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Programs, discounts,
and tools to help
you stay healthy
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association
Live a
Healthier Life
Everything
You Need to
All in One Place
www.bluecrossma.com/ahealthyme
Whatever your health
goals are — from losing
weight to managing
stress — ahealthyme
can help you get there.
Access &
Convenience
Discounts &
Deals
Pregnancy &
Parenthood
Alternative
Medicine &
Services
Español
Encuentra estos programas,
herramientas y recursos disponibles
en español que te ayudarán a
mantenerte saludable.
Live a
Healthier Life
Everything
You Need to
All in One Place
www.bluecrossma.com/ahealthyme
Your personal
wellness planner
Create your own action plan
with
• A health assessment that gives
you a personal wellness score
• Self-paced workshops on
topics like healthy eating and
quitting smoking
• Nutrition and exercise trackers
to keep you motivated
Healthy resources
Learn about health your way
• Read articles, tips, and our
Healthy Times newsletter
• Watch videos and listen to podcasts
• Take quizzes, risk assessments,
and more
Recursos saludables
para conocer el camino
hacia una buena salud.
www.paramisalud.com
Español
Visita
Co Acc
nv es
en s
ie &
nc
e
Connected
Web, Apps,
Texts & Social
Always on the go?
No problem. Access our
collection of mobile applications
anywhere, anytime.
There’s so much
you can do on the go
• Find a doctor or hospital
• Manage your prescriptions
• Get weekly health tips via
text throughout pregnancy
and motherhood
• Follow us on Facebook,
Twitter, and YouTube
• Track your progress toward
your fitness and nutrition goals
Go to
www.bluecrossma.com/mobile
sc
De oun
al ts
s &
Di
Deals
Blue365
®
From gym memberships
and diet programs
to family activities,
we have just
the deal for you.
Get special savings, 365 days a year
• Healthy Choices: fitness, weight management,
food and nutrition, and stress management
• Health Care Resources: financial services and
assessments, information about prescription
drugs, hearing and vision care, and insurance tips
• Recreation and Travel: arts and entertainment,
outdoor recreation, and travel tips
Go to
www.bluecrossma.com/blue365
Pr
Pa egn
re an
n t cy
ho &
od
Family
Living Healthy
Babies ´
®
Have questions about
pregnancy, labor, and what
to expect during your
baby’s first year?
We can help answer
your questions.
A trusted, online resource for new parents
• Pregnancy Prep: understand your body and plan
ahead with ovulation calculators
• Pregnancy: know what to expect in each trimester
and download a birth plan
• New Parents: learn more about your baby’s first year
Go to
www.livinghealthybabies.com
Español
Visita
¿Tienes preguntas sobre
el embarazo, el parto y qué
esperar durante el primer
año de tu bebé?
http://espanol.livinghealthybabies.com
A
M lter
ed na
Se ic ti
r v ine ve
ic &
es
Alternative
Living Healthy
Naturally ´
SM
Save on alternative
services nationwide like
massage therapy
and acupuncture.
A complementary approach to health
• Services: massage therapy, acupuncture,
pilates, yoga, and much more
• Discounts: save up to 30 percent on
select services or medicine
• Peace of mind: relax knowing all
practitioners meet requirements for
education, training, and facilities
Go to
www.bluecrossma.com/alternative-care
We are here to help
Member Service
For questions about your health coverage,
claims, and benefits.
Call the number on your Blue Cross
ID card, Monday through Friday,
8:00 a.m. to 6:00 p.m. ET.
Español
stamos para responder a tus preguntas
E
sobre tu plan médico. Llama al número
que se encuentra en tu tarjeta de
identificación de Blue Cross.
Member Central
Review your claims and benefits information,
order a new ID card, change your primary care
provider, and do so much more.
www.bluecrossma.com/membercentral
Blue Care LineSM
For questions about your health if you’re
hurt or sick and not sure where to get care.
Call us 24/7 to speak directly to a nurse
who can help guide your care.
Español Si tienes preguntas sobre tu salud,
puedes comunicarte con un enfermero
disponible las 24 horas del día, los
7 días de la semana.
1-888-247-BLUE (2583)
®, SM Registered Marks and Service Marks of the Blue Cross and
Blue Shield Association. ®´, SM´ Registered Marks and Service Marks
of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross
and Blue Shield of Massachusetts HMO Blue, Inc. © 2014 Blue Cross
and Blue Shield of Massachusetts, Inc.
134021M 55-0830 (5/14)
Blue Care Line
SM
We’re here for you 24/7
Have a question about your health? You can talk to a
professionally trained, registered nurse 24 hours a day, seven
days a week. They’re ready when you are—even at 4 a.m.
Know your options
Calling the Blue Care Line is a quick way to find out if
you need to see a doctor, go to an emergency room,
or if you’re able to treat it yourself at home.
We’ll call you
Depending on your type of illness or injury, the registered
nurse will call and follow up to see how you’re responding to
the self-treatment.
Confidentiality
Your information is kept in accordance with our policy
on confidentiality.
Call 1-888-247-BLUE (2583)
for the Blue Care Line.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee
of the Blue Cross and Blue Shield Association. ®, SM Registered Marks and
Service Marks of the Blue Cross and Blue Shield Association. © 2014 Blue
Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue
Shield of Massachusetts HMO Blue, Inc.
134148 32-6765 (5/14)
Pref
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Pref
Did You Remember To…
Your Mail Service
Pharmacy Benefit
Detach
envelope
to mail
presciption
order form
• Complete all applicable information
• Include your ID number on the mail order form
• Enclose the original prescription, mail order form, and
appropriate copayment
Patient 1 (Cardholder)
Name:

•Make checks or money orders payable to “Express
Scripts”, or include credit card information
I want non-child resistant caps,
when available.
Date of Birth (MM/DD/YYYY)
/
REMINDER: This section must be removed before mailing.
/
DEVICES
OTC
HEALTH CONDITIONS
DRUG ALLERGIES
List other Allergies here:
OTHER
Pref
Home Delivery Service
PO Box 66566
St Louis, MO 63166-9967
BUSINESS
REPLY MAIL
FIRST-CLASS MAIL PERMIT NO. 3580 ST LOUIS MO
POSTAGE WILL BE PAID BY ADDRESSEE
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
Please note that all prescriptions requiring a formulary
exception will not be processed without prior approval.
To prevent any delays, make sure that an approved
formulary exception (if applicable) is on file before you
place your order.
Please note
Thank you for using our mail service
prescription drug program.
Pref
Fold
(Tear here)
List other Health
Conditions here:
List other OTC that you take
on a regular basis:
List Medical Devices here:
Patient 2
Date of Birth is required for
patient identification.
Failure to provide complete and
accurate information may prevent
the pharmacy from detecting drug
related problems.
Name:
I want non-child resistant caps,
when available.
/
/
No Known Allergies
Acetaminophen/Tylenol®
Amoxicillin
Aspirin
Cephalosporin (i.e., Keflex®, Cephalexin)
Codeine
Erythromycin, Biaxin®, Zithromax®
NSAIDs (i.e., Ibuprofen, Naproxen)
Oxycodone (i.e., OxyContin®, Percocet®)
Penicillin
Sulfa
Tetracycline (i.e., Doxycycline, Minocycline)
No Known Health Conditions
Arthritis (715.9)
Asthma (493.9)
Chronic Bronchitis or Emphysema (496)
Depression (311)
Diabetes Type I (250.01)
Diabetes Type II (250.00)
Epilepsy/Seizures (345.9)
GERD (530.81)
Glaucoma (365.9)
High Cholesterol (272.9)
Hormone Replacement Therapy (627.9)
Hypertension (401.9)
Thyroid: Low (244.9)
No Over-the-Counter Medications
Acetaminophen/Tylenol®
Advil®/Aleve®/Motrin®
Aspirin/Excedrin®
List other Allergies here:
No Medical Devices
List Medical Devices here:
It’s a great way to save by purchasing
prescriptions on a long-term basis.
List other Health
Conditions here:
List other OTC that you take
on a regular basis:
Medical Devices (i.e., Glucose Testing
Device, Insulin Pump, Nebulizer) and
specify brand name and model.
List other Prescription
Medications here:
No Other Prescriptions
Prescription Medications not filled
through Express Scripts Pharmacy.
List other Prescription
Medications here:
FDA approved generic medications will be dispensed when allowed by your doctor, subject to the terms
outlined in your plan. I certify that all the information on this form is correct. I permit Express Scripts Inc. to
release all information on this form concerning prescription orders to my plan sponsor, administrator or health
plan for the purpose of payment, treatment or health care operations.
Signature Required
X
More than two family members on your plan? On a separate sheet of paper, write the family member(s)
name, date of birth, allergies and health conditions along with the name and phone number of their
doctor/prescriber.
MLRBENP
As a member of Blue Cross Blue Shield of
Massachusetts, you can buy certain medications
at the Express Scripts mail service pharmacy.
Check Out These Benefits!
Three Easy Steps To Use Mail Service
Savings: The biggest advantage of the mail service pharmacy is
that for most long-term maintenance medications you can order
up to a 90-day supply. Often times, using mail service results in
the lowest possible out-of-pocket costs to you as a member.
For long-term prescriptions, use our mail service pharmacy to save.
1. Ask your doctor to prescribe medications for up to a 90-day
supply, plus refills when applicable. (If you’re already taking
medication on a long-term basis, ask your doctor for a new
prescription.)
Convenience: Your medications will be delivered to your home,
postage paid, within 14 days of mailing your new prescription.
Confidentiality: If you have questions, you can
call Express Scripts toll-free, 24 hours a day. Registered
pharmacists are available to answer your questions about your
prescriptions confidentially. Call 1-800-892-5119.
Special-Needs Services Available: For the convenience of our
hearing-impaired members, Express Scripts is TTY-ready, and has
installed a separate toll-free number for you to use with your TTY
equipment. The number is 1-800-305-5376.
For our vision-impaired members, upon special request with
your order, Express Scripts can provide Braille labels for your
medication.
And for our non-English-speaking members, Express Scripts can
provide translation services when you call the toll-free line.
Refer to your benefit literature for specific coverage information.
Please Note: Your order may be filled at any one of our Express Scripts Pharmacies located nationwide.
MLR- DRAFTONLY (MAILER) REV 07/27/2011
Pref
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Pref
Pref
2. C
omplete the attached Mail Order Form for each member
submitting a prescription. Be sure to answer all of the questions.
3. Seal the form, prescriptions, and the appropriate copayment in
the pocket in this brochure (do not send cash). Then simply mail
it in. Be sure to write your ID number exactly as it appears on
your ID card.
Your order will be quickly processed and sent to you by mail or
UPS. Allow 14 days for delivery from the date you mail the order.
To prevent delays, do not fill medications that are needed quickly or
short-term medications (e.g. antibiotics) via mail service.
Confidential Subscriber/Patient Profile
Please write your ID number, name, and address on the attached
form. Then complete the Patient Profile for you and each of your
dependents submitting prescriptions, indicating any drug
allergies, and health conditions. Express Scripts will use this
information to check any potential drug interactions when you
have prescriptions filled. If there are no drug allergies, please
check “None” in the box provided.
Pref
Express Scripts Pharmacy Prescription Order Form
Detach
envelope
to mail
presciption
order form
Detach Here
To order online: sign in at www.StartHomeDelivery.com and follow the prompts.
To order by mail: complete this form and ask your doctor to write your prescription for a
90-day supply or the maximum days supply allowed by your plan.
• Use ALL CAPITAL LETTERS in BLACK INK. Fill in the ovals as shown (
).
• Remember to mail your prescription with this completed form. Your medication
will arrive within two weeks from the date we receive your first order.

For all orders after 08/01/2011, use this form.
Fold and tear off this piece before putting in the return envelope.
NOTE: Standard shipping is FREE for online and mail orders.
ID Card Number
(Tear here)
Glue
MI
First Name
Pref
Pref
Fold
Glue
/
/
Last Name
PATIENT 1 (CARDHOLDER)
Inside envelope
M
F
Some medications cannot be delivered to a PO Box. Provide a street address to allow delivery of your order.
Shipping Address 1
Shipping Address 2
City
State
Zip Code
Check here for rush shipment. Your order, once
received and filled, will be shipped overnight for $21.
Email
Please select one
as your preferred
telephone number
Daytime Phone
(
)
Evening Phone
(
)
Cell Phone
(
Doctor/Prescriber Last Name
)
Doctor/Prescriber Phone Number
(
)
First Name
PATIENT 2
Inside envelope
MI
/
/
Last Name
Gender
M
F
Email
Doctor/Prescriber Last Name
(
Doctor/Prescriber Phone Number
)
Apply to this order only
Check Card
Card #
Credit Card
Apply to all orders
Check / Money Order
$
Amount Enclosed
Exp. Date (MM/YY)
/
Sign here to authorize card payment X
MLR- DRAFTONLY (MAILER) REV 07/27/2011
Pref
Pref
Pref
Glue
Glue
Answers to Your Questions
New Prescriptions:
• Have your doctor/provider write the prescription for up to a
90-day supply
How Do I Determine What Copayment Amount?
I Should Include With My Order?
Check your benefit literature, and if you still have specific
questions, call the Blue Cross Blue Shield of Massachusetts
Member Service phone number listed on the front of your ID card.
• To prevent any delays, make sure that an approved formulary
exception (if applicable) for any medications that are non-covered
or require prior authorization is on file before you place your order
• Complete all information requested on the attached Mail Order Form
• Select your preference for Safety Caps in the appropriate box
• Ensure that the patient’s full name, age, ID number, and address
appear on each prescription
• Find out the appropriate copayment necessary for the medication
prescribed
• Place prescriptions and copayments in return envelope and mail
Refills:
• Call 1-800-892-5119 or visit www.express-scripts.com to refill
your order, or
• Place refill slips and copayments in the return envelope and mail it
Make all checks or money orders payable to “Express Scripts”.
Do not send cash. If paying by credit card, complete the
information under “Credit Card Information.”
What Do I Do in Emergency Situations?
When you need medication immediately, simply have your
prescription filled at a local pharmacy. If you need medication
immediately, but will be taking it on an ongoing basis, you can ask
your doctor to write two prescriptions:
• You can fill the first prescription at a local participating pharmacy;
• Send the second prescription (up to a 90-day supply), along with
your copayment, to Express Scripts immediately.
About Your Prescription
Blue Cross Blue Shield of Massachusetts maintains a list of
covered prescription drugs. If you have any questions about
whether or not your medications are covered, or subject to Quality
Care Dosing, Step Therapy, or Prior Authorization, please visit
www.bluecrossma.com/pharmacy or call Blue Cross Blue Shield of
Massachusetts Member Service at the number on the front of your
ID card.
Mail Service Questions
Call Express Scripts customer service 24 hours a day, 7 days a
week. Pharmacy consultation is also available around-the-clock.
Toll-free number: 1-800-892-5119 (TTY: 1-800-305-5376)
Why Did My Order Contain Generic Drugs?
When My Prescription Requested a Brand-Name Version?
When authorized by your doctor and permitted by applicable law,
Express Scripts will dispense a generic drug. This usually saves
you money, so whenever possible, ask your doctor to prescribe
generic drugs.
Why Isn’t My Drug Available Through the ESI Mail Service?
Certain medications that require immediate administration or are
used for short periods of time are inappropriate for mail service.
In addition, for certain medications classified as specialty drugs,
Blue Cross Blue Shield of Massachusetts has established a
relationship with a preferred specialty pharmacy. They offer
additional services that are not offered by our mail service
pharmacy.
How Do I Order Refills?
Simply call the toll-free number, 1-800-892-5119, and order your
refills over the phone. You can also visit the Express Scripts
website to refill your order (www.express-scripts.com). Once you
have ordered through mail service, you will receive a refill slip with
your prescription.
Enclose the slip and the appropriate copayment amount in the
order envelope (which is provided).
Please Note:
Certain controlled substances and several other prescribed
medications may be subject to other dispensing limitations
and to the professional judgment of the pharmacist. If you have
any questions regarding your medication, please call Express
Scripts customer service at 1-800-892-5119.
It’s the patient’s responsibility to report to Express Scripts any
changes in drug allergies, health conditions, chronic diseases,
and drug sensitivities.
Prescription information about members and dependents
is used by Express Scripts to administer your prescription
program. As part of the administration, Express Scripts reports
that information to Blue Cross Blue Shield of Massachusetts.
Express Scripts also uses the information and prescription
data gathered from claims submitted nationwide for reporting
and analysis, without identifying individual patients in
accordance with applicable laws.
.
Detach Here
PAYMENT
All individuals included in the family will be charged to this credit card.
Fold
Glue
Gender
Instructions
Express Scripts, an independent company, administers your prescription benefit and its services are being provided on behalf of
Blue Cross Blue Shield of Massachusetts. ® Registered Marks of the Blue Cross and Blue Shield Association.
© 2015 Blue Cross and Blue Shield of Massachusetts, and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
147610M32-7040
Our Commitment
to Confidentiality
This Notice describes how medical
information about you may be used
and disclosed and how you can get
access to this information.
Please review it carefully.
Use and Disclosure of Information
We are required by law to protect the confidentiality of your
personal and medical information and to notify you in case of a
breach affecting your personal or medical information. We will
supply your information to you upon your request or to help you
understand treatment options and other benefits available to you.
We also may use and disclose your information without your
written authorization for the following purposes, and as otherwise
permitted or required by law:
• Treatment—to help providers manage or coordinate your health
care and related services. For example, to refer you to another
provider or remind you of appointments.
Our Commitment
We respect your right to privacy. We will not disclose personally
identifiable information about you without your permission, unless
the disclosure is necessary to provide our services to you or is
otherwise in accordance with the law.
Collection of Information
We collect only personal or medical information we need to carry
out our business.
• Examples of personal information are name, address, date of
birth, and social security number. Most often, you and your
employer supply this information to enroll you in a plan.
• Examples of medical information are diagnoses, treatments, and
names of providers who treat you. Most often, your providers
supply this information.
• Payment—to obtain payment for your coverage, provide you
with health benefits, and assist another health plan or provider
in its payment activities. For example, to manage enrollment
records, make coverage determinations, administer claims, or
coordinate benefits with other coverage you may have.
•Health Care Operations—to operate our business, including
accreditation, credentialing, customer service, disease
management, and fraud-prevention activities. For example, to
do business planning, arrange for medical review, and conduct
quality assessment and improvement activities.
• Legal Compliance—to comply with applicable law. For example,
to respond to regulatory authorities responsible for oversight of
government benefit programs or our operations; to parties or
courts in the course of judicial or administrative proceedings; to
law enforcement officials during an investigation; or as necessary
to comply with workers’ compensation laws.
• Research and Public Health—for medical research studies
in accordance with laws for the protection of human research
subjects, and to report to public health authorities and otherwise
prevent or lessen a serious and imminent threat to health or
safety. For example, for the purpose of preventing or controlling
disease, injury, or disability.
• To an Account (such as an employer) or Party It Designates—
for administration of its health plan. For example, to a selfinsured account for claim review and audits. We will disclose
your information only to designated individuals. That, along
with contract obligations, helps protect your information from
unauthorized use.
To carry out these purposes, we share information with entities
that perform functions for us subject to contracts that limit use
and disclosure to intended purposes. We use physical, electronic,
and procedural safeguards to protect your privacy. Even when
allowed, uses and disclosures are limited to the minimum amount
reasonably necessary for the intended task.
Your Privacy Rights
Special Notes Regarding Disclosure
You have the following rights with respect to your personal and
medical information. To exercise any of these rights, contact us
using the information listed at the end of this notice.
Special protections apply to information about certain medical
conditions. For example, with very few exceptions allowed by law,
we will not disclose any information regarding HIV or AIDS to any
party without your written permission. We will not disclose mental
health treatment records to you without first receiving approval
from your treating provider or another equally qualified mental
health professional. Also, we are prohibited from using or disclosing
genetic information for underwriting purposes.
• You have the right to receive information about privacy
protections. Your member-education materials include a notice
of your rights, and you may request a paper copy of this notice at
any time.
•You have the right to inspect and get copies of information
we collect about you. We will provide access to this information
within 30 days of receiving a written request. We may charge a
reasonable fee for copying and mailing records. You may also
ask your providers for access to your records.
• You have the right to receive an accounting of disclosures.
Your request must be in writing. Our response will exclude
any disclosures made in support of treatment, payment, and
health care operations, or that you authorized (among others).
An example of a disclosure that would be reported to you is a
disclosure of your information in response to a subpoena.
• You have the right to ask us to correct or amend information
you believe to be incorrect. Your request to correct, amend,
or delete information should be in writing. We will notify you if
we make an adjustment as a result of your request. If we do
not make an adjustment, we will send you a letter explaining
why within 30 days. In this case, you may ask us to make
your request part of your records, or ask the commissioner of
insurance to review our decision. We may also provide notice of
your requested changes to others who received this information
in the past two years.
• You have the right to designate someone to receive
information and interact with us on your behalf. Your personal
representative has the same rights concerning your information
as you. Your designation and any subsequent revocation must
be in writing, and a form for this purpose is available on our
website or by calling
Member Service.
• You have the right to ask that we restrict or refuse to disclose
personally identifiable information, and that we direct
communications to you by alternative means or to alternative
locations. While we may not always be able to agree, we will
make reasonable efforts to accommodate requests. Your request
and any subsequent revocation must be in writing.
• If you believe your privacy rights have been violated, you
have the right to complain to us, using the standard grievance
process outlined in your benefit materials, or to the Secretary
of the U.S. Department of Health and Human Services, without
fear of retaliation.
® Registered Marks of the Blue Cross and Blue Shield Association. © 2013 Blue Cross and Blue Shield of Massachusetts, Inc.,
and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
147552MB32-7900
Except as provided in this notice, we will not use or disclose your
personal or medical information without your written authorization.
A form for this purpose is available on our website or by calling
Member Service.
Specifically, we must have your written authorization to use or
disclose your information for:
• Marketing purposes;
• The sale of PHI;
• Most use and disclosures of psychotherapy notes.
You may revoke your authorization at any time. Your authorization
must be in writing. Your revocation will not affect any action that
we have already taken in reliance on your authorization.
About This Notice
This notice is effective September 23, 2013. We are required by law
to provide this notice to you and to abide by it while it is in effect.
We reserve the right to change this notice. Any changes will apply
to all personal and medical information that we maintain, regardless
of when it was created or received. Before we make any material
changes in our privacy practices, we will post a new notice on
our website. We will provide information about the changes to our
privacy practices and how to obtain a new notice in our next annual
mailing to members who are then covered by one of our health
plans.
If you have any questions, contact Member Service. We’re here to
help. Please call the Member Service toll-free number on the front
of your ID card or visit our website at www.bluecrossma.com.
Find a Doctor
www.bluecrossma.com/findadoctor
Search for a Doctor, Dentist, Hospital,
or other Health Care Provider
With our easy to use Find a Doctor tool,
you can find the right care for you.
Now you can easily:
How to Search from the Find a Doctor Home Page
• Get search results based on your plan
when logged into Member Central
• Search by name of health care provider
or specialty, e.g., Dermatology, General
Dentistry, Physical Therapy
• See updated doctor and hospital
quality information
• Locate nearby hospitals, doctors,
and other health care providers with
Google Maps
3
1
TM
• Compare up to three health care
providers at a time to see their hospital
affiliations, quality scores, and more
2
• Search nationwide for health care
providers
To get all this information, and more,
including an online brochure on how to
get the most from our easy to use tool,
simply visit Member Central or
www.bluecrossma.com/findadoctor.
1: Health Care Professional
Start here if you’re looking for individual doctors, dentists, eye doctors, behavioral health and
substance abuse professionals, or other health care providers.
2: Medical Facility
Begin here to search for hospitals, freestanding labs and imaging centers, X-rays/radiology, MRIs,
MinuteClinic ,́ ambulance services, durable medical equipment suppliers, physical therapy groups or
other specialty care service providers.
®
3: Specialty
Start your search here to find health care providers by specialty such as chiropractic, general
dentistry, neurology or other specialties.
Quality Information for Doctors
Learn from other patients’ experiences
This information reflects the experience of patients at a
doctor’s office. Specifically:
• How well the doctor communicates with his or her patients
• Ease of getting timely appointments, care, and information from
the doctor’s office
• How well doctors know their patients
See how doctors perform on clinical quality data
You can compare doctors on a range of important preventive care
and chronic disease management measures for children and adults
such as:
Enhanced!
Get Quality of Care Ratings on Find a Doctor.
Quality and cost of health care vary by doctor and hospitals. Selecting
the right care is an important decision for you and your family.
We offer two different types of objective and reliable quality information
in the Find a Doctor tool to help you make your decision:
• Patient care experiences based on feedback from patients
• Clinical quality data based on patient outcomes, adherence to
best practices, etc.
• Number of eligible women who were screened for breast cancer
• Number of diabetics who received appropriate care
Physician Recognition Program
The Blue Physician Recognition program recognizes doctors
who agree to take on accountability for providing high-quality,
high-value, patient-centered health care.
Need a Health Care Provider,
Dentist or Medical Facility?
Simply visit Member Central or www.bluecrossma.com/findadoctor
or call us at the number on your Blue Cross ID card.
Quality Information for Hospitals
Learn from other patients’ experiences
This data highlights the percentage of patients who:
• Would recommend the hospital to family and friends
• Felt the hospital’s clinical team communicated well with them
• Rate the hospital as a clean and quiet facility
Specialty Care Recognition Program - Blue Distinction Centers
Blue Distinction Centers are hospitals that have received
recognition for delivering high quality specialty care.
Specialties include:
• Bariatric Surgery—hospitals that provide weight‐loss surgery
• Spine Surgery—hospitals that provide full inpatient spine
surgery services, including discectomy, fusion,
and decompression procedures
• Knee and Hip Replacement—hospitals that provide full
inpatient knee and hip replacement services, including total
knee replacement and total hip replacement surgeries
• Cardiac Care—hospitals that treat certain heart problems
with both surgery and catheter procedures
• Transplants—hospitals that perform organ transplants
Blue Cross Blue Shield of Massachusetts is an Independent licensee of the Blue Cross and Blue Shield Association. ®, Registered Marks of the Blue Cross and Blue Shield
Association. TM ®’ Trademarks and Registered Marks are the property of their respective owners. © 2015 Blue Cross and Blue Shield of Massachusetts, Inc. and Blue Cross
and Blue Shield of Massachusetts HMO Blue, Inc.
147561M32-8525
Enrollment Form
Thank you for choosing a
Blue Cross Blue Shield plan.
Please take a few minutes to help us set up
your membership by filling out the attached
enrollment form.
Before You Begin
Please read the instructions
carefully.
For members of HMO Blue,® Network Blue,® Blue Choice,® HMO Blue New England,SM
or Blue Choice New EnglandSM: You are required to choose a primary care physician
(PCP) when you enroll. Please choose a PCP from your plan’s provider directory.
Be sure to read “PCP ID #” in Section 2. List your PCP choice on your enrollment
form. The PCP ID number can also be found by visiting www.bluecrossma.com and
selecting Find a Doctor.
For Access BlueSM Members: Although you are not required to choose a PCP, we
recommend you choose one by following the instructions in Section 2 on the back of
this page.
Important: Are you covered by Medicare or other insurance? We need to know if you
or any family member listed have Medicare and/or other insurance. Please be sure
to circle either Y (for yes) or N (for no) in the correct box. This information will help us
accurately coordinate your benefits. Please follow the instructions in Section 2 and 3.
If you have not indicated Yes or No regarding your Medicare or other insurance status,
you may receive a follow-up questionnaire.
Print two copies, one for your records and one for your employer to sign and mail
to Blue Cross Blue Shield of Massachusetts. In order to complete your enrollment
request, your employer is required to sign the application.
Special Instructions for Student Coverage: If you are seeking coverage for a full-time
student dependent over age 19, you may need to fill out a Student Certificate form.
Check with your employer to see if this coverage is available.
Blue Cross Blue Shield of Massachusetts
P.O. Box 986001
Boston, MA 02298
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ®, SM Registered Marks and Service Marks of the
Blue Cross and Blue Shield Association. © 2014 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
147569MB
36-3630
Section 1
To Be Filled Out By Your Employer
Instructions
Your employer will fill out this section.
Type of Transaction—Check the box(es) that apply.
Subscriber Cancellation Codes. If the subscriber will not be continuing any Blue Cross Blue Shield coverage, carefully select one of the following and indicate
the three-digit code on the form.
Code #
Reason for Canceling
Code #
Reason for Canceling
041
• Changing to other health plan
• Voluntary termination
• COBRA cancellation (under 18 months or nonpayment)
061
• Left employment
• COBRA ending
063
• Transfer
042
• Over 65, changing to Group Medex® plan. (Requires Medicare A and B)
• Over 65, changing to direct-pay Medex plan. (Requires Medicare A and B)
• Over 65, changing to Medicare supplement other than Medex plans.
064
• Cancellation as of original effective date
070
• Deceased
071
• Moved out of state (out of HMO service area)
076
• Military service
043
• Medicare (age =< 65)
Note: If your subscribers are adding or dropping one benefit only (medical/dental), please indicate “add medical,” “add dental,” “cancel medical,” or “cancel dental”
in the “Remarks” section.
If your new hires are subject to a probationary period, please indicate the time frame in the “Remarks” section, as well as the qualifying events for new enrollees.
If a subscriber is being moved from an active group to a retiree group (within the same account), this is a transfer and not a termination. Please include the Medical
or Dental Group # transferring to.
Cancellation date will be the first day of no coverage.
Qualifying Events—Remarks:
To assist in the enrollment process, please use check boxes or write in applicable information in the “Remarks” section of the form.
• Open Enrollment—Check this box for open enrollment.
• New Hire—Check this box for new hires to the company.
• COBRA—Check this box if person is continuing coverage under COBRA.
• Add Spouse—Check this box if spouse is being added. Ensure date of marriage is within approved retroactive period.
• Add Dependent—Check this box if adding any dependent.
• Loss of Coverage—Check this box if person lost coverage through spouse or parent. Please include HIPAA Continuous of Coverage Letter from prior company/insurer.
If you have questions contact your account service representative.
• Other—Check this box if change to family requires additional explanation. Please write in the reason for change (e.g., Court Order, Adoption, New Dependent Law under
HCR, Legal Guardianship, etc.). Include supporting documentation. If you have questions contact your account service representative.
Section 2
Yourself (Member 1)
Please fill in all information that applies to you. (REQUIRED)*
PCP ID#—If your health plan requires you to choose a primary care physician (PCP), please fill in this section. Write the PCP ID number (not the telephone number)
of the doctor you have chosen to coordinate your health care. You’ll find the doctor’s PCP ID number in the provider directory for your health plan. If you need help
choosing a PCP, please call our Physician Selection Service at 1-800-821-1388. A representative will be happy to help you select a doctor. PCP ID number can be found
at www.bluecrossma.com, select Find a Doctor.
Other Insurance—Do you have other health insurance or Medicare? Please be sure to circle either Y (for yes) or N (for no) ) in the correct box. If you have other insurance,
please write the name of the other insurance company and its location (city and state).
To Add or Delete a Member—Are you adding or deleting a member under your existing membership? If yes, please fill in the areas in Sections 1 and 2. You may need help
from your employer to fill in Section 1. Then, give us the details about the members you’re adding or deleting in Section 3 and/or Section 4.
Section 3
Member 2
If you choose a Family membership, please fill in this section if you want Member 2 to be covered. (REQUIRED)* (Note: Member 2 cannot be covered under
an Individual membership.)
Other Insurance—Does your spouse have other health insurance or Medicare? Please be sure to circle either Y (for yes) or N (for no) in the correct box. If your spouse has
other insurance, please write the name of the other insurance company and its location (city and state).
Section 4
Your Eligible Dependents (Members 3, 4, and 5)
If you choose a Family membership, please fill in this section for all children or other eligible dependents you want to be covered. (REQUIRED)* (Note: Dependents cannot
be covered under an Individual membership.)
If you have more than three dependents to be covered, please use additional Enrollment Forms as needed. Please indicate on the form that additional forms have been used
and write in the total number of dependents you want to be enrolled.
Section 5
Personal Savings Account
Your employer may have chosen to offer a personal savings account alongside your medical offering. Please consult your open enrollment materials and/or your HR department
to determine if this applies to you.
For each option:
Start Date: Your start date will be considered established for tax purposes as of the start date of your medical plan, provided that you have signed, dated and submitted the
completed application for these accounts on or before that date.
End Date: Your end date is the date you choose to stop deposits into the selected financial account. If you have any questions please see your employer.
Note: If you are transferring from one medical/dental plan to another medical/dental plan, please provide notification that you will be continuing your personal savings account
by completing Section 5 of the Enrollment and Change form.
Section 6
Signatures (Employer & Employee)
Employee: Please sign & date the application and return it to your employer. Employer: Please sign & date the application and return to Blue Cross Blue Shield of Massachusetts.
(REQUIRED)* Under the Affordable Care Act, we are required to collect the Social Security number for you and any dependent enrolling in your plan.
® Registered Marks of the Blue Cross and Blue Shield Association.
© 2014 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
Please Read the Instructions
Before Filling Out This Form.
Enrollment and Change Form
Please TYPE OR PRINT CLEARLY using blue
or black ink to avoid coverage delay or type in information
Please mail to: P.O. Box 986001
Boston, MA 02298 or fax to 1-617-246-7531
1. To Be Filled Out by Your Employer
Company Name
Current BCBS ID #, If any
Current Medical Group #:
Requested Effective Date
MM
DD
Date of Hire
YYYY
Type of Transaction
MM
Current Dental Group #:
DD
❒ Loss of Coverage (HIPAA Continuation of Coverage Letter Required)
❒ Other:___________________________________________
2. Yourself (Member 1)
What
❒ Access Blue
❒ Blue Medicare Rx (Part D) ❒ HMO Blue New England
products? ❒ Blue Choice
❒ Dental Blue
❒ Managed Blue for Seniors
❒ Blue Choice New England ❒ HMO Blue
❒ Medex (Group)
Your First
M.I.
Last
Name
Name
Street Address/
Apt. #
City/
P.O. Box #
Town
Home
Cell
Phone (
)
Phone (
)
Social Security #
Other Insurance?2 Other Insurance
(REQUIRED)1
Y ❒ / N ❒
Company Name
PCP ID #
Name of
(see instructions)
PCP
Are you covered Part A Effective Date
Part B Effective Date
Part D Effective Date
by Medicare?2
Y❒ / N❒
MM
DD
YYYY MM
DD
YYYY MM
DD
3. Member 2
Dental Group #, Transferring To
YYYY
Remarks: (i.e., qualifying event for a new
add, change to family or other instruction)
Change to Family
❒ Open Enrollment
❒ Add Spouse
❒ New Hire
❒ Add Dependent
❒ COBRA
❒ ADD
❒ CANCEL
❒ CHANGE
Three digit
❒ TRANSFER termination code
Medical Group #, Transfering To:
❒ Network Blue
❒ PPO
❒ Saver Blue
Membership Type
Membership Type
(Medical)
(Dental)
❒ Individual ❒ Family ❒ Individual ❒ Family
Sex
Date of Birth
State
Zip Code
Email
City / State
City / State
Is this your current PCP?
Y❒ / N❒
❒ 65+ ❒ Disabled ❒ ESRD
If Retired,
Date
Medicare #
YYYY Actively Working? Y ❒ / N ❒
❒ Domestic Partner ❒ Divorced Spouse (court ordered) Plan Type: ❒ Medical ❒ Dental
M.I.
Last
Sex
Date of Birth
Name
Phone
City / State
Other Insurance?1 Other Insurance
(
)
Y ❒ / N ❒
Company Name
City / State
Is this your current PCP?
Name of
Y❒ / N❒
PCP
Part B Effective Date
Part D Effective Date
Medicare #
❒ 65+ ❒ Disabled ❒ ESRD
If Retired,
MM
DD
YYYY MM
DD
YYYY Actively Working? Y ❒ / N ❒ Date
Please Check One: ❒ Spouse
First
Name
Social Security #
(REQUIRED)1
PCP ID #
(see instructions)
Are you covered Part A Effective Date
by Medicare?2
Y❒ / N❒
MM
DD
YYYY
4. Your Eligible Dependents (Member 3, 4, and 5)
Dependent’s First Name
3.)
Social Security #
(REQUIRED)1
Is this your current PCP? Y ❒ / N ❒
4.)
Social Security #
(REQUIRED)1
5.)
Social Security #
(REQUIRED)1
M.I.
Last
Name
Sex
PCP ID # (see
Name of
instructions)
PCP
Full-time student and aged 19 or older ❒ Disabled and aged 26 or older ❒
M.I.
Last
Name
PCP ID # (see
Name of
instructions)
PCP
M.I.
Last
Name
PCP ID # (see
Name of
instructions)
PCP
Please check if you are using separate forms for additional dependent children
5. Personal Savings Account
❒
Date of Birth
Plan Type: ❒ Medical ❒ Dental
Sex
Date of Birth
Sex
Date of Birth
Total # of dependents:__________________________________
HSA: Health Savings Account
Start Date
End Date
FSA: Health Flexible Spending Account
FSA: Dependent Care Reimbursement Account
Start Date
End Date
FSA Goal Amount (Please
see instructions for limits.): $
Health: $
Start Date
End Date
Dependent Care: $
6. Signature (Employer & Employee)
The information here is complete and true. I understand that Blue Cross and Blue Shield will rely on this information to enroll me and my dependents or to make changes to my
membership. I understand that I should read the subscriber certificate or benefit booklet provided by my employer to understand my benefits and any restrictions that apply to my
health care plan. I understand that Blue Cross and Blue Shield may obtain personal and medical information about me to carry out its business, and that it may use and disclose that
information in accordance with law. I acknowledge that I may obtain further information about the collection, use, and disclosure of my information in “Our Commitment to
Confidentiality,” Blue Cross and Blue Shield’s notice of privacy practices.
Employee’s Signature___________________________________Date______________ Employer’s Signature____________________________________ Date______________
1. REQUIRED: Under the Affordable Care Act, we are required to collect the Social Security number for you and any dependent enrolling in your plan.
2. If you have not indicated Y or N regarding your Medicare or other insurance status, you may receive a follow-up questionnaire.
Blue Cross Blue Shield of Massachusetts is an Independent Licence of the Blue Cross and Blue Shield Association.
Your Pharmacy Program
Effective January 1, 2015
Table of Contents
About This Guide and Online Resources
1
Mail Service Pharmacy
2
Your Pharmacy Cost Share and ID Card
2
Top Covered Medications
3
Over-the-Counter Medications
6
Quality Care Dosing
7
Prior Authorization
12
Specialty Pharmacy Medications
14
Step Therapy
19
Non-Covered Medications
21
Medication Resource List Index
29
New Medication Approval Process
43
Overview
Pharmacy Program Overview
Online Resources
Our pharmacy program is designed to provide you and
your doctor with access to a wide variety of safe, clinically
effective medications. We have carefully developed a
substantial formulary that includes many medications at
affordable cost share levels.
From our main website, www.bluecrossma.com, to the
www.express-scripts.com website, we offer a variety
of online resources to help you manage your medications.
About This Guide
This guide is up-to-date as of January 1, 2015, and is subject
to change. Keep this guide handy, and use it as a reference
whenever you need coverage information about a specific
medication. To get the most current coverage information
about a specific medication, visit our website at
www.bluecrossma.com/pharmacy.
• Top Covered Medications—includes many commonly
prescribed covered medications and your cost share tier
that applies
• Over-the-Counter Medications—includes a list of
over-the-counter medications that are covered when
prescribed for you by your doctor
• Quality Care Dosing—includes a list of medications
subject to Quality Care Dosing limits
• Prior Authorization—includes a list of medications
that require Prior Authorization
• Specialty Pharmacy Medications—includes a list of
medications that are available through pharmacies in the
Specialty Pharmacy Network
• Step Therapy—includes a list of medications subject to
Step Therapy
• Medication Resource List Index—includes all prescription
medications listed in this booklet, along with the page(s)
on which they can be found
1
• Search for Medication Information. To learn whether
your medications will be covered, you can visit
www.bluecrossma.com/pharmacy, and use the
Medication Look Up feature, listed on the left-hand side
of the page. You can use this tool before you enroll. (The
medication information represents our standard pharmacy
coverage; your individual coverage may vary.) Our 2015
formulary changes will not be reflected in this tool until
January 1, 2015.
• Member Central. Want more detailed information about
your health care coverage, claims, or deductibles? You can
log on to Member Central by going to our website,
www.bluecrossma.com/member-central. To register,
click Create an Account, on the upper right-hand side
of the page.
—— If you’re already registered, just log in with your
user name and password.
• Express Scripts Online. Once registered with Member
Central, you can also get immediate, online access to
information about your specific pharmacy benefit by
visiting Express Scripts Inc., (ESI), our pharmacy
management partner, at www.express-scripts.com.
Once there, you’ll have access to:
—— Price a Drug
—— Find a Pharmacy
—— M
ail Service features (which allow you
to order refills and renew prescriptions)
Usually, you will pay the least amount of cost share for Tier 1 medications and
the most for Tier 3 medications .
Your cost share may include your copayment, co-insurance, deductibles,
and maximums . For more about your specific prescription benefits, review the
information in your benefit literature, which you should have received when
you enrolled in your plan, or call the Member Service number listed on the front
of your ID card, Monday through Friday, 8:00 a .m . to 9:00 p .m . ET .
Overview
Mail Service Pharmacy
Your ID Card
YouryouID Card Your ID card contains important information about your
With the Mail Service Pharmacy (administered by ESI),
can enjoy the convenience of having certain prescriptions
benefits. Be
sure to bring
the card
you and
Your ID card pharmacy
contains important
information
about
yourwith
pharmacy
delivered to you. Depending on your specific coverage,
you Be sure
benefits .
to
bring
the
card
with
you
and
give
it
to
your
give it to your pharmacist when you fill a prescription.pharmacist
prescription .
card is shown below .
can use the Mail Service Pharmacy to order up to a when
90-dayyou fillAasample
ID cardAissample
shown ID
below.
supply of certain long-term maintenance medications
(like those used to treat high blood pressure), for less than
HMO Blue
you may normally pay at a retail pharmacy.
TM
It’s convenient, cost-effective, and all information is handled
in accordance with our confidentiality policy.
If you would like to use the Mail Service Pharmacy, you can
download an order form and ﬁnd additional information on
our website. Go to www.bluecrossma.com/pharmacy and
choose Mail Service Pharmacy from the menu on the lefthand side. If you’d like our Mail Service Pharmacy brochure
mailed to you, please call 1-800-262-BLUE (2583).
SAM SAMPLE
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MEMBER SUFFIX: 00
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Your Pharmacy Cost Share
Our pharmacy program formulary is based on a tiered cost
share structure. When you fill a prescription, the amount you
pay the pharmacy (your prescription cost share) is determined
by the tier your medication is on. Medications are placed on
tiers according to a variety of factors, including what they
are used for, their cost, and whether equivalent or alternative
medications are available. The pharmacy will advise you
of the amount you owe. Usually, you will pay the least
amount of cost share for Tier 1 medications and the most
for Tier 3 medications.
3
Your cost share may include your copayment, co-insurance,
and deductibles. For more about your specific prescription
benefits, review the information in your benefit literature, which
you should have received when you enrolled in your plan, or
call the Member Service number listed on the front of your ID
card, Monday through Friday, 8:00 a.m. to 9:00 p.m. ET.
2
Covered Medications
Medications
Top Covered
Our pharmacy formulary includes over 4,000 covered
prescription medications. The following sample list includes
covered medications most commonly prescribed for
our members.
This list is up-to-date as of January 1, 2015, and is subject
to change at any time. You can find the most up-to-date
information about a specific prescription medication on our
website at www.bluecrossma.com/pharmacy.
Please note that this is a sample of top prescribed
medications based on our standard formulary.
For more information about your specific prescription benefits,
review the information in your benefit literature, which you
should have received when you enrolled in your plan, or call
the Member Service number listed on the front of your ID card.
The following covered medication list is based on our
standard formulary. The tier that is assigned to the drug
is the tier used in a three-tier cost share benefit structure.
For members with a two-tier or four-tier cost share benefit
structure, please log on to the Blue Cross and Blue Shield
web site at www.bluecrossma.com/pharmacy and use
the Medication Lookup feature.
Abilify tablets (STEP)
Tier 2
Aviane
Tier 1
Cephalexin
Tier 1
Accu-Chek Aviva testing strips (QCD)
Tier 2
Azathioprine
Tier 1
Chantix
Tier 2
Acetaminophen/Codeine
Tier 1
Azelastine (QCD)
Tier 1
Chlorhexadine Gluconate
Tier 1
Acyclovir
Tier 1
Azithromycin
Tier 1
Chlorthalidone
Tier 1
Adapalene
Tier 1
Baclofen
Tier 1
Cialis
Tier 3
Advair Diskus (QCD) (STEP)
Tier 3
Benicar (STEP)
Tier 2
Ciprofloxacin
Tier 1
Albuterol
Tier 1
Benicar HCT (STEP)
Tier 2
Citalopram (QCD)
Tier 1
Alendronate (QCD)
Tier 1
Benzonatate
Tier 1
Clarithromycin
Tier 1
Allopurinol
Tier 1
Betamethasone Dipropionate
Tier 1
Clindamycin
Tier 1
Alprazolam
Tier 1
Budesonide (QCD)
Tier 1
Clindamycin/Benzoyl Peroxide
Tier 1
Altavera
Tier 1
Buprenorphine/Naloxone (PA) (QCD)
Tier 2
Clobetasol Propionate
Tier 1
Alyacen
Tier 1
Bupropion
Tier 1
Clonazepam
Tier 1
Amitriptyline
Tier 1
Bupropion SR (QCD)
Tier 1
Clonidine
Tier 1
Amlodipine/Benazepril
Tier 1
Bupropion XL (QCD)
Tier 1
Clopidogrel
Tier 1
Amolodipine (QCD)
Tier 1
Buspirone
Tier 1
Clotrimazole/Betamethasone
Tier 1
Amoxicillin
Tier 1
Butalbital/APAP/Caffeine
Tier 1
Colcrys
Tier 2
Amoxicillin TR-Potassium Clavulanate
Tier 1
Camila
Tier 1
Combivent Respimat (QCD)
Tier 2
Amphetamine Salt Combination
Tier 1
Carbidopa/Levodopa
Tier 1
Crestor (QCD) (STEP)
Tier 2
Anastrozole
Tier 1
Carisoprodol
Tier 1
Cryselle
Tier 1
Apri
Tier 1
Carvedilol
Tier 1
Cyclobenzaprine
Tier 1
Armour Thyroid
Tier 3
Cefadroxil
Tier 1
Desonide
Tier 1
Asacol HD
Tier 2
Cefdinir
Tier 1
Dexamethasone
Tier 1
Atenolol
Tier 1
Cefuroxime
Tier 1
Dextroamphetamine/Amphetamine
Tier 2
Atorvastatin (QCD)
Tier 1
Celebrex (QCD) (STEP)
Tier 3
Diazepam
Tier 1
(PA) Prior Authorization required
(QCD) Quality Care Dosing limits apply
(STEP) Step Therapy required
3
Diclofenac
Tier 1
Gildess FE
Tier 1
Lidocaine
Tier 1
Dicyclomine
Tier 1
Glimepiride
Tier 1
Liothyronine Sodium
Tier 1
Digoxin
Tier 1
Glipizide
Tier 1
Lisinopril
Tier 1
Diltiazem ER
Tier 1
Glipizide ER
Tier 1
Lisinopril/HCTZ
Tier 1
Diovan (STEP)
Tier 3
Glipizide XL
Tier 1
Lithium Carbonate
Tier 1
Divalproex Sodium
Tier 1
Glyburide
Tier 1
lo Loestrin FE
Tier 3
Divalproex Sodium ER
Tier 1
Guanfacine
Tier 1
Lorazepam
Tier 1
Donepezil
Tier 1
Humalog (QCD)
Tier 2
Loryna
Tier 1
Dorzolamide/Timolol
Tier 1
Humira (PA) (QCD)
Tier 2
Losartan
Tier 1
Doxazosin
Tier 1
Hydrochlorothiazide
Tier 1
Losartan/HCTZ
Tier 1
Doxycycline Hyclate
Tier 1
Hydrocodone/APAP
Tier 1
Lovastatin (QCD)
Tier 1
Doxycycline Monohydrate
Tier 1
Hydrocodone/Chlorpheniramine
Tier 1
Lutera
Tier 1
Duloxetine (QCD)
Tier 1
Hydrocortisone
Tier 1
Medroxyprogesterone
Tier 1
Econazole
Tier 1
Hydromorphone
Tier 1
Meloxicam (QCD)
Tier 1
Emoquette
Tier 1
Hydroxychloroquine
Tier 1
Metformin
Tier 1
Enalapril
Tier 1
Hydroxyzine
Tier 1
Metformin ER
Tier 1
Enbrel (PA) (QCD)
Tier 2
Ibuprofen
Tier 1
Methimazole
Tier 1
Enoxparin Sodium (QCD)
Tier 2
Indomethacin
Tier 1
Methocarbamol
Tier 1
Enpresse
Tier 1
Iophen-C NR
Tier 1
Methotrexate
Tier 1
Epi-Pen AutoInjector (QCD)
Tier 2
Irbesartan
Tier 1
Methylphenidate
Tier 1
Epi-Pen JR. AutoInjector (QCD)
Tier 2
Isosorbide Mononitrate
Tier 1
Methylphenidate ER (QCD)
Tier 1
Erythromycin
Tier 1
Januvia (STEP)
Tier 2
Methylprednisolone
Tier 1
Escitalopram (QCD)
Tier 1
Junel
Tier 1
Metoclopramide
Tier 1
Estrace Cream
Tier 2
Junel FE
Tier 1
Metoprolol Succinate
Tier 1
Estradiol
Tier 1
Kariva
Tier 1
Metoprolol Tartrate
Tier 1
Fenofibrate
Tier 1
Kelnor 1-35
Tier 1
Metronidazole
Tier 1
Fentanyl patches (PA) (QCD)
Tier 1
Ketoconazole
Tier 1
Microgestin FE
Tier 1
Finasteride
Tier 1
Ketorolac
Tier 1
Minastrin FE
Tier 3
Flovent HFA inhaler (QCD)
Tier 2
Klor-Con
Tier 1
Minocycline
Tier 1
Fluconazole (QCD)
Tier 1
Labetalol
Tier 1
Mirtazapine (QCD)
Tier 1
Fluocinonide
Tier 1
Lamotrigine
Tier 1
Modafinil (PA)
Tier 1
Fluoxetine (QCD)
Tier 1
Lansoprazole (PA) (QCD)
Tier 1
Mometasone
Tier 1
Fluticasone nasal spray (QCD)
Tier 1
Lantus (QCD)
Tier 2
Montelukast
Tier 1
Folic Acid
Tier 1
Lantus Solostar (QCD)
Tier 2
Morphine Sulfate ER (PA) (QCD)
Tier 1
Furosemide
Tier 1
Latanoprost
Tier 1
Mupirocin
Tier 1
Gabapentin
Tier 1
Levetiracetam
Tier 1
Nabumetone
Tier 1
Gemfibrozil
Tier 1
Levitra
Tier 3
Nadolol
Tier 1
Gianvi
Tier 1
Levofloxacin
Tier 1
Namenda
Tier 2
Gildess
Tier 1
Levothyroxine
Tier 1
Naproxen
Tier 1
4
Necon
Tier 1
Progesterone
Tier 1
Trazodone
Tier 1
Nifedipine ER
Tier 1
Promethazine
Tier 1
Tretinoin (PA)
Tier 1
Nitrofurantoin
Tier 1
Promethazine/Codeine
Tier 1
Tri-Previfem
Tier 1
Norethindrone
Tier 1
Propranolol
Tier 1
Tri-Sprintec
Tier 1
Norgestimate/Ethinyl Estradiol
Tier 1
Propranolol ER
Tier 1
Triamcinolone Acetonide
Tier 1
Nortrel
Tier 1
Pulmicort FlexHaler (QCD)
Tier 2
Triamterene/HCTZ
Tier 1
Nortriptyline
Tier 1
Quetiapine
Tier 1
Trinessa
Tier 1
Nystatin
Tier 1
Quinapril
Tier 1
Vagifem
Tier 2
Nystatin/Triamcinolone
Tier 1
QVAR (QCD)
Tier 2
Valacyclovir (QCD)
Tier 1
Ocella
Tier 1
Ramipril
Tier 1
Valsartan/HCTZ
Tier 1
Ofloxacin
Tier 1
Ranitidine
Tier 1
Venlafaxine
Tier 1
Olanzapine
Tier 1
Reclipsen
Tier 1
Venlafaxine ER capsules (QCD)
Tier 1
Omeprazole (QCD)
Tier 1
Restasis (PA) (QCD)
Tier 3
Verapmil ER
Tier 1
Ondasetron (QCD)
Tier 1
Risperidone
Tier 1
Vesicare (STEP)
Tier 2
Ondasetron ODT (QCD)
Tier 1
Ropinirole
Tier 1
Viagra
Tier 3
One Touch Delica testing strips (QCD)
Tier 2
Sertraline (QCD)
Tier 1
Viorelle
Tier 1
One Touch Ultra testing strips (QCD)
Tier 2
Simvastatin
Tier 1
Vitamin D2
Tier 1
Orsythia
Tier 1
Spiriva HandiHaler (QCD)
Tier 2
Vivelle-DOT (QCD)
Tier 3
Ortho Tri-Cyclen Lo
Tier 3
Spironolactone
Tier 1
Voltaren gel
Tier 3
Oxcarbazepine
Tier 1
Sprintec
Tier 1
Warfarin
Tier 1
Oxybutynin
Tier 1
Strattera (PA) (QCD)
Tier 3
Xarelto
Tier 2
Oxycodone
Tier 1
Suboxone (PA) (QCD)
Tier 2
Zetia (QCD) (STEP)
Tier 3
Oxycodone/APAP
Tier 1
Sulfamethoxizole/Trimethoprim
Tier 1
Zolpidem (QCD)
Tier 1
Oxycontin (PA) (QCD)
Tier 2
Sumatriptan (QCD)
Tier 1
Zolpidem ER (QCD)
Tier 1
Pantoprazole (QCD)
Tier 1
Suprep
Tier 3
Paroxetine (QCD)
Tier 1
Symbicort (QCD) (STEP)
Tier 2
Penicillin
Tier 1
Synthroid
Tier 3
Phenazopyridine
Tier 1
Tamiflu
Tier 3
Pioglitazone (QCD) (STEP)
Tier 1
Tamoxifen
Tier 1
Ploymyxin B-Sul/Trimethoprim
Tier 1
Tamsulosin
Tier 1
Potassium Chloride
Tier 1
Temazepam
Tier 1
Pramipexole
Tier 1
Terazosin
Tier 1
Pravastatin (QCD)
Tier 1
Terbinafine
Tier 1
Prednisone
Tier 1
Timolol Maleate
Tier 1
Premarin
Tier 2
Tizanidine
Tier 1
Prempro
Tier 2
Tobramycin/Dexamethasone
Tier 1
Prenatal Plus
Tier 1
Topiramate
Tier 1
ProAir HFA inhaler (QCD)
Tier 2
Toprol XL
Tier 3
Prochlorperazine
Tier 1
Tramadol
Tier 1
5
Over-the-Counter Medications
For non-grandfathered health plans under the Affordable Care Act, the following list includes over-the-counter
medications that are covered with no cost share when they are prescribed for you by your doctor. This list is up to
date as of January 1, 2015, and is subject to change at any time.
Generic Aspirin (81mg) is covered for females age 55–79 and males age 45–79.
Generic Folic Acid is covered for females up to age 50.
Generic Iron is covered for infants up to 12 months old.
Generic Smoking Cessation is covered for up to two 90-day supplies per calendar year.
Generic Vitamin D is covered for females of child bearing age and males age 65 and older.
Generic women’s contraceptives (e.g. female condoms, sponges, and spermicide) are covered.
6
Quality Care Dosing
Quality Care Dosing
Quality Care Dosing
Our Quality Care Dosing program helps to ensure that the
quantity and dose of medications you receive comply with
Food and Drug Administration (FDA) recommendations, as
well as manufacturer and clinical information. When you fill
a prescription for one of the following medications, it is
checked electronically in two ways:
• Dose Consolidation—Checks to see whether you’re taking
two or more pills a day that can be replaced with one pill
providing the same daily dosage.
• Recommended Monthly Dosing Level—Checks to
see that your monthly dosage is consistent with the
manufacturer’s and FDA’s monthly dosing
recommendations and clinical information.
We will get your doctor’s approval before making
any changes to your prescribed medications.
For the most up-to-date list of medications subject to
Quality Care Dosing, along with associated dosing limits,
please visit our website at www.bluecrossma.com/pharmacy
and proceed to the Quality Care Dosing section.
Please note: Your doctor may request an exception from
the guidelines for medications that are subject to Quality
Care Dosing (when medically necessary).
Quality Care Dosing List
This list of medications that are in our Quality Care Dosing
program is up-to-date as of January 1, 2015, and may
change from time to time.
Abstral * (PA)
Alendronate Sodium
Aplenzin ER *
AcipHex * (PA)
Alora *
Aranesp (PA) (SP) (SPO)
Actiq * (PA)
Alrex *
Arava *
Actonel (STEP)
Alsuma *
Arcapta Neohaler *
ACTOplus Met (STEP)
Altoprev (STEP)
Arixtra *
ACTOplus Met XR (STEP)
Alupent inhaler
Asmanex Twisthaler *
Actos (STEP)
Alvesco *
Astelin
Acular *
Ambien *
Astepro *
Acular LS *
Ambien CR *
Atelvia DR * (STEP)
Acular PF
Amerge
Atorvastatin
Adderall XR
Amitiza
Atrovent (nasal spray)
Advair Diskus (STEP)
Amlodipine
Atrovent HFA
Advair HFA (STEP)
Amlodipine-Atorvastatin
Auvi-Q *
Advicor (STEP)
Ampyra (PA) (SP)
Avandamet (STEP)
Aerobid *
Anzemet *
Avandia (STEP)
Aerobid-M *
* (non-covered medication) Quality Care Dosing limits apply for members with approved formulary exceptions
** (new to market drug; non-covered while under review) quantity limits apply to members with approved formulary exceptions
(PA) prior authorization required
(PA17) prior authorization required for members who are 17 years of age or older
(SP) Medication is part of the specialty pharmacy network
(SPO) Available in pharmacy benefit only
(STEP) step therapy required
7
Quality Care Dosing
Avinza *
Ciclodin solution/kit
Epi-Pen Auto-Injector
Avonex (SP) (SPO)
Ciclopirox nail lacquer
Epinephrine injection
Axert *
Citalopram
Epogen (PA) (SP) (SPO)
Azelastine (nasal spray)
Climara
Escitalopram
Azmacort *
Climara Pro
Esomeprazole Strontium * (QCD)
Beconase AQ *
Clonidine patch
Estraderm
Belviq (PA)
CNL 8 nail kit *
Estradiol patch
Betaseron (SP) (SPO)
Combivent
Estrasorb *
Binosto * (STEP)
Combivent Respimat
Estrogel *
Boniva tablets * (STEP)
Concerta
Eszopiclone
Brintellix *
Copaxone (SP) (SPO)
Evamist *
Brisdelle *
Crestor (STEP)
Evzio
Budeprion SR
Crolom ophthalmic
Exalgo *
Budeprion XL
Cromolyn ophthalmic
Extavia (SP) (SPO)
Budesonide (nasal spray)
Cymbalta
Famciclovir
Budesonide (nebules)
Desvenlafaxine ER *
Famvir *
Bunavail (PA)
Dexilant * (PA)
Fentanyl oral/mucosal (PA)
Buprenex (PA)
Dexmethylphenidate XR
Fentanyl patch (PA)
Buprenorphine (PA)
Dextroamphetamine/Amphetamine ER
Fentora * (PA)
Buprenorphine-Naloxone (PA)
Diflucan (150 mg only)
Fetzima
Bupropion SR
Dihydroergotamine (nasal spray)
Flonase *
Bupropion XL
Doxazosin
Flovent/HFA
Butorphanol NS
Dulera (STEP)
Fluconazole (150 mg only)
Butrans *
Duloxetine
Flunisolide
Cabergoline
Duragesic * (PA)
Fluoxetine
Caduet * (STEP)
Dymista *
Fluoxetine DR
Cardura *
Edluar *
Fluticasone
Cardura XL *
Effexor XR *
Fluvastatin
Catapres TTS
Embeda *
Fluvoxamine
Celebrex
Emend
Fluvoxamine CR
Celexa *
Enbrel (PA) (SP) (SPO)
Focalin XR *
Cesamet *
Enoxaparin
Fondaparinux
8
Quality Care Dosing
Foradil
Lazanda * (PA)
Moxeza *
Forfivo XL *
Leflunomide
MS Contin (PA)
Forteo (PA) (SP) (SPO)
Lescol * (STEP)
Naratriptan
Fosamax * (STEP)
Lescol XL * (STEP)
Nasonex *
Fosamax Plus D (STEP)
Lexapro
NebuPent
Fragmin *
Lidocaine Patch
Neulasta (SP)
Frova *
Lidoderm
Neupogen (SP)
Gatifloxacin
Linzess
Nexium * (PA)
Gilenya (SP)
Lipitor * (STEP)
Norvasc *
Glucose testing strips (all brands)
Liptruzet **
Olanzepine-Fluoxetine
Granisetron
Livalo * (STEP)
Omeprazole
Granisol
Lotronex
Omeprazole-Sod. Bicarbonate * (PA)
Granix
Lovastatin
Omnaris *
Grastek (PA)
Lovenox *
Omontys (PA) (SP)
Hetlioz (PA)
Lunesta
Ondansetron
Humira (PA) (SP) (SPO)
Luvox CR *
Ondansetron ODT
Hydromorphone ER (PA)
Lysteda *
Onmel *
Hytrin *
Maxair Autohaler *
Onsolis * (PA)
Ibandronate
Maxalt *
Opana ER * (PA)
Imitrex
Maxalt-MLT *
Optivar *
Infergen (PA) (SP) (SPO)
Meloxicam
Oralair (PA)
Insulins (all brands)
Menostar *
Oramorph SR * (PA)
Intermezzo *
Metadate CD
Otezla (PA) (SP)
Ipratropium NS
Methylphenidate CD
Oxycodone ER (PA)
Itraconazole
Methylphenidate ER
OxyContin (PA)
Kadian * (PA)
Mevacor * (STEP)
Oxymorphone ER (PA)
Ketorolac ophthalmic
Migranal
Pantoprazole
Khedezla *
Minivelle
Paroxetine
Kytril *
Mirtazapine
Paroxetine CR
Lamisil *
Mirtazapine Rapid Dissolve
Patanase *
Lansoprazole (PA)
Mobic *
Paxil *
Lansoprazole/Amoxicillin/Clarithromycin
Morphine Sulfate ER (PA)
Paxil CR *
9
Quality Care Dosing
Pediapirox-4
Remeron Soltab *
Tudorza
PEG-Intron (SP) (SPO)
Restasis (PA)
Valacylovir
Pegasys (SP) (SPO)
Rhinocort Aqua *
Valtrex
Penlac *
Risedronate
Venlafaxine ER capsule
Pexeva *
Ritalin LA *
Venlafaxine ER tablet
Pioglitazone (STEP)
Rizatriptan
Ventolin HFA *
Pioglitazone-Glimepiride (STEP)
Rozerem
Veramyst *
Pioglitazone-Metformin (STEP)
Sancuso *
Vigamox *
Pravachol * (STEP)
Sarafem *
Viibryd *
Pravastatin
Selferma
Vivelle
Prevacid * (PA)
Serevent Diskus
Vivelle-Dot
PrevPac *
Sertraline
Vytorin * (STEP)
Prilosec * (PA)
Silenor *
Vyvanse *
Pristiq *
Simcor * (STEP)
Wellbutrin SR *
ProAir HFA
Simponi (PA) (SP) (SPO)
Wellbutrin XL *
Procrit (PA) (SP) (SPO)
Simvastatin
Xartemis XR * (PA)
Protonix * (PA)
Sonata
Xopenex HFA *
Proventil HFA *
Spiriva
Zaleplon
Prozac *
Sporanox *
Zegerid * (PA)
Prozac Weekly *
Strattera (PA17)
Zetia (STEP)
Pulmicort Flexhaler
Suboxone (PA)
Zetonna *
Pulmicort Respules
Subsys * (PA)
Zocor * (STEP)
QNASL *
Subutex (PA)
Zofran *
Qualaquin
Sumatriptan
Zofran ODT *
Qutenza (SP)
Sumavel Dosepro *
Zohydro ER * (PA)
QVAR
Symbicort (STEP)
Zolmitriptan
Rabeprazole (PA)
Symbyax
Zolmitriptan ODT
Ragwitek (PA)
Terazosin
Zoloft *
Rapaflux
Terbinafine
Zolpidem
Rebif (SP) (SPO)
Terbinex *
Zolpidem ER
Relpax *
Tranexamic Acid
Zolpimist *
Remeron *
Treximet *
Zomig *
10
Quality Care Dosing
Zomig ZMT *
Zubsolv **
Zuplenz *
Zymar *
Zymaxid *
11
Prior Authorization
Prior Authorization
Prior Authorization
Your doctor is required to obtain prior authorization before
prescribing specific medications. This ensures that your
doctor has determined that this medication is necessary
to treat you, based on specific medical standards.
For the most up-to-date list of medications that
require prior authorization, please visit our website,
www.bluecrossma.com/pharmacy, click on Pharmacy
Management Program, and proceed to Prior Authorization.
Another part of our prior authorization program is step
therapy. Please refer to page 19 for a list of medications
that require step therapy.
Prior Authorization List
This list of medications that require prior authorization
is up-to-date as of January 1, 2015, and may change
from time to time.
Abstral * (QCD)
Buprenorphine-Naloxone (QCD)
Entyvio (SP)
AcipHex * (QCD)
Butrans * (QCD)
Epogen (QCD) (SP) (SPO)
Actemra (SP)
Ceredase (MBO)
Erbitux (MBO)
Acthar (SP)
Cerezyme (MBO)
Esomeprazole Strontium * (QCD)
Actiq * (QCD)
Cimzia (SP) (SPO)
Euflexxa * (SPO)
Adcirca (SP)
Cinryze (MBO)
Exalgo * (QCD)
Amevive (MBO)
Desoxyn (PA17)
Eylea (MBO)
Amphetamines (e.g Amphetamine,
Dexilant * (QCD)
Factor VIII, VIIIa, IX, XIII (MBO)
Methamphetamine, Liquadd, Procentra)
Dextroamphetamines (e.g. Dexedrine)
Fentanyl oral/mucosal (QCD)
Ampyra (QCD) (SP)
(PA17)
Fentanyl patch (QCD)
Aralast (MBO)
Dificid
Fentora * (QCD)
Aralast NP (MBO)
Diskets
First-lansoprazole
Aranesp (QCD) (SP) (SPO)
Dolophine
First-omeprazole
Avinza * (QCD)
Duragesic * (QCD)
Forteo (QCD) (SP) (SPO)
Belviq
Dysport
Gel-One * (SPO)
Boniva syringe * (SP)
Egrifta (SP)
Grastek (QCD)
Botulinum toxin
Elidel
Growth Hormone (SP) (SPO)
Bunavail (QCD)
Embeda * (QCD)
Hetlioz (QCD)
Buprenex
Enbrel (QCD) (SP) (SPO)
Humira (QCD) (SP) (SPO)
Buprenorphine (QCD)
Enteral formula
Hyalgan * (SPO)
(MBO) medical benefit only
(SPO) pharmacy benefit only
12
Prior Authorization
Ilaris (SP) (SPO)
Oralair (QCD)
Stelara * (SP) (SPO)
Incivek (SP) (SPO)
Oramorph SR * (QCD)
Strattera (PA17) (QCD)
Interferons (alpha, gamma)
Orencia (SP)
Suboxone (QCD)
IV Immunoglobulin (MBO)
Orthovisc * (SPO)
Subsys * (QCD)
Kadian * (QCD)
Otezla (QCD) (SP)
Supartz * (SPO)
Kalydeco
Oxycodone ER (QCD)
Synagis (SP)
Kineret (SP) (SPO)
Oxycontin (QCD)
Synvisc * (SPO)
Lansoprazole (QCD)
Oxymorphone ER (QCD)
Synvisc One * (SPO)
Lazanda * (QCD)
Preservative-Free Morphine (MBO)
Topical Retinoic Acid derivatives (e.g.
Leukine (SP)
Prevacid * (QCD)
Retin A) (PA30)
Lucentis (MBO)
Prilosec * (QCD)
TPN (total parenteral nutrition) (MBO)
Lyrica
Procrit (QCD) (SP) (SPO)
Tysabri (MBO)
Macugen (MBO)
Prolastin (MBO)
Vectibix (MBO)
Makena (SP)
Prolastin C (MBO)
Victrelis (SP)
Methadone
Proleukin (SP)
Xalkori (SP)
Methadose
Prolia (SP) (SPO)
Xeljanz * (SP)
Modafinil
Protonix * (QCD)
Xenazine
Monovisc * (SPO)
Protopic
Xeomin
Morphine Sulfate CR (QCD)
Provigil (PA17)
Xgeva (SP) (SPO)
Morphine Sulfate ER (QCD)
Rabeprazole (QCD)
Xiaflex (MBO)
MS Contin (QCD)
Ragwitek (QCD)
Xolair (MBO)
Myalept (SP)
Reclast (MBO)
Zegerid * (QCD)
Nexium * (QCD)
Regranex
Zelboraf (SP)
Nucynta ER *
Remicade (SP)
Zometa (MBO)
Nutritional Supplements
Respiratory SyncytialVirus IG/Synagis (SP)
Zubsolv (QCD)
Nuvigil * (PA17)
Restasis (QCD)
Zykadia (SP)
Olysio (SP)
Revatio * (SP)
Omeprazole-Sod. Bicarbonate * (QCD)
Rituxan (SP)
Omontys (SP) (SPO)
Sildenafil (SP)
Onsolis * (QCD)
Simponi (QCD) (SP) (SPO)
Opana ER * (QCD)
Sovaldi (SP)
(MBO) medical benefit only
(SPO) pharmacy benefit only
13
Specialty Pharmacy MedicationsSpecialty Pharmacy
Specialty Pharmacy Medications
Blue Cross Blue Shield of Massachusetts has set up a
network of retail specialty pharmacies to dispense certain
medications classified as specialty. The following is a
list of medications that can only be purchased from one
of the pharmacies in this network in order for coverage
to be available.
Network Pharmacy Information
AcariaHealth
1-866-892-1202
www.acariahealth.com
Accredo Health Group, Inc. /CuraScript
1-877-988-0058
www.accredo.com
CVS Caremark, Inc.
1-866-846-3096
www.caremark.com
OncoMed, the Oncology Pharmacy
1-877-662-6633
www.oncomed.net
This list is up-to-date as of January 1, 2015. You can
find the latest information about your medications and
look up pharmacy contact information by visiting
www.bluecrossma.com/pharmacy.
Network Pharmacy Information for
Medications Most Commonly Used for Fertility
BriovaRx
1-800-850-9122
www.briovarx.com
Freedom Fertility Pharmacy
1-866-297-9452
www.freedomfertility.com
Metro Drugs
1-888-258-0106
www.metrodrugs.com
Village Fertility Pharmacy
1-877-334-1610
www.villagefertilitypharmacy.com
Walgreens
1-800-424-9002
www.walgreens.com/pharmacy/specialpharmacy.jsp
14
Specialty Pharmacy
Fertility Medications
Arcalyst Injection (SPO)
Doxil
Bravelle * (SPO)
Aredia
Doxorubicin HCl
Cetrotide (SPO)
Arzerra
DTIC-Dome
Clomid
Aveed
Egrifta (PA)
Clomiphene
Avonex (QCD) (SPO)
Eligard
Endometrin
Betaseron (QCD) (SPO)
Ellence
Follistim AQ * (SPO)
BiCNu
Eloxatin
Ganirelix (SPO)
Bleomycin Sulfate
Elspar
Gonal F Rff Rediject (SPO)
Boniva Injection * (PA)
Enbrel (PA) (QCD) (SPO)
Gonal F/Gonal F RFF (SPO)
Busulfex
Entyvio (PA)
Human Chorionic Gonadotropin (HCG)
Calcium Folanate
Epirubicin
(SPO)
Camptosar
Epogen (PA) (QCD) (SPO)
Leuprolide (SPO)
Carboplatin
Ethyol
Lupron Depot
Cerubidine
Etopophos
Lupron Depot-Ped
Cimzia (PA) (SPO)
Etoposide
Luveris (SPO)
Cisplatin
Extavia * (QCD) (SPO)
Menopur (SPO)
Cladribine
Faslodex
Novarel
Copaxone (QCD) (SPO)
Firazyr
Ovidrel (SPO)
Cosmegen
Firmagon
Pregnyl (SPO)
Cyclophosphamide
Floxuridine
Repronex (SPO)
Cyramza
Fludara
Serophene
Cytarabine
Fludarabine phosphate
Injectable Medications
Cytoxan
Fluorouracil
Abraxane
Dacarbazine
Forteo (PA) (QCD) (SPO)
Actemra (PA)
Dactinomycin
FUDR
Acthar (PA)
Daunorubicin HCL
Fusilev I.V.
Actimmune (PA) (SPO)
DaunoXome
Fuzeon (SPO)
Adriamycin PFS
DDAVP *
Gattex
Adrucil
Depocyt
Gazyva
Alferon N (PA)
Desmopressin Acetate
Gemcitabine
Alkeran
Dexrazoxane
Gemzar
Apokyn
Docefrez
Genotropin * (PA) (SPO)
Aranesp (PA) (QCD) (SPO)
Docetaxel
Granix
(SPO) available in pharmacy benefit only
15
Specialty Pharmacy
Herceptin
Methotrexate
Pegasys (QCD) (SPO)
Humatrope (PA) (SPO)
Mitomycin
Photofrin
Humira (PA) (QCD) (SPO)
Mitoxantrone
Procrit (PA) (QCD) (SPO)
Hycamtin
Mozobil
Proleukin (PA)
Ibandronate
Mustargen
Prolia (PA) (SPO)
Idamycin PFS
Myalept (PA)
Raptiva
Idarubicin
Mylotarg
Rebif (QCD) (SPO)
Ifex
Navelbine
Remicade (PA)
Ifosfamide
Neosar
Revatio * (PA)
Ifosfamide/Mesna
Neulasta (QCD)
Rituxan (PA)
Ilaris (PA) (SPO)
Neumega
Ruconest **
Increlex (PA) (SPO)
Neupogen (QCD)
Saizen * (PA) (SPO)
Infergen (PA) (QCD) (SPO)
Nipent
Sandostatin (SPO)
Intron A (PA) (SPO)
Norditropin * (PA) (SPO)
Sandostatin-LAR
Irinotecan
Norditropin Flexpro * (PA) (SPO)
Serostim (PA) (SPO)
Istodax
Norditropin Nordiflex * (PA) (SPO)
Signafor **
Kenalog
Novantrone
Simponi (PA) (QCD) (SPO)
Keytruda
Nplate
Simponi Aria (PA)
Kineret (PA) (SPO)
Nutropin (PA) (SPO)
Simulect
Kynamro (STEP)
Nutropin AQ (PA) (SPO)
Somatuline
Leucovorin Calcium
Nutropin AQ Nuspin (PA) (SPO)
Somavert (SPO)
Leukine (PA)
Octreotide injection (SPO)
Stelara * (PA) (SPO)
Leuprolide Acetate (SPO)
Omnitrope * (PA) (SPO)
Sylatron (PA)
Leustatin
Omontys (PA) (QCD)
Sylvant
Lipodox
Oncaspar
Synagis (PA)
Lipodox-50
Ontak
Synribo
Lupaneta Pack
Onxol
Tarabine
Lupron Depot
Orencia (PA)
Taxol
Lupron Depot-Ped
Oxaliplatin
Taxotere
Makena (PA)
Paclitaxel
Teniposide
Marqibo
Pamidronate
Tev-Tropin * (PA) (SPO)
Mesna
Pamidronate disodium
TheraCys
Mesnex
Peg-Intron (QCD) (SPO)
Thiotepa
16
Specialty Pharmacy
Thyrogen
Cometriq
Orfadin (SPO)
Toposar
Copegus (SPO)
Otezla (PA) (QCD)
Totect
Cystagon
Otezla Starter Pack *
Trelstar
Cytoxan
Pomalyst
Trelstar Depot
Erivedge
Procysbi
Trelstar LA
Etoposide
Promacta
Valstar
Exjade
Pulmozyme (SPO)
Velcade
Gilenya (QCD)
Ravicti
Vimzim
Gilotrif
Rebetol (SPO)
VinBLAStine
Gleevec
Revatio * (PA)
VinCRIStine
Havroni ** (PA)
Revlimid
Vinorelbine
Hetlioz (PA)
Ribapak (SPO)
Vumon
Hycamtin
Ribasphere (SPO)
Xgeva (PA) (SPO)
Iclusig
Ribatab
Zaltrap
Imbruvica
Ribavirin (SPO)
Zanosar
Incivek (PA)
Rilutek
Zenapax
Inlyta
Riluzole
Zinecard
Iressa
Sabril
Zoladex
Jakafi
Sildenafil (PA)
Zorbtive (PA) (SPO)
Kalydeco (PA)
Sovaldi (PA)
Oral Medications
Korlym
Sprycel
8-Mop
Kuvan
Stivarga
Adcirca (PA)
Letairis
Sucraid
Adempas
Mekinist
Sutent
Afinitor
Mesnex
Tafinlar (PA)
Alkeran
Moderiba
Tarceva
Ampyra (PA) (QCD)
Nexavar
Tasigna
Aubagio
Northera
Tecfidera
Bethkis
Oforta
Temodar
Bosulif
Olysio (PA)
Temozoloamide
Capecitabine
Onsolis * (PA) (QCD)
Thalomid
Carbaglu
Opsumit
TOBI ampules (SPO)
Cerdelga **
Orenitram
TOBI-Podhaler (SPO)
17
Specialty Pharmacy
Tobramycin ampules
Tracleer
Tykerb
Tyvaso
Victrelis (PA)
Votrient
Xalkori (PA)
Xeljanz *
Xeloda
Xenazine
Xtandi (STEP)
Xyrem
Zavesca
Zelboraf (PA)
Zolinza
Zydelig
Zykadia (PA)
Zytiga
Topical
Cystaran
Panretin (SPO)
Qutenza (QCD)
Valchlor
18
Therapy
Step Therapy
Step Therapy
Step Therapy List
Step therapy is a key part of our prior authorization program
that allows us to help your doctor provide you with an
appropriate and affordable drug treatment. Before coverage
is allowed for certain costly “second-step” medications,
we require that you first try an effective, but less expensive,
“first-step” medication. Some medications may have
multiple steps.
This list is up-to-date as of January 1, 2015, and is subject
to change at any time. For the most up-to-date list of
medications that require step therapy, please visit our website
www.bluecrossma.com/pharmacy, click on Pharmacy
Management Program, and proceed to Step Therapy.
Asthma Management
Latuda *
Livalo * (QCD)
Accolate *
Loxitane
Mevacor * (QCD)
Advair Diskus (QCD)
Risperdal
Pravachol * (QCD)
Advair HFA (QCD)
Risperdal Consta
Simcor * (QCD)
Anoro Ellipta (QCD)
Risperdal M-Tab *
Vytorin * (QCD)
Breo Ellipta * (QCD)
Saphris *
Zetia (QCD)
Dulera (QCD)
Seroquel
Zocor * (QCD)
Singulair
Seroquel XR
Diabetes Management
Symbicort (QCD)
Symbyax (QCD)
ACTOplus Met (QCD)
Zyflo *
Zyprexa
ACTOplus Met XR (QCD)
Zyflo CR *
Zyprexa IM *
Actos (QCD)
Atypical Antipsychotic
Medications
Zyprexa Relprevv *
Avandamet (QCD)
Zyprexa Zydis
Avandaryl
Cholesterol Treatment
Avandia (QCD)
Abilify
Abilify DiscMelt *
Advicor (QCD)
Duetact
Abilify Maintenna *
Altoprev * (QCD)
Farxiga *
Clozaril
Caduet * (QCD)
Fortamet *
Fanapt *
Crestor (QCD)
Glucophage *
FazaClo *
Juxtapid
Glucophage XR *
Geodon
Kynamro (SP)
Glumetza *
Haldol
Lescol * (QCD)
Invokamet
Haldol Decanoate
Lescol XL * (QCD)
Invokana
Invega *
Lipitor * (QCD)
Janumet
Invega Sustenna
Liptruzet ** (QCD)
Janumet XR
19
Step Therapy
Januvia
Diovan HCT
Sanctura *
Jardiance
Edarbi *
Sanctura XR *
Jentadueto *
Edarbiclor *
Toviaz *
Kazano *
Exforge
Vesicare
Kombiglyze XR
Exforge-HCT
Nesina *
Hyzaar *
Pain Relievers (Cox II
Inhibitors)
Onglyza
Micardis *
Celebrex (QCD)
Oseni *
Micardis HCT *
Pioglitazone (QCD)
Tekamlo *
Parkinson's Disease
Treatment
Pioglitazone-Glimepiride (QCD)
Tekturna *
Pioglitazone-Metformin (QCD)
Tekturna HCT *
PrandiMet *
Teveten *
Prandin *
Teveten HCT *
Tradjenta *
Tribenzor
Victoza
Twynsta *
Glaucoma
Valturna *
Lumigan
Rescula *
Osteoporosis Treatment
(Oral)
Travatan
Actonel (QCD)
Proscar *
Travatan Z
Atelvia DR * (QCD)
Topical Testosterone
Xalatan
Binosto * (QCD)
Fortesta *
Boniva tablets * (QCD)
Testim *
Fosamax * (QCD)
Testosterone gel (Fortesta Authorized
Amturnide *
Fosamax Plus D (QCD)
product) *
Atacand *
Overactive Bladder Treatment
Testosterone gel (Testim Authorized
Atacand HCT *
Detrol *
product) *
Avalide
Detrol LA *
Testosterone gel (Vogelxo Authorized
Avapro
Ditropan *
product) *
Azor
Ditropan XL *
Vogelxo *
Benicar
Enablex *
Benicar HCT
Gelnique *
Cozaar *
Myrbetriq *
Diovan
Oxytrol *
Heart/Blood Modifiers/
Circulation
Mirapex
Mirapex ER *
Requip *
Requip XL *
Prostate Cancer - Oral
Xtandi
Prostate Treatment
Avodart
Jalyn
20
Non-Covered Medication Non-Covered Medication
Non-Covered Medication
Non-Covered Medication List
Your pharmacy program provides coverage for over 4,000
prescription medications. Most medications on our noncovered list have equally safe, effective, covered alternatives
for treating the same medical conditions. If a non-covered
drug is approved, it will be covered at the highest tier or cost
share. Check with your doctor about appropriate alternatives
if you currently take any of these medications.
This list of non-covered medications is up-to-date as
of January 1, 2015, and may change from time to time.
For the most up-to-date list of medications that are not
covered and their covered alternatives, please visit our
website, www.bluecrossma.com/pharmacy, click on
Medication Look Up, and proceed to the Medications that are not Covered section.
Please note: Your doctor may request coverage for a
non-covered medication if no covered alternative is
appropriate for treating your condition.
Abilify DiscMelt (STEP)
Adalat CC
Amturnide (STEP)
Abilify Maintenna (STEP)
Adderall
Anafranil
Absorica
Adoxa CK
Analpram Advanced
Abstral (PA) (QCD)
Adoxa TT
Analpram-E kit
Acanya
Aerobid (QCD)
Angeliq
Accolate (STEP)
Aerobid-M (QCD)
Antara
AccuNeb
Airet
Anzemet (QCD)
Accupril
Alodox
Apidra
Accuretic
Aloquin
Aplenzin ER (QCD)
Accutane
Alora (QCD)
Appformin-D
Aceon
Alrex (QCD)
Aqua Glycolic HC
AcipHex (PA) (QCD)
Alsuma (QCD)
Arava (QCD)
Acticlate
Altabax
Arcapta Neohaler (QCD)
Actigall
Altace
Arixtra (QCD)
Actiq (PA) (QCD)
Altoprev (STEP) (QCD)
Ascensia diabetic testing supplies (QCD)
Activella
Aluvea
Asmanex Twisthaler (QCD)
Acular (QCD)
Alvesco (QCD)
Assure Pro diabetic testing supplies (QCD)
Acular LS (QCD)
Ambien (QCD)
Astepro (QCD)
Acuvail
Ambien CR (QCD)
Atacand (STEP)
Aczone
Amrix
Atacand HCT (STEP)
21
Atelvia DR (STEP) (QCD)
Brintellix (QCD)
Cleocin T
Ativan
Brisdelle (QCD)
Clindacin ETZ Kit
Atopiclair
Bromday
Clindacin PAC
Atralin
Brovana
Clindagel
Atrapro CP
Butrans (PA) (QCD)
Clindamax
Atrapro Dermal Spray
Bystolic
Clindareach
Atrapro Hydrogel
Caduet (QCD)
Clindets
Atropen
Calcitriol Topical
Clobeta + Plus
Augmentin XR
Cambia
Clobex
Aurstat
Caphosol
Clodan Kit
Auvi-Q (QCD)
Capoten
CNL 8 nail kit (QCD)
Avelox
Cardene
Colazal
Avidoxy
Cardene SR
Combigan
Avidoxy DK
Cardizem CD
Combunox
Avinza (PA) (QCD)
Cardizem LA
Contour Next diabetic testing
Avita
Cardura XL (QCD)
supplies (QCD)
Axert (QCD)
Cataflam
Conzip
Axid
Ceclor
Coreg
Azasite
Ceclor CD
Coreg CR
Azmacort (QCD)
Cedax
Cosopt PF
B-D diabetic testing supplies (QCD)
Celexa (QCD)
Cozaar (STEP)
Beconase AQ (QCD)
Cem-Urea
Cymbalta (QCD)
BenzaClin kit
Cenestin
Daliresp
Besivance
Centany
Darvocet N-100
Binosto (STEP) (QCD)
Centany AT
Daypro
Bionect
Cesamet (QCD)
Daytrana
Boniva syringe (PA) (SP)
Cetraxel
DDAVP
Boniva tablets (STEP) (QCD)
Chenodal
Demulen
Bravelle (SP)
Chibroxin Ocumeter
Depo-Sub Q Provera 104
Breo Ellipta (PA) (QCD)
Cipro-XR
Derma-Smoothe/FS
Brevicon
Cleanse and Treat
Dermasorb-AF
Brilinta
Cleervue-M
Dermasorb-HC
22
Dermasorb-TA
Edarbiclor (STEP)
Farxiga (STEP)
Dermasorb-XM
Edluar (QCD)
FazaClo (STEP)
DermOtic
Effexor
Femtrace
Desogen
Effexor XR (QCD)
Fenoglide
Desonil + Plus
Elestrin
Fentora (PA) (QCD)
DesOwen kit
Eletone
Fertinex (SP)
Desvenlafaxine ER (QCD)
Embeda (QCD)
Fexmid
Detrol (STEP)
Embrace diabetic testing supplies (QCD)
Fibracor
Detrol LA (STEP)
Emsam
Finacea Plus
Dexedrine (PA)
Enablex (STEP)
Fioricet
Dexilant (PA) (QCD)
Enjuvia
Fiorinal
Dilacor XR
Epaned
Fiorinal with Codeine
Dilaudid
EpiCeram
Flagyl
Dipentum
Epiduo
Flagyl ER
Dispermox
Episil
Flagyl IV
Ditropan (STEP)
Equetro
Flector
Ditropan XL (STEP)
Ertaczo
Flonase (QCD)
Divigel
Esomeprazole Strontium (STEP) (QCD)
FML Forte
Doryx
Estrace
Focalin
Duavee
Estrasorb (QCD)
Focalin XR (QCD)
Duexis
Estrogel (QCD)
Follistim AQ (SP)
Duragesic (PA) (QCD)
Euflexxa (PA) (SPO)
Forfivo XL (QCD)
Durezol
Evamist (QCD)
Fortamet (STEP)
Dymista (QCD)
Evoclin
Fortesta (STEP)
Dynabac
ExacTech diabetic testing supplies (QCD)
Fosamax (STEP) (QCD)
Dynacin
Exalgo (PA) (QCD)
Fragmin (QCD)
Dynacirc
Extavia
Freestyle diabetic testing supplies (QCD)
Dynacirc CR
Extina
Fresh Kote
Dytan
Factive
Frova (QCD)
Easy Step diabetic testing supplies (QCD)
Falessa kit
Garamide
Easy-Trak diabetic testing supplies (QCD)
Famvir (QCD)
Gel-One (PA) (SPO)
Edarbi (STEP)
Fanapt (STEP)
Gelclair
23
Gelnique (STEP)
InnoPran XL
Lipofen
GelX
Intermezzo (QCD)
Liptruzet (STEP) (QCD)
Genotropin (PA) (SP)
Intuniv
Livalo (STEP) (QCD)
Giazo
Invega (STEP)
Lodine
Glucometer diabetic testing
Iquix
Lodine XL
supplies (QCD)
Istalol
Lofibra
Glucophage
Jentadueto (STEP)
Lopressor
Glucophage XR
Jublia
Lorabid
Glumetza
Kadian (PA) (QCD)
LoSeasonique
Halonate
Kapvay
Lotensin
Halotin
Kazano (STEP)
Lotensin HCT
Helidac
Keppra XR
Loutrex
Horizant
Keralyt kit
Lovaza
HPR
Ketocon + Plus
Lovenox (QCD)
HPR Plus
Khedezla (QCD)
Lunesta (QCD)
Hyalgan (PA) (SPO)
Klonopin
Luvox CR (QCD)
Hydrocortisone-Lidocaine kit
Kytril (QCD)
Luzu
Hylase
Lamictal ODT
Lysteda (QCD)
Hylatopic
Lamisil (QCD)
Lytensopril
Hylatopic Plus
Lamisil Granules (QCD)
Mavik
Hylatopic Plus-Aurstat
Latuda (STEP)
Maxair Autohaler (QCD)
Hylira
Lazanda (PA) (QCD)
Maxalt (QCD)
Hytrin (QCD)
Lescol (STEP) (QCD)
Maxalt-MLT (QCD)
Hyzaar (STEP)
Lescol XL (STEP) (QCD)
Maxipime
IB-Stat
Levaquin
MB Hydrogel
IC400 kit
Levemir (QCD)
Megace ES
IC800 kit
Levlen
Menostar (QCD)
Ilevro
Lexapro (QCD)
Metaglip
Imuran
Lexxel
Metozolv ODT
Inderal LA
Lialda
Metrogel kit
Inderal XL
Lidovir
Mevacor (STEP) (QCD)
Innohep
Lipitor (STEP) (QCD)
Micardis (STEP)
24
Micardis HCT (STEP)
Nexium (PA) (QCD)
Ortho-Prefest
Minocin
Niravam
Orthovisc (PA) (SPO)
Minocin Combo Pack
Nivatropic Plus
Oseni (STEP)
Mirapex ER (STEP)
Nor-Q-D
Osphena
Mobic (QCD)
Norditropin (PA) (SP)
Otezla Starter Pack (SP)
Momexin
Norinyl
Ovcon
Monodox
Noroxin
Oxecta
Monopril
Norvasc (QCD)
Oxytrol (STEP)
Monopril HCT
Novacort
Pamelor
Monovisc (PA) (SPO)
Novolin Insulin products
Pamine FQ
Morgidox
Novolog Insulin products
Pancreaze
Moxatag
NuCort
Paptase
Moxeza (QCD)
Nucynta
Patanase (QCD)
Myoxin
Nucynta ER (PA)
Paxil (QCD)
Myrbetriq
NutriDox
Paxil CR (QCD)
Naprelan
Nuvigil (PA)
PCE
Naprelan CR
Ocudox kit
PCE Dispertab
Naprosyn
Oleptro ER
Pediaderm AF
Naprosyn EC
Olux
Pediaderm HC
Nasarel (QCD)
Omeprazole-Sod. Bicarbonate (PA) (QCD)
Pediaderm TA
Nasonex (QCD)
Omnaris (QCD)
Penlac (QCD)
Natazia
Omnicef
Pennsaid
Neo-Synalar Kit
Omnitrope (PA) (SP)
Pepcid
Neosalus
Onmel (QCD)
Percocet
Neosalus CP
Onsolis (PA) (QCD)
Pertzye
Nesina (STEP)
Opana
Pexeva (QCD)
Neuac Kit
Opana ER (PA) (QCD)
Phoslyra
Neupro
Optase
Plaquenil
Neurontin
Oracea
PR-Cream
NeutraSal
Oramorph SR (PA) (QCD)
Pram-HCA
Nevanac
Orapred ODT
Pramcort
Nexiclon XR
Oravig
Pramosone E
25
PrandiMet (STEP)
Quixin
Salkera
Pravachol (STEP) (QCD)
RadiaPlex Rx
Salvax
Precision QID diabetic supplies (QCD)
Radigel
Salvax Duo
Precision X-Tra diabetic supllies (QCD)
Raniclor
Salvax Duo Plus
Presera
Rapaflo
Sanctura (STEP)
Prestige diabetic testing supplies (QCD)
Rayos
Sanctura XR (STEP)
Prevacid (PA) (QCD)
Reciphexamine
Sancuso (QCD)
Prevacid NapraPAC
Recothrom
Saphris (STEP)
PrevPac
Relafen
Sarafem (QCD)
Prilosec (PA) (QCD)
Relpax (QCD)
Scalacort
Prinivil
Remeron (QCD)
Seasonique
Prinzide
Remeron Soltab (QCD)
Senophylline
Pristiq (QCD)
Requip (STEP)
Silenor (QCD)
Procentra (PA)
Requip XL (STEP)
Silvrstat
Procort
Rescula (STEP)
Simbrinza
Prodigy diabetic testing supplies (QCD)
Restoril
Simcor (STEP) (QCD)
Prolensa
Retin-A Micro (PA30)
Sinemet
Promiseb
Revatio (PA)
Sitavig
Promiseb Light
Rhinocort Aqua (QCD)
Skelid
Proquin XR
Rinnovi
Sof-Tact diabetic supplies (QCD)
Protonix (PA) (QCD)
Risperdal M-Tab (STEP)
Solodyn
Proventil
Ritalin
Soltamox
Proventil HFA (QCD)
Ritalin LA (QCD)
Soma
Proventil inhaler (QCD)
Ritalin SR
Sonata (QCD)
Proventil Repetab
Rosadan
Spectracef
Prozac (QCD)
Rosanil
Sporanox (QCD)
Prozac Weekly (QCD)
Rybix ODT
Sprix
Purinethol
Rynatan
Stavzor
Pylera
Rythmol
Stelara (PA) (SPO)
QNASL (QCD)
Ryzolt
Striant
Quartette
Saizen (PA) (SP)
Subsys (PA) (QCD)
Quillivant XR
Salicylic Acid-Ceramide kit
Sular
26
Sumadan
Tiazac
Valium
Sumavel Dosepro (QCD)
Tindamax
Valturna (STEP)
Sumaxin
Tirosint
Vanos
Sumaxin CP
TL-Triseb
Vantin
Sumaxin TS
TobraDex ST
Vascepa
Supartz (PA) (SPO)
Tofranil
Vaseretic
Synalar Combo-Pack
Tornalate
Vasolex
Synalar TS
Toviaz (STEP)
Vasotec
Synvisc (PA) (SPO)
Tradjenta (STEP)
Vectical
Synvisc-One (PA) (SPO)
Tranxene T-Tab
Vectrin
Tagamet
Tretin-X (PA)
Velphoro
Tekamlo (STEP)
Treximet (QCD)
Veltin (PA30)
Tekturna (STEP)
Tri-Levlen
Ventolin HFA (QCD)
Tekturna HCT (STEP)
Tri-Norinyl
Veramyst (QCD)
Tenormin
Tricor
Veregen
Tequin
Triglide
Vexa
Terbinex (QCD)
Trilipix
Vexol
Tersi
Trinalin
Vigamox (QCD)
Testim (STEP)
TriOxin
Viibryd (QCD)
Tritec
Vimovo
product) (STEP)
Tropazone
Virasal
TrueTest diabetic supplies (QCD)
Vogelxo (STEP)
product) (STEP)
TrueTrack diabetic supplies (QCD)
Voltaren
Testosterone gel (Vogelxo) Authorized
Twynsta (STEP)
Voltaren XR
product) (STEP)
Ultracet
Vusion
Tetrix
Ultram/ER
Vytorin (STEP) (QCD)
Tev-Tropin (PA) (SP)
Ultrasal ER
Vyvanse (QCD)
Teveten (STEP)
Ultravate PAC
Welchol
Teveten HCT (STEP)
Ultravate X
Wellbutrin
Therapentin
Ultressa
Wellbutrin SR (QCD)
Theraproxen
Uramaxin
Wellbutrin XL (QCD)
Tiamate
Urea kit
X-Clair
27
Xanax
Zoloft (QCD)
Xanax XR
Zolpimist (QCD)
Xartemis XR (PA) (QCD)
Zomig (QCD)
Xeljanz (SP)
Zomig ZMT (QCD)
Xenaderm
Zontivity
Xerese
Zovirax
Xibrom
Zuplenz (QCD)
Xifaxan
Zyflo (STEP)
Xolegel
Zyflo CR (STEP)
Xolox
Zymar (QCD)
Xopenex HFA (QCD)
Zymaxid
Xopenex nebules
Zypram
Xyralid
Zyprexa IM (STEP)
Z-Pram
Zyprexa Relprevv (STEP)
Zanaflex
Zytopic
Zantac
Zebeta
Zegerid (PA) (QCD)
Zelapar
Zenieva
Zestril
Zetonna (QCD)
Ziana
Zinotic
Zinotic ES
Zipsor
Zithromax
Zmax
Zocor (STEP) (QCD)
Zofran (QCD)
Zofran ODT (QCD)
Zohydro ER (PA) (QCD)
28
Medication Resource
ResourceList
ListIndex
Index
Medication
8-Mop
17
Adapalene
Abilify
19
Adcirca
12, 17
Abilify DiscMelt
19, 21
Adderall
21
Amerge
7
Abilify Maintenna
19, 21
Adderall XR
7
Amevive
12
Abilify tablets
3
Ambien
7, 21
Ambien CR
7, 21
3
Adempas
17
Amitiza
7
Abraxane
15
Adoxa CK
21
Amitriptyline
3
Absorica
21
Adoxa TT
21
Amlodipine
7
Adriamycin PFS
15
Amlodipine-Atorvastatin
7
Adrucil
15
Amlodipine/Benazepril
3
Amolodipine
3
Abstral
7, 12, 21
Acanya
21
Accolate
Accu-Chek Aviva testing strips
19, 21
3
Advair Diskus
3, 7, 19
Advair HFA
7, 19
Amoxicillin
3
AccuNeb
21
Advicor
7, 19
Amoxicillin TR-Potassium Clavulanate
3
Accupril
21
Aerobid
7, 21
Amphetamine Salt Combination
3
Accuretic
21
Aerobid-M
7, 21
Amphetamines
Accutane
21
Afinitor
17
Ampyra
Aceon
21
Airet
21
Amrix
21
Acetaminophen/Codeine
3
12
7, 12, 17
Albuterol
3
Amturnide
20
Alendronate
3
Anafranil
21
Analpram Advanced
21
Analpram-E kit
21
AcipHex
7, 12, 21
Actemra
12, 15
Alferon N
Acthar
12, 15
Alkeran
15
15, 17
Acticlate
21
Allopurinol
Actigall
21
Alodox
21
Angeliq
21
Actimmune
15
Aloquin
21
Anoro Ellipta
19
Antara
21
Actiq
Activella
7, 12, 21
21
Alora
Alprazolam
3
7, 21
3
Anastrozole
Anzemet
3
7, 21
Actonel
7, 20
Alrex
7, 21
Apidra
21
ACTOplus Met
7, 19
Alsuma
7, 21
Aplenzin ER
21
ACTOplus Met XR
7, 19
Altabax
21
Apokyn
15
Actos
7, 19
Altace
21
Appformin-D
21
Acular
7, 21
Altavera
3
Acular LS
7, 21
Altoprev
7, 19, 21
Acular PF
7
Acuvail
Acyclovir
Aczone
29
Alupent inhaler
7
21
Aluvea
21
3
Alvesco
7, 21
21
Alyacen
3
Apri
3
Aqua Glycolic HC
21
Aralast
12
Aralast NP
12
Aranesp
Arava
7, 12, 15
7, 21
Arcapta Neohaler
7, 21
Aredia
15
Arixtra
7, 21
Armour Thyroid
3
Arzerra
15
Asacol HD
Ascensia diabetic testing supplies
Asmanex Twisthaler
Astelin
22
Botulinum toxin
Avidoxy
22
Bravelle
15, 22
Avidoxy DK
22
Breo Ellipta
19, 22
Avinza
22
3
Avodart
20
Brintellix
8
21
Avonex
8, 15
Brisdelle
8, 22
Axert
8, 22
Bromday
22
22
21
7
Axid
22
Brovana
Azasite
22
Budeprion SR
8
3
Budeprion XL
8
Atacand
20, 21
Azelastine
Atacand HCT
20-22
Azithromycin
7, 20
3
Azathioprine
Azmacort
3
8, 22
Budesonide
3, 8
Bunavail
8, 12
Buprenex
8, 12
8, 12
20
Buprenorphine
22
Buprenorphine-Naloxone
8
3
Buprenorphine/Naloxone
3
3
22
B-D diabetic testing supplies
Atopiclair
22
Baclofen
3, 7
3, 8
Azor
Ativan
Atorvastatin
22
Brilinta
7, 21
Atenolol
Brevicon
22
Astepro
Atelvia DR
12, 22
12
Avita
7, 21
Assure Pro diabetic testing supplies
Avelox
Beconase AQ
8, 22
Bupropion
Atralin
22
Belviq
8, 12
Bupropion SR
3, 8
Atrapro CP
22
Benicar
3, 20
Bupropion XL
3, 8
Atrapro Dermal Spray
22
Benicar HCT
3, 20
Buspirone
Atrapro Hydrogel
22
BenzaClin kit
22
Atropen
22
Benzonatate
3
Atrovent
7
Besivance
Atrovent HFA
7
Betamethasone Dipropionate
22
Busulfex
3
Butorphanol NS
8
3
Butrans
8, 12, 22
8, 15
Bystolic
22
17
Betaseron
Augmentin XR
22
Bethkis
17
Cabergoline
Aurstat
22
BiCNu
15
Caduet
Auvi-Q
7, 22
Binosto
8, 20, 22
Avalide
20
Bionect
Avandaryl
Avandia
7, 19
19
15
Butalbital/APAP/Caffeine
Aubagio
Avandamet
3
8
8, 19, 22
Calcitriol Topical
22
22
Calcium Folanate
15
Bleomycin Sulfate
15
Cambia
22
Boniva Injection
15
Camila
3
7, 8, 19
Boniva syringe
12, 22
Avapro
20
Boniva tablets
8, 20, 22
Aveed
15
Bosulif
17
Camptosar
15
Capecitabine
17
Caphosol
22
30
Capoten
22
Chibroxin Ocumeter
Carbaglu
17
Chlorhexadine Gluconate
3
Clozaril
Chlorthalidone
3
CNL 8 nail kit
Carbidopa/Levodopa
3
22
Clotrimazole/Betamethasone
3
19
8, 22
Carboplatin
15
Cialis
3
Colazal
22
Cardene
22
Ciclopirox nail lacquer
8
Colcrys
3
Cardene SR
22
Cimzia
Cardizem CD
22
Cardizem LA
22
Cardura
Cardura XL
8
8, 22
12, 15
Combigan
22
Cinryze
12
Combivent
8
Cipro-XR
22
Combivent Respimat
Ciprofloxacin
Cisplatin
3
15
Carisoprodol
3
Citalopram
3, 8
Carvedilol
3
Cladribine
15
Cataflam
22
Catapres TTS
8
Clarithromycin
Combunox
Concerta
3, 8
22
8
Contour Next diabetic testing supplies 22
Conzip
22
3
Copaxone
8, 15
Cleanse and Treat
22
Copegus
17
22
Coreg
22
Ceclor
22
Cleervue-M
Ceclor CD
22
Climara
8
Coreg CR
22
Cedax
22
Climara Pro
8
Cosmegen
15
22
Cefadroxil
3
Clindacin ETZ Kit
22
Cosopt PF
Cefdinir
3
Clindacin PAC
22
Cozaar
20, 22
Cefuroxime
3
Clindagel
22
Crestor
3, 8, 19
Clindamax
22
Crolom ophthalmic
8
Celebrex
Celexa
3, 8, 20
8, 22
Clindamycin
3
Cromolyn ophthalmic
8
3
Cryselle
3
3
Cem-Urea
22
Clindamycin/Benzoyl Peroxide
Cenestin
22
Clindareach
22
Cyclobenzaprine
Centany
22
Clindets
22
Cyclophosphamide
Centany AT
22
Clobeta + Plus
22
Cymbalta
Cerdelga
17
Clobetasol Propionate
3
Cyramza
15
Ceredase
12
Clobex
22
Cystagon
17
Cerezyme
12
Clodan Kit
22
Cystaran
18
Cerubidine
15
Clomid
15
Cytarabine
15
Cytoxan
15
8, 22
Cesamet
8, 22
Clomiphene
15
Cetraxel
22
Clonazepam
3
Dacarbazine
15
Cetrotide
15
Clonidine
3
Dactinomycin
15
Clonidine patch
8
Daliresp
22
Clopidogrel
3
Darvocet N-100
22
Chantix
Chenodal
31
3
22
15, 17
Daunorubicin HCL
15
Dihydroergotamine
DaunoXome
15
Dilacor XR
Daypro
22
Dilaudid
Daytrana
22
Diltiazem ER
DDAVP
15, 22
Diovan
8
Dynacirc CR
23
23
Dysport
12
23
Dytan
23
4
Easy Step diabetic testing supplies
23
4, 20
Easy-Trak diabetic testing supplies
23
Demulen
22
Dipentum
23
Econazole
4
Depo-Sub Q Provera 104
22
Diskets
12
Edarbi
Depocyt
15
Dispermox
23
Edarbiclor
Derma-Smoothe/FS
22
Ditropan
20, 23
Edluar
8, 23
Dermasorb-AF
22
Ditropan XL
20, 23
Effexor
23
Dermasorb-HC
22, 23
Dermasorb-XM
20, 23
20
Divalproex Sodium
4
Effexor XR
23
Divalproex Sodium ER
4
Egrifta
DermOtic
23
Divigel
23
Elestrin
23
Desmopressin Acetate
15
Docefrez
15
Eletone
23
Desogen
23
Docetaxel
15
Elidel
12
Desonide
3
Dolophine
12
Eligard
15
Desonil + Plus
23
Donepezil
4
Ellence
15
DesOwen kit
23
Doryx
23
Eloxatin
15
Desoxyn
12
Dorzolamide/Timolol
Elspar
15
Desvenlafaxine ER
8, 23
Doxazosin
4
4, 8
12, 15
Embeda
8, 12, 23
Detrol
20, 23
Doxorubicin HCl
Detrol LA
20, 23
Doxycycline Hyclate
4
Emend
8
Doxycycline Monohydrate
4
Emoquette
4
Dexamethasone
3
Dexedrine
Embrace diabetic testing supplies
23
DTIC-Dome
15
Emsam
23
8, 12, 23
Duavee
23
Enablex
20, 23
8
Duetact
19
Enalapril
4
15
Duexis
23
Enbrel
Dextroamphetamine/Amphetamine
3
Dulera
8, 19
Dextroamphetamine/Amphetamine ER
8
Duloxetine
4, 8
12
Duragesic
8, 12, 23
Dexilant
23
15
8, 23
Dexmethylphenidate XR
Dexrazoxane
Dextroamphetamines
Diazepam
4, 8, 12, 15
Endometrin
15
Enjuvia
23
Enoxaparin
8
Enoxparin Sodium
4
Enpresse
4
3, 4
Durezol
23
4
Dymista
8, 23
12
Dynabac
23
Enteral formula
12
Diflucan
8
Dynacin
23
Entyvio
15
Digoxin
4
Dynacirc
23
Epaned
23
Dicyclomine
Dificid
32
Epi-Pen AutoInjector
4
Extavia
Epi-Pen JR. AutoInjector
4
Extina
23
Flonase
EpiCeram
23
Eylea
12
Flovent HFA inhaler
4
Epiduo
23
Factive
23
Flovent/HFA
8
Factor VIII, VIIIa, IX, XIII
12
Floxuridine
15
Fluconazole
4, 8
Epinephrine injection
8
8, 15, 23
Epirubicin
15
Falessa kit
23
Episil
23
Famciclovir
8
Epogen
8, 12, 15
Famvir
8, 23
Equetro
23
Fanapt
19, 23
Erbitux
12
Farxiga
Erivedge
17
Faslodex
Ertaczo
23
FazaClo
Erythromycin
4
Femtrace
Escitalopram
4, 8
Esomeprazole Strontium
8, 12, 23
Estrace
23
Fenofibrate
Fenoglide
Flector
15
Fludarabine phosphate
15
Flunisolide
8
19
Fluocinonide
4
15
Fluorouracil
15
19, 23
23
4
23
Fluoxetine
4, 8
Fluoxetine DR
8
Fluticasone
8
Fluticasone nasal spray
4
Fentanyl oral/mucosal
8, 12
Fluvastatin
8
8, 12
Fluvoxamine
8
Fluvoxamine CR
8
4
Fentanyl patch
Estraderm
8
Fentanyl patches
Estradiol
4
Fentora
8, 12, 23
Estradiol patch
8
Fertinex
23
Estrasorb
8, 23
Fetzima
8
Focalin XR
Estrogel
8, 23
Fexmid
23
Folic Acid
Fibracor
23
Follistim AQ
23
Fondaparinux
8
8, 23
Fludara
Estrace Cream
Eszopiclone
23
Ethyol
15
Finacea Plus
Etopophos
15
Finasteride
4
FML Forte
23
Focalin
23
8, 23
4
15, 23
8, 9
4
Forfivo XL
9, 23
19, 23
Etoposide
15, 17
Fioricet
23
Fortamet
Euflexxa
12, 23
Fiorinal
23
Forteo
Evamist
8, 23
Fiorinal with Codeine
23
Fortesta
Firazyr
15
Fosamax
Firmagon
15
Fosamax Plus D
9, 20
First-lansoprazole
12
Fragmin
9, 23
First-omeprazole
12
Freestyle diabetic testing supplies
23
23
Evoclin
23
Evzio
8
ExacTech diabetic testing supplies
Exalgo
23
8, 12, 23
9, 12, 15
20, 23
9, 20, 23
Exforge
20
Flagyl
23
Fresh Kote
Exforge-HCT
20
Flagyl ER
23
Frova
9, 23
Exjade
17
Flagyl IV
23
FUDR
15
33
Furosemide
4
Fusilev I.V.
15
Granisetron
Fuzeon
15
Granisol
Gabapentin
Gonal F/Gonal F RFF
4
Granix
Ganirelix
15
Grastek
Garamide
23
Growth Hormone
Gatifloxacin
9
15
Hylatopic Plus-Aurstat
24
9
Hylira
24
9
Hytrin
9, 24
9, 15, 16
Hyzaar
20, 24
9, 12
IB-Stat
24
12
Guanfacine
Ibandronate
9, 16
4
Ibuprofen
4
Gattex
15
Haldol
19
IC400 kit
24
Gazyva
15
Haldol Decanoate
19
IC800 kit
24
Gel-One
12, 23
Halonate
24
Iclusig
17
Gelclair
23, 24
Halotin
24
Idamycin PFS
16
Gelnique
20
Havroni
17
Idarubicin
16
GelX
24
Helidac
24
Ifex
16
Gemcitabine
15
Hetlioz
9, 12, 17
Ifosfamide
16
Gemfibrozil
4
Gemzar
Genotropin
Geodon
Horizant
24
Ifosfamide/Mesna
16
HPR
24
Ilaris
16
15, 24
HPR Plus
24
Ilevro
24
19
Humalog
4
Imbruvica
17
15
Gianvi
4
Giazo
24
Gildess
4
Gilenya
9, 17
Human Chorionic Gonadotropin (HCG) 15
Imitrex
9
Humatrope
16
Imuran
24
Humira
4, 9, 12, 16
Incivek
13, 17
Hyalgan
12, 13, 24
Increlex
16
16, 17
Inderal LA
24
24
Gilotrif
17
Hycamtin
Gleevec
17
Hydrochlorothiazide
4
Inderal XL
Glimepiride
4
Hydrocodone/APAP
4
Indomethacin
Glipizide
4
Hydrocodone/Chlorpheniramine
4
Infergen
Glipizide ER
4
Hydrocortisone
4
Inlyta
17
Glipizide XL
4
Hydrocortisone-Lidocaine kit
24
Innohep
24
Hydromorphone
4
Insulins
9
Glucometer diabetic testing supplies
24
4
9, 16
Glucophage
19, 24
Hydromorphone ER
9
Interferons (alpha, gamma)
Glucophage XR
19, 24
Hydroxychloroquine
4
Intermezzo
Hydroxyzine
4
Intron A
16
Hylase
24
Intuniv
24
Hylatopic
24
Invega
19, 24
Hylatopic Plus
24
Invega Sustenna
Glucose testing strips
9
Glumetza
19, 24
Glyburide
4
Gonal F Rff Rediject
15
13
9, 24
19
34
Invokamet
19
Ketorolac
4
Levetiracetam
4
Invokana
19
Ketorolac ophthalmic
9
Levitra
4
Levlen
24
Iophen-C NR
4
Keytruda
16
Ipratropium NS
9
Khedezla
9, 24
Iquix
Irbesartan
24
Kineret
13, 16
Levofloxacin
4
Levothyroxine
4
4
Klonopin
24
Iressa
17
Klor-Con
4
Lexxel
24
Irinotecan
16
Kombiglyze XR
20
Lialda
24
4
Korlym
17
Lidocaine Patch
9
Istalol
24
Kuvan
17
Lidoderm
9
Istodax
16
Kynamro
Isosorbide Mononitrate
Itraconazole
9
Kytril
IV Immunoglobulin
13
Labetalol
Jakafi
17
Lamictal ODT
Jalyn
20
Lamisil
Janumet
19
Lamisil Granules
Janumet XR
Januvia
Jardiance
Jentadueto
19, 20
4
20
20, 24
Lamotrigine
Kelnor 1-35
4
24
9, 24
24
Lipitor
9, 19, 24
Lipodox
16
Lipodox-50
16
Lantus
4
Lithium Carbonate
4
Lantus Solostar
4
Livalo
4
lo Loestrin FE
19
20, 24
4
4
Juxtapid
Kazano
Liothyronine Sodium
4
Lisinopril/HCTZ
Latuda
4
9
Lansoprazole/Amoxicillin/Clarithromycin 9
4
Kariva
Linzess
4
Junel FE
24
9, 24
Lisinopril
Latanoprost
Kapvay
24
4, 9, 13
Lansoprazole
4
13, 17
Lidovir
9, 19, 24
Junel
Kalydeco
16, 19
Liptruzet
24
9, 13, 24
9, 24
4
Jublia
Kadian
Lexapro
Lazanda
Leflunomide
24
13, 24
9
9, 24
4
Lodine
24
Lodine XL
24
Lofibra
24
Lescol
9, 19, 24
Lopressor
24
Lescol XL
9, 19, 24
Lorabid
24
Letairis
17
Lorazepam
4
Leucovorin Calcium
16
Loryna
4
Losartan
4
Leukine
13, 16
Kenalog
16
Leuprolide
15
Losartan/HCTZ
4
Keppra XR
24
Leuprolide Acetate
16
LoSeasonique
24
Keralyt kit
24
Leustatin
16
Lotensin
24
Ketocon + Plus
24
Levaquin
24
Lotensin HCT
24
4
Levemir
24
Lotronex
Ketoconazole
35
9
Loutrex
Lovastatin
Lovaza
24
4, 9
24
Metadate CD
Mobic
9, 25
24
Modafinil
4, 13
Metformin
4
Moderiba
17
Metformin ER
4
Mometasone
Metaglip
9
Lovenox
9, 24
Loxitane
19
Methadone
13
Momexin
25
Lucentis
13
Methadose
13
Monodox
25
Lumigan
20
Methimazole
4
Monopril
25
Lunesta
9, 24
Methocarbamol
4
Monopril HCT
25
Methotrexate
4
Monovisc
Lupaneta Pack
16
4
13, 25
Lupron Depot
15, 16
Methylphenidate
4
Montelukast
Lupron Depot-Ped
15, 16
Methylphenidate CD
9
Morgidox
25
Lutera
4
Methylphenidate ER
4, 9
Morphine Sulfate CR
13
Luveris
15
Methylprednisolone
4
Morphine Sulfate ER
4, 9, 13
Metoclopramide
4
Moxatag
25
Luvox CR
9, 24
4
Luzu
24
Metoprolol Succinate
4
Moxeza
25
Lyrica
13
Metoprolol Tartrate
4
Mozobil
16
Lysteda
9, 24
Metozolv ODT
24
MS Contin
9, 13
24
Mupirocin
4
4
Mustargen
16
Lytensopril
24
Metrogel kit
Macugen
13
Metronidazole
Makena
13, 16
Mevacor
9, 19, 24
Myalept
13, 16
Marqibo
16
Micardis
20, 24, 25
Mylotarg
16
Mavik
24
Micardis HCT
20
Myoxin
25
Maxair Autohaler
9, 24
Microgestin FE
4
Myrbetriq
20, 25
Maxalt
9, 24
Migranal
9
Nabumetone
4
Maxalt-MLT
9, 24
Minastrin FE
4
Nadolol
4
Maxipime
24
Minivelle
9
Namenda
4
MB Hydrogel
24
Minocin
25
Naprelan
25
Minocin Combo Pack
25
Naprelan CR
25
Naprosyn
25
Naprosyn EC
25
Medroxyprogesterone
4
Megace ES
24
Minocycline
Mekinist
17
Mirapex
Meloxicam
4
20
4, 9
Mirapex ER
20, 25
Menopur
15
Mirtazapine
4, 9
Menostar
9, 24
Mesna
Mesnex
16
16, 17
Mirtazapine Rapid Dissolve
Naproxen
Naratriptan
9
Nasarel
Mitomycin
16
Nasonex
Mitoxantrone
16
Natazia
4, 5
9
25
9, 25
25
36
Navelbine
16
NebuPent
9
Novacort
25
Ondansetron ODT
9
Novantrone
16
Ondasetron
5
Neo-Synalar Kit
25
Novarel
15
Ondasetron ODT
5
Neosalus
25
Novolin Insulin products
25
One Touch Delica testing strips
5
Neosalus CP
25
Novolog Insulin products
25
One Touch Ultra testing strips
5
Neosar
16
Nplate
16
Onglyza
Nesina
20, 25
NuCort
25
Onmel
Nucynta
25
Onsolis
Neuac Kit
Neulasta
Neumega
Neupogen
25
9, 16
16
9, 16
Nucynta ER
20
9, 25
9, 13, 17, 25
13, 25
Ontak
16
NutriDox
25
Onxol
16
Nutritional Supplements
13
Opana
25
Neupro
25
Nutropin
16
Opana ER
Neurontin
25
Nutropin AQ
16
Opsumit
17
NeutraSal
25
Nutropin AQ Nuspin
16
Optase
25
Nevanac
25
Nuvigil
13, 25
Optivar
9
Nexavar
17
Nystatin
5
Oracea
25
Nexiclon XR
25
Nystatin/Triamcinolone
5
Oralair
9
Ocella
5
Oramorph SR
9, 13, 25
Octreotide injection
16
Orapred ODT
25
25
Oravig
25
5
Orencia
Nexium
Nifedipine ER
9, 13
5
Nipent
16
Ocudox kit
Niravam
25
Ofloxacin
Nitrofurantoin
5
Oforta
17
Orenitram
9, 13, 25
13, 16
17
Nivatropic Plus
25
Olanzapine
5
Orsythia
5
Nor-Q-D
25
Olanzepine-Fluoxetine
9
Ortho Tri-Cyclen Lo
5
Norditropin
16, 25
Oleptro ER
25
Orthovisc
13, 25
25
Oseni
20, 25
Norditropin Flexpro
16
Olux
Norditropin Nordiflex
16
Olysio
Norethindrone
5
Omeprazole
Norgestimate/Ethinyl Estradiol
5
Omeprazole-Sod. Bicarbonate
13, 17
5, 9
9, 13, 25
Osphena
Otezla
Otezla Starter Pack
25
9, 13, 17
17, 25
Norinyl
25
Omnaris
9, 25
Ovcon
25
Noroxin
25
Omnicef
25
Ovidrel
15
Northera
17
Omnitrope
Oxaliplatin
16
16, 25
Nortrel
5
Omontys
9, 13, 16
Nortriptyline
5
Oncaspar
16
Norvasc
37
9, 25
Ondansetron
9
Oxcarbazepine
Oxecta
Oxybutynin
5
25
5
Oxycodone
Oxycodone ER
5
9, 13
Pexeva
10, 25
Phenazopyridine
5
Prinzide
Pristiq
Oxycodone/APAP
5
Phoslyra
25
ProAir HFA
OxyContin
9
Photofrin
16
ProAir HFA inhaler
Oxycontin
5, 13
Pioglitazone
Oxymorphone ER
9, 13
Pioglitazone-Glimepiride
10, 20
Prochlorperazine
20, 25
Pioglitazone-Metformin
10, 20
Procort
Oxytrol
Paclitaxel
16
Plaquenil
Pamelor
25
Ploymyxin B-Sul/Trimethoprim
Pamidronate
16
Pomalyst
Pamidronate disodium
16
Potassium Chloride
Pamine FQ
25
PR-Cream
Pancreaze
25
Panretin
18
Pantoprazole
Paptase
Paroxetine
Paroxetine CR
26
5
26
10, 13, 16
26
Prolastin
13
25
Prolastin C
13
Pram-HCA
25
Prolensa
26
Pramcort
25
Proleukin
13, 16
Prolia
13, 16
Pramosone E
17
5
5
25, 26
Promacta
17
PrandiMet
20
Promethazine
5
Prandin
20
Promethazine/Codeine
5
Patanase
9, 25
Pravachol
Paxil
9, 25
Pravastatin
Paxil CR
5
Prodigy diabetic testing supplies
25
5
Procrit
10
17
Pramipexole
9
25
Procentra
10, 26
Procysbi
5, 9
5, 9
5, 10, 20
26
10, 19, 26
5, 10
Promiseb
26
Promiseb Light
26
9, 10, 25
Precision QID diabetic supplies
26
Propranolol
5
PCE
25
Precision X-Tra diabetic supllies
26
Propranolol ER
5
PCE Dispertab
25
Prednisone
Pediaderm AF
25
Pregnyl
Pediaderm HC
25
Pediaderm TA
Proquin XR
26
15
Proscar
20
Premarin
5
Protonix
10, 13, 26
25
Prempro
5
Protopic
13
Peg-Intron
16
Prenatal Plus
5
Proventil
26
PEG-Intron
10
Presera
26
Proventil HFA
Pegasys
10
Preservative-Free Morphine
13
Proventil inhaler
26
Penicillin
5
Prestige diabetic testing supplies
26
Proventil Repetab
26
10, 13, 26
Provigil
13
26
Prozac
10, 26
Prozac Weekly
10, 26
Penlac
10, 25
Prevacid
5
10, 26
Pennsaid
25
Prevacid NapraPAC
Pepcid
25
PrevPac
10, 26
Percocet
25
Prilosec
10, 13, 26
Pulmicort FlexHaler
5
Pertzye
25
Prinivil
26
Pulmicort Flexhaler
10
38
Pulmicort Respules
10
Remicade
13, 16
Rynatan
26
Pulmozyme
17
Repronex
15
Rythmol
26
Purinethol
26
Requip
20, 26
Ryzolt
26
Pylera
26
Requip XL
20, 26
Sabril
17
Rescula
20, 26
Saizen
QNASL
10, 26
Qualaquin
10
Respiratory SyncytialVirus IG/Synagis
Quartette
26
Restasis
5
Restoril
Retin-A Micro
Quetiapine
Quillivant XR
26
Quinapril
5
Qutenza
10, 18
QVAR
Rabeprazole
5, 10
10, 13
Revatio
Revlimid
Rhinocort Aqua
13
16, 26
Salicylic Acid-Ceramide kit
26
Salvax
26
26
Salvax Duo
26
26
Salvax Duo Plus
26
Sanctura
26
5, 10, 13
13, 16, 17, 26
17
10, 26
Sanctura XR
20, 26
Sancuso
10, 26
Ribapak
17
Sandostatin
16
16
RadiaPlex Rx
26
Ribasphere
17
Sandostatin-LAR
Radigel
26
Ribatab
17
Saphris
19, 26
Ribavirin
17
Sarafem
10, 26
Ragwitek
10, 13
Ramipril
5
Rilutek
17
Scalacort
26
Raniclor
26
Riluzole
17
Seasonique
26
5
Rinnovi
26
Selferma
10
Ranitidine
Rapaflo
26
Risedronate
10
Senophylline
26
Rapaflux
10
Risperdal
19
Serevent Diskus
10
Raptiva
16
Risperdal Consta
19
Serophene
15
Ravicti
17
Risperdal M-Tab
Seroquel
19
Rayos
26
Risperidone
Seroquel XR
19
Rebetol
17
Ritalin
26
Serostim
16
Sertraline
5, 10
Rebif
19, 26
5
10, 16
Ritalin LA
10, 26
Reciphexamine
26
Ritalin SR
26
Reclast
13
Rituxan
13, 16
Signafor
16
Sildenafil
13, 17
10, 26
Reclipsen
5
Rizatriptan
10
Silenor
Recothrom
26
Ropinirole
5
Silvrstat
26
Regranex
13
Rosadan
26
Simbrinza
26
Relafen
26
Rosanil
26
Simcor
10, 19, 26
Relpax
10, 26
Rozerem
10
Simponi
10, 13, 16
Remeron
10, 26
Ruconest
16
Simponi Aria
16
Rybix ODT
26
Simulect
16
Remeron Soltab
39
26
Simvastatin
5, 10
Sumaxin CP
27
Tenormin
27
Sinemet
26
Sumaxin TS
27
Tequin
27
Singulair
19
Supartz
13, 27
Sitavig
26
Suprep
5
Skelid
26
Sutent
17
Terbinex
Sof-Tact diabetic supplies
26
Sylatron
16
Tersi
Solodyn
26
Sylvant
16
Testim
Soltamox
26
Symbicort
Soma
26
Symbyax
10, 19
product)
Somatuline
16
Synagis
13, 16
Somavert
16
Synalar Combo-Pack
27
product)
5, 10, 19
Terazosin
5, 10
Terbinafine
5, 10
10, 27
27
20, 27
20, 27
20, 27
Sonata
10, 26
Synalar TS
27
Testosterone gel (Vogelxo Authorized
Sovaldi
13, 17
Synribo
16
product)
Spectracef
26
Synthroid
Spiriva
10
Synvisc
5
13, 27
20
Testosterone gel (Vogelxo) Authorized
product)
27
27
Spiriva HandiHaler
5
Synvisc One
13
Tetrix
Spironolactone
5
Synvisc-One
27
Tev-Tropin
16, 27
Tafinlar
17
Teveten
20, 27
Tagamet
27
Teveten HCT
20, 27
Sporanox
Sprintec
10, 26
5
Sprix
26
Tamiflu
5
Thalomid
17
Sprycel
17
Tamoxifen
5
TheraCys
16
Stavzor
26
Tamsulosin
5
Therapentin
27
Stelara
16, 26
Tarabine
16
Theraproxen
27
Stivarga
17
Tarceva
17
Thiotepa
Strattera
5, 10, 13
Tasigna
17
Tiamate
Taxol
16
Timolol Maleate
5, 10, 13
Taxotere
16
Tindamax
27
10, 13, 26
Tecfidera
17
Tirosint
27
Striant
Suboxone
Subsys
26
16, 17
27
5
Subutex
10
Tekamlo
20, 27
Tizanidine
5
Sucraid
17
Tekturna
20, 27
TL-Triseb
27
Tekturna HCT
20, 27
TOBI ampules
17
Sular
Sulfamethoxizole/Trimethoprim
Sumatriptan
Sumavel Dosepro
Sumaxin
26, 27
5
5, 10
10, 27
27
Temazepam
5
TOBI-Podhaler
Temodar
17
TobraDex ST
Temozoloamide
17
Tobramycin/Dexamethasone
Teniposide
16
Tofranil
17, 18
27
5
27
40
Topical Retinoic Acid derivatives
Topiramate
Toposar
13
Tropazone
27
Venlafaxine
5
TrueTest diabetic supplies
27
Venlafaxine ER capsule
10
17
TrueTrack diabetic supplies
27
Venlafaxine ER capsules
5
Twynsta
20, 27
Venlafaxine ER tablet
5
Toprol XL
5
10
Tornalate
27
Tykerb
18
Ventolin HFA
10, 27
Totect
17
Tysabri
13
Veramyst
10, 27
Toviaz
20, 27
Tyvaso
18
Verapmil ER
5
TPN
13
Ultracet
27
Veregen
27
Tracleer
18
Ultram/ER
27
Vesicare
5, 20
Ultrasal ER
27
Vexa
27
Ultravate PAC
27
Vexol
27
Tradjenta
20, 27
Tramadol
5
Tranexamic Acid
10
Ultravate X
27
Viagra
5
Tranxene T-Tab
27
Ultressa
27
Victoza
20
Travatan
20
Uramaxin
27
Victrelis
13, 18
Travatan Z
20
Urea kit
27
Vigamox
10, 27
Trelstar
17
Vagifem
5
Viibryd
10, 27
Trelstar Depot
17
Valacyclovir
5
Vimovo
27
Trelstar LA
17
Valacylovir
10
Vimzim
17
Tretin-X
27
Valchlor
18
VinBLAStine
17
Tretinoin
5
5
VinCRIStine
17
Treximet
10, 27
Valstar
17
Vinorelbine
17
Tri-Levlen
27
Valtrex
10
Viorelle
5
Tri-Norinyl
27
Valturna
20, 27
Virasal
27
Valsartan/HCTZ
Tri-Previfem
5
Vanos
27
Vitamin D2
5
Tri-Sprintec
5
Vantin
27
Vivelle
10
Triamcinolone Acetonide
5
Vascepa
27
Vivelle-Dot
10
Triamterene/HCTZ
5
Vaseretic
27
Vivelle-DOT
5
Tribenzor
20
Vasolex
27
Vogelxo
20, 27
Tricor
27
Vasotec
27
Voltaren
27
Triglide
27
Vectibix
13
Voltaren gel
5
Trilipix
27
Vectical
27
Voltaren XR
27
Trinalin
27
Vectrin
27
Votrient
18
Trinessa
5
Velcade
17
Vumon
17
TriOxin
27
Velphoro
27
Vusion
27
Tritec
27
Veltin
27
Vytorin
10, 19, 27
41
Vyvanse
10, 27
Zantac
28
Zovirax
28
Warfarin
5
Zavesca
18
Zubsolv
11, 13
Welchol
27
Zebeta
28
Zuplenz
11, 28
Wellbutrin
27
Zegerid
10, 13, 28
Zydelig
18
Wellbutrin SR
10, 27
Zelapar
28
Wellbutrin XL
10, 27
Zelboraf
13, 18
X-Clair
27, 28
Zenapax
Xalatan
20
Xalkori
13, 18
Xanax XR
Xarelto
Xartemis XR
28
5
10, 28
Zyflo
19, 28
Zyflo CR
19, 28
17
Zykadia
13, 18
Zenieva
28
Zymar
11, 28
Zestril
28
Zymaxid
11, 28
Zetia
Zetonna
5, 10, 19
Zypram
28
10, 28
Zyprexa
19
Ziana
28
Zyprexa IM
19, 28
Zinecard
17
Zyprexa Relprevv
19, 28
Xeljanz
13, 18, 28
Xeloda
18
Zinotic
28
Zyprexa Zydis
19
Xenaderm
28
Zinotic ES
28
Zytiga
18
Zipsor
28
Zytopic
28
Xenazine
13, 18
Xeomin
13
Zithromax
28
Xerese
28
Zmax
28
Xgeva
13, 17
Zocor
10, 19, 28
Xiaflex
13
Zofran
10, 28
Xibrom
28
Zofran ODT
10, 28
Xifaxan
28
Zohydro ER
10, 28
Xolair
13
Zoladex
17
Xolegel
28
Zolinza
18
Xolox
28
Zolmitriptan
10
Zolmitriptan ODT
10
Zoloft
10
Xopenex HFA
Xopenex nebules
10, 28
28
Xtandi
18, 20
Zolpidem
5, 10
Xyralid
28
Zolpidem ER
5, 10
Xyrem
18
Zolpimist
Z-Pram
28
Zometa
Zaleplon
10
Zomig
Zaltrap
17
Zomig ZMT
28
Zanaflex
28
Zontivity
28
Zanosar
17
Zorbtive
17
10, 28
13
10, 11, 28
42
Our Pharmacy and Therapeutics Committee, which is
made up of pharmacists and doctors of various specialties,
reviews the effectiveness and overall value of new
medications approved by the FDA on an ongoing basis.
The Committee provides expertise and advice to help us
give our members prescription drug options that meet
their medical needs and achieve desired treatment goals.
Approved medications are added to our formulary as they
are approved by our Pharmacy and Therapeutics Committee
throughout the year.
43
While under review, new medications will not be covered
by your plan. As with other medications that are not covered,
your doctor may request coverage when medically necessary.
If a non-covered drug is approved, it will be covered at the
highest tier or cost share.
#141665
55-0071 (10/14)
Fitness Benefit
Your Blue Cross Blue Shield of Massachusetts
health plan can save you money annually
in qualified health club membership fees or
up to 10 fitness classes taken at a qualified
health club.
3 Easy Steps to Getting Reimbursed1
1.
2.
3.
Choose
Complete
Mail
Start by picking a
qualified health club.
Once you pay for the program,
fill out the attached form.
Send the completed form to the
address listed at the bottom.
Important Information
What’s covered:2
•T
he reimbursement is for each individual
(or family) health plan and can only be
submitted once each calendar year.
Your benefit will reimburse you for three consecutive months of membership fees from a
qualified health club or for up to 10 fitness classes taken at a qualified health club.
• Keep copies of all your paperwork and
proof of payment in case you are denied
reimbursement.
Proof of payment includes the following:
– Itemized, dated, paid receipts from your
health club
– Bank or credit card statements
– Paycheck stubs if your club fees are
automatically deducted from that
account
• Receipts or statements should include
the name of the family member enrolled
and the individual charges for a full
reimbursement of health club fees or
fitness classes.
• The dollar amount you receive may be
considered taxable income. Consult
your tax advisor about how to treat this
reimbursement on your taxes.
A qualified health club is:
A full-service health club with a variety of exercise equipment, including:
• Cardiovascular equipment like treadmills and bikes
• Strength-training equipment like free weights and weight machines
To receive the fitness reimbursement for a qualified pay-as-you-go health club, get paid
receipts from the club for your records.
What doesn’t qualify?
You can’t receive the fitness reimbursement for expenses for personal training, lessons,
coaching, equipment, clothing, or any of the clubs below:
• Martial arts or yoga centers
• Gymnastics, tennis, aerobic, or pool-only facilities
• Country clubs or social clubs
• Sports teams or leagues
Be sure to talk with your doctor before starting an exercise program.
1. Before starting, check to see if your plan includes the Fitness Benefit.
2. Most plans offer a reimbursement for three months of membership or up to 10 fitness classes, but your employer may have offered a different benefit. Please refer to your benefits information to confirm.
Fitness Reimbursement Form3
To verify this reimbursement is within your plan, log in to Member Central at www.bluecrossma.com/membercentral or call Member
Service at the number on your ID card. Submit this form once per calendar year, no later than March 31 of the following year. PLEASE PRINT ALL INFORMATION CLEARLY
Subscriber Information (Policyholder)
Identification Number (including first 3 letters) Address—Number and Street
Subscriber’s Last Name
First Name
City State Middle Initial
Zip Code
Employer’s Name
Member and Claim Information
Member’s Last Name
First Name
Middle Initial
Mailing Address—Number and Street (if different from subscriber’s)
Gender
Date of Birth: Mo.
City State
Day
Yr.
Zip Code
Claim is for (check one):
Male
Subscriber (policyholder)
Ex-Spouse
Other (specify) ___________________
Female
Spouse (of policyholder)
Dependent (up to age 26)
Name, Address, and Phone Number of Qualified Health Club
I am due $___________________ for the following reimbursement (check one):
Membership at a qualified health club. My monthly fee is $___________________.
Fitness classes at a qualified health club.
Health Plan Year
My fee per class is $___________________.
Certification and Authorization (This form must be signed and dated below.)
I authorize the release of any information to Blue Cross Blue Shield of Massachusetts about my health club membership. I certify that the
information provided in support of this submission is complete and correct and that I have not previously submitted for these services.
I understand that Blue Cross may require additional evidence of health club membership and proof of payment for my membership before
reimbursement is provided.
Subscriber’s or
Member’s Signature:__________________________________________________________________ Date: _____________________________________
Questions?
Please complete and mail this form to:
To verify this reimbursement is within your plan or for further
information, please log in to the Member Central website
at www.bluecrossma.com/membercentral or call
Member Service at the number on the front of your ID card.
Local Claims Department
PO Box 986030
Boston, MA 02298
3. Blue Cross will make a reimbursement decision within 30 calendar days of receiving a completed request for coverage or payment.
147581M55-0821 (4/15)
Weight Loss Benefit
Your Blue Cross Blue Shield of Massachusetts
health plan can save you money annually
in qualified Weight Watchers®´ and
2
3 Easy Steps to Getting Reimbursed
hospital-based weight-loss programs.
3 Easy Steps to Getting Reimbursed1
1.
2.
3.
Choose
Complete
Mail
Start by picking a qualified
weight-loss program.
Once you pay for the program,
fill out the attached form.
Send the completed form and proof of
payment to the address listed at the bottom.
Important Information
What's covered:2
•T
he reimbursement is for each individual
(or family) health plan and can only be
submitted once each calendar year.
Your benefit will reimburse you for up to three months of participation in a qualified
weight-loss program.
• Keep copies of all your paperwork
and proof of payment in case you are
denied reimbursement. Proof of payment
includes the following:
– Paid receipts from qualified program
– Weight Watchers Membership Book
• Receipts, statements, or Weight Watchers
Membership Book should include the
name of the family member enrolled in the
program, the amount paid per session(s),
and date(s) paid.
• The dollar amount you receive may be
considered taxable income. Consult
your tax advisor about how to treat this
reimbursement on your taxes.
Be sure to check with your doctor before
starting any weight-loss program.
A qualified weight-loss program is:
• Weight Watchers meetings
• Weight Watchers At Work
• A hospital-based weight-loss program
What doesn’t qualify?
• Weight Watchers Online
• Weight Watchers At Home
•F
ees paid for individual nutrition-counseling
sessions, food, books, videos, or scales
1. Before starting, check to see if your plan includes the Weight Loss Benefit.
2. Most plans offer a three-month reimbursement, but your employer may have offered a different benefit. Please refer to your benefits information to confirm.
Weight-Loss Reimbursement Form3
To verify this reimbursement is within your plan, log in to Member Central at www.bluecrossma.com/membercentral or call
Member Service at the number on your ID card. Submit this form when you have paid receipts from a qualified weight-loss
program, once per calendar year, no later than March 31 of the following year. PLEASE PRINT ALL INFORMATION CLEARLY
Subscriber Information (Policyholder)
Identification Number (including first 3 letters) Subscriber’s Last Name
Address—Number and Street
First Name
City Middle Initial
State Zip Code
Employer’s Name
Member and Claim Information
Member’s Last Name
First Name
Middle Initial
Mailing Address—Number and Street (if different from subscriber’s)
Gender
Date of Birth: Mo.
City Day
State
Yr.
Zip Code
Claim is for (check one):
Male
Subscriber (policyholder)
Ex-Spouse
Other (specify) ___________________
Female
Spouse (of policyholder)
Dependent (up to age 26)
Class or Program Information Required:
Attach 8.5" x 11" photocopies of paid receipts from your qualified weight-loss program. Receipts must show Blue Cross Blue Shield
of Massachusetts member’s name, name or logo of program, amount paid per session(s), and date(s) paid. For qualified Weight Watchers
programs, a photocopy of your program Membership Book showing this information is required.
Name and Address of Class or Program
Health Plan Year
Total Amount Submitted: $ ________________________________________
Certification and Authorization (This form must be signed and dated below.)
I authorize the release of any information to Blue Cross and Blue Shield of Massachusetts about my weight-loss program. I certify that the
information provided in support of this submission is complete and correct and that I have not previously submitted for these services.
Subscriber’s or
Member’s Signature:__________________________________________________________________ Date: ________________________________________
Questions?
To verify this reimbursement is within your plan or for further
information, please log in to the Member Central website
at www.bluecrossma.com/membercentral or call
Member Service at the number on the front of your ID card.
3. Blue Cross will make a reimbursement decision within 30 calendar days of receiving a completed request for coverage or payment.
® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks are the property of their respective owners.
© 2015 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
147582M55-0822
Please complete and mail this form
(including copies of paid receipts) to:
Local Claims Department
PO Box 986030
Boston, MA 02298

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Appendix 1