docRevised 8/12/16 Level 4 Medication List The medications listed
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Revised 8/12/16 Level 4 Medication List The medications listed
Revised 10/3/16 Level 4 Medication List The medications listed below have the highest copayment level Abilify Discmelt Abilify Oral solution Abilify Tablets Absorica Abstral Aciphex Aciphex Sprinkle Acticlate Actiq Actonel 5mg, 30mg, 35mg Adoxa Adoxa Pak Adempas Adrenaclick Afrezza Akynzeo Alocril Alomide Alphagan P 0.15% Alrex Alsuma Ambien Ambien CR Amlodipine-Atorvastatin Amnesteem Androderm Androgel Androderm Aplenzin Aptensio XR Aptiom Amrix Arestin Aripiprazole ODT Armodafinil Atelvia Ativan Atralin Auvi-Q Avar LS Cleanser Avar-E LS Cream Avinza Axiron Bactroban Cream Baraclude tablets Belbuca Belsomra Benzaclin Gel 1-5% Benzefoamultra Bepreve Betapace AF Betimol Biaxin XL Binosto Brisdelle Briviact Butrans Caduet Calcitriol ointment Cambia Carbaglu Cardura XL Carisoprodol 250mg Celexa Cerdelga Ciprofloxacin ER/SR Claravis Clarinex Clarinex D Clarinex ODT Cleocin-T Solution 1% Cleocin-T Gel 1% Cleocin-T Lotion 1% Cleocin-T Swab 1% Clindamax Gel 1% Clindamycin PhosphateTretinoin Gel 1.2-0.025% Clonidine ER Clozapine ODT Concerta Conzip Cordran cream Cordran lotion Cordran ointment Coreg CR Cyclogyl 0.5% Daraprim Daytrana Desloratadine 5mg tab Desloratadine ODT Detrol Detrol LA Dexmethylphenidate ER/SR Diabeta Differin cream Differin gel Differin lotion Dificid Diflorasone ointment Diovan Diovan HCT Ditropan XL Doryx Doryx MPC Doxycycline (Rosacea) cap Doxycycline Hyclate DR tablet Doxycycline Monohydrate 150mg capsule Drospirenone-Ethinyl-Estradiol Duac gel Duavee Duexis Dulera Duragesic Disc DuoNeb Dymista Nasal Spray Elimite Edluar Elestat Emadine Enablex Envarsus XR Epinephrine Pen Equetro Erygel Esbriet Esomeprazole strontium Eszopiclone Eurax cream Eurax lotion Evoclin Exalgo Exforge Exforge HCT Extina Fanapt Fazaclo Fentanyl lollipop Fentora Ferriprox Flector patch 1 Revised 10/3/16 Level 4 Medication List The medications listed below have the highest copayment level Fluoxteine capsules (PMDD) Fluoxetine 60mg Tab Fluoxetine 90mg DR Flurandrenolide Cream Focalin XR Fortamet Fortesta Fosamax Plus D Gelnique Generess FE Gianvi Glucophage XR Glumetza Glyxambi Gralise Gralise Starter Kit Grastek Guanfacine ER/SR HC Butyrate cream Hemangeol Hetlioz Horizant Hydroc/APAP sol 10-325mg Hydroc/IBU 2.5-200mg Hydroc/IBU 5-200mg Hydroc/IBU 10-200mg Hydromorphone HCL ER Hysingla ER Ibudone Imitrex cartridge Imitrex syringe Intermezzo Intuniv Invega Istalol Jadenu Jublia Kadian Kalydeco Tab Kalydeco Pak Kapvay Karbinal ER Keppra Keppra XR Kerafoam Kerydin Keveyis Klaron Kuvan Lansoprazole/Amox/Clarithr Latuda Lastacaft Letairis Levocetirizine dihydrochlor Lexapro Linezolid Lipitor Liptruzet Locoid Lipocream Lortab Loryna Lotemax Lovaza Lunesta Luzu cream Magnacet Metformin HCL SR Metrocream 0.75% Metrogel 1% Metrolotion 0.75% Minocycline ER/SR Mometasone Furoate Morphine sulfate ER/SR beads Morphine sulfate ER/SR capsules Myfortic Myorisan Naprelan Nasonex Natazia Natesto Natroba Neuac gel Nexium Nexium granules Nikki Niravam Neurontin Non-Lifescan Glucose Test Strips Non-Lifescan Glucose Test Disks Northera Nucynta Nucynta ER Nuedexta Nuvigil Ofev Oleptro Olopatadine NS Olysio Omeprazole/Bicarbonate Omeprazole-Sodium Bicarbonate Powd Pack Omnaris Onfi Opana ER Opsumit Optivar Oracea Oralair Orenitram Otezla Otrexup Ovide Oxaydo Oxistat Oxtellar XR Oxycontin Oxycodone HCL ER Oxymorphone ER/SR Oxytrol Paliperidone ER/SR Pataday Patanase Patanol Paxil Paxil CR Paroxetine SR/ER Pazeo Percocet Pexeva Plavix Plexion Cream 9.8-4.8% Plexion Lotion 9.8-4.8% Plexion Cleanser 9.8-4.8% Prandimet Prestalia Prevacid Prevacid Solu-tab PrevPac 2 Revised 10/3/16 Level 4 Medication List The medications listed below have the highest copayment level Prilosec ProAir HFA ProAir Respiclick Prolensa Protonix Protonix Pak Proventil HFA Prozac Prozac Weekly Pylera Qnasl Qnasl Childrens Qudexy XR Radiogardase Ragwitek Ravicti Rasuvo Rayos Relenza Reprexain Retin-A cream Retin-A gel Retin-A Micro Rexulti Rilutek Risperdal M-ODT Risperidone M-ODT Rosula Rybix ODT Safryl Sanctura Sanctura XR Saphris Silenor Sitavig Sivextro Sklice Sod sul/sulf cream 9.8-4.8% Solodyn Soma Sonata Soolantra Sorilux Spinosad Spirtam Sprix Striant Stromectol Subsys Sulfacetamide sodium sulfur cleansing pad 10-4% Sumadan Wash Sumatriptan cartridge Sumatriptan syringe Sumavel Sumaxin Sumaxin TS Symbicort Synera Topical Patch Synjardy Tamiflu Tecfidera Technivie Temodar Testosterone gel 1%, 2% Testosterone gel pump 1% Timoptic Timoptic Ocudose Timoptic-XE Tizanidine capsules Tolterodine capsules ER/SR Toviaz Tracleer Tramadol Biphasic Cap ER/SR Tramadol Biphasic Tab ER/SR Tretin-X Treximet Trokendi XR Trospium Chloride ER/SR Tussicaps Tuzistra XR Ulesfia Ultram ER Uptravi Vanatol LQ Valium Varubi Vascepa Vectical Veltassa Veltin Veramyst Vestura Viberzi Vicodin Vicoprofen Viekira Pak Viekira XR Viibryd Vimovo Vivlodex Vogelxo Vusion Wellbutrin XL Xanax Xanax XR Xartemis XR Xeljanz Xeljanz XR Xifaxan Xtampza ER Xyrem Xyzal Zamicet Zanaflex capsules Zavesca Zegerid Zembrace Symtouch Zemplar Zenatane Zepatier Ziagen tablets Ziana Zipsor Zithranol shampoo Zocor Zofran Zofran ODT Zofran oral solution Zohydro ER Zoloft Zolpidem Tartrate SL Zolpimist Zorvolex Zutripro Zyprexa Zyvox 3 Multi-language Interpreter Services Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call (602) 864-4884 for Spanish and (877)475-4799 for all other languages and other aids and services. If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: S!Z’s ivil Rights oordinator, !ttn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ 85002-3466, (602) 8642288, TTY/TDD (602) 864-4823, crc@azblue.com. You can file a grievance in person or by mail or email. If you need help filing a grievance S!Z’s ivil Rights oordinator is available to help you; You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1–800–368–1019, 800–537–7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
