Blue Cross and BCN Custom Select Drug List · 1J Quinolones ... 1N Miscellaneous anti-infectives..... . 21. Cardiovascular, hypertension, cholesterol. 2A ACE-Inhibitors and combinations

2018

Custom Select Drug List

PPO (Blue Cross Blue Shield) HMO (Blue Care Network)Blue Cross® Physician Choice PPO Blue Cross® Metro Detroit HMOBlue Cross® Premier and Premier Value Blue Cross® Preferred HMO Community BlueSM PPO Blue Cross® Select HMOHealthy Blue AchieveSM PPO Blue Elect PlusSM Self Referral OptionSimply BlueSM PPO BCN Healthy Blue LivingSM HMO

BCN HMOSM

BCN HRASM HMO BCN HSASM HMOBCN Routine CareSM

Confidence comes with every card.®

Blue Cross and BCN Custom Select Drug List March 2018Table of contents

Individual & Small Group Plans................................................................................................. 5Specific information for Blue Cross Members........................................................................... 9Specific information for Blue Care Network Members............................................................... 12How to read the Blue Cross and BCN Custom Select Drug List............................................... 15

Anti-infectives1A 16Antifungals....................................................................................................................1B 16Antimalarials.................................................................................................................1C 16Antiparasitics and anthelmintics...................................................................................1D 17Antiretrovirals................................................................................................................1E 18Antituberculars..............................................................................................................1F 18Antivirals.......................................................................................................................1G 19Cephalosporins.............................................................................................................1H 19Macrolides.....................................................................................................................1I 19Penicillins......................................................................................................................1J 20Quinolones....................................................................................................................1K 20Sulfonamides and combinations...................................................................................1L 20Tetracyclines.................................................................................................................1M 20Urinary tract agents.......................................................................................................1N 21Miscellaneous anti-infectives........................................................................................

Cardiovascular, hypertension, cholesterol2A 22ACE-Inhibitors and combinations.................................................................................2B 22Alpha-adrenergic agents...............................................................................................2C 23Angiotensin II Receptor Blockers and combinations....................................................2D 24Anticoagulants and hemostasis agents........................................................................2E 25Beta blockers and combinations...................................................................................2F 25Calcium channel blockers and combinations...............................................................2G 26Cardiovascular treatment..............................................................................................2H 26Diuretics........................................................................................................................2I 27Lipid-lowering agents....................................................................................................2J 28Nitrates and combinations............................................................................................2K 28Renin-inhibitors and combinations................................................................................2L 28Miscellaneous antihypertensives..................................................................................

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Central nervous system3A 29Alzheimer's therapy.......................................................................................................3B 30Anticonvulsants.............................................................................................................3C 31Antidepressants............................................................................................................3D 32Antipsychotics...............................................................................................................3E 32Anxiolytics.....................................................................................................................3F 33CNS stimulants.............................................................................................................3G 33Migraine therapy...........................................................................................................3H 33Myasthenia gravis.........................................................................................................3I 34Narcotic antagonists.....................................................................................................3J 34Narcotic mixed agonist and antagonist.........................................................................3K 34Narcotic and analgesic combinations...........................................................................3L 35Narcotics.......................................................................................................................3M 35Nonsteroidal anti-inflammatory drugs...........................................................................3N 36Parkinsons disease and related disorders....................................................................3O 36Salicylates.....................................................................................................................3P 36Sedative and hypnotics.................................................................................................3Q 37Skeletal muscle relaxants.............................................................................................3R 37Miscellaneous CNS......................................................................................................

Gastrointestinal agents4A 385-Aminosalicylic Acid (5-ASA) agents..........................................................................4B 38Antidiarrheals and antispasmodics...............................................................................4C 38Antiemetics...................................................................................................................4D 39Bile acids.......................................................................................................................4E 39Bowel preparation and cleansing agents......................................................................4F 39Digestive enzymes........................................................................................................4G 39H2-Receptor antagonists..............................................................................................4H 40Proton Pump Inhibitors (PPI)........................................................................................4I 40Topical anti-Inflammatory agents..................................................................................4J 40Tumor Necrosis Factor (TNF) blocking agents............................................................4K 40Ulcer therapy.................................................................................................................4L 41Miscellaneous gastrointestinal agents..........................................................................

Obstetrics and gynecology5A 42Contraceptives-Biphasic...............................................................................................5B 42Contraceptives-Misc.....................................................................................................5C 43Contraceptives-Monophasic.........................................................................................5D 43Contraceptives-Postcoital.............................................................................................5E 43Contraceptives-Triphasic..............................................................................................5F 44Estrogen and progestin combinations..........................................................................5G 44Estrogens......................................................................................................................5H 44Infertility treatment*.......................................................................................................5I 45Progestins.....................................................................................................................5J 45Vaginal anti-infective and antifungal.............................................................................5K 45Miscellaneous OB-GYN................................................................................................

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Rheumatology and musculoskeletal6A 46Corticosteroids..............................................................................................................6B 46Gout therapy.................................................................................................................6C 46Non-Tumor Necrosis Factor (TNF) blocking agents.....................................................6D 46Osteoporosis and bone resorption................................................................................6E 47Osteoporosis and hormonal treatment.........................................................................6F 47Salicylates.....................................................................................................................6G 47Tumor Necrosis Factor (TNF) blocking agents............................................................6H 47Miscellaneous rheumatologic agents............................................................................

Endocrinology7A 48Androgens.....................................................................................................................7B 48Antithyroid agents.........................................................................................................7C 48Corticosteroids..............................................................................................................7D 49Growth Hormone and related products.........................................................................7E 49Insulins..........................................................................................................................7F 50Non-insulin hypoglycemic agents.................................................................................7G 51Somatostatin analogs...................................................................................................7H 51Thyroid hormones.........................................................................................................7I 51Urea cycle disorder agents ..........................................................................................7J 51Vitamin D analogs ........................................................................................................7K 52Miscellaneous endocrine..............................................................................................

Antineoplastics and immunosuppresants8A 53Adjuvant therapy...........................................................................................................8B 53Alkylating agents...........................................................................................................8C 53Antimetabolites.............................................................................................................8D 54Hormonal agents..........................................................................................................8E 54Immunomodulators.......................................................................................................8F 55Kinase inhibitors and molecular target inhibitors..........................................................8G 56Miscellaneous antineoplastic agents............................................................................

Immunology and hematology9A 57Hematopoietic agents...................................................................................................9B 57Immunoglobulins...........................................................................................................9C 57Interferons and MS therapy..........................................................................................9D 58Miscellaneous immunology and hematology................................................................

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Dermatology10A 59Acne treatment.............................................................................................................10B 59Antipsoriatic and antiseborrheic....................................................................................10C 59Corticosteriods - very high potency...............................................................................10D 60Corticosteroids - high potency......................................................................................10E 60Corticosteroids - medium potency................................................................................10F 60Corticosteroids - low potency........................................................................................10G 60Scabicides and pediculicides........................................................................................10H 61Topical anesthetics.......................................................................................................10I 61Topical antibacterials....................................................................................................10J 61Topical antifungals........................................................................................................10K 61Topical antineoplastic agents and immunomodulators.................................................10L 62Topical antivirals...........................................................................................................10M 62Wound and burn therapy..............................................................................................10N 62Miscellaneous dermatologicals.....................................................................................

Ophthalmology11A 63Cycloplegic mydriatics..................................................................................................11B 63Glaucoma agents..........................................................................................................11C 63Ophthalmic anti-allergy agents.....................................................................................11D 64Ophthalmic anti-infective and steroid combinations.....................................................11E 64Ophthalmic anti-infectives.............................................................................................11F 64Ophthalmic anti-inflammatory agents...........................................................................11G 65Ophthalmic beta blockers.............................................................................................11H 65Ophthalmic steroids......................................................................................................11I 65Miscellaneous ophthalmic agents.................................................................................

Otic and nasal preparations12A 66Nasal preparations........................................................................................................12B 66Otic preparations..........................................................................................................

Respiratory, cough and cold13A 67Antihistamine and decongestant combinations............................................................13B 67Antihistamines..............................................................................................................13C 67Antitussives...................................................................................................................13D 67Cystic Fibrosis agents ..................................................................................................13E 67Epinephrine...................................................................................................................13F 67Inhaled anticholinergics................................................................................................13G 68Inhaled beta-agonist and anticholinergic combinations................................................13H 68Inhaled beta-agonists....................................................................................................13I 68Inhaled steroid and beta-agonist combinations ...........................................................13J 68Inhaled steroids.............................................................................................................13K 68Intranasal steroids........................................................................................................13L 69Oral beta-agonists........................................................................................................13M 69Pulmonary Hypertension Agents .................................................................................13N 69Theophyllines................................................................................................................13O 69Miscellaneous respiratory agents.................................................................................

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Urology14A 70BPH Treatment.............................................................................................................14B 70Ion-Removing Agents...................................................................................................14C 70Urinary Antispasmodics................................................................................................14D 71Miscellaneous Urologicals............................................................................................

Vitamins and supplements15A 72Potassium Replacement...............................................................................................15B 72Vitamins and Minerals..................................................................................................

Diagnostic and other miscellaneous16A 73Chelating Agents...........................................................................................................16B 73Diagnostics and Other Miscellaneous..........................................................................16C 73Vaccines.......................................................................................................................

Lifestyle modification17A 74Sexual Dysfunction.......................................................................................................17B 74Smoking Cessation.......................................................................................................17C 74Weight Loss Preparations............................................................................................

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Individual and small group plans that use the Blue Cross and BCN Custom Select Drug List include: Individual plans

Plan name Market type Plan type Plan level Drug copay option Blue Care Network HMO Blue Cross® Partnered HMO Individual HMO (BCN) Gold, silver, silver saver,

bronze (HSA), bronze saver (HSA)

6 tier

Blue Cross® Partnered HMO Extra Individual HMO (BCN) Silver, bronze 4 tier Blue Cross® Metro Detroit HMO Individual HMO (BCN) Silver, silver saver, bronze

(HSA), bronze saver (HSA) 6 tier

Blue Cross® Metro Detroit HMO Extra

Individual HMO (BCN) Silver, bronze 4 tier

Blue Cross® Select HMO Individual HMO (BCN) Gold, silver, silver saver, bronze (HSA), bronze saver (HSA), value

6 tier

Blue Cross® Select HMO Extra Individual HMO (BCN) Silver, bronze 4 tier Blue Cross® Preferred HMO Individual HMO (BCN) Gold, silver, silver saver,

bronze (HSA) 6 tier

Blue Cross® Preferred HMO Extra Individual HMO (BCN) Silver 4 tier Blue Cross PPO Blue Cross® Premier Individual PPO (Blue Cross) Gold, silver,

bronze, catastrophic 5 tier

Blue Cross® Premier Silver Extra and Bronze Extra

Individual PPO (Blue Cross) Silver, bronze 4 tier

Blue Cross® Silver Extra with Dental and Vision, a Multi-State Plan

Individual PPO (Blue Cross) Silver 4 tier

Blue Cross® Gold Extra with Dental and Vision, a Multi-State Plan

Individual PPO (Blue Cross) Gold 4 tier

Blue Cross EPO Blue Cross® Metro Detroit EPO Individual EPO (Blue Cross) Silver, bronze 5 tier

Small group plans

Plan name Market type Plan type Plan level Drug copay option Blue Care Network HMO Blue Elect Plus Self Referral Option Small group HMO (BCN) Gold 6 tier BCN Small group HMO (BCN) Platinum, gold, silver 6 tier BCN Routine Care Small group HMO (BCN) Silver 6 tier BCN HRA Small group HMO (BCN) Platinum, gold 6 tier BCN HRA PCP Focus Small group HMO (BCN) Platinum 6 tier BCN HSA Small group HMO (BCN) Gold, silver, bronze 6 tier BCN HSA PCP Focus Small group HMO (BCN) Bronze 6 tier BCN PCP Focus Small group HMO (BCN) Platinum, gold, silver 6 tier BCN Healthy Blue Living Small group HMO (BCN) Platinum, gold 6 tier Blue Cross PPO Community Blue PPO Small group PPO (Blue Cross) Platinum, gold 3 tier Simply Blue PPO Small group PPO (Blue Cross) Platinum, gold, silver,

bronze 5 tier

Healthy Blue Achieve PPO Small group PPO (Blue Cross) Platinum, gold 5 tier Physician Choice PPO Small group PPO (Blue Cross) Gold, silver 5 tier

Blue Cross and BCN Custom Select Drug List

The Blue Cross Blue Shield of Michigan and Blue Care Network Custom Select Drug List is a useful reference and educational tool for prescribers, pharmacists and members. The Custom Select Drug List is based on our Custom Drug List but provides lower cost and better value to our customers and members. Most Blue Cross and BCN health care plans for small groups and individual members use this list, including those who enrolled through the Health Insurance Marketplace. Other groups and individuals may also choose a pharmacy benefit that uses this drug list. We update this list monthly with medications approved by the U.S. Food and Drug Administration and reviewed by our Pharmacy and Therapeutics Committee. The list represents the clinical judgment of Michigan doctors, 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 Select Drug List helps maintain quality of care and contain costs for our members. About this drug list 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. Refer to the How to Read section for details.

We encourage doctors 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 a 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 nonpreferred or excluded drug.

Coverage and applicable copay amounts for drugs on the Blue Cross and BCN Custom Select 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. Drugs not listed on the Custom Select Drug List are not covered. Some medications excluded by a Blue Cross or BCN member’s pharmacy benefit may be covered under his or her medical benefit. These are medications that are generally administered in a doctor’s office under the supervision of appropriate health care personnel and aren’t normally dispensed to the member for self-administration.

Several drugs and drug categories are excluded from coverage under this drug list. These include:

• Brand-name drugs that have generic equivalents • Over-the-counter medications (unless considered preventive by the United States

Preventive Services Task Force) • Lifestyle drugs (drugs for erectile dysfunction or weight loss) • Drugs prescribed for cosmetic purposes • Drugs used to treat heartburn and acid reflux (except select generic versions) • Drugs that treat coughs and colds, including most antihistamines • Prenatal vitamins • Compounded products, with some exceptions for Blue Cross PPO drug plans

Specialty drugs

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 Prog ram. Drugs included on this list are limited to a 15-day supply for all fills. 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 care plans must cover certain preventive services and drugs with no cost sharing. These drugs appear as a $0 tier on the drug list. For a complete list of preventive drugs, and coverage requirements, please refer to Preventive drug coverage or visit bcbsm.com/pharmacy.

This document is current at the time of publication and is subject to change. Please visit bcbsm.com/pharmacy and click on Drug Lists for the most up-to-date information about the Blue Cross and BCN Custom Select Drug List.

This document content was developed to comply with applicable federal and state regulations. To learn more about your plan, go to bcbsm.com and type “How Health Insurance Works” in the search field.

http://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/specialty-drug-program-member-guide.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/specialty-drug-program-member-guide.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/15-day-specialty-drug-list.pdfhttp://www.bcbsm.com/preventivedruglisthttp://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy.htmlhttp://www.bcbsm.com/pharmacyhttp://www.bcbsm.com/index/health-insurance-help/faqs/topics/how-health-insurance-works.html

Click on one of the links below for more information specific to your plan.

Blue Cross (PPO) BCN (HMO)

How to read the Blue Cross and BCN Custom Select Drug List

Blue Cross members

How do I know what type of prescription coverage I have?

For details about your drug benefit, please call the Customer Service phone number on the back of your Blue Cross member ID card. If you have online access, log in to your account at bcbsm.com. You can also find more general information about Blue Cross prescription coverage at bcbsm.com/pharmacy.

Tier descriptions

3-tier plans 4-tier plans 5-tier plans

Tier 1

Generics — lowest copay All Tier 1 drugs are generic drugs. Members pay the lowest copay for generics, which make them the most cost-effective option for treatment. This tier includes generic specialty drugs.

Generics — lowest copay This tier includes most generic drugs. Members pay the lowest copay for generics, making them the most cost-effective option for treatment. Generic specialty drugs are in Tier 4.

Generics — lowest copay This tier includes most generic drugs. Members pay the lowest copay for generics, making them the most cost-effective option for treatment. Generic specialty drugs are in Tier 4.

Tier 2

Preferred brand — higher copay This tier includes preferred, brand-name drugs. These drugs are more expensive than generics, and members pay a higher copay for them. This tier includes preferred brand specialty drugs.

Preferred brand — higher copay This tier includes preferred, nonspecialty, brand-name drugs. These drugs are more expensive than generics, and members pay a higher copay for them. Brand specialty drugs are in Tier 4.

Preferred brand — higher copay This tier includes preferred, nonspecialty, brand-name drugs. These drugs are more expensive than generics, and members pay a higher copay for them.

Tier 3

Nonpreferred brands — highest copay This tier includes nonpreferred, brand-name drugs for which there’s a more cost-effective generic alternative or preferred brand-name drug available. Members pay the highest copay for these drugs. This tier includes nonpreferred specialty drugs.

Nonpreferred brands — highest nonspecialty copay This tier includes nonspecialty brand-name drugs for which there’s either a generic alternative or a more cost-effective, preferred brand-name drug available. Members pay a higher copay for these nonpreferred brand drugs. Brand specialty drugs are in Tier 4.

Nonpreferred brands — highest nonspecialty copay This tier includes nonspecialty, brand-name drugs for which there’s either a generic alternative or a more cost-effective, preferred brand-name drug available. Members pay a higher copay for these nonpreferred brand drugs.

Tier 4 Does not apply

Specialty drugs — highest cost sharing This tier consists of specialty drugs, both generic and brand name, that are used to treat difficult health conditions.

Preferred specialty — lower specialty drug cost sharing This tier includes specialty drugs, both generic and brand name, that are used to treat difficult health conditions. These drugs are generally more cost-effective than nonpreferred specialty drugs.

Tier 5 Does not apply Does not apply

Nonpreferred specialty — higher specialty drug cost sharing This tier includes nonpreferred, specialty drugs that are used to treat difficult health conditions. Members pay a higher copay for nonpreferred specialty drugs because there are more cost-effective generic or preferred drugs available.

http://www.bcbsm.com/pharmacy

New generics

When a generic version of a brand-name drug becomes available, the generic version is generally added to Tier 1. Once the generic drug is added, the original, brand-name version won’t be covered.

How prior approval, step therapy and quantity limits work

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.

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.

To view a current list of drugs requiring prior approval or step therapy for Blue Cross PPO and EPO plans, please see the Blue Cross Prior Authorization and Step Therapy Guidelines and refer to the column labeled Custom Select Drug List.

Quantity limits and dose optimization

Quantity limits are set based on clinical appropriateness and manufacturer-recommended dosing for particular drugs.

To view a current list of drugs that have quantity limits, please see the Blue Cross Quantity Limit Program, and refer to the column labeled Custom Select Drug List.

The Blue Cross dose optimization program encourages appropriate prescribing of medications intended for once-daily administration. For certain medications, doctors are encouraged to prescribe prescription drugs in once-daily dosage regimens to help increase a member’s adherence to the medication, as opposed to using multiple lower doses of the same drug.

Obtaining prior approval or step therapy

Blue Cross members should consult their prescription drug benefit packet for information on how to obtain prior approval or how to request a review for coverage of a drug that isn't included in their plan. Members can also call the Customer Service number on the back of their Blue Cross member 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.

http://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/prior-authorization-and-step-therapy-guidelines.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/quantity-limit-program-drug-list.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/quantity-limit-program-drug-list.pdfhttp://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy/why-do-i-need-prior-authorization-for-prescription-drug/expedited-request-form.htmlhttp://www.bcbsm.com/

Or write to:

Blue Cross Blue Shield of Michigan Pharmacy Services P.O. Box 2320 Detroit, MI 48231-2320

For doctors:

Doctors can request approval for Blue Cross members one of four ways: 1. Online at 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

Doctors can download the medication request forms through web-DENIS under Blue Cross 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 doctor of approved requests and process the member’s claim accordingly. If a request isn’t approved, we’ll notify the member and doctor in writing. The notification includes the reason for the denial and an explanation of the member’s appeal rights and the appeals process.

http://www.bcbsm.com/providers.html

Blue Care Network members

Tier descriptions

Tier 1: Generics — lowest copayment Most Tier 1 drugs are generic drugs. Members pay the lowest copay for generics, which make them the most cost-effective option for treatment. Tier 1 drugs are grouped into two tiers for BCN members with a six-tier pharmacy benefit:

Tier 1A: Preferred generics — lower generic drug copay This tier includes commonly prescribed 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 diabetes, are also included in this tier. Offering these drugs at the lowest copay makes them 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 in Tier 1A. The Tier 1B copay is higher than the Tier 1A copay, but it’s still lower than the copay for brand-name drugs.

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’s either a generic alternative or a more cost-effective, preferred brand-name drug available. Members pay the highest copay for these nonspecialty drugs. 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 specialty drugs in Tier 5. That’s because there may be a more cost-effective generic or preferred brand available. Some BCN plans combine all specialty drugs into one specialty tier, Tier 4.

How do I know what type of prescription coverage I have?

For details about your drug benefit, please call the Customer Service phone number on the back of your BCN member ID card. If you have online access, log in to your account at bcbsm.com. You can also find more general information about BCN prescription coverage at bcbsm.com/pharmacy.

http://www.bcbsm.com/pharmacy

How prior approval, step therapy and quantity limits work

Prior approval and step therapy 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 considered. Drugs subject to step therapy may require previous treatment with one or more preferred drugs before coverage is approved.

Clinical criteria are based on current medical information and approved by our Pharmacy and Therapeutics Committee.

To view the list of drugs that require prior approval or step therapy for BCN HMO plans, please refer to Blue Care Network Custom Select Drug List Prior Authorization and Step Therapy Guidelines. Quantity limits BCN sets quantity limits based on clinical appropriateness and manufacturer-recommended dosing for particular drugs. For certain medications, BCN limits the day supply that can be dispensed per fill.

To view the list of drugs that require quantity limits for BCN HMO plans, please refer to: BCN Quantity Limits. Changes made following the publication of the BCN Prior Authorization and Step Therapy Guidelines and Quantity Limits are listed in the BCN Drug List Updates document.

Obtaining prior approval

For members:

To request approval for a drug, BCN members can talk to their doctors.

Members can also start a request by contacting BCN Customer Service at the number on the backs of their BCN member ID cards. Members can submit a request online by filling out our callback form at bcbsm.com.

Or write to:

Blue Care Network Clinical Pharmacy Help Desk — Mail Code C303 P.O. Box 5043 Southfield, MI 48076

http://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/bcn-custom-select-drug-list-prior-auth-step-therapy.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/bcn-custom-select-drug-list-prior-auth-step-therapy.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/bcn-quantity-limits.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/bcn-quantity-limits.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/bcn-drug-list-updates.pdfhttp://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy/why-do-i-need-prior-authorization-for-prescription-drug/prior-authorization-callback-form.htmlhttp://www.bcbsm.com/

For doctors: Doctors can request approval for BCN members 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

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 Clinical Pharmacy Help Desk — Mail Code C303 P.O. Box 5043

Southfield, MI 48076

Doctors can download the medication request forms through web-DENIS under 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 doctor of approved requests and process the member’s claim accordingly. If a request isn’t approved, we’ll notify the member and doctor in writing. The notification includes the reason for the denial and an explanation of the member’s appeal rights and the appeals process.

How to read the Custom Select 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 brand-name drug isn’t covered. If only a brand name is listed, there isn’t a generic version available.

BCBSM: The information in this section applies to members with a Blue Cross drug plan.

BCN: The information in this section applies to members with a BCN drug plan.

Drugs are organized based on drug class or indication for use.

Kynamro™ is a brand-name specialty drug. It requires a Tier 2 copay for Blue Cross members with a three-tier drug plan, and a Tier 4 copay for all other drug plans. Prior approval and quantity limits apply for both Blue Cross and BCN plans.

The generic drug, atorvastatin calcium, requires a Tier 1A copay for BCN members with a six-tier drug plan and a Tier 1 copay for all other plans. Quantity limits apply for both Blue Cross and BCN plans. 10 and 20mg strengths of atorvastatin calcium is a preventive drug, and may be covered with $0 cost-share for members who meet criteria. Its brand-name equivalent, Lipitor®, isn’t covered.

Livalo® is a brand-name drug that requires a Tier 3 copay. It requires step therapy for coverage and quantity limits apply for both Blue Cross and BCN plans.

The generic drug fenofibric acid (choline) requires a Tier 1B copay for BCN members with a six-tier drug plan, and a Tier 1 copay for all other drug plans. Quantity limits apply for BCN plans.

Welchol® is a brand-name drug that requires a Tier 2 copay.

Limits: This section lists information, such as prior approval, step therapy and quantity limits.

Prior approval: Plan approval is required for coverage (listed as PA in the chart).

Step therapy: Previous treatment with preferred drugs is required (listed as ST in the chart).

Quantity limits: Prescriptions can’t exceed a specific quantity per fill (listed as QL in the chart)

1

2

3

4

5

6

7

8

9

4

3

1

2

5 6 7 8

“Prevent” indicates a preventive drug.

9 9

5

1. Anti-infectives

Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier

1A. Antifungals BCN (HMO)BCBSM (PPO)Trade name Generic name

Ancobon flucytosine 1 1 1B1 1Cresemba capsule 2 2 2QL QL2 2Diflucan fluconazole 1 1 1B1 1Grifulvin V griseofulvin, microsize 1 1 1B1 1Gris-PEG griseofulvin ultramicrosize 1 1 1B1 1Lamisil tablet terbinafine hcl 1 1 1B1 1Mycelex Troche clotrimazole 1 1 1B1 1Nizoral ketoconazole 1 1 1B1 1Noxafil suspension 2 2 22 2Noxafil tablet 2 2 2QL QL2 2Nystatin nystatin 1 1 1B1 1Sporanox itraconazole 1 1 1B1 1Sporanox solution 2 2 22 2Vfend voriconazole 1 1 1B1 1


1B. Antimalarials BCN (HMO)BCBSM (PPO)Trade name Generic name

Aralen chloroquine phosphate 1 1 1B1 1Coartem 2 2 2 QL2 2Daraprim 2 4 4 PA4 4Lariam mefloquine hcl 1 1 1B1 1Malarone atovaquone/proguanil hcl 1 1 1B1 1Plaquenil hydroxychloroquine sulfate 1 1 1B1 1Primaquine 2 2 22 2Qualaquin quinine sulfate 1 1 1B1 1


1C. Antiparasitics and anthelmintics BCN (HMO)BCBSM (PPO)Trade name Generic name

Albenza 2 2 2QL2 2Alinia 2 2 22 2Benznidazole 2 2 2QL QL2 2Biltricide 2 2 22 2Flagyl metronidazole 1 1 1B1 1Humatin paromomycin sulfate 1 1 1B1 1Impavido 2 2 2PA, QL QL2 2Mepron atovaquone 1 1 1B1 1Nebupent aerosol 2 2 22 2Stromectol ivermectin 1 1 1B1 1Tindamax tinidazole 1 1 1B QL1 1

Page 16BCBSM/BCN Custom Select Drug List - March-2018

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug

rev. 2


1D. Antiretrovirals BCN (HMO)BCBSM (PPO)Trade name Generic name

Aptivus 2 2 22 2Atripla 2 2 22 2Combivir lamivudine/zidovudine 1 1 1B1 1Complera 2 2 2QL QL2 2Crixivan 2 2 22 2Descovy 2 2 2QL QL2 2Edurant 2 2 2QL QL2 2Emtriva 2 2 22 2Epivir lamivudine 1 1 1B1 1Epzicom abacavir sulfate/lamivudine 1 1 1B1 1Evotaz 2 2 2QL QL2 2Fuzeon 2 2 22 2Genvoya 2 2 2QL QL2 2Intelence 2 2 22 2Invirase 2 2 22 2Isentress 2 2 22 2Isentress HD 2 2 22 2Juluca 3 3 3QL QL3 3Kaletra lopinavir/ritonavir 1 1 1B1 1Kaletra tablet 2 2 22 2Lexiva fosamprenavir calcium 1 1 1B1 1Lexiva suspension 2 2 22 2Norvir 2 2 22 2Odefsey 2 2 2QL QL2 2Prezcobix 2 2 2QL QL2 2Prezista 2 2 22 2Rescriptor 2 2 22 2Retrovir zidovudine 1 1 1B1 1Reyataz atazanavir sulfate 1 1 1B1 1Reyataz powder pack 2 2 22 2Selzentry 2 2 22 2Stribild 2 2 2QL QL2 2Sustiva efavirenz 1 1 1B1 1Tivicay 2 2 22 2Triumeq 2 2 2QL QL2 2Trizivir abacavir/lamivudine/zidovudine 1 1 1B1 1Truvada 2 2 22 2Tybost 2 2 2QL2 2Vemlidy 2 4 4QL QL4 4Videx 2 2 22 2Videx EC didanosine 1 1 1B1 1Viracept 2 2 22 2Viramune, XR nevirapine 1 1 1B1 1Viread tenofovir disoproxil fumarate 1 1 1B1 1Viread 150mg, 200mg, 250mg tablet; powder

2 2 22 2

Zerit stavudine 1 1 1B1 1Ziagen abacavir sulfate 1 1 1B1 1



rev. 2


1E. Antituberculars BCN (HMO)BCBSM (PPO)Trade name Generic name

Cycloserine 2 2 22 2Ethambutol ethambutol hcl 1 1 1B1 1Isoniazid isoniazid 1 1 1B1 1Mycobutin rifabutin 1 1 1B1 1Paser 3 3 33 3Priftin 3 3 33 3Pyrazinamide pyrazinamide 1 1 1B1 1Rifadin rifampin 1 1 1B1 1Rifamate 3 3 33 3Rifater 3 3 33 3Sirturo 2 2 2PA PA, QL2 2Trecator 3 3 33 3


1F. Antivirals BCN (HMO)BCBSM (PPO)Trade name Generic name

Baraclude entecavir 1 4 44 4Baraclude solution 2 4 44 4Copegus ribavirin 1 4 44 4Daklinza 3 5 5PA, QL PA, QL4 4Epclusa 2 4 4PA, QL PA, QL4 4Epivir HBV lamivudine 1 1 1B1 1Epivir HBV solution 2 2 22 2Famvir famciclovir 1 1 1B1 1Flumadine rimantadine hcl 1 1 1B1 1Harvoni 3 5 5PA, QL PA, QL4 4Hepsera adefovir dipivoxil 1 4 44 4Mavyret 3 5 5PA, QL PA, QL4 4Olysio 3 5 5PA, QL PA, QL4 4Rebetol ribavirin 1 4 44 4Rebetol solution 2 4 44 4Relenza 2 2 2QL QL2 2Ribapak; Ribatab ribavirin 1 4 44 4Ribasphere Ribapak tablet ribavirin 1 4 44 4Sovaldi 3 5 5PA, QL PA, QL4 4Symmetrel amantadine hcl 1 1 1B1 1Tamiflu oseltamivir phosphate 1 1 1BQL QL1 1Technivie 3 5 5PA, QL PA, QL4 4Valcyte valganciclovir hcl 1 1 1B1 1Valtrex valacyclovir hcl 1 1 1B1 1Vosevi 3 5 5PA, QL PA, QL4 4Zepatier 2 4 4PA, QL PA, QL4 4Zovirax capsule, solution, tablet acyclovir 1 1 1B1 1



rev. 2


1G. Cephalosporins BCN (HMO)BCBSM (PPO)Trade name Generic name

Ceclor, ER cefaclor 1 1 1B1 1Cedax ceftibuten 1 1 1B1 1Ceftin cefuroxime axetil 1 1 1B1 1Ceftin suspension 2 2 22 2Cefzil cefprozil 1 1 1B1 1Duricef cefadroxil 1 1 1B1 1Keflex cephalexin 1 1 1B1 1Omnicef cefdinir 1 1 1B1 1Spectracef cefditoren pivoxil 1 1 1B QL1 1Suprax cefixime 1 1 1B1 1Suprax capsule, chew tablet, 500mg/5ml suspension

3 3 33 3

Vantin cefpodoxime proxetil 1 1 1B1 1


1H. Macrolides BCN (HMO)BCBSM (PPO)Trade name Generic name

Biaxin, XL clarithromycin 1 1 1B1 1Dificid 3 3 3QL QL3 3E.E.S. erythromycin ethylsuccinate 1 1 1B1 1Eryped 200mg/5ml, 400mg/5ml 3 3 33 3Ery-tab erythromycin base 1 1 1B1 1Ery-tab 500mg 3 3 33 3Erythromycin Base erythromycin base 1 1 1B1 1Erythromycin Stearate erythromycin stearate 1 1 1B1 1PCE 3 3 33 3Zithromax azithromycin 1 1 1B1 1Zmax 3 3 33 3


1I. Penicillins BCN (HMO)BCBSM (PPO)Trade name Generic name

Amoxil amoxicillin 1 1 1B1 1Ampicillin ampicillin trihydrate 1 1 1B1 1Augmentin 125mg-31.25mg/ml suspension

2 2 22 2

Augmentin, ES, XR amoxicillin/potassium clav 1 1 1B1 1Dicloxacillin dicloxacillin sodium 1 1 1B1 1Penicillin VK penicillin v potassium 1 1 1B1 1



rev. 2


1J. Quinolones BCN (HMO)BCBSM (PPO)Trade name Generic name

Avelox moxifloxacin hcl 1 1 1B1 1Baxdela tablet 3 3 33 3Cipro suspension ciprofloxacin 1 1 1B1 1Cipro tablet ciprofloxacin hcl 1 1 1B1 1Cipro XR ciprofloxacin/ciprofloxa hcl 1 1 1B1 1Factive 3 3 33 3Floxin tablet ofloxacin 1 1 1B1 1Levaquin levofloxacin 1 1 1B1 1


1K. Sulfonamides and combinations BCN (HMO)BCBSM (PPO)Trade name Generic name

Bactrim, DS; Septra, DS sulfamethoxazole/trimethoprim 1 1 1B1 1Sulfadiazine sulfadiazine 1 1 1B1 1


1L. Tetracyclines BCN (HMO)BCBSM (PPO)Trade name Generic name

Declomycin demeclocycline hcl 1 1 1B1 1Minocin capsule minocycline hcl 1 1 1B1 1Monodox doxycycline monohydrate 1 1 1B1 1Periostat doxycycline hyclate 1 1 1B1 1Tetracycline tetracycline hcl 1 1 1B1 1Vibramycin doxycycline hyclate 1 1 1B1 1Vibramycin suspension doxycycline monohydrate 1 1 1B1 1Vibramycin syrup 3 3 33 3


1M. Urinary tract agents BCN (HMO)BCBSM (PPO)Trade name Generic name

Furadantin nitrofurantoin 1 1 1B1 1Hiprex/Urex methenamine hippurate 1 1 1B1 1Macrobid nitrofurantoin monohyd/m-cryst 1 1 1B1 1Macrodantin nitrofurantoin macrocrystal 1 1 1B1 1Monurol 3 3 33 3Primsol 3 3 33 3Trimethoprim trimethoprim 1 1 1B1 1Trimpex 3 3 33 3



rev. 2


1N. Miscellaneous anti-infectives BCN (HMO)BCBSM (PPO)Trade name Generic name

Cayston 3 5 5PA, QL PA, QL4 4Cleocin capsule clindamycin hcl 1 1 1B1 1Cleocin solution clindamycin palmitate hcl 1 1 1B1 1Dapsone dapsone 1 1 1B1 1Neomycin neomycin sulfate 1 1 1B1 1Sivextro 2 2 2QL QL2 2Tobi tobramycin in 0.225% nacl 1 4 4QL4 4Vancocin vancomycin hcl 1 1 1B1 1Xifaxan 200mg 3 3 3 QL3 3Zyvox linezolid 1 1 1B1 1



rev. 2

2. Cardiovascular, hypertension, cholesterol


2A. ACE-Inhibitors and combinations BCN (HMO)BCBSM (PPO)Trade name Generic name

Accupril quinapril hcl 1 1 1A1 1Accuretic quinapril/hydrochlorothiazide 1 1 1A1 1Aceon perindopril erbumine 1 1 1A1 1Altace ramipril 1 1 1A1 1Capoten captopril 1 1 1A1 1Capozide captopril/hydrochlorothiazide 1 1 1A1 1Lotensin benazepril hcl 1 1 1A1 1Lotensin HCT benazepril/hydrochlorothiazide 1 1 1A1 1Lotrel amlodipine besylate/benazepril 1 1 1A1 1Mavik trandolapril 1 1 1A1 1Monopril fosinopril sodium 1 1 1A1 1Monopril HCT fosinopril/hydrochlorothiazide 1 1 1A1 1Prinivil; Zestril lisinopril 1 1 1A1 1Prinzide; Zestoretic lisinopril/hydrochlorothiazide 1 1 1A1 1Tarka trandolapril/verapamil hcl 1 1 1B1 1Uniretic moexipril/hydrochlorothiazide 1 1 1A1 1Univasc moexipril hcl 1 1 1A1 1Vaseretic enalapril/hydrochlorothiazide 1 1 1A1 1Vasotec enalapril maleate 1 1 1A1 1


2B. Alpha-adrenergic agents BCN (HMO)BCBSM (PPO)Trade name Generic name

Aldomet methyldopa 1 1 1B1 1Aldoril methyldopa/hydrochlorothiazide 1 1 1B1 1Cardura doxazosin mesylate 1 1 1B1 1Catapres clonidine hcl 1 1 1A1 1Catapres-TTS clonidine 1 1 1B1 1Clorpres clonidine hcl/chlorthalidone 1 1 1B1 1Clorpres 0.3mg-15mg 3 3 33 3Dibenzyline phenoxybenzamine hcl 1 1 1BPA, QL PA1 1Hytrin terazosin hcl 1 1 1B1 1Minipress prazosin hcl 1 1 1B1 1Tenex guanfacine hcl 1 1 1B1 1



rev. 2


2C. Angiotensin II Receptor Blockers and combinations BCN (HMO)BCBSM (PPO)Trade name Generic name

Atacand candesartan cilexetil 1 1 1A1 1Atacand HCT candesartan/hydrochlorothiazid 1 1 1A1 1Avalide irbesartan/hydrochlorothiazide 1 1 1A1 1Avapro irbesartan 1 1 1A1 1Azor amlodipine bes/olmesartan med 1 1 1B QL1 1Benicar olmesartan medoxomil 1 1 1B ST, QL1 1Benicar HCT olmesartan/hydrochlorothiazide 1 1 1B ST, QL1 1Cozaar losartan potassium 1 1 1A1 1Diovan valsartan 1 1 1A1 1Diovan HCT valsartan/hydrochlorothiazide 1 1 1A1 1Edarbi 3 3 3ST, QL ST, QL3 3Edarbyclor 3 3 3ST, QL ST, QL3 3Entresto 2 2 2QL QL2 2Exforge amlodipine/valsartan 1 1 1B1 1Exforge HCT amlodipine/valsartan/hcthiazid 1 1 1B1 1Hyzaar losartan/hydrochlorothiazide 1 1 1A1 1Micardis telmisartan 1 1 1B1 1Micardis HCT telmisartan/hydrochlorothiazid 1 1 1B1 1Teveten eprosartan mesylate 1 1 1A1 1Tribenzor olmesartan/amlodipin/hcthiazid 1 1 1BQL QL1 1Twynsta telmisartan/amlodipine 1 1 1B1 1



rev. 2


2D. Anticoagulants and hemostasis agents BCN (HMO)BCBSM (PPO)Trade name Generic name

Aggrenox aspirin/dipyridamole 1 1 1B1 1Agrylin anagrelide hcl 1 1 1B1 1Amicar 2 2 22 2Arixtra fondaparinux sodium 1 4 44 4Bevyxxa tablet 3 3 3QL QL3 3Brilinta 2 2 2 QL2 2Coumadin warfarin sodium 1 1 1A1 1Effient prasugrel hcl 1 1 1B QL1 1Eliquis 2 2 2QL QL2 2Fragmin 3 5 54 4Heparin 1000u/ml heparin sodium,porcine/pf 1 1 1B1 1Heparin 5000/0.5ml heparin sodium,porcine/pf 1 4 44 4Heparin 5000/ml, 10000/ml, 20000/ml

heparin sodium,porcine 1 4 44 4

Iprivask 3 5 54 4Lovenox enoxaparin sodium 1 4 44 4Mephyton 2 2 22 2Persantine dipyridamole 1 1 1B1 1Plavix clopidogrel bisulfate 1 1 1A QL1 1Pletal cilostazol 1 1 1B1 1Pradaxa 3 3 3QL QL3 3Savaysa 3 3 3QL QL3 3Ticlid ticlopidine hcl 1 1 1B1 1Trental pentoxifylline 1 1 1B1 1Vitamin K ampule phytonadione 1 1 1B1 1Xarelto, starter kit 2 2 2QL QL2 2Zontivity 3 3 3PA, QL QL3 3



rev. 2


2E. Beta blockers and combinations BCN (HMO)BCBSM (PPO)Trade name Generic name

Betapace, AF sotalol hcl 1 1 1A1 1Blocadren timolol maleate 1 1 1A1 1Bystolic 2.5, 5, 10mg 3 3 3 ST, QL3 3Bystolic 20mg 3 3 3 ST3 3Coreg immediate-release carvedilol 1 1 1A1 1Corgard nadolol 1 1 1A1 1Corzide nadolol/bendroflumethiazide 1 1 1A1 1Dutoprol 3 3 33 3Inderal, LA propranolol hcl 1 1 1A1 1Inderide propranolol/hydrochlorothiazid 1 1 1A1 1Kerlone betaxolol hcl 1 1 1A1 1Levatol 3 3 33 3Lopressor metoprolol tartrate 1 1 1A1 1Lopressor HCT metoprolol/hydrochlorothiazide 1 1 1A1 1Normodyne labetalol hcl 1 1 1A1 1Sectral acebutolol hcl 1 1 1A1 1Tenoretic atenolol/chlorthalidone 1 1 1A1 1Tenormin atenolol 1 1 1A1 1Toprol XL metoprolol succinate 1 1 1A1 1Visken pindolol 1 1 1A1 1Zebeta bisoprolol fumarate 1 1 1A1 1Ziac bisoprolol fumarate/hctz 1 1 1A1 1


2F. Calcium channel blockers and combinations BCN (HMO)BCBSM (PPO)Trade name Generic name

Adalat CC; Procardia, XL nifedipine 1 1 1B1 1Azor amlodipine bes/olmesartan med 1 1 1B QL1 1Caduet amlodipine/atorvastatin 1 1 1BQL QL1 1Calan SR; Isoptin SR verapamil hcl 1 1 1B1 1Cardene nicardipine hcl 1 1 1B1 1Cardizem, CD, LA, SR diltiazem hcl 1 1 1B1 1Cardizem LA 120mg 3 3 33 3Dynacirc isradipine 1 1 1B1 1Exforge amlodipine/valsartan 1 1 1B1 1Exforge HCT amlodipine/valsartan/hcthiazid 1 1 1B1 1Lotrel amlodipine besylate/benazepril 1 1 1A1 1Norvasc amlodipine besylate 1 1 1A1 1Plendil felodipine 1 1 1B1 1Sular nisoldipine 1 1 1B1 1Tarka trandolapril/verapamil hcl 1 1 1B1 1Tiazac diltiazem hcl 1 1 1B1 1Tribenzor olmesartan/amlodipin/hcthiazid 1 1 1BQL QL1 1Twynsta telmisartan/amlodipine 1 1 1B1 1Verelan, PM verapamil hcl 1 1 1B1 1



rev. 2


2G. Cardiovascular treatment BCN (HMO)BCBSM (PPO)Trade name Generic name

Betapace, AF sotalol hcl 1 1 1A1 1Cordarone; Pacerone amiodarone hcl 1 1 1B1 1Corlanor 2 2 2PA, QL PA, QL2 2Lanoxin digoxin 1 1 1B1 1Lanoxin 62.5, 187.5mcg 3 3 33 3Mexitil mexiletine hcl 1 1 1B1 1Multaq 2 2 2QL QL2 2Norpace disopyramide phosphate 1 1 1B1 1Norpace CR 2 2 22 2Proamatine midodrine hcl 1 1 1B1 1Quinidex quinidine sulfate 1 1 1B1 1Quinidine Gluconate SA quinidine gluconate 1 1 1B1 1Ranexa 3 3 3 PA3 3Rythmol, SR propafenone hcl 1 1 1B1 1Tambocor flecainide acetate 1 1 1B1 1Tikosyn dofetilide 1 1 1B1 1


2H. Diuretics BCN (HMO)BCBSM (PPO)Trade name Generic name

Aldactazide spironolact/hydrochlorothiazid 1 1 1A1 1Aldactazide 50/50mg 3 3 33 3Aldactone spironolactone 1 1 1A1 1Bumex bumetanide 1 1 1A1 1Demadex torsemide 1 1 1A1 1Diamox, Sequels acetazolamide 1 1 1B1 1Diuril chlorothiazide 1 1 1A1 1Diuril suspension 3 3 33 3Dyazide; Maxzide triamterene/hydrochlorothiazid 1 1 1A1 1Dyrenium 2 2 22 2Edecrin ethacrynic acid 1 1 1B1 1Enduron methyclothiazide 1 1 1B1 1Hydrodiuril; Microzide hydrochlorothiazide 1 1 1A1 1Hygroton; Thalitone chlorthalidone 1 1 1A1 1Inspra eplerenone 1 1 1A1 1Lasix furosemide 1 1 1A1 1Lozol indapamide 1 1 1A1 1Midamor amiloride hcl 1 1 1A1 1Moduretic amiloride/hydrochlorothiazide 1 1 1A1 1Zaroxolyn metolazone 1 1 1A1 1



rev. 2


2I. Lipid-lowering agents BCN (HMO)BCBSM (PPO)Trade name Generic name

Antara fenofibrate,micronized 1 1 1B1 1Antara 30, 90mg 3 3 33 3Caduet amlodipine/atorvastatin 1 1 1BQL QL1 1Colestid colestipol hcl 1 1 1B1 1Colestid granules, packet 3 3 33 3Crestor rosuvastatin calcium 1 1 1BQL QL1 1Crestor* 5mg, 10mg (Prevent) rosuvastatin calcium $0 $0 $0QL QL$0 $0Fibricor fenofibric acid 1 1 1B1 1Kynamro 2 4 4PA, QL PA, QL4 4Lescol, XL fluvastatin sodium 1 1 1BQL QL1 1Lescol, XL* (all strengths) (Prevent) fluvastatin sodium $0 $0 $0QL QL$0 $0Lipitor atorvastatin calcium 1 1 1AQL QL1 1Lipitor* 10mg, 20mg (Prevent) atorvastatin calcium $0 $0 $0QL QL$0 $0Livalo 3 3 3ST, QL ST, QL3 3Lofibra capsule fenofibrate,micronized 1 1 1A1 1Lofibra tablet fenofibrate 1 1 1A1 1Lopid gemfibrozil 1 1 1A1 1Lovaza omega-3 acid ethyl esters 1 1 1BPA PA, QL1 1Mevacor lovastatin 1 1 1AQL QL1 1Mevacor* (all strengths) (Prevent) lovastatin $0 $0 $0QL QL$0 $0Niacor 3 3 33 3Niaspan niacin 1 1 1B1 1Praluent 3 5 5PA, QL PA, QL4 4Pravachol pravastatin sodium 1 1 1AQL QL1 1Pravachol* (all strengths) (Prevent) pravastatin sodium $0 $0 $0QL QL$0 $0Questran cholestyramine (with sugar) 1 1 1B1 1Questran Light cholestyramine/aspartame 1 1 1B1 1Repatha 3 5 5PA, QL PA, QL4 4Tricor fenofibrate nanocrystallized 1 1 1B1 1Trilipix fenofibric acid (choline) 1 1 1B1 1Vytorin ezetimibe/simvastatin 1 1 1BQL QL1 1Welchol 2 2 22 2Zetia ezetimibe 1 1 1BQL QL1 1Zocor simvastatin 1 1 1AQL QL1 1Zocor* 5mg, 10mg, 20mg, 40mg(Prevent)

simvastatin $0 $0 $0QL QL$0 $0

*Age restrictions apply.



rev. 2


2J. Nitrates and combinations BCN (HMO)BCBSM (PPO)Trade name Generic name

Bidil 2 2 22 2Dilatrate-SR 2 2 22 2Imdur; Ismo; Monoket isosorbide mononitrate 1 1 1A1 1Isordil isosorbide dinitrate 1 1 1B1 1Isordil 40mg 3 3 33 3Nitro-bid ointment nitroglycerin 1 1 1B1 1Nitro-Dur 0.3mg, 0.8mg 3 3 33 3Nitroglycerin capsule, patch nitroglycerin 1 1 1B1 1Nitromist nitroglycerin 1 1 1B1 1Nitrostat nitroglycerin 1 1 1B1 1


2K. Renin-inhibitors and combinations BCN (HMO)BCBSM (PPO)Trade name Generic name

Tekturna, HCT 3 3 33 3


2L. Miscellaneous antihypertensives BCN (HMO)BCBSM (PPO)Trade name Generic name

Apresoline hydralazine hcl 1 1 1B1 1Demser 3 3 33 3Loniten minoxidil 1 1 1B1 1



rev. 2

3. Central nervous system


3A. Alzheimer's therapy BCN (HMO)BCBSM (PPO)Trade name Generic name

Aricept 5, 10mg; ODT donepezil hcl 1 1 1B1 1Exelon capsule rivastigmine tartrate 1 1 1B1 1Exelon patch rivastigmine 1 1 1B1 1Namenda dosepak 2 2 22 2Namenda immediate release memantine hcl 1 1 1B1 1Razadyne, ER galantamine hbr 1 1 1B1 1

Page 29BCBSM/BCN Custom Select Drug List - March-2018(Prevent) - Prevent drugs may be covered at $0 if criteria are met


rev. 2


3B. Anticonvulsants BCN (HMO)BCBSM (PPO)Trade name Generic name

Banzel 2 2 22 2Briviact 3 3 3PA, QL PA, QL3 3Carbatrol carbamazepine 1 1 1B1 1Celontin 3 3 33 3Depakene capsule valproic acid 1 1 1B1 1Depakene solution valproic acid (as sodium salt) 1 1 1B1 1Depakote, ER, sprinkles divalproex sodium 1 1 1B1 1Diamox, Sequels acetazolamide 1 1 1B1 1Diastat 2.5mg diazepam 1 1 1B1 1Diastat 2.5mg 2 2 22 2Diastat Acudial diazepam 1 1 1B1 1Dilantin phenytoin 1 1 1A1 1Dilantin 30mg capsule 2 2 22 2Dilantin; Phenytek capsule phenytoin sodium extended 1 1 1A1 1Equetro 3 3 33 3Felbatol felbamate 1 1 1B1 1Fycompa suspension 3 3 3PA, QL3 3Fycompa tablet 3 3 3PA, QL QL3 3Gabitril tiagabine hcl 1 1 1B1 1Gabitril 12mg, 16mg 2 2 22 2Keppra, XR levetiracetam 1 1 1A1 1Klonopin, Wafer clonazepam 1 1 1B1 1Lamictal, dispertabs, ODT, XR lamotrigine 1 1 1B1 1Lamictal XR dosepak 3 3 33 3Lyrica 3 3 3PA PA, QL3 3Mysoline primidone 1 1 1B1 1Neurontin gabapentin 1 1 1B1 1Onfi 3 3 3PA, QL PA, QL3 3Peganone 2 2 22 2Phenobarbital phenobarbital 1 1 1B1 1Sabril vigabatrin 1 4 44 4Sabril tablet 2 4 44 4Tegretol, XR carbamazepine 1 1 1B1 1Topamax, Sprinkle topiramate 1 1 1B1 1Trileptal oxcarbazepine 1 1 1B1 1Vimpat 2 2 22 2Zarontin ethosuximide 1 1 1B1 1Zonegran zonisamide 1 1 1B1 1



rev. 2


3C. Antidepressants BCN (HMO)BCBSM (PPO)Trade name Generic name

Adapin; Sinequan doxepin hcl 1 1 1A1 1Amoxapine amoxapine 1 1 1B1 1Anafranil clomipramine hcl 1 1 1B1 1Aplenzin 3 3 3ST PA3 3Aventyl; Pamelor nortriptyline hcl 1 1 1A1 1Celexa citalopram hydrobromide 1 1 1A1 1Cymbalta duloxetine hcl 1 1 1B1 1Desyrel trazodone hcl 1 1 1A1 1Effexor venlafaxine hcl 1 1 1A1 1Effexor XR; Venlafaxine hcl ER venlafaxine hcl 1 1 1A1 1Elavil amitriptyline hcl 1 1 1A1 1Emsam 3 3 33 3Etrafon perphenazine/amitriptyline hcl 1 1 1B1 1Fluoxetine 60mg fluoxetine hcl 1 1 1BQL1 1Lexapro escitalopram oxalate 1 1 1A1 1Limbitrol, DS amitrip hcl/chlordiazepoxide 1 1 1B1 1Luvox fluvoxamine maleate 1 1 1A1 1Luvox CR fluvoxamine maleate 1 1 1B1 1Maprotiline hcl maprotiline hcl 1 1 1A1 1Marplan 3 3 33 3Nardil phenelzine sulfate 1 1 1B1 1Norpramin desipramine hcl 1 1 1A1 1Parnate tranylcypromine sulfate 1 1 1B1 1Paxil paroxetine hcl 1 1 1A1 1Paxil CR paroxetine hcl 1 1 1B1 1Paxil suspension 3 3 33 3Pexeva 3 3 3ST PA, QL3 3Pristiq desvenlafaxine succinate 1 1 1B QL1 1Prozac fluoxetine hcl 1 1 1A1 1Prozac Weekly fluoxetine hcl 1 1 1AQL1 1Remeron mirtazapine 1 1 1A1 1Serzone nefazodone hcl 1 1 1B1 1Surmontil trimipramine maleate 1 1 1B1 1Tofranil imipramine hcl 1 1 1A1 1Tofranil-PM imipramine pamoate 1 1 1B1 1Trintellix 3 3 3ST, QL PA, QL3 3Viibryd, dosepak 3 3 3ST, QL PA, QL3 3Vivactil protriptyline hcl 1 1 1B1 1Wellbutrin, SR, XL bupropion hcl 1 1 1A1 1Zoloft sertraline hcl 1 1 1A1 1



rev. 2


3D. Antipsychotics BCN (HMO)BCBSM (PPO)Trade name Generic name

Abilify aripiprazole 1 1 1B1 1Clozapine 200mg clozapine 1 1 1B1 1Clozapine ODT; Fazaclo 150, 200mg

3 3 3 ST3 3

Clozaril clozapine 1 1 1A1 1Etrafon perphenazine/amitriptyline hcl 1 1 1B1 1Fanapt 3 3 3ST ST3 3Fazaclo clozapine 1 1 1B ST1 1Geodon ziprasidone hcl 1 1 1B1 1Haldol liquid haloperidol lactate 1 1 1A1 1Haldol tablet haloperidol 1 1 1A1 1Invega paliperidone 1 1 1BQL ST, QL1 1Latuda 3 3 3ST ST3 3Loxitane loxapine succinate 1 1 1B1 1Mellaril thioridazine hcl 1 1 1A1 1Navane thiothixene 1 1 1B1 1Nuplazid 3 3 3PA, QL PA, QL3 3Orap pimozide 1 1 1B1 1Perphenazine perphenazine 1 1 1B1 1Prolixin fluphenazine hcl 1 1 1A1 1Risperdal, M-Tab risperidone 1 1 1A1 1Saphris 3 3 3ST, QL ST, QL3 3Seroquel quetiapine fumarate 1 1 1A1 1Seroquel XR quetiapine fumarate 1 1 1BQL QL1 1Stelazine trifluoperazine hcl 1 1 1A1 1Symbyax olanzapine/fluoxetine hcl 1 1 1B1 1Thorazine chlorpromazine hcl 1 1 1B1 1Vraylar 3 3 3ST, QL ST, QL3 3Zyprexa, Zydis olanzapine 1 1 1A1 1


3E. Anxiolytics BCN (HMO)BCBSM (PPO)Trade name Generic name

Ativan lorazepam 1 1 1B1 1Buspar buspirone hcl 1 1 1B1 1Equanil; Miltown meprobamate 1 1 1B1 1Librium chlordiazepoxide hcl 1 1 1B1 1Lorazepam intensol lorazepam 1 1 1B1 1Niravam alprazolam 1 1 1B1 1Serax oxazepam 1 1 1B1 1Tranxene T-Tab clorazepate dipotassium 1 1 1B1 1Valium diazepam 1 1 1B1 1Xanax, XR alprazolam 1 1 1B1 1



rev. 2


3F. CNS stimulants BCN (HMO)BCBSM (PPO)Trade name Generic name

Adderall, XR dextroamphetamine/amphetamine 1 1 1BQL QL1 1

Concerta methylphenidate hcl 1 1 1B QL1 1Daytrana 3 3 3 QL3 3Desoxyn methamphetamine hcl 1 1 1B QL1 1Dexedrine dextroamphetamine sulfate 1 1 1B QL1 1Focalin immediate-release dexmethylphenidate hcl 1 1 1B QL1 1Metadate CD methylphenidate hcl 1 1 1B QL1 1Methylin, ER methylphenidate hcl 1 1 1B QL1 1Nuvigil armodafinil 1 1 1BQL PA, QL1 1Procentra dextroamphetamine sulfate 1 1 1B PA, QL1 1Provigil modafinil 1 1 1BQL PA, QL1 1Ritalin LA 10mg 3 3 3 QL3 3Ritalin, LA, SR methylphenidate hcl 1 1 1B QL1 1Vyvanse 3 3 3QL QL3 3Zenzedi 3 3 3 QL3 3


3G. Migraine therapy BCN (HMO)BCBSM (PPO)Trade name Generic name

Alsuma sumatriptan succinate 1 1 1BQL QL1 1Amerge naratriptan hcl 1 1 1BQL QL1 1Axert almotriptan malate 1 1 1BST, QL QL1 1Cafergot ergotamine tartrate/caffeine 1 1 1B QL1 1D.H.E.45 dihydroergotamine mesylate 1 1 1B QL1 1Esgic; Fioricet 50/325/40mg butalb/acetaminophen/caffeine 1 1 1B QL1 1Fioricet 50/300/40mg butalb/acetaminophen/caffeine 1 1 1B PA, QL1 1Fioricet w/codeine 50/300/30mg butalbit/acetamin/caff/codeine 1 1 1BQL PA, QL1 1Fioricet w/codeine 50/325/30mg butalbit/acetamin/caff/codeine 1 1 1BQL QL1 1Fiorinal butalbital/aspirin/caffeine 1 1 1B1 1Fiorinal w/codeine codeine/butalbital/asa/caffein 1 1 1BQL QL1 1Frova frovatriptan succinate 1 1 1BST, QL ST, QL1 1Imitrex sumatriptan succinate 1 1 1BQL QL1 1Imitrex nasal spray sumatriptan 1 1 1BQL QL1 1Maxalt, MLT rizatriptan benzoate 1 1 1BQL QL1 1Migergot ergotamine tartrate/caffeine 1 1 1B1 1Migranal dihydroergotamine mesylate 1 1 1BQL QL1 1Phrenilin tablet butalbital/acetaminophen 1 1 1B1 1Relpax eletriptan hbr 1 1 1BST, QL ST, QL1 1Zomig nasal spray 3 3 3ST, QL ST, QL3 3Zomig, ZMT zolmitriptan 1 1 1BST, QL QL1 1


3H. Myasthenia gravis BCN (HMO)BCBSM (PPO)Trade name Generic name

Mestinon syrup 2 2 22 2Mestinon, Timespan pyridostigmine bromide 1 1 1B1 1



rev. 2


3I. Narcotic antagonists BCN (HMO)BCBSM (PPO)Trade name Generic name

Naloxone hcl injection naloxone hcl 1 1 1B1 1Narcan nasal spray 2 2 2QL QL2 2Revia naltrexone hcl 1 1 1B1 1


3J. Narcotic mixed agonist and antagonist BCN (HMO)BCBSM (PPO)Trade name Generic name

Bunavail 3 3 3QL3 3Buprenorphine patch 2 2 2QL QL2 2Butrans 2 2 2QL QL2 2Ryzolt tramadol hcl 1 1 1BQL QL1 1Stadol NS butorphanol tartrate 1 1 1BQL QL1 1Suboxone buprenorphine hcl/naloxone hcl 1 1 1BQL1 1Suboxone film 2 2 2QL2 2Subutex buprenorphine hcl 1 1 1BPA, QL PA, QL1 1Talwin NX pentazocine hcl/naloxone hcl 1 1 1BQL QL1 1Ultracet tramadol hcl/acetaminophen 1 1 1BQL QL1 1Ultram, ER tramadol hcl 1 1 1BQL QL1 1Zubsolv 3 3 3QL3 3


3K. Narcotic and analgesic combinations BCN (HMO)BCBSM (PPO)Trade name Generic name

Esgic; Fioricet 50/325/40mg butalb/acetaminophen/caffeine 1 1 1B QL1 1Fioricet 50/300/40mg butalb/acetaminophen/caffeine 1 1 1B PA, QL1 1Fioricet w/codeine 50/300/30mg butalbit/acetamin/caff/codeine 1 1 1BQL PA, QL1 1Fioricet w/codeine 50/325/30mg butalbit/acetamin/caff/codeine 1 1 1BQL QL1 1Fiorinal butalbital/aspirin/caffeine 1 1 1B1 1Fiorinal w/codeine codeine/butalbital/asa/caffein 1 1 1BQL QL1 1Hycet hydrocodone/acetaminophen 1 1 1BQL QL1 1Norco; Vicodin; Xodol hydrocodone/acetaminophen 1 1 1BQL QL1 1Percocet oxycodone hcl/acetaminophen 1 1 1BQL QL1 1Percodan oxycodone hcl/aspirin 1 1 1BQL QL1 1Phrenilin tablet butalbital/acetaminophen 1 1 1B1 1Tylenol w/codeine acetaminophen with codeine 1 1 1BQL QL1 1Tylenol w/codeine solution acetaminophen with codeine 1 1 1BQL QL1 1Vicoprofen hydrocodone/ibuprofen 1 1 1BQL QL1 1



rev. 2


3L. Narcotics BCN (HMO)BCBSM (PPO)Trade name Generic name

Actiq fentanyl citrate 1 1 1BPA, QL PA, QL1 1Belladonna & Opium opium/belladonna alkaloids 1 1 1BQL QL1 1Codeine sulfate tablet codeine sulfate 1 1 1BQL QL1 1Dilaudid hydromorphone hcl 1 1 1BQL QL1 1Duragesic fentanyl 1 1 1BQL QL1 1Exalgo hydromorphone hcl 1 1 1BQL PA, QL1 1Levorphanol Tartrate levorphanol tartrate 1 1 1BQL QL1 1Methadone methadone hcl 1 1 1BQL QL1 1MS Contin morphine sulfate 1 1 1BQL QL1 1MSIR morphine sulfate 1 1 1BQL QL1 1Nucynta, ER 3 3 3PA, QL PA, QL3 3Oxycodone hcl ER 3 3 3PA, QL PA, QL3 3Oxycodone immediate release, solution

oxycodone hcl 1 1 1BQL QL1 1

Oxycontin 3 3 3PA, QL PA, QL3 3RMS Suppository morphine sulfate 1 1 1BQL QL1 1Roxanol morphine sulfate 1 1 1BQL QL1 1Zohydro ER 3 3 3PA, QL PA, QL3 3


3M. Nonsteroidal anti-inflammatory drugs BCN (HMO)BCBSM (PPO)Trade name Generic name

Anaprox, DS naproxen sodium 1 1 1A1 1Ansaid flurbiprofen 1 1 1B1 1Cataflam diclofenac potassium 1 1 1B1 1Celebrex celecoxib 1 1 1B1 1Clinoril sulindac 1 1 1B1 1Daypro oxaprozin 1 1 1B1 1EC-Naproxyn naproxen 1 1 1A1 1Feldene piroxicam 1 1 1B1 1Indocin, SR indomethacin 1 1 1B1 1Indocin suppository 2 2 22 2Indocin suspension 3 3 33 3Ketoprofen ketoprofen 1 1 1B1 1Lodine, XL etodolac 1 1 1B1 1Meclomen meclofenamate sodium 1 1 1B1 1Mobic meloxicam 1 1 1A1 1Motrin (Rx Only) ibuprofen 1 1 1A1 1Nalfon 600mg fenoprofen calcium 1 1 1B1 1Naprosyn (Rx Only) naproxen 1 1 1A1 1Relafen nabumetone 1 1 1B1 1Tolectin, DS tolmetin sodium 1 1 1B1 1Toradol injection ketorolac tromethamine 1 1 1B1 1Toradol tablet ketorolac tromethamine 1 1 1BQL QL1 1Voltaren gel diclofenac sodium 1 1 1BQL QL1 1Voltaren tablet diclofenac sodium 1 1 1A1 1Voltaren-XR diclofenac sodium 1 1 1B1 1



rev. 2


3N. Parkinsons disease and related disorders BCN (HMO)BCBSM (PPO)Trade name Generic name

Apokyn 2 4 44 4Artane trihexyphenidyl hcl 1 1 1B1 1Azilect rasagiline mesylate 1 1 1B1 1Cogentin benztropine mesylate 1 1 1B1 1Comtan entacapone 1 1 1B1 1Duopa 2 4 4PA, QL PA, QL4 4Eldepryl selegiline hcl 1 1 1B1 1Lodosyn carbidopa 1 1 1B1 1Mirapex immediate-release pramipexole di-hcl 1 1 1B1 1Nuplazid 3 3 3PA, QL PA, QL3 3Parcopa carbidopa/levodopa 1 1 1B1 1Parlodel bromocriptine mesylate 1 1 1B1 1Requip, XL ropinirole hcl 1 1 1B1 1Sinemet, CR carbidopa/levodopa 1 1 1B1 1Stalevo carbidopa/levodopa/entacapone 1 1 1B1 1Symmetrel amantadine hcl 1 1 1B1 1Tasmar tolcapone 1 1 1B1 1Xadago 3 3 3QL QL3 3


3O. Salicylates BCN (HMO)BCBSM (PPO)Trade name Generic name

Aspirin; Ecotrin 81mg, 325mg (OTC) (Prevent)

aspirin $0 $0 $0$0 $0

Disalcid salsalate 1 1 1B1 1Dolobid diflunisal 1 1 1B1 1


3P. Sedative and hypnotics BCN (HMO)BCBSM (PPO)Trade name Generic name

Ambien zolpidem tartrate 1 1 1BQL QL1 1Ambien CR zolpidem tartrate 1 1 1BQL QL1 1Dalmane flurazepam hcl 1 1 1BQL QL1 1Halcion triazolam 1 1 1BQL QL1 1Hetlioz 3 5 5PA, QL PA, QL4 4Lunesta eszopiclone 1 1 1BQL QL1 1Prosom estazolam 1 1 1BQL QL1 1Restoril temazepam 1 1 1BQL QL1 1Rozerem 3 3 3ST, QL ST, QL3 3Sonata zaleplon 1 1 1BQL QL1 1Versed syrup midazolam hcl 1 1 1B1 1



rev. 2


3Q. Skeletal muscle relaxants BCN (HMO)BCBSM (PPO)Trade name Generic name

Baclofen baclofen 1 1 1B1 1Dantrium dantrolene sodium 1 1 1B1 1Flexeril cyclobenzaprine hcl 1 1 1B1 1Lorzone 3 3 33 3Norflex orphenadrine citrate 1 1 1B1 1Parafon Forte DSC 500mg chlorzoxazone 1 1 1B1 1Robaxin methocarbamol 1 1 1B1 1Skelaxin metaxalone 1 1 1B PA1 1Soma carisoprodol 1 1 1B PA, QL1 1Valium diazepam 1 1 1B1 1Zanaflex capsule tizanidine hcl 1 1 1B PA1 1Zanaflex tablet tizanidine hcl 1 1 1B1 1


3R. Miscellaneous CNS BCN (HMO)BCBSM (PPO)Trade name Generic name

Antabuse disulfiram 1 1 1B1 1Austedo 3 5 5PA, QL PA, QL4 4Cafcit caffeine citrate 1 1 1B1 1Campral acamprosate calcium 1 1 1B1 1Cuvposa 3 3 33 3Ergoloid Mesylates ergoloid mesylates 1 1 1B1 1Eskalith, CR; Lithobid lithium carbonate 1 1 1A1 1Guanidine hcl guanidine hcl 1 1 1B1 1Ingrezza 3 5 5PA, QL PA, QL4 4Kapvay clonidine hcl 1 1 1BQL QL1 1Lithium Citrate lithium citrate 1 1 1B1 1Nimotop nimodipine 1 1 1B1 1Nuedexta 2 2 2PA, QL PA, QL2 2Nymalize 3 3 3QL QL3 3Rilutek riluzole 1 1 1B1 1Savella 3 3 3PA, QL PA, QL3 3Savella dose pack 3 3 3PA PA, QL3 3Strattera atomoxetine hcl 1 1 1B QL1 1Xenazine tetrabenazine 1 4 4PA, QL PA, QL4 4Xyrem 3 5 5PA, QL PA, QL4 4



rev. 2

4. Gastrointestinal agents


4A. 5-Aminosalicylic Acid (5-ASA) agents BCN (HMO)BCBSM (PPO)Trade name Generic name

Apriso 3 3 33 3Asacol HD 2 2 22 2Azulfidine, EN-tab sulfasalazine 1 1 1B1 1Canasa 2 2 22 2Colazal balsalazide disodium 1 1 1B1 1Delzicol 2 2 22 2Dipentum 3 3 33 3Giazo 3 3 3ST, QL QL3 3Lialda mesalamine 1 1 1B QL1 1Mesalamine ER tablet 3 3 33 3Pentasa 2 2 22 2SfRowasa enema mesalamine 1 1 1B1 1


4B. Antidiarrheals and antispasmodics BCN (HMO)BCBSM (PPO)Trade name Generic name

Bentyl dicyclomine hcl 1 1 1B1 1Levbid hyoscyamine sulfate 1 1 1B1 1Levsin, SL hyoscyamine sulfate 1 1 1B1 1Librax chlordiazepoxide/clidinium br 1 1 1B1 1Lomotil diphenoxylate hcl/atropine 1 1 1B1 1Mytesi 2 2 2PA, QL PA, QL2 2


4C. Antiemetics BCN (HMO)BCBSM (PPO)Trade name Generic name

Akynzeo 3 3 3PA, QL PA, QL3 3Anzemet 3 3 3 QL3 3Cesamet 3 3 33 3Compazine suppository prochlorperazine 1 1 1B1 1Compazine tablet prochlorperazine maleate 1 1 1B1 1Emend 40mg aprepitant 1 1 1B1 1Emend 80mg, 125mg, 125mg-80mg aprepitant 1 1 1B QL1 1Emend suspension 2 2 2ST, QL QL2 2Kytril granisetron hcl 1 1 1B QL1 1Marinol dronabinol 1 1 1B1 1Phenergan promethazine hcl 1 1 1B1 1Sancuso 3 3 3PA, QL ST, QL3 3Tigan trimethobenzamide hcl 1 1 1B1 1Transderm-Scop scopolamine 1 1 1B1 1Zofran ondansetron hcl 1 1 1B1 1Zofran ODT ondansetron 1 1 1B1 1



rev. 2


4D. Bile acids BCN (HMO)BCBSM (PPO)Trade name Generic name

Actigall ursodiol 1 1 1B1 1Chenodal 3 5 5PA PA4 4Ocaliva 2 4 4PA, QL PA, QL4 4Urso; Forte ursodiol 1 1 1B1 1


4E. Bowel preparation and cleansing agents BCN (HMO)BCBSM (PPO)Trade name Generic name

Bisacodyl OTC (Prevent) bisacodyl $0 $0 $0QL QL$0 $0Citrate of Magnesia OTC (Prevent) magnesium citrate $0 $0 $0QL QL$0 $0Colyte (Prevent) peg3350/sod sulf,bicarb,cl/kcl $0 $0 $0QL QL$0 $0Colyte peg3350/sod sulf,bicarb,cl/kcl 1 1 1B1 1Glycolax (Prevent) polyethylene glycol 3350 $0 $0 $0QL QL$0 $0Glycolax polyethylene glycol 3350 1 1 1B1 1Glycolax OTC (Prevent) polyethylene glycol 3350 $0 $0 $0QL QL$0 $0Golytely (Prevent) peg 3350/na sulf,bicarb,cl/kcl $0 $0 $0QL QL$0 $0Golytely peg 3350/na sulf,bicarb,cl/kcl 1 1 1B1 1Golytely flavored 2 2 22 2Halflytely-Bisacodyl (Prevent) bisac/nacl/nahco3/kcl/peg 3350 $0 $0 $0QL QL$0 $0Halflytely-Bisacodyl bisac/nacl/nahco3/kcl/peg 3350 1 1 1B QL1 1Milk of Magnesia OTC (Prevent) magnesium hydroxide $0 $0 $0QL QL$0 $0Moviprep 3 3 33 3Nulytely (Prevent) sodium chloride/nahco3/kcl/peg $0 $0 $0QL QL$0 $0Nulytely sodium chloride/nahco3/kcl/peg 1 1 1B1 1Oral Saline Laxative liquid OTC(Prevent)

sodium phosphate,mono-dibasic $0 $0 $0QL QL$0 $0

Suprep 3 3 33 3


4F. Digestive enzymes BCN (HMO)BCBSM (PPO)Trade name Generic name

Creon 2 2 22 2Zenpep 2 2 22 2


4G. H2-Receptor antagonists BCN (HMO)BCBSM (PPO)Trade name Generic name

Axid (Rx only) nizatidine 1 1 1B1 1Pepcid (Rx Only) famotidine 1 1 1B1 1Tagamet (Rx only) cimetidine 1 1 1B1 1Tagamet liquid (Rx only) cimetidine hcl 1 1 1B1 1Zantac (Rx Only) ranitidine hcl 1 1 1B1 1



rev. 2


4H. Proton Pump Inhibitors (PPI) BCN (HMO)BCBSM (PPO)Trade name Generic name

Aciphex tablet rabeprazole sodium 1 1 1B1 1Nexium suspension 3 3 3ST PA3 3Prevacid capsule (Rx Only) lansoprazole 1 1 1BQL1 1Prilosec capsule (Rx Only) omeprazole 1 1 1BQL1 1Protonix tablet pantoprazole sodium 1 1 1BQL1 1


4I. Topical anti-Inflammatory agents BCN (HMO)BCBSM (PPO)Trade name Generic name

Analpram-HC 1-1% cream 2 2 22 2Analpram-HC cream 2.5-1%, 1-1% hydrocortisone/pramoxine 1 1 1B1 1Anamantle HC cream with applicator

lidocaine/hydrocortisone ac 1 1 1B1 1

Cortenema hydrocortisone 1 1 1B1 1Cortifoam 3 3 33 3Epifoam 2 2 22 2Pramosone cream hydrocortisone/pramoxine 1 1 1B1 1Proctocort hydrocortisone 1 1 1B1 1Proctocort suppository hydrocortisone acetate 1 1 1B1 1Proctofoam-HC 2 2 22 2Procto-Pak hydrocortisone 1 1 1B1 1Proctosol-HC suppository hydrocortisone acetate 1 1 1B1 1


4J. Tumor Necrosis Factor (TNF) blocking agents BCN (HMO)BCBSM (PPO)Trade name Generic name

Cimzia syringe 3 5 5PA, QL PA, QL4 4Humira 2 4 4PA, QL QL4 4Simponi 3 5 5PA, QL PA, QL4 4


4K. Ulcer therapy BCN (HMO)BCBSM (PPO)Trade name Generic name

Carafate sucralfate 1 1 1B1 1Carafate suspension 2 2 22 2Cytotec misoprostol 1 1 1B1 1Pamine, Forte methscopolamine bromide 1 1 1B1 1Pro-Banthine propantheline bromide 1 1 1B1 1Robinul tablet, Forte glycopyrrolate 1 1 1B1 1



rev. 2


4L. Miscellaneous gastrointestinal agents BCN (HMO)BCBSM (PPO)Trade name Generic name

Amitiza 2 2 2 QL2 2Evoxac cevimeline hcl 1 1 1B1 1Gastrocrom cromolyn sodium 1 1 1B1 1Gattex 2 4 4PA, QL PA, QL4 4Lactulose lactulose 1 1 1B1 1Linzess 2 2 2QL QL2 2Lotronex alosetron hcl 1 1 1B QL1 1Rectiv 3 3 3QL QL3 3Reglan metoclopramide hcl 1 1 1B1 1Salagen pilocarpine hcl 1 1 1B1 1Stelara 2 4 4PA, QL PA, QL4 4Sucraid 3 5 54 4Xifaxan 200mg 3 3 3 QL3 3Xifaxan 550mg 3 3 3PA, QL PA, QL3 3Zorbtive 3 5 5PA PA4 4



rev. 2

5. Obstetrics and gynecology


5A. Contraceptives-Biphasic BCN (HMO)BCBSM (PPO)Trade name Generic name

Lo Loestrin Fe 3 3 33 3Loseasonique (Prevent) l-norgest/e.estradiol-e.estrad $0 $0 $0QL$0 $0Mircette (Prevent) desog-e.estradiol/e.estradiol $0 $0 $0$0 $0Seasonique (Prevent) l-norgest/e.estradiol-e.estrad $0 $0 $0QL$0 $0


5B. Contraceptives-Misc. BCN (HMO)BCBSM (PPO)Trade name Generic name

Conceptrol (Prevent) $0 $0 $0QL$0 $0Depo-Provera 150mg (Prevent) medroxyprogesterone acetate $0 $0 $0$0 $0Depo-subq Provera 104 2 2 22 2FC2 female condom (Prevent) $0 $0 $0QL$0 $0Gynol II (Prevent) nonoxynol 9 $0 $0 $0QL$0 $0Natazia 3 3 33 3Nuvaring (Prevent) $0 $0 $0QL QL$0 $0Ortho Evra (Prevent) norelgestromin/ethin.estradiol $0 $0 $0QL QL$0 $0Ortho Micronor; Nor-QD (Prevent) norethindrone $0 $0 $0$0 $0Quartette (Prevent) l-norgest-eth estr/ethin estra $0 $0 $0QL$0 $0Safyral 3 3 33 3Today contraceptive sponge(Prevent)

$0 $0 $0QL$0 $0

VCF film, gel (Prevent) $0 $0 $0QL$0 $0VCF foam (Prevent) nonoxynol 9 $0 $0 $0QL$0 $0



rev. 2


5C. Contraceptives-Monophasic BCN (HMO)BCBSM (PPO)Trade name Generic name

Alesse; Levlite (Prevent) levonorgestrel-ethin estradiol $0 $0 $0$0 $0Beyaz (Prevent) drospir/eth estra/levomefol ca $0 $0 $0$0 $0Demulen (Prevent) ethynodiol d-ethinyl estradiol $0 $0 $0$0 $0Desogen; Ortho-cept (Prevent) desogestrel-ethinyl estradiol $0 $0 $0$0 $0Femcon Fe (Prevent) noreth-ethinyl estradiol/iron $0 $0 $0$0 $0Generess Fe (Prevent) noreth-ethinyl estradiol/iron $0 $0 $0$0 $0Levlen; Nordette (Prevent) levonorgestrel-ethin estradiol $0 $0 $0$0 $0Lo/Ovral (Prevent) norgestrel-ethinyl estradiol $0 $0 $0$0 $0Loestrin (Prevent) norethindrone ac-eth estradiol $0 $0 $0$0 $0Loestrin 24 Fe (Prevent) norethindrone-e.estradiol-iron $0 $0 $0$0 $0Loestrin Fe (Prevent) norethindrone-e.estradiol-iron $0 $0 $0$0 $0Lybrel (Prevent) levonorgestrel-ethin estradiol $0 $0 $0$0 $0Minastrin 24 FE (Prevent) norethindrone-e.estradiol-iron $0 $0 $0$0 $0Modicon (Prevent) norethindrone-ethinyl estrad $0 $0 $0$0 $0Norinyl 1/35; Ortho-novum 1/35(Prevent)

norethindrone-ethinyl estrad $0 $0 $0$0 $0

Ortho-Cyclen (Prevent) norgestimate-ethinyl estradiol $0 $0 $0$0 $0Ovcon 35 (Prevent) norethindrone-ethinyl estrad $0 $0 $0$0 $0Ovral (Prevent) norgestrel-ethinyl estradiol $0 $0 $0$0 $0Seasonale (Prevent) levonorgestrel-ethin estradiol $0 $0 $0QL$0 $0Taytulla 3 3 33 3Yasmin 28 (Prevent) ethinyl estradiol/drospirenone $0 $0 $0$0 $0Yaz (Prevent) ethinyl estradiol/drospirenone $0 $0 $0$0 $0

Limits Limits5-Tier3-Tier 4-