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2018
Custom Select Drug List
PPO (Blue Cross Blue Shield) HMO (Blue Care Network)Blue Cross®
Physician Choice PPO Blue Cross® Metro Detroit HMOBlue Cross®
Premier and Premier Value Blue Cross® Preferred HMO Community
BlueSM PPO Blue Cross® Select HMOHealthy Blue AchieveSM PPO Blue
Elect PlusSM Self Referral OptionSimply BlueSM PPO BCN Healthy Blue
LivingSM HMO
BCN HMOSM
BCN HRASM HMO BCN HSASM HMOBCN Routine CareSM
Confidence comes with every card.®
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Blue Cross and BCN Custom Select Drug List March 2018Table of
contents
Individual & Small Group
Plans.................................................................................................
5Specific information for Blue Cross
Members...........................................................................
9Specific information for Blue Care Network
Members...............................................................
12How to read the Blue Cross and BCN Custom Select Drug
List............................................... 15
Anti-infectives1A
16Antifungals....................................................................................................................1B
16Antimalarials.................................................................................................................1C
16Antiparasitics and
anthelmintics...................................................................................1D
17Antiretrovirals................................................................................................................1E
18Antituberculars..............................................................................................................1F
18Antivirals.......................................................................................................................1G
19Cephalosporins.............................................................................................................1H
19Macrolides.....................................................................................................................1I
19Penicillins......................................................................................................................1J
20Quinolones....................................................................................................................1K
20Sulfonamides and
combinations...................................................................................1L
20Tetracyclines.................................................................................................................1M
20Urinary tract
agents.......................................................................................................1N
21Miscellaneous
anti-infectives........................................................................................
Cardiovascular, hypertension, cholesterol2A 22ACE-Inhibitors and
combinations.................................................................................2B
22Alpha-adrenergic
agents...............................................................................................2C
23Angiotensin II Receptor Blockers and
combinations....................................................2D
24Anticoagulants and hemostasis
agents........................................................................2E
25Beta blockers and
combinations...................................................................................2F
25Calcium channel blockers and
combinations...............................................................2G
26Cardiovascular
treatment..............................................................................................2H
26Diuretics........................................................................................................................2I
27Lipid-lowering
agents....................................................................................................2J
28Nitrates and
combinations............................................................................................2K
28Renin-inhibitors and
combinations................................................................................2L
28Miscellaneous
antihypertensives..................................................................................
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Central nervous system3A 29Alzheimer's
therapy.......................................................................................................3B
30Anticonvulsants.............................................................................................................3C
31Antidepressants............................................................................................................3D
32Antipsychotics...............................................................................................................3E
32Anxiolytics.....................................................................................................................3F
33CNS
stimulants.............................................................................................................3G
33Migraine
therapy...........................................................................................................3H
33Myasthenia
gravis.........................................................................................................3I
34Narcotic
antagonists.....................................................................................................3J
34Narcotic mixed agonist and
antagonist.........................................................................3K
34Narcotic and analgesic
combinations...........................................................................3L
35Narcotics.......................................................................................................................3M
35Nonsteroidal anti-inflammatory
drugs...........................................................................3N
36Parkinsons disease and related
disorders....................................................................3O
36Salicylates.....................................................................................................................3P
36Sedative and
hypnotics.................................................................................................3Q
37Skeletal muscle
relaxants.............................................................................................3R
37Miscellaneous
CNS......................................................................................................
Gastrointestinal agents4A 385-Aminosalicylic Acid (5-ASA)
agents..........................................................................4B
38Antidiarrheals and
antispasmodics...............................................................................4C
38Antiemetics...................................................................................................................4D
39Bile
acids.......................................................................................................................4E
39Bowel preparation and cleansing
agents......................................................................4F
39Digestive
enzymes........................................................................................................4G
39H2-Receptor
antagonists..............................................................................................4H
40Proton Pump Inhibitors
(PPI)........................................................................................4I
40Topical anti-Inflammatory
agents..................................................................................4J
40Tumor Necrosis Factor (TNF) blocking
agents............................................................4K
40Ulcer
therapy.................................................................................................................4L
41Miscellaneous gastrointestinal
agents..........................................................................
Obstetrics and gynecology5A
42Contraceptives-Biphasic...............................................................................................5B
42Contraceptives-Misc.....................................................................................................5C
43Contraceptives-Monophasic.........................................................................................5D
43Contraceptives-Postcoital.............................................................................................5E
43Contraceptives-Triphasic..............................................................................................5F
44Estrogen and progestin
combinations..........................................................................5G
44Estrogens......................................................................................................................5H
44Infertility
treatment*.......................................................................................................5I
45Progestins.....................................................................................................................5J
45Vaginal anti-infective and
antifungal.............................................................................5K
45Miscellaneous
OB-GYN................................................................................................
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Rheumatology and musculoskeletal6A
46Corticosteroids..............................................................................................................6B
46Gout
therapy.................................................................................................................6C
46Non-Tumor Necrosis Factor (TNF) blocking
agents.....................................................6D
46Osteoporosis and bone
resorption................................................................................6E
47Osteoporosis and hormonal
treatment.........................................................................6F
47Salicylates.....................................................................................................................6G
47Tumor Necrosis Factor (TNF) blocking
agents............................................................6H
47Miscellaneous rheumatologic
agents............................................................................
Endocrinology7A
48Androgens.....................................................................................................................7B
48Antithyroid
agents.........................................................................................................7C
48Corticosteroids..............................................................................................................7D
49Growth Hormone and related
products.........................................................................7E
49Insulins..........................................................................................................................7F
50Non-insulin hypoglycemic
agents.................................................................................7G
51Somatostatin
analogs...................................................................................................7H
51Thyroid
hormones.........................................................................................................7I
51Urea cycle disorder agents
..........................................................................................7J
51Vitamin D analogs
........................................................................................................7K
52Miscellaneous
endocrine..............................................................................................
Antineoplastics and immunosuppresants8A 53Adjuvant
therapy...........................................................................................................8B
53Alkylating
agents...........................................................................................................8C
53Antimetabolites.............................................................................................................8D
54Hormonal
agents..........................................................................................................8E
54Immunomodulators.......................................................................................................8F
55Kinase inhibitors and molecular target
inhibitors..........................................................8G
56Miscellaneous antineoplastic
agents............................................................................
Immunology and hematology9A 57Hematopoietic
agents...................................................................................................9B
57Immunoglobulins...........................................................................................................9C
57Interferons and MS
therapy..........................................................................................9D
58Miscellaneous immunology and
hematology................................................................
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Dermatology10A 59Acne
treatment.............................................................................................................10B
59Antipsoriatic and
antiseborrheic....................................................................................10C
59Corticosteriods - very high
potency...............................................................................10D
60Corticosteroids - high
potency......................................................................................10E
60Corticosteroids - medium
potency................................................................................10F
60Corticosteroids - low
potency........................................................................................10G
60Scabicides and
pediculicides........................................................................................10H
61Topical
anesthetics.......................................................................................................10I
61Topical
antibacterials....................................................................................................10J
61Topical
antifungals........................................................................................................10K
61Topical antineoplastic agents and
immunomodulators.................................................10L
62Topical
antivirals...........................................................................................................10M
62Wound and burn
therapy..............................................................................................10N
62Miscellaneous
dermatologicals.....................................................................................
Ophthalmology11A 63Cycloplegic
mydriatics..................................................................................................11B
63Glaucoma
agents..........................................................................................................11C
63Ophthalmic anti-allergy
agents.....................................................................................11D
64Ophthalmic anti-infective and steroid
combinations.....................................................11E
64Ophthalmic
anti-infectives.............................................................................................11F
64Ophthalmic anti-inflammatory
agents...........................................................................11G
65Ophthalmic beta
blockers.............................................................................................11H
65Ophthalmic
steroids......................................................................................................11I
65Miscellaneous ophthalmic
agents.................................................................................
Otic and nasal preparations12A 66Nasal
preparations........................................................................................................12B
66Otic
preparations..........................................................................................................
Respiratory, cough and cold13A 67Antihistamine and decongestant
combinations............................................................13B
67Antihistamines..............................................................................................................13C
67Antitussives...................................................................................................................13D
67Cystic Fibrosis agents
..................................................................................................13E
67Epinephrine...................................................................................................................13F
67Inhaled
anticholinergics................................................................................................13G
68Inhaled beta-agonist and anticholinergic
combinations................................................13H
68Inhaled
beta-agonists....................................................................................................13I
68Inhaled steroid and beta-agonist combinations
...........................................................13J
68Inhaled
steroids.............................................................................................................13K
68Intranasal
steroids........................................................................................................13L
69Oral
beta-agonists........................................................................................................13M
69Pulmonary Hypertension Agents
.................................................................................13N
69Theophyllines................................................................................................................13O
69Miscellaneous respiratory
agents.................................................................................
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Urology14A 70BPH
Treatment.............................................................................................................14B
70Ion-Removing
Agents...................................................................................................14C
70Urinary
Antispasmodics................................................................................................14D
71Miscellaneous
Urologicals............................................................................................
Vitamins and supplements15A 72Potassium
Replacement...............................................................................................15B
72Vitamins and
Minerals..................................................................................................
Diagnostic and other miscellaneous16A 73Chelating
Agents...........................................................................................................16B
73Diagnostics and Other
Miscellaneous..........................................................................16C
73Vaccines.......................................................................................................................
Lifestyle modification17A 74Sexual
Dysfunction.......................................................................................................17B
74Smoking
Cessation.......................................................................................................17C
74Weight Loss
Preparations............................................................................................
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Individual and small group plans that use the Blue Cross and BCN
Custom Select Drug List include: Individual plans
Plan name Market type Plan type Plan level Drug copay option
Blue Care Network HMO Blue Cross® Partnered HMO Individual HMO
(BCN) Gold, silver, silver saver,
bronze (HSA), bronze saver (HSA)
6 tier
Blue Cross® Partnered HMO Extra Individual HMO (BCN) Silver,
bronze 4 tier Blue Cross® Metro Detroit HMO Individual HMO (BCN)
Silver, silver saver, bronze
(HSA), bronze saver (HSA) 6 tier
Blue Cross® Metro Detroit HMO Extra
Individual HMO (BCN) Silver, bronze 4 tier
Blue Cross® Select HMO Individual HMO (BCN) Gold, silver, silver
saver, bronze (HSA), bronze saver (HSA), value
6 tier
Blue Cross® Select HMO Extra Individual HMO (BCN) Silver, bronze
4 tier Blue Cross® Preferred HMO Individual HMO (BCN) Gold, silver,
silver saver,
bronze (HSA) 6 tier
Blue Cross® Preferred HMO Extra Individual HMO (BCN) Silver 4
tier Blue Cross PPO Blue Cross® Premier Individual PPO (Blue Cross)
Gold, silver,
bronze, catastrophic 5 tier
Blue Cross® Premier Silver Extra and Bronze Extra
Individual PPO (Blue Cross) Silver, bronze 4 tier
Blue Cross® Silver Extra with Dental and Vision, a Multi-State
Plan
Individual PPO (Blue Cross) Silver 4 tier
Blue Cross® Gold Extra with Dental and Vision, a Multi-State
Plan
Individual PPO (Blue Cross) Gold 4 tier
Blue Cross EPO Blue Cross® Metro Detroit EPO Individual EPO
(Blue Cross) Silver, bronze 5 tier
Small group plans
Plan name Market type Plan type Plan level Drug copay option
Blue Care Network HMO Blue Elect Plus Self Referral Option Small
group HMO (BCN) Gold 6 tier BCN Small group HMO (BCN) Platinum,
gold, silver 6 tier BCN Routine Care Small group HMO (BCN) Silver 6
tier BCN HRA Small group HMO (BCN) Platinum, gold 6 tier BCN HRA
PCP Focus Small group HMO (BCN) Platinum 6 tier BCN HSA Small group
HMO (BCN) Gold, silver, bronze 6 tier BCN HSA PCP Focus Small group
HMO (BCN) Bronze 6 tier BCN PCP Focus Small group HMO (BCN)
Platinum, gold, silver 6 tier BCN Healthy Blue Living Small group
HMO (BCN) Platinum, gold 6 tier Blue Cross PPO Community Blue PPO
Small group PPO (Blue Cross) Platinum, gold 3 tier Simply Blue PPO
Small group PPO (Blue Cross) Platinum, gold, silver,
bronze 5 tier
Healthy Blue Achieve PPO Small group PPO (Blue Cross) Platinum,
gold 5 tier Physician Choice PPO Small group PPO (Blue Cross) Gold,
silver 5 tier
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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.
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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 15-day 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.
http://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/specialty-drug-program-member-guide.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/specialty-drug-program-member-guide.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/15-day-specialty-drug-list.pdfhttp://www.bcbsm.com/preventivedruglisthttp://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy.htmlhttp://www.bcbsm.com/pharmacyhttp://www.bcbsm.com/index/health-insurance-help/faqs/topics/how-health-insurance-works.html
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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
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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
3-tier plans 4-tier plans 5-tier plans
Tier 1
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.
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.
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.
Tier 2
Preferred brand — higher copay This tier includes preferred,
brand-name drugs. These drugs are more expensive than generics, and
members pay a higher copay for them. This tier includes preferred
brand specialty drugs.
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.
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 3
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.
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.
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.
Tier 4 Does not apply
Specialty drugs — highest cost sharing This tier consists of
specialty drugs, both generic and brand name, that are used to
treat difficult health conditions.
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.
Tier 5 Does not apply Does not apply
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.
http://www.bcbsm.com/pharmacy
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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.
http://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/prior-authorization-and-step-therapy-guidelines.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/quantity-limit-program-drug-list.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/quantity-limit-program-drug-list.pdfhttp://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy/why-do-i-need-prior-authorization-for-prescription-drug/expedited-request-form.htmlhttp://www.bcbsm.com/
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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.
http://www.bcbsm.com/providers.html
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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:
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.
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.
http://www.bcbsm.com/pharmacy
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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
http://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/bcn-custom-select-drug-list-prior-auth-step-therapy.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/bcn-custom-select-drug-list-prior-auth-step-therapy.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/bcn-quantity-limits.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/bcn-quantity-limits.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/bcn-drug-list-updates.pdfhttp://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy/why-do-i-need-prior-authorization-for-prescription-drug/prior-authorization-callback-form.htmlhttp://www.bcbsm.com/
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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
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.
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Page 15
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.
BCBSM: The information in this section applies to members with a
Blue Cross drug plan.
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. 10 and 20mg strengths of atorvastatin calcium is a
preventive drug, and may be covered with $0 cost-share for members
who meet criteria. Its brand-name equivalent, Lipitor®, isn’t
covered.
Livalo® is a brand-name drug that requires a Tier 3 copay. It
requires step therapy for coverage and quantity limits apply for
both Blue Cross and BCN plans.
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)
1
2
3
4
5
6
7
8
9
4
3
1
2
5 6 7 8
“Prevent” indicates a preventive drug.
9 9
5
-
1. Anti-infectives
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1A. Antifungals BCN (HMO)BCBSM (PPO)Trade name Generic name
Ancobon flucytosine 1 1 1B1 1Cresemba capsule 2 2 2QL QL2
2Diflucan fluconazole 1 1 1B1 1Grifulvin V griseofulvin, microsize
1 1 1B1 1Gris-PEG griseofulvin ultramicrosize 1 1 1B1 1Lamisil
tablet terbinafine hcl 1 1 1B1 1Mycelex Troche clotrimazole 1 1 1B1
1Nizoral ketoconazole 1 1 1B1 1Noxafil suspension 2 2 22 2Noxafil
tablet 2 2 2QL QL2 2Nystatin nystatin 1 1 1B1 1Sporanox
itraconazole 1 1 1B1 1Sporanox solution 2 2 22 2Vfend voriconazole
1 1 1B1 1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1B. Antimalarials BCN (HMO)BCBSM (PPO)Trade name Generic
name
Aralen chloroquine phosphate 1 1 1B1 1Coartem 2 2 2 QL2
2Daraprim 2 4 4 PA4 4Lariam mefloquine hcl 1 1 1B1 1Malarone
atovaquone/proguanil hcl 1 1 1B1 1Plaquenil hydroxychloroquine
sulfate 1 1 1B1 1Primaquine 2 2 22 2Qualaquin quinine sulfate 1 1
1B1 1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1C. Antiparasitics and anthelmintics BCN (HMO)BCBSM (PPO)Trade
name Generic name
Albenza 2 2 2QL2 2Alinia 2 2 22 2Benznidazole 2 2 2QL QL2
2Biltricide 2 2 22 2Flagyl metronidazole 1 1 1B1 1Humatin
paromomycin sulfate 1 1 1B1 1Impavido 2 2 2PA, QL QL2 2Mepron
atovaquone 1 1 1B1 1Nebupent aerosol 2 2 22 2Stromectol ivermectin
1 1 1B1 1Tindamax tinidazole 1 1 1B QL1 1
Page 16BCBSM/BCN Custom Select Drug List - March-2018
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rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1D. Antiretrovirals BCN (HMO)BCBSM (PPO)Trade name Generic
name
Aptivus 2 2 22 2Atripla 2 2 22 2Combivir lamivudine/zidovudine 1
1 1B1 1Complera 2 2 2QL QL2 2Crixivan 2 2 22 2Descovy 2 2 2QL QL2
2Edurant 2 2 2QL QL2 2Emtriva 2 2 22 2Epivir lamivudine 1 1 1B1
1Epzicom abacavir sulfate/lamivudine 1 1 1B1 1Evotaz 2 2 2QL QL2
2Fuzeon 2 2 22 2Genvoya 2 2 2QL QL2 2Intelence 2 2 22 2Invirase 2 2
22 2Isentress 2 2 22 2Isentress HD 2 2 22 2Juluca 3 3 3QL QL3
3Kaletra lopinavir/ritonavir 1 1 1B1 1Kaletra tablet 2 2 22 2Lexiva
fosamprenavir calcium 1 1 1B1 1Lexiva suspension 2 2 22 2Norvir 2 2
22 2Odefsey 2 2 2QL QL2 2Prezcobix 2 2 2QL QL2 2Prezista 2 2 22
2Rescriptor 2 2 22 2Retrovir zidovudine 1 1 1B1 1Reyataz atazanavir
sulfate 1 1 1B1 1Reyataz powder pack 2 2 22 2Selzentry 2 2 22
2Stribild 2 2 2QL QL2 2Sustiva efavirenz 1 1 1B1 1Tivicay 2 2 22
2Triumeq 2 2 2QL QL2 2Trizivir abacavir/lamivudine/zidovudine 1 1
1B1 1Truvada 2 2 22 2Tybost 2 2 2QL2 2Vemlidy 2 4 4QL QL4 4Videx 2
2 22 2Videx EC didanosine 1 1 1B1 1Viracept 2 2 22 2Viramune, XR
nevirapine 1 1 1B1 1Viread tenofovir disoproxil fumarate 1 1 1B1
1Viread 150mg, 200mg, 250mg tablet; powder
2 2 22 2
Zerit stavudine 1 1 1B1 1Ziagen abacavir sulfate 1 1 1B1 1
Page 17BCBSM/BCN Custom Select Drug List - March-2018
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rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1E. Antituberculars BCN (HMO)BCBSM (PPO)Trade name Generic
name
Cycloserine 2 2 22 2Ethambutol ethambutol hcl 1 1 1B1 1Isoniazid
isoniazid 1 1 1B1 1Mycobutin rifabutin 1 1 1B1 1Paser 3 3 33
3Priftin 3 3 33 3Pyrazinamide pyrazinamide 1 1 1B1 1Rifadin
rifampin 1 1 1B1 1Rifamate 3 3 33 3Rifater 3 3 33 3Sirturo 2 2 2PA
PA, QL2 2Trecator 3 3 33 3
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1F. Antivirals BCN (HMO)BCBSM (PPO)Trade name Generic name
Baraclude entecavir 1 4 44 4Baraclude solution 2 4 44 4Copegus
ribavirin 1 4 44 4Daklinza 3 5 5PA, QL PA, QL4 4Epclusa 2 4 4PA, QL
PA, QL4 4Epivir HBV lamivudine 1 1 1B1 1Epivir HBV solution 2 2 22
2Famvir famciclovir 1 1 1B1 1Flumadine rimantadine hcl 1 1 1B1
1Harvoni 3 5 5PA, QL PA, QL4 4Hepsera adefovir dipivoxil 1 4 44
4Mavyret 3 5 5PA, QL PA, QL4 4Olysio 3 5 5PA, QL PA, QL4 4Rebetol
ribavirin 1 4 44 4Rebetol solution 2 4 44 4Relenza 2 2 2QL QL2
2Ribapak; Ribatab ribavirin 1 4 44 4Ribasphere Ribapak tablet
ribavirin 1 4 44 4Sovaldi 3 5 5PA, QL PA, QL4 4Symmetrel amantadine
hcl 1 1 1B1 1Tamiflu oseltamivir phosphate 1 1 1BQL QL1 1Technivie
3 5 5PA, QL PA, QL4 4Valcyte valganciclovir hcl 1 1 1B1 1Valtrex
valacyclovir hcl 1 1 1B1 1Vosevi 3 5 5PA, QL PA, QL4 4Zepatier 2 4
4PA, QL PA, QL4 4Zovirax capsule, solution, tablet acyclovir 1 1
1B1 1
Page 18BCBSM/BCN Custom Select Drug List - March-2018
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rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1G. Cephalosporins BCN (HMO)BCBSM (PPO)Trade name Generic
name
Ceclor, ER cefaclor 1 1 1B1 1Cedax ceftibuten 1 1 1B1 1Ceftin
cefuroxime axetil 1 1 1B1 1Ceftin suspension 2 2 22 2Cefzil
cefprozil 1 1 1B1 1Duricef cefadroxil 1 1 1B1 1Keflex cephalexin 1
1 1B1 1Omnicef cefdinir 1 1 1B1 1Spectracef cefditoren pivoxil 1 1
1B QL1 1Suprax cefixime 1 1 1B1 1Suprax capsule, chew tablet,
500mg/5ml suspension
3 3 33 3
Vantin cefpodoxime proxetil 1 1 1B1 1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1H. Macrolides BCN (HMO)BCBSM (PPO)Trade name Generic name
Biaxin, XL clarithromycin 1 1 1B1 1Dificid 3 3 3QL QL3 3E.E.S.
erythromycin ethylsuccinate 1 1 1B1 1Eryped 200mg/5ml, 400mg/5ml 3
3 33 3Ery-tab erythromycin base 1 1 1B1 1Ery-tab 500mg 3 3 33
3Erythromycin Base erythromycin base 1 1 1B1 1Erythromycin Stearate
erythromycin stearate 1 1 1B1 1PCE 3 3 33 3Zithromax azithromycin 1
1 1B1 1Zmax 3 3 33 3
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1I. Penicillins BCN (HMO)BCBSM (PPO)Trade name Generic name
Amoxil amoxicillin 1 1 1B1 1Ampicillin ampicillin trihydrate 1 1
1B1 1Augmentin 125mg-31.25mg/ml suspension
2 2 22 2
Augmentin, ES, XR amoxicillin/potassium clav 1 1 1B1
1Dicloxacillin dicloxacillin sodium 1 1 1B1 1Penicillin VK
penicillin v potassium 1 1 1B1 1
Page 19BCBSM/BCN Custom Select Drug List - March-2018
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1J. Quinolones BCN (HMO)BCBSM (PPO)Trade name Generic name
Avelox moxifloxacin hcl 1 1 1B1 1Baxdela tablet 3 3 33 3Cipro
suspension ciprofloxacin 1 1 1B1 1Cipro tablet ciprofloxacin hcl 1
1 1B1 1Cipro XR ciprofloxacin/ciprofloxa hcl 1 1 1B1 1Factive 3 3
33 3Floxin tablet ofloxacin 1 1 1B1 1Levaquin levofloxacin 1 1 1B1
1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1K. Sulfonamides and combinations BCN (HMO)BCBSM (PPO)Trade name
Generic name
Bactrim, DS; Septra, DS sulfamethoxazole/trimethoprim 1 1 1B1
1Sulfadiazine sulfadiazine 1 1 1B1 1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1L. Tetracyclines BCN (HMO)BCBSM (PPO)Trade name Generic
name
Declomycin demeclocycline hcl 1 1 1B1 1Minocin capsule
minocycline hcl 1 1 1B1 1Monodox doxycycline monohydrate 1 1 1B1
1Periostat doxycycline hyclate 1 1 1B1 1Tetracycline tetracycline
hcl 1 1 1B1 1Vibramycin doxycycline hyclate 1 1 1B1 1Vibramycin
suspension doxycycline monohydrate 1 1 1B1 1Vibramycin syrup 3 3 33
3
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1M. Urinary tract agents BCN (HMO)BCBSM (PPO)Trade name Generic
name
Furadantin nitrofurantoin 1 1 1B1 1Hiprex/Urex methenamine
hippurate 1 1 1B1 1Macrobid nitrofurantoin monohyd/m-cryst 1 1 1B1
1Macrodantin nitrofurantoin macrocrystal 1 1 1B1 1Monurol 3 3 33
3Primsol 3 3 33 3Trimethoprim trimethoprim 1 1 1B1 1Trimpex 3 3 33
3
Page 20BCBSM/BCN Custom Select Drug List - March-2018
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rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
1N. Miscellaneous anti-infectives BCN (HMO)BCBSM (PPO)Trade name
Generic name
Cayston 3 5 5PA, QL PA, QL4 4Cleocin capsule clindamycin hcl 1 1
1B1 1Cleocin solution clindamycin palmitate hcl 1 1 1B1 1Dapsone
dapsone 1 1 1B1 1Neomycin neomycin sulfate 1 1 1B1 1Sivextro 2 2
2QL QL2 2Tobi tobramycin in 0.225% nacl 1 4 4QL4 4Vancocin
vancomycin hcl 1 1 1B1 1Xifaxan 200mg 3 3 3 QL3 3Zyvox linezolid 1
1 1B1 1
Page 21BCBSM/BCN Custom Select Drug List - March-2018
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rev. 2
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2. Cardiovascular, hypertension, cholesterol
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
2A. ACE-Inhibitors and combinations BCN (HMO)BCBSM (PPO)Trade
name Generic name
Accupril quinapril hcl 1 1 1A1 1Accuretic
quinapril/hydrochlorothiazide 1 1 1A1 1Aceon perindopril erbumine 1
1 1A1 1Altace ramipril 1 1 1A1 1Capoten captopril 1 1 1A1 1Capozide
captopril/hydrochlorothiazide 1 1 1A1 1Lotensin benazepril hcl 1 1
1A1 1Lotensin HCT benazepril/hydrochlorothiazide 1 1 1A1 1Lotrel
amlodipine besylate/benazepril 1 1 1A1 1Mavik trandolapril 1 1 1A1
1Monopril fosinopril sodium 1 1 1A1 1Monopril HCT
fosinopril/hydrochlorothiazide 1 1 1A1 1Prinivil; Zestril
lisinopril 1 1 1A1 1Prinzide; Zestoretic
lisinopril/hydrochlorothiazide 1 1 1A1 1Tarka
trandolapril/verapamil hcl 1 1 1B1 1Uniretic
moexipril/hydrochlorothiazide 1 1 1A1 1Univasc moexipril hcl 1 1
1A1 1Vaseretic enalapril/hydrochlorothiazide 1 1 1A1 1Vasotec
enalapril maleate 1 1 1A1 1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
2B. Alpha-adrenergic agents BCN (HMO)BCBSM (PPO)Trade name
Generic name
Aldomet methyldopa 1 1 1B1 1Aldoril
methyldopa/hydrochlorothiazide 1 1 1B1 1Cardura doxazosin mesylate
1 1 1B1 1Catapres clonidine hcl 1 1 1A1 1Catapres-TTS clonidine 1 1
1B1 1Clorpres clonidine hcl/chlorthalidone 1 1 1B1 1Clorpres
0.3mg-15mg 3 3 33 3Dibenzyline phenoxybenzamine hcl 1 1 1BPA, QL
PA1 1Hytrin terazosin hcl 1 1 1B1 1Minipress prazosin hcl 1 1 1B1
1Tenex guanfacine hcl 1 1 1B1 1
Page 22BCBSM/BCN Custom Select Drug List - March-2018
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
2C. Angiotensin II Receptor Blockers and combinations BCN
(HMO)BCBSM (PPO)Trade name Generic name
Atacand candesartan cilexetil 1 1 1A1 1Atacand HCT
candesartan/hydrochlorothiazid 1 1 1A1 1Avalide
irbesartan/hydrochlorothiazide 1 1 1A1 1Avapro irbesartan 1 1 1A1
1Azor amlodipine bes/olmesartan med 1 1 1B QL1 1Benicar olmesartan
medoxomil 1 1 1B ST, QL1 1Benicar HCT
olmesartan/hydrochlorothiazide 1 1 1B ST, QL1 1Cozaar losartan
potassium 1 1 1A1 1Diovan valsartan 1 1 1A1 1Diovan HCT
valsartan/hydrochlorothiazide 1 1 1A1 1Edarbi 3 3 3ST, QL ST, QL3
3Edarbyclor 3 3 3ST, QL ST, QL3 3Entresto 2 2 2QL QL2 2Exforge
amlodipine/valsartan 1 1 1B1 1Exforge HCT
amlodipine/valsartan/hcthiazid 1 1 1B1 1Hyzaar
losartan/hydrochlorothiazide 1 1 1A1 1Micardis telmisartan 1 1 1B1
1Micardis HCT telmisartan/hydrochlorothiazid 1 1 1B1 1Teveten
eprosartan mesylate 1 1 1A1 1Tribenzor
olmesartan/amlodipin/hcthiazid 1 1 1BQL QL1 1Twynsta
telmisartan/amlodipine 1 1 1B1 1
Page 23BCBSM/BCN Custom Select Drug List - March-2018
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
2D. Anticoagulants and hemostasis agents BCN (HMO)BCBSM
(PPO)Trade name Generic name
Aggrenox aspirin/dipyridamole 1 1 1B1 1Agrylin anagrelide hcl 1
1 1B1 1Amicar 2 2 22 2Arixtra fondaparinux sodium 1 4 44 4Bevyxxa
tablet 3 3 3QL QL3 3Brilinta 2 2 2 QL2 2Coumadin warfarin sodium 1
1 1A1 1Effient prasugrel hcl 1 1 1B QL1 1Eliquis 2 2 2QL QL2
2Fragmin 3 5 54 4Heparin 1000u/ml heparin sodium,porcine/pf 1 1 1B1
1Heparin 5000/0.5ml heparin sodium,porcine/pf 1 4 44 4Heparin
5000/ml, 10000/ml, 20000/ml
heparin sodium,porcine 1 4 44 4
Iprivask 3 5 54 4Lovenox enoxaparin sodium 1 4 44 4Mephyton 2 2
22 2Persantine dipyridamole 1 1 1B1 1Plavix clopidogrel bisulfate 1
1 1A QL1 1Pletal cilostazol 1 1 1B1 1Pradaxa 3 3 3QL QL3 3Savaysa 3
3 3QL QL3 3Ticlid ticlopidine hcl 1 1 1B1 1Trental pentoxifylline 1
1 1B1 1Vitamin K ampule phytonadione 1 1 1B1 1Xarelto, starter kit
2 2 2QL QL2 2Zontivity 3 3 3PA, QL QL3 3
Page 24BCBSM/BCN Custom Select Drug List - March-2018
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rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
2E. Beta blockers and combinations BCN (HMO)BCBSM (PPO)Trade
name Generic name
Betapace, AF sotalol hcl 1 1 1A1 1Blocadren timolol maleate 1 1
1A1 1Bystolic 2.5, 5, 10mg 3 3 3 ST, QL3 3Bystolic 20mg 3 3 3 ST3
3Coreg immediate-release carvedilol 1 1 1A1 1Corgard nadolol 1 1
1A1 1Corzide nadolol/bendroflumethiazide 1 1 1A1 1Dutoprol 3 3 33
3Inderal, LA propranolol hcl 1 1 1A1 1Inderide
propranolol/hydrochlorothiazid 1 1 1A1 1Kerlone betaxolol hcl 1 1
1A1 1Levatol 3 3 33 3Lopressor metoprolol tartrate 1 1 1A1
1Lopressor HCT metoprolol/hydrochlorothiazide 1 1 1A1 1Normodyne
labetalol hcl 1 1 1A1 1Sectral acebutolol hcl 1 1 1A1 1Tenoretic
atenolol/chlorthalidone 1 1 1A1 1Tenormin atenolol 1 1 1A1 1Toprol
XL metoprolol succinate 1 1 1A1 1Visken pindolol 1 1 1A1 1Zebeta
bisoprolol fumarate 1 1 1A1 1Ziac bisoprolol fumarate/hctz 1 1 1A1
1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
2F. Calcium channel blockers and combinations BCN (HMO)BCBSM
(PPO)Trade name Generic name
Adalat CC; Procardia, XL nifedipine 1 1 1B1 1Azor amlodipine
bes/olmesartan med 1 1 1B QL1 1Caduet amlodipine/atorvastatin 1 1
1BQL QL1 1Calan SR; Isoptin SR verapamil hcl 1 1 1B1 1Cardene
nicardipine hcl 1 1 1B1 1Cardizem, CD, LA, SR diltiazem hcl 1 1 1B1
1Cardizem LA 120mg 3 3 33 3Dynacirc isradipine 1 1 1B1 1Exforge
amlodipine/valsartan 1 1 1B1 1Exforge HCT
amlodipine/valsartan/hcthiazid 1 1 1B1 1Lotrel amlodipine
besylate/benazepril 1 1 1A1 1Norvasc amlodipine besylate 1 1 1A1
1Plendil felodipine 1 1 1B1 1Sular nisoldipine 1 1 1B1 1Tarka
trandolapril/verapamil hcl 1 1 1B1 1Tiazac diltiazem hcl 1 1 1B1
1Tribenzor olmesartan/amlodipin/hcthiazid 1 1 1BQL QL1 1Twynsta
telmisartan/amlodipine 1 1 1B1 1Verelan, PM verapamil hcl 1 1 1B1
1
Page 25BCBSM/BCN Custom Select Drug List - March-2018
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
2G. Cardiovascular treatment BCN (HMO)BCBSM (PPO)Trade name
Generic name
Betapace, AF sotalol hcl 1 1 1A1 1Cordarone; Pacerone amiodarone
hcl 1 1 1B1 1Corlanor 2 2 2PA, QL PA, QL2 2Lanoxin digoxin 1 1 1B1
1Lanoxin 62.5, 187.5mcg 3 3 33 3Mexitil mexiletine hcl 1 1 1B1
1Multaq 2 2 2QL QL2 2Norpace disopyramide phosphate 1 1 1B1
1Norpace CR 2 2 22 2Proamatine midodrine hcl 1 1 1B1 1Quinidex
quinidine sulfate 1 1 1B1 1Quinidine Gluconate SA quinidine
gluconate 1 1 1B1 1Ranexa 3 3 3 PA3 3Rythmol, SR propafenone hcl 1
1 1B1 1Tambocor flecainide acetate 1 1 1B1 1Tikosyn dofetilide 1 1
1B1 1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
2H. Diuretics BCN (HMO)BCBSM (PPO)Trade name Generic name
Aldactazide spironolact/hydrochlorothiazid 1 1 1A1 1Aldactazide
50/50mg 3 3 33 3Aldactone spironolactone 1 1 1A1 1Bumex bumetanide
1 1 1A1 1Demadex torsemide 1 1 1A1 1Diamox, Sequels acetazolamide 1
1 1B1 1Diuril chlorothiazide 1 1 1A1 1Diuril suspension 3 3 33
3Dyazide; Maxzide triamterene/hydrochlorothiazid 1 1 1A1 1Dyrenium
2 2 22 2Edecrin ethacrynic acid 1 1 1B1 1Enduron methyclothiazide 1
1 1B1 1Hydrodiuril; Microzide hydrochlorothiazide 1 1 1A1
1Hygroton; Thalitone chlorthalidone 1 1 1A1 1Inspra eplerenone 1 1
1A1 1Lasix furosemide 1 1 1A1 1Lozol indapamide 1 1 1A1 1Midamor
amiloride hcl 1 1 1A1 1Moduretic amiloride/hydrochlorothiazide 1 1
1A1 1Zaroxolyn metolazone 1 1 1A1 1
Page 26BCBSM/BCN Custom Select Drug List - March-2018
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
2I. Lipid-lowering agents BCN (HMO)BCBSM (PPO)Trade name Generic
name
Antara fenofibrate,micronized 1 1 1B1 1Antara 30, 90mg 3 3 33
3Caduet amlodipine/atorvastatin 1 1 1BQL QL1 1Colestid colestipol
hcl 1 1 1B1 1Colestid granules, packet 3 3 33 3Crestor rosuvastatin
calcium 1 1 1BQL QL1 1Crestor* 5mg, 10mg (Prevent) rosuvastatin
calcium $0 $0 $0QL QL$0 $0Fibricor fenofibric acid 1 1 1B1 1Kynamro
2 4 4PA, QL PA, QL4 4Lescol, XL fluvastatin sodium 1 1 1BQL QL1
1Lescol, XL* (all strengths) (Prevent) fluvastatin sodium $0 $0
$0QL QL$0 $0Lipitor atorvastatin calcium 1 1 1AQL QL1 1Lipitor*
10mg, 20mg (Prevent) atorvastatin calcium $0 $0 $0QL QL$0 $0Livalo
3 3 3ST, QL ST, QL3 3Lofibra capsule fenofibrate,micronized 1 1 1A1
1Lofibra tablet fenofibrate 1 1 1A1 1Lopid gemfibrozil 1 1 1A1
1Lovaza omega-3 acid ethyl esters 1 1 1BPA PA, QL1 1Mevacor
lovastatin 1 1 1AQL QL1 1Mevacor* (all strengths) (Prevent)
lovastatin $0 $0 $0QL QL$0 $0Niacor 3 3 33 3Niaspan niacin 1 1 1B1
1Praluent 3 5 5PA, QL PA, QL4 4Pravachol pravastatin sodium 1 1
1AQL QL1 1Pravachol* (all strengths) (Prevent) pravastatin sodium
$0 $0 $0QL QL$0 $0Questran cholestyramine (with sugar) 1 1 1B1
1Questran Light cholestyramine/aspartame 1 1 1B1 1Repatha 3 5 5PA,
QL PA, QL4 4Tricor fenofibrate nanocrystallized 1 1 1B1 1Trilipix
fenofibric acid (choline) 1 1 1B1 1Vytorin ezetimibe/simvastatin 1
1 1BQL QL1 1Welchol 2 2 22 2Zetia ezetimibe 1 1 1BQL QL1 1Zocor
simvastatin 1 1 1AQL QL1 1Zocor* 5mg, 10mg, 20mg, 40mg(Prevent)
simvastatin $0 $0 $0QL QL$0 $0
*Age restrictions apply.
Page 27BCBSM/BCN Custom Select Drug List - March-2018
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rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
2J. Nitrates and combinations BCN (HMO)BCBSM (PPO)Trade name
Generic name
Bidil 2 2 22 2Dilatrate-SR 2 2 22 2Imdur; Ismo; Monoket
isosorbide mononitrate 1 1 1A1 1Isordil isosorbide dinitrate 1 1
1B1 1Isordil 40mg 3 3 33 3Nitro-bid ointment nitroglycerin 1 1 1B1
1Nitro-Dur 0.3mg, 0.8mg 3 3 33 3Nitroglycerin capsule, patch
nitroglycerin 1 1 1B1 1Nitromist nitroglycerin 1 1 1B1 1Nitrostat
nitroglycerin 1 1 1B1 1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
2K. Renin-inhibitors and combinations BCN (HMO)BCBSM (PPO)Trade
name Generic name
Tekturna, HCT 3 3 33 3
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
2L. Miscellaneous antihypertensives BCN (HMO)BCBSM (PPO)Trade
name Generic name
Apresoline hydralazine hcl 1 1 1B1 1Demser 3 3 33 3Loniten
minoxidil 1 1 1B1 1
Page 28BCBSM/BCN Custom Select Drug List - March-2018
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3. Central nervous system
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3A. Alzheimer's therapy BCN (HMO)BCBSM (PPO)Trade name Generic
name
Aricept 5, 10mg; ODT donepezil hcl 1 1 1B1 1Exelon capsule
rivastigmine tartrate 1 1 1B1 1Exelon patch rivastigmine 1 1 1B1
1Namenda dosepak 2 2 22 2Namenda immediate release memantine hcl 1
1 1B1 1Razadyne, ER galantamine hbr 1 1 1B1 1
Page 29BCBSM/BCN Custom Select Drug List - March-2018(Prevent) -
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required QL - Quantity limits may apply - Specialty Drug
rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3B. Anticonvulsants BCN (HMO)BCBSM (PPO)Trade name Generic
name
Banzel 2 2 22 2Briviact 3 3 3PA, QL PA, QL3 3Carbatrol
carbamazepine 1 1 1B1 1Celontin 3 3 33 3Depakene capsule valproic
acid 1 1 1B1 1Depakene solution valproic acid (as sodium salt) 1 1
1B1 1Depakote, ER, sprinkles divalproex sodium 1 1 1B1 1Diamox,
Sequels acetazolamide 1 1 1B1 1Diastat 2.5mg diazepam 1 1 1B1
1Diastat 2.5mg 2 2 22 2Diastat Acudial diazepam 1 1 1B1 1Dilantin
phenytoin 1 1 1A1 1Dilantin 30mg capsule 2 2 22 2Dilantin; Phenytek
capsule phenytoin sodium extended 1 1 1A1 1Equetro 3 3 33 3Felbatol
felbamate 1 1 1B1 1Fycompa suspension 3 3 3PA, QL3 3Fycompa tablet
3 3 3PA, QL QL3 3Gabitril tiagabine hcl 1 1 1B1 1Gabitril 12mg,
16mg 2 2 22 2Keppra, XR levetiracetam 1 1 1A1 1Klonopin, Wafer
clonazepam 1 1 1B1 1Lamictal, dispertabs, ODT, XR lamotrigine 1 1
1B1 1Lamictal XR dosepak 3 3 33 3Lyrica 3 3 3PA PA, QL3 3Mysoline
primidone 1 1 1B1 1Neurontin gabapentin 1 1 1B1 1Onfi 3 3 3PA, QL
PA, QL3 3Peganone 2 2 22 2Phenobarbital phenobarbital 1 1 1B1
1Sabril vigabatrin 1 4 44 4Sabril tablet 2 4 44 4Tegretol, XR
carbamazepine 1 1 1B1 1Topamax, Sprinkle topiramate 1 1 1B1
1Trileptal oxcarbazepine 1 1 1B1 1Vimpat 2 2 22 2Zarontin
ethosuximide 1 1 1B1 1Zonegran zonisamide 1 1 1B1 1
Page 30BCBSM/BCN Custom Select Drug List - March-2018(Prevent) -
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rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3C. Antidepressants BCN (HMO)BCBSM (PPO)Trade name Generic
name
Adapin; Sinequan doxepin hcl 1 1 1A1 1Amoxapine amoxapine 1 1
1B1 1Anafranil clomipramine hcl 1 1 1B1 1Aplenzin 3 3 3ST PA3
3Aventyl; Pamelor nortriptyline hcl 1 1 1A1 1Celexa citalopram
hydrobromide 1 1 1A1 1Cymbalta duloxetine hcl 1 1 1B1 1Desyrel
trazodone hcl 1 1 1A1 1Effexor venlafaxine hcl 1 1 1A1 1Effexor XR;
Venlafaxine hcl ER venlafaxine hcl 1 1 1A1 1Elavil amitriptyline
hcl 1 1 1A1 1Emsam 3 3 33 3Etrafon perphenazine/amitriptyline hcl 1
1 1B1 1Fluoxetine 60mg fluoxetine hcl 1 1 1BQL1 1Lexapro
escitalopram oxalate 1 1 1A1 1Limbitrol, DS amitrip
hcl/chlordiazepoxide 1 1 1B1 1Luvox fluvoxamine maleate 1 1 1A1
1Luvox CR fluvoxamine maleate 1 1 1B1 1Maprotiline hcl maprotiline
hcl 1 1 1A1 1Marplan 3 3 33 3Nardil phenelzine sulfate 1 1 1B1
1Norpramin desipramine hcl 1 1 1A1 1Parnate tranylcypromine sulfate
1 1 1B1 1Paxil paroxetine hcl 1 1 1A1 1Paxil CR paroxetine hcl 1 1
1B1 1Paxil suspension 3 3 33 3Pexeva 3 3 3ST PA, QL3 3Pristiq
desvenlafaxine succinate 1 1 1B QL1 1Prozac fluoxetine hcl 1 1 1A1
1Prozac Weekly fluoxetine hcl 1 1 1AQL1 1Remeron mirtazapine 1 1
1A1 1Serzone nefazodone hcl 1 1 1B1 1Surmontil trimipramine maleate
1 1 1B1 1Tofranil imipramine hcl 1 1 1A1 1Tofranil-PM imipramine
pamoate 1 1 1B1 1Trintellix 3 3 3ST, QL PA, QL3 3Viibryd, dosepak 3
3 3ST, QL PA, QL3 3Vivactil protriptyline hcl 1 1 1B1 1Wellbutrin,
SR, XL bupropion hcl 1 1 1A1 1Zoloft sertraline hcl 1 1 1A1 1
Page 31BCBSM/BCN Custom Select Drug List - March-2018(Prevent) -
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required QL - Quantity limits may apply - Specialty Drug
rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3D. Antipsychotics BCN (HMO)BCBSM (PPO)Trade name Generic
name
Abilify aripiprazole 1 1 1B1 1Clozapine 200mg clozapine 1 1 1B1
1Clozapine ODT; Fazaclo 150, 200mg
3 3 3 ST3 3
Clozaril clozapine 1 1 1A1 1Etrafon perphenazine/amitriptyline
hcl 1 1 1B1 1Fanapt 3 3 3ST ST3 3Fazaclo clozapine 1 1 1B ST1
1Geodon ziprasidone hcl 1 1 1B1 1Haldol liquid haloperidol lactate
1 1 1A1 1Haldol tablet haloperidol 1 1 1A1 1Invega paliperidone 1 1
1BQL ST, QL1 1Latuda 3 3 3ST ST3 3Loxitane loxapine succinate 1 1
1B1 1Mellaril thioridazine hcl 1 1 1A1 1Navane thiothixene 1 1 1B1
1Nuplazid 3 3 3PA, QL PA, QL3 3Orap pimozide 1 1 1B1 1Perphenazine
perphenazine 1 1 1B1 1Prolixin fluphenazine hcl 1 1 1A1 1Risperdal,
M-Tab risperidone 1 1 1A1 1Saphris 3 3 3ST, QL ST, QL3 3Seroquel
quetiapine fumarate 1 1 1A1 1Seroquel XR quetiapine fumarate 1 1
1BQL QL1 1Stelazine trifluoperazine hcl 1 1 1A1 1Symbyax
olanzapine/fluoxetine hcl 1 1 1B1 1Thorazine chlorpromazine hcl 1 1
1B1 1Vraylar 3 3 3ST, QL ST, QL3 3Zyprexa, Zydis olanzapine 1 1 1A1
1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3E. Anxiolytics BCN (HMO)BCBSM (PPO)Trade name Generic name
Ativan lorazepam 1 1 1B1 1Buspar buspirone hcl 1 1 1B1 1Equanil;
Miltown meprobamate 1 1 1B1 1Librium chlordiazepoxide hcl 1 1 1B1
1Lorazepam intensol lorazepam 1 1 1B1 1Niravam alprazolam 1 1 1B1
1Serax oxazepam 1 1 1B1 1Tranxene T-Tab clorazepate dipotassium 1 1
1B1 1Valium diazepam 1 1 1B1 1Xanax, XR alprazolam 1 1 1B1 1
Page 32BCBSM/BCN Custom Select Drug List - March-2018(Prevent) -
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rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3F. CNS stimulants BCN (HMO)BCBSM (PPO)Trade name Generic
name
Adderall, XR dextroamphetamine/amphetamine 1 1 1BQL QL1 1
Concerta methylphenidate hcl 1 1 1B QL1 1Daytrana 3 3 3 QL3
3Desoxyn methamphetamine hcl 1 1 1B QL1 1Dexedrine
dextroamphetamine sulfate 1 1 1B QL1 1Focalin immediate-release
dexmethylphenidate hcl 1 1 1B QL1 1Metadate CD methylphenidate hcl
1 1 1B QL1 1Methylin, ER methylphenidate hcl 1 1 1B QL1 1Nuvigil
armodafinil 1 1 1BQL PA, QL1 1Procentra dextroamphetamine sulfate 1
1 1B PA, QL1 1Provigil modafinil 1 1 1BQL PA, QL1 1Ritalin LA 10mg
3 3 3 QL3 3Ritalin, LA, SR methylphenidate hcl 1 1 1B QL1 1Vyvanse
3 3 3QL QL3 3Zenzedi 3 3 3 QL3 3
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3G. Migraine therapy BCN (HMO)BCBSM (PPO)Trade name Generic
name
Alsuma sumatriptan succinate 1 1 1BQL QL1 1Amerge naratriptan
hcl 1 1 1BQL QL1 1Axert almotriptan malate 1 1 1BST, QL QL1
1Cafergot ergotamine tartrate/caffeine 1 1 1B QL1 1D.H.E.45
dihydroergotamine mesylate 1 1 1B QL1 1Esgic; Fioricet 50/325/40mg
butalb/acetaminophen/caffeine 1 1 1B QL1 1Fioricet 50/300/40mg
butalb/acetaminophen/caffeine 1 1 1B PA, QL1 1Fioricet w/codeine
50/300/30mg butalbit/acetamin/caff/codeine 1 1 1BQL PA, QL1
1Fioricet w/codeine 50/325/30mg butalbit/acetamin/caff/codeine 1 1
1BQL QL1 1Fiorinal butalbital/aspirin/caffeine 1 1 1B1 1Fiorinal
w/codeine codeine/butalbital/asa/caffein 1 1 1BQL QL1 1Frova
frovatriptan succinate 1 1 1BST, QL ST, QL1 1Imitrex sumatriptan
succinate 1 1 1BQL QL1 1Imitrex nasal spray sumatriptan 1 1 1BQL
QL1 1Maxalt, MLT rizatriptan benzoate 1 1 1BQL QL1 1Migergot
ergotamine tartrate/caffeine 1 1 1B1 1Migranal dihydroergotamine
mesylate 1 1 1BQL QL1 1Phrenilin tablet butalbital/acetaminophen 1
1 1B1 1Relpax eletriptan hbr 1 1 1BST, QL ST, QL1 1Zomig nasal
spray 3 3 3ST, QL ST, QL3 3Zomig, ZMT zolmitriptan 1 1 1BST, QL QL1
1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3H. Myasthenia gravis BCN (HMO)BCBSM (PPO)Trade name Generic
name
Mestinon syrup 2 2 22 2Mestinon, Timespan pyridostigmine bromide
1 1 1B1 1
Page 33BCBSM/BCN Custom Select Drug List - March-2018(Prevent) -
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3I. Narcotic antagonists BCN (HMO)BCBSM (PPO)Trade name Generic
name
Naloxone hcl injection naloxone hcl 1 1 1B1 1Narcan nasal spray
2 2 2QL QL2 2Revia naltrexone hcl 1 1 1B1 1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3J. Narcotic mixed agonist and antagonist BCN (HMO)BCBSM
(PPO)Trade name Generic name
Bunavail 3 3 3QL3 3Buprenorphine patch 2 2 2QL QL2 2Butrans 2 2
2QL QL2 2Ryzolt tramadol hcl 1 1 1BQL QL1 1Stadol NS butorphanol
tartrate 1 1 1BQL QL1 1Suboxone buprenorphine hcl/naloxone hcl 1 1
1BQL1 1Suboxone film 2 2 2QL2 2Subutex buprenorphine hcl 1 1 1BPA,
QL PA, QL1 1Talwin NX pentazocine hcl/naloxone hcl 1 1 1BQL QL1
1Ultracet tramadol hcl/acetaminophen 1 1 1BQL QL1 1Ultram, ER
tramadol hcl 1 1 1BQL QL1 1Zubsolv 3 3 3QL3 3
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3K. Narcotic and analgesic combinations BCN (HMO)BCBSM
(PPO)Trade name Generic name
Esgic; Fioricet 50/325/40mg butalb/acetaminophen/caffeine 1 1 1B
QL1 1Fioricet 50/300/40mg butalb/acetaminophen/caffeine 1 1 1B PA,
QL1 1Fioricet w/codeine 50/300/30mg butalbit/acetamin/caff/codeine
1 1 1BQL PA, QL1 1Fioricet w/codeine 50/325/30mg
butalbit/acetamin/caff/codeine 1 1 1BQL QL1 1Fiorinal
butalbital/aspirin/caffeine 1 1 1B1 1Fiorinal w/codeine
codeine/butalbital/asa/caffein 1 1 1BQL QL1 1Hycet
hydrocodone/acetaminophen 1 1 1BQL QL1 1Norco; Vicodin; Xodol
hydrocodone/acetaminophen 1 1 1BQL QL1 1Percocet oxycodone
hcl/acetaminophen 1 1 1BQL QL1 1Percodan oxycodone hcl/aspirin 1 1
1BQL QL1 1Phrenilin tablet butalbital/acetaminophen 1 1 1B1
1Tylenol w/codeine acetaminophen with codeine 1 1 1BQL QL1 1Tylenol
w/codeine solution acetaminophen with codeine 1 1 1BQL QL1
1Vicoprofen hydrocodone/ibuprofen 1 1 1BQL QL1 1
Page 34BCBSM/BCN Custom Select Drug List - March-2018(Prevent) -
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required QL - Quantity limits may apply - Specialty Drug
rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3L. Narcotics BCN (HMO)BCBSM (PPO)Trade name Generic name
Actiq fentanyl citrate 1 1 1BPA, QL PA, QL1 1Belladonna &
Opium opium/belladonna alkaloids 1 1 1BQL QL1 1Codeine sulfate
tablet codeine sulfate 1 1 1BQL QL1 1Dilaudid hydromorphone hcl 1 1
1BQL QL1 1Duragesic fentanyl 1 1 1BQL QL1 1Exalgo hydromorphone hcl
1 1 1BQL PA, QL1 1Levorphanol Tartrate levorphanol tartrate 1 1
1BQL QL1 1Methadone methadone hcl 1 1 1BQL QL1 1MS Contin morphine
sulfate 1 1 1BQL QL1 1MSIR morphine sulfate 1 1 1BQL QL1 1Nucynta,
ER 3 3 3PA, QL PA, QL3 3Oxycodone hcl ER 3 3 3PA, QL PA, QL3
3Oxycodone immediate release, solution
oxycodone hcl 1 1 1BQL QL1 1
Oxycontin 3 3 3PA, QL PA, QL3 3RMS Suppository morphine sulfate
1 1 1BQL QL1 1Roxanol morphine sulfate 1 1 1BQL QL1 1Zohydro ER 3 3
3PA, QL PA, QL3 3
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3M. Nonsteroidal anti-inflammatory drugs BCN (HMO)BCBSM
(PPO)Trade name Generic name
Anaprox, DS naproxen sodium 1 1 1A1 1Ansaid flurbiprofen 1 1 1B1
1Cataflam diclofenac potassium 1 1 1B1 1Celebrex celecoxib 1 1 1B1
1Clinoril sulindac 1 1 1B1 1Daypro oxaprozin 1 1 1B1 1EC-Naproxyn
naproxen 1 1 1A1 1Feldene piroxicam 1 1 1B1 1Indocin, SR
indomethacin 1 1 1B1 1Indocin suppository 2 2 22 2Indocin
suspension 3 3 33 3Ketoprofen ketoprofen 1 1 1B1 1Lodine, XL
etodolac 1 1 1B1 1Meclomen meclofenamate sodium 1 1 1B1 1Mobic
meloxicam 1 1 1A1 1Motrin (Rx Only) ibuprofen 1 1 1A1 1Nalfon 600mg
fenoprofen calcium 1 1 1B1 1Naprosyn (Rx Only) naproxen 1 1 1A1
1Relafen nabumetone 1 1 1B1 1Tolectin, DS tolmetin sodium 1 1 1B1
1Toradol injection ketorolac tromethamine 1 1 1B1 1Toradol tablet
ketorolac tromethamine 1 1 1BQL QL1 1Voltaren gel diclofenac sodium
1 1 1BQL QL1 1Voltaren tablet diclofenac sodium 1 1 1A1
1Voltaren-XR diclofenac sodium 1 1 1B1 1
Page 35BCBSM/BCN Custom Select Drug List - March-2018(Prevent) -
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rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3N. Parkinsons disease and related disorders BCN (HMO)BCBSM
(PPO)Trade name Generic name
Apokyn 2 4 44 4Artane trihexyphenidyl hcl 1 1 1B1 1Azilect
rasagiline mesylate 1 1 1B1 1Cogentin benztropine mesylate 1 1 1B1
1Comtan entacapone 1 1 1B1 1Duopa 2 4 4PA, QL PA, QL4 4Eldepryl
selegiline hcl 1 1 1B1 1Lodosyn carbidopa 1 1 1B1 1Mirapex
immediate-release pramipexole di-hcl 1 1 1B1 1Nuplazid 3 3 3PA, QL
PA, QL3 3Parcopa carbidopa/levodopa 1 1 1B1 1Parlodel bromocriptine
mesylate 1 1 1B1 1Requip, XL ropinirole hcl 1 1 1B1 1Sinemet, CR
carbidopa/levodopa 1 1 1B1 1Stalevo carbidopa/levodopa/entacapone 1
1 1B1 1Symmetrel amantadine hcl 1 1 1B1 1Tasmar tolcapone 1 1 1B1
1Xadago 3 3 3QL QL3 3
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3O. Salicylates BCN (HMO)BCBSM (PPO)Trade name Generic name
Aspirin; Ecotrin 81mg, 325mg (OTC) (Prevent)
aspirin $0 $0 $0$0 $0
Disalcid salsalate 1 1 1B1 1Dolobid diflunisal 1 1 1B1 1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3P. Sedative and hypnotics BCN (HMO)BCBSM (PPO)Trade name
Generic name
Ambien zolpidem tartrate 1 1 1BQL QL1 1Ambien CR zolpidem
tartrate 1 1 1BQL QL1 1Dalmane flurazepam hcl 1 1 1BQL QL1 1Halcion
triazolam 1 1 1BQL QL1 1Hetlioz 3 5 5PA, QL PA, QL4 4Lunesta
eszopiclone 1 1 1BQL QL1 1Prosom estazolam 1 1 1BQL QL1 1Restoril
temazepam 1 1 1BQL QL1 1Rozerem 3 3 3ST, QL ST, QL3 3Sonata
zaleplon 1 1 1BQL QL1 1Versed syrup midazolam hcl 1 1 1B1 1
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rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3Q. Skeletal muscle relaxants BCN (HMO)BCBSM (PPO)Trade name
Generic name
Baclofen baclofen 1 1 1B1 1Dantrium dantrolene sodium 1 1 1B1
1Flexeril cyclobenzaprine hcl 1 1 1B1 1Lorzone 3 3 33 3Norflex
orphenadrine citrate 1 1 1B1 1Parafon Forte DSC 500mg chlorzoxazone
1 1 1B1 1Robaxin methocarbamol 1 1 1B1 1Skelaxin metaxalone 1 1 1B
PA1 1Soma carisoprodol 1 1 1B PA, QL1 1Valium diazepam 1 1 1B1
1Zanaflex capsule tizanidine hcl 1 1 1B PA1 1Zanaflex tablet
tizanidine hcl 1 1 1B1 1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
3R. Miscellaneous CNS BCN (HMO)BCBSM (PPO)Trade name Generic
name
Antabuse disulfiram 1 1 1B1 1Austedo 3 5 5PA, QL PA, QL4 4Cafcit
caffeine citrate 1 1 1B1 1Campral acamprosate calcium 1 1 1B1
1Cuvposa 3 3 33 3Ergoloid Mesylates ergoloid mesylates 1 1 1B1
1Eskalith, CR; Lithobid lithium carbonate 1 1 1A1 1Guanidine hcl
guanidine hcl 1 1 1B1 1Ingrezza 3 5 5PA, QL PA, QL4 4Kapvay
clonidine hcl 1 1 1BQL QL1 1Lithium Citrate lithium citrate 1 1 1B1
1Nimotop nimodipine 1 1 1B1 1Nuedexta 2 2 2PA, QL PA, QL2 2Nymalize
3 3 3QL QL3 3Rilutek riluzole 1 1 1B1 1Savella 3 3 3PA, QL PA, QL3
3Savella dose pack 3 3 3PA PA, QL3 3Strattera atomoxetine hcl 1 1
1B QL1 1Xenazine tetrabenazine 1 4 4PA, QL PA, QL4 4Xyrem 3 5 5PA,
QL PA, QL4 4
Page 37BCBSM/BCN Custom Select Drug List - March-2018(Prevent) -
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rev. 2
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4. Gastrointestinal agents
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
4A. 5-Aminosalicylic Acid (5-ASA) agents BCN (HMO)BCBSM
(PPO)Trade name Generic name
Apriso 3 3 33 3Asacol HD 2 2 22 2Azulfidine, EN-tab
sulfasalazine 1 1 1B1 1Canasa 2 2 22 2Colazal balsalazide disodium
1 1 1B1 1Delzicol 2 2 22 2Dipentum 3 3 33 3Giazo 3 3 3ST, QL QL3
3Lialda mesalamine 1 1 1B QL1 1Mesalamine ER tablet 3 3 33 3Pentasa
2 2 22 2SfRowasa enema mesalamine 1 1 1B1 1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
4B. Antidiarrheals and antispasmodics BCN (HMO)BCBSM (PPO)Trade
name Generic name
Bentyl dicyclomine hcl 1 1 1B1 1Levbid hyoscyamine sulfate 1 1
1B1 1Levsin, SL hyoscyamine sulfate 1 1 1B1 1Librax
chlordiazepoxide/clidinium br 1 1 1B1 1Lomotil diphenoxylate
hcl/atropine 1 1 1B1 1Mytesi 2 2 2PA, QL PA, QL2 2
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
4C. Antiemetics BCN (HMO)BCBSM (PPO)Trade name Generic name
Akynzeo 3 3 3PA, QL PA, QL3 3Anzemet 3 3 3 QL3 3Cesamet 3 3 33
3Compazine suppository prochlorperazine 1 1 1B1 1Compazine tablet
prochlorperazine maleate 1 1 1B1 1Emend 40mg aprepitant 1 1 1B1
1Emend 80mg, 125mg, 125mg-80mg aprepitant 1 1 1B QL1 1Emend
suspension 2 2 2ST, QL QL2 2Kytril granisetron hcl 1 1 1B QL1
1Marinol dronabinol 1 1 1B1 1Phenergan promethazine hcl 1 1 1B1
1Sancuso 3 3 3PA, QL ST, QL3 3Tigan trimethobenzamide hcl 1 1 1B1
1Transderm-Scop scopolamine 1 1 1B1 1Zofran ondansetron hcl 1 1 1B1
1Zofran ODT ondansetron 1 1 1B1 1
Page 38BCBSM/BCN Custom Select Drug List - March-2018
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
4D. Bile acids BCN (HMO)BCBSM (PPO)Trade name Generic name
Actigall ursodiol 1 1 1B1 1Chenodal 3 5 5PA PA4 4Ocaliva 2 4
4PA, QL PA, QL4 4Urso; Forte ursodiol 1 1 1B1 1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
4E. Bowel preparation and cleansing agents BCN (HMO)BCBSM
(PPO)Trade name Generic name
Bisacodyl OTC (Prevent) bisacodyl $0 $0 $0QL QL$0 $0Citrate of
Magnesia OTC (Prevent) magnesium citrate $0 $0 $0QL QL$0 $0Colyte
(Prevent) peg3350/sod sulf,bicarb,cl/kcl $0 $0 $0QL QL$0 $0Colyte
peg3350/sod sulf,bicarb,cl/kcl 1 1 1B1 1Glycolax (Prevent)
polyethylene glycol 3350 $0 $0 $0QL QL$0 $0Glycolax polyethylene
glycol 3350 1 1 1B1 1Glycolax OTC (Prevent) polyethylene glycol
3350 $0 $0 $0QL QL$0 $0Golytely (Prevent) peg 3350/na
sulf,bicarb,cl/kcl $0 $0 $0QL QL$0 $0Golytely peg 3350/na
sulf,bicarb,cl/kcl 1 1 1B1 1Golytely flavored 2 2 22
2Halflytely-Bisacodyl (Prevent) bisac/nacl/nahco3/kcl/peg 3350 $0
$0 $0QL QL$0 $0Halflytely-Bisacodyl bisac/nacl/nahco3/kcl/peg 3350
1 1 1B QL1 1Milk of Magnesia OTC (Prevent) magnesium hydroxide $0
$0 $0QL QL$0 $0Moviprep 3 3 33 3Nulytely (Prevent) sodium
chloride/nahco3/kcl/peg $0 $0 $0QL QL$0 $0Nulytely sodium
chloride/nahco3/kcl/peg 1 1 1B1 1Oral Saline Laxative liquid
OTC(Prevent)
sodium phosphate,mono-dibasic $0 $0 $0QL QL$0 $0
Suprep 3 3 33 3
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
4F. Digestive enzymes BCN (HMO)BCBSM (PPO)Trade name Generic
name
Creon 2 2 22 2Zenpep 2 2 22 2
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
4G. H2-Receptor antagonists BCN (HMO)BCBSM (PPO)Trade name
Generic name
Axid (Rx only) nizatidine 1 1 1B1 1Pepcid (Rx Only) famotidine 1
1 1B1 1Tagamet (Rx only) cimetidine 1 1 1B1 1Tagamet liquid (Rx
only) cimetidine hcl 1 1 1B1 1Zantac (Rx Only) ranitidine hcl 1 1
1B1 1
Page 39BCBSM/BCN Custom Select Drug List - March-2018
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
4H. Proton Pump Inhibitors (PPI) BCN (HMO)BCBSM (PPO)Trade name
Generic name
Aciphex tablet rabeprazole sodium 1 1 1B1 1Nexium suspension 3 3
3ST PA3 3Prevacid capsule (Rx Only) lansoprazole 1 1 1BQL1
1Prilosec capsule (Rx Only) omeprazole 1 1 1BQL1 1Protonix tablet
pantoprazole sodium 1 1 1BQL1 1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
4I. Topical anti-Inflammatory agents BCN (HMO)BCBSM (PPO)Trade
name Generic name
Analpram-HC 1-1% cream 2 2 22 2Analpram-HC cream 2.5-1%, 1-1%
hydrocortisone/pramoxine 1 1 1B1 1Anamantle HC cream with
applicator
lidocaine/hydrocortisone ac 1 1 1B1 1
Cortenema hydrocortisone 1 1 1B1 1Cortifoam 3 3 33 3Epifoam 2 2
22 2Pramosone cream hydrocortisone/pramoxine 1 1 1B1 1Proctocort
hydrocortisone 1 1 1B1 1Proctocort suppository hydrocortisone
acetate 1 1 1B1 1Proctofoam-HC 2 2 22 2Procto-Pak hydrocortisone 1
1 1B1 1Proctosol-HC suppository hydrocortisone acetate 1 1 1B1
1
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
4J. Tumor Necrosis Factor (TNF) blocking agents BCN (HMO)BCBSM
(PPO)Trade name Generic name
Cimzia syringe 3 5 5PA, QL PA, QL4 4Humira 2 4 4PA, QL QL4
4Simponi 3 5 5PA, QL PA, QL4 4
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
4K. Ulcer therapy BCN (HMO)BCBSM (PPO)Trade name Generic
name
Carafate sucralfate 1 1 1B1 1Carafate suspension 2 2 22 2Cytotec
misoprostol 1 1 1B1 1Pamine, Forte methscopolamine bromide 1 1 1B1
1Pro-Banthine propantheline bromide 1 1 1B1 1Robinul tablet, Forte
glycopyrrolate 1 1 1B1 1
Page 40BCBSM/BCN Custom Select Drug List - March-2018
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
4L. Miscellaneous gastrointestinal agents BCN (HMO)BCBSM
(PPO)Trade name Generic name
Amitiza 2 2 2 QL2 2Evoxac cevimeline hcl 1 1 1B1 1Gastrocrom
cromolyn sodium 1 1 1B1 1Gattex 2 4 4PA, QL PA, QL4 4Lactulose
lactulose 1 1 1B1 1Linzess 2 2 2QL QL2 2Lotronex alosetron hcl 1 1
1B QL1 1Rectiv 3 3 3QL QL3 3Reglan metoclopramide hcl 1 1 1B1
1Salagen pilocarpine hcl 1 1 1B1 1Stelara 2 4 4PA, QL PA, QL4
4Sucraid 3 5 54 4Xifaxan 200mg 3 3 3 QL3 3Xifaxan 550mg 3 3 3PA, QL
PA, QL3 3Zorbtive 3 5 5PA PA4 4
Page 41BCBSM/BCN Custom Select Drug List - March-2018
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5. Obstetrics and gynecology
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
5A. Contraceptives-Biphasic BCN (HMO)BCBSM (PPO)Trade name
Generic name
Lo Loestrin Fe 3 3 33 3Loseasonique (Prevent)
l-norgest/e.estradiol-e.estrad $0 $0 $0QL$0 $0Mircette (Prevent)
desog-e.estradiol/e.estradiol $0 $0 $0$0 $0Seasonique (Prevent)
l-norgest/e.estradiol-e.estrad $0 $0 $0QL$0 $0
Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
5B. Contraceptives-Misc. BCN (HMO)BCBSM (PPO)Trade name Generic
name
Conceptrol (Prevent) $0 $0 $0QL$0 $0Depo-Provera 150mg (Prevent)
medroxyprogesterone acetate $0 $0 $0$0 $0Depo-subq Provera 104 2 2
22 2FC2 female condom (Prevent) $0 $0 $0QL$0 $0Gynol II (Prevent)
nonoxynol 9 $0 $0 $0QL$0 $0Natazia 3 3 33 3Nuvaring (Prevent) $0 $0
$0QL QL$0 $0Ortho Evra (Prevent) norelgestromin/ethin.estradiol $0
$0 $0QL QL$0 $0Ortho Micronor; Nor-QD (Prevent) norethindrone $0 $0
$0$0 $0Quartette (Prevent) l-norgest-eth estr/ethin estra $0 $0
$0QL$0 $0Safyral 3 3 33 3Today contraceptive sponge(Prevent)
$0 $0 $0QL$0 $0
VCF film, gel (Prevent) $0 $0 $0QL$0 $0VCF foam (Prevent)
nonoxynol 9 $0 $0 $0QL$0 $0
Page 42BCBSM/BCN Custom Select Drug List - March-2018(Prevent) -
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rev. 2
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Limits Limits5-Tier3-Tier 4-Tier4-Tier 6-Tier
5C. Contraceptives-Monophasic BCN (HMO)BCBSM (PPO)Trade name
Generic name
Alesse; Levlite (Prevent) levonorgestrel-ethin estradiol $0 $0
$0$0 $0Beyaz (Prevent) drospir/eth estra/levomefol ca $0 $0 $0$0
$0Demulen (Prevent) ethynodiol d-ethinyl estradiol $0 $0 $0$0
$0Desogen; Ortho-cept (Prevent) desogestrel-ethinyl estradiol $0 $0
$0$0 $0Femcon Fe (Prevent) noreth-ethinyl estradiol/iron $0 $0 $0$0
$0Generess Fe (Prevent) noreth-ethinyl estradiol/iron $0 $0 $0$0
$0Levlen; Nordette (Prevent) levonorgestrel-ethin estradiol $0 $0
$0$0 $0Lo/Ovral (Prevent) norgestrel-ethinyl estradiol $0 $0 $0$0
$0Loestrin (Prevent) norethindrone ac-eth estradiol $0 $0 $0$0
$0Loestrin 24 Fe (Prevent) norethindrone-e.estradiol-iron $0 $0
$0$0 $0Loestrin Fe (Prevent) norethindrone-e.estradiol-iron $0 $0
$0$0 $0Lybrel (Prevent) levonorgestrel-ethin estradiol $0 $0 $0$0
$0Minastrin 24 FE (Prevent) norethindrone-e.estradiol-iron $0 $0
$0$0 $0Modicon (Prevent) norethindrone-ethinyl estrad $0 $0 $0$0
$0Norinyl 1/35; Ortho-novum 1/35(Prevent)
norethindrone-ethinyl estrad $0 $0 $0$0 $0
Ortho-Cyclen (Prevent) norgestimate-ethinyl estradiol $0 $0 $0$0
$0Ovcon 35 (Prevent) norethindrone-ethinyl estrad $0 $0 $0$0
$0Ovral (Prevent) norgestrel-ethinyl estradiol $0 $0 $0$0
$0Seasonale (Prevent) levonorgestrel-ethin estradiol $0 $0 $0QL$0
$0Taytulla 3 3 33 3Yasmin 28 (Prevent) ethinyl
estradiol/drospirenone $0 $0 $0$0 $0Yaz (Prevent) ethinyl
estradiol/drospirenone $0 $0 $0$0 $0
Limits Limits5-Tier3-Tier 4-