2016 BlueChoice Healthlan rescription Drug List Important Information About This List This is not a comprehensive list of all drugs covered under your prescription drug benefit. Not all benefit plans cover all drugs listed here. To find more information about a drug not on this list or to verify how coverage of a certain drug applies to you, please log into My Health Toolkit and use the Drug Coverage and Cost Tool. You can also refer to your plan materials for more information about coverage exceptions, limitations, etc. Drug Exclusions: We cover most drugs under your pharmacy benefit. We currently exclude the drugs Adynovate, Coagadex, Cotellic, Daklinza, Darzalex, Genvoya, Harvoni, Imlygic, Jublia, Kerydin, Ninlaro, Nucala, Nuwiq, Onivyde, raluent, Repatha, Strensiq, Tagrisso, Technivie, Tresiba, Varubi, Veltassa and Yondelis, from coverage. The list of excluded drugs is subject to change at any time. Your benefit plan may include the right for you, your doctor or another person of your choosing to request that we cover an excluded drug based on medical necessity. To find out more about requesting a formulary exception for an excluded drug, please contact Member Services at 800-868-2528. Additionally, your pharmacy benefit also may not cover certain categories of drugs, such as those for weight loss or drugs to treat impotence. lease check your plan materials for more details about coverage for a specific drug category. Copayments harmacy benefits cover prescription drugs at three levels. They are generic (), preferred (Tier 2) and non-preferred (Tier 3). drugs typically have the lowest copayment. This category includes most generic drugs and covered over-the-counter (OTC) drugs. Many members have a two-tier generic benefit. drugs costing more than $15 have a low Standard generic copayment. drugs that cost less than $15 and OTC drugs have the lowest Value generic copayment. referred drugs are generally brand drugs that have the middle copayment. Non-preferred drugs are brand-name drugs and occasionally, highpriced generic drugs, which have the highest copayment. We assign these levels based on cost, availability of a generic substitute and clinical value. Drugs may change levels at any time during the year without prior notice. These changes usually occur when new drugs become available. We do not cover specific lifestyle medications under the pharmacy benefit. Some examples of these types of drugs include those for: The treatment of hair loss Sexual dysfunction Weight loss Skin pigmentation treatments Members can get these types of drugs at a discounted price by presenting their prescription and member ID cards at network pharmacies. Quantity The BlueChoice harmacy and Therapeutics Committee is made up of doctors and pharmacists. The Committee sets maximum-allowed amounts for certain prescription drugs. It bases the amounts on U.S. Food and Drug Administration (FDA) prescribing guidelines and available package sizes. As a result, we limit coverage for some drugs to a certain quantity within a certain period of time. In this drug list, you will see QL next to drugs with quantity limits. Unless otherwise noted, one month equals a 31-day supply.
rior Authorization Doctors must get prior authorization for certain drugs. This helps make sure the drugs are used according to their product labeling. We base the need for prior authorization on current FDA guidelines. We also base it on clinical decisions from the BlueChoice harmacy and Therapeutics Committee. Before a doctor prescribes a prior authorization drug, he or she should call Caremark at 800-294-5979. Caremark is an independent company that administers prescription drug benefits on behalf of BlueChoice. In this drug list, you will see A next to drugs that require prior authorization. Medical Necessity rior Authorization We will not cover some medications without prior authorization for medical necessity (MN). Before a doctor prescribes an MN prior authorization drug, he or she should call Caremark at 800-294-5979. In this drug list, you will see MN next to drugs that require medical necessity prior authorization. Step Therapy Some drugs require members to satisfy certain step therapy criteria before they can get the drug. Before a doctor prescribes a step therapy drug, he or she should call BlueChoice at 800-950-5387. We will decide if we can approve the drug based on the step therapy criteria for that drug. In this drug list, you will see ST next to drugs that have a step therapy requirement. Unless otherwise noted, the requirement only applies to brand medications, not the generic version if there is one available. Specialty harmaceuticals Specialty pharmaceuticals are drugs that treat complex or chronic medical conditions and that are usually very expensive. We cover some of these drugs under the pharmacy benefit (oral and self-injectable drugs) and we cover others under the medical benefit. Specialty drugs are not included in this rescription Drug List.* For information about specialty drugs, please see the Specialty Drug list. *One exception to this is Lovenox. lease see Lovenox in this rescription Drug List for more details. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 2
ABILIFY G N ST ABSTRAL N ACCOLATE G N ACCU-CHEK kits and test strips N ACCURIL G N ACCURETIC G N acetazolamide A, QL. QL is 120 doses per month. MN ACIHEX G N ST, QL ACTICLATE N A ACTIGALL G N ACTIQ G N ACTIVELLA G N A, QL. QL is 120 doses per month. Requires 30-day trial of aripiprazole, clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, paliperidone, quetiapine, risperidone or Seroquel XR in the last 365 days Coverage provided for members 18 years and older for the management of breakthrough cancer pain in patients with cancer who are already receiving and are tolerant of opioid therapy for their underlying persistent cancer pain Alternatives that do not require A for medical necessity are OneTouch products Requires step thru generic esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, and OTC I. A required for more than once-daily dosing. Coverage allows up to 14 days of therapy in 365 days. Requests for additional days of therapy for acne diagnoses require medical review. ACTONEL (daily dose) G N QL QL of 31 tabs per month ACTONEL (weekly dose) G N QL QL of 4 tabs per month ACTONEL 150 mg (monthly dose) ACTOLUS MET G N ACTOLUS MET XR Coverage provided for members 16 years and older for the management of breakthrough cancer pain in patients with cancer who are already receiving and are tolerant of opioid therapy for their underlying persistent cancer pain. A is required for both brand and generic. G N QL QL of 1 tab per month or 3 tabs per 3 months N Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 3
ACTOS G N ACULAR G N ADALAT CC G N ADDERALL G N QL Quantiy Limits: 5mg-10mg: 90 per month 15mg-20mg: 60 per month 30mg: 60 per month ADDERALL XR G N QL QL of 30 caps per month ADOXA G N A Coverage allows up to 14 days of therapy in 365 days. Requests for additional days of therapy for acne diagnoses require medical review. ADVAIR DISKUS QL QL of 1 inhaler per month ADVAIR HFA QL QL of 1 inhaler per month ADVICOR N MN ALAVERT OTC ALAVERT-D OTC albuterol inhalation solution, syrup, tabs ALDACTAZIDE G N ALDACTONE G N ALLEGRA OTC ALLEGRA-D OTC ALHAGAN 0.1% ALTACE G N ALTOREV N MN QL Alternatives that do not require A for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Simcor OTC preparation available at copayment with prescription OTC preparation available at copayment with prescription OTC preparation available at copayment with prescription OTC preparation available at copayment with prescription Alternatives that do not require A for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 4
ALVESCO QL QL of 2 inhalers per month at retail or 6 units per 3 months by mail order amantadine AMARYL G N AMBIEN G N MN, QL AMBIEN CR G N MN, QL AMERGE G N QL Alternatives that do not require A for medical necessity are eszopiclone, zaleplon, zolpidem, zolpidem ext-rel. QL of 31 tabs per month at retail or 93 per 3 months by mail order. Alternatives that do not require A for medical necessity are eszopiclone, zaleplon, zolpidem, zolpidem ext-rel. QL of 31 per month at retail or 93 per 3 months by mail order. QL of 8 tabs per month, all strengths. Additional quantities require A. amiloride/ hydrochlorothiazide AMITIZA N MN Alternative that does not require A for medical necessity is Linzess. amitriptyline AMNESTEEM amoxicillin ampicillin AMRIX N MN ANADROL-50 N A Alternative that does not require A for medical necessity is cyclobenzaprine Coverage provided for treatment of anemias caused by deficient red blood cell production. ANAFRANIL G N ANAROX G N ANDRODERM A ANDROGEL G N MN ANORO ELLITA Coverage provided for male members who need replacement therapy in conditions associated with deficiency or absence of endogenous testosterone If initial A criteria is met (see Androderm or Axiron), MN applies to non-preferred options. A is required for both brand and generic formulations. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 5
ANTARA G N ST ANTIVERT G N ANUSOL HC G N AIDRA N MN ARISO ATENSIO XR N QL ATIVUS ARALEN G N ARTHROTEC G N ASACOL HD ASMANEX QL ASTERO G N QL ATACAND G N MN ATACAND HCT G N MN ATIVAN G N ATRILA Coverage requires a 30-day trial of a generic fenofibrate before an N brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix) Alternatives that do not require A for medical necessity are Novolin, Novolog Quantity Limit: 10mg-30mg; 60 caps per month 40mg-60mg: 30 caps per month QL varies by strength. Retail: Asmanex 7 2 inhalers; Asmanex 14 4 inhalers; Asmanex 30 2 inhalers (220mcg/inhaler) or Asmanex 30 1 inhaler (110mcg/inhaler); Asmanex 60 1 inhaler; Asmanex 120 1 inhaler at retail. Multiply each strength by 3 for mail order. QL of 1 inhaler per month at retail or 3 inhalers per 3 months by mail order Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 6
ATROVENT INHAL SOLN G N ATROVENT HFA QL QL of 2 inhalers per month ATROVENT NASAL G N QL AUGMENTIN G N AUGMENTIN XR G N AVALIDE G N MN AVARO G N MN AVELOX G N Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT AXERT G N QL AXID G N AXIRON A azelastine nasal spray QL AZOT AZOR AZULFIDINE G N bacitracin ophthalmic ointment baclofen BACTROBAN G N BACTROBAN NASAL N QL of 8 tabs per month, all strengths. Additional quantities require A. Coverage provided for male members who need replacement therapy in conditions associated with deficiency or absence of endogenous testosterone QL 1 inhaler per month at retail or 3 inhalers per 3 months by mail order Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 7
BANZEL Drug BARACLUDE G N BECONASE AQ N MN, QL BELSOMRA N MN, QL BENICAR BENICAR HCT BENTYL G N benztropine BETAGAN G N betamethasone dipropionate crm, gel, lotion, oint 0.05% BETAACE G N BETAACE AF G N BETIMOL N BIAXIN G N BIAXIN XL G N bimatoprost 0.03% BLEH-10 G N BLEHAMIDE SO BONIVA 150 mg TABS G N QL QL of 1 tab per month BREO ELLITA BREVICON G $0 brimonidine 0.15%, 0.2% Alternatives that do not require A for medical necessity are budesonide spray, flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex. QL of 2 inhalers per month at retail or 6 inhalers per 3 months by mail order Alternatives that do not require A for medical necessity are eszopiclone, zaleplon, zolpidem, zolpidem ext-rel. QL of 31 per month at retail or 93 per 3 months by mail order. your plan materials Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 8
BUNAVAIL N MN, QL buprenorphine A, QL Coverage provided for members who are confirmed to be receiving treatment for opioid dependence in a valid opioid-addiction treatment program. Alternatives that do not require A for medical necessity are generic buprenorphine-naloxone sublingual tablets and Suboxone film. Coverage provided for members who are confirmed to be receiving treatment for opioid dependence in a valid opioid-addiction treatment program buprenorphine/naloxone sublingual tabs A, QL Coverage provided for members who are confirmed to be receiving treatment for opioid dependence in a valid opioid-addiction treatment program bupropion 150 mg extended release A, QL your plan materials Limit of 30-day supply for each prescription; maximum therapy of 180 days per each 365 period. buspirone BUTRANS N QL QL of 4 patches per month butorphanol nasal spray QL, A QL of 2 units per month. Additional quantities require A. BYDUREON BYETTA N MN Alternatives that do not require A for medical necessity are Bydureon, Victoza BYSTOLIC CAFERGOT N CALAN G N CALAN SR G N CAMBIA N QL QL of 4 packets per month CANASA SUOSITORY captopril CARAFATE G N CARDIZEM CD G N CARDIZEM LA G N Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 9
CARDURA G N CATARES G N CAYSTON, inhalation N cefdinir CEFTIN G N cefprozil CELEBREX G N ST, QL, A CELEXA G N cetirizine OTC cetirizine-d OTC CHANTIX $0 A, QL chlorthalidone CIALIS N ciclopirox cimetidine CIRO HC OTIC CIRO G N ciprofloxacin ext-rel tabs CITRANATAL VITAMINS See limitations CLARINEX G N ST Requires step thru generic DMARDs, NSAIDs, or GI drugs. QL of 62 of 100 mg or 31 of 200 mg per month. A required for doses > 200 mg daily. ST and A are required for both brand and generic formulations. OTC preparation available at copayment with prescription for OTC formulation OTC preparation available at copayment with prescription for OTC formulation your plan materials Limit of 30-day supply for each prescription; maximum therapy of 180 days per each 365 period. Check member drug benefit for coverage of oral erectile dysfunction drugs Requires 21-day trial of OTC non-sedating/mildly sedating antihistamine in the last 12 months Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 10
CLARINEX D N ST CLARITIN OTC CLARITIN-D OTC CLARAVIS CLEOCIN G N CLEOCIN VAG SU N CLEOCIN T G N CLIMARA G N CLOZARIL G N ST COLAZAL G N Requires 21-day trial of OTC non-sedating/mildly sedating antihistamine in the last 12 months COLCRYS G N QL QL of 60 tabs per month COLOCORT G COMBIGAN OTC preparation available at copayment with prescription OTC preparation available at copayment with prescription Requires 30-day trial of aripiprazole, clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, paliperidone, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days COMBIVENT RESIMAT QL QL of 2 inhalers per month COMBIVIR G N COMLERA COMTAN G N CONCERTA G N QL CONDYLOX GEL N CONDYLOX SOLN G N COEGUS G N CORDARONE G N COREG G N Quantity Limit: 18mg-36mg: 60 per month 54mg: 30 per month Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 11
CORGARD G N CORTEF G N CORTIFOAM CORTISORIN OTIC G N COSOT G N COUMADIN G N COZAAR G N MN CREON CRESTOR N MN CRIXIVAN cromolyn inhalation, ophthalmic CYCLESSA G $0 cyclobenzaprine cyclosporine CYMBALTA G N ST, QL cyproheptadine CYTOTEC G N DANTRIUM G N dapsone DAYRO G N Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Alternative that does not require A for medical necessity is atorvastatin your plan materials Requires 30-day trial of generic SSRI/SNRI in last 180 days. QL of 62 per month for 20 mg, 31 per month for 30 mg, 62 per month for 60 mg. DDAV SRAY G N QL QL of 2 bottles per month DEMADEX G N demeclocycline Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 12
DENAVIR N QL QL of 1 5gm tube per month DEAKENE G N DEAKOTE G N DEAKOTE ER G N DEAKOTE SRINKLES G N DESOGEN G $0 DESVENLAFAXINE ER N ST, QL DETROL G N MN DETROL LA G N MN dexamethasone dexamethasone sodium phosphate DEXEDRINE G N QL DEXILANT N ST, QL dextroamphetamine QL diclofenac sodium delayed-rel tabs diclofenac sodium ophthalmic your plan materials Requires 30-day trial of generic SNRI in last 180 days. QL of 31 per month. Alternatives that do not require A for medical necessity are oxybutynin ext-rel, tolterodine, tolterodine ext rel, trospium, trospium ext-rel, Gelnique, Vesicare Alternatives that do not require A for medical necessity are oxybutynin ext-rel, tolterodine, tolterodine ext rel, trospium, trospium ext-rel, Gelnique, Vesicare Quantity Limit: 5mg-10mg: 90 per month 15mg:60 per month Requires step thru generic esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, OTC I. A required for more than once-daily dosing. Quantity Limit: 2.5mg-10mg: 90 per month 15mg-20mg: 60 per month 30mg: 30 per month Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 13
dicloxacillin DIFLUCAN TABS G N DILANTIN 100 mg CAS G N DILANTIN 125/5 SUS G N DILANTIN 30 mg CAS DILANTIN 50 mg CHEW G N DILAUDID G N QL QL of 180 tabs per month at retail DIOVAN G N MN DIOVAN HCT G N MN diphenhydramine DITROAN XL G N MN DORYX N A DOVONEX G N doxepin DUAC G N DUEXIS N MN DULERA N MN, QL DURAGESIC G N QL Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Alternatives that do not require A for medical necessity are oxybutynin ext-rel, tolterodine, tolterodine ext rel, trospium, trospium ext-rel, Gelnique, Vesicare Coverage allows up to 14 days of therapy in 365 days. Requests for additional days of therapy for acne diagnoses require medical review. Alternatives that do not require A for medical necessity are generic NSAIDs plus generic Is Alternatives that do not require A for medical necessity are Advair, Advair HFA, Symbicort. QL of 1 inhaler per month QL of 10 patches per month. Additional quantities require A. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 14
DUREZOL Drug DYAZIDE G N DYMISTA N MN, QL EDARBI N MN EDARBYCLOR N MN EDLUAR N MN, QL EDURANT E.E.S. G N EFFEXOR XR G N QL EFUDEX G N ELIDEL CREAM ELIQUIS EMEND 40 mg N QL, A EMEND 80 mg, 125 mg N QL, A EMTRIVA ENJUVIA TABS Alternatives that do not require A for medical necessity are budesonide spray, flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex. QL of 1 inhaler per month at retail or 3 inhalers per 3 months by mail order Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Alternatives that do not require A for medical necessity are eszopiclone, zaleplon, zolpidem, zolpidem ext-rel. QL of 31 per month at retail or 93 per 3 months by mail order. QL of 31 per month for 37.5 mg, 75 mg XR, or 150 mg XR. Coverage for 2 years of age and up. If less than 2 years old, call BlueChoice at 800-950-5387. QL of 4 of 40 mg per month. Additional quantities require A. QL of 2 of 80 mg or 125 mg per month. Additional quantities require A. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 15
EANOVA N A EIEN EIEN JR. EIVIR TABS G N EIVIR SOLUTION G N EZICOM ERY-TAB erythromycin erythromycin stearate ESTRACE TABS G N ESTRING N etodolac etoposide EVEKEO N A,QL EVISTA G N EXALGO G N QL EXELON CAS G N EXFORGE G EXFORGE HCT G FABIOR N ST FAMVIR G N Coverage provided to members 18 years and older who have elevated triglycerides above 500 mg/dl and have failed on previous FDA-approved therapy to lower triglycerides along with diet ackaged as 90-day supply for two times the applicable copayment Coverage provided for ADHD or narcolepsy after trial of 2 generic amphetamine products. QL of 60 per month. Coverage provided for treatment of opioid-tolerant patients who require continuous, around-the-clock analgesia for an extended timeframe. QL applies based on dosing. A is required for both brand and generic formulations. Requires 30-day trial of generic tretinoin product in the last 365 days Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 16
FANAT N ST Requires 30-day trial of aripiprazole, clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, paliperidone, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days FARXIGA FAZACLO G N ST Requires 30-day trial of aripiprazole, clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, paliperidone, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days FELDENE G N FEMHRT 0.5/2.5 G N FEMRING ackaged as 90-day supply for 2 times the applicable copayment FENOGLIDE G N ST Coverage requires a 30-day trial of a generic fenofibrate before an N brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix) FENTORA N A, QL QL is 120 doses per month. Coverage provided for members 16 years and older for the management of breakthrough cancer pain in patients with cancer who are already receiving and are tolerant of opioid therapy for their underlying persistent cancer pain FETZIMA N ST, QL fexofenadine OTC fexofenadine-d OTC FIBRICOR G N ST finasteride 5 mg A Requires 30-day trial of generic SNRI in last 180 days. QL of 31 per month. OTC preparation available at copayment with prescription for OTC formulation OTC preparation available at copayment with prescription for OTC formulation Coverage requires a 30-day trial of a generic fenofibrate before an N brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix) Coverage provided for the treatment of symptomatic benign prostatic hypertrophy in males over age 40. A is required for both brand and generic formulations. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 17
FIORICET G N FIORINAL G N FIRST-LANSORAZOLE N ST,QL FIRST-OMERAZOLE N ST,QL FLAGYL G N FLAGYL ER N fludrocortisone FLOMAX G N FLOVENT DISKUS QL QL of 1 inhaler per month Require step thru generic esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, or OTC I. A required for more than once-daily dosing. Require step thru generic esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, or OTC I. A required for more than once-daily dosing. FLOVENT HFA QL QL of 2 inhalers per month flunisolide nasal QL QL of 1 inhaler per month fluocinonide crm, gel, oint, soln 0.05% FLUOROLEX fluphenazine fluticasone QL QL of 1 inhaler per month FML OHTH DRO G N FOCALIN G N QL QL of 60 per month FOCALIN XR G N QL FORTAMET N MN FORTESTA G N MN Quantity Limit: 5mg-20mg: 60 per month 25mg-40mg: 30 per month Alternatives that do not require A for medical necessity are metformin, metformin ext-rel FOSAMAX (daily dose) G N QL QL of 31 tabs per month If initial A criteria is met (see Androderm or Axiron), MN applies to non-preferred options. A is required for both brand and generic formulations. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 18
FOSAMAX (weekly dose) FOSAMAX LUS D (weekly dose) FROVA N QL GELNIQUE gentamicin ophthalmic, topical G N QL QL of 4 tabs per month N QL QL of 4 tabs per month GEODON G N ST GIANVI $0 GLUCAGON GLUCOHAGE G N GLUCOHAGE XR G N GLUCOTROL G N GLUCOTROL XL G N GLUCOVANCE G N GLUMETZA N MN GOLYTELY G N GRALISE N A granisetron tabs QL, A GRIS-EG G N haloperidol QL of 8 tabs per month. Additional quantities require A. Requires 30-day trial of aripiprazole, clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, paliperidone, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days your plan materials Alternatives that do not require A for medical necessity are metformin, metformin ext-rel Coverage requires that members have tried at least a 30-day supply of gabapentin immediate-release at a dose of 1800 mg daily without adequate response QL of 4 tabs per month. Additional quantities require A. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 19
HUMALOG (ALL FORMS) N MN HUMULIN (ALL FORMS except R U-500) HUMULIN R U-500 N hydralazine HYDREA G N hydrochlorothiazide hydrocortisone crm 2.5% MN HYZAAR G N MN IMITREX INJECTION G N QL IMITREX NASAL G N QL IMITREX TABS G N QL IMURAN G N INDERAL LA G N INTELENCE INTERMEZZO N MN, QL INVEGA G N ST INVIRASE Alternatives that do not require A for medical necessity are Novolin, Novolog Alternatives that do not require A for medical necessity are Novolin, Novolog Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT QL of 3 kits or 5 vials per month. Additional quantities require A. QL of 3 boxes (20 mg) or (5 mg) per month. Additional quantities require A. QL of 8 tabs per month, all strengths. Additional quantities require A. Alternatives that do not require A for medical necessity are eszopiclone, zaleplon, zolpidem, zolpidem ext-rel. QL of 31 per month at retail or 93 per 3 months by mail order. Requires 30-day trial of aripiprazole, clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, paliperidone, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 20
INVOKAMET INVOKANA Drug ipratropium/albuterol inhalation N N MN MN IRENKA N ST, QL ISENTRESS isoniazid ISOTO CARINE G N ISORDIL G N JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO N MN jinteli $0 KALETRA Alternatives that do not require A for medical necessity are Farxiga, Jardiance, Synjardy, and Xigduo XR Alternatives that do not require A for medical necessity are Farxiga, Jardiance, Synjardy, and Xigduo XR Requires 30-day trial of generic SSRI/SNRI in last 180 days. QL of 30 per month. Alternatives that do not require A for medical necessity are Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza your plan materials KAVAY G N QL QL of 120 tablets per month KAZANO N MN KEFLEX G N KERA G N KERA XR G N ketoconazole tabs Alternatives that do not require A for medical necessity are Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 21
ketoprofen KHEDEZLA N ST, QL KLONOIN G N KOMBIGLYZE XR labetalol lactulose LAMICTAL CHEW TABS G N LAMICTAL TABS G N LAMICTAL XR G N LAMISIL TABS G N LANOXIN G N lansoprazole delayed-rel OTC lansoprazole delayed-rel (Rx) LANTUS (ALL FORMS) LASIX G N LATUDA N ST LAZANDA QL Requires 30-day trial of generic SNRI in last 180 days. QL of 31 per month. OTC preparation available at copayment with prescription. QL of 128 per month. QL A required for more than once-daily dosing N A, QL. QL is 8 bottles at retail per month. LESCOL G N MN LESCOL XL G N MN LEVAQUIN G N Requires 30-day trial of aripiprazole, clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, paliperidone, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days Coverage provided for members 18 years and older for the management of breakthrough cancer pain in patients with cancer who are already receiving and are tolerant of opioid therapy for their underlying persistent cancer pain Alternatives that do not require A for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin Alternatives that do not require A for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 22
LEVEMIR N MN LEVITRA N LEVORA $0 LEVOXYL LEVSIN G N LEXARO G N LEXIVA lidocaine viscous LINZESS See limitations LIITOR G N MN LIOFEN N ST LITRUZET N MN lithium carbonate LITHOBID G N LIVALO N MN LOFIBRA G N ST LOMOTIL G N loperamide LOID G N Alternative that does not require A for medical necessity is Lantus Check member drug benefit for coverage of oral erectile dysfunction drugs your plan materials Alternatives that do not require A for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin Coverage requires a 30-day trial of a generic fenofibrate before an N brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix) Alternative that does not require A for medical necessity is atorvastatin Alternatives that do not require A for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin Coverage requires a 30-day trial of a generic fenofibrate before an N brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix) to align with Tricor, TriGlide, Trilipix Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 23
LORESSOR G N LOROX GEL, LOTION G N loratadine OTC loratadine-d OTC LOTEMAX LOTENSIN G N LOTENSIN HCT G N LOTREL G N LOTRONEX G N A LOVAZA G N A LOVENOX G Specialty QL, A LOW-OGESTREL LUMIGAN 0.01% N MN LUNESTA G N MN, QL LURIDE G N LURIDE LOZI-TABS G N OTC preparation available at copayment with prescription for OTC formulation OTC preparation available at copayment with prescription for OTC formulation Coverage provided to female members with severe diarrhea-predominant irritable bowel syndrome (IBS) who have chronic IBS symptoms (generally lasting six months or longer), had anatomic or biochemical abnormalities of the gastrointestinal tract excluded, and not responded adequately to conventional therapy. A is required for both brand and generic formulations. Coverage provided to members 18 years and older who have elevated triglycerides above 500 mg/dl and have failed on previous FDA-approved therapy to lower triglycerides along with diet. A is required for both brand and generic formulations. QL of maximum 35-day supply at retail pharmacy. Additional quantities require A through preferred specialty pharmacy. Alternatives that do not require A for medical necessity are latanoprost, travoprost, Travatan Z, Zioptan Alternatives that do not require A for medical necessity are eszopiclone, zaleplon, zolpidem, zolpidem ext-rel. QL of 31 per month at retail or 93 per 3 months by mail order. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 24
LYRICA N QL MACRODANTIN G N MALARONE G N MAVIK G N MAXALT/MAXALT-MLT G N QL MAXITROL G N MAXZIDE G N MENEST N MESTINON 60 mg G N MESTINON SYRU MESTINON TIMESAN G N METADATE CD G N QL METAGLI N methazolamide methotrexate 2.5 mg, oral methyldopa METROGEL TOICAL G N METROGEL VAG 0.75% GEL MEVACOR G N MN G N QL for doses 200 mg, 90 caps per 30 days. QL for doses 225 mg, 60 caps per 30 days. Lyrica solution QL 900 ml per 30 days. QL of 8 tabs per month. Additional quantities require A. QuantityLimit: 10mg-30mg: 60 per month 40mg-60mg: 30 per month MIACALCIN SRAY G N QL QL of 2 units per month MICARDIS G N MN Alternatives that do not require A for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 25
MICARDIS HCT G N MN MICRO-K G N MIGRANAL NASAL G N QL QL of 8 units per month MINIRESS G N MINOCIN G N minocycline ext-rel ST MIRAEX G N MIRCETTE G $0 MODICON G $0 MONODOX G N A morphine sulfate immediate release morphine suppository MOVIRE Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Coverage requires that members be 12 years or older and must have tried at least 30 days of a generic immediate-release minocycline and a 30- day supply of one of these generics (doxycycline, erythromycin or tetracycline) within the previous 365 days your plan materials your plan materials Coverage allows up to 14 days of therapy in 365 days. Requests for additional days of therapy for acne diagnoses require medical review. QL QL of 150 tabs per month MS CONTIN G N QL QL of 90 tabs per month MYAMBUTOL G N MYRBETRIQ N MN MYFORTIC G N Alternatives that do not require A for medical necessity are oxybutynin ext-rel, tolterodine, tolterodine ext rel, trospium, trospium ext-rel, Gelnique, Vesicare Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 26
MYSOLINE G N nabumetone NAMENDA SOLUTION G N NAMENDA XR NARELAN G N MN N NAROSYN G N NARDIL G N NASACORT AQ G N MN, QL Alternatives that do not require A for medical necessity are generic NSAIDs Alternatives that do not require A for medical necessity are budesonide spray, flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex. QL of 1 inhaler per month NASONEX QL QL of 2 inhalers per month NATESTO N MN NECON 10/11 N NEORAL G N NEOSORIN G N NESINA N MN NEURONTIN G N NEXIUM (Rx) G N MN, ST, QL NEXIUM 24HR (OTC) QL NIASAN G N nicotine transdermal patches OTC If initial A criteria is met (see Androderm oraxiron), MN applies to non-preferred options Alternatives that do not require A for medical necessity are Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza A for medical necessity requires trial/failure of both Nexium 24HR (OTC) and a generic I (lansoprazole, omeprazole, rabeprazole or pantoprazole). QL of 31 caps or granule packets per month. A required for more than once-daily dosing. OTC preparation available at copayment with prescription. QL of 84 per month. Check member drug benefit for coverage of smoking cessation drugs. OTC preparation available at copayment with prescription. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 27
NICOTROL INHALER $0 A, QL NICOTROL NS $0 A, QL your plan materials Limit of 30-day supply for each prescription; maximum therapy of 180 days per each 365 period. your plan materials Limit of 30-day supply for each prescription; maximum therapy of 180 days per each 365 period. NIMOTO G N NITRO-DUR G N nitroglycerin transdermal patches NITROSTAT N NORCO G N QL Max 3 grams acetaminophen (AA) per day NORRAMIN G N NORVASC G N NORVIR NOVOFINE NOVOLIN (ALL FORMS) NOVOLOG (ALL FORMS) NOXAFIL N NUVARING NUVIGIL N A, QL your plan materials. ackaged as 90-day supply for 2 times the applicable copayment Coverage provided for members with a diagnosis of narcolepsy, multiple sclerosis-related fatigue, persistent sleepiness due to obstructive sleep apnea refractory to traditional treatments (i.e., CA, etc.) and sleepiness associated with diagnosed shift work sleep disorder nystatin OCUFLOX G N Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 28
ofloxacin otic OLUX-E FOAM G N MN omeprazole caps (Rx) QL omeprazole OTC QL OMNARIS N MN, QL OMTRYG N A ONE TOUCH kits and test strips ONGLYZA ONMEL N A ORTHO-CYCLEN G $0 ORTHO EVRA G $0 ORTHO MICRONOR G $0 ORTHO TRI-CYCLEN G $0 ORTHO TRI-CYCLEN LO $0 Alternative that does not require A for medical necessity is clobetasol propionate foam 0.05% QL of 31-caps-per month. A required for more than once-daily dosing. OTC preparation available at copayment with prescription. QL of 128 per month. Alternatives that do not require A for medical necessity are budesonide spray, flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex. QL of 1 inhaler per month. Coverage provided to members 18 years and older who have elevated triglycerides above 500 mg/dl and have failed on previous FDA-approved therapy to lower triglycerides along with diet Coverage provided to members who have diagnosis of onychomychosis of the toenail. your plan materials your plan materials your plan materials your plan materials your plan materials Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 29
ORTHO-NOVUM G $0 OSENI N MN OVIDE G N OXANDRIN N A oxazepam oxybutynin OXYCONTIN QL OXYTROL N MN AMELOR G N ANCREAZE ANRETIN ATADAY N your plan materials Alternatives that do not require A for medical necessity are Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza Coverage provided for adjunctive therapy to promote weight gain after weight loss following extensive surgery, chronic infections, or severe trauma. QL of 120 tabs per month. Additional quantities require A. Alternatives that do not require A for medical necessity are oxybutynin ext-rel, tolterodine, tolterodine ext rel, trospium,trospium ext-rel, Gelnique, Vesicare ATANASE G N QL QL of 1 inhaler per month pantoprazole QL ARLODEL G N ARNATE G N AXIL G N AXIL CR G N CE N penicillin VK ENNSAID 2% N MN QL of 31 caps per month. A required for more than once-daily dosing. Alternatives that do not require A for medical necessity are generic NSAIDs Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 30
ECID (Rx) G N ERCOCET G N QL ERIDEX G N perphenazine ERSANTINE G N phenobarbital HOSLO G N pindolol LAQUENIL G N LAVIX G N OLYTRIM G N potassium chloride extrel, liquid RADAXA N RANDIN G N RAVACHOL G N MN RECOSE G N RED FORTE G N RED MILD prednisolone acetate 1% prednisone REFERAOB VITAMINS RELONE G N REMARIN REMHASE REMRO Alternatives that do not require A for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 31
REVACID (Rx) G N ST, QL REVACID 24HR OTC QL REZISTA RILOSEC (Rx) G N ST, QL RILOSEC OTC QL RISTIQ N ST, QL Require step thru generic esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, or OTC I. A required for more than once-daily dosing. OTC preparation available at copayment with prescription. QL of 128 per month. Require step thru generic esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, or OTC I. A required for more than once-daily dosing. OTC preparation available at copayment with prescription. QL of 128 per month. Requires 30-day trial of generic SNRI in last 180 days. QL of 31 per month. ROAIR HFA, Respiclick QL QL of 2 inhalers per month probenecid ROCARDIA XL G N prochlorperazine promethazine promethazine w/ codeine promethazine w/ dextromethorphan propranolol tabs propylthiouracil ROSCAR G N A ROTONIX G N ST, QL Coverage provided for the treatment of symptomatic benign prostatic hypertrophy in males over age 40. A is required for both brand and generic formulations. Require step thru generic esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, or OTC I. A required for more than once-daily dosing. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 32
ROTOIC G N Coverage for 2 years of age and up for 0.03%, 16 years and up for 0.1%. Outside of these ages, call BlueChoice at 800-950-5387. ROVENTIL HFA N QL QL of 2 inhalers per month ROVERA G N ROVIGIL G N A, QL ROZAC G N ROZAC WEEKLY G N QL ULMICORT FLEXHALER Coverage requires members try and fail at least a 30-day trial of Nuvigil in the last 365 days and meet A requirement for indications. QL of 60 per month. QL of 4 per month at retail or 12 per 3 months by mail order N QL QL of 2 inhalers per month ULMICORT RESULES G N QL QL of 1 box per month pyrazinamide YRIDIUM G N QUILLIVANT XR N QL QL of 360 ml per month QNASL N MN, QL QUALAQUIN G N QL, A QUESTRAN/QUESTRAN- LIGHT G N Alternatives that do not require A for medical necessity are budesonide spray, flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex. QL of 1 inhaler per month at retail or 3 inhalers per 90 days by mail order. QL of 42 caps per year. Additional quantities require A. QVAR QL QL of 2 inhalers per month ramipril RAYOS N MN RAZADYNE G N REGLAN TABS G N RELAX N QL Alternative that does not require A for medical necessity is prednisone QL of 8 tabs per month, all strengths. Additional quantities require A. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 33
REMERON G N REMERON SOLTAB G N RENAGEL RENVELA N REQUI G N REQUI XL G N RESCRITOR RESTORIL G N QL QL of 31 per month RETIN-A CREAM, GEL G N ST RETIN-A MICRO GEL G N ST RETROVIR G N REYATAZ RHINOCORT AQ G N MN, QL ribasphere tabs & caps ribavirin tabs & caps RIFADIN G N RIOMET N MN RISERDAL/RISERDAL M G N ST RITALIN G N QL QL of 90 per month RITALIN-LA N QL ROBAXIN G N Coverage up to age 25 for acne. If over 25 yrs, A required. Coverage up to age 25 for acne. If over 25 yrs, A required. Alternatives that do not require A for medical necessity are budesonide spray, flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex. QL of 2 inhalers per month. Alternatives that do not require A for medical necessity are metformin, metformin ext-rel Requires 30-day trial of aripiprazole, clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, paliperidone, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days Quantity Limit: 10mg-30mg:60 per month 40mg-60mg: 30 per month Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 34
ROCALTROL G N ROWASA ENEMA G N ROXICODONE G N QL QL of 90 per month ROZEREM QL RYTHMOL G N RYTHMOL SR G N SANCUSO N QL, A SANDIMMUNE G N SAHRIS N ST QL of 31 per month at retail or 93 per 3 months by mail order SAVELLA QL QL of 62 caps per month SEASONIQUE G $0 selegiline tabs selenium sulfide shampoo 2.5% SELZENTRY SENSIAR QL of 2 patches per month, all strengths. Additional quantities require A. Requires 30-day trial of aripiprazole, clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, paliperidone, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days SEREVENT DISKUS QL QL of 1 inhaler per month SEROQUEL G N ST SEROQUEL XR your plan materials ackaged as 90-day supply for 2 times the applicable copayment Requires 30-day trial of aripiprazole, clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, paliperidone, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 35
SILENOR N MN, QL SILVADENE G N SIMCOR SINEMET G N SINEMET CR G N SINGULAIR G N SOLODYN G N ST SOMA G N SONATA G N MN, QL Alternatives that do not require A for medical necessity are eszopiclone, zaleplon, zolpidem, zolpidem ext-rel. QL of 31 per month at retail or 93 per 3 months by mail order. Coverage requires that members be 12 years or older and must have tried at least 30 days of a generic immediate-release minocycline and a 30- day supply of one of these generics (doxycycline, erythromycin or tetracycline) within the previous 365 days. ST is required for brand and generic. Alternatives that do not require A for medical necessity are eszopiclone, zaleplon, zolpidem, zolpidem ext-rel. QL of 31 tabs per month at retail or 93 per 3 months by mail order. SORIATANE CAS G N A A for treatment of severe psoriasis in adults SIRIVA HANDIHALER QL QL of 1 inhaler per month SIRIVA RESIMAT QL QL of 1 inhaler per month SORANOX CAS G N A, QL SORANOX SOLUTION N A, QL SRIX N MN STAXYN N See limitations Coverage provided to members for treatment of onychomycosis. QL of 31 caps per month. Max 3 months of therapy per year. A is required for both brand and generic formulations. Coverage provided for members for treatment of oropharyngeal and esophageal candidiasis. QL of 600mL per month, with max 1800mL per year. Alternatives that do not require A for medical necessity are generic NSAIDs Check member drug benefit for coverage of oral erectile dysfunction drugs Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 36
STRATTERA QL Quantity Limit: 10mg-40mg: 60 per month 60mg-100mg: 30 per month SUBOXONE sublingual film A, QL Coverage provided for members who are confirmed to be receiving treatment for opioid dependence in a valid opioid-addiction treatment program SUBSYS N A, QL QL is 120 doses per month. Coverage provided for members 18 years and older for the management of breakthrough cancer pain in patients with cancer who are already receiving and are tolerant of opioid therapy for their underlying persistent cancer pain sulfamethoxazoletrimethoprim SUMAVEL DOSERO N ST, QL Coverage requires that members must have filled 14 days of generic sumatriptan injection in the last 180 days. QL of 6 per month. Additional quantities require A. SUSTIVA SYMBICORT QL QL of 2 inhalers per month SYMLINEN SYNJARDY N SYNTHROID G N TAMIFLU N QL QL of 10 caps (1 blister pack) per year tamoxifen TANZEUM N MN, QL QL of 4 pens per month. Alternatives that do not require A for medical necessity are Bydureon and Victoza TAAZOLE G N TARGADOX N A Coverage allows up to 14 days of therapy in 365 days. Requests for additional days of therapy for acne diagnoses require medical review. TARKA N TAZORAC N ST Requires 30-day trial of generic tretinoin product in the last 365 days TEGRETOL G N Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 37
TEGRETOL XR G N TEKTURNA N MN TEKTURNA HCT N MN TEMOVATE G N TENORMIN G N terazosin terbutaline TESSALON G N TEST STRIS (except ONETOUCH) N MN TESTIM G N MN tetracycline TEVETEN N MN TEVETEN HCT N MN THEOCHRON G N theophylline ext-rel (12 hr) thiothixene TIMOTIC G N Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Alternatives that do not require A for medical necessity are OneTouch products If initial A criteria is met (see Androderm oraxiron), MN applies to non-preferred options. A is required for both brand and generic formulations. Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Alternatives that do not require A for medical necessity are candesartan, candesartan-hct, eprosartan, irbesartan, irbesartan-hct, losartan, losartan-hct, telmisartan, telmisartan HCT, valsartan, valsartan-hct, Benicar, Benicar HCT Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 38
TOBRADEX ST tobramycindexamethasone 0.3-0.1% TOBREX G N TOFRANIL G N TOAMAX G N TOROL XL G N TOUJEO N MN TOVIAZ N MN TRADJENTA N MN TRAVATAN Z travoprost trazodone TREXIMET N QL triamcinolone crm 0.5% triamcinolone crm, lotion 0.025% triamcinolone crm, lotion, oint 0.1% triamcinolone paste TRIBENZOR TRICOR G N ST Alternative that does not require A for medical necessity is Lantus. Alternatives that do not require A for medical necessity are oxybutynin ext-rel, tolterodine, tolterodine ext rel. trospium, trospium ext-rel, Gelnique, Vesicare Alternatives that do not require A for medical necessity are Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza QL of 9 tabs per month. Additional quantities require A. Coverage requires a 30-day trial of a generic fenofibrate before an N brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix) Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 39
TRIGLIDE N ST trihexyphenidyl TRILETAL G N TRILIIX N ST trimethoprim TRI-NORINYL G $0 TRIVORA $0 TRIZIVIR G N trospium trospium ext-rel TRULICITY N MN, QL TRUSOT G N TRUVADA TWYNSTA G N TYLENOL w/ CODEINE G N QL QL of 300 per month ULORIC N ST ULTRAM G N QL QL of 240 per month ULTRAM ER G N QL QL of 30 per month UNIRETIC G N URECHOLINE G N URSO G N Coverage requires a 30-day trial of a generic fenofibrate before an N brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix) Coverage requires a 30-day trial of a generic fenofibrate before an N brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix) your plan materials your plan materials QL of 4 pens per month. Alternatives that do not require A for medical necessity are Bydureon and Victoza. Coverage requires a 30-day trial of allopurinol in the past 180 days Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 40
VALCYTE G N VALIUM G N VALTREX G N QL VASCEA N A VASERETIC G N VASOTEC G N venlafaxine venlafaxine ext-rel QL QL of 42 caps of 500 mg per fill or 84 caps per month; QL of 31 caps of 1000 mg per month. Coverage provided to members 18 years and older who have elevated triglycerides above 500 mg/dl and have failed on previous FDA-approved therapy to lower triglycerides along with diet QL of 31 of 37.5 mg, 75 mg, 150 mg. QL of 31 of 225 mg or use (31 of 150 mg + 31 of 75 mg) = 1 copayment. VENTOLIN HFA QL QL of 2 inhalers per month VERAMYST N MN, QL VERSACLOZ N ST VESICARE VFEND G N VIAGRA N VIBRAMYCIN G N See limitations Alternatives that do not require A for medical necessity are budesonide spray, flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex. QL of 1 inhaler per month. Requires 30-day trial of clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days Check member drug benefit for coverage of oral erectile dysfunction drugs VICODIN ES G N QL Max 3 grams acetaminophen (AA) per day VICTOZA VIDEX EC G N VIDEX SOLN VIGAMOX Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 41
VIMOVO N MN, QL VIRACET VIRAMUNE G N VIRAMUNE XR G VIREAD VIROTIC G N vitamin B-12 inj VIVELLE-DOT G N VOGELXO G N MN VYTORIN N MN VYVANSE N QL WELCHOL WELLBUTRIN G N WELLBUTRIN SR G N Alternatives that do not require A for medical necessity are generic NSAIDs plus generic Is. QL of 62 tabs per month If initial A criteria is met (see Androdermor Axiron), MN applies to non-preferred options. A is required for both brand and generic formulations. Alternative that does not require A for medical necessity is atorvastatin. Quantity Limit: 10mg-30mg: 60 per month 40mg-70mg: 30 per month WELLBUTRIN XL G N QL QL of 31 per month for 150 mg or 300 mg. XALATAN G N XANAX G N XARELTO XARTEMIS XR N QL Max 3 grams acetaminophen (AA) per day XIGDUO XR XYZAL G N ST YASMIN G $0 Coverage requires a trial of OTC nonsedating/mildly sedating antihistamine for 21 days in the last 12 months your plan materials Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 42
YAZ G $0 ZANTAC (Rx) G N ZARONTIN G N ZAROXOLYN G N ZEGERID G N ST, QL ZEGERID OTC G QL ZEMLAR G N ZERIT G N ZESTORETIC G N ZESTRIL G N ZETIA ZETONNA N MN, QL ZIAGEN tabs G ZIAGEN SOLUTION ZIOTAN ZISOR N MN N ZITHROMAX G N ZOCOR G N MN ZOFRAN G N QL, A your plan materials Requires step thru generic esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, or OTC I. A required for more than once-daily dosing. ST is required for brand and generic. OTC preparation available at copayment with prescription. QL of 128 per month. Alternatives that do not require A for medical necessity are budesonide spray, flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex Alternatives that do not require A for medical necessity are generic NSAIDs Alternatives that do not require A for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin. QL of 9 per month for 4 mg, 6 per month for 8 mg, 50 ml per month for solution. Additional quantities require A. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 43
ZOHYDRO ER N QL ZOLOFT G N ZOLIMIST N MN, QL Coverage provided for members with pain severe enough to require daily, around-the-clock, long-term treatment and for which alternative treatment options are inadequate. QL of 120 per month for 10, 15 and 20 mg. QL of 60 per month for 30, 40 and 50 mg. Alternatives that do not require A for medical necessity are eszopiclone, zaleplon, zolpidem, zolpidem ext-rel. QL of 31 tabs per month at retail or 93 per 3 months by mail order. ZOMIG NASAL N QL QL of 1 package (6 units) per month ZOMIG/ZOMIG-ZMT G N QL QL of 6 per month. Additional quantities require A. ZONEGRAN G N ZORTRESS N QL ZORVOLEX N MN ZOVIA $0 ZOVIRAX CAS, OINT, SUS, TABS ZOVIRAX CREAM ZUBSOLV N MN, QL ZULENZ N QL, A ZYLET G N N ZYLORIM G N ZYMAXID G N QL of 62 per month for 0.25 mg. QL of 124 for 0.5 mg and 0.75 mg. Alternatives that do not require A for medical necessity are generic NSAIDs your plan materials Coverage provided for members who are confirmed to be receiving treatment for opioid dependence in a valid opioid-addiction treatment program. Alternatives that do not require A for medical necessity are generic buprenorphine-naloxone sublingual tablets and Suboxone film. QL of 10 per month. Additional quantities require A. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 44
ZYREXA G N ST ZYRTEC OTC ZYRTEC-D OTC Requires 30-day trial of aripiprazole, clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, paliperidone, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days OTC preparation available at copayment with prescription OTC preparation available at copayment with prescription ZYVOX G N Health Care Reform Coverage The Affordable Care Act (ACA) requires health insurance plans to cover certain drugs such as aspirin, female contraceptives, folic acid, iron supplements, oral fluoride agents, vaccines and tobacco cessation products at $0 (no charge.) Covered OTC products require a prescription to have coverage under your pharmacy benefit. These ACA benefits apply to most, but not all, employer groups. Check your plan documents or log into My Health Toolkit and use the Drug Coverage and Cost Tool. MISCELLANEOUS Aspirin: Coverage is for OTC generics only for members aged 12-79. Maximum of one dose per day of 81mg, 162 mg or 325mg tablets or capsules. No coverage for buffered aspirin, powders, suppositories or effervescent tablets. Bowel reparations for colonoscopy: Halflytely, Moviprep, repopik, Suprep (Only those aged 50-75 have $0 coverage) Breast Cancer revention: We cover generic tamoxifen and raloxifene for females aged 35 and older. Folic Acid: We cover prescription generics or OTC products for females only. Max one dose per day of 0.4 and 0.8mg strength. We do not cover OTC prenatal vitamins or combination products. Iron Supplements: Oral liquid dosage forms on single-ingredient only. We cover OTC generics and brands for those up to age 1 only. Oral Fluorides: We cover only single-ingredient prescription generics. There is a maximum daily dose limit. Only ages zero to 17 years old have $0 coverage. Tobacco Cessation: We cover prescription products (bupropion 150mg, Chantix, Nicotrol nasal spray, Nicotrol inhaler) with prior authorization. We cover OTC products (nicotine patches, gum and lozenges) with prescription. Limit of 30-day supply for each prescription filled. Maximum therapy of 180 days per each 365 period. Vitamin D: Only those aged 65 and older have $0 coverage. Includes OTC with prescription. (continued) Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 45
VACCINES DIHTHERIA-TETANUS TOXOID & ERTUSSIS VACCINE MEASLES, MUMS & RUBELLA VIRUS VACCINES DIHTHERIA-TETANUS TOXOIDS (DT) DIHTHERIA, ERTUSSIS & TETANUS HAEMOHILUS B OLYSACCHARIDE CONJUGATE HEATITIS A (INACTIVATED) - HEATITIS B (RECOMB) MENINGOCOCCAL NEUMOCOCCAL OLIO VACCINE RECOMBIVAX HB HEATITIS A VACCINE HEATITIS B VACCINE (RECOMB) HUMAN AILLOMAVIRUS (HV) INFLUENZA MEASLES-MUMS-RUBELLA-VARICELLA VIRUS VACCINE ROTAVIRUS VACCINE TETANUS TOXOID TETANUS-DIHTHERIA TOXOIDS (TD) VARICELLA VIRUS VACCINE LIVE ZOSTER VACCINE LIVE FEMALE CONTRACETIVES Oral Contraceptives All generic oral contraceptives (birth control pills) are available at $0 if your plan has ACA benefits. The only brand oral contraceptive we cover at $0 is ORTHO TRI CYCLEN LO. Other Female Contraceptives Cervical Cap: FEMCA, RENTIF, RENTIF FITTING KIT Diaphragms: OMNIFLEX DIARAGM, ORTHO COIL SRING KIT, ORTHO FLAT SRING KIT, ORTHO FLEX, WIDE- SEAL Emergency Contraception: ELLA, NEXT CHOICE Female Condom: FC2 FEMALE CONDOM Implantable Rod: NEXLANON Intrauterine Device (IUD): MIRENA, ARAGARD atch: XULANE Shot/Injection: MEDROXYROGESTERONE AC (generic Depo-rovera) Spermicide: CONCETROL GEL,GYNOL II GEL, ENCARE SUOSITORIES, SHUR-SEAL GEL, VCF VAGINAL CONTRACETIVE FILM, VCF VAGINAL FOAM Sponge: TODAY SONGE Vaginal Contraceptive Ring: NUVARING BlueChoice Healthlan of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. Bold available at tier 1 referred available at tier 2 N Non-preferred available at tier 3 ST Step Therapy QL Quantity Limit A rior Authorization Required MN Medical Necessity rior Authorization $0 See Health Care Reform section for more information 46