Blue MedicareRxSM Premier (PDP) 2020 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 06/01/2020. For more recent information or other questions, please contact Blue MedicareRx Premier, at:
Connecticut 1-888-620-1747 Rhode Island 1-888-620-1748
Massachusetts 1-888-543-4917 Vermont 1-888-620-1746
or, for TTY/TDD users, 711, 24 hours a day, 7 days a week, or visit www.RxMedicarePlans.com.
Note to existing members: This formulary has changed since last year.Please review this document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us,” or “our,” it means Blue
MedicareRxSM (PDP). When it refers to “plan” or “our plan,” it means Blue MedicareRx Premier.
This document includes a list of the drugs (formulary) for our plan which is current as of June 1, 2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.
S2893_1964_C 00020362_v11_06/2020
What is the Blue MedicareRx Premier Formulary?
A formulary is a list of covered drugs selected by Blue MedicareRx Premier in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Blue MedicareRx Premier will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Blue MedicareRx Premier network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Most changes in drug coverage happen on January 1, but Blue MedicareRx Premier may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.
Changes that can affect you this year: In the below cases, you will be affected bycoverage changes during the year:
· New generic drugs. We may immediately remove a brand name drug on our DrugList if we are replacing it with a new generic drug that will appear on the same orlower cost-sharing tier and with the same or fewer restrictions. Also, when adding thenew generic drug, we may decide to keep the brand name drug on our Drug List,but immediately move it to a different cost-sharing tier or add new restrictions. Ifyou are currently taking that brand name drug, we may not tell you in advancebefore we make that change, but we will later provide you with information aboutthe specific change(s) we have made.
o If we make such a change, you or your prescriber can ask us to make anexception and continue to cover the brand name drug for you. Thenotice we provide you will also include information on how to request anexception, and you can also find information in the section belowentitled “How do I request an exception to the Blue MedicareRxPremier Formulary?”
· Drugs removed from the market. If the Food and Drug Administration deems adrug on our formulary to be unsafe or the drug’s manufacturer removes the drugfrom the market, we will immediately remove the drug from our formulary andprovide notice to members who take the drug.
· Other changes. We may make other changes that affect members currently taking adrug. For instance, we may add a generic drug that is not new to market to replace abrand name drug currently on the formulary or add new restrictions to the brandname drug or move it to a different cost-sharing tier. Or we may make changes basedon new clinical guidelines. If we remove drugs from our formulary, add priorauthorization, quantity limits and/or step therapy restrictions on a drug or move adrug to a higher cost-sharing tier, we must notify affected members of the change atleast 30 days before the change becomes effective, or at the time the memberrequests a refill of the drug, at which time the member will receive a 30-day supplyof the drug.
I
o If we make these other changes, you or your prescriber can ask us tomake an exception and continue to cover the brand name drug for you.The notice we provide you will also include information on how torequest an exception, and you can also find the information in thesection below entitled “How do I request an exception to the BlueMedicareRx Premier Formulary?”
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year.
The enclosed formulary is current as of June 1, 2020. To get updated information about the drugs covered by Blue MedicareRx Premier, please contact us. Our contact information appears on the front and back cover pages. If we have other types of mid-year non-maintenance formulary changes unrelated to the reasons stated above (e.g. remove drugs from our formulary, add prior authorization requirements, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier), we will notify you by mail. You may also access our formulary on our website at www.RxMedicarePlans.com to get information showing changes to, additions, and/or deletions of medications contained in our formulary.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular.” If you know what your drug is used for, look for the category name in the list that begins on page number 1. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in theIndex that begins at the back of this document. The Index provides an alphabetical listof all of the drugs included in this document. Both brand name drugs and generic drugsare listed in the Index. Look in the Index and find your drug. Next to your drug, youwill see the page number where you can find coverage information. Turn to the pagelisted in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
Blue MedicareRx Premier covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
II
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. Theserequirements and limits may include:
· Prior Authorization: Blue MedicareRx Premier requires you or your physician toget prior authorization for certain drugs. This means that you will need to getapproval from our plan before you fill your prescriptions. If you don’t get approval,we may not cover the drug.
· Quantity Limits: For certain drugs, Blue MedicareRx Premier limits the amount ofthe drug that we will cover. For example, our plan provides 2 units per prescriptionfor FLOVENT HFA. This may be in addition to a standard one-month orthree-month supply.
· Step Therapy: In some cases, Blue MedicareRx Premier requires you to first trycertain drugs to treat your medical condition before we will cover another drug forthat condition. For example, if Drug A and Drug B both treat your medicalcondition, our plan may not cover Drug B unless you try Drug A first. If Drug A doesnot work for you, we will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in theformulary that begins on page 1. You can also get more information about the restrictionsapplied to specific covered drugs by visiting our website. We have posted online documentsthat explain our prior authorization and step therapy restrictions. You may also ask us tosend you a copy. Our contact information, along with the date we last updated theformulary, appears on the front and back cover pages.
You can ask Blue MedicareRx Premier to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Blue MedicareRx Premier formulary?” on page III for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contactCustomer Care and ask if your drug is covered.
If you learn that Blue MedicareRx Premier does not cover your drug, you have two options:
· You can ask Customer Care for a list of similar drugs that are covered by BlueMedicareRx Premier. When you receive the list, show it to your doctor and ask himor her to prescribe a similar drug that is covered by our plan.
· You can ask Blue MedicareRx Premier to make an exception and cover your drug.See below for information about how to request an exception.
Compounds may or may not be covered by your plan benefit.
How do I request an exception to the Blue MedicareRx Premier Formulary?
You can ask us to make an exception to our coverage rules. There are several types ofexceptions that you can ask us to make.
III
· You can ask us to cover a drug even if it is not on our formulary. If approved, thisdrug will be covered at a pre-determined cost-sharing level, and you would not beable to ask us to provide the drug at a lower cost-sharing level.
· You can ask us to cover a formulary drug at a lower cost-sharing level if this drug isnot on the specialty tier. If approved this would lower the amount you must pay foryour drug.
· You can ask us to waive coverage restrictions or limits on your drug. For example, forcertain drugs, Blue MedicareRx Premier limits the amount of the drug that we willcover. If your drug has a quantity limit, you can ask us to waive the limit and cover agreater amount.
Generally, Blue MedicareRx Premier will only approve your request for an exception if the alternative drug is included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering orutilization restriction exception. When you request a formulary, tiering or utilization
restriction exception you should submit a statement from your prescriber orphysician supporting your request. Generally, we must make our decision within 72hours of getting your prescriber’s supporting statement. You can request an expedited (fast)exception if you or your doctor believe that your health could be seriously harmed bywaiting up to 72 hours for a decision. If your request to expedite is granted, we must giveyou a decision no later than 24 hours after we get a supporting statement from your doctoror other prescriber.
What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on ourformulary. Or, you may be taking a drug that is on our formulary but your ability to get it islimited. For example, you may need a prior authorization from us before you can fill yourprescription. You should talk to your doctor to decide if you should switch to an appropriatedrug that we cover or request a formulary exception so that we will cover the drug you take.While you talk to your doctor to determine the right course of action for you, we may coveryour drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs islimited, we will cover a temporary 30-day supply. If your prescription is written for fewerdays, we’ll allow refills to provide up to a maximum 30-day supply of medication. After yourfirst 30-day supply, we will not pay for these drugs, even if you have been a member of theplan less than 90 days.
If you are a resident of a long-term care facility, and you need a drug that is not on ourformulary or if your ability to get your drugs is limited, but you are past the first 90 days ofmembership in our plan, we will cover a 31-day emergency supply of that drug while youpursue a formulary exception.
IV
If you change your level of care, such as a move from a hospital to a home setting, and youneed a drug that is not on our formulary or if your ability to get your drugs is limited, butyou are past the first 90 days of membership in our plan, we will cover up to a temporary30-day supply when you go to a network pharmacy. After your first 30-day supply, you arerequired to use the plan's exception process.
Our transition supply will not cover drugs that Medicare does not allow Part D plans tocover or drugs that are covered under Medicare Part B.
For more information
For more detailed information about your Blue MedicareRx Premier prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about Blue MedicareRx Premier, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit https://www.medicare.gov.
Blue MedicareRx Premier Formulary
The formulary that begins on page 1 provides coverage information about the drugs covered by Blue MedicareRx Premier. If you have trouble finding your drug in the list, turn to the Index that begins at the back of this document.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,ADVAIR DISKUS) and generic drugs are listed in lower-case italics (e.g., atorvastatin).
The information in the Requirements/Limits column tells you if Blue MedicareRx Premier has any special requirements for coverage of your drug. The abbreviations you may see in the drug listing include:
o B/D stands for drugs covered under Medicare Part B or D.
o QL stands for Quantity Limits.
o PA stands for Prior Authorization.
o ST stands for Step Therapy.
o LA stands for Limited Access. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Care at the numbers that appear on the front and back cover pages, 24 hours a day, 7 days a week. TTY/TDD users should call 711.
o NMO stands for No Mail Order. This prescription drug is not available throughmail order service.
o GC stands for Gap Coverage. We provide additional coverage of this prescriptiondrug in the coverage gap. Please refer to our Evidence of Coverage for moreinformation about this coverage.
V
Explanation of Tiers and Copayments/Coinsurance:
Blue MedicareRx Premier Initial Coverage Stage
Tier Label Retail Cost-Sharing or
Out-of-Network (OON)
Cost-Sharing*
30-day supply/ Long-term Care (LTC)**
31-day supply
Mail Order
Cost-Sharing
90-day supply
Preferred Retail Standard Retail Cost-Sharing Cost-Sharing/
OON/LTC
Tier 1: Preferred Generic $1 $6 $1
Certain generic drugs that are available at the lowest copayment
Tier 2: Generic $7 $12 $14
Higher cost generic drugs available at a higher copayment than Tier 1 generic drugs
Tier 3: Preferred Brand $30 $40 $60
Many common brand name drugs and some higher cost generic drugs
Tier 4: Non-Preferred Drug
Higher cost generic and non-preferred drugs, many of which may have lower cost options available on Tier 1, Tier 2, and Tier 3
35% 45% 35%
Tier 5: Specialty Tier
Unique and/or very high-cost brand and some generic drugs of which you pay a percentage of the total drug cost which may require special handling and/or close monitoring
33% 33% Not Applicable†
* In addition to your copayment, at an out-of-network pharmacy you will pay the differencebetween the actual charge and what you would have paid at a network pharmacy. Amountsyou pay may vary at out-of-network pharmacies.
** Standard Retail Cost-Sharing applies to all Out-of-Network (OON) and Long-term Care (LTC) Cost-Sharing.
† Specialty Tier drugs are not available for a 90-day retail or mail order supply.
VI
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
1
Drug Name Drug Tier
Requirements/Limits
ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM)
Tier 2 GC
colchicine w/ probenecid Tier 3
COLCRYS QL (120 tabs / 30 days)
Tier 3 QL
MITIGARE QL (60 caps / 30 days)
Tier 3 QL
probenecid Tier 2 GC
NSAIDS celecoxib (generic of CELEBREX) CAPS 50mg
QL (240 caps / 30 days)
Tier 3 QL
celecoxib (generic of CELEBREX) CAPS 100mg
QL (120 caps / 30 days)
Tier 3 QL
celecoxib (generic of CELEBREX) CAPS 200mg
QL (60 caps / 30 days)
Tier 3 QL
celecoxib (generic of CELEBREX) CAPS 400mg
QL (30 caps / 30 days)
Tier 3 QL
diclofenac potassium QL (120 tabs / 30 days)
Tier 3 QL
diclofenac sodium TB24 Tier 3
diclofenac sodium TBEC Tier 2 GC
diflunisal TABS Tier 3
etodolac CAPS Tier 3
etodolac (generic of LODINE) TABS 400mg
Tier 3
etodolac TABS 500mg Tier 3
etodolac TB24 Tier 3
flurbiprofen TABS 100mg Tier 2 GC
ibu tab 600mg Tier 1 GC
ibu tab 800mg Tier 1 GC
ibuprofen SUSP Tier 3
ibuprofen TABS 400mg, 600mg, 800mg
Tier 1 GC
Drug Name Drug Tier
Requirements/Limits
meloxicam (generic of MOBIC) TABS
Tier 1 GC
nabumetone TABS Tier 2 GC
naproxen (generic of NAPROSYN) TABS 250mg
Tier 1 GC
naproxen TABS 375mg, 500mg
Tier 1 GC
naproxen dr (generic of EC-NAPROSYN) 375mg
Tier 2 GC
naproxen dr (generic of EC-NAPROXEN) 500mg
Tier 2 GC
naproxen sodium TABS 275mg
Tier 3
naproxen sodium (generic of ANAPROX DS) TABS 550mg
Tier 3
piroxicam (generic of FELDENE) CAPS
Tier 3
sulindac TABS Tier 2 GC
OPIOID ANALGESICS acetaminophen w/ codeine 300-15mg
QL (400 tabs / 30 days)
Tier 2 GC QL
acetaminophen w/ codeine 300-30mg (generic of TYLENOL/CODEINE #3)
QL (360 tabs / 30 days)
Tier 2 GC QL
acetaminophen w/ codeine 300-60mg
QL (180 tabs / 30 days)
Tier 2 GC QL
acetaminophen w/ codeine soln
QL (2700 mL / 30 days)
Tier 2 GC QL
butorphanol tartrate SOLN 1mg/ml, 2mg/ml
Tier 4
nalbuphine hcl SOLN Tier 4
tramadol hcl tab 50 mg (generic of ULTRAM)
QL (240 tabs / 30 days)
Tier 2 GC QL
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
2
Drug Name Drug Tier
Requirements/Limits
tramadol-acetaminophen (generic of ULTRACET)
QL (240 tabs / 30 days)
Tier 3 QL
OPIOID ANALGESICS, CII endocet 2.5-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
Tier 3 QL
endocet 5-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
Tier 3 QL
endocet 7.5-325mg (generic of PERCOCET)
QL (240 tabs / 30 days)
Tier 3 QL
endocet 10-325mg (generic of PERCOCET)
QL (180 tabs / 30 days)
Tier 3 QL
fentanyl citrate (generic of ACTIQ) LPOP
QL (120 lozenges / 30 days)
Tier 5 QL PA
fentanyl patch 12 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
Tier 4 QL PA
fentanyl patch 25 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
Tier 4 QL PA
fentanyl patch 50 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
Tier 4 QL PA
fentanyl patch 75 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
Tier 4 QL PA
fentanyl patch 100 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
Tier 4 QL PA
Drug Name Drug Tier
Requirements/Limits
hydroco/apap tab 5-325mg (generic of NORCO,LORCET)
QL (240 tabs / 30 days)
Tier 3 QL
hydroco/apap tab 7.5-325 (generic of NORCO,LORCET PLUS)
QL (180 tabs / 30 days)
Tier 3 QL
hydroco/apap tab 10-325mg (generic of NORCO,LORCET HD)
QL (180 tabs / 30 days)
Tier 3 QL
hydrocodone-acetaminophen 7.5-325 mg/15ml
QL (2700 mL / 30 days)
Tier 4 QL
hydrocodone-ibuprofen tab 7.5-200 mg
QL (150 tabs / 30 days)
Tier 3 QL
hydromorphone hcl (generic of DILAUDID) LIQD
QL (600 mL / 30 days)
Tier 4 QL
hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml
Tier 4 B/D
hydromorphone hcl (generic of DILAUDID) TABS
QL (180 tabs / 30 days)
Tier 3 QL
HYSINGLA ER QL (30 tabs / 30 days)
Tier 3 QL PA
lorcet hd tab 10-325mg (generic of NORCO)
QL (180 tabs / 30 days)
Tier 3 QL
lorcet plus tab 7.5-325 (generic of NORCO)
QL (180 tabs / 30 days)
Tier 3 QL
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
3
Drug Name Drug Tier
Requirements/Limits
lorcet tab 5-325mg (generic of NORCO)
QL (240 tabs / 30 days)
Tier 3 QL
methadone hcl SOLN 5mg/5ml, 10mg/5ml
QL (450 mL / 30 days)
Tier 3 QL PA
methadone hcl 5mg (generic of DOLOPHINE)
QL (90 tabs / 30 days)
Tier 3 QL PA
methadone hcl 10mg (generic of DOLOPHINE)
QL (90 tabs / 30 days)
Tier 3 QL PA
methadone hcl intensol (generic of METHADOSE)
QL (90 mL / 30 days)
Tier 3 QL PA
morphine ext-rel tab (generic of MS CONTIN)
QL (90 tabs / 30 days)
Tier 3 QL PA
morphine sul inj 1mg/ml Tier 4 B/D
MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml
Tier 4 B/D
morphine sulfate (generic of MORPHINE SULFATE) SOLN 4mg/ml, 8mg/ml, 10mg/ml
Tier 4 B/D
morphine sulfate TABS QL (180 tabs / 30 days)
Tier 3 QL
morphine sulfate oral soln 10mg/5ml
QL (900 mL / 30 days)
Tier 3 QL
morphine sulfate oral soln 20mg/5ml
QL (900 mL / 30 days)
Tier 3 QL
morphine sulfate oral soln 100mg/5ml
QL (180 mL / 30 days)
Tier 3 QL
NUCYNTA ER QL (60 tabs / 30 days)
Tier 3 QL PA
oxycodone hcl CAPS QL (180 caps / 30 days)
Tier 4 QL
Drug Name Drug Tier
Requirements/Limits
oxycodone hcl CONC QL (180 mL / 30 days)
Tier 4 QL
oxycodone hcl SOLN QL (900 mL / 30 days)
Tier 4 QL
oxycodone hcl (generic of ROXICODONE) TABS 5mg, 15mg, 30mg
QL (180 tabs / 30 days)
Tier 3 QL
oxycodone hcl TABS 10mg, 20mg
QL (180 tabs / 30 days)
Tier 3 QL
oxycodone w/ acetaminophen 2.5-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
Tier 3 QL
oxycodone w/ acetaminophen 5-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
Tier 3 QL
oxycodone w/ acetaminophen 7.5-325mg (generic of PERCOCET)
QL (240 tabs / 30 days)
Tier 3 QL
oxycodone w/ acetaminophen 10-325mg (generic of PERCOCET)
QL (180 tabs / 30 days)
Tier 3 QL
ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE) 2%
Tier 2 GC B/D
lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) .5%, 1%
Tier 2 GC B/D
lidocaine inj 0.5% (generic of XYLOCAINE)
Tier 2 GC B/D
lidocaine inj 1% (generic of XYLOCAINE)
Tier 2 GC B/D
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
4
Drug Name Drug Tier
Requirements/Limits
lidocaine inj 1.5% preservative free (pf) (generic of XYLOCAINE-MPF)
Tier 2 GC B/D
ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN Tier 4
gentamicin in saline Tier 2 GC
gentamicin sulfate SOLN Tier 2 GC
neomycin sulfate TABS Tier 2 GC
paromomycin sulfate CAPS Tier 4
streptomycin sulfate SOLR Tier 5
SULFADIAZINE TABS Tier 4
tobramycin (generic of KITABIS PAK) NEBU
Tier 5 NMO PA
tobramycin inj 1.2 gm/30ml Tier 3
tobramycin inj 1.2gm Tier 5
tobramycin inj 10mg/ml Tier 3
tobramycin inj 80mg/2ml Tier 3
tobramycin sulfate SOLN Tier 3
ANTI-INFECTIVES - MISCELLANEOUS albendazole (generic of ALBENZA) TABS
Tier 5
ALINIA Tier 5
atovaquone (generic of MEPRON) SUSP
Tier 5
aztreonam (generic of AZACTAM)
Tier 4
CAYSTON Tier 5 NMO LA PA
clindamycin cap 75mg (generic of CLEOCIN)
Tier 1 GC
clindamycin cap 300 mg (generic of CLEOCIN)
Tier 1 GC
clindamycin hcl cap 150 mg (generic of CLEOCIN)
Tier 1 GC
clindamycin phosphate in d5w
Tier 4
CLINDAMYCIN PHOSPHATE IN NACL
Tier 4
clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE)
Tier 3
Drug Name Drug Tier
Requirements/Limits
clindamycin soln 75mg/5ml (generic of CLEOCIN PEDIATRIC GRANULE)
Tier 4
colistimethate sodium (generic of COLY-MYCIN M) SOLR
Tier 4
dapsone TABS Tier 3
daptomycin (generic of DAPTOMYCIN) 350mg
Tier 5
daptomycin (generic of CUBICIN) 500mg
Tier 5
EMVERM QL (12 tabs / 365 days)
Tier 5 QL
ertapenem sodium (generic of INVANZ)
Tier 4
imipenem-cilastatin Tier 3
imipenem-cilastatin (generic of PRIMAXIN IV)
Tier 3
ivermectin (generic of STROMECTOL) TABS
Tier 3
linezolid in sodium chloride Tier 4
linezolid inj (generic of ZYVOX)
Tier 4
linezolid susp (generic of ZYVOX)
Tier 5
linezolid tab 600mg (generic of ZYVOX)
Tier 4
meropenem (generic of MERREM)
Tier 4
methenamine hippurate (generic of HIPREX)
Tier 3
metronidazole (generic of FLAGYL) TABS
Tier 2 GC
metronidazole in nacl Tier 2 GC
nitrofurantoin macrocrystal (generic of MACRODANTIN) 50mg, 100mg
Tier 3
nitrofurantoin monohyd macro (generic of MACROBID)
Tier 3
pentamidine isethionate inh (generic of NEBUPENT)
Tier 4 B/D
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
5
Drug Name Drug Tier
Requirements/Limits
pentamidine isethionate inj (generic of PENTAM 300)
Tier 4
praziquantel (generic of BILTRICIDE) TABS
Tier 3
SIVEXTRO Tier 5
sulfamethoxazole-trimethop ds (generic of BACTRIM DS)
Tier 1 GC
sulfamethoxazole-trimethoprim inj
Tier 4
sulfamethoxazole-trimethoprim susp
Tier 3
sulfamethoxazole-trimethoprim tab 400-80mg (generic of BACTRIM)
Tier 1 GC
SYNERCID Tier 5
tigecycline (generic of TYGACIL)
Tier 5
trimethoprim TABS Tier 2 GC
vancomycin hcl (generic of VANCOCIN HCL) CAPS 125mg
QL (120 caps / 30 days)
Tier 4 QL
vancomycin hcl (generic of VANCOCIN) CAPS 250mg
QL (240 caps / 30 days)
Tier 5 QL
vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg
Tier 4
VANCOMYCIN IN NACL Tier 4
ANTIFUNGALS ABELCET Tier 5 B/D
AMBISOME Tier 5 B/D
amphotericin b SOLR Tier 4 B/D
caspofungin acetate (generic of CANCIDAS)
Tier 5
fluconazole (generic of DIFLUCAN) SUSR
Tier 3
fluconazole (generic of DIFLUCAN) TABS 50mg, 100mg, 200mg
Tier 3
fluconazole (generic of DIFLUCAN) TABS 150mg
Tier 1 GC
Drug Name Drug Tier
Requirements/Limits
fluconazole inj nacl 200 Tier 3
fluconazole inj nacl 400 Tier 3
flucytosine (generic of ANCOBON) CAPS
Tier 5
griseofulvin microsize Tier 4
griseofulvin ultramicrosize Tier 4
itraconazole (generic of SPORANOX) CAPS
Tier 4 PA
ketoconazole TABS Tier 3 PA
MYCAMINE Tier 5
NOXAFIL SUSP QL (630 mL / 30 days)
Tier 5 QL
nystatin TABS Tier 3
posaconazole (generic of NOXAFIL)
QL (93 tabs / 30 days)
Tier 5 QL
terbinafine hcl (generic of LAMISIL) TABS
QL (90 tabs / year)
Tier 1 GC QL
voriconazole (generic of VFEND IV) SOLR
Tier 5 PA
voriconazole (generic of VFEND) SUSR
Tier 5 PA
voriconazole (generic of VFEND) TABS 50mg
Tier 4
voriconazole (generic of VFEND) TABS 200mg
Tier 5
ANTIMALARIALS atovaquone-proguanil hcl (generic of MALARONE)
Tier 4
chloroquine phosphate TABS
Tier 3
COARTEM Tier 4
mefloquine hcl Tier 3
PRIMAQUINE PHOSPHATE 26.3mg
Tier 3
primaquine phosphate (generic of PRIMAQUINE PHOSPHATE) 26.3mg
Tier 3
quinine sulfate (generic of QUALAQUIN) CAPS
Tier 4 PA
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
6
Drug Name Drug Tier
Requirements/Limits
ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN) SOLN
Tier 4 NMO
abacavir sulfate (generic of ZIAGEN) TABS
Tier 3 NMO
APTIVUS Tier 5 NMO
atazanavir sulfate (generic of REYATAZ)
Tier 4 NMO
CRIXIVAN Tier 4 NMO
didanosine Tier 4 NMO
EDURANT Tier 5 NMO
efavirenz (generic of SUSTIVA) CAPS 50mg
Tier 4 NMO
efavirenz (generic of SUSTIVA) CAPS 200mg
Tier 5 NMO
efavirenz (generic of SUSTIVA) TABS
Tier 5 NMO
EMTRIVA Tier 3 NMO
fosamprenavir tab 700 mg (generic of LEXIVA)
Tier 5 NMO
FUZEON Tier 5 NMO
INTELENCE 25mg Tier 4 NMO
INTELENCE 100mg, 200mg
Tier 5 NMO
INVIRASE Tier 5 NMO
ISENTRESS CHEW 25mg Tier 3 NMO
ISENTRESS CHEW 100mg Tier 5 NMO
ISENTRESS PACK Tier 3 NMO
ISENTRESS TABS Tier 5 NMO
ISENTRESS HD Tier 5 NMO
lamivudine (generic of EPIVIR)
Tier 3 NMO
LEXIVA SUSP Tier 4 NMO
nevirapine susp 50 mg/5ml (generic of VIRAMUNE)
Tier 4 NMO
nevirapine tab 100mg er Tier 4 NMO
nevirapine tab 200mg (generic of VIRAMUNE)
Tier 3 NMO
nevirapine tab 400mg er (generic of VIRAMUNE XR)
Tier 4 NMO
NORVIR PACK Tier 4 NMO
NORVIR SOLN Tier 4 NMO
PIFELTRO Tier 5 NMO
Drug Name Drug Tier
Requirements/Limits
PREZISTA SUSP QL (400 mL / 30 days)
Tier 5 QL NMO
PREZISTA TABS 75mg QL (480 tabs / 30 days)
Tier 4 QL NMO
PREZISTA TABS 150mg QL (240 tabs / 30 days)
Tier 5 QL NMO
PREZISTA TABS 600mg QL (60 tabs / 30 days)
Tier 5 QL NMO
PREZISTA TABS 800mg QL (30 tabs / 30 days)
Tier 5 QL NMO
REYATAZ PACK Tier 5 NMO
ritonavir (generic of NORVIR)
Tier 3 NMO
SELZENTRY SOLN Tier 5 NMO
SELZENTRY TABS 25mg Tier 4 NMO
SELZENTRY TABS 75mg, 150mg, 300mg
Tier 5 NMO
stavudine 15mg, 20mg Tier 3 NMO
stavudine (generic of ZERIT) 30mg, 40mg
Tier 3 NMO
tenofovir disoproxil fumarate (generic of VIREAD)
Tier 3 NMO
TIVICAY 10mg Tier 3 NMO
TIVICAY 25mg, 50mg Tier 5 NMO
TROGARZO Tier 5 NMO LA
TYBOST Tier 4 NMO
VIDEX EC 125MG Tier 4 NMO
VIDEX PEDIATRIC Tier 4 NMO
VIRACEPT Tier 5 NMO
VIREAD POWD Tier 5 NMO
VIREAD TABS 150mg, 200mg, 250mg
Tier 5 NMO
zidovudine cap 100mg (generic of RETROVIR)
Tier 4 NMO
zidovudine syp 50mg/5ml (generic of RETROVIR)
Tier 4 NMO
zidovudine tab 300mg Tier 3 NMO
ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine (generic of EPZICOM)
Tier 3 NMO
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
7
Drug Name Drug Tier
Requirements/Limits
abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR)
Tier 5 NMO
ATRIPLA Tier 5 NMO
BIKTARVY Tier 5 NMO
CIMDUO Tier 5 NMO
COMPLERA Tier 5 NMO
DELSTRIGO Tier 5 NMO
DESCOVY Tier 5 NMO
DOVATO Tier 5 NMO
EVOTAZ Tier 5 NMO
GENVOYA Tier 5 NMO
JULUCA Tier 5 NMO
KALETRA TAB 100-25MG Tier 4 NMO
KALETRA TAB 200-50MG Tier 5 NMO
lamivudine-zidovudine (generic of COMBIVIR)
Tier 4 NMO
lopinavir-ritonavir (generic of KALETRA)
Tier 4 NMO
ODEFSEY Tier 5 NMO
PREZCOBIX Tier 5 NMO
STRIBILD Tier 5 NMO
SYMFI Tier 5 NMO
SYMFI LO Tier 5 NMO
SYMTUZA Tier 5 NMO
TEMIXYS Tier 5 NMO
TRIUMEQ Tier 5 NMO
TRUVADA TAB 100-150 QL (30 tabs / 30 days)
Tier 5 QL NMO
TRUVADA TAB 133-200 QL (30 tabs / 30 days)
Tier 5 QL NMO
TRUVADA TAB 167-250 QL (30 tabs / 30 days)
Tier 5 QL NMO
TRUVADA TAB 200-300 QL (30 tabs / 30 days)
Tier 5 QL NMO
ANTITUBERCULAR AGENTS cycloserine CAPS Tier 5
ethambutol hcl TABS 100mg
Tier 3
ethambutol hcl (generic of MYAMBUTOL) TABS 400mg
Tier 3
isoniazid TABS Tier 1 GC
isoniazid syp 50mg/5ml Tier 4
Drug Name Drug Tier
Requirements/Limits
PASER D/R Tier 4
PRIFTIN Tier 4
pyrazinamide TABS Tier 4
rifabutin (generic of MYCOBUTIN)
Tier 4
rifampin (generic of RIFADIN) CAPS
Tier 3
rifampin (generic of RIFADIN) SOLR
Tier 4
RIFATER Tier 4
SIRTURO Tier 5 LA PA
TRECATOR Tier 4
ANTIVIRALS acyclovir CAPS Tier 2 GC
acyclovir (generic of ZOVIRAX) SUSP
Tier 4
acyclovir (generic of ZOVIRAX) TABS
Tier 2 GC
acyclovir sodium Tier 4 B/D
adefovir dipivoxil (generic of HEPSERA)
Tier 5 NMO
BARACLUDE SOLN Tier 5 NMO
entecavir (generic of BARACLUDE)
Tier 4 NMO
EPCLUSA Tier 5 NMO PA
EPIVIR HBV SOLN Tier 4 NMO
famciclovir TABS Tier 3
ganciclovir sodium (generic of CYTOVENE)
Tier 4 B/D
HARVONI Tier 5 NMO PA
lamivudine (hbv) (generic of EPIVIR HBV)
Tier 4 NMO
MAVYRET Tier 5 NMO PA
oseltamivir phosphate (generic of TAMIFLU) CAPS 30mg
QL (168 caps / year)
Tier 3 QL
oseltamivir phosphate (generic of TAMIFLU) CAPS 45mg, 75mg
QL (84 caps / year)
Tier 3 QL
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
8
Drug Name Drug Tier
Requirements/Limits
oseltamivir phosphate (generic of TAMIFLU) SUSR
QL (1080 mL / year)
Tier 3 QL
PEGASYS Tier 5 NMO PA
PEGASYS PROCLICK Tier 5 NMO PA
RELENZA DISKHALER QL (6 inhalers / year)
Tier 3 QL
ribavirin cap 200mg Tier 3 NMO
ribavirin tab 200mg Tier 4 NMO
rimantadine hydrochloride Tier 3
valacyclovir hcl (generic of VALTREX) TABS
Tier 3
valganciclovir hcl (generic of VALCYTE)
Tier 5
VEMLIDY Tier 5 NMO
VOSEVI Tier 5 NMO PA
CEPHALOSPORINS cefaclor CAPS Tier 3
cefaclor SUSR Tier 4
CEFACLOR ER TAB 500MG
Tier 4
cefadroxil CAPS Tier 2 GC
cefadroxil SUSR Tier 3
cefadroxil TABS Tier 4
CEFAZOLIN IN DEXTROSE 2GM/100ML-4%
Tier 3
cefazolin inj Tier 3
cefazolin sodium SOLR 1gm
Tier 3
CEFAZOLIN SODIUM 1 GM/50ML
Tier 3
cefdinir CAPS Tier 2 GC
cefdinir SUSR Tier 4
cefepime for inj Tier 4
cefixime (generic of SUPRAX) SUSR
Tier 4
cefoxitin for inj Tier 4
cefpodoxime proxetil SUSR Tier 4
cefpodoxime proxetil TABS Tier 3
cefprozil Tier 3
ceftazidime SOLR Tier 3
CEFTAZIDIME/DEXTROSE Tier 4
Drug Name Drug Tier
Requirements/Limits
ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg
Tier 3
cefuroxime axetil Tier 3
cefuroxime sodium Tier 3
cephalexin (generic of KEFLEX) CAPS 250mg, 500mg
Tier 1 GC
cephalexin SUSR Tier 3
tazicef SOLR Tier 3
TEFLARO Tier 5
ERYTHROMYCINS/MACROLIDES azithromycin PACK Tier 3
azithromycin (generic of ZITHROMAX) SOLR
Tier 3
azithromycin (generic of ZITHROMAX) SUSR
Tier 3
azithromycin (generic of ZITHROMAX) TABS 250mg, 500mg
Tier 1 GC
azithromycin TABS 600mg Tier 1 GC
clarithromycin TABS Tier 3
clarithromycin er (generic of BIAXIN XL)
Tier 3
clarithromycin for susp Tier 4
DIFICID Tier 5
e.e.s. 400 Tier 4
ery-tab Tier 4
ERYTHROCIN LACTOBIONATE
Tier 4
erythrocin stearate Tier 4
erythromycin base Tier 4
erythromycin cap 250mg ec Tier 4
erythromycin ethylsuccinate TABS
Tier 4
erythromycin tab ec Tier 4
FLUOROQUINOLONES CIPRO SUSR 500mg/5ml Tier 4
ciprofloxacin hcl tab 100mg Tier 4
ciprofloxacin hcl tab (generic of CIPRO) 250mg, 500mg
Tier 1 GC
ciprofloxacin hcl tab 750mg Tier 1 GC
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
9
Drug Name Drug Tier
Requirements/Limits
ciprofloxacin in d5w Tier 3
levofloxacin (generic of LEVAQUIN) TABS
Tier 1 GC
levofloxacin in d5w Tier 3
levofloxacin inj 25mg/ml Tier 4
levofloxacin oral soln 25 mg/ml
Tier 4
PENICILLINS amoxicillin CAPS; SUSR; TABS
Tier 1 GC
amoxicillin CHEW Tier 2 GC
amoxicillin & pot clavulanate 200-28.5 chw tabs
Tier 4
amoxicillin & pot clavulanate 200/5ml susr
Tier 3
amoxicillin & pot clavulanate 250-125 tabs
Tier 4
amoxicillin & pot clavulanate 250/5ml susr (generic of AUGMENTIN)
Tier 4
amoxicillin & pot clavulanate 400-57 chw tabs
Tier 4
amoxicillin & pot clavulanate 400/5ml susr
Tier 3
amoxicillin & pot clavulanate 500-125 tabs (generic of AUGMENTIN)
Tier 2 GC
amoxicillin & pot clavulanate 600/5ml susr
Tier 3
amoxicillin & pot clavulanate 875-125 tabs
Tier 2 GC
amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs
Tier 4
ampicillin & sulbactam sodium (generic of UNASYN)
Tier 4
ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)
Tier 4
ampicillin cap 500mg Tier 2 GC
ampicillin inj Tier 4
ampicillin sodium Tier 4
BICILLIN L-A Tier 4
dicloxacillin sodium Tier 3
Drug Name Drug Tier
Requirements/Limits
nafcillin sodium for inj 1gm, 2gm
Tier 4
nafcillin sodium for inj 10gm Tier 5
NAFCILLIN SODIUM FOR INJ 10GM
Tier 4
oxacillin sodium SOLR 1gm, 2gm
Tier 4
oxacillin sodium SOLR 10gm
Tier 5
PENICILLIN G POT IN DEXTROSE 2MU
Tier 4
PENICILLIN G POT IN DEXTROSE 3MU
Tier 4
PENICILLIN G PROCAINE Tier 4
penicillin g sodium Tier 4
penicillin v potassium SOLR
Tier 2 GC
penicillin v potassium TABS Tier 1 GC
penicilln gk inj 5mu Tier 4
penicilln gk inj 20mu Tier 4
pfizerpen-g inj 5mu Tier 4
pfizerpen-g inj 20mu Tier 4
piper/tazoba inj 2-0.25gm Tier 4
piper/tazoba inj 3-0.375gm Tier 4
piper/tazoba inj 4-0.5gm Tier 4
piper/tazoba inj 12-1.5gm Tier 4
piper/tazoba inj 36-4.5gm Tier 4
TETRACYCLINES doxy 100 Tier 4
doxycycline (monohydrate) CAPS 50mg, 100mg
Tier 2 GC
doxycycline (monohydrate) TABS 50mg, 75mg, 100mg
Tier 3
doxycycline hyclate CAPS 50mg
Tier 3
doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg
Tier 3
doxycycline hyclate SOLR Tier 4
doxycycline hyclate 20 mg Tier 3
doxycycline hyclate 100 mg Tier 3
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
10
Drug Name Drug Tier
Requirements/Limits
minocycline hcl (generic of MINOCIN) CAPS 50mg, 100mg
Tier 2 GC
minocycline hcl CAPS 75mg
Tier 2 GC
mondoxyne nl cap 100mg Tier 2 GC
tetracycline hcl CAPS Tier 4
ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA Tier 5 B/D NMO
cyclophosphamide CAPS Tier 3 B/D
cyclophosphamide SOLR Tier 5 B/D
EMCYT Tier 4
GLEOSTINE 10mg Tier 4
GLEOSTINE 40mg, 100mg Tier 5
LEUKERAN Tier 5
ANTHRACYCLINES adriamycin SOLN Tier 4 B/D
doxorubicin hcl Tier 4 B/D
doxorubicin hcl liposomal (generic of DOXIL)
Tier 5 B/D
epirubicin hcl 50mg/25ml Tier 4 B/D
epirubicin hcl (generic of ELLENCE) 200mg/100ml
Tier 4 B/D
ANTIMETABOLITES adrucil inj Tier 3 B/D
ALIMTA Tier 5 B/D
azacitidine (generic of VIDAZA)
Tier 5 B/D NMO
cytarabine 20mg/ml Tier 3 B/D
fluorouracil SOLN Tier 3 B/D
gemcitabine inj soln (generic of GEMCITABINE)
Tier 4 B/D
gemcitabine inj solr Tier 4 B/D
mercaptopurine TABS Tier 3
methotrexate sodium inj soln
Tier 2 GC B/D
methotrexate sodium inj solr Tier 2 GC B/D
PURIXAN Tier 5 NMO
TABLOID Tier 5
ANTIMITOTIC, TAXOIDS ABRAXANE Tier 5 B/D
docetaxel CONC 20mg/ml Tier 5 B/D
Drug Name Drug Tier
Requirements/Limits
docetaxel (generic of TAXOTERE) CONC 80mg/4ml
Tier 5 B/D
DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml
Tier 5 B/D
docetaxel (generic of DOCETAXEL) CONC 160mg/8ml
Tier 5 B/D
DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml
Tier 5 B/D
docetaxel (generic of DOCETAXEL) SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml
Tier 5 B/D
paclitaxel Tier 4 B/D
TAXOTERE Tier 5 B/D
ANTIMITOTIC, VINCA ALKALOIDS vincristine sulfate Tier 2 GC B/D
vinorelbine tartrate Tier 3 B/D
BIOLOGIC RESPONSE MODIFIERS AVASTIN Tier 5 NMO LA PA
BORTEZOMIB Tier 5 NMO PA
DAURISMO Tier 5 NMO LA PA
ERIVEDGE Tier 5 NMO LA PA
FARYDAK Tier 5 NMO LA PA
HERCEPTIN Tier 5 NMO PA
HERCEPTIN HYLECTA Tier 5 NMO PA
IBRANCE CAPS QL (21 caps / 28 days)
Tier 5 QL NMO LA PA
IBRANCE TABS QL (21 tabs / 28 days)
Tier 5 QL NMO LA PA
IDHIFA QL (30 tabs / 30 days)
Tier 5 QL NMO LA PA
KADCYLA Tier 5 B/D NMO
KANJINTI Tier 5 NMO PA
KEYTRUDA Tier 5 NMO PA
KISQALI Tier 5 NMO PA
KISQALI FEMARA 200 DOSE
Tier 5 NMO PA
KISQALI FEMARA 400 DOSE
Tier 5 NMO PA
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
11
Drug Name Drug Tier
Requirements/Limits
KISQALI FEMARA 600 DOSE
Tier 5 NMO PA
LYNPARZA Tier 5 NMO LA PA
MVASI Tier 5 NMO LA PA
NINLARO Tier 5 NMO PA
ODOMZO Tier 5 NMO LA PA
OGIVRI Tier 5 NMO PA
RITUXAN Tier 5 NMO LA PA
RITUXAN HYCELA Tier 5 NMO LA PA
RUBRACA Tier 5 NMO LA PA
RUXIENCE Tier 5 NMO PA
TALZENNA Tier 5 NMO LA PA
TECENTRIQ Tier 5 NMO LA PA
TIBSOVO Tier 5 NMO LA PA
TRAZIMERA Tier 5 NMO PA
TRUXIMA Tier 5 NMO PA
VELCADE Tier 5 NMO PA
VENCLEXTA 10mg Tier 4 NMO LA PA
VENCLEXTA 50mg, 100mg Tier 5 NMO LA PA
VENCLEXTA STARTING PACK
Tier 5 NMO LA PA
VERZENIO Tier 5 NMO LA PA
ZEJULA Tier 5 NMO LA PA
ZIRABEV Tier 5 NMO PA
ZOLINZA Tier 5 NMO PA
HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate (generic of ZYTIGA)
Tier 5 NMO PA
anastrozole (generic of ARIMIDEX) TABS
Tier 1 GC
bicalutamide (generic of CASODEX)
Tier 2 GC
DEPO-PROVERA INJ 400/ML
Tier 4 B/D
ERLEADA Tier 5 NMO LA PA
exemestane (generic of AROMASIN)
Tier 4
flutamide Tier 3
fulvestrant (generic of FASLODEX)
Tier 5 B/D
letrozole (generic of FEMARA) TABS
Tier 1 GC
leuprolide inj 1mg/0.2 Tier 3 NMO PA
Drug Name Drug Tier
Requirements/Limits
LUPRON DEPOT (1-MONTH) 3.75mg
Tier 5 NMO PA
LUPRON DEPOT INJ 11.25MG (3-MONTH)
Tier 5 NMO PA
LYSODREN Tier 3
megestrol ac sus 40mg/ml Tier 3
megestrol ac tab 20mg Tier 3
megestrol ac tab 40mg Tier 3
megestrol sus 625mg/5ml Tier 4 PA
nilutamide (generic of NILANDRON)
Tier 5
NUBEQA Tier 5 NMO LA PA
SOLTAMOX Tier 5
tamoxifen citrate TABS Tier 1 GC
toremifene citrate (generic of FARESTON)
Tier 5
TRELSTAR DEP INJ 3.75MG
Tier 5 NMO PA
TRELSTAR LA INJ 11.25MG
Tier 5 NMO PA
XTANDI Tier 5 NMO LA PA
ZYTIGA 500mg Tier 5 NMO LA PA
IMMUNOMODULATORS POMALYST 1mg, 2mg
QL (21 caps / 21 days) Tier 5 QL NMO LA
PA
POMALYST 3mg, 4mg QL (21 caps / 28 days)
Tier 5 QL NMO LA PA
REVLIMID QL (28 caps / 28 days)
Tier 5 QL NMO LA PA
THALOMID 50mg, 100mg QL (28 caps / 28 days)
Tier 5 QL NMO PA
THALOMID 150mg, 200mg QL (56 caps / 28 days)
Tier 5 QL NMO PA
KINASE INHIBITORS AFINITOR 10mg
QL (30 tabs / 30 days) Tier 5 QL NMO PA
AFINITOR DISPERZ 2mg QL (150 tabs / 30 days)
Tier 5 QL NMO PA
AFINITOR DISPERZ 3mg QL (90 tabs / 30 days)
Tier 5 QL NMO PA
AFINITOR DISPERZ 5mg QL (60 tabs / 30 days)
Tier 5 QL NMO PA
ALECENSA Tier 5 NMO LA PA
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
12
Drug Name Drug Tier
Requirements/Limits
ALUNBRIG Tier 5 NMO LA PA
AYVAKIT QL (30 tabs / 30 days)
Tier 5 QL NMO LA PA
BALVERSA Tier 5 NMO LA PA
BOSULIF Tier 5 NMO PA
BRAFTOVI Tier 5 NMO LA PA
BRUKINSA Tier 5 NMO LA PA
CABOMETYX QL (30 tabs / 30 days)
Tier 5 QL NMO LA PA
CALQUENCE Tier 5 NMO LA PA
CAPRELSA Tier 5 NMO LA PA
COMETRIQ Tier 5 NMO LA PA
COPIKTRA Tier 5 NMO LA PA
COTELLIC Tier 5 NMO LA PA
erlotinib hcl (generic of TARCEVA) 25mg
QL (90 tabs / 30 days)
Tier 5 QL NMO PA
erlotinib hcl (generic of TARCEVA) 100mg, 150mg
QL (30 tabs / 30 days)
Tier 5 QL NMO PA
everolimus (generic of AFINITOR)
QL (30 tabs / 30 days)
Tier 5 QL NMO PA
GILOTRIF TAB 20MG Tier 5 NMO LA PA
GILOTRIF TAB 30MG Tier 5 NMO LA PA
GILOTRIF TAB 40MG Tier 5 NMO LA PA
ICLUSIG Tier 5 NMO LA PA
imatinib mesylate (generic of GLEEVEC) 100mg
QL (90 tabs / 30 days)
Tier 5 QL NMO PA
imatinib mesylate (generic of GLEEVEC) 400mg
QL (60 tabs / 30 days)
Tier 5 QL NMO PA
IMBRUVICA Tier 5 NMO LA PA
INLYTA 1mg QL (180 tabs / 30 days)
Tier 5 QL NMO LA PA
INLYTA 5mg QL (120 tabs / 30 days)
Tier 5 QL NMO LA PA
INREBIC Tier 5 NMO LA PA
IRESSA Tier 5 NMO LA PA
JAKAFI QL (60 tabs / 30 days)
Tier 5 QL NMO LA PA
Drug Name Drug Tier
Requirements/Limits
LENVIMA 4 MG DAILY DOSE
Tier 5 NMO LA PA
LENVIMA 8 MG DAILY DOSE
Tier 5 NMO LA PA
LENVIMA 10 MG DAILY DOSE
Tier 5 NMO LA PA
LENVIMA 12MG DAILY DOSE
Tier 5 NMO LA PA
LENVIMA 14 MG DAILY DOSE
Tier 5 NMO LA PA
LENVIMA 18 MG DAILY DOSE
Tier 5 NMO LA PA
LENVIMA 20 MG DAILY DOSE
Tier 5 NMO LA PA
LENVIMA 24 MG DAILY DOSE
Tier 5 NMO LA PA
LORBRENA Tier 5 NMO LA PA
MEKINIST Tier 5 NMO LA PA
MEKTOVI Tier 5 NMO LA PA
NERLYNX Tier 5 NMO LA PA
NEXAVAR Tier 5 NMO LA PA
PIQRAY 200MG DAILY DOSE
Tier 5 NMO PA
PIQRAY 250MG DAILY DOSE
Tier 5 NMO PA
PIQRAY 300MG DAILY DOSE
Tier 5 NMO PA
ROZLYTREK Tier 5 NMO LA PA
RYDAPT Tier 5 NMO PA
SPRYCEL Tier 5 NMO PA
STIVARGA Tier 5 NMO LA PA
SUTENT QL (30 caps / 30 days)
Tier 5 QL NMO PA
TAFINLAR Tier 5 NMO LA PA
TAGRISSO QL (30 tabs / 30 days)
Tier 5 QL NMO LA PA
TASIGNA Tier 5 NMO PA
TURALIO Tier 5 NMO LA PA
TYKERB Tier 5 NMO LA PA
VITRAKVI Tier 5 NMO LA PA
VIZIMPRO Tier 5 NMO LA PA
VOTRIENT Tier 5 NMO LA PA
XALKORI Tier 5 NMO LA PA
XOSPATA Tier 5 NMO LA PA
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
13
Drug Name Drug Tier
Requirements/Limits
ZELBORAF Tier 5 NMO LA PA
ZYDELIG Tier 5 NMO LA PA
ZYKADIA Tier 5 NMO LA PA
MISCELLANEOUS bexarotene (generic of TARGRETIN)
Tier 5 NMO PA
hydroxyurea (generic of HYDREA) CAPS
Tier 2 GC
LONSURF Tier 5 NMO PA
MATULANE Tier 5 LA
SYLATRON 200mcg, 300mcg
Tier 5 NMO PA
SYNRIBO Tier 5 NMO PA
TAZVERIK Tier 5 NMO LA PA
tretinoin (chemotherapy) Tier 5
XPOVIO 60 MG ONCE WEEKLY
Tier 5 NMO LA PA
XPOVIO 80 MG ONCE WEEKLY
Tier 5 NMO LA PA
XPOVIO 80 MG TWICE WEEKLY
Tier 5 NMO LA PA
XPOVIO 100 MG ONCE WEEKLY
Tier 5 NMO LA PA
PLATINUM-BASED AGENTS carboplatin Tier 3 B/D
cisplatin SOLN Tier 3 B/D
oxaliplatin inj 50mg Tier 5 B/D
oxaliplatin inj 50mg/10ml Tier 4 B/D
oxaliplatin inj 100mg Tier 5 B/D
oxaliplatin inj 100mg/20ml Tier 4 B/D
PROTECTIVE AGENTS leucovorin calcium SOLN 500mg/50ml
Tier 4 B/D
leucovorin calcium SOLR Tier 4 B/D
leucovorin calcium TABS 5mg, 10mg
Tier 3
leucovorin calcium TABS 15mg, 25mg
Tier 4
MESNEX TABS Tier 5
TOPOISOMERASE INHIBITORS etoposide SOLN Tier 3 B/D
Drug Name Drug Tier
Requirements/Limits
irinotecan hcl (generic of CAMPTOSAR) 40mg/2ml, 100mg/5ml
Tier 4 B/D
irinotecan hcl 300mg/15ml, 500mg/25ml
Tier 4 B/D
toposar Tier 3 B/D
CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-10 mg
Tier 1 GC
amlodipine besylate-benazepril hcl cap 5-10 mg (generic of LOTREL)
Tier 1 GC
amlodipine besylate-benazepril hcl cap 5-20 mg (generic of LOTREL)
Tier 1 GC
amlodipine besylate-benazepril hcl cap 5-40 mg
Tier 1 GC
amlodipine besylate-benazepril hcl cap 10-20 mg (generic of LOTREL)
Tier 1 GC
amlodipine besylate-benazepril hcl cap 10-40 mg (generic of LOTREL)
Tier 1 GC
benazepril & hydrochlorothiazide
Tier 1 GC
benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)
Tier 1 GC
captopril & hydrochlorothiazide
Tier 1 GC
enalapril maleate & hydrochlorothiazide
Tier 1 GC
enalapril maleate & hydrochlorothiazide (generic of VASERETIC)
Tier 1 GC
fosinopril sodium & hydrochlorothiazide
Tier 1 GC
lisinopril & hydrochlorothiazide (generic of ZESTORETIC)
Tier 1 GC
quinapril-hydrochlorothiazide (generic of ACCURETIC)
Tier 1 GC
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
14
Drug Name Drug Tier
Requirements/Limits
ACE INHIBITORS benazepril hcl TABS 5mg Tier 1 GC
benazepril hcl (generic of LOTENSIN) TABS 10mg, 20mg, 40mg
Tier 1 GC
captopril TABS Tier 1 GC
enalapril maleate (generic of VASOTEC) TABS
Tier 1 GC
fosinopril sodium Tier 1 GC
lisinopril (generic of ZESTRIL) TABS 2.5mg, 5mg, 30mg, 40mg
Tier 1 GC
lisinopril (generic of PRINIVIL) TABS 10mg, 20mg
Tier 1 GC
moexipril hcl Tier 1 GC
perindopril erbumine Tier 1 GC
quinapril hcl (generic of ACCUPRIL)
Tier 1 GC
ramipril (generic of ALTACE)
Tier 1 GC
trandolapril 1mg, 2mg Tier 1 GC
trandolapril (generic of MAVIK) 4mg
Tier 1 GC
ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone (generic of INSPRA)
Tier 3
spironolactone (generic of ALDACTONE) TABS
Tier 1 GC
ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA) TABS
Tier 2 GC
prazosin hcl (generic of MINIPRESS)
Tier 3
terazosin hcl 1mg, 2mg, 5mg
Tier 1 GC
terazosin hcl 10mg Tier 2 GC
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil (generic of AZOR)
Tier 1 GC
Drug Name Drug Tier
Requirements/Limits
amlodipine besylate-valsartan tab (generic of EXFORGE)
Tier 1 GC
amlodipine-valsartan-hydrochlorothiazide tab (generic of EXFORGE HCT)
Tier 1 GC
ENTRESTO Tier 3
irbesartan-hydrochlorothiazide (generic of AVALIDE)
Tier 1 GC
losartan-hydrochlorothiazide (generic of HYZAAR)
Tier 1 GC
olmesartan medoxomil-amlodipine-hydrochlorothiazide (generic of TRIBENZOR)
Tier 1 GC
olmesartan medoxomil-hydrochlorothiazide (generic of BENICAR HCT)
Tier 1 GC
valsartan-hydrochlorothiazide (generic of DIOVAN HCT)
Tier 1 GC
ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan (generic of AVAPRO)
Tier 1 GC
losartan potassium (generic of COZAAR) TABS
Tier 1 GC
olmesartan medoxomil (generic of BENICAR) TABS
Tier 1 GC
telmisartan (generic of MICARDIS)
Tier 1 GC
valsartan (generic of DIOVAN)
Tier 1 GC
ANTIARRHYTHMICS amiodarone hcl soln Tier 2 GC
amiodarone tab 100mg Tier 4
amiodarone tab 200mg Tier 1 GC
amiodarone tab 400mg Tier 4
disopyramide phosphate (generic of NORPACE)
Tier 4
dofetilide (generic of TIKOSYN)
Tier 4 NMO
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
15
Drug Name Drug Tier
Requirements/Limits
flecainide acetate Tier 3
MULTAQ Tier 4
NORPACE CR Tier 4
pacerone 100mg, 400mg Tier 4
pacerone 200mg Tier 1 GC
propafenone hcl Tier 2 GC
propafenone hcl 12hr (generic of RYTHMOL SR)
Tier 4
quinidine sulfate Tier 2 GC
sorine (generic of BETAPACE) 80mg, 120mg, 160mg
Tier 2 GC
sorine 240mg Tier 2 GC
sotalol hcl (generic of BETAPACE) 80mg, 120mg, 160mg
Tier 2 GC
sotalol hcl 240mg Tier 2 GC
sotalol hcl (afib/afl) (generic of BETAPACE AF)
Tier 2 GC
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium (generic of LIPITOR) TABS
Tier 1 GC
lovastatin Tier 1 GC
pravastatin sodium 10mg, 80mg
Tier 1 GC
pravastatin sodium (generic of PRAVACHOL) 20mg, 40mg
Tier 1 GC
rosuvastatin calcium (generic of CRESTOR)
QL (30 tabs / 30 days)
Tier 1 GC QL
simvastatin (generic of ZOCOR) TABS 5mg, 10mg, 20mg, 40mg
Tier 1 GC
simvastatin (generic of ZOCOR) TABS 80mg
QL (30 tabs / 30 days)
Tier 1 GC QL
ANTILIPEMICS, MISCELLANEOUS cholestyramine (generic of QUESTRAN)
Tier 3
cholestyramine light pack Tier 4
Drug Name Drug Tier
Requirements/Limits
cholestyramine light powd (generic of QUESTRAN LIGHT)
Tier 3
colesevelam hcl (generic of WELCHOL)
Tier 4
colestipol hcl gran (generic of COLESTID)
Tier 4
colestipol hcl pack (generic of COLESTID)
Tier 4
colestipol hcl tabs (generic of COLESTID)
Tier 3
ezetimibe (generic of ZETIA)
Tier 3
ezetimibe-simvastatin (generic of VYTORIN)
Tier 1 GC
fenofibrate (generic of TRICOR) TABS 48mg, 145mg
Tier 3
fenofibrate TABS 54mg, 160mg
Tier 3
fenofibrate micronized 67mg, 134mg, 200mg
Tier 3
gemfibrozil (generic of LOPID) TABS
Tier 1 GC
JUXTAPID Tier 5 NMO LA PA
niacin (antihyperlipidemic) Tier 4
niacin er (antihyperlipidemic) (generic of NIASPAN) 500mg
QL (60 tabs / 30 days)
Tier 4 QL
niacin er (antihyperlipidemic) (generic of NIASPAN) 750mg, 1000mg
Tier 4
niacor Tier 4
PRALUENT Tier 3 NMO PA
prevalite PACK Tier 4
prevalite (generic of QUESTRAN LIGHT) POWD
Tier 3
VASCEPA Tier 4
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
16
Drug Name Drug Tier
Requirements/Limits
BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone (generic of TENORETIC 50)
Tier 2 GC
atenolol & chlorthalidone (generic of TENORETIC 100)
Tier 2 GC
bisoprolol & hydrochlorothiazide (generic of ZIAC)
Tier 1 GC
metoprolol & hydrochlorothiazide
Tier 3
metoprolol & hydrochlorothiazide (generic of LOPRESSOR HCT)
Tier 3
propranolol & hydrochlorothiazide
Tier 3
BETA-BLOCKERS acebutolol hcl CAPS Tier 2 GC
atenolol (generic of TENORMIN) TABS
Tier 1 GC
bisoprolol fumarate Tier 2 GC
BYSTOLIC 2.5mg, 5mg, 10mg
QL (30 tabs / 30 days)
Tier 4 QL
BYSTOLIC 20mg QL (60 tabs / 30 days)
Tier 4 QL
carvedilol (generic of COREG)
Tier 1 GC
labetalol hcl TABS Tier 3
metoprolol succinate (generic of TOPROL XL)
Tier 2 GC
metoprolol tartrate SOCT Tier 3
metoprolol tartrate SOLN Tier 3
metoprolol tartrate TABS 25mg
Tier 1 GC
metoprolol tartrate (generic of LOPRESSOR) TABS 50mg, 100mg
Tier 1 GC
nadolol (generic of CORGARD) TABS
Tier 3
pindolol Tier 3
propranolol cap er (generic of INDERAL LA)
Tier 3
Drug Name Drug Tier
Requirements/Limits
propranolol hcl TABS Tier 2 GC
propranolol oral sol Tier 3
timolol maleate TABS Tier 3
CALCIUM CHANNEL BLOCKERS amlodipine besylate (generic of NORVASC) TABS
Tier 1 GC
cartia xt (generic of CARDIZEM CD)
Tier 2 GC
dilt-xr cap Tier 2 GC
diltiazem cap 240mg cd (generic of CARDIZEM CD)
Tier 2 GC
diltiazem cap 360mg cd (generic of CARDIZEM CD)
Tier 4
diltiazem cap er/12hr Tier 4
diltiazem hcl (generic of CARDIZEM) TABS 30mg, 60mg, 120mg
Tier 2 GC
diltiazem hcl TABS 90mg Tier 2 GC
diltiazem hcl coated beads (generic of CARDIZEM CD) CP24
Tier 4
diltiazem hcl coated beads cap sr 24hr (generic of CARDIZEM CD)
Tier 2 GC
diltiazem hcl extended release beads cap sr (generic of TIAZAC) 120mg, 180mg, 240mg, 300mg, 360mg, 420mg
Tier 2 GC
diltiazem hcl extended release beads cap sr (generic of CARDIZEM CD) 180mg
Tier 2 GC
diltiazem inj Tier 2 GC
felodipine Tier 2 GC
isradipine Tier 3
nicardipine hcl CAPS Tier 4
nifedipine (generic of PROCARDIA XL) TB24
Tier 2 GC
nifedipine er Tier 2 GC
nimodipine CAPS Tier 5
NYMALIZE 60mg/20ml Tier 5
taztia xt (generic of TIAZAC) Tier 2 GC
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
17
Drug Name Drug Tier
Requirements/Limits
tiadylt er (generic of TIAZAC)
Tier 2 GC
verapamil cap er (generic of VERELAN PM) 100mg, 200mg
Tier 4
verapamil cap er (generic of VERELAN) 120mg, 180mg, 240mg
Tier 3
verapamil cap er 300mg, 360mg
Tier 4
verapamil hcl SOLN Tier 4
verapamil hcl TABS Tier 1 GC
verapamil hcl (generic of CALAN SR) TBCR
Tier 2 GC
verapamil tab er 180mg Tier 2 GC
verapamil tab er (generic of CALAN SR) 240mg
Tier 2 GC
DIGITALIS GLYCOSIDES digitek (generic of LANOXIN) .25mg
PA if 70 years and older
Tier 2 GC PA
digitek (generic of LANOXIN) .125mg
QL (30 tabs / 30 days)
Tier 2 GC QL
digox (generic of LANOXIN) 125mcg
QL (30 tabs / 30 days)
Tier 2 GC QL
digox (generic of LANOXIN) 250mcg
PA if 70 years and older
Tier 2 GC PA
digoxin (generic of LANOXIN) TABS 125mcg
QL (30 tabs / 30 days)
Tier 2 GC QL
digoxin (generic of LANOXIN) TABS 250mcg
PA if 70 years and older
Tier 2 GC PA
digoxin inj (generic of LANOXIN)
Tier 4
digoxin sol 50mcg/ml PA if 70 years and older
Tier 4 PA
DIURETICS acetazolamide CP12 Tier 4
acetazolamide TABS Tier 3
Drug Name Drug Tier
Requirements/Limits
amiloride & hydrochlorothiazide
Tier 2 GC
amiloride hcl TABS Tier 2 GC
bumetanide inj 0.25/ml Tier 3
bumetanide tab (generic of BUMEX)
Tier 3
chlorothiazide TABS Tier 3
chlorthalidone Tier 2 GC
furosemide SOLN Tier 2 GC
furosemide (generic of LASIX) TABS
Tier 1 GC
furosemide inj Tier 2 GC
hydrochlorothiazide CAPS; TABS
Tier 1 GC
indapamide Tier 2 GC
methazolamide TABS Tier 4
metolazone Tier 3
spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)
Tier 3
torsemide tabs Tier 2 GC
triamterene & hydrochlorothiazide cap 37.5-25 mg (generic of DYAZIDE)
Tier 1 GC
triamterene & hydrochlorothiazide tabs (generic of MAXZIDE)
Tier 1 GC
triamterene & hydrochlorothiazide tabs (generic of MAXZIDE-25)
Tier 1 GC
MISCELLANEOUS aliskiren fumarate (generic of TEKTURNA)
Tier 4
clonidine hcl (generic of CATAPRES) TABS
Tier 1 GC
clonidine hcl ptwk (generic of CATAPRES-TTS-1) .1mg/24hr
Tier 4
clonidine hcl ptwk (generic of CATAPRES-TTS-2) .2mg/24hr
Tier 4
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
18
Drug Name Drug Tier
Requirements/Limits
clonidine hcl ptwk (generic of CATAPRES-TTS-3) .3mg/24hr
Tier 4
CORLANOR Tier 4
DEMSER Tier 5 PA
hydralazine hcl SOLN Tier 4
hydralazine hcl TABS Tier 2 GC
midodrine hcl Tier 3
minoxidil TABS Tier 2 GC
NORTHERA 100mg QL (90 caps / 30 days)
Tier 5 QL NMO LA PA
NORTHERA 200mg, 300mg
QL (180 caps / 30 days)
Tier 5 QL NMO LA PA
RANEXA Tier 4
ranolazine (generic of RANEXA)
Tier 4
NITRATES isosorb mononitrate tab Tier 2 GC
isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg
Tier 3
isosorbide dinitrate 10mg, 20mg, 30mg
Tier 3
isosorbide mononitrate er Tier 1 GC
minitran (generic of NITRO-DUR)
Tier 2 GC
NITRO-BID Tier 3
NITRO-DUR DIS 0.3MG/HR Tier 4
NITRO-DUR DIS 0.8MG/HR Tier 4
nitroglycerin (generic of NITROSTAT) SUBL
Tier 3
nitroglycerin td patch .1mg/hr
Tier 2 GC
nitroglycerin td patch (generic of NITRO-DUR) .2mg/hr, .4mg/hr, .6mg/hr
Tier 2 GC
PULMONARY ARTERIAL HYPERTENSION ADCIRCA
QL (60 tabs / 30 days) Tier 5 QL NMO PA
ADEMPAS QL (90 tabs / 30 days)
Tier 5 QL NMO LA PA
Drug Name Drug Tier
Requirements/Limits
alyq (generic of ADCIRCA) QL (60 tabs / 30 days)
Tier 5 QL NMO PA
ambrisentan (generic of LETAIRIS)
QL (30 tabs / 30 days)
Tier 5 QL NMO LA PA
bosentan (generic of TRACLEER) 62.5mg
QL (120 tabs / 30 days)
Tier 5 QL NMO LA PA
bosentan (generic of TRACLEER) 125mg
QL (60 tabs / 30 days)
Tier 5 QL NMO LA PA
OPSUMIT QL (30 tabs / 30 days)
Tier 5 QL NMO LA PA
sildenafil citrate tab 20 mg (pulmonary hypertension) (generic of REVATIO)
QL (90 tabs / 30 days)
Tier 3 QL NMO PA
tadalafil (pulmonary hypertension) (generic of ADCIRCA)
QL (60 tabs / 30 days)
Tier 5 QL NMO PA
treprostinil Tier 5 NMO LA PA
VENTAVIS Tier 5 NMO PA
CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.5mg (generic of XANAX)
QL (150 tabs / 30 days)
Tier 2 GC QL
alprazolam tab 0.25mg (generic of XANAX)
QL (150 tabs / 30 days)
Tier 2 GC QL
alprazolam tab 1mg (generic of XANAX)
QL (150 tabs / 30 days)
Tier 2 GC QL
alprazolam tab 2 mg (generic of XANAX)
QL (150 tabs / 30 days)
Tier 2 GC QL
buspirone hcl TABS 5mg, 10mg, 15mg
Tier 1 GC
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
19
Drug Name Drug Tier
Requirements/Limits
buspirone hcl TABS 7.5mg, 30mg
Tier 3
fluvoxamine maleate TABS Tier 2 GC
lorazepam (generic of ATIVAN) SOLN
Tier 2 GC
lorazepam (generic of ATIVAN) TABS
QL (150 tabs / 30 days)
Tier 2 GC QL
lorazepam intensol QL (150 mL / 30 days)
Tier 3 QL
ANTICONVULSANTS APTIOM
QL (60 tabs / 30 days) Tier 5 QL
BANZEL SUS 40MG/ML Tier 5 PA
BANZEL TAB 200MG Tier 5 PA
BANZEL TAB 400MG Tier 5 PA
BRIVIACT INJ 50MG/5ML Tier 4 PA
BRIVIACT SOL 10MG/ML Tier 5 PA
BRIVIACT TAB 10MG Tier 5 PA
BRIVIACT TAB 25MG Tier 5 PA
BRIVIACT TAB 50MG Tier 5 PA
BRIVIACT TAB 75MG Tier 5 PA
BRIVIACT TAB 100MG Tier 5 PA
carbamazepine CHEW Tier 3
carbamazepine (generic of CARBATROL) CP12
Tier 4
carbamazepine (generic of TEGRETOL) SUSP
Tier 4
carbamazepine (generic of TEGRETOL) TABS
Tier 3
carbamazepine (generic of TEGRETOL-XR) TB12
Tier 4
CELONTIN Tier 4
clobazam (generic of ONFI) Tier 4 PA
clonazepam (generic of KLONOPIN) TABS 2mg
QL (300 tabs / 30 days)
Tier 2 GC QL
clonazepam (generic of KLONOPIN) TABS .5mg, 1mg
QL (90 tabs / 30 days)
Tier 2 GC QL
Drug Name Drug Tier
Requirements/Limits
clonazepam TBDP 2mg QL (300 tabs / 30 days)
Tier 3 QL
clonazepam TBDP .125mg, .25mg, .5mg, 1mg
QL (90 tabs / 30 days)
Tier 3 QL
clorazepate dipotassium QL (180 tabs / 30 days)
PA if 65 years and older
Tier 4 QL PA
DIASTAT ACUDIAL Tier 4
DIASTAT PEDIATRIC Tier 4
diazepam (generic of VALIUM) TABS
QL (120 tabs / 30 days)
PA if 65 years and older
Tier 2 GC QL PA
diazepam gel Tier 4
diazepam inj Tier 3
diazepam intensol QL (240 mL / 30 days)
PA if 65 years and older
Tier 3 QL PA
diazepam oral soln 1 mg/ml QL (1200 mL / 30 days)
PA if 65 years and older
Tier 3 QL PA
DILANTIN CAP 30MG Tier 3
DILANTIN CAP 100MG Tier 3
DILANTIN CHEW TAB 50MG
Tier 3
DILANTIN-125 SUSP Tier 4
divalproex sodium (generic of DEPAKOTE SPRINKLES) CSDR
Tier 4
divalproex sodium (generic of DEPAKOTE ER) TB24
Tier 3
divalproex sodium (generic of DEPAKOTE) TBEC
Tier 3
EPIDIOLEX QL (600 mL / 30 days)
Tier 5 QL NMO LA PA
epitol (generic of TEGRETOL)
Tier 3
ethosuximide (generic of ZARONTIN) CAPS; SOLN
Tier 4
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
20
Drug Name Drug Tier
Requirements/Limits
felbamate (generic of FELBATOL) SUSP
Tier 5
felbamate (generic of FELBATOL) TABS
Tier 4
FYCOMPA SUSP QL (720 mL / 30 days)
Tier 5 QL PA
FYCOMPA TABS 2mg QL (60 tabs / 30 days)
Tier 4 QL PA
FYCOMPA TABS 4mg, 6mg
QL (60 tabs / 30 days)
Tier 5 QL PA
FYCOMPA TABS 8mg, 10mg, 12mg
QL (30 tabs / 30 days)
Tier 5 QL PA
gabapentin (generic of NEURONTIN) CAPS 100mg
QL (1080 caps / 30 days)
Tier 2 GC QL
gabapentin (generic of NEURONTIN) CAPS 300mg
QL (360 caps / 30 days)
Tier 2 GC QL
gabapentin (generic of NEURONTIN) CAPS 400mg
QL (270 caps / 30 days)
Tier 2 GC QL
gabapentin (generic of NEURONTIN) SOLN
QL (2160 mL / 30 days)
Tier 3 QL
gabapentin (generic of NEURONTIN) TABS 600mg
QL (180 tabs / 30 days)
Tier 3 QL
gabapentin (generic of NEURONTIN) TABS 800mg
QL (120 tabs / 30 days)
Tier 3 QL
Drug Name Drug Tier
Requirements/Limits
lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW
Tier 3
lamotrigine (generic of LAMICTAL) TABS
Tier 1 GC
lamotrigine (generic of LAMICTAL XR) TB24
Tier 4
levetiracetam (generic of KEPPRA) SOLN
Tier 4
levetiracetam (generic of KEPPRA) TABS
Tier 2 GC
levetiracetam (generic of KEPPRA XR) TB24
Tier 3
levetiracetam in sodium chloride (generic of LEVETIRACETAM)
Tier 4
levetiracetam oral soln 100 mg/ml (generic of KEPPRA)
Tier 3
NAYZILAM Tier 4
oxcarbazepine (generic of TRILEPTAL) SUSP
Tier 4
oxcarbazepine (generic of TRILEPTAL) TABS
Tier 3
PEGANONE Tier 4
phenobarbital ELIX PA if 70 years and older
Tier 4 PA
phenobarbital TABS PA if 70 years and older
Tier 3 PA
phenobarbital sodium SOLN
PA if 70 years and older
Tier 4 PA
PHENYTEK Tier 3
phenytoin (generic of DILANTIN INFATABS) CHEW
Tier 3
phenytoin (generic of DILANTIN-125) SUSP
Tier 3
phenytoin sodium extended (generic of DILANTIN) 100mg
Tier 3
phenytoin sodium extended (generic of PHENYTEK) 200mg, 300mg
Tier 3
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
21
Drug Name Drug Tier
Requirements/Limits
phenytoin sodium inj 50mg/ml
Tier 3
pregabalin (generic of LYRICA) CAPS 25mg, 50mg, 75mg, 100mg, 150mg
QL (120 caps / 30 days)
Tier 3 QL PA
pregabalin (generic of LYRICA) CAPS 200mg
QL (90 caps / 30 days)
Tier 3 QL PA
pregabalin (generic of LYRICA) CAPS 225mg, 300mg
QL (60 caps / 30 days)
Tier 3 QL PA
pregabalin (generic of LYRICA) SOLN
QL (900 mL / 30 days)
Tier 4 QL PA
primidone (generic of MYSOLINE) TABS
Tier 2 GC
roweepra (generic of KEPPRA)
Tier 2 GC
roweepra xr (generic of KEPPRA XR)
Tier 3
SPRITAM Tier 4
subvenite tab (generic of LAMICTAL)
Tier 1 GC
SYMPAZAN 5mg Tier 4 PA
SYMPAZAN 10mg, 20mg Tier 5 PA
tiagabine hcl (generic of GABITRIL)
Tier 4
topiramate (generic of TOPAMAX SPRINKLE) CPSP
Tier 3
topiramate (generic of TOPAMAX) TABS
Tier 2 GC
valproate sodium SOLN Tier 3
valproate sodium oral soln Tier 3
valproic acid CAPS Tier 3
VALTOCO Tier 4
vigabatrin powd pack 500mg (generic of SABRIL)
QL (180 packets / 30 days)
Tier 5 QL NMO LA PA
Drug Name Drug Tier
Requirements/Limits
vigabatrin tab 500mg (generic of SABRIL)
QL (180 tabs / 30 days)
Tier 5 QL NMO LA PA
vigadrone (generic of SABRIL)
QL (180 packets / 30 days)
Tier 5 QL NMO LA PA
VIMPAT 50mg QL (120 tabs / 30 days)
Tier 4 QL
VIMPAT 100mg, 150mg, 200mg
QL (60 tabs / 30 days)
Tier 5 QL
VIMPAT INJ 200MG/20ML Tier 5
VIMPAT SOL 10MG/ML QL (1200 mL / 30 days)
Tier 5 QL
zonisamide (generic of ZONEGRAN) CAPS 25mg, 100mg
Tier 2 GC
zonisamide CAPS 50mg Tier 2 GC
ANTIDEMENTIA donepezil hydrochloride (generic of ARICEPT) TABS 5mg
QL (30 tabs / 30 days)
Tier 2 GC QL
donepezil hydrochloride (generic of ARICEPT) TABS 10mg
Tier 2 GC
donepezil hydrochloride TBDP 5mg
QL (30 tabs / 30 days)
Tier 2 GC QL
donepezil hydrochloride TBDP 10mg
Tier 2 GC
galantamine hydrobromide SOLN
Tier 4
galantamine hydrobromide (generic of RAZADYNE) TABS 4mg
QL (60 tabs / 30 days)
Tier 3 QL
galantamine hydrobromide TABS 8mg, 12mg
QL (60 tabs / 30 days)
Tier 3 QL
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
22
Drug Name Drug Tier
Requirements/Limits
galantamine hydrobromide er (generic of RAZADYNE ER)
QL (30 caps / 30 days)
Tier 3 QL
memantine hcl cp24 (generic of NAMENDA XR)
PA if < 30 yrs
Tier 4 PA
memantine soln PA if < 30 yrs
Tier 4 PA
memantine tabs (generic of NAMENDA)
PA if < 30 yrs
Tier 3 PA
NAMZARIC Tier 4
rivastigmine tartrate 1.5mg, 3mg
QL (90 caps / 30 days)
Tier 4 QL
rivastigmine tartrate 4.5mg, 6mg
QL (60 caps / 30 days)
Tier 4 QL
rivastigmine td patch 24hr 4.6 mg/24hr (generic of EXELON)
QL (30 patches / 30 days)
Tier 4 QL
rivastigmine td patch 24hr 9.5 mg/24hr (generic of EXELON)
QL (30 patches / 30 days)
Tier 4 QL
rivastigmine td patch 24hr 13.3 mg/24hr (generic of EXELON)
QL (30 patches / 30 days)
Tier 4 QL
ANTIDEPRESSANTS amitriptyline hcl TABS Tier 3
amoxapine Tier 3
bupropion hcl TABS Tier 3
bupropion hcl (generic of WELLBUTRIN SR) TB12
Tier 2 GC
bupropion hcl (generic of WELLBUTRIN XL) TB24 150mg, 300mg
Tier 3
Drug Name Drug Tier
Requirements/Limits
citalopram hydrobromide SOLN
Tier 3
citalopram hydrobromide (generic of CELEXA) TABS
Tier 1 GC
clomipramine hcl (generic of ANAFRANIL) CAPS
Tier 4 PA
desipramine hcl (generic of NORPRAMIN) TABS 10mg, 25mg
Tier 4
desipramine hcl TABS 50mg, 75mg, 100mg, 150mg
Tier 4
desvenlafaxine succinate (generic of PRISTIQ)
QL (30 tabs / 30 days)
Tier 4 QL PA
doxepin hcl CAPS; CONC Tier 3
DRIZALMA SPRINKLE 20mg, 30mg, 60mg
QL (60 caps / 30 days)
Tier 4 QL PA
DRIZALMA SPRINKLE 40mg
QL (90 caps / 30 days)
Tier 4 QL PA
duloxetine hcl (generic of CYMBALTA) CPEP 20mg, 30mg, 60mg
QL (60 caps / 30 days)
Tier 3 QL
EMSAM QL (30 patches / 30 days)
Tier 5 QL PA
escitalopram oxalate SOLN Tier 4
escitalopram oxalate (generic of LEXAPRO) TABS
Tier 1 GC
FETZIMA 20mg, 40mg QL (60 caps / 30 days)
Tier 4 QL PA
FETZIMA 80mg, 120mg QL (30 caps / 30 days)
Tier 4 QL PA
FETZIMA TITRATION PACK
Tier 4 PA
fluoxetine cap 10mg (generic of PROZAC)
Tier 1 GC
fluoxetine cap 20mg (generic of PROZAC)
Tier 1 GC
fluoxetine cap 40mg (generic of PROZAC)
Tier 2 GC
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
23
Drug Name Drug Tier
Requirements/Limits
fluoxetine hcl SOLN Tier 2 GC
imipramine hcl TABS Tier 2 GC
maprotiline hcl Tier 3
MARPLAN TAB 10MG QL (180 tabs / 30 days)
Tier 4 QL
mirtazapine TABS 7.5mg Tier 3
mirtazapine (generic of REMERON) TABS 15mg, 30mg
Tier 1 GC
mirtazapine TABS 45mg Tier 1 GC
mirtazapine (generic of REMERON SOLTAB) TBDP
Tier 3
nefazodone hcl Tier 4
nortriptyline hcl (generic of PAMELOR) CAPS
Tier 2 GC
nortriptyline hcl SOLN Tier 4
paroxetine hcl tabs (generic of PAXIL)
Tier 2 GC
PAXIL SUSP QL (900 mL / 30 days)
Tier 4 QL
phenelzine sulfate (generic of NARDIL) TABS
Tier 3
protriptyline hcl Tier 4
sertraline hcl (generic of ZOLOFT) CONC
Tier 4
sertraline hcl (generic of ZOLOFT) TABS
Tier 1 GC
tranylcypromine sulfate (generic of PARNATE)
Tier 4
trazodone hcl TABS 50mg, 100mg, 150mg
Tier 1 GC
trimipramine maleate CAPS 25mg
QL (240 caps / 30 days)
Tier 4 QL
trimipramine maleate CAPS 50mg
QL (120 caps / 30 days)
Tier 4 QL
trimipramine maleate CAPS 100mg
QL (60 caps / 30 days)
Tier 4 QL
Drug Name Drug Tier
Requirements/Limits
TRINTELLIX 5mg QL (120 tabs / 30 days)
Tier 4 QL
TRINTELLIX 10mg QL (60 tabs / 30 days)
Tier 4 QL
TRINTELLIX 20mg QL (30 tabs / 30 days)
Tier 4 QL
venlafaxine hcl (generic of EFFEXOR XR) CP24
Tier 2 GC
venlafaxine hcl TABS Tier 2 GC
VIIBRYD STARTER PACK Tier 4
VIIBRYD TAB QL (30 tabs / 30 days)
Tier 4 QL
ANTIPARKINSONIAN AGENTS amantadine hcl CAPS
QL (120 caps / 30 days)
Tier 3 QL
amantadine hcl SYRP Tier 2 GC
amantadine hcl TABS Tier 3
APOKYN QL (20 cartridges / 30 days)
Tier 5 QL NMO LA PA
benztropine mesylate inj (generic of COGENTIN)
Tier 4
benztropine mesylate tab 0.5mg
PA if 70 years and older
Tier 3 PA
benztropine mesylate tab 1mg
PA if 70 years and older
Tier 3 PA
benztropine mesylate tab 2mg
PA if 70 years and older
Tier 3 PA
bromocriptine mesylate (generic of PARLODEL) CAPS; TABS
Tier 4
carbidopa-levodopa (generic of SINEMET) TABS
Tier 2 GC
carbidopa-levodopa TBCR Tier 3
carbidopa-levodopa TBDP Tier 4
carbidopa/levodopa/entacapone
Tier 4
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
24
Drug Name Drug Tier
Requirements/Limits
carbidopa/levodopa/entacapone (generic of STALEVO 100)
Tier 4
carbidopa/levodopa/entacapone (generic of STALEVO 150)
Tier 4
entacapone (generic of COMTAN)
Tier 4
NEUPRO Tier 4
pramipexole tab 0.5mg (generic of MIRAPEX)
Tier 1 GC
pramipexole tab 0.25mg Tier 1 GC
pramipexole tab 0.75mg (generic of MIRAPEX)
Tier 1 GC
pramipexole tab 0.125mg (generic of MIRAPEX)
Tier 1 GC
pramipexole tab 1.5mg Tier 1 GC
pramipexole tab 1mg (generic of MIRAPEX)
Tier 1 GC
rasagiline mesylate (generic of AZILECT) TABS
Tier 4
ropinirole tab 0.5mg Tier 2 GC
ropinirole tab 0.25mg Tier 2 GC
ropinirole tab 1mg Tier 2 GC
ropinirole tab 2mg Tier 2 GC
ropinirole tab 3mg Tier 2 GC
ropinirole tab 4mg Tier 2 GC
ropinirole tab 5mg Tier 2 GC
selegiline hcl CAPS; TABS Tier 3
trihexyphenidyl hcl PA if 70 years and older
Tier 3 PA
ANTIPSYCHOTICS ABILIFY MAINTENA
QL (1 injection / 28 days)
Tier 5 QL
aripiprazole odt QL (60 tabs / 30 days)
Tier 5 QL
aripiprazole oral solution 1 mg/ml
QL (900 mL / 30 days)
Tier 5 QL
aripiprazole tab (generic of ABILIFY)
QL (30 tabs / 30 days)
Tier 4 QL
Drug Name Drug Tier
Requirements/Limits
ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml
QL (1 injection / 28 days)
Tier 5 QL
ARISTADA 1064mg/3.9ml QL (1 injection / 56 days)
Tier 5 QL
ARISTADA INITIO Tier 5
CAPLYTA QL (30 caps / 30 days)
Tier 4 QL
chlorpromazine hcl TABS Tier 4
CHLORPROMAZINE INJ Tier 4
clozapine odt 12.5mg, 25mg
Tier 4 PA
clozapine odt 100mg QL (270 tabs / 30 days)
Tier 4 QL PA
clozapine odt 150mg QL (180 tabs / 30 days)
Tier 4 QL PA
clozapine odt 200mg QL (135 tabs / 30 days)
Tier 4 QL PA
clozapine tab 25mg (generic of CLOZARIL)
Tier 3
clozapine tab 50mg (generic of CLOZARIL)
Tier 3
clozapine tab 100mg (generic of CLOZARIL)
QL (270 tabs / 30 days)
Tier 4 QL
clozapine tab 200mg (generic of CLOZARIL)
QL (135 tabs / 30 days)
Tier 4 QL
FANAPT QL (60 tabs / 30 days)
Tier 4 QL PA
FANAPT TITRATION PACK Tier 4 PA
fluphenazine decanoate SOLN
Tier 4
fluphenazine hcl Tier 4
GEODON SOLR QL (6 mL / 3 days)
Tier 4 QL
haloperidol TABS Tier 3
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
25
Drug Name Drug Tier
Requirements/Limits
haloperidol conc 2mg/ml Tier 2 GC
haloperidol decanoate (generic of HALDOL DECANOATE 50) SOLN 50mg/ml
Tier 3
haloperidol decanoate (generic of HALDOL DECANOATE 100) SOLN 100mg/ml
Tier 3
haloperidol lactate inj 5mg/ml (generic of HALDOL)
Tier 3
INVEGA SUST INJ 39 MG/0.25 ML
QL (1 injection / 28 days)
Tier 4 QL
INVEGA SUST INJ 78 MG/0.5 ML
QL (1 injection / 28 days)
Tier 5 QL
INVEGA SUST INJ 117 MG/0.75 ML
QL (1 injection / 28 days)
Tier 5 QL
INVEGA SUST INJ 156MG/ML
QL (1 injection / 28 days)
Tier 5 QL
INVEGA SUST INJ 234 MG/1.5 ML
QL (1 injection / 28 days)
Tier 5 QL
INVEGA TRINZA QL (1 injection / 90 days)
Tier 5 QL
LATUDA 20mg, 40mg, 60mg, 120mg
QL (30 tabs / 30 days)
Tier 4 QL
LATUDA 80mg QL (60 tabs / 30 days)
Tier 4 QL
loxapine succinate Tier 3
molindone hcl Tier 4
NUPLAZID CAPS QL (30 caps / 30 days)
Tier 5 QL NMO LA PA
Drug Name Drug Tier
Requirements/Limits
NUPLAZID TABS 10MG QL (30 tabs / 30 days)
Tier 5 QL NMO LA PA
olanzapine (generic of ZYPREXA) SOLR
QL (3 vials / 1 day)
Tier 4 QL
olanzapine (generic of ZYPREXA) TABS 2.5mg, 5mg, 10mg
QL (60 tabs / 30 days)
Tier 2 GC QL
olanzapine (generic of ZYPREXA) TABS 7.5mg, 15mg, 20mg
QL (30 tabs / 30 days)
Tier 2 GC QL
olanzapine (generic of ZYPREXA ZYDIS) TBDP 5mg, 15mg, 20mg
QL (30 tabs / 30 days)
Tier 4 QL
olanzapine (generic of ZYPREXA ZYDIS) TBDP 10mg
QL (60 tabs / 30 days)
Tier 4 QL
paliperidone (generic of INVEGA) 1.5mg, 3mg, 9mg
QL (30 tabs / 30 days)
Tier 4 QL
paliperidone (generic of INVEGA) 6mg
QL (60 tabs / 30 days)
Tier 4 QL
perphenazine TABS Tier 3
PERSERIS QL (1 injection / 30 days)
Tier 5 QL
pimozide Tier 4
quetiapine fumarate (generic of SEROQUEL) TABS
Tier 2 GC
quetiapine fumarate (generic of SEROQUEL XR) TB24 50mg, 300mg, 400mg
QL (60 tabs / 30 days)
Tier 4 QL PA
quetiapine fumarate (generic of SEROQUEL XR) TB24 150mg, 200mg
QL (30 tabs / 30 days)
Tier 4 QL PA
REXULTI 3mg, 4mg QL (30 tabs / 30 days)
Tier 5 QL
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
26
Drug Name Drug Tier
Requirements/Limits
REXULTI .25mg, .5mg, 1mg, 2mg
QL (60 tabs / 30 days)
Tier 5 QL
RISPERDAL INJ 12.5MG QL (2 injections / 28 days)
Tier 4 QL
RISPERDAL INJ 25MG QL (2 injections / 28 days)
Tier 4 QL
RISPERDAL INJ 37.5MG QL (2 injections / 28 days)
Tier 5 QL
RISPERDAL INJ 50MG QL (2 injections / 28 days)
Tier 5 QL
risperidone (generic of RISPERDAL) SOLN
QL (240 mL / 30 days)
Tier 3 QL
risperidone (generic of RISPERDAL) TABS .5mg, 1mg, 2mg, 3mg, 4mg
Tier 2 GC
risperidone TABS .25mg Tier 2 GC
risperidone TBDP 1mg, 2mg, 3mg, 4mg
QL (60 tabs / 30 days)
Tier 4 QL
risperidone TBDP .25mg, .5mg
QL (90 tabs / 30 days)
Tier 4 QL
SAPHRIS QL (60 tabs / 30 days)
Tier 4 QL
SECUADO QL (30 patches / 30 days)
Tier 4 QL
thioridazine hcl TABS Tier 3
thiothixene Tier 4
trifluoperazine hcl Tier 3
VERSACLOZ QL (600 mL / 30 days)
Tier 5 QL PA
VRAYLAR 1.5mg QL (60 caps / 30 days)
Tier 5 QL PA
VRAYLAR 3mg, 4.5mg, 6mg
QL (30 caps / 30 days)
Tier 5 QL PA
VRAYLAR THERAPY PACK Tier 4 PA
Drug Name Drug Tier
Requirements/Limits
ziprasidone hcl (generic of GEODON)
QL (60 caps / 30 days)
Tier 4 QL
ziprasidone mesylate (generic of GEODON)
QL (6 injections / 3 days)
Tier 4 QL
ZYPREXA RELPREVV 300mg
QL (2 vials / 28 days)
Tier 5 QL PA
ZYPREXA RELPREVV 405mg
QL (1 vial / 28 days)
Tier 5 QL PA
ZYPREXA RELPREVV INJ 210MG
QL (2 vials / 28 days)
Tier 4 QL PA
ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap sr 24hr 5 mg (generic of ADDERALL XR)
QL (90 caps / 30 days)
Tier 4 QL
amphetamine-dextroamphetamine cap sr 24hr 10 mg (generic of ADDERALL XR)
QL (90 caps / 30 days)
Tier 4 QL
amphetamine-dextroamphetamine cap sr 24hr 15 mg (generic of ADDERALL XR)
QL (30 caps / 30 days)
Tier 4 QL
amphetamine-dextroamphetamine cap sr 24hr 20 mg (generic of ADDERALL XR)
QL (30 caps / 30 days)
Tier 4 QL
amphetamine-dextroamphetamine cap sr 24hr 25 mg (generic of ADDERALL XR)
QL (30 caps / 30 days)
Tier 4 QL
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
27
Drug Name Drug Tier
Requirements/Limits
amphetamine-dextroamphetamine cap sr 24hr 30 mg (generic of ADDERALL XR)
QL (30 caps / 30 days)
Tier 4 QL
amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)
QL (120 tabs / 30 days)
Tier 3 QL
amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)
QL (120 tabs / 30 days)
Tier 3 QL
amphetamine-dextroamphetamine tab 10 mg (generic of ADDERALL)
QL (120 tabs / 30 days)
Tier 3 QL
amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)
QL (120 tabs / 30 days)
Tier 3 QL
amphetamine-dextroamphetamine tab 15 mg (generic of ADDERALL)
QL (90 tabs / 30 days)
Tier 3 QL
amphetamine-dextroamphetamine tab 20 mg (generic of ADDERALL)
QL (90 tabs / 30 days)
Tier 3 QL
amphetamine-dextroamphetamine tab 30 mg (generic of ADDERALL)
QL (60 tabs / 30 days)
Tier 3 QL
atomoxetine hcl (generic of STRATTERA) 10mg, 18mg, 25mg
QL (120 caps / 30 days)
Tier 4 QL
Drug Name Drug Tier
Requirements/Limits
atomoxetine hcl (generic of STRATTERA) 40mg
QL (60 caps / 30 days)
Tier 4 QL
atomoxetine hcl (generic of STRATTERA) 60mg, 80mg, 100mg
QL (30 caps / 30 days)
Tier 4 QL
dexmethylphenidate hcl (generic of FOCALIN) TABS 2.5mg, 5mg
QL (120 tabs / 30 days)
Tier 3 QL
dexmethylphenidate hcl (generic of FOCALIN) TABS 10mg
QL (60 tabs / 30 days)
Tier 3 QL
guanfacine er (adhd) (generic of INTUNIV)
PA if 70 years and older
Tier 3 PA
metadate er tab 20mg QL (90 tabs / 30 days)
Tier 4 QL
methylphenidate hcl (generic of RITALIN) TABS 5mg, 10mg
QL (180 tabs / 30 days)
Tier 3 QL
methylphenidate hcl (generic of RITALIN) TABS 20mg
QL (90 tabs / 30 days)
Tier 3 QL
methylphenidate hcl oral soln (generic of METHYLIN) 5mg/5ml
QL (1800 mL / 30 days)
Tier 4 QL
methylphenidate hcl oral soln (generic of METHYLIN) 10mg/5ml
QL (900 mL / 30 days)
Tier 4 QL
methylphenidate hcl tbcr 10 mg
QL (90 tabs / 30 days)
Tier 4 QL
methylphenidate hcl tbcr 20mg
QL (90 tabs / 30 days)
Tier 4 QL
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
28
Drug Name Drug Tier
Requirements/Limits
HYPNOTICS BELSOMRA
QL (30 tabs / 30 days) Tier 4 QL
doxepin hcl (sleep) (generic of SILENOR)
QL (30 tabs / 30 days)
Tier 3 QL
HETLIOZ Tier 5 NMO LA PA
temazepam (generic of RESTORIL) 7.5mg
QL (30 caps / 30 days) PA applies if 65 years and older after a 90 day supply in a calendar year
Tier 4 QL PA
temazepam (generic of RESTORIL) 15mg
QL (60 caps / 30 days) PA applies if 65 years and older after a 90 day supply in a calendar year
Tier 4 QL PA
zolpidem tartrate (generic of AMBIEN) TABS
QL (30 tabs / 30 days) PA applies if 70 years and older after a 90 day supply in a calendar year
Tier 2 GC QL PA
MIGRAINE AIMOVIG
QL (1 pen / 30 days) Tier 3 QL NMO PA
dihydroergotamine mesylate inj 1 mg/ml (generic of D.H.E. 45)
Tier 5
dihydroergotamine mesylate nasal spr 4 mg/ml (generic of MIGRANAL)
QL (8 mL / 30 days)
Tier 5 QL PA
eletriptan hydrobromide (generic of RELPAX)
QL (12 tabs / 30 days)
Tier 4 QL
EMGALITY SOAJ QL (2 pens / 30 days)
Tier 3 QL NMO PA
EMGALITY SOSY 120mg/ml
QL (2 syringes / 30 days)
Tier 3 QL NMO PA
Drug Name Drug Tier
Requirements/Limits
ergotamine w/ caffeine (generic of CAFERGOT) TABS
Tier 4
naratriptan hcl (generic of AMERGE)
QL (12 tabs / 30 days)
Tier 3 QL
rizatriptan benzoate 5mg QL (18 tabs / 30 days)
Tier 3 QL
rizatriptan benzoate (generic of MAXALT) 10mg
QL (18 tabs / 30 days)
Tier 3 QL
rizatriptan benzoate odt 5mg
QL (18 tabs / 30 days)
Tier 3 QL
rizatriptan benzoate odt (generic of MAXALT-MLT) 10mg
QL (18 tabs / 30 days)
Tier 3 QL
sumatriptan (generic of IMITREX) SOLN 5mg/act
QL (24 inhalers / 30 days)
Tier 4 QL
sumatriptan (generic of IMITREX) SOLN 20mg/act
QL (12 inhalers / 30 days)
Tier 4 QL
sumatriptan inj 4mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ
QL (18 injections / 30 days)
Tier 4 QL
sumatriptan inj 4mg/0.5ml (generic of IMITREX STATDOSE REFILL) SOCT
QL (18 injections / 30 days)
Tier 4 QL
sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ
QL (12 injections / 30 days)
Tier 4 QL
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
29
Drug Name Drug Tier
Requirements/Limits
sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE REFILL) SOCT
QL (12 injections / 30 days)
Tier 4 QL
sumatriptan inj 6mg/0.5ml (generic of IMITREX) SOLN
QL (12 injections / 30 days)
Tier 4 QL
sumatriptan inj 6mg/0.5ml SOSY
QL (12 injections / 30 days)
Tier 4 QL
sumatriptan succinate (generic of IMITREX) TABS
QL (12 tabs / 30 days)
Tier 2 GC QL
zolmitriptan (generic of ZOMIG) TABS
QL (12 tabs / 30 days)
Tier 4 QL
zolmitriptan odt (generic of ZOMIG ZMT)
QL (12 tabs / 30 days)
Tier 4 QL
MISCELLANEOUS AUSTEDO 6mg
QL (60 tabs / 30 days) Tier 5 QL NMO PA
AUSTEDO 9mg, 12mg QL (120 tabs / 30 days)
Tier 5 QL NMO PA
lithium carbonate CAPS Tier 1 GC
lithium carbonate TABS Tier 2 GC
lithium carbonate er (generic of LITHOBID) 300mg
Tier 2 GC
lithium carbonate er 450mg Tier 2 GC
LITHIUM SOLN 8MEQ/5ML Tier 4
LYRICA CR QL (60 tabs / 30 days)
Tier 3 QL PA
NUEDEXTA QL (60 caps / 30 days)
Tier 4 QL PA
pyridostigmine tab 60mg (generic of MESTINON)
Tier 3
riluzole (generic of RILUTEK)
Tier 3
Drug Name Drug Tier
Requirements/Limits
tetrabenazine (generic of XENAZINE) 12.5mg
QL (240 tabs / 30 days)
Tier 5 QL NMO PA
tetrabenazine (generic of XENAZINE) 25mg
QL (120 tabs / 30 days)
Tier 5 QL NMO PA
MULTIPLE SCLEROSIS AGENTS BETASERON
QL (14 syringes / 28 days)
Tier 5 QL NMO PA
dalfampridine (generic of AMPYRA) TB12
Tier 5 NMO PA
GILENYA QL (28 caps / 28 days)
Tier 5 QL NMO PA
glatiramer acetate 20mg/ml (generic of COPAXONE)
QL (30 syringes / 30 days)
Tier 5 QL NMO PA
glatiramer acetate 40mg/ml (generic of COPAXONE)
QL (12 syringes / 28 days)
Tier 5 QL NMO PA
glatopa (generic of COPAXONE) 20mg/ml
QL (30 syringes / 30 days)
Tier 5 QL NMO PA
glatopa (generic of COPAXONE) 40mg/ml
QL (12 syringes / 28 days)
Tier 5 QL NMO PA
MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 10mg, 20mg
Tier 3
cyclobenzaprine hcl TABS 5mg, 10mg
PA if 70 years and older
Tier 3 PA
dantrolene sodium (generic of DANTRIUM) CAPS 25mg, 50mg
Tier 4
dantrolene sodium CAPS 100mg
Tier 4
tizanidine hcl TABS 2mg Tier 2 GC
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
30
Drug Name Drug Tier
Requirements/Limits
tizanidine hcl (generic of ZANAFLEX) TABS 4mg
Tier 2 GC
NARCOLEPSY/CATAPLEXY armodafinil (generic of NUVIGIL) 50mg
QL (90 tabs / 30 days)
Tier 3 QL PA
armodafinil (generic of NUVIGIL) 150mg, 200mg, 250mg
QL (30 tabs / 30 days)
Tier 3 QL PA
XYREM QL (540 mL / 30 days)
Tier 5 QL NMO LA PA
PSYCHOTHERAPEUTIC-MISC acamprosate calcium Tier 4
buprenorphine hcl SUBL QL (90 tabs / 30 days)
Tier 3 QL PA
buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg (generic of SUBOXONE)
QL (90 films / 30 days)
Tier 4 QL
buprenorphine hcl-naloxone hcl dihydrate 4-1mg (generic of SUBOXONE)
QL (90 films / 30 days)
Tier 4 QL
buprenorphine hcl-naloxone hcl dihydrate 8-2mg (generic of SUBOXONE)
QL (90 films / 30 days)
Tier 4 QL
buprenorphine hcl-naloxone hcl dihydrate 12-3mg (generic of SUBOXONE)
QL (60 films / 30 days)
Tier 4 QL
buprenorphine hcl-naloxone hcl sl
QL (90 tabs / 30 days)
Tier 2 GC QL
bupropion hcl (smoking deterrent)
Tier 3
CHANTIX Tier 4 PA
CHANTIX CONTINUING MONTH
Tier 4 PA
CHANTIX STARTER PACK Tier 4 PA
disulfiram (generic of ANTABUSE) TABS
Tier 3
naloxone inj 0.4mg/ml Tier 2 GC
Drug Name Drug Tier
Requirements/Limits
naloxone inj 1mg/ml Tier 2 GC
naltrexone hcl TABS Tier 3
NARCAN Tier 3
NICOTROL INHALER Tier 4
NICOTROL NS Tier 4
VIVITROL Tier 5 NMO
ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 Tier 5 PA
ANDRODERM QL (30 patches / 30 days)
Tier 4 QL PA
oxandrolone tab 2.5mg Tier 3 PA
oxandrolone tab 10mg Tier 4 PA
testosterone GEL 1% QL (300 grams / 30 days)
Tier 4 QL PA
testosterone (generic of ANDROGEL) GEL 25mg/2.5gm, 50mg/5gm
QL (300 grams / 30 days)
Tier 4 QL PA
testosterone cypionate (generic of DEPO-TESTOSTERONE) SOLN
Tier 3 PA
testosterone enanthate SOLN
Tier 3 PA
ANTIDIABETICS, INJECTABLE BASAGLAR KWIKPEN Tier 3
BD ALCOHOL SWABS Tier 3
BD ULTRAFINE INSULIN SYRINGE
Tier 3
BD ULTRAFINE/NANO PEN NEEDLES
Tier 3
BYDUREON BCISE QL (4 pens / 28 days)
Tier 3 QL
BYDUREON PEN QL (4 pens / 28 days)
Tier 3 QL
BYETTA QL (1 pen / 30 days)
Tier 4 QL
FIASP Tier 3
FIASP FLEXTOUCH Tier 3
FIASP PENFILL Tier 3
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
31
Drug Name Drug Tier
Requirements/Limits
GAUZE PADS 2" X 2" Tier 3
HUMULIN R INJ U-500 Tier 5 B/D
HUMULIN R U-500 KWIKPEN
Tier 5
INSULIN PEN NEEDLE Tier 3
INSULIN SAFETY NEEDLES
Tier 3
INSULIN SYRINGE Tier 3
LEVEMIR Tier 3
LEVEMIR FLEXTOUCH Tier 3
NOVOLIN 70/30 (brand RELION not covered)
Tier 3
NOVOLIN 70/30 FLEXPEN (brand RELION not covered)
Tier 3
NOVOLIN N (brand RELION not covered)
Tier 3
NOVOLIN N FLEXPEN (brand RELION not covered)
Tier 3
NOVOLIN R (brand RELION not covered)
Tier 3
NOVOLIN R FLEXPEN (brand RELION not covered)
Tier 3
NOVOLOG Tier 3
NOVOLOG 70/30 FLEXPEN Tier 3
NOVOLOG FLEXPEN Tier 3
NOVOLOG MIX 70/30 Tier 3
NOVOLOG PENFILL Tier 3
OZEMPIC INJ 0.25 OR 0.5MG/DOSE
QL (1 pen / 28 days)
Tier 3 QL
OZEMPIC INJ 1MG/DOSE QL (2 pens / 28 days)
Tier 3 QL
SOLIQUA 100/33 QL (10 pens / 30 days)
Tier 3 QL
SYMLINPEN 60 Tier 5 PA
SYMLINPEN 120 Tier 5 PA
TRESIBA FLEXTOUCH Tier 3
Drug Name Drug Tier
Requirements/Limits
TRESIBA INJ Tier 3
TRULICITY QL (4 pens / 28 days)
Tier 3 QL
VICTOZA QL (3 pens / 30 days)
Tier 3 QL
XULTOPHY 100/3.6 QL (5 pens / 30 days)
Tier 3 QL
ANTIDIABETICS, ORAL acarbose (generic of PRECOSE) TABS
Tier 3
FARXIGA QL (30 tabs / 30 days)
Tier 3 QL
glimepiride (generic of AMARYL) 1mg, 2mg
QL (90 tabs / 30 days)
Tier 2 GC QL
glimepiride (generic of AMARYL) 4mg
QL (60 tabs / 30 days)
Tier 2 GC QL
glip/metform tab 2.5-250mg QL (240 tabs / 30 days)
Tier 1 GC QL
glip/metform tab 2.5-500mg QL (120 tabs / 30 days)
Tier 1 GC QL
glip/metform tab 5-500mg QL (120 tabs / 30 days)
Tier 1 GC QL
glipizide (generic of GLUCOTROL) TABS 5mg
QL (240 tabs / 30 days)
Tier 1 GC QL
glipizide (generic of GLUCOTROL) TABS 10mg
QL (120 tabs / 30 days)
Tier 1 GC QL
glipizide (generic of GLUCOTROL XL) TB24 2.5mg, 5mg
QL (90 tabs / 30 days)
Tier 1 GC QL
glipizide (generic of GLUCOTROL XL) TB24 10mg
QL (60 tabs / 30 days)
Tier 1 GC QL
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
32
Drug Name Drug Tier
Requirements/Limits
glipizide xl (generic of GLUCOTROL XL) 2.5mg, 5mg
QL (90 tabs / 30 days)
Tier 1 GC QL
glipizide xl (generic of GLUCOTROL XL) 10mg
QL (60 tabs / 30 days)
Tier 1 GC QL
GLYXAMBI QL (30 tabs / 30 days)
Tier 3 QL
JANUMET QL (60 tabs / 30 days)
Tier 3 QL
JANUMET XR TAB 50-500MG
QL (60 tabs / 30 days)
Tier 3 QL
JANUMET XR TAB 50-1000 QL (60 tabs / 30 days)
Tier 3 QL
JANUMET XR TAB 100-1000
QL (30 tabs / 30 days)
Tier 3 QL
JANUVIA QL (30 tabs / 30 days)
Tier 3 QL
JARDIANCE 10mg QL (60 tabs / 30 days)
Tier 3 QL
JARDIANCE 25mg QL (30 tabs / 30 days)
Tier 3 QL
JENTADUETO QL (60 tabs / 30 days)
Tier 3 QL
JENTADUETO TAB XR 2.5-1000 MG
QL (60 tabs / 30 days)
Tier 3 QL
JENTADUETO TAB XR 5-1000 MG
QL (30 tabs / 30 days)
Tier 3 QL
metformin er 500mg QL (120 tabs / 30 days)
(generic of GLUCOPHAGE XR)
Tier 1 GC QL
metformin er 750mg QL (60 tabs / 30 days)
(generic of GLUCOPHAGE XR)
Tier 1 GC QL
metformin hcl TABS 500mg QL (150 tabs / 30 days)
Tier 1 GC QL
Drug Name Drug Tier
Requirements/Limits
metformin hcl TABS 850mg QL (90 tabs / 30 days)
Tier 1 GC QL
metformin hcl TABS 1000mg
QL (75 tabs / 30 days)
Tier 1 GC QL
nateglinide (generic of STARLIX)
QL (90 tabs / 30 days)
Tier 1 GC QL
pioglitazone hcl (generic of ACTOS)
QL (30 tabs / 30 days)
Tier 1 GC QL
repaglinide 2mg QL (240 tabs / 30 days)
Tier 1 GC QL
repaglinide .5mg, 1mg QL (120 tabs / 30 days)
Tier 1 GC QL
SYNJARDY TAB 5-500MG QL (120 tabs / 30 days)
Tier 3 QL
SYNJARDY TAB 5-1000MG QL (60 tabs / 30 days)
Tier 3 QL
SYNJARDY TAB 12.5-500MG
QL (60 tabs / 30 days)
Tier 3 QL
SYNJARDY TAB 12.5-1000MG
QL (60 tabs / 30 days)
Tier 3 QL
SYNJARDY XR TAB 5-1000MG
QL (60 tabs / 30 days)
Tier 3 QL
SYNJARDY XR TAB 10-1000MG
QL (60 tabs / 30 days)
Tier 3 QL
SYNJARDY XR TAB 12.5-1000MG
QL (60 tabs / 30 days)
Tier 3 QL
SYNJARDY XR TAB 25-1000MG
QL (30 tabs / 30 days)
Tier 3 QL
TRADJENTA QL (30 tabs / 30 days)
Tier 3 QL
XIGDUO XR TAB 2.5-1000MG
QL (60 tabs / 30 days)
Tier 3 QL
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
33
Drug Name Drug Tier
Requirements/Limits
XIGDUO XR TAB 5-500MG QL (60 tabs / 30 days)
Tier 3 QL
XIGDUO XR TAB 5-1000MG
QL (60 tabs / 30 days)
Tier 3 QL
XIGDUO XR TAB 10-500MG
QL (30 tabs / 30 days)
Tier 3 QL
XIGDUO XR TAB 10-1000MG
QL (30 tabs / 30 days)
Tier 3 QL
BISPHOSPHONATES ACTONEL 5mg, 35mg, 150mg
Tier 4
alendronate sodium tab 5 mg
Tier 1 GC
alendronate sodium tab 10 mg
Tier 1 GC
alendronate sodium tab 35 mg
Tier 1 GC
alendronate sodium tab 40 mg
Tier 3
alendronate sodium tab 70 mg (generic of FOSAMAX)
Tier 1 GC
ibandronate sodium tabs (generic of BONIVA)
Tier 3 B/D
PAMIDRONATE DISODIUM 6mg/ml
Tier 3 B/D
pamidronate disodium 30mg/10ml, 90mg/10ml
Tier 3 B/D
pamidronate inj 30mg Tier 3 B/D
pamidronate inj 90mg Tier 3 B/D
risedronate sodium (generic of ACTONEL) TABS 5mg, 35mg, 150mg
Tier 4
zoledronic acid inj 4mg/100ml
Tier 4 B/D NMO
zoledronic acid inj 5mg/100ml (generic of RECLAST)
Tier 4 B/D NMO
zoledronic inj 4mg/5ml Tier 4 B/D NMO
CHELATING AGENTS CHEMET Tier 4
Drug Name Drug Tier
Requirements/Limits
clovique (generic of SYPRINE)
Tier 5 PA
deferasirox (generic of JADENU) TABS 90mg, 360mg
Tier 5 NMO PA
deferasirox (generic of EXJADE) TBSO
Tier 5 NMO PA
EXJADE Tier 5 NMO LA PA
JADENU 180mg Tier 5 NMO LA PA
JADENU SPRINKLE Tier 5 NMO LA PA
kionex sus 15gm/60ml Tier 3
LOKELMA Tier 3
penicillamine (generic of DEPEN TITRATABS) TABS
Tier 5
sodium polystyrene sulfonate powder
Tier 3
sodium polystyrene sulfonate susp
Tier 3
sps susp 15gm/60ml Tier 3
trientine hcl (generic of SYPRINE)
Tier 5 PA
VELTASSA Tier 4 LA PA
CONTRACEPTIVES altavera tab Tier 2 GC
alyacen 1/35 Tier 2 GC
apri Tier 2 GC
aranelle Tier 3
aubra Tier 2 GC
aviane Tier 2 GC
balziva Tier 3
bekyree (generic of MIRCETTE)
Tier 3
blisovi fe 1.5/30 (generic of LOESTRIN FE 1.5/30)
Tier 2 GC
briellyn Tier 3
camila Tier 2 GC
caziant pak Tier 2 GC
cryselle-28 Tier 2 GC
cyclafem 1/35 Tier 2 GC
cyclafem 7/7/7 (generic of ORTHO-NOVUM 7/7/7)
Tier 2 GC
cyred tab Tier 2 GC
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
34
Drug Name Drug Tier
Requirements/Limits
dasetta 1/35 Tier 2 GC
dasetta 7/7/7 (generic of ORTHO-NOVUM 7/7/7)
Tier 2 GC
deblitane Tier 2 GC
desogestrel & ethinyl estradiol
Tier 2 GC
desogestrel-ethinyl estradiol (biphasic) (generic of MIRCETTE)
Tier 3
drospirenone-ethinyl estradiol (generic of YASMIN 28)
Tier 3
drospirenone-ethinyl estradiol (generic of YAZ)
Tier 3
ELLA Tier 3
eluryng (generic of NUVARING)
Tier 4
emoquette Tier 2 GC
enpresse-28 Tier 2 GC
enskyce Tier 2 GC
errin (generic of ORTHO MICRONOR)
Tier 2 GC
estarylla tab 0.25-35 Tier 2 GC
ethynodiol diacet & eth estrad
Tier 2 GC
ethynodiol tab 1-50 Tier 3
etonogestrel-ethinyl estradiol (generic of NUVARING)
Tier 4
falmina Tier 2 GC
femynor Tier 2 GC
gianvi tab 3-0.02mg (generic of YAZ)
Tier 3
heather Tier 2 GC
incassia Tier 2 GC
introvale Tier 3
isibloom Tier 2 GC
jasmiel (generic of YAZ) Tier 3
jolessa tab 0.15-0.03 mg Tier 3
jolivette (generic of ORTHO MICRONOR)
Tier 2 GC
juleber Tier 2 GC
junel 1.5/30 (generic of LOESTRIN 1.5/30-21)
Tier 2 GC
Drug Name Drug Tier
Requirements/Limits
junel 1/20 (generic of LOESTRIN 1/20-21)
Tier 2 GC
junel fe 1.5/30 (generic of LOESTRIN FE 1.5/30)
Tier 2 GC
junel fe 1/20 (generic of LOESTRIN FE 1/20)
Tier 2 GC
kariva (generic of MIRCETTE)
Tier 3
kelnor 1/35 Tier 2 GC
kelnor 1/50 Tier 3
kurvelo Tier 2 GC
larin 1.5/30 (generic of LOESTRIN 1.5/30-21)
Tier 2 GC
larin 1/20 (generic of LOESTRIN 1/20-21)
Tier 2 GC
larin fe 1.5/30 (generic of LOESTRIN FE 1.5/30)
Tier 2 GC
larin fe 1/20 (generic of LOESTRIN FE 1/20)
Tier 2 GC
larissia tab Tier 2 GC
leena tab Tier 3
lessina Tier 2 GC
levonest Tier 2 GC
levonor/ethi tab Tier 2 GC
levonorgestrel & eth estradiol
Tier 2 GC
levonorgestrel-ethinyl estradiol (91-day)
Tier 3
levora 0.15/30-28 Tier 2 GC
loryna (generic of YAZ) Tier 3
low-ogestrel Tier 2 GC
lutera Tier 2 GC
lyza (generic of ORTHO MICRONOR)
Tier 2 GC
marlissa Tier 2 GC
medroxyprogesterone acetate (contraceptive) (generic of DEPO-PROVERA CONTRACEPTIV)
Tier 2 GC
microgestin 1.5/30 (generic of LOESTRIN 1.5/30-21)
Tier 2 GC
microgestin 1/20 (generic of LOESTRIN 1/20-21)
Tier 2 GC
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
35
Drug Name Drug Tier
Requirements/Limits
microgestin fe 1.5/30 (generic of LOESTRIN FE 1.5/30)
Tier 2 GC
microgestin fe 1/20 (generic of LOESTRIN FE 1/20)
Tier 2 GC
mili Tier 2 GC
mono-linyah tab 0.25-35 Tier 2 GC
necon 0.5/35-28 Tier 3
nikki (generic of YAZ) Tier 3
nora-be tab 0.35mg Tier 2 GC
norethindrone (contraceptive) (generic of ORTHO MICRONOR)
Tier 2 GC
norethindrone acet & eth estra (generic of LOESTRIN 1/20-21)
Tier 2 GC
norgest/ethi tab 0.25/35 Tier 2 GC
norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg (generic of ORTHO TRI-CYCLEN LO)
Tier 3
norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg
Tier 2 GC
nortrel 0.5/35 (28) Tier 3
nortrel 1/35 Tier 2 GC
nortrel 7/7/7 (generic of ORTHO-NOVUM 7/7/7)
Tier 2 GC
ocella tab 3-0.03mg (generic of YASMIN 28)
Tier 3
orsythia Tier 2 GC
philith Tier 3
pimtrea (generic of MIRCETTE)
Tier 3
pirmella 1/35 Tier 2 GC
portia-28 Tier 2 GC
previfem Tier 2 GC
reclipsen Tier 2 GC
setlakin tab Tier 3
sharobel (generic of ORTHO MICRONOR)
Tier 2 GC
sprintec 28 Tier 2 GC
Drug Name Drug Tier
Requirements/Limits
sronyx Tier 2 GC
syeda (generic of YASMIN 28)
Tier 3
tarina fe 1/20 (generic of LOESTRIN FE 1/20)
Tier 2 GC
tilia fe (generic of ESTROSTEP FE)
Tier 3
tri-estarylla Tier 2 GC
tri-legest fe (generic of ESTROSTEP FE)
Tier 3
tri-linyah Tier 2 GC
tri-lo marzia (generic of ORTHO TRI-CYCLEN LO)
Tier 3
tri-lo-estarylla (generic of ORTHO TRI-CYCLEN LO)
Tier 3
tri-lo-sprintec (generic of ORTHO TRI-CYCLEN LO)
Tier 3
tri-mili Tier 2 GC
tri-previfem Tier 2 GC
tri-sprintec Tier 2 GC
tri-vylibra Tier 2 GC
tri-vylibra lo (generic of ORTHO TRI-CYCLEN LO)
Tier 3
trivora-28 Tier 2 GC
tulana Tier 2 GC
velivet Tier 2 GC
vienva Tier 2 GC
viorele (generic of MIRCETTE)
Tier 3
vyfemla Tier 3
vylibra Tier 2 GC
xulane dis 150-35 Tier 4
zarah (generic of YASMIN 28)
Tier 3
zovia 1/35e Tier 2 GC
ENDOMETRIOSIS danazol CAPS Tier 4
SYNAREL Tier 5
ENZYME REPLACEMENTS ALDURAZYME Tier 5 NMO LA PA
CARBAGLU Tier 5 NMO LA PA
CERDELGA Tier 5 NMO PA
CEREZYME Tier 5 NMO LA PA
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
36
Drug Name Drug Tier
Requirements/Limits
CYSTADANE Tier 5 NMO LA
CYSTAGON Tier 4 NMO LA PA
FABRAZYME Tier 5 NMO LA PA
KUVAN Tier 5 NMO LA PA
levocarnitine (metabolic modifiers) (generic of CARNITOR)
Tier 4 B/D
LUMIZYME Tier 5 NMO LA PA
miglustat (generic of ZAVESCA)
Tier 5 NMO PA
NAGLAZYME Tier 5 NMO LA PA
nitisinone (generic of ORFADIN)
Tier 5 NMO PA
NITYR Tier 5 NMO LA PA
ORFADIN Tier 5 NMO LA PA
sodium phenylbutyrate (generic of BUPHENYL)
Tier 5 NMO PA
ESTROGENS DELESTROGEN 10mg/ml Tier 4
estradiol (generic of CLIMARA) PTWK
Tier 3
estradiol (generic of ESTRACE) TABS
Tier 2 GC
estradiol vaginal cream (generic of ESTRACE)
Tier 3
estradiol vaginal tab (generic of VAGIFEM)
Tier 4
estradiol valerate inj (generic of DELESTROGEN)
Tier 4
fyavolv Tier 3
fyavolv (generic of FEMHRT LOW DOSE)
Tier 3
jinteli Tier 3
norethindrone acetate-ethinyl estradiol
Tier 3
norethindrone acetate-ethinyl estradiol (generic of FEMHRT LOW DOSE)
Tier 3
yuvafem vaginal tablet 10mcg (generic of VAGIFEM)
Tier 4
GLUCOCORTICOIDS cortisone acetate TABS Tier 4
Drug Name Drug Tier
Requirements/Limits
DEXAMETHASONE CONC Tier 4
dexamethasone ELIX; SOLN
Tier 3
dexamethasone TABS Tier 2 GC
dexamethasone sodium phosphate 4mg/ml, 10mg/ml, 20mg/5ml, 100mg/10ml, 120mg/30ml
Tier 2 GC
dexamethasone sodium phosphate (generic of DEXAMETHASONE SODIUM PHOS) 10mg/ml
Tier 2 GC
fludrocortisone acetate TABS
Tier 2 GC
hydrocortisone (generic of CORTEF) TABS
Tier 3
methylpr ss inj (generic of SOLU-MEDROL)
Tier 3 B/D
methylpred pak 4mg (generic of MEDROL DOSEPAK)
Tier 2 GC
methylpred tab 4mg (generic of MEDROL)
Tier 3 B/D
methylpred tab 8mg (generic of MEDROL)
Tier 3 B/D
methylpred tab 16mg (generic of MEDROL)
Tier 3 B/D
methylpred tab 32mg (generic of MEDROL)
Tier 3 B/D
methylprednisolone acetate (generic of DEPO-MEDROL)
Tier 2 GC B/D
pred sod pho sol 5mg/5ml (generic of PEDIAPRED)
Tier 4 B/D
prednisolone sodium phosphate SOLN 15mg/5ml
Tier 2 GC B/D
prednisolone sol 15mg/5ml Tier 2 GC B/D
prednisolone sol 25mg/5ml Tier 4 B/D
PREDNISONE CON 5MG/ML
Tier 4 B/D
prednisone pak 5mg Tier 3
prednisone pak 10mg Tier 3
prednisone sol 5mg/5ml Tier 4 B/D
prednisone tab 1mg Tier 1 GC B/D
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
37
Drug Name Drug Tier
Requirements/Limits
prednisone tab 2.5mg Tier 1 GC B/D
prednisone tab 5mg Tier 1 GC B/D
prednisone tab 10mg Tier 1 GC B/D
prednisone tab 20mg Tier 1 GC B/D
prednisone tab 50mg Tier 1 GC B/D
SOLU-CORTEF Tier 4
GLUCOSE ELEVATING AGENTS diazoxide (generic of PROGLYCEM) SUSP
Tier 4
GLUCAGEN HYPOKIT Tier 3
GLUCAGON EMERGENCY KIT
Tier 3
GVOKE PFS Tier 3
PROGLYCEM SUS 50MG/ML
Tier 4
MISCELLANEOUS cabergoline Tier 3
calcitonin (salmon) (generic of MIACALCIN)
Tier 3 B/D
cinacalcet hcl (generic of SENSIPAR) 30mg, 90mg
QL (120 tabs / 30 days)
Tier 5 B/D QL NMO
cinacalcet hcl (generic of SENSIPAR) 60mg
QL (60 tabs / 30 days)
Tier 5 B/D QL NMO
FORTEO Tier 5 NMO PA
GENOTROPIN Tier 5 NMO PA
GENOTROPIN MINIQUICK .2mg
Tier 3 NMO PA
GENOTROPIN MINIQUICK .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg
Tier 5 NMO PA
INCRELEX Tier 5 NMO LA PA
KORLYM Tier 5 NMO LA PA
LUPRON DEP-PED INJ 7.5MG
Tier 5 NMO PA
LUPRON DEP-PED INJ 11.25MG (3-MONTH)
Tier 5 NMO PA
LUPRON DEPOT-PED (1-MONTH
Tier 5 NMO PA
LUPRON DEPOT-PED (3-MONTH
Tier 5 NMO PA
Drug Name Drug Tier
Requirements/Limits
NATPARA Tier 5 NMO PA
octreotide acetate (generic of SANDOSTATIN) 50mcg/ml, 100mcg/ml
Tier 4 NMO PA
octreotide acetate 200mcg/ml
Tier 4 NMO PA
octreotide acetate (generic of SANDOSTATIN) 500mcg/ml
Tier 5 NMO PA
octreotide acetate 1000mcg/ml
Tier 5 NMO PA
OSPHENA Tier 3 PA
PROLIA QL (1 injection / 180 days)
Tier 4 QL NMO
raloxifene tab 60mg (generic of EVISTA)
Tier 3
SIGNIFOR Tier 5 NMO LA PA
SOMATULINE DEPOT Tier 5 NMO PA
SOMAVERT Tier 5 NMO LA PA
TYMLOS Tier 5 NMO PA
XGEVA Tier 5 NMO PA
PHOSPHATE BINDER AGENTS AURYXIA
QL (360 tabs / 30 days)
Tier 5 QL PA
calcium acetate (phosphate binder) (generic of PHOSLO) CAPS
QL (360 caps / 30 days)
Tier 3 QL
calcium acetate (phosphate binder) TABS
QL (360 tabs / 30 days)
Tier 3 QL
sevelamer carbonate (generic of RENVELA) PACK 2.4gm
QL (180 packets / 30 days)
Tier 5 QL
sevelamer carbonate (generic of RENVELA) PACK .8gm
QL (540 packets / 30 days)
Tier 5 QL
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
38
Drug Name Drug Tier
Requirements/Limits
sevelamer carbonate (generic of RENVELA) TABS
QL (540 tabs / 30 days)
Tier 4 QL
PROGESTINS medroxyprogesterone acetate tab (generic of PROVERA)
Tier 1 GC
norethindrone acetate (generic of AYGESTIN) TABS
Tier 3
THYROID AGENTS euthyrox (generic of SYNTHROID)
Tier 2 GC
levo-t (generic of SYNTHROID)
Tier 2 GC
levothyroxine sodium (generic of SYNTHROID) TABS
Tier 2 GC
levoxyl (generic of SYNTHROID)
Tier 2 GC
liothyronine sodium (generic of CYTOMEL) TABS
Tier 3
methimazole (generic of TAPAZOLE) TABS
Tier 1 GC
propylthiouracil TABS Tier 3
SYNTHROID Tier 4
unithroid (generic of SYNTHROID)
Tier 2 GC
VASOPRESSINS desmopressin acetate spray (generic of DDAVP)
Tier 4
desmopressin acetate spray refrigerated
Tier 4
desmopressin acetate tabs (generic of DDAVP)
Tier 3
desmopressin inj 4mcg/ml (generic of DDAVP)
Tier 4
STIMATE Tier 5 NMO
GASTROINTESTINAL ANTIEMETICS aprepitant (generic of EMEND) 40mg, 80mg
Tier 4 B/D
Drug Name Drug Tier
Requirements/Limits
aprepitant 125mg Tier 4 B/D
aprepitant pak 80mg & 125mg
Tier 4 B/D
compro supp Tier 4
dronabinol (generic of MARINOL)
QL (60 caps / 30 days)
Tier 4 B/D QL
EMEND SUSR Tier 4 B/D
granisetron hcl SOLN Tier 3
granisetron hcl TABS Tier 4 B/D
meclizine hcl TABS Tier 2 GC
metoclopramide hcl SOLN Tier 2 GC
metoclopramide hcl (generic of REGLAN) TABS
Tier 1 GC
metoclopramide hcl inj Tier 2 GC
ondansetron hcl (generic of ZOFRAN) TABS 4mg, 8mg
Tier 3 B/D
ondansetron hcl TABS 24mg
Tier 3 B/D
ondansetron hcl inj Tier 2 GC
ondansetron hcl oral soln Tier 4 B/D
ondansetron odt Tier 2 GC B/D
prochlorperazine inj Tier 4
prochlorperazine maleate TABS
Tier 2 GC
prochlorperazine supp Tier 4
promethazine hcl SYRP; TABS
PA if 70 years and older
Tier 2 GC PA
promethazine hcl inj (generic of PHENERGAN)
PA if 70 years and older
Tier 4 PA
scopolamine (generic of TRANSDERM SCOP)
QL (10 patches / 30 days)
PA if 70 years and older
Tier 4 QL PA
ANTISPASMODICS dicyclomine hcl cap 10mg Tier 3
dicyclomine hcl soln 10mg/5ml
Tier 4
dicyclomine hcl tab 20mg Tier 3
glycopyrrolate tab 1mg Tier 3
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
39
Drug Name Drug Tier
Requirements/Limits
glycopyrrolate tab 2mg Tier 3
H2-RECEPTOR ANTAGONISTS famotidine SUSR Tier 4
famotidine (generic of PEPCID) TABS 20mg, 40mg
Tier 1 GC
famotidine in nacl Tier 2 GC
famotidine inj Tier 2 GC
nizatidine CAPS Tier 3
INFLAMMATORY BOWEL DISEASE balsalazide disodium (generic of COLAZAL)
Tier 3
budesonide ec (generic of ENTOCORT EC)
Tier 4
colocort (generic of CORTENEMA)
Tier 4
hydrocortisone (enema) (generic of CORTENEMA)
Tier 4
mesalamine (generic of DELZICOL) CPDR
Tier 4
mesalamine ENEM Tier 4
mesalamine (generic of CANASA) SUPP
Tier 5
mesalamine (generic of LIALDA) TBEC 1.2gm
Tier 4
mesalamine w/ cleanser (generic of ROWASA)
Tier 4
sulfasalazine (generic of AZULFIDINE) TABS
Tier 2 GC
sulfasalazine ec (generic of AZULFIDINE EN-TABS)
Tier 3
LAXATIVES constulose Tier 3
enulose Tier 3
gavilyte-c Tier 2 GC
gavilyte-g (generic of GOLYTELY)
Tier 2 GC
gavilyte-n/flavor pack (generic of NULYTELY/FLAVOR PACKS)
Tier 2 GC
generlac Tier 3
GOLYTELY Tier 3
Drug Name Drug Tier
Requirements/Limits
lactulose SOLN Tier 3
lactulose (encephalopathy) Tier 3
NULYTELY/FLAVOR PACKS
Tier 3
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
Tier 2 GC
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (generic of GOLYTELY)
Tier 2 GC
peg 3350-potassium chloride-sod bicarbonate-sod chloride (generic of NULYTELY/FLAVOR PACKS)
Tier 2 GC
PLENVU Tier 4
SUPREP BOWEL PREP KIT
Tier 4
trilyte (generic of NULYTELY/FLAVOR PACKS)
Tier 2 GC
MISCELLANEOUS alosetron hcl (generic of LOTRONEX)
Tier 5 PA
AMITIZA CAP 8MCG QL (180 caps / 30 days)
Tier 3 QL
AMITIZA CAP 24MCG QL (60 caps / 30 days)
Tier 3 QL
cromolyn sodium (mastocytosis) (generic of GASTROCROM)
Tier 5
diphenoxylate w/ atropine LIQD
Tier 4
diphenoxylate w/ atropine (generic of LOMOTIL) TABS
Tier 3
GATTEX Tier 5 NMO LA PA
LINZESS QL (30 caps / 30 days)
Tier 4 QL
loperamide hcl CAPS Tier 3
misoprostol (generic of CYTOTEC) TABS
Tier 3
MOVANTIK 12.5mg QL (60 tabs / 30 days)
Tier 3 QL
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
40
Drug Name Drug Tier
Requirements/Limits
MOVANTIK 25mg QL (30 tabs / 30 days)
Tier 3 QL
RELISTOR SOLN Tier 5 PA
sucralfate (generic of CARAFATE) TABS
Tier 2 GC
ursodiol (generic of ACTIGALL) CAPS
Tier 3
ursodiol (generic of URSO 250) TABS 250mg
Tier 4
ursodiol (generic of URSO FORTE) TABS 500mg
Tier 4
XIFAXAN 550mg Tier 5 PA
PANCREATIC ENZYMES CREON Tier 3
ZENPEP Tier 4
PROTON PUMP INHIBITORS DEXILANT
QL (30 caps / 30 days) Tier 4 QL
esomeprazole magnesium (generic of NEXIUM) CPDR
QL (30 caps / 30 days)
Tier 4 QL ST
lansoprazole (generic of PREVACID) CPDR
QL (30 caps / 30 days)
Tier 3 QL
omeprazole cap 10mg Tier 1 GC
omeprazole cap 20mg Tier 1 GC
omeprazole cap 40mg Tier 1 GC
pantoprazole sodium (generic of PROTONIX) SOLR
Tier 4
pantoprazole sodium tbec (generic of PROTONIX)
Tier 1 GC
GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)
QL (30 tabs / 30 days)
Tier 2 GC QL
dutasteride (generic of AVODART) CAPS
QL (30 caps / 30 days)
Tier 3 QL
dutasteride-tamsulosin hcl (generic of JALYN)
QL (30 caps / 30 days)
Tier 4 QL
Drug Name Drug Tier
Requirements/Limits
finasteride (generic of PROSCAR) TABS 5mg
Tier 1 GC
tamsulosin hcl (generic of FLOMAX)
Tier 2 GC
MISCELLANEOUS bethanechol chloride TABS 5mg, 10mg
Tier 3
bethanechol chloride (generic of URECHOLINE) TABS 25mg, 50mg
Tier 3
potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 15) 15meq
Tier 4
potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 5) 540mg
Tier 4
potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 10) 1080mg
Tier 4
URINARY ANTISPASMODICS MYRBETRIQ
QL (30 tabs / 30 days) Tier 4 QL
oxybutynin chloride SYRP Tier 3
oxybutynin chloride TABS Tier 3
oxybutynin chloride (generic of DITROPAN XL) TB24 5mg
QL (30 tabs / 30 days)
Tier 3 QL
oxybutynin chloride (generic of DITROPAN XL) TB24 10mg
QL (60 tabs / 30 days)
Tier 3 QL
oxybutynin chloride TB24 15mg
QL (60 tabs / 30 days)
Tier 3 QL
solifenacin succinate (generic of VESICARE)
QL (30 tabs / 30 days)
Tier 4 QL
tolterodine tartrate (generic of DETROL LA) CP24
QL (30 caps / 30 days)
Tier 4 QL ST
tolterodine tartrate (generic of DETROL) TABS
Tier 4 ST
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
41
Drug Name Drug Tier
Requirements/Limits
TOVIAZ QL (30 tabs / 30 days)
Tier 3 QL
trospium chloride TABS QL (60 tabs / 30 days)
Tier 3 QL
VESICARE QL (30 tabs / 30 days)
Tier 4 QL
VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal (generic of CLEOCIN)
Tier 3
metronidazole vaginal Tier 4
terconazole vaginal Tier 3
vandazole Tier 4
HEMATOLOGIC ANTICOAGULANTS COUMADIN Tier 3
ELIQUIS 2.5mg QL (60 tabs / 30 days)
Tier 3 QL
ELIQUIS 5mg QL (74 tabs / 30 days)
Tier 3 QL
ELIQUIS STARTER PACK QL (74 tabs / 30 days)
Tier 3 QL
enoxaparin sodium (generic of LOVENOX)
Tier 4
fondaparinux sodium (generic of ARIXTRA) 2.5mg/0.5ml
Tier 4
fondaparinux sodium (generic of ARIXTRA) 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml
Tier 5
heparin sod (porcine) in d5w Tier 3
heparin sod inj 1000/ml Tier 3 B/D
heparin sod inj 5000/ml Tier 3 B/D
heparin sod inj 10000/ml Tier 3 B/D
heparin sod inj 20000/ml Tier 3 B/D
HEPARIN SODIUM/NACL 0.45%
Tier 3
jantoven (generic of COUMADIN) 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg
Tier 1 GC
jantoven 10mg Tier 1 GC
Drug Name Drug Tier
Requirements/Limits
PRADAXA QL (60 caps / 30 days)
Tier 4 QL
warfarin sodium (generic of COUMADIN) 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg
Tier 1 GC
warfarin sodium 10mg Tier 1 GC
XARELTO 2.5mg QL (60 tabs / 30 days)
Tier 3 QL
XARELTO 10mg, 15mg, 20mg
QL (30 tabs / 30 days)
Tier 3 QL
XARELTO STARTER PACK QL (51 tabs / 30 days)
Tier 3 QL
HEMATOPOIETIC GROWTH FACTORS PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml
Tier 3 NMO PA
PROCRIT 20000unit/ml, 40000unit/ml
Tier 5 NMO PA
ZARXIO Tier 5 NMO PA
MISCELLANEOUS anagrelide hcl 1mg Tier 4
anagrelide hcl (generic of AGRYLIN) .5mg
Tier 4
BERINERT QL (24 boxes / 30 days)
Tier 5 QL NMO LA PA
cilostazol Tier 2 GC
DROXIA Tier 3
ENDARI Tier 5 NMO LA PA
HAEGARDA 2000unit QL (30 vials / 30 days)
Tier 5 QL NMO LA PA
HAEGARDA 3000unit QL (20 vials / 30 days)
Tier 5 QL NMO LA PA
icatibant acetate (generic of FIRAZYR)
QL (9 syringes / 30 days)
Tier 5 QL NMO PA
pentoxifylline TBCR Tier 2 GC
PROMACTA PACK 12.5mg QL (360 packets / 30 days)
Tier 5 QL NMO LA PA
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
42
Drug Name Drug Tier
Requirements/Limits
PROMACTA TABS 12.5mg, 25mg
QL (30 tabs / 30 days)
Tier 5 QL NMO LA PA
PROMACTA TABS 50mg, 75mg
QL (60 tabs / 30 days)
Tier 5 QL NMO LA PA
tranexamic acid (generic of CYKLOKAPRON) SOLN
Tier 4
tranexamic acid (generic of LYSTEDA) TABS
Tier 3
PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole (generic of AGGRENOX)
Tier 4
BRILINTA Tier 3
clopidogrel tab 75mg (generic of PLAVIX)
Tier 1 GC
prasugrel hcl (generic of EFFIENT)
Tier 3
IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ENBREL SOLR
QL (16 vials / 28 days) Tier 5 QL NMO PA
ENBREL SOSY 25mg/0.5ml
QL (16 syringes / 28 days)
Tier 5 QL NMO PA
ENBREL SOSY 50mg/ml QL (8 syringes / 28 days)
Tier 5 QL NMO PA
ENBREL MINI QL (8 injections / 28 days)
Tier 5 QL NMO PA
ENBREL SURECLICK QL (8 injections / 28 days)
Tier 5 QL NMO PA
HUMIRA 10mg/0.1ml, 20mg/0.2ml
QL (2 injections / 28 days)
Tier 5 QL NMO PA
HUMIRA 40mg/0.4ml QL (6 injections / 28 days)
Tier 5 QL NMO PA
Drug Name Drug Tier
Requirements/Limits
HUMIRA INJ 10MG/0.2ML QL (2 syringes / 28 days)
Tier 5 QL NMO PA
HUMIRA KIT 20MG/0.4ML QL (2 syringes / 28 days)
Tier 5 QL NMO PA
HUMIRA KIT 40MG/0.8ML QL (6 syringes / 28 days)
Tier 5 QL NMO PA
HUMIRA PEDIATRIC CROHNS DISEASE
Tier 5 NMO PA
HUMIRA PEN QL (6 pens / 28 days)
Tier 5 QL NMO PA
HUMIRA PEN CD/UC/HS STARTER
Tier 5 NMO PA
HUMIRA PEN INJ CD/UC/HS STARTER
Tier 5 NMO PA
HUMIRA PEN INJ PS/UV STARTER
Tier 5 NMO PA
HUMIRA PEN-PS/UV STARTER
Tier 5 NMO PA
hydroxychloroquine sulfate (generic of PLAQUENIL)
Tier 3
leflunomide (generic of ARAVA) TABS
QL (30 tabs / 30 days)
Tier 3 QL
methotrexate sodium tabs Tier 3
REMICADE Tier 5 NMO PA
RENFLEXIS Tier 5 NMO LA PA
RINVOQ QL (30 tabs / 30 days)
Tier 5 QL NMO PA
SKYRIZI QL (7 injections / year)
Tier 5 QL NMO PA
STELARA SOLN 45mg/0.5ml
QL (1 vial / 28 days)
Tier 5 QL NMO LA PA
STELARA SOSY QL (1 syringe / 28 days)
Tier 5 QL NMO PA
XATMEP Tier 4 B/D
XELJANZ QL (60 tabs / 30 days)
Tier 5 QL NMO PA
XELJANZ XR QL (30 tabs / 30 days)
Tier 5 QL NMO PA
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
43
Drug Name Drug Tier
Requirements/Limits
IMMUNOGLOBULINS BIVIGAM Tier 5 NMO PA
GAMASTAN S/D Tier 3 B/D NMO
GAMMAGARD LIQUID Tier 5 NMO PA
GAMMAGARD S/D Tier 5 NMO PA
GAMMAKED Tier 5 NMO PA
GAMMAPLEX Tier 5 NMO PA
GAMMAPLEX 10GM/100ML Tier 5 NMO PA
GAMUNEX-C Tier 5 NMO PA
OCTAGAM Tier 5 NMO PA
PANZYGA Tier 5 NMO PA
PRIVIGEN Tier 5 NMO PA
IMMUNOMODULATORS ACTIMMUNE Tier 5 NMO LA PA
ARCALYST Tier 5 NMO PA
INTRON-A INJ 10MU Tier 5 B/D NMO
INTRON-A INJ 18MU Tier 5 B/D NMO
INTRON-A INJ 25MU Tier 5 B/D NMO
INTRON-A INJ 50MU Tier 5 B/D NMO
IMMUNOSUPPRESSANTS azathioprine (generic of IMURAN) TABS
Tier 3 B/D
BENLYSTA Tier 5 NMO PA
cyclosporine (generic of SANDIMMUNE) CAPS; SOLN
Tier 4 B/D NMO
cyclosporine modified (for microemulsion) (generic of NEORAL) CAPS 25mg, 100mg
Tier 4 B/D NMO
cyclosporine modified (for microemulsion) CAPS 50mg
Tier 4 B/D NMO
cyclosporine modified (for microemulsion) (generic of NEORAL) SOLN
Tier 4 B/D NMO
everolimus (immunosuppressant) (generic of ZORTRESS) .5mg, .75mg
Tier 5 B/D NMO
everolimus (immunosuppressant) (generic of ZORTRESS) .25mg
Tier 4 B/D NMO
Drug Name Drug Tier
Requirements/Limits
gengraf (generic of NEORAL)
Tier 4 B/D NMO
mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS
Tier 3 B/D NMO
mycophenolate mofetil (generic of CELLCEPT) SUSR
Tier 5 B/D NMO
mycophenolate sodium tbec (generic of MYFORTIC)
Tier 4 B/D NMO
NULOJIX Tier 5 B/D NMO
PROGRAF PACK Tier 4 B/D NMO
SANDIMMUNE SOLN 100mg/ml
Tier 3 B/D NMO
sirolimus (generic of RAPAMUNE) SOLN
Tier 5 B/D NMO
sirolimus (generic of RAPAMUNE) TABS 2mg
Tier 5 B/D NMO
sirolimus (generic of RAPAMUNE) TABS .5mg, 1mg
Tier 4 B/D NMO
tacrolimus (generic of PROGRAF) CAPS
Tier 4 B/D NMO
ZORTRESS TAB 0.5MG Tier 5 B/D NMO
ZORTRESS TAB 0.25MG Tier 5 B/D NMO
ZORTRESS TAB 0.75MG Tier 5 B/D NMO
ZORTRESS TAB 1MG Tier 5 B/D NMO
VACCINES ACTHIB Tier 3
ADACEL Tier 3
BCG VACCINE Tier 3
BEXSERO Tier 3
BOOSTRIX Tier 3
DAPTACEL Tier 3
DIPHTHERIA/TETANUS TOXOID
Tier 3 B/D
ENGERIX-B SUSP Tier 3 B/D
GARDASIL 9 Tier 3
HAVRIX Tier 3
HIBERIX Tier 3
IMOVAX RABIES (H.D.C.V.)
Tier 3 B/D
INFANRIX Tier 3
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
44
Drug Name Drug Tier
Requirements/Limits
IPOL INACTIVATED IPV Tier 3
IXIARO Tier 3
KINRIX Tier 3
M-M-R II Tier 3
MENACTRA Tier 3
MENVEO Tier 3
PEDIARIX Tier 3
PEDVAX HIB Tier 3
PENTACEL Tier 3
PROQUAD Tier 3
QUADRACEL Tier 3
RABAVERT Tier 3 B/D
RECOMBIVAX HB Tier 3 B/D
ROTARIX Tier 3
ROTATEQ Tier 3
SHINGRIX QL (2 vials per lifetime)
Tier 3 QL
TDVAX Tier 3 B/D
TENIVAC Tier 3 B/D
TRUMENBA Tier 3
TWINRIX INJ Tier 3
TYPHIM VI Tier 3
VAQTA Tier 3
VARIVAX Tier 3
YF-VAX Tier 3
ZOSTAVAX QL (1 vial per lifetime)
Tier 3 QL
NUTRITIONAL/SUPPLEMENTS ELECTROLYTES klor-con 8 Tier 2 GC
klor-con 10 Tier 2 GC
klor-con m10 Tier 2 GC
klor-con m15 Tier 2 GC
klor-con m20 Tier 2 GC
klor-con pak 20meq Tier 4
klor-con spr cap 8meq Tier 3
klor-con spr cap 10meq Tier 3
MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml
Tier 3
Drug Name Drug Tier
Requirements/Limits
magnesium sulfate (generic of MAGNESIUM SULFATE) SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml
Tier 3
magnesium sulfate SOLN 50%
Tier 3
MAGNESIUM SULFATE IN D5W
Tier 3
magnesium sulfate in dextrose (generic of MAGNESIUM SULFATE IN D5W)
Tier 3
magnesium sulfate inj 50% Tier 3
potassium chloride CPCR Tier 3
potassium chloride PACK Tier 4
potassium chloride SOLN 10%, 20%
Tier 4
potassium chloride TBCR 8meq, 10meq
Tier 2 GC
potassium chloride (generic of K-TAB) TBCR 20meq
Tier 2 GC
potassium chloride microencapsulated crystals er
Tier 2 GC
sodium chloride SOLN 2.5meq/ml
Tier 3
sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln
Tier 2 GC
TPN ELECTROLYTES Tier 4 B/D
IV NUTRITION AMINOSYN II INJ 10% Tier 4 B/D
AMINOSYN-PF 7% Tier 4 B/D
AMINOSYN-PF INJ 10% Tier 4 B/D
CLINIMIX 4.25%/DEXTROSE 5%
Tier 4 B/D
CLINIMIX 5%/DEXTROSE 15%
Tier 4 B/D
CLINIMIX 5%/DEXTROSE 20%
Tier 4 B/D
CLINIMIX INJ 4.25/D10 Tier 4 B/D
clinisol sf 15% Tier 4 B/D
CLINOLIPID Tier 4 B/D
FREAMINE HBC 6.9% Tier 4 B/D
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
45
Drug Name Drug Tier
Requirements/Limits
FREAMINE III Tier 4 B/D
hepatamine Tier 4 B/D
INTRALIPID 30% Tier 4 B/D
INTRALIPID INJ 20% Tier 4 B/D
NEPHRAMINE Tier 4 B/D
NUTRILIPID INJ 20% Tier 4 B/D
plenamine Tier 4 B/D
PREMASOL 10% Tier 4 B/D
PROCALAMINE Tier 4 B/D
PROSOL Tier 4 B/D
TRAVASOL Tier 4 B/D
TROPHAMINE INJ 10% Tier 4 B/D
IV REPLACEMENT SOLUTIONS dextrose 2.5%/nacl 0.45% Tier 2 GC
dextrose 5% Tier 2 GC
DEXTROSE 5% /ELECTROLYTE
Tier 3
dextrose 5%/nacl 0.2% Tier 2 GC
DEXTROSE 5%/NACL 0.3%
Tier 4
dextrose 5%/nacl 0.9% Tier 2 GC
dextrose 5%/nacl 0.45% Tier 2 GC
dextrose 5%/nacl 0.225% Tier 2 GC
dextrose 5%/potassium chl Tier 2 GC
dextrose 10% flex contain Tier 2 GC
DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%
Tier 3
dextrose 10%/nacl 0.45% Tier 2 GC
dextrose 50% Tier 2 GC
dextrose in lactated ringers Tier 2 GC
dextrose inj 70% Tier 2 GC
ISOLYTE P Tier 4
ISOLYTE S Tier 4
kcl0.15%/d5w/nacl0.2% Tier 3
KCL 0.3%/D5W/NACL 0.9% Tier 4
kcl 0.3%/d5w/nacl 0.45% Tier 3
kcl 0.15%/d5w/nacl 0.9% Tier 3
KCL 0.15%/D5W/NACL 0.225%
Tier 4
kcl 0.075%/d5w/nacl 0.45% Tier 3
kcl/d5w inj 0.3% Tier 2 GC
kcl/d5w/nacl inj 0.22%/0.45%
Tier 3
Drug Name Drug Tier
Requirements/Limits
kcl/d5w/nacl inj .15/.45% Tier 3
kcl/nacl inj 0.3-0.9 Tier 2 GC
kcl/nacl inj 0.15%-0.9% Tier 2 GC
lactated ringer's Tier 2 GC
NORMOSOL-M IN D5W Tier 4
NORMOSOL-R Tier 4
NORMOSOL-R IN D5W Tier 4
PLASMA-LYTE A Tier 4
PLASMA-LYTE-148 Tier 4
pot chloride inj 2meq/ml Tier 2 GC
potassium chloride SOLN 2meq/ml
Tier 2 GC
POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml
Tier 2 GC
potassium chloride in nacl Tier 2 GC
sodium chloride SOLN 3%, 5%
Tier 3
sodium chloride 0.45% Tier 3
sodium chloride inj 0.9% Tier 3
VITAMINS calcitriol (generic of ROCALTROL) CAPS
Tier 2 GC B/D
calcitriol inj Tier 4 B/D
calcitriol oral soln 1 mcg/ml (generic of ROCALTROL)
Tier 4 B/D
M-NATAL PLUS Tier 3
paricalcitol (generic of ZEMPLAR) CAPS 1mcg, 2mcg
Tier 4 B/D
paricalcitol CAPS 4mcg Tier 4 B/D
PNV FOLIC ACID + IRON MUL
Tier 3
PRENATAL Tier 3
PRENATAL PLUS Tier 3
PRENATAL PLUS LOW IRON
Tier 3
RAYALDEE Tier 5
TRICARE Tier 3
OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc Tier 3
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
46
Drug Name Drug Tier
Requirements/Limits
BLEPHAMIDE OINT Tier 4
neomycin-polymy-dexameth (generic of MAXITROL)
Tier 2 GC
neomycin-polymyxin-hc (ophth)
Tier 4
sulfacetamide sod-prednisolone
Tier 2 GC
TOBRADEX OINT Tier 3
TOBRADEX ST Tier 3
tobramycin-dexamethasone (generic of TOBRADEX)
Tier 4
ZYLET Tier 3
ANTI-INFECTIVES AZASITE Tier 4
bacitracin (ophthalmic) Tier 3
bacitracin-polymyxin b (ophth)
Tier 2 GC
BESIVANCE Tier 3
CILOXAN OINT Tier 3
ciprofloxacin hcl (ophth) (generic of CILOXAN)
Tier 2 GC
erythromycin (ophth) Tier 2 GC
gatifloxacin (ophth) (generic of ZYMAXID)
Tier 3
gentak Tier 2 GC
gentamicin sulfate soln (ophth)
Tier 2 GC
MOXEZA Tier 3
moxifloxacin hcl (ophth) (generic of MOXEZA) .5%
Tier 3
moxifloxacin hcl (ophth) (generic of VIGAMOX) .5%
Tier 3
NATACYN Tier 4
neomycin-bacitracin zn-polymyxin
Tier 3
neomycin-polymyxin-gramicidin
Tier 3
ofloxacin (ophth) (generic of OCUFLOX)
Tier 2 GC
polymyxin b-trimethoprim (generic of POLYTRIM)
Tier 2 GC
sulfacetamide sodium (ophth) OINT
Tier 3
Drug Name Drug Tier
Requirements/Limits
sulfacetamide sodium (ophth) (generic of BLEPH-10) SOLN
Tier 3
tobramycin (ophth) (generic of TOBREX)
Tier 2 GC
trifluridine Tier 3
ZIRGAN Tier 4
ANTI-INFLAMMATORIES ALREX Tier 3
bromfenac sodium (ophth) Tier 4
BROMSITE Tier 4
dexamethasone sodium phosphate (ophth)
Tier 3
diclofenac sodium (ophth) Tier 3
DUREZOL Tier 3
fluorometholone Tier 3
flurbiprofen sodium Tier 3
ILEVRO Tier 3
ketorolac tromethamine (ophth) (generic of ACULAR LS) .4%
Tier 3
ketorolac tromethamine (ophth) (generic of ACULAR) .5%
Tier 2 GC
LOTEMAX GEL; OINT Tier 3
loteprednol etabonate (generic of LOTEMAX)
Tier 3
prednisolone acetate (ophth) (generic of PRED FORTE)
Tier 3
PREDNISOLONE SODIUM PHOSPHATE (OPHTH)
Tier 3
PROLENSA Tier 3
ANTIALLERGICS azelastine drop 0.05% Tier 3
BEPREVE Tier 3
cromolyn sodium (ophth) Tier 1 GC
LASTACAFT Tier 4
olopatadine hcl 0.2% Tier 4
PAZEO Tier 3
ANTIGLAUCOMA ALPHAGAN P SOL 0.1% Tier 3
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
47
Drug Name Drug Tier
Requirements/Limits
AZOPT Tier 3
betaxolol hcl (ophth) Tier 3
BETOPTIC-S Tier 3
brimonidine sol 0.2% Tier 1 GC
brimonidine sol 0.15% (generic of ALPHAGAN P)
Tier 4
carteolol hcl (ophth) Tier 2 GC
COMBIGAN Tier 3
dorzolamide hcl (generic of TRUSOPT)
Tier 2 GC
dorzolamide hcl-timolol maleate (generic of COSOPT)
Tier 2 GC
latanoprost (generic of XALATAN) SOLN
Tier 2 GC
levobunolol hcl Tier 2 GC
LUMIGAN Tier 3
PHOSPHOLINE IODIDE Tier 4
pilocarpine hcl (generic of ISOPTO CARPINE) SOLN
Tier 3
RHOPRESSA Tier 3
SIMBRINZA Tier 3
timolol maleate (ophth) soln (generic of TIMOPTIC)
Tier 1 GC
timolol maleate gel (generic of TIMOPTIC-XE)
Tier 4
timolol maleate ophth soln 0.5% (once-daily) (generic of ISTALOL)
Tier 4
travoprost (generic of TRAVATAN Z)
Tier 4
MISCELLANEOUS ATROPINE SULFATE SOLN 1%
Tier 3
CYSTARAN Tier 5 NMO LA PA
proparacaine hcl (generic of ALCAINE) SOLN
Tier 3
RESTASIS QL (60 single use vials / 30 days)
Tier 3 QL
RESTASIS MULTIDOSE QL (1 bottle / 30 days)
Tier 3 QL
Drug Name Drug Tier
Requirements/Limits
RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA
QL (60 blisters / 30 days)
Tier 3 QL
BEVESPI AEROSPHERE QL (1 inhaler / 30 days)
Tier 3 QL
COMBIVENT RESPIMAT QL (2 inhalers / 30 days)
Tier 4 QL
ipratropium-albuterol nebu Tier 3 B/D
TRELEGY ELLIPTA QL (60 blisters / 30 days)
Tier 3 QL
ANTICHOLINERGICS ATROVENT HFA
QL (2 inhalers / 30 days)
Tier 4 QL
INCRUSE ELLIPTA QL (30 blisters / 30 days)
Tier 3 QL
ipratropium bromide SOLN Tier 2 GC B/D
ipratropium bromide (nasal) Tier 3
ANTIHISTAMINES azelastine spr 0.1% Tier 3
azelastine spr 0.15% Tier 3
cetirizine syrup Tier 2 GC
cyproheptadine hcl SYRP; TABS
PA if 70 years and older
Tier 3 PA
diphenhydramine hcl inj 50mg/ml
Tier 3
hydroxyzine hcl SYRP PA if 70 years and older
Tier 3 PA
hydroxyzine hcl TABS PA if 70 years and older
Tier 2 GC PA
hydroxyzine hcl inj PA if 70 years and older
Tier 4 PA
hydroxyzine pamoate (generic of VISTARIL) CAPS 25mg, 50mg
PA if 70 years and older
Tier 2 GC PA
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
48
Drug Name Drug Tier
Requirements/Limits
levocetirizine dihydrochloride SOLN
Tier 4
levocetirizine dihydrochloride TABS
Tier 2 GC
BETA AGONISTS albuterol sulfate AERS 108mcg/act
QL (2 inhalers / 30 days)
(generic of Ventolin HFA)
Tier 3 QL
albuterol sulfate (generic of PROAIR HFA) AERS 108mcg/act
QL (2 inhalers / 30 days)
(generic of Proair HFA)
Tier 3 QL
albuterol sulfate NEBU .63mg/3ml, 1.25mg/3ml, 2.5mg/0.5ml
Tier 3 B/D
albuterol sulfate NEBU .083%
Tier 2 GC B/D
albuterol sulfate SYRP Tier 2 GC
albuterol sulfate TABS Tier 4
albuterol sulfate TB12 Tier 3
levalbuterol hcl (generic of XOPENEX) NEBU 1.25mg/3ml
Tier 4 B/D
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (generic of XOPENEX CONCENTRATE)
Tier 4 B/D
levalbuterol tartrate hfa QL (2 inhalers / 30 days)
Tier 3 QL
SEREVENT DISKUS QL (60 inhalations / 30 days)
Tier 3 QL
terbutaline sulfate TABS Tier 4
VENTOLIN HFA QL (2 inhalers / 30 days)
Tier 3 QL
Drug Name Drug Tier
Requirements/Limits
LEUKOTRIENE MODULATORS montelukast sodium (generic of SINGULAIR) CHEW
Tier 2 GC
montelukast sodium (generic of SINGULAIR) PACK
Tier 4
montelukast sodium (generic of SINGULAIR) TABS
Tier 1 GC
zafirlukast (generic of ACCOLATE)
Tier 3
MAST CELL STABILIZERS cromolyn sod neb 20mg/2ml Tier 3 B/D
MISCELLANEOUS acetylcysteine SOLN 10%, 20%
Tier 3 B/D
ARALAST NP Tier 5 NMO LA PA
DALIRESP Tier 4
epinephrine (anaphylaxis) (generic of EPIPEN 2-PAK) .3mg/0.3ml
(generic of EpiPen)
Tier 3
epinephrine (anaphylaxis) (generic of EPIPEN-JR 2-PAK) .15mg/0.3ml
(generic of EpiPen)
Tier 3
epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml
(generic of Adrenaclick)
Tier 3
ESBRIET Tier 5 NMO PA
FASENRA Tier 5 NMO LA PA
FASENRA PEN Tier 5 NMO LA PA
KALYDECO Tier 5 NMO PA
NUCALA Tier 5 NMO LA PA
OFEV Tier 5 NMO PA
ORKAMBI Tier 5 NMO PA
PROLASTIN-C Tier 5 NMO LA PA
PULMOZYME Tier 5 NMO PA
SYMDEKO Tier 5 NMO LA PA
SYMJEPI Tier 4
THEO-24 Tier 4
theophylline Tier 4
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
49
Drug Name Drug Tier
Requirements/Limits
theophylline tab er 12hr 300 mg
Tier 4
theophylline tab er 12hr 450 mg
Tier 4
theophylline tab sr 24hr Tier 3
TRIKAFTA Tier 5 NMO LA PA
XOLAIR Tier 5 NMO LA PA
ZEMAIRA Tier 5 NMO LA PA
NASAL STEROIDS flunisolide (nasal)
QL (3 bottles / 30 days)
Tier 3 QL
fluticasone propionate (nasal)
QL (1 bottle / 30 days)
Tier 2 GC QL
STEROID INHALANTS ARNUITY ELLIPTA
QL (30 inhalations / 30 days)
Tier 3 QL
budesonide (inhalation) (generic of PULMICORT) .25mg/2ml, .5mg/2ml
Tier 4 B/D
FLOVENT DISKUS 50mcg/blist, 100mcg/blist
QL (120 inhalations / 30 days)
Tier 3 QL
FLOVENT DISKUS 250mcg/blist
QL (240 inhalations / 30 days)
Tier 3 QL
FLOVENT HFA QL (2 inhalers / 30 days)
Tier 3 QL
PULMICORT FLEXHALER QL (2 inhalers / 30 days)
Tier 4 QL
STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS
QL (60 inhalations / 30 days)
Tier 3 QL
ADVAIR HFA QL (1 inhaler / 30 days)
Tier 3 QL
Drug Name Drug Tier
Requirements/Limits
BREO ELLIPTA QL (60 blisters / 30 days)
Tier 3 QL
SYMBICORT QL (1 inhaler / 30 days)
Tier 3 QL
TOPICAL DERMATOLOGY, ACNE amnesteem Tier 4 PA
avita (generic of RETIN-A) CREA
QL (45 grams / 30 days)
Tier 4 QL PA
avita GEL QL (45 grams / 30 days)
Tier 4 QL PA
benzoyl peroxide-erythromycin (generic of BENZAMYCIN)
Tier 4
claravis Tier 4 PA
clindamycin phosphate (topical) (generic of CLEOCIN-T) GEL
QL (75 grams / 30 days)
Tier 4 QL
clindamycin phosphate (topical) (generic of CLEOCIN-T) LOTN
Tier 3
clindamycin phosphate (topical) SOLN
QL (60 mL / 30 days)
Tier 4 QL
ery pad 2% Tier 3
erythromycin (acne aid) (generic of ERYGEL) GEL
Tier 4
erythromycin (acne aid) SOLN
Tier 3
isotretinoin CAPS Tier 4 PA
myorisan Tier 4 PA
sulfacetamide sodium (acne) (generic of KLARON)
Tier 4
tretinoin (generic of RETIN-A) CREA
QL (45 grams / 30 days)
Tier 4 QL PA
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
50
Drug Name Drug Tier
Requirements/Limits
tretinoin (generic of RETIN-A) GEL .01%, .025%
QL (45 grams / 30 days)
Tier 4 QL PA
zenatane Tier 4 PA
DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) CREA
Tier 4
gentamicin sulfate (topical) OINT
Tier 3
mupirocin OINT QL (220 grams / 30 days)
Tier 2 GC QL
silver sulfadiazine (generic of SILVADENE) CREA
Tier 2 GC
ssd (generic of SILVADENE)
Tier 2 GC
SULFAMYLON CREA Tier 4
DERMATOLOGY, ANTIFUNGALS ciclopirox (generic of LOPROX) CREA
QL (90 grams / 30 days)
Tier 3 QL
ciclopirox (generic of LOPROX) SUSP
QL (60 mL / 30 days)
Tier 3 QL
clotrimazole (topical) CREA Tier 3
clotrimazole (topical) SOLN QL (30 mL / 30 days)
Tier 3 QL
clotrimazole w/ betamethasone CREA
Tier 3
ketoconazole cream QL (60 grams / 30 days)
Tier 3 QL
nyamyc QL (60 grams / 30 days)
Tier 3 QL
nystatin (topical) CREA; OINT
Tier 3
nystatin (topical) POWD QL (60 grams / 30 days)
Tier 3 QL
Drug Name Drug Tier
Requirements/Limits
nystop QL (60 grams / 30 days)
Tier 3 QL
DERMATOLOGY, ANTIPSORIATICS acitretin (generic of SORIATANE) 10mg, 25mg
Tier 4 PA
acitretin 17.5mg Tier 4 PA
calcipotriene (generic of DOVONEX) CREA
QL (120 grams / 30 days)
Tier 4 QL PA
calcipotriene OINT QL (120 grams / 30 days)
Tier 4 QL PA
calcipotriene SOLN QL (120 mL / 30 days)
Tier 4 QL PA
calcitrene QL (120 grams / 30 days)
Tier 4 QL PA
tazarotene (generic of TAZORAC) CREA
QL (60 grams / 30 days)
Tier 3 QL PA
TAZORAC CREA .05% QL (60 grams / 30 days)
Tier 4 QL PA
DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo Tier 2 GC
selenium sulfide LOTN Tier 2 GC
DERMATOLOGY, CORTICOSTEROIDS ala-cort cre 1% Tier 1 GC
ala-cort cre 2.5% Tier 2 GC
alclometasone dipropionate CREA
Tier 4
alclometasone dipropionate OINT
Tier 3
betamethasone dipropionate (topical) CREA; LOTN
Tier 3
betamethasone dipropionate (topical) OINT
Tier 4
betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA
Tier 3
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
51
Drug Name Drug Tier
Requirements/Limits
betamethasone dipropionate augmented GEL; LOTN
Tier 4
betamethasone dipropionate augmented (generic of DIPROLENE) OINT
Tier 4
betamethasone valerate CREA; LOTN; OINT
Tier 3
ENSTILAR QL (120 grams / 30 days)
Tier 4 QL PA
fluocinolone acetonide CREA .01%
Tier 3
fluocinolone acetonide (generic of SYNALAR) CREA .025%
Tier 3
fluocinolone acetonide (generic of DERMA-SMOOTHE/FS BODY) OIL
Tier 4
fluocinolone acetonide (generic of SYNALAR) OINT
Tier 3
fluocinolone acetonide (generic of SYNALAR) SOLN
QL (90 mL / 30 days)
Tier 4 QL
fluocinolone acetonide oil body (generic of DERMA-SMOOTHE/FS SCALP)
Tier 4
fluocinonide CREA .05% QL (120 grams / 30 days)
Tier 4 QL
fluocinonide GEL QL (60 grams / 30 days)
Tier 4 QL
fluocinonide OINT QL (60 grams / 30 days)
Tier 4 QL
fluocinonide SOLN QL (60 mL / 30 days)
Tier 4 QL
fluocinonide emulsified base QL (120 grams / 30 days)
Tier 4 QL
fluticasone propionate CREA; OINT
Tier 3
Drug Name Drug Tier
Requirements/Limits
halobetasol propionate CREA; OINT
QL (50 grams / 30 days)
Tier 4 QL
hydrocortisone (topical) cream 1%
Tier 1 GC
hydrocortisone (topical) cream 2.5%
Tier 2 GC
hydrocortisone (topical) lotion 2.5%
Tier 3
hydrocortisone (topical) oint 2.5%
Tier 2 GC
hydrocortisone butyrate cream 0.1% (generic of LOCOID)
QL (45 grams / 30 days)
Tier 4 QL
hydrocortisone butyrate oint 0.1%
QL (45 grams / 30 days)
Tier 4 QL
mometasone furoate CREA; OINT; SOLN
Tier 3
TEXACORT SOLN 2.5% Tier 4
triamcinolone acetonide (topical) CREA .1%
QL (454 grams / 30 days)
Tier 2 GC QL
triamcinolone acetonide (topical) CREA .025%, .5%
Tier 2 GC
triamcinolone acetonide (topical) LOTN
Tier 3
triamcinolone acetonide (topical) OINT .025%, .1%, .5%
Tier 2 GC
DERMATOLOGY, LOCAL ANESTHETICS glydo
QL (30 mL / 30 days) Tier 3 QL PA
lidocaine (generic of LIDODERM) PTCH 5%
QL (3 patches / 1 day)
Tier 4 QL PA
lidocaine hcl GEL QL (30 mL / 30 days)
Tier 3 QL PA
lidocaine hcl SOLN 4% QL (50 mL / 30 days)
Tier 3 QL PA
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
52
Drug Name Drug Tier
Requirements/Limits
lidocaine oint 5% QL (50 grams / 30 days)
Tier 4 QL PA
lidocaine-prilocaine QL (30 grams / 30 days)
Tier 3 QL PA
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA Tier 2 GC
ammonium lactate LOTN Tier 3
diclofenac sodium (topical) 1% gel (generic of VOLTAREN)
QL (1000 grams / 30 days)
Tier 3 QL PA
fluorouracil (topical) (generic of EFUDEX) CREA 5%
QL (40 grams / 30 days)
Tier 4 QL
fluorouracil (topical) SOLN QL (10 mL / 30 days)
Tier 3 QL
imiquimod (generic of ALDARA) CREA 5%
QL (24 packets / 30 days)
Tier 3 QL
metronidazole (topical) (generic of METROCREAM) CREA
Tier 4
metronidazole (topical) (generic of METROLOTION) LOTN
Tier 4
metronidazole gel 0.75% Tier 4
PANRETIN QL (60 grams / 30 days)
Tier 5 QL
PICATO .05% QL (2 tubes / 30 days)
Tier 4 QL
PICATO .015% QL (3 tubes / 30 days)
Tier 4 QL
podofilox SOLN Tier 3
procto-med hc (generic of ANUSOL-HC)
Tier 3
procto-pak (generic of PROCTOCORT)
Tier 3
Drug Name Drug Tier
Requirements/Limits
proctosol hc cre 2.5% (generic of ANUSOL-HC)
Tier 3
proctozone-hc (generic of ANUSOL-HC)
Tier 3
RECTIV QL (30 grams / 30 days)
Tier 4 QL
rosadan cre 0.75% (generic of METROCREAM)
Tier 4
tacrolimus (topical) (generic of PROTOPIC)
QL (100 grams / 30 days)
Tier 4 QL
TARGRETIN GEL QL (60 grams / 30 days)
Tier 5 QL NMO PA
VALCHLOR QL (60 grams / 30 days)
Tier 5 QL NMO LA PA
DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion Tier 4
permethrin cre 5% (generic of ELIMITE)
Tier 3
DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% Tier 2 GC
REGRANEX QL (30 grams / 30 days)
Tier 5 QL PA
SANTYL Tier 4
sodium chlor sol 0.9% irr Tier 2 GC
water for irrigation, sterile Tier 2 GC
MOUTH/THROAT/DENTAL AGENTS cevimeline hcl (generic of EVOXAC)
Tier 4
chlorhexidine gluconate (mouth-throat) (generic of PERIDEX)
Tier 1 GC
clotrimazole LOZG Tier 4
lidocaine hcl (mouth-throat) Tier 2 GC
nystatin (mouth-throat) Tier 3
paroex sol 0.12% (generic of PERIDEX)
Tier 1 GC
Blue MedicareRx Premier 2020 Comprehensive Drug List
You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020
53
Drug Name Drug Tier
Requirements/Limits
periogard (generic of PERIDEX)
Tier 1 GC
pilocarpine hcl (oral) (generic of SALAGEN)
Tier 4
triamcinolone acetonide (mouth)
Tier 3
OTIC acetic acid (otic) Tier 3
CIPRODEX Tier 3
flac (generic of DERMOTIC) Tier 4
fluocinolone acetonide (otic) (generic of DERMOTIC)
Tier 4
neomycin-polymyxin-hc (otic)
Tier 3
ofloxacin (otic) Tier 4
Blue MedicareRx Premier 2020 Comprehensive Drug List
54
Index A abacavir sulfate ................... 6
abacavir sulfate-lamivudine ........................................... 6
abacavir sulfate-lamivudine-zidovudine ... 7
ABELCET ............................. 5
ABILIFY
see aripiprazole tab ...... 24
ABILIFY MAINTENA ........ 24
abiraterone acetate .......... 11
ABRAXANE ....................... 10
acamprosate calcium ....... 30
acarbose ............................ 31
ACCOLATE
see zafirlukast ............... 48
ACCUPRIL
see quinapril hcl ............ 14
ACCURETIC
see quinapril-hydrochlorothiazide .. 13
acebutolol hcl .................... 16
acetaminophen w/ codeine 300-15mg ......................... 1
acetaminophen w/ codeine 300-30mg ......................... 1
acetaminophen w/ codeine 300-60mg ......................... 1
acetaminophen w/ codeine soln.................................... 1
acetazolamide ................... 17
acetic acid .......................... 52
acetic acid (otic) ................ 53
acetylcysteine .................... 48
acitretin ............................... 50
ACTHIB .............................. 43
ACTIGALL
see ursodiol ................... 40
ACTIMMUNE ..................... 43
ACTIQ
see fentanyl citrate ......... 2
ACTONEL .......................... 33
see risedronate sodium ..................................... 33
ACTOS see pioglitazone hcl ...... 32
ACULAR
see ketorolac tromethamine (ophth) .................................... 46
ACULAR LS
see ketorolac tromethamine (ophth) .................................... 46
acyclovir ............................... 7
acyclovir sodium ................. 7
ADACEL ............................ 43
ADCIRCA .......................... 18
see alyq ......................... 18
see tadalafil (pulmonary hypertension) ............ 18
ADDERALL
see amphetamine-dextroamphetamine tab 10 mg .................. 27
see amphetamine-dextroamphetamine tab 12.5 mg ............... 27
see amphetamine-dextroamphetamine tab 15 mg .................. 27
see amphetamine-dextroamphetamine tab 20 mg .................. 27
see amphetamine-dextroamphetamine tab 30 mg .................. 27
see amphetamine-dextroamphetamine tab 5 mg ..................... 27
see amphetamine-dextroamphetamine tab 7.5 mg ................. 27
ADDERALL XR
see amphetamine-dextroamphetamine cap sr 24hr 10 mg .... 26
see amphetamine-dextroamphetamine cap sr 24hr 15 mg .... 26
see amphetamine-dextroamphetamine cap sr 24hr 20 mg .... 26
see amphetamine-dextroamphetamine cap sr 24hr 25 mg .... 26
see amphetamine-dextroamphetamine cap sr 24hr 30 mg .... 27
see amphetamine-dextroamphetamine cap sr 24hr 5 mg ....... 26
adefovir dipivoxil ................. 7
ADEMPAS ......................... 18
adriamycin ......................... 10
adrucil inj ............................ 10
ADVAIR DISKUS .............. 49
ADVAIR HFA ..................... 49
AFINITOR .......................... 11
see everolimus .............. 12
AFINITOR DISPERZ ........ 11
AGGRENOX
see aspirin-dipyridamole ..................................... 42
AGRYLIN
see anagrelide hcl ........ 41
AIMOVIG ............................ 28
ala-cort cre 1% .................. 50
ala-cort cre 2.5% .............. 50
albendazole ......................... 4
ALBENZA
see albendazole .............. 4
albuterol sulfate ................ 48
ALCAINE
see proparacaine hcl .... 47
alclometasone dipropionate ......................................... 50
ALDACTAZIDE
see spironolactone & hydrochlorothiazide .. 17
ALDACTONE
see spironolactone ....... 14
ALDARA
see imiquimod ............... 52
ALDURAZYME ................. 35
ALECENSA ....................... 11
alendronate sodium tab 10 mg ................................... 33
alendronate sodium tab 35 mg ................................... 33
Blue MedicareRx Premier 2020 Comprehensive Drug List
55
alendronate sodium tab 40 mg ................................... 33
alendronate sodium tab 5 mg ................................... 33
alendronate sodium tab 70 mg ................................... 33
alfuzosin hcl ....................... 40
ALIMTA .............................. 10
ALINIA .................................. 4
aliskiren fumarate ............. 17
allopurinol tab ...................... 1
alosetron hcl ...................... 39
ALPHAGAN P see brimonidine sol
0.15% ......................... 47
ALPHAGAN P SOL 0.1% 46
alprazolam tab 0.25mg .... 18
alprazolam tab 0.5mg ...... 18
alprazolam tab 1mg .......... 18
alprazolam tab 2 mg ......... 18
ALREX ................................ 46
ALTACE
see ramipril .................... 14
altavera tab ........................ 33
ALUNBRIG ........................ 12
alyacen 1/35 ...................... 33
alyq...................................... 18
amantadine hcl .................. 23
AMARYL
see glimepiride .............. 31
AMBIEN
see zolpidem tartrate ... 28
AMBISOME ......................... 5
ambrisentan ....................... 18
AMERGE
see naratriptan hcl ........ 28
amikacin sulfate .................. 4
amiloride & hydrochlorothiazide ...... 17
amiloride hcl ...................... 17
AMINOSYN II INJ 10% .... 44
AMINOSYN-PF 7% .......... 44
AMINOSYN-PF INJ 10% . 44
amiodarone hcl soln ......... 14
amiodarone tab 100mg .... 14
amiodarone tab 200mg .... 14
amiodarone tab 400mg .... 14
AMITIZA CAP 24MCG ..... 39
AMITIZA CAP 8MCG ...... 39
amitriptyline hcl ................. 22
amlodipine besylate ......... 16
amlodipine besylate-benazepril hcl cap 10-20 mg ................................... 13
amlodipine besylate-benazepril hcl cap 10-40 mg ................................... 13
amlodipine besylate-benazepril hcl cap 2.5-10 mg ................................... 13
amlodipine besylate-benazepril hcl cap 5-10 mg ................................... 13
amlodipine besylate-benazepril hcl cap 5-20 mg ................................... 13
amlodipine besylate-benazepril hcl cap 5-40 mg ................................... 13
amlodipine besylate-olmesartan medoxomil 14
amlodipine besylate-valsartan tab ................. 14
amlodipine-valsartan-hydrochlorothiazide tab 14
ammonium lactate ............ 52
amnesteem ....................... 49
amoxapine ......................... 22
amoxicillin ............................ 9
amoxicillin & pot clavulanate 200/5ml susr .......................................... 9
amoxicillin & pot clavulanate 200-28.5 chw tabs ................................... 9
amoxicillin & pot clavulanate 250/5ml susr .......................................... 9
amoxicillin & pot clavulanate 250-125 tabs .......................................... 9
amoxicillin & pot clavulanate 400/5ml susr .......................................... 9
amoxicillin & pot clavulanate 400-57 chw tabs ................................... 9
amoxicillin & pot clavulanate 500-125 tabs ........................................... 9
amoxicillin & pot clavulanate 600/5ml susr ........................................... 9
amoxicillin & pot clavulanate 875-125 tabs ........................................... 9
amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs .......................... 9
amphetamine-dextroamphetamine cap sr 24hr 10 mg ................ 26
amphetamine-dextroamphetamine cap sr 24hr 15 mg ................ 26
amphetamine-dextroamphetamine cap sr 24hr 20 mg ................ 26
amphetamine-dextroamphetamine cap sr 24hr 25 mg ................ 26
amphetamine-dextroamphetamine cap sr 24hr 30 mg ................ 27
amphetamine-dextroamphetamine cap sr 24hr 5 mg .................. 26
amphetamine-dextroamphetamine tab 10 mg .............................. 27
amphetamine-dextroamphetamine tab 12.5 mg .......................... 27
amphetamine-dextroamphetamine tab 15 mg .............................. 27
amphetamine-dextroamphetamine tab 20 mg .............................. 27
amphetamine-dextroamphetamine tab 30 mg .............................. 27
Blue MedicareRx Premier 2020 Comprehensive Drug List
56
amphetamine-dextroamphetamine tab 5 mg ................................... 27
amphetamine-dextroamphetamine tab 7.5 mg ............................. 27
amphotericin b ..................... 5
ampicillin & sulbactam sodium .............................. 9
ampicillin cap 500mg ......... 9
ampicillin inj ......................... 9
ampicillin sodium ................ 9
AMPYRA
see dalfampridine ......... 29
ANADROL-50 .................... 30
ANAFRANIL
see clomipramine hcl ... 22
anagrelide hcl .................... 41
ANAPROX DS
see naproxen sodium ..... 1
anastrozole ........................ 11
ANCOBON
see flucytosine ................ 5
ANDRODERM ................... 30
ANDROGEL
see testosterone ........... 30
ANORO ELLIPTA ............. 47
ANTABUSE
see disulfiram ................ 30
ANUSOL-HC
see procto-med hc ........ 52
see proctosol hc cre 2.5% ............................ 52
see proctozone-hc ........ 52
APOKYN ............................ 23
aprepitant ........................... 38
aprepitant pak 80mg & 125mg ............................. 38
apri ...................................... 33
APTIOM.............................. 19
APTIVUS .............................. 6
ARALAST NP .................... 48
aranelle ............................... 33
ARAVA
see leflunomide ............. 42
ARCALYST ........................ 43
ARICEPT
see donepezil hydrochloride ............ 21
ARIMIDEX
see anastrozole ............ 11
aripiprazole odt ................. 24
aripiprazole oral solution 1 mg/ml ............................. 24
aripiprazole tab ................. 24
ARISTADA ........................ 24
ARISTADA INITIO ........... 24
ARIXTRA
see fondaparinux sodium .................................... 41
armodafinil ......................... 30
ARNUITY ELLIPTA .......... 49
AROMASIN
see exemestane ........... 11
aspirin-dipyridamole ........ 42
atazanavir sulfate ............... 6
atenolol .............................. 16
atenolol & chlorthalidone 16
ATIVAN
see lorazepam .............. 19
atomoxetine hcl ................ 27
atorvastatin calcium ......... 15
atovaquone ......................... 4
atovaquone-proguanil hcl . 5
ATRIPLA .............................. 7
ATROPINE SULFATE ..... 47
ATROVENT HFA ............. 47
aubra .................................. 33
AUGMENTIN
see amoxicillin & pot clavulanate 250/5ml susr ............................... 9
see amoxicillin & pot clavulanate 500-125 tabs ............................... 9
AURYXIA ........................... 37
AUSTEDO ......................... 29
AVALIDE
see irbesartan-hydrochlorothiazide .. 14
AVAPRO
see irbesartan ............... 14
AVASTIN ........................... 10
aviane ................................ 33
avita .................................... 49
AVODART
see dutasteride ............. 40
AYGESTIN
see norethindrone acetate ........................ 38
AYVAKIT ............................ 12
azacitidine .......................... 10
AZACTAM
see aztreonam ................ 4
AZASITE ............................ 46
azathioprine ....................... 43
azelastine drop 0.05% ..... 46
azelastine spr 0.1% .......... 47
azelastine spr 0.15% ........ 47
AZILECT
see rasagiline mesylate ..................................... 24
azithromycin ........................ 8
AZOPT ............................... 47
AZOR
see amlodipine besylate-olmesartan medoxomil ..................................... 14
aztreonam ............................ 4
AZULFIDINE
see sulfasalazine .......... 39
AZULFIDINE EN-TABS
see sulfasalazine ec ..... 39
B bacitracin (ophthalmic) .... 46
bacitracin-polymyxin b (ophth) ............................ 46
bacitracin-poly-neomycin-hc .................................... 45
baclofen .............................. 29
BACTRIM
see sulfamethoxazole-trimethoprim tab 400-80mg ............................. 5
BACTRIM DS
see sulfamethoxazole-trimethop ds ................. 5
balsalazide disodium ........ 39
BALVERSA ........................ 12
balziva ................................ 33
BANZEL SUS 40MG/ML . 19
BANZEL TAB 200MG ...... 19
BANZEL TAB 400MG ...... 19
Blue MedicareRx Premier 2020 Comprehensive Drug List
57
BARACLUDE ...................... 7
see entecavir ................... 7
BASAGLAR KWIKPEN .... 30
BCG VACCINE ................. 43
BD ALCOHOL SWABS ... 30
BD ULTRAFINE INSULIN SYRINGE ....................... 30
BD ULTRAFINE/NANO PEN NEEDLES ............. 30
bekyree ............................... 33
BELSOMRA ....................... 28
benazepril & hydrochlorothiazide ...... 13
benazepril hcl .................... 14
BENDEKA .......................... 10
BENICAR
see olmesartan medoxomil ................. 14
BENICAR HCT
see olmesartan medoxomil-hydrochlorothiazide .. 14
BENLYSTA ........................ 43
BENZAMYCIN
see benzoyl peroxide-erythromycin .............. 49
benzoyl peroxide-erythromycin .................. 49
benztropine mesylate inj .. 23
benztropine mesylate tab 0.5mg .............................. 23
benztropine mesylate tab 1mg ................................. 23
benztropine mesylate tab 2mg ................................. 23
BEPREVE .......................... 46
BERINERT ......................... 41
BESIVANCE ...................... 46
betamethasone dipropionate (topical) ... 50
betamethasone dipropionate augmented ................................... 50, 51
betamethasone valerate .. 51
BETAPACE
see sorine ...................... 15
see sotalol hcl ............... 15
BETAPACE AF
see sotalol hcl (afib/afl) 15
BETASERON .................... 29
betaxolol hcl (ophth) ........ 47
bethanechol chloride ....... 40
BETOPTIC-S .................... 47
BEVESPI AEROSPHERE ........................................ 47
bexarotene ........................ 13
BEXSERO ......................... 43
BIAXIN XL
see clarithromycin er ..... 8
bicalutamide ...................... 11
BICILLIN L-A ....................... 9
BIKTARVY .......................... 7
BILTRICIDE
see praziquantel ............. 5
bisoprolol & hydrochlorothiazide ...... 16
bisoprolol fumarate .......... 16
BIVIGAM ............................ 43
BLEPH-10
see sulfacetamide sodium (ophth) .......... 46
BLEPHAMIDE .................. 46
blisovi fe 1.5/30 ................ 33
BONIVA
see ibandronate sodium tabs ............................. 33
BOOSTRIX ........................ 43
BORTEZOMIB .................. 10
bosentan ............................ 18
BOSULIF ........................... 12
BRAFTOVI ........................ 12
BREO ELLIPTA ................ 49
briellyn ................................ 33
BRILINTA .......................... 42
brimonidine sol 0.15% ..... 47
brimonidine sol 0.2% ....... 47
BRIVIACT INJ 50MG/5ML ........................................ 19
BRIVIACT SOL 10MG/ML ........................................ 19
BRIVIACT TAB 100MG ... 19
BRIVIACT TAB 10MG ..... 19
BRIVIACT TAB 25MG ..... 19
BRIVIACT TAB 50MG ..... 19
BRIVIACT TAB 75MG ..... 19
bromfenac sodium (ophth) ......................................... 46
bromocriptine mesylate ... 23
BROMSITE ........................ 46
BRUKINSA ........................ 12
budesonide (inhalation) ... 49
budesonide ec ................... 39
bumetanide inj 0.25/ml .... 17
bumetanide tab ................. 17
BUMEX
see bumetanide tab ...... 17
BUPHENYL
see sodium phenylbutyrate .......... 36
buprenorphine hcl ............. 30
buprenorphine hcl-naloxone hcl dihydrate 12-3mg ........................... 30
buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg .............................. 30
buprenorphine hcl-naloxone hcl dihydrate 4-1mg ................................. 30
buprenorphine hcl-naloxone hcl dihydrate 8-2mg ................................. 30
buprenorphine hcl-naloxone hcl sl .............. 30
bupropion hcl ..................... 22
bupropion hcl (smoking deterrent) ....................... 30
buspirone hcl ............... 18, 19
butorphanol tartrate ............ 1
BYDUREON BCISE ......... 30
BYDUREON PEN ............. 30
BYETTA ............................. 30
BYSTOLIC ......................... 16
C cabergoline ........................ 37
CABOMETYX .................... 12
CAFERGOT
see ergotamine w/ caffeine ....................... 28
CALAN SR
see verapamil hcl .......... 17
see verapamil tab er .... 17
calcipotriene ...................... 50
Blue MedicareRx Premier 2020 Comprehensive Drug List
58
calcitonin (salmon) ........... 37
calcitrene ............................ 50
calcitriol .............................. 45
calcitriol inj ......................... 45
calcitriol oral soln 1 mcg/ml ......................................... 45
calcium acetate (phosphate binder) ............................ 37
CALQUENCE .................... 12
camila ................................. 33
CAMPTOSAR
see irinotecan hcl .......... 13
CANASA
see mesalamine ............ 39
CANCIDAS
see caspofungin acetate 5
CAPLYTA ........................... 24
CAPRELSA ....................... 12
captopril .............................. 14
captopril & hydrochlorothiazide ...... 13
CARAFATE
see sucralfate ................ 40
CARBAGLU ....................... 35
carbamazepine ................. 19
CARBATROL
see carbamazepine ...... 19
carbidopa/levodopa/entacapone .......................... 23, 24
carbidopa-levodopa .......... 23
carboplatin ......................... 13
CARDIZEM
see diltiazem hcl ........... 16
CARDIZEM CD
see cartia xt ................... 16
see diltiazem cap 240mg cd ................................. 16
see diltiazem cap 360mg cd ................................. 16
see diltiazem hcl coated beads .......................... 16
see diltiazem hcl coated beads cap sr 24hr ..... 16
see diltiazem hcl extended release beads cap sr .............. 16
CARDURA
see doxazosin mesylate .................................... 14
CARNITOR
see levocarnitine (metabolic modifiers) 36
carteolol hcl (ophth) ......... 47
cartia xt .............................. 16
carvedilol ........................... 16
CASODEX
see bicalutamide .......... 11
caspofungin acetate .......... 5
CATAPRES
see clonidine hcl ........... 17
CATAPRES-TTS-1
see clonidine hcl ptwk . 17
CATAPRES-TTS-2
see clonidine hcl ptwk . 17
CATAPRES-TTS-3
see clonidine hcl ptwk . 18
CAYSTON ........................... 4
caziant pak ........................ 33
cefaclor ................................ 8
CEFACLOR ER TAB 500MG ............................. 8
cefadroxil ............................. 8
CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ............. 8
cefazolin inj ......................... 8
cefazolin sodium ................ 8
CEFAZOLIN SODIUM 1 GM/50ML ......................... 8
cefdinir ................................. 8
cefepime for inj ................... 8
cefixime ................................ 8
cefoxitin for inj ..................... 8
cefpodoxime proxetil .......... 8
cefprozil ............................... 8
ceftazidime .......................... 8
CEFTAZIDIME/DEXTROSE ........................................ 8
ceftriaxone sodium ............. 8
cefuroxime axetil ................ 8
cefuroxime sodium ............. 8
CELEBREX
see celecoxib .................. 1
celecoxib .............................. 1
CELEXA
see citalopram hydrobromide ............ 22
CELLCEPT
see mycophenolate mofetil ......................... 43
CELONTIN ........................ 19
cephalexin ............................ 8
CERDELGA ....................... 35
CEREZYME ...................... 35
cetirizine syrup .................. 47
cevimeline hcl .................... 52
CHANTIX ........................... 30
CHANTIX CONTINUING MONTH .......................... 30
CHANTIX STARTER PACK ......................................... 30
CHEMET ............................ 33
chlorhexidine gluconate (mouth-throat) ............... 52
chloroquine phosphate ...... 5
chlorothiazide .................... 17
chlorpromazine hcl ........... 24
CHLORPROMAZINE INJ 24
chlorthalidone .................... 17
cholestyramine .................. 15
cholestyramine light pack 15
cholestyramine light powd ......................................... 15
ciclopirox ............................ 50
cilostazol ............................ 41
CILOXAN ........................... 46
see ciprofloxacin hcl (ophth) ........................ 46
CIMDUO .............................. 7
cinacalcet hcl ..................... 37
CIPRO .................................. 8
see ciprofloxacin hcl tab 8
CIPRODEX ........................ 53
ciprofloxacin hcl (ophth) .. 46
ciprofloxacin hcl tab ............ 8
ciprofloxacin in d5w ............ 9
cisplatin .............................. 13
citalopram hydrobromide . 22
claravis ............................... 49
clarithromycin ...................... 8
clarithromycin er ................. 8
clarithromycin for susp ....... 8
CLEOCIN
Blue MedicareRx Premier 2020 Comprehensive Drug List
59
see clindamycin cap 300 mg ................................. 4
see clindamycin cap 75mg ............................. 4
see clindamycin hcl cap 150 mg ......................... 4
see clindamycin phosphate vaginal .... 41
CLEOCIN PEDIATRIC GRANULE
see clindamycin soln 75mg/5ml ..................... 4
CLEOCIN PHOSPHATE
see clindamycin phosphate inj ............... 4
CLEOCIN-T
see clindamycin phosphate (topical) ... 49
CLIMARA
see estradiol .................. 36
clindamycin cap 300 mg .... 4
clindamycin cap 75mg ....... 4
clindamycin hcl cap 150 mg ........................................... 4
clindamycin phosphate (topical) ........................... 49
clindamycin phosphate in d5w.................................... 4
CLINDAMYCIN PHOSPHATE IN NACL . 4
clindamycin phosphate inj . 4
clindamycin phosphate vaginal ............................ 41
clindamycin soln 75mg/5ml ........................................... 4
CLINIMIX 4.25%/DEXTROSE 5% 44
CLINIMIX 5%/DEXTROSE 15% ................................. 44
CLINIMIX 5%/DEXTROSE 20% ................................. 44
CLINIMIX INJ 4.25/D10 ... 44
clinisol sf 15% ................... 44
CLINOLIPID ....................... 44
clobazam ............................ 19
clomipramine hcl ............... 22
clonazepam ....................... 19
clonidine hcl ....................... 17
clonidine hcl ptwk ....... 17, 18
clopidogrel tab 75mg ....... 42
clorazepate dipotassium . 19
clotrimazole ....................... 52
clotrimazole (topical) ........ 50
clotrimazole w/ betamethasone ............. 50
clovique .............................. 33
clozapine odt ..................... 24
clozapine tab 100mg ....... 24
clozapine tab 200mg ....... 24
clozapine tab 25mg .......... 24
clozapine tab 50mg .......... 24
CLOZARIL
see clozapine tab 100mg .................................... 24
see clozapine tab 200mg .................................... 24
see clozapine tab 25mg .................................... 24
see clozapine tab 50mg .................................... 24
COARTEM .......................... 5
COGENTIN
see benztropine mesylate inj ............... 23
COLAZAL
see balsalazide disodium .................................... 39
colchicine w/ probenecid ... 1
COLCRYS ........................... 1
colesevelam hcl ................ 15
COLESTID
see colestipol hcl gran . 15
see colestipol hcl pack 15
see colestipol hcl tabs . 15
colestipol hcl gran ............ 15
colestipol hcl pack ............ 15
colestipol hcl tabs ............. 15
colistimethate sodium ........ 4
colocort .............................. 39
COLY-MYCIN M
see colistimethate sodium ......................... 4
COMBIGAN ...................... 47
COMBIVENT RESPIMAT 47
COMBIVIR
see lamivudine-zidovudine .................... 7
COMETRIQ ....................... 12
COMPLERA ........................ 7
compro supp ...................... 38
COMTAN
see entacapone ............ 24
constulose .......................... 39
COPAXONE
see glatiramer acetate 20mg/ml ..................... 29
see glatiramer acetate 40mg/ml ..................... 29
see glatopa .................... 29
COPIKTRA ........................ 12
COREG
see carvedilol ................ 16
CORGARD
see nadolol .................... 16
CORLANOR ...................... 18
CORTEF
see hydrocortisone ....... 36
CORTENEMA
see colocort ................... 39
see hydrocortisone (enema) ...................... 39
cortisone acetate .............. 36
COSOPT
see dorzolamide hcl-timolol maleate .......... 47
COTELLIC ......................... 12
COUMADIN ....................... 41
see jantoven .................. 41
see warfarin sodium ..... 41
COZAAR
see losartan potassium 14
CREON .............................. 40
CRESTOR
see rosuvastatin calcium ..................................... 15
CRIXIVAN ............................ 6
cromolyn sod neb 20mg/2ml ....................... 48
cromolyn sodium (mastocytosis) ............... 39
cromolyn sodium (ophth) . 46
cryselle-28 ......................... 33
CUBICIN
Blue MedicareRx Premier 2020 Comprehensive Drug List
60
see daptomycin ............... 4
cyclafem 1/35 .................... 33
cyclafem 7/7/7 ................... 33
cyclobenzaprine hcl .......... 29
cyclophosphamide ............ 10
cycloserine ........................... 7
cyclosporine ....................... 43
cyclosporine modified (for microemulsion) .............. 43
CYKLOKAPRON
see tranexamic acid ..... 42
CYMBALTA
see duloxetine hcl ......... 22
cyproheptadine hcl ........... 47
cyred tab ............................ 33
CYSTADANE .................... 36
CYSTAGON ...................... 36
CYSTARAN ....................... 47
cytarabine .......................... 10
CYTOMEL
see liothyronine sodium ..................................... 38
CYTOTEC
see misoprostol ............. 39
CYTOVENE
see ganciclovir sodium .. 7
D D.H.E. 45
see dihydroergotamine mesylate inj 1 mg/ml 28
dalfampridine ..................... 29
DALIRESP ......................... 48
danazol ............................... 35
DANTRIUM
see dantrolene sodium 29
dantrolene sodium ............ 29
dapsone ............................... 4
DAPTACEL ........................ 43
daptomycin .......................... 4
DAPTOMYCIN
see daptomycin ............... 4
dasetta 1/35 ....................... 34
dasetta 7/7/7 ...................... 34
DAURISMO ....................... 10
DDAVP
see desmopressin acetate spray ............. 38
see desmopressin acetate tabs .............. 38
see desmopressin inj 4mcg/ml ..................... 38
deblitane ............................ 34
deferasirox ........................ 33
DELESTROGEN .............. 36
see estradiol valerate inj .................................... 36
DELSTRIGO ....................... 7
DELZICOL
see mesalamine ........... 39
DEMSER ........................... 18
DEPAKOTE
see divalproex sodium 19
DEPAKOTE ER
see divalproex sodium 19
DEPAKOTE SPRINKLES
see divalproex sodium 19
DEPEN TITRATABS
see penicillamine .......... 33
DEPO-MEDROL
see methylprednisolone acetate ....................... 36
DEPO-PROVERA CONTRACEPTIV
see medroxyprogesterone acetate (contraceptive) .................................... 34
DEPO-PROVERA INJ 400/ML ........................... 11
DEPO-TESTOSTERONE see testosterone
cypionate ................... 30
DERMA-SMOOTHE/FS BODY
see fluocinolone acetonide ................... 51
DERMA-SMOOTHE/FS SCALP
see fluocinolone acetonide oil body .... 51
DERMOTIC
see flac .......................... 53
see fluocinolone acetonide (otic) ......... 53
DESCOVY ........................... 7
desipramine hcl ................. 22
desmopressin acetate spray ............................... 38
desmopressin acetate spray refrigerated ......... 38
desmopressin acetate tabs ......................................... 38
desmopressin inj 4mcg/ml ......................................... 38
desogestrel & ethinyl estradiol .......................... 34
desogestrel-ethinyl estradiol (biphasic) ....... 34
desvenlafaxine succinate 22
DETROL
see tolterodine tartrate . 40
DETROL LA
see tolterodine tartrate . 40
dexamethasone ................ 36
DEXAMETHASONE ........ 36
DEXAMETHASONE SODIUM PHOS
see dexamethasone sodium phosphate .... 36
dexamethasone sodium phosphate ...................... 36
dexamethasone sodium phosphate (ophth) ........ 46
DEXILANT ......................... 40
dexmethylphenidate hcl ... 27
dextrose 10% flex contain ......................................... 45
DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% ................................ 45
dextrose 10%/nacl 0.45%45
dextrose 2.5%/nacl 0.45% ......................................... 45
dextrose 5% ...................... 45
DEXTROSE 5% /ELECTROLYTE ........... 45
dextrose 5%/nacl 0.2% .... 45
dextrose 5%/nacl 0.225%45
DEXTROSE 5%/NACL 0.3% ................................ 45
dextrose 5%/nacl 0.45% .. 45
dextrose 5%/nacl 0.9% .... 45
Blue MedicareRx Premier 2020 Comprehensive Drug List
61
dextrose 5%/potassium chl ......................................... 45
dextrose 50% .................... 45
dextrose in lactated ringers ......................................... 45
dextrose inj 70% ............... 45
DIASTAT ACUDIAL ......... 19
DIASTAT PEDIATRIC ..... 19
diazepam ........................... 19
diazepam gel ..................... 19
diazepam inj ...................... 19
diazepam intensol ............. 19
diazepam oral soln 1 mg/ml ......................................... 19
diazoxide ............................ 37
diclofenac potassium ......... 1
diclofenac sodium ............... 1
diclofenac sodium (ophth) ......................................... 46
diclofenac sodium (topical) 1% gel ............................. 52
dicloxacillin sodium ............. 9
dicyclomine hcl cap 10mg ......................................... 38
dicyclomine hcl soln 10mg/5ml ....................... 38
dicyclomine hcl tab 20mg 38
didanosine ........................... 6
DIFICID ................................ 8
DIFLUCAN
see fluconazole ............... 5
diflunisal ............................... 1
digitek ................................. 17
digox ................................... 17
digoxin ................................ 17
digoxin inj ........................... 17
digoxin sol 50mcg/ml ....... 17
dihydroergotamine mesylate inj 1 mg/ml .... 28
dihydroergotamine mesylate nasal spr 4 mg/ml .............................. 28
DILANTIN
see phenytoin sodium extended .................... 20
DILANTIN CAP 100MG ... 19
DILANTIN CAP 30MG ..... 19
DILANTIN CHEW TAB 50MG ............................. 19
DILANTIN INFATABS
see phenytoin ............... 20
DILANTIN-125 see phenytoin ............... 20
DILANTIN-125 SUSP ...... 19
DILAUDID
see hydromorphone hcl 2
diltiazem cap 240mg cd .. 16
diltiazem cap 360mg cd .. 16
diltiazem cap er/12hr ....... 16
diltiazem hcl ...................... 16
diltiazem hcl coated beads ........................................ 16
diltiazem hcl coated beads cap sr 24hr .................... 16
diltiazem hcl extended release beads cap sr ... 16
diltiazem inj ....................... 16
dilt-xr cap ........................... 16
DIOVAN
see valsartan ................ 14
DIOVAN HCT
see valsartan-hydrochlorothiazide .. 14
diphenhydramine hcl inj 50mg/ml ......................... 47
diphenoxylate w/ atropine 39
DIPHTHERIA/TETANUS TOXOID ......................... 43
DIPROLENE
see betamethasone dipropionate augmented ................ 51
DIPROLENE AF
see betamethasone dipropionate augmented ................ 50
disopyramide phosphate . 14
disulfiram ........................... 30
DITROPAN XL
see oxybutynin chloride .................................... 40
divalproex sodium ............ 19
docetaxel ........................... 10
DOCETAXEL .................... 10
see docetaxel ................ 10
dofetilide ............................. 14
DOLOPHINE
see methadone hcl 10mg ....................................... 3
see methadone hcl 5mg 3
donepezil hydrochloride .. 21
dorzolamide hcl ................. 47
dorzolamide hcl-timolol maleate .......................... 47
DOVATO .............................. 7
DOVONEX
see calcipotriene ........... 50
doxazosin mesylate .......... 14
doxepin hcl ........................ 22
doxepin hcl (sleep) ........... 28
DOXIL
see doxorubicin hcl liposomal .................... 10
doxorubicin hcl .................. 10
doxorubicin hcl liposomal 10
doxy 100 .............................. 9
doxycycline (monohydrate) ........................................... 9
doxycycline hyclate ............ 9
doxycycline hyclate 100 mg ........................................... 9
doxycycline hyclate 20 mg 9
DRIZALMA SPRINKLE .... 22
dronabinol .......................... 38
drospirenone-ethinyl estradiol .......................... 34
DROXIA ............................. 41
duloxetine hcl .................... 22
DURAGESIC
see fentanyl patch 100 mcg/hr .......................... 2
see fentanyl patch 12 mcg/hr .......................... 2
see fentanyl patch 25 mcg/hr .......................... 2
see fentanyl patch 50 mcg/hr .......................... 2
see fentanyl patch 75 mcg/hr .......................... 2
DUREZOL .......................... 46
dutasteride ......................... 40
dutasteride-tamsulosin hcl ......................................... 40
Blue MedicareRx Premier 2020 Comprehensive Drug List
62
DYAZIDE
see triamterene & hydrochlorothiazide cap 37.5-25 mg ......... 17
E e.e.s. 400 ............................. 8
EC-NAPROSYN
see naproxen dr .............. 1
EC-NAPROXEN
see naproxen dr .............. 1
EDURANT............................ 6
efavirenz ............................... 6
EFFEXOR XR
see venlafaxine hcl ....... 23
EFFIENT
see prasugrel hcl .......... 42
EFUDEX
see fluorouracil (topical) ..................................... 52
eletriptan hydrobromide ... 28
ELIMITE
see permethrin cre 5% . 52
ELIQUIS ............................. 41
ELIQUIS STARTER PACK ......................................... 41
ELLA ................................... 34
ELLENCE
see epirubicin hcl .......... 10
eluryng ................................ 34
EMCYT ............................... 10
EMEND .............................. 38
see aprepitant ............... 38
EMGALITY ......................... 28
emoquette .......................... 34
EMSAM .............................. 22
EMTRIVA ............................. 6
EMVERM ............................. 4
enalapril maleate .............. 14
enalapril maleate & hydrochlorothiazide ...... 13
ENBREL ............................. 42
ENBREL MINI ................... 42
ENBREL SURECLICK ..... 42
ENDARI .............................. 41
endocet 10-325mg ............. 2
endocet 2.5-325mg ............ 2
endocet 5-325mg ................ 2
endocet 7.5-325mg ............ 2
ENGERIX-B ...................... 43
enoxaparin sodium .......... 41
enpresse-28 ...................... 34
enskyce .............................. 34
ENSTILAR ......................... 51
entacapone ....................... 24
entecavir .............................. 7
ENTOCORT EC
see budesonide ec ....... 39
ENTRESTO ...................... 14
enulose .............................. 39
EPCLUSA ............................ 7
EPIDIOLEX ....................... 19
epinephrine (anaphylaxis) ........................................ 48
EPIPEN 2-PAK
see epinephrine (anaphylaxis) ............ 48
EPIPEN-JR 2-PAK
see epinephrine (anaphylaxis) ............ 48
epirubicin hcl ..................... 10
epitol ................................... 19
EPIVIR
see lamivudine ................ 6
EPIVIR HBV ........................ 7
see lamivudine (hbv) ..... 7
eplerenone ........................ 14
EPZICOM
see abacavir sulfate-lamivudine ................... 6
ergotamine w/ caffeine .... 28
ERIVEDGE ........................ 10
ERLEADA .......................... 11
erlotinib hcl ........................ 12
errin .................................... 34
ertapenem sodium ............. 4
ery pad 2% ........................ 49
ERYGEL
see erythromycin (acne aid) .............................. 49
ery-tab .................................. 8
ERYTHROCIN LACTOBIONATE ........... 8
erythrocin stearate ............. 8
erythromycin (acne aid) .. 49
erythromycin (ophth) ........ 46
erythromycin base .............. 8
erythromycin cap 250mg ec ........................................... 8
erythromycin ethylsuccinate ........................................... 8
erythromycin tab ec ............ 8
ESBRIET ............................ 48
escitalopram oxalate ........ 22
esomeprazole magnesium ......................................... 40
estarylla tab 0.25-35 ........ 34
ESTRACE
see estradiol .................. 36
see estradiol vaginal cream .......................... 36
estradiol .............................. 36
estradiol vaginal cream .... 36
estradiol vaginal tab ......... 36
estradiol valerate inj ......... 36
ESTROSTEP FE
see tilia fe ....................... 35
see tri-legest fe ............. 35
ethambutol hcl ..................... 7
ethosuximide ..................... 19
ethynodiol diacet & eth estrad .............................. 34
ethynodiol tab 1-50 ........... 34
etodolac ................................ 1
etonogestrel-ethinyl estradiol .......................... 34
etoposide ........................... 13
euthyrox ............................. 38
everolimus ......................... 12
everolimus (immunosuppressant) .. 43
EVISTA
see raloxifene tab 60mg ..................................... 37
EVOTAZ ............................... 7
EVOXAC
see cevimeline hcl ........ 52
EXELON
see rivastigmine td patch 24hr 13.3 mg/24hr .... 22
see rivastigmine td patch 24hr 4.6 mg/24hr ...... 22
see rivastigmine td patch 24hr 9.5 mg/24hr ...... 22
exemestane ....................... 11
Blue MedicareRx Premier 2020 Comprehensive Drug List
63
EXFORGE
see amlodipine besylate-valsartan tab .............. 14
EXFORGE HCT
see amlodipine-valsartan-hydrochlorothiazide tab ..................................... 14
EXJADE ............................. 33
see deferasirox ............. 33
ezetimibe ............................ 15
ezetimibe-simvastatin ...... 15
F FABRAZYME .................... 36
falmina ................................ 34
famciclovir ............................ 7
famotidine .......................... 39
famotidine in nacl .............. 39
famotidine inj ..................... 39
FANAPT ............................. 24
FANAPT TITRATION PACK .............................. 24
FARESTON
see toremifene citrate .. 11
FARXIGA ........................... 31
FARYDAK .......................... 10
FASENRA .......................... 48
FASENRA PEN ................. 48
FASLODEX
see fulvestrant ............... 11
felbamate ........................... 20
FELBATOL
see felbamate ................ 20
FELDENE
see piroxicam .................. 1
felodipine ............................ 16
FEMARA
see letrozole .................. 11
FEMHRT LOW DOSE
see fyavolv ..................... 36
see norethindrone acetate-ethinyl estradiol ...................... 36
femynor .............................. 34
fenofibrate .......................... 15
fenofibrate micronized ..... 15
fentanyl citrate ..................... 2
fentanyl patch 100 mcg/hr . 2
fentanyl patch 12 mcg/hr .. 2
fentanyl patch 25 mcg/hr .. 2
fentanyl patch 50 mcg/hr .. 2
fentanyl patch 75 mcg/hr .. 2
FETZIMA ........................... 22
FETZIMA TITRATION PACK ............................. 22
FIASP ................................. 30
FIASP FLEXTOUCH ....... 30
FIASP PENFILL ............... 30
finasteride .......................... 40
FIRAZYR
see icatibant acetate .... 41
flac ...................................... 53
FLAGYL
see metronidazole .......... 4
flecainide acetate ............. 15
FLOMAX
see tamsulosin hcl ....... 40
FLOVENT DISKUS .......... 49
FLOVENT HFA ................. 49
fluconazole .......................... 5
fluconazole inj nacl 200 ..... 5
fluconazole inj nacl 400 ..... 5
flucytosine ........................... 5
fludrocortisone acetate .... 36
flunisolide (nasal) ............. 49
fluocinolone acetonide .... 51
fluocinolone acetonide (otic) ............................... 53
fluocinolone acetonide oil body ................................ 51
fluocinonide ....................... 51
fluocinonide emulsified base ................................ 51
fluorometholone ................ 46
fluorouracil ......................... 10
fluorouracil (topical) ......... 52
fluoxetine cap 10mg ........ 22
fluoxetine cap 20mg ........ 22
fluoxetine cap 40mg ........ 22
fluoxetine hcl ..................... 23
fluphenazine decanoate .. 24
fluphenazine hcl ............... 24
flurbiprofen .......................... 1
flurbiprofen sodium .......... 46
flutamide ............................ 11
fluticasone propionate ..... 51
fluticasone propionate (nasal) ............................ 49
fluvoxamine maleate ........ 19
FOCALIN
see dexmethylphenidate hcl ................................ 27
fondaparinux sodium ........ 41
FORTEO ............................ 37
FOSAMAX
see alendronate sodium tab 70 mg ................... 33
fosamprenavir tab 700 mg 6
fosinopril sodium ............... 14
fosinopril sodium & hydrochlorothiazide ...... 13
FREAMINE HBC 6.9% .... 44
FREAMINE III .................... 45
fulvestrant .......................... 11
furosemide ......................... 17
furosemide inj .................... 17
FUZEON .............................. 6
fyavolv ................................ 36
FYCOMPA ......................... 20
G gabapentin ......................... 20
GABITRIL
see tiagabine hcl ........... 21
galantamine hydrobromide ......................................... 21
galantamine hydrobromide er ..................................... 22
GAMASTAN S/D .............. 43
GAMMAGARD LIQUID .... 43
GAMMAGARD S/D .......... 43
GAMMAKED ..................... 43
GAMMAPLEX ................... 43
GAMMAPLEX 10GM/100ML ................ 43
GAMUNEX-C .................... 43
ganciclovir sodium .............. 7
GARDASIL 9 ..................... 43
GASTROCROM
see cromolyn sodium (mastocytosis) ........... 39
gatifloxacin (ophth) ........... 46
GATTEX ............................. 39
GAUZE PADS 2 ................ 31
gavilyte-c ............................ 39
Blue MedicareRx Premier 2020 Comprehensive Drug List
64
gavilyte-g ............................ 39
gavilyte-n/flavor pack ....... 39
GEMCITABINE
see gemcitabine inj soln ..................................... 10
gemcitabine inj soln .......... 10
gemcitabine inj solr ........... 10
gemfibrozil ......................... 15
generlac ............................. 39
gengraf ............................... 43
GENOTROPIN .................. 37
GENOTROPIN MINIQUICK ......................................... 37
gentak ................................. 46
gentamicin in saline ............ 4
gentamicin sulfate ............... 4
gentamicin sulfate (topical) ......................................... 50
gentamicin sulfate soln (ophth) ............................ 46
GENVOYA ........................... 7
GEODON ........................... 24
see ziprasidone hcl ....... 26
see ziprasidone mesylate ..................................... 26
gianvi tab 3-0.02mg .......... 34
GILENYA ........................... 29
GILOTRIF TAB 20MG ..... 12
GILOTRIF TAB 30MG ..... 12
GILOTRIF TAB 40MG ..... 12
glatiramer acetate 20mg/ml ......................................... 29
glatiramer acetate 40mg/ml ......................................... 29
glatopa ................................ 29
GLEEVEC
see imatinib mesylate .. 12
GLEOSTINE ...................... 10
glimepiride ......................... 31
glip/metform tab 2.5-250mg ......................................... 31
glip/metform tab 2.5-500mg ......................................... 31
glip/metform tab 5-500mg ......................................... 31
glipizide .............................. 31
glipizide xl .......................... 32
GLUCAGEN HYPOKIT .... 37
GLUCAGON EMERGENCY KIT ....... 37
GLUCOTROL
see glipizide .................. 31
GLUCOTROL XL see glipizide .................. 31
see glipizide xl .............. 32
glycopyrrolate tab 1mg .... 38
glycopyrrolate tab 2mg .... 39
glydo ................................... 51
GLYXAMBI ........................ 32
GOLYTELY ....................... 39
see gavilyte-g ................ 39
see peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ................. 39
granisetron hcl .................. 38
griseofulvin microsize ........ 5
griseofulvin ultramicrosize 5
guanfacine er (adhd) ....... 27
GVOKE PFS ..................... 37
H HAEGARDA ...................... 41
HALDOL
see haloperidol lactate inj 5mg/ml ....................... 25
HALDOL DECANOATE 100
see haloperidol decanoate .................. 25
HALDOL DECANOATE 50
see haloperidol decanoate .................. 25
halobetasol propionate .... 51
haloperidol ......................... 24
haloperidol conc 2mg/ml . 25
haloperidol decanoate ..... 25
haloperidol lactate inj 5mg/ml ........................... 25
HARVONI ............................ 7
HAVRIX ............................. 43
heather ............................... 34
heparin sod (porcine) in d5w ................................. 41
heparin sod inj 1000/ml ... 41
heparin sod inj 10000/ml . 41
heparin sod inj 20000/ml . 41
heparin sod inj 5000/ml ... 41
HEPARIN SODIUM/NACL 0.45% ............................. 41
hepatamine ........................ 45
HEPSERA
see adefovir dipivoxil ...... 7
HERCEPTIN ...................... 10
HERCEPTIN HYLECTA .. 10
HETLIOZ ............................ 28
HIBERIX ............................. 43
HIPREX
see methenamine hippurate ...................... 4
HUMIRA ............................. 42
HUMIRA INJ 10MG/0.2ML ......................................... 42
HUMIRA KIT 20MG/0.4ML ......................................... 42
HUMIRA KIT 40MG/0.8ML ......................................... 42
HUMIRA PEDIATRIC CROHNS DISEASE ..... 42
HUMIRA PEN .................... 42
HUMIRA PEN CD/UC/HS STARTER ...................... 42
HUMIRA PEN INJ CD/UC/HS STARTER .. 42
HUMIRA PEN INJ PS/UV STARTER ...................... 42
HUMIRA PEN-PS/UV STARTER ...................... 42
HUMULIN R INJ U-500 ... 31
HUMULIN R U-500 KWIKPEN ...................... 31
hydralazine hcl .................. 18
HYDREA
see hydroxyurea ........... 13
hydrochlorothiazide .......... 17
hydroco/apap tab 10-325mg .............................. 2
hydroco/apap tab 5-325mg ........................................... 2
hydroco/apap tab 7.5-325 . 2
hydrocodone-acetaminophen 7.5-325 mg/15ml ........................... 2
hydrocodone-ibuprofen tab 7.5-200 mg ...................... 2
hydrocortisone .................. 36
Blue MedicareRx Premier 2020 Comprehensive Drug List
65
hydrocortisone (enema) ... 39
hydrocortisone (topical) cream 1% ....................... 51
hydrocortisone (topical) cream 2.5% ................... 51
hydrocortisone (topical) lotion 2.5% ..................... 51
hydrocortisone (topical) oint 2.5% ................................ 51
hydrocortisone butyrate cream 0.1% ................... 51
hydrocortisone butyrate oint 0.1% ................................ 51
hydromorphone hcl ............. 2
hydroxychloroquine sulfate ......................................... 42
hydroxyurea ....................... 13
hydroxyzine hcl ................. 47
hydroxyzine hcl inj ............ 47
hydroxyzine pamoate ....... 47
HYSINGLA ER .................... 2
HYZAAR
see losartan-hydrochlorothiazide .. 14
I ibandronate sodium tabs . 33
IBRANCE ........................... 10
ibu tab 600mg ..................... 1
ibu tab 800mg ..................... 1
ibuprofen .............................. 1
icatibant acetate ................ 41
ICLUSIG ............................. 12
IDHIFA ................................ 10
ILEVRO .............................. 46
imatinib mesylate .............. 12
IMBRUVICA ....................... 12
imipenem-cilastatin ............. 4
imipramine hcl ................... 23
imiquimod ........................... 52
IMITREX
see sumatriptan ............ 28
see sumatriptan inj 6mg/0.5ml .................. 29
see sumatriptan succinate .................... 29
IMITREX STATDOSE REFILL
see sumatriptan inj 4mg/0.5ml .................. 28
see sumatriptan inj 6mg/0.5ml .................. 29
IMITREX STATDOSE SYSTEM
see sumatriptan inj 4mg/0.5ml .................. 28
see sumatriptan inj 6mg/0.5ml .................. 28
IMOVAX RABIES (H.D.C.V.) ...................... 43
IMURAN
see azathioprine ........... 43
incassia .............................. 34
INCRELEX ........................ 37
INCRUSE ELLIPTA ......... 47
indapamide ........................ 17
INDERAL LA
see propranolol cap er 16
INFANRIX .......................... 43
INLYTA .............................. 12
INREBIC ............................ 12
INSPRA
see eplerenone ............. 14
INSULIN PEN NEEDLE .. 31
INSULIN SAFETY NEEDLES ...................... 31
INSULIN SYRINGE ......... 31
INTELENCE ........................ 6
INTRALIPID 30% ............. 45
INTRALIPID INJ 20% ...... 45
INTRON-A INJ 10MU ...... 43
INTRON-A INJ 18MU ...... 43
INTRON-A INJ 25MU ...... 43
INTRON-A INJ 50MU ...... 43
introvale ............................. 34
INTUNIV
see guanfacine er (adhd) .................................... 27
INVANZ
see ertapenem sodium .. 4
INVEGA
see paliperidone ........... 25
INVEGA SUST INJ 117 MG/0.75 ML .................. 25
INVEGA SUST INJ 156MG/ML .................... 25
INVEGA SUST INJ 234 MG/1.5 ML ..................... 25
INVEGA SUST INJ 39 MG/0.25 ML ................... 25
INVEGA SUST INJ 78 MG/0.5 ML ..................... 25
INVEGA TRINZA .............. 25
INVIRASE ............................ 6
IPOL INACTIVATED IPV. 44
ipratropium bromide ......... 47
ipratropium bromide (nasal) ......................................... 47
ipratropium-albuterol nebu ......................................... 47
irbesartan ........................... 14
irbesartan-hydrochlorothiazide ...... 14
IRESSA .............................. 12
irinotecan hcl ..................... 13
ISENTRESS ........................ 6
ISENTRESS HD ................. 6
isibloom .............................. 34
ISOLYTE P ........................ 45
ISOLYTE S ........................ 45
isoniazid ............................... 7
isoniazid syp 50mg/5ml ..... 7
ISOPTO CARPINE
see pilocarpine hcl ........ 47
ISORDIL TITRADOSE
see isosorbide dinitrate 18
isosorb mononitrate tab ... 18
isosorbide dinitrate ........... 18
isosorbide mononitrate er 18
isotretinoin ......................... 49
isradipine ............................ 16
ISTALOL
see timolol maleate ophth soln 0.5% (once-daily) ........................... 47
itraconazole ......................... 5
ivermectin ............................ 4
IXIARO ............................... 44
J JADENU ............................. 33
see deferasirox ............. 33
JADENU SPRINKLE ........ 33
JAKAFI ............................... 12
JALYN
Blue MedicareRx Premier 2020 Comprehensive Drug List
66
see dutasteride-tamsulosin hcl ........... 40
jantoven .............................. 41
JANUMET .......................... 32
JANUMET XR TAB 100-1000 ................................ 32
JANUMET XR TAB 50-1000 ................................ 32
JANUMET XR TAB 50-500MG ............................ 32
JANUVIA ............................ 32
JARDIANCE ...................... 32
jasmiel ................................ 34
JENTADUETO .................. 32
JENTADUETO TAB XR 2.5-1000 MG ................. 32
JENTADUETO TAB XR 5-1000 MG ........................ 32
jinteli .................................... 36
jolessa tab 0.15-0.03 mg . 34
jolivette ............................... 34
juleber ................................. 34
JULUCA ............................... 7
junel 1.5/30 ........................ 34
junel 1/20 ........................... 34
junel fe 1.5/30 .................... 34
junel fe 1/20 ....................... 34
JUXTAPID.......................... 15
K KADCYLA .......................... 10
KALETRA
see lopinavir-ritonavir ..... 7
KALETRA TAB 100-25MG 7
KALETRA TAB 200-50MG 7
KALYDECO ....................... 48
KANJINTI ........................... 10
kariva .................................. 34
kcl 0.075%/d5w/nacl 0.45% ......................................... 45
KCL 0.15%/D5W/NACL 0.225% ........................... 45
kcl 0.15%/d5w/nacl 0.9% 45
kcl 0.3%/d5w/nacl 0.45% 45
KCL 0.3%/D5W/NACL 0.9% ................................ 45
kcl/d5w inj 0.3% ................ 45
kcl/d5w/nacl inj .15/.45% . 45
kcl/d5w/nacl inj 0.22%/0.45% ................ 45
kcl/nacl inj 0.15%-0.9% ... 45
kcl/nacl inj 0.3-0.9 ............ 45
kcl0.15%/d5w/nacl0.2% .. 45
KEFLEX
see cephalexin ................ 8
kelnor 1/35 ........................ 34
kelnor 1/50 ........................ 34
KEPPRA
see levetiracetam ......... 20
see levetiracetam oral soln 100 mg/ml ......... 20
see roweepra ................ 21
KEPPRA XR
see levetiracetam ......... 20
see roweepra xr ............ 21
ketoconazole ....................... 5
ketoconazole cream ........ 50
ketoconazole shampoo ... 50
ketorolac tromethamine (ophth) ............................ 46
KEYTRUDA ...................... 10
KINRIX ............................... 44
kionex sus 15gm/60ml .... 33
KISQALI ............................. 10
KISQALI FEMARA 200 DOSE ............................. 10
KISQALI FEMARA 400 DOSE ............................. 10
KISQALI FEMARA 600 DOSE ............................. 11
KITABIS PAK
see tobramycin ............... 4
KLARON
see sulfacetamide sodium (acne) ........... 49
KLONOPIN
see clonazepam ........... 19
klor-con 10 ........................ 44
klor-con 8 ........................... 44
klor-con m10 ..................... 44
klor-con m15 ..................... 44
klor-con m20 ..................... 44
klor-con pak 20meq ......... 44
klor-con spr cap 10meq .. 44
klor-con spr cap 8meq ..... 44
KORLYM ........................... 37
K-TAB
see potassium chloride 44
kurvelo ................................ 34
KUVAN ............................... 36
L labetalol hcl ........................ 16
lactated ringer's ................. 45
lactulose ............................. 39
lactulose (encephalopathy) ......................................... 39
LAMICTAL
see lamotrigine .............. 20
see subvenite tab ......... 21
LAMICTAL CHEWABLE DISPERS
see lamotrigine .............. 20
LAMICTAL XR
see lamotrigine .............. 20
LAMISIL
see terbinafine hcl .......... 5
lamivudine ............................ 6
lamivudine (hbv) ................. 7
lamivudine-zidovudine ....... 7
lamotrigine ......................... 20
LANOXIN
see digitek ...................... 17
see digox ........................ 17
see digoxin .................... 17
see digoxin inj ............... 17
lansoprazole ...................... 40
larin 1.5/30 ......................... 34
larin 1/20 ............................ 34
larin fe 1.5/30 .................... 34
larin fe 1/20 ........................ 34
larissia tab .......................... 34
LASIX
see furosemide ............. 17
LASTACAFT ...................... 46
latanoprost ......................... 47
LATUDA ............................. 25
leena tab ............................ 34
leflunomide ........................ 42
LENVIMA 10 MG DAILY DOSE ............................. 12
LENVIMA 12MG DAILY DOSE ............................. 12
LENVIMA 14 MG DAILY DOSE ............................. 12
Blue MedicareRx Premier 2020 Comprehensive Drug List
67
LENVIMA 18 MG DAILY DOSE.............................. 12
LENVIMA 20 MG DAILY DOSE.............................. 12
LENVIMA 24 MG DAILY DOSE.............................. 12
LENVIMA 4 MG DAILY DOSE.............................. 12
LENVIMA 8 MG DAILY DOSE.............................. 12
lessina ................................ 34
LETAIRIS
see ambrisentan ........... 18
letrozole .............................. 11
leucovorin calcium ............ 13
LEUKERAN ....................... 10
leuprolide inj 1mg/0.2 ....... 11
levalbuterol hcl .................. 48
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml ...... 48
levalbuterol tartrate hfa .... 48
LEVAQUIN
see levofloxacin .............. 9
LEVEMIR ........................... 31
LEVEMIR FLEXTOUCH .. 31
levetiracetam ..................... 20
LEVETIRACETAM
see levetiracetam in sodium chloride ......... 20
levetiracetam in sodium chloride ........................... 20
levetiracetam oral soln 100 mg/ml .............................. 20
levobunolol hcl .................. 47
levocarnitine (metabolic modifiers) ....................... 36
levocetirizine dihydrochloride .............. 48
levofloxacin .......................... 9
levofloxacin in d5w ............. 9
levofloxacin inj 25mg/ml .... 9
levofloxacin oral soln 25 mg/ml ................................ 9
levonest .............................. 34
levonor/ethi tab ................. 34
levonorgestrel & eth estradiol .......................... 34
levonorgestrel-ethinyl estradiol (91-day) ......... 34
levora 0.15/30-28 ............. 34
levo-t .................................. 38
levothyroxine sodium ....... 38
levoxyl ................................ 38
LEXAPRO
see escitalopram oxalate .................................... 22
LEXIVA ................................ 6
see fosamprenavir tab 700 mg ......................... 6
LIALDA
see mesalamine ........... 39
lidocaine ............................ 51
lidocaine hcl ...................... 51
lidocaine hcl (local anesth.) .......................................... 3
lidocaine hcl (mouth-throat) ........................................ 52
lidocaine inj 0.5% ............... 3
lidocaine inj 1% .................. 3
lidocaine inj 1.5% preservative free (pf) ..... 4
lidocaine oint 5% .............. 52
lidocaine-prilocaine .......... 52
LIDODERM
see lidocaine ................. 51
linezolid in sodium chloride .......................................... 4
linezolid inj ........................... 4
linezolid susp ...................... 4
linezolid tab 600mg ............ 4
LINZESS ............................ 39
liothyronine sodium .......... 38
LIPITOR
see atorvastatin calcium .................................... 15
lisinopril .............................. 14
lisinopril & hydrochlorothiazide ...... 13
lithium carbonate .............. 29
lithium carbonate er ......... 29
LITHIUM SOLN 8MEQ/5ML ........................................ 29
LITHOBID
see lithium carbonate er .................................... 29
LOCOID
see hydrocortisone butyrate cream 0.1% 51
LODINE
see etodolac .................... 1
LOESTRIN 1.5/30-21
see junel 1.5/30 ............ 34
see larin 1.5/30 ............. 34
see microgestin 1.5/30 34
LOESTRIN 1/20-21
see junel 1/20 ................ 34
see larin 1/20 ................. 34
see microgestin 1/20 .... 34
see norethindrone acet & eth estra ..................... 35
LOESTRIN FE 1.5/30
see blisovi fe 1.5/30 ..... 33
see junel fe 1.5/30 ........ 34
see larin fe 1.5/30 ......... 34
see microgestin fe 1.5/30 ..................................... 35
LOESTRIN FE 1/20
see junel fe 1/20 ........... 34
see larin fe 1/20 ............ 34
see microgestin fe 1/20 35
see tarina fe 1/20 .......... 35
LOKELMA .......................... 33
LOMOTIL
see diphenoxylate w/ atropine ...................... 39
LONSURF .......................... 13
loperamide hcl ................... 39
LOPID
see gemfibrozil .............. 15
lopinavir-ritonavir ................ 7
LOPRESSOR
see metoprolol tartrate . 16
LOPRESSOR HCT
see metoprolol & hydrochlorothiazide .. 16
LOPROX
see ciclopirox ................ 50
lorazepam .......................... 19
lorazepam intensol ........... 19
LORBRENA ....................... 12
lorcet hd tab 10-325mg ...... 2
lorcet plus tab 7.5-325 ....... 2
lorcet tab 5-325mg ............. 3
Blue MedicareRx Premier 2020 Comprehensive Drug List
68
loryna .................................. 34
losartan potassium ........... 14
losartan-hydrochlorothiazide ...... 14
LOTEMAX .......................... 46
see loteprednol etabonate ................... 46
LOTENSIN
see benazepril hcl ......... 14
LOTENSIN HCT
see benazepril & hydrochlorothiazide .. 13
loteprednol etabonate ...... 46
LOTREL
see amlodipine besylate-benazepril hcl cap 10-20 mg .......................... 13
see amlodipine besylate-benazepril hcl cap 10-40 mg .......................... 13
see amlodipine besylate-benazepril hcl cap 5-10 mg ............................... 13
see amlodipine besylate-benazepril hcl cap 5-20 mg ............................... 13
LOTRONEX
see alosetron hcl ........... 39
lovastatin ............................ 15
LOVENOX
see enoxaparin sodium 41
low-ogestrel ....................... 34
loxapine succinate ............ 25
LUMIGAN ........................... 47
LUMIZYME ........................ 36
LUPRON DEPOT (1-MONTH) ......................... 11
LUPRON DEPOT INJ 11.25MG (3-MONTH) .. 11
LUPRON DEPOT-PED (1-MONTH .......................... 37
LUPRON DEPOT-PED (3-MONTH .......................... 37
LUPRON DEP-PED INJ 11.25MG (3-MONTH) .. 37
LUPRON DEP-PED INJ 7.5MG ............................. 37
lutera ................................... 34
LYNPARZA ....................... 11
LYRICA
see pregabalin .............. 21
LYRICA CR ....................... 29
LYSODREN ...................... 11
LYSTEDA
see tranexamic acid ..... 42
lyza ..................................... 34
M MACROBID
see nitrofurantoin monohyd macro .......... 4
MACRODANTIN
see nitrofurantoin macrocrystal ................ 4
magnesium sulfate ........... 44
MAGNESIUM SULFATE 44
see magnesium sulfate 44
MAGNESIUM SULFATE IN D5W ............................... 44
see magnesium sulfate in dextrose ..................... 44
magnesium sulfate in dextrose ......................... 44
magnesium sulfate inj 50% ........................................ 44
MALARONE
see atovaquone-proguanil hcl ................ 5
malathion ........................... 52
maprotiline hcl .................. 23
MARINOL
see dronabinol .............. 38
marlissa ............................. 34
MARPLAN TAB 10MG .... 23
MATULANE ...................... 13
MAVIK
see trandolapril ............. 14
MAVYRET ........................... 7
MAXALT
see rizatriptan benzoate .................................... 28
MAXALT-MLT
see rizatriptan benzoate odt ............................... 28
MAXITROL
see neomycin-polymy-dexameth ................... 46
MAXZIDE
see triamterene & hydrochlorothiazide tabs ............................. 17
MAXZIDE-25
see triamterene & hydrochlorothiazide tabs ............................. 17
meclizine hcl ...................... 38
MEDROL
see methylpred tab 16mg ..................................... 36
see methylpred tab 32mg ..................................... 36
see methylpred tab 4mg ..................................... 36
see methylpred tab 8mg ..................................... 36
MEDROL DOSEPAK
see methylpred pak 4mg ..................................... 36
medroxyprogesterone acetate (contraceptive) 34
medroxyprogesterone acetate tab ..................... 38
mefloquine hcl ..................... 5
megestrol ac sus 40mg/ml ......................................... 11
megestrol ac tab 20mg .... 11
megestrol ac tab 40mg .... 11
megestrol sus 625mg/5ml ......................................... 11
MEKINIST .......................... 12
MEKTOVI ........................... 12
meloxicam ............................ 1
memantine hcl cp24 ......... 22
memantine soln ................ 22
memantine tabs ................ 22
MENACTRA ...................... 44
MENVEO ........................... 44
MEPRON
see atovaquone .............. 4
mercaptopurine ................. 10
meropenem ......................... 4
MERREM
see meropenem .............. 4
mesalamine ....................... 39
mesalamine w/ cleanser .. 39
Blue MedicareRx Premier 2020 Comprehensive Drug List
69
MESNEX ............................ 13
MESTINON
see pyridostigmine tab 60mg ........................... 29
metadate er tab 20mg ...... 27
metformin er ...................... 32
metformin hcl ..................... 32
methadone hcl ..................... 3
methadone hcl 10mg ......... 3
methadone hcl 5mg ............ 3
methadone hcl intensol ...... 3
METHADOSE
see methadone hcl intensol ......................... 3
methazolamide .................. 17
methenamine hippurate ..... 4
methimazole ...................... 38
methotrexate sodium inj soln.................................. 10
methotrexate sodium inj solr .................................. 10
methotrexate sodium tabs ......................................... 42
METHYLIN
see methylphenidate hcl oral soln ...................... 27
methylphenidate hcl ......... 27
methylphenidate hcl oral soln.................................. 27
methylphenidate hcl tbcr 10 mg ................................... 27
methylphenidate hcl tbcr 20mg ............................... 27
methylpr ss inj ................... 36
methylpred pak 4mg ......... 36
methylpred tab 16mg ....... 36
methylpred tab 32mg ....... 36
methylpred tab 4mg ......... 36
methylpred tab 8mg ......... 36
methylprednisolone acetate ......................................... 36
metoclopramide hcl .......... 38
metoclopramide hcl inj ..... 38
metolazone ........................ 17
metoprolol & hydrochlorothiazide ...... 16
metoprolol succinate ........ 16
metoprolol tartrate ............ 16
METROCREAM
see metronidazole (topical) ...................... 52
see rosadan cre 0.75% 52
METROLOTION see metronidazole
(topical) ...................... 52
metronidazole ..................... 4
metronidazole (topical) .... 52
metronidazole gel 0.75% 52
metronidazole in nacl ........ 4
metronidazole vaginal ..... 41
MIACALCIN
see calcitonin (salmon) 37
MICARDIS
see telmisartan ............. 14
microgestin 1.5/30 ............ 34
microgestin 1/20 ............... 34
microgestin fe 1.5/30 ....... 35
microgestin fe 1/20 .......... 35
midodrine hcl .................... 18
miglustat ............................ 36
MIGRANAL
see dihydroergotamine mesylate nasal spr 4 mg/ml ......................... 28
mili ...................................... 35
MINIPRESS
see prazosin hcl ........... 14
minitran .............................. 18
MINOCIN
see minocycline hcl ...... 10
minocycline hcl ................. 10
minoxidil ............................. 18
MIRAPEX
see pramipexole tab 0.125mg ..................... 24
see pramipexole tab 0.5mg ......................... 24
see pramipexole tab 0.75mg ....................... 24
see pramipexole tab 1mg .................................... 24
MIRCETTE
see bekyree .................. 33
see desogestrel-ethinyl estradiol (biphasic) ... 34
see kariva ...................... 34
see pimtrea .................... 35
see viorele ..................... 35
mirtazapine ........................ 23
misoprostol ........................ 39
MITIGARE ........................... 1
M-M-R II ............................. 44
M-NATAL PLUS ................ 45
MOBIC
see meloxicam ................ 1
moexipril hcl ...................... 14
molindone hcl .................... 25
mometasone furoate ........ 51
mondoxyne nl cap 100mg ......................................... 10
mono-linyah tab 0.25-35 .. 35
montelukast sodium ......... 48
morphine ext-rel tab ........... 3
morphine sul inj 1mg/ml .... 3
morphine sulfate ................. 3
MORPHINE SULFATE ...... 3
see morphine sulfate ...... 3
morphine sulfate oral soln 100mg/5ml ....................... 3
morphine sulfate oral soln 10mg/5ml ......................... 3
morphine sulfate oral soln 20mg/5ml ......................... 3
MOVANTIK .................. 39, 40
MOXEZA ............................ 46
see moxifloxacin hcl (ophth) ........................ 46
moxifloxacin hcl (ophth) ... 46
MS CONTIN
see morphine ext-rel tab 3
MULTAQ ............................ 15
mupirocin ........................... 50
MVASI ................................ 11
MYAMBUTOL
see ethambutol hcl ......... 7
MYCAMINE ......................... 5
MYCOBUTIN
see rifabutin ..................... 7
mycophenolate mofetil ..... 43
mycophenolate sodium tbec ................................. 43
MYFORTIC
see mycophenolate sodium tbec ............... 43
Blue MedicareRx Premier 2020 Comprehensive Drug List
70
myorisan ............................. 49
MYRBETRIQ ..................... 40
MYSOLINE
see primidone ................ 21
N nabumetone ......................... 1
nadolol ................................ 16
nafcillin sodium for inj ......... 9
NAFCILLIN SODIUM FOR INJ 10GM ......................... 9
NAGLAZYME .................... 36
nalbuphine hcl ..................... 1
naloxone inj 0.4mg/ml ...... 30
naloxone inj 1mg/ml ......... 30
naltrexone hcl .................... 30
NAMENDA
see memantine tabs ..... 22
NAMENDA XR
see memantine hcl cp24 ..................................... 22
NAMZARIC ........................ 22
NAPROSYN
see naproxen ................... 1
naproxen .............................. 1
naproxen dr ......................... 1
naproxen sodium ................ 1
naratriptan hcl ................... 28
NARCAN ............................ 30
NARDIL
see phenelzine sulfate . 23
NATACYN .......................... 46
nateglinide ......................... 32
NATPARA .......................... 37
NAYZILAM ......................... 20
NEBUPENT
see pentamidine isethionate inh ............. 4
necon 0.5/35-28 ................ 35
nefazodone hcl .................. 23
neomycin sulfate ................. 4
neomycin-bacitracin zn-polymyxin ....................... 46
neomycin-polymy-dexameth ....................... 46
neomycin-polymyxin-gramicidin ....................... 46
neomycin-polymyxin-hc (ophth) ............................ 46
neomycin-polymyxin-hc (otic) ............................... 53
NEORAL
see cyclosporine modified (for microemulsion) ......... 43
see gengraf ................... 43
NEPHRAMINE .................. 45
NERLYNX ......................... 12
NEUPRO ........................... 24
NEURONTIN
see gabapentin ............. 20
nevirapine susp 50 mg/5ml .......................................... 6
nevirapine tab 100mg er ... 6
nevirapine tab 200mg ........ 6
nevirapine tab 400mg er ... 6
NEXAVAR ......................... 12
NEXIUM
see esomeprazole magnesium ................ 40
niacin (antihyperlipidemic) ........................................ 15
niacin er (antihyperlipidemic) ...... 15
niacor ................................. 15
NIASPAN
see niacin er (antihyperlipidemic) .. 15
nicardipine hcl ................... 16
NICOTROL INHALER ..... 30
NICOTROL NS ................. 30
nifedipine ........................... 16
nifedipine er ...................... 16
nikki .................................... 35
NILANDRON
see nilutamide .............. 11
nilutamide .......................... 11
nimodipine ......................... 16
NINLARO .......................... 11
nitisinone ........................... 36
NITRO-BID ........................ 18
NITRO-DUR
see minitran .................. 18
see nitroglycerin td patch .................................... 18
NITRO-DUR DIS 0.3MG/HR ..................... 18
NITRO-DUR DIS 0.8MG/HR ...................... 18
nitrofurantoin macrocrystal 4
nitrofurantoin monohyd macro ................................ 4
nitroglycerin ....................... 18
nitroglycerin td patch ........ 18
NITROSTAT
see nitroglycerin ............ 18
NITYR ................................. 36
nizatidine ............................ 39
nora-be tab 0.35mg .......... 35
NORCO see hydroco/apap tab 10-
325mg .......................... 2
see hydroco/apap tab 5-325mg .......................... 2
see hydroco/apap tab 7.5-325 ......................... 2
see lorcet hd tab 10-325mg .......................... 2
see lorcet plus tab 7.5-325 ................................ 2
see lorcet tab 5-325mg .. 3
norethindrone (contraceptive) .............. 35
norethindrone acet & eth estra ................................ 35
norethindrone acetate ...... 38
norethindrone acetate-ethinyl estradiol ............. 36
norgest/ethi tab 0.25/35 ... 35
norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ................................. 35
norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg ................................. 35
NORMOSOL-M IN D5W .. 45
NORMOSOL-R ................. 45
NORMOSOL-R IN D5W .. 45
NORPACE
see disopyramide phosphate .................. 14
NORPACE CR .................. 15
NORPRAMIN
Blue MedicareRx Premier 2020 Comprehensive Drug List
71
see desipramine hcl ..... 22
NORTHERA ...................... 18
nortrel 0.5/35 (28) ............. 35
nortrel 1/35 ......................... 35
nortrel 7/7/7 ....................... 35
nortriptyline hcl .................. 23
NORVASC
see amlodipine besylate ..................................... 16
NORVIR
see ritonavir ..................... 6
NORVIR PACK ................... 6
NORVIR SOLN ................... 6
NOVOLIN 70/30 ................ 31
NOVOLIN 70/30 FLEXPEN ......................................... 31
NOVOLIN N ....................... 31
NOVOLIN N FLEXPEN.... 31
NOVOLIN R ....................... 31
NOVOLIN R FLEXPEN.... 31
NOVOLOG ......................... 31
NOVOLOG 70/30 FLEXPEN ....................... 31
NOVOLOG FLEXPEN ..... 31
NOVOLOG MIX 70/30 ..... 31
NOVOLOG PENFILL ....... 31
NOXAFIL .............................. 5
see posaconazole ........... 5
NUBEQA ............................ 11
NUCALA ............................. 48
NUCYNTA ER ..................... 3
NUEDEXTA ....................... 29
NULOJIX ............................ 43
NULYTELY/FLAVOR PACKS ........................... 39
see gavilyte-n/flavor pack ..................................... 39
see peg 3350-potassium chloride-sod bicarbonate-sod chloride ....................... 39
see trilyte ........................ 39
NUPLAZID CAPS ............. 25
NUPLAZID TABS 10MG . 25
NUTRILIPID INJ 20% ...... 45
NUVARING
see eluryng .................... 34
see etonogestrel-ethinyl estradiol ..................... 34
NUVIGIL
see armodafinil ............. 30
nyamyc .............................. 50
NYMALIZE ........................ 16
nystatin ................................ 5
nystatin (mouth-throat) .... 52
nystatin (topical) ............... 50
nystop ................................ 50
O ocella tab 3-0.03mg ......... 35
OCTAGAM ........................ 43
octreotide acetate ............ 37
OCUFLOX
see ofloxacin (ophth) ... 46
ODEFSEY ........................... 7
ODOMZO .......................... 11
OFEV ................................. 48
ofloxacin (ophth) ............... 46
ofloxacin (otic) .................. 53
OGIVRI .............................. 11
olanzapine ......................... 25
olmesartan medoxomil .... 14
olmesartan medoxomil-amlodipine-hydrochlorothiazide ...... 14
olmesartan medoxomil-hydrochlorothiazide ...... 14
olopatadine hcl 0.2% ....... 46
omeprazole cap 10mg ..... 40
omeprazole cap 20mg ..... 40
omeprazole cap 40mg ..... 40
ondansetron hcl ................ 38
ondansetron hcl inj ........... 38
ondansetron hcl oral soln 38
ondansetron odt ............... 38
ONFI see clobazam ................ 19
OPSUMIT .......................... 18
ORFADIN .......................... 36
see nitisinone ................ 36
ORKAMBI .......................... 48
orsythia .............................. 35
ORTHO MICRONOR
see errin ......................... 34
see jolivette ................... 34
see lyza .......................... 34
see norethindrone (contraceptive) .......... 35
see sharobel .................. 35
ORTHO TRI-CYCLEN LO
see norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ................. 35
see tri-lo marzia ............ 35
see tri-lo-estarylla ......... 35
see tri-lo-sprintec .......... 35
see tri-vylibra lo ............. 35
ORTHO-NOVUM 7/7/7
see cyclafem 7/7/7 ....... 33
see dasetta 7/7/7 .......... 34
see nortrel 7/7/7 ............ 35
oseltamivir phosphate .... 7, 8
OSPHENA ......................... 37
oxacillin sodium .................. 9
oxaliplatin inj 100mg ........ 13
oxaliplatin inj 100mg/20ml ......................................... 13
oxaliplatin inj 50mg ........... 13
oxaliplatin inj 50mg/10ml . 13
oxandrolone tab 10mg ..... 30
oxandrolone tab 2.5mg .... 30
oxcarbazepine ................... 20
oxybutynin chloride .......... 40
oxycodone hcl ..................... 3
oxycodone w/ acetaminophen 10-325mg .............................. 3
oxycodone w/ acetaminophen 2.5-325mg .............................. 3
oxycodone w/ acetaminophen 5-325mg ........................................... 3
oxycodone w/ acetaminophen 7.5-325mg .............................. 3
OZEMPIC INJ 0.25 OR 0.5MG/DOSE ................ 31
OZEMPIC INJ 1MG/DOSE ......................................... 31
P pacerone ............................ 15
paclitaxel ............................ 10
Blue MedicareRx Premier 2020 Comprehensive Drug List
72
paliperidone ....................... 25
PAMELOR
see nortriptyline hcl ...... 23
pamidronate disodium ..... 33
PAMIDRONATE DISODIUM ..................... 33
pamidronate inj 30mg ...... 33
pamidronate inj 90mg ...... 33
PANRETIN ......................... 52
pantoprazole sodium ........ 40
pantoprazole sodium tbec ......................................... 40
PANZYGA .......................... 43
paricalcitol .......................... 45
PARLODEL
see bromocriptine mesylate ..................... 23
PARNATE
see tranylcypromine sulfate ......................... 23
paroex sol 0.12% .............. 52
paromomycin sulfate .......... 4
paroxetine hcl tabs ........... 23
PASER D/R ......................... 7
PAXIL ................................. 23
see paroxetine hcl tabs 23
PAZEO ............................... 46
PEDIAPRED
see pred sod pho sol 5mg/5ml...................... 36
PEDIARIX .......................... 44
PEDVAX HIB ..................... 44
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ......................................... 39
peg 3350-potassium chloride-sod bicarbonate-sod chloride ................... 39
PEGANONE ...................... 20
PEGASYS ............................ 8
PEGASYS PROCLICK ...... 8
penicillamine ...................... 33
PENICILLIN G POT IN DEXTROSE 2MU ........... 9
PENICILLIN G POT IN DEXTROSE 3MU ........... 9
PENICILLIN G PROCAINE ........................................... 9
penicillin g sodium .............. 9
penicillin v potassium ........ 9
penicilln gk inj 20mu .......... 9
penicilln gk inj 5mu ............ 9
PENTACEL ....................... 44
PENTAM 300
see pentamidine isethionate inj .............. 5
pentamidine isethionate inh .......................................... 4
pentamidine isethionate inj 5
pentoxifylline ..................... 41
PEPCID
see famotidine .............. 39
PERCOCET
see endocet 10-325mg . 2
see endocet 2.5-325mg 2
see endocet 5-325mg .... 2
see endocet 7.5-325mg 2
see oxycodone w/ acetaminophen 10-325mg .......................... 3
see oxycodone w/ acetaminophen 2.5-325mg .......................... 3
see oxycodone w/ acetaminophen 5-325mg .......................... 3
see oxycodone w/ acetaminophen 7.5-325mg .......................... 3
PERIDEX
see chlorhexidine gluconate (mouth-throat) ......................... 52
see paroex sol 0.12% .. 52
see periogard ................ 53
perindopril erbumine ........ 14
periogard ........................... 53
permethrin cre 5% ............ 52
perphenazine .................... 25
PERSERIS ........................ 25
pfizerpen-g inj 20mu .......... 9
pfizerpen-g inj 5mu ............ 9
phenelzine sulfate ............ 23
PHENERGAN
see promethazine hcl inj .................................... 38
phenobarbital .................... 20
phenobarbital sodium ...... 20
PHENYTEK ....................... 20
see phenytoin sodium extended .................... 20
phenytoin ........................... 20
phenytoin sodium extended ......................................... 20
phenytoin sodium inj 50mg/ml ......................... 21
philith .................................. 35
PHOSLO
see calcium acetate (phosphate binder) ... 37
PHOSPHOLINE IODIDE . 47
PICATO .............................. 52
PIFELTRO ........................... 6
pilocarpine hcl ................... 47
pilocarpine hcl (oral) ......... 53
pimozide ............................. 25
pimtrea ............................... 35
pindolol ............................... 16
pioglitazone hcl ................. 32
piper/tazoba inj 12-1.5gm .. 9
piper/tazoba inj 2-0.25gm .. 9
piper/tazoba inj 3-0.375gm9
piper/tazoba inj 36-4.5gm .. 9
piper/tazoba inj 4-0.5gm .... 9
PIQRAY 200MG DAILY DOSE ............................. 12
PIQRAY 250MG DAILY DOSE ............................. 12
PIQRAY 300MG DAILY DOSE ............................. 12
pirmella 1/35 ...................... 35
piroxicam .............................. 1
PLAQUENIL
see hydroxychloroquine sulfate ......................... 42
PLASMA-LYTE A ............. 45
PLASMA-LYTE-148 ......... 45
PLAVIX
see clopidogrel tab 75mg ..................................... 42
plenamine .......................... 45
PLENVU ............................. 39
PNV FOLIC ACID + IRON MUL ................................ 45
Blue MedicareRx Premier 2020 Comprehensive Drug List
73
podofilox ............................. 52
polymyxin b-trimethoprim 46
POLYTRIM
see polymyxin b-trimethoprim ............... 46
POMALYST ....................... 11
portia-28 ............................. 35
posaconazole ...................... 5
pot chloride inj 2meq/ml ... 45
potassium chloride ..... 44, 45
POTASSIUM CHLORIDE 45
potassium chloride in nacl ......................................... 45
potassium chloride microencapsulated crystals er ....................... 44
potassium citrate (alkalinizer) er tabs ....... 40
PRADAXA .......................... 41
PRALUENT........................ 15
pramipexole tab 0.125mg 24
pramipexole tab 0.25mg .. 24
pramipexole tab 0.5mg .... 24
pramipexole tab 0.75mg .. 24
pramipexole tab 1.5mg .... 24
pramipexole tab 1mg ....... 24
prasugrel hcl ...................... 42
PRAVACHOL
see pravastatin sodium 15
pravastatin sodium ........... 15
praziquantel ......................... 5
prazosin hcl ....................... 14
PRECOSE
see acarbose ................. 31
PRED FORTE
see prednisolone acetate (ophth) ........................ 46
pred sod pho sol 5mg/5ml ......................................... 36
prednisolone acetate (ophth) ............................ 46
prednisolone sodium phosphate ...................... 36
PREDNISOLONE SODIUM PHOSPHATE (OPHTH) ......................................... 46
prednisolone sol 15mg/5ml ......................................... 36
prednisolone sol 25mg/5ml ........................................ 36
PREDNISONE CON 5MG/ML ......................... 36
prednisone pak 10mg ...... 36
prednisone pak 5mg ........ 36
prednisone sol 5mg/5ml .. 36
prednisone tab 10mg ....... 37
prednisone tab 1mg ......... 36
prednisone tab 2.5mg ...... 37
prednisone tab 20mg ....... 37
prednisone tab 50mg ....... 37
prednisone tab 5mg ......... 37
pregabalin .......................... 21
PREMASOL 10% ............. 45
PRENATAL ....................... 45
PRENATAL PLUS ............ 45
PRENATAL PLUS LOW IRON .............................. 45
PREVACID
see lansoprazole .......... 40
prevalite ............................. 15
previfem ............................. 35
PREZCOBIX ....................... 7
PREZISTA ........................... 6
PRIFTIN ............................... 7
primaquine phosphate ....... 5
PRIMAQUINE PHOSPHATE .................. 5
see primaquine phosphate .................... 5
PRIMAXIN IV
see imipenem-cilastatin 4
primidone ........................... 21
PRINIVIL
see lisinopril .................. 14
PRISTIQ
see desvenlafaxine succinate ................... 22
PRIVIGEN ......................... 43
PROAIR HFA
see albuterol sulfate .... 48
probenecid .......................... 1
PROCALAMINE ............... 45
PROCARDIA XL
see nifedipine ................ 16
prochlorperazine inj ......... 38
prochlorperazine maleate 38
prochlorperazine supp ..... 38
PROCRIT ........................... 41
PROCTOCORT
see procto-pak .............. 52
procto-med hc ................... 52
procto-pak .......................... 52
proctosol hc cre 2.5% ...... 52
proctozone-hc ................... 52
PROGLYCEM
see diazoxide ................ 37
PROGLYCEM SUS 50MG/ML ....................... 37
PROGRAF ......................... 43
see tacrolimus ............... 43
PROLASTIN-C .................. 48
PROLENSA ....................... 46
PROLIA .............................. 37
PROMACTA ................ 41, 42
promethazine hcl .............. 38
promethazine hcl inj ......... 38
propafenone hcl ................ 15
propafenone hcl 12hr ....... 15
proparacaine hcl ............... 47
propranolol & hydrochlorothiazide ...... 16
propranolol cap er ............ 16
propranolol hcl .................. 16
propranolol oral sol ........... 16
propylthiouracil .................. 38
PROQUAD ........................ 44
PROSCAR
see finasteride ............... 40
PROSOL ............................ 45
PROTONIX
see pantoprazole sodium ..................................... 40
see pantoprazole sodium tbec ............................. 40
PROTOPIC
see tacrolimus (topical) 52
protriptyline hcl .................. 23
PROVERA
see medroxyprogesterone acetate tab ................. 38
PROZAC
see fluoxetine cap 10mg ..................................... 22
Blue MedicareRx Premier 2020 Comprehensive Drug List
74
see fluoxetine cap 20mg ..................................... 22
see fluoxetine cap 40mg ..................................... 22
PULMICORT
see budesonide (inhalation) ................. 49
PULMICORT FLEXHALER ......................................... 49
PULMOZYME.................... 48
PURIXAN ........................... 10
pyrazinamide ....................... 7
pyridostigmine tab 60mg . 29
Q QUADRACEL .................... 44
QUALAQUIN
see quinine sulfate ......... 5
QUESTRAN
see cholestyramine ...... 15
QUESTRAN LIGHT
see cholestyramine light powd ........................... 15
see prevalite .................. 15
quetiapine fumarate ......... 25
quinapril hcl ....................... 14
quinapril-hydrochlorothiazide ...... 13
quinidine sulfate ................ 15
quinine sulfate ..................... 5
R RABAVERT ....................... 44
raloxifene tab 60mg .......... 37
ramipril ................................ 14
RANEXA ............................ 18
see ranolazine ............... 18
ranolazine .......................... 18
RAPAMUNE
see sirolimus ................. 43
rasagiline mesylate ........... 24
RAYALDEE ....................... 45
RAZADYNE
see galantamine hydrobromide ............ 21
RAZADYNE ER
see galantamine hydrobromide er ........ 22
RECLAST
see zoledronic acid inj 5mg/100ml ................ 33
reclipsen ............................ 35
RECOMBIVAX HB ........... 44
RECTIV .............................. 52
REGLAN
see metoclopramide hcl .................................... 38
REGRANEX ...................... 52
RELENZA DISKHALER .... 8
RELISTOR ........................ 40
RELPAX
see eletriptan hydrobromide ............ 28
REMERON
see mirtazapine ............ 23
REMERON SOLTAB
see mirtazapine ............ 23
REMICADE ....................... 42
RENFLEXIS ...................... 42
RENVELA
see sevelamer carbonate .............................. 37, 38
repaglinide ......................... 32
RESTASIS ........................ 47
RESTASIS MULTIDOSE 47
RESTORIL
see temazepam ............ 28
RETIN-A
see avita ........................ 49
see tretinoin ............ 49, 50
RETROVIR
see zidovudine cap 100mg .......................... 6
see zidovudine syp 50mg/5ml ..................... 6
REVATIO
see sildenafil citrate tab 20 mg (pulmonary hypertension) ............ 18
REVLIMID ......................... 11
REXULTI ..................... 25, 26
REYATAZ ............................ 6
see atazanavir sulfate ... 6
RHOPRESSA ................... 47
ribavirin cap 200mg ........... 8
ribavirin tab 200mg ............ 8
rifabutin ................................ 7
RIFADIN
see rifampin ..................... 7
rifampin ................................ 7
RIFATER .............................. 7
RILUTEK
see riluzole .................... 29
riluzole ................................ 29
rimantadine hydrochloride . 8
RINVOQ ............................. 42
risedronate sodium ........... 33
RISPERDAL
see risperidone ............. 26
RISPERDAL INJ 12.5MG 26
RISPERDAL INJ 25MG ... 26
RISPERDAL INJ 37.5MG 26
RISPERDAL INJ 50MG ... 26
risperidone ......................... 26
RITALIN
see methylphenidate hcl ..................................... 27
ritonavir ................................ 6
RITUXAN ........................... 11
RITUXAN HYCELA .......... 11
rivastigmine tartrate .......... 22
rivastigmine td patch 24hr 13.3 mg/24hr ................. 22
rivastigmine td patch 24hr 4.6 mg/24hr ................... 22
rivastigmine td patch 24hr 9.5 mg/24hr ................... 22
rizatriptan benzoate .......... 28
rizatriptan benzoate odt ... 28
ROCALTROL
see calcitriol ................... 45
see calcitriol oral soln 1 mcg/ml ........................ 45
ropinirole tab 0.25mg ....... 24
ropinirole tab 0.5mg ......... 24
ropinirole tab 1mg ............. 24
ropinirole tab 2mg ............. 24
ropinirole tab 3mg ............. 24
ropinirole tab 4mg ............. 24
ropinirole tab 5mg ............. 24
rosadan cre 0.75% ........... 52
rosuvastatin calcium ........ 15
ROTARIX ........................... 44
ROTATEQ ......................... 44
ROWASA
Blue MedicareRx Premier 2020 Comprehensive Drug List
75
see mesalamine w/ cleanser ...................... 39
roweepra ............................ 21
roweepra xr ........................ 21
ROXICODONE
see oxycodone hcl .......... 3
ROZLYTREK ..................... 12
RUBRACA ......................... 11
RUXIENCE ........................ 11
RYDAPT ............................. 12
RYTHMOL SR
see propafenone hcl 12hr ..................................... 15
S SABRIL
see vigabatrin powd pack 500mg ......................... 21
see vigabatrin tab 500mg ..................................... 21
see vigadrone ................ 21
SALAGEN
see pilocarpine hcl (oral) ..................................... 53
SANDIMMUNE.................. 43
see cyclosporine ........... 43
SANDOSTATIN
see octreotide acetate . 37
SANTYL ............................. 52
SAPHRIS ........................... 26
scopolamine ...................... 38
SECUADO ......................... 26
selegiline hcl ...................... 24
selenium sulfide ................ 50
SELZENTRY ....................... 6
SENSIPAR
see cinacalcet hcl ......... 37
SEREVENT DISKUS ....... 48
SEROQUEL
see quetiapine fumarate ..................................... 25
SEROQUEL XR
see quetiapine fumarate ..................................... 25
sertraline hcl ...................... 23
setlakin tab ......................... 35
sevelamer carbonate . 37, 38
sharobel ............................. 35
SHINGRIX.......................... 44
SIGNIFOR ......................... 37
sildenafil citrate tab 20 mg (pulmonary hypertension) ........................................ 18
SILENOR
see doxepin hcl (sleep) 28
SILVADENE
see silver sulfadiazine . 50
see ssd .......................... 50
silver sulfadiazine ............. 50
SIMBRINZA ...................... 47
simvastatin ........................ 15
SINEMET
see carbidopa-levodopa .................................... 23
SINGULAIR
see montelukast sodium .................................... 48
sirolimus ............................ 43
SIRTURO ............................ 7
SIVEXTRO .......................... 5
SKYRIZI ............................. 42
sodium chlor sol 0.9% irr 52
sodium chloride .......... 44, 45
sodium chloride 0.45% .... 45
sodium chloride inj 0.9% . 45
sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln ... 44
sodium phenylbutyrate .... 36
sodium polystyrene sulfonate powder .......... 33
sodium polystyrene sulfonate susp .............. 33
solifenacin succinate ....... 40
SOLIQUA 100/33 ............. 31
SOLTAMOX ...................... 11
SOLU-CORTEF ................ 37
SOLU-MEDROL
see methylpr ss inj ....... 36
SOMATULINE DEPOT ... 37
SOMAVERT ...................... 37
SORIATANE
see acitretin ................... 50
sorine ................................. 15
sotalol hcl .......................... 15
sotalol hcl (afib/afl) ........... 15
spironolactone .................. 14
spironolactone & hydrochlorothiazide ...... 17
SPORANOX
see itraconazole .............. 5
sprintec 28 ......................... 35
SPRITAM ........................... 21
SPRYCEL .......................... 12
sps susp 15gm/60ml ........ 33
sronyx ................................. 35
ssd ...................................... 50
STALEVO 100
see carbidopa/levodopa/entacapone .................... 24
STALEVO 150
see carbidopa/levodopa/entacapone .................... 24
STARLIX
see nateglinide .............. 32
stavudine .............................. 6
STELARA .......................... 42
STIMATE ........................... 38
STIVARGA ........................ 12
STRATTERA
see atomoxetine hcl ..... 27
streptomycin sulfate ........... 4
STRIBILD ............................. 7
STROMECTOL
see ivermectin ................. 4
SUBOXONE
see buprenorphine hcl-naloxone hcl dihydrate 12-3mg ....................... 30
see buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg ...................... 30
see buprenorphine hcl-naloxone hcl dihydrate 4-1mg ......................... 30
see buprenorphine hcl-naloxone hcl dihydrate 8-2mg ......................... 30
subvenite tab ..................... 21
sucralfate ........................... 40
sulfacetamide sodium (acne) ............................. 49
Blue MedicareRx Premier 2020 Comprehensive Drug List
76
sulfacetamide sodium (ophth) ............................ 46
sulfacetamide sod-prednisolone .................. 46
SULFADIAZINE .................. 4
sulfamethoxazole-trimethop ds ....................................... 5
sulfamethoxazole-trimethoprim inj ............... 5
sulfamethoxazole-trimethoprim susp ........... 5
sulfamethoxazole-trimethoprim tab 400-80mg ................................. 5
SULFAMYLON .................. 50
sulfasalazine ...................... 39
sulfasalazine ec ................ 39
sulindac ................................ 1
sumatriptan ........................ 28
sumatriptan inj 4mg/0.5ml ......................................... 28
sumatriptan inj 6mg/0.5ml ................................... 28, 29
sumatriptan succinate ...... 29
SUPRAX
see cefixime ..................... 8
SUPREP BOWEL PREP KIT ................................... 39
SUSTIVA
see efavirenz ................... 6
SUTENT ............................. 12
syeda .................................. 35
SYLATRON ....................... 13
SYMBICORT ..................... 49
SYMDEKO ......................... 48
SYMFI ................................... 7
SYMFI LO ............................ 7
SYMJEPI ............................ 48
SYMLINPEN 120 .............. 31
SYMLINPEN 60 ................ 31
SYMPAZAN ....................... 21
SYMTUZA ............................ 7
SYNALAR
see fluocinolone acetonide ................... 51
SYNAREL .......................... 35
SYNERCID .......................... 5
SYNJARDY TAB 12.5-1000MG ......................... 32
SYNJARDY TAB 12.5-500MG ........................... 32
SYNJARDY TAB 5-1000MG ......................... 32
SYNJARDY TAB 5-500MG ........................................ 32
SYNJARDY XR TAB 10-1000MG ......................... 32
SYNJARDY XR TAB 12.5-1000MG ......................... 32
SYNJARDY XR TAB 25-1000MG ......................... 32
SYNJARDY XR TAB 5-1000MG ......................... 32
SYNRIBO .......................... 13
SYNTHROID ..................... 38
see euthyrox ................. 38
see levo-t ....................... 38
see levothyroxine sodium .................................... 38
see levoxyl .................... 38
see unithroid ................. 38
SYPRINE
see clovique .................. 33
see trientine hcl ............ 33
T TABLOID ........................... 10
tacrolimus .......................... 43
tacrolimus (topical) ........... 52
tadalafil (pulmonary hypertension) ................ 18
TAFINLAR ......................... 12
TAGRISSO ........................ 12
TALZENNA ....................... 11
TAMIFLU
see oseltamivir phosphate ................ 7, 8
tamoxifen citrate ............... 11
tamsulosin hcl ................... 40
TAPAZOLE
see methimazole .......... 38
TARCEVA
see erlotinib hcl ............ 12
TARGRETIN ..................... 52
see bexarotene ............. 13
tarina fe 1/20 ..................... 35
TASIGNA ........................... 12
TAXOTERE ....................... 10
see docetaxel ................ 10
tazarotene .......................... 50
tazicef ................................... 8
TAZORAC .......................... 50
see tazarotene .............. 50
taztia xt ............................... 16
TAZVERIK ......................... 13
TDVAX ............................... 44
TECENTRIQ ...................... 11
TEFLARO ............................ 8
TEGRETOL
see carbamazepine ...... 19
see epitol ........................ 19
TEGRETOL-XR
see carbamazepine ...... 19
TEKTURNA
see aliskiren fumarate .. 17
telmisartan ......................... 14
temazepam ........................ 28
TEMIXYS ............................. 7
TENIVAC ........................... 44
tenofovir disoproxil fumarate ........................... 6
TENORETIC 100
see atenolol & chlorthalidone ............ 16
TENORETIC 50
see atenolol & chlorthalidone ............ 16
TENORMIN
see atenolol ................... 16
terazosin hcl ...................... 14
terbinafine hcl ...................... 5
terbutaline sulfate ............. 48
terconazole vaginal .......... 41
testosterone ....................... 30
testosterone cypionate .... 30
testosterone enanthate .... 30
tetrabenazine .................... 29
tetracycline hcl .................. 10
TEXACORT SOLN 2.5% . 51
THALOMID ........................ 11
THEO-24 ............................ 48
theophylline ....................... 48
theophylline tab er 12hr 300 mg ........................... 49
Blue MedicareRx Premier 2020 Comprehensive Drug List
77
theophylline tab er 12hr 450 mg ........................... 49
theophylline tab sr 24hr ... 49
thioridazine hcl .................. 26
thiothixene ......................... 26
tiadylt er .............................. 17
tiagabine hcl ...................... 21
TIAZAC
see diltiazem hcl extended release beads cap sr .............. 16
see taztia xt ................... 16
see tiadylt er .................. 17
TIBSOVO ........................... 11
tigecycline ............................ 5
TIKOSYN
see dofetilide ................. 14
tilia fe .................................. 35
timolol maleate .................. 16
timolol maleate (ophth) soln ......................................... 47
timolol maleate gel ........... 47
timolol maleate ophth soln 0.5% (once-daily) .......... 47
TIMOPTIC
see timolol maleate (ophth) soln ................ 47
TIMOPTIC-XE
see timolol maleate gel 47
TIVICAY ............................... 6
tizanidine hcl ................ 29, 30
TOBRADEX ....................... 46
see tobramycin-dexamethasone ........ 46
TOBRADEX ST ................. 46
tobramycin ........................... 4
tobramycin (ophth) ........... 46
tobramycin inj 1.2 gm/30ml ........................................... 4
tobramycin inj 1.2gm .......... 4
tobramycin inj 10mg/ml ...... 4
tobramycin inj 80mg/2ml ... 4
tobramycin sulfate .............. 4
tobramycin-dexamethasone ......................................... 46
TOBREX
see tobramycin (ophth) 46
tolterodine tartrate ............ 40
TOPAMAX
see topiramate .............. 21
TOPAMAX SPRINKLE
see topiramate .............. 21
topiramate ......................... 21
toposar ............................... 13
TOPROL XL
see metoprolol succinate .................................... 16
toremifene citrate ............. 11
torsemide tabs .................. 17
TOVIAZ .............................. 41
TPN ELECTROLYTES .... 44
TRACLEER
see bosentan ................ 18
TRADJENTA ..................... 32
tramadol hcl tab 50 mg ...... 1
tramadol-acetaminophen .. 2
trandolapril ........................ 14
tranexamic acid ................ 42
TRANSDERM SCOP
see scopolamine .......... 38
tranylcypromine sulfate ... 23
TRAVASOL ....................... 45
TRAVATAN Z
see travoprost ............... 47
travoprost .......................... 47
TRAZIMERA ..................... 11
trazodone hcl .................... 23
TRECATOR ........................ 7
TRELEGY ELLIPTA ........ 47
TRELSTAR DEP INJ 3.75MG .......................... 11
TRELSTAR LA INJ 11.25MG ........................ 11
treprostinil .......................... 18
TRESIBA FLEXTOUCH .. 31
TRESIBA INJ .................... 31
tretinoin ........................ 49, 50
tretinoin (chemotherapy) . 13
triamcinolone acetonide (mouth) .......................... 53
triamcinolone acetonide (topical) .......................... 51
triamterene & hydrochlorothiazide cap 37.5-25 mg .................... 17
triamterene & hydrochlorothiazide tabs ......................................... 17
TRIBENZOR
see olmesartan medoxomil-amlodipine-hydrochlorothiazide .. 14
TRICARE ........................... 45
TRICOR
see fenofibrate .............. 15
trientine hcl ........................ 33
tri-estarylla ......................... 35
trifluoperazine hcl ............. 26
trifluridine ........................... 46
trihexyphenidyl hcl ............ 24
TRIKAFTA ......................... 49
tri-legest fe ......................... 35
TRILEPTAL
see oxcarbazepine ....... 20
tri-linyah .............................. 35
tri-lo marzia ........................ 35
tri-lo-estarylla ..................... 35
tri-lo-sprintec ...................... 35
trilyte ................................... 39
trimethoprim ........................ 5
tri-mili .................................. 35
trimipramine maleate ....... 23
TRINTELLIX ...................... 23
tri-previfem ......................... 35
tri-sprintec .......................... 35
TRIUMEQ ............................ 7
trivora-28 ............................ 35
tri-vylibra ............................ 35
tri-vylibra lo ........................ 35
TRIZIVIR
see abacavir sulfate-lamivudine-zidovudine ....................................... 7
TROGARZO ........................ 6
TROPHAMINE INJ 10% .. 45
trospium chloride .............. 41
TRULICITY ........................ 31
TRUMENBA ...................... 44
TRUSOPT
see dorzolamide hcl ..... 47
TRUVADA TAB 100-150 ... 7
TRUVADA TAB 133-200 ... 7
TRUVADA TAB 167-250 ... 7
Blue MedicareRx Premier 2020 Comprehensive Drug List
78
TRUVADA TAB 200-300 ... 7
TRUXIMA ........................... 11
tulana .................................. 35
TURALIO............................ 12
TWINRIX INJ ..................... 44
TYBOST ............................... 6
TYGACIL
see tigecycline ................. 5
TYKERB ............................. 12
TYLENOL/CODEINE #3
see acetaminophen w/ codeine 300-30mg ...... 1
TYMLOS ............................ 37
TYPHIM VI ......................... 44
U ULTRACET
see tramadol-acetaminophen ........... 2
ULTRAM
see tramadol hcl tab 50 mg ................................. 1
UNASYN
see ampicillin & sulbactam sodium ....... 9
UNASYN BULK PACK
see ampicillin & sulbactam sodium ....... 9
unithroid ............................. 38
URECHOLINE
see bethanechol chloride ..................................... 40
UROCIT-K 10
see potassium citrate (alkalinizer) er tabs ... 40
UROCIT-K 15
see potassium citrate (alkalinizer) er tabs ... 40
UROCIT-K 5
see potassium citrate (alkalinizer) er tabs ... 40
UROXATRAL
see alfuzosin hcl ........... 40
URSO 250
see ursodiol ................... 40
URSO FORTE
see ursodiol ................... 40
ursodiol ............................... 40
V VAGIFEM
see estradiol vaginal tab .................................... 36
see yuvafem vaginal tablet 10mcg ............. 36
valacyclovir hcl ................... 8
VALCHLOR ....................... 52
VALCYTE
see valganciclovir hcl .... 8
valganciclovir hcl ................ 8
VALIUM
see diazepam ............... 19
valproate sodium .............. 21
valproate sodium oral soln ........................................ 21
valproic acid ...................... 21
valsartan ............................ 14
valsartan-hydrochlorothiazide ...... 14
VALTOCO ......................... 21
VALTREX
see valacyclovir hcl ........ 8
VANCOCIN
see vancomycin hcl ....... 5
VANCOCIN HCL
see vancomycin hcl ....... 5
vancomycin hcl ................... 5
VANCOMYCIN IN NACL .. 5
vandazole .......................... 41
VAQTA ............................... 44
VARIVAX ........................... 44
VASCEPA ......................... 15
VASERETIC
see enalapril maleate & hydrochlorothiazide .. 13
VASOTEC
see enalapril maleate .. 14
VELCADE .......................... 11
velivet ................................. 35
VELTASSA ........................ 33
VEMLIDY ............................. 8
VENCLEXTA .................... 11
VENCLEXTA STARTING PACK ............................. 11
venlafaxine hcl .................. 23
VENTAVIS ........................ 18
VENTOLIN HFA ............... 48
verapamil cap er ............... 17
verapamil hcl ..................... 17
verapamil tab er ................ 17
VERELAN
see verapamil cap er .... 17
VERELAN PM
see verapamil cap er .... 17
VERSACLOZ .................... 26
VERZENIO ........................ 11
VESICARE ........................ 41
see solifenacin succinate ..................................... 40
VFEND
see voriconazole ............. 5
VFEND IV
see voriconazole ............. 5
VIBRAMYCIN
see doxycycline hyclate . 9
VICTOZA ........................... 31
VIDAZA
see azacitidine .............. 10
VIDEX EC 125MG .............. 6
VIDEX PEDIATRIC ............ 6
vienva ................................. 35
vigabatrin powd pack 500mg ............................ 21
vigabatrin tab 500mg ....... 21
vigadrone ........................... 21
VIGAMOX
see moxifloxacin hcl (ophth) ........................ 46
VIIBRYD STARTER PACK ......................................... 23
VIIBRYD TAB .................... 23
VIMPAT .............................. 21
VIMPAT INJ 200MG/20ML ......................................... 21
VIMPAT SOL 10MG/ML .. 21
vincristine sulfate .............. 10
vinorelbine tartrate ............ 10
viorele ................................. 35
VIRACEPT ........................... 6
VIRAMUNE
see nevirapine susp 50 mg/5ml .......................... 6
see nevirapine tab 200mg .......................... 6
VIRAMUNE XR
Blue MedicareRx Premier 2020 Comprehensive Drug List
79
see nevirapine tab 400mg er ...................... 6
VIREAD ................................ 6
see tenofovir disoproxil fumarate ....................... 6
VISTARIL
see hydroxyzine pamoate ..................... 47
VITRAKVI ........................... 12
VIVITROL ........................... 30
VIZIMPRO.......................... 12
VOLTAREN
see diclofenac sodium (topical) 1% gel ......... 52
voriconazole ........................ 5
VOSEVI ................................ 8
VOTRIENT ......................... 12
VRAYLAR .......................... 26
VRAYLAR THERAPY PACK .............................. 26
vyfemla ............................... 35
vylibra ................................. 35
VYTORIN
see ezetimibe-simvastatin ................. 15
W warfarin sodium ................. 41
water for irrigation, sterile ......................................... 52
WELCHOL
see colesevelam hcl ..... 15
WELLBUTRIN SR
see bupropion hcl ......... 22
WELLBUTRIN XL
see bupropion hcl ......... 22
X XALATAN
see latanoprost ............. 47
XALKORI ........................... 12
XANAX
see alprazolam tab 0.25mg ....................... 18
see alprazolam tab 0.5mg .......................... 18
see alprazolam tab 1mg ..................................... 18
see alprazolam tab 2 mg ..................................... 18
XARELTO .......................... 41
XARELTO STARTER PACK ............................. 41
XATMEP ............................ 42
XELJANZ ........................... 42
XELJANZ XR .................... 42
XENAZINE
see tetrabenazine ........ 29
XGEVA .............................. 37
XIFAXAN ........................... 40
XIGDUO XR TAB 10-1000MG ......................... 33
XIGDUO XR TAB 10-500MG ........................... 33
XIGDUO XR TAB 2.5-1000MG ......................... 32
XIGDUO XR TAB 5-1000MG ......................... 33
XIGDUO XR TAB 5-500MG ........................................ 33
XOLAIR .............................. 49
XOPENEX
see levalbuterol hcl ...... 48
XOPENEX CONCENTRATE
see levalbuterol hcl soln nebu conc 1.25 mg/0.5ml .................... 48
XOSPATA ......................... 12
XPOVIO 100 MG ONCE WEEKLY ........................ 13
XPOVIO 60 MG ONCE WEEKLY ........................ 13
XPOVIO 80 MG ONCE WEEKLY ........................ 13
XPOVIO 80 MG TWICE WEEKLY ........................ 13
XTANDI .............................. 11
xulane dis 150-35 ............. 35
XULTOPHY 100/3.6 ........ 31
XYLOCAINE
see lidocaine hcl (local anesth.) ........................ 3
see lidocaine inj 0.5% .... 3
see lidocaine inj 1% ....... 3
XYLOCAINE-MPF
see lidocaine hcl (local anesth.) ........................ 3
see lidocaine inj 1.5% preservative free (pf) .. 4
XYREM .............................. 30
Y YASMIN 28
see drospirenone-ethinyl estradiol ...................... 34
see ocella tab 3-0.03mg ..................................... 35
see syeda ...................... 35
see zarah ....................... 35
YAZ
see drospirenone-ethinyl estradiol ...................... 34
see gianvi tab 3-0.02mg ..................................... 34
see jasmiel ..................... 34
see loryna ...................... 34
see nikki ......................... 35
YF-VAX .............................. 44
yuvafem vaginal tablet 10mcg ............................. 36
Z zafirlukast ........................... 48
ZANAFLEX
see tizanidine hcl .......... 30
zarah ................................... 35
ZARONTIN
see ethosuximide .......... 19
ZARXIO .............................. 41
ZAVESCA
see miglustat ................. 36
ZEJULA .............................. 11
ZELBORAF ........................ 13
ZEMAIRA ........................... 49
ZEMPLAR
see paricalcitol .............. 45
zenatane ............................ 50
ZENPEP ............................. 40
ZERIT
see stavudine .................. 6
ZESTORETIC
see lisinopril & hydrochlorothiazide .. 13
ZESTRIL
see lisinopril ................... 14
ZETIA
see ezetimibe ................ 15
Blue MedicareRx Premier 2020 Comprehensive Drug List
80
ZIAC
see bisoprolol & hydrochlorothiazide .. 16
ZIAGEN
see abacavir sulfate ....... 6
zidovudine cap 100mg ....... 6
zidovudine syp 50mg/5ml .. 6
zidovudine tab 300mg ........ 6
ziprasidone hcl .................. 26
ziprasidone mesylate ....... 26
ZIRABEV ............................ 11
ZIRGAN .............................. 46
ZITHROMAX see azithromycin ............. 8
ZOCOR
see simvastatin ............. 15
ZOFRAN
see ondansetron hcl ..... 38
zoledronic acid inj 4mg/100ml ..................... 33
zoledronic acid inj 5mg/100ml ..................... 33
zoledronic inj 4mg/5ml ..... 33
ZOLINZA ............................ 11
zolmitriptan ........................ 29
zolmitriptan odt ................. 29
ZOLOFT
see sertraline hcl .......... 23
zolpidem tartrate .............. 28
ZOMIG
see zolmitriptan ............ 29
ZOMIG ZMT
see zolmitriptan odt ...... 29
ZONEGRAN
see zonisamide ............ 21
zonisamide ........................ 21
ZORTRESS
see everolimus (immunosuppressant) .................................... 43
ZORTRESS TAB 0.25MG ........................................ 43
ZORTRESS TAB 0.5MG 43
ZORTRESS TAB 0.75MG ........................................ 43
ZORTRESS TAB 1MG .... 43
ZOSTAVAX ....................... 44
zovia 1/35e ........................ 35
ZOVIRAX
see acyclovir .................... 7
ZYDELIG ............................ 13
ZYKADIA ............................ 13
ZYLET ................................ 46
ZYLOPRIM
see allopurinol tab .......... 1
ZYMAXID
see gatifloxacin (ophth) 46
ZYPREXA
see olanzapine .............. 25
ZYPREXA RELPREVV .... 26
ZYPREXA RELPREVV INJ 210MG ............................ 26
ZYPREXA ZYDIS
see olanzapine .............. 25
ZYTIGA .............................. 11
see abiraterone acetate ..................................... 11
ZYVOX
see linezolid inj ................ 4
see linezolid susp ........... 4
see linezolid tab 600mg . 4
P.O. Box 30011, Pittsburgh, PA 15222-0330
This formulary was updated on 06/01/2020. For more recent information or other questions, please contact Blue MedicareRx Premier, at:
Connecticut 1-888-620-1747 Rhode Island 1-888-620-1748
Massachusetts 1-888-543-4917 Vermont 1-888-620-1746
or, for TTY/TDD users, 711, 24 hours a day, 7 days a week, or visit www.RxMedicarePlans.com
You can get prescription drugs shipped to your home through our network mail order delivery programwhich is called CVS Caremark Mail Service Pharmacy.
You also have the option to enroll your prescriptions in an automatic refill program. Under thisprogram, we will start to process your next refill automatically when our records show that you shouldbe close to running out of your drug. And, when your prescription is going to expire or is out of refills,we’ll contact your doctor for a new one. We’ll contact you by phone, text message or email (yourchoice) before we mail your medication.
For new prescriptions, we’ll let you know before we send the first fill of your medication. There maybe times when Medicare requires us to get your approval before sending your prescription to you. Onevery order, you’ll have time to make changes or cancel, and you won’t be charged until it ships. Youcan start or stop automatic refills at any time.
Typically, you should expect to receive your prescription drugs within 10 calendar days from the time that the mail order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact us at the number listed in the table above. TTY/TDD users should call 711.
Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare Contract. Blue MedicareRxValue Plus (PDP) and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plansavailable to service residents of Connecticut, Massachusetts, Rhode Island, and Vermont.
Coverage is available to residents of the service area or members of an employer or union group andseparately issued by one of the following plans: Anthem Blue Cross® and Blue Shield® ofConnecticut, Blue Cross Blue Shield of Massachusetts, Blue Cross and Blue Shield of Rhode Island,and Blue Cross and Blue Shield of Vermont.
Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross &Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities whichhave contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) andare the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is aMedicare-approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends on contractrenewal.
Independent Licensees of the Blue Cross and Blue Shield Association ®Registered Marks of the Blue Cross and Blue Shield Association. ®´, SM, TM Registered Marks and Trademarks are property of their respective owners. ©2020 All Rights Reserved.