2017
every card.
Confidence comes with
®
Custom Select
Drug List
EPO (Blue Cross Blue Shield)
Blue Cross® Metro Detroit EPO
PPO (Blue Cross Blue Shield)
Blue Cross® Personal Choice PPO
Blue Cross® Premier and Premier Value
Blue Cross Extra with Dental and Vision,
a Multi‑State Plan
Community BlueSM PPO
Healthy Blue AchieveSM PPO
Simply BlueSM PPO
HMO (Blue Care Network)
Blue Cross® Metro Detroit HMO
Blue Cross® Partnered
Blue Cross® Preferred
Blue Cross® Select
Blue Elect PlusSM Self Referral Option
BCN Healthy Blue LivingSM HMO
BCN HMOSM
BCN HRASM HMO
BCN HSASM HMO
BCN Routine CareSM
Blue Cross and BCN Custom Select Drug List July 2017
Table of contents
Individual & Small Group Plans.................................................................................................
Specific information for Blue Cross Members...........................................................................
Specific information for Blue Care Network Members...............................................................
How to read the Blue Cross and BCN Custom Select Drug List...............................................
5
9
12
15
Anti-infectives
1A
1B
1C
1D
1E
1F
1G
1H
1I
1J
1K
1L
1M
1N
Antifungals....................................................................................................................
Antimalarials.................................................................................................................
Antiparasitics and anthelmintics...................................................................................
Antiretrovirals................................................................................................................
Antituberculars..............................................................................................................
Antivirals.......................................................................................................................
Cephalosporins.............................................................................................................
Macrolides.....................................................................................................................
Penicillins......................................................................................................................
Quinolones....................................................................................................................
Sulfonamides and combinations...................................................................................
Tetracyclines.................................................................................................................
Urinary tract agents.......................................................................................................
Miscellaneous anti-infectives........................................................................................
7
7
7
8
9
9
10
10
10
11
11
11
11
12
Cardiovascular, hypertension, cholesterol
2A
2B
2C
2D
2E
2F
2G
2H
2I
2J
2K
2L
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..................................................................................
13
13
14
15
16
16
17
17
18
18
19
19
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 and antagonist.........................................................................
Narcotic and analgesic combinations...........................................................................
Narcotics.......................................................................................................................
Nonsteroidal anti-inflammatory drugs...........................................................................
Parkinsons disease and related disorders....................................................................
Salicylates.....................................................................................................................
Sedative and hypnotics.................................................................................................
Skeletal muscle relaxants.............................................................................................
Miscellaneous CNS......................................................................................................
20
21
22
23
23
24
24
25
25
25
25
26
27
28
28
28
29
29
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..............................................................................................
Proton Pump Inhibitors (PPI)........................................................................................
Topical anti-Inflammatory agents..................................................................................
Tumor Necrosis Factor (TNF) blocking agents............................................................
Ulcer therapy.................................................................................................................
Miscellaneous gastrointestinal agents..........................................................................
30
30
30
31
31
31
31
32
32
32
32
33
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 and progestin combinations..........................................................................
Estrogens......................................................................................................................
Infertility treatment*.......................................................................................................
Progestins.....................................................................................................................
Vaginal anti-infective and antifungal.............................................................................
Miscellaneous OB-GYN................................................................................................
34
34
35
35
35
36
36
36
37
37
37
Page 2
Rheumatology and musculoskeletal
6A
6B
6C
6D
6E
6F
6G
6H
Corticosteroids.............................................................................................................. 38
Gout therapy................................................................................................................. 38
Non-Tumor Necrosis Factor (TNF) blocking agents..................................................... 38
Osteoporosis and bone resorption................................................................................ 38
Osteoporosis and hormonal treatment......................................................................... 39
Salicylates..................................................................................................................... 39
Tumor Necrosis Factor (TNF) blocking agents............................................................ 39
Miscellaneous rheumatologic agents............................................................................ 39
Endocrinology
7A
7B
7C
7D
7E
7F
7G
7H
7I
7J
7K
Androgens..................................................................................................................... 40
Antithyroid agents......................................................................................................... 40
Corticosteroids.............................................................................................................. 40
Growth Hormone and related products......................................................................... 41
Insulins.......................................................................................................................... 41
Non-insulin hypoglycemic agents................................................................................. 42
Somatostatin analogs................................................................................................... 42
Thyroid hormones......................................................................................................... 43
Urea cycle disorder agents .......................................................................................... 43
Vitamin D analogs ........................................................................................................ 43
Miscellaneous endocrine.............................................................................................. 44
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............................................................................
45
45
45
46
46
47
48
Immunology and hematology
9A
9B
9C
9D
Hematopoietic agents...................................................................................................
Immunoglobulins...........................................................................................................
Interferons and MS therapy..........................................................................................
Miscellaneous immunology and hematology................................................................
49
49
49
50
Dermatology
10A
10B
10C
10D
10E
10F
10G
10H
10I
10J
10K
10L
10M
10N
Acne treatment............................................................................................................. 51
Antipsoriatic and antiseborrheic.................................................................................... 51
Corticosteriods - very high potency............................................................................... 51
Corticosteroids - high potency...................................................................................... 52
Corticosteroids - medium potency................................................................................ 52
Corticosteroids - low potency........................................................................................ 52
Scabicides and pediculicides........................................................................................ 52
Topical anesthetics....................................................................................................... 53
Topical antibacterials.................................................................................................... 53
Topical antifungals........................................................................................................ 53
Topical antineoplastic agents and immunomodulators................................................. 53
Topical antivirals........................................................................................................... 54
Wound and burn therapy.............................................................................................. 54
Miscellaneous dermatologicals..................................................................................... 54
Page 3
Ophthalmology
11A
11B
11C
11D
11E
11F
11G
11H
11I
Cycloplegic mydriatics..................................................................................................
Glaucoma agents..........................................................................................................
Ophthalmic anti-allergy agents.....................................................................................
Ophthalmic anti-infective and steroid combinations.....................................................
Ophthalmic anti-infectives.............................................................................................
Ophthalmic anti-inflammatory agents...........................................................................
Ophthalmic beta blockers.............................................................................................
Ophthalmic steroids......................................................................................................
Miscellaneous ophthalmic agents.................................................................................
55
55
55
56
56
56
57
57
57
Otic and nasal preparations
12A
12B
Nasal preparations........................................................................................................ 58
Otic preparations.......................................................................................................... 58
Respiratory, cough and cold
13A
13B
13C
13D
13E
13F
13G
13H
13I
13J
13K
13L
13M
13N
13O
Antihistamine and decongestant combinations............................................................
Antihistamines..............................................................................................................
Antitussives...................................................................................................................
Cystic Fibrosis agents ..................................................................................................
Epinephrine...................................................................................................................
Inhaled anticholinergics................................................................................................
Inhaled beta-agonist and anticholinergic combinations................................................
Inhaled beta-agonists....................................................................................................
Inhaled steroid and beta-agonist combinations ...........................................................
Inhaled steroids.............................................................................................................
Intranasal steroids........................................................................................................
Oral beta-agonists........................................................................................................
Pulmonary Hypertension Agents .................................................................................
Theophyllines................................................................................................................
Miscellaneous respiratory agents.................................................................................
59
59
59
59
59
59
60
60
60
60
60
61
61
61
61
BPH Treatment.............................................................................................................
Ion-Removing Agents...................................................................................................
Urinary Antispasmodics................................................................................................
Miscellaneous Urologicals............................................................................................
62
62
62
63
Urology
14A
14B
14C
14D
Vitamins and supplements
15A
15B
Potassium Replacement............................................................................................... 64
Vitamins and Minerals.................................................................................................. 64
Diagnostic and other miscellaneous
16A
16B
16C
Chelating Agents........................................................................................................... 65
Diagnostics and Other Miscellaneous.......................................................................... 65
Vaccines....................................................................................................................... 66
Lifestyle modification
17A
17B
17C
Sexual Dysfunction....................................................................................................... 67
Smoking Cessation....................................................................................................... 67
Weight Loss Preparations............................................................................................ 67
Page 4
Individual and small group plans that use the Blue Cross and BCN Custom Select Drug
List include:
Individual plans
Plan name
Blue Care Network HMO
Blue Cross® Partnered HMO
Market type
Plan type
Individual
HMO (BCN)
Blue Cross® Partnered HMO Extra
Blue Cross® Metro Detroit HMO
Individual
Individual
HMO (BCN)
HMO (BCN)
Blue Cross® Metro Detroit HMO
Extra
Blue Cross® Select HMO
Individual
HMO (BCN)
Individual
HMO (BCN)
Blue Cross® Select HMO Extra
Blue Cross® Preferred HMO
Individual
Individual
HMO (BCN)
HMO (BCN)
Blue Cross® Preferred HMO Extra
Blue Cross PPO
Blue Cross® Premier
Individual
HMO (BCN)
Individual
PPO (Blue Cross)
Blue Cross® Premier Silver Extra
and Bronze Extra
Blue Cross® Silver Extra with Dental
and Vision, a Multi-State Plan
Blue Cross® Gold Extra with Dental
and Vision, a Multi-State Plan
Blue Cross EPO
Blue Cross® Metro Detroit EPO
Individual
Plan level
Drug copay option
Gold, silver, silver saver,
bronze (HSA), bronze saver
(HSA)
Silver, bronze
Silver, silver saver, bronze
(HSA), bronze saver (HSA)
Silver, bronze
6 tier
Gold, silver, silver saver,
bronze (HSA), bronze saver
(HSA), value
Silver, bronze
Gold, silver, silver saver,
bronze (HSA)
Silver
6 tier
5 tier
PPO (Blue Cross)
Gold, silver, bronze,
catastrophic
Silver, bronze
Individual
PPO (Blue Cross)
Silver
4 tier
Individual
PPO (Blue Cross)
Gold
4 tier
Individual
EPO (Blue Cross)
Silver, bronze
5 tier
4 tier
6 tier
4 tier
4 tier
6 tier
4 tier
4 tier
Small group plans
Plan name
Blue Care Network HMO
Blue Elect Plus Self Referral Option
BCN
BCN Routine Care
BCN HRA
BCN HRA PCP Focus
BCN HSA
BCN HSA PCP Focus
BCN PCP Focus
BCN Healthy Blue Living
Blue Cross PPO
Community Blue PPO
Simply Blue PPO
Healthy Blue Achieve PPO
Personal Choice PPO
Market type
Plan type
Plan level
Drug copay option
Small group
Small group
Small group
Small group
Small group
Small group
Small group
Small group
Small group
HMO (BCN)
HMO (BCN)
HMO (BCN)
HMO (BCN)
HMO (BCN)
HMO (BCN)
HMO (BCN)
HMO (BCN)
HMO (BCN)
Gold
Platinum, gold, silver
Silver
Platinum, gold
Platinum
Gold, silver, bronze
Bronze
Platinum, gold, silver
Platinum, gold
6 tier
6 tier
6 tier
6 tier
6 tier
6 tier
6 tier
6 tier
6 tier
Small group
Small group
PPO (Blue Cross)
PPO (Blue Cross)
3 tier
5 tier
Small group
Small group
PPO (Blue Cross)
PPO (Blue Cross)
Platinum, gold
Platinum, gold, silver,
bronze
Platinum, gold
Gold, silver
5 tier
5 tier
Page 5
Blue Cross and BCN Custom Select Drug List
The Blue Cross Blue Shield of Michigan and Blue Care Network Custom Select Drug List is a
useful reference and educational tool for prescribers, pharmacists and members. The Custom
Select Drug List is based on our Custom Drug List but provides lower cost and better value to
our customers and members.
Most Blue Cross and BCN health care plans for small groups and individual members use this
list, including those who enrolled through the Health Insurance Marketplace. Other groups and
individuals may also choose a pharmacy benefit that uses this drug list.
We update this list monthly with medications approved by the U.S. Food and Drug
Administration and reviewed by our Pharmacy and Therapeutics Committee. The list represents
the clinical judgment of Michigan doctors, pharmacists and other experts in the diagnosis and
treatment of disease and the promotion of health. The committee selects medications based on
safety, clinical effectiveness and opportunity for cost savings. This is how the Blue Cross and
BCN Custom Select Drug List helps maintain quality of care and contain costs for our members.
About this drug list
Use this list to find information about drug coverage and therapeutic options for Blue Cross and
BCN members. This list is divided into major drug classes or indication for use by chapter, so
it’s easy to use. Products approved for more than one use may be included in more than one
chapter. Within each chapter, drugs are identified according to their tier placement. Refer to the
How to Read section for details.
We encourage doctors to prescribe preferred medications whenever possible. Blue Cross and
BCN respect the judgment of the dispensing pharmacists and expect them to contact the
prescriber when a prescription for a drug or dose may not be appropriate for a member. We
also encourage pharmacists to contact the prescriber to suggest an alternative when a Blue
Cross or BCN member’s prescription is written for a nonpreferred or excluded drug.
Coverage and applicable copay amounts for drugs on the Blue Cross and BCN Custom Select
Drug List are based on a member’s drug plan. Not all drugs included in the drug list are
necessarily covered by each member’s plan. Drugs not listed on the Custom Select Drug List
are not covered.
Some medications excluded by a Blue Cross or BCN member’s pharmacy benefit may be
covered under his or her medical benefit. These are medications that are generally administered
in a doctor’s office under the supervision of appropriate health care personnel and aren’t
normally dispensed to the member for self-administration.
Page 6
Several drugs and drug categories are excluded from coverage under this drug list. These
include:
• Brand-name drugs that have generic equivalents
• Over-the-counter medications (unless considered preventive by the United States
Preventive Services Task Force)
• Lifestyle drugs (drugs for erectile dysfunction or weight loss)
• Drugs prescribed for cosmetic purposes
• Drugs used to treat heartburn and acid reflux (except select generic versions)
• Drugs that treat coughs and colds, including most antihistamines
• Prenatal vitamins
• Compounded products, with some exceptions for Blue Cross PPO drug plans
Specialty drugs
For more information on specialty drugs, see Specialty Drug Program Rx Benefit Member
Guide. Specialty drugs are limited to a 30-day supply. Select specialty drugs are managed by
the 15-Day Specialty Drug Limitation Prog ram. Drugs included on this list are limited to a 15day supply for all fills. Members pay half their copay for a 15-day supply. For additional details,
visit bcbsm.com/pharmacy.
Preventive drug coverage
Under the Patient Protection and Affordable Care Act, also known as national health care
reform, most health care plans must cover certain preventive services and drugs with no cost
sharing. These drugs appear as a $0 tier on the drug list. For a complete list of preventive
drugs, and coverage requirements, please refer to Preventive drug coverage or visit
bcbsm.com/pharmacy.
This document is current at the time of publication and is subject to change. Please visit
bcbsm.com/pharmacy and click on Drug Lists for the most up-to-date information about
the Blue Cross and BCN Custom Select Drug List.
This document content was developed to comply with applicable federal and state regulations.
To learn more about your plan, go to bcbsm.com and type “How Health Insurance Works” in
the search field.
Page 7
Click on one of the links below for more information specific to your plan.
Blue Cross (PPO)
BCN (HMO)
How to read the Blue Cross and BCN Custom Select Drug List
Page 8
Blue Cross members
How do I know what type of prescription coverage I have?
For details about your drug benefit, please call the Customer Service phone number on the
back of your Blue Cross member ID card. If you have online access, log in to your account at
bcbsm.com. You can also find more general information about Blue Cross prescription
coverage at bcbsm.com/pharmacy.
Tier descriptions
Tier 1
Tier 2
Tier 3
3-tier plans
4-tier plans
5-tier plans
Generics — lowest copay
All Tier 1 drugs are generic drugs.
Members pay the lowest copay for
generics, which make them the most
cost-effective option for treatment.
This tier includes generic specialty
drugs.
Preferred brand — higher copay
This tier includes preferred, brandname drugs. These drugs are more
expensive than generics, and
members pay a higher copay for
them. This tier includes preferred
brand specialty drugs.
Nonpreferred brands — highest
copay
This tier includes nonpreferred,
brand-name drugs for which there’s
a more cost-effective generic
alternative or preferred brand-name
drug available. Members pay the
highest copay for these drugs. This
tier includes nonpreferred specialty
drugs.
Generics — lowest copay
This tier includes most generic
drugs. Members pay the lowest
copay for generics, making them the
most cost-effective option for
treatment. Generic specialty drugs
are in Tier 4.
Preferred brand — higher copay
This tier includes preferred,
nonspecialty, brand-name drugs.
These drugs are more expensive
than generics, and members pay a
higher copay for them. Brand
specialty drugs are in Tier 4.
Nonpreferred brands — highest
nonspecialty copay
This tier includes nonspecialty
brand-name drugs for which there’s
either a generic alternative or a more
cost-effective, preferred brand-name
drug available. Members pay a
higher copay for these nonpreferred
brand drugs. Brand specialty drugs
are in Tier 4.
Specialty drugs — highest cost
sharing
This tier consists of specialty drugs,
both generic and brand name, that
are used to treat difficult health
conditions.
Generics — lowest copay
This tier includes most generic
drugs. Members pay the lowest
copay for generics, making them the
most cost-effective option for
treatment. Generic specialty drugs
are in Tier 4.
Preferred brand — higher copay
This tier includes preferred,
nonspecialty, brand-name drugs.
These drugs are more expensive
than generics, and members pay a
higher copay for them.
Tier 4
Does not apply
Tier 5
Does not apply
Does not apply
Nonpreferred brands — highest
nonspecialty copay
This tier includes nonspecialty,
brand-name drugs for which there’s
either a generic alternative or a more
cost-effective, preferred brand-name
drug available. Members pay a
higher copay for these nonpreferred
brand drugs.
Preferred specialty — lower
specialty drug cost sharing
This tier includes specialty drugs,
both generic and brand name, that
are used to treat difficult health
conditions. These drugs are
generally more cost-effective than
nonpreferred specialty drugs.
Nonpreferred specialty — higher
specialty drug cost sharing
This tier includes nonpreferred,
specialty drugs that are used to treat
difficult health conditions. Members
pay a higher copay for nonpreferred
specialty drugs because there are
more cost-effective generic or
preferred drugs available.
Page 9
New generics
When a generic version of a brand-name drug becomes available, the generic version is
generally added to Tier 1. Once the generic drug is added, the original, brand-name version
won’t be covered.
How prior approval, step therapy and quantity limits work
Prior approval
Prior approval may be necessary for coverage of certain medications. In these cases, the
member must meet clinical criteria, or additional information must be provided before coverage
is approved.
Criteria are based on current medical information and approved by the Blue Cross and BCN
Pharmacy and Therapeutics Committee.
Step therapy
Drugs subject to step therapy may require previous treatment with one or more preferred drugs
before coverage is approved.
To view a current list of drugs requiring prior approval or step therapy for Blue Cross PPO and
EPO plans, please see the Blue Cross Prior Authorization and Step Therapy Guidelines and
refer to the column labeled Custom Select Drug List.
Quantity limits and dose optimization
Quantity limits are set based on clinical appropriateness and manufacturer-recommended
dosing for particular drugs.
To view a current list of drugs that have quantity limits, please see the Blue Cross Quantity Limit
Program, and refer to the column labeled Custom Select Drug List.
The Blue Cross dose optimization program encourages appropriate prescribing of medications
intended for once-daily administration. For certain medications, doctors are encouraged to
prescribe prescription drugs in once-daily dosage regimens to help increase a member’s
adherence to the medication, as opposed to using multiple lower doses of the same drug.
Obtaining prior approval or step therapy
Blue Cross members should consult their prescription drug benefit packet for information on
how to obtain prior approval or how to request a review for coverage of a drug that isn't included
in their plan. Members can also call the Customer Service number on the back of their Blue
Cross member ID card for additional information. Members who have a PPO plan and need a
request taken care of right away can fill out an expedited request form on the web at
bcbsm.com.
Page 10
Or write to:
Blue Cross Blue Shield of Michigan
Pharmacy Services
P.O. Box 2320
Detroit, MI 48231-2320
For doctors:
Doctors can request approval for Blue Cross members one of four ways:
1. Online at bcbsm.com
a. Log in as a provider.
b. Select Medication Prior Authorization.
2. Call — 1-800-437-3803
3. Fax — 1-866-601-4425
4. Write
Blue Cross Blue Shield of Michigan
Pharmacy Services
P.O. Box 2320
Detroit, MI 48231-2320
Doctors can download the medication request forms through web-DENIS under Blue Cross
Provider Publications and Resources. Be sure to identify urgent requests, and return the
completed request forms to the Pharmacy Services Clinical Help Desk for review. We notify the
doctor of approved requests and process the member’s claim accordingly. If a request isn’t
approved, we’ll notify the member and doctor in writing. The notification includes the reason for
the denial and an explanation of the member’s appeal rights and the appeals process.
Page 11
Blue Care Network members
Tier descriptions
Tier 1: Generics — lowest copayment
Most Tier 1 drugs are generic drugs. Members pay
the lowest copay for generics, which make them the
most cost-effective option for treatment.
Tier 1 drugs are grouped into two tiers for BCN
members with a six-tier pharmacy benefit:
How do I know what type of
prescription coverage I have?
For details about your drug benefit,
please call the Customer Service
phone number on the back of your
BCN member ID card. If you have
online access, log in to your
account at bcbsm.com. You can
also find more general information
about BCN prescription coverage
at bcbsm.com/pharmacy.
Tier 1A: Preferred generics — lower
generic drug copay
This tier includes commonly prescribed drugs
that treat chronic diseases, such as
depression, hypertension, cholesterol, diabetes, heart disease and congestive heart
failure. Select brand-name drugs that treat chronic diseases, such as diabetes, are also
included in this tier. Offering these drugs at the lowest copay makes them more
accessible to members and helps ensure that they continue to take these important
drugs regularly as prescribed.
Tier 1B: Generics — higher generic drug copay
Tier 1B includes generic drugs that aren’t in Tier 1A. The Tier 1B copay is higher than
the Tier 1A copay, but it’s still lower than the copay for brand-name drugs.
Tier 2: Preferred brand — higher copay
This tier includes preferred, brand-name drugs that don’t have a generic equivalent. These
drugs are more expensive than generics, and members pay a higher copay for them.
Tier 3: Nonpreferred brands — highest copay
This tier includes brand-name drugs for which there’s either a generic alternative or a more
cost-effective, preferred brand-name drug available. Members pay the highest copay for these
nonspecialty drugs.
Tier 4: Preferred specialty — lower specialty drug cost sharing
Specialty drugs in Tier 4 are generally more effective and less expensive than nonpreferred
specialty drugs in Tier 5.
Tier 5: Nonpreferred specialty — higher specialty drug cost sharing
Members pay the highest copay for specialty drugs in Tier 5. That’s because there may be a
more cost-effective generic or preferred brand available.
Some BCN plans combine all specialty drugs into one specialty tier, Tier 4.
Page 12
How prior approval, step therapy and quantity limits work
Prior approval and step therapy
Prior approval may be necessary for coverage of certain medications. In these cases, the
member must meet clinical criteria or additional information must be provided before coverage
is considered. Drugs subject to step therapy may require previous treatment with one or more
preferred drugs before coverage is approved.
Clinical criteria are based on current medical information and approved by our Pharmacy and
Therapeutics Committee.
To view the list of drugs that require prior approval or step therapy for BCN HMO plans, please
refer to Blue Care Network Custom Select Drug List Prior Authorization and Step Therapy
Guidelines.
Quantity limits
BCN sets quantity limits based on clinical appropriateness and manufacturer-recommended
dosing for particular drugs. For certain medications, BCN limits the day supply that can be
dispensed per fill.
To view the list of drugs that require quantity limits for BCN HMO plans, please refer to: BCN
Quantity Limits.
Changes made following the publication of the BCN Prior Authorization and Step Therapy
Guidelines and Quantity Limits are listed in the BCN Drug List Updates document.
Obtaining prior approval
For members:
To request approval for a drug, BCN members can talk to their doctors.
Members can also start a request by contacting BCN Customer Service at the number on the
backs of their BCN member ID cards. Members can submit a request online by filling out our
callback form at bcbsm.com.
Or write to:
Blue Care Network
Clinical Pharmacy Help Desk — Mail Code C303
P.O. Box 5043
Southfield, MI 48076
Page 13
For doctors:
Doctors can request approval for BCN members one of three ways:
1. Call — 1-800-437-3803
a. Provide the member’s numeric contract number or enrollee ID. Do not use the
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
Clinical Pharmacy Help Desk — Mail Code C303
P.O. Box 5043
Southfield, MI 48076
Doctors can download the medication request forms through web-DENIS under BCN Provider
Publications and Resources. Be sure to identify urgent requests, and return the completed
request forms to the Pharmacy Services Clinical Help Desk for review. We notify the doctor of
approved requests and process the member’s claim accordingly. If a request isn’t approved,
we’ll notify the member and doctor in writing. The notification includes the reason for the denial
and an explanation of the member’s appeal rights and the appeals process.
Page 14
How to read the Custom Select Drug List
This drug list shows the drug’s copayment tier and whether the drug has special requirements for
coverage.
Drugs are listed alphabetically by brand name. If a generic version is available, the name is included in
the “Generic name” column next to the brand name, and coverage is provided for the generic version.
The brand name is included for informational purposes only, as the brand-name drug isn’t covered. If only
a brand name is listed, there isn’t a generic version available.
1
2
9
9
3
4
5
6
7
8
1
2
3
4
5
6
BCBSM: The information in this section
applies to members with a Blue Cross
drug plan.
therapy for coverage and quantity limits
apply for both Blue Cross and BCN plans.
7
BCN: The information in this section
applies to members with a BCN drug
plan.
Drugs are organized based on drug class
or indication for use.
Kynamro™ is a brand-name specialty
drug. It requires a Tier 2 copay for Blue
Cross members with a three-tier drug
plan, and a Tier 4 copay for all other drug
plans. Prior approval and quantity limits
apply for both Blue Cross and BCN plans.
The generic drug, atorvastatin calcium,
requires a Tier 1A copay for BCN
members with a six-tier drug plan and a
Tier 1 copay for all other plans. Quantity
limits apply for both Blue Cross and BCN
plans. Its brand-name equivalent, Lipitor®,
isn’t covered.
Livalo® is a brand-name drug that
requires a Tier 3 copay. It requires step
8
9
The generic drug fenofibric acid (choline)
requires a Tier 1B copay for BCN
members with a six-tier drug plan, and a
Tier 1 copay for all other drug plans.
Quantity limits apply for BCN plans.
Welchol® is a brand-name drug that
requires a Tier 2 copay.
Limits: This section lists information,
such as prior approval, step therapy and
quantity limits.
Prior approval: Plan approval is required
for coverage (listed as PA in the chart).
Step therapy: Previous treatment with
preferred drugs is required (listed as ST
in the chart).
Quantity limits: Prescriptions can’t
exceed a specific quantity per fill (listed
as QL in the chart)
“Prevent” indicates a preventive drug.
Page 15
1. Anti-infectives
1A. Antifungals
BCBSM (EPO/PPO)
Trade name
Ancobon
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
flucytosine
Cresemba capsule
1
1
1
1
QL
1B
2
2
2
2
2
Diflucan
fluconazole
1
1
1
1
1B
Grifulvin V
griseofulvin, microsize
1
1
1
1
1B
Gris-PEG
griseofulvin ultramicrosize
1
1
1
1
1B
Lamisil tablet
terbinafine hcl
1
1
1
1
1B
Mycelex Troche
clotrimazole
1
1
1
1
1B
Nizoral
ketoconazole
1
1
1
1
1B
Noxafil suspension
2
2
2
2
2
Noxafil tablet
2
2
2
2
2
QL
Nystatin
nystatin
1
1
1
1
1B
Sporanox capsule
itraconazole
1
1
1
1
1B
2
2
2
2
2
1
1
1
1
1B
Sporanox solution
Vfend
voriconazole
1B. Antimalarials
BCBSM (EPO/PPO)
Trade name
Aralen
Generic name
BCN (HMO)
1
1
1
1
1B
Coartem
2
2
2
2
2
Daraprim <s>
2
4
4
4
4
Lariam
mefloquine hcl
1
1
1
1
1B
Malarone
atovaquone/proguanil hcl
1
1
1
1
1B
1B
hydroxychloroquine sulfate
Primaquine
Qualaquin
quinine sulfate
1C. Antiparasitics and anthelmintics
Trade name
1
1
1
1
2
2
2
2
2
1
1
1
1
1B
BCBSM (EPO/PPO)
Generic name
Albenza
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
2
2
2
2
2
2
2
2
2
2
Biltricide
2
2
2
2
2
1
1
1
1
1B
2
2
2
2
2
1
1
1
1
1B
2
2
2
metronidazole
Flagyl ER
Humatin
paromomycin sulfate
Impavido
Mepron
atovaquone
Nebupent aerosol
PA, QL
2
2
1B
1
1
1
1
2
2
2
2
2
Stromectol
ivermectin
1
1
1
1
1B
Tindamax
tinidazole
1
1
1
1
1B
PA - Prior approval may be required
QL
PA
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
BCN (HMO)
Alinia
Flagyl
QL
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
chloroquine phosphate
Plaquenil
QL
1
2
3
4
5
6
7
8
9
10
11
12
13
14
QL
QL
<s> - Specialty Drug
Page 16
1
2
3
4
5
6
7
8
9
10
11
1D. Antiretrovirals
Trade name
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Aptivus
2
2
2
2
2
Atripla
2
2
2
2
2
1
1
1
1
1B
Complera
2
2
2
2
2
Crixivan
2
2
2
2
2
Descovy
2
2
2
2
2
Edurant
2
2
2
2
2
Combivir
lamivudine/zidovudine
Emtriva
QL
QL
QL
2
2
2
2
2
Epivir
lamivudine
1
1
1
1
1B
Epzicom
abacavir sulfate/lamivudine
1
1
1
1
1B
2
2
2
2
2
2
2
Evotaz
QL
Fuzeon
2
2
2
Genvoya
2
2
2
2
2
Intelence
2
2
2
2
2
Invirase
2
2
2
2
2
Isentress
2
2
2
2
2
Kaletra
QL
1
1
1
1
1B
Kaletra tablet
2
2
2
2
2
Lexiva
2
2
2
2
2
Norvir
2
2
2
2
2
2
2
lopinavir/ritonavir
QL
QL
Odefsey
2
2
2
Prezcobix
2
2
2
2
2
Prezista
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1B
Reyataz
2
2
2
2
2
Selzentry
2
2
2
2
2
Stribild
2
2
2
2
2
Sustiva
2
2
2
2
2
Tivicay
2
2
2
2
2
2
2
2
1
1
1
Truvada
2
2
2
Tybost
2
2
2
Vemlidy <s>
2
4
4
Videx
2
2
2
1
1
2
2
3
1
Rescriptor
Retrovir
zidovudine
Triumeq
Trizivir
Videx EC
abacavir/lamivudine/zidovudine
didanosine
Viracept
Viramune suspension
Viramune, XR
nevirapine
Viread
Zerit
stavudine
Ziagen solution
Ziagen tablet
PA - Prior approval may be required
abacavir sulfate
ST - Step therapy may be required
QL
QL
2
2
1
1B
2
2
2
2
4
4
2
2
1
1
1B
2
2
2
3
3
3
3
1
1
1
1B
2
2
2
2
2
1
1
1
1
1B
2
2
2
2
2
1
1
1
1
1B
QL
QL
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
<s> - Specialty Drug
Page 17
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
1E. Antituberculars
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Cycloserine
2
2
2
2
2
Ethambutol
ethambutol hcl
1
1
1
1
1B
Isoniazid
isoniazid
1
1
1
1
1B
Mycobutin
rifabutin
1
1
1
1
1B
3
3
3
3
3
Paser
Priftin
3
3
3
3
3
Pyrazinamide
pyrazinamide
1
1
1
1
1B
Rifadin
rifampin
1
1
1
1
1B
Rifamate
3
3
3
3
3
Rifater
3
3
3
3
3
Sirturo
2
2
2
2
2
3
3
PA
Trecator
3
1F. Antivirals
BCBSM (EPO/PPO)
Trade name
Generic name
3
3
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Baraclude solution <s>
2
4
4
4
4
4
4
4
4
4
5
Baraclude tablet <s>
entecavir
1
4
4
Copegus <s>
ribavirin
1
4
4
Daklinza <s>
3
4
5
Epclusa <s>
2
4
4
4
4
Epivir HBV solution
2
2
2
2
2
PA, QL
PA, QL
Epivir HBV tablet
lamivudine
1
1
1
1
1B
Famvir
famciclovir
1
1
1
1
1B
1
1B
4
5
4
4
4
5
4
4
4
4
2
2
Flumadine
rimantadine hcl
Harvoni <s>
Hepsera <s>
adefovir dipivoxil
Olysio <s>
Rebetol capsule <s>
ribavirin
Rebetol solution <s>
Relenza
Ribapak; Ribatab <s>
Ribasphere Ribapak tablet <s>
ribavirin
ribavirin
Sovaldi <s>
1
1
1
3
4
5
1
4
4
3
4
5
1
4
4
2
4
4
1
4
4
4
4
4
4
4
5
1
1B
1
1B
2
2
1
4
4
3
4
5
1
1
1
oseltamivir phosphate
1
1
1
2
2
2
3
4
5
Valcyte
valganciclovir hcl
1
1
1
Valtrex
valacyclovir hcl
1
1
1
2
4
4
1
1
1
Zepatier <s>
PA - Prior approval may be required
acyclovir
ST - Step therapy may be required
QL
2
amantadine hcl
Technivie <s>
PA, QL
2
Tamiflu
Tamiflu suspension
PA, QL
2
Symmetrel
Zovirax
1
2
3
4
5
6
7
8
9
10
PA, QL 11
12
PA, QL
QL
QL
PA, QL
PA, QL
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
4
5
1
1B
1
1B
4
4
1
1B
PA, QL
PA, QL
PA, QL
PA, QL
QL
PA, QL
QL
QL
PA, QL
PA, QL
<s> - Specialty Drug
Page 18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
1G. Cephalosporins
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Ceftin tablet
cefuroxime axetil
1
1
1
1
1B
Cefzil
cefprozil
1
1
1
1
1B
Duricef
cefadroxil
1
1
1
1
1B
Keflex
cephalexin
1
1
1
1
1B
Omnicef
cefdinir
1
1
1
1
1B
Spectracef
cefditoren pivoxil
1
1
1
1
1B
Suprax
cefixime
1
1
1
1
1B
3
3
3
3
3
1
2
3
4
5
6
7
8
9
10
11
1
1
1
1
1B
12
Ceclor, ER
cefaclor
1
1
1
1
1B
Cedax
ceftibuten
1
1
1
1
1B
2
2
2
2
2
Ceftin suspension
Suprax capsule, chew tablet,
500mg/5ml suspension
Vantin
cefpodoxime proxetil
1H. Macrolides
Trade name
Biaxin, XL
BCBSM (EPO/PPO)
Generic name
Dificid
erythromycin ethylsuccinate
Eryped 200mg/5ml, 400mg/5ml
Ery-tab
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
clarithromycin
E.E.S.
erythromycin base
Ery-tab 500mg
1
1B
3
3
1
1
1B
3
3
3
1
1
1
1B
3
3
3
3
1
1
1
3
3
3
1
1
3
3
1
3
QL
Erythromycin Base
erythromycin base
1
1
1
1
1B
Erythromycin Stearate
erythromycin stearate
1
1
1
1
1B
3
Ketek
3
3
3
3
3
3
3
3
3
1
1
1
1
1B
Zmax
3
3
3
3
3
1I. Penicillins
BCBSM (EPO/PPO)
PCE
Zithromax
azithromycin
Trade name
Generic name
QL
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
amoxicillin
1
1
1
1
1B
Ampicillin
ampicillin trihydrate
1
1
1
1
1B
2
2
2
2
2
Augmentin 125mg-31.25mg/ml
suspension
Augmentin, ES, XR
amoxicillin/potassium clav
1
1
1
1
1B
Dicloxacillin
dicloxacillin sodium
1
1
1
1
1B
Penicillin VK
penicillin v potassium
1
1
1
1
1B
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
9
10
11
12
BCN (HMO)
Amoxil
PA - Prior approval may be required
QL
1
2
3
4
5
6
<s> - Specialty Drug
Page 19
1J. Quinolones
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Avelox
moxifloxacin hcl
1
1
1
1
1B
Cipro suspension
ciprofloxacin
1
1
1
1
1B
3
3
3
3
3
Cipro suspension
Cipro tablet
ciprofloxacin hcl
1
1
1
1
1B
Cipro XR
ciprofloxacin/ciprofloxa hcl
1
1
1
1
1B
Factive
3
3
3
3
3
Floxin tablet
ofloxacin
1
1
1
1
1B
Levaquin
levofloxacin
1
1
1
1
1B
1K. Sulfonamides and combinations
Trade name
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Bactrim, DS; Septra, DS
sulfamethoxazole/trimethoprim
1
1
1
1
1B
Sulfadiazine
sulfadiazine
1
1
1
1
1B
1L. Tetracyclines
Trade name
BCBSM (EPO/PPO)
Generic name
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
demeclocycline hcl
1
1
1
1
1B
Minocin capsule
minocycline hcl
1
1
1
1
1B
Monodox
doxycycline monohydrate
1
1
1
1
1B
1B
Periostat
doxycycline hyclate
1
1
1
1
Tetracycline
tetracycline hcl
1
1
1
1
1B
Vibramycin
doxycycline hyclate
1
1
1
1
1B
Vibramycin suspension
doxycycline monohydrate
1
1
1
1
1B
Vibramycin syrup
3
3
3
3
3
1M. Urinary tract agents
BCBSM (EPO/PPO)
Generic name
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
nitrofurantoin
1
1
1
1
1B
Hiprex/Urex
methenamine hippurate
1
1
1
1
1B
Macrobid
nitrofurantoin monohyd/m-cryst
1
1
1
1
1B
Macrodantin
nitrofurantoin macrocrystal
1
1
1
1
1B
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1B
Primsol
Trimethoprim
PA - Prior approval may be required
trimethoprim
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
BCN (HMO)
Furadantin
Monurol
1
2
BCN (HMO)
Declomycin
Trade name
1
2
3
4
5
6
7
8
<s> - Specialty Drug
Page 20
1
2
3
4
5
6
7
1N. Miscellaneous anti-infectives
BCBSM (EPO/PPO)
Trade name
Generic name
Cayston <s>
Cleocin capsule
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL
PA, QL 1
4
5
3
4
5
clindamycin hcl
1
1
1B
1
1
1
1B
1
1
1
1B
1
1
1
1
1B
2
2
4
4
1
Cleocin solution
clindamycin palmitate hcl
1
Dapsone
dapsone
1
Neomycin
neomycin sulfate
Sivextro
1
QL
QL
2
2
2
Tobi <s>
tobramycin in 0.225% nacl
1
4
4
Vancocin
vancomycin hcl
1
1
1
1
1B
3
3
3
3
3
1
1
1
1
1B
Xifaxan 200mg
Zyvox
PA - Prior approval may be required
linezolid
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
QL
QL
<s> - Specialty Drug
Page 21
2
3
4
5
6
7
8
9
10
2. Cardiovascular, hypertension, cholesterol
2A. ACE-Inhibitors and combinations
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Accupril
quinapril hcl
1
1
1
1
1A
Accuretic
quinapril/hydrochlorothiazide
1
1
1
1
1A
Aceon
perindopril erbumine
1
1
1
1
1A
Altace
ramipril
1
1
1
1
1A
Capoten
captopril
1
1
1
1
1A
Capozide
captopril/hydrochlorothiazide
1
1
1
1
1A
Lotensin
benazepril hcl
1
1
1
1
1A
Lotensin HCT
benazepril/hydrochlorothiazide
1
1
1
1
1A
Lotrel
amlodipine besylate/benazepril
1
1
1
1
1A
Mavik
trandolapril
1
1
1
1
1A
Monopril
fosinopril sodium
1
1
1
1
1A
Monopril HCT
fosinopril/hydrochlorothiazide
1
1
1
1
1A
Prinivil; Zestril
lisinopril
1
1
1
1
1A
Prinzide; Zestoretic
lisinopril/hydrochlorothiazide
1
1
1
1
1A
Tarka
trandolapril/verapamil hcl
1
1
1
1
1B
Uniretic
moexipril/hydrochlorothiazide
1
1
1
1
1A
1A
Univasc
moexipril hcl
1
1
1
1
Vaseretic
enalapril/hydrochlorothiazide
1
1
1
1
1A
Vasotec
enalapril maleate
1
1
1
1
1A
2B. Alpha-adrenergic agents
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Aldomet
methyldopa
1
1
1
1
1B
Aldoril
methyldopa/hydrochlorothiazide
1
1
1
1
1B
Cardura
doxazosin mesylate
1
1
1
1
1B
Catapres
clonidine hcl
1
1
1
1
1A
Catapres-TTS
clonidine
1
1
1
1
1B
Clorpres
clonidine hcl/chlorthalidone
1
1
1
1
1B
3
3
3
3
3
1
1B
Clorpres 0.3mg-15mg
PA, QL
Dibenzyline
phenoxybenzamine hcl
1
1
1
Hytrin
terazosin hcl
1
1
1
1
1B
Minipress
prazosin hcl
1
1
1
1
1B
Reserpine
reserpine
1
1
1
1
1B
Tenex
guanfacine hcl
1
1
1
1
1B
PA - Prior approval may be required
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
PA
<s> - Specialty Drug
Page 22
1
2
3
4
5
6
7
8
9
10
11
12
2C. Angiotensin II Receptor Blockers and combinations
Trade name
Generic name
BCBSM (EPO/PPO)
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Atacand
candesartan cilexetil
1
1
1
1
1A
Atacand HCT
candesartan/hydrochlorothiazid
1
1
1
1
1A
Avalide
irbesartan/hydrochlorothiazide
1
1
1
1
1A
Avapro
irbesartan
1
1
1
1
1A
Azor
amlodipine bes/olmesartan med
1
1
1
1
1B
Benicar
olmesartan medoxomil
1
1
1
1
1B
Benicar HCT
olmesartan/hydrochlorothiazide
1
1
1
1
1B
Cozaar
losartan potassium
1
1
1
1
1A
Diovan
valsartan
1
1
1
1
1B
Diovan HCT
valsartan/hydrochlorothiazide
1
1
1
1
1A
3
3
3
3
3
3
3
Edarbi
Edarbyclor
3
3
3
Entresto
3
3
3
ST, QL
ST, QL
PA, QL
3
3
Exforge
amlodipine/valsartan
1
1
1
1
1B
Exforge HCT
amlodipine/valsartan/hcthiazid
1
1
1
1
1B
Hyzaar
losartan/hydrochlorothiazide
1
1
1
1
1A
Micardis
telmisartan
1
1
1
1
1B
Micardis HCT
telmisartan/hydrochlorothiazid
1
1
1
1
1B
Teveten
eprosartan mesylate
1
1
1
1
1A
Tribenzor
olmesartan/amlodipin/hcthiazid
1
1
1
1
1B
1
1B
Twynsta
PA - Prior approval may be required
telmisartan/amlodipine
ST - Step therapy may be required
1
1
QL
1
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
ST, QL
ST, QL
ST, QL
ST, QL
ST, QL
PA, QL
ST, QL
<s> - Specialty Drug
Page 23
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
2D. Anticoagulants and hemostasis agents
Trade name
Generic name
BCBSM (EPO/PPO)
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Aggrenox
aspirin/dipyridamole
1
1
1
1
1B
Agrylin
anagrelide hcl
1
1
1
1
1B
2
2
2
2
2
1
4
4
4
4
2
2
2
2
2
Amicar
Arixtra <s>
fondaparinux sodium
Brilinta
Coumadin
1
1
1
1
1A
Effient
2
2
2
2
2
Eliquis
2
2
2
2
2
Fragmin <s>
3
4
5
4
5
warfarin sodium
QL
Heparin 1000u/ml
heparin sodium,porcine/pf
1
1
1
1
1B
Heparin 5000/0.5ml <s>
heparin sodium,porcine/pf
1
4
4
4
4
Heparin 5000/ml, 10000/ml,
20000/ml <s>
heparin sodium,porcine
1
4
4
4
4
3
4
5
4
5
1
4
4
4
4
2
2
2
2
2
1
1
1
1
1B
Iprivask <s>
Lovenox <s>
enoxaparin sodium
Mephyton
Persantine
dipyridamole
Phytonadione
3
3
3
3
3
Plavix
clopidogrel bisulfate
1
1
1
1
1A
Pletal
cilostazol
1
1B
2
2
3
3
1
1
1
Pradaxa
2
2
2
Savaysa
3
3
3
QL
QL
Ticlid
ticlopidine hcl
1
1
1
1
1B
Trental
pentoxifylline
1
1
1
1
1B
Vitamin K ampule
phytonadione
1
1B
2
2
3
3
1
1
1
Xarelto, starter kit
2
2
2
Zontivity
3
3
3
PA - Prior approval may be required
ST - Step therapy may be required
QL
PA, QL
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
QL
QL
QL
QL
QL
QL
QL
QL
<s> - Specialty Drug
Page 24
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
2E. Beta blockers and combinations
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Betapace, AF
sotalol hcl
1
1
1
1
1A
Blocadren
timolol maleate
1
1
1
1
1A
3
3
3
3
3
Bystolic 2.5, 5, 10mg
Bystolic 20mg
3
3
3
3
3
Coreg immediate-release
carvedilol
1
1
1
1
1A
Corgard
nadolol
1
1
1
1
1A
Corzide
nadolol/bendroflumethiazide
1
1
1
1
1A
Dutoprol
3
3
3
3
3
Inderal, LA
propranolol hcl
1
1
1
1
1A
Inderide
propranolol/hydrochlorothiazid
1
1
1
1
1A
Kerlone
betaxolol hcl
1
1
1
1
1A
3
Levatol
3
3
3
3
Lopressor
metoprolol tartrate
1
1
1
1
1A
Lopressor HCT
metoprolol/hydrochlorothiazide
1
1
1
1
1A
Normodyne
labetalol hcl
1
1
1
1
1A
Sectral
acebutolol hcl
1
1
1
1
1A
Tenoretic
atenolol/chlorthalidone
1
1
1
1
1A
Tenormin
atenolol
1
1
1
1
1A
Toprol XL
metoprolol succinate
1
1
1
1
1A
Visken
pindolol
1
1
1
1
1A
1A
1A
Zebeta
bisoprolol fumarate
1
1
1
1
Ziac
bisoprolol fumarate/hctz
1
1
1
1
2F. Calcium channel blockers and combinations
Trade name
Generic name
BCBSM (EPO/PPO)
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Adalat CC; Procardia, XL
nifedipine
1
1
1
1
1B
Azor
amlodipine bes/olmesartan med
1
1
1
1
1B
Caduet
amlodipine/atorvastatin
1
1
1
1
1B
Calan SR; Isoptin SR
verapamil hcl
1
1
1
1
1B
Cardene
nicardipine hcl
1
1
1
1
1B
Cardizem, CD, LA, SR
diltiazem hcl
1
1
1
1
1B
Cardizem LA 120mg
QL
3
3
3
3
3
Dynacirc
isradipine
1
1
1
1
1B
Exforge
amlodipine/valsartan
1
1
1
1
1B
Exforge HCT
amlodipine/valsartan/hcthiazid
1
1
1
1
1B
Lotrel
amlodipine besylate/benazepril
1
1
1
1
1A
Norvasc
amlodipine besylate
1
1
1
1
1A
Plendil
felodipine
1
1
1
1
1B
Sular
nisoldipine
1
1
1
1
1B
Tarka
trandolapril/verapamil hcl
1
1
1
1
1B
Tekamlo
3
3
3
Tiazac
diltiazem hcl
1
1
1
Tribenzor
olmesartan/amlodipin/hcthiazid
1
1
1
Twynsta
telmisartan/amlodipine
1
1
1
1
Verelan, PM
PA - Prior approval may be required
1
2
ST, QL 3
ST
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
verapamil hcl
ST - Step therapy may be required
1
1
QL
QL
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
3
3
1
1B
1
1B
1
1B
1
1B
1
ST, QL 2
QL
3
4
5
6
7
8
9
10
11
12
13
14
15
ST, QL 16
17
ST, QL 18
19
20
<s> - Specialty Drug
Page 25
2G. Cardiovascular treatment
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Betapace, AF
sotalol hcl
1
1
1
1
1A
Cordarone; Pacerone
amiodarone hcl
1
1
1
1
1B
2
2
2
2
2
1
1
1
1
1B
3
3
3
3
3
1
1
1
1
1B
2
2
2
2
2
1
1
1
1
1B
2
2
2
2
2
Corlanor
Lanoxin
digoxin
Lanoxin 62.5, 187.5mcg
Mexitil
mexiletine hcl
Multaq
Norpace
disopyramide phosphate
Norpace CR
PA, QL
QL
Proamatine
midodrine hcl
1
1
1
1
1B
Quinidex
quinidine sulfate
1
1
1
1
1B
1B
Quinidine Gluconate SA
quinidine gluconate
Ranexa
1
1
1
1
3
3
3
3
3
Rythmol, SR
propafenone hcl
1
1
1
1
1B
Tambocor
flecainide acetate
1
1
1
1
1B
Tikosyn
dofetilide
1
1
1
1
1B
2H. Diuretics
Trade name
Aldactazide
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
spironolact/hydrochlorothiazid
Aldactazide 50/50mg
1
1
1
1
1A
3
3
3
3
3
Aldactone
spironolactone
1
1
1
1
1A
Bumex
bumetanide
1
1
1
1
1A
Demadex
torsemide
1
1
1
1
1A
1B
Diamox, Sequels
acetazolamide
1
1
1
1
Diuril
chlorothiazide
1
1
1
1
1A
3
3
3
3
3
1
1
1
1
1A
2
2
2
2
2
Diuril suspension
Dyazide; Maxzide
triamterene/hydrochlorothiazid
Dyrenium
Edecrin
ethacrynic acid
1
1
1
1
1B
Enduron
methyclothiazide
1
1
1
1
1B
Hydrodiuril; Microzide
hydrochlorothiazide
1
1
1
1
1A
Hygroton; Thalitone
chlorthalidone
1
1
1
1
1A
Inspra
eplerenone
1
1
1
1
1A
Lasix
furosemide
1
1
1
1
1A
Lozol
indapamide
1
1
1
1
1A
Midamor
amiloride hcl
1
1
1
1
1A
Moduretic
amiloride/hydrochlorothiazide
1
1
1
1
1A
Zaroxolyn
metolazone
1
1
1
1
1A
PA - Prior approval may be required
1
2
PA, QL 3
4
5
6
QL
7
8
9
10
11
12
PA 13
14
15
16
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
<s> - Specialty Drug
Page 26
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
2I. Lipid-lowering agents
BCBSM (EPO/PPO)
Trade name
Antara
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
fenofibrate,micronized
Antara 30, 90mg
1
1
1
1
1B
3
3
3
3
3
1
1B
QL
Caduet
amlodipine/atorvastatin
1
1
1
Colestid
colestipol hcl
1
1
1
1
1B
3
3
3
3
3
1
1B
1
1B
Colestid granules, packet
Crestor
rosuvastatin calcium
1
1
1
Fibricor
fenofibric acid
1
1
1
Kynamro <s>
2
4
4
Lescol, XL
fluvastatin sodium
1
1
1
Lipitor
atorvastatin calcium
1
1
1
3
3
3
Livalo
QL
PA, QL
QL
QL
ST, QL
4
4
1
1B
1
1A
3
3
1A
Lofibra capsule
fenofibrate,micronized
1
1
1
1
Lofibra tablet
fenofibrate
1
1
1
1
1A
Lopid
gemfibrozil
1
1
1
1
1A
Lovaza
omega-3 acid ethyl esters
1
1
1
1
1B
Mevacor
lovastatin
1
1
1
1
1A
3
3
3
3
3
1
1
1
1
1B
Niacor
Niaspan
niacin
Praluent <s>
5
1
1A
1
1
1B
1
1
1B
4
5
4
5
pravastatin sodium
1
1
1
Questran
cholestyramine (with sugar)
1
1
Questran Light
cholestyramine/aspartame
1
1
Tricor
fenofibrate nanocrystallized
4
5
1
1
1
1
1B
1
1B
1
1B
2
2
1
1B
1
1A
fenofibric acid (choline)
1
1
1
Vytorin
ezetimibe/simvastatin
1
1
1
2
2
2
Zetia
ezetimibe
1
1
1
Zocor
simvastatin
1
1
1
2J. Nitrates and combinations
Trade name
PA, QL
3
Trilipix
Welchol
PA, QL
QL
4
3
Pravachol
Repatha <s>
PA
QL
QL
QL
QL
BCBSM (EPO/PPO)
Generic name
ST, QL
PA, QL
PA, QL
PA, QL
QL
QL
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
2
2
2
2
2
Dilatrate-SR
2
2
2
2
2
Imdur; Ismo; Monoket
isosorbide mononitrate
1
1
1
1
1A
Isordil
isosorbide dinitrate
1
1
1
1
1B
3
3
3
3
3
1
1
1
1
1B
3
3
3
3
3
1B
Isordil 40mg
nitroglycerin
Nitro-Dur 0.3mg, 0.8mg
Nitroglycerin capsule, patch
nitroglycerin
1
1
1
1
Nitromist
nitroglycerin
1
1
1
1
1B
Nitrostat
nitroglycerin
1
1
1
1
1B
PA - Prior approval may be required
PA, QL
BCN (HMO)
Bidil
Nitro-bid ointment
QL
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
<s> - Specialty Drug
Page 27
1
2
3
4
5
6
7
8
9
10
2K. Renin-inhibitors and combinations
BCBSM (EPO/PPO)
Trade name
Generic name
Tekamlo
Tekturna
Tekturna HCT
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
ST, QL 1
3
3
3
3
3
PA
PA
3
3
3
3
3
2
PA
3
3
3
3
3
3
2L. Miscellaneous antihypertensives
BCBSM (EPO/PPO)
Trade name
Apresoline
Generic name
PA - Prior approval may be required
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
hydralazine hcl
Demser
Loniten
BCN (HMO)
minoxidil
ST - Step therapy may be required
1
1
1
1
1B
3
3
3
3
3
1
1
1
1
1B
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
<s> - Specialty Drug
Page 28
1
2
3
3. Central nervous system
3A. Alzheimer's therapy
Trade name
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Aricept 5, 10mg; ODT
donepezil hcl
1
1
1
1
1B
Exelon capsule
rivastigmine tartrate
1
1
1
1
1B
Exelon patch
rivastigmine
1
1
1
1
1B
Namenda dosepak
2
2
2
2
2
Namenda immediate release
memantine hcl
1
1
1
1
1B
Razadyne, ER
galantamine hbr
1
1
1
1
1B
PA - Prior approval may be required
ST - Step therapy may be required
QL - Quantity limits may apply
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
Page 29
1
2
3
4
5
6
3B. Anticonvulsants
Trade name
BCBSM (EPO/PPO)
Generic name
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Banzel
2
2
2
Briviact
3
3
3
1
1
3
Carbatrol
BCN (HMO)
carbamazepine
Celontin
2
2
3
3
1
1
1B
3
3
3
3
PA, QL
Depakene capsule
valproic acid
1
1
1
1
1B
Depakene solution
valproic acid (as sodium salt)
1
1
1
1
1B
Depakote, ER, sprinkles
divalproex sodium
1
1
1
1
1B
Diamox, Sequels
acetazolamide
1
1
1
1
1B
Diastat 2.5mg
diazepam
1
1
1
1
1B
Diastat 2.5mg
2
2
2
2
2
Diastat Acudial
diazepam
1
1
1
1
1B
Dilantin
phenytoin
1
1
1
1
1A
Dilantin 30mg capsule
2
2
2
2
2
Dilantin; Phenytek capsule 100mg
phenytoin sodium extended
1
1
1
1
1A
Dilantin; Phenytek capsule 200mg,
300mg
Equetro
phenytoin sodium extended
1
1
1
1
1B
3
3
3
3
3
Felbatol
felbamate
1
1
1
1
1B
Fycompa suspension
3
3
3
3
3
Fycompa tablet
3
3
3
Gabitril
tiagabine hcl
Gabitril 12mg, 16mg
PA, QL
PA, QL
3
3
1B
1
1
1
1
2
2
2
2
2
Keppra
levetiracetam
1
1
1
1
1A
Keppra XR
levetiracetam
1
1
1
1
1B
Klonopin, Wafer
clonazepam
1
1
1
1
1B
Lamictal, dispertabs, ODT, XR
lamotrigine
1
1
1
1
1B
Lamictal dosepak
2
2
2
2
2
Lamictal XR dosepak
3
3
3
3
3
Lyrica
3
3
3
PA
3
3
1
1B
1
1B
3
3
Mysoline
primidone
1
1
1
Neurontin
gabapentin
1
1
1
3
3
3
2
2
2
2
2
1
1
1
1
1B
Potiga
3
3
3
3
3
Sabril <s>
2
4
4
4
4
Onfi
Peganone
Phenobarbital
phenobarbital
PA, QL
Tegretol, XR
carbamazepine
1
1
1
1
1B
Topamax, Sprinkle
topiramate
1
1
1
1
1B
Trileptal
oxcarbazepine
1
1
1
1
1B
2
2
2
2
2
1B
1B
Vimpat
Zarontin
ethosuximide
1
1
1
1
Zonegran
zonisamide
1
1
1
1
PA - Prior approval may be required
ST - Step therapy may be required
QL - Quantity limits may apply
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
QL 19
20
21
22
23
24
25
26
27
PA, QL 28
29
30
PA, QL 31
32
33
34
35
36
37
38
39
40
41
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
1
PA, QL 2
Page 30
3C. Antidepressants
Trade name
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Adapin; Sinequan
doxepin hcl
1
1
1
1
1A
Amoxapine
amoxapine
1
1
1
1
1B
Anafranil
clomipramine hcl
1
1
1
1
1B
Aplenzin
ST
3
3
3
3
3
Aventyl; Pamelor
nortriptyline hcl
1
1
1
1
1A
Celexa
citalopram hydrobromide
1
1
1
1
1A
Cymbalta
duloxetine hcl
1
1
1
1
1B
Desvenlafaxine ER
ST, QL
3
3
3
3
3
Desyrel
trazodone hcl
1
1
1
1
1A
Effexor
venlafaxine hcl
1
1
1
1
1A
Effexor XR; Venlafaxine hcl ER
venlafaxine hcl
1
1
1
1
1A
1A
Elavil
amitriptyline hcl
Emsam
Etrafon
perphenazine/amitriptyline hcl
Fluoxetine 60mg
1
1
1
1
3
3
3
3
3
1
1
1
1
1B
QL
3
3
3
3
3
Lexapro
escitalopram oxalate
1
1
1
1
1A
Limbitrol, DS
amitrip hcl/chlordiazepoxide
1
1
1
1
1B
Luvox
fluvoxamine maleate
1
1
1
1
1A
Luvox CR
fluvoxamine maleate
1
1
1
1
1B
Maprotiline hcl
maprotiline hcl
1
1
1
1
1A
3
Marplan
3
3
3
3
Nardil
phenelzine sulfate
1
1
1
1
1B
Norpramin
desipramine hcl
1
1
1
1
1A
Parnate
tranylcypromine sulfate
1
1
1
1
1B
Paxil
paroxetine hcl
1
1
1
1
1A
Paxil CR
paroxetine hcl
1
1
1
1
1B
3
3
3
3
3
Paxil suspension
Pexeva
3
1
1A
1
1A
1
1
1A
1
1
1B
1
1
1
1B
1
1
1
1A
1
1
1
1
1B
3
3
3
3
3
3
3
fluoxetine hcl
1
1
1
Prozac Weekly
fluoxetine hcl
1
1
1
Remeron
mirtazapine
1
1
Serzone
nefazodone hcl
1
1
Surmontil
trimipramine maleate
1
Tofranil
imipramine hcl
1
Tofranil-PM
imipramine pamoate
Trintellix
Viibryd, dosepak
ST
3
3
Prozac
QL
ST, QL
ST, QL
3
3
3
3
3
Vivactil
protriptyline hcl
1
1
1
1
1B
Wellbutrin, SR, XL
bupropion hcl
1
1
1
1
1A
Zoloft
sertraline hcl
1
1
1
1
1A
PA - Prior approval may be required
ST - Step therapy may be required
QL - Quantity limits may apply
PA
PA, QL
PA, QL
PA, QL
PA, QL
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
Page 31
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
3D. Antipsychotics
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Abilify
aripiprazole
1
1
1
1
1B
Clozapine 200mg
clozapine
1
1
1
1
1B
Clozaril
clozapine
1
1
1
1
1A
Etrafon
perphenazine/amitriptyline hcl
1
1
1
1
1B
3
3
3
3
3
1
1
1
1
1B
3
3
3
3
3
Fanapt
Fazaclo
clozapine
Fazaclo 150, 200mg
ST
Geodon
ziprasidone hcl
1
1
1
1
1B
Haldol liquid
haloperidol lactate
1
1
1
1
1B
Haldol tablet
haloperidol
1
1
1
1
1A
Invega
paliperidone
1
1
1
1
1B
3
3
Latuda
QL
ST
3
3
3
Loxitane
loxapine succinate
1
1
1
1
1B
Mellaril
thioridazine hcl
1
1
1
1
1A
Navane
thiothixene
1
1
1
1
1B
3
3
3
3
3
Nuplazid
PA, QL
Orap
pimozide
1
1
1
1
1B
Perphenazine
perphenazine
1
1
1
1
1B
Prolixin
fluphenazine hcl
1
1
1
1
1A
Risperdal, M-Tab
risperidone
1
1
1
1
1A
3
3
1
1A
1
1B
Saphris
3
3
3
ST, QL
Seroquel
quetiapine fumarate
1
1
1
Seroquel XR
quetiapine fumarate
1
1
1
Stelazine
trifluoperazine hcl
1
1
1
1
1A
Symbyax
olanzapine/fluoxetine hcl
1
1
1
1
1B
Thorazine
chlorpromazine hcl
1
1
1
1
1B
3
3
3
3
3
1
1
1
1
1A
Vraylar
Zyprexa, Zydis
olanzapine
3E. Anxiolytics
Trade name
ST, QL
ST, QL
BCBSM (EPO/PPO)
Generic name
ST, QL
ST
PA, QL
ST, QL
ST, QL
ST, QL
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Ativan
lorazepam
1
1
1
1
1B
Buspar
buspirone hcl
1
1
1
1
1B
Equanil; Miltown
meprobamate
1
1
1
1
1B
Librium
chlordiazepoxide hcl
1
1
1
1
1B
Lorazepam intensol
lorazepam
1
1
1
1
1B
Niravam
alprazolam
1
1
1
1
1B
Serax
oxazepam
1
1
1
1
1B
Tranxene T-Tab
clorazepate dipotassium
1
1
1
1
1B
Valium
diazepam
1
1
1
1
1B
Xanax, XR
alprazolam
1
1
1
1
1B
PA - Prior approval may be required
ST
ST
ST
ST - Step therapy may be required
QL - Quantity limits may apply
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Page 32
1
2
3
4
5
6
7
8
9
10
3F. CNS stimulants
BCBSM (EPO/PPO)
BCN (HMO)
Adderall
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
QL
1
1B
1
1
1
dextroamphetamine/amphetamine
Adderall XR
dextroamphetamine/amphetamine
1
1
1
Concerta
methylphenidate hcl
1
1
3
Trade name
Generic name
Daytrana
QL
1
1B
QL
2
1
1
1B
3
3
3
3
QL
QL
QL
QL
QL
QL
QL
PA, QL
PA, QL
PA, QL
QL
QL
PA, QL
QL
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Desoxyn
methamphetamine hcl
1
1
1
1
1B
Dexedrine
dextroamphetamine sulfate
1
1
1
1
1B
Focalin immediate-release
dexmethylphenidate hcl
1
1
1
1
1B
Metadate CD
methylphenidate hcl
1
1
1
1
1B
Methylin, ER
methylphenidate hcl
1
1
1
1
1B
Nuvigil
armodafinil
1
1
1
1
1B
Procentra
dextroamphetamine sulfate
1
1
1
1
1B
Provigil
modafinil
1
1
1
1
1B
3
3
3
3
3
1
1B
3
3
3
3
Ritalin LA 10mg
Ritalin, LA, SR
QL
QL
1
1
1
Vyvanse
3
3
3
Zenzedi
3
3
3
3G. Migraine therapy
BCBSM (EPO/PPO)
Trade name
methylphenidate hcl
Generic name
Alsuma
sumatriptan succinate
Amerge
naratriptan hcl
Axert
almotriptan malate
Cafergot
ergotamine tartrate/caffeine
D.H.E.45
dihydroergotamine mesylate
Ergomar
PA, QL
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
QL
1
1B
1
1
1
QL
QL
1
1B
1
1
1
ST, QL
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
2
2
2
2
2
QL
1
1B
1
1
1
PA,
QL
1
1B
1
1
1
PA, QL
1
1B
1
1
1
QL
1
1B
1
1
1
Esgic; Fioricet 50/325/40mg
butalb/acetaminophen/caffeine
Fioricet 50/300/40mg
butalb/acetaminophen/caffeine
Fioricet w/codeine 50/300/30mg
butalbit/acetamin/caff/codeine
Fioricet w/codeine 50/325/30mg
butalbit/acetamin/caff/codeine
Fiorinal
butalbital/aspirin/caffeine
1
1
1
1
1B
Fiorinal w/codeine
codeine/butalbital/asa/caffein
1
1
1
1
1B
Frova
frovatriptan succinate
1
1
1
1
1B
Imitrex
sumatriptan succinate
1
1
1
1
1B
Imitrex nasal spray
sumatriptan
1
1
1
1
1B
Maxalt, MLT
rizatriptan benzoate
1
1
1
1
1B
Migergot
ergotamine tartrate/caffeine
1
1
1
1
1B
Migranal
dihydroergotamine mesylate
1
1
1
1
1B
1
1B
3
3
3
3
1
1B
Phrenilin tablet
1
1
1
Relpax
3
3
3
Zomig nasal spray
3
3
3
1
1
1
Zomig, ZMT
PA - Prior approval may be required
butalbital/acetaminophen
zolmitriptan
ST - Step therapy may be required
ST, QL
QL
QL
QL
QL
ST, QL
ST, QL
ST, QL
QL - Quantity limits may apply
1
2
3
4
5
6
7
8
9
10
11
12
ST, QL 13
QL 14
QL 15
QL 16
17
QL 18
19
ST, QL 20
ST, QL 21
QL 22
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
1
Page 33
3H. Myesthenia gravis
Trade name
BCBSM (EPO/PPO)
Generic name
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Mestinon syrup
Mestinon, Timespan
pyridostigmine bromide
3I. Narcotic antagonists
Trade name
Generic name
2
2
2
2
1
1
1
1
1B
naloxone hcl
naltrexone hcl
1
1
1
2
2
2
1
1
1
1
QL
1
2
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
QL
2
2
2
2
2
Narcan nasal spray
Revia
2
BCBSM (EPO/PPO)
Evzio
Naloxone hcl injection
BCN (HMO)
1B
2
2
1
1B
QL
1
2
3
4
MB - may be covered under medical benefit
3J. Narcotic mixed agonist and antagonist
Trade name
Generic name
Bunavail
Butrans
Ryzolt
tramadol hcl
Stadol NS
butorphanol tartrate
Suboxone
buprenorphine hcl/naloxone hcl
Suboxone film
Subutex
buprenorphine hcl
Talwin NX
pentazocine hcl/naloxone hcl
Ultracet
tramadol hcl/acetaminophen
Ultram, ER
tramadol hcl
BCBSM (EPO/PPO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
3
3
3
3
3
PA, QL 3
PA, QL
3
3
3
3
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
2
2
2
2
2
PA, QL
PA, QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
1
1
1
Zubsolv
3
3
3
3K. Narcotic and analgesic combinations
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
QL
1
1B
3
3
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
1
1B
1
1
1
PA, QL
1
1B
1
1
1
PA, QL
1
1B
1
1
1
QL
1
1B
1
1
1
Esgic; Fioricet 50/325/40mg
butalb/acetaminophen/caffeine
Fioricet 50/300/40mg
butalb/acetaminophen/caffeine
Fioricet w/codeine 50/300/30mg
butalbit/acetamin/caff/codeine
Fioricet w/codeine 50/325/30mg
butalbit/acetamin/caff/codeine
Fiorinal
butalbital/aspirin/caffeine
1
1
1
1
1B
Fiorinal w/codeine
codeine/butalbital/asa/caffein
1
1
1
1
1B
Hycet
hydrocodone/acetaminophen
1
1
1
1
1B
Norco; Vicodin; Xodol
hydrocodone/acetaminophen
1
1
1
1
1B
Percocet
oxycodone hcl/acetaminophen
1
1
1
1
1B
Percodan
oxycodone hcl/aspirin
1
1
1
1
1B
1
1B
QL
QL
Phrenilin tablet
butalbital/acetaminophen
1
1
1
Tylenol w/codeine
acetaminophen with codeine
1
1
1
1
1B
Tylenol w/codeine solution
acetaminophen with codeine
1
1
1
1
1B
Vicoprofen
hydrocodone/ibuprofen
1
1
1
1
1B
PA - Prior approval may be required
ST - Step therapy may be required
QL
QL - Quantity limits may apply
QL
QL
QL
QL
QL
QL
QL
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
9
10
11
Page 34
1
2
3
4
5
6
7
8
9
10
11
12
13
14
3L. Narcotics
BCBSM (EPO/PPO)
Trade name
Generic name
Actiq
fentanyl citrate
Belladonna & Opium
opium/belladonna alkaloids
Codeine sulfate tablet
codeine sulfate
Dilaudid
hydromorphone hcl
Duragesic
fentanyl
Exalgo
hydromorphone hcl
Levorphanol Tartrate
levorphanol tartrate
Methadone
methadone hcl
MS Contin
morphine sulfate
MSIR
morphine sulfate
Nubain
nalbuphine hcl
Nucynta, ER
Oxycodone hcl ER
Oxycodone immediate release,
solution
Oxycontin
oxycodone hcl
RMS Suppository
Roxanol
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL
PA, QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
PA, QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
PA,
QL
PA,
QL
3
3
3
3
3
PA, QL
PA, QL
3
3
3
3
3
QL
QL
1
1B
1
1
1
3
1
1
1B
1
1
1B
3
3
3
3
morphine sulfate
1
1
morphine sulfate
1
1
3
ST - Step therapy may be required
3
PA, QL
3
3
Zohydro ER
PA - Prior approval may be required
BCN (HMO)
3
PA, QL
QL - Quantity limits may apply
PA, QL
QL
QL
PA, QL
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
Page 35
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
3M. Nonsteroidal anti-inflammatory drugs
Trade name
Generic name
BCBSM (EPO/PPO)
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Anaprox, DS
naproxen sodium
1
1
1
1
1A
Ansaid
flurbiprofen
1
1
1
1
1B
Cataflam
diclofenac potassium
1
1
1
1
1B
Celebrex
celecoxib
1
1
1
1
1B
Clinoril
sulindac
1
1
1
1
1B
Daypro
oxaprozin
1
1
1
1
1B
EC-Naproxyn
naproxen
1
1
1
1
1A
Feldene
piroxicam
1
1
1
1
1B
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1B
2
2
2
2
2
Fenoprofen Calcium 200mg, 400mg
Fenortho
Indocin, SR
indomethacin
Indocin suppository
Indocin suspension
PA
3
3
3
3
3
Ketoprofen
ketoprofen
1
1
1
1
1B
Lodine, XL
etodolac
1
1
1
1
1B
Meclomen
meclofenamate sodium
1
1
1
1
1B
Mobic
meloxicam
1
1
1
1
1A
Motrin (Rx Only)
ibuprofen
1
1
1
1
1A
Nalfon
fenoprofen calcium
1
1
1
1
1B
3
3
3
3
3
1A
Nalfon 400mg
Naprosyn (Rx Only)
naproxen
1
1
1
1
Relafen
nabumetone
1
1
1
1
1B
Tolectin, DS
tolmetin sodium
1
1
1
1
1B
Toradol injection
ketorolac tromethamine
1
1
1
1
1B
Toradol tablet
ketorolac tromethamine
1
1
1
1
1B
Voltaren gel
diclofenac sodium
1
1
1
1
1B
Voltaren tablet
diclofenac sodium
1
1
1
1
1A
Voltaren-XR
diclofenac sodium
1
1
1
1
1B
PA - Prior approval may be required
ST - Step therapy may be required
QL
ST, QL
QL - Quantity limits may apply
QL
QL
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
Page 36
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
3N. Parkinsons disease and related disorders
Trade name
Generic name
BCBSM (EPO/PPO)
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Apokyn <s>
2
4
4
4
4
Artane
trihexyphenidyl hcl
1
1
1
1
1B
Azilect
rasagiline mesylate
1
1
1
1
1B
Cogentin
benztropine mesylate
1
1
1
1
1B
Comtan
entacapone
1
1
1
1
1B
PA, QL
2
4
4
4
4
Eldepryl
selegiline hcl
1
1
1
1
1B
Lodosyn
carbidopa
1
1
1
1
1B
Mirapex immediate-release
pramipexole di-hcl
1
1
1
1
1B
Duopa <s>
Nuplazid
PA, QL
3
3
3
3
3
Parcopa
carbidopa/levodopa
1
1
1
1
1B
Parlodel
bromocriptine mesylate
1
1
1
1
1B
Requip
ropinirole hcl
1
1
1
1
1B
1B
Requip XL
ropinirole hcl
1
1
1
1
Sinemet, CR
carbidopa/levodopa
1
1
1
1
1B
Stalevo
carbidopa/levodopa/entacapone
1
1
1
1
1B
Symmetrel
amantadine hcl
1
1
1
1
1B
Tasmar
tolcapone
1
1
1
1
1B
3O. Salicylates
BCBSM (EPO/PPO)
Trade name
Generic name
1
2
3
4
5
PA, QL 6
7
8
9
PA, QL 10
11
12
13
14
15
16
17
18
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Aspirin; Ecotrin 81mg, 325mg
(OTC) (Prevent)
aspirin
$0
$0
$0
$0
$0
1
Disalcid
salsalate
1
1
1
1
1B
Dolobid
diflunisal
1
1
1
1
1B
2
3
3P. Sedative and hypnotics
BCBSM (EPO/PPO)
Trade name
Generic name
Ambien
zolpidem tartrate
Ambien CR
zolpidem tartrate
Dalmane
flurazepam hcl
Halcion
triazolam
Hetlioz <s>
Lunesta
eszopiclone
Prosom
estazolam
Restoril
temazepam
Rozerem
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
1
1B
1
1
1
ST, QL
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
PA, QL
PA, QL
4
5
3
4
5
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
ST,
QL
ST
3
3
3
3
3
Seconal
secobarbital sodium
1
1
1
Sonata
zaleplon
1
1
1
Versed syrup
midazolam hcl
1
1
1
PA - Prior approval may be required
BCN (HMO)
ST - Step therapy may be required
QL
QL - Quantity limits may apply
1
1B
1
1B
1
1B
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
Page 37
1
2
3
4
5
6
7
8
9
10
11
12
3Q. Skeletal muscle relaxants
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Baclofen
baclofen
1
1
1
1
1B
Dantrium
dantrolene sodium
1
1
1
1
1B
Flexeril
cyclobenzaprine hcl
1
1
1
1
1B
Lorzone
3
3
3
3
3
Norflex
orphenadrine citrate
1
1
1
1
1B
Parafon Forte DSC
chlorzoxazone
1
1
1
1
1B
Robaxin
methocarbamol
1
1
1
1
1B
Skelaxin
metaxalone
1
1
1
1
1B
Soma
carisoprodol
1
1
1
1
1B
Valium
diazepam
1
1
1
1
1B
Zanaflex capsule
tizanidine hcl
1
1
1
1
1B
1
1
1B
Zanaflex tablet
tizanidine hcl
1
3R. Miscellaneous CNS
1
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Antabuse
disulfiram
1
1
1
1
1B
Cafcit
caffeine citrate
1
1
1
1
1B
Campral
acamprosate calcium
1
1
1
1
1B
Cuvposa
3
3
3
3
3
Ergoloid Mesylates
ergoloid mesylates
1
1
1
1
1B
Eskalith, CR; Lithobid
lithium carbonate
1
1
1
1
1A
Guanidine hcl
guanidine hcl
1
1
1
1
1B
Kapvay
clonidine hcl
1
1
1
1
1B
Lithium Citrate
lithium citrate
1
1
1
1
1B
Nimotop
nimodipine
1
1
1
1
1B
Nuedexta
2
2
2
2
2
Nymalize
3
3
3
3
3
1
1
1
1
1B
3
3
3
3
3
Rilutek
riluzole
Savella
Savella dose pack
3
3
3
Strattera
atomoxetine hcl
1
1
1
Xenazine <s>
tetrabenazine
1
4
4
3
4
5
Xyrem <s>
PA - Prior approval may be required
1
2
3
4
5
6
7
PA
8
PA, QL 9
10
PA 11
12
ST - Step therapy may be required
QL
PA, QL
QL
PA, QL
PA
PA, QL
PA, QL
QL - Quantity limits may apply
3
3
1
1B
4
4
4
5
QL
PA, QL
QL
PA, QL
PA, QL
ST, QL
PA, QL
PA, QL
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
Page 38
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
4. Gastrointestinal agents
4A. 5-Aminosalicylic Acid (5-ASA) agents
Trade name
Generic name
BCBSM (EPO/PPO)
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Apriso
3
3
3
3
2
2
2
2
2
1
1
1
1
1B
2
2
2
2
2
1
1
1
1
1B
Delzicol
2
2
2
2
2
Dipentum
3
3
3
3
3
Giazo
3
3
3
3
3
Lialda
3
3
3
3
3
Mesalamine tablet
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1B
Asacol HD
Azulfidine, EN-tab
sulfasalazine
Canasa
Colazal
balsalazide disodium
Pentasa
Rowasa enema
mesalamine
4B. Antidiarrheals and antispasmodics
Trade name
ST, QL
BCBSM (EPO/PPO)
Generic name
3
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Bentyl
dicyclomine hcl
1
1
1
1
1B
Levbid
hyoscyamine sulfate
1
1
1
1
1B
Levsin, SL
hyoscyamine sulfate
1
1
1
1
1B
Librax
chlordiazepoxide/clidinium br
1
1
1
1
1B
Lomotil
diphenoxylate hcl/atropine
1
1
1
1
1B
2
2
PA, QL
Mytesi
2
4C. Antiemetics
BCBSM (EPO/PPO)
Trade name
Generic name
Akynzeo
Anzemet
QL
QL
2
2
1
2
3
4
5
PA, QL 6
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL
PA, QL 1
3
3
3
3
3
QL
3
3
3
3
3
2
Cesamet
3
3
3
3
3
Compazine suppository
prochlorperazine
1
1
1
1
1B
Compazine tablet
prochlorperazine maleate
1
1
1
1
1B
2
2
2
2
2
QL
1
1
1
1
1B
2
2
2
2
2
QL
QL
QL
Emend 80mg (1 pack, 6 pack),
125mg capsule
Emend 80mg, 125mg dose pack
aprepitant
Emend suspension
ST, QL
Kytril
granisetron hcl
1
1
1
1
1B
Marinol
dronabinol
1
1
1
1
1B
1
1B
Phenergan
promethazine hcl
Sancuso
Tigan
trimethobenzamide hcl
Transderm-Scop
1
1
1
3
3
3
3
3
1
1
1
1
1B
PA, QL
2
2
2
2
2
Zofran
ondansetron hcl
1
1
1
1
1B
Zofran ODT
ondansetron
1
1
1
1
1B
PA - Prior approval may be required
1
2
3
4
5
6
7
8
9
10
11
12
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
3
4
5
6
7
8
9
10
11
ST, QL 12
13
14
15
16
<s> - Specialty Drug
Page 39
4D. Bile acids
BCBSM (EPO/PPO)
Trade name
Actigall
Generic name
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
ursodiol
1
1
1
Chenodal <s>
3
4
5
Ocaliva <s>
2
4
4
1
1
1
Urso; Forte
ursodiol
4E. Bowel preparation and cleansing agents
Trade name
Bisacodyl OTC (Prevent)
Generic name
bisacodyl
Citrate of Magnesia OTC (Prevent) magnesium citrate
BCN (HMO)
PA
PA, QL
1
1B
4
5
4
4
1
1B
BCBSM (EPO/PPO)
BCN (HMO)
Colyte (Prevent)
peg 3350/na sulf,bicarb,cl/kcl
Colyte
peg 3350/na sulf,bicarb,cl/kcl
1
1
1
Glycolax (Prevent)
polyethylene glycol 3350
$0
$0
$0
Glycolax
polyethylene glycol 3350
1
1
1
Glycolax OTC (Prevent)
polyethylene glycol 3350
$0
$0
$0
Golytely (Prevent)
peg 3350/na sulf,bicarb,cl/kcl
$0
$0
$0
$0
$0
Golytely
peg 3350/na sulf,bicarb,cl/kcl
1
1
1
1
1B
2
2
2
2
2
$0
$0
$0
Halflytely-Bisacodyl (Prevent)
bisac/nacl/nahco3/kcl/peg 3350
Halflytely-Bisacodyl
bisac/nacl/nahco3/kcl/peg 3350
1
1
1
Milk of Magnesia OTC (Prevent)
magnesium hydroxide
$0
$0
$0
Moviprep
3
3
3
1
1B
QL
$0
$0
1
1B
QL
QL
$0
$0
QL
QL
QL
$0
1
1B
$0
$0
3
3
$0
1
1B
$0
$0
3
3
3
3
3
3
3
3
3
sodium chloride/nahco3/kcl/peg
$0
$0
$0
Nulytely
sodium chloride/nahco3/kcl/peg
1
1
1
Oral Saline Laxative liquid OTC
(Prevent)
sodium phosphate,mono-dibasic
$0
$0
$0
Osmoprep
3
3
Prepopik
3
3
Suprep
3
3
4F. Digestive enzymes
BCBSM (EPO/PPO)
Generic name
$0
$0
Nulytely (Prevent)
Trade name
QL
2
2
2
2
2
2
2
2
2
2
Pertzye
3
3
3
3
3
Viokace
2
2
2
2
2
Zenpep
2
2
2
2
2
4G. H2-Receptor antagonists
BCBSM (EPO/PPO)
QL
QL
QL
QL
QL
18
19
20
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
nizatidine
1
1
1
1
1B
Pepcid (Rx Only)
famotidine
1
1
1
1
1B
Tagamet (Rx only)
cimetidine
1
1
1
1
1B
Tagamet liquid (Rx only)
cimetidine hcl
1
1
1
1
1B
Zantac (Rx Only)
ranitidine hcl
1
1
1
1
1B
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
BCN (HMO)
Axid (Rx only)
PA - Prior approval may be required
QL
QL
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Pancreaze
Generic name
QL
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
BCN (HMO)
Creon
Trade name
4
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
QL
$0
$0
$0
$0
$0
QL
QL
$0
$0
$0
$0
$0
QL
QL
$0
$0
$0
$0
$0
Golytely flavored
1
PA
2
PA, QL 3
<s> - Specialty Drug
Page 40
1
2
3
4
5
4H. Proton Pump Inhibitors (PPI)
Trade name
Aciphex tablet
BCBSM (EPO/PPO)
Generic name
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
rabeprazole sodium
Nexium suspension
1
1
1
3
3
3
Prevacid capsule (Rx Only)
lansoprazole
1
1
1
Prilosec capsule (Rx Only)
omeprazole
1
1
1
Protonix tablet
pantoprazole sodium
1
1
1
4I. Topical anti-Inflammatory agents
Trade name
BCN (HMO)
ST
QL
QL
QL
1
1B
3
3
1
1B
1
1B
1
1B
BCBSM (EPO/PPO)
Generic name
2
2
2
2
2
Analpram-HC cream 2.5-1%, 1-1%
hydrocortisone/pramoxine
1
1
1
1
1B
Anamantle HC
lidocaine/hydrocortisone ac
1
1
1
1
1B
Cortenema
hydrocortisone
1
1
1
1
1B
2
2
2
2
2
Cortifoam
Epifoam
3
3
3
3
3
Lidocaine-HC
lidocaine/hydrocortisone ac
1
1
1
1
1B
Pramosone cream
hydrocortisone/pramoxine
1
1
1
1
1B
Proctocort
hydrocortisone
1
1
1
1
1B
Proctocort suppository
hydrocortisone acetate
1
1
1
1
1B
Proctofoam-HC
2
2
2
2
2
Procto-Pak
hydrocortisone
1
1
1
1
1B
Proctosol-HC suppository
hydrocortisone acetate
1
1
1
1
1B
4J. Tumor Necrosis Factor (TNF) blocking agents
Generic name
Cimzia syringe <s>
Humira <s>
Simponi <s>
BCBSM (EPO/PPO)
Trade name
BCN (HMO)
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
sucralfate
Carafate suspension
1
1
1
1
1B
2
2
2
2
2
Cytotec
misoprostol
1
1
1
1
1B
Pamine, Forte
methscopolamine bromide
1
1
1
1
1B
Pro-Banthine
propantheline bromide
1
1
1
1
1B
Robinul tablet, Forte
glycopyrrolate
1
1
1
1
1B
PA - Prior approval may be required
1
2
3
4
5
6
7
8
9
10
11
12
13
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL
PA, QL 1
4
5
3
4
5
PA, QL
QL
4
4
2
4
4
2
PA, QL
PA, QL 3
4
5
3
4
5
4K. Ulcer therapy
Carafate
1
2
3
4
5
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Analpram-HC 1-1% cream
Trade name
PA
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
<s> - Specialty Drug
Page 41
1
2
3
4
5
6
4L. Miscellaneous gastrointestinal agents
Trade name
Generic name
Amitiza
BCBSM (EPO/PPO)
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA
PA, QL 1
3
3
3
3
3
Evoxac
cevimeline hcl
1
1
1
1
1B
Gastrocrom
cromolyn sodium
1
1
1
1
1B
Gattex <s>
2
4
4
4
4
Kristalose
3
3
3
3
3
1
1
1
1
1B
3
3
3
3
3
1
1
1
1
1B
3
3
3
3
3
Lactulose
lactulose
Linzess
Lotronex
alosetron hcl
Rectiv
PA, QL
PA, QL
QL
Reglan
metoclopramide hcl
1
1
1
1
1B
Salagen
pilocarpine hcl
1
1
1
1
1B
4
4
PA, QL
Stelara <s>
2
4
4
Sucraid <s>
3
4
5
4
5
Xifaxan 200mg
3
3
3
3
3
Xifaxan 550mg
3
3
3
3
3
4
5
Zorbtive <s>
PA - Prior approval may be required
3
ST - Step therapy may be required
4
5
PA, QL
PA
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
PA, QL
PA, QL
QL
QL
PA, QL
QL
PA, QL
PA
<s> - Specialty Drug
Page 42
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
5. Obstetrics and gynecology
5A. Contraceptives-Biphasic
Trade name
BCBSM (EPO/PPO)
Generic name
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Lo Loestrin Fe
3
3
3
Loseasonique (Prevent)
l-norgest/e.estradiol-e.estrad
$0
$0
$0
Mircette (Prevent)
desog-e.estradiol/e.estradiol
$0
$0
$0
Necon 10/11 (Prevent)
norethindrone-ethinyl estrad
$0
$0
$0
Seasonique (Prevent)
l-norgest/e.estradiol-e.estrad
$0
$0
$0
5B. Contraceptives-Misc.
Trade name
Generic name
medroxyprogesterone acetate
FC2 female condom (Prevent)
$0
$0
$0
$0
$0
$0
$0
$0
nonoxynol 9
$0
$0
$0
$0
2
2
2
2
2
$0
$0
$0
$0
$0
$0
QL
QL
$0
$0
$0
$0
3
3
QL
QL
$0
$0
$0
$0
$0
$0
$0
$0
3
3
3
3
3
Nuvaring (Prevent)
$0
$0
$0
$0
$0
$0
norelgestromin/ethin.estradiol
Ortho Micronor; Nor-QD (Prevent)
norethindrone
$0
$0
$0
Quartette (Prevent)
l-norgest-eth estr/ethin estra
$0
$0
$0
QL
Safyral
3
3
3
Today contraceptive sponge
(Prevent)
$0
$0
$0
QL
$0
$0
VCF film, gel (Prevent)
$0
$0
$0
QL
QL
$0
$0
$0
$0
VCF foam (Prevent)
PA - Prior approval may be required
nonoxynol 9
ST - Step therapy may be required
$0
$0
$0
QL - Quantity limits may apply
QL
QL
1
2
3
4
5
6
7
8
9
10
11
12
13
14
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
BCN (HMO)
$0
Natazia
Ortho Evra (Prevent)
QL
3
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
$0
$0
$0
$0
$0
Depo-subq Provera 104
Gynol II (Prevent)
QL
3
BCBSM (EPO/PPO)
Conceptrol (Prevent)
Depo-Provera 150mg (Prevent)
BCN (HMO)
Page 43
5C. Contraceptives-Monophasic
Trade name
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Alesse; Levlite (Prevent)
levonorgestrel-ethin estradiol
$0
$0
$0
$0
$0
Beyaz (Prevent)
drospir/eth estra/levomefol ca
$0
$0
$0
$0
$0
Demulen (Prevent)
ethynodiol d-ethinyl estradiol
$0
$0
$0
$0
$0
Desogen; Ortho-cept (Prevent)
desogestrel-ethinyl estradiol
$0
$0
$0
$0
$0
Femcon Fe (Prevent)
noreth-ethinyl estradiol/iron
$0
$0
$0
$0
$0
Generess Fe (Prevent)
noreth-ethinyl estradiol/iron
$0
$0
$0
$0
$0
Levlen; Nordette (Prevent)
levonorgestrel-ethin estradiol
$0
$0
$0
$0
$0
Lo/Ovral (Prevent)
norgestrel-ethinyl estradiol
$0
$0
$0
$0
$0
Loestrin (Prevent)
norethindrone ac-eth estradiol
$0
$0
$0
$0
$0
Loestrin 24 Fe (Prevent)
norethindrone-e.estradiol-iron
$0
$0
$0
$0
$0
Loestrin Fe (Prevent)
norethindrone-e.estradiol-iron
$0
$0
$0
$0
$0
Lybrel (Prevent)
levonorgestrel-ethin estradiol
$0
$0
$0
$0
$0
Minastrin 24 FE (Prevent)
norethindrone-e.estradiol-iron
$0
$0
$0
$0
$0
Modicon (Prevent)
norethindrone-ethinyl estrad
$0
$0
$0
$0
$0
Norinyl 1/35; Ortho-novum 1/35
(Prevent)
norethindrone-ethinyl estrad
$0
$0
$0
$0
$0
Norinyl 1/50 (Prevent)
norethindrone-mestranol
$0
$0
$0
$0
$0
Ortho-Cyclen (Prevent)
norgestimate-ethinyl estradiol
$0
$0
$0
$0
$0
Ovcon 35 (Prevent)
norethindrone-ethinyl estrad
$0
$0
$0
$0
$0
$0
$0
$0
$0
3
Ovral (Prevent)
norgestrel-ethinyl estradiol
$0
$0
$0
Seasonale (Prevent)
levonorgestrel-ethin estradiol
$0
$0
$0
Taytulla
Yasmin 28 (Prevent)
Yaz (Prevent)
ethinyl estradiol/drospirenone
ethinyl estradiol/drospirenone
Trade name
Generic name
3
$0
$0
$0
$0
$0
$0
$0
$0
$0
levonorgestrel
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
desogestrel-ethinyl estradiol
$0
$0
$0
$0
$0
Estrostep Fe (Prevent)
norethindrone-e.estradiol-iron
$0
$0
$0
$0
$0
Ortho Tri-Cyclen (Prevent)
norgestimate-ethinyl estradiol
$0
$0
$0
$0
$0
Ortho Tri-Cyclen Lo (Prevent)
norgestimate-ethinyl estradiol
$0
$0
$0
$0
$0
Ortho-Novum 7/7/7 (Prevent)
norethindrone-ethinyl estrad
$0
$0
$0
$0
$0
Trilevlen (Prevent)
levonorgestrel-ethin estradiol
$0
$0
$0
$0
$0
Tri-Norinyl (Prevent)
norethindrone-ethinyl estrad
$0
$0
$0
$0
$0
ST - Step therapy may be required
QL - Quantity limits may apply
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
1
2
BCN (HMO)
Cyclessa (Prevent)
PA - Prior approval may be required
16
17
18
19
20
21
22
23
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
QL
$0
$0
$0
$0
$0
QL
$0
$0
$0
$0
$0
5E. Contraceptives-Triphasic
Trade name
3
BCBSM (EPO/PPO)
Ella (Prevent)
Plan B One-step (Prevent)
3
3
$0
5D. Contraceptives-Postcoital
QL
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Page 44
1
2
3
4
5
6
7
5F. Estrogen and progestin combinations
Trade name
Activella
Generic name
BCBSM (EPO/PPO)
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
estradiol/norethindrone acet
1
1B
3
3
3
3
1
1
1
Angeliq
3
3
3
Climara Pro
3
3
3
3
3
3
3
3
1
1
1
1
1B
Prefest
3
3
3
3
3
Prempro, Low Dose; Premphase
2
2
2
2
2
5G. Estrogens
BCBSM (EPO/PPO)
Combipatch
FemHRT
norethindrone ac-eth estradiol
Trade name
Generic name
Alora
Climara
estradiol
Delestrogen
estradiol valerate
1
1
1
3
3
3
Elestrin
3
3
3
estradiol
QL
QL
1
1B
3
3
3
3
1
1B
3
3
2
2
3
3
3
3
3
3
3
3
3
3
3
3
1B
1
1
1
3
3
3
Estring
2
2
2
Estrogel
3
3
3
Evamist
3
3
3
Femring
3
3
3
Menest
3
3
3
Menostar
3
3
3
Minivelle
3
3
3
1
1
1
1
estropipate
Premarin, cream, Low Dose
QL
QL
QL
QL
QL
2
2
2
2
2
Vagifem
estradiol
1
1
1
1
1B
Vivelle-Dot
estradiol
1
1
1
1
1B
5H. Infertility treatment*
Trade name
BCBSM (EPO/PPO)
Generic name
Chorionic Gonadotropin <s>
Clomid
clomiphene citrate
Follistim AQ <s>
Gonal-F, RFF, Redi-ject <s>
Lupron <s>
QL
QL
QL
QL
QL
QL
QL
leuprolide acetate
1
4
4
2
4
4
Ovidrel <s>
2
4
4
Pregnyl <s>
2
4
4
PA, QL
PA, QL
PA, QL
4
4
NC
4*
NC
4*
NC
4*
PA
PA
PA
*Drugs used for the treatment of infertility may not be covered for select benefits. Cost-sharing depends on the medical benefit for BCN
members.
NC - Not Covered for BCN members with a 4-Tier benefit
PA - Prior approval may be required
ST - Step therapy may be required
QL - Quantity limits may apply
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL NC
PA
4*
2
4
4
QL
1
1B
1
1
1
PA, QL NC
PA
5*
3
4
5
PA, QL NC
PA
4*
2
4
4
Novarel <s>
1
2
3
4
5
6
7
BCN (HMO)
Estrace vaginal cream
Ogen
QL
QL
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
QL
2
2
2
2
2
QL
QL
1
1B
1
1
1
Divigel
Estrace tablet
QL
QL
QL
Page 45
1
2
3
4
5
6
7
8
5I. Progestins
BCBSM (EPO/PPO)
Trade name
Aygestin
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
norethindrone acetate
Depo-subq Provera 104
1
1
1
1
1B
2
2
2
2
2
Progesterone In Oil (inj)
progesterone
1
1
1
1
1B
Prometrium
progesterone,micronized
1
1
1
1
1B
Provera
medroxyprogesterone acetate
1
1
1
1
1B
5J. Vaginal anti-infective and antifungal
Trade name
BCBSM (EPO/PPO)
Generic name
Cleocin vaginal cream
clindamycin phosphate
Cleocin vaginal ovules
Clindesse
Diflucan
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
AVC
fluconazole
Gynazole-1
3
3
3
3
3
1
1
1
1
1B
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1B
3
3
3
3
3
Metrogel-Vaginal
metronidazole
1
1
1
1
1B
Monistat 3
miconazole nitrate
1
1
1
1
1B
Terazol- 3, 7
terconazole
1
1
1
1
1B
5K. Miscellaneous OB-GYN
Trade name
Covaryx, H.S.
BCBSM (EPO/PPO)
Generic name
1
1
1
1
1B
Duavee
3
3
3
3
3
Lupron Depot 3.75mg, 11.25mg
<s>
2
4
4
4
4
QL
Lysteda
tranexamic acid
1
1
1
1
1B
Methergine
methylergonovine maleate
1
1
1
1
1B
Osphena
3
3
3
3
3
Synarel
2
2
2
2
2
PA
QL
MB - May be covered under medical benefit
PA - Prior approval may be required
ST - Step therapy may be required
QL - Quantity limits may apply
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
9
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
estrogen,ester/me-testosterone
1
2
3
4
5
Page 46
1
2
3
4
5
6
7
6. Rheumatology and musculoskeletal
6A. Corticosteroids
BCBSM (EPO/PPO)
Trade name
Corticosteroids
Generic name
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
See Chapter 7C
6B. Gout therapy
BCBSM (EPO/PPO)
Trade name
Colbenemid
BCN (HMO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
1
1
1
1
1B
Colchicine tablet
2
2
2
2
2
Colcrys
2
2
2
2
2
1
1
1
1
1B
2
2
2
2
2
1
1
1
1
1B
Probenecid
colchicine/probenecid
probenecid
Uloric
Zyloprim
allopurinol
6C. Non-Tumor Necrosis Factor (TNF) blocking agents
Trade name
Generic name
Actemra syringe <s>
Cosentyx <s>
Kineret <s>
Orencia Clickject, sub-q <s>
Otezla <s>
Stelara <s>
Xeljanz, XR <s>
Trade name
Generic name
Atelvia
risedronate sodium
Boniva
ibandronate sodium
Didronel
etidronate disodium
Evista
raloxifene hcl
Fosamax
alendronate sodium
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL 4
PA, QL 1
4
2
4
4
PA, QL 4
PA, QL 2
4
2
4
4
PA, QL
PA, QL 3
4
5
3
4
5
PA, QL
PA, QL 4
4
5
3
4
5
PA, QL
PA, QL 5
4
4
2
4
4
PA, QL
PA, QL 6
4
4
2
4
4
PA, QL
PA, QL 7
4
4
2
4
4
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
ST, QL
1
1B
1
1
1
ST, QL
ST, QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1A
1
1
1
Miacalcin injection
PA - Prior approval may be required
1
2
3
4
ST, QL 5
6
BCN (HMO)
BCBSM (EPO/PPO)
risedronate sodium
Miacalcin nasal spray
ST, QL
BCBSM (EPO/PPO)
6D. Osteoporosis and bone resorption
Actonel
1
calcitonin,salmon,synthetic
ST - Step therapy may be required
2
2
2
2
2
1
1
1
1
1B
QL - Quantity limits may apply
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
Page 47
1
2
3
4
5
6
7
8
6E. Osteoporosis and hormonal treatment
Trade name
Generic name
Alora
Climara
estradiol
Duavee
BCBSM (EPO/PPO)
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
QL
2
2
2
2
2
QL
QL
1
1B
1
1
1
PA
3
3
3
3
3
Estrace tablet
estradiol
1
1
1
1
1B
FemHRT
norethindrone ac-eth estradiol
1
1
1
1
1B
Forteo <s>
3
4
5
4
5
Menest
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1B
Premarin, cream, Low Dose
2
2
2
2
2
Prempro, Low Dose; Premphase
2
2
2
2
2
1
1B
Minivelle
Ogen
estropipate
Vivelle-Dot
estradiol
1
6F. Salicylates
Trade name
NSAIDS and Salicylates
Generic name
Generic name
Enbrel <s>
Humira <s>
Simponi <s>
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
BCBSM (EPO/PPO)
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
leflunomide
sulfasalazine
Depen
1
1
1
1
1B
3
3
3
3
3
1
1
1
1
1B
2
2
2
2
2
Gengraf; Neoral <s>
cyclosporine, modified
1
4
4
4
4
Imuran
azathioprine
1
1
1
1
1B
Methotrexate
methotrexate sodium
1
1
1
1
1B
1B
Methotrexate PF injection
methotrexate sodium/pf
1
1
1
1
Plaquenil
hydroxychloroquine sulfate
1
1
1
1
1B
Ridaura
2
2
2
2
2
Trexall
2
2
2
2
2
PA - Prior approval may be required
1
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL 4
PA, QL 1
5
3
4
5
PA, QL 4
PA, QL 2
4
2
4
4
PA, QL
QL
4
4
2
4
4
3
PA, QL
PA, QL 4
4
5
3
4
5
Azasan
Azulfidine, EN-tab
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
6H. Miscellaneous rheumatologic agents
Trade name
QL
See Chapters 3M & 3O
Cimzia syringe <s>
Arava
1
QL
BCBSM (EPO/PPO)
6G. Tumor Necrosis Factor (TNF) blocking agents
Trade name
1
PA, QL
1
2
3
4
5
PA, QL 6
7
QL
8
9
10
11
QL 12
ST - Step therapy may be required
QL - Quantity limits may apply
QL
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
Page 48
1
2
3
4
5
6
7
8
9
10
11
7. Endocrinology
7A. Androgens
BCBSM (EPO/PPO)
Trade name
Generic name
Anadrol-50
Androderm
Androgel 1%
testosterone
Androgel 1.62%
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA
3
3
3
3
3
1
PA, QL 2
PA, QL 2
2
2
2
2
PA, QL 1
PA, QL 3
1B
1
1
1
PA, QL
PA, QL 4
2
2
2
2
2
PA, QL
PA, QL 5
1
1B
1
1
1
Androxy
fluoxymesterone
Danocrine
danazol
1
1
1
1
1B
Delatestryl
testosterone enanthate
1
1
1
1
1B
Depo-Testosterone
testosterone cypionate
1
1
1
1
1B
3
3
3
1
1
1
Methitest
Oxandrin
oxandrolone
7B. Antithyroid agents
Trade name
Propylthiouracil
PA
3
3
1
1B
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
propylthiouracil
SSKI
1
1
1
1
1B
3
3
3
3
3
Strong Iodine
potassium iodide/iodine
1
1
1
1
1B
Tapazole
methimazole
1
1
1
1
1B
7C. Corticosteroids
Trade name
BCBSM (EPO/PPO)
Generic name
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
hydrocortisone
1
1
1
1
1B
Cortisone acetate
cortisone acetate
1
1
1
1
1B
Decadron
dexamethasone
1
1
1
1
1A
Deltasone
prednisone
1
1
1
1
1A
3
Dexpak, Jr. dosepak
3
3
3
3
Entocort EC
budesonide
1
1
1
1
1B
Florinef
fludrocortisone acetate
1
1
1
1
1B
Medrol 2mg
3
3
3
3
3
Medrol, Dosepak
methylprednisolone
1
1
1
1
1B
Millipred
prednisolone
1
1
1
1
1A
Millipred dose pack
prednisolone
1
1
1
1
1B
Millipred solution
prednisolone sod phosphate
1
1
1
1
1B
Orapred solution
prednisolone sod phosphate
1
1
1
1
1B
Pediapred solution
prednisolone sod phosphate
1
1
1
1
1B
Prednisolone, tablet, syrup
prednisolone
1
1
1
1
1A
1
1
1A
PA - Prior approval may be required
prednisone
ST - Step therapy may be required
1
1
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
BCN (HMO)
Cortef; Hydrocortisone
Prednisone
6
7
8
PA, QL 9
10
<s> - Specialty Drug
Page 49
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
7D. Growth Hormone and related products
Trade name
Generic name
Genotropin <s>
Humatrope <s>
Increlex <s>
Norditropin FlexPro <s>
Nutropin AQ, Nuspin <s>
Omnitrope <s>
Saizen <s>
Saizenprep <s>
Serostim <s>
Zomacton <s>
BCBSM (EPO/PPO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA
PA
4
4
2
4
4
1
PA
PA
4
5
3
4
5
2
PA
PA
4
5
3
4
5
3
PA
PA
4
5
3
4
5
4
PA
PA
4
4
2
4
4
5
PA
PA
4
5
3
4
5
6
PA
PA
4
5
3
4
5
7
PA
PA
4
5
3
4
5
8
PA
PA
4
5
3
4
5
9
PA
PA 10
4
5
3
4
5
7E. Insulins
Trade name
Apidra, Solostar
BCN (HMO)
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
ST
2
2
2
2
2
Basaglar Kwikpen U-100
2
2
2
1
1A
Humalog, Mix
2
2
2
2
2
Humalog U-200
2
2
2
2
2
Humulin, Kwikpen (all forms)
2
2
2
2
2
Humulin R U-500 (all forms)
2
2
2
2
2
Lantus, Solostar
2
2
2
1
1A
Levemir, Flextouch
2
2
2
1
1A
Novolin (all forms)
2
2
2
1
1A
Novolog, Mix (all forms)
2
2
2
1
1A
Toujeo Solostar
2
2
2
2
2
Tresiba Flextouch
2
2
2
1
1A
PA - Prior approval may be required
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
ST
ST
<s> - Specialty Drug
Page 50
1
2
3
4
5
6
7
8
9
10
11
12
7F. Non-insulin hypoglycemic agents
BCBSM (EPO/PPO)
Trade name
Actoplus Met
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
pioglitazone hcl/metformin hcl
Actoplus Met XR
1
1
1
1
1B
3
3
3
3
3
Actos
pioglitazone hcl
1
1
1
1
1A
Amaryl
glimepiride
1
1
1
1
1A
Avandamet
3
3
3
3
3
Avandia
3
3
3
3
3
Bydureon, Pen
2
2
2
2
2
Byetta
3
3
3
3
3
Cycloset
3
3
3
3
3
PA, QL
PA, QL
PA, QL
Diabeta; Micronase
glyburide
1
1
1
1
1A
Diabinese
chlorpropamide
1
1
1
1
1B
1
1B
Duetact
pioglitazone hcl/glimepiride
Farxiga
1
1
1
ST, QL
2
2
2
2
2
Fortamet
metformin hcl
1
1
1
1
1B
Glucophage, XR
metformin hcl
1
1
1
1
1A
Glucotrol, XL
glipizide
1
1
1
1
1A
Glucovance
glyburide/metformin hcl
1
1
1
1
1A
Glynase
glyburide,micronized
1
1
1
1
1A
Glyset
miglitol
1
1
1
1
1B
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Invokamet
ST, QL
ST, QL
ST, QL
Invokamet XR
2
2
2
Invokana
2
2
2
Janumet
2
2
2
Janumet XR
2
2
2
Januvia
2
2
2
2
2
2
2
2
1
1
1
1
1A
Kombiglyze XR
Metaglip
glipizide/metformin hcl
Onglyza
QL
QL
QL
2
2
2
2
2
Orinase
tolbutamide
1
1
1
1
1B
PrandiMet
repaglinide/metformin hcl
1
1
1
1
1B
Prandin
repaglinide
1
1
1
1
1B
Precose
acarbose
1
1
1
1
1B
Starlix
nateglinide
1
1
1
1
1B
3
3
3
3
3
1
1B
3
3
2
2
2
2
Symlinpen
Tolinase
1
1
1
Tradjenta
tolazamide
3
3
3
Victoza
2
2
2
Xigduo XR
2
2
2
7G. Somatostatin analogs
BCBSM (EPO/PPO)
Trade name
Sandostatin <s>
Sandostatin kit, LAR Depot <s>
Signifor <s>
Somatuline Depot <s>
PA - Prior approval may be required
Generic name
octreotide acetate
ST, QL
PA, QL
ST, QL
ST, QL
ST, QL
PA, QL
PA, QL
ST, QL
ST, QL
ST, QL
ST, QL
ST, QL
QL
QL
QL
QL
QL
PA
ST, QL
PA, QL
ST, QL
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA
4
4
1
4
4
PA
4
4
2
4
4
PA, QL
PA, QL
4
4
2
4
4
PA, QL
4
4
2
4
4
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
<s> - Specialty Drug
Page 51
1
2
3
4
7H. Thyroid hormones
BCBSM (EPO/PPO)
Trade name
Armour Thyroid
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
1
1
1
1
1B
Armour Thyroid 15mg, 30mg, 60mg,
90mg, 120mg, 180mg, 240mg,
300mg
Cytomel
liothyronine sodium
Levoxyl; Synthroid
levothyroxine sodium
3
3
3
3
3
1
1
1
1
1B
1
1
1
1
1A
Nature-throid
thyroid,pork
1
1
1
1
1B
NP Thyroid
thyroid,pork
1
1
1
1
1B
2
2
2
2
2
3
3
3
3
3
1
1
1
1
1B
WP Thyroid
3
3
3
3
3
7I. Urea cycle disorder agents
BCBSM (EPO/PPO)
thyroid,pork
Thyrolar
Tirosint
Westhroid
thyroid,pork
Trade name
Buphenyl powder
Generic name
sodium phenylbutyrate
1
1
Buphenyl tablet
2
2
2
Carbaglu <s>
2
4
4
Ravicti <s>
3
4
5
7J. Vitamin D analogs
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
PA, QL
PA
PA, QL
1
1B
2
2
4
4
4
5
1
2
PA
3
PA, QL 4
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
ergocalciferol (vitamin d2)
1
Hectorol
doxercalciferol
1
Rocaltrol
calcitriol
1
Zemplar
paricalcitol
1
PA - Prior approval may be required
3
4
5
6
7
8
9
10
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
1
Calciferol (Rx Only)
1
2
ST - Step therapy may be required
1
1
1B
1
1
1
1B
1
1
1
1B
1
1
1
1B
1
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
<s> - Specialty Drug
Page 52
1
2
3
4
7K. Miscellaneous endocrine
Trade name
BCBSM (EPO/PPO)
Generic name
Cerdelga <s>
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL
PA, QL 1
4
5
3
4
5
Cetylev
3
Cholbam <s>
DDAVP
BCN (HMO)
desmopressin (nonrefrigerated)
3
3
PA, QL
3
3
4
4
2
4
4
1
1
1
1
1B
1B
DDAVP
desmopressin acetate
1
1
1
1
Dostinex
cabergoline
1
1
1
1
1B
GlucaGen
3
3
3
3
3
Glucagon Emergency Kit
2
2
2
2
2
Korlym <s>
2
4
4
4
4
Kuvan <s>
2
4
4
4
4
Lupron Depot-PED <s>
2
4
4
4
4
2
2
2
2
2
1
1
1
1
1B
Myalept <s>
3
4
5
4
5
Natpara <s>
2
4
4
4
4
Proglycem
3
3
3
3
3
Sensipar <s>
2
4
4
4
4
Somavert <s>
2
4
4
4
4
Stimate <s>
2
4
4
4
4
Strensiq <s>
2
4
4
4
4
Synarel
2
2
2
2
2
Zavesca <s>
3
4
5
4
5
Miacalcin injection
Miacalcin nasal spray
PA - Prior approval may be required
calcitonin,salmon,synthetic
ST - Step therapy may be required
PA, QL
PA, QL
PA, QL
PA
PA, QL
PA, QL
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
PA
PA, QL
PA
PA, QL
PA, QL
PA
PA, QL
<s> - Specialty Drug
Page 53
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
8. Antineoplastics and immunossuppresants
8A. Adjuvant therapy
Trade name
BCBSM (EPO/PPO)
Generic name
Aranesp <s>
Epogen <s>
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA
PA
4
5
3
4
5
PA
PA
4
5
3
4
5
Granix <s>
Leucovorin tablet
BCN (HMO)
2
4
4
4
4
1
1
1
1
1B
Leukine <s>
2
4
4
4
4
Mesnex tablet
2
2
2
2
2
Neulasta <s>
3
4
5
4
5
Neupogen <s>
2
4
4
4
4
Procrit <s>
2
4
4
4
4
Zarxio <s>
3
4
5
4
5
8B. Alkylating agents
BCBSM (EPO/PPO)
Trade name
leucovorin calcium
Generic name
QL
PA
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
2
2
2
2
2
Cyclophosphamide
2
2
2
2
2
Emcyt
2
2
2
2
2
Gleostine; Lomustine
2
2
2
2
2
Leukeran
2
2
2
2
2
Matulane <s>
2
4
4
4
4
2
2
2
2
2
1
4
4
4
4
Myleran
temozolomide
8C. Antimetabolites
Trade name
BCBSM (EPO/PPO)
Generic name
Lonsurf <s>
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL
PA, QL 1
4
4
2
4
4
methotrexate sodium
1
1
1
1
1B
Methotrexate PF injection
methotrexate sodium/pf
1
1
1
1
1B
Purinethol
mercaptopurine
1
1B
4
5
1
1
1
Purixan <s>
3
4
5
Tabloid
2
2
2
2
2
Trexall
2
2
2
2
2
1
4
4
4
4
PA - Prior approval may be required
1
2
3
4
5
6
7
8
BCN (HMO)
Methotrexate
Xeloda <s>
PA
BCN (HMO)
Alkeran tablet
Temodar <s>
QL
1
2
3
4
5
6
7
8
9
10
capecitabine
ST - Step therapy may be required
PA
QL - Quantity limits may apply
2
3
4
5
6
7
8
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
Page 54
8D. Hormonal agents
BCBSM (EPO/PPO)
Trade name
Generic name
Arimidex
anastrozole
Aromasin
exemestane
Casodex
bicalutamide
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA
PA
1
1A
1
1
1
PA
PA
1
1B
1
1
1
1
1
1
1
1B
Depo-Provera 400mg
2
2
2
2
2
Eligard <s>
3
4
5
4
5
Eulexin
flutamide
1
1
1
Evista (Prevent)
raloxifene hcl
$0
$0
$0
Evista
raloxifene hcl
1
1
1
2
2
2
Fareston
Faslodex
1
1B
$0
$0
1
1B
2
2
3
3
1
1A
4
4
4
4
4
4
3
3
3
Femara
letrozole
1
1
1
Lupron <s>
leuprolide acetate
1
4
2
4
Lupron Depot <s>
PA, QL
QL
PA
2
4
4
MB
MB
Megace, ES
megestrol acetate
1
1
1
1
1B
Nilandron
nilutamide
1
1
1
1
1B
3
3
3
3
3
$0
$0
1
1A
4
4
4
4
4
4
4
4
Lupron Depot 45mg <s>
Soltamox
Tamoxifen (Prevent)
tamoxifen citrate
$0
$0
$0
Tamoxifen
tamoxifen citrate
1
1
1
PA, QL
QL
Trelstar, Depot, LA <s>
2
4
4
Xtandi <s>
2
4
4
Zoladex <s>
2
4
4
Zytiga <s>
2
4
4
8E. Immunomodulators
BCBSM (EPO/PPO)
Trade name
Generic name
Arcalyst <s>
PA, QL
QL
QL
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA
PA, QL 1
4
4
2
4
4
Astagraf XL <s>
3
4
5
4
5
Azasan
3
3
3
3
3
1
4
4
4
4
3
4
5
4
5
Cellcept <s>
mycophenolate mofetil
Envarsus XR <s>
Gengraf; Neoral <s>
cyclosporine, modified
1
4
4
4
4
Imuran
azathioprine
1
1
1
1
1B
3
4
5
4
5
1
4
4
4
4
Kineret <s>
Myfortic <s>
mycophenolate sodium
PA, QL
PA, QL
3
4
5
4
5
Prednisone
prednisone
1
1
1
1
1A
Prograf <s>
tacrolimus
1
4
4
4
4
2
4
4
4
4
1
4
4
4
4
3
4
5
4
5
Pomalyst <s>
Rapamune solution <s>
Rapamune tablet <s>
sirolimus
Revlimid <s>
QL
1
4
4
4
4
Sandimmune solution <s>
3
4
5
4
5
Somatuline Depot <s>
2
4
4
4
4
Thalomid <s>
2
4
4
4
4
Sandimmune capsule <s>
PA - Prior approval may be required
1
2
3
4
5
6
PA
7
8
9
10
PA 11
12
13
14
15
16
17
PA 18
19
20
PA, QL 21
22
PA, QL 23
cyclosporine
ST - Step therapy may be required
PA, QL
QL - Quantity limits may apply
2
3
4
5
6
7
PA, QL 8
9
PA, QL 10
11
12
13
14
PA, QL 15
16
17
18
19
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
Page 55
8F. Kinase inhibitors and molecular target inhibitors
Trade name
Generic name
Afinitor, Disperz <s>
Alecensa <s>
Bosulif <s>
Cabometyx <s>
Caprelsa <s>
Cometriq <s>
Cotellic <s>
Gilotrif <s>
Gleevec <s>
BCBSM (EPO/PPO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
PA, QL 1
4
4
2
4
4
PA, QL
PA, QL 2
4
4
2
4
4
PA,
QL
PA, QL 3
4
4
2
4
4
PA, QL
PA, QL 4
4
4
2
4
4
QL
PA, QL 5
4
4
2
4
4
PA, QL
PA, QL 6
4
4
2
4
4
PA, QL 4
PA, QL 7
4
2
4
4
PA, QL 4
PA, QL 8
4
2
4
4
1
4
4
Ibrance <s>
2
4
4
Iclusig <s>
2
4
4
Imbruvica <s>
2
4
4
Inlyta <s>
2
4
4
Iressa <s>
2
4
4
Jakafi <s>
2
4
4
Lenvima <s>
2
4
4
Lynparza <s>
2
4
4
Mekinist <s>
2
4
4
Nexavar <s>
2
4
4
imatinib mesylate
Ninlaro <s>
2
4
4
Sprycel <s>
2
4
4
Stivarga <s>
2
4
4
Sutent <s>
2
4
4
Tafinlar <s>
2
4
4
Tagrisso <s>
2
4
4
Tarceva <s>
2
4
4
Tasigna <s>
2
4
4
Tykerb <s>
2
4
4
Venclexta <s>
2
4
4
Votrient <s>
2
4
4
Xalkori <s>
2
4
4
Zelboraf <s>
2
4
4
Zortress <s>
3
4
5
Zydelig <s>
2
4
4
Zykadia <s>
2
4
4
PA - Prior approval may be required
BCN (HMO)
ST - Step therapy may be required
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
QL
PA, QL
QL
PA, QL
QL
PA, QL
PA, QL
QL
PA, QL
QL
PA, QL
PA, QL
PA, QL
PA, QL
QL - Quantity limits may apply
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
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
5
4
4
4
4
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
PA, QL 34
PA, QL 35
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
PA
PA, QL
PA, QL
PA, QL
PA, QL
PA
PA, QL
PA
PA, QL
PA
PA, QL
PA, QL
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
Page 56
8G. Miscellaneous antineoplastic agents
Trade name
Generic name
BCBSM (EPO/PPO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Droxia
2
2
2
Erivedge <s>
2
4
4
Farydak <s>
2
4
4
Hexalen
2
2
Hycamtin capsule <s>
Hydrea
hydroxyurea
Lysodren
Odomzo <s>
Sandostatin <s>
BCN (HMO)
octreotide acetate
Sandostatin kit, LAR Depot <s>
2
2
4
4
4
4
2
2
2
4
PA, QL
PA, QL
2
4
4
4
1
1
1
1
1B
2
2
2
2
2
2
4
4
4
4
1
4
4
4
4
2
4
4
4
4
4
4
PA, QL
PA
PA
PA
Targretin capsule <s>
bexarotene
1
4
4
Vepesid
etoposide
1
1
1
1
1B
Vesanoid
tretinoin
1
1
1
1
1B
2
4
4
4
4
Zolinza <s>
PA - Prior approval may be required
ST - Step therapy may be required
QL - Quantity limits may apply
4
5
6
7
PA, QL 8
9
10
PA 11
12
13
PA 14
PA
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
1
PA, QL 2
PA, QL 3
Page 57
9. Immunology and hematology
9A. Hematopoietic agents
Trade name
BCBSM (EPO/PPO)
Generic name
Aranesp <s>
Epogen <s>
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA
PA
4
5
3
4
5
PA
PA
4
5
3
4
5
Granix <s>
2
4
4
Leukine <s>
2
4
4
Neulasta <s>
3
4
5
Neupogen <s>
2
4
4
Procrit <s>
2
4
4
Promacta <s>
2
4
4
QL
PA
PA
Zarxio <s>
3
9B. Immunoglobulins
BCBSM (EPO/PPO)
Trade name
Generic name
Gammagard liquid <s>
Gammaked <s>
Gamunex-C sub-q <s>
Hizentra <s>
HyQvia <s>
BCN (HMO)
4
5
4
4
4
4
4
5
4
4
4
4
4
4
4
5
QL
PA
PA
1
2
3
4
5
6
7
8
9
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA
PA
4
5
3
4
5
PA
PA
4
5
3
4
5
PA
PA
4
5
3
4
5
PA
PA
4
5
3
4
5
PA
PA
4
5
3
4
5
1
2
3
4
5
MB - May be covered under medical benefit
9C. Interferons and MS therapy
Trade name
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Actimmune <s>
2
4
4
4
4
Alferon N
2
2
2
2
2
Ampyra <s>
3
4
5
4
5
Aubagio <s>
3
4
5
4
5
Avonex <s>
2
4
4
4
4
Betaseron <s>
3
4
5
4
5
1
4
4
4
4
4
4
4
5
4
4
4
4
4
4
4
4
4
4
4
5
4
4
Copaxone <s>
glatiramer acetate
Copaxone 40mg/ml <s>
2
4
4
Extavia <s>
3
4
5
Gilenya <s>
2
4
4
Intron A <s>
2
4
4
Pegasys, Proclick <s>
2
4
4
Peg-Intron, Redipen <s>
2
4
4
Rebif, Rebidose <s>
2
4
4
Sylatron <s>
3
4
5
Tecfidera <s>
2
4
4
PA - Prior approval may be required
ST - Step therapy may be required
PA, QL
PA, QL
PA, QL
QL
QL
QL
PA, QL
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
PA, QL 3
PA, QL 4
5
PA
6
7
8
PA
9
QL 10
11
QL 12
QL 13
14
QL 15
QL 16
<s> - Specialty Drug
Page 58
9D. Miscellaneous immunology and hematology
Trade name
Firazyr <s>
Ruconest <s>
PA - Prior approval may be required
Generic name
BCBSM (EPO/PPO)
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL
PA, QL 1
4
5
3
4
5
PA, QL
PA, QL 2
4
5
3
4
5
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
<s> - Specialty Drug
Page 59
10. Dermatology
10A. Acne treatment
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Benzaclin
clindamycin phos/benzoyl perox
1
1
1
1
1B
Benzamycin
erythromycin/benzoyl peroxide
1
1
1
1
1B
Cleocin-T swabs
clindamycin phosphate
1
1
1
1
1B
Differin 0.1% cream, gel
adapalene
1
1
1
1
1B
Minocin capsule
minocycline hcl
1
1
1
1
1B
Monodox
doxycycline monohydrate
1
1
1
1
1B
Retin-A; Avita
tretinoin
1
1
1
1
1B
Tazorac
tazarotene
1
1
1
1
1B
Tazorac 0.5%; 0.1% gel
2
2
2
2
2
Vibramycin
doxycycline hyclate
1
1
1
1
1B
Vibramycin suspension
doxycycline monohydrate
1
1
1
1
1B
Vibramycin syrup
3
3
3
3
3
10B. Antipsoriatic and antiseborrheic
BCBSM (EPO/PPO)
Trade name
Generic name
Cosentyx <s>
Dovonex
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL 4
PA, QL 1
4
2
4
4
1
1
1
Enbrel <s>
calcipotriene
2
4
4
Humira <s>
2
4
4
Otezla <s>
2
4
4
PA, QL
PA, QL
PA, QL
1
1B
4
4
4
4
4
4
Oxsoralen-Ultra
methoxsalen, rapid
1
1
1
1
1B
Selsun 2.5% (Rx Only)
selenium sulfide
1
1
1
1
1B
Soriatane
acitretin
1
1
1
1
1B
2
4
4
4
4
1
1
1
1
1B
3
3
3
3
3
1
1
1
1
1B
Stelara <s>
Taclonex ointment
calcipotriene/betamethasone
Taclonex topical suspension
Vectical
calcitriol
10C. Corticosteriods - very high potency
Trade name
Generic name
PA, QL
BCBSM (EPO/PPO)
2
PA, QL 3
QL
4
PA, QL 5
6
7
8
PA, QL 9
PA 10
PA 11
12
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Clobevate; Temovate
clobetasol propionate
1
1
1
1
1B
Clobex shampoo
clobetasol propionate
1
1
1
1
1B
Diprolene lotion, ointment
betamethasone/propylene glyc
1
1
1
1
1B
Temovate Emollient
clobetasol propionate/emoll
1
1
1
1
1B
Ultravate cream, ointment
halobetasol propionate
1
1
1
1
1B
PA - Prior approval may be required
1
2
3
4
5
6
7
8
9
10
11
12
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
<s> - Specialty Drug
Page 60
1
2
3
4
5
10D. Corticosteroids - high potency
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Aristocort; Kenalog 0.5%
triamcinolone acetonide
1
1
1
1
1B
Diprolene, AF
betamethasone/propylene glyc
1
1
1
1
1B
Diprosone; Maxivate
betamethasone dipropionate
1
1
1
1
1B
Elocon ointment
mometasone furoate
1
1
1
1
1B
Florone; Psorcon
diflorasone diacetate
1
1
1
1
1B
Lidex
fluocinonide
1
1
1
1
1B
Lidex E
fluocinonide/emollient base
1
1
1
1
1B
Valisone
betamethasone valerate
1
1
1
1
1B
10E. Corticosteroids - medium potency
Trade name
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Cutivate
fluticasone propionate
1
1
1
1
1B
Elocon cream, solution
mometasone furoate
1
1
1
1
1B
Kenalog 0.025%, 0.05%, 0.1%
triamcinolone acetonide
1
1
1
1
1B
Kenalog spray
triamcinolone acetonide
1
1
1
1
1B
1B
Locoid cream, ointment, solution
hydrocortisone butyrate
1
1
1
1
Oralone paste
triamcinolone acetonide
1
1
1
1
1B
3
3
3
3
3
Pandel
Synalar 0.025%
fluocinolone acetonide
1
1
1
1
1B
Westcort
hydrocortisone valerate
1
1
1
1
1B
10F. Corticosteroids - low potency
BCBSM (EPO/PPO)
Trade name
Aclovate
Generic name
Capex shampoo
1
1
1
1
1B
2
2
2
2
2
Dermacort, Hytone 2.5%
hydrocortisone
1
1
1
1
1B
Derma-smoothe-FS
fluocinolone/shower cap
1
1
1
1
1B
Derma-smoothe-FS
fluocinolone acetonide
1
1
1
1
1B
Desonate
3
3
3
3
3
Desowen
desonide
1
1
1
1
1B
Synalar 0.01%
fluocinolone acetonide
1
1
1
1
1B
10G. Scabicides and pediculicides
BCBSM (EPO/PPO)
Trade name
Elimite
Generic name
Eurax
1
1
1
1
1B
2
2
2
2
2
Lindane
lindane
1
1
1
1
1B
Natroba
spinosad
1
1
1
1
1B
Ovide
malathion
1
1
1
1
1B
Sklice
3
3
3
3
3
Ulesfia
3
3
3
3
3
PA - Prior approval may be required
ST - Step therapy may be required
QL
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
permethrin
1
2
3
4
5
6
7
8
9
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
alclometasone dipropionate
1
2
3
4
5
6
7
8
<s> - Specialty Drug
Page 61
1
2
3
4
5
6
7
10H. Topical anesthetics
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Emla
lidocaine/prilocaine
1
1
1
1
1B
Lidocaine 5% ointment
lidocaine
1
1
1
1
1B
Xylocaine Viscous (Rx Only)
lidocaine hcl
1
1
1
1
1B
10I. Topical antibacterials
BCBSM (EPO/PPO)
Trade name
Bactroban cream
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
1
1
1
1
1B
2
2
2
2
2
1
1
1
1
1B
Cortisporin cream 0.5%
3
3
3
3
3
Cortisporin ointment 1%
3
3
3
3
3
1
1
1
1
1B
mupirocin calcium
Bactroban nasal
Bactroban ointment
Gentamicin cream, ointment
mupirocin
gentamicin sulfate
10J. Topical antifungals
BCBSM (EPO/PPO)
Trade name
Generic name
3
3
3
3
3
Extina
ketoconazole
1
1
1
1
1B
Loprox cream, suspension
ciclopirox olamine
1
1
1
1
1B
Loprox gel, shampoo
ciclopirox
1
1
1
1
1B
1B
Lotrimin
clotrimazole
1
1
1
1
Lotrisone
clotrimazole/betamethasone dip
1
1
1
1
1B
Mycostatin
nystatin
1
1
1
1
1B
Nizoral cream, shampoo 2%
ketoconazole
1
1
1
1
1B
Nystatin
nystatin
1
1
1
1
1B
Nystatin w/Triamcinolone
nystatin/triamcin
1
1
1
1
1B
Penlac
ciclopirox
1
1
1
1
1B
Spectazole
econazole nitrate
1
1
1
1
1B
10K. Topical antineoplastic agents and immunomodulators
Trade name
Generic name
Aldara
imiquimod
Efudex
fluorouracil
BCBSM (EPO/PPO)
1
1
1
1
1B
Elidel
2
2
2
2
2
Fluoroplex
3
3
3
3
3
2
2
2
2
2
3
3
3
1
1
1
Targretin gel <s>
3
4
5
Tolak
3
3
3
Valchlor <s>
3
4
5
Veregen
3
3
3
Zyclara
3
3
3
Picato
Protopic
PA - Prior approval may be required
tacrolimus
ST - Step therapy may be required
PA, QL
QL
PA
PA, QL
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
9
10
11
12
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
1
1B
1
1
1
Panretin
1
2
3
4
5
6
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Exelderm
1
2
3
3
3
1
1B
4
5
3
3
4
5
3
3
3
3
1
2
3
4
5
ST, QL 6
7
PA
8
9
PA, QL 10
11
QL 12
<s> - Specialty Drug
Page 62
10L. Topical antivirals
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Denavir
3
3
3
3
3
Zovirax cream
2
2
2
2
2
1
1
1
1
1B
Zovirax ointment
acyclovir
10M. Wound and burn therapy
BCBSM (EPO/PPO)
Trade name
Generic name
Regranex
Silvadene
silver sulfadiazine
10N. Miscellaneous dermatologicals
2
2
2
2
2
1
1
1
1
1B
BCBSM (EPO/PPO)
Trade name
Generic name
podofilox
Dupixent <s>
Finacea gel
2
2
2
2
2
1
1
1
1
1B
3
4
5
4
5
PA, QL
3
3
3
3
3
Lac-Hydrin
ammonium lactate
1
1
1
1
1B
Metrocream, gel, lotion 0.75%
metronidazole
1
1
1
1
1B
Prudoxin
doxepin hcl
1
1
1
1
1B
Sodium chloride irrigation
sodium chloride irrig solution
1
1
1
1
1B
Solaraze
diclofenac sodium
1
1
1
1
1B
3
3
Zonalon
PA - Prior approval may be required
3
ST - Step therapy may be required
3
PA, QL
3
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Condylox gel
Condylox solution
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
3
3
3
3
3
Santyl
1
2
3
1
2
PA, QL 3
4
5
6
7
8
PA
9
10
<s> - Specialty Drug
Page 63
11. Ophthalmology
11A. Cycloplegic mydriatics
BCBSM (EPO/PPO)
Trade name
Cyclogyl
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
1
1
1
1
1B
Cyclogyl 5ml
3
3
3
3
3
Cyclomydril
3
3
3
3
3
cyclopentolate hcl
Isopto Atropine
atropine sulfate
1
1
1
1
1B
Isopto Homatropine
homatropine hbr
1
1
1
1
1B
Mydriacyl
tropicamide
1
1
1
1
1B
Paremyd
3
3
3
3
3
11B. Glaucoma agents
BCBSM (EPO/PPO)
Trade name
Alphagan 0.2%, P 0.15%
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
1
1
1B
2
2
2
2
2
2
2
2
1
1
1
1
1B
Cosopt PF
3
3
3
3
3
Iopidine droperette
3
3
3
3
3
brimonidine tartrate
1
Alphagan P 0.1%
2
Azopt
2
Cosopt
dorzolamide hcl/timolol maleat
1
Iopidine drops
apraclonidine hcl
1
1
1
1
1B
Isopto-Carpine; Pilocar
pilocarpine hcl
1
1
1
1
1B
Lumigan
bimatoprost
1
1
1
1
1B
2
2
2
2
2
1B
Lumigan 0.01%
Neptazane
1
1
1
1
Phospholine Iodide
2
2
2
2
2
Travatan Z
2
2
2
2
2
methazolamide
Trusopt
dorzolamide hcl
1
1
1
1
1B
Xalatan
latanoprost
1
1
1
1
1A
Zioptan
3
3
3
3
3
11C. Ophthalmic anti-allergy agents
BCBSM (EPO/PPO)
Trade name
Generic name
Alocril
2
2
2
2
2
Alomide
2
2
2
2
2
3
3
3
3
3
1
1
1
1
1B
Emadine
3
3
3
3
3
Lastacaft
3
3
3
3
3
1B
Elestat
epinastine hcl
Opticrom
cromolyn sodium
1
1
1
1
Optivar
azelastine hcl
1
1
1
1
1B
Pataday
olopatadine hcl
1
1
1
1
1B
Patanol
olopatadine hcl
1
1
1
1
1B
PA - Prior approval may be required
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Bepreve
1
2
3
4
5
6
7
<s> - Specialty Drug
Page 64
1
2
3
4
5
6
7
8
9
10
11D. Ophthalmic anti-infective and steroid combinations
Trade name
Generic name
BCBSM (EPO/PPO)
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Blephamide
2
2
2
2
2
Cortisporin eye drops
neomycin/polymyxin b sulf/hc
1
1
1
1
1B
Cortisporin eye ointment
neomycin su/baci zn/poly/hc
1
1
1
1
1B
Maxitrol
neo/polymyx b sulf/dexameth
1
1
1
1
1B
Pred-G
3
3
3
3
3
Tobradex ointment
2
2
2
2
2
Tobradex ST
3
3
3
3
3
Tobradex suspension
tobramycin/dexamethasone
1
1
1
1
1B
Vasocidin
sulfacetamide/prednisolone sp
1
1
1
1
1B
Zylet
3
3
3
3
3
11E. Ophthalmic anti-infectives
BCBSM (EPO/PPO)
Trade name
Generic name
Bacitracin
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Azasite
bacitracin
Besivance
3
3
3
3
3
1
1
1
1
1B
3
3
3
3
3
Bleph-10, Sodium Sulamyde drops
sulfacetamide sodium
1
1
1
1
1B
Ciloxan drops
ciprofloxacin hcl
1
1
1
1
1B
Ciloxan ointment
2
2
2
2
2
Garamycin
gentamicin sulfate
1
1
1
1
1B
Ilotycin
erythromycin base
1
1
1
1
1B
2
2
2
2
2
Moxeza
Natacyn
2
2
2
2
2
Neosporin ophthalmic ointment
neomycin su/bacitra/polymyxin
1
1
1
1
1B
Neosporin ophthalmic solution
neomycin/polymyxn b/gramicidin
1
1
1
1
1B
Ocuflox
ofloxacin
1
1
1
1
1B
Polysporin
bacitracin/polymyxin b sulfate
1
1
1
1
1B
Polytrim
polymyxin b sulf/trimethoprim
1
1
1
1
1B
Quixin
levofloxacin
1
1
1
1
1B
Tobrex drops
tobramycin
1
1
1
1
1B
3
3
3
3
3
2
2
2
2
2
1
1
1
1
1B
2
2
2
2
2
1
1
1
1
1B
Tobrex ointment
Vigamox
Viroptic
trifluridine
Zirgan
Zymaxid
gatifloxacin
11F. Ophthalmic anti-inflammatory agents
Trade name
Acular, LS
Bromday; Xibrom
Generic name
BCBSM (EPO/PPO)
bromfenac sodium
Nevanac
1
1
1
1
1B
1B
1
1
1
1
3
3
3
3
3
Ocufen
flurbiprofen sodium
1
1
1
1
1B
Voltaren ophthalmic solution
diclofenac sodium
1
1
1
1
1B
PA - Prior approval may be required
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
ketorolac tromethamine
1
2
3
4
5
6
7
8
9
10
<s> - Specialty Drug
Page 65
1
2
3
4
5
11G. Ophthalmic beta blockers
BCBSM (EPO/PPO)
Trade name
Betagan
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
levobunolol hcl
Betoptic S
1
1
1
1
1A
2
2
2
2
2
Betoptic solution
betaxolol hcl
1
1
1
1
1B
Ocupress
carteolol hcl
1
1
1
1
1B
Optipranolol
metipranolol
1
1
1
1
1B
Timoptic, XE
timolol maleate
1
1
1
1
1A
11H. Ophthalmic steroids
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Alrex
3
3
3
3
3
1
1
1
1
1B
3
3
3
3
3
1
1
1
1
1B
2
2
2
2
2
1
1
1
1
1B
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1B
Pred Mild
2
2
2
2
2
11I. Miscellaneous ophthalmic agents
BCBSM (EPO/PPO)
Decadron ophthalmic
dexamethasone sod phosphate
Durezol
FML
fluorometholone
FML Forte, S.O.P.
Inflamase, Forte
prednisolone sod phosphate
Lotemax
Maxidex
Pred Forte
prednisolone acetate
Trade name
Generic name
Cystaran <s>
phenylephrine hcl
Restasis
PA - Prior approval may be required
1
2
3
4
5
6
7
8
9
10
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL
PA, QL 1
4
4
2
4
4
Lacrisert
Neo-Synephrine
1
2
3
4
5
6
ST - Step therapy may be required
2
2
2
2
2
1
1
1
1
1B
2
2
2
2
2
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
2
3
4
<s> - Specialty Drug
Page 66
12. Otic and nasal preparations
12A. Nasal preparations
BCBSM (EPO/PPO)
Trade name
Generic name
Astelin nasal spray
azelastine hcl
Atrovent nasal spray
ipratropium bromide
Flonase (Rx Only)
fluticasone propionate
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
1
1B
1
1
1
QL
1
1B
1
1
1
QL
1
1B
1
1
1
12B. Otic preparations
BCBSM (EPO/PPO)
Trade name
Cetraxal
BCN (HMO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
1
1
1
1
1B
Cipro HC
3
3
3
3
3
Ciprodex
2
2
2
2
2
ciprofloxacin hcl
Coly-Mycin S; Cortisporin-TC
3
3
3
3
3
Cortisporin
neomycin/polymyxin b sulf/hc
1
1
1
1
1B
Domeboro Otic
acetic acid/aluminum acetate
1
1
1
1
1B
Floxin Otic
ofloxacin
1
1
1
1
1B
Vosol
acetic acid
1
1
1
1
1B
PA - Prior approval may be required
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
<s> - Specialty Drug
Page 67
1
2
3
4
5
6
7
8
13. Respiratory, cough and cold
13A. Antihistamine and decongestant combinations
Trade name
Antihistamine/Decongestant
Generic name
BCBSM (EPO/PPO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
See Chapter 13B
13B. Antihistamines
Trade name
BCN (HMO)
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
1
1B
1
1
1
Astelin nasal spray
azelastine hcl
Atarax
hydroxyzine hcl
1
1
1
1
1B
Benadryl (Rx Only)
diphenhydramine hcl
1
1
1
1
1B
Periactin tablet, 2mg/5 ml syrup
cyproheptadine hcl
1
1
1
1
1B
Phenergan
promethazine hcl
1
1
1
1
1B
Tavist tablet (Rx Only)
clemastine fumarate
1
1
1
1
1B
Vistaril
hydroxyzine pamoate
1
1
1
1
1B
1
1B
1
1B
Xyzal
levocetirizine dihydrochloride
1
1
1
Zyrtec solution (Rx Only)
cetirizine hcl
1
1
1
13C. Antitussives
Trade name
Generic name
N/A
Generic name
Kalydeco <s>
Orkambi <s>
2
tobramycin in 0.225% nacl
4
1
13E. Epinephrine
4
4
4
QL
3
3
3
Epinephrine auto-injector
2
2
2
13F. Inhaled anticholinergics
BCBSM (EPO/PPO)
Trade name
Atrovent solution
Generic name
4
4
4
4
5
BCN (HMO)
QL
3
3
2
2
QL
ipratropium bromide
1
1
1
2
2
2
Tudorza Pressair
3
3
3
ST - Step therapy may be required
QL
QL
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
2
2
2
2
2
Spiriva, Respimat
PA - Prior approval may be required
4
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Adrenalin Chloride Nasal
Atrovent HFA
1
BCN (HMO)
BCBSM (EPO/PPO)
Generic name
N/A
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL 4
PA, QL 1
5
3
4
5
PA, QL 4
PA, QL 2
4
2
4
4
PA, QL 4
PA, QL 3
4
2
4
4
Pulmozyme <s>
Trade name
N/A
N/A
BCBSM (EPO/PPO)
Cayston <s>
Tobi <s>
N/A
1
2
3
4
5
6
7
8
9
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
13D. Cystic Fibrosis agents
Trade name
QL
BCBSM (EPO/PPO)
Drugs in this category are not
covered
1
1
1B
2
2
3
3
QL
<s> - Specialty Drug
Page 68
1
2
3
4
13G. Inhaled beta-agonist and anticholinergic combinations
Trade name
Generic name
Anoro Ellipta
BCBSM (EPO/PPO)
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
QL
2
2
2
2
2
Combivent Respimat
2
2
2
2
2
1
1
1
1
1B
Stiolto Respimat
2
2
2
2
2
13H. Inhaled beta-agonists
BCBSM (EPO/PPO)
Duoneb
ipratropium/albuterol sulfate
Trade name
Albuterol nebulizer solution
Generic name
albuterol sulfate
1
1
1
3
3
3
Brovana
3
3
3
Foradil
2
2
2
Perforomist
3
3
3
ProAir HFA; Ventolin HFA
2
2
2
Proair Respiclick
2
2
2
Proventil HFA
3
3
3
Serevent Diskus
Xopenex HFA
levalbuterol hcl
13I. Inhaled steroid and beta-agonist combinations
Trade name
Generic name
Advair Diskus, HFA
Breo Ellipta
Dulera
Symbicort
2
2
2
3
3
3
1
1
1
QL
QL
QL
QL
QL
QL
QL
Generic name
Alvesco
Asmanex, HFA
Flovent HFA, Diskus
Pulmicort Flexhaler
budesonide
1
1
1
QL
13K. Intranasal steroids
BCBSM (EPO/PPO)
PA - Prior approval may be required
3
3
3
2
2
3
3
2
2
2
2
3
3
2
2
3
3
1
1B
Generic name
2
2
4
ST, QL 5
6
7
8
9
10
11
BCN (HMO)
1
1A
2
2
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
BCN (HMO)
See Chapter 12A
QL - Quantity limits may apply
1
2
3
4
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
ST - Step therapy may be required
1
QL
2
ST, QL 3
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
3
3
3
3
3
QL
2
2
2
2
2
QL
2
2
2
2
2
QL
2
2
2
2
2
QL
2
2
2
2
2
2
Trade name
1B
3
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
2
2
2
2
2
QL
QL
2
2
2
2
2
QL
QL
2
2
2
2
2
QL
2
2
2
2
2
Qvar
Intranasal Steroids
1
BCBSM (EPO/PPO)
Aerospan
Pulmicort solution
BCN (HMO)
BCBSM (EPO/PPO)
13J. Inhaled steroids
Trade name
QL
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Arcapta Neohaler
Xopenex solution
QL
1
2
3
4
<s> - Specialty Drug
Page 69
1
13L. Oral beta-agonists
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Alupent
metaproterenol sulfate
1
1
1
1
1B
Brethine
terbutaline sulfate
1
1
1
1
1B
Proventil solution
albuterol sulfate
1
1
1
1
1B
Proventil/Ventolin tablet
albuterol sulfate
1
1
1
1
1B
Vospire ER
albuterol sulfate
1
1
1
1
1B
13M. Pulmonary Hypertension Agents
Trade name
BCBSM (EPO/PPO)
Generic name
Adcirca <s>
Adempas <s>
Letairis <s>
Opsumit <s>
Orenitram ER <s>
3
sildenafil citrate
4
5
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
1
1
1
Revatio suspension
2
2
2
Tracleer <s>
2
4
4
Tyvaso <s>
2
4
4
Uptravi <s>
2
4
4
Ventavis <s>
2
4
4
13N. Theophyllines
BCBSM (EPO/PPO)
Trade name
Generic name
2
theophylline anhydrous
Trade name
2
1
13O. Miscellaneous respiratory agents
Accolate
4
5
1
1B
2
2
4
4
4
4
4
4
4
4
1
zafirlukast
Daliresp
Esbriet <s>
Glassia <s>
2
2
2
1
1
1B
BCN (HMO)
3
3
3
3
3
Intal solution
cromolyn sodium
1
1
1
1
1B
Mucomyst
acetylcysteine
1
1
1
1
1B
Nebusal
3
3
3
3
3
Ofev <s>
3
4
5
4
5
1
1B
1
1B
Singulair
montelukast sodium
1
1
1
Sodium chloride inhalation
sodium chloride for inhalation
1
1
1
3
3
3
1
1
1
Zyflo
PA - Prior approval may be required
1
2
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
1
1B
1
1
1
1
PA, QL
PA, QL 2
3
3
3
3
3
PA, QL
PA, QL 3
4
4
2
4
4
PA, QL
PA
4
4
2
4
4
4
Hyper-Sal
Zyflo CR
6
7
8
9
10
11
12
BCN (HMO)
BCBSM (EPO/PPO)
Generic name
PA, QL
PA
PA, QL
PA, QL
PA, QL
PA, QL
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Theo-24
Theophylline anhydrous
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
PA, QL
PA, QL 1
4
4
2
4
4
PA, QL
PA, QL 2
4
4
2
4
4
PA, QL
PA, QL 3
4
4
2
4
4
PA, QL
PA, QL 4
4
4
2
4
4
PA,
QL
PA, QL 5
4
4
2
4
4
Remodulin <s>
Revatio
1
2
3
4
5
zileuton
ST - Step therapy may be required
PA, QL
QL
QL
QL
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
3
3
1
1B
5
6
7
8
PA, QL 9
10
11
12
QL 13
<s> - Specialty Drug
Page 70
14. Urology
14A. BPH Treatment
Trade name
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Avodart
dutasteride
1
1
1
1
1B
Cardura
doxazosin mesylate
1
1
1
1
1B
3
3
3
3
3
Cardura XL
Flomax
tamsulosin hcl
1
1
1
1
1B
Hytrin
terazosin hcl
1
1
1
1
1B
1
1B
1
1B
3
3
1
1B
Jalyn
dutasteride/tamsulosin hcl
1
1
1
Proscar
finasteride
1
1
1
3
3
3
1
1
1
Rapaflo
Uroxatral
alfuzosin hcl
14B. Ion-Removing Agents
Trade name
QL
QL
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Auryxia
3
3
3
3
3
Fosrenol tablet
3
3
3
3
3
Kayexalate
sodium polystyrene sulfonate
1
1
1
1
1B
Phoslo
calcium acetate
1
1
1
1
1B
Phoslyra
3
3
3
3
3
Renagel
2
2
2
2
2
Renvela
2
2
2
2
2
SPS
sodium polystyrene sulfonate
1
1
1
1
1B
SPS
sodium polystyrene sulfon/sorb
1
1
1
1
1B
SPS 50g/200ml enema
3
3
3
3
3
Veltassa
2
2
2
2
2
14C. Urinary Antispasmodics
BCBSM (EPO/PPO)
Trade name
Generic name
PA, QL
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
tolterodine tartrate
1
1
1
1
1B
Ditropan, XL
oxybutynin chloride
1
1
1
1
1B
Enablex
darifenacin hydrobromide
1
1
1
1
1B
Levbid
hyoscyamine sulfate
1
1
1
1
1B
Levsin, SL
hyoscyamine sulfate
1
1
1
1
1B
Myrbetriq
3
3
3
Sanctura
trospium chloride
1
1
1
Sanctura XR
trospium chloride
1
1
1
3
3
3
Toviaz
flavoxate hcl
Vesicare
PA - Prior approval may be required
ST - Step therapy may be required
1
1
1
3
3
3
QL
ST, QL
QL
QL
ST, QL
ST, QL
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
8
9
10
11
BCN (HMO)
Detrol, LA
Urispas
1
2
3
4
5
ST, QL 6
7
QL
8
9
3
3
1
1B
1
1B
3
3
1
1B
3
3
1
2
3
4
5
PA, QL 6
7
QL
8
QL
9
10
11
<s> - Specialty Drug
Page 71
14D. Miscellaneous Urologicals
Trade name
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Cystagon <s>
2
4
4
4
4
Depen
2
2
2
2
2
Elmiron
2
2
2
2
2
Lithostat
3
3
3
3
3
Renacidin
2
2
2
2
2
Resectisol
3
3
3
3
3
Sorbitol-mannitol
3
3
3
3
3
Thiola
3
3
3
Urecholine
bethanechol chloride
1
1
1
Urocit-K
potassium citrate
1
1
1
2
4
4
Xuriden <s>
PA - Prior approval may be required
ST - Step therapy may be required
PA
PA, QL
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
3
3
1
1B
1
1B
4
4
1
2
3
4
5
6
7
PA
8
9
10
PA, QL 11
QL
<s> - Specialty Drug
Page 72
15. Vitamins and supplements
15A. Potassium Replacement
BCBSM (EPO/PPO)
Trade name
K-Lor; Klor-Con packet
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
potassium chloride
Klor-Con 25 mEq packet
1
1
1
1
1B
3
3
3
3
3
Klor-Con M15
potassium chloride
1
1
1
1
1B
K-Lyte; Klor-con/EF
potassium bicarbonate/cit ac
1
1
1
1
1B
K-Sol; Potassium Chloride
potassium chloride
1
1
1
1
1B
K-Tab; K-Dur; Slow-K; Kaon CL;
Klor-con
Micro-K
potassium chloride
1
1
1
1
1B
potassium chloride
1
1
1
1
1B
Potassium Chloride effervescent
pot chloride/pot bicarb/cit ac
1
1
1
1
1B
15B. Vitamins and Minerals
BCBSM (EPO/PPO)
Trade name
Generic name
1
2
3
4
5
6
7
8
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Calciferol (Rx Only)
ergocalciferol (vitamin d2)
1
1
1
1
1B
Calcium + Vitamin D 600mg
(Prevent)
calcium carbonate/vitamin d3
$0
$0
$0
$0
$0
1
2
Calcium + Vitamin D capsule
(Prevent)
calcium carbonate/vitamin d3
$0
$0
$0
$0
$0
3
Calcium + Vitamin D chewable
(Prevent)
calcium carbonate/vitamin d3
$0
$0
$0
$0
$0
4
Calcium + Vitamin D tablet
(Prevent)
calcium carb & citrate/vit d3
$0
$0
$0
$0
$0
5
Calcium + Vitamin D tablet
(Prevent)
calcium carbonate/vitamin d3
$0
$0
$0
$0
$0
6
Calcium Citrate w/Vitamin D
(Prevent)
calcium citrate/vitamin d3
$0
$0
$0
$0
$0
7
Calvite P&D (Prevent)
calcium phosphate dibas/vit d3
$0
$0
$0
$0
$0
Cyanocobalamin injection
cyanocobalamin (vitamin b-12)
1
1
1
1
1B
Fluor-a-Day 0.25mg, 0.5mg
(Prevent)
sodium fluoride/xylitol
$0
$0
$0
$0
$0
8
9
10
Fluoritab; Sodium Fluoride 0.25mg, sodium fluoride
0.5mg (Prevent)
$0
$0
$0
$0
$0
11
Folic Acid 0.4mg, 0.8mg (OTC)
(Prevent)
folic acid
$0
$0
$0
$0
$0
12
Folic Acid 1mg
folic acid
1
1
1
1
1B
3
3
3
3
3
1
1
1
1
1B
13
14
15
16
17
18
19
Galzin
Hydroxocobalamin
hydroxocobalamin
K-Phos Neutral
phosphorus #1
1
1
1
1
1B
Luride 0.5mg/ml (Prevent)
sodium fluoride
$0
$0
$0
$0
$0
2
2
2
2
2
calcium carbonate/vitamin d2
$0
$0
$0
$0
$0
3
3
3
3
3
Mephyton
Oyster shell Calcium w/vitamin D
(Prevent)
Vitamin D2 (OTC) (1,000 units or
less) (Prevent)
ergocalciferol (vitamin d2)
$0
$0
$0
$0
$0
20
21
Vitamin D3 (OTC) (1,000 units or
less) (Prevent)
cholecalciferol (vitamin d3)
$0
$0
$0
$0
$0
22
Vitamin K ampule
phytonadione
1
1
1
1
1B
23
Phytonadione
PA - Prior approval may be required
ST - Step therapy may be required
QL - Quantity limits may apply
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
Page 73
16. Diagnostic and other miscellaneous
16A. Chelating Agents
Trade name
BCBSM (EPO/PPO)
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Chemet
2
2
2
2
2
2
2
2
2
1
1
1
1
1B
Exjade <s>
3
4
5
4
5
Ferriprox <s>
3
4
5
4
5
Syprine <s>
3
4
5
4
5
16B. Diagnostics and Other Miscellaneous
BCBSM (EPO/PPO)
Depen
Desferal
deferoxamine mesylate
Trade name
Generic name
PA
PA, QL
PA, QL
2
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Acetic Acid
acetic acid
1
1
1
1
1B
Carnitor
levocarnitine
1
1
1
1
1B
3
3
3
3
3
1
1
1
1
1B
Cystadane <s>
3
4
5
4
5
Keveyis <s>
3
4
5
4
5
Orfadin <s>
2
4
4
4
4
Radiogardase
2
2
2
2
2
Samsca <s>
2
4
4
4
4
Vistogard <s>
2
4
4
4
4
Carnitor SF
Carnitor solution
PA - Prior approval may be required
1
QL
2
3
PA
4
PA, QL 5
PA, QL 6
levocarnitine (with sugar)
ST - Step therapy may be required
PA, QL
QL
QL
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
PA, QL 6
7
8
9
QL 10
<s> - Specialty Drug
Page 74
16C. Vaccines*
BCBSM (EPO/PPO)
Trade name
Generic name
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
Adacel (Prevent)
$0
$0
$0
$0
$0
Afluria (Prevent)
$0
$0
$0
$0
$0
Afluria Quad (Prevent)
$0
$0
$0
$0
$0
Boostrix (Prevent)
$0
$0
$0
$0
$0
Cervarix** (Prevent)
$0
$0
$0
$0
$0
Ez Flu (Afluria) (Prevent)
$0
$0
$0
$0
$0
Ez Flu (Fluvirin) (Prevent)
$0
$0
$0
$0
$0
Ez Flu (Fluzone) (Prevent)
$0
$0
$0
$0
$0
Fluad (Prevent)
$0
$0
$0
$0
$0
Fluarix Quad (Prevent)
$0
$0
$0
$0
$0
Flublok 2016-2017 (Prevent)
$0
$0
$0
$0
$0
Flucelvax Quad 2016-2017
(Prevent)
$0
$0
$0
$0
$0
Flulaval Quad (Prevent)
$0
$0
$0
$0
$0
Fluvirin (Prevent)
$0
$0
$0
$0
$0
Fluzone (all) (Prevent)
$0
$0
$0
$0
$0
Fluzone Quad (all) (Prevent)
$0
$0
$0
$0
$0
Gardasil, 9** (Prevent)
$0
$0
$0
$0
$0
Menactra (Prevent)
$0
$0
$0
$0
$0
$0
Menomune-A/C/Y/W-135 (Prevent)
$0
$0
$0
$0
Menveo (Prevent)
$0
$0
$0
$0
$0
$0
Pneumovax 23 (Prevent)
$0
$0
$0
$0
Prevnar 13** (Prevent)
$0
$0
$0
$0
$0
$0
$0
$0
Zostavax** (Prevent)
$0
$0
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
*Covered under medical benefit for BCN members, at participating retail pharmacies.
**Age restrictions apply.
PA - Prior approval may be required
ST - Step therapy may be required
QL - Quantity limits may apply
BCBSM/BCN Custom Select Drug List
<s> - Specialty Drug
Page 75
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
17. Lifestyle modification
17A. Sexual Dysfunction
BCBSM (EPO/PPO)
Trade name
Generic name
Drugs in this category are not
covered
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
N/A
17B. Smoking Cessation
Generic name
Chantix (Prevent)
Commit Lozenge OTC (Prevent)
nicotine polacrilex
Nicorette lozenge (Prevent)
nicotine polacrilex
Nicotine gum; Nicorette (Prevent)
nicotine polacrilex
Nicotine patch (Prevent)
nicotine
Nicotrol, NS (Prevent)
Zyban (Prevent)
PA - Prior approval may be required
N/A
N/A
bupropion hcl
ST - Step therapy may be required
N/A
N/A
N/A
QL - Quantity limits may apply
N/A
<s> - Specialty Drug
(Prevent) - Prevent drugs may be covered at $0 if criteria are met
BCBSM/BCN Custom Select Drug List
1
2
3
4
5
6
7
BCN (HMO)
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
N/A
1
BCN (HMO)
BCBSM (EPO/PPO)
Generic name
N/A
3-Tier 4-Tier 5-Tier Limits 4-Tier 6-Tier Limits
QL
$0
$0
$0
$0 ST, QL $0
QL
QL
$0
$0
$0
$0
$0
QL
QL
$0
$0
$0
$0
$0
QL
QL
$0
$0
$0
$0
$0
QL
QL
$0
$0
$0
$0
$0
ST, QL
$0
$0
$0
$0 ST, QL $0
QL
$0
$0
$0
$0
$0
17C. Weight Loss Preparations
Trade name
N/A
BCBSM (EPO/PPO)
Trade name
Drugs in this category are not
covered
BCN (HMO)
Page 76
1
We speak your language
If you, or someone you’re helping, needs assistance, you have the
right to get help and information in your language at no cost. To
talk to an interpreter, call the Customer Service number on the
back of your card, or 877-469-2583, TTY: 711 if you are not
already a member.
Si usted, o alguien a quien usted está ayudando, necesita
asistencia, tiene derecho a obtener ayuda e información en su
idioma sin costo alguno. Para hablar con un intérprete, llame al
número telefónico de Servicio al cliente, que aparece en la parte
trasera de su tarjeta, o 877-469-2583, TTY: 711 si usted todavía no
es un miembro.
‫ ﻓﻠﺪﯾﻚ اﻟﺤﻖ ﻓﻲ اﻟﺤﺼﻮل ﻋﻠﻰ‬،‫إذا ﻛﻨﺖ أﻧﺖ أو ﺷﺨﺺ آﺧﺮ ﺗﺴﺎﻋﺪه ﺑﺤﺎﺟﺔ ﻟﻤﺴﺎﻋﺪة‬
‫ ﻟﻠﺘﺤﺪث إﻟﻰ ﻣﺘﺮﺟﻢ اﺗﺼﻞ ﺑﺮﻗﻢ‬.‫اﻟﻤﺴﺎﻋﺪة واﻟﻤﻌﻠﻮﻣﺎت اﻟﻀﺮورﯾﺔ ﺑﻠﻐﺘﻚ دون أﯾﺔ ﺗﻜﻠﻔﺔ‬
‫ إذا‬،877-469-2583 TTY:711 ‫ أو ﺑﺮﻗﻢ‬،‫ﺧﺪﻣﺔ اﻟﻌﻤﻼء اﻟﻤﻮﺟﻮد ﻋﻠﻰ ظﮭﺮ ﺑﻄﺎﻗﺘﻚ‬
.‫ﻟﻢ ﺗﻜﻦ ﻣﺸﺘﺮﻛﺎ ﺑﺎﻟﻔﻌﻞ‬
如果您，或是您正在協助的對象，需要協助，您有權利免費
以您的母語得到幫助和訊息。要洽詢一位翻譯員，請撥在您
的卡背面的客戶服務電話；如果您還不是會員，請撥電話
877-469-2583, TTY: 711。
ܿ
ܵ ‫ܝܬܘܢ ܿܗ ܿܝ‬
ܵ ܿ
ܿ
ܿ ‫ ܣܢܝܩܝ‬، ‫ܬܘܢ‬
ܿ ‫ܕܗܝܘܪܘ‬
ܿ
ܿ
،‫ܪܬܐ‬
ܼ ܼ ܼ ‫ ܿ ܼܝܢ ܿ ܼܚܕ ܼܦܪܨܘܦܐ‬،‫ܐܢ ܼܐܚܬܘܢ‬
ܼ ܼ
ܸ
ܼ ܼ ܵ
ܵ
ܵ
ܵ
ܿ
ܿ
ܿ
ܿ
ܿ
ܵ
ܿ
ܿ
ܿ
ܵ
ܿ
ܵ
ܿ
‫ܘܟܘܢ‬
݂ ‫ܐܚܬܘܢ ܐ ܼܝܬܠ‬
݂ ‫ܢܘܬܐ ܒ ܸܠܫܢ‬
ܼ ‫ܕܩܒܠ ܼܝܬܘܢ ܼܗ ܼܝܪܬܐ‬
ܼ ‫ܩܘܬܐ‬
ܼ ‫ܘܟܘܢ ܼܗ‬
ܼ
ܼ ‫ܘܡܘܕܥ‬
ܵ
ܿ
ܵ
ܿ
ܿ
ܿ
ܵ
ܵ
ܿ
ܵ
ܵ
ܿ
ܿ
ܿ
ܵ
‫ ܩܪܘܢ ܼܥܠ ܹܬܠ ܼܝܦܘܢ ܸܡܢܝܢܐ‬،‫ܡܬܪܓܡܢܐ‬
‫ܠܗ‬
ܼ ‫ܡܙܡܬܐ ܼܥܡ ܼܚܕ‬
ܼ .‫ܕ� ܛ ܼܝܡܐ‬
ܼ
ܵ ܵ
ܿ
ܵ
ܿ
ܵ
ܿ
ܵ
�‫ܐܢ ܗ‬
ܸ ‫ܕܐ ܼܝܢܐ ܼܥܠ ܚܨܐ‬
ܸ 877-469-2583 TTY:711 ‫ܕܦܬܩܘ ݂ܟ ܼܘܢ ܼܝܢ‬
.‫ܬܘܢ ܼܿܗ ܵܕ ܹ̈ܡܐ‬
ܼ ‫ܠ ܼܝ‬
Nếu quý vị, hay người mà quý vị đang giúp đỡ, cần trợ giúp, quý vị
sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của
mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi số
Dịch vụ Khách hàng ở mặt sau thẻ của quý vị, hoặc 877-469-2583,
TTY: 711 nếu quý vị chưa phải là một thành viên.
Nëse ju, ose dikush që po ndihmoni, ka nevojë për asistencë, keni
të drejtë të merrni ndihmë dhe informacion falas në gjuhën tuaj.
Për të folur me një përkthyes, telefononi numrin e Shërbimit të
Klientit në anën e pasme të kartës tuaj, ose 877-469-2583,
TTY: 711 nëse nuk jeni ende një anëtar.
만약 귀하 또는 귀하가 돕고 있는 사람이 지원이 필요하다면,
귀하는 도움과 정보를 귀하의 언어로 비용 부담 없이 얻을 수
있는 권리가 있습니다. 통역사와 대화하려면 귀하의 카드
뒷면에 있는 고객 서비스 번호로 전화하거나, 이미 회원이
아닌 경우 877-469-2583, TTY: 711로 전화하십시오.
যিদ আপনার, বা আপিন সাহাযয্ করেছন এমন কােরা, সাহাযয্ �েয়াজন হয়,
তাহেল আপনার ভাষায় িবনামূেলয্ সাহাযয্ ও তথয্ পাওয়ার অিধকার আপনার
রেয়েছ। েকােনা একজন েদাভাষীর সােথ কথা বলেত, আপনার কােডর্র েপছেন
েদওয়া �াহক সহায়তা ন�ের কল কর‍ন বা 877-469-2583, TTY: 711
যিদ ইেতামেধয্ আপিন সদসয্ না হেয় থােকন।
Jeśli Ty lub osoba, której pomagasz, potrzebujecie pomocy, masz
prawo do uzyskania bezpłatnej informacji i pomocy we własnym
języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer
działu obsługi klienta, wskazanym na odwrocie Twojej karty lub
pod numer 877-469-2583, TTY: 711, jeżeli jeszcze nie masz
członkostwa.
Falls Sie oder jemand, dem Sie helfen, Unterstützung benötigt,
haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer
Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen,
rufen Sie bitte die Nummer des Kundendienstes auf der Rückseite
Ihrer Karte an oder 877-469-2583, TTY: 711, wenn Sie noch kein
Mitglied sind.
Se tu o qualcuno che stai aiutando avete bisogno di assistenza, hai
il diritto di ottenere aiuto e informazioni nella tua lingua
gratuitamente. Per parlare con un interprete, rivolgiti al Servizio
Assistenza al numero indicato sul retro della tua scheda o chiama
il 877-469-2583, TTY: 711 se non sei ancora membro.
ご本人様、またはお客様の身の回りの方で支援を必要とさ
れる方でご質問がございましたら、ご希望の言語でサポー
トを受けたり、情報を入手したりすることができます。料
金はかかりません。通訳とお話される場合はお持ちのカー
ドの裏面に記載されたカスタマーサービスの電話番号
(メンバーでない方は877-469-2583, TTY: 711)
までお電話ください。
Если вам или лицу, которому вы помогаете, нужна помощь, то
вы имеете право на бесплатное получение помощи и
информации на вашем языке. Для разговора с переводчиком
позвоните по номеру телефона отдела обслуживания
клиентов, указанному на обратной стороне вашей карты, или
по номеру 877-469-2583, TTY: 711, если у вас нет членства.
Ukoliko Vama ili nekome kome Vi pomažete treba pomoć, imate
pravo da besplatno dobijete pomoć i informacije na svom jeziku.
Da biste razgovarali sa prevodiocem, pozovite broj korisničke
službe sa zadnje strane kartice ili 877-469-2583, TTY: 711 ako već
niste član.
Kung ikaw, o ang iyong tinutulungan, ay nangangailangan ng
tulong, may karapatan ka na makakuha ng tulong at impormasyon
sa iyong wika ng walang gastos. Upang makausap ang isang
tagasalin, tumawag sa numero ng Customer Service sa likod ng
iyong tarheta, o 877-469-2583, TTY: 711 kung ikaw ay hindi pa
isang miyembro.
Important disclosure
Blue Cross Blue Shield of Michigan and Blue Care Network comply
with Federal civil rights laws and do not discriminate on the basis
of race, color, national origin, age, disability, or sex. Blue Cross
Blue Shield of Michigan and Blue Care Network provide free
auxiliary aids and services to people with disabilities to
communicate effectively with us, such as qualified sign language
interpreters and information in other formats. If you need these
services, call the Customer Service number on the back of your
card, or 877-469-2583, TTY: 711 if you are not already a member.
If you believe that Blue Cross Blue Shield of Michigan or Blue Care
Network has failed to provide services or discriminated in another
way on the basis of race, color, national origin, age, disability, or
sex, you can file a grievance in person, by mail, fax, or email with:
Office of Civil Rights Coordinator, 600 E. Lafayette Blvd., MC 1302,
Detroit, MI 48226, phone: 888-605-6461, TTY: 711,
fax: 866-559-0578, email: [email protected]. If you need
help filing a grievance, the Office of Civil Rights Coordinator is
available to help you.
You can also file a civil rights complaint with the U.S. Department
of Health & Human Services Office for Civil Rights electronically
through the Office for Civil Rights Complaint Portal available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail, phone,
or email at: U.S. Department of Health & Human Services,
200 Independence Ave, S.W., Washington, D.C. 20201,
phone: 800-368-1019, TTD: 800-537-7697,
email: [email protected]. Complaint forms are
available at http://www.hhs.gov/ocr/office/file/index.html.
bcbsm.com/pharmacy
For members with 3-tier,
4-tier, 5-tier or 6-tier
pharmacy benefit designs
CB 13546 SEP 16
R058734