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Level 4 Medication List Revised 7/24/20 The medications listed
below have the highest copayment level
Abilify oral solution Abilify tablet Abstral Absorica* Absorica
LD* Acanya* Acetaminophen/Caffeine/ Dihydrocodeine Bitartrate
325-30-16mg Aciphex* Aciphex Sprinkle* Acticlate* Actiq Actonel
5mg, 30mg, 35mg Actoplus Met Actos Adapalene cream 0.1%* Adapalene
gel 0.3%* Adapalene lotion 0.1%* Adapalene-Benzoyl Peroxide gel
0.1-2.5%* Adhansia XR Adzenys ER Adzenys XR ODT Afrezza* AirDuo
Respiclick Aklief cream Akynzeo Albuterol HFA Aldara cream
Almotriptan tablet Alocril Alogliptin Alomide Alphagan P 0.15%
Alrex Altreno* Ambien Ambien CR Amlodipine-Atorvastatin*
Amphetamine sulfate 5 & 10mg* Amnesteem Amicar solution
0.25GM/ML Amicar tablet 500mg & 1000mg Aminocarpoic acid
solution 0.25GM/ML
Aminocarpoic acid tablet 500mg & 1000mg Androderm Androgel
Aplenzin* Aptensio XR Aptiom Amrix* Arakoda* Arestin Aripiprazole
ODT Armodafinil Aspirin/Omeprazole 81-40mg* Astepro nasal spray
Astagraf XL Ativan* Atelvia* Atralin* Azel/Flutic NS Axert Axiron
Bactroban cream* Balcoltra Basaglar Kwikpen* Baxdela Belbuca
Belsomra Benzaclin Gel 1-5%* Benzefoamultra Bepreve Betapace AF
Betimol* Beyaz Biaxin XL Binosto* Brisdelle* Briviact Bynfezia Pen*
Caduet* Calcitriol ointment Cambia* Carbaglu Carbinoxamine 6mg tab
* Cardura XL Carisoprodol 250mg* Carisoprodol/Aspirin
Carisoprodol/Aspirin/Codeine Carvedilol Phosphate
Caplyta * Capsules ER Celexa tablet 10mg, 20mg,
40mg* Chlorzoxazone 375mg & 750mg Ciprofloxacin ER/SR
Claravis Clarinex Clarinex D
Clarinex ODT Cleocin-T solution 1%* Cleocin-T gel 1%* Cleocin-T
lotion 1%* Cleocin-T swab 1%* Clindamycin Phosphate-
Tretinoin Gel 1.2-0.025%* Clindamycin Phosphate-
Benzoyl Peroxide gel 1.2-2.5%
& 1.2 (1) -5%* Clobex lotion 0.05% Clobex spray 0.05%*
Clocortolone cream 0.1% Cloderm cream 0.1% Clonidine ER Clozapine
ODT Coly-Mycin S otic susp Consensi tablet* Conzip* Cordran cream*
Cordran lotion* Cordran ointment* Cordran tape Cortisporin-TC otic
susp Coreg CR Coremino* Corzide tablet 80-5mg Cresemba Crestor
Crotan lot 10% Cyclessa Pak Cyclobenzaprine HCL ER* Cyclogyl 0.5%
Daraprim Davigo Daxbia* Daytrana Desloratadine 5mg tablet
* Coverage may vary by benefit plan 1
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Level 4 Medication List Revised 7/24/20 The medications listed
below have the highest copayment level
Desloratadine ODT Desowen* Detrol* Detrol LA* Dexmethylphenidate
ER/SR Diabeta Diclofenac Epolamine patch Differin cream* Differin
gel 0.3%* Differin lotion* Dificid Diflorasone cream Diflorasone
ointment Diovan Diovan HCT Ditropan XL* Doryx* Doryx MPC* Doxepin
Doxycycline (Rosacea) capsule* Doxycycline Hyclate tablet 75mg
&150mg* Doxycycline Hyclate DR tablet 50mg* Doxycycline Hyclate
DR tablet 75mg* Doxycycline Hyclate DR tablet 80mg* Doxycycline
Hyclate DR tablet 150mg* Doxycycline Hyclate DR tablet 200mg*
Doxycycline Monohydrate 150mg capsule* Drospirenone/Ethinyl
Estradiol/Levomefolate Calcium tablet Duac gel* Duaklir Pressair*
Duavee Duexis* Dulera* Duragesic Disc DuoNeb Dutoprol Tablets*
Dyanavel XR Dymista Nasal Spray
Elimite Edluar* Elestat Emadine Enablex Envarsus XR Epiduo Gel*
Epiduo Forte* Epinephrine Pen (non Mylan) Epi-Pen Epi-Pen JR
Epzicom Equetro Ertaczo cream Erygel Esomeprazole strontium* Eurax
cream Eurax lotion Evekeo* Evekeo ODT* Evoclin* Exalgo Exforge
Exforge HCT Extina* Ezallor Sprinkle Capsules* Fanapt Fazaclo
Febuxostat Fentanyl Citrate Buccal tablet Fentanyl Citrate Inj
Fentanyl lollipop Fentora Fetzima Fiasp vial Fiasp Flextouch
Flector patch Flowtuss Fluocinonide cream 0.1%* Fluoxetine capsules
(PMDD) Fluoxetine tablets (PMDD) Fluoxetine 60mg tablet *
Fluoxetine 90mg DR* Flurandrenolide Cream Flurandrenolide Lotion
Flurandrenolide Ointment Focalin XR Fortamet
Fortesta Fosamax Plus D* Fulyzaq Gelnique* Generess FE
Glucophage XR Glumetza* Glyxambi* Gocovri Gonitro* Gralise* Gralise
Starter Kit* Grastek Gvoke Hypopen* Gvoke PFS* Gynazole-1 cream
Halog* HC Butyrate cream* Horizant* Hydroc/APAP sol 10-325mg
Hydrocodone Bitartrate ER Hydroc/Guaif sol 2.5-200mg Hydroc/IBU
2.5-200mg Hydroc/IBU 5-200mg Hydroc/IBU 10-200mg Hydromorphone HCL
ER 24HR Ibudone Imitrex cartridge Imitrex syringe Intermezzo*
Inderal LA* Inderal XL* Innopran XL* Intuniv* Invega Inveltys Susp*
Istalol Isotretinoin capsules Ivermectin cream 1% Jatenzo capsules*
Jublia Kadian Kapvay* Karbinal ER* Ketorolac NS* Keppra Keppra
XR
* Coverage may vary by benefit plan 2
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Level 4 Medication List Revised 7/24/20 The medications listed
below have the highest copayment level
Kerydin Klaron* Krintafel* Kristalose crystal packet 10GM &
20GM* Lactulose crystal packet 10GM* Lansoprazole ODT Solultab*
Lansoprazole/Amox/Clarithr* Latuda Lastacaft Levorphanol tartrate
tablet Lexapro tablet 5mg, 10mg, 20mg* Lipitor Liptruzet Locoid
Lipocream* Lodine Loestrin 1/20-21 Loestrin FE 1/20 Loestrin FE
1.5/30 Loprox suspension Loprox cream Loprox shampoo Lortab*
Lorzone Loseasonique Lotemax* Loteprednol Lovaza Lunesta
Luliconazole CR* Luzu cream* Lyrica CR Magnacet Metformin HCL
modified release ER/SR* Metoprolol/HCTZ SR tablets* Metrocream
0.75%* Metrogel 1%* Metrolotion 0.75%* Minastrin 24 FE Chew tabs
Minocycline ER/SR tabs* Minocycline ER/SR caps Mircette Monodox*
Morphabond ER* Morphine sulfate ER/SR beads
Morphine sulfate ER/SR capsules Myfortic Myorisan Mytesi Namenda
Naphazoline HCL Opth Sol Naprelan CR/ER* Naproxen sodium ER/CR*
Naproxen-Esomeprazole tab DR* Nasonex Natesto Natroba Nayzilam NS
Neo-Synalar cream* Nesina Neuac gel* Nexium* Nexium granules*
Niravam Neurontin Noctiva Nolix lotion Non-Lifescan Glucose Test
Strips Non-Lifescan Glucose Test Disks Nor QD Noxafil tabs Noxafil
oral suspension Norinyl 1/35 Nucynta Nucynta ER Nuedexta Nuplazid
Nurtec Nuvigil Obredon Odactra Olopatadine NS Olopatadine Opth Sol
0.2% Omeppi* Omeprazole/Bicarbonate* Omeprazole-Sodium Bicarb*
Omnaris Omnipod DASH 5 pack
Ondansetron HCL tablet 24mg* Onexton* Onfi* Onzetra Xsail* Opana
ER Optivar Oracea* Oralair Orfadin Bicarbonate Powd Pack
Ortho-Micron Ortho-Cyclen Ortho Novum 7/7/7 Ortho Novum 1/35 Ortho
Tri-Cyclen Ortho Tri-Cyclen Lo Osphena Otrexup Ovcon-35 Ovide
Oxistat lotion 1%* Oxaydo Oxtellar XR Oxycontin Oxycodone HCL ER
Oxymorphone ER/SR Oxytrol Ozobax Sol 5mg/5ml* Palforzia
Paliperidone ER/SR Paricalcitrol capsule 4mg Pataday Sol 0.2%
Patanase Paxil tablet 10mg, 20mg, 30mg, 40mg* Paxil CR tablet
12.5mg, 25mg, 37.5mg* Paroxetine capsule 7.5mg* Paroxetine SR/ER
Pazeo Percocet Pexeva* Plavix Plexion Cream 9.8-4.8%* Plexion
Lotion 9.8-4.8%* Plexion Cleanser 9.8-4.8%* Posaconazole oral
suspension
* Coverage may vary by benefit plan 3
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Level 4 Medication List Revised 7/24/20 The medications listed
below have the highest copayment level
Prandimet Prestalia* Prevacid* Prevacid ODT Solutab* PrevPac*
Pristiq Prilosec* Prolensa Protonix* Protonix Pak* Proventil HFA
Prozac capsule 10mg, 20mg, 40mg* Psorcon Pulmicort suspension
0.25mg/2ml, 0.5mg/2ml Pylera* Pyridium Pyrimethamin Qnasl Qnasl
Childrens Qtern Qudexy XR Radiogardase Ragwitek Rajani Ravicti
Rasuvo Rayaldee Rayos* Regranex* Relenza Relistor tablet
Repaglinide/Metformin Hydrochloride* Relafen tablet 1000mg*
Reprexain Retin-A cream* Retin-A gel* Retin-A Micro* Rexulti
Rilutek* Riomet ER suspension* Risperdal M-ODT Risperidone M-ODT
Rocklatan Rukobia Rybelsus
Rybix ODT Ryvent * Sanctura Sanctura XR Saphris Savella
Seasonique Semprex-D Seroquel Silenor Simbrinza Sitavig Sivextro
Sklice Sod sul/sulf cream 9.8-4.8%* Solodyn Solosec Soloxide* Soma*
Sonata Soolantra Sorilux Spinosad Spirtam Sprix* Sporanox Striant
Striverdi Respimat Stromectol Subsys Sulfacetamide sodium sulfur
cleansing pad 10-4%* Sumadan Wash* Sumatriptan cartridge
Sumatriptan syringe Sumaxin* Sumaxin TS* Sympazan* Syndros Symproic
Synera Topical Patch* Talicia Tamiflu Taytulla Temodar Testosterone
gel 2% Testosterone TD Patch
Timolol Maleate 0.5% (once daily) Timoptic Timoptic Ocudose
Tirosint Tirosint-Sol Tizanidine capsules* Tolsura* Tosymra Toviaz
Tramadol Biphasic Capsule ER/SR* Tramadol Biphasic tablet ER/SR
Tretin-X* Treximet* Tridesilon* Trifluridine Ophth Soln 1%*
Trintellix Trokendi XR Trospium Chloride ER/SR Tussicaps* Tuzistra
XR* Twirla Ubrelvy* Ulesfia Uloric Ultram ER Vanatol LQ/S* Valium*
Valtoco NS* Vanos cream* Varubi Vascepa Vectical Veltassa Veltin*
Velphoro Verdeso* Vfend Viberzi Vicodin Vicoprofen Viibryd Vimovo*
Vivlodex* Vogelxo Wellbutrin XL*
* Coverage may vary by benefit plan 4
-
Level 4 Medication List The medications listed below have the
highest copayment level
Xanax* Xanax XR* Xartemis XR Xcopri* Xifaxan Xiidra Ximino*
Xofluza Xolegel* Xopenex HFA Xtampza ER Xyosted* Yasmin 28 Yaz
Yosprala* Zamicet* Zanaflex capsules Zegerid* Zembrace Symtouch*
Zemplar Zenatane Zepatier Zerviate Zetia Ziagen tablets Ziana*
Zilxi * Zioptan Zipsor* Zithranol shampoo Zocor Zofran Zofran ODT
Zofran oral solution Zohydro ER Zoloft tablet 25mg, 50mg, 100mg*
Zolpidem Tartrate SL* Zolpimist* Zorvolex* Zurampic Zutripro
Zyprexa Zyvox
Revised 7/24/20
* Coverage may vary by benefit plan 5
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Blue Cross Blue Shield of Arizona (BCBSAZ) complies with
applicable Federal civil rights laws and does not discriminate on
the basis of race, color, national origin, age, disability or sex.
BCBSAZ provides appropriate free aids and services, such as
qualified interpreters and written information in other formats, to
people with disabilities to communicate effectively with us. BCBSAZ
also provides free language services to people whose primary
language is not English, such as qualified interpreters and
information written in other languages. If you need these services,
call 602-864-4884 for Spanish and 877-475-4799 for all other
languages and other aids and services.
If you believe that BCBSAZ has failed to provide these services
or discriminated in another way on the basis of race, color,
national origin, age, disability or sex, you can file a grievance
with: BCBSAZ’s Civil Rights Coordinator, Attn: Civil Rights
Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466,
Phoenix, AZ 85002-3466, 602-864-2288, TTY/TDD 602-864-4823,
[email protected]. You can file a grievance in person or by mail or
email. If you need help filing a grievance BCBSAZ’s Civil Rights
Coordinator is available to help you. You can also file a civil
rights complaint with the U.S. Department of Health and 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 or phone
at: U.S. Department of Health and Human Services, 200 Independence
Avenue SW., Room 509F, HHH Building, Washington, DC 20201,
1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available
at http://www.hhs.gov/ocr/office/file/index.html.
mailto:[email protected]://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf
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Multi-language Interpreter Service
Level 4 Medication List Multi-language Interpreter Service