Preferred Drug List - 2016 List subject to change prior to Jan. 1, 2016 Allergy/Cough & Cold azelastine codeine/guaifenesin fluticasone benzonatate cyproheptadine hydroxyzine brompheniramine/pseudoephedrine desloratadine levocetirizine budesonide Astepro Auvi-Q QL flunisolide EpiPen QL EpiPen Jr. QL Grastek PA Oralair PA SPRx Ragwitek PA Anti-Infectives Antibiotics/Antifungal/Antiviral amoxicillin clindamycin cream nystatin amoxicillin/potassium clavulanate doxycycline penicillin VK ampicillin erythromycin ribavirin PA SPRx azithromycin famciclovir sulfamethoxazole/trimethoprim cefdinir fluconazole terconazole cefuroxime ketoconazole tetracycline cephalexin levofloxacin valacyclovir ciprofloxacin tabs metronidazole valganciclovir clarithromycin minocycline immediate-release Zovirax ointment clarithromycin ext-rel clindamycin moxifloxacin nitrofurantoin macrocrystals Cleocin Ovules Pegasys PA SPRx Xifaxin 550mg Clindesse Sovaldi PA SPRx Zovirax cream Harvoni PA SPRx Tobi Podhaler QL SPRx Avelox Noxafil Nuvessa Antineoplastics and Immunosuppressants anastrozole exemestane mycophenolate mofetil azathioprine letrozole sirolimus bicalutamide mercaptopurine tacrolimus cyclosporine methotrexate tamoxifen Alkeran Leukeran
Cyclophosphamide Antivirals HIV/AIDS Purixan didanosine nevirapine zidovudine lamivudine/zidovudine stavudine Atripla SPRx Norvir Trizivir Complera SPRx Prezcobix SPRx Truvada Crixivan Prezista Tybost Edurant Rescriptor Viracept Emtriva Reyataz Viramune XR Epzicom Selzentry Viread Evotaz SPRx Stribild SPRx Vitekta SPRx Isentress Sustiva Ziagen Kaletra Lexiva Asthma/COPD Tivicay SPRx Triumeq SPRx albuterol nebulizer soln levabuterol nebulizer soln zafirlukast budesonide nebulizer susp ipratropium montelukast theophylline Adcirca PA Brovana Proair Respiclick Advair Diskus Combivent Respimat QVAR Advair HFA Daliresp Serevent Diskus Anoro Ellipta Dulera Spiriva Arnuity Ellipta Flovent HFA Symbicort Asmanex Foradil Tudorza Pressair Asmanex HFA Breo Ellipta Perforomist ProAir HFA Aerospan Proventil HFA ST Ventolin HFA ST Arcapta Neohaler Pulmicort Flexhaler Xopenex HFA ST Atrovent HFA Cardiovascular Drugs Coagulation Therapy Striverdi Respimat clopidogrel enoxaparin QL Jantoven dipyridamole fondaparinux QL warfarin Brilinta Eliquis Xarelto Effient Pradaxa Advate SPRx Bebulin SPRx Koate-DVI SPRx Advate H SPRx BeneFIX SPRx Kogenate FS SPRx Advate L SPRx Corifact SPRx Monoclate-P SPRx
Advate M SPRx Fragmin QL Profilnine SPRx Advate UH SPRx Helixate FS SPRx Recombinate SPRx Alphanate SPRx Hemofil-P SPRx Tretten SPRx Alphanate SD SPRx Humate-P SPRx Wilate SPRx Cardiovascular Drugs High Blood Pressure amlodipine enalapril metoprolol amlodipine/benazepril enalapril/hctz metoprolol ext-rel amlodipine/valsartan eplerenone nifedipine ext-rel amlodipine/valsartan/hctz eprosartan propranolol atenolol fosinopril quinapril benazepril fosinopril/hctz quinapril/hctz benazepril/hctz furosemide ramipril bisoprolol guanfacine spironolactone bisoprolol/hctz hydrochlorothiazide telmisartan bumetanide indapamide telmisartan/amlodipine candesartan/hctz irbesartan telmisartan/hctz captopril irbesartan/hctz triamterene/hctz captopril/hctz lisinopril valsartan carvedilol lisinopril/hctz valsartan/hctz clonidine losartan verapamil ext-rel diltiazem ext-rel losartan/hctz Azor Benicar HCT Coreg CR Benicar Bystolic Tribenzor Atacand Edarbyclor ST Teveten HCT ST Diovan Micardis Twynsta Diovan HCT Edarbi ST Cardiovascular Drugs High Cholesterol Micardis HCT Teveten ST atorvastatin fluvastatin pravastatin cholestyramine gemfibrozil simvastatin fenofibrate fenofibric acid lovastatin niacin ext-rel Crestor Simcor Zetia Liptruzet Vytorin Altoprev Livalo Trilipix Lescol XL Niaspan Welchol Cardiovascular Drugs Other amiodarone propafenone sotalol digoxin quinidine
Corlanor Central Nervous System Anxiety/Depression alprazolam diazepam paroxetine bupropion duloxetine paroxetine ext-rel bupropion ext-rel escitalopram sertraline chlordiazepoxide fluoxetine venlafaxine citalopram lorazepam venlafaxine ext-rel clorazepate Pristiq ER mirtazapine Cymbalta Central Nervous System Attention Deficit Disorder Adderall XR dextroamphetamine ext-rel methylphenidate clonidine ext-rel guanfacine ext-rel Quillivant XR Strattera Vyvanse Daytrana Focalin XR Intuniv Central Nervous System Migraine almotriptan QL naratriptan QL sumatriptan QL butalbital compound rizatriptan QL zolmitriptan QL Relpax QL Sumavel Dosepro QL Central Nervous System Seizure Disorders carbamazepine gabapentin phenytoin clonazepam lamotrigine primidone divalproex levetiracetam topiramate divalproex ext-rel oxcarbazepine valproic acid felbamate phenobarbital zonisamide Dilantin Qudexy XR Vimpat Oxtellar XR Trokendi XR Aptiom Onfi Potiga Fycompa Central Nervous System Sleep Agents eszopiclone zolpidem zolpidem ext-rel
zaleplon Rozerem Central Nervous System Other amantadine gabapentin pramipexole aripiprazole PA galantamine quetiapine PA benztropine Glatopa SPRx risperidone PA carbidopa/levodopa memantine rivastigmine carbidopa/levodopa/entacapone modafinil PA ropinirole clozapine PA olanzapine PA ziprasidone PA donepezil olanzapine/fluoxetine PA Ampyra PA SPRx Latuda PA Savella Avonex SPRx Lyrica Seroquel XR PA Copaxone SPRx Namenda XR Tecfidera PA SPRx Exelon Patch Gilenya PA SPRx Nuvigil PA Rebif SPRx Abilify PA Fanapt PA Namzaric Aubagio PA SPRx Fazaclo PA Nuedexta Betaseron ST SPRx Geodon PA Plegridy SPRx Extavia SPRx Invega PA Saphris PA Dermatology adapalene desoximetasone mometasone Amnesteem econazole mupirocin betamethasone erythromycin topical nystatin Claravis fluocinonide nystatin/triamcinolone clindamycin/benzoyl peroxide fluticasone Retin-A Micro PA clindamycin topical hydrocortisone 2.5% silver sulfadiazine clobetasol ketoconazole tacrolimus clotrimazole/betamethasone lindane triamcinolone desonide Acanya Atralin metronidazole topical Elidel Epiduo Carac Differin Picato Dermasorb HC Fabior PA Tazorac PA Dermasorb TA Finacea Zyclara Diabetes Blood Glucose Monitoring Bayer Contour/Breeze2 products QL Abbott Freestyle products QL ST Lifescan OneTouch products QL Roche Accu-Chek products QL ST
Diabetes Diabetic Drugs glimepiride glyburide/metformin pioglitazone glipizide metformin pioglitazone/glimepiride glipizide ext-rel metformin ext-rel pioglitazone/metformin glyburide nateglinide repaglinide Bydureon Invokamet Jentadueto Byetta Invokana Tradjenta Farxiga Janumet Victoza Glucagon emergency kit Janumet XR V-Go Glyxambi Januvia Xigduo XR Diabetes Insulin BD syringes Novolin Toujeo Lantus vials/pens Levemir vials/pens Novolog Novolog Mix Afrezza Humalog ST Humulin Kwikpen ST Apidra ST Eye/Ear Humulin ST bimatoprost 0.03% gentamicin ophthalmic polymyxin B/bacitracin/neomycin ophth brimonidine ketotifen polymyxin B/neomycin/hydrocortisone otic bromfenac latanoprost polymyxin B/trimethoprim ophthalmic carteolol solution naphazoline timolol maleate ciprofloxacin otic ofloxacin tobramycin ophthalmic diclofenac sodium ophthalmic olopatadine travoprost Alrex Lumigan Tobradex Ointment Azopt Moxeza TobraDex ST Bepreve Pataday Travatan Z Betimol Patanol Vigamox Ciprodex Pazeo Zylet Durezol Lotemax Rescula ST Simbrinza Gastrointestinal Agents Prolensa Restasis Xalatan ST Zioptan ST cimetidine lansoprazole ondansetron diphenoxylate/atropine metoclopramide pantoprazole famotidine Nexium promethazine granisetron nizatidine ranitidine lactulose omeprazole sulfasalazine
Amitiza Creon Prepopik Analpram Advanced Kristalose Suclear Analpram HC Lialda Suprep Apriso Linzess Uceris Canasa Pentasa Zenpep Anzemet Emend Fulyzaq Gout Therapy allopurinol Colcrys Hormone Replacement probenecid Uloric estradiol estropipate progesterone estradiol transdermal medroxyprogesterone Androgel PA Enjuvia Premphase Cenestin Evamist Prempro Divigel Premarin Vagifem Androderm PA Combipatch Estrace Climara Pro Duavee Vivelle-Dot Miscellaneous Drugs OB/GYN Osphena Oral Contraceptives Monophasic all generic monophasic Junel Microgestin Apri Junel Fe Microgestin Fe Aviane Levora Necon 1/35, 1/50 Gianvi Low-Ogestrel Ocella Minastrin 24 FE Beyaz Oral Contraceptives Biphasic all generic biphasic Oral Contraceptives Triphasic Kariva all generic triphasic Tilia FE Trinessa Enpresse Tri-Legest FE Trivora Necon 7/7/7 norgestimate/ethinyl estradiol Tri-Previfem Tri-Sprintec
Lo Loestrin FE Ortho Tri-Cyclen Lo Oral Contraceptives Other all generic extended-cycle Camila Jolivette all generic progestin Camrese Lo Xulane Amethia Lo NuvaRing Osteoporosis/Bone Diseases Errin alendronate calcitonin-salmon raloxifene alendronate plus OTC Vitamin D ibandronate risedronate Forteo SPRx Actonel Rheumatology Atelvia celecoxib indomethacin nabumetone diclofenac ketoprofen naproxen diclofenac/misoprostol leflunomide naproxen sodium etodolac meloxicam piroxicam ibuprofen methotrexate sulindac Actemra SQ PA ST SPRx Humira PA SPRx Xeljanz PA ST SPRx Enbrel PA SPRx Thyroid Medications levothyroxine Armour Thyroid Urologic Disorders Orencia SQ PA ST SPRx Synthroid alfuzosin oxybutynin ext-rel tolterodine doxazosin prazosin trospium finasteride oxybutynin Enablex Gelnique Avodart Detrol LA tamsulosin terazosin Myrbetriq Vesicare Jalyn Rapaflo
Vitamins (prescription only) all generics Legend PA This drug requires prior authorization ST Requires other selected drugs to be tried first QL This drug has quantity limits on amount covered SPRx Specialty drug; many plans require you to get this type of drug from a Specialty Pharmacy This list is not all-inclusive and does not guarantee coverage. Please refer to your EOC or member handbook for specific terms, conditions, limitations, and exclusions relative to your drug coverage. This list is subject to change throughout the year. Please call Member Service at the phone number listed on your BlueCross BlueShield of Tennessee member ID card or visit our website at bcbst.com for the most up-to-date information.
Tagalog: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-565-9140 Chinese: 1-800-565-9140 Navajo: Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-565-9140 BlueCross does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN 37402 bcbst.com BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association 15PHM2322 (8/15) Preferred Drug List Flier