Value-Based Tier Drugs

Select Blue Shield pharmacy plans have a Value-Based Tier Drug benefit1

Value-Based Tier Drugs are specific preventive drugs taken when risk factors are present for a disease that has not manifested (or is asymptomatic), or to prevent the occurrence of a disease from which an individual has recovered. Value-Based Tier Drugs are select generic and brand-name drugs that are FDA-approved for high blood pressure, high cholesterol, diabetes, and asthma. These drugs are covered at no charge, or at an otherwise reduced member cost share. The following is a list of Value-Based Tier Drugs2 used to treat these select chronic conditions. This list is current as of the date printed below and is subject to change. To access the Blue Shield Plus Formulary, visit blueshieldca.com/pharmacy.

Asthma

ANTI-ASTHMATICS • Incruse Ellipta • Theo-24 • Advair HFA • ipratropium-albuterol • theophylline • albuterol • levalbuterol • theophylline er • Arnuity Ellipta • metaproterenol • Ventolin HFA • Atrovent HFA • montelukast • Wixela • Breo Ellipta • Pulmicort-Flexhaler • zafirlukast • Qvar • budesonide ASTHMA SUPPLIES • Combivent • Serevent diskus • Aerochamber • cromolyn inhaler • Spiriva • OptiChamber • Flovent • Symbicort • fluticasone-salmeterol • terbutaline

Diabetes

ANTI-DIABETIC DRUGS • Humulin vial • Toujeo Solostar • acarbose • insulin lispro 100u/ml vial • tolazamide and pen • Actoplus Met XR • tolbutamide • Janumet • alogliptin • Tresiba • Janumet XR • alogliptin-metformin • Trulicity • Januvia • alogliptin-pioglitazone • Victoza • Jardiance • chlorpropamide • Xigduo XR • Lantus vial and pen • Farxiga • Levemir DIABETIC SUPPLIES • glimepiride • metformin • Accu-chek test strips and lancets • glipizide/glipizide er • metformin er3 • insulin syringes and needles • glipizide-metformin • nateglinide • glyburide • pioglitazone • glyburide micronized • pioglitazone-metformin • glyburide-metformin • repaglinide-metformin • Glyxambi • Rybelsus • Humalog vial and pen • Synjardy/Synjardy XR • HumaPen Luxura blueshieldca.com High blood pressure

ACE INHIBITORS • methyldopa CALCIUM CHANNEL BLOCKERS • benazepril • methyldopa-hctz • Afeditab CR • captopril • metoprolol-hctz • amlodipine • enalapril • minoxidil • Cartia XT • fosinopril • olmesatan-amlodipine-hctz • diltiazem • lisinopril • olmesartan medoxomil • diltiazem er • moexipril • olmesartan-hctz • felodipine er • perindopril • prazosin • isradipine • quinapril • propranolol-hctz • Matzim LA • ramipril • quinapril-hctz • nicardipine • telmisartan • Nifediac CC ANTI-HYPERTENSIVES • telmisartan-amlodipine • Nifedical XL • aliskiren • telmisartan-hctz • nifedipine • amlodipine-atorvastatin • terazosin • nifedipine er • amlodipine besylate- • trandolapril-verapamil er benazepril hcl • nisoldipine • valsartan • amlodipine-olmesartan • Taztia XT • valsartan-hctz • amlodipine-valsartan-hctz • Tiadylt ER • atenolol-chlorthalidone BETA-BLOCKERS • verapamil • verapamil er • benazepril-hctz • acebutolol • bisoprolol-hctz • atenolol DIURETICS • captopril-hctz • betaxolol • amiloride • clonidine • bisoprolol • amiloride-hctz • doxazosin • Bystolic • chlorothiazide A52403 (8/20) • enalapril-hctz • carvedilol • chlorthalidone • eprosartan • carvedilol er • eplerenone • fosinopril-hctz • labetalol • hydrochlorothiazide • guanfacine • metoprolol succinate • indapamide • hydralazine • metoprolol tartrate • methyclothiazide • irbesartan • nadolol • metolazone • irbesartan-hctz • pindolol • spironolactone • lisinopril-hctz • propranolol • spironolactone-hctz • losartan • timolol maleate (oral) • triamterene • losartan-hctz • triamterene-hctz

High cholesterol

DYSLIPIDEMICS • fenofibrate-nanocrystallized • niacin-er • atorvastatin • fenofibric acid • omega-3 acid ethyl esters • cholestyramine • fenofibric acid (choline) • pravastatin • colesevelam • fluvastatin • prevalite • colestipol • fluvastatin-er • rosuvastatin • ezetimibe • gemfibrozil • simvastatin • fenofibrate • lovastatin

Updated: August 2020.

1 Refer to your Evidence of Coverage or Certificate of Insurance to determine if you have a Value-Based Tier Drug benefit. Blue Shield of California is an independent member of the Blue Shield Association 2 Generic drugs begin with lowercase letters and brand-name drugs begin with capital letters. In addition, this list does not include all the drugs that are included in your outpatient prescription drug benefit. Some strengths or dosage forms may not be covered. Combination products of drugs on this list may also be included. 3 Generic Glucophage XR only. blueshieldca.com