Blue Cross Blue Shield of Alabama PrimeChoice Essential Prescription Drug List

325 Pages·2014·3.39 MB·English

by  Susanne Patterson

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Blue Cross and Blue Shield of Alabama PrimeChoice Essential
April 2014
Prescription Drug List

Contents Therapeutic Class Drug List
Introduction .................................................................... I Anti-Infective Drugs...................................................... 1
How drugs are selected ................................................... I Biologicals .................................................................. 16
Coverage considerations ................................................. I Antineoplastic Agents ................................................ 20
Member Prescription Benefit .......................................... II Endocrine and Metabolic Drugs ................................. 23
Brand Drugs and Generic Drugs .................................... II Cardiovascular Agents ............................................... 43
Affordable Care Act ........................................................ II Respiratory Agents .................................................... 64
Compounds ................................................................... III Gastrointestinal Agents .............................................. 73
Specialty ........................................................................ III Genitourinary Agents ................................................. 80
Utilization Management ................................................. III Central Nervous System Drugs ................................. 84
Step Therapy ................................................................. III Analgesics and Anesthetics ..................................... 102
Prior Authorization ......................................................... III Neuromuscular Drugs .............................................. 116
Dispensing Limits ........................................................... IV Nutritional Products.................................................. 125
Notice ............................................................................. IV Hematological Agents .............................................. 140
Key ................................................................................. IV Topical Products ...................................................... 149
Miscellaneous Products ........................................... 173
Index ........................................................................ 206

The Prescription Drug List is regularly updated. Please visit AlabamaBlue.com/pharmacy for the most
up-to-date information.
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or
go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for
and click on Search.

4157-H AL IVL © Prime Therapeutics LLC 04/14
Introduction

The attached Blue Cross and Blue Shield of Alabama PrimeChoice Essential Prescription Drug List shows
covered drugs for a broad range of diseases.

Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand
drug in (parentheses). Some generic products have no reference brand.

Brand prescription drugs are shown in capital letters followed by the generic name.
The Blue Cross and Blue Shield of Alabama PrimeChoice Essential Prescription Drug List is organized into
broad categories (e.g. Anti-Infective drugs). Within most categories, drugs are sub-grouped by drug class (e.g.
Penicillins) or by use for a specific medical condition (e.g. Diabetes).
Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to
prescribe drugs on this list, when right for the member. However, decisions regarding therapy and treatment are
always between members and their physician.
The current version of this Prescription Drug List is available at AlabamaBlue.com/pharmacy or by calling the
customer service number listed on back of your identification card. Online pharmacy tools are available at
AlabamaBlue.com/pharmacy. Blue Cross members can find drug cost estimates or check if a particular drug
is on the Essential Prescription Drug List.

How drugs are selected

Drugs on this list are selected based on the recommendations of a committee made up of physicians and
pharmacists from throughout the country. The committee, which includes at least one representative from the
health insurer or claims administrator of your health plan, reviews drugs regulated by the U.S. Food and Drug
Administration (FDA).

Both drugs that are newly approved by the FDA as well as those that have been on the market for some time
are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs
currently on the list.

Coverage Considerations

Most prescription drug benefit plans provide coverage for up to a 30- to 34-day supply of medication, with some
exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications.
Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood
pressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories,
like those used for erectile dysfunction (example: Viagra) or infertility (example: Follistim AQ). You should refer to
your benefit plan booklet for details about your particular benefits.

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Member Prescription Benefit

The Blue Cross prescription benefit is multi-tiered, placing prescription drugs into one of four tier levels; Generic
drugs (Tier 1), Preferred Brand drugs (Tier 2), Other Brand drugs (Tier 3) and Specialty drugs (Tier 4). Coverage
and copayment/co-insurance levels vary depending on the plan. Drugs that require Prior Authorization, Step
Therapy, or that have Dispensing Limits are noted in the Prescription Drug List.
• Generic drugs (Tier 1)
• Preferred Brand drugs (Tier 2)
• Other Brand drugs (Tier 3)
• Specialty drugs (Tier 4)

Brand Drugs and Generic Drugs

Classification

Prescription drugs are classified as either: (1) Brand drug or (2) Generic drug. The Brand/Generic classification is
linked to the copayment/co-insurance level or Tier. Blue Cross uses the Brand or Generic status provided by a
nationally recognized company providing drug product information. The Brand/Generic status for a specific
drug/specific marketer can sometimes change over the life of a product in the marketplace and change from
Brand to Generic or from Generic to Brand. Such changes might change your copayment/co-insurance share.
Brand drug or Generic drug status is never based upon a product having a trade name. Generic drugs often have
trade names.

Generic Substitution

Blue Cross encourages generic utilization as a way to provide high quality drugs at a reduced cost. Generic drugs
are as safe and effective as their brand counterparts, but are usually less expensive. Generic drugs are
manufactured under the same strict requirements of FDA’s current Good Manufacturing Practice regulations
required for Brand drugs and cover the manufacturing, and identity, strength, purity and quality.
An FDA-approved Generic drug may be substituted for the Brand counterpart when it:
• Contains the same active ingredient(s) as the brand drug;
• Is identical in strength, dosage form and route of administration; and
• Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile.

Affordable Care Act

Please note, some drugs may have limited or $0 cost-sharing under the Affordable Care Act. Examples of
categories of drugs that may be subject to limited or $0 cost share include aspirin, breast cancer preventive,
fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco
cessation, vaccines, vitamin D supplements, and some contraceptive drugs and devices. If you do not find the
drug you are searching for, consult or contact Blue Cross to find out if the drug is available over the counter or is
covered under your medical benefit.

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Compounds

Compounded prescriptions contain two or more drugs mixed together. These prescriptions are processed
according to member benefits. To be eligible for coverage, compounded medications must contain at least one
FDA-approved prescription ingredient and must not be a copy of a commercially available product. All
compounded medications are subject to review and may require prior authorization.

Specialty

Specialty drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and
rheumatoid arthritis. Specialty drugs may be oral or injectable medications that can either be self-
administered or administered by a health care professional.
Some Blue Cross members must obtain their specialty drugs from Prime Therapeutics Specialty Pharmacy.
If the preferred provider is not utilized you may be responsible for up to 100 percent of the drug cost.

Utilization Management

Blue Cross is committed to supporting proper selection and use of drugs for its members. To help assure these
goals are met, several programs have been developed to promote drug selection that encourages both
effectiveness and safety. Detailed coverage criteria can be found at AlabamaBlue.com/pharmacy. Drugs
requiring Prior Authorization or Step Therapy, or drugs with Dispensing Limits will be noted in the Therapeutic
Class Drug List portion of the Prescription Drug List.

Step Therapy

Your benefit plan may include a step therapy program. This means you may need to try another proven,
cost-effective medication before coverage may be available for the drug included in the program. Many
brand drugs have less-expensive generic or brand alternatives that might be an option for you. If step
therapy is required for a medication listed in this document, it will be noted next to the medication with a dot
under the step therapy column.

Prior Authorization

Your benefit plan may require prior authorization for certain drugs that are high-cost or have the potential for
misuse. This means that your doctor will need to submit a prior authorization request for coverage of these
medications, and the request will need to be approved, before the medication will be covered under your plan.
If prior authorization is required for a medication listed in this document, it will be noted next to the medication
with a dot under the prior authorization column.

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Dispensing Limits

Drug dispensing limits help encourage medication use as intended by the FDA. Dispensing limits are placed on
medications in certain drug categories. For the medications listed in this document, if a dispensing limit applies, it
will be noted next to the medication with a dot under the dispensing limits column.
Limits may include: quantity of covered medication per prescription and/or quantity of covered medication in
a given time period. If your doctor prescribes a greater quantity of medication than what the dispensing limit
allows, you can still get the medication. However, you will be responsible for the full cost of the prescription
beyond what your coverage allows. For a list of medications and their dispensing limits, visit
AlabamaBlue.com/pharmacy.
There may also be limits for members within a certain age range, and coverage only for members of a
specific gender.

Notice

The purpose of the Blue Cross and Blue Shield of Alabama PrimeChoice Essential Prescription Drug List is to
provide a guide to coverage. This Essential Prescription Drug List is not intended to dictate to physicians how
to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most
appropriate for their patients.
Neither this Prescription Drug List, nor the successful adjudication of a pharmacy claim, is guarantee of payment
Key
cap ................................................................. capsules odt. ....................................... orally disintegrating tabs
chew ............................................................. chewable oint ................................................................ ointment
conc .......................................................... concentrate ophth ............................................................ opthalmic
cr...................................................... controlled release osm ..................................................... osmotic release
dr ........................................................ delayed release powd ................................................................ powder
ec ........................................................... enteric coated sa ....................................................... sustained action
effe............................................................ effervescent sl .................................................................. sublingual
equiv ........................................................... equivalent soln .................................................................. solution
er....................................................... extended release sr ...................................................... sustained release
inhal.............................................................. inhalation suppos ................................................... suppositories
inj .................................................................... injection susp ........................................................... suspension
liq ......................................................................... liquid tab ...................................................................... tablets
lotn ...................................................................... lotion td ............................................................... transdermal
nebu .............................................................. nebulizer

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Drug Name Drug Prior Step Dispe Drug Name Drug Prior Step Dispe
ANTI-INFECTIVE AGENTS AMPICILLIN- ampicillin for susp 125 3
mg/5ml
PENICILLINS
AMOXICILLIN- amoxicillin (trihydrate) 3 AMPICILLIN- ampicillin for susp 250 3
mg/5ml
chew tab 125 mg
AMOXICILLIN- amoxicillin (trihydrate) 3 ampicillin & sulbactam sodium for 1
inj 1-0.5 gm (Unasyn)
chew tab 250 mg
amoxicillin (trihydrate) cap 250 mg 1 ampicillin & sulbactam sodium for 1
inj 10-5 gm (Unasyn bulk pack)
amoxicillin (trihydrate) cap 500 mg 1
ampicillin & sulbactam sodium for 1
amoxicillin (trihydrate) for susp 1
inj 2-1 gm (Unasyn)
125 mg/5ml
ampicillin & sulbactam sodium for iv 1
amoxicillin (trihydrate) for susp 1
soln 1-0.5 gm
200 mg/5ml
ampicillin & sulbactam sodium for iv 1
amoxicillin (trihydrate) for susp 1
soln 10-5 gm
250 mg/5ml
ampicillin cap 250 mg 1
amoxicillin (trihydrate) for susp 1
ampicillin cap 500 mg 1
400 mg/5ml
amoxicillin (trihydrate) tab 500 mg 1 AMPICILLIN SODIUM- ampicillin 3
sodium for inj 125 mg
amoxicillin (trihydrate) tab 875 mg 1
AMPICILLIN SODIUM- ampicillin 3
amoxicillin & k clavulanate chew tab 1
sodium for iv soln 1 gm
200-28.5 mg
AMPICILLIN SODIUM- ampicillin 3
amoxicillin & k clavulanate chew tab 1
sodium for iv soln 2 gm
400-57 mg
AMPICILLIN SODIUM- ampicillin 1
amoxicillin & k clavulanate for susp 1
sodium for inj 10 gm
200-28.5 mg/5ml
ampicillin sodium for inj 1 gm 1
amoxicillin & k clavulanate for susp 1
ampicillin sodium for inj 10 gm 1
250-62.5 mg/5ml (Augmentin)
amoxicillin & k clavulanate for susp 1 ampicillin sodium for inj 125 mg 1
400-57 mg/5ml ampicillin sodium for inj 2 gm 1
amoxicillin & k clavulanate for susp 1 ampicillin sodium for inj 250 mg 1
600-42.9 mg/5ml (Augmentin es-600) ampicillin sodium for inj 500 mg 1
amoxicillin & k clavulanate tab sr 1 ampicillin sodium for iv soln 10 gm 1
12hr 1000-62.5 mg (Augmentin xr)
AMPICILLIN-SULBACTAM- ampicillin & 3
amoxicillin & k clavulanate tab 1
sulbactam sodium for iv soln 2-1 gm
250-125 mg
AUGMENTIN- amoxicillin & k 3
amoxicillin & k clavulanate tab 1
clavulanate tab 500-125 mg
500-125 mg (Augmentin)
AUGMENTIN- amoxicillin & k 3
amoxicillin & k clavulanate tab 1
clavulanate tab 875-125 mg
875-125 mg (Augmentin)
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Drug Name Drug Prior Step Dispe Drug Name Drug Prior Step Dispe
AUGMENTIN- amoxicillin & k 3 PENICILLIN G PROCAINE- penicillin g 3
clavulanate for susp 125-31.25 procaine intramuscular susp 600000
mg/5ml unit/ml
AUGMENTIN- amoxicillin & k 3 PENICILLIN G SODIUM- penicillin g 3
clavulanate for susp 250-62.5 mg/5ml sodium for inj 5000000 unit
AUGMENTIN ES-600- amoxicillin & k 3 penicillin v potassium for soln 1
clavulanate for susp 600-42.9 mg/5ml 125 mg/5ml
AUGMENTIN XR- amoxicillin & k 3 penicillin v potassium for soln 1
clavulanate tab sr 12hr 1000-62.5 mg 250 mg/5ml
BICILLIN C-R- penicillin g benzathine & 3 penicillin v potassium tab 250 mg 1
procaine inj susp 1200000 unit/2ml penicillin v potassium tab 500 mg 1
BICILLIN C-R- penicillin g benzathine & 3 PFIZERPEN-G- penicillin g potassium 3
procaine inj 900000-300000 unt/2ml
for inj 5000000 unit
BICILLIN L-A- penicillin g benzathine 3 PFIZERPEN-G- penicillin g potassium 3
intramuscular susp 600000 unit/ml
for inj 20000000 unit
BICILLIN L-A- penicillin g benzathine 3 piperacillin sodium-tazobactam 1
intramuscular susp 1200000 unit/2ml
sodium for inj 2-0.25 gm (Zosyn)
BICILLIN L-A- penicillin g benzathine 3 piperacillin sodium-tazobactam 1
intramuscular susp 2400000 unit/4ml
sodium for inj 3-0.375 gm (Zosyn)
dicloxacillin sodium cap 250 mg 1 piperacillin sodium-tazobactam 1
dicloxacillin sodium cap 500 mg 1 sodium for inj 36-4.5 gm (Zosyn)
MOXATAG- amoxicillin (trihydrate) tab 3 piperacillin sodium-tazobactam 1
sr 24hr 775 mg sodium for inj 4-0.5 gm (Zosyn)
NAFCILLIN SODIUM- nafcillin sodium 3 TIMENTIN- ticarcillin & k clavulanate for 3
for iv soln 1 gm inj 3.1 gm
NAFCILLIN SODIUM- nafcillin sodium 3 TIMENTIN- ticarcillin & k clavulanate for 3
for iv soln 2 gm inj 31 gm
nafcillin sodium for inj 1 gm 1 UNASYN- ampicillin & sulbactam 3
nafcillin sodium for inj 10 gm 1 sodium for inj 1-0.5 gm
nafcillin sodium for inj 2 gm 1 UNASYN- ampicillin & sulbactam 3
sodium for iv soln 1-0.5 gm
oxacillin sodium for inj 1 gm 1
UNASYN- ampicillin & sulbactam 3
oxacillin sodium for inj 10 gm 1
sodium for inj 2-1 gm
oxacillin sodium for inj 2 gm 1 UNASYN ADD-VANTAGE- ampicillin 3
penicillin g potassium for inj 1 & sulbactam sodium for iv soln 1-0.5
20000000 unit (Pfizerpen-g) gm
penicillin g potassium for inj 1 UNASYN ADD-VANTAGE- ampicillin & 3
5000000 unit (Pfizerpen-g) sulbactam sodium for iv soln 2-1 gm
UNASYN BULK PACK- ampicillin & 3
sulbactam sodium for inj 10-5 gm
2 Blue Cross and Blue Shield of Alabama PrimeChoice Essential Prescription Drug List April 2014
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Drug Name Drug Prior Step Dispe Drug Name Drug Prior Step Dispe
ZOSYN- piperacillin sodium- 3 cefdinir for susp 125 mg/5ml 1
tazobactam sodium for inj 2-0.25 gm cefdinir for susp 250 mg/5ml 1
ZOSYN- piperacillin sodium- 3 CEFDITOREN PIVOXIL- cefditoren 3
tazobactam sodium for inj 3-0.375 gm
pivoxil tab 200 mg (base equivalent)
ZOSYN- piperacillin sodium- 3 CEFDITOREN PIVOXIL- cefditoren 3
tazobactam sodium for inj 4-0.5 gm
pivoxil tab 400 mg (base equivalent)
ZOSYN- piperacillin sodium- 3 cefepime hcl for inj 1 gm (Maxipime) 1
tazobactam sodium for inj 36-4.5 gm
cefepime hcl for inj 2 gm (Maxipime) 1
CEPHALOSPORINS
cefotaxime sodium for inj 1 gm 1
CEDAX- ceftibuten cap 400 mg 3
(Claforan)
CEDAX- ceftibuten for susp 90 mg/5ml 3 cefotaxime sodium for inj 10 gm 1
CEDAX- ceftibuten for susp 180 3 (Claforan)
mg/5ml cefotaxime sodium for inj 2 gm 1
CEFACLOR- cefaclor for susp 125 3 (Claforan)
mg/5ml cefotaxime sodium for inj 500 mg 1
CEFACLOR- cefaclor for susp 250 3 (Claforan)
mg/5ml CEFOTETAN- cefotetan disodium for 3
CEFACLOR- cefaclor for susp 375 3 inj 1 gm
mg/5ml CEFOTETAN- cefotetan disodium for 3
cefaclor cap 250 mg 1 inj 2 gm
cefaclor cap 500 mg 1 CEFOTETAN- cefotetan disodium for 3
CEFACLOR ER- cefaclor monohydrate 3 inj 10 gm
tab sr 12hr 500 mg cefoxitin sodium for inj 1 gm 1
cefadroxil cap 500 mg 1 cefoxitin sodium for inj 10 gm 1
cefadroxil for susp 250 mg/5ml 1 cefoxitin sodium for inj 2 gm 1
cefadroxil for susp 500 mg/5ml 1 cefpodoxime proxetil for susp 1
cefadroxil tab 1 gm 1 100 mg/5ml
CEFAZOLIN SODIUM- cefazolin 3 cefpodoxime proxetil for susp 1
50 mg/5ml
sodium for iv soln 1 gm
CEFAZOLIN SODIUM- cefazolin 3 cefpodoxime proxetil tab 100 mg 1
sodium (bulk) for inj 100 gm cefpodoxime proxetil tab 200 mg 1
CEFAZOLIN SODIUM- cefazolin 3 cefprozil for susp 125 mg/5ml 1
sodium (bulk) for inj 300 gm cefprozil for susp 250 mg/5ml 1
cefazolin sodium for inj 1 gm 1 cefprozil tab 250 mg 1
cefazolin sodium for inj 10 gm 1 cefprozil tab 500 mg 1
cefazolin sodium for inj 20 gm 1 CEFTAZIDIME- ceftazidime (bulk) for 3
cefazolin sodium for inj 500 mg 1 inj 100 gm
cefdinir cap 300 mg 1 ceftazidime for inj 1 gm (Fortaz) 1
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Drug Name Drug Prior Step Dispe Drug Name Drug Prior Step Dispe
ceftazidime for inj 2 gm (Fortaz) 1 cefuroxime sodium for inj 750 mg 1
ceftazidime for inj 500 mg 1 (Zinacef)
ceftazidime for inj 6 gm (Fortaz) 1 cefuroxime sodium for iv soln 1.5 gm 1
(Zinacef)
ceftazidime for iv soln 1 gm (Fortaz) 1
CEPHALEXIN- cephalexin tab 250 mg 3
ceftazidime for iv soln 2 gm (Fortaz) 1
CEPHALEXIN- cephalexin tab 500 mg 3
CEFTIBUTEN- ceftibuten cap 400 mg 3
cephalexin cap 250 mg (Keflex) 1
CEFTIBUTEN- ceftibuten for susp 180 3
cephalexin cap 500 mg (Keflex) 1
mg/5ml
CEFTIN- cefuroxime axetil tab 250 mg 3 cephalexin cap 750 mg (Keflex) 1
CEFTIN- cefuroxime axetil tab 500 mg 3 cephalexin for susp 125 mg/5ml 1
CEFTIN- cefuroxime axetil for susp 125 3 cephalexin for susp 250 mg/5ml 1
mg/5ml CLAFORAN- cefotaxime sodium for inj 3
CEFTIN- cefuroxime axetil for susp 250 3 500 mg
mg/5ml CLAFORAN- cefotaxime sodium for inj 3
ceftriaxone sodium for inj 1 gm 1 1 gm
(Rocephin) CLAFORAN- cefotaxime sodium for iv 3
ceftriaxone sodium for inj 10 gm 1 soln 1 gm
ceftriaxone sodium for inj 2 gm 1 CLAFORAN- cefotaxime sodium for inj 3
2 gm
ceftriaxone sodium for inj 250 mg 1
CLAFORAN- cefotaxime sodium for iv 3
ceftriaxone sodium for inj 500 mg 1
soln 2 gm
(Rocephin)
CLAFORAN- cefotaxime sodium for inj 3
ceftriaxone sodium for iv soln 1 gm 1
10 gm
ceftriaxone sodium for iv soln 2 gm 1 FORTAZ- ceftazidime for inj 500 mg 3
cefuroxime axetil for susp 1 FORTAZ- ceftazidime for inj 1 gm 3
125 mg/5ml (Ceftin)
FORTAZ- ceftazidime for iv soln 1 gm 3
cefuroxime axetil tab 250 mg (Ceftin) 1
FORTAZ- ceftazidime for inj 2 gm 3
cefuroxime axetil tab 500 mg (Ceftin) 1
FORTAZ- ceftazidime for iv soln 2 gm 3
CEFUROXIME SODIUM- cefuroxime 3
FORTAZ- ceftazidime for inj 6 gm 3
sodium for iv soln 7.5 gm
CEFUROXIME SODIUM- cefuroxime 3 KEFLEX- cephalexin cap 250 mg 3
sodium (bulk) for inj 75 gm KEFLEX- cephalexin cap 500 mg 3
CEFUROXIME SODIUM- cefuroxime 3 KEFLEX- cephalexin cap 750 mg 3
sodium (bulk) for inj 225 gm MAXIPIME- cefepime hcl for inj 1 gm 3
cefuroxime sodium for inj 1.5 gm 1 MAXIPIME- cefepime hcl for iv soln 1 3
(Zinacef)
gm
cefuroxime sodium for inj 7.5 gm 1 MAXIPIME- cefepime hcl for inj 2 gm 3
(Zinacef)
MAXIPIME- cefepime hcl for iv soln 2 3
gm
4 Blue Cross and Blue Shield of Alabama PrimeChoice Essential Prescription Drug List April 2014