Prior Review and Quantity Limitations

Prior Review and Certification

The following programs apply for members with Blue Care^SM, Blue Options^SM, Blue Choice^SM, Blue Advantage^SM, Blue Value^SM and Blue Select^SM.

Prior Review

Some medications require prior review from BCBSNC before the prescription can be accepted for payment.
Prior review requires that your physician contact BCBSNC at 1-800-672-7897 or fax a request form to 1-800-795-9403.

Restricted-Access Drugs

For the non-preferred prescription drugs listed below, BCBSNC requires that the member has tried a preferred drug or device. Coverage for these prescription drugs may be provided without the use of a preferred drug or device if the provider certifies in writing that the member has previously used a preferred drug or device and the preferred drug or device has been detrimental to the member's health or has been ineffective in treating the same condition and, in the opinion of the provider, is likely to be detrimental to the member's health or ineffective in treating the condition in the future.

Quantity Limitations

BCBSNC covers certain medications up to a set quantity. Quantity limitations are designed to ensure medications are used according to FDA regulations and help identify excessive use of drugs.
If a physician feels it is medically necessary to exceed quantity limitations on your medication, he must get prior review from BCBSNC at 1-800-672-7897 before a higher quantity will be covered.

Enhanced Formulary (Open)

The Enhanced Formulary (4-tier) is an open formulary, meaning that nearly all commercially available prescription drugs are covered. Benefit exclusions apply.

Basic Formulary (Closed)

The Basic Formulary (5-tier) is a closed formulary that covers only the drugs that are specifically listed on the formulary. Benefit exclusions apply.
If a provider recommends a drug that is not on the Basic Formulary, ask your doctor if there are any appropriate alternative medications available on the Basic Formulary.
In certain circumstances, your doctor may be able to request a drug not on the Basic Formulary through an exception process. See below for the criteria and appropriate fax form.
Please note if the requested drug is listed below, than the additional criteria would also apply (Restricted Access / Step Therapy does not apply to the Basic Formulary).

*Specialty pharmacy drugs indicated by "S"
*Nonformulary drugs are indicated by "NF"

A
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Abstral®	Transmucosal Fentanyl Citrate	x	NF	x		Abstral®	x	x			Abstral®
Aciphex®	Rabeprazole	x	NF	x		Preferred drug must be tried			x	Omeprazole, Pantoprazole, Lansoprazole, Omeprazole/sodium bicarbonate, Nexium	Aciphex®
Actemra®	Tocilizumab				s	Actemra®	x	x	x	Enbrel, Humira	Actemra®
Acthar® H.P. Gel	Repository Corticotropin	x	NF	s	s	Acthar® H.P. Gel	x		x	Corticosteroid	Standard Fax Form
Actiq®	Transmucosal Fentanyl Citrate	x	x	x		Actiq®	x	x			Actiq®
Actonel®	Risedronate	x	NF	x		Preferred drug must be tried			x	Alendronate ± vit D, Ibandronate	Actonel®
Adcirca®	Tadalafil	x	NF	s		Adcirca®	x				Adcirca®
Adderall® / Adderall® XR	amphetamine/dextroamphetamine (ER)	x	x	x		Adderall® / Adderall® XR		x			Adderall® / Adderall® XR
Adoxa®	doxycycline monohydrate	x	x	x		Adoxa®			x	Doxycycline	Adoxa®
Advicor®	Lovastatin/Niacin	x	NF	x		Advicor®	x		x	Atorvastatin, Lovastatin, Pravastatin, Simvastatin	Advicor®
AlodoxTM	doxycycline hyclate	x	NF	x		AlodoxTM			x	Doxycycline	AlodoxTM
AlsumaTM	Sumatriptan	x	NF	x		AlsumaTM		x	x	Sumatriptan, Naratriptan, Maxalt/MLT, Relpax, Sumavel	AlsumaTM
Amerge®	Naratriptan	x	x	x		Amerge®		x			Amerge®
Ampyra®	Dalfampridine	x	x	s		Ampyra®	x				Ampyra®
AmturnideTM	Aliskiren/amlodipine/ HCTZ	x	NF	x		Preferred drug must be tried			x	Losartan, Eprosartan, Diovan, Micardis, Exforge	AmturnideTM
Anadrol-50®	Oxymetholone	x	NF	x		Anadrol-50®	x				Anadrol-50®
Androderm®	Testosterone, topical	x	x	x		Androderm®	x				Androderm®
AndroGel®	Testosterone, topical	x	x	x		AndroGel®	x				AndroGel®
Android®	Methyltestosterone	x	x	x		Android®	x				Android®
Androxy®	Fluoxymesterone	x	NF	x		Androxy®	x				Androxy®
Atacand®	Candesartan or Candesartan HCTZ	x	NF	x		Preferred drug must be tried			x	Losartan, Eprosartan, Diovan, Micardis, Exforge	Atacand®
Atelvia®	Risedronate Sodium	x	NF	x		Preferred drug must be tried			x	Alendronate ± vit D, Ibandronate	Atelvia®
Atralin®	Tretinoin	x	NF	x		Atralin®	x		x	Generic Tretinoin	Atralin®
AubagioTM	Teriflunomide	x	NF	s		AubagioTM	x				AubagioTM
AvidoxyTM DK	doxycycline monohydrate	x	x	x		AvidoxyTMDK			x	Doxycycline	AvidoxyTMDK
Avita®	Tretinoin	x	x	x		Avita®	x		x	Generic Tretinoin	Avita®
Avonex®	Interferon Beta-1a	x	NF	s		Avonex®	x		x	Rebif, Betaseron	Avonex®
Axert®	Almotriptan	x	NF	x		Axert®		x	x	Sumatriptan, Naratriptan, Maxalt/MLT, Relpax, Sumavel	Axert®
Axiron®	Testosterone, topical	x	NF	x		Axiron®	x		x	Androderm, Androgel	Axiron®
B
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Beconase AQ®	Beclomethasone	x	NF	x		Preferred drug must be tried			x	Flunisolide, Fluticasone, Nasonex, Triamcinolone	Beconase AQ®
Benicar® or Benicar HCT®	Olmesartan or Olmesartan/HCTZ	x	NF	x		Preferred drug must be tried			x	Losartan, Eprosartan, Diovan, Micardis, Exforge	Benicar® or Benicar HCT®
Benlysta®	Belimumab				s	Benlysta®	x				Benlysta®
Berinert®	C1 Esterase Inhibitor, Human				s	Berinert®	x				Standard Fax Form
Betaseron®	Interferon Beta-1b	x	x	s		Betaseron®	x			Rebif, Betaseron	Betaseron®
Binosto	Alendronate Sodium	x	NF	x		Preferred drug must be tried			x	Alendronate ± vit D, Ibandronate	Binosto
Bio-T-GelTM		x	NF	x		Bio-T-GelTM	x		x		Bio-T-GelTM
Botox	OnabotulinumtoxinA				s	Botox	x				Call 1-800-672-7897 for prior review
C
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
CambiaTM	Diclofenac Potassium	x	NF	x		CambiaTM	x	x	x		CambiaTM
Carimune®	IVIG				s	Carimune®	x				Call 1-800-672-7897 for prior review
Celebrex®	Celecoxib	x	x	x		Celebrex®	x				Celebrex®
Cialis® (5mg tablets)	Tadalafil (5mg tablets)	x	NF	x		Cialis®	x	x			Cialis®
Cimzia®	Certolizumab	x	NF	s		Cimzia®	x	x	x	Enbrel, Humira	Cimzia®
Cinryze®	C1 Esterase Inhibitor, Human				s	Cinryze®	x				Standard Fax Form
Compound Drugs	Compound Drugs	x	x	x		Compound Drugs	x				Compound Drugs
Concerta®	methylphenidate ER	x	x	x		Concerta®		x			Concerta®
Copaxone®	Glatiramer acetate	x	x	s		Copaxone®	x				Copaxone®
Crestor® (5mg, 10mg, 20mg strengths)	Rosuvastatin (5mg, 10mg, 20mg strengths)	x	x	x		Crestor®	x		x	Atorvastatin, Lovastatin, Pravastatin, Simvastatin	Crestor®
D
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Daytrana®	methylphenidate transdermal patch	x	NF	x		Daytrana®		x			Daytrana®
Delatestryl®	Testosterone enanthate	x	x			Delatestryl®	x				Delatestryl®
Depo-Testosterone®	Testosterone cypionate	x	x			Depo-Testosterone®	x				Depo-Testosterone®
Desoxyn®	methamphetamine	x	NF	x		Desoxyn®		x			Desoxyn®
Dexedrine®	dextroamphetamine ER	x	x	x		Dexedrine®		x			Dexedrine®
DexilantTM (KapidexTM)	Dexlansoprazole	x	NF	x		Preferred drug must be tried			x	Omeprazole, Pantoprazole, Lansoprazole, Omeprazole/sodium bicarbonate, Nexium	DexilantTM
DextroStat®	dextroampthetamine	x	NF	x		DextroStat®		x			DextroStat®
Differin®	Adapalene	x	x	x		Differin®	x		x	Generic Adapalene	Differin®
DificidTM	Fidaxomicin	x	x	x		DificidTM	x	x	x	Vancomycin	DificidTM
Doryx®	Doxycycline Hyclate	x	NF	x		Preferred drug must be tried			x	Generic Doxycycline	Doryx®
Duexis®	Famotidine/ Ibuprofen	x	NF	x		Duexis®	x				Duexis®
DymistaTM	Azelastine HCl	x	NF	x		Preferred drug must be tried			x	Flunisolide, Fluticasone, Nasonex, Triamcinolone	DymistaTM
Dynacin®	Minocycline	x	x	x		Dynacin®			x	Minocycline	Dynacin®
Dysport®	AbobotulinumtoxinA				s	Dysport®	x				Call 1-800-672-7897 for prior review
E
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Edarbi®	Azilsartan	x	NF	x		Preferred drug must be tried			x	Losartan, Eprosartan, Diovan, Micardis, Exforge	Edarbi®
Edarbyclor®	Azilsartan/Chlorthalidone	x	NF	x		Preferred drug must be tried			x	Losartan, Eprosartan, Diovan, Micardis, Exforge	Edarbyclor®
Edluar®	Zolpidem	x	NF	x		Preferred drug must be tried			x	Zolpidem, Zaleplon	Edluar®
Egrifta®	Tesamorelin	x	NF	s		Egrifta®	x				Egrifta®
Enbrel®	Etanercept	x	x	s		Enbrel®	x	x		Enbrel, Humira	Enbrel®
Epiduo®	Adapalene/ Benzoyl peroxide	x	NF	x		Epiduo®	x		x	Generic Adapalene	Epiduo®
Exforge®	valsartan/amlodipine	x	NF	x		Exforge®			x	Candesartan/HCTZ, Diovan, Eprosartan, Irbesartan Losartan,Valsartan	Exforge®
Exforge® HCT	valsartan/amlodipine/hydrochlorothiazide	x	NF	x		Exforge® HCT			x	Candesartan/HCTZ, Diovan, Eprosartan, Irbesartan Losartan,Valsartan	Exforge® HCT
Extavia®	Interferon Beta-1b	x	NF	s		Extavia®	x		x	Rebif, Betaseron	Extavia®
F
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Fabior®	Tazarotene foam	x	NF	x		Fabior®	x		x	Generic Tretinoin	Fabior®
Fentora®	Transmucosal Fentanyl Citrate	x	NF	x		Fentora®	x	x			Fentora®
Firazyr®	Icatibant Inj	x	x	s	S -effective 7/1/13	Firazyr®	x				Standard Fax Form
Flebogamma®, Flegogamma® DIF	IVIG				s	Flebogamma®	x				Call 1-800-672-7897 for prior review
Flector Patch®	Diclofenac epolamine	x	NF	x		Flector Patch®	x				Flector Patch®
Flolan®	Epoprostenol injection				s	Flolan®	x				Flolan®
Focalin®	dexmethylphenidate	x	x	x		Focalin®		x			Focalin®
Focalin® XR	dexmethylphenidate ER	x	NF	x		Focalin® XR		x			Focalin®XR
Forteo®	Teriparatide	x	x	s		Forteo®	x		x	Bisphosphonates	Forteo®
Fortesta®	Testosterone, topical	x	NF	x		Fortesta®	x		x	Androderm, Androgel	Fortesta®
Frova®	Frovatriptan	x	NF	x		Frova®		x	x	Sumatriptan, Naratriptan, Maxalt/MLT, Relpax, Sumavel	Frova®
G
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Gammagard® Liquid, Gammagard® S/D	IVIG				s	Gammagard®	x				Call 1-800-672-7897 for prior review
Gammaplex®	IVIG				s	Gammaplex®	x				Call 1-800-672-7897 for prior review
Gamunex®, Gamunex®-C	IVIG				s	Gamunex®	x				Call 1-800-672-7897 for prior review
Genotropin®	Somatropin (Growth Hormone)	x	NF	s		Genotropin®	x		x	Omnitrope	Genotropin®
Gilenya®	Fingolimod	x	x	s		Gilenya®	x				Gilenya®
Glucose Test Strips	Abbott (e.g. FreeStyle), Roche (e.g. Accu-Chek) and others	x	x	x		Glucose Test Strips	x		x	Bayer (e.g. Contour) and Lifescan (e.g. OneTouch) test strips	Glucose Test Strips
H
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Hizentra®	SCIG				s	Hizentra®	x				Call 1-800-672-7897 for prior review
Humatrope®	Somatropin (Growth Hormone)	x	NF	s		Humatrope®	x		x	Omnitrope	Humatrope®
Humira®	Adalimumab Injection	x	x	s		Humira®	x	x		Enbrel, Humira	Humira®
I
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Imitrex®	sumatriptan	x	x	x		Imitrex®		x			Imitrex®
Incivek®	Telaprevir	x	x	s		Incivek®	x				Incivek®
IncrelexTM	Mecasermin (Insulin-like Growth Factor)				s	IncrelexTM	x				Call 1-800-672-7897 for prior review
Intermezzo®	Zolpidem SL	x	NF	x		Preferred drug must be tried			x	Zolpidem, Zaleplon	Intermezzo®
Intuniv®	guanfacine ER	x	NF	x		Intuniv®		x			Intuniv®
K
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Kalbitor®	Ecallantide				s	Kalbitor®	x				Standard Fax Form
KalydecoTM	Ivacaftor	x	NF	s		KalydecoTM	x				KalydecoTM
Kapvay®	clonidine ER	x	NF	x		Kapvay®		x			Kapvay®
KineretTM	Anakinra Injection	x	NF	s		KineretTM	x				KineretTM
KorlymTM	Mifepristone	x	NF	s		KorlymTM	x				KorlymTM
L
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Lansoprazole Powder	(for pharmacy compounding only)	x	NF	x		Preferred drug must be tried			x	Omeprazole, Pantoprazole, Lansoprazole, Omeprazole/sodium bicarbonate, Nexium	Lansoprazole Powder
Lazanda®	Transmucosal Fentanyl Citrate	x	NF	x		Lazanda®	x	x			Lazanda®
Lescol XL®	Fluvastatin	x	NF	x		Lescol XL®	x		x	Atorvastatin, Lovastatin, Pravastatin, Simvastatin	Lescol XL®
Letairis®	Ambrisentan	x	NF	s		Letairis®	x				Letairis®
Lidoderm®	Lidocaine patch	x	x	x		Lidoderm®	x	x			Lidoderm®
Lipitor® (Brand ONLY)	atorvastatin	x	x	x		Lipitor®	Applicable under Enhanced Formulary, not Basic Formulary		x	Atorvastatin, Lovastatin, Pravastatin, Simvastatin	Lipitor®
Liptruzet	atorvastatin/ezetimibe	x	NF	x		Liptruzet	x		x	Atorvastatin, Lovastatin, Pravastatin, Simvastatin	Liptruzet
Livalo®	pitavastatin	x	NF	x		Livalo®	x		x	Atorvastatin, Lovastatin, Pravastatin, Simvastatin	Livalo®
Lunesta®	Eszopiclone	x	NF	x		Preferred drug must be tried			x	Zolpidem, Zaleplon	Lunesta®
Luvox CR®	Fluvoxamine	x	NF	x		Preferred drug must be tried			x	Citalopram, Fluoxetine, Sertraline, Fluvoxamine, Paroxetine	Luvox CR®
M
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Maxalt®/Maxalt MLT®	Rizatriptan	x	NF	x		Maxalt®		x			Maxalt®
Metadate® CD / Metadate® ER	methylphenidate ER	x	x	x		Metadate® CD / Metadate® ER		x			Metadate® CD / Metadate® ER
Methitest®	Methyltestosterone	x	NF	x		Methitest®	x				Methitest®
Methylin® / Methylin® ER	methylphenidate (ER)	x	x	x		Methylin® / Methylin® ER		x			Methylin® / Methylin® ER
Micardis®	telmisartan	x	NF	x		Micardis®			x	Candesartan/HCTZ, Diovan, Eprosartan, Irbesartan Losartan,Valsartan	Micardis®
Micardis® HCT	telmisartan/hydrochlorothiazide	x	NF	x		Micardis® HCT			x	Candesartan/HCTZ, Diovan, Eprosartan, Irbesartan Losartan,Valsartan	Micardis®HCT
Minocin®	minocycline	x	x	x		Minocin®			x	Minocycline	Minocin®
Minocin® Kit	minocycline	x	x	x		Minocin® Kit			x	Minocycline	Minocin®Kit
Monodox®	doxycycline monohydrate	x	x	x		Monodox®			x	Doxycycline	Monodox®
Morgidox® Kit	doxycycline hyclate	x	NF	x		Morgidox® Kit			x	Doxycycline	Morgidox®Kit
Myobloc®	RimabotulinumtoxinB				s	Myobloc®	x				Call 1-800-672-7897 for prior review
N
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Norditropin®	Somatropin (Growth Hormone)	x	NF	s		Norditropin®	x		x	Omnitrope	Norditropin®
NutridoxTM Kit	doxycycline hyclate	x	NF	x		NutridoxTM Kit			x	Doxycycline	Nutridox®Kit
Nutropin®	Somatropin (Growth Hormone)	x	NF	s		Nutropin®	x		x	Omnitrope	Nutropin®
Nutropin AQ®	Somatropin (Growth Hormone)	x	NF	s		Nutropin AQ®	x		x	Omnitrope	Nutropin AQ®
Nuvigil®	Armodafinil	x	NF	x		Provigil - Nuvigil	x	x			Nuvigil®
O
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Octagam®	IVIG				s	Octagam®	x				Call 1-800-672-7897 for prior review
Ocudox® Kit	doxycycline hyclate	x	NF	x		Ocudox® Kit			x	Doxycycline	Ocudox®Kit
Omnaris®	Ciclesonide	x	NF	x		Preferred drug must be tried			x	Flunisolide, Fluticasone, Nasonex, Triamcinolone	Omnaris®
Omnitrope® (Somatropin)	Somatropin (Growth Hormone)	x	x	s		Omnitrope®	x			Omnitrope	Omnitrope®
Onmel®	Itraconazole	x	NF	x		Onmel®	x				Onmel®
Onsolis®	Transmucosal Fentanyl Citrate	x	NF	x		Onsolis®	x	x			Onsolis®
Oracea®	doxycycline monohydrate delayed-release	x	NF	x		Oracea®			x	Doxycycline	Oracea®
Oraxyl®	doxycycline hyclate	x	NF	x		Oraxyl®			x	Doxycycline	Oraxyl®
Orencia®	Abatacept	x	NF (SubQ Injection)	S(SubQ Injection)	S (IV)	Orencia®	x	x			Orencia®
Oxandrin®	Oxandrolone	x	x	x		Oxandrin®	x				Oxandrin®
OxyContin®	oxycodone ER	x	x	x		OxyContin®		x			OxyContin®
P
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Pegasys®	Peginterferon	x	x	s		Pegasys®	x				Pegasys®
Peg-Intron®	Peginterferon	x	NF	s		Peg-Intron®	x				Peg-Intron®
Pennsaid®	Diclofenac sodium topical solution	x	NF	x		Pennsaid®	x				Pennsaid®
Pexeva®	Paroxetine	x	NF	x		Preferred drug must be tried	x		x	Citalopram, Fluoxetine, Sertraline, Fluvoxamine, Paroxetine	Pexeva®
Pomalyst®	Pomalidomide	x	NF	s		Pomalyst®	x				Pomalyst®
Prevacid® Powder	Lansoprazole Powder	x	NF	x		Preferred drug must be tried			x	Omeprazole, Pantoprazole, Lansoprazole, Omeprazole/sodium bicarbonate, Nexium	Prevacid® Powder
Prevacid® Solutabs	Lansoprazole solutabs	x	NF	x		Preferred drug must be tried			x	Omeprazole, Pantoprazole, Lansoprazole, Omeprazole/sodium bicarbonate, Nexium	Prevacid® Solutabs
Prilosec® for oral suspension	Omeprazole for oral suspension	x	NF	x		Preferred drug must be tried			x	Omeprazole, Pantoprazole, Lansoprazole, Omeprazole/sodium bicarbonate, Nexium	Prilosec®
Pristiq®	Desvenlafaxine	x	NF	x		Preferred drug must be tried	x		x	Citalopram, Fluoxetine, Sertraline, Fluvoxamine, Paroxetine	Pristiq®
Privigen®	IVIG				s	Privigen®	x				Call 1-800-672-7897 for prior review
Procentra®	dextroamphetamine	x	NF	x		Procentra®		x			Procentra®
Prolia®	Denosumab				s	Prolia®	x				Prolia®
Protonix® suspension	Pantoprazole suspension	x	NF	x		Preferred drug must be tried			x	Omeprazole, Pantoprazole, Lansoprazole, Omeprazole/sodium bicarbonate, Nexium	Protonix® suspension
Provenge®	Sipuleucel-T				x	Provenge®	x				Call 1-800-672-7897 for prior review
Provigil®	Modafinil	x	x	x		Provigil - Nuvigil	x	x			Provigil®
Q
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
QnaslTM	Beclomethasone	x	NF	x		Preferred drug must be tried			x	Flunisolide, Fluticasone, Nasonex, Triamcinolone	QnaslTM
QsymiaTM	Phentermine/Topiramate ER	x	NF	x		Weightloss	x				Weightloss
Quillivant XRTM	Methylphenidate HCl	x	NF	x		Quillivant XRTM		x			Quillivant XRTM
Qutenza®	Capsaicin Patch				s	Qutenza®	x	x			Qutenza®
R
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Rebif®	Interferon Beta-1a	x	x	s		Rebif®	x		x	Rebif, Betaseron	Rebif®
Relpax®	Eletriptan	x	NF	x		Relpax®		x			Relpax®
Remicade®	Infliximab				s	Remicade®	x	x			Remicade®
Remodulin®	Treprostinil injection				s	Remodulin®	x				Remodulin®
Restasis®	Cyclosporine Opthalmic	x	NF	x		Restasis®	x				Restasis®
Retin-A®	Tretinoin	x	x	x		Retin-A®	x		x	Generic Tretinoin	Retin-A®
Revatio®	Sildenafil	x	x	s		Revatio®	x				Revatio®
Revlimid®	Lenalidomide	x	x	s		Revlimid®	x				Revlimid®
Rhinocort Aqua®	Budesonide	x	NF	x		Preferred drug must be tried			x	Flunisolide, Fluticasone, Nasonex, Triamcinolone	Rhinocort Aqua®
Ritalin® / Ritalin® LA / Ritalin® SR	methylphenidate (ER)	x	x	x		Ritalin® / Ritalin® LA / Ritalin® SR		x			Ritalin® / Ritalin® LA / Ritalin® SR
Rituxan® (RA ONLY)	Rituximab				s	Rituxan®	x				Rituxan®
Rozerem®	Ramelteon	x	NF	x		Preferred drug must be tried			x	Zolpidem, Zaleplon	Rozerem®
S
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Saizen®	Somatropin (Growth Hormone)	x	NF	s		Saizen®	x		x	Omnitrope	Saizen®
Serostim®	Somatropin (Growth Hormone)	x	NF	s		Serostim®	x		x	Omnitrope	Serostim®
Silenor®	Doxepin	x	NF	x		Preferred drug must be tried			x	Zolpidem, Zaleplon	Silenor®
Simcor®	Simvastatin/Niacin	x	NF	x		Simcor®	x		x	Atorvastatin, Lovastatin, Pravastatin, Simvastatin	Simcor®
Simponi®	Golimumab	x	NF	s		Simponi®	x	x	x	Enbrel, Humira	Simponi®
Solodyn®	Minocycline	x	NF	x		Preferred drug must be tried			x	Generic Minocycline	Solodyn®
Sporanox®	Itraconazole	x	x	x		Sporanox®	x				Sporanox®
Strattera®	atomoxetine	x	NF	x		Strattera®		x			Strattera®
Stelara®	Ustekinumab				s	Stelara®	x	x			Stelara®
Striant®	Testosterone, buccal	x	NF	x		Striant®	x				Striant®
Suboxone®, Films	Buprenorphine / Naloxone	x	x	x		Suboxone®	x	x	x	Suboxone SL films	Suboxone®
Suboxone®, Tablets	Buprenorphine / Naloxone	x	x	x		Suboxone®	x	x	x	Suboxone SL films	Suboxone®
Subutex®	Buprenorphine	x	x	x		Subutex®	x	x			Subutex®
Subsys®	Transmucosal Fentanyl Citrate	x	NF	x		Subsys®	x	x			Subsys®
Sumavel DosePro®	Sumatriptan	x	NF	x		Sumavel DosePro®		x			Sumavel DosePro®
Synagis®	Palivizumab				s	Synagis®	x	x			Synagis®
T
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Tazorac®	Tazarotene	x	x	x		Tazorac®	x		x	Generic Tretinoin	Tazorac®
Tecfidera	Dimethyl Fumarate	x	x	x		Tecfidera	x				Tecfidera
TekamloTM	Aliskiren/ amlodipine	x	NF	x		Preferred drug must be tried			x	Losartan, Eprosartan, Diovan, Micardis, Exforge	TekamloTM
Tekturna® or Tekturna HCT®	Aliskiren/ HCTZ	x	NF	x		Preferred drug must be tried			x	Losartan, Eprosartan, Diovan, Micardis, Exforge	Tekturna®
Testim®	Testosterone, topical	x	NF	x		Testim®	x		x	Androderm, Androgel	Testim®
Testred®	Methyltestosterone	x	x	x		Testred®	x				Testred®
Teveten® or Teveten HCT®	Eprosartan	x	NF	x		Preferred drug must be tried			x	Losartan, Eprosartan, Diovan, Micardis, Exforge	Teveten®
Tev-Tropin®	Somatropin (Growth Hormone)	x	NF	s		Tev-Tropin®	x		x	Omnitrope	Tev-Tropin®
Thalomid®	Thalidomide	x	x	s		Thalomid®	x				Thalomid®
Tracleer®	Bosentan	x	x	s		Tracleer®	x				Tracleer®
Tretinoin (Powder)	Tretinoin	x	NF	x		Tretinoin (Powder)	x		x	Generic Tretinoin	Tretinoin (Powder)
Tretinoin emollient	Tretinoin emollient	x	x	x		Tretinoin emollient	x		x	Generic Tretinoin	Tretinoin emollient
Tretin-X®	Tretinoin	x	NF	x		Tretin-X®	x		x	Generic Tretinoin	Tretin-X®
Treximet®	Sumatriptan/Naprosyn	x	NF	x		Treximet®		x	x	Sumatriptan, Naratriptan, Maxalt/MLT, Relpax, Sumavel	Treximet®
Tribenzor®	olmesartan/amlodipine/hydrochlorothiazide	x	NF	x		Tribenzor®			x	Candesartan/HCTZ, Diovan, Eprosartan, Irbesartan Losartan,Valsartan	Tribenzor®
Twynsta®	olmesartan/amlodipine	x	NF	x		Twynsta®			x	Candesartan/HCTZ, Diovan, Eprosartan, Irbesartan Losartan,Valsartan	Twynsta®
Tysabri®	Natalizumab				s	Tysabri®	x				Tysabri®
Tyvaso®	Treprostinil inhaled				s	Tyvaso®	x				Tyvaso®
V
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Valturna®	Aliskiren/ valsartan	x	NF	x		Preferred drug must be tried			x	Losartan, Eprosartan, Diovan, Micardis, Exforge	Valturna®
Veletri®	Epoprostenol injection				s	Veletri®	x				Veletri®
Veltin®	Tretinoin	x	NF			Veltin®	x		x	Generic Tretinoin	Veltin®
Ventavis®	Iloprost inhalation				s	Ventavis®	x				Ventavis®
Veramyst®	Fluticasone	x	NF	x		Preferred drug must be tried			x	Flunisolide, Fluticasone, Nasonex, Triamcinolone	Veramyst®
Vibramycin® cap	doxycycline hyclate	x	x	x		Vibramycin® cap			x	Doxycycline	Vibramycin® cap
Vibramycin® susp, syr	doxycycline monohydrate / calcium	x	NF	x		Vibramycin® susp, syr			x	Doxycycline	Vibramycin® susp, syr
Victrelis®	Boceprevir	x	x	s		Victrelis®	x				Victrelis®
Vimovo®	esomeprazole/naproxen	x	NF	x		Vimovo®	x				Vimovo®
Vivaglobin®	IVIG				s	Vivaglobin®	x				Call 1-800-672-7897 for prior review
Voltaren Gel®	Diclofenac sodium	x	NF	x		Voltaren Gel®	x				Voltaren Gel®
Vytorin®	simvastatin/ ezetimibe	x	NF	x		Vytorin®	x		x	Atorvastatin, Lovastatin, Pravastatin, Simvastatin	Vytorin®
Vyvanse®	lisdexamphetamine	x	x	x		Vyvanse®		x			Vyvanse®
X
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Xeljanz®	Tofacitinib	x	NF	x		Xeljanz® Xeljanz® -effective 7/1/13	x	x			Xeljanz®
Xeomin®	IncobotulinumtoxinA				s	Xeomin®	x				Call 1-800-672-7897 for prior review
Xgeva®	Denosumab				s	Xgeva®	x				Xgeva®
Xiaflex®	Collagenase clostridium histolyticum				s	Xiaflex®	x				Call 1-800-672-7897 for prior review
Xolair®	Omalizumab				s	Xolair®	x				Xolair®
Xyrem®	Sodium oxybate	x	x	s		Xyrem®	x				Xyrem®
Y
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Yervoy®	Ipilimumab				s	Yervoy®	x				Call 1-800-672-7897 for prior review
Z
Brand Drug Name	Generic Drug Name	Enhanced Formulary	Basic Formulary	Pharmacy Benefit	Medical Benefit	Criteria	Prior Review	Quantity Limits	Restricted Access / Step Therapy	Preferred Drug(s)	Fax Form
Zegerid®	omeprazole/ sodium bicarbonate	x	NF	x		Preferred drug must be tried			x	Omeprazole, Pantoprazole, Lansoprazole, Omeprazole/sodium bicarbonate, Nexium	Zegerid®
Zelboraf®	Vemurafenib	x	x	s		Zelboraf®	x				Zelboraf®
ZetonnaTM	Ciclesonide Inh	x	NF	x		Preferred drug must be tried			x	Flunisolide, Fluticasone, Nasonex, Triamcinolone	ZetonnaTM
Ziana®	Tretinoin	x	NF	x		Ziana®	x		x	Generic Tretinoin	Ziana®
Zolpimist®	Zolpidem spray	x	NF	x		Preferred drug must be tried			x	Zolpidem, Zaleplon	Zolpimist®
Zomig® or Zomig ZMT®	Zolmitriptan	x	NF	x		Zomig®		x	x	Sumatriptan, Naratriptan, Maxalt/MLT, Relpax, Sumavel	Zomig®
Zorbitive®	Somatropin (Growth Hormone)	x	NF	s		Zorbitive®	x		x	Omnitrope	Zorbitive®

Benefit Limits

If you are unsure whether your group is an underwritten or self funded/ASO group, call the customer service number listed on the back of your ID card for assistance.