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Prior Review and Quantity Limitations


Prior Review and Certification

The following programs apply for members with Blue CareSM, Blue OptionsSM, Blue ChoiceSM, Blue AdvantageSM, Blue ValueSM and Blue SelectSM.

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).

Non-Formulary Exception Criteria Non-Formulary Exception Fax Form
(PLEASE NOTE: THIS FAX FORM IS ONLY TO BE USED FOR DRUGS THAT ARE NOT ON THE BASIC FORMULARY; SEE THE BELOW TABLE TO DETERMINE IF A DRUG IS NONFORMULARY)

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

*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

Drug Type Benefit Limit
Hypnotics ("sleeping pills," e.g., Ambien®, Lunesta®, Sonata®, Zolpidem, Intermezzo) Underwritten groups: No limit
Individual & family plans:20 tablets or capsules per 30 days
Self funded / ASO groups: Covered with no limit or not covered
Infertility Drugs $5,000 per benefit period (usually a calendar year)
Sexual Dysfunction Drugs (e.g., Cialis®, Viagra®, Caverject®) 4 tablets or units per 30 days
Smoking Cessation Drugs Underwritten groups:  No limit
Individual & family plans: 1 treatment episode per year, 2 treatment episodes per lifetime
Self funded / ASO groups: Typically either covered with no limit or not covered; call customer service to confirm

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.

 

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