Drug List Exclusions for Blue Cross Blue Shield of Michigan and Blue Care Network Custom and Clinical Drug Lists

The drugs shown below aren’t covered on the commercial Blue Cross Blue Shield of Michigan (PPO) and Blue Care Network (HMO) drug lists. In most cases, if you fill a prescription for one of these drugs, you’ll pay the full retail price.

This list contains the class, subclass and suggested preferred alternatives for the excluded drugs. Unless otherwise listed as an alternative, the generic equivalents of the brand-name excluded drugs are also excluded.

If you’re currently using one of the excluded drugs, ask your doctor if one of the following preferred alternatives is right for you. They have similar effectiveness, quality and safety but at a fraction of the cost. Our exclusions criteria are based on current medical information and have been approved by Blue Cross' Pharmacy and Therapeutics Committee. If coverage of a drug is approved as medically necessary, quantity limits may apply.

The following list isn’t comprehensive. If you have a question about a drug that isn’t covered and doesn’t appear on this list, call the Customer Service number on the back of your Blue Cross member ID card.

Preferred alternatives for excluded drugs

The brand names for the preferred alternatives are provided for reference. If available, the generic equivalent will be dispensed when the member fills a prescription. This list is intended as a reference guide and doesn’t dictate coverage. Members should refer to their specific drug benefit information for a full list of covered drugs and requirements. Find the full drug lists and coverage requirements at bcbsm.com/pharmacy.

Drug Class: Anti-infectives Drug Subclass Excluded Drug Preferred Alternatives Gris-PEG®, Grifulvin V®, Lamisil® oral, Tolsura® Sporanox®

Page 1 of 11 Updated 10/1/2021 1 Represents drugs that are considered brand drugs and don’t have generic equivalents. These may be considered “authorized generics” which are the same as the brand drugs but are not true generic drugs.

Go to bcbsm.com for a complete list of covered alternatives. Members Antiretrovirals Crixivan®, Trizivir®, Videx®/EC, Viracept®, Zerit® should discuss treatment options with their doctors. Antivirals Viekira Pak® Epclusa®, Zepatier® Acticlate®, Coremino®, Doryx®, 80mg, hyclate 80mg1 (authorized generic for Doryx®), Minocin®, Monodox®, , ER1 (authorized generic for Ximino®), Vibramycin® Minolira®, Seysara®, Solodyn®, Targadox®, Ximino® : Antineoplastics and immunosuppresants Drug Subclass Excluded Drug Preferred Alternatives Hormonal agents Yonsa®, Zytiga® 500mg Zytiga® 250mg Kinase inhibitors and molecular target Imbruvica® 140mg tablet Imbruvica® 140mg inhibitors Drug Class: Cardiovascular, hypertension, cholesterol Drug Subclass Excluded Drug Preferred Alternatives Beta-blockers and Kapspargo® Sprinkle® Toprol®/XL combinations Inderal XL®, Innopran XL® Inderal®/LA, Inderide® Calcium channel Consensi® Norvasc® plus Celebrex® blockers and Conjupri® Norvasc® combinations Crestor®, Lescol®/XL, Lipitor®, Altoprev®, Ezallor®, FloLipid®, Zypitamag® Mevacor®, Pravachol®, Vytorin®, Zocor® Lipid-lowering agents Niacor® Niaspan® Antara®, Fenoglide®, Lofibra®, Lopid®, Fibricor® Tricor®, Trilipix® Roszet® Crestor® plus Zetia®, Vytorin® Nitrates and Nitro-Dur® (brand only) generic nitroglycerin patch combinations Drug Class: Central nervous system Drug Subclass Excluded Drug Preferred Alternatives A generic SSRI/SNRI (such as Celexa®, Drizalma® Sprinkle® Cymbalta®, Effexor®/XR, Pristiq®, Prozac®, Zoloft®, etc.) Aplenzin®, Forfivo® XL, bupropion XL 450mg tablet1 Wellbutrin®/SR/XL (authorized generic for Forfivo® XL)

Page 2 of 11 Updated 10/1/2021 1 Represents drugs that are considered brand drugs and don’t have generic equivalents. These may be considered “authorized generics” which are the same as the brand drugs but are not true generic drugs.

Antipsychotics Abilify Mycite® Abilify® Adderall XR®*, Aptensio XR®, Concerta®, Focalin®/XR, Metadate CD®*, Methylin®, Ritalin®/LA/SR, CNS Stimulants Adhansia XR®, Cotempla XR-ODT®, Evekeo ODT® Strattera® *can be opened and sprinkled on applesauce Allzital®, Bupap® (butalbital/acetaminophen Esgic®, Fiorinal®, Phrenilin® 300mg), Vanatol LQ, Vanatol S (butalbital/acetaminophen 325mg) Fioricet® w/codeine, Fiorinal® Dvorah® w/codeine Cafergot®, D.H.E. 45®, Imitrex® nasal Migraine therapy Migergot® spray/pen-injector, Maxalt® MLT®, Zomig® ZMT® A generic triptan (such as Amerge®, Axert®, Frova®, Imitrex®, Tosymra® Maxalt®/MLT®, Relpax®, Zomig®/ZMT®, etc.) Miscellanous CNS Firdapse® Ruzurgi® Mestinon® (pyridostigmine bromide Myasthenia gravis pyridostigmine bromide 30mg1 60mg) Butrans®, Duragesic®, Exalgo®, Arymo® ER, Xtampza® ER , MS Contin®, Opana® ER, Ultram® ER, Zohydro ER® Dilaudid®, morphine sulfate immediate-release (MSIR®), Oxaydo® Narcotics Opana®, oxycodone immediate- release, Ultram® Actiq®, Dilaudid®, morphine sulfate immediate-release Lazanda® (MSIR®), Opana®, oxycodone immediate-release, Ultram® Narcotic mixed Conzip®, extended-release biphasic capsule1 Ultram®/ER agonist and (authorized generic for Conzip®) antagonist Qdolo® Ultram® Apadaz®, benzhydrocodone/acetaminophen1 Narcotic and analgesic Norco®, Vicodin®, Vicoprofen® (authorized generic for Apadaz®) combinations Nalocet®, Primlev®, Prolate® Percocet®

Page 3 of 11 Updated 10/1/2021 1 Represents drugs that are considered brand drugs and don’t have generic equivalents. These may be considered “authorized generics” which are the same as the brand drugs but are not true generic drugs.

A generic oral NSAID (such as Anaprox®, Indocin®, Lodine®, Mobic®, Motrin® (Rx only), Naprosyn®, Voltaren®/XR, etc.); Cambia®, ketorolac nasal spray1, (authorized generic

for Sprix®) Sprix® A generic triptan (such as Amerge®, Axert®, Frova®, Imitrex®, Maxalt®/MLT®, Relpax®, Zomig®/ZMT®, etc.) Nonsteroidal anti- Consensi® Norvasc® plus Celebrex® inflammatory drugs Duexis® Motrin® (Rx only) plus Pepcid® (NSAIDs) A generic oral NSAID (such as ® ® Indocin suspension, Naprelan , naproxen sodium Anaprox®, Indocin®, Lodine®, Mobic®, extended-release 750mg tablet1 (authorized generic Motrin® (Rx only), Naprosyn®, for Naprelan®) Voltaren®/XR, etc.) Relafen® (generic 500mg, 750mg Relafen DS® tablet) naproxen (Naprosyn® or Anaprox®) plus a generic proton pump inhibitor Vimovo® (such as Aciphex®, Nexium®, Prilosec®, Prevacid®, Protonix®) Parkinson’s disease Gocovri®, Osmolex ER® Symmetrel® and related disorders Apokyn® Kynmobi® Durlaza® Ecotrin® (generic ) Salicylates Yosprala®, aspirin/ tablet1 (authorized Ecotrin® (generic aspirin) plus generic for Yosprala®) Prilosec® Sedative and Doral®, quazepam1 (authorized generic for Doral®), Ambien®/CR, Lunesta®, Desyrel®, hypnotics Zolpimist® Restoril®, Sonata® chlorzoxazone 250mg, Lorzone® (chlorzoxazone chlorzoxazone 500mg (Parafon Forte 350mg, 750mg) DSC®) Flexeril® (cyclobenzaprine 5mg, Amrix® 7.5mg, 10mg tablet) A generic muscle relaxant (such as Skeletal muscle Soma®, Soma® compound with aspirin, Soma® Norflex®, Parafon Forte DSC®, relaxants compound with codeine Flexeril®, Robaxin®, Zanaflex®, etc.) A generic muscle relaxant (such as Norflex®, Parafon Forte DSC®, Norgesic Forte®, Orphengesic Forte® Flexeril®, Robaxin®, Zanaflex®, etc.) plus Ecotrin® (generic aspirin)

Page 4 of 11 Updated 10/1/2021 1 Represents drugs that are considered brand drugs and don’t have generic equivalents. These may be considered “authorized generics” which are the same as the brand drugs but are not true generic drugs.

Drug Class: Dermatology Drug Subclass Excluded Drug Preferred Alternatives Accutane®, Amnesteem®, Claravis®, Absorica® 25mg, 35mg, Absorica LD® Myorisan®, Zenatane® Acticlate®, Coremino®, Doryx®, 80mg, doxycycline hyclate 80mg1 (authorized generic for Doryx®), Monodox®, Minocin®, tetracycline, minocycline ER1 (authorized generic for Ximino®), Vibramycin® Minolira®, Seysara®, Solodyn®, Targadox®, Ximino® Benzaclin®, Benzamycin®, Differin®, Aczone® 7.5%, Aklief®, Arazlo® Duac®, Epiduo®, Retin-A®, Tazorac® 0.1% medicated swab, solution adapalene (Differin®) cream or Clindagel®, 1% gel1 Cleocin-T® (authorized generic for Clindagel®), Evoclin® treatment Onexton® Benzaclin®, Benzamycin®, Duac® Retin-A Micro® Retin-A® sodium , sodium sulfacetamide/, sodium sulfacetamide/sulfur/urea (such as: Avar LS®, Avar®, Avar-E®, Klaron®, Ovace®, Plexion®, SSS 10-5®, Sulfacleanse 8-4®, Sumadan®, Rosanil® Sumaxin®, Sumaxin TS®) Benzaclin®, Benzamycin®, Cleocin-T® Veltin®, Ziana® plus Retin-A®, Duac® Finacea® gel, Metrocream®, Metrogel®, Metrolotion®, Minocin®, Zilxi® Monodox®, Retin-A®, Tazorac®, tetracycline, Vibramycin® Enbrel®, Humira®, Otezla®, Cosentyx® methotrexate, Skyrizi®, Stelara® 45mg, 90mg, Taltz®, Tremfya® Antipsoriatic and sodium sulfacetamide, sodium sulfacetamide/sulfur, antiseborrheic sodium sulfacetamide/sulfur/urea (such as: Avar LS®, Avar®, Avar-E®, Klaron®, Ovace®, Plexion®, SSS 10-5®, Sulfacleanse 8-4®, Sumadan®, Rosanil® Sumaxin®, Sumaxin TS®) Wynzora® Dovonex® plus Diprosone®; Taclonex® A generic medium potency topical such as: – Cordran® 0.025% cream, Pandel®, Sernivo® Aristocort®, Cutivate®, Diprosone®, medium potency Elocon®, Kenalog®, Locoid®, Valisone®, etc.

Page 5 of 11 Updated 10/1/2021 1 Represents drugs that are considered brand drugs and don’t have generic equivalents. These may be considered “authorized generics” which are the same as the brand drugs but are not true generic drugs.

A generic high potency topical steroid such as: Corticosteroids – high Impoyz® Apexicon®, Cyclocort®, Diprosone®, potency Elocon®, Lidex®, Lidex E®,Topicort®, Valisone®, etc. A generic very-high potency topical steroid such as: Corticosteroids – very Impeklo®, Lexette®, Ultravate® lotion Clobevate®, Clobex®, Diprolene® high potency gel/ointment, Olux®, Olux-E®, Ultravate® cream/ointment, etc. lidocaine 5% ointment and 2% gel® Emla® A generic oral NSAID (such as Mobic®, Motrin® (Rx only), Naprosyn®, Topical anesthetics Dithol, Licart® Voltaren/XR®, etc.), Voltaren® topical gel Ztlido® Lidoderm® Bactroban® ointment, Topical antibacterials Altabax®, Bactroban® cream, Centany® cream/ointment Penlac®, Sporanox®, Lamisil® oral, Topical antifungals Jublia®, Kerydin® Gris-PEG® Topical antineoplastic Carac®, fluorouracil 0.5% cream1 (authorized generic agents and Aldara®, Efudex®, Solaraze®, Tolak® for Carac®) immunomodulators A generic oral antiviral (Famvir®, Topical antivirals Denavir®, Xerese®, Zovirax® cream Valtrex®, Zovirax®); Zovirax® ointment Drug Class: Diagnostic and other miscellaneous Drug Subclass Excluded Drug Preferred Alternatives Chelating agents Cuprimine® Depen® Drug Class: Endocrinology Drug Subclass Excluded Drug Preferred Alternatives dose packs (Dxevo®, Hemady®, Corticosteroids Decadron®, DexPak®, DexPak® Jr. Hidex®, TaperDex®, Zcort®)

Page 6 of 11 Updated 10/1/2021 1 Represents drugs that are considered brand drugs and don’t have generic equivalents. These may be considered “authorized generics” which are the same as the brand drugs but are not true generic drugs.

Admelog®, Apidra®, Apidra® Solostar®, Humulin® (all forms except U-500), Humulin® Mix, Humalog®, Humalog® Mix, insulin aspart1 (all forms; authorized generic for Novolog®), Fiasp® (all forms), Novolin® (NDCs insulin lispro 100mg/mL vial and Kwikpen1 ending in 00, 01, 11, or 15), Novolog® (authorized generic for Humalog®), insulin lispro (NDCs ending in -111, -312, -512, - protamine1 (authorized generic for Humalog® Mix 75- 619, -910) 25), Lyumjev®, ReliOn® Novolin® (NDCs not ending in Insulins 00, 01, 11, or 15), ReliOn® Novolog (NDCs not ending in -111, -312, -512, -619, -910) insulin lispro junior1 (authorized Humalog Jr Kwikpen® (brand) generic for Humalog Jr Kwikpen®, nonpreferred brand copay applies) Lantus® (all forms), Levemir® (all Semglee® forms), Toujeo® (all forms), Tresiba® (all forms) Adlyxin®, Bydureon® (all forms), Byetta® Ozempic®, Trulicity®, Victoza® Glumetza® Glucophage®/XR alogliptin1 (authorized generic for Nesina®), Onglyza®, Januvia®, Tradjenta® Nesina® metformin (Glucophage®/XR) plus a alogliptin/metformin1 (authorized generic for DPP-4 inhibitor (Januvia®,

Kazano®), Kazano®, Kombiglyze® Tradjenta®); Janumet®/XR, Non-insulin Jentadueto®/XR hypoglycemic agents alogliptin/pioglitazone1 (authorized generic for A DPP-4 inhibitor (Januvia®, Oseni®), Oseni® Tradjenta®) plus pioglitazone (Actos®) A DPP-4 inhibitor (Januvia®, Tradjenta®), plus a SGLT-2 inhibitor Steglujan® (Farxiga®, Invokana®, Jardiance®); Glyxambi®, Qtern® Thyroid Thyquidity® Synthroid® Drug Class: Gastrointestinal Drug Subclass Excluded Drug Preferred Alternatives Antidiarrheals and Donnatal®, Phenohytro® Bentyl®, Levbid®, Levsin®, Librax® antispasmodics Antivert® (brand 50mg) Antivert® (generic 12.5mg, 25mg) Antiemetics Zuplenz® Kytril®, Zofran®/ODT Bile acids Reltone® Actigall®, Urso®/Forte® Corticosteroids Ortikos® Entocort EC®, Uceris® tablet

Page 7 of 11 Updated 10/1/2021 1 Represents drugs that are considered brand drugs and don’t have generic equivalents. These may be considered “authorized generics” which are the same as the brand drugs but are not true generic drugs.

lubiprostone capsule1 (authorized generic for Miscellaneous Amitiza®, lactulose solution, Linzess® Amitiza®), Relistor® injection, Trulance® gastrointestinal agents Kristalose® (lactulose packet) lactulose solution Gimoti® Metosolv ODT®, Reglan® over-the-counter PPIs (such as All PPIs (HMO only) Prilosec OTC®, Prevacid OTC®, etc.) Proton Pump esomeprazole strontium 49.3mg1, rabeprazole A generic PPI (such as Aciphex®, Inhibitors (PPIs) sodium capsule 10mg1 (authorized generic for Nexium®, Prilosec®, Prevacid®, Aciphex® Sprinkle®), Zegerid® Protonix®) Robinul®, Robinul Forte® Glycate® (glycopyrrolate 1.5mg) (glycopyrrolate 1mg, 2mg) Ulcer therapy PrevPac®, tetracycline plus Flagyl® Pylera® plus OTC bismuth subsalicylate Drug Class: Immunology and hematology Drug Subclass Excluded Drug Preferred Alternatives Hematopoietic agents Mulpleta® Doptelet® Drug Class: Obstetrics and gynecology Drug Subclass Excluded Drug Preferred Alternatives Annovera® Nuvaring® Contraceptives – Phexxi® OTC spermicides Misc. Twirla® Ortho Evra® Infertility treatment ganirelix acetate (brand only) generic ganirelix acetate, Cetrotide® Cleocin® vaginal cream, Flagyl®, Vaginal anti-infective Solosec® Metrogel®-Vaginal and Brexafemme® Diflucan® Drug Class: Ophthalmology Drug Subclass Excluded Drug Preferred Alternatives Ophthalmic anti- Alrex®, Bepreve®, Elestat®, Opticrom®, Zerviate® allergy agents Optivar®, Pataday®, Patanol® Acular®, Bromday®, Ocufen®, Ophthalmic anti- Bromsite®, Eysuvis® Voltaren® ophthalmic solution, inflammatory agents Xibrom® Drug Class: Otic and nasal preparations Drug Subclass Excluded Drug Preferred Alternatives

Page 8 of 11 Updated 10/1/2021 1 Represents drugs that are considered brand drugs and don’t have generic equivalents. These may be considered “authorized generics” which are the same as the brand drugs but are not true generic drugs.

An over-the-counter nasal steroid (such as Flonase OTC®, Nasacort All nasal (HMO only) Nasal preparations Allergy 24 HR®, Nasonex OTC®, etc.), Astelin®, Patanase® Xhance® Flonase®, Nasolide®, Nasonex® Otic preparations Cetraxal® (single-source brand only) 0.2% dropperette Drug Class: Respiratory, cough and cold Drug Subclass Excluded Drug Preferred Alternatives An over-the-counter non-sedating All non-sedating antihistamines (HMO only) antihistamine (such as Claritin® OTC, Zyrtec® OTC, etc.) ® ® ® Antihistamines Atarax , Benadryl (Rx only), Claritin OTC*, Histex PD®, Tavist® tablet, Ryvent®, Ryclora®, Tavist® syrup Vistaril®, Xyzal®, Zyrtec® OTC* *May be covered with a prescription for some PPO members epinephrine 0.15mg and 0.3mg auto- Epinephrine Auvi-Q® injector, EpiPen®, EpiPen® Jr albuterol sulfate HFA1 Inhaled beta-agonists (authorized generic for Ventolin® HFA), ProAir® ProAir® HFA, Proventil® HFA Digihaler®/Respiclick®, Ventolin® HFA Combination products: Anoro® Ellipta®, Breztri® Aerosphere®, Inhaled beta agonist Stiolto® Respimat®, Trelegy® Ellipta® and anticholinergic Duaklir® Pressair® combinations Single ingredient products: Incruse® Ellipta®, Serevent® Diskus®, Spiriva®/Respimat® Arnuity® Ellipta®, Asmanex®/HFA, Inhaled steroids Alvesco®, ArmonAir® Digihaler® Flovent® HFA/Diskus, Pulmicort® Flexhaler®/solution, Qvar® Redihaler®

Page 9 of 11 Updated 10/1/2021 1 Represents drugs that are considered brand drugs and don’t have generic equivalents. These may be considered “authorized generics” which are the same as the brand drugs but are not true generic drugs.

Combination products: Advair® Diskus®/HFA, Breo® Ellipta®, Breztri® Aerosphere®, Dulera®, fluticasone propionate/ salmeterol1 (authorized generic for AirDuo® Respiclick, nonpreferred brand copay Inhaled steroid and AirDuo® Digihaler/Respiclick, budesonide-formoterol applies), Symbicort®, Trelegy® Ellipta® beta agonist fumarate HFA1 (authorized generic for Symbicort®) combinations Single ingredient products: Arnuity® Ellipta®, Asmanex®/HFA, Flovent® HFA/Diskus, Incruse® Ellipta®, Pulmicort® Flexhaler®/solution, Qvar® Redihaler®, Spiriva®/Respimat®, Serevent® Diskus® Drug Class: Rheumatology and musculoskeletal Drug Subclass Excluded Drug Preferred Alternatives Gout therapy Gloperba® Colcrys® Non-Tumor Necrosis Enbrel®, Humira®, Otezla®, Factor (TNF) blocking Cosentyx® methotrexate, Skyrizi®, Stelara® agents 45mg, 90mg, Taltz®, Tremfya® Osteoporosis and teriparatide injection Forteo®, Tymlos® hormonal treatment Drug Class: Urology Drug Subclass Excluded Drug Preferred Alternatives Urinary Detrol®/LA, Ditropan®/XL, Enablex®, Gemtesa®, Oxytrol® antispasmodics Sanctura®/XR, Vesicare®

Drug Class: Vitamins and supplements Drug Subclass Excluded Drug Preferred Alternatives

Page 10 of 11 Updated 10/1/2021 1 Represents drugs that are considered brand drugs and don’t have generic equivalents. These may be considered “authorized generics” which are the same as the brand drugs but are not true generic drugs.

The following prenatal vitamins are covered:

Generic products: Complete Natal DHA, M-Natal Plus, PNV 29-1, Prenatabs FA, Prenatatabs All prenatal vitamins not listed as a covered Rx, Prenatal Plus, Prenatal vitamin Vitamins and alternative plus low iron, PrePLUS, PreTAB, supplements Trinatal Rx 1

Brand-name products: (nonpreferred brand copay applies): Prenata, Prenatal Plus-DHA, Thrivite Rx cyanocobalamin injection (vitamin B- Nascobal® 12)

Page 11 of 11 Updated 10/1/2021 1 Represents drugs that are considered brand drugs and don’t have generic equivalents. These may be considered “authorized generics” which are the same as the brand drugs but are not true generic drugs.