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Step Therapy Medications

Step therapy is a limitation that requires you to try preferred medications before the plan will pay for another medication for the same medical condition that the doctor may have originally prescribed. An automated, electronic review of your medication history is performed to determine whether other medications have been tried first for your condition. This ensures clinically sound and cost-effective treatment options are tried. If a prescribed medication does not meet the step therapy criteria, it may not be covered. You should consult with your doctor about alternative therapy. If a medication does not meet the step therapy criteria for automatic approval, it will reject at the pharmacy; your provider may request prior authorization.

Questions?

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Member Services Phone Number Standard Hours of Operation

Pharmacy Benefits 1 (866) 325-1794 24/7/365

BCBSAZ Call the number on your ID card 8:30 a.m. to 4:30 p.m.

Monday - Friday

Step Therapy Drug List

Table of Contents

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* ..............................................................................................................4*Antiasthmatic And Bronchodilator Agents* ........................................................................................................................4*Anticonvulsants* ................................................................................................................................................................... 6*Antidepressants* ................................................................................................................................................................... 7*Antidiabetics* .........................................................................................................................................................................8*Antiemetics* ......................................................................................................................................................................... 12*Antifungals* ..........................................................................................................................................................................12*Antihistamines* ....................................................................................................................................................................12*Antihyperlipidemics* ........................................................................................................................................................... 12*Antimalarials* .......................................................................................................................................................................13*Antipsychotics/Antimanic Agents* .................................................................................................................................... 13*Antivirals* ............................................................................................................................................................................. 13*Beta Blockers* ..................................................................................................................................................................... 14*Calcium Channel Blockers* ................................................................................................................................................ 14*Cardiovascular Agents - Misc.* .......................................................................................................................................... 14*Corticosteroids* ...................................................................................................................................................................14*Dermatologicals* ................................................................................................................................................................. 14*Diagnostic Products* .......................................................................................................................................................... 16*Digestive Aids* .....................................................................................................................................................................29*Gastrointestinal Agents - Misc.* .........................................................................................................................................29*Gout Agents* ........................................................................................................................................................................30*Hematopoietic Agents* ....................................................................................................................................................... 30*Hypnotics/Sedatives/Sleep Disorder Agents* ...................................................................................................................30*Medical Devices And Supplies* ..........................................................................................................................................30*Migraine Products* .............................................................................................................................................................. 32*Musculoskeletal Therapy Agents* ..................................................................................................................................... 32*Ophthalmic Agents* ............................................................................................................................................................ 32*Psychotherapeutic And Neurological Agents - Misc.* ..................................................................................................... 32*Ulcer Drugs/Antispasmodics/Anticholinergics* ............................................................................................................... 32*Vaccines* ..............................................................................................................................................................................33

2

Step 2 Product Step 1 Product

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*

*Adhd Agent - Selective Norepinephrine Reuptake Inhibitor***

QELBREE

QL (1 capsule per day); Step Therapy Required (EST as follows:ST through atomoxetine (generic for Strattera) for at least 3 months in the last 12 months.)

*Amphetamine Mixtures***

MYDAYIS

QL (1 capsule per day); Step Therapy Required (Trial of the following for 3 months in last 12 months: ADDERALL XR or amphetamine/dextroamphetamine ER); AL (Min 6 Years)

*Antiasthmatic And Bronchodilator Agents*

*5-Lipoxygenase Inhibitors***

zileuton er

QL (4 tablets per day); Step Therapy Required (Trial of both of the following for at least 3 months each in last 12 months: montelukast, zafirlukast); AL (Min 12 Years)

ZYFLOStep Therapy Required (Trial of both of the following for at least 3 months each in last 12 months: montelukast, zafirlukast)

ZYFLO CR

QL (4 tablets per day); Step Therapy Required (Trial of both of the following for at least 3 months each in last 12 months: montelukast, zafirlukast); AL (Min 12 Years)

*Adrenergic Combinations***

AIRDUO DIGIHALER

QL (1 inhaler per month); Step Therapy Required (Trial of two of the following for 3 months each in the last 12 months: ADVAIR (DISKUS or HFA), BREO ELLIPTA, fluticasone propionate/salmeterol, SYMBICORT); AL (Min 12 Years)

AIRDUO RESPICLICK 113/14

QL (1 inhaler per month); Step Therapy Required (Trial of two the following for 3 months in the last 12 months: ADVAIR (DISKUS or HFA), BREO ELLIPTA, fluticasone propionate/salmeterol, SYMBICORT); AL (Min 12 Years)



Last revision date:08/12/2021 To search for a drug use control + f 4




BEVESPI AEROSPHERE

QL (1x 5.9gm or 1x 10.7gm inhaler per month); Step Therapy Required (Trial of both of the following in the last 12 months: ANORO ELLIPTA, STIOLTO RESPIMAT); AL (Min 15 Years)

BREZTRI AEROSPHERE

Step Therapy Required (Trial of two of the following for 3 months each in the last 12 months: Bevespi, Duaklir Pressair, Lonhala Magnair)

DUAKLIR PRESSAIRStep Therapy Required (Trial of both of the following in the last 6 months: ANORO ELLIPTA, SYMBICORT)

DULERA

QL (1x 8.8gm or 1x 13gm inhaler per month); Step Therapy Required (Trial of two the following for 3 months in the last 12 months: ADVAIR (DISKUS or HFA), BREO ELLIPTA, fluticasone propionate/salmeterol, SYMBICORT)

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

QL (2 blisters per day); Step Therapy Required (Trial of the following in last 3 months: ADVAIR DISKUS)

fluticasone-salmeterol inhalation aerosol powder breath activated 113-14 mcg/act, 232-14 mcg/act, 55-14 mcg/act

QL (1 inhaler per month); Step Therapy Required (Trial of the following in last 3 months: ADVAIR DISKUS); AL (Min 12 Years)

UTIBRON NEOHALERStep Therapy Required (Trial of both of the following in the last 12 months: ANORO ELLIPTA, STIOLTO RESPIMAT)

WIXELA INHUBQL (2 blisters per day); Step Therapy Required (Trial of the following in last 3 months: ADVAIR DISKUS)

*Beta Adrenergics***

levalbuterol tartrateQL (1gm per day); Step Therapy Required (Trial of the following in the last 1 month: Albuterol HFA)

PROVENTIL HFA

Step Therapy Required (Trial of both of the following in the last 12 months: PROAIR (HFA or RESPICLICK) and VENTOLIN HFA)

STRIVERDI RESPIMAT

Step Therapy Required (Trial of three of the following for 3 months each In the last 12 months: ANORO ELLIPTA, ARCAPTA NEOHALER, SEREVENT DISKUS, simultaneous use of SPIRIVA with SEREVENT DISKUS, simultaneous use of SPIRIVA with ARCAPTA NEOHALER)



XOPENEX HFAQL (1gm per day); Step Therapy Required (Trial of the following in the last 1 month: Albuterol HFA)

*Bronchodilators - Anticholinergics***

LONHALA MAGNAIR REFILL KIT

Step Therapy Required (Trial of two of the following for 3 months each in the last 12 months: INCRUSE ELLIPTA, SEEBRI NEOHALER, SPIRIVA (HANDIHALER or RESPIMAT), TUDORZA PRESSAIR); AL (Min 18 Years)

LONHALA MAGNAIR STARTER KIT

Step Therapy Required (Trial of two of the following for 3 months each in the last 12 months: INCRUSE ELLIPTA, SEEBRI NEOHALER, SPIRIVA (HANDIHALER or RESPIMAT), TUDORZA PRESSAIR); AL (Min 18 Years)

*Steroid Inhalants***

ARMONAIR DIGIHALERStep Therapy Required (Trial of the following in the last 3 months: Flovent)

*Anticonvulsants*

*Anticonvulsants - Benzodiazepines***

SYMPAZANQL (2 films per day); Step Therapy Required (Trial of the following in the last 3 months: ONFI)

*Anticonvulsants - Misc.***

APTIOM ORAL TABLET 200 MG, 400 MG

QL (1 tablet per day); Step Therapy Required (Trial of three of the following in the last 12 months: gabapentin, lamotrigine, levetiracetam, oxcarbazepine, pregabalin, topiramate, zonisamide)

APTIOM ORAL TABLET 600 MG, 800 MG

QL (2 tablets per day); Step Therapy Required (Trial of three of the following in the last 12 months: gabapentin, lamotrigine, levetiracetam, oxcarbazepine, pregabalin, topiramate, zonisamide)

BRIVIACT ORAL SOLUTION

QL (20ml per day); Step Therapy Required (Trial of the following for 2 months in the last 12 months: levetiracetam (generic for KEPPRA)); AL (Min 4 Years)

BRIVIACT ORAL TABLET

QL (2 tablets per day); Step Therapy Required (Trial of the following for 2 months in the last 12 months: levetiracetam (generic for KEPPRA)); AL (Min 4 Years)

ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG

QL (3 tablets per day); Step Therapy Required (EST as follows: ST through levetircetam 24hr tablet (generic for KEPPRA ) for at least 3 months in the last 12 months.); AL (Min 12 Years)



ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 1500 MG

QL (2 tablets per day); Step Therapy Required (EST as follows: ST through levetircetam 24hr tablet (generic for KEPPRA ) for at least 3 months in the last 12 months.); AL (Min 12 Years)

QUDEXY XR

Step Therapy Required (Trial of the following for 3 months in the last 12 months: topiramate (generic for TOPAMAX)); AL (Min 3 Years)

topiramate er

Step Therapy Required (Trial of the following for 3 months in the last 12 months: topiramate (generic for TOPAMAX)); AL (Min 3 Years)

TROKENDI XR

Step Therapy Required (Trial of both of the following for 3 months each in the last 12 months: topiramate (generic for TOPAMAX) and topiramate ER capsule (generic for QUDEXY XR)); AL (Min 6 Years)

*Carbamates***

XCOPRI

QL (1 tablet per day); Step Therapy Required (Trial of at least 3 of the following in the last 12 months: carbamazepine, lacosamide (generic for VIMPAT), lamotrigine, levetiracetam IR, oxcarbazepine, topiramate, valproic acid & derivatives)

XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 50 & 200 MG

QL (2 tablets per day); Step Therapy Required (Trial of at least 3 of the following in the last 12 months: carbamazepine, lacosamide (generic for VIMPAT), lamotrigine, levetiracetam IR, oxcarbazepine, topiramate, valproic acid & derivatives)

XCOPRI (350 MG DAILY DOSE)

QL (2 tablets per day); Step Therapy Required (Trial of at least 3 of the following in the last 12 months: carbamazepine, lacosamide (generic for VIMPAT), lamotrigine, levetiracetam IR, oxcarbazepine, topiramate, valproic acid & derivatives)

*Antidepressants*

*Serotonin Modulators***

TRINTELLIX ORAL TABLET 10 MG

QL (2 tablets per day); Step Therapy Required (Trial of two drugs in either of the following classes for at least 2 months in last 12 months: selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors); AL (Min 18 Years)



TRINTELLIX ORAL TABLET 20 MG, 5 MG

QL (1 tablet per day); Step Therapy Required (Trial of two drugs in either of the following classes for at least 2 months in last 12 months: selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors); AL (Min 18 Years)

*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)***

DRIZALMA SPRINKLE

QL (1 capsule per day); Step Therapy Required (Trial of the following for 3 month in the last 6 months: CYMBALTA, duloxetine); AL (Min 7 Years)

FETZIMA

QL (1 capsule per day); Step Therapy Required (Trial of two drugs in either of the following classes for at least 2 months in last 12 months: selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors)

FETZIMA TITRATION

QL (1 capsule per day); Step Therapy Required (Trial of two drugs in either of the following classes for at least 2 months in last 12 months: selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors)

*Antidiabetics*

*Biguanides***

FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG

QL (2 tablets per day); Step Therapy Required (Trial of both of the following for 3 months each in the last 12 months: generic GLUCOPHAGE XR and generic FORTAMET)

FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG

QL (4 tablets per day); Step Therapy Required (Trial of both of the following for 3 months each in the last 12 months: generic GLUCOPHAGE XR and generic FORTAMET)

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg

QL (2 tablets per day); Step Therapy Required (Trial of the following for 3 months in the last 12 months: generic GLUCOPHAGE XR)

metformin hcl er (osm) oral tablet extended release 24 hour 500 mg

QL (4 tablets per day); Step Therapy Required (Trial of the following for 3 months in the last 12 months: generic GLUCOPHAGE XR)

RIOMET ERQL (20ml per day); Step Therapy Required (Trial of the following in the last 6 months: generic GLUCOPHAGE ER tablet 500mg)

*Diabetic Other***

ZEGALOGUE

QL (0.6ml/day with fill limit of 2 fills/month); DS (2); Step Therapy Required (EST: Step through generic Glucagon (NDC 00548585000) for at least 1 month in the last 12 months); AL (Min 6 Years)



*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors***

alogliptin benzoate

Step Therapy Required (Trial of one the following for 3 months in the last 12 months: simultaneous use of metformin with ONGLYZA or simultaneous use of metformin with JANUVIA)

NESINA

Step Therapy Required (Trial of one the following for 3 months in the last 12 months: simultaneous use of metformin with ONGLYZA or simultaneous use of metformin with JANUVIA)

*Human Insulin***

ADMELOGQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

ADMELOG SOLOSTARQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

APIDRAQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTORQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

BASAGLAR KWIKPENQL (2ml per day); Step Therapy Required (Trial history of LANTUS)

FIASPQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

FIASP FLEXTOUCHQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

HUMULIN R U-500 (CONCENTRATED)QL (2ml per day); Step Therapy Required (Trial of the following for 3 months in the last 6 months: HUMULIN R U-100)

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

QL (2ml per day); Step Therapy Required (Trial of the following for 3 months in the last 6 months: HUMULIN R U-100)

insulin asp prot & asp flexpenQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG MIX 75/25)

insulin aspartQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

insulin aspart flexpenQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

insulin aspart penfillQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)



insulin aspart prot & aspartQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG MIX 75/25)

insulin lispro (1 unit dial)QL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

insulin lispro junior kwikpenQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

insulin lispro prot & lisproQL (60ml per month); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

insulin lispro subcutaneous solutionQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

LEVEMIRQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: LANTUS)

LEVEMIR FLEXTOUCHQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: LANTUS)

NOVOLIN 70/30QL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMULIN 70/30)

NOVOLIN 70/30 FLEXPENQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMULIN 70/30)

NOVOLIN 70/30 FLEXPEN RELIONQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMULIN 70/30)

NOVOLIN 70/30 RELIONQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMULIN 70/30)

NOVOLIN NQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMULIN N)

NOVOLIN N FLEXPENQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMULIN N)

NOVOLIN N FLEXPEN RELIONQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMULIN N)

NOVOLIN N RELIONQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMULIN N)

NOVOLIN RQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMULIN R)

NOVOLIN R FLEXPENQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMULIN R)



NOVOLIN R FLEXPEN RELIONQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMULIN R)

NOVOLIN R RELIONQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMULIN R)

NOVOLOGQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTORQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

NOVOLOG MIX 70/30QL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG MIX 75/25)

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

QL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG MIX 75/25)

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGEQL (2ml per day); Step Therapy Required (Trial of the following in the last 12 months: HUMALOG)

SEMGLEEQL (2ml per day); Step Therapy Required (Trial history of LANTUS)

TRESIBAQL (1ml per day); Step Therapy Required (Trial of the following in the last 12 months: LANTUS); AL (Min 1 Years)

TRESIBA FLEXTOUCHStep Therapy Required (Trial of the following in the last 12 months: LANTUS); AL (Min 1 Years)

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)***

ADLYXIN

QL (2 pens (6ml) per month); Step Therapy Required (Trial of either Byetta or Bydureon/Bydureon Bisce AND one of 4 following drugs-Victoza, Rybelsus, Orencia or Trulicity.); AL (Min 18 Years)

ADLYXIN STARTER PACK

QL (2 pens per lifetime); Step Therapy Required (Trial of either Byetta or Bydureon/Bydureon Bisce AND one of 4 following drugs-Victoza, Rybelsus, Orencia or Trulicity.); AL (Min 18 Years)

*Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations***

QTERN

Step Therapy Required (Trial of one drug in each category for at least 3 months: FARXIGA or XIGDUO XR and GLYXAMBI, JARDIANCE, SYNJARDY, SYNJARDY XR, or TRIJARDY)

STEGLUJAN




*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors***

INVOKANA


STEGLATRO

QL (1ml per day); Step Therapy Required (Trial of one drug in each category for at least 3 months: FARXIGA or XIGDUO XR and GLYXAMBI, JARDIANCE, SYNJARDY, SYNJARDY XR, or TRIJARDY)

*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb***

INVOKAMET


INVOKAMET XR


SEGLUROMET


*Antiemetics*

*Antiemetic Combinations***

AKYNZEO ORALStep Therapy Required (Trial of the following in the last 3 months: simultaneous use of ondansetron with aprepitant)

*Antifungals*

*Triazoles***

tolsuraStep Therapy Required (Trial of the following in the last 6 months: itraconazole 100mg capsule)

*Antihistamines*

*Antihistamines - Ethanolamines***

KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE

QL (4ml per day); DS (30); Step Therapy Required (Trial through the following for at least one month in the last 60 days: carbinoxamine 4 mg tablet); AL (Min 2 Years)

*Antihyperlipidemics*

*Acl Inhib-Intestinal Cholesterol Absorption Inhib Comb***

NEXLIZET

Step Therapy Required (Trial of the following for at least 2 months each in last 12 months: two statins plus ezetimbe (generic for ZETIA))



*Adenosine Triphosphate-Citrate Lyase (Acl) Inhibitors***

NEXLETOL

Step Therapy Required (Trial of the following for at least 2 months each in last 12 months: two statins plus ezetimbe (generic for ZETIA))

*Hmg Coa Reductase Inhibitors***

LIVALOStep Therapy Required (Trial of two of the following in the last 12 months: atorvastatin, simvastatin, rosuvastatin)

ZYPITAMAGStep Therapy Required (Trial of two of the following in the last 12 months: atorvastatin, simvastatin, rosuvastatin)

*Antimalarials*

*Antimalarials***

chloroquine phosphate oral tablet 250 mgStep Therapy Required (If new to therapy (no prior history of chronic usage): limit of one fill of 30 tablets per 180 days)

chloroquine phosphate oral tablet 500 mgStep Therapy Required (If new to therapy (no prior history of chronic usage): limit of one fill of 30 tablets per 180 days)

hydroxychloroquine sulfate oral

QL (30 tablets for a 14 day supply, limited to 1 fill per 180 days); DS (14); Step Therapy Required (If new to therapy (no prior history of chronic usage): limit of one fill of 30 tablets per 180 days)

PLAQUENIL

QL (30 tablets for a 14 day supply, limited to 1 fill per 180 days); DS (14); Step Therapy Required (If new to therapy (no prior history of chronic usage): limit of one fill of 30 tablets per 180 days)

*Antipsychotics/Antimanic Agents*

*Antipsychotics - Misc.***

VRAYLAR ORAL CAPSULE

QL (1 capsule per day); Step Therapy Required (Trial of at least 2 of the following in the last 12 months: aripiprazole, quetiapine, risperidone, Saphris, ziprasidone.); AL (Min 18 Years)

VRAYLAR ORAL CAPSULE THERAPY PACK

QL (1 box per 7 days); Step Therapy Required (Trial of at least 2 of the following in the last 12 months: aripiprazole, quetiapine, risperidone, Saphris, ziprasidone.); AL (Min 18 Years)

*Antivirals*

*Antiretroviral Combinations***

DELSTRIGOStep Therapy Required (Reject if any history within last 180 days of antiretroviral therapy)

DOVATOStep Therapy Required (Reject if any history within last 180 days of antiretroviral therapy)



*Antiretrovirals - Rti-Non-Nucleoside Analogues***

PIFELTROStep Therapy Required (Reject if any history within last 180 days of antiretroviral therapy)

*Beta Blockers*

*Beta Blockers Cardio-Selective***

KAPSPARGO SPRINKLE

Step Therapy Required (Trial of the following for at least 3 months in the last 12 months: Metoprolol Succinate Er Oral Tablet Extended Release 24 Hour or Toprol Xl Oral Tablet Extended Release 24 Hour)

*Calcium Channel Blockers*

*Calcium Channel Blockers***

CONJUPRIQL (1 tablet per day); Step Therapy Required (Trial of the following in the last 3 months: amlodipine)

*Cardiovascular Agents - Misc.*

*Selective Cgmp Phosphodiesterase Type 5 Inhibitors***

CIALIS ORAL TABLET 2.5 MG, 5 MG

QL (1 tablet per day); Step Therapy Required (ST: thru 3 meds x 3 mo EACH: alfuzosin ER, tamsulosin, silodosin, finasteride 5mg, dutasteride, generic Jalyn AND tadalafil.); AL (Min 18 Years)

tadalafil oral tablet 2.5 mg, 5 mg

QL (1 tablet per day); Step Therapy Required (Trial of three of the following for benign prostatic hyperplasia (BPH) for 3 months each in the last 18 months: alfuzosin ER, tamsulosin, silodosin, finasteride 5mg, dutasteride, dutasteride-tamsulosin (generic for JALYN)); AL (Min 18 Years)

*Corticosteroids*

*Glucocorticosteroids***

ORTIKOSStep Therapy Required (Trial of the following for at least 3 months in last 12 months: budesonide capsule 3 mg DR )

*Dermatologicals*

*Acne Antibiotics***

AMZEEQ

Step Therapy Required (Trial of both of the following within the last 3 months: minocycline hcl capsule 100mg, tretinoin gel 0.04%)

*Acne Products***

AKLIEF

Step Therapy Required (Trial of at least two of the following within the last 12 months: adapalene gel 0.1%, tazarotene cream 0.1%, tretinoin cream 0.1% or 0.05%)



WINLEVI

Step Therapy Required (ST: Trial of 2 of the following within l year-adapalene gel 0.1%, tazarotene CR 0.1%, tretinoin CR 0.1% or tret 0.01% CR )

*Antibiotics - Topical***

XEPI

QL (30gm in 30 days); Step Therapy Required (Trial of the following for 3 months in the last 12 months: mupirocin ointment 2%)

*Antipruritics - Topical***

doxepin hcl external

DS (30gm in 30 days); Step Therapy Required (Trial: of two of the following within the last 6 months: fluocinolone, triamcinolone, betamethasone diporprionate)

PRUDOXIN


ZONALON


*Corticosteroids - Topical***

CORDRAN EXTERNAL CREAM 0.05 %

QL (4gm per day); DS (30); Step Therapy Required (Trial of two of the following in the last six months: betamethasone, clobetasol, hydrocortisone, triamcinolone)

CORDRAN EXTERNAL LOTION


CORDRAN EXTERNAL OINTMENT

QL (2gm per day); Step Therapy Required (Trial of two of the following in the last six months: betamethasone, clobetasol, hydrocortisone, triamcinolone)

CORDRAN EXTERNAL TAPE

QL (1 box per month); Step Therapy Required (Trial of two of the following in the last six months: betamethasone, clobetasol, hydrocortisone, triamcinolone)

diflorasone diacetate external

QL (2gm per day); DS (30); Step Therapy Required (Trial of two of the following in the last three months: betamethasone, clobetasol, hydrocortisone, triamcinolone)

flurandrenolide external cream




flurandrenolide external lotion


flurandrenolide external ointment

QL (2gm per day); Step Therapy Required (Trial of two of the following in the last six months: betamethasone, clobetasol, hydrocortisone, triamcinolone)

halcinonide


NOLIX


psorcon

QL (2gm per day); DS (30); Step Therapy Required (Trial of two of the following in the last three months: betamethasone, clobetasol, hydrocortisone, triamcinolone)

*Microtubule Inhibitors - Topical***

KLISYRI

DS (30); Step Therapy Required (Trial of fluorouracil 5% and generic Aldara in last 6 mo.); CP (Specialty Tier B if CP does not apply)

*Rosacea Agents***

ivermectin external cream

Step Therapy Required (Trial of any of following for 60 days in the last 6 months: metronidazole cream 0.75%, metronidazole gel 0.75% or 1%, metronidazole lotion 0.75%)

SOOLANTRA

Step Therapy Required (Trial of any of following for 60 days in the last 6 months: metronidazole cream 0.75%, metronidazole gel 0.75% or 1%, metronidazole lotion 0.75%)

ZILXI

Step Therapy Required (Trial of both of the following within the last 3 months: minocycline hcl capsule 100mg, tretinoin gel 0.04%)

*Diagnostic Products*

*Diagnostic Tests***

ACCU-CHEK AVIVA PLUS IN VITRO

QL (Max #100 per 30 days); DS (30); Step Therapy Required (ST: Insulin at least 2 month in last 3 months and One Touch Test Strips 1 in last 3 mo. Limited to 30 day supply.)

ACCU-CHEK COMPACT PLUS




ACCU-CHEK GUIDE IN VITRO


ACCU-CHEK SMARTVIEW


ACCUTREND GLUCOSE


ADVANCE INTUITION TEST


ADVANCE MICRO-DRAW TEST


ADVOCATE REDI-CODE IN VITRO


ADVOCATE REDI-CODE+ TEST


ADVOCATE TEST


AGAMATRIX AMP TEST


AGAMATRIX JAZZ TEST




AGAMATRIX KEYNOTE TEST


AGAMATRIX PRESTO TEST


ASSURE 3 TEST


ASSURE 4 TEST


ASSURE II


ASSURE II CHECK


ASSURE PLATINUM


ASSURE PRISM MULTI TEST


ASSURE PRO TEST


BIOSCANNER GLUCOSE TEST




blood glucose test


BLULINK GLUCOSE TEST


CAREONE BLOOD GLUCOSE TEST


CARESENS N GLUCOSE TEST


CARETOUCH TEST


CLEVER CHEK AUTO-CODE TEST


CLEVER CHEK AUTO-CODE VOICE IN VITRO


CLEVER CHEK TEST


CLEVER CHOICE AUTO-CODE TEST


CLEVER CHOICE MICRO TEST




CLEVER CHOICE NO CODING


CLEVER CHOICE TALK SYSTEM IN VITRO


FORACARE GD40 TEST

QL (Max #100 per 30 days.); DS (30); Step Therapy Required (ST: Insulin at least 2 month in last 3 months and One Touch Test Strips 1 in last 3 mo. Limited to 30 day supply.)

FORACARE PREMIUM V10 TEST


FORACARE TEST N GO TEST


FORTISCARE TEST


FREESTYLE INSULINX TEST


FREESTYLE LITE TEST


FREESTYLE PRECISION NEO TEST


FREESTYLE TEST




ge100 blood glucose test


GENULTIMATE TEST


ght test


GLUCO PERFECT 3 TEST


GLUCOCARD 01 SENSOR PLUS


GLUCOCARD EXPRESSION TEST


GLUCOCARD SHINE TEST


GLUCOCARD VITAL TEST


GLUCOCARD X-SENSOR


GLUCOCOM TEST




GLUCONAVII BLOOD GLUCOSE TEST


glucose meter test


gnp easy touch glucose test


GOJJI BLOOD GLUCOSE TEST


GOJJI BLOOD TEST STRIP/LANCETS


goodsense blood glucose in vitro


HW EMBRACE PRO GLUCOSE TEST


HW EMBRACE TALK GLUCOSE TEST


IGLUCOSE TEST STRIPS


IN TOUCH BLOOD GLUCOSE TEST




INFINITY BLOOD GLUCOSE TEST


INFINITY VOICE IN VITRO STRIP


kroger blood glucose test


KROGER HEALTHPRO GLUCOSE TEST


kroger premium glucose test


kroger test


LIBERTY NEXT GENERATION TEST


liberty test


meijer blood glucose test


meijer essential glucose test




meijer premium glucose test


MEIJER TRUETEST TEST


MEIJER TRUETRACK TEST


MICRODOT TEST


MM EASY TOUCH GLUCOSE


MYGLUCOHEALTH TEST


NEUTEK 2TEK TEST


NOVA MAX GLUCOSE TEST


one drop test


OPTIUM TEST




OPTIUMEZ TEST


PHARMACIST CHOICE AUTOCODE


pharmacist choice no coding


POCKETCHEM EZ TEST


POGO AUTOMATIC TEST CARTRIDGES


PRECISION PCX


PRECISION PCX PLUS TEST


PRECISION POINT OF CARE TEST


PRECISION QID TEST


PRECISION SOF-TACT TEST




PRECISION XTRA BLOOD GLUCOSE


premium blood glucose test


pro voice v8/v9 glucose


PRODIGY NO CODING BLOOD GLUC IN VITRO


PTS PANELS GLUCOSE TEST


QUICKTEK TEST


QUINTET AC BLOOD GLUCOSE TEST


QUINTET BLOOD GLUCOSE TEST


REFUAH PLUS BLOOD GLUCOSE TEST


RELION BLOOD GLUCOSE TEST




RELION CONFIRM/MICRO TEST


RELION PREMIER TEST


RELION PRIME TEST


RELION TRUE METRIX TEST STRIPS


RELION ULTIMA TEST


REXALL BLOOD GLUCOSE TEST


RIGHTEST GS100 BLOOD GLUCOSE






SMART SENSE PREMIUM TEST




SMART SENSE VALUE TEST


SMARTEST BLOOD GLUCOSE TEST


SOLUS V2 TEST


SUPREME TEST


SURE-TEST EASYPLUS MINI TEST


tgt blood glucose test


true focus blood glucose strip


TRUE METRIX BLOOD GLUCOSE TEST


TRUE METRIX PRO BLOOD GLUCOSE


TRUETEST TEST




TRUETRACK TEST


UNISTRIP1 GENERIC


verasens blood glucose test


VIVAGUARD INO TEST STRIPS


*Digestive Aids*

*Digestive Enzymes***

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000-54700 UNIT, 2600-8800 UNIT, 37000-97300 UNIT, 4200-14200 UNIT

QL (12 capsules per day); Step Therapy Required (Trial of both of the following in the last 12 months: CREON and ZENPEP)

PERTZYEQL (12 capsules per day); Step Therapy Required (Trial of both of the following in the last 12 months: CREON and ZENPEP)

VIOKACEQL (12 capsules per day); Step Therapy Required (Trial of both of the following in the last 12 months: CREON and ZENPEP)

*Gastrointestinal Agents - Misc.*

*Cic Agents - Guanylate Cyclase-C (Gc-C) Agonists***

TRULANCE

QL (2 tablets per day); Step Therapy Required (EST as follows:ST through Linzess for 1 fill in the last 6 months.); AL (Min 18 Years)

*Gastrointestinal Chloride Channel Activators***

AMITIZA

QL (2 capsules per day); Step Therapy Required (EST as follows:ST through Linzess for 1 fill in the last 6 months.); AL (Min 18 Years)

lubiprostone

QL (2 capsules per day); Step Therapy Required (EST as follows:ST through Linzess for 1 fill in the last 6 months.); AL (Min 18 Years)

*Ibs Agent - 5-Ht4 Receptor Partial Agonists***

ZELNORM

QL (2 tablets per day); Step Therapy Required (Trial of one of the following in last 6 months: Linzess); AL (Min 18 Years and Max 65 Years)



*Gout Agents*

*Gout Agents***

febuxostat

QL (1 tablet per day); Step Therapy Required (Trial of the following for 3 months in last 6 months: allopurinol 100mg, 300mg tablet); AL (Min 18 Years)

GLOPERBAStep Therapy Required (Trial of any of the following in the last 3 months: colchicine 0.6mg tablet or colchicine 0.6mg capsule)

ULORIC

QL (1 tablet per day); Step Therapy Required (Trial of both of the following for 3 months each in last 12 months: allopurinol 100mg, 300mg tablet and febuxostat 40mg, 80mg tablet); AL (Min 18 Years)

*Hematopoietic Agents*

*Cytotoxic Agents***

DROXIA

DS (30); Step Therapy Required (Trial of both of the following for 3 months each in the last 12 months: SIKLOS 100mg, 1000mg tablet, hydroxyurea 500mg capsule)

*Hypnotics/Sedatives/Sleep Disorder Agents*

*Hypnotics - Tricyclic Agents***

doxepin hcl oral tablet

QL (1 tablet per day); Step Therapy Required (Trial of the following for 3 months in the last 12 months: doxepin hcl 10mg capsule); AL (Min 18 Years)

SILENOR

QL (1 tablet per day); Step Therapy Required (Trial of the following for 3 months in the last 12 months: doxepin hcl 10mg capsule); AL (Min 18 Years)

*Orexin Receptor Antagonists***

BELSOMRA

QL (1 tablet per day); Step Therapy Required (Trial of at least 2 of the following in last 6 months: eszopiclone tablet, zaleplon capsule, rozerem tablet); AL (Min 18 Years)

DAYVIGO

QL (1 tablet per day); Step Therapy Required (Trial of at least 2 of the following in last 6 months: eszopiclone tablet, zaleplon capsule, rozerem tablet); AL (Min 18 Years)

*Medical Devices And Supplies*

*Glucose Monitoring Test Supplies***

DEXCOM G6 RECEIVERQL (1 receiver per lifetime); Step Therapy Required (Trial of any of the following in last 3 months: insulins)

DEXCOM G6 SENSORQL (3 sensors (1 box) per month); DS (30); Step Therapy Required (Trial of any of the following in last 3 months: insulins)



DEXCOM G6 TRANSMITTERQL (1 transmitter (1 box) per 90 days); Step Therapy Required (Trial of any of the following in last 3 months: insulins)

FREESTYLE LIBRE 14 DAY READER

QL (1 receiver per lifetime); Step Therapy Required (Trial of any of the following in last 3 months: insulins, amylin analogs, incretin mimetic agents (GLP-1), sulfonylureas, meglitinide analogues, sodium-glucose co-transporter 2 inhibitors, insulin sensitizing agents)

FREESTYLE LIBRE 14 DAY SENSOR

QL (3 sensors (1 box) per month); DS (30); Step Therapy Required (Trial of any of the following in last 3 months: insulins, amylin analogs, incretin mimetic agents (GLP-1), sulfonylureas, meglitinide analogues, sodium-glucose co-transporter 2 inhibitors, insulin sensitizing agents)

FREESTYLE LIBRE 2 READER


FREESTYLE LIBRE 2 READER SYSTM


FREESTYLE LIBRE 2 SENSOR


FREESTYLE LIBRE 2 SENSOR SYSTM


FREESTYLE LIBRE READER




FREESTYLE LIBRE SENSOR SYSTEM


*Migraine Products*

*Selective Serotonin Agonists 5-Ht(1)***

frovatriptan succinate

QL (12 tablets per month); Step Therapy Required (Trial of two of the following in the last 12 months: almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan)

*Musculoskeletal Therapy Agents*

*Central Muscle Relaxants***

chlorzoxazone oral tablet 375 mg, 750 mgStep Therapy Required (Trial of the following in last 3 months: chlorzoxazone 500mg tablet)

LORZONEStep Therapy Required (Trial of the following in last 3 months: chlorzoxazone 500mg tablet)

*Ophthalmic Agents*

*Ophthalmic Antiallergic***

ZERVIATEStep Therapy Required (Trial of the following for at least 2 months in the last 6 months: azelastine drops 0.05%)

*Prostaglandins - Ophthalmic***

VYZULTAStep Therapy Required (Trial of two of the following in the last 12 months: LUMIGAN, XALATAN, ZIOPTAN)

*Psychotherapeutic And Neurological Agents - Misc.*

*Postherpetic Neuralgia (Phn)/Neuropathic Pain Agents***

LYRICA CRQL (1 tablet per day); Step Therapy Required (Trial of one of the following in the last 6 months: pregabalin, LYRICA)

pregabalin erQL (1 tablet per day); Step Therapy Required (Trial of one of the following in the last 6 months: pregabalin, LYRICA)

*Ulcer Drugs/Antispasmodics/Anticholinergics*

*Ulcer Anti-Infective W/ Proton Pump Inhibitors***

TALICIAStep Therapy Required (Trial of all of the following in the last 90 days: clarithromycin, amoxicillin, pantoprazole)



*Vaccines*

*Viral Vaccines***

moderna covid-19 vaccine

QL (2 injections); DS (328); Step Therapy Required (Step through 1st dose of Moderna to get 2nd dose); Vaccine; AL (Min 18 Years)

pfizer-biontech covid-19 vaccQL (2 injections); DS (328); Step Therapy Required (Step through 1st Pfizer dose to get 2nd dose); Vaccine; AL (Min 12 Years)


Index

ACCU-CHEK AVIVA PLUS .............16ACCU-CHEK COMPACT PLUS ..... 16ACCU-CHEK GUIDE .......................17ACCU-CHEK SMARTVIEW ............ 17ACCUTREND GLUCOSE ............... 17ADLYXIN ......................................... 11ADLYXIN STARTER PACK ............ 11ADMELOG .........................................9ADMELOG SOLOSTAR ....................9ADVANCE INTUITION TEST .......... 17ADVANCE MICRO-DRAW TEST ....17ADVOCATE REDI-CODE ................17ADVOCATE REDI-CODE+ TEST ... 17ADVOCATE TEST ...........................17AGAMATRIX AMP TEST ................ 17AGAMATRIX JAZZ TEST ............... 17AGAMATRIX KEYNOTE TEST .......18AGAMATRIX PRESTO TEST ......... 18AIRDUO DIGIHALER ........................ 4AIRDUO RESPICLICK 113/14 .......... 4AIRDUO RESPICLICK 232/14 .......... 4AIRDUO RESPICLICK 55/14 ............ 5AKLIEF ............................................ 14AKYNZEO ....................................... 12alogliptin benzoate ............................. 9AMITIZA .......................................... 29AMZEEQ ..........................................14APIDRA ............................................. 9APIDRA SOLOSTAR ........................ 9APTIOM ............................................. 6ARMONAIR DIGIHALER .................. 6ASSURE 3 TEST .............................18ASSURE 4 TEST .............................18ASSURE II ....................................... 18ASSURE II CHECK ......................... 18ASSURE PLATINUM ...................... 18ASSURE PRISM MULTI TEST ....... 18ASSURE PRO TEST ....................... 18BASAGLAR KWIKPEN .....................9BELSOMRA .................................... 30BEVESPI AEROSPHERE ................. 5BIOSCANNER GLUCOSE TEST ....18blood glucose test ............................ 19BLULINK GLUCOSE TEST ............ 19BREZTRI AEROSPHERE ................. 5BRIVIACT .......................................... 6CAREONE BLOOD GLUCOSE TEST ................................................19CARESENS N GLUCOSE TEST .... 19CARETOUCH TEST ........................19chloroquine phosphate .....................13chlorzoxazone ..................................32CIALIS ............................................. 14CLEVER CHEK AUTO-CODE TEST ................................................19CLEVER CHEK AUTO-CODE VOICE ..............................................19CLEVER CHEK TEST ..................... 19

CLEVER CHOICE AUTO-CODE TEST ................................................19CLEVER CHOICE MICRO TEST .... 19CLEVER CHOICE NO CODING ......20CLEVER CHOICE TALK SYSTEM . 20CONJUPRI ...................................... 14CORDRAN .......................................15DAYVIGO ........................................ 30DELSTRIGO .................................... 13DEXCOM G6 RECEIVER ................ 30DEXCOM G6 SENSOR ................... 30DEXCOM G6 TRANSMITTER .........31diflorasone diacetate ........................15DOVATO ..........................................13doxepin hcl .................................15, 30DRIZALMA SPRINKLE ..................... 8DROXIA ........................................... 30DUAKLIR PRESSAIR ....................... 5DULERA ............................................ 5ELEPSIA XR ..................................6, 7febuxostat ........................................ 30FETZIMA ........................................... 8FETZIMA TITRATION ....................... 8FIASP ................................................ 9FIASP FLEXTOUCH ......................... 9flurandrenolide ........................... 15, 16fluticasone-salmeterol ........................ 5FORACARE GD40 TEST ................ 20FORACARE PREMIUM V10 TEST . 20FORACARE TEST N GO TEST ...... 20FORTAMET ....................................... 8FORTISCARE TEST ....................... 20FREESTYLE INSULINX TEST ........20FREESTYLE LIBRE 14 DAY READER ..........................................31FREESTYLE LIBRE 14 DAY SENSOR ..........................................31FREESTYLE LIBRE 2 READER .....31FREESTYLE LIBRE 2 READER SYSTM .............................................31FREESTYLE LIBRE 2 SENSOR .....31FREESTYLE LIBRE 2 SENSOR SYSTM .............................................31FREESTYLE LIBRE READER ........31FREESTYLE LIBRE SENSOR SYSTEM .......................................... 32FREESTYLE LITE TEST .................20FREESTYLE PRECISION NEO TEST ................................................20FREESTYLE TEST ..........................20frovatriptan succinate .......................32ge100 blood glucose test ................. 21GENULTIMATE TEST .....................21ght test ............................................. 21GLOPERBA .....................................30GLUCO PERFECT 3 TEST ............. 21GLUCOCARD 01 SENSOR PLUS ..21GLUCOCARD EXPRESSION TEST ................................................21

GLUCOCARD SHINE TEST ........... 21GLUCOCARD VITAL TEST ............ 21GLUCOCARD X-SENSOR ..............21GLUCOCOM TEST ......................... 21GLUCONAVII BLOOD GLUCOSE TEST ................................................22glucose meter test ............................22gnp easy touch glucose test ............ 22GOJJI BLOOD GLUCOSE TEST ... 22GOJJI BLOOD TEST STRIP/LANCETS ............................ 22goodsense blood glucose ................ 22halcinonide .......................................16HUMULIN R U-500 (CONCENTRATED) .......................... 9HUMULIN R U-500 KWIKPEN .......... 9HW EMBRACE PRO GLUCOSE TEST ................................................22HW EMBRACE TALK GLUCOSE TEST ................................................22hydroxychloroquine sulfate .............. 13IGLUCOSE TEST STRIPS .............. 22IN TOUCH BLOOD GLUCOSE TEST ................................................22INFINITY BLOOD GLUCOSE TEST ................................................23INFINITY VOICE ..............................23insulin asp prot & asp flexpen ............ 9insulin aspart ......................................9insulin aspart flexpen ......................... 9insulin aspart penfill ........................... 9insulin aspart prot & aspart .............. 10insulin lispro ..................................... 10insulin lispro (1 unit dial) .................. 10insulin lispro junior kwikpen ............. 10insulin lispro prot & lispro ................. 10INVOKAMET ................................... 12INVOKAMET XR ............................. 12INVOKANA ......................................12ivermectin .........................................16KAPSPARGO SPRINKLE ...............14KARBINAL ER ................................ 12KLISYRI ...........................................16kroger blood glucose test .................23KROGER HEALTHPRO GLUCOSE TEST ............................. 23kroger premium glucose test ............23kroger test ........................................ 23levalbuterol tartrate ............................ 5LEVEMIR ......................................... 10LEVEMIR FLEXTOUCH .................. 10LIBERTY NEXT GENERATION TEST ................................................23liberty test .........................................23LIVALO ............................................13LONHALA MAGNAIR REFILL KIT ...6LONHALA MAGNAIR STARTER KIT ..................................................... 6LORZONE ....................................... 32

34

lubiprostone ..................................... 29LYRICA CR ..................................... 32meijer blood glucose test ................. 23meijer essential glucose test ............23meijer premium glucose test ............ 24MEIJER TRUETEST TEST ............. 24MEIJER TRUETRACK TEST .......... 24metformin hcl er (osm) ....................... 8MICRODOT TEST ........................... 24MM EASY TOUCH GLUCOSE ........24moderna covid-19 vaccine ............... 33MYDAYIS ...........................................4MYGLUCOHEALTH TEST ..............24NESINA ............................................. 9NEUTEK 2TEK TEST ......................24NEXLETOL ......................................13NEXLIZET ........................................12NOLIX .............................................. 16NOVA MAX GLUCOSE TEST .........24NOVOLIN 70/30 ...............................10NOVOLIN 70/30 FLEXPEN ............. 10NOVOLIN 70/30 FLEXPEN RELION ........................................... 10NOVOLIN 70/30 RELION ................ 10NOVOLIN N ..................................... 10NOVOLIN N FLEXPEN ................... 10NOVOLIN N FLEXPEN RELION .....10NOVOLIN N RELION ...................... 10NOVOLIN R ..................................... 10NOVOLIN R FLEXPEN ................... 10NOVOLIN R FLEXPEN RELION .....11NOVOLIN R RELION ...................... 11NOVOLOG .......................................11NOVOLOG FLEXPEN ..................... 11NOVOLOG MIX 70/30 ..................... 11NOVOLOG MIX 70/30 FLEXPEN ....11NOVOLOG PENFILL .......................11one drop test .................................... 24OPTIUM TEST .................................24OPTIUMEZ TEST ............................ 25ORTIKOS .........................................14PANCREAZE ...................................29PERTZYE ........................................ 29pfizer-biontech covid-19 vacc .......... 33PHARMACIST CHOICE AUTOCODE .................................... 25pharmacist choice no coding ........... 25PIFELTRO ....................................... 14PLAQUENIL .................................... 13POCKETCHEM EZ TEST ................25POGO AUTOMATIC TEST CARTRIDGES ................................. 25PRECISION PCX .............................25PRECISION PCX PLUS TEST ........ 25PRECISION POINT OF CARE TEST ................................................25PRECISION QID TEST ....................25PRECISION SOF-TACT TEST ........25PRECISION XTRA BLOOD GLUCOSE ....................................... 26

pregabalin er .................................... 32premium blood glucose test ............. 26pro voice v8/v9 glucose ................... 26PRODIGY NO CODING BLOOD GLUC ...............................................26PROVENTIL HFA .............................. 5PRUDOXIN ...................................... 15psorcon ............................................ 16PTS PANELS GLUCOSE TEST ..... 26QELBREE ..........................................4QTERN ............................................ 11QUDEXY XR ......................................7QUICKTEK TEST ............................ 26QUINTET AC BLOOD GLUCOSE TEST ................................................26QUINTET BLOOD GLUCOSE TEST ................................................26REFUAH PLUS BLOOD GLUCOSE TEST ............................. 26RELION BLOOD GLUCOSE TEST 26RELION CONFIRM/MICRO TEST .. 27RELION PREMIER TEST ................27RELION PRIME TEST .....................27RELION TRUE METRIX TEST STRIPS ............................................ 27RELION ULTIMA TEST ...................27REXALL BLOOD GLUCOSE TEST ................................................27RIGHTEST GS100 BLOOD GLUCOSE ....................................... 27RIGHTEST GS300 BLOOD GLUCOSE ....................................... 27RIGHTEST GS550 BLOOD GLUCOSE ....................................... 27RIOMET ER ....................................... 8SEGLUROMET ................................12SEMGLEE ....................................... 11SILENOR ......................................... 30SMART SENSE PREMIUM TEST ...27SMART SENSE VALUE TEST ........28SMARTEST BLOOD GLUCOSE TEST ................................................28SOLUS V2 TEST ............................. 28SOOLANTRA .................................. 16STEGLATRO ...................................12STEGLUJAN ................................... 11STRIVERDI RESPIMAT .................... 5SUPREME TEST ............................. 28SURE-TEST EASYPLUS MINI TEST ................................................28SYMPAZAN .......................................6tadalafil .............................................14TALICIA ...........................................32tgt blood glucose test ....................... 28tolsura .............................................. 12topiramate er ......................................7TRESIBA ......................................... 11TRESIBA FLEXTOUCH .................. 11TRINTELLIX .................................. 7, 8TROKENDI XR .................................. 7

true focus blood glucose strip .......... 28TRUE METRIX BLOOD GLUCOSE TEST ............................. 28TRUE METRIX PRO BLOOD GLUCOSE ....................................... 28TRUETEST TEST ............................28TRUETRACK TEST ........................ 29TRULANCE ..................................... 29ULORIC ........................................... 30UNISTRIP1 GENERIC .....................29UTIBRON NEOHALER ..................... 5verasens blood glucose test ............ 29VIOKACE .........................................29VIVAGUARD INO TEST STRIPS ....29VRAYLAR ........................................13VYZULTA ........................................ 32WINLEVI .......................................... 15WIXELA INHUB .................................5XCOPRI ............................................. 7XCOPRI (250 MG DAILY DOSE) ...... 7XCOPRI (350 MG DAILY DOSE) ...... 7XEPI .................................................15XOPENEX HFA ................................. 6ZEGALOGUE .................................... 8ZELNORM ....................................... 29ZERVIATE ....................................... 32zileuton er .......................................... 4ZILXI ................................................ 16ZONALON ....................................... 15ZYFLO ............................................... 4ZYFLO CR ......................................... 4ZYPITAMAG ....................................13

35

Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call 602-864-4884 for Spanish and 877-475-4799 for all other languages and other aids and services. If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: BCBSAZ’s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ 85002-3466, 602-864-2288, TTY/TDD 602-864-4823, [email protected]. You can file a grievance in person or by mail or email. If you need help filing a grievance BCBSAZ’s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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