Custom Drug List Formulary

2016
every card.
Confidence comes with
Custom
Drug List
BCBSM and BCN Custom Drug List (Formulary) - July 2016

Table of contents
Blue Cross and BCN Custom Drug List (Formulary)
Generic substitution and Preferred alternatives
Blue Cross and BCN Preferred alternatives
How to read the Blue Cross and BCN Custom Drug
Blue Cross and BCN Preferred Alternatives List
6
11
12
13
Appendix A
Anti-infectives
1A
1B
1C
1D
1E
1F
1G
1H
1I
1J
1K
1L
1M
1N
Antifungals
Antimalarials
Antiparasitics/Anthelmintics
Antiretrovirals
Antituberculars
Antivirals
Cephalosporins
Macrolides
Penicillins
Quinolones
Sulfonamides and Combinations
Tetracyclines
Urinary Tract Agents
Miscellaneous Anti-infectives
14
14
14
15
16
16
17
17
17
17
18
18
18
18
Cardiovascular, hypertension, cholesterol

2A
2B
2C
2D
2E
2F
2G
2H
2I
2J
2K
2K
ACE-Inhibitors and Combinations

Alpha-adrenergic Agents
Angiotensin II Receptor Blockers and Combinations
Anticoagulants and Hemostasis Agents
Beta Blockers and Combinations
Calcium Channel Blockers and Combinations
Cardiovascular Treatment
Diuretics
Lipid-lowering Agents
Nitrates and Combinations
Renin-inhibitors and Combinations
Miscellaneous Antihypertensives
19
19
20
20
21
21
22
22
23
23
24
24
Page 1
Central nervous system

3A
3B
3C
3D
3E
3F
3G
3H
3I
3J
3K
3L
3M
3N
3O
3P
3Q
3R
Alzheimer's therapy
Anticonvulsants
Antidepressants
Antipsychotics
Anxiolytics
CNS Stimulants
Migraine Therapy
Myesthenia Gravis
Narcotic Antagonists
Narcotic Mixed Agonist/Antagonist
Narcotic/Analgesic Combinations
Narcotics
Nonsteroidal Anti-inflammatory Drugs
Parkinsons Disease and Related Disorders
Salicylates
Sedative/Hypnotics
Skeletal Muscle Relaxants
Miscellaneous CNS
25
26
27
28
28
29
30
30
30
31
31
32
33
34
34
35
35
36
Gastrointestinal agents
4A
4B
4C
4D
4E
4F
4G
4H
4I
4J
4K
4L
5-Aminosalicylic Acid (5-ASA) Agents

Antidiarrheals and Antispasmodics
Antiemetics
Bile Acids
Bowel Preparation and Cleansing Agents
Digestive Enzymes
H2-Receptor Antagonists
Other Ulcer Therapy
Proton Pump Inhibitors
Topical Anti-Inflammatory Agents
Tumor Necrosis Factor (TNF) Blocking Agents
Miscellaneous Gastrointestinal Agents
37
37
37
38
38
38
38
38
39
39
39
40
Obstetrics and gynecology

5A
5B
5C
5D
5E
5F
5G
5H
5I
5J
5K
Contraceptives-Biphasic
Contraceptives-Misc.
Contraceptives-Monophasic
Contraceptives-Postcoital
Contraceptives-Triphasic
Estrogen/Progestin Combinations
Estrogens
Infertility Treatment
Progestins
Vaginal Anti-infective/Antifungal
Miscellaneous OB-GYN
41
41
41
42
42
42
42
43
43
43
44
Page 2
Rheumatology and musculoskeletal

6A
6B
6C
6D
6E
6F
6G
6H
Corticosteroids
Gout Therapy
Non-Tumor Necrosis Factor (TNF) Blocking Agents
Osteoporosis/Bone Resorption
Osteoporosis/Hormonal Treatment
Salicylates
Tumor Necrosis Factor (TNF) Blocking Agents
Miscellaneous Rheumatologic Agents
45
45
45
45
46
46
46
46
Endocrinology
7A
7B
7C
7D
7E
7F
7G
7H
7I
7J
7K
Androgens
Antithyroid Agents
Corticosteroids
Growth Hormone and Related Products
Insulins
Non-insulin Hypoglycemic Agents
Somatostatin Analogs
Thyroid Hormones
Urea Cycle Disorder Agents
Vitamin D Analogs
Miscellaneous Endocrine
47
47
47
48
48
49
50
50
50
50
51
Antineoplastics and immunossuppresants

8A
8B
8C
8D
8E
8F
8G
Adjuvant Therapy
Alkylating Agents
Antimetabolites
Hormonal Agents
Immunomodulators
Kinase Inhibitors and Molecular Target Inhibitors
Miscellaneous Antineoplastic Agents
52
52
52
53
53
54
54
Immunology and hematology

9A
9B
9C
9D
Hematopoietic Agents
Immunoglobulins
Interferons and MS Therapy
Miscellaneous Immunology and Hepatology
55
55
55
55
Page 3
Dermatology
10A
10B
10C
10D
10E
10F
10G
10H
10I
10J
10K
10L
10M
10N
Acne Treatment
Antipsoriatic/Antiseborrheic
Corticosteriods - Very High Potency
Corticosteroids - High Potency
Corticosteroids - Medium Potency
Corticosteroids - Low Potency
Scabicides/Pediculicides
Topical Anesthetics
Topical Antibacterials
Topical Antifungals
Topical Antineoplastic Agents and Immunomodulators
Topical Antivirals
Wound and Burn Therapy
Miscellaneous Dermatologicals
56
57
57
57
58
58
58
58
59
59
59
60
60
60
Ophthalmology
11A
11B
11C
11D
11E
11F
11G
11H
11I
Cycloplegic Mydriatics
Ophthalmic Anti-Allergy Agents
Ophthalmic Anti-infective/Steroid Combinations
Ophthalmic Anti-infectives
Ophthalmic Anti-inflammatory Agents
Ophthalmic Beta Blockers
Ophthalmic Steroids
Other Glaucoma Agents
Miscellaneous Ophthalmic Agents
61
61
61
62
62
62
63
63
63
Otic and nasal preparations

12A
12B
Nasal Preparations
Otic Preparations
64
64
Respiratory, cough and cold

13A
13B
13C
13D
13E
13F
13G
13H
13I
13J
13K
13L
13M
13N
13O
Antihistamine/Decongestant Combinations
Antihistamines
Antitussives
Cystic Fibrosis Agents
Epinephrine
Inhaled Anticholinergics
Inhaled Beta-Agonist/Anticholinergic Combinations
Inhaled Beta-Agonists
Inhaled Steroid/Beta-Agonist Combinations
Inhaled Steroids
Intranasal Steroids
Oral Beta-Agonists
Pulmonary Hypertension Agents
Theophyllines
Miscellaneous Respiratory Agents
65
65
65
66
66
66
66
66
67
67
67
67
67
68
68
Page 4
Urology
14A
14B
14C
BPH Treatment
Urinary Antispasmodics
Miscellaneous Urologicals
69
69
69
Vitamins and supplements

15A
15B
Potassium Replacement
Vitamins and Minerals
70
70
Diagnostic and other miscellaneous

16A
16B
16C
Chelating Agents
Ion-Removing Agents
Diagnostics and Other Miscellaneous
71
71
71
Lifestyle modification
17A
17B
17C
Impotence, Sexual Dysfunction

Smoking Cessation
Weight Loss Preparations
72
72
72
Page 5
Blue Cross and BCN Custom Drug List
We regularly update this list with medications approved by the U.S. Food and Drug
Administration and reviewed by the Blue Cross and BCN Pharmacy and Therapeutics
Committee. The list represents the clinical judgment of Michigan physicians, pharmacists and
other experts in the diagnosis and treatment of disease and the promotion of health. The
committee selects medications based on safety, clinical effectiveness and opportunity for cost
savings. This is how the Blue Cross and BCN Custom Drug List helps maintain quality of care
and contain costs for our members.
Tier descriptions
Tier 1: Generics lowest copayment
Most drugs in this category are generic drugs. Members pay the lowest copay for these drugs,
which make them the most cost-effective option for treatment.
Tier 1 drugs are grouped into two tiers for some BCN pharmacy benefits:
Tier 1A: Preferred Generics lower generic drug copay
This tier includes commonly prescribed generic drugs that treat chronic diseases such
as depression, hypertension, cholesterol, diabetes, heart disease and congestive heart
failure. Select brand-name drugs that treat chronic diseases such as asthma and
diabetes are also included in this tier. Offering these drugs at the lowest copay makes
these drugs more accessible to members and helps ensure that they continue to take
these important drugs regularly as prescribed.
Tier 1B: Generics higher generic drug copay
Tier 1B includes generic drugs that arent listed in Tier 1A. The Tier 1B copay is higher
than the Tier 1A copay, but is still lower than the copay for brand-name drugs.
Tiers 1A and 1B apply only to BCN members with a six-tier drug plan. Blue Cross
considers all generic, nonspecialty drugs to be Tier 1.
Tier 2: Preferred Brand higher copay
This tier includes preferred, brand-name drugs that dont have a generic equivalent. These
drugs are more expensive than generics and members pay a higher copay for them.
Tier 3: Nonpreferred Brands highest copay
This tier includes brand-name drugs for which there is either a generic alternative or a more
cost-effective preferred brand-name drug available. Members pay the highest copay for these
drugs.
Page 6
Tier 4: Preferred Specialty lower specialty drug cost sharing

Specialty drugs in Tier 4 are generally more effective and less expensive than nonpreferred
specialty drugs in Tier 5.
Tier 5: Nonpreferred Specialty higher specialty drug cost sharing
Members pay the highest copay for these specialty drugs because a more cost-effective generic
or preferred brand-name drug is available.
Some plans group specialty drugs into Tiers 4 and 5. If you dont have this type of plan, youll
find specialty drugs grouped under Tiers 1, 2 or 3.
For more information on specialty drugs, see Specialty Drug Program Rx Benefit Member
Guide. Specialty drugs are limited to a 30-day supply. Select specialty drugs are managed by
the 15-Day Specialty Drug Limitation Program. Drugs included on this list are limited to a 15-day
supply for all fills for Blue Cross PPO and BCN HMO drug plans. Members pay half their copay
for a 15-day supply. For additional details visit bcbsm.com/pharmacy.
Preventive drug coverage

Under the Patient Protection and Affordable Care Act, also known as national health care
reform, most health plans must cover certain preventive services and drugs with no cost
sharing. For a complete list of preventive drugs refer to Preventive drug coverage or visit
bcbsm.com/pharmacy. Members must meet plan requirements and have a prescription to be
covered.
For details, see How prior approval, step therapy and quantity limits work.
What you should know

Use this list to find information about drug coverage and therapeutic options for Blue Cross and
BCN members. This list is divided into major drug classes or indication for use by chapter so its
easy to use. Products approved for more than one use may be included in more than one
chapter. Within each chapter, drugs are identified according to their tier placement (Tiers 1
through 5).
We encourage physicians to prescribe preferred medications whenever possible. Blue Cross
and BCN respect the judgment of the dispensing pharmacists and expect them to contact the
prescriber when a prescription for a drug or dose may not be appropriate for the member. We
also encourage pharmacists to contact the prescriber to suggest an alternative when a Blue
Cross or BCN members prescription is written for a Tier 3 or Tier 5 (nonpreferred) drug that
isnt covered.
Page 7
Coverage and applicable copay amounts for drugs on the Blue Cross and BCN Custom Drug
List are based on a members drug plan. Not all drugs included in the drug list are necessarily
covered by each members plan.
Some medications excluded from a members pharmacy benefit may be covered under his or
her medical benefit. Examples include serums, vaccines and other medications that are
generally administered in a physicians office under the supervision of appropriate health care
personnel and arent normally dispensed to the member for self-administration.
New generics: When a generic version of a Tier 2 or Tier 3 drug becomes available, the
generic version is generally added to Tier 1. The status of the original branded version will be
Tier 3 for Blue Cross and Tier 2 for BCN. All BCN members and some Blue Cross members,
depending on their plan, may be required to pay the difference between the brand name drug
and the generic drug, as well as the applicable brand-name copay.
How prior approval, step therapy and quantity limits work

The Blue Care Network Prior Authorization and Step Therapy Guidelines and the Blue Cross
Prior Authorization and Step Therapy Guidelines provide a list of drugs that require approval or
step-therapy prior to coverage. To view the current version, visit bcbsm.com/pharmacy.
Prior approval
Prior approval may be necessary for coverage of certain medications. In these cases, the
member must meet clinical criteria or additional information must be provided before coverage
is approved.
Clinical criteria are based on current medical information and approved by the Blue Cross and
BCN Pharmacy and Therapeutics Committee.
Step therapy
Drugs subject to step therapy may require previous treatment with one or more preferred drugs
before coverage is approved.
Quantity limits and dose optimization
Blue Cross and BCN set quantity limits based on clinical appropriateness and manufacturerrecommended dosing for particular drugs.
Blue Cross and BCN dose optimization programs encourage appropriate prescribing of
medications that are intended for once-daily administration. For certain medications, physicians
are encouraged to prescribe prescription drugs in once-daily dosage regimens, as opposed to
using multiple lower doses of the same drug to help increase a members adherence the
medication.
Page 8
Obtaining prior approval or step therapy
For members:
Blue Cross
Members should consult their
prescription drug benefit packet for
information on how to obtain approval or
how to request a review for coverage of a
drug that isn't included in your plan.
Members can also call the Customer
Service number on the back of their
Blues ID card for additional information.
Members who have a PPO plan and
need a request taken care of right away
can fill out an expedited request form on
the web at bcbsm.com.
Or write to:
Blue Cross Blue Shield of Michigan
Pharmacy Services
P.O. BOX 2320
Detroit, MI 48231-2320
BCN
To request approval for a drug, members
can talk to their doctor.
Members can also initiate the request by
calling the Customer Service number on
the back of their BCN ID card.
For physicians:
Blue Cross
Physicians can request approval one of
four ways:
1. Web - bcbsm.com
a. Log in as a provider
b. Select Medication Prior
Authorization
2. Call - 1-800-437-3803
3. Fax - 1-866-601-4425
4. Write
Pharmacy Services
P.O. BOX 2320
BCN
Physicians can request approval one of
three ways:
1. Call: 1-800-437-3803
a. Provide the members numeric
contract number or enrollee ID.
Do not use the alpha prefix
b. Enter the requested
information accurately and
completely so your request is
routed correctly.
2. Fax: 1-877-442-3778
3. Write:
Blue Care Network
Pharmacy Services Help Desk
Mail Code C303
Southfield, MI 48076
Page 9
Physicians can download the medication request forms through web-DENIS under Blue
Cross or BCN Provider Publications and Resources. Be sure to identify urgent requests,
and return the completed request forms to the Pharmacy Services Clinical Help Desk for
review. We notify the physician of approved requests and process the members claim
accordingly. If a request isnt approved, well notify the member and physician in writing.
The notification includes the reason for the denial and an explanation of the appeal rights
and the appeals process.
This document is current at the time of publication and is subject to change. Please go to
bcbsm.com/pharmacy and click Drug Lists for the most up-to-date information regarding
the Blue Cross and BCN Custom Drug List.
Page 10
Generic drug substitution and possible therapeutic alternatives

Generic drug substitution
Generic drug substitution occurs when a pharmacist dispenses a generic equivalent rather than
the brand-name product. Generics approved by the U.S. Food and Drug Administration are
listed in the Generic name column to the right of the brand-name drug. Generic substitution is
required for all BCN members and most Blue Cross members. If both the generic and brand
names are listed, the tier number matches the available generic. The brand-name tier is always
higher, reflecting the higher copayment when theres an available generic.
Blue Cross members
Members are encouraged to receive the
generic equivalent, if available, or they
may be required to pay the difference in
cost between the brand dispensed and
the generic equivalent, in addition to the
applicable copay.
BCN members
If a brand-name drug is requested when a
generic version is available, members will
pay their Tier 2 or Tier 4 copay plus the
difference in cost between the brand and
generic versions. Prescribers may request
authorization for the brand-name version,
based on medical necessity. A completed
MedWatch form is required.
The maximum allowable cost, or MAC, list sets the highest prices for reimbursement of certain
generic prescription drugs. The drugs on the MAC list are commonly prescribed and dispensed,
and have undergone the FDAs review and approval process, which ensures that:
Generic drugs contain the same active ingredients and are the same strengths and
dosage forms as their brand-name counterparts.
The FDA has given the generics an A rating and has determined theyre the equivalent
of their brand-name counterparts, or the Blue Cross and BCN Pharmacy and
Therapeutics Committee has reviewed the products and found them to be acceptable
generic substitutes.
When the above two criteria are met, generics can be substituted with the full expectation that
theyll produce the same clinical effects and have the same safety profiles as the prescribed
brand-name products.
Possible brand alternatives
Some medications are identical in strength and formulation, and are produced by multiple
manufacturers, but are marketed as brand-name products with different brand names. We
encourage prescribers to select preferred (Tier 1 or Tier 2) products to help members save on
their out-of-pocket costs.
Nonpreferred drugs
Epogen
Follistim
Possible brand alternatives

Preferred alternatives
Procrit
Gonal-F
Page 11
Humatrope, Norditropin , Omnitrope,

Saizen, Serostim, Zomacton, Zorbtive
Genotropin, Nutropin
Possible therapeutic alternatives

The Blue Cross and BCN Preferred Alternatives July 2016 list represents possible
alternatives to nonpreferred drugs. These alternative medications can generally be prescribed
without approval from Blue Cross or BCN, and can be dispensed with lower out-of-pocket costs
for members. Therapeutic alternatives may represent a different drug class, contain different
ingredients or may be available in strengths or dosage forms that differ from the prescribed
branded products. Pharmacists must obtain authorization from a patients physician to dispense
an alternative product.
Appendix A, lists examples of the therapeutic alternatives a members physician should
consider when determining appropriate treatment for the member. The physician should
consider individual drug product characteristics and member factors such as coexisting disease
states, contraindications, therapeutic history, concurrent medications and other relevant
circumstances. This list is also available at bcbsm.com/pharmacy.
Editors note:
Please send us your comments and suggestions regarding the Blue Cross and BCN Custom
Drug List. Your input is vital to its continued success. We review and consider all responses.
Please send your comments to:
Drug Information Services Mail Code
512C
600 E. Lafayette Boulevard
Pharmacy Services Mail Code C303

Blue Care Network of Michigan
OR
20500 Civic Center Drive
Southfield, MI 48076-5043
Page 12
How to read the Custom Drug List

This drug list shows the drugs copayment tier and whether the drug has special requirements
for coverage.
Drugs are listed alphabetically by brand name. If a generic version is available, the name is
included in the Generic Name column next to the brand name and coverage is provided for the
generic version. The brand name is included for informational purposes only, as the brandname drugs arent covered or may require a higher copay, depending on the members plan. If
only a brand name is listed, there isnt a generic version available.
9
7
11
12
10
13
12
11
13
1
2
3
4
5
6
1
2
Drugs are organized based on drug class

or indication for use.
Kynamro is a brand-name specialty drug
(<s>). Its listed under Tier 2 for most
members and requires a Tier 4 copay with
a five-tier or six-tier plan. Prior approval and
quantity limits apply for both Blue Cross
and BCN plans.
The generic drug, atorvastatin calcium,
requires a Tier 1 copay and a Tier 1A
copay for BCN members with a six-tier drug
plan. Quantity limits apply for both plans.
Livalo is a brand-name drug that requires
a Tier 3 copay. Both Blue Cross and BCN
require step therapy for coverage and
quantity limits.
The generic drug, fenofibric acid (choline),
requires a Tier 1 copay and a Tier 1B
copay for BCN members with a six-tier drug
plan. Quantity limits apply for BCN plans.
Zetia is a brand-name drug that requires a
Tier 2 copay. Quantity limits apply for both
Blue Cross and BCN plans.
Tiers:
Custom: Applies to most Blue Cross
and BCN members (with a two-tier
closed or three-tier drug plan)
Five-tier: Applies to members with a
five-tier, or three-tier + specialty drug
plan.
BCN 6-Tier: Applies to BCN members with

a six-tier drug plan.
Blue Cross: Requirements for coverage
include prior approval, step therapy and
quantity limits.
10
BCN: Requirements for coverage include

prior authorization, step therapy and
quantity limits.
11
Prior approval: Approval from Blue Cross

or BCN is required for coverage.
12
Step therapy: Criteria must be met prior to

coverage.
13
Quantity limits: Prescriptions cant exceed

a specific quantity per fill.
Prevent designates preventive drug
Page 13
1. ANTI-INFECTIVES
1A. Antifungals
BCBSM/BCN BCBSM
Trade name
Ancobon
Cresemba capsule
Diflucan
Grifulvin V
Gris-PEG
Lamisil granules
Lamisil tablet
Mycelex Troche
Nizoral
Noxafil suspension
Noxafil tablet
Nystatin
Onmel (Not Covered for BCBSM)
Oravig
Sporanox capsule
Sporanox solution
Vfend
Generic name
flucytosine
fluconazole
griseofulvin,microsize
griseofulvin ultramicrosize
terbinafine hcl
clotrimazole
ketoconazole
nystatin
itraconazole
voriconazole
1B. Antimalarials
Generic name
chloroquine phosphate
mefloquine hcl
atovaquone/proguanil hcl
hydroxychloroquine sulfate
quinine sulfate
1C. Antiparasitics/Anthelmintics
Trade name
Albenza
Alinia
Biltricide
Emverm
Flagyl
Flagyl ER
Humatin
Impavido
Mepron
Mepron blister pak
Nebupent Aerosol
Stromectol
Tindamax
PA - Prior approval may be required
Custom 5-Tier PA ST QL 6-Tier PA ST QL

1
2
1
1
1
3
1
1
1
2
2
1
3
3
1
2
1
1
2
1
1
1
3
1
1
1
2
2
1
3
3
1
2
1
1B
2
1B
1B
1B
3
1B
1B
1B
2
2
1B
3
3
1B
2
1B
BCBSM/BCN BCBSM
Trade name
Aralen
Coartem
Daraprim <s>
Lariam
Malarone
Plaquenil
Primaquine
Qualaquin
BCN
metronidazole
paromomycin sulfate
atovaquone
ivermectin
tinidazole
ST - Step therapy may be required
BCN

1
2
2
1
1
1
2
1
1
2
4
1
1
1
2
1
1B
2
4
1B
1B
1B
2
1B
BCBSM/BCN BCBSM
Generic name
BCN

2
2
2
3
1
2
1
2
1
2
2
1
1
2
2
2
3
1
2
1
2
1
2
2
1
1
QL - Quantity limits may apply
BCBSM/BCN Custom Drug List (July 2016)
2
2
2
3
1B
2
1B
2
1B
2
2
1B
1B
<s> - Specialty Drug
Page 14
1D. Antiretrovirals
Trade name
Aptivus
Atripla
Combivir
Complera
Crixivan
Descovy
Edurant
Emtriva
Epivir
Epzicom
Evotaz
Fuzeon
Genvoya
Intelence
Invirase
Isentress
Kaletra
Lexiva
Norvir
Odefsey
Prezcobix
Prezista
Rescriptor
Retrovir
Reyataz
Selzentry
Stribild
Sustiva
Tivicay
Triumeq
Trizivir
Truvada
Tybost
Videx
Videx EC
Viracept
Viramune, XR
Viread
Vitekta
Zerit
Ziagen solution
Ziagen tablet
BCBSM/BCN BCBSM
Generic name
lamivudine/zidovudine
lamivudine
zidovudine
abacavir/lamivudine/zidovudine
didanosine
nevirapine
stavudine
abacavir sulfate
BCN

2
2
1
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
1
2
2
2
1
2
1
2
2
1
2
1
2
2
1
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
1
2
2
2
1
2
1
2
2
1
2
1
2
2
1B
2
2
2
2
2
1B
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1B
2
2
2
2
2
2
1B
2
2
2
1B
2
1B
2
2
1B
2
1B
Page 15
1E. Antituberculars
BCBSM/BCN BCBSM
Trade name
Cycloserine
Dapsone
Ethambutol
Isoniazid
Mycobutin
Paser (BCN tier 2 only)
Priftin
Pyrazinamide
Rifadin
Rifater
Sirturo
Trecator
Generic name
dapsone
ethambutol hcl
isoniazid
rifabutin
pyrazinamide
rifampin
1F. Antivirals

2
1
1
1
1
3
3
1
1
3
2
3
2
1
1
1
1
3
3
1
1
3
2
3
2
1B
1B
1B
1B
2
3
1B
1B
3
2
3
BCBSM/BCN BCBSM
Trade name
Amantadine hcl
Baraclude solution <s>
Baraclude tablet <s>
Copegus <s>
Daklinza <s>
Epivir HBV solution
Epivir HBV tablet
Famvir
Flumadine
Harvoni <s>
Hepsera <s>
Olysio <s>
Rebetol capsule <s>
Rebetol solution <s>
Relenza
Ribasphere, Ribapak <s>
Ribatab <s>
Sitavig
Sovaldi <s>
Tamiflu
Technivie <s>
Tyzeka <s>
Valcyte solution
Valcyte tablet
Valtrex
Viekira Pak <s>
Zovirax
BCN
Generic name
amantadine hcl
entecavir
ribavirin
lamivudine
famciclovir
rimantadine hcl
adefovir dipivoxil
ribavirin
ribavirin
ribavirin
valganciclovir hydrochloride
valacyclovir hcl
acyclovir
BCN

1
2
1
1
3
2
1
1
1
2
1
2
1
2
2
1
1
3
2
2
3
3
2
1
1
2
1
1
4
4
4
5
2
1
1
1
4
4
4
4
4
2
4
4
3
4
2
5
5
2
1
1
4
1
1B
4
4
4
5
2
1B
1B
1B
4
4
4
4
4
2
4
4
3
4
2
5
5
2
1B
1B
4
1B
Page 16
1G. Cephalosporins
BCBSM/BCN BCBSM
Trade name
Ceclor, ER
Cedax
Ceftin suspension
Ceftin tablet
Cefzil
Duricef
Keflex
Omnicef
Spectracef (28 Count)
Spectracef
Suprax chew, capsule, tablet
Suprax suspension 100/5, 200mg/5ml
Suprax suspension 500mg/5ml
Vantin
Generic name
cefaclor
ceftibuten dihydrate
cefuroxime axetil
cefprozil
cefadroxil hydrate
cephalexin monohydrate
cefdinir
cefditoren pivoxil
cefixime
cefpodoxime proxetil
1H. Macrolides
Trade name
Biaxin, XL
Dificid
E. E. S. tablet
E.E.S.; Eryped 200mg/5ml
Eryped
Eryped
Ery-Tab
Ery-Tab 500mg (Tier 2 BCN Only)
Erythromycin base
Erythromycin Stearate
Ketek
Zithromax
Zmax
Trade name
Generic name
clarithromycin
erythromycin ethylsuccinate
erythromycin ethylsuccinate
erythromycin
erythromycin base
erythromycin stearate
azithromycin
Trade name
1
1
2
1
1
1
1
1
3
1
3
1
3
1
1
1
2
1
1
1
1
1
3
1
3
1
3
1
1B
1B
2
1B
1B
1B
1B
1B
3
1B
3
1B
3
1B
Generic name
amoxicillin trihydrate
ampicillin trihydrate
amox tr/potassium clavulanate

dicloxacillin sodium
penicillin v potassium

1
3
1
2
2
1
1
3
1
1
3
1
3
1
3
1
2
2
1
1
3
1
1
3
1
3
1B
3
1B
2
2
1B
1B
2
1B
1B
3
1B
3
Generic name
ciprofloxacin hcl
ciprofloxacin hcl-betaine comb
ofloxacin
levofloxacin
BCN

3
1
1
2
1
1
3
1
3
1
1
2
1
1
3
1
3
1B
1B
2
1B
1B
3
1B
BCBSM/BCN BCBSM
moxifloxacin hcl
BCN
BCBSM/BCN BCBSM
1J. Quinolones
Avelox
Avelox ABC
Cipro
Cipro XR
Factive
Floxin tablet
Levaquin
BCBSM/BCN BCBSM
1I. Penicillins
Amoxicillin ER
Amoxil
Ampicillin
Augmentin 125mg-31.25mg/5ml susp
Augmentin, ES, XR
Dicloxacillin
Moxatag
Penicillin VK
BCN
BCN

1
2
1
1
3
1
1
1
2
1
1
3
1
1
1B
2
1B
1B
3
1B
1B
Page 17
1K. Sulfonamides and Combinations

Trade name
Bactrim, DS
Sulfadiazine
Generic name
sulfamethoxazole/trimethoprim
sulfadiazine
1L. Tetracyclines
Generic name
doxycycline monohydrate
demeclocycline hcl
doxycycline hyclate
minocycline hcl
doxycycline hyclate
minocycline hcl
tetracycline hcl
doxycycline hyclate
1M. Urinary Tract Agents

1
1
1
1
1B
1B
BCN

3
1
1
1
1
3
1
1
3
1
1
3
1
1
3
3
1
1
1
1
3
1
1
3
1
1
3
1
1
3
3
1B
1B
1B
1B
3
1B
1B
3
1B
1B
3
1B
1B
2
BCBSM/BCN BCBSM
Trade name
Furadantin
Hiprex/Urex
Macrobid
Macrodantin
Monurol
Primsol (Tier 2 BCN Only)
Pyridium (BCBSM only)
Trimethoprim
UTA (BCBSM only)
BCN
BCBSM/BCN BCBSM
Trade name
Acticlate tablet
Adoxa capsule
Adoxa tablet
Declomycin
Doryx
Doxycycline IR-DR
Minocin
Monodox
Oracea
Periostat
Solodyn
Solodyn 55, 65, 80, 105, 115mg
Tetracycline
Vibramycin
Vibramycin syrup (Tier 2 BCN only)
BCBSM/BCN BCBSM
Generic name
nitrofurantoin
methenamine hippurate
nitrofurantoin
nitrofurantoin macrocrystal
phenazopyridine hcl
trimethoprim
BCN

1
1
1
1
3
3
1
1
3
1
1
1
1
3
3
1
1
3
1B
1B
1B
1B
3
2
NC
1B
NC
NC - Not Covered for members with a BCN drug benefit
1N. Miscellaneous Anti-infectives

Trade name
Bethkis <s>
Cayston <s>
Cleocin
Cleocin 75mg
Neomycin
Peridex
Sivextro
Tobi <s>
Tobi Podhaler <s>
Vancocin hcl
Xifaxan 200mg
Zyvox
BCBSM/BCN BCBSM
Generic name
clindamycin hcl
neomycin sulfate
chlorhexidine gluconate
tobramycin/0.25 normal saline

vancomycin hcl
linezolid
BCN

3
3
1
2
1
1
2
1
3
1
3
1
5
5
1
2
1
1
2
4
5
1
3
1
5
5
1B
2
1B
1B
2
4
5
1B
3
1B
Page 18
2. CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL

2A. ACE-Inhibitors and Combinations
Trade name
Generic name
Accupril
Accuretic
Aceon
Altace
Capoten
Capozide
Epaned
Lotensin
Lotensin HCT
Lotrel
Mavik
Monopril
Monopril HCT
Prestalia
Prinivil; Zestril
Prinzide; Zestoretic
Tarka
Uniretic
Univasc
Vaseretic
Vasotec
quinapril hcl
quinapril/hydrochlorothiazide
perindopril erbumine
ramipril
captopril
captopril/hydrochlorothiazide
benazepril hcl
benazepril/hydrochlorothiazide
amlodipine besylate/benazepril
trandolapril
fosinopril sodium
fosinopril/hydrochlorothiazide
lisinopril
lisinopril/hydrochlorothiazide
trandolapril/verapamil hcl
moexipril/hydrochlorothiazide
moexipril hcl
enalapril/hydrochlorothiazide
enalapril maleate
2B. Alpha-adrenergic Agents

Trade name
Aldomet
Aldoril
Cardura
Catapres
Catapres TTS
Clorpres
Clorpres 0.3-15mg (Tier 2 - BCN Only)
Dibenzyline
Hytrin
Minipress
Reserpine
Tenex
BCBSM/BCN BCBSM
BCN

1
1
1
1
1
1
3
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1A
1A
1B
1A
1A
1A
3
1A
1A
1A
1A
1A
1A
3
1A
1A
1B
1A
1A
1A
1A
BCBSM/BCN BCBSM
Generic name
methyldopa
methyldopa/hydrochlorothiazide
doxazosin mesylate
clonidine hcl
clonidine hcl
clonidine hcl/chlorthalidone
phenoxybenzamine hcl
terazosin hcl
prazosin hcl
reserpine
guanfacine hcl
BCN

1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1B
1B
1B
1A
1B
1B
2
1B
1B
1B
1B
1B
Page 19
2C. Angiotensin II Receptor Blockers and Combinations

Trade name
Atacand
Atacand HCT
Avalide
Avapro
Azor
Benicar, HCT
Cozaar
Diovan
Diovan HCT
Edarbi
Edarbyclor
Entresto
Exforge
Exforge HCT
Hyzaar
Micardis
Micardis HCT
Teveten
Tribenzor
Twynsta
Generic name
candesartan cilexetil
candesartan/hydrochlorothiazide
irbesartan/hydrochlorothiazide
irbesartan
losartan potassium
valsartan
valsartan/hydrochlorothiazide
amlodipine/valsartan
amlodipine/valsartan/hctz
losartan/hydrochlorothiazide
telmisartan
telmisartan/hydrochlorothiazide
eprosartan mesylate
telmisartan/amlodipine
2D. Anticoagulants and Hemostasis Agents

Trade name
Aggrenox
Agrylin
Amicar
Arixtra <s>
Astringyn
Brilinta
Coumadin
Effient
Eliquis
Fragmin <s>
Heparin <s>
Iprivask <s>
Lovenox <s>
Mephyton
Persantine
Plavix
Pletal
Pradaxa
Savaysa
Ticlid
Trental
Vitamin K ampule
Xarelto
Zontivity
Generic name
aspirin/dipyridamole
anagrelide hcl
fondaparinux sodium
warfarin sodium
heparin sodium,porcine
enoxaparin sodium
dipyridamole
clopidogrel bisulfate
cilostazol
ticlopidine hcl
pentoxifylline
phytonadione
BCBSM/BCN BCBSM
BCN

1
1
1
1
3
2
1
1
1
3
3
3
1
1
1
1
1
1
3
1
1
1
1
1
3
2
1
1
1
3
3
3
1
1
1
1
1
1
3
1
1A
1A
1A
1A
3
2
1A
1B
1A
3
3
3
1B
1B
1A
1B
1B
1A
3
1B
BCBSM/BCN BCBSM
BCN

1
1
2
1
3
2
1
2
2
3
1
3
1
2
1
1
1
2
3
1
1
1
2
3
1
1
2
4
3
2
1
2
2
5
4
5
4
2
1
1
1
2
3
1
1
1
2
3
1B
1B
2
4
3
2
1A
2
2
5
4
5
4
2
1B
1A
1B
2
3
1B
1B
1B
2
3
Page 20
2E. Beta Blockers and Combinations

Trade name
Betapace, AF
Blocadren
Bystolic
Bystolic 20mg
Coreg CR
Coreg immediate release
Corgard
Corzide
Dutoprol
Hemangeol
Inderal solution
Inderal XL
Inderal, LA
Inderide
Innopran XL
Kerlone
Levatol
Lopressor
Lopressor HCT
Normodyne; Trandate
Sectral
Sotylize
Tenoretic
Tenormin
Toprol XL
Visken
Zebeta
Ziac
Generic name
sotalol hcl
timolol maleate
carvedilol
nadolol
nadolol/bendroflumethiazide
propranolol hcl
propranolol hcl
propranolol/hydrochlorothiazide
betaxolol hcl
metoprolol tartrate
metoprolol/hydrochlorothiazide
labetalol hcl
acebutolol hcl
atenolol/chlorthalidone
atenolol
metoprolol succinate
pindolol
bisoprolol fumarate
bisoprolol/hydrochlorothiazide
2F. Calcium Channel Blockers and Combinations

Trade name
Azor
Caduet
Calan SR; Isoptin SR
Cardene
Cardene SR
Cardizem LA 120mg
Cardizem, SR, CD, LA
Dynacirc
Exforge
Exforge HCT
Lotrel
Norvasc
Plendil
Prestalia
Procardia, XL; Adalat CC
Sular
Tarka
Tekamlo
Tiazac
Tribenzor
Twynsta
Verelan PM
Generic name
amlodipine/atorvastatin cal
verapamil hcl
nicardipine hcl
diltiazem hcl
isradipine
amlodipine/valsartan
amlodipine/valsartan/hctz
amlodipine besylate/benazepril
amlodipine besylate
felodipine
nifedipine
nisoldipine
trandolapril/verapamil hcl
diltiazem hcl
telmisartan/amlodipine
verapamil hcl
BCBSM/BCN BCBSM
BCN

1
1
3
3
3
1
1
1
3
3
1
3
1
1
3
1
3
1
1
1
1
3
1
1
1
1
1
1
1
1
3
3
3
1
1
1
3
3
1
3
1
1
3
1
3
1
1
1
1
3
1
1
1
1
1
1
1A
1A
3
3
3
1A
1A
1A
3
3
1B
3
1A
1A
3
1A
3
1A
1A
1A
1A
3
1A
1A
1A
1A
1A
1A
BCBSM/BCN BCBSM
BCN

3
1
1
1
3
3
1
1
1
1
1
1
1
3
1
1
1
3
1
3
1
1
3
1
1
1
3
3
1
1
1
1
1
1
1
3
1
1
1
3
1
3
1
1
3
1B
1B
1B
3
3
1B
1B
1B
1B
1A
1A
1B
3
1B
1B
1B
3
1B
3
1B
1B
Page 21
2G. Cardiovascular Treatment
BCBSM/BCN BCBSM
Trade name
Betapace, AF
Cordarone
Corlanor
Lanoxin
Lanoxin 62.5, 187.5mcg
Mexitil
Multaq
Norpace
Norpace CR
Northera <s>
Papaverine capsule
Proamatine
Quinidex
Quinidine gluconate SA
Ranexa
Rythmol, SR
Sotylize
Tambocor
Tikosyn
Vasodilan (BCBSM only)
Generic name
sotalol hcl
amiodarone hcl
digoxin
mexiletine hcl
disopyramide phosphate
papaverine hcl
midodrine hcl
quinidine sulfate
quinidine gluconate
propafenone hcl
flecainide acetate
isoxsuprine hcl
BCN

1
1
2
1
3
1
2
1
2
3
1
1
1
1
3
1
3
1
2
1
1
1
2
1
3
1
2
1
2
5
1
1
1
1
3
1
3
1
2
1
1A
1B
2
1B
3
1B
2
1B
2
5
1B
1B
1B
1B
3
1B
3
1B
2
NC
2H. Diuretics
Trade name
Aldactazide
Aldactazide 50/50mg (Tier 2 BCN only)
Aldactone
Bumex
Demadex
Diamox, Sequels
Diuril capsule, tablet
Diuril suspension (Tier 2 BCN only)
Dutoprol
Dyazide, Maxzide
Dyrenium
Edecrin
Furosemide solution (Tier 2 BCN only)
Hydrodiuril; Microzide
Hygroton; Thalitone
Inspra
Lasix
Lozol
Midamor
Moduretic
Zaroxolyn
BCBSM/BCN BCBSM
Generic name
spironolact/hydrochlorothiazid
spironolactone
bumetanide
torsemide
acetazolamide
chlorothiazide
triamterene/hydrochlorothiazide
hydrochlorothiazide
chlorthalidone
eplerenone
furosemide
indapamide
amiloride hcl
amiloride/hydrochlorothiazide
metolazone
BCN

1
3
1
1
1
1
1
3
3
1
2
2
3
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
3
3
1
2
2
3
1
1
1
1
1
1
1
1
1A
2
1A
1A
1A
1B
1A
2
3
1A
2
2
2
1A
1A
1A
1A
1A
1A
1A
1A
Page 22
2I. Lipid-lowering Agents
BCBSM/BCN BCBSM
Trade name
Altoprev
Antara
Antara 30, 90mg
Caduet
Colestid
Colestid granules, packet
Crestor
Fenofibrate capsule
Fenoglide
Fibricor
Juxtapid <s>
Kynamro <s>
Lescol
Lescol XL
Lipitor
Lipofen
Liptruzet
Livalo
Lofibra
Lopid
Lovaza
Mevacor
Niacor (Tier 2 BCN only)
Niaspan
Praluent <s>
Pravachol
Questran, Light
Repatha <s>
Tricor
Triglide
Trilipix
Vascepa
Vytorin
Welchol
Zetia
Zocor
Generic name
fenofibrate,micronized
amlodipine/atorvastatin cal
colestipol hcl
rosuvastatin calcium
fenofibric acid
fluvastatin sodium
fluvastatin sodium
atorvastatin calcium
fenofibrate,micronized
gemfibrozil
omega-3 acid ethyl esters
lovastatin
niacin
pravastatin sodium
cholestyramine
fenofibrate nanocrystallized
fenofibric acid (choline)
simvastatin
2J. Nitrates and Combinations

Trade name
BiDil
Dilatrate-SR
Imdur
Isordil
Isordil 40mg (Tier 2 BCN Only)
Minitran
Nitro-Bid ointment
Nitro-Dur (Tier 2 BCN Only)
Nitro-Dur patch 0.3mg, 0.8mg
Nitroglycerin caps, patch, spray, tablet
Nitromist
Nitrostat
BCN

3
1
3
1
1
3
1
3
3
1
3
2
1
1
1
3
3
3
1
1
1
1
3
1
3
1
1
3
1
3
1
3
3
2
2
1
3
1
3
1
1
3
1
3
3
1
5
4
1
1
1
3
3
3
1
1
1
1
3
1
5
1
1
5
1
3
1
3
3
2
2
1
3
1B
3
1B
1B
3
1B
3
3
1B
5
4
1B
1B
1A
3
3
3
1A
1A
1B
1A
2
1B
5
1A
1B
5
1B
3
1B
3
3
2
2
1A
BCBSM/BCN BCBSM
Generic name
isosorbide mononitrate
isosorbide dinitrate
nitroglycerin
nitroglycerin
nitroglycerin
BCN

2
2
1
1
3
2
1
3
3
1
1
2
2
2
1
1
3
2
1
3
3
1
1
2
2
2
1A
1B
2
2
1B
2
3
1B
1B
2
Page 23
2K. Renin-inhibitors and Combinations

Trade name
Generic name
Tekamlo
Tekturna
Tekturna HCT
Trade name
Generic name
hydralazine hcl
minoxidil
BCN

3
3
3
2L. Miscellaneous Antihypertensives

Apresoline
Demser (Tier 2 BCN Only)
Loniten
Vecamyl
BCBSM/BCN BCBSM
3
3
3
3
3
3
BCBSM/BCN BCBSM
BCN

1
3
1
3
1
3
1
3
1B
2
1B
3
Page 24
3. CENTRAL NERVOUS SYSTEM

3A. Alzheimer's therapy
Trade name
Aricept 23mg
Aricept, ODT
Exelon capsule
Exelon patch
Memantine Hcl dosepack
Namenda
Namenda dosepak
Namenda XR
Namzaric
Razadyne, ER
BCBSM/BCN BCBSM
Generic name
donepezil hcl
donepezil hcl
rivastigmine tartrate
rivastigmine
memantine hcl
galantamine hydrobromide
BCN

1
1
1
1
2
1
2
3
3
1
1
1
1
1
2
1
2
3
3
1

Prevent - Prevent drugs may be covered at $0 if criteria are met
1B
1B
1B
1B
2
1B
2
3
3
1B
Page 25
3B. Anticonvulsants
Trade name
Acthar H.P. <s>
Aptiom
Banzel
Briviact
Carbatrol
Celontin
Depakene
Depakote, ER, Sprinkles
Diamox, Sequels
Diastat 2.5mg Kit
Diastat Acudial
Dilantin
Dilantin 30mg
Dilantin Chew Tabs
Felbatol
Fycompa
Gabitril
Gabitril 12, 16mg
Keppra
Keppra XR
Klonopin, Wafer
Lamictal dosepak
Lamictal dosepak ODT
Lamictal ODT, XR
Lamictal tabs, dispertabs
Lamictal XR dosepak
Lyrica
Mebaral
Mysoline
Neurontin
Onfi
Oxtellar XR
Peganone
Phenobarbital
Potiga
Qudexy XR
Sabril <s>
Spritam
Tegretol, XR
Topamax
Topiramate ER
Trileptal
Trokendi XR
Vimpat
Zarontin
Zonegran
BCBSM/BCN BCBSM
Generic name
carbamazepine
valproate sodium
divalproex sodium
acetazolamide
diazepam
phenytoin sodium extended
phenytoin
felbamate
tiagabine hcl
levetiracetam
levetiracetam
clonazepam
lamotrigine
lamotrigine
lamotrigine
mephobarbital
primidone
gabapentin
phenobarbital
carbamazepine
topiramate
oxcarbazepine
ethosuximide
zonisamide
BCN

3
3
2
3
1
2
1
1
1
2
1
1
2
1
1
3
1
2
1
1
1
2
1
1
1
3
3
1
1
1
3
3
2
1
3
3
2
3
1
1
3
1
3
2
1
1
5
3
2
3
1
2
1
1
1
2
1
1
2
1
1
3
1
2
1
1
1
2
1
1
1
3
3
1
1
1
3
3
2
1
3
3
4
3
1
1
3
1
3
2
1
1

5
3
2
3
1B
2
1B
1B
1B
2
1B
1A
2
1A
1B
3
1B
2
1A
1B
1B
2
1B
1B
1B
3
3
1B
1B
1B
3
3
2
1B
3
3
4
3
1B
1B
3
1B
3
2
1B
1B
Page 26
3C. Antidepressants
Trade name
Amoxapine
Anafranil
Aplenzin
Aventyl; Pamelor
Celexa
Cymbalta
Cymbalta 60 mg
Desvenlafaxine ER
Desvenlafaxine Fumarate ER
Desyrel
Effexor
Effexor XR
Elavil
Emsam
Etrafon
Fetzima
Fluoxetine 60mg
Forfivo XL
Khedezla
Lexapro
Limbitrol, DS
Luvox
Luvox CR
Maprotiline hcl
Marplan
Nardil
Norpramin
Oleptro ER
Parnate
Paxil
Paxil CR
Paxil suspension
Perphenazine/amitriptyline hcl
Pexeva
Pristiq ER
Protriptyline hcl
Prozac
Prozac Weekly
Remeron
Sarafem
Serzone
Sinequan; Adapin
Surmontil
Tofranil
Tofranil-PM
Trintellix
Venlafaxine hcl ER
Viibryd
Wellbutrin XL 300mg
Wellbutrin, SR, XL
Zoloft
BCBSM/BCN BCBSM
Generic name
amoxapine
clomipramine hcl
nortriptyline hcl
citalopram hydrobromide
duloxetine hcl
duloxetine hcl
trazodone hcl
venlafaxine hcl
venlafaxine hcl
amitriptyline hcl
amitriptyline hcl/perphenazine
escitalopram oxalate
amitrip hcl/chlordiazepoxide
fluvoxamine maleate
fluvoxamine maleate
maprotiline hcl
phenelzine sulfate
desipramine hcl
tranylcypromine sulfate
paroxetine hcl
paroxetine hcl
protriptyline hcl
fluoxetine hcl
fluoxetine hcl
mirtazapine
nefazodone hcl
doxepin hcl
trimipramine maleate
imipramine hcl
imipramine pamoate
venlafaxine hcl
bupropion hcl
bupropion hcl
sertraline hcl
BCN

1
1
3
1
1
1
1
3
3
1
1
1
1
3
1
3
3
3
3
1
1
1
1
1
3
1
1
3
1
1
1
3
1
3
3
1
1
1
1
3
1
1
1
1
1
3
1
3
1
1
1
1
1
3
1
1
1
1
3
3
1
1
1
1
3
1
3
3
3
3
1
1
1
1
1
3
1
1
3
1
1
1
3
1
3
3
1
1
1
1
3
1
1
1
1
1
3
1
3
1
1
1

1B
1B
3
1A
1A
1B
1B
3
3
1A
1A
1A
1A
3
1B
3
3
3
3
1A
1B
1A
1B
1A
3
1B
1A
3
1B
1A
1B
3
1B
3
3
1B
1A
1B
1A
3
1B
1A
1B
1A
1B
3
1B
3
1A
1A
1A
Page 27
3D. Antipsychotics
Trade name
Abilify
Clozapine 200mg
Clozaril
Equetro
Etrafon
Fanapt
Fazaclo
Fazaclo 150, 200mg
Geodon
Haldol
Haldol liquid 2mg/ml
Invega
Latuda
Loxitane
Mellaril
Molindone
Navane
Orap
Perphenazine
Prolixin
Rexulti
Risperdal, M-Tab, solution
Saphris
Seroquel
Seroquel XR
Stelazine
Symbyax
Thorazine
Versacloz
Vraylar
Zyprexa, Zydis
BCBSM/BCN BCBSM
Generic name
aripiprazole
clozapine
clozapine
clozapine
ziprasidone hcl
haloperidol
haloperidol lactate
paliperidone
loxapine succinate
thioridazine hcl
molindone hcl
thiothixene
pimozide
perphenazine
fluphenazine hcl
risperidone
quetiapine fumarate
trifluoperazine hcl
olanzapine/fluoxetine hcl
chlorpromazine hcl
olanzapine
3E. Anxiolytics
Trade name
Ativan
Buspar
Equanil; Miltown
Librium
Niravam
Serax
Tranxene T-Tab
Valium
Xanax, XR
BCN

1
1
1
3
1
3
1
3
1
1
1
1
3
1
1
1
1
1
1
1
3
1
3
1
3
1
1
1
3
3
1
1
1
1
3
1
3
1
3
1
1
1
1
3
1
1
1
1
1
1
1
3
1
3
1
3
1
1
1
3
3
1
1B
1B
1A
3
1B
3
1B
3
1B
1A
1B
1B
3
1B
1A
1B
1B
1B
1B
1A
3
1A
3
1A
3
1A
1B
1A
3
3
1A
BCBSM/BCN BCBSM
Generic name
lorazepam
buspirone hcl
meprobamate
chlordiazepoxide hcl
alprazolam
oxazepam
clorazepate dipotassium
diazepam
alprazolam
BCN

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

1B
1B
1B
1B
1B
1B
1B
1B
1B
Page 28
3F. CNS Stimulants

Trade name
Adderall
Adderall XR (Brand BCN-Only)
Adderall XR
Adzenys XR-ODT
Aptensio XR
Concerta
Daytrana
Desoxyn
Dexedrine
Dyanavel XR
Evekeo
Focalin immediate release
Focalin XR
Focalin XR 25, 35mg
Metadate CD
Methylin, ER
Nuvigil
Procentra
Provigil
Quillichew ER
Quillivant XR
Ritalin LA 10mg, 60mg
Ritalin, LA, SR
Vyvanse
Zenzedi
BCBSM/BCN BCBSM
Generic name
amphet asp/amphet/d-amphet
amphet asp/amphet/d-amphet
methylphenidate hcl
methamphetamine hcl
d-amphetamine sulfate
dexmethylphenidate hcl
dexmethylphenidate hcl
methylphenidate hcl
methylphenidate hcl
armodafinil
d-amphetamine sulfate
modafinil
methylphenidate hcl
BCN

1
1
1
3
3
1
3
1
1
3
3
1
1
3
1
1
1
1
1
3
3
3
1
3
3
1
1
1
3
3
1
3
1
1
3
3
1
1
3
1
1
1
1
1
3
3
3
1
3
3

1B
1B
1B
3
3
1B
3
1B
1B
3
3
1B
1B
3
1B
1B
1B
1B
1B
3
3
3
1B
3
3
Page 29
3G. Migraine Therapy

Trade name
Allzital
Alsuma
Amerge
Axert
Cafergot
Cambia
D.H.E.45
Ergomar
Esgic
Fioricet 50/300/40mg capsule
Fioricet w/codeine 50/300/30mg
Fiorinal
Fiorinal w/codeine
Frova
Imitrex (All Forms)
Maxalt, MLT
Midrin (BCBSM only)
Migranal
Onzetra Xsail
Phrenilin tablet
Relpax
Sumavel Dosepro
Treximet
Zembrace Symtouch
Zomig, ZMT
Zomig nasal spray 2.5mg
Zomig nasal spray 5mg
BCBSM/BCN BCBSM
Generic name
sumatriptan succinate
naratriptan hcl
almotriptan malate
dihydroergotamine mesylate
butalb/acetaminophen/caffeine
butalbit/acetamin/caff/codeine
butalbital/aspirin/caffeine
codeine/butalbital/asa/caffein
frovatriptan succinate
sumatriptan succinate
rizatriptan benzoate
isometheptene/apap/dichlphen
dihydroergotamine mesylate
butalbital/acetaminophen
zolmitriptan
BCN

3
1
1
1
2
3
1
2
1
1
1
1
1
1
1
1
1
1
3
1
3
3
3
3
1
3
3
3
1
1
1
2
3
1
2
1
1
1
1
1
1
1
1
1
1
3
1
3
3
3
3
1
3
3
3
1B
1B
1B
2
3
1B
2
1B
1B
1B
1B
1B
1B
1B
1B
NC
1B
3
1B
3
3
3
3
1B
3
3
3H. Myesthenia Gravis

Trade name
Mestinon Syrup
Mestinon Timespan
BCBSM/BCN BCBSM
Generic name
pyridostigmine bromide
3I. Narcotic Antagonists

Trade name
Evzio
Movantik
Narcan nasal spray
Relistor syringe
Relistor vial
Revia
BCN

2
1
2
1
2
1B
BCBSM/BCN BCBSM
Generic name
naltrexone hcl
BCN

2
3
2
2
2
1
2
3
2
2
2
1

2
3
2
2
2
1B
Page 30
3J. Narcotic Mixed Agonist/Antagonist

Trade name
Generic name
Belbuca
Bunavail
Butrans
Conzip
Ryzolt
Stadol, NS
Suboxone
Suboxone Film
Subutex
Talwin NX
Ultracet
Ultram, ER
Zubsolv
tramadol hcl
butorphanol tartrate
buprenorphine hcl/naloxone hcl
buprenorphine hcl
pentazocine hcl/naloxone hcl
tramadol hcl/acetaminophen
tramadol hcl
3K. Narcotic/Analgesic Combinations

Trade name
Generic name
Esgic
Fiorinal
Fiorinal w/codeine
Hycet
Ibudone
Ibudone 5mg/200mg (Tier 2 BCN Only)
levorphanol tartrate
Lortab solution
Lortab; Norco; Vicodin; Xodol
Percocet
Percodan
Phrenilin
Reprexain
Synalgos-DC
Synalgos-DC (Tier 2 BCN Only)
Trezix
Trezix
Tylenol w/Codeine
Vicoprofen
Xartemis XR
butalb/acetaminophen/caffeine
butalbital/aspirin/caffeine
codeine/butalbital/asa/caffein
hydrocodone bit/acetaminophen
hydrocodone/ibuprofen
levorphanol tartrate
hydrocodone bit/acetaminophen
oxycodone hcl/acetaminophen
oxycodone hcl/aspirin
butalbital/acetaminophen
dihydrocodeine/aspirin/caffein
dhcodeine bt/acetaminophn/caff
codeine phos/acetaminophen
BCBSM/BCN BCBSM
BCN

3
3
3
3
1
1
1
2
1
1
1
1
3
3
3
3
3
1
1
1
2
1
1
1
1
3
3
3
3
3
1B
1B
1B
2
1B
1B
1B
1B
3
BCBSM/BCN BCBSM
BCN

1
1
1
1
1
1
1
3
1
3
1
1
1
1
1
1
3
3
1
1
1
3
1
1
1
1
1
1
1
3
1
3
1
1
1
1
1
1
3
3
1
1
1
3

1B
1B
1B
1B
1B
1B
1B
2
1B
3
1B
1B
1B
1B
1B
1B
2
3
1B
1B
1B
3
Page 31
3L. Narcotics
Trade name
Abstral
Actiq
Avinza
Belladonna & Opium
Codeine sulfate tablet
Demerol
Dilaudid
Duragesic
Embeda
Exalgo
Fentanyl patch 37.5, 62.5, 87.5mg
Fentora
Hysingla ER
Kadian
Kadian 40, 200mg
Lazanda
Methadone
MS Contin
MSIR
Nucynta, ER
Opana
Opana ER
Oxaydo
Oxycodone hcl ER
Oxycodone immediate release
Oxycontin
RMS suppository
Roxanol
Subsys
Zohydro ER
BCBSM/BCN BCBSM
Generic name
fentanyl citrate
morphine sulfate
opium/belladonna alkaloids
codeine sulfate
meperidine hcl
hydromorphone hcl
fentanyl
hydromorphone hcl
morphine sulfate
methadone hcl
morphine sulfate
morphine sulfate
oxymorphone hcl
oxymorphone hcl
oxycodone hcl
morphine sulfate
morphine sulfate
BCN

3
1
1
1
1
1
1
1
3
1
3
3
3
1
3
3
1
1
1
3
1
1
3
3
1
3
1
1
3
3
3
1
1
1
1
1
1
1
3
1
3
3
3
1
3
3
1
1
1
3
1
1
3
3
1
3
1
1
3
3

3
1B
1B
1B
1B
1B
1B
1B
3
1B
3
3
3
1B
3
3
1B
1B
1B
3
1B
1B
3
3
1B
3
1B
1B
3
3
Page 32
3M. Nonsteroidal Anti-inflammatory Drugs

Trade name
Generic name
Anaprox, DS
Ansaid
Arthrotec
Cambia
Cataflam
Celebrex
Clinoril
Daypro
Duexis
EC-Naprosyn
Feldene
Fenoprofen Calcium 400mg (Tier 2 BCN
Flector patch
Indocin suppository
Indocin suspension (Tier 2 BCN only)
Indocin, SR
Ketoprofen
Lodine, XL
Meclomen
Mobic
Motrin (Rx only)
Nalfon
Nalfon 400mg (Tier 2 BCN only)
Naprelan
Naprelan 750mg
Naprosyn (Rx only)
Pennsaid 1.5%
Pennsaid 2%
Ponstel
Relafen
Sprix
Tivorbex
Tolectin, DS
Toradol
Vimovo
Vivlodex
Voltaren gel
Voltaren tablet
Voltaren XR
Zipsor
Zorvolex
naproxen sodium
flurbiprofen
diclofenac sodium/misoprostol
diclofenac potassium
celecoxib
sulindac
oxaprozin
naproxen
piroxicam
indomethacin
ketoprofen
etodolac
meclofenamate sodium
meloxicam
ibuprofen
fenoprofen calcium
naproxen sodium
naproxen
diclofenac sodium
mefenamic acid
nabumetone
tolmetin sodium
ketorolac tromethamine
diclofenac sodium
diclofenac sodium
diclofenac sodium
BCBSM/BCN BCBSM
BCN

1
1
1
3
1
1
1
1
3
1
1
3
3
2
3
1
1
1
1
1
1
1
3
1
3
1
1
3
1
1
3
3
1
1
3
3
1
1
1
3
3
1
1
1
3
1
1
1
1
3
1
1
3
3
2
3
1
1
1
1
1
1
1
3
1
3
1
1
3
1
1
3
3
1
1
3
3
1
1
1
3
3

1A
1B
1B
3
1B
1B
1B
1B
3
1A
1B
2
3
2
2
1B
1B
1B
1B
1A
1A
1B
2
1B
3
1A
1B
3
1B
1B
3
3
1B
1B
3
3
1B
1A
1B
3
3
Page 33
3N. Parkinsons Disease and Related Disorders

Trade name
Generic name
Apokyn <s>
Artane
Azilect
Cogentin
Comtan
Duopa <s>
Eldepryl
Lodosyn
Mirapex
Mirapex ER
Mirapex ER 3.75
Neupro
Parcopa
Parlodel
Requip
Requip XL
Requip XL 12mg
Rytary
Sinemet, CR
Stalevo
Symmetrel
Tasmar
Zelapar
trihexyphenidyl hcl
benztropine mesylate
entacapone
selegiline hcl
carbidopa
pramipexole di-hcl
pramipexole di-hcl
carbidopa/levodopa
bromocriptine mesylate
ropinirole hcl
ropinirole hcl
ropinirole hcl
carbidopa/levodopa
carbidopa/levodopa/entacapone
amantadine hcl
tolcapone
3O. Salicylates
BCBSM/BCN BCBSM
BCN

2
1
2
1
1
2
1
1
1
1
3
3
1
1
1
1
1
3
1
1
1
1
3
4
1
2
1
1
4
1
1
1
1
3
3
1
1
1
1
1
3
1
1
1
1
3
4
1B
2
1B
1B
4
1B
1B
1B
1B
3
3
1B
1B
1B
1B
1B
3
1B
1B
1B
1B
3
BCBSM/BCN BCBSM
Trade name
Generic name
Aspirin, Ecotrin 81, 325mg (Prevent)

Disalcid
Dolobid
Durlaza
Frenadol (BCBSM only)
Trilisate (BCBSM only)
aspirin
salsalate
diflunisal
choline magnesium trisalicylate
BCN

$0
1
1
3
3
1
$0
1
1
3
3
1
$0
1B
1B
3
NC
NC

Page 34
3P. Sedative/Hypnotics
BCBSM/BCN BCBSM
Trade name
Ambien
Ambien CR
Belsomra
Butisol sodium
Chloral Hydrate (BCBSM Only)
Dalmane
Doral
Edluar
Halcion
Hetlioz <s>
Intermezzo
Lunesta
Prosom
Restoril
Rozerem
Seconal
Silenor
Sonata
Zolpimist
Generic name
zolpidem tartrate
zolpidem tartrate
chloral hydrate
flurazepam hcl
quazepam
triazolam
zolpidem tartrate
eszopiclone
estazolam
temazepam
secobarbital sodium
zaleplon
BCN

1
1
3
3
1
1
1
3
1
3
1
1
1
1
3
1
3
1
3
1
1
3
3
1
1
1
3
1
5
1
1
1
1
3
1
3
1
3
1B
1B
3
3
NC
1B
1B
3
1B
5
1B
1B
1B
1B
3
1B
3
1B
3
3Q. Skeletal Muscle Relaxants

Trade name
Amrix
Baclofen
Dantrium
Fexmid
Flexeril
Lorzone
Norflex
Norgesic, Forte
Parafon Forte DSC
Robaxin
Skelaxin
Soma
Soma Compound
Soma Compound w/Codeine
Valium
Zanaflex capsule
Zanaflex tablet
BCBSM/BCN BCBSM
Generic name
baclofen
dantrolene sodium
cyclobenzaprine hcl
cyclobenzaprine hcl
orphenadrine citrate
orphenadrine/aspirin/caffeine
chlorzoxazone
methocarbamol
metaxalone
carisoprodol
carisoprodol/aspirin
codeine phos/carisoprodol/asa
diazepam
tizanidine hcl
tizanidine hcl
BCN

3
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1

3
1B
1B
1B
1B
3
1B
1B
1B
1B
1B
1B
1B
1B
1B
1B
1B
Page 35
3R. Miscellaneous CNS
BCBSM/BCN BCBSM
Trade name
Antabuse
Cafcit
Campral
Cuvposa
Ergoloid Mesylates
Eskalith, CR
Gralise
Horizant
Intuniv
Kapvay
Lithium Citrate
Lithobid
Nimotop
Nuedexta
Nymalize
Rilutek
Savella
Strattera
Xenazine <s>
Xyrem <s>
Generic name
disulfiram
caffeine citrated
acamprosate calcium
ergoloid mesylates
lithium carbonate
guanfacine hcl
clonidine hcl
lithium citrate
lithium carbonate
nimodipine
riluzole
tetrabenazine
BCN

1
1
1
3
1
1
3
3
1
1
1
1
1
2
3
1
3
3
1
3
1
1
1
3
1
1
3
3
1
1
1
1
1
2
3
1
3
3
4
5

1B
1B
1B
3
1B
1A
3
3
1B
1B
1A
1A
1B
2
3
1B
3
3
4
5
Page 36
4. GASTROINTESTINAL AGENTS
4A. 5-Aminosalicylic Acid (5-ASA) Agents
Trade name
Apriso
Asacol HD
Azulfidine, En-Tab
Canasa
Colazal
Delzicol
Dipentum
Giazo
Lialda
Pentasa
Rowasa enema; SfRowasa enema
Generic name
sulfasalazine
balsalazide disodium
mesalamine
4B. Antidiarrheals and Antispasmodics

Trade name
Bentyl
Donnatal, Extentabs (BCBSM only)
Fulyzaq
Imodium
Levbid
Levsin, SL
Levsinex
Librax
Lomotil
Motofen
Paregoric (BCBSM only)
Pro-Banthine
Generic name
dicyclomine hcl
loperamide hcl
hyoscyamine sulfate
hyoscyamine sulfate
hyoscyamine sulfate
clidinium br/chlordiazepoxide
diphenoxylate hcl/atrop sulf
paregoric
propantheline bromide
BCBSM/BCN BCBSM
BCN

3
2
1
2
1
2
3
3
3
2
1
3
2
1
2
1
2
3
3
3
2
1
3
2
1B
2
1B
2
3
3
3
2
1B
BCBSM/BCN BCBSM
BCN

1
3
2
1
1
1
1
1
1
3
1
1
1
3
2
1
1
1
1
1
1
3
1
1
1B
NC
2
1B
1B
1B
1B
1B
1B
3
NC
1B
4C. Antiemetics
Trade name
Akynzeo
Antivert
Anzemet
Cesamet
Compazine
Compazine suppositories
Diclegis
Emend 40mg (BCBSM only)
Emend 80, 125mg; dosepak capsule
Kytril
Marinol
Phenergan
Sancuso
Tigan
Transderm-Scop
Varubi
Zofran, ODT
Zuplenz
BCBSM/BCN BCBSM
Generic name
meclizine hcl
prochlorperazine maleate
prochlorperazine
granisetron hcl
dronabinol
promethazine hcl
trimethobenzamide hcl
ondansetron
BCN

3
1
3
3
1
1
3
2
2
1
1
1
3
1
2
3
1
3
3
1
3
3
1
1
3
2
2
1
1
1
3
1
2
3
1
3
3
1B
3
3
1B
1B
3
MB
2
1B
1B
1B
3
1B
2
3
1B
3
MB - May be covered under medical benefit
Page 37
4D. Bile Acids
BCBSM/BCN BCBSM
Trade name
Generic name
Actigall
Chenodal <s>
Urso, Urso Forte
ursodiol
4E. Bowel Preparation and Cleansing Agents

Trade name
Generic name
Colyte
Golytely
Golytely packet
Halflytely
Moviprep
Nulytely
Osmoprep
Prepopik
Suprep
sod sulf/sod/nahco3/kcl/peg's
peg 3350/na sulf,bicarb,cl/kcl
bisac/nacl/nahco3/kcl/peg 3350
sod sulf/sod/nahco3/kcl/peg's
4F. Digestive Enzymes

Trade name
Generic name
lipase/protease/amylase
4G. H2-Receptor Antagonists

Axid (RX Only)
Pepcid (RX Only)
Tagamet (RX Only)
Zantac (RX Only)
Trade name
1B
5
1B
BCBSM/BCN BCBSM
nizatidine
famotidine
cimetidine
ranitidine hcl

1
1
2
1
3
1
3
3
3
1
1
2
1
3
1
3
3
3
1B
1B
2
1B
3
1B
3
3
3
Generic name
lansoprazole/amoxiciln/clarith
glycopyrrolate
BCN

2
2
3
2
2
1
2
2
3
2
2
1
2
2
3
2
2
1B
BCN

1
1
1
1
1
1
1
1
1B
1B
1B
1B
BCBSM/BCN BCBSM
sucralfate
misoprostol
BCN
BCBSM/BCN BCBSM
Generic name
4H. Other Ulcer Therapy

Carafate
Cytotec
Omeclamox-Pak
Prevpac
Pylera
Robinul, Forte
1
5
1
BCBSM/BCN BCBSM
Creon
Pancreaze
Pertzye
Viokace
Zenpep
Zenpep 5,000
Trade name

1
3
1
ursodiol
BCN
BCN

1
1
3
1
3
1
1
1
3
1
3
1
1B
1B
3
1B
3
1B
Page 38
4I. Proton Pump Inhibitors

Trade name
Aciphex
Aciphex Sprinkle
Dexilant
Nexium
Nexium suspension
Omeprazole OTC
Prevacid capsule
Prevacid Solutab
Prilosec capsule
Prilosec OTC
Prilosec suspension
Protonix suspension
Protonix tablet
Vimovo
Zegerid packet
Zegerid RX
BCBSM/BCN BCBSM
Generic name
rabeprazole sodium
esomeprazole magnesium
omeprazole
lansoprazole
omeprazole
omeprazole magnesium
pantoprazole sodium
omeprazole/sodium bicarbonate
4J. Topical Anti-Inflammatory Agents

Trade name
Analpram HC
Analpram HC lot, cream (BCBSM Only)
Anamantle HC
Anusol HC
Cortenema
Cortifoam
Epifoam (Tier 2 BCN only)
HC Acetate/Pramoxine hcl
Pramosone (BCBSM Only)
Proctocort
Proctofoam-HC
Procto-kit
Proctosol-HC suppository
Generic name
hydrocortisone/pramoxine hcl
lidocaine hcl/hc
hydrocortisone
hydrocortisone acetate
hc acetate/pramoxine hcl
hydrocortisone
BCN

1
3
3
1
3
1
1
2
1
1
3
3
1
3
3
1
1
3
3
1
3
1
1
2
1
1
3
3
1
3
3
1
1B
3
3
1B
3
1B
1B
2
1B
1B
3
3
1B
3
3
1B
BCBSM/BCN BCBSM
BCN

1
2
1
1
1
2
3
1
3
1
2
1
1
1
2
1
1
1
2
3
1
3
1
2
1
1
1B
NC
1B
1B
1B
2
2
1B
NC
1B
2
1B
1B
4K. Tumor Necrosis Factor (TNF) Blocking Agents

Trade name
Generic name
Cimzia Syringe <s>

Humira <s>
Simponi <s>
BCBSM/BCN BCBSM

3
2
3
BCN
5
4
5
5
4
5
Page 39
4L. Miscellaneous Gastrointestinal Agents

Trade name
Amitiza
Evoxac
Gastrocrom
Gattex <s>
Glycolax
Kristalose (Tier 2 BCN only)
Lactulose
Linzess
Lotronex
Metozolv ODT
Movantik
Rectiv
Reglan
Relistor syringe
Relistor vial
Salagen
Sucraid <s>
Viberzi
Xifaxan 200mg
Xifaxan 550mg
Zorbtive <s>
Generic name
cevimeline hcl
cromolyn sodium
polyethylene glycol 3350
lactulose
alosetron hcl
metoclopramide hcl
metoclopramide hcl
pilocarpine hcl
BCBSM/BCN BCBSM
BCN

3
1
1
2
1
3
1
3
1
1
3
3
1
2
2
1
3
3
3
3
3
3
1
1
4
1
3
1
3
1
1
3
3
1
2
2
1
5
3
3
3
5
3
1B
1B
4
1B
2
1B
3
1B
1B
3
3
1B
2
2
1B
5
3
3
3
5
Page 40
5. OBSTETRICS AND GYNECOLOGY

5A. Contraceptives-Biphasic
BCBSM/BCN BCBSM
Trade name
Generic name
Lo Loestrin Fe
Loseasonique (Prevent)
Mircette (Prevent)
Necon 10/11 (Prevent)
Seasonique (Prevent)
l-norgest-eth estr/ethin estra

desog-et estra/ethin estra
norethindrone-ethinyl estrad
l-norgest-eth estr/ethin estra
5B. Contraceptives-Misc.

3
$0
$0
$0
$0
3
$0
$0
$0
$0
3
$0
$0
$0
$0
BCBSM/BCN BCBSM
Trade name
Generic name
Conceptrol (Prevent)
Depo-Provera 150mg (Prevent)
Depo-Subq Provera 104
FC2 Female Condom (Prevent)
Gynol II (Prevent)
Natazia
Nor-QD; Ortho Micronor (Prevent)
Nuvaring (Prevent)
Ortho Evra (Prevent)
Quartette
Safyral
Today Contraceptive Sponge (Prevent)
VCF film (Prevent)
VCF foam (Prevent)
medroxyprogesterone acet
nonoxynol 9
norethindrone
norelgestromin/ethin.estradiol
nonoxynol 9
5C. Contraceptives-Monophasic
Trade name
levonorgestrel-eth estra
ethynodiol d-ethinyl estradiol

desogestrel-ethinyl estradiol
noreth-ethinyl estradiol/iron
noreth-ethinyl estradiol/iron
norgestrel-ethinyl estradiol
noreth a-et estra/fe fumarate
norethindrone a-e estradiol
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
ethinyl estradiol/drospirenone
ethinyl estradiol/drospirenone
BCN

$0
$0
2
$0
$0
3
$0
$0
$0
3
3
$0
$0
$0
$0
$0
2
$0
$0
3
$0
$0
$0
3
3
$0
$0
$0
$0
$0
2
$0
$0
3
$0
$0
$0
3
3
$0
$0
$0
BCBSM/BCN BCBSM
Generic name
Alesse, Levlite (Prevent)

Beyaz
Demulen (Prevent)
Desogen; Ortho-cept (Prevent)
Femcon Fe (Prevent)
Generess Fe (Prevent)
Levlen; Nordette (Prevent)
Lo/Ovral (Prevent)
Loestrin 24 Fe (Prevent)
Loestrin, Fe (Prevent)
Lybrel (Prevent)
Modicon (Prevent)
Norinyl/Ortho-Novum 1/35 (Prevent)
Norinyl/Ortho-Novum 1/50 (Prevent)
Ortho-Cyclen (Prevent)
Ovcon 35 (Prevent)
Ovral (Prevent)
Seasonale (Prevent)
Yasmin 28 (Prevent)
Yaz (Prevent)
BCN
BCN

$0
3
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
3
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
3
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Page 41
5D. Contraceptives-Postcoital
BCBSM/BCN BCBSM
Trade name
Generic name
Ella (Prevent)
Plan B, One-Step (Prevent)
levonorgestrel
5E. Contraceptives-Triphasic
Generic name
desogestrel-ethinyl estradiol
noreth a-et estra/fe fumarate
5F. Estrogen/Progestin Combinations

Trade name
Activella
Angeliq
Climara Pro
Combipatch
FemHRT
Prefest
Prempro, Low Dose; Premphase
Generic name
estradiol/norethindrone acet
norethindrone ac-eth estradiol
5G. Estrogens
$0
$0
$0
$0
$0
$0
Generic name
estradiol
estradiol valerate
estradiol
estropipate
estradiol
BCN

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
BCBSM/BCN BCBSM
BCN

1
3
3
3
1
3
2
1
3
3
3
1
3
2
1B
3
3
3
1B
3
2
BCBSM/BCN BCBSM
Trade name
Alora
Climara
Delestrogen
Divigel
Elestrin
Enjuvia
Estrace tablet
Estrace Vaginal cream
Estring
Estrogel
Evamist
Femring
Femtrace
Menest
Menostar
Minivelle
Ogen
Premarin, Low Dose, cream
Vagifem
Vivelle-Dot
BCBSM/BCN BCBSM
Trade name
Cyclessa (Prevent)
Estrostep Fe (Prevent)
Ortho Tri-Cyclen (Prevent)
Ortho Tri-Cyclen Lo (Prevent)
Ortho-Novum 7/7/7 (Prevent)
Trilevlen; Triphasil (Prevent)
Tri-Norinyl (Prevent)
BCN
BCN

2
1
1
3
3
2
1
3
2
3
3
3
3
3
3
3
1
2
2
1
2
1
1
3
3
2
1
3
2
3
3
3
3
3
3
3
1
2
2
1

2
1B
1B
3
3
2
1B
3
2
3
3
3
3
3
3
3
1B
2
2
1B
Page 42
5H. Infertility Treatment*
BCBSM/BCN BCBSM
Trade name
Bravelle <s>
Cetrotide <s>
Clomid
Crinone 8%
Endometrin
Follistim AQ <s>
Ganirelix Acetate <s>
Gonal-F, RFF, Redi-Ject <s>
Lupron <s>
Menopur <s>
Novarel <s>
Ovidrel <s>
Pregnyl <s>
Generic name
clomiphene citrate
leuprolide acetate
chorionic gonadotropin, human

chorionic gonadotropin, human
BCN

2
2
1
2
2
3
2
2
1
3
1
2
2
4
4
1
2
2
5
4
4
4
5
4
4
4
4
4
1B
2
2
5
4
4
4
5
4
4
4
*Drugs used for the treatment of infertility may not be covered for select benefits. Copay depends on the members medical drug rider.
5I. Progestins
BCBSM/BCN BCBSM
Trade name
Aygestin
Crinone 4%
Progesterone in Oil (Inj)
Prometrium
Provera
Generic name
norethindrone acetate
progesterone
progesterone,micronized
medroxyprogesterone acet
5J. Vaginal Anti-infective/Antifungal

Trade name
AVC
Cleocin vaginal cream
Cleocin vaginal ovules
Clindesse
Diflucan
Gynazole-1
Metrogel-Vaginal
Monistat 3
Nuvessa
Nystatin
Terazol-3, 7
BCN

1
2
2
1
1
1
1
2
2
1
1
1
1B
2
2
1B
1B
1B
BCBSM/BCN BCBSM
Generic name
clindamycin phosphate
fluconazole
metronidazole
miconazole nitrate
nystatin
terconazole
BCN

3
1
3
3
1
3
1
1
3
1
1
3
1
3
3
1
3
1
1
3
1
1

3
1B
3
3
1B
3
1B
1B
3
1B
1B
Page 43
5K. Miscellaneous OB-GYN

Trade name
BCBSM/BCN BCBSM
Generic name
Brisdelle
Covaryx, H.S.
Diclegis
Duavee
Lupaneta pack <s>
Lupron Depot <s>
Lupron Depot 45mg (BCBSM Only) <s>
Lysteda
Methergine tablet
Osphena
Synarel
estrogen,ester/me-testosterone
tranexamic acid
methylergonovine maleate
BCN

3
1
3
3
3
2
2
1
1
3
2
3
1
3
3
5
4
4
1
1
3
2
3
1B
3
3
5
4
MB
1B
1B
3
2

Page 44
6. RHEUMATOLOGY AND MUSCULOSKELETAL

6A. Corticosteroids
BCBSM/BCN BCBSM
Trade name
Generic name
BCN
Corticosteroids - See Chapter 7C
6B. Gout Therapy
BCBSM/BCN BCBSM
Trade name
Colbenemid
Colchicine capsule
Colchicine tablet
Colcrys
Mitigare
Probenecid
Uloric
Zyloprim
Generic name
colchicine/probenecid
probenecid
allopurinol
6C. Non-Tumor Necrosis Factor (TNF) Blocking Agents

Trade name
Generic name
Actemra syringe <s>

Kineret <s>
Orencia sub-q <s>
Otezla <s>
Xeljanz, XR <s>
Trade name
Actonel 35mg, 150mg
Actonel 5, 30mg
Atelvia
Binosto
Boniva
Didronel
Evista
Fosamax
Fosamax 35mg, 70mg
Fosamax Plus D
Miacalcin injection
Miacalcin Nasal Spray; Fortical
1
3
2
2
3
1
2
1
1
3
2
2
3
1
2
1
1B
3
2
2
3
1B
2
1B
BCBSM/BCN BCBSM
Generic name
ibandronate sodium
etidronate disodium
raloxifene hcl
alendronate sodium
alendronate sodium
calcitonin,salmon,synthetic
BCN
5
5
5
5
5
5
5
5
5
5
BCBSM/BCN BCBSM
risedronate sodium
risedronate sodium
risedronate sodium

3
3
3
3
3
6D. Osteoporosis/Bone Resorption
BCN
BCN

1
1
1
3
1
1
1
1
1
3
2
1
1
1
1
3
1
1
1
1
1
3
2
1
1B
1B
1B
3
1B
1B
1A
1A
1A
3
2
1B
Page 45
6E. Osteoporosis/Hormonal Treatment

Trade name
Alora
Climara
Covaryx, H.S.
Duavee
Enjuvia
Estrace tablet
FemHRT
Forteo <s>
Menest
Minivelle
Ogen
Vivelle-Dot
Generic name
estradiol
estrogen,ester/me-testosterone
estradiol
norethindrone ac-eth estradiol
estropipate
estradiol
6F. Salicylates
Trade name
Salicylates and NSAIDS
Generic name
Generic name
2
1
1
3
2
1
1
3
3
3
1
2
2
1
2
1
1
3
2
1
1
5
3
3
1
2
2
1
2
1B
1B
3
2
1B
1B
5
3
3
1B
2
2
1B
BCN
BCBSM/BCN BCBSM
Generic name
leflunomide
sulfasalazine
cyclosporine, modified
azathioprine
methotrexate sodium
hydroxychloroquine sulfate
BCN

3
2
2
3
6H. Miscellaneous Rheumatologic Agents

Arava
Azasan
Azulfidine, En-Tab
Cuprimine
Depen
Gengraf; Neoral <s>
Imuran
Methotrexate
Otrexup <s>
Plaquenil
Rasuvo <s>
Rheumatrex (Tier 2 BCN Only)
Ridaura
Trexall
See Chapters 3M & 3O
Cimzia Syringe <s>

Enbrel <s>
Humira, Pediatric <s>
Simponi <s>
Trade name
BCN
BCBSM/BCN BCBSM
6G. Tumor Necrosis Factor (TNF) Blocking Agents

Trade name
BCBSM/BCN BCBSM
5
4
4
5
5
4
4
5
BCBSM/BCN BCBSM
BCN

1
3
1
3
2
1
1
1
3
1
3
3
2
2
1
3
1
3
2
4
1
1
5
1
5
3
2
2
1B
3
1B
3
2
4
1B
1B
5
1B
5
2
2
2
Page 46
7. ENDOCRINOLOGY
7A. Androgens
Trade name
Anadrol-50
Androderm
Androgel 1%
Androgel 1.62%
Android; Testred
Androxy
Axiron
Danocrine
Delatestryl
Depo-Testosterone
Fortesta
Methitest
Natesto
Oxandrin
Striant
Testim
Testosterone gel, packet, pump
Vogelxo
BCBSM/BCN BCBSM
Generic name
testosterone
fluoxymesterone
danazol
testosterone enanthate
testosterone cypionate
oxandrolone
7B. Antithyroid Agents

Trade name
Propylthiouracil
SSKI (Tier 2 BCN only)
Tapazole
Cortef; Hydrocortisone
Cortisone Acetate
Decadron
Entocort EC
Florinef
Medrol 2mg (Tier 2 BCN only)
Medrol, Dosepak
Orapred ODT
Orapred solution 15mg/5ml
Prednisolone, tablet, syrup
Prednisone
Rayos
Uceris foam
Uceris tablet

3
2
1
2
3
1
3
1
1
1
3
3
3
1
3
3
3
3
3
2
1
2
3
1
3
1
1
1
3
3
3
1
3
3
3
3
3
2
1B
2
3
1B
3
1B
1B
1B
3
3
3
1B
3
3
3
3
BCBSM/BCN BCBSM
Generic name
propylthiouracil
methimazole
7C. Corticosteroids
Trade name
BCN
hydrocortisone
cortisone acetate
dexamethasone
budesonide
fludrocortisone acetate
methylprednisolone
prednisolone sod phosphate
prednisolone
prednisone
BCN

1
3
1
1
3
1
1B
2
1B
BCBSM/BCN BCBSM
Generic name
BCN

1
1
1
1
1
3
1
1
1
1
1
3
3
3
1
1
1
1
1
3
1
1
1
1
1
3
3
3
1B
1B
1A
1B
1B
2
1B
1B
1A
1A
1A
3
3
3
Page 47
7D. Growth Hormone and Related Products

Trade name
Generic name
7E. Insulins
BCN

2
3
3
3
2
3
3
3
3
Genotropin <s>
Humatrope <s>
Increlex <s>
Norditropin Flexpro <s>
Nutropin AQ, Nuspin <s>
Omnitrope <s>
Saizen <s>
Serostim <s>
Zomacton <s>
4
5
5
5
4
5
5
5
5
4
5
5
5
4
5
5
5
5
BCBSM/BCN BCBSM
Trade name
Generic name
Afrezza
Apidra, Solostar
Humalog U-200
Humalog, Mix
Humulin R U-500 (all forms)
Humulin, KwikPen (all forms)
Lantus, Solostar (Tier 2 BCBSM only)
Levemir, Flextouch (Tier 2 BCBSM only)
Novolin (all forms) (Tier 2 BCBSM only)
Novolog (all forms) (Tier 2 BCBSM only)
Toujeo Solostar
Tresiba Flextouch
BCBSM/BCN BCBSM
BCN

3
2
2
2
2
2
1
1
1
1
2
3
3
2
2
2
2
2
1
1
1
1
2
3
3
2
2
2
2
2
1A
1A
1A
1A
2
3
Page 48
7F. Non-insulin Hypoglycemic Agents

Trade name
Actoplus MET
Actoplus MET XR
Actos
Alogliptin
Alogliptin-metformin
Alogliptin-pioglitazone
Amaryl
Avandamet
Avandia
Bydureon, Pen
Byetta
Cycloset
Diabeta; Micronase
Diabinese
Duetact
Farxiga
Glucophage, XR; Fortamet
Glucotrol, XL
Glucovance
Glumetza
Glynase
Glyset
Glyxambi
Invokamet
Invokana
Janumet
Janumet XR
Januvia
Jardiance
Jentadueto
Kazano
Kombiglyze XR
Metaglip
Nesina
Onglyza
Orinase
Oseni
PrandiMet
Prandin
Precose
Riomet
Starlix
Symlinpen
Synjardy
Tanzeum
Tolazamide
Tradjenta
Trulicity
Victoza
Xigduo XR
Generic name
pioglitazone hcl/metformin hcl
pioglitazone hcl
glimepiride
glyburide
chlorpropamide
pioglitazone/glimepiride
metformin hcl
glipizide
glyburide/metformin hcl
metformin hcl
glyburide,micronized
miglitol
glipizide/metformin hcl
tolbutamide
repaglinide/metformin hcl
repaglinide
acarbose
nateglinide
tolazamide
BCBSM/BCN BCBSM
BCN

1
3
1
3
3
3
1
3
3
2
3
3
1
1
1
2
1
1
1
1
1
1
3
2
2
2
2
2
3
3
3
2
1
3
2
1
3
1
1
1
3
1
3
3
3
1
3
3
2
2
1
3
1
3
3
3
1
3
3
2
3
3
1
1
1
2
1
1
1
1
1
1
3
2
2
2
2
2
3
3
3
2
1
3
2
1
3
1
1
1
3
1
3
3
3
1
3
3
2
2
1B
3
1A
3
3
3
1A
3
3
2
3
3
1A
1B
1B
2
1A
1A
1A
1B
1A
1B
3
2
2
2
2
2
3
3
3
2
1A
3
2
1B
3
1B
1B
1B
3
1B
3
3
3
1B
3
3
2
2
Page 49
7G. Somatostatin Analogs
BCBSM/BCN BCBSM
Trade name
Sandostatin <s>
Sandostatin LAR, Depot <s>
Signifor <s>
Signifor LAR <s>
Somatuline Depot <s>
Generic name
octreotide acetate
7H. Thyroid Hormones

Generic name
liothyronine sodium
thyroid,pork
thyroid,pork
levothyroxine sodium
thyroid,pork
7I. Urea Cycle Disorder Agents

Trade name
Buphenyl powder
Buphenyl tablet
Carbaglu <s>
Ravicti <s>
Calciferol
Hectorol
Rocaltrol
Zemplar
1
2
2
3
2
4
4
4
5
4
4
4
4
5
4
Generic name
sodium phenylbutyrate
ergocalciferol
doxercalciferol
calcitriol
paricalcitol

3
1
1
1
1
2
3
1
3
3
1
1
1
1
2
3
1
3
3
1B
1B
1B
1A
2
3
1B
3
BCN

1
2
2
3
1
2
4
5
1B
2
4
5
BCBSM/BCN BCBSM
Generic name
BCN
BCBSM/BCN BCBSM
7J. Vitamin D Analogs

Trade name
BCBSM/BCN BCBSM
Trade name
Armour Thyroid
Cytomel
Nature-Throid
NP Thyroid
Synthroid, Levoxyl
Thyrolar
Tirosint
Westhroid
WP Thyroid
BCN
BCN

1
1
1
1
1
1
1
1
1B
1B
1B
1B
Page 50
7K. Miscellaneous Endocrine

Trade name
Cerdelga <s>
Cholbam <s>
DDAVP
DDAVP solution (Tier 2 BCN only)
Dostinex
Egrifta <s>
GlucaGen
Glucagon Emergency Kit
Korlym <s>
Lupron Depot-Ped <s>
Miacalcin Injection
Miacalcin Nasal Spray
Myalept <s>
Natpara <s>
Proglycem
Sensipar <s>
Somavert <s>
Stimate <s>
Strensiq <s>
Synarel
Zavesca <s>
BCBSM/BCN BCBSM
Generic name
desmopressin acetate
cabergoline
calcitonin,salmon,synthetic
BCN

3
2
1
3
1
3
2
2
2
2
2
1
3
2
2
2
2
2
2
2
3
5
4
1
3
1
5
2
2
4
4
2
1
5
4
2
4
4
4
4
2
5
5
4
1B
2
1B
5
2
2
4
4
2
1B
5
4
2
4
4
4
4
2
5
Page 51
8. ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS

8A. Adjuvant Therapy
Trade name
Aranesp <s>
Epogen <s>
Granix <s>
Leucovorin tablet
Leukine <s>
Mesnex tablet
Mircera <s>
Neulasta <s>
Neupogen <s>
Procrit <s>
Zarxio <s>
BCBSM/BCN BCBSM
Generic name
leucovorin calcium
8B. Alkylating Agents

Trade name
Alkeran
Cyclophosphamide
Emcyt
Gleostine; Lomustine
Leukeran
Matulane <s>
Myleran
Temodar <s>
Lonsurf <s>
Methotrexate tablet
Purinethol
Purixan <s>
Tabloid
Trexall
Xeloda <s>

3
3
2
1
2
2
3
3
2
2
3
5
5
4
1
4
2
5
5
4
4
5
5
5
4
1B
4
2
5
5
4
4
5
BCBSM/BCN BCBSM
Generic name
temozolomide
8C. Antimetabolites
Trade name
BCN
methotrexate sodium
mercaptopurine
capecitabine
BCN

2
2
2
2
2
2
2
1
2
2
2
2
2
4
2
4
2
2
2
2
2
4
2
4
BCBSM/BCN BCBSM
Generic name
BCN

2
1
1
3
3
2
2
1
4
1
1
5
3
2
2
4

4
1B
1B
5
2
2
2
4
Page 52
8D. Hormonal Agents
BCBSM/BCN BCBSM
Trade name
Generic name
Arimidex
Aromasin
Casodex
Depo-Provera 400mg
Eligard <s>
Eulexin
Evista
Evista (Prevent)
Fareston
Faslodex
Femara
Lupaneta pack <s>
Lupron <s>
Lupron Depot <s>
Megace, ES
Nilandron
Soltamox
Tamoxifen citrate
Tamoxifen citrate (Prevent)
Trelstar, Depot, LA <s>
Xtandi <s>
Zoladex <s>
Zytiga (Tier 3/5 - BCN only) <s>
anastrozole
exemestane
bicalutamide
flutamide
raloxifene hcl
raloxifene hcl
letrozole
leuprolide acetate
megestrol acetate
tamoxifen citrate
tamoxifen citrate
8E. Immunomodulators

1
1
1
2
3
1
1
$0
2
3
1
3
1
2
1
2
3
1
$0
2
2
2
2
1
1
1
2
5
1
1
$0
2
3
1
5
4
4
1
2
3
1
$0
4
4
4
4
1A
1B
1B
2
5
1B
1A
$0
2
3
1A
5
4
4
1B
2
3
1A
$0
4
4
4
5
BCBSM/BCN BCBSM
Trade name
Generic name
Arcalyst <s>
Astagraf XL <s>
Azasan
Cellcept <s>
Envarsus XR <s>
Gengraf; Neoral <s>
Imuran
Kineret <s>
Myfortic <s>
Pomalyst <s>
Prednisone
Prograf <s>
Rapamune solution <s>
Rapamune tablet <s>
Rayos
Revlimid <s>
Sandimmune <s>
Sandimmune soln (Tier 2/4 BCN) <s>
Somatuline Depot <s>
Thalomid <s>
BCN
mycophenolate mofetil
cyclosporine, modified
azathioprine
mycophenolate sodium
prednisone
tacrolimus anhydrous
sirolimus
cyclosporine
BCN

2
3
3
1
3
1
1
3
1
3
1
1
2
1
3
3
1
3
2
2
4
5
3
4
5
4
1
5
4
5
1
4
4
4
3
5
4
5
4
4

4
5
3
4
5
4
1B
5
4
5
1A
4
4
4
3
5
4
4
4
4
Page 53
8F. Kinase Inhibitors and Molecular Target Inhibitors BCBSM/BCN BCBSM

Trade name
Afinitor, Disperz <s>
Bosulif <s>
Caprelsa <s>
Cometriq <s>
Cotellic <s>
Gilotrif <s>
Gleevec <s>
Ibrance <s>
Iclusig <s>
Imbruvica <s>
Inlyta <s>
Iressa <s>
Jakafi <s>
Lenvima <s>
Lynparza <s>
Mekinist <s>
Nexavar <s>
Ninlaro <s>
Sprycel <s>
Stivarga <s>
Sutent <s>
Tafinlar <s>
Tagrisso <s>
Tarceva <s>
Tasigna <s>
Tykerb <s>
Votrient <s>
Xalkori <s>
Zelboraf <s>
Zortress <s>
Zydelig <s>
Zykadia <s>
Generic name
imatinib mesylate
8G. Miscellaneous Antineoplastic Agents

Trade name
Droxia
Erivedge <s>
Farydak <s>
Hexalen
Hycamtin <s>
Hydrea
Lysodren
Odomzo <s>
Sandostatin <s>
Sandostatin LAR, Depot <s>
Targretin capsule <s>
Vepesid
Vesanoid
Zolinza <s>
Generic name
hydroxyurea
octreotide acetate
bexarotene
etoposide
tretinoin
BCN

2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
5
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
5
4
4
BCBSM/BCN BCBSM
BCN

2
2
2
2
2
1
2
2
1
2
1
1
1
2
2
4
4
2
4
1
2
4
4
4
4
1
1
4

2
4
4
2
4
1B
2
4
4
4
4
1B
1B
4
Page 54
9. IMMUNOLOGY AND HEMATOLOGY

9A. Hematopoietic Agents
BCBSM/BCN BCBSM
Trade name
Generic name

3
3
2
2
3
3
2
2
2
3
Aranesp <s>
Epogen <s>
Granix <s>
Leukine <s>
Mircera <s>
Neulasta <s>
Neupogen <s>
Procrit <s>
Promacta <s>
Zarxio <s>
9B. Immunoglobulins
BCN
5
5
4
4
5
5
4
4
4
5
5
5
4
4
5
5
4
4
4
5
BCBSM/BCN BCBSM
Trade name
Generic name
Gammagard Liquid (BCBSM Only) <s>

Gammaked Liquid (BCBSM Only) <s>
Gamunex-C sub-q (BCBSM Only) <s>
Hizentra (BCBSM Only) <s>
HyQvia (BCBSM Only) <s>
BCN

3
3
3
3
3
5
5
5
5
5
MB
MB
MB
MB
MB
9C. Interferons and MS Therapy

Trade name
Actimmune <s>
Alferon N
Ampyra <s>
Aubagio <s>
Avonex <s>
Betaseron <s>
Copaxone <s>
Extavia <s>
Gilenya <s>
Glatopa <s>
Intron A <s>
Pegasys, Proclick <s>
Peg-Intron, Redipen <s>
Plegridy <s>
Rebif, Rebidose <s>
Sylatron <s>
Tecfidera <s>
BCBSM/BCN BCBSM
Generic name
glatiramer acetate
9D. Miscellaneous Immunology and Hepatology

Trade name
Firazyr <s>
Ruconest <s>
Generic name
BCN

2
2
3
3
2
3
2
3
2
1
2
2
2
3
2
3
2
4
2
5
5
4
5
4
5
4
4
4
4
4
5
4
5
4
4
2
5
5
4
5
4
5
4
4
4
4
4
5
4
5
4
BCBSM/BCN BCBSM
BCN

3
3
5
5

5
5
Page 55
10. DERMATOLOGY
10A. Acne Treatment
BCBSM/BCN BCBSM
Trade name
Generic name
Absorica
Acanya
Acticlate tablet
Aczone 5%
Aczone 7.5% (Not Covered for BCBSM)
Adapalene 0.1% lotion
Adoxa capsule
Adoxa tablet
Atralin
Avita gel
Azelex
Benzaclin
Benzamycin
Benzoyl Peroxide (RX) (BCBSM only)
Brevoxyl gel (BCBSM only)
Cleocin T
Differin
Differin 0.1% lotion
Doryx
Doxycycline 20mg tablet
Doxycycline IR-DR
Duac
Epiduo
Epiduo Forte
Erythromycin topical gel, solution
Evoclin foam
Fabior
Minocin
Monodox
Myorisan; Zenatane
Noritate
Onexton
Oracea
Plexion, TS (BCBSM only)
Retin-A
Retin-A Micro pump 0.08%
Retin-A Micro, pump
Rosula Cleanser (BCBSM only)
Solodyn
Solodyn 55, 65, 80, 105, 115mg
Sulfacet-R (BCBSM only)
Tazorac
Tretin-X
Veltin
Vibramycin
Ziana
tretinoin
clindamycin phos/benzoyl perox

erythromycin base/benz per
benzoyl peroxide
benzoyl peroxide
adapalene
doxycycline hyclate
doxycycline hyclate
clindamycin phosphate/benz per
erythromycin base/ethanol
minocycline hcl
isotretinoin
sulfacetamide sodium/sulfur
tretinoin
tretinoin microspheres
sulfacetamide sod/sulfur/urea
minocycline hcl
sulfacetamide sodium/sulfur
doxycycline hyclate
BCN

3
3
3
3
3
3
1
1
1
3
3
1
1
1
1
1
1
3
1
1
3
1
3
3
1
1
3
1
1
1
3
3
3
1
1
3
1
1
1
3
1
2
3
3
1
3
3
3
3
3
3
3
3
1
1
1
3
3
1
1
1
1
1
1
3
1
1
3
1
3
3
1
1
3
1
1
1
3
3
3
1
1
3
1
1
1
3
1
2
3
3
1
3
3
3
3
3
3
3
3
1B
1B
1B
3
3
1B
1B
NC
NC
1B
1B
3
1B
1B
3
1B
3
3
1B
1B
3
1B
1B
1B
3
3
3
NC
1B
3
1B
NC
1B
3
NC
2
3
3
1B
2
3
Page 56
10B. Antipsoriatic/Antiseborrheic
Trade name
BCBSM/BCN BCBSM
Generic name
8-MOP (Tier 2 BCN Only)

Cosentyx <s>
Dovonex
Drithocreme HP(BCBSM only)
Enbrel <s>
Enstilar
Humira <s>
Otezla <s>
Otrexup <s>
Ovace, Plus (BCBSM only)
Oxsoralen
Oxsoralen-Ultra
Rasuvo <s>
Selsun 2.5% (Rx Only)
Soriatane
Sorilux
Stelara <s>
Taclonex ointment
Taclonex topical solution
Vectical
calcipotriene
anthralin
sulfacetamide sodium
methoxsalen, rapid
selenium sulfide
acitretin
calcipotriene/betamethasone
calcitriol
BCN

3
3
1
1
2
3
2
3
3
1
2
1
3
1
1
3
3
1
3
1
3
5
1
1
4
3
4
5
5
1
2
1
5
1
1
3
5
1
3
1
2
5
1B
NC
4
3
4
5
5
NC
2
1B
5
1B
1B
3
5
1B
3
1B
10C. Corticosteriods - Very High Potency

Trade name
Generic name
Clobevate; Temovate
Clobex
Diprolene ointment
Elocon ointment
Olux
Olux-E
Ultravate
Ultravate lotion (Not Covered for BCBSM)
Vanos
clobetasol propionate
betamet diprop/prop gly
mometasone furoate
clobetasol propionate/emoll
halobetasol propionate
fluocinonide
10D. Corticosteroids - High Potency

Trade name
Apexicon, E
Aristocort; Kenalog 0.5% cream
Cyclocort
Diprolene AF, gel, cream, lotion
Diprosone; Maxivate
Florone; Psorcon
Halog
Lidex, E
Topicort cream, gel, ointment
Topicort Spray
Valisone
BCBSM/BCN BCBSM
BCN

1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
3
1
1B
1B
1B
1B
1B
1B
1B
3
1B
BCBSM/BCN BCBSM
Generic name
diflorasone diacetate
triamcinolone acetonide
amcinonide
betamet diprop/prop gly
betamethasone dipropionate
diflorasone diacetate
fluocinonide
desoximetasone
betamethasone valerate
BCN

1
1
1
1
1
1
3
1
1
3
1
1
1
1
1
1
1
3
1
1
3
1
1B
1B
1B
1B
1B
1B
3
1B
1B
3
1B
Page 57
10E. Corticosteroids - Medium Potency

Trade name
Clocortolone Pivalate
Cloderm
Cordran cream
Cordran lotion, tape, SP
Cordran ointment (Tier 2 BCN Only)
Cutivate
Dermatop
Elocon cream, solution
Kenalog 0.1%
Locoid cream, oint, soln
Locoid Lipocream
Locoid Lotion
Luxiq
Oralone paste
Pandel
Synalar 0.025%
Topicort LP
Westcort
Generic name
flurandrenolide
fluticasone propionate
prednicarbate
mometasone furoate
hydrocortisone butyrate
hydrocortisone butyrate/emoll
betamethasone valerate
fluocinolone acetonide
desoximetasone
hydrocortisone valerate
10F. Corticosteroids - Low Potency

Trade name
Aclovate
Ala-Scalp HP
Capex Shampoo
Dermacort; Hytone (RX Only)
Derma-Smoothe/FS
Desonate
Desowen
Kenalog 0.025%
Neo-Synalar
Synalar 0.01%
Verdeso
Trade name
alclometasone dipropionate
hydrocortisone
hydrocortisone
desonide
Generic name
lindane
spinosad
malathion
10H. Topical Anesthetics

Trade name

2
2
1
2
3
1
1
1
1
1
1
3
1
1
3
1
1
1
2
2
1
2
3
1
1
1
1
1
1
3
1
1
3
1
1
1
2
2
1B
2
2
1B
1B
1B
1B
1B
1B
3
1B
1B
3
1B
1B
1B
BCN

1
1
2
1
1
3
1
1
3
1
3
1
1
2
1
1
3
1
1
3
1
3
1B
1B
2
1B
1B
3
1B
1B
3
1B
3
BCBSM/BCN BCBSM
permethrin
Emla
Lidoderm patch
Xylocaine, Viscous (Rx only)
BCN
BCBSM/BCN BCBSM
Generic name
10G. Scabicides/Pediculicides
Elimite
Eurax
Lindane
Natroba
Ovide
Sklice
Ulesfia
BCBSM/BCN BCBSM
BCN

1
2
1
1
1
3
3
1
2
1
1
1
3
3
1B
2
1B
1B
1B
3
3
BCBSM/BCN BCBSM
Generic name
lidocaine/prilocaine
lidocaine
lidocaine hcl
BCN

1
1
1
1
1
1
1B
1B
1B
Page 58
10I. Topical Antibacterials

Trade name
Altabax
Bactroban
Bactroban Nasal
Centany ointment (Tier 2 BCN Only)
Gentamicin cream, ointment
Neo-Synalar
BCBSM/BCN BCBSM
Generic name
mupirocin calcium
gentamicin sulfate
10J. Topical Antifungals

Trade name
Ecoza
Ertaczo
Exelderm
Extina
Jublia (Not Covered for BCBSM)
Kerydin (Not Covered for BCBSM)
Loprox
Lotrimin
Lotrisone
Luzu
Mentax
Monistat-Derm
Mycostatin
Naftifine hcl 1%
Naftin
Naftin gel
Nizoral cream, shampoo 2%
Nystatin w/Triamcinolone
Oxistat
Oxistat lotion
Penlac
Spectazole
Vusion
Xolegel
Trade name

3
1
2
3
1
3
3
1
2
3
1
3
3
1B
2
2
1B
3
BCBSM/BCN BCBSM
Generic name
ketoconazole
ciclopirox olamine
clotrimazole
clotrimazole/betamet diprop
miconazole nitrate
nystatin
naftifine hcl
ketoconazole
nystatin/triamcin
oxiconazole nitrate
ciclopirox
econazole nitrate
10K. Topical Antineoplastic Agents and Immunomodulators

Aldara
Carac
Efudex
Elidel
Fluoroplex (Tier 2 BCN only)
Fluorouracil 0.5% Cream
Panretin
Picato
Protopic
Targretin gel <s>
Tolak
Valchlor <s>
Veregen
Zyclara
BCN
Generic name
imiquimod
fluorouracil
tacrolimus
BCN

3
3
3
1
3
3
1
1
1
3
2
1
1
3
1
3
1
1
1
3
1
1
3
3
3
3
3
1
3
3
1
1
1
3
2
1
1
3
1
3
1
1
1
3
1
1
3
3
3
3
3
1B
3
3
1B
1B
1B
3
2
1B
1B
3
1B
3
1B
1B
1B
3
1B
1B
3
3
BCBSM/BCN BCBSM
BCN

1
3
1
2
3
3
2
3
1
3
3
3
3
3
1
3
1
2
3
3
2
3
1
5
3
5
3
3
1B
3
1B
2
2
3
2
3
1B
5
3
5
3
3
Page 59
10L. Topical Antivirals
BCBSM/BCN BCBSM
Trade name
Denavir
Xerese
Zovirax cream
Zovirax ointment
Generic name
acyclovir
10M. Wound and Burn Therapy

Trade name
Granulex (BCBSM only)
Regranex
Santyl
Silvadene
BCN

3
3
2
1
3
3
2
1
3
3
2
1B
BCBSM/BCN BCBSM
Generic name
trypsin/balsam peru/castor oil
silver sulfadiazine
BCN

1
3
2
1
1
3
2
1
NC
3
2
1B
10N. Miscellaneous Dermatologicals

Trade name
Condylox gel
Condylox solution
Drysol
Finacea
Finacea foam
Metrocream, gel, lotion
Metrogel Topical 1%, pump
Solaraze
Soolantra
Zonalon
Zonalon
Generic name
podofilox
aluminum chloride
metronidazole
metronidazole
diclofenac sodium
doxepin hcl
BCBSM/BCN BCBSM
BCN

2
1
1
3
3
1
1
1
3
3
1
2
1
1
3
3
1
1
1
3
3
1
2
1B
1B
3
3
1B
1B
1B
3
3
1B
Page 60
11. OPHTHALMOLOGY
11A. Cycloplegic Mydriatics
BCBSM/BCN BCBSM
Trade name
Generic name
Cyclogyl 0.5%
Cyclogyl 0.5%, 1% 5ml (Tier 2 BCN only)
Cyclogyl 1%, 2%
Isopto Atropine
Isopto Homatropine 5%
Mydriacyl
Paremyd
cyclopentolate hcl
atropine sulfate
homatropine hbr
tropicamide
11B. Ophthalmic Anti-Allergy Agents

Trade name
Alocril
Alomide
Bepreve
Elestat
Emadine
Lastacaft
Opticrom
Optivar
Pataday
Patanol
Pazeo
Generic name
epinastine hcl
cromolyn sodium
azelastine hcl
olopatadine hcl
BCN

3
3
1
1
1
1
3
3
3
1
1
1
1
3
3
2
1B
1B
1B
1B
3
BCBSM/BCN BCBSM
BCN

2
2
3
1
3
3
1
1
3
1
3
2
2
3
1
3
3
1
1
3
1
3
2
2
3
1B
3
3
1B
1B
3
1B
3
11C. Ophthalmic Anti-infective/Steroid Combinations BCBSM/BCN BCBSM

Trade name
Blephamide
Cortisporin
Maxitrol
Pred-G
Tobradex ointment
Tobradex ST
Tobradex suspension
Vasocidin
Zylet
Generic name
neomy sulf/polymyx b sulf/hc
neo/polymyx b sulf/dexameth
tobramycin sulfate/dexameth
sulfacetamide/prednisolone sp
BCN

2
1
1
3
2
3
1
1
3
2
1
1
3
2
3
1
1
3
2
1B
1B
3
2
3
1B
1B
3
Page 61
11D. Ophthalmic Anti-infectives

Trade name
Azasite
Bacitracin
Besivance
Bleph-10 drops (Tier 2 BCN only)
Bleph-10, Sodium Sulamyde
Ciloxan drops
Ciloxan ointment
Garamycin
Ilotycin
Moxeza
Natacyn
Neosporin Ophth ointment
Neosporin Ophth solution
Ocuflox
Polysporin
Polytrim
Quixin
Tobrex drops
Tobrex ointment (BCN tier 2 only)
Vigamox
Viroptic
Zirgan
Zymaxid
BCBSM/BCN BCBSM
Generic name
bacitracin
sulfacetamide sodium
ciprofloxacin hcl
gentamicin sulfate
erythromycin base
neomy sulf/bacitra/polymyxin b
neomycin/gramicidin/polymyxn b
ofloxacin
bacitracin/polymyxin b sulfate
polymyxin b sulfate/tmp
levofloxacin
tobramycin sulfate
trifluridine
gatifloxacin
11E. Ophthalmic Anti-inflammatory Agents

Trade name
Acular, LS
Acuvail
Bromday; Xibrom
Ilevro
Nevanac
Ocufen
Prolensa
Voltaren drops
Generic name
ketorolac tromethamine
bromfenac sodium
flurbiprofen sodium
diclofenac sodium
11F. Ophthalmic Beta Blockers

Trade name
Betagan
Betimol (Tier 3 BCN only)
Betoptic S
Betoptic solution
Istalol (Tier 2 for BCN only)
Ocupress
Optipranolol
Timoptic Ocudose (Tier 2 BCN only)
Timoptic, - XE
BCN

3
1
3
3
1
1
2
1
1
2
2
1
1
1
1
1
1
1
3
2
1
2
1
3
1
3
3
1
1
2
1
1
2
2
1
1
1
1
1
1
1
3
2
1
2
1
3
1B
3
2
1B
1B
2
1B
1B
2
2
1B
1B
1B
1B
1B
1B
1B
2
2
1B
2
1B
BCBSM/BCN BCBSM
BCN

1
3
1
3
3
1
3
1
1
3
1
3
3
1
3
1
1B
3
1B
3
3
1B
3
1B
BCBSM/BCN BCBSM
Generic name
levobunolol hcl
betaxolol hcl
carteolol hcl
metipranolol
timolol maleate
BCN

1
2
2
1
3
1
1
3
1
1
2
2
1
3
1
1
3
1
1A
3
2
1B
2
1B
1B
2
1A
Page 62
11G. Ophthalmic Steroids
BCBSM/BCN BCBSM
Trade name
Generic name
Alrex
Decadron opthalmic
Durezol
FML
FML Forte, S.O.P.
Inflamase, Forte
Lotemax
Maxidex
Pred Forte
Pred Mild
Vexol
dexamethasone sod phosphate

fluorometholone
prednisolone acetate
11H. Other Glaucoma Agents

Trade name
Alphagan 0.2%, P 0.15%
Alphagan P 0.1%
Azopt
Combigan
Cosopt
Cosopt PF
Iopidine droperette
Iopidine drops
Lumigan
Lumigan 0.01%
Phospholine Iodide
Pilocar; Isopto-Carpine
Rescula
Simbrinza
Travatan
Travatan Z
Trusopt
Xalatan
Zioptan
Trade name

3
1
3
1
2
1
3
3
1
2
2
3
1
3
1
2
1
3
3
1
2
2
3
1B
3
1B
2
1B
3
3
1B
2
2
BCBSM/BCN BCBSM
Generic name
brimonidine tartrate
timolol maleate/dorzolam hcl
apraclonidine hcl
bimatoprost
pilocarpine hcl
travoprost (benzalkonium)
dorzolamide hcl
latanoprost
11I. Miscellaneous Ophthalmic Agents

Albalon
Cystaran <s>
Lacrisert
Neo-Synephrine
Restasis
BCN
Generic name
naphazoline hcl
phenylephrine hcl
BCN

1
2
2
3
1
3
3
1
1
2
2
1
3
3
1
2
1
1
3
1
2
2
3
1
3
3
1
1
2
2
1
3
3
1
2
1
1
3
1B
2
2
3
1B
3
3
1B
1B
2
2
1B
3
3
1B
2
1B
1A
3
BCBSM/BCN BCBSM
BCN

1
2
2
1
2
1
4
2
1
2
1B
4
2
1B
2
Page 63
12. OTIC & NASAL PREPARATIONS

12A. Nasal Preparations
Trade name
Astelin
Astepro
Atrovent nasal spray
Beconase AQ
Dymista
Flonase (Rx only)
Nasacort AQ (Rx only)
Nasalide
Nasonex
Omnaris
Patanase
Qnasl, Children's
Rhinocort Aqua
Tyzine
Veramyst
Zetonna
BCBSM/BCN BCBSM
Generic name
azelastine hcl
azelastine hcl
ipratropium bromide
flunisolide 0.025% spray
mometasone furoate
olopatadine hcl
budesonide
12B. Otic Preparations

Trade name
Acetasol HC
Auralgan
Cetraxal
Cipro HC
Ciprodex
Coly-Mycin S
Cortisporin
Cortisporin-TC
Domeboro Otic
Floxin Otic
Floxin Otic Singles
Vosol
Vosol HC
BCN

1
1
1
3
3
1
1
1
1
3
1
3
1
2
3
3
1
1
1
3
3
1
1
1
1
3
1
3
1
2
3
3
1B
1B
1B
3
3
1B
1B
1B
1B
3
1B
3
1B
2
3
3
BCBSM/BCN BCBSM
Generic name
acetic acid/hydrocortisone
aa/antpy/bcaine/polico/al acet
ciprofloxacin hcl
neomy sulf/polymyx b sulf/hc
acetic acid/aluminum acetate

ofloxacin
acetic acid
acetic acid/hydrocortisone
BCN

1
1
1
2
2
3
1
3
1
1
3
1
2
1
1
1
2
2
3
1
3
1
1
3
1
2
1B
1B
1B
2
2
3
1B
3
1B
1B
3
1B
2
Page 64
13. RESPIRATORY, COUGH & COLD

13A. Antihistamine/Decongestant Combinations
Trade name
Clarinex-D
Claritin-D (OTC)
Phenergan VC
Phenergan VC w/Codeine
Semprex-D
Zyrtec-D (OTC)
Generic name
p-ephed sul/loratadine
phenylephrine hcl/prometh hcl
promethazine/phenyleph/codeine
p-ephed hcl/cetirizine hcl
13B. Antihistamines
Trade name
Astelin
Astepro
Atarax; Vistaril
Benadryl (Rx only)
Clarinex syrup
Clarinex tablet, Redi-tabs
Claritin Redi-tab
Claritin, Alavert (OTC)
Karbinal ER
Patanase
Periactin
Phenergan
Xyzal solution
Xyzal tablet
Zyrtec (OTC)
Bromfed-DM
Flowtuss
Hycodan
Hycofenix
Obredon
Phenergan DM
Phenergan w/Codeine
Rezira
Robitussin AC
Tessalon, Perles; Zonatuss
Tussicaps
Tussionex
Tuzistra XR
Vituz
Zutripro
BCN

3
1
1
1
3
1
3
1
1
1
3
1
3
1B
1B
1B
3
1B
BCBSM/BCN BCBSM
Generic name
azelastine hcl
azelastine hcl
hydroxyzine
diphenhydramine hcl
desloratadine
loratadine
olopatadine hcl
cyproheptadine hcl
promethazine hcl
levocetirizine dihydrochloride
levocetirizine dihydrochloride
cetirizine hcl
13C. Antitussives
Trade name
BCBSM/BCN BCBSM
BCN

1
1
1
1
3
1
3
1
3
1
1
1
1
1
1
1
1
1
1
3
1
3
1
3
1
1
1
1
1
1
1B
1B
1B
1B
3
1B
3
1B
3
1B
1B
1B
1B
1B
1B
BCBSM/BCN BCBSM
Generic name
d-methorphan hb/p-epd hcl/bpm
hydrocodone bit/homatrop me-br
d-methorphan hb/prometh hcl

codeine/promethazine hcl
guaifenesin/codeine phosphate
benzonatate
hydrocodone/chlorphen polis
pseudoephed/hydrocodone/cpm
BCN

1
3
1
3
3
1
1
3
1
1
2
1
3
3
1
1
3
1
3
3
1
1
3
1
1
2
1
3
3
1
1B
3
1B
3
3
1B
1B
3
1B
1B
2
1B
3
3
1B
Page 65
13D. Cystic Fibrosis Agents
BCBSM/BCN BCBSM
Trade name
Generic name
Bethkis <s>
Cayston <s>
Kalydeco <s>
Orkambi <s>
Pulmozyme <s>
Tobi <s>
Tobi Podhaler <s>
tobramycin/0.25 normal saline
13E. Epinephrine
Trade name
Generic name
epinephrine
epinephrine
13F. Inhaled Anticholinergics

Trade name
Anoro Ellipta
Combivent Respimat
Duoneb
Stiolto Respimat
Utibron Neohaler
Generic name
ipratropium bromide
Generic name
ipratropium/albuterol sulfate
13H. Inhaled Beta-Agonists

Trade name
Accuneb; Albuterol nebulizer solution
Arcapta Neohaler
Brovana
Foradil
Metaproterenol soln
Perforomist
Proair HFA, Respiclick; Ventolin HFA
Proventil HFA
Serevent Diskus
Striverdi Respimat
Xopenex HFA
Xopenex nebulizer solution
3
3
2
2
2
1
3
5
5
4
4
4
4
5
5
5
4
4
4
4
5
Generic name
metaproterenol sulfate
levalbuterol hcl

1
3
1
2
1
3
1
2
1B
2
1B
2
BCN

2
1
3
3
2
3
2
1
3
3
2
3
2
1B
3
3
2
3
BCBSM/BCN BCBSM
BCN

3
2
1
2
3
3
2
1
2
3
3
2
1B
2
3
BCBSM/BCN BCBSM
albuterol sulfate
BCN
BCBSM/BCN BCBSM
13G. Inhaled Beta-Agonist/Anticholinergic Combinations

Trade name
BCBSM/BCN BCBSM
Adrenaclick
Adrenalin chloride (Tier 2 BCN Only)
Epinephrine auto-injector
Epipen, Jr
Atrovent HFA
Atrovent solution
Incruse Ellipta
Seebri Neohaler
Spiriva, Respimat
Tudorza Pressair
BCN
BCN

1
3
3
2
1
3
2
3
2
3
3
1
1
3
3
2
1
3
2
3
2
3
3
1
1B
3
3
2
1B
3
2
3
2
3
3
1B
Page 66
13I. Inhaled Steroid/Beta-Agonist Combinations

Trade name
Generic name
Advair
Breo Ellipta
Dulera
Symbicort
BCBSM/BCN BCBSM

2
3
2
2
13J. Inhaled Steroids

Trade name
Aerospan
Alvesco (Tier 1-BCN Only)
Arnuity Ellipta
Asmanex, HFA (Tier 1-BCN Only)
Flovent HFA, Diskus (Tier 1-BCN Only)
Pulmicort Flexhaler (Tier 1-BCN Only)
Pulmicort solution
Qvar (Tier 1-BCN Only)
Trade name
Generic name
budesonide
Trade name
2
3
2
2
Generic name
flunisolide 0.025% spray
mometasone furoate
budesonide

3
2
3
2
2
2
1
2
3
2
3
2
2
2
1
2
3
1A
3
1A
1A
1A
1A
1A
BCN

3
3
1
1
1
1
3
3
1
3
3
3
3
1
1
1
1
3
3
1
3
3
3
3
1B
1B
1B
1B
3
3
1B
3
3
BCBSM/BCN BCBSM
Generic name
metaproterenol sulfate
albuterol sulfate
terbutaline sulfate
albuterol sulfate
BCN
BCBSM/BCN BCBSM
13L. Oral Beta-Agonists

Alupent
Proventil solution
Terbutaline sulfate
Vospire ER
2
3
2
2
BCBSM/BCN BCBSM
13K. Intranasal Steroids

Beconase AQ
Dymista
Flonase (Rx only)
Nasacort AQ (Rx only)
Nasalide
Nasonex
Omnaris
Qnasl, Children's
Rhinocort Aqua
Veramyst
Zetonna
BCN
BCN

1
1
1
1
1
1
1
1
1B
1B
1B
1B
Page 67
13M. Pulmonary Hypertension Agents

Trade name
Adcirca <s>
Adempas <s>
Letairis <s>
Opsumit <s>
Orenitram ER <s>
Remodulin <s>
Revatio
Revatio suspension
Tracleer <s>
Tyvaso <s>
Uptravi <s>
Ventavis <s>
Generic name
sildenafil citrate
13N. Theophyllines
Trade name
Theo-24
Theophylline Anhydrous
Trade name
BCN

2
2
2
2
2
3
1
2
2
2
2
2
4
4
4
4
4
5
1
2
4
4
4
4
4
4
4
4
4
5
1B
2
4
4
4
4
BCBSM/BCN BCBSM
Generic name
theophylline anhydrous
13O. Miscellaneous Respiratory Agents

Accolate
Daliresp
Esbriet <s>
Grastek
Hyper-Sal (Tier 2 BCN only)
Intal solution
Mucomyst
Nebusal
Ofev <s>
Oralair
Ragwitek
Singulair
Sodium Chloride inhalation
Zyflo
Zyflo CR
BCBSM/BCN BCBSM
Generic name
zafirlukast
cromolyn sodium
acetylcysteine
montelukast sodium
sodium chloride for inhalation
BCN

2
1
2
1
2
1B
BCBSM/BCN BCBSM
BCN

1
3
3
3
3
1
1
3
3
3
3
1
1
3
3
1
3
5
3
3
1
1
3
5
3
3
1
1
3
3
1B
3
5
3
2
1B
1B
3
5
3
3
1B
1B
3
3
Page 68
14. UROLOGY
14A. BPH Treatment
BCBSM/BCN BCBSM
Trade name
Generic name
Avodart
Cardura
Cardura XL
Cialis 2.5, 5mg
Flomax
Hytrin
Jalyn
Proscar
Rapaflo
Uroxatral
dutasteride
doxazosin mesylate
tamsulosin hcl
terazosin hcl
dutasteride/tamsulosin hcl
finasteride
alfuzosin hcl
14B. Urinary Antispasmodics

Generic name
tolterodine tartrate
oxybutynin chloride
darifenacin hydrobromide
hyoscyamine sulfate
hyoscyamine sulfate
hyoscyamine sulfate
propantheline bromide
trospium chloride
trospium chloride
flavoxate hcl
14C. Miscellaneous Urologicals

Trade name
Azuphen MB (BCBSM only)
Cuprimine
Cystagon <s>
Cytra-2 (BCBSM only)
Cytra-3 (BCBSM only)
Cytra-K (BCBSM only)
Depen
Elmiron
Procysbi <s>
Pyridium (BCBSM only)
Renacidin
Thiola (Tier 2 BCN Only)
Urecholine
Urocit-K
Xuriden <s>

1
1
3
2
1
1
1
1
3
1
1
1
3
2
1
1
1
1
3
1
1B
1B
3
2
1B
1B
1B
1B
3
1B
BCBSM/BCN BCBSM
Trade name
Detrol, LA
Ditropan, XL
Enablex
Gelnique
Gelnique pump
Levbid
Levsin, SL
Levsinex
Myrbetriq
Oxytrol
Pro-Banthine
Sanctura
Sanctura XR
Toviaz (Tier 3 BCBSM Only)
Urispas
Vesicare
BCN
Generic name
citric acid/sodium citrate

citric acid/potassium citrate
potassium citrate/citric acid
phenazopyridine hcl
bethanechol chloride
potassium citrate
BCN

1
1
1
3
3
1
1
1
3
3
1
1
1
2
1
3
1
1
1
3
3
1
1
1
3
3
1
1
1
2
1
3
1B
1B
1B
3
3
1B
1B
1B
3
3
1B
1B
1B
2
1B
3
BCBSM/BCN BCBSM
methen/m-blue/sal/na phos/hyos
BCN

1
3
2
1
1
1
2
2
3
1
2
3
1
1
2
1
3
4
1
1
1
2
2
5
1
2
3
1
1
4
NC
3
4
NC
NC
NC
2
2
5
NC
2
2
1B
1B
4
Page 69
15. VITAMINS AND SUPPLEMENTS

15A. Potassium Replacement
Trade name
BCBSM/BCN BCBSM
Generic name
Kay Ciel, Kaon-Cl, Kaon Liquid

K-Lor, Klor-Con
Klor-con packet (BCN Tier 2 only)
K-Lyte, Klor-Con/EF
K-Sol, potassium chloride
K-Tab, K-Dur, Slow-K, Kaon CL
Micro-K
potassium chloride
potassium chloride
potassium bicarbonate/cit ac
potassium chloride
potassium chloride
potassium chloride
15B. Vitamins and Minerals
BCN

1
1
3
1
1
1
1
1
1
3
1
1
1
1
1B
1B
2
1B
1B
1B
1B
BCBSM/BCN BCBSM
Trade name
Generic name
Calciferol
Calcium + Vitamin D 600mg (Prevent)
Calcium + Vitamin D capsule (Prevent)
Calcium + Vitamin D chewable (Prevent)
Calcium + Vitamin D tablet (Prevent)
Calcium + Vitamin D tablet (Prevent)
Calcium Citrate w/Vitamin D (Prevent)
Calcium Citrate w/Vitamin D (Prevent)
Calvite P&D (Prevent)
Cyanocobalamin inj
Fer-in-sol 15mg drops (Prevent)
Fluoride 0.25, 0.5mg drops (Prevent)
Folic Acid 0.4, 0.8mg [OTC] (Prevent)
Folic Acid 1mg
Folvite
Galzin
Mephyton
Nascobal Spray
Niferex-150 Forte (BCBSM Only)
Poly-Vi-Flor (BCBSM Only)
Prenatal Plus, Tricare
Prenatal Vitamins
Prevident
Rulavite DHA
Supervite
Vitamin D3 (1000IU or less) (Prevent)
Vitamin K ampule
ergocalciferol
calcium carbonate/vitamin d3
calcium carb & cit/vitamin d3
calcium citrate/vitamin d3
calcium citrate/vitamin d2
calcium phosphate dibas/vit d3
cyanocobalamin
ferrous sulfate
sodium fluoride
folic acid
folic acid
folic acid
iron ps cmplx/vit b12/fa

pnv with ca,no.72/iron/fa
prenatal vit/iron,carb/doss/fa
sodium fluoride
pnv combo#47/iron/fa #1/dha
cholecalciferol (vitamin d3)
phytonadione
BCN

1
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
$0
$0
1
1
3
2
3
1
3
1
1
1
1
3
$0
1
1
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
$0
$0
1
1
3
2
3
1
3
1
1
1
1
3
$0
1
1B
$0
$0
$0
$0
$0
$0
$0
$0
1B
$0
$0
$0
1B
1B
3
2
3
NC
NC
1A
1B
1B
1B
3
$0
1B

Page 70
16. DIAGNOSTIC AND OTHER MISCELLANEOUS

16A. Chelating Agents
Trade name
Cuprimine
Depen
Desferal
Exjade <s>
Ferriprox <s>
Jadenu <s>
Syprine <s>
BCBSM/BCN BCBSM
Generic name
deferoxamine mesylate
16B. Ion-Removing Agents

Trade name
Auryxia
Fosrenol
Kayexalate
Phoslo
Phoslyra
Renagel
Renvela
SPS
Velphoro
Veltassa
Generic name
sodium polystyrene sulfonate
16C. Diagnostics and Other Miscellaneous

Carnitor
Carnitor SF solution (BCN tier 2 only)
Chemet
Cystadane (BCN Tier 2/4 only) <s>
Keveyis <s>
Kuvan <s>
Orfadin <s>
Provocholine
Radiogardase
Samsca <s>

3
2
1
3
3
3
3
3
2
1
5
5
5
5
3
2
1B
5
5
5
5
BCBSM/BCN BCBSM
sodium polystyrene sulfonate

calcium acetate
Trade name
BCN
Generic name
levocarnitine
BCN

3
3
1
1
3
2
2
1
3
2
3
3
1
1
3
2
2
1
3
2
3
3
1B
1B
3
2
2
1B
3
2
BCBSM/BCN BCBSM
BCN

1
3
2
3
3
2
2
2
2
2
1
3
2
5
5
4
4
2
2
4
1B
2
2
4
5
4
4
2
2
4
Page 71
17. LIFESTYLE MODIFICATION

17A. Impotence, Sexual Dysfunction
Trade name
BCBSM/BCN BCBSM
Generic name
Addyi
Caverject
Cialis
Edex
Levitra
Muse
Staxyn
Stendra
Viagra

3
2
2
3
3
2
3
3
2
17B. Smoking Cessation

Generic name
nicotine polacrilex
nicotine polacrilex
nicotine
bupropion hcl
17C. Weight Loss Preparations

Trade name
Adipex, P
Belviq
Bontril PDM
Contrave ER
Didrex
Diethylpropion hcl, ER
Qsymia
Regimex
Saxenda
Suprenza ODT
Xenical
3
2
2
3
3
2
3
3
2
3
2
2
3
3
2
3
3
2
BCBSM/BCN BCBSM
Trade name
Chantix (Prevent)
Commit Lozenge OTC (Prevent)
Nicotine Gum, Nicorette (Prevent)
Nicotine Patch (Prevent)
Nicotrol, NS (Prevent)
Zyban (Prevent)
BCN
phentermine hcl
phendimetrazine tartrate
benzphetamine hcl
diethylpropion hcl
BCN

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
BCBSM/BCN BCBSM
Generic name
BCN

1
3
1
3
1
1
3
3
3
3
3
1
3
1
3
1
1
3
3
3
3
3

1B
3
1B
3
1B
1B
3
3
3
3
3
Page 72
Appendix A
Blue Cross and BCN Preferred Alternatives
July 2016
Blue Cross and BCN Preferred Alternatives - July 2016

Tier 3
Preferred Alternatives
Tier 3
ABSORICA
Generic Isotretinoin [Claravis(g),

Myorisan(g), Zenatane(g)]*
ALOGLIPTINMETFORMIN
ABSTRAL
Actiq(g)*, MSIR(g), Opana IR(g)*,

oxycodone IR(g), Roxanol(g)
ACANYA
Benzaclin(g), Duac(g), Individual

agents (over-the-counter (OTC)
benzoyl peroxide and clindamycin)
ActoPlus Met(g), Actos(g),

Glucophage(g)/XR(g), Insulin,
Janumet/XR, Januvia, Kombiglyze
XR, Onglyza, a sulfonylurea
[Amaryl(g), Glucotrol(g)/XL(g),
Glynase(g)]
ALOGLIPTINPIOGLITAZONE
Actos(g), Glucophage(g), Insulin,

Janumet/XR, Januvia, Kombiglyze,
Onglyza, a sulfonylurea [Amaryl(g),
Glucotrol(g)/XL(g), Glynase(g)]
ALREX
Decadron ophth(g), FML(g), Pred

Forte(g), Pred Mild
ACIPHEX
SPRINKLE
Aciphex(g), Nexium(g)*,
Prevacid(g)/Solutab*,
Prilosec(g)/Prilosec OTC**,
Protonix(g), Zantac(g)
ACTEMRA
Enbrel*, Humira*, methotrexate
ALTABAX
ACTICLATE
Minocin(g), Monodox(g), tetracycline,

Vibramycin(g)
Bactroban(g), OTC Triple Antibiotic

ointment
ALTOPREV
Crestor(g)*, Lescol(g)/XL(g),
Lipitor(g), Mevacor(g), Pravachol(g),
Zocor(g)
AMITIZA
Glycolax(g), Lactulose(g), OTC fiber,

OTC stimulant laxative and OTC stool
softeners
AMOXICILLIN ER
Amoxil capsules(g)
AMRIX
Baclofen(g), Flexeril(g), Norflex(g),

Parafon Forte(g), Robaxin(g),
Zanaflex(g)
ANADROL-50
Procrit*
ANGELIQ
FemHRT(g), Premphase; an estradiol

plus a progestin, Prempro
ACTOPLUS MET
XR
ActoPlus MET(g), or
Glucophage(g)/XR(g); plus Actos(g)
ACUVAIL
Acular(g)/LS(g), Ocular(g), Voltaren

ophth(g)
ACZONE
Differin(g), OTC benzoyl peroxide,

topical clindamycin, topical
erythromycin
ADAPALENE 0.1%
LOTION
Differin cream(g), gel(g)
ADZENYS XR-ODT
Adderall XR(brand BCN only),

Metadate CD(g) (Both of which may
be "sprinkled" on food); Methylin(g)
AEROSPAN
Alvesco, Asmanex, Flovent HFA,

Pulmicort solution(g)/Flexhaler, Qvar
ANORO ELLIPTA
Serevent Diskus plus

Spiriva/Respimat, Stiolto Respimat
AFREZZA
Apidra*/Solostar*, Novolin (Tier 1

BCN Only), Novolog (Tier 1 BCN
Only), Humalog*, Humulin*
ANTARA 30, 90MG
Antara(g), Lofibra(g), Lopid(g),

Tricor(g), Trilipix(g)
ANZEMET
Kytril(g), Zofran(g)/ODT(g)
AKYNZEO
Emend(g); plus Zofran(g), or Kytril(g)

APEXICON E
Apexicon(g)
ALLZITAL
Esgic(g), Phrenilin(g)
APLENZIN
ALOGLIPTIN

Celexa(g), Effexor(g)/XR(g),
Prozac(g), Zoloft(g)
APRISO
Asacol HD, Azulfidine(g)/En-Tab(g),

Delzicol, Pentasa
APTENSIO XR
Adderall(g)/XR(Brand BCN only),

Concerta(g), Focalin(g)/XR(g),
Metadate CD(g), Ritalin(g)/LA(g)/SR(g)
(g) Generic equivalent covered. Brand not covered or requires higher copay.
* Prior Approval (Authorization) or Step Therapy may be required.
** Covered with a prescription for BCN members and some Blue Cross members.
Most BCN members and some Blue Cross and members do not have coverage for Tier 3 (nonformulary) agents. Please use this
list as a guide when selecting alternatives.
Page 1
Tier 3
Tier 3
APTIOM
Dilantin(g), Keppra(g), Tegretol(g),

Topamax(g), Trileptal(g)
BELSOMRA
Ambien(g)/CR(g), Intermezzo(g)*,
Lunesta(g), Restoril(g), Sonata(g)
ARANESP
Procrit*
BELVIQ
Adipex-P(g), Bontril(g), Didrex(g),

OTC Alli, Tenuate(g)
ARCAPTA
NEOHALER
Serevent Diskus, Spiriva/Respimat

BEPREVE
Alocril, Elestat(g), Optivar(g), OTC

Zaditor(g), Patanol
BESIVANCE
Ciloxan(g), Ocuflox(g), Quixin(g),

Vigamox, Zymaxid(g)
BETASERON
Avonex, Copaxone(g), Copaxone

40mg/mL, Gilenya*, Rebif, Tecfidera*
BETHKIS
Tobi(g)
BETIMOL
Betagan(g), Betoptic(g), Ocupress(g),

Optipranolol(g), Timoptic(g)
BEYAZ
Yasmin(g) or Yaz(g) plus folic acid

1mg
BINOSTO
Actonel(g)*, Atelvia(g)*, Boniva(g),

Fosamax(g)
BREO ELLIPTA
Advair, Dulera, Serevent Diskus,

Spiriva, Symbicort
BRISDELLE
Effexor/XR(g), Paxil(g)
BRIVIACT
Keppra(g)/XR(g), Depakote(g)/ER(g),
Lamictal(g)/ODT(g), Tegretol(g),
BROVANA
BUNAVAIL
Suboxone(g), Suboxone film
BUTISOL SODIUM
Ambien(g), Intermezzo(g)*,
Lunesta(g), Prosom(g), Restoril(g),
Sonata(g)
BUTRANS
Duragesic(g), Exalgo(g)*,
Methadone(g), MS Contin(g), Opana
ER(g)*, Ultram ER(g)
BYETTA
Actos(g), Bydureon*, Glucophage(g),

Insulin, Januvia, Onglyza, a
sulfonylurea [Amaryl(g),
Glucotrol(g)/XL(g), Glynase(g)],
Victoza*
BYSTOLIC
Cardioselective beta-blockers:
Lopressor(g), Tenormin(g), Toprol
XL(g), etc
ARMOUR THYROID Levoxyl(g), Synthroid(g)

ARNUITY ELLIPTA
Asmanex, Flovent HFA, Pulmicort

solution(g)/Flexhaler, Qvar
ASTAGRAF XL
Prograf(g)
AUBAGIO

AURYXIA
OTC Tums, Phoslo(g), Renagel,

Renvela
AVANDAMET
ActoPlus Met(g); or Glucophage(g)

plus Actos(g)
AVANDIA
Actos(g), Glucophage(g), Insulin, a

sulfonylurea [Amaryl(g), Diabeta(g),
Glucotrol(g)/XL(g)]
AVC
Diflucan(g) oral, Terazol(g) vaginal
AVITA GEL
Retin-A (g)
AXIRON
Androderm*, Androgel 1%(g)*,

Androgel 1.62%*, Delatestryl(g)*,
Depo-Testosterone(g)*
AZASAN
Imuran (g)
AZASITE

Vigamox, Zymaxid(g)
AZELEX
Benzaclin(g), Differin(g), Retin-A(g)
AZOR
Generic angiotensin converting

enzyme (ACE) inhibitor (lisinopril,
benazepril, etc) or angiotensin
receptor antagonist (ARB) (such as
Cozaar(g)) plus Norvasc(g)
BECONASE AQ
Flonase(g), Nasacort AQ(g),

Nasalide(g), Nasonex(g)*, OTC
Nasacort, OTC Rhinocort,
Patanase(g), Rhinocort Aqua(g)*
BELBUCA
ER(g)*, Ultram ER(g)
Page 2
Tier 3
CAMBIA
Generic non-steroidal antiinflammatory drug (NSAID) such as
Mobic(g), Naprosyn EC(g)
Tier 3
CUPRIMINE
Depen
CYCLOSET

Januvia, Onglyza, a sulfonylurea
Glynase(g)]
CARAC
Aldara(g), Efudex(g), Fluoroplex
CARDENE SR
Cardene(g), Norvasc(g), Procardia

XL(g)
DALIRESP
Advair, Serevent Diskus,

Spiriva/Respimat, Symbicort
Avodart(g), Cardura(g), Flomax(g),

Hytrin(g), Jalyn(g)*, Uroxatral(g)
DAYTRANA
Adderall(g)/XR(brand BCN only),

DENAVIR
Famvir(g), Valtrex(g), Zovirax cream

5%/ointment(g)/tablets(g)
DESONATE
Elocon(g), Locoid(g), Synalar

solution(g)
CARDURA XL
CAYSTON
Tobi(g)
CERDELGA
Cerezyme (medical benefit)
CESAMET
Kytril(g), Marinol(g), Zofran(g)/ODT(g)
CHENODAL
Actigall(g), Urso(g)
CIMZIA SYRINGE
CLARINEX-D,
SYRUP
OTC Claritin(g)**, OTC Zyrtec(g)**,

Xyzal(g)
DESVENLAFAXINE Generic SSRI/SNRI [Celexa(g),

ER
Effexor(g)/XR(g), Prozac(g), Zoloft(g),
etc.]
CLEOCIN VAGINAL Cleocin vaginal cream(g), MetrogelOVULES

Vaginal(g)
DESVENLAFAXINE Generic SSRI/SNRI [Celexa(g),

FUMARATE ER
etc.]
CLIMARA PRO
Alora, Climara(g) or Vivelle-Dot(g),

plus a progestin; or FemHRT(g)
DEXILANT
CLINDESSE
Cleocin vaginal cream(g), Metrogelvaginal(g)
Prilosec(g)/Prilosec OTC**, Protonix(g)
DICLEGIS
OTC doxylamine plus OTC vitamin

B6; Zofran(g)/ODT(g)
DIFFERIN 0.1%
LOTION
Differin cream(g), gel(g)
DIFICID
Flagyl(g), Vancocin(g)
COLCHICINE
CAPSULES
colchicine tablets, Colcrys
COLESTID
FLAVORED
Colestid(g), Questran(g)/Light(g),
Welchol
COLY-MYCIN S
Cipro HC, Cortisporin(g), Floxin Otic

(g)
DIPENTUM

Delzicol, Pentasa
COMBIGAN
Alphagan(g) plus Timoptic(g)
DIVIGEL
COMBIPATCH
Alora, Climara(g) or Vivelle-Dot(g),

plus a progestin; or FemHRT(g)
Alora, Climara(g), Estrace tablets(g),

Vivelle-Dot(g)
DORAL

DORYX

Vibramycin(g)
DOXCYCLINE IRDR

Vibramycin(g)
DUAVEE
Climara(g), Enjuvia, Estrace(g) or

Premarin plus a progestin;
Effexor(g)/XR(g), Paxil(g)
CONTRAVE ER
CONZIP
Ryzolt(g), Ultram(g)/ER(g)
COREG CR
Coreg(g) or Toprol XL(g)
COSENTYX
COSOPT PF
Cosopt(g)
Page 3
Tier 3
DUEXIS
Arthrotec(g); Motrin(g) plus Pepcid(g)
DUREZOL

Forte(g)
DURLAZA
Aspirin, Ecotrin(g)
DUTOPROL
Toprol XL(g) plus HCTZ(g)
DYANAVEL XR

DYMISTA
ECOZA
EDARBI
Astelin(g) plus Flonase(g); Nasacort

AQ(g), Nasalide(g), Nasonex(g)*,
OTC Nasacort, OTC Rhinocort,
Diflucan(g), Lamisil(g), Nizoral(g),
OTC Clotrimazole(g), OTC
Miconazole(g), Spectazole(g),
Sporanox(g)
Atacand(g)/HCT(g), Avalide(g),
Avapro(g), Benicar*/HCT*, Cozaar(g),
Diovan(g)/HCT(g), Exforge(g)/HCT(g),
Hyzaar(g), Micardis(g)/HCT(g)
Tier 3
ENTRESTO
Generic ACE inhibitor (lisinopril,

benazepril, etc) or generic ARB
[Cozaar(g), Hyzaar(g)]
ENVARSUS XR
Prograf(g)
EPANED
Vasotec(g)
EPIDUO, FORTE,
PUMP
OTC benzoyl peroxide plus Differin(g);

Retin-A(g)
EPOGEN
Procrit*
EQUETRO
Abilify(g), Lamictal(g)/ODT(g),
Lithium(g), Tegretol(g)/XR(g)
ERTACZO
Monistat-Derm(g), Nizoral cream(g),

OTC Lamisil AT(g), OTC Lotrimin
Ultra, Spectazole(g)
ESTRACE
VAGINAL CREAM
Premarin cream, Vagifem
ESTROGEL
Alora, Climara(g), Estrace(g), VivelleDot(g)
EVAMIST
EVEKEO

Concerta(g), Metadate CD(g),
Ritalin(g)/LA(g)/SR(g); Bontril(g), OTC
Alli, phentermine
EDARBYCLOR
Generic ARB [such as Cozaar(g)] plus

chlorthalidone; Atacand HCT(g),
Benicar HCT*, Diovan HCT(g),
Exforge HCT(g)
EDEX
Caverject*, Cialis*, Muse*, Revatio(g)

(BCN only), Viagra*
EXELDERM
Lotrimin(g), Monistat-Derm(g),
Nizoral(g), Spectazole(g)
EDLUAR
EXJADE
Desferal(g)
ELESTRIN
EXTAVIA

ELIGARD
Lupron(g)/Depot, Trelstar/LA; Depot
FABIOR
Differin(g), Retin-A(g), Tazorac
EMADINE

Zaditor(g), Patanol
FACTIVE
Avelox(g), Erythromycin(g),
Levaquin(g), Vibramycin(g),
Zithromax(g)
EMBEDA
ER(g)*
FANAPT
Abilify(g), Clozaril(g), Geodon(g),

Invega(g)*, Risperdal(g), Seroquel(g),
Zyprexa(g)
EMSAM
Celexa(g), Effexor(g)/XR(g),
Lexapro(g), Paxil(g), Prozac(g),
Wellbutrin/SR/XL(g)
FARYDAK
Thalomid
FASLODEX
Fareston, Tamoxifen
ENSTILAR
Dovonex(g) plus
Diprosone/Diprolene(g); Taclonex(g)
ointment*
Page 4
Tier 3
Tier 3
FAZACLO

Zyprexa(g)
FORTESTA

FEMRING
Alora, Climara(g), Estring, VivelleDot(g)
FOSAMAX PLUS D

Fosamax(g) plus OTC Vitamin D
FENOGLIDE

FOSRENOL

Renvela
FENTANYL PATCH
37.5 62.5, 87.5MG
Duragesic(g)
FRAGMIN
Lovenox(g)
FYCOMPA
FENTORA

Depakote(g)/ER(g),
FERRIPROX
Desferal(g)
GALZIN
OTC zinc supplements
FETZIMA
Generic SSRI/SNRI [Celexa(g),

etc.], Wellbutrin/SR/XL(g)
GELNIQUE
Detrol(g)/LA(g), Ditropan(g)/XL(g),
Enablex(g), Sanctura(g)/XR(g)
GIAZO
FINACEA, FOAM
Metrocream(g), Metrogel topical(g),

Metrolotion(g), Retin-A(g)

Delzicol, Pentasa
GLYSET
FLECTOR PATCH
Generic NSAIDs [Naproxen(g),

Lodine(g)/XL(g), Mobic(g), Motrin(g),
Voltaren oral(g)/XR(g)], Lidoderm(g),
Topical OTC analgesic balms, (i.e.
trolamine salicylate)

Januvia, Onglyza, Precose(g), a
GLYXAMBI

GRALISE
Generic tricyclic antidepressant (TCA)

[Adapin(g), Elavil(g), Sinequan(g),
Tofranil(g)], Neurontin(g),
Ultram(g)/ER(g)
GRASTEK
Accolate(g), Clarinex(g), Flonase(g),

Nasacort AQ(g), Nasonex(g)*, OTC
Claritin(g)**, OTC Nasacort, OTC
Zyrtec(g)**, Singulair(g), Xyzal(g)
FLOWTUSS
Phenergan DM(g), Phenergan VC(g),

Robitussin AC(g), Tussionex(g),
Zutripro(g)
FLOXIN OTIC
SINGLES
Cetraxal(g), Floxin Otic(g)
FLUOROURACIL
0.5% CREAM
Aldara(g), Efudex(g), Fluoroplex
FLUOXETINE 60MG Prozac(g)

FOCALIN XR 25,
35MG

GYNAZOLE-1
Diflucan 150mg(g), OTC Lotrimin,

OTC Monistat, Terazol(g)
FOLLISTIM AQ
Gonal-F, RFF, Redi-Ject
HALOG
FORFIVO XL

Apexicon(g), Cyclocort(g),
Diprosone(g), Topicort(g), Valisone(g)
HEMANGEOL
Inderal(g)
HETLIOZ
OTC melatonin, Restoril(g), Sonata(g)
FORTEO

Fosamax(g), Miacalcin(g)
Page 5
Tier 3
HORIZANT
Generic TCA [Adapin(g), Elavil(g),

Sinequan(g), Tofranil(g)],
Mirapex(g)/ER(g)*, Neurontin(g),
Requip(g)
HUMATROPE
Genotropin*, Nutropin AQ*/Nuspin*
HYCOFENIX
Tier 3
KAZANO
ActoPlus Met(g), Actos(g),

Glucophage(g)/XR(g), Insulin,
Janumet/XR, Januvia, Kombiglyze
XR, Onglyza, a sulfonylurea
Glynase(g)]
Phenergan DM(g), Phenergan VC(g),

Robitussin AC(g), Tussionex(g),
Zutripro(g)
KERYDIN (NOT
COVERED FOR
BCBSM)
Lamisil(g), Penlac(g), Sporanox(g)
HYSINGLA ER
ER(g)*
KETEK
Biaxin(g), Erythromycin(g),
Zithromax(g)
KEVEYIS
Diamox(g)
ILEVRO
Acular(g), Bromday(g), Ocufen(g),

Voltaren ophth(g)
KHEDEZLA

Effexor(g)/XR(g), Prozac(g),
Zoloft(g), etc.]
KINERET
KORLYM
Ketoconazole, Lysodren(g)
LAMISIL
GRANULES
Lamisil(g)
LANOXIN 62.5,
187.5MCG
Lanoxin(g)
INCRUSE ELLIPTA
Serevent, Spiriva/Respimat, Stiolto

Respimat
INDERAL XL
Inderal(g)/LA(g), Inderide(g)
INNOPRAN XL
Inderal(g)/LA(g), Inderide(g)
IOPIDINE
DROPPERETTE
Alphagan(g), Alphagan P 0.15%(g),

0.1%
JADENU
Desferal(g)
JARDIANCE
Actos(g), Farxiga*, Glucophage(g),

Insulin, Invokamet*, Invokana*,
Xigduo XR*
LASTACAFT

Zaditor(g), Patanol
LATUDA

Zyprexa(g)

LAZANDA

LEVATOL
Inderal(g)/LA(g), Lopressor(g),
Sectral(g), Tenormin(g), Toprol XL(g)
LEVITRA
Cialis*, Revatio(g) (BCN only), Viagra*
LIALDA

Delzicol, Pentasa
JENTADUETO
JUBLIA (NOT
COVERED FOR
BCBSM)
Lamisil(g), Penlac(g), Sporanox(g)
JUXTAPID
Kynamro*
KADIAN
ER(g)*
LINZESS

OTC laxatives and OTC stool
softeners
KARBINAL ER
Clarinex(g), OTC Claritin(g)**, OTC

Zyrtec(g)**, Xyzal(g)
LIPOFEN

LIVALO
Crestor(g)*, Lescol(g)/XL(g),
Zocor(g)
Page 6
Tier 3
LO LOESTRIN FE
Generic biphasic contraceptives

(Loseasonique(g), Mircette(g), etc)
LOCOID
LIPOCREAM,
LOTION
Aristocort(g), Elocon(g), Locoid(g),

Synalar(g), Topicort(g)
LORZONE
Flexeril(g), Norflex(g), Robaxin(g),

Zanaflex(g) tablets
LOTEMAX

Forte(g), Pred Mild
LUPANETA PACK
Lupron(g)/Depot, plus Ortho

Micronor(g) or Nor-QD(g)
LUZU

Miconazole(g), Sporanox(g)
LYRICA
Flexeril(g), generic SSRI/SNRI

[Celexa(g), Effexor(g)/XR(g),
Prozac(g), Zoloft(g), etc.], generic
TCA [Adapin(g), Elavil(g),
Sinequan(g), Tofranil(g)] Neurontin(g),
Ultram(g)
Tier 3
MOVANTIK

OTC stimulant laxatives and OTC
stool softeners
MOVIPREP
Colyte(g), Nulytely(g)
MOXATAG
Amoxil capsules(g)
MYALEPT
Crestor(g)*, Insulin, Lescol/XL(g),

Zocor(g)
MYRBETRIQ
NAFTIFINE HCL
Lotrimin(g), Monistat-derm(g), Nizoral

CR(g), Nystatin(g)
NAFTIN
Lotrimin(g), Monistat-derm(g), Nizoral

CR(g), Nystatin(g)
NAMENDA XR
Aricept(g)/ODT(g), Exelon(g),
Namenda(g), solution
NAMZARIC
Aricept(g)/ODT(g), Exelon(g),
Namenda(g), solution
MARPLAN
Nardil(g), Parnate(g)
NASCOBAL SPRAY Cyanocobalamin injection, OTC

Cyanocobalamin tabs (Vitamin-B)
MAXIDEX

Forte(g), Pred Mild
NATAZIA
Mircette(g), Ortho Tri-Cyclen(g),

Yasmin(g), Yaz(g)
MENEST
NATESTO
MENOSTAR

NESINA

NEULASTA
Granix, Neupogen
NEUPRO
Mirapex(g)/ER(g)*, Neurontin(g),
Requip(g)
MENTAX
Monistat-Derm(g), Nizoral cream(g),

OTC Lamisil(g)/AT(g), OTC
Lotrimin(g)/Ultra, Spectazole(g)
METHITEST

MINASTRIN 24 FE
Generic minophasic contraceptives

(Loestrin 24 Fe(g), Femcon Fe(g), etc)
NEVANAC
Acular(g), Ocufen(g), Voltaren

ophth(g)
MINIVELLE
NICOTROL, NS
OTC nicotine gum(g)**, lozenge(g),

patch(g)**; Zyban(g)
MIRCERA
Procrit*
colchicine tablets, Colcrys
NORDITROPIN
FLEXPRO
Genotropin*, Nutropin AQ*, Nuspin*
MITIGARE
MONUROL
Avelox(g), Bactrim(g)/DS(g), Cipro(g),

Levaquin(g), Macrobid(g)
NORITATE
MetroCream(g), Metrogel(g)
Page 7
Tier 3
NORTHERA
fludrocortisone, midodrine
NUCYNTA
MSIR(g), Opana(g), oxycodone IR(g),

Ultram(g)
NUCYNTA ER
Duragesic(g), Methadone(g), MS
contin(g), Opana ER(g)*, Ultram ER(g)
NUVESSA
Metrogel-Vaginal(g)
NYMALIZE
Nimotop(g)*
OBREDON
OLEPTRO ER
Tier 3
OSENI

OSMOPREP
OSPHENA
Estring or Vagifem plus a progestin
OTEZLA
Enbrel*, Humira*, methotrexate,

Rheumatrex (BCN only), Trexall
Hycodan(g)
OTREXUP
Desyrel(g), Generic SSRI/SNRI

[Celexa(g), Effexor(g)/XR(g),
Prozac(g), Zoloft(g), etc.]

OXAYDO
MS-IR(g), Norco(g), Opana IR(g)*,

oxycodone IR(g)
OXISTAT LOTION

Miconazole(g), Oxistat cream(g),
Spectazole(g), Sporanox(g)
OXTELLAR XR
Depakote(g)/ER(g),
Lamictal(g)/ODT(g), Neurontin(g),
Tegretol(g)/XR(g), Topamax(g),
Trileptal(g)
OXYCODONE HCL
ER
ER(g)*
OXYCONTIN
ER(g)*
OXYTROL
PANDEL
Aristocort(g), Cloderm, Cordran

cream(g), Elocon(g), Locoid(g),
Synalar(g), Topicort(g)
PAREMYD
Cyclogyl(g), Isopto Atropine(g) plus

Mydriacyl(g)
PATADAY

Zaditor(g), Patanol
PAZEO

Zaditor(g), Patanol
PCE
Biaxin(g), Erythromycin(g),
Zithromax(g)
OMECLAMOX-PAK
Generic Proton Pump Inhibitor (PPI)

[Nexium(g)*, Prilosec(g), Prilosec
OTC, Omeprazole OTC] plus
Biaxin(g) plus Amoxil capsules(g); or
Prevpac(g)
OMNARIS

OMNITROPE
ONEXTON
Benzaclin(g), Benzamycin(g), Duac(g)
ONFI
Depakene(g), Depakote(g),
Klonopin(g), Topamax(g)
ONMEL (NOT
COVERED FOR
BCBSM)
Grifulvin(g), Lamisil(g), Sporanox(g)
ONZETRA XSAIL
Amerge(g), Axert(g)*, Frova(g)*,

Imitrex(g), Maxalt(g)/MLT(g),
Zomig(g)*/ZMT(g)*
ORACEA

Vibramycin(g)
ORALAIR
Accolate(g), Clarinex(g), Flonase(g),

Nasacort AQ(g), Nasonex(g)*, OTC
Claritin(g)**, OTC Nasacort, OTC
Zyrtec(g)**, Singulair(g), Xyzal(g)
ORAVIG
Diflucan(g), Mycelex Troche(g),

Nystatin, Sporanox(g)
ORENCIA SUBQ
Page 8
Tier 3
PENNSAID 2%
Generic NSAIDs [Naproxen(g),
Voltaren oral(g)/XR(g)], Pennsaid
1.5%(g)*, topical OTC analgesic
balms, (i.e. trolamine salicylate)
Tier 3
PROVENTIL HFA
Proair HFA/Respiclick, Ventolin HFA
PURIXAN
mercaptopurine tablets
PYLERA
PrevPac(g), OR tetracycline plus

Flagyl(g) plus OTC Bismuth
QNASL

QSYMIA

PERFOROMIST
PERTZYE
Creon, Ultresa, Viokase, Zenpep
PEXEVA

Paxil(g), Prozac(g), Zoloft(g), etc.]
PHOSLYRA
Phoslo(g), Renagel, Renvela
PICATO
Aldara(g), Efudex(g)
QUARTETTE
Alesse(g), Lybrel(g), Seasonale(g)
PLEGRIDY
Avenox, Copaxone(g), Copaxone

QUDEXY XR
POMALYST
Thalomid
QUILLICHEW ER
POTIGA
Dilantin(g), Klonopin(g)

QUILLIVANT XR
PRALUENT
Colestid(g), Crestor(g)*,
Lescol(g)/XL(g), Lipitor(g),
Mevacor(g), Pravachol(g),
Questran(g)/Light(g), Zetia, Zocor(g)

RAGWITEK
Accolate(g), Clarinex(g), Claritin(g),

Nasonex(g)*, OTC Claritin(g)**, OTC
Nasacort, OTC Zyrtec(g)**,
Singulair(g), Xyzal(g), Zyrtec(g)
RANEXA
Beta-blocker [such as Toprol XL(g)] or

calcium channel blocker [such as
Norvasc(g)] in combination with a longacting nitrate [such as Imdur(g)]
PRAMOSONE
Analpram HC(g)
PRED-G
Garamycin(g) plus Pred Forte(g)
PREFEST
FemHRT(g), Premphase; an estradiol

plus a progestin, Prempro
PREPOPIK
PRESTALIA
Aceon(g) plus Norvasc(g); Exforge(g),

Lotrel(g), Twynsta(g)
RAPAFLO
Avodart(g), Cardura(g), Flomax(g),

Hytrin(g), Jalyn(g)*, Uroxatral(g)
PRILOSEC
SUSPENSION
RASUVO

PRISTIQ ER

etc.]
RAVICTI
Buphenyl(g)
RAYOS
cortisone, Medrol(g), prednisolone,

prednisone
PROCYSBI
Cystagon
RECTIV
Nitroglycerin ointment
PROLENSA
Acular(g), Bromday(g), Ocufen(g),

Voltaren opthalmic(g)
REGRANEX
OTC papain/urea
PROTONIX
SUSPENSION
RELPAX

Zomig(g)*/ZMT(g)*
Page 9
Tier 3
REMODULIN
Tyvaso
REPATHA
Colestid(g), Crestor(g)*,
Mevacor(g), Pravachol(g),
Questran(g)/Light(g), Zetia, Zocor(g)
RESCULA
Alphagan(g), Cosopt(g), Lumigan,

Travatan(g)/Z, Xalatan(g)
RETIN-A MICRO
PUMP 0.08%
Duac(g), Differin(g), Retin-A(g)/Micro

gel(g)
REVLIMID
Thalomid
REXULTI

Zyprexa(g)
Tier 3
SEEBRI NEOHALER Serevent Diskus, Spiriva/Respimat,

Stiolto Respimat
SEMPREX-D
Astelin(g), OTC Claritin-D(g)**, OTC

Zyrtec-D(g)**, Xyzal(g)
SEROQUEL XR

Zyprexa(g)
SEROSTIM
SIGNIFOR
Ketoconazole, Lysodren(g)
SIGNIFOR LAR
Sandostatin LAR Depot*, Somatuline

Depot*, Somavert*
SILENOR
Adapin(g), Ambien(g)/CR(g),
Desyrel(g), Intermezzo(g)*,
Lunesta(g), Sinequan(g), Sonata(g)
SIMBRINZA

Travatan(g)/Z, Trusopt(g), Xalatan(g)
REZIRA
Zutripro(g)
RIOMET
Actos(g), Glucophage(g), Januvia,

SIMPONI
RITALIN LA 10MG,
60MG

Ritalin(g)/LA(g)/SR(g)
SITAVIG
Famvir(g), Valtrex(g), Zovirax(g)
SKLICE
Elimite(g), Eurax, Lindane(g)
ROZEREM
Lunesta(g), OTC melatonin,
Prosom(g), Restoril(g), Sonata(g)
SOLODYN

Vibramycin(g)
RYTARY
Parcopa(g), Sinemet(g)/CR(g)
SOLTAMOX
Tamoxifen
SAFYRAL
Generic contraceptive plus OTC folic

acid
SOOLANTRA
Generic topical metronidazole, RetinA(g)
SAIZEN
SORILUX
Dovonex(g)
SANCUSO
SOTYLIZE
Betapace(g), Calan(g), Cardizem(g),

Inderal(g)
SAPHRIS

Zyprexa(g)
SPRITAM
Keppra(g)/XR(g), Depakote(g)/ER(g),
SARAFEM TABLET
Prozac(g)
SPRIX
Toradol(g)
SAVAYSA
Eliquis, Pradaxa, Xarelto
STAXYN
SAVELLA
Cymbalta(g), Effexor(g)/XR(g),
Flexeril(g), generic SSRI [Celexa(g),
Prozac(g), Zoloft(g)], generic TCA
Tofranil(g)], Neurontin(g), Ultram(g)
STELARA
STENDRA
STRATTERA

Intuniv(g), Kapvay(g), Metadate
CD(g), Ritalin(g)/LA(g)/SR(g)
SAXENDA

Page 10
Tier 3
STRIANT

STRIVERDI
RESPIMAT
Serevent Diskus, Spriva/Respimat
SUBSYS

SUMAVEL
DOSEPRO

Zomig(g)*/ZMT(g)*
SUPRAX CHEW
TABLETS,
500MG/5ML SUSP
Omnicef(g), Suprax suspension(g)

Vantin(g)
SUPRENZA ODT

Generic ACE inhibitor [lisinopril,

benazepril, etc.] or generic ARB
[Atacand(g)/HCT(g), Avalide(g),
Avapro(g), Benicar*/HCT*, Cozaar(g),
Diovan(g)/HCT(g), Exforge(g),
Hyzaar(g), Teveten(g)]
TESTIM

TESTOSTERONE,
GEL, PACKET,
PUMP

TESTRED,
ANDROID

TIMOPTIC PF
Betagan(g), Betoptic(g), Ocupress(g),

Optipranolol(g), Timoptic(g)
TIROSINT
Levoxyl(g), Synthroid(g)
TIVORBEX
Generic NSAIDs [Indomethacin(g),

Naprosyn(g), Voltaren oral(g)/XR(G)]
Actos(g), Farxiga*, Glucophage(g),

Insulin, Invokamet*, Invokana*,
Xigduo XR*
TOBI PODHALER
Tobi(g)
TOBRADEX ST
sulfacetamide/prednisolone solution,
Tobradex suspension(g)/ointment
TOLAK
Efudex(g), Fluroplex
Depen
TOPIRAMATE ER
Keppra(g), Klonopin(g), Topamax(g),
Trileptal(g)
TOVIAZ (BCBSM
ONLY)
TRADJENTA

TRESIBA
Lantus (BCN Tier 1 only); Levemir

(BCN Tier 1 only), Toujeo
TRETIN-X
Retin-A (g), Retin-A Micro (g)
TREXIMET

Imitrex(g) plus naproxen;
Maxalt(g)/MLT(g), Zomig(g)*/ZMT(g)*
TREZIX
Esgic(g), Norco(g), Synalgos(g),

Tylenol #3(g)
SYMLIN

Januvia, Onglyza, Precose(g), a
SYPRINE
TACLONEX SCALP Dovonex(g) plus

Diprosone/Diprolene(g), Taclonex(g)
ointment*
TANZEUM
TEKAMLO
TEKTURNA, HCT
SUPREP
SYNJARDY
Tier 3

Victoza*
Lotrel(g); Norvasc(g) plus generic
ACE inhibitor (lisinopril, benazepril,
etc.) or generic ARB
(Atacand(g)/HCT(g),
Avapro(g), Avalide(g), Cozaar(g), etc.)
Page 11
Tier 3
TRIBENZOR
Generic ARB [such as Cozaar(g)] plus

Norvasc(g) plus hydrochlorothiazide
TRIGLIDE

TRINTELLIX

TROKENDI XR
Keppra(g), Klonopin(g), Topamax(g),
Trileptal(g)
TRULICITY

Victoza*
TUDORZA
PRESSAIR
Serevent Diskus, Spiriva/Respimat,

Stiolto Respimat
TYZEKA
Baraclude(g), Epivir HBV(g),

Hepsera(g)
UCERIS
Azulfidine(g), Delzicol, Entocort EC(g),

Pentasa(g), prednisolone, prednisone
Tier 3
VERAMYST

VERDESO
Capex, Dermacort(g), DermaSmoothe(g), Desowen(g), Synalar

solution(g)
VEREGEN
Condylox solution(g)/gel
VERSACLOZ
Clozaril(g), Fazaclo(g)*
VESICARE
VIBERZI
Bentyl(g), Imodium(g), Lactulose,

Levbid(g), Levsin(g), SSRI [Celexa(g),
Prozac(g), Zoloft(g)], generic TCA
Tofranil(g)]
VIIBRYD, DOSEPAK Generic SSRI/SNRI [Celexa(g),

Cymbalta(g), Effexor(g)/XR(g),
Prozac(g), Zoloft(g), etc.],
Wellbutrin/SR/XL(g)
VIMOVO
Generic PPI [Aciphex(g), Nexium(g)*,

Prilosec(g)/Prilosec OTC**,
Prevacid(g)/Solutab*, Protonix(g)] plus
Naprosyn(g)
UCERIS FOAM
Canasa, Cortenema(g), Cortifoam,

Rowasa(g), Sfrowasa(g)
ULTRAVATE
LOTION
Clobevate(g), Diprolene(g), Elocon(g),

Olux(g)
VITUZ SOLUTION
Hycodan(g), Phenergan w/codeine(g),

Tussionex(g)
UTIBRON
NEOHALER
Serevent, Spiriva/Respimat, Stiolto

Respimat
VIVLODEX
Celebrex(g), Lodine(g), Mobic(g),

Naprosyn(g), Voltaren oral(g)/XR(g)
VALCHLOR
8-Mop (Tier 2 BCN Only), Oxsoralen,

Zolinza*
VOGELXO
VARUBI
Emend, Kytril(g), Zofran(g)

VASCEPA

Lovaza(g)*, OTC Omega-3 or -3FA
products, Tricor(g), Trilipix(g)
VRAYLAR

Zyprexa(g)
VECAMYL
Catapres(g), Cozaar(g), Toprol XL(g),

Zestril(g)
VUSION
OTC diaper rash products
VYTORIN
Generic statin [Crestor(g)*,

Mevacor(g), Pravachol(g), Zocor(g)]
plus Zetia
VYVANSE

Ritalin(g)/LA(g)/SR(g)
WP THYROID
Nature-throid(g), NP Thyroid(g)
VELPHORO

Renvela
VELTIN
Cleocin topical(g) plus Retin-A(g);

Differin(g), or Duac(g)
Page 12
Tier 3
XARTEMIS XR
Norco(g), Opana IR(g)*, oxycodone

IR(g), Percocet(g), Ultram(g)/ER(g)
XELJANZ, XR
XENICAL
Tier 3
ZETONNA


ZIANA
Cleocin topical(g) plus Retin-A(g);

Differin(g), or Duac(g)
XERESE
Zovirax cream plus hydrocortisone

cream
ZIOPTAN

Travatan(g)/Z, Trusopt(g), Xalatan(g)
XIFAXAN 200MG
Bactrim DS(g), Vibramycin(g),

Zithromax(g)
ZIPSOR
XIFAXAN 550MG
Bentyl(g), Imodium(g), Lactulose,

Levbid(g), Levsin(g), generic SSRI
[Celexa(g), Prozac(g), Zoloft(g)],
generic TCA [Adapin(g), Elavil(g),
Sinequan(g), Tofranil(g)]
Generic NSAIDs [Lodine(g)/XL(g),

Mobic(g), Motrin(g), Naprosyn(g),
Voltaren oral(g)/XR(g)]
ZMAX
Zithromax(g)
ZOHYDRO ER
ER(g)*
ZOLPIMIST
XOLEGEL

Miconazole(g), Selsun RX(g),
Spectazole(g), Sporanox(g)
ZOMACTON
Albuterol(g), Proair HFA/Respiclick,

Ventolin HFA, Xopenex nebulizer
solution(g)
ZOMIG NASAL
SPRAY

Zomig(g)*/ZMT(g)*

Provigil(g)*
ZONTIVITY
Brilinta, Effient, Persantine(g) plus

OTC Aspirin; Plavix(g), Ticlid(g)
ZARXIO
Granix, Neupogen
ZORBTIVE
ZAVESCA
Cerezyme (medical benefit)
ZORTRESS
Afinitor*, Disperz*
ZECUITY

Zomig(g)*/ZMT(g)*
ZORVOLEX

Naprosyn(g), Voltaren oral(g)/XR(g)
ZUBSOLV
Suboxone(g), Suboxone Film
ZEGERID PACKET
ZUPLENZ
ZYCLARA
Aldara(g), Condylox solution(g),

Efudex(g)
ZYFLO, CR
Accolate(g), Singulair(g)
ZYLET
Cortisporin(g), Maxitrol(g),
sulfacetamide/prednisolone solution,
Tobradex(g)
ZYMAR

Vigamox, Zymaxid(g)
XOPENEX HFA
XYREM
ZELAPAR
Azilect, Eldepryl(g)
ZEMBRACE
SYMTOUCH

Zomig(g)*/ZMT(g)*
ZENZEDI

Dexedrine(g), Metadate CD(g),
Ritalin(g)/LA(g)
Page 13
Index
Trade Name
Page
Trade Name
Page
8-MOP (Tier 2 BCN Only)
57
Albenza
14
Abilify (aripiprazole)
28
Aldactazide 50/50mg (Tier 2 BCN only)
22
Absorica
56
Aldactazide (spironolact/hydrochlorothiazid)
22
Abstral
32
Aldactone (spironolactone)
22
Acanya
56
Aldara (imiquimod)
59
Accolate (zafirlukast)
68
Aldomet (methyldopa)
19
Accuneb; Albuterol nebulizer solution (albuterol sulfate)
66
Aldoril (methyldopa/hydrochlorothiazide)
19
Accupril (quinapril hcl)
19
Alesse, Levlite
41
Accuretic (quinapril/hydrochlorothiazide)
19
Alferon N
55
Aceon (perindopril erbumine)
19
Alinia
14
Acetasol HC (acetic acid/hydrocortisone)
64
Alkeran
52
Aciphex (rabeprazole sodium)
39
Allzital
30
Aciphex Sprinkle
39
Alocril
61
Aclovate (alclometasone dipropionate)
58
Alogliptin
49
Actemra syringe
45
Alogliptin-metformin
49
Acthar H.P.
26
Alogliptin-pioglitazone
49
Acticlate tablet
18
Alomide
61
Acticlate tablet
56
Alora
46
Actigall (ursodiol)
38
Alora
42
Actimmune
55
Alphagan 0.2%, P 0.15% (brimonidine tartrate)
63
Actiq (fentanyl citrate)
32
Alphagan P 0.1%
63
Activella (estradiol/norethindrone acet)
42
Alrex
63
Actonel 35mg, 150mg (risedronate sodium)
45
Alsuma (sumatriptan succinate)
30
Actonel 5, 30mg (risedronate sodium)
45
Altabax
59
Actoplus MET (pioglitazone hcl/metformin hcl)
49
Altace (ramipril)
19
Actoplus MET XR
49
Altoprev
23
Actos (pioglitazone hcl)
49
Alupent (metaproterenol sulfate)
67
Acular, LS (ketorolac tromethamine)
62
Alvesco (Tier 1-BCN Only)
67
Acuvail
62
Amantadine hcl (amantadine hcl)
16
Aczone 5%
56
Amaryl (glimepiride)
49
Aczone 7.5% (Not Covered for BCBSM)
56
Ambien CR (zolpidem tartrate)
35
Adapalene 0.1% lotion
56
Ambien (zolpidem tartrate)
35
Adcirca
67
Amerge (naratriptan hcl)
30
Adderall XR (Brand BCN-Only) (amphet asp/amphet/damphet)

Adderall XR (amphet asp/amphet/d-amphet)
29
Amicar
20
Amitiza
40
29
Amoxapine (amoxapine)
27
Adderall (amphet asp/amphet/d-amphet)
29
Amoxicillin ER
17
Addyi
72
Amoxil (amoxicillin trihydrate)
17
Adempas
67
Ampicillin (ampicillin trihydrate)
17
Adipex, P (phentermine hcl)
72
Ampyra
55
Adoxa capsule (doxycycline monohydrate)
56
Amrix
35
Adoxa capsule (doxycycline monohydrate)
18
Anadrol-50
47
Adoxa tablet (doxycycline monohydrate)
56
Anafranil (clomipramine hcl)
27
Adoxa tablet (doxycycline monohydrate)
18
Analpram HC lot, cream (BCBSM Only)
39
Adrenaclick (epinephrine)
66
Analpram HC (hydrocortisone/pramoxine hcl)
39
Adrenalin chloride (Tier 2 BCN Only)
66
Anamantle HC (lidocaine hcl/hc)
39
Advair
67
Anaprox, DS (naproxen sodium)
33
Adzenys XR-ODT
29
Ancobon (flucytosine)
14
Aerospan
67
Androderm
47
Afinitor, Disperz
54
Androgel 1% (testosterone)
47
Afrezza
48
Androgel 1.62%
47
Aggrenox (aspirin/dipyridamole)
20
Android; Testred
47
Agrylin (anagrelide hcl)
20
Androxy (fluoxymesterone)
47
Akynzeo
37
Angeliq
42
Ala-Scalp HP (hydrocortisone)
58
Anoro Ellipta
66
Albalon (naphazoline hcl)
63
Trade Name
Page
Trade Name
Page
Ansaid (flurbiprofen)
33
Avalide (irbesartan/hydrochlorothiazide)
20
Antabuse (disulfiram)
36
Avandamet
49
Antara (fenofibrate,micronized)
23
Avandia
49
Antara 30, 90mg
23
Avapro (irbesartan)
20
Antivert (meclizine hcl)
37
AVC
43
Anusol HC (hydrocortisone)
39
Avelox (moxifloxacin hcl)
17
Anzemet
37
Avelox ABC
17
Apexicon, E (diflorasone diacetate)
57
Aventyl; Pamelor (nortriptyline hcl)
27
Apidra, Solostar
48
Avinza (morphine sulfate)
32
Aplenzin
27
Avita gel
56
Apokyn
34
Avodart (dutasteride)
69
Apresoline (hydralazine hcl)
24
Avonex
55
Apriso
37
Axert (almotriptan malate)
30
Aptensio XR
29
Axid (RX Only) (nizatidine)
38
Aptiom
26
Axiron
47
Aptivus
15
Aygestin (norethindrone acetate)
43
Aralen (chloroquine phosphate)
14
Azasan
53
Aranesp
52
Azasan
46
Aranesp
55
Azasite
62
Arava (leflunomide)
46
Azelex
56
Arcalyst
53
Azilect
34
Arcapta Neohaler
66
Azopt
63
Aricept 23mg (donepezil hcl)
25
Azor
21
Aricept, ODT (donepezil hcl)
25
Azor
20
Arimidex (anastrozole)
53
Azulfidine, En-Tab (sulfasalazine)
46
Aristocort; Kenalog 0.5% cream (triamcinolone

acetonide)
Arixtra (fondaparinux sodium)
57
Azulfidine, En-Tab (sulfasalazine)
37
69
20
Armour Thyroid
50
Azuphen MB (BCBSM only) (methen/m-blue/sal/na

phos/hyos)
Bacitracin (bacitracin)
Arnuity Ellipta
67
Baclofen (baclofen)
35
Aromasin (exemestane)
53
Bactrim, DS (sulfamethoxazole/trimethoprim)
18
Artane (trihexyphenidyl hcl)
34
Bactroban (mupirocin calcium)
59
Arthrotec (diclofenac sodium/misoprostol)
33
Bactroban Nasal
59
Asacol HD
37
Banzel
26
Asmanex, HFA (Tier 1-BCN Only)
67
Baraclude solution
16
Aspirin, Ecotrin 81, 325mg
34
Baraclude tablet (entecavir)
16
Astagraf XL
53
Beconase AQ
67
Astelin (azelastine hcl)
64
Beconase AQ
64
Astelin (azelastine hcl)
65
Belbuca
31
Astepro (azelastine hcl)
64
Belladonna & Opium (opium/belladonna alkaloids)
32
Astepro (azelastine hcl)
65
Belsomra
35
Astringyn
20
Belviq
72
Atacand (candesartan cilexetil)
20
Benadryl (Rx only) (diphenhydramine hcl)
65
Atacand HCT (candesartan/hydrochlorothiazide)
20
Benicar, HCT
20
Atarax; Vistaril (hydroxyzine)
65
Bentyl (dicyclomine hcl)
37
Atelvia (risedronate sodium)
45
Benzaclin (clindamycin phos/benzoyl perox)
56
Ativan (lorazepam)
28
Benzamycin (erythromycin base/benz per)
56
Atralin (tretinoin)
56
Benzoyl Peroxide (RX) (BCBSM only) (benzoyl peroxide)
56
Atripla
15
Bepreve
61
Atrovent HFA
66
Besivance
62
Atrovent nasal spray (ipratropium bromide)
64
Betagan (levobunolol hcl)
62
Atrovent solution (ipratropium bromide)
66
Betapace, AF (sotalol hcl)
21
Aubagio
55
Betapace, AF (sotalol hcl)
22
Augmentin 125mg-31.25mg/5ml susp
17
Betaseron
55
Augmentin, ES, XR (amox tr/potassium clavulanate)
17
Bethkis
66
Auralgan (aa/antpy/bcaine/polico/al acet)
64
Bethkis
18
Auryxia
71
Betimol (Tier 3 BCN only)
62
62
Trade Name
Page
Trade Name
Page
Betoptic S
62
Carac
59
Betoptic solution (betaxolol hcl)
62
Carafate (sucralfate)
38
Beyaz
41
Carbaglu
50
Biaxin, XL (clarithromycin)
17
Carbatrol (carbamazepine)
26
BiDil
23
Cardene SR
21
Biltricide
14
Cardene (nicardipine hcl)
21
Binosto
45
Cardizem LA 120mg
21
Bleph-10 drops (Tier 2 BCN only)
62
Cardizem, SR, CD, LA (diltiazem hcl)
21
Bleph-10, Sodium Sulamyde (sulfacetamide sodium)
62
Cardura XL
69
Blephamide
61
Cardura (doxazosin mesylate)
19
Blocadren (timolol maleate)
21
Cardura (doxazosin mesylate)
69
Boniva (ibandronate sodium)
45
Carnitor SF solution (BCN tier 2 only)
71
Bontril PDM (phendimetrazine tartrate)
72
Carnitor (levocarnitine)
71
Bosulif
54
Casodex (bicalutamide)
53
Bravelle
43
Cataflam (diclofenac potassium)
33
Breo Ellipta
67
Catapres TTS (clonidine hcl)
19
Brevoxyl gel (BCBSM only) (benzoyl peroxide)
56
Catapres (clonidine hcl)
19
Brilinta
20
Caverject
72
Brisdelle
44
Cayston
66
Briviact
26
Cayston
18
Bromday; Xibrom (bromfenac sodium)
62
Ceclor, ER (cefaclor)
17
Bromfed-DM (d-methorphan hb/p-epd hcl/bpm)
65
Cedax (ceftibuten dihydrate)
17
Brovana
66
Ceftin suspension
17
Bumex (bumetanide)
22
Ceftin tablet (cefuroxime axetil)
17
Bunavail
31
Cefzil (cefprozil)
17
Buphenyl powder (sodium phenylbutyrate)
50
Celebrex (celecoxib)
33
Buphenyl tablet
50
Celexa (citalopram hydrobromide)
27
Buspar (buspirone hcl)
28
Cellcept (mycophenolate mofetil)
53
Butisol sodium
35
Celontin
26
Butrans
31
Centany ointment (Tier 2 BCN Only)
59
Bydureon, Pen
49
Cerdelga
51
Byetta
49
Cesamet
37
Bystolic
21
Cetraxal (ciprofloxacin hcl)
64
Bystolic 20mg
21
Cetrotide
43
Caduet (amlodipine/atorvastatin cal)
23
Chantix
72
Caduet (amlodipine/atorvastatin cal)
21
Chemet
71
Cafcit (caffeine citrated)
36
Chenodal
38
Cafergot
30
Chloral Hydrate (BCBSM Only) (chloral hydrate)
35
Calan SR; Isoptin SR (verapamil hcl)
21
Cholbam
51
Calciferol (ergocalciferol)
70
Cialis
72
Calciferol (ergocalciferol)
50
Cialis 2.5, 5mg
69
Calcium + Vitamin D 600mg
70
Ciloxan drops (ciprofloxacin hcl)
62
Calcium + Vitamin D capsule
70
Ciloxan ointment
62
Calcium + Vitamin D chewable
70
Cimzia Syringe
46
Calcium + Vitamin D tablet
70
Cimzia Syringe
39
Calcium + Vitamin D tablet
70
Cipro HC
64
Calcium Citrate w/Vitamin D
70
Cipro XR (ciprofloxacin hcl-betaine comb)
17
Calcium Citrate w/Vitamin D
70
Cipro (ciprofloxacin hcl)
17
Calvite P&D
70
Ciprodex
64
Cambia
33
Clarinex syrup
65
Cambia
30
Clarinex tablet, Redi-tabs (desloratadine)
65
Campral (acamprosate calcium)
36
Clarinex-D
65
Canasa
37
Claritin Redi-tab
65
Capex Shampoo
58
Claritin, Alavert (OTC) (loratadine)
65
Capoten (captopril)
19
Claritin-D (OTC) (p-ephed sul/loratadine)
65
Capozide (captopril/hydrochlorothiazide)
19
Cleocin 75mg
18
Caprelsa
54
Cleocin T (clindamycin phosphate)
56
Trade Name
Page
Trade Name
Page
Cleocin vaginal cream (clindamycin phosphate)
43
Cortifoam
39
Cleocin vaginal ovules
43
Cortisone Acetate (cortisone acetate)
47
Cleocin (clindamycin hcl)
18
Cortisporin (neomy sulf/polymyx b sulf/hc)
61
Climara Pro
42
Cortisporin (neomy sulf/polymyx b sulf/hc)
64
Climara (estradiol)
46
Cortisporin-TC
64
Climara (estradiol)
42
Corzide (nadolol/bendroflumethiazide)
21
Clindesse
43
Cosentyx
57
Clinoril (sulindac)
33
Cosopt PF
63
Clobevate; Temovate (clobetasol propionate)
57
Cosopt (timolol maleate/dorzolam hcl)
63
Clobex (clobetasol propionate)
57
Cotellic
54
Clocortolone Pivalate
58
Coumadin (warfarin sodium)
20
Cloderm
58
Covaryx, H.S. (estrogen,ester/me-testosterone)
44
Clomid (clomiphene citrate)
43
Covaryx, H.S. (estrogen,ester/me-testosterone)
46
Clorpres (clonidine hcl/chlorthalidone)
19
Cozaar (losartan potassium)
20
Clorpres 0.3-15mg (Tier 2 - BCN Only)
19
Creon
38
Clozapine 200mg (clozapine)
28
Cresemba capsule
14
Clozaril (clozapine)
28
Crestor (rosuvastatin calcium)
23
Coartem
14
Crinone 4%
43
Codeine sulfate tablet (codeine sulfate)
32
Crinone 8%
43
Cogentin (benztropine mesylate)
34
Crixivan
15
Colazal (balsalazide disodium)
37
Cuprimine
69
Colbenemid (colchicine/probenecid)
45
Cuprimine
46
Colchicine capsule
45
Cuprimine
71
Colchicine tablet
45
Cutivate (fluticasone propionate)
58
Colcrys
45
Cuvposa
36
Colestid granules, packet
23
Cyanocobalamin inj (cyanocobalamin)
70
Colestid (colestipol hcl)
23
Cyclessa
42
Coly-Mycin S
64
Cyclocort (amcinonide)
57
Colyte (sod sulf/sod/nahco3/kcl/peg's)
38
Cyclogyl 0.5%
61
Combigan
63
Cyclogyl 0.5%, 1% 5ml (Tier 2 BCN only)
61
Combipatch
42
Cyclogyl 1%, 2% (cyclopentolate hcl)
61
Combivent Respimat
66
Cyclophosphamide
52
Combivir (lamivudine/zidovudine)
15
Cycloserine
16
Cometriq
54
Cycloset
49
Commit Lozenge OTC
72
Cymbalta 60 mg (duloxetine hcl)
27
Compazine suppositories (prochlorperazine)
37
Cymbalta (duloxetine hcl)
27
Compazine (prochlorperazine maleate)
37
Cystadane (BCN Tier 2/4 only)
71
Complera
15
Cystagon
69
Comtan (entacapone)
34
Cystaran
63
Conceptrol
41
Cytomel (liothyronine sodium)
50
Concerta (methylphenidate hcl)
29
Cytotec (misoprostol)
38
Condylox gel
60
Cytra-2 (BCBSM only) (citric acid/sodium citrate)
69
Condylox solution (podofilox)
60
Cytra-3 (BCBSM only) (citric acid/potassium citrate)
69
Contrave ER
72
Cytra-K (BCBSM only) (potassium citrate/citric acid)
69
Conzip
31
D.H.E.45 (dihydroergotamine mesylate)
30
Copaxone 40mg/mL
55
Daklinza
16
Copegus (ribavirin)
16
Daliresp
68
Cordarone (amiodarone hcl)
22
Dalmane (flurazepam hcl)
35
Cordran cream (flurandrenolide)
58
Danocrine (danazol)
47
Cordran lotion, tape, SP
58
Dantrium (dantrolene sodium)
35
Cordran ointment (Tier 2 BCN Only)
58
Dapsone (dapsone)
16
Coreg CR
21
Daraprim
14
Coreg immediate release (carvedilol)
21
Daypro (oxaprozin)
33
Corgard (nadolol)
21
Daytrana
29
Corlanor
22
DDAVP (desmopressin acetate)
51
Cortef; Hydrocortisone (hydrocortisone)
47
DDAVP solution (Tier 2 BCN only)
51
Cortenema (hydrocortisone acetate)
39
Decadron opthalmic (dexamethasone sod phosphate)
63
Trade Name
Page
Trade Name
Page
Decadron (dexamethasone)
47
Dilaudid (hydromorphone hcl)
32
Declomycin (demeclocycline hcl)
18
Diovan (valsartan)
20
Delatestryl (testosterone enanthate)
47
Diovan HCT (valsartan/hydrochlorothiazide)
20
Delestrogen (estradiol valerate)
42
Dipentum
37
Delzicol
37
Diprolene AF, gel, cream, lotion (betamet diprop/prop gly)
57
Demadex (torsemide)
22
Diprolene ointment (betamet diprop/prop gly)
57
Demerol (meperidine hcl)
32
Diprosone; Maxivate (betamethasone dipropionate)
57
Demser (Tier 2 BCN Only)
24
Disalcid (salsalate)
34
Demulen
41
Ditropan, XL (oxybutynin chloride)
69
Denavir
60
Diuril capsule, tablet (chlorothiazide)
22
Depakene (valproate sodium)
26
Diuril suspension (Tier 2 BCN only)
22
Depakote, ER, Sprinkles (divalproex sodium)
26
Divigel
42
Depen
69
Dolobid (diflunisal)
34
Depen
46
Domeboro Otic (acetic acid/aluminum acetate)
64
Depen
71
Donnatal, Extentabs (BCBSM only)
37
Depo-Provera 150mg
41
Doral (quazepam)
35
Depo-Provera 400mg
53
Doryx (doxycycline hyclate)
56
41
Doryx (doxycycline hyclate)
18
43
Dostinex (cabergoline)
51
Depo-Testosterone (testosterone cypionate)
47
Dovonex (calcipotriene)
57
Dermacort; Hytone (RX Only) (hydrocortisone)
58
Doxycycline 20mg tablet (doxycycline hyclate)
56
Derma-Smoothe/FS (fluocinolone acetonide)
58
Doxycycline IR-DR
18
Dermatop (prednicarbate)
58
Doxycycline IR-DR
56
Descovy
15
Drithocreme HP(BCBSM only) (anthralin)
57
Desferal (deferoxamine mesylate)
71
Droxia
54
Desogen; Ortho-cept
41
Drysol (aluminum chloride)
60
Desonate
58
Duac (clindamycin phosphate/benz per)
56
Desowen (desonide)
58
Duavee
46
Desoxyn (methamphetamine hcl)
29
Duavee
44
Desvenlafaxine ER
27
Duetact (pioglitazone/glimepiride)
49
Desvenlafaxine Fumarate ER
27
Duexis
33
Desyrel (trazodone hcl)
27
Dulera
67
Detrol, LA (tolterodine tartrate)
69
Duoneb (ipratropium/albuterol sulfate)
66
Dexedrine (d-amphetamine sulfate)
29
Duopa
34
Dexilant
39
Duragesic (fentanyl)
32
Diabeta; Micronase (glyburide)
49
Durezol
63
Diabinese (chlorpropamide)
49
Duricef (cefadroxil hydrate)
17
Diamox, Sequels (acetazolamide)
26
Durlaza
34
Diamox, Sequels (acetazolamide)
22
Dutoprol
21
Diastat 2.5mg Kit
26
Dutoprol
22
Diastat Acudial (diazepam)
26
Dyanavel XR
29
Dibenzyline (phenoxybenzamine hcl)
19
Dyazide, Maxzide (triamterene/hydrochlorothiazide)
22
Diclegis
44
Dymista
67
Diclegis
37
Dymista
64
Dicloxacillin (dicloxacillin sodium)
17
Dynacirc (isradipine)
21
Didrex (benzphetamine hcl)
72
Dyrenium
22
Didronel (etidronate disodium)
45
E. E. S. tablet (erythromycin ethylsuccinate)
17
Diethylpropion hcl, ER (diethylpropion hcl)
72
E.E.S.; Eryped 200mg/5ml
17
Differin (adapalene)
56
EC-Naprosyn (naproxen)
33
Differin 0.1% lotion
56
Ecoza
59
Dificid
17
Edarbi
20
Diflucan (fluconazole)
43
Edarbyclor
20
Diflucan (fluconazole)
14
Edecrin
22
Dilantin 30mg
26
Edex
72
Dilantin Chew Tabs (phenytoin)
26
Edluar
35
Dilantin (phenytoin sodium extended)
26
Edurant
15
Dilatrate-SR
23
Effexor XR (venlafaxine hcl)
27
Trade Name
Page
Trade Name
Page
Effexor (venlafaxine hcl)
27
Erythromycin base (erythromycin base)
17
Effient
20
Erythromycin Stearate (erythromycin stearate)
17
Efudex (fluorouracil)
59
56
Egrifta
51
Elavil (amitriptyline hcl)
27
Erythromycin topical gel, solution (erythromycin

base/ethanol)
Esbriet
Esgic (butalb/acetaminophen/caffeine)
30
Esgic (butalb/acetaminophen/caffeine)
31
Eskalith, CR (lithium carbonate)
36
Estrace tablet (estradiol)
46
Estrace tablet (estradiol)
42
Estrace Vaginal cream
42
Estring
42
Estrogel
42
Estrostep Fe
42
Ethambutol (ethambutol hcl)
16
Etrafon (amitriptyline hcl/perphenazine)
28
Etrafon (amitriptyline hcl/perphenazine)
27
Eulexin (flutamide)
53
Eurax
58
Evamist
42
Evekeo
29
Evista (raloxifene hcl)
45
Evista
53
Evista (raloxifene hcl)
53
Evoclin foam (clindamycin phosphate)
56
Evotaz
15
Evoxac (cevimeline hcl)
40
Evzio
30
Exalgo (hydromorphone hcl)
32
Exelderm
59
Exelon capsule (rivastigmine tartrate)
25
Exelon patch (rivastigmine)
25
Exforge (amlodipine/valsartan)
21
Exforge (amlodipine/valsartan)
20
Exforge HCT (amlodipine/valsartan/hctz)
20
Exforge HCT (amlodipine/valsartan/hctz)
21
Exjade
71
Extavia
55
Extina (ketoconazole)
59
Fabior
56
Factive
17
Famvir (famciclovir)
16
Fanapt
28
Fareston
53
Farxiga
49
Farydak
54
Faslodex
53
Fazaclo (clozapine)
28
Fazaclo 150, 200mg
28
FC2 Female Condom
41
Felbatol (felbamate)
26
Feldene (piroxicam)
33
Femara (letrozole)
53
Femcon Fe
41
FemHRT (norethindrone ac-eth estradiol)
46
FemHRT (norethindrone ac-eth estradiol)
42
Femring
42
Eldepryl (selegiline hcl)

Elestat (epinastine hcl)
Elestrin
Elidel
Eligard
Elimite (permethrin)
Eliquis
Ella
Elmiron
Elocon cream, solution (mometasone furoate)
Elocon ointment (mometasone furoate)
Emadine
Embeda
Emcyt
Emend 40mg (BCBSM only)
Emend 80, 125mg; dosepak capsule
Emla (lidocaine/prilocaine)
Emsam
Emtriva
Emverm
Enablex (darifenacin hydrobromide)
Enbrel
Enbrel
Endometrin
Enjuvia
Enjuvia
Enstilar
Entocort EC (budesonide)
Entresto
Envarsus XR
Epaned
Epiduo
Epiduo Forte
Epifoam (Tier 2 BCN only)
Epinephrine auto-injector (epinephrine)
Epipen, Jr
Epivir (lamivudine)
Epivir HBV solution
Epivir HBV tablet (lamivudine)
Epogen
Epogen
Epzicom
Equanil; Miltown (meprobamate)
Equetro
Ergoloid Mesylates (ergoloid mesylates)
Ergomar
Erivedge
Ertaczo
Eryped
Eryped (erythromycin ethylsuccinate)
Ery-Tab 500mg (Tier 2 BCN Only)
Ery-Tab (erythromycin)
34
61
42
59
53
58
20
42
69
58
57
61
32
52
37
37
58
27
15
14
69
46
57
43
46
42
57
47
20
53
19
56
56
39
66
66
15
16
16
52
55
15
28
28
36
30
54
59
17
17
17
17
68
Trade Name
Page
Trade Name
Page
Femtrace
42
Fosamax 35mg, 70mg (alendronate sodium)
45
Fenofibrate capsule
23
Fosamax Plus D
45
Fenoglide
23
Fosamax (alendronate sodium)
45
Fenoprofen Calcium 400mg (Tier 2 BCN only)
33
Fosrenol
71
Fentanyl patch 37.5, 62.5, 87.5mg
32
Fragmin
20
Fentora
32
Frenadol (BCBSM only)
34
Fer-in-sol 15mg drops
70
Frova (frovatriptan succinate)
30
Ferriprox
71
Fulyzaq
37
Fetzima
27
Furadantin (nitrofurantoin)
18
Fexmid (cyclobenzaprine hcl)
35
Furosemide solution (Tier 2 BCN only)
22
Fibricor (fenofibric acid)
23
Fuzeon
15
Finacea
60
Fycompa
26
Finacea foam
60
Gabitril (tiagabine hcl)
26

(butalbit/acetamin/caff/codeine)
Fiorinal w/codeine (codeine/butalbital/asa/caffein)
31
Gabitril 12, 16mg
26
Galzin
70
Gammagard Liquid (BCBSM Only)
55
Gammaked Liquid (BCBSM Only)
55
Gamunex-C sub-q (BCBSM Only)
55
Ganirelix Acetate
43
Garamycin (gentamicin sulfate)
62
Fiorinal w/codeine (codeine/butalbital/asa/caffein)
Gastrocrom (cromolyn sodium)
30
40
Fiorinal (butalbital/aspirin/caffeine)
Gattex
30
40
Fiorinal (butalbital/aspirin/caffeine)
Gelnique
31
69
Firazyr
Gelnique pump
55
69
Flagyl ER
Generess Fe
14
41
Flagyl (metronidazole)
Gengraf; Neoral (cyclosporine, modified)
14
46
Flector patch
Gengraf; Neoral (cyclosporine, modified)
33
53
Flexeril (cyclobenzaprine hcl)
Genotropin
35
48
Flomax (tamsulosin hcl)
Gentamicin cream, ointment (gentamicin sulfate)
69
59
Flonase (Rx only) (fluticasone propionate)
Genvoya
64
15
Flonase (Rx only) (fluticasone propionate)
Geodon (ziprasidone hcl)
67
28
Florinef (fludrocortisone acetate)
Giazo
47
37
Florone; Psorcon (diflorasone diacetate)
Gilenya
57
55
Flovent HFA, Diskus (Tier 1-BCN Only)
Gilotrif
67
54
Flowtuss
Glatopa (glatiramer acetate)
65
55
Floxin Otic Singles
Gleevec (imatinib mesylate)
64
54
Floxin Otic (ofloxacin)
Gleostine; Lomustine
64
52
Floxin tablet (ofloxacin)
GlucaGen
17
51
Flumadine (rimantadine hcl)
Glucagon Emergency Kit
16
51
Fluoride 0.25, 0.5mg drops
Glucophage, XR; Fortamet (metformin hcl)
70
49
Fluoroplex (Tier 2 BCN only)
Glucotrol, XL (glipizide)
59
49
Fluorouracil 0.5% Cream
Glucovance (glyburide/metformin hcl)
59
49
Fluoxetine 60mg
Glumetza (metformin hcl)
27
49
FML Forte, S.O.P.
Glycolax (polyethylene glycol 3350)
63
40
FML (fluorometholone)
Glynase (glyburide,micronized)
63
49
Focalin immediate release (dexmethylphenidate hcl)
Glyset (miglitol)
29
49
Focalin XR (dexmethylphenidate hcl)
Glyxambi
29
49
Focalin XR 25, 35mg
Golytely packet
29
38
Folic Acid 0.4, 0.8mg [OTC]
Golytely (peg 3350/na sulf,bicarb,cl/kcl)
70
38
Folic Acid 1mg (folic acid)
Gonal-F, RFF, Redi-Ject
70
43
Follistim AQ
Gralise
43
36
Folvite (folic acid)
Granix
70
55
Foradil
Granix
66
52
Forfivo XL
Granulex (BCBSM only) (trypsin/balsam peru/castor oil)
27
60
Forteo
Grastek
46
68
Fortesta
Grifulvin V (griseofulvin,microsize)
47
14
Gris-PEG (griseofulvin ultramicrosize)
14
30
31
30
31
Trade Name
Page
Trade Name
Page
Gynazole-1
43
Inderal, LA (propranolol hcl)
21
Gynol II
41
Inderide (propranolol/hydrochlorothiazide)
21
Halcion (triazolam)
35
Indocin suppository
33
Haldol liquid 2mg/ml (haloperidol lactate)
28
Indocin suspension (Tier 2 BCN only)
33
Haldol (haloperidol)
28
Indocin, SR (indomethacin)
33
Halflytely (bisac/nacl/nahco3/kcl/peg 3350)
38
Inflamase, Forte (prednisolone sod phosphate)
63
Halog
57
Inlyta
54
Harvoni
16
Innopran XL
21
HC Acetate/Pramoxine hcl (hc acetate/pramoxine hcl)
39
Inspra (eplerenone)
22
Hectorol (doxercalciferol)
50
Intal solution (cromolyn sodium)
68
Hemangeol
21
Intelence
15
Heparin (heparin sodium,porcine)
20
Intermezzo (zolpidem tartrate)
35
Hepsera (adefovir dipivoxil)
16
Intron A
55
Hetlioz
35
Intuniv (guanfacine hcl)
36
Hexalen
54
Invega (paliperidone)
28
Hiprex/Urex (methenamine hippurate)
18
Invirase
15
Hizentra (BCBSM Only)
55
Invokamet
49
Horizant
36
Invokana
49
Humalog U-200
48
Iopidine droperette
63
Humalog, Mix
48
Iopidine drops (apraclonidine hcl)
63
Humatin (paromomycin sulfate)
14
Iprivask
20
Humatrope
48
Iressa
54
Humira
57
Isentress
15
Humira
39
Isoniazid (isoniazid)
16
Humira, Pediatric
46
Isopto Atropine (atropine sulfate)
61
Humulin R U-500 (all forms)
48
Isopto Homatropine 5% (homatropine hbr)
61
Humulin, KwikPen (all forms)
48
Isordil 40mg (Tier 2 BCN Only)
23
Hycamtin
54
Isordil (isosorbide dinitrate)
23
Hycet (hydrocodone bit/acetaminophen)
31
Istalol (Tier 2 for BCN only)
62
Hycodan (hydrocodone bit/homatrop me-br)
65
Jadenu
71
Hycofenix
65
Jakafi
54
Hydrea (hydroxyurea)
54
Jalyn (dutasteride/tamsulosin hcl)
69
Hydrodiuril; Microzide (hydrochlorothiazide)
22
Janumet
49
Hygroton; Thalitone (chlorthalidone)
22
Janumet XR
49
Hyper-Sal (Tier 2 BCN only)
68
Januvia
49
HyQvia (BCBSM Only)
55
Jardiance
49
Hysingla ER
32
Jentadueto
49
Hytrin (terazosin hcl)
19
Jublia
59
Hytrin (terazosin hcl)
69
Juxtapid
23
Hyzaar (losartan/hydrochlorothiazide)
20
Kadian 40, 200mg
32
Ibrance
54
Kadian (morphine sulfate)
32
Ibudone (hydrocodone/ibuprofen)
31
Kaletra
15
Ibudone 5mg/200mg (Tier 2 BCN Only)
31
Kalydeco
66
Iclusig
54
Kapvay (clonidine hcl)
36
Ilevro
62
Karbinal ER
65
Ilotycin (erythromycin base)
62
Kay Ciel, Kaon-Cl, Kaon Liquid (potassium chloride)
70
Imbruvica
54
Kayexalate (sodium polystyrene sulfonate)
71
Imdur (isosorbide mononitrate)
23
Kazano
49
Imitrex (All Forms) (sumatriptan succinate)
30
Keflex (cephalexin monohydrate)
17
Imodium (loperamide hcl)
37
Kenalog 0.025% (triamcinolone acetonide)
58
Impavido
14
Kenalog 0.1% (triamcinolone acetonide)
58
Imuran (azathioprine)
46
Keppra XR (levetiracetam)
26
Imuran (azathioprine)
53
Keppra (levetiracetam)
26
Increlex
48
Kerlone (betaxolol hcl)
21
Incruse Ellipta
66
Kerydin
59
Inderal solution (propranolol hcl)
21
Ketek
17
Inderal XL
21
Ketoprofen (ketoprofen)
33
Trade Name
Page
Trade Name
Page
Keveyis
71
Librax (clidinium br/chlordiazepoxide)
37
Khedezla
27
Librium (chlordiazepoxide hcl)
28
Kineret
45
Lidex, E (fluocinonide)
57
Kineret
53
Lidoderm patch (lidocaine)
58
Klonopin, Wafer (clonazepam)
26
Limbitrol, DS (amitrip hcl/chlordiazepoxide)
27
K-Lor, Klor-Con (potassium chloride)
70
Lindane (lindane)
58
Klor-con packet (BCN Tier 2 only)
70
Linzess
40
K-Lyte, Klor-Con/EF (potassium bicarbonate/cit ac)
70
Lipitor (atorvastatin calcium)
23
Kombiglyze XR
49
Lipofen
23
Korlym
51
Liptruzet
23
Kristalose (Tier 2 BCN only)
40
Lithium Citrate (lithium citrate)
36
K-Sol, potassium chloride (potassium chloride)
70
Lithobid (lithium carbonate)
36
K-Tab, K-Dur, Slow-K, Kaon CL (potassium chloride)
70
Livalo
23
Kuvan
71
Lo Loestrin Fe
41
Kynamro
23
Lo/Ovral
41
Kytril (granisetron hcl)
37
Locoid cream, oint, soln (hydrocortisone butyrate)
58
Lacrisert
63
Locoid Lipocream (hydrocortisone butyrate/emoll)
58
Lactulose (lactulose)
40
Locoid Lotion
58
Lamictal dosepak
26
Lodine, XL (etodolac)
33
Lamictal dosepak ODT (lamotrigine)
26
Lodosyn (carbidopa)
34
Lamictal ODT, XR (lamotrigine)
26
Loestrin 24 Fe
41
Lamictal tabs, dispertabs (lamotrigine)
26
Loestrin, Fe
41
Lamictal XR dosepak
26
Lofibra (fenofibrate,micronized)
23
Lamisil granules
14
Lomotil (diphenoxylate hcl/atrop sulf)
37
Lamisil tablet (terbinafine hcl)
14
Loniten (minoxidil)
24
Lanoxin 62.5, 187.5mcg
22
Lonsurf
52
Lanoxin (digoxin)
22
Lopid (gemfibrozil)
23
Lantus, Solostar (Tier 2 BCBSM only) (insulin

glargine,hum.rec.anlog)
Lariam (mefloquine hcl)
48
Lopressor HCT (metoprolol/hydrochlorothiazide)
21
Lopressor (metoprolol tartrate)
21
Loprox (ciclopirox olamine)
59
Lasix (furosemide)
22
Lortab solution
31
Lastacaft
61
31
Latuda
28
Lazanda
32
Lortab; Norco; Vicodin; Xodol (hydrocodone

bit/acetaminophen)
Lorzone
Lenvima
54
Loseasonique
41
Lescol (fluvastatin sodium)
23
Lotemax
63
Lescol XL (fluvastatin sodium)
23
Lotensin HCT (benazepril/hydrochlorothiazide)
19
Letairis
67
Lotensin (benazepril hcl)
19
Leucovorin tablet (leucovorin calcium)
52
Lotrel (amlodipine besylate/benazepril)
21
Leukeran
52
Lotrel (amlodipine besylate/benazepril)
19
Leukine
55
Lotrimin (clotrimazole)
59
Leukine
52
Lotrisone (clotrimazole/betamet diprop)
59
Levaquin (levofloxacin)
17
Lotronex (alosetron hcl)
40
Levatol
21
Lovaza (omega-3 acid ethyl esters)
23
Levbid (hyoscyamine sulfate)
37
Lovenox (enoxaparin sodium)
20
Levbid (hyoscyamine sulfate)
69
Loxitane (loxapine succinate)
28
Levemir, Flextouch (Tier 2 BCBSM only) (insulin detemir)
48
Lozol (indapamide)
22
Levitra
72
Lumigan (bimatoprost)
63
Levlen; Nordette
41
Lumigan 0.01%
63
levorphanol tartrate (levorphanol tartrate)
31
Lunesta (eszopiclone)
35
Levsin, SL (hyoscyamine sulfate)
37
Lupaneta pack
53
Levsin, SL (hyoscyamine sulfate)
69
Lupaneta pack
44
Levsinex (hyoscyamine sulfate)
37
Lupron Depot
44
Levsinex (hyoscyamine sulfate)
69
Lupron Depot
53
Lexapro (escitalopram oxalate)
27
Lupron Depot 45mg (BCBSM Only)
44
Lexiva
15
Lupron Depot-Ped
51
Lialda
37
Lupron (leuprolide acetate)
53
14
35
Trade Name
Page
Trade Name
Page
Lupron (leuprolide acetate)
43
Miacalcin Injection
51
Luvox CR (fluvoxamine maleate)
27
Miacalcin Nasal Spray (calcitonin,salmon,synthetic)
51
Luvox (fluvoxamine maleate)
27
45
Luxiq (betamethasone valerate)
58
Luzu
59
Miacalcin Nasal Spray; Fortical

(calcitonin,salmon,synthetic)
Micardis (telmisartan)
Micardis HCT (telmisartan/hydrochlorothiazide)
20
Micro-K (potassium chloride)
70
Midamor (amiloride hcl)
22
Midrin (BCBSM only) (isometheptene/apap/dichlphen)
30
Migranal (dihydroergotamine mesylate)
30
Minipress (prazosin hcl)
19
Minitran
23
Minivelle
46
Minivelle
42
Minocin (minocycline hcl)
56
Minocin (minocycline hcl)
18
Mirapex ER (pramipexole di-hcl)
34
Mirapex ER 3.75
34
Mirapex (pramipexole di-hcl)
34
Mircera
52
Mircera
55
Mircette
41
Mitigare
45
Mobic (meloxicam)
33
Modicon
41
Moduretic (amiloride/hydrochlorothiazide)
22
Molindone (molindone hcl)
28
Monistat 3 (miconazole nitrate)
43
Monistat-Derm (miconazole nitrate)
59
Monodox (doxycycline monohydrate)
56
Monodox (doxycycline monohydrate)
18
Monopril HCT (fosinopril/hydrochlorothiazide)
19
Monopril (fosinopril sodium)
19
Monurol
18
Motofen
37
Motrin (Rx only) (ibuprofen)
33
Movantik
30
Movantik
40
Moviprep
38
Moxatag
17
Moxeza
62
MS Contin (morphine sulfate)
32
MSIR (morphine sulfate)
32
Mucomyst (acetylcysteine)
68
Multaq
22
Muse
72
Myalept
51
Mycelex Troche (clotrimazole)
14
Mycobutin (rifabutin)
16
Mycostatin (nystatin)
59
Mydriacyl (tropicamide)
61
Myfortic (mycophenolate sodium)
53
Myleran
52
Myorisan; Zenatane (isotretinoin)
56
Myrbetriq
69
Mysoline (primidone)
26
Naftifine hcl 1%
59
Lybrel
Lynparza
Lyrica
Lysodren
Lysteda (tranexamic acid)
Macrobid (nitrofurantoin)
Macrodantin (nitrofurantoin macrocrystal)
Malarone (atovaquone/proguanil hcl)
Maprotiline hcl (maprotiline hcl)
Marinol (dronabinol)
Marplan
Matulane
Mavik (trandolapril)
Maxalt, MLT (rizatriptan benzoate)
Maxidex
Maxitrol (neo/polymyx b sulf/dexameth)
Mebaral (mephobarbital)
Meclomen (meclofenamate sodium)
Medrol 2mg (Tier 2 BCN only)
Medrol, Dosepak (methylprednisolone)
Megace, ES (megestrol acetate)
Mekinist
Mellaril (thioridazine hcl)
Memantine Hcl dosepack
Menest
Menest
Menopur
Menostar
Mentax
Mephyton
Mephyton
Mepron (atovaquone)
Mepron blister pak
Mesnex tablet
Mestinon Syrup
Mestinon Timespan (pyridostigmine bromide)
Metadate CD (methylphenidate hcl)
Metaglip (glipizide/metformin hcl)
Metaproterenol soln (metaproterenol sulfate)
Methadone (methadone hcl)
Methergine tablet (methylergonovine maleate)
Methitest
Methotrexate tablet (methotrexate sodium)
Methotrexate (methotrexate sodium)
Methylin, ER (methylphenidate hcl)
Metozolv ODT (metoclopramide hcl)
Metrocream, gel, lotion (metronidazole)
Metrogel Topical 1%, pump (metronidazole)
Metrogel-Vaginal (metronidazole)
Mevacor (lovastatin)
Mexitil (mexiletine hcl)
Miacalcin injection
41
54
26
54
44
18
18
14
27
37
27
52
19
30
63
61
26
33
47
47
53
54
28
25
42
46
43
42
59
70
20
14
14
52
30
30
29
49
66
32
44
47
52
46
29
40
60
60
43
23
22
45
20
Trade Name
Page
Trade Name
Page
Naftin gel
59
Ninlaro
54
Naftin (naftifine hcl)
59
Niravam (alprazolam)
28
Nalfon (fenoprofen calcium)
33
Nitro-Bid ointment (nitroglycerin)
23
Nalfon 400mg (Tier 2 BCN only)
33
Nitro-Dur (Tier 2 BCN Only)
23
Namenda (memantine hcl)
25
Nitro-Dur patch 0.3mg, 0.8mg
23
Namenda dosepak
25
Nitroglycerin caps, patch, spray, tablet (nitroglycerin)
23
Namenda XR
25
Nitromist (nitroglycerin)
23
Namzaric
25
Nitrostat
23
Naprelan (naproxen sodium)
33
Nizoral cream, shampoo 2% (ketoconazole)
59
Naprelan 750mg
33
Nizoral (ketoconazole)
14
Naprosyn (Rx only) (naproxen)
33
Norditropin Flexpro
48
Narcan nasal spray
30
Norflex (orphenadrine citrate)
35
Nardil (phenelzine sulfate)
27
Norgesic, Forte (orphenadrine/aspirin/caffeine)
35
Nasacort AQ (Rx only) (triamcinolone acetonide)
64
Norinyl/Ortho-Novum 1/35
41
Nasacort AQ (Rx only) (triamcinolone acetonide)
67
Norinyl/Ortho-Novum 1/50
41
Nasalide (flunisolide 0.025% spray)
64
Noritate
56
Nasalide (flunisolide 0.025% spray)
67
Normodyne; Trandate (labetalol hcl)
21
Nascobal Spray
70
Norpace CR
22
Nasonex (mometasone furoate)
67
Norpace (disopyramide phosphate)
22
Nasonex (mometasone furoate)
64
Norpramin (desipramine hcl)
27
Natacyn
62
Nor-QD; Ortho Micronor
41
Natazia
41
Northera
22
Natesto
47
Norvasc (amlodipine besylate)
21
Natpara
51
Norvir
15
Natroba (spinosad)
58
Novarel (chorionic gonadotropin, human)
43
Nature-Throid (thyroid,pork)
50
48
Navane (thiothixene)
28
Nebupent Aerosol
14
Novolin (all forms) (Tier 2 BCBSM only) (insulin regular

human rec)
Novolog (all forms) (Tier 2 BCBSM only) (insulin aspart)
Noxafil suspension
14
Noxafil tablet
14
NP Thyroid (thyroid,pork)
50
Nucynta, ER
32
Nuedexta
36
Nulytely (sod sulf/sod/nahco3/kcl/peg's)
38
Nutropin AQ, Nuspin
48
Nuvaring
41
Nuvessa
43
Nuvigil (armodafinil)
29
Nebusal
Necon 10/11
Neomycin (neomycin sulfate)
68
41
18
48
Neosporin Ophth ointment (neomy sulf/bacitra/polymyxin

b)
Neosporin Ophth solution (neomycin/gramicidin/polymyxn
b)
Neo-Synalar
62
Neo-Synalar
58
Neo-Synephrine (phenylephrine hcl)
63
Nesina
49
Nymalize
36
Neulasta
52
Nystatin w/Triamcinolone (nystatin/triamcin)
59
Neulasta
55
Nystatin (nystatin)
14
Neupogen
52
Nystatin (nystatin)
43
Neupogen
55
Obredon
65
Neupro
34
Ocufen (flurbiprofen sodium)
62
Neurontin (gabapentin)
26
Ocuflox (ofloxacin)
62
Nevanac
62
Ocupress (carteolol hcl)
62
Nexavar
54
Odefsey
15
Nexium (esomeprazole magnesium)
39
Odomzo
54
Nexium suspension
39
Ofev
68
Niacor (Tier 2 BCN only)
23
Ogen (estropipate)
46
Niaspan (niacin)
23
Ogen (estropipate)
42
Nicotine Gum, Nicorette
72
Oleptro ER
27
Nicotine Patch
72
Olux (clobetasol propionate)
57
Nicotrol, NS
72
Olux-E (clobetasol propionate/emoll)
57
Niferex-150 Forte (BCBSM Only) (iron ps cmplx/vit

b12/fa)
Nilandron
70
Olysio
16
53
Omeclamox-Pak
38
36
Omeprazole OTC (omeprazole)
39
Nimotop (nimodipine)
62
59
Trade Name
Page
Trade Name
Page
Omnaris
67
Pandel
58
Omnaris
64
Panretin
59
Omnicef (cefdinir)
17
Papaverine capsule (papaverine hcl)
22
Omnitrope
48
Parafon Forte DSC (chlorzoxazone)
35
Onexton
56
Parcopa (carbidopa/levodopa)
34
Onfi
26
Paregoric (BCBSM only) (paregoric)
37
Onglyza
49
Paremyd
61
Onmel
14
Parlodel (bromocriptine mesylate)
34
Onzetra Xsail
30
Parnate (tranylcypromine sulfate)
27
Opana (oxymorphone hcl)
32
Paser (BCN tier 2 only)
16
Opana ER (oxymorphone hcl)
32
Pataday
61
Opsumit
67
Patanase (olopatadine hcl)
65
Opticrom (cromolyn sodium)
61
Patanase (olopatadine hcl)
64
Optipranolol (metipranolol)
62
Patanol (olopatadine hcl)
61
Optivar (azelastine hcl)
61
Paxil CR (paroxetine hcl)
27
Oracea
56
Paxil suspension
27
Oracea
18
Paxil (paroxetine hcl)
27
Oralair
68
Pazeo
61
Oralone paste (triamcinolone acetonide)
58
Peganone
26
Orap (pimozide)
28
Pegasys, Proclick
55
Orapred ODT (prednisolone sod phosphate)
47
Peg-Intron, Redipen
55
Orapred solution 15mg/5ml (prednisolone sod phosphate)
47
Penicillin VK (penicillin v potassium)
17
Oravig
14
Penlac (ciclopirox)
59
Orencia sub-q
45
Pennsaid 1.5% (diclofenac sodium)
33
Orenitram ER
67
Pennsaid 2%
33
Orfadin
71
Pentasa
37
Orinase (tolbutamide)
49
Pepcid (RX Only) (famotidine)
38
Orkambi
66
Percocet (oxycodone hcl/acetaminophen)
31
Ortho Evra
41
Percodan (oxycodone hcl/aspirin)
31
Ortho Tri-Cyclen Lo
42
Perforomist
66
Ortho Tri-Cyclen
42
Periactin (cyproheptadine hcl)
65
Ortho-Cyclen
41
Peridex (chlorhexidine gluconate)
18
Ortho-Novum 7/7/7
42
Periostat (doxycycline hyclate)
18
Oseni
49
Perphenazine (perphenazine)
28
Osmoprep
38
27
Osphena
44
Otezla
57
Perphenazine/amitriptyline hcl (amitriptyline

hcl/perphenazine)
Persantine (dipyridamole)
Pertzye
38
Pexeva
27
Phenergan DM (d-methorphan hb/prometh hcl)
65
65
Otezla
Otrexup
Otrexup
45
46
57
20
Ovace, Plus (BCBSM only) (sulfacetamide sodium)
57
Ovcon 35
41
Phenergan VC w/Codeine
(promethazine/phenyleph/codeine)
Phenergan VC (phenylephrine hcl/prometh hcl)
Ovide (malathion)
58
Phenergan w/Codeine (codeine/promethazine hcl)
65
Ovidrel
43
Phenergan (promethazine hcl)
37
Ovral
41
Phenergan (promethazine hcl)
65
Oxandrin (oxandrolone)
47
Phenobarbital (phenobarbital)
26
Oxaydo
32
Phoslo (calcium acetate)
71
Oxistat (oxiconazole nitrate)
59
Phoslyra
71
Oxistat lotion
59
Phospholine Iodide
63
Oxsoralen
57
Phrenilin tablet (butalbital/acetaminophen)
30
Oxsoralen-Ultra (methoxsalen, rapid)
57
Phrenilin (butalbital/acetaminophen)
31
Oxtellar XR
26
Picato
59
Oxycodone hcl ER
32
Pilocar; Isopto-Carpine (pilocarpine hcl)
63
Oxycodone immediate release (oxycodone hcl)
32
Plan B, One-Step
42
Oxycontin
32
Plaquenil (hydroxychloroquine sulfate)
46
Oxytrol
69
Plaquenil (hydroxychloroquine sulfate)
14
Pancreaze
38
Plavix (clopidogrel bisulfate)
20
65
Trade Name
Page
Trade Name
Page
Plegridy
55
Procrit
55
Plendil (felodipine)
21
Proctocort (hydrocortisone acetate)
39
Pletal (cilostazol)
20
Proctofoam-HC
39
Plexion, TS (BCBSM only) (sulfacetamide sodium/sulfur)
56
Procto-kit (hydrocortisone)
39
Polysporin (bacitracin/polymyxin b sulfate)
62
Proctosol-HC suppository (hydrocortisone acetate)
39
Polytrim (polymyxin b sulfate/tmp)
62
Procysbi
69
Poly-Vi-Flor (BCBSM Only)
70
Progesterone in Oil (Inj) (progesterone)
43
Pomalyst
53
Proglycem
51
Ponstel (mefenamic acid)
33
Prograf (tacrolimus anhydrous)
53
Potiga
26
Prolensa
62
Pradaxa
20
Prolixin (fluphenazine hcl)
28
Praluent
23
Promacta
55
Pramosone (BCBSM Only)
39
Prometrium (progesterone,micronized)
43
PrandiMet (repaglinide/metformin hcl)
49
Propylthiouracil (propylthiouracil)
47
Prandin (repaglinide)
49
Proscar (finasteride)
69
Pravachol (pravastatin sodium)
23
Prosom (estazolam)
35
Precose (acarbose)
49
Protonix suspension
39
Pred Forte (prednisolone acetate)
63
Protonix tablet (pantoprazole sodium)
39
Pred Mild
63
Protopic (tacrolimus)
59
Pred-G
61
Protriptyline hcl (protriptyline hcl)
27
Prednisolone, tablet, syrup (prednisolone)
47
Proventil HFA
66
Prednisone (prednisone)
47
Proventil solution (albuterol sulfate)
67
Prednisone (prednisone)
53
Provera (medroxyprogesterone acet)
43
Prefest
42
Provigil (modafinil)
29
Pregnyl
43
Provocholine
71
46
Prozac Weekly (fluoxetine hcl)
27
42
Prozac (fluoxetine hcl)
27
42
Pulmicort Flexhaler (Tier 1-BCN Only)
67
46
Pulmicort solution (budesonide)
67
Prenatal Plus, Tricare (pnv with ca,no.72/iron/fa)
70
Pulmozyme
66
Prenatal Vitamins (prenatal vit/iron,carb/doss/fa)
70
Purinethol (mercaptopurine)
52
Prepopik
38
Purixan
52
Prestalia
19
Pylera
38
Prestalia
21
Pyrazinamide (pyrazinamide)
16
Prevacid capsule (lansoprazole)
39
Pyridium (BCBSM only) (phenazopyridine hcl)
18
Prevacid Solutab
39
Pyridium (BCBSM only) (phenazopyridine hcl)
69
Prevident (sodium fluoride)
70
Qnasl, Children's
67
Prevpac (lansoprazole/amoxiciln/clarith)
38
Qnasl, Children's
64
Prezcobix
15
Qsymia
72
Prezista
15
Qualaquin (quinine sulfate)
14
Priftin
16
Quartette
41
Prilosec capsule (omeprazole)
39
Qudexy XR
26
Prilosec OTC (omeprazole magnesium)
39
Questran, Light (cholestyramine)
23
Prilosec suspension
39
Quillichew ER
29
Primaquine
14
Quillivant XR
29
Primsol (Tier 2 BCN Only)
18
Quinidex (quinidine sulfate)
22
Prinivil; Zestril (lisinopril)
19
Quinidine gluconate SA (quinidine gluconate)
22
Prinzide; Zestoretic (lisinopril/hydrochlorothiazide)
19
Quixin (levofloxacin)
62
Pristiq ER
27
Qvar (Tier 1-BCN Only)
67
Proair HFA, Respiclick; Ventolin HFA
66
Radiogardase
71
Proamatine (midodrine hcl)
22
Ragwitek
68
Pro-Banthine (propantheline bromide)
37
Ranexa
22
Pro-Banthine (propantheline bromide)
69
Rapaflo
69
Probenecid (probenecid)
45
Rapamune solution
53
Procardia, XL; Adalat CC (nifedipine)
21
Rapamune tablet (sirolimus)
53
Procentra (d-amphetamine sulfate)
29
Rasuvo
57
Procrit
52
Rasuvo
46
Trade Name
Page
Trade Name
Page
Ravicti
50
Ritalin, LA, SR (methylphenidate hcl)
29
Rayos
47
RMS suppository (morphine sulfate)
32
Rayos
53
Robaxin (methocarbamol)
35
Razadyne, ER (galantamine hydrobromide)
25
Robinul, Forte (glycopyrrolate)
38
Rebetol capsule (ribavirin)
16
Robitussin AC (guaifenesin/codeine phosphate)
65
Rebetol solution
16
Rocaltrol (calcitriol)
50
Rebif, Rebidose
55
56
Rectiv
40
Regimex
72
Rosula Cleanser (BCBSM only) (sulfacetamide

sod/sulfur/urea)
Rowasa enema; SfRowasa enema (mesalamine)
Roxanol (morphine sulfate)
32
Rozerem
35
Ruconest
55
Rulavite DHA (pnv combo#47/iron/fa #1/dha)
70
Rytary
34
Rythmol, SR (propafenone hcl)
22
Ryzolt (tramadol hcl)
31
Sabril
26
Safyral
41
Saizen
48
Salagen (pilocarpine hcl)
40
Salicylates and NSAIDS
46
Samsca
71
Sanctura XR (trospium chloride)
69
Sanctura (trospium chloride)
69
Sancuso
37
Sandimmune (cyclosporine)
53
Sandimmune soln (Tier 2/4 BCN)
53
Sandostatin LAR, Depot
50
Sandostatin LAR, Depot
54
Sandostatin (octreotide acetate)
50
Sandostatin (octreotide acetate)
54
Santyl
60
Saphris
28
Sarafem
27
Savaysa
20
Savella
36
Saxenda
72
Seasonale
41
Seasonique
41
Seconal (secobarbital sodium)
35
Sectral (acebutolol hcl)
21
Seebri Neohaler
66
Selsun 2.5% (Rx Only) (selenium sulfide)
57
Selzentry
15
Semprex-D
65
Sensipar
51
Serax (oxazepam)
28
Serevent Diskus
66
Seroquel (quetiapine fumarate)
28
Seroquel XR
28
Serostim
48
Serzone (nefazodone hcl)
27
Signifor
50
Signifor LAR
50
Silenor
35
Silvadene (silver sulfadiazine)
60
Simbrinza
63
Reglan (metoclopramide hcl)

Regranex
Relafen (nabumetone)
Relenza
Relistor syringe
Relistor syringe
Relistor vial
Relistor vial
Relpax
Remeron (mirtazapine)
Remodulin
Renacidin
Renagel
Renvela
Repatha
Reprexain (hydrocodone/ibuprofen)
Requip XL (ropinirole hcl)
Requip XL 12mg (ropinirole hcl)
Requip (ropinirole hcl)
Rescriptor
Rescula
Reserpine (reserpine)
Restasis
Restoril (temazepam)
Retin-A Micro pump 0.08%
Retin-A Micro, pump (tretinoin microspheres)
Retin-A (tretinoin)
Retrovir (zidovudine)
Revatio (sildenafil citrate)
Revatio suspension
Revia (naltrexone hcl)
Revlimid
Rexulti
Reyataz
Rezira
Rhinocort Aqua (budesonide)
Rhinocort Aqua (budesonide)
Ribasphere, Ribapak (ribavirin)
Ribatab (ribavirin)
Ridaura
Rifadin (rifampin)
Rifater
Rilutek (riluzole)
Riomet
Risperdal, M-Tab, solution (risperidone)
Ritalin LA 10mg, 60mg
40
60
33
16
40
30
30
40
30
27
67
69
71
71
23
31
34
34
34
15
63
19
63
35
56
56
56
15
67
67
30
53
28
15
65
52
46
67
64
16
16
46
16
16
36
49
28
29
37
Trade Name
Page
Trade Name
Page
Simponi
39
Stromectol (ivermectin)
14
Simponi
46
Suboxone (buprenorphine hcl/naloxone hcl)
31
Sinemet, CR (carbidopa/levodopa)
34
Suboxone Film
31
Sinequan; Adapin (doxepin hcl)
27
Subsys
32
Singulair (montelukast sodium)
68
Subutex (buprenorphine hcl)
31
Sirturo
16
Sucraid
40
Sitavig
16
Sular (nisoldipine)
21
Sivextro
18
Sulfacet-R (BCBSM only) (sulfacetamide sodium/sulfur)
56
Skelaxin (metaxalone)
35
Sulfadiazine (sulfadiazine)
18
Sklice
58
Sumavel Dosepro
30
Sodium Chloride inhalation (sodium chloride for

inhalation)
Solaraze (diclofenac sodium)
68
Supervite
70
Suprax chew, capsule, tablet
17
60
Suprax suspension 100/5, 200mg/5ml (cefixime)
17
Solodyn (minocycline hcl)
56
Suprax suspension 500mg/5ml
17
Solodyn (minocycline hcl)
18
Suprenza ODT
72
Solodyn 55, 65, 80, 105, 115mg
18
Suprep
38
Solodyn 55, 65, 80, 105, 115mg
56
Surmontil (trimipramine maleate)
27
Soltamox
53
Sustiva
15
Soma Compound w/Codeine (codeine

phos/carisoprodol/asa)
Soma Compound (carisoprodol/aspirin)
35
Sutent
54
35
Sylatron
55
35
Symbicort
67
50
Symbyax (olanzapine/fluoxetine hcl)
28
53
Symlinpen
49
51
Symmetrel (amantadine hcl)
34
Sonata (zaleplon)
35
Synalar 0.01% (fluocinolone acetonide)
58
Soolantra
60
Synalar 0.025% (fluocinolone acetonide)
58
57
Synalgos-DC (Tier 2 BCN Only)
31
57
Synalgos-DC (dihydrocodeine/aspirin/caffein)
31
21
Synarel
44
22
Synarel
51
16
Synjardy
49
59
Synthroid, Levoxyl (levothyroxine sodium)
50
17
Syprine
71
17
Tabloid
52
66
Taclonex ointment (calcipotriene/betamethasone)
57
14
Taclonex topical solution
57
14
Tafinlar
54
26
Tagamet (RX Only) (cimetidine)
38
33
Tagrisso
54
54
Talwin NX (pentazocine hcl/naloxone hcl)
31
71
Tambocor (flecainide acetate)
22
47
Tamiflu
16
31
Tamoxifen citrate
53
34
Tamoxifen citrate (tamoxifen citrate)
53
49
Tanzeum
49
Staxyn
72
Tapazole (methimazole)
47
Stelara
57
Tarceva
54
28
Targretin capsule (bexarotene)
54
72
Targretin gel
59
51
Tarka (trandolapril/verapamil hcl)
19
66
Tarka (trandolapril/verapamil hcl)
21
54
Tasigna
54
36
Tasmar (tolcapone)
34
51
Tazorac
56
47
Tecfidera
55
15
Technivie
16
66
Tegretol, XR (carbamazepine)
26
Soma (carisoprodol)
Somatuline Depot
Somatuline Depot
Somavert
Soriatane (acitretin)
Sorilux
Sotylize
Sotylize
Sovaldi
Spectazole (econazole nitrate)
Spectracef (28 Count)
Spectracef (cefditoren pivoxil)
Spiriva, Respimat
Sporanox capsule (itraconazole)
Sporanox solution
Spritam
Sprix
Sprycel
SPS (sodium polystyrene sulfonate)
SSKI (Tier 2 BCN only)
Stadol, NS (butorphanol tartrate)
Stalevo (carbidopa/levodopa/entacapone)
Starlix (nateglinide)
Stelazine (trifluoperazine hcl)

Stendra
Stimate
Stiolto Respimat
Stivarga
Strattera
Strensiq
Striant
Stribild
Striverdi Respimat
Trade Name
Page
Trade Name
Page
Tekamlo
24
Transderm-Scop
37
Tekamlo
21
Tranxene T-Tab (clorazepate dipotassium)
28
Tekturna
24
Travatan (travoprost (benzalkonium))
63
Tekturna HCT
24
Travatan Z
63
Temodar (temozolomide)
52
Trecator
16
Tenex (guanfacine hcl)
19
Trelstar, Depot, LA
53
Tenoretic (atenolol/chlorthalidone)
21
Trental (pentoxifylline)
20
Tenormin (atenolol)
21
Tresiba Flextouch
48
Terazol-3, 7 (terconazole)
43
Tretin-X
56
Terbutaline sulfate (terbutaline sulfate)
67
Trexall
52
Tessalon, Perles; Zonatuss (benzonatate)
65
Trexall
46
Testim
47
Treximet
30
Testosterone gel, packet, pump
47
Trezix
31
Tetracycline (tetracycline hcl)
18
Trezix (dhcodeine bt/acetaminophn/caff)
31
Teveten (eprosartan mesylate)
20
Tribenzor
20
Thalomid
53
Tribenzor
21
Theo-24
68
Tricor (fenofibrate nanocrystallized)
23
Theophylline Anhydrous (theophylline anhydrous)
68
Triglide
23
Thiola (Tier 2 BCN Only)
69
Trileptal (oxcarbazepine)
26
Thorazine (chlorpromazine hcl)
28
Trilevlen; Triphasil
42
Thyrolar
50
Trilipix (fenofibric acid (choline))
23
Tiazac (diltiazem hcl)
21
Trilisate (BCBSM only) (choline magnesium trisalicylate)
34
Ticlid (ticlopidine hcl)
20
Trimethoprim (trimethoprim)
18
Tigan (trimethobenzamide hcl)
37
Tri-Norinyl
42
Tikosyn
22
Trintellix
27
Timoptic Ocudose (Tier 2 BCN only)
62
Triumeq
15
Timoptic, - XE (timolol maleate)
62
Trizivir (abacavir/lamivudine/zidovudine)
15
Tindamax (tinidazole)
14
Trokendi XR
26
Tirosint
50
Trulicity
49
Tivicay
15
Trusopt (dorzolamide hcl)
63
Tivorbex
33
Truvada
15
Tobi Podhaler
18
Tudorza Pressair
66
Tobi Podhaler
66
Tussicaps
65
Tobi (tobramycin/0.25 normal saline)
18
Tussionex (hydrocodone/chlorphen polis)
65
Tobi (tobramycin/0.25 normal saline)
66
Tuzistra XR
65
Tobradex ointment
61
Twynsta (telmisartan/amlodipine)
21
Tobradex ST
61
Twynsta (telmisartan/amlodipine)
20
Tobradex suspension (tobramycin sulfate/dexameth)
61
Tybost
15
Tobrex drops (tobramycin sulfate)
62
Tykerb
54
Tobrex ointment (BCN tier 2 only)
62
Tylenol w/Codeine (codeine phos/acetaminophen)
31
Today Contraceptive Sponge
41
Tyvaso
67
Tofranil (imipramine hcl)
27
Tyzeka
16
Tofranil-PM (imipramine pamoate)
27
Tyzine
64
Tolak
59
Uceris foam
47
Tolazamide (tolazamide)
49
Uceris tablet
47
Tolectin, DS (tolmetin sodium)
33
Ulesfia
58
Topamax (topiramate)
26
Uloric
45
Topicort cream, gel, ointment (desoximetasone)
57
Ultracet (tramadol hcl/acetaminophen)
31
Topicort LP (desoximetasone)
58
Ultram, ER (tramadol hcl)
31
Topicort Spray
57
Ultravate lotion (Not Covered for BCBSM)
57
Topiramate ER
26
Ultravate (halobetasol propionate)
57
Toprol XL (metoprolol succinate)
21
Uniretic (moexipril/hydrochlorothiazide)
19
Toradol (ketorolac tromethamine)
33
Univasc (moexipril hcl)
19
Toujeo Solostar
48
Uptravi
67
Toviaz (Tier 3 BCBSM Only)
69
Urecholine (bethanechol chloride)
69
Tracleer
67
Urispas (flavoxate hcl)
69
Tradjenta
49
Urocit-K (potassium citrate)
69
Trade Name
Page
Trade Name
Page
Uroxatral (alfuzosin hcl)
69
Viokace
38
Urso, Urso Forte (ursodiol)
38
Viracept
15
UTA (BCBSM only)
18
Viramune, XR (nevirapine)
15
Utibron Neohaler
66
Viread
15
Vagifem
42
Viroptic (trifluridine)
62
Valchlor
59
Visken (pindolol)
21
Valcyte solution
16
Vitamin D3 (1000IU or less)
70
Valcyte tablet (valganciclovir hydrochloride)
16
Vitamin K ampule (phytonadione)
70
Valisone (betamethasone valerate)
57
Vitamin K ampule (phytonadione)
20
Valium (diazepam)
28
Vitekta
15
Valium (diazepam)
35
Vituz
65
Valtrex (valacyclovir hcl)
16
Vivelle-Dot (estradiol)
42
Vancocin hcl (vancomycin hcl)
18
Vivelle-Dot (estradiol)
46
Vanos (fluocinonide)
57
Vivlodex
33
Vantin (cefpodoxime proxetil)
17
Vogelxo
47
Varubi
37
Voltaren drops (diclofenac sodium)
62
Vascepa
23
Voltaren gel (diclofenac sodium)
33
Vaseretic (enalapril/hydrochlorothiazide)
19
Voltaren tablet (diclofenac sodium)
33
Vasocidin (sulfacetamide/prednisolone sp)
61
Voltaren XR (diclofenac sodium)
33
Vasodilan (BCBSM only) (isoxsuprine hcl)
22
Vosol HC
64
Vasotec (enalapril maleate)
19
Vosol (acetic acid)
64
VCF film
41
Vospire ER (albuterol sulfate)
67
VCF foam
41
Votrient
54
Vecamyl
24
Vraylar
28
Vectical (calcitriol)
57
Vusion
59
Velphoro
71
Vytorin
23
Veltassa
71
Vyvanse
29
Veltin
56
Welchol
23
Venlafaxine hcl ER (venlafaxine hcl)
27
Wellbutrin XL 300mg (bupropion hcl)
27
Ventavis
67
Wellbutrin, SR, XL (bupropion hcl)
27
Vepesid (etoposide)
54
Westcort (hydrocortisone valerate)
58
Veramyst
67
Westhroid (thyroid,pork)
50
Veramyst
64
WP Thyroid
50
Verdeso
58
Xalatan (latanoprost)
63
Veregen
59
Xalkori
54
Verelan PM (verapamil hcl)
21
Xanax, XR (alprazolam)
28
Versacloz
28
Xarelto
20
Vesanoid (tretinoin)
54
Xartemis XR
31
Vesicare
69
Xeljanz, XR
45
Vexol
63
Xeloda (capecitabine)
52
Vfend (voriconazole)
14
Xenazine (tetrabenazine)
36
Viagra
72
Xenical
72
Viberzi
40
Xerese
60
18
Xifaxan 200mg
18
56
Xifaxan 200mg
40
Vibramycin (doxycycline hyclate)
18
Xifaxan 550mg
40
Vibramycin (doxycycline hyclate)
56
Xigduo XR
49
Vicoprofen (hydrocodone/ibuprofen)
31
Xolegel
59
Victoza
49
Xopenex HFA
66
Videx
15
Xopenex nebulizer solution (levalbuterol hcl)
66
Videx EC (didanosine)
15
Xtandi
53
Viekira Pak
16
Xuriden
69
Vigamox
62
Xylocaine, Viscous (Rx only) (lidocaine hcl)
58
Viibryd
27
Xyrem
36
Vimovo
33
Xyzal solution (levocetirizine dihydrochloride)
65
Vimovo
39
Xyzal tablet (levocetirizine dihydrochloride)
65
Vimpat
26
Yasmin 28
41
Trade Name
Page
Trade Name
Page
Yaz
41
Zyclara
59
Zanaflex capsule (tizanidine hcl)
35
Zydelig
54
Zanaflex tablet (tizanidine hcl)
35
Zyflo
68
Zantac (RX Only) (ranitidine hcl)
38
Zyflo CR
68
Zarontin (ethosuximide)
26
Zykadia
54
Zaroxolyn (metolazone)
22
Zylet
61
Zarxio
52
Zyloprim (allopurinol)
45
Zarxio
55
Zymaxid (gatifloxacin)
62
Zavesca
51
Zyprexa, Zydis (olanzapine)
28
Zebeta (bisoprolol fumarate)
21
Zyrtec (OTC) (cetirizine hcl)
65
Zegerid packet
39
Zyrtec-D (OTC) (p-ephed hcl/cetirizine hcl)
65
Zegerid RX (omeprazole/sodium bicarbonate)
39
Zytiga (Tier 3/5 - BCN only)
53
Zelapar
34
Zyvox (linezolid)
18
Zelboraf
54
Zembrace Symtouch
30
Zemplar (paricalcitol)
50
Zenpep
38
Zenpep 5,000 (lipase/protease/amylase)
38
Zenzedi
29
Zerit (stavudine)
15
Zetia
23
Zetonna
64
Zetonna
67
Ziac (bisoprolol/hydrochlorothiazide)
21
Ziagen solution
15
Ziagen tablet (abacavir sulfate)
15
Ziana
56
Zioptan
63
Zipsor
33
Zirgan
62
Zithromax (azithromycin)
17
Zmax
17
Zocor (simvastatin)
23
Zofran, ODT (ondansetron)
37
Zohydro ER
32
Zoladex
53
Zolinza
54
Zoloft (sertraline hcl)
27
Zolpimist
35
Zomacton
48
Zomig , ZMT (zolmitriptan)
30
Zomig nasal spray 2.5mg
30
Zomig nasal spray 5mg
30
Zonalon
60
Zonalon (doxepin hcl)
60
Zonegran (zonisamide)
26
Zontivity
20
Zorbtive
40
Zortress
54
Zorvolex
33
Zovirax cream
60
Zovirax ointment (acyclovir)
60
Zovirax (acyclovir)
16
Zubsolv
31
Zuplenz
37
Zutripro (pseudoephed/hydrocodone/cpm)
65
Zyban
72
bcbsm.com/pharmacy
For members with 3-tier,

5-tier, 6-tier or closed
pharmacy benefit designs
CB 2870 OCT 15
r6
R045824

Custom Drug List Formulary

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Custom Drug List Formulary

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2016

BCBSM and BCN Custom Drug List (Formulary) - July 2016

Cardiovascular, hypertension, cholesterol

ACE-Inhibitors and Combinations

Central nervous system

5-Aminosalicylic Acid (5-ASA) Agents

Obstetrics and gynecology

Rheumatology and musculoskeletal

Antineoplastics and immunossuppresants

Immunology and hematology

Otic and nasal preparations

Respiratory, cough and cold

Vitamins and supplements

Diagnostic and other miscellaneous

Impotence, Sexual Dysfunction

Blue Cross and BCN Custom Drug List

Tier 4: Preferred Specialty lower specialty drug cost sharing

Preventive drug coverage

What you should know

How prior approval, step therapy and quantity limits work

Obtaining prior approval or step therapy

Generic drug substitution and possible therapeutic alternatives

Possible brand alternatives

Humatrope, Norditropin , Omnitrope,

Possible therapeutic alternatives

Pharmacy Services Mail Code C303

How to read the Custom Drug List

Drugs are organized based on drug class

BCN 6-Tier: Applies to BCN members with

BCN: Requirements for coverage include

Prior approval: Approval from Blue Cross

Step therapy: Criteria must be met prior to

Quantity limits: Prescriptions cant exceed

PA - Prior approval may be required

Custom 5-Tier PA ST QL 6-Tier PA ST QL

ST - Step therapy may be required

Custom 5-Tier PA ST QL 6-Tier PA ST QL

Custom 5-Tier PA ST QL 6-Tier PA ST QL

QL - Quantity limits may apply

BCBSM/BCN Custom Drug List (July 2016)

<s> - Specialty Drug

PA - Prior approval may be required

ST - Step therapy may be required

Custom 5-Tier PA ST QL 6-Tier PA ST QL

QL - Quantity limits may apply

BCBSM/BCN Custom Drug List (July 2016)

<s> - Specialty Drug

PA - Prior approval may be required

Custom 5-Tier PA ST QL 6-Tier PA ST QL

ST - Step therapy may be required

Custom 5-Tier PA ST QL 6-Tier PA ST QL

QL - Quantity limits may apply

BCBSM/BCN Custom Drug List (July 2016)

<s> - Specialty Drug

PA - Prior approval may be required

amox tr/potassium clavulanate

Custom 5-Tier PA ST QL 6-Tier PA ST QL

Custom 5-Tier PA ST QL 6-Tier PA ST QL

Custom 5-Tier PA ST QL 6-Tier PA ST QL

Custom 5-Tier PA ST QL 6-Tier PA ST QL

QL - Quantity limits may apply

BCBSM/BCN Custom Drug List (July 2016)

<s> - Specialty Drug

1K. Sulfonamides and Combinations