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Blue Care Network Quantity Limits July 2020 These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070 Pharmacy programs ensure safety and cost-effectiveness We monitor the use of certain medications to help ensure you receive the most appropriate and cost-effective drug therapy. Our Quantity Limits program is one of the ways we monitor medications. This document is published monthly. Quantity limits Our Quantity Limits program limits the amount of medicine that you can fill for certain medications. For example, a drug may have a limit of 30 pills per 30 days. We apply such limits, based on drug studies and reviews by actively practicing doctors, to certain drugs in weight loss, smoking cessation, erectile dysfunction, nausea and several other categories. If you refill a prescription too soon or if your doctor prescribes an amount that’s higher than usual, your pharmacist will tell you that the drug isn’t covered. Only your doctor can request coverage for drugs that exceed BCN limits. All opioids are limited to 90 morphine milligram equivalent (MME) per day. ACE-Inhibitors and combinations Custom Custom Select Katerzia TM 2 bottles (300mg) per 30 days Not covered Alpha-adrenergic agents Custom Custom Select Lucemyra TM 224 tablets per 30 days Alzheimer's Therapy Custom Custom Select Aricept ® 23mg (g)* 1 tablet per day Not covered Namenda ® titration pack 1 pack per 365 days Namenda XR ® 1 capsule per day Namenda XR ® titration pack 1 pack per 365 days Namzaric TM * 1 capsule per day Not covered

Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

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Page 1: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Pharmacy programs ensure safety and cost-effectiveness We monitor the use of certain medications to help ensure you receive the most appropriate and cost-effective drug therapy. Our Quantity Limits program is one of the ways we monitor medications.

This document is published monthly.

Quantity limits Our Quantity Limits program limits the amount of medicine that you can fill for certain medications. For example, a drug may have a limit of 30 pills per 30 days. We apply such limits, based on drug studies and reviews by actively practicing doctors, to certain drugs in weight loss, smoking cessation, erectile dysfunction, nausea and several other categories. If you refill a prescription too soon or if your doctor prescribes an amount that’s higher than usual, your pharmacist will tell you that the drug isn’t covered.

Only your doctor can request coverage for drugs that exceed BCN limits.

All opioids are limited to 90 morphine milligram equivalent (MME) per day.

ACE-Inhibitors and combinations Custom Custom Select

KaterziaTM 2 bottles (300mg) per 30 days Not covered

Alpha-adrenergic agents Custom Custom Select

LucemyraTM 224 tablets per 30 days

Alzheimer's Therapy Custom Custom Select

Aricept® 23mg (g)* 1 tablet per day Not covered

Namenda® titration pack 1 pack per 365 days

Namenda XR® 1 capsule per day

Namenda XR® titration pack 1 pack per 365 days

NamzaricTM* 1 capsule per day Not covered

Page 2: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Angiotensin II Receptor Blockers and Combinations Custom Custom Select

Edarbi®* 1 tablet per day

Edarbyclor®* 1 tablet per day

EntrestoTM* 2 tablets per day

Tribenzor®* (g) 1 tablet per day

Anticoagulant and Hemostasis Agents Custom Custom Select

BevyxxaTM 1 tablet per day

Brilinta® 2 tablets per day

Cablivi®* <s> 1 vial (kit) per day

Effient® (g) 1 tablet per day

Eliquis® 74 tablets per 30 days 194 tablets per 90 days

Eliquis® pack 1 pack per 365 days

Pradaxa® 2 capsules per day

Savaysa® 1 tablet per day

Xarelto® 10mg, 15mg, 20mg 1 tablet per day

Xarelto® 2.5mg 2 tablets per day

Xarelto® starter kit 1 pack per 365 days

Zontivity® 1 tablet per day

Anticonvulsants Custom Custom Select

Acthar® H.P.* <s> 4 vials per 30 days Not covered

Aptiom® 200mg, 400mg* 1 tablet per day Not covered

Aptiom® 600mg, 800mg* 2 tablets per day Not covered

Briviact®* 2 tablets per day

Briviact® solution* 20 mL per day

Diacomit®* <s> 3,000mg per day

Page 3: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Anticonvulsants (cont.) Custom Custom Select

Epidiolex®* 20 mL per day (6 bottles per 30 days)

Fycompa® tablet 1 tablet per day

Lyrica® capsules (all strengths)* 3 capsules per day

Lyrica CR 82.5mg, 165mg 1 tablet per day Not covered

Lyrica CR 330mg 2 tablets per day Not covered

Lyrica® solution* 2 bottles (946mL) per 30 days

Nayzilam® 5 boxes (10 nasal spray units) per 30 days

Onfi®* 3 tablets per day

Onfi® suspension* 16 mL (40 mg) per day

Oxtellar XR® 150mg, 300mg 1 tablet per day Not covered

Oxtellar XR 600mg 4 tablets per day Not covered

Qudexy® XR 25mg, 50mg, 100mg, 150mg* 1 capsule per day Not covered

Qudexy® XR 200mg* 2 capsules per day Not covered

Sabril tablets®* 6 tablets per day

SympazanTM* 2 films per day Not covered

TopiramateTM ER, Trokendi XR®* (25mg, 50mg, 100mg or 150mg) 1 capsule per day Not covered

TopiramateTM ER* 200mg 2 capsules per day Not covered

Valtoco® 5 boxes (10 nasal spray units) per 30 days

XcopriTM 1 tablet per day

XcopriTM Titration Pack 2 packs per 365 days

Antidepressants Custom Custom Select

Desvenlafaxine ER®* 1 tablet per day

Fetzima®* 1 capsule per day Not covered

KhedezlaTM* 1 tablet per day Not covered

Page 4: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Antidepressants (cont.) Custom Custom Select

Pexeva®* 1 tablet per day

Pristiq® (g) 1 tablet per day

Trintellix® * 1 tablet per day

Viibryd®* 1 tablet per day

Viibryd® Titration pack* 1 pack per 1 year

Antidiabetics Custom Custom Select

Avandia® 2 tablets per day

Cycloset®* 6 tablets per day

FarxigaTM 1 tablet per day

Glyxambi®* 1 tablet per day

Insulin syringes 200 syringes per Rx

Invokamet®, XR® 2 tablets per day

Invokana® 1 tablet per day

Janumet®, XR 50/1000mg 2 tablets per day

Janumet XR 50/500mg, 100/1000mg 1 tablet per day

Januvia® 1 tablet per day

Jardiance® 1 tablet per day

Jentadueto®* 2 tablets per day Not covered

Jentadueto® XR 2.5/1000mg* 2 tablets per day Not covered

Jentadueto XR 5mg/1000mg* 1 tablet per day Not covered

Ozempic®* 4 pens for 30 days

Qtern®* 1 tablet per day

Riomet ERTM 1 bottle (473 mL) per 30 days Not covered

Rybelsus®* 1 tablet per day

Segluromet™* 2.5mg/1,000mg, 7.5mg/500mg, 7.5mg/1,000mg 2 tablets per day

Page 5: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Antidiabetics (cont.) Custom Custom Select

Segluromet™* 2.5mg/500mg 4 tablets per day

Soliqua™* 5 pens per 30 days

Steglatro™* 5mg 2 tablets per day

Steglatro™* 15mg 1 tablet per day

Synjardy® 2 tablets per day

Synjardy® XR 5/1000 and 12.5/1000mg 2 tablets per day

Synjardy® XR 10/1000 and 25/1000mg 1 tablet per day

Tradjenta®* 1 tablet per day

Trijardy XR™ 5/2.5/1000mg, 10/5/1000mg, 12.5/2.5/1000mg 2 tablets per day

Trijardy XR™ 25/5/1000mg 1 tablet per day

Trulicity® 4 pens (2 mL) per 30 days

Victoza® 3 syringes (9 mL) per 30 days

Xigduo XR® 5mg/500mg, 10mg/500mg, or 10/1000mg 1 tablet per day

Xigduo XR® 2.5mg/1000mg, 5mg/1000mg 2 tablets per day

Xultophy® 5 pens per 30 days

Antiemetics Custom Custom Select

Akynzeo®* 4 capsules per 30 days

Bonjesta®* 2 tablets per day Not covered

Emend® (g) 80mg 4 capsules per Rx

Emend (g) 125mg 2 capsules per Rx

Emend suspension 6 packets per 30 days

Emend Trifold Pack 2 packs per Rx

Kytril® (g) 12 tablets per Rx

Page 6: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Antiemetics (cont.) Custom Custom Select

Sancuso®* 2 patches per Rx

Varubi™* 8 tablets per 30 days Not covered

Zuplenz®* 24 films per Rx Not covered

Antifungals Custom Custom Select

Cresemba® 70 capsules per 30 days

Noxafil® tablet 99 tablets per 30 days

Oravig® 1 tablet per day Not covered

Anti-Infectives Custom Custom Select

Aemcolo™ 12 tablets per 90 days Not covered

ArakodaTM 1 carton (16 tablets) per 30 days

Arikayce* 1 kit (28 vials) per 28 days

Coartem® 24 tablets per Rx

Dificid® 20 tablets per Rx

FirvanqTM 1 gram per day

Krintafel 2 tablets per Rx

Nuzyra™ 30 tablets per 10 days

Pretomanid* 1 tablet per day

Sirturo® * 2 tablets per day

Sivextro® 1 tablet per day/6 days per 30 days

Spectracef® (g) 14 tablets per Rx

Xenleta™ 20 tablets per 10 days

Xepi™* 1 tube per 30 days Not covered

Xifaxan® 200mg 9 tablets every 7 days

Antineoplastics and Immunosuppressants Custom Custom Select

Afinitor®, Disperz* <s> 1 tablet per day (Limited to 15 day supply per fill)

Page 7: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Antineoplastics and Immunosuppressants (cont.) Custom Custom Select

Alecensa®* <s> 8 capsules per day

AlunbrigTM* 30 mg <s> 2 tablets per day

AlunbrigTM* 90mg, 180mg <s> 1 tablet per day

AlunbrigTM* starter pack <s> 1 pack per 365 days

Arcalyst®* <s> 4 vials per 30 days

AyvakitTM* <s> 30 tablets per 30 days (Limited to 15 day supply per fill)

BalversaTM* <s> 3mg = 90 tablets per 30 days (Limited to 15 day supply per fill) 4mg = 60 tablets per 30 days (Limited to 15 day supply per fill) 5mg = 30 tablets per 30 days (Limited to 15 day supply per fill)

Bosulif® 100mg* <s> 90 tablets per 30 days (Limited to 15 day supply per fill)

Bosulif® 400mg, 500mg* <s> 30 tablets per 30 days (Limited to 15 day supply per fill)

Braftovi™*<s> 50mg = 1 carton (2 bottles of 60 capsules) per 30 days

75mg = 1 carton (2 bottles of 90 capsules) per 30 days

Brukinsa™*<s> 120 capsules per 30 days (Limited to 15 day supply per fill)

Cabometyx™*<s> 30 tablet per 30 days (Limited to 15 day supply per fill)

Cabometyx™ 40mg*<s> 60 tablets per 30 days (Limited to 15 day supply per fill)

Calquence®* <s> 120 capsules per 30 days (Limited to 15 day supply per fill)

Caprelsa® 100mg* <s> 60 tablets per 30 days (Limited to 15 day supply per fill)

Caprelsa® 300mg* <s> 30 tablet per 30 days (Limited to 15 day supply per fill)

Cometriq®*<s> 4 cards (1 box) per 30 days

(Limited to 15 day supply per fill)

Copiktra* 1 carton (56 capsules) per 30 days

Cotellic™*<s> 63 tablets per 28 days

Daurismo®*<s> 100mg tablets - 30 tablets per 30 days (limited to a 15 day supply per fill) 25mg tablets - 90 tablets per 30 days (limited to a 15 day supply per fill)

Erivedge®*<s> 30 capsule per 30 days (Limited to 15 day supply per fill)

Erleada®*<s> 4 tablets per day

Exjade®* <s> Limited to 15 day supply per fill

Page 8: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Antineoplastics and Immunosuppressants (cont.) Custom Custom Select

Farydak®*<s> 6 capsules per 21 days

Gilotrif™*<s> 1 tablet per day

Ibrance®*<s> 21 tablets/capsules per 30 days

Iclusig® 15mg<s> 60 tablets per 30 days (Limited to 15 day supply per fill)

Iclusig® 45mg<s> 30 tablets per 30 days (Limited to 15 day supply per fill)

Idhifa®*<s> 1 tablet per day

Imbruvica® capsules*<s> 120 capsules per 30 days (Limited to 15 day supply per fill)

Imbruvica® tablets*<s> 1 tablet per day

Inlyta® 1mg*<s> 180 tablets per 30 days (Limited to 15 day supply per fill)

Inlyta® 5mg*<s> 120 tablets per 30 days (Limited to 15 day supply per fill)

Inrebic®*<s> 120 capsules per 30 days (Limited to a 15 day supply)

Iressa®*<s> 1 tablet per day

Jakafi®* <s> 60 tablets per 30 days (Limited to 15 day supply per fill)

Kisqali®* <s> 63 tablets per 30 days

Kisqali Femara co-pack®*<s> 91 tablets per 30 days

Lenvima™*<s> 90 capsules per 30 days (Limited to 15 day supply per fill)

Lonsurf®* <s> 100 tablets per 30 days

Lynparza™ tablets*<s> 120 tablets per 30 days (Limited to 15 day supply per fill)

Mekinist®*<s> 0.5mg = 3 tablets per day 2mg = 1 tablet per day

Mektovi®*<s> 6 tablets per day

Mircera® * <s> 2 syringes per 30 days Not covered

NerlynxTM* <s> 180 tablets per 30 days (Limited to 15 day supply per fill)

Neulasta® <s> 2 syringes per 30 days

Nexavar®*<s> 120 tablets per 30 days (Limited to 15 day supply per fill)

Ninlaro® *<s> 3 capsules per 30 days

Page 9: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Antineoplastics and Immunosuppressants (cont.) Custom Custom Select

Odomzo®* <s> 30 tablets per 30 days (Limited to 15 day supply per fill)

Piqray®* <s> 1 carton per 30 days

Pomalyst®* <s> 21 capsules per 30 days

Revlimid®* <s> 1 capsule per day

RozlytrekTM* <s> 90 capsules per 30 days (Limited to a 15 day supply)

Rubraca™* <s> 4 tablets per day

Rydapt®*<s> 8 capsules per day

Sprycel®*<s> Limited to 15 day supply per fill

Stivarga®*<s> 84 tablets per 30 days

Sutent®*<s> 30 capsules per 30 days (Limited to 15 day supply per fill)

SylatronTM <s> 1 kit (4 vials) per 28 days

Tafinlar®*<s> 4 capsules per day

TagrissoTM*<s> 30 tablets per 30 days (Limited to 15 day supply per fill)

Tarceva®*<s> Limited to 15 day supply per fill

Targretin®* capsules<s> Limited to 15 day supply per fill

Tasigna®*<s> 120 capsules per 30 days (Limited to 15 day supply per fill)

TazverikTM*<s> 240 tablets per 30 days (Limited to 15 day supply per fill)

Tibsovo®*<s> 60 tablets per 30 days (Limited to 15 day supply per fill)

TuralioTM* <s> 4 capsules per day

VenclextaTM*<s> 4 tablets per day

VerzenioTM* <s> 60 tablets per 30 days (Limited to 15 day supply per fill)

Vitrakvi®* 100mg - 60 capsules per 30 days (limited to a 15 day supply per fill); 25mg - 180 capsules per 30 days (limited to a 15 day supply per fill);

Solution - 10mL per day

Vizimpro®* 30 tablets per 30 days (Limited to 15 day supply per fill)

Votrient®*<s> Limited to 15 day supply per fill

Xalkori®*<s> 60 capsules per 30 days (Limited to 15 day supply per fill)

Page 10: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Antineoplastics and Immunosuppressants (cont.) Custom Custom Select

XpovioTM*<s> 1 carton (4 blister packs) per 30 days (Limited to a 15 day supply)

Xospata® <s> 3 tablets per day

Xtandi® <s> 120 capsules per 30 days (Limited to 15 day supply per fill)

Zejula™*<s> 90 capsules per 30 days (Limited to 15 day supply per fill)

Zelboraf®* <s> 240 tablets per 30 days (Limited to 15 day supply per fill)

Zolinza®*<s> Limited to 15 day supply per fill

Zydelig®*<s> 2 tablets per day

ZykadiaTM* <s> 90 capsules per 30 days (Limited to 15 day supply per fill)

Zytiga® 250mg* <s> 4 tablets per day

Antiparasitics/Anthelmintics Custom Custom Select

Benzidazole 12.5 mg 12 tablets/day

Benzidazole 100 mg 4 tablets/day

Emverm™ 6 tablets per 30 days Not covered

Impavido® 84 tablets per 30 days

Tindamax® (g) 20 tablets per 20 days

Antipsychotics Custom Custom Select Aristada® (441mg, 662mg and 882mg) 1 syringe per 30 days

Aristada® (1,064mg) 1 syringe per 60 days

Caplyta® 1 tablet per day

Invega® 1.5mg, 3mg, 9mg (g)* 1 tablet per day

Invega® 6mg (g)* 2 tablets per day

Invega® Trinza 4 kits per 365 days

Nuplazid™* 1 tablet/capsule per day

Perseris™ 2 syringes per 30 days

Rexulti® * 1 tablet per day Not covered

Page 11: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Antipsychotics (cont.) Custom Custom Select

Saphris®* 2 tablets per day

Secuado®* 1 patch per day

Seroquel XR® (g)* 2 tablets per day

VraylarTM* 1 tablet per day

Antiretrovirals Custom Custom Select

Biktarvy® 1 tablet per day

Cimduo TM 1 tablet per day

Complera® 1 tablet per day

Delstrigo TM 1 tablet per day

Descovy® 1 tablet per day

Dovato 1 tablet per day

Edurant® 1 tablet per day

EvotazTM 1 tablet per day

Genvoya® 1 tablet per day

Juluca® 1 tablet per day

Odefsey® 1 tablet per day

Pifeltro TM 1 tablet per day

Prezcobix TM 1 tablet per day

Stribild® 1 tablet per day

Symfi TM 1 tablet per day

Symfil Lo TM 1 tablet per day

Symtuza TM 1 tablet per day

Temixys TM 1 tablet per day

Triumeq® 1 tablet per day

Truvada® 1 tablet per day

Vemlidy® 1 tablet per day

Page 12: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Antitussives Custom Custom Select

Vituz® 240 mL per Rx Not covered

Antivirals Custom Custom Select

Epclusa®* <s> 1 tablet per day

Harvoni®*<s> 1 tablet per day Not Covered

Ledipasvir-sofosbuvir <s> 1 tablet per day

MavyretTM*<s> 3 tablets per day

PrevymisTM 28 tablets (1 carton) per 30 days

Relenza® 1 inhaler per Rx, 2 Rx per 270 days

Sovaldi®*<s> 1 tablet per day

Tamiflu® 30mg 20 capsules per Rx, 2 Rx per 270 days

Tamiflu® 45mg, 75mg 10 capsules per Rx, 2 Rx per 270 days

Tamiflu suspension 180 mL per Rx, 2 Rx per 270 days

VoseviTM*<s> 1 tablet per day

XofluzaTM 2 blister packs per 180 days

Zepatier®* <s> 1 tablet per day

Beta-Blockers and Combinations Custom Custom Select

Bystolic® 2.5, 5, &10mg* 1 tablet per day

Coreg CR®* (g) 1 capsule per day Not covered

Hemangeol® 3 bottles (360 mL) per 30 days Not covered

Bowel Preparation and Cleansing Agents Custom Custom Select

OTC and prescription products - Generic only

One bowel preparation regimen per 365 days with $0 copay (for colonoscopy screening of colorectal cancer only)

BPH Treatment Custom Custom Select

Cialis 2.5mg, 5mg* 1 tablet per day Not covered

Jalyn®* (g) 1 capsule per day

Rapaflo® 1 capsule per day

Page 13: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Calcium Channel Blockers and Combinations Custom Custom Select

Caduet® (g) 1 tablet per day

Prestalia® * 1 tablet per day Not covered

Tribenzor®* (g) 1 tablet per day

Cardiovascular treatment Custom Custom Select

Corlanor® 2 tablets per day

Corlanor® solution 4 cartons (112 pouches) per 30 days

Multaq® 2 tablets per day

Northera™*<s> 100mg, 200mg 3 tablets per day Not covered

Northera™*<s> 300mg 6 tablets per day Not covered

Vyndamax®*<s> 1 capsule per day

Vyndaqel™*<s> 4 capsules per day

Chelating Agents Custom Custom Select

Depen® 8 capsules per day

Ferriprox® oral solution* <s> 2,700 mL per 30 days

Ferriprox® tablet* <s> 540 tablets per 30 days

Jadenu™*<s> Limited to 15 day supply per fill

Syprine®* <s> 8 capsules per day

CNS Stimulants Custom Custom Select Adderall® 5mg, 7.5mg, 10mg, 12.5mg, 15mg (g) 4 tablets per day

Adderall® 20mg (g) 3 tablets per day

Adderall® 30mg (g) 2 tablets per day

Adderall XR® 2 capsules per day Not covered

Adderall XR® (g)* 2 capsules per day

Adzenys ER™ 15 mL (18.8mg per day) Not covered

Adzenys XR-ODT™* 2 tablets per day Not covered

Page 14: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

CNS Stimulants (cont.) Custom Custom Select

Aptensio XR™ 1 capsule per day Not covered

Concerta® (g) 2 tablets per day

Daytrana® 1 patch per day

Desoxyn® (g) 5 tablets per day

Dexedrine® (g) 4 tablets/capsules per day

Dyanavel™ XR* 8 mL per day Not covered

Evekeo™ 4 tablets per day Not covered

Focalin® (g) 3 tablets per day

Focalin® XR (g) 2 capsules per day

Jornay PM™* 1 capsule per day Not covered

Metadate CD® (g) 10, 20, 30mg 3 capsules per day

Metadate CD® (g) 40, 50, 60mg 2 capsules per day

Methylin® chew tablet 2.5, 5, 10mg (g) 7 tablets per day Not covered

Methylin® (g); Ritalin (g) 7 tablets per day

Methylin® ER (g) 6 tablets per day

Methylin® solution (g) 80 mg per day

Methylphenidate ER 72mg 1 tablet per day

Nuvigil® (g)* 1 tablet per day

Procentra® (g)* 60 mL (60 mg) per day

Provigil® (g)* 2 tablets per day

Quillichew ER™* 60 mg per day Not covered

Quillivant XR™* 12 mL (60 mg) per day Not covered

Relexxii™ 1 tablet per day

Ritalin LA® 10mg 4 capsules per day

Ritalin LA® 20, 30mg (g) 4 capsules per day

Ritalin LA® 40mg (g) 3 capsules per day

Page 15: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

CNS Stimulants (cont.) Custom Custom Select

Ritalin LA® 60mg 2 capsules per day

Vyvanse®* 1 capsule per day

Zenzedi® 4 tablets per day

Contraceptives and Estrogens/Combinations Custom Custom Select

Bijuva™ 1 capsule per day Not covered

Ella® 2 tablets per 30 days

Nuvaring® 1 vaginal ring per 30 days

Ortho Evra® (g) 3 patches per 28 days

Slynd® 1 blister pack per 30 days

Wide Seal® diaphragms 1 unit per 90 days

Cystic Fibrosis Agents Custom Custom Select

Bethkis®* <s> 56 ampules per 42 days Not covered

Cayston®* <s> 1 kit (84 vials) per 42 days

Kalydeco®* <s> 2 tablets or packets per day

Orkambi™* <s> 4 tablets per day

Orkambi™ granules* <s> 56 packets per 30 days

Symdeko®* <s> 1 carton (56 tablets) per 28 days

Tobi TM PodhalerTM*<s> 224 capsules per 42 days Not covered

TrikaftaTM*<s> 84 tablets (1 carton) per 28 days

Dermatology Custom Custom Select

Accutane (isotretinoin) 5 capsules per day

Aczone® 5% 90 grams per 30 days Not covered

Altreno® 1 tube (45 grams) per 30 days

Amzeeq TM* 1 can per 30 days Not covered

Doxepin Cream* 1 tube per 365 days

Page 16: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Dermatology (cont.) Custom Custom Select

Dupixent®* 2 syringes per 30 days

EucrisaTM* 1 tube per Rx Not covered

QbrexzaTM* 1 box (30 pouches) per 30 days Not covered

Regranex® 3 tubes (45 gm) per 150 days

Vusion® 1 tube (50 gm) per Rx Not covered

Diagnostic and Other Miscellaneous Custom Custom Select

EndariTM* 6 packets per day

Firazyr®* <s> 12 syringes (36 mL) per 30 days

Haegarda® * <s> 2,000 units per day

JynarqueTM* <s> 4 tablets per day (15mg, 30mg) 2 tablets per day (45mg, 60mg, and 90mg)

KeveyisTM* <s> 4 tablets per day

Methergine® 8 tablets per day

Ruconest®* <s> 2 doses (4 vials) per 30 days

Vistogard®* <s> 20 packets per fill

Gastrointestinal Custom Custom Select

AemcoloTM 12 tablets per 90 days Not covered

Amitiza® 2 capsules per day

Gattex®* <s> 1 kit (30 vials) per 30 days

Giazo® 6 tablets per day

Lialda® 4 tablets per day

Linzess® 1 capsule per day

Lotronex® (g) 2 tablets per day

MotegrityTM 1 tablet per day Not covered

MovantikTM * 1 tablet per day Not covered

Page 17: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Gastrointestinal (cont.) Custom Custom Select

Mytesi®* 2 tablets per day

OcalivaTM*<s> 1 tablet per day

Rectiv® 1 tube (30 gm) per Rx

Relistor tablet* 3 tablets per day Not covered

Sucraid®*<s> 4 bottles (472mL) per 30 days

Symproic®* 1 tablet per day Not covered

Talicia® 168 capsules per 90 days Not covered

Uceris®* 1 tablet per day Not covered

Viberzi™* 2 tablets per day Not covered

Xifaxan® 200mg 9 tablets every 7 days

Xifaxan® 550mg* 3 tablets per day

Gout Therapy Custom Custom Select

Duzallo®* 1 tablet per day Not covered

Uloric®* 1 tablet per day

Zurampic®* 1 tablet per day Not covered

Infertility Custom Custom Select

Chorionic Gonadotropin® Not applicable 2 vials per 30 days, 6 vials per 365 days

Clomid® Not applicable 30 tablets per 365 days

Follistim® AQ 150 IU/0.5mL vial Not applicable 30 vials per 30 days, 90 vials per 365 days

Follistim® AQ 300 IU/0.36mL cartridge Not applicable 15 cartridges per 30 days,

45 cartridges per 365 days Follistim® AQ 600 IU/0.72mL cartridge Not applicable 8 cartridges per 30 days,

24 cartridges per 365 days

Follistim® AQ 75 IU/0.5mL vial Not applicable 15 vials per 30 days, 45 vials per 365 days

Follistim® AQ 900 IU/1.08mL cartridge Not applicable 5 cartridges per 30 days,

15 cartridges per 365 days

Gonal-f® 1050 units/vial Not applicable 4 vials per 30 days, 12 vials per 365 days

Gonal-f® 450 units/vial Not applicable 7 vials per 30 days, 21 vials per 365 days

Page 18: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Infertility (cont.) Custom Custom Select Gonal-f® RFF Pen 300 units/0.5mL cartridge Not applicable 15 cartridges per 30 days,

45 cartridges per 365 days Gonal-f® RFF Pen 450 units/0.75mL cartridge Not applicable 10 cartridges per 30 days,

30 cartridges per 365 days

Gonal-f® RFF 75 units/vial Not applicable 10 vials per 30 days, 30 vials per 365 days

Gonal-f® RFF Pen 900 units/1.5mL cartridge Not applicable 5 cartridges per 30 days,

15 cartridges per 365 days

Ovidrel® Not applicable 2 syringes per 30 days, 6 syringes per 365 days

Pregnyl® Not applicable 2 vials per 30 days, 6 vials per 365 days

Inhaled Anticholinergics Custom Custom Select

Atrovent HFA® 2 inhalers per 30 days

Incruse™ Ellipta® 1 inhaler per 30 days Not covered

Lonhala™ Magnair™ 2 vials per day 1 starter pack per 365 days

SeebriTM Neohaler® 60 capsules per 30 days Not covered

Spiriva HandiHaler® 1 box (30 capsules) per 30 days

Spiriva Respimat® 1 inhaler per 30 days

Tudorza Pressair® 1 inhaler per 30 days

Yupelri™ 1 vial per day

Inhaled Beta-Agonist Custom Custom Select

Arcapta Neohaler® 1 capsule per day

Brovana®* 2 vials (4 mL) per day

Perforomist®* 2 vials (4 mL) per day

Proair® HFA / Ventolin® HFA 4 inhalers per 30 days

ProAir® RespiClick 4 inhalers per 30 days

Proventil® HFA 4 inhalers per 30 days

Serevent Diskus® 1 inhaler per 30 days

Striverdi® Respimat® 1 inhaler (4 g) per 30 days Not covered

Page 19: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Inhaled Beta-Agonist (cont.) Custom Custom Select

Xopenex® HFA 2 inahalers per 30 days

Inhaled Beta-Agonist and Anticholinergic Combinations Custom Custom Select

Anoro® Ellipta® 1 inhaler per 30 days

Bevespi Aerosphere™ 1 inhaler per 30 days Not covered

Combivent Respimat 2 inhalers per 30 days

Stiolto™ Respimat® 1 inhaler (4 g) per 30 days

Utibron™ Neohaler® 2 capsules per day Not covered

Inhaled Corticosteroids Custom Custom Select

Arnuity™ Ellipta® 1 inhaler per 30 days

Asmanex® HFA 1 inhaler per 30 days

Asmanex Twisthaler® 1 inhaler per 30 days

Flovent® Diskus 2 inhalers per 30 days

Flovent® HFA (all strengths) 2 inhalers per 30 days

Pulmicort Flexhaler™ 2 inhalers per 30 days

Qvar® Redihaler™ 2 inhalers per 30 days

Inhaled Steroid and Beta-Agonist Combinations Custom Custom Select

Advair Diskus® 1 inhaler (60 blisters) per 30 days

Advair HFA® 1 inhaler per 30 days

Airduo™ RespiClick® 1 inhaler per 30 days Not covered

ArmonAir™ RespiClick® 1 inhaler per 30 days Not covered

Breo® Ellipta® 1 inhaler (60 blisters) per 30 days

Dulera® 1 inhaler per 30 days

Fluticasone-salmeterol RespiClick® 1 inhaler per 30 days

Symbicort® 1 inhaler per 30 days

Page 20: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Inhaled Steroid, Anticholinergic, and Beta-Agonist Combinations

Custom Custom Select

TrelegyTM Ellipta® 30 inhalations (60 blisters) per 30 days

Ion Removing Agents Custom Custom Select

LokelmaTM 10 gm = 1 packet per day

5 gm = 3 packets per day

Lipid Lowering Agents Custom Custom Select

Caduet® (g) 1 tablet per day

Crestor (g) 1.5 tablets per day

Juxtapid®* <s> 1 capsule per day Not covered

Lescol, XL (g) 1 tablet per day

Lipitor (g) 1.5 tablets per day

Livalo®* 1 tablet per day

Lovaza® (g)* 4 capsules per day

Mevacor (g) 10 mg, 20 mg 1.5 tablets per day

Mevacor (g) 40 mg 2 tablets per day

NexletolTM* 1 tablet per day

NexlizetTM* 1 tablet per day

Praluent®* <s> 2 injections per 30 days

Pravachol (g) 1.5 tablets per day

Repatha®* <s> 3 injections per 30 days

Repatha® Pushtronex* <s> 1 unit per 30 days

Vascepa®* 4 capsules per day

Vytorin® (g) 1 tablet per day

Zetia® (g) 1 tablet per day

Zocor (g) 1.5 tablets per day

Page 21: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Migraine Therapy Custom Custom Select

Aimovig 1 autoinjector/syringe (1 pack) per 30 days

Ajovy®* 1 syringe (1 pack) per 30 days

AlsumaTM (g) 2 syringes per Rx

Amerge® (g) 9 tablets per Rx

Axert® (g) 9 tablets per Rx

Cafergot® 50 tablets per Rx

D.H.E. 45® (g) 5 ampules per Rx

EmgalityTM 100mg* 1 carton (3 syringes) per 30 days; 4 cartons (12 syringes) per 365 days

EmgalityTM 120mg/mL* 1 pen/syringe per 30 days Carton of 2 syringes: 1 carton per 365 days

Ergomar® 20 tablets per Rx

Frova® (g)* 9 tablets per Rx

Imitrex® injection (g) 5 injections per Rx

Imitrex® nasal spray (g) 6 units (1 box) per Rx

Imitrex® tablet (g) 9 tablets per Rx

Maxalt®, MLT® (g) 9 tablets per Rx

Migranal® nasal spray (g) 1 kit (8 vials) per Rx

Nurtec ODTTM* 15 tablets per 30 days Not covered

OnzetraTM XsailTM* 1 dose kit per Rx Not covered

Relpax®* 9 tablets per Rx

ReyvowTM* 8 tablets per 30 days

UbrelvyTM* 16 tablets per 30 days

Treximet®* 9 tablets per Rx Not covered

ZembraceTM SymtouchTM* 2 injections per Rx Not covered

Zomig® Nasal Spray* 6 units per Rx

Zomig®, ZMT® 2.5mg (g) 9 tablets per Rx

Page 22: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Migraine Therapy (cont.) Custom Custom Select

Zomig®, ZMT® 5mg (g) 9 tablets per Rx

Miscellaneous CNS Custom Custom Select

AustedoTM 9mg, 12mg* <s> 4 tablets per day

AustedoTM 6mg* <s> 7 tablets per day

Gralise®* 3 tablets per day Not covered

Gralise® starter pack * 78 tablets per 365 days Not covered

Horizant® * 2 tablets per day Not covered

IngrezzaTM* <s> 1 capsules per day

IngrezzaTM* titration pack <s> 1 pack per 365 days

Intuniv® (g) 1 tablet per day

Kapvay® (g) 4 tablets per day

Narcan® nasal spray 2 packages (4 sprays) per Rx

Nuedexta®* 2 tablets per day

Nymalize® 120 mL per day/2 Rxs per 365 days

Ozobax TM* 5 bottles (2,400 mL) per 30 days Not covered

Ruzurgi™* 10 tablets per day

Savella®* 2 tablets per day

Savella® Titration Pack* 1 pack per 180 days

Soma® (g)* N/A 4 tablets per day

Strattera® (g)* 2 capsules per day

Sunosi* 1 tablet per day

Tegsedi <s> 4 syringes per 30 days

Tiglutik 2 bottles (600 mL) per 30 days

Wakix®* <s> 2 tablets per day

Xenazine® (g)* <s> 2 tablets per day

Xyrem®* <s> 3 bottles (540 mL) per 30 days

Page 23: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Miscellaneous Endocrine Custom Custom Select

Baqsimi™ 8 units per 30 days; 16 units per 365 days

Cerdelga™* <s> 2 capsules per day

Egrifta®* 1 mg <s> 2 vials per day Not covered

Egrifta®* 2 mg <s> 1 vial per day Not covered

Galafold™* 1 wallet pack (14 capsules) per 28 days

Gvoke™ Syringe/Hypopen 8 units per 30 days; 16 units per 365 days

Isturisa TM*<s> 1 mg, 5 mg 4 tablets per day

Isturisa TM*<s> 10 mg 6 tablets per day

Korlym®* <s> 4 tablets per day

Myalept®* <s> 1 vial per day

Natpara® *<s> 2 pens per 30 days

Nocdurna®* 1 carton (30 tablets) per 30 days Not covered

Noctiva TM* 1 bottle per 30 days Not covered

Nubeqa® *<s> 120 tablets per 30 days (Limitied to a 15 day supply)

Palynziq TM *<s>

20mg/ml = 2 injections per day

10mg/0.5ml = 1 injection per day

2.5mg/0.5ml = 8 injections per 30 days

Ravicti®* <s> 19 gm (17.5 mL) per day

Revcovi®* <s> 48 vials per 30 days

Signifor®*<s> 2 ampules per day

Signifor® LAR* <s> 1 kit per 30 days Not covered

Somatuline® Depot* <s> 1 syringe per 30 days

Xermelo TM* <s> 3 tablets per day

Zavesca®* <s> 3 capsules per day

Page 24: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Miscellaneous Immunology & Hematology Custom Custom Select

BenlystaTM* <s> 4 injections per 28 days

Doptelet®*<s> 2 tablets per day

Fulphila®<s> 2 syringes per 30 days

Nivestym®<s> 2 vials per day

OxbrytaTM*<s> 3 tablets per day

Takhzyro TM 2 vials per 30 days

Tavalisse TM*<s> 2 tablets per day

Udenyca®<s> 2 syringes per 30 days

Ziextenzo®<s> 2 syringes per 30 days

Miscellaneous OB-GYN Custom Custom Select

Brisdelle®* (g) 1 capsule per day Not covered

Lysteda® (g) 30 tablets per fill

Orilissa TM 150mg = 1 carton (28 tablets) per 30 days

200mg = 1 carton (56 tablets) per 30 days

Miscellaneous Respiratory Custom Custom Select

Daliresp®* 1 tablet per day

Epinephrine auto-injector 4 injectors per Rx, 8 injectors per 365 days

Esbriet® <s> 9 capsules per day

Epipen® 4 injectors per Rx, 8 injectors per 356 days

Epipen® Jr 4 injectors per Rx, 8 injectors per 365 days

Esbriet® tablets <s> 3 tablets per day (801 mg); 9 tablets per day (267 mg)

Fasenra®* pen <s> 1 pen per 30 days

Glassia ®* <s> 9 vials per 30 days

Grastek®* 1 tablet per day Not covered

Nucala®* <s> 3 auto-injectors per 30 days

Page 25: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Miscellaneous Respiratory (cont.) Custom Custom Select

OdactraTM* 1 tablet per day Not covered

Ofev®* <s> 2 capsules per day

Oralair®* 1 tablet per day Not covered

Ragwitek®* 1 tablet per day Not covered

SymjepiTM 4 injections per Rx 8 injections per 365 days

Zyflo CR® 4 tablets per day

Miscellaneous Urologicals Custom Custom Select

PalforziaTM*<s> 1 kit per 30 days

Thiola®* 10 tablets per day

Thiola EC®* 100mg = 10 tablets per day; 300mg = 3 tablets per day

Multiple Sclerosis Custom Custom Select

Ampyra®* <s> 2 tablets per day

Aubagio®*<s> 1 tablet per day

Avonex® 4 syringes/pens per 28 days

Betaseron® 14 syringes per 28 days

Copaxone® 20 mg 1 syringe per day

Copaxone® 40 mg 12 syringes per 30 days

Extavia® 14 vials/kits per 28 days

Gilenya® <s> 1 capsule per day

GlatopaTM 1 syringe per day

MavencladTM <s> 2 boxes per 365 days

Mayzent® <s> 0.25mg – 4 tablets per day 2mg – 1 tablet per day

Mayzent® starter pack<s> 2 packs per 365 days

Pegasys®, ProclickTM<s> 4 syringes / vials / pens per 30 days

Peg-Intron®, Redipen <s> 4 vials / redipens per 30 days

Page 26: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Multiple Sclerosis (cont.) Custom Custom Select

Plegridy®* <s> 1 carton (2 syringes) per 30 days

Plegridy®*starter pack <s> 1 pack per 365 days

Rebif® 12 syringes or pens per 28 days

Rebif® titration pack 1 pack per 365 days

Rebif® Rebidose® titration pack 1 pack per 365 days

Tecfidera® <s> 2 capsules per day

VumerityTM <s> 4 capsules per day

VumerityTM starter pack <s> 1 bottle per 365 days

Narcotics/Analgesic Combinations Custom Custom Select

Click here to see quantity limits for Narcotics/Analgesic Combinations

Narcotic Mixed Agonist and Antagonist Custom Custom Select

Subutex® (g)* 3 tablets per day

Non-Tumor Necrosis Factor (TNF) Blocking Agents Custom Custom Select

Actemra® subcutaneous* <s> 4 syringes per 28 days

Cosentyx™*<s> 2 pens / syringes per 30 days

Kevzara® <s> 2 syringes (1 pack) per 28 days

Kineret®* <s> 30 syringes per 30 days

Olumiant®*<s> 1 tablet per day

Orencia®* <s> 4 syringes per 30 days

Otezla®* <s> 2 tablets per day

RinvoqTM*<s> 1 tablet per day

Siliq®*<s> 1 carton (2 syringes) per 30 days

SkyriziTM*<s> 1 kit (2 syringes) per 12 weeks

Stelara®* <s> 1 syringe/vial every 56 days

Taltz®* <s> 1 injection per 30 days Not covered

Taltz® 2-pack* <s> 2 packs per 365 days Not covered

Page 27: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Non-Tumor Necrosis Factor (TNF) Blocking Agents (cont.) Custom Custom Select

Taltz® 3-pack* <s> 1 pack per 365 days Not covered

Tremfya™*<s> 8 syringes per 365 days

Xeljanz®* <s> 2 tablets per day

Xeljanz® XR* <s> 1 tablet per day

NSAIDs Custom Custom Select

Fenoprofen* 200mg 16 tablets per day

Fenoprofen* 400mg 8 tablets per day

Fenoprofen* 600mg 5 tablets per day

FenorthoTM* 200mg 16 capsules per day Not covered

Flector®* 2 patches per day Not covered

Indocin® suppository 4 suppositories per day

Ketoprofen 25mg 4 capsules per day

Pennsaid® (all strengths)* 2 bottles per 30 days Not covered

Sprix® 5 bottles (630 mg) per 28 days Not covered

Toradol® tablet (g) 20 tablets every 26 days

Voltaren® gel (g) 4 tubes (400 gm) per 28 days

Ophthalmology Custom Custom Select

CequaTM 1 box (60 vials) per 30 days Not covered

CystaranTM*<s> 4 bottles (60 mL) per 30 days

InveltysTM 1 bottle per 30 days Not covered

Lotemax SM®* 1 bottle per 30 days Not covered

OxervateTM 4 cartons per 30 days (Limited to 8 cartons per 60 days)

Pazeo® Not applicable 2 bottles per 30 days

Rhopressa®* 2 (2.5ml) bottles per 30 days Not covered

RocklatanTM* 2 (2.5ml) bottles per 30 days

XelprosTM 1 bottle per Rx Not covered

Page 28: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Osteoporosis Custom Custom Select

Actonel ® 5, 30mg 1 tablet per day

Actonel ® 35mg 4 tablets per 30 days

Actonel ® 150mg 1 tablet per 30 days

Atelvia® (g)* 4 tablets per 30 days

Binosto®* 4 tablets per 30 days Not covered

Boniva® 150mg 1 tablet per 30 days

Evista®* 1 tablet per day

Forteo®* <s> 1 pen per 30 days

Fosamax D® Solution 4 bottles (300mL) per 30days

Fosamax Plus D®* 4 tablets per 30 days Not covered

Fosamax® 5, 10mg 1 tablet per day

Fosamax® 35, 70mg 4 tablets per 30 days

Tymlos™*<s> 1 unit per 30 days , 3 units per 90 days

Parkinson's Disease Custom Custom Select

DuopaTM *<s> 4 cartons (2800mL) per 30 days

InbrijaTM Carton of 60 – 5 cartons per 30 days; Carton of 92 – 3 cartons per 30 days

Mirapex® ER® (g)* 1 tablet per day Not covered

Neupro®* 1 patch per day Not covered

NourianzTM* 1 tablet per day

Rytary®* 12 capsules per day Not covered

Xadago® 1 tablet per day

Zelapar® 2 tablets per day

Pulmonary Hypertension Agent Custom Custom Select

Adcirca®* <s> 2 tablets per day

Adempas®* <s> 3 tablets per day

Letairis®* <s> 1 tablet per day

Page 29: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Pulmonary Hypertension Agent (cont.) Custom Custom Select

Opsumit®* <s> 1 tablet per day

Orenitram® ER* <s> 12.5 mg per day

Revatio® (g)* 3 tablets per day

Revatio® suspension* 2 bottles per 30 days

Tracleer®* <s> 2 tablets per day

Tyvaso® starter kit*<s> 1 kit per 365 days

Tyvaso® refill/replacement kit* <s> 1 kit (82 mL) per 30 days

Tyvaso® vials* <s> 28 ampules (81.2 mL) per 28 days

Uptravi®* <s> 2 tablets per day

Uptravi®* starter pack<s> 1 pack per 365 days

Ventavis®* <s> 270 ampules per 30 days

Rheumatology Custom Custom Select

OtrexupTM* <s> 4 injections per 30 days Not covered

Rasuvo®* <s> 4 injections per 30 days Not covered

Sedative/Hypnotics Custom Custom Select

Ambien® (g) 1 tablet per day

Ambien CR® (g) 1 tablet per day

Belsomra®* 1 tablet per day Not covered

Dalmane® 1 capsule per day

DayvigoTM* 1 tablet per day Not covered

Edluar®* 1 tablet per day Not covered

Halcion® 0.125 mg – 1 tablet per day

0.25mg – 2 tablets per day

HetliozTM* <s> 1 capsule per day

Intermezzo® (g)* 60 tablets per 90 days Not covered

Page 30: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Sedative/Hypnotics (cont.) Custom Custom Select

Lunesta® 1 tablet per day

ProsomTM 1 tablet per day

Restoril® 1 capsule per day

Rozerem® 1 tablet per day

Silenor®* 1 tablet per day Not covered

Sonata® 10 mg – 2 capsules per day

5 mg – 1 capsule per day

Sexual Dysfunction Custom Custom Select

AddyiTM* 1 tablet per day Not covered

Caverject® 6 units per 28 days Not covered

Cialis®* 6 tablets per 28 days Not covered

Edex® 12 vials per 30 days Not covered

Levitra®* 6 units per 28 days Not covered

Muse®

Revatio® (g) 1 tablet per day Excluded for use as Sexual Dysfunction agent

Staxyn®*

6 units per 28 days Not covered Stendra®*

Viagra®* (g)

Vylessi TM* 2 cartons (8 autoinjectors per 30 days) Not covered

Smoking Cessation Custom Custom Select

Chantix® 2 tablets per day

Nicotrol®* 3 packages per 30 days

Nicotrol NS®* 40ml (4 bottles) per 30 days

Page 31: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Smoking Cessation (cont.) Custom Custom Select Over-the-Counter Nicotine Patch, Gum, Lozenge 1 fill/month and 6 fills/year

Testosterone Replacement Custom Custom Select

Androderm®* 30 patches per 30 days

Androgel 1% (5gm) packets® (g)* 60 packets (300 gm) per 30 days

Androgel 1% (2.5gm) packets® (g)* 90 packets (225 gm) per 30 days

Androgel 1% pump® (g)* 4 bottles (300 gm) per 30 days

Androgel 1.62% (1.25gm) packets®* 30 packets (37.5 gm) per 30 days

Androgel 1.62% (2.5gm) packets®* 60 packets (150 gm) per 30 days

Androgel 1.62% pump®* 2 bottles (150 gm) per 30 days

Android® (g)* 1 tablet per day Not covered

Axiron®* 2 bottles (180 mL) per 30 days Not covered

Fortesta®* 2 bottles (120 gm) per 30 days Not covered

Jatenzo 158mg, 198mg®* 4 capsules per day Not covered

Jatenzo 237mg®* 2 capsules per day Not covered

Methitest™* 1 tablet per day

Natesto™* 3 bottles (22 gm) per 30 days Not covered

Striant®* 2 buccal systems per day Not covered

Testim®* 60 tubes (300 gm) per 30 days Not covered

TestosteroneTM gel* 60 tubes (300 gm) per 30 days Not covered

TestosteroneTM packets* 60 packets (300 gm) per 30 days Not covered

TestosteroneTM 1% pump* 4 bottles (300 gm) per 30 days Not covered

TestosteroneTM 2% pump* 2 bottles (180 mL) per 30 days Not covered

Testred® (g)* 1 capsule per day Not covered

VogelxoTM packets* 60 packets (300 gm) per 30 days Not covered

VogelxoTM pump* 4 bottles (300 gm) per 30 days Not covered

Page 32: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Testosterone Replacement (cont.) Custom Custom Select

XyostedTM 1 carton (4 injectors) per 30 days Not covered

Topical Antineoplastic Agents and Immunomodulators Custom Custom Select

Aldara® (g) 1 packet per day

Lorbrena®

25mg = 90 tablets per 30 days (Limited to a 15 day supply)

100mg = 30 tablets per 30 days (Limited to a 15 day supply)

25mg = 90 tablets per 30 days (Limited to a 15 day supply per

fill)

100mg = 30 tablets per 30 days (Limited to a 15 day

supply per fill)

Picato®* 1 carton per 30 days

Talzenna®

0.25mg = 90 tablets per 30 days (Limited to 15 day supply per fill)

1mg = 30 tablets per 30 days (Limited to 15 day supply per fill)

Valchlor®*<s> 2 tubes (120 gm) per 30 days

ZyclaraTM packet 1 packet per day

Zyclara pump 1 bottle (7.5 gm) per 30 days

Topical Antifungals Custom Custom Select

EcozaTM* 1 bottle per 30 days Not covered

LuzuTM* 1 tube per 30 days Not covered

Naftin®* 1 bottle per 30 days Not covered

Oxistat®* 1 bottle per 30 days Not covered

Xolegel®* 1 tube per 30 days Not covered

Topical Corticosteroids Custom Custom Select

Bryhali TM* 1 tube per 30 days

Duobrii TM 1 tube per 30 days

Kenalog® Spray 1 can per 365 days

Vanos® 0.1% cream 4 tubes (240gm) per 30 days

Page 33: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Tumor Necrosis Factor Blocking Agents Custom Custom Select

Cimzia®* <s> 2 packages (4 syringes per 30 days / 2 kits in 30 days)

Cimzia® starter kit* <s> 2 starter kits per 365 days

Enbrel®* 25mg <s> 8 syringes/vials per 30 days

Enbrel®* 50mg <s> 4 syringes/vials per 30 days

Humira® <s>

10mg/0.2mL 20mg/0.4mL

1 package (2 syringes) per 30 days 40mg/0.8mL

2 packages (4 syringes) per 30 days

Humira 80mg-40mg <s> 8 kits per 365 days

Humira Crohn's kit <s> 1 kit (6 syringes) per 365 days

Humira Psoriasis kit <s> 1 kit (4 syringes) per 365 days

Simponi®* <s> 1 syringe per 30 days

Urinary Antispasmodics Custom Custom Select

Gelnique® packet 1 packet per day Not covered

Gelnique® 10% pump 1 gram per day Not covered

Myrbetriq®* 1 tablet per day

Sanctura XR® (g) 1 capsule per day

Toviaz® 1 tablet per day

Vesicare® 1 tablet per day

Urology Custom Custom Select

Procysbi® * granules <s> 2 cartons per 30 days Not covered

Procysbi® 25mg* capsules <s> 2 capsules per day Not covered

Xuriden™* <s> 4 cartons per 30 days

Vaccines Custom Custom Select

Adacel 0.5mL per fill

Afluria 0.5 mL per fill

> 9 years old 1 vaccine per 180 days

Page 34: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Vaccines (cont.) Custom Custom Select

Afluria Quad 0.5 mL per fill

> 9 years old 1 vaccine per 180 days

Boostrix/Boostrix TDAP 0.5 mL per fill

Chicken pox vaccine (Varivax) 0.5 mL per Rx

Fluad 0.5 mL per fill

> 9 years old 1 vaccine per 180 days

Flublok 0.5 mL per fill

> 9 years old 1 vaccine per 180 days

Flublok Quad 0.5 mL per fill

> 9 years old 1 vaccine per 180 days

Flucelvax Quad 0.5 mL per fill

> 9 years old 1 vaccine per 180 days

Flulaval 0.5 mL per fill

> 9 years old 1 vaccine per 180 days

Flumist 2 nasal spray syringes per 6 months

Fluzone High-dose 0.5 mL per fill 1 vaccine per 180 days

Fluzone Quad (all) 0.5 mL per fill

> 9 years old 1 vaccine per 180 days

Gardasil/Gardasil I-9 0.5 mL per fill

Havrix 720/0.5 ml 0.5 mL per fill

Havrix 1,440/1 ml 1 mL per fill

Measles, Mumps, Rubella vaccine (MMR II) 0.5 mL per Rx

Menactra 0.5 mL per fill

Meningococcal B vaccine (Trumenba, Bexsero) 0.5 mL per Rx

Menveo 1 kit per fill

Pneumovax 23 0.5 mL per fill

Pneumovax 23 1 fill per 2 years

Polio vaccine (Ipol) 0.5 mL per Rx

Prevnar 13 0.5 mL per fill

Page 35: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Vaccines (cont.) Custom Custom Select

Prevnar 13 1 fill per 2 years

Shingrix 2 vial kits per 720 days

Tetanus/diphtheria booster (Tenivac, Tdvax) 0.5 mL per Rx

Twinrix 1 mL per fill

Vaqta 25/0.5 ml 0.5 mL per fill

Vaqta 50/1 ml 1 mL per fill

Zostavax 1 fill per 2 years

Weight Reduction Custom Custom Select

Contrave® ER* 4 tablets per day Not covered

Qsymia®* 1 capsule per day Not covered

Saxenda®* 5 pens (15 mL) per 30 days Not covered

Xenical®* 3 capsules per day Not covered

Narcotics/Analgesic Combinations Custom Custom Select

5-day limit for first fill

30-day limit

Abstral®* 4 tablets per day Not covered

Actiq® (g)* 4 lozenges per day

Avinza® (g) 1 capsule per day Not covered Yes

BelbucaTM* 2 films per day Not covered Yes

Belladonna & Opium Yes

Butrans® 4 patches per 30 days Yes

Page 36: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Narcotics/Analgesic Combinations (cont.) Custom Custom Select

5-day limit for first fill

30-day limit

Capital® w-Codeine (g) Yes Yes

Codeine sulfate (g) Yes Yes

Combunox® (g) Yes Yes

DemerolTM (g) Yes Yes

Dilaudid® (g) Yes Yes

Duragesic® 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr (g)

10 patches per 30 days Yes

Duragesic® 37.5mcg/hr, 62.5mcg/hr, 87.5mcg/hr (g)

10 patches per 30 days Not covered Yes

Duragesic Patch® (g) 10 patches per 30 days Yes

Esgic, Fioricet® 325mg (g) 4 grams APAP per day

Exalgo® (g)* 1 tablet per day Not covered Yes

Fentora®* 4 tablets per day Not covered

Fioricet® 300mg (g)* 4 grams APAP per day

Fioricet® w/codeine (g)* 4 grams APAP per day Yes

Fiorinal w/codeine (g) Yes

Hycet® (g) Yes Yes

Hysingla® ER* 1 tablet per day Not covered Yes

Ibudone® (g) Yes Yes

Page 37: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Narcotics/Analgesic Combinations (cont.) Custom Custom Select

5-day limit for first fill

30-day limit

Ibudone 5/200mg Yes Yes

Kadian® (g) 1 capsule per day Yes

Kadian 40mg, 200mg Yes

Levorphanol tartrate Yes Yes

Long acting narcotics/combination products- brand and generic Yes

Lortab solution Yes Yes

Methadone (g) Yes

MS Contin (g) 4 tablets per day Yes

MSIR (g) Yes Yes

Norco®, Vicodin®, Xodol® (g) 4 grams APAP per day Yes Yes

Nucynta®* 6 tablets per day Yes Yes

Nucynta® ER* 2 tablets per day Yes

Opana® (g) Not covered Yes Yes

Opana ER® (g)* 4 tablets per day Yes

Oxycodone IR (g) 6 tablets per day/5,400 mg per 30 days Yes Yes

Oxycodone 5mg/5mL solution 180 mL(180 mg) per day Yes Yes

Oxycodone 20mg/mL solution 5 mL (100 mg) per day Yes Yes

Page 38: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Narcotics/Analgesic Combinations (cont.) Custom Custom Select

5-day limit for first fill

30-day limit

Oxycodone HCl ER* 3 tablets per day 2 tablets per day Yes

Oxycontin®* 3 tablets per day 2 tablets per day Yes

Percocet® (g) 4 grams APAP per day Yes Yes

Percodan (g) Yes Yes

RMS® suppository (g) Yes Yes

Roxanol (g) Yes Yes

RoxicetTM (g) Yes Yes

Short acting immediate release narcotics/analgesics and combinations – brand and generic

Yes Yes

Soma Compound w/codeine (g) Yes

Stadol, NS (g) Yes Yes

Subsys®* 4 units per day Not covered

TrezixTM (g) 4 grams

APAP per day

Not covered Yes Yes

Tylenol® #3, #4 (g) 4 grams APAP per day Yes Yes

Ultracet® (g) 4 grams APAP per day Yes

Ultram (g) Yes

Ultram ER (g) Yes

Vicoprofen® (g) Yes Yes

Page 39: Blue Care Network Quantity Limits - bcbsm.com€¦ · 12 tablets per 90 days . Not covered . Arakoda. TM. 1 carton (16 tablets) per 30 days . Arikayce* 1 kit (28 vials) per 28 days

Blue Care Network Quantity Limits

July 2020

These limits do not apply to BCN Advantage members. * Prior Authorization or Step Therapy may also be required. Please refer to BCN’s Prior Authorization and Step Therapy Guidelines available on the web at: bcbsm.com/rxinfo. <s> Specialty drug (g) generic drug R001070

Narcotics/Analgesic Combinations (cont.) Custom Custom Select

5-day limit for first fill

30-day limit

Zohydro® ER* 2 capsules per day Yes