FlexRx Standard Prior Authorization, Quantity Limit, and Step Therapy Drug List How to use this drug list This drug list includes drugs that have a prior authorization (PA) requirement, a quantity limitation (QL), or a step therapy (ST) requirement. For additional information about the various drug programs, you can refer to Bluecrossmn.com. This information is subject to change. Generic drugs are listed in lowercase boldface (e.g., rabeprazole) Brand name drugs are capitalized (e.g., ACIPHEX) Acronyms PA = Prior Authorization, QL = Quantity Limit per 30 days, ST = Step Therapy Program *Unless otherwise noted, prior authorization program and quantity limits applies to both brand and generic. These programs and quantity limitations may not apply. Check your certificate or other plan information for benefit details. BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± ABILIFY MAINTENA QL 1 vial/4 weeks ABILIFY tabs (aripiprazole) QL ST* 30 tabs ABSTRAL PA QL 120 tabs ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE QL 300 caps or tabs acetaminophen/codeine solution, 120-12 mg/5 mL QL 2700 mL ACIPHEX (rabeprazole) 20 mg tab QL ST* 30 tabs ACIPHEX sprinkle QL ST 30 caps ACTEMRA QL ST 4 syringes/28 days ACTICLATE (doxycycline hyclate) PA ACTIQ (fentanyl citrate lozenge on a handle) PA QL 120 lozenges ACTONEL (risedronate) 150 mg QL 1 tab ACTONEL (risedronate) 35 mg QL 4 tabs/28 days ACTONEL (risedronate) 5 mg, 30 mg QL 30 tabs ADCIRCA PA** QL 60 tabs ADDERALL (amphetamine/dextroamphetamine) 20 mg QL 90 tabs ADDERALL (amphetamine/dextroamphetamine) 5 mg, 7.5 mg, 10 mg, 12.5 mg, QL 60 tabs 15 mg, 30 mg ADDERALL XR (amphetamine/dextroamphetamine ext-release) QL 30 caps ADDYI PA QL 30 tabs ADEMPAS PA QL 90 tabs ADIPEX-P (phentermine) PA QL 30 caps or tabs ADLYXIN ST ADOXA (doxycycline monohydrate) PA ADVAIR DISKUS QL 1 canister ADVAIR HFA QL 1 canister ADZENYS XR-ODT 3.1 mg, 6.3 mg QL 60 tabs ADZENYS XR-ODT 9.4 mg, 12.5 mg, 15.7 mg, 18.8 mg QL 30 tabs AEROSPAN QL 2 canisters AFINITOR PA QL 30 tabs AFINITOR DISPERZ 2 mg, 5 mg PA QL 60 tabs AFINITOR DISPERZ 3 mg PA QL 90 tabs AFREZZA 12 units/cartridge PA QL 900 cartridges AFREZZA 4 units/cartridge PA QL 2,520 cartridges AFREZZA 4 units/cartridge & 8 units/cartridge PA QL 1,890 cartridges AFREZZA 8 units/cartridge PA QL 1,260 cartridges AFREZZA 8 units/cartridge & 12 units/cartridge PA QL 1,260 cartridges AFREZZA TITRATION PACK: 4 units/cartridge & 8 units/cartridge PA QL 1,800 cartridges AFREZZA TITRATION PACK: 4 units/cartridge, 8 units/cartridge & 12 units/cartridge PA QL 7 boxes (10,080 units) AIRDUO RESPICLICK QL 1 inhaler AKYNZEO QL 2 caps External genital and perianal warts or ALDARA (imiquimod 5% cream) PA QL actinic keratosis: 12 packets/month for up to 4 months Superficial basal cell carcinoma: 24 ALDARA (imiquimod 5% cream) PA QL packets/month for up to 2 months ALECENSA PA QL 240 caps alendronate 35 mg, 70 mg QL 4 tabs ALENDRONATE 40 mg QL 30 tabs alendronate 5 mg, 10 mg QL 30 tabs ALENDRONATE solution QL 300 mL/28 days BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± ALLZITAL QL 360 tabs ALOGLIPTIN QL 30 tabs ALOGLIPTIN/METFORMIN QL 60 tabs ALOGLIPTIN/PIOGLITAZONE QL 30 tabs ALTOPREV QL ST 30 tabs ALUNBRIG PA QL 180 tabs ALVESCO 160 mcg QL 2 canisters ALVESCO 80 mcg QL 1 canister AMBIEN (zolpidem) QL ST* 30 tabs AMBIEN CR (zolpidem ext-release) QL ST* 30 tabs AMERGE (naratriptan) QL 18 tabs AMITIZA PA AMPYRA PA ANDRODERM 2 mg/day, 4 mg/day PA QL 30 patches ANDROGEL (testosterone) 1% GEL packet PA QL 60 packets ANDROGEL 1.62% GEL pump PA QL 300 g ANDROGEL 1.62% GEL, 20.25 mg/1.25 g packet PA QL 30 packets ANDROGEL 1.62% GEL, 40.5 mg/2.5 g packet PA QL 60 packets ANORO ELLIPTA QL 60 blisters ANTARA 30 mg QL 60 caps ANTARA 90 mg QL 30 caps ANZEMET QL 7 tabs APIDRA QL 100 mL APLENZIN QL ST 30 tabs APTENSIO XR QL 30 caps APTIVUS caps QL 120 caps APTIVUS oral solution QL 380 mL ARANESP PA ARCAPTA NEOHALER QL 30 caps ARICEPT (donepezil) QL 30 tabs aripiprazole ODT QL 60 tabs aripiprazole solution QL 25 mL ARISTADA QL ST 1 syringe/56 days ARIXTRA (fondaparinux) QL 30 syringes/90 days ARNUITY ELLIPTA QL 30 blisters ARYMO ER QL 90 tabs Ascomp/codeine 50-325-40-30 mg QL 180 caps ASMANEX HFA QL 1 inhaler ASMANEX TWISTHALER 30, 60, 120 metered doses QL 1 canister ASPIRIN/CAFFEINE/DIHYDROCODEINE caps QL 360 caps ASTEPRO (azelastine 0.15%) QL 2 bottles ATACAND (candesartan) 32 mg QL ST* 30 tabs ATACAND (candesartan) 4 mg, 8 mg, 16 mg QL ST* 60 tabs ATACAND HCT (candesartan/hydrochlorothiazide) QL ST* 30 tabs ATELVIA (risedronate delayed-release) QL 4 tabs/28 days ATRIPLA QL 30 tabs ATROVENT HFA QL 2 canisters AUBAGIO QL 30 tabs AUSTEDO 6 mg PA QL 60 tabs AUSTEDO 9 mg, 12 mg PA QL 120 tabs AVALIDE (irbesartan/hydrochlorothiazide) QL ST* 30 tabs AVAPRO (irbesartan) QL ST* 30 tabs AVIDOXY DK PA AVODART (dutasteride) QL 30 caps AVONEX 30 mcg vial QL 4 vials or one kit of 4 vials/28 days AVONEX 30 mcg/0.5 mL auto-injector pen QL One kit of 4 pens/28 days AVONEX 30 mcg/0.5 mL prefilled syringe QL One kit of 4 syringes/28 days AXERT (almotriptan) QL 12 tabs AXIRON (testosterone) transdermal solution, 30 mg/act PA QL 3600 mg azelastine 0.1% QL 2 bottles AZENASE QL 1 inhaler AZOR (amlodipine/olmesartan) QL ST* 30 tabs BASAGLAR KWIKPEN QL 100 mL BECONASE AQ QL 2 bottles BELBUCA QL 60 films BELSOMRA QL ST 30 tabs BELVIQ PA QL 60 tabs BELVIQ XR PA QL 60 tabs BENICAR (olmesartan) 20 mg, 40 mg QL ST* 30 tabs © Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 2 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± BENICAR (olmesartan) 5 mg QL ST* 60 tabs BENICAR HCT (olmesartan/hydrochlorothiazide) QL ST* 30 tabs benzphetamine PA QL 90 tabs BERINERT PA QL 10 vials (5,000 IU) BETASERON QL 14 vial/syringe units (1 box)/28 days BEVESPI AEROSPHERE QL 1 inhaler (10.7 gm) BIMATOPROST QL 2.5 mL BINOSTO QL 4 tabs/28 days BIO-T-GEL PA QL 60 packets BONIVA (ibandronate) tabs QL 1 blister pack BOSULIF 100 mg PA QL 120 tabs BOSULIF 500 mg PA QL 30 tabs BREO ELLIPTA QL 1 package (60 blisters) BRIVIACT ST budesonide nasal susp QL 2 bottles BUNAVAIL 2.1-0.3 mg QL 90 films BUNAVAIL 4.2-0.7 mg, 6.3-1 mg QL 60 films Bupap 50-300 mg QL 180 tabs BUPHENYL (sodium phenylbutyrate) PA buprenorphine QL 15 tabs/90 days BUPRENORPHINE transdermal patch weekly QL 4 patch/28 days buprenorphine/naloxone QL 90 tabs bupropion 100 mg QL 120 tabs bupropion 75 mg tab QL 60 tabs butalbital/acetaminophen 50-300 mg, 50-325 mg QL 180 tabs butalbital/acetaminophen/caffeine 50-325-40 mg QL 180 tabs/caps butalbital/acetaminophen/caffeine/codeine 50-325-40-30 mg QL 180 caps butorphanol 10 mg/mL nasal spray QL 87.5 mL butorphanol nasal spray QL 3 x 2.5 mL BUTRANS QL 4 patch/28 days BYDUREON ST BYETTA ST BYVALSON QL ST 30 tabs CABOMETYX PA QL 30 tabs Capacet QL 180 caps CAPRELSA 100 mg PA QL 60 tabs CAPRELSA 300 mg PA QL 30 tabs CARAC PA QL one 30 g tube/month for up to 4 weeks CARDURA (doxazosin) 1 mg, 2 mg, 4 mg QL 30 tabs CARDURA (doxazosin) 8 mg QL 60 tabs CARDURA XL QL 30 tabs CATENA PA CELEXA (citalopram) QL ST* 30 tabs CERDELGA PA QL 60 caps CESAMET QL 42 caps CIALIS 10 mg, 20 mg QL 6 tabs CIALIS 2.5 mg, 5 mg QL 30 tabs CIMZIA 2x200 mg vial, kit QL ST 2 vials (1 kit)/28 days CIMZIA 2x200 mg/mL syringe, kit QL ST 2 syringes (1 kit)/28 days CIMZIA 6x200 mg/mL syringe starter kit QL ST 1 kit/180 days CINRYZE PA QL 20 vials (10,000 IU) citalopram solution QL 600 mL clozapine 200 mg QL 120 tabs clozapine 50 mg QL 90 tabs CLOZAPINE ODT 12.5 mg QL ST 90 tabs CLOZAPINE ODT 150 mg QL ST 180 tabs CLOZAPINE ODT 200 mg QL ST 120 tabs CLOZARIL (clozapine) 25 mg QL ST* 90 tabs CLOZARIL (clozapine) 100 mg QL ST* 270 tabs CODEINE SULFATE (codeine sulfate) 15 mg, 30 mg, 60 mg QL 180 tabs COMBIVENT RESPIMAT QL 2 canisters COMBIVIR (lamivudine/zidovudine) QL 60 tabs COMETRIQ PA QL 1 carton/28 days COMMIT (nicotine) QL 680 lozenges COMPLERA QL 30 tabs CONCERTA (methylphenidate ext-release OSM) 18 mg, 27 mg, 54 mg QL 30 tabs CONCERTA (methylphenidate ext-release OSM) 36 mg QL 60 tabs CONTRAVE PA QL 120 tabs CONZIP QL 30 caps COPAXONE (glatiramer) 20 mg/mL syringe QL 1 box of 30 syringes © Prime Therapeutics LLC Information in this document is proprietary and confidential. 2016 Page 3 of 18 BRAND NAME (generic name - if available) Requirement Quantity Limits per 30 days± COPAXONE 40 mg/mL syringe QL 12 mLs/28 days CORLANOR PA QL 60 tabs COSENTYX 150 mg/mL pre-filled syringe QL ST 1 syringe/28 days COSENTYX SENSOREADY PEN 150 mg/mL auto-injector QL ST 1 injector/28 days COTELLIC PA QL 63 tabs/28 days COZAAR (losartan) 100 mg tabs QL ST* 30 tabs COZAAR (losartan) 25 mg, 50 mg QL ST* 60 tabs CRESTOR (rosuvastatin) 40 mg QL ST* 30 tabs CRESTOR (rosuvastatin) 5 mg, 10 mg, 20 mg QL ST* 45 tabs CRIXIVAN 200 mg QL 270 caps CRIXIVAN 400 mg QL 180 caps CYMBALTA (duloxetine) QL ST* 60 caps DAKLINZA PA DAYTRANA QL 30 patches DEMEROL (meperidine) 100 mg QL 240 tabs DESCOVY QL 30 tabs DESOXYN (methamphetamine) QL 150 tabs DESVENLAFAXINE FUMARATE EXT-RELEASE 24 hr QL ST 30 tabs DETROL (tolterodine) QL 60 tabs DETROL LA (tolterodine ext-release) QL 30 caps DEXEDRINE SPANSULES (dextroamphetamine ext-release) 10 mg, 15 mg QL 120 caps DEXEDRINE SPANSULES (dextroamphetamine ext-release) 5 mg QL 90 caps DEXILANT QL ST 30 caps dextroamphetamine 10 mg QL 180 tabs dextroamphetamine 5 mg QL 90 tabs diclofenac sodium 1.5% solution QL ST¥ 2 bottles (300 mL) DIETHYLPROPION PA QL 90 tabs diethylpropion PA QL 90 tabs diethylpropion ext-release PA QL 30 tabs