Drug List Exclusions for Blue Cross commercial plans

Transcription

1 Drug List Exclusions for Blue Cross commercial plans The drugs shown below aren t covered on the commercial Blue Cross Blue Shield of Michigan (PPO) and Blue Care Network (HMO) drug lists. In most cases, if you fill a prescription for one of these drugs, you ll pay the full retail price. If you re currently using one of the excluded drugs, please ask your doctor whether a prescription for one of the following preferred alternatives is right for you. They have similar effectiveness, quality and safety but at a fraction of the cost. Our exclusions criteria are based on current medical information and have been approved by the Blue Cross Pharmacy and Therapeutics Committee. If medical necessity coverage is approved, quantity limits may apply. This list contains the class, subclass and suggested preferred alternatives for the excluded drugs. The generic equivalents of the brand name drugs are also excluded. The following list isn t comprehensive. If you have a question about a drug that isn t covered and doesn t appear on this list, call the Customer Service number on the back of your Blue Cross ID card. These exclusions apply to most Blue Cross Blue Shield of Michigan (PPO) and Blue Care Network (HMO) commercial members; they don t apply to Medicare plans. Preferred alternatives for excluded drugs The brand (trade) names for the preferred alternatives are listed for reference. The generic equivalent will be dispensed when the member fills a prescription. This list is intended as a reference guide and does not dictate coverage. Members should refer to their specific drug benefit information for a full list of covered drugs and requirements. Full drug lists and coverage requirements can be found at bcbsm.com/pharmacy. Drug Class: Anti-infectives Antifungals Tolsura Sporanox Antivirals Viekira Pak, Viekira XR Epclusa, Zepatier Antiretrovirals Crixivan, Rescriptor, Trizivir, Videx /EC, Viracept, Zerit Go to bcbsm.com for a complete list of covered alternatives. Members should discuss treatment options with their doctors. P a g e

2 Drug Class: Anti-infectives (cont.) Cephalosporins Daxbia Keflex Tetracyclines Acticlate, Targadox, Ximino Monodox, Minocin, tetracycline Drug Class: Cardiovascular, hypertension, cholesterol Beta-blockers and combinations Lipid-lowering agents Kapspargo Sprinkle metoprolol succinate/hctz tablet Altoprev, Ezallor, Nikita, Zypitamag Toprol, Toprol XL Dutoprol, Lopressor HCT Crestor, Lescol, Lescol XL, Lipitor, Mevacor, Pravachol, Zocor Drug Class: Central nervous system CNS stimulants Cotempla XR-ODT, Mydayis Evekeo ODT Adderall XR *, Metadate CD *, Methylin solution/chewable tablet *can be opened and sprinkled on applesauce Adderall XR, Concerta, Focalin /XR Metadate CD, Methylin, Strattera 2 P a g e

3 Drug Class: Central nervous system (cont.) acetaminophen/caffeine/dihydrocodone, Allzital, butalbital/acetaminophen 300mg, Midrin/Prodrin (HMO only), Vanatol LQ, Vanatol S Esgic, Fiorinal, Phrenilin (butalbital/acetaminophen 325mg) Migraine therapy Ajovy Aimovig, Emgality Narcotics Narcotic antagonists and withdrawal management Tosymra Arymo ER, MorphaBond ER, Troxyca ER, Vantrela ER, Xtampza ER Oxaydo, Roxybond Evzio generic triptan (such as Imitrex /nasal spray, Maxalt, Maxalt MLT, Zomig, Zomig ZMT ) Butrans, Duragesic, Exalgo, methadone, MS Contin Dilaudid, morphine sulfate immediate-release, oxycodone immediate-release naloxone injection, Narcan nasal spray Narcotic and analgesic combinations Apadaz benzhydrocodone/acetaminophen Norco, Vicodin, Vicoprofen Nalocet, Primlev Percocet, Percodan 3 P a g e

4 Drug Class: Central nervous system (cont.) Cambia Generic oral NSAID (such as Anaprox, Indocin, Lodine, Mobic, Motrin (Rx only), Naprosyn, Voltaren, Voltaren XR); Generic triptan (such as Imitrex, Maxalt, Maxalt MLT, Zomig, Zomig ZMT ) Nonsteroidal antiinflammatory drugs (NSAIDs) Parkinsons disease and related disorders Duexis Motrin (Rx only) plus Pepcid Naprelan, Qmiiz ODT Vimovo Generic oral NSAID (such as Anaprox, Indocin, Lodine, Mobic, Motrin (Rx only), Naprosyn, Voltaren, Voltaren XR) naproxen (Naprosyn or Anaprox ) plus a generic proton pump inhibitor (Aciphex tablet, Nexium capsule, Prilosec capsule, Prevacid capsule, Protonix tablet) Gocovri, Osmolex ER Symmetrel Salicylates Sedative and hypnotics Skeletal muscle relaxants Durlaza Yosprala Brand name drug for the following product (HMO only): salsalate (such as Disalcid ) Zolpimist chlorzoxazone 250mg Ecotrin (generic aspirin) Ecotrin (generic aspirin) plus Prilosec capsule Generic product is covered Ambien, Lunesta, Desyrel, Sonata chlorzoxazone 500mg (Parafon Forte DSC ) 4 P a g e

5 Drug Class: Dermatology Absorica Claravis, Myorisan, Zenatane Acticlate, Coremino, Minolira, Seysara, Solodyn Aczone 7.5%, Brevoxyl (HMO only) Minocin, Monodox, Vibramycin Differin, Duac, Benzaclin, RetinA, Tazorac Acne treatment adapalene 0.% solution Clindagel, clindamycin % gel, Evoclin Cleocin-T adapalene (Differin ) cream or gel Onexton (HMO only) Benzaclin, Duac Retin-A Micro Atralin, Avita, Retin-A Veltin, Ziana Cleocin-T plus generic topical tretinoin (Atralin, Avita, RetinA ) Antipsoriatic and antiseborrheic (Treatment of Psoriasis) Siliq Cosentyx, Humira, Otezla, Stelara Corticosteroids- medium potency Corticosteroids- high to very high potency Nonsteroidal anti- inflammatory drugs (NSAIDs) Cordran 0.025% cream, Cordran lotion (PPO only), Locoid lotion, Sernivo Impoyz, Lexette, Ultravate lotion, Ultravate-X, Vanos (HMO only) Dithol, Licart Aristocort, Cutivate, Diprosone, Elocon, Kenalog, Locoid cream/ointment/ solution, Valisone Clobex, Diprolene, Lidex, LidexE, Ultravate cream/ointment General oral NSAID (such as Mobic, Motrin (Rx only), Naprosyn, Voltaren, Voltaren XR ), Voltaren topical gel Topical anesthetics lidocaine 5% ointment and 2% gel, Synera Emla ZTlido Lidoderm 5 P a g e

6 Drug Class: Dermatology (cont.) Topical antibacterials Centany, Bactroban Nasal Bactroban ointment Topical antifungals Jublia, Kerydin, Onmel Penlac, Sporanox, Lamisil, GrisPeg Topical antineoplastic agents and immunomodulators Carac (HMO only), fluorouracil 0.5% cream (HMO only) Tolak Drug Class: Diagnostic and other miscellaneous Chelating agents Cuprimine Depen Drug Class: Endocrinology Corticosteroids Insulins Dxevo, Hidex, LoCort, TaperDex, ZoDex, ZonaCort Admelog, Apidra, Apidra Solostar, Humulin (all forms except U-500), Humulin Mix, Humalog (except Junior Kwikpen), Humalog Mix Decadron, DexPak, DexPak Jr. Novolin ; 70/30 vial, Novolog, Novolog Mix 6 P a g e

7 Drug Class: Endocrinology (cont.) Byetta, Bydureon (all forms) Ozempic, Trulicity, Victoza Glumetza Glucophage, Glucophage XR alogliptin, Onglyza, Nesina Januvia, Tradjenta Non-insulin hypoglycemic agents alogliptin/metformin, Kazano, Kombiglyze metformin (Glucophage /XR) plus a DPP-4 inhibitor (Januvia, Tradjenta ); Janumet /XR, Jentadueto /XR alogliptin/pioglitazone, Oseni Steglujan a DPP-4 inhibitor (Januvia, Tradjenta ) plus pioglitazone (Actos ) a DPP-4 inhibitor (Januvia, Tradjenta ), plus a SGLT-2 inhibitor (Farxiga, Invokana, Jardiance ); Glyxambi, Qtern, Drug Class: Gastrointestinal Antidiarrheals and antispasmodics Donnatal (HMO only), Donnatal Extentabs (HMO only) Brand name drugs for the following products (HMO only): hyoscyamine sulfate (such as Levbid, Levsin ) Bentyl, Levbid, Levsin, Librax Generic products are covered (please refer to full Custom Drug List for complete list of covered products) 7 P a g e

8 Drug Class: Gastrointestinal (cont.) Proton Pump Inhibitors (PPIs) Topical anti-inflammatory agents Ulcer therapy All PPIs (HMO only) Zegerid Brand name drugs for the following products (HMO only): hydrocortisone acetate (such as Proctosol /-HC suppository) hydrocortisone/pramoxine (such as Analpram -HC cream, Pramosone cream) lidocaine/hydrocortisone (Anamantle HC) Glycate (glycopyrrolate.5mg) over-the-counter PPIs (such as Prilosec OTC, Prevacid OTC ) over-the-counter Zegerid OTC Generic products are covered (please refer to full Custom Drug List for complete list of covered products) Robinul, Robinul Forte (glycopyrrolate mg, 2mg) Miscellaneous gastrointestinal agents Relistor injection, Trulance Amitiza, Glycolax, lactulose, Linzess Drug Class: Obstetrics and gynecology Infertility treatment Vaginal anti-infective and antifungal ganirelix acetate (single-source brand only) Solosec generic ganirelix acetate, Cetrotide Cleocin vaginal cream, Flagyl, Metrogel -Vaginal 8 P a g e

9 Drug Class: Ophthalmology Ophthalmic anti- inflammatory agents Bromsite Acular, Bromday, Voltaren, Xibrom Drug Class: Otic and nasal preparations Nasal preparations All nasal steroids (HMO only) over-the-counter nasal steroids (such as Flonase OTC, Nasacort Allergy 24 HR, Nasonex OTC ) Xhance Astelin, Flonase Otic preparations Cetraxal (single-source brand only) ciprofloxacin 0.2% dropperette Drug Class: Respiratory, cough and cold Antihistamines All non-sedating antihistamines (HMO only) Ryvent, Ryclora over-the-counter non-sedating antihistamines (such as Claritin OTC, Zyrtec OTC) Atarax, Benadryl (Rx only), Claritin, Histex PD, Tavist, Vistaril, Xyzal, Zyrtec Antitussives hydrocodone-guaifenesin solution Hycodan Epinephrine Auvi-Q, EpiPen, EpiPen Jr epinephrine 0.5mg and 0.3mg auto-injector Inhaled beta-agonists albuterol sulfate HFA ProAir HFA, Ventolin HFA Inhaled steroids Alvesco Arnuity Ellipta, Flovent HFA, Flovent Diskus, Pulmicort Flexhaler, Pulmicort solution, Qvar Redihaler 9 P a g e

10 Drug Class: Respiratory, cough and cold (cont.) Inhaled steroid and beta agonist combinations Drug Class: Urology AirDuo Respiclick Advair HFA, Breo Ellipta, Dulera, fluticasone propionate/salmeterol, Symbicort Urinary antispasmodics Oxytrol Detrol, Detrol LA, Ditropan, Ditropan XL, Enablex, Sanctura, Sanctura XR Drug Class: Vitamins and supplements Potassium replacement Vitamins and minerals Brand name drugs for the following products (HMO only): potassium chloride (such as Klor-Con, KLyte, K-Sol, Micro-K, K-Dur ) Brand name drugs for the following products (HMO only): Oral dental products (such as Prevident ) Generic products are covered (please refer to full Custom Drug List for complete list of covered products) Generic products are covered (please refer to full Custom Drug List for complete list of covered products) 0 P a g e