Transcription of Drugs that are Not Covered - BCBSFL
1 Drugs that are Not Covered * (Medicinas que no est n cubiertas*)Current (Corriente) 1/1/18 In addition to this list, newly marketed prescription medications may not be Covered until the Pharmacy & Therapeutics Committee has had an opportunity to review the medication, to determine whether the medication will be Covered and if so, which tier will apply based on safety, efficacy and the availability of other products within that class of medications. The current list of newly marketed Drugs can be found on our New to Market drug list. *Please check member benefit documentation to determine inclusion in the Drugs Not Covered program. Alternatives may be Covered or available for purchase Over The Counter (OTC).(*Consulte con la p liza de miembro individual para la inclusi n dentro del programa de medicinas no cubiertas)( Los ingredientes disponibles que no necesitan receta m dica)Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association Abilify Absorica Abstral acetaminophen 325 mg/caffeine/dihydro-codeine bitartrate Aciphex Aciphex Sprinkle Acticlate Actoplus Met Actos Acuvail Aczone adapalene lotion Adlyxin Adoxa/Adoxa Pak Adrenaclick Adrenalin Adzenys XR AirDuo Aktipak Aldara Allegra Children s Allergy Allegra Allegra D Alltizal Ambien Ambien CR Amerge Amrix Anafranil Androderm Android Antara Apexicon E Apidra Aplenzin Apriso Arestin Armonair Arymo ER aspirin/caffeine/dihydro-codeine bitartrate Ativan Atralin Auryxia Auvi-Q Azasite Beconase AQ Belbuca Belsomra Benicar Benicar HCT BenzaClin benzoyl peroxide foams benzoyl peroxide pledgets benzoyl peroxide washes benzoyl peroxide kits Betapace Betoptic S Brisdelle BromSite Bunavail Cambia Capital and Codeine Cardizem Cardizem CD Cardizem LA 180, 240, 300, 360.
2 And 420 mg carisoprodol 250 mg carisoprodol/ASA carisoprodol/ASA/codeine Cefaclor ER tablet Celebrex Celexa Cephalexin tablets Cervidil cetirizine syrup Ciclodan Cream Kit Ciclodan Kit Clarinex/D Clindacin Pac Clindagel clindamycin foam clindamycin/tretinoin gel Cleocin-T Clobex spray Clodan kit CNL8 Nail Kit Conzip Cordran (all formulations) Cotempla XR-ODT Crestor Crinone Cuprimine Cutivate cream Cutivate lotion Cutivate ointment Cyclobenzaprine Comfort Pac Cyclobenzaprine Kit Cymbalta Daxbia DDAVP nasal spray Demerol Demser Dermapak Plus Dermasorb kits (all) desloratadine ODT Desonate desoximetasone cream desoximetasone ointment desvenlafaxine ER (generic Khedezla) Detrol Detrol LA Dexilant diclofenac 3% gel Differin Differin pump dihydroergotamine nasal spray Dilaudid Dipentum diphenhydramine elixir Ditropan XL Doral Doryx doxycycline (all brand name products) doxycycline hyclate DR tablets doxycycline monohydrate 75 and 150 mg capsules Duetact Duexis Duragesic Durlaza Dymista Ecoza foam Edluar Effexor XR Elavil Enstilar Epaned EPIsnap Ergomar Esgic esomeprazole strontium Evoclin Exalgo Extina Fabior Femara Fenoglide fenofibrate 40 and 120 mg fenoprofen 400 mg Fenortho 200 and 400 mg fentanyl patch , , and mcg Fentora Fexmid fexofenadine (Rx) fexofenadine combinations (Rx) Page 1 of 3 Drugs that are Not Covered * (Medicinas que no est n cubiertas*)Continued (Continuado) *Please check member benefit documentation to determine inclusion in the Drugs Not Covered program.
3 Alternatives may be Covered or available for purchase Over The Counter (OTC). Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association Fioricet Fiorinal Flector Flonase Flolipid Flowtuss fluocinonide fluorouracil cream (authorized generic of Carac) fluoxetine 60 mg tablet fluoxetine 10 and 20 mg tablet/ capsule (Sarafem generics only) flunisolide 29 mcg flurandrenolide cream flurandrenolide lotion flurandrenolide ointment fluticasone propionate lotion fluvoxamine ER Focalin XR Forfivo XL Fortamet Fortesta Frova Gelnique Geodon Giazo Gleevec Glumetza Gocovri GoNitro Gralise Grastek Halog cream Horizant ER Humalog Humulin 70/30 Humulin N Humulin R Hycofenix hydrocortisone butyrate lipid cream (lipocream) Hysingla ER Ibudone Ibuprofen Comfort Pac Imitrex Innopran XL Intermezzo Intuniv Ionsys Irenka Isordil Istalol Jublia Kadian Karbinal ER Kenalog Kerydin ketoconazole foam Khedezla Klonopin Kristalose Lamisil AT spray Lazanda levocetirizine oral solution levorphanol Lexapro Librax Lidocaine HC kit lidocaine 5% lidocaine HCl 3% lotion Lidocaine/Prilocaine kit Lipitor Locoid Locoid lipocream LoCort Loestrin Loestrin 1/20-21 Loprox shampoo Lorcet Lortab Lorzone Lunesta Luzu Maxalt Maxalt MLT Maxidone Meloxicam Comfort Pac Mesalamine Kit Mestinon tablet metformin ER (generic Fortamet) metformin ER (generic Glumetza) methylphenidate ER (osmotic)
4 Metoclopramide ODT metoprolol succinate/ hydrochlorothiazide Metozolv MiCort-HC Millipred Millipred DP minocycline ER tablet Minocin Miralax Mirapex ER Mircette Mirvaso gel Mirvaso Pump gel Mobic Monodox mometasone nasal spray Morgidox Morphabond ER Motofen MS Contin Mydayis Mysoline naftifine cream Naftin Nalfon 400 mg capsule Naprelan Naprosyn suspension Naproxen Comfort Pac Nasacort AQ Nasonex Natesto Neuac Kit Nevanac Nexium capsules Niaspan Niravam Norco Noritate cream Northera Nucynta IR Nuvessa Nuvigil Obredon Ocudox Olux foam Olux E foam Omega-3/D- 3 kit omeprazole-sodium bicarb. (generic Zegerid) Omnaris Onexton Onmel Onzetra Xsail Oracea Oralair Orbivan Ovace Plus Ovcon-35 Ovcon-50 Oxaydo OxyContin Oxytrol Pancreaze Pancrelipase Pandel Panoxyl paroxetine ER Patanase Patanol Paxil Paxil CR Pediaderm Kit Penlac Pennsaid 2% Pepcid Percocet brand Perforomist Pertyze Pexeva Physicians EZ Use B-12 Compliance Injection Kit pioglitazone/glimepiride Plavix Pliaglis Ponstel Pramosone Prandin Prestalia Prevacid (Rx) Prevacid Solutab Prilosec (Rx) Primlev Prodrin Protonix Proventil HFA Provigil Page 2 of 3 Drugs that are Not Covered * (Medicinas que no est n cubiertas*)Continued (Continuado) *Please check member benefit documentation to determine inclusion in the Drugs Not Covered program.
5 Alternatives may be Covered or available for purchase Over The Counter (OTC). Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association Prozac Prozac Weekly quazepam Qbrelis Qnasl Qnasl Children s Qutenza Kit Ragwitek Rayaldee Rayos Remeron Remeron Soltab Reprexain Restoril Retin-A Micro Gel/Pump Revatio Rezira Rhinocort AQ Rhofade Risperdal Risperdal M tab Ritalin LA Rosadan Kit Rowasa Kit Roxicodone Rybix ODT Rytary RyVent Ryzolt Sanctura Sarafem Semprex-D Sernivo Seroquel Seroquel XR Silenor Singulair Sitavig Solaraze 3% Solodyn Soma Sorilux Sotilyze solution Spritam Sprix Striant Subsys Sumavel Dosepro Synalar topical/Kit Synalar TS Kit Synalgos-DC Syndros Taclonex ointment Taclonex suspension Targiniq Targiniq ER Tenormin Testim Testone CIK Kit testosterone topical 1% Testred Texacort Tiazac Tivorbex Tizanidine Comfort Pac Tobi nebulizer solution Tofranil Tofranil PM Topicort cream Topicort ointment Topicort spray Tranxene T Tretin-X
6 Treximet Trianex TussiCaps Tuxarin Tuzistra XR Tyzine Pediatric nasal drops Uceris Ultracet Ultram Ultram ER Ultravate Ultravate Kit/PAC Ultresa Uroxatral Valcyte Valium Valtrex Vanatol LQ Vantotol S Vanos cream Vaseretic Vasotec Veltin Veramyst Verdeso Veregen ointment Vibramycin Vicodin Vicoprofen Vimovo Viokace Vivlodex Vogelxo Vusion Wellbutrin Wellbutrin SR Wellbutrin XL WhyteDerm TDPak Whytederm Trilasil Pak Xanax Xanax XR Xartemis XR Xatmep Xenazine Xerese cream Xodol Xolegel Xopenex Xopenex HFA Xopenex concentrate Xyzal Yosprala Zantac Zecuity Zegerid Zelapar Zembrace Zestoretic Zestril Zetia Zetonna Ziana gel Zipsor Zohydro ER Zoloft zolpidem sublingual tablet Zolpimist Zomig Zomig-ZMT ZonaCort Zorvolex Zovirax topical Zubsolv Zuplenz Zyclara Zyflo Zylet Zyprexa Zyprexa Zydis Zyrtec Zytrec Children s Zyrtec-D Page 3 of 3
