Pharmacy Program Bluecross

Your Pharmacy Program
Effective January 1, 2015
Table of Contents
About This Guide and Online Resources
Mail Service Pharmacy
Your Pharmacy Cost Share and ID Card
Top Covered Medications
Over-the-Counter Medications
Quality Care Dosing
Prior Authorization
12
Specialty Pharmacy Medications
14
Step Therapy
19
Non-Covered Medications
21
Medication Resource List Index
29
New Medication Approval Process
43
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association
Overview
Pharmacy Program Overview
Online Resources
Our pharmacy program is designed to provide you and

your doctor with access to a wide variety of safe, clinically
effective medications. We have carefully developed a
substantial formulary that includes many medications at
affordable cost share levels.
From our main website, www.bluecrossma.com, to the

www.express-scripts.com website, we offer a variety
of online resources to help you manage your medications.
About This Guide

This guide is up-to-date as of January 1, 2015, and is subject
to change. Keep this guide handy, and use it as a reference
whenever you need coverage information about a specific
medication. To get the most current coverage information
about a specific medication, visit our website at
www.bluecrossma.com/pharmacy.
Top Covered Medicationsincludes many commonly
prescribed covered medications and your cost share tier
that applies
Over-the-Counter Medicationsincludes a list of
over-the-counter medications that are covered when
prescribed for you by your doctor
Quality Care Dosingincludes a list of medications
subject to Quality Care Dosing limits
Prior Authorizationincludes a list of medications
that require Prior Authorization
Specialty Pharmacy Medicationsincludes a list of
medications that are available through pharmacies in the
Specialty Pharmacy Network
Step Therapyincludes a list of medications subject to
Step Therapy
Medication Resource List Indexincludes all prescription
medications listed in this booklet, along with the page(s)
on which they can be found
Search for Medication Information. To learn whether

your medications will be covered, you can visit
www.bluecrossma.com/pharmacy, and use the
Medication Look Up feature, listed on the left-hand side
of the page. You can use this tool before you enroll. (The
medication information represents our standard pharmacy
coverage; your individual coverage may vary.) Our 2015
formulary changes will not be reflected in this tool until
January 1, 2015.
Member Central. Want more detailed information about
your health care coverage, claims, or deductibles? You can
log on to Member Central by going to our website,
www.bluecrossma.com/member-central. To register,
click Create an Account, on the upper right-hand side
of the page.
If youre already registered, just log in with your
user name and password.
Express Scripts Online. Once registered with Member
Central, you can also get immediate, online access to
information about your specific pharmacy benefit by
visiting Express Scripts Inc., (ESI), our pharmacy
management partner, at www.express-scripts.com.
Once there, youll have access to:
Price a Drug
Find a Pharmacy
M
ail Service features (which allow you
to order refills and renew prescriptions)
Usually, you will pay the least amount of cost share for Tier 1 medications and
the most for Tier 3 medications .
Your cost share may include your copayment, co-insurance, deductibles,

and maximums . For more about your specific prescription benefits, review the
information in your benefit literature, which you should have received when
you enrolled in your plan, or call the Member Service number listed on the front
of your ID card, Monday through Friday, 8:00 a .m . to 9:00 p .m . ET .
Overview
Mail Service Pharmacy
Your ID Card
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in accordance with our confidentiality policy.
If you would like to use the Mail Service Pharmacy, you can
download an order form and nd additional information on
our website. Go to www.bluecrossma.com/pharmacy and
choose Mail Service Pharmacy from the menu on the lefthand side. If youd like our Mail Service Pharmacy brochure
mailed to you, please call 1-800-262-BLUE (2583).
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Your Pharmacy Cost Share

Our pharmacy program formulary is based on a tiered cost
share structure. When you fill a prescription, the amount you
pay the pharmacy (your prescription cost share) is determined
by the tier your medication is on. Medications are placed on
tiers according to a variety of factors, including what they
are used for, their cost, and whether equivalent or alternative
medications are available. The pharmacy will advise you
of the amount you owe. Usually, you will pay the least
amount of cost share for Tier 1 medications and the most
for Tier 3 medications.
Your cost share may include your copayment, co-insurance,

and deductibles. For more about your specific prescription
benefits, review the information in your benefit literature, which
you should have received when you enrolled in your plan, or
call the Member Service number listed on the front of your ID
card, Monday through Friday, 8:00 a.m. to 9:00 p.m. ET.
Covered Medications
Medications
Top Covered
Our pharmacy formulary includes over 4,000 covered
prescription medications. The following sample list includes
covered medications most commonly prescribed for
our members.
This list is up-to-date as of January 1, 2015, and is subject
to change at any time. You can find the most up-to-date
information about a specific prescription medication on our
website at www.bluecrossma.com/pharmacy.
Please note that this is a sample of top prescribed
medications based on our standard formulary.
For more information about your specific prescription benefits,

review the information in your benefit literature, which you
should have received when you enrolled in your plan, or call
the Member Service number listed on the front of your ID card.
The following covered medication list is based on our
standard formulary. The tier that is assigned to the drug
is the tier used in a three-tier cost share benefit structure.
For members with a two-tier or four-tier cost share benefit
structure, please log on to the Blue Cross and Blue Shield
web site at www.bluecrossma.com/pharmacy and use
the Medication Lookup feature.
Abilify tablets (STEP)
Tier 2
Aviane
Tier 1
Cephalexin
Tier 1
Accu-Chek Aviva testing strips (QCD)
Tier 2
Azathioprine
Tier 1
Chantix
Tier 2
Acetaminophen/Codeine
Tier 1
Azelastine (QCD)
Tier 1
Chlorhexadine Gluconate
Tier 1
Acyclovir
Tier 1
Azithromycin
Tier 1
Chlorthalidone
Tier 1
Adapalene
Tier 1
Baclofen
Tier 1
Cialis
Tier 3
Advair Diskus (QCD) (STEP)
Tier 3
Benicar (STEP)
Tier 2
Ciprofloxacin
Tier 1
Albuterol
Tier 1
Benicar HCT (STEP)
Tier 2
Citalopram (QCD)
Tier 1
Alendronate (QCD)
Tier 1
Benzonatate
Tier 1
Clarithromycin
Tier 1
Allopurinol
Tier 1
Betamethasone Dipropionate
Tier 1
Clindamycin
Tier 1
Alprazolam
Tier 1
Budesonide (QCD)
Tier 1
Clindamycin/Benzoyl Peroxide
Tier 1
Altavera
Tier 1
Buprenorphine/Naloxone (PA) (QCD)
Tier 2
Clobetasol Propionate
Tier 1
Alyacen
Tier 1
Bupropion
Tier 1
Clonazepam
Tier 1
Amitriptyline
Tier 1
Bupropion SR (QCD)
Tier 1
Clonidine
Tier 1
Amlodipine/Benazepril
Tier 1
Bupropion XL (QCD)
Tier 1
Clopidogrel
Tier 1
Amolodipine (QCD)
Tier 1
Buspirone
Tier 1
Clotrimazole/Betamethasone
Tier 1
Amoxicillin
Tier 1
Butalbital/APAP/Caffeine
Tier 1
Colcrys
Tier 2
Amoxicillin TR-Potassium Clavulanate
Tier 1
Camila
Tier 1
Combivent Respimat (QCD)
Tier 2
Amphetamine Salt Combination
Tier 1
Carbidopa/Levodopa
Tier 1
Crestor (QCD) (STEP)
Tier 2
Anastrozole
Tier 1
Carisoprodol
Tier 1
Cryselle
Tier 1
Apri
Tier 1
Carvedilol
Tier 1
Cyclobenzaprine
Tier 1
Armour Thyroid
Tier 3
Cefadroxil
Tier 1
Desonide
Tier 1
Asacol HD
Tier 2
Cefdinir
Tier 1
Dexamethasone
Tier 1
Atenolol
Tier 1
Cefuroxime
Tier 1
Dextroamphetamine/Amphetamine
Tier 2
Atorvastatin (QCD)
Tier 1
Celebrex (QCD) (STEP)
Tier 3
Diazepam
Tier 1
(PA) Prior Authorization required

(QCD) Quality Care Dosing limits apply
(STEP) Step Therapy required

Diclofenac
Tier 1
Gildess FE
Tier 1
Lidocaine
Tier 1
Dicyclomine
Tier 1
Glimepiride
Tier 1
Liothyronine Sodium
Tier 1
Digoxin
Tier 1
Glipizide
Tier 1
Lisinopril
Tier 1
Diltiazem ER
Tier 1
Glipizide ER
Tier 1
Lisinopril/HCTZ
Tier 1
Diovan (STEP)
Tier 3
Glipizide XL
Tier 1
Lithium Carbonate
Tier 1
Divalproex Sodium
Tier 1
Glyburide
Tier 1
lo Loestrin FE
Tier 3
Divalproex Sodium ER
Tier 1
Guanfacine
Tier 1
Lorazepam
Tier 1
Donepezil
Tier 1
Humalog (QCD)
Tier 2
Loryna
Tier 1
Dorzolamide/Timolol
Tier 1
Humira (PA) (QCD)
Tier 2
Losartan
Tier 1
Doxazosin
Tier 1
Hydrochlorothiazide
Tier 1
Losartan/HCTZ
Tier 1
Doxycycline Hyclate
Tier 1
Hydrocodone/APAP
Tier 1
Lovastatin (QCD)
Tier 1
Doxycycline Monohydrate
Tier 1
Hydrocodone/Chlorpheniramine
Tier 1
Lutera
Tier 1
Duloxetine (QCD)
Tier 1
Hydrocortisone
Tier 1
Medroxyprogesterone
Tier 1
Econazole
Tier 1
Hydromorphone
Tier 1
Meloxicam (QCD)
Tier 1
Emoquette
Tier 1
Hydroxychloroquine
Tier 1
Metformin
Tier 1
Enalapril
Tier 1
Hydroxyzine
Tier 1
Metformin ER
Tier 1
Enbrel (PA) (QCD)
Tier 2
Ibuprofen
Tier 1
Methimazole
Tier 1
Enoxparin Sodium (QCD)
Tier 2
Indomethacin
Tier 1
Methocarbamol
Tier 1
Enpresse
Tier 1
Iophen-C NR
Tier 1
Methotrexate
Tier 1
Epi-Pen AutoInjector (QCD)
Tier 2
Irbesartan
Tier 1
Methylphenidate
Tier 1
Epi-Pen JR. AutoInjector (QCD)
Tier 2
Isosorbide Mononitrate
Tier 1
Methylphenidate ER (QCD)
Tier 1
Erythromycin
Tier 1
Januvia (STEP)
Tier 2
Methylprednisolone
Tier 1
Escitalopram (QCD)
Tier 1
Junel
Tier 1
Metoclopramide
Tier 1
Estrace Cream
Tier 2
Junel FE
Tier 1
Metoprolol Succinate
Tier 1
Estradiol
Tier 1
Kariva
Tier 1
Metoprolol Tartrate
Tier 1
Fenofibrate
Tier 1
Kelnor 1-35
Tier 1
Metronidazole
Tier 1
Fentanyl patches (PA) (QCD)
Tier 1
Ketoconazole
Tier 1
Microgestin FE
Tier 1
Finasteride
Tier 1
Ketorolac
Tier 1
Minastrin FE
Tier 3
Flovent HFA inhaler (QCD)
Tier 2
Klor-Con
Tier 1
Minocycline
Tier 1
Fluconazole (QCD)
Tier 1
Labetalol
Tier 1
Mirtazapine (QCD)
Tier 1
Fluocinonide
Tier 1
Lamotrigine
Tier 1
Modafinil (PA)
Tier 1
Fluoxetine (QCD)
Tier 1
Lansoprazole (PA) (QCD)
Tier 1
Mometasone
Tier 1
Fluticasone nasal spray (QCD)
Tier 1
Lantus (QCD)
Tier 2
Montelukast
Tier 1
Folic Acid
Tier 1
Lantus Solostar (QCD)
Tier 2
Morphine Sulfate ER (PA) (QCD)
Tier 1
Furosemide
Tier 1
Latanoprost
Tier 1
Mupirocin
Tier 1
Gabapentin
Tier 1
Levetiracetam
Tier 1
Nabumetone
Tier 1
Gemfibrozil
Tier 1
Levitra
Tier 3
Nadolol
Tier 1
Gianvi
Tier 1
Levofloxacin
Tier 1
Namenda
Tier 2
Gildess
Tier 1
Levothyroxine
Tier 1
Naproxen
Tier 1


Necon
Tier 1
Progesterone
Tier 1
Trazodone
Tier 1
Nifedipine ER
Tier 1
Promethazine
Tier 1
Tretinoin (PA)
Tier 1
Nitrofurantoin
Tier 1
Promethazine/Codeine
Tier 1
Tri-Previfem
Tier 1
Norethindrone
Tier 1
Propranolol
Tier 1
Tri-Sprintec
Tier 1
Norgestimate/Ethinyl Estradiol
Tier 1
Propranolol ER
Tier 1
Triamcinolone Acetonide
Tier 1
Nortrel
Tier 1
Pulmicort FlexHaler (QCD)
Tier 2
Triamterene/HCTZ
Tier 1
Nortriptyline
Tier 1
Quetiapine
Tier 1
Trinessa
Tier 1
Nystatin
Tier 1
Quinapril
Tier 1
Vagifem
Tier 2
Nystatin/Triamcinolone
Tier 1
QVAR (QCD)
Tier 2
Valacyclovir (QCD)
Tier 1
Ocella
Tier 1
Ramipril
Tier 1
Valsartan/HCTZ
Tier 1
Ofloxacin
Tier 1
Ranitidine
Tier 1
Venlafaxine
Tier 1
Olanzapine
Tier 1
Reclipsen
Tier 1
Venlafaxine ER capsules (QCD)
Tier 1
Omeprazole (QCD)
Tier 1
Restasis (PA) (QCD)
Tier 3
Verapmil ER
Tier 1
Ondasetron (QCD)
Tier 1
Risperidone
Tier 1
Vesicare (STEP)
Tier 2
Ondasetron ODT (QCD)
Tier 1
Ropinirole
Tier 1
Viagra
Tier 3
One Touch Delica testing strips (QCD)
Tier 2
Sertraline (QCD)
Tier 1
Viorelle
Tier 1
One Touch Ultra testing strips (QCD)
Tier 2
Simvastatin
Tier 1
Vitamin D2
Tier 1
Orsythia
Tier 1
Spiriva HandiHaler (QCD)
Tier 2
Vivelle-DOT (QCD)
Tier 3
Ortho Tri-Cyclen Lo
Tier 3
Spironolactone
Tier 1
Voltaren gel
Tier 3
Oxcarbazepine
Tier 1
Sprintec
Tier 1
Warfarin
Tier 1
Oxybutynin
Tier 1
Strattera (PA) (QCD)
Tier 3
Xarelto
Tier 2
Oxycodone
Tier 1
Suboxone (PA) (QCD)
Tier 2
Zetia (QCD) (STEP)
Tier 3
Oxycodone/APAP
Tier 1
Sulfamethoxizole/Trimethoprim
Tier 1
Zolpidem (QCD)
Tier 1
Oxycontin (PA) (QCD)
Tier 2
Sumatriptan (QCD)
Tier 1
Zolpidem ER (QCD)
Tier 1
Pantoprazole (QCD)
Tier 1
Suprep
Tier 3
Paroxetine (QCD)
Tier 1
Symbicort (QCD) (STEP)
Tier 2
Penicillin
Tier 1
Synthroid
Tier 3
Phenazopyridine
Tier 1
Tamiflu
Tier 3
Pioglitazone (QCD) (STEP)
Tier 1
Tamoxifen
Tier 1
Ploymyxin B-Sul/Trimethoprim
Tier 1
Tamsulosin
Tier 1
Potassium Chloride
Tier 1
Temazepam
Tier 1
Pramipexole
Tier 1
Terazosin
Tier 1
Pravastatin (QCD)
Tier 1
Terbinafine
Tier 1
Prednisone
Tier 1
Timolol Maleate
Tier 1
Premarin
Tier 2
Tizanidine
Tier 1
Prempro
Tier 2
Tobramycin/Dexamethasone
Tier 1
Prenatal Plus
Tier 1
Topiramate
Tier 1
ProAir HFA inhaler (QCD)
Tier 2
Toprol XL
Tier 3
Prochlorperazine
Tier 1
Tramadol
Tier 1

Over-the-Counter Medications
For non-grandfathered health plans under the Affordable Care Act, the following list includes over-the-counter
medications that are covered with no cost share when they are prescribed for you by your doctor. This list is up to
date as of January 1, 2015, and is subject to change at any time.
Generic Aspirin (81mg) is covered for females age 5579 and males age 4579.
Generic Folic Acid is covered for females up to age 50.
Generic Iron is covered for infants up to 12 months old.
Generic Smoking Cessation is covered for up to two 90-day supplies per calendar year.
Generic Vitamin D is covered for females of child bearing age and males age 65 and older.
Generic womens contraceptives (e.g. female condoms, sponges, and spermicide) are covered.
Quality Care Dosing
Quality Care Dosing

Quality Care Dosing
Our Quality Care Dosing program helps to ensure that the
quantity and dose of medications you receive comply with
Food and Drug Administration (FDA) recommendations, as
well as manufacturer and clinical information. When you fill
a prescription for one of the following medications, it is
checked electronically in two ways:
Dose ConsolidationChecks to see whether youre taking
two or more pills a day that can be replaced with one pill
providing the same daily dosage.
Recommended Monthly Dosing LevelChecks to
see that your monthly dosage is consistent with the
manufacturers and FDAs monthly dosing
recommendations and clinical information.
We will get your doctors approval before making

any changes to your prescribed medications.
For the most up-to-date list of medications subject to
Quality Care Dosing, along with associated dosing limits,
please visit our website at www.bluecrossma.com/pharmacy
and proceed to the Quality Care Dosing section.
Please note: Your doctor may request an exception from
the guidelines for medications that are subject to Quality
Care Dosing (when medically necessary).
Quality Care Dosing List

This list of medications that are in our Quality Care Dosing
program is up-to-date as of January 1, 2015, and may
change from time to time.
Abstral * (PA)
Alendronate Sodium
Aplenzin ER *
AcipHex * (PA)
Alora *
Aranesp (PA) (SP) (SPO)
Actiq * (PA)
Alrex *
Arava *
Actonel (STEP)
Alsuma *
Arcapta Neohaler *
ACTOplus Met (STEP)
Altoprev (STEP)
Arixtra *
ACTOplus Met XR (STEP)
Alupent inhaler
Asmanex Twisthaler *
Actos (STEP)
Alvesco *
Astelin
Acular *
Ambien *
Astepro *
Acular LS *
Ambien CR *
Atelvia DR * (STEP)
Acular PF
Amerge
Atorvastatin
Adderall XR
Amitiza
Atrovent (nasal spray)
Advair Diskus (STEP)
Amlodipine
Atrovent HFA
Advair HFA (STEP)
Amlodipine-Atorvastatin
Auvi-Q *
Advicor (STEP)
Ampyra (PA) (SP)
Avandamet (STEP)
Aerobid *
Anzemet *
Avandia (STEP)
Aerobid-M *
* (non-covered medication) Quality Care Dosing limits apply for members with approved formulary exceptions
** (new to market drug; non-covered while under review) quantity limits apply to members with approved formulary exceptions
(PA) prior authorization required
(PA17) prior authorization required for members who are 17 years of age or older
(SP) Medication is part of the specialty pharmacy network
(SPO) Available in pharmacy benefit only
(STEP) step therapy required
Quality Care Dosing

Avinza *
Ciclodin solution/kit
Epi-Pen Auto-Injector
Avonex (SP) (SPO)
Ciclopirox nail lacquer
Epinephrine injection
Axert *
Citalopram
Epogen (PA) (SP) (SPO)
Azelastine (nasal spray)
Climara
Escitalopram
Azmacort *
Climara Pro
Esomeprazole Strontium * (QCD)
Beconase AQ *
Clonidine patch
Estraderm
Belviq (PA)
CNL 8 nail kit *
Estradiol patch
Betaseron (SP) (SPO)
Combivent
Estrasorb *
Binosto * (STEP)
Combivent Respimat
Estrogel *
Boniva tablets * (STEP)
Concerta
Eszopiclone
Brintellix *
Copaxone (SP) (SPO)
Evamist *
Brisdelle *
Crestor (STEP)
Evzio
Budeprion SR
Crolom ophthalmic
Exalgo *
Budeprion XL
Cromolyn ophthalmic
Extavia (SP) (SPO)
Budesonide (nasal spray)
Cymbalta
Famciclovir
Budesonide (nebules)
Desvenlafaxine ER *
Famvir *
Bunavail (PA)
Dexilant * (PA)
Fentanyl oral/mucosal (PA)
Buprenex (PA)
Dexmethylphenidate XR
Fentanyl patch (PA)
Buprenorphine (PA)
Dextroamphetamine/Amphetamine ER
Fentora * (PA)
Buprenorphine-Naloxone (PA)
Diflucan (150 mg only)
Fetzima
Bupropion SR
Dihydroergotamine (nasal spray)
Flonase *
Bupropion XL
Doxazosin
Flovent/HFA
Butorphanol NS
Dulera (STEP)
Fluconazole (150 mg only)
Butrans *
Duloxetine
Flunisolide
Cabergoline
Duragesic * (PA)
Fluoxetine
Caduet * (STEP)
Dymista *
Fluoxetine DR
Cardura *
Edluar *
Fluticasone
Cardura XL *
Effexor XR *
Fluvastatin
Catapres TTS
Embeda *
Fluvoxamine
Celebrex
Emend
Fluvoxamine CR
Celexa *
Enbrel (PA) (SP) (SPO)
Focalin XR *
Cesamet *
Enoxaparin
Fondaparinux
Quality Care Dosing

Foradil
Lazanda * (PA)
Moxeza *
Forfivo XL *
Leflunomide
MS Contin (PA)
Forteo (PA) (SP) (SPO)
Lescol * (STEP)
Naratriptan
Fosamax * (STEP)
Lescol XL * (STEP)
Nasonex *
Fosamax Plus D (STEP)
Lexapro
NebuPent
Fragmin *
Lidocaine Patch
Neulasta (SP)
Frova *
Lidoderm
Neupogen (SP)
Gatifloxacin
Linzess
Nexium * (PA)
Gilenya (SP)
Lipitor * (STEP)
Norvasc *
Glucose testing strips (all brands)
Liptruzet **
Olanzepine-Fluoxetine
Granisetron
Livalo * (STEP)
Omeprazole
Granisol
Lotronex
Omeprazole-Sod. Bicarbonate * (PA)
Granix
Lovastatin
Omnaris *
Grastek (PA)
Lovenox *
Omontys (PA) (SP)
Hetlioz (PA)
Lunesta
Ondansetron
Humira (PA) (SP) (SPO)
Luvox CR *
Ondansetron ODT
Hydromorphone ER (PA)
Lysteda *
Onmel *
Hytrin *
Maxair Autohaler *
Onsolis * (PA)
Ibandronate
Maxalt *
Opana ER * (PA)
Imitrex
Maxalt-MLT *
Optivar *
Infergen (PA) (SP) (SPO)
Meloxicam
Oralair (PA)
Insulins (all brands)
Menostar *
Oramorph SR * (PA)
Intermezzo *
Metadate CD
Otezla (PA) (SP)
Ipratropium NS
Methylphenidate CD
Oxycodone ER (PA)
Itraconazole
Methylphenidate ER
OxyContin (PA)
Kadian * (PA)
Mevacor * (STEP)
Oxymorphone ER (PA)
Ketorolac ophthalmic
Migranal
Pantoprazole
Khedezla *
Minivelle
Paroxetine
Kytril *
Mirtazapine
Paroxetine CR
Lamisil *
Mirtazapine Rapid Dissolve
Patanase *
Lansoprazole (PA)
Mobic *
Paxil *
Lansoprazole/Amoxicillin/Clarithromycin
Morphine Sulfate ER (PA)
Paxil CR *
Quality Care Dosing

Pediapirox-4
Remeron Soltab *
Tudorza
PEG-Intron (SP) (SPO)
Restasis (PA)
Valacylovir
Pegasys (SP) (SPO)
Rhinocort Aqua *
Valtrex
Penlac *
Risedronate
Venlafaxine ER capsule
Pexeva *
Ritalin LA *
Venlafaxine ER tablet
Pioglitazone (STEP)
Rizatriptan
Ventolin HFA *
Pioglitazone-Glimepiride (STEP)
Rozerem
Veramyst *
Pioglitazone-Metformin (STEP)
Sancuso *
Vigamox *
Pravachol * (STEP)
Sarafem *
Viibryd *
Pravastatin
Selferma
Vivelle
Prevacid * (PA)
Serevent Diskus
Vivelle-Dot
PrevPac *
Sertraline
Vytorin * (STEP)
Prilosec * (PA)
Silenor *
Vyvanse *
Pristiq *
Simcor * (STEP)
Wellbutrin SR *
ProAir HFA
Simponi (PA) (SP) (SPO)
Wellbutrin XL *
Procrit (PA) (SP) (SPO)
Simvastatin
Xartemis XR * (PA)
Protonix * (PA)
Sonata
Xopenex HFA *
Proventil HFA *
Spiriva
Zaleplon
Prozac *
Sporanox *
Zegerid * (PA)
Prozac Weekly *
Strattera (PA17)
Zetia (STEP)
Pulmicort Flexhaler
Suboxone (PA)
Zetonna *
Pulmicort Respules
Subsys * (PA)
Zocor * (STEP)
QNASL *
Subutex (PA)
Zofran *
Qualaquin
Sumatriptan
Zofran ODT *
Qutenza (SP)
Sumavel Dosepro *
Zohydro ER * (PA)
QVAR
Symbicort (STEP)
Zolmitriptan
Rabeprazole (PA)
Symbyax
Zolmitriptan ODT
Ragwitek (PA)
Terazosin
Zoloft *
Rapaflux
Terbinafine
Zolpidem
Rebif (SP) (SPO)
Terbinex *
Zolpidem ER
Relpax *
Tranexamic Acid
Zolpimist *
Remeron *
Treximet *
Zomig *
10
Quality Care Dosing

Zomig ZMT *
Zubsolv **
Zuplenz *
Zymar *
Zymaxid *
11
Prior Authorization
Prior Authorization
Prior Authorization
Your doctor is required to obtain prior authorization before
prescribing specific medications. This ensures that your
doctor has determined that this medication is necessary
to treat you, based on specific medical standards.
For the most up-to-date list of medications that
require prior authorization, please visit our website,
www.bluecrossma.com/pharmacy, click on Pharmacy
Management Program, and proceed to Prior Authorization.
Another part of our prior authorization program is step

therapy. Please refer to page 19 for a list of medications
that require step therapy.
Prior Authorization List

This list of medications that require prior authorization
is up-to-date as of January 1, 2015, and may change
from time to time.
Abstral * (QCD)
Buprenorphine-Naloxone (QCD)
Entyvio (SP)
AcipHex * (QCD)
Butrans * (QCD)
Epogen (QCD) (SP) (SPO)
Actemra (SP)
Ceredase (MBO)
Erbitux (MBO)
Acthar (SP)
Cerezyme (MBO)
Esomeprazole Strontium * (QCD)
Actiq * (QCD)
Cimzia (SP) (SPO)
Euflexxa * (SPO)
Adcirca (SP)
Cinryze (MBO)
Exalgo * (QCD)
Amevive (MBO)
Desoxyn (PA17)
Eylea (MBO)
Amphetamines (e.g Amphetamine,
Dexilant * (QCD)
Factor VIII, VIIIa, IX, XIII (MBO)
Methamphetamine, Liquadd, Procentra)
Dextroamphetamines (e.g. Dexedrine)
Fentanyl oral/mucosal (QCD)
Ampyra (QCD) (SP)
(PA17)
Fentanyl patch (QCD)
Aralast (MBO)
Dificid
Fentora * (QCD)
Aralast NP (MBO)
Diskets
First-lansoprazole
Aranesp (QCD) (SP) (SPO)
Dolophine
First-omeprazole
Avinza * (QCD)
Duragesic * (QCD)
Forteo (QCD) (SP) (SPO)
Belviq
Dysport
Gel-One * (SPO)
Boniva syringe * (SP)
Egrifta (SP)
Grastek (QCD)
Botulinum toxin
Elidel
Growth Hormone (SP) (SPO)
Bunavail (QCD)
Embeda * (QCD)
Hetlioz (QCD)
Buprenex
Enbrel (QCD) (SP) (SPO)
Humira (QCD) (SP) (SPO)
Buprenorphine (QCD)
Enteral formula
Hyalgan * (SPO)
(MBO) medical benefit only
(SPO) pharmacy benefit only
12
Prior Authorization
Ilaris (SP) (SPO)
Oralair (QCD)
Stelara * (SP) (SPO)
Incivek (SP) (SPO)
Oramorph SR * (QCD)
Strattera (PA17) (QCD)
Interferons (alpha, gamma)
Orencia (SP)
Suboxone (QCD)
IV Immunoglobulin (MBO)
Orthovisc * (SPO)
Subsys * (QCD)
Kadian * (QCD)
Otezla (QCD) (SP)
Supartz * (SPO)
Kalydeco
Oxycodone ER (QCD)
Synagis (SP)
Kineret (SP) (SPO)
Oxycontin (QCD)
Synvisc * (SPO)
Lansoprazole (QCD)
Oxymorphone ER (QCD)
Synvisc One * (SPO)
Lazanda * (QCD)
Preservative-Free Morphine (MBO)
Topical Retinoic Acid derivatives (e.g.
Leukine (SP)
Prevacid * (QCD)
Retin A) (PA30)
Lucentis (MBO)
Prilosec * (QCD)
TPN (total parenteral nutrition) (MBO)
Lyrica
Procrit (QCD) (SP) (SPO)
Tysabri (MBO)
Macugen (MBO)
Prolastin (MBO)
Vectibix (MBO)
Makena (SP)
Prolastin C (MBO)
Victrelis (SP)
Methadone
Proleukin (SP)
Xalkori (SP)
Methadose
Prolia (SP) (SPO)
Xeljanz * (SP)
Modafinil
Protonix * (QCD)
Xenazine
Monovisc * (SPO)
Protopic
Xeomin
Morphine Sulfate CR (QCD)
Provigil (PA17)
Xgeva (SP) (SPO)
Morphine Sulfate ER (QCD)
Rabeprazole (QCD)
Xiaflex (MBO)
MS Contin (QCD)
Ragwitek (QCD)
Xolair (MBO)
Myalept (SP)
Reclast (MBO)
Zegerid * (QCD)
Nexium * (QCD)
Regranex
Zelboraf (SP)
Nucynta ER *
Remicade (SP)
Zometa (MBO)
Nutritional Supplements
Respiratory SyncytialVirus IG/Synagis (SP)
Zubsolv (QCD)
Nuvigil * (PA17)
Restasis (QCD)
Zykadia (SP)
Olysio (SP)
Revatio * (SP)
Omeprazole-Sod. Bicarbonate * (QCD)
Rituxan (SP)
Omontys (SP) (SPO)
Sildenafil (SP)
Onsolis * (QCD)
Simponi (QCD) (SP) (SPO)
Opana ER * (QCD)
Sovaldi (SP)
(MBO) medical benefit only
(SPO) pharmacy benefit only
13
Specialty Pharmacy MedicationsSpecialty Pharmacy

Specialty Pharmacy Medications
Blue Cross Blue Shield of Massachusetts has set up a
network of retail specialty pharmacies to dispense certain
medications classified as specialty. The following is a
list of medications that can only be purchased from one
of the pharmacies in this network in order for coverage
to be available.
Network Pharmacy Information

AcariaHealth
1-866-892-1202
www.acariahealth.com
Accredo Health Group, Inc. /CuraScript
1-877-988-0058
www.accredo.com
CVS Caremark, Inc.
1-866-846-3096
www.caremark.com
OncoMed, the Oncology Pharmacy
1-877-662-6633
www.oncomed.net
This list is up-to-date as of January 1, 2015. You can

find the latest information about your medications and
look up pharmacy contact information by visiting
www.bluecrossma.com/pharmacy.
Network Pharmacy Information for

Medications Most Commonly Used for Fertility
BriovaRx
1-800-850-9122
www.briovarx.com
Freedom Fertility Pharmacy
1-866-297-9452
www.freedomfertility.com
Metro Drugs
1-888-258-0106
www.metrodrugs.com
Village Fertility Pharmacy
1-877-334-1610
www.villagefertilitypharmacy.com
Walgreens
1-800-424-9002
www.walgreens.com/pharmacy/specialpharmacy.jsp
14
Specialty Pharmacy
Fertility Medications
Arcalyst Injection (SPO)
Doxil
Bravelle * (SPO)
Aredia
Doxorubicin HCl
Cetrotide (SPO)
Arzerra
DTIC-Dome
Clomid
Aveed
Egrifta (PA)
Clomiphene
Avonex (QCD) (SPO)
Eligard
Endometrin
Betaseron (QCD) (SPO)
Ellence
Follistim AQ * (SPO)
BiCNu
Eloxatin
Ganirelix (SPO)
Bleomycin Sulfate
Elspar
Gonal F Rff Rediject (SPO)
Boniva Injection * (PA)
Enbrel (PA) (QCD) (SPO)
Gonal F/Gonal F RFF (SPO)
Busulfex
Entyvio (PA)
Human Chorionic Gonadotropin (HCG)
Calcium Folanate
Epirubicin
(SPO)
Camptosar
Epogen (PA) (QCD) (SPO)
Leuprolide (SPO)
Carboplatin
Ethyol
Lupron Depot
Cerubidine
Etopophos
Lupron Depot-Ped
Cimzia (PA) (SPO)
Etoposide
Luveris (SPO)
Cisplatin
Extavia * (QCD) (SPO)
Menopur (SPO)
Cladribine
Faslodex
Novarel
Copaxone (QCD) (SPO)
Firazyr
Ovidrel (SPO)
Cosmegen
Firmagon
Pregnyl (SPO)
Cyclophosphamide
Floxuridine
Repronex (SPO)
Cyramza
Fludara
Serophene
Cytarabine
Fludarabine phosphate
Injectable Medications
Cytoxan
Fluorouracil
Abraxane
Dacarbazine
Forteo (PA) (QCD) (SPO)
Actemra (PA)
Dactinomycin
FUDR
Acthar (PA)
Daunorubicin HCL
Fusilev I.V.
Actimmune (PA) (SPO)
DaunoXome
Fuzeon (SPO)
Adriamycin PFS
DDAVP *
Gattex
Adrucil
Depocyt
Gazyva
Alferon N (PA)
Desmopressin Acetate
Gemcitabine
Alkeran
Dexrazoxane
Gemzar
Apokyn
Docefrez
Genotropin * (PA) (SPO)
Aranesp (PA) (QCD) (SPO)
Docetaxel
Granix
(SPO) available in pharmacy benefit only
15
Specialty Pharmacy
Herceptin
Methotrexate
Pegasys (QCD) (SPO)
Humatrope (PA) (SPO)
Mitomycin
Photofrin
Humira (PA) (QCD) (SPO)
Mitoxantrone
Procrit (PA) (QCD) (SPO)
Hycamtin
Mozobil
Proleukin (PA)
Ibandronate
Mustargen
Prolia (PA) (SPO)
Idamycin PFS
Myalept (PA)
Raptiva
Idarubicin
Mylotarg
Rebif (QCD) (SPO)
Ifex
Navelbine
Remicade (PA)
Ifosfamide
Neosar
Revatio * (PA)
Ifosfamide/Mesna
Neulasta (QCD)
Rituxan (PA)
Ilaris (PA) (SPO)
Neumega
Ruconest **
Increlex (PA) (SPO)
Neupogen (QCD)
Saizen * (PA) (SPO)
Infergen (PA) (QCD) (SPO)
Nipent
Sandostatin (SPO)
Intron A (PA) (SPO)
Norditropin * (PA) (SPO)
Sandostatin-LAR
Irinotecan
Norditropin Flexpro * (PA) (SPO)
Serostim (PA) (SPO)
Istodax
Norditropin Nordiflex * (PA) (SPO)
Signafor **
Kenalog
Novantrone
Simponi (PA) (QCD) (SPO)
Keytruda
Nplate
Simponi Aria (PA)
Kineret (PA) (SPO)
Nutropin (PA) (SPO)
Simulect
Kynamro (STEP)
Nutropin AQ (PA) (SPO)
Somatuline
Leucovorin Calcium
Nutropin AQ Nuspin (PA) (SPO)
Somavert (SPO)
Leukine (PA)
Octreotide injection (SPO)
Stelara * (PA) (SPO)
Leuprolide Acetate (SPO)
Omnitrope * (PA) (SPO)
Sylatron (PA)
Leustatin
Omontys (PA) (QCD)
Sylvant
Lipodox
Oncaspar
Synagis (PA)
Lipodox-50
Ontak
Synribo
Lupaneta Pack
Onxol
Tarabine
Lupron Depot
Orencia (PA)
Taxol
Lupron Depot-Ped
Oxaliplatin
Taxotere
Makena (PA)
Paclitaxel
Teniposide
Marqibo
Pamidronate
Tev-Tropin * (PA) (SPO)
Mesna
Pamidronate disodium
TheraCys
Mesnex
Peg-Intron (QCD) (SPO)
Thiotepa
16
Specialty Pharmacy
Thyrogen
Cometriq
Orfadin (SPO)
Toposar
Copegus (SPO)
Otezla (PA) (QCD)
Totect
Cystagon
Otezla Starter Pack *
Trelstar
Cytoxan
Pomalyst
Trelstar Depot
Erivedge
Procysbi
Trelstar LA
Etoposide
Promacta
Valstar
Exjade
Pulmozyme (SPO)
Velcade
Gilenya (QCD)
Ravicti
Vimzim
Gilotrif
Rebetol (SPO)
VinBLAStine
Gleevec
Revatio * (PA)
VinCRIStine
Havroni ** (PA)
Revlimid
Vinorelbine
Hetlioz (PA)
Ribapak (SPO)
Vumon
Hycamtin
Ribasphere (SPO)
Xgeva (PA) (SPO)
Iclusig
Ribatab
Zaltrap
Imbruvica
Ribavirin (SPO)
Zanosar
Incivek (PA)
Rilutek
Zenapax
Inlyta
Riluzole
Zinecard
Iressa
Sabril
Zoladex
Jakafi
Sildenafil (PA)
Zorbtive (PA) (SPO)
Kalydeco (PA)
Sovaldi (PA)
Oral Medications
Korlym
Sprycel
8-Mop
Kuvan
Stivarga
Adcirca (PA)
Letairis
Sucraid
Adempas
Mekinist
Sutent
Afinitor
Mesnex
Tafinlar (PA)
Alkeran
Moderiba
Tarceva
Ampyra (PA) (QCD)
Nexavar
Tasigna
Aubagio
Northera
Tecfidera
Bethkis
Oforta
Temodar
Bosulif
Olysio (PA)
Temozoloamide
Capecitabine
Onsolis * (PA) (QCD)
Thalomid
Carbaglu
Opsumit
TOBI ampules (SPO)
Cerdelga **
Orenitram
TOBI-Podhaler (SPO)
17
Specialty Pharmacy
Tobramycin ampules
Tracleer
Tykerb
Tyvaso
Victrelis (PA)
Votrient
Xalkori (PA)
Xeljanz *
Xeloda
Xenazine
Xtandi (STEP)
Xyrem
Zavesca
Zelboraf (PA)
Zolinza
Zydelig
Zykadia (PA)
Zytiga
Topical
Cystaran
Panretin (SPO)
Qutenza (QCD)
Valchlor
18
Therapy
Step Therapy
Step Therapy
Step Therapy List
Step therapy is a key part of our prior authorization program

that allows us to help your doctor provide you with an
appropriate and affordable drug treatment. Before coverage
is allowed for certain costly second-step medications,
we require that you first try an effective, but less expensive,
first-step medication. Some medications may have
multiple steps.
This list is up-to-date as of January 1, 2015, and is subject

to change at any time. For the most up-to-date list of
medications that require step therapy, please visit our website
www.bluecrossma.com/pharmacy, click on Pharmacy
Management Program, and proceed to Step Therapy.
Asthma Management
Latuda *
Livalo * (QCD)
Accolate *
Loxitane
Mevacor * (QCD)
Advair Diskus (QCD)
Risperdal
Pravachol * (QCD)
Advair HFA (QCD)
Risperdal Consta
Simcor * (QCD)
Anoro Ellipta (QCD)
Risperdal M-Tab *
Vytorin * (QCD)
Breo Ellipta * (QCD)
Saphris *
Zetia (QCD)
Dulera (QCD)
Seroquel
Zocor * (QCD)
Singulair
Seroquel XR
Diabetes Management
Symbicort (QCD)
Symbyax (QCD)
ACTOplus Met (QCD)
Zyflo *
Zyprexa
ACTOplus Met XR (QCD)
Zyflo CR *
Zyprexa IM *
Actos (QCD)
Atypical Antipsychotic
Medications
Zyprexa Relprevv *
Avandamet (QCD)
Zyprexa Zydis
Avandaryl
Cholesterol Treatment
Avandia (QCD)
Abilify
Abilify DiscMelt *
Advicor (QCD)
Duetact
Abilify Maintenna *
Altoprev * (QCD)
Farxiga *
Clozaril
Caduet * (QCD)
Fortamet *
Fanapt *
Crestor (QCD)
Glucophage *
FazaClo *
Juxtapid
Glucophage XR *
Geodon
Kynamro (SP)
Glumetza *
Haldol
Lescol * (QCD)
Invokamet
Haldol Decanoate
Lescol XL * (QCD)
Invokana
Invega *
Lipitor * (QCD)
Janumet
Invega Sustenna
Liptruzet ** (QCD)
Janumet XR
19
Step Therapy
Januvia
Diovan HCT
Sanctura *
Jardiance
Edarbi *
Sanctura XR *
Jentadueto *
Edarbiclor *
Toviaz *
Kazano *
Exforge
Vesicare
Kombiglyze XR
Exforge-HCT
Nesina *
Hyzaar *
Pain Relievers (Cox II

Inhibitors)
Onglyza
Micardis *
Celebrex (QCD)
Oseni *
Micardis HCT *
Pioglitazone (QCD)
Tekamlo *
Parkinson's Disease
Treatment
Pioglitazone-Glimepiride (QCD)
Tekturna *
Pioglitazone-Metformin (QCD)
Tekturna HCT *
PrandiMet *
Teveten *
Prandin *
Teveten HCT *
Tradjenta *
Tribenzor
Victoza
Twynsta *
Glaucoma
Valturna *
Lumigan
Rescula *
Osteoporosis Treatment
(Oral)
Travatan
Actonel (QCD)
Proscar *
Travatan Z
Atelvia DR * (QCD)
Topical Testosterone
Xalatan
Binosto * (QCD)
Fortesta *
Boniva tablets * (QCD)
Testim *
Fosamax * (QCD)
Testosterone gel (Fortesta Authorized
Amturnide *
Fosamax Plus D (QCD)
product) *
Atacand *
Overactive Bladder Treatment
Testosterone gel (Testim Authorized
Atacand HCT *
Detrol *
product) *
Avalide
Detrol LA *
Testosterone gel (Vogelxo Authorized
Avapro
Ditropan *
product) *
Azor
Ditropan XL *
Vogelxo *
Benicar
Enablex *
Benicar HCT
Gelnique *
Cozaar *
Myrbetriq *
Diovan
Oxytrol *
Heart/Blood Modifiers/
Circulation
Mirapex
Mirapex ER *
Requip *
Requip XL *
Prostate Cancer - Oral

Xtandi
Prostate Treatment
Avodart
Jalyn
20
Non-Covered Medication Non-Covered Medication

Non-Covered Medication
Non-Covered Medication List
Your pharmacy program provides coverage for over 4,000

prescription medications. Most medications on our noncovered list have equally safe, effective, covered alternatives
for treating the same medical conditions. If a non-covered
drug is approved, it will be covered at the highest tier or cost
share. Check with your doctor about appropriate alternatives
if you currently take any of these medications.
This list of non-covered medications is up-to-date as

of January 1, 2015, and may change from time to time.
For the most up-to-date list of medications that are not
covered and their covered alternatives, please visit our
website, www.bluecrossma.com/pharmacy, click on
Medication Look Up, and proceed to the Medications
that are not Covered section.
Please note: Your doctor may request coverage for a

non-covered medication if no covered alternative is
appropriate for treating your condition.
Abilify DiscMelt (STEP)
Adalat CC
Amturnide (STEP)
Abilify Maintenna (STEP)
Adderall
Anafranil
Absorica
Adoxa CK
Analpram Advanced
Abstral (PA) (QCD)
Adoxa TT
Analpram-E kit
Acanya
Aerobid (QCD)
Angeliq
Accolate (STEP)
Aerobid-M (QCD)
Antara
AccuNeb
Airet
Anzemet (QCD)
Accupril
Alodox
Apidra
Accuretic
Aloquin
Aplenzin ER (QCD)
Accutane
Alora (QCD)
Appformin-D
Aceon
Alrex (QCD)
Aqua Glycolic HC
AcipHex (PA) (QCD)
Alsuma (QCD)
Arava (QCD)
Acticlate
Altabax
Arcapta Neohaler (QCD)
Actigall
Altace
Arixtra (QCD)
Actiq (PA) (QCD)
Altoprev (STEP) (QCD)
Ascensia diabetic testing supplies (QCD)
Activella
Aluvea
Asmanex Twisthaler (QCD)
Acular (QCD)
Alvesco (QCD)
Assure Pro diabetic testing supplies (QCD)
Acular LS (QCD)
Ambien (QCD)
Astepro (QCD)
Acuvail
Ambien CR (QCD)
Atacand (STEP)
Aczone
Amrix
Atacand HCT (STEP)
21
Atelvia DR (STEP) (QCD)
Brintellix (QCD)
Cleocin T
Ativan
Brisdelle (QCD)
Clindacin ETZ Kit
Atopiclair
Bromday
Clindacin PAC
Atralin
Brovana
Clindagel
Atrapro CP
Butrans (PA) (QCD)
Clindamax
Atrapro Dermal Spray
Bystolic
Clindareach
Atrapro Hydrogel
Caduet (QCD)
Clindets
Atropen
Calcitriol Topical
Clobeta + Plus
Augmentin XR
Cambia
Clobex
Aurstat
Caphosol
Clodan Kit
Auvi-Q (QCD)
Capoten
CNL 8 nail kit (QCD)
Avelox
Cardene
Colazal
Avidoxy
Cardene SR
Combigan
Avidoxy DK
Cardizem CD
Combunox
Avinza (PA) (QCD)
Cardizem LA
Contour Next diabetic testing
Avita
Cardura XL (QCD)
supplies (QCD)
Axert (QCD)
Cataflam
Conzip
Axid
Ceclor
Coreg
Azasite
Ceclor CD
Coreg CR
Azmacort (QCD)
Cedax
Cosopt PF
B-D diabetic testing supplies (QCD)
Celexa (QCD)
Cozaar (STEP)
Beconase AQ (QCD)
Cem-Urea
Cymbalta (QCD)
BenzaClin kit
Cenestin
Daliresp
Besivance
Centany
Darvocet N-100
Binosto (STEP) (QCD)
Centany AT
Daypro
Bionect
Cesamet (QCD)
Daytrana
Boniva syringe (PA) (SP)
Cetraxel
DDAVP
Boniva tablets (STEP) (QCD)
Chenodal
Demulen
Bravelle (SP)
Chibroxin Ocumeter
Depo-Sub Q Provera 104
Breo Ellipta (PA) (QCD)
Cipro-XR
Derma-Smoothe/FS
Brevicon
Cleanse and Treat
Dermasorb-AF
Brilinta
Cleervue-M
Dermasorb-HC
22
Dermasorb-TA
Edarbiclor (STEP)
Farxiga (STEP)
Dermasorb-XM
Edluar (QCD)
FazaClo (STEP)
DermOtic
Effexor
Femtrace
Desogen
Effexor XR (QCD)
Fenoglide
Desonil + Plus
Elestrin
Fentora (PA) (QCD)
DesOwen kit
Eletone
Fertinex (SP)
Desvenlafaxine ER (QCD)
Embeda (QCD)
Fexmid
Detrol (STEP)
Embrace diabetic testing supplies (QCD)
Fibracor
Detrol LA (STEP)
Emsam
Finacea Plus
Dexedrine (PA)
Enablex (STEP)
Fioricet
Dexilant (PA) (QCD)
Enjuvia
Fiorinal
Dilacor XR
Epaned
Fiorinal with Codeine
Dilaudid
EpiCeram
Flagyl
Dipentum
Epiduo
Flagyl ER
Dispermox
Episil
Flagyl IV
Ditropan (STEP)
Equetro
Flector
Ditropan XL (STEP)
Ertaczo
Flonase (QCD)
Divigel
Esomeprazole Strontium (STEP) (QCD)
FML Forte
Doryx
Estrace
Focalin
Duavee
Estrasorb (QCD)
Focalin XR (QCD)
Duexis
Estrogel (QCD)
Follistim AQ (SP)
Duragesic (PA) (QCD)
Euflexxa (PA) (SPO)
Forfivo XL (QCD)
Durezol
Evamist (QCD)
Fortamet (STEP)
Dymista (QCD)
Evoclin
Fortesta (STEP)
Dynabac
ExacTech diabetic testing supplies (QCD)
Fosamax (STEP) (QCD)
Dynacin
Exalgo (PA) (QCD)
Fragmin (QCD)
Dynacirc
Extavia
Freestyle diabetic testing supplies (QCD)
Dynacirc CR
Extina
Fresh Kote
Dytan
Factive
Frova (QCD)
Easy Step diabetic testing supplies (QCD)
Falessa kit
Garamide
Easy-Trak diabetic testing supplies (QCD)
Famvir (QCD)
Gel-One (PA) (SPO)
Edarbi (STEP)
Fanapt (STEP)
Gelclair
23
Gelnique (STEP)
InnoPran XL
Lipofen
GelX
Intermezzo (QCD)
Liptruzet (STEP) (QCD)
Genotropin (PA) (SP)
Intuniv
Livalo (STEP) (QCD)
Giazo
Invega (STEP)
Lodine
Glucometer diabetic testing
Iquix
Lodine XL
supplies (QCD)
Istalol
Lofibra
Glucophage
Jentadueto (STEP)
Lopressor
Glucophage XR
Jublia
Lorabid
Glumetza
Kadian (PA) (QCD)
LoSeasonique
Halonate
Kapvay
Lotensin
Halotin
Kazano (STEP)
Lotensin HCT
Helidac
Keppra XR
Loutrex
Horizant
Keralyt kit
Lovaza
HPR
Ketocon + Plus
Lovenox (QCD)
HPR Plus
Khedezla (QCD)
Lunesta (QCD)
Hyalgan (PA) (SPO)
Klonopin
Luvox CR (QCD)
Hydrocortisone-Lidocaine kit
Kytril (QCD)
Luzu
Hylase
Lamictal ODT
Lysteda (QCD)
Hylatopic
Lamisil (QCD)
Lytensopril
Hylatopic Plus
Lamisil Granules (QCD)
Mavik
Hylatopic Plus-Aurstat
Latuda (STEP)
Maxair Autohaler (QCD)
Hylira
Lazanda (PA) (QCD)
Maxalt (QCD)
Hytrin (QCD)
Lescol (STEP) (QCD)
Maxalt-MLT (QCD)
Hyzaar (STEP)
Lescol XL (STEP) (QCD)
Maxipime
IB-Stat
Levaquin
MB Hydrogel
IC400 kit
Levemir (QCD)
Megace ES
IC800 kit
Levlen
Menostar (QCD)
Ilevro
Lexapro (QCD)
Metaglip
Imuran
Lexxel
Metozolv ODT
Inderal LA
Lialda
Metrogel kit
Inderal XL
Lidovir
Mevacor (STEP) (QCD)
Innohep
Lipitor (STEP) (QCD)
Micardis (STEP)
24
Micardis HCT (STEP)
Nexium (PA) (QCD)
Ortho-Prefest
Minocin
Niravam
Orthovisc (PA) (SPO)
Minocin Combo Pack
Nivatropic Plus
Oseni (STEP)
Mirapex ER (STEP)
Nor-Q-D
Osphena
Mobic (QCD)
Norditropin (PA) (SP)
Otezla Starter Pack (SP)
Momexin
Norinyl
Ovcon
Monodox
Noroxin
Oxecta
Monopril
Norvasc (QCD)
Oxytrol (STEP)
Monopril HCT
Novacort
Pamelor
Monovisc (PA) (SPO)
Novolin Insulin products
Pamine FQ
Morgidox
Novolog Insulin products
Pancreaze
Moxatag
NuCort
Paptase
Moxeza (QCD)
Nucynta
Patanase (QCD)
Myoxin
Nucynta ER (PA)
Paxil (QCD)
Myrbetriq
NutriDox
Paxil CR (QCD)
Naprelan
Nuvigil (PA)
PCE
Naprelan CR
Ocudox kit
PCE Dispertab
Naprosyn
Oleptro ER
Pediaderm AF
Naprosyn EC
Olux
Pediaderm HC
Nasarel (QCD)
Omeprazole-Sod. Bicarbonate (PA) (QCD)
Pediaderm TA
Nasonex (QCD)
Omnaris (QCD)
Penlac (QCD)
Natazia
Omnicef
Pennsaid
Neo-Synalar Kit
Omnitrope (PA) (SP)
Pepcid
Neosalus
Onmel (QCD)
Percocet
Neosalus CP
Onsolis (PA) (QCD)
Pertzye
Nesina (STEP)
Opana
Pexeva (QCD)
Neuac Kit
Opana ER (PA) (QCD)
Phoslyra
Neupro
Optase
Plaquenil
Neurontin
Oracea
PR-Cream
NeutraSal
Oramorph SR (PA) (QCD)
Pram-HCA
Nevanac
Orapred ODT
Pramcort
Nexiclon XR
Oravig
Pramosone E
25
PrandiMet (STEP)
Quixin
Salkera
Pravachol (STEP) (QCD)
RadiaPlex Rx
Salvax
Precision QID diabetic supplies (QCD)
Radigel
Salvax Duo
Precision X-Tra diabetic supllies (QCD)
Raniclor
Salvax Duo Plus
Presera
Rapaflo
Sanctura (STEP)
Prestige diabetic testing supplies (QCD)
Rayos
Sanctura XR (STEP)
Prevacid (PA) (QCD)
Reciphexamine
Sancuso (QCD)
Prevacid NapraPAC
Recothrom
Saphris (STEP)
PrevPac
Relafen
Sarafem (QCD)
Prilosec (PA) (QCD)
Relpax (QCD)
Scalacort
Prinivil
Remeron (QCD)
Seasonique
Prinzide
Remeron Soltab (QCD)
Senophylline
Pristiq (QCD)
Requip (STEP)
Silenor (QCD)
Procentra (PA)
Requip XL (STEP)
Silvrstat
Procort
Rescula (STEP)
Simbrinza
Prodigy diabetic testing supplies (QCD)
Restoril
Simcor (STEP) (QCD)
Prolensa
Retin-A Micro (PA30)
Sinemet
Promiseb
Revatio (PA)
Sitavig
Promiseb Light
Rhinocort Aqua (QCD)
Skelid
Proquin XR
Rinnovi
Sof-Tact diabetic supplies (QCD)
Protonix (PA) (QCD)
Risperdal M-Tab (STEP)
Solodyn
Proventil
Ritalin
Soltamox
Proventil HFA (QCD)
Ritalin LA (QCD)
Soma
Proventil inhaler (QCD)
Ritalin SR
Sonata (QCD)
Proventil Repetab
Rosadan
Spectracef
Prozac (QCD)
Rosanil
Sporanox (QCD)
Prozac Weekly (QCD)
Rybix ODT
Sprix
Purinethol
Rynatan
Stavzor
Pylera
Rythmol
Stelara (PA) (SPO)
QNASL (QCD)
Ryzolt
Striant
Quartette
Saizen (PA) (SP)
Subsys (PA) (QCD)
Quillivant XR
Salicylic Acid-Ceramide kit
Sular
26
Sumadan
Tiazac
Valium
Sumavel Dosepro (QCD)
Tindamax
Valturna (STEP)
Sumaxin
Tirosint
Vanos
Sumaxin CP
TL-Triseb
Vantin
Sumaxin TS
TobraDex ST
Vascepa
Supartz (PA) (SPO)
Tofranil
Vaseretic
Synalar Combo-Pack
Tornalate
Vasolex
Synalar TS
Toviaz (STEP)
Vasotec
Synvisc (PA) (SPO)
Tradjenta (STEP)
Vectical
Synvisc-One (PA) (SPO)
Tranxene T-Tab
Vectrin
Tagamet
Tretin-X (PA)
Velphoro
Tekamlo (STEP)
Treximet (QCD)
Veltin (PA30)
Tekturna (STEP)
Tri-Levlen
Ventolin HFA (QCD)
Tekturna HCT (STEP)
Tri-Norinyl
Veramyst (QCD)
Tenormin
Tricor
Veregen
Tequin
Triglide
Vexa
Terbinex (QCD)
Trilipix
Vexol
Tersi
Trinalin
Vigamox (QCD)
Testim (STEP)
TriOxin
Viibryd (QCD)
Tritec
Vimovo
product) (STEP)
Tropazone
Virasal
TrueTest diabetic supplies (QCD)
Vogelxo (STEP)
product) (STEP)
TrueTrack diabetic supplies (QCD)
Voltaren
Testosterone gel (Vogelxo) Authorized
Twynsta (STEP)
Voltaren XR
product) (STEP)
Ultracet
Vusion
Tetrix
Ultram/ER
Vytorin (STEP) (QCD)
Tev-Tropin (PA) (SP)
Ultrasal ER
Vyvanse (QCD)
Teveten (STEP)
Ultravate PAC
Welchol
Teveten HCT (STEP)
Ultravate X
Wellbutrin
Therapentin
Ultressa
Wellbutrin SR (QCD)
Theraproxen
Uramaxin
Wellbutrin XL (QCD)
Tiamate
Urea kit
X-Clair
27
Xanax
Zoloft (QCD)
Xanax XR
Zolpimist (QCD)
Xartemis XR (PA) (QCD)
Zomig (QCD)
Xeljanz (SP)
Zomig ZMT (QCD)
Xenaderm
Zontivity
Xerese
Zovirax
Xibrom
Zuplenz (QCD)
Xifaxan
Zyflo (STEP)
Xolegel
Zyflo CR (STEP)
Xolox
Zymar (QCD)
Xopenex HFA (QCD)
Zymaxid
Xopenex nebules
Zypram
Xyralid
Zyprexa IM (STEP)
Z-Pram
Zyprexa Relprevv (STEP)
Zanaflex
Zytopic
Zantac
Zebeta
Zegerid (PA) (QCD)
Zelapar
Zenieva
Zestril
Zetonna (QCD)
Ziana
Zinotic
Zinotic ES
Zipsor
Zithromax
Zmax
Zocor (STEP) (QCD)
Zofran (QCD)
Zofran ODT (QCD)
Zohydro ER (PA) (QCD)
28
Medication Resource
ResourceList
ListIndex
Index
Medication
8-Mop
17
Adapalene
Abilify
19
Adcirca
12, 17
Abilify DiscMelt
19, 21
Adderall
21
Amerge
Abilify Maintenna
19, 21
Adderall XR
Amevive
12
Abilify tablets
Ambien
7, 21
Ambien CR
7, 21
Adempas
17
Amitiza
Abraxane
15
Adoxa CK
21
Amitriptyline
Absorica
21
Adoxa TT
21
Amlodipine
Adriamycin PFS
15
Amlodipine-Atorvastatin
Adrucil
15
Amlodipine/Benazepril
Amolodipine
Abstral
7, 12, 21
Acanya
21
Accolate
Accu-Chek Aviva testing strips
19, 21
3
Advair Diskus
3, 7, 19
Advair HFA
7, 19
Amoxicillin
AccuNeb
21
Advicor
7, 19
Amoxicillin TR-Potassium Clavulanate
Accupril
21
Aerobid
7, 21
Amphetamine Salt Combination
Accuretic
21
Aerobid-M
7, 21
Amphetamines
Accutane
21
Afinitor
17
Ampyra
Aceon
21
Airet
21
Amrix
21
Acetaminophen/Codeine
12
7, 12, 17
Albuterol
Amturnide
20
Alendronate
Anafranil
21
Analpram Advanced
21
Analpram-E kit
21
AcipHex
7, 12, 21
Actemra
12, 15
Alferon N
Acthar
12, 15
Alkeran
15
15, 17
Acticlate
21
Allopurinol
Actigall
21
Alodox
21
Angeliq
21
Actimmune
15
Aloquin
21
Anoro Ellipta
19
Antara
21
Actiq
Activella
7, 12, 21
21
Alora
Alprazolam
7, 21
3
Anastrozole
Anzemet
7, 21
Actonel
7, 20
Alrex
7, 21
Apidra
21
ACTOplus Met
7, 19
Alsuma
7, 21
Aplenzin ER
21
ACTOplus Met XR
7, 19
Altabax
21
Apokyn
15
Actos
7, 19
Altace
21
Appformin-D
21
Acular
7, 21
Altavera
Acular LS
7, 21
Altoprev
7, 19, 21
Acular PF
Acuvail
Acyclovir
Aczone
29
Alupent inhaler
21
Aluvea
21
Alvesco
7, 21
21
Alyacen
Apri
Aqua Glycolic HC
21
Aralast
12
Aralast NP
12
Aranesp
Arava
7, 12, 15
7, 21

Arcapta Neohaler
7, 21
Aredia
15
Arixtra
7, 21
Armour Thyroid
Arzerra
15
Asacol HD
Ascensia diabetic testing supplies
Asmanex Twisthaler
Astelin
22
Botulinum toxin
Avidoxy
22
Bravelle
15, 22
Avidoxy DK
22
Breo Ellipta
19, 22
Avinza
22
Avodart
20
Brintellix
21
Avonex
8, 15
Brisdelle
8, 22
Axert
8, 22
Bromday
22
22
21
7
Axid
22
Brovana
Azasite
22
Budeprion SR
Budeprion XL
Atacand
20, 21
Azelastine
Atacand HCT
20-22
Azithromycin
7, 20
3
Azathioprine
Azmacort
3
8, 22
Budesonide
3, 8
Bunavail
8, 12
Buprenex
8, 12
8, 12
20
Buprenorphine
22
Buprenorphine-Naloxone
Buprenorphine/Naloxone
3
3
22
B-D diabetic testing supplies
Atopiclair
22
Baclofen
3, 7
3, 8
Azor
Ativan
Atorvastatin
22
Brilinta
7, 21
Atenolol
Brevicon
22
Astepro
Atelvia DR
12, 22
12
Avita
7, 21
Assure Pro diabetic testing supplies
Avelox
Beconase AQ
8, 22
Bupropion
Atralin
22
Belviq
8, 12
Bupropion SR
3, 8
Atrapro CP
22
Benicar
3, 20
Bupropion XL
3, 8
Atrapro Dermal Spray
22
Benicar HCT
3, 20
Buspirone
Atrapro Hydrogel
22
BenzaClin kit
22
Atropen
22
Benzonatate
Atrovent
Besivance
Atrovent HFA
Betamethasone Dipropionate
22
Busulfex
Butorphanol NS
Butrans
8, 12, 22
8, 15
Bystolic
22
17
Betaseron
Augmentin XR
22
Bethkis
17
Cabergoline
Aurstat
22
BiCNu
15
Caduet
Auvi-Q
7, 22
Binosto
8, 20, 22
Avalide
20
Bionect
Avandaryl
Avandia
7, 19
19
15
Butalbital/APAP/Caffeine
Aubagio
Avandamet
8
8, 19, 22
Calcitriol Topical
22
22
Calcium Folanate
15
Bleomycin Sulfate
15
Cambia
22
Boniva Injection
15
Camila
7, 8, 19
Boniva syringe
12, 22
Avapro
20
Boniva tablets
8, 20, 22
Aveed
15
Bosulif
17
Camptosar
15
Capecitabine
17
Caphosol
22
30

Capoten
22
Chibroxin Ocumeter
Carbaglu
17
Chlorhexadine Gluconate
Clozaril
Chlorthalidone
CNL 8 nail kit
Carbidopa/Levodopa
22
Clotrimazole/Betamethasone
3
19
8, 22
Carboplatin
15
Cialis
Colazal
22
Cardene
22
Ciclopirox nail lacquer
Colcrys
Cardene SR
22
Cimzia
Cardizem CD
22
Cardizem LA
22
Cardura
Cardura XL
8
8, 22
12, 15
Combigan
22
Cinryze
12
Combivent
Cipro-XR
22
Combivent Respimat
Ciprofloxacin
Cisplatin
3
15
Carisoprodol
Citalopram
3, 8
Carvedilol
Cladribine
15
Cataflam
22
Catapres TTS
Clarithromycin
Combunox
Concerta
3, 8
22
8
Contour Next diabetic testing supplies 22

Conzip
22
Copaxone
8, 15
Cleanse and Treat
22
Copegus
17
22
Coreg
22
Ceclor
22
Cleervue-M
Ceclor CD
22
Climara
Coreg CR
22
Cedax
22
Climara Pro
Cosmegen
15
22
Cefadroxil
Clindacin ETZ Kit
22
Cosopt PF
Cefdinir
Clindacin PAC
22
Cozaar
20, 22
Cefuroxime
Clindagel
22
Crestor
3, 8, 19
Clindamax
22
Crolom ophthalmic
Celebrex
Celexa
3, 8, 20
8, 22
Clindamycin
Cromolyn ophthalmic
Cryselle
3
3
Cem-Urea
22
Clindamycin/Benzoyl Peroxide
Cenestin
22
Clindareach
22
Cyclobenzaprine
Centany
22
Clindets
22
Cyclophosphamide
Centany AT
22
Clobeta + Plus
22
Cymbalta
Cerdelga
17
Clobetasol Propionate
Cyramza
15
Ceredase
12
Clobex
22
Cystagon
17
Cerezyme
12
Clodan Kit
22
Cystaran
18
Cerubidine
15
Clomid
15
Cytarabine
15
Cytoxan
15
8, 22
Cesamet
8, 22
Clomiphene
15
Cetraxel
22
Clonazepam
Dacarbazine
15
Cetrotide
15
Clonidine
Dactinomycin
15
Clonidine patch
Daliresp
22
Clopidogrel
Darvocet N-100
22
Chantix
Chenodal
31
3
22
15, 17

Daunorubicin HCL
15
Dihydroergotamine
DaunoXome
15
Dilacor XR
Daypro
22
Dilaudid
Daytrana
22
Diltiazem ER
DDAVP
15, 22
Diovan
Dynacirc CR
23
23
Dysport
12
23
Dytan
23
Easy Step diabetic testing supplies
23
4, 20
Easy-Trak diabetic testing supplies
23
Demulen
22
Dipentum
23
Econazole
Depo-Sub Q Provera 104
22
Diskets
12
Edarbi
Depocyt
15
Dispermox
23
Edarbiclor
Derma-Smoothe/FS
22
Ditropan
20, 23
Edluar
8, 23
Dermasorb-AF
22
Ditropan XL
20, 23
Effexor
23
Dermasorb-HC
22, 23
Dermasorb-XM
20, 23
20
Divalproex Sodium
Effexor XR
23
Divalproex Sodium ER
Egrifta
DermOtic
23
Divigel
23
Elestrin
23
Desmopressin Acetate
15
Docefrez
15
Eletone
23
Desogen
23
Docetaxel
15
Elidel
12
Desonide
Dolophine
12
Eligard
15
Desonil + Plus
23
Donepezil
Ellence
15
DesOwen kit
23
Doryx
23
Eloxatin
15
Desoxyn
12
Dorzolamide/Timolol
Elspar
15
Desvenlafaxine ER
8, 23
Doxazosin
4
4, 8
12, 15
Embeda
8, 12, 23
Detrol
20, 23
Doxorubicin HCl
Detrol LA
20, 23
Doxycycline Hyclate
Emend
Doxycycline Monohydrate
Emoquette
Dexamethasone
Dexedrine
Embrace diabetic testing supplies
23
DTIC-Dome
15
Emsam
23
8, 12, 23
Duavee
23
Enablex
20, 23
Duetact
19
Enalapril
15
Duexis
23
Enbrel
Dextroamphetamine/Amphetamine
Dulera
8, 19
Dextroamphetamine/Amphetamine ER
Duloxetine
4, 8
12
Duragesic
8, 12, 23
Dexilant
23
15
8, 23
Dexmethylphenidate XR
Dexrazoxane
Dextroamphetamines
Diazepam
4, 8, 12, 15
Endometrin
15
Enjuvia
23
Enoxaparin
Enoxparin Sodium
Enpresse
3, 4
Durezol
23
Dymista
8, 23
12
Dynabac
23
Enteral formula
12
Diflucan
Dynacin
23
Entyvio
15
Digoxin
Dynacirc
23
Epaned
23
Dicyclomine
Dificid
32

Epi-Pen AutoInjector
Extavia
Epi-Pen JR. AutoInjector
Extina
23
Flonase
EpiCeram
23
Eylea
12
Flovent HFA inhaler
Epiduo
23
Factive
23
Flovent/HFA
Factor VIII, VIIIa, IX, XIII
12
Floxuridine
15
Fluconazole
4, 8
Epinephrine injection
8, 15, 23
Epirubicin
15
Falessa kit
23
Episil
23
Famciclovir
Epogen
8, 12, 15
Famvir
8, 23
Equetro
23
Fanapt
19, 23
Erbitux
12
Farxiga
Erivedge
17
Faslodex
Ertaczo
23
FazaClo
Erythromycin
Femtrace
Escitalopram
4, 8
Esomeprazole Strontium
8, 12, 23
Estrace
23
Fenofibrate
Fenoglide
Flector
15
Fludarabine phosphate
15
Flunisolide
19
Fluocinonide
15
Fluorouracil
15
19, 23
23
4
23
Fluoxetine
4, 8
Fluoxetine DR
Fluticasone
Fluticasone nasal spray
Fentanyl oral/mucosal
8, 12
Fluvastatin
8, 12
Fluvoxamine
Fluvoxamine CR
Fentanyl patch
Estraderm
Fentanyl patches
Estradiol
Fentora
8, 12, 23
Estradiol patch
Fertinex
23
Estrasorb
8, 23
Fetzima
Focalin XR
Estrogel
8, 23
Fexmid
23
Folic Acid
Fibracor
23
Follistim AQ
23
Fondaparinux
8, 23
Fludara
Estrace Cream
Eszopiclone
23
Ethyol
15
Finacea Plus
Etopophos
15
Finasteride
FML Forte
23
Focalin
23
8, 23
4
15, 23
8, 9
Forfivo XL
9, 23
19, 23
Etoposide
15, 17
Fioricet
23
Fortamet
Euflexxa
12, 23
Fiorinal
23
Forteo
Evamist
8, 23
Fiorinal with Codeine
23
Fortesta
Firazyr
15
Fosamax
Firmagon
15
Fosamax Plus D
9, 20
First-lansoprazole
12
Fragmin
9, 23
First-omeprazole
12
Freestyle diabetic testing supplies
23
23
Evoclin
23
Evzio
ExacTech diabetic testing supplies

Exalgo
23
8, 12, 23
9, 12, 15
20, 23
9, 20, 23
Exforge
20
Flagyl
23
Fresh Kote
Exforge-HCT
20
Flagyl ER
23
Frova
9, 23
Exjade
17
Flagyl IV
23
FUDR
15
33

Furosemide
Fusilev I.V.
15
Granisetron
Fuzeon
15
Granisol
Gabapentin
Gonal F/Gonal F RFF
Granix
Ganirelix
15
Grastek
Garamide
23
Growth Hormone
Gatifloxacin
15
Hylatopic Plus-Aurstat
24
Hylira
24
Hytrin
9, 24
9, 15, 16
Hyzaar
20, 24
9, 12
IB-Stat
24
12
Guanfacine
Ibandronate
9, 16
Ibuprofen
Gattex
15
Haldol
19
IC400 kit
24
Gazyva
15
Haldol Decanoate
19
IC800 kit
24
Gel-One
12, 23
Halonate
24
Iclusig
17
Gelclair
23, 24
Halotin
24
Idamycin PFS
16
Gelnique
20
Havroni
17
Idarubicin
16
GelX
24
Helidac
24
Ifex
16
Gemcitabine
15
Hetlioz
9, 12, 17
Ifosfamide
16
Gemfibrozil
Gemzar
Genotropin
Geodon
Horizant
24
Ifosfamide/Mesna
16
HPR
24
Ilaris
16
15, 24
HPR Plus
24
Ilevro
24
19
Humalog
Imbruvica
17
15
Gianvi
Giazo
24
Gildess
Gilenya
9, 17
Human Chorionic Gonadotropin (HCG) 15
Imitrex
Humatrope
16
Imuran
24
Humira
4, 9, 12, 16
Incivek
13, 17
Hyalgan
12, 13, 24
Increlex
16
16, 17
Inderal LA
24
24
Gilotrif
17
Hycamtin
Gleevec
17
Hydrochlorothiazide
Inderal XL
Glimepiride
Hydrocodone/APAP
Indomethacin
Glipizide
Hydrocodone/Chlorpheniramine
Infergen
Glipizide ER
Hydrocortisone
Inlyta
17
Glipizide XL
Hydrocortisone-Lidocaine kit
24
Innohep
24
Hydromorphone
Insulins
Glucometer diabetic testing supplies
24
4
9, 16
Glucophage
19, 24
Hydromorphone ER
Interferons (alpha, gamma)
Glucophage XR
19, 24
Hydroxychloroquine
Intermezzo
Hydroxyzine
Intron A
16
Hylase
24
Intuniv
24
Hylatopic
24
Invega
19, 24
Hylatopic Plus
24
Invega Sustenna
Glucose testing strips
Glumetza
19, 24
Glyburide
Gonal F Rff Rediject
15
13
9, 24
19
34

Invokamet
19
Ketorolac
Levetiracetam
Invokana
19
Ketorolac ophthalmic
Levitra
Levlen
24
Iophen-C NR
Keytruda
16
Ipratropium NS
Khedezla
9, 24
Iquix
Irbesartan
24
Kineret
13, 16
Levofloxacin
Levothyroxine
Klonopin
24
Iressa
17
Klor-Con
Lexxel
24
Irinotecan
16
Kombiglyze XR
20
Lialda
24
Korlym
17
Lidocaine Patch
Istalol
24
Kuvan
17
Lidoderm
Istodax
16
Kynamro
Isosorbide Mononitrate
Itraconazole
Kytril
IV Immunoglobulin
13
Labetalol
Jakafi
17
Lamictal ODT
Jalyn
20
Lamisil
Janumet
19
Lamisil Granules
Janumet XR
Januvia
Jardiance
Jentadueto
19, 20
4
20
20, 24
Lamotrigine
Kelnor 1-35
24
9, 24
24
Lipitor
9, 19, 24
Lipodox
16
Lipodox-50
16
Lantus
Lithium Carbonate
Lantus Solostar
Livalo
lo Loestrin FE
19
20, 24
Juxtapid
Kazano
Liothyronine Sodium
Lisinopril/HCTZ
Latuda
Lansoprazole/Amoxicillin/Clarithromycin 9
Kariva
Linzess
Junel FE
24
9, 24
Lisinopril
Latanoprost
Kapvay
24
4, 9, 13
Lansoprazole
13, 17
Lidovir
9, 19, 24
Junel
Kalydeco
16, 19
Liptruzet
24
9, 13, 24
9, 24
Jublia
Kadian
Lexapro
Lazanda
Leflunomide
24
13, 24
9
9, 24
4
Lodine
24
Lodine XL
24
Lofibra
24
Lescol
9, 19, 24
Lopressor
24
Lescol XL
9, 19, 24
Lorabid
24
Letairis
17
Lorazepam
Leucovorin Calcium
16
Loryna
Losartan
Leukine
13, 16
Kenalog
16
Leuprolide
15
Losartan/HCTZ
Keppra XR
24
Leuprolide Acetate
16
LoSeasonique
24
Keralyt kit
24
Leustatin
16
Lotensin
24
Ketocon + Plus
24
Levaquin
24
Lotensin HCT
24
Levemir
24
Lotronex
Ketoconazole
35

Loutrex
Lovastatin
Lovaza
24
4, 9
24
Metadate CD
Mobic
9, 25
24
Modafinil
4, 13
Metformin
Moderiba
17
Metformin ER
Mometasone
Metaglip
Lovenox
9, 24
Loxitane
19
Methadone
13
Momexin
25
Lucentis
13
Methadose
13
Monodox
25
Lumigan
20
Methimazole
Monopril
25
Lunesta
9, 24
Methocarbamol
Monopril HCT
25
Methotrexate
Monovisc
Lupaneta Pack
16
13, 25
Lupron Depot
15, 16
Methylphenidate
Montelukast
Lupron Depot-Ped
15, 16
Methylphenidate CD
Morgidox
25
Lutera
Methylphenidate ER
4, 9
Morphine Sulfate CR
13
Luveris
15
Methylprednisolone
Morphine Sulfate ER
4, 9, 13
Metoclopramide
Moxatag
25
Luvox CR
9, 24
Luzu
24
Metoprolol Succinate
Moxeza
25
Lyrica
13
Metoprolol Tartrate
Mozobil
16
Lysteda
9, 24
Metozolv ODT
24
MS Contin
9, 13
24
Mupirocin
Mustargen
16
Lytensopril
24
Metrogel kit
Macugen
13
Metronidazole
Makena
13, 16
Mevacor
9, 19, 24
Myalept
13, 16
Marqibo
16
Micardis
20, 24, 25
Mylotarg
16
Mavik
24
Micardis HCT
20
Myoxin
25
Maxair Autohaler
9, 24
Microgestin FE
Myrbetriq
20, 25
Maxalt
9, 24
Migranal
Nabumetone
Maxalt-MLT
9, 24
Minastrin FE
Nadolol
Maxipime
24
Minivelle
Namenda
MB Hydrogel
24
Minocin
25
Naprelan
25
Minocin Combo Pack
25
Naprelan CR
25
Naprosyn
25
Naprosyn EC
25
Medroxyprogesterone
Megace ES
24
Minocycline
Mekinist
17
Mirapex
Meloxicam
4
20
4, 9
Mirapex ER
20, 25
Menopur
15
Mirtazapine
4, 9
Menostar
9, 24
Mesna
Mesnex
16
16, 17
Mirtazapine Rapid Dissolve
Naproxen
Naratriptan
Nasarel
Mitomycin
16
Nasonex
Mitoxantrone
16
Natazia
4, 5
9
25
9, 25
25
36

Navelbine
16
NebuPent
Novacort
25
Ondansetron ODT
Novantrone
16
Ondasetron
Neo-Synalar Kit
25
Novarel
15
Ondasetron ODT
Neosalus
25
Novolin Insulin products
25
One Touch Delica testing strips
Neosalus CP
25
Novolog Insulin products
25
One Touch Ultra testing strips
Neosar
16
Nplate
16
Onglyza
Nesina
20, 25
NuCort
25
Onmel
Nucynta
25
Onsolis
Neuac Kit
Neulasta
Neumega
Neupogen
25
9, 16
16
9, 16
Nucynta ER
20
9, 25
9, 13, 17, 25
13, 25
Ontak
16
NutriDox
25
Onxol
16
Nutritional Supplements
13
Opana
25
Neupro
25
Nutropin
16
Opana ER
Neurontin
25
Nutropin AQ
16
Opsumit
17
NeutraSal
25
Nutropin AQ Nuspin
16
Optase
25
Nevanac
25
Nuvigil
13, 25
Optivar
Nexavar
17
Nystatin
Oracea
25
Nexiclon XR
25
Nystatin/Triamcinolone
Oralair
Ocella
Oramorph SR
9, 13, 25
Octreotide injection
16
Orapred ODT
25
25
Oravig
25
Orencia
Nexium
Nifedipine ER
9, 13
5
Nipent
16
Ocudox kit
Niravam
25
Ofloxacin
Nitrofurantoin
Oforta
17
Orenitram
9, 13, 25
13, 16
17
Nivatropic Plus
25
Olanzapine
Orsythia
Nor-Q-D
25
Olanzepine-Fluoxetine
Ortho Tri-Cyclen Lo
Norditropin
16, 25
Oleptro ER
25
Orthovisc
13, 25
25
Oseni
20, 25
Norditropin Flexpro
16
Olux
Norditropin Nordiflex
16
Olysio
Norethindrone
Omeprazole
Norgestimate/Ethinyl Estradiol
Omeprazole-Sod. Bicarbonate
13, 17
5, 9
9, 13, 25
Osphena
Otezla
Otezla Starter Pack
25
9, 13, 17
17, 25
Norinyl
25
Omnaris
9, 25
Ovcon
25
Noroxin
25
Omnicef
25
Ovidrel
15
Northera
17
Omnitrope
Oxaliplatin
16
16, 25
Nortrel
Omontys
9, 13, 16
Nortriptyline
Oncaspar
16
Norvasc
37
9, 25
Ondansetron
Oxcarbazepine
Oxecta
Oxybutynin
5
25
5

Oxycodone
Oxycodone ER
5
9, 13
Pexeva
10, 25
Phenazopyridine
Prinzide
Pristiq
Oxycodone/APAP
Phoslyra
25
ProAir HFA
OxyContin
Photofrin
16
ProAir HFA inhaler
Oxycontin
5, 13
Pioglitazone
Oxymorphone ER
9, 13
Pioglitazone-Glimepiride
10, 20
Prochlorperazine
20, 25
Pioglitazone-Metformin
10, 20
Procort
Oxytrol
Paclitaxel
16
Plaquenil
Pamelor
25
Ploymyxin B-Sul/Trimethoprim
Pamidronate
16
Pomalyst
Pamidronate disodium
16
Potassium Chloride
Pamine FQ
25
PR-Cream
Pancreaze
25
Panretin
18
Pantoprazole
Paptase
Paroxetine
Paroxetine CR
26
5
26
10, 13, 16
26
Prolastin
13
25
Prolastin C
13
Pram-HCA
25
Prolensa
26
Pramcort
25
Proleukin
13, 16
Prolia
13, 16
Pramosone E
17
5
5
25, 26
Promacta
17
PrandiMet
20
Promethazine
Prandin
20
Promethazine/Codeine
Patanase
9, 25
Pravachol
Paxil
9, 25
Pravastatin
Paxil CR
Prodigy diabetic testing supplies
25
Procrit
10
17
Pramipexole
25
Procentra
10, 26
Procysbi
5, 9
5, 9
5, 10, 20
26
10, 19, 26
5, 10
Promiseb
26
Promiseb Light
26
9, 10, 25
Precision QID diabetic supplies
26
Propranolol
PCE
25
Precision X-Tra diabetic supllies
26
Propranolol ER
PCE Dispertab
25
Prednisone
Pediaderm AF
25
Pregnyl
Pediaderm HC
25
Pediaderm TA
Proquin XR
26
15
Proscar
20
Premarin
Protonix
10, 13, 26
25
Prempro
Protopic
13
Peg-Intron
16
Prenatal Plus
Proventil
26
PEG-Intron
10
Presera
26
Proventil HFA
Pegasys
10
Preservative-Free Morphine
13
Proventil inhaler
26
Penicillin
Prestige diabetic testing supplies
26
Proventil Repetab
26
10, 13, 26
Provigil
13
26
Prozac
10, 26
Prozac Weekly
10, 26
Penlac
10, 25
Prevacid
10, 26
Pennsaid
25
Prevacid NapraPAC
Pepcid
25
PrevPac
10, 26
Percocet
25
Prilosec
10, 13, 26
Pulmicort FlexHaler
Pertzye
25
Prinivil
26
Pulmicort Flexhaler
10
38

Pulmicort Respules
10
Remicade
13, 16
Rynatan
26
Pulmozyme
17
Repronex
15
Rythmol
26
Purinethol
26
Requip
20, 26
Ryzolt
26
Pylera
26
Requip XL
20, 26
Sabril
17
Rescula
20, 26
Saizen
QNASL
10, 26
Qualaquin
10
Respiratory SyncytialVirus IG/Synagis
Quartette
26
Restasis
Restoril
Retin-A Micro
Quetiapine
Quillivant XR
26
Quinapril
Qutenza
10, 18
QVAR
Rabeprazole
5, 10
10, 13
Revatio
Revlimid
Rhinocort Aqua
13
16, 26
Salicylic Acid-Ceramide kit
26
Salvax
26
26
Salvax Duo
26
26
Salvax Duo Plus
26
Sanctura
26
5, 10, 13
13, 16, 17, 26

17
10, 26
Sanctura XR
20, 26
Sancuso
10, 26
Ribapak
17
Sandostatin
16
16
RadiaPlex Rx
26
Ribasphere
17
Sandostatin-LAR
Radigel
26
Ribatab
17
Saphris
19, 26
Ribavirin
17
Sarafem
10, 26
Ragwitek
10, 13
Ramipril
Rilutek
17
Scalacort
26
Raniclor
26
Riluzole
17
Seasonique
26
Rinnovi
26
Selferma
10
Ranitidine
Rapaflo
26
Risedronate
10
Senophylline
26
Rapaflux
10
Risperdal
19
Serevent Diskus
10
Raptiva
16
Risperdal Consta
19
Serophene
15
Ravicti
17
Risperdal M-Tab
Seroquel
19
Rayos
26
Risperidone
Seroquel XR
19
Rebetol
17
Ritalin
26
Serostim
16
Sertraline
5, 10
Rebif
19, 26
5
10, 16
Ritalin LA
10, 26
Reciphexamine
26
Ritalin SR
26
Reclast
13
Rituxan
13, 16
Signafor
16
Sildenafil
13, 17
10, 26
Reclipsen
Rizatriptan
10
Silenor
Recothrom
26
Ropinirole
Silvrstat
26
Regranex
13
Rosadan
26
Simbrinza
26
Relafen
26
Rosanil
26
Simcor
10, 19, 26
Relpax
10, 26
Rozerem
10
Simponi
10, 13, 16
Remeron
10, 26
Ruconest
16
Simponi Aria
16
Rybix ODT
26
Simulect
16
Remeron Soltab
39
26

Simvastatin
5, 10
Sumaxin CP
27
Tenormin
27
Sinemet
26
Sumaxin TS
27
Tequin
27
Singulair
19
Supartz
13, 27
Sitavig
26
Suprep
Skelid
26
Sutent
17
Terbinex
Sof-Tact diabetic supplies
26
Sylatron
16
Tersi
Solodyn
26
Sylvant
16
Testim
Soltamox
26
Symbicort
Soma
26
Symbyax
10, 19
product)
Somatuline
16
Synagis
13, 16
Somavert
16
Synalar Combo-Pack
27
product)
5, 10, 19
Terazosin
5, 10
Terbinafine
5, 10
10, 27
27
20, 27

20, 27
20, 27
Sonata
10, 26
Synalar TS
27
Testosterone gel (Vogelxo Authorized
Sovaldi
13, 17
Synribo
16
product)
Spectracef
26
Synthroid
Spiriva
10
Synvisc
5
13, 27
20
Testosterone gel (Vogelxo) Authorized

product)
27
27
Spiriva HandiHaler
Synvisc One
13
Tetrix
Spironolactone
Synvisc-One
27
Tev-Tropin
16, 27
Tafinlar
17
Teveten
20, 27
Tagamet
27
Teveten HCT
20, 27
Sporanox
Sprintec
10, 26
5
Sprix
26
Tamiflu
Thalomid
17
Sprycel
17
Tamoxifen
TheraCys
16
Stavzor
26
Tamsulosin
Therapentin
27
Stelara
16, 26
Tarabine
16
Theraproxen
27
Stivarga
17
Tarceva
17
Thiotepa
Strattera
5, 10, 13
Tasigna
17
Tiamate
Taxol
16
Timolol Maleate
5, 10, 13
Taxotere
16
Tindamax
27
10, 13, 26
Tecfidera
17
Tirosint
27
Striant
Suboxone
Subsys
26
16, 17
27
5
Subutex
10
Tekamlo
20, 27
Tizanidine
Sucraid
17
Tekturna
20, 27
TL-Triseb
27
Tekturna HCT
20, 27
TOBI ampules
17
Sular
Sulfamethoxizole/Trimethoprim
Sumatriptan
Sumavel Dosepro
Sumaxin
26, 27
5
5, 10
10, 27
27
Temazepam
TOBI-Podhaler
Temodar
17
TobraDex ST
Temozoloamide
17
Tobramycin/Dexamethasone
Teniposide
16
Tofranil
17, 18
27
5
27
40

Topical Retinoic Acid derivatives
Topiramate
Toposar
13
Tropazone
27
Venlafaxine
TrueTest diabetic supplies
27
Venlafaxine ER capsule
10
17
TrueTrack diabetic supplies
27
Venlafaxine ER capsules
Twynsta
20, 27
Venlafaxine ER tablet
Toprol XL
10
Tornalate
27
Tykerb
18
Ventolin HFA
10, 27
Totect
17
Tysabri
13
Veramyst
10, 27
Toviaz
20, 27
Tyvaso
18
Verapmil ER
TPN
13
Ultracet
27
Veregen
27
Tracleer
18
Ultram/ER
27
Vesicare
5, 20
Ultrasal ER
27
Vexa
27
Ultravate PAC
27
Vexol
27
Tradjenta
20, 27
Tramadol
Tranexamic Acid
10
Ultravate X
27
Viagra
Tranxene T-Tab
27
Ultressa
27
Victoza
20
Travatan
20
Uramaxin
27
Victrelis
13, 18
Travatan Z
20
Urea kit
27
Vigamox
10, 27
Trelstar
17
Vagifem
Viibryd
10, 27
Trelstar Depot
17
Valacyclovir
Vimovo
27
Trelstar LA
17
Valacylovir
10
Vimzim
17
Tretin-X
27
Valchlor
18
VinBLAStine
17
Tretinoin
VinCRIStine
17
Treximet
10, 27
Valstar
17
Vinorelbine
17
Tri-Levlen
27
Valtrex
10
Viorelle
Tri-Norinyl
27
Valturna
20, 27
Virasal
27
Valsartan/HCTZ
Tri-Previfem
Vanos
27
Vitamin D2
Tri-Sprintec
Vantin
27
Vivelle
10
Triamcinolone Acetonide
Vascepa
27
Vivelle-Dot
10
Triamterene/HCTZ
Vaseretic
27
Vivelle-DOT
Tribenzor
20
Vasolex
27
Vogelxo
20, 27
Tricor
27
Vasotec
27
Voltaren
27
Triglide
27
Vectibix
13
Voltaren gel
Trilipix
27
Vectical
27
Voltaren XR
27
Trinalin
27
Vectrin
27
Votrient
18
Trinessa
Velcade
17
Vumon
17
TriOxin
27
Velphoro
27
Vusion
27
Tritec
27
Veltin
27
Vytorin
10, 19, 27
41

Vyvanse
10, 27
Zantac
28
Zovirax
28
Warfarin
Zavesca
18
Zubsolv
11, 13
Welchol
27
Zebeta
28
Zuplenz
11, 28
Wellbutrin
27
Zegerid
10, 13, 28
Zydelig
18
Wellbutrin SR
10, 27
Zelapar
28
Wellbutrin XL
10, 27
Zelboraf
13, 18
X-Clair
27, 28
Zenapax
Xalatan
20
Xalkori
13, 18
Xanax XR
Xarelto
Xartemis XR
28
5
10, 28
Zyflo
19, 28
Zyflo CR
19, 28
17
Zykadia
13, 18
Zenieva
28
Zymar
11, 28
Zestril
28
Zymaxid
11, 28
Zetia
Zetonna
5, 10, 19
Zypram
28
10, 28
Zyprexa
19
Ziana
28
Zyprexa IM
19, 28
Zinecard
17
Zyprexa Relprevv
19, 28
Xeljanz
13, 18, 28
Xeloda
18
Zinotic
28
Zyprexa Zydis
19
Xenaderm
28
Zinotic ES
28
Zytiga
18
Zipsor
28
Zytopic
28
Xenazine
13, 18
Xeomin
13
Zithromax
28
Xerese
28
Zmax
28
Xgeva
13, 17
Zocor
10, 19, 28
Xiaflex
13
Zofran
10, 28
Xibrom
28
Zofran ODT
10, 28
Xifaxan
28
Zohydro ER
10, 28
Xolair
13
Zoladex
17
Xolegel
28
Zolinza
18
Xolox
28
Zolmitriptan
10
Zolmitriptan ODT
10
Zoloft
10
Xopenex HFA
Xopenex nebules
10, 28
28
Xtandi
18, 20
Zolpidem
5, 10
Xyralid
28
Zolpidem ER
5, 10
Xyrem
18
Zolpimist
Z-Pram
28
Zometa
Zaleplon
10
Zomig
Zaltrap
17
Zomig ZMT
28
Zanaflex
28
Zontivity
28
Zanosar
17
Zorbtive
17
10, 28
13
10, 11, 28
42

Our Pharmacy and Therapeutics Committee, which is
made up of pharmacists and doctors of various specialties,
reviews the effectiveness and overall value of new
medications approved by the FDA on an ongoing basis.
The Committee provides expertise and advice to help us
give our members prescription drug options that meet
their medical needs and achieve desired treatment goals.
Approved medications are added to our formulary as they
are approved by our Pharmacy and Therapeutics Committee
throughout the year.
43
While under review, new medications will not be covered

by your plan. As with other medications that are not covered,
your doctor may request coverage when medically necessary.
If a non-covered drug is approved, it will be covered at the
highest tier or cost share.
Registered Marks of the Blue Cross and Blue Shield Association. 2014 Blue Cross and Blue Shield of Massachusetts, Inc.,
and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
#141665
55-0071 (10/14)

Pharmacy Program Bluecross

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Pharmacy Program Bluecross

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Your Pharmacy Program

Effective January 1, 2015

Mail Service Pharmacy

Your Pharmacy Cost Share and ID Card

Top Covered Medications

Quality Care Dosing

Specialty Pharmacy Medications

Medication Resource List Index

New Medication Approval Process

Our pharmacy program is designed to provide you and

From our main website, www.bluecrossma.com, to the

About This Guide

Search for Medication Information. To learn whether

Your cost share may include your copayment, co-insurance, deductibles,

Mail Service Pharmacy

YouryouID Card Your ID card contains important information about your

Its convenient, cost-effective, and all information is handled

Your Pharmacy Cost Share

Your cost share may include your copayment, co-insurance,

For more information about your specific prescription benefits,

Abilify tablets (STEP)

Accu-Chek Aviva testing strips (QCD)

Advair Diskus (QCD) (STEP)

Benicar HCT (STEP)

Buprenorphine/Naloxone (PA) (QCD)

Amoxicillin TR-Potassium Clavulanate

Combivent Respimat (QCD)

Amphetamine Salt Combination

Crestor (QCD) (STEP)

Celebrex (QCD) (STEP)

(PA) Prior Authorization required

Top Covered Medications

Humira (PA) (QCD)

Enbrel (PA) (QCD)

Enoxparin Sodium (QCD)

Epi-Pen AutoInjector (QCD)

Epi-Pen JR. AutoInjector (QCD)

Fentanyl patches (PA) (QCD)

Flovent HFA inhaler (QCD)

Lansoprazole (PA) (QCD)

Fluticasone nasal spray (QCD)

Lantus Solostar (QCD)

Morphine Sulfate ER (PA) (QCD)

(PA) Prior Authorization required

Top Covered Medications

Pulmicort FlexHaler (QCD)

Venlafaxine ER capsules (QCD)

Restasis (PA) (QCD)

Ondasetron ODT (QCD)

One Touch Delica testing strips (QCD)

One Touch Ultra testing strips (QCD)

Spiriva HandiHaler (QCD)

Strattera (PA) (QCD)

Suboxone (PA) (QCD)

Zetia (QCD) (STEP)

Oxycontin (PA) (QCD)

Symbicort (QCD) (STEP)

Pioglitazone (QCD) (STEP)

ProAir HFA inhaler (QCD)

(PA) Prior Authorization required

Quality Care Dosing

Quality Care Dosing

We will get your doctors approval before making

Quality Care Dosing List