Rwu.ohoacquia.com

PREFERRED DRUG LIST
Effective October 2013 – March 2014
PREFERRED ALTERNATIVES
NCE DEXILANT#, lansoprazole#, omeprazole#, pantoprazole# NCE benzoyl peroxide products*, topical tretinoin*, topical clindamycin* ASMANEX#, FLOVENT#, PULMICORT FLEXHALER#, QVAR# DIOVAN#, candisartan#,irbesartan#, lisinopril, losartan#, quinapril NC DIOVAN HCT#, irbesartan/HCTZ#, lisinopril/HCTZ, losartan/HCTZ#, quinapril/HCTZ naratriptan#, RELPAX#, rizatriptan#, sumatriptan#, zolmitriptan# NCE benzoyl peroxide products*, topical tretinoin*, topical clindamycin* DIOVAN#, candisartan#, irbesartan#, lisinopril, losartan#, quinapril DIOVAN HCT#, irbesartan/HCTZ#, lisinopril/HCTZ, losartan/HCTZ#, quinapril/HCTZ diclofenac, ibuprofen, meloxicam#, nabumetone NC cetirizine# (OTC), desloratadine#*, levocetirizine#*, loratadine# (OTC) NCE cetirizine# (OTC), levocetirizine#*, loratadine# (OTC) # - Quantity Limits for some plans; * = tier 2 generic OTC - Over the Counter; P = Preferred drug; N = Non-Preferred drug UPPERCASE = BRAND; lowercase = generic ^ May require Prior Authorization for some plans NC = Not Covered - Drugs not covered are not eligible for an exception process. NCE = Not Covered, eligible for medical criteria exception This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. PREFERRED ALTERNATIVES
(CONCERTA)#*, methylphenidate/ext-rel#, mixed salts amphetamines ext-rel#* divalproex sodium/divalproex sodium ext-rel granisetron#, metoclopramide, ondansetron# DETROL LA, oxybutynin ext-rel, tolterodine, trospium, VESICARE RELPAX#, naratriptan#, rizatriptan#, sumatriptan#, zolmitriptan# atorvastatin#, CRESTOR#, fluvastatin#, lovastatin#, simvastatin# # - Quantity Limits for some plans; * = tier 2 generic OTC - Over the Counter; P = Preferred drug; N = Non-Preferred drug UPPERCASE = BRAND; lowercase = generic ^ May require Prior Authorization for some plans NC = Not Covered - Drugs not covered are not eligible for an exception process. NCE = Not Covered, eligible for medical criteria exception This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. PREFERRED ALTERNATIVES
(CONCERTA)#*, methylphenidate ext-rel#, mixed salts amphetamines ext-rel#* DIOVAN#, candisartan#, irbesartan#, lisinopril, losartan#, quinapril DIOVAN HCT#, irbesartan/HCTZ#, lisinopril/HCTZ, losartan/HCTZ#, quinapril/HCTZ NCE DEXILANT#, lansoprazole#, omeprazole#, pantoprazole# OMEPRAZOLE/SODIUM BICARBONATE 40-1100 MG NCE DEXILANT#, lansoprazole#, omeprazole#, pantoprazole#OMNARIS# DEXILANT#, lansoprazole#, omeprazole#, pantoprazole# NCE DEXILANT#, lansoprazole#, omeprazole#, pantoprazole# flunisolide#, fluticasone#, NASONEX#, triamcinolone nasal spray# NC methylphenidate ext-rel (CONCERTA)#*, methylphenidate ext-rel# NC Amethia (3 copayments), Camrese (3 copayments) # - Quantity Limits for some plans; * = tier 2 generic OTC - Over the Counter; P = Preferred drug; N = Non-Preferred drug UPPERCASE = BRAND; lowercase = generic ^ May require Prior Authorization for some plans NC = Not Covered - Drugs not covered are not eligible for an exception process. NCE = Not Covered, eligible for medical criteria exception This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. PREFERRED ALTERNATIVES
benazepril, enalapril, lisinopril, quinapril, trandolapril benazepril/HCTZ, enalapril/HCTZ, lisinopril/HCTZ, quinapril/HCTZ, trandolapril/HCTZ DETROL LA, oxybutynin ext-rel, tolterodine, trospium, VESICARE NC alfuzosin ext-rel, doxazosin, tamsulosin, terazosin NCE DEXILANT#, lansoprazole#, omeprazole#, pantoprazole# # - Quantity Limits for some plans; * = tier 2 generic OTC - Over the Counter; P = Preferred drug; N = Non-Preferred drug UPPERCASE = BRAND; lowercase = generic ^ May require Prior Authorization for some plans NC = Not Covered - Drugs not covered are not eligible for an exception process. NCE = Not Covered, eligible for medical criteria exception This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. SPECIALTY DRUG LIST
The following is the Specialty Drug List, many of the drugs are oral tablets or self administered while some drugs (in bold type) are typically provided within a physician office setting with
coverage under the medical benefit.
For members with a specialty benefit, coverage for drugs listed in bold type wil not be provided under the medical benefit. Providers must obtain these products through a preferred
specialty vendor. Medications noted with a ^ below may require prior authorization. Medications with a # may be subject to quantity limits. Please refer to www.bcbsri.com for more detailed
program benefit information.
DRUG CATEGORY
SPECIALTY MEDICATION/HIGHEST TIER
ANTI-INFECTIVE
Antivirals, Hepatitis C Incivek
Infergen (interferon alfacon-1) Intron A (interferon alfa 2b) Pegasys (peginterferon alfa 2a)^ PegIntron (peginterferon alfa 2b)^ PegIntron Redipen (peginterferon alfa 2b)^ Victrelis (boceprevir)^# HIV, AIDS
DERMATOLOGY
Psoriasis
Enbrel (etanercept)^# PREFERRED self administered
Humira (adalimumab)^# PREFERRED self administered
Remicade (infliximab)^ PREFERRED provider administered
Stelara (ustekinumab)^ PREFERRED provider administered
ENDOCRINE
Growth Hormone Products Genotropin
Humatrope (somatropin)^# Increlex (mecasermin)^ Norditropin (somatropin)^# Norditropin Nordiflex (somatropin)^# Nutropin (somatropin)^# PREFERRED Nutropin AQ (somatropin)^# PREFERRED Omnitrope (somatropin)^# Saizen (somatropin)^# Serostim (somatropin)^# Signifor (pasireotide)^# Tev-tropin (somatropin)^# Zorbtive (somatropin)^# Miscellaneous Endocrine Disorders
H.P. Acthar gel (corticotrophin)^
Korlym (mifepristone)^
Procysbi (cysteamine bitartrate)^
Ravicti (glycerol phenylbutyrate)^
Sandostatin LAR Depot (octreotide acetate)
Somatuline Depot (lanreotide acetate)
Somavert (pegvisomant)
Supprelin LA (histrelin acetate)
Osteoporosis
Boniva IV formulation only (ibandronate)^
Forteo (teriparatide)^
Prolia (denosumab)^
zoledronic acid^
Phenylketonuria Treatment Agents Kuvan
GASTROENTEROLOGY
Crohns, UC
Cimzia (certolizumab)^#
Humira (adalimumab)^# PREFERRED self administered
Remicade (infliximab)^ PREFERRED provider administered
Tysabri (natalizumab)^
HEMATOLOGICAL
Anemia
Aranesp (darbepoetin alfa)^ Epogen (epoetin alfa)^ Procrit (epoetin alfa)^ PREFERRED Fibrinogen Deficiency
Hemophilia
Hemophilia, Factor IX Alphanine
Bebulin Benefix Mononine Profilnine SD Proplex T Hemophilia, Factor VIIa Novoseven
# - Quantity Limits for some plans; * = tier 2 generic OTC - Over the Counter P = Preferred drug; N = Non-Preferred Drug UPPERCASE = BRAND; lowercase = generic ^=May require Prior Authorization for some plans PREFERRED - These medications are preferred within their class. NC = Not Covered - Drugs not covered are not eligible for an exception process. NCE = Not Covered, eligible for medical criteria exception This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. Hemophilia, Factor VIII
Helixate FS Hemofil M Humate-P Koate-DVI Kogenate FS Monoclate-P Recombinate Refacto Wilate (VWF/FactorVIII) Xyntha Hereditary Angioedema
Berinert (C1 esterase inhibitor)^# Cinryze (human C1 inhibitor)^# Firazyr (icatibant)^# Immune Globulins
Carimmune^
Flebogamma^
Gamastan^
Gammagard^
Gamunex^ PREFERRED, Gamunex-C^ PREFERRED
Hizentra^
Octagam^
Privigen^
Vivaglobin^
Miscellaneous
Mozobil (plerixafor)
Thrombocytopenia
WBC Deficiencies
Leukine (sargramostim) Neulasta (pegfilgrastim)# Neupogen (filgrastim) IMMUNOMODULATOR
Cryopyrin-Associated Periodic Syndromes Arcalyst
Lupus Erythematosus
Benlysta (belimumab)^
Rheumatoid Arthritis
Actemra (tocilizumab)^#
Cimzia (certolizumab)^#
Enbrel (etanercept)^# PREFERRED self administered
Humira (adalimumab)^# PREFERRED self administered
Kineret (anakinra)^
Orencia (abatacept)^#
Remicade (infliximab)^ PREFERRED provider administered
Rituxan (rituximab)^
Simponi (golimumab)^
Xekljanz (tofacitinib)^#
IMMUNOSUPPRESSIVE
Transplant Drugs
INFERTILITY
Follitropins
Follistim AQ (follitropin beta) PREFERRED Gonal-F (follitropin alfa) GnRH Antagonists
Cetrotide (cetrorelix acetate) Ganirelix acetate chorionic gonadotropin (generic) Novarel (chorionic gonadotropins) Ovidrel (choriogonadotropin alfa) Pregnyl (chorionic gonadotropins) Menotropins
Menopur (gonadotropins/menotropins) Repronex (gonadotropins/menotropins) Urofollitropins
MISCELLANEOUS
Neurologicals
Chronic Gout
Krystexxa (pegloticase)^
# - Quantity Limits for some plans; * = tier 2 generic OTC - Over the Counter P = Preferred drug; N = Non-Preferred Drug UPPERCASE = BRAND; lowercase = generic ^=May require Prior Authorization for some plans PREFERRED - These medications are preferred within their class. NC = Not Covered - Drugs not covered are not eligible for an exception process. NCE = Not Covered, eligible for medical criteria exception This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. Enzyme Replacements
Aldurazyme (laronidase)
Carbaglu (carglumic acid)^
Cerezyme (imiglucerase)
Elaprase (idursulfase)
Elylyso (paliglucerase alfa)^
Fabrazyme (agalsidase beta)
Lumizyme (alglucosidase alfa)^
Myozyme (alglucosidase alfa)^
Naglazyme (galsulfase)
Vpriv (velaglucerase)^
Zavesca (miglustat)^
Iron Overload
Exjade (deferasirox)^ Ferriprox (deferiprone)^ Macular Degeneration
Eylea (aflibercept)^#
Lucentis (ranibizumab)^
Macugen (pegaptanib)^
NEUROMUSCULAR
Huntington's
Multiple Sclerosis
Ampyra (dalfampridine)^
Aubagio (teriflunomide)^
Avonex (interferon beta 1a)
Betaseron (interferon beta 1b)
Copaxone (glatiramer)
Extavia (interferon beta 1b)
Gilenya (fingolimod)^
Rebif (interferon beta 1a)
Tecfidera (dimethyl fumartae)^#
Tysabri (natalizumab)^
Muscular Disorder
Botox (botulinum toxin type A)^
Dysport (botulinum toxin type A)^
Myobloc (botulinum toxin type B)^
Xeomin (botulinum toxin type A)^
ONCOLOGY/HEMATOLOGY
Hematology
NPlate (romiplostim)^
Promacta (eltrombopag olamine)^
Oral Agents
Afinitor (everolimus)^ Bosulif (bosutinib)^ Caprelsa (vandetanib)^# Cometriq (cabozantinib)^ Erivedge (vismodegib)^# Gleevec (imatinib)^ Iclusig (ponatinib)^ Inlyta (axitinib)^ Iressa (gefitinib) Jakafi (ruxolitinib)^ Mekinist (trametinib)^ Nexavar (sorafenib)^ Oforta (fludarabine)^ Pomalyst (pomalidomide)^# Revlimid (lenalidomide)^# Sprycel (dasatinib)^ Stivarga (regorafenib)^ Sutent (sunitinib)^ Tafinlar (dabrafenib)^ Tarceva (erlotinib)^ Targretin caps (bexarotene)^ Tasigna (nilotinib)^ Temodar (temozolomide)^ Thalomid (thalidomide)^ Tykerb (lapatinib)^ Votrient (pazopanib)^ Xalkori (crizotinib)^# Xeloda (capecitabine)^ Xtandi (enzalutamide)^# Zelboraf (vemurafenib)^# Zolinza (vorinostat)^ # - Quantity Limits for some plans; * = tier 2 generic OTC - Over the Counter P = Preferred drug; N = Non-Preferred Drug UPPERCASE = BRAND; lowercase = generic ^=May require Prior Authorization for some plans PREFERRED - These medications are preferred within their class. NC = Not Covered - Drugs not covered are not eligible for an exception process. NCE = Not Covered, eligible for medical criteria exception This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. Topical Agents
Injectable Agents
Eligard (leuprolide acetate) PREFERRED
Firmagon (degarelix)
Lupron Depot (leuprolide acetate)^
Sylatron (peginterferon alfa-2b)^
Trelstar Depot (triptorelin pamoate)
Trelstar LA (triptorelin pamoate)
Vantas (histrelin acetate)
Xgeva (denosumab)^
Zoladex (goserelin acetate)
PULMONARY
Asthma
Xolair (omalizumab)^
Cystic Fibrosis
Cayston (aztreonam inhaled) Kalydeco (ivacaftor)^# Pulmozyme (dornase alfa inhaled) TOBI (tobramycin inhaled) Pulmonary Hypertension epoprostenol^
Adcirca (tadalafil)^# Flolan (epoprostenol)^ Letairis (ambrisentan)^# Remodulin (treprostinil)^ Revatio (sildenafil)^# Tracleer (bosentan)^# Tyvaso (treprostinil)^ Ventavis (iloprost inhaled)^ Respiratory Enzymes
Aralast (alpha1 proteinase inhibitor)
Glassia (alpha1 proteinase inhibitor)
Prolastin (alpha1 proteinase inhibitor)
Zemaira (alpha1 proteinase inhibitor)
Synagis (palivizumab)^
Preferred Specialty Vendors
VILLAGE FERTILITY PHARMACY
CAREMARK CONNECT
Resource Information for Physicians/Providers
BLUE CROSS & BLUE SHIELD OF RHODE ISLAND
Local (401) 459-1000 • Toll free 1-800-637-3718 PATIENT HEALTH EDUCATION PROGRAMS
PHYSICIAN AND PROVIDER SERVICE
We reserve the right to make changes to this list. Upon availability of generic equivalents, Brand drug coverage status may change without written notice. Please refer to our website @ www.bcbsri.com for the most current information. Questions? Please call the Customer Service number on the back of your ID card. # - Quantity Limits for some plans; * = tier 2 generic OTC - Over the Counter P = Preferred drug; N = Non-Preferred Drug UPPERCASE = BRAND; lowercase = generic ^=May require Prior Authorization for some plans PREFERRED - These medications are preferred within their class. NC = Not Covered - Drugs not covered are not eligible for an exception process. NCE = Not Covered, eligible for medical criteria exception This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage.

Source: http://rwu.ohoacquia.com/sites/default/files/downloads/hr/bcbs_ri_pref_pocket_guide-preferred_drug_list.pdf