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BlueCross BlueShield Medicaid Formulary Guide Please bring this guide with you the next time you visit your doctor. * M G 4 6 6 0 5 A* If you have questions about your prescription drug benefit, visit the Pharmacy Services section of the BlueCross BlueShield web site at www.bcbswny.com. MG46605A (Revise Date 07/01/2016) A Division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. The Cross and Shield are registered trademarks of the BlueCross BlueShield Association. 183894_MG46605A -BCBS WNY - Medicaid_v2.indd 1 6/1/16 12:51 PM 183894_MG46605A -BCBS WNY - Medicaid_v2.indd 1 6/1/16 12:51 PM TABLE OF CONTENTS Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii Formularies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii Understanding the symbols used throughout this book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using 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 — Medicaid Over-the-Counter (OTC) Medication List . . . . . . . . . . . . . . . . . . . . . . . . . 5 Section III — Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 ii 183894_MG46605A -BCBS WNY - Medicaid_v2.indd 2 6/1/16 12:51 PM The BlueCross BlueShield Medicaid Formulary Guide 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 BlueCross Blue Shield of Western 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. Formularies In order to serve the diverse needs of patients and their plan sponsors, BlueCross BlueShield of Western New York makes available this formulary design: Closed Formulary—Features the requirement that prescribed drugs must be on the formulary in order for the member to receive coverage. If a prescription is written for a medication that is not on the formulary, the patient will be responsible for the full cost. If special circumstances necessitate that the patient take the nonpreferred drug, prescribers may request a coverage review. If coverage is approved, the medication will be covered. If coverage is not approved, the patient will be responsible for the full cost of the medication. 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 network specialty pharmacies. Medications must be obtained through a specialty pharmacy. iii 183894_MG46605A -BCBS WNY - Medicaid_v2.indd 3 6/1/16 12:51 PM Using this formulary book to help contain costs We realize that the formulary may not include every drug from every manufacturer. However, using a generic or preferred drug can help you stay healthy at a more affordable cost. 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. Formulary generic drugs Formulary brand-name drugs Non-formulary drugs Lowest cost to you Highest cost to you The amount you pay for a drug is determined by which medication you purchase and where it appears on the guide. Some drug plans also 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. 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 on the guide to see what drugs are on the formulary. Generic drugs are listed as G and brand drugs are listed with a B. Section 2:Alphabetically by drug name. Use this list to find your drug. Questions? Please call Member Services at 1-866-544-7948 if you have any questions about the BlueCross BlueShield Medicaid Formulary Guide. For the most up-to-date version of the Guide, visit the Pharmacy Services section of our web site at www.bcbswny.com/NYSdrug. Disclaimer: The BlueCross BlueShield Medicaid/Family Health Plus Formulary Guide is subject to change, as we regularly review medications and existing therapies for inclusion in the BlueCross BlueShield Medicaid Formulary Guide. The tier that a medication is currently in may change during the effective dates of the guides due to generic availability. iv 183894_MG46605A -BCBS WNY - Medicaid_v2.indd 4 6/1/16 12:51 PM Section I — Therapeutic drug categories TIER Allergy/Cough & Cold Antihistamines & Decongestants brompheniramine/ phenylephrineG brompheniramine pseudoephedrineG zcetirizine G chlorpheniramine/ pseudoephedrineG clemastine G cyproheptadine G dexchlorpheniramine G diphenhydramine G hydroxyzine HCL G hydroxyzine pamoate G loratadine G loratadine-D G promethazine G pseudoephedrine G zGrastek B Histex IE B zOralair B zRagwitek B Semprex-D B Expectorant & Cough Products benzonatate G cardec/DM G guaifenesin 1200/DM G guaifenesin/codeine G hydrocodone/chlorpheniramineG hydrocodone/homatropineG promethazine/codeine G pseudoephedrine/codeine G Mucolytic Agents acetylcysteine inh soln. G z z z azelastine 0.1% nasal spray Flonase Allergy Relief fluticasone nasal spray ipratropium nasal spray Nasacort OTC G G G G B Nasal Medications Alzheimer Agents zdonepezil ergoloid mesylates zgalantamine zrivastigamine z Exelon Patch zNamenda G G G G B B Bladder/Kidney Alkalinizers citric acid/sod citrate potassium citrate Analgesics G G G zoxybutynin z oxybutynin ER ztolterodine z tolterodine ER ztrospium G G G G G BPH zfinasteride tamsulosin G G bethanecol G Cholinergic Agents Blood Anticoagulants/antithrombotics anagrelide clopidogrel dipyridamole enoxaparin fondaparinux heparin jantoven ticlopidine warfarin Aggrenox Brilinta zDurlaza Effient Eliquis Fragmin KEY: Other Blood Modifiers G G G G G G G G G B B B B B B TIER +zSprycel +Stivarga +zSutent +zSylatron +zTafinlar zTagrisso +zTarceva +zTasigna +Thalomid +zTykerb +zValchlor +Votrient +zXalkori +zZelboraf +Zolinza zZydelig +zZykadia B B B B B cilostazol G pentoxifylline G +zActimmune B +Aranesp B +Epogen B +Exjade B +Jadenu B +Leukine B Miacalcin inj. B Mircera B Neulasta B +Neumega B +Neupogen B +Procrit B +zPromacta B +zRevlimid B z SyprineB Alkylating Agents cyclophosphamide melphalan CeeNu Emcyt Hexalen Leukeran Myleran G G B B B B B capecitabine mercaptopurine methotrexate Purixan G G G B anastrozole bicalutamide exemestane flutamide letrozole leuprolide megestrol tamoxifen Fareston +zXtandi +zZytiga G G G G G G G G B B B etoposide hydroxyurea +zimatinib mesna +temozolomide topotecan +zAfinitor +Arcalyst +zBosulif zCaprelsa zCometriq zCotellic +zErivedge +zFarydak +zGilotrif +Hycamptin +zIbrance zIclusig zImbruvica +zInlyta + Intron A zIressa +zJakafi +zLenvima +zLonsurf zLynparza Lysodren Matulane +zMekinist +zNexavar Nilandron zNinlaro +zOdomzo +zPomalyst +zSignifor G G G G G G B B B B B B B B B B B B B B B B B B B B B B B B B B B B B Antimetabolites Hormones TIER Rexinoids bexarotene Targretin gel B B B B B B B B B B B B B B B B B G B Diabetes Antidiabetic Agents, Injectable Cancer Drugs Miscellaneous phenazopyridine Anticholinergics Innohep zPradaxa zSavaysa Xarelto zZontivity Apidra zBydureon zByetta Humalog insulin Humulin (all types) Lantus Levemir Novolin Novolog zSymlin zTanzeum Toujeo zTrulicity Tresiba zVictoza B B B B B B B B B B B B B B B acarbose chlorpropamide zglimepiride glipizide z glipizide ER zglipizide/metformin glyburide glyburide micronized metformin z metformin ER zmetformin/glyburide znateglinide zpioglitazone zrepaglanide tolazamide tolbutamide Afrezza zAvandamet zAvandaryl zAvandia zFarxiga Glucagon zGlyxambi zInvokamet zInvokana zJanumet zJanuvia zJardiance Jentadueto Juvisync Kazano Kombiglyze Nesina Onglyza Oseni zSynjardy Tradjenta z Xigduo XR G G G G G G G G G G G G G G G G B B B B B B B B B B B B B B B B B B B B B B Antidiabetic Agents, Glucose Elevating Agents Diabetic Test Strips Accu-Chek Ascensia Breeze Contour FreeStyle OneTouch Precision TRUEtest 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. B B B B B B B TRUEtrack TIER B Ear Anti-infective Agents acetic acid otic acetic acid/aluminum acetate ofloxacin otic G G G acetic acid HC otic neomycin/polymyxin/HC otic Ciprodex G G B Anti-infective/Anti-inflammatory combinations Eye Antiallergy Agents (Eye) azelastine ophth cromolyn ophth ketotifen opthalmic solution Patanol G G G B bacitracin ophth bacitracin/polymyxin ciprofloxacin ophth erythromycin ophth gentamicin ophth neomycin/bacitracin/poly B ofloxacin ophth polymyxin B/TMP sulfacetamide 10% tobramycin soln G G G G G G G G G G G G G G B B B B Anti-infective Agents Anti-inflammatory dexamethasone ophth fluorometholone ophth prednisolone acetate prednisolone sod acetate FML Forte FML S.O.P. Lotemax suspension Pred Mild Anti-inflammatory/Anti-infective combinations dexameth/neomycin/poly B G neomycin/bacitracin/poly B/HC G sulfacetamide/prednisolone ophthG tobramycin/dexameth G Antiviral zfamciclovir trifluridine G G betaxolol HCl carteolol levobunolol metipranolol timolol Betoptic-S G G G G G B Beta-Blockers (Eye) Carbonic Anhydrase Inhibitors dorzolamide 2% eye drops dorzolamide/timolol eye drops Azopt G G B pilocarpine Isopto Carbachol 1.5% Phospholine Iodide G B B Cystaran B atropine sulfate ophth homatropine tropicamide G G G bromfenac flurbiprofen ophth ketorolac tromethamine Nevanac G G G B latanoprost travoprost Lumigan G G B brimonidine G naphazoline phenylephrine ophth G G Miotics Miscellaneous Mydriatics NSAIDs Prostaglandin Analogues/Prostamines Sympathomimetics Vasoconstrictors Note: * Some drugs are limited to 1 unit of use package per dispensing. 1 183894_MG46605A -BCBS WNY - Medicaid_v2.indd 1 6/1/16 12:51 PM Section I — Therapeutic drug categories (cont’d) TIER Gout allopurinol colchicine/probenecid indomethacin probenecid Colcrys G G G G B Heart TIER G G G G G G G G atenolol/chlorthalidone benazepril/HCTZ bisoprolol/HCTZ zcandesartan/HCTZ captopril/HCTZ enalapril/HCTZ zirbesartan/HCTZ lisinopril/HCTZ z losartan HCT methyldopa/HCTZ metoprolol/HCTZ propranolol/HCTZ quinapril/HCTZ ztelmisartan/HCTZ zvalsartan/HCTZ G G G G G G G G G G G G G G G G Anti-Hypertensive Angiotensin Converting Enzyme Inhibitors Combination amlodipine/benazepril benazepril captopril enalapril fosinopril lisinopril quinapril ramipril G G G G G G G zcandesartan zeprosartan zirbesartan zlosartan ztelmisartan zvalsartan G G G G G G Angiotensin II Antagonists Anti-Adrenergic Blockers Centrally acting clonidine, oral, patch guanabenz guanfacine methyldopa midodrine Dibenzyline +zNorthera G G G G G B B doxazosin prazosin terazosin G G G amiodarone digoxin disopyramide disopyramide CR flecainide mexiletine propafenone quinidine gluconate quinidine sulfate SR sotalol G G G G G G G G G G atorvastatin calcium cholestyramine colestipol fenofibrate fenofibric acid, tab fluvastatin gemfibrozil zulovastatin niacin ER zupravastatin rosuvastatin zusimvastatin +zKynamro +zPraluent +zRepatha zZetia G G G G G G G G G G G G B B B B Anti-Adrenergic Blockers Peripheral Antiarrhythmics Antilipidemics Beta Blockers acebutolol atenolol betaxolol bisoprolol carvedilol labetalol metoprolol metoprolol ER nadolol pindolol propranolol timolol G G G G G G G G G G G G amlodipine cartia XT diltia XT diltiazem diltiazem CD/SR/ER/XR felodipine ER isradipine nicardipine G G G G G G G G Calcium Channel Blockers KEY: Diuretics acetazolamide acetazolamide ER amiloride amiloride/HCTZ bumetanide chlorothiazide chlorthalidone furosemide hydrochlorothiazide indapamide methazolamide metolazone spironolactone spironolactone/HCTZ torsemide triamterene/HCTZ G G G G G G G G G G G G G G G G eplerenone midodrine Berinert +Cinryze +Firazyr Ranexa zRuconest zSamsca zTekturna z Tekturna HCT G G B B B B B B B B Miscellaneous Cardiovascular Agents Pulmonary Arterial Hypertension hydralazine isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate SA isoxsuprine minoxidil oral nitroglycerin oint nitroglycerin pumpspray nitroglycerin SR nitroglycerin transdermal patch Dilatrate SR Nitrostat abacavir/lamivudine/ zidovudineG lamivudine/zidovudine G Dutrebis B Stribild B Triumeq B Truvada B Viread B Nucleoside Reverse Transcriptase Inhibitors nevirapine Atripla Intelence Rescriptor Sustiva Viramune XR abacavir sulfate didanosine lamivudine stavudine zidovudine Emtriva Epivir solution Epzicom Retrovir IV infusion vial Videx Videx pediatric solution G G G G G B B B B B B Complera Edurant +Fuzeon Genvoya Isentress Odefsey Selzentry Tivicay Tybost Vitekta B B B B B B B B B B Aptivus Crixivan Evotaz Invirase Lexiva Norvir Prezcobix Prezista Reyataz Viracept B B B B B B B B B B Kaletra B Other Protease Inhibitors Protease Inhibitors Combinations Huntington’s Disease +ztetrabenazine G azathioprine cyclosporine gengraf mycophenolate mofetil sirolimus tacrolimus Astagraf XL z Envarsus XR Sandimmune G G G G G G B B B Immunosuppressants Infection Antibacterial agents/Antibiotics G G G G G G G G G G B B amoxicillin amoxicillin-clavulanate ER ampicillin azithromycin suspension azithromycin tablets cefaclor cefadroxil cefdinir cefpodoxime cefprozil cefuroxime cephalexin ciprofloxacin clarithromycin susp clarithromycin tabs clindamycin dicloxacillin doxycycline erythromycin base erythromycin ethylsuccinate erythromycin stearate HIV - Antivirals Non-Nucleoside Reverse Transcriptase Inhibitor TIER Nucleoside Analog Reverse Transcriptase erythromycin/sulfisoxazoleG minocycline G Inhibitor Combination + epoprostenolG + veletriG +zAdcirca B +zAdempas B +zLetairis B +zOpsumit B +zOrenitram B +zTracleer B zUptravi B Vasodilators TIER nifediac CC nifedical XL nifedipine nifedipine SR nimodipine nisoldipine verapamil verapamil SR G B B B B B 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. G G G G G G G G G G G G G G G G G G G G G ofloxacin G penicillin VK G sulfamethoxazole/trimethoprimG tetracycline G Ery-Tab B Ketek B Zmax B Antifungals ciclodan clotrimazole lozenge fluconazole flucytosine griseofulvin zitraconazole ketoconazole nystatin zterbinafine zvoriconazole G G G G G G G G G G chloroquine phosphate hydroxychloroquine mefloquine Daraprim Malarone Primaquine G G G B B B ethambutol isoniazid pyrazinamide rifabutin rifampin Coartem Rifater G G G G G B B z acyclovir oral amantadine zfamciclovir ganciclovir lamivudine tabs ribapak +ribasphere +ribavirin rimantadine zvalacyclovir valganciclovir tablets +PzDaklinza Epivir-HBV solution +zHarvoni zHepsera +zOlysio +Pegasys zRelenza +zSovaldi zTamiflu +PzTechnivie +Pz Viekira Pak PzZepatier G G G G G G G G G G G B B B B B B B B B B B B atovaquone methenamine combination metronidazole neomycin nitrofurantoin paromomycin + tobramycin amp/neb trimethoprim vancomycin Dapsone Nebupent zSivextro + Tobi Podhaler zZyvox G G G G G G G G G B B B B B Antimalarials Antituberculosis Antivirals Other Anti-Infectives Men’s Health Impotence - possible contract exclusion; refer to individual contract yohimbine G Androderm patch zAndrogel zAxiron zFortesta zNatesto zTestim B B B B B B Male Hormones Note: * Some drugs are limited to 1 unit of use package per dispensing. 2 183894_MG46605A -BCBS WNY - Medicaid_v2.indd 2 6/1/16 12:51 PM Section I — Therapeutic drug categories (cont’d) TIER z Testosterone gel zVogelxo Prostate Health zalfuzosin zfinasteride tamsulosin B B G G G Mental Health Antidepressants amitriptyline G amitriptyline/chlordiazepoxideG amitriptyline/perphenazineG amoxapine G zbupropion G z bupropion ER G z bupropion XL G ucitalopram G clomipramine G desipramine G doxepin G duloxetine G uescitalopram G u fluoxetine 10, 20mg tablet G fluoxetine capsule G fluvoxamine ER G fluvoxamine tab G u imipramine G maprotiline G umirtazapine G nefazodone G nortriptyline G u paroxetine HCl G phenelzine G usertraline G tranylcypromine G trazodone G uvenlafaxine G venlafaxine ER G Desvenlafaxine ER B Desvenlafaxine fumarate B Fetzima B Fluoxetine 60mg tablet B Khedezla B Pexeva B Pristiq B Trintellix B Viibryd B Antimanic Agents lithium carbonate Antipsychotic Agents aripiprazole chlorpromazine clozapine fluphenazine decanoate fluphenazine, oral haloperidol decanoate haloperidol, oral loxapine zolanzapine zolanzapine/fluoxetine paliperidone perphenazine zquetiapine zrisperidone z risperidone m-tab thioridazine thiothixene trifluoperazine z ziprasidone caps zFanapt zLatuda zRexulti zSaphris z Seroquel XR Versacloz zVraylar Anxiolytics, Sedatives, and Hypnotics alprazolam/ER buspirone chloral hydrate chlordiazepoxide clorazepate diazepam estazolam flurazepam lorazepam KEY: G G G G G G G G G G G G G G G G G G G G B B B B B B B G G G G G G G G G TIER G G G G G G G B dexmethylphenidate dexmethylphenidate ER dextroamphetamine tabs generic Adderall generic Adderall XR generic Concerta generic Dexedrine spansules metadate ER methylphenidate/SR/CD zmodafinil procentra Daytrana Intuniv zNuvigil Strattera G G G G G G G G G G G B B B B Cerebral Stimulants baclofen carisoprodol carisoprodol/ASA chlorzoxazone cyclobenzaprine dantrolene sodium diazepam methocarbamol orphenadrine tizanidine G G G B acamprosate calcium tablet EC buprenorphine HCl disulfiram naltrexone Campral dosepack z Narcan Nasal Spray Rilutek Savella Suboxone Film G G G G B B B B B danazol fludrocortisone +octreotide +z Acthar H.P. gel +zCerdelga Egrifta +Genotropin +Humatrope +zMyalept +Natpara +Norditropin +Nutropin +Omnitrope +Saizen +Sensipar +zSomavert Synarel +Tev-Tropin +zZavesca +Zorbtive G G G B B B B B B B B B B B B B B B B B + Gamunex C +Hizentra zKeveyis Procysbi +Ravicti Strensiq B B B B B B +glatopa +Ampyra +zAubagio +Avonex +Betaseron + Copaxone 40mg +Extavia +zGilenya +zPlegridy +Rebif +zTecfidera G B B B B B B B B B B Other Endocrine Other Miscellaneous G G G G G G G B B B B B Pain/Arthritis desmopressin solution desmopressin tabs desmopressin vial 4mcg/ml +Stimate Other CNS G G G G G G G G G G Osteoporosis zalendronate zcalcitonin-salmon z fortical NS zibandronate zraloxifene z risedronate 150mg z risedronate DR z Actonel 5mg, 30mg z Actonel with Calcium zBinosto z Fosamax Plus D +zForteo Analgesics, Narcotic acetaminophen w/codeine G belladonna & opium supp G butorphanol NS G codeine sulfate G endocet G z fentanyl lozenge G fentanyl patch G hydrocodone/ibuprofen G hydromorphone G meperidine G meperidine/promethazine G methadone G morphine SR G morphine tab, soln, supp G MSIR tabs, sol G oxycodone G oxycodone/acetaminophenG oxycodone/aspirin G oxymorphone ER G pentazocine/naloxone G Opana ER B Analgesics, Salicylates aspirin SR choline mag. trisalicylate diflunisal salsalate G G G G hydroxychloroquine leflunomide methotrexate +z Actemra SC zCuprimine +zEnbrel +zHumira zKineret +zOrencia +zOtezla Ridaura +zSimponi +zXeljanz G G G B B B B B B B B B B zcelecoxib G Anti-Rheumatic Cox-2s Migraine (Analgesics, Non-narcotic) butalbital/APAP G butalbital/APAP/caffeine G butalbital/aspirin/caffeine G dihydroergotamine mesylate G ergotamine/caffeine G isometh/dichloralphen/APAPG znaratriptan G G zsumatriptan tramadol G Ergomar B Multiple Sclerosis Agents Nonsteroidal Anti-Inflammatory/ Combination Products 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. diclofenac potassium diclofenac sodium TIER Muscle Relaxants Miscellaneous Antidiuretic Agents TIER meprobamate oxazepam temazepam triazolam zzaleplon zzolpidem z zolpidem CR +zHetlioz etodolac etodolac SA fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketorolac inj. ketorolac tab z meclofenamate meloxicam nabumetone naproxen naproxen EC piroxicam sulindac Voltaren gel Parkinson’s Disease amantadine G benztropine G bromocriptine G carbidopa/levodopa G carbidopa/levodopa SA G carbidopa/levodopa/entacaponeG entacapone G pramipexole G ropinirole G zselegiline G trihexyphenidyl G B +Apokyn +zDuopa B Potassium Potassium agents potassium bicarbonate potassium chloride G G sod. polystyrene sulfonate G Potassium Removing agent Respiratory/Asthma Adrenergic epinephrine inj. Epipen/Jr. Corticosteroids G B budesonide inh. (0.25mg/2ml, 0.5mg/2ml)G zAlvesco B z Flovent Diskus B z Flovent HFA B z Pulmicort Flexhaler B zQvar B zSymbicort B Leukotrienes zmontelukast zzafirlukast Other Agents G G cromolyn inh. soln. ipratropium inh. soln. z Advair diskus zAtrovent/HFA z Combivent Respimat zDulera +zEsbriet +zKalydeco +zOfev +zOrkambi +Pulmozyme zSpiriva z Spiriva Respimat z Stiolto Respimat G G B B B B B B B B B B B B albuterol sulfate ER albuterol tab, syr metaproterenol syr terbutaline tab Maxair Autohaler ProAir HFA/RespiClick Serevent Diskus Ventolin HFA G G G G B B B B Sympathomimetics z z z z z z Xanthine Derivatives G G G G G G G G G G G G G G G G G G B aminophylline theochron theophylline/SR tabs, liquid G G G Note: * Some drugs are limited to 1 unit of use package per dispensing. 3 183894_MG46605A -BCBS WNY - Medicaid_v3.indd 3 6/2/16 2:00 PM Section I — Therapeutic drug categories (cont’d) TIER Seizures Barbiturates phenobarbital G phenytoin G Hydantoins Miscellaneous carbamazepine G carbamazepine XR 200mg, 400mgG clonazepam G divalproex sodium/ER G felbamate G gabapentin G lamotrigine G levetiracetam G oxcarbazepine G primidone G tiagabine G topiramate G valproic acid G zonisamide G Aptiom B Banzel B Equetro B zFycompa B Gabitril B Lyrica B Onfi B Potiga B Qudexy XR B Sabril B Spritam B Topiramate ER (SSB) capsules B Trokendi XR B Succinimides ethosuximide Celontin G B Skin adapalene amnesteem avita cream benzoyl peroxide claravis erythromycin/benz peroxide prascion RA sod.sulfacetamide/sulfur emulsion cleanser sod. sulfacetamide/sulfur lot sotret sulfacetamide tretinoin cr/gel Tazorac Antibiotics (Topical) G G G G G G G G G G G G B acitretin G clindamycin sol/swabs/gel/ lotionG erythromycin sol/swabs/gel G gentamicin cr/oint G metronidazole cream/lotion/gel G mupirocin G Centany B Antipsoriatics calcipotriene ointment calcipotriene solution tacrolimus ointment +zCosentyx Elidel +zStelara G G G B B B G Burn preparation silver sulfadiazine Fungicides betamethasone/clotrimazoleG ciclopirox cream/gel G ciclopirox soln G econazole G ketoconazole G nystatin G nystatin/triamcinolone G nystop G Exelderm B Oxistat B KEY: G G G G G B B B 8-MOP Oxsoralen Ultra B B acticin Lindane Ulesfia G B B Psoralens Scabicides & Pediculicides Topical Anti-Inflammatory Agents Antidiarrheal lidocaine z lidocaine patch selenium sulf 2.25% shampoo G G G acyclovir G G G G G G G B B G peg 3350/electrolyte Creon Pancreaze Pertzye Ultresa Viokace Zenpep B B B B B B ursodiol G cimetidine famotidine nizatidine ranitidine (all) G G G G misoprostol sucralfate G G cromolyn sodium enulose lactulose mesalamine enema sulfasalazine sulfasalazine EC Asacol Asacol HD Canasa supp. Cholbam +zCimzia Delzicol Dipentum +Gattex +Kuvan Linzess Pentasa zRelistor Uceris ER tablet G G G G G G B B B B B B B B B B B B B zlansoprazole zomeprazole zpantoprazole zPrilosec-OTC G G G G Gallstone Solubilizing Agents H2 Antagonists Other Antiulcer Other GI Products G G G G B B B Proton Pump Inhibitors Steroids cortisone acetate dexamethasone oral hydrocortisone oral methylprednisolone prednisolone ODT prednisolone oral prednisone oral zgranisetron meclizine zondansetron prochlorperazine promethazine trimethobenzamide zEmend Transderm Scop Digestants Members coverage varies by plan. Patient should be in a smoking cessation program. zbupropion z Nicotine Gum z Nicotine lozenges z Nicotine patches various zChantix zCommit z Nicotrol Inhaler/NS G G B B Bowel Evacuants Smoking Cessation diphenoxylate/atropine paregoric zAlinia Fulyzaq Antiemetic/Antivertigo alclometasone G amcinonide G betamethasone dipropionate G betamethasone dipropionate augmented oint G betamethasone valerate G clobetasol propionate G desonide G desoximetasone G diflorasone G fluocinolone acetonide G fluocinonide 0.05% G fluticasone propionate G halobetasol G hydrocortisone 2.5% G hydrocortisone valerate G hydrocortisone/iodoquinolG hydrocortisone/urea G mometasone cr/oint G z triamcinolone acetonide G Cordran tape B Topical Antivirals TIER aluminum chloride 20% fluorouracil imiquimod 5% cream podofilox sodium chloride irrigating soln Carac Phisohex Regranex Topical Antipruritics/Anesthetics Acne TIER Other Topicals Thyroid G G G G G G G Antithyroid methimazole propylthiouracil G G levothroid levothyroxine levoxyl liothyronine thyroid unithroid Synthroid Thyrolar G G G G G G B B Thyroid Stomach/Ulcer Anorectal hydrocortisone/pramoxineG hydrocortisone rectal cr. & supp. G hydrocortisone rectal enema G pramoxine/HC acetate 2.5% G Cortifoam B Proctofoam-HC B Vitamins calcitriol calcium acetate cyanocobalamin inj. etidronate disodium folic acid leucovorin levocarnitine multivitamin + fluoride phytonadione potassium aminobenzoate pre-natal vitamins Anticholinergics/Antispasmodic/ GI Motility belladonna/phenobarbital G chlordiazepoxide/clindiniumG dicyclomine G glycopyrrolate G hyoscyamine/CR G metoclopramide G Donnatal B 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. G G G G G G G G G G G TIER sodium fluoride chewable tab & drops vit A,D,C + fluoride vit A,D,C + fluoride and iron Galzin Mephyton Nascobal Orfadin Renvela G G G B B B B B Women’s Health Contraceptives - Other zxulane Mirena NuvaRing G B B z estradiol/noreth ac z estradiol oral z estradiol patches zestropipate zestrogen/methyltesterone medroxyprogesterone norethindrone progesterone, micronized Cenestin z Climara Pro zCombipatch Enjuvia zEstring zEvamist Menest Premarin Premarin vag cream Premphase Prempro Vagifem G G G G G G G G B B B B B B B B B B B B Brisdelle B amethia apri aranelle aviane balziva camila camrese cesia cryselle enpresse errin jolessa jolivette junel/FE kariva lessina zlevonorgestrel levora low-ogestrel lutera microgestin/FE mononessa necon z next choice z next choice one dose nora-BE norethindrone a-e estradiol/ ferrous fumarate nortrel ocella ogestrel portia previfem quasense solia sprintec tri-sprintec trinessa trivora velivet zarah zenchent zovia G G G G G G G G G G G G G G G G G G G G G G G G G G miconazole vag supp nystatin vag tab terconazole vandazole vag G G G G Hormones Miscellaneous Oral Contraceptives Vaginal Preparations G G G G G G G G G G G G G G G G Note: * Some drugs are limited to 1 unit of use package per dispensing. 4 183894_MG46605A -BCBS WNY - Medicaid_v2.indd 4 6/1/16 12:51 PM Section II — Medicaid Over-the-Counter (OTC) Medication List acetaminophen hydrocortisone permethrin AFRIN hydrocortisone acetate PINX ALAVERT ibuprofen polyethylene glycol alum/mag hydroxide w/simethicone iron prenatal aluminum acetate lice treatment PRILOSEC OTC aluminum hydroxide loperamide solution pyridoxine HCl artificial tears loratadine ranitidine HCl aspirin loratadine-D reese’s pinworm aspirin buffered lubricant eye drops ROBITUSSIN B complex w/ vitamin C MAALOX ROBITUSSIN-DM bacitracin MAALOX PLUS EXTRA STRENGTH saline nasal spray BENADRYL magnesium senna BENEFIBER magnesium gluconate sennosides benzoyl peroxide mag-oxide SENOKOT beta-carotene meclizine HCl sinus congestion & pain bisacodyl METAMUCIL sochlor bismuth subsalicylate MICONAZOLE 3 SPECTRAVITE calcium + vitamin D MICONAZOLE 7 SPECTRAVITE SENIOR calcium carbonate miconazole nitrate SUDAFED PE calcium lactate MILK OF MAGNESIA SUDAFED SINUS NIGHTTIME CENTRA-VITE mineral oil suphedrine PE CENTRUM SILVER MONISTAT 1 SYSTANE cetirizine HCl MUCINEX THERAFLU children’s vitamin with minerals MUCINEX DM THERA-M children’s acetaminophen multivitamin tolnaftate children’s cold & cough multivitamin w/iron tussin CHILDREN’S MUCINEX multivitamin w/iron tussin DM CHILDREN’S PEPTO multivitamin w/minerals TYLENOL SINUS chlorpheniramine maleate multivitamin with calcium-iron VISINE cimetidine MYLANTA vitamin A clotrimazole vaginal NASACORT OTC vitamin B-1 cold multi-symptom nighttime nasal moisturizer vitamin C daytime cold & flu niacin vitamin D diabetic tussin DM NICODERM CQ vitamin D3 DIMAPHEN NICOTINE GUM vitamins A-D-E dimenhydrinate nighttime cold & flu relief ZANTAC OTC DIMETAPP NIX DIMETAPP DM OCUTABS diphenhydramine HCl OCUVITE docusate sodium OCUVITE PRESERVISION DRAMAMINE omeprazole famotidine oxymetazoline HCl fexofenadine oyster shell calcium fiber tabs oyster shell calcium w/vit D fiber therapy pedia relief cough & cold GAVISCON pediatric electrolyte guaifenesin PEPCID COMPLETE guaifenesin DM PEPTO-BISMOL 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. Note: * Some drugs are limited to 1 unit of use package per dispensing. 5 183894_MG46605A -BCBS WNY - Medicaid_v2.indd 5 6/1/16 12:51 PM Section III — Index DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME A B abacavir sulfate G 2 abacavir/lamivudine/ zidovudine G2 acamprosate calcium tablet EC G 3 G1 acarbose Accu-Chek B1 acebutolol G2 acetaminophen w/codeineG 3 acetazolamide G2 acetazolamide ER G 2 acetic acid HC otic G 1 acetic acid otic G 1 acetic acid/aluminum acetateG 1 acetylcysteine inh soln. G 1 acitretin G4 +zActemra SC B 3 +zActhar H.P. gel B 3 acticin G4 +zActimmune B1 zActonel 5mg, 30mg B 3 zActonel with Calcium B 3 acyclovir G4 zacyclovir oral G 2 G4 adapalene +zAdcirca B2 +zAdempas B2 zAdvair diskus B 3 +zAfinitor B1 B1 Afrezza Aggrenox B1 zalbuterol sulfate ER G 3 zalbuterol tab, syr G 3 alclometasone G4 zalendronate G3 zalfuzosin G3 zAlinia B4 allopurinol G2 alprazolam/ER G3 aluminum chloride 20% G 4 zAlvesco B3 amantadine G2 amantadine G3 G4 amcinonide amethia G4 amiloride G2 G2 amiloride/HCTZ aminophylline G3 amiodarone G2 amitriptyline G3 amitriptyline/chlordiazepoxideG 3 amitriptyline/perphenazineG 3 amlodipine G2 amlodipine/benazeprilG 2 amnesteem G4 amoxapine G3 amoxicillin G2 amoxicillin-clavulanate ERG 2 ampicillin G2 +Ampyra B3 G1 anagrelide anastrozole G1 Androderm patch B 2 zAndrogel B2 Apidra B1 +Apokyn B3 apri G4 Aptiom B4 Aptivus B2 aranelle G4 +Aranesp B1 +Arcalyst B1 aripiprazole G3 Asacol B4 Asacol HD B 4 Ascensia Breeze B 1 aspirin SR G 3 Astagraf XL B 2 atenolol G2 atenolol/chlorthalidoneG 2 atorvastatin calcium G 2 atovaquone G2 Atripla B2 atropine sulfate ophth G 1 zAtrovent/HFA B3 +zAubagio B3 zAvandamet B1 zAvandaryl B1 zAvandia B1 aviane G4 avita cream G 4 +Avonex B3 zAxiron B2 azathioprine G2 zazelastine 0.1% nasal sprayG 1 azelastine ophth G 1 azithromycin suspension G 2 azithromycin tablets G 2 Azopt B1 bacitracin ophth G 1 bacitracin/polymyxinG1 baclofen G3 balziva G4 Banzel B4 belladonna & opium suppG 3 4 belladonna/phenobarbitalG benazepril G2 benazepril/HCTZ G2 benzonatate G1 benzoyl peroxide G 4 benztropine G3 Berinert B2 betamethasone dipropionateG 4 betamethasone dipropionate G 4 augmented oint betamethasone valerate G 4 betamethasone/ clotrimazole G4 +Betaseron B3 betaxolol G2 betaxolol HCl G 1 bethanecol G1 Betoptic-S B1 bexarotene G1 G1 bicalutamide zBinosto B3 bisoprolol G2 bisoprolol/HCTZ G2 +zBosulif B1 Brilinta B1 brimonidine G1 Brisdelle B4 G1 bromfenac bromocriptine G3 brompheniramine/ pseudoephedrine G1 brompheniramine/ phenylephrine G1 budesonide inh. (0.25mg/2ml, 0.5mg/2ml)G 3 bumetanide G2 buprenorphine HCl G 3 zbupropion G3 zbupropion G4 zbupropion ER G 3 zbupropion XL G 3 buspirone G3 butalbital/APAP G3 butalbital/APAP/caffeineG 3 3 butalbital/aspirin/caffeineG butorphanol NS G 3 zBydureon B1 zByetta B1 KEY: C calcipotriene ointment calcipotriene solution zcalcitonin-salmon calcitriol calcium acetate camila Campral dosepack camrese Canasa supp. zcandesartan zcandesartan/HCTZ capecitabine zCaprelsa captopril captopril/HCTZ Carac carbamazepine carbamazepine XR 200mg, 400mg carbidopa/levodopa carbidopa/levodopa SA carbidopa/levodopa/ entacapone cardec/DM carisoprodol carisoprodol/ASA carteolol cartia XT carvedilol CeeNu cefaclor cefadroxil cefdinir cefpodoxime cefprozil cefuroxime zcelecoxib Celontin Cenestin Centany cephalexin +zCerdelga cesia zcetirizine zChantix chloral hydrate chlordiazepoxide TIER PAGE DRUG NAME chlordiazepoxide/clindiniumG 4 chloroquine phosphate G 2 chlorothiazide G2 chlorpheniramine/ pseudoephedrine G1 chlorpromazine G3 G1 chlorpropamide chlorthalidone G2 G3 chlorzoxazone Cholbam B4 cholestyramine G2 3 choline mag. trisalicylate G ciclodan G2 ciclopirox cream/gel G 4 ciclopirox soln G 4 cilostazol G1 G4 cimetidine +zCimzia B4 +Cinryze B2 Ciprodex B1 ciprofloxacin G2 ciprofloxacin ophth G 1 ucitalopram G3 G 1 citric acid/sod citrate claravis G4 clarithromycin susp G 2 clarithromycin tabs G 2 clemastine G1 zClimara Pro B 4 G2 clindamycin clindamycin sol/swabs/ gel/lotion G4 clobetasol propionate G 4 G3 clomipramine clonazepam G4 clonidine, oral, patch G 2 clopidogrel G1 clorazepate G3 clotrimazole lozenge G 2 clozapine G3 Coartem B2 codeine sulfate G 3 colchicine/probenecidG 2 Colcrys B2 colestipol G2 zCombipatch B4 zCombivent Respimat B 3 zCometriq B1 zCommit B4 B2 Complera Contour B1 B 3 +Copaxone 40mg Cordran tape B 4 Cortifoam B4 G 4 cortisone acetate +zCosentyx B4 zCotellic B1 B4 Creon Crixivan B2 cromolyn inh. soln. G 3 cromolyn ophth G 1 cromolyn sodium G 4 cryselle G4 zCuprimine B3 cyanocobalamin inj. G 4 cyclobenzaprine G3 cyclophosphamide G1 G2 cyclosporine cyproheptadine G1 Cystaran B1 G 4 G 4 G3 G4 G 4 G4 B 3 G4 B 4 G2 G2 G1 B1 D G2 G2 +PzDaklinza B2 B4 danazol G3 G4 dantrolene sodium G 3 Dapsone B2 G 4 Daraprim B2 G3 Daytrana B3 G 3 Delzicol B4 G3 desipramine G3 desmopressin solution G 3 G1 desmopressin tabs G 3 G3 desmopressin vial 4mcg/mlG 3 G3 desonide G4 G1 desoximetasone G4 G 2 Desvenlafaxine ER B 3 G2 Desvenlafaxine fumarate B 3 B1 dexameth/neomycin/poly BG 1 G2 dexamethasone ophth G 1 G2 dexamethasone oral G 4 G2 dexchlorpheniramineG 1 G2 dexmethylphenidate G3 G2 dexmethylphenidate ER G 3 G2 dextroamphetamine tabs G 3 G3 diazepam G3 B4 diazepam G3 B4 Dibenzyline B2 B4 diclofenac potassium G 3 G2 diclofenac sodium G 3 B3 dicloxacillin G2 G4 dicyclomine G4 G1 didanosine G2 B4 diflorasone G4 G 3 diflunisal G3 G3 digoxin G2 TIER PAGE DRUG NAME dihydroergotamine mesylateG 3 Dilatrate SR B 2 diltia XT G 2 diltiazem G2 diltiazem CD/SR/ER/XR G 2 Dipentum B4 diphenhydramine G1 diphenoxylate/atropineG 4 dipyridamole G1 disopyramide G2 disopyramide CR G 2 disulfiram G3 divalproex sodium/ER G 4 zdonepezil G1 Donnatal B4 dorzolamide 2% eye drops G1 dorzolamide/timolol eye drops G 1 doxazosin G2 doxepin G3 doxycycline G2 zDulera B3 duloxetine G3 B3 +zDuopa zDurlaza B1 Dutrebis B2 E econazole G4 Edurant B2 Effient B1 Egrifta B3 8-MOP B4 Elidel B4 Eliquis B1 Emcyt B1 B4 zEmend Emtriva B2 enalapril G2 enalapril/HCTZ G2 B3 +zEnbrel endocet G3 Enjuvia B4 enoxaparin G1 enpresse G4 entacapone G3 enulose G4 zEnvarsus XR B 2 epinephrine inj. G 3 Epipen/Jr. B3 Epivir solution B 2 Epivir-HBV solution B 2 eplerenone G2 +Epogen B1 +epoprostenol G2 zeprosartan G2 Epzicom B2 Equetro B4 ergoloid mesylates G 1 Ergomar B3 ergotamine/caffeine G3 B1 +zErivedge errin G4 Ery-Tab B2 erythromycin base G 2 erythromycin G2 ethylsuccinate erythromycin ophth G 1 erythromycin sol/swabs/gelG 4 erythromycin stearate G 2 erythromycin/benz peroxideG 4 erythromycin/sulfisoxazoleG 2 B3 +zEsbriet uescitalopram G3 estazolam G3 zestradiol oral G 4 zestradiol patches G 4 zestradiol/noreth ac G 4 zEstring B4 zestrogen/methyltesteroneG 4 zestropipate G4 ethambutol G2 G4 ethosuximide etidronate disodium G 4 etodolac G3 etodolac SA G 3 etoposide G1 zEvamist B4 Evotaz B2 Exelderm B4 zExelon Patch B 1 exemestane G1 +Exjade B1 +Extavia B3 F zfamciclovir zfamciclovir famotidine zFanapt Fareston zFarxiga +zFarydak felbamate felodipine ER 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. G1 G2 G4 B3 B1 B1 B1 G4 G 2 TIER PAGE DRUG NAME fenofibrate G2 fenofibric acid, tab G 2 fenoprofen G3 G 3 zfentanyl lozenge fentanyl patch G 3 Fetzima B3 G1 zfinasteride G3 zfinasteride +Firazyr B2 flecainide G2 Flonase Allergy Relief G 1 zFlovent Diskus B 3 zFlovent HFA B 3 fluconazole G2 flucytosine G2 fludrocortisone G3 fluocinolone acetonide G 4 fluocinonide 0.05% G 4 fluorometholone ophth G 1 fluorouracil G4 ufluoxetine 10, 20mg tabletG 3 Fluoxetine 60mg tablet B 3 fluoxetine capsule G 3 fluphenazine decanoate G 3 fluphenazine, oral G 3 flurazepam G3 flurbiprofen G3 flurbiprofen ophth G 1 flutamide G1 zfluticasone nasal spray G 1 fluticasone propionate G 4 fluvastatin G2 fluvoxamine ER G 3 ufluvoxamine tab G 3 FML Forte B 1 FML S.O.P. B 1 folic acid G 4 fondaparinux G1 B3 +zForteo zFortesta B2 zfortical NS G 3 zFosamax Plus D B 3 fosinopril G2 Fragmin B1 FreeStyle B1 Fulyzaq B4 furosemide G2 +Fuzeon B2 zFycompa B4 G gabapentin G4 Gabitril B4 zgalantamine G1 Galzin B4 +Gamunex C B 3 ganciclovir G2 +Gattex B4 gemfibrozil G2 generic Adderall G 3 generic Adderall XR G 3 generic Concerta G 3 generic Dexedrine spansulesG 3 gengraf G2 +Genotropin B3 gentamicin cr/oint G 4 gentamicin ophth G 1 Genvoya B2 B3 +zGilenya B1 +zGilotrif +glatopa G3 zglimepiride G1 glipizide G1 zglipizide ER G 1 zglipizide/metforminG1 Glucagon B1 glyburide G1 glyburide micronized G 1 glycopyrrolate G4 zGlyxambi B1 G4 zgranisetron B1 zGrastek griseofulvin G2 guaifenesin 1200/DM G 1 guaifenesin/codeine G1 guanabenz G2 guanfacine G2 H halobetasol haloperidol decanoate haloperidol, oral +zHarvoni heparin zHepsera +zHetlioz Hexalen Histex IE +Hizentra homatropine Humalog insulin +Humatrope +zHumira Humulin (all types) +Hycamptin TIER PAGE hydralazine G2 hydrochlorothiazide G2 hydrocodone/ chlorpheniramine G1 hydrocodone/homatropineG 1 hydrocodone/ibuprofenG 3 G 4 hydrocortisone 2.5% hydrocortisone oral G 4 hydrocortisone rectal cr. & supp. G 4 hydrocortisone rectal enemaG 4 4 hydrocortisone valerate G hydrocortisone/iodoquinolG 4 hydrocortisone/pramoxineG 4 hydrocortisone/urea G4 G3 hydromorphone hydroxychloroquine G2 hydroxychloroquine G3 hydroxyurea G1 hydroxyzine HCL G 1 G 1 hydroxyzine pamoate hyoscyamine/CR G4 I zibandronate +zIbrance G3 B1 ibuprofen G3 zIclusig B1 +zimatinib G1 zImbruvica B1 imipramine G3 G 4 imiquimod 5% cream indapamide G2 indomethacin G2 indomethacin G3 +zInlyta B1 Innohep B1 Intelence B2 +Intron A B 1 Intuniv B3 Invirase B2 zInvokamet B1 zInvokana B1 ipratropium inh. soln. G 3 1 ipratropium nasal spray G zirbesartan G2 zirbesartan/HCTZ G2 zIressa B1 Isentress B2 isometh/dichloralphen/APAPG 3 isoniazid G2 Isopto Carbachol 1.5% B 1 G 2 isosorbide dinitrate isosorbide mononitrate G 2 isosorbide mononitrate SAG 2 isoxsuprine G2 isradipine G2 zitraconazole G2 J B1 B1 G1 B1 B1 B1 B1 G4 G4 G4 B1 +Jadenu +zJakafi jantoven zJanumet zJanuvia zJardiance Jentadueto jolessa jolivette junel/FE Juvisync K Kaletra B2 +zKalydeco B3 G4 kariva Kazano B1 Ketek B2 ketoconazole G2 ketoconazole G4 ketoprofen G3 ketorolac inj. G 3 zketorolac tab G 3 ketorolac tromethamine G 1 ketotifen opthalmic solutionG 1 zKeveyis B3 Khedezla B3 zKineret B3 B1 G4 Kombiglyze +Kuvan B4 G 3 B2 G 3 +zKynamro B2 L G1 G2 B2 labetalol G4 B3 lactulose G2 B1 lamivudine G 2 B 1 lamivudine tabs B3 lamivudine/zidovudineG 2 G4 G1 lamotrigine G4 B 1 zlansoprazole B1 B3 Lantus G1 B3 latanoprost B3 B 1 zLatuda G3 B1 leflunomide Note: * Some drugs are limited to 1 unit of use package per dispensing. 6 183894_MG46605A -BCBS WNY - Medicaid_v3.indd 6 6/2/16 2:01 PM Section III — Index (cont’d) DRUG NAME TIER PAGE DRUG NAME +zLenvima lessina +zLetairis letrozole leucovorin Leukeran +Leukine leuprolide Levemir levetiracetam levobunolol levocarnitine zlevonorgestrel levora levothroid levothyroxine levoxyl Lexiva lidocaine zlidocaine patch Lindane Linzess liothyronine lisinopril lisinopril/HCTZ lithium carbonate +zLonsurf loratadine loratadine-D lorazepam zlosartan zlosartan HCT Lotemax suspension zulovastatin low-ogestrel loxapine Lumigan lutera zLynparza Lyrica Lysodren B1 G4 B2 G1 G4 B1 B1 G1 B1 G4 G1 G4 G4 G4 G4 G4 G4 B2 G4 G 4 B4 B4 G4 G2 G2 G 3 B1 G1 G1 G3 G2 G 2 B 1 G2 G4 G3 B1 G4 B1 B4 B1 M Malarone B2 maprotiline G3 Matulane B1 zMaxair Autohaler B 3 meclizine G4 meclofenamate G3 medroxyprogesteroneG 4 mefloquine G2 megestrol G1 +zMekinist B1 meloxicam G3 melphalan G1 Menest B4 meperidine G3 meperidine/promethazineG 3 Mephyton B4 meprobamate G3 mercaptopurine G1 mesalamine enema G 4 mesna G1 metadate ER G 3 metaproterenol syr G 3 metformin G1 zmetformin ER G 1 zmetformin/glyburideG 1 methadone G3 methazolamide G2 methenamine combinationG 2 methimazole G4 methocarbamol G3 methotrexate G1 methotrexate G3 methyldopa G2 methyldopa/HCTZ G2 methylphenidate/SR/CDG 3 methylprednisolone G4 metipranolol G1 metoclopramide G4 metolazone G2 metoprolol G2 metoprolol ER G 2 metoprolol/HCTZ G2 metronidazole G2 metronidazole cream/ lotion/gel G4 mexiletine G2 Miacalcin inj. B 1 miconazole vag supp G 4 microgestin/FE G4 midodrine G2 midodrine G2 minocycline G2 minoxidil oral G 2 Mircera B1 Mirena B4 umirtazapine G3 misoprostol G4 zmodafinil G3 mometasone cr/oint G 4 mononessa G4 zmontelukast G3 morphine SR G 3 KEY: TIER PAGE DRUG NAME TIER PAGE DRUG NAME morphine tab, soln, supp MSIR tabs, sol multivitamin V fluoride mupirocin +zMyalept mycophenolate mofetil Myleran G 3 G 3 G 4 G4 B3 G 2 B1 N nabumetone G3 nadolol G2 naltrexone G3 zNamenda B1 naphazoline G1 naproxen G3 naproxen EC G 3 znaratriptan G3 zNarcan Nasal Spray B 3 zNasacort OTC B 1 Nascobal B4 znateglinide G1 zNatesto B2 +Natpara B3 Nebupent B2 necon G4 nefazodone G3 neomycin G2 neomycin/bacitracin/poly BG 1 neomycin/bacitracin/ poly B/HC G 1 neomycin/polymyxin/ HC otic G 1 Nesina B1 Neulasta B1 +Neumega B1 +Neupogen B1 Nevanac B1 nevirapine G2 +zNexavar B1 znext choice G 4 znext choice one dose G 4 niacin ER G 2 nicardipine G2 zNicotine Gum G 4 zNicotine lozenges G 4 zNicotine patches variousG 4 zNicotrol Inhaler/NS B 4 nifediac CC G 2 nifedical XL G 2 nifedipine G2 nifedipine SR G 2 Nilandron B1 nimodipine G2 zNinlaro B1 nisoldipine G2 nitrofurantoin G2 nitroglycerin oint G 2 nitroglycerin pumpspray G 2 nitroglycerin SR G 2 nitroglycerin transdermal patch G 2 Nitrostat B2 nizatidine G4 nora-BE G4 +Norditropin B3 norethindrone G4 norethindrone a-e estradiol/ ferrous fumarate G 4 +zNorthera B2 nortrel G4 nortriptyline G3 Norvir B2 Novolin B1 Novolog B1 +Nutropin B3 NuvaRing B4 zNuvigil B3 nystatin G2 nystatin G4 nystatin vag tab G 4 nystatin/triamcinoloneG 4 G4 nystop O ocella G4 +octreotide G3 Odefsey B2 +zOdomzo B1 +zOfev B3 ofloxacin G2 ofloxacin ophth G 1 ofloxacin otic G 1 ogestrel G4 zolanzapine G3 zolanzapine/fluoxetineG 3 +zOlysio B2 zomeprazole G4 +Omnitrope B3 zondansetron G4 OneTouch B1 Onfi B4 Onglyza B1 Opana ER B 3 +zOpsumit B2 zOralair B1 +zOrencia B3 +zOrenitram B2 Orfadin B4 +zOrkambi B3 orphenadrine G3 Oseni B1 +zOtezla B3 oxazepam G3 oxcarbazepine G4 Oxistat B4 Oxsoralen Ultra B 4 zoxybutynin G1 zoxybutynin ER G 1 oxycodone G3 oxycodone/acetaminophenG 3 oxycodone/aspirin G3 oxymorphone ER G 3 P paliperidone G3 Pancreaze B4 zpantoprazole G4 paregoric G4 paromomycin G2 uparoxetine HCl G 3 Patanol B1 peg 3350/electrolyte G 4 +Pegasys B2 penicillin VK G 2 Pentasa B4 pentazocine/naloxoneG 3 pentoxifylline G1 perphenazine G3 Pertzye B4 Pexeva B3 phenazopyridine G1 phenelzine G3 phenobarbital G4 phenylephrine ophth G 1 G4 phenytoin Phisohex B4 Phospholine Iodide B 1 phytonadione G4 pilocarpine G1 pindolol G2 zpioglitazone G1 piroxicam G3 +zPlegridy B3 podofilox G4 polymyxin B/TMP G 1 +zPomalyst B1 portia G4 potassium aminobenzoateG 4 potassium bicarbonate G 3 potassium chloride G 3 potassium citrate G 1 Potiga B4 zPradaxa B1 +zPraluent B2 pramipexole G3 pramoxine/HC acetate 2.5%G 4 prascion RA G 4 zupravastatin G2 prazosin G2 pre-natal vitamins G 4 Precision B1 Pred Mild B 1 prednisolone acetate G 1 prednisolone ODT G 4 prednisolone oral G 4 prednisolone sod acetate G 1 prednisone oral G 4 Premarin B4 Premarin vag cream B 4 Premphase B4 Prempro B4 previfem G4 Prezcobix B2 Prezista B2 zPrilosec-OTC G4 Primaquine B2 primidone G4 Pristiq B3 zProAir HFA/RespiClick B 3 probenecid G2 procentra G3 prochlorperazine G4 +Procrit B1 Proctofoam-HC B4 Procysbi B3 progesterone, micronized G 4 +zPromacta B1 promethazine G1 promethazine G4 promethazine/codeineG 1 propafenone G2 propranolol G2 propranolol/HCTZ G2 propylthiouracil G4 pseudoephedrine G1 pseudoephedrine/codeineG 1 zPulmicort Flexhaler B 3 +Pulmozyme B3 Purixan B1 pyrazinamide G2 TIER PAGE DRUG NAME Q quasense Qudexy XR zquetiapine quinapril quinapril/HCTZ quinidine gluconate quinidine sulfate SR zQvar G4 B 4 G3 G2 G2 G 2 G 2 B3 R zRagwitek zraloxifene ramipril Ranexa ranitidine (all) +Ravicti +Rebif Regranex zRelenza zRelistor Renvela zrepaglanide +zRepatha Rescriptor Retrovir IV infusion vial +zRevlimid zRexulti Reyataz ribapak +ribasphere +ribavirin Ridaura rifabutin rifampin Rifater Rilutek rimantadine zrisedronate 150mg zrisedronate DR zrisperidone zrisperidone m-tab zrivastigamine ropinirole rosuvastatin zRuconest B1 G3 G2 B2 G 4 B3 B3 B4 B2 B4 B4 G1 B2 B2 B 2 B1 B3 B2 G2 G2 G2 B3 G2 G2 B2 B3 G2 G 3 G 3 G3 G 3 G1 G3 G2 B2 S Sabril B4 +Saizen B3 salsalate G3 zSamsca B2 Sandimmune B2 zSaphris B3 zSavaysa B1 Savella B3 zselegiline G3 selenium sulf 2.25% shampoo G4 Selzentry B2 Semprex-D B1 +Sensipar B3 zSerevent Diskus B 3 zSeroquel XR B 3 usertraline G3 +zSignifor B1 silver sulfadiazine G 4 +zSimponi B3 zusimvastatin G2 sirolimus G2 zSivextro B2 sod. polystyrene sulfonateG 3 sod. sulfacetamide/ sulfur lot G 4 sod.sulfacetamide/ sulfur emulsion cleanserG 4 sodium chloride irrigating soln G 4 sodium fluoride chewable tab & drops G 4 solia G4 +zSomavert B3 sotalol G2 sotret G4 +zSovaldi B2 zSpiriva B3 zSpiriva Respimat B 3 spironolactone G2 spironolactone/HCTZG 2 sprintec G4 Spritam B4 +zSprycel B1 stavudine G2 +zStelara B4 +Stimate B3 zStiolto Respimat B 3 +Stivarga B1 Strattera B3 Strensiq B3 Stribild B2 Suboxone Film B 3 sucralfate G4 sulfacetamide G4 sulfacetamide 10% G 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. sulfacetamide/ prednisolone ophth sulfamethoxazole/ trimethoprim sulfasalazine sulfasalazine EC sulindac zsumatriptan Sustiva +zSutent +zSylatron zSymbicort zSymlin Synarel zSynjardy Synthroid zSyprine TIER PAGE DRUG NAME Truvada 1 Tybost +zTykerb G2 G4 U G 4 Uceris ER tablet G3 Ulesfia G3 Ultresa B2 unithroid B1 zUptravi B1 ursodiol B3 B1 V B3 B1 Vagifem B4 zvalacyclovir B1 +zValchlor valganciclovir tablets valproic acid T zvalsartan tacrolimus G2 zvalsartan/HCTZ tacrolimus ointment G 4 vancomycin +zTafinlar B1 vandazole vag zTagrisso B1 +veletri zTamiflu B2 velivet tamoxifen G1 uvenlafaxine tamsulosin G1 venlafaxine ER tamsulosin G3 zVentolin HFA zTanzeum B1 verapamil +zTarceva B1 verapamil SR Targretin gel B 1 Versacloz +zTasigna B1 zVictoza Tazorac B4 Videx +zTecfidera B3 Videx pediatric solution +PzTechnivie B2 +PzViekira Pak zTekturna B2 Viibryd zTekturna HCT B 2 Viokace ztelmisartan G2 Viracept ztelmisartan/HCTZ G2 Viramune XR temazepam G3 Viread +temozolomide G1 vit A,D,C V fluoride terazosin G2 vit A,D,C V fluoride zterbinafine G2 and iron terbutaline tab G 3 Vitekta terconazole G4 zVogelxo zTestim B2 Voltaren gel zTestosterone gel B 3 zvoriconazole +ztetrabenazine G2 +Votrient tetracycline G2 zVraylar +Tev-Tropin B3 +Thalomid B1 W theochron G3 warfarin theophylline/SR tabs, liquid G 3 X thioridazine G3 thiothixene G3 +zXalkori thyroid G4 Xarelto Thyrolar B4 +zXeljanz tiagabine G4 zXigduo XR ticlopidine G1 +zXtandi timolol G1 zxulane timolol G2 Tivicay B2 Y tizanidine G3 yohimbine +Tobi Podhaler B 2 +tobramycin amp/neb G 2 Z tobramycin soln G 1 tobramycin/dexamethG 1 zzafirlukast z zaleplon tolazamide G1 tolbutamide G1 zarah ztolterodine G1 +zZavesca ztolterodine ER G 1 +zZelboraf topiramate G4 zenchent Zenpep Topiramate ER (SSB) capsules B4 PzZepatier topotecan G1 zZetia torsemide G2 zidovudine Toujeo B1 zziprasidone caps +zTracleer B2 Zmax Tradjenta B1 +Zolinza tramadol G3 zzolpidem Transderm Scop B 4 zzolpidem CR G3 zonisamide tranylcypromine travoprost G1 zZontivity trazodone G3 +Zorbtive Tresiba B1 zovia tretinoin cr/gel G 4 zZydelig tri-sprintec G4 +zZykadia ztriamcinolone acetonide G 4 +zZytiga triamterene/HCTZ G2 zZyvox triazolam G3 trifluoperazine G3 trifluridine G1 trihexyphenidyl G3 trimethobenzamide G4 trimethoprim G2 trinessa G4 Trintellix B3 Triumeq B2 trivora G4 Trokendi XR B 4 tropicamide G1 ztrospium G1 TRUEtest B1 TRUEtrack B1 zTrulicity B1 G TIER PAGE B2 B2 B1 B 4 B4 B4 G4 B2 G4 B4 G2 B1 G 2 G 4 G2 G2 G2 G 4 G2 G4 G3 G 3 B 3 G2 G 2 B3 B1 B2 B 2 B 2 B3 B4 B2 B 2 B2 G 4 G 4 B2 B3 B 3 G2 B1 B3 G1 B1 B1 B3 B 1 B1 G4 G2 G3 G3 G4 B3 B1 G4 B4 B2 B2 G2 G 3 B2 B1 G3 G 3 G4 B1 B3 G4 B1 B1 B1 B2 Note: * Some drugs are limited to 1 unit of use package per dispensing. 7 183894_MG46605A -BCBS WNY - Medicaid_v3.indd 7 6/2/16 2:01 PM
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