs, dispertabs Lamictal XR dosepak Lyrica Mebaral Mysoline Neurontin Onfi Oxtellar XR Peganone Phenobarbital Potiga Qudexy XR Sabril <s> Tegretol XR 100mg Tegretol, XR Topamax Topiramate ER Trileptal Trokendi XR Vimpat Zarontin Zonegran PA - Prior approval may be required carbamazepine valproate sodium divalproex sodium acetazolamide diazepam phenytoin sodium extended phenytoin felbamate tiagabine hcl levetiracetam levetiracetam clonazepam lamotrigine lamotrigine lamotrigine mephobarbital primidone gabapentin phenobarbital carbamazepine topiramate oxcarbazepine ethosuximide zonisamide BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 2 3 1 2 1 1 1 2 1 1 2 1 1 3 1 2 1 1 1 2 1 1 1 3 3 1 1 1 3 3 2 1 3 3 2 2 1 1 3 1 3 2 1 1 5 3 2 3 1 2 1 1 1 2 1 1 2 1 1 3 1 2 1 1 1 2 1 1 1 3 3 1 1 1 3 3 2 1 3 3 4 2 1 1 3 1 3 2 1 1 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 5 3 2 2 1B 2 1B 1B 1B 2 1B 1A 2 1A 1B 3 1B 2 1A 1B 1B 2 1B 1B 1B 3 3 1B 1B 1B 3 3 2 1B 3 3 4 2 1B 1B 3 1B 3 2 1B 1B <s> - Specialty Drug Page 26 3C. Antidepressants Trade name Amoxapine Anafranil Aplenzin Aventyl; Pamelor Brintellix Celexa Cymbalta Cymbalta 60 mg Desvenlafaxine ER Desvenlafaxine Fumarate ER Desyrel Effexor Effexor XR Elavil Emsam Etrafon Fetzima Fluoxetine 60mg Forfivo XL Khedezla Lexapro Limbitrol, DS Luvox Luvox CR Maprotiline hcl Marplan Nardil Norpramin Oleptro ER Parnate Paxil Paxil CR Paxil solution Perphenazine/amitriptyline hcl Pexeva Pristiq ER Protriptyline hcl Prozac Prozac Weekly Remeron Sarafem Serzone Sinequan; Adapin Surmontil Tofranil Tofranil-PM Venlafaxine hcl ER Viibryd Wellbutrin 300mg Wellbutrin, SR, XL Zoloft PA - Prior approval may be required BCBSM/BCN BCBSM Generic name amoxapine clomipramine hcl nortriptyline hcl citalopram hydrobromide duloxetine hcl duloxetine hcl trazodone hcl venlafaxine hcl venlafaxine hcl amitriptyline hcl amitriptyline hcl/perphenazine escitalopram oxalate amitrip hcl/chlordiazepoxide fluvoxamine maleate fluvoxamine maleate maprotiline hcl phenelzine sulfate desipramine hcl tranylcypromine sulfate paroxetine hcl paroxetine hcl amitriptyline hcl/perphenazine protriptyline hcl fluoxetine hcl fluoxetine hcl mirtazapine nefazodone hcl doxepin hcl trimipramine maleate imipramine hcl imipramine pamoate venlafaxine hcl bupropion hcl bupropion hcl sertraline hcl BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 3 1 3 1 1 1 3 3 1 1 1 1 3 1 3 3 3 3 1 1 1 1 1 3 1 1 3 1 1 1 3 1 3 3 1 1 1 1 3 1 1 1 1 1 1 3 1 1 1 1 1 3 1 3 1 1 1 3 3 1 1 1 1 3 1 3 3 3 3 1 1 1 1 1 3 1 1 3 1 1 1 3 1 3 3 1 1 1 1 3 1 1 1 1 1 1 3 1 1 1 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 1B 1B 3 1A 3 1A 1B 1B 3 3 1A 1A 1A 1A 3 1B 3 3 3 3 1A 1B 1A 1B 1A 3 1B 1A 3 1B 1A 1B 3 1B 3 3 1B 1A 1B 1A 3 1B 1A 1B 1A 1B 1B 3 1A 1A 1A <s> - Specialty Drug Page 27 3D. Antipsychotics Trade name Abilify Clozapine 200mg Clozaril Equetro Etrafon Fanapt Fazaclo Fazaclo 150, 200mg Geodon Haldol Haldol liquid 2mg/ml Invega Latuda Loxitane Mellaril Molindone Navane Orap Perphenazine Prolixin Rexulti Risperdal, M-Tab, solution Saphris Seroquel Seroquel XR Stelazine Symbyax Thorazine Versacloz Zyprexa, Zydis BCBSM/BCN BCBSM Generic name aripiprazole clozapine clozapine amitriptyline hcl/perphenazine clozapine ziprasidone hcl haloperidol haloperidol lactate paliperidone loxapine succinate thioridazine hcl molindone hcl thiothixene pimozide perphenazine fluphenazine hcl risperidone quetiapine fumarate trifluoperazine hcl olanzapine/fluoxetine hcl chlorpromazine hcl olanzapine 3E. Anxiolytics Trade name Ativan Buspar Equanil; Miltown Librium Niravam Serax Tranxene T-Tab Valium Xanax, XR PA - Prior approval may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 3 1 3 1 3 1 1 1 1 3 1 1 1 1 1 1 1 3 1 3 1 3 1 1 1 3 1 1 1 1 3 1 3 1 3 1 1 1 1 3 1 1 1 1 1 1 1 3 1 3 1 3 1 1 1 3 1 1B 1B 1A 3 1B 3 1B 3 1B 1A 1B 1B 3 1B 1A 1B 1B 1B 1B 1A 3 1A 3 1A 3 1A 1B 1A 3 1A BCBSM/BCN BCBSM Generic name lorazepam buspirone hcl meprobamate chlordiazepoxide hcl alprazolam oxazepam clorazepate dipotassium diazepam alprazolam BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 1B 1B 1B 1B 1B 1B 1B 1B 1B <s> - Specialty Drug Page 28 3F. CNS Stimulants Trade name Adderall Adderall XR (Brand BCN-Only) Adderall XR Aptensio XR Concerta Daytrana Desoxyn Dexedrine Evekeo Focalin immediate release Focalin XR Focalin XR 25, 35mg Metadate CD Methylin, ER Nuvigil Procentra Provigil Quillivant XR Ritalin LA Ritalin LA 10mg, 60mg Ritalin, SR Vyvanse Zenzedi BCBSM/BCN BCBSM Generic name amphet asp/amphet/d-amphet amphet asp/amphet/d-amphet methylphenidate hcl methamphetamine hcl d-amphetamine sulfate dexmethylphenidate hcl dexmethylphenidate hcl methylphenidate hcl methylphenidate hcl d-amphetamine sulfate modafinil methylphenidate hcl methylphenidate hcl 3G. Migraine Therapy Trade name Alsuma Amerge Axert Cafergot Cambia D.H.E.45 Ergomar Esgic Fioricet 50/300/40mg capsule Fioricet w/codeine 50/300/30mg Fiorinal Fiorinal w/codeine Frova Imitrex (All Forms) Maxalt, MLT Midrin (BCBSM only) Migranal Phrenilin tablet Relpax Sumavel Dosepro Treximet Zecuity Zomig, ZMT Zomig Nasal Spray 2.5mg Zomig Nasal Spray 5mg BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 3 1 3 1 1 3 1 1 3 1 1 3 1 1 3 1 3 1 3 3 1 1 1 3 1 3 1 1 3 1 1 3 1 1 3 1 1 3 1 3 1 3 3 1B 1B 1B 3 1B 3 1B 1B 3 1B 1B 3 1B 1B 3 1B 1B 3 1B 3 1B 3 3 BCBSM/BCN BCBSM Generic name sumatriptan succinate naratriptan hcl almotriptan malate dihydroergotamine mesylate butalb/acetaminophen/caffeine butalbit/acetamin/caff/codeine butalbit/acetamin/caff/codeine butalbital/aspirin/caffeine codeine/butalbital/asa/caffein sumatriptan succinate rizatriptan benzoate isometheptene/apap/dichlphen dihydroergotamine mesylate butalbital/acetaminophen zolmitriptan BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 2 3 1 2 1 1 1 1 1 3 1 1 1 1 1 3 3 3 3 1 3 3 1 1 1 2 3 1 2 1 1 1 1 1 3 1 1 1 1 1 3 3 3 3 1 3 3 1B 1B 1B 2 3 1B 2 1B 1B 1B 1B 1B 3 1B 1B NC 1B 1B 3 3 3 3 1B 3 3 NC - Not Covered for members with a BCN drug benefit PA - Prior approval may be required QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) <s> - Specialty Drug Page 29 3H. Myesthenia Gravis BCBSM/BCN BCBSM Trade name Generic name Mestinon Syrup Mestinon Timespan pyridostigmine bromide 3I. Narcotic Antagonists Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 1 2 1 2 1B BCBSM/BCN BCBSM Trade name Generic name Evzio Movantik Relistor Revia naltrexone hcl 3J. Narcotic Mixed Agonist/Antagonist Trade name Generic name Belbuca Bunavail Butrans Conzip Ryzolt Stadol, NS Suboxone Suboxone Film Talwin NX Ultracet Ultram, ER Zubsolv tramadol hcl butorphanol tartrate buprenorphine hcl/naloxone hcl pentazocine hcl/naloxone hcl tramadol hcl/acetaminophen tramadol hcl 3K. Narcotic/Analgesic Combinations Trade name Generic name Belladonna & Opium Esgic Fioricet 50/300/40mg capsule Fioricet w/codeine 50/300/30mg Fiorinal Fiorinal w/codeine Hycet Ibudone Ibudone 5mg/200mg (Tier 2 BCN Only) levorphanol tartrate Lortab; Norco; Vicodin; Xodol Percocet Percodan Phrenilin Reprexain Synalgos-DC (Tier 2 BCN Only) Trezix Trezix Tylenol w/Codeine Vicoprofen Xartemis XR PA - Prior approval may be required BCN opium/belladonna alkaloids butalb/acetaminophen/caffeine butalbit/acetamin/caff/codeine butalbit/acetamin/caff/codeine butalbital/aspirin/caffeine codeine/butalbital/asa/caffein hydrocodone bit/acetaminophen hydrocodone/ibuprofen levorphanol tartrate hydrocodone bit/acetaminophen oxycodone hcl/acetaminophen oxycodone hcl/aspirin butalbital/acetaminophen hydrocodone/ibuprofen dhcodeine bt/acetaminophn/caff codeine phos/acetaminophen hydrocodone/ibuprofen BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 3 2 1 2 3 2 1 2 3 2 1B BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 3 3 1 1 1 2 1 1 1 3 3 3 3 3 1 1 1 2 1 1 1 3 3 3 3 3 1B 1B 1B 2 1B 1B 1B 3 BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 1 1 1 1 3 1 1 1 1 1 1 3 3 1 1 1 3 1 1 1 1 1 1 1 1 3 1 1 1 1 1 1 3 3 1 1 1 3 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 1B 1B 1B 1B 1B 1B 1B 1B 2 1B 1B 1B 1B 1B 1B 2 3 1B 1B 1B 3 <s> - Specialty Drug Page 30 3L. Narcotics Trade name Abstral Actiq Avinza Codeine sulfate tablets Demerol Dilaudid Duragesic Embeda Exalgo Fentanyl patch 37.5 62.5, 87.5mg Fentora Hysingla ER Kadian Kadian 40, 200mg Lazanda Methadone MS Contin MSIR Nucynta, ER Opana Opana, ER Oxaydo Oxycodone hcl ER Oxycodone immediate release Oxycontin RMS suppository Roxanol Subsys Zohydro ER PA - Prior approval may be required BCBSM/BCN BCBSM Generic name fentanyl citrate morphine sulfate codeine sulfate meperidine hcl hydromorphone hcl fentanyl hydromorphone hcl morphine sulfate methadone hcl morphine sulfate morphine sulfate oxymorphone hcl oxymorphone hcl oxycodone hcl morphine sulfate morphine sulfate BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 1 1 1 1 1 3 1 3 3 3 1 3 3 1 1 1 3 1 1 3 3 1 3 1 1 3 3 3 1 1 1 1 1 1 3 1 3 3 3 1 3 3 1 1 1 3 1 1 3 3 1 3 1 1 3 3 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 3 1B 1B 1B 1B 1B 1B 3 1B 3 3 3 1B 3 3 1B 1B 1B 3 1B 1B 3 3 1B 3 1B 1B 3 3 <s> - Specialty Drug Page 31 3M. Nonsteroidal Anti-inflammatory Drugs Trade name Generic name Anaprox, DS Ansaid Arthrotec Cambia Cataflam Celebrex Clinoril Daypro Duexis EC-Naprosyn Feldene Fenoprofen Calcium 400mg (Tier 2 BCN Flector patch Indocin suppository Indocin suspension (Tier 2 BCN only) Indocin, SR Ketoprofen Lodine, XL Meclomen Mobic Motrin (Rx only) Nalfon Nalfon 400mg (Tier 2 BCN only) Naprelan Naprelan 750mg Naprosyn (Rx only) Pennsaid 1.5% Pennsaid 2% Ponstel Relafen Sprix Tivorbex Tolectin, DS Toradol Vimovo Vivlodex Voltaren gel Voltaren tablets Voltaren XR Zipsor Zorvolex PA - Prior approval may be required naproxen sodium flurbiprofen diclofenac sodium/misoprostol diclofenac potassium celecoxib sulindac oxaprozin naproxen piroxicam indomethacin ketoprofen etodolac meclofenamate sodium meloxicam ibuprofen fenoprofen calcium naproxen sodium naproxen diclofenac sodium mefenamic acid nabumetone tolmetin sodium ketorolac tromethamine diclofenac sodium diclofenac sodium BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 3 1 1 1 1 3 1 1 3 3 2 3 1 1 1 1 1 1 1 3 1 3 1 1 3 1 1 3 3 1 1 3 3 3 1 1 3 3 1 1 1 3 1 1 1 1 3 1 1 3 3 2 3 1 1 1 1 1 1 1 3 1 3 1 1 3 1 1 3 3 1 1 3 3 3 1 1 3 3 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 1A 1B 1B 3 1B 1B 1B 1B 3 1A 1B 2 3 2 2 1B 1B 1B 1B 1A 1A 1B 2 1B 3 1A 1B 3 1B 1B 3 3 1B 1B 3 3 3 1A 1B 3 3 <s> - Specialty Drug Page 32 3N. Parkinsons Disease and Related Disorders Trade name Generic name Apokyn <s> Artane Azilect Cogentin Comtan Duopa <s> Eldepryl Lodosyn Mirapex Mirapex ER Mirapex ER 3.75 Neupro Parcopa Parlodel Requip Requip XL Requip XL 12mg Rytary Sinemet, CR Stalevo Symmetrel Tasmar Zelapar trihexyphenidyl hcl benztropine mesylate entacapone selegiline hcl carbidopa pramipexole di-hcl pramipexole di-hcl carbidopa/levodopa bromocriptine mesylate ropinirole hcl ropinirole hcl ropinirole hcl carbidopa/levodopa carbidopa/levodopa/entacapone amantadine hcl tolcapone 3O. Salicylates BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 1 2 1 1 2 1 1 1 1 3 3 1 1 1 1 1 3 1 1 1 1 3 4 1 2 1 1 4 1 1 1 1 3 3 1 1 1 1 1 3 1 1 1 1 3 4 1B 2 1B 1B 4 1B 1B 1B 1B 3 3 1B 1B 1B 1B 1B 3 1B 1B 1B 1B 3 BCBSM/BCN BCBSM Trade name Generic name Aspirin, Ecotrin 81, 325mg (Prevent) Disalcid Dolobid Durlaza Frenadol (BCBSM only) Trilisate (BCBSM only) aspirin salsalate diflunisal choline magnesium trisalicylate BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL $0 1 1 3 3 1 $0 1 1 3 3 1 $0 1B 1B 3 NC NC NC - Not Covered for members with a BCN drug benefit PA - Prior approval may be required QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) <s> - Specialty Drug Page 33 3P. Sedative/Hypnotics BCBSM/BCN BCBSM Trade name Ambien Ambien CR Belsomra Butisol sodium Chloral Hydrate (BCBSM Only) Dalmane Doral Edluar Halcion Hetlioz <s> Intermezzo Lunesta Prosom Restoril Rozerem Seconal Silenor Sonata Zolpimist Generic name zolpidem tartrate zolpidem tartrate chloral hydrate flurazepam hcl quazepam triazolam eszopiclone estazolam temazepam secobarbital sodium zaleplon BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 3 3 1 1 1 3 1 3 3 1 1 1 3 1 3 1 3 1 1 3 3 1 1 1 3 1 5 3 1 1 1 3 1 3 1 3 1B 1B 3 3 NC 1B 1B 3 1B 5 3 1B 1B 1B 3 1B 3 1B 3 NC - Not Covered for members with a BCN drug benefit 3Q. Skeletal Muscle Relaxants Trade name Amrix Baclofen Dantrium Fexmid Flexeril Lorzone Norflex Norgesic, Forte Parafon Forte DSC Robaxin Skelaxin Soma Soma Compound Soma Compound w/Codeine Valium Zanaflex capsule Zanaflex tablet PA - Prior approval may be required BCBSM/BCN BCBSM Generic name baclofen dantrolene sodium cyclobenzaprine hcl cyclobenzaprine hcl orphenadrine citrate orphenadrine/aspirin/caffeine chlorzoxazone methocarbamol metaxalone carisoprodol carisoprodol/aspirin codeine phos/carisoprodol/asa diazepam tizanidine hcl tizanidine hcl BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 3 1B 1B 1B 1B 3 1B 1B 1B 1B 1B 1B 1B 1B 1B 1B 1B <s> - Specialty Drug Page 34 3R. Miscellaneous CNS Trade name Antabuse Cafcit Campral Cuvposa Ergoloid Mesylates Eskalith Eskalith CR Gralise Gralise dosepak Horizant Intuniv Kapvay Lithium Citrate Lithobid Nimotop Nuedexta Nymalize Rilutek Robinul, Forte Savella Strattera Xenazine <s> Xyrem <s> PA - Prior approval may be required BCBSM/BCN BCBSM Generic name disulfiram caffeine citrated acamprosate calcium ergoloid mesylates lithium carbonate lithium carbonate guanfacine hcl clonidine hcl lithium citrate lithium carbonate nimodipine riluzole glycopyrrolate tetrabenazine BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 3 1 1 1 3 3 3 1 1 1 1 1 2 3 1 1 3 3 1 3 1 1 1 3 1 1 1 3 3 3 1 1 1 1 1 2 3 1 1 3 3 4 5 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 1B 1B 1B 3 1B 1A 1A 3 3 3 1B 1B 1A 1A 1B 2 3 1B 1B 3 3 4 5 <s> - Specialty Drug Page 35 4. GASTROINTESTINAL AGENTS 4A. 5-Aminosalicylic Acid (5-ASA) Agents Trade name Apriso Asacol HD Azulfidine, En-Tab Canasa Colazal Delzicol Dipentum Giazo Lialda Pentasa Rowasa enema; SfRowasa enema Generic name sulfasalazine balsalazide disodium mesalamine 4B. Antidiarrheals and Antispasmodics Trade name Bentyl Donnatal, Extentabs (BCBSM only) Fulyzaq Imodium Levbid Levsin, SL Levsinex Librax Lomotil Paregoric (BCBSM only) Pro-Banthine Generic name dicyclomine hcl loperamide hcl hyoscyamine sulfate hyoscyamine sulfate hyoscyamine sulfate clidinium br/chlordiazepoxide diphenoxylate hcl/atrop sulf paregoric propantheline bromide BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 2 1 2 1 2 3 3 3 2 1 3 2 1 2 1 2 3 3 3 2 1 3 2 1B 2 1B 2 3 3 3 2 1B BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 2 1 1 1 1 1 1 1 1 1 3 2 1 1 1 1 1 1 1 1 1B NC 2 1B 1B 1B 1B 1B 1B NC 1B NC - Not Covered for members with a BCN drug benefit 4C. Antiemetics Trade name Akynzeo Antivert Anzemet Cesamet Compazine Compazine suppositories Diclegis Emend 40mg (BCBSM only) Emend 80, 125mg; dosepak capsules Kytril Marinol Phenergan Sancuso Tigan Transderm-Scop Zofran, ODT Zuplenz BCBSM/BCN BCBSM Generic name meclizine hcl prochlorperazine maleate prochlorperazine granisetron hcl dronabinol promethazine hcl trimethobenzamide hcl ondansetron BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 3 3 1 1 3 2 2 1 1 1 3 1 2 1 3 3 1 3 3 1 1 3 2 2 1 1 1 3 1 2 1 3 3 1B 3 3 1B 1B 3 MB 2 1B 1B 1B 3 1B 2 1B 3 MB - May be covered under medical benefit PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) <s> - Specialty Drug Page 36 4D. Bile Acids BCBSM/BCN BCBSM Trade name Generic name Actigall Chenodal <s> Urso, Urso Forte ursodiol 4E. Bowel Preparation and Cleansing Agents Trade name Generic name Colyte Golytely Golytely packet Halflytely Moviprep Nulytely Osmoprep Prepopik Suprep sod sulf/sod/nahco3/kcl/peg's peg 3350/na sulf,bicarb,cl/kcl bisac/nacl/nahco3/kcl/peg 3350 sod sulf/sod/nahco3/kcl/peg's 4F. Digestive Enzymes Trade name Generic name lipase/protease/amylase 4G. H2-Receptor Antagonists Axid (RX Only) Pepcid (RX Only) Tagamet (RX Only) Zantac (RX Only) Trade name PA - Prior approval may be required 1B 5 1B BCBSM/BCN BCBSM nizatidine famotidine cimetidine ranitidine hcl Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 2 1 3 1 3 3 3 1 1 2 1 3 1 3 3 3 1B 1B 2 1B 3 1B 3 3 3 sucralfate misoprostol lansoprazole/amoxiciln/clarith ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 3 2 2 2 1 2 2 3 2 2 2 1 2 2 3 2 2 2 1B BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 1 1 1 1 1B 1B 1B 1B BCBSM/BCN BCBSM Generic name BCN BCBSM/BCN BCBSM Generic name 4H. Other Ulcer Therapy Cantil Carafate Cytotec Omeclamox-Pak Prevpac Pylera 1 5 1 BCBSM/BCN BCBSM Creon Pancreaze Pertzye Ultresa Viokace Zenpep Zenpep 5,000 Trade name Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 1 ursodiol BCN BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 1 3 1 3 3 1 1 3 1 3 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 3 1B 1B 3 1B 3 <s> - Specialty Drug Page 37 4I. Proton Pump Inhibitors BCBSM/BCN BCBSM Trade name Generic name Aciphex Aciphex Sprinkle Dexilant Nexium Nexium suspension Omeprazole OTC Prevacid Prevacid Solutab Prilosec Prilosec OTC Prilosec suspension Protonix Protonix suspension Vimovo Zegerid packet Zegerid RX rabeprazole sodium esomeprazole magnesium omeprazole lansoprazole omeprazole omeprazole magnesium pantoprazole sodium omeprazole/sodium bicarbonate 4J. Topical Anti-Inflammatory Agents Trade name Generic name Analpram HC Analpram HC lot, cream (BCBSM Only) Anamantle HC Anusol HC Cortenema Cortifoam Epifoam (Tier 2 BCN only) HC Acetate/Pramoxine hcl Pramosone (BCBSM Only) Proctocort Proctosol-HC suppository hydrocortisone/pramoxine hcl lidocaine hcl/hc hydrocortisone hydrocortisone acetate hc acetate/pramoxine hcl hydrocortisone acetate hydrocortisone acetate BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 3 1 3 1 1 2 1 1 3 1 3 3 3 1 1 3 3 1 3 1 1 2 1 1 3 1 3 3 3 1 1B 3 3 1B 3 1B 1B 2 1B 1B 3 1B 3 3 3 1B BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 2 1 1 1 2 3 1 3 1 1 1 2 1 1 1 2 3 1 3 1 1 1B NC 1B 1B 1B 2 2 1B NC 1B 1B NC - Not Covered for members with a BCN drug benefit 4K. Tumor Necrosis Factor (TNF) Blocking Agents Trade name Generic name Cimzia Syringe <s> Humira <s> Simponi <s> PA - Prior approval may be required BCBSM/BCN BCBSM Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 2 3 ST - Step therapy may be required BCN 5 4 5 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 5 4 5 <s> - Specialty Drug Page 38 4L. Miscellaneous Gastrointestinal Agents Trade name Amitiza Evoxac Gastrocrom Gattex <s> Glycolax Kristalose (Tier 2 BCN only) Lactulose Linzess Lotronex Metozolv ODT Movantik Rectiv Reglan Relistor Robinul, Forte Salagen Sucraid <s> Xifaxan 200mg Xifaxan 550mg Zorbtive <s> PA - Prior approval may be required Generic name cevimeline hcl cromolyn sodium polyethylene glycol 3350 lactulose alosetron hcl metoclopramide hcl metoclopramide hcl glycopyrrolate pilocarpine hcl ST - Step therapy may be required BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 1 2 1 3 1 3 1 1 3 3 1 2 1 1 3 3 3 3 3 1 1 4 1 3 1 3 1 1 3 3 1 2 1 1 5 3 3 5 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 3 1B 1B 4 1B 2 1B 3 1B 1B 3 3 1B 2 1B 1B 5 3 3 5 <s> - Specialty Drug Page 39 5. OBSTETRICS AND GYNECOLOGY 5A. Contraceptives-Biphasic BCBSM/BCN BCBSM Trade name Generic name Lo Loestrin Fe Loseasonique (Prevent) Mircette (Prevent) Necon 10/11 (Prevent) Seasonique (Prevent) l-norgest-eth estr/ethin estra desog-et estra/ethin estra norethindrone-ethinyl estrad l-norgest-eth estr/ethin estra 5B. Contraceptives-Misc. Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 $0 $0 $0 $0 3 $0 $0 $0 $0 3 $0 $0 $0 $0 BCBSM/BCN BCBSM Trade name Generic name Conceptrol (Prevent) Depo-Provera 150mg (Prevent) Depo-Subq Provera 104 FC2 Female Condom (Prevent) Gynol II (Prevent) Natazia Nor-QD; Ortho Micronor (Prevent) Nuvaring (Prevent) Ortho Evra (Prevent) Quartette Safyral Today Contraceptive Sponge (Prevent) VCF film (Prevent) VCF foam (Prevent) medroxyprogesterone acet norethindrone norelgestromin/ethin.estradiol nonoxynol 9 5C. Contraceptives-Monophasic Trade name levonorgestrel-eth estra ethynodiol d-ethinyl estradiol desogestrel-ethinyl estradiol noreth-ethinyl estradiol/iron noreth-ethinyl estradiol/iron levonorgestrel-eth estra norgestrel-ethinyl estradiol noreth a-et estra/fe fumarate norethindrone a-e estradiol levonorgestrel-eth estra norethindrone-ethinyl estrad norethindrone-mestranol norethindrone-ethinyl estrad norgestimate-ethinyl estradiol norethindrone-ethinyl estrad norgestrel-ethinyl estradiol levonorgestrel-eth estra ethinyl estradiol/drospirenone ethinyl estradiol/drospirenone BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL $0 $0 2 $0 $0 3 $0 $0 $0 3 3 $0 $0 $0 $0 $0 2 $0 $0 3 $0 $0 $0 3 3 $0 $0 $0 $0 $0 2 $0 $0 3 $0 $0 $0 3 3 $0 $0 $0 BCBSM/BCN BCBSM Generic name Alesse, Levlite (Prevent) Beyaz Demulen (Prevent) Desogen; Ortho-cept Femcon Fe (Prevent) Generess Fe (Prevent) Levlen; Nordette (Prevent) Lo/Ovral (Prevent) Loestrin 24 Fe (Prevent) Loestrin, Fe (Prevent) Lybrel (Prevent) Modicon (Prevent) Norinyl/Ortho-Novum 1/35 (Prevent) Norinyl/Ortho-Novum 1/50 (Prevent) Ortho-Cyclen (Prevent) Ovcon 35 (Prevent) Ovral (Prevent) Seasonale (Prevent) Yasmin 28 (Prevent) Yaz (Prevent) PA - Prior approval may be required BCN BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL $0 3 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 3 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) $0 3 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 <s> - Specialty Drug Page 40 5D. Contraceptives-Postcoital BCBSM/BCN BCBSM Trade name Generic name Ella (Prevent) Plan B, One-Step (Prevent) levonorgestrel 5E. Contraceptives-Triphasic Generic name desogestrel-ethinyl estradiol noreth a-et estra/fe fumarate norgestimate-ethinyl estradiol norethindrone-ethinyl estrad levonorgestrel-eth estra norethindrone-ethinyl estrad 5F. Estrogen/Progestin Combinations Trade name Activella Angeliq Climara Pro Combipatch FemHRT Prefest Prempro, Low Dose; Premphase Generic name estradiol/norethindrone acet norethindrone ac-eth estradiol 5G. Estrogens PA - Prior approval may be required $0 $0 $0 $0 $0 $0 Generic name estradiol estradiol valerate estradiol estropipate estradiol BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL $0 $0 $0 2 $0 $0 $0 $0 $0 $0 2 $0 $0 $0 $0 $0 $0 2 $0 $0 $0 BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 3 3 1 3 2 1 3 3 3 1 3 2 1B 3 3 3 1B 3 2 BCBSM/BCN BCBSM Trade name Alora Climara Delestrogen Divigel Elestrin Enjuvia Estrace tablets Estrace Vaginal cream Estring Estrogel Evamist Femring Femtrace Menest Menostar Ogen; Ortho-Est Premarin, Low Dose, cream Vagifem Vivelle-Dot Custom 5-Tier PA ST QL 6-Tier PA ST QL BCBSM/BCN BCBSM Trade name Cyclessa (Prevent) Estrostep Fe (Prevent) Ortho Tri-Cyclen (Prevent) Ortho Tri-Cyclen Lo Ortho-Novum 7/7/7 (Prevent) Trilevlen; Triphasil (Prevent) Tri-Norinyl (Prevent) BCN BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 1 2 3 3 2 1 3 2 3 3 3 3 3 3 1 2 2 1 2 1 2 3 3 2 1 3 2 3 3 3 3 3 3 1 2 2 1 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 2 1B 2 3 3 2 1B 3 2 3 3 3 3 3 3 1B 2 2 1B <s> - Specialty Drug Page 41 5H. Infertility Treatment* BCBSM/BCN BCBSM Trade name Bravelle <s> Cetrotide <s> Clomid Crinone 8% Endometrin Follistim AQ <s> Ganirelix Acetate <s> Gonal-F, RFF, Redi-Ject <s> Lupron <s> Menopur <s> Novarel <s> Ovidrel <s> Pregnyl <s> Repronex <s> Generic name clomiphene citrate leuprolide acetate chorionic gonadotropin, human chorionic gonadotropin, human BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 1 2 2 3 2 2 1 3 1 2 2 2 4 4 1 2 2 5 4 4 4 5 4 4 4 4 4 4 1B 2 2 5 4 4 4 5 4 4 4 4 *Drugs used for the treatment of infertility may not be covered for select benefits. Copay depends on the members medical drug rider. 5I. Progestins BCBSM/BCN BCBSM Trade name Aygestin Crinone 4% Depo-Subq Provera 104 Progesterone in Oil (Inj) Prometrium Provera Generic name norethindrone acetate progesterone progesterone,micronized medroxyprogesterone acet 5J. Vaginal Anti-infective/Antifungal Trade name AVC Cleocin vaginal cream Cleocin vaginal ovules Clindesse Diflucan Gynazole-1 Metrogel-Vaginal Monistat 3 Nuvessa Nystatin Terazol-3, 7 PA - Prior approval may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 2 2 1 1 1 1 2 2 1 1 1 1B 2 2 1B 1B 1B BCBSM/BCN BCBSM Generic name clindamycin phosphate fluconazole metronidazole miconazole nitrate nystatin terconazole BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 3 3 1 3 1 1 3 1 1 3 1 3 3 1 3 1 1 3 1 1 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 3 1B 3 3 1B 3 1B 1B 3 1B 1B <s> - Specialty Drug Page 42 5K. Miscellaneous OB-GYN Trade name BCBSM/BCN BCBSM Generic name Brisdelle Covaryx, H.S. Diclegis Duavee Lupaneta pack <s> Lupron Depot <s> Lupron Depot 45mg (BCBSM Only) <s> Lysteda Methergine tablets Osphena Synarel estrogen,ester/me-testosterone tranexamic acid methylergonovine maleate BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 3 3 3 2 2 1 1 3 2 3 1 3 3 5 4 4 1 1 3 2 3 1B 3 3 5 4 MB 1B 1B 3 2 MB - May be covered under medical benefit PA - Prior approval may be required QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) <s> - Specialty Drug Page 43 6. RHEUMATOLOGY AND MUSCULOSKELETAL 6A. Corticosteroids BCBSM/BCN BCBSM Trade name Generic name BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL Corticosteroids - See Chapter 7C 6B. Gout Therapy BCBSM/BCN BCBSM Trade name Colbenemid Colchicine capsules Colchicine tablets Colcrys Mitigare Probenecid Uloric Zyloprim Generic name colchicine/probenecid probenecid allopurinol 6C. Non-Tumor Necrosis Factor (TNF) Blocking Trade name Generic name Actemra syringe <s> Kineret <s> Orencia sub-q <s> Otezla <s> Xeljanz <s> Trade name Actonel 35mg, 150mg Actonel 5, 30mg Atelvia Binosto Boniva Didronel Evista Fosamax Fosamax 35mg, 70mg Fosamax Plus D Miacalcin injection Miacalcin Nasal Spray; Fortical PA - Prior approval may be required 1 3 2 2 3 1 2 1 1 3 2 2 3 1 2 1 1B 3 2 2 3 1B 2 1B BCBSM/BCN BCBSM Generic name ibandronate sodium etidronate disodium raloxifene hcl alendronate sodium alendronate sodium calcitonin,salmon,synthetic ST - Step therapy may be required BCN 5 5 5 5 5 5 5 5 5 5 BCBSM/BCN BCBSM risedronate sodium risedronate sodium risedronate sodium Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 3 3 3 6D. Osteoporosis/Bone Resorption BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 3 1 1 1 1 1 3 2 1 1 1 1 3 1 1 1 1 1 3 2 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 1B 1B 3 1B 1B 1A 1A 1A 3 2 1B <s> - Specialty Drug Page 44 6E. Osteoporosis/Hormonal Treatment Trade name Alora Climara Covaryx, H.S. Duavee Enjuvia Estrace FemHRT Forteo <s> Menest Minivelle Ogen; Ortho-Est Premarin, Low Dose, cream Prempro, Low Dose; Premphase Vivelle-Dot Generic name estradiol estrogen,ester/me-testosterone estradiol norethindrone ac-eth estradiol estropipate estradiol 6F. Salicylates Trade name Salicylates and NSAIDS Generic name Generic name PA - Prior approval may be required 2 1 1 3 2 1 1 3 3 3 1 2 2 1 2 1 1 3 2 1 1 5 3 3 1 2 2 1 2 1B 1B 3 2 1B 1B 5 3 3 1B 2 2 1B BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL BCBSM/BCN BCBSM Generic name leflunomide sulfasalazine cyclosporine, modified azathioprine methotrexate sodium hydroxychloroquine sulfate ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 2 2 3 6H. Miscellaneous Rheumatologic Agents Arava Azasan Azulfidine, En-Tab Cuprimine Depen Gengraf <s> Imuran Methotrexate Neoral <s> Otrexup <s> Plaquenil Rasuvo <s> Rheumatrex (Tier 2 BCN Only) Ridaura Trexall Custom 5-Tier PA ST QL 6-Tier PA ST QL See Chapters 3M & 3O Cimzia Syringe <s> Enbrel <s> Humira, Pediatric <s> Simponi <s> Trade name BCN BCBSM/BCN BCBSM 6G. Tumor Necrosis Factor (TNF) Blocking Agents Trade name BCBSM/BCN BCBSM 5 4 4 5 5 4 4 5 BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 1 3 2 1 1 1 3 3 1 3 3 2 2 1 3 1 3 2 4 1 1 5 5 1 5 3 2 2 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 3 1B 3 2 4 1B 1B 5 5 1B 5 2 2 2 <s> - Specialty Drug Page 45 7. ENDOCRINOLOGY 7A. Androgens Trade name Anadrol-50 Androderm Androgel (1%) Androgel 1.62% Android; Testred Androxy Axiron Danocrine Delatestryl Depo-Testosterone Fortesta Methitest Natesto Oxandrin Striant Testim Testosterone gel, packet, pump Vogelxo BCBSM/BCN BCBSM Generic name testosterone fluoxymesterone danazol testosterone enanthate testosterone cypionate oxandrolone 7B. Antithyroid Agents Trade name Propylthiouracil SSKI (Tier 2 BCN only) Tapazole Cortef; Hydrocortisone Cortisone Acetate Decadron Entocort EC Florinef Medrol 2mg (Tier 2 BCN only) Medrol, Dosepak Orapred ODT Orapred solution 15mg/5ml Prednisolone, tablets, syrup Prednisone Rayos Uceris Uceris foam PA - Prior approval may be required Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 2 1 2 3 1 3 1 1 1 3 3 3 1 3 3 3 3 3 2 1 2 3 1 3 1 1 1 3 3 3 1 3 3 3 3 3 2 1B 2 3 1B 3 1B 1B 1B 3 3 3 1B 3 3 3 3 BCBSM/BCN BCBSM Generic name propylthiouracil methimazole 7C. Corticosteroids Trade name BCN hydrocortisone cortisone acetate dexamethasone budesonide fludrocortisone acetate methylprednisolone prednisolone sod phosphate prednisolone sod phosphate prednisolone prednisone ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 1 1 3 1 1B 2 1B BCBSM/BCN BCBSM Generic name BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 1 3 1 1 1 1 1 3 3 3 1 1 1 1 1 3 1 1 1 1 1 3 3 3 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 1B 1A 1B 1B 2 1B 1B 1A 1A 1A 3 3 3 <s> - Specialty Drug Page 46 7D. Growth Hormone and Related Products Trade name Generic name 7E. Insulins BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 3 3 3 2 3 3 3 3 Genotropin <s> Humatrope <s> Increlex <s> Norditropin Flexpro <s> Nutropin AQ, Nuspin <s> Omnitrope <s> Saizen <s> Serostim <s> Zomacton <s> 4 5 5 5 4 5 5 5 5 4 5 5 5 4 5 5 5 5 BCBSM/BCN BCBSM Trade name Generic name Afrezza Apidra, Solostar Humalog U-200 Humalog, Mix Humulin R U-500 (vial) Humulin, KwikPen Lantus, Solostar (Tier 2 BCBSM only) Levemir, Flextouch (Tier 2 BCBSM only) Novolin (all forms) (Tier 2 BCBSM only) Novolog (all forms) (Tier 2 BCBSM only) Toujeo Solostar PA - Prior approval may be required BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 2 2 2 2 2 1 1 1 1 2 ST - Step therapy may be required 3 2 2 2 2 2 1 1 1 1 2 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 3 2 2 2 2 2 1A 1A 1A 1A 2 <s> - Specialty Drug Page 47 7F. Non-insulin Hypoglycemic Agents Trade name Actoplus MET Actoplus MET XR Actos Amaryl Avandamet Avandia Bydureon, Pen Byetta Cycloset Diabeta; Micronase Diabinese Duetact Farxiga Glucophage, XR; Fortamet Glucotrol, XL Glucovance Glumetza Glynase Glyset Glyxambi Invokamet Invokana Janumet Janumet XR Januvia Jardiance Jentadueto Kazano Kombiglyze XR Metaglip Nesina Onglyza Oseni PrandiMet Prandin Precose Riomet Starlix Symlinpen Synjardy Tanzeum Tolazamide Tolbutamide Tradjenta Trulicity Victoza Xigduo XR PA - Prior approval may be required Generic name pioglitazone hcl/metformin hcl pioglitazone hcl glimepiride glyburide chlorpropamide pioglitazone/glimepiride metformin hcl glipizide glyburide/metformin hcl glyburide,micronized glipizide/metformin hcl repaglinide/metformin hcl repaglinide acarbose nateglinide tolazamide tolbutamide ST - Step therapy may be required BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 1 1 3 3 2 3 3 1 1 1 2 1 1 1 3 1 3 3 2 2 2 2 2 3 3 3 2 1 3 2 3 1 1 1 3 1 3 3 3 1 1 3 3 2 2 1 3 1 1 3 3 2 3 3 1 1 1 2 1 1 1 3 1 3 3 2 2 2 2 2 3 3 3 2 1 3 2 3 1 1 1 3 1 3 3 3 1 1 3 3 2 2 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 3 1A 1A 3 3 2 3 3 1A 1B 1B 2 1A 1A 1A 3 1A 3 3 2 2 2 2 2 3 3 3 2 1A 3 2 3 1B 1B 1B 3 1B 3 3 3 1B 1B 3 3 2 2 <s> - Specialty Drug Page 48 7G. Somatostatin Analogs BCBSM/BCN BCBSM Trade name Generic name Sandostatin <s> Sandostatin LAR, Depot <s> Signifor <s> Signifor LAR <s> Somatuline Depot <s> octreotide acetate 7H. Thyroid Hormones Trade name Generic name liothyronine sodium levothyroxine sodium thyroid,pork 7I. Urea Cycle Disorder Agents Trade name sodium phenylbutyrate 7J. Vitamin D Analogs 4 4 4 5 4 4 4 4 5 4 Generic name Calciferol Hectorol Rocaltrol Zemplar ergocalciferol doxercalciferol calcitriol paricalcitol 7K. Miscellaneous Endocrine Generic name desmopressin acetate ST - Step therapy may be required Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 1 2 3 1 3 1 1 2 3 1 3 1B 1A 2 3 1B BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 2 2 3 1 2 4 5 1B 2 4 5 BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 1 1 1 1 1B 1B 1B 1B BCBSM/BCN BCBSM cabergoline BCN BCBSM/BCN BCBSM Trade name PA - Prior approval may be required 1 2 2 3 2 BCBSM/BCN BCBSM Generic name Buphenyl powder Buphenyl tablets Carbaglu <s> Ravicti <s> Trade name Custom 5-Tier PA ST QL 6-Tier PA ST QL BCBSM/BCN BCBSM Armour Thyroid Cytomel Synthroid, Levoxyl Thyrolar Tirosint Westhroid Cabergoline Cerdelga <s> Cholbam <s> DDAVP DDAVP solution (Tier 2 BCN only) Egrifta <s> GlucaGen Glucagon Emergency Kit Korlym <s> Lupron Depot-Ped <s> Myalept <s> Natpara <s> Sensipar <s> Somavert <s> Stimate <s> Synarel Zavesca <s> BCN BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 2 1 3 3 2 2 2 2 3 2 2 2 2 2 3 1 5 4 1 3 5 2 2 4 4 5 4 4 4 4 2 5 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 5 4 1B 2 5 2 2 4 4 5 4 4 4 4 2 5 <s> - Specialty Drug Page 49 8. ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS 8A. Adjuvant Therapy Trade name Aranesp <s> Epogen <s> Granix <s> Leucovorin tablet Leukine <s> Mesnex tablets Mircera <s> Neulasta <s> Neupogen <s> Procrit <s> Zarxio <s> BCBSM/BCN BCBSM Generic name leucovorin calcium 8B. Alkylating Agents Trade name Alkeran Cyclophosphamide Emcyt Gleostine; Lomustine Leukeran Matulane <s> Myleran Temodar <s> Methotrexate tablets Purinethol Purixan <s> Tabloid Trexall Xeloda <s> PA - Prior approval may be required Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 2 1 2 2 3 3 2 2 3 5 5 4 1 4 2 5 5 4 4 5 5 5 4 1B 4 2 5 5 4 4 5 BCBSM/BCN BCBSM Generic name temozolomide 8C. Antimetabolites Trade name BCN methotrexate sodium mercaptopurine capecitabine BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 2 2 2 2 2 1 2 2 2 2 2 4 2 4 2 2 2 2 2 4 2 4 BCBSM/BCN BCBSM Generic name BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 3 2 2 1 1 1 5 2 2 4 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 1B 1B 5 2 2 4 <s> - Specialty Drug Page 50 8D. Hormonal Agents BCBSM/BCN BCBSM Trade name Generic name Arimidex Aromasin Casodex Depo-Provera 400mg Eligard <s> Eulexin Evista Evista (Prevent) Fareston Faslodex Femara Lupron <s> Lupron Depot <s> Megace, ES Nilandron Soltamox Tamoxifen citrate (Prevent) Tamoxifen citrate Trelstar, Depot, LA <s> Xtandi <s> Zoladex <s> Zytiga (Tier 3/5 - BCN only) <s> anastrozole exemestane bicalutamide flutamide raloxifene hcl raloxifene hcl letrozole leuprolide acetate megestrol acetate tamoxifen citrate tamoxifen citrate 8E. Immunomodulators Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 2 3 1 1 $0 2 3 1 1 2 1 2 3 $0 1 2 2 2 2 1 1 1 2 5 1 1 $0 2 3 1 4 4 1 2 3 $0 1 4 4 4 4 1A 1B 1B 2 5 1B 1A $0 2 3 1A 4 4 1B 2 3 $0 1A 4 4 4 5 BCBSM/BCN BCBSM Trade name Generic name Arcalyst <s> Astagraf XL <s> Azasan Cellcept <s> Envarsus XR <s> Gengraf <s> Imuran Kineret <s> Myfortic <s> Neoral <s> Pomalyst <s> Prednisone Prograf <s> Rapamune solution <s> Rapamune tablets <s> Rayos Revlimid <s> Sandimmune capsules <s> Sandimmune soln (Tier 2/4 BCN) <s> Thalomid <s> PA - Prior approval may be required BCN mycophenolate mofetil cyclosporine, modified azathioprine mycophenolate sodium prednisone tacrolimus anhydrous sirolimus BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 3 3 1 3 1 1 3 1 3 3 1 1 2 1 3 3 2 3 2 4 5 3 4 5 4 1 5 4 5 5 1 4 4 4 3 5 4 5 4 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 4 5 3 4 5 4 1B 5 4 5 5 1A 4 4 4 3 5 4 4 4 <s> - Specialty Drug Page 51 8F. Kinase Inhibitors and Molecular Target Inhibitors BCBSM/BCN BCBSM Trade name Generic name 8G. Miscellaneous Antineoplastic Agents Trade name Droxia Erivedge <s> Farydak <s> Hexalen Hycamtin <s> Hydrea Lysodren Odomzo <s> Sandostatin <s> Sandostatin LAR, Depot <s> Somatuline Depot <s> Targretin capsules <s> Vepesid Vesanoid Zolinza <s> PA - Prior approval may be required Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 2 2 Afinitor, Disperz <s> Bosulif <s> Caprelsa <s> Cometriq <s> Gilotrif <s> Gleevec <s> Ibrance <s> Iclusig <s> Imbruvica <s> Inlyta <s> Iressa <s> Jakafi <s> Lenvima <s> Lynparza <s> Mekinist <s> Nexavar <s> Sprycel <s> Stivarga <s> Sutent <s> Tafinlar <s> Tarceva <s> Tasigna <s> Tykerb <s> Votrient <s> Xalkori <s> Zelboraf <s> Zortress <s> Zydelig <s> Zykadia <s> Generic name hydroxyurea octreotide acetate bexarotene etoposide tretinoin BCN 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 4 4 BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 2 2 2 1 2 2 1 2 2 1 1 1 2 2 4 4 2 4 1 2 4 4 4 4 4 1 1 4 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 2 4 4 2 4 1B 2 4 4 4 4 4 1B 1B 4 <s> - Specialty Drug Page 52 9. IMMUNOLOGY AND HEMATOLOGY 9A. Hematopoietic Agents BCBSM/BCN BCBSM Trade name Generic name Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 2 2 3 3 2 2 2 3 Aranesp <s> Epogen <s> Granix <s> Leukine <s> Mircera <s> Neulasta <s> Neupogen <s> Procrit <s> Promacta <s> Zarxio <s> 9B. Immunoglobulins BCN 5 5 4 4 5 5 4 4 4 5 5 5 4 4 5 5 4 4 4 5 BCBSM/BCN BCBSM Trade name Generic name Gammagard Liquid (BCBSM Only) <s> Gammaked Liquid (BCBSM Only) <s> Gamunex-C sub-q (BCBSM Only) <s> Hizentra (BCBSM Only) <s> HyQvia (BCBSM Only) <s> BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 3 3 3 5 5 5 5 5 MB MB MB MB MB MB - May be covered under medical benefit 9C. Interferons and MS Therapy Trade name Actimmune <s> Alferon N Ampyra <s> Aubagio <s> Avonex <s> Betaseron <s> Copaxone <s> Extavia <s> Gilenya <s> Glatopa <s> Infergen <s> Intron A <s> Pegasys, Proclick <s> Peg-Intron, Redipen <s> Plegridy <s> Rebif, Rebidose <s> Sylatron <s> Tecfidera <s> BCBSM/BCN BCBSM Generic name glatiramer acetate 9D. Miscellaneous Immunology and Hepatology Trade name Firazyr <s> Ruconest <s> PA - Prior approval may be required Generic name BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 3 3 2 3 2 3 2 1 2 2 2 2 3 2 3 2 4 2 5 5 4 5 4 5 4 4 4 4 4 4 5 4 5 4 4 2 5 5 4 5 4 5 4 4 4 4 4 4 5 4 5 4 BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 5 5 QL - Quantity limits may apply ST - Step therapy may be required MB - May be covered under medical benefit BCBSM/BCN Custom Drug List (January 2016) 5 5 <s> - Specialty Drug Page 53 10. DERMATOLOGY 10A. Acne Treatment Trade name Absorica Acanya Acticlate Aczone Adapalene 0.1% lotion Adoxa capsule Adoxa tablet Amnesteem; Myorisan; Zenatane Atralin Avita gel Azelex Benzaclin Benzamycin Benzoyl Peroxide (RX) (BCBSM only) Brevoxyl gel (BCBSM only) Cleocin T Differin Differin 0.1% lotion Doryx Doryx 50, 200mg Doxycycline 20mg tablet Doxycycline IR-DR Duac Epiduo Epiduo Forte Erythromycin topical soln, gel Evoclin foam Fabior Minocin Monodox Noritate Onexton Oracea Plexion, TS (BCBSM only) Retin-A Retin-A Micro pump 0.08% Retin-A Micro, pump Rosula Cleanser (BCBSM only) Solodyn Solodyn 55, 65, 80, 105, 115mg Sulfacet-R (BCBSM only) Tazorac Tretin-X Veltin Vibramycin Vibramycin syrup (Tier 2 BCN only) Ziana BCBSM/BCN BCBSM Generic name doxycycline monohydrate doxycycline monohydrate isotretinoin tretinoin clindamycin phos/benzoyl perox erythromycin base/benz per benzoyl peroxide benzoyl peroxide clindamycin phosphate adapalene doxycycline hyclate doxycycline hyclate clindamycin phosphate/benz per erythromycin base/ethanol clindamycin phosphate minocycline hcl doxycycline monohydrate sulfacetamide sodium/sulfur tretinoin tretinoin microspheres sulfacetamide sod/sulfur/urea minocycline hcl sulfacetamide sodium/sulfur doxycycline hyclate BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 3 3 3 1 1 1 1 3 3 1 1 1 1 1 1 3 1 3 1 3 1 3 3 1 1 3 1 1 3 3 3 1 1 3 1 1 1 3 1 2 3 3 1 3 3 3 3 3 3 3 1 1 1 1 3 3 1 1 1 1 1 1 3 1 3 1 3 1 3 3 1 1 3 1 1 3 3 3 1 1 3 1 1 1 3 1 2 3 3 1 3 3 3 3 3 3 3 1B 1B 1B 1B 3 3 1B 1B NC NC 1B 1B 3 1B 3 1B 3 1B 3 3 1B 1B 3 1B 1B 3 3 3 NC 1B 3 1B NC 1B 3 NC 2 3 3 1B 2 3 NC - Not Covered for members with a BCN drug benefit PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) <s> - Specialty Drug Page 54 10B. Antipsoriatic/Antiseborrheic Trade name 8-MOP (Tier 2 BCN Only) Cosentyx <s> Dovonex Drithocreme HP(BCBSM only) Enbrel <s> Humira <s> Otezla <s> Otrexup <s> Ovace, Plus (BCBSM only) Oxsoralen Oxsoralen-Ultra Rasuvo <s> Selsun 2.5% [Rx Only] Soriatane Sorilux Stelara <s> Taclonex ointment Taclonex topical solution Vectical BCBSM/BCN BCBSM Generic name calcipotriene anthralin sulfacetamide sodium methoxsalen, rapid selenium sulfide acitretin calcipotriene/betamethasone calcitriol BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 1 1 2 2 3 3 1 2 1 3 1 1 3 3 1 3 1 3 5 1 1 4 4 5 5 1 2 1 5 1 1 3 5 1 3 1 2 5 1B NC 4 4 5 5 NC 2 1B 5 1B 1B 3 5 1B 3 1B NC - Not Covered for members with a BCN drug benefit 10C. Corticosteriods - Very High Potency Trade name Clobevate; Temovate Clobex Diprolene ointment Elocon ointment Olux Olux-E Ultravate Vanos Generic name clobetasol propionate clobetasol propionate betamet diprop/prop gly mometasone furoate clobetasol propionate clobetasol propionate/emoll halobetasol propionate fluocinonide 10D. Corticosteroids - High Potency Trade name Apexicon, E Aristocort; Kenalog 0.5% cream Cyclocort Diprolene AF, gel, cream, lotion Diprosone; Maxivate Halog Lidex, E Topicort cream, gel, ointment Topicort Spray Valisone PA - Prior approval may be required BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1B 1B 1B 1B 1B 1B 1B 1B BCBSM/BCN BCBSM Generic name diflorasone diacetate triamcinolone acetonide amcinonide betamet diprop/prop gly betamethasone dipropionate fluocinonide desoximetasone betamethasone valerate ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 1 3 1 1 3 1 1 1 1 1 1 3 1 1 3 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 1B 1B 1B 1B 3 1B 1B 3 1B <s> - Specialty Drug Page 55 10E. Corticosteroids - Medium Potency Trade name Clocortolone Pivalate Cloderm Cordran lotion, tape, SP Cordran ointment (Tier 2 BCN Only) Cutivate Dermatop Elocon cream, solution Kenalog 0.1% Locoid cream, oint, soln Locoid Lipocream Locoid Lotion Luxiq Oralone paste Pandel Synalar 0.025% Topicort LP Westcort Generic name fluticasone propionate prednicarbate mometasone furoate triamcinolone acetonide hydrocortisone butyrate hydrocortisone butyrate/emoll betamethasone valerate triamcinolone acetonide fluocinolone acetonide desoximetasone hydrocortisone valerate 10F. Corticosteroids - Low Potency Trade name Aclovate Ala-Scalp HP Capex Shampoo Dermacort; Hytone (RX Only) Derma-Smoothe/FS Desonate Desowen Kenalog 0.025% Neo-Synalar Synalar 0.01% Verdeso Trade name Generic name alclometasone dipropionate hydrocortisone hydrocortisone fluocinolone acetonide desonide triamcinolone acetonide fluocinolone acetonide Generic name lindane spinosad malathion 10H. Topical Anesthetics Trade name PA - Prior approval may be required Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 2 3 1 1 1 1 1 1 3 1 1 3 1 1 1 2 2 2 3 1 1 1 1 1 1 3 1 1 3 1 1 1 2 2 2 2 1B 1B 1B 1B 1B 1B 3 1B 1B 3 1B 1B 1B BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 2 1 1 3 1 1 3 1 3 1 1 2 1 1 3 1 1 3 1 3 1B 1B 2 1B 1B 3 1B 1B 3 1B 3 BCBSM/BCN BCBSM permethrin Emla Lidoderm patch Xylocaine, Viscous (Rx only) BCN BCBSM/BCN BCBSM 10G. Scabicides/Pediculicides Elimite Eurax Lindane Natroba Ovide Sklice Ulesfia BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 2 1 1 1 3 3 1 2 1 1 1 3 3 1B 2 1B 1B 1B 3 3 BCBSM/BCN BCBSM Generic name lidocaine/prilocaine lidocaine lidocaine hcl ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 1 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 1B 1B <s> - Specialty Drug Page 56 10I. Topical Antibacterials Trade name Altabax Bactroban Bactroban Nasal Centany ointment (Tier 2 BCN Only) Gentamicin cream, ointment BCBSM/BCN BCBSM Generic name mupirocin calcium gentamicin sulfate 10J. Topical Antifungals Trade name Ecoza Ertaczo Exelderm Extina Jublia Kerydin Loprox Lotrimin Lotrisone Luzu Mentax Monistat-Derm Mycostatin Naftin Nizoral cream, shampoo 2% Nystatin w/Triamcinolone Oxistat Penlac Spectazole Vusion Xolegel Trade name PA - Prior approval may be required Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 2 3 1 3 1 2 3 1 3 1B 2 2 1B BCBSM/BCN BCBSM Generic name ketoconazole ciclopirox olamine clotrimazole clotrimazole/betamet diprop miconazole nitrate nystatin ketoconazole nystatin/triamcin ciclopirox econazole nitrate 10K. Topical Antineoplastic Agents and Immunomodulators Aldara Carac Efudex Efudex Occlusion Elidel Panretin Picato Protopic Targretin gel <s> Tolak Valchlor <s> Veregen Zyclara BCN Generic name imiquimod fluorouracil tacrolimus ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 3 1 3 3 1 1 1 3 2 1 1 3 1 1 3 1 1 3 3 3 3 3 1 3 3 1 1 1 3 2 1 1 3 1 1 3 1 1 3 3 3 3 3 1B 3 3 1B 1B 1B 3 2 1B 1B 3 1B 1B 3 1B 1B 3 3 BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 1 3 2 2 3 1 3 3 3 3 3 1 3 1 3 2 2 3 1 5 3 5 3 3 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 3 1B 3 2 2 3 1B 5 3 5 3 3 <s> - Specialty Drug Page 57 10L. Topical Antivirals BCBSM/BCN BCBSM Trade name Denavir Xerese Zovirax cream Zovirax ointment Generic name acyclovir 10M. Wound and Burn Therapy Trade name Granulex (BCBSM only) Regranex Santyl Silvadene BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 2 1 3 3 2 1 3 3 2 1B BCBSM/BCN BCBSM Generic name trypsin/balsam peru/castor oil silver sulfadiazine BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 2 1 1 3 2 1 NC 3 2 1B NC - Not Covered for members with a BCN drug benefit 10N. Miscellaneous Dermatologicals Trade name Condylox gel Condylox solution Drysol Finacea Finacea foam Metrocream, gel, lotion Metrogel Topical 1%, pump Solaraze Soolantra Zonalon PA - Prior approval may be required Generic name podofilox aluminum chloride metronidazole metronidazole diclofenac sodium doxepin hcl ST - Step therapy may be required BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 1 1 3 3 1 1 1 3 1 2 1 1 3 3 1 1 1 3 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 2 1B 1B 3 3 1B 1B 1B 3 1B <s> - Specialty Drug Page 58 11. OPHTHALMOLOGY 11A. Cycloplegic Mydriatics BCBSM/BCN BCBSM Trade name Generic name Cyclogyl 0.5% Cyclogyl 0.5%, 1% 5ml (Tier 2 BCN only) Cyclogyl 1%, 2% Isopto Atropine Isopto Homatropine 5% Isopto Hyoscine Mydriacyl Paremyd cyclopentolate hcl atropine sulfate homatropine hbr tropicamide 11B. Ophthalmic Anti-Allergy Agents Trade name Alocril Alomide Bepreve Cromolyn sodium Elestat Emadine Lastacaft Optivar Pataday Patanol Pazeo Generic name cromolyn sodium epinastine hcl azelastine hcl BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 1 1 1 2 1 3 3 3 1 1 1 2 1 3 3 2 1B 1B 1B 2 1B 3 BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 3 1 1 3 3 1 3 2 3 2 2 3 1 1 3 3 1 3 2 3 2 2 3 1B 1B 3 3 1B 3 2 3 11C. Ophthalmic Anti-infective/Steroid Combinations BCBSM/BCN BCBSM Trade name Blephamide Cortisporin Maxitrol Pred-G Tobradex ointment Tobradex ST Tobradex susp Vasocidin Zylet PA - Prior approval may be required Generic name neomy sulf/polymyx b sulf/hc neo/polymyx b sulf/dexameth tobramycin sulfate/dexameth sulfacetamide/prednisolone sp ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 1 1 3 2 3 1 1 3 2 1 1 3 2 3 1 1 3 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 2 1B 1B 3 2 3 1B 1B 3 <s> - Specialty Drug Page 59 11D. Ophthalmic Anti-infectives Trade name Azasite Bacitracin Besivance Bleph-10 (Tier 2 BCN only) Bleph-10, Sodium Sulamyde Ciloxan drops Ciloxan ointment Garamycin Ilotycin Moxeza Natacyn Neosporin Ophth ointment Neosporin Ophth solution Ocuflox Polysporin Polytrim Quixin Tobrex drops Tobrex ointment (BCN tier 2 only) Vigamox Viroptic Zirgan Zymaxid BCBSM/BCN BCBSM Generic name bacitracin sulfacetamide sodium ciprofloxacin hcl gentamicin sulfate erythromycin base neomy sulf/bacitra/polymyxin b neomycin/gramicidin/polymyxn b ofloxacin bacitracin/polymyxin b sulfate polymyxin b sulfate/tmp levofloxacin tobramycin sulfate trifluridine gatifloxacin 11E. Ophthalmic Anti-inflammatory Agents Trade name Acular, LS Acuvail Bromday; Xibrom Ilevro Nevanac Ocufen Prolensa Voltaren drops Generic name ketorolac tromethamine bromfenac sodium flurbiprofen sodium diclofenac sodium 11F. Ophthalmic Beta Blockers Trade name Betagan Betimol (Tier 3 BCN only) Betoptic S Betoptic solution Istalol (Tier 2 for BCN only) Ocupress Optipranolol Timoptic Ocudose (Tier 2 BCN only) Timoptic, - XE PA - Prior approval may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 3 3 1 1 2 1 1 2 2 1 1 1 1 1 1 1 3 2 1 2 1 3 1 3 3 1 1 2 1 1 2 2 1 1 1 1 1 1 1 3 2 1 2 1 3 1B 3 2 1B 1B 2 1B 1B 2 2 1B 1B 1B 1B 1B 1B 1B 2 2 1B 2 1B BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 1 3 3 1 3 1 1 3 1 3 3 1 3 1 1B 3 1B 3 3 1B 3 1B BCBSM/BCN BCBSM Generic name levobunolol hcl betaxolol hcl carteolol hcl metipranolol timolol maleate ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 2 2 1 3 1 1 3 1 1 2 2 1 3 1 1 3 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1A 3 2 1B 2 1B 1B 2 1A <s> - Specialty Drug Page 60 11G. Ophthalmic Steroids BCBSM/BCN BCBSM Trade name Generic name Alrex Decadron Opth Durezol FML FML Forte, S.O.P. Inflamase, Forte Lotemax Maxidex Pred Forte Pred Mild Vexol dexamethasone sod phosphate fluorometholone prednisolone sod phosphate prednisolone acetate 11H. Other Glaucoma Agents Trade name Alphagan 0.2%, P 0.15% Alphagan P 0.1% Azopt Combigan Cosopt Cosopt PF Iopidine droperette Iopidine drops Lumigan Lumigan 0.01% Phospholine Iodide Pilocar; Isopto-Carpine Rescula Simbrinza Travatan Travatan Z Trusopt Xalatan Zioptan Trade name PA - Prior approval may be required Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 3 1 2 1 3 3 1 2 2 3 1 3 1 2 1 3 3 1 2 2 3 1B 3 1B 2 1B 3 3 1B 2 2 BCBSM/BCN BCBSM Generic name brimonidine tartrate timolol maleate/dorzolam hcl apraclonidine hcl bimatoprost pilocarpine hcl travoprost (benzalkonium) dorzolamide hcl latanoprost 11I. Miscellaneous Ophthalmic Agents Cystaran <s> Lacrisert Naphazoline hcl Phenylephrine hcl drops Restasis BCN Generic name naphazoline hcl phenylephrine hcl ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 2 2 3 1 3 3 1 1 2 2 1 3 3 1 2 1 1 3 1 2 2 3 1 3 3 1 1 2 2 1 3 3 1 2 1 1 3 1B 2 2 3 1B 3 3 1B 1B 2 2 1B 3 3 1B 2 1B 1A 3 BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 1 1 2 4 2 1 1 2 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 4 2 1B 1B 2 <s> - Specialty Drug Page 61 12. OTIC & NASAL PREPARATIONS 12A. Nasal Preparations Trade name Astelin Astepro Atrovent nasal spray Beconase AQ Dymista Flonase (Rx only) Nasacort AQ (Rx only) Nasalide Nasonex Omnaris Patanase Qnasl, Children's Rhinocort Aqua Veramyst Zetonna BCBSM/BCN BCBSM Generic name azelastine hcl azelastine hcl ipratropium bromide fluticasone propionate triamcinolone acetonide flunisolide 0.025% spray olopatadine hcl budesonide 12B. Otic Preparations Trade name Acetasol HC Auralgan Cetraxal Cipro HC Ciprodex Coly-Mycin S Cortisporin Cortisporin-TC Domeboro Otic Floxin Otic Floxin Otic Singles PA - Prior approval may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 3 3 1 1 1 3 3 1 3 1 3 3 1 1 1 3 3 1 1 1 3 3 1 3 1 3 3 1B 1B 1B 3 3 1B 1B 1B 3 3 1B 3 1B 3 3 BCBSM/BCN BCBSM Generic name acetic acid/hydrocortisone aa/antpy/bcaine/polico/al acet ciprofloxacin hcl neomy sulf/polymyx b sulf/hc acetic acid/aluminum acetate ofloxacin ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 2 2 3 1 3 1 1 3 1 1 1 2 2 3 1 3 1 1 3 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 1B 1B 2 2 3 1B 3 1B 1B 3 <s> - Specialty Drug Page 62 13. RESPIRATORY, COUGH & COLD 13A. Antihistamine/Decongestant Combinations Trade name Clarinex-D Claritin-D (OTC) Phenergan VC Semprex-D Zyrtec-D (OTC) Generic name p-ephed sul/loratadine phenylephrine hcl/prometh hcl p-ephed hcl/cetirizine hcl 13B. Antihistamines Trade name Astelin Astepro Atarax; Vistaril Benadryl (Rx only) Clarinex syrup Clarinex tablets, Redi-tabs Claritin, Alavert (OTC) Karbinal ER Patanase Periactin Phenergan Xyzal Xyzal solution Zyrtec (OTC) Bromfed-DM Flowtuss Hycodan Hycofenix Obredon Phenergan DM Phenergan w/Codeine Rezira Robitussin AC Tessalon, Perles; Zonatuss Tussicaps Tussionex Tuzistra XR Vituz Zutripro PA - Prior approval may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 1 1 3 1 3 1 1 3 1 3 1B 1B 3 1B BCBSM/BCN BCBSM Generic name azelastine hcl azelastine hcl hydroxyzine diphenhydramine hcl desloratadine loratadine olopatadine hcl cyproheptadine hcl promethazine hcl levocetirizine dihydrochloride levocetirizine dihydrochloride cetirizine hcl 13C. Antitussives Trade name BCBSM/BCN BCBSM d-methorphan hb/p-epd hcl/bpm hydrocodone bit/homatrop me-br d-methorphan hb/prometh hcl codeine/promethazine hcl guaifenesin/codeine phosphate benzonatate hydrocodone/chlorphen polis pseudoephed/hydrocodone/cpm ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 3 1 1 3 1 1 1 1 1 1 1 1 1 1 3 1 1 3 1 1 1 1 1 1 1B 1B 1B 1B 3 1B 1B 3 1B 1B 1B 1B 1B 1B BCBSM/BCN BCBSM Generic name BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 1 3 3 1 1 3 1 1 2 1 3 3 1 1 3 1 3 3 1 1 3 1 1 2 1 3 3 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 3 1B 3 3 1B 1B 3 1B 1B 2 1B 3 3 1B <s> - Specialty Drug Page 63 13D. Cystic Fibrosis Agents BCBSM/BCN BCBSM Trade name Generic name Bethkis <s> Cayston <s> Kalydeco <s> Orkambi <s> Pulmozyme <s> Tobi <s> Tobi Podhaler <s> tobramycin/0.25 normal saline 13E. Epinephrine Trade name Generic name epinephrine epinephrine 13F. Inhaled Anticholinergics Trade name Anoro Ellipta Combivent Respimat Duoneb Stiolto Respimat Generic name ipratropium bromide Generic name ipratropium/albuterol sulfate 13H. Inhaled Beta-Agonists Trade name Accuneb; Albuterol nebulizer solution Arcapta Neohaler Brovana Foradil Metaproterenol soln Perforomist Proair HFA, Respiclick; Ventolin HFA Proventil HFA Serevent Diskus Striverdi Respimat Xopenex HFA Xopenex nebulizer solution PA - Prior approval may be required 3 3 2 2 2 1 3 5 5 4 4 4 4 5 5 5 4 4 4 4 5 Generic name metaproterenol sulfate levalbuterol hcl ST - Step therapy may be required Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 1 2 1 3 1 2 1B 2 1B 2 BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 1 3 2 3 2 1 3 2 3 2 1B 3 2 3 BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 2 1 2 3 2 1 2 3 2 1B 2 BCBSM/BCN BCBSM albuterol sulfate BCN BCBSM/BCN BCBSM 13G. Inhaled Beta-Agonist/Anticholinergic Combinations Trade name Custom 5-Tier PA ST QL 6-Tier PA ST QL BCBSM/BCN BCBSM Adrenaclick Adrenalin chloride (Tier 2 BCN Only) Epinephrine auto-injector Epipen, Jr Atrovent HFA Atrovent solution Incruse Ellipta Spiriva, Respimat Tudorza Pressair BCN BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 3 2 1 3 2 3 2 3 3 1 1 3 3 2 1 3 2 3 2 3 3 1 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 3 3 2 1B 3 2 3 2 3 3 1B <s> - Specialty Drug Page 64 13I. Inhaled Steroid/Beta-Agonist Combinations Trade name Generic name Advair Breo Ellipta Dulera Symbicort BCBSM/BCN BCBSM Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 3 2 2 13J. Inhaled Steroids Trade name Aerospan Alvesco (Tier 1-BCN Only) Arnuity Ellipta Asmanex, HFA (Tier 1-BCN Only) Flovent HFA, Diskus (Tier 1-BCN Only) Pulmicort Flexhaler (Tier 1-BCN Only) Pulmicort solution Qvar (Tier 1-BCN Only) Trade name Generic name budesonide Trade name Generic name fluticasone propionate triamcinolone acetonide flunisolide 0.025% spray budesonide Adcirca <s> Adempas <s> Letairis <s> Opsumit <s> Orenitram ER <s> Remodulin <s> Revatio Revatio suspension Tracleer <s> Tyvaso <s> Ventavis <s> PA - Prior approval may be required 2 3 2 2 Generic name metaproterenol sulfate albuterol sulfate terbutaline sulfate albuterol sulfate Generic name sildenafil citrate ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 2 3 2 2 2 1 2 3 2 3 2 2 2 1 2 3 1A 3 1A 1A 1A 1A 1A BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 1 1 1 3 3 3 1 3 3 3 3 1 1 1 3 3 3 1 3 3 3 3 1B 1B 1B 3 3 3 1B 3 3 BCBSM/BCN BCBSM 13M. Pulmonary Hypertension Agents Trade name BCBSM/BCN BCBSM 13L. Oral Beta-Agonists Alupent Proventil solution Terbutaline sulfate Vospire ER 2 3 2 2 BCBSM/BCN BCBSM 13K. Intranasal Steroids Beconase AQ Dymista Flonase (Rx only) Nasacort AQ (Rx only) Nasalide Nasonex Omnaris Qnasl, Children's Rhinocort Aqua Veramyst Zetonna BCN BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 1 1 1 1 1 1 1B 1B 1B 1B BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 2 2 2 2 3 1 2 2 2 2 4 4 4 4 4 5 1 2 4 4 4 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 4 4 4 4 4 5 1B 2 4 4 4 <s> - Specialty Drug Page 65 13N. Theophyllines BCBSM/BCN BCBSM Trade name Generic name Theo-24 Theophylline Anhydrous theophylline anhydrous 13O. Miscellaneous Respiratory Agents Trade name Generic name Accolate Acetylcysteine Daliresp Esbriet <s> Grastek Hyper-Sal (Tier 2 BCN only) Intal solution Nebusal Ofev <s> Oralair Ragwitek Singulair Sodium Chloride inhalation 3%, 7%, 10% Zyflo Zyflo CR PA - Prior approval may be required zafirlukast acetylcysteine cromolyn sodium montelukast sodium sodium chloride for inhalation ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 2 1 2 1 2 1B BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 3 3 3 3 1 3 3 3 3 1 1 3 3 1 1 3 5 3 3 1 3 5 3 3 1 1 3 3 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 1B 3 5 3 2 1B 3 5 3 3 1B 1B 3 3 <s> - Specialty Drug Page 66 14. UROLOGY 14A. BPH Treatment BCBSM/BCN BCBSM Trade name Generic name Avodart Cardura Cardura XL Cialis 2.5, 5mg Flomax Hytrin Jalyn Proscar Rapaflo Uroxatral dutasteride doxazosin mesylate tamsulosin hcl terazosin hcl dutasteride/tamsulosin hcl finasteride alfuzosin hcl 14B. Urinary Antispasmodics Generic name tolterodine tartrate oxybutynin chloride hyoscyamine sulfate hyoscyamine sulfate hyoscyamine sulfate propantheline bromide trospium chloride trospium chloride flavoxate hcl 14C. Miscellaneous Urologicals Trade name Azuphen MB (BCBSM only) Cuprimine Cystagon <s> Cytra-2 (BCBSM only) Cytra-3 (BCBSM only) Cytra-K (BCBSM only) Depen Elmiron Polycitra Procysbi <s> Pyridium (BCBSM only) Renacidin Thiola (Tier 2 BCN Only) Urecholine Urocit-K Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 3 2 1 1 1 1 3 1 1 1 3 2 1 1 1 1 3 1 1B 1B 3 2 1B 1B 1B 1B 3 1B BCBSM/BCN BCBSM Trade name Detrol, LA Ditropan, XL Enablex Gelnique Gelnique pump Levbid Levsin, SL Levsinex Myrbetriq Oxytrol Pro-Banthine Sanctura Sanctura XR Toviaz (Tier 3 BCBSM Only) Urispas Vesicare BCN Generic name citric acid/sodium citrate citric acid/potassium citrate potassium citrate/citric acid sod/potass/k cit/sod cit/ca phenazopyridine hcl bethanechol chloride potassium citrate BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 3 3 3 1 1 1 3 3 1 1 1 2 1 3 1 1 3 3 3 1 1 1 3 3 1 1 1 2 1 3 1B 1B 3 3 3 1B 1B 1B 3 3 1B 1B 1B 2 1B 3 BCBSM/BCN BCBSM methen/m-blue/sal/na phos/hyos BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 2 1 1 1 2 2 1 3 1 2 3 1 1 1 3 4 1 1 1 2 2 1 5 1 2 3 1 1 NC 3 4 NC NC NC 2 2 1B 5 NC 2 2 1B 1B NC - Not Covered for members with a BCN drug benefit PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) <s> - Specialty Drug Page 67 15. VITAMINS AND SUPPLEMENTS 15A. Potassium Replacement Trade name BCBSM/BCN BCBSM Generic name Kay Ciel, Kaon-Cl, Kaon Liquid K-Lor, Klor-Con Klor-con packet (BCN Tier 2 only) K-Lyte, Klor-Con/EF K-Sol, potassium chloride K-Tab, K-Dur, Slow-K, Kaon CL Micro-K potassium chloride potassium chloride potassium bicarbonate/cit ac potassium chloride potassium chloride potassium chloride 15B. Vitamins and Minerals Trade name Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 3 1 1 1 1 1 1 3 1 1 1 1 1B 1B 2 1B 1B 1B 1B BCBSM/BCN BCBSM Generic name Calciferol Cyanocobalamin inj Fer-in-sol 15mg drops (Prevent) Folic Acid 0.4, 0.8mg [OTC] (Prevent) Folvite Galzin Mephyton Nascobal Spray Niferex-150 Forte (BCBSM Only) Poly-Vi-Flor (BCBSM Only) Prenatal Plus, Tricare Prenatal Vitamins Prevident Rulavite DHA Sodium Fluoride 0.25, 0.5mg drops Supervite Vitamin D3 (Prevent) BCN ergocalciferol cyanocobalamin ferrous sulfate folic acid folic acid iron ps cmplx/vit b12/fa pnv with ca,no.72/iron/fa prenatal vit/iron,carb/doss/fa sodium fluoride pnv combo#47/iron/fa #1/dha sodium fluoride cholecalciferol (vitamin d3) BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 1 $0 $0 1 3 2 3 1 3 1 1 1 1 $0 3 $0 1 1 $0 $0 1 3 2 3 1 3 1 1 1 1 $0 3 $0 1B 1B $0 $0 1B 3 2 3 NC NC 1A 1B 1B 1B $0 3 $0 NC - Not Covered for members with a BCN drug benefit PA - Prior approval may be required QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) <s> - Specialty Drug Page 68 16. DIAGNOSTIC AND OTHER MISCELLANEOUS 16A. Chelating Agents Trade name Cuprimine Depen Desferal Exjade <s> Ferriprox <s> Syprine <s> BCBSM/BCN BCBSM Generic name deferoxamine mesylate 16B. Ion-Removing Agents Trade name Auryxia Fosrenol Kayexalate Phoslo Phoslyra Renagel Renvela, packet Velphoro Carnitor Carnitor SF solution (BCN tier 2 only) Cystadane (BCN Tier 2/4 only) <s> Kuvan, powder <s> Orfadin <s> Radiogardase Samsca <s> PA - Prior approval may be required Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 2 1 3 3 3 3 2 1 5 5 5 3 2 1B 5 5 5 BCBSM/BCN BCBSM Generic name sodium polystyrene sulfonate calcium acetate 16C. Diagnostics and Other Miscellaneous Trade name BCN Generic name levocarnitine ST - Step therapy may be required BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 3 1 1 3 2 2 3 3 3 1 1 3 2 2 3 3 3 1B 1B 3 2 2 3 BCBSM/BCN BCBSM BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 3 2 3 2 2 1 3 5 4 5 2 4 QL - Quantity limits may apply BCBSM/BCN Custom Drug List (January 2016) 1B 2 4 4 5 2 4 <s> - Specialty Drug Page 69 17. LIFESTYLE MODIFICATION 17A. Impotence, Sexual Dysfunction Trade name BCBSM/BCN BCBSM Generic name Addyi Caverject Cialis Edex Levitra Muse Staxyn Stendra Viagra Custom 5-Tier PA ST QL 6-Tier PA ST QL 3 2 2 3 3 2 3 3 2 17B. Smoking Cessation Generic name nicotine polacrilex nicotine polacrilex nicotine bupropion hcl 17C. Weight Loss Preparations Trade name Adipex, P Belviq Bontril PDM Contrave ER Didrex Diethylpropion hcl, ER Qsymia Saxenda Suprenza ODT Xenical PA - Prior approval may be required 3 2 2 3 3 2 3 3 2 3 2 2 3 3 2 3 3 2 BCBSM/BCN BCBSM Trade name Chantix (Prevent) Commit Lozenge OTC (Prevent) Nicotine Gum, Nicorette (Prevent) Nicotine Patch (Prevent) Nicotrol, NS (Prevent) Zyban (Prevent) BCN phentermine hcl phendimetrazine tartrate benzphetamine hcl diethylpropion hcl BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 BCBSM/BCN BCBSM Generic name BCN Custom 5-Tier PA ST QL 6-Tier PA ST QL 1 3 1 3 1 1 3 3 3 3 1 3 1 3 1 1 3 3 3 3 QL - Quantity limits may apply ST - Step therapy may be required Prevent - Prevent drugs may be covered at $0 if criteria are met BCBSM/BCN Custom Drug List (January 2016) 1B 3 1B 3 1B 1B 3 3 3 3 <s> - Specialty Drug Page 70 Appendix A Blue Cross and BCN Preferred Alternatives January 2016 Blue Cross and BCN Preferred Alternatives - January 2016 Tier 3 Preferred Alternatives Tier 3 Preferred Alternatives ABSORICA (REQ DERM CONSULT) Generic Isotretinoin [Amnesteem(g), Claravis(g), Myorisan(g), Zenatane(g)](REQ DERM CONSULT)* AMITIZA Glycolax(g), Lactulose(g), OTC fiber, OTC stimulant laxative and OTC stool softeners ABSTRAL Actiq(g)*, MSIR(g), Opana IR(g)*, oxycodone IR(g), Roxanol(g) AMOXICILLIN ER Amoxil capsules(g) AMRIX ACANYA Benzaclin(g), Duac(g), Individual agents (over-the-counter (OTC) benzoyl peroxide and clindamycin) Baclofen, Flexeril(g), Norflex(g), Parafon Forte(g), Robaxin(g), Zanaflex(g) ANADROL-50 Procrit* ACIPHEX SPRINKLE Aciphex(g), Nexium(g)*, Prevacid(g), Solutab*; Prilosec(g)/Prilosec OTC**, Protonix(g), Zantac(g), Zegerid(g)* ANGELIQ FemHRT(g), Premphase; an estradiol plus a progestin, Prempro ACTEMRA Enbrel*, Humira*, methotrexate ANORO ELLIPTA Serevent Diskus plus Spiriva/Respimat ACTICLATE Minocin(g), Monodox(g), tetracycline, Vibramycin(g) ANTARA 30, 90MG Antara(g), Lofibra(g), Lopid(g), Tricor(g), Trilipix(g) ACTOPLUS MET XR ActoPlus MET(g), or Glucophage(g)/XR(g) plus Actos(g) ANZEMET Kytril(g), Zofran(g)/ODT(g) APEXICON E Apexicon(g) ACUVAIL Acular(g)/LS(g), Ocular(g), Voltaren ophth(g) APLENZIN Celexa(g), Prozac(g), Effexor(g)/XR(g), Zoloft(g) Differin(g), OTC benzoyl peroxide, Topical clindamycin, Topical erythromycin APRISO Asacol HD, Azulfidine(g), En-Tab(g); Delzicol, Pentasa ACZONE ADVICOR Lescol(g)/XL(g), Lipitor(g), Mevacor(g), Pravachol(g) or Zocor(g) plus Niaspan(g) APTENSIO XR Adderall(g)/XR(Brand BCN only); Concerta(g), Focalin(g)/XR(g)*, Metadate CD(g), Ritalin(g)/LA(g)/SR(g) AEROSPAN Alvesco, Asmanex, Flovent HFA, Pulmicort solution(g), Flexhaler; Qvar APTIOM Dilantin(g), Keppra(g), Tegretol(g), Topamax(g), Trileptal(g) AFREZZA Apidra*/Solostar*, Novolin (Tier 1 BCN Only), Novolog (Tier 1 BCN Only), Humalog*, Humulin* ARANESP Procrit* ARCAPTA NEOHALER Serevent Diskus, Spiriva/Respimat AKYNZEO Emend(g) plus Zofran(g) plus dexamethasone ARMOUR THYROID Levoxyl(g), Synthroid(g) ALREX Decadron ophth(g), FML(g), Pred Forte(g), Pred Mild ARNUITY ELLIPTA Asmanex, Flovent HFA, Pulmicort solution(g), Flexhaler; Qvar ALTABAX Bactroban(g), OTC Triple Antibiotic ointment ASTAGRAF XL Prograf(g) AUBAGIO ALTOPREV Lescol(g)/XL(g), Lipitor(g), Mevacor(g), Pravachol(g), Zocor(g) Avonex, Copaxone(g), Copaxone 40mg/mL, Extavia, Gilenya*, Rebif, Tecfidera* AURYXIA OTC Tums, Phoslo(g), Renagel, Renvela (g) Generic equivalent covered. Brand not covered or requires higher copay. * Prior Approval (Authorization) or Step Therapy may be required. ** Covered with a prescription for BCN members and some Blue Cross members. Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives. Page 1 Tier 3 Preferred Alternatives Tier 3 Preferred Alternatives AVANDAMET ActoPlus Met(g); or Glucophage(g) plus Actos(g) BINOSTO Actonel(g), Atelvia(g)*, Boniva(g), Fosamax(g) AVANDIA Actos(g), Glucophage(g), Insulin, a sulfonylurea [Amaryl(g), Diabeta(g), Glucotrol(g)/XL(g)] BREO ELLIPTA Advair, Dulera, Spiriva, Symbicort BRINTELLIX Generic SSRI/SNRI [Celexa(g), Prozac(g), Effexor(g)/XR(g), Zoloft(g), etc.], Wellbutrin/SR/XL(g) AVC Diflucan(g) oral, Terazol(g) vaginal AVITA GEL Retin-A (g) BRISDELLE Paxil(g), Effexor/XR(g) AXIRON Androgel 1%(g)*, Androgel 1.62%*, Androderm*, Delatestryl(g)*, DepoTestosterone(g)* BROVANA Serevent Diskus, Spiriva/Respimat BUNAVAIL Suboxone(g), Suboxone film AZASAN Imuran (g) BUTISOL SODIUM Ambien(g), Lunesta(g), Prosom(g), Restoril(g), Sonata(g) AZASITE Ciloxan(g), Ocuflox(g), Quixin(g), Vigamox, Zymaxid BUTRANS Duragesic(g), Exalgo(g)*, Methadone(g), MS Contin(g), Opana ER(g)*, Ultram ER(g) AZELEX Benzaclin(g), Differin(g), Retin-A(g) AZOR Generic angiotensin converting enzyme (ACE) inhibitor (lisinopril, benazepril, etc) or angiotensin receptor antagonist (ARB) (such as Cozaar(g)) plus Norvasc(g) BYETTA Actos(g), Bydureon*, Glucophage(g), Insulin, Januvia, Onglyza, a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g), Glynase(g)], Victoza* BECONASE AQ Flonase(g), Nasacort AQ(g), Nasalide(g), OTC Nasacort, Patanase(g), Rhinocort Aqua(g)* BYSTOLIC Cardioselective beta-blockers: Lopressor(g), Tenormin(g), Toprol XL(g), etc BELSOMRA Ambien(g)/CR(g)*, Lunesta(g), Restoril(g), Sonata(g) CAMBIA generic non-steroidal antiinflammatory drug (NSAID) such as Mobic(g), Naprosyn EC(g) BELVIQ Adipex-P(g), Bontril(g)*, Didrex(g)*, OTC Alli, Tenuate(g)* CANTIL Generic Proton Pump Inhibitors [such as Prilosec(g)], Generic H-2 blockers [such as Zantac(g)] CARAC Aldara(g), Efudex(g) CARDENE SR Cardene(g), Norvasc(g), Procardia XL(g) Avonex, Copaxone(g), Copaxone 40mg/mL, Extavia, Gilenya*, Rebif, Tecfidera* CARDURA XL Avodart(g), Cardura(g), Flomax(g), Hytrin(g), Jalyn(g)*, Uroxatral(g) BETHKIS Tobi(g) CAYSTON Tobi(g) BETIMOL Betagan(g), Betoptic(g), Ocupress(g), Optipranolol(g), Timoptic(g) CERDELGA Cerezyme (medical benefit) CESAMET Kytril(g), Marinol(g), Zofran(g)/ODT(g) BEYAZ Yasmin(g) or Yaz(g) plus folic acid 1mg CHENODAL Actigall(g), Urso(g) CIMZIA SYRINGE Enbrel*, Humira*, methotrexate BEPREVE Alocril, Elestat(g), Optivar(g), OTC Zaditor(g), Patanol BESIVANCE Ciloxan(g), Ocuflox(g), Quixin(g), Vigamox, Zymaxid BETASERON (g) Generic equivalent covered. Brand not covered or requires higher copay. * Prior Approval (Authorization) or Step Therapy may be required. ** Covered with a prescription for BCN members and some Blue Cross members. Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives. Page 2 Tier 3 CLARINEX-D, SYRUP Preferred Alternatives OTC Claritin(g)**, OTC Zyrtec(g)**, Xyzal(g) Tier 3 Preferred Alternatives DENAVIR Famvir(g), Valtrex(g), Zovirax cream 5%/ointment(g)/tablets(g) CLEOCIN VAGINAL Cleocin vaginal cream(g), MetrogelOVULES Vaginal(g) DESONATE Elocon(g), Locoid(g), Synalar solution(g) CLIMARA PRO Alora, Climara(g) or Vivelle-Dot(g), plus a progestin; or FemHRT(g) DESVENLAFAXINE Generic SSRI/SNRI [Celexa(g), ER Prozac(g), Effexor(g)/XR(g), Zoloft(g), etc.] CLINDESSE Cleocin vaginal cream(g), Metrogelvaginal(g) COLCHICINE CAPSULES colchicine tablets, Colcrys COLESTID FLAVORED Colestid(g), Questran(g)/Light(g), Welchol COLY-MYCIN S DESVENLAFAXINE Generic SSRI/SNRI [Celexa(g), FUMARATE ER Prozac(g), Effexor(g)/XR(g), Zoloft(g), etc.] DEXILANT Aciphex(g), Nexium(g)*, Prevacid(g), Solutab*; Prilosec(g)/Prilosec OTC**, Protonix(g), Zegerid(g)* Cipro HC, Cortisporin(g), Floxin Otic (g) DICLEGIS OTC doxylamine plus OTC vitamin B6; Zofran(g)/ODT(g) COMBIGAN Alphagan(g) plus Timoptic(g) DIFFERIN 0.1% LOTION Differin gel(g), cream(g) COMBIPATCH Alora, Climara(g) or Vivelle-Dot(g), plus a progestin; or FemHRT(g) DIFICID Flagyl(g), Vancocin(g) CONTRAVE Adipex-P(g), Bontril(g)*, Didrex(g)*, OTC Alli, Tenuate(g)* DIPENTUM Asacol HD, Azulfidine(g), En-Tab(g); Delzicol, Pentasa CONZIP Ryzolt(g), Ultram(g)/ER(g) DIVIGEL Alora, Climara(g), Estrace tablets(g), Vivelle-Dot(g) COREG CR Coreg(g) or Toprol XL(g) DORYX CORTISPORIN-TC Cipro Otic HC, Cortisporin(g), Floxin Otic(g) Minocin(g), Monodox(g), tetracycline, Vibramycin(g) COSENTYX Enbrel*, Humira*, methotrexate DOXCYCLINE IRDR Minocin(g), Monodox(g), tetracycline, Vibramycin(g) COSOPT PF Cosopt(g) DUAVEE CRESTOR Lescol(g)/XL(g), Lipitor(g), Mevacor(g), Pravachol(g), Zetia, Zocor(g) Climara(g), Enjuvia, Estrace(g) or Premarin plus a progestin; Effexor(g)/XR(g), Paxil(g) DUEXIS Arthrotec(g), Motrin(g) plus Pepcid(g) CUPRIMINE Depen DUREZOL Decadron ophth(g), FML(g), Pred Forte(g) CYCLOSET Actos(g), Glucophage(g), Insulin, a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g); Glynase(g)] DURLAZA Aspirin, Ecotrin(g) DUTOPROL Toprol XL(g) plus HCTZ(g) DYMISTA Astelin(g) plus Flonase(g); Nasacort AQ(g), Nasalide(g), OTC Nasacort, Patanase(g), Rhinocort Aqua(g)* DALIRESP DAYTRANA Advair, Serevent Diskus, Spiriva/Respimat, Symbicort Adderall(g)/XR(brand BCN only); Concerta(g), Focalin(g), Metadate CD(g), Ritalin(g)/LA(g), SR(g) (g) Generic equivalent covered. Brand not covered or requires higher copay. * Prior Approval (Authorization) or Step Therapy may be required. ** Covered with a prescription for BCN members and some Blue Cross members. Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives. Page 3 Tier 3 ECOZA EDARBI Preferred Alternatives Diflucan(g), Lamisil(g), Nizoral(g), OTC Clotrimazole(g), OTC Miconazole(g), Spectazole(g), Sporanox(g) Atacand(g)/HCT(g), Avalide(g), Avapro(g), Benicar*/HCT*, Cozaar(g), Diovan(g), Exforge(g), Hyzaar(g), Micardis(g)/HCT(g) Tier 3 Preferred Alternatives EQUETRO Abilify(g), Lamictal(g)/ODT(g), Lithium(g), Tegretol(g)/XR(g) ERTACZO Monistat-Derm(g), Nizoral cream(g), OTC Lamisil AT(g), OTC Lotrimin Ultra, Spectazole(g) ESTRACE VAGINAL CREAM Premarin cream, Vagifem ESTROGEL Alora, Climara(g), Estrace(g), OgenEst(g), Vivelle-Dot(g) EVAMIST Alora, Climara(g), Estrace(g), OgenEst(g), Vivelle-Dot(g) EVEKEO Adderall(g)/XR(brand BCN only), Concerta(g), Metadate CD(g), Ritalin(g)/LA(g)/SR(g); Bontril(g), OTC Alli, phentermine EXELDERM Lotrimin(g), Monistat-Derm(g), Nizoral(g), Spectazole(g) EDARBYCLOR Generic ARB [such as Cozaar(g)] plus chlorthalidone; Atacand HCT(g), Benicar HCT*, Diovan HCT(g) EDEX Caverject*, Cialis*, Muse*, Revatio(g) (BCN only), Viagra* EDLUAR Ambien(g)/CR(g)*, Lunesta(g), Restoril(g), Sonata(g) EFUDEX OCCLUSION Aldara(g), Efudex(g) ELESTRIN Alora, Climara(g), Estrace(g), VivelleDot(g) EXJADE Desferal(g) ELIGARD Lupron(g), Depot; Trelstar, Depot EXTAVIA Avonex, Copaxone(g), Copaxone 40mg/mL, Gilenya*, Rebif, Tecfidera* EMADINE Alocril, Elestat(g), Optivar(g), OTC Zaditor(g), Patanol FABIOR Differin(g), Retin-A(g), Tazorac EMBEDA Duragesic(g), Exalgo(g)*, Methadone(g), MS Contin(g), Opana ER(g)* FACTIVE Avelox(g), Erythromycin(g), Levaquin(g), Vibramycin(g), Zithromax(g) EMSAM Celexa(g), Effexor(g)/XR(g), Lexapro(g), Paxil(g), Prozac(g), Wellbutrin/SR/XL(g) FANAPT Abilify(g), Clozaril(g), Geodon(g), Invega(g), Risperdal(g), Seroquel(g), Zyprexa(g) ENABLEX Detrol(g)/LA(g), Ditropan(g)/XL(g), Sanctura(g)/XR(g) FARYDAK Thalomid FASLODEX Fareston, Tamoxifen ENTRESTO Generic angiotensin converting enzyme (ACE) inhibitor (lisinopril,benazepril, etc) or angiotensinreceptor antagonist (ARB) such as Cozaar(g) FAZACLO Abilify(g), Clozaril(g), Geodon(g), Invega(g), Risperdal(g), Seroquel(g), Zyprexa(g) FEMRING Alora, Climara(g), Estring, VivelleDot(g) ENVARSUS XR Prograf(g) EPANED Vasotec(g) FEMTRACE Estrace(g), Ogen(g) EPIDUO, FORTE, PUMP OTC benzoyl peroxide plus Differin(g); Retin-A(g) FENOGLIDE Antara(g), Lofibra(g), Lopid(g), Tricor(g), Trilipix(g) EPOGEN Procrit* FENTANYL PATCH 37.5 62.5, 87.5MG Duragesic(g) (g) Generic equivalent covered. Brand not covered or requires higher copay. * Prior Approval (Authorization) or Step Therapy may be required. ** Covered with a prescription for BCN members and some Blue Cross members. Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives. Page 4 Tier 3 Preferred Alternatives FENTORA Actiq(g)*, MSIR(g), Opana IR(g)*, oxycodone IR(g), Roxanol(g) FERRIPROX Desferal(g) FETZIMA Generic SSRI/SNRI [Celexa(g), Prozac(g), Effexor(g)/XR(g), Zoloft(g); etc.], Wellbutrin/SR/XL(g) Tier 3 Preferred Alternatives FYCOMPA Depakote(g)/ER(g); Lamictal(g)/ODT(g); Tegretol(g), Topamax(g), Trileptal(g) GALZIN OTC zinc supplements GELNIQUE Detrol(g)/LA(g), Ditropan(g)/XL(g), Sanctura(g)/XR(g) FINACEA, FOAM Metrocream(g), Metrogel topical(g), Metrolotion(g), Retin-A(g) GIAZO Asacol HD, Azulfidine(g)/En-Tab(g); Delzicol, Pentasa FLECTOR PATCH Generic NSAIDs [Voltaren oral(g), Mobic(g), Motrin(g), Lodine(g)/XL(g), Naproxen(g)], Lidoderm(g), Topical OTC analgesic balms, (i.e. trolamine salicylate) GLUMETZA Glucophage(g)/XR(g) GLYSET Actos(g), Glucophage(g), Insulin, Januvia, Onglyza, Precose(g), a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g), Glynase(g)] GLYXAMBI Actos(g), Glucophage(g), Insulin, Janumet/XR, Januvia, Kombiglyze, Onglyza, a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g), Glynase(g)] GRALISE Generic TCAs [Adapin(g), Elavil(g), Sinequan(g), Tofranil(g)], Neurontin(g), Ultram(g) GRASTEK Accolate(g), Clarinex(g), Claritin(g), Flonase(g), Nasacort AQ(g), OTC Nasacort, Singulair(g), Xyzal(g), Zyrtec(g) FLOWTUSS Phenergan DM (g), Phenergan VC(g), Robitussin AC(g), Tussionex(g), Zutripro(g) FLOXIN OTIC SINGLES Cetraxal(g), Floxin Otic(g) FLUOROURACIL Aldara(g), Efudex(g) FLUOXETINE 60MG Prozac(g) FOCALIN XR 25, 35MG Adderall(g)/XR(brand BCN only); Concerta(g), Focalin(g)/XR(g), Metadate CD(g), Ritalin(g)/LA(g)/SR(g) FOLLISTIM AQ Gonal-F, RFF, Redi-Ject GYNAZOLE-1 Diflucan 150mg(g), OTC Lotrimin, OTC Monistat, Terazol(g) FORFIVO XL Generic SSRI/SNRI [Celexa(g), Prozac(g), Effexor(g)/XR(g), Zoloft(g); etc.], Wellbutrin/SR/XL(g) HALOG Apexicon(g), Cyclocort(g), Diprosone(g), Topicort(g), Valisone(g) HEMANGEOL Inderal(g) HETLIOZ Ambien(g)/CR(g)*, OTC melatonin, Restoril(g), Sonata(g) HORIZANT Generic TCA [Adapin(g), Elavil(g), Sinequan(g), Tofranil(g)], Mirapex(g)/ER(g)*, Neurontin(g), Requip(g) HUMATROPE Genotropin*, Nutropin AQ*/Nuspin* HYCOFENIX Phenergan DM (g), Phenergan VC(g), Robitussin AC(g), Tussionex(g), Zutripro(g) FORTEO Actonel(g), Atelvia(g)*, Boniva(g), Fosamax(g), Miacalcin(g) FORTESTA Androgel 1%(g)*, Androgel 1.62%*, Androderm*, Delatestryl(g)*, DepoTestosterone(g)* FOSAMAX PLUS D Actonel(g), Atelvia(g)*, Boniva(g), Fosamax(g) plus OTC Vitamin D FOSRENOL OTC Tums, Phoslo(g), Renagel, Renvela FRAGMIN Lovenox(g) FROVA Amerge(g), Axert(g)*, Imitrex(g), Maxalt(g)/MLT(g), Zomig(g)*/ZMT(g)* (g) Generic equivalent covered. Brand not covered or requires higher copay. * Prior Approval (Authorization) or Step Therapy may be required. ** Covered with a prescription for BCN members and some Blue Cross members. Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives. Page 5 Tier 3 Preferred Alternatives Tier 3 Preferred Alternatives HYSINGLA ER Duragesic(g), Exalgo(g)*, Methadone(g), MS Contin(g), Opana ER(g)* KHEDEZLA Generic SSRI/SNRI [Celexa(g), Effexor(g)/XR(g), Prozac(g), Zoloft(g), etc.] ILEVRO Acular(g), Bromday(g), Ocufen(g), Voltaren ophth(g) KINERET Enbrel*, Humira*, methotrexate KORLYM Ketoconazole, Lysodren(g) INCRUSE ELLIPTA Foradil, Serevent, Spiriva/Respimat Inderal(g)/LA(g), Inderide(g) LAMISIL GRANULES Lamisil(g) INDERAL XL INNOPRAN XL Inderal(g)/LA(g), Inderide(g) LANOXIN 62.5, 187.5MCG Lanoxin(g) INTERMEZZO Ambien(g)/CR(g)*, Lunesta(g), Restoril(g), Sonata(g) LASTACAFT Alocril, Elestat(g), Optivar(g), Patanol, OTC Zaditor(g) IOPIDINE DROPPERETTE Alphagan(g), Alphagan P 0.15%(g), 0.1% LATUDA IPRAVASK Lovenox(g) Abilify(g), Clozaril(g), Geodon(g), Invega(g), Risperdal(g), Seroquel(g), Zyprexa(g) JARDIANCE Actos(g), Farxiga*, Glucophage(g), Insulin, Invokamet*, Invokana*, Janumet/XR, Januvia, Kombiglyze, Onglyza, a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g); Glynase(g)], Xigduo XR* LAZANDA Actiq(g)*, MSIR(g), Opana IR(g)*, oxycodone IR(g), Roxanol(g) LEVATOL Inderal(g)/LA(g), Lopressor(g), Sectral(g), Tenormin(g), Toprol XL(g) LEVITRA Cialis*, Revatio(g) (BCN only), Viagra* LIALDA Asacol HD, Azulfidine(g), En-Tab(g), Delzicol, Pentasa LINZESS Glycolax(g), Lactulose(g), OTC fiber, OTC laxatives and OTC stool softeners, OTC stimulant JENTADUETO Actos(g), Glucophage(g), Insulin, Janumet/XR, Januvia, Kombiglyze, Onglyza, a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g), Glynase(g)] JUBLIA Lamisil(g), Penlac(g), Sporanox(g) JUXTAPID Kynamro* LIPOFEN KADIAN Duragesic(g), Exalgo(g)*, Methadone(g), MS Contin(g), Opana ER(g)* Antara(g), Lofibra(g), Lopid(g), Tricor(g), Trilipix(g) LIVALO Lescol(g)/XL(g), Lipitor(g), Mevacor(g), Pravachol(g), Zocor(g) Clarinex(g), OTC Claritin(g)**, OTC Zyrtec(g)**, Xyzal(g) LO LOESTRIN FE Generic biphasic contraceptives (Loseasonique(g), Mircette(g), etc) LOCOID LIPOCREAM Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g) LORZONE Flexeril(g), Norflex(g), Robaxin(g), Zanaflex(g) tablets KARBINAL ER KAZANO Actos(g), ActoPlus Met(g), Glucophage(g)/XR(g), Insulin, Janumet/XR, Januvia, Kombiglyze XR, Onglyza, a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g); Glynase(g)] KERYDIN Lamisil(g), Penlac(g), Sporanox(g) LOTEMAX Decadron ophth(g), FML(g), Pred Forte(g), Pred Mild KETEK Biaxin(g), Erythromycin(g), Zithromax(g) LUPANETA PACK Lupron(g), Depot; plus Ortho Micronor(g) or Nor-QD(g) (g) Generic equivalent covered. Brand not covered or requires higher copay. * Prior Approval (Authorization) or Step Therapy may be required. ** Covered with a prescription for BCN members and some Blue Cross members. Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives. Page 6 Tier 3 Preferred Alternatives LUZU Diflucan(g), Lamisil(g), Nizoral(g), OTC Clotrimazole(g), OTC Miconazole(g), Sporanox(g) LYRICA Flexeril(g), Generic SSRI/SNRI [Celexa(g), Prozac(g), Effexor(g)/XR(g), Zoloft(g), etc.], Generic tricyclic antidepressant (TCA) such as Elavil(g), Neurontin(g), Ultram(g), MARPLAN Nardil(g), Parnate(g) MAXIDEX Decadron ophth(g), FML(g), Pred Forte(g), Pred Mild MENEST Alora, Climara(g), Estrace(g), OgenEst(g), Vivelle-Dot(g) MENOPUR MENOSTAR MENTAX Tier 3 Preferred Alternatives NAFTIFINE HCL Lotrimin(g), Monistat-derm(g), Nizoral CR(g), Nystatin(g) NAFTIN Lotrimin(g), Monistat-derm(g), Nizoral CR(g), Nystatin(g) NAMENDA XR Aricept(g)/ODT(g), Exelon(g), Namenda(g), solution NAMZARIC Aricept(g)/ODT(g), Exelon(g), Namenda(g), solution NASCOBAL SPRAY Cyanocobalamin injection, OTC Cyanocobalamin tabs (Vitamin-B) NASONEX Flonase(g), Nasacort AQ(g), Nasalide(g), OTC Nasacort, Patanase(g), Rhinocort Aqua(g)* Repronex* NATAZIA Mircette(g), Ortho Tri-Cyclen(g), Yasmin(g), Yaz(g) Alora, Climara(g), Estrace(g), OgenEst(g), Vivelle-Dot(g) NATESTO Monistat-Derm(g), Nizoral cream(g), OTC Lamisil(g)/AT(g), OTC Lotrimin(g)/Ultra, Spectazole(g) Androgel 1%(g)*, Androgel 1.62%*, Androderm*, Delatestryl(g)*, DepoTestosterone(g)* NESINA Actos(g), Glucophage(g), Insulin, Janumet/XR, Januvia, Kombiglyze, Onglyza, a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g), Glynase(g)] NEULASTA Granix, Neupogen NEUPRO Mirapex(g)/ER(g)*, Neurontin(g), Requip(g) NEVANAC Acular(g), Ocufen(g), Voltaren ophth(g) NEXICLON XR Catapres-TTS(g), Catapres(g) NICOTROL, NS OTC nicotine gum(g)**, lozenge(g), patch(g)**; Zyban(g) NORDITROPIN FLEXPRO Genotropin*, Nutropin AQ*, Nuspin* NORITATE MetroCream(g), Metrogel(g) METHITEST Androgel 1%(g)*, Androgel 1.62%*, Androderm*, Delatestryl(g)*, DepoTestosterone(g)* MINIVELLE Alora, Climara(g), Vivelle(g), VivelleDot(g) MIRCERA Procrit* MITIGARE colchicine tablets, Colcrys MONUROL Avelox(g), Bactrim(g)/DS(g), Cipro(g), Macrobid(g), Levaquin(g) MOVANTIK Glycolax(g), Lactulose(g), OTC fiber, OTC stimulant laxatives and OTC stool softeners MOVIPREP Colyte(g), Nulytely(g) MOXATAG Amoxil capsules(g) NORTHERA fludrocortisone, midodrine MYALEPT Insulin, Lescol/XL(g), Lipitor(g), Mevacor(g), Pravachol(g), Zocor(g) NUCYNTA MSIR(g), Opana(g), oxycodone IR(g), Ultram(g) Detrol(g)/LA(g), Ditropan(g)/XL(g), Sanctura(g)/XR(g) NUCYNTA ER Duragesic(g), Methadone(g), Opana ER(g), MS contin(g), Ultram ER(g) MYRBETRIQ (g) Generic equivalent covered. Brand not covered or requires higher copay. * Prior Approval (Authorization) or Step Therapy may be required. ** Covered with a prescription for BCN members and some Blue Cross members. Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives. Page 7 Tier 3 Preferred Alternatives NUVESSA Metrogel-Vaginal(g) NUVIGIL Provigil(g)* NYMALIZE Nimotop OBREDON Hycodan(g) OLEPTRO Desyrel(g), Generic SSRI/SNRI [Celexa(g), Prozac(g), Effexor(g)/XR(g), Zoloft(g), etc.] OMECLAMOX-PAK Nexium(g)*, Prilosec(g), Prilosec OTC, Omeprazole OTC plus Biaxin(g) plus Amoxil capsules(g) or Prevpac(g) OMNARIS Flonase(g), Nasacort AQ(g), Nasalide(g), OTC Nasacort, Patanase(g), Rhinocort Aqua(g)* OMNITROPE Genotropin*, Nutropin AQ*, Nuspin* ONEXTON Benzaclin(g), Benzamycin(g), Duac(g) ONFI Depakene(g), Depakote(g), Klonopin(g), Topamax (g) ONMEL Grifulvin(g), Lamisil(g), Sporanox(g) ORACEA Minocin(g), Monodox(g), tetracycline, Vibramycin(g) ORALAIR Accolate(g), Clarinex(g), Claritin(g), Flonase(g), Nasacort AQ(g), OTC Nasacort, Singulair(g), Xyzal(g), Zyrtec(g) Tier 3 Preferred Alternatives OXAYDO MS-IR(g), Norco(g), Opana IR(g)*, Oxycodone immediate-release(g) OXISTAT Diflucan(g), Nizoral(g), Lamisil(g), OTC Clotrimazole(g), OTC Miconazole(g), Spectazole(g), Sporanox(g) OXTELLAR XR Depakote(g)/ER(g), Lamictal(g)/ODT(g), Neurontin(g), Tegretol(g)/XR(g), Topamax(g), Trileptal(g) OXYCODONE HCL ER Duragesic(g), Exalgo(g)*, Methadone(g), MS Contin(g), Opana ER(g)* OXYCONTIN Duragesic(g), Exalgo(g)*, Methadone(g), MS Contin(g), Opana ER(g)* OXYTROL Detrol(g)/LA(g), Ditropan(g)/XL(g), Sanctura(g)/XR(g) PANDEL Aristocort(g), Cloderm, Cordran, Elocon(g), Locoid(g), Synalar(g), Topicort(g) PAREMYD Cyclogyl(g), Isopto Atropine(g) plus Mydriacyl(g) PATADAY Alocril, Elestat(g), Optivar(g), Patanol, OTC Zaditor PAZEO Alocril, Elestat(g), Optivar(g), Patanol, OTC Zaditor(g) ORAVIG Diflucan(g), Mycelex Troche(g), Nystatin, Sporanox(g) PCE Biaxin(g), Erythromycin(g), Zithromax(g) ORENCIA SUBQ Enbrel*, Humira*, methotrexate PENNSAID 2% OSENI Actos(g), Glucophage(g), Insulin, Janumet/XR, Januvia, Kombiglyze, Onglyza, a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g), Glynase(g)] Oral NSAID [such as Mobic(g)], Pennsaid 1.5%(g)*, Topical OTC analgesic balms (i.e. trolamine salicylate) PERFOROMIST Advair, Serevent Diskus, Spiriva/Respimat PERTZYE Creon, Ultresa, Viokase, Zenpep PEXEVA Generic SSRI/SNRI [Celexa(g), Prozac(g), Paxil(g), Zoloft(g), etc.] PHOSLYRA Phoslo(g), Renagel, Renvela PICATO Aldara(g), Efudex(g) OSMOPREP Colyte(g), Nulytely(g) OSPHENA Estring or Vagifem plus a progestin OTEZLA Enbrel*, Humira*, methotrexate, Rheumatrex, Trexall OTREXUP Enbrel*, Humira*, methotrexate, Rheumatrex, Trexall (g) Generic equivalent covered. Brand not covered or requires higher copay. * Prior Approval (Authorization) or Step Therapy may be required. ** Covered with a prescription for BCN members and some Blue Cross members. Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives. Page 8 Tier 3 Preferred Alternatives Tier 3 Preferred Alternatives PLEGRIDY Avenox, Copaxone(g), Copaxone 40mg/mL, Gilenya*, Rebif, Tecfidera* QUDEXY XR Depakene(g), Depakote(g), Topamax(g), Trileptal(g) POMALYST Thalomid QUILLIVANT XR POTIGA Depakene(g), Depakote(g), Dilantin(g), Klonopin(g) Adderall XR(brand BCN only), Metadate CD(g) (Both of which may be "sprinkled" on food); Methylin(g) RAGWITEK PRALUENT Colestid (g), Lescol(g)/XL(g), Lipitor(g), Mevacor(g), Pravachol(g), Questran/Light (g), Zetia, Zocor(g) Accolate(g), Clarinex(g), Claritin(g), Flonase(g), Nasacort AQ(g), OTC Nasacort, Singulair(g), Xyzal(g), Zyrtec(g) PRAMOSONE Analpram HC(g) RANEXA PRED-G Garamycin(g) plus Pred Forte(g) Beta-blocker [such as Toprol XL(g)] or calcium channel blocker [such as Norvasc(g)] in combination with a longacting nitrate [such as Imdur(g)] PREFAST Activella(g), FemHRT(g), Prempro/Premphase RAPAFLO Avodart(g), Cardura(g), Flomax(g), Hytrin(g), Jalyn(g)*, Uroxatral(g) RASUVO Enbrel*, Humira*, methotrexate, Rheumatrex, Trexall RAVICTI Buphenyl(g) RAYOS cortisone, Medrol(g), prednisolone, prednisone PREPOPIK Colyte(g), Nulytely(g) PRESTALIA Aceon(g) plus Norvasc(g); Exforge(g), Lotrel(g), Twynsta(g) PRILOSEC SUSPENSION Aciphex(g), Nexium(g)*, Prevacid(g), Solutab*; Prilosec(g)/Prilosec OTC**, Protonix(g) PRISTIQ ER Generic SSRI/SNRI [Celexa(g), Prozac(g), Effexor(g)/XR(g), Zoloft(g), etc.] RECTIV Nitroglycerin ointment REGRANEX papain/urea PROCYSBI Cystagon RELPAX Amerge(g), Axert(g)*, Imitrex(g), Maxalt(g)/MLT(g), Zomig(g)*/ZMT(g)* PROLENSA Acular(g), Bromday(g), Ocufen(g), Voltaren(g) REMODULIN Tyvaso PROTONIX SUSPENSION Aciphex(g), Nexium(g)*, Prevacid(g), Solutab*; Prilosec(g)/Prilosec OTC**, Protonix(g) REPATHA Colestid (g), Lescol(g)/XL(g), Lipitor(g), Mevacor(g), Pravachol(g), Questran/Light (g), Zetia, Zocor(g) PROVENTIL HFA Proair HFA, Respiclick; Ventolin HFA RESCULA Alphagan(g), Cosopt(g), Lumigan, Travatan(g)/Z, Xalatan(g) PURIXAN mercaptopurine tablets PYLERA PrevPac(g), Tetracycline plus Flagyl(g) plus OTC Bismuth RETIN-A MICRO PUMP 0.08% Duac(g), Differin(g), Retin-A(g), Micro(g) REVLIMID Thalomid QNASL, CHILDREN'S Flonase(g), Nasacort AQ(g), Nasalide(g), OTC Nasacort, Patanase(g), Rhinocort Aqua(g)* REXULTI Abilify(g), Clozaril(g), Geodon(g), Invega(g), Risperdal(g), Seroquel(g), Zyprexa(g) QSYMIA Adipex-P(g), Bontril(g)*, Didrex(g)*, OTC Alli, Tenuate(g)* REZIRA Zutripro(g) QUARTETTE Alesse(g), Lybrel(g), Seasonale(g) (g) Generic equivalent covered. Brand not covered or requires higher copay. * Prior Approval (Authorization) or Step Therapy may be required. ** Covered with a prescription for BCN members and some Blue Cross members. Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives. Page 9 Tier 3 RIOMET Preferred Alternatives Tier 3 Preferred Alternatives Actos(g), Glucophage(g), Januvia, Onglyza, a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g); Glynase(g)] SIMCOR Zocor(g) plus Niaspan(g) SIMPONI Enbrel*, Humira*, methotrexate Adderall(g)/XR(brand BCN only); Concerta(g), Metadate CD(g), Ritalin(g)/LA(g)/SR(g) SITAVIG Famvir(g), Valtrex(g), Zovirax(g) SKLICE Elimite(g), Eurax, Lindane(g) ROZEREM Ambien(g)/CR(g)*, Lunesta(g), OTC melatonin, Prosom(g), Restoril(g), Sonata(g) SOLODYN Minocin(g), Monodox(g), tetracycline, Vibramycin(g) SOLTAMOX Tamoxifen RYTARY Parcopa(g), Sinemet(g)/CR(g) SOOLANTRA Generic topical metronidazole, RetinA(g) SORILUX Dovonex(g) SOTYLIZE Betapace(g), Calan(g), Cardizem(g), Inderal(g) RITALIN LA 10MG, 60MG SAFYRAL Generic contraceptive plus OTC folic acid SAIZEN Genotropin*, Nutropin AQ*, Nuspin* SANCUSO Kytril(g), Zofran(g)/ODT(g) SAPHRIS Abilify(g), Clozaril(g), Geodon(g), Invega(g), Risperdal(g), Seroquel(g), Zyprexa(g) SPRIX Toradol(g) STAXYN Cialis*, Revatio(g) (BCN only), Viagra* SARAFEM TABLET Prozac(g) STELARA Enbrel*, Humira*, methotrexate SAVAYSA Eliquis, Pradaxa, Xarelto STENDRA Cialis*, Revatio(g) (BCN only), Viagra* SAVELLA Cymbalta(g), Effexor(g)/XR(g), Flexeril(g), Neurontin(g), generic SSRI [Celexa(g), Prozac(g), Zoloft(g)], generic TCA [Adapin(g), Elavil(g), Sinequan(g), Tofranil(g)], Ultram(g) STRATTERA Adderall(g)/XR(brand BCN only); Concerta(g), Focalin(g)/XR(g), Intuniv(g), Kapvay(g), Metadate CD(g), Ritalin(g)/LA(g)/SR(g) STRIANT Androgel 1%(g)*, Androgel 1.62%*, Androderm*, Delatestryl(g)*, DepoTestosterone(g)* SAXENDA Adipex-P(g), Bontril(g)*, Didrex(g)*, OTC Alli, Tenuate(g)* SEMPREX-D Astelin(g), OTC Claritin-D(g)**, OTC Zyrtec-D(g)**, Xyzal(g) STRIVERDI RESPIMAT Serevent Diskus SEROQUEL XR Abilify(g), Clozaril(g), Geodon(g), Invega(g), Risperdal(g), Seroquel(g), Zyprexa(g) SUBSYS Actiq(g)*, MSIR(g), Opana IR(g)*, oxycodone IR, Roxanol(g) SUMAVEL DOSEPRO Amerge(g), Axert(g)*, Imitrex(g), Maxalt(g)/MLT(g); Zomig(g)*/ZMT(g)* SUPRAX CHEW TABLETS, 500MG/5ML SUSP Omnicef(g), Suprax suspension(g) Vantin(g) SUPRENZA ODT Adipex-P(g), Bontril(g)*, Didrex(g)*, OTC Alli, Tenuate(g)* SUPREP Colyte(g), Nulytely(g) SEROSTIM Genotropin*, Nutropin AQ*, Nuspin* SIGNIFOR Ketoconazole, Lysodren(g) SIGNIFOR LAR Sandostatin LAR Depot*, Somatuline Depot*; Somavert* SILENOR Adapin(g), Ambien(g), Desyrel(g), Lunesta(g), Sinequan(g), Sonata(g) SIMBRINZA Alphagan(g), Cosopt(g), Lumigan, Travatan(g)/Z, Trusopt(g), Xalatan(g) (g) Generic equivalent covered. Brand not covered or requires higher copay. * Prior Approval (Authorization) or Step Therapy may be required. ** Covered with a prescription for BCN members and some Blue Cross members. Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives. Page 10 Tier 3 SYMLIN Preferred Alternatives Tier 3 Preferred Alternatives Actos(g), Glucophage(g), Insulin, Januvia, Onglyza, Precose(g), a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g), Glynase(g)] TOBRADEX ST Tobradex suspension(g), ointment; sulfacetamide/prednisolone solution TOLAK Carac(g), Efudex(g) Actos(g), Glucophage(g), Farxiga*, Insulin, Invokana*, Invokamet*, Janumet/XR, Januvia, Kombiglyze, Onglyza, a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g); Glynase(g)], Xigduo XR* TOPIRAMATE ER Depakene(g), Depakote(g), Keppra(g), Klonopin(g), Topamax(g), Trileptal(g) TOVIAZ (BCBSM ONLY) Detrol(g)/LA(g), Ditropan(g)/XL(g), Sanctura(g)/XR(g) Depen TRADJENTA Actos(g), Glucophage(g), Insulin, Janumet/XR, Januvia, Kombiglyze, Onglyza, a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g), Glynase(g)] Actos(g), Bydureon*, Glucophage(g), Insulin, Januvia, Onglyza, a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g), Glynase(g)], Victoza* TRETIN-X Retin-A (g), Retin-A Micro (g) TREXIMET Amerge(g), Axert(g)*, Imitrex(g) plus naproxen; Maxalt(g)/MLT(g), Zomig(g)*/ZMT(g)* TEKAMLO generic ACE Inhibitor (lisinopril, benazepril, etc.), Lotrel(g), generic ARB plus Norvasc(g) TREZIX Esgic(g), Norco(g), Tylenol #3(g), Synalgos(g) TRIBENZOR TEKTURNA, HCT Generic ACE (lisinopril, benazepril, etc.) or ARB (Atacand(g)/HCT(g), Avapro(g), Avalide(g), Cozaar(g), Diovan(g)/HCT(g), Exforge(g), Hyzaar(g), Teveten(g), or Benicar*/HCT*) Generic angiotension receptor antagonist (ARB) such as Cozaar(g) plus Norvasc(g) and hydrochlorothiazide TRIGLIDE Antara(g), Lofibra(g), Lopid(g), Tricor(g), Trilipix(g) SYNJARDY SYPRINE TACLONEX SCALP Dovonex(g) plus Diprosone/Diprolene(g) TANZEUM TESTIM Androgel 1%(g)*, Androgel 1.62%*, Androderm*, Delatestryl(g)*, DepoTestosterone(g)* TROKENDI XR Depakene(g), Depakote(g), Keppra(g), Klonopin(g), Topamax(g), Trileptal(g) TESTOSTERONE, GEL, PACKET, PUMP Androgel 1%(g)*, Androgel 1.62%*, Androderm*, Delatestryl(g)*, DepoTestosterone(g)* TRULICITY TESTRED, ANDROID Androgel 1%(g)*, Androgel 1.62%*, Androderm*, Delatestryl(g)*, DepoTestosterone(g)* Actos(g), Bydureon*, Glucophage(g), Insulin, Januvia, Onglyza, a sulfonylurea [Amaryl(g), Glucotrol(g)/XL(g), Glynase(g)], Victoza* TUDORZA PRESSAIR Advair, Serevent Diskus, Spiriva/Respimat TYZEKA Baraclude(g), Epivir HBV(g), Hepsera(g) UCERIS Azulfidine(g), Delzicol, Entocort EC(g), Pentasa(g), prednisolone, prednisone UCERIS FOAM Canasa, Cortenema(g), Cortifoam, Rowasa(g), Sfrowasa(g) VALCHLOR 8-Mop, Oxsoralen, Zolinza* TIMOPTIC PF Betagan(g), Betoptic(g), Ocupress(g), Optipranolol(g), Timoptic(g) TIROSINT Levoxyl(g), Synthroid(g) TIVORBEX Generic NSAIDs [Indomethacin(g), Lodine(g)/XL(g); Mobic(g), Motrin(g), Naprosyn(g), Voltaren oral(g)] TOBI PODHALER Tobi(g) (g) Generic equivalent covered. Brand not covered or requires higher copay. * Prior Approval (Authorization) or Step Therapy may be required. ** Covered with a prescription for BCN members and some Blue Cross members. Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives. Page 11 Tier 3 Preferred Alternatives Tier 3 Preferred Alternatives VASCEPA Antara(g), Lofibra(g), Lopid(g), Lovaza(g)*, OTC Omega-3 or -3FA products, Tricor(g), Trilipix(g) VYVANSE Adderall(g)/XR(brand BCN only); Concerta(g), Metadate CD(g), Ritalin(g)/LA(g)/SR(g) VECAMYL Catapres(g), Cozaar(g), Toprol XL(g), Zestril(g) XARTEMIS XR Norco(g), Opana IR(g)*, oxycodone IR(g), Percocet(g), Ultram(g)/ER(g) VELPHORO OTC Tums, Phoslo(g), Renagel, Renvela XELJANZ Enbrel*, Humira*, methotrexate XENICAL VELTIN Cleocin topical(g) plus Retin-A(g), Differin(g), Duac(g) Adipex-P(g), Bontril(g)*, Didrex(g)*, OTC Alli, Tenuate(g)* XERESE VERAMYST Flonase(g), Nasacort AQ(g), Nasalide(g), Patanase(g), OTC Nasacort, Rhinocort Aqua(g)* Zovirax cream plus hydrocortisone cream XIFAXAN 200MG Bactrim DS(g), Vibramycin(g), Zithromax(g) XIFAXAN 550MG Bentyl(g), Imodium(g), Levbid(g), Levsin(g), Lactulose, SSRI [Celexa(g), Prozac(g), Zoloft(g)], TCA [Adapin(g), Elavil(g), Sinequan(g), Tofranil(g)] XOLEGEL Diflucan(g), Lamisil(g), Nizoral(g), OTC Clotrimazole(g), OTC Miconazole(g), Spectazole(g), Selsun RX(g), Sporanox(g) XOPENEX HFA Albuterol(g), Proair HFA, Respiclick; Ventolin HFA, Xopenex nebulizer solution(g) XYREM Adderall(g)/XR(brand BCN only); Concerta(g), Metadate CD(g), Provigil(g)* ZARXIO Granix, Neupogen ZAVESCA Cerezyme (medical benefit) ZECUITY Amerge(g)*, Axert(g)*, Imitrex(g), Maxalt(g)/MLT(g); Zomig(g)*/ZMT(g)* ZEGERID PACKET Nexium(g)*, Prevacid(g)/Solutab*; Prilosec(g)/Prilosec OTC**, Protonix(g), Zegerid(g)* ZELAPAR Azilect, Eldepryl(g) ZENZEDI Adderall(g)/XR(brand BCN only), Dexedrine(g), Metadate CD(g), Ritalin(g)/LA(g) ZETONNA Flonase(g), Nasacort AQ(g), Nasalide(g), Patanase(g), OTC Nasacort, Rhinocort Aqua(g)* VERDESO Capex, Dermacort(g), DermaSmoothe(g), Desowen(g), Synalar solution(g) VEREGEN Condylox solution(g), gel VERSACLOZ Clozaril(g), Fazaclo(g)* VESICARE Detrol(g)/LA(g), Ditropan(g)/XL(g), Sanctura(g)/XR(g) VIIBRYD, DOSEPAK Generic SSRI/SNRI [Celexa(g),Cymbalta(g), Prozac(g), Zoloft(g), Effexor(g)/XR(g), etc.], Wellbutrin/SR/XL(g) VIMOVO Generic PPIs [Aciphex(g), Nexium(g)*, Prilosec(g), Protonix(g), Prevacid(g)] plus Naprosyn(g) VITUZ SOLUTION Hycodan(g), Phenergan w/codeine(g), Tussionex(g) VOGELXO Androgel 1%(g)*, Androgel 1.62%*, Androderm*, Delatestryl(g)*, DepoTestosterone(g)* VOLTAREN GEL Topical OTC analgesic balms, (i.e. trolamine salicylate); Generic NSAIDs [Voltaren(g), Lodine(g)/XL(g); Mobic(g), Motrin(g), Naprosyn(g)], Pennsaid 1.5%(g)* VUSION OTC diaper rash products VYTORIN Generic Statin [Lescol(g)/XL(g), Lipitor(g), Mevacor(g), Pravachol(g), Zocor(g)] plus Zetia (g) Generic equivalent covered. Brand not covered or requires higher copay. * Prior Approval (Authorization) or Step Therapy may be required. ** Covered with a prescription for BCN members and some Blue Cross members. Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives. Page 12 Tier 3 Preferred Alternatives ZIANA GEL Cleocin topical(g) plus Retin-A(g), Differin(g), Duac(g) ZIOPTAN Alphagan(g), Cosopt(g), Lumigan, Travatan(g)/Z, Trusopt(g), Xalatan(g) ZIPSOR Generic NSAIDs [Lodine(g)/XL(g); Mobic(g), Motrin(g), Naprosyn(g), Voltaren oral(g)] ZMAX Zithromax(g) ZOHYDRO ER Duragesic(g), Exalgo(g)*, Methadone(g), MS Contin(g), Opana ER(g)* ZOLPIMIST Ambien(g)/CR(g)*, Lunesta(g), Restoril(g), Sonata(g) ZOMACTON Genotropin*, Nutropin AQ*, Nuspin* ZOMIG NASAL SPRAY Amerge(g)*, Axert(g)*, Imitrex(g), Maxalt(g)/MLT(g); Zomig(g)*/ZMT(g)* ZONTIVITY Brilinta, Effient, Plavix(g), Ticlid(g); Persantine(g) plus OTC Aspirin ZORBTIVE Genotropin*, Nutropin AQ*, Nuspin* ZORTRESS Afinitor*, Disperz* ZORVOLEX Mobic(g), Motrin(g), Naprosyn, EC(g); Voltaren(g) ZUBSOLV Suboxone(g), Suboxone Film ZUPLENZ Kytril(g), Zofran(g)/ODT(g) ZYCLARA Aldara(g), Condylox soln(g), Efudex(g) ZYFLO, CR Accolate(g), Flovent HFA, Singulair(g) ZYLET Cortisporin(g), Maxitrol(g), sulfacetamide/prednisolone solution, Tobradex(g) ZYMAR Ciloxan(g), Ocuflox(g), Quxin(g), Vigamox, Zymaxid Tier 3 Preferred Alternatives (g) Generic equivalent covered. Brand not covered or requires higher copay. * Prior Approval (Authorization) or Step Therapy may be required. ** Covered with a prescription for BCN members and some Blue Cross members. Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this list as a guide when selecting alternatives. Page 13 Index Trade Name Page Trade Name Page 8-MOP (Tier 2 BCN Only) 55 Aldactazide 50/50mg (Tier 2 BCN only) 22 Abilify (aripiprazole) 28 Aldactazide (spironolact/hydrochlorothiazid) 22 Absorica 54 Aldactone (spironolactone) 22 Abstral 31 Aldara (imiquimod) 57 Acanya 54 Aldomet (methyldopa) 19 Accolate (zafirlukast) 66 Aldoril (methyldopa/hydrochlorothiazide) 19 Accuneb; Albuterol nebulizer solution (albuterol sulfate) 64 Alesse, Levlite 40 Accupril (quinapril hcl) 19 Alferon N 53 Accuretic (quinapril/hydrochlorothiazide) 19 Alinia 14 Aceon (perindopril erbumine) 19 Alkeran 50 Acetasol HC (acetic acid/hydrocortisone) 62 Alocril 59 Acetylcysteine (acetylcysteine) 66 Alomide 59 Aciphex (rabeprazole sodium) 38 Alora 45 Aciphex Sprinkle 38 Alora 41 Aclovate (alclometasone dipropionate) 56 Alphagan 0.2%, P 0.15% (brimonidine tartrate) 61 Actemra syringe 44 Alphagan P 0.1% 61 Acthar H.P. 26 Alrex 61 Acticlate 54 Alsuma (sumatriptan succinate) 29 Acticlate 18 Altabax 57 Actigall (ursodiol) 37 Altace (ramipril) 19 Actimmune 53 Altoprev 23 Actiq (fentanyl citrate) 31 Alupent (metaproterenol sulfate) 65 Activella (estradiol/norethindrone acet) 41 Alvesco (Tier 1-BCN Only) 65 Actonel 35mg, 150mg (risedronate sodium) 44 Amantadine hcl (amantadine hcl) 16 Actonel 5, 30mg (risedronate sodium) 44 Amaryl (glimepiride) 48 Actoplus MET (pioglitazone hcl/metformin hcl) 48 Ambien CR (zolpidem tartrate) 34 Actoplus MET XR 48 Ambien (zolpidem tartrate) 34 Actos (pioglitazone hcl) 48 Amerge (naratriptan hcl) 29 Acular, LS (ketorolac tromethamine) 60 Amicar 20 Acuvail 60 Amicar solution (aminocaproic acid) 20 Aczone 54 Amitiza 39 Adapalene 0.1% lotion 54 Amnesteem; Myorisan; Zenatane (isotretinoin) 54 Adcirca 65 Amoxapine (amoxapine) 27 Adderall XR (Brand BCN-Only) (amphet asp/amphet/damphet) Adderall XR (amphet asp/amphet/d-amphet) 29 Amoxicillin ER 17 Amoxil (amoxicillin trihydrate) 17 29 Ampicillin (ampicillin trihydrate) 17 Adderall (amphet asp/amphet/d-amphet) 29 Ampyra 53 Addyi 70 Amrix 34 Adempas 65 Anadrol-50 46 Adipex, P (phentermine hcl) 70 Anafranil (clomipramine hcl) 27 Adoxa capsule (doxycycline monohydrate) 54 Analpram HC lot, cream (BCBSM Only) 38 Adoxa capsule (doxycycline monohydrate) 18 Analpram HC (hydrocortisone/pramoxine hcl) 38 Adoxa tablet (doxycycline monohydrate) 54 Anamantle HC (lidocaine hcl/hc) 38 Adoxa tablet (doxycycline monohydrate) 18 Anaprox, DS (naproxen sodium) 32 Adrenaclick (epinephrine) 64 Ancobon (flucytosine) 14 Adrenalin chloride (Tier 2 BCN Only) 64 Androderm 46 Advair 65 Androgel (1%) (testosterone) 46 Advicor 23 Androgel 1.62% 46 Aerospan 65 Android; Testred 46 Afinitor, Disperz 52 Androxy (fluoxymesterone) 46 Afrezza 47 Angeliq 41 Aggrenox (aspirin/dipyridamole) 20 Anoro Ellipta 64 Agrylin (anagrelide hcl) 20 Ansaid (flurbiprofen) 32 Akynzeo 36 Antabuse (disulfiram) 35 Ala-Scalp HP (hydrocortisone) 56 Antara (fenofibrate,micronized) 23 Albenza 14 Trade Name Page Antara 30, 90mg 23 Trade Name AVC Page 42 Antivert (meclizine hcl) 36 Avelox (moxifloxacin hcl) 17 Anusol HC (hydrocortisone) 38 Avelox ABC 17 Anzemet 36 Aventyl; Pamelor (nortriptyline hcl) 27 Apexicon, E (diflorasone diacetate) 55 Avinza (morphine sulfate) 31 Apidra, Solostar 47 Avita gel 54 Aplenzin 27 Avodart (dutasteride) 67 Apokyn 33 Avonex 53 Apresoline (hydralazine hcl) 25 Axert (almotriptan malate) 29 Apriso 36 Axid (RX Only) (nizatidine) 37 Aptensio XR 29 Axiron 46 Aptiom 26 Aygestin (norethindrone acetate) 42 Aptivus 15 Azasan 51 Aralen (chloroquine phosphate) 14 Azasan 45 Aranesp 50 Azasite 60 Aranesp 53 Azelex 54 Arava (leflunomide) 45 Azilect 33 Arcalyst 51 Azopt 61 Arcapta Neohaler 64 Azor 21 Aricept 23mg (donepezil hcl) 25 Azor 20 Aricept, ODT (donepezil hcl) 25 Azulfidine, En-Tab (sulfasalazine) 45 Arimidex (anastrozole) 51 Azulfidine, En-Tab (sulfasalazine) 36 Aristocort; Kenalog 0.5% cream (triamcinolone acetonide) Arixtra (fondaparinux sodium) 55 67 20 Azuphen MB (BCBSM only) (methen/m-blue/sal/na phos/hyos) Bacitracin (bacitracin) Armour Thyroid 49 Baclofen (baclofen) 34 Arnuity Ellipta 65 Bactrim, DS (sulfamethoxazole/trimethoprim) 18 Aromasin (exemestane) 51 Bactroban (mupirocin calcium) 57 Artane (trihexyphenidyl hcl) 33 Bactroban Nasal 57 Arthrotec (diclofenac sodium/misoprostol) 32 Banzel 26 Asacol HD 36 Banzel suspension (Tier 2 BCN only) 26 Asmanex, HFA (Tier 1-BCN Only) 65 Baraclude solution 16 Aspirin, Ecotrin 81, 325mg 33 Baraclude tablets (entecavir) 16 Astagraf XL 51 Beconase AQ 62 Astelin (azelastine hcl) 63 Beconase AQ 65 Astelin (azelastine hcl) 62 Belbuca 30 Astepro (azelastine hcl) 63 Belladonna & Opium (opium/belladonna alkaloids) 30 Astepro (azelastine hcl) 62 Belsomra 34 Atacand (candesartan cilexetil) 20 Belviq 70 Atacand HCT (candesartan/hydrochlorothiazide) 20 Benadryl (Rx only) (diphenhydramine hcl) 63 Atarax; Vistaril (hydroxyzine) 63 Benicar, HCT 20 Atelvia (risedronate sodium) 44 Bentyl (dicyclomine hcl) 36 Ativan (lorazepam) 28 Benzaclin (clindamycin phos/benzoyl perox) 54 Atralin (tretinoin) 54 Benzamycin (erythromycin base/benz per) 54 Atripla 15 Benzoyl Peroxide (RX) (BCBSM only) (benzoyl peroxide) 54 Atrovent HFA 64 Bepreve 59 Atrovent nasal spray (ipratropium bromide) 62 Besivance 60 Atrovent solution (ipratropium bromide) 64 Betagan (levobunolol hcl) 60 Aubagio 53 Betapace, AF (sotalol hcl) 21 Augmentin 125mg-31.25mg/5ml 17 Betapace, AF (sotalol hcl) 22 Augmentin, ES, XR (amox tr/potassium clavulanate) 17 Betaseron 53 Auralgan (aa/antpy/bcaine/polico/al acet) 62 Bethkis 64 Auryxia 69 Bethkis 18 Avalide (irbesartan/hydrochlorothiazide) 20 Betimol (Tier 3 BCN only) 60 Avandamet 48 Betoptic S 60 Avandia 48 Betoptic solution (betaxolol hcl) 60 Avapro (irbesartan) 20 Beyaz 40 60 Trade Name Page Trade Name Page Biaxin, XL (clarithromycin) 17 Cardura (doxazosin mesylate) 19 BiDil 23 Cardura (doxazosin mesylate) 67 Biltricide 14 Carnitor SF solution (BCN tier 2 only) 69 Binosto 44 Carnitor (levocarnitine) 69 Bleph-10 (Tier 2 BCN only) 60 Casodex (bicalutamide) 51 Bleph-10, Sodium Sulamyde (sulfacetamide sodium) 60 Cataflam (diclofenac potassium) 32 Blephamide 59 Catapres TTS (clonidine hcl) 19 Blocadren (timolol maleate) 21 Catapres (clonidine hcl) 19 Boniva (ibandronate sodium) 44 Caverject 70 Bontril PDM (phendimetrazine tartrate) 70 Cayston 64 Bosulif 52 Cayston 18 Bravelle 42 Ceclor, ER (cefaclor) 17 Breo Ellipta 65 Cedax (ceftibuten dihydrate) 17 Brevoxyl gel (BCBSM only) (benzoyl peroxide) 54 Ceftin suspension 17 Brilinta 20 Ceftin tablets (cefuroxime axetil) 17 Brintellix 27 Cefzil (cefprozil) 17 Brisdelle 43 Celebrex (celecoxib) 32 Bromday; Xibrom (bromfenac sodium) 60 Celexa (citalopram hydrobromide) 27 Bromfed-DM (d-methorphan hb/p-epd hcl/bpm) 63 Cellcept (mycophenolate mofetil) 51 Brovana 64 Celontin 26 Bumex (bumetanide) 22 Centany ointment (Tier 2 BCN Only) 57 Bunavail 30 Cerdelga 49 Buphenyl powder (sodium phenylbutyrate) 49 Cesamet 36 Buphenyl tablets 49 Cetraxal (ciprofloxacin hcl) 62 Buspar (buspirone hcl) 28 Cetrotide 42 Butisol sodium 34 Chantix 70 Butrans 30 Chenodal 37 Bydureon, Pen 48 Chloral Hydrate (BCBSM Only) (chloral hydrate) 34 Byetta 48 Cholbam 49 Bystolic 21 Cialis 70 Bystolic 20mg 21 Cialis 2.5, 5mg 67 Cabergoline (cabergoline) 49 Ciloxan drops (ciprofloxacin hcl) 60 Caduet (amlodipine/atorvastatin cal) 21 Ciloxan ointment 60 Caduet (amlodipine/atorvastatin cal) 23 Cimzia Syringe 38 Cafcit (caffeine citrated) 35 Cimzia Syringe 45 Cafergot 29 Cipro HC 62 Calan SR; Isoptin SR (verapamil hcl) 21 Cipro XR (ciprofloxacin hcl-betaine comb) 17 Calciferol (ergocalciferol) 68 Cipro (ciprofloxacin hcl) 17 Calciferol (ergocalciferol) 49 Ciprodex 62 Cambia 32 Clarinex syrup 63 Cambia 29 Clarinex tablets, Redi-tabs (desloratadine) 63 Campral (acamprosate calcium) 35 Clarinex-D 63 Canasa 36 Claritin, Alavert (OTC) (loratadine) 63 Cantil 37 Claritin-D (OTC) (p-ephed sul/loratadine) 63 Capex Shampoo 56 Cleocin 75mg 18 Capoten (captopril) 19 Cleocin T (clindamycin phosphate) 54 Capozide (captopril/hydrochlorothiazide) 19 Cleocin vaginal cream (clindamycin phosphate) 42 Caprelsa 52 Cleocin vaginal ovules 42 Carac 57 Cleocin (clindamycin hcl) 18 Carafate (sucralfate) 37 Climara Pro 41 Carbaglu 49 Climara (estradiol) 41 Carbatrol (carbamazepine) 26 Climara (estradiol) 45 Cardene SR 21 Clindesse 42 Cardene (nicardipine hcl) 21 Clinoril (sulindac) 32 Cardizem LA 120mg 21 Clobevate; Temovate (clobetasol propionate) 55 Cardizem, SR, CD, LA (diltiazem hcl) 21 Clobex (clobetasol propionate) 55 Cardura XL 67 Clocortolone Pivalate 56 Trade Name Page Trade Name Page Cloderm 56 Cozaar (losartan potassium) 20 Clomid (clomiphene citrate) 42 Creon 37 Clorpres (clonidine hcl/chlorthalidone) 19 Cresemba capsules 14 Clorpres 0.3-15mg (Tier 2 - BCN Only) 19 Crestor 23 Clozapine 200mg (clozapine) 28 Crinone 4% 42 Clozaril (clozapine) 28 Crinone 8% 42 Coartem 14 Crixivan 15 Codeine sulfate tablets (codeine sulfate) 31 Cromolyn sodium (cromolyn sodium) 59 Cogentin (benztropine mesylate) 33 Cuprimine 67 Colazal (balsalazide disodium) 36 Cuprimine 45 Colbenemid (colchicine/probenecid) 44 Cuprimine 69 Colchicine capsules 44 Cutivate (fluticasone propionate) 56 Colchicine tablets 44 Cuvposa 35 Colcrys 44 Cyanocobalamin inj (cyanocobalamin) 68 Colestid granules, packet 23 Cyclessa 41 Colestid (colestipol hcl) 23 Cyclocort (amcinonide) 55 Coly-Mycin S 62 Cyclogyl 0.5% 59 Colyte (sod sulf/sod/nahco3/kcl/peg's) 37 Cyclogyl 0.5%, 1% 5ml (Tier 2 BCN only) 59 Combigan 61 Cyclogyl 1%, 2% (cyclopentolate hcl) 59 Combipatch 41 Cyclophosphamide 50 Combivent Respimat 64 Cycloserine 16 Combivir (lamivudine/zidovudine) 15 Cycloset 48 Cometriq 52 Cymbalta 60 mg (duloxetine hcl) 27 Commit Lozenge OTC 70 Cymbalta (duloxetine hcl) 27 Compazine suppositories (prochlorperazine) 36 Cystadane (BCN Tier 2/4 only) 69 Compazine (prochlorperazine maleate) 36 Cystagon 67 Complera 15 Cystaran 61 Comtan (entacapone) 33 Cytomel (liothyronine sodium) 49 Conceptrol 40 Cytotec (misoprostol) 37 Concerta (methylphenidate hcl) 29 Cytra-2 (BCBSM only) (citric acid/sodium citrate) 67 Condylox gel 58 Cytra-3 (BCBSM only) (citric acid/potassium citrate) 67 Condylox solution (podofilox) 58 Cytra-K (BCBSM only) (potassium citrate/citric acid) 67 Contrave ER 70 D.H.E.45 (dihydroergotamine mesylate) 29 Conzip 30 Daklinza 16 Copaxone 53 Daliresp 66 Copegus (ribavirin) 16 Dalmane (flurazepam hcl) 34 Cordarone (amiodarone hcl) 22 Danocrine (danazol) 46 Cordran lotion, tape, SP 56 Dantrium (dantrolene sodium) 34 Cordran ointment (Tier 2 BCN Only) 56 Dapsone 16 Coreg CR 21 Daraprim 14 Coreg immediate release (carvedilol) 21 Daypro (oxaprozin) 32 Corgard (nadolol) 21 Daytrana 29 Corlanor 22 DDAVP (desmopressin acetate) 49 Cortef; Hydrocortisone (hydrocortisone) 46 DDAVP solution (Tier 2 BCN only) 49 Cortenema (hydrocortisone acetate) 38 Decadron Opth (dexamethasone sod phosphate) 61 Cortifoam 38 Decadron (dexamethasone) 46 Cortisone Acetate (cortisone acetate) 46 Declomycin (demeclocycline hcl) 18 Cortisporin (neomy sulf/polymyx b sulf/hc) 59 Delatestryl (testosterone enanthate) 46 Cortisporin (neomy sulf/polymyx b sulf/hc) 62 Delestrogen 41 Cortisporin-TC 62 Delzicol 36 Corzide (nadolol/bendroflumethiazide) 21 Demadex (torsemide) 22 Cosentyx 55 Demerol (meperidine hcl) 31 Cosopt PF 61 Demser (Tier 2 BCN Only) 25 Cosopt (timolol maleate/dorzolam hcl) 61 Demulen 40 Coumadin (warfarin sodium) 20 Denavir 57 Covaryx, H.S. (estrogen,ester/me-testosterone) 43 Depakene (valproate sodium) 26 Covaryx, H.S. (estrogen,ester/me-testosterone) 45 Depakote, ER, Sprinkles (divalproex sodium) 26 Trade Name Page Trade Name Page Depen 45 Domeboro Otic (acetic acid/aluminum acetate) 62 Depen 67 Donnatal, Extentabs (BCBSM only) 36 Depen 69 Doral (quazepam) 34 Depo-Provera 150mg 40 Doryx 50, 200mg 54 Depo-Provera 400mg 51 Doryx 50, 200mg 18 Depo-Subq Provera 104 40 Doryx (doxycycline hyclate) 54 Depo-Subq Provera 104 42 Doryx (doxycycline hyclate) 18 Depo-Testosterone (testosterone cypionate) 46 Dovonex (calcipotriene) 55 Dermacort; Hytone (RX Only) (hydrocortisone) 56 Doxycycline 20mg tablet (doxycycline hyclate) 54 Derma-Smoothe/FS (fluocinolone acetonide) 56 Doxycycline IR-DR 18 Dermatop (prednicarbate) 56 Doxycycline IR-DR 54 Desferal (deferoxamine mesylate) 69 Drithocreme HP(BCBSM only) (anthralin) 55 Desogen; Ortho-cept 40 Droxia 52 Desonate 56 Drysol (aluminum chloride) 58 Desowen (desonide) 56 Duac (clindamycin phosphate/benz per) 54 Desoxyn (methamphetamine hcl) 29 Duavee 43 Desvenlafaxine ER 27 Duavee 45 Desvenlafaxine Fumarate ER 27 Duetact (pioglitazone/glimepiride) 48 Desyrel (trazodone hcl) 27 Duexis 32 Detrol, LA (tolterodine tartrate) 67 Dulera 65 Dexedrine (d-amphetamine sulfate) 29 Duoneb (ipratropium/albuterol sulfate) 64 Dexilant 38 Duopa 33 Diabeta; Micronase (glyburide) 48 Duragesic (fentanyl) 31 Diabinese (chlorpropamide) 48 Durezol 61 Diamox, Sequels (acetazolamide) 26 Duricef (cefadroxil hydrate) 17 Diamox, Sequels (acetazolamide) 22 Durlaza 33 Diastat 2.5mg Kit 26 Dutoprol 21 Diastat Acudial (diazepam) 26 Dutoprol 22 Dibenzyline (phenoxybenzamine hcl) 19 Dyazide, Maxzide (triamterene/hydrochlorothiazide) 22 Diclegis 36 Dymista 65 Diclegis 43 Dymista 62 Dicloxacillin (dicloxacillin sodium) 17 Dynacirc (isradipine) 21 Didrex (benzphetamine hcl) 70 Dyrenium 22 Didronel (etidronate disodium) 44 E. E. S. tablet (erythromycin ethylsuccinate) 17 Diethylpropion hcl, ER (diethylpropion hcl) 70 EC-Naprosyn (naproxen) 32 Differin (adapalene) 54 Ecoza 57 Differin 0.1% lotion 54 Edarbi 20 Dificid 17 Edarbyclor 20 Diflucan (fluconazole) 14 Edecrin 22 Diflucan (fluconazole) 42 Edex 70 Dilantin 30mg 26 Edluar 34 Dilantin Chew Tabs (phenytoin) 26 Edurant 15 Dilantin (phenytoin sodium extended) 26 Effexor XR (venlafaxine hcl) 27 Dilatrate-SR 23 Effexor (venlafaxine hcl) 27 Dilaudid (hydromorphone hcl) 31 Effient 20 Diovan (valsartan) 20 Efudex Occlusion 57 Diovan HCT (valsartan/hydrochlorothiazide) 20 Efudex (fluorouracil) 57 Dipentum 36 Egrifta 49 Diprolene AF, gel, cream, lotion (betamet diprop/prop gly) 55 Elavil (amitriptyline hcl) 27 Diprolene ointment (betamet diprop/prop gly) 55 Eldepryl (selegiline hcl) 33 Diprosone; Maxivate (betamethasone dipropionate) 55 Elestat (epinastine hcl) 59 Disalcid (salsalate) 33 Elestrin 41 Ditropan, XL (oxybutynin chloride) 67 Elidel 57 Diuril capsules, tablets (chlorothiazide) 22 Eligard 51 Diuril suspension (Tier 2 BCN only) 22 Elimite (permethrin) 56 Divigel 41 Eliquis 20 Dolobid (diflunisal) 33 Ella 41 Trade Name Page Trade Name Page Elmiron 67 Etrafon (amitriptyline hcl/perphenazine) 28 Elocon cream, solution (mometasone furoate) 56 Eulexin (flutamide) 51 Elocon ointment (mometasone furoate) 55 Eurax 56 Emadine 59 Evamist 41 Embeda 31 Evekeo 29 Emcyt 50 Evista (raloxifene hcl) 51 Emend 40mg (BCBSM only) 36 Evista 51 Emend 80, 125mg; dosepak capsules 36 Evista (raloxifene hcl) 44 Emla (lidocaine/prilocaine) 56 Evoclin foam (clindamycin phosphate) 54 Emsam 27 Evotaz 15 Emtriva 15 Evoxac (cevimeline hcl) 39 Enablex 67 Evzio 30 Enbrel 55 Exalgo (hydromorphone hcl) 31 Enbrel 45 Exelderm 57 Endometrin 42 Exelon capsules (rivastigmine tartrate) 25 Enjuvia 45 Exelon patch (rivastigmine) 25 Enjuvia 41 Exforge (amlodipine/valsartan) 20 Entocort EC (budesonide) 46 Exforge (amlodipine/valsartan) 21 Entresto 20 Exforge HCT (amlodipine/valsartan/hctz) 21 Envarsus XR 51 Exforge HCT (amlodipine/valsartan/hctz) 20 Epaned 19 Exjade 69 Epiduo 54 Extavia 53 Epiduo Forte 54 Extina (ketoconazole) 57 Epifoam (Tier 2 BCN only) 38 Fabior 54 Epinephrine auto-injector (epinephrine) 64 Factive 17 Epipen, Jr 64 Famvir (famciclovir) 16 Epivir (lamivudine) 15 Fanapt 28 Epivir HBV solution 16 Fareston 51 Epivir HBV tablets (lamivudine) 16 Farxiga 48 Epogen 50 Farydak 52 Epogen 53 Faslodex 51 Epzicom 15 Fazaclo (clozapine) 28 Equanil; Miltown (meprobamate) 28 Fazaclo 150, 200mg 28 Equetro 28 FC2 Female Condom 40 Ergoloid Mesylates (ergoloid mesylates) 35 Felbatol (felbamate) 26 Ergomar 29 Feldene (piroxicam) 32 Erivedge 52 Femara (letrozole) 51 Ertaczo 57 Femcon Fe 40 Ery-Tab 500mg (Tier 2 BCN Only) 17 FemHRT (norethindrone ac-eth estradiol) 41 Ery-Tab (erythromycin) 17 FemHRT (norethindrone ac-eth estradiol) 45 Erythromycin base (erythromycin base) 17 Femring 41 Erythromycin Stearate (erythromycin stearate) 17 Femtrace 41 Erythromycin topical soln, gel (erythromycin base/ethanol) Esbriet 54 Fenoglide; Fenofibrate 23 Fenoprofen Calcium 400mg (Tier 2 BCN only) 32 66 Fentanyl patch 37.5 62.5, 87.5mg 31 Esgic (butalb/acetaminophen/caffeine) 30 Fentora 31 Esgic (butalb/acetaminophen/caffeine) 29 Fer-in-sol 15mg drops 68 Eskalith CR (lithium carbonate) 35 Ferriprox 69 Eskalith (lithium carbonate) 35 Fetzima 27 Estrace tablets (estradiol) 41 Fexmid (cyclobenzaprine hcl) 34 Estrace Vaginal cream 41 Fibricor (fenofibric acid) 23 Estrace (estradiol) 45 Finacea 58 Estring 41 Finacea foam 58 Estrogel 41 29 Estrostep Fe 41 Ethambutol (ethambutol hcl) 16 Etrafon (amitriptyline hcl/perphenazine) 27 Fioricet 50/300/40mg capsule (butalbit/acetamin/caff/codeine) Fioricet 50/300/40mg capsule (butalbit/acetamin/caff/codeine) 30 Trade Name Page Fioricet w/codeine 50/300/30mg (butalbit/acetamin/caff/codeine) Fioricet w/codeine 50/300/30mg (butalbit/acetamin/caff/codeine) Fiorinal w/codeine (codeine/butalbital/asa/caffein) 29 Fiorinal w/codeine (codeine/butalbital/asa/caffein) Trade Name Page Gelnique 67 Gelnique pump 67 Generess Fe 40 30 Gengraf (cyclosporine, modified) 45 29 Gengraf (cyclosporine, modified) 51 30 Genotropin 47 29 Gentamicin cream, ointment (gentamicin sulfate) 57 53 Geodon (ziprasidone hcl) 28 14 Giazo 36 14 Gilenya 53 32 Gilotrif 52 34 Glatopa (glatiramer acetate) 53 67 Gleevec 52 65 Gleostine; Lomustine 50 62 GlucaGen 49 46 Glucagon Emergency Kit 49 65 Glucophage, XR; Fortamet (metformin hcl) 48 63 Glucotrol, XL (glipizide) 48 62 Glucovance (glyburide/metformin hcl) 48 62 Glumetza 48 17 Glycolax (polyethylene glycol 3350) 39 16 Glynase (glyburide,micronized) 48 27 Glyset 48 61 Glyxambi 48 FML (fluorometholone) 61 Golytely packet 37 Focalin immediate release (dexmethylphenidate hcl) 29 Golytely (peg 3350/na sulf,bicarb,cl/kcl) 37 29 Gonal-F, RFF, Redi-Ject 42 29 Gralise 35 68 Gralise dosepak 35 42 Granix 50 68 Granix 53 64 Granulex (BCBSM only) (trypsin/balsam peru/castor oil) 58 27 Grastek 66 45 Grifulvin V (griseofulvin,microsize) 14 46 Gris-PEG (griseofulvin ultramicrosize) 14 44 Gynazole-1 42 44 Gynol II 40 44 Halcion (triazolam) 34 69 Haldol liquid 2mg/ml (haloperidol lactate) 28 20 Haldol (haloperidol) 28 33 Halflytely (bisac/nacl/nahco3/kcl/peg 3350) 37 29 Halog 55 36 Harvoni 16 18 HC Acetate/Pramoxine hcl (hc acetate/pramoxine hcl) 38 22 Hectorol (doxercalciferol) 49 Fuzeon 15 Hemangeol 21 Fycompa 26 Heparin (heparin sodium,porcine) 20 26 Hepsera (adefovir dipivoxil) 16 26 Hetlioz 34 68 Hexalen 52 53 Hiprex/Urex (methenamine hippurate) 18 53 Hizentra (BCBSM Only) 53 53 Horizant 35 42 Humalog U-200 47 60 Humalog, Mix 47 39 Humatin (paromomycin sulfate) 14 39 Humatrope 47 Fiorinal (butalbital/aspirin/caffeine) Fiorinal (butalbital/aspirin/caffeine) Firazyr Flagyl ER Flagyl (metronidazole) Flector patch Flexeril (cyclobenzaprine hcl) Flomax (tamsulosin hcl) Flonase (Rx only) (fluticasone propionate) Flonase (Rx only) (fluticasone propionate) Florinef (fludrocortisone acetate) Flovent HFA, Diskus (Tier 1-BCN Only) Flowtuss Floxin Otic Singles Floxin Otic (ofloxacin) Floxin tablet (ofloxacin) Flumadine (rimantadine hcl) Fluoxetine 60mg FML Forte, S.O.P. Focalin XR (dexmethylphenidate hcl) Focalin XR 25, 35mg Folic Acid 0.4, 0.8mg [OTC] Follistim AQ Folvite (folic acid) Foradil Forfivo XL Forteo Fortesta Fosamax 35mg, 70mg (alendronate sodium) Fosamax Plus D Fosamax (alendronate sodium) Fosrenol Fragmin Frenadol (BCBSM only) Frova Fulyzaq Furadantin (nitrofurantoin) Furosemide solution (Tier 2 BCN only) Gabitril (tiagabine hcl) Gabitril 12, 16mg Galzin Gammagard Liquid (BCBSM Only) Gammaked Liquid (BCBSM Only) Gamunex-C sub-q (BCBSM Only) Ganirelix Acetate Garamycin (gentamicin sulfate) Gastrocrom (cromolyn sodium) Gattex 30 Trade Name Page Trade Name Page Humira 55 Isoniazid (isoniazid) 16 Humira 38 Isopto Atropine (atropine sulfate) 59 Humira, Pediatric 45 Isopto Homatropine 5% (homatropine hbr) 59 Humulin R U-500 (vial) 47 Isopto Hyoscine 59 Humulin, KwikPen 47 Isordil 40mg (Tier 2 BCN Only) 23 Hycamtin 52 Isordil (isosorbide dinitrate) 23 Hycet (hydrocodone bit/acetaminophen) 30 Istalol (Tier 2 for BCN only) 60 Hycodan (hydrocodone bit/homatrop me-br) 63 Jakafi 52 Hycofenix 63 Jalyn (dutasteride/tamsulosin hcl) 67 Hydrea (hydroxyurea) 52 Janumet 48 Hydrodiuril; Microzide (hydrochlorothiazide) 22 Janumet XR 48 Hygroton; Thalitone (chlorthalidone) 22 Januvia 48 Hyper-Sal (Tier 2 BCN only) 66 Jardiance 48 HyQvia (BCBSM Only) 53 Jentadueto 48 Hysingla ER 31 Jublia 57 Hytrin (terazosin hcl) 67 Juxtapid 23 Hytrin (terazosin hcl) 19 Kadian 40, 200mg 31 Hyzaar (losartan/hydrochlorothiazide) 20 Kadian (morphine sulfate) 31 Ibrance 52 Kaletra 15 Ibudone (hydrocodone/ibuprofen) 30 Kalydeco 64 Ibudone 5mg/200mg (Tier 2 BCN Only) 30 Kapvay (clonidine hcl) 35 Iclusig 52 Karbinal ER 63 Ilevro 60 Kay Ciel, Kaon-Cl, Kaon Liquid (potassium chloride) 68 Ilotycin (erythromycin base) 60 Kayexalate (sodium polystyrene sulfonate) 69 Imbruvica 52 Kazano 48 Imdur (isosorbide mononitrate) 23 Keflex (cephalexin monohydrate) 17 Imitrex (All Forms) (sumatriptan succinate) 29 Kenalog 0.025% (triamcinolone acetonide) 56 Imodium (loperamide hcl) 36 Kenalog 0.1% (triamcinolone acetonide) 56 Imuran (azathioprine) 45 Keppra XR (levetiracetam) 26 Imuran (azathioprine) 51 Keppra (levetiracetam) 26 Increlex 47 Kerlone (betaxolol hcl) 21 Incruse Ellipta 64 Kerydin 57 Inderal XL 21 Ketek 17 Inderal, LA (propranolol hcl) 21 Ketoprofen (ketoprofen) 32 Inderide (propranolol/hydrochlorothiazide) 21 Khedezla 27 Indocin suppository 32 Kineret 44 Indocin suspension (Tier 2 BCN only) 32 Kineret 51 Indocin, SR (indomethacin) 32 Klonopin, Wafer (clonazepam) 26 Infergen 53 K-Lor, Klor-Con (potassium chloride) 68 Inflamase, Forte (prednisolone sod phosphate) 61 Klor-con packet (BCN Tier 2 only) 68 Inlyta 52 K-Lyte, Klor-Con/EF (potassium bicarbonate/cit ac) 68 Innopran XL 21 Kombiglyze XR 48 Inspra (eplerenone) 22 Korlym 49 Intal solution (cromolyn sodium) 66 Kristalose (Tier 2 BCN only) 39 Intelence 15 K-Sol, potassium chloride (potassium chloride) 68 Intermezzo 34 K-Tab, K-Dur, Slow-K, Kaon CL (potassium chloride) 68 Intron A 53 Kuvan, powder 69 Intuniv (guanfacine hcl) 35 Kynamro 23 Invega (paliperidone) 28 Kytril (granisetron hcl) 36 Invirase 15 Lacrisert 61 Invokamet 48 Lactulose (lactulose) 39 Invokana 48 Lamictal dosepak 26 Iopidine droperette 61 Lamictal dosepak ODT (lamotrigine) 26 Iopidine drops (apraclonidine hcl) 61 Lamictal ODT, XR (lamotrigine) 26 Iprivask 20 Lamictal tabs, dispertabs (lamotrigine) 26 Iressa 52 Lamictal XR dosepak 26 Isentress 15 Lamisil granules 14 Trade Name Page Trade Name Page Lamisil tablets (terbinafine hcl) 14 Loniten (minoxidil) 25 Lanoxin 62.5, 187.5mcg 22 Lopid (gemfibrozil) 23 Lanoxin (digoxin) 22 Lopressor HCT (metoprolol/hydrochlorothiazide) 21 Lantus, Solostar (Tier 2 BCBSM only) (insulin glargine,hum.rec.anlog) Lariam (mefloquine hcl) 47 Lopressor (metoprolol tartrate) 21 Loprox (ciclopirox olamine) 57 30 Lasix (furosemide) 22 Lastacaft 59 Lortab; Norco; Vicodin; Xodol (hydrocodone bit/acetaminophen) Lorzone Latuda 28 Loseasonique 40 Lazanda 31 Lotemax 61 Lenvima 52 Lotensin HCT (benazepril/hydrochlorothiazide) 19 Lescol (fluvastatin sodium) 23 Lotensin (benazepril hcl) 19 Lescol XL (fluvastatin sodium) 23 Lotrel (amlodipine besylate/benazepril) 21 Letairis 65 Lotrel (amlodipine besylate/benazepril) 19 Leucovorin tablet (leucovorin calcium) 50 Lotrimin (clotrimazole) 57 Leukeran 50 Lotrisone (clotrimazole/betamet diprop) 57 Leukine 53 Lotronex (alosetron hcl) 39 Leukine 50 Lovaza (omega-3 acid ethyl esters) 23 Levaquin (levofloxacin) 17 Lovenox (enoxaparin sodium) 20 Levatol 21 Loxitane (loxapine succinate) 28 Levbid (hyoscyamine sulfate) 36 Lozol (indapamide) 22 Levbid (hyoscyamine sulfate) 67 Lumigan (bimatoprost) 61 Levemir, Flextouch (Tier 2 BCBSM only) (insulin detemir) 47 Lumigan 0.01% 61 Levitra 70 Lunesta (eszopiclone) 34 Levlen; Nordette 40 Lupaneta pack 43 levorphanol tartrate (levorphanol tartrate) 30 Lupron Depot 43 Levsin, SL (hyoscyamine sulfate) 36 Lupron Depot 51 Levsin, SL (hyoscyamine sulfate) 67 Lupron Depot 45mg (BCBSM Only) 43 Levsinex (hyoscyamine sulfate) 36 Lupron Depot-Ped 49 Levsinex (hyoscyamine sulfate) 67 Lupron (leuprolide acetate) 42 Lexapro (escitalopram oxalate) 27 Lupron (leuprolide acetate) 51 Lexiva 15 Luvox CR (fluvoxamine maleate) 27 Lialda 36 Luvox (fluvoxamine maleate) 27 Librax (clidinium br/chlordiazepoxide) 36 Luxiq (betamethasone valerate) 56 Librium (chlordiazepoxide hcl) 28 Luzu 57 Lidex, E (fluocinonide) 55 Lybrel 40 Lidoderm patch (lidocaine) 56 Lynparza 52 Limbitrol, DS (amitrip hcl/chlordiazepoxide) 27 Lyrica 26 Lindane (lindane) 56 Lysodren 52 Linzess 39 Lysteda (tranexamic acid) 43 Lipitor (atorvastatin calcium) 23 Macrobid (nitrofurantoin) 18 Lipofen 23 Macrodantin (nitrofurantoin macrocrystal) 18 Liptruzet 23 Malarone (atovaquone/proguanil hcl) 14 Lithium Citrate (lithium citrate) 35 Maprotiline hcl (maprotiline hcl) 27 Lithobid (lithium carbonate) 35 Marinol (dronabinol) 36 Livalo 23 Marplan 27 Lo Loestrin Fe 40 Matulane 50 Lo/Ovral 40 Mavik (trandolapril) 19 Locoid cream, oint, soln (hydrocortisone butyrate) 56 Maxalt, MLT (rizatriptan benzoate) 29 Locoid Lipocream (hydrocortisone butyrate/emoll) 56 Maxidex 61 Locoid Lotion 56 Maxitrol (neo/polymyx b sulf/dexameth) 59 Lodine, XL (etodolac) 32 Mebaral (mephobarbital) 26 Lodosyn (carbidopa) 33 Meclomen (meclofenamate sodium) 32 Loestrin 24 Fe 40 Medrol 2mg (Tier 2 BCN only) 46 Loestrin, Fe 40 Medrol, Dosepak (methylprednisolone) 46 Lofibra (fenofibrate,micronized) 23 Megace, ES (megestrol acetate) 51 Lomotil (diphenoxylate hcl/atrop sulf) 36 Mekinist 52 14 34 Trade Name Page Trade Name Page Mellaril (thioridazine hcl) 28 Monurol 18 Menest 45 Motrin (Rx only) (ibuprofen) 32 Menest 41 Movantik 39 Menopur 42 Movantik 30 Menostar 41 Moviprep 37 Mentax 57 Moxatag 17 Mephyton 20 Moxeza 60 Mephyton 68 MS Contin (morphine sulfate) 31 Mepron (atovaquone) 14 MSIR (morphine sulfate) 31 Mesnex tablets 50 Multaq 22 Mestinon Syrup 30 Muse 70 Mestinon Timespan (pyridostigmine bromide) 30 Myalept 49 Metadate CD (methylphenidate hcl) 29 Mycelex Troche (clotrimazole) 14 Metaglip (glipizide/metformin hcl) 48 Mycobutin (rifabutin) 16 Metaproterenol soln (metaproterenol sulfate) 64 Mycostatin (nystatin) 57 Methadone (methadone hcl) 31 Mydriacyl (tropicamide) 59 Methergine tablets (methylergonovine maleate) 43 Myfortic (mycophenolate sodium) 51 Methitest 46 Myleran 50 Methotrexate tablets (methotrexate sodium) 50 Myrbetriq 67 Methotrexate (methotrexate sodium) 45 Mysoline (primidone) 26 Methylin, ER (methylphenidate hcl) 29 Naftin 57 Metozolv ODT (metoclopramide hcl) 39 Nalfon (fenoprofen calcium) 32 Metrocream, gel, lotion (metronidazole) 58 Nalfon 400mg (Tier 2 BCN only) 32 Metrogel Topical 1%, pump (metronidazole) 58 Namenda (memantine hcl) 25 Metrogel-Vaginal (metronidazole) 42 Namenda dosepak 25 Mevacor (lovastatin) 23 Namenda XR 25 Mexitil (mexiletine hcl) 22 Namzaric 25 Miacalcin injection 44 Naphazoline hcl (naphazoline hcl) 61 Miacalcin Nasal Spray; Fortical (calcitonin,salmon,synthetic) Micardis (telmisartan) 44 Naprelan (naproxen sodium) 32 Naprelan 750mg 32 Naprosyn (Rx only) (naproxen) 32 Micardis HCT (telmisartan/hydrochlorothiazide) 20 Nardil (phenelzine sulfate) 27 Micro-K (potassium chloride) 68 Nasacort AQ (Rx only) (triamcinolone acetonide) 65 Midamor (amiloride hcl) 22 Nasacort AQ (Rx only) (triamcinolone acetonide) 62 Midrin (BCBSM only) (isometheptene/apap/dichlphen) 29 Nasalide (flunisolide 0.025% spray) 65 Migranal (dihydroergotamine mesylate) 29 Nasalide (flunisolide 0.025% spray) 62 Minipress (prazosin hcl) 19 Nascobal Spray 68 Minivelle 45 Nasonex 65 Minocin (minocycline hcl) 18 Nasonex 62 Minocin (minocycline hcl) 54 Natacyn 60 Mirapex ER (pramipexole di-hcl) 33 Natazia 40 Mirapex ER 3.75 33 Natesto 46 Mirapex (pramipexole di-hcl) 33 Natpara 49 Mircera 50 Natroba (spinosad) 56 Mircera 53 Navane (thiothixene) 28 Mircette 40 Nebupent Aerosol 14 Mitigare 44 Nebusal 66 Mobic (meloxicam) 32 Necon 10/11 40 Modicon 40 Neomycin (neomycin sulfate) 18 Moduretic (amiloride/hydrochlorothiazide) 22 Neoral 51 Molindone (molindone hcl) 28 Neoral 45 Monistat 3 (miconazole nitrate) 42 60 Monistat-Derm (miconazole nitrate) 57 Monodox (doxycycline monohydrate) 18 Monodox (doxycycline monohydrate) 54 Monopril HCT (fosinopril/hydrochlorothiazide) 19 Neosporin Ophth ointment (neomy sulf/bacitra/polymyxin b) Neosporin Ophth solution (neomycin/gramicidin/polymyxn b) Neo-Synalar Nesina 48 Neulasta 50 Monopril (fosinopril sodium) 20 19 60 56 Trade Name Page Trade Name Page Neulasta 53 Ocufen (flurbiprofen sodium) 60 Neupogen 53 Ocuflox (ofloxacin) 60 Neupogen 50 Ocupress (carteolol hcl) 60 Neupro 33 Odomzo 52 Neurontin (gabapentin) 26 Ofev 66 Nevanac 60 Ogen; Ortho-Est (estropipate) 45 Nexavar 52 Ogen; Ortho-Est (estropipate) 41 Nexium (esomeprazole magnesium) 38 Oleptro ER 27 Nexium suspension 38 Olux (clobetasol propionate) 55 Niacor (Tier 2 BCN only) 23 Olux-E (clobetasol propionate/emoll) 55 Niaspan (niacin) 23 Olysio 16 Nicotine Gum, Nicorette 70 Omeclamox-Pak 37 Nicotine Patch 70 Omeprazole OTC (omeprazole) 38 Nicotrol, NS 70 Omnaris 62 Niferex-150 Forte (BCBSM Only) (iron ps cmplx/vit b12/fa) Nilandron 68 Omnaris 65 Omnicef (cefdinir) 17 51 Omnitrope 47 Nimotop (nimodipine) 35 Onexton 54 Niravam (alprazolam) 28 Onfi 26 Nitro-Bid ointment (nitroglycerin) 23 Onglyza 48 Nitro-Dur (Tier 2 BCN Only) 23 Onmel 14 Nitro-Dur 0.3mg, 0.8mg 23 Opana (oxymorphone hcl) 31 Nitroglycerin caps, patch, spray, tablet (nitroglycerin) 23 Opana, ER (oxymorphone hcl) 31 Nitrostat 23 Opsumit 65 Nizoral cream, shampoo 2% (ketoconazole) 57 Optipranolol (metipranolol) 60 Nizoral (ketoconazole) 14 Optivar (azelastine hcl) 59 Norditropin Flexpro 47 Oracea 54 Norflex (orphenadrine citrate) 34 Oracea 18 Norgesic, Forte (orphenadrine/aspirin/caffeine) 34 Oralair 66 Norinyl/Ortho-Novum 1/35 40 Oralone paste (triamcinolone acetonide) 56 Norinyl/Ortho-Novum 1/50 40 Orap (pimozide) 28 Noritate 54 Orapred ODT (prednisolone sod phosphate) 46 Normodyne; Trandate (labetalol hcl) 21 Orapred solution 15mg/5ml (prednisolone sod phosphate) 46 Norpace CR 22 Oravig 14 Norpace (disopyramide phosphate) 22 Orencia sub-q 44 Norpramin (desipramine hcl) 27 Orenitram ER 65 Nor-QD; Ortho Micronor 40 Orfadin 69 Northera 22 Orkambi 64 Norvasc (amlodipine besylate) 21 Ortho Evra 40 Norvir 15 Ortho Tri-Cyclen Lo 41 Novarel (chorionic gonadotropin, human) 42 Ortho Tri-Cyclen 41 Novolin (all forms) (Tier 2 BCBSM only) (insulin regular human rec) Novolog (all forms) (Tier 2 BCBSM only) (insulin aspart) 47 Ortho-Cyclen 40 47 Ortho-Novum 7/7/7 41 14 Oseni 48 14 Osmoprep 37 Nucynta, ER 31 Osphena 43 Nuedexta 35 Otezla 55 37 Otezla 44 47 Otrexup 45 40 Otrexup 55 42 Ovace, Plus (BCBSM only) (sulfacetamide sodium) 55 29 Ovcon 35 40 35 Ovide (malathion) 56 57 Ovidrel 42 42 Ovral 40 14 Oxandrin (oxandrolone) 46 63 Oxaydo 31 Noxafil suspension Noxafil tablet Nulytely (sod sulf/sod/nahco3/kcl/peg's) Nutropin AQ, Nuspin Nuvaring Nuvessa Nuvigil Nymalize Nystatin w/Triamcinolone (nystatin/triamcin) Nystatin (nystatin) Nystatin (nystatin) Obredon Trade Name Page Trade Name Page Oxistat 57 Phoslo (calcium acetate) 69 Oxsoralen 55 Phoslyra 69 Oxsoralen-Ultra (methoxsalen, rapid) 55 Phospholine Iodide 61 Oxtellar XR 26 Phrenilin tablet (butalbital/acetaminophen) 29 Oxycodone hcl ER 31 Phrenilin (butalbital/acetaminophen) 30 Oxycodone immediate release (oxycodone hcl) 31 Picato 57 Oxycontin 31 Pilocar; Isopto-Carpine (pilocarpine hcl) 61 Oxytrol 67 Pindolol (pindolol) 21 Pancreaze 37 Plan B, One-Step 41 Pandel 56 Plaquenil (hydroxychloroquine sulfate) 45 Panretin 57 Plaquenil (hydroxychloroquine sulfate) 14 Papaverine capsule (papaverine hcl) 22 Plavix (clopidogrel bisulfate) 20 Parafon Forte DSC (chlorzoxazone) 34 Plegridy 53 Parcopa (carbidopa/levodopa) 33 Plendil (felodipine) 21 Paregoric (BCBSM only) (paregoric) 36 Pletal (cilostazol) 20 Paremyd 59 Plexion, TS (BCBSM only) (sulfacetamide sodium/sulfur) 54 Parlodel (bromocriptine mesylate) 33 Polycitra (sod/potass/k cit/sod cit/ca) 67 Parnate (tranylcypromine sulfate) 27 Polysporin (bacitracin/polymyxin b sulfate) 60 Paser (BCN tier 2 only) 16 Polytrim (polymyxin b sulfate/tmp) 60 Pataday 59 Poly-Vi-Flor (BCBSM Only) 68 Patanase (olopatadine hcl) 62 Pomalyst 51 Patanase (olopatadine hcl) 63 Ponstel (mefenamic acid) 32 Patanol 59 Potiga 26 Paxil CR (paroxetine hcl) 27 Pradaxa 20 Paxil solution 27 Praluent 23 Paxil (paroxetine hcl) 27 Pramosone (BCBSM Only) 38 Pazeo 59 PrandiMet (repaglinide/metformin hcl) 48 Pediazole (ery e-succ/sulfisoxazole) 17 Prandin (repaglinide) 48 Pediazole (ery e-succ/sulfisoxazole) 18 Pravachol (pravastatin sodium) 23 Peganone 26 Precose (acarbose) 48 Pegasys, Proclick 53 Pred Forte (prednisolone acetate) 61 Peg-Intron, Redipen 53 Pred Mild 61 Penicillin VK (penicillin v potassium) 17 Pred-G 59 Penlac (ciclopirox) 57 Prednisolone, tablets, syrup (prednisolone) 46 Pennsaid 1.5% (diclofenac sodium) 32 Prednisone (prednisone) 46 Pennsaid 2% 32 Prednisone (prednisone) 51 Pentasa 36 Prefest 41 Pepcid (RX Only) (famotidine) 37 Pregnyl 42 Percocet (oxycodone hcl/acetaminophen) 30 Premarin, Low Dose, cream 45 Percodan (oxycodone hcl/aspirin) 30 Premarin, Low Dose, cream 41 Perforomist 64 Prempro, Low Dose; Premphase 45 Periactin (cyproheptadine hcl) 63 Prempro, Low Dose; Premphase 41 Peridex (chlorhexidine gluconate) 18 Prenatal Plus, Tricare (pnv with ca,no.72/iron/fa) 68 Periostat (doxycycline hyclate) 18 Prenatal Vitamins (prenatal vit/iron,carb/doss/fa) 68 Perphenazine (perphenazine) 28 Prepopik 37 Perphenazine/amitriptyline hcl (amitriptyline hcl/perphenazine) Persantine (dipyridamole) 27 Prestalia 21 Prestalia 19 Prevacid (lansoprazole) 38 Pertzye 37 Prevacid Solutab 38 Pexeva 27 Prevident (sodium fluoride) 68 Phenergan DM (d-methorphan hb/prometh hcl) 63 Prevpac (lansoprazole/amoxiciln/clarith) 37 Phenergan VC (phenylephrine hcl/prometh hcl) 63 Prezcobix 15 Phenergan w/Codeine (codeine/promethazine hcl) 63 Prezista (Must Be Used With Norvir) 15 Phenergan (promethazine hcl) 36 Priftin 16 Phenergan (promethazine hcl) 63 Prilosec (omeprazole) 38 Phenobarbital (phenobarbital) 26 Prilosec OTC (omeprazole magnesium) 38 Phenylephrine hcl drops (phenylephrine hcl) 61 Prilosec suspension 38 20 Trade Name Page Trade Name Page Primaquine 14 Radiogardase 69 Primsol (Tier 2 BCN Only) 18 Ragwitek 66 Prinivil; Zestril (lisinopril) 19 Ranexa 22 Prinzide; Zestoretic (lisinopril/hydrochlorothiazide) 19 Rapaflo 67 Pristiq ER 27 Rapamune solution 51 Proair HFA, Respiclick; Ventolin HFA 64 Rapamune tablets (sirolimus) 51 Proamatine (midodrine hcl) 22 Rasuvo 45 Pro-Banthine (propantheline bromide) 67 Rasuvo 55 Pro-Banthine (propantheline bromide) 36 Ravicti 49 Probenecid (probenecid) 44 Rayos 51 Procardia, XL; Adalat CC (nifedipine) 21 Rayos 46 Procentra (d-amphetamine sulfate) 29 Razadyne, ER (galantamine hydrobromide) 25 Procrit 50 Rebetol capsule (ribavirin) 16 Procrit 53 Rebetol solution 16 Proctocort (hydrocortisone acetate) 38 Rebif, Rebidose 53 Proctosol-HC suppository (hydrocortisone acetate) 38 Rectiv 39 Procysbi 67 Reglan (metoclopramide hcl) 39 Progesterone in Oil (Inj) (progesterone) 42 Regranex 58 Prograf (tacrolimus anhydrous) 51 Relafen (nabumetone) 32 Prolensa 60 Relenza 16 Prolixin (fluphenazine hcl) 28 Relistor 30 Promacta 53 Relistor 39 Prometrium (progesterone,micronized) 42 Relpax 29 Propylthiouracil (propylthiouracil) 46 Remeron (mirtazapine) 27 Proscar (finasteride) 67 Remodulin 65 Prosom (estazolam) 34 Renacidin 67 Protonix (pantoprazole sodium) 38 Renagel 69 Protonix suspension 38 Renvela, packet 69 Protopic (tacrolimus) 57 Repatha 23 Protriptyline hcl (protriptyline hcl) 27 Reprexain (hydrocodone/ibuprofen) 30 Proventil HFA 64 Repronex 42 Proventil solution (albuterol sulfate) 65 Requip XL (ropinirole hcl) 33 Provera (medroxyprogesterone acet) 42 Requip XL 12mg (ropinirole hcl) 33 Provigil (modafinil) 29 Requip (ropinirole hcl) 33 Prozac Weekly (fluoxetine hcl) 27 Rescriptor 15 Prozac (fluoxetine hcl) 27 Rescula 61 Pulmicort Flexhaler (Tier 1-BCN Only) 65 Reserpine (reserpine) 19 Pulmicort solution (budesonide) 65 Restasis 61 Pulmozyme 64 Restoril (temazepam) 34 Purinethol (mercaptopurine) 50 Retin-A Micro pump 0.08% 54 Purixan 50 Retin-A Micro, pump (tretinoin microspheres) 54 Pylera 37 Retin-A (tretinoin) 54 Pyrazinamide (pyrazinamide) 16 Retrovir (zidovudine) 15 Pyridium (BCBSM only) (phenazopyridine hcl) 18 Revatio (sildenafil citrate) 65 Pyridium (BCBSM only) (phenazopyridine hcl) 67 Revatio suspension 65 Qnasl, Children's 65 Revia (naltrexone hcl) 30 Qnasl, Children's 62 Revlimid 51 Qsymia 70 Rexulti 28 Qualaquin (quinine sulfate) 14 Reyataz 15 Quartette 40 Rezira 63 Qudexy XR 26 Rheumatrex (Tier 2 BCN Only) 45 Questran, Light (cholestyramine) 23 Rhinocort Aqua (budesonide) 65 Quillivant XR 29 Rhinocort Aqua (budesonide) 62 Quinidine gluconate (quinidine gluconate) 22 Ribasphere, Ribapak (ribavirin) 16 Quinidine sulfate (quinidine sulfate) 22 Ribatab (ribavirin) 16 Quixin (levofloxacin) 60 Ridaura 45 Qvar (Tier 1-BCN Only) 65 Rifadin (rifampin) 16 Trade Name Page Trade Name Page Rifater 16 Serzone (nefazodone hcl) 27 Rilutek (riluzole) 35 Signifor 49 Riomet 48 Signifor LAR 49 Risperdal, M-Tab, solution (risperidone) 28 Silenor 34 Ritalin LA (methylphenidate hcl) 29 Silvadene (silver sulfadiazine) 58 Ritalin LA 10mg, 60mg 29 Simbrinza 61 Ritalin, SR (methylphenidate hcl) 29 Simcor 23 RMS suppository (morphine sulfate) 31 Simponi 38 Robaxin (methocarbamol) 34 Simponi 45 Robinul, Forte (glycopyrrolate) 39 Sinemet, CR (carbidopa/levodopa) 33 Robinul, Forte (glycopyrrolate) 35 Sinequan; Adapin (doxepin hcl) 27 Robitussin AC (guaifenesin/codeine phosphate) 63 Singulair (montelukast sodium) 66 Rocaltrol (calcitriol) 49 Sirturo 16 Rosula Cleanser (BCBSM only) (sulfacetamide sod/sulfur/urea) Rowasa enema; SfRowasa enema (mesalamine) 54 Sitavig 16 Sivextro 18 Skelaxin (metaxalone) 34 Roxanol (morphine sulfate) 31 Sklice 56 Rozerem 34 66 Ruconest 53 Rulavite DHA (pnv combo#47/iron/fa #1/dha) 68 Sodium Chloride inhalation 3%, 7%, 10% (sodium chloride for inhalation) Sodium Fluoride 0.25, 0.5mg drops Rytary 33 Solaraze (diclofenac sodium) 58 Rythmol, SR (propafenone hcl) 22 Solodyn (minocycline hcl) 18 Ryzolt (tramadol hcl) 30 Solodyn (minocycline hcl) 54 Sabril 26 Solodyn 55, 65, 80, 105, 115mg 18 Safyral 40 Solodyn 55, 65, 80, 105, 115mg 54 Saizen 47 Soltamox 51 Salagen (pilocarpine hcl) 39 34 Salicylates and NSAIDS 45 Samsca 69 Soma Compound w/Codeine (codeine phos/carisoprodol/asa) Soma Compound (carisoprodol/aspirin) Soma (carisoprodol) 34 Somatuline Depot 52 Somatuline Depot 49 Somavert 49 Sonata (zaleplon) 34 Soolantra 58 Soriatane (acitretin) 55 Sorilux 55 Sotylize 22 Sotylize 21 Sovaldi 16 Spectazole (econazole nitrate) 57 Spectracef (28 Count) 17 Spectracef (cefditoren pivoxil) 17 Spiriva, Respimat 64 Sporanox capsule (itraconazole) 14 Sporanox solution 14 Sprix 32 Sprycel 52 SSKI (Tier 2 BCN only) 46 Stadol, NS (butorphanol tartrate) 30 Stalevo (carbidopa/levodopa/entacapone) 33 Starlix (nateglinide) 48 Staxyn 70 Stelara 55 Stelazine (trifluoperazine hcl) 28 Stendra 70 Stimate 49 Stiolto Respimat 64 Sanctura XR (trospium chloride) Sanctura (trospium chloride) Sancuso Sandimmune capsules Sandimmune soln (Tier 2/4 BCN) Sandostatin LAR, Depot Sandostatin LAR, Depot Sandostatin (octreotide acetate) Sandostatin (octreotide acetate) Santyl Saphris Sarafem Savaysa Savella Saxenda Seasonale Seasonique Seconal (secobarbital sodium) Sectral (acebutolol hcl) Selsun 2.5% [Rx Only] (selenium sulfide) Selzentry Semprex-D Sensipar Serax (oxazepam) Serevent Diskus Seroquel (quetiapine fumarate) Seroquel XR Serostim 36 67 67 36 51 51 52 49 52 49 58 28 27 20 35 70 40 40 34 21 55 15 63 49 28 64 28 28 47 68 34 Trade Name Page Trade Name Page Stivarga 52 Technivie 16 Strattera 35 Tegretol XR 100mg 26 Striant 46 Tegretol, XR (carbamazepine) 26 Stribild 15 Tekamlo 24 Striverdi Respimat 64 Tekturna 24 Stromectol (ivermectin) 14 Tekturna HCT 24 Suboxone (buprenorphine hcl/naloxone hcl) 30 Temodar (temozolomide) 50 Suboxone Film 30 Tenex (guanfacine hcl) 19 Subsys 31 Tenoretic (atenolol/chlorthalidone) 21 Sucraid 39 Tenormin (atenolol) 21 Sular (nisoldipine) 21 Terazol-3, 7 (terconazole) 42 Sulfacet-R (BCBSM only) (sulfacetamide sodium/sulfur) 54 Terbutaline sulfate (terbutaline sulfate) 65 Sulfadiazine (sulfadiazine) 18 Tessalon, Perles; Zonatuss (benzonatate) 63 Sumavel Dosepro 29 Testim 46 Supervite 68 Testosterone gel, packet, pump 46 Suprax chew, capsules, tablets 17 Tetracycline (tetracycline hcl) 18 Suprax suspension 100/5, 200mg/5ml (cefixime) 17 Teveten (eprosartan mesylate) 20 Suprax suspension 500mg/5ml 17 Thalomid 51 Suprenza ODT 70 Theo-24 66 Suprep 37 Theophylline Anhydrous (theophylline anhydrous) 66 Surmontil (trimipramine maleate) 27 Thiola (Tier 2 BCN Only) 67 Sustiva 15 Thorazine (chlorpromazine hcl) 28 Sutent 52 Thyrolar 49 Sylatron 53 Tiazac (diltiazem hcl) 21 Symbicort 65 Ticlid (ticlopidine hcl) 20 Symbyax (olanzapine/fluoxetine hcl) 28 Tigan (trimethobenzamide hcl) 36 Symlinpen 48 Tikosyn 22 Symmetrel (amantadine hcl) 33 Timoptic Ocudose (Tier 2 BCN only) 60 Synalar 0.01% (fluocinolone acetonide) 56 Timoptic, - XE (timolol maleate) 60 Synalar 0.025% (fluocinolone acetonide) 56 Tindamax (tinidazole) 14 Synalgos-DC (Tier 2 BCN Only) 30 Tirosint 49 Synarel 49 Tivicay 15 Synarel 43 Tivorbex 32 Synjardy 48 Tobi Podhaler 64 Synthroid, Levoxyl (levothyroxine sodium) 49 Tobi Podhaler 18 Syprine 69 Tobi (tobramycin/0.25 normal saline) 18 Tabloid 50 Tobi (tobramycin/0.25 normal saline) 64 Taclonex ointment (calcipotriene/betamethasone) 55 Tobradex ointment 59 Taclonex topical solution 55 Tobradex ST 59 Tafinlar 52 Tobradex susp (tobramycin sulfate/dexameth) 59 Tagamet (RX Only) (cimetidine) 37 Tobrex drops (tobramycin sulfate) 60 Talwin NX (pentazocine hcl/naloxone hcl) 30 Tobrex ointment (BCN tier 2 only) 60 Tambocor (flecainide acetate) 22 Today Contraceptive Sponge 40 Tamiflu 16 Tofranil (imipramine hcl) 27 Tamoxifen citrate (tamoxifen citrate) 51 Tofranil-PM (imipramine pamoate) 27 Tamoxifen citrate 51 Tolak 57 Tanzeum 48 Tolazamide (tolazamide) 48 Tapazole (methimazole) 46 Tolbutamide (tolbutamide) 48 Tarceva 52 Tolectin, DS (tolmetin sodium) 32 Targretin capsules (bexarotene) 52 Topamax (topiramate) 26 Targretin gel 57 Topicort cream, gel, ointment (desoximetasone) 55 Tarka (trandolapril/verapamil hcl) 21 Topicort LP (desoximetasone) 56 Tarka (trandolapril/verapamil hcl) 19 Topicort Spray 55 Tasigna 52 Topiramate ER 26 Tasmar (tolcapone) 33 Toprol XL (metoprolol succinate) 21 Tazorac 54 Toradol (ketorolac tromethamine) 32 Tecfidera 53 Toujeo Solostar 47 Trade Name Page Trade Name Page Toviaz (Tier 3 BCBSM Only) 67 Urso, Urso Forte (ursodiol) 37 Tracleer 65 UTA (BCBSM only) 18 Tradjenta 48 Vagifem 41 Transderm-Scop 36 Valchlor 57 Tranxene T-Tab (clorazepate dipotassium) 28 Valcyte solution 16 Travatan (travoprost (benzalkonium)) 61 Valcyte tablets (valganciclovir hydrochloride) 16 Travatan Z 61 Valisone (betamethasone valerate) 55 Trecator 16 Valium (diazepam) 28 Trelstar, Depot, LA 51 Valium (diazepam) 34 Trental (pentoxifylline) 20 Valtrex (valacyclovir hcl) 16 Tretin-X 54 Vancocin hcl (vancomycin hcl) 18 Trexall 45 Vanos (fluocinonide) 55 Trexall 50 Vantin (cefpodoxime proxetil) 17 Treximet 29 Vascepa 23 Trezix 30 Vaseretic (enalapril/hydrochlorothiazide) 19 Trezix (dhcodeine bt/acetaminophn/caff) 30 Vasocidin (sulfacetamide/prednisolone sp) 59 Tribenzor 20 Vasodilan (BCBSM only) (isoxsuprine hcl) 22 Tribenzor 21 Vasotec (enalapril maleate) 19 Tricor (fenofibrate nanocrystallized) 23 VCF film 40 Triglide 23 VCF foam 40 Trileptal (oxcarbazepine) 26 Vecamyl 25 Trilevlen; Triphasil 41 Vectical (calcitriol) 55 Trilipix (fenofibric acid (choline)) 23 Velphoro 69 Trilisate (BCBSM only) (choline magnesium trisalicylate) 33 Veltin 54 Trimethoprim (trimethoprim) 18 Venlafaxine hcl ER (venlafaxine hcl) 27 Tri-Norinyl 41 Ventavis 65 Triumeq 15 Vepesid (etoposide) 52 Trizivir (abacavir/lamivudine/zidovudine) 15 Veramyst 65 Trokendi XR 26 Veramyst 62 Trulicity 48 Verdeso 56 Trusopt (dorzolamide hcl) 61 Veregen 57 Truvada 15 Verelan PM (verapamil hcl) 21 Tudorza Pressair 64 Versacloz 28 Tussicaps 63 Vesanoid (tretinoin) 52 Tussionex (hydrocodone/chlorphen polis) 63 Vesicare 67 Tuzistra XR 63 Vexol 61 Twynsta (telmisartan/amlodipine) 20 Vfend (voriconazole) 14 Twynsta (telmisartan/amlodipine) 21 Viagra 70 Tybost 15 Vibramycin syrup (Tier 2 BCN only) 18 Tykerb 52 Vibramycin syrup (Tier 2 BCN only) 54 Tylenol w/Codeine (codeine phos/acetaminophen) 30 Vibramycin (doxycycline hyclate) 54 Tyvaso 65 Vibramycin (doxycycline hyclate) 18 Tyzeka 16 Vicoprofen (hydrocodone/ibuprofen) 30 Uceris 46 Victoza 48 Uceris foam 46 Videx 15 Ulesfia 56 Videx EC (didanosine) 15 Uloric 44 Viekira Pak 16 Ultracet (tramadol hcl/acetaminophen) 30 Vigamox 60 Ultram, ER (tramadol hcl) 30 Viibryd 27 Ultravate (halobetasol propionate) 55 Vimovo 32 Ultresa 37 Vimovo 38 Uniretic (moexipril/hydrochlorothiazide) 19 Vimpat 26 Univasc (moexipril hcl) 19 Viokace 37 Urecholine (bethanechol chloride) 67 Viracept 15 Urispas (flavoxate hcl) 67 Viramune XR 100mg 15 Urocit-K (potassium citrate) 67 Viramune, XR (nevirapine) 15 Uroxatral (alfuzosin hcl) 67 Viread 15 Trade Name Page Trade Name Page Viroptic (trifluridine) 60 Zegerid packet 38 Vitamin D3 68 Zegerid RX (omeprazole/sodium bicarbonate) 38 Vitamin K (phytonadione) 20 Zelapar 33 Vitekta 15 Zelboraf 52 Vituz 63 Zemplar (paricalcitol) 49 Vivelle-Dot (estradiol) 41 Zenpep 37 Vivelle-Dot (estradiol) 45 Zenpep 5,000 (lipase/protease/amylase) 37 Vivlodex 32 Zenzedi 29 Vogelxo 46 Zerit (stavudine) 15 Voltaren drops (diclofenac sodium) 60 Zetia 23 Voltaren gel 32 Zetonna 65 Voltaren tablets (diclofenac sodium) 32 Zetonna 62 Voltaren XR (diclofenac sodium) 32 Ziac (bisoprolol/hydrochlorothiazide) 21 Vospire ER (albuterol sulfate) 65 Ziagen solution 15 Votrient 52 Ziagen tablet (abacavir sulfate) 15 Vusion 57 Ziana 54 Vytorin 23 Zioptan 61 Vyvanse 29 Zipsor 32 Welchol 23 Zirgan 60 Wellbutrin 300mg (bupropion hcl) 27 Zithromax (azithromycin) 17 Wellbutrin, SR, XL (bupropion hcl) 27 Zmax 17 Westcort (hydrocortisone valerate) 56 Zocor (simvastatin) 23 Westhroid (thyroid,pork) 49 Zofran, ODT (ondansetron) 36 Xalatan (latanoprost) 61 Zohydro ER 31 Xalkori 52 Zoladex 51 Xanax, XR (alprazolam) 28 Zolinza 52 Xarelto 20 Zoloft (sertraline hcl) 27 Xartemis XR 30 Zolpimist 34 Xeljanz 44 Zomacton 47 Xeloda (capecitabine) 50 Zomig , ZMT (zolmitriptan) 29 Xenazine (tetrabenazine) 35 Zomig Nasal Spray 2.5mg 29 Xenical 70 Zomig Nasal Spray 5mg 29 Xerese 57 Zonalon (doxepin hcl) 58 Xifaxan 200mg 39 Zonegran (zonisamide) 26 Xifaxan 200mg 18 Zontivity 20 Xifaxan 550mg 39 Zorbtive 39 Xigduo XR 48 Zortress 52 Xolegel 57 Zorvolex 32 Xopenex HFA 64 Zovirax cream 57 Xopenex nebulizer solution (levalbuterol hcl) 64 Zovirax ointment (acyclovir) 57 Xtandi 51 Zovirax (acyclovir) 16 Xylocaine, Viscous (Rx only) (lidocaine hcl) 56 Zubsolv 30 Xyrem 35 Zuplenz 36 Xyzal solution (levocetirizine dihydrochloride) 63 Zutripro (pseudoephed/hydrocodone/cpm) 63 Xyzal (levocetirizine dihydrochloride) 63 Zyban 70 Yasmin 28 40 Zyclara 57 Yaz 40 Zydelig 52 Zanaflex capsule (tizanidine hcl) 34 Zyflo 66 Zanaflex tablet (tizanidine hcl) 34 Zyflo CR 66 Zantac (RX Only) (ranitidine hcl) 37 Zykadia 52 Zarontin (ethosuximide) 26 Zylet 59 Zaroxolyn (metolazone) 22 Zyloprim (allopurinol) 44 Zarxio 53 Zymaxid (gatifloxacin) 60 Zarxio 50 Zyprexa, Zydis (olanzapine) 28 Zavesca 49 Zyrtec (OTC) (cetirizine hcl) 63 Zebeta (bisoprolol fumarate) 21 Zyrtec-D (OTC) (p-ephed hcl/cetirizine hcl) 63 Zecuity 29 Zytiga (Tier 3/5 - BCN only) 51 Trade Name Page Zyvox (linezolid) 18 Trade Name Page bcbsm.com/pharmacy For members with 3-tier, 5-tier, 6-tier or closed pharmacy benefit designs CB 2870 OCT 15 r5 R045824
