BlueShield of Northeastern New York Formulary 2
Transcription
BlueShield of Northeastern New York Formulary 2
BlueShield of Northeastern New York Formulary 2 Please bring this guide with you the next time you visit your doctor. If you have questions about your prescription drug benefit, visit the Pharmacy Services section of the BlueShield web site at www.bsneny.com. * M G 4 6 6 0 2 S* MG46602S (Revise Date 07/01/2016) A Division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. The Shield is a registered trademark of the BlueCross BlueShield Association. 183894_MG46602S -BCBS NENY - INSURED_v1.indd 1 6/1/16 12:54 PM 183894_MG46602S -BCBS NENY - INSURED_v1.indd 1 6/1/16 12:54 PM TABLE OF CONTENTS Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understanding the symbols used throughout this book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using iii iii this formulary book to help contain costs . iv Save Money on Your Prescription Drugs. . . . . . . . . . . . . . . . . iv Finding Medications in the Guide . . . . . . . . . . . . . . . . . . . . . . . iv Section 1 — Therapeutic Drug Categories . . . . . . . . . . 1 Section II — Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 ii 183894_MG46602S -BCBS NENY - INSURED_v1.indd 2 6/1/16 12:54 PM The BlueShield of Northeastern New York Formulary 2 is a list of drugs to help guide physicians and pharmacists to select the medication that provides the appropriate treatment for the best price. Introduction Blue Shield of Northeastern New York has established an independent committee of practicing physicians and a pharmacist to help ensure that our formularies are medically sound and that they support your patients’ health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories. Understanding the symbols used throughout this book Throughout this book, you will see certain symbols that indicate a management program is in place for selected medications. The symbols are as follows: Key P= step edit applies to this drug. Step therapy means that in order to receive the medication A with a step edit, a preferred medication must be tried first. z = Specific quantity limits apply. Quantity limits are in place to ensure members receive the appropriate amount of medication not to exceed the maximum allowable daily dosage of medication. = Prior authorization required. Prior authorization (also referred to as coverage review) means that a healthcare professional must submit clinical documentation to obtain approval for a member to receive the medication. Prior authorizations ensure medications are being used appropriately. = Included in tablet-splitting program. The medication can be cut in half to obtain the daily u dose of medication (i.e., 20mg daily of simvastatin can be obtained by 1/2 tablet of simvastatin 40mg). A member will receive a 1-month supply for half their regular 1-month copay. + = Access restricted to specialty pharmacy. Medications must be obtained through a specialty pharmacy. o=Customer Home Delivery. The medication should be obtained through the mail service pharmacy. The medication is subject to a retail refill allowance. iii 183894_MG46602S -BCBS NENY - INSURED_v1.indd 3 6/1/16 12:54 PM Using this formulary book to help contain costs Many employers, benefit sponsors, and individuals may use the formulary to help manage the overall cost of providing prescription drug benefits. The formulary offers a wide range of outpatient medications. Because there are over 40,000 Food and Drug Administration (FDA)-approved prescription drugs on the market, not all tier 3 drugs can be listed in this formulary guide. We have included in this printed formulary guide the drugs that are most commonly prescribed for our members. If you have any questions regarding coverage of a drug, please call the customer service number on your card. Save Money on Your Prescription Drugs Here’s what you can do to save money: 1. Bring this member guide to your doctor and review the cost-saving information below. 2. Ask your doctor whether a drug listed in this guide is right for you.* Tier 1 Tier 2 Tier 3 Lowest cost to you Highest cost to you The amount you pay for a drug is determined by which medication you purchase and to what tier it is assigned. Some drug plans exclude certain drugs or classes of drugs from coverage. Please check your contract or other plan documents if you have a question about your specific drug coverage. Please refer to your plan documents to confirm your cost share for diabetic drugs and supplies. Cost share may vary by plan. Customer Home Delivery: Members must obtain maintenance medications at mail-order after retail allowance is exhausted for members with Customer Home Delivery Benefit. Finding Medications in the Guide This guide lists medications two different ways: Section 1:Alphabetically by drug category (such as Diabetes, Heart or Pain/Arthritis) Locate a category and drug on the guide and you will see the tier and copayment for that drug—Tier 1, Tier 2 or Tier 3—which determines your copayment. To determine if a drug is a generic or brand-name medication, look at the name of the drug. Generic medications are lower case (e.g., amoxicillin), and brand-name medications are capitalized (e.g., Advair). Section 2:Alphabetically by drug name. Use this list to find your drug. Questions? Please call Pharmacy Services at 1 800 939-3751 if you have any questions about the BlueShield of Northeastern New York Formulary 2. For the most up-to-date version of the Guide, visit the Pharmacy Services section of our web site at www.bsneny.com. * Some plan designs require that you use a Tier 1 generic drug if a generic is available. Disclaimer: The BlueShield of Northeastern New York Medication Guide is subject to change, as we regularly review medications and existing therapies for inclusion in the BlueShield of Northeastern New York Formulary 2. The tier that a medication is currently in may change during the effective dates of the guides due to generic availability. iv 183894_MG46602S -BCBS NENY - INSURED_v1.indd 4 6/1/16 12:54 PM Section I — Therapeutic drug categories TIER TIER TIER Allergy/Cough & Cold Antihistamines & Decongestants brompheniramine/ phenylephrine 1 brompheniramine/ pseudoephedrine 1 ocetirizine 1 clemastine 1 cyproheptadine 1 dexchlorpheniramine 1 diphenhydramine 1 zofexofenadine 1 zofexofenadine-D 1 hydroxyzine HCl 1 hydroxyzine pamoate 1 zolevocetirizine 1 loratadine 1 loratadine-D 1 pseudoephedrine 1 Semprex-D 2 zoClarinex-D 3 zodesloratadine 3 zGrastek 3 +zOralair 3 zRagwitek 3 Expectorant & Cough Products benzonatate 1 guaifenesin/codeine 1 hydrocodone/chlorpheniramine 1 hydrocodone/homatropine 1 promethazine/codeine 1 promethazine/DM 1 promethazine/phenylephrine/ codeine 1 pseudoephedrine/codeine 1 Cardec/DM 3 Guaifenesin DM 3 Hycodan 3 Rondec DM/TR 3 Vituz 3 Mucolytic Agents acetylcysteine inh soln. 1 Nasal Medications azelastine nasal spray 1 Flonase Allergy Relief 1 zo fluticasone nasal spray 1 ipratropium nasal spray 1 z Nasacort OTC 1 Atrovent Nasal Spray 3 Pzo Beconase AQ 3 zo flunisolide nasal spray 3 PzoOmnaris 3 Pz mometasone nasal spray 3 Pzo Nasacort AQ 3 PzNasonex 3 PzoQnasl 3 Pzo Rhinocort Aqua 3 zo triamcinolone acetonide nasal spray 3 PzoVeramyst 3 PzoZetonna 3 Alzheimer Agents zodonepezil ergoloid mesylates zogalantamine zo galantamine ER zomemantine zorivastigmine zo rivastigmine patch zo Namenda XR zNamzaric 1 1 1 1 1 1 1 2 3 Bladder/Kidney Acidifiers K-Phos Alkalinizers citric acid/sod citrate potassium citrate Oracit Analgesics phenazopyridine KEY: Anticholinergics oxybutynin z oxybutynin ER ztolterodine z tolterodine ER ztrospium z trospium ER zMyrbetriq zToviaz zVesicare PzDetrol Pz Detrol LA Pz Ditropan XL PzEnablex PzGelnique PzOxytrol PzSanctura Pz Sanctura XR Cholinergic Agents Urecholine Antimetabolites capecitabine 1 mercaptopurine 1 methotrexate 1 Purixan 2 Trexall 3 Hormones bicalutamide 1 exemastine 1 flutamide 1 letrozole 1 leuprolide 1 megestrol 1 tamoxifen 1 anastrozole 1 Fareston 2 Miscellaneous etoposide 1 hydroxyurea 1 +zimatinib 1 +temozolomide 1 +zAfinitor 2 zArcalyst 2 +zBosulif 2 zCaprelsa 2 zCometriq 2 +z Cotellic2 +zErivedge 2 +zFarydak 2 zGilotrif 2 +Hycamtin 2 +zIbrance 2 zIclusig 2 zImbruvica 2 +zInlyta 2 + Intron A 2 zIressa 2 +zJakafi 2 zLenvima 2 +z Lonsurf2 zLynparza 2 Lysodren 2 Matulane 2 +zMekinist 2 Mesnex 2 +zNexavar 2 Nilandron 2 +z Ninlaro2 +zOdomzo 2 +zPomalyst 2 +zSprycel 2 +Stivarga 2 +zSutent 2 +zSylatron 2 +zSynribo 2 +zTafinlar 2 z Tagrisso2 +zTarceva 2 +zTasigna 2 +Thalomid 2 +zTykerb 2 zValchlor 2 +zVotrient 2 +zXalkori 2 +zXtandi 2 +zZelboraf 2 +zZolinza 2 zZydelig 2 +zZykadia 2 +zZytiga 2 +z Alecensa3 +z Cabometyx3 +Temodar 3 z Venclexta3 Rexinoids +bexarotene 1 Targretin gel 2 1 1 1 1 1 1 2 2 2 3 3 3 3 3 3 3 3 3 Blood Anticoagulants/antithrombotics anagrelide oclopidogrel odipyridamole enoxaparin fondaparinux sodium heparin jantoven oticlopidine warfarin oAggrenox Coumadin oEffient Fragmin zPradaxa Xarelto oBrilinta zDurlaza Eliquis Innohep zSavaysa zoZontivity Other Blood Modifiers ocilostazol pentoxifylline +zActimmune +Aranesp +Exjade +Jadenu +Leukine o Miacalcin inj. Neulasta +Neupogen +zPromacta +Procrit +zRevlimid +Syprine +Alprolix +Eloctate +Epogen Ferriprox +Granix Mircera +Neumega Omontys +Zarxio 1 1 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 Alkylating Agents cyclophosphamide Alkeran CeeNu Emcyt Hexalen Leukeran Myleran 1 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 Cancer Drugs 3 1 1 3 1 P =A step edit applies to this drug. z =Specific Quantity Limits Apply. =Prior Authorization Required. u = Included in Tablet-Splitting Program + = Access restricted to specialty pharmacy. o = Home Service Delivery. TIER Diabetes Please refer to your plan documents to confirm your cost share for diabetic drugs. Cost share may vary by plan. Antidiabetic Agents, Injectable PzBydureon 2 PzByetta 2 Humalog insulin 2 Humulin (all types) 2 Lantus 2 zSymlin 2 Toujeo 2 PzVictoza 2 PApidra 3 PLevemir 3 PNovolin 3 PNovolog 3 PzTanzeum 3 PTresiba 3 PzTrulicity 3 Antidiabetic Agents, Glucose Elevating Agents acarbose 1 chlorpropamide 1 zglimepiride 1 glipizide 1 z glipizide ER 1 zglipizide/metformin 1 glyburide 1 glyburide micronized 1 metformin 1 z metformin ER (generic Glucophage XR) 1 zmetformin/glyburide 1 znateglinide 1 zpioglitazone/metformin 1 zrepaglinide 1 tolazamide 1 tolbutamide 1 zAvandamet 2 zAvandaryl 2 zAvandia 2 zDuetact 2 Glucagon 2 zInvokamet 2 zInvokana 2 zJanumet 2 z Janumet XR 2 zJanuvia 2 zJardiance 2 Jentadueto 2 Juvisync 2 zSynjardy 2 Tradjenta 2 Afrezza 3 PzFarxiga 3 PzFortamet 3 PzGlumetza 3 zGlyset 3 zGlyxambi 3 PKazano 3 P Kombiglyze XR 3 P metformin ER (except generic Glucophage XR) 3 PNesina 3 POnglyza 3 POseni 3 repaglinide/metformin 3 Riomet solution 3 Pz Xigduo XR 3 Diabetic Test Strips Please refer to your plan documents to confirm your cost share for diabetic supplies. Cost share may vary by plan. Test strips other than OneTouch require prior authorization. OneTouch Test Strips PAccu-Chek P Ascensia Breeze PContour PFreestyle Note: 1. * Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive. 2. * Some drugs are limited to 1 unit of use package per dispensing. 1 183894_MG46602S -BCBS NENY - INSURED_v1.indd 1 6/1/16 12:54 PM Section I — Therapeutic drug categories (cont’d) PPrecision PTRUEtest PTRUEtrack TIER Ear Anti-infective Agents acetic acid otic acetic acid/aluminum acetate ofloxacin otic Domeboro Xtoro Anti-infective/Anti-inflammatory combinations acetic acid HC otic neomycin/polymyxin/HC otic Ciprodex Cipro HC Eye Antiallergy Agents (Eye) azelastine ophth cromolyn ophth olopatadine ophth Alomide Bepreve ketotifen opthalmic solution Pataday Pazeo Zaditor Anti-infective Agents bacitracin ophth bacitracin/polymyxin ciprofloxacin ophth erythromycin ophth gatifloxacin gentamicin ophth neomycin/bacitracin/poly B ofloxacin ophth polymyxin B/TMP sulfacetamide 10% tobramycin soln Tobrex ointment Vigamox Azasite Besivance Ciloxan Tobrex solution Anti-inflammatory fluorometholone ophth prednisolone acetate prednisolone sod phosphate FML Forte FML S.O.P. Lotemax Pred Mild Flarex Maxidex Anti-inflammatory/Anti-infective combinations dexameth/neomycin/poly B neomycin/bacitracin/poly B/HC sulfacetamide/prednisolone ophth tobramycin/dexameth Tobradex ointment Maxitrol ophth Pred-G Zylet Antiviral z famciclovir ophth trifluridine Beta-Blockers (Eye) o betaxolol HCl ocarteolol olevobunolol ometipranolol otimolol oBetoptic-S oIstalol Carbonic Anhydrase Inhibitors o dorzolamide 2% eye drops o dorzolamide/timolol eye drops oAzopt KEY: 1 1 1 3 3 1 1 2 3 1 1 1 2 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 2 2 3 3 3 3 1 1 1 2 2 2 2 3 3 1 1 1 1 2 3 3 3 1 1 1 1 1 1 1 2 3 1 1 2 Miotics opilocarpine o Isopto Carbachol 1.5% Phospholine Iodide o Isopto Carbachol 3% Miscellaneous +Cystaran Restasis Mydriatics atropine sulfate ophth homatropine tropicamide NSAIDs bromfenac diclofenac flurbiprofen ophth ketorolac tromethamine Nevanac Acular PF Prolensa Prostaglandin Analogues/Prostamines olatanoprost otravoprost oLumigan PIzba PoRescula Po Travatan Z PoXalatan PoZioptan Sympathomimetics obrimonidine o Alphagan P 0.1% Vasoconstrictors naphazoline phenylephrine ophth Gout allopurinol colchicine/probenecid probenecid Colcrys zMitigare PzUloric PzZurampic Heart Angiotensin Converting Enzyme Inhibitors obenazepril ocaptopril oenalapril ofosinopril olisinopril omoexipril operindopril oquinapril oramipril otrandolapril oEpaned Angiotensin II Antagonists zo eprosartan 600mg zoirbesartan zolosartan zotelmisartan zovalsartan PzoAtacand PzoAvapro PzoBenicar PzoCozaar PzoDiovan PzoEdarbi PzoMicardis PzoTeveten Anti-Adrenergic Blockers Centrally Acting o clonidine, oral, patch oguanabenz oguanfacine omethyldopa midodrine oDibenzyline +zNorthera P =A step edit applies to this drug. z =Specific Quantity Limits Apply. =Prior Authorization Required. u = Included in Tablet-Splitting Program + = Access restricted to specialty pharmacy. o = Home Service Delivery. TIER Anti-Adrenergic Blockers Peripheral odoxazosin oprazosin oterazosin o Cardura XL Antiarrhythmics oamiodarone digoxin odisopyramide oflecainide omexiletine procainamide opropafenone o propafenone SR o quinidine gluconate o quinidine sulfate SR osotalol Lanoxin oMultaq oNorpace/CR oTikosyn Antilipidemics zuo atorvastatin calcium ocholestyramine ocolestipol ofenofibrate o fenofibric acid, tab ogemfibrozil zuolovastatin o niacin ER zoniacin/simvastatin zuopravastatin zuosimvastatin oAdvicor oColestid zuoCrestor +zKynamro +zPraluent +zRepatha zoAltoprev zEpanova zo fenofibric acid, capsule DR zofluvastatin zJuxtapid zo Lescol XL oLiptruzet oLivalo z omega-3 acid ethyl esters zOmtryg Vascepa zoVytorin oWelchol zoZetia Beta Blockers oacebutolol oatenolol betaxolol obisoprolol ocarvedilol olabetalol ometoprolol o metoprolol ER ometoprolol/HCTZ onadolol opindolol opropranolol otimolol o Coreg CR o Innopran XL oBystolic oCorgard Hemangeol Calcium Channel Blockers oamlodipine o cartia XT o diltia XT odiltiazem o diltiazem CD/SR/ER/XR o felodipine ER oisradipine 1 2 2 3 2 2 1 1 1 1 1 1 1 2 3 3 1 1 2 3 3 3 3 3 1 2 1 1 1 1 1 2 3 3 3 1 1 1 1 1 1 1 1 1 1 3 1 1 1 1 1 3 3 3 3 3 3 3 3 1 1 1 1 1 2 2 TIER 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 2 2 2 3 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 3 3 3 1 1 1 1 1 1 1 onicardipine o nifediac CC o nifedical XL onifedipine o nifedipine SR onimodipine onisoldipine overapamil/SR oDynacirc/CR zoNymalize Combination Anti-Hypertensive zoamlodipine/atorvastatin oamlodipine/benazepril oatenolol/chlorthalidone obenazepril/HCTZ obisoprolol/HCTZ Pzocandesartan/HCTZ ocaptopril/HCTZ oenalapril/HCTZ ofosinopril/HCTZ zoirbesartan/HCTZ olisinopril/HCTZ zolosartan/HCTZ omethyldopa/HCTZ ometoprolol/HCTZ opropranolol/HCTZ oquinapril/HCTZ zotelmisartan/HCTZ zovalsartan/HCTZ PzoTekamlo PzoTekturna Pzo Tekturna HCT zoamlodipine/valsartan zoamlodipine/valsartan/HCTZ PzoAmturnide Pzo Atacand HCT PzoAvalide zoAzor Pzo Benicar HCT Pzo Diovan HCT PzoEdarbyclor zo Exforge HCT PzoHyzaar Pzo Micardis HCT zoPrestalia zotelmisartan/amlodipine Pzo Teveten HCT otrandolapril/verapamil zoTribenzor Diuretics oacetazolamide o acetazolamide ER oamiloride oamiloride/HCTZ obumetanide ochlorothiazide ochlorthalidone ofurosemide ohydrochlorothiazide oindapamide omethazolamide omethyclothiazide ometolazone ospironolactone ospironolactone/HCTZ otorsemide otriamterene/HCTZ Miscellaneous Cardiovascular Agents zoeplerenone midodrine +zBerinert zCinryze +zFirazyr oRanexa +zRuconest +zSamsca zoCorlanor zoEntresto TIER 1 1 1 1 1 1 1 1 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 3 3 Note: 1. * Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive. 2. * Some drugs are limited to 1 unit of use package per dispensing. 2 183894_MG46602S -BCBS NENY - INSURED_v1.indd 2 6/1/16 12:54 PM Section I — Therapeutic drug categories (cont’d) TIER Pulmonary Arterial Hypertension +z sildenafil citrate +zAdcirca +zLetairis +zTracleer zUptravi zAdempas epoprostenol +zOpsumit zOrenitram zTyvaso veletri zVentavis Vasodilators ohydralazine o isosorbide dinitrate o isosorbide mononitrate o isosorbide mononitrate SA oisoxsuprine o minoxidil oral nitroglycerin pumpspray nitroglycerin SR nitroglycerin transdermal patch o Dilatrate SR Nitrostat SL tabs Minitran NitroDur patches HIV - Antivirals 1 2 2 2 2 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 1 2 2 3 3 Non-Nucleoside Reverse Transcriptase Inhibitor Atripla 2 Edurant 2 Intelence 2 Rescriptor 2 Sustiva 2 Viramune, XR 2 Nucleoside Analog Reverse Transcriptase Inhibitor Combination abacavir/lamivudine/zidovudine 1 lamivudine/zidovudine 1 Complera 2 Dutrebis 2 Stribild 2 Triumeq 2 Truvada 2 Viread 2 Nucleoside Reverse Transcriptase Inhibitors didanosine 1 lamivudine tabs 1 stavudine 1 zidovudine 1 Emtriva 2 Epivir solution 2 Epzicom 2 Videx 2 Ziagen 2 Other +Fuzeon 2 Genvoya 2 Isentress 2 Selzentry 2 Tivicay 2 Tybost 2 Vitekta 2 Protease Inhibitors Aptivus 2 Crixivan 2 Evotaz 2 Invirase 2 Lexiva 2 Norvir 2 Prezcobix 2 Prezista 2 Reyataz 2 Viracept 2 Protease Inhibitors Combinations Kaletra 2 Huntington’s Disease +zXenazine KEY: 2 P TIER Immunosuppressants azathioprine cyclosporine gengraf mycophenolate mofetil mycophenolic acid sirolimus tacrolimus Astagraf XL Cellcept Neoral Prograf Rapamune solution Sandimmune Zortress z Envarsus XR Infection 1 1 1 1 1 1 1 2 2 2 2 2 2 2 3 Antibacterial Agents/Antibiotics amoxicillin 1 amoxicillin-clavulanate ER 1 ampicillin 1 azithromycin suspension 1 azithromycin tablets 1 cefaclor 1 cefadroxil 1 cefdinir 1 cefpodoxime 1 cefprozil 1 cefuroxime 1 cephalexin 1 ciprofloxacin 1 clarithromycin susp 1 clarithromycin tabs 1 clindamycin 1 dicloxacillin 1 doxycycline 1 erythromycin base 1 erythromycin ethylsuccinate 1 erythromycin stearate 1 erythromycin/sulfisoxazole 1 levofloxacin 1 minocycline 1 nitrofurantoin 1 ofloxacin 1 penicillin VK 1 sulfamethoxazole/trimethoprim 1 tetracycline 1 Ery-Tab 2 Ketek 2 Zmax 2 zActiclate 3 Biaxin XL 3 Ceftin 3 Cleocin 3 erythromycin estolate 3 Factive 3 Minocin 3 moxifloxacin 3 Noroxin 3 PCE 3 Spectracef 3 Suprax 3 Vibramycin 3 Antifungals clotrimazole lozenge 1 fluconazole 1 flucytosine 1 griseofulvin 1 zitraconazole 1 ketoconazole 1 nystatin 1 zterbinafine 1 zvoriconazole 1 zNoxafil 2 z Sporanox suspension 2 zCresemba 3 Ecoza 3 z Lamisil Oral 3 Luzu 3 =A step edit applies to this drug. z =Specific Quantity Limits Apply. =Prior Authorization Required. u = Included in Tablet-Splitting Program + = Access restricted to specialty pharmacy. o = Home Service Delivery. TIER Oravig 3 Antimalarials atovaquone/proguanil HCl 1 chloroquine phosphate 1 mefloquine 1 +Daraprim 2 Primaquine 2 quinine sulfate 3 Antituberculosis oethambutol 1 oisoniazid 1 opyrazinamide 1 orifabutin 1 orifampin 1 Coartem 2 oRifater 2 oMyambutol 3 oRifadin 3 oRifamate 3 oSirturo 3 Antivirals z acyclovir oral 1 oamantadine 1 zfamciclovir 1 ganciclovir 1 +moderiba 1 +ribapak 1 +ribasphere 1 +ribavirin 1 rimantadine 1 zvalacyclovir 1 valganciclovir tablets 1 +PzDaklinza 2 Epivir-HBV solution 2 +zHarvoni 2 zHepsera 2 +zOlysio 2 +Pegasys 2 zRelenza 2 +zSovaldi 2 zTamiflu 2 +Victrelis 2 +PzViekira 2 Baraclude solution 3 +Copegus 3 entecavir tablets 3 +Infergen 3 +PPeg-Intron 3 +Rebetol 3 +Ribatab 3 zSitavig 3 +Pz Technivie3 zTyzeka 3 Valcyte 3 zValtrex 3 +Pz Zepatier3 Other Anti-Infectives atovaquone 1 methenamine combination 1 metronidazole 1 neomycin 1 nitrofurantoin 1 paromomycin 1 trimethoprim 1 tinidazole 1 + tobramycin ampule/neb 1 vancomycin caps 1 Dapsone 2 Nebupent 2 zSivextro 2 + Tobi Podhaler 2 zZyvox 2 +Bethkis 3 +Cayston 3 zDificid 3 Flagyl/ER 3 zImpavido 3 +z Kitabis Pak 3 Macrodantin 3 TIER 3 3 3 +Tobi Vancocin zXifaxan Men’s Health Impotence - possible contract exclusion; refer to individual contract yohimbine zCaverject zoCialis zMUSE zEdex PzoLevitra PzoStaxyn PzoStendra PzoViagra Male Hormones testosterone cypionate testosterone enanthionate Androderm patch zAndrogel Android fluoxymesterone PzAxiron PzFortesta PzNatesto PStriant PzTestim Pz Testosterone gel (brand) PzVogelxo Prostate Health zoalfuzosin zo dutasteride zo finasteride 5mg otamsulosin odutasteride/tamsulosin oRapaflo 1 1 1 1 3 3 Antidepressants amitriptyline amitriptyline/ chlordiazepoxide amitriptyline/perphenazine amoxapine bupropion bupropion ER bupropion XL ucitalopram clomipramine desipramine doxepin duloxetine 20mg, 30mg, 60mg uescitalopram u fluoxetine 10mg and 20mg tablet fluoxetine capsule u fluvoxamine tablet imipramine maprotiline umirtazapine nefazodone nortriptyline uparoxetine phenelzine protriptyline usertraline tranylcypromine trazodone uvenlafaxine venlafaxine ER Pristiq ER Viibryd Desvenlafaxine ER Desvenlafaxine Fumarate ER duloxetine 40mg Fetzima fluoxetine 60mg tablet fluvoxamine ER capsule Forfivo Khedezla zu Oleptro ER 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 3 3 3 3 3 3 3 3 3 Mental Health 1 2 2 2 3 3 3 3 3 1 1 2 2 3 3 3 3 3 3 3 3 3 Note: 1. * Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive. 2. * Some drugs are limited to 1 unit of use package per dispensing. 3 183894_MG46602S -BCBS NENY - INSURED_v1.indd 3 6/1/16 12:54 PM Section I — Therapeutic drug categories (cont’d) TIER Pexeva 3 Sarafem 3 Trintellix 3 Antimanic Agents lithium carbonate 1 Antipsychotic Agents aripiprazole 1 chlorpromazine 1 clozapine 1 fluphenazine 1 haloperidol 1 loxapine 1 zolanzapine 1 perphenazine 1 zquetiapine 1 zrisperidone 1 z risperidone m-tab 1 thioridazine 1 thiothixene 1 trifluoperazine 1 z ziprasidone caps 1 zLatuda 2 zSaphris 2 z Seroquel XR 2 zFanapt 3 Fazaclo 3 zolanzapine/fluoxetine 3 z paliperidone3 zRexulti 3 PVersacloz 3 zVraylar 3 zZyprexa 3 z Zyprexa Zydis 3 Anxiolytics, Sedatives, and Hypnotics alprazolam/ER 1 buspirone 1 chloral hydrate 1 chlordiazepoxide 1 clorazepate 1 diazepam 1 estazolam 1 flurazepam 1 lorazepam 1 meprobamate 1 oxazepam 1 temazepam 1 triazolam 1 zzaleplon 1 zzolpidem 1 z zolpidem ER 1 +zHetlioz 2 Somnote 3 PzAmbien 3 Pz Ambien CR 3 Ativan 3 PzBelsomra 3 PzEdluar 3 Pzeszopiclone 3 PzIntermezzo 3 Librium 3 PzLunesta 3 PRozerem 3 PzSilenor 3 PzSonata 3 Pz zolpidem ER sublingual tablet 3 PzZolpimist 3 Cerebral Stimulants dexmethylphenidate 1 dexmethylphenidate XR 1 dextroamphetamine tabs 1 generic Adderall 1 generic Adderall XR 1 generic Concerta 1 generic Dexedrine spansules 1 guanfacine ER 1 metadate ER 1 methylphenidate CD 1 methylphenidate/SR 1 zmodafinil 1 KEY: procentra Ritalin LA 10mg, 60mg Strattera Vyvanse z Adzenys XR ODT z Dyanavel XR Focalin XR zNuvigil z Quillichew ER Quillivant XR Miscellaneous Antidiuretic Agents desmopressin solution desmopressin tabs Stimate DDAVP nasal spray DDAVP sol, tab Other CNS acamprosate calcium tablet EC buprenorphine disulfiram naltrexone riluzole z Narcan nasal spray Suboxone film PBunavail Pbuprenorphine-naloxone Campral dosepack zEvzio zGralise PzHorizant zNuedexta Savella Suboxone tablet PZubsolv Other Endocrine danazol fludrocortisone +octreotide +zCerdelga +zEgrifta +z HP Acthar Gel zMyalept +Norditropin +Sensipar Synarel zZavesca +PGenotropin +PHumatrope +Increlex +Natpara +PNutropin/AQ +POmnitrope +PSaizen +Sandostatin + Sandostatin LAR +PSerostim + Somatuline Depot +zSomavert +PTev-Tropin +PZorbtive Other Miscellaneous z Keveyis zSignifor Strensiq Carbaglu Cystadane zKorlym Procysbi +Ravicti + sodium phenylbutyrate +zVeltassa zXuriden Miscellaneous Immunologicals + Gammagard Liquid +Gammaked +Gamunex-C +Hizentra +HyQvia P =A step edit applies to this drug. z =Specific Quantity Limits Apply. =Prior Authorization Required. u = Included in Tablet-Splitting Program + = Access restricted to specialty pharmacy. o = Home Service Delivery. TIER Vivaglobin 1 2 2 2 3 3 3 3 3 3 TIER Multiple Sclerosis Agents 1 1 2 3 3 +zglatopa +Avonex +Rebif + Copaxone 40mg +zGilenya +zTecfidera +Ampyra +zAubagio +PBetaseron + Copaxone 20mg +PExtavia +PzPlegridy 1 2 2 2 2 2 3 3 3 3 3 3 baclofen carisoprodol carisoprodol/ASA chlorzoxazone cyclobenzaprine dantrolene sodium metaxalone methocarbamol orphenadrine tizanidine 1 1 1 1 1 1 1 1 1 1 zoalendronate zocalcitonin-salmon zo fortical NS zo ibandronate tabs zoraloxifene +zForteo PzoActonel PzoAtelvia PzoBinosto PzoBoniva PzoFosamax Pzo Fosamax D zo risedronate 150mg Pzo risedronate DR 1 1 1 1 1 2 3 3 3 3 3 3 3 3 Muscle Relaxants 1 1 1 1 1 2 2 3 3 3 3 3 3 3 3 3 3 Osteoporosis 1 1 1 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Pain/Arthritis Analgesics, Narcotic acetaminophen w/codeine belladonna & opium supp butalbital/APAP/codeine butalbital/aspirin/codeine butorphanol NS codeine sulfate endocet z fentanyl lozenge fentanyl patch hydrocodone/APAP hydrocodone/ibuprofen hydromorphone meperidine methadone morphine SR z morphine sulfate ER morphine tab, soln, supp oxycodone oxycodone/acetaminophen oxycodone/aspirin oxycodone/ibuprofen oxymorphone/ER pentazocine/naloxone Kadian (40mg, 70mg, 130mg, 150mg, 200mg) Oxycodone ER Oxycontin zAbstral zBelbuca Demerol Embeda fentanyl patch 37.5mcg/hr, 62.5mcg/hr, and 87.5mcg/hr zFentora Fioricet/codeine 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 3 3 3 3 3 3 3 TIER Fiorinal/codeine hydromorphone ER Hysingla ER zLazanda Nucynta/ER Roxicet Soln zSubsys Targiniq ER Trezix Tylenol/codeine Vicodin/ES Xartemis XR Zohydro ER Analgesics, Salicylates o choline mag. trisalicylate odiflunisal osalsalate oEasprin Anti-Rheumatic ohydroxychloroquine leflunomide methotrexate zoCuprimine +zEnbrel +zHumira zKineret oRidaura +PzActemra +PzCimzia zoDepen +Pz Orencia SC +PzOtezla Otrexup Rasuvo +PzSimponi +PzXeljanz +Pz Xeljanz XR Cox-2s zocelecoxib Migraine (Analgesics, Non-narcotic) butalbital/APAP butalbital/APAP/caffeine butalbital/aspirin/caffeine z dihydroergotamine mesylate ergotamine/caffeine isometh/dichloralphen/APAP znaratriptan zrizatriptan zsumatriptan tramadol/ER tablet tramadol/acetaminopen zzolmitriptan Ergomar zRelpax PzAmerge PzAxert Cafergot zCambia PzFrova PzImitrex PzMaxalt Pz Maxalt MLT PzOnzetra zSumavel tramadol ER capsule PzTreximet +PzZecuity PzZembrace PzZomig Pz Zomig Nasal Pz Zomig ZMT Nonsteroidal Anti-Inflammatory/Combination Products o diclofenac potassium o diclofenac sodium z diclofenac sodium gel 1% oetodolac o etodolac SA ofenoprofen 3 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 3 1 1 1 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 1 1 Note: 1. * Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive. 2. * Some drugs are limited to 1 unit of use package per dispensing. 4 183894_MG46602S -BCBS NENY - INSURED_v1.indd 4 6/1/16 12:54 PM Section I — Therapeutic drug categories (cont’d) TIER oflurbiprofen oibuprofen oindomethacin oketoprofen ketorolac inj. z ketorolac tab omeclofenamate o mefenamic acid omeloxicam onabumetone onaproxen/EC ooxaprozin opiroxicam osulindac otolmetin diclofenac sodium 3% gel o diclofenac sodium/misoprostol Pz diclofenac sodium topical solution PDuexis PzFlector oNaprosyn PzPennsaid zSprix oTivorbex PzoVimovo PzVivlodex oZorvolex 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 3 3 3 3 3 3 3 3 3 3 3 obenztropine obromocriptine ocarbidopa/levodopa o carbidopa/levodopa SA oentacapone opramipexole oropinirole zoselegiline otrihexyphenidyl +Apokyn zDuopa ocarbidopa pergolide o pramipexole ER o ropinirole ER oRytary Tasmar 1 1 1 1 1 1 1 1 1 2 2 3 3 3 3 3 3 Parkinson’s Disease Potassium Potassium agents o potassium bicarb/potassium chloride o potassium bicarbonate o potassium chloride oMicro-K Potassium Removing agent sod. polystyrene sulfonate Kayexalate 1 1 1 3 1 3 Respiratory/Asthma Adrenergic epinephrine inj. Epipen/Jr. Twinject PAdrenaclick PAuviQ Corticosteroids o budesonide inh. (0.25mg/2ml, 0.5mg/2ml) zo Arnuity Ellipta zoAsmanex zo Flovent HFA/Diskus zo Pulmicort flexhaler/powder o Pulmicort respules (1mg/2ml) zoQvar zAerobid/M oAlvesco Leukotrienes omontelukast ozafirlukast zoZyflo/CR KEY: 1 2 2 3 3 1 2 2 2 2 2 2 3 3 1 1 3 TIER Other Agents cromolyn inh. soln. ipratropium inh. soln. ipratropium/albuterol z Advair diskus Anoro Ellipta z Atrovent HFA Breo Ellipta z Combivent Respimat +zEsbriet +zKalydeco +zOfev +zOrkambi +Pulmozyme zSpiriva z Spiriva Respimat z Stiolto Respimat zSymbicort oDaliresp zDulera z Incruse Ellipta zSeebri Tudorza zUtibron Sympathomimetics o albuterol sulfate ER o albuterol tab, syr o metaproterenol syr o terbutaline tab zForadil z Maxair Autohaler z ProAir HFA/RespiClick z Serevent Diskus z Ventolin HFA Arcapta z Proventil HFA z Striverdi Respimat Xopenex HFA Xanthine Derivatives oaminophylline otheochron o theophylline/SR tabs, liquid oTheo-24 oElixophyllin Seizures Barbiturates mephobarbital phenobarbital Hydantoins ophenytoin oDilantin oPeganone Miscellaneous ocarbamazepine o carbamazepine XR 200mg, 400mg clonazepam o divalproex sodium/ER felbamate ogabapentin olamotrigine olevetiracetam ooxcarbazepine oprimidone otopiramate o valproic acid ozonisamide o Banzel tablets o Gabitril 12mg, 16mg oTegretol o Tegretol XR 100mg oAptiom o Banzel suspension zBriviact zFycompa o lamotrigine ER/ODT Lyrica o Oxtellar XR Potiga o Qudexy XR P =A step edit applies to this drug. z =Specific Quantity Limits Apply. =Prior Authorization Required. u = Included in Tablet-Splitting Program + = Access restricted to specialty pharmacy. o = Home Service Delivery. Sabril o topiramate ER o Trokendi XR Vimpat Succinimides oethosuximide oCelontin 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 Skin TIER 3 3 3 3 1 2 Acne/Rosacea adapalene 1 amnesteem 1 avita cream 1 benzoyl peroxide 1 claravis 1 clindamycin/benzoyl peroxide 1 clindamycin phospate 1 erythromycin/benz peroxide 1 minocycline 1 prascion RA 1 sodium sulfacetamide 1 sod. sulfacetamide/sulfur emulsion cleanser 1 sod. sulfacetamide/sulfur lot 1 sotret 1 tretinoin cr/gel 1 PAbsorica 3 P Acanya3 P Aczone3 P Adapalene lotion 3 P Avar3 P Avita gel 3 P Azelex3 P Benzaclin3 P Benzamycin3 P Cleocin T 3 P Differin3 PDoryx 3 P Duac3 P doxycycline hyclate DR 3 P Doxycycline IR-DR 3 P Epiduo/Forte3 P Evoclin3 PFabior 3 P Finacea3 P Metrogel topical 1% 3 P minocycline HCl ER 3 PMirvaso 3 PNoritate 3 POnexton 3 POracea 3 P Retin-A/Micro3 P Rosula3 PSolodyn 3 Soolantra 3 PTazorac 3 P tretinoin microsphere 3 P Veltin gel 3 P Ziana gel 3 Antibiotics (Topical) clindamycin sol/swabs/gel/lotion 1 erythromycin sol/swabs/gel 1 gentamicin cr/oint 1 metronidazole cream/lotion/ 0.75% gel 1 mupirocin 1 Bactroban cream 3 Centany 3 Antipsoriatics acitretin 1 calcipotriene 1 tacrolimus 1 Dritho-Scalp 2 Elidel 2 P calcipotriene-betamethasone ointment 3 calcitriol ointment 3 +zCosentyx 3 PEnstilar 3 +PzStelara 3 PTaclonex 3 +zTaltz 3 1 1 1 1 2 2 2 2 2 3 3 3 3 1 1 1 2 3 1 1 1 2 3 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 3 3 3 3 3 3 3 3 3 TIER Burn preparation silver sulfadiazine Fungicides betamethasone/clotrimazole ciclopirox cream ciclopirox soln econazole ketoconazole nystatin nystatin/triamcinolone nystop Exelderm Oxistat zJublia zKerydin Naftin Other Topicals aluminum chloride 20% fluorouracil imiquimod 5% cream podofilox sodium chloride irrigating soln Panretin Phisohex Picato Regranex Carac Fluoroplex Regenecare Psoralens 8-MOP Oxsoralen Ultra Scabicides & Pediculicides acticin permethrin spinosad Lindane Ulesfia Eurax Sklice Topical Anti-Inflammatory Agents alclometasone amcinonide aug. betamethasone diprop betamethasone dipropionate betamethasone valerate clobetasol propionate desonide desoximetasone diflorasone fluocinolone acetonide fluocinonide fluticasone propionate halobetasol halobetasol propionate hydrocortisone 2.5% hydrocortisone valerate hydrocortisone/iodoquinol mometasone cr/oint prednicarbate triamcinolone acetonide Cordran tape betamethasone valerate foam Capex Shampoo clobetasol propionate shampoo Cordran SP fluocinonide cream (generic Vanos) Halog hydrocortisone butyrate/emoll cream Kenalog/aerosol Topical Antipruritics/Anesthetics lidocaine z lidocaine patch selenium sulf 2.5% suspension Rectiv Topical Antivirals acyclovir ointment Zovirax Cream Denavir 1 1 1 1 1 1 1 1 1 2 2 3 3 3 1 1 1 1 1 2 2 2 2 3 3 3 2 2 1 1 1 2 2 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 3 3 3 3 3 3 3 3 1 1 1 3 1 2 3 Note: 1. * Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive. 2. * Some drugs are limited to 1 unit of use package per dispensing. 5 183894_MG46602S -BCBS NENY - INSURED_v1.indd 5 6/1/16 12:54 PM Section I — Therapeutic drug categories (cont’d) TIER Smoking Cessation TIER Gallstone Solubilizing Agents Members coverage varies by plan. Patient should be oursodiol H2 Antagonists in a smoking cessation program. ocimetidine zbupropion 1 ofamotidine z Nicorelief gum 1 onizatidine z Nicorelief lozenge 1 o ranitidine (all) z Nicotine Gum 1 Other Antiulcer z Nicotine lozenges 1 omisoprostol z Nicotine patches various 1 propantheline bromide zChantix 2 osucralfate zCommit 2 Helidac z Nicotrol Inhaler 2 lansoprazole/amox/clarith z Nicotrol NS 2 Other GI Products zZyban 3 balsalazide Steroids budesonide EC cromolyn sodium cortisone acetate 1 o dexamethasone oral 1 enulose hydrocortisone oral 1 lactulose mesalamine enema methylprednisolone 4mg, 8mg, 16mg, 32mg 1 osulfasalazine sulfasalazine EC prednisolone oral 1 o Asacol HD prednisone oral 1 Canasa supp. Medrol 2mg 2 Rayos 3 Cholbam Delzicol Stomach/Ulcer Dipentum Anorectal +Kuvan hydrocortisone rectal cr. & supp. 1 Linzess hydrocortisone rectal enema 1 Pentasa pramoxine/HC acetate 2.5% 1 Relistor Analpram-HC 1-1% 2 alosetron Cortifoam 2 PzAmitiza Proctofoam-HC 2 Apriso Analpram-HC 2.5% cr/lot 3 oAzulfidine Anticholinergics/Antispasmodic/GI Motility +Gattex belladonna/phenobarbital 1 Giazo chlordiazepoxide/clindinium 1 zMovantik dicyclomine 1 Uceris glycopyrrolate 1 Proton Pump Inhibitors hyoscyamine/CR 1 zolansoprazole metoclopramide 1 z Nexium 24HR Donnatal tablet 2 zoomeprazole Antidiarrheal zopantoprazole diphenoxylate/atropine 1 z Prevacid 24HR paregoric 1 zPrilosec-OTC zAlinia 2 zo Nexium susp Fulyzaq 2 zo Prevacid Solutab Antiemetic/Antivertigo PzoAciphex zgranisetron 1 PzoDexilant meclizine 1 Pzo esomeprazole magnesium zondansetron 1 PzoNexium prochlorperazine 1 PzoPrevacid promethazine 1 PzoPrilosec trimethobenzamide 1 PzoProtonix Antivert 50mg 2 zorabeprazole zAnzemet 2 PzoZegerid zEmend 2 Thyroid Transderm Scop 2 +PzAkynzeo 3 Antithyroid zDiclegis 3 omethimazole zGranisol 3 opropylthiouracil zSancuso 3 Thyroid zVarubi 3 levothroid zZuplenz 3 olevothyroxine olevoxyl Bowel Evacuants peg 3350/electrolyte 1 oliothyronine Trilyte 1 othyroid Halflytely 2 ounithroid Nulytely 3 oSynthroid Thyroid (Armour) Prepopik 3 o oThyrolar Suclear 3 Vitamins Digestants oCreon 2 ocalcitriol oZenpep 2 o calcitriol inj oPancreaze 3 calcium acetate oPertzye 3 cholecalciferol oUltresa 3 o cyanocobalamin inj. oViokace 3 o ergocalciferol capsule KEY: P =A step edit applies to this drug. z =Specific Quantity Limits Apply. =Prior Authorization Required. u = Included in Tablet-Splitting Program + = Access restricted to specialty pharmacy. o = Home Service Delivery. 1 1 1 1 1 1 1 1 3 3 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 TIER oetidronate o folic acid Rx 1mg tab leucovorin levocarnitine omultivitamin + fluoride potassium aminobenzoate o pre-natal vitamins sevelamer o sodium fluoride chewable tab & drops o vit A,D,C + fluoride o vit A,D,C + fluoride and iron Galzin oMephyton oNascobal Orfadin ophytonadione o Prenate Elite Renagel Renvela zAuryxia Fosrenol paricalcitol oPoly-Vi-Flor + Iron oTri-Vi-Flor Velphoro 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 3 3 3 3 3 3 benzphetamine diethylpropion phentermine Belviq zContrave zQsymia zSaxenda Suprenza ODT Xenical 1 1 1 3 3 3 3 3 3 Weight Loss - possible contract exclusion; refer to individual contract Women’s Health Contraceptives - Other oxulane Mirena oNuvaRing Skyla o Depo-SubQ Provera Liletta Paragard Fertility Induction Agents - possible contract exclusion; refer to individual contract chorionic gonadotropin 10000 unit vial clomiphene progesterone in oil serophene Bravelle Cetrotide Follistim AQ Novarel Ovidrel Repronex Ganirelix P Gonal F Menopur Pregnyl Hormones zo estradiol/noreth ac zo estradiol oral zo estradiol patches zoestropipate zoestrogen/methyltesterone zojinteli omedroxyprogesterone onorethindrone o progesterone, micronized zoAlora oCenestin zoCombipatch oEnjuvia o Estrace Vag. Cream zoEstraderm zoEstring 1 1 1 1 1 1 2 2 3 3 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 2 2 2 1 1 1 1 1 1 1 2 2 2 3 3 3 1 1 1 1 2 2 2 2 2 2 3 3 3 3 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 oEvamist oMenest oPremarin Premarin vag cream oPremphase Prempro oVagifem zo Climara Pro o Crinone 8% Duavee zo Estrasorb packet zoEstrogel zoFemring zoMenostar Ortho-Est Osphena zoPrefest Miscellaneous zAddyi Brisdelle Oral Contraceptives oamethia oamethyst oapri oaranelle oaviane obalziva ocamila ocamrese ocesia ocryselle oenpresse oerrin ojolessa ojolivette ojunel/FE okariva olessina olevora olow-ogestrel olutera omicrogestin/FE omononessa onecon onora-BE o norethindrone a-e estradiol/ ferrous fumarate onortrel oocella oogestrel oportia oprevifem oquasense osolia osprintec otri-sprintec otrinessa otriprevifem otrivora ovelivet ozarah ozenchent ozovia o Ortho Tri-Cyclen Lo oOvcon-50 oBeyaz Oxytocic Agents methylergonovine maleate Methergine Vaginal Preparations miconazole vag supp nystatin vag tab terconazole vandazole vag Cleocin Vag/Ovules Clindesse Gynazole-1 TIER 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 3 1 3 1 1 1 1 3 3 3 Note: 1. * Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive. 2. * Some drugs are limited to 1 unit of use package per dispensing. 6 183894_MG46602S -BCBS NENY - INSURED_v1.indd 6 6/1/16 12:54 PM Section II — Index DRUG NAME TIER PAGE DRUG NAME A abacavir/lamivudine/ zidovudine 13 PAbsorica 35 zAbstral 34 acamprosate calcium tablet EC 1 4 PAcanya 35 acarbose 11 PAccu-Chek1 oacebutolol 12 acetaminophen w/codeine 1 4 oacetazolamide 12 oacetazolamide ER 1 2 acetic acid HC otic 1 2 acetic acid otic 1 2 acetic acid/aluminum acetate1 2 acetylcysteine inh soln. 1 1 PzoAciphex 36 acitretin 15 +PzActemra 34 acticin 15 zActiclate 33 +zActimmune 21 PzoActonel 34 Acular PF 3 2 acyclovir ointment 1 5 zacyclovir oral 1 3 PAczone 35 adapalene 15 PAdapalene lotion 3 5 +zAdcirca 23 zAddyi 36 zAdempas 33 PAdrenaclick 35 oAdvicor 22 zAdzenys XR ODT 3 4 zAerobid/M 35 +zAfinitor 21 Afrezza 31 oAggrenox 21 +PzAkynzeo 36 oalbuterol sulfate ER 1 5 oalbuterol tab, syr 1 5 alclometasone 15 +zAlecensa 31 zoalendronate 14 zoalfuzosin 13 zAlinia 26 Alkeran 21 allopurinol 12 Alomide 22 zoAlora 26 alosetron 36 oAlphagan P 0.1% 2 2 alprazolam/ER 14 +Alprolix 31 zoAltoprev 32 aluminum chloride 20% 1 5 oAlvesco 35 oamantadine 13 PzAmbien 34 PzAmbien CR 3 4 amcinonide 15 PzAmerge 34 oamethia 16 oamethyst 16 oamiloride 12 oamiloride/HCTZ 12 oaminophylline 15 oamiodarone 12 PzAmitiza 36 amitriptyline 13 amitriptyline/ chlordiazepoxide 13 amitriptyline/perphenazine1 3 oamlodipine 12 zoamlodipine/atorvastatin1 2 oamlodipine/benazepril1 2 zoamlodipine/valsartan3 2 zoamlodipine/ valsartan/HCTZ 32 amnesteem 15 amoxapine 13 amoxicillin 13 amoxicillin-clavulanate ER1 3 ampicillin 13 +Ampyra 34 PzoAmturnide 32 anagrelide 11 Analpram-HC 1-1% 2 6 KEY: TIER PAGE DRUG NAME TIER PAGE DRUG NAME Analpram-HC 2.5% cr/lot 3 6 anastrozole 11 Androderm patch 2 3 zAndrogel 23 Android 33 Antivert 50mg 2 6 zAnzemet 26 PApidra 31 +Apokyn 25 oapri 16 Apriso 36 oAptiom 35 Aptivus 23 oaranelle 16 +Aranesp 21 zArcalyst 21 Arcapta 35 aripiprazole 14 zoArnuity Ellipta 2 5 Asacol HD 2 6 PAscensia Breeze 1 zoAsmanex 25 Astagraf XL 2 3 PzoAtacand 32 PzoAtacand HCT 3 2 PzoAtelvia 34 oatenolol 12 oatenolol/chlorthalidone1 2 Ativan 34 zuoatorvastatin calcium1 2 atovaquone 13 atovaquone/proguanil HCl 1 3 Atripla 23 atropine sulfate ophth 1 2 Atrovent Nasal Spray 3 1 +zAubagio 34 aug. betamethasone diprop1 5 zAuryxia 36 PAuviQ 35 PzoAvalide 32 zAvandamet 21 zAvandaryl 21 zAvandia 21 PzoAvapro 32 PAvar 35 oaviane 16 avita cream 1 5 PAvita gel 3 5 +Avonex 24 PzAxert 34 PzAxiron 33 Azasite 32 azathioprine 13 azelastine nasal spray 1 1 azelastine ophth 1 2 PAzelex 35 azithromycin suspension 1 3 azithromycin tablets 1 3 oAzopt 22 zoAzor 32 oAzulfidine 36 B bacitracin ophth 1 2 bacitracin/polymyxin 12 baclofen 14 Bactroban cream 3 5 balsalazide 16 obalziva 16 oBanzel suspension 3 5 oBanzel tablets 2 5 Baraclude solution 3 3 PzoBeconase AQ 3 1 zBelbuca 34 belladonna & opium supp 1 4 belladonna/phenobarbital1 6 PzBelsomra 34 Belviq 36 obenazepril 12 obenazepril/HCTZ 12 PzoBenicar 32 PzoBenicar HCT 3 2 PBenzaclin 35 PBenzamycin 35 benzonatate 11 benzoyl peroxide 1 5 benzphetamine 16 obenztropine 15 Bepreve 32 +zBerinert 22 Besivance 32 betamethasone dipropionate1 5 P =A step edit applies to this drug. z =Specific Quantity Limits Apply. =Prior Authorization Required. u = Included in Tablet-Splitting Program + = Access restricted to specialty pharmacy. o = Home Service Delivery. betamethasone valerate 1 5 betamethasone valerate foam 35 betamethasone/clotrimazole1 5 +PBetaseron 34 betaxolol 12 obetaxolol HCl 1 2 +Bethkis 33 oBetoptic-S 22 +bexarotene 11 oBeyaz 36 Biaxin XL 3 3 bicalutamide 11 PzoBinosto 34 obisoprolol 12 obisoprolol/HCTZ 12 PzoBoniva 34 +zBosulif 21 Bravelle 26 oBrilinta 31 obrimonidine 12 Brisdelle 36 zBriviact 35 bromfenac 12 obromocriptine 15 brompheniramine/ phenylephrine 11 brompheniramine/ pseudoephedrine 11 budesonide EC 1 6 obudesonide inh. (0.25mg/2ml, 0.5mg/2ml) 15 obumetanide 12 PBunavail 34 buprenorphine 14 Pbuprenorphine-naloxone3 4 bupropion 13 zbupropion 16 bupropion ER 1 3 bupropion XL 1 3 buspirone 14 butalbital/APAP 14 butalbital/APAP/caffeine1 4 butalbital/APAP/codeine1 4 butalbital/aspirin/caffeine1 4 butalbital/aspirin/codeine1 4 butorphanol NS 1 4 PzBydureon 21 PzByetta 21 oBystolic 32 C +zCabometyx 31 Cafergot 34 calcipotriene 15 Pcalcipotriene-betamethasone 35 ointment zocalcitonin-salmon1 4 ocalcitriol 16 ocalcitriol inj 1 6 calcitriol ointment 3 5 calcium acetate 1 6 zCambia 34 ocamila 16 Campral dosepack 3 4 ocamrese 16 Canasa supp. 2 6 Pzocandesartan/HCTZ1 2 capecitabine 11 Capex Shampoo 3 5 zCaprelsa 21 ocaptopril 12 ocaptopril/HCTZ 12 Carac 35 Carbaglu 34 ocarbamazepine 15 ocarbamazepine XR 200mg, 400mg 1 5 ocarbidopa 35 ocarbidopa/levodopa1 5 ocarbidopa/levodopa SA 1 5 Cardec/DM 31 oCardura XL 3 2 carisoprodol 14 carisoprodol/ASA 14 ocarteolol 12 ocartia XT 1 2 ocarvedilol 12 zCaverject 23 +Cayston 33 CeeNu 21 cefaclor 13 TIER PAGE DRUG NAME cefadroxil 13 cefdinir 13 cefpodoxime 13 cefprozil 13 Ceftin 33 cefuroxime 13 zocelecoxib 14 Cellcept 23 oCelontin 25 oCenestin 26 Centany 35 cephalexin 13 24 +zCerdelga ocesia 16 ocetirizine 11 Cetrotide 26 zChantix 26 chloral hydrate 1 4 chlordiazepoxide 14 chlordiazepoxide/clindinium1 6 chloroquine phosphate 1 3 ochlorothiazide 12 chlorpromazine 14 chlorpropamide 11 ochlorthalidone 12 chlorzoxazone 14 Cholbam 26 cholecalciferol 16 ocholestyramine 12 ocholine mag. trisalicylate1 4 chorionic gonadotropin 10000 unit vial 1 6 zoCialis 23 ciclopirox cream 1 5 ciclopirox soln 1 5 ocilostazol 11 Ciloxan 32 ocimetidine 16 34 +PzCimzia zCinryze 22 Cipro HC 3 2 Ciprodex 22 ciprofloxacin 13 ciprofloxacin ophth 1 2 ucitalopram 13 citric acid/sod citrate 1 1 claravis 15 zoClarinex-D 31 clarithromycin susp 1 3 clarithromycin tabs 1 3 clemastine 11 Cleocin 33 PCleocin T 3 5 Cleocin Vag/Ovules 3 6 zoClimara Pro 3 6 clindamycin 13 clindamycin phospate 1 5 clindamycin sol/swabs/ 15 gel/lotion clindamycin/benzoyl peroxide 15 Clindesse 36 clobetasol propionate 1 5 clobetasol propionate shampoo 35 clomiphene 16 clomipramine 13 clonazepam 15 oclonidine, oral, patch 1 2 oclopidogrel 11 clorazepate 14 clotrimazole lozenge 1 3 clozapine 14 Coartem 23 codeine sulfate 1 4 colchicine/probenecid1 2 Colcrys 22 oColestid 22 ocolestipol 12 zoCombipatch 26 zCometriq 21 zCommit 26 Complera 23 PContour1 zContrave 36 3 4 +Copaxone 20mg 2 4 +Copaxone 40mg 33 +Copegus Cordran SP 3 5 Cordran tape 2 5 oCoreg CR 2 2 oCorgard 32 zoCorlanor TIER PAGE DRUG NAME zodonepezil 11 Donnatal tablet 2 6 PDoryx 35 odorzolamide 2% eye drops 1 2 odorzolamide/timolol eye drops 1 2 odoxazosin 12 doxepin 13 doxycycline 13 Pdoxycycline hyclate DR 3 5 PDoxycycline IR-DR 3 5 Dritho-Scalp 25 PDuac 35 Duavee 36 zDuetact 21 PDuexis 35 duloxetine 20mg, 30mg, 60mg1 3 duloxetine 40mg 3 3 zDuopa 25 zDurlaza 31 zodutasteride 1 3 odutasteride/tamsulosin3 3 Dutrebis 23 D zDyanavel XR 3 4 32 +PzDaklinza 23 oDynacirc/CR danazol 14 E dantrolene sodium 1 4 34 Dapsone 23 oEasprin 15 +Daraprim 23 econazole 33 DDAVP nasal spray 3 4 Ecoza 32 DDAVP sol, tab 3 4 PzoEdarbi P z oEdarbyclor 32 Delzicol 26 z Edex 33 Demerol 34 34 Denavir 35 PzEdluar 23 zoDepen 34 Edurant 21 oDepo-SubQ Provera 3 6 oEffient + z Egrifta 24 desipramine 13 25 zodesloratadine 31 8-MOP 25 desmopressin solution 1 4 Elidel Eliquis 31 desmopressin tabs 1 4 35 desonide 15 oElixophyllin 31 desoximetasone 15 +Eloctate Embeda 34 Desvenlafaxine ER 3 3 Emcyt 21 Desvenlafaxine Fumarate ER3 3 26 PzDetrol 31 zEmend 23 PzDetrol LA 3 1 Emtriva P z Enablex 31 dexameth/neomycin/poly B1 2 oenalapril 12 dexamethasone oral 1 6 12 dexchlorpheniramine11 oenalapril/HCTZ 24 PzoDexilant 36 +zEnbrel endocet 14 dexmethylphenidate 14 oEnjuvia 26 dexmethylphenidate XR 1 4 11 dextroamphetamine tabs 1 4 enoxaparin oenpresse 16 diazepam 14 PEnstilar 35 oDibenzyline 22 15 zDiclegis 36 oentacapone 3 3 diclofenac 12 entecavir tablets z oEntresto 32 odiclofenac potassium 1 4 enulose 16 odiclofenac sodium 1 4 3 3 diclofenac sodium 3% gel3 5 zEnvarsus XR 32 zdiclofenac sodium gel 1%1 4 oEpaned z Epanova 32 Pzdiclofenac sodium 35 topical solution 3 5 PEpiduo/Forte epinephrine inj. 1 5 odiclofenac sodium/ Epipen/Jr. 25 misoprostol 35 Epivir solution 2 3 dicloxacillin 13 2 3 dicyclomine 16 Epivir-HBV solution 12 didanosine 13 zoeplerenone + Epogen 31 diethylpropion 16 33 PDifferin 35 epoprostenol 1 2 zDificid 33 zoeprosartan 600mg 23 diflorasone 15 Epzicom oergocalciferol capsule 1 6 odiflunisal 14 1 1 digoxin 12 ergoloid mesylates 24 zdihydroergotamine mesylate1 4 Ergomar oDilantin 25 ergotamine/caffeine 14 21 oDilatrate SR 2 3 +zErivedge 16 odiltia XT 1 2 oerrin 23 odiltiazem 12 Ery-Tab erythromycin base 1 3 odiltiazem CD/SR/ER/XR 1 2 3 3 PzoDiovan 32 erythromycin estolate 3 PzoDiovan HCT 3 2 erythromycin ethylsuccinate1 1 2 Dipentum 26 erythromycin ophth diphenhydramine 11 erythromycin sol/swabs/gel 15 1 3 diphenoxylate/atropine1 6 erythromycin stearate odipyridamole 11 erythromycin/benz peroxide1 5 odisopyramide 12 erythromycin/sulfisoxazole1 3 disulfiram 14 uescitalopram 13 PzDitropan XL 3 1 Pzoesomeprazole 36 odivalproex sodium/ER 1 5 magnesium Domeboro 32 estazolam 14 Cortifoam cortisone acetate +zCosentyx +zCotellic Coumadin PzoCozaar oCreon zCresemba zuoCrestor oCrinone 8% Crixivan cromolyn ophth ocromolyn sodium ocryselle zoCuprimine ocyanocobalamin inj. cyclobenzaprine cyclophosphamide cyclosporine cyproheptadine Cystadane +Cystaran 32 26 1 6 35 21 21 32 26 33 22 3 6 23 1 2 1 6 16 24 1 6 14 11 13 11 34 22 TIER PAGE Note: 1. * Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive. 2. * Some drugs are limited to 1 unit of use package per dispensing. 7 183894_MG46602S -BCBS NENY - INSURED_v1.indd 7 6/1/16 12:54 PM Section II — Index (cont’d) DRUG NAME TIER PAGE DRUG NAME oEstrace Vag. Cream 2 6 zoEstraderm 26 zoestradiol oral 1 6 zoestradiol patches 1 6 zoestradiol/noreth ac 1 6 zoEstrasorb packet 3 6 zoEstring 26 zoEstrogel 36 zoestrogen/methyltesterone1 6 zoestropipate 16 Pzeszopiclone 34 oethambutol 13 oethosuximide 15 oetidronate 16 oetodolac 14 oetodolac SA 1 4 etoposide 11 Eurax 35 oEvamist 26 PEvoclin 35 Evotaz 23 zEvzio 34 Exelderm 25 exemastine 11 zoExforge HCT 3 2 +Exjade 21 +PExtavia 34 F PFabior 35 33 13 1 2 16 34 21 31 21 34 15 1 2 36 12 Factive zfamciclovir zfamciclovir ophth ofamotidine zFanapt Fareston PzFarxiga +zFarydak Fazaclo felbamate ofelodipine ER zoFemring ofenofibrate zofenofibric acid, capsule DR 3 2 ofenofibric acid, tab 1 2 ofenoprofen 14 zfentanyl lozenge 1 4 fentanyl patch 1 4 fentanyl patch 37.5mcg/hr, 62.5mcg/hr, and 87.5mcg/hr 3 4 zFentora 34 Ferriprox 31 Fetzima 33 zofexofenadine 11 zofexofenadine-D 11 PFinacea 35 zofinasteride 5mg 1 3 Fioricet/codeine 34 Fiorinal/codeine 34 +zFirazyr 22 Flagyl/ER 33 Flarex 32 oflecainide 12 PzFlector 35 Flonase Allergy Relief 1 1 zoFlovent HFA/Diskus 2 5 fluconazole 13 flucytosine 13 fludrocortisone 14 zoflunisolide nasal spray 3 1 fluocinolone acetonide 1 5 fluocinonide 15 fluocinonide cream (generic Vanos) 3 5 fluorometholone ophth 1 2 Fluoroplex 35 fluorouracil 15 ufluoxetine 10mg and 13 20mg tablet fluoxetine 60mg tablet 3 3 fluoxetine capsule 1 3 fluoxymesterone 33 fluphenazine 14 flurazepam 14 oflurbiprofen 15 flurbiprofen ophth 1 2 flutamide 11 zofluticasone nasal spray1 1 fluticasone propionate 1 5 zofluvastatin 32 KEY: TIER PAGE DRUG NAME TIER PAGE DRUG NAME fluvoxamine ER capsule 3 3 ufluvoxamine tablet 1 3 FML Forte 2 2 FML S.O.P. 2 2 Focalin XR 3 4 1 6 ofolic acid Rx 1mg tab Follistim AQ 2 6 fondaparinux sodium 1 1 zForadil 25 Forfivo 33 31 PzFortamet 24 +zForteo 33 PzFortesta zofortical NS 1 4 34 PzoFosamax 3 4 PzoFosamax D ofosinopril 12 ofosinopril/HCTZ 12 Fosrenol 36 Fragmin 21 PFreestyle1 34 PzFrova Fulyzaq 26 ofurosemide 12 +Fuzeon 23 zFycompa 35 G ogabapentin 15 oGabitril 12mg, 16mg 2 5 zogalantamine 11 zogalantamine ER 1 1 Galzin 26 4 +Gammagard Liquid 3 34 +Gammaked 34 +Gamunex-C ganciclovir 13 Ganirelix 36 gatifloxacin 12 36 +Gattex 31 PzGelnique ogemfibrozil 12 generic Adderall 1 4 generic Adderall XR 1 4 generic Concerta 1 4 generic Dexedrine spansules 14 gengraf 13 +PGenotropin 34 gentamicin cr/oint 1 5 gentamicin ophth 1 2 Genvoya 23 Giazo 36 24 +zGilenya zGilotrif 21 14 +zglatopa zglimepiride 11 glipizide 11 zglipizide ER 1 1 zglipizide/metformin 11 Glucagon 21 31 PzGlumetza glyburide 11 glyburide micronized 1 1 glycopyrrolate 16 zGlyset 31 zGlyxambi 31 PGonal F 3 6 zGralise 34 zgranisetron 16 zGranisol 36 31 +Granix zGrastek 31 griseofulvin 13 Guaifenesin DM 3 1 guaifenesin/codeine 11 oguanabenz 12 oguanfacine 12 guanfacine ER 1 4 Gynazole-1 36 H Halflytely halobetasol halobetasol propionate Halog haloperidol +zHarvoni Helidac Hemangeol heparin zHepsera 26 15 1 5 35 14 23 36 32 11 23 P =A step edit applies to this drug. z =Specific Quantity Limits Apply. =Prior Authorization Required. u = Included in Tablet-Splitting Program + = Access restricted to specialty pharmacy. o = Home Service Delivery. +zHetlioz 24 Hexalen 21 34 +Hizentra homatropine 12 PzHorizant 34 2 4 +zHP Acthar Gel Humalog insulin 2 1 +PHumatrope 34 24 +zHumira Humulin (all types) 2 1 +Hycamtin 21 Hycodan 31 ohydralazine 13 ohydrochlorothiazide1 2 hydrocodone/APAP 14 hydrocodone/ chlorpheniramine 11 hydrocodone/homatropine1 1 hydrocodone/ibuprofen1 4 hydrocortisone 2.5% 1 5 hydrocortisone butyrate/ emoll cream 3 5 hydrocortisone oral 1 6 hydrocortisone rectal cr. & supp. 1 6 hydrocortisone rectal enema 1 6 hydrocortisone valerate 1 5 hydrocortisone/iodoquinol1 5 hydromorphone 14 hydromorphone ER 3 4 ohydroxychloroquine1 4 hydroxyurea 11 hydroxyzine HCl 1 1 hydroxyzine pamoate 1 1 hyoscyamine/CR 16 34 +HyQvia Hysingla ER 3 4 32 PzoHyzaar I zoibandronate tabs +zIbrance 1 4 21 oibuprofen 15 zIclusig 21 11 +zimatinib zImbruvica 21 imipramine 13 imiquimod 5% cream 1 5 34 PzImitrex zImpavido 33 34 +Increlex oindapamide 12 oindomethacin 15 33 +Infergen 21 +zInlyta Innohep 31 oInnopran XL 2 2 Intelence 23 34 PzIntermezzo 2 1 +Intron A Invirase 23 zInvokamet 21 zInvokana 21 ipratropium nasal spray 1 1 zoirbesartan 12 zoirbesartan/HCTZ 12 zIressa 21 Isentress 23 isometh/dichloralphen/ APAP 14 oisoniazid 13 oIsopto Carbachol 1.5% 2 2 oIsopto Carbachol 3% 3 2 oisosorbide dinitrate 1 3 oisosorbide mononitrate 1 3 oisosorbide mononitrate SA 13 oisoxsuprine 13 oisradipine 12 oIstalol 32 zitraconazole 13 PIzba 32 J +Jadenu +zJakafi jantoven zJanumet zJanumet XR zJanuvia zJardiance Jentadueto 21 21 11 21 2 1 21 21 21 TIER PAGE DRUG NAME zojinteli ojolessa ojolivette zJublia ojunel/FE Juvisync zJuxtapid 16 16 16 35 16 21 32 K K-Phos 31 Kadian (40mg, 70mg, 130mg, 150mg, 200mg) 2 4 Kaletra 23 okariva 16 Kayexalate 35 PKazano 31 Kenalog/aerosol 35 zKerydin 35 Ketek 23 ketoconazole 13 ketoconazole 15 oketoprofen 15 ketorolac inj. 1 5 zketorolac tab 1 5 ketorolac tromethamine 1 2 ketotifen opthalmic solution3 2 zKeveyis 2 4 Khedezla 33 zKineret 24 3 3 +zKitabis Pak PKombiglyze XR 3 1 zKorlym 34 26 +Kuvan 22 +zKynamro L olabetalol 12 lactulose 16 zLamisil Oral 3 3 lamivudine tabs 1 3 lamivudine/zidovudine1 3 olamotrigine 15 olamotrigine ER/ODT 3 5 Lanoxin 22 zolansoprazole 16 lansoprazole/amox/clarith3 6 Lantus 21 olatanoprost 12 zLatuda 24 zLazanda 34 leflunomide 14 zLenvima 21 zoLescol XL 3 2 olessina 16 23 +zLetairis letrozole 11 leucovorin 16 Leukeran 21 21 +Leukine leuprolide 11 PLevemir 31 olevetiracetam 15 33 PzoLevitra olevobunolol 12 levocarnitine 16 zolevocetirizine 11 levofloxacin 13 olevora 16 levothroid 16 olevothyroxine 16 olevoxyl 16 Lexiva 23 Librium 34 lidocaine 15 zlidocaine patch 1 5 Liletta 36 Lindane 25 Linzess 26 oliothyronine 16 oLiptruzet 32 olisinopril 12 olisinopril/HCTZ 12 lithium carbonate 1 4 oLivalo 32 21 +zLonsurf loratadine 11 loratadine-D 11 lorazepam 14 zolosartan 12 zolosartan/HCTZ 12 Lotemax 22 zuolovastatin 12 TIER PAGE DRUG NAME olow-ogestrel loxapine oLumigan PzLunesta olutera Luzu zLynparza Lyrica Lysodren 16 14 22 34 16 33 21 35 21 M Macrodantin 33 maprotiline 13 Matulane 21 zMaxair Autohaler 2 5 PzMaxalt 34 PzMaxalt MLT 3 4 Maxidex 32 Maxitrol ophth 3 2 meclizine 16 omeclofenamate 15 Medrol 2mg 2 6 omedroxyprogesterone1 6 omefenamic acid 1 5 mefloquine 13 megestrol 11 +zMekinist 21 omeloxicam 15 zomemantine 11 oMenest 26 Menopur 36 zoMenostar 36 meperidine 14 mephobarbital 15 oMephyton 26 meprobamate 14 mercaptopurine 11 mesalamine enema 1 6 Mesnex 21 metadate ER 1 4 ometaproterenol syr 1 5 metaxalone 14 metformin 11 Pmetformin ER (except generic Glucophage XR) 3 1 zmetformin ER (generic Glucophage XR) 1 1 zmetformin/glyburide1 1 methadone 14 omethazolamide 12 methenamine combination1 3 Methergine 36 omethimazole 16 methocarbamol 14 methotrexate 11 methotrexate 14 omethyclothiazide 12 omethyldopa 12 omethyldopa/HCTZ 12 methylergonovine maleate 1 6 methylphenidate CD 1 4 methylphenidate/SR 14 methylprednisolone 4mg, 8mg, 16mg, 32mg 1 6 ometipranolol 12 metoclopramide 16 ometolazone 12 ometoprolol 12 ometoprolol ER 1 2 ometoprolol/HCTZ 12 ometoprolol/HCTZ 12 PMetrogel topical 1% 3 5 metronidazole 13 metronidazole cream/ lotion/ 0.75% gel 1 5 omexiletine 12 oMiacalcin inj. 2 1 PzoMicardis 32 PzoMicardis HCT 3 2 miconazole vag supp 1 6 oMicro-K 35 omicrogestin/FE 16 midodrine 12 midodrine 12 Minitran 33 Minocin 33 minocycline 13 minocycline 15 Pminocycline HCl ER 3 5 ominoxidil oral 1 3 Mircera 31 Mirena 26 TIER PAGE umirtazapine PMirvaso omisoprostol zMitigare zmodafinil +moderiba omoexipril mometasone cr/oint Pzmometasone nasal spray omononessa omontelukast morphine SR zmorphine sulfate ER morphine tab, soln, supp zMovantik moxifloxacin oMultaq omultivitamin V fluoride mupirocin zMUSE zMyalept oMyambutol mycophenolate mofetil mycophenolic acid Myleran zMyrbetriq 13 35 16 32 14 13 12 1 5 3 1 16 15 1 4 1 4 1 4 36 33 22 1 6 15 23 24 33 1 3 1 3 21 21 N onabumetone 15 onadolol 12 Naftin 35 naltrexone 14 zoNamenda XR 2 1 zNamzaric 31 naphazoline 12 oNaprosyn 35 onaproxen/EC 15 znaratriptan 14 zNarcan nasal spray 2 4 PzoNasacort AQ 3 1 zNasacort OTC 1 1 oNascobal 26 PzNasonex 31 znateglinide 11 PzNatesto 33 +Natpara 34 Nebupent 23 onecon 16 nefazodone 13 neomycin 13 neomycin/bacitracin/ poly B 1 2 neomycin/bacitracin/ poly B/HC 1 2 neomycin/polymyxin/ HC otic 1 2 Neoral 23 PNesina 31 Neulasta 21 +Neumega 31 +Neupogen 21 Nevanac 22 +zNexavar 21 PzoNexium 36 zNexium 24HR 1 6 zoNexium susp 2 6 oniacin ER 1 2 zoniacin/simvastatin1 2 onicardipine 12 zNicorelief gum 1 6 zNicorelief lozenge 1 6 zNicotine Gum 1 6 zNicotine lozenges 1 6 zNicotine patches various 1 6 zNicotrol Inhaler 2 6 zNicotrol NS 2 6 onifediac CC 1 2 onifedical XL 1 2 onifedipine 12 onifedipine SR 1 2 Nilandron 21 onimodipine 12 +zNinlaro 21 onisoldipine 12 NitroDur patches 3 3 nitrofurantoin 13 nitrofurantoin 13 nitroglycerin pumpspray 1 3 nitroglycerin SR 1 3 nitroglycerin transdermal patch 13 Note: 1. * Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive. 2. * Some drugs are limited to 1 unit of use package per dispensing. 8 183894_MG46602S -BCBS NENY - INSURED_v1.indd 8 6/1/16 12:54 PM Section II — Index (cont’d) DRUG NAME TIER PAGE DRUG NAME Nitrostat SL tabs 2 3 onizatidine 16 onora-BE 16 24 +Norditropin onorethindrone 16 onorethindrone a-e estradiol/ ferrous fumarate 16 PNoritate 35 Noroxin 33 oNorpace/CR 22 22 +zNorthera onortrel 16 nortriptyline 13 Norvir 23 Novarel 26 PNovolin 31 PNovolog 31 zNoxafil 23 Nucynta/ER 34 zNuedexta 34 Nulytely 36 +PNutropin/AQ 34 oNuvaRing 26 zNuvigil 34 zoNymalize 32 nystatin 13 nystatin 15 nystatin vag tab 1 6 nystatin/triamcinolone1 5 nystop 15 O oocella 16 +octreotide 14 21 +zOdomzo ofloxacin 13 ofloxacin ophth 1 2 ofloxacin otic 1 2 oogestrel 16 zolanzapine 14 zolanzapine/fluoxetine3 4 zuOleptro ER 3 3 olopatadine ophth 1 2 23 +zOlysio zomega-3 acid ethyl esters3 2 zoomeprazole 16 31 PzoOmnaris +POmnitrope 34 Omontys 31 zOmtryg 32 zondansetron 16 OneTouch Test Strips 1 POnexton 35 POnglyza 31 34 PzOnzetra 33 +zOpsumit POracea 35 Oracit 31 31 +zOralair Oravig 33 3 4 +PzOrencia SC zOrenitram 33 Orfadin 26 orphenadrine 14 oOrtho Tri-Cyclen Lo 2 6 Ortho-Est 36 POseni 31 Osphena 36 34 +PzOtezla Otrexup 34 oOvcon-50 26 Ovidrel 26 ooxaprozin 15 oxazepam 14 ooxcarbazepine 15 Oxistat 25 Oxsoralen Ultra 2 5 oOxtellar XR 3 5 oxybutynin 11 zoxybutynin ER 1 1 oxycodone 14 Oxycodone ER 2 4 oxycodone/acetaminophen1 4 oxycodone/aspirin 14 oxycodone/ibuprofen14 Oxycontin 24 oxymorphone/ER 14 31 PzOxytrol KEY: TIER PAGE DRUG NAME TIER PAGE DRUG NAME P zpaliperidone 34 oPancreaze 36 Panretin 25 zopantoprazole 16 Paragard 36 paregoric 16 paricalcitol 36 paromomycin 13 uparoxetine 13 Pataday 32 Pazeo 32 PCE 33 peg 3350/electrolyte 1 6 +PPeg-Intron 33 oPeganone 35 23 +Pegasys penicillin VK 1 3 35 PzPennsaid Pentasa 26 pentazocine/naloxone1 4 pentoxifylline 11 pergolide 35 operindopril 12 permethrin 15 perphenazine 14 oPertzye 36 Pexeva 34 phenazopyridine 11 phenelzine 13 phenobarbital 15 phentermine 16 phenylephrine ophth 1 2 ophenytoin 15 Phisohex 25 Phospholine Iodide 2 2 ophytonadione 26 Picato 25 opilocarpine 12 opindolol 12 zpioglitazone/metformin1 1 opiroxicam 15 34 +PzPlegridy podofilox 15 oPoly-Vi-Flor V Iron 3 6 polymyxin B/TMP 1 2 21 +zPomalyst oportia 16 6 potassium aminobenzoate 1 opotassium bicarb/ potassium chloride 1 5 opotassium bicarbonate 1 5 opotassium chloride 1 5 potassium citrate 1 1 Potiga 35 zPradaxa 21 22 +zPraluent opramipexole 15 opramipexole ER 3 5 6 pramoxine/HC acetate 2.5% 1 prascion RA 1 5 zuopravastatin 12 oprazosin 12 opre-natal vitamins 1 6 PPrecision2 Pred Mild 2 2 Pred-G 32 prednicarbate 15 prednisolone acetate 1 2 prednisolone oral 1 6 prednisolone sod phosphate 12 prednisone oral 1 6 zoPrefest 36 Pregnyl 36 oPremarin 26 Premarin vag cream 2 6 oPremphase 26 Prempro 26 oPrenate Elite 2 6 Prepopik 36 zoPrestalia 32 36 PzoPrevacid zPrevacid 24HR 1 6 zoPrevacid Solutab 2 6 oprevifem 16 Prezcobix 23 Prezista 23 36 PzoPrilosec zPrilosec-OTC 16 Primaquine 23 P =A step edit applies to this drug. z =Specific Quantity Limits Apply. =Prior Authorization Required. u = Included in Tablet-Splitting Program + = Access restricted to specialty pharmacy. o = Home Service Delivery. oprimidone 15 Pristiq ER 2 3 zProAir HFA/RespiClick 2 5 probenecid 12 procainamide 12 procentra 14 prochlorperazine 16 21 +Procrit Proctofoam-HC 26 Procysbi 34 progesterone in oil 1 6 6 oprogesterone, micronized 1 Prograf 23 Prolensa 32 21 +zPromacta promethazine 16 promethazine/codeine1 1 promethazine/DM 11 promethazine/ phenylephrine/ codeine 1 1 opropafenone 12 opropafenone SR 1 2 propantheline bromide 1 6 opropranolol 12 opropranolol/HCTZ 12 opropylthiouracil 16 36 PzoProtonix protriptyline 13 zProventil HFA 3 5 pseudoephedrine 11 pseudoephedrine/codeine1 1 zoPulmicort flexhaler/ powder 25 oPulmicort respules (1mg/2ml) 25 Purixan 21 opyrazinamide 13 Q PzoQnasl zQsymia oquasense oQudexy XR zquetiapine zQuillichew ER Quillivant XR oquinapril oquinapril/HCTZ oquinidine gluconate oquinidine sulfate SR quinine sulfate zoQvar R zorabeprazole zRagwitek zoraloxifene 31 36 16 3 5 14 3 4 3 4 12 12 1 2 1 2 3 3 25 36 31 14 oramipril 12 oRanexa 22 oranitidine (all) 1 6 oRapaflo 33 Rapamune solution 2 3 Rasuvo 34 34 +Ravicti Rayos 36 33 +Rebetol 24 +Rebif Rectiv 35 Regenecare 35 Regranex 25 zRelenza 23 Relistor 26 zRelpax 24 Renagel 26 Renvela 26 zrepaglinide 11 repaglinide/metformin3 1 22 +zRepatha Repronex 26 Rescriptor 23 PoRescula 32 Restasis 22 PRetin-A/Micro 35 21 +zRevlimid zRexulti 34 Reyataz 23 3 1 PzoRhinocort Aqua 13 +ribapak 13 +ribasphere 33 +Ribatab 13 +ribavirin oRidaura 24 TIER PAGE DRUG NAME orifabutin oRifadin oRifamate orifampin oRifater riluzole rimantadine Riomet solution zorisedronate 150mg Pzorisedronate DR zrisperidone zrisperidone m-tab Ritalin LA 10mg, 60mg zorivastigmine zorivastigmine patch zrizatriptan Rondec DM/TR oropinirole oropinirole ER PRosula Roxicet Soln PRozerem +zRuconest oRytary 13 33 33 13 23 14 13 3 1 3 4 3 4 14 1 4 2 4 11 1 1 14 3 1 15 3 5 35 3 4 34 22 35 S Sabril 35 +PSaizen 34 osalsalate 14 +zSamsca 22 PzSanctura 31 PzSanctura XR 3 1 zSancuso 36 Sandimmune 23 +Sandostatin 34 +Sandostatin LAR 3 4 zSaphris 24 Sarafem 34 zSavaysa 31 Savella 34 zSaxenda 36 zSeebri 35 zoselegiline 15 selenium sulf 2.5% suspension 15 Selzentry 23 Semprex-D 21 +Sensipar 24 zSerevent Diskus 2 5 serophene 16 zSeroquel XR 2 4 +PSerostim 34 usertraline 13 sevelamer 16 zSignifor 24 +zsildenafil citrate 1 3 PzSilenor 34 silver sulfadiazine 1 5 +PzSimponi 34 zuosimvastatin 12 sirolimus 13 oSirturo 33 zSitavig 33 zSivextro 23 Sklice 35 Skyla 26 sod. polystyrene sulfonate1 5 sod. sulfacetamide/sulfur emulsion cleanser 1 5 sod. sulfacetamide/sulfur lot1 5 sodium chloride irrigating soln 1 5 osodium fluoride chewable 1 6 tab & drops +sodium phenylbutyrate 3 4 sodium sulfacetamide 1 5 osolia 16 PSolodyn 35 +Somatuline Depot 3 4 +zSomavert 34 Somnote 34 PzSonata 34 Soolantra 35 osotalol 12 sotret 15 +zSovaldi 23 Spectracef 33 spinosad 15 ospironolactone 12 ospironolactone/HCTZ1 2 zSporanox suspension 2 3 osprintec 16 TIER PAGE DRUG NAME zSprix +zSprycel 35 21 stavudine 13 PzoStaxyn 33 +PzStelara 35 PzoStendra 33 Stimate 24 +Stivarga 21 Strattera 24 Strensiq 24 PStriant 33 Stribild 23 zStriverdi Respimat 3 5 Suboxone film 2 4 Suboxone tablet 3 4 zSubsys 34 Suclear 36 osucralfate 16 sulfacetamide 10% 1 2 sulfacetamide/prednisolone ophth 12 sulfamethoxazole/ trimethoprim 13 osulfasalazine 16 osulfasalazine EC 1 6 osulindac 15 zsumatriptan 14 zSumavel 34 Suprax 33 Suprenza ODT 3 6 Sustiva 23 +zSutent 21 +zSylatron 21 zSymlin 21 Synarel 24 zSynjardy 21 +zSynribo 21 oSynthroid 26 +Syprine 21 T PTaclonex 35 tacrolimus 13 tacrolimus 15 +zTafinlar 21 zTagrisso 21 +zTaltz 35 zTamiflu 23 tamoxifen 11 otamsulosin 13 PzTanzeum 31 +zTarceva 21 Targiniq ER 3 4 Targretin gel 2 1 +zTasigna 21 Tasmar 35 PTazorac 35 +zTecfidera 24 +PzTechnivie 33 oTegretol 25 oTegretol XR 100mg 2 5 PzoTekamlo 22 PzoTekturna 22 PzoTekturna HCT 2 2 zotelmisartan 12 zotelmisartan/amlodipine3 2 zotelmisartan/HCTZ12 temazepam 14 +Temodar 31 +temozolomide 11 oterazosin 12 zterbinafine 13 oterbutaline tab 1 5 terconazole 16 PzTestim 33 testosterone cypionate 1 3 testosterone 13 enanthionate PzTestosterone gel (brand) 33 tetracycline 13 +PTev-Tropin 34 PzoTeveten 32 PzoTeveten HCT 3 2 +Thalomid 21 oTheo-24 25 otheochron 15 otheophylline/SR tabs, liquid 15 thioridazine 14 thiothixene 14 othyroid 16 TIER PAGE oThyroid (Armour) 2 6 oThyrolar 26 oticlopidine 11 oTikosyn 32 otimolol 12 otimolol 12 tinidazole 13 Tivicay 23 oTivorbex 35 tizanidine 14 +Tobi 33 +Tobi Podhaler 2 3 Tobradex ointment 2 2 +tobramycin ampule/neb 1 3 tobramycin soln 1 2 tobramycin/dexameth1 2 Tobrex ointment 2 2 Tobrex solution 3 2 tolazamide 11 tolbutamide 11 otolmetin 15 ztolterodine 11 ztolterodine ER 1 1 otopiramate 15 otopiramate ER 3 5 otorsemide 12 Toujeo 21 zToviaz 21 23 +zTracleer Tradjenta 21 tramadol ER capsule 3 4 tramadol/acetaminopen1 4 tramadol/ER tablet 1 4 otrandolapril 12 otrandolapril/verapamil3 2 Transderm Scop 2 6 tranylcypromine 13 PoTravatan Z 3 2 otravoprost 12 trazodone 13 PTresiba 31 tretinoin cr/gel 1 5 Ptretinoin microsphere3 5 Trexall 31 34 PzTreximet Trezix 34 otri-sprintec 16 oTri-Vi-Flor 36 triamcinolone acetonide 1 5 zotriamcinolone acetonide nasal spray 3 1 otriamterene/HCTZ 12 triazolam 14 zoTribenzor 32 trifluoperazine 14 trifluridine 12 otrihexyphenidyl 15 Trilyte 16 trimethobenzamide 16 trimethoprim 13 otrinessa 16 Trintellix 34 otriprevifem 16 Triumeq 23 otrivora 16 oTrokendi XR 3 5 tropicamide 12 ztrospium 11 ztrospium ER 1 1 PTRUEtest2 PTRUEtrack2 PzTrulicity 31 Truvada 23 Twinject 25 Tybost 23 21 +zTykerb Tylenol/codeine 34 zTyvaso 33 zTyzeka 33 U Uceris Ulesfia PzUloric oUltresa ounithroid zUptravi Urecholine oursodiol zUtibron 36 25 32 36 16 23 31 16 35 Note: 1. * Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive. 2. * Some drugs are limited to 1 unit of use package per dispensing. 9 183894_MG46602S -BCBS NENY - INSURED_v1.indd 9 6/1/16 12:54 PM Section II — Index (cont’d) DRUG NAME TIER PAGE DRUG NAME V oVagifem zvalacyclovir zValchlor Valcyte valganciclovir tablets ovalproic acid zovalsartan zovalsartan/HCTZ zValtrex Vancocin vancomycin caps vandazole vag zVarubi Vascepa veletri ovelivet Velphoro +zVeltassa PVeltin gel zVenclexta uvenlafaxine KEY: venlafaxine ER 26 13 21 33 1 3 1 5 12 12 33 33 1 3 1 6 36 32 33 16 36 34 3 5 31 13 zVentavis zVentolin HFA PzoVeramyst overapamil/SR PVersacloz zVesicare PzoViagra Vibramycin Vicodin/ES PzVictoza +Victrelis Videx +PzViekira Vigamox Viibryd PzoVimovo Vimpat oViokace Viracept Viramune, XR Viread ovit A,D,C V fluoride TIER PAGE DRUG NAME TIER PAGE DRUG NAME 1 3 33 2 5 31 12 34 21 33 33 34 21 23 23 23 22 23 35 35 36 23 2 3 23 1 6 P =A step edit applies to this drug. z =Specific Quantity Limits Apply. =Prior Authorization Required. u = Included in Tablet-Splitting Program + = Access restricted to specialty pharmacy. o = Home Service Delivery. ovit A,D,C V fluoride and iron Vitekta Vituz Vivaglobin PzVivlodex PzVogelxo zvoriconazole +zVotrient zVraylar zoVytorin Vyvanse W warfarin oWelchol X PoXalatan +zXalkori Xarelto Xartemis XR +PzXeljanz 1 6 23 31 34 35 33 13 21 34 32 24 TIER PAGE DRUG NAME +PzXeljanz XR +zXenazine Xenical zXifaxan PzXigduo XR Xopenex HFA +zXtandi Xtoro oxulane zXuriden 3 4 23 36 33 3 1 3 5 21 32 16 34 yohimbine 13 Y Z 11 32 Zaditor ozafirlukast zzaleplon 32 ozarah 21 +Zarxio 21 zZavesca 3 4 +PzZecuity 34 PzoZegerid 32 15 14 16 31 24 34 36 +zZelboraf PzZembrace ozenchent oZenpep +PzZepatier zoZetia PzoZetonna Ziagen PZiana gel zidovudine PoZioptan zziprasidone caps Zmax Zohydro ER +zZolinza zzolmitriptan zzolpidem zzolpidem ER Pzzolpidem ER sublingual tablet PzZolpimist PzZomig PzZomig Nasal TIER PAGE DRUG NAME 21 34 16 26 33 32 31 23 3 5 13 32 1 4 23 3 4 21 14 14 1 4 34 34 34 3 4 TIER PAGE PzZomig ZMT ozonisamide zoZontivity +PZorbtive Zortress oZorvolex ozovia Zovirax Cream PZubsolv zZuplenz PzZurampic zZyban zZydelig zoZyflo/CR +zZykadia Zylet zZyprexa zZyprexa Zydis +zZytiga zZyvox 3 4 15 31 34 23 35 16 2 5 34 36 32 36 21 35 21 32 34 3 4 21 23 Note: 1. * Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive. 2. * Some drugs are limited to 1 unit of use package per dispensing. 10 183894_MG46602S -BCBS NENY - INSURED_v1.indd 10 6/1/16 12:54 PM 183894_MG46602S -BCBS NENY - INSURED_v1.indd 11 6/1/16 12:54 PM