Preferred Drug List - Blue Cross Complete of Michigan

Preferred Drug List

Effective August 1, 2022

The Preferred Drug List is a list of medicines that are covered by your pharmacy benefit. The list includes prescription and non-prescription medicines. In addition to this list, you can use our online search tool. You'll also find the Preferred Drug List on our website at . This is an easy-to-use summary of the medicines we cover. If you have questions, please contact Blue Cross Complete of Michigan's Pharmacy Services at 1-888-288-3231. You can call this number from 8:30 a.m. until 6 p.m., Monday through Friday.

Encl: Nondiscrimination Notice and Language Services Blue Cross Complete participates in the Michigan Common Formulary WEB-011Rev072922

CURRENT AS OF 8/1/2022

Prescriptions Drug Name

Alternative Therapy Alternative Therapy - Antidepressants

st. john's wort oral capsule 300 mg st. john's wort oral tablet tryptophan oral tablet

Alternative Therapy Sedative/Hypnotics

LYDIA PINKHAM HERBAL ORAL ELIXIR tryptophan oral capsule

Analgesic, Anti-Inflammatory Or Antipyretic Analgesic Opioid Agonists

ACTIQ codeine sulfate CONZIP DILAUDID DISKETS fentanyl citrate fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 72 hour 37.5 mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour FENTORA hydrocodone bitartrate hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr hydromorphone rectal

Tier Status

Coverage Requirements and Limits

Carve-out Carve-out Carve-out

OTC

Carve-out Carve-out

NP

PA; QL

P

QL

NP

PA

NP

PA; QL

NP

PA

NP

PA; QL

P

QL

NP

PA

NP

PA; QL

NP

PA

P

QL

P

QL

NP

PA

NP

PA

AL = Age Limit

F = Formulary product

NP = Formulary; PDL Non-Preferred; PA required

P = Formulary; PDL Preferred

P-PA = Formulary; PDL Preferred; PA required

PA = Prior Authorization

QL = Quantity Limit

ST = Step Therapy

State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.

1

Prescriptions Drug Name

HYSINGLA ER levorphanol tartrate meperidine oral solution meperidine oral tablet 50 mg methadone injection solution METHADONE INTENSOL methadone oral concentrate methadone oral solution methadone oral tablet methadone oral tablet,soluble METHADOSE ORAL CONCENTRATE METHADOSE ORAL TABLET,SOLUBLE morphine concentrate oral solution morphine concentrate oral syringe 10 mg/0.5 ml morphine oral capsule, er multiphase 24 hr morphine oral capsule,extend.release pellets 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution morphine oral tablet morphine oral tablet extended release morphine rectal MS CONTIN NUCYNTA NUCYNTA ER OXAYDO oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral syringe oxycodone oral tablet 10 mg, 15 mg, 5 mg

Tier Status

NP NP NP NP NP NP NP NP NP NP NP NP P P NP

NP

P P P P NP NP NP NP NP NP P NP P

Coverage Requirements and Limits

PA PA PA; QL PA; QL PA PA PA PA PA PA PA PA QL

PA

PA

QL QL

PA PA PA PA; QL PA; QL PA; QL QL PA; QL QL

AL = Age Limit

F = Formulary product

NP = Formulary; PDL Non-Preferred; PA required

P = Formulary; PDL Preferred

P-PA = Formulary; PDL Preferred; PA required

PA = Prior Authorization

QL = Quantity Limit

ST = Step Therapy

State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.

2

Prescriptions Drug Name

oxycodone oral tablet 20 mg, 30 mg oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 20 mg, 40 mg, 80 mg OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR oxymorphone oral tablet oxymorphone oral tablet extended release 12 hr ROXICODONE tramadol oral capsule,er biphase 24 hr 17-83 tramadol oral capsule,er biphase 24 hr 25-75 100 mg, 200 mg tramadol oral solution tramadol oral tablet tramadol oral tablet extended release 24 hr tramadol oral tablet, er multiphase 24 hr ULTRAM XTAMPZA ER

Analgesic Opioid Codeine Combinations

acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet ASCOMP WITH CODEINE BUTALBITAL COMPOUND W/CODEINE butalbital-acetaminop-caf-cod codeine-butalbital-asa-caff FIORICET WITH CODEINE

Analgesic Opioid Dihydrocodeine Combinations

acetaminophen-caff-dihydrocod

Tier Status

NP NP

NP NP NP NP NP NP NP P P P NP NP

Coverage Requirements and Limits

PA; QL PA; QL

PA; QL PA; QL PA PA; QL PA PA PA; QL; AL

PA PA; QL

P

P

NP

PA

NP

PA

NP

PA

NP

PA

NP

PA

NP

PA

AL = Age Limit

F = Formulary product

NP = Formulary; PDL Non-Preferred; PA required

P = Formulary; PDL Preferred

P-PA = Formulary; PDL Preferred; PA required

PA = Prior Authorization

QL = Quantity Limit

ST = Step Therapy

State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.

3

Prescriptions Drug Name

Analgesic Opioid Dihydrocodeine, NonSalicylate Analgesic,Xanthine

acetaminophen-caff-dihydrocod

Analgesic Opioid Hydrocodone And Non-Salicylate Combinations

APADAZ benzhydrocodone-acetaminophen hydrocodone-acetaminophen oral solution 7.5325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg LORTAB ELIXIR

Analgesic Opioid Hydrocodone And Nsaid Combinations

hydrocodone-ibuprofen

Analgesic Opioid Hydrocodone Combinations

hydrocodone-acetaminophen oral solution 7.5325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg hydrocodone-ibuprofen LORTAB ELIXIR

Analgesic Opioid Oxycodone And NonSalicylate Combinations

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG NALOCET oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Tier Status

Coverage Requirements and Limits

NP

PA

NP

PA

NP

PA

P

P

NP

PA

NP

PA

P

P

NP

PA

NP

PA

P

NP

PA

P

AL = Age Limit

F = Formulary product

NP = Formulary; PDL Non-Preferred; PA required

P = Formulary; PDL Preferred

P-PA = Formulary; PDL Preferred; PA required

PA = Prior Authorization

QL = Quantity Limit

ST = Step Therapy

State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.

4

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download