Excluded Drugs List 4-9-20 - AZBlue/media/azblue/files/pharmacy...Page 1 Excluded Drugs List Effective 10/1/17 * Date last updated: 4/9/20 Your benefit plan does not cover all drugs

Page 1

Excluded Drugs List Effective 10/1/17*

Date last updated: 4/9/20

Your benefit plan does not cover all drugs. Your benefit plan excludes coverage for drugs with one or more principal ingredients that are already available in greater/lesser strengths and / or combinations. Your plan also excludes drugs that only modify the dosage form (tablet, capsule, liquid, suspension, extended release, tamper resistant) for a drug that is already available in a common dosage form.

The table below lists drugs that are not covered for one of these reasons. The drugs listed in the “Not Covered” column are excluded under your plan. If you use them, you will have to pay the full cost of the drug. BCBSAZ may update and add to this list at any time.

For each excluded drug, we have also listed some alternatives. Any alternatives are subject to normal plan-requirements such as medical necessity. Alternatives are also subject to member cost share requirements such as copayments or coinsurance. Some alternatives may not be covered due to other plan limitations - for example, because the alternative is available over-the counter. If you are currently taking, or have been prescribed, one of these non-covered drugs, talk to your prescriber about whether one of the alternatives would work for you. Be sure to review the Pharmacy Benefit section for Benefit-Specific Exclusions and What is Not Covered in your benefit book for general exclusions and limitations that apply to all benefits.

To check coverage and copay information for a medication under your plan, visit azblue.com and log in to BlueNet. If you do not have access to the website, call the Pharmacy Benefits number on the back of your member ID card.

Therapeutic Class Not Covered Examples of Alternative Options

Analgesics - Anti-Inflammatory Nonsteroidal Anti-Inflammatory Agents (NSAIDs)

ANAPROX DS (Naproxen sodium) tablet 550mg naproxen sodium capsule 220mg (OTC)

DUEXIS (ibuprofen-famotidine) tablet 800-26.6mg ibuprofen tablet 800mg plus famotidine tablet 20mg

fenoprofen capsule 200mg fenoprofen tablet 600mg

fenoprofen capsule 400mg fenoprofen tablet 600mg

FENORTHO (fenoprofen calcium) capsule 200mg fenoprofen tablet 600mg

NALFON (fenoprofen calcium) capsule 200mg fenoprofen tablet 600mg

NALFON (fenoprofen calcium) capsule 400mg fenoprofen tablet 600mg

NAPRELAN CR (naproxen sodium ER) tablet 24-hour 375mg

naproxen DR or EC tablet 375mg


naproxen DR or EC tablet 500mg


naproxen DR or EC tablet 375mg or 500mg

NAPROSYN (naproxen) suspension 125mg/5ml naproxen tablet 250mg or naproxen (OTC)

naproxen suspension 125mg/5ml naproxen tablet 250mg or naproxen (OTC)

naproxen sodium CR tablet 375mg naproxen DR or EC tablet 375mg

naproxen sodium CR tablet 500mg naproxen DR or EC tablet 500mg

naproxen sodium tablet 550mg naproxen sodium capsule 220mg (OTC)

naproxen-esomeprazole magnesium DR tablet 375-20

naproxen DR or EC tablet 375mg plus esomeprazole magnesium tablet 20mg

naproxen-esomeprazole magnesium DR tablet 500-20mg

naproxen DR or EC tablet 500mg plus esomeprazole magnesium DR capsule 20mg

* Effective dates for contract exclusions will vary by plan, and are usually tied to the plan renewal date. If you are currently receiving benefit coverage for any of the non-covered drugs, you will receive a benefit change notice before these exclusions become effective for your plan.

D15112 08/17

http://azblue.com


Date last updated 8/21/19


SPRIX (ketorolac tromethamine) nasal spray 15.75mg-spray

ketorolac tablet 10mg

VIMOVO (naproxen-esomeprazole magnesium) DR tablet 375-20mg

naproxen DR or EC tablet 375mg plus esomeprazole magnesium tablet 20mg

VIMOVO (naproxen-esomeprazole magnesium) DR tablet 500-20mg

naproxen DR or EC tablet 500mg plus esomeprazole magnesium DR capsule 20mg

VIVLODEX (meloxicam) capsule 10mg meloxicam tablet 7.5mg or 15mg

VIVLODEX (meloxicam) capsule 5mg meloxicam tablet 7.5mg or 15mg

ZIPSOR (diclofenac potassium) capsule 25mg diclofenac potassium tablet 50mg or diclofenac sodium DR tablet 50mg

ZORVOLEX (diclofenac) capsule 18mg diclofenac potassium tablet 50mg or diclofenac sodium DR tablet 50mg

ZORVOLEX (diclofenac) capsule 35mg diclofenac potassium tablet 50mg or diclofenac sodium DR tablet 50mg

QMIIZ ODT (meloxicam) orally disintegrating tablet 7.5mg

meloxicam (non-orally disintegrating) tablet

QMIIZ ODT (meloxicam) orally disintegrating tablet 15mg

meloxicam (non-orally disintegrating) tablet

Analgesics - Nonnarcotic Analgesic Combinations ALLZITAL (butalbital-acetaminophen) tablet 25-

325mg butalbital-acetaminophen tablet 50-325mg

BUPAP (butalbital-acetaminophen) tablet 50-300mg

butalbital-acetaminophen tablet 50-325mg

butalbital-acetaminophen tablet 50mg-300mg butalbital-acetaminophen tablet 50-325mg

butalbital-acetaminophen capsule 50mg-300mg butalbital-acetaminophen tablet 50-325mg

VANATOL LQ (butalbital-acetaminophen-caffeine) solution 50-325-40mg/15ml

butalbital-acetaminophen-caffeine tablet 50-325-40mg

VANATOL S (butalbital-acetaminophen-caffeine) solution 50-325-40mg/15ml

butalbital-acetaminophen-caffeine tablet 50-325-40mg

Analgesics - Opioid Opioid Agonists ARYMO ER (morphine sulfate) tablet abuse-

deterrent 15mg morphine sulfate CR tablet 15mg

ARYMO ER (morphine sulfate) tablet abuse-deterrent 30mg

morphine sulfate ER capsule 24-hour 30mg or morphine sulfate CR tablet 30mg

ARYMO ER (morphine sulfate) tablet abuse-deterrent 60mg


CONZIP (tramadol hcl ER) capsule 24-hour biphasic release 100mg

tramadol hcl ER tablet 24-hour biphasic release 100mg





MORPHABOND ER (morphine sulfate) tablet 12-hour deterrent 15mg

morphine sulfate CR tablet 15mg





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tramadol hcl ER capsule biphasic release 100mg tramadol hcl ER tablet 24-hour biphasic release 100mg

tramadol hcl ER capsule biphasic release 150mg tramadol hcl ER tablet 24-hour biphasic release 100mg or 200mg



Opioid Combinations acetaminophen-caffeine-dihydrocodeine bitartrate tablet 325-30-16mg

acetaminophen-codeine tablet 300-30mg

APADAZ (benzhydrocodone hcl-acetaminophen) tablet 4.08-325mg

benzhydrocodone hcl-acetaminophen tablet 4.08-325mg





butalbital-acetaminophen-caffeine-codeine capsule 50-300-40-30mg


DVORAH (acetaminophen-caffeine-dihydrocodeine) tablet 325-30-16mg


FIORICET-CODEINE (butalbital-acetaminophen-caffeine-codeine) capsule 50-300-40-30mg


PANLOR (acetaminophen-caffeine-dihydrocodeine) tablet 325-30-16mg


Anorectal Agents

Rectal Steroids hydrocortisone acetate suppository 30mg hydrocortisone acetate rectal suppository 25mg

PROCTOCORT (hydrocortisone acetate) suppository 30mg

hydrocortisone acetate rectal suppository 25mg

Antianginal Agents Nitrates GONITRO (nitroglycerin) sublingual powder

packet 400mcg nitroglycerin sublingual tablet 0.4mg

Antianxiety Agents Benzodiazepines ATIVAN (lorazepam) tablet 0.5mg lorazepam tablet 0.5mg

ATIVAN (lorazepam) tablet 1mg lorazepam tablet 1mg

ATIVAN (lorazepam) tablet 2mg lorazepam tablet 2mg

Antidepressants Miscellaneous APLENZIN (bupropion HBR ER) tablet 24-hour

174mg bupropion hcl ER tablet 24-hour 150mg

APLENZIN (bupropion HBR ER) tablet 24-hour 348mg

bupropion hcl ER tablet 24-hour 300mg

APLENZIN (bupropion HBR ER) tablet 24-hour 522mg

bupropion hcl ER tablet 24-hour 150mg plus bupropion hcl ER tablet 24-hour 300mg

bupropion XL tablet ER 24-hour 450mg bupropion hcl XL tablet 150mg plus bupropion hcl XR tablet 300mg

FORFIVO XL (bupropion XL) tablet ER 24-hour 450mg

bupropion hcl XL tablet 150mg plus bupropion hcl XR tablet 300mg

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WELLBUTRIN XL (buproprion HCL ER) tablet 24-hour 150mg

bupropion hcl XL tablet, 150mg or 300mg

WELLBUTRIN XL (buproprion HCL ER) tablet 24-hour 300mg

bupropion hcl XL tablet, 150mg or 300mg

Selective Serotonin Reuptake Inhibitors (SSRIs)

fluoxetine tablet 60mg fluoxetine capsule 20mg x2/day or fluoxetine tablet 20mg x2/day

fluoxetine DR capsule 90mg fluoxetine capsule 20mg x3/day or fluoxetine tablet 20mg x3/day

PEXEVA (paroxetine mesylate) tablet 10mg paroxetine hcl tablet 10mg




Antidiabetics Antidiabetic Combinations DUETACT (pioglitazone hcl-glimepiride) tablet

30-2mg glimepiride tablet 2mg plus pioglitazone hcl tablet 30mg

DUETACT (pioglitazone hcl-glimepiride) tablet 30-4mg

glimepiride tablet 4mg plus pioglitazone hcl tablet 30mg

pioglitazone hcl-glimepiride tablet 30-2mg glimepiride tablet 2mg plus pioglitazone hcl tablet 30mg

pioglitazone hcl-glimepiride tablet 30-4mg glimepiride tablet 4mg plus pioglitazone hcl tablet 30mg

repaglinide-metformin hydrochloride (repaglinide-metformin hcl) tablet 1-500mg

repaglinide tablet 1mg plus metformin tablet 500mg

repaglinide-metformin hydrochloride (repaglinide-metformin hcl) tablet 2-500mg

repaglinide tablet 2mg plus metformin tablet 500mg

Biguanides GLUMETZA (metformin hcl ER) tablet 24-hour modified release 500mg

metformin hcl ER tablet 500mg or 750mg (generic GLUCOPHAGE XR)

GLUMETZA (metformin hcl ER) tablet 24-hour modified release 1000mg


metformin hcl ER tablet 24-hour modified release tablet 500mg


metformin hcl ER tablet 24-hour modified release tablet 1000mg


Diabetic Other

GVOKE PFS (glucagon) subcutaneous solution prefilled syringe 0.5mg/0.1ml

glucagon injection reconstituted solution 1mg or BAQSIMI ONE PACK (glucagon) nasal powder 3mg/dose or BAQSIMI TWO PACK (glucagon) nasal powder 3mg/dose

GVOKE PFS (glucagon) subcutaneous solution prefillled syringe 1mg/0.2ml

glucagon injection reconstituted solution 1mg or BAQSIMI ONE PACK (glucagon) nasal powder 3mg/dose or BAQSIMI TWO PACK (glucagon) nasal powder 3mg/dose

Antihistamines Ethanolamines carbinoxamine maleate tablet 6mg carbinoxamine maleate tablet 4mg

RYVENT (carbinoxamine maleate) tablet 6mg carbinoxamine maleate tablet 4mg

Antihyperlipidemics HMG COA Reductase Inhibitors

FLOLIPID (simvastatin) suspension 20mg/5ml simvastatin tablet 20mg

FLOLIPID (simvastatin) suspension 40mg/5ml simvastatin tablet 40mg Miscellaneous TRIKLO (omega-3-acid ethyl esters) capsule 1gm omega-3-acid capsule 1gm

D15112 08/17 Page 4




Anti-Infective Agents

Miscellaneous PRIMSOL (trimethoprim hcl) oral solution 50mg/5ml

trimethoprim tablet 100mg

TRIMPEX (trimethoprim hcl) oral solution 50mg/5ml

trimethoprim tablet 100mg

Antihypertensives Antihypertensive Combinations

DUTOPROL ER (metoprolol succinate ER-hydrochlorothiazide) tablet 24-hour 25-12.5mg

metoprolol ER tablet 25mg plus hydrochlorothiazide tablet 12.5mg





metoprolol succinate ER-hydrochlorothiazide tablet 24-hour 25-12.5mg






PRESTALIA (perindopril arginine-amlodipine besylate) tablet 3.5-2.5mg

perindopril erbumine tablet 2mg, 4mg, or 8mg plus amlodipine besylate tablet 2.5mg

PRESTALIA (perindopril arginine-amlodipine besylate) tablet 7-5mg

perindopril erbumine tablet 2mg, 4mg, or 8mg plus amlodipine besylate tablet 5mg

PRESTALIA (perindopril arginine-amlodipine besylate) tablet 14-10mg

perindopril erbumine tablet 2mg, 4mg, or 8mg plus amlodipine besylate tablet 10mg

Antimuscarnics Antispasmodics glycopyrrolate tablet 1.5mg glycopyrrolate tablet 1mg and/or 2mg

Antiparkinson Agents Monoamine Oxidase Inhibitors

ZELAPAR (selegiline hcl) orally disintegrating tablet 1.25mg

selegiline hcl capsule 5mg or selegiline hcl tablet 5mg

Attention-Deficit Hyperactivity Disorder Amphetamines ZENZEDI (dextroamphetamine sulfate) tablet

15mg ZENZEDI (dextroamphetamine sulfate) tablet 5mg or 10mg

ZENZEDI (dextroamphetamine sulfate) tablet 2.5mg

ZENZEDI (dextroamphetamine sulfate) tablet 5mg or 10mg

ZENZEDI (dextroamphetamine sulfate) tablet 20mg


ZENZEDI (dextroamphetamine sulfate) tablet 30mg


ZENZEDI (dextroamphetamine sulfate) tablet 7.5mg


Attention-Deficit Hyperactivity Disorder (ADHD) Agents

KAPVAY (clonidine hcl) tablet ER 12-hour 0.1mg clonidine hcl ER tablet 12-hour 0.1mg

Stimulants- Miscellaneous CONCERTA (methylphenidate hcl) tablet osmotic release 18mg

methylphenidate hcl tablet osmotic release 18mg

CONCERTA (methylphenidate hcl) tablet osmotic release 27mg




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methylphenidate hcl tablet osmotic release 72mg methylphenidate hcl tablet osmotic release 36mg

RELEXXI (methylphenidate hcl) tablet osmotic release 72mg


Beta Blockers Non-Selective INDERAL LA (propranolol hcl) capsule ER 24-

hour 60mg propranolol hcl ER capsule 24-hour 60mg

INDERAL LA (propranolol hcl) capsule ER 24-hour 120mg

propranolol hcl ER capsule 24-hour 120mg





INDERAL XL (propranolol hcl) beads capsule ER 24-hour 120mg


INDERAL XL (propranolol hcl) beads capsule ER 24-hour 80mg


INNOPRAN XL (propranolol hcl) beads capsule ER 24-hour 120mg


INNOPRAN XL (propranolol hcl) beads capsule ER 24-hour 80mg


Cardiovascular Agents Cardiovascular Combinations

amlodipine besylate-atorvastatin calcium tablet 2.5-10mg

amlodipine besylate tablet 2.5mg plus atorvastatin calcium tablet 10mg





amlodipine besylate-atorvastatin calcium tablet 5-10mg

amlodipine besylate tablet 5mg plus atorvastatin calcium tablet 10mg















CADUET (amlodipine besylate-atorvastatin calcium) tablet 5-10mg


D15112 08/17 Page 6














Cephalosporins

Cephalosporins cephalexin capsule 750mg

cephalexin capsule 250mg plus cephalexin capsule 500mg

DAXBIA capsule 333mg cephalexin capsule 250mg or cephalexin capsule 500mg

KEFLEX capsule 750mg cephalexin capsule 250mg plus cephalexin capsule 500mg

Corticosteroids Glucocorticosteroids RAYOS (prednisone) DR tablet 1mg prednisone tablet 1mg

RAYOS (prednisone) DR tablet 2mg prednisone tablet 1mg or 2.5mg

RAYOS (prednisone) DR tablet 5mg prednisone tablet 5mg

Cough/Cold/Allergy Antitussives

benzonatate capsule 150mg benzonatate capsule 100mg or benzonatate capsule 200mg

Combinations TUSSICAPS (hydrocodone polistirex-chlorpheniramine polistirex) capsule ER 12-hour 5-4mg

hydrocodone polistirex-chlorpheniramine polistirex ER suspension 10-8mg/5ml

TUSSICAPS (hydrocodone polistirex-chlorpheniramine polistirex) capsule ER 12-hour 10-8mg

hydrocodone polistirex-chlorpheniramine polistirex ER suspension 10-8mg/5ml

TUXARIN ER (codeine phos-chlorpheniramine maleate) tablet 12-hour 54.3-8mg

codeine sulfate tablet 60mg plus chlorpheniramine (OTC)

TUZISTRA XR (codeine polistirex-chlorpheniramine polistirex) suspension 14.7-2.8mg/5ml

LEXUSS 210 (chlorpheniramine w/ codeine) liquid 2-10mg/5ml

Dermatologicals Acne Products

ABSORICA (isotretinoin) capsule 10mg AMNESTEEM, CLARAVIS, isotretinoin, MYORISAN or ZENATANE






D15112 08/17 Page 7




ABSORICA LD (isotretinoin micronized) capsule 8mg

AMNESTEEM, CLARAVIS, isotretinoin, MYORISAN or ZENATANE







ACANYA (clindamycin phosphate-benzoyl peroxide) gel 1.2-2.5%

clindamycin phosphate gel 1% plus benzoyl peroxide gel 2.5%

adapalene gel 0.3% adapalene gel 0.1%

adapalene lotion 0.1% adapalene gel 0.1%

adapalene pad 0.1% swab DIFFERIN (adapalene) gel 0.1% (OTC)

adapalene-benzoyl peroxide gel 0.1-2.5% adapalene gel 0.1% plus benzoyl peroxide gel 2.5%

AKTIPAK (benzoyl peroxide-erythromycin) gel pack 5-3%

benzoyl peroxide gel 5% (OTC) plus erythromycin gel

ATRALIN (tretinoin) gel 0.05% tretinoin gel 0.05%

AVAR-E LS (sulfacetamide sodium with sulfur) cream 10-2%

sulfacetamide sodium lotion 10% (acne) with OTC acne sulfur lotion

AVITA (tretinoin) cream 0.025% tretinoin cream 0.025%

AVITA (tretinoin) gel 0.025% tretinoin gel 0.025%

BENZACLIN (clindamycin phosphate-benzoyl peroxide) gel 1-5%

clindamycin phosphate gel 1% plus benzoyl peroxide gel 5%

benzoyl peroxide gel 6.5% benzoyl peroxide gel 5% (OTC) or OC8 gel 7% (OTC)

CLEOCIN-T (clindamycin phosphate) gel 1% clindamycin phosphate gel 1%

CLEOCIN-T (clindamycin phosphate) lotion 1% clindamycin phosphate lotion 1%

CLEOCIN-T (clindamycin phosphate) solution 1% clindamycin phosphate solution 1%

CLEOCIN-T (clindamycin phosphate) swab 1% clindamycin phosphate swab 1%

CLINDAGEL (clindamycin phosphate) gel 1% clindamycin phosphate gel 1%

clindamycin phosphate-benzoyl peroxide gel 1.2-2.5%

clindamycin phosphate gel 1% plus benzoyl peroxide gel 2.5%

clindamycin phosphate-tretinoin gel 1.2-0.025% clindamycin phosphate gel 1% plus tretinoin gel 0.25%

clindamycin phosphate-benzoyl peroxide gel 1.2-5%


DIFFERIN (adapalene) cream 0.1% adapalene gel 0.1%

DIFFERIN (adapalene) gel 0.1% adapalene gel 0.1%

DIFFERIN (adapalene) gel 0.3% adapalene gel 0.1%

DIFFERIN (adapalene) lotion 0.1% adapalene gel 0.1%

DUAC (clindamycin phosphate-benzoyl peroxide) gel 1.2 (1)-5%


EPIDUO (adapalene-benzoyl peroxide) gel 0.1-2.5%

adapalene gel 0.1% plus benzoyl peroxide gel 2.5%

EPIDUO FORTE (adapalene-benzoyl peroxide) gel 0.3-2.5%

adapalene gel 0.3% (OTC) plus benzoyl peroxide gel 2.5%

EVOCLIN (clindamycin phosphate) foam 1% clindamycin phosphate foam 1%

D15112 08/17 Page 8




FABIOR (tazarotene) foam 0.1% tazarotene cream 0.1%

KLARON (sulfacetamide sodium) lotion 10% sulfacetamide sodium lotion 10% (acne)

NEUAC (clindamycin phosphate-benzoyl peroxide) gel 1.2 (1)-5%


ONEXTON (clindamycin phosphate-benzoyl peroxide) gel 1.2-3.75%


PLEXION (sulfacetamide sodium-sulfur) cleansing cloth 9.8-4.8%

sulfacetamide sodium lotion 10% (acne)

PLEXION (sulfacetamide sodium-sulfur) cream 9.8-4.8%


PLEXION (sulfacetamide sodium-sulfur) liquid cleanser 9.8-4.8%


PLEXION (sulfacetamide sodium-sulfur) lotion 9.8-4.8%


RETIN-A (tretinoin) cream 0.025% tretinoin cream 0.025%



RETIN-A (tretinoin) gel 0.025% tretinoin gel 0.025%

RETIN-A (tretinoin) gel 0.1% tretinoin gel 0.1% RETIN-A MICRO (tretinoin) microsphere gel 0.04%

tretinoin gel 0.04%

RETIN-A MICRO (tretinoin) microsphere gel 0.1% tretinoin gel 0.1%

RETIN-A MICRO PUMP (tretinoin) microsphere gel 0.08%

tretinoin gel 0.025%, 0.04%, 0.05%, or 0.1%

sodium sulfacetamide-sulfur cleansing pad 10-4% ZENCIA (sulfacetamide sodium-sulfur) 9-4% liquid wash

sodium sulfacetamide-sulfur liquid wash 9-4% ZENCIA (sulfacetamide sodium-sulfur) 9-4% liquid wash

sodium sulfacetamide-sulfur suspension 8-4% sodium sulfacetamide-sulfur wash 9-4.5%

sulfacetamide sodium-sulfur cream 9.8-4.8% sulfacetamide sodium lotion 10% (acne)

sulfacetamide sodium-sulfur cream 10-2% sulfacetamide sodium lotion 10% (acne) with OTC acne sulfur lotion

sulfacetamide sodium-sulfur liquid cleanser 9.8-4.8%


sulfacetamide sodium-sulfur lotion 9.8-4.8% sulfacetamide sodium lotion 10% (acne)

sulfacleanse suspension 8-4% sodium sulfacetamide-sulfur wash 9-4.5%

SUMADAN WASH (sulfacetamide sodium-sulfur) wash 9-4.5%

sodium sulfacetamide-sulfur wash 9-4.5%

SUMAXIN (sulfacetamide sodium-sulfur) cleansing pad 10-4%

ZENCIA (sulfacetamide sodium-sulfur) 9-4% liquid wash

SUMAXIN (sulfacetamide sodium-sulfur) liquid wash 9-4%

ZENCIA (sulfacetamide sodium-sulfur) 9-4% liquid wash

SUMAXIN TS (sulfacetamide sodium-sulfur) suspension 8-4%

sodium sulfacetamide-sulfur wash 9-4.5%

TRETIN-X (tretinoin) cream 0.0375% tretinoin cream 0.05%

TRETIN-X (tretinoin) cream 0.075% tretinoin cream 0.1%

VELTIN (clindamycin phosphate-tretinoin) gel 1.2-0.025%

clindamycin phosphate gel 1% plus tretinoin gel 0.25%

D15112 08/17 Page 9




ZIANA (clindamycin phosphate-tretinoin) gel 1.2-0.025%

clindamycin phosphate gel 1% plus tretinoin gel 0.25%

Antibiotics - Topical mupirocin cream 2% mupirocin ointment 2%

NEO-SYNALAR (neomycin sulfate-fluocinolone acetonide) cream 0.5-0.025%

neomycin-bacitracin-polymyxin ointment plus fluocinonide ointment 0.05%

Antifungal-Topical Azoles EXTINA (ketoconazole) foam 2%

ketoconazole cream 2% or ketoconazole shampoo 2%

ketoconazole aerosol foam 2% ketoconazole cream 2% or ketoconazole shampoo 2%

KETODAN (ketoconazole) foam 2% ketoconazole cream 2% or ketoconazole shampoo 2%

luliconazole cream 1% clotrimazole cream 1%

LUZU (luliconazole) cream clotrimazole cream 1%

OXISTAT (oxiconazole nitrate) lotion 1% oxiconazole cream 1%

XOLEGEL (ketoconazole) gel 2% ketoconazole cream 2% or ketoconazole shampoo 2%

Anti-Inflammatory Agents - Topical PENNSAID (diclofenac sodium) solution 2% diclofenac sodium solution 1.5%

Corticosteroids - Topical DESOWEN (desonide) cream 0.05% desonide cream 0.05%

desoximetasone ointment 0.05% desoximetasone ointment 0.25%

desoximetasone spray 0.25% desoximetasone ointment 0.25%

DUOBRII (halobetasol propionate-tazarotene) lotion 0.01-0.045%

TAZORAC (tazarotene) plus halobetasol

ENSTILAR (calcipotriene-betamethasone dipropionate) foam 0.005-0.064%

calcipotriene cream 0.005% plus betamethasone dipropionate cream 0.05%

fluocinonide cream 0.1% fluocinonide cream 0.05%

halobetasol propionate foam 0.05% halobetasol ointment 0.05% or halobetasol cream 0.05%

hydrocortisone butyrate cream 0.1% hydrocortisone butyrate solution 0.1% or hydrocortisone butyrate lotion 0.1%

IMPOYZ (clobetasol propionate) 0.025% clobetasol propionate cream 0.05%

LEXETTE (halobetasol propionate) foam 0.05% halobetasol ointment 0.05% or halobetasol cream 0.05%

LOCOID LIPOCREAM (hydrocortisone butyrate hydrophilic lipo base) cream 0.1%

hydrocortisone butyrate solution 0.1% or hydrocortisone butyrate lotion 0.1%

SYNALAR (fluocinolone acetonide) solution 0.01%

fluocinolone acetonide solution 0.01% or fluocinonide cream 0.05%

TOPICORT (desoximetasone) ointment 0.05% desoximetasone ointment 0.25%

TOPICORT (desoximetasone) spray 0.25% desoximetasone ointment 0.25%

TRIDESILON (desonide) cream 0.05% desonide cream 0.05%

ULTRAVATE (halobetasol propionate) cream 0.05%

halobetasol ointment 0.05% or halobetasol cream 0.05%

ULTRAVATE (halobetasol propionate) lotion 0.05%


ULTRAVATE (halobetasol propionate) ointment 0.05%


VANOS (fluocinonide) cream 0.1% fluocinonide cream 0.05%

D15112 08/17 Page 10




Immunomodulating Agents-Topical

imiquimod cream 3.75% imiquimod cream 5%

ZYCLARA (imiquimod) cream 3.75% imiquimod cream 5%

ZYCLARA PUMP (imiquimod) cream 2.5% imiquimod cream 5%

ZYCLARA PUMP (imiquimod) cream 3.75% imiquimod cream 5% Local Anesthetics - Topical lidocaine and tetracaine cream 7-7% aspercreme 4% or lidocaine cream 4%, 5%

PLIAGLIS (lidocaine-tetracaine) cream 7-7% aspercreme 4% or lidocaine cream 4%, 5%

SYNERA (lidocaine-tetracaine) topical patch 70-70mg

lidocaine-prilocaine cream 2.5-2.5%

ZTLIDO PAD (lidocaine) patch 1.8% lidocaine cream 2% Rosacea Agents doxycycline DR capsule 40mg doxycycline hyclate tablet 20mg

METROCREAM (metronidazole) cream 0.75% metronidazole cream 0.75%

METROGEL (metronidazole) gel 1% metronidazole gel 1%

METROLOTION (metronidazole) lotion 0.75% metronidazole lotion 0.75%

NORITATE (metronidazole) cream 1% metronidazole lotion 0.75%

ORACEA (doxycycline) DR capsule 40mg doxycycline hyclate tablet 20mg

Diuretics Potassium Sparing Diuretics

CAROSPIR (spironolactone) oral suspension 25mg/5ml

spironolactone tablet 25mg

Endocrine and Metabolic Bone Density Regulators ATELVIA (risedronate sodium) DR tablet 35mg alendronate sodium tablet 70mg

BINOSTO (alendronate sodium effervescent) tablet 70mg

alendronate sodium tablet 70mg

FOSAMAX + D (alendronate sodium-cholecalciferol) tablet 70-2800mg-unit

alendronate sodium tablet 70mg plus vitamin d-3 (cholecalciferol) tablet 2000unit

FOSAMAX + D (alendronate sodium-cholecalciferol) tablet 70-5600mg-unit

alendronate sodium tablet 70mg plus vitamin d-3 (cholecalciferol) tablet 5000unit

risedronate sodium DR tablet 35mg alendronate sodium tablet 70mg Estrogens

Estrogen Combinations BIJUVA (estradiol-progesterone) capsule 1-100mg

progesterone micronized capsule 100mg plus estradiol 1mg

Heavy Metal Antagonists Chelating Agents CUPRIMINE (penicillamine) capsule 250mg DEPEN TITRA (penicillamine) tablets 250mg

penicillamine capsules 250mg DEPEN TITRA (penicillamine) tablets 250mg

Hematologicals Platelet Aggregation Inhibitors

aspirin/omeprazole (aspirin-omeprazole) DR tablet 325-40mg

aspirin DR tablet 325mg plus omeprazole DR capsule 40mg

YOSPRALA (aspirin-omeprazole) DR tablet 325-40mg


YOSPRALA (aspirin-omeprazole) DR tablet 81-40mg


aspirin-omeprazole (aspirin-omeprazole) DR tablet 81-40mg


Hematopoietic Agents Agents For Sickle Cell Anemia

ENDARI (glutamine) powder pack 5gm glutamine powder packet (OTC), glutamine capsule 500mg (OTC) or L-glutamine tablet 500mg (OTC)

D15112 08/17 Page 11




Hypnotics/Sedatives/Sleep Disorder Non-Barbiturate Hypnotics EDLUAR (zolpidem tartrate) sublingual tablet

10mg zolpidem tartrate tablet 10mg

EDLUAR (zolpidem tartrate) sublingual tablet 5mg

zolpidem tartrate tablet 5mg

INTERMEZZO (zolpidem tartrate) sublingual tablet 1.75mg


INTERMEZZO (zolpidem tartrate) sublingual tablet 3.5mg


zolpidem tartrate sublingual tablet 1.75mg zolpidem tartrate tablet 5mg

zolpidem tartrate sublingual tablet 3.5mg zolpidem tartrate tablet 5mg ZOLPIMIST (zolpidem tartrate) oral spray 5mg/act


Migraine Products Migraine Combinations sumatriptan-naproxen sodium (sumatriptan-

naproxen sodium) tablet 85-500mg sumatriptan succinate tablet 50mg or 100mg plus naproxen tablet 500mg

TREXIMET (sumatriptan-naproxen sodium) tablet 10-60mg

sumatriptan succinate tablet 25mg plus naproxen tablet 250mg

TREXIMET (sumatriptan-naproxen sodium) tablet 85-500mg

sumatriptan succinate tablet 50mg or 100mg plus naproxen tablet 500mg

Migraine Products D.H.E. 45 (dihydroergotamine mesylate) injection 1mg/ml

dihydroergotamine mesylate injection 1mg/ml

NSAIDS CAMBIA (diclofenac potassium) packet 50mg diclofenac potassium tablet 50mg Serotonin Agonists FROVA (frovatriptan succinate) tablet 2.5mg frovatriptan succinate tablet 2.5mg

ONZETRA XSAIL (sumatriptan succinate) exhaler powder 11mg

sumatriptan succinate tablet 25mg

ZEMBRACE SYMTOUCH (sumatriptan succinate) solution auto-injector 3mg/0.5ml

sumatriptan succinate injection 4mg/0.5ml

Musculoskeletal Therapy Central Muscle Relaxants AMRIX (cyclobenzaprine hcl) capsule ER 24-hour

15mg cyclobenzaprine hcl tablet 5mg or 10mg

AMRIX (cyclobenzaprine hcl) capsule ER 24-hour 30mg

cyclobenzaprine hcl tablet 5mg or 10mg

carisoprodol tablet 250mg carisoprodol tablet 350mg

chlorzoxazone tablet 250mg chlorzoxazone tablet 500mg

cyclobenzaprine hcl tablet 7.5mg cyclobenzaprine hcl tablet 5mg or 10mg

SOMA (carisoprodol) tablet 250mg carisoprodol tablet 350mg

tizanidine capsule 2mg tizanidine tablet 2mg

tizanidine capsule 4mg tizanidine tablet 4mg

tizanidine capsule 6mg tizanidine tablet 2mg plus 4mg

Neuromuscular Agents ALS Agents/Benzathiazoles RILUTEK (riluzole) tablet 50mg riluzole tablet 50mg

Nasal Agents

D15112 08/17 Page 12




Nasal Steroids

XHANCE (fluticasone propionate) nasal exhaler suspension 93 mcg/act

FLONASE Allergy Relief (fluticasone propionate) nasal suspension 50 mcg/act (OTC) or goodsense nasoflow (fluticasone propionate) nasal suspension 50 mcg/act (OTC)

Ophthalmic Agents Beta-Blockers BETIMOL (timolol) ophthalmic solution 0.25% timolol maleate ophthalmic solution 0.25%

BETIMOL (timolol) ophthalmic solution 0.5% timolol maleate ophthalmic solution 0.5% Prostaglandin Analogs XALATAN (latanoprost) ophthalmic solution

0.005% latanoprost ophthalmic solution 0.005%.

Psychotherapeutic and Neurological Postherpetic Neuralgia (PHN)

GRALISE (gabapentin) tablet 300mg gabapentin capsule 300mg

GRALISE (gabapentin) tablet 600mg gabapentin tablet 600mg

GRALISE STARTER MIS (gabapentin) 300/600mg

gabapentin capsule 300mg plus gabapentin tablet 600mg

Restless Leg Syndrome (RLS)

HORIZANT (gabapentin enacarbil) CR tablet 300mg

gabapentin capsule 300mg

HORIZANT (gabapentin enacarbil) CR tablet 600mg

gabapentin tablet 600mg

Vasomotor Symptom BRISDELLE (paroxetine mesylate) capsule 7.5mg

paroxetine tablet 10mg

paroxetine mesylate capsule 7.5mg paroxetine tablet 10mg

Tetracyclines Tetracyclines ACTICLATE (doxycycline hyclate) tablet 75mg doxycycline hyclate capsule 50mg

ACTICLATE (doxycycline hyclate) tablet 150mg doxycycline hyclate capsule 50mg plus doxycycline hyclate capsule 100mg

COREMINO (minocycline hcl) tablet ER 24-hour 45mg

minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg

COREMINO (minocycline hcl ER) tablet 90mg minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg

COREMINO (minocycline hcl ER) tablet 135mg minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg

DORYX (doxycycline hyclate) DR tablet 50mg doxycycline hyclate capsule 50mg

DORYX (doxycycline hyclate) DR tablet 200mg doxycycline hyclate DR tablet 100mg

DORYX MPC (doxycycline hyclate) DR tablet 120mg

doxycycline hyclate DR tablet 100mg

doxycycline hyclate tablet 50mg doxycycline hyclate tablet 20mg or capsule 50mg

doxycycline hyclate tablet 75mg doxycycline hyclate capsule 50mg

doxycycline hyclate tablet 80mg doxycycline hyclate capsule 50mg

doxycycline hyclate tablet 150mg doxycycline hyclate capsule 50mg plus doxycycline hyclate capsule 100mg

doxycycline hyclate DR tablet 50mg doxycycline hyclate capsule 50mg

doxycycline hyclate DR tablet 150mg doxycycline monohydrate capsule 50mg and/or doxycycline monohydrate capsule 100mg

doxycycline hyclate DR tablet 200mg doxycycline hyclate DR tablet 100mg

doxycycline monohydrate capsule 75mg doxycycline monohydrate capsules or tablets

D15112 08/17 Page 13




doxycycline monohydrate capsule 150mg doxycycline monohydrate capsules or tablets

minocycline hcl ER tablet 45mg minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg



MONDOXYNE NL (doxycycline monohydrate) capsule 50mg

doxycycline monohydrate capsules or tablets





MONODOX (doxycycline monohydrate) capsule 75mg


OKEBO (doxycycline monohydrate) capsule 75mg


SOLOXIDE DR oral tablet 150mg doxycycline monohydrate capsule 50mg and/or doxycycline monohydrate capsule 100mg

TARGADOX (doxycycline hyclate) 50mg tablet doxycycline hyclate tablet 20mg or capsule 50mg

XIMINO (minocycline) ER capsule 45mg minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg



Ulcer Proton Pump Inhibitors ACIPHEX (rabeprazole sodium) DR tablet 20mg rabeprazole sodium EC tablet 20mg

ACIPHEX SPRINKLE (rabeprazole sodium) DR capsule 5mg

rabeprazole sodium EC tablet 20mg

ACIPHEX SPRINKLE (rabeprazole sodium) DR capsule 10mg


esomeprazole strontium DR capsule 24.65mg NEXIUM 24HR capsule 20mg (OTC)

esomeprazole strontium DR capsule 49.3mg NEXIUM 24HR capsule 20mg (OTC) lansoprazole DR tablet dispersible (Solutab) 15mg

lansoprazole DR capsule 15mg

lansoprazole DR tablet dispersible (Solutab) 30mg


NEXIUM (esomeprazole magnesium) DR capsule 20mg

NEXIUM 24HR capsule 20mg (OTC)

NEXIUM (esomeprazole magnesium) DR capsule 40mg


D15112 08/17 Page 14




NEXIUM (esomeprazole magnesium) DR suspension 2.5mg


NEXIUM (esomeprazole magnesium) DR suspension 5mg








PREVACID (lansoprazole) DR capsule 15mg lansoprazole DR capsule 15mg

PREVACID (lansoprazole) DR capsule 30mg lansoprazole DR capsule 30mg

PREVACID (lansoprazole) DR tablet dispersible (solutab)15mg


PREVACID (lansoprazole) DR tablet dispersible (solutab) 30mg


PRILOSEC (omeprazole magnesium) DR suspension packet 2.5mg

omeprazole DR capsule 10mg

PRILOSEC (omeprazole magnesium) DR suspension packet 10mg


PROTONIX (pantoprazole sodium) EC tablet 20mg

pantoprazole sodium EC tablet 20mg

PROTONIX (pantoprazole sodium) EC tablet 40mg


PROTONIX (pantoprazole sodium) DR suspension packet 40mg


raberazole (rabeprazole sodium) DR capsule 10mg


Ulcer Therapy Combinations lansoprazole-amoxicillin-clarithromycin therapy

pack

lansoprazole DR capsule 30mg, amoxicillin (trihydrate) capsule 500mg plus clarithromycin 500mg tablets

omeppi (omeprazole-sodium bicarbonate) capsule 20-1100mg


omeppi (omeprazole-sodium bicarbonate) capsule 40-1100mg


omeprazole-sodium bicarbonate capsule 20-1100mg


omeprazole-sodium bicarbonate capsule 40-1100mg


omeprazole-sodium bicarbonate powder pack for suspension 20-1680mg


omeprazole-sodium bicarbonate powder pack for suspension 40-1680mg


PREVPAC (amoxicillin capsule-clarithromycin tablet-lansoprazole capsule DR) therapy pack

lansoprazole DR capsule 30mg, amoxicillin (trihydrate) capsule 500mg plus clarithromycin 500mg tablets

PYLERA (bismuth subcitrate potassium-metronidazole-tetracycline) capsule 140-125-125mg

bismutah chew 262mg (OTC), metronidazole tablet 250mg plus tetracycline capsule 250mg

D15112 08/17 Page 15




ZEGERID (omeprazole-sodium bicarbonate) capsule 20-1100mg


ZEGERID (omeprazole-sodium bicarbonate) capsule 40-1100mg


ZEGERID (omeprazole-sodium bicarbonate) powder pack for suspension 20-1680mg


ZEGERID (omeprazole-sodium bicarbonate) powder pack for suspension 40-1680mg


Urinary Antispasmodics Antimuscarinics (Anticholinergic)

DETROL (tolterodine tartrate) tablet 1mg tolterodine tartrate tablet 1mg

DETROL (tolterodine tartrate) tablet 2mg tolterodine tartrate tablet 2mg DETROL LA (tolterodine tartrate) capsule ER 2mg

tolterodine tartrate tablet 2mg

DETROL LA (tolterodine tartrate) capsule ER 4mg

tolterodine tartrate tablet 2mg

DITROPAN XL (oxybutynin chloride) tablet ER 5mg

oxybutynin ER tablet 5mg





GELNIQUE (oxybutynin) gel 10% 1gm box oxybutynin chloride tablet 5mg

GELNIQUE PUMP (oxybutynin) gel 10% 30gm pump bottle

oxybutynin chloride tablet 5mg

tolterodine tartrate capsule ER 2mg tolterodine tartrate tablet 2mg

tolterodine tartrate capsule ER 4mg tolterodine tartrate tablet 2mg

Vaginal Estrogens Estrogens IMVEXXY (estradiol) vaginal insert 4mcg ESTRACE (estradiol) vaginal cream 0.01%

IMVEXXY (estradiol) vaginal insert 10mcg ESTRACE (estradiol) vaginal cream 0.01%

D15112 08/17 Page 16

Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call 602‐864‐4884 for Spanish and 877‐475‐4799 for all other languages and other aids and services.

If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: BCBSAZ’s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ 85002‐3466, 602‐864‐2288, TTY/TDD 602‐864‐4823, [email protected]. You can file a grievance in person or by mail or email. If you need help filing a grievance BCBSAZ’s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1‐800‐368‐1019, 800‐537‐7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

mailto:[email protected]

Multi-language Interpreter Services Spanish: Si usted, o alguien a quien usted esta ayudando, tiene preguntas acerca de Blue Cross Blue

Shield of Arizona, tiene derecho a obtener ayuda e informacion en su idiioma sin costo alguno. Para hablar con un interprete, llame al 602-864-4884.

Navajo: Dii kwe'e atah nflfnigff Blue Cross Blue Shield of Arizona haada yit'eego bfna'fditkidgo ef doodago Haida blja anilyeedfgfi t'aadoo le'e yfna'fdftkidgo beehaz'aanii hoiQ dff t'aa hazaadk'ehji haka a'doowotgo bee haz'q doo bqqh ilfnfgoo. Ata' halne'fgii kojt' bichT hodiilnih 877-475-4799.

Chinese: :Ml~1~ . ~~1~lEi±t~WJIY-Jf.t~ . ~lm:li'Nili.A.Ifi §IY-J:g~ Blue Cross Blue Shield of Arizona :tJiiii 1¥.1 PQ~~ . 1~~m fiJ ~ ~ J;.J. 1~ ~£}~fi~~$1J ~ llJJ fD~fl,~, o 5ft~- frr ~~~~i ~ . ~~15l~~i5 1":£ tttnfi.A.~::f: 877-475-47990

Vietnamese: Neu quy vi, hay ngU'O'i rna quy vi dang giup do, co cau hoi ve Blue Cross Blue Shield of Arizona quy vise co quyen dU'<;YC giup va co them thong tin bang ngon ngU' cua mlnh mien phi. De n6i chuy~n v6'i mot thong dich vien, xin goi 877-475-4799.

Arabic: ~ J~l ~ 0=JI ~.ili •Blue Cross Blue Shield of Arizona tY'l~ 4.t...,i ~~w ~ <.>-ll _,i dl;-ll 0~ u!

877-475-4799. '-:-l J..-:;1 ~_?. ~ ~~- ;i..ilS:; ~~ 0J.l 0-o ~ ~.JJ~I ~.::A ... _,h.JI_, ~~WI

Tag.alog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue Cross Blue Shield of Arizona, may karapatan ka na makakuha ng tulong at imporma.syon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 877-475-4799.

Korean: eJ-Q{ 71-l o~ EE::: 71-lo~J~ §~ 21.::: 01~ N~OI BlueCrossBiueShieldofA.rizona Oll 21- oH fd ~ ~ 0 I ~ C~ e:! 711 o~::: ~ 2.1 e!- ~ ~ Jll- ~ 5:!. ~ ~I o~ ~ ~ 01 £ tll ~ ~ EJ- lli 0 I ~ ~ -* 21.::: ~2.1J~ 21.~LICL~~Jil ~Q:l N2~ OH J i o~JI ~loHJd::: 877-475-4799~ ~2~0~~1-1 2.

French: Si vous, ou quelqu'un que vous etes en train d'aider, a des questions a propos de Blue Cross Blue Shield of Arizona, vous avez le droit d'obtenir de I' aide et !'information dans votre langue a aucun coOt. Pourparler a un interprete, appelez 877-475-4799.

German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Blue Cross Blue Shield of Arizona haben, haben Sie das Recht, kostenlose Hilfe und lnformationen in lhrer Sprache zu erhalten. Urn mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 877-475-4799 an.

Russian: Ec1n1 y sac lilflll1 !1111L.J,a, KoropoMy Bbl noMoraere, 111MeiOTCR sonpocbl no noBOAY Blue Cross Blue Shield of Arizona, TO Bbl 111Meere npaso Ha 6ecnnarHoe nonyYeHII1e noMOW,I-1 111 111H¢opMaU,r.1111 Ha saweM fl3b1Ke. ,D,nfl pa3rosopa c nepeBOA4111KOM no3BOHII1Te no rene¢oHy 877-475-4799.

Japanese: .:.•/.$:A~, *f::IJ:;t-3~~0)~0)@] L) 0)/JT! t, Blue Cross Blue Shield of Arizona 1:: -::>l, '"'C .::.·~rp~iJ~ --·2:·l, '* L t:: i;, ---*~0) ~ ~fi~-ififf- r- ~~Itt:: "J, t~'~ ~A.-¥ L t:: "J 9 ~.::. c iJ~ ~ ~ *9 o *~~fiiJ'iJ' LJ *tt Alo il~c }.)gli ~n0±~rEI, 877-475-4799 *~ }J~gli < t: ~ L '0 Farsi :

0:... ~~ ~b' Blue Cross Blue Shield of Arizona ~.JJ"" .J.l J l_,....,' ~ ~ _,1 ""-! W <I..S ~ l:! ,w pi 877-475-4799 ~w L:..!91..:U.l ut~-:!1.) .)__,h ""-! 1.) ~~ u~j ""-! wU:.)Lbl J .....s_...s <\S .l:1)~ 1.) 0:!1

Assyrian: . ~w J..:>b. L>"W].

1~0.001 .... =~~1 ,o~l •Blue Cross Blue Shield of Arizona ~o.::~ l:i.ao.::~ .... =~~l . ,o~ .. ao)a..."'il 4-!ol:iS il- l"' . ,o~l , 1

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Serbo-Croatian: Ukoliko Vi iii neko kome Vi pomazete ima pitanje o Blue Cross Blue Shield of Arizona, imate pravo da besplatno dobijete pomoc i informacije na Vasem jeziku .. Da biste razgovarali sa prevodiocem, nazovite 877-475-4799.

Thai : l-11flAru l-1)£lAUVIAntfl1~\1·1fHJLl-1~£llJA1fl1lJLfl tJ1fl1J Blue Cross Blue Shield of Arizona ArulJ~Vlnvr~::i.61~1JA11lJ"111 m l-1~ £l LL~::"ll t:JlJ~ tu.n1~1 "11 t:JvA ru 1.61 L61 £.Ji.lJlJA1 t"11~1 £.J W61 A £.J n11 ~1lJ 'i w~ 877-475-4799

" BlueCross +. ~~ Blue~hield • • ofArizona

Documents

Excluded Drugs List 4-9-20 - AZBlue/media/azblue/files/pharmacy...Page 1 Excluded Drugs List Effective 10/1/17 * Date last updated: 4/9/20 Your benefit plan does not cover all drugs