Level 4 Medication List Revised 7/24/20 The medications listed below have the highest copayment level

Abilify oral solution Abilify tablet Abstral Absorica* Absorica LD* Acanya* Acetaminophen/Caffeine/ Dihydrocodeine Bitartrate 325-30-16mg Aciphex* Aciphex Sprinkle* Acticlate* Actiq Actonel 5mg, 30mg, 35mg Actoplus Met Actos Adapalene cream 0.1%* Adapalene gel 0.3%* Adapalene lotion 0.1%* Adapalene-Benzoyl Peroxide gel 0.1-2.5%* Adhansia XR Adzenys ER Adzenys XR ODT Afrezza* AirDuo Respiclick Aklief cream Akynzeo Albuterol HFA Aldara cream Almotriptan tablet Alocril Alogliptin Alomide Alphagan P 0.15% Alrex Altreno* Ambien Ambien CR Amlodipine-Atorvastatin* Amphetamine sulfate 5 & 10mg* Amnesteem Amicar solution 0.25GM/ML Amicar tablet 500mg & 1000mg Aminocarpoic acid solution 0.25GM/ML

Aminocarpoic acid tablet 500mg & 1000mg Androderm Androgel Aplenzin* Aptensio XR Aptiom Amrix* Arakoda* Arestin Aripiprazole ODT Armodafinil Aspirin/Omeprazole 81-40mg* Astepro nasal spray Astagraf XL Ativan* Atelvia* Atralin* Azel/Flutic NS Axert Axiron Bactroban cream* Balcoltra Basaglar Kwikpen* Baxdela Belbuca Belsomra Benzaclin Gel 1-5%* Benzefoamultra Bepreve Betapace AF Betimol* Beyaz Biaxin XL Binosto* Brisdelle* Briviact Bynfezia Pen* Caduet* Calcitriol ointment Cambia* Carbaglu Carbinoxamine 6mg tab * Cardura XL Carisoprodol 250mg* Carisoprodol/Aspirin Carisoprodol/Aspirin/Codeine Carvedilol Phosphate

Caplyta * Capsules ER Celexa tablet 10mg, 20mg,

40mg* Chlorzoxazone 375mg & 750mg Ciprofloxacin ER/SR Claravis Clarinex Clarinex D

Clarinex ODT Cleocin-T solution 1%* Cleocin-T gel 1%* Cleocin-T lotion 1%* Cleocin-T swab 1%* Clindamycin Phosphate-

Tretinoin Gel 1.2-0.025%* Clindamycin Phosphate-

Benzoyl Peroxide gel 1.2-2.5%

& 1.2 (1) -5%* Clobex lotion 0.05% Clobex spray 0.05%* Clocortolone cream 0.1% Cloderm cream 0.1% Clonidine ER Clozapine ODT Coly-Mycin S otic susp Consensi tablet* Conzip* Cordran cream* Cordran lotion* Cordran ointment* Cordran tape Cortisporin-TC otic susp Coreg CR Coremino* Corzide tablet 80-5mg Cresemba Crestor Crotan lot 10% Cyclessa Pak Cyclobenzaprine HCL ER* Cyclogyl 0.5% Daraprim Davigo Daxbia* Daytrana Desloratadine 5mg tablet

* Coverage may vary by benefit plan 1

Level 4 Medication List Revised 7/24/20 The medications listed below have the highest copayment level

Desloratadine ODT Desowen* Detrol* Detrol LA* Dexmethylphenidate ER/SR Diabeta Diclofenac Epolamine patch Differin cream* Differin gel 0.3%* Differin lotion* Dificid Diflorasone cream Diflorasone ointment Diovan Diovan HCT Ditropan XL* Doryx* Doryx MPC* Doxepin Doxycycline (Rosacea) capsule* Doxycycline Hyclate tablet 75mg &150mg* Doxycycline Hyclate DR tablet 50mg* Doxycycline Hyclate DR tablet 75mg* Doxycycline Hyclate DR tablet 80mg* Doxycycline Hyclate DR tablet 150mg* Doxycycline Hyclate DR tablet 200mg* Doxycycline Monohydrate 150mg capsule* Drospirenone/Ethinyl Estradiol/Levomefolate Calcium tablet Duac gel* Duaklir Pressair* Duavee Duexis* Dulera* Duragesic Disc DuoNeb Dutoprol Tablets* Dyanavel XR Dymista Nasal Spray

Elimite Edluar* Elestat Emadine Enablex Envarsus XR Epiduo Gel* Epiduo Forte* Epinephrine Pen (non Mylan) Epi-Pen Epi-Pen JR Epzicom Equetro Ertaczo cream Erygel Esomeprazole strontium* Eurax cream Eurax lotion Evekeo* Evekeo ODT* Evoclin* Exalgo Exforge Exforge HCT Extina* Ezallor Sprinkle Capsules* Fanapt Fazaclo Febuxostat Fentanyl Citrate Buccal tablet Fentanyl Citrate Inj Fentanyl lollipop Fentora Fetzima Fiasp vial Fiasp Flextouch Flector patch Flowtuss Fluocinonide cream 0.1%* Fluoxetine capsules (PMDD) Fluoxetine tablets (PMDD) Fluoxetine 60mg tablet * Fluoxetine 90mg DR* Flurandrenolide Cream Flurandrenolide Lotion Flurandrenolide Ointment Focalin XR Fortamet

Fortesta Fosamax Plus D* Fulyzaq Gelnique* Generess FE Glucophage XR Glumetza* Glyxambi* Gocovri Gonitro* Gralise* Gralise Starter Kit* Grastek Gvoke Hypopen* Gvoke PFS* Gynazole-1 cream Halog* HC Butyrate cream* Horizant* Hydroc/APAP sol 10-325mg Hydrocodone Bitartrate ER Hydroc/Guaif sol 2.5-200mg Hydroc/IBU 2.5-200mg Hydroc/IBU 5-200mg Hydroc/IBU 10-200mg Hydromorphone HCL ER 24HR Ibudone Imitrex cartridge Imitrex syringe Intermezzo* Inderal LA* Inderal XL* Innopran XL* Intuniv* Invega Inveltys Susp* Istalol Isotretinoin capsules Ivermectin cream 1% Jatenzo capsules* Jublia Kadian Kapvay* Karbinal ER* Ketorolac NS* Keppra Keppra XR

* Coverage may vary by benefit plan 2

Level 4 Medication List Revised 7/24/20 The medications listed below have the highest copayment level

Kerydin Klaron* Krintafel* Kristalose crystal packet 10GM & 20GM* Lactulose crystal packet 10GM* Lansoprazole ODT Solultab* Lansoprazole/Amox/Clarithr* Latuda Lastacaft Levorphanol tartrate tablet Lexapro tablet 5mg, 10mg, 20mg* Lipitor Liptruzet Locoid Lipocream* Lodine Loestrin 1/20-21 Loestrin FE 1/20 Loestrin FE 1.5/30 Loprox suspension Loprox cream Loprox shampoo Lortab* Lorzone Loseasonique Lotemax* Loteprednol Lovaza Lunesta Luliconazole CR* Luzu cream* Lyrica CR Magnacet Metformin HCL modified release ER/SR* Metoprolol/HCTZ SR tablets* Metrocream 0.75%* Metrogel 1%* Metrolotion 0.75%* Minastrin 24 FE Chew tabs Minocycline ER/SR tabs* Minocycline ER/SR caps Mircette Monodox* Morphabond ER* Morphine sulfate ER/SR beads

Morphine sulfate ER/SR capsules Myfortic Myorisan Mytesi Namenda Naphazoline HCL Opth Sol Naprelan CR/ER* Naproxen sodium ER/CR* Naproxen-Esomeprazole tab DR* Nasonex Natesto Natroba Nayzilam NS Neo-Synalar cream* Nesina Neuac gel* Nexium* Nexium granules* Niravam Neurontin Noctiva Nolix lotion Non-Lifescan Glucose Test Strips Non-Lifescan Glucose Test Disks Nor QD Noxafil tabs Noxafil oral suspension Norinyl 1/35 Nucynta Nucynta ER Nuedexta Nuplazid Nurtec Nuvigil Obredon Odactra Olopatadine NS Olopatadine Opth Sol 0.2% Omeppi* Omeprazole/Bicarbonate* Omeprazole-Sodium Bicarb* Omnaris Omnipod DASH 5 pack

Ondansetron HCL tablet 24mg* Onexton* Onfi* Onzetra Xsail* Opana ER Optivar Oracea* Oralair Orfadin Bicarbonate Powd Pack Ortho-Micron Ortho-Cyclen Ortho Novum 7/7/7 Ortho Novum 1/35 Ortho Tri-Cyclen Ortho Tri-Cyclen Lo Osphena Otrexup Ovcon-35 Ovide Oxistat lotion 1%* Oxaydo Oxtellar XR Oxycontin Oxycodone HCL ER Oxymorphone ER/SR Oxytrol Ozobax Sol 5mg/5ml* Palforzia Paliperidone ER/SR Paricalcitrol capsule 4mg Pataday Sol 0.2% Patanase Paxil tablet 10mg, 20mg, 30mg, 40mg* Paxil CR tablet 12.5mg, 25mg, 37.5mg* Paroxetine capsule 7.5mg* Paroxetine SR/ER Pazeo Percocet Pexeva* Plavix Plexion Cream 9.8-4.8%* Plexion Lotion 9.8-4.8%* Plexion Cleanser 9.8-4.8%* Posaconazole oral suspension

* Coverage may vary by benefit plan 3

Level 4 Medication List Revised 7/24/20 The medications listed below have the highest copayment level

Prandimet Prestalia* Prevacid* Prevacid ODT Solutab* PrevPac* Pristiq Prilosec* Prolensa Protonix* Protonix Pak* Proventil HFA Prozac capsule 10mg, 20mg, 40mg* Psorcon Pulmicort suspension 0.25mg/2ml, 0.5mg/2ml Pylera* Pyridium Pyrimethamin Qnasl Qnasl Childrens Qtern Qudexy XR Radiogardase Ragwitek Rajani Ravicti Rasuvo Rayaldee Rayos* Regranex* Relenza Relistor tablet Repaglinide/Metformin Hydrochloride* Relafen tablet 1000mg* Reprexain Retin-A cream* Retin-A gel* Retin-A Micro* Rexulti Rilutek* Riomet ER suspension* Risperdal M-ODT Risperidone M-ODT Rocklatan Rukobia Rybelsus

Rybix ODT Ryvent * Sanctura Sanctura XR Saphris Savella Seasonique Semprex-D Seroquel Silenor Simbrinza Sitavig Sivextro Sklice Sod sul/sulf cream 9.8-4.8%* Solodyn Solosec Soloxide* Soma* Sonata Soolantra Sorilux Spinosad Spirtam Sprix* Sporanox Striant Striverdi Respimat Stromectol Subsys Sulfacetamide sodium sulfur cleansing pad 10-4%* Sumadan Wash* Sumatriptan cartridge Sumatriptan syringe Sumaxin* Sumaxin TS* Sympazan* Syndros Symproic Synera Topical Patch* Talicia Tamiflu Taytulla Temodar Testosterone gel 2% Testosterone TD Patch

Timolol Maleate 0.5% (once daily) Timoptic Timoptic Ocudose Tirosint Tirosint-Sol Tizanidine capsules* Tolsura* Tosymra Toviaz Tramadol Biphasic Capsule ER/SR* Tramadol Biphasic tablet ER/SR Tretin-X* Treximet* Tridesilon* Trifluridine Ophth Soln 1%* Trintellix Trokendi XR Trospium Chloride ER/SR Tussicaps* Tuzistra XR* Twirla Ubrelvy* Ulesfia Uloric Ultram ER Vanatol LQ/S* Valium* Valtoco NS* Vanos cream* Varubi Vascepa Vectical Veltassa Veltin* Velphoro Verdeso* Vfend Viberzi Vicodin Vicoprofen Viibryd Vimovo* Vivlodex* Vogelxo Wellbutrin XL*

* Coverage may vary by benefit plan 4

Level 4 Medication List The medications listed below have the highest copayment level

Xanax* Xanax XR* Xartemis XR Xcopri* Xifaxan Xiidra Ximino* Xofluza Xolegel* Xopenex HFA Xtampza ER Xyosted* Yasmin 28 Yaz Yosprala* Zamicet* Zanaflex capsules Zegerid* Zembrace Symtouch* Zemplar Zenatane Zepatier Zerviate Zetia Ziagen tablets Ziana* Zilxi * Zioptan Zipsor* Zithranol shampoo Zocor Zofran Zofran ODT Zofran oral solution Zohydro ER Zoloft tablet 25mg, 50mg, 100mg* Zolpidem Tartrate SL* Zolpimist* Zorvolex* Zurampic Zutripro Zyprexa Zyvox

Revised 7/24/20

* Coverage may vary by benefit plan 5

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, crc@azblue.com. 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.

mailto:crc@azblue.comhttp://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Multi-language Interpreter Service

Level 4 Medication List Multi-language Interpreter Service