2016 Formulary Exclusion List for Preferred Formulary
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1 2016 Formulary Exclusion List for Preferred Formulary The medications shown below are not covered on the 2016 Preferred Formulary. An exclusion does not mean you cannot have a particular drug. It simply means that no benefits will be provided, and you will be responsible for the total cost of the drug. Take action to avoid paying full price. If you re currently using one of the excluded medications, please ask your provider to consider writing you a new prescription for one of the following preferred alternatives. Excluded Absorica Aciphex, Aciphex Sprinkle Acticlate Acuvail acyclovir ointment* Adynovate Adzenys XR-ODT Akynzeo alogliptin alogliptin-metformin alogliptin-pioglitazone Alvesco amphetamine mix ER* Amrix Analpram E Aplenzin Aptensio XR Asacol HD Axert Axiron Beconase AQ Belbuca Belsomra Besivance Bethkis Brintellix Brisdelle Bulk Powders/Select Bulk Chemicals buprenorphine hcl Cambia Carac Cetraxal Claravis, Myorisan, Zenatane doxycycline hyclate ketorolac, Prolensa Zovirax ointment amphetamine mix ER**, Adderall XR granisetron, ondansetron, Anzemet Januvia, Tradjenta Janumet, Jentadueto Januvia or Tradjenta plus pioglitazone Arnuity Ellipta, Asmanex HFA, Flovent HFA, Qvar Adderall XR cyclobenzaprine oral tablet hydrocortisone-pramoxine bupropion XL methylphenidate ER**, Concerta Apriso, Lialda, Pentasa budesonide, flunisolide, fluticasone proprionate buprenorphine/naloxone, Bunavail, Suboxone, Zubsolv eszopiclone, zaleplon, zolpidem oral tablet, zolpidem ER oral tablet Moxeza, Vigamox SPRx tobramycin ampules, Tobi, TobiPodhaler generic SSRI paroxetine hcl buprenorphine/naloxone, Bunavail, Suboxone, Zubsolv diclofenac oral tablet fluorouracil 2% topical solution or 5% topical cream ciprofloxacin otic solution
2 Clindacin Pac, Clindacin ETZ Kit colchicine (single source) Comfort Pac-Cyclobenzaprine Comfort Pac-Ibuprofen Comfort Pac-Meloxicam Comfort Pac-Tizanidine Conzip Cosentyx Cuprimine Daklinza Dapsone (multi source) Delzicol desvenlafaxine ER (single source) Dexilant Diclegis Doryx doxycycline IR-DR Duexis Dyanavel XR Dymista Ecoza Edluar Egrifta Eligen B12 Eloctate Embeda Emverm Enstilar Envarsus XR esomeprazole strontium Evekeo Evzio Exalgo fenofibrate 50 mg and 150 mg capsule (single source) fenofibrate 40 mg and 120 mg tablet (single source) fentanyl patch 37.5/62.5/87.5 mcg Fetzima Flonase Forfivo XL Fortesta Frova Glumetza clindamycin topical Colcrys, Uloric cyclobenzaprine oral tablet ibuprofen oral tablet meloxicam oral tablet tizanidine oral tablet tramadol, tramadol ER Enbrel, Humira Depen Harvoni dapsone (generic) Apriso, Lialda, Pentasa generic SSRI, generic SNRI, Pristiq OTC doxylamine plus OTC pyridoxine doxycycline hyclate, doxycycline monohydrate doxycycline hyclate, doxycycline monohydrate OTC ibuprofen plus OTC famotidine amphetamine mix ER**, Adderall XR budesonide, flunisolide, fluticasone proprionate econazole nitrate zolpidem oral tablet cyanocobalamin morphine sulfate CR/ER/SR, Nucynta ER, Opana ER, Oxycontin Albenza, ivermectin calcipotriene-betamethasone dipropionate ointment tacrolimus oral capsule, Astagraf XL SPRx amphetamine mix ER**, Adderall XR naloxone hydromorphone IR QL (generic) fenofibrate 67 mg, 134 mg, 200 mg capsule (generic) fenofibrate 48 mg, 54 mg, 145 mg, and 160 mg tablet fentanyl patch 12/25/50/75/100 mcg generic SSRI, generic SNRI budesonide, flunisolide, fluticasone proprionate bupropion XL metformin hcl (generic Glucophage), metformin hcl ER (generic Glucophage XR)
3 Gralise Growth Hormone (including, but not limited to: Genotropin, Humatrope, Nutropin, and Omnitrope) Hemangeol Hetlioz hydromorphone ER Hysingla ER Ilevro Incruse Ellipta Intermezzo Irenka Ixinity Jardiance Jublia Karbinal ER Kazano Kerydin Khedezla Kitabis Pak Kombiglyze XR Kovaltry Lamisil oral granules Latisse Lazanda Letairis Lorzone Lovaza Luzu Maxalt MLT Medical Foods/Nutritional Supplements Metaxall metaxalone 400 mg metformin hcl ER (generic Glumetza) methylphenidate ER* Metozolv ODT, metoclopramide hcl ODT Migralam Minocin, minocycline ER Mirvaso Mitigare Monodox Morgidox gabapentin Norditropin propranolol oral solution OTC melatonin hydromorphone IR QL hydrocodone-apap QL bromfenac, Prolensa Spiriva, Tudorza Pressair zaleplon, zolpidem oral tablet, zolpidem ER oral tablet duloxetine oral capsule BeneFIX SPRx Farxiga, Invokana ciclopirox topical solution carbinoxamine maleate Janumet, Jentadueto ciclopirox topical solution generic SSRI, generic SNRI SPRx tobramycin ampules, Tobi, TobiPodhaler Janumet XR Helixate SPRx, Recombinate SPRx terbinafine oral tablet fentanyl lozenge QL Tracleer PA SPRx, Opsumit chlorzoxazone OTC fish oil, fenofibrate, gemfibrozil econazole nitrate metaxalone 800 mg oral tablet metaxalone 800 mg oral tablet metformin hcl (generic Glucophage), metformin hcl ER (generic Glucophage XR) Concerta metoclopramide oral tablet isometheptene-caffeine-apap minocycline IR Finacea, topical metronidazole Colcrys, Uloric doxycycline monohydrate doxycycline hyclate
4 Movantik Amitiza Moxatag amoxicillin Narcan naloxone Nasacort AQ Nascobal cyanocobalamin Nasonex Natesto Nesina Januvia, Tradjenta Nevanac bromfenac, Prolensa Novoeight Nymalize nimodipine Obizur Oleptro ER trazodone Olysio Harvoni, Sovaldi omega-3 acid ethyl esters OTC fish oil, fenofibrate, gemfibrozil omeprazole-sodium bicarbonate Omnaris Onexton Acanya, benzoyl peroxide/clindamycin Onglyza Januvia, Tradjenta Oracea doxycycline hyclate, doxycycline monohydrate Oseni Januvia or Tradjenta plus pioglitazone Otrexup methotrexate oxycodone hcl ER (single source) Oxycontin QL Pancreaze Creon, Zenpep Pediaderm HC OTC hydrocortisone cream Pennsaid diclofenac oral tablet Pertzye Creon, Zenpep Prescription Drugs With Over The Counter (OTC) Equivalents Prodrin isometheptene-caffeine-apap Provigil modafinil PA, Nuvigil PA Prumyx OTC moisturizers and emollients Qnasl/Qnasl Children QuilliChew ER methylphenidate ER**, Concerta rabeprazole sodium Rasuvo methotrexate Rayos prednisone Rectiv nitroglycerin ointment Regimex diethylpropion, phendimetrazine, phentermine Rexulti PA all aripiprazole, risperidone, quetiapine Rhinocort Aqua Ribasphere Ribapak ribavirin, Ribasphere Rytary carbidopa/levodopa ER Sancuso granisetron oral tablet Savaysa Eliquis, Pradaxa, Xarelto PA all #
5 Seebri Neohaler Select Single Source Brand Generics Sernivo Silenor Sitavig Sivextro Sklice sodium sulfacetamide 10% cleanser gel sodium sulfacetamide-s 9/4.5% kit Solodyn Soolantra Strensiq Subsys Sumadan Sumaxin CP Kit Synjardy Tanzeum Technivie Terbinex Testim Tirosint Tivorbex Toviaz Tresiba Flextouch U-100, U-200 Tretinoin Microsphere* Tretten Treximet triamcinolone acetonide nasal spray Trulicity Uptravi Uta Utibron Neohaler Varubi Vascepa Vecamyl Veltassa Veltin Veramyst Versacloz Viberzi Spiriva, Tudorza Pressair betamethasone dipropionate cream/lotion/ointment doxepin acyclovir, famciclovir, valacyclovir linezolid QL Lindane sodium sulfacetamide 10% cleanser, sodium sulfacetamide 10% shampoo sodium sulfacetamide-s 9/4.5% cleanser/cream/lotion, sodium sulfacetamide-s 10/5% cleanser/cream/lotion minocycline hcl Finacea, topical metronidazole fentanyl lozenge QL sodium sulfacetamide-s 9/4.5% cleanser/cmb Cln Cr sodium sulfacetamide-s 9/4.5% cleanser/cream/lotion, sodium sulfacetamide-s 10/5% cleanser/cream/lotion, sodium sulfacetamide-s 10/4% medicated pad Farxiga or Invokana plus metformin Bydureon, Byetta, Victoza Harvoni terbinafine oral tablet levothyroxine, Levoxyl, Synthroid indomethacin oral capsule darifenacin ER, oxybutynin, oxybutynin ER, Vesicare Lantus, Levemir Retin-A Micro, Retin-A Micro Pump, Xyntha SPRx sumatriptan QL plus naproxen Byetta, Bydureon, Victoza Orenitram ER Uretron D-S, Urimar, Ustell Arcapta Neohaler, Brovana, Perforomist Emend oral capsule OTC fish oil, fenofibrate, gemfibrozil generic ACE inhibitor, ARB, beta blocker, or calcium channel blocker sodium polystyrene sulfonate topical clindamycin & tretinoin clozapine PA Xifaxan
6 Viekira Pak Viibryd Vimovo Vituz Vivlodex Vogelxo Vraylar Xartemis XR Xerese Zecuity Zegerid Zembrace Symtouch Zetonna Ziana Zipsor Zohydro ER zolpidem SL tablet Zolpimist Zomig, Zomig ZMT Zorbtive Zorvolex Zuplenz Zyflo, Zyflo CR Zymaxid Zypram Harvoni, Sovaldi generic SSRI naproxen & OTC Nexium (esomeprazole) hydrocodone/ chlorpheniramine meloxicam oral tablet PA all aripiprazole, risperidone, ziprasidone oxycodone-apap QL Zovirax topical & OTC hydrocortisone sumatriptan oral tablet/injection sumatriptan oral tablet/injection topical clindamycin and tretinoin diclofenac potassium oral tablet hydrocodone-apap QL zaleplon, zolpidem oral tablet, zolpidem ER oral tablet zaleplon, zolpidem oral tablet, zolpidem ER oral tablet Gattex diclofenac sodium oral tablet ondansetron oral tablet montelukast, zafirlukast Moxeza, Vigamox hydrocortisone acetate-pramoxine Legend * Does not apply to co-insurance plans. ** Does not apply to copay plans. # May not be covered by your plan. Check with customer service to determine coverage. PA This drug requires prior authorization. ST Requires other selected drugs to be tried first. QL This drug has quantity limits on amount covered. SPRx Specialty drug. Many plans require you to get this type of drug from a preferred Specialty Pharmacy. Remember: You or your physician may appeal the denial of a drug benefit by faxing supportive documents and information to Please refer to your EOC or member handbook for more information on your grievance rights. Please note that this list is not all-inclusive and is subject to change throughout the year.
7 This list is subject to change throughout the year. Please call Member Service at the phone number listed on your BlueCross BlueShield of Tennessee member ID card or visit our website at bcbst.com for the most up-to-date information. Spanish: Para obtener ayuda en español, llame al Tagalog: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese: 如果需要中文的帮助, 请拨打这个号码 Navajo: Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' BlueCross does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN bcbst.com BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association 15PHM3720 (04/16) Preferred Formulary Exclusion List
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$0 See the chart starting on page 2 for your costs for services this plan covers.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthfirstny.org or by calling 1-888-250-2220. Important
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthfirstny.org or by calling 1-888-250-2220. Important
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UMP Classic 2015 High Cost Generic Tier 2 Drug Program
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Monthly Copays. Medications must be tried for 30 days before ordering through Aspire Indiana CanaRx.
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$4, 30-day $10, 90-day
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Are there other deductibles for specific services?
Blue Shield of CA Life & Health Active Choice Plan 750 Coverage Period: 04/01/2015-03/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan
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$0. See the chart starting on page 2 for your costs for services this plan covers.
San Francisco Electrical Workers Custom HMO Coverage Period: 08/01/2015-07/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: HMO
Alyeska Pipeline Service Company: Consumer Choice Medical Plan Coverage Period: 03/01/2016-02/28/2017
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BCBS Premier 1, a Multi-State Plan Coverage Period: 01/01/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Important Questions What is the overall deductible? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsmt.com/pages/policyforms.aspx
HMO 3000b Silver Coverage Period: 01/01/2016-12/31/2016
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Enhanced Exclusive HMO for Small Business $55 Coverage Period: Beginning On or After 1/1/2014
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Kaiser Permanente: KP CA Silver 1250/40
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LifeWise: LifeWise Oregon Standard Gold Plan 1300 Coverage Period: 1/1/2015-12/31/2015
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Physicians Plus Insurance Corporation Coverage Period: 2015 Summary of Benefits and Coverage: WPE Traditional Uniform Benefits Plan Code: EHSTWWPE
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020. Important Questions
Highmark Health Insurance Company: Comprehensive Care Blue PPO 500
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.highmarkblueshield.com or by calling 1-888-510-1064.
The Ohio State University: Basic PPO Plan Coverage Period: 01/01/2015 12/31/2015
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at hr.osu.edu/hrpubs/ben/medicalspd.pdf or by calling 614-292-1050