July 2021 A Iii\ Arkansas +• BlueAdvantage T. ~ BlueCross BlueShield • 9. Administrators of Arkansas MhlependentlicenseeoiftheBlueCroaandBlueSl'.idAsaocialion Nl~~tt1.-.11... a..N-..»..~ Arkansas Blue Cross and Blue Shield Standard with Step Drug List The Arkansas Blue Cross and Blue Shield Standard with Step Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN MEMBER HEALTH CARE PROVIDER Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered by Arkansas Blue Cross and Blue Shield. Ask your administered by Arkansas Blue Cross and Blue Shield. As a way to doctor to consider prescribing, when medically appropriate, a help manage health care costs, authorize generic substitution preferred medicine from this list. Take this list along when you or a whenever possible. If you believe a brand-name product is covered family member sees a doctor. necessary, consider prescribing a brand name on this list. Please note: Please note: • Your specific prescription benefit plan design may not cover • Generics should be considered the first line of prescribing. certain products or categories, regardless of their appearance The member's prescription benefit plan design may alter in this document. Products recently approved by the U.S. • coverage of certain products or vary copay amounts based on Food and Drug Administration (FDA) may not be covered the condition being treated. upon release to the market. • This drug list represents a summary of prescription coverage. • Your prescription benefit plan design may alter coverage of 1 It is not all-inclusive and does not guarantee coverage. The certain products or vary copay amounts based on the member's specific prescription benefit plan design may not condition being treated. cover certain products or categories, regardless of their • You may be responsible for the full cost of non-formulary appearance in this document. Products recently approved by products that are removed from coverage. the FDA may not be covered upon release to the market. For specific information regarding your prescription benefit • • The member's prescription benefit plan may have a different coverage and copay information, please visit copay for specific products on the list. www.arkansasbluecross.com or contact an Unless specifically indicated, drug list products will include all Arkansas Blue Cross and Blue Shield Customer Care • dosage forms. representative at 1-800-863-5561. • Log in to www.arkansasbluecross.com to check coverage • Arkansas Blue Cross and Blue Shield may contact your doctor and copay information for a specific medicine. after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription. • In most instances, a brand-name drug for which a generic product becomes available will be designated as a non- preferred option upon release of the generic product to the market. ANALGESICS naproxen (except naproxen CR or § NSAIDs, TOPICAL § OPIOID ANALGESICS § GOUT naproxen suspension) diclofenac sodium gel 1% PA buprenorphine transdermal § NSAIDs allopurinol diclofenac sodium solution QL § NSAIDs, COMBINATIONS colchicine tablet diclofenac sodium codeine-acetaminophen QL diclofenac sodium- § COX-2 INHIBITORS probenecid ibuprofen fentanyl transdermal QL meloxicam misoprostol celecoxib Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561. fentanyl transmucosal efavirenz-emtricitabine- nitrofurantoin (except NDC^ PROSTATE CANCER § ANTIARRHYTHMICS lozenge PA tenofovir disoproxil 70408023932) § LUTEINIZING HORMONE- disopyramide hydrocodone ext-rel QL fumarate QL pyrimethamine PA RELEASING HORMONE sotalol hydrocodone-acetaminophen efavirenz-lamivudine- sulfamethoxazole- (LHRH) AGONISTS MULTAQ QL tenofovir disoproxil trimethoprim ELIGARD SGM hydromorphone QL fumarate QL vancomycin capsule QL ANTILIPEMICS hydromorphone ext-rel QL BIKTARVY QL EMVERM LUTEINIZING HORMONE- ACL INHIBITORS / methadone QL CIMDUO QL XIFAXAN 550 MG PA RELEASING HORMONE COMBINATIONS morphine QL COMPLERA QL (LHRH) ANTAGONISTS NEXLETOL PA ANTINEOPLASTIC morphine ext-rel QL DESCOVY QL FIRMAGON † NEXLIZET PA morphine suppository QL DOVATO QL AGENTS oxycodone QL EVOTAZ QL § MISCELLANEOUS § BILE ACID RESINS ANTIMETABOLITES oxycodone-acetaminophen GENVOYA QL ERIVEDGE SGM cholestyramine LONSURF SGM QL ODEFSEY QL LYNPARZA SGM colesevelam tramadol (except NDC^ PREZCOBIX QL BIOSIMILARS ODOMZO SGM § CHOLESTEROL STRIBILD QL RUBRACA SGM 52817019610) QL KANJINTI † ABSORPTION INHIBITORS SYMTUZA QL ZEJULA SGM tramadol ext-rel tablet QL RUXIENCE † BELBUCA QL TEMIXYS QL ezetimibe TRAZIMERA † NUCYNTA QL TRIUMEQ QL CARDIOVASCULAR ZIRABEV † § FIBRATES TRUVADA QL NUCYNTA ER QL § ACE INHIBITORS fenofibrate (except fenofibrate capsule SUBSYS PA HORMONAL INTEGRASE INHIBITORS fosinopril 50 mg, 130 mg; fenofibrate tablet 40 mg, XTAMPZA ER QL ANTINEOPLASTIC AGENTS ISENTRESS QL lisinopril 120 mg) § ANTIANDROGENS quinapril ANTI -INFECTIVES TIVICAY QL fenofibric acid delayed-rel abiraterone SGM ramipril ANTIBACTERIALS § NUCLEOSIDE REVERSE bicalutamide § HMG-CoA REDUCTASE § ACE INHIBITOR / § CEPHALOSPORINS TRANSCRIPTASE ERLEADA SGM INHIBITORS / INHIBITORS NUBEQA SGM DIURETIC COMBINATIONS COMBINATIONS cefdinir XTANDI SGM fosinopril-hydrochlorothiazide cefprozil abacavir tablet QL atorvastatin lamivudine QL YONSA SGM lisinopril-hydrochlorothiazide ezetimibe-simvastatin cefuroxime axetil quinapril-hydrochlorothiazide fluvastatin cephalexin § KINASE INHIBITORS § PROTEASE INHIBITORS SUPRAX lovastatin imatinib mesylate SGM § ANGIOTENSIN II atazanavir QL pravastatin § ERYTHROMYCINS / RECEPTOR ANTAGONISTS / NORVIR QL AFINITOR SGM MACROLIDES rosuvastatin ALECENSA SGM DIURETIC COMBINATIONS PREZISTA QL simvastatin azithromycin ALUNBRIG SGM candesartan / candesartan- clarithromycin ANTIVIRALS BOSULIF SGM hydrochlorothiazide § NIACINS clarithromycin ext-rel § CYTOMEGALOVIRUS CABOMETYX SGM irbesartan / irbesartan- niacin ext-rel erythromycins AGENTS COPIKTRA SGM hydrochlorothiazide § OMEGA-3 FATTY ACIDS DIFICID ST, QL IBRANCE SGM losartan / losartan- valganciclovir omega-3 acid ethyl esters PA IRESSA SGM hydrochlorothiazide § FLUOROQUINOLONES VASCEPA PA § HEPATITIS B AGENTS KISQALI SGM olmesartan / olmesartan- ciprofloxacin entecavir KISQALI FEMARA CO- hydrochlorothiazide PCSK9 INHIBITORS levofloxacin lamivudine PACK SGM telmisartan / telmisartan- PRALUENT PA moxifloxacin RYDAPT SGM hydrochlorothiazide VEMLIDY SPRYCEL SGM § BETA-BLOCKERS § PENICILLINS valsartan / valsartan- § HEPATITIS C AGENTS STIVARGA SGM hydrochlorothiazide atenolol amoxicillin ribavirin SGM XOSPATA SGM carvedilol amoxicillin-clavulanate § ANGIOTENSIN II EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) carvedilol phosphate ext-rel dicloxacillin MONOCLONAL ANTIBODIES RECEPTOR ANTAGONIST / SGM metoprolol succinate ext-rel penicillin VK PERJETA † CALCIUM CHANNEL HARVONI (genotypes 1, 4, 5, 6) metoprolol tartrate PHESGO SGM BLOCKER COMBINATIONS § TETRACYCLINES SGM nadolol 2 VOSEVI SGM amlodipine-olmesartan pindolol doxycycline hyclate 20 mg MULTIPLE MYELOMA amlodipine-telmisartan propranolol doxycycline hyclate capsule § HERPES AGENTS IMMUNOMODULATORS amlodipine-valsartan propranolol ext-rel minocycline acyclovir capsule, tablet POMALYST SGM tetracycline BYSTOLIC § ANGIOTENSIN II valacyclovir REVLIMID SGM RECEPTOR ANTAGONIST / § ANTIFUNGALS THALOMID SGM § CALCIUM CHANNEL § INFLUENZA AGENTS CALCIUM CHANNEL BLOCKERS fluconazole PROTEASOME INHIBITORS BLOCKER / DIURETIC oseltamivir QL itraconazole PA amlodipine COMBINATIONS RELENZA QL NINLARO SGM diltiazem ext-rel (except generics terbinafine tablet VELCADE † amlodipine-valsartan- for CARDIZEM LA) § MISCELLANEOUS ANTIRETROVIRAL AGENTS hydrochlorothiazide nifedipine ext-rel clindamycin olmesartan-amlodipine- § ANTIRETROVIRAL verapamil ext-rel ivermectin hydrochlorothiazide COMBINATIONS linezolid PA abacavir-lamivudine QL metronidazole Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561. § CALCIUM CHANNEL CENTRAL NERVOUS REUPTAKE INHIBITORS HYPNOTICS POSTHERPETIC BLOCKER / ANTILIPEMIC SYSTEM (SNRIs) § NONBENZODIAZEPINES NEURALGIA (PHN) COMBINATIONS desvenlafaxine ext-rel eszopiclone GRALISE ST ANTIANXIETY amlodipine-atorvastatin duloxetine ramelteon § BENZODIAZEPINES PSYCHOTHERAPEUTIC - venlafaxine zolpidem § DIGITALIS GLYCOSIDES MISCELLANEOUS