Blue Cross Blue Shield and Blue Care Network Preferred ...

Blue Cross Blue Shield and Blue Care Network Preferred Alternatives -- December 2020

The Blue Cross and BCN Preferred Alternatives list is a helpful guide when selecting alternative prescription drugs. This list is intended as a reference guide and doesn't dictate coverage. Some Blue Cross and BCN members don't have coverage for tier 3 (non-preferred) agents, or the suggested alternatives. The brand (trade) names for the preferred alternatives are listed for reference. The generic equivalent will be dispensed when the member fills a prescription. The brand may not be covered or may require a higher copay. Prior approval or step therapy may be required for tier 3 drugs or preferred alternatives.

Members should refer to their specific drug benefit information at pharmacy for a full list of covered drugs and requirements.

Tier 3

Preferred alternatives

ACIPHEX SPRINKLE Aciphex, Nexium, Prevacid, Prilosec, Protonix

ACUVAIL

Acular, Bromday, Ocufen, Voltaren ophthalmic

ADZENYS ER, XRODT; AMPHETAMINE 1.25MG/ML SUSPENSION (AUTHORIZED GENERIC OF ADZENYS ER)

Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR, Metadate CD*, Methylin, Ritalin LA/SR *can be opened and sprinkled on applesauce

AEMCOLO

Bactrim DS, Cipro, Vibramycin, Zithromax

AFREZZA

Fiasp (all forms), Novolin (NDCs ending in 00, 01, 11, and 15), Novolog (all forms)

AKYNZEO

Emend plus Zofran/ODT or Kytril

ALOCRIL

Alrex, Bepreve, Elestat, Opticrom, Optivar, Pataday, Patanol, Pazeo

ALOMIDE

Alrex, Bepreve, Elestat, Opticrom, Optivar, Pataday, Patanol, Pazeo

ALTRENO

Retin-A

AMZEEQ

Minocin, Monodox, tetracycline, Vibramycin

ANADROL-50

Procrit

ANGELIQ

Activella, Alora, Climara, Fem-HRT, Premphase, Prempro, Minivelle, Vagifem, Vivelle-Dot

APTIOM

Dilantin, Keppra, Tegretol, Topamax, Trileptal

ARAKODA

Aralen, Lariam, Malarone, Monodox, Primaquine, Vibramycin

ARANESP

Procrit

ARCAPTA NEOHALER

Serevent Diskus, Spiriva/Respimat

Tier 3

ARMOUR THYROID ASTAGRAF XL AUBAGIO AURYXIA AVANDIA AZASAN AZASITE

AZELEX BAFIERTAM BALCOLTRA

BASAGLAR KWIKPEN U-100 BAXDELA BECONASE AQ BELBUCA

BELSOMRA BESIVANCE

BETASERON

Preferred alternatives

NP Thyroid, Westhroid

Prograf capsules

Avonex, Copaxone, Gilenya, Mayzent, Plegridy, Rebif, Tecfidera

OTC Tums, Phoslo, Renagel, Renvela

Actos, Glucophage, a sulfonylurea (Amaryl, Diabeta, Glucotrol/XL)

Imuran

Bacitracin, Bleph-10, Ciloxan, Moxeza, Ocuflox, Polysporin, Polytrim, Quixin, Tobrex, Vigamox, Zymaxid

Benzaclin, Benzamycin, Differin, Duac, Epiduo , Retin-A, Tazorac

Avonex, Copaxone, Gilenya, Mayzent, Plegridy, Rebif, Tecfidera

Generic monophasic contraceptives with iron (Femcon Fe, Generess Fe, Loestrin Fe, Loestrin 24 Fe, Minastrin 24 Fe, etc.)

Lantus (all forms), Levemir (all forms), Toujeo (all forms), Tresiba Flextouch

Avelox, Cipro/XR, Floxin, Levaquin, Zyvox

Flonase, Nasalide, Nasonex, OTC Nasacort, OTC Rhinocort, Patanase

Butrans, Duragesic, Exalgo, methadone, MS Contin, Opana ER, Ultram ER, Zohydro ER

Ambien/CR, Intermezzo, Lunesta, Restoril, Rozerem, Silenor, Sonata

Bacitracin, Bleph-10, Ciloxan, Moxeza, Ocuflox, Polysporin, Polytrim, Quixin, Tobrex, Vigamox, Zymaxid

Avonex, Copaxone, Gilenya, Mayzent, Plegridy, Rebif, Tecfidera

** May be covered with a prescription for some Blue Cross members.

NOTE: This document serves as a quick reference guide. For the most current list of covered medications and requirements, visit pharmacy.

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Tier 3

BEVESPI AEROSPHERE

BIJUVA

BINOSTO BONJESTA BRIVIACT BROVANA BRYHALI

BUNAVAIL BYNFEZIA BYSTOLIC CAPLYTA CARDURA XL CAROSPIR CAYSTON CEQUA CESAMET CHENODAL CHORIONIC GONADOTROPIN CIMZIA SYRINGE

CIPRO HC CLARINEX-D CLENPIQ CLEOCIN VAGINAL OVULES CLIMARA PRO

CLINDESSE COMBIGAN

Preferred alternatives

Combination products: Anoro Ellipta, Breztri Aerosphere, Stiolto Respimat, Trelegy Ellipta Single ingredient products: Serevent Diskus, Spiriva/Respimat

Activella, Alora, Climara, Fem-HRT, Premphase, Prempro, Minivelle, Vagifem, Vivelle-Dot

Actonel, Atelvia, Boniva, Fosamax

OTC doxylamine plus OTC vitamin B6, Kytril, Zofran/ODT

Depakote/ER, Keppra/XR, Lamictal/ODT, Tegretol, Topamax, Trileptal

Anoro Ellipta, Serevent Diskus, Spiriva/Respimat, Stiolto Respimat

Clobevate, Clobex, Diprolene gel, ointment; Olux/-E, Ultravate cream, ointment

Suboxone

Sandostatin

Cardioselective beta-blockers: Lopressor, Tenormin, Toprol XL, etc

Abilify, Clozaril, Geodon, Invega, Risperal, Seroquel/XR, Zyprexa

Avodart, Cardura, Flomax, Hytrin, Jalyn, Proscar, Rapaflo, Uroxatral

Aldactone

Tobi

Restasis, Xiidra

Kytril, Marinol, Zofran/ODT

Actigall, Urso/Forte

Pregnyl

Actemra Actpen/syringe, Cosentyx, Enbrel, Humira, methotrexate, Otezla, Rinvoq, Stelara, Skyrizi, Tremfya, Xeljanz/XR

ciprofloxacin 0.2% dropperette, Ciprodex, Cortisporin, Floxin otic, Otovel

Clarinex, Histex PD, OTC Claritin**, OTC Zyrtec**, Palgic, Xyzal

Colyte, Golytely, Moviprep, Nulytely, PegPrep

Cleocin vaginal cream, Metrogel-Vaginal

Activella, Alora, Climara, Fem-HRT, Premphase, Prempro, Minivelle, Vagifem, Vivelle-Dot

Cleocin vaginal cream, Metrogel-vaginal

Alphagan plus Timoptic

Tier 3

Preferred alternatives

COMBIPATCH

Activella, Alora, Climara, Fem-HRT, Premphase, Prempro, Minivelle, Vagifem, Vivelle-Dot

CONTRAVE

Adipex-P, Bontril, Didrex, OTC Alli, Tenuate

CORTIFOAM

Cortenema, Proctocort cream, Proctocort suppositories, Proctofoam-HC

CORTISPORIN

Bactroban ointment, gentamicin

CREAM/OINTMENT cream/ointment

CYCLOSET

Actos, Glucophage, a DPP-4 inhibitor (Januvia, Tradjenta), an SGLT-2 inhibitor (Farxiga, Invokana, Invokamet, Jardiance), a sulfonylurea (Amaryl, Glucotrol/XL, Glynase)

CYSTADROPS

Cystaran

DAYTRANA

Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR, Metadate CD*, Methylin, Ritalin LA/SR *can be opened and sprinkled on applesauce

DAYVIGO

Ambien/CR, Intermezzo, Lunesta, Restoril, Rozerem, Silenor, Sonata

DESVENLAFAXINE ER

Generic SSRI/SNRI (Celexa, Cymbalta, Effexor/XR, Pristiq, Prozac, Zoloft, etc.), Wellbutrin/SR/XL

DEXILANT

Aciphex, Nexium, Prevacid, Prilosec, Protonix

DIACOMIT

Depakote, Onfi, Topamax

DICLOFENAC EPOLAMINE PATCH (AUTHORIZED GENERIC OF FLECTOR PATCH)

Generic NSAIDs [Celebrex, Lodine/XL, Mobic, Motrin (Rx only), Naprosyn (Rx only), Voltaren oral/XR, etc.], Lidoderm, OTC topical analgesic balms (i.e. trolamine salicylate); Voltaren gel

DIFICID DIPENTUM DIVIGEL DORYX MPC DUAVEE DUOBRII DUPIXENT

Flagyl, Vancocin

Apriso, Asacol HD, Azulfidine/En-Tab, Canasa, Colazal, Delzicol, Lialda, Pentasa

Alora, Climara, Estrace, Estring, Estrogel, Minivelle, Vagifem, Vivelle-Dot

Minocin, Monodox, tetracycline, Vibramycin

Climara, Estrace or Premarin plus a progestin; Effexor/XR, Paxil

Ultravate cream/ointment plus Tazorac

For asthma: Advair, Dulera, Symbicort For atopic dermatitis: Cellcept, generic topical steroids, Gengraf/Neoral, Elidel, Imuran, methotrexate, Protopic For chronic rhinosinusitis with nasal polyposis: Flonase; Nasalide, Nasonex, OTC Nasacort, OTC Rhinocort

** May be covered with a prescription for some Blue Cross members.

NOTE: This document serves as a quick reference guide. For the most current list of covered medications and requirements, visit pharmacy.

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Tier 3

DUREZOL DUTOPROL DYANAVEL XR

ECOZA

EDARBI

EDARBYCLOR EDEX EDLUAR ELESTRIN ELIGARD ELIXOPHYLLIN EMFLAZA EMSAM

EMVERM ENDARI ENDOMETRIN ENSTILAR ENVARSUS XR EPANED EPIDIOLEX EPIDUO FORTE

EPOGEN EQUETRO ERTACZO EUCRISA EVAMIST

Preferred alternatives

Decadron ophthalmic, FML, Inflamase/Forte, Pred Forte, Pred Mild

Toprol XL plus hydrochlorothiazide

Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR, Metadate CD*, Methylin, Ritalin LA/SR *can be opened and sprinkled on applesauce

Diflucan, Lamisil, Nizoral, OTC Clotrimazole, OTC Miconazole, Spectazole, Sporanox

Atacand/HCT, Avalide, Avapro, Benicar/HCT, Cozaar, Exforge, Hyzaar, Micardis/HCT

Atacand HCT, Benicar HCT, Generic ARB (such as Cozaar) plus chlorthalidone

Caverject, Cialis, Levitra, Muse, Staxyn, Viagra

Ambien/CR, Intermezzo, Lunesta, Restoril, Rozerem, Silenor, Sonata

Alora, Climara, Estrace, Estring, Estrogel, Vagifem, Vivelle-Dot

Lupron/Depot, Trelstar/LA/Depot

Theophlline anhydrous, Theo-24

Prednisone, Prednisolone

Generic SSRI/SNRI (Celexa, Effexor/XR, Pristiq, Prozac, Zoloft, etc.), Wellbutrin/SR/XL

Albenza

Droxia, Hydrea

Crinone 8%

Dovonex plus Diprolene/Diprosone; Taclonex

Prograf capsules

Vasotec

Depakene, Keppra, Topamax

Benzaclin, Benzamycin, Duac, Epiduo, OTC benzoyl peroxide plus Differin; RetinA, Tazorac

Procrit

Abilify, Lamictal/ODT, Lithium, Tegretol/XR

Lotrimin, Naftin, Nizoral, Spectazole

Elidel, generic topical steroids, Protopic

Alora, Climara, Estrace, Estring, Estrogel, Minivelle, Vagifem, Vivelle-Dot

Tier 3

Preferred alternatives

EXELDERM, SULCONAZOLE NITRATE 1% CREAM AND SOLUTION (AUTHORIZED GENERIC OF EXELDERM)

Lotrimin, Naftin, Nizoral, Spectazole

EXTAVIA

Avonex, Copaxone, Gilenya, Mayzent, Plegridy, Rebif, Tecfidera

FABIOR

Benzaclin, Benzamycin, Duac, Epiduo, Differin, Retin-A, Tazorac

FACTIVE

Avelox, Erythromycin, Levaquin, Vibramycin, Zithromax

FANAPT

Abilify, Clozaril, Geodon, Invega, Risperdal, Seroquel/XR, Zyprexa

FEMRING

Alora, Climara, Estring, Estrogel, Minivelle, Vagifem, Vivelle-Dot

FENORTHO

Generic NSAIDs [Celebrex, Lodine/XL, Mobic Motrin (Rx only), Naprosyn (Rx only), Voltaren oral/XR, etc.]

FENTORA, FENTANYL BUCCAL TABLET (AUTHORIZED GENERIC OF FENTORA)

Actiq, MSIR, Opana IR, oxycodone IR, Roxanol

FETZIMA

Generic SSRI/SNRI (Celexa, Cymbalta, Effexor/XR, Pristiq, Prozac, Zoloft, etc.), Wellbutrin/SR/XL

FINTEPLA

Depakote, Onfi, Topamax

FLAREX

Acular, Bromday, Ocufen, Voltaren ophthalmic

FLUOROPLEX

Aldara, Efudex, Tolak

FLUTICASONESALMETEROL RESPICLICK (AUTHORIZED GENERIC OF AIRDUO RESPICLICK)

Combination products: Advair Diskus/HFA, Breo Ellipta, Breztri Aerosphere, Dulera, Symbicort, Trelegy Ellipta Single ingredient products: Arnuity Ellipta, Asmanex/HFA, Flovent HFA/Diskus, Pulmicort Flexhaler/solution, Qvar Redihaler, Spiriva/Respimat, Serevent Diskus

FOLLISTIM AQ

Gonal-F/RFF/Redi-Ject

FOSAMAX PLUS D Actonel, Atelvia, Boniva, Fosamax plus OTC Vitamin D

FRAGMIN

Lovenox

FYCOMPA

Depakote/ER, Lamictal/ODT, Tegretol, Topamax, Trileptal

GALZIN

OTC zinc supplements

GELNIQUE

Detrol/LA, Ditropan/XL, Enablex, Sanctura/XR, Vesicare

GONITRO

nitroglycerin, Nitrostat

** May be covered with a prescription for some Blue Cross members.

NOTE: This document serves as a quick reference guide. For the most current list of covered medications and requirements, visit pharmacy.

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Tier 3

GRALISE

GRANIX GRASTEK

GYNAZOLE-1 HARVONI HEMANGEOL HETLIOZ HORIZANT

HUMATROPE HYSINGLA ER

ILEVRO IMVEXXY INBRIJA INCRUSE ELLIPTA INGREZZA INREBIC INSULIN LISPRO JUNIOR (AUTHORIZED GENERIC OF HUMALOG JUNIOR KWIKPEN) INTRAROSA INVELTYS ISTURISA JATENZO

JORNAY PM

KARBINAL ER KATERZIA

Preferred alternatives

Cymbalta, Generic TCA (Adapin, Elavil, Sinequan, Tofranil, etc.), Lyrica, Neurontin, Ultram/ER

Nivestym, Zarxio

Accolate, Clarinex, Flonase, Nasalide, Nasonex, OTC Claritin**, OTC Nasacort, OTC Zyrtec**, Singulair, Xyzal

Diflucan 150mg, Monistat 3, Terazol

Epclusa (genotypes 5 and 6), Epclusa or Zepatier (genotypes 1 and 4)

Inderal

Ambien/CR, Intermezzo, OTC melatonin, Restoril, Rozerem, Silenor, Sonata

Generic TCA (Adapin, Elavil, Sinequan, Tofranil, etc.), Lyrica, Mirapex, Neurontin, Requip

Genotropin, Norditropin Flexpro, Nutropin AQ NuSpin

Butrans, Duragesic, Exalgo, methadone, MS Contin, Opana ER, Ultram ER, Zohydro ER

Acular, Bromday, Ocufen, Voltaren ophthalmic

Estrace, Estring, Estrogel, Premarin, Vagifem

Azilect, Comtan, Eldepryl, Mirapex/ER, Requip/XL, Sinemet/CR, Tasmar

Anoro Ellipta, Serevent, Spiriva/Respimat, Stiolto Respimat

Austedo

Jakafi

Fiasp (all forms), Novolin (NDCs ending in 00, 01, 11, and 15), Novolog (all forms)

Estring, Premarin, Vagifem

Decadron ophthalmic, FML, Inflamase/Forte, Pred Forte, Pred Mild

Signifor

Androderm, Androgel, Android, Axiron, Delatestryl, Depo-Testosterone, Testim, Testred

Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR, Metadate CD*, Methylin, Ritalin LA/SR *can be opened and sprinkled on applesauce

Clarinex, Histex PD, OTC Claritin**, OTC Zyrtec**, Palgic, Xyzal

Norvasc

Tier 3

Preferred alternatives

KEVEYIS

Diamox

KEVZARA

Actemra Actpen/syringe, Enbrel, Humira, methotrexate, Rinvoq, Xeljanz/XR

KINERET

Actemra Actpen/syringe, Enbrel, Humira, methotrexate, Rinvoq, Xeljanz/XR

KYNMOBI

Azilect, Comtan, Eldepryl, Mirapex/ER, Requip/XL, Sinemet/CR, Tasmar

LAMPIT

benznidazole

LASTACAFT

Alrex, Bepreve, Elestat, Opticrom, Optivar, Pataday, Patanol, Pazeo

LATUDA

Abilify, Clozaril, Geodon, Invega, Risperdal, Seroquel/XR, Zyprexa

LIPOFEN, FENOFIBRATE 50MG, 150MG (AUTHORIZED GENERIC OF LIPOFEN)

Antara, Fenoglide, Lofibra, Lopid, Tricor, Trilipix

LIVALO

Crestor, Lescol/XL, Lipitor, Mevacor, Pravachol, Vytorin, Zocor

LO LOESTRIN FE

Generic biphasic contraceptives (Loseasonique, Mircette, etc)

LOMAIRA

Adipex-P, Bontril, Didrex, OTC Alli, Tenuate

LONHALA MAGNAIR Anoro Ellipta, Serevent Diskus, Spiriva/Respimat, Stiolto Respimat

LOTEMAX SM

Decadron ophthalmic, FML, Inflamase/Forte, Pred Forte, Pred Mild

LUPANETA PACK Lupron/Depot plus Aygestin

LUZU, LULICONAZOLE 1% CREAM (AUTHORIZED GENERIC OF LUZU)

Lotrimin, Naftin, Nizoral, Spectazole

LYRICA CR

generic TCA (Adapin, Elavil, Sinequan, Tofranil, etc.), Lyrica, Neurontin

MARPLAN

Nardil, Parnate

MAVENCLAD

Avonex, Copaxone, Gilenya, Mayzent, Plegridy, Rebif, Tecfidera

MAVYRET

Epclusa or Zepatier (genotypes 1 and 4), Epclusa (genotypes 2-3, 5-6)

MAXIDEX

Decadron ophthalmic, FML, Inflamase/Forte, Pred Forte, Pred Mild

MENEST

Alora, Climara, Estrace, Estring, Estrogel, Minivelle, Vagifem, Vivelle-Dot

MENOSTAR

Alora, Climara, Estrace, Estring, Estrogel, Minivelle, Vagifem, Vivelle-Dot

METHITEST

Androderm, Androgel, Android, Axiron, Delatestryl, Depo-Testosterone, Testim, Testred

MINITRAN

nitroglycerin, Nitrostat

MIRCERA

Procrit

** May be covered with a prescription for some Blue Cross members.

NOTE: This document serves as a quick reference guide. For the most current list of covered medications and requirements, visit pharmacy.

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Tier 3

MITIGARE, COLCHICINE CAPSULES (AUTHORIZED GENERIC OF MITIGARE) MOTEGRITY

MOTOFEN MOVANTIK

MOXATAG MYALEPT

MYCAPSSA MYRBETRIQ

NAMZARIC NATAZIA

NATESTO

NEBUSAL NEUPOGEN NEUPRO NEVANAC

NICOTROL, NS

NOCDURNA

NOCTIVA

NORITATE

NORTHERA NOURIANZ

NOVAREL NUCYNTA NUCYNTA ER

NURTEC ODT

NUVESSA NUZYRA TABLET

NYMALIZE

Preferred alternatives

Colchicine tablets, Colcrys

Amitiza, lactulose solution, Linzess, OTC fiber, OTC laxatives, OTC stool softeners Imodium, Lomotil Amitiza, lactulose solution, Linzess, OTC fiber, OTC stimulant laxatives, OTC stool softeners Amoxil capsules Crestor, Insulin, Lescol/XL, Lipitor, Mevacor, Pravachol, Vytorin, Zocor Sandostatin, Somatuline Depot Detrol/LA, Ditropan/XL, Enablex, Sanctura/XR, Vesicare Aricept/ODT, Exelon, Namenda/solution Mircette, Ortho Tri-Cyclen, Quartette, Yasmin, Yaz Androderm, Androgel, Android, Axiron, Delatestryl, Depo-Testosterone, Testim, Testred generic sodium chloride inhalation Nivestym, Zarxio Lyrica, Mirapex/ER, Neurontin, Requip/XL Acular, Bromday, Ocufen, Voltaren ophthalmic OTC nicotine products (gum, lozenge, patch) (covered with Rx); Zyban Detrol/LA, Ditropan/XL, Enablex, Sanctura/XR, Vesicare Detrol/LA, Ditropan/XL, Enablex, Sanctura/XR, Vesicare Finacea gel, Metrocream, Metrogel, Metrolotion, Retin-A, Tazorac Florinef, Proamatine Azilect, Comtan, Eldepryl, Mirapex/ER, Requip/XL, Sinemet/CR, Tasmar Pregnyl MSIR, Opana IR, oxycodone IR, Ultram Butrans, Duragesic, methadone, MS contin, Opana ER, Ultram ER, Zohydro ER Amerge, Axert, Frova, Imitrex, Maxalt/MLT, Relpax, Zomig/ZMT Cleocin vaginal cream, Metrogel-vaginal Generic doxycycline, azithromycin, clarithomycin, erythromycin, cephalexin Nimotop

Tier 3

OBREDON ODACTRA

OLUMIANT

OMECLAMOX-PAK

OMNARIS

OMNITROPE

ONGENTYS

ONZETRA XSAIL

ORACEA, DOXYCYCLINE IRDR (AUTHORIZED GENERIC OF ORACEA) ORALAIR

ORAVIG

ORENCIA CLICKJET/SUBQ

ORIAHNN

OSMOPREP

OSPHENA OTREXUP

OXBRYTA OXTELLAR XR

OXYCONTIN, OXYCODONE HCL ER (AUTHORIZED GENERIC OF OXYCONTIN) OZOBAX

PANCREAZE PAREMYD PERFOROMIST

PERTZYE

Preferred alternatives

Hycodan

Accolate, Clarinex, Flonase, Nasalide, Nasonex, OTC Claritin**, OTC Nasacort, OTC Zyrtec**, Singulair, Xyzal

Actemra Actpen/syringe, Enbrel, Humira, methotrexate, Rinvoq, Xeljanz, Xeljanz XR

Prevacid or Prilosec plus Amoxil plus Biaxin/XL

Flonase, Nasalide, Nasonex, OTC Nasacort, OTC Rhinocort, Patanase

Genotropin, Norditropin Flexpro, Nutropin AQ NuSpin

Azilect, Comtan, Eldepryl, Mirapex/ER, Requip/XL, Sinemet/CR, Tasmar

Amerge, Axert, Frova, Imitrex, Maxalt/MLT, Relpax, Zomig/ZMT

Finacea gel, Metrocream, Metrogel, Metrolotion, Minocin, Monodox, tetracycline, Vibramycin

Accolate, Clarinex, Flonase, Nasalide, Nasonex, OTC Claritin**, OTC Nasacort, OTC Zyrtec**, Singulair, Xyzal

Diflucan, Mycelex Troche, Nystatin, Sporanox

Actemra Actpen/syringe, Cosentyx, Enbrel, Humira, methotrexate, Otezla, Rinvoq, Stelara, Xeljanz/XR

generic contraceptives (various), Lupron Depot

Colyte, Golytely, Moviprep, Nulytely, PegPrep

Estring or Vagifem plus a progestin

Actemra SC, Enbrel, Humira, methotrexate, Rinvoq Trexall, Xeljanz/XR

Droxia, Hydrea

Depakote/ER, Lamictal/ODT, Lyrica, Neurontin, Tegretol/XR, Topamax, Trileptal

Butrans, Duragesic, Exalgo, methadone, MS Contin, Opana ER, Ultram ER, Zohydro ER

Generic muscle relaxant (such as baclofen, Norflex, Parafon Forte DSC, Flexeril, Robaxin, Zanaflex)

Creon, Viokace, Zenpep

Cyclogyl, Isopto Atropine plus Mydriacyl

Anoro Ellipta, Serevent Diskus, Spiriva/Respimat, Stiolto Respimat

Creon, Viokace, Zenpep

** May be covered with a prescription for some Blue Cross members.

NOTE: This document serves as a quick reference guide. For the most current list of covered medications and requirements, visit pharmacy.

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