hmo blue - bcbs electronic sales kit

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Please review it carefully.

Our CommitmentWe respect your right to privacy. We will not disclose personally identifiable information about you without your permission, unless the disclosure is necessary to provide our services to you or is otherwise in accordance with the law.

Collection of InformationWe collect only personal or medical information we need to carry out our business.

• Examples of personal information are name, address, date of birth, and social security number. Most often, you and your employer supply this information to enroll you in a plan.

• Examples of medical information are diagnoses, treatments, and names of providers who treat you. Most often, your providers supply this information.

Use and Disclosure of InformationWe are required by law to protect the confidentiality of your personal and medical information and to notify you in case of a breach affecting your personal or medical information. We will supply your information to you upon your request or to help you understand treatment options and other benefits available to you.

We also may use and disclose your information without your written authorization for the following purposes, and as otherwise permitted or required by law:

• Treatment—to help providers manage or coordinate your health care and related services. For example, to refer you to another provider or remind you of appointments.

• Payment—to obtain payment for your coverage, provide you with health benefits, and assist another health plan or provider in its payment activities. For example, to manage enrollment records, make coverage determinations, administer claims, or coordinate benefits with other coverage you may have.

• Health Care Operations—to operate our business, including accreditation, credentialing, customer service, disease management, and fraud-prevention activities. For example, to do business planning, arrange for medical review, and conduct quality assessment and improvement activities.

• Legal Compliance—to comply with applicable law. For example, to respond to regulatory authorities responsible for oversight of government benefit programs or our operations; to parties or courts in the course of judicial or administrative proceedings; to law enforcement officials during an investigation; or as necessary to comply with workers’ compensation laws.

• Research and Public Health—for medical research studies in accordance with laws for the protection of human research subjects, and to report to public health authorities and otherwise prevent or lessen a serious and imminent threat to health or safety. For example, for the purpose of preventing or controlling disease, injury, or disability.

• To an Account (such as an employer) or Party It Designates— for administration of its health plan. For example, to a self-insured account for claim review and audits. We will disclose your information only to designated individuals. That, along with contract obligations, helps protect your information from unauthorized use.

To carry out these purposes, we share information with entities that perform functions for us subject to contracts that limit use and disclosure to intended purposes. We use physical, electronic, and procedural safeguards to protect your privacy. Even when allowed, uses and disclosures are limited to the minimum amount reasonably necessary for the intended task.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association

Our Commitment to Confidentiality

Your Privacy RightsYou have the following rights with respect to your personal and medical information. To exercise any of these rights, contact us using the information listed at the end of this notice.

• You have the right to receive information about privacy protections. Your member-education materials include a notice of your rights, and you may request a paper copy of this notice at any time.

• You have the right to inspect and get copies of information we collect about you. We will provide access to this information within 30 days of receiving a written request. We may charge a reasonable fee for copying and mailing records. You may also ask your providers for access to your records.

• You have the right to receive an accounting of disclosures. Your request must be in writing. Our response will exclude any disclosures made in support of treatment, payment, and health care operations, or that you authorized (among others). An example of a disclosure that would be reported to you is a disclosure of your information in response to a subpoena.

• You have the right to ask us to correct or amend information you believe to be incorrect. Your request to correct, amend, or delete information should be in writing. We will notify you if we make an adjustment as a result of your request. If we do not make an adjustment, we will send you a letter explaining why within 30 days. In this case, you may ask us to make your request part of your records, or ask the commissioner of insurance to review our decision. We may also provide notice of your requested changes to others who received this information in the past two years.

• You have the right to designate someone to receive information and interact with us on your behalf. Your personal representative has the same rights concerning your information as you. Your designation and any subsequent revocation must be in writing, and a form for this purpose is available on our website or by calling Member Service.

• You have the right to ask that we restrict or refuse to disclose personally identifiable information, and that we direct communications to you by alternative means or to alternative locations. While we may not always be able to agree, we will make reasonable efforts to accommodate requests. Your request and any subsequent revocation must be in writing.

• If you believe your privacy rights have been violated, you have the right to complain to us, using the standard grievance process outlined in your benefit materials, or to the Secretary of the U.S. Department of Health and Human Services, without fear of retaliation.

Special Notes Regarding DisclosureSpecial protections apply to information about certain medical conditions. For example, with very few exceptions allowed by law, we will not disclose any information regarding HIV or AIDS to any party without your written permission. We will not disclose mental health treatment records to you without first receiving approval from your treating provider or another equally qualified mental health professional. Also, we are prohibited from using or disclosing genetic information for underwriting purposes.

Except as provided in this notice, we will not use or disclose your personal or medical information without your written authorization. A form for this purpose is available on our website or by calling Member Service. Specifically, we must have your written authorization to use or disclose your information for:

• Marketing purposes;

• The sale of PHI;

• Most use and disclosures of psychotherapy notes.

You may revoke your authorization at any time. Your authorization must be in writing. Your revocation will not affect any action that we have already taken in reliance on your authorization.

About This NoticeThis notice is effective September 23, 2013. We are required by law to provide this notice to you and to abide by it while it is in effect. We reserve the right to change this notice. Any changes will apply to all personal and medical information that we maintain, regardless of when it was created or received. Before we make any material changes in our privacy practices, we will post a new notice on our website. We will provide information about the changes to our privacy practices and how to obtain a new notice in our next annual mailing to members who are then covered by one of our health plans.

If you have any questions, contact Member Service. We’re here to help. Please call the Member Service toll-free number on the front of your ID card or visit our website at www.bluecrossma.com.

® Registered Marks of the Blue Cross and Blue Shield Association. © 2013 Blue Cross and Blue Shield of Massachusetts, Inc.,and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 147552MB 32-7900

Find a Doctor www.bluecrossma.com/findadoctor

1: Health Care ProfessionalStart here if you’re looking for individual doctors, dentists, eye doctors, behavioral health and substance abuse professionals, or other health care providers.

2: Medical FacilityBegin here to search for hospitals, freestanding labs and imaging centers, X-rays/radiology, MRIs, MinuteClinic®,́ ambulance services, durable medical equipment suppliers, physical therapy groups or other specialty care service providers.

3: SpecialtyStart your search here to find health care providers by specialty such as chiropractic, general dentistry, neurology or other specialties.

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Now you can easily:• Get search results based on your plan

when logged into Member Central

• Search by name of health care provider or specialty, e.g., Dermatology, General Dentistry, Physical Therapy

• See updated doctor and hospital quality information

• Locate nearby hospitals, doctors, and other health care providers with Google MapsTM

• Compare up to three health care providers at a time to see their hospital affiliations, quality scores, and more

• Search nationwide for health care providers

To get all this information, and more, including an online brochure on how to get the most from our easy to use tool, simply visit Member Central or www.bluecrossma.com/findadoctor.

How to Search from the Find a Doctor Home Page

Search for a Doctor, Dentist, Hospital, or other Health Care Provider

With our easy to use Find a Doctor tool, you can find the right care for you.

Blue Cross Blue Shield of Massachusetts is an Independent licensee of the Blue Cross and Blue Shield Association. ®, Registered Marks of the Blue Cross and Blue Shield Association. TM ®’ Trademarks and Registered Marks are the property of their respective owners. © 2015 Blue Cross and Blue Shield of Massachusetts, Inc. and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 147561M 32-8525

Quality Information for DoctorsLearn from other patients’ experiencesThis information reflects the experience of patients at a doctor’s office. Specifically:• How well the doctor communicates with his or her patients

• Ease of getting timely appointments, care, and information from the doctor’s office

• How well doctors know their patients

See how doctors perform on clinical quality dataYou can compare doctors on a range of important preventive care and chronic disease management measures for children and adults such as:

• Number of eligible women who were screened for breast cancer

• Number of diabetics who received appropriate care

Physician Recognition ProgramThe Blue Physician Recognition program recognizes doctors who agree to take on accountability for providing high-quality, high-value, patient-centered health care.

Quality Information for HospitalsLearn from other patients’ experiencesThis data highlights the percentage of patients who:

• Would recommend the hospital to family and friends

• Felt the hospital’s clinical team communicated well with them

• Rate the hospital as a clean and quiet facility

Specialty Care Recognition Program - Blue Distinction CentersBlue Distinction Centers are hospitals that have received recognition for delivering high quality specialty care. Specialties include:

• Bariatric Surgery—hospitals that provide weight ‐loss surgery

• Spine Surgery—hospitals that provide full inpatient spine surgery services, including discectomy, fusion, and decompression procedures

• Knee and Hip Replacement—hospitals that provide full inpatient knee and hip replacement services, including total knee replacement and total hip replacement surgeries

• Cardiac Care—hospitals that treat certain heart problems with both surgery and catheter procedures

• Transplants—hospitals that perform organ transplants

Enhanced! Get Quality of Care Ratings on Find a Doctor.Quality and cost of health care vary by doctor and hospitals. Selecting the right care is an important decision for you and your family.

We offer two different types of objective and reliable quality information in the Find a Doctor tool to help you make your decision:

• Patient care experiences based on feedback from patients

• Clinical quality data based on patient outcomes, adherence to best practices, etc.

Need a Health Care Provider, Dentist or Medical Facility?Simply visit Member Central or www.bluecrossma.com/findadoctor or call us at the number on your Blue Cross ID card.

Enrollment Form

Thank you for choosing a Blue Cross Blue Shield plan.

Please take a few minutes to help us set up your membership by filling out the attached enrollment form.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ®, SM Registered Marks and Service Marks of the Blue Cross and Blue Shield Association. © 2014 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 147569MB 36-3630

For members of HMO Blue,® Network Blue,® Blue Choice,® HMO Blue New England,SM or Blue Choice New EnglandSM: You are required to choose a primary care physician (PCP) when you enroll. Please choose a PCP from your plan’s provider directory. Be sure to read “PCP ID #” in Section 2. List your PCP choice on your enrollment form. The PCP ID number can also be found by visiting www.bluecrossma.com and selecting Find a Doctor.

For Access BlueSM Members: Although you are not required to choose a PCP, we recommend you choose one by following the instructions in Section 2 on the back of this page.

Important: Are you covered by Medicare or other insurance? We need to know if you or any family member listed have Medicare and/or other insurance. Please be sure to circle either Y (for yes) or N (for no) in the correct box. This information will help us accurately coordinate your benefits. Please follow the instructions in Section 2 and 3. If you have not indicated Yes or No regarding your Medicare or other insurance status, you may receive a follow-up questionnaire.

Print two copies, one for your records and one for your employer to sign and mail to Blue Cross Blue Shield of Massachusetts. In order to complete your enrollment request, your employer is required to sign the application.

Special Instructions for Student Coverage: If you are seeking coverage for a full-time student dependent over age 19, you may need to fill out a Student Certificate form. Check with your employer to see if this coverage is available.

Blue Cross Blue Shield of Massachusetts P.O. Box 986001 Boston, MA 02298

Before You BeginPlease read the instructions carefully.

InstructionsSection 1 To Be Filled Out By Your Employer

Your employer will fill out this section.Type of Transaction—Check the box(es) that apply.Subscriber Cancellation Codes. If the subscriber will not be continuing any Blue Cross Blue Shield coverage, carefully select one of the following and indicate the three-digit code on the form.

Code # Reason for Canceling

041 • Changing to other health plan• Voluntary termination• COBRA cancellation (under 18 months or nonpayment)

042 • Over 65, changing to Group Medex® plan. (Requires Medicare A and B)• Over 65, changing to direct-pay Medex plan. (Requires Medicare A and B)• Over 65, changing to Medicare supplement other than Medex plans.

043 • Medicare (age =< 65)

Code # Reason for Canceling

061 • Left employment• COBRA ending

063 • Transfer

064 • Cancellation as of original effective date

070 • Deceased

071 • Moved out of state (out of HMO service area)

076 • Military service

Note: If your subscribers are adding or dropping one benefit only (medical/dental), please indicate “add medical,” “add dental,” “cancel medical,” or “cancel dental” in the “Remarks” section.If your new hires are subject to a probationary period, please indicate the time frame in the “Remarks” section, as well as the qualifying events for new enrollees.If a subscriber is being moved from an active group to a retiree group (within the same account), this is a transfer and not a termination. Please include the Medical or Dental Group # transferring to.Cancellation date will be the first day of no coverage.Qualifying Events—Remarks:To assist in the enrollment process, please use check boxes or write in applicable information in the “Remarks” section of the form.• Open Enrollment—Check this box for open enrollment.• New Hire—Check this box for new hires to the company.• COBRA—Check this box if person is continuing coverage under COBRA.• Add Spouse—Check this box if spouse is being added. Ensure date of marriage is within approved retroactive period.• Add Dependent—Check this box if adding any dependent.• Loss of Coverage—Check this box if person lost coverage through spouse or parent. Please include HIPAA Continuous of Coverage Letter from prior company/insurer.

If you have questions contact your account service representative.• Other—Check this box if change to family requires additional explanation. Please write in the reason for change (e.g., Court Order, Adoption, New Dependent Law under

HCR, Legal Guardianship, etc.). Include supporting documentation. If you have questions contact your account service representative.

Section 2 Yourself (Member 1)Please fill in all information that applies to you. (REQUIRED)*PCP ID#—If your health plan requires you to choose a primary care physician (PCP), please fill in this section. Write the PCP ID number (not the telephone number) of the doctor you have chosen to coordinate your health care. You’ll find the doctor’s PCP ID number in the provider directory for your health plan. If you need help choosing a PCP, please call our Physician Selection Service at 1-800-821-1388. A representative will be happy to help you select a doctor. PCP ID number can be found at www.bluecrossma.com, select Find a Doctor.Other Insurance—Do you have other health insurance or Medicare? Please be sure to circle either Y (for yes) or N (for no) ) in the correct box. If you have other insurance, please write the name of the other insurance company and its location (city and state).To Add or Delete a Member—Are you adding or deleting a member under your existing membership? If yes, please fill in the areas in Sections 1 and 2. You may need help from your employer to fill in Section 1. Then, give us the details about the members you’re adding or deleting in Section 3 and/or Section 4.

Section 3 Member 2If you choose a Family membership, please fill in this section if you want Member 2 to be covered. (REQUIRED)* (Note: Member 2 cannot be covered under an Individual membership.)Other Insurance—Does your spouse have other health insurance or Medicare? Please be sure to circle either Y (for yes) or N (for no) in the correct box. If your spouse has other insurance, please write the name of the other insurance company and its location (city and state).

Section 4 Your Eligible Dependents (Members 3, 4, and 5)If you choose a Family membership, please fill in this section for all children or other eligible dependents you want to be covered. (REQUIRED)* (Note: Dependents cannot be covered under an Individual membership.)If you have more than three dependents to be covered, please use additional Enrollment Forms as needed. Please indicate on the form that additional forms have been used and write in the total number of dependents you want to be enrolled.

Section 5 Personal Savings AccountYour employer may have chosen to offer a personal savings account alongside your medical offering. Please consult your open enrollment materials and/or your HR department to determine if this applies to you.For each option:Start Date: Your start date will be considered established for tax purposes as of the start date of your medical plan, provided that you have signed, dated and submitted the completed application for these accounts on or before that date.End Date: Your end date is the date you choose to stop deposits into the selected financial account. If you have any questions please see your employer.Note: If you are transferring from one medical/dental plan to another medical/dental plan, please provide notification that you will be continuing your personal savings account by completing Section 5 of the Enrollment and Change form.

Section 6 Signatures (Employer & Employee)Employee: Please sign & date the application and return it to your employer. Employer: Please sign & date the application and return to Blue Cross Blue Shield of Massachusetts.

(REQUIRED)* Under the Affordable Care Act, we are required to collect the Social Security number for you and any dependent enrolling in your plan.

® Registered Marks of the Blue Cross and Blue Shield Association. © 2014 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

1. To Be Filled Out by Your EmployerCompany Name

Current Medical Group #: Medical Group #, Transfering To:

Current BCBS ID #, If any Requested Effective Date

Date of Hire

Current Dental Group #: Dental Group #, Transferring To

MM DD YYYY MM DD YYYY

Type of Transaction

❒ ADD ❒ CANCEL ❒ CHANGE Three digit❒ TRANSFER termination code

Remarks: (i.e., qualifying event for a new add, change to family or other instruction)

❒ Open Enrollment ❒ New Hire ❒ COBRA

Change to Family ❒ Add Spouse ❒ Add Dependent

❒ Loss of Coverage (HIPAA Continuation of Coverage Letter Required)

❒ Other: __________________________________________

2. Yourself (Member 1)Whatproducts?

❒ Access Blue❒ Blue Choice❒ Blue Choice New England

❒ Blue Medicare Rx (Part D)❒ Dental Blue❒ HMO Blue

❒ HMO Blue New England❒ Managed Blue for Seniors❒ Medex (Group)

❒ Network Blue❒ PPO❒ Saver Blue

Membership Type (Medical) ❒ Individual ❒ Family

Membership Type (Dental) ❒ Individual ❒ Family

Your First Name

M.I. Last Name

Sex Date of Birth

Street Address/ P.O. Box #

Apt. # City/ Town

State Zip Code

Home Phone ( )

Cell Phone ( )

Email

Social Security # (REQUIRED)1

Other Insurance?2 Y ❒ / N ❒

Other Insurance Company Name

City / State

PCP ID # (see instructions)

Name of PCP

City / State Is this your current PCP?Y ❒ / N ❒

Are you covered by Medicare?2

Y ❒ / N ❒

Part A Effective Date Part B Effective Date Part D Effective Date Medicare # ❒ 65+ ❒ Disabled ❒ ESRDIf Retired, DateMM DD YYYY MM DD YYYY MM DD YYYY Actively Working? Y ❒ / N ❒

3. Member 2 Please Check One: ❒ Spouse ❒ Domestic Partner ❒ Divorced Spouse (court ordered) Plan Type: ❒ Medical ❒ DentalFirst Name

M.I. Last Name

Sex Date of Birth


Phone ( )

Other Insurance?1 Y ❒ / N ❒

Other Insurance Company Name

City / State


Name of PCP

City / State Is this your current PCP?Y ❒ / N ❒

Are you covered by Medicare?2

Y ❒ / N ❒

Part A Effective Date Part B Effective Date Part D Effective Date Medicare # ❒ 65+ ❒ Disabled ❒ ESRD

MM DD YYYY MM DD YYYY MM DD YYYY

If Retired, DateActively Working? Y ❒ / N ❒

4. Your Eligible Dependents (Member 3, 4, and 5)Dependent’s First Name 3.)

M.I. Last Name

Sex Date of Birth



Name of PCP

Is this your current PCP? Y ❒ / N ❒ Full-time student and aged 19 or older ❒ Disabled and aged 26 or older ❒ Plan Type: ❒ Medical ❒ DentalDependent’s First Name 4.)

M.I. Last Name

Sex Date of Birth



Name of PCP

Is this your current PCP? Y ❒ / N ❒ Full-time student and aged 19 or older ❒ Disabled and aged 26 or older ❒ Plan Type: ❒ Medical ❒ DentalDependent’s First Name 5.)

M.I. Last Name

Sex Date of Birth



Name of PCP

Is this your current PCP? Y ❒ / N ❒ Full-time student and aged 19 or older ❒ Disabled and aged 26 or older ❒ Plan Type: ❒ Medical ❒ Dental

Please check if you are using separate forms for additional dependent children ❒ Total # of dependents: _________________________________

5. Personal Savings Account HSA: Health Savings Account Start Date End Date FSA Goal Amount (Please

see instructions for limits.): $

FSA: Health Flexible Spending Account Start Date End Date Health: $

FSA: Dependent Care Reimbursement Account Start Date End Date Dependent Care: $

6. Signature (Employer & Employee)The information here is complete and true. I understand that Blue Cross and Blue Shield will rely on this information to enroll me and my dependents or to make changes to my membership. I understand that I should read the subscriber certificate or benefit booklet provided by my employer to understand my benefits and any restrictions that apply to my health care plan. I understand that Blue Cross and Blue Shield may obtain personal and medical information about me to carry out its business, and that it may use and disclose that information in accordance with law. I acknowledge that I may obtain further information about the collection, use, and disclosure of my information in “Our Commitment to Confidentiality,” Blue Cross and Blue Shield’s notice of privacy practices.

Employee’s Signature __________________________________Date _____________ Employer’s Signature ___________________________________ Date _____________

Please Read the Instructions Before Filling Out This Form.Please TYPE OR PRINT CLEARLY using blue or black ink to avoid coverage delay or type in information

Enrollment and Change FormPlease mail to: P.O. Box 986001

Boston, MA 02298 or fax to 1-617-246-7531

Blue Cross Blue Shield of Massachusetts is an Independent Licence of the Blue Cross and Blue Shield Association.

1. REQUIRED: Under the Affordable Care Act, we are required to collect the Social Security number for you and any dependent enrolling in your plan.2. If you have not indicated Y or N regarding your Medicare or other insurance status, you may receive a follow-up questionnaire.


Table of Contents

About This Guide and Online Resources 1

Mail Service Pharmacy 2

Your Pharmacy Cost Share and ID Card 2

Top Covered Medications

Over-the-Counter Medications

Quality Care Dosing

Prior Authorization

Specialty Pharmacy Medications

Step Therapy

Non-Covered Medications

Medication Resource List Index

New Medication Approval Process

Your Pharmacy Program

Effective January 1, 2015

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Overview

Pharmacy Program Overview

Our pharmacy program is designed to provide you and your doctor with access to a wide variety of safe, clinically effective medications. We have carefully developed a substantial formulary that includes many medications at affordable cost share levels.

About This Guide

This guide is up-to-date as of January 1, 2015, and is subject to change. Keep this guide handy, and use it as a reference whenever you need coverage information about a specific medication. To get the most current coverage information about a specific medication, visit our website at www.bluecrossma.com/pharmacy.

• TopCoveredMedications—includes many commonlyprescribed covered medications and your cost share tierthat applies

• Over-the-CounterMedications—includes a list ofover-the-counter medications that are covered whenprescribed for you by your doctor

• QualityCareDosing—includes a list of medicationssubject to Quality Care Dosing limits

• PriorAuthorization—includes a list of medicationsthat require Prior Authorization

• SpecialtyPharmacyMedications—includes a list ofmedications that are available through pharmacies in theSpecialty Pharmacy Network

• StepTherapy—includes a list of medications subject toStep Therapy

• MedicationResourceListIndex—includes all prescriptionmedications listed in this booklet, along with the page(s)on which they can be found

Online Resources

From our main website, www.bluecrossma.com, to the www.express-scripts.com website, we offer a variety of online resources to help you manage your medications.

• SearchforMedicationInformation. To learn whetheryour medications will be covered, you can visitwww.bluecrossma.com/pharmacy, and use theMedicationLookUp feature, listed on the left-hand sideof the page. You can use this tool before you enroll. (Themedication information represents our standard pharmacycoverage; your individual coverage may vary.) Our 2015formulary changes will not be reflected in this tool untilJanuary 1, 2015.

• MemberCentral. Want more detailed information aboutyour health care coverage, claims, or deductibles? You canlog on to Member Central by going to our website,www.bluecrossma.com/member-central. To register, click CreateanAccount, on the upper right-hand sideof the page.

— If you’re already registered, just log in with your user name and password.

• ExpressScriptsOnline. Once registered with MemberCentral, you can also get immediate, online access toinformation about your specific pharmacy benefit byvisiting Express Scripts Inc., (ESI), our pharmacymanagement partner, at www.express-scripts.com.Once there, you’ll have access to:

— Price a Drug

— Find a Pharmacy

— Mail Service features (which allow you to order refills and renew prescriptions)

1

Overview

Mail Service Pharmacy

With the Mail Service Pharmacy (administered by ESI), you can enjoy the convenience of having certain prescriptions delivered to you. Depending on your specific coverage, you can use the Mail Service Pharmacy to order up to a 90-day supply of certain long-term maintenance medications (like those used to treat high blood pressure), for less than you may normally pay at a retail pharmacy.

It’s convenient, cost-effective, and all information is handled in accordance with our confidentiality policy.

If you would like to use the Mail Service Pharmacy, you can download an order form and find additional information on our website. Go to www.bluecrossma.com/pharmacy and choose Mail Service Pharmacy from the menu on the left-hand side. If you’d like our MailServicePharmacy brochure mailed to you, please call 1-800-262-BLUE(2583).

Your Pharmacy Cost Share

Our pharmacy program formulary is based on a tiered cost share structure. When you fill a prescription, the amount you pay the pharmacy (your prescription cost share) is determined by the tier your medication is on. Medications are placed on tiers according to a variety of factors, including what they are used for, their cost, and whether equivalent or alternative medications are available. The pharmacy will advise you of the amount you owe. Usually, you will pay the least amount of cost share for Tier 1 medications and the most for Tier 3 medications.

Your cost share may include your copayment, co-insurance, and deductibles. For more about your specific prescription benefits, review the information in your benefit literature, which you should have received when you enrolled in your plan, or call the Member Service number listed on the front of your ID card, Monday through Friday, 8:00 a.m. to 9:00 p.m. ET.

Your ID Card

Your ID card contains important information about your pharmacy benefits. Be sure to bring the card with you and give it to your pharmacist when you fill a prescription. A sample ID card is shown below.

3

Your Pharmacy Cost ShareOur pharmacy program formulary is based on a tiered cost share structure .When you fill a prescription, the amount you pay the pharmacy (yourprescription cost share) is determined by the tier your medication is on .Medications are placed on tiers according to a variety of factors, including whatthey are used for, their cost, and whether equivalent or alternative medicationsare available . The pharmacy will advise you of the amount you owe .Usually, you will pay the least amount of cost share for Tier 1 medications andthe most for Tier 3 medications .

Your cost share may include your copayment, co-insurance, deductibles,and maximums . For more about your specific prescription benefits, review theinformation in your benefit literature, which you should have received whenyou enrolled in your plan, or call the Member Service number listed on the frontof your ID card, Monday through Friday, 8:00 a .m . to 9:00 p .m . ET .

Your ID CardYour ID card contains important information about your pharmacybenefits . Be sure to bring the card with you and give it to your pharmacistwhen you fill a prescription . A sample ID card is shown below .

SAM SAMPLE

XXH123456789MEMBER SUFFIX: 00

HMO BlueTM

Copays OV 15BH 15 ER 40

Member Service 1-800-000-0000RxBin: 003858 PCN: A4RxGRP: MASA

SMPLL

r Sr SerervvSeServrvr Ser Servrv0-0-000000-0-000 000000 0000 000000 0000 000000 00

RxBinRxBin: 0: 0038503858 P8 PRxBinRxBin: 0: 00385038588RxBin: RxBin: 0000385385RxGRP: RxGRP: MMRxGRP:RxGRP:RxGRRxGR

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Our pharmacy formulary includes over 4,000 covered prescription medications. The following sample list includes covered medications most commonly prescribed for our members.

This list is up-to-date as of January 1, 2015, and is subject to change at any time. You can find the most up-to-date information about a specific prescription medication on our website at www.bluecrossma.com/pharmacy.

Pleasenotethatthisisasampleoftopprescribedmedicationsbasedonourstandardformulary.

For more information about your specific prescription benefits, review the information in your benefit literature, which you should have received when you enrolled in your plan, or call the Member Service number listed on the front of your ID card.

The following covered medication list is based on our standard formulary. The tier that is assigned to the drug is the tier used in a three-tier cost share benefit structure. For members with a two-tier or four-tier cost share benefit structure, please log on to the Blue Cross and Blue Shield web site at www.bluecrossma.com/pharmacy and use the Medication Lookup feature.

Abilify tablets (STEP) Tier 2

Accu-Chek Aviva testing strips (QCD) Tier 2

Acetaminophen/Codeine Tier 1

Acyclovir Tier 1

Adapalene Tier 1

Advair Diskus (QCD) (STEP) Tier 3

Albuterol Tier 1

Alendronate (QCD) Tier 1

Allopurinol Tier 1

Alprazolam Tier 1

Altavera Tier 1

Alyacen Tier 1

Amitriptyline Tier 1

Amlodipine/Benazepril Tier 1

Amolodipine (QCD) Tier 1

Amoxicillin Tier 1

Amoxicillin TR-Potassium Clavulanate Tier 1

Amphetamine Salt Combination Tier 1

Anastrozole Tier 1

Apri Tier 1

Armour Thyroid Tier 3

Asacol HD Tier 2

Atenolol Tier 1

Atorvastatin (QCD) Tier 1

Aviane Tier 1

Azathioprine Tier 1

Azelastine (QCD) Tier 1

Azithromycin Tier 1

Baclofen Tier 1

Benicar (STEP) Tier 2

Benicar HCT (STEP) Tier 2

Benzonatate Tier 1

Betamethasone Dipropionate Tier 1

Budesonide (QCD) Tier 1

Buprenorphine/Naloxone (PA) (QCD) Tier 2

Bupropion Tier 1

Bupropion SR (QCD) Tier 1

Bupropion XL (QCD) Tier 1

Buspirone Tier 1

Butalbital/APAP/Caffeine Tier 1

Camila Tier 1

Carbidopa/Levodopa Tier 1

Carisoprodol Tier 1

Carvedilol Tier 1

Cefadroxil Tier 1

Cefdinir Tier 1

Cefuroxime Tier 1

Celebrex (QCD) (STEP) Tier 3

Cephalexin Tier 1

Chantix Tier 2

Chlorhexadine Gluconate Tier 1

Chlorthalidone Tier 1

Cialis Tier 3

Ciprofloxacin Tier 1

Citalopram (QCD) Tier 1

Clarithromycin Tier 1

Clindamycin Tier 1

Clindamycin/Benzoyl Peroxide Tier 1

Clobetasol Propionate Tier 1

Clonazepam Tier 1

Clonidine Tier 1

Clopidogrel Tier 1

Clotrimazole/Betamethasone Tier 1

Colcrys Tier 2

Combivent Respimat (QCD) Tier 2

Crestor (QCD) (STEP) Tier 2

Cryselle Tier 1

Cyclobenzaprine Tier 1

Desonide Tier 1

Dexamethasone Tier 1

Dextroamphetamine/Amphetamine Tier 2

Diazepam Tier 1


(PA) Prior Authorization required(QCD) Quality Care Dosing limits apply

(STEP) Step Therapy required

3

Diclofenac Tier 1

Dicyclomine Tier 1

Digoxin Tier 1

Diltiazem ER Tier 1

Diovan (STEP) Tier 3

Divalproex Sodium Tier 1

Divalproex Sodium ER Tier 1

Donepezil Tier 1

Dorzolamide/Timolol Tier 1

Doxazosin Tier 1

Doxycycline Hyclate Tier 1

Doxycycline Monohydrate Tier 1

Duloxetine (QCD) Tier 1

Econazole Tier 1

Emoquette Tier 1

Enalapril Tier 1

Enbrel (PA) (QCD) Tier 2

Enoxparin Sodium (QCD) Tier 2

Enpresse Tier 1

Epi-Pen AutoInjector (QCD) Tier 2

Epi-Pen JR. AutoInjector (QCD) Tier 2

Erythromycin Tier 1

Escitalopram (QCD) Tier 1

Estrace Cream Tier 2

Estradiol Tier 1

Fenofibrate Tier 1

Fentanyl patches (PA) (QCD) Tier 1

Finasteride Tier 1

Flovent HFA inhaler (QCD) Tier 2

Fluconazole (QCD) Tier 1

Fluocinonide Tier 1

Fluoxetine (QCD) Tier 1

Fluticasone nasal spray (QCD) Tier 1

Folic Acid Tier 1

Furosemide Tier 1

Gabapentin Tier 1

Gemfibrozil Tier 1

Gianvi Tier 1

Gildess Tier 1

Gildess FE Tier 1

Glimepiride Tier 1

Glipizide Tier 1

Glipizide ER Tier 1

Glipizide XL Tier 1

Glyburide Tier 1

Guanfacine Tier 1

Humalog (QCD) Tier 2

Humira (PA) (QCD) Tier 2

Hydrochlorothiazide Tier 1

Hydrocodone/APAP Tier 1

Hydrocodone/Chlorpheniramine Tier 1

Hydrocortisone Tier 1

Hydromorphone Tier 1

Hydroxychloroquine Tier 1

Hydroxyzine Tier 1

Ibuprofen Tier 1

Indomethacin Tier 1

Iophen-C NR Tier 1

Irbesartan Tier 1

Isosorbide Mononitrate Tier 1

Januvia (STEP) Tier 2

Junel Tier 1

Junel FE Tier 1

Kariva Tier 1

Kelnor 1-35 Tier 1

Ketoconazole Tier 1

Ketorolac Tier 1

Klor-Con Tier 1

Labetalol Tier 1

Lamotrigine Tier 1

Lansoprazole (PA) (QCD) Tier 1

Lantus (QCD) Tier 2

Lantus Solostar (QCD) Tier 2

Latanoprost Tier 1

Levetiracetam Tier 1

Levitra Tier 3

Levofloxacin Tier 1

Levothyroxine Tier 1

Lidocaine Tier 1

Liothyronine Sodium Tier 1

Lisinopril Tier 1

Lisinopril/HCTZ Tier 1

Lithium Carbonate Tier 1

lo Loestrin FE Tier 3

Lorazepam Tier 1

Loryna Tier 1

Losartan Tier 1

Losartan/HCTZ Tier 1

Lovastatin (QCD) Tier 1

Lutera Tier 1

Medroxyprogesterone Tier 1

Meloxicam (QCD) Tier 1

Metformin Tier 1

Metformin ER Tier 1

Methimazole Tier 1

Methocarbamol Tier 1

Methotrexate Tier 1

Methylphenidate Tier 1

Methylphenidate ER (QCD) Tier 1

Methylprednisolone Tier 1

Metoclopramide Tier 1

Metoprolol Succinate Tier 1

Metoprolol Tartrate Tier 1

Metronidazole Tier 1

Microgestin FE Tier 1

Minastrin FE Tier 3

Minocycline Tier 1

Mirtazapine (QCD) Tier 1

Modafinil (PA) Tier 1

Mometasone Tier 1

Montelukast Tier 1

Morphine Sulfate ER (PA) (QCD) Tier 1

Mupirocin Tier 1

Nabumetone Tier 1

Nadolol Tier 1

Namenda Tier 2

Naproxen Tier 1


(PA) Prior Authorization required(QCD) Quality Care Dosing limits apply(STEP) Step Therapy required

4

Necon Tier 1

Nifedipine ER Tier 1

Nitrofurantoin Tier 1

Norethindrone Tier 1

Norgestimate/Ethinyl Estradiol Tier 1

Nortrel Tier 1

Nortriptyline Tier 1

Nystatin Tier 1

Nystatin/Triamcinolone Tier 1

Ocella Tier 1

Ofloxacin Tier 1

Olanzapine Tier 1

Omeprazole (QCD) Tier 1

Ondasetron (QCD) Tier 1

Ondasetron ODT (QCD) Tier 1

One Touch Delica testing strips (QCD) Tier 2

One Touch Ultra testing strips (QCD) Tier 2

Orsythia Tier 1

Ortho Tri-Cyclen Lo Tier 3

Oxcarbazepine Tier 1

Oxybutynin Tier 1

Oxycodone Tier 1

Oxycodone/APAP Tier 1

Oxycontin (PA) (QCD) Tier 2

Pantoprazole (QCD) Tier 1

Paroxetine (QCD) Tier 1

Penicillin Tier 1

Phenazopyridine Tier 1

Pioglitazone (QCD) (STEP) Tier 1

Ploymyxin B-Sul/Trimethoprim Tier 1

Potassium Chloride Tier 1

Pramipexole Tier 1

Pravastatin (QCD) Tier 1

Prednisone Tier 1

Premarin Tier 2

Prempro Tier 2

Prenatal Plus Tier 1

ProAir HFA inhaler (QCD) Tier 2

Prochlorperazine Tier 1

Progesterone Tier 1

Promethazine Tier 1

Promethazine/Codeine Tier 1

Propranolol Tier 1

Propranolol ER Tier 1

Pulmicort FlexHaler (QCD) Tier 2

Quetiapine Tier 1

Quinapril Tier 1

QVAR (QCD) Tier 2

Ramipril Tier 1

Ranitidine Tier 1

Reclipsen Tier 1

Restasis (PA) (QCD) Tier 3

Risperidone Tier 1

Ropinirole Tier 1

Sertraline (QCD) Tier 1

Simvastatin Tier 1

Spiriva HandiHaler (QCD) Tier 2

Spironolactone Tier 1

Sprintec Tier 1

Strattera (PA) (QCD) Tier 3

Suboxone (PA) (QCD) Tier 2

Sulfamethoxizole/Trimethoprim Tier 1

Sumatriptan (QCD) Tier 1

Suprep Tier 3

Symbicort (QCD) (STEP) Tier 2

Synthroid Tier 3

Tamiflu Tier 3

Tamoxifen Tier 1

Tamsulosin Tier 1

Temazepam Tier 1

Terazosin Tier 1

Terbinafine Tier 1

Timolol Maleate Tier 1

Tizanidine Tier 1

Tobramycin/Dexamethasone Tier 1

Topiramate Tier 1

Toprol XL Tier 3

Tramadol Tier 1

Trazodone Tier 1

Tretinoin (PA) Tier 1

Tri-Previfem Tier 1

Tri-Sprintec Tier 1

Triamcinolone Acetonide Tier 1

Triamterene/HCTZ Tier 1

Trinessa Tier 1

Vagifem Tier 2

Valacyclovir (QCD) Tier 1

Valsartan/HCTZ Tier 1

Venlafaxine Tier 1

Venlafaxine ER capsules (QCD) Tier 1

Verapmil ER Tier 1

Vesicare (STEP) Tier 2

Viagra Tier 3

Viorelle Tier 1

Vitamin D2 Tier 1

Vivelle-DOT (QCD) Tier 3

Voltaren gel Tier 3

Warfarin Tier 1

Xarelto Tier 2

Zetia (QCD) (STEP) Tier 3

Zolpidem (QCD) Tier 1

Zolpidem ER (QCD) Tier 1


(PA) Prior Authorization required(QCD) Quality Care Dosing limits apply

(STEP) Step Therapy required

5

For non-grandfathered health plans under the Affordable Care Act, the following list includes over-the-counter medications that are covered with no cost share when they are prescribed for you by your doctor. This list is up to date as of January 1, 2015, and is subject to change at any time.

Generic Aspirin (81mg) is covered for females age 55–79 and males age 45–79.

Generic Folic Acid is covered for females up to age 50.

Generic Iron is covered for infants up to 12 months old.

Generic Smoking Cessation is covered for up to two 90-day supplies per calendar year.

Generic Vitamin D is covered for females of child bearing age and males age 65 and older.

Generic women’s contraceptives (e.g. female condoms, sponges, and spermicide) are covered.

6

Over-the-Counter Medications

Quality Care Dosing

Quality Care Dosing

Our Quality Care Dosing program helps to ensure that the quantity and dose of medications you receive comply with Food and Drug Administration (FDA) recommendations, as well as manufacturer and clinical information. When you fill a prescription for one of the following medications, it is checked electronically in two ways:

• DoseConsolidation—Checks to see whether you’re takingtwo or more pills a day that can be replaced with one pillproviding the same daily dosage.

• RecommendedMonthlyDosingLevel—Checks tosee that your monthly dosage is consistent with themanufacturer’s and FDA’s monthly dosingrecommendations and clinical information.

We will get your doctor’s approval before making any changes to your prescribed medications.

For the most up-to-date list of medications subject to Quality Care Dosing, along with associated dosing limits, please visit our website at www.bluecrossma.com/pharmacy and proceed to the QualityCareDosing section.

Please note: Your doctor may request an exception from the guidelines for medications that are subject to Quality Care Dosing (when medically necessary).

Quality Care Dosing List

This list of medications that are in our Quality Care Dosing program is up-to-date as of January 1, 2015, and may change from time to time.

Abstral * (PA)

AcipHex * (PA)

Actiq * (PA)

Actonel (STEP)

ACTOplus Met (STEP)

ACTOplus Met XR (STEP)

Actos (STEP)

Acular *

Acular LS *

Acular PF

Adderall XR

Advair Diskus (STEP)

Advair HFA (STEP)

Advicor (STEP)

Aerobid *

Aerobid-M *

Alendronate Sodium

Alora *

Alrex *

Alsuma *

Altoprev (STEP)

Alupent inhaler

Alvesco *

Ambien *

Ambien CR *

Amerge

Amitiza

Amlodipine

Amlodipine-Atorvastatin

Ampyra (PA) (SP)

Anzemet *

Aplenzin ER *

Aranesp (PA) (SP) (SPO)

Arava *

Arcapta Neohaler *

Arixtra *

Asmanex Twisthaler *

Astelin

Astepro *

Atelvia DR * (STEP)

Atorvastatin

Atrovent (nasal spray)

Atrovent HFA

Auvi-Q *

Avandamet (STEP)

Avandia (STEP)

Quality Care Dosing

* (non-covered medication) Quality Care Dosing limits apply for members with approved formulary exceptions** (new to market drug; non-covered while under review) quantity limits apply to members with approved formulary exceptions

(PA) prior authorization required(PA17) prior authorization required for members who are 17 years of age or older

(QCD) Quality Care Dosing limits apply(SP) Medication is part of the specialty pharmacy network

(SPO) Available in pharmacy benefit only(STEP) step therapy required

7

Avinza *

Avonex (SP) (SPO)

Axert *

Azelastine (nasal spray)

Azmacort *

Beconase AQ *

Belviq (PA)

Betaseron (SP) (SPO)

Binosto * (STEP)

Boniva tablets * (STEP)

Brintellix *

Brisdelle *

Budeprion SR

Budeprion XL

Budesonide (nasal spray)

Budesonide (nebules)

Bunavail (PA)

Buprenex (PA)

Buprenorphine (PA)

Buprenorphine-Naloxone (PA)

Bupropion SR

Bupropion XL

Butorphanol NS

Butrans *

Cabergoline

Caduet * (STEP)

Cardura *

Cardura XL *

Catapres TTS

Celebrex

Celexa *

Cesamet *

Ciclodin solution/kit

Ciclopirox nail lacquer

Citalopram

Climara

Climara Pro

Clonidine patch

CNL 8 nail kit *

Combivent

Combivent Respimat

Concerta

Copaxone (SP) (SPO)

Crestor (STEP)

Crolom ophthalmic

Cromolyn ophthalmic

Cymbalta

Desvenlafaxine ER *

Dexilant * (PA)

Dexmethylphenidate XR

Dextroamphetamine/Amphetamine ER

Diflucan (150 mg only)

Dihydroergotamine (nasal spray)

Doxazosin

Dulera (STEP)

Duloxetine

Duragesic * (PA)

Dymista *

Edluar *

Effexor XR *

Embeda *

Emend

Enbrel (PA) (SP) (SPO)

Enoxaparin

Epi-Pen Auto-Injector

Epinephrine injection

Epogen (PA) (SP) (SPO)

Escitalopram

Esomeprazole Strontium * (QCD)

Estraderm

Estradiol patch

Estrasorb *

Estrogel *

Eszopiclone

Evamist *

Evzio

Exalgo *

Extavia (SP) (SPO)

Famciclovir

Famvir *

Fentanyl oral/mucosal (PA)

Fentanyl patch (PA)

Fentora * (PA)

Fetzima

Flonase *

Flovent/HFA

Fluconazole (150 mg only)

Flunisolide

Fluoxetine

Fluoxetine DR

Fluticasone

Fluvastatin

Fluvoxamine

Fluvoxamine CR

Focalin XR *

Fondaparinux

Quality Care Dosing

* (non-covered medication) Quality Care Dosing limits apply for members with approved formulary exceptions** (new to market drug; non-covered while under review) quantity limits apply to members with approved formulary exceptions(PA) prior authorization required(PA17) prior authorization required for members who are 17 years of age or older(QCD) Quality Care Dosing limits apply(SP) Medication is part of the specialty pharmacy network(SPO) Available in pharmacy benefit only(STEP) step therapy required

8

Foradil

Forfivo XL *

Forteo (PA) (SP) (SPO)

Fosamax * (STEP)

Fosamax Plus D (STEP)

Fragmin *

Frova *

Gatifloxacin

Gilenya (SP)

Glucose testing strips (all brands)

Granisetron

Granisol

Granix

Grastek (PA)

Hetlioz (PA)

Humira (PA) (SP) (SPO)

Hydromorphone ER (PA)

Hytrin *

Ibandronate

Imitrex

Infergen (PA) (SP) (SPO)

Insulins (all brands)

Intermezzo *

Ipratropium NS

Itraconazole

Kadian * (PA)

Ketorolac ophthalmic

Khedezla *

Kytril *

Lamisil *

Lansoprazole (PA)

Lansoprazole/Amoxicillin/Clarithromycin

Lazanda * (PA)

Leflunomide

Lescol * (STEP)

Lescol XL * (STEP)

Lexapro

Lidocaine Patch

Lidoderm

Linzess

Lipitor * (STEP)

Liptruzet **

Livalo * (STEP)

Lotronex

Lovastatin

Lovenox *

Lunesta

Luvox CR *

Lysteda *

Maxair Autohaler *

Maxalt *

Maxalt-MLT *

Meloxicam

Menostar *

Metadate CD

Methylphenidate CD

Methylphenidate ER

Mevacor * (STEP)

Migranal

Minivelle

Mirtazapine

Mirtazapine Rapid Dissolve

Mobic *

Morphine Sulfate ER (PA)

Moxeza *

MS Contin (PA)

Naratriptan

Nasonex *

NebuPent

Neulasta (SP)

Neupogen (SP)

Nexium * (PA)

Norvasc *

Olanzepine-Fluoxetine

Omeprazole

Omeprazole-Sod. Bicarbonate * (PA)

Omnaris *

Omontys (PA) (SP)

Ondansetron

Ondansetron ODT

Onmel *

Onsolis * (PA)

Opana ER * (PA)

Optivar *

Oralair (PA)

Oramorph SR * (PA)

Otezla (PA) (SP)

Oxycodone ER (PA)

OxyContin (PA)

Oxymorphone ER (PA)

Pantoprazole

Paroxetine

Paroxetine CR

Patanase *

Paxil *

Paxil CR *

Quality Care Dosing





9

Pediapirox-4

PEG-Intron (SP) (SPO)

Pegasys (SP) (SPO)

Penlac *

Pexeva *

Pioglitazone (STEP)

Pioglitazone-Glimepiride (STEP)

Pioglitazone-Metformin (STEP)

Pravachol * (STEP)

Pravastatin

Prevacid * (PA)

PrevPac *

Prilosec * (PA)

Pristiq *

ProAir HFA

Procrit (PA) (SP) (SPO)

Protonix * (PA)

Proventil HFA *

Prozac *

Prozac Weekly *

Pulmicort Flexhaler

Pulmicort Respules

QNASL *

Qualaquin

Qutenza (SP)

QVAR

Rabeprazole (PA)

Ragwitek (PA)

Rapaflux

Rebif (SP) (SPO)

Relpax *

Remeron *

Remeron Soltab *

Restasis (PA)

Rhinocort Aqua *

Risedronate

Ritalin LA *

Rizatriptan

Rozerem

Sancuso *

Sarafem *

Selferma

Serevent Diskus

Sertraline

Silenor *

Simcor * (STEP)

Simponi (PA) (SP) (SPO)

Simvastatin

Sonata

Spiriva

Sporanox *

Strattera (PA17)

Suboxone (PA)

Subsys * (PA)

Subutex (PA)

Sumatriptan

Sumavel Dosepro *

Symbicort (STEP)

Symbyax

Terazosin

Terbinafine

Terbinex *

Tranexamic Acid

Treximet *

Tudorza

Valacylovir

Valtrex

Venlafaxine ER capsule

Venlafaxine ER tablet

Ventolin HFA *

Veramyst *

Vigamox *

Viibryd *

Vivelle

Vivelle-Dot

Vytorin * (STEP)

Vyvanse *

Wellbutrin SR *

Wellbutrin XL *

Xartemis XR * (PA)

Xopenex HFA *

Zaleplon

Zegerid * (PA)

Zetia (STEP)

Zetonna *

Zocor * (STEP)

Zofran *

Zofran ODT *

Zohydro ER * (PA)

Zolmitriptan

Zolmitriptan ODT

Zoloft *

Zolpidem

Zolpidem ER

Zolpimist *

Zomig *

Quality Care Dosing

* (non-covered medication) Quality Care Dosing limits apply for members with approved formulary exceptions** (new to market drug; non-covered while under review) quantity limits apply to members with approved formulary exceptions(PA) prior authorization required(PA17) prior authorization required for members who are 17 years of age or older(QCD) Quality Care Dosing limits apply(SP) Medication is part of the specialty pharmacy network(SPO) Available in pharmacy benefit only(STEP) step therapy required

10

Zomig ZMT *

Zubsolv **

Zuplenz *

Zymar *

Zymaxid *

Quality Care Dosing





11

Prior Authorization

Prior Authorization

Your doctor is required to obtain prior authorization before prescribing specific medications. This ensures that your doctor has determined that this medication is necessary to treat you, based on specific medical standards.

For the most up-to-date list of medications that require prior authorization, please visit our website, www.bluecrossma.com/pharmacy, click on PharmacyManagementProgram, and proceed to PriorAuthorization.

Another part of our prior authorization program is step therapy. Please refer to page for a list of medications

that require step therapy.

Prior Authorization List

This list of medications that require prior authorization is up-to-date as of January 1, 2015, and may change from time to time.

19

Abstral * (QCD)

AcipHex * (QCD)

Actemra (SP)

Acthar (SP)

Actiq * (QCD)

Adcirca (SP)

Amevive (MBO)

Amphetamines (e.g Amphetamine,

Methamphetamine, Liquadd, Procentra)

Ampyra (QCD) (SP)

Aralast (MBO)

Aralast NP (MBO)

Aranesp (QCD) (SP) (SPO)

Avinza * (QCD)

Belviq

Boniva syringe * (SP)

Botulinum toxin

Bunavail (QCD)

Buprenex

Buprenorphine (QCD)

Buprenorphine-Naloxone (QCD)

Butrans * (QCD)

Ceredase (MBO)

Cerezyme (MBO)

Cimzia (SP) (SPO)

Cinryze (MBO)

Desoxyn (PA17)

Dexilant * (QCD)

Dextroamphetamines (e.g. Dexedrine)

(PA17)

Dificid

Diskets

Dolophine

Duragesic * (QCD)

Dysport

Egrifta (SP)

Elidel

Embeda * (QCD)

Enbrel (QCD) (SP) (SPO)

Enteral formula

Entyvio (SP)

Epogen (QCD) (SP) (SPO)

Erbitux (MBO)

Esomeprazole Strontium * (QCD)

Euflexxa * (SPO)

Exalgo * (QCD)

Eylea (MBO)

Factor VIII, VIIIa, IX, XIII (MBO)

Fentanyl oral/mucosal (QCD)

Fentanyl patch (QCD)

Fentora * (QCD)

First-lansoprazole

First-omeprazole

Forteo (QCD) (SP) (SPO)

Gel-One * (SPO)

Grastek (QCD)

Growth Hormone (SP) (SPO)

Hetlioz (QCD)

Humira (QCD) (SP) (SPO)

Hyalgan * (SPO)

Prior Authorization

* (non-covered medication) Quality Care Dosing limits apply for members with approved formulary exceptions** (new to market drug; non-covered while under review) quantity limits apply to members with approved formulary exceptions(MBO) medical benefit only(PA) prior authorization required(PA17) prior authorization required for members who are 17 years of age or older(PA30) prior authorization required for members who are 30 years of age or older(QCD) Quality Care Dosing limits apply(SP) Medication is part of the specialty pharmacy network(SPO) pharmacy benefit only(STEP) step therapy required

12

Ilaris (SP) (SPO)

Incivek (SP) (SPO)

Interferons (alpha, gamma)

IV Immunoglobulin (MBO)

Kadian * (QCD)

Kalydeco

Kineret (SP) (SPO)

Lansoprazole (QCD)

Lazanda * (QCD)

Leukine (SP)

Lucentis (MBO)

Lyrica

Macugen (MBO)

Makena (SP)

Methadone

Methadose

Modafinil

Monovisc * (SPO)

Morphine Sulfate CR (QCD)

Morphine Sulfate ER (QCD)

MS Contin (QCD)

Myalept (SP)

Nexium * (QCD)

Nucynta ER *

Nutritional Supplements

Nuvigil * (PA17)

Olysio (SP)

Omeprazole-Sod. Bicarbonate * (QCD)

Omontys (SP) (SPO)

Onsolis * (QCD)

Opana ER * (QCD)

Oralair (QCD)

Oramorph SR * (QCD)

Orencia (SP)

Orthovisc * (SPO)

Otezla (QCD) (SP)

Oxycodone ER (QCD)

Oxycontin (QCD)

Oxymorphone ER (QCD)

Preservative-Free Morphine (MBO)

Prevacid * (QCD)

Prilosec * (QCD)

Procrit (QCD) (SP) (SPO)

Prolastin (MBO)

Prolastin C (MBO)

Proleukin (SP)

Prolia (SP) (SPO)

Protonix * (QCD)

Protopic

Provigil (PA17)

Rabeprazole (QCD)

Ragwitek (QCD)

Reclast (MBO)

Regranex

Remicade (SP)

Respiratory SyncytialVirus IG/Synagis (SP)

Restasis (QCD)

Revatio * (SP)

Rituxan (SP)

Sildenafil (SP)

Simponi (QCD) (SP) (SPO)

Sovaldi (SP)

Stelara * (SP) (SPO)

Strattera (PA17) (QCD)

Suboxone (QCD)

Subsys * (QCD)

Supartz * (SPO)

Synagis (SP)

Synvisc * (SPO)

Synvisc One * (SPO)

Topical Retinoic Acid derivatives (e.g.

Retin A) (PA30)

TPN (total parenteral nutrition) (MBO)

Tysabri (MBO)

Vectibix (MBO)

Victrelis (SP)

Xalkori (SP)

Xeljanz * (SP)

Xenazine

Xeomin

Xgeva (SP) (SPO)

Xiaflex (MBO)

Xolair (MBO)

Zegerid * (QCD)

Zelboraf (SP)

Zometa (MBO)

Zubsolv (QCD)

Zykadia (SP)

Prior Authorization


(MBO) medical benefit only(PA) prior authorization required

(PA17) prior authorization required for members who are 17 years of age or older(PA30) prior authorization required for members who are 30 years of age or older


(SPO) pharmacy benefit only(STEP) step therapy required

13



Blue Cross Blue Shield of Massachusetts has set up a network of retail specialty pharmacies to dispense certain medications classified as specialty. The following is a list of medications that can only be purchased from one of the pharmacies in this network in order for coverage to be available.

This list is up-to-date as of January 1, 2015. You can find the latest information about your medications and look up pharmacy contact information by visiting www.bluecrossma.com/pharmacy.

Network Pharmacy Information

AcariaHealth 1-866-892-1202www.acariahealth.com

Accredo Health Group, Inc. /CuraScript 1-877-988-0058www.accredo.com

CVS Caremark, Inc. 1-866-846-3096www.caremark.com

OncoMed, the Oncology Pharmacy 1-877-662-6633www.oncomed.net

Network Pharmacy Information for Medications Most Commonly Used for Fertility

BriovaRx 1-800-850-9122www.briovarx.com

Freedom Fertility Pharmacy 1-866-297-9452www.freedomfertility.com

Metro Drugs 1-888-258-0106www.metrodrugs.com

Village Fertility Pharmacy 1-877-334-1610www.villagefertilitypharmacy.com

Walgreens 1-800-424-9002www.walgreens.com/pharmacy/specialpharmacy.jsp

Specialty Pharmacy

14

Fertility MedicationsBravelle * (SPO)

Cetrotide (SPO)

Clomid

Clomiphene

Endometrin

Follistim AQ * (SPO)

Ganirelix (SPO)

Gonal F Rff Rediject (SPO)

Gonal F/Gonal F RFF (SPO)

Human Chorionic Gonadotropin (HCG)

(SPO)

Leuprolide (SPO)

Lupron Depot

Lupron Depot-Ped

Luveris (SPO)

Menopur (SPO)

Novarel

Ovidrel (SPO)

Pregnyl (SPO)

Repronex (SPO)

Serophene

Injectable MedicationsAbraxane

Actemra (PA)

Acthar (PA)

Actimmune (PA) (SPO)

Adriamycin PFS

Adrucil

Alferon N (PA)

Alkeran

Apokyn

Aranesp (PA) (QCD) (SPO)

Arcalyst Injection (SPO)

Aredia

Arzerra

Aveed

Avonex (QCD) (SPO)

Betaseron (QCD) (SPO)

BiCNu

Bleomycin Sulfate

Boniva Injection * (PA)

Busulfex

Calcium Folanate

Camptosar

Carboplatin

Cerubidine

Cimzia (PA) (SPO)

Cisplatin

Cladribine

Copaxone (QCD) (SPO)

Cosmegen

Cyclophosphamide

Cyramza

Cytarabine

Cytoxan

Dacarbazine

Dactinomycin

Daunorubicin HCL

DaunoXome

DDAVP *

Depocyt

Desmopressin Acetate

Dexrazoxane

Docefrez

Docetaxel

Doxil

Doxorubicin HCl

DTIC-Dome

Egrifta (PA)

Eligard

Ellence

Eloxatin

Elspar

Enbrel (PA) (QCD) (SPO)

Entyvio (PA)

Epirubicin

Epogen (PA) (QCD) (SPO)

Ethyol

Etopophos

Etoposide

Extavia * (QCD) (SPO)

Faslodex

Firazyr

Firmagon

Floxuridine

Fludara

Fludarabine phosphate

Fluorouracil

Forteo (PA) (QCD) (SPO)

FUDR

Fusilev I.V.

Fuzeon (SPO)

Gattex

Gazyva

Gemcitabine

Gemzar

Genotropin * (PA) (SPO)

Granix

Specialty Pharmacy



(QCD) Quality Care Dosing limits apply(SPO) available in pharmacy benefit only

(STEP) step therapy required

15

Herceptin

Humatrope (PA) (SPO)

Humira (PA) (QCD) (SPO)

Hycamtin

Ibandronate

Idamycin PFS

Idarubicin

Ifex

Ifosfamide

Ifosfamide/Mesna

Ilaris (PA) (SPO)

Increlex (PA) (SPO)

Infergen (PA) (QCD) (SPO)

Intron A (PA) (SPO)

Irinotecan

Istodax

Kenalog

Keytruda

Kineret (PA) (SPO)

Kynamro (STEP)

Leucovorin Calcium

Leukine (PA)

Leuprolide Acetate (SPO)

Leustatin

Lipodox

Lipodox-50

Lupaneta Pack

Lupron Depot

Lupron Depot-Ped

Makena (PA)

Marqibo

Mesna

Mesnex

Methotrexate

Mitomycin

Mitoxantrone

Mozobil

Mustargen

Myalept (PA)

Mylotarg

Navelbine

Neosar

Neulasta (QCD)

Neumega

Neupogen (QCD)

Nipent

Norditropin * (PA) (SPO)

Norditropin Flexpro * (PA) (SPO)

Norditropin Nordiflex * (PA) (SPO)

Novantrone

Nplate

Nutropin (PA) (SPO)

Nutropin AQ (PA) (SPO)

Nutropin AQ Nuspin (PA) (SPO)

Octreotide injection (SPO)

Omnitrope * (PA) (SPO)

Omontys (PA) (QCD)

Oncaspar

Ontak

Onxol

Orencia (PA)

Oxaliplatin

Paclitaxel

Pamidronate

Pamidronate disodium

Peg-Intron (QCD) (SPO)

Pegasys (QCD) (SPO)

Photofrin

Procrit (PA) (QCD) (SPO)

Proleukin (PA)

Prolia (PA) (SPO)

Raptiva

Rebif (QCD) (SPO)

Remicade (PA)

Revatio * (PA)

Rituxan (PA)

Ruconest **

Saizen * (PA) (SPO)

Sandostatin (SPO)

Sandostatin-LAR

Serostim (PA) (SPO)

Signafor **

Simponi (PA) (QCD) (SPO)

Simponi Aria (PA)

Simulect

Somatuline

Somavert (SPO)

Stelara * (PA) (SPO)

Sylatron (PA)

Sylvant

Synagis (PA)

Synribo

Tarabine

Taxol

Taxotere

Teniposide

Tev-Tropin * (PA) (SPO)

TheraCys

Thiotepa

Specialty Pharmacy

* (non-covered medication) Quality Care Dosing limits apply for members with approved formulary exceptions** (new to market drug; non-covered while under review) quantity limits apply to members with approved formulary exceptions(PA) prior authorization required(PA17) prior authorization required for members who are 17 years of age or older(QCD) Quality Care Dosing limits apply(SPO) available in pharmacy benefit only(STEP) step therapy required

16

Thyrogen

Toposar

Totect

Trelstar

Trelstar Depot

Trelstar LA

Valstar

Velcade

Vimzim

VinBLAStine

VinCRIStine

Vinorelbine

Vumon

Xgeva (PA) (SPO)

Zaltrap

Zanosar

Zenapax

Zinecard

Zoladex

Zorbtive (PA) (SPO)

Oral Medications8-Mop

Adcirca (PA)

Adempas

Afinitor

Alkeran

Ampyra (PA) (QCD)

Aubagio

Bethkis

Bosulif

Capecitabine

Carbaglu

Cerdelga **

Cometriq

Copegus (SPO)

Cystagon

Cytoxan

Erivedge

Etoposide

Exjade

Gilenya (QCD)

Gilotrif

Gleevec

Havroni ** (PA)

Hetlioz (PA)

Hycamtin

Iclusig

Imbruvica

Incivek (PA)

Inlyta

Iressa

Jakafi

Kalydeco (PA)

Korlym

Kuvan

Letairis

Mekinist

Mesnex

Moderiba

Nexavar

Northera

Oforta

Olysio (PA)

Onsolis * (PA) (QCD)

Opsumit

Orenitram

Orfadin (SPO)

Otezla (PA) (QCD)

Otezla Starter Pack *

Pomalyst

Procysbi

Promacta

Pulmozyme (SPO)

Ravicti

Rebetol (SPO)

Revatio * (PA)

Revlimid

Ribapak (SPO)

Ribasphere (SPO)

Ribatab

Ribavirin (SPO)

Rilutek

Riluzole

Sabril

Sildenafil (PA)

Sovaldi (PA)

Sprycel

Stivarga

Sucraid

Sutent

Tafinlar (PA)

Tarceva

Tasigna

Tecfidera

Temodar

Temozoloamide

Thalomid

TOBI ampules (SPO)

TOBI-Podhaler (SPO)

Specialty Pharmacy



(QCD) Quality Care Dosing limits apply(SPO) available in pharmacy benefit only

(STEP) step therapy required

17

Tobramycin ampules

Tracleer

Tykerb

Tyvaso

Victrelis (PA)

Votrient

Xalkori (PA)

Xeljanz *

Xeloda

Xenazine

Xtandi (STEP)

Xyrem

Zavesca

Zelboraf (PA)

Zolinza

Zydelig

Zykadia (PA)

Zytiga

TopicalCystaran

Panretin (SPO)

Qutenza (QCD)

Valchlor

Specialty Pharmacy

* (non-covered medication) Quality Care Dosing limits apply for members with approved formulary exceptions** (new to market drug; non-covered while under review) quantity limits apply to members with approved formulary exceptions(PA) prior authorization required(PA17) prior authorization required for members who are 17 years of age or older(QCD) Quality Care Dosing limits apply(SPO) available in pharmacy benefit only(STEP) step therapy required

18

Step Therapy

Step Therapy

Step therapy is a key part of our prior authorization program that allows us to help your doctor provide you with an appropriate and affordable drug treatment. Before coverage is allowed for certain costly “second-step” medications, we require that you first try an effective, but less expensive, “first-step” medication. Some medications may have multiple steps.

Step Therapy List

This list is up-to-date as of January 1, 2015, and is subject to change at any time. For the most up-to-date list of medications that require step therapy, please visit our website www.bluecrossma.com/pharmacy, click on PharmacyManagementProgram, and proceed to StepTherapy.

Asthma ManagementAccolate *

Advair Diskus (QCD)

Advair HFA (QCD)

Anoro Ellipta (QCD)

Breo Ellipta * (QCD)

Dulera (QCD)

Singulair

Symbicort (QCD)

Zyflo *

Zyflo CR *

Atypical AntipsychoticMedicationsAbilify

Abilify DiscMelt *

Abilify Maintenna *

Clozaril

Fanapt *

FazaClo *

Geodon

Haldol

Haldol Decanoate

Invega *

Invega Sustenna

Latuda *

Loxitane

Risperdal

Risperdal Consta

Risperdal M-Tab *

Saphris *

Seroquel

Seroquel XR

Symbyax (QCD)

Zyprexa

Zyprexa IM *

Zyprexa Relprevv *

Zyprexa Zydis

Cholesterol TreatmentAdvicor (QCD)

Altoprev * (QCD)

Caduet * (QCD)

Crestor (QCD)

Juxtapid

Kynamro (SP)

Lescol * (QCD)

Lescol XL * (QCD)

Lipitor * (QCD)

Liptruzet ** (QCD)

Livalo * (QCD)

Mevacor * (QCD)

Pravachol * (QCD)

Simcor * (QCD)

Vytorin * (QCD)

Zetia (QCD)

Zocor * (QCD)

Diabetes ManagementACTOplus Met (QCD)

ACTOplus Met XR (QCD)

Actos (QCD)

Avandamet (QCD)

Avandaryl

Avandia (QCD)

Duetact

Farxiga *

Fortamet *

Glucophage *

Glucophage XR *

Glumetza *

Invokamet

Invokana

Janumet

Janumet XR

Step Therapy




19

Januvia

Jardiance

Jentadueto *

Kazano *

Kombiglyze XR

Nesina *

Onglyza

Oseni *

Pioglitazone (QCD)

Pioglitazone-Glimepiride (QCD)

Pioglitazone-Metformin (QCD)

PrandiMet *

Prandin *

Tradjenta *

Victoza

GlaucomaLumigan

Rescula *

Travatan

Travatan Z

Xalatan

Heart/Blood Modifiers/CirculationAmturnide *

Atacand *

Atacand HCT *

Avalide

Avapro

Azor

Benicar

Benicar HCT

Cozaar *

Diovan

Diovan HCT

Edarbi *

Edarbiclor *

Exforge

Exforge-HCT

Hyzaar *

Micardis *

Micardis HCT *

Tekamlo *

Tekturna *

Tekturna HCT *

Teveten *

Teveten HCT *

Tribenzor

Twynsta *

Valturna *

Osteoporosis Treatment(Oral)Actonel (QCD)

Atelvia DR * (QCD)

Binosto * (QCD)

Boniva tablets * (QCD)

Fosamax * (QCD)

Fosamax Plus D (QCD)

Overactive Bladder TreatmentDetrol *

Detrol LA *

Ditropan *

Ditropan XL *

Enablex *

Gelnique *

Myrbetriq *

Oxytrol *

Sanctura *

Sanctura XR *

Toviaz *

Vesicare

Pain Relievers (Cox IIInhibitors)Celebrex (QCD)

Parkinson's DiseaseTreatmentMirapex

Mirapex ER *

Requip *

Requip XL *

Prostate Cancer - OralXtandi

Prostate TreatmentAvodart

Jalyn

Proscar *

Topical TestosteroneFortesta *

Testim *

Testosterone gel (Fortesta Authorized

product) *

Testosterone gel (Testim Authorized

product) *

Testosterone gel (Vogelxo Authorized

product) *

Vogelxo *

Step Therapy

* (non-covered medication) Quality Care Dosing limits apply for members with approved formulary exceptions** (new to market drug; non-covered while under review) quantity limits apply to members with approved formulary exceptions(PA) prior authorization required(PA17) prior authorization required for members who are 17 years of age or older(QCD) Quality Care Dosing limits apply(SP) Medication is part of the specialty pharmacy network

20

Non-Covered Medication


Your pharmacy program provides coverage for over 4,000 prescription medications. Most medications on our non-covered list have equally safe, effective, covered alternatives for treating the same medical conditions. If a non-covered drug is approved, it will be covered at the highest tier or cost share. Check with your doctor about appropriate alternatives if you currently take any of these medications.

Please note: Your doctor may request coverage for a non-covered medication if no covered alternative is appropriate for treating your condition.

Non-Covered Medication List

This list of non-covered medications is up-to-date as of January 1, 2015, and may change from time to time. For the most up-to-date list of medications that are not covered and their covered alternatives, please visit our website,www.bluecrossma.com/pharmacy, click on MedicationLookUp, and proceed to the MedicationsthatarenotCovered section.

Abilify DiscMelt (STEP)

Abilify Maintenna (STEP)

Absorica

Abstral (PA) (QCD)

Acanya

Accolate (STEP)

AccuNeb

Accupril

Accuretic

Accutane

Aceon

AcipHex (PA) (QCD)

Acticlate

Actigall

Actiq (PA) (QCD)

Activella

Acular (QCD)

Acular LS (QCD)

Acuvail

Aczone

Adalat CC

Adderall

Adoxa CK

Adoxa TT

Aerobid (QCD)

Aerobid-M (QCD)

Airet

Alodox

Aloquin

Alora (QCD)

Alrex (QCD)

Alsuma (QCD)

Altabax

Altace

Altoprev (STEP) (QCD)

Aluvea

Alvesco (QCD)

Ambien (QCD)

Ambien CR (QCD)

Amrix

Amturnide (STEP)

Anafranil

Analpram Advanced

Analpram-E kit

Angeliq

Antara

Anzemet (QCD)

Apidra

Aplenzin ER (QCD)

Appformin-D

Aqua Glycolic HC

Arava (QCD)

Arcapta Neohaler (QCD)

Arixtra (QCD)

Ascensia diabetic testing supplies (QCD)

Asmanex Twisthaler (QCD)

Assure Pro diabetic testing supplies (QCD)

Astepro (QCD)

Atacand (STEP)

Atacand HCT (STEP)





(SPO) available in pharmacy benefit only(STEP) step therapy required

21

Atelvia DR (STEP) (QCD)

Ativan

Atopiclair

Atralin

Atrapro CP

Atrapro Dermal Spray

Atrapro Hydrogel

Atropen

Augmentin XR

Aurstat

Auvi-Q (QCD)

Avelox

Avidoxy

Avidoxy DK

Avinza (PA) (QCD)

Avita

Axert (QCD)

Axid

Azasite

Azmacort (QCD)

B-D diabetic testing supplies (QCD)

Beconase AQ (QCD)

BenzaClin kit

Besivance

Binosto (STEP) (QCD)

Bionect

Boniva syringe (PA) (SP)

Boniva tablets (STEP) (QCD)

Bravelle (SP)

Breo Ellipta (PA) (QCD)

Brevicon

Brilinta

Brintellix (QCD)

Brisdelle (QCD)

Bromday

Brovana

Butrans (PA) (QCD)

Bystolic

Caduet (QCD)

Calcitriol Topical

Cambia

Caphosol

Capoten

Cardene

Cardene SR

Cardizem CD

Cardizem LA

Cardura XL (QCD)

Cataflam

Ceclor

Ceclor CD

Cedax

Celexa (QCD)

Cem-Urea

Cenestin

Centany

Centany AT

Cesamet (QCD)

Cetraxel

Chenodal

Chibroxin Ocumeter

Cipro-XR

Cleanse and Treat

Cleervue-M

Cleocin T

Clindacin ETZ Kit

Clindacin PAC

Clindagel

Clindamax

Clindareach

Clindets

Clobeta + Plus

Clobex

Clodan Kit

CNL 8 nail kit (QCD)

Colazal

Combigan

Combunox

Contour Next diabetic testing

supplies (QCD)

Conzip

Coreg

Coreg CR

Cosopt PF

Cozaar (STEP)

Cymbalta (QCD)

Daliresp

Darvocet N-100

Daypro

Daytrana

DDAVP

Demulen

Depo-Sub Q Provera 104

Derma-Smoothe/FS

Dermasorb-AF

Dermasorb-HC


* (non-covered medication) Quality Care Dosing limits apply for members with approved formulary exceptions** (new to market drug; non-covered while under review) quantity limits apply to members with approved formulary exceptions(PA) prior authorization required(PA17) prior authorization required for members who are 17 years of age or older(QCD) Quality Care Dosing limits apply(SP) Medication is part of the specialty pharmacy network(SPO) available in pharmacy benefit only(STEP) step therapy required

22

Dermasorb-TA

Dermasorb-XM

DermOtic

Desogen

Desonil + Plus

DesOwen kit

Desvenlafaxine ER (QCD)

Detrol (STEP)

Detrol LA (STEP)

Dexedrine (PA)

Dexilant (PA) (QCD)

Dilacor XR

Dilaudid

Dipentum

Dispermox

Ditropan (STEP)

Ditropan XL (STEP)

Divigel

Doryx

Duavee

Duexis

Duragesic (PA) (QCD)

Durezol

Dymista (QCD)

Dynabac

Dynacin

Dynacirc

Dynacirc CR

Dytan

Easy Step diabetic testing supplies (QCD)

Easy-Trak diabetic testing supplies (QCD)

Edarbi (STEP)

Edarbiclor (STEP)

Edluar (QCD)

Effexor

Effexor XR (QCD)

Elestrin

Eletone

Embeda (QCD)

Embrace diabetic testing supplies (QCD)

Emsam

Enablex (STEP)

Enjuvia

Epaned

EpiCeram

Epiduo

Episil

Equetro

Ertaczo

Esomeprazole Strontium (STEP) (QCD)

Estrace

Estrasorb (QCD)

Estrogel (QCD)

Euflexxa (PA) (SPO)

Evamist (QCD)

Evoclin

ExacTech diabetic testing supplies (QCD)

Exalgo (PA) (QCD)

Extavia

Extina

Factive

Falessa kit

Famvir (QCD)

Fanapt (STEP)

Farxiga (STEP)

FazaClo (STEP)

Femtrace

Fenoglide

Fentora (PA) (QCD)

Fertinex (SP)

Fexmid

Fibracor

Finacea Plus

Fioricet

Fiorinal

Fiorinal with Codeine

Flagyl

Flagyl ER

Flagyl IV

Flector

Flonase (QCD)

FML Forte

Focalin

Focalin XR (QCD)

Follistim AQ (SP)

Forfivo XL (QCD)

Fortamet (STEP)

Fortesta (STEP)

Fosamax (STEP) (QCD)

Fragmin (QCD)

Freestyle diabetic testing supplies (QCD)

Fresh Kote

Frova (QCD)

Garamide

Gel-One (PA) (SPO)

Gelclair






23

Gelnique (STEP)

GelX

Genotropin (PA) (SP)

Giazo

Glucometer diabetic testing

supplies (QCD)

Glucophage

Glucophage XR

Glumetza

Halonate

Halotin

Helidac

Horizant

HPR

HPR Plus

Hyalgan (PA) (SPO)

Hydrocortisone-Lidocaine kit

Hylase

Hylatopic

Hylatopic Plus

Hylatopic Plus-Aurstat

Hylira

Hytrin (QCD)

Hyzaar (STEP)

IB-Stat

IC400 kit

IC800 kit

Ilevro

Imuran

Inderal LA

Inderal XL

Innohep

InnoPran XL

Intermezzo (QCD)

Intuniv

Invega (STEP)

Iquix

Istalol

Jentadueto (STEP)

Jublia

Kadian (PA) (QCD)

Kapvay

Kazano (STEP)

Keppra XR

Keralyt kit

Ketocon + Plus

Khedezla (QCD)

Klonopin

Kytril (QCD)

Lamictal ODT

Lamisil (QCD)

Lamisil Granules (QCD)

Latuda (STEP)

Lazanda (PA) (QCD)

Lescol (STEP) (QCD)

Lescol XL (STEP) (QCD)

Levaquin

Levemir (QCD)

Levlen

Lexapro (QCD)

Lexxel

Lialda

Lidovir

Lipitor (STEP) (QCD)

Lipofen

Liptruzet (STEP) (QCD)

Livalo (STEP) (QCD)

Lodine

Lodine XL

Lofibra

Lopressor

Lorabid

LoSeasonique

Lotensin

Lotensin HCT

Loutrex

Lovaza

Lovenox (QCD)

Lunesta (QCD)

Luvox CR (QCD)

Luzu

Lysteda (QCD)

Lytensopril

Mavik

Maxair Autohaler (QCD)

Maxalt (QCD)

Maxalt-MLT (QCD)

Maxipime

MB Hydrogel

Megace ES

Menostar (QCD)

Metaglip

Metozolv ODT

Metrogel kit

Mevacor (STEP) (QCD)

Micardis (STEP)



24

Micardis HCT (STEP)

Minocin

Minocin Combo Pack

Mirapex ER (STEP)

Mobic (QCD)

Momexin

Monodox

Monopril

Monopril HCT

Monovisc (PA) (SPO)

Morgidox

Moxatag

Moxeza (QCD)

Myoxin

Myrbetriq

Naprelan

Naprelan CR

Naprosyn

Naprosyn EC

Nasarel (QCD)

Nasonex (QCD)

Natazia

Neo-Synalar Kit

Neosalus

Neosalus CP

Nesina (STEP)

Neuac Kit

Neupro

Neurontin

NeutraSal

Nevanac

Nexiclon XR

Nexium (PA) (QCD)

Niravam

Nivatropic Plus

Nor-Q-D

Norditropin (PA) (SP)

Norinyl

Noroxin

Norvasc (QCD)

Novacort

Novolin Insulin products

Novolog Insulin products

NuCort

Nucynta

Nucynta ER (PA)

NutriDox

Nuvigil (PA)

Ocudox kit

Oleptro ER

Olux

Omeprazole-Sod. Bicarbonate (PA) (QCD)

Omnaris (QCD)

Omnicef

Omnitrope (PA) (SP)

Onmel (QCD)

Onsolis (PA) (QCD)

Opana

Opana ER (PA) (QCD)

Optase

Oracea

Oramorph SR (PA) (QCD)

Orapred ODT

Oravig

Ortho-Prefest

Orthovisc (PA) (SPO)

Oseni (STEP)

Osphena

Otezla Starter Pack (SP)

Ovcon

Oxecta

Oxytrol (STEP)

Pamelor

Pamine FQ

Pancreaze

Paptase

Patanase (QCD)

Paxil (QCD)

Paxil CR (QCD)

PCE

PCE Dispertab

Pediaderm AF

Pediaderm HC

Pediaderm TA

Penlac (QCD)

Pennsaid

Pepcid

Percocet

Pertzye

Pexeva (QCD)

Phoslyra

Plaquenil

PR-Cream

Pram-HCA

Pramcort

Pramosone E






25

PrandiMet (STEP)

Pravachol (STEP) (QCD)

Precision QID diabetic supplies (QCD)

Precision X-Tra diabetic supllies (QCD)

Presera

Prestige diabetic testing supplies (QCD)

Prevacid (PA) (QCD)

Prevacid NapraPAC

PrevPac

Prilosec (PA) (QCD)

Prinivil

Prinzide

Pristiq (QCD)

Procentra (PA)

Procort

Prodigy diabetic testing supplies (QCD)

Prolensa

Promiseb

Promiseb Light

Proquin XR

Protonix (PA) (QCD)

Proventil

Proventil HFA (QCD)

Proventil inhaler (QCD)

Proventil Repetab

Prozac (QCD)

Prozac Weekly (QCD)

Purinethol

Pylera

QNASL (QCD)

Quartette

Quillivant XR

Quixin

RadiaPlex Rx

Radigel

Raniclor

Rapaflo

Rayos

Reciphexamine

Recothrom

Relafen

Relpax (QCD)

Remeron (QCD)

Remeron Soltab (QCD)

Requip (STEP)

Requip XL (STEP)

Rescula (STEP)

Restoril

Retin-A Micro (PA30)

Revatio (PA)

Rhinocort Aqua (QCD)

Rinnovi

Risperdal M-Tab (STEP)

Ritalin

Ritalin LA (QCD)

Ritalin SR

Rosadan

Rosanil

Rybix ODT

Rynatan

Rythmol

Ryzolt

Saizen (PA) (SP)

Salicylic Acid-Ceramide kit

Salkera

Salvax

Salvax Duo

Salvax Duo Plus

Sanctura (STEP)

Sanctura XR (STEP)

Sancuso (QCD)

Saphris (STEP)

Sarafem (QCD)

Scalacort

Seasonique

Senophylline

Silenor (QCD)

Silvrstat

Simbrinza

Simcor (STEP) (QCD)

Sinemet

Sitavig

Skelid

Sof-Tact diabetic supplies (QCD)

Solodyn

Soltamox

Soma

Sonata (QCD)

Spectracef

Sporanox (QCD)

Sprix

Stavzor

Stelara (PA) (SPO)

Striant

Subsys (PA) (QCD)

Sular



26

Sumadan

Sumavel Dosepro (QCD)

Sumaxin

Sumaxin CP

Sumaxin TS

Supartz (PA) (SPO)

Synalar Combo-Pack

Synalar TS

Synvisc (PA) (SPO)

Synvisc-One (PA) (SPO)

Tagamet

Tekamlo (STEP)

Tekturna (STEP)

Tekturna HCT (STEP)

Tenormin

Tequin

Terbinex (QCD)

Tersi

Testim (STEP)


product) (STEP)


product) (STEP)

Testosterone gel (Vogelxo) Authorized

product) (STEP)

Tetrix

Tev-Tropin (PA) (SP)

Teveten (STEP)

Teveten HCT (STEP)

Therapentin

Theraproxen

Tiamate

Tiazac

Tindamax

Tirosint

TL-Triseb

TobraDex ST

Tofranil

Tornalate

Toviaz (STEP)

Tradjenta (STEP)

Tranxene T-Tab

Tretin-X (PA)

Treximet (QCD)

Tri-Levlen

Tri-Norinyl

Tricor

Triglide

Trilipix

Trinalin

TriOxin

Tritec

Tropazone

TrueTest diabetic supplies (QCD)

TrueTrack diabetic supplies (QCD)

Twynsta (STEP)

Ultracet

Ultram/ER

Ultrasal ER

Ultravate PAC

Ultravate X

Ultressa

Uramaxin

Urea kit

Valium

Valturna (STEP)

Vanos

Vantin

Vascepa

Vaseretic

Vasolex

Vasotec

Vectical

Vectrin

Velphoro

Veltin (PA30)

Ventolin HFA (QCD)

Veramyst (QCD)

Veregen

Vexa

Vexol

Vigamox (QCD)

Viibryd (QCD)

Vimovo

Virasal

Vogelxo (STEP)

Voltaren

Voltaren XR

Vusion

Vytorin (STEP) (QCD)

Vyvanse (QCD)

Welchol

Wellbutrin

Wellbutrin SR (QCD)

Wellbutrin XL (QCD)

X-Clair






27

Xanax

Xanax XR

Xartemis XR (PA) (QCD)

Xeljanz (SP)

Xenaderm

Xerese

Xibrom

Xifaxan

Xolegel

Xolox

Xopenex HFA (QCD)

Xopenex nebules

Xyralid

Z-Pram

Zanaflex

Zantac

Zebeta

Zegerid (PA) (QCD)

Zelapar

Zenieva

Zestril

Zetonna (QCD)

Ziana

Zinotic

Zinotic ES

Zipsor

Zithromax

Zmax

Zocor (STEP) (QCD)

Zofran (QCD)

Zofran ODT (QCD)

Zohydro ER (PA) (QCD)

Zoloft (QCD)

Zolpimist (QCD)

Zomig (QCD)

Zomig ZMT (QCD)

Zontivity

Zovirax

Zuplenz (QCD)

Zyflo (STEP)

Zyflo CR (STEP)

Zymar (QCD)

Zymaxid

Zypram

Zyprexa IM (STEP)

Zyprexa Relprevv (STEP)

Zytopic



28


8-Mop 17

Abilify 19

Abilify DiscMelt 19, 21

Abilify Maintenna 19, 21

Abilify tablets 3

Abraxane 15

Absorica 21

Abstral 7, 12, 21

Acanya 21

Accolate 19, 21

Accu-Chek Aviva testing strips 3

AccuNeb 21

Accupril 21

Accuretic 21

Accutane 21

Aceon 21

Acetaminophen/Codeine 3

AcipHex 7, 12, 21

Actemra 12, 15

Acthar 12, 15

Acticlate 21

Actigall 21

Actimmune 15

Actiq 7, 12, 21

Activella 21

Actonel 7, 20

ACTOplus Met 7, 19

ACTOplus Met XR 7, 19

Actos 7, 19

Acular 7, 21

Acular LS 7, 21

Acular PF 7

Acuvail 21

Acyclovir 3

Aczone 21

Adapalene 3

Adcirca 12, 17

Adderall 21

Adderall XR 7

Adempas 17

Adoxa CK 21

Adoxa TT 21

Adriamycin PFS 15

Adrucil 15

Advair Diskus 3, 7, 19

Advair HFA 7, 19

Advicor 7, 19

Aerobid 7, 21

Aerobid-M 7, 21

Afinitor 17

Airet 21

Albuterol 3

Alendronate 3

Alferon N 15

Alkeran 15, 17

Allopurinol 3

Alodox 21

Aloquin 21

Alora 7, 21

Alprazolam 3

Alrex 7, 21

Alsuma 7, 21

Altabax 21

Altace 21

Altavera 3

Altoprev 7, 19, 21

Alupent inhaler 7

Aluvea 21

Alvesco 7, 21

Alyacen 3

Ambien 7, 21

Ambien CR 7, 21

Amerge 7

Amevive 12

Amitiza 7

Amitriptyline 3

Amlodipine 7

Amlodipine-Atorvastatin 7

Amlodipine/Benazepril 3

Amolodipine 3

Amoxicillin 3

Amoxicillin TR-Potassium Clavulanate 3

Amphetamine Salt Combination 3

Amphetamines 12

Ampyra 7, 12, 17

Amrix 21

Amturnide 20

Anafranil 21

Analpram Advanced 21

Analpram-E kit 21

Anastrozole 3

Angeliq 21

Anoro Ellipta 19

Antara 21

Anzemet 7, 21

Apidra 21

Aplenzin ER 21

Apokyn 15

Appformin-D 21

Apri 3

Aqua Glycolic HC 21

Aralast 12

Aralast NP 12

Aranesp 7, 12, 15

Arava 7, 21


29

Arcapta Neohaler 7, 21

Aredia 15

Arixtra 7, 21

Armour Thyroid 3

Arzerra 15

Asacol HD 3

Ascensia diabetic testing supplies 21

Asmanex Twisthaler 7, 21

Assure Pro diabetic testing supplies 21

Astelin 7

Astepro 7, 21

Atacand 20, 21

Atacand HCT 20-22

Atelvia DR 7, 20

Atenolol 3

Ativan 22

Atopiclair 22

Atorvastatin 3, 7

Atralin 22

Atrapro CP 22

Atrapro Dermal Spray 22

Atrapro Hydrogel 22

Atropen 22

Atrovent 7

Atrovent HFA 7

Aubagio 17

Augmentin XR 22

Aurstat 22

Auvi-Q 7, 22

Avalide 20

Avandamet 7, 19

Avandaryl 19

Avandia 7, 8, 19

Avapro 20

Aveed 15

Avelox 22

Avidoxy 22

Avidoxy DK 22

Avinza 12, 22

Avita 22

Avodart 20

Avonex 8, 15

Axert 8, 22

Axid 22

Azasite 22

Azathioprine 3

Azelastine 3, 8

Azithromycin 3

Azmacort 8, 22

Azor 20

B-D diabetic testing supplies 22

Baclofen 3

Beconase AQ 8, 22

Belviq 8, 12

Benicar 3, 20

Benicar HCT 3, 20

BenzaClin kit 22

Benzonatate 3

Besivance 22

Betamethasone Dipropionate 3

Betaseron 8, 15

Bethkis 17

BiCNu 15

Binosto 8, 20, 22

Bionect 22

Bleomycin Sulfate 15

Boniva Injection 15

Boniva syringe 12, 22

Boniva tablets 8, 20, 22

Bosulif 17

Botulinum toxin 12

Bravelle 15, 22

Breo Ellipta 19, 22

Brevicon 22

Brilinta 22

Brintellix 8

Brisdelle 8, 22

Bromday 22

Brovana 22

Budeprion SR 8

Budeprion XL 8

Budesonide 3, 8

Bunavail 8, 12

Buprenex 8, 12

Buprenorphine 8, 12

Buprenorphine-Naloxone 8

Buprenorphine/Naloxone 3

Bupropion 3

Bupropion SR 3, 8

Bupropion XL 3, 8

Buspirone 3

Busulfex 15

Butalbital/APAP/Caffeine 3

Butorphanol NS 8

Butrans 8, 12, 22

Bystolic 22

Cabergoline 8

Caduet 8, 19, 22

Calcitriol Topical 22

Calcium Folanate 15

Cambia 22

Camila 3

Camptosar 15

Capecitabine 17

Caphosol 22


30

Capoten 22

Carbaglu 17

Carbidopa/Levodopa 3

Carboplatin 15

Cardene 22

Cardene SR 22

Cardizem CD 22

Cardizem LA 22

Cardura 8

Cardura XL 8, 22

Carisoprodol 3

Carvedilol 3

Cataflam 22

Catapres TTS 8

Ceclor 22

Ceclor CD 22

Cedax 22

Cefadroxil 3

Cefdinir 3

Cefuroxime 3

Celebrex 3, 8, 20

Celexa 8, 22

Cem-Urea 22

Cenestin 22

Centany 22

Centany AT 22

Cerdelga 17

Ceredase 12

Cerezyme 12

Cerubidine 15

Cesamet 8, 22

Cetraxel 22

Cetrotide 15

Chantix 3

Chenodal 22

Chibroxin Ocumeter 22

Chlorhexadine Gluconate 3

Chlorthalidone 3

Cialis 3

Ciclopirox nail lacquer 8

Cimzia 12, 15

Cinryze 12

Cipro-XR 22

Ciprofloxacin 3

Cisplatin 15

Citalopram 3, 8

Cladribine 15

Clarithromycin 3

Cleanse and Treat 22

Cleervue-M 22

Climara 8

Climara Pro 8

Clindacin ETZ Kit 22

Clindacin PAC 22

Clindagel 22

Clindamax 22

Clindamycin 3

Clindamycin/Benzoyl Peroxide 3

Clindareach 22

Clindets 22

Clobeta + Plus 22

Clobetasol Propionate 3

Clobex 22

Clodan Kit 22

Clomid 15

Clomiphene 15

Clonazepam 3

Clonidine 3

Clonidine patch 8

Clopidogrel 3

Clotrimazole/Betamethasone 3

Clozaril 19

CNL 8 nail kit 8, 22

Colazal 22

Colcrys 3

Combigan 22

Combivent 8

Combivent Respimat 3, 8

Combunox 22

Concerta 8

Contour Next diabetic testing supplies 22

Conzip 22

Copaxone 8, 15

Copegus 17

Coreg 22

Coreg CR 22

Cosmegen 15

Cosopt PF 22

Cozaar 20, 22

Crestor 3, 8, 19

Crolom ophthalmic 8

Cromolyn ophthalmic 8

Cryselle 3

Cyclobenzaprine 3

Cyclophosphamide 15

Cymbalta 8, 22

Cyramza 15

Cystagon 17

Cystaran 18

Cytarabine 15

Cytoxan 15, 17

Dacarbazine 15

Dactinomycin 15

Daliresp 22

Darvocet N-100 22


31

Daunorubicin HCL 15

DaunoXome 15

Daypro 22

Daytrana 22

DDAVP 15, 22

Demulen 22

Depo-Sub Q Provera 104 22

Depocyt 15

Derma-Smoothe/FS 22

Dermasorb-AF 22

Dermasorb-HC 22, 23

Dermasorb-XM 23

DermOtic 23

Desmopressin Acetate 15

Desogen 23

Desonide 3

Desonil + Plus 23

DesOwen kit 23

Desoxyn 12

Desvenlafaxine ER 8, 23

Detrol 20, 23

Detrol LA 20, 23

Dexamethasone 3

Dexedrine 23

Dexilant 8, 12, 23

Dexmethylphenidate XR 8

Dexrazoxane 15

Dextroamphetamine/Amphetamine 3

Dextroamphetamine/Amphetamine ER 8

Dextroamphetamines 12

Diazepam 3, 4

Dicyclomine 4

Dificid 12

Diflucan 8

Digoxin 4

Dihydroergotamine 8

Dilacor XR 23

Dilaudid 23

Diltiazem ER 4

Diovan 4, 20

Dipentum 23

Diskets 12

Dispermox 23

Ditropan 20, 23

Ditropan XL 20, 23

Divalproex Sodium 4

Divalproex Sodium ER 4

Divigel 23

Docefrez 15

Docetaxel 15

Dolophine 12

Donepezil 4

Doryx 23

Dorzolamide/Timolol 4

Doxazosin 4, 8

Doxorubicin HCl 15

Doxycycline Hyclate 4

Doxycycline Monohydrate 4

DTIC-Dome 15

Duavee 23

Duetact 19

Duexis 23

Dulera 8, 19

Duloxetine 4, 8

Duragesic 8, 12, 23

Durezol 23

Dymista 8, 23

Dynabac 23

Dynacin 23

Dynacirc 23

Dynacirc CR 23

Dysport 12

Dytan 23

Easy Step diabetic testing supplies 23

Easy-Trak diabetic testing supplies 23

Econazole 4

Edarbi 20, 23

Edarbiclor 20

Edluar 8, 23

Effexor 23

Effexor XR 8, 23

Egrifta 12, 15

Elestrin 23

Eletone 23

Elidel 12

Eligard 15

Ellence 15

Eloxatin 15

Elspar 15

Embeda 8, 12, 23

Embrace diabetic testing supplies 23

Emend 8

Emoquette 4

Emsam 23

Enablex 20, 23

Enalapril 4

Enbrel 4, 8, 12, 15

Endometrin 15

Enjuvia 23

Enoxaparin 8

Enoxparin Sodium 4

Enpresse 4

Enteral formula 12

Entyvio 15

Epaned 23


32

Epi-Pen AutoInjector 4

Epi-Pen JR. AutoInjector 4

EpiCeram 23

Epiduo 23

Epinephrine injection 8

Epirubicin 15

Episil 23

Epogen 8, 12, 15

Equetro 23

Erbitux 12

Erivedge 17

Ertaczo 23

Erythromycin 4

Escitalopram 4, 8

Esomeprazole Strontium 8, 12, 23

Estrace 23

Estrace Cream 4

Estraderm 8

Estradiol 4

Estradiol patch 8

Estrasorb 8, 23

Estrogel 8, 23

Eszopiclone 8

Ethyol 15

Etopophos 15

Etoposide 15, 17

Euflexxa 12, 23

Evamist 8, 23

Evoclin 23

Evzio 8

ExacTech diabetic testing supplies 23

Exalgo 8, 12, 23

Exforge 20

Exforge-HCT 20

Exjade 17

Extavia 8, 15, 23

Extina 23

Eylea 12

Factive 23

Factor VIII, VIIIa, IX, XIII 12

Falessa kit 23

Famciclovir 8

Famvir 8, 23

Fanapt 19, 23

Farxiga 19

Faslodex 15

FazaClo 19, 23

Femtrace 23

Fenofibrate 4

Fenoglide 23

Fentanyl oral/mucosal 8, 12

Fentanyl patch 8, 12

Fentanyl patches 4

Fentora 8, 12, 23

Fertinex 23

Fetzima 8

Fexmid 23

Fibracor 23

Finacea Plus 23

Finasteride 4

Fioricet 23

Fiorinal 23

Fiorinal with Codeine 23

Firazyr 15

Firmagon 15

First-lansoprazole 12

First-omeprazole 12

Flagyl 23

Flagyl ER 23

Flagyl IV 23

Flector 23

Flonase 8, 23

Flovent HFA inhaler 4

Flovent/HFA 8

Floxuridine 15

Fluconazole 4, 8

Fludara 15

Fludarabine phosphate 15

Flunisolide 8

Fluocinonide 4

Fluorouracil 15

Fluoxetine 4, 8

Fluoxetine DR 8

Fluticasone 8

Fluticasone nasal spray 4

Fluvastatin 8

Fluvoxamine 8

Fluvoxamine CR 8

FML Forte 23

Focalin 23

Focalin XR 8, 23

Folic Acid 4

Follistim AQ 15, 23

Fondaparinux 8, 9

Forfivo XL 9, 23

Fortamet 19, 23

Forteo 9, 12, 15

Fortesta 20, 23

Fosamax 9, 20, 23

Fosamax Plus D 9, 20

Fragmin 9, 23

Freestyle diabetic testing supplies 23

Fresh Kote 23

Frova 9, 23

FUDR 15


33

Furosemide 4

Fusilev I.V. 15

Fuzeon 15

Gabapentin 4

Ganirelix 15

Garamide 23

Gatifloxacin 9

Gattex 15

Gazyva 15

Gel-One 12, 23

Gelclair 23, 24

Gelnique 20

GelX 24

Gemcitabine 15

Gemfibrozil 4

Gemzar 15

Genotropin 15, 24

Geodon 19

Gianvi 4

Giazo 24

Gildess 4

Gilenya 9, 17

Gilotrif 17

Gleevec 17

Glimepiride 4

Glipizide 4

Glipizide ER 4

Glipizide XL 4

Glucometer diabetic testing supplies 24

Glucophage 19, 24

Glucophage XR 19, 24

Glucose testing strips 9

Glumetza 19, 24

Glyburide 4

Gonal F Rff Rediject 15

Gonal F/Gonal F RFF 15

Granisetron 9

Granisol 9

Granix 9, 15, 16

Grastek 9, 12

Growth Hormone 12

Guanfacine 4

Haldol 19

Haldol Decanoate 19

Halonate 24

Halotin 24

Havroni 17

Helidac 24

Hetlioz 9, 12, 17

Horizant 24

HPR 24

HPR Plus 24

Humalog 4

Human Chorionic Gonadotropin (HCG) 15

Humatrope 16

Humira 4, 9, 12, 16

Hyalgan 12, 13, 24

Hycamtin 16, 17

Hydrochlorothiazide 4

Hydrocodone/APAP 4

Hydrocodone/Chlorpheniramine 4

Hydrocortisone 4

Hydrocortisone-Lidocaine kit 24

Hydromorphone 4

Hydromorphone ER 9

Hydroxychloroquine 4

Hydroxyzine 4

Hylase 24

Hylatopic 24

Hylatopic Plus 24

Hylatopic Plus-Aurstat 24

Hylira 24

Hytrin 9, 24

Hyzaar 20, 24

IB-Stat 24

Ibandronate 9, 16

Ibuprofen 4

IC400 kit 24

IC800 kit 24

Iclusig 17

Idamycin PFS 16

Idarubicin 16

Ifex 16

Ifosfamide 16

Ifosfamide/Mesna 16

Ilaris 16

Ilevro 24

Imbruvica 17

Imitrex 9

Imuran 24

Incivek 13, 17

Increlex 16

Inderal LA 24

Inderal XL 24

Indomethacin 4

Infergen 9, 16

Inlyta 17

Innohep 24

Insulins 9

Interferons (alpha, gamma) 13

Intermezzo 9, 24

Intron A 16

Intuniv 24

Invega 19, 24

Invega Sustenna 19


34

Invokamet 19

Invokana 19

Iophen-C NR 4

Ipratropium NS 9

Iquix 24

Irbesartan 4

Iressa 17

Irinotecan 16

Isosorbide Mononitrate 4

Istalol 24

Istodax 16

Itraconazole 9

IV Immunoglobulin 13

Jakafi 17

Jalyn 20

Janumet 19

Janumet XR 19, 20

Januvia 4

Jardiance 20

Jentadueto 20, 24

Jublia 24

Junel 4

Junel FE 4

Juxtapid 19

Kadian 9, 13, 24

Kalydeco 13, 17

Kapvay 24

Kariva 4

Kazano 20, 24

Kelnor 1-35 4

Kenalog 16

Keppra XR 24

Keralyt kit 24

Ketocon + Plus 24

Ketoconazole 4

Ketorolac 4

Ketorolac ophthalmic 9

Keytruda 16

Khedezla 9, 24

Kineret 13, 16

Klonopin 24

Klor-Con 4

Kombiglyze XR 20

Korlym 17

Kuvan 17

Kynamro 16, 19

Kytril 9, 24

Labetalol 4

Lamictal ODT 24

Lamisil 9, 24

Lamisil Granules 24

Lamotrigine 4

Lansoprazole 4, 9, 13

Lansoprazole/Amoxicillin/Clarithromycin 9

Lantus 4

Lantus Solostar 4

Latanoprost 4

Latuda 24

Lazanda 13, 24

Leflunomide 9

Lescol 9, 19, 24

Lescol XL 9, 19, 24

Letairis 17

Leucovorin Calcium 16

Leukine 13, 16

Leuprolide 15

Leuprolide Acetate 16

Leustatin 16

Levaquin 24

Levemir 24

Levetiracetam 4

Levitra 4

Levlen 24

Levofloxacin 4

Levothyroxine 4

Lexapro 9, 24

Lexxel 24

Lialda 24

Lidocaine Patch 9

Lidoderm 9

Lidovir 24

Linzess 9

Liothyronine Sodium 4

Lipitor 9, 19, 24

Lipodox 16

Lipodox-50 16

Liptruzet 9, 19, 24

Lisinopril 4

Lisinopril/HCTZ 4

Lithium Carbonate 4

Livalo 9, 24

lo Loestrin FE 4

Lodine 24

Lodine XL 24

Lofibra 24

Lopressor 24

Lorabid 24

Lorazepam 4

Loryna 4

Losartan 4

Losartan/HCTZ 4

LoSeasonique 24

Lotensin 24

Lotensin HCT 24

Lotronex 9


35

Loutrex 24

Lovastatin 4, 9

Lovaza 24

Lovenox 9, 24

Loxitane 19

Lucentis 13

Lumigan 20

Lunesta 9, 24

Lupaneta Pack 16

Lupron Depot 15, 16

Lupron Depot-Ped 15, 16

Lutera 4

Luveris 15

Luvox CR 9, 24

Luzu 24

Lyrica 13

Lysteda 9, 24

Lytensopril 24

Macugen 13

Makena 13, 16

Marqibo 16

Mavik 24

Maxair Autohaler 9, 24

Maxalt 9, 24

Maxalt-MLT 9, 24

Maxipime 24

MB Hydrogel 24

Medroxyprogesterone 4

Megace ES 24

Mekinist 17

Meloxicam 4, 9

Menopur 15

Menostar 9, 24

Mesna 16

Mesnex 16, 17

Metadate CD 9

Metaglip 24

Metformin 4

Metformin ER 4

Methadone 13

Methadose 13

Methimazole 4

Methocarbamol 4

Methotrexate 4

Methylphenidate 4

Methylphenidate CD 9

Methylphenidate ER 4, 9

Methylprednisolone 4

Metoclopramide 4

Metoprolol Succinate 4

Metoprolol Tartrate 4

Metozolv ODT 24

Metrogel kit 24

Metronidazole 4

Mevacor 9, 19, 24

Micardis 20, 24, 25

Micardis HCT 20

Microgestin FE 4

Migranal 9

Minastrin FE 4

Minivelle 9

Minocin 25

Minocin Combo Pack 25

Minocycline 4

Mirapex 20

Mirapex ER 20, 25

Mirtazapine 4, 9

Mirtazapine Rapid Dissolve 9

Mitomycin 16

Mitoxantrone 16

Mobic 9, 25

Modafinil 4, 13

Moderiba 17

Mometasone 4

Momexin 25

Monodox 25

Monopril 25

Monopril HCT 25

Monovisc 13, 25

Montelukast 4

Morgidox 25

Morphine Sulfate CR 13

Morphine Sulfate ER 4, 9, 13

Moxatag 25

Moxeza 25

Mozobil 16

MS Contin 9, 13

Mupirocin 4

Mustargen 16

Myalept 13, 16

Mylotarg 16

Myoxin 25

Myrbetriq 20, 25

Nabumetone 4

Nadolol 4

Namenda 4

Naprelan 25

Naprelan CR 25

Naprosyn 25

Naprosyn EC 25

Naproxen 4, 5

Naratriptan 9

Nasarel 25

Nasonex 9, 25

Natazia 25


36

Navelbine 16

NebuPent 9

Neo-Synalar Kit 25

Neosalus 25

Neosalus CP 25

Neosar 16

Nesina 20, 25

Neuac Kit 25

Neulasta 9, 16

Neumega 16

Neupogen 9, 16

Neupro 25

Neurontin 25

NeutraSal 25

Nevanac 25

Nexavar 17

Nexiclon XR 25

Nexium 9, 13

Nifedipine ER 5

Nipent 16

Niravam 25

Nitrofurantoin 5

Nivatropic Plus 25

Nor-Q-D 25

Norditropin 16, 25

Norditropin Flexpro 16

Norditropin Nordiflex 16

Norethindrone 5

Norgestimate/Ethinyl Estradiol 5

Norinyl 25

Noroxin 25

Northera 17

Nortrel 5

Nortriptyline 5

Norvasc 9, 25

Novacort 25

Novantrone 16

Novarel 15

Novolin Insulin products 25

Novolog Insulin products 25

Nplate 16

NuCort 25

Nucynta 25

Nucynta ER 13, 25

NutriDox 25

Nutritional Supplements 13

Nutropin 16

Nutropin AQ 16

Nutropin AQ Nuspin 16

Nuvigil 13, 25

Nystatin 5

Nystatin/Triamcinolone 5

Ocella 5

Octreotide injection 16

Ocudox kit 25

Ofloxacin 5

Oforta 17

Olanzapine 5

Olanzepine-Fluoxetine 9

Oleptro ER 25

Olux 25

Olysio 13, 17

Omeprazole 5, 9

Omeprazole-Sod. Bicarbonate 9, 13, 25

Omnaris 9, 25

Omnicef 25

Omnitrope 16, 25

Omontys 9, 13, 16

Oncaspar 16

Ondansetron 9

Ondansetron ODT 9

Ondasetron 5

Ondasetron ODT 5

One Touch Delica testing strips 5

One Touch Ultra testing strips 5

Onglyza 20

Onmel 9, 25

Onsolis 9, 13, 17, 25

Ontak 16

Onxol 16

Opana 25

Opana ER 9, 13, 25

Opsumit 17

Optase 25

Optivar 9

Oracea 25

Oralair 9

Oramorph SR 9, 13, 25

Orapred ODT 25

Oravig 25

Orencia 13, 16

Orenitram 17

Orsythia 5

Ortho Tri-Cyclen Lo 5

Orthovisc 13, 25

Oseni 20, 25

Osphena 25

Otezla 9, 13, 17

Otezla Starter Pack 17, 25

Ovcon 25

Ovidrel 15

Oxaliplatin 16

Oxcarbazepine 5

Oxecta 25

Oxybutynin 5


37

Oxycodone 5

Oxycodone ER 9, 13

Oxycodone/APAP 5

OxyContin 9

Oxycontin 5, 13

Oxymorphone ER 9, 13

Oxytrol 20, 25

Paclitaxel 16

Pamelor 25

Pamidronate 16

Pamidronate disodium 16

Pamine FQ 25

Pancreaze 25

Panretin 18

Pantoprazole 5, 9

Paptase 25

Paroxetine 5, 9

Paroxetine CR 9

Patanase 9, 25

Paxil 9, 25

Paxil CR 9, 10, 25

PCE 25

PCE Dispertab 25

Pediaderm AF 25

Pediaderm HC 25

Pediaderm TA 25

Peg-Intron 16

PEG-Intron 10

Pegasys 10

Penicillin 5

Penlac 10, 25

Pennsaid 25

Pepcid 25

Percocet 25

Pertzye 25

Pexeva 10, 25

Phenazopyridine 5

Phoslyra 25

Photofrin 16

Pioglitazone 5, 10, 20

Pioglitazone-Glimepiride 10, 20

Pioglitazone-Metformin 10, 20

Plaquenil 25

Ploymyxin B-Sul/Trimethoprim 5

Pomalyst 17

Potassium Chloride 5

PR-Cream 25

Pram-HCA 25

Pramcort 25

Pramipexole 5

Pramosone E 25, 26

PrandiMet 20

Prandin 20

Pravachol 10, 19, 26

Pravastatin 5, 10

Precision QID diabetic supplies 26

Precision X-Tra diabetic supllies 26

Prednisone 5

Pregnyl 15

Premarin 5

Prempro 5

Prenatal Plus 5

Presera 26

Preservative-Free Morphine 13

Prestige diabetic testing supplies 26

Prevacid 10, 13, 26

Prevacid NapraPAC 26

PrevPac 10, 26

Prilosec 10, 13, 26

Prinivil 26

Prinzide 26

Pristiq 10, 26

ProAir HFA 10

ProAir HFA inhaler 5

Procentra 26

Prochlorperazine 5

Procort 26

Procrit 10, 13, 16

Procysbi 17

Prodigy diabetic testing supplies 26

Prolastin 13

Prolastin C 13

Prolensa 26

Proleukin 13, 16

Prolia 13, 16

Promacta 17

Promethazine 5

Promethazine/Codeine 5

Promiseb 26

Promiseb Light 26

Propranolol 5

Propranolol ER 5

Proquin XR 26

Proscar 20

Protonix 10, 13, 26

Protopic 13

Proventil 26

Proventil HFA 10, 26

Proventil inhaler 26

Proventil Repetab 26

Provigil 13

Prozac 10, 26

Prozac Weekly 10, 26

Pulmicort FlexHaler 5

Pulmicort Flexhaler 10


38

Pulmicort Respules 10

Pulmozyme 17

Purinethol 26

Pylera 26

QNASL 10, 26

Qualaquin 10

Quartette 26

Quetiapine 5

Quillivant XR 26

Quinapril 5

Qutenza 10, 18

QVAR 5, 10

Rabeprazole 10, 13

RadiaPlex Rx 26

Radigel 26

Ragwitek 10, 13

Ramipril 5

Raniclor 26

Ranitidine 5

Rapaflo 26

Rapaflux 10

Raptiva 16

Ravicti 17

Rayos 26

Rebetol 17

Rebif 10, 16

Reciphexamine 26

Reclast 13

Reclipsen 5

Recothrom 26

Regranex 13

Relafen 26

Relpax 10, 26

Remeron 10, 26

Remeron Soltab 26

Remicade 13, 16

Repronex 15

Requip 20, 26

Requip XL 20, 26

Rescula 20, 26

Respiratory SyncytialVirus IG/Synagis 13

Restasis 5, 10, 13

Restoril 26

Retin-A Micro 26

Revatio 13, 16, 17, 26

Revlimid 17

Rhinocort Aqua 10, 26

Ribapak 17

Ribasphere 17

Ribatab 17

Ribavirin 17

Rilutek 17

Riluzole 17

Rinnovi 26

Risedronate 10

Risperdal 19

Risperdal Consta 19

Risperdal M-Tab 19, 26

Risperidone 5

Ritalin 26

Ritalin LA 10, 26

Ritalin SR 26

Rituxan 13, 16

Rizatriptan 10

Ropinirole 5

Rosadan 26

Rosanil 26

Rozerem 10

Ruconest 16

Rybix ODT 26

Rynatan 26

Rythmol 26

Ryzolt 26

Sabril 17

Saizen 16, 26

Salicylic Acid-Ceramide kit 26

Salvax 26

Salvax Duo 26

Salvax Duo Plus 26

Sanctura 26

Sanctura XR 20, 26

Sancuso 10, 26

Sandostatin 16

Sandostatin-LAR 16

Saphris 19, 26

Sarafem 10, 26

Scalacort 26

Seasonique 26

Selferma 10

Senophylline 26

Serevent Diskus 10

Serophene 15

Seroquel 19

Seroquel XR 19

Serostim 16

Sertraline 5, 10

Signafor 16

Sildenafil 13, 17

Silenor 10, 26

Silvrstat 26

Simbrinza 26

Simcor 10, 19, 26

Simponi 10, 13, 16

Simponi Aria 16

Simulect 16


39

Simvastatin 5, 10

Sinemet 26

Singulair 19

Sitavig 26

Skelid 26

Sof-Tact diabetic supplies 26

Solodyn 26

Soltamox 26

Soma 26

Somatuline 16

Somavert 16

Sonata 10, 26

Sovaldi 13, 17

Spectracef 26

Spiriva 10

Spiriva HandiHaler 5

Spironolactone 5

Sporanox 10, 26

Sprintec 5

Sprix 26

Sprycel 17

Stavzor 26

Stelara 16, 26

Stivarga 17

Strattera 5, 10, 13

Striant 26

Suboxone 5, 10, 13

Subsys 10, 13, 26

Subutex 10

Sucraid 17

Sular 26, 27

Sulfamethoxizole/Trimethoprim 5

Sumatriptan 5, 10

Sumavel Dosepro 10, 27

Sumaxin 27

Sumaxin CP 27

Sumaxin TS 27

Supartz 13, 27

Suprep 5

Sutent 17

Sylatron 16

Sylvant 16

Symbicort 5, 10, 19

Symbyax 10, 19

Synagis 13, 16

Synalar Combo-Pack 27

Synalar TS 27

Synribo 16

Synthroid 5

Synvisc 13, 27

Synvisc One 13

Synvisc-One 27

Tafinlar 17

Tagamet 27

Tamiflu 5

Tamoxifen 5

Tamsulosin 5

Tarabine 16

Tarceva 17

Tasigna 17

Taxol 16

Taxotere 16

Tecfidera 17

Tekamlo 20, 27

Tekturna 20, 27

Tekturna HCT 20, 27

Temazepam 5

Temodar 17

Temozoloamide 17

Teniposide 16

Tenormin 27

Tequin 27

Terazosin 5, 10

Terbinafine 5, 10

Terbinex 10, 27

Tersi 27

Testim 20, 27


product) 20, 27


product) 20, 27

Testosterone gel (Vogelxo Authorized

product) 20

Testosterone gel (Vogelxo) Authorized

product) 27

Tetrix 27

Tev-Tropin 16, 27

Teveten 20, 27

Teveten HCT 20, 27

Thalomid 17

TheraCys 16

Therapentin 27

Theraproxen 27

Thiotepa 16, 17

Tiamate 27

Timolol Maleate 5

Tindamax 27

Tirosint 27

Tizanidine 5

TL-Triseb 27

TOBI ampules 17

TOBI-Podhaler 17, 18

TobraDex ST 27

Tobramycin/Dexamethasone 5

Tofranil 27


40

Topical Retinoic Acid derivatives 13

Topiramate 5

Toposar 17

Toprol XL 5

Tornalate 27

Totect 17

Toviaz 20, 27

TPN 13

Tracleer 18

Tradjenta 20, 27

Tramadol 5

Tranexamic Acid 10

Tranxene T-Tab 27

Travatan 20

Travatan Z 20

Trelstar 17

Trelstar Depot 17

Trelstar LA 17

Tretin-X 27

Tretinoin 5

Treximet 10, 27

Tri-Levlen 27

Tri-Norinyl 27

Tri-Previfem 5

Tri-Sprintec 5

Triamcinolone Acetonide 5

Triamterene/HCTZ 5

Tribenzor 20

Tricor 27

Triglide 27

Trilipix 27

Trinalin 27

Trinessa 5

TriOxin 27

Tritec 27

Tropazone 27

TrueTest diabetic supplies 27

TrueTrack diabetic supplies 27

Twynsta 20, 27

Tykerb 18

Tysabri 13

Tyvaso 18

Ultracet 27

Ultram/ER 27

Ultrasal ER 27

Ultravate PAC 27

Ultravate X 27

Ultressa 27

Uramaxin 27

Urea kit 27

Vagifem 5

Valacyclovir 5

Valacylovir 10

Valchlor 18

Valsartan/HCTZ 5

Valstar 17

Valtrex 10

Valturna 20, 27

Vanos 27

Vantin 27

Vascepa 27

Vaseretic 27

Vasolex 27

Vasotec 27

Vectibix 13

Vectical 27

Vectrin 27

Velcade 17

Velphoro 27

Veltin 27

Venlafaxine 5

Venlafaxine ER capsule 10

Venlafaxine ER capsules 5

Venlafaxine ER tablet 10

Ventolin HFA 10, 27

Veramyst 10, 27

Verapmil ER 5

Veregen 27

Vesicare 5, 20

Vexa 27

Vexol 27

Viagra 5

Victoza 20

Victrelis 13, 18

Vigamox 10, 27

Viibryd 10, 27

Vimovo 27

Vimzim 17

VinBLAStine 17

VinCRIStine 17

Vinorelbine 17

Viorelle 5

Virasal 27

Vitamin D2 5

Vivelle 10

Vivelle-Dot 10

Vivelle-DOT 5

Vogelxo 20, 27

Voltaren 27

Voltaren gel 5

Voltaren XR 27

Votrient 18

Vumon 17

Vusion 27

Vytorin 10, 19, 27


41

Vyvanse 10, 27

Warfarin 5

Welchol 27

Wellbutrin 27

Wellbutrin SR 10, 27

Wellbutrin XL 10, 27

X-Clair 27, 28

Xalatan 20

Xalkori 13, 18

Xanax XR 28

Xarelto 5

Xartemis XR 10, 28

Xeljanz 13, 18, 28

Xeloda 18

Xenaderm 28

Xenazine 13, 18

Xeomin 13

Xerese 28

Xgeva 13, 17

Xiaflex 13

Xibrom 28

Xifaxan 28

Xolair 13

Xolegel 28

Xolox 28

Xopenex HFA 10, 28

Xopenex nebules 28

Xtandi 18, 20

Xyralid 28

Xyrem 18

Z-Pram 28

Zaleplon 10

Zaltrap 17

Zanaflex 28

Zanosar 17

Zantac 28

Zavesca 18

Zebeta 28

Zegerid 10, 13, 28

Zelapar 28

Zelboraf 13, 18

Zenapax 17

Zenieva 28

Zestril 28

Zetia 5, 10, 19

Zetonna 10, 28

Ziana 28

Zinecard 17

Zinotic 28

Zinotic ES 28

Zipsor 28

Zithromax 28

Zmax 28

Zocor 10, 19, 28

Zofran 10, 28

Zofran ODT 10, 28

Zohydro ER 10, 28

Zoladex 17

Zolinza 18

Zolmitriptan 10

Zolmitriptan ODT 10

Zoloft 10

Zolpidem 5, 10

Zolpidem ER 5, 10

Zolpimist 10, 28

Zometa 13

Zomig 10, 11, 28

Zomig ZMT 28

Zontivity 28

Zorbtive 17

Zovirax 28

Zubsolv 11, 13

Zuplenz 11, 28

Zydelig 18

Zyflo 19, 28

Zyflo CR 19, 28

Zykadia 13, 18

Zymar 11, 28

Zymaxid 11, 28

Zypram 28

Zyprexa 19

Zyprexa IM 19, 28

Zyprexa Relprevv 19, 28

Zyprexa Zydis 19

Zytiga 18

Zytopic 28


42



Our Pharmacy and Therapeutics Committee, which is made up of pharmacists and doctors of various specialties, reviews the effectiveness and overall value of new medications approved by the FDA on an ongoing basis. The Committee provides expertise and advice to help us give our members prescription drug options that meet their medical needs and achieve desired treatment goals. Approved medications are added to our formulary as they are approved by our Pharmacy and Therapeutics Committee throughout the year.

While under review, new medications will not be covered by your plan. As with other medications that are not covered, your doctor may request coverage when medically necessary. If a non-covered drug is approved, it will be covered at the highest tier or cost share.

43

® Registered Marks of the Blue Cross and Blue Shield Association. © 2014 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.#141665 55-0071 (10/14)

What’s covered:2

Your benefit will reimburse you for three consecutive months of membership fees from a qualified health club or for up to 10 fitness classes taken at a qualified health club.

A qualified health club is:A full-service health club with a variety of exercise equipment, including:

• Cardiovascular equipment like treadmills and bikes

• Strength-training equipment like free weights and weight machines

To receive the fitness reimbursement for a qualified pay-as-you-go health club, get paid receipts from the club for your records.

What doesn’t qualify?You can’t receive the fitness reimbursement for expenses for personal training, lessons, coaching, equipment, clothing, or any of the clubs below:

• Martial arts or yoga centers

• Gymnastics, tennis, aerobic, or pool-only facilities

• Country clubs or social clubs

• Sports teams or leagues

Be sure to talk with your doctor before starting an exercise program.

Your Blue Cross Blue Shield of Massachusetts health plan can save you money annually in qualified health club membership fees or up to 10 fitness classes taken at a qualified health club.

1. Before starting, check to see if your plan includes the Fitness Benefit. 2. Most plans offer a reimbursement for three months of membership or up to 10 fitness classes, but your employer may have offered a different benefit. Please refer to your benefits information to confirm.


Important Information• The reimbursement is for each individual

(or family) health plan and can only be submitted once each calendar year.

• Keep copies of all your paperwork and proof of payment in case you are denied reimbursement. Proof of payment includes the following:

– Itemized, dated, paid receipts from your health club

– Bank or credit card statements– Paycheck stubs if your club fees are

automatically deducted from that account

• Receipts or statements should include the name of the family member enrolled and the individual charges for a full reimbursement of health club fees or fitness classes.

• The dollar amount you receive may be considered taxable income. Consult your tax advisor about how to treat this reimbursement on your taxes.

Fitness Benefit

ChooseStart by picking a

qualified health club.

1. 2. 3.Complete

Once you pay for the program, fill out the attached form.

MailSend the completed form to the

address listed at the bottom.

3 Easy Steps to Getting Reimbursed1

Certification and Authorization (This form must be signed and dated below.)

I authorize the release of any information to Blue Cross Blue Shield of Massachusetts about my health club membership. I certify that the information provided in support of this submission is complete and correct and that I have not previously submitted for these services. I understand that Blue Cross may require additional evidence of health club membership and proof of payment for my membership before reimbursement is provided.

Subscriber’s or

Member’s Signature: _________________________________________________________________ Date: ____________________________________

Questions?To verify this reimbursement is within your plan or for further information, please log in to the Member Central website at www.bluecrossma.com/membercentral or call Member Service at the number on the front of your ID card.

Subscriber Information (Policyholder)Identification Number (including first 3 letters) Subscriber’s Last Name First Name Middle Initial

Address—Number and Street City State Zip Code

Employer’s Name

Member and Claim InformationMember’s Last Name First Name Middle Initial Date of Birth: Mo. Day Yr.

Mailing Address—Number and Street (if different from subscriber’s) City State Zip Code

Gender

Male

Female

Claim is for (check one):

Subscriber (policyholder) Ex-Spouse Other (specify) ___________________

Spouse (of policyholder) Dependent (up to age 26)

Name, Address, and Phone Number of Qualified Health Club

I am due $___________________ for the following reimbursement (check one):

Membership at a qualified health club. My monthly fee is $___________________.

Fitness classes at a qualified health club.

My fee per class is $___________________.

Health Plan Year

3. Blue Cross will make a reimbursement decision within 30 calendar days of receiving a completed request for coverage or payment.

® Registered Marks of the Blue Cross and Blue Shield Association. © 2015 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.147581M 55-0821 (4/15)

Fitness Reimbursement Form3

To verify this reimbursement is within your plan, log in to Member Central at www.bluecrossma.com/membercentral or call Member Service at the number on your ID card. Submit this form once per calendar year, no later than March 31 of the following year.

PLEASE PRINT ALL INFORMATION CLEARLY

Please complete and mail this form to:Blue Cross Blue Shield of MassachusettsLocal Claims Department PO Box 986030 Boston, MA 02298


Your Blue Cross Blue Shield of Massachusetts health plan can save you money annually in qualified Weight Watchers®´ and hospital-based weight-loss programs.

Weight Loss Benefit

ChooseStart by picking a qualified

weight-loss program.

1. 2. 3.Complete

Once you pay for the program, fill out the attached form.

MailSend the completed form and proof of

payment to the address listed at the bottom.


1. Before starting, check to see if your plan includes the Weight Loss Benefit.2. Most plans offer a three-month reimbursement, but your employer may have offered a different benefit. Please refer to your benefits information to confirm.


Important Information• The reimbursement is for each individual

(or family) health plan and can only be submitted once each calendar year.

• Keep copies of all your paperwork and proof of payment in case you are denied reimbursement. Proof of payment includes the following:

– Paid receipts from qualified program– Weight Watchers Membership Book

• Receipts, statements, or Weight Watchers Membership Book should include the name of the family member enrolled in the program, the amount paid per session(s), and date(s) paid.

• The dollar amount you receive may be considered taxable income. Consult your tax advisor about how to treat this reimbursement on your taxes.

Be sure to check with your doctor before starting any weight-loss program.

What's covered:2

Your benefit will reimburse you for up to three months of participation in a qualified weight-loss program.

A qualified weight-loss program is:• Weight Watchers meetings

• Weight Watchers At Work

• A hospital-based weight-loss program

What doesn’t qualify?• Weight Watchers Online

• Weight Watchers At Home

• Fees paid for individual nutrition-counseling sessions, food, books, videos, or scales

Weight-Loss Reimbursement Form3

To verify this reimbursement is within your plan, log in to Member Central at www.bluecrossma.com/membercentral or call Member Service at the number on your ID card. Submit this form when you have paid receipts from a qualified weight-loss program, once per calendar year, no later than March 31 of the following year.

Subscriber Information (Policyholder)Identification Number (including first 3 letters) Subscriber’s Last Name First Name Middle Initial

Address—Number and Street City State Zip Code

Employer’s Name

Member and Claim InformationMember’s Last Name First Name Middle Initial Date of Birth: Mo. Day Yr.

Mailing Address—Number and Street (if different from subscriber’s) City State Zip Code

Gender

Male

Female

Claim is for (check one):

Subscriber (policyholder) Ex-Spouse Other (specify) ___________________

Spouse (of policyholder) Dependent (up to age 26)

Class or Program Information Required: Attach 8.5" x 11" photocopies of paid receipts from your qualified weight-loss program. Receipts must show Blue Cross Blue Shieldof Massachusetts member’s name, name or logo of program, amount paid per session(s), and date(s) paid. For qualified Weight Watchersprograms, a photocopy of your program Membership Book showing this information is required.

Name and Address of Class or Program Health Plan Year

PLEASE PRINT ALL INFORMATION CLEARLY

Total Amount Submitted: $ ________________________________________

3. Blue Cross will make a reimbursement decision within 30 calendar days of receiving a completed request for coverage or payment.

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks are the property of their respective owners. © 2015 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 147582M 55-0822

Please complete and mail this form (including copies of paid receipts) to:Blue Cross Blue Shield of MassachusettsLocal Claims Department PO Box 986030 Boston, MA 02298

Certification and Authorization (This form must be signed and dated below.)

I authorize the release of any information to Blue Cross and Blue Shield of Massachusetts about my weight-loss program. I certify that the information provided in support of this submission is complete and correct and that I have not previously submitted for these services.

Subscriber’s or Member’s Signature: _________________________________________________________________ Date: _______________________________________

Questions?To verify this reimbursement is within your plan or for further information, please log in to the Member Central website at www.bluecrossma.com/membercentral or call Member Service at the number on the front of your ID card.


Programs, discounts, and tools to help you stay healthy

Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life

EverythingYou Need to

All in One Placewww.bluecrossma.com/ahealthyme

Access & Convenience

Alternative Medicine &

Services

Discounts & Deals

Pregnancy & Parenthood

Encuentra estos programas, herramientas y recursos disponibles

en español que te ayudarán a mantenerte saludable.

Español

Whatever your health goals are — from losing weight to managing stress — ahealthyme can help you get there.

Create your own action plan with

• A health assessment that gives you a personal wellness score

• Self-paced workshops on topics like healthy eating and quitting smoking

• Nutrition and exercise trackers to keep you motivated

Your personal wellness planner

www.paramisalud.comVisita

Learn about health your way

• Read articles, tips, and our Healthy Times newsletter

• Watch videos and listen to podcasts• Take quizzes, risk assessments,

and more

Healthy resources

Recursos saludables para conocer el camino hacia una buena salud.

Español

Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life Live a Healthier Life

EverythingYou Need to

All in One Placewww.bluecrossma.com/ahealthyme

Web, Apps, Texts & Social

There’s so much you can do on the go• Find a doctor or hospital • Manage your prescriptions • Get weekly health tips via

text throughout pregnancy and motherhood

• Follow us on Facebook, Twitter, and YouTube

• Track your progress toward your fitness and nutrition goals

www.bluecrossma.com/mobile Go to

ConnectedAlways on the go?

No problem. Access our

collection of mobile applications

anywhere, anytime.

Acces

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Get special savings, 365 days a year• Healthy Choices: fitness, weight management,

food and nutrition, and stress management• Health Care Resources: financial services and

assessments, information about prescription drugs, hearing and vision care, and insurance tips

• Recreation and Travel: arts and entertainment, outdoor recreation, and travel tips

Blue365®

www.bluecrossma.com/blue365 Go to

DealsFrom gym memberships

and diet programs

to family activities,

we have just

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A trusted, online resource for new parents• Pregnancy Prep: understand your body and plan

ahead with ovulation calculators• Pregnancy: know what to expect in each trimester

and download a birth plan• New Parents: learn more about your baby’s first year

Living Healthy Babies®´

http://espanol.livinghealthybabies.comVisita

www.livinghealthybabies.com Go to

Español ¿Tienes preguntas sobre el embarazo, el parto y qué esperar durante el primer año de tu bebé?

FamilyHave questions about

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to expect during your

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We can help answer

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A complementary approach to health• Services: massage therapy, acupuncture,

pilates, yoga, and much more• Discounts: save up to 30 percent on

select services or medicine• Peace of mind: relax knowing all

practitioners meet requirements for education, training, and facilities

Living Healthy NaturallySM´

www. bluecrossma.com/alternative-care Go to

AlternativeSave on alternative

services nationwide like

massage therapy

and acupuncture.

Altern

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Medici

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®, SM Registered Marks and Service Marks of the Blue Cross and Blue Shield Association. ®´, SM´ Registered Marks and Service Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. © 2014 Blue Cross and Blue Shield of Massachusetts, Inc.

134021M 55-0830 (5/14)

We are here to helpMember Service For questions about your health coverage, claims, and benefits.

Call the number on your Blue Cross ID card, Monday through Friday, 8:00 a.m. to 6:00 p.m. ET.

Estamos para responder a tus preguntas sobre tu plan médico. Llama al número que se encuentra en tu tarjeta de identificación de Blue Cross.

Member CentralReview your claims and benefits information, order a new ID card, change your primary care provider, and do so much more. www.bluecrossma.com/membercentral

Blue Care LineSM For questions about your health if you’re hurt or sick and not sure where to get care. Call us 24/7 to speak directly to a nurse who can help guide your care.

Si tienes preguntas sobre tu salud, puedes comunicarte con un enfermero disponible las 24 horas del día, los 7 días de la semana.

1-888-247-BLUE (2583)

Español

Español

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ®, SM Registered Marks and Service Marks of the Blue Cross and Blue Shield Association. © 2014 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 134148 32-6765 (5/14)

Blue Care LineSM

We’re here for you 24/7

Have a question about your health? You can talk to a professionally trained, registered nurse 24 hours a day, seven days a week. They’re ready when you are—even at 4 a.m.

Know your options

Calling the Blue Care Line is a quick way to find out if you need to see a doctor, go to an emergency room, or if you’re able to treat it yourself at home.

We’ll call you

Depending on your type of illness or injury, the registered nurse will call and follow up to see how you’re responding to the self-treatment.

Confidentiality

Your information is kept in accordance with our policy on confidentiality.

Call 1-888-247-BLUE (2583)for the Blue Care Line.

FDA approved generic medications will be dispensed when allowed by your doctor, subject to the termsoutlined in your plan. I certify that all the information on this form is correct. I permit Express Scripts Inc. torelease all information on this form concerning prescription orders to my plan sponsor, administrator or healthplan for the purpose of payment, treatment or health care operations.

No Known AllergiesAcetaminophen/Tylenol®

AmoxicillinAspirin

Cephalosporin (i.e., Keflex®, Cephalexin)Codeine

Erythromycin, Biaxin®, Zithromax®

NSAIDs (i.e., Ibuprofen, Naproxen)Oxycodone (i.e., OxyContin®, Percocet®)

PenicillinSulfa

Tetracycline (i.e., Doxycycline, Minocycline)No Known Health Conditions

Arthritis (715.9)Asthma (493.9)

Chronic Bronchitis or Emphysema (496)Depression (311)

Diabetes Type I (250.01)Diabetes Type II (250.00)Epilepsy/Seizures (345.9)

GERD (530.81)Glaucoma (365.9)

High Cholesterol (272.9)Hormone Replacement Therapy (627.9)

Hypertension (401.9)Thyroid: Low (244.9)

No Over-the-Counter MedicationsAcetaminophen/Tylenol®

Advil®/Aleve®/Motrin®

Aspirin/Excedrin®

No Medical Devices

Medical Devices (i.e., Glucose TestingDevice, Insulin Pump, Nebulizer) and

specify brand name and model.

No Other Prescriptions

Prescription Medications not filledthrough Express Scripts Pharmacy.

List other Allergies here:

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List other HealthConditions here:

OTC

List other OTC that you takeon a regular basis:

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Name:

Date of Birth (MM/DD/YYYY)

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I want non-child resistant caps,when available.

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Signature Required X

List Medical Devices here:

List other PrescriptionMedications here:

List other Allergies here:

List other HealthConditions here:

List other OTC that you takeon a regular basis:

List Medical Devices here:

List other PrescriptionMedications here:

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MLR- DRAFTONLY (MAILER) REV 07/27/2011

Name:


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I want non-child resistant caps,when available.

/

Date of Birth is required forpatient identification.

Failure to provide complete andaccurate information may preventthe pharmacy from detecting drugrelated problems.

More than two family members on your plan? On a separate sheet of paper, write the family member(s)name, date of birth, allergies and health conditions along with the name and phone number of theirdoctor/prescriber.

Please Note: Your order may be filled at any one of our Express Scripts Pharmacies located nationwide.


Check Out These Benefits!Savings: The biggest advantage of the mail service pharmacy is that for most long-term maintenance medications you can order up to a 90-day supply. Often times, using mail service results in the lowest possible out-of-pocket costs to you as a member.

Convenience: Your medications will be delivered to your home, postage paid, within 14 days of mailing your new prescription.

Confidentiality: If you have questions, you can call Express Scripts toll-free, 24 hours a day. Registered pharmacists are available to answer your questions about your prescriptions confidentially. Call 1-800-892-5119.

Special-Needs Services Available: For the convenience of our hearing-impaired members, Express Scripts is TTY-ready, and has installed a separate toll-free number for you to use with your TTY equipment. The number is 1-800-305-5376.

For our vision-impaired members, upon special request with your order, Express Scripts can provide Braille labels for your medication.

And for our non-English-speaking members, Express Scripts can provide translation services when you call the toll-free line.

Refer to your benefit literature for specific coverage information.

Three Easy Steps To Use Mail ServiceFor long-term prescriptions, use our mail service pharmacy to save. 1. Ask your doctor to prescribe medications for up to a 90-day

supply, plus refills when applicable. (If you’re already taking medication on a long-term basis, ask your doctor for a new prescription.)

2. Complete the attached Mail Order Form for each member submitting a prescription. Be sure to answer all of the questions.

3. Seal the form, prescriptions, and the appropriate copayment in the pocket in this brochure (do not send cash). Then simply mail it in. Be sure to write your ID number exactly as it appears on your ID card.

Your order will be quickly processed and sent to you by mail or UPS. Allow 14 days for delivery from the date you mail the order. To prevent delays, do not fill medications that are needed quickly or short-term medications (e.g. antibiotics) via mail service.

Confidential Subscriber/Patient ProfilePlease write your ID number, name, and address on the attached form. Then complete the Patient Profile for you and each of your dependents submitting prescriptions, indicating any drug allergies, and health conditions. Express Scripts will use this information to check any potential drug interactions when you have prescriptions filled. If there are no drug allergies, please check “None” in the box provided.

Your Mail Service Pharmacy Benefit

As a member of Blue Cross Blue Shield of Massachusetts, you can buy certain medications at the Express Scripts mail service pharmacy.

It’s a great way to save by purchasing prescriptions on a long-term basis.

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Did You Remember To…• Complete all applicable information

• Include your ID number on the mail order form

• Enclose the original prescription, mail order form, and appropriate copayment

• Make checks or money orders payable to “Express Scripts”, or include credit card information

Detach envelope to mail presciption order form

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InstructionsNew Prescriptions:• Have your doctor/provider write the prescription for up to a

90-day supply

• To prevent any delays, make sure that an approved formulary exception (if applicable) for any medications that are non-covered or require prior authorization is on file before you place your order

• Complete all information requested on the attached Mail Order Form

• Select your preference for Safety Caps in the appropriate box

• Ensure that the patient’s full name, age, ID number, and address appear on each prescription

• Find out the appropriate copayment necessary for the medication prescribed

• Place prescriptions and copayments in return envelope and mail

Refills:• Call 1-800-892-5119 or visit www.express-scripts.com to refill

your order, or

• Place refill slips and copayments in the return envelope and mail it

Make all checks or money orders payable to “Express Scripts”. Do not send cash. If paying by credit card, complete the information under “Credit Card Information.”

What Do I Do in Emergency Situations?When you need medication immediately, simply have your prescription filled at a local pharmacy. If you need medication immediately, but will be taking it on an ongoing basis, you can ask your doctor to write two prescriptions: • You can fill the first prescription at a local participating pharmacy;

• Send the second prescription (up to a 90-day supply), along with your copayment, to Express Scripts immediately.

About Your PrescriptionBlue Cross Blue Shield of Massachusetts maintains a list of covered prescription drugs. If you have any questions about whether or not your medications are covered, or subject to Quality Care Dosing, Step Therapy, or Prior Authorization, please visit www.bluecrossma.com/pharmacy or call Blue Cross Blue Shield of Massachusetts Member Service at the number on the front of your ID card.

Mail Service QuestionsCall Express Scripts customer service 24 hours a day, 7 days a week. Pharmacy consultation is also available around-the-clock.Toll-free number: 1-800-892-5119 (TTY: 1-800-305-5376)

Answers to Your QuestionsHow Do I Determine What Copayment Amount? I Should Include With My Order?Check your benefit literature, and if you still have specific questions, call the Blue Cross Blue Shield of Massachusetts Member Service phone number listed on the front of your ID card.

Why Did My Order Contain Generic Drugs? When My Prescription Requested a Brand-Name Version?When authorized by your doctor and permitted by applicable law, Express Scripts will dispense a generic drug. This usually saves you money, so whenever possible, ask your doctor to prescribe generic drugs.

Why Isn’t My Drug Available Through the ESI Mail Service?Certain medications that require immediate administration or are used for short periods of time are inappropriate for mail service. In addition, for certain medications classified as specialty drugs, Blue Cross Blue Shield of Massachusetts has established a relationship with a preferred specialty pharmacy. They offer additional services that are not offered by our mail service pharmacy.

How Do I Order Refills? Simply call the toll-free number, 1-800-892-5119, and order your refills over the phone. You can also visit the Express Scripts website to refill your order (www.express-scripts.com). Once you have ordered through mail service, you will receive a refill slip with your prescription.

Enclose the slip and the appropriate copayment amount in the order envelope (which is provided).

Please Note: Certain controlled substances and several other prescribed medications may be subject to other dispensing limitations and to the professional judgment of the pharmacist. If you have any questions regarding your medication, please call Express Scripts customer service at 1-800-892-5119.

It’s the patient’s responsibility to report to Express Scripts any changes in drug allergies, health conditions, chronic diseases, and drug sensitivities.

Prescription information about members and dependents is used by Express Scripts to administer your prescription program. As part of the administration, Express Scripts reports that information to Blue Cross Blue Shield of Massachusetts. Express Scripts also uses the information and prescription data gathered from claims submitted nationwide for reporting and analysis, without identifying individual patients in accordance with applicable laws.

Email


Express Scripts Pharmacy Prescription Order FormTo order online: sign in at www.StartHomeDelivery.com and follow the prompts.To order by mail: complete this form and ask your doctor to write your prescription for a90-day supply or the maximum days supply allowed by your plan.

• Use ALL CAPITAL LETTERS in BLACK INK. Fill in the ovals as shown ( ).• Remember to mail your prescription with this completed form. Your medication

will arrive within two weeks from the date we receive your first order.NOTE: Standard shipping is FREE for online and mail orders.

State

Zip Code

Daytime Phone

Some medications cannot be delivered to a PO Box. Provide a street address to allow delivery of your order.Shipping Address 1

ID Card Number

( )

( )

Evening PhonePlease select oneas your preferredtelephone number

City

MIFirst Name

Last Name

All individuals included in the family will be charged to this credit card.

Exp. Date (MM/YY)Card #

Amount Enclosed$ .Check / Money OrderCheck Card Credit Card

Apply to this order only Apply to all orders

PATI

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PAT

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PAYM

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Doctor/Prescriber Phone NumberDoctor/Prescriber Last Name

Shipping Address 2

Gender M F

( )Cell Phone

( )

/ /

Check here for rush shipment. Your order, oncereceived and filled, will be shipped overnight for $21.

Date of Birth (MM/DD/YYYY)MIFirst Name

Last NameGender M F

/ /

Doctor/Prescriber Phone NumberDoctor/Prescriber Last Name( )

Email

/

Sign here to authorize card payment X

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MLR- DRAFTONLY (MAILER) REV 07/27/2011

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Inside envelope

Inside envelope

Express Scripts, an independent company, administers your prescription benefit and its services are being provided on behalf of Blue Cross Blue Shield of Massachusetts. ® Registered Marks of the Blue Cross and Blue Shield Association.

© 2015 Blue Cross and Blue Shield of Massachusetts, and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 147610M 32-7040

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