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KANSAS ACA MEMBER PRESCRIPTION DRUG LIST 2019 HIX 2019 BCBSKC KS eff dte 07-01-2019.docx Table of Contents ANTI - INFECTIVES ........................................................................................................................................ 4 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ..................................................................... 13 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ....................................................................... 20 CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................. 39 DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 47 DIAGNOSTICS & MISCELLANEOUS AGENTS ...................................................................................... 57 EAR, NOSE & THROAT MEDICATIONS .................................................................................................. 60 ENDOCRINE/DIABETES .............................................................................................................................. 61 GASTROENTEROLOGY .............................................................................................................................. 79 IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 85 MUSCULOSKELETAL & RHEUMATOLOGY ......................................................................................... 89 OBSTETRICS & GYNECOLOGY ................................................................................................................ 91 OPHTHALMOLOGY ..................................................................................................................................... 97 RESPIRATORY, ALLERGY, COUGH & COLD ..................................................................................... 101 UROLOGICALS ............................................................................................................................................ 106 VITAMINS, HEMATINICS & ELECTROLYTES ................................................................................... 108 Index ................................................................................................................................................................ 115 2 Please see the benefit schedule in your member certificate for member cost sharing associated with Generic and Brand (Preferred and Non Preferred) drugs. List of Abbreviations for Prescription Drugs Drug Category: 1: Generic Drug and Generic Specialty Drug 2: Preferred Drug and Non Preferred Generic Drug 3: Non Preferred Drug and Preferred Specialty Drug 4: Non Preferred Specialty Drug 5: Zero Cost Share Preventive Drug 6: Medical Service Drugs 7: Infertility Drug ACA*: Affordable Care Act is a zero cost share preventive drug. M: Maintenance drug. MSD: Medical Service Drug. This drug is only covered under the medical benefit. OTC*: Over the Counter drug. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. S: Specialty drug. SLA: Specialty Limited Availability. This prescription may be available only at certain pharmacies. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. *Your plan has tobacco use coverage through the Routine Preventive Care benefit. Tobacco use includes two tobacco cessation attempts per year (both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by an in-network health care provider without prior authorization. 3 Drug Name Drug Requirements Drug Name Drug Requirements Category / Limits Category / Limits ANTI - INFECTIVES griseofulvin 1 microsize ANTIFUNGAL AGENTS griseofulvin 1 AMBISOME 6 MSD ultramicrosize amphotericin b 6 MSD itraconazole oral 1 QL capsule ANCOBON 3 itraconazole oral 1 CANCIDAS 6 MSD solution caspofungin 6 MSD ketoconazole 1 clotrimazole 1 NOXAFIL 2 CRESEMBA 6 MSD nystatin 1 INTRAVENOUS ONMEL 3 QL CRESEMBA ORAL 2 ORAVIG 3 DIFLUCAN ORAL 3 SUSPENSION FOR SPORANOX 3 RECONSTITUTIO SPORANOX 3 QL N PULSEPAK DIFLUCAN ORAL 3 terbinafine hcl 1 TABLET 100 MG, 200 MG, 50 MG TOLSURA 3 DIFLUCAN ORAL 3 QL VFEND 3 TABLET 150 MG VFEND IV 6 MSD ERAXIS(WATER 6 MSD voriconazole 6 MSD DILUENT) intravenous fluconazole in 6 MSD voriconazole oral 1 dextrose(iso-o) ANTIVIRALS fluconazole in nacl 6 MSD (iso-osm) abacavir 1 S; QL fluconazole oral 1 abacavir-lamivudine 1 S; QL suspension for abacavir- 1 S; QL reconstitution lamivudine- fluconazole oral 1 zidovudine tablet 100 mg, 200 acyclovir 1 mg, 50 mg adefovir 1 fluconazole oral 1 QL tablet 150 mg amantadine hcl 1 M flucytosine 1 APTIVUS 3 S; QL atazanavir 1 S You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 4 Drug Name Drug Requirements Drug Name Drug Requirements Category / Limits Category / Limits ATRIPLA 4 S; QL FOSCAVIR 6 MSD BARACLUDE 2 FUZEON 3 S; QL ORAL SOLUTION GANCICLOVIR 6 MSD BARACLUDE 3 ganciclovir sodium 6 MSD ORAL TABLET GENVOYA 3 S BIKTARVY 3 S HARVONI 3 PA; S; SLA; cidofovir 6 MSD QL CIMDUO 3 S HEPSERA 3 COMBIVIR 4 S; QL INTELENCE 3 S; QL COMPLERA 3 S; QL INVIRASE 3 S; QL CRIXIVAN 3 S; QL ISENTRESS 3 S; QL CYTOVENE 6 MSD ISENTRESS HD 3 S DAKLINZA 4 PA; ST; S; JULUCA 3 S SLA KALETRA ORAL 4 S; QL DELSTRIGO 4 S SOLUTION DESCOVY 3 S KALETRA ORAL 3 S; QL didanosine 1 S; QL TABLET DOVATO 3 S lamivudine oral 1 S; QL solution EDURANT 3 S; QL lamivudine oral 1 QL efavirenz 1 S; QL tablet 100 mg EMTRIVA 3 S; QL lamivudine oral 1 S; QL entecavir 1 tablet 150 mg, 300 mg EPCLUSA 3 PA; S; SLA lamivudine- 1 S; QL EPIVIR 4 S; QL zidovudine EPIVIR HBV 2 LEDIPASVIR- 4 PA; S; QL ORAL SOLUTION SOFOSBUVIR EPIVIR HBV 3 QL LEXIVA ORAL 3 S; QL ORAL TABLET SUSPENSION EPZICOM 4 S; QL LEXIVA ORAL 4 S; QL EVOTAZ 4 S; QL TABLET famciclovir 1 QL lopinavir-ritonavir 1 S; QL FLUMADINE 3 MAVYRET 4 ST; S fosamprenavir 1 S; QL nevirapine 1 S; QL You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 5 Drug Name Drug Requirements Drug Name Drug Requirements Category / Limits Category / Limits NORVIR ORAL 3 S; QL SELZENTRY 3 S CAPSULE ORAL TABLET 25 MG, 75 MG NORVIR ORAL 3 S POWDER IN SOFOSBUVIR- 4 PA; S PACKET VELPATASVIR NORVIR ORAL 3 S; QL SOVALDI 4 PA; S; SLA; SOLUTION QL NORVIR ORAL 4 S; QL stavudine 1 S; QL TABLET STRIBILD 3 S; QL ODEFSEY 3 S SUSTIVA 4 S; QL oseltamivir 1 QL SYMFI 3 S PIFELTRO 4 S SYMFI LO 3 S PREVYMIS 6 MSD SYMTUZA 4 S INTRAVENOUS SYNAGIS 6 MSD PREVYMIS ORAL 2 QL TAMIFLU 3 QL PREZCOBIX 4 S tenofovir disoproxil 1 S; QL PREZISTA 3 S; QL fumarate RELENZA 2 QL TIVICAY ORAL 3 S DISKHALER TABLET 10 MG, 25 RESCRIPTOR 3 S; QL MG RETROVIR 6 MSD TIVICAY ORAL 3 S; QL INTRAVENOUS TABLET 50 MG RETROVIR ORAL 4 S; QL TRIUMEQ 3 S; QL REYATAZ ORAL 4 S TRIZIVIR 4 S; QL CAPSULE TROGARZO 6 PA; MSD REYATAZ ORAL 3 S TRUVADA ORAL 3 S POWDER IN TABLET 100-150 PACKET MG, 133-200 MG, ribavirin 1 S; SLA 167-250 MG rimantadine 1 TRUVADA ORAL 3 S; QL TABLET 200-300 ritonavir 1 S; QL MG SELZENTRY 3 S TYBOST 4 S; QL ORAL SOLUTION valacyclovir 1 QL SELZENTRY 3 S; QL ORAL TABLET VALCYTE 3 150 MG, 300 MG You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 6 Drug Name Drug Requirements Drug Name Drug Requirements Category / Limits Category / Limits valganciclovir 1 CEFAZOLIN IN 6 MSD 0.9% SOD VALTREX 3 ST; QL CHLORIDE VEMLIDY 2 cefazolin in dextrose 6 MSD VIDEX 2 GRAM 3 S; QL (iso-os) intravenous PEDIATRIC piggyback 1 gram/50 ml, 2 gram/50 ml VIDEX EC 4 S; QL CEFAZOLIN IN 6 MSD VIEKIRA PAK 4 PA; S; SLA; DEXTROSE (ISO- QL OS) VIRACEPT 3 S; QL INTRAVENOUS PIGGYBACK 2 VIRAMUNE 4 S; QL GRAM/100 ML VIRAMUNE XR 4 S; QL CEFAZOLIN IN 6 MSD VIRAZOLE 4 S; SLA DEXTROSE 5 % VIREAD ORAL 3 S; QL CEFAZOLIN IN 6 MSD POWDER STERILE WATER VIREAD ORAL 3 S; QL cefdinir 1 TABLET 150 MG, cefditoren pivoxil 1 200 MG, 250 MG cefepime 6 MSD VIREAD ORAL 4 S; QL TABLET 300 MG cefepime in 6 MSD dextrose,iso-osm VOSEVI 3 S; SLA cefixime 1 XOFLUZA 2 QL CEFOTAN 6 MSD ZEPATIER 3 PA; ST; S; SLA cefotaxime 6 MSD ZERIT 4 S; QL cefotetan 6 MSD ZIAGEN 4 S; QL cefoxitin 6 MSD zidovudine 1 S; QL cefpodoxime 1 ZOVIRAX 3 cefprozil 1 CEPHALOSPORINS ceftriaxone in 6 MSD dextrose,iso-os AVYCAZ 6 MSD ceftriaxone injection 6 MSD cefaclor 1 recon soln 1 gram, cefadroxil 1 10 gram, 2 gram, cefazolin 6 MSD 250 mg, 500 mg You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 7 Drug Name Drug Requirements Drug Name Drug Requirements Category / Limits Category / Limits CEFTRIAXONE 6 MSD erythromycin 1 INJECTION erythromycin 1 RECON SOLN 100 ethylsuccinate GRAM ZITHROMAX 6 MSD cefuroxime axetil 1 INTRAVENOUS cefuroxime sodium 6 MSD ZITHROMAX 3 cephalexin 1 ORAL CLAFORAN 6 MSD ZITHROMAX TRI- 3 PAK KEFLEX 3 ZITHROMAX Z- 3 MAXIPIME 6 MSD PAK SPECTRACEF 3 MISCELLANEOUS SUPRAX 3 ANTIINFECTIVES TAZICEF 6 MSD AEMCOLO 3 TEFLARO 6 MSD albendazole 1 ERYTHROMYCINS & OTHER ALBENZA 3 QL MACROLIDES ALINIA 2 QL azithromycin 6 MSD amikacin 6 MSD intravenous ARAKODA 3 azithromycin oral 1 ARIKAYCE 2 SLA clarithromycin 1 atovaquone 1 DIFICID 3 atovaquone- 1 QL e.e.s. 400 1 proguanil E.E.S. GRANULES 3 BENZNIDAZOLE 2 PA ERYPED 200 3 BETHKIS 6 MSD ERYPED 400 3 BILTRICIDE 3 ery-tab oral 1 CAPASTAT 6 MSD tablet,delayed release (dr/ec) 250 CAYSTON 3 S; SLA; QL mg, 333 mg chloramphenicol sod 6 MSD ERY-TAB ORAL 3 succinate TABLET,DELAYE chloroquine 1 D RELEASE phosphate (DR/EC) 500 MG CLEOCIN HCL 3 erythrocin (as 1 stearate) You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 8 Drug Name Drug Requirements Drug Name Drug Requirements Category / Limits Category / Limits CLEOCIN 6 MSD ethambutol 1 INJECTION FLAGYL 3 cleocin intravenous 6 MSD gentamicin 6 MSD solution 300 mg/2 ml gentamicin in nacl 1 CLEOCIN 6 MSD (iso-osm) INTRAVENOUS intravenous SOLUTION 600 piggyback 100 MG/4 ML, 900 mg/100 ml, 60 mg/50 MG/6 ML ml, 70 mg/50 ml, 80 CLEOCIN 3 mg/100 ml, 80 mg/50 PEDIATRIC ml, 90 mg/100 ml clindamycin hcl 1 GENTAMICIN IN 2 NACL (ISO-OSM) CLINDAMYCIN IN 6 MSD INTRAVENOUS 0.9 % SOD CHLOR PIGGYBACK 100 clindamycin in 5 % 6 MSD MG/50 ML dextrose GENTAMICIN IN 3 clindamycin 1 NACL (ISO-OSM) palmitate hcl INTRAVENOUS PIGGYBACK 120 clindamycin 1 MG/100 ML pediatric gentamicin sulfate 1 clindamycin 6 MSD (ped) (pf) phosphate gentamicin sulfate 1 COARTEM 2 QL (pf) intravenous colistin 1 solution 100 mg/10 (colistimethate na) ml COLY-MYCIN M 3 GENTAMICIN 3 PARENTERAL SULFATE (PF) INTRAVENOUS CUBICIN 6 MSD SOLUTION 60 CUBICIN RF 6 MSD MG/6 ML CYCLOSERINE 3 GENTAMICIN- 6 PA; MSD dapsone 1 M SODIUM CITRATE daptomycin 6 MSD hydroxychloroquine 1 M DARAPRIM 2 PA; SLA; QL imipenem-cilastatin 6 MSD DORIPENEM 6 MSD IMPAVIDO 3 S; QL EMVERM 2 QL INVANZ 6 MSD ertapenem 6 MSD isoniazid 1 You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 9 Drug Name Drug Requirements Drug Name Drug Requirements Category / Limits Category / Limits ivermectin 1 QL PRIMAXIN IV 6 MSD KITABIS PAK 3 S; SLA pyrazinamide 1 KRINTAFEL 3 QUALAQUIN 3 QL LINCOCIN 6 MSD quinine sulfate 1 QL lincomycin 6 MSD rifabutin 1 linezolid 1 PA RIFADIN 6 MSD INTRAVENOUS linezolid in dextrose 6 MSD 5% RIFADIN ORAL 3 MALARONE 3 QL RIFAMATE 3 MALARONE 3 QL rifampin intravenous 6 MSD PEDIATRIC rifampin oral 1 mefloquine 1 QL RIFATER 3 MEPRON 3 SIRTURO 2 SLA meropenem 6 MSD SIVEXTRO 3 PA MEROPENEM- 6 MSD SOLOSEC 3 PA 0.9% SODIUM CHLORIDE STREPTOMYCIN 6 MSD MERREM 6 MSD STROMECTOL 3 QL metro i.v. 6 MSD SYNERCID 6 MSD metronidazole 1 tigecycline 6 MSD metronidazole in 6 MSD tinidazole 1 QL nacl (iso-os) TOBI 3 ST; QL MYAMBUTOL 3 TOBI PODHALER 2 QL MYCOBUTIN 3 tobramycin in 0.225 1 QL NEBUPENT 2 QL % nacl neomycin 1 tobramycin sulfate 6 MSD paromomycin 1 TOBRAMYCIN 4 S WITH NEBULIZER PASER 3 TRECATOR 3 PLAQUENIL 3 ST; M TYGACIL 6 MSD polymyxin b sulfate 6 MSD VABOMERE 6 MSD praziquantel 1 XIFAXAN 2 PRIFTIN 2 ZEMDRI 6 MSD PRIMAQUINE 2 M; QL You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 10
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