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Flexrx standard quantity limit, specialty, and step therapy drug list (bluelinktpa)

FlexRx Standard Quantity Limit, Specialty, and Step Therapy
Drug List

How to use the drug list
This drug list includes drugs that have a quantity limitation, step therapy requirement, or it is a specialty drug. The drug's preferred or non-preferred status is also included. Generic drugs are shown in lowercase (e.g. acetaminophen) and brand name drugs are shown in capital letters (e.g. ACIPHEX). For additional information about the various drug programs, you can refer to bluelinktpamn.com. Helpful hints
If your physician feels that a change to your prescription is not right for you, your physician must submit a Quantity Limit override request form. Refer to the topic 'Specialty Drug Program' on bluelinktpamn.com for a list of specialty drug vendors.
To help you find alternative drugs, refer to the list of FlexRx Standard Step Therapy Drug Alternatives at the end of this document. You and your physician can review your options. If your physician feels that a change to your prescription is not right for you, your physician must submit a Step Therapy Authorization request form.
Acronyms
NP = Non-preferred, P = Preferred, PA = Prior Authorization, QL = Quantity Limit per 30 days, SP = Specialty Drug Program, ST = Step Therapy Program These programs and quantity limitations may not apply. Check your certificate or other plan information
for benefit details.

Product Name and Requirements
Product Name and Requirements
acetaminophen / caffeine / dihydrocodeine 712.8 mg-60 mg- ALTOPREV (NP)(ST=Cholesterol Lowering-Statins (Lipid acetaminophen / codeine solution 120 mg-12 mg/5 mL AMERGE (naratriptan) (generic (P); brand (NP))(QL=18 AMEVIVE (NP)(SP)(ST=Biological Immunomodulators) ACTEMRA (NP)(SP)(ST=Biological Immunomodulators) AUBAGIO 7mg, 14mg (NP)(SP)(ST=Multiple Sclerosis Agents) ADDERALL (amphetamine/dextroamphetamine) 20 mg (generic (P); brand (NP))(QL=90 tablets) ADDERALL (amphetamine/dextroamphetamine) 5 mg, 7.5 AVONEX (NP)(SP)(ST=Multiple Sclerosis Agents) mg, 10 mg, 12.5 mg, 15 mg, 30 mg (generic (P); brand (NP))(QL=60 tablets) ADVICOR (NP)(ST=Cholesterol Lowering-Statins (Lipid BERINERT Kit (Intravenous) - 500unit (NP)(PA)(SP) BETASERON (P)(SP)(ST=Multiple Sclerosis Agents) This list is subject to change without notice.
FlexRx Standard Quantity Limit, Specialty, and Step Therapy Drug List (7/1/2013)
Product Name and Requirements
Product Name and Requirements
DEXTROAMPHETAMINE 10 mg (P)(QL=180 tablets) dextroamphetamine 5 mg (P)(QL=60 tablets) Butalbital/APAP 50-325mg (P)(QL=180 tabs) Diabetic meters and strips manufacturers other than the Roche and Bayer lines. (NP)(ST=Diabetic Meters and butalbital/aspirin/caffeine 50 mg/325 mg/40 mg (P)(QL=180 DITROPAN XL (oxybutynin chloride extended-release) 10 butorphanol nasal spray (NP)(QL=3 x 2.5 mL) mg, 15 mg (generic (P); brand (NP))(QL=60 tablets) DITROPAN XL (oxybutynin chloride extended-release) 5 mg (generic (P); brand (NP))(QL=30 tablets) CAFERGOT (ergotamine tartrate/caffeine) (generic (P); brand (NP))(QL=40 tablets) ENBREL (NP)(SP)(ST=Biological Immunomodulators) CIALIS, covered for males only > 18 years (NP)(QL=6 ESGIC (butalbital/acetaminophen/caffeine) 50 mg-325 mg- CIMZIA (NP)(SP)(ST=Biological Immunomodulators) 40 mg (generic (P); brand (NP))(QL=180 tablets/capsules) ESGIC-Plus (butalbital/acetaminophen/caffeine) 50 mg-500 mg-40 mg (NP)(QL=180 tablets/capsules) EXALGO extended-release 8 mg, 12 mg, 16 mg, 32 mg COMMIT (nicotine) lozenges (P)(QL=680 lozenges) CONCERTA 18 mg, 27 mg, 54 mg (NP)(QL=30 tablets) EXTAVIA (NP)(SP)(ST=Multiple Sclerosis Agents) CONZIP 100, 200, 300mg (NP)(QL=30 tablets) EYLEA Solution (Intraocular) - 2mg/0.05ml (NP)(SP) COPAXONE (P)(SP)(ST=Multiple Sclerosis Agents) CRESTOR (P)(ST=Cholesterol Lowering-Statins (Lipid FIORICET (butalbital/acetaminophen/caffeine) 50 mg-325 mg-40 mg (generic (P); brand (NP))(QL=180 tablets) D. H. E. 45 (dihydroergotamine) (generic (P); brand (butalbital/acetaminophen/caffeine/codeine) 50 mg-325 mg- FIORINAL (butalbital/aspirin/caffeine) 50 mg-325 mg-40 mg (generic (P); brand (NP))(QL=180 capsules) DESOXYN (methamphetamine) (NP)(QL=150 tablets ) FIORINAL w/CODEINE (butalbital/aspirin/caffeine/codeine) DESVENLAFAXINE XR (NP)(ST=Antidepressants) 50 mg-325 mg-40 mg-30 mg (generic (P); brand (NP))(QL=180 capsules) DEXEDRINE Spansules (dextroamphetamine extended-release) 10 mg, 15 mg (generic (P); brand (NP))(QL=120 FIRST-LANSOPRAZOLE SUS 3mg/ml (NP)(QL=10mls/day) FIRST-OMEPRAZOLE SUS 2-3mg/ml (NP)(QL=20 mls/day) DEXEDRINE Spansules (dextroamphetamine extended-release) 5 mg (generic (P); brand (NP))(QL=90 capsules) This list is subject to change without notice.
FlexRx Standard Quantity Limit, Specialty, and Step Therapy Drug List (7/1/2013)
Product Name and Requirements
Product Name and Requirements
FOCALIN (dexmethylphenidate) (generic (P); brand IMITREX STATdose (sumatriptan) (NP)(QL=12 syringes) FOSAMAX (alendronate) tablets 35 mg, 70 mg (generic (P); brand (NP))(QL=4 tablets) FOSAMAX (alendronate) tablets 5 mg, 10 mg, 40 mg JAKAFI 5mg, 10mg, 15mg, 20mg, 2mg, (P)(SP) KINERET (NP)(SP)(ST=Biological Immunomodulators) GENOTROPIN (NP)(PA)(SP)(ST=Growth Hormone) GILENYA (NP)(SP)(ST=Multiple Sclerosis Agents) LESCOL (NP)(ST=Cholesterol Lowering-Statins (Lipid LESCOL XL (NP)(ST=Cholesterol Lowering-Statins (Lipid Management)) HUMATROPE (NP)(PA)(SP)(ST=Growth Hormone) HUMIRA (P)(SP)(ST=Biological Immunomodulators) LEVITRA, covered for males only > 18 years (NP)(QL=6 HYCET (hydrocodone/acetaminophen) solution 7.5 mg/325 LIPITOR (NP)(ST=Cholesterol Lowering-Statins (Lipid hydrocodone/acetaminophen capsules 5 mg-500 mg LIVALO (NP)(ST=Cholesterol Lowering-Statins (Lipid HYDROCODONE/ACETAMINOPHEN solution 10 mg/325 LORCET (hydrocodone/acetaminophen) tablets 10 mg-650 hydrocodone/acetaminophen tablets 2.5 mg-500 mg mg (generic (P); brand (NP))(QL=180 tablets) LORCET Plus (hydrocodone/acetaminophen) tablets 7.5 mg-650 mg (generic (P); brand (NP))(QL=180 tablets) IBUDONE (hydrocodone/ibuprofen) 10 mg-200 mg (generic LORTAB (hydrocodone/acetaminophen) solution 7.5 mg- 500 mg/15 mL (generic (P); brand (NP))(QL=2700 mL) LORTAB (hydrocodone/acetaminophen) tablets 5 mg-500 mg (generic (P); brand (NP))(QL=240 tablets) IMITREX (sumatriptan) single dose vial 6 mg/0.5 mL (generic (P); brand (NP))(QL=10 vials) LORTAB (hydrocodone/acetaminophen) tablets 7.5 mg-500 mg, 10 mg-500 mg (generic (P); brand (NP))(QL=180 IMITREX (sumatriptan) tablets (generic (P); brand IMITREX nasal spray 20 mg (NP)(QL=12 spray units) IMITREX nasal spray 5 mg (NP)(QL=12 spray units) This list is subject to change without notice.
FlexRx Standard Quantity Limit, Specialty, and Step Therapy Drug List (7/1/2013)
Product Name and Requirements
Product Name and Requirements
NICORETTE (nicotine) gum (P)(QL=816 pieces) NORCO (hydrocodone/acetaminophen) 5 mg-325 mg (generic (P); brand (NP))(QL=360 tablets) NORCO (hydrocodone/acetaminophen) 7.5 mg-325 mg, 10 mg-325 mg (generic (P); brand (NP))(QL=180 tablets) MAGNACET (oxycodone/acetaminophen) 10 mg-400 mg NORDITROPIN (NP)(PA)(SP)(ST=Growth Hormone) MAGNACET (oxycodone/acetaminophen) 2.5 mg-400 mg, 5 mg-400 mg (NP)(QL=300 tablets) MAGNACET (oxycodone/acetaminophen) 7.5 mg-400 mg NUCYNTA ER 50, 100, 150, 200, 250mg (NP)(QL=60 NUTROPIN AQ (NP)(PA)(SP)(ST=Growth Hormone) MAXIDONE (hydrocodone/acetaminophen) 10 mg-750 mg (generic (P); brand (NP))(QL=150 tablets ) METHYLIN (methylphenidate) solution 10 mg/5 mL (NP)(QL=900 mL) ORENCIA (NP)(SP)(ST=Biological Immunomodulators) METHYLIN (methylphenidate) solution 5 mg/5 mL METHYLIN chewable tablets 10 mg (NP)(QL=180 tablets) METHYLIN chewable tablets 2.5 mg, 5 mg (NP)(QL=90 oxycodone/ibuprofen 5 mg-400 mg (NP)(QL=120 tablets) OXYCONTIN 10 mg, 15 mg, 20 mg, 30 mg, 40 mg METHYLPHENIDATE extended-release 10 mg (P)(QL=90 OXYCONTIN 60 mg, 80 mg (P)(QL=120 tablets) METHYLPHENIDATE extended-release OSM 18 mg, 27 mg, 54 mg (NP)(QL=30 tablets) METHYLPHENIDATE extended-release OSM 36 mg MEVACOR (NP)(ST=Cholesterol Lowering-Statins (Lipid Management)) pentazocine/acetaminophen 25 mg-650 mg (NP)(QL=180 tablets) PERCOCET (oxycodone/acetaminophen) 10 mg-325 mg, 10 mg-650 mg (generic (P); brand (NP))(QL=180 tablets) PERCOCET (oxycodone/acetaminophen) 2.5 mg-325 mg, 5 mg-325 mg (generic (P); brand (NP))(QL=360 tablets) MS CONTIN (morphine sulfate extended-release) (generic (P); brand (NP))(QL=90 tablets) PERCOCET (oxycodone/acetaminophen) 7.5 mg-325 mg, 7.5 mg-500 mg (generic (P); brand (NP))(QL=240 tablets) PERCODAN (oxycodone/aspirin) 4.88 mg-325 mg (generic PRAVACHOL (NP)(ST=Cholesterol Lowering-Statins (Lipid This list is subject to change without notice.
FlexRx Standard Quantity Limit, Specialty, and Step Therapy Drug List (7/1/2013)
Product Name and Requirements
Product Name and Requirements
PREVACID, PREVACID SoluTab (NP)(ST=Proton Pump SIMCOR (NP)(ST=Cholesterol Lowering-Statins (Lipid PROTONIX packets (P)(ST=Proton Pump Inhibitors) PROTONIX tablets (NP)(ST=Proton Pump Inhibitors) SIMPONI (NP)(SP)(ST=Biological Immunomodulators) STAXYN, covered for males only > 18 years 10 mg (NP)(QL=6 tablets) STELARA (NP)(SP)(ST=Biological Immunomodulators) REBIF (P)(SP)(ST=Multiple Sclerosis Agents) STRATTERA 10 mg, 18 mg, 25 mg, 40 mg, 60 mg REBIF REBIDOSE (P)(SP)(ST=Multiple Sclerosis Agents) STRATTERA 80 mg, 100 mg (P)(QL=30 capsules) SUCRAID Solution (Oral) - 8500unit/ml (NP)(SP) SUMATRIPTAN nasal spray (P)(QL=12 spray units) SUMATRIPTAN single dose vial 4 mg/0.5 mL (P)(QL=12 vials) REMICADE ()(ST=Biological Immunomodulators) REPREXAIN (hydrocodone/ibuprofen) 5 mg-200 mg (generic (P); brand (NP))(QL=150 tablets ) REPREXAIN 2.5 mg-200 mg (NP)(QL=150 tablets ) TEV-TROPIN (NP)(PA)(SP)(ST=Growth Hormone) RITALIN (methylphenidate) (generic (P); brand RITALIN LA 10 mg, 20 mg, 40 mg (NP)(QL=30 capsules) RITALIN SR (methylphenidate extended-release) 20 mg (generic (P); brand (NP))(QL=90 tablets) TREZIX (acetaminophen/caffeine/dihydrocodeine) 356.4 mg-30 mg-16 mg (NP)(QL=300 capsules) TRILEPTAL suspension (P)(ST=Anticonvulsants) This list is subject to change without notice.
FlexRx Standard Quantity Limit, Specialty, and Step Therapy Drug List (7/1/2013)
Product Name and Requirements
Product Name and Requirements
XARELTO 15, 20 mg (P)(QL=1 tablet per day) TYLENOL w/CODEINE (acetaminophen/codeine) 300 mg- XELJANZ 5mg (NP)(SP)(ST=Biological Immunomodulators) 15 mg, 300 mg-30 mg (generic (P); brand (NP))(QL=360 tablets) TYLENOL w/CODEINE (acetaminophen/codeine) 300 mg- 60 mg (generic (P); brand (NP))(QL=180 tablets) XODOL (hydrocodone/acetaminophen) 5 mg-300 mg TYLOX (oxycodone/acetaminophen) (generic (P); brand XODOL (hydrocodone/acetaminophen) 7.5 mg-300 mg, ULTRACET (tramadol/acetaminophen) (generic (P); brand ULTRAM (tramadol) 50 mg (generic (P); brand ULTRAM ER (tramadol extended-release) 100 mg, 200 mg (generic (P); brand (NP))(QL=30 tablets) ULTRAM ER (tramadol extended-release) 300 mg VENLAFAXINE ext-release 225 mg (NP)(ST=Antidepressants) ZOCOR (NP)(ST=Cholesterol Lowering-Statins (Lipid Management)) VIAGRA, covered only for males > 18 years (P)(QL=6 tablets) ZOMIG nasal spray (NP)(QL=12 spray units) VICODIN (hydrocodone/acetaminophen) 5 mg-500 mg (generic (P); brand (NP))(QL=240 tablets) VICODIN ES (hydrocodone/acetaminophen) 7.5 mg-750 mg (generic (P); brand (NP))(QL=150 tablets ) VICODIN HP (hydrocodone/acetaminophen) 10 mg-660 mg ZYDONE 7.5 mg/400 mg, 10 mg/400 mg (NP)(QL=180 (generic (P); brand (NP))(QL=180 tablets) VICOPROFEN (hydrocodone/ibuprofen) 7.5 mg-200 mg (generic (P);brand (NP))(QL=150 tablets ) VYTORIN (NP)(ST=Cholesterol Lowering-Statins (Lipid Management)) XARELTO 10 mg (P)(QL=35 tablets per 90 days) This list is subject to change without notice.
FlexRx Standard Quantity Limit, Specialty, and Step Therapy Drug List (7/1/2013)
FlexRx Standard Step Therapy Program Alternative Drug List
Anticonvulsants Step Therapy Alternatives
Proton Pump Inhibitors Step Therapy Alternatives
lansoprazole, lansoprazole orally disintegrating tablet (P) Antidepressants Step Therapy Alternatives
Additional options for members with the OTC Benefit
venlafaxine ext-release except for 225 mg (P) Additional options for CYMBALTA only
Cholesterol Lowering-Statins (Lipid Management) Step
Therapy Alternatives

Diabetic Meters and Strips Step Therapy Alternatives
Growth Hormone Step Therapy Alternatives
Makena Step Therapy Alternatives
This list is subject to change without notice.
FlexRx Standard Quantity Limit, Specialty, and Step Therapy Drug List (7/1/2013)

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