Therapeutic Class Not Covered Examples of alternative options Analgesics - Anti-Inflammatory Nonsteroidal Anti-Inflammatory Agents (NSAIDS)

Transcription

1 Date last updated: 3/23/18 Your benefit plan does not cover all drugs. Your benefit plan excludes coverage for drugs with one or more principal ingredients that are already available in greater/lesser strengths and / or combinations. Your plan also excludes drugs that only modify the dosage form (tablet, capsule, liquid, suspension, extended release, tamper resistant) for a drug that is already available in a common dosage form. The table below lists drugs that are not covered for one of these reasons. The drugs listed in the Not Covered column are excluded under your plan. If you use them, you will have to pay the full cost of the drug. BCBSAZ may update and add to this list at any time. For each excluded drug, we have also listed some alternatives. Any alternatives are subject to normal plan-requirements such as medical necessity. Alternatives are also subject to member cost share requirements such as copayments or coinsurance. Some alternatives may not be covered due to other plan limitations - for example, because the alternative is available over-the counter. If you are currently taking, or have been prescribed, one of these non-covered drugs, talk to your prescriber about whether one of the alternatives would work for you. Be sure to review the Pharmacy Benefit section for Benefit-Specific Exclusions and What is Not Covered in your benefit book for general exclusions and limitations that apply to all benefits. To check coverage and copay information for a medication under your plan, visit azblue.com and log in to BlueNet. If you do not have access to the website, call the Pharmacy Benefits number on the back of your member ID card. Analgesics - Anti-Inflammatory Nonsteroidal Anti-Inflammatory Agents (NSAIDS) DUEXIS (ibuprofen-famotidine) tablet mg ibuprofen tablet 800mg plus famotodine tablet 20mg NAPRELAN CR (naproxen sodium er) tablet naproxen DR or EC tablet 375mg 24-hour 375mg naproxen sodium tablet 375mg CR naproxen DR or EC tablet 375mg NAPRELAN CR (naproxen sodium er) tablet naproxen DR or EC tablet 500mg 24-hour 500mg naproxen sodium tablet 500mg CR naproxen DR or EC tablet 500mg NAPRELAN CR (naproxen sodium er) tablet naproxen DR or EC tablet 375mg or 500mg 24-hour 750mg SPRIX (ketorolac tromethamine) nasal spray ketorolac tablet 10mg 15.75mg/spray VIMOVO (naproxen-esomeprazole magnesium) tablet DR mg naproxen DR or EC tablet 375mg plus esomeprazole magnesium tablet 20mg VIMOVO (naproxen-esomeprazole magnesium) tablet DR mg naproxen DR or EC tablet 500mg plus esomeprazole magnesium DR capsule 20mg VIVLODEX (meloxicam) capsule 5mg meloxicam tablet 7.5mg or 15mg VIVLODEX (meloxicam) capsule 10mg meloxicam tablet 7.5mg or 15mg ZIPSOR (diclofenac potassium) capsule 25mg diclofenac potassium tablet 50mg or diclofenac sodium tablet DR 50mg ZORVOLEX (diclofenac) capsule 18mg diclofenac potassium tablet 50mg or diclofenac sodium tablet DR 50mg ZORVOLEX (diclofenac) capsule 35mg diclofenac potassium tablet 50mg or diclofenac sodium tablet DR 50mg Analgesics - Nonnarcotic Analgesic Combinations BUPAP (butalbital-acetaminophen) tablet 50- butalbital-acetaminophen tablet mg 300mg butalbital/acetaminophen 50mg-300mg butalbital-acetaminophen tablet mg * Effective dates for contract exclusions will vary by plan, and are usually tied to the plan renewal date. If you are currently receiving benefit coverage for any of the non-covered drugs, you will receive a benefit change notice before these exclusions become effective for your plan. D /17 Page 1

2 VANATOL LQ (butalbital-acetaminophencaffeine) solution mg/15ml butalbital-acetaminophen-caffeine tablet mg VANATOL S (butalbital-acetaminophencaffeine) solution mg/15ml butalbital-acetaminophen-caffeine tablet mg Analgesics Opioid Opioid Combinations Opioid Agonists Antianginal Agents Nitrates Antidepressants Miscellaneous Selective Serotonin Reuptake Inhibitors (SSRIs) FIORICET/CODEINE (butalbitalacetaminophen-caffeine-codeine) capsule mg butalbital-acetaminophen-caffeine-codeine capsule mg ACETAMINOPHEN/CAFFEINE/ DIHYDROCODEINE BITARTRATE tablet mg ARYMO ER (morphine sulfate) tablet abusedeterrent 15mg ARYMO ER (morphine sulfate) tablet abusedeterrent 30mg ARYMO ER (morphine sulfate) tablet abusedeterrent 60mg MORPHABOND ER (morphine sulfate) tablet ER 12-hour deterrent 15mg MORPHABOND ER (morphine sulfate) tablet ER 12-hour deterrent 30mg MORPHABOND ER (morphine sulfate) tablet ER 12-hour deterrent 60mg MORPHABOND ER (morphine sulfate) tablet ER 12-hour deterrent 100mg CONZIP (tramadol hcl er) capsule 24-hour biphasic release 100mg CONZIP (tramadol hcl er) capsule 24-hour biphasic release 200mg CONZIP (tramadol hcl er) capsule 24-hour biphasic release 300mg TRAMADOL HCL ER capsule biphasic release 100mg TRAMADOL HCL ER capsule biphasic release 150mg TRAMADOL HCL ER capsule biphasic release 200mg TRAMADOL HCL ER capsule biphasic release 300mg GONITRO (nitroglycerin) sublingual powder packet 400mcg APLENZIN (bupropion HBR) tablet ER 24-hour 174mg APLENZIN (bupropion HBR) tablet ER 24-hour 348mg APLENZIN (bupropion HBR) tablet ER 24-hour 522mg FLUOXETINE tablet 60mg FLUOXETINE DR capsule 90mg butalbital-acetaminophen-caffeine-codeine capsule mg butalbital-acetaminophen-caffeine-codeine capsule mg apap/codeine tablet mg morphine sulfate tablet CR 15mg morphine sulfate capsule er 24-hour 30mg or morphine sulfate tablet CR 30mg morphine sulfate capsule er 24-hour 60mg or morphine sulfate tablet CR 60mg morphine sulfate tablet CR 15mg morphine sulfate capsule er 24-hour 30mg or morphine sulfate tablet CR 30mg morphine sulfate capsule er 24-hour 60mg or morphine sulfate tablet CR 60mg morphine sulfate capsule er 24-hour 100mg or morphine sulfate tablet CR 100mg 100mg 200mg 300mg 100mg 100mg or 200mg 200mg 300mg nitroglycerin sublingual tablet 0.4mg bupropion hcl tablet er 24-hour 150mg bupropion hcl tablet er 24-hour 300 mg bupropion hcl tablet er 24-hour 150mg plus bupropion hcl tablet er 24-hour 300 mg fluoxetine capsule 20mg x 3/day or fluoxetine tablet 20mg x 3/day fluoxetine capsule 20mg daily or fluoxetine tablet 20mg daily D /17 Page 2

3 PROZAC WEEKLY (fluoxetine hcl dr) capsule 90mg fluoxetine capsule 20mg daily or fluoxetine tablet 20mg daily PEXEVA (paroxetine mesylate) tablet 10mg paroxetine hcl tablet 10mg PEXEVA (paroxetine mesylate) tablet 20mg paroxetine hcl tablet 20mg PEXEVA (paroxetine mesylate) tablet 30mg paroxetine hcl tablet 30mg PEXEVA (paroxetine mesylate) tablet 40mg paroxetine hcl tablet 40mg Antidiabetics Antidiabetic Combinations PRANDIMET (repaglinide-metformin hcl) tablet 1-500mg repaglinide tablet 1mg plus metformin tablet 500mg PRANDIMET (repaglinide-metformin hcl) tablet 2-500mg repaglinide tablet 2mg plus metformin tablet 500mg REPAGLINIDE (repaglinide-metformin hcl) tablet 1-500mg repaglinide tablet 1mg plus metformin tablet 500mg REPAGLINIDE (repaglinide-metformin hcl) tablet 2-500mg repaglinide tablet 2mg plus metformin tablet 500mg Antihistamines Ethanolamines RYVENT (carbinoxamine maleate) tablet 6mg carbinoxamine maleate tablet 4mg Antihyperlipidemics HMG COA Reductase Inhibitors FLOLIPID (simvastatin) suspension 20mg/5ml simvastatin tablet 20mg FLOLIPID (simvastatin) suspension 40mg/5ml simvastatin tablet 40mg Miscellaneous triklo (omega-3-acid ethyl esters) capsule 1gm omega-3-acid capsule 1gm Antihypertensives Antihypertensive Combinations DUTOPROL (metoprolol-hydrochlorothiazide) tablet ER 24-hour mg metoprolol tablet er 25mg plus hydrochlorothiazide tablet 12.5mg Antiparkinson Agents Monoamine Oxidase Inhibitors DUTOPROL (metoprolol-hydrochlorothiazide) tablet ER 24-hour mg DUTOPROL (metoprolol-hydrochlorothiazide) tablet ER 24-hour mg METOPROLOL SUCCINATE ER/ HYDROCHLOROTHIAZIDE tablet ER 24-hour mg METOPROLOL SUCCINATE ER/ HYDROCHLOROTHIAZIDE tablet ER 24-hour mg METOPROLOL SUCCINATE ER/ HYDROCHLOROTHIAZIDE tablet ER 24-hour mg PRESTALIA (perindopril arginine-amlodipine besylate) tablet mg PRESTALIA (perindopril arginine-amlodipine besylate) tablet 7-5mg PRESTALIA (perindopril arginine-amlodipine besylate) tablet 14-10mg ZELAPAR (selegiline hcl) orally disintegrating tablet 1.25mg Beta Blockers Non-Selective INDERAL LA (propranolol hcl) capsule SR 24- hour 60mg INDERAL LA (propranolol hcl) capsule SR 24- hour 80mg INDERAL LA (propranolol hcl) capsule SR 24- hour 120mg INDERAL LA (propranolol hcl) capsule SR 24- hour 160mg metoprolol tablet er 50mg plus hydrochlorothiazide tablet 12.5mg metoprolol tablet er 100mg plus hydrochlorothiazide tablet 12.5mg metoprolol tablet er 25mg plus hydrochlorothiazide tablet 12.5mg metoprolol tablet er 50mg plus hydrochlorothiazide tablet 12.5mg metoprolol tablet er 100mg plus hydrochlorothiazide tablet 12.5mg perindopril erbumine tablet 2mg, 4mg, or 8mg plus amlodipine besylate tablet 2.5mg perindopril erbumine tablet 2mg, 4mg, or 8mg plus amlodipine besylate tablet 5mg perindopril erbumine tablet 2mg, 4mg, or 8mg plus amlodipine besylate tablet 10mg selegiline hcl capsule 5mg or selegiline hcl tablet 5mg propranolol hcl capsule SR 24-hour 60mg propranolol hcl capsule SR 24-hour 80mg propranolol hcl capsule SR 24-hour 120mg propranolol hcl capsule SR 24-hour 160mg D /17 Page 3

4 INDERAL XL (propranolol hcl) beads capsule propranolol hcl capsule SR 24-hour 80mg SR 24-hour 80mg INDERAL XL (propranolol hcl) beads capsule propranolol hcl capsule SR 24-hour 120mg SR 24-hour 120mg Innopran XL (propranolol hcl) beads capsule propranolol hcl capsule SR 24-hour 80mg SR 24-hour 80mg Innopran XL (propranolol hcl) beads capsule propranolol hcl capsule SR 24-hour 120mg SR 24-hour 120mg Cardiovascular Agents Cardiovascular Combinations calcium) tablet mg amlodipine besylate tablet 2.5mg plus atorvastatin calcium tablet 10mg calcium) tablet mg amlodipine besylate tablet 2.5mg plus atorvastatin calcium tablet 20mg calcium) tablet mg amlodipine besylate tablet 2.5mg plus atorvastatin calcium tablet 40mg calcium) tablet 5-10 mg atorvastatin calcium tablet 10mg calcium) tablet 5-20 mg atorvastatin calcium tablet 20mg calcium) tablet 5-40 mg atorvastatin calcium tablet 40mg calcium) tablet 5-80 mg atorvastatin calcium tablet 80mg calcium) tablet mg atorvastatin calcium tablet 10mg calcium) tablet mg atorvastatin calcium tablet 20mg calcium) tablet mg atorvastatin calcium tablet 40mg calcium) tablet mg atorvastatin calcium tablet 80mg mg amlodipine besylate tablet 2.5mg plus atorvastatin calcium tablet 10mg mg amlodipine besylate tablet 2.5mg plus atorvastatin calcium tablet 20mg mg amlodipine besylate tablet 2.5mg plus atorvastatin calcium tablet 40mg 5-10 mg atorvastatin calcium tablet 10mg 5-20 mg atorvastatin calcium tablet 20mg 5-40 mg atorvastatin calcium tablet 40mg 5-80 mg atorvastatin calcium tablet 80mg mg atorvastatin calcium tablet 10mg mg atorvastatin calcium tablet 20mg Corticosteroids Glucocorticosteroids mg mg RAYOS (prednisone) tablet delayed release 1mg atorvastatin calcium tablet 40mg atorvastatin calcium tablet 80mg prednisone tablet 1mg D /17 Page 4

5 RAYOS (prednisone) tablet delayed release 2mg prednisone tablet 1mg or prednisone tablet 2.5mg RAYOS (prednisone) tablet delayed release prednisone tablet 5mg 5mg Cough/Cold/Allergy Antitussives benzonatate capsule 150mg benzonatate capsule 100mg or benzonatate capsule 200mg ZONATUSS capsule 150mg benzonatate capsule 100mg or benzonatate capsule 200mg Combinations TUSSICAPS (hydrocod polst-chlorphen polst er) capsule 12-hour 5-4mg hydrocodone polistirex/chlorpheniramine polistirex er suspension 10-8mg/5ml TUSSICAPS (hydrocod polst-chlorphen polst hydrocodone polistirex/chlorpheniramine Dermatologicals Acne Products er) capsule 12-hour 10-8mg TUZISTRA XR (codeine polist-chlorphen polist er) suspension mg/5ml polistirex er suspension 10-8mg/5ml LEXUSS 210 (chlorpheniramine w/ codeine) liquid 2-10 mg/5ml ABSORICA (Isotretinoin Caps) 10mg, 20mg, 25mg. 30mg, 35mg, 40mg Amnesteem, Claravis, Isotretinoin, Myorisan or Zenatane ACANYA (clindamycin phosphate-benzoyl peroxide) gel % clindamycin phosphate gel 1% and benzoyl peroxide gel 2.5% ADAPALENE gel 0.3% adapalene gel 0.1% ADAPALENE lotion 0.1% adapalene gel 0.1% adapalene-benzoyl peroxide gel % adapalene gel 0.1% and benzoyl peroxide gel 2.5% AKTIPAK (benzoyl peroxide-erythromycin) gel pack 5-3% benzoyl peroxide gel 5% (OTC) and erythromycin gel ATRALIN (tretinoin) gel 0.05% tretinoin gel 0.05% avita (tretinoin) cream 0.025% tretinoin cream 0.025% avita (tretinoin) gel 0.025% tretinoin gel 0.025% BENZACLIN (clindamycin phosphate-benzoyl peroxide) gel 1-5% clindamycin phosphate gel 1% and benzoyl peroxide gel 5% CLEOCIN-T (clindamycin phosphate) gel 1% clindamycin phosphate gel 1% CLEOCIN-T (clindamycin phosphate) lotion 1% clindamycin phosphate lotion 1% CLEOCIN-T (clindamycin phosphate) solution clindamycin phosphate soln 1% 1% CLEOCIN-T (clindamycin phosphate) swab 1% clindamycin phosphate swab 1% CLINDAGEL (clindamycin phosphate) gel 1% clindamycin phosphate gel 1% clindamycin phosphate-tretinoin gel % clindamycin phosphate gel 1% and tretinoin gel 0.25% DIFFERIN (adapalene) cream 0.1% adapalene cream 0.1% DIFFERIN (adapalene) gel 0.1% adapalene gel 0.1% DIFFERIN (adapalene) gel 0.3% adapalene gel 0.1% DIFFERIN (adapalene) lotion 0.1% adapalene gel 0.1% DUAC (clindamycin phosphate-benzoyl peroxide) gel 1.2 (1)-5% clindamycin phosphate gel 1% and benzoyl peroxide gel 5% EPIDUO (adapalene-benzoyl peroxide) gel % adapalene gel 0.1% and benzoyl peroxide gel 2.5% EPIDUO FORTE (adapalene-benzoyl peroxide) gel % adapalene gel 0.3% and benzoyl peroxide gel 2.5% EVOCLIN (clindamycin phosphate) foam 1% clindamycin phosphate foam 1% KLARON (sulfacetamide sodium) lotion 10% sulfacetamide sodium lotion 10% (acne) NEUAC (clindamycin phosphate-benzoyl peroxide) gel 1.2 (1)-5% clindamycin phosphate gel 1% and benzoyl peroxide gel 5% ONEXTON (clindamycin phosphate-benzoyl peroxide) gel % clindamycin phosphate gel 1% and benzoyl peroxide gel 5% D /17 Page 5

6 PLEXION (sulfacetamide sodium w/ sulfur) sulfacetamide sodium lotion 10% (acne) cleansing cloth % PLEXION (sulfacetamide sodium w/ sulfur) sulfacetamide sodium lotion 10% (acne) liquid cleanser % PLEXION (sulfacetamide sodium w/ sulfur) sulfacetamide sodium lotion 10% (acne) cream % PLEXION (sulfacetamide sodium w/ sulfur) sulfacetamide sodium lotion 10% (acne) lotion % RETIN-A (tretinoin) cream 0.025% tretinoin cream 0.025% RETIN-A (tretinoin) cream 0.05% tretinoin cream 0.05% RETIN-A (tretinoin) cream 0.1% tretinoin cream 0.1% RETIN-A (tretinoin) gel 0.025% tretinoin gel 0.025% RETIN-A (tretinoin) gel 0.1% tretinoin gel 0.1% RETIN-A MICRO (tretinoin) microsphere gel tretinoin gel 0.04% 0.04% RETIN-A MICRO (tretinoin) microsphere gel tretinoin gel 0.1% 0.1% RETIN-A MICRO PUMP (tretinoin) microsphere tretinoin gel 0.025%, 0.04%, 0.05%, 0.1% gel 0.08% ROSULA (sulfacetamide sodium w/ sulfur) sulfacetamide sodium lotion 10% (acne) cleansing cloth 10-5% ROSULA (sulfacetamide sodium w/ sulfur) sulfacetamide sodium lotion 10% (acne) wash % sodium sulfacetamide w/ sulfur cleansing cloth sulfacetamide sodium lotion 10% (acne) 10-5% sodium sulfacetamide/sulfur cleansing pad 10-4% zencia (sulfacetamide sodium w/ sulfur) 9-4% liquid wash sodium sulfacetamide/sulfur liquid wash 9-4% zencia (sulfacetamide sodium w/ sulfur) 9-4% liquid wash sodium sulfacetamide/sulfur suspension 8-4% sodium sulfacetamide/sulfur wash 9-4.5% sulfacetamide sodium w/ sulfur cream % sulfacetamide sodium lotion 10% (acne) sulfacetamide sodium w/ sulfur liquid cleanser sulfacetamide sodium lotion 10% (acne) % sulfacetamide sodium w/ sulfur lotion % sulfacetamide sodium lotion 10% (acne) sulfacleanse suspension 8-4% sodium sulfacetamide/sulfur wash 9-4.5% SUMADAN WASH (sulfacetamide sodium w/ sodium sulfacetamide/sulfur wash 9-4.5% sulfur) wash 9-4.5% SUMAXIN (sulfacetamide sodium w/ sulfur) cleansing pad 10-4% zencia (sulfacetamide sodium w/ sulfur) 9-4% liquid wash SUMAXIN (sulfacetamide sodium w/ sulfur) liquid wash 9-4% zencia (sulfacetamide sodium w/ sulfur) 9-4% liquid wash SUMAXIN TS (sulfacetamide sodium w/ sulfur) sodium sulfacetamide/sulfur wash 9-4.5% suspension 8-4% TRETIN-X (tretinoin) cream % tretinoin cream 0.05% TRETIN-X (tretinoin) cream 0.075% tretinoin cream 0.1% VELTIN (clindamycin phosphate-tretinoin) gel % clindamycin phosphate gel 1% and tretinoin gel 0.25% ZIANA (clindamycin phosphate-tretinoin) gel % clindamycin phosphate gel 1% and tretinoin gel 0.25% Antibiotics Topical NEO-SYNALAR (neomycin sulfate-fluocinolone acetonide) cream % neomycin-bacitracin-polymyxin ointment with fluocinonide ointment 0.05% EXTINA (ketoconazole) foam 2% ketoconazole cream 2% or ketoconazole shampoo 2% ketoconazole aerosol foam 2% ketoconazole cream 2% or ketoconazole shampoo 2% D /17 Page 6

7 ketodan (ketoconazole) foam 2% ketoconazole cream 2% or ketoconazole shampoo 2% LUZU (luliconazole) cream CLOTRIMAZOLE CREAM 1% XOLEGEL (ketoconazole) gel 2% ketoconazole cream 2% or ketoconazole shampoo 2% Anti-Inflammatory Agents - PENNSAID (diclofenac sodium) solution 2% diclofenac sodium solution 1.5% Topical Corticosteroids - Topical DESOWEN (desonide) cream 0.05% desonide cream 0.05% ENSTILAR (calcipotriene-betamethasone dipropionate) foam % calcipotriene cream 0.005% with betamethasone dipropionate cream 0.05% fluocinonide cream 0.1% fluocinonide cream 0.05% hc butyrate (hydrocortisone butyrate hydrophilic lipo base) cream 0.1% hydrocortisone butyrate solution 0.1% or hydrocortisone butyrate cream 0.1% LOCOID LIPOCREAM (hydrocortisone butyrate hydrophilic lipo base) cream 0.1% hydrocortisone butyrate solution 0.1% or hydrocortisone butyrate cream 0.1% TRIDESILON (desonide) cream 0.05% desonide cream 0.05% VANOS (fluocinonide) cream 0.1% fluocinonide cream 0.05% Local Anesthetics - Topical SYNERA (lidocaine-tetracaine) topical patch lidocaine-prilocaine cream % 70-70mg Rosacea Agents DOXYCYCLINE capsule 40 mg DR 40mg doxycycline hyclate tablet 20mg METROCREAM (metronidazole) cream 0.75% metronidazole cream 0.75% METROGEL (metronidazole) gel 1% metronidazole gel 1% Diuretics Potassium Sparing Diuretics METROLOTION (metronidazole) lotion 0.75% metronidazole lotion 0.75% ORACEA (doxycycline) capsule DR 40mg doxycycline hyclate tablet 20mg CAROSPIR (spironolactone) oral suspension 25mg/5ml spironolactone tablet 25mg Endocrine and Metabolic Bone Density Regulators ATELVIA (risedronate sodium) tablet DR 35mg alendronate sodium tablet 70mg BINOSTO (alendronate sodium effervescent) alendronate sodium tablet 70mg tablet 70mg risedronate sodium tablet delayed release alendronate sodium tablet 70mg 35mg FOSAMAX + D (alendronate sodiumcholecalciferol) tablet mg-unit alendronate sodium tablet 70mg plus VITAMIN D-3 (cholecalciferol) tablet 2000unit FOSAMAX + D (alendronate sodiumcholecalciferol) tablet mg-unit alendronate sodium tablet 70mg plus VITAMIN D-3 (cholecalciferol) tablet 5000unit Hematologicals Platelet Aggregation Inhibitors YOSPRALA (aspirin-omeprazole) tablet DR mg YOSPRALA (aspirin-omeprazole) tablet DR 81-40mg aspirin tablet delayed release 325mg plus omeprazole capsule delayed release 40mg aspirin tablet delayed release 81mg plus omeprazole capsule delayed release 40mg Hematopoietic Agents Agents For Sickle Cell Anemia ENDARI (glutamine) powder pack 5 gm glutamine powder packet (OTC), glutamine capsule 500mg (OTC), or L-glutamine tablet 500mg (OTC) Hypnotics/Sedatives/Sleep Disorder Non-Barbiturate Hypnotics EDLUAR (zolpidem tartrate) sublingual tablet 10mg EDLUAR (zolpidem tartrate) sublingual tablet 5mg INTERMEZZO (zolpidem tartrate) sublingual tablet 1.75mg INTERMEZZO (zolpidem tartrate) sublingual tablet 3.5mg zolpidem tartrate tablet 10mg zolpidem tartrate tablet 5mg zolpidem tartrate tablet 5mg zolpidem tartrate tablet 5mg D /17 Page 7

8 zolpidem tartrate sublingual tablet 1.75mg zolpidem tartrate tablet 5mg zolpidem tartrate sublingual tablet 3.5mg zolpidem tartrate tablet 5mg ZOLPIMIST (zolpidem tartrate) oral spray zolpidem tartrate tablet 5mg 5mg/ACT 5mg Migraine Products Serotonin Agonists TREXIMET (sumatriptan-naproxen sodium) tablet 10-60mg sumatriptan succinate tablet 25mg plus naproxen tablet 250mg TREXIMET (sumatriptan-naproxen sodium) tablet mg sumatriptan succinate tablet 50mg or 100mg plus naproxen tablet 500mg SUMATRIPTAN-NAPROXEN SODIUM (sumatriptan-naproxen sodium) tablet mg sumatriptan succinate tablet 50mg or 100mg plus naproxen tablet 500mg CAMBIA (diclofenac potassium) packet 50mg diclofenac potassium tablet 50mg ONZETRA XSAIL (sumatriptan succinate) sumatriptan succinate tablet 25mg exhaler powder 11mg SUMAVEL DOSEPRO (sumatriptan succinate) sumatriptan succinate injection 4mg/0.5ml solution jet-injector 4mg/0.5ml SUMAVEL DOSEPRO (sumatriptan succinate) sumatriptan succinate injection 6mg/0.5ml solution jet-injector 6mg/0.5ml ZEMBRACE SYMTOUCH (sumatriptan succinate) solution auto-injector 3/0.5ml Musculoskeletal Therapy Central Muscle Relaxants AMRIX (cyclobenzaprine hcl) capsule ER 24- hour 15mg Nasal Agents Systemic and Topical, Nasal Steroids AMRIX (cyclobenzaprine hcl) capsule ER 24- hour 30mg CARISOPRODOL tablet 250mg CHLORZOXAZONE tablet 250mg cyclobenzaprine hcl tablet 7.5mg SOMA (CARISOPRODOL) tablet 250mg tizanidine capsule 2mg tizanidine capsule 4mg tizanidine capsule 6mg XHANCE (fluticasone propionate) nasal exhaler suspension 93 mcg/act Ophthalmic Agents Beta-Blockers BETIMOL (timolol) ophthalmic solution 0.25% (hemihydrate) BETIMOL (timolol) ophthalmic solution 0.5% (hemihydrate) sumatriptan succinate injection 4mg/0.5ml cyclobenzaprine hcl tablet 5mg or 10mg cyclobenzaprine hcl tablet 5mg or 10mg carisoprodol tablet 350mg chlorzoxazone tablet 500mg cyclobenzaprine hcl tablet 5mg or 10mg carisoprodol tablet 350mg tizanidine tablet 2mg tizanidine tablet 4mg tizanidine tablet 2mg plus 4mg Flonase Allergy Relief (fluticasone propionate) nasal suspension 50 mcg/act (OTC) or GoodSense NasoFlow (fluticasone propionate) nasal suspension 50 mcg/act (OTC) timolol maleate ophthalmic solution 0.25% timolol maleate ophthalmic solution 0.5% Psychotherapeutic and Neurological Postherpetic Neuralgia (PHN) GRALISE (gabapentin) tablet 300mg gabapentin capsule 300mg Restless Leg Syndrome (RLS) Vasomotor Symptom Tetracyclines GRALISE (gabapentin) tablet 600mg GRALISE (gabapentin) tablet pack 300mg (9) & 600mg (69) HORIZANT (gabapentin enacarbil) tablet CR 300mg HORIZANT (gabapentin enacarbil) tablet CR 600mg BRISDELLE (paroxetine mesylate) capsule 7.5mg paroxetine mesylate capsule 7.5mg gabapentin tablet 600mg gabapentin capsule 300mg plus gabapentin tablet 600mg gabapentin capsule 300mg gabapentin tablet 600mg paroxetine tablet 10mg paroxetine tablet 10mg D /17 Page 8

9 Tetracyclines ACTICLATE (doxycycline hyclate) tablet 150mg doxycycline hyclate capsule 50mg plus doxycycline hyclate capsule 100mg ACTICLATE (doxycycline hyclate) tablet 75mg doxycycline hyclate capsule 50mg ADOXA (doxycycline monohydrate) capsule 150mg doxycycline monohydrate tablet 75mg ADOXA (doxycycline monohydrate) tablet 100mg doxycycline monohydrate tablet 100mg ADOXA (doxycycline monohydrate) tablet 50mg doxycycline monohydrate tablet 50mg ADOXA (doxycycline monohydrate) tablet 75mg doxycycline monohydrate tablet 75mg ADOXA PAK 1/100 (doxycycline monohydrate) doxycycline monohydrate tablet 100mg tablet 100mg ADOXA PAK 1/150 (doxycycline monohydrate) doxycycline monohydrate tablet 75mg tablet 150mg ADOXA PAK 2/100 (doxycycline monohydrate) doxycycline monohydrate tablet 100mg tablet 100mg DORYX (doxycycline hyclate) tablet DR 200mg doxycycline hyclate dr tablet 100mg DORYX (doxycycline hyclate) tablet DR 50mg doxycycline hyclate capsule 50mg DORYX MPC ( doxycycline hyclate) tablet DR doxycycline hyclate dr tablet 100mg 120mg doxycycline hyclate tablet 75mg doxycycline hyclate capsule 50mg doxycycline hyclate tablet DR 200mg doxycycline hyclate dr tablet 100mg doxycycline hyclate tablet DR 50mg doxycycline hyclate capsule 50mg doxycycline hyclate) tablet 150mg doxycycline hyclate capsule 50mg plus doxycycline hyclate capsule 100mg doxycycline monohydrate capsule 150mg doxycycline monohydrate tablet 75mg MINOCYCLINE HCL ER tablet 135mg MINOCYCLINE HCL ER tablet 45mg MINOCYCLINE HCL ER tablet 90mg Coremino tab 135mg (minocycline HCL ER tablet) Coremino tab 45mg (minocycline HCL ER tablet) Coremino tab 90 mg (minocycline HCL ER tablet) XIMINO (minocycline) extended-release capsule 45mg XIMINO (minocycline) extended-release capsule 90mg XIMINO (minocycline) extended-release capsule 135mg Ulcer Proton Pump Inhibitors ACIPHEX (rabeprazole sodium) tablet EC 20mg rabeprazole sodium tablet EC 20mg ACIPHEX SPRINKLE (rabeprazole sodium) capsule DR 10mg rabeprazole sodium tablet EC 20mg D /17 Page 9

10 ACIPHEX SPRINKLE (rabeprazole sodium) rabeprazole sodium tablet EC 20mg capsule DR 5mg ESOMEPRAZOLE STRONTIUM capsule DR Nexium 24HR capsule 20mg (OTC) 24.65mg ESOMEPRAZOLE STRONTIUM capsule DR Nexium 24HR capsule 20mg (OTC) 49.3mg LANSOPRAZOLE tablet dispersible (Solutab) DR lansoprazole capsule delayed release 15mg 15mg LANSOPRAZOLE tablet dispersible (Solutab) DR lansoprazole capsule delayed release 30mg 30mg NEXIUM (esomeprazole magnesium) capsule Nexium 24HR capsule 20mg (OTC) DR 20mg NEXIUM (esomeprazole magnesium) Nexium 24HR capsule 20mg (OTC) suspension DR 2.5mg NEXIUM (esomeprazole magnesium) capsule Nexium 24HR capsule 20mg (OTC) DR 40mg NEXIUM (esomeprazole magnesium) suspension Nexium 24HR capsule 20mg (OTC) DR 10mg NEXIUM (esomeprazole magnesium) suspension Nexium 24HR capsule 20mg (OTC) DR 20mg NEXIUM (esomeprazole magnesium) suspension Nexium 24HR capsule 20mg (OTC) DR 40mg NEXIUM (esomeprazole magnesium) suspension Nexium 24HR capsule 20mg (OTC) DR 5mg PREVACID (lansoprazole) capsule DR 15mg lansoprazole capsule delayed release 15mg PREVACID (lansoprazole) capsule DR 30mg lansoprazole capsule delayed release 30mg PREVACID (lansoprazole) tablet Solutab lansoprazole capsule delayed release 15mg (dispersible) DR 15mg PREVACID (lansoprazole) tablet Solutab lansoprazole capsule delayed release 30mg (dispersible) DR 30mg PRILOSEC (omeprazole magnesium) omeprazole capsule delayed release 10mg suspension packet DR 10mg PRILOSEC (omeprazole magnesium) omeprazole capsule delayed release 10mg suspension packet DR 2.5mg PRILOSEC (omeprazole) capsule DR 10mg omeprazole capsule delayed release 10mg PRILOSEC (omeprazole) capsule DR 20mg omeprazole capsule delayed release 20mg PRILOSEC (omeprazole) capsule DR 40mg omeprazole capsule delayed release 40mg PROTONIX (pantoprazole sodium) EC tablet pantoprazole sodium EC tablet 20mg 20mg PROTONIX (pantoprazole sodium) EC tablet pantoprazole sodium EC tablet 40mg 40mg PROTONIX (pantoprazole sodium) suspension pantoprazole sodium EC tablet 40mg packet DR 40mg Ulcer Therapy Combinations lansopr/amox mis /clarith therapy pack lansoprazole capsule delayed release 30mg, amoxicillin (trihydrate) cap 500mg, plus clarithromycin 500 mg tablets omeprazole-sodium bicarbonate capsule 20- omeprazole capsule delayed release 20mg 1100mg omeprazole-sodium bicarbonate capsule 40- omeprazole capsule delayed release 40mg 1100mg omeprazole-sodium bicarbonate powder pack for omeprazole capsule delayed release 20mg suspension mg omeprazole-sodium bicarbonate powder pack for suspension mg omeprazole capsule delayed release 40mg D /17 Page 10

11 Urinary Antispasmodics Antimuscarinics (Anticholinergic) PREVPAC (amoxicillin capsule, clarithromycin tablet, lansoprazole capsule DR) therapy pack PYLERA (bismuth subcit-metronidazoletetracycline) capsule mg ZEGERID (omeprazole-sodium bicarbonate) capsule mg ZEGERID (omeprazole-sodium bicarbonate) capsule mg ZEGERID (omeprazole-sodium bicarbonate) powder pack for suspension mg ZEGERID (omeprazole-sodium bicarbonate) powder pack for suspension mg DETROL (tolterodine tartrate) tablet 1mg DETROL (tolterodine tartrate) tablet 2mg DETROL LA (tolterodine tartrate) capsule SR 2mg DETROL LA (tolterodine tartrate) capsule SR 4mg DITROPAN XL (oxybutynin chloride) tablet SR 10mg DITROPAN XL (oxybutynin chloride) tablet SR 15mg DITROPAN XL (oxybutynin chloride) tablet SR 5mg GELNIQUE (oxybutynin) gel 10% 1mg box GELNIQUE (oxybutynin) gel 10% 30mg pump GELNIQUE (oxybutynin) gel 3% pump tolterodine tartrate capsule SR 2mg tolterodine tartrate capsule SR 4mg lansoprazole capsule delayed release 30mg, amoxicillin (trihydrate) cap 500mg, plus clarithromycin 500 mg tablets bismuth chew 262mg (OTC), metronidazole tablet 250mg, plus tetracycline capsule 250mg omeprazole capsule delayed release 20mg omeprazole capsule delayed release 40mg omeprazole capsule delayed release 20mg omeprazole capsule delayed release 40mg tolterodine tartrate tablet 1mg tolterodine tartrate tablet 2mg tolterodine tartrate tablet 2mg tolterodine tartrate tablet 2mg oxybutynin tablet 10mg er oxybutynin tablet 15mg er oxybutynin tablet 5mg er oxybutynin chloride tablet 5mg oxybutynin chloride tablet 5mg oxybutynin chloride tablet 5mg tolterodine tartrate tablet 2mg tolterodine tartrate tablet 2mg D /17 Page 11

12 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 for Spanish and 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 , , TTY/TDD , crc@azblue.com. You can file a grievance in person or by mail or . 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 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, , (TDD). Complaint forms are available at

13 Multi-language Interpreter Services