Health Insurance Marketplace Generics Plus Drug List
October 2015
Contents
Introduction .................................................................... I Therapeutic Class Drug List ........................................ 1
How drugs are selected ................................................... I Anti-Infective Agents ....................................................... 1
How member payment is determined .............................. I Biologicals ..................................................................... 12
How to use this list .......................................................... II Antineoplastic Agents ................................................... 16
Drugs used to treat multiple conditions .......................... II Endocrine and Metabolic Drugs ................................... 19
Generic drugs ................................................................. II Cardiovascular Agents .................................................. 39
Consider talking to your doctor about generic
Respiratory Agents ....................................................... 58
drugs ........................................................................... II Gastrointestinal Agents ................................................. 65
Coverage considerations ............................................... III Genitourinary Agents .................................................... 72
Specialty drugs .............................................................. IV Central Nervous System Drugs .................................... 75
Prime Therapeutics Specialty Pharmacy
Analgesics and Anesthetics .......................................... 93
program...................................................................... IV Neuromuscular Drugs ................................................. 106
Abbreviation key ............................................................. V Nutritional Products .................................................... 115
Hematological Agents ................................................. 128
Topical Products ......................................................... 137
Miscellaneous Products .............................................. 162
Index........................................................................... 166
Please consider talking to your doctor about prescribing preferred medications, which may help reduce your
out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.
The drug list is regularly updated. Please visit bcbstx.com for the most up-to-date information.
To find a contracting pharmacy, please access the link below:
https://www.myprime.com/content/myprime/en/find-pharmacy/find-pharmacy-results.html
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to
Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click
on Search.
41722-K TX HIM © Prime Therapeutics LLC 10/15
Introduction
Members are encouraged to show this list to their physicians and pharmacists. Physicians are
encouraged to prescribe drugs on this list, when right for the member. However decisions regarding
therapy and treatment are always between members and their physician.
Drug lists updates – This list is regularly updated as generic drugs become available and changes take place in
the pharmaceuticals market. For the most up-to-date information, visit bcbstx.com and log in to
Blue Access for MembersSM or call the number on the back of your ID card. Physicians can access the list from
the provider portal at bcbstx.com.
How drugs are selected
Drugs on this list are selected based on the recommendations of a committee made up of physicians and
pharmacists from throughout the country. The committee, which includes at least one representative from
BCBSTX, reviews drugs regulated by the U.S. Food and Drug Administration (FDA).
Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are
considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on
the list.
How member payment is determined
This list shows prescription drug products in tiers. Generally, each drug is placed into one of five member
payment tiers: Preferred Generic (Tier 1), Non-preferred Generic (Tier 2), Preferred Brand (Tier 3),
Non-preferred Brand (Tier 4) and Specialty (Tier 5). To verify your payment amount for a drug, visit bcbstx.com
and log in to Blue Access for Members or call the number on the back of your ID card.
Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply.
Generally, if a drug is not listed on the drug list it is not covered. For example, drugs indicated for cosmetic
purposes, e.g., Propecia, for hair growth, may not be covered. Drugs that are not FDA-approved for selfadministration may be available through your medical benefit.
Some drugs may have limited or $0 member cost-sharing (co-pay or co-insurance) under the Affordable Care Act.
Examples of these drug categories include aspirin, breast cancer preventive, fluoride supplements, folic acid
supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, vaccines, vitamin D
supplements, and some contraceptive drugs and devices. Call the customer service number on the back of your
ID card to find out if the drug is available over-the-counter or is covered under your medical benefit.
I
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
How to use this list
Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand
drug in (parentheses). Some generic products have no reference brand.
Example: atorvastatin (Lipitor – brand is NF)
Brand prescription drugs are shown in capital letters followed by the generic name.
Drugs used to treat multiple conditions
Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances,
each medication is classified according to its first FDA-approved use. Please check the index if you do not find
your particular medication in the class/condition section that corresponds to your use.
Generic drugs
Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs
must be approved by the FDA just as brand drugs are, and must meet the same standards.
There are two types of generic drugs:
•
A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug.
•
A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s)
differs from the brand drug.
According to the FDA, compared to its brand counterpart, an FDA-approved generic drug:
•
Is chemically the same
•
Works just as well in the body
•
Is as safe and effective
•
Meets the same standards set by the FDA
The main difference between the reference brand drug and the generic equivalent is that the generic often costs
much less.
Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available.
You may be responsible for the brand member payment amount plus the difference in cost between the brand and
generic equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs have
the lowest member payment amount.
Consider talking to your doctor about generic drugs
If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an
appropriate generic alternative is available.
You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is
available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new
prescription from your doctor.
Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
II
Coverage considerations
Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some
exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications.
Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood
pressure, diabetes or high cholesterol.
Over-the-counter exclusions: Your benefit plan does not provide coverage for prescription medications that
have an over-the-counter version. You should refer to your benefit plan materials for details about your particular
benefits.
Compounded medications: Your benefit plan does not provide coverage for compounded medications. Please
see your plan materials or call the number on the back of your ID card to determine whether compounded
medications are covered and/or verify your payment amount.
Repackaged medications: Repackaged versions of medications already available on the market are not covered.
Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means that
your doctor will need to submit a prior authorization request for coverage of these medications, and the request
will need to be approved, before the medication will be covered under your plan. For the preferred medications
listed in this document, if a prior authorization is commonly required, it will be noted next to the medication with a
dot under the prior authorization column. Some plans may have prior authorization on additional medications
beyond those noted in this document.
Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try
another proven, cost-effective medication before coverage may be available for the drug included in the program.
Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the
preferred medications listed in this document, if a step therapy is commonly required it will generally be noted
next to the medication with a dot under the step therapy column. Some plans may have step therapy programs on
additional medications beyond those noted in this document.
Dispensing Limits (DL): Drug Dispensing limits are designed to help encourage medication use as intended by
the FDA. Coverage limits are placed on medications in certain drug categories. For the preferred medications
listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot
under the dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity
of covered medication in a given time period, coverage only for members within a certain age range, and
coverage only for members of a specific gender. If your doctor prescribes a greater quantity of medication than
what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost
of the prescription beyond what your coverage allows.* For a list of medications and their dispensing limits, visit
bcbstx.com.
*Please note: For certain controlled substance medications, some state laws may not allow coverage by a health
benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be
responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the
dispensing limit.
Remember, medication decisions are between you and your doctor. Only you and your doctor can determine
which medication is right for you. Discuss any questions or concerns you have about medications you are taking
or are prescribed with your doctor. BCBSTX does not provide health care services and, therefore, cannot
guarantee any results or outcomes.
III
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Specialty drugs
Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis
and rheumatoid arthritis. Specialty drugs may be oral, topical, or injectable medications that can either be selfadministered or administered by a health care professional. For a current list of specialty medications,
visit myprime.com or bcbstx.com and log in to Blue Access for Members.
Note that some drug classes may be excluded by some plans and therefore may not be covered under your
pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you
have questions about your coverage for specialty medications or your prescription drug benefit, call the
number on the back of your ID card.
Prime Therapeutics Specialty Pharmacy Program
Through Prime Therapeutics Specialty Pharmacy, members can have covered specialty medications delivered
directly to them or their doctor’s office. When you receive specialty medications through Prime, you also receive at
no additional charge the following services:
•
Coordination of coverage between you, your doctor and your health plan
•
Educational materials about your particular condition and information about managing potential
medication side effects
•
Syringes, sharps containers and other supplies with every shipment for self-injectables
•
24/7/365 phone access to a pharmacist for urgent medication issues
To order through Prime Therapeutics Specialty Pharmacy:
•
Have your doctor call or fax your prescription to Prime Therapeutics Specialty Pharmacy. Your doctor can
call 877-627-6337 or fax to 877-828-3939.
•
If you have an existing prescription for a covered specialty medication, you can call 877-627-6337 to
transfer your prescription.
•
A Prime Therapeutics coordinator will contact you to arrange delivery of your medication.
•
The prescription can be shipped directly to you or your prescribing doctor’s office. Each package is
individually marked for each member. Refrigerated drugs are shipped in temperature-controlled
packaging.
If you have questions, please contact Prime Therapeutics Specialty Pharmacy at 877-627-6337,
visit www.PrimeTherapeutics.com/specialty, or call the number on the back of your ID card.
•
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (“HCSC”).
HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to provide
pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as
well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC.
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
IV
Abbreviation key
cap ...................................................................... capsules
chew .................................................................. chewable
odt ............................................. orally disintegrating tabs
oint ..................................................................... ointment
conc ............................................................. concentrate
ophth ................................................................. opthalmic
osm .......................................................... osmotic release
cr .......................................................... controlled release
dr ............................................................. delayed release
ec ................................................................ enteric coated
effe................................................................. effervescent
equiv ................................................................ equivalent
er ...........................................................extended release
inhal................................................................... inhalation
inj ......................................................................... injection
liq .............................................................................. liquid
lotn ........................................................................... lotion
powd..................................................................... powder
sa ............................................................ sustained action
sl ...................................................................... sublingual
soln ....................................................................... solution
sr .......................................................... sustained release
suppos ........................................................ suppositories
susp ................................................................ suspension
tab ...........................................................................tablets
td ................................................................... transdermal
nebu ................................................................... nebulizer
You, or your prescribing health care provider, can ask for a Drug List exception if your drug is not on the Drug List
(also known as a formulary). To request this exception, you, or your prescriber, can call the number on the back
of your ID card to ask for a review. If you have a health condition that may jeopardize your life, health or keep you
from regaining function, or your current drug therapy uses a non-covered drug, you, or your prescriber, may be
able to ask for an expedited review process. BCBSTX will let you, and your prescriber, know the coverage
decision within 24 hours after they receive your request for an expedited review. If the coverage request is
denied, BCBSTX will let you and your prescriber know why it was denied and offer you a covered alternative
drug (if applicable). Call the number on the back of your ID card if you have any questions.
V
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
ANTI-INFECTIVE AGENTS
PENICILLINS
AMOXICILLIN ER - amoxicillin
(trihydrate) tab sr 24hr 775 mg
4
AMOXICILLIN - amoxicillin (trihydrate)
chew tab 125 mg
4
AMPICILLIN - ampicillin for susp 125
mg/5ml
4
AMOXICILLIN - amoxicillin (trihydrate)
chew tab 250 mg
4
AMPICILLIN - ampicillin for susp 250
mg/5ml
4
amoxicillin (trihydrate) cap 250 mg
1
ampicillin cap 250 mg
1
amoxicillin (trihydrate) cap 500 mg
1
ampicillin cap 500 mg
1
amoxicillin (trihydrate) for susp
125 mg/5ml
1
AUGMENTIN - amoxicillin & k
clavulanate tab 500-125 mg
4
amoxicillin (trihydrate) for susp
200 mg/5ml
1
AUGMENTIN - amoxicillin & k
clavulanate tab 875-125 mg
4
amoxicillin (trihydrate) for susp
250 mg/5ml
1
4
amoxicillin (trihydrate) for susp
400 mg/5ml
1
AUGMENTIN - amoxicillin & k
clavulanate for susp 125-31.25
mg/5ml
4
amoxicillin (trihydrate) tab 500 mg
1
AUGMENTIN - amoxicillin & k
clavulanate for susp 250-62.5 mg/5ml
1
AUGMENTIN ES-600 - amoxicillin & k
clavulanate for susp 600-42.9 mg/5ml
4
amoxicillin (trihydrate) tab 875 mg
amoxicillin & k clavulanate chew tab
200-28.5 mg
2
AUGMENTIN XR - amoxicillin & k
clavulanate tab sr 12hr 1000-62.5 mg
4
amoxicillin & k clavulanate chew tab
400-57 mg
2
dicloxacillin sodium cap 250 mg
1
2
dicloxacillin sodium cap 500 mg
2
amoxicillin & k clavulanate for susp
200-28.5 mg/5ml
4
amoxicillin & k clavulanate for susp
250-62.5 mg/5ml (Augmentin)
2
MOXATAG - amoxicillin (trihydrate) tab
sr 24hr 775 mg
1
amoxicillin & k clavulanate for susp
400-57 mg/5ml
2
penicillin v potassium for soln
125 mg/5ml
penicillin v potassium for soln
250 mg/5ml
1
penicillin v potassium tab 250 mg
1
penicillin v potassium tab 500 mg
1
2
amoxicillin & k clavulanate for susp
600-42.9 mg/5ml (Augmentin es-600)
2
amoxicillin & k clavulanate tab sr
12hr 1000-62.5 mg (Augmentin xr)
2
amoxicillin & k clavulanate tab
250-125 mg
2
amoxicillin & k clavulanate tab
500-125 mg (Augmentin)
2
amoxicillin & k clavulanate tab
875-125 mg (Augmentin)
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
CEPHALOSPORINS
CEDAX - ceftibuten cap 400 mg
4
CEDAX - ceftibuten for susp 90 mg/5ml
4
CEDAX - ceftibuten for susp 180
mg/5ml
4
CEFACLOR - cefaclor for susp 125
mg/5ml
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
1
CEFACLOR - cefaclor for susp 250
mg/5ml
4
CEFTIN - cefuroxime axetil for susp 125
mg/5ml
3
CEFACLOR - cefaclor for susp 375
mg/5ml
4
CEFTIN - cefuroxime axetil for susp 250
mg/5ml
4
cefaclor cap 250 mg
2
cefuroxime axetil tab 250 mg (Ceftin)
1
cefaclor cap 500 mg
2
cefuroxime axetil tab 500 mg (Ceftin)
1
CEFACLOR ER - cefaclor monohydrate
tab sr 12hr 500 mg
4
CEPHALEXIN - cephalexin tab 250 mg
4
CEPHALEXIN - cephalexin tab 500 mg
4
cefadroxil cap 500 mg
1
cephalexin cap 250 mg (Keflex)
1
cefadroxil for susp 250 mg/5ml
2
cephalexin cap 500 mg (Keflex)
1
cefadroxil for susp 500 mg/5ml
2
cephalexin cap 750 mg (Keflex)
2
cefadroxil tab 1 gm
2
cephalexin for susp 125 mg/5ml
1
cefdinir cap 300 mg
2
cephalexin for susp 250 mg/5ml
1
cefdinir for susp 125 mg/5ml
2
KEFLEX - cephalexin cap 250 mg
4
cefdinir for susp 250 mg/5ml
2
KEFLEX - cephalexin cap 500 mg
4
CEFDITOREN PIVOXIL - cefditoren
pivoxil tab 200 mg (base equivalent)
4
KEFLEX - cephalexin cap 750 mg
4
4
SPECTRACEF - cefditoren pivoxil tab
200 mg (base equivalent)
4
CEFDITOREN PIVOXIL - cefditoren
pivoxil tab 400 mg (base equivalent)
2
SPECTRACEF - cefditoren pivoxil tab
400 mg (base equivalent)
4
cefixime for susp 100 mg/5ml
(Suprax)
2
SUPRAX - cefixime cap 400 mg
4
cefixime for susp 200 mg/5ml
(Suprax)
SUPRAX - cefixime chew tab 100 mg
4
cefpodoxime proxetil for susp
50 mg/5ml
2
SUPRAX - cefixime chew tab 200 mg
4
4
cefpodoxime proxetil for susp
100 mg/5ml
2
SUPRAX - cefixime for susp 100
mg/5ml
4
cefpodoxime proxetil tab 100 mg
2
SUPRAX - cefixime for susp 200
mg/5ml
cefpodoxime proxetil tab 200 mg
2
4
cefprozil for susp 125 mg/5ml
2
SUPRAX - cefixime for susp 500
mg/5ml
cefprozil for susp 250 mg/5ml
2
cefprozil tab 250 mg
2
cefprozil tab 500 mg
2
CEFTIBUTEN - ceftibuten cap 400 mg
4
CEFTIBUTEN - ceftibuten for susp 180
mg/5ml
Dispensing Limits
Step Therapy
MACROLIDES
AZITHROMYCIN - azithromycin powd
pack for susp 1 gm
4
azithromycin for susp 100 mg/5ml
(Zithromax)
2
4
azithromycin for susp 200 mg/5ml
(Zithromax)
1
CEFTIN - cefuroxime axetil tab 250 mg
4
azithromycin tab 250 mg (Zithromax)
1
CEFTIN - cefuroxime axetil tab 500 mg
4
azithromycin tab 500 mg (Zithromax)
1
2
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
BIAXIN - clarithromycin for susp 250
mg/5ml
Dispensing Limits
2
Step Therapy
azithromycin tab 600 mg (Zithromax)
Prior Authorization
Drug Name
Drug Tier
2015
4
4
ERYTHROMYCIN ETHYLSUCCINA erythromycin ethylsuccinate tab 400
mg
BIAXIN - clarithromycin tab 250 mg
4
2
BIAXIN - clarithromycin tab 500 mg
4
erythromycin w/ delayed release
particles cap 250 mg
4
•
PCE - erythromycin w/ enteric coated
particles tab 333 mg
4
BIAXIN XL - clarithromycin tab sr 24hr
500 mg
4
•
PCE - erythromycin w/ enteric coated
particles tab 500 mg
4
BIAXIN XL PAC - clarithromycin tab sr
24hr 500 mg
2
ZITHROMAX - azithromycin tab 250 mg
4
clarithromycin for susp 125 mg/5ml
2
ZITHROMAX - azithromycin tab 500 mg
4
clarithromycin for susp 250 mg/5ml
(Biaxin)
ZITHROMAX - azithromycin tab 600 mg
4
clarithromycin tab sr 24hr 500 mg
(Biaxin xl pac)
2
ZITHROMAX - azithromycin for susp
100 mg/5ml
4
clarithromycin tab 250 mg (Biaxin)
2
4
clarithromycin tab 500 mg (Biaxin)
2
ZITHROMAX - azithromycin for susp
200 mg/5ml
4
ZITHROMAX - azithromycin powd pack
for susp 1 gm
4
DIFICID - fidaxomicin tab 200 mg
E.E.S. GRANULES - erythromycin
ethylsuccinate for susp 200 mg/5ml
4
ZITHROMAX TRI-PAK - azithromycin
tab 500 mg
4
•
E.E.S. 400 - erythromycin
ethylsuccinate tab 400 mg
4
ZITHROMAX Z-PAK - azithromycin tab
250 mg
4
•
ERY-TAB - erythromycin tab delayed
release 250 mg
4
ZMAX - azithromycin extended release
for oral susp 2 gm
4
ERY-TAB - erythromycin tab delayed
release 333 mg
4
4
ACTICLATE - doxycycline hyclate tab
75 mg
4
ERY-TAB - erythromycin tab delayed
release 500 mg
•
4
ACTICLATE - doxycycline hyclate tab
150 mg
4
ERYPED 200 - erythromycin
ethylsuccinate for susp 200 mg/5ml
•
4
ADOXA - doxycycline monohydrate cap
150 mg
4
ERYPED 400 - erythromycin
ethylsuccinate for susp 400 mg/5ml
•
4
ADOXA - doxycycline monohydrate tab
50 mg
4
ERYTHROCIN STEARATE erythromycin stearate tab 250 mg
•
4
ADOXA - doxycycline monohydrate tab
75 mg
4
ERYTHROMYCIN BASE - erythromycin
tab 250 mg
•
4
ADOXA - doxycycline monohydrate tab
100 mg
4
ERYTHROMYCIN BASE - erythromycin
tab 500 mg
•
ADOXA PAK 1/100 - doxycycline
monohydrate tab 100 mg
4
•
•
•
•
•
TETRACYCLINES
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
3
ADOXA PAK 2/100 - doxycycline
monohydrate tab 100 mg
4
•
MINOCIN - minocycline hcl cap 50 mg
4
MINOCIN - minocycline hcl cap 75 mg
4
AVIDOXY DK - doxycycline tab 100 mg
& suncreen & sal acid wash 2% kit
4
MINOCIN - minocycline hcl cap 100 mg
4
2
MINOCIN KIT - minocycline hcl cap 50
mg w/ acne care products kit
4
demeclocycline hcl tab 150 mg
•
•
•
•
demeclocycline hcl tab 300 mg
2
•
•
4
MINOCIN KIT - minocycline hcl cap 100
mg w/ acne care products kit
4
DORYX - doxycycline hyclate tab
delayed release 50 mg
1
DORYX - doxycycline hyclate tab
delayed release 200 mg
•
minocycline hcl cap 50 mg (Minocin)
4
minocycline hcl cap 75 mg (Minocin)
1
doxycycline hyclate cap 50 mg
2
doxycycline hyclate cap 100 mg
(Vibramycin)
2
doxycycline hyclate tab delayed
release 75 mg
2
doxycycline hyclate tab delayed
release 100 mg
2
•
doxycycline hyclate tab delayed
release 150 mg (Doryx)
2
•
doxycycline hyclate tab 20 mg
2
doxycycline hyclate tab 100 mg
2
doxycycline monohydrate cap 50 mg
2
doxycycline monohydrate cap 75 mg
(Monodox)
2
doxycycline monohydrate cap
100 mg (Monodox)
2
doxycycline monohydrate cap
150 mg (Adoxa)
2
doxycycline monohydrate for susp
25 mg/5ml (Vibramycin)
2
doxycycline monohydrate tab 50 mg
(Adoxa)
2
doxycycline monohydrate tab 75 mg
(Adoxa)
2
doxycycline monohydrate tab
100 mg (Adoxa pak 1/100)
2
4
minocycline hcl cap 100 mg (Minocin) 1
2
minocycline hcl tab sr 24hr 45 mg
•
Dispensing Limits
2
Step Therapy
doxycycline monohydrate tab
150 mg (Adoxa pak 1/150)
•
Prior Authorization
•
Drug Name
Drug Tier
4
Dispensing Limits
Prior Authorization
ADOXA PAK 1/150 - doxycycline
monohydrate tab 150 mg
Drug Name
Step Therapy
Drug Tier
2015
•
•
•
minocycline hcl tab sr 24hr 90 mg
2
minocycline hcl tab sr 24hr 135 mg
2
minocycline hcl tab 50 mg
2
minocycline hcl tab 75 mg
2
minocycline hcl tab 100 mg
2
MONODOX - doxycycline monohydrate
cap 75 mg
4
•
MONODOX - doxycycline monohydrate
cap 100 mg
4
•
MORGIDOX 1X100MG - doxycycline
hyclate cap 1 x 100 mg w/ cleanser
kit
4
•
MORGIDOX 2X100MG - doxycycline
hyclate cap 2 x 100 mg w/ cleanser
kit
4
•
NUTRIDOX - doxycycline monohyd cap
75 mg w/ omega 3-vit e cap kit
4
•
SOLODYN - minocycline hcl tab sr 24hr
55 mg
4
•
SOLODYN - minocycline hcl tab sr 24hr
65 mg
4
•
SOLODYN - minocycline hcl tab sr 24hr
80 mg
4
•
SOLODYN - minocycline hcl tab sr 24hr
105 mg
4
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
TARGADOX - doxycycline hyclate tab
50 mg
4
•
ciprofloxacin hcl tab 500 mg (base
equiv) (Cipro)
1
TETRACYCLINE HCL - tetracycline hcl
cap 250 mg
4
ciprofloxacin hcl tab 750 mg (base
equiv)
1
TETRACYCLINE HCL - tetracycline hcl
cap 500 mg
4
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 500 mg (base eq) (Cipro xr)
2
VIBRAMYCIN - doxycycline
monohydrate for susp 25 mg/5ml
4
•
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 1000 mg(base eq) (Cipro xr)
2
VIBRAMYCIN - doxycycline calcium
syrup 50 mg/5ml
4
•
FACTIVE - gemifloxacin mesylate tab
320 mg (base equiv)
4
VIBRAMYCIN - doxycycline hyclate cap
100 mg
4
•
LEVAQUIN - levofloxacin oral soln 25
mg/ml
4
LEVAQUIN - levofloxacin tab 250 mg
4
LEVAQUIN - levofloxacin tab 500 mg
4
LEVAQUIN - levofloxacin tab 750 mg
4
levofloxacin oral soln 25 mg/ml
(Levaquin)
2
levofloxacin tab 250 mg (Levaquin)
1
levofloxacin tab 500 mg (Levaquin)
1
levofloxacin tab 750 mg (Levaquin)
1
FLUOROQUINOLONES
Dispensing Limits
1
Step Therapy
ciprofloxacin hcl tab 250 mg (base
equiv) (Cipro)
Prior Authorization
•
Drug Name
Drug Tier
4
Dispensing Limits
Prior Authorization
SOLODYN - minocycline hcl tab sr 24hr
115 mg
Drug Name
Step Therapy
Drug Tier
2015
AVELOX - moxifloxacin hcl tab 400 mg
(base equiv)
4
AVELOX ABC PACK - moxifloxacin hcl
tab 400 mg (base equiv)
4
CIPRO - ciprofloxacin for oral susp 250
mg/5ml (5%) (5 gm/100ml)
4
CIPRO - ciprofloxacin for oral susp 500
mg/5ml (10%) (10 gm/100ml)
4
CIPRO - ciprofloxacin hcl tab 250 mg
(base equiv)
4
moxifloxacin hcl tab 400 mg (base
equiv) (Avelox)
2
CIPRO - ciprofloxacin hcl tab 500 mg
(base equiv)
4
OFLOXACIN - ofloxacin tab 400 mg
4
CIPRO XR - ciprofloxacin-ciprofloxacin
hcl tab sr 24hr 500 mg (base eq)
4
BETHKIS - tobramycin nebu soln 300
mg/4ml
5
•
•
CIPRO XR - ciprofloxacin-ciprofloxacin
hcl tab sr 24hr 1000 mg(base eq)
4
KITABIS PAK - tobramycin nebu soln
300 mg/5ml
5
•
•
ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
(Cipro)
2
neomycin sulfate tab 500 mg
1
paromomycin sulfate cap 250 mg
2
2
TOBI - tobramycin nebu soln 300
mg/5ml
5
ciprofloxacin for oral susp
500 mg/5ml (10%) (10 gm/100ml)
(Cipro)
•
•
5
•
•
CIPROFLOXACIN HCL - ciprofloxacin
hcl tab 100 mg (base equiv)
2
TOBI PODHALER - tobramycin inhal
cap 28 mg
tobramycin nebu soln 300 mg/5ml
(Tobi)
5
•
•
AMINOGLYCOSIDES
SULFONAMIDES
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
5
SULFADIAZINE - sulfadiazine tab 500
mg
4
ANTIMYCOBACTERIAL AGENTS
CYCLOSERINE - cycloserine cap 250
mg
4
ethambutol hcl tab 100 mg
(Myambutol)
2
ethambutol hcl tab 400 mg
(Myambutol)
2
ISONIAZID - isoniazid syrup 50 mg/5ml
4
isoniazid tab 100 mg
1
isoniazid tab 300 mg
1
4
DIFLUCAN - fluconazole tab 150 mg
4
DIFLUCAN - fluconazole tab 200 mg
4
DIFLUCAN - fluconazole for susp 10
mg/ml
4
DIFLUCAN - fluconazole for susp 40
mg/ml
4
MYAMBUTOL - ethambutol hcl tab 100
mg
fluconazole for susp 10 mg/ml
(Diflucan)
1
4
2
MYAMBUTOL - ethambutol hcl tab 400
mg
4
fluconazole for susp 40 mg/ml
(Diflucan)
fluconazole tab 50 mg (Diflucan)
1
MYCOBUTIN - rifabutin cap 150 mg
4
fluconazole tab 100 mg (Diflucan)
1
PASER - aminosalicylic acid cr granules
packet 4 gm
4
fluconazole tab 150 mg (Diflucan)
1
3
fluconazole tab 200 mg (Diflucan)
1
PRIFTIN - rifapentine tab 150 mg
2
flucytosine cap 250 mg (Ancobon)
2
pyrazinamide tab 500 mg
2
flucytosine cap 500 mg (Ancobon)
2
rifabutin cap 150 mg (Mycobutin)
4
GRIFULVIN V - griseofulvin microsize
tab 500 mg
4
RIFADIN - rifampin cap 150 mg
RIFADIN - rifampin cap 300 mg
4
4
GRIS-PEG - griseofulvin ultramicrosize
tab 125 mg
4
RIFAMATE - isoniazid & rifampin cap
150-300 mg
rifampin cap 150 mg (Rifadin)
GRIS-PEG - griseofulvin ultramicrosize
tab 250 mg
4
2
rifampin cap 300 mg (Rifadin)
2
2
RIFATER - isoniazid-rifampin w/
pyrazinamide tab 50-120-300 mg
4
griseofulvin microsize susp
125 mg/5ml
2
SEROMYCIN - cycloserine cap 250 mg
4
griseofulvin microsize tab 500 mg
(Grifulvin v)
SIRTURO - bedaquiline fumarate tab
100 mg (base equiv)
4
griseofulvin ultramicrosize tab
125 mg (Gris-peg)
2
TRECATOR - ethionamide tab 250 mg
4
griseofulvin ultramicrosize tab
250 mg (Gris-peg)
2
itraconazole cap 100 mg (Sporanox)
2
ketoconazole tab 200 mg
1
LAMISIL - terbinafine hcl tab 250 mg
4
ANCOBON - flucytosine cap 250 mg
4
ANCOBON - flucytosine cap 500 mg
4
BIO-STATIN - nystatin cap 500000 unit
4
6
Dispensing Limits
Step Therapy
BIO-STATIN - nystatin cap 1000000 unit 4
CRESEMBA - isavuconazonium sulfate 4
cap 186 mg
4
DIFLUCAN - fluconazole tab 50 mg
DIFLUCAN - fluconazole tab 100 mg
ANTIFUNGALS
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
LAMISIL - terbinafine hcl oral granules
packet 125 mg
4
APTIVUS - tipranavir oral soln 100 mg/
ml
3
•
LAMISIL - terbinafine hcl oral granules
packet 187.5 mg
4
ATRIPLA - efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
3
•
NOXAFIL - posaconazole tab delayed
release 100 mg
4
•
BARACLUDE - entecavir oral soln 0.05
mg/ml
3
NOXAFIL - posaconazole susp 40 mg/
ml
3
•
BARACLUDE - entecavir tab 0.5 mg
3
BARACLUDE - entecavir tab 1 mg
3
nystatin oral powder
2
•
nystatin tab 500000 unit
COMBIVIR - lamivudine-zidovudine tab
150-300 mg
4
2
ONMEL - itraconazole tab 200 mg
4
4
•
SPORANOX - itraconazole oral soln 10
mg/ml
4
COMPLERA - emtricitabine-rilpivirinetenofovir df tab 200-25-300 mg
COPEGUS - ribavirin tab 200 mg
5
SPORANOX - itraconazole cap 100 mg
4
•
SPORANOX PULSEPAK - itraconazole
cap 100 mg
4
CRIXIVAN - indinavir sulfate cap 200
mg
3
3
•
terbinafine hcl tab 250 mg (Lamisil)
1
CRIXIVAN - indinavir sulfate cap 400
mg
VFEND - voriconazole for susp 40 mg/
ml
4
•
DAKLINZA - daclatasvir dihydrochloride
tab 30 mg (base equivalent)
5
•
VFEND - voriconazole tab 50 mg
4
•
4
DAKLINZA - daclatasvir dihydrochloride
tab 60 mg (base equivalent)
5
VFEND - voriconazole tab 200 mg
2
didanosine delayed release capsule
125 mg (Videx ec)
2
voriconazole for susp 40 mg/ml
(Vfend)
•
•
•
•
2
didanosine delayed release capsule
200 mg (Videx ec)
•
voriconazole tab 200 mg (Vfend)
2
•
•
2
voriconazole tab 50 mg (Vfend)
didanosine delayed release capsule
250 mg (Videx ec)
2
•
ANTIVIRALS
•
abacavir sulfate tab 300 mg (base
equiv) (Ziagen)
2
•
didanosine delayed release capsule
400 mg (Videx ec)
2
•
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
2
•
EDURANT - rilpivirine hcl tab 25 mg
(base equivalent)
4
•
EMTRIVA - emtricitabine caps 200 mg
3
acyclovir cap 200 mg (Zovirax)
1
EMTRIVA - emtricitabine soln 10 mg/ml
3
•
•
acyclovir susp 200 mg/5ml (Zovirax)
2
entecavir tab 0.5 mg (Baraclude)
2
acyclovir tab 400 mg (Zovirax)
1
entecavir tab 1 mg (Baraclude)
2
acyclovir tab 800 mg (Zovirax)
1
EPIVIR - lamivudine tab 150 mg
4
adefovir dipivoxil tab 10 mg
(Hepsera)
2
EPIVIR - lamivudine tab 300 mg
4
3
EPIVIR - lamivudine oral soln 10 mg/ml
3
APTIVUS - tipranavir cap 250 mg
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
7
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
EPIVIR HBV - lamivudine tab 100 mg
(hbv)
4
KALETRA - lopinavir-ritonavir tab
200-50 mg
3
•
EPIVIR HBV - lamivudine oral soln 5
mg/ml (hbv)
4
lamivudine oral soln 10 mg/ml
(Epivir)
2
•
EPZICOM - abacavir sulfate-lamivudine
tab 600-300 mg
3
•
lamivudine tab 100 mg (hbv) (Epivir
hbv)
2
EVOTAZ - atazanavir sulfate-cobicistat
tab 300-150 mg (base equiv)
5
•
lamivudine tab 150 mg (Epivir)
2
lamivudine tab 300 mg (Epivir)
2
famciclovir tab 125 mg (Famvir)
2
2
famciclovir tab 250 mg (Famvir)
2
lamivudine-zidovudine tab
150-300 mg (Combivir)
•
•
•
famciclovir tab 500 mg (Famvir)
2
3
•
FAMVIR - famciclovir tab 125 mg
4
LEXIVA - fosamprenavir calcium tab
700 mg (base equiv)
FAMVIR - famciclovir tab 250 mg
4
3
•
FAMVIR - famciclovir tab 500 mg
4
LEXIVA - fosamprenavir calcium susp
50 mg/ml (base equiv)
4
MODERIBA - ribavirin tab 200 mg &
ribavirin tab 400 mg dose pack
5
FLUMADINE - rimantadine
hydrochloride tab 100 mg
•
5
MODERIBA - ribavirin tab 400 mg &
ribavirin tab 600 mg dose pack
5
FUZEON - enfuvirtide for inj 90 mg
•
HARVONI - ledipasvir-sofosbuvir tab
90-400 mg
5
MODERIBA 1200 DOSE PACK ribavirin tab 600 mg
5
•
HEPSERA - adefovir dipivoxil tab 10 mg
4
INTELENCE - etravirine tab 100 mg
3
•
3
NEVIRAPINE - nevirapine susp 50
mg/5ml
4
INTELENCE - etravirine tab 200 mg
INVIRASE - saquinavir mesylate cap
200 mg
3
•
•
•
•
•
INTELENCE - etravirine tab 25 mg
MODERIBA 800 DOSE PACK - ribavirin
tab 400 mg
5
3
nevirapine tab sr 24hr 400 mg
(Viramune xr)
2
•
INVIRASE - saquinavir mesylate tab
500 mg
3
•
nevirapine tab 200 mg (Viramune)
2
NORVIR - ritonavir cap 100 mg
3
ISENTRESS - raltegravir potassium tab
400 mg (base equiv)
3
NORVIR - ritonavir tab 100 mg
3
3
ISENTRESS - raltegravir potassium
packet for susp 100 mg (base equiv)
3
•
NORVIR - ritonavir oral soln 80 mg/ml
•
•
•
•
5
•
ISENTRESS - raltegravir potassium
chew tab 25 mg (base equiv)
3
•
OLYSIO - simeprevir sodium cap 150
mg (base equivalent)
•
ISENTRESS - raltegravir potassium
chew tab 100 mg (base equiv)
3
•
KALETRA - lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
3
•
KALETRA - lopinavir-ritonavir tab
100-25 mg
3
•
PEG-INTRON - peginterferon alfa-2b for 5
inj kit 50 mcg/0.5ml
PEG-INTRON - peginterferon alfa-2b for 5
inj kit 80 mcg/0.5ml
PEG-INTRON - peginterferon alfa-2b for 5
inj kit 120 mcg/0.5ml
8
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
PEG-INTRON - peginterferon alfa-2b for 5
inj kit 150 mcg/0.5ml
PEG-INTRON REDIPEN - peginterferon 5
alfa-2b for inj kit 50 mcg/0.5ml
PEG-INTRON REDIPEN - peginterferon 5
alfa-2b for inj kit 80 mcg/0.5ml
PEG-INTRON REDIPEN - peginterferon 5
alfa-2b for inj kit 120 mcg/0.5ml
PEG-INTRON REDIPEN - peginterferon 5
alfa-2b for inj kit 150 mcg/0.5ml
5
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 50
mcg/0.5ml
5
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 80
mcg/0.5ml
5
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 120
mcg/0.5ml
5
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 150
mcg/0.5ml
5
PEGASYS - peginterferon alfa-2a inj
180 mcg/ml
5
PEGASYS - peginterferon alfa-2a inj
180 mcg/0.5ml
5
PEGASYS PROCLICK - peginterferon
alfa-2a inj 135 mcg/0.5ml
5
PEGASYS PROCLICK - peginterferon
alfa-2a inj 180 mcg/0.5ml
PEGINTRON - peginterferon alfa-2b for 5
inj kit 50 mcg/0.5ml
PEGINTRON - peginterferon alfa-2b for 5
inj kit 80 mcg/0.5ml
PEGINTRON - peginterferon alfa-2b for 5
inj kit 120 mcg/0.5ml
PEGINTRON - peginterferon alfa-2b for 5
inj kit 150 mcg/0.5ml
5
PREZCOBIX - darunavir-cobicistat tab
800-150 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
PREZISTA - darunavir ethanolate susp
100 mg/ml (base equiv)
3
•
•
PREZISTA - darunavir ethanolate tab 75 3
mg (base equiv)
3
PREZISTA - darunavir ethanolate tab
150 mg (base equiv)
3
PREZISTA - darunavir ethanolate tab
600 mg (base equiv)
3
PREZISTA - darunavir ethanolate tab
800 mg (base equiv)
5
REBETOL - ribavirin cap 200 mg
•
•
•
•
•
•
•
•
•
•
REBETOL - ribavirin soln 40 mg/ml
5
•
RELENZA DISKHALER - zanamivir
aero powder breath activated 5 mg/
blister
4
•
•
RESCRIPTOR - delavirdine mesylate
tab 100 mg
3
•
RESCRIPTOR - delavirdine mesylate
tab 200 mg
3
•
RETROVIR - zidovudine cap 100 mg
4
•
•
•
•
RETROVIR - zidovudine syrup 10 mg/ml 4
3
REYATAZ - atazanavir sulfate oral
powder packet 50 mg (base equiv)
3
REYATAZ - atazanavir sulfate cap 150
mg (base equiv)
3
REYATAZ - atazanavir sulfate cap 200
mg (base equiv)
3
REYATAZ - atazanavir sulfate cap 300
mg (base equiv)
5
RIBASPHERE - ribavirin tab 400 mg
•
•
•
•
•
•
•
•
•
•
•
•
RIBASPHERE - ribavirin tab 600 mg
5
RIBASPHERE RIBAPAK - ribavirin tab
400 mg
5
•
•
•
RIBASPHERE RIBAPAK - ribavirin tab
600 mg
5
•
RIBASPHERE RIBAPAK - ribavirin tab
200 mg & ribavirin tab 400 mg dose
pack
5
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
9
RIBATAB - ribavirin tab 400 mg &
ribavirin tab 600 mg dose pack
5
ribavirin cap 200 mg (Rebetol)
5
ribavirin tab 200 mg (Copegus)
5
rimantadine hydrochloride tab
100 mg (Flumadine)
2
SELZENTRY - maraviroc tab 150 mg
3
SELZENTRY - maraviroc tab 300 mg
3
SITAVIG - acyclovir buccal tab 50 mg
4
SOVALDI - sofosbuvir tab 400 mg
5
stavudine cap 15 mg (Zerit)
2
stavudine cap 20 mg (Zerit)
2
stavudine cap 30 mg (Zerit)
2
stavudine cap 40 mg (Zerit)
2
stavudine for oral soln 1 mg/ml
(Zerit)
2
STRIBILD - elvitegrav-cobicisemtricitab-tenofov tab
150-150-200-300 mg
3
SUSTIVA - efavirenz tab 600 mg
3
SUSTIVA - efavirenz cap 50 mg
3
SUSTIVA - efavirenz cap 200 mg
3
TAMIFLU - oseltamivir phosphate for
susp 6 mg/ml (base equiv)
4
•
•
•
•
TAMIFLU - oseltamivir phosphate cap
30 mg (base equiv)
4
TAMIFLU - oseltamivir phosphate cap
45 mg (base equiv)
•
•
•
•
•
•
•
•
•
•
•
•
•
Dispensing Limits
RIBATAB - ribavirin tab 600 mg
5
Step Therapy
RIBATAB - ribavirin tab 400 mg
5
Prior Authorization
•
Drug Name
Drug Tier
5
Dispensing Limits
Prior Authorization
RIBASPHERE RIBAPAK - ribavirin tab
400 mg & ribavirin tab 600 mg dose
pack
Drug Name
Step Therapy
Drug Tier
2015
TIVICAY - dolutegravir sodium tab 50
mg (base equiv)
3
•
TRIUMEQ - abacavir-dolutegravirlamivudine tab 600-50-300 mg
4
•
TRIZIVIR - abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
4
•
TRUVADA - emtricitabine-tenofovir
disoproxil fumarate tab 200-300 mg
3
•
TYBOST - cobicistat tab 150 mg
5
•
TYZEKA - telbivudine tab 600 mg
4
valacyclovir hcl tab 500 mg (Valtrex)
2
valacyclovir hcl tab 1 gm (Valtrex)
2
VALCYTE - valganciclovir hcl for soln 50 3
mg/ml (base equiv)
2
VALCYTE - valganciclovir hcl tab 450
mg (base equivalent)
2
valganciclovir hcl tab 450 mg (base
equivalent) (Valcyte)
VALTREX - valacyclovir hcl tab 500 mg 4
VALTREX - valacyclovir hcl tab 1 gm
4
VICTRELIS - boceprevir cap 200 mg
5
VIDEX - didanosine for soln 2 gm
3
VIDEX - didanosine for soln 4 gm
3
VIDEX EC - didanosine delayed release
capsule 125 mg
4
•
•
•
VIDEX EC - didanosine delayed release
capsule 200 mg
4
•
VIDEX EC - didanosine delayed release
capsule 250 mg
4
•
•
VIDEX EC - didanosine delayed release
capsule 400 mg
4
•
4
•
5
TAMIFLU - oseltamivir phosphate cap
75 mg (base equiv)
4
•
VIEKIRA PAK - ombitas-paritapre-riton
& dasab tab pak 12.5-75-50 & 250
mg
VIRACEPT - nelfinavir mesylate tab 250
mg
3
•
TECHNIVIE - ombitasvir-paritaprevirritonavir tab 12.5-75-50 mg
5
VIRACEPT - nelfinavir mesylate tab 625
mg
3
•
VIRAMUNE - nevirapine tab 200 mg
4
•
10
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
VIRAMUNE - nevirapine susp 50
mg/5ml
3
•
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
2
VIRAMUNE XR - nevirapine tab sr 24hr
100 mg
3
•
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
2
VIRAMUNE XR - nevirapine tab sr 24hr
400 mg
4
•
chloroquine phosphate tab 250 mg
2
4
chloroquine phosphate tab 500 mg
(Aralen)
1
VIRAZOLE - ribavirin for inhal soln 6 gm
VIREAD - tenofovir disoproxil fumarate
oral powder 40 mg/gm
3
•
COARTEM - artemether-lumefantrine
tab 20-120 mg
4
VIREAD - tenofovir disoproxil fumarate
tab 150 mg
3
•
DARAPRIM - pyrimethamine tab 25 mg
3
VIREAD - tenofovir disoproxil fumarate
tab 200 mg
•
hydroxychloroquine sulfate tab
200 mg (Plaquenil)
1
3
VIREAD - tenofovir disoproxil fumarate
tab 250 mg
•
MALARONE - atovaquone-proguanil hcl
tab 62.5-25 mg
4
3
3
•
MALARONE - atovaquone-proguanil hcl
tab 250-100 mg
4
VIREAD - tenofovir disoproxil fumarate
tab 300 mg
2
4
VITEKTA - elvitegravir tab 150 mg
PLAQUENIL - hydroxychloroquine
sulfate tab 200 mg
4
4
ZERIT - stavudine for oral soln 1 mg/ml
4
4
ZERIT - stavudine cap 20 mg
4
PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3 mg
(15 mg base)
3
ZERIT - stavudine cap 15 mg
4
QUALAQUIN - quinine sulfate cap 324
mg
4
ZERIT - stavudine cap 30 mg
ZERIT - stavudine cap 40 mg
4
4
quinine sulfate cap 324 mg
(Qualaquin)
2
ZIAGEN - abacavir sulfate tab 300 mg
(base equiv)
•
•
•
•
•
•
•
•
mefloquine hcl tab 250 mg
VITEKTA - elvitegravir tab 85 mg
ZIAGEN - abacavir sulfate soln 20 mg/
ml (base equiv)
3
•
zidovudine cap 100 mg (Retrovir)
2
zidovudine syrup 10 mg/ml (Retrovir)
2
zidovudine tab 300 mg
2
•
•
•
ZOVIRAX - acyclovir cap 200 mg
4
ZOVIRAX - acyclovir susp 200 mg/5ml
4
ZOVIRAX - acyclovir tab 400 mg
4
ZOVIRAX - acyclovir tab 800 mg
4
ANTIMALARIALS
ARALEN - chloroquine phosphate tab
500 mg
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
AMEBICIDES
YODOXIN - iodoquinol tab 210 mg
4
YODOXIN - iodoquinol tab 650 mg
4
ANTHELMINTICS
ALBENZA - albendazole tab 200 mg
3
BILTRICIDE - praziquantel tab 600 mg
3
ivermectin tab 3 mg (Stromectol)
2
STROMECTOL - ivermectin tab 3 mg
3
ANTI-INFECTIVE AGENTS - MISC.
ALINIA - nitazoxanide tab 500 mg
4
ALINIA - nitazoxanide for susp 100
mg/5ml
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
11
atovaquone susp 750 mg/5ml
(Mepron)
2
BACTRIM - sulfamethoxazoletrimethoprim tab 400-80 mg
4
BACTRIM DS - sulfamethoxazoletrimethoprim tab 800-160 mg
4
CAYSTON - aztreonam lysine for inhal
soln 75 mg (base equivalent)
5
CLEOCIN - clindamycin hcl cap 75 mg
4
CLEOCIN - clindamycin hcl cap 150 mg
4
CLEOCIN - clindamycin hcl cap 300 mg
4
PRIMSOL - trimethoprim hcl oral soln 50 4
mg/5ml (base equiv)
4
SIVEXTRO - tedizolid phosphate tab
200 mg
sulfamethoxazole-trimethoprim susp 1
200-40 mg/5ml
1
sulfamethoxazole-trimethoprim tab
400-80 mg (Bactrim)
1
sulfamethoxazole-trimethoprim tab
800-160 mg (Bactrim ds)
4
TINDAMAX - tinidazole tab 250 mg
CLEOCIN PEDIATRIC GRANULE clindamycin palmitate hcl for soln 75
mg/5ml (base equiv)
4
TINDAMAX - tinidazole tab 500 mg
4
tinidazole tab 250 mg (Tindamax)
2
tinidazole tab 500 mg (Tindamax)
2
clindamycin hcl cap 75 mg (Cleocin)
1
trimethoprim tab 100 mg
1
clindamycin hcl cap 150 mg (Cleocin)
1
1
VANCOCIN HCL - vancomycin hcl cap
125 mg
4
clindamycin hcl cap 300 mg (Cleocin)
clindamycin palmitate hcl for soln
75 mg/5ml (base equiv) (Cleocin
pediatric gr)
2
VANCOCIN HCL - vancomycin hcl cap
250 mg
4
DAPSONE - dapsone tab 25 mg
vancomycin hcl cap 125 mg
(Vancocin hcl)
2
3
DAPSONE - dapsone tab 100 mg
3
2
FLAGYL - metronidazole cap 375 mg
4
vancomycin hcl cap 250 mg
(Vancocin hcl)
FLAGYL - metronidazole tab 250 mg
4
XIFAXAN - rifaximin tab 200 mg
4
FLAGYL - metronidazole tab 500 mg
4
XIFAXAN - rifaximin tab 550 mg
3
FLAGYL ER - metronidazole tab sr 24hr
750 mg
4
ZYVOX - linezolid tab 600 mg
3
ZYVOX - linezolid for susp 100 mg/5ml
3
KETEK - telithromycin tab 300 mg
4
BIOLOGICALS
KETEK - telithromycin tab 400 mg
4
VACCINES
linezolid tab 600 mg (Zyvox)
2
MEPRON - atovaquone susp 750
mg/5ml
4
metronidazole cap 375 mg (Flagyl)
2
metronidazole tab 250 mg (Flagyl)
1
metronidazole tab 500 mg (Flagyl)
1
NEBUPENT - pentamidine isethionate
for nebulization soln 300 mg
4
12
•
•
•
AFLURIA PF 2011-2012 - influenza
virus vaccine split pf susp pref
syringe 0.5 ml
4
AFLURIA PF 2012-2013 - influenza
virus vaccine split pf susp pref
syringe 0.5 ml
4
AFLURIA PF 2013-2014 - influenza
virus vaccine split pf susp pref
syringe 0.5 ml
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
•
AFLURIA PF 2014-2015 - influenza
virus vaccine split pf susp pref
syringe 0.5 ml
4
FLUARIX 2013-2014 - influenza virus
vaccine split pf susp pref syringe 0.5
ml
4
AFLURIA PF 2015-2016 - influenza
virus vaccine split pf susp pref
syringe 0.5 ml
4
FLUARIX 2014-2015 - influenza virus
vaccine split pf susp pref syringe 0.5
ml
4
AFLURIA 2011-2012 - influenza virus
vaccine split im susp
4
4
AFLURIA 2012-2013 - influenza virus
vaccine split im susp
4
FLUBLOK 2013-2014 - influenza virus
vac recombinant hemagglutinin (ha)
inj
4
AFLURIA 2013-2014 - influenza virus
vaccine split im susp
4
FLUBLOK 2014-2015 - influenza virus
vac recombinant hemagglutinin (ha)
inj
AFLURIA 2014-2015 - influenza virus
vaccine split im susp
4
4
AFLURIA 2015-2016 - influenza virus
vaccine split im susp
4
FLUBLOK 2015-2016 - influenza virus
vac recombinant hemagglutinin (ha)
inj
4
ENGERIX-B - hepatitis b vaccine
(recombinant) susp 10 mcg/0.5ml
4
FLUCELVAX 2012-2013 - influenza
virus vac tiss-cult subunit susp pref
syr 0.5 ml
4
FLUCELVAX 2013-2014 - influenza
virus vac tiss-cult subunit susp pref
syr 0.5 ml
4
ENGERIX-B - hepatitis b vaccine
(recombinant) susp 20 mcg/ml
ENGERIX-B - hepatitis b vaccine
(recombinant) 10 mcg/0.5ml
4
4
ENGERIX-B - hepatitis b vaccine
(recombinant) 20 mcg/ml
4
FLUCELVAX 2014-2015 - influenza
virus vac tiss-cult subunit susp pref
syr 0.5 ml
FLUARIX QUADRIVALENT 2013 influenza virus vac split quadrivalent
susp pref syr 0.5ml
FLUCELVAX 2015-2016 - influenza
virus vac tiss-cult subunit susp pref
syr 0.5 ml
4
4
4
FLULAVAL QUADRIVALENT 201 influenza virus vac split quadrivalent
susp pref syr 0.5ml
4
FLUARIX QUADRIVALENT 2014 influenza virus vac split quadrivalent
susp pref syr 0.5ml
FLUARIX QUADRIVALENT 2015 influenza virus vac split quadrivalent
susp pref syr 0.5ml
FLULAVAL QUADRIVALENT
201 - influenza virus vaccine split
quadrivalent im inj
4
4
FLUARIX 2011-2012 - influenza virus
vaccine split pf susp pref syringe 0.5
ml
FLULAVAL 2011-2012 - influenza virus
vaccine split im susp
4
4
FLULAVAL 2012-2013 - influenza virus
vaccine split im susp
4
FLUARIX 2012-2013 - influenza virus
vaccine split pf susp pref syringe 0.5
ml
4
FLULAVAL 2013-2014 - influenza virus
vaccine split im susp
4
FLULAVAL 2014-2015 - influenza virus
vaccine split im susp
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
13
FLUMIST QUADRIVALENT - influenza
virus vaccine live quadrivalent
intranasal susp
4
FLUZONE INTRADERMAL QUADR influenza virus vac split quad
intradermal pen 9 mcg/strain
4
FLUVIRIN PF 2011-2012 - influenza
virus vac types a & b pf susp prefilled
syr 0.5 ml
4
FLUZONE PF 2012-2013 - influenza
virus vaccine split pf susp pref
syringe 0.5 ml
4
FLUVIRIN PF 2012-2013 - influenza
virus vac types a & b pf susp prefilled
syr 0.5 ml
4
FLUZONE PF 2013-2014 - influenza
virus vaccine split pf susp pref
syringe 0.5 ml
4
FLUVIRIN PF 2013-2014 - influenza
virus vac types a & b pf susp prefilled
syr 0.5 ml
4
FLUZONE PF 2014-2015 - influenza
virus vaccine split pf susp pref
syringe 0.5 ml
4
FLUVIRIN PF 2014-2015 - influenza
virus vac types a & b pf susp prefilled
syr 0.5 ml
4
FLUZONE QUADRIVALENT 2013 influenza virus vac split quadrivalent
susp pref syr 0.25 ml
4
FLUVIRIN 2011-2012 - influenza virus
vaccine types a & b surface antigen
im susp
4
FLUZONE QUADRIVALENT 2013 influenza virus vac split quadrivalent
susp pref syr 0.5ml
4
FLUVIRIN 2012-2013 - influenza virus
vaccine types a & b surface antigen
im susp
4
FLUZONE QUADRIVALENT 2013 influenza virus vaccine split
quadrivalent inj 0.5 ml
4
FLUVIRIN 2013-2014 - influenza virus
vaccine types a & b surface antigen
im susp
4
FLUZONE QUADRIVALENT 2014 influenza virus vac split quadrivalent
susp pref syr 0.25 ml
4
FLUVIRIN 2014-2015 - influenza virus
vaccine types a & b surface antigen
im susp
4
FLUZONE QUADRIVALENT 2014 influenza virus vac split quadrivalent
susp pref syr 0.5ml
4
FLUVIRIN 2015-2016 - influenza virus
vaccine types a & b surface antigen
im susp
4
FLUZONE QUADRIVALENT 2014 influenza virus vaccine split
quadrivalent im inj
4
FLUZONE HIGH-DOSE PF 2012 influenza virus vac split high-dose pf
susp pref syr 0.5ml
4
FLUZONE QUADRIVALENT 2014 influenza virus vaccine split
quadrivalent inj 0.5 ml
4
FLUZONE HIGH-DOSE PF 2013 influenza virus vac split high-dose pf
susp pref syr 0.5ml
4
FLUZONE QUADRIVALENT 2015 influenza virus vac split quadrivalent
susp pref syr 0.25 ml
4
FLUZONE HIGH-DOSE PF 2014 influenza virus vac split high-dose pf
susp pref syr 0.5ml
4
FLUZONE QUADRIVALENT 2015 influenza virus vac split quadrivalent
susp pref syr 0.5ml
4
FLUZONE HIGH-DOSE PF 2015 influenza virus vac split high-dose pf
susp pref syr 0.5ml
4
FLUZONE QUADRIVALENT 2015 influenza virus vaccine split
quadrivalent im inj
4
14
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
FLUZONE QUADRIVALENT 2015 influenza virus vaccine split
quadrivalent inj 0.5 ml
4
FLUZONE SPLIT 2012-2013 - influenza
virus vaccine split im susp
4
FLUZONE SPLIT 2013-2014 - influenza
virus vaccine split im susp
4
FLUZONE SPLIT 2014-2015 - influenza
virus vaccine split im susp
4
FLUZONE SPLIT 2015-2016 - influenza
virus vaccine split im susp
Dispensing Limits
Step Therapy
TOXOIDS
ADACEL - tet tox-diph-acell pertuss ad
inj 5-2-15.5 lf-lf-mcg/0.5ml
4
BOOSTRIX - tet tox-diph-acell pertuss
ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml
4
DAPTACEL - diph, acellular pert & tet
tox inj 15 lf-10 mcg-5 lf/0.5ml
4
4
4
DIPHTHERIA/TETANUS TOXOID diphtheria-tetanus tox adsorbed (dt)
im inj 25-5 unit/0.5ml
IMOVAX RABIES (H.D.C.V.) - rabies
virus vaccine, hdc inj
INFANRIX - diph, acellular pert & tet tox
inj 25 lf-58 mcg-10 lf/0.5ml
4
4
MEDICAL PROVIDER EZ FLU S influenza virus vac types a & b pf pref
syringe kit 0.5 ml
KINRIX - diph-tetanus tox ad-acell pert
& polio virus, ipv vac inj
4
4
PEDIARIX - diph-tetanus tox-acell perthepatitis b-polio ipv vac inj
4
MEDICAL PROVIDER EZ FLU S influenza virus vac tiss-cult subunit
pref syr kit 0.5 ml
4
PENTACEL - diph-ac per-tet tox adpoliov-haemoph b poly vac for im
susp
4
PNEUMOVAX 23 - pneumococcal
vaccine polyvalent inj 25 mcg/0.5ml
4
QUADRACEL - diph-tetanus tox adacell pert & polio virus, ipv vac inj
4
PNEUMOVAX 23/1 DOSE pneumococcal vaccine polyvalent inj
25 mcg/0.5ml
4
TENIVAC - tetanus-diphtheria toxoids
(td) inj 5-2 lfu
4
4
TETANUS/DIPHTHERIA TOXOID tetanus-diphtheria toxoids (td) inj 2-2
lf/0.5ml
4
PNEUMOVAX 23/5 DOSE pneumococcal vaccine polyvalent inj
25 mcg/0.5ml
PREVNAR 13 - pneumococcal 13-valent 4
conjugate vaccine inj
4
RABAVERT - rabies vaccine, pcec for
inj
RECOMBIVAX HB - hepatitis b vaccine 4
(recombinant) susp 5 mcg/0.5ml
RECOMBIVAX HB - hepatitis b vaccine 4
(recombinant) susp 10 mcg/ml
RECOMBIVAX HB - hepatitis b vaccine 4
(recombinant) susp 40 mcg/ml
4
VIVOTIF BERNA - typhoid vaccine cap
delayed release
4
ZOSTAVAX - zoster vaccine live for inj
19400 unit/0.65ml
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
PASSIVE IMMUNIZING AGENTS
HEPAGAM B - hepatitis b immune
globulin (human) inj soln
4
HYPERHEP B S/D - hepatitis b immune
globulin (human) im inj soln
4
HYPERRAB S/D - rabies immune
globulin (human) inj 150 unit/ml
4
HYPERTET S/D - tetanus immune
globulin (human) inj 250 unit/ml
4
HYQVIA - immun glob inj 2.5 gm/25mlhyaluron inj 200 unt/1.25 ml kit
5
HYQVIA - immun glob inj 5 gm/50mlhyaluron inj 400 unt/2.5 ml kit
5
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
15
•
HYQVIA - immun glob inj 20 gm/200mlhyaluron inj 1600 unt/10 ml kit
5
AFINITOR DISPERZ - everolimus tab
for oral susp 3 mg
5
•
•
HYQVIA - immun glob inj 30 gm/300mlhyaluron inj 2400 unt/15 ml kit
5
AFINITOR DISPERZ - everolimus tab
for oral susp 5 mg
5
•
•
IMOGAM RABIES-HT - rabies immune
globulin (human) inj 150 unit/ml
4
ALKERAN - melphalan tab 2 mg
3
anastrozole tab 1 mg (Arimidex)
1
NABI-HB - hepatitis b immune globulin
(human) im inj soln
4
ARIMIDEX - anastrozole tab 1 mg
4
4
AROMASIN - exemestane tab 25 mg
4
VARIZIG - varicella-zoster immune glob
(human) for im inj 125 unit
bexarotene cap 75 mg (Targretin)
5
bicalutamide tab 50 mg (Casodex)
2
BOSULIF - bosutinib tab 100 mg
5
BOSULIF - bosutinib tab 500 mg
5
capecitabine tab 150 mg (Xeloda)
5
capecitabine tab 500 mg (Xeloda)
5
CAPRELSA - vandetanib tab 100 mg
5
CAPRELSA - vandetanib tab 300 mg
5
CASODEX - bicalutamide tab 50 mg
4
CEENU - lomustine cap 10 mg
3
CEENU - lomustine cap 40 mg
3
CEENU - lomustine cap 100 mg
3
BIOLOGICALS MISC
GRASTEK - timothy grass pollen
allergen ext tab sl 2800 bau
4
ORALAIR - grass mixed pollen ext tab sl 4
300 ir (index of reactivity)
ORALAIR ADULT SAMPLE KIT - grass 4
mixed pollen ext tab sl 300 ir (index of
reactivity)
4
ORALAIR ADULT STARTER PAC grass mixed pollen ext tab sl 300 ir
(index of reactivity)
4
ORALAIR CHILDREN/ADOLESCE grass mixed pollen tab sl therpak 100
(3) ir & 300 (6) ir
4
ORALAIR CHILDREN/ADOLESCE grass mixed pollen ext tab sl 100 ir
(index of reactivity)
4
RAGWITEK - short ragweed pollen
allergen extract tab sl 12 amb a 1-u
•
•
ANTINEOPLASTIC AGENTS
ANTINEOPLASTICS
ACTIMMUNE - interferon gamma-1b inj
100 mcg/0.5ml (2000000 unit/0.5ml)
5
•
AFINITOR - everolimus tab 2.5 mg
5
AFINITOR - everolimus tab 5 mg
5
AFINITOR - everolimus tab 7.5 mg
5
AFINITOR - everolimus tab 10 mg
5
•
•
•
•
16
•
•
•
•
COMETRIQ - cabozantinib s-malate cap 5
3 x 20 mg (60 mg dose) kit
COMETRIQ - cabozantinib s-mal cap 1 5
x 80 mg & 1 x 20 mg (100 dose) kit
COMETRIQ - cabozantinib s-mal cap 1 5
x 80 mg & 3 x 20 mg (140 dose) kit
4
CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg
4
CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg
5
ELIGARD - leuprolide acetate for
subcutaneous inj kit 7.5 mg
ELIGARD - leuprolide acetate (3 month) 5
for subcutaneous inj kit 22.5mg
ELIGARD - leuprolide acetate (4 month) 5
for subcutaneous inj kit 30 mg
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
5
Dispensing Limits
AFINITOR DISPERZ - everolimus tab
for oral susp 2 mg
Step Therapy
5
Drug Tier
HYQVIA - immun glob inj 10 gm/100mlhyaluron inj 800 unt/5 ml kit
Drug Name
Prior Authorization
2015
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
5
ETOPOSIDE - etoposide cap 50 mg
IBRANCE - palbociclib cap 125 mg
5
ICLUSIG - ponatinib hcl tab 15 mg
(base equiv)
Dispensing Limits
ERIVEDGE - vismodegib cap 150 mg
5
Step Therapy
EMCYT - estramustine phosphate
sodium cap 140 mg
4
IBRANCE - palbociclib cap 100 mg
Prior Authorization
•
Drug Name
Drug Tier
5
Dispensing Limits
Prior Authorization
ELIGARD - leuprolide acetate (6 month)
for subcutaneous inj kit 45 mg
Drug Name
Step Therapy
Drug Tier
2015
5
•
•
•
•
•
•
5
•
•
4
ICLUSIG - ponatinib hcl tab 45 mg
(base equiv)
exemestane tab 25 mg (Aromasin)
2
IMBRUVICA - ibrutinib cap 140 mg
5
FARESTON - toremifene citrate tab 60
mg (base equivalent)
4
INLYTA - axitinib tab 1 mg
5
INLYTA - axitinib tab 5 mg
5
•
•
•
INTRON A - interferon alfa-2b inj
6000000 unit/ml
5
•
•
•
•
INTRON A - interferon alfa-2b inj
10000000 unit/ml
5
•
INTRON A - interferon alfa-2b for inj
10000000 unit
5
•
INTRON A - interferon alfa-2b for inj
18000000 unit
5
•
FARYDAK - panobinostat lactate cap 10 5
mg (base equivalent)
FARYDAK - panobinostat lactate cap 15 5
mg (base equivalent)
FARYDAK - panobinostat lactate cap 20 5
mg (base equivalent)
4
FEMARA - letrozole tab 2.5 mg
•
•
•
•
•
•
•
•
flutamide cap 125 mg
2
GILOTRIF - afatinib dimaleate tab 20
mg (base equivalent)
5
•
•
INTRON A - interferon alfa-2b for inj
50000000 unit
5
•
GILOTRIF - afatinib dimaleate tab 30
mg (base equivalent)
5
•
•
INTRON A W/DILUENT - interferon
alfa-2b for inj 10000000 unit
5
•
GILOTRIF - afatinib dimaleate tab 40
mg (base equivalent)
5
•
•
INTRON A W/DILUENT - interferon
alfa-2b for inj 18000000 unit
5
•
GLEEVEC - imatinib mesylate tab 100
mg (base equivalent)
5
•
•
INTRON A W/DILUENT - interferon
alfa-2b for inj 50000000 unit
5
•
GLEEVEC - imatinib mesylate tab 400
mg (base equivalent)
5
•
•
IRESSA - gefitinib tab 250 mg
5
5
•
•
GLEOSTINE - lomustine cap 10 mg
4
JAKAFI - ruxolitinib phosphate tab 5 mg
(base equivalent)
•
•
GLEOSTINE - lomustine cap 40 mg
4
5
•
•
GLEOSTINE - lomustine cap 100 mg
4
JAKAFI - ruxolitinib phosphate tab 10
mg (base equivalent)
HEXALEN - altretamine cap 50 mg
5
JAKAFI - ruxolitinib phosphate tab 15
mg (base equivalent)
5
•
•
JAKAFI - ruxolitinib phosphate tab 20
mg (base equivalent)
5
•
•
JAKAFI - ruxolitinib phosphate tab 25
mg (base equivalent)
5
•
•
LENVIMA 10MG DAILY DOSE lenvatinib cap therapy pack 10 mg
(10 mg daily dose)
5
•
•
HYCAMTIN - topotecan hcl cap 0.25 mg 5
(base equiv)
5
HYCAMTIN - topotecan hcl cap 1 mg
(base equiv)
4
HYDREA - hydroxyurea cap 500 mg
hydroxyurea cap 500 mg (Hydrea)
2
IBRANCE - palbociclib cap 75 mg
5
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
17
LENVIMA 24MG DAILY DOSE lenvatinib cap therapy pack 10 (2) & 4
mg (24 mg daily dose)
5
letrozole tab 2.5 mg (Femara)
2
methotrexate sodium inj pf 25 mg/ml
1
•
•
methotrexate sodium inj 25 mg/ml
1
methotrexate sodium tab 2.5 mg
(base equiv)
2
•
•
MYLERAN - busulfan tab 2 mg
3
NEXAVAR - sorafenib tosylate tab 200
mg (base equivalent)
5
1
NILANDRON - nilutamide tab 150 mg
4
LEUCOVORIN CALCIUM - leucovorin
calcium tab 10 mg
3
POMALYST - pomalidomide cap 1 mg
5
POMALYST - pomalidomide cap 2 mg
5
LEUCOVORIN CALCIUM - leucovorin
calcium tab 15 mg
3
POMALYST - pomalidomide cap 3 mg
5
2
POMALYST - pomalidomide cap 4 mg
5
leucovorin calcium tab 5 mg
2
LEUKERAN - chlorambucil tab 2 mg
3
PURIXAN - mercaptopurine susp 2000
mg/100ml (20 mg/ml)
4
leucovorin calcium tab 25 mg
leuprolide acetate inj kit 5 mg/ml
5
LOMUSTINE - lomustine cap 10 mg
4
SOLTAMOX - tamoxifen citrate oral soln 4
10 mg/5ml (base equivalent)
5
SPRYCEL - dasatinib tab 20 mg
LOMUSTINE - lomustine cap 40 mg
4
SPRYCEL - dasatinib tab 50 mg
5
LOMUSTINE - lomustine cap 100 mg
4
SPRYCEL - dasatinib tab 70 mg
5
LYNPARZA - olaparib cap 50 mg
5
SPRYCEL - dasatinib tab 80 mg
5
LYSODREN - mitotane tab 500 mg
5
SPRYCEL - dasatinib tab 100 mg
5
MATULANE - procarbazine hcl cap 50
mg
5
SPRYCEL - dasatinib tab 140 mg
5
5
4
STIVARGA - regorafenib tab 40 mg
MEGACE ORAL - megestrol acetate
susp 40 mg/ml
megestrol acetate susp 40 mg/ml
(Megace oral)
2
SUTENT - sunitinib malate cap 12.5 mg
(base equivalent)
megestrol acetate tab 20 mg
1
megestrol acetate tab 40 mg
1
MEKINIST - trametinib dimethyl
sulfoxide tab 0.5 mg (base
equivalent)
5
•
•
MEKINIST - trametinib dimethyl
sulfoxide tab 2 mg (base equivalent)
5
•
•
Dispensing Limits
5
methotrexate sodium for inj 1 gm
Step Therapy
LENVIMA 20MG DAILY DOSE lenvatinib cap therapy pack 10 (2) mg
(20 mg daily dose)
•
Prior Authorization
•
Drug Name
Drug Tier
5
Dispensing Limits
Prior Authorization
LENVIMA 14MG DAILY DOSE lenvatinib cap therapy pack 10 & 4
mg (14 mg daily dose)
Drug Name
Step Therapy
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
5
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
SUTENT - sunitinib malate cap 25 mg
(base equivalent)
5
•
•
SUTENT - sunitinib malate cap 37.5 mg
(base equivalent)
5
•
•
SUTENT - sunitinib malate cap 50 mg
(base equivalent)
5
•
•
SYLATRON - peginterferon alfa-2b for
inj kit 200 mcg
5
•
•
mercaptopurine tab 50 mg
(Purinethol)
SYLATRON - peginterferon alfa-2b for
inj kit 300 mcg
5
2
•
MESNEX - mesna tab 400 mg
SYLATRON - peginterferon alfa-2b for
inj kit 600 mcg
5
4
18
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
5
•
•
tamoxifen citrate tab 20 mg (base
equivalent)
1
VOTRIENT - pazopanib hcl tab 200 mg
(base equiv)
XALKORI - crizotinib cap 200 mg
5
TARCEVA - erlotinib hcl tab 25 mg
(base equivalent)
5
•
•
XALKORI - crizotinib cap 250 mg
5
•
•
5
TARCEVA - erlotinib hcl tab 100 mg
(base equivalent)
•
•
XELODA - capecitabine tab 150 mg
5
XELODA - capecitabine tab 500 mg
5
5
•
•
XTANDI - enzalutamide cap 40 mg
5
TARCEVA - erlotinib hcl tab 150 mg
(base equivalent)
ZELBORAF - vemurafenib tab 240 mg
5
TARGRETIN - bexarotene cap 75 mg
5
ZOLINZA - vorinostat cap 100 mg
5
TASIGNA - nilotinib hcl cap 150 mg
(base equivalent)
5
ZYDELIG - idelalisib tab 100 mg
5
ZYDELIG - idelalisib tab 150 mg
5
TASIGNA - nilotinib hcl cap 200 mg
(base equivalent)
5
•
ZYKADIA - ceritinib cap 150 mg
5
TEMODAR - temozolomide cap 5 mg
ZYTIGA - abiraterone acetate tab 250
mg
5
5
TEMODAR - temozolomide cap 20 mg
5
TEMODAR - temozolomide cap 100 mg
5
TEMODAR - temozolomide cap 140 mg
5
TEMODAR - temozolomide cap 180 mg
5
TEMODAR - temozolomide cap 250 mg
5
temozolomide cap 5 mg (Temodar)
5
temozolomide cap 20 mg (Temodar)
5
temozolomide cap 100 mg (Temodar)
5
temozolomide cap 140 mg (Temodar)
5
temozolomide cap 180 mg (Temodar)
5
temozolomide cap 250 mg (Temodar)
5
tretinoin cap 10 mg
5
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
TREXALL - methotrexate sodium tab 5
mg (base equiv)
TREXALL - methotrexate sodium tab
7.5 mg (base equiv)
5
TAFINLAR - dabrafenib mesylate cap
75 mg (base equivalent)
5
tamoxifen citrate tab 10 mg (base
equivalent)
•
•
•
•
•
Step Therapy
5
1
TYKERB - lapatinib ditosylate tab 250
mg (base equiv)
TAFINLAR - dabrafenib mesylate cap
50 mg (base equivalent)
•
•
Dispensing Limits
Prior Authorization
4
•
TREXALL - methotrexate sodium tab 15
mg (base equiv)
4
Drug Tier
4
•
TREXALL - methotrexate sodium tab 10
mg (base equiv)
TABLOID - thioguanine tab 40 mg
Step Therapy
Drug Name
Drug Name
Drug Tier
Dispensing Limits
Prior Authorization
2015
•
•
•
•
•
•
•
ENDOCRINE AND METABOLIC DRUGS
CORTICOSTEROIDS
budesonide cap sr 24hr 3 mg
(Entocort ec)
2
CORTEF - hydrocortisone tab 5 mg
4
CORTEF - hydrocortisone tab 10 mg
4
CORTEF - hydrocortisone tab 20 mg
4
CORTISONE ACETATE - cortisone
acetate tab 25 mg
3
DEXAMETHASONE - dexamethasone
soln 0.5 mg/5ml
4
DEXAMETHASONE - dexamethasone
tab 1 mg
4
4
DEXAMETHASONE - dexamethasone
tab 2 mg
4
4
dexamethasone elixir 0.5 mg/5ml
2
DEXAMETHASONE INTENSOL dexamethasone conc 1 mg/ml
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
19
dexamethasone tab 4 mg
1
dexamethasone tab 6 mg
1
DEXPAK 10 DAY - dexamethasone tab
1.5 mg taper pack
4
DEXPAK 13 DAY - dexamethasone tab
1.5 mg taper pack
4
DEXPAK 6 DAY - dexamethasone tab
1.5 mg taper pack
4
ENTOCORT EC - budesonide cap sr
24hr 3 mg
4
FLO-PRED - prednisolone acetate oral
susp 16.7 mg/5ml (15 mg/5ml base)
4
fludrocortisone acetate tab 0.1 mg
2
hydrocortisone tab 5 mg (Cortef)
2
hydrocortisone tab 10 mg (Cortef)
2
hydrocortisone tab 20 mg (Cortef)
2
INTERARTICULAR JOINT KIT triamcinolone inj 40 mg/ml & lidocaine
1% & ammonia inh kit
4
MEDROL - methylprednisolone tab 2
mg
4
MEDROL - methylprednisolone tab 4
mg
4
MEDROL - methylprednisolone tab 8
mg
4
MEDROL - methylprednisolone tab 16
mg
4
MEDROL - methylprednisolone tab 32
mg
4
MEDROL DOSEPAK methylprednisolone tab 4 mg dose
pack
4
methylprednisolone tab 4 mg dose
pack (Medrol dosepak)
2
methylprednisolone tab 4 mg
(Medrol)
2
20
methylprednisolone tab 16 mg
(Medrol)
2
methylprednisolone tab 32 mg
(Medrol)
2
MILLIPRED - prednisolone tab 5 mg
4
MILLIPRED - prednisolone sod
phosphate oral soln 10 mg/5ml (base
equiv)
4
MILLIPRED DP - prednisolone tab 5 mg
dose pack
4
ORAPRED ODT - prednisolone sod
phos orally disintegr tab 10 mg (base
eq)
4
ORAPRED ODT - prednisolone sod
phos orally disintegr tab 15 mg (base
eq)
4
ORAPRED ODT - prednisolone sod
phos orally disintegr tab 30 mg (base
eq)
4
Dispensing Limits
1
2
Step Therapy
dexamethasone tab 1.5 mg
methylprednisolone tab 8 mg
(Medrol)
Prior Authorization
1
Drug Name
Drug Tier
dexamethasone tab 0.75 mg
Dispensing Limits
1
Step Therapy
dexamethasone tab 0.5 mg
Prior Authorization
Drug Name
Drug Tier
2015
PEDIAPRED - prednisolone sod phosph 4
oral soln 6.7 mg/5ml (5 mg/5ml base)
4
PHYSICIANS EZ USE JOINT T triamcinolone inj 40 mg/ml & lidocaine
1% & ammonia inh kit
2
prednisolone sod phos orally
disintegr tab 10 mg (base eq)
(Orapred odt)
2
prednisolone sod phos orally
disintegr tab 15 mg (base eq)
(Orapred odt)
2
prednisolone sod phos orally
disintegr tab 30 mg (base eq)
(Orapred odt)
2
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml base)
(Pediapred)
1
prednisolone sod phosphate oral
soln 15 mg/5ml (base equiv)
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
PREDNISONE - prednisone tab 50 mg
ANDROGEL - testosterone td gel 40.5
mg/2.5gm (1.62%)
4
4
PREDNISONE - prednisone oral soln 5
mg/5ml
4
•
•
PREDNISONE - prednisone tab 5 mg
dose pack
4
•
•
PREDNISONE - prednisone tab 10 mg
dose pack
4
PREDNISONE INTENSOL - prednisone
conc 5 mg/ml
4
prednisone tab 1 mg
1
prednisone tab 2.5 mg
1
prednisone tab 5 mg
1
ANDROGEL PUMP - testosterone td gel 4
12.5 mg/act (1%)
ANDROGEL PUMP - testosterone td gel 4
20.25 mg/act (1.62%)
4
ANDROID - methyltestosterone cap 10
mg
4
AVEED - testosterone undecanoate im
inj in oil 750 mg/3ml (250mg/ml)
4
AXIRON - testosterone td soln 30 mg/
act
2
danazol cap 50 mg
prednisone tab 10 mg
1
danazol cap 100 mg
2
prednisone tab 20 mg
1
danazol cap 200 mg
2
RAYOS - prednisone tab delayed
release 1 mg
4
DEPO-TESTOSTERONE - testosterone
cypionate im inj in oil 100 mg/ml
RAYOS - prednisone tab delayed
release 2 mg
4
RAYOS - prednisone tab delayed
release 5 mg
Dispensing Limits
Prior Authorization
•
prednisolone syrup 15 mg/5ml (usp
solution equivalent) (Prelone)
ANDROGEL - testosterone td gel 20.25
mg/1.25gm (1.62%)
4
1
Drug Name
Step Therapy
Drug Tier
•
4
Dispensing Limits
•
PREDNISOLONE SODIUM PHOSP prednisolone sodium phosphate oral
soln 25 mg/5ml (base eq)
Step Therapy
4
Drug Tier
ANDROGEL - testosterone td gel 50
mg/5gm (1%)
Drug Name
Prior Authorization
2015
•
•
•
•
•
4
•
•
•
•
•
DEPO-TESTOSTERONE - testosterone
cypionate im inj in oil 200 mg/ml
4
•
•
4
FORTESTA - testosterone td gel 10mg/
act (2%)
4
•
•
UCERIS - budesonide tab sr 24hr 9 mg
4
4
•
VERIPRED 20 - prednisolone sod
phosphate oral soln 20 mg/5ml (base
equiv)
4
METHITEST - methyltestosterone oral
tab 10 mg
NATESTO - testosterone nasal gel 5.5
mg/act
4
•
•
OXANDRIN - oxandrolone tab 2.5 mg
4
OXANDRIN - oxandrolone tab 10 mg
4
oxandrolone tab 2.5 mg (Oxandrin)
2
•
ANADROL-50 - oxymetholone tab 50
mg
4
ANDRODERM - testosterone td patch
24hr 2 mg/24hr
4
•
•
oxandrolone tab 10 mg (Oxandrin)
2
4
•
STRIANT - testosterone buccal
mucoadhesive system 30 mg
4
ANDRODERM - testosterone td patch
24hr 4 mg/24hr
•
•
•
•
•
•
•
•
•
ANDROGEL - testosterone td gel 25
mg/2.5gm (1%)
•
TESTIM - testosterone td gel 50
mg/5gm (1%)
4
4
TESTOSTERONE - testosterone td gel
25 mg/2.5gm (1%)
4
•
•
ANDROGEN-ANABOLIC
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
21
4
•
TESTOSTERONE - testosterone td gel
10mg/act (2%)
4
•
•
CLIMARA - estradiol td patch weekly
0.05 mg/24hr
4
•
TESTOSTERONE - testosterone
cypionate im inj in oil 250 mg/ml
4
CLIMARA - estradiol td patch weekly
0.06 mg/24hr
4
•
testosterone cypionate im inj in oil
100 mg/ml (Depo-testosterone)
2
•
•
CLIMARA - estradiol td patch weekly
0.075 mg/24hr
4
•
testosterone cypionate im inj in oil
200 mg/ml (Depo-testosterone)
2
•
•
•
testosterone enanthate im inj in oil
200 mg/ml
2
•
•
TESTOSTERONE PUMP - testosterone
td gel 12.5 mg/act (1%)
4
•
•
TESTRED - methyltestosterone cap 10
mg
4
•
VOGELXO - testosterone td gel 50
mg/5gm (1%)
4
•
•
VOGELXO PUMP - testosterone td gel
12.5 mg/act (1%)
4
•
•
CLIMARA - estradiol td patch weekly 0.1 4
mg/24hr
4
CLIMARA PRO - estradiollevonorgestrel td patch weekly
0.045-0.015 mg/day
COMBIPATCH - estradiol-norethindrone 3
ace td pttw 0.05-0.14 mg/day
COMBIPATCH - estradiol-norethindrone 3
ace td pttw 0.05-0.25 mg/day
3
DIVIGEL - estradiol td gel 0.25
mg/0.25gm (0.1%)
DIVIGEL - estradiol td gel 0.5 mg/0.5gm 3
(0.1%)
3
DIVIGEL - estradiol td gel 1 mg/gm
(0.1%)
4
DUAVEE - conjugated estrogensbazedoxifene tab 0.45-20 mg
4
ELESTRIN - estradiol gel 0.06% (0.52
mg/0.87 gm metered-dose pump)
4
ENJUVIA - estrogens, conjugated
synthetic b tab 0.3 mg
4
ENJUVIA - estrogens, conjugated
synthetic b tab 0.45 mg
4
ENJUVIA - estrogens, conjugated
synthetic b tab 0.625 mg
4
ENJUVIA - estrogens, conjugated
synthetic b tab 0.9 mg
4
ENJUVIA - estrogens, conjugated
synthetic b tab 1.25 mg
2
esterified estrogens &
methyltestosterone tab
0.625-1.25 mg
ACTIVELLA - estradiol & norethindrone
acetate tab 0.5-0.1 mg
4
ACTIVELLA - estradiol & norethindrone
acetate tab 1-0.5 mg
4
ALORA - estradiol td patch twice weekly
0.025 mg/24hr
4
•
ALORA - estradiol td patch twice weekly
0.05 mg/24hr
4
•
ALORA - estradiol td patch twice weekly
0.075 mg/24hr
4
•
ALORA - estradiol td patch twice weekly
0.1 mg/24hr
4
•
ANGELIQ - drospirenone-estradiol tab
0.25-0.5 mg
4
ANGELIQ - drospirenone-estradiol tab
0.5-1 mg
4
CLIMARA - estradiol td patch weekly
0.025 mg/24hr
4
22
•
Dispensing Limits
CLIMARA - estradiol td patch weekly
0.0375 mg/24hr (37.5 mcg/24hr)
Step Therapy
•
ESTROGENS
Prior Authorization
•
Drug Name
Drug Tier
4
Dispensing Limits
Prior Authorization
TESTOSTERONE - testosterone td gel
50 mg/5gm (1%)
Drug Name
Step Therapy
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
esterified estrogens &
methyltestosterone tab 1.25-2.5 mg
2
estropipate tab 1.5 mg
1
ESTRACE - estradiol tab 0.5 mg
EVAMIST - estradiol transdermal spray
1.53 mg/spray
4
4
ESTRACE - estradiol tab 1 mg
4
4
ESTRACE - estradiol tab 2 mg
4
estradiol & norethindrone acetate
tab 0.5-0.1 mg (Activella)
2
FEMHRT LOW DOSE - norethindrone
acetate-ethinyl estradiol tab 0.5
mg-2.5 mcg
4
estradiol & norethindrone acetate
tab 1-0.5 mg (Activella)
2
MENEST - esterified estrogens tab 0.3
mg
4
estradiol tab 0.5 mg (Estrace)
1
MENEST - esterified estrogens tab
0.625 mg
1
MENEST - esterified estrogens tab 1.25
mg
4
estradiol tab 1 mg (Estrace)
estradiol tab 2 mg (Estrace)
1
estradiol td patch twice weekly
0.025 mg/24hr (Vivelle-dot)
•
MENEST - esterified estrogens tab 2.5
mg
4
2
4
2
•
•
estradiol td patch twice weekly
0.0375 mg/24hr (Vivelle-dot)
MENOSTAR - estradiol td patch weekly
14 mcg/24hr
•
•
2
MINIVELLE - estradiol td patch twice
weekly 0.025 mg/24hr
4
estradiol td patch twice weekly
0.05 mg/24hr (Vivelle-dot)
•
estradiol td patch twice weekly
0.075 mg/24hr (Vivelle-dot)
•
MINIVELLE - estradiol td patch twice
weekly 0.0375 mg/24hr
4
2
•
•
estradiol td patch twice weekly
0.1 mg/24hr (Vivelle-dot)
MINIVELLE - estradiol td patch twice
weekly 0.05 mg/24hr
4
2
•
•
estradiol td patch weekly
0.025 mg/24hr (Climara)
MINIVELLE - estradiol td patch twice
weekly 0.075 mg/24hr
4
2
•
•
2
MINIVELLE - estradiol td patch twice
weekly 0.1 mg/24hr
4
estradiol td patch weekly
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
2
estradiol td patch weekly
0.05 mg/24hr (Climara)
2
•
norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
(Femhrt low dose)
estradiol td patch weekly
0.06 mg/24hr (Climara)
•
PREFEST - estradiol tab 1
mg(15)/estrad-norgestimate tab
1-0.09mg(15)
4
2
estradiol td patch weekly
0.075 mg/24hr (Climara)
2
•
PREMARIN - estrogens, conjugated tab
0.3 mg
4
estradiol td patch weekly
0.1 mg/24hr (Climara)
2
•
PREMARIN - estrogens, conjugated tab
0.45 mg
4
ESTROGEL - estradiol gel 0.06% (0.75
mg/1.25 gm metered-dose pump)
4
PREMARIN - estrogens, conjugated tab
0.625 mg
4
ESTROPIPATE - estropipate tab 3 mg
4
4
estropipate tab 0.75 mg
1
PREMARIN - estrogens, conjugated tab
0.9 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
23
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
PREMARIN - estrogens, conjugated tab
1.25 mg
4
DESOGEN - desogestrel & ethinyl
estradiol tab 0.15 mg-30 mcg
4
•
PREMPHASE - conj est 0.625(14)/conj
est-medroxypro ac tab 0.625-5mg(14)
4
desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5) (Mircette)
2
•
PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.3-1.5
mg
4
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
2
•
PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.45-1.5
mg
4
desogestrel & ethinyl estradiol tab
0.15 mg-30 mcg (Desogen)
1
•
•
PREMPRO - conjugated estrogenmedroxyprogest acetate tab
0.625-2.5 mg
drospirenone-ethinyl estradiol tab
3-0.02 mg (Yaz)
2
4
drospirenone-ethinyl estradiol tab
3-0.03 mg (Yasmin 28)
2
•
PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.625-5
mg
4
ELLA - ulipristal acetate tab 30 mg
3
•
•
VIVELLE-DOT - estradiol td patch twice
weekly 0.025 mg/24hr
4
•
ESTROSTEP FE - norethindrone acethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg
4
4
•
ethynodiol diacetate & ethinyl
estradiol tab 1 mg-35 mcg
2
VIVELLE-DOT - estradiol td patch twice
weekly 0.0375 mg/24hr
•
4
•
FALESSA - levonorgest-eth estrad tab
0.1 mg-20 mcg & fa tab 1 mg kit
4
VIVELLE-DOT - estradiol td patch twice
weekly 0.05 mg/24hr
•
4
•
FEMCON FE - norethindrone & ethinyl
estradiol-fe chew tab 0.4 mg-35 mcg
4
VIVELLE-DOT - estradiol td patch twice
weekly 0.075 mg/24hr
•
4
•
GENERESS FE - norethindrone &
ethinyl estradiol-fe chew tab 0.8
mg-25 mcg
4
VIVELLE-DOT - estradiol td patch twice
weekly 0.1 mg/24hr
•
•
levonorg-eth est tab 0.1-0.02mg(84)
& eth est tab 0.01mg(7)
(Loseasonique)
2
•
4
BREVICON-28 - norethindrone & ethinyl 4
estradiol tab 0.5 mg-35 mcg
4
CYCLESSA - desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg
4
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im
susp 150 mg/ml
4
DEPO-SUBQ PROVERA 104 medroxyprogesterone acetate
subcutaneous susp 104 mg/0.65ml
•
levonorg-eth est tab 0.15-0.03mg(84)
& eth est tab 0.01mg(7)
(Seasonique)
2
•
levonorgestrel & ethinyl estradiol
(91-day) tab 0.15-0.03 mg
2
•
levonorgestrel & ethinyl estradiol tab
0.1 mg-20 mcg
1
•
levonorgestrel & ethinyl estradiol tab
0.15 mg-30 mcg
2
•
levonorgestrel tab 1.5 mg (Plan b
one-step)
2
•
CONTRACEPTIVES
BEYAZ - drospirenone-ethinyl estradlevomefolate tab 3-0.02-0.451 mg
24
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg
2
•
norethindrone & ethinyl estradiol tab
0.4 mg-35 mcg (Ovcon-35)
2
•
levonorgestrel-ethinyl estradiol
(continuous) tab 90-20 mcg
2
•
norethindrone & ethinyl estradiol tab
0.5 mg-35 mcg (Brevicon-28)
2
•
LO LOESTRIN FE - norethin-eth
estradiol-fe tab 1 mg-10 mcg (24)/10
mcg (2)
4
•
norethindrone & ethinyl estradiol tab
1 mg-35 mcg (Norinyl 1+35)
2
•
•
•
4
norethindrone & ethinyl estradiol-fe
chew tab 0.4 mg-35 mcg (Femcon
fe)
2
LOESTRIN FE 1.5/30 - norethindrone
ace & ethinyl estradiol-fe tab 1.5
mg-30 mcg
•
LOESTRIN FE 1/20 - norethindrone
ace & ethinyl estradiol-fe tab 1 mg-20
mcg
•
norethindrone & ethinyl estradiol-fe
chew tab 0.8 mg-25 mcg (Generess
fe)
2
4
•
•
LOESTRIN 1.5/30-21 - norethindrone
ace & ethinyl estradiol tab 1.5 mg-30
mcg
norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg
(Estrostep fe)
2
4
2
4
•
•
LOESTRIN 1/20-21 - norethindrone ace
& ethinyl estradiol tab 1 mg-20 mcg
norethindrone ace & ethinyl estradiol
tab 1 mg-20 mcg (Loestrin 1/20-21)
•
•
4
norethindrone ace & ethinyl estradiol
tab 1.5 mg-30 mcg (Loestrin
1.5/30-21)
2
LOSEASONIQUE - levonorg-eth est
tab 0.1-0.02mg(84) & eth est tab
0.01mg(7)
•
medroxyprogesterone acetate im
susp 150 mg/ml (Depo-provera
contrac)
norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg
(Loestrin fe 1/20)
2
1
•
•
MINASTRIN 24 FE - norethindrone aceeth estradiol-fe chew tab 1 mg-20
mcg (24)
norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
(Loestrin fe 1.5/30)
2
4
•
•
4
norethindrone ace-ethinyl estradiolfe tab 1 mg-20 mcg (24) (Lomedia
24 fe)
2
MIRCETTE - desogest-eth estrad & eth
estrad tab 0.15-0.02/0.01 mg(21/5)
MODICON - norethindrone & ethinyl
estradiol tab 0.5 mg-35 mcg
4
•
norethindrone tab 0.35 mg (Nor-qd)
2
NATAZIA - estradiol valerate-dienogest
tab 3 mg /2-2 mg/2-3 mg/1 mg
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg (Orthonovum 7/7/7)
2
4
•
•
•
NECON 1/50-28 - norethindrone &
mestranol tab 1 mg-50 mcg
4
•
2
•
NECON 10/11-28 - norethindrone-eth
estradiol tab 0.5-35/1-35 mg-mcg
(10/11)
4
•
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28)
norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg (Ortho-cyclen)
1
•
NOR-QD - norethindrone tab 0.35 mg
4
1
•
norelgestromin-ethinyl estradiol td
ptwk 150-35 mcg/24hr (Ortho evra)
2
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg
(Ortho tri-cyclen)
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
25
norgestrel & ethinyl estradiol tab
0.3 mg-30 mcg
2
•
NORINYL 1+35 - norethindrone &
ethinyl estradiol tab 1 mg-35 mcg
4
NORINYL 1+50 - norethindrone &
mestranol tab 1 mg-50 mcg
4
NUVARING - etonogestrel-ethinyl
estradiol va ring 0.120-0.015 mg/24hr
3
OGESTREL - norgestrel & ethinyl
estradiol tab 0.5 mg-50 mcg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
4
•
•
TRI-NORINYL 28 - norethindrone-eth
estradiol tab 0.5-35/1-35/0.5-35 mgmcg
4
•
•
YASMIN 28 - drospirenone-ethinyl
estradiol tab 3-0.03 mg
4
•
•
YAZ - drospirenone-ethinyl estradiol tab
3-0.02 mg
4
•
4
•
ZOVIA 1/50E - ethynodiol diacetate &
ethinyl estradiol tab 1 mg-50 mcg
ORTHO EVRA - norelgestromin-ethinyl
estradiol td ptwk 150-35 mcg/24hr
4
•
AYGESTIN - norethindrone acetate tab
5 mg
4
ORTHO MICRONOR - norethindrone
tab 0.35 mg
4
•
medroxyprogesterone acetate tab
2.5 mg (Provera)
1
ORTHO TRI-CYCLEN norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg
4
•
medroxyprogesterone acetate tab
5 mg (Provera)
1
4
•
medroxyprogesterone acetate tab
10 mg (Provera)
1
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg
4
ORTHO-CEPT - desogestrel & ethinyl
estradiol tab 0.15 mg-30 mcg
4
•
MEGACE ES - megestrol acetate susp
625 mg/5ml
4
ORTHO-CYCLEN - norgestimate &
ethinyl estradiol tab 0.25 mg-35 mcg
4
•
megestrol acetate susp 625 mg/5ml
(Megace es)
2
ORTHO-NOVUM 1/35 - norethindrone & 4
ethinyl estradiol tab 1 mg-35 mcg
ORTHO-NOVUM 7/7/7 - norethindrone- 4
eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg
4
OVCON-35 - norethindrone & ethinyl
estradiol tab 0.4 mg-35 mcg
PLAN B ONE-STEP - levonorgestrel tab 4
1.5 mg
4
QUARTETTE - levonor-eth est tab
0.15-0.02/0.025/0.03 mg &eth est
0.01 mg
SAFYRAL - drospirenone-ethinyl estrad- 4
levomefolate tab 3-0.03-0.451 mg
4
SEASONIQUE - levonorg-eth est
tab 0.15-0.03mg(84) & eth est tab
0.01mg(7)
•
norethindrone acetate tab 5 mg
(Aygestin)
progesterone im in oil 50 mg/ml
2
progesterone micronized cap 100 mg
(Prometrium)
2
progesterone micronized cap 200 mg
(Prometrium)
2
PROMETRIUM - progesterone
micronized cap 100 mg
4
PROMETRIUM - progesterone
micronized cap 200 mg
4
PROVERA - medroxyprogesterone
acetate tab 2.5 mg
4
•
PROVERA - medroxyprogesterone
acetate tab 5 mg
4
•
PROVERA - medroxyprogesterone
acetate tab 10 mg
4
26
PROGESTINS
•
•
•
•
ANTIDIABETICS
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-500 mg
4
ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-850 mg
4
ACTOPLUS MET XR - pioglitazone hclmetformin hcl tab sr 24hr 15-1000 mg
4
ACTOPLUS MET XR - pioglitazone hclmetformin hcl tab sr 24hr 30-1000 mg
4
ACTOS - pioglitazone hcl tab 15 mg
(base equiv)
CVS GLUCOSE - glucose chew tab 4
gm
4
CVS GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
CVS GLUCOSE BITS - glucose chew
tab 1 gm
4
CYCLOSET - bromocriptine mesylate
tab 0.8 mg (base equivalent)
4
DEX4 - glucose chew tab 1 gm
4
4
DEX4 - glucose-vitamin c chew tab
4-0.006 gm
4
ACTOS - pioglitazone hcl tab 30 mg
(base equiv)
4
DEX4 FAST ACTING GLUCOSE glucose oral liquid 15 gm/59ml
4
ACTOS - pioglitazone hcl tab 45 mg
(base equiv)
4
DEX4 FAST ACTING GLUCOSE glucose gel 15 gm/33gm
4
AMARYL - glimepiride tab 1 mg
4
4
AMARYL - glimepiride tab 2 mg
4
DEX4 FAST ACTING GLUCOSE glucose-vitamin c chew tab 4-0.006
gm
AMARYL - glimepiride tab 4 mg
4
AVANDAMET - rosiglitazone maleatemetformin hcl tab 2-1000 mg
DEX4 GLUCOSE - glucose chew tab 4
gm
4
4
AVANDIA - rosiglitazone maleate tab 2
mg (base equiv)
DEX4 GLUCOSE - glucose oral liquid
15 gm/59ml
4
4
4
DEX4 NATURALS - glucose-vitamin c
chew tab 4-0.006 gm
4
AVANDIA - rosiglitazone maleate tab 4
mg (base equiv)
AVANDIA - rosiglitazone maleate tab 8
mg (base equiv)
DEX4 POUCH PACK - glucose-vitamin
c chew tab 4-0.006 gm
4
4
BD GLUCOSE - glucose chew tab 5 gm
DEX4 QUICK DISSOLVE GLUCO glucose chew tab 4 gm
4
4
BYDUREON - exenatide extended
release for susp pen-injector 2 mg
4
DIABETA - glyburide tab 1.25 mg
4
4
BYDUREON - exenatide extended
release for inj susp 2 mg
• •
DIABETA - glyburide tab 2.5 mg
4
DIABETA - glyburide tab 5 mg
4
4
• •
DRUG MART GLUCOSE - glucose
chew tab 4 gm
4
BYETTA - exenatide soln pen-injector 5
mcg/0.02ml
4
• •
DRUG MART GLUCOSE - glucosevitamin c chew tab 4-0.006 gm
4
BYETTA - exenatide soln pen-injector
10 mcg/0.04ml
4
DUETACT - pioglitazone hcl-glimepiride
tab 30-2 mg
4
CHLORPROPAMIDE - chlorpropamide
tab 100 mg
• •
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
2
4
Step Therapy
acarbose tab 100 mg (Precose)
CHLORPROPAMIDE - chlorpropamide
tab 250 mg
Prior Authorization
2
Drug Name
Drug Tier
acarbose tab 50 mg (Precose)
Dispensing Limits
2
Step Therapy
acarbose tab 25 mg (Precose)
Prior Authorization
Drug Name
Drug Tier
2015
27
DUETACT - pioglitazone hcl-glimepiride
tab 30-4 mg
4
FARXIGA - dapagliflozin propanediol
tab 10 mg (base equivalent)
4
FORTAMET - metformin hcl tab sr 24hr
osmotic 500 mg
4
FORTAMET - metformin hcl tab sr 24hr
osmotic 1000 mg
4
glimepiride tab 1 mg (Amaryl)
1
glimepiride tab 2 mg (Amaryl)
1
glimepiride tab 4 mg (Amaryl)
1
GLUCOSE - glucose-vitamin c chew tab
4-0.006 gm
4
glucose gel 40%
1
glucose oral liquid 15 gm/59ml
2
GLUCOTROL - glipizide tab 5 mg
4
GLUCOTROL - glipizide tab 10 mg
4
GLUCOTROL XL - glipizide tab sr 24hr
2.5 mg
4
GLUCOTROL XL - glipizide tab sr 24hr
5 mg
4
glipizide tab sr 24hr 2.5 mg (Glucotrol
xl)
GLUCOTROL XL - glipizide tab sr 24hr
10 mg
4
1
glipizide tab sr 24hr 5 mg (Glucotrol
xl)
GLUCOVANCE - glyburide-metformin
tab 1.25-250 mg
4
1
1
GLUCOVANCE - glyburide-metformin
tab 2.5-500 mg
4
glipizide tab sr 24hr 10 mg (Glucotrol
xl)
1
GLUCOVANCE - glyburide-metformin
tab 5-500 mg
4
glipizide tab 5 mg (Glucotrol)
glipizide tab 10 mg (Glucotrol)
1
4
glipizide-metformin hcl tab
2.5-250 mg
2
GLUMETZA - metformin hcl tab sr 24hr
modified release 500 mg
4
glipizide-metformin hcl tab
2.5-500 mg
2
GLUMETZA - metformin hcl tab sr 24hr
modified release 1000 mg
GLYBURIDE - glyburide tab 1.25 mg
4
glipizide-metformin hcl tab 5-500 mg
2
GLYBURIDE - glyburide tab 2.5 mg
4
GLUCAGEN HYPOKIT - glucagon hcl
(rdna) for inj 1 mg (base equiv)
4
GLYBURIDE - glyburide tab 5 mg
4
GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg
glyburide micronized tab 1.5 mg
(Glynase)
1
3
GLUCOPHAGE - metformin hcl tab 500
mg
glyburide micronized tab 3 mg
(Glynase)
1
4
GLUCOPHAGE - metformin hcl tab 850
mg
glyburide micronized tab 6 mg
(Glynase)
1
4
glyburide tab 1.25 mg
1
GLUCOPHAGE - metformin hcl tab
1000 mg
4
glyburide tab 2.5 mg
1
4
glyburide tab 5 mg
1
GLUCOPHAGE XR - metformin hcl tab
sr 24hr 500 mg
1
GLUCOPHAGE XR - metformin hcl tab
sr 24hr 750 mg
4
glyburide-metformin tab 1.25-250 mg
(Glucovance)
1
GLUCOSE - glucose chew tab 4 gm
4
glyburide-metformin tab 2.5-500 mg
(Glucovance)
28
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
glyburide-metformin tab 5-500 mg
(Glucovance)
1
JANUMET - sitagliptin-metformin hcl tab
50-1000 mg
4
•
GLYNASE - glyburide micronized tab
1.5 mg
4
JANUMET XR - sitagliptin-metformin hcl
tab sr 24hr 50-500 mg
4
•
GLYNASE - glyburide micronized tab 3
mg
4
JANUMET XR - sitagliptin-metformin hcl
tab sr 24hr 50-1000 mg
4
•
GLYNASE - glyburide micronized tab 6
mg
4
JANUMET XR - sitagliptin-metformin hcl
tab sr 24hr 100-1000 mg
4
•
GLYSET - miglitol tab 25 mg
4
4
•
GLYSET - miglitol tab 50 mg
4
JANUVIA - sitagliptin phosphate tab 25
mg (base equiv)
GLYSET - miglitol tab 100 mg
4
4
•
GLYXAMBI - empagliflozin-linagliptin
tab 10-5 mg
4
•
JANUVIA - sitagliptin phosphate tab 50
mg (base equiv)
•
GLYXAMBI - empagliflozin-linagliptin
tab 25-5 mg
4
•
JANUVIA - sitagliptin phosphate tab 100 4
mg (base equiv)
3
JARDIANCE - empagliflozin tab 10 mg
GNP GLUCOSE - glucose chew tab 4
gm
4
JARDIANCE - empagliflozin tab 25 mg
3
4
GNP GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
JENTADUETO - linagliptin-metformin
hcl tab 2.5-500 mg
•
•
•
4
•
GNP QUICK DISSOLVE GLUCOS glucose chew tab 4 gm
4
JENTADUETO - linagliptin-metformin
hcl tab 2.5-850 mg
JENTADUETO - linagliptin-metformin
hcl tab 2.5-1000 mg
4
•
KAZANO - alogliptin-metformin hcl tab
12.5-500 mg
4
•
KAZANO - alogliptin-metformin hcl tab
12.5-1000 mg
4
•
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 2.5-1000
mg
4
•
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-500 mg
4
•
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-1000 mg
4
•
KORLYM - mifepristone tab 300 mg
5
KROGER GLUCOSE - glucose chew
tab 4 gm
4
KROGER GLUCOSE - glucose-vitamin
c chew tab 4-0.006 gm
4
LEADER GLUCOSE - glucose chew tab
4 gm
4
HM GLUCOSE - glucose-vitamin c chew 4
tab 4-0.006 gm
HY-VEE GLUCOSE - glucose-vitamin c 4
chew tab 4-0.006 gm
4
INSTA-GLUCOSE - glucose gel 77.4%
INVOKAMET - canagliflozin-metformin
hcl tab 50-500 mg
4
•
INVOKAMET - canagliflozin-metformin
hcl tab 50-1000 mg
4
•
INVOKAMET - canagliflozin-metformin
hcl tab 150-500 mg
4
INVOKAMET - canagliflozin-metformin
hcl tab 150-1000 mg
4
INVOKANA - canagliflozin tab 100 mg
4
INVOKANA - canagliflozin tab 300 mg
4
JANUMET - sitagliptin-metformin hcl tab
50-500 mg
4
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
29
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
LEADER GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
OSENI - alogliptin-pioglitazone tab
12.5-15 mg
4
•
LEADER QUICK DISSOLVE GLU glucose chew tab 4 gm
4
OSENI - alogliptin-pioglitazone tab
12.5-30 mg
4
•
LONGS GLUCOSE - glucose chew tab
4 gm
4
OSENI - alogliptin-pioglitazone tab
12.5-45 mg
4
•
LONGS GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
OSENI - alogliptin-pioglitazone tab
25-15 mg
4
•
MEDICINE SHOPPE GLUCOSE glucose chew tab 4 gm
4
OSENI - alogliptin-pioglitazone tab
25-30 mg
4
•
MEIJER GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
OSENI - alogliptin-pioglitazone tab
25-45 mg
4
•
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
1
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
1
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
1
pioglitazone hcl tab 30 mg (base
equiv) (Actos)
1
metformin hcl tab sr 24hr osmotic
500 mg (Fortamet)
2
pioglitazone hcl tab 45 mg (base
equiv) (Actos)
1
metformin hcl tab sr 24hr osmotic
1000 mg (Fortamet)
2
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
2
metformin hcl tab 500 mg
(Glucophage)
1
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
2
metformin hcl tab 850 mg
(Glucophage)
1
pioglitazone hcl-metformin hcl tab
15-500 mg (Actoplus met)
2
metformin hcl tab 1000 mg
(Glucophage)
1
pioglitazone hcl-metformin hcl tab
15-850 mg (Actoplus met)
2
MS QUICK DISSOLVE GLUCOSE glucose chew tab 4 gm
4
PRANDIMET - repaglinide-metformin
hcl tab 1-500 mg
4
nateglinide tab 60 mg (Starlix)
2
4
nateglinide tab 120 mg (Starlix)
2
PRANDIMET - repaglinide-metformin
hcl tab 2-500 mg
NESINA - alogliptin benzoate tab 6.25
mg (base equiv)
4
PRANDIN - repaglinide tab 0.5 mg
4
PRANDIN - repaglinide tab 1 mg
4
NESINA - alogliptin benzoate tab 12.5
mg (base equiv)
4
•
PRANDIN - repaglinide tab 2 mg
4
4
4
•
PRECOSE - acarbose tab 25 mg
NESINA - alogliptin benzoate tab 25 mg
(base equiv)
PRECOSE - acarbose tab 50 mg
4
4
•
PRECOSE - acarbose tab 100 mg
4
ONGLYZA - saxagliptin hcl tab 2.5 mg
(base equiv)
4
ONGLYZA - saxagliptin hcl tab 5 mg
(base equiv)
4
PREFERRED PLUS GLUCOSE glucose chew tab 4 gm
30
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
TRADJENTA - linagliptin tab 5 mg
4
TRULICITY - dulaglutide soln peninjector 0.75 mg/0.5ml
4
•
• •
TRULICITY - dulaglutide soln peninjector 1.5 mg/0.5ml
4
• •
ULTILET GLUCOSE - glucose chew tab
4 gm
4
UP & UP GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
VALUE PLUS GLUCOSE - glucose
chew tab 4 gm
4
VALUE PLUS GLUCOSE - glucosevitamin c chew tab 4-0.006 gm
4
3
PREFERRED PLUS GLUCOSE glucose-vitamin c chew tab 4-0.006
gm
4
PROGLYCEM - diazoxide susp 50 mg/
ml
4
PX GLUCOSE - glucose-vitamin c chew
tab 4-0.006 gm
4
RA GLUCOSE - glucose-vitamin c chew
tab 4-0.006 gm
4
RELION GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
repaglinide tab 0.5 mg (Prandin)
2
repaglinide tab 1 mg (Prandin)
2
repaglinide tab 2 mg (Prandin)
2
RIOMET - metformin hcl oral soln 500
mg/5ml
4
VICTOZA - liraglutide soln pen-injector
18 mg/3ml (6 mg/ml)
4
SM GLUCOSE - glucose chew tab 4 gm
4
WALGREENS GLUCOSE - glucose
chew tab 4 gm
WALGREENS GLUCOSE - glucosevitamin c chew tab 4-0.006 gm
4
XIGDUO XR - dapagliflozin-metformin
hcl tab sr 24hr 5-500 mg
4
•
XIGDUO XR - dapagliflozin-metformin
hcl tab sr 24hr 5-1000 mg
4
•
XIGDUO XR - dapagliflozin-metformin
hcl tab sr 24hr 10-500 mg
4
•
XIGDUO XR - dapagliflozin-metformin
hcl tab sr 24hr 10-1000 mg
4
•
SM GLUCOSE - glucose-vitamin c chew 4
tab 4-0.006 gm
4
SMART SENSE GLUCOSE - glucosevitamin c chew tab 4-0.006 gm
4
STARLIX - nateglinide tab 60 mg
STARLIX - nateglinide tab 120 mg
4
SYMLINPEN 120 - pramlintide acetate
pen-inj 2700 mcg/2.7ml (1000 mcg/
ml)
4
SYMLINPEN 60 - pramlintide acetate
pen-inj 1500 mcg/1.5ml (1000 mcg/
ml)
4
TANZEUM - albiglutide for soln peninjector 30 mg
4
TANZEUM - albiglutide for soln peninjector 50 mg
4
TGT GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
•
•
• •
Rapid-Acting Insulins
4
•
•
•
•
HUMALOG - insulin lispro (human) soln
cartridge 100 unit/ml
4
•
•
4
HUMALOG - insulin lispro (human) inj
100 unit/ml
4
•
•
TOLAZAMIDE - tolazamide tab 500 mg
4
4
•
•
tolazamide tab 250 mg
2
HUMALOG KWIKPEN - insulin lispro
(human) soln pen-injector 100 unit/ml
TOLBUTAMIDE - tolbutamide tab 500
mg
4
HUMALOG KWIKPEN - insulin lispro
(human) soln pen-injector 200 unit/ml
4
•
•
APIDRA - insulin glulisine inj 100 unit/ml
4
• •
APIDRA SOLOSTAR - insulin glulisine
soln pen-injector inj 100 unit/ml
• •
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
31
•
•
NOVOLOG FLEXPEN - insulin aspart
soln pen-injector 100 unit/ml
2
•
4
•
•
NOVOLOG PENFILL - insulin aspart
soln cartridge 100 unit/ml
2
•
HUMULIN N KWIKPEN - insulin nph
(human) (isophane) susp pen-injector
100 unit/ml
4
•
•
NOVOLOG PENFILL - insulin aspart inj
100 unit/ml
2
HUMULIN N U-100 PEN - insulin nph
(human) (isophane) susp pen-injector
100 unit/ml
HUMULIN 70/30 - insulin nph isophane
& regular human inj 100 unit/ml
(70-30)
4
•
•
HUMULIN 70/30 KWIKPEN - insulin nph 4
& regular susp pen-inj 100 unit/ml
(70-30)
4
HUMULIN 70/30 PEN - insulin nph
& regular susp pen-inj 100 unit/ml
(70-30)
2
NOVOLIN N - insulin nph (human)
(isophane) inj 100 unit/ml
2
NOVOLIN N RELION - insulin nph
(human) (isophane) inj 100 unit/ml
2
NOVOLIN 70/30 - insulin nph isophane
& regular human inj 100 unit/ml
(70-30)
2
NOVOLIN 70/30 RELION - insulin nph
isophane & regular human inj 100
unit/ml (70-30)
2
NOVOLOG MIX 70/30 - insulin aspart
prot & aspart (human) inj 100 unit/ml
(70-30)
NOVOLOG MIX 70/30 PREFILL - insulin 2
aspart prot & aspart sus pen-inj 100
unit/ml (70-30)
•
•
•
•
•
Short-Acting Insulins
AFREZZA - insulin regular (human)
inhalation powder 4 unit/cartridge
4
•
•
AFREZZA - insulin regular (human)
inhal powd 4 (30) & 8 (60) unit/cart
4
•
•
AFREZZA - insulin regular (human)
inhal powd 4 (60) & 8 (30) unit/cart
4
•
•
AFREZZA - insulin regular (human) inh
powd 8 (60) & 12 (30) unit/cart
4
•
•
HUMULIN R - insulin regular (human) inj 4
100 unit/ml
4
HUMULIN R U-500 (CONCENTR insulin regular (human) inj 500 unit/ml
NOVOLIN R - insulin regular (human) inj 2
100 unit/ml
2
NOVOLIN R RELION - insulin regular
(human) inj 100 unit/ml
3
RELION R - insulin regular (human) inj
100 unit/ml
•
•
•
•
•
•
Intermediate-Acting Insulins
HUMALOG MIX 50/50 - insulin lispro
prot & lispro (human) inj 100 unit/ml
(50-50)
4
•
•
HUMALOG MIX 50/50 KWIKPEN insulin lispro prot & lispro sus pen-inj
100 unit/ml (50-50)
4
•
•
HUMALOG MIX 75/25 - insulin lispro
prot & lispro (human) inj 100 unit/ml
(75-25)
4
•
•
HUMALOG MIX 75/25 KWIKPEN insulin lispro prot & lispro sus pen-inj
100 unit/ml (75-25)
4
•
•
32
Dispensing Limits
Prior Authorization
4
Drug Name
Step Therapy
Drug Tier
HUMULIN N - insulin nph (human)
(isophane) inj 100 unit/ml
Dispensing Limits
•
Step Therapy
2
Drug Tier
NOVOLOG - insulin aspart inj 100 unit/
ml
Drug Name
Prior Authorization
2015
•
•
•
•
•
•
Basal Insulins
LANTUS - insulin glargine inj 100 unit/ml 3
3
LANTUS SOLOSTAR - insulin glargine
soln pen-injector 100 unit/ml
3
LEVEMIR - insulin detemir inj 100 unit/
ml
3
LEVEMIR FLEXPEN - insulin detemir
soln pen-injector 100 unit/ml
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
•
LEVEMIR FLEXTOUCH - insulin
detemir soln pen-injector 100 unit/ml
3
•
levothyroxine sodium tab 125 mcg
(Synthroid)
1
TOUJEO SOLOSTAR - insulin glargine
soln pen-injector 300 unit/ml
3
•
levothyroxine sodium tab 137 mcg
(Synthroid)
1
levothyroxine sodium tab 150 mcg
(Synthroid)
1
levothyroxine sodium tab 175 mcg
(Synthroid)
1
levothyroxine sodium tab 200 mcg
(Synthroid)
1
levothyroxine sodium tab 300 mcg
(Synthroid)
1
liothyronine sodium tab 5 mcg
(Cytomel)
2
liothyronine sodium tab 25 mcg
(Cytomel)
2
liothyronine sodium tab 50 mcg
(Cytomel)
2
methimazole tab 5 mg (Tapazole)
1
methimazole tab 10 mg (Tapazole)
1
NATURE-THROID - thyroid tab 16.25
mg
4
NATURE-THROID - thyroid tab 32.5 mg
4
NATURE-THROID - thyroid tab 48.75
mg (3/4 grain)
4
NATURE-THROID - thyroid tab 65 mg
4
NATURE-THROID - thyroid tab 81.25
mg
4
NATURE-THROID - thyroid tab 97.5 mg
4
NATURE-THROID - thyroid tab 113.75
mg
4
NATURE-THROID - thyroid tab 130 mg
4
NATURE-THROID - thyroid tab 195 mg
4
NATURE-THROID - thyroid tab 260 mg
4
NATURE-THROID - thyroid tab 325 mg
(5 grain)
4
NATURE-THROID - thyroid tab 146.25
mg
4
THYROID AGENTS
ARMOUR THYROID - thyroid tab 15 mg 4
(1/4 grain)
ARMOUR THYROID - thyroid tab 30 mg 4
(1/2 grain)
ARMOUR THYROID - thyroid tab 60 mg 4
(1 grain)
ARMOUR THYROID - thyroid tab 90 mg 4
(1 1/2 grain)
4
ARMOUR THYROID - thyroid tab 120
mg (2 grain)
4
ARMOUR THYROID - thyroid tab 180
mg (3 grain)
4
ARMOUR THYROID - thyroid tab 240
mg (4 grain)
4
ARMOUR THYROID - thyroid tab 300
mg (5 grain)
4
CYTOMEL - liothyronine sodium tab 5
mcg
CYTOMEL - liothyronine sodium tab 25 4
mcg
CYTOMEL - liothyronine sodium tab 50 4
mcg
1
levothyroxine sodium tab 25 mcg
(Synthroid)
1
levothyroxine sodium tab 50 mcg
(Synthroid)
1
levothyroxine sodium tab 75 mcg
(Synthroid)
1
levothyroxine sodium tab 88 mcg
(Synthroid)
1
levothyroxine sodium tab 100 mcg
(Synthroid)
1
levothyroxine sodium tab 112 mcg
(Synthroid)
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
33
NATURE-THROID NT-2.5 - thyroid tab
162.5 mg (2 1/2 grain)
4
THYROLAR-1/4 - liotrix (t3-t4) tab 15
mg (3.1-12.5 mcg)
4
propylthiouracil tab 50 mg
2
THYROLAR-2 - liotrix (t3-t4) tab 120 mg
(25-100 mcg)
4
THYROLAR-3 - liotrix (t3-t4) tab 180 mg
(37.5-150 mcg)
4
TIROSINT - levothyroxine sodium cap
13 mcg
4
TIROSINT - levothyroxine sodium cap
25 mcg
4
TIROSINT - levothyroxine sodium cap
50 mcg
4
TIROSINT - levothyroxine sodium cap
75 mcg
4
TIROSINT - levothyroxine sodium cap
88 mcg
4
TIROSINT - levothyroxine sodium cap
100 mcg
4
TIROSINT - levothyroxine sodium cap
112 mcg
4
TIROSINT - levothyroxine sodium cap
125 mcg
4
TIROSINT - levothyroxine sodium cap
137 mcg
4
TIROSINT - levothyroxine sodium cap
150 mcg
4
WESTHROID - thyroid tab 16.25 mg
4
WESTHROID - thyroid tab 32.5 mg
4
WESTHROID - thyroid tab 48.75 mg
(3/4 grain)
4
WESTHROID - thyroid tab 65 mg
4
WESTHROID - thyroid tab 81.25 mg
4
WESTHROID - thyroid tab 97.5 mg
4
WESTHROID - thyroid tab 113.75 mg
4
WESTHROID - thyroid tab 130 mg
4
WESTHROID - thyroid tab 162.5 mg (2
1/2 grain)
4
WESTHROID - thyroid tab 195 mg
4
WESTHROID - thyroid tab 260 mg
4
SYNTHROID - levothyroxine sodium tab 4
25 mcg
SYNTHROID - levothyroxine sodium tab 4
50 mcg
SYNTHROID - levothyroxine sodium tab 4
75 mcg
SYNTHROID - levothyroxine sodium tab 4
88 mcg
SYNTHROID - levothyroxine sodium tab 4
100 mcg
SYNTHROID - levothyroxine sodium tab 4
112 mcg
SYNTHROID - levothyroxine sodium tab 4
125 mcg
SYNTHROID - levothyroxine sodium tab 4
137 mcg
SYNTHROID - levothyroxine sodium tab 4
150 mcg
SYNTHROID - levothyroxine sodium tab 4
175 mcg
SYNTHROID - levothyroxine sodium tab 4
200 mcg
SYNTHROID - levothyroxine sodium tab 4
300 mcg
4
TAPAZOLE - methimazole tab 5 mg
TAPAZOLE - methimazole tab 10 mg
4
thyroid tab 30 mg (1/2 grain) (Armour
thyroid)
1
thyroid tab 60 mg (1 grain) (Armour
thyroid)
1
thyroid tab 90 mg (1 1/2 grain)
(Armour thyroid)
1
THYROLAR-1 - liotrix (t3-t4) tab 60 mg
(12.5-50 mcg)
4
THYROLAR-1/2 - liotrix (t3-t4) tab 30
mg (6.25-25 mcg)
4
34
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
WESTHROID - thyroid tab 325 mg (5
grain)
4
ACTONEL - risedronate sodium tab 150
mg
4
•
WESTHROID - thyroid tab 146.25 mg
4
•
WESTHROID-P - thyroid tab 16.25 mg
4
WESTHROID-P - thyroid tab 32.5 mg
4
WESTHROID-P - thyroid tab 48.75 mg
(3/4 grain)
4
ALENDRONATE SODIUM - alendronate 4
sodium oral soln 70 mg/75ml
ALENDRONATE SODIUM - alendronate 4
sodium tab 40 mg
1
alendronate sodium tab 5 mg
WESTHROID-P - thyroid tab 65 mg
4
alendronate sodium tab 10 mg
1
WESTHROID-P - thyroid tab 97.5 mg
4
alendronate sodium tab 35 mg
1
WESTHROID-P - thyroid tab 130 mg
4
1
WP THYROID - thyroid tab 16.25 mg
4
alendronate sodium tab 70 mg
(Fosamax)
•
•
•
•
4
ATELVIA - risedronate sodium tab
delayed release 35 mg
4
WP THYROID - thyroid tab 32.5 mg
•
WP THYROID - thyroid tab 48.75 mg
(3/4 grain)
4
BINOSTO - alendronate sodium
effervescent tab 70 mg
4
•
WP THYROID - thyroid tab 65 mg
4
•
4
BONIVA - ibandronate sodium tab 150
mg (base equivalent)
4
WP THYROID - thyroid tab 81.25 mg
WP THYROID - thyroid tab 97.5 mg
4
5
•
WP THYROID - thyroid tab 113.75 mg
4
BUPHENYL - sodium phenylbutyrate
tab 500 mg
WP THYROID - thyroid tab 130 mg
4
BUPHENYL - sodium phenylbutyrate
oral powder 3 gm/teaspoonful
5
•
cabergoline tab 0.5 mg
2
calcitonin (salmon) nasal soln 200
unit/act (Miacalcin)
2
calcitriol cap 0.25 mcg (Rocaltrol)
2
calcitriol cap 0.5 mcg (Rocaltrol)
2
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
2
CARBAGLU - carglumic acid tab 200
mg
5
CARNITOR - levocarnitine tab 330 mg
4
4
•
CARNITOR - levocarnitine oral soln 1
gm/10ml (10%)
4
•
CARNITOR SF - levocarnitine oral soln
1 gm/10ml (10%)
4
•
CYSTADANE - betaine powder for oral
solution
DDAVP - desmopressin acetate nasal
soln 0.01% (refrigerated)
4
OXYTOCICS
CERVIDIL - dinoprostone vaginal inserts 4
10 mg
2
methylergonovine maleate tab
0.2 mg
4
PREPIDIL - dinoprostone cervical gel
0.5 mg/3gm
4
PROSTIN E2 - dinoprostone vaginal
suppos 20 mg
ENDOCRINE and METABOLIC AGENTS - MISC.
5 •
ACTHAR HP - corticotropin inj gel 80
unit/ml
4
ACTONEL - risedronate sodium tab 5
mg
4
ACTONEL - risedronate sodium tab 30
mg
4
ACTONEL - risedronate sodium tab 35
mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
35
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
DDAVP - desmopressin acetate nasal
spray soln 0.01%
4
FOSAMAX - alendronate sodium tab 70
mg
4
•
DDAVP - desmopressin acetate tab 0.1
mg
4
4
•
DDAVP - desmopressin acetate tab 0.2
mg
4
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab 70-2800
mg-unit
4
•
DDAVP - desmopressin acetate inj 4
mcg/ml
4
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab 70-5600
mg-unit
desmopressin acetate inj 4 mcg/ml
(Ddavp)
2
GENOTROPIN - somatropin for
subcutaneous inj 5 mg
5
•
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
2
GENOTROPIN - somatropin for inj 12
mg (13.8 mg overfill)
5
•
desmopressin acetate nasal spray
soln 0.01% (Ddavp)
2
GENOTROPIN MINIQUICK somatropin for inj 0.2 mg
5
•
desmopressin acetate nasal spray
soln 0.01% (refrigerated)
2
GENOTROPIN MINIQUICK somatropin for inj 0.4 mg
5
•
desmopressin acetate tab 0.1 mg
(Ddavp)
2
GENOTROPIN MINIQUICK somatropin for inj 0.6 mg
5
•
desmopressin acetate tab 0.2 mg
(Ddavp)
2
GENOTROPIN MINIQUICK somatropin for inj 0.8 mg
5
•
DIDRONEL - etidronate disodium tab
400 mg
4
GENOTROPIN MINIQUICK somatropin for inj 1 mg
5
•
doxercalciferol cap 0.5 mcg
(Hectorol)
2
GENOTROPIN MINIQUICK somatropin for inj 1.2 mg
5
•
doxercalciferol cap 1 mcg (Hectorol)
2
5
•
doxercalciferol cap 2.5 mcg
(Hectorol)
2
GENOTROPIN MINIQUICK somatropin for inj 1.4 mg
5
•
EGRIFTA - tesamorelin acetate for inj 1
mg (base equiv)
5
GENOTROPIN MINIQUICK somatropin for inj 1.6 mg
5
•
EGRIFTA - tesamorelin acetate for inj 2
mg (base equiv)
5
GENOTROPIN MINIQUICK somatropin for inj 1.8 mg
5
•
ETIDRONATE DISODIUM - etidronate
disodium tab 200 mg
4
GENOTROPIN MINIQUICK somatropin for inj 2 mg
5
•
ETIDRONATE DISODIUM - etidronate
disodium tab 400 mg
4
H.P. ACTHAR - corticotropin inj gel 80
unit/ml
4
EVISTA - raloxifene hcl tab 60 mg
4
HECTOROL - doxercalciferol cap 0.5
mcg
5
HECTOROL - doxercalciferol cap 1 mcg
4
FORTEO - teriparatide (recombinant) inj
600 mcg/2.4ml
4
FORTICAL - calcitonin (salmon) nasal
soln 200 unit/act
4
HECTOROL - doxercalciferol cap 2.5
mcg
HUMATROPE - somatropin for inj 5 mg
5
36
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
NORDITROPIN FLEXPRO - somatropin
inj 10 mg/1.5ml
5
•
HUMATROPE - somatropin for inj 12
mg (36 unit)
5
•
NORDITROPIN FLEXPRO - somatropin
inj 15 mg/1.5ml
5
•
HUMATROPE - somatropin for inj 24
mg
5
•
NORDITROPIN FLEXPRO - somatropin
inj 30 mg/3ml
5
•
HUMATROPE COMBO PACK somatropin for inj 5 mg
5
•
NORDITROPIN NORDIFLEX PEN somatropin inj 30 mg/3ml
5
•
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
2
NUTROPIN AQ NUSPIN 10 somatropin inj 10 mg/2ml
5
•
INCRELEX - mecasermin inj 40 mg/4ml
(10 mg/ml)
5
•
NUTROPIN AQ NUSPIN 20 somatropin inj 20 mg/2ml
5
•
KUVAN - sapropterin dihydrochloride
soluble tab 100 mg
5
•
NUTROPIN AQ NUSPIN 5 - somatropin
inj 5 mg/2ml
5
•
KUVAN - sapropterin dihydrochloride
powder packet 100 mg
5
•
NUTROPIN AQ PEN - somatropin inj 10
mg/2ml
5
•
KUVAN - sapropterin dihydrochloride
powder packet 500 mg
5
•
NUTROPIN AQ PEN - somatropin inj 20
mg/2ml
5
•
levocarnitine oral soln 1 gm/10ml
(10%) (Carnitor)
2
octreotide acetate inj 50 mcg/ml
(0.05 mg/ml) (Sandostatin)
5
•
levocarnitine tab 330 mg (Carnitor)
2
octreotide acetate inj 100 mcg/ml
(0.1 mg/ml) (Sandostatin)
5
•
octreotide acetate inj 200 mcg/ml
(0.2 mg/ml) (Sandostatin)
5
•
octreotide acetate inj 500 mcg/ml
(0.5 mg/ml) (Sandostatin)
5
•
octreotide acetate inj 1000 mcg/ml
(1 mg/ml) (Sandostatin)
5
•
OMNITROPE - somatropin inj 5
mg/1.5ml
5
•
OMNITROPE - somatropin inj 10
mg/1.5ml
5
•
OMNITROPE - somatropin for inj 5.8 mg 5
5
ORFADIN - nitisinone cap 2 mg
•
•
•
•
MIACALCIN - calcitonin (salmon) inj 200 4
unit/ml
MIACALCIN - calcitonin (salmon) nasal 4
soln 200 unit/act
5
MYALEPT - metreleptin for
subcutaneous inj 11.3 mg
5
NATPARA - parathyroid hormone
(recombinant) for inj cartridge 25 mcg
5
NATPARA - parathyroid hormone
(recombinant) for inj cartridge 50 mcg
5
NATPARA - parathyroid hormone
(recombinant) for inj cartridge 75 mcg
5
NATPARA - parathyroid hormone
(recombinant) for inj cartridge 100
mcg
5
NORDITROPIN CARTRIDGE somatropin inj 5 mg/1.5ml
NORDITROPIN FLEXPRO - somatropin 5
inj 5 mg/1.5ml
•
ORFADIN - nitisinone cap 5 mg
5
•
ORFADIN - nitisinone cap 10 mg
5
OSPHENA - ospemifene tab 60 mg
4
•
paricalcitol cap 1 mcg (Zemplar)
2
paricalcitol cap 2 mcg (Zemplar)
2
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
5
Dispensing Limits
Prior Authorization
HUMATROPE - somatropin for inj 6 mg
(18 unit)
Drug Name
Step Therapy
Drug Tier
2015
37
2
RAVICTI - glycerol phenylbutyrate liquid
1.1 gm/ml
5
risedronate sodium tab delayed
release 35 mg (Atelvia)
2
•
risedronate sodium tab 5 mg
(Actonel)
2
•
risedronate sodium tab 30 mg
(Actonel)
2
•
risedronate sodium tab 35 mg
(Actonel)
2
•
risedronate sodium tab 150 mg
(Actonel)
2
•
•
ROCALTROL - calcitriol oral soln 1 mcg/ 4
ml
4
ROCALTROL - calcitriol cap 0.25 mcg
SENSIPAR - cinacalcet hcl tab 60 mg
(base equiv)
3
SENSIPAR - cinacalcet hcl tab 90 mg
(base equiv)
3
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj 4
mg
5
•
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj 5
mg
5
•
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj 6
mg
5
•
SIGNIFOR - pasireotide diaspartate inj
0.3 mg/ml (base equiv)
5
•
•
SIGNIFOR - pasireotide diaspartate inj
0.6 mg/ml (base equiv)
5
•
•
SIGNIFOR - pasireotide diaspartate inj
0.9 mg/ml (base equiv)
5
•
•
ROCALTROL - calcitriol cap 0.5 mcg
4
SAIZEN - somatropin (non-refrigerated)
for inj 5 mg
5
•
sodium phenylbutyrate oral powder
3 gm/teaspoonful (Buphenyl)
5
•
SAIZEN - somatropin (non-refrigerated)
for inj 8.8 mg
5
•
•
SAIZEN CLICK.EASY - somatropin
(non-refrigerated) for inj 8.8 mg
5
•
SAMSCA - tolvaptan tab 15 mg
5
SAMSCA - tolvaptan tab 30 mg
5
SANDOSTATIN - octreotide acetate inj
50 mcg/ml (0.05 mg/ml)
5
•
•
•
SANDOSTATIN - octreotide acetate inj
100 mcg/ml (0.1 mg/ml)
5
•
SANDOSTATIN - octreotide acetate inj
200 mcg/ml (0.2 mg/ml)
5
•
SANDOSTATIN - octreotide acetate inj
500 mcg/ml (0.5 mg/ml)
5
•
SANDOSTATIN - octreotide acetate inj
1000 mcg/ml (1 mg/ml)
5
•
SENSIPAR - cinacalcet hcl tab 30 mg
(base equiv)
3
SOMAVERT - pegvisomant for inj 10 mg 5
(as protein)
SOMAVERT - pegvisomant for inj 15 mg 5
(as protein)
SOMAVERT - pegvisomant for inj 20 mg 5
(as protein)
SOMAVERT - pegvisomant for inj 25 mg 5
(as protein)
SOMAVERT - pegvisomant for inj 30 mg 5
(as protein)
STIMATE - desmopressin acetate nasal 3
soln 1.5 mg/ml
SYNAREL - nafarelin acetate nasal soln 3
2 mg/ml
5
TEV-TROPIN - somatropin for
subcutaneous inj 5 mg
4
ZEMPLAR - paricalcitol cap 1 mcg
38
•
•
Dispensing Limits
raloxifene hcl tab 60 mg (Evista)
Step Therapy
2
Prior Authorization
paricalcitol cap 4 mcg (Zemplar)
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
Prior Authorization
2015
ZEMPLAR - paricalcitol cap 2 mcg
•
•
•
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
ZOMACTON - somatropin for inj 10 mg
5
isosorbide mononitrate tab 10 mg
1
ZORBTIVE - somatropin (nonrefrigerated) for subcutaneous inj 8.8
mg
5
•
•
isosorbide mononitrate tab 20 mg
1
NITRO-BID - nitroglycerin oint 2%
4
NITRO-DUR - nitroglycerin td patch
24hr 0.1 mg/hr
4
NITRO-DUR - nitroglycerin td patch
24hr 0.2 mg/hr
4
CARDIOVASCULAR AGENTS
CARDIOTONICS
DIGOXIN - digoxin oral soln 0.05 mg/ml
4
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
1
NITRO-DUR - nitroglycerin td patch
24hr 0.3 mg/hr
4
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
1
NITRO-DUR - nitroglycerin td patch
24hr 0.4 mg/hr
4
LANOXIN - digoxin tab 62.5 mcg
(0.0625 mg)
4
NITRO-DUR - nitroglycerin td patch
24hr 0.6 mg/hr
4
LANOXIN - digoxin tab 125 mcg (0.125
mg)
4
NITRO-DUR - nitroglycerin td patch
24hr 0.8 mg/hr
4
LANOXIN - digoxin tab 187.5 mcg
(0.1875 mg)
4
nitroglycerin cap cr 2.5 mg
1
nitroglycerin cap cr 6.5 mg
2
LANOXIN - digoxin tab 250 mcg (0.25
mg)
4
nitroglycerin cap cr 9 mg
2
4
DILATRATE SR - isosorbide dinitrate
cap cr 40 mg
4
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400 mcg/
spray
4
nitroglycerin td patch 24hr 0.1 mg/hr
(Nitro-dur)
2
ISORDIL TITRADOSE - isosorbide
dinitrate tab 5 mg
4
nitroglycerin td patch 24hr 0.2 mg/hr
(Nitro-dur)
2
ISORDIL TITRADOSE - isosorbide
dinitrate tab 40 mg
ISOSORBIDE DINITRATE - isosorbide
dinitrate tab 30 mg
nitroglycerin td patch 24hr 0.4 mg/hr
(Nitro-dur)
2
4
isosorbide dinitrate tab cr 40 mg
nitroglycerin td patch 24hr 0.6 mg/hr
(Nitro-dur)
2
2
isosorbide dinitrate tab 5 mg (Isordil
titradose)
2
2
isosorbide dinitrate tab 10 mg
2
nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray) (Nitrolingual
pumpspr)
isosorbide dinitrate tab 20 mg
2
4
isosorbide mononitrate tab sr 24hr
30 mg (Imdur)
1
NITROLINGUAL PUMPSPRAY nitroglycerin tl soln 0.4 mg/spray (400
mcg/spray)
1
NITROMIST - nitroglycerin lingual
aerosol 400 mcg/spray
4
isosorbide mononitrate tab sr 24hr
60 mg (Imdur)
ANTIANGINAL AGENTS
Dispensing Limits
1
Step Therapy
isosorbide mononitrate tab sr 24hr
120 mg (Imdur)
Prior Authorization
•
Drug Name
Drug Tier
5
Dispensing Limits
Prior Authorization
ZOMACTON - somatropin for
subcutaneous inj 5 mg
Drug Name
Step Therapy
Drug Tier
2015
NITROSTAT - nitroglycerin sl tab 0.3 mg 3
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
39
RANEXA - ranolazine tab sr 12hr 500
mg
4
RANEXA - ranolazine tab sr 12hr 1000
mg
4
BETA BLOCKERS
acebutolol hcl cap 200 mg (Sectral)
1
acebutolol hcl cap 400 mg (Sectral)
1
atenolol tab 25 mg (Tenormin)
1
atenolol tab 50 mg (Tenormin)
1
atenolol tab 100 mg (Tenormin)
1
BETAPACE - sotalol hcl tab 80 mg
4
BETAPACE - sotalol hcl tab 120 mg
4
BETAPACE - sotalol hcl tab 160 mg
4
BETAPACE AF - sotalol hcl (afib/afl) tab
80 mg
4
BETAPACE AF - sotalol hcl (afib/afl) tab
120 mg
4
BETAPACE AF - sotalol hcl (afib/afl) tab
160 mg
4
betaxolol hcl tab 10 mg (Kerlone)
2
betaxolol hcl tab 20 mg (Kerlone)
2
bisoprolol fumarate tab 5 mg
(Zebeta)
2
bisoprolol fumarate tab 10 mg
(Zebeta)
2
BYSTOLIC - nebivolol hcl tab 2.5 mg
(base equivalent)
4
BYSTOLIC - nebivolol hcl tab 5 mg
(base equivalent)
4
BYSTOLIC - nebivolol hcl tab 10 mg
(base equivalent)
4
BYSTOLIC - nebivolol hcl tab 20 mg
(base equivalent)
4
carvedilol tab 3.125 mg (Coreg)
1
carvedilol tab 6.25 mg (Coreg)
1
carvedilol tab 12.5 mg (Coreg)
1
40
COREG - carvedilol tab 3.125 mg
4
COREG - carvedilol tab 6.25 mg
4
COREG - carvedilol tab 12.5 mg
4
COREG - carvedilol tab 25 mg
4
COREG CR - carvedilol phosphate cap
sr 24hr 10 mg
4
COREG CR - carvedilol phosphate cap
sr 24hr 20 mg
4
COREG CR - carvedilol phosphate cap
sr 24hr 40 mg
4
COREG CR - carvedilol phosphate cap
sr 24hr 80 mg
4
CORGARD - nadolol tab 20 mg
4
CORGARD - nadolol tab 40 mg
4
CORGARD - nadolol tab 80 mg
4
Dispensing Limits
1
Step Therapy
carvedilol tab 25 mg (Coreg)
Prior Authorization
Dispensing Limits
Drug Name
Drug Tier
NITROSTAT - nitroglycerin sl tab 0.4 mg 3
NITROSTAT - nitroglycerin sl tab 0.6 mg 3
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
HEMANGEOL - propranolol hcl oral soln 4
4.28 mg/ml
4
INDERAL LA - propranolol hcl cap sr
24hr 60 mg
4
INDERAL LA - propranolol hcl cap sr
24hr 80 mg
4
INDERAL LA - propranolol hcl cap sr
24hr 120 mg
4
INDERAL LA - propranolol hcl cap sr
24hr 160 mg
4
INDERAL XL - propranolol hcl
sustained-release beads cap sr 24hr
80 mg
4
INDERAL XL - propranolol hcl
sustained-release beads cap sr 24hr
120 mg
4
INNOPRAN XL - propranolol hcl
sustained-release beads cap sr 24hr
80 mg
4
INNOPRAN XL - propranolol hcl
sustained-release beads cap sr 24hr
120 mg
4
KERLONE - betaxolol hcl tab 10 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
1
labetalol hcl tab 100 mg (Trandate)
2
propranolol hcl tab 20 mg
1
labetalol hcl tab 200 mg (Trandate)
2
propranolol hcl tab 40 mg
1
labetalol hcl tab 300 mg (Trandate)
2
propranolol hcl tab 60 mg
2
LEVATOL - penbutolol sulfate tab 20 mg 4
4
LOPRESSOR - metoprolol tartrate tab
50 mg
4
LOPRESSOR - metoprolol tartrate tab
100 mg
2
metoprolol succinate tab sr 24hr
25 mg (Toprol xl)
2
metoprolol succinate tab sr 24hr
50 mg (Toprol xl)
2
metoprolol succinate tab sr 24hr
100 mg (Toprol xl)
2
metoprolol succinate tab sr 24hr
200 mg (Toprol xl)
1
metoprolol tartrate tab 25 mg
propranolol hcl tab 80 mg
1
SECTRAL - acebutolol hcl cap 200 mg
4
SECTRAL - acebutolol hcl cap 400 mg
4
sotalol hcl (afib/afl) tab 80 mg
(Betapace af)
2
sotalol hcl (afib/afl) tab 120 mg
(Betapace af)
2
sotalol hcl (afib/afl) tab 160 mg
(Betapace af)
2
sotalol hcl tab 80 mg (Betapace)
1
sotalol hcl tab 120 mg (Betapace)
1
sotalol hcl tab 160 mg (Betapace)
1
sotalol hcl tab 240 mg
2
metoprolol tartrate tab 50 mg
(Lopressor)
1
SOTYLIZE - sotalol hcl oral solution 5
mg/ml
4
metoprolol tartrate tab 100 mg
(Lopressor)
1
TENORMIN - atenolol tab 25 mg
4
TENORMIN - atenolol tab 50 mg
4
nadolol tab 20 mg (Corgard)
2
TENORMIN - atenolol tab 100 mg
4
nadolol tab 40 mg (Corgard)
2
4
nadolol tab 80 mg (Corgard)
2
TIMOLOL MALEATE - timolol maleate
tab 5 mg
pindolol tab 5 mg
2
4
pindolol tab 10 mg
2
TIMOLOL MALEATE - timolol maleate
tab 10 mg
4
TIMOLOL MALEATE - timolol maleate
tab 20 mg
4
PROPRANOLOL HCL - propranolol hcl
oral soln 20 mg/5ml
4
TOPROL XL - metoprolol succinate tab
sr 24hr 25 mg
4
PROPRANOLOL HCL - propranolol hcl
oral soln 40 mg/5ml
2
TOPROL XL - metoprolol succinate tab
sr 24hr 50 mg
4
propranolol hcl cap sr 24hr 60 mg
(Inderal la)
2
TOPROL XL - metoprolol succinate tab
sr 24hr 100 mg
4
propranolol hcl cap sr 24hr 80 mg
(Inderal la)
2
TOPROL XL - metoprolol succinate tab
sr 24hr 200 mg
4
propranolol hcl cap sr 24hr 120 mg
(Inderal la)
2
TRANDATE - labetalol hcl tab 100 mg
4
propranolol hcl cap sr 24hr 160 mg
(Inderal la)
TRANDATE - labetalol hcl tab 200 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
propranolol hcl tab 10 mg
Step Therapy
4
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
KERLONE - betaxolol hcl tab 20 mg
Prior Authorization
Drug Name
Drug Tier
2015
41
CALCIUM CHANNEL BLOCKERS
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 180 mg
4
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 240 mg
4
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 300 mg
4
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 360 mg
4
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 420 mg
4
diltiazem hcl cap sr 12hr 60 mg
2
diltiazem hcl cap sr 12hr 90 mg
2
diltiazem hcl cap sr 12hr 120 mg
2
diltiazem hcl cap sr 24hr 120 mg
2
diltiazem hcl cap sr 24hr 180 mg
2
diltiazem hcl cap sr 24hr 240 mg
2
ADALAT CC - nifedipine tab sr 24hr 30
mg
4
ADALAT CC - nifedipine tab sr 24hr 60
mg
4
ADALAT CC - nifedipine tab sr 24hr 90
mg
4
amlodipine besylate tab 2.5 mg
(Norvasc)
1
amlodipine besylate tab 5 mg
(Norvasc)
1
amlodipine besylate tab 10 mg
(Norvasc)
1
CALAN - verapamil hcl tab 80 mg
4
CALAN - verapamil hcl tab 120 mg
4
CALAN SR - verapamil hcl tab cr 120
mg
diltiazem hcl coated beads cap sr
24hr 120 mg (Cardizem cd)
1
4
CALAN SR - verapamil hcl tab cr 180
mg
diltiazem hcl coated beads cap sr
24hr 180 mg (Cardizem cd)
1
4
2
CALAN SR - verapamil hcl tab cr 240
mg
4
diltiazem hcl coated beads cap sr
24hr 240 mg (Cardizem cd)
4
diltiazem hcl coated beads cap sr
24hr 300 mg (Cardizem cd)
2
CARDIZEM - diltiazem hcl tab 30 mg
CARDIZEM - diltiazem hcl tab 60 mg
4
2
CARDIZEM - diltiazem hcl tab 120 mg
4
diltiazem hcl coated beads cap sr
24hr 360 mg (Cardizem cd)
CARDIZEM CD - diltiazem hcl coated
beads cap sr 24hr 120 mg
4
diltiazem hcl coated beads tab sr
24hr 180 mg (Cardizem la)
2
CARDIZEM CD - diltiazem hcl coated
beads cap sr 24hr 180 mg
4
diltiazem hcl coated beads tab sr
24hr 240 mg (Cardizem la)
2
CARDIZEM CD - diltiazem hcl coated
beads cap sr 24hr 240 mg
4
diltiazem hcl coated beads tab sr
24hr 300 mg (Cardizem la)
2
CARDIZEM CD - diltiazem hcl coated
beads cap sr 24hr 300 mg
4
diltiazem hcl coated beads tab sr
24hr 360 mg (Cardizem la)
2
CARDIZEM CD - diltiazem hcl coated
beads cap sr 24hr 360 mg
4
diltiazem hcl coated beads tab sr
24hr 420 mg (Cardizem la)
2
42
Dispensing Limits
4
4
Step Therapy
ZEBETA - bisoprolol fumarate tab 10
mg
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 120 mg
Prior Authorization
4
Drug Name
Drug Tier
ZEBETA - bisoprolol fumarate tab 5 mg
Dispensing Limits
4
Step Therapy
TRANDATE - labetalol hcl tab 300 mg
Prior Authorization
Drug Name
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
diltiazem hcl extended release beads
cap sr 24hr 120 mg (Tiazac)
2
nifedipine tab sr 24hr osmotic 30 mg
(Procardia xl)
2
diltiazem hcl extended release beads
cap sr 24hr 180 mg (Tiazac)
2
nifedipine tab sr 24hr osmotic 60 mg
(Procardia xl)
2
diltiazem hcl extended release beads
cap sr 24hr 240 mg (Tiazac)
2
nifedipine tab sr 24hr osmotic 90 mg
(Procardia xl)
2
diltiazem hcl extended release beads
cap sr 24hr 300 mg (Tiazac)
2
nimodipine cap 30 mg
2
2
NISOLDIPINE - nisoldipine tab sr 24hr
20 mg
4
diltiazem hcl extended release beads
cap sr 24hr 360 mg (Tiazac)
diltiazem hcl extended release beads
cap sr 24hr 420 mg (Tiazac)
NISOLDIPINE - nisoldipine tab sr 24hr
30 mg
4
2
diltiazem hcl tab 30 mg (Cardizem)
NISOLDIPINE - nisoldipine tab sr 24hr
40 mg
4
1
diltiazem hcl tab 60 mg (Cardizem)
1
4
diltiazem hcl tab 90 mg
1
NISOLDIPINE ER - nisoldipine tab sr
24hr 25.5 mg
diltiazem hcl tab 120 mg (Cardizem)
1
nisoldipine tab sr 24hr 8.5 mg (Sular)
2
felodipine tab sr 24hr 2.5 mg
2
nisoldipine tab sr 24hr 17 mg (Sular)
2
felodipine tab sr 24hr 5 mg
2
nisoldipine tab sr 24hr 34 mg (Sular)
2
felodipine tab sr 24hr 10 mg
2
4
ISOPTIN SR - verapamil hcl tab cr 120
mg
4
NORVASC - amlodipine besylate tab
2.5 mg
4
ISOPTIN SR - verapamil hcl tab cr 180
mg
4
NORVASC - amlodipine besylate tab 5
mg
4
ISOPTIN SR - verapamil hcl tab cr 240
mg
4
NORVASC - amlodipine besylate tab 10
mg
4
isradipine cap 2.5 mg
2
NYMALIZE - nimodipine oral soln 60
mg/20ml
2
PROCARDIA - nifedipine cap 10 mg
4
isradipine cap 5 mg
2
PROCARDIA XL - nifedipine tab sr 24hr
osmotic 30 mg
4
nicardipine hcl cap 20 mg
nicardipine hcl cap 30 mg
2
nifedipine cap 10 mg (Procardia)
PROCARDIA XL - nifedipine tab sr 24hr
osmotic 60 mg
4
2
nifedipine cap 20 mg
2
4
nifedipine tab sr 24hr 30 mg (Adalat
cc)
2
PROCARDIA XL - nifedipine tab sr 24hr
osmotic 90 mg
SULAR - nisoldipine tab sr 24hr 8.5 mg
4
nifedipine tab sr 24hr 60 mg (Adalat
cc)
2
SULAR - nisoldipine tab sr 24hr 17 mg
4
SULAR - nisoldipine tab sr 24hr 34 mg
4
nifedipine tab sr 24hr 90 mg (Adalat
cc)
2
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
TIAZAC - diltiazem hcl extended release 4
beads cap sr 24hr 120 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
43
TIAZAC - diltiazem hcl extended release 4
beads cap sr 24hr 180 mg
TIAZAC - diltiazem hcl extended release 4
beads cap sr 24hr 240 mg
TIAZAC - diltiazem hcl extended release 4
beads cap sr 24hr 300 mg
TIAZAC - diltiazem hcl extended release 4
beads cap sr 24hr 360 mg
TIAZAC - diltiazem hcl extended release 4
beads cap sr 24hr 420 mg
VERAPAMIL HCL - verapamil hcl tab 40 4
mg
2
verapamil hcl cap sr 24hr 100 mg
(Verelan pm)
2
verapamil hcl cap sr 24hr 120 mg
(Verelan)
2
verapamil hcl cap sr 24hr 180 mg
(Verelan)
2
verapamil hcl cap sr 24hr 200 mg
(Verelan pm)
2
verapamil hcl cap sr 24hr 240 mg
(Verelan)
2
verapamil hcl cap sr 24hr 300 mg
(Verelan pm)
2
verapamil hcl cap sr 24hr 360 mg
(Verelan)
1
verapamil hcl tab cr 120 mg (Calan
sr)
1
verapamil hcl tab cr 180 mg (Calan
sr)
1
verapamil hcl tab cr 240 mg (Calan
sr)
1
verapamil hcl tab 80 mg (Calan)
VERELAN - verapamil hcl cap sr 24hr
360 mg
4
VERELAN PM - verapamil hcl cap sr
24hr 100 mg
4
VERELAN PM - verapamil hcl cap sr
24hr 200 mg
4
VERELAN PM - verapamil hcl cap sr
24hr 300 mg
4
Dispensing Limits
Step Therapy
ANTIARRHYTHMICS
amiodarone hcl tab 100 mg
2
amiodarone hcl tab 200 mg
(Cordarone)
1
amiodarone hcl tab 400 mg
2
CORDARONE - amiodarone hcl tab 200 4
mg
disopyramide phosphate cap 100 mg 2
(Norpace)
disopyramide phosphate cap 150 mg 2
(Norpace)
2
flecainide acetate tab 50 mg
flecainide acetate tab 100 mg
2
flecainide acetate tab 150 mg
2
mexiletine hcl cap 150 mg
2
mexiletine hcl cap 200 mg
2
mexiletine hcl cap 250 mg
2
MULTAQ - dronedarone hcl tab 400 mg
(base equivalent)
4
NORPACE - disopyramide phosphate
cap 100 mg
4
NORPACE - disopyramide phosphate
cap 150 mg
4
NORPACE CR - disopyramide
phosphate cap sr 12hr 100 mg
4
verapamil hcl tab 120 mg (Calan)
1
VERELAN - verapamil hcl cap sr 24hr
120 mg
4
NORPACE CR - disopyramide
phosphate cap sr 12hr 150 mg
4
VERELAN - verapamil hcl cap sr 24hr
180 mg
4
propafenone hcl cap sr 12hr 225 mg
(Rythmol sr)
2
VERELAN - verapamil hcl cap sr 24hr
240 mg
4
propafenone hcl cap sr 12hr 325 mg
(Rythmol sr)
2
44
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
propafenone hcl cap sr 12hr 425 mg
(Rythmol sr)
2
ACCURETIC - quinaprilhydrochlorothiazide tab 20-25 mg
4
propafenone hcl tab 150 mg
(Rythmol)
2
ACEON - perindopril erbumine tab 4 mg
4
ACEON - perindopril erbumine tab 8 mg
4
propafenone hcl tab 225 mg
(Rythmol)
2
ALTACE - ramipril cap 1.25 mg
4
2
ALTACE - ramipril cap 2.5 mg
4
propafenone hcl tab 300 mg
2
ALTACE - ramipril cap 5 mg
4
quinidine gluconate tab cr 324 mg
4
ALTACE - ramipril cap 10 mg
4
QUINIDINE SULFATE - quinidine
sulfate tab 200 mg
2
QUINIDINE SULFATE ER - quinidine
sulfate tab cr 300 mg
4
amlodipine besylate-benazepril hcl
cap 2.5-10 mg (Lotrel)
2
quinidine sulfate tab 300 mg
2
amlodipine besylate-benazepril hcl
cap 5-10 mg (Lotrel)
4
amlodipine besylate-benazepril hcl
cap 5-20 mg (Lotrel)
2
RYTHMOL - propafenone hcl tab 150
mg
4
amlodipine besylate-benazepril hcl
cap 5-40 mg (Lotrel)
2
RYTHMOL - propafenone hcl tab 225
mg
4
amlodipine besylate-benazepril hcl
cap 10-20 mg (Lotrel)
2
RYTHMOL SR - propafenone hcl cap sr
12hr 225 mg
4
amlodipine besylate-benazepril hcl
cap 10-40 mg (Lotrel)
2
RYTHMOL SR - propafenone hcl cap sr
12hr 325 mg
4
amlodipine besylate-valsartan tab
5-160 mg (Exforge)
2
RYTHMOL SR - propafenone hcl cap sr
12hr 425 mg
4
amlodipine besylate-valsartan tab
5-320 mg (Exforge)
2
TIKOSYN - dofetilide cap 125 mcg
(0.125 mg)
amlodipine besylate-valsartan tab
10-160 mg (Exforge)
2
amlodipine besylate-valsartan tab
10-320 mg (Exforge)
2
amlodipine-valsartanhydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)
2
amlodipine-valsartanhydrochlorothiazide tab
5-160-25 mg (Exforge hct)
2
amlodipine-valsartanhydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)
2
amlodipine-valsartanhydrochlorothiazide tab
10-160-25 mg (Exforge hct)
2
TIKOSYN - dofetilide cap 250 mcg (0.25 4
mg)
4
TIKOSYN - dofetilide cap 500 mcg (0.5
mg)
ANTIHYPERTENSIVES
ACCUPRIL - quinapril hcl tab 5 mg
4
ACCUPRIL - quinapril hcl tab 10 mg
4
ACCUPRIL - quinapril hcl tab 20 mg
4
ACCUPRIL - quinapril hcl tab 40 mg
4
ACCURETIC - quinaprilhydrochlorothiazide tab 10-12.5 mg
4
ACCURETIC - quinaprilhydrochlorothiazide tab 20-12.5 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
45
amlodipine-valsartanhydrochlorothiazide tab
10-320-25 mg (Exforge hct)
2
ATACAND - candesartan cilexetil tab 4
mg
4
ATACAND - candesartan cilexetil tab 8
mg
4
ATACAND - candesartan cilexetil tab 16
mg
4
ATACAND - candesartan cilexetil tab 32
mg
4
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg
4
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg
4
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-25 mg
4
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
1
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
1
AVALIDE - irbesartanhydrochlorothiazide tab 150-12.5 mg
4
AVALIDE - irbesartanhydrochlorothiazide tab 300-12.5 mg
4
AVAPRO - irbesartan tab 75 mg
4
AVAPRO - irbesartan tab 150 mg
4
AVAPRO - irbesartan tab 300 mg
4
AZOR - amlodipine besylate-olmesartan
medoxomil tab 5-20 mg
4
AZOR - amlodipine besylate-olmesartan
medoxomil tab 5-40 mg
4
AZOR - amlodipine besylate-olmesartan
medoxomil tab 10-20 mg
4
AZOR - amlodipine besylate-olmesartan
medoxomil tab 10-40 mg
4
benazepril & hydrochlorothiazide tab
5-6.25 mg
2
benazepril & hydrochlorothiazide tab
10-12.5 mg (Lotensin hct)
2
46
benazepril & hydrochlorothiazide tab
20-12.5 mg (Lotensin hct)
2
benazepril & hydrochlorothiazide tab
20-25 mg (Lotensin hct)
2
benazepril hcl tab 5 mg
1
benazepril hcl tab 10 mg (Lotensin)
1
benazepril hcl tab 20 mg (Lotensin)
1
benazepril hcl tab 40 mg (Lotensin)
1
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BENICAR - olmesartan medoxomil tab 5 4
mg
4
BENICAR - olmesartan medoxomil tab
20 mg
4
BENICAR - olmesartan medoxomil tab
40 mg
4
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide tab
20-12.5 mg
4
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide tab
40-12.5 mg
4
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide tab
40-25 mg
bisoprolol & hydrochlorothiazide tab 1
2.5-6.25 mg (Ziac)
bisoprolol & hydrochlorothiazide tab 1
5-6.25 mg (Ziac)
bisoprolol & hydrochlorothiazide tab 1
10-6.25 mg (Ziac)
2
candesartan cilexetil tab 4 mg
(Atacand)
2
candesartan cilexetil tab 8 mg
(Atacand)
2
candesartan cilexetil tab 16 mg
(Atacand)
2
candesartan cilexetil tab 32 mg
(Atacand)
2
candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg
(Atacand hct)
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
clonidine hcl tab 0.3 mg (Catapres)
1
clonidine hcl td patch weekly
0.1 mg/24hr (Catapres-tts-1)
2
clonidine hcl td patch weekly
0.2 mg/24hr (Catapres-tts-2)
2
clonidine hcl td patch weekly
0.3 mg/24hr (Catapres-tts-3)
2
CLORPRES - clonidine & chlorthalidone
tab 0.1-15 mg
4
CLORPRES - clonidine & chlorthalidone
tab 0.2-15 mg
4
CLORPRES - clonidine & chlorthalidone
tab 0.3-15 mg
4
CORZIDE - nadolol &
bendroflumethiazide tab 40-5 mg
4
CORZIDE - nadolol &
bendroflumethiazide tab 80-5 mg
4
COZAAR - losartan potassium tab 25
mg
4
COZAAR - losartan potassium tab 50
mg
4
COZAAR - losartan potassium tab 100
mg
4
DEMSER - metyrosine cap 250 mg
4
candesartan cilexetilhydrochlorothiazide tab 32-25 mg
(Atacand hct)
2
captopril tab 12.5 mg
1
captopril tab 25 mg
1
captopril tab 50 mg
2
captopril tab 100 mg
2
CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab
25-15 mg
4
CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab
25-25 mg
4
CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab
50-15 mg
4
CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab
50-25 mg
4
CARDURA - doxazosin mesylate tab 1
mg
4
CARDURA - doxazosin mesylate tab 2
mg
4
CARDURA - doxazosin mesylate tab 4
mg
4
DIBENZYLINE - phenoxybenzamine hcl
cap 10 mg
3
CARDURA - doxazosin mesylate tab 8
mg
4
DIOVAN - valsartan tab 40 mg
4
DIOVAN - valsartan tab 80 mg
4
CATAPRES - clonidine hcl tab 0.1 mg
4
DIOVAN - valsartan tab 160 mg
4
CATAPRES - clonidine hcl tab 0.2 mg
4
DIOVAN - valsartan tab 320 mg
4
CATAPRES - clonidine hcl tab 0.3 mg
4
4
CATAPRES-TTS-1 - clonidine hcl td
patch weekly 0.1 mg/24hr
4
DIOVAN HCT - valsartanhydrochlorothiazide tab 80-12.5 mg
4
CATAPRES-TTS-2 - clonidine hcl td
patch weekly 0.2 mg/24hr
4
DIOVAN HCT - valsartanhydrochlorothiazide tab 160-12.5 mg
4
CATAPRES-TTS-3 - clonidine hcl td
patch weekly 0.3 mg/24hr
4
DIOVAN HCT - valsartanhydrochlorothiazide tab 160-25 mg
4
clonidine hcl tab 0.1 mg (Catapres)
1
DIOVAN HCT - valsartanhydrochlorothiazide tab 320-12.5 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
1
2
Step Therapy
clonidine hcl tab 0.2 mg (Catapres)
candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg
(Atacand hct)
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
47
DIOVAN HCT - valsartanhydrochlorothiazide tab 320-25 mg
4
eplerenone tab 50 mg (Inspra)
2
doxazosin mesylate tab 1 mg
(Cardura)
EPROSARTAN MESYLATE eprosartan mesylate tab 600 mg
2
1
doxazosin mesylate tab 2 mg
(Cardura)
EXFORGE - amlodipine besylatevalsartan tab 5-160 mg
4
1
1
EXFORGE - amlodipine besylatevalsartan tab 5-320 mg
4
doxazosin mesylate tab 4 mg
(Cardura)
1
EXFORGE - amlodipine besylatevalsartan tab 10-160 mg
4
doxazosin mesylate tab 8 mg
(Cardura)
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
25-12.5 mg
EXFORGE - amlodipine besylatevalsartan tab 10-320 mg
4
4
4
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
50-12.5 mg
4
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5
mg
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg
4
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
100-12.5 mg
4
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5
mg
4
EDARBI - azilsartan medoxomil tab 40
mg
4
4
EDARBI - azilsartan medoxomil tab 80
mg
4
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-25
mg
EDARBYCLOR - azilsartan medoxomilchlorthalidone tab 40-12.5 mg
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-320-25
mg
4
4
EDARBYCLOR - azilsartan medoxomilchlorthalidone tab 40-25 mg
4
fosinopril sodium &
hydrochlorothiazide tab 10-12.5 mg
2
enalapril maleate &
hydrochlorothiazide tab 5-12.5 mg
1
fosinopril sodium &
hydrochlorothiazide tab 20-12.5 mg
2
enalapril maleate &
hydrochlorothiazide tab 10-25 mg
(Vaseretic)
1
fosinopril sodium tab 10 mg
1
fosinopril sodium tab 20 mg
1
1
fosinopril sodium tab 40 mg
1
enalapril maleate tab 2.5 mg
(Vasotec)
guanfacine hcl tab 1 mg (Tenex)
1
enalapril maleate tab 5 mg (Vasotec)
1
guanfacine hcl tab 2 mg (Tenex)
1
enalapril maleate tab 10 mg (Vasotec) 1
enalapril maleate tab 20 mg (Vasotec) 1
hydralazine hcl tab 10 mg
1
hydralazine hcl tab 25 mg
1
EPANED - enalapril maleate for oral
soln 1 mg/ml
4
hydralazine hcl tab 50 mg
1
hydralazine hcl tab 100 mg
2
eplerenone tab 25 mg (Inspra)
2
48
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
HYZAAR - losartan potassium &
hydrochlorothiazide tab 50-12.5 mg
4
HYZAAR - losartan potassium &
hydrochlorothiazide tab 100-12.5 mg
1
4
losartan potassium &
hydrochlorothiazide tab 100-25 mg
(Hyzaar)
1
HYZAAR - losartan potassium &
hydrochlorothiazide tab 100-25 mg
4
losartan potassium tab 25 mg
(Cozaar)
1
INSPRA - eplerenone tab 25 mg
4
losartan potassium tab 50 mg
(Cozaar)
INSPRA - eplerenone tab 50 mg
4
1
irbesartan tab 75 mg (Avapro)
1
losartan potassium tab 100 mg
(Cozaar)
1
LOTENSIN - benazepril hcl tab 10 mg
4
irbesartan tab 150 mg (Avapro)
1
LOTENSIN - benazepril hcl tab 20 mg
4
irbesartan tab 300 mg (Avapro)
1
LOTENSIN - benazepril hcl tab 40 mg
4
irbesartan-hydrochlorothiazide tab
150-12.5 mg (Avalide)
4
irbesartan-hydrochlorothiazide tab
300-12.5 mg (Avalide)
1
LOTENSIN HCT - benazepril &
hydrochlorothiazide tab 10-12.5 mg
4
lisinopril & hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
1
LOTENSIN HCT - benazepril &
hydrochlorothiazide tab 20-12.5 mg
4
lisinopril & hydrochlorothiazide tab
20-12.5 mg (Zestoretic)
1
LOTENSIN HCT - benazepril &
hydrochlorothiazide tab 20-25 mg
4
lisinopril & hydrochlorothiazide tab
20-25 mg (Zestoretic)
1
LOTREL - amlodipine besylatebenazepril hcl cap 2.5-10 mg
4
lisinopril tab 2.5 mg (Zestril)
1
LOTREL - amlodipine besylatebenazepril hcl cap 5-10 mg
1
LOTREL - amlodipine besylatebenazepril hcl cap 5-20 mg
4
lisinopril tab 5 mg (Prinivil)
lisinopril tab 10 mg (Prinivil)
1
1
LOTREL - amlodipine besylatebenazepril hcl cap 10-20 mg
4
lisinopril tab 20 mg (Prinivil)
lisinopril tab 30 mg (Zestril)
1
4
lisinopril tab 40 mg (Zestril)
1
LOTREL - amlodipine besylatebenazepril hcl cap 10-40 mg
LOPRESSOR HCT - metoprolol &
hydrochlorothiazide tab 50-25 mg
4
MAVIK - trandolapril tab 1 mg
4
MAVIK - trandolapril tab 2 mg
4
LOPRESSOR HCT - metoprolol &
hydrochlorothiazide tab 100-25 mg
4
MAVIK - trandolapril tab 4 mg
4
methyldopa tab 250 mg
1
losartan potassium &
hydrochlorothiazide tab 50-12.5 mg
(Hyzaar)
1
methyldopa tab 500 mg
1
4
losartan potassium &
hydrochlorothiazide tab
100-12.5 mg (Hyzaar)
1
METHYLDOPA/HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab
250-15 mg
METHYLDOPA/HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab
250-25 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
49
prazosin hcl cap 5 mg (Minipress)
2
PRESTALIA - perindopril arginineamlodipine besylate tab 3.5-2.5 mg
4
PRESTALIA - perindopril arginineamlodipine besylate tab 7-5 mg
4
metoprolol & hydrochlorothiazide
tab 100-25 mg (Lopressor hct)
2
metoprolol & hydrochlorothiazide
tab 100-50 mg
2
MICARDIS - telmisartan tab 20 mg
4
4
PRESTALIA - perindopril arginineamlodipine besylate tab 14-10 mg
4
MICARDIS - telmisartan tab 40 mg
MICARDIS - telmisartan tab 80 mg
4
PRINIVIL - lisinopril tab 5 mg
4
MICARDIS HCT - telmisartanhydrochlorothiazide tab 40-12.5 mg
4
PRINIVIL - lisinopril tab 10 mg
4
PRINIVIL - lisinopril tab 20 mg
4
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-12.5 mg
4
PRINZIDE - lisinopril &
hydrochlorothiazide tab 10-12.5 mg
4
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-25 mg
4
4
MINIPRESS - prazosin hcl cap 1 mg
4
PROPRANOLOL/HYDROCHLOROTH propranolol & hydrochlorothiazide tab
40-25 mg
MINIPRESS - prazosin hcl cap 2 mg
4
4
MINIPRESS - prazosin hcl cap 5 mg
4
minoxidil tab 2.5 mg
1
PROPRANOLOL/HYDROCHLOROTH propranolol & hydrochlorothiazide tab
80-25 mg
1
quinapril hcl tab 5 mg (Accupril)
1
minoxidil tab 10 mg
2
quinapril hcl tab 10 mg (Accupril)
1
moexipril hcl tab 7.5 mg (Univasc)
2
quinapril hcl tab 20 mg (Accupril)
1
moexipril hcl tab 15 mg (Univasc)
2
quinapril hcl tab 40 mg (Accupril)
1
moexipril-hydrochlorothiazide tab
7.5-12.5 mg
2
moexipril-hydrochlorothiazide tab
15-12.5 mg (Uniretic)
2
quinapril-hydrochlorothiazide tab
10-12.5 mg (Accuretic)
2
moexipril-hydrochlorothiazide tab
15-25 mg
2
quinapril-hydrochlorothiazide tab
20-12.5 mg (Accuretic)
2
nadolol & bendroflumethiazide tab
40-5 mg (Corzide)
2
quinapril-hydrochlorothiazide tab
20-25 mg (Accuretic)
ramipril cap 1.25 mg (Altace)
1
nadolol & bendroflumethiazide tab
80-5 mg (Corzide)
2
ramipril cap 2.5 mg (Altace)
1
ramipril cap 5 mg (Altace)
1
perindopril erbumine tab 2 mg
2
ramipril cap 10 mg (Altace)
1
perindopril erbumine tab 4 mg
(Aceon)
2
RESERPINE - reserpine tab 0.1 mg
4
RESERPINE - reserpine tab 0.25 mg
4
perindopril erbumine tab 8 mg
(Aceon)
2
TARKA - trandolapril-verapamil hcl tab
cr 1-240 mg
4
prazosin hcl cap 1 mg (Minipress)
1
50
Dispensing Limits
1
2
Step Therapy
prazosin hcl cap 2 mg (Minipress)
metoprolol & hydrochlorothiazide
tab 50-25 mg (Lopressor hct)
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
TARKA - trandolapril-verapamil hcl tab
cr 2-180 mg
4
TENORETIC 50 - atenolol &
chlorthalidone tab 50-25 mg
4
TARKA - trandolapril-verapamil hcl tab
cr 2-240 mg
4
terazosin hcl cap 1 mg
1
terazosin hcl cap 2 mg
1
TARKA - trandolapril-verapamil hcl tab
cr 4-240 mg
4
terazosin hcl cap 5 mg
1
4
terazosin hcl cap 10 mg
1
TEKTURNA - aliskiren fumarate tab 150
mg (base equivalent)
4
TEKTURNA - aliskiren fumarate tab 300
mg (base equivalent)
4
TEVETEN - eprosartan mesylate tab
600 mg
4
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-12.5 mg
4
TEVETEN HCT - eprosartan mesylatehydrochlorothiazide tab 600-25 mg
trandolapril tab 1 mg (Mavik)
1
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-25 mg
4
trandolapril tab 2 mg (Mavik)
1
trandolapril tab 4 mg (Mavik)
1
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-12.5 mg
4
trandolapril-verapamil hcl tab cr
1-240 mg (Tarka)
2
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-25 mg
4
trandolapril-verapamil hcl tab cr
2-180 mg (Tarka)
2
telmisartan tab 20 mg (Micardis)
2
2
telmisartan tab 40 mg (Micardis)
2
trandolapril-verapamil hcl tab cr
2-240 mg (Tarka)
telmisartan tab 80 mg (Micardis)
2
2
telmisartan-amlodipine tab 40-5 mg
(Twynsta)
2
trandolapril-verapamil hcl tab cr
4-240 mg (Tarka)
4
telmisartan-amlodipine tab 40-10 mg
(Twynsta)
2
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 20-5-12.5 mg
4
telmisartan-amlodipine tab 80-5 mg
(Twynsta)
2
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-5-12.5 mg
4
telmisartan-amlodipine tab 80-10 mg
(Twynsta)
2
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-5-25 mg
4
telmisartan-hydrochlorothiazide tab
40-12.5 mg (Micardis hct)
2
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-10-12.5
mg
2
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-10-25 mg
4
telmisartan-hydrochlorothiazide tab
80-12.5 mg (Micardis hct)
2
TWYNSTA - telmisartan-amlodipine tab
40-5 mg
4
telmisartan-hydrochlorothiazide tab
80-25 mg (Micardis hct)
4
TWYNSTA - telmisartan-amlodipine tab
40-10 mg
4
TENEX - guanfacine hcl tab 1 mg
TENEX - guanfacine hcl tab 2 mg
4
TENORETIC 100 - atenolol &
chlorthalidone tab 100-25 mg
TWYNSTA - telmisartan-amlodipine tab
80-5 mg
4
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
51
TWYNSTA - telmisartan-amlodipine tab
80-10 mg
4
ZIAC - bisoprolol & hydrochlorothiazide
tab 2.5-6.25 mg
4
valsartan tab 40 mg (Diovan)
2
4
valsartan tab 80 mg (Diovan)
2
ZIAC - bisoprolol & hydrochlorothiazide
tab 5-6.25 mg
valsartan tab 160 mg (Diovan)
2
4
valsartan tab 320 mg (Diovan)
2
ZIAC - bisoprolol & hydrochlorothiazide
tab 10-6.25 mg
valsartan-hydrochlorothiazide tab
80-12.5 mg (Diovan hct)
2
valsartan-hydrochlorothiazide tab
160-12.5 mg (Diovan hct)
2
valsartan-hydrochlorothiazide tab
160-25 mg (Diovan hct)
2
valsartan-hydrochlorothiazide tab
320-12.5 mg (Diovan hct)
Dispensing Limits
Step Therapy
DIURETICS
ACETAZOLAMIDE - acetazolamide tab
125 mg
4
acetazolamide cap sr 12hr 500 mg
(Diamox)
2
acetazolamide tab 250 mg
2
2
ALDACTAZIDE - spironolactone &
hydrochlorothiazide tab 25-25 mg
4
valsartan-hydrochlorothiazide tab
320-25 mg (Diovan hct)
2
ALDACTAZIDE - spironolactone &
hydrochlorothiazide tab 50-50 mg
4
VASERETIC - enalapril maleate &
hydrochlorothiazide tab 10-25 mg
4
ALDACTONE - spironolactone tab 25
mg
4
VASOTEC - enalapril maleate tab 2.5
mg
4
ALDACTONE - spironolactone tab 50
mg
4
VASOTEC - enalapril maleate tab 5 mg
4
4
VASOTEC - enalapril maleate tab 10
mg
4
ALDACTONE - spironolactone tab 100
mg
1
VASOTEC - enalapril maleate tab 20
mg
4
amiloride & hydrochlorothiazide tab
5-50 mg
amiloride hcl tab 5 mg
2
VECAMYL - mecamylamine hcl tab 2.5
mg
4
bumetanide tab 0.5 mg
1
bumetanide tab 1 mg
1
ZESTORETIC - lisinopril &
hydrochlorothiazide tab 10-12.5 mg
4
bumetanide tab 2 mg
1
ZESTORETIC - lisinopril &
hydrochlorothiazide tab 20-12.5 mg
CHLOROTHIAZIDE - chlorothiazide tab
250 mg
4
4
chlorothiazide tab 500 mg
1
ZESTORETIC - lisinopril &
hydrochlorothiazide tab 20-25 mg
4
CHLORTHALIDONE - chlorthalidone
tab 25 mg
4
ZESTRIL - lisinopril tab 2.5 mg
4
4
CHLORTHALIDONE - chlorthalidone
tab 50 mg
4
ZESTRIL - lisinopril tab 5 mg
ZESTRIL - lisinopril tab 10 mg
4
4
ZESTRIL - lisinopril tab 20 mg
4
CHLORTHALIDONE - chlorthalidone
tab 100 mg
ZESTRIL - lisinopril tab 30 mg
4
DEMADEX - torsemide tab 5 mg
4
ZESTRIL - lisinopril tab 40 mg
4
DEMADEX - torsemide tab 10 mg
4
52
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2
DIAMOX - acetazolamide cap sr 12hr
500 mg
4
metolazone tab 10 mg
2
DIURIL - chlorothiazide susp 250
mg/5ml
MICROZIDE - hydrochlorothiazide cap
12.5 mg
4
4
4
DYAZIDE - triamterene &
hydrochlorothiazide cap 37.5-25 mg
4
NEPTAZANE - methazolamide tab 25
mg
4
NEPTAZANE - methazolamide tab 50
mg
4
DYRENIUM - triamterene cap 50 mg
DYRENIUM - triamterene cap 100 mg
4
2
EDECRIN - ethacrynic acid tab 25 mg
4
FUROSEMIDE - furosemide oral soln 8
mg/ml
4
spironolactone &
hydrochlorothiazide tab 25-25 mg
(Aldactazide)
spironolactone tab 25 mg (Aldactone)
1
furosemide oral soln 10 mg/ml
1
spironolactone tab 50 mg (Aldactone)
1
furosemide tab 20 mg (Lasix)
1
2
furosemide tab 40 mg (Lasix)
1
spironolactone tab 100 mg
(Aldactone)
1
torsemide tab 5 mg (Demadex)
1
furosemide tab 80 mg (Lasix)
1
torsemide tab 10 mg (Demadex)
1
hydrochlorothiazide cap 12.5 mg
(Microzide)
torsemide tab 20 mg (Demadex)
1
hydrochlorothiazide tab 12.5 mg
1
torsemide tab 100 mg (Demadex)
2
hydrochlorothiazide tab 25 mg
1
1
hydrochlorothiazide tab 50 mg
1
triamterene & hydrochlorothiazide
cap 37.5-25 mg (Dyazide)
1
triamterene & hydrochlorothiazide
tab 37.5-25 mg (Maxzide-25)
1
indapamide tab 1.25 mg
indapamide tab 2.5 mg
1
4
triamterene & hydrochlorothiazide
tab 75-50 mg (Maxzide)
1
INTROL - glycerin soln 75%
LASIX - furosemide tab 20 mg
4
4
LASIX - furosemide tab 40 mg
4
LASIX - furosemide tab 80 mg
4
TRIAMTERENE/HYDROCHLOROTH triamterene & hydrochlorothiazide
cap 50-25 mg
MAXZIDE - triamterene &
hydrochlorothiazide tab 75-50 mg
4
MAXZIDE-25 - triamterene &
hydrochlorothiazide tab 37.5-25 mg
4
methazolamide tab 25 mg
(Neptazane)
2
methazolamide tab 50 mg
(Neptazane)
2
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
4
metolazone tab 2.5 mg (Zaroxolyn)
2
Dispensing Limits
metolazone tab 5 mg (Zaroxolyn)
Step Therapy
4
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
DEMADEX - torsemide tab 20 mg
Prior Authorization
Drug Name
Drug Tier
2015
VASOPRESSORS
ADRENACLICK - epinephrine solution
auto-injector 0.15 mg/0.15ml (1:1000)
4
ADRENACLICK - epinephrine solution
auto-injector 0.3 mg/0.3ml (1:1000)
4
AUVI-Q - epinephrine solution autoinjector 0.15 mg/0.15ml (1:1000)
4
AUVI-Q - epinephrine solution autoinjector 0.3 mg/0.3ml (1:1000)
4
EPINEPHRINE - epinephrine solution
auto-injector 0.15 mg/0.15ml (1:1000)
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
53
EPINEPHRINE - epinephrine solution
auto-injector 0.3 mg/0.3ml (1:1000)
4
atorvastatin calcium tab 80 mg (base
equivalent) (Lipitor)
1
EPIPEN 2-PAK - epinephrine solution
auto-injector 0.3 mg/0.3ml (1:1000)
3
cholestyramine light powder packets
4 gm
2
EPIPEN-JR 2-PAK - epinephrine
solution auto-injector 0.15 mg/0.3ml
(1:2000)
3
cholestyramine light powder 4 gm/
dose (Questran light)
2
2
cholestyramine powder packets
4 gm (Questran)
2
midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
2
2
midodrine hcl tab 10 mg
2
cholestyramine powder 4 gm/dose
(Questran)
NORTHERA - droxidopa cap 100 mg
4
2
NORTHERA - droxidopa cap 200 mg
4
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
4
choline fenofibrate cap dr 135 mg
(fenofibric acid equiv) (Trilipix)
2
NORTHERA - droxidopa cap 300 mg
COLESTID - colestipol hcl tab 1 gm
4
COLESTID - colestipol hcl granules 5
gm
4
COLESTID - colestipol hcl granule
packets 5 gm
4
COLESTID FLAVORED - colestipol hcl
granules 5 gm
4
COLESTID FLAVORED - colestipol hcl
granule packets 5 gm
4
colestipol hcl granule packets 5 gm
(Colestid flavored)
2
ANTIHYPERLIPIDEMICS
ADVICOR - niacin-lovastatin tab sr 24hr
500-20 mg
4
•
ADVICOR - niacin-lovastatin tab sr 24hr
750-20 mg
4
•
ADVICOR - niacin-lovastatin tab sr 24hr
1000-20 mg
4
•
ADVICOR - niacin-lovastatin tab sr 24hr
1000-40 mg
4
•
ALTOPREV - lovastatin tab sr 24hr 20
mg
4
•
ALTOPREV - lovastatin tab sr 24hr 40
mg
4
•
ALTOPREV - lovastatin tab sr 24hr 60
mg
4
•
ANTARA - fenofibrate micronized cap
30 mg
4
ANTARA - fenofibrate micronized cap
90 mg
4
atorvastatin calcium tab 10 mg (base
equivalent) (Lipitor)
1
atorvastatin calcium tab 20 mg (base
equivalent) (Lipitor)
1
atorvastatin calcium tab 40 mg (base
equivalent) (Lipitor)
1
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
colestipol hcl granules 5 gm (Colestid 2
flavored)
2
colestipol hcl tab 1 gm (Colestid)
CRESTOR - rosuvastatin calcium tab 5
mg
3
CRESTOR - rosuvastatin calcium tab 10 3
mg
CRESTOR - rosuvastatin calcium tab 20 3
mg
CRESTOR - rosuvastatin calcium tab 40 3
mg
FENOFIBRATE - fenofibrate cap 50 mg 4
FENOFIBRATE - fenofibrate cap 150
mg
4
FENOFIBRATE - fenofibrate tab 120 mg 4
54
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2
LESCOL - fluvastatin sodium cap 20 mg
4
fenofibrate micronized cap 67 mg
(Lofibra)
2
LESCOL - fluvastatin sodium cap 40 mg
4
4
fenofibrate micronized cap 130 mg
2
LESCOL XL - fluvastatin sodium tab sr
24 hr 80 mg
•
•
•
fenofibrate micronized cap 134 mg
(Lofibra)
2
LIPITOR - atorvastatin calcium tab 10
mg (base equivalent)
4
•
fenofibrate micronized cap 200 mg
(Lofibra)
2
LIPITOR - atorvastatin calcium tab 20
mg (base equivalent)
4
•
fenofibrate tab 48 mg (Tricor)
2
4
•
fenofibrate tab 54 mg (Lofibra)
1
LIPITOR - atorvastatin calcium tab 40
mg (base equivalent)
fenofibrate tab 145 mg (Tricor)
2
4
•
fenofibrate tab 160 mg (Lofibra)
2
LIPITOR - atorvastatin calcium tab 80
mg (base equivalent)
4
LIPOFEN - fenofibrate cap 50 mg
4
FENOFIBRIC ACID - fenofibric acid tab
35 mg
LIPOFEN - fenofibrate cap 150 mg
4
FENOFIBRIC ACID - fenofibric acid tab
105 mg
4
LIPTRUZET - ezetimibe-atorvastatin tab
10-10 mg
4
•
FENOGLIDE - fenofibrate tab 40 mg
4
4
•
FENOGLIDE - fenofibrate tab 120 mg
4
LIPTRUZET - ezetimibe-atorvastatin tab
10-20 mg
4
LIPTRUZET - ezetimibe-atorvastatin tab
10-40 mg
4
FIBRICOR - fenofibric acid tab 35 mg
•
FIBRICOR - fenofibric acid tab 105 mg
4
•
fluvastatin sodium cap 20 mg
(Lescol)
LIPTRUZET - ezetimibe-atorvastatin tab
10-80 mg
4
2
4
•
fluvastatin sodium cap 40 mg
(Lescol)
2
LIVALO - pitavastatin calcium tab 1 mg
(base equiv)
•
1
LIVALO - pitavastatin calcium tab 2 mg
(base equiv)
4
gemfibrozil tab 600 mg (Lopid)
JUXTAPID - lomitapide mesylate cap 5
mg (base equiv)
5
•
•
LIVALO - pitavastatin calcium tab 4 mg
(base equiv)
4
•
JUXTAPID - lomitapide mesylate cap 10 5
mg (base equiv)
JUXTAPID - lomitapide mesylate cap 20 5
mg (base equiv)
JUXTAPID - lomitapide mesylate cap 30 5
mg (base equiv)
JUXTAPID - lomitapide mesylate cap 40 5
mg (base equiv)
JUXTAPID - lomitapide mesylate cap 60 5
mg (base equiv)
5
KYNAMRO - mipomersen sodium soln
prefilled syringe 200 mg/ml
•
•
LOFIBRA - fenofibrate tab 54 mg
4
LOFIBRA - fenofibrate tab 160 mg
4
LOFIBRA - fenofibrate micronized cap
67 mg
4
LOFIBRA - fenofibrate micronized cap
134 mg
4
LOFIBRA - fenofibrate micronized cap
200 mg
4
LOPID - gemfibrozil tab 600 mg
4
lovastatin tab 10 mg
1
lovastatin tab 20 mg (Mevacor)
1
•
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
fenofibrate micronized cap 43 mg
Prior Authorization
Drug Name
Drug Tier
2015
55
4
4
QUESTRAN - cholestyramine powder 4
gm/dose
4
MEVACOR - lovastatin tab 40 mg
4
QUESTRAN - cholestyramine powder
packets 4 gm
niacin tab cr 500 mg
(antihyperlipidemic) (Niaspan)
2
QUESTRAN LIGHT - cholestyramine
light powder 4 gm/dose
4
niacin tab cr 750 mg
(antihyperlipidemic) (Niaspan)
2
niacin tab cr 1000 mg
(antihyperlipidemic) (Niaspan)
2
NIASPAN - niacin tab cr 500 mg
(antihyperlipidemic)
4
NIASPAN - niacin tab cr 750 mg
(antihyperlipidemic)
4
NIASPAN - niacin tab cr 1000 mg
(antihyperlipidemic)
4
omega-3-acid ethyl esters cap 1 gm
(Lovaza)
2
SIMCOR - niacin-simvastatin tab sr 24hr 4
500-20 mg
SIMCOR - niacin-simvastatin tab sr 24hr 4
500-40 mg
SIMCOR - niacin-simvastatin tab sr 24hr 4
750-20 mg
SIMCOR - niacin-simvastatin tab sr 24hr 4
1000-20 mg
SIMCOR - niacin-simvastatin tab sr 24hr 4
1000-40 mg
1
simvastatin tab 5 mg (Zocor)
PRALUENT - alirocumab subcutaneous
soln pen-injector 75 mg/ml
5
•
•
PRALUENT - alirocumab subcutaneous
soln pen-injector 150 mg/ml
5
•
•
PRALUENT - alirocumab subcutaneous
soln prefilled syringe 75 mg/ml
5
•
PRALUENT - alirocumab subcutaneous
soln prefilled syringe 150 mg/ml
5
•
PRAVACHOL - pravastatin sodium tab
20 mg
4
PRAVACHOL - pravastatin sodium tab
40 mg
4
PRAVACHOL - pravastatin sodium tab
80 mg
4
pravastatin sodium tab 10 mg
1
pravastatin sodium tab 20 mg
(Pravachol)
•
•
•
•
•
•
simvastatin tab 10 mg (Zocor)
1
simvastatin tab 20 mg (Zocor)
1
simvastatin tab 40 mg (Zocor)
1
simvastatin tab 80 mg (Zocor)
1
•
TRICOR - fenofibrate tab 48 mg
4
TRICOR - fenofibrate tab 145 mg
4
•
TRIGLIDE - fenofibrate tab 160 mg
4
4
•
TRILIPIX - choline fenofibrate cap dr 45
mg (fenofibric acid equiv)
4
•
TRILIPIX - choline fenofibrate cap dr
135 mg (fenofibric acid equiv)
VASCEPA - icosapent ethyl cap 1 gm
4
VYTORIN - ezetimibe-simvastatin tab
10-10 mg
4
•
4
•
1
VYTORIN - ezetimibe-simvastatin tab
10-20 mg
4
•
pravastatin sodium tab 40 mg
(Pravachol)
1
VYTORIN - ezetimibe-simvastatin tab
10-40 mg
4
•
pravastatin sodium tab 80 mg
(Pravachol)
1
VYTORIN - ezetimibe-simvastatin tab
10-80 mg
WELCHOL - colesevelam hcl tab 625
mg
4
56
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
LOVAZA - omega-3-acid ethyl esters
cap 1 gm
Dispensing Limits
1
Step Therapy
lovastatin tab 40 mg (Mevacor)
Prior Authorization
Drug Name
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
WELCHOL - colesevelam hcl packet for
susp 3.75 gm
4
ZETIA - ezetimibe tab 10 mg
4
ZOCOR - simvastatin tab 5 mg
4
ZOCOR - simvastatin tab 10 mg
4
ZOCOR - simvastatin tab 20 mg
4
ZOCOR - simvastatin tab 40 mg
4
ZOCOR - simvastatin tab 80 mg
4
•
•
•
•
•
•
CARDIOVASCULAR AGENTS - MISC.
•
•
•
•
•
•
•
•
•
•
•
•
BIDIL - isosorbide dinitrate-hydralazine
hcl tab 20-37.5 mg
4
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-10 mg
4
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-20 mg
4
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-40 mg
4
CADUET - amlodipine besylateatorvastatin calcium tab 5-10 mg
4
CADUET - amlodipine besylateatorvastatin calcium tab 5-20 mg
4
CADUET - amlodipine besylateatorvastatin calcium tab 5-40 mg
4
CADUET - amlodipine besylateatorvastatin calcium tab 5-80 mg
4
ADCIRCA - tadalafil tab 20 mg (pah)
5
ADEMPAS - riociguat tab 0.5 mg
5
ADEMPAS - riociguat tab 1 mg
5
ADEMPAS - riociguat tab 1.5 mg
5
ADEMPAS - riociguat tab 2 mg
5
ADEMPAS - riociguat tab 2.5 mg
5
amlodipine besylate-atorvastatin
calcium tab 2.5-10 mg (Caduet)
CADUET - amlodipine besylateatorvastatin calcium tab 10-10 mg
4
2
amlodipine besylate-atorvastatin
calcium tab 2.5-20 mg (Caduet)
CADUET - amlodipine besylateatorvastatin calcium tab 10-20 mg
4
2
amlodipine besylate-atorvastatin
calcium tab 2.5-40 mg (Caduet)
CADUET - amlodipine besylateatorvastatin calcium tab 10-40 mg
4
2
4
amlodipine besylate-atorvastatin
calcium tab 5-10 mg (Caduet)
2
CADUET - amlodipine besylateatorvastatin calcium tab 10-80 mg
CIALIS - tadalafil tab 2.5 mg
3
amlodipine besylate-atorvastatin
calcium tab 5-20 mg (Caduet)
2
CIALIS - tadalafil tab 5 mg
3
2
CORLANOR - ivabradine hcl tab 5 mg
(base equiv)
4
amlodipine besylate-atorvastatin
calcium tab 5-40 mg (Caduet)
2
CORLANOR - ivabradine hcl tab 7.5 mg
(base equiv)
4
amlodipine besylate-atorvastatin
calcium tab 5-80 mg (Caduet)
amlodipine besylate-atorvastatin
calcium tab 10-10 mg (Caduet)
2
ENTRESTO - sacubitril-valsartan tab
24-26 mg
amlodipine besylate-atorvastatin
calcium tab 10-20 mg (Caduet)
2
amlodipine besylate-atorvastatin
calcium tab 10-40 mg (Caduet)
amlodipine besylate-atorvastatin
calcium tab 10-80 mg (Caduet)
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
4
•
•
ENTRESTO - sacubitril-valsartan tab
49-51 mg
4
•
•
2
ENTRESTO - sacubitril-valsartan tab
97-103 mg
4
•
•
2
ISOXSUPRINE HCL - isoxsuprine hcl
tab 20 mg
4
isoxsuprine hcl tab 10 mg
2
LETAIRIS - ambrisentan tab 5 mg
5
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
57
5
ORENITRAM - treprostinil diolamine tab
cr 0.125 mg (base equiv)
5
ORENITRAM - treprostinil diolamine tab
cr 0.25 mg (base equiv)
5
ORENITRAM - treprostinil diolamine tab
cr 1 mg (base equiv)
5
ORENITRAM - treprostinil diolamine tab
cr 2.5 mg (base equiv)
5
•
•
REVATIO - sildenafil citrate tab 20 mg
5
REVATIO - sildenafil citrate for
suspension 10 mg/ml
5
•
•
•
•
sildenafil citrate tab 20 mg (Revatio)
5
TRACLEER - bosentan tab 62.5 mg
5
TRACLEER - bosentan tab 125 mg
5
TYVASO - treprostinil inhalation solution 5
0.6 mg/ml
TYVASO REFILL - treprostinil inhalation 5
solution 0.6 mg/ml
5
TYVASO STARTER - treprostinil
inhalation solution 0.6 mg/ml
VENTAVIS - iloprost inhalation solution 5
10 mcg/ml
VENTAVIS - iloprost inhalation solution 5
20 mcg/ml
•
•
•
•
•
4
CLARINEX - desloratadine syrup 0.5
mg/ml
4
4
•
CLARINEX REDITABS - desloratadine
tab orally disintegrating 2.5 mg
4
•
CLARINEX REDITABS - desloratadine
tab orally disintegrating 5 mg
•
•
•
3
•
•
CIALIS - tadalafil tab 5 mg
3
RESPIRATORY AGENTS
ANTIHISTAMINES
•
•
CLEMASTINE FUMARATE - clemastine 4
fumarate syrup 0.67 mg/5ml (0.5
mg/5ml base eq)
1
clemastine fumarate tab 2.68 mg
cyproheptadine hcl syrup 2 mg/5ml
2
cyproheptadine hcl tab 4 mg
1
desloratadine tab orally
disintegrating 2.5 mg (Clarinex
reditabs)
2
desloratadine tab orally
disintegrating 5 mg (Clarinex
reditabs)
2
desloratadine tab 5 mg (Clarinex)
2
KARBINAL ER - carbinoxamine maleate 4
er susp 4 mg/5ml
2
levocetirizine dihydrochloride soln
2.5 mg/5ml (0.5 mg/ml) (Xyzal)
2
levocetirizine dihydrochloride tab
5 mg (Xyzal)
2
promethazine hcl suppos 12.5 mg
•
ERECTLIE DYSFUNCTION
CIALIS - tadalafil tab 2.5 mg
•
•
promethazine hcl suppos 25 mg
2
promethazine hcl suppos 50 mg
2
promethazine hcl syrup 6.25 mg/5ml
1
promethazine hcl tab 12.5 mg
1
promethazine hcl tab 25 mg
1
promethazine hcl tab 50 mg
1
RESPA-BR - brompheniramine maleate
tab sr 12hr 11 mg
4
4
4
brompheniramine maleate tab sr
12hr 6 mg
1
BROMPHENIRAMINE TANNATE brompheniramine tannate chew tab
12 mg
4
carbinoxamine maleate soln
4 mg/5ml
1
XYZAL - levocetirizine dihydrochloride
tab 5 mg
carbinoxamine maleate tab 4 mg
2
XYZAL - levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
58
Dispensing Limits
OPSUMIT - macitentan tab 10 mg
•
CLARINEX - desloratadine tab 5 mg
•
•
•
Step Therapy
5
Prior Authorization
LETAIRIS - ambrisentan tab 10 mg
•
•
•
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
Prior Authorization
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
NASAL AGENTS - SYSTEMIC and TOPICAL
4
ADRENALIN - epinephrine hcl nasal
soln 0.1%
4
ASTEPRO - azelastine hcl nasal spray
0.15% (205.5 mcg/spray)
ATROVENT - ipratropium bromide nasal 4
soln 0.03% (21 mcg/spray)
ATROVENT - ipratropium bromide nasal 4
soln 0.06% (42 mcg/spray)
2
azelastine hcl nasal spray 0.1%
(137 mcg/spray)
2
azelastine hcl nasal spray 0.15%
(205.5 mcg/spray) (Astepro)
4
BACTROBAN NASAL - mupirocin
calcium nasal oint 2%
4
BECONASE AQ - beclomethasone
dipropionate monohyd nasal susp 42
mcg/spray
2
budesonide nasal susp 32 mcg/act
(Rhinocort aqua)
4
DYMISTA - azelastine hcl-fluticasone
prop nasal spray 137-50 mcg/act
4
FLONASE - fluticasone propionate
nasal susp 50 mcg/act
4
FLUNISOLIDE - flunisolide nasal soln
25 mcg/act (0.025%)
2
flunisolide nasal soln 25 mcg/act
(0.025%) (Flunisolide)
1
fluticasone propionate nasal susp
50 mcg/act (Flonase)
2
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
2
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
NASONEX - mometasone furoate nasal 4
susp 50 mcg/act
2
olopatadine hcl nasal soln 0.6%
(Patanase)
4
OMNARIS - ciclesonide nasal susp 50
mcg/act
•
•
•
•
•
•
•
•
•
•
QNASL - beclomethasone dipropionate
nasal aerosol 80 mcg/act
4
•
QNASL CHILDRENS - beclomethasone
dipropionate nasal aerosol 40 mcg/
act
4
•
RHINOCORT AQUA - budesonide nasal 4
susp 32 mcg/act
2
triamcinolone acetonide nasal
aerosol suspension 55 mcg/act
(Nasacort aq)
TYZINE - tetrahydrozoline hcl nasal soln 4
0.1%
4
TYZINE PEDIATRIC NASAL DR tetrahydrozoline hcl nasal soln 0.05%
4
VERAMYST - fluticasone furoate nasal
susp 27.5 mcg/spray
4
ZETONNA - ciclesonide nasal aerosol
soln 37 mcg/act (50 mcg/valve)
•
acetylcysteine inhal soln 20%
2
1
•
benzonatate cap 100 mg (Tessalon
perles)
benzonatate cap 150 mg (Zonatuss)
2
benzonatate cap 200 mg
1
brompheniramine &
pseudoephedrine tab sr 12hr
6-45 mg
1
CAPCOF - phenylephrine-chlorphen w/
codeine syrup 5-2-10 mg/5ml
4
CARBAPHEN 12 - phenylephchlorphen-carbetapentane liqd
10-4-27.5 mg/5ml
4
CARBAPHEN 12 PED - phenylephchlorphen-carbetapentane susp
2.5-1.25-7.5 mg/ml
4
•
•
•
•
•
•
COUGH/COLD/ALLERGY
•
•
Dispensing Limits
4
2
•
Step Therapy
PATANASE - olopatadine hcl nasal soln
0.6%
acetylcysteine inhal soln 10%
•
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
59
CLARINEX-D 12 HOUR - desloratadine
& pseudoephedrine tab sr 12hr
2.5-120 mg
4
hydrocodone w/ homatropine syrup
5-1.5 mg/5ml
2
CODAR AR - chlorpheniramine w/
codeine liquid 2-8 mg/5ml
hydrocodone w/ homatropine tab
5-1.5 mg
2
4
CODAR D - pseudoephedrine w/
codeine liquid 30-8 mg/5ml
HYPER-SAL - sodium chloride soln
nebu 7%
4
4
CPB WC - pseudoephedrine-bromphencodeine liq 10-1.3-6.3 mg/5ml
4
DECON-A - brompheniramine &
phenylephrine elixir 2-5 mg/5ml
4
DECON-G - phenylephrinebrompheniramine-guaifenesin liqd
2-1-40 mg/ml
4
DEX-TUSS - guaifenesin-codeine liquid
300-10 mg/5ml
4
DEXTROMETHORPHAN HBR/CHLO phenylephrine-chlorphen-dm liquid
1.75-0.75-2.75 mg/ml
4
EXACTUSS - phenylephrine w/ dm-gg
liqd 10-28-388 mg/5ml
4
GILPHEX TR - phenylephrineguaifenesin tab 10-388 mg
4
GILTUSS - phenylephrine w/ dm-gg liqd
10-28-388 mg/5ml
4
GILTUSS PED-C - phenylephrine w/
codeine-gg liquid 2.5-3-50 mg/ml
4
GILTUSS TR - phenylephrine w/ dm-gg
tab 10-28-388 mg
4
guaifenesin-codeine liquid
200-8 mg/5ml
2
guaifenesin-codeine liquid
225-7.5 mg/5ml
1
guaifenesin-codeine soln
100-6.3 mg/5ml
1
guaifenesin-codeine soln
100-10 mg/5ml
1
hydrocod polst-chlorphen polst
cr susp 10-8 mg/5ml (Tussionex
pennkineti)
2
60
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
HYPERSAL - sodium chloride soln nebu 4
3.5%
HYPERSAL - sodium chloride soln nebu 4
7%
1
LEXUSS 210 - chlorpheniramine w/
codeine liquid 2-10 mg/5ml
4
LORTUSS EX - pseudoephedrine w/
cod-gg liquid 30-10-100 mg/5ml
4
M-END MAX D - pseudoephedrinedexbromphen-codeine liqd
20-0.667-6 mg/5ml
4
M-END PE - phenylephrine-bromphen
w/ codeine liqd 3.33-1.33-6.33
mg/5ml
4
MAR-COF BP - pseudoephedrinebromphen-codeine liqd 30-2-7.5
mg/5ml
4
MAR-COF CG EXPECTORANT guaifenesin-codeine liquid 225-7.5
mg/5ml
4
NEBUSAL - sodium chloride soln nebu
6%
4
NEOTUSS PLUS - phenylephrinechlorphen-dm liquid 7.5-4-30 mg/5ml
NEOTUSS-D - pseudoephed-chlorphen 4
w/ dm-gg liqd 30-2-30-200 mg/5ml
4
NORTUSS-EX - dextromethorphanguaifenesin liquid 20-200 mg/5ml
4
NOTUSS-NX - codeine-chlorcyclizine
liquid 10-9.375 mg/5ml
4
NOTUSS-NXD - codeinepseudoephedrine-chlorcyclizine liq
10-30-9.375mg/5ml
4
OBREDON - hydrocodone-guaifenesin
soln 2.5-200 mg/5ml
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
PANATUSS DXP - phenylephrinedexbromphen-dm-gg liquid
5-1-15-100 mg/5ml
4
pseudoeph-chlorphen w/
hydrocodone soln 60-4-5 mg/5ml
(Zutripro)
2
PEDIATEX TDM - pseudoephedtriprolidine-dm susp 10-0.938-4 mg/
ml
4
pseudoephed-bromphen-dm syrup
30-2-10 mg/5ml
2
1
phenylephrine w/ dm-gg liqd
10-30-200 mg/5ml
2
pseudoephedrine w/ cod-gg soln
30-10-100 mg/5ml
2
pseudoephedrine w/ cod-gg syrup
30-10-100 mg/5ml (Suttar-sf)
1
phenylephrine w/ dm-gg liqd
2.5-7.5-88 mg/ml
phenylephrine-brompheniramine-dm
liquid 7.5-4-15 mg/5ml
pseudoephedrine-bromphen-codeine
liq 10-1.33-6.33 mg/5ml
1
1
phenylephrine-guaifenesin liqd
7.5-100 mg/5ml (1.5-20 mg/ml)
2
phenylephrine-promethazine w/
codeine syrup 5-6.25-10 mg/5ml
4
PHENYLHISTINE DH pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml
4
POLY-TUSSIN - codeine-chlorcyclizine
liquid 10-9.375 mg/5ml
4
POLY-TUSSIN AC - phenylephrinebromphen w/ codeine liquid 10-4-10
mg/5ml
4
POLY-TUSSIN D - codeinepseudoephedrine-chlorcyclizine liq
10-30-9.375mg/5ml
4
PRO-CLEAR AC - codeine-pyrilamine
syrup 9-8.33 mg/5ml
4
PRO-RED AC - phenylephrinedexchlorphenir-codeine syrup 5-1-9
mg/5ml
4
PROMETHAZINE VC PLAIN promethazine & phenylephrine syrup
6.25-5 mg/5ml
4
promethazine w/ codeine syrup
6.25-10 mg/5ml
1
promethazine-dm syrup
6.25-15 mg/5ml
1
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
RELHIST - bromphen tan-phenyleph tan 4
chew tab 6-15 mg
4
RESCON-MX - dexchlorpheniraminephenylephrine tab sr 12hr 6-40 mg
4
REZIRA - pseudoephedrine w/
hydrocodone soln 60-5 mg/5ml
4
RYDEX - pseudoephedrine-bromphencodeine liq 10-1.33-6.33 mg/5ml
4
SEMPREX-D - acrivastine &
pseudoephedrine cap 8-60 mg
2
sodium chloride soln nebu 0.9%
sodium chloride soln nebu 3%
2
sodium chloride soln nebu 7%
(Hyper-sal)
2
sodium chloride soln nebu 10%
2
STATUSS GREEN - codeinepseudoephedrine-chlorcyclizine liq
9-30-12.5 mg/5ml
4
SUTTAR-SF - pseudoephedrine w/ codgg syrup 30-10-100 mg/5ml
4
SUTTAR-2 - pseudoephedrine w/ codgg syrup 30-10-100 mg/5ml
4
TESSALON PERLES - benzonatate cap 4
100 mg
4
TGQ 15DM/5PEH/2CPM phenylephrine-chlorphen-dm syrup
5-2-15 mg/5ml
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
61
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
TGQ 30PSE/150GFN/15DM pseudoephedrine w/ dm-gg syrup
30-15-150 mg/5ml
4
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 100-50
mcg/dose
4
•
TGQ 30PSE/3BRM/15DM pseudoephed-bromphen-dm syrup
30-3-15 mg/5ml
4
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 250-50
mcg/dose
4
•
TGQ 50PSE/3BRM/30DM pseudoephed-bromphen-dm syrup
50-3-30 mg/5ml
4
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 500-50
mcg/dose
4
•
TRICODE AR - pseudoephedrinechlorphen w/ codeine liq 30-2-8
mg/5ml
4
ADVAIR HFA - fluticasone-salmeterol
inhal aerosol 45-21 mcg/act
4
•
•
TRICODE GF - pseudoephedrine w/
cod-gg liquid 30-8-200 mg/5ml
ADVAIR HFA - fluticasone-salmeterol
inhal aerosol 115-21 mcg/act
4
4
•
TUSNEL - brompheniramine w/ dm-gg
cap 2-15-200 mg
ADVAIR HFA - fluticasone-salmeterol
inhal aerosol 230-21 mcg/act
4
4
4
•
TUSSICAPS - hydrocod polst-chlorphen
polst cap sr 12hr 5-4 mg
4
AEROSPAN - flunisolide hfa inhal
aerosol 80 mcg/act
•
4
albuterol sulfate soln nebu 0.083%
(2.5 mg/3ml)
2
TUSSICAPS - hydrocod polst-chlorphen
polst cap sr 12hr 10-8 mg
•
TUSSIONEX PENNKINETIC EXT hydrocod polst-chlorphen polst cr
susp 10-8 mg/5ml
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
2
4
albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
2
•
TUZISTRA XR - codeine polistchlorphen polist er susp 14.7-2.8
mg/5ml
4
albuterol sulfate soln nebu
1.25 mg/3ml (base equiv)
2
•
4
albuterol sulfate syrup 2 mg/5ml
1
VANACOF CD - phenylephrinedexchlorphenir-codeine liquid 5-1-10
mg/5ml
albuterol sulfate tab sr 12hr 4 mg
(Vospire er)
2
VITUZ - hydrocodone-chlorpheniramine
soln 5-4 mg/5ml
4
albuterol sulfate tab sr 12hr 8 mg
(Vospire er)
2
Z-TUSS AC - chlorpheniramine w/
codeine liquid 2-9 mg/5ml
4
albuterol sulfate tab 2 mg
2
albuterol sulfate tab 4 mg
2
ZONATUSS - benzonatate cap 150 mg
4
ZUTRIPRO - pseudoeph-chlorphen w/
hydrocodone soln 60-4-5 mg/5ml
4
ANTIASTHMATIC and BRONCHODILATOR AGENTS
4
ACCOLATE - zafirlukast tab 10 mg
ACCOLATE - zafirlukast tab 20 mg
62
4
ALVESCO - ciclesonide inhal aerosol 80 4
mcg/act
4
ALVESCO - ciclesonide inhal aerosol
160 mcg/act
4
ANORO ELLIPTA - umeclidiniumvilanterol aero powd ba 62.5-25 mcg/
inh
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
ARCAPTA NEOHALER - indacaterol
maleate inhal powder cap 75 mcg
(base equiv)
4
•
COMBIVENT RESPIMAT - ipratropiumalbuterol inhal aerosol soln 20-100
mcg/act
4
•
ARNUITY ELLIPTA - fluticasone furoate
aerosol powder breath activ 100 mcg/
act
3
•
CROMOLYN SODIUM - cromolyn
sodium soln nebu 20 mg/2ml
2
•
4
ARNUITY ELLIPTA - fluticasone furoate
aerosol powder breath activ 200 mcg/
act
3
•
DALIRESP - roflumilast tab 500 mcg
4
•
ASMANEX HFA - mometasone furoate
inhal aerosol suspension 100 mcg/act
4
•
DULERA - mometasone furoateformoterol fumarate aerosol 100-5
mcg/act
4
•
ASMANEX HFA - mometasone furoate
inhal aerosol suspension 200 mcg/act
4
•
DULERA - mometasone furoateformoterol fumarate aerosol 200-5
mcg/act
ASMANEX TWISTHALER 120 ME mometasone furoate inhal powd 220
mcg/inh (breath activated)
•
dyphylline-guaifenesin liqd
100-100 mg/5ml
1
4
4
ASMANEX TWISTHALER 30 MET mometasone furoate inhal powd 110
mcg/inh (breath activated)
4
•
ELIXOPHYLLIN - theophylline elixir 80
mg/15ml
FLOVENT DISKUS - fluticasone
propionate aer pow ba 50 mcg/blister
3
•
4
•
FLOVENT DISKUS - fluticasone
propionate aer pow ba 100 mcg/
blister
3
ASMANEX TWISTHALER 30 MET mometasone furoate inhal powd 220
mcg/inh (breath activated)
•
4
•
FLOVENT DISKUS - fluticasone
propionate aer pow ba 250 mcg/
blister
3
ASMANEX TWISTHALER 60 MET mometasone furoate inhal powd 220
mcg/inh (breath activated)
•
4
•
FLOVENT HFA - fluticasone propionate
hfa inhal aero 44 mcg/act (50/valve)
3
ATROVENT HFA - ipratropium bromide
hfa inhal aerosol 17 mcg/act
•
4
•
FLOVENT HFA - fluticasone propionate
hfa inhal aer 110 mcg/act (125/valve)
3
BREO ELLIPTA - fluticasone furoatevilanterol aero powd ba 100-25 mcg/
inh
•
3
•
BREO ELLIPTA - fluticasone furoatevilanterol aero powd ba 200-25 mcg/
inh
4
FLOVENT HFA - fluticasone propionate
hfa inhal aer 220 mcg/act (250/valve)
FORADIL AEROLIZER - formoterol
fumarate inhal cap 12 mcg
3
•
BROVANA - arformoterol tartrate soln
nebu 15 mcg/2ml (base equiv)
4
3
•
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
2
INCRUSE ELLIPTA - umeclidinium br
aero powd breath act 62.5 mcg/inh
(base eq)
1
•
budesonide inhalation susp
0.5 mg/2ml (Pulmicort)
2
ipratropium bromide inhal soln
0.02%
2
•
budesonide inhalation susp
1 mg/2ml (Pulmicort)
2
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
2
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
63
2
levalbuterol hcl soln nebu
0.31 mg/3ml (base equiv) (Xopenex)
2
levalbuterol hcl soln nebu
0.63 mg/3ml (base equiv) (Xopenex)
2
levalbuterol hcl soln nebu
1.25 mg/3ml (base equiv) (Xopenex)
4
LUFYLLIN - dyphylline tab 400 mg
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
4
•
•
PULMICORT FLEXHALER budesonide inhal aero powd 180
mcg/act (breath activated)
3
•
•
QVAR - beclomethasone dipropionate
inhal aero soln 40 mcg/act
QVAR - beclomethasone dipropionate
inhal aero soln 80 mcg/act
3
•
•
METAPROTERENOL SULFATE metaproterenol sulfate syrup 10
mg/5ml
4
SEREVENT DISKUS - salmeterol
xinafoate aer pow ba 50 mcg/dose
(base equiv)
4
METAPROTERENOL SULFATE metaproterenol sulfate tab 10 mg
4
SINGULAIR - montelukast sodium tab
10 mg (base equiv)
4
METAPROTERENOL SULFATE metaproterenol sulfate tab 20 mg
4
SINGULAIR - montelukast sodium oral
granules packet 4 mg (base equiv)
4
montelukast sodium chew tab 4 mg
(base equiv) (Singulair)
1
SINGULAIR - montelukast sodium chew
tab 4 mg (base equiv)
4
montelukast sodium chew tab 5 mg
(base equiv) (Singulair)
1
SINGULAIR - montelukast sodium chew
tab 5 mg (base equiv)
4
SPIRIVA HANDIHALER - tiotropium
bromide monohydrate inhal cap 18
mcg (base equiv)
3
•
SPIRIVA RESPIMAT - tiotropium
bromide monohydrate inhal aerosol
2.5 mcg/act
3
•
STIOLTO RESPIMAT - tiotropium brolodaterol inhal aero soln 2.5-2.5
mcg/act
4
•
STRIVERDI RESPIMAT - olodaterol hcl
inhal aerosol soln 2.5 mcg/act (base
equiv)
4
•
SYMBICORT - budesonide-formoterol
fumarate dihyd aerosol 80-4.5 mcg/
act
3
•
SYMBICORT - budesonide-formoterol
fumarate dihyd aerosol 160-4.5 mcg/
act
3
•
terbutaline sulfate tab 2.5 mg
2
terbutaline sulfate tab 5 mg
2
THEO-24 - theophylline cap sr 24hr 100
mg
4
2
montelukast sodium oral granules
packet 4 mg (base equiv) (Singulair)
montelukast sodium tab 10 mg (base 1
equiv) (Singulair)
4
PERFOROMIST - formoterol fumarate
soln nebu 20 mcg/2ml
3
PROAIR HFA - albuterol sulfate inhal
aero 108 mcg/act (90mcg base equiv)
3
PROAIR RESPICLICK - albuterol
sulfate aer pow ba 108 mcg/act (90
mcg base equiv)
4
PROVENTIL HFA - albuterol sulfate
inhal aero 108 mcg/act (90mcg base
equiv)
4
PULMICORT - budesonide inhalation
susp 0.25 mg/2ml
4
PULMICORT - budesonide inhalation
susp 0.5 mg/2ml
4
PULMICORT - budesonide inhalation
susp 1 mg/2ml
4
PULMICORT FLEXHALER budesonide inhal aero powd 90 mcg/
act (breath activated)
64
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
THEO-24 - theophylline cap sr 24hr 300
mg
4
OFEV - nintedanib esylate cap 150 mg
(base equivalent)
5
•
•
THEO-24 - theophylline cap sr 24hr 400
mg
4
ORKAMBI - lumacaftor-ivacaftor tab
200-125 mg
5
•
•
theophylline soln 80 mg/15ml
2
5
•
theophylline tab sr 12hr 100 mg
1
PULMOZYME - dornase alfa inhal soln
1 mg/ml
theophylline tab sr 12hr 200 mg
1
4
theophylline tab sr 12hr 300 mg
1
SURFAXIN - lucinactant intratracheal
susp 30 mg/ml
2
theophylline tab sr 24hr 400 mg
2
SURVANTA INTRATRACHEAL beractant in nacl 0.9% intratracheal
susp 25 mg/ml
4
theophylline tab sr 12hr 450 mg
theophylline tab sr 24hr 600 mg
2
GASTROINTESTINAL AGENTS
TUDORZA PRESSAIR - aclidinium
bromide aerosol powd breath
activated 400 mcg/act
4
VENTOLIN HFA - albuterol sulfate inhal
aero 108 mcg/act (90mcg base equiv)
3
VOSPIRE ER - albuterol sulfate tab sr
12hr 4 mg
4
VOSPIRE ER - albuterol sulfate tab sr
12hr 8 mg
4
XOPENEX HFA - levalbuterol tartrate
inhal aerosol 45 mcg/act (base equiv)
4
zafirlukast tab 10 mg (Accolate)
2
zafirlukast tab 20 mg (Accolate)
2
ZYFLO - zileuton tab 600 mg
4
•
•
•
ZYFLO CR - zileuton tab sr 12hr 600 mg 4
RESPIRATORY AGENTS - MISC.
CUROSURF - poractant alfa
intratracheal susp 80 mg/ml
4
ESBRIET - pirfenidone cap 267 mg
5
INFASURF - calfactant in nacl 0.9%
intratracheal susp 35 mg/ml
4
KALYDECO - ivacaftor tab 150 mg
5
KALYDECO - ivacaftor packet 50 mg
5
KALYDECO - ivacaftor packet 75 mg
5
•
•
•
•
•
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
5
Dispensing Limits
OFEV - nintedanib esylate cap 100 mg
(base equivalent)
Step Therapy
4
Drug Tier
THEO-24 - theophylline cap sr 24hr 200
mg
Drug Name
Prior Authorization
2015
LAXATIVES
bisacodyl tab & peg 3350-kcl-sod
bicarb-nacl for soln kit
2
CASCARA SAGRADA - cascara
sagrada fl ext 1 gm/ml
4
COLYTE-FLAVOR PACKS - peg 3350kcl-na bicarb-nacl-na sulfate for soln
227.1 gm
4
COLYTE-FLAVOR PACKS - peg 3350kcl-na bicarb-nacl-na sulfate for soln
240 gm
4
GOLYTELY - peg 3350-kcl-na bicarbnacl-na sulfate packet 227.1 gm
4
GOLYTELY - peg 3350-kcl-na bicarbnacl-na sulfate for soln 236 gm
4
KRISTALOSE - lactulose oral crystal
packet 10 gm
4
KRISTALOSE - lactulose oral crystal
packet 20 gm
4
lactulose solution 10 gm/15ml
1
MINERAL OIL HEAVY - mineral oil
4
MOVIPREP - peg 3350-kcl-nacl-na
sulfate-na ascorbate-c for soln 100
gm
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
65
NULYTELY/FLAVOR PACKS - peg
3350-kcl-sod bicarb-nacl for soln 420
gm
4
OSMOPREP - sod phos mono-sod phos 4
di tabs 1.102-0.398 gm(1.5gm na
phos)
4
PCP 100 - mag cit-bisacodyl-petrolatpeg-metoclopramide-electrol kit
peg 3350-kcl-sod bicarb-nacl for soln 1
420 gm (Nulytely/flavor pack)
1
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 236 gm (Golytely)
1
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm (Colyteflavor packs)
polyethylene glycol 3350 oral packet 2
polyethylene glycol 3350 oral
powder
1
PREPOPIK - sod picosulfate-mg oxidecitric acid pack 10 mg-3.5 gm-12 gm
4
SENNA LEAVES - senna leaves
4
SUPREP BOWEL PREP - sodium
sulfate-potassium sulfate-magnesium
sulfate oral soln
4
ANTIDIARRHEALS
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
1
DIPHENOXYLATE/ATROPINE diphenoxylate w/ atropine liq
2.5-0.025 mg/5ml
4
FULYZAQ - crofelemer tab delayed
release 125 mg
4
LOMOTIL - diphenoxylate w/ atropine
tab 2.5-0.025 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
ULCER DRUGS
ACIPHEX - rabeprazole sodium ec tab
20 mg
4
•
ACIPHEX SPRINKLE - rabeprazole
sodium capsule sprinkle dr 5 mg
4
•
ACIPHEX SPRINKLE - rabeprazole
sodium capsule sprinkle dr 10 mg
4
•
amoxicillin cap-clarithro tablansopraz cap dr therapy pack
(Prevpac)
2
ANASPAZ - hyoscyamine sulfate tab
disp 0.125 mg
4
AXID - nizatidine cap 300 mg
4
BELLADONNA & OPIUM - belladonna
alkaloids & opium suppos 16.2-30 mg
4
BELLADONNA ALKALOIDS & OP belladonna alkaloids & opium suppos
16.2-60 mg
4
BENTYL - dicyclomine hcl cap 10 mg
4
BENTYL - dicyclomine hcl tab 20 mg
4
CANTIL - mepenzolate bromide tab 25
mg
4
CARAFATE - sucralfate tab 1 gm
4
CARAFATE - sucralfate susp 1 gm/10ml 4
2
chlordiazepoxide hcl-clidinium
bromide cap 5-2.5 mg (Librax)
1
cimetidine hcl soln 300 mg/5ml
cimetidine tab 300 mg
1
cimetidine tab 400 mg
1
cimetidine tab 800 mg
2
4
CUVPOSA - glycopyrrolate oral soln 1
mg/5ml
4
4
CYTOTEC - misoprostol tab 100 mcg
4
MOTOFEN - difenoxin w/ atropine tab
1-0.025 mg
CYTOTEC - misoprostol tab 200 mcg
4
opium tincture 1% (10 mg/ml)
(morphine equiv)
2
DEXILANT - dexlansoprazole cap
delayed release 30 mg
4
•
RESTORA RX - lactobacillus casei-folic
acid cap 60-1.25 mg
4
DEXILANT - dexlansoprazole cap
delayed release 60 mg
4
•
dicyclomine hcl cap 10 mg (Bentyl)
1
66
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
DIGEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15 mg
Prior Authorization
1
Drug Name
Drug Tier
dicyclomine hcl tab 20 mg (Bentyl)
Dispensing Limits
4
Step Therapy
dicyclomine hcl oral soln 10 mg/5ml
Prior Authorization
Drug Name
Drug Tier
2015
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
2
4
hyoscyamine sulfate tab 0.125 mg
(Levsin)
2
DONNATAL - pb-hyoscy-atrop-scopol
tab 16.2-0.1037-0.0194-0.0065 mg
3
lansoprazole cap delayed release
15 mg (Prevacid)
2
•
DONNATAL - pb-hyoscy-atrop-scopol
elix 16.2-0.1037-0.0194-0.0065
mg/5ml
4
lansoprazole cap delayed release
30 mg (Prevacid)
2
•
4
DONNATAL EXTENTABS - pbhyoscy-atrop-scopol tab cr
48.6-0.3111-0.0582-0.0195 mg
4
LEVBID - hyoscyamine sulfate tab sr
12hr 0.375 mg
esomeprazole magnesium cap
delayed release 20 mg (base eq)
(Nexium)
2
•
esomeprazole magnesium cap
delayed release 40 mg (base eq)
(Nexium)
2
•
famotidine for susp 40 mg/5ml
(Pepcid)
2
famotidine tab 40 mg (Pepcid)
1
FIRST-LANSOPRAZOLE - lansoprazole 4
susp 3 mg/ml (compound kit)
4
FIRST-OMEPRAZOLE - omeprazole
susp 2 mg/ml (compound kit)
4
GASTRINEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15 mg
4
GLYCATE - glycopyrrolate tab 1.5 mg
glycopyrrolate tab 1 mg (Robinul)
2
glycopyrrolate tab 2 mg (Robinul
forte)
2
hyoscyamine sulfate elixir
0.125 mg/5ml
1
hyoscyamine sulfate soln 0.125 mg/
ml
2
hyoscyamine sulfate tab disp
0.125 mg (Anaspaz)
2
hyoscyamine sulfate tab sl 0.125 mg
(Levsin/sl)
2
LEVSIN - hyoscyamine sulfate tab 0.125 4
mg
LEVSIN/SL - hyoscyamine sulfate tab sl 4
0.125 mg
LIBRAX - chlordiazepoxide hcl-clidinium 4
bromide cap 5-2.5 mg
2
methscopolamine bromide tab
2.5 mg (Pamine)
2
methscopolamine bromide tab 5 mg
(Pamine forte)
1
misoprostol tab 100 mcg (Cytotec)
misoprostol tab 200 mcg (Cytotec)
1
NEXIUM - esomeprazole magnesium for 4
delayed release susp pack 2.5 mg
NEXIUM - esomeprazole magnesium for 4
delayed release susp packet 5 mg
NEXIUM - esomeprazole magnesium for 4
delayed release susp packet 10 mg
NEXIUM - esomeprazole magnesium for 4
delayed release susp packet 20 mg
NEXIUM - esomeprazole magnesium for 4
delayed release susp packet 40 mg
4
NEXIUM - esomeprazole magnesium
cap delayed release 20 mg (base eq)
4
NEXIUM - esomeprazole magnesium
cap delayed release 40 mg (base eq)
2
nizatidine cap 150 mg
nizatidine cap 300 mg (Axid)
2
nizatidine oral soln 15 mg/ml (Axid)
2
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
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•
•
•
•
•
•
67
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
PRILOSEC - omeprazole cap delayed
release 10 mg
4
•
PRILOSEC - omeprazole cap delayed
release 20 mg
4
•
PRILOSEC - omeprazole cap delayed
release 40 mg
4
•
PRILOSEC - omeprazole magnesium
for delayed release susp packet 2.5
mg
4
•
PRILOSEC - omeprazole magnesium
for delayed release susp packet 10
mg
4
•
•
PROPANTHELINE BROMIDE propantheline bromide tab 15 mg
4
•
PROTONIX - pantoprazole sodium for
delayed release susp packet 40 mg
4
•
4
PROTONIX - pantoprazole sodium ec
tab 20 mg (base equiv)
4
•
PAMINE FORTE - methscopolamine
bromide tab 5 mg
4
PROTONIX - pantoprazole sodium ec
tab 40 mg (base equiv)
4
•
PAMINE FQ - methscopolamine tab 5
mg & misc intestinal flora reg cap
4
4
pantoprazole sodium ec tab 20 mg
(base equiv) (Protonix)
1
•
PYLERA - bismuth subcitmetronidazole-tetracycline cap
140-125-125 mg
2
pantoprazole sodium ec tab 40 mg
(base equiv) (Protonix)
1
•
rabeprazole sodium ec tab 20 mg
(Aciphex)
ranitidine hcl cap 150 mg
2
PEPCID - famotidine tab 40 mg
4
ranitidine hcl cap 300 mg
2
PEPCID - famotidine for susp 40
mg/5ml
4
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
1
PREVACID - lansoprazole cap delayed
release 15 mg
4
ranitidine hcl tab 300 mg (Zantac)
1
4
PREVACID - lansoprazole cap delayed
release 30 mg
•
ROBINUL - glycopyrrolate tab 1 mg
4
4
PREVACID SOLUTAB - lansoprazole
tab delayed release orally
disintegrating 15 mg
4
•
ROBINUL FORTE - glycopyrrolate tab 2
mg
sucralfate tab 1 gm (Carafate)
2
PREVACID SOLUTAB - lansoprazole
tab delayed release orally
disintegrating 30 mg
4
PREVPAC - amoxicillin cap-clarithro
tab-lansopraz cap dr therapy pack
4
OMECLAMOX-PAK - amoxicillin capclarithro tab w/ omepraz cap dr
therapy pack
4
OMEPRAZOLE + SYRSPEND SF omeprazole susp 2 mg/ml (compound
kit)
4
omeprazole cap delayed release
10 mg (Prilosec)
2
•
omeprazole cap delayed release
20 mg (Prilosec)
1
•
omeprazole cap delayed release
40 mg (Prilosec)
1
•
omeprazole-sodium bicarbonate cap
20-1100 mg (Zegerid)
2
omeprazole-sodium bicarbonate cap
40-1100 mg (Zegerid)
2
PAMINE - methscopolamine bromide
tab 2.5 mg
68
•
•
•
SYMAX DUOTAB - hyoscyamine sulfate 4
tab cr 0.375 mg (0.125 mg ir/0.25 mg
cr)
4
ZANTAC - ranitidine hcl tab 300 mg
ZEGERID - omeprazole-sodium
bicarbonate cap 20-1100 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
ZEGERID - omeprazole-sodium
bicarbonate cap 40-1100 mg
4
•
ondansetron orally disintegrating tab
8 mg (Zofran odt)
2
•
ZEGERID - omeprazole-sodium
bicarbonate powd pack for susp
20-1680 mg
4
•
SANCUSO - granisetron td patch 3.1
mg/24hr (contains 34.3 mg)
4
•
ZEGERID - omeprazole-sodium
bicarbonate powd pack for susp
40-1680 mg
4
•
AKYNZEO - netupitant-palonosetron
cap 300-0.5 mg
4
•
ANZEMET - dolasetron mesylate tab 50
mg
4
•
ANZEMET - dolasetron mesylate tab
100 mg
4
•
CESAMET - nabilone cap 1 mg
4
DICLEGIS - doxylamine-pyridoxine tab
delayed release 10-10 mg
4
dronabinol cap 2.5 mg (Marinol)
2
dronabinol cap 5 mg (Marinol)
2
dronabinol cap 10 mg (Marinol)
2
EMEND - aprepitant capsule therapy
pack 80 & 125 mg
3
EMEND - aprepitant capsule 40 mg
3
EMEND - aprepitant capsule 80 mg
3
EMEND - aprepitant capsule 125 mg
3
granisetron hcl tab 1 mg
2
MARINOL - dronabinol cap 2.5 mg
4
MARINOL - dronabinol cap 5 mg
4
MARINOL - dronabinol cap 10 mg
4
ondansetron hcl oral soln 4 mg/5ml
(Zofran)
2
ondansetron hcl tab 4 mg (Zofran)
1
ondansetron hcl tab 8 mg (Zofran)
2
ondansetron hcl tab 24 mg
2
ondansetron orally disintegrating tab
4 mg (Zofran odt)
2
ANTIEMETICS
•
•
•
•
TIGAN - trimethobenzamide hcl cap 300 4
mg
4
TRANSDERM-SCOP - scopolamine td
patch 72hr 1 mg/3days
2
trimethobenzamide hcl cap 300 mg
(Tigan)
4
ZOFRAN - ondansetron hcl oral soln 4
mg/5ml
4
ZOFRAN - ondansetron hcl tab 4 mg
•
ZOFRAN - ondansetron hcl tab 8 mg
4
ZOFRAN ODT - ondansetron orally
disintegrating tab 4 mg
4
•
•
•
ZOFRAN ODT - ondansetron orally
disintegrating tab 8 mg
4
•
ZUPLENZ - ondansetron oral soluble
film 4 mg
4
•
ZUPLENZ - ondansetron oral soluble
film 8 mg
4
•
DIGESTIVE AIDS
•
•
•
•
•
•
•
•
CREON - pancrelipase (lip-prot-amyl) dr
cap 3000-9500-15000 unit
4
CREON - pancrelipase (lip-prot-amyl) dr
cap 6000-19000-30000 unit
4
CREON - pancrelipase (lip-prot-amyl) dr
cap 12000-38000-60000 unit
4
CREON - pancrelipase (lip-prot-amyl) dr
cap 24000-76000-120000 unit
4
CREON - pancrelipase (lip-prot-amyl) dr
cap 36000-114000-180000 unit
4
•
•
•
•
PANCREAZE - pancrelipase (lip-protamyl) dr cap 4200-10000-17500 unit
4
PANCREAZE - pancrelipase (lip-protamyl) dr cap 10500-25000-43750 unit
4
PANCREAZE - pancrelipase (lip-protamyl) dr cap 16800-40000-70000 unit
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
69
PANCREAZE - pancrelipase (lip-protamyl) dr cap 21000-37000-61000 unit
4
alosetron hcl tab 1 mg (base equiv)
(Lotronex)
2
PANCRELIPASE - pancrelipase (lipprot-amyl) dr cap 5000-17000-27000
unit
4
AMITIZA - lubiprostone cap 8 mcg
4
AMITIZA - lubiprostone cap 24 mcg
4
4
APRISO - mesalamine cap sr 24hr
0.375 gm
4
PERTZYE - pancrelipase (lip-prot-amyl)
dr cap 8000-28750-30250 unit
4
ASACOL HD - mesalamine tab delayed
release 800 mg
4
PERTZYE - pancrelipase (lip-prot-amyl)
dr cap 16000-57500-60500 unit
5
AURYXIA - ferric citrate tab 1 gm (210
mg ferric iron)
4
SUCRAID - sacrosidase soln 8500 unit/
ml
4
AZULFIDINE - sulfasalazine tab 500 mg
4
ULTRESA - pancrelipase (lip-prot-amyl)
dr cap 13800-27600-27600 unit
4
ULTRESA - pancrelipase (lip-prot-amyl)
dr cap 20700-41400-41400 unit
4
AZULFIDINE EN-TABS - sulfasalazine
tab delayed release 500 mg
2
ULTRESA - pancrelipase (lip-prot-amyl)
dr cap 23000-46000-46000 unit
4
balsalazide disodium cap 750 mg
(Colazal)
2
VIOKACE - pancrelipase (lip-prot-amyl)
tab 10440-39150-39150 unit
4
calcium acetate (phosphate binder)
cap 667 mg (169 mg ca) (Phoslo)
2
VIOKACE - pancrelipase (lip-prot-amyl)
tab 20880-78300-78300 unit
4
calcium acetate (phosphate binder)
tab 667 mg (Eliphos)
3
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 3000-10000-16000 unit
3
CANASA - mesalamine suppos 1000
mg
CHENODAL - chenodiol tab 250 mg
5
CHOLBAM - cholic acid cap 50 mg
5
CHOLBAM - cholic acid cap 250 mg
5
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
•
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 5000-17000-27000 unit
3
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 10000-34000-55000 unit
3
CIMZIA - certolizumab pegol inj kit 2 x
200 mg/ml
5
• •
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 15000-51000-82000 unit
3
CIMZIA STARTER KIT - certolizumab
pegol inj kit 6 x 200 mg/ml
5
• •
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 20000-68000-109000 unit
3
COLAZAL - balsalazide disodium cap
750 mg
4
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 25000-85000-136000 unit
3
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
2
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 40000-136000-218000 unit
3
DELZICOL - mesalamine cap dr 400 mg 4
DIPENTUM - olsalazine sodium cap 250 4
mg
ELIPHOS - calcium acetate (phosphate 4
binder) tab 667 mg
4
ENTEREG - alvimopan cap 12 mg
GASTROINTESTINAL AGENTS- MISC.
ACTIGALL - ursodiol cap 300 mg
4
alosetron hcl tab 0.5 mg (base equiv)
(Lotronex)
2
70
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
FOSRENOL - lanthanum carbonate
chew tab 500 mg (elemental)
4
MOVANTIK - naloxegol oxalate tab 12.5
mg (base equivalent)
4
FOSRENOL - lanthanum carbonate
chew tab 750 mg (elemental)
4
MOVANTIK - naloxegol oxalate tab 25
mg (base equivalent)
4
FOSRENOL - lanthanum carbonate
chew tab 1000 mg (elemental)
4
PENTASA - mesalamine cap cr 250 mg
4
PENTASA - mesalamine cap cr 500 mg
4
FOSRENOL - lanthanum carbonate oral
powder pack 750 mg (elemental)
4
PHOSLO - calcium acetate (phosphate
binder) cap 667 mg (169 mg ca)
4
FOSRENOL - lanthanum carbonate oral
powder pack 1000 mg (elemental)
4
4
GASTROCROM - cromolyn sodium oral
conc 100 mg/5ml
4
PHOSLYRA - calcium acetate
(phosphate binder) oral soln 667
mg/5ml
GATTEX - teduglutide (rdna) for inj kit 5
mg
5
GIAZO - balsalazide disodium tab 1.1
gm
4
lactulose (encephalopathy) solution
10 gm/15ml
1
LIALDA - mesalamine tab delayed
release 1.2 gm
4
LINZESS - linaclotide cap 145 mcg
4
LINZESS - linaclotide cap 290 mcg
4
LOTRONEX - alosetron hcl tab 0.5 mg
(base equiv)
4
LOTRONEX - alosetron hcl tab 1 mg
(base equiv)
4
mesalamine enema 4 gm
2
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
REGLAN - metoclopramide hcl tab 5 mg 4
4
REGLAN - metoclopramide hcl tab 10
mg
RELISTOR - methylnaltrexone bromide 4
inj 8 mg/0.4ml (20 mg/ml)
RELISTOR - methylnaltrexone bromide 4
inj 12 mg/0.6ml (20 mg/ml)
4
RENAGEL - sevelamer hcl tab 400 mg
RENAGEL - sevelamer hcl tab 800 mg
4
RENVELA - sevelamer carbonate tab
800 mg
4
RENVELA - sevelamer carbonate
packet 0.8 gm
4
RENVELA - sevelamer carbonate
packet 2.4 gm
4
mesalamine rectal enema 4 gm &
cleanser wipe kit (Rowasa)
ROWASA - mesalamine rectal enema 4
gm & cleanser wipe kit
4
2
metoclopramide hcl orally
disintegrating tab 5 mg (Metozolv
odt)
SEVELAMER CARBONATE sevelamer carbonate tab 800 mg
4
2
SFROWASA - mesalamine sulfite-free
(sf) enema 4 gm/60ml
4
metoclopramide hcl soln 5 mg/5ml
(10 mg/10ml)
1
sulfasalazine tab delayed release
500 mg (Azulfidine en-tabs)
2
metoclopramide hcl tab 5 mg
(Reglan)
1
sulfasalazine tab 500 mg (Azulfidine)
2
1
URSO FORTE - ursodiol tab 500 mg
4
metoclopramide hcl tab 10 mg
(Reglan)
URSO 250 - ursodiol tab 250 mg
4
METOZOLV ODT - metoclopramide hcl
orally disintegrating tab 5 mg
4
ursodiol cap 300 mg (Actigall)
2
ursodiol tab 250 mg (Urso 250)
2
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
71
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
FURADANTIN - nitrofurantoin susp 25
mg/5ml
4
HIPREX - methenamine hippurate tab 1
gm
4
MACROBID - nitrofurantoin
monohydrate macrocrystalline cap
100 mg
4
MACRODANTIN - nitrofurantoin
macrocrystalline cap 25 mg
4
MACRODANTIN - nitrofurantoin
macrocrystalline cap 50 mg
4
MACRODANTIN - nitrofurantoin
macrocrystalline cap 100 mg
4
methenamine hippurate tab 1 gm
(Hiprex)
2
METHENAMINE MANDELATE methenamine mandelate tab 0.5 gm
4
methenamine mandelate tab 1 gm
2
methenamine-hyos-meth blue-sod
phos-phen sal tab 81.6 mg
2
methenamine-hyosc-meth blue-benz 2
acid-phenyl sal tab 81.6mg (Prosed/
ds)
2
methenamine-hyosc-meth blue-sod
phos-phen sal cap 118 mg
2
methenamine-hyosc-meth blue-sod
phos-phen sal cap 120 mg
2
methenamine-hyosc-meth blue-sod
phos-phen sal tab 81 mg
2
methenamine-hyoscamine-meth
blue-sod phos tab 81.6 mg
(Urogesic-blue)
4
MONUROL - fosfomycin tromethamine
powd pack 3 gm (base equivalent)
72
nitrofurantoin macrocrystalline cap
50 mg (Macrodantin)
2
nitrofurantoin macrocrystalline cap
100 mg (Macrodantin)
2
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
(Macrobid)
2
nitrofurantoin susp 25 mg/5ml
(Furadantin)
2
PROSED/DS - methenamine-hyoscmeth blue-benz acid-phenyl sal tab
81.6mg
4
URETRON D/S - methenamine-hyoscmeth blue-sod phos-phen sal tab 120
mg
4
UREX - methenamine hippurate tab 1
gm
4
URIMAR-T - methenamine-hyosc-meth
blue-sod phos-phen sal tab 120 mg
4
UROGESIC-BLUE - methenaminehyoscamine-meth blue-sod phos tab
81.6 mg
4
UROQID #2 - methenamine mandelatesod phosphate monobasic tab
500-500 mg
4
UTA - methenamine-hyoscamine-meth
blue-sod phos cap 120 mg
4
Dispensing Limits
Step Therapy
Prior Authorization
4
Drug Name
Drug Tier
VELPHORO - sucroferric oxyhydroxide
chew tab 500 mg
Dispensing Limits
2
Step Therapy
ursodiol tab 500 mg (Urso forte)
Prior Authorization
Drug Name
Drug Tier
2015
URINARY ANTISPASMODICS
bethanechol chloride tab 5 mg
(Urecholine)
2
bethanechol chloride tab 10 mg
(Urecholine)
2
bethanechol chloride tab 25 mg
(Urecholine)
2
bethanechol chloride tab 50 mg
(Urecholine)
2
DETROL - tolterodine tartrate tab 1 mg
4
DETROL - tolterodine tartrate tab 2 mg
4
DETROL LA - tolterodine tartrate cap sr
24hr 2 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
DETROL LA - tolterodine tartrate cap sr
24hr 4 mg
4
TOVIAZ - fesoterodine fumarate tab sr
24hr 8 mg
4
DITROPAN XL - oxybutynin chloride tab
sr 24hr 5 mg
4
trospium chloride cap sr 24hr 60 mg
2
trospium chloride tab 20 mg
2
DITROPAN XL - oxybutynin chloride tab
sr 24hr 10 mg
4
URECHOLINE - bethanechol chloride
tab 5 mg
4
DITROPAN XL - oxybutynin chloride tab
sr 24hr 15 mg
4
URECHOLINE - bethanechol chloride
tab 10 mg
4
ENABLEX - darifenacin hydrobromide
tab sr 24hr 7.5 mg (base equiv)
4
URECHOLINE - bethanechol chloride
tab 25 mg
4
ENABLEX - darifenacin hydrobromide
tab sr 24hr 15 mg (base equiv)
4
URECHOLINE - bethanechol chloride
tab 50 mg
4
flavoxate hcl tab 100 mg
2
GELNIQUE - oxybutynin td gel 3% (28
mg/act metered-dose pump)
•
VESICARE - solifenacin succinate tab 5
mg
4
4
4
•
VESICARE - solifenacin succinate tab
10 mg
4
GELNIQUE - oxybutynin chloride td gel
10%
MYRBETRIQ - mirabegron tab sr 24 hr
25 mg
4
MYRBETRIQ - mirabegron tab sr 24 hr
50 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
VAGINAL PRODUCTS
AVC - sulfanilamide vaginal cream 15%
4
4
CLEOCIN - clindamycin phosphate
vaginal cream 2%
4
1
CLEOCIN - clindamycin phosphate
vaginal suppos 100 mg
4
oxybutynin chloride syrup 5 mg/5ml
oxybutynin chloride tab sr 24hr 5 mg
(Ditropan xl)
2
clindamycin phosphate vaginal
cream 2% (Cleocin)
2
oxybutynin chloride tab sr 24hr
10 mg (Ditropan xl)
2
CLINDESSE - clindamycin phosphate
(one dose) vaginal cream 2%
4
oxybutynin chloride tab sr 24hr
15 mg (Ditropan xl)
2
ESTRACE - estradiol vaginal cream 0.1
mg/gm
3
oxybutynin chloride tab 5 mg
2
OXYTROL - oxybutynin td patch twice
weekly 3.9 mg/24hr
ESTRING - estradiol vaginal ring 2 mg
(7.5 mcg/24hrs)
4
4
tolterodine tartrate cap sr 24hr 2 mg
(Detrol la)
FEM PH - acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
4
2
4
tolterodine tartrate cap sr 24hr 4 mg
(Detrol la)
2
FEMRING - estradiol acetate vaginal
ring 0.05 mg/24hr
2
FEMRING - estradiol acetate vaginal
ring 0.1 mg/24hr
4
tolterodine tartrate tab 1 mg (Detrol)
tolterodine tartrate tab 2 mg (Detrol)
2
4
TOVIAZ - fesoterodine fumarate tab sr
24hr 4 mg
4
GYNAZOLE-1 - butoconazole nitrate
(one dose) vaginal cream 2%
METROGEL-VAGINAL - metronidazole
vaginal gel 0.75%
4
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
73
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
2
FLOMAX - tamsulosin hcl cap 0.4 mg
4
miconazole nitrate vaginal supp
200 mg & 2% cream 9 gm kit
JALYN - dutasteride-tamsulosin hcl cap
0.5-0.4 mg
4
1
MICONAZOLE 3 - miconazole nitrate
vaginal suppos 200 mg
K-PHOS NO 2 - potassium & sodium
acid phosphates tab 305-700 mg
4
4
4
LITHOSTAT - acetohydroxamic acid tab
250 mg
4
NUVESSA - metronidazole vaginal gel
1.3%
4
ORACIT - sodium citrate & citric acid
soln 490-640 mg/5ml
4
PREMARIN - estrogens, conjugated
vaginal cream 0.625 mg/gm
RELAGARD - acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
phenazopyridine hcl tab 100 mg
(Pyridium)
1
4
TERAZOL 3 - terconazole vaginal
cream 0.8%
phenazopyridine hcl tab 200 mg
(Pyridium)
1
4
TERAZOL 7 - terconazole vaginal
cream 0.4%
pot & sod citrates w/ cit ac soln
550-500-334 mg/5ml
2
4
2
potassium citrate & citric acid
powder pack 3300-1002 mg
2
terconazole vaginal cream 0.4%
(Terazol 7)
2
potassium citrate & citric acid soln
1100-334 mg/5ml
2
terconazole vaginal cream 0.8%
(Terazol 3)
terconazole vaginal suppos 80 mg
potassium citrate tab cr 5 meq
(540 mg) (Urocit-k 5)
2
2
potassium citrate tab cr 10 meq
(1080 mg) (Urocit-k 10)
2
VAGIFEM - estradiol vaginal tab 10 mcg 3
GENITOURINARY AGENTS - MISC.
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
1
potassium citrate tab cr 15 meq
(1620 mg) (Urocit-k 15)
2
AVODART - dutasteride cap 0.5 mg
4
5
•
CARDURA XL - doxazosin mesylate tab
sr 24 hr 4 mg (base equiv)
4
PROCYSBI - cysteamine bitartrate cap
delayed release 25 mg (base equiv)
5
•
CARDURA XL - doxazosin mesylate tab
sr 24 hr 8 mg (base equiv)
4
PROCYSBI - cysteamine bitartrate cap
delayed release 75 mg (base equiv)
PROSCAR - finasteride tab 5 mg
4
CYSTAGON - cysteamine bitartrate cap
50 mg
5
•
PYRIDIUM - phenazopyridine hcl tab
100 mg
4
CYSTAGON - cysteamine bitartrate cap
150 mg
5
•
PYRIDIUM - phenazopyridine hcl tab
200 mg
4
CYTRA-3 - pot & sod citrates w/ cit ac
syrup 550-500-334 mg/5ml
4
RAPAFLO - silodosin cap 4 mg
4
RAPAFLO - silodosin cap 8 mg
4
ELMIRON - pentosan polysulfate
sodium caps 100 mg
4
4
finasteride tab 5 mg (Proscar)
1
SHOHLS SOLUTION MODIFIED sodium citrate & citric acid soln
500-334 mg/5ml
74
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
buspirone hcl tab 5 mg
1
buspirone hcl tab 7.5 mg
2
buspirone hcl tab 10 mg
1
buspirone hcl tab 15 mg
1
buspirone hcl tab 30 mg
2
chlordiazepoxide hcl cap 5 mg
1
chlordiazepoxide hcl cap 10 mg
1
tamsulosin hcl cap 0.4 mg (Flomax)
1
THIOLA - tiopronin tab 100 mg
4
UROCIT-K 10 - potassium citrate tab cr
10 meq (1080 mg)
4
UROCIT-K 15 - potassium citrate tab cr
15 meq (1620 mg)
4
UROCIT-K 5 - potassium citrate tab cr 5
meq (540 mg)
4
chlordiazepoxide hcl cap 25 mg
1
UROXATRAL - alfuzosin hcl tab sr 24hr
10 mg
clorazepate dipotassium tab 3.75 mg
(Tranxene t)
1
4
clorazepate dipotassium tab 7.5 mg
(Tranxene t)
1
clorazepate dipotassium tab 15 mg
(Tranxene t)
2
DIAZEPAM - diazepam soln 1 mg/ml
4
diazepam conc 5 mg/ml
2
diazepam tab 2 mg (Valium)
1
diazepam tab 5 mg (Valium)
1
diazepam tab 10 mg (Valium)
1
hydroxyzine hcl syrup 10 mg/5ml
1
hydroxyzine hcl tab 10 mg
1
hydroxyzine hcl tab 25 mg
1
CENTRAL NERVOUS SYSTEM DRUGS
ANTIANXIETY AGENTS
ALPRAZOLAM INTENSOL - alprazolam
conc 1 mg/ml
4
alprazolam orally disintegrating tab
0.25 mg (Niravam)
2
alprazolam orally disintegrating tab
0.5 mg
2
alprazolam orally disintegrating tab
1 mg
2
alprazolam orally disintegrating tab
2 mg
2
alprazolam tab sr 24hr 0.5 mg (Xanax
xr)
2
hydroxyzine hcl tab 50 mg
1
alprazolam tab sr 24hr 1 mg (Xanax
xr)
HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100 mg
4
2
alprazolam tab sr 24hr 2 mg (Xanax
xr)
hydroxyzine pamoate cap 25 mg
(Vistaril)
1
2
alprazolam tab sr 24hr 3 mg (Xanax
xr)
hydroxyzine pamoate cap 50 mg
(Vistaril)
1
2
1
lorazepam conc 2 mg/ml (Lorazepam
intensol)
2
alprazolam tab 0.25 mg (Xanax)
alprazolam tab 0.5 mg (Xanax)
1
4
alprazolam tab 1 mg (Xanax)
1
LORAZEPAM INTENSOL - lorazepam
conc 2 mg/ml
alprazolam tab 2 mg (Xanax)
1
lorazepam tab 0.5 mg (Ativan)
1
ATIVAN - lorazepam tab 0.5 mg
4
lorazepam tab 1 mg (Ativan)
1
ATIVAN - lorazepam tab 1 mg
4
lorazepam tab 2 mg (Ativan)
1
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
4
1
Step Therapy
ATIVAN - lorazepam tab 2 mg
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution
modi)
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
75
2
amitriptyline hcl tab 150 mg
1
meprobamate tab 400 mg
2
AMOXAPINE - amoxapine tab 25 mg
4
NIRAVAM - alprazolam orally
disintegrating tab 0.25 mg
4
AMOXAPINE - amoxapine tab 50 mg
4
AMOXAPINE - amoxapine tab 100 mg
4
oxazepam cap 10 mg
2
AMOXAPINE - amoxapine tab 150 mg
4
oxazepam cap 15 mg
2
2
ANAFRANIL - clomipramine hcl cap 25
mg
4
oxazepam cap 30 mg
TRANXENE T - clorazepate
dipotassium tab 3.75 mg
4
ANAFRANIL - clomipramine hcl cap 50
mg
4
TRANXENE T - clorazepate
dipotassium tab 7.5 mg
4
ANAFRANIL - clomipramine hcl cap 75
mg
4
TRANXENE T - clorazepate
dipotassium tab 15 mg
4
APLENZIN - bupropion hbr tab sr 24hr
174 mg
4
•
VALIUM - diazepam tab 2 mg
4
4
•
VALIUM - diazepam tab 5 mg
4
APLENZIN - bupropion hbr tab sr 24hr
348 mg
VALIUM - diazepam tab 10 mg
4
4
•
VISTARIL - hydroxyzine pamoate cap
25 mg
4
APLENZIN - bupropion hbr tab sr 24hr
522 mg
4
•
VISTARIL - hydroxyzine pamoate cap
50 mg
4
BRINTELLIX - vortioxetine hbr tab 5 mg
(base equiv)
4
•
XANAX - alprazolam tab 0.25 mg
4
BRINTELLIX - vortioxetine hbr tab 10
mg (base equiv)
4
BRINTELLIX - vortioxetine hbr tab 20
mg (base equiv)
4
XANAX - alprazolam tab 0.5 mg
•
XANAX - alprazolam tab 1 mg
4
4
bupropion hcl tab sr 12hr 100 mg
(Wellbutrin sr)
2
XANAX - alprazolam tab 2 mg
XANAX XR - alprazolam tab sr 24hr 0.5
mg
4
bupropion hcl tab sr 12hr 150 mg
(Wellbutrin sr)
2
XANAX XR - alprazolam tab sr 24hr 1
mg
4
bupropion hcl tab sr 12hr 200 mg
(Wellbutrin sr)
2
XANAX XR - alprazolam tab sr 24hr 2
mg
4
bupropion hcl tab sr 24hr 150 mg
(Wellbutrin xl)
2
XANAX XR - alprazolam tab sr 24hr 3
mg
4
bupropion hcl tab sr 24hr 300 mg
(Wellbutrin xl)
2
bupropion hcl tab 75 mg (Wellbutrin)
2
ANTIDEPRESSANTS
amitriptyline hcl tab 10 mg
1
amitriptyline hcl tab 25 mg
1
amitriptyline hcl tab 50 mg
1
amitriptyline hcl tab 75 mg
1
amitriptyline hcl tab 100 mg
1
76
bupropion hcl tab 100 mg (Wellbutrin) 2
CELEXA - citalopram hydrobromide tab 4
10 mg (base equiv)
CELEXA - citalopram hydrobromide tab 4
20 mg (base equiv)
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
meprobamate tab 200 mg
Prior Authorization
Drug Name
Drug Tier
2015
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr
50 mg (base equiv)
4
•
4
•
citalopram hydrobromide tab 10 mg
(base equiv) (Celexa)
1
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr
100 mg (base equiv)
citalopram hydrobromide tab 20 mg
(base equiv) (Celexa)
1
DOXEPIN HCL - doxepin hcl cap 75 mg
4
doxepin hcl cap 10 mg
1
citalopram hydrobromide tab 40 mg
(base equiv) (Celexa)
1
doxepin hcl cap 25 mg
1
doxepin hcl cap 50 mg
1
clomipramine hcl cap 25 mg
(Anafranil)
2
doxepin hcl cap 100 mg
1
2
doxepin hcl cap 150 mg
1
clomipramine hcl cap 50 mg
(Anafranil)
doxepin hcl conc 10 mg/ml
1
clomipramine hcl cap 75 mg
(Anafranil)
2
DULOXETINE HCL - duloxetine hcl
enteric coated pellets cap 40 mg
4
• •
CYMBALTA - duloxetine hcl enteric
coated pellets cap 20 mg
4
• •
duloxetine hcl enteric coated pellets
cap 20 mg (Cymbalta)
2
•
CYMBALTA - duloxetine hcl enteric
coated pellets cap 30 mg
4
• •
duloxetine hcl enteric coated pellets
cap 30 mg (Cymbalta)
2
•
CYMBALTA - duloxetine hcl enteric
coated pellets cap 60 mg
4
• •
duloxetine hcl enteric coated pellets
cap 60 mg (Cymbalta)
2
•
desipramine hcl tab 10 mg
(Norpramin)
2
EFFEXOR XR - venlafaxine hcl cap sr
24hr 37.5 mg (base equivalent)
4
•
desipramine hcl tab 25 mg
(Norpramin)
2
EFFEXOR XR - venlafaxine hcl cap sr
24hr 75 mg (base equivalent)
4
•
desipramine hcl tab 50 mg
(Norpramin)
2
EFFEXOR XR - venlafaxine hcl cap sr
24hr 150 mg (base equivalent)
4
•
desipramine hcl tab 75 mg
(Norpramin)
2
EMSAM - selegiline td patch 24hr 6
mg/24hr
4
desipramine hcl tab 100 mg
(Norpramin)
2
EMSAM - selegiline td patch 24hr 9
mg/24hr
4
desipramine hcl tab 150 mg
(Norpramin)
2
EMSAM - selegiline td patch 24hr 12
mg/24hr
4
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 50 mg
4
•
escitalopram oxalate soln 5 mg/5ml
(base equiv) (Lexapro)
2
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 100 mg
4
•
escitalopram oxalate tab 5 mg (base
equiv) (Lexapro)
1
escitalopram oxalate tab 10 mg
(base equiv) (Lexapro)
1
CELEXA - citalopram hydrobromide tab
40 mg (base equiv)
4
citalopram hydrobromide oral soln
10 mg/5ml
2
•
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
77
escitalopram oxalate tab 20 mg
(base equiv) (Lexapro)
1
FETZIMA - levomilnacipran hcl cap sr
24hr 20 mg (base equivalent)
4
FETZIMA - levomilnacipran hcl cap sr
24hr 40 mg (base equivalent)
imipramine pamoate cap 125 mg
(Tofranil-pm)
2
•
imipramine pamoate cap 150 mg
(Tofranil-pm)
2
4
•
IRENKA - duloxetine hcl enteric coated
pellets cap 40 mg
4
FETZIMA - levomilnacipran hcl cap sr
24hr 80 mg (base equivalent)
4
•
FETZIMA - levomilnacipran hcl cap sr
24hr 120 mg (base equivalent)
4
•
FETZIMA TITRATION PACK levomilnacipran hcl cap sr 24hr 20 &
40 mg therapy pack
4
•
FLUOXETINE HCL - fluoxetine hcl tab
60 mg
4
•
fluoxetine hcl cap delayed release
90 mg (Prozac weekly)
2
fluoxetine hcl cap 10 mg (Prozac)
1
fluoxetine hcl cap 20 mg (Prozac)
1
fluoxetine hcl cap 40 mg (Prozac)
1
fluoxetine hcl solution 20 mg/5ml
1
fluoxetine hcl tab 10 mg
1
fluoxetine hcl tab 20 mg
2
fluvoxamine maleate cap sr 24hr
100 mg (Luvox cr)
2
KHEDEZLA - desvenlafaxine tab sr 24hr 4
50 mg
KHEDEZLA - desvenlafaxine tab sr 24hr 4
100 mg
LEXAPRO - escitalopram oxalate soln 5 4
mg/5ml (base equiv)
4
LEXAPRO - escitalopram oxalate tab 5
mg (base equiv)
LEXAPRO - escitalopram oxalate tab 10 4
mg (base equiv)
LEXAPRO - escitalopram oxalate tab 20 4
mg (base equiv)
4
MAPROTILINE HCL - maprotiline hcl
tab 25 mg
4
MAPROTILINE HCL - maprotiline hcl
tab 50 mg
4
MAPROTILINE HCL - maprotiline hcl
tab 75 mg
4
MARPLAN - isocarboxazid tab 10 mg
2
mirtazapine orally disintegrating tab
15 mg (Remeron soltab)
2
fluvoxamine maleate cap sr 24hr
150 mg (Luvox cr)
2
mirtazapine orally disintegrating tab
30 mg (Remeron soltab)
2
fluvoxamine maleate tab 25 mg
fluvoxamine maleate tab 50 mg
2
fluvoxamine maleate tab 100 mg
mirtazapine orally disintegrating tab
45 mg (Remeron soltab)
2
2
mirtazapine tab 7.5 mg
2
mirtazapine tab 15 mg (Remeron)
1
mirtazapine tab 30 mg (Remeron)
1
mirtazapine tab 45 mg (Remeron)
1
NARDIL - phenelzine sulfate tab 15 mg
4
NEFAZODONE HCL - nefazodone hcl
tab 50 mg
4
FORFIVO XL - bupropion hcl tab sr 24hr 4
450 mg
1
imipramine hcl tab 10 mg (Tofranil)
imipramine hcl tab 25 mg (Tofranil)
1
imipramine hcl tab 50 mg (Tofranil)
1
imipramine pamoate cap 75 mg
(Tofranil-pm)
2
imipramine pamoate cap 100 mg
(Tofranil-pm)
2
78
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
• •
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
NEFAZODONE HCL - nefazodone hcl
tab 100 mg
4
paroxetine hcl tab sr 24hr 37.5 mg
(Paxil cr)
2
NEFAZODONE HCL - nefazodone hcl
tab 150 mg
4
paroxetine hcl tab 10 mg (Paxil)
1
paroxetine hcl tab 20 mg (Paxil)
1
NEFAZODONE HCL - nefazodone hcl
tab 200 mg
4
paroxetine hcl tab 30 mg (Paxil)
1
2
paroxetine hcl tab 40 mg (Paxil)
1
nefazodone hcl tab 250 mg
4
PAXIL - paroxetine hcl oral susp 10
mg/5ml (base equiv)
4
NORPRAMIN - desipramine hcl tab 10
mg
•
4
PAXIL - paroxetine hcl tab 10 mg
4
NORPRAMIN - desipramine hcl tab 25
mg
PAXIL - paroxetine hcl tab 20 mg
4
NORPRAMIN - desipramine hcl tab 50
mg
4
PAXIL - paroxetine hcl tab 30 mg
4
PAXIL - paroxetine hcl tab 40 mg
4
NORPRAMIN - desipramine hcl tab 75
mg
4
PAXIL CR - paroxetine hcl tab sr 24hr
12.5 mg
4
•
•
•
•
•
NORPRAMIN - desipramine hcl tab 100
mg
4
PAXIL CR - paroxetine hcl tab sr 24hr
25 mg
4
•
NORPRAMIN - desipramine hcl tab 150
mg
4
PAXIL CR - paroxetine hcl tab sr 24hr
37.5 mg
4
•
NORTRIPTYLINE HCL - nortriptyline hcl 4
soln 10 mg/5ml
nortriptyline hcl cap 10 mg (Pamelor) 1
PEXEVA - paroxetine mesylate tab 10
mg (base equiv)
4
•
PEXEVA - paroxetine mesylate tab 20
mg (base equiv)
4
•
PEXEVA - paroxetine mesylate tab 30
mg (base equiv)
4
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
nortriptyline hcl cap 25 mg (Pamelor)
1
nortriptyline hcl cap 50 mg (Pamelor)
1
nortriptyline hcl cap 75 mg (Pamelor)
1
4
•
PEXEVA - paroxetine mesylate tab 40
mg (base equiv)
4
OLEPTRO - trazodone hcl tab sr 24hr
150 mg
4
•
phenelzine sulfate tab 15 mg (Nardil)
2
OLEPTRO - trazodone hcl tab sr 24hr
300 mg
4
• •
PAMELOR - nortriptyline hcl cap 10 mg
4
PRISTIQ - desvenlafaxine succinate tab
sr 24hr 25 mg (base equiv)
4
PRISTIQ - desvenlafaxine succinate tab
sr 24hr 50 mg (base equiv)
4
PAMELOR - nortriptyline hcl cap 25 mg
• •
PAMELOR - nortriptyline hcl cap 50 mg
4
• •
4
PRISTIQ - desvenlafaxine succinate tab
sr 24hr 100 mg (base equiv)
4
PAMELOR - nortriptyline hcl cap 75 mg
PARNATE - tranylcypromine sulfate tab
10 mg
4
protriptyline hcl tab 5 mg (Vivactil)
2
protriptyline hcl tab 10 mg (Vivactil)
2
paroxetine hcl tab sr 24hr 12.5 mg
(Paxil cr)
2
PROZAC - fluoxetine hcl cap 10 mg
4
2
PROZAC - fluoxetine hcl cap 20 mg
4
paroxetine hcl tab sr 24hr 25 mg
(Paxil cr)
PROZAC - fluoxetine hcl cap 40 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
79
2
venlafaxine hcl cap sr 24hr 37.5 mg
(base equivalent) (Effexor xr)
1
venlafaxine hcl cap sr 24hr 75 mg
(base equivalent) (Effexor xr)
1
venlafaxine hcl cap sr 24hr 150 mg
(base equivalent) (Effexor xr)
1
VENLAFAXINE HCL ER - venlafaxine
hcl tab sr 24hr 37.5 mg (base
equivalent)
4
•
VENLAFAXINE HCL ER - venlafaxine
hcl tab sr 24hr 75 mg (base
equivalent)
4
•
VENLAFAXINE HCL ER - venlafaxine
hcl tab sr 24hr 150 mg (base
equivalent)
4
•
VENLAFAXINE HCL ER - venlafaxine
hcl tab sr 24hr 225 mg (base
equivalent)
4
•
venlafaxine hcl tab sr 24hr 37.5 mg
(base equivalent) (Venlafaxine hcl
er)
2
venlafaxine hcl tab sr 24hr 75 mg
(base equivalent) (Venlafaxine hcl
er)
2
venlafaxine hcl tab sr 24hr 150 mg
(base equivalent) (Venlafaxine hcl
er)
2
venlafaxine hcl tab 25 mg
2
venlafaxine hcl tab 37.5 mg
2
venlafaxine hcl tab 50 mg
2
venlafaxine hcl tab 75 mg
2
venlafaxine hcl tab 100 mg
2
VIIBRYD - vilazodone hcl tab starter kit
10 (7) & 20 (7) & 40 (16) mg
4
•
VIIBRYD - vilazodone hcl tab 10 mg
4
•
•
•
•
4
• •
REMERON - mirtazapine tab 15 mg
4
REMERON - mirtazapine tab 30 mg
4
REMERON - mirtazapine tab 45 mg
4
REMERON SOLTAB - mirtazapine
orally disintegrating tab 15 mg
4
•
•
•
•
REMERON SOLTAB - mirtazapine
orally disintegrating tab 30 mg
4
•
REMERON SOLTAB - mirtazapine
orally disintegrating tab 45 mg
4
•
sertraline hcl oral conc 20 mg/ml
(Zoloft)
2
sertraline hcl tab 25 mg (Zoloft)
1
sertraline hcl tab 50 mg (Zoloft)
1
sertraline hcl tab 100 mg (Zoloft)
1
SURMONTIL - trimipramine maleate
cap 25 mg
4
SURMONTIL - trimipramine maleate
cap 50 mg
4
SURMONTIL - trimipramine maleate
cap 100 mg
4
TOFRANIL - imipramine hcl tab 10 mg
4
TOFRANIL - imipramine hcl tab 25 mg
4
TOFRANIL - imipramine hcl tab 50 mg
4
TOFRANIL-PM - imipramine pamoate
cap 75 mg
4
TOFRANIL-PM - imipramine pamoate
cap 100 mg
4
TOFRANIL-PM - imipramine pamoate
cap 125 mg
4
TOFRANIL-PM - imipramine pamoate
cap 150 mg
4
tranylcypromine sulfate tab 10 mg
(Parnate)
2
trazodone hcl tab 50 mg
1
VIIBRYD - vilazodone hcl tab 20 mg
4
trazodone hcl tab 100 mg
1
VIIBRYD - vilazodone hcl tab 40 mg
4
trazodone hcl tab 150 mg
1
WELLBUTRIN - bupropion hcl tab 75
mg
4
Dispensing Limits
Step Therapy
trazodone hcl tab 300 mg
PROZAC WEEKLY - fluoxetine hcl cap
delayed release 90 mg
80
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
WELLBUTRIN - bupropion hcl tab 100
mg
4
•
CLOZAPINE ODT - clozapine orally
disintegrating tab 12.5 mg
4
•
WELLBUTRIN SR - bupropion hcl tab sr
12hr 100 mg
4
•
CLOZAPINE ODT - clozapine orally
disintegrating tab 25 mg
4
•
WELLBUTRIN SR - bupropion hcl tab sr
12hr 150 mg
4
•
CLOZAPINE ODT - clozapine orally
disintegrating tab 100 mg
4
•
WELLBUTRIN SR - bupropion hcl tab sr
12hr 200 mg
4
•
CLOZAPINE ODT - clozapine orally
disintegrating tab 150 mg
4
•
WELLBUTRIN XL - bupropion hcl tab sr
24hr 150 mg
4
•
CLOZAPINE ODT - clozapine orally
disintegrating tab 200 mg
4
•
WELLBUTRIN XL - bupropion hcl tab sr
24hr 300 mg
4
•
clozapine tab 25 mg (Clozaril)
2
2
ZOLOFT - sertraline hcl oral conc 20
mg/ml
•
clozapine tab 50 mg
4
clozapine tab 100 mg (Clozaril)
2
4
clozapine tab 200 mg
4
CLOZARIL - clozapine tab 25 mg
4
ZOLOFT - sertraline hcl tab 50 mg
4
CLOZARIL - clozapine tab 100 mg
4
ZOLOFT - sertraline hcl tab 100 mg
•
•
•
2
ZOLOFT - sertraline hcl tab 25 mg
•
•
•
•
•
•
COMPAZINE - prochlorperazine
maleate tab 5 mg (base equivalent)
4
COMPAZINE - prochlorperazine
maleate tab 10 mg (base equivalent)
4
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 100 mg
4
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 200 mg
4
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 300 mg
4
FANAPT - iloperidone tab 1 mg
4
FANAPT - iloperidone tab 2 mg
4
FANAPT - iloperidone tab 4 mg
4
FANAPT - iloperidone tab 6 mg
4
FANAPT - iloperidone tab 8 mg
4
FANAPT - iloperidone tab 10 mg
4
FANAPT - iloperidone tab 12 mg
4
FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg & 4 mg
& 6 mg titration pak
4
•
•
•
•
•
•
•
•
FAZACLO - clozapine orally
disintegrating tab 12.5 mg
4
•
ANTIPSYCHOTICS
ABILIFY - aripiprazole tab 2 mg
4
ABILIFY - aripiprazole tab 5 mg
4
ABILIFY - aripiprazole tab 10 mg
4
ABILIFY - aripiprazole tab 15 mg
4
ABILIFY - aripiprazole tab 20 mg
4
ABILIFY - aripiprazole tab 30 mg
4
ADASUVE - loxapine aerosol powder
breath activated 10 mg
4
aripiprazole tab 2 mg (Abilify)
2
aripiprazole tab 5 mg (Abilify)
2
aripiprazole tab 10 mg (Abilify)
2
aripiprazole tab 15 mg (Abilify)
2
aripiprazole tab 20 mg (Abilify)
2
aripiprazole tab 30 mg (Abilify)
2
chlorpromazine hcl tab 10 mg
2
chlorpromazine hcl tab 25 mg
2
chlorpromazine hcl tab 50 mg
2
chlorpromazine hcl tab 100 mg
2
chlorpromazine hcl tab 200 mg
2
•
•
•
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
81
FAZACLO - clozapine orally
disintegrating tab 25 mg
4
•
LITHIUM - lithium oral solution 8
meq/5ml
4
FAZACLO - clozapine orally
disintegrating tab 100 mg
4
•
LITHIUM CARBONATE - lithium
carbonate cap 150 mg
4
FAZACLO - clozapine orally
disintegrating tab 150 mg
4
•
LITHIUM CARBONATE - lithium
carbonate cap 600 mg
4
FAZACLO - clozapine orally
disintegrating tab 200 mg
4
•
lithium carbonate cap 150 mg
(Lithium carbonate)
1
FLUPHENAZINE HCL - fluphenazine
hcl elixir 2.5 mg/5ml
3
lithium carbonate cap 300 mg
1
FLUPHENAZINE HCL - fluphenazine
hcl oral conc 5 mg/ml
lithium carbonate cap 600 mg
(Lithium carbonate)
1
3
fluphenazine hcl tab 1 mg
lithium carbonate tab cr 300 mg
(Lithobid)
2
1
fluphenazine hcl tab 2.5 mg
1
lithium carbonate tab cr 450 mg
2
fluphenazine hcl tab 5 mg
1
lithium carbonate tab 300 mg
1
fluphenazine hcl tab 10 mg
1
GEODON - ziprasidone hcl cap 20 mg
4
GEODON - ziprasidone hcl cap 40 mg
4
LITHOBID - lithium carbonate tab cr 300 4
mg
2
loxapine succinate cap 5 mg
GEODON - ziprasidone hcl cap 60 mg
4
GEODON - ziprasidone hcl cap 80 mg
4
haloperidol lactate oral conc 2 mg/ml
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
loxapine succinate cap 10 mg
2
loxapine succinate cap 25 mg
2
1
loxapine succinate cap 50 mg
2
haloperidol tab 0.5 mg
1
2
•
haloperidol tab 1 mg
1
olanzapine orally disintegrating tab
5 mg (Zyprexa zydis)
1
olanzapine orally disintegrating tab
10 mg (Zyprexa zydis)
2
haloperidol tab 2 mg
•
haloperidol tab 5 mg
2
•
haloperidol tab 10 mg
olanzapine orally disintegrating tab
15 mg (Zyprexa zydis)
2
2
haloperidol tab 20 mg
2
2
•
INVEGA - paliperidone tab sr 24hr 1.5
mg
4
olanzapine orally disintegrating tab
20 mg (Zyprexa zydis)
olanzapine tab 2.5 mg (Zyprexa)
1
olanzapine tab 5 mg (Zyprexa)
1
olanzapine tab 7.5 mg (Zyprexa)
1
olanzapine tab 10 mg (Zyprexa)
2
olanzapine tab 15 mg (Zyprexa)
2
olanzapine tab 20 mg (Zyprexa)
2
•
•
•
•
•
•
perphenazine tab 2 mg
2
perphenazine tab 4 mg
2
perphenazine tab 8 mg
2
INVEGA - paliperidone tab sr 24hr 3 mg
4
INVEGA - paliperidone tab sr 24hr 6 mg
4
INVEGA - paliperidone tab sr 24hr 9 mg
4
LATUDA - lurasidone hcl tab 20 mg
4
LATUDA - lurasidone hcl tab 40 mg
4
LATUDA - lurasidone hcl tab 60 mg
4
LATUDA - lurasidone hcl tab 80 mg
4
LATUDA - lurasidone hcl tab 120 mg
4
82
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
prochlorperazine maleate tab 5 mg
(base equivalent) (Compazine)
Dispensing Limits
2
Step Therapy
perphenazine tab 16 mg
Prior Authorization
Drug Name
Drug Tier
2015
4
•
1
RISPERDAL M-TAB - risperidone orally
disintegrating tab 3 mg
4
•
prochlorperazine maleate tab 10 mg
(base equivalent) (Compazine)
1
RISPERDAL M-TAB - risperidone orally
disintegrating tab 4 mg
2
•
prochlorperazine suppos 25 mg
2
risperidone orally disintegrating tab
0.25 mg
quetiapine fumarate tab 25 mg
(Seroquel)
1
•
risperidone orally disintegrating tab
0.5 mg (Risperdal m-tab)
2
•
quetiapine fumarate tab 50 mg
(Seroquel)
1
•
risperidone orally disintegrating tab
1 mg (Risperdal m-tab)
2
•
quetiapine fumarate tab 100 mg
(Seroquel)
1
•
risperidone orally disintegrating tab
2 mg (Risperdal m-tab)
2
•
quetiapine fumarate tab 200 mg
(Seroquel)
2
•
risperidone orally disintegrating tab
3 mg (Risperdal m-tab)
2
•
quetiapine fumarate tab 300 mg
(Seroquel)
2
•
risperidone orally disintegrating tab
4 mg (Risperdal m-tab)
2
•
quetiapine fumarate tab 400 mg
(Seroquel)
2
•
risperidone soln 1 mg/ml (Risperdal)
2
risperidone tab 0.25 mg (Risperdal)
1
REXULTI - brexpiprazole tab 0.25 mg
4
risperidone tab 0.5 mg (Risperdal)
1
REXULTI - brexpiprazole tab 0.5 mg
4
risperidone tab 1 mg (Risperdal)
1
REXULTI - brexpiprazole tab 1 mg
4
risperidone tab 2 mg (Risperdal)
1
REXULTI - brexpiprazole tab 2 mg
4
risperidone tab 3 mg (Risperdal)
1
REXULTI - brexpiprazole tab 3 mg
4
risperidone tab 4 mg (Risperdal)
1
REXULTI - brexpiprazole tab 4 mg
4
4
RISPERDAL - risperidone soln 1 mg/ml
4
SAPHRIS - asenapine maleate sl tab
2.5 mg (base equiv)
•
•
•
•
•
•
•
•
RISPERDAL - risperidone tab 0.25 mg
4
4
•
RISPERDAL - risperidone tab 0.5 mg
4
SAPHRIS - asenapine maleate sl tab 5
mg (base equiv)
4
SAPHRIS - asenapine maleate sl tab 10
mg (base equiv)
4
RISPERDAL - risperidone tab 1 mg
•
RISPERDAL - risperidone tab 2 mg
4
•
RISPERDAL - risperidone tab 3 mg
SEROQUEL - quetiapine fumarate tab
25 mg
4
4
RISPERDAL - risperidone tab 4 mg
4
4
•
RISPERDAL M-TAB - risperidone orally
disintegrating tab 0.5 mg
4
SEROQUEL - quetiapine fumarate tab
50 mg
4
•
RISPERDAL M-TAB - risperidone orally
disintegrating tab 1 mg
4
•
SEROQUEL - quetiapine fumarate tab
100 mg
4
•
RISPERDAL M-TAB - risperidone orally
disintegrating tab 2 mg
4
•
SEROQUEL - quetiapine fumarate tab
200 mg
SEROQUEL - quetiapine fumarate tab
300 mg
4
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
83
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
SEROQUEL - quetiapine fumarate tab
400 mg
4
•
ZYPREXA ZYDIS - olanzapine orally
disintegrating tab 10 mg
4
•
SEROQUEL XR - quetiapine fumarate
tab sr 24hr 50 mg
3
•
ZYPREXA ZYDIS - olanzapine orally
disintegrating tab 15 mg
4
•
SEROQUEL XR - quetiapine fumarate
tab sr 24hr 150 mg
3
•
ZYPREXA ZYDIS - olanzapine orally
disintegrating tab 20 mg
4
•
SEROQUEL XR - quetiapine fumarate
tab sr 24hr 200 mg
3
•
HYPNOTICS
4
3
•
AMBIEN - zolpidem tartrate tab 5 mg
SEROQUEL XR - quetiapine fumarate
tab sr 24hr 300 mg
AMBIEN - zolpidem tartrate tab 10 mg
4
3
•
AMBIEN CR - zolpidem tartrate tab cr
6.25 mg
4
SEROQUEL XR - quetiapine fumarate
tab sr 24hr 400 mg
•
•
•
1
AMBIEN CR - zolpidem tartrate tab cr
12.5 mg
4
thioridazine hcl tab 10 mg
•
thioridazine hcl tab 25 mg
2
BELSOMRA - suvorexant tab 5 mg
4
thioridazine hcl tab 50 mg
2
BELSOMRA - suvorexant tab 10 mg
4
thioridazine hcl tab 100 mg
2
BELSOMRA - suvorexant tab 15 mg
4
thiothixene cap 1 mg
1
BELSOMRA - suvorexant tab 20 mg
4
•
•
•
•
thiothixene cap 2 mg
1
thiothixene cap 5 mg
BUTISOL SODIUM - butabarbital
sodium tab 30 mg
4
1
thiothixene cap 10 mg
2
4
trifluoperazine hcl tab 1 mg
2
BUTISOL SODIUM - butabarbital
sodium tab 50 mg
trifluoperazine hcl tab 2 mg
2
DORAL - quazepam tab 15 mg
4
trifluoperazine hcl tab 5 mg
2
EDLUAR - zolpidem tartrate sl tab 5 mg
4
trifluoperazine hcl tab 10 mg
2
EDLUAR - zolpidem tartrate sl tab 10
mg
4
estazolam tab 1 mg
1
estazolam tab 2 mg
1
eszopiclone tab 1 mg (Lunesta)
2
eszopiclone tab 2 mg (Lunesta)
2
eszopiclone tab 3 mg (Lunesta)
2
FLURAZEPAM HCL - flurazepam hcl
cap 15 mg
1
FLURAZEPAM HCL - flurazepam hcl
cap 30 mg
1
HALCION - triazolam tab 0.25 mg
4
HETLIOZ - tasimelteon capsule 20 mg
4
INTERMEZZO - zolpidem tartrate sl tab
1.75 mg
4
VERSACLOZ - clozapine susp 50 mg/ml 4
2
ziprasidone hcl cap 20 mg (Geodon)
ziprasidone hcl cap 40 mg (Geodon)
2
ziprasidone hcl cap 60 mg (Geodon)
2
ziprasidone hcl cap 80 mg (Geodon)
2
ZYPREXA - olanzapine tab 2.5 mg
4
ZYPREXA - olanzapine tab 5 mg
4
ZYPREXA - olanzapine tab 7.5 mg
4
ZYPREXA - olanzapine tab 10 mg
4
ZYPREXA - olanzapine tab 15 mg
4
ZYPREXA - olanzapine tab 20 mg
4
ZYPREXA ZYDIS - olanzapine orally
disintegrating tab 5 mg
4
84
•
•
•
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
•
•
•
LUNESTA - eszopiclone tab 1 mg
4
LUNESTA - eszopiclone tab 2 mg
4
LUNESTA - eszopiclone tab 3 mg
4
•
•
•
midazolam hcl syrup 2 mg/ml (base
equivalent)
1
PHENOBARBITAL - phenobarbital tab
15 mg
4
PHENOBARBITAL - phenobarbital tab
30 mg
4
PHENOBARBITAL - phenobarbital tab
60 mg
4
PHENOBARBITAL - phenobarbital tab
100 mg
4
phenobarbital elixir 20 mg/5ml
2
phenobarbital tab 16.2 mg
1
phenobarbital tab 32.4 mg
1
phenobarbital tab 64.8 mg
2
phenobarbital tab 97.2 mg
2
QUAZEPAM - quazepam tab 15 mg
4
RESTORIL - temazepam cap 7.5 mg
4
RESTORIL - temazepam cap 15 mg
4
RESTORIL - temazepam cap 22.5 mg
4
RESTORIL - temazepam cap 30 mg
4
ROZEREM - ramelteon tab 8 mg
4
SECONAL - secobarbital sodium cap
100 mg
4
SILENOR - doxepin hcl (sleep) tab 3 mg 4
(base equiv)
SILENOR - doxepin hcl (sleep) tab 6 mg 4
(base equiv)
4
SONATA - zaleplon cap 5 mg
SONATA - zaleplon cap 10 mg
4
temazepam cap 7.5 mg (Restoril)
2
temazepam cap 15 mg (Restoril)
1
temazepam cap 22.5 mg (Restoril)
2
•
•
•
•
•
Dispensing Limits
temazepam cap 30 mg (Restoril)
Step Therapy
•
Prior Authorization
4
Drug Tier
INTERMEZZO - zolpidem tartrate sl tab
3.5 mg
Step Therapy
Drug Name
Drug Name
Drug Tier
Dispensing Limits
Prior Authorization
2015
1
triazolam tab 0.125 mg
1
triazolam tab 0.25 mg (Halcion)
1
zaleplon cap 5 mg (Sonata)
1
zaleplon cap 10 mg (Sonata)
1
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
2
•
•
•
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
2
•
zolpidem tartrate tab 5 mg (Ambien)
1
zolpidem tartrate tab 10 mg (Ambien)
1
ZOLPIMIST - zolpidem tartrate oral
spray 5 mg/act
4
•
•
•
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
4
ADDERALL - amphetaminedextroamphetamine tab 5 mg
4
ADDERALL - amphetaminedextroamphetamine tab 7.5 mg
4
ADDERALL - amphetaminedextroamphetamine tab 10 mg
4
ADDERALL - amphetaminedextroamphetamine tab 12.5 mg
4
ADDERALL - amphetaminedextroamphetamine tab 15 mg
4
ADDERALL - amphetaminedextroamphetamine tab 20 mg
4
ADDERALL - amphetaminedextroamphetamine tab 30 mg
4
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 5 mg
4
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 10
mg
4
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 15
mg
4
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 20
mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
•
•
•
•
•
•
•
•
85
•
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 25
mg
4
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 30
mg
4
amphetamine-dextroamphetamine
cap sr 24hr 5 mg (Adderall xr)
2
•
amphetamine-dextroamphetamine
cap sr 24hr 10 mg (Adderall xr)
2
•
amphetamine-dextroamphetamine
cap sr 24hr 15 mg (Adderall xr)
2
•
amphetamine-dextroamphetamine
cap sr 24hr 20 mg (Adderall xr)
2
•
amphetamine-dextroamphetamine
cap sr 24hr 25 mg (Adderall xr)
2
•
amphetamine-dextroamphetamine
cap sr 24hr 30 mg (Adderall xr)
2
•
amphetamine-dextroamphetamine
tab 5 mg (Adderall)
2
•
amphetamine-dextroamphetamine
tab 7.5 mg (Adderall)
2
•
amphetamine-dextroamphetamine
tab 10 mg (Adderall)
2
•
amphetamine-dextroamphetamine
tab 12.5 mg (Adderall)
2
•
amphetamine-dextroamphetamine
tab 15 mg (Adderall)
2
•
amphetamine-dextroamphetamine
tab 20 mg (Adderall)
2
•
amphetamine-dextroamphetamine
tab 30 mg (Adderall)
2
•
APTENSIO XR - methylphenidate hcl
cap er 24hr 10 mg (xr)
4
•
APTENSIO XR - methylphenidate hcl
cap er 24hr 15 mg (xr)
4
•
APTENSIO XR - methylphenidate hcl
cap er 24hr 20 mg (xr)
4
•
APTENSIO XR - methylphenidate hcl
cap er 24hr 30 mg (xr)
4
•
86
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
APTENSIO XR - methylphenidate hcl
cap er 24hr 40 mg (xr)
4
•
APTENSIO XR - methylphenidate hcl
cap er 24hr 50 mg (xr)
4
•
APTENSIO XR - methylphenidate hcl
cap er 24hr 60 mg (xr)
4
•
caffeine citrate oral soln 60 mg/3ml
(10 mg/ml base equiv) (Cafcit)
2
clonidine hcl tab sr 12hr 0.1 mg
(Kapvay)
2
•
CONCERTA - methylphenidate hcl tab
sa osm 18 mg
4
•
CONCERTA - methylphenidate hcl tab
sa osm 27 mg
4
•
CONCERTA - methylphenidate hcl tab
sa osm 36 mg
4
•
CONCERTA - methylphenidate hcl tab
sa osm 54 mg
4
•
DAYTRANA - methylphenidate td patch
10 mg/9hr
4
•
DAYTRANA - methylphenidate td patch
15 mg/9hr
4
•
DAYTRANA - methylphenidate td patch
20 mg/9hr
4
•
DAYTRANA - methylphenidate td patch
30 mg/9hr
4
•
DESOXYN - methamphetamine hcl tab
5 mg
4
•
DEXEDRINE - dextroamphetamine
sulfate cap sr 24hr 5 mg
4
•
DEXEDRINE - dextroamphetamine
sulfate cap sr 24hr 10 mg
4
•
DEXEDRINE - dextroamphetamine
sulfate cap sr 24hr 15 mg
4
•
dexmethylphenidate hcl cap sr 24 hr
5 mg (Focalin xr)
2
•
dexmethylphenidate hcl cap sr 24 hr
10 mg (Focalin xr)
2
•
dexmethylphenidate hcl cap sr 24 hr
15 mg (Focalin xr)
2
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
dexmethylphenidate hcl cap sr 24 hr
20 mg (Focalin xr)
2
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 20 mg
4
•
dexmethylphenidate hcl cap sr 24 hr
30 mg (Focalin xr)
2
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 25 mg
4
•
dexmethylphenidate hcl cap sr 24 hr
40 mg (Focalin xr)
2
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 30 mg
4
•
dexmethylphenidate hcl tab 2.5 mg
(Focalin)
2
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 35 mg
4
•
dexmethylphenidate hcl tab 5 mg
(Focalin)
2
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 40 mg
4
•
dexmethylphenidate hcl tab 10 mg
(Focalin)
2
•
guanfacine hcl tab sr 24hr 1 mg
(base equiv) (Intuniv)
2
•
dextroamphetamine sulfate cap sr
24hr 5 mg (Dexedrine)
2
•
guanfacine hcl tab sr 24hr 2 mg
(base equiv) (Intuniv)
2
•
dextroamphetamine sulfate cap sr
24hr 10 mg (Dexedrine)
2
•
guanfacine hcl tab sr 24hr 3 mg
(base equiv) (Intuniv)
2
•
dextroamphetamine sulfate cap sr
24hr 15 mg (Dexedrine)
2
•
guanfacine hcl tab sr 24hr 4 mg
(base equiv) (Intuniv)
2
•
dextroamphetamine sulfate oral
solution 5 mg/5ml (Procentra)
2
•
INTUNIV - guanfacine hcl tab sr 24hr 1
mg (base equiv)
3
•
dextroamphetamine sulfate tab 5 mg
2
•
2
INTUNIV - guanfacine hcl tab sr 24hr 2
mg (base equiv)
3
dextroamphetamine sulfate tab
10 mg
•
•
3
•
EVEKEO - amphetamine sulfate tab 5
mg
4
•
INTUNIV - guanfacine hcl tab sr 24hr 3
mg (base equiv)
3
•
EVEKEO - amphetamine sulfate tab 10
mg
4
•
INTUNIV - guanfacine hcl tab sr 24hr 4
mg (base equiv)
4
•
FOCALIN - dexmethylphenidate hcl tab
2.5 mg
4
•
KAPVAY - clonidine hcl tab sr 12hr 0.1
mg
4
•
FOCALIN - dexmethylphenidate hcl tab
5 mg
4
•
METADATE CD - methylphenidate hcl
cap cr 10 mg
4
•
FOCALIN - dexmethylphenidate hcl tab
10 mg
4
•
METADATE CD - methylphenidate hcl
cap cr 20 mg
4
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 5 mg
4
•
METADATE CD - methylphenidate hcl
cap cr 30 mg
4
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 10 mg
4
•
METADATE CD - methylphenidate hcl
cap cr 40 mg
4
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 15 mg
4
•
METADATE CD - methylphenidate hcl
cap cr 50 mg
METADATE CD - methylphenidate hcl
cap cr 60 mg
4
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
87
methamphetamine hcl tab 5 mg
(Desoxyn)
2
•
METHYLIN - methylphenidate hcl chew
tab 2.5 mg
4
•
METHYLIN - methylphenidate hcl chew
tab 5 mg
4
•
METHYLIN - methylphenidate hcl chew
tab 10 mg
4
•
METHYLIN - methylphenidate hcl soln 5
mg/5ml
4
•
METHYLIN - methylphenidate hcl soln
10 mg/5ml
4
methylphenidate hcl cap cr 10 mg
(Metadate cd)
2
methylphenidate hcl cap cr 20 mg
(Metadate cd)
2
methylphenidate hcl cap cr 30 mg
(Metadate cd)
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm 27
mg
2
•
METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm 36
mg
2
•
METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm 54
mg
2
•
methylphenidate hcl soln 5 mg/5ml
(Methylin)
2
•
methylphenidate hcl soln 10 mg/5ml
(Methylin)
2
•
methylphenidate hcl tab cr 10 mg
4
•
methylphenidate hcl tab cr 20 mg
(Ritalin sr)
2
•
2
•
methylphenidate hcl tab 5 mg
(Ritalin)
2
•
methylphenidate hcl cap cr 40 mg
(Metadate cd)
2
•
methylphenidate hcl tab 10 mg
(Ritalin)
2
•
methylphenidate hcl cap cr 50 mg
(Metadate cd)
2
•
methylphenidate hcl tab 20 mg
(Ritalin)
2
•
methylphenidate hcl cap cr 60 mg
(Metadate cd)
2
•
modafinil tab 100 mg (Provigil)
2
modafinil tab 200 mg (Provigil)
2
methylphenidate hcl cap sr 24hr
20 mg (la) (Ritalin la)
2
•
NUVIGIL - armodafinil tab 50 mg
4
4
2
•
NUVIGIL - armodafinil tab 150 mg
methylphenidate hcl cap sr 24hr
30 mg (la) (Ritalin la)
NUVIGIL - armodafinil tab 200 mg
4
2
•
NUVIGIL - armodafinil tab 250 mg
4
methylphenidate hcl cap sr 24hr
40 mg (la) (Ritalin la)
4
methylphenidate hcl chew tab 2.5 mg
(Methylin)
2
PROCENTRA - dextroamphetamine
sulfate oral solution 5 mg/5ml
PROVIGIL - modafinil tab 100 mg
4
•
PROVIGIL - modafinil tab 200 mg
4
4
•
•
QUILLIVANT XR - methylphenidate hcl
for er susp 25 mg/5ml (5 mg/ml)
RITALIN - methylphenidate hcl tab 5 mg
4
RITALIN - methylphenidate hcl tab 10
mg
4
•
•
RITALIN - methylphenidate hcl tab 20
mg
4
•
methylphenidate hcl chew tab 5 mg
(Methylin)
2
methylphenidate hcl chew tab 10 mg
(Methylin)
2
METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm 18
mg
2
88
•
•
•
•
•
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
RITALIN LA - methylphenidate hcl cap
sr 24hr 10 mg (la)
4
•
ZENZEDI - dextroamphetamine sulfate
tab 7.5 mg
4
•
RITALIN LA - methylphenidate hcl cap
sr 24hr 20 mg (la)
4
•
ZENZEDI - dextroamphetamine sulfate
tab 15 mg
4
•
RITALIN LA - methylphenidate hcl cap
sr 24hr 30 mg (la)
4
•
ZENZEDI - dextroamphetamine sulfate
tab 20 mg
4
•
RITALIN LA - methylphenidate hcl cap
sr 24hr 40 mg (la)
4
•
ZENZEDI - dextroamphetamine sulfate
tab 30 mg
4
•
RITALIN LA - methylphenidate hcl cap
sr 24hr 60 mg (la)
4
•
STRATTERA - atomoxetine hcl cap 10
mg (base equiv)
4
•
STRATTERA - atomoxetine hcl cap 18
mg (base equiv)
4
•
STRATTERA - atomoxetine hcl cap 25
mg (base equiv)
4
•
STRATTERA - atomoxetine hcl cap 40
mg (base equiv)
4
•
PSYCHOTHERAPEUTIC and NEUROLOGICAL
AGENTS - MISC.
2
acamprosate calcium tab delayed
release 333 mg (Campral)
4
ACTIVE-PAC/GABAPENTIN gabapentin oral cap 300 mg &
lidocaine-menthol gel ther pk
AMPYRA - dalfampridine tab sr 12hr 10 5 •
mg
4
ANTABUSE - disulfiram tab 250 mg
STRATTERA - atomoxetine hcl cap 60
mg (base equiv)
4
•
ANTABUSE - disulfiram tab 500 mg
4
STRATTERA - atomoxetine hcl cap 80
mg (base equiv)
•
ARICEPT - donepezil hydrochloride tab
5 mg
4
4
STRATTERA - atomoxetine hcl cap 100
mg (base equiv)
•
ARICEPT - donepezil hydrochloride tab
10 mg
4
4
4
VYVANSE - lisdexamfetamine
dimesylate cap 10 mg
4
•
ARICEPT - donepezil hydrochloride tab
23 mg
5
4
•
AUBAGIO - teriflunomide tab 7 mg
VYVANSE - lisdexamfetamine
dimesylate cap 20 mg
AUBAGIO - teriflunomide tab 14 mg
5
4
•
AVONEX - interferon beta-1a for im inj
kit 30mcg (33mcg(6.6 mu)/vial)
5
VYVANSE - lisdexamfetamine
dimesylate cap 30 mg
• •
• •
• •
4
•
AVONEX - interferon beta-1a im inj kit
30 mcg/0.5ml
5
VYVANSE - lisdexamfetamine
dimesylate cap 40 mg
• •
VYVANSE - lisdexamfetamine
dimesylate cap 50 mg
4
•
• •
VYVANSE - lisdexamfetamine
dimesylate cap 60 mg
4
•
VYVANSE - lisdexamfetamine
dimesylate cap 70 mg
4
•
ZENZEDI - dextroamphetamine sulfate
tab 2.5 mg
4
•
AVONEX PEN - interferon beta-1a im inj 5
kit 30 mcg/0.5ml
BETASERON - interferon beta-1b for inj 5
kit 0.3 mg
4
BRISDELLE - paroxetine mesylate cap
7.5 mg (base equiv)
2
bupropion hcl (smoking deterrent)
tab sr 12hr 150 mg (Zyban)
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
89
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
CHANTIX - varenicline tartrate tab 0.5
mg (base equiv)
3
EXELON - rivastigmine td patch 24hr
9.5 mg/24hr
4
CHANTIX - varenicline tartrate tab 1 mg
(base equiv)
3
EXELON - rivastigmine td patch 24hr
13.3 mg/24hr
4
CHANTIX CONTINUING MONTH varenicline tartrate tab 1 mg (base
equiv)
3
EXELON - rivastigmine tartrate cap 1.5
mg
4
3
EXELON - rivastigmine tartrate cap 3
mg
4
CHANTIX STARTING MONTH PA varenicline tartrate tab 0.5 mg x 11 &
tab 1 mg x 42 pack
EXELON - rivastigmine tartrate cap 4.5
mg
4
CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab
5-12.5 mg
4
EXELON - rivastigmine tartrate cap 6
mg
4
4
EXTAVIA - interferon beta-1b for inj kit
0.3 mg
5
CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab
10-25 mg
fluoxetine hcl (pmdd) cap 10 mg
2
COMMIT - nicotine polacrilex lozenge 2
mg
4
fluoxetine hcl (pmdd) cap 20 mg
2
2
COMMIT - nicotine polacrilex lozenge 4
mg
4
GALANTAMINE HYDROBROMIDE galantamine hydrobromide oral soln 4
mg/ml
COPAXONE - glatiramer acetate soln
prefilled syringe 20 mg/ml
5
•
galantamine hydrobromide cap sr
24hr 8 mg (Razadyne er)
2
COPAXONE - glatiramer acetate soln
prefilled syringe 40 mg/ml
5
•
galantamine hydrobromide cap sr
24hr 16 mg (Razadyne er)
2
disulfiram tab 250 mg (Antabuse)
2
2
disulfiram tab 500 mg (Antabuse)
2
galantamine hydrobromide cap sr
24hr 24 mg (Razadyne er)
2
galantamine hydrobromide tab 4 mg
(Razadyne)
2
donepezil hydrochloride orally
disintegrating tab 5 mg
2
galantamine hydrobromide tab 8 mg
(Razadyne)
2
donepezil hydrochloride orally
disintegrating tab 10 mg (Aricept
odt)
2
donepezil hydrochloride tab 5 mg
(Aricept)
1
galantamine hydrobromide tab
12 mg (Razadyne)
5
• •
donepezil hydrochloride tab 10 mg
(Aricept)
1
GILENYA - fingolimod hcl cap 0.5 mg
(base equiv)
5
•
donepezil hydrochloride tab 23 mg
(Aricept)
2
glatiramer acetate soln prefilled
syringe 20 mg/ml (Copaxone)
4
•
ergoloid mesylates tab 1 mg
2
GRALISE - gabapentin (phn) tab 300
mg
4
GRALISE - gabapentin (phn) tab 600
mg
4
EXELON - rivastigmine td patch 24hr
4.6 mg/24hr
•
90
• •
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
GRALISE STARTER - gabapentin (phn)
tab starter pack 300 mg (9) & 600 mg
(69)
4
HORIZANT - gabapentin enacarbil tab
cr 300 mg
4
HORIZANT - gabapentin enacarbil tab
cr 600 mg
4
memantine hcl tab 5 mg (Namenda)
2
memantine hcl tab 10 mg (Namenda)
2
memantine hcl tab 5 mg (28) & 10 mg
(21) titration pak (Namenda titration
pa)
2
NAMENDA - memantine hcl oral
solution 2 mg/ml
•
NICORETTE - nicotine polacrilex gum 2
mg
4
4
•
NICORETTE - nicotine polacrilex gum 4
mg
4
•
NICORETTE - nicotine polacrilex
lozenge 2 mg
NICORETTE - nicotine polacrilex
lozenge 4 mg
4
NICORETTE MINI - nicotine polacrilex
lozenge 2 mg
4
NICORETTE MINI - nicotine polacrilex
lozenge 4 mg
4
4
NICORETTE STARTER KIT - nicotine
polacrilex gum 2 mg
4
NAMENDA - memantine hcl tab 5 mg
4
4
NAMENDA - memantine hcl tab 10 mg
4
NICORETTE STARTER KIT - nicotine
polacrilex gum 4 mg
NAMENDA TITRATION PAK memantine hcl tab 5 mg (28) & 10 mg
(21) titration pak
4
nicotine polacrilex gum 2 mg
2
nicotine polacrilex gum 4 mg
2
nicotine polacrilex lozenge 2 mg
2
NAMENDA XR - memantine hcl cap sr
24hr 7 mg
4
nicotine polacrilex lozenge 4 mg
2
4
nicotine td patch 24hr 7 mg/24hr
2
NAMENDA XR - memantine hcl cap sr
24hr 14 mg
nicotine td patch 24hr 14 mg/24hr
2
NAMENDA XR - memantine hcl cap sr
24hr 21 mg
4
nicotine td patch 24hr 21 mg/24hr
2
4
NAMENDA XR - memantine hcl cap sr
24hr 28 mg
4
NICOTINE TRANSDERMAL SYST nicotine td patch 24 hr kit 21-14-7
mg/24hr
NAMENDA XR TITRATION PACK memantine hcl cap sr 24hr 7 mg & 14
mg & 21 mg & 28 mg pack
4
NICOTROL INHALER - nicotine inhaler
system 10 mg (4 mg delivered)
3
NAMZARIC - memantine hcl-donepezil
hcl cap sr 24hr 14-10 mg
4
NAMZARIC - memantine hcl-donepezil
hcl cap sr 24hr 28-10 mg
4
NICODERM CQ - nicotine td patch 24hr
7 mg/24hr
4
NICODERM CQ - nicotine td patch 24hr
14 mg/24hr
4
NICODERM CQ - nicotine td patch 24hr
21 mg/24hr
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
NICOTROL NS - nicotine nasal spray 10 3
mg/ml (0.5 mg/spray)
3
NUEDEXTA - dextromethorphan hbrquinidine sulfate cap 20-10 mg
2
olanzapine-fluoxetine hcl cap
3-25 mg (Symbyax)
2
olanzapine-fluoxetine hcl cap
6-25 mg (Symbyax)
2
olanzapine-fluoxetine hcl cap
6-50 mg (Symbyax)
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
91
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
olanzapine-fluoxetine hcl cap
12-25 mg (Symbyax)
2
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 16 mg
4
olanzapine-fluoxetine hcl cap
12-50 mg (Symbyax)
2
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 24 mg
4
ORAP - pimozide tab 1 mg
4
5
•
ORAP - pimozide tab 2 mg
4
REBIF - interferon beta-1a inj 22
mcg/0.5ml (12mu/ml) (44 mcg/ml)
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 2-10
mg
4
REBIF - interferon beta-1a inj 44
mcg/0.5ml (24mu/ml) (88 mcg/ml)
5
•
5
•
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 2-25
mg
4
REBIF REBIDOSE - interferon beta-1a
inj 22 mcg/0.5ml (12mu/ml) (44 mcg/
ml)
5
•
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 4-10
mg
4
REBIF REBIDOSE - interferon beta-1a
inj 44 mcg/0.5ml (24mu/ml) (88 mcg/
ml)
5
•
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 4-25
mg
4
REBIF REBIDOSE TITRATION interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
5
•
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 4-50
mg
4
REBIF TITRATION PACK - interferon
beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22
mcg/0.5ml
2
PLEGRIDY - peginterferon beta-1a soln
pen-injector 125 mcg/0.5ml
5
•
rivastigmine tartrate cap 1.5 mg
(Exelon)
2
PLEGRIDY - peginterferon beta-1a soln
prefilled syringe 125 mcg/0.5ml
5
•
rivastigmine tartrate cap 3 mg
(Exelon)
2
PLEGRIDY STARTER PACK peginterferon beta-1a soln pen-inj 63
& 94 mcg/0.5ml pack
5
•
rivastigmine tartrate cap 4.5 mg
(Exelon)
rivastigmine tartrate cap 6 mg
(Exelon)
2
PLEGRIDY STARTER PACK peginterferon beta-1a soln pref syr 63
& 94 mcg/0.5ml pack
5
SARAFEM - fluoxetine hcl (pmdd) tab
10 mg
4
RAZADYNE - galantamine
hydrobromide tab 4 mg
SARAFEM - fluoxetine hcl (pmdd) tab
20 mg
4
4
SAVELLA - milnacipran hcl tab 12.5 mg
4
RAZADYNE - galantamine
hydrobromide tab 8 mg
4
SAVELLA - milnacipran hcl tab 25 mg
4
4
SAVELLA - milnacipran hcl tab 50 mg
4
RAZADYNE - galantamine
hydrobromide tab 12 mg
SAVELLA - milnacipran hcl tab 100 mg
4
RAZADYNE - galantamine
hydrobromide oral soln 4 mg/ml
4
4
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 8 mg
4
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) & 25
mg (8) & 50 mg (42) pak
92
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
•
•
SYMBYAX - olanzapine-fluoxetine hcl
cap 3-25 mg
4
butalbital-acetaminophen-caffeine
tab 50-325-40 mg (Esgic)
1
SYMBYAX - olanzapine-fluoxetine hcl
cap 6-25 mg
4
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
2
SYMBYAX - olanzapine-fluoxetine hcl
cap 6-50 mg
4
choline & magnesium salicylates liq
500 mg/5ml
2
SYMBYAX - olanzapine-fluoxetine hcl
cap 12-25 mg
4
2
SYMBYAX - olanzapine-fluoxetine hcl
cap 12-50 mg
4
CHOLINE MAGNESIUM TRISALI choline & magnesium salicylates tab
1000 mg
diflunisal tab 500 mg
2
TECFIDERA - dimethyl fumarate
capsule delayed release 120 mg
5
DISALCID - salsalate tab 500 mg
4
4
TECFIDERA - dimethyl fumarate
capsule delayed release 240 mg
•
DISALCID - salsalate tab 750 mg
5
TECFIDERA STARTER PACK dimethyl fumarate capsule dr starter
pack 120 mg & 240 mg
5
•
XENAZINE - tetrabenazine tab 12.5 mg
5
XENAZINE - tetrabenazine tab 25 mg
5
XYREM - sodium oxybate oral solution
500 mg/ml
5
ZYBAN - bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
4
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
acetaminophen-salicylamidephenyltoloxamine cap
300-200-20mg
1
aspirin chew tab 81 mg
1
EQUAGESIC - meprobamate-aspirin tab 4
200-325 mg
4
ESGIC - butalbital-acetaminophencaffeine tab 50-325-40 mg
4
FIORICET - butalbital-acetaminophencaffeine cap 50-300-40 mg
4
FIORICET - butalbital-acetaminophencaffeine tab 50-325-40 mg
4
FIORINAL - butalbital-aspirin-caffeine
cap 50-325-40 mg
4
LEVACET - aspirin-apap-salicylamidecaffeine tab 500-250-150-32.5 mg
4
ORBIVAN - butalbital-acetaminophencaffeine cap 50-300-40 mg
4
ORBIVAN CF - butalbitalacetaminophen tab 50-300 mg
2
salsalate tab 500 mg
ASPIRIN LOW DOSE - aspirin tab 81
mg
4
salsalate tab 750 mg
2
aspirin tab delayed release 81 mg
BUPAP - butalbital-acetaminophen tab
50-300 mg
4
VANATOL LQ - butalbitalacetaminophen-caffeine soln
50-325-40 mg/15ml
2
1
butalbital-acetaminophen tab
50-325 mg
1
ABSTRAL - fentanyl citrate sl tab 100
mcg (base equiv)
4
•
•
butalbital-acetaminophen-caffeine
cap 50-300-40 mg (Fioricet)
2
ABSTRAL - fentanyl citrate sl tab 200
mcg (base equiv)
4
•
•
butalbital-acetaminophen-caffeine
cap 50-325-40 mg
2
ABSTRAL - fentanyl citrate sl tab 300
mcg (base equiv)
4
•
•
ANALGESICS AND ANESTHETICS
ANALGESICS - NON-NARCOTIC
•
•
•
•
•
•
ANALGESICS - NARCOTIC
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
93
4
•
•
ABSTRAL - fentanyl citrate sl tab 800
mcg (base equiv)
4
•
•
acetaminophen w/ codeine soln
120-12 mg/5ml
1
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
1
acetaminophen w/ codeine tab
300-30 mg (Tylenol/codeine #3)
1
acetaminophen w/ codeine tab
300-60 mg (Tylenol/codeine #4)
1
ACTIQ - fentanyl citrate lozenge on a
handle 200 mcg
4
•
•
ACTIQ - fentanyl citrate lozenge on a
handle 400 mcg
4
•
•
ACTIQ - fentanyl citrate lozenge on a
handle 600 mcg
4
•
•
ACTIQ - fentanyl citrate lozenge on a
handle 800 mcg
4
•
•
ACTIQ - fentanyl citrate lozenge on a
handle 1200 mcg
4
•
•
ACTIQ - fentanyl citrate lozenge on a
handle 1600 mcg
4
•
•
ASPIRIN-CAFFEINE-DIHYDROC aspirin-caffeine-dihydrocodeine cap
356.4-30-16 mg
4
AVINZA - morphine sulfate beads cap sr 4
24hr 30 mg
AVINZA - morphine sulfate beads cap sr 4
24hr 45 mg
AVINZA - morphine sulfate beads cap sr 4
24hr 60 mg
AVINZA - morphine sulfate beads cap sr 4
24hr 75 mg
AVINZA - morphine sulfate beads cap sr 4
24hr 90 mg
94
•
•
•
•
•
Dispensing Limits
ABSTRAL - fentanyl citrate sl tab 600
mcg (base equiv)
AVINZA - morphine sulfate beads cap sr 4
24hr 120 mg
4
BUNAVAIL - buprenorphine-naloxone
buccal film 2.1-0.3 mg (base equiv)
4
BUNAVAIL - buprenorphine-naloxone
buccal film 4.2-0.7 mg (base equiv)
4
BUNAVAIL - buprenorphine-naloxone
buccal film 6.3-1 mg (base equiv)
2
buprenorphine hcl sl tab 2 mg (base
equiv)
2
buprenorphine hcl sl tab 8 mg (base
equiv)
2
buprenorphine hcl-naloxone hcl sl
tab 2-0.5 mg (base equiv)
2
buprenorphine hcl-naloxone hcl sl
tab 8-2 mg (base equiv)
2
butalbital-acetaminophen-caff w/
cod cap 50-300-40-30 mg (Fioricet/
codeine)
butalbital-acetaminophen-caff w/ cod 1
cap 50-325-40-30 mg
butalbital-aspirin-caff w/ codeine cap 2
50-325-40-30 mg (Fiorinal/codeine
#3)
2
butorphanol tartrate nasal soln
10 mg/ml
4
BUTRANS - buprenorphine td patch
weekly 5 mcg/hr
4
BUTRANS - buprenorphine td patch
weekly 7.5 mcg/hr
4
BUTRANS - buprenorphine td patch
weekly 10 mcg/hr
4
BUTRANS - buprenorphine td patch
weekly 15 mcg/hr
4
BUTRANS - buprenorphine td patch
weekly 20 mcg/hr
4
CAPITAL/CODEINE - acetaminophen
w/ codeine susp 120-12 mg/5ml
4
CODEINE SULFATE - codeine sulfate
tab 15 mg
Step Therapy
•
Prior Authorization
•
Drug Name
Drug Tier
4
Dispensing Limits
Prior Authorization
ABSTRAL - fentanyl citrate sl tab 400
mcg (base equiv)
Drug Name
Step Therapy
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
CODEINE SULFATE - codeine sulfate
tab 30 mg
2
EMBEDA - morphine-naltrexone cap cr
30-1.2 mg
4
•
CODEINE SULFATE - codeine sulfate
tab 60 mg
2
EMBEDA - morphine-naltrexone cap cr
50-2 mg
4
•
codeine sulfate tab 15 mg (Codeine
sulfate)
2
EMBEDA - morphine-naltrexone cap cr
60-2.4 mg
4
•
codeine sulfate tab 30 mg
2
4
•
codeine sulfate tab 60 mg
2
EMBEDA - morphine-naltrexone cap cr
80-3.2 mg
CONZIP - tramadol hcl cap sr 24hr
biphasic release 100 mg
4
•
EMBEDA - morphine-naltrexone cap cr
100-4 mg
4
•
CONZIP - tramadol hcl cap sr 24hr
biphasic release 200 mg
4
•
EXALGO - hydromorphone hcl tab er
24hr deter 8 mg
4
•
CONZIP - tramadol hcl cap sr 24hr
biphasic release 300 mg
4
•
EXALGO - hydromorphone hcl tab er
24hr deter 12 mg
4
•
DEMEROL - meperidine hcl tab 50 mg
4
4
•
DEMEROL - meperidine hcl tab 100 mg
4
EXALGO - hydromorphone hcl tab er
24hr deter 16 mg
4
EXALGO - hydromorphone hcl tab er
24hr deter 32 mg
4
DILAUDID - hydromorphone hcl liqd 1
mg/ml
•
DILAUDID - hydromorphone hcl tab 2
mg
4
•
DILAUDID - hydromorphone hcl tab 4
mg
4
DILAUDID - hydromorphone hcl tab 8
mg
4
DOLOPHINE - methadone hcl tab 10
mg
4
DOLOPHINE HCL - methadone hcl tab
5 mg
4
FENTANYL - fentanyl td patch 72hr 37.5 4
mcg/hr
FENTANYL - fentanyl td patch 72hr 62.5 4
mcg/hr
FENTANYL - fentanyl td patch 72hr 87.5 4
mcg/hr
2
fentanyl citrate lozenge on a handle
200 mcg (Actiq)
2
fentanyl citrate lozenge on a handle
400 mcg (Actiq)
2
fentanyl citrate lozenge on a handle
600 mcg (Actiq)
2
fentanyl citrate lozenge on a handle
800 mcg (Actiq)
2
fentanyl citrate lozenge on a handle
1200 mcg (Actiq)
2
fentanyl citrate lozenge on a handle
1600 mcg (Actiq)
2
fentanyl td patch 72hr 12 mcg/hr
(Duragesic)
2
fentanyl td patch 72hr 25 mcg/hr
(Duragesic)
DURAGESIC - fentanyl td patch 72hr 12 4
mcg/hr
DURAGESIC - fentanyl td patch 72hr 25 4
mcg/hr
DURAGESIC - fentanyl td patch 72hr 50 4
mcg/hr
DURAGESIC - fentanyl td patch 72hr 75 4
mcg/hr
4
DURAGESIC - fentanyl td patch 72hr
100 mcg/hr
4
EMBEDA - morphine-naltrexone cap cr
20-0.8 mg
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
95
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
fentanyl td patch 72hr 50 mcg/hr
(Duragesic)
2
•
hydrocodone-ibuprofen tab
2.5-200 mg (Reprexain)
2
fentanyl td patch 72hr 75 mcg/hr
(Duragesic)
2
•
hydrocodone-ibuprofen tab 5-200 mg
(Reprexain)
2
fentanyl td patch 72hr 100 mcg/hr
(Duragesic)
2
•
hydrocodone-ibuprofen tab
7.5-200 mg (Vicoprofen)
1
FENTORA - fentanyl citrate buccal tab
100 mcg (base equiv)
4
•
•
hydrocodone-ibuprofen tab
10-200 mg (Ibudone)
2
FENTORA - fentanyl citrate buccal tab
200 mcg (base equiv)
4
•
•
4
FENTORA - fentanyl citrate buccal tab
400 mcg (base equiv)
4
•
•
HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen soln
10-325 mg/15ml
4
FENTORA - fentanyl citrate buccal tab
600 mcg (base equiv)
4
•
HYDROMORPHONE HCL hydromorphone hcl suppos 3 mg
4
FENTORA - fentanyl citrate buccal tab
800 mcg (base equiv)
4
HYDROMORPHONE HCL ER hydromorphone hcl tab er 24hr deter
32 mg
FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap
50-300-40-30 mg
4
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
2
2
•
FIORINAL/CODEINE #3 - butalbitalaspirin-caff w/ codeine cap
50-325-40-30 mg
4
hydromorphone hcl tab er 24hr deter
8 mg (Exalgo)
hydromorphone hcl tab er 24hr deter
12 mg (Exalgo)
2
•
HYCET - hydrocodone-acetaminophen
soln 7.5-325 mg/15ml
4
hydromorphone hcl tab er 24hr deter
16 mg (Exalgo)
2
•
hydrocodone-acetaminophen soln
7.5-325 mg/15ml (Hycet)
2
hydromorphone hcl tab 2 mg
(Dilaudid)
1
hydrocodone-acetaminophen tab
2.5-325 mg
2
hydromorphone hcl tab 4 mg
(Dilaudid)
1
hydrocodone-acetaminophen tab
10-325 mg (Norco)
1
hydromorphone hcl tab 8 mg
(Dilaudid)
2
hydrocodone-acetaminophen tab
5-300 mg (Xodol)
2
HYSINGLA ER - hydrocodone bitartrate
tab er 24hr deter 20 mg
4
•
hydrocodone-acetaminophen tab
7.5-300 mg (Xodol)
2
HYSINGLA ER - hydrocodone bitartrate
tab er 24hr deter 30 mg
4
•
hydrocodone-acetaminophen tab
5-325 mg (Norco)
1
HYSINGLA ER - hydrocodone bitartrate
tab er 24hr deter 40 mg
4
•
hydrocodone-acetaminophen tab
7.5-325 mg (Norco)
1
HYSINGLA ER - hydrocodone bitartrate
tab er 24hr deter 60 mg
4
•
hydrocodone-acetaminophen tab
10-300 mg (Xodol)
2
HYSINGLA ER - hydrocodone bitartrate
tab er 24hr deter 80 mg
4
•
96
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
HYSINGLA ER - hydrocodone bitartrate
tab er 24hr deter 100 mg
4
•
METHADONE HCL - methadone hcl
soln 5 mg/5ml
4
HYSINGLA ER - hydrocodone bitartrate
tab er 24hr deter 120 mg
4
•
METHADONE HCL - methadone hcl
soln 10 mg/5ml
4
IBUDONE - hydrocodone-ibuprofen tab
10-200 mg
4
methadone hcl conc 10 mg/ml
(Methadose)
2
IONSYS - fentanyl hcl iontophoretic td
system 40 mcg/act (base equiv)
4
methadone hcl soln 5 mg/5ml
(Methadone hcl)
2
KADIAN - morphine sulfate cap sr 24hr
10 mg
4
•
methadone hcl soln 10 mg/5ml
(Methadone hcl)
2
KADIAN - morphine sulfate cap sr 24hr
20 mg
4
•
methadone hcl tab for oral susp
40 mg
2
KADIAN - morphine sulfate cap sr 24hr
30 mg
4
•
methadone hcl tab 5 mg (Dolophine
hcl)
1
KADIAN - morphine sulfate cap sr 24hr
40 mg
4
•
methadone hcl tab 10 mg (Dolophine)
1
4
•
METHADOSE - methadone hcl conc 10
mg/ml
4
KADIAN - morphine sulfate cap sr 24hr
50 mg
4
•
METHADOSE SUGAR-FREE methadone hcl conc 10 mg/ml
4
KADIAN - morphine sulfate cap sr 24hr
60 mg
KADIAN - morphine sulfate cap sr 24hr
80 mg
•
MORPHINE SULFATE - morphine
sulfate tab 15 mg
3
4
KADIAN - morphine sulfate cap sr 24hr
100 mg
•
MORPHINE SULFATE - morphine
sulfate tab 30 mg
3
4
3
KADIAN - morphine sulfate cap sr 24hr
200 mg
4
•
MORPHINE SULFATE - morphine
sulfate suppos 5 mg
4
•
•
MORPHINE SULFATE - morphine
sulfate suppos 10 mg
3
LAZANDA - fentanyl citrate nasal spray
100 mcg/act (base equiv)
LAZANDA - fentanyl citrate nasal spray
400 mcg/act (base equiv)
•
•
MORPHINE SULFATE - morphine
sulfate suppos 20 mg
3
4
LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg
MORPHINE SULFATE - morphine
sulfate suppos 30 mg
3
4
morphine sulfate (concentrate) oral
soln 20 mg/ml
2
morphine sulfate cap sr 24hr 10 mg
(Kadian)
2
•
morphine sulfate cap sr 24hr 20 mg
(Kadian)
2
•
morphine sulfate cap sr 24hr 30 mg
(Kadian)
2
•
MEPERIDINE HCL - meperidine hcl oral 4
soln 50 mg/5ml
1
meperidine hcl tab 50 mg (Demerol)
meperidine hcl tab 100 mg (Demerol)
2
MEPERIDINE HCL/PROMETHAZI meperidine w/ promethazine cap
50-25 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
97
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
morphine sulfate cap sr 24hr 50 mg
(Kadian)
2
•
MS CONTIN - morphine sulfate tab cr
200 mg
4
morphine sulfate cap sr 24hr 60 mg
(Kadian)
2
•
NORCO - hydrocodone-acetaminophen
tab 10-325 mg
4
morphine sulfate cap sr 24hr 80 mg
(Kadian)
2
•
NORCO - hydrocodone-acetaminophen
tab 5-325 mg
4
morphine sulfate cap sr 24hr 100 mg
(Kadian)
2
•
NORCO - hydrocodone-acetaminophen
tab 7.5-325 mg
4
MORPHINE SULFATE ER - morphine
sulfate beads cap sr 24hr 30 mg
2
•
NUCYNTA - tapentadol hcl tab 50 mg
4
4
MORPHINE SULFATE ER - morphine
sulfate beads cap sr 24hr 45 mg
•
NUCYNTA - tapentadol hcl tab 75 mg
2
NUCYNTA - tapentadol hcl tab 100 mg
4
2
•
NUCYNTA ER - tapentadol hcl tab sr
12hr 50 mg
4
MORPHINE SULFATE ER - morphine
sulfate beads cap sr 24hr 60 mg
•
•
•
•
2
•
NUCYNTA ER - tapentadol hcl tab sr
12hr 100 mg
4
MORPHINE SULFATE ER - morphine
sulfate beads cap sr 24hr 75 mg
•
2
•
NUCYNTA ER - tapentadol hcl tab sr
12hr 150 mg
4
MORPHINE SULFATE ER - morphine
sulfate beads cap sr 24hr 90 mg
•
2
•
NUCYNTA ER - tapentadol hcl tab sr
12hr 200 mg
4
MORPHINE SULFATE ER - morphine
sulfate beads cap sr 24hr 120 mg
•
1
NUCYNTA ER - tapentadol hcl tab sr
12hr 250 mg
4
morphine sulfate oral soln 10 mg/5ml
•
morphine sulfate oral soln 20 mg/5ml
2
4
morphine sulfate tab cr 15 mg (Ms
contin)
•
OPANA - oxymorphone hcl tab 5 mg
2
OPANA - oxymorphone hcl tab 10 mg
4
2
•
•
morphine sulfate tab cr 60 mg (Ms
contin)
2
•
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 5
mg
4
morphine sulfate tab cr 30 mg (Ms
contin)
4
•
morphine sulfate tab cr 100 mg (Ms
contin)
2
•
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter
7.5 mg
•
•
morphine sulfate tab cr 200 mg (Ms
contin)
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 10
mg
4
2
MS CONTIN - morphine sulfate tab cr
15 mg
4
•
4
•
MS CONTIN - morphine sulfate tab cr
30 mg
4
•
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 15
mg
4
•
MS CONTIN - morphine sulfate tab cr
60 mg
4
•
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 20
mg
MS CONTIN - morphine sulfate tab cr
100 mg
4
•
98
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
Dispensing Limits
•
oxycodone-ibuprofen tab 5-400 mg
2
OXYCONTIN - oxycodone hcl tab er
12hr deter 10 mg
3
•
OXYCONTIN - oxycodone hcl tab er
12hr deter 15 mg
3
•
Step Therapy
Drug Name
Drug Tier
Prior Authorization
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 30
mg
4
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 40
mg
4
4
OXYCONTIN - oxycodone hcl tab er
12hr deter 20 mg
3
OXYCODONE HCL - oxycodone hcl
conc 100 mg/5ml (20 mg/ml)
•
4
OXYCONTIN - oxycodone hcl tab er
12hr deter 30 mg
3
OXYCODONE HCL - oxycodone hcl
soln 5 mg/5ml
•
2
OXYCONTIN - oxycodone hcl tab er
12hr deter 40 mg
3
oxycodone hcl cap 5 mg
•
oxycodone hcl conc 100 mg/5ml
(20 mg/ml) (Oxycodone hcl)
2
3
•
OXYCODONE HCL ER - oxycodone hcl
tab er 12hr deter 10 mg
4
•
OXYCONTIN - oxycodone hcl tab er
12hr deter 60 mg
3
•
OXYCODONE HCL ER - oxycodone hcl
tab er 12hr deter 20 mg
4
•
OXYCONTIN - oxycodone hcl tab er
12hr deter 80 mg
oxymorphone hcl tab sr 12hr 5 mg
2
4
•
oxymorphone hcl tab sr 12hr 7.5 mg
2
OXYCODONE HCL ER - oxycodone hcl
tab er 12hr deter 40 mg
oxymorphone hcl tab sr 12hr 10 mg
2
OXYCODONE HCL ER - oxycodone hcl
tab er 12hr deter 80 mg
4
•
oxymorphone hcl tab sr 12hr 15 mg
2
oxymorphone hcl tab sr 12hr 20 mg
2
oxycodone hcl soln 5 mg/5ml
(Oxycodone hcl)
2
oxymorphone hcl tab sr 12hr 30 mg
2
oxymorphone hcl tab sr 12hr 40 mg
2
•
•
•
•
•
•
•
oxymorphone hcl tab 5 mg (Opana)
2
oxymorphone hcl tab 10 mg (Opana)
2
pentazocine w/ naloxone tab
50-0.5 mg
2
oxycodone hcl tab 5 mg (Roxicodone) 1
2
oxycodone hcl tab 10 mg
•
oxycodone hcl tab 15 mg
(Roxicodone)
2
oxycodone hcl tab 20 mg
2
oxycodone hcl tab 30 mg
(Roxicodone)
PERCOCET - oxycodone w/
acetaminophen tab 2.5-325 mg
4
2
oxycodone w/ acetaminophen tab
2.5-325 mg (Percocet)
PERCOCET - oxycodone w/
acetaminophen tab 5-325 mg
4
2
oxycodone w/ acetaminophen tab
5-325 mg (Percocet)
PERCOCET - oxycodone w/
acetaminophen tab 7.5-325 mg
4
1
2
PERCOCET - oxycodone w/
acetaminophen tab 10-325 mg
4
oxycodone w/ acetaminophen tab
7.5-325 mg (Percocet)
2
PERCODAN - oxycodone-aspirin tab
4.8355-325 mg
4
oxycodone w/ acetaminophen tab
10-325 mg (Percocet)
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
PRIMLEV - oxycodone w/
acetaminophen tab 5-300 mg
4
2
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
99
PRIMLEV - oxycodone w/
acetaminophen tab 10-300 mg
4
SYNALGOS-DC - aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg
4
REPREXAIN - hydrocodone-ibuprofen
tab 2.5-200 mg
4
TRAMADOL HCL ER - tramadol hcl cap
sr 24hr biphasic release 100 mg
4
•
REPREXAIN - hydrocodone-ibuprofen
tab 5-200 mg
4
TRAMADOL HCL ER - tramadol hcl cap
sr 24hr biphasic release 150 mg
4
•
ROXICET - oxycodone w/
acetaminophen soln 5-325 mg/5ml
4
TRAMADOL HCL ER - tramadol hcl cap
sr 24hr biphasic release 200 mg
4
•
ROXICODONE - oxycodone hcl tab 5
mg
4
TRAMADOL HCL ER - tramadol hcl cap
sr 24hr biphasic release 300 mg
4
•
ROXICODONE - oxycodone hcl tab 15
mg
4
tramadol hcl tab sr 24hr 100 mg
(Ultram er)
2
•
ROXICODONE - oxycodone hcl tab 30
mg
4
tramadol hcl tab sr 24hr 200 mg
(Ultram er)
2
•
SUBOXONE - buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base
equiv)
4
•
•
tramadol hcl tab sr 24hr 300 mg
(Ultram er)
2
•
•
•
SUBOXONE - buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
•
tramadol hcl tab sr 24hr biphasic
release 100 mg
2
4
2
•
SUBOXONE - buprenorphine hclnaloxone hcl sl film 8-2 mg (base
equiv)
4
•
•
tramadol hcl tab sr 24hr biphasic
release 200 mg
tramadol hcl tab sr 24hr biphasic
release 300 mg
2
•
4
•
•
tramadol hcl tab 50 mg (Ultram)
1
SUBOXONE - buprenorphine hclnaloxone hcl sl film 12-3 mg (base
equiv)
•
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
1
•
•
TREZIX - acetaminophen-caffeinedihydrocodeine cap 320.5-30-16 mg
4
•
•
TYLENOL/CODEINE - acetaminophen
w/ codeine tab 300-15 mg
4
•
•
4
•
•
TYLENOL/CODEINE #3 acetaminophen w/ codeine tab
300-30 mg
4
•
•
TYLENOL/CODEINE #4 acetaminophen w/ codeine tab
300-60 mg
•
•
ULTRACET - tramadol-acetaminophen
tab 37.5-325 mg
4
ULTRAM - tramadol hcl tab 50 mg
4
SUBSYS - fentanyl sublingual spray 100 4
mcg
SUBSYS - fentanyl sublingual spray 200 4
mcg
SUBSYS - fentanyl sublingual spray 400 4
mcg
SUBSYS - fentanyl sublingual spray 600 4
mcg
SUBSYS - fentanyl sublingual spray 800 4
mcg
4
SUBSYS - fentanyl sublingual spray
1200 mcg (600 mcg x 2)
100
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
4
Dispensing Limits
SUBSYS - fentanyl sublingual spray
1600 mcg (800 mcg x 2)
Step Therapy
4
Drug Tier
PRIMLEV - oxycodone w/
acetaminophen tab 7.5-300 mg
Drug Name
Prior Authorization
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
ULTRAM ER - tramadol hcl tab sr 24hr
100 mg
4
•
ANAPROX - naproxen sodium tab 275
mg
4
ULTRAM ER - tramadol hcl tab sr 24hr
200 mg
4
•
ANAPROX DS - naproxen sodium tab
550 mg
4
ULTRAM ER - tramadol hcl tab sr 24hr
300 mg
4
•
ARAVA - leflunomide tab 10 mg
4
ARAVA - leflunomide tab 20 mg
4
VICOPROFEN - hydrocodone-ibuprofen
tab 7.5-200 mg
4
ARCALYST - rilonacept for inj 220 mg
5
4
ARTHROTEC 50 - diclofenac w/
misoprostol tab delayed release
50-0.2 mg
4
XARTEMIS XR - oxycodone w/
acetaminophen tab cr 7.5-325 mg
XODOL - hydrocodone-acetaminophen
tab 5-300 mg
4
4
XODOL - hydrocodone-acetaminophen
tab 7.5-300 mg
4
ARTHROTEC 75 - diclofenac w/
misoprostol tab delayed release
75-0.2 mg
CELEBREX - celecoxib cap 50 mg
4
XODOL - hydrocodone-acetaminophen
tab 10-300 mg
4
CELEBREX - celecoxib cap 100 mg
4
4
CELEBREX - celecoxib cap 200 mg
4
ZAMICET - hydrocodoneacetaminophen soln 10-325 mg/15ml
CELEBREX - celecoxib cap 400 mg
4
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr abuse-deterrent 10 mg
4
celecoxib cap 50 mg (Celebrex)
2
celecoxib cap 100 mg (Celebrex)
2
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr abuse-deterrent 15 mg
4
celecoxib cap 200 mg (Celebrex)
2
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr abuse-deterrent 20 mg
•
celecoxib cap 400 mg (Celebrex)
2
4
DAYPRO - oxaprozin tab 600 mg
4
4
•
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr abuse-deterrent 40 mg
4
•
DERMA SILKRX ANODYNEXA PA diclofen dr tab 75mg-ranitidine tab
150mg-capsaicin cr thpk
4
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr abuse-deterrent 30 mg
4
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr abuse-deterrent 50 mg
4
•
DERMACINRX ANALGESIC COMB diclofenac sod tab dr 75 mg & lidomen-methyl sal ptch kit
DERMACINRX INFLAMMATRAL P diclofen dr tab 75mg-ranitidine tab
150mg-capsaicin cr thpk
4
diclofenac potassium tab 50 mg
(Cataflam)
2
diclofenac sodium tab delayed
release 25 mg
2
diclofenac sodium tab delayed
release 50 mg
2
diclofenac sodium tab delayed
release 75 mg
2
ZUBSOLV - buprenorphine hcl-naloxone 4
hcl sl tab 1.4-0.36 mg (base eq)
ZUBSOLV - buprenorphine hcl-naloxone 4
hcl sl tab 5.7-1.4 mg (base eq)
ZUBSOLV - buprenorphine hcl-naloxone 4
hcl sl tab 8.6-2.1 mg (base eq)
•
•
•
•
•
•
•
•
ANALGESICS - ANTI-INFLAMMATORY
ACTEMRA - tocilizumab subcutaneous
soln prefilled syringe 162 mg/0.9ml
5
• •
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
•
•
•
101
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
diclofenac sodium tab sr 24hr
100 mg (Voltaren-xr)
2
HUMIRA - adalimumab prefilled syringe
kit 10 mg/0.2ml
5
• •
diclofenac w/ misoprostol tab
delayed release 50-0.2 mg
(Arthrotec 50)
2
HUMIRA - adalimumab prefilled syringe
kit 20 mg/0.4ml
5
• •
• •
diclofenac w/ misoprostol tab
delayed release 75-0.2 mg
(Arthrotec 75)
HUMIRA - adalimumab prefilled syringe
kit 40 mg/0.8ml
5
2
5
• •
DUEXIS - ibuprofen-famotidine tab
800-26.6 mg
4
HUMIRA PEDIATRIC CROHNS D adalimumab prefilled syringe kit 40
mg/0.8ml
• •
EC-NAPROSYN - naproxen tab ec 375
mg
HUMIRA PEN - adalimumab peninjector kit 40 mg/0.8ml
5
4
• •
EC-NAPROSYN - naproxen tab ec 500
mg
HUMIRA PEN-CROHNS DISEASE adalimumab pen-injector kit 40
mg/0.8ml
5
4
ENBREL - etanercept for subcutaneous
inj kit 25 mg
5
• •
5
• •
ENBREL - etanercept subcutaneous
soln prefilled syringe 25 mg/0.5ml
5
• •
HUMIRA PEN-PSORIASIS STAR adalimumab pen-injector kit 40
mg/0.8ml
4
ENBREL - etanercept subcutaneous
soln prefilled syringe 50 mg/ml
5
• •
IBUPROFEN COMFORT PAC ibuprofen tab 800 mg & liniment
topical gel kit
ENBREL SURECLICK - etanercept
subcutaneous solution auto-injector
50 mg/ml
5
• •
ibuprofen tab 400 mg
1
ibuprofen tab 600 mg
1
ibuprofen tab 800 mg
1
etodolac cap 200 mg
2
etodolac cap 300 mg
IC 400 - ibuprofen tab 400 mg &
caffeine-vitamins cap kit
4
2
etodolac tab sr 24hr 400 mg
2
4
etodolac tab sr 24hr 500 mg
2
IC 800 - ibuprofen tab 800 mg &
caffeine-vitamins cap kit
etodolac tab sr 24hr 600 mg
2
4
etodolac tab 400 mg
2
INDOCIN - indomethacin susp 25
mg/5ml
2
INDOCIN - indomethacin suppos 50 mg
4
etodolac tab 500 mg
4
indomethacin cap cr 75 mg
2
FELDENE - piroxicam cap 10 mg
4
indomethacin cap 25 mg
1
FELDENE - piroxicam cap 20 mg
4
indomethacin cap 50 mg
1
FENOPROFEN CALCIUM - fenoprofen
calcium tab 600 mg
ketoprofen cap 50 mg
1
FENOPROFEN CALCIUM - fenoprofen
calcium cap 400 mg
4
ketoprofen cap 75 mg
1
4
flurbiprofen tab 50 mg
1
KETOPROFEN ER - ketoprofen cap sr
24hr 200 mg
flurbiprofen tab 100 mg
1
ketorolac tromethamine tab 10 mg
1
102
• •
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
KINERET - anakinra subcutaneous soln
prefilled syringe 100 mg/0.67ml
5
leflunomide tab 10 mg (Arava)
1
leflunomide tab 20 mg (Arava)
1
MECLOFENAMATE SODIUM meclofenamate sodium cap 50 mg
• •
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
naproxen sodium tab sr 24hr 500 mg
(base equiv) (Naprelan)
2
naproxen sodium tab 275 mg
(Anaprox)
1
4
naproxen sodium tab 550 mg
(Anaprox ds)
1
MECLOFENAMATE SODIUM meclofenamate sodium cap 100 mg
4
naproxen tab ec 375 mg (Ecnaprosyn)
1
mefenamic acid cap 250 mg (Ponstel)
2
1
MELOXICAM - meloxicam susp 7.5
mg/5ml
4
naproxen tab ec 500 mg (Ecnaprosyn)
naproxen tab 250 mg (Naprosyn)
1
MELOXICAM COMFORT PAC meloxicam tab 15 mg & liniment
topical gel kit
4
naproxen tab 375 mg (Naprosyn)
1
naproxen tab 500 mg (Naprosyn)
1
5
• •
meloxicam tab 7.5 mg (Mobic)
1
ORENCIA - abatacept subcutaneous
soln prefilled syringe 125 mg/ml
meloxicam tab 15 mg (Mobic)
1
5
• •
MOBIC - meloxicam tab 7.5 mg
4
OTEZLA - apremilast tab starter therapy
pack 10 mg & 20 mg & 30 mg
MOBIC - meloxicam tab 15 mg
4
OTEZLA - apremilast tab 30 mg
5
• •
MOBIC - meloxicam susp 7.5 mg/5ml
4
4
nabumetone tab 500 mg
1
OTREXUP - methotrexate soln pf autoinjector 10 mg/0.4ml
1
OTREXUP - methotrexate soln pf autoinjector 15 mg/0.4ml
4
nabumetone tab 750 mg
NALFON - fenoprofen calcium cap 400
mg
4
OTREXUP - methotrexate soln pf autoinjector 20 mg/0.4ml
4
NAPRELAN - naproxen sodium tab sr
24hr 375 mg (base equiv)
4
OTREXUP - methotrexate soln pf autoinjector 25 mg/0.4ml
4
NAPRELAN - naproxen sodium tab sr
24hr 500 mg (base equiv)
4
oxaprozin tab 600 mg (Daypro)
2
4
piroxicam cap 10 mg (Feldene)
2
NAPRELAN - naproxen sodium tab sr
24hr 750 mg (base equiv)
piroxicam cap 20 mg (Feldene)
2
NAPROSYN - naproxen tab 250 mg
4
4
NAPROSYN - naproxen tab 375 mg
4
PONSTEL - mefenamic acid cap 250
mg
4
PRASTERA - prasterone cap 200 mg &
ibuprofen tab 400 mg kit
4
NAPROSYN - naproxen tab 500 mg
NAPROSYN - naproxen susp 125
mg/5ml
4
RASUVO - methotrexate soln pf autoinjector 7.5 mg/0.15ml
4
NAPROXEN - naproxen susp 125
mg/5ml
2
RASUVO - methotrexate soln pf autoinjector 10 mg/0.2ml
4
NAPROXEN COMFORT PAC naproxen tab 500 mg & liniment
topical gel kit
4
RASUVO - methotrexate soln pf autoinjector 12.5 mg/0.25ml
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
103
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
RASUVO - methotrexate soln pf autoinjector 15 mg/0.3ml
4
VIMOVO - naproxen-esomeprazole
magnesium tab dr 500-20 mg
4
• •
RASUVO - methotrexate soln pf autoinjector 17.5 mg/0.35ml
4
XELJANZ - tofacitinib citrate tab 5 mg
(base equivalent)
5
• •
RASUVO - methotrexate soln pf autoinjector 20 mg/0.4ml
4
ZIPSOR - diclofenac potassium cap 25
mg
4
RASUVO - methotrexate soln pf autoinjector 22.5 mg/0.45ml
4
ZORVOLEX - diclofenac cap 18 mg
4
ZORVOLEX - diclofenac cap 35 mg
4
RASUVO - methotrexate soln pf autoinjector 25 mg/0.5ml
4
4
acetaminophen-isometheptenedichloral cap 325-65-100 mg
2
RASUVO - methotrexate soln pf autoinjector 27.5 mg/0.55ml
4
almotriptan malate tab 6.25 mg
(Axert)
2
RASUVO - methotrexate soln pf autoinjector 30 mg/0.6ml
•
4
almotriptan malate tab 12.5 mg
(Axert)
2
RHEUMATREX - methotrexate sodium
tab 2.5 mg (antirheumatic)
•
4
•
SIMPONI - golimumab subcutaneous
soln auto-injector 50 mg/0.5ml
5
• •
ALSUMA - sumatriptan succinate
solution auto-injector 6 mg/0.5ml
4
RIDAURA - auranofin cap 3 mg
4
•
SIMPONI - golimumab subcutaneous
soln auto-injector 100 mg/ml
5
• •
AMERGE - naratriptan hcl tab 1 mg
(base equiv)
4
•
SIMPONI - golimumab subcutaneous
soln prefilled syringe 50 mg/0.5ml
5
• •
AMERGE - naratriptan hcl tab 2.5 mg
(base equiv)
4
•
SIMPONI - golimumab subcutaneous
soln prefilled syringe 100 mg/ml
5
• •
AXERT - almotriptan malate tab 6.25
mg
4
•
SPRIX - ketorolac tromethamine nasal
spray 15.75 mg/spray
4
•
AXERT - almotriptan malate tab 12.5
mg
CAFERGOT - ergotamine w/ caffeine
tab 1-100 mg
4
sulindac tab 150 mg
1
sulindac tab 200 mg
CAMBIA - diclofenac potassium packet
50 mg
4
1
TIVORBEX - indomethacin cap 20 mg
4
4
TIVORBEX - indomethacin cap 40 mg
4
TOLMETIN SODIUM - tolmetin sodium
tab 200 mg
4
DIHYDROERGOTAMINE MESYLAT dihydroergotamine mesylate nasal
spray 4 mg/ml
4
TOLMETIN SODIUM - tolmetin sodium
tab 600 mg
4
ERGOMAR - ergotamine tartrate sl tab
2 mg
4
•
tolmetin sodium cap 400 mg
2
FROVA - frovatriptan succinate tab 2.5
mg (base equivalent)
4
IMITREX - sumatriptan nasal spray 5
mg/act
3
VIMOVO - naproxen-esomeprazole
magnesium tab dr 375-20 mg
•
IMITREX - sumatriptan nasal spray 20
mg/act
3
•
104
MIGRAINE PRODUCTS
• •
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
IMITREX - sumatriptan succinate tab 25
mg
4
•
RELPAX - eletriptan hydrobromide tab
20 mg (base equivalent)
4
•
IMITREX - sumatriptan succinate tab 50
mg
4
•
RELPAX - eletriptan hydrobromide tab
40 mg (base equivalent)
4
•
IMITREX - sumatriptan succinate tab
100 mg
4
•
rizatriptan benzoate orally
disintegrating tab 5 mg (Maxalt-mlt)
2
•
IMITREX - sumatriptan succinate inj 6
mg/0.5ml
4
•
2
•
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 4 mg/0.5ml
4
•
rizatriptan benzoate orally
disintegrating tab 10 mg (Maxaltmlt)
rizatriptan benzoate tab 5 mg
(Maxalt)
2
•
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 6 mg/0.5ml
4
rizatriptan benzoate tab 10 mg
(Maxalt)
2
•
•
IMITREX STATDOSE SYSTEM sumatriptan succinate solution autoinjector 4 mg/0.5ml
SUMATRIPTAN - sumatriptan nasal
spray 5 mg/act
4
4
SUMATRIPTAN - sumatriptan nasal
spray 20 mg/act
4
•
IMITREX STATDOSE SYSTEM sumatriptan succinate solution autoinjector 6 mg/0.5ml
4
SUMATRIPTAN SUCCINATE sumatriptan succinate solution
prefilled syringe 6 mg/0.5ml
4
•
isometheptene-caffeineacetaminophen tab 65-20-325 mg
(Prodrin)
2
SUMATRIPTAN SUCCINATE sumatriptan succinate inj 4 mg/0.5ml
4
•
sumatriptan succinate inj 6 mg/0.5ml
(Imitrex)
2
•
sumatriptan succinate solution auto- 2
injector 4 mg/0.5ml (Imitrex statdose
sys)
sumatriptan succinate solution auto- 2
injector 6 mg/0.5ml (Imitrex statdose
sys)
2
sumatriptan succinate solution
cartridge 4 mg/0.5ml (Imitrex
statdose ref)
2
sumatriptan succinate solution
cartridge 6 mg/0.5ml (Imitrex
statdose ref)
1
sumatriptan succinate tab 25 mg
(Imitrex)
1
sumatriptan succinate tab 50 mg
(Imitrex)
•
MAXALT - rizatriptan benzoate tab 5 mg 4
4
MAXALT - rizatriptan benzoate tab 10
mg
4
MAXALT-MLT - rizatriptan benzoate
orally disintegrating tab 5 mg
4
MAXALT-MLT - rizatriptan benzoate
orally disintegrating tab 10 mg
4
MIGERGOT - ergotamine w/ caffeine
suppos 2-100 mg
4
MIGRANAL - dihydroergotamine
mesylate nasal spray 4 mg/ml
naratriptan hcl tab 1 mg (base equiv) 2
(Amerge)
2
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
4
PRODRIN - isometheptene-caffeineacetaminophen tab 65-20-325 mg
•
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
•
•
105
SUMAVEL DOSEPRO - sumatriptan
succinate solution jet-injector 4
mg/0.5ml
4
•
SUMAVEL DOSEPRO - sumatriptan
succinate solution jet-injector 6
mg/0.5ml
4
TREXIMET - sumatriptan-naproxen
sodium tab 85-500 mg
4
•
zolmitriptan orally disintegrating tab
2.5 mg (Zomig zmt)
2
•
zolmitriptan orally disintegrating tab
5 mg (Zomig zmt)
2
•
zolmitriptan tab 2.5 mg (Zomig)
2
zolmitriptan tab 5 mg (Zomig)
2
ZOMIG - zolmitriptan tab 2.5 mg
4
ZOMIG - zolmitriptan tab 5 mg
4
ZOMIG - zolmitriptan nasal spray 2.5
mg/spray unit
4
•
•
•
•
•
ZOMIG - zolmitriptan nasal spray 5 mg/
spray unit
4
ZOMIG NASAL SPRAY - zolmitriptan
nasal spray 5 mg/spray unit
4
ZOMIG ZMT - zolmitriptan orally
disintegrating tab 2.5 mg
4
•
ZOMIG ZMT - zolmitriptan orally
disintegrating tab 5 mg
4
•
4
ZYLOPRIM - allopurinol tab 100 mg
4
ZYLOPRIM - allopurinol tab 300 mg
4
NEUROMUSCULAR DRUGS
GOUT AGENTS
•
ANTICONVULSANTS
APTIOM - eslicarbazepine acetate tab
200 mg
4
APTIOM - eslicarbazepine acetate tab
400 mg
4
APTIOM - eslicarbazepine acetate tab
600 mg
4
APTIOM - eslicarbazepine acetate tab
800 mg
4
BANZEL - rufinamide susp 40 mg/ml
4
BANZEL - rufinamide tab 200 mg
4
BANZEL - rufinamide tab 400 mg
4
carbamazepine cap sr 12hr 100 mg
(Carbatrol)
2
2
•
carbamazepine cap sr 12hr 200 mg
(Carbatrol)
2
•
carbamazepine cap sr 12hr 300 mg
(Carbatrol)
carbamazepine chew tab 100 mg
1
carbamazepine susp 100 mg/5ml
(Tegretol)
2
carbamazepine tab sr 12hr 200 mg
(Tegretol-xr)
2
2
allopurinol tab 100 mg (Zyloprim)
1
carbamazepine tab sr 12hr 400 mg
(Tegretol-xr)
allopurinol tab 300 mg (Zyloprim)
1
carbamazepine tab 200 mg (Tegretol)
1
COLCHICINE - colchicine cap 0.6 mg
4
4
COLCHICINE - colchicine tab 0.6 mg
4
CARBATROL - carbamazepine cap sr
12hr 100 mg
2
CARBATROL - carbamazepine cap sr
12hr 200 mg
4
colchicine w/ probenecid tab
0.5-500 mg
4
CARBATROL - carbamazepine cap sr
12hr 300 mg
4
COLCRYS - colchicine tab 0.6 mg
MITIGARE - colchicine cap 0.6 mg
4
CELONTIN - methsuximide cap 300 mg
4
probenecid tab 500 mg
2
ULORIC - febuxostat tab 40 mg
clonazepam orally disintegrating tab
0.125 mg
2
4
106
Dispensing Limits
ULORIC - febuxostat tab 80 mg
Step Therapy
•
Prior Authorization
1
Drug Tier
sumatriptan succinate tab 100 mg
(Imitrex)
Drug Name
Step Therapy
Drug Name
Drug Tier
Dispensing Limits
Prior Authorization
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
clonazepam orally disintegrating tab
0.25 mg
2
DILANTIN - phenytoin sodium extended
cap 100 mg
4
clonazepam orally disintegrating tab
0.5 mg
2
DILANTIN INFATABS - phenytoin chew
tab 50 mg
4
clonazepam orally disintegrating tab
1 mg
2
DILANTIN-125 - phenytoin susp 125
mg/5ml
4
clonazepam orally disintegrating tab
2 mg
2
divalproex sodium cap sprinkle
125 mg (Depakote sprinkles)
2
clonazepam tab 0.5 mg (Klonopin)
1
1
clonazepam tab 1 mg (Klonopin)
1
divalproex sodium tab delayed
release 125 mg (Depakote)
clonazepam tab 2 mg (Klonopin)
1
1
DEPAKENE - valproate sodium syrup
250 mg/5ml (base equiv)
4
divalproex sodium tab delayed
release 250 mg (Depakote)
2
DEPAKENE - valproic acid cap 250 mg
4
divalproex sodium tab delayed
release 500 mg (Depakote)
4
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
2
DEPAKOTE - divalproex sodium tab
delayed release 125 mg
4
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
2
DEPAKOTE - divalproex sodium tab
delayed release 250 mg
4
ethosuximide cap 250 mg (Zarontin)
2
DEPAKOTE - divalproex sodium tab
delayed release 500 mg
2
DEPAKOTE ER - divalproex sodium tab
sr 24 hr 250 mg
4
ethosuximide soln 250 mg/5ml
(Zarontin)
felbamate susp 600 mg/5ml (Felbatol)
2
DEPAKOTE ER - divalproex sodium tab
sr 24 hr 500 mg
4
felbamate tab 400 mg (Felbatol)
2
felbamate tab 600 mg (Felbatol)
2
DEPAKOTE SPRINKLES - divalproex
sodium cap sprinkle 125 mg
4
FELBATOL - felbamate susp 600
mg/5ml
4
DIASTAT ACUDIAL - diazepam rectal
gel delivery system 10 mg
3
FELBATOL - felbamate tab 400 mg
4
FELBATOL - felbamate tab 600 mg
4
DIASTAT ACUDIAL - diazepam rectal
gel delivery system 20 mg
3
FYCOMPA - perampanel tab 2 mg
4
3
FYCOMPA - perampanel tab 4 mg
4
DIASTAT PEDIATRIC - diazepam rectal
gel delivery system 2.5 mg
FYCOMPA - perampanel tab 6 mg
4
DIAZEPAM - diazepam rectal gel
delivery system 2.5 mg
4
FYCOMPA - perampanel tab 8 mg
4
FYCOMPA - perampanel tab 10 mg
4
DIAZEPAM - diazepam rectal gel
delivery system 10 mg
4
FYCOMPA - perampanel tab 12 mg
4
gabapentin cap 100 mg (Neurontin)
1
DIAZEPAM - diazepam rectal gel
delivery system 20 mg
4
gabapentin cap 300 mg (Neurontin)
1
4
gabapentin cap 400 mg (Neurontin)
1
DILANTIN - phenytoin sodium extended
cap 30 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
107
gabapentin oral soln 250 mg/5ml
(Neurontin)
2
LAMICTAL ODT - lamotrigine orally
disintegrating tab 25 mg
4
gabapentin tab 600 mg (Neurontin)
2
4
gabapentin tab 800 mg (Neurontin)
2
LAMICTAL ODT - lamotrigine orally
disintegrating tab 50 mg
GABITRIL - tiagabine hcl tab 2 mg
4
4
GABITRIL - tiagabine hcl tab 4 mg
4
LAMICTAL ODT - lamotrigine orally
disintegrating tab 100 mg
4
LAMICTAL ODT - lamotrigine orally
disintegrating tab 200 mg
4
GABITRIL - tiagabine hcl tab 12 mg
GABITRIL - tiagabine hcl tab 16 mg
4
KEPPRA - levetiracetam oral soln 100
mg/ml
LAMICTAL STARTER/NOT TAKI lamotrigine tab 25 mg (42) & 100 mg
(7) starter kit
4
4
KEPPRA - levetiracetam tab 250 mg
4
4
KEPPRA - levetiracetam tab 500 mg
4
KEPPRA - levetiracetam tab 750 mg
4
LAMICTAL STARTER/TAKING C lamotrigine tab 25 mg (84) & 100 mg
(14) starter kit
4
LAMICTAL STARTER/TAKING V lamotrigine tab 25 mg (35) starter kit
4
KEPPRA - levetiracetam tab 1000 mg
KEPPRA XR - levetiracetam tab sr 24hr
500 mg
4
LAMICTAL XR - lamotrigine tab sr 24hr
25 mg (21) & 50 mg (7) titration kit
4
KEPPRA XR - levetiracetam tab sr 24hr
750 mg
4
LAMICTAL XR - lamotrigine tab sr 24hr
25 (14) & 50 mg (14) & 100 mg(7) kit
4
KLONOPIN - clonazepam tab 0.5 mg
4
KLONOPIN - clonazepam tab 1 mg
LAMICTAL XR - lamotrigine tab sr 24hr
50 (14) & 100 mg(14) & 200 mg(7) kit
4
4
KLONOPIN - clonazepam tab 2 mg
4
4
LAMICTAL - lamotrigine tab 25 mg
4
LAMICTAL XR - lamotrigine tab sr 24hr
25 mg
LAMICTAL - lamotrigine tab 100 mg
4
4
LAMICTAL - lamotrigine tab 150 mg
4
LAMICTAL XR - lamotrigine tab sr 24hr
50 mg
4
LAMICTAL XR - lamotrigine tab sr 24hr
100 mg
4
LAMICTAL - lamotrigine tab 200 mg
LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible
5 mg
4
LAMICTAL XR - lamotrigine tab sr 24hr
200 mg
4
4
LAMICTAL XR - lamotrigine tab sr 24hr
250 mg
4
LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible
25 mg
4
LAMICTAL ODT - lamotrigine tab disp
25 mg (21) & 50 mg (7) titration kit
4
LAMICTAL XR - lamotrigine tab sr 24hr
300 mg
2
LAMICTAL ODT - lamotrigine tab disp
50 mg (42) & 100 mg (14) titration kit
4
lamotrigine orally disintegrating tab
25 mg (Lamictal odt)
2
LAMICTAL ODT - lamotrigine tab disp
25 (14) & 50 mg (14) & 100 mg (7) kit
4
lamotrigine orally disintegrating tab
50 mg (Lamictal odt)
lamotrigine orally disintegrating tab
100 mg (Lamictal odt)
2
108
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
LYRICA - pregabalin cap 225 mg
4
LYRICA - pregabalin cap 300 mg
4
MYSOLINE - primidone tab 50 mg
4
MYSOLINE - primidone tab 250 mg
4
lamotrigine tab chewable dispersible
5 mg (Lamictal chewable di)
2
lamotrigine tab chewable dispersible
25 mg (Lamictal chewable di)
2
lamotrigine tab sr 24hr 25 mg
(Lamictal xr)
2
NEURONTIN - gabapentin oral soln 250
mg/5ml
4
lamotrigine tab sr 24hr 50 mg
(Lamictal xr)
2
NEURONTIN - gabapentin cap 100 mg
4
NEURONTIN - gabapentin cap 300 mg
4
lamotrigine tab sr 24hr 100 mg
(Lamictal xr)
2
NEURONTIN - gabapentin cap 400 mg
4
NEURONTIN - gabapentin tab 600 mg
4
lamotrigine tab sr 24hr 200 mg
(Lamictal xr)
2
NEURONTIN - gabapentin tab 800 mg
4
2
ONFI - clobazam suspension 2.5 mg/ml
4
lamotrigine tab sr 24hr 250 mg
(Lamictal xr)
ONFI - clobazam tab 10 mg
4
lamotrigine tab sr 24hr 300 mg
(Lamictal xr)
2
ONFI - clobazam tab 20 mg
4
2
lamotrigine tab 25 mg (Lamictal)
1
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
lamotrigine tab 100 mg (Lamictal)
1
oxcarbazepine tab 150 mg (Trileptal)
2
lamotrigine tab 150 mg (Lamictal)
1
oxcarbazepine tab 300 mg (Trileptal)
2
lamotrigine tab 200 mg (Lamictal)
1
oxcarbazepine tab 600 mg (Trileptal)
2
levetiracetam oral soln 100 mg/ml
(Keppra)
2
OXTELLAR XR - oxcarbazepine tab sr
24hr 150 mg
4
levetiracetam tab sr 24hr 500 mg
(Keppra xr)
2
OXTELLAR XR - oxcarbazepine tab sr
24hr 300 mg
4
levetiracetam tab sr 24hr 750 mg
(Keppra xr)
2
OXTELLAR XR - oxcarbazepine tab sr
24hr 600 mg
4
levetiracetam tab 250 mg (Keppra)
2
PEGANONE - ethotoin tab 250 mg
4
levetiracetam tab 500 mg (Keppra)
2
4
levetiracetam tab 750 mg (Keppra)
2
PHENYTEK - phenytoin sodium
extended cap 200 mg
2
LYRICA - pregabalin soln 20 mg/ml
4
PHENYTEK - phenytoin sodium
extended cap 300 mg
4
levetiracetam tab 1000 mg (Keppra)
4
phenytoin chew tab 50 mg (Dilantin
infatabs)
2
LYRICA - pregabalin cap 25 mg
LYRICA - pregabalin cap 50 mg
4
2
LYRICA - pregabalin cap 75 mg
4
phenytoin sodium extended cap
100 mg (Dilantin)
LYRICA - pregabalin cap 100 mg
4
phenytoin susp 125 mg/5ml (Dilantin)
2
LYRICA - pregabalin cap 150 mg
4
POTIGA - ezogabine tab 50 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
4
2
Step Therapy
LYRICA - pregabalin cap 200 mg
lamotrigine orally disintegrating tab
200 mg (Lamictal odt)
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
109
4
POTIGA - ezogabine tab 300 mg
4
4
POTIGA - ezogabine tab 400 mg
4
TOPAMAX SPRINKLE - topiramate
sprinkle cap 15 mg
primidone tab 50 mg (Mysoline)
1
4
primidone tab 250 mg (Mysoline)
1
TOPAMAX SPRINKLE - topiramate
sprinkle cap 25 mg
4
TOPIRAMATE ER - topiramate cap er
24hr sprinkle 25 mg
4
QUDEXY XR - topiramate cap er 24hr
sprinkle 25 mg
4
TOPIRAMATE ER - topiramate cap er
24hr sprinkle 50 mg
4
QUDEXY XR - topiramate cap er 24hr
sprinkle 50 mg
4
TOPIRAMATE ER - topiramate cap er
24hr sprinkle 100 mg
4
QUDEXY XR - topiramate cap er 24hr
sprinkle 100 mg
4
TOPIRAMATE ER - topiramate cap er
24hr sprinkle 150 mg
4
QUDEXY XR - topiramate cap er 24hr
sprinkle 150 mg
4
TOPIRAMATE ER - topiramate cap er
24hr sprinkle 200 mg
4
QUDEXY XR - topiramate cap er 24hr
sprinkle 200 mg
3
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
2
SABRIL - vigabatrin tab 500 mg
SABRIL - vigabatrin powd pack 500 mg
3
STAVZOR - valproic acid cap delayed
release 125 mg
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
2
4
topiramate tab 25 mg (Topamax)
1
STAVZOR - valproic acid cap delayed
release 250 mg
4
topiramate tab 50 mg (Topamax)
1
4
topiramate tab 100 mg (Topamax)
1
STAVZOR - valproic acid cap delayed
release 500 mg
topiramate tab 200 mg (Topamax)
1
TEGRETOL - carbamazepine tab 200
mg
4
TRILEPTAL - oxcarbazepine susp 300
mg/5ml (60 mg/ml)
4
TEGRETOL - carbamazepine susp 100
mg/5ml
4
TRILEPTAL - oxcarbazepine tab 150
mg
4
TEGRETOL-XR - carbamazepine tab sr
12hr 100 mg
4
TRILEPTAL - oxcarbazepine tab 300
mg
4
TEGRETOL-XR - carbamazepine tab sr
12hr 200 mg
4
TRILEPTAL - oxcarbazepine tab 600
mg
4
TEGRETOL-XR - carbamazepine tab sr
12hr 400 mg
4
TROKENDI XR - topiramate cap sr 24hr
25 mg
4
tiagabine hcl tab 2 mg (Gabitril)
2
4
tiagabine hcl tab 4 mg (Gabitril)
2
TROKENDI XR - topiramate cap sr 24hr
50 mg
4
TROKENDI XR - topiramate cap sr 24hr
100 mg
4
TOPAMAX - topiramate tab 25 mg
TOPAMAX - topiramate tab 50 mg
4
TOPAMAX - topiramate tab 100 mg
TROKENDI XR - topiramate cap sr 24hr
200 mg
4
4
110
Dispensing Limits
TOPAMAX - topiramate tab 200 mg
Step Therapy
4
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
POTIGA - ezogabine tab 200 mg
Prior Authorization
Drug Name
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
valproate sodium syrup 250 mg/5ml
(base equiv) (Depakene)
2
carbidopa & levodopa orally
disintegrating tab 25-250 mg
2
valproic acid cap 250 mg (Depakene)
2
2
VIMPAT - lacosamide oral solution 10
mg/ml
4
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
2
VIMPAT - lacosamide tab 50 mg
4
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
VIMPAT - lacosamide tab 100 mg
4
1
VIMPAT - lacosamide tab 150 mg
4
carbidopa & levodopa tab 10-100 mg
(Sinemet)
4
carbidopa & levodopa tab 25-100 mg
(Sinemet)
2
VIMPAT - lacosamide tab 200 mg
ZARONTIN - ethosuximide cap 250 mg
4
ZARONTIN - ethosuximide soln 250
mg/5ml
carbidopa & levodopa tab 25-250 mg
(Sinemet)
2
4
carbidopa tab 25 mg (Lodosyn)
2
ZONEGRAN - zonisamide cap 25 mg
4
4
ZONEGRAN - zonisamide cap 100 mg
4
zonisamide cap 25 mg (Zonegran)
2
CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs
12.5-50-200 mg
zonisamide cap 50 mg
2
4
zonisamide cap 100 mg (Zonegran)
2
CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs
18.75-75-200 mg
CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs
25-100-200 mg
4
CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs
31.25-125-200 mg
4
CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs
37.5-150-200 mg
4
CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs
50-200-200 mg
4
COMTAN - entacapone tab 200 mg
4
4
ANTIPARKINSON AGENTS
AMANTADINE HCL - amantadine hcl
tab 100 mg
4
amantadine hcl cap 100 mg
2
amantadine hcl syrup 50 mg/5ml
1
APOKYN - apomorphine hydrochloride
inj 10 mg/ml
5
AZILECT - rasagiline mesylate tab 0.5
mg (base equiv)
4
AZILECT - rasagiline mesylate tab 1 mg
(base equiv)
4
benztropine mesylate tab 0.5 mg
1
benztropine mesylate tab 1 mg
1
benztropine mesylate tab 2 mg
1
DUOPA - carbidopa-levodopa enteral
susp 4.63-20 mg/ml
bromocriptine mesylate cap 5 mg
(Parlodel)
2
ELDEPRYL - selegiline hcl cap 5 mg
4
entacapone tab 200 mg (Comtan)
2
bromocriptine mesylate tab 2.5 mg
2
LODOSYN - carbidopa tab 25 mg
4
carbidopa & levodopa orally
disintegrating tab 10-100 mg
2
carbidopa & levodopa orally
disintegrating tab 25-100 mg
2
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
MIRAPEX - pramipexole dihydrochloride 4
tab 0.125 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
111
MIRAPEX - pramipexole dihydrochloride 4
tab 0.25 mg
MIRAPEX - pramipexole dihydrochloride 4
tab 0.5 mg
MIRAPEX - pramipexole dihydrochloride 4
tab 0.75 mg
MIRAPEX - pramipexole dihydrochloride 4
tab 1 mg
MIRAPEX - pramipexole dihydrochloride 4
tab 1.5 mg
4
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 0.375 mg
4
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 0.75 mg
4
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 1.5 mg
4
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 2.25 mg
4
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 3 mg
4
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 3.75 mg
4
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 4.5 mg
4
NEUPRO - rotigotine td patch 24hr 1
mg/24hr
4
NEUPRO - rotigotine td patch 24hr 2
mg/24hr
4
NEUPRO - rotigotine td patch 24hr 3
mg/24hr
4
NEUPRO - rotigotine td patch 24hr 4
mg/24hr
4
NEUPRO - rotigotine td patch 24hr 6
mg/24hr
4
NEUPRO - rotigotine td patch 24hr 8
mg/24hr
4
PARLODEL - bromocriptine mesylate
cap 5 mg
2
pramipexole dihydrochloride tab sr
24hr 0.375 mg (Mirapex er)
112
pramipexole dihydrochloride tab sr
24hr 0.75 mg (Mirapex er)
2
pramipexole dihydrochloride tab sr
24hr 1.5 mg (Mirapex er)
2
pramipexole dihydrochloride tab sr
24hr 3 mg (Mirapex er)
2
pramipexole dihydrochloride tab
0.125 mg (Mirapex)
1
pramipexole dihydrochloride tab
0.25 mg (Mirapex)
1
pramipexole dihydrochloride tab
0.5 mg (Mirapex)
1
pramipexole dihydrochloride tab
0.75 mg (Mirapex)
1
pramipexole dihydrochloride tab
1 mg (Mirapex)
1
pramipexole dihydrochloride tab
1.5 mg (Mirapex)
1
REQUIP - ropinirole hydrochloride tab
0.25 mg
4
REQUIP - ropinirole hydrochloride tab
0.5 mg
4
REQUIP - ropinirole hydrochloride tab 1
mg
4
REQUIP - ropinirole hydrochloride tab 2
mg
4
REQUIP - ropinirole hydrochloride tab 3
mg
4
REQUIP - ropinirole hydrochloride tab 4
mg
4
REQUIP - ropinirole hydrochloride tab 5
mg
4
REQUIP XL - ropinirole hydrochloride
tab sr 24hr 2 mg (base equivalent)
4
REQUIP XL - ropinirole hydrochloride
tab sr 24hr 4 mg (base equivalent)
4
REQUIP XL - ropinirole hydrochloride
tab sr 24hr 6 mg (base equivalent)
4
REQUIP XL - ropinirole hydrochloride
tab sr 24hr 8 mg (base equivalent)
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
REQUIP XL - ropinirole hydrochloride
tab sr 24hr 12 mg (base equivalent)
4
SINEMET - carbidopa & levodopa tab
25-250 mg
4
ropinirole hydrochloride tab sr 24hr
2 mg (base equivalent) (Requip xl)
2
SINEMET CR - carbidopa & levodopa
tab cr 25-100 mg
4
ropinirole hydrochloride tab sr 24hr
4 mg (base equivalent) (Requip xl)
2
SINEMET CR - carbidopa & levodopa
tab cr 50-200 mg
4
ropinirole hydrochloride tab sr 24hr
6 mg (base equivalent) (Requip xl)
2
STALEVO 100 - carbidopa-levodopaentacapone tabs 25-100-200 mg
4
ropinirole hydrochloride tab sr 24hr
8 mg (base equivalent) (Requip xl)
2
STALEVO 125 - carbidopa-levodopaentacapone tabs 31.25-125-200 mg
4
ropinirole hydrochloride tab sr 24hr
12 mg (base equivalent) (Requip xl)
2
STALEVO 150 - carbidopa-levodopaentacapone tabs 37.5-150-200 mg
4
ropinirole hydrochloride tab 0.25 mg
(Requip)
1
STALEVO 200 - carbidopa-levodopaentacapone tabs 50-200-200 mg
4
ropinirole hydrochloride tab 0.5 mg
(Requip)
1
STALEVO 50 - carbidopa-levodopaentacapone tabs 12.5-50-200 mg
4
ropinirole hydrochloride tab 1 mg
(Requip)
1
STALEVO 75 - carbidopa-levodopaentacapone tabs 18.75-75-200 mg
4
ropinirole hydrochloride tab 2 mg
(Requip)
1
TASMAR - tolcapone tab 100 mg
4
tolcapone tab 100 mg (Tasmar)
2
ropinirole hydrochloride tab 3 mg
(Requip)
1
trihexyphenidyl hcl elixir 0.4 mg/ml
2
1
trihexyphenidyl hcl tab 2 mg
1
ropinirole hydrochloride tab 4 mg
(Requip)
trihexyphenidyl hcl tab 5 mg
1
ropinirole hydrochloride tab 5 mg
(Requip)
1
ZELAPAR - selegiline hcl orally
disintegrating tab 1.25 mg
4
RYTARY - carbidopa & levodopa cap cr
23.75-95 mg
4
NEUROMUSCULAR AGENTS
RYTARY - carbidopa & levodopa cap cr
36.25-145 mg
4
RYTARY - carbidopa & levodopa cap cr
48.75-195 mg
4
RYTARY - carbidopa & levodopa cap cr
61.25-245 mg
4
selegiline hcl cap 5 mg (Eldepryl)
2
selegiline hcl tab 5 mg
2
SINEMET - carbidopa & levodopa tab
10-100 mg
4
SINEMET - carbidopa & levodopa tab
25-100 mg
4
RILUTEK - riluzole tab 50 mg
4
riluzole tab 50 mg (Rilutek)
2
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
MUSCULOSKELETAL THERAPY AGENTS
4
AMRIX - cyclobenzaprine hcl cap sr
24hr 15 mg
4
AMRIX - cyclobenzaprine hcl cap sr
24hr 30 mg
1
baclofen tab 10 mg
baclofen tab 20 mg
1
CARISOPRODOL - carisoprodol tab
250 mg
4
carisoprodol tab 350 mg (Soma)
1
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
113
carisoprodol w/ aspirin & codeine
tab 200-325-16 mg
2
PARAFON FORTE DSC chlorzoxazone tab 500 mg
4
carisoprodol w/ aspirin tab
200-325 mg
2
ROBAXIN - methocarbamol tab 500 mg
4
chlorzoxazone tab 500 mg (Parafon
forte dsc)
1
ROBAXIN-750 - methocarbamol tab 750 4
mg
4
SKELAXIN - metaxalone tab 800 mg
CYCLOBENZAPRINE COMFORT P cyclobenzaprine hcl tab 10 mg &
liniment topical gel kit
4
cyclobenzaprine hcl tab 5 mg
1
cyclobenzaprine hcl tab 7.5 mg
(Fexmid)
2
cyclobenzaprine hcl tab 10 mg
1
DANTRIUM - dantrolene sodium cap 25
mg
4
DANTRIUM - dantrolene sodium cap 50
mg
4
DANTRIUM - dantrolene sodium cap
100 mg
4
DANTROLENE SODIUM - dantrolene
sodium cap 100 mg
4
dantrolene sodium cap 25 mg
(Dantrium)
2
dantrolene sodium cap 50 mg
(Dantrium)
2
FEXMID - cyclobenzaprine hcl tab 7.5
mg
4
LORZONE - chlorzoxazone tab 375 mg
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
SOMA - carisoprodol tab 250 mg
4
SOMA - carisoprodol tab 350 mg
4
TIZANIDINE COMFORT PAC tizanidine tab 4 mg & liniment topical
gel pack
4
tizanidine hcl cap 2 mg (base
equivalent) (Zanaflex)
2
•
tizanidine hcl cap 4 mg (base
equivalent) (Zanaflex)
2
•
tizanidine hcl cap 6 mg (base
equivalent) (Zanaflex)
2
•
tizanidine hcl tab 2 mg (base
equivalent)
1
•
tizanidine hcl tab 4 mg (base
equivalent) (Zanaflex)
1
•
ZANAFLEX - tizanidine hcl tab 4 mg
(base equivalent)
4
•
ZANAFLEX - tizanidine hcl cap 2 mg
(base equivalent)
4
•
ZANAFLEX - tizanidine hcl cap 4 mg
(base equivalent)
4
•
•
LORZONE - chlorzoxazone tab 750 mg
ZANAFLEX - tizanidine hcl cap 6 mg
(base equivalent)
4
4
METAXALONE - metaxalone tab 400
mg
4
ANTIMYASTHENIC AGENTS
metaxalone tab 800 mg (Skelaxin)
GUANIDINE HCL - guanidine hcl tab
125 mg
4
2
MESTINON - pyridostigmine bromide
tab 60 mg
4
MESTINON - pyridostigmine bromide
syrup 60 mg/5ml
4
MESTINON TIMESPAN pyridostigmine bromide tab cr 180 mg
4
pyridostigmine bromide tab cr
180 mg (Mestinon timespan)
2
methocarbamol tab 500 mg (Robaxin) 1
1
methocarbamol tab 750 mg
(Robaxin-750)
2
orphenadrine citrate tab sr 12hr
100 mg
2
orphenadrine w/ aspirin & caffeine
tab 25-385-30 mg
114
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
pyridostigmine bromide tab 60 mg
(Mestinon)
2
NUTRITIONAL PRODUCTS
VITAMINS
AMINOBENZOATE POTASSIUM potassium aminobenzoate packet 2
gm
4
BABY DDROPS - cholecalciferol drops
400 unit/0.03ml (per drop)
4
cholecalciferol cap 400 unit
2
cholecalciferol cap 1000 unit
1
cholecalciferol cap 50000 unit
1
cholecalciferol chew tab 400 unit
2
cholecalciferol chew tab 1000 unit
1
cholecalciferol drops 5000 unit/ml
(1000 unit/0.2ml)
2
cholecalciferol drops 400 unit/0.03ml
(per drop)
2
cholecalciferol oral liquid 400 unit/ml
1
cholecalciferol tab 400 unit
1
cholecalciferol tab 1000 unit
1
D-VI-SOL - cholecalciferol oral liquid
400 unit/ml
SUPER DAILY D3 - cholecalciferol
drops 1000 unit/0.03ml (per drop)
4
VITAMIN D - cholecalciferol cap 400
unit
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
VITAMIN D2 - ergocalciferol tab 400 unit 4
4
VITAMIN D3 - cholecalciferol spray
1000 unit/spray
4
VITAMIN K1 - phytonadione inj 10 mg/
ml
4
WELLESSE VITAMIN D3 cholecalciferol oral liquid 1000
unit/10ml
MULTIVITAMINS
ACTIVE OB - prenatal w/o a w/fe cbnfa-dha cap 20-1-320 mg
4
ADRENAL C FORMULA - bioflavonoid
products tab
4
ADVANCED AM/PM - multiple vitamins
w/ calcium therapy pack
4
ATABEX EC - prenatal vit w/ dss-iron
carbonyl-fa tab dr 29-1 mg
4
1
4
b-complex w/ c & folic acid cap 1 mg
(Nephrocaps)
1
DDROPS - cholecalciferol drops 1000
unit/0.03ml (per drop)
4
b-complex w/ c & folic acid tab 1 mg
(Nephro-vite rx)
b-complex w/ c & folic acid tab 5 mg
1
DECARA - cholecalciferol cap 25000
unit
4
b-complex w/ c-biotin-minerals &
folic acid tab 5 mg (Diatx zn)
1
DRISDOL - ergocalciferol cap 50000
unit
4
B-NEXA - prenatal w/ calcium-vit b6-faginger tab 1.22 mg
4
ergocalciferol cap 50000 unit
(Drisdol)
1
4
MEPHYTON - phytonadione tab 5 mg
3
BAL-CARE DHA - prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr
430mg
phytonadione inj 1 mg/0.5ml (2 mg/
ml)
2
4
POTABA - potassium aminobenzoate
cap 500 mg
4
BP FOLINATAL PLUS B - prenatal w/
calcium carbonate-b6-b12-fa tab 1
mg
POTABA - potassium aminobenzoate
tab 500 mg
4
BP MULTINATAL PLUS - prenatal w/o a 4
vit w/ fe fumarate-fa tab 30-1 mg
BP MULTINATAL PLUS - prenatal w/o a 4
vit w/ fe fum-fa tab chew 40-1 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
115
C-NATE DHA - prenatal vit w/ fe fum-faomega 3 cap 28-1-200 mg
4
CORVITE - multiple vitamins w/
minerals & fa tab 1.25 mg
4
CALCIUM PNV - prenatal w/o vit a w/ fe
fum-fa-omega 3 cap 28-1-250 mg
4
DIALYVITE SUPREME D - multiple
vitamins w/ minerals & fa tab 3 mg
4
CHOICE-OB+DHA - prenatal mv w/fe
poly-fa chw 29-1 mg & dha cap 250
mg pak
4
DIALYVITE 3000 - b-complex w/ cbiotin-e-minerals & folic acid tab 3 mg
4
4
DIALYVITE 5000 - b-complex w/ cbiotin-e-minerals & folic acid tab 5 mg
4
CITRANATAL ASSURE - prenat w/o
a w/fecbn-fegl-dss-fa tab & dha cap
300 mg pack
DIALYVITE/ZINC - b-complex w/ c-zn &
folic acid tab 1 mg
4
CITRANATAL B-CALM - prenat w/o a
w/ fe cbnyl-fa tab 20-1 mg & vit b6 tab
pak
4
DIATX ZN - b-complex w/ c-biotinminerals & folic acid tab 5 mg
4
4
DUET DHA - prenat w/fe poly-na feredfa tab 25-1 & omega cap 400 mg
4
CITRANATAL B-CALM - prenat w/o a
w/fecbn-feglu-fa tab 20-1 mg & vit b6
tab pak
4
CITRANATAL DHA - prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap 250
mg pack
4
DUET DHA BALANCED - prenat w/fe
poly-na fered-fa tab 25-1 & omega
cap 267 mg
4
CITRANATAL HARMONY - prenatal w/
o a w/fe cbn-dss-fa-dha cap 29-1-265
mg
4
DUET DHA BALANCED - prenat w/fe
poly-na fered-fa tab 27-1 & omega
cap dr 380mg
4
CITRANATAL HARMONY - prenat w/
o a w/fe fum-fe cbn-dss-fa-dha cap
27-1-260 mg
4
DUET DHA 400 - prenat w/fe poly-na
fered-fa tab 25-1 & omega cap 400
mg
CITRANATAL RX - prenatal w/o a w/ fe
carbonyl-fe gluc-dss-fa tab 27-1mg
4
CITRANATAL 90 DHA - prenat w/o a
w/fecbn-fegl-dss-fa tab 90 &dha cap
300mg pak
4
CO-NATAL FA - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
4
COMPLETE NATAL DHA - prenat-fe
bis-fe prot succ-fa-ca tab & omega 3
cap 250 pk
4
COMPLETENATE - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
4
CONCEPT DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 53.5-38-1 mg
4
CONCEPT OB - prenatal w/o a w/fe
fum-fe poly-fa cap 130-92.4-1 mg
4
116
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
ELITE-OB - prenatal vit w/ iron carbonyl- 4
fa tab 50-1.25 mg
4
ENBRACE HR - prenatal vit w/ fe gly
cys-fa-omega 3 fatty acids cap
4
ESCAVITE - pediatric multiple vitamins
w/ fl-fe chew tab 0.25-7.5 mg
4
ESCAVITE D - pediatric multiple
vitamins w/ fl-fe chew tab 0.25-6 mg
1
ESCAVITE LQ - pediatric multiple
vitamins w/ fl-fe drops 0.25-6 mg/ml
4
EXTRA-VIRT PLUS DHA - prenatal
w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
4
FLORIVA - ped multiple vitamins &
minerals w/ fl chew tab 0.5 mg
4
FLORIVA - ped multiple vitamins &
minerals w/ fl chew tab 1 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
FOCALGIN CA - prenat w/o a w/fecbnfegl-dss-fa tab & dha cap 300 mg
pack
4
L-METHYLFOLATE PNV DHA - prenat
w/fe fum-l methylfolate-fa-dha cap
27-1.13-0.4 mg
4
FOCALGIN 90 DHA - prenat w/o a w/
fecbn-fegl-dss-fa tab 90 &dha cap
300mg pak
4
LEVOMEFOLATE DHA - prenat w/
fe fum-l methylfolate-fa-dha cap
27-1.13-0.4 mg
4
FOCALGIN-B - prenatal w/ calcium-vit
b6-fa-ginger tab 1.22 mg
4
FOLBECAL - prenatal w/ calcium
carbonate-b6-b12-fa tab 1 mg
4
FOLCAL DHA - prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 27-1.25-300 mg
4
FOLCAPS OMEGA 3 - prenatal vit w/
fe cbn-fe asp glyc-fa-omega 3 cap
27-1mg
4
FOLET DHA - prenat w/fecbn-bisgmethylf-dss tab dr & dha cap pak
4
FOLET ONE - prenat w/o a w/fecbnbisg-methylf-dss-dha cap 38-1-225
mg
4
FOLGARD OS - multiple vit w/ min &
calcium-folic acid tab 500-1.1 mg
4
FOLIVANE-OB - prenatal w/o a w/fe
fum-fe poly-fa cap 130-92.4-1 mg
4
HEMENATAL OB - prenat vit-fe poly
cmplx-fe heme poly-fa tab 28-6-1 mg
4
HEMENATAL OB + DHA - prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
4
M-VIT - prenatal vit w/ fe fumarate-fa tab 4
27-1 mg
4
MACNATAL CN DHA - prenatal w/o a
w/fe cbn-dss-fa-dha cap 28-1-250 mg
4
MARNATAL-F - prenatal w/o vit a w/ fe
polysac cmplx-fa cap 60-1 mg
1
multiple vitamins w/ minerals & fa
tab 1.25 mg (Corvite)
4
MYKIDZ IRON FL - pediatric vitamins
acd fluoride & fe susp 0.25-10
mg/2ml
4
MYNATAL - prenatal multivitamins &
minerals w/ iron & fa cap 1 mg
4
MYNATAL ADVANCE - prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
4
MYNATAL PLUS - prenatal vit w/ fe
fumarate-fa tab 65-1 mg
MYNATAL ULTRACAPLET - prenatal vit 4
w/ dss-iron carbonyl-fa tab 90-1 mg
4
MYNATAL-Z - prenatal vit w/ fe
fumarate-fa tab 65-1 mg
MYNATE 90 PLUS - prenatal vit w/ dss- 4
fe fumarate-fa tab cr 90-1 mg
4
NATACHEW - prenatal vit w/ fe fum-fe
bisglycin-fa chew tab 28-1 mg
4
NATAL-V RX - prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
NATALVIRT CA - prenat w/o a w/fecbn- 4
fegl-dss-fa tab & dha cap 300 mg
pack
4
NATALVIRT 90 DHA - prenat w/o a w/
fecbn-fegl-dss-fa tab 90 &dha cap
300mg pak
NATALVIT - prenatal vit w/ fe fumarate- 4
fa tab 75-1 mg
INATAL ADVANCE - prenatal vit w/ dss- 4
iron carbonyl-fa tab 90-1 mg
4
INATAL GT - prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
INATAL ULTRA - prenatal vit w/ dss-iron 4
carbonyl-fa tab 90-1 mg
4
INFANATE BALANCE - prenatal w/o a
w/fe cbn-dss-fa-dha cap 29-1-265 mg
4
INFANATE PLUS - prenat w/o a w/fe
fum-fe cbn-dss-fa-dha cap 27-1-260
mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
117
NATELLE ONE - prenatal w/o vit a w/ fe
fum-fa-omega 3 cap 28-1-250 mg
4
OB COMPLETE - prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
4
NEEVO DHA - prenat w/o a w/fefummethylfol-omegas cap 27-1.13 mg
4
4
NEPHPLEX RX - b-complex w/ c-zn &
folic acid tab 1 mg
4
OB COMPLETE ONE - prenatal w/
o a w/fecbn-fe asp glyc-fa-fish cap
50-1-476 mg
4
NEPHRO-VITE RX - b-complex w/ c &
folic acid tab 1 mg
4
OB COMPLETE PETITE - prenat w/o
a w/fecbn-feaspglyc-fa-omega cap
35-5-1-200 mg
NEPHROCAPS - b-complex w/ c & folic
acid cap 1 mg
4
NEPHROCAPS QT - b-complex w/ cbiotin-d & folic acid tab disp 1 mg
4
NESTABS - prenatal vit w/o vit a w/ fe
bisglycinate-fa tab 32-1 mg
4
NESTABS ABC - prenatal w/o vit a w/fe
polysac-fa-ca tab & omega 3 cap
4
NESTABS DHA - prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega cap
pack
4
NEWGEN - prenatal vit w/o vit a w/ fe
bisglycinate-fa tab 32-1 mg
4
NEXA PLUS - prenatal w/o vit a w/ fe
fum-doc-fa-dha cap 29-1.25-350 mg
4
NEXA SELECT - prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 29-1.25-325 mg
4
NICOMIDE - niacinamide w/ zn-cumethylfol-se-cr tab 750-27-2-0.5 mg
4
NIVA-PLUS - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
4
NUTRI-TAB OB - prenatal vit w/o vit a
w/ fe bisglycinate-fa tab 32-1 mg
4
NUTRI-TAB OB + DHA - prenat w/o a
w/ fe bisglyc-fa tab 32-1 mg & omega
cap pack
4
NUTRIVIT - b-complex w/ lysine-min-fe
& fa liqd 800-15-1 mg/15ml
4
O-CAL FA - prenatal vit w/ fe fumaratefa tab 27-1 mg
4
O-CAL PRENATAL - prenatal vit w/ fe
fumarate-fa tab 15-1 mg
4
118
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
OB COMPLETE PREMIER - prenatal vit 4
w/ fe cbn-fe asp glyc-fa tab 30-20-1
mg
4
OB COMPLETE/DHA - prenat w/
iron cbn-fe asp glyc-fa-omega cap
30-10-1-200 mg
OB-NATAL ONE - prenatal vit w/ fe cbn- 4
fe asp glyc-fa-omega 3 cap 27-1mg
4
OBSTETRIX DHA - prenat w/fecbn-fadss tab 29-1 mg & omega 3 cap 387
mg pak
4
OBSTETRIX EC - prenatal vit w/ dssiron carbonyl-fa tab 29-1 mg
OCUVEL - multiple vitamins w/ minerals 4
& fa cap 0.5 mg
4
PAIRE OB - prenat w/ fe poly cmplx-fe
asp-fe gly-fa tab & dha cap pak
1
pediatric multiple vitamins w/ fl-fe
drops 0.25-10 mg/ml
1
pediatric multiple vitamins w/
fluoride chew tab 0.25 mg
1
pediatric multiple vitamins w/
fluoride chew tab 0.5 mg
1
pediatric multiple vitamins w/
fluoride chew tab 1 mg
1
pediatric multiple vitamins w/
fluoride soln 0.25 mg/ml
1
pediatric multiple vitamins w/
fluoride soln 0.5 mg/ml
1
pediatric vitamins acd w/ fluoride
soln 0.25 mg/ml
1
pediatric vitamins acd w/ fluoride
soln 0.5 mg/ml
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
PNV FERROUS FUMARATE/DOCU prenatal vit w/ dss-fe fumarate-fa tab
29-1 mg
4
PNV FOLIC ACID + IRON MUL prenatal vit w/ fe fumarate-fa tab 27-1
mg
4
PNV OB+DHA - prenat w/o a w/fecbnfegl-dss-fa tab & dha cap 250 mg
pack
4
PNV PRENATAL PLUS MULTIVI prenatal vit w/ fe fumarate-fa tab 27-1
mg
4
PNV TABS 29-1 - prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
4
PNV-DHA - prenat w/o a w/fefummethfol-fa-dha cap 27-0.6-0.4-300
mg
4
PNV-DHA+DOCUSATE - prenatal
w/o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
4
PNV-FIRST - prenatal mv w/ fe polysac
cmplx-fa-dha cap 29-1-200 mg
4
PNV-OB/DHA - prenatal mv w/fe fum-fa
tab 65-1 mg & dha cap 250 mg pack
4
PNV-OMEGA - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega 3
cap
4
PNV-SELECT - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
4
PNV-TOTAL - prenat w/ fe cbn-fe
bisglyc-fa-fish oil cap 35-5-1.2 mg
4
PNV-VP-U - prenatal w/o a vit w/ fe
fumarate-fa cap 106.5-1 mg
4
POLY-VI-FLOR - ped multiple vit w/
fluoride biphasic susp 0.25 mg/ml
4
POLY-VI-FLOR - ped multiple vit w/
fluoride biphasic chew tab 0.25 mg
4
POLY-VI-FLOR - ped multiple vit w/
fluoride biphasic chew tab 0.5 mg
4
POLY-VI-FLOR - ped multiple vit w/
fluoride biphasic chew tab 1 mg
4
POLY-VI-FLOR FS - pediatric multiple
vit w/ fluoride oral strip 0.25 mg
4
POLY-VI-FLOR FS - pediatric multiple
vit w/ fluoride oral strip 0.5 mg
4
POLY-VI-FLOR FS - pediatric multiple
vitamins w/ fluoride oral strip 1 mg
4
POLY-VI-FLOR/IRON - ped multiple
vitamin w/ fl-fe biphasic susp 0.25-7
mg/ml
4
POLY-VI-FLOR/IRON - ped multiple vit
w/ fl-fe biphasic chew tab 0.5-10 mg
4
PR NATAL 400 - prenat-fe bis-fe prot
succ-fa-ca tab & omega 3 cap 400 pk
4
PR NATAL 400 EC - prenat-fe bis-fe
prot succ-fa-ca tab & omega cap dr
400 pk
4
PR NATAL 430 - prenat-fe bis-fe prot
succ-fa-ca tab & omega 3 cap 430 pk
4
PR NATAL 430 EC - prenat-fe bis-fe
prot succ-fa-ca tab & omega cap dr
430 pk
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
PREFERA OB - prenat vit-fe poly cmplx- 4
fe heme poly-fa tab 28-6-1 mg
4
PREFERA OB + DHA - prenat-fe poly
cmplx-fe heme poly-fa tab & omega 3
cap pck
4
PREFERAOB +DHA - prenat-fe poly
cmplx 28mg-fe heme poly-fa tab&dha
cap pack
4
PREFERAOB ONE - prenat-fe poly
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
4
PREFOL-DHA - prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 26-1.2-300 mg
PRENAISSANCE - prenatal w/o vit a w/ 4
fe fum-dss-fa-dha cap 29-1.25-325
mg
4
PRENAISSANCE BALANCE - prenatal
w/o vit a w/ fe cbn-dss-fa-dha cap
30-1-260 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
119
PRENAISSANCE DHA - prenat w/o a w/ 4
fecbn-fegl-dss-fa tab & dha cap 250
mg pack
4
PRENAISSANCE HARMONY DHA prenat w/fe poly-na fered-fa tab 27-1
& omega cap dr 380mg
4
PRENAISSANCE NEXT - prenatal w/
calcium-vit b6-fa-ginger tab 1.2 mg
PRENAISSANCE NEXT-B - prenatal w/ 4
calcium-vit b6-fa-ginger tab 1.22 mg
PRENAISSANCE PLUS - prenatal w/o a 4
w/fe cbn-dss-fa-dha cap 28-1-250 mg
PRENAISSANCE PROMISE - prenat w/ 4
o a w/fecbn-fegl-dss-fa tab & dha cap
300 mg pack
4
PRENAISSANCE 90 DHA - prenat w/
o a w/fecbn-fegl-dss-fa tab 90 &dha
cap 300mg pak
4
PRENAPLUS - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
PRENATA - prenatal w/o a vit w/ fe fum- 4
fa tab chew 29-1 mg
4
PRENATABS FA - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
4
PRENATABS RX - prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
4
PRENATAL - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
PRENATAL AD - prenatal vit w/ dss-iron 4
carbonyl-fa tab 90-1 mg
PRENATAL LOW IRON - prenatal vit w/ 4
fe fumarate-fa tab 27-1 mg
3
PRENATAL PLUS - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
4
PRENATAL PLUS IRON - prenatal vit
w/ iron carbonyl-fa tab 29-1 mg
PRENATAL VITAMINS PLUS - prenatal 3
vit w/ fe fumarate-fa tab 27-1 mg
4
PRENATAL 19 - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
120
PRENATAL 19 - prenatal vit w/ dss-fe
fumarate-fa tab 29-1 mg
4
PRENATAL-U - prenatal w/o a vit w/ fe
fumarate-fa cap 106.5-1 mg
4
PRENATE - prenat mv & min w/ lmethylfolate-fa chew tab 0.6-0.4 mg
4
PRENATE AM - prenatal w/ calcium-vit
b6-vit b12-fa-ginger tab 1 mg
4
PRENATE DHA - prenat w/o a w/fefummethfol-fa-dha cap 28-0.6-0.4-300
mg
4
PRENATE DHA - prenat w/o a
w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
4
PRENATE ELITE - prenatal w/ fe asp
gly-l methylfol-fa tab 20-0.6-0.4 mg
4
PRENATE ELITE - prenatal vit w/ fe
fum-methylfolate-fa tab 26-0.6-0.4 mg
4
PRENATE ENHANCE - prenat w/
o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-400 mg
4
PRENATE ESSENTIAL - prenat w/
o a w/feasp-methylf-fa-omeg cap
29-0.6-0.4-340 mg
4
PRENATE ESSENTIAL - prenat w/
o a w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
4
PRENATE MINI - prenat w/oa w/
fecb-feasp-meth-fa-dha cap
18-0.6-0.4-350 mg
4
PRENATE PIXIE - prenat w/o a
w/feaspg-methfol-fa-dha cap
10-0.6-0.4-200 mg
4
PRENATE RESTORE - prenat w/
o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-400 mg
4
PRENATE STAR - prenatal vit w/ fe
asparto glycinate-fa tab 20-1 mg
4
PRENA1 CHEW - prenat w/ b2-b6-b12d3-folic acid chew tab 1.4 mg
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
PRENA1 PEARL - prenat w/oa w/fefumna fered-fa-dha cap cr 30-1.4-200 mg
4
RELNATE DHA - prenatal vit w/ fe fumfa-omega 3 cap 28-1-200 mg
PRENA1 PLUS/QUATREFOLIC prenat w/o a w/ fe chelate-l methylfolfa tab & dha cap pk
4
PRENA1/QUATREFOLIC - prenat
w/o a w/fefum-methfol-fa-dha cap
30-0.6-0.4-200 mg
4
RENATABS - b-complex w/ c-biotin-vit e 4
& folic acid tab 1 mg
RENATABS WITH IRON - b complex-c- 4
biotin-e-fa tab 1mg & fe cbn tab 100
mg pack
4
SE-NATAL 19 - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
4
SE-NATAL 19 - prenatal vit w/ dss-fe
fumarate-fa tab 29-1 mg
SE-TAN DHA - prenatal w/fe fum-fe poly 4
-fa-omega 3 cap 15-15-1 mg
SELECT-OB - prenatal vit w/ fe polysac 4
cmplx-fa chew tab 29-1 mg
4
SELECT-OB - prenat w/ fepolycmplxmethylfol-fa chew tab 29-0.6-0.4 mg
4
SELECT-OB+DHA - prenatal mv w/fe
poly-fa chw 29-1 mg & dha cap 250
mg pak
4
SETON ET-EC - prenat-fe bis-fe prot
succ-fa-ca tab & omega cap dr 430
pk
4
SETONET - prenat-fe bis-fe prot succfa-ca tab & omega 3 cap 430 pk
4
STROVITE FORTE - multiple vitamins
w/ minerals & fa syrup 1 mg/15ml
SUPERVITE - b-complex w/ lysine-zn & 4
folic acid liquid
4
SUPERVITE EC - multiple vitamins w/
minerals & fa tab dr 1 mg
4
SYNAGEX - multiple vitamins w/
minerals & fa cap 1.25 mg
4
SYNATEK - multiple vitamins w/
minerals & fa cap 1.25 mg
TARON-BC - prenat w/o a w/ fe cbnyl-fa 4
tab 20-1 mg & vit b6 tab pak
4
TARON-C DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 53.5-38-1 mg
PRENEXA - prenatal w/o vit a w/ fe fum- 4
dss-fa-dha cap 27-1.25-300 mg
PREPLUS - prenatal vit w/ fe fumarate- 4
fa tab 27-1 mg
4
PREQUE 10 - prenatal mv w/fe
carbonyl-dss-fa-dha tab 15-25-0.5-50
mg
PRETAB - prenatal vit w/ fe fumarate-fa 4
tab 29-1 mg
PROVIDA DHA - prenat w/o a w/fe fum- 4
fe poly-fa-dha cap 16-16-1.25-110 mg
PROVIDA OB - prenatal w/o a w/fe fum- 4
fe poly-fa cap 20-20-1.25 mg
PUREFE OB PLUS - prenatal w/o a w/fe 4
fum-fe poly-fa cap 162.115.2-1 mg
4
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride chew tab
0.25 mg
4
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride chew tab
0.5 mg
4
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride chew tab
1 mg
4
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride soln 0.25
mg/ml
4
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride soln 0.5
mg/ml
R-NATAL OB - prenatal w/o a w/fe cbn- 4
fa-dha cap 20-1-320 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
4
121
TARON-DUO EC - prenat-fe bis-fe prot
succ-fa-ca tab & omega cap dr 400
pk
4
TARON-PREX - prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 30-1.2-265 mg
4
TEXAVITE LQ - pediatric multivitamins
w/fl-fe-zn drops 0.25-7-3 mg/ml
4
THRIVITE 19 - prenatal vit w/ dss-fe
fumarate-fa tab 29-1 mg
4
TL FOLATE - prenatal vit w/ fe fummethylfolate-fa tab 27-0.5-0.5 mg
4
TL G-FOL OS - multiple vit w/ min &
calcium-folic acid tab 500-1.1 mg
4
TL-CARE DHA - prenatal w/fe fumarate- 4
fa-dss-fish oil cap 27-1-500 mg
4
TL-FLUORIVITE - pediatric multiple
vitamins w/ fl-fe chew tab 0.25-7.5 mg
4
TL-SELECT - prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 29-1.25-325 mg
TL-SELECT DHA - prenatal w/o vit a w/ 4
fe fum-doc-fa-dha cap 29-1.25-350
mg
4
TRI-TABS DHA - prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega cap
pack
TRI-VI-FLOR - ped vit acd & l-methylfol 4
w/ fl biphasic susp 0.25 mg/ml
TRI-VI-FLOR - ped vit acd & l-methylfol 4
w/ fl biphasic susp 0.5 mg/ml
4
TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.25 mg/
ml
4
TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.5 mg/
ml
4
TRI-VIT/FLUORIDE/IRON - pediatric
vitamins acd fluoride & fe drops
0.25-10 mg/ml
TRIADVANCE - prenatal vit w/ dss-iron 4
carbonyl-fa tab 90-1 mg
122
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
TRICARE - prenatal vit w/ fe fumarate-fa 4
tab 27-1 mg
4
TRICARE PRENATAL COMPLEAT prenat w/o a fefum-fa tab 27-1 mg &
fish oil chew cap pak
4
TRICARE PRENATAL DHA ONE prenatal w/fe fumarate-fa-dss-fish oil
cap 27-1-500 mg
TRINATAL GT - prenatal vit w/ dss-iron 4
carbonyl-fa tab 90-1 mg
4
TRINATAL RX 1 - prenatal vit w/ fe
fumarate-fa tab 60-1 mg
TRINATAL ULTRA - prenatal vit w/ dss- 4
iron carbonyl-fa tab 90-1 mg
TRINATE - prenatal vit w/ fe fumarate-fa 4
tab 28-1 mg
TRISTART DHA - prenat w/o a w/fecbn- 4
methylf-fa-dha cap 31-0.6-0.4-200 mg
4
TRIVEEN-DUO DHA - prenat-fe bis-fe
prot succ-fa-ca tab & omega 3 cap
400 pk
TRIVEEN-PRX RNF - prenatal w/o vit a 4
w/ fe fum-dss-fa-dha cap 26-1.2-300
mg
4
UDAMIN SP - multiple vitamins w/
minerals & fa tab 1 mg
4
ULTIMATE OB DHA - prenat w/ fe poly
cmplx-fe asp-fe gly-fa tab & dha cap
pak
4
ULTIMATECARE ONE - prenatal vit w/
fe cbn-fe asp glyc-fa-omega 3 cap
27-1mg
4
ULTIMATECARE ONE NF - prenatal
w/fe cbnyl-fe asp glyc-fa-dss-omega
cap 20-7-1 mg
4
ULTRA TABS - prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
4
V-NATAL - prenatal vit w/o vit a w/ fe
bisglycinate-fa tab 32-1 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
V-NATAL DHA - prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega cap
pack
4
VIRT-ADVANCE - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
4
VEMAVITE-PRX 2 - prenatal w/o vit a
w/ fe fum-dss-fa-dha cap 27-1.25-300
mg
VIRT-BAL DHA PLUS - prenat w/fe
poly-na fered-fa tab 27-1 & omega
cap dr 380mg
4
4
4
VENA-BAL DHA - prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr
430mg
4
VIRT-C DHA - prenatal w/fe fum-fe poly
-fa-omega 3 cap 53.5-38-1 mg
4
VENATAL-FA - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
4
VIRT-CARE ONE - prenatal vit w/ fe
cbn-fe asp glyc-fa-omega 3 cap
27-1mg
VINACAL - prenatal w/o a w/ fe
carbonyl-fe gluc-dss-fa tab 27-1mg
VIRT-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
4
4
VINACAL B - prenat w/o a w/fecbnfeglu-fa tab 20-1 mg & vit b6 tab pak
VIRT-PN DHA - prenat w/o a w/fefummethfol-fa-dha cap 27-0.6-0.4-300
mg
4
4
VINATE AZ EXTRA - prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1 mg
4
4
VINATE C - prenatal w/o a vit w/ fe
fumarate-fa tab 30-1 mg
4
VIRT-PN PLUS - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega 3
cap
4
VINATE CALCIUM - prenatal vit w/ iron
carbonyl-fe gluc-fa tab 27-1 mg
4
VIRT-SELECT - prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 29-1.25-325 mg
4
VINATE CARE - prenatal w/o a vit w/ fe
fum-fa tab chew 40-1 mg
4
VIRT-VITE GT - prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
4
VINATE DHA RF - prenat w/o a w/
fefum-methylfol-omegas cap 27-1.13
mg
4
VIRTPREX - prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 26-1.2-300 mg
VITA-PREN - prenatal vit w/ docusateiron-fa tab 65-1 mg
4
VINATE GT - prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
4
4
VINATE IC - prenatal w/o a w/fe fum-fe
poly-fa cap 162.115.2-1 mg
4
VITAFOL ULTRA - prenat w/fe polymethylfol-fa-dha cap 29-0.6-0.4-200
mg
4
VINATE II - prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1 mg
4
VITAFOL-NANO - prenatal w/o a w/
fefum-l methylfol-fa tab 18-0.6-0.4 mg
4
VINATE M - prenatal vit w/ sel-fe
fumarate-fa tab 27-1 mg
4
VITAFOL-OB - prenatal vit w/ fe
fumarate-fa tab 65-1 mg
4
VINATE ONE - prenatal vit w/ fe
fumarate-fa tab 60-1 mg
4
VITAFOL-OB+DHA - prenatal mv w/fe
fum-fa tab 65-1 mg & dha cap 250
mg pack
VINATE ULTRA - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
4
VITAFOL-ONE - prenatal mv w/ fe
polysac cmplx-fa-dha cap 29-1-200
mg
4
VITAFOL-PN - prenatal vit w/ fe
fumarate-fa tab 65-1 mg
4
VIRT NATE - prenatal vit w/ fe fumarate- 4
fa tab 28-1 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
123
VITAL-D RX - b-complex w/ c-biotin-dzinc & folic acid tab 1 mg
4
ZATEAN-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
4
VITAMEDMD ONE RX/QUATREFO prenat w/o a w/fefum-methfol-fa-dha
cap 30-0.6-0.4-200 mg
4
ZATEAN-PN DHA - prenat w/o
a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
4
VITAMEDMD PLUS RX/QUATRE prenat w/o a w/ fe chelate-l methylfolfa tab & dha cap pk
4
ZATEAN-PN PLUS - prenat w/o a w/
fe fumerate-methylfolate-fa-omega 3
cap
4
VITAMEDMD REDICHEW RX - prenat
w/ b2-b6-b12-d3-folic acid chew tab
1.4 mg
4
ZINGIBER - prenatal w/ calcium-vit b6fa-ginger tab 1.2 mg
4
VITAPEARL - prenat w/oa w/fefum-na
fered-fa-dha cap cr 30-1.4-200 mg
4
VIVA DHA - prenatal vit w/ fe fum-faomega 3 cap 28-1-200 mg
4
VOL-NATE - prenatal vit w/ fe fumaratefa tab 28-1 mg
Dispensing Limits
Step Therapy
MINERALS and ELECTROLYTES
CALCIFOL - ca carb-folic acid-vit d-b6b12-boron-mag wafer 1342-1.6 mg
4
4
4
CALCIUM-FOLIC ACID PLUS D - ca
carb-folic acid-vit d-b6-b12-boronmag wafer 1342-1 mg
4
EFFER-K - potassium bicarbonate-citric
acid effer tab 10 meq
4
VOL-PLUS - prenatal vit w/ fe fumaratefa tab 27-1 mg
VOL-TAB RX - prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
EFFER-K - potassium bicarbonate-citric
acid effer tab 20 meq
4
4
VP CH ULTRA - prenat w/o a w/fe fumfe cbn-dss-fa-dha cap 27-1-260 mg
FLORICAL - sodium fluoride w/ calcium
carb cap 8.3-364 mg
4
4
VP-CH PLUS - prenatal w/o a w/fe cbndss-fa-dha cap 29-1-265 mg
FLORICAL - sodium fluoride w/ calcium
carb tab 8.3-364 mg
4
4
4
VP-CH-PNV - prenatal w/o vit a w/ fe
cbn-dss-fa-dha cap 30-1-260 mg
4
FLORIVA - sodium fluoride-vitamin d
liqd drops 0.25 mg/ml-400 unit/ml
4
FLUOR-A-DAY - sodium fluoride-xylitol
chew tab 0.55 (0.25 mg f)-236.79 mg
4
VP-GGR-B6 PRENATAL - prenatal w/
calcium-vit b6-fa-ginger tab 1.2 mg
VP-HEME OB - prenat vit-fe poly cmplxfe heme poly-fa tab 28-6-1 mg
FLUOR-A-DAY - sodium fluoride-xylitol
chew tab 1.1 (0.5 mg f)-236.79 mg
4
4
VP-HEME OB + DHA - prenat-fe poly
cmplx-fe heme poly-fa tab & omega 3
cap pck
FLUOR-A-DAY - sodium fluoride-xylitol
chew tab 2.2 (1 mg f)-236.79 mg
4
4
4
VP-HEME ONE - prenat-fe poly cmplxfe heme poly-fa-dha cap 22-6-1-200
mg
4
FLUORABON - sodium fluoride soln
0.25 mg/0.6ml (from 0.55 mg/0.6ml
naf)
4
VP-PNV-DHA - prenatal vit w/ fe fum-faomega 3 cap 28-1-215.8 mg
4
FLURA-DROPS - sodium fluoride soln
0.25 mg/drop f (from 0.55 mg/drop
naf)
ZATEAN-CH - prenatal w/o a w/fe cbndss-fa-dha cap 27-1-250 mg
GALZIN - zinc acetate cap 25 mg
(elemental zinc)
4
4
124
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
GALZIN - zinc acetate cap 50 mg
(elemental zinc)
4
MICRO-K - potassium chloride cap cr 8
meq
GNP VITAMIN D-400 - calcium
carbonate-cholecalciferol tab 90
mg-400 unit
1
GNP VITAMIN D-400 - calcium
carbonate-cholecalciferol tab 90
mg-400 unit
4
IODINE STRONG - iodine solution
strong 5% (lugol's)
4
K-PHOS - potassium phosphate
monobasic tab 500 mg
4
K-PHOS NEUTRAL - pot phos
monobasic w/sod phos di & monobas
tab 155-852-130mg
4
K-TAB - potassium chloride tab cr 8
meq (600 mg)
4
K-TAB - potassium chloride tab cr 10
meq
4
K-TAB - potassium chloride tab cr 20
meq (1500 mg)
4
KLOR-CON M15 - potassium chloride
microencapsulated crys cr tab 15
meq
4
KLOR-CON 25 - potassium chloride
powder packet 25 meq
4
KLOR-CON/25 - potassium chloride
powder packet 25 meq
4
LOZI-FLUR - sodium fluoride lozenge 1
mg f (from 2.2 mg naf)
4
MICRO-K - potassium chloride cap cr 10 4
meq
4
MONOCAL - sodium
monofluorophosphate-calcium carb
tab 22.75-625 mg
2
pot bicarbonate & chloride effer tab
25 meq
2
pot phos monobasic w/sod phos di
& monobas tab 155-852-130mg (Kphos neutral)
2
potassium bicarbonate effer tab 25
meq
2
potassium chloride cap cr 8 meq
(Micro-k)
2
potassium chloride cap cr 10 meq
(Micro-k)
1
POTASSIUM CHLORIDE ER potassium chloride tab cr 8 meq (600
mg)
4
POTASSIUM CHLORIDE ER potassium chloride tab cr 20 meq
(1500 mg)
1
potassium chloride
microencapsulated crys cr tab 10
meq
1
potassium chloride
microencapsulated crys cr tab 20
meq
1
potassium chloride oral liq 10% (20
meq/15ml)
1
potassium chloride oral liq 20% (40
meq/15ml)
2
potassium chloride powder packet
20 meq
1
potassium chloride tab cr 8 meq
(600 mg)
potassium chloride tab cr 10 meq (K- 1
tab)
LURIDE - sodium fluoride chew tab 0.25 4
mg f (from 0.55 mg naf)
4
LURIDE - sodium fluoride chew tab 0.5
mg f (from 1.1 mg naf)
4
LURIDE - sodium fluoride chew tab 1
mg f (from 2.2 mg naf)
4
LURIDE - sodium fluoride soln 0.5 mg/
ml f (from 1.1 mg/ml naf)
4
MAGNEBIND 400 - magnesiumcalcium-folic acid tab 400-200-1 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
4
125
SODIUM FLUORIDE - sodium fluoride
tab 0.5 mg f (from 1.1 mg naf)
4
SODIUM FLUORIDE - sodium fluoride
tab 1 mg f (from 2.2 mg naf)
4
sodium fluoride chew tab 0.25 mg f
(from 0.55 mg naf) (Luride)
CYANOCOBALAMIN/LEVOMEFOLA l-methylfolate w/ vit b6-vit b12 tab
1.13-25-2 mg
4
DEPLIN - l-methylfolate tab 7.5 mg
4
1
DEPLIN - l-methylfolate tab 15 mg
4
1
DEPLIN 15 - l-methylfolate-algae cap
15-90.314 mg
4
sodium fluoride chew tab 0.5 mg f
(from 1.1 mg naf) (Luride)
1
DEPLIN 7.5 - l-methylfolate-algae cap
7.5-90.314 mg
4
sodium fluoride chew tab 1 mg f
(from 2.2 mg naf) (Luride)
sodium fluoride soln 0.125 mg/drop f
(0.275 mg/drop naf)
ELIGEN B12 - cyanocobalaminsalcaprozate sodium tab 1000
mcg-100 mg
4
2
sodium fluoride soln 0.5 mg/ml f
(from 1.1 mg/ml naf) (Luride)
1
4
SSKI - potassium iodide soln 1 gm/ml
4
ENTERAGAM - serum-derived bovine
immunoglob/protein isolate 5 gm
packet
FALESSA - levomefolate glucosamine
tab 1 mg (folate equivalent)
4
flaxseed oil-evening primrosebilberry cap 1000-500-40 mg (Tears
again hydrate)
2
FOLBEE AR - folic acid-b12-b6arginine-black pepper tab
4
FOLBIC RF - l-methylfolate w/ vit b6-vit
b12 tab 1.13-25-2 mg
4
folic acid-pyridoxinecyanocobalamin tab 2.5-25-2 mg
2
FOLTANX - l-methylfolate w/ vit b6-vit
b12 tab 3-35-2 mg
4
FOLTANX RF - l-methylfolate-algae-vit
b12-b6 cap 3-90.314-2-35 mg
4
FOLTX - l-methylfolate w/ vit b6-vit b12
tab 1.13-25-2 mg
4
FOSTEUM - genistein-zinc amino acid
chelate-vitamin d cap
4
L-METHYL-B6-B12 - l-methylfolate w/
vit b6-vit b12 tab 3-35-2 mg
4
L-METHYL-MC - l-methylfolate w/ vit
b12-vit b6-vit b2 tab 6-1-50-5 mg
4
L-METHYL-MC NAC - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
4
NUTRIENTS
acetylcysteine cap 600 mg
2
CARDIOVID PLUS - dha-epa-vit b6b12-folic acid cap 240-360-20-0.5-0.8
mg
4
LECITHIN - lecithin granules
4
NUTRESTORE - glutamine powd pack
5 gm
4
DIETARY PRODUCTS
ALZ-NAC - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
4
AVAILNEX - carbocysteine chew tab
750 mg
4
CARDIOTEK-RX - folic acid-b12-b6arginine-black pepper tab
4
CEREFOLIN - l-methylfolate w/ vit b12vit b6-vit b2 tab 6-1-50-5 mg
4
CEREFOLIN NAC - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
4
CEREFOLIN NAC - l-methylfolatealgae-b12-acetylcyst tab
6-90.314-2-600mg
4
126
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
L-METHYLFOLATE - l-methylfolate tab
7.5 mg
4
LIMBREL250 - flavocoxid-citrated zinc
bisglycinate cap 250-50 mg
4
L-METHYLFOLATE - l-methylfolate tab
15 mg
4
LIMBREL500 - flavocoxid-citrated zinc
bisglycinate cap 500-50 mg
4
L-METHYLFOLATE CA ME-CBL - lmethylfolate-algae-b12-acetylcyst tab
6-90.314-2-600mg
4
LMTHF/PYRIDOXINE HCL/CYAN l-methylfolate w/ vit b6-vit b12 tab
1.13-25-2 mg
4
L-METHYLFOLATE CA/ME-CBL/ l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg
4
METAFOLBIC - l-methylfolate w/ vit
b12-vit b6-vit b2 tab 6-1-50-5 mg
4
L-METHYLFOLATE CA/P-5-P/M - lmethylfolate w/ vit b6-vit b12 tab
3-35-2 mg
METAFOLBIC PLUS - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
4
4
L-METHYLFOLATE CA/P-5-P/M - lmethylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg
METAFOLBIC PLUS RF - lmethylfolate-algae-b12-acetylcyst tab
6-90.314-2-600mg
4
4
4
L-METHYLFOLATE CALCIUM - lmethylfolate tab 7.5 mg
4
METANX - l-methylfolate w/ vit b6-vit
b12 tab 3-35-2 mg
4
METANX - l-methylfolate-algae-vit b12b6 cap 3-90.314-2-35 mg
4
L-METHYLFOLATE CALCIUM - lmethylfolate tab 15 mg
L-METHYLFOLATE FORMULA 15 - lmethylfolate-algae cap 15-90.314 mg
METHYLFOL-ALGAE-B12-ACETY - lmethylfolate-algae-b12-acetylcyst tab
6-90.314-2-600mg
4
4
L-METHYLFOLATE FORMULA 7. - lmethylfolate-algae cap 7.5-90.314 mg
4
PKU EASY MICROTABS - nutritional
supplement tabs delayed release
4
L-METHYLFOLATE FORTE - lmethylfolate-algae cap 7.5-90.314 mg
4
PODIAPN - l-methylfolate-b12-b6-alpha
lipoic ac cap 5-2-35-300 mg
4
L-METHYLFOLATE FORTE - lmethylfolate-algae cap 15-90.314 mg
4
LEVOMEFOLATE CALCIUM/ACET - lmethylfolate-algae-b12-acetylcyst tab
6-90.314-2-600mg
4
LEVOMEFOLATE CALCIUM/ALGA - lmethylfolate-algae cap 7.5-90.314 mg
4
LEVOMEFOLATE CALCIUM/ALGA - lmethylfolate-algae cap 15-90.314 mg
4
LEVOMEFOLATE CALCIUM/PYRI l-methylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg
4
LIMBREL - flavocoxid cap 250 mg
4
LIMBREL - flavocoxid cap 500 mg
4
Q-TABS - levomefolate glucosamine tab 4
1 mg (folate equivalent)
4
TEARS AGAIN HYDRATE - flaxseed
oil-evening primrose-bilberry cap
1000-500-40 mg
4
VAYACOG - phosphatidylserine-dhaepa cap 100-19.5-6.5 mg
VAYARIN - phosphatidylserine-dha-epa 4
cap 75-21.5-8.5 mg
VAYAROL - phytosterol esters-dha-epa 4
cap 630-232.5-92.5 mg
4
VITA-RESPA - folic acid-pyridoxinecyanocobalamin tab 2.2-25-1.3 mg
VITACIRC-B - l-methylfolate w/ vit b6-vit 4
b12 tab 3-35-2 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
127
ZYTAZE - zinc citrate-phytase cap
25-500 mg
4
•
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 150 mcg/0.3ml
5
•
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 200 mcg/ml
5
•
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 200 mcg/0.4ml
5
•
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 300 mcg/ml
5
•
5
•
•
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 300 mcg/0.6ml
5
•
•
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 500 mcg/ml
B-6 FOLIC ACID - cobalamine
combination cap
4
•
BIFERARX - polysacch fe cmplx-fe
heme poly-fa-b12 tab 22-6-1-0.025
mg
4
•
BP VIT 3 - folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg
4
BP VIT 3 PLUS - folic acid-b6-b12-domega 3-phytosterols cap 1 mg
4
carbonyl iron susp 15 mg/1.25ml
(elemental iron)
1
CENFOL - folic acid-vitamin b6-vitamin
b12 tab 2.3-24.5-2 mg
4
•
CENTRATEX - ferrous fumarate-fa-b
complex-c-zn-mg-mn-cu cap 106-1
mg
4
•
CERDELGA - eliglustat tartrate cap 84
mg (base equivalent)
5
CIFEREX - folic acid-cholecalciferol cap
1 mg-3775 unit
4
HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
ABANEU-SL - cyanocobalaminmethylcobalamin tab sl 600-600 mcg
4
ACTIVE FE - fe carbonyl-fa-b complexa-c-d-e-min tab 75-1.25 mg
4
ANIMI-3 - folic acid-vit b6-vit b12-omega 4
3-phytosterols cap 1 mg
ANIMI-3 - folic acid-b6-b12-d-omega 3- 4
phytosterols cap 1 mg
ANIMI-3/VITAMIN D - folic acid-b6-b12- 4
d-omega 3-phytosterols cap 1 mg
5
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 10 mcg/0.4ml
5
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 25 mcg/ml
5
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 25 mcg/0.42ml
5
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 40 mcg/ml
5
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 40 mcg/0.4ml
5
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 60 mcg/ml
5
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 60 mcg/0.3ml
5
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 100 mcg/ml
128
•
•
Dispensing Limits
5
Drug Name
Step Therapy
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 100 mcg/0.5ml
Dispensing Limits
Prior Authorization
4
Drug Tier
VP-GSTN - genistein-zinc amino acid
chelate-vitamin d cap
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
4
4
FERRALET 90 - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab 90-1
mg
CORVITE 150 - iron combination tab
4
4
cyanocobalamin inj 1000 mcg/ml
1
FERRAPLUS 90 - iron-folic acid-vit b12vit c-docusate sod tab 90-1 mg
4
FERRETTS CHEWABLE IRON carbonyl iron chew tab 18 mg
(elemental iron)
4
DIVISTA - folic acid-vit b6-vit b12omega 3-biotin-cr cap 1 mg
DROXIA - hydroxyurea cap 200 mg
4
DROXIA - hydroxyurea cap 300 mg
DROXIA - hydroxyurea cap 400 mg
4
FERREX 150 FORTE PLUS - fe asp
gly-fe polysacch-succ ac-c-threon acb12-fa cap
4
4
DURACHOL - folic acid-cholecalciferol
cap 1 mg-3775 unit
4
FERREX 28 - fe asparto gly-fe fum-b12fa-c-succinic ac tab ther pack
4
ED CYTE F - ferrous fumarate-folic
acid-docusate sodium tab 324-1-50
mg
4
FERRO-PLEX HEMATINIC - fe fumdss-vit c-vit e-vit b12-if-fa tab 115-1
mg
4
EPOGEN - epoetin alfa inj 2000 unit/ml
5
4
EPOGEN - epoetin alfa inj 3000 unit/ml
5
FERROTRIN - iron w/ b12-vit c-fa-ifc
cap 36-0.015-75-0.5-240 mg
5
ferrous fumarate-fa-b complex-c-znmg-mn-cu tab 106-1 mg
1
EPOGEN - epoetin alfa inj 4000 unit/ml
ferrous fumarate-folic acid tab
324-1 mg
1
4
EPOGEN - epoetin alfa inj 10000 unit/ml 5
EPOGEN - epoetin alfa inj 20000 unit/ml 5
•
•
•
•
•
FA-8 - folic acid cap 0.8 mg
4
fe fum-iron polysacch complex-fab cmplx-c-zn-mn-cu cap (Tandem
plus)
1
FERROUS SULFATE - ferrous sulfate
syrup 300 mg/5ml (60 mg/5ml
elemental fe)
4
fe fumarate w/ b12-vit c-fa-ifc cap
110-0.015-75-0.5-240 mg
1
FERROUS SULFATE - ferrous sulfate
liquid 220 mg/5ml (44 mg/5ml
elemental fe)
fe fumarate-vit c-vit b12-fa cap 460
(151 fe)-60-0.01-1 mg
1
ferrous sulfate elixir 220 mg/5ml
(44 mg/5ml elemental fe)
1
FE 90 PLUS - fe carbonyl-fe gluconatefa-vit b12-vit c-dss tab 90-1 mg
4
ferrous sulfate soln 75 mg/ml (15 mg/
ml elemental fe)
1
FER-IN-SOL - ferrous sulfate soln 75
mg/ml (15 mg/ml elemental fe)
4
4
FERIVA - fe bisglycin-fe carbonyl-c-fab12-biotin-dss cap 75-1 mg
4
FOCALGIN DSS - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab 90-1
mg
4
FERIVA 21/7 - fe asparto gly-b12-fa-cdss-succinic acid-zn tab 75-1 mg
4
FOLGARD RX - folic acid-vitamin b6vitamin b12 tab 2.2-25-1 mg
folic acid tab 400 mcg
1
folic acid tab 800 mcg
1
folic acid tab 1 mg
1
FERIVAFA - iron-c-fa-b12-biotin-copper- 4
docusate cap 110-1 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
CORVITE 150 - iron-folic acid-vit c-vit
b6-vit b12-zinc tab 150-1.25 mg
Dispensing Limits
4
Step Therapy
CORVITE FE - iron combination tab
Prior Authorization
Drug Name
Drug Tier
2015
129
folic acid-vitamin b6-vitamin b12 tab
2.2-25-0.5 mg
1
IRON CHEWS PEDIATRIC - carbonyl
iron chew tab 15 mg (elemental iron)
2
folic acid-vitamin b6-vitamin b12 tab
2.2-25-1 mg (Folgard rx)
1
iron combination cap
1
folic acid-vitamin b6-vitamin b12 tab
2.5-25-1 mg
iron polysacch complex-vit b12-fa
cap 150-0.025-1 mg
1
1
4
iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg (Hematron-af)
1
FOLIVANE-F - fe fum-fe poly-fa-c-b3
cap 62.5-62.5-1-40-3mg(125 mg fe)
4
iron-folic acid-vit c-vit b6-vit b12-zinc
tab 150-1.25 mg (Corvite 150)
2
FOLIVANE-PLUS - fe fum-iron
polysacch complex-fa-b complex-cbiotin cap
iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg (Icar-c plus)
1
FUSION PLUS - fe fum-iron poly cmplxfa-b cmplx-c-biotin-probiotic cap
4
GRANIX - tbo-filgrastim soln prefilled
syringe 300 mcg/0.5ml
4
GRANIX - tbo-filgrastim soln prefilled
syringe 480 mcg/0.8ml
4
HEMATOGEN FA - fe fumarate-vit c-vit
b12-fa cap 200-250-0.01-1 mg
4
HEMATRON-AF - iron-docusate-b12folic acid-c-e-cu-biotin tab 150-1 mg
4
HEMETAB - polysacch fe cmplx-fe
heme poly-fa-b12 tab 22-6-1-0.025
mg
4
HEMOCYTE PLUS - ferrous fumaratefa-b complex-c-zn-mg-mn-cu cap
106-1 mg
4
ICAR - carbonyl iron chew tab 15 mg
(elemental iron)
4
ICAR PEDIATRIC - carbonyl iron susp
15 mg/1.25ml (elemental iron)
4
ICAR-C PLUS - iron-vit c-vit b12-folic
acid tab 100-250-0.025-1 mg
4
INTEGRA F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)
4
INTEGRA PLUS - fe fum-iron polysacch
complex-fa-b complex-c-biotin cap
4
IRON ASP GLY/ POLYSACCH C - fe
asp gly-fe polysacch-succ ac-c-threon
ac-b12-fa cap
4
130
IROSPAN 24/6 - fe bisglyc-fe polys-succ 4
acd-b cmplx-c-ca-fa tab ther pk
4
IS 24/6 - fe bisglyc-fe polys-succ acd-b
cmplx-c-ca-fa tab ther pk
LEUKINE - sargramostim lyophilized for 5
inj 250 mcg
MAXARON FORTE - fe gly-fe fum-vit c- 4
vit b12-methylfolate tab
4
MAXFE - iron-fa-vit b12-biotin-vit cdocusate-mg-zn tab 160-1 mg
4
MIRCERA - methoxy polyethylene
glycol-epoetin beta inj 50 mcg/0.3ml
4
MIRCERA - methoxy polyethylene
glycol-epoetin beta inj 75 mcg/0.3ml
4
MIRCERA - methoxy polyethylene
glycol-epoetin beta inj 100 mcg/0.3ml
4
MIRCERA - methoxy polyethylene
glycol-epoetin beta inj 200 mcg/0.3ml
MULTIGEN - fe asparto gly-succ acd-c- 4
threonic acd-b12-des stom tab
4
MULTIGEN FOLIC - fe asparto glysuccinic acd-vit c-threonic acd-b12-fa
tab
MULTIGEN PLUS - fe aspart gly-fe fum- 4
succ acd-c-threonic acd-b12-fa tab
4
MV FE ASPARTO GLY/FE FUM/ - fe
aspart gly-fe fum-succ acd-c-threonic
acd-b12-fa tab
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
MV FE ASPARTO GLY/VIT C/V - fe
asparto gly-succ acd-c-threonic acdb12-des stom tab
4
PROFERRIN-FORTE - iron heme
polypeptide-folic acid tab 12-1 mg (fe
equiv)
4
MYKIDZ IRON 10 - iron susp 15
mg/1.5ml
4
PROMACTA - eltrombopag olamine tab
12.5 mg (base equiv)
5
•
•
NASCOBAL - cyanocobalamin nasal
spray 500 mcg/0.1ml
4
PROMACTA - eltrombopag olamine tab
25 mg (base equiv)
5
•
•
NATALVIRT FLT - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab 90-1
mg
4
PROMACTA - eltrombopag olamine tab
50 mg (base equiv)
5
•
•
•
•
NEPHRON FA - ferrous fumarate w/ fadss-b complex-vit c tab
PROMACTA - eltrombopag olamine tab
75 mg (base equiv)
5
4
NEULASTA - pegfilgrastim inj 6
mg/0.6ml
•
PROTECTIRON - iron polysacch-fa-b
complex-vit c-e & minerals tab 60-1
mg
4
5
NEULASTA DELIVERY KIT pegfilgrastim inj 6 mg/0.6ml
5
•
4
NEUMEGA - oprelvekin for inj 5 mg
5
NEUPOGEN - filgrastim inj 300 mcg/ml
5
5
REVESTA - folic acid-cholecalciferol
cap 1 mg-5750 unit
4
NEUPOGEN - filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
•
•
•
PUREFE PLUS - ferrous fumarate-fab complex-c-zn-mg-mn-cu cap 106-1
mg
4
NEUPOGEN - filgrastim inj 300
mcg/0.5ml (600 mcg/ml)
5
•
SPATONE PUR-ABSORB IRON ferrous sulfate liquid 5 mg/20ml
(elemental iron)
5
•
TANDEM F - ferrous fum-iron
polysacch-fa cap 162-115.2-1 mg
(106 mg fe)
4
NEUPOGEN - filgrastim inj 480
mcg/0.8ml (600 mcg/ml)
NEURIN-SL - cyanocobalaminmethylcobalamin tab sl 600-600 mcg
4
TANDEM PLUS - fe fum-iron polysacch
complex-fa-b cmplx-c-zn-mn-cu cap
4
NOVAFERRUM - polysacch iron
complex-vit c-fa for soln 100-60-1
mg/5ml
4
TARON FORTE - fe bisglycinate-fe
polysacch-vit c-vit b12-fa cap
4
4
ZAVESCA - miglustat cap 100 mg
5
PRE-FOLIC - folic acid-vitamin c tab
1-100 mg
PROCRIT - epoetin alfa inj 2000 unit/ml
5
PROCRIT - epoetin alfa inj 3000 unit/ml
5
PROCRIT - epoetin alfa inj 4000 unit/ml
5
PROCRIT - epoetin alfa inj 10000 unit/
ml
5
•
•
•
•
PROCRIT - epoetin alfa inj 20000 unit/
ml
5
•
PROCRIT - epoetin alfa inj 40000 unit/
ml
5
•
•
ANTICOAGULANTS
ARIXTRA - fondaparinux sodium
subcutaneous inj 2.5 mg/0.5ml
4
•
ARIXTRA - fondaparinux sodium
subcutaneous inj 5 mg/0.4ml
4
•
ARIXTRA - fondaparinux sodium
subcutaneous inj 7.5 mg/0.6ml
4
•
ARIXTRA - fondaparinux sodium
subcutaneous inj 10 mg/0.8ml
4
•
COUMADIN - warfarin sodium tab 1 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
131
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
COUMADIN - warfarin sodium tab 2.5
mg
Dispensing Limits
4
Step Therapy
COUMADIN - warfarin sodium tab 2 mg
Prior Authorization
Drug Name
Drug Tier
2015
4
•
4
FRAGMIN - dalteparin sodium inj 2500
unit/0.2ml
4
•
COUMADIN - warfarin sodium tab 3 mg
4
FRAGMIN - dalteparin sodium inj 5000
unit/0.2ml
COUMADIN - warfarin sodium tab 4 mg
4
4
•
COUMADIN - warfarin sodium tab 5 mg
4
FRAGMIN - dalteparin sodium inj 7500
unit/0.3ml
4
FRAGMIN - dalteparin sodium inj 12500
unit/0.5ml
4
COUMADIN - warfarin sodium tab 6 mg
•
COUMADIN - warfarin sodium tab 7.5
mg
4
FRAGMIN - dalteparin sodium inj 15000
unit/0.6ml
4
•
COUMADIN - warfarin sodium tab 10
mg
4
4
•
ELIQUIS - apixaban tab 2.5 mg
4
•
ELIQUIS - apixaban tab 5 mg
FRAGMIN - dalteparin sodium inj 95000
unit/3.8ml
4
4
enoxaparin sodium inj 30 mg/0.3ml
(Lovenox)
2
•
•
•
FRAGMIN - dalteparin sodium inj 18000
unit/0.72ml
HEPARIN SODIUM - heparin sodium
(porcine) inj 2000 unit/ml
4
enoxaparin sodium inj 40 mg/0.4ml
(Lovenox)
2
•
HEPARIN SODIUM - heparin sodium
(porcine) inj 2500 unit/ml
4
enoxaparin sodium inj 60 mg/0.6ml
(Lovenox)
2
•
heparin sodium (porcine) inj 1000
unit/ml
2
enoxaparin sodium inj 80 mg/0.8ml
(Lovenox)
2
•
heparin sodium (porcine) inj 5000
unit/ml
2
enoxaparin sodium inj 100 mg/ml
(Lovenox)
2
•
heparin sodium (porcine) inj 10000
unit/ml
2
enoxaparin sodium inj 120 mg/0.8ml
(Lovenox)
2
•
heparin sodium (porcine) inj 20000
unit/ml
2
enoxaparin sodium inj 150 mg/ml
(Lovenox)
2
•
heparin sodium (porcine) pf inj 5000
unit/0.5ml
2
enoxaparin sodium inj 300 mg/3ml
(Lovenox)
2
•
LOVENOX - enoxaparin sodium inj 30
mg/0.3ml
4
•
fondaparinux sodium subcutaneous
inj 2.5 mg/0.5ml (Arixtra)
2
•
LOVENOX - enoxaparin sodium inj 40
mg/0.4ml
4
•
fondaparinux sodium subcutaneous
inj 5 mg/0.4ml (Arixtra)
2
•
LOVENOX - enoxaparin sodium inj 60
mg/0.6ml
4
•
fondaparinux sodium subcutaneous
inj 7.5 mg/0.6ml (Arixtra)
2
•
LOVENOX - enoxaparin sodium inj 80
mg/0.8ml
4
•
fondaparinux sodium subcutaneous
inj 10 mg/0.8ml (Arixtra)
2
•
LOVENOX - enoxaparin sodium inj 100
mg/ml
4
•
FRAGMIN - dalteparin sodium inj 10000
unit/ml
4
•
LOVENOX - enoxaparin sodium inj 120
mg/0.8ml
4
•
132
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
LOVENOX - enoxaparin sodium inj 150
mg/ml
4
•
AMICAR - aminocaproic acid tab 500
mg
4
LOVENOX - enoxaparin sodium inj 300
mg/3ml
4
•
AMICAR - aminocaproic acid tab 1000
mg
4
PRADAXA - dabigatran etexilate
mesylate cap 75 mg (etexilate base
eq)
4
•
AMINOCAPROIC ACID - aminocaproic
acid tab 1000 mg
4
4
4
•
LYSTEDA - tranexamic acid tab 650 mg
PRADAXA - dabigatran etexilate
mesylate cap 150 mg (etexilate base
eq)
tranexamic acid tab 650 mg (Lysteda)
2
SAVAYSA - edoxaban tosylate tab 15
mg (base equivalent)
4
•
ADVATE - antihemophilic factor rahfpfm for inj 250 unit
5
•
SAVAYSA - edoxaban tosylate tab 30
mg (base equivalent)
4
•
ADVATE - antihemophilic factor rahfpfm for inj 500 unit
5
•
SAVAYSA - edoxaban tosylate tab 60
mg (base equivalent)
4
•
ADVATE - antihemophilic factor rahfpfm for inj 1000 unit
5
•
ADVATE - antihemophilic factor rahfpfm for inj 1500 unit
5
•
ADVATE - antihemophilic factor rahfpfm for inj 2000 unit
5
•
ADVATE - antihemophilic factor rahfpfm for inj 3000 unit
5
•
ADVATE - antihemophilic factor rahfpfm for inj 4000 unit
5
•
AGGRENOX - aspirin-dipyridamole cap
sr 12hr 25-200 mg
4
AGRYLIN - anagrelide hcl cap 0.5 mg
4
ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for
inj 250 unit
5
•
ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for
inj 500 unit
5
•
ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for
inj 1000 unit
5
•
ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for
inj 1500 unit
5
•
Dispensing Limits
HEMATOLOGICAL AGENTS - MISC.
warfarin sodium tab 1 mg (Coumadin) 1
warfarin sodium tab 2 mg (Coumadin) 1
warfarin sodium tab 2.5 mg
(Coumadin)
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
1
warfarin sodium tab 3 mg (Coumadin) 1
warfarin sodium tab 4 mg (Coumadin) 1
warfarin sodium tab 5 mg (Coumadin) 1
warfarin sodium tab 6 mg (Coumadin) 1
1
warfarin sodium tab 7.5 mg
(Coumadin)
1
warfarin sodium tab 10 mg
(Coumadin)
4
XARELTO - rivaroxaban tab 10 mg
XARELTO - rivaroxaban tab 15 mg
4
XARELTO - rivaroxaban tab 20 mg
4
XARELTO STARTER PACK rivaroxaban tab starter therapy pack
15 mg & 20 mg
4
HEMOSTATICS
AMICAR - aminocaproic acid syrup 25% 4
4
AMICAR - aminocaproic acid oral soln
0.25 gm/ml
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
133
clopidogrel bisulfate tab 75 mg (base
equiv) (Plavix)
1
2
•
clopidogrel bisulfate tab 300 mg
(base equiv) (Plavix)
ALPHANINE SD - coagulation factor ix
for inj 1000 unit
•
CORIFACT - factor xiii concentrate
(human) for inj kit 1000-1600 unit
5
5
1
5
•
dipyridamole tab 25 mg (Persantine)
ALPHANINE SD - coagulation factor ix
for inj 1500 unit
dipyridamole tab 50 mg (Persantine)
2
5
•
dipyridamole tab 75 mg (Persantine)
2
ALPROLIX - coagulation factor ix
(recomb) (rfixfc) for inj 500 unit
4
ALPROLIX - coagulation factor ix
(recomb) (rfixfc) for inj 1000 unit
5
EFFIENT - prasugrel hcl tab 5 mg (base
equiv)
4
ALPROLIX - coagulation factor ix
(recomb) (rfixfc) for inj 2000 unit
5
EFFIENT - prasugrel hcl tab 10 mg
(base equiv)
5
•
ALPROLIX - coagulation factor ix
(recomb) (rfixfc) for inj 3000 unit
5
ELOCTATE - antihemophilic factor
(recomb) rfviiifc for inj 250 unit
5
•
anagrelide hcl cap 0.5 mg (Agrylin)
2
ELOCTATE - antihemophilic factor
(recomb) rfviiifc for inj 500 unit
2
ELOCTATE - antihemophilic factor
(recomb) rfviiifc for inj 750 unit
5
anagrelide hcl cap 1 mg
•
ASPIRIN/DIPYRIDAMOLE - aspirindipyridamole cap sr 12hr 25-200 mg
4
5
•
BEBULIN - factor ix complex for inj
200-1200 unit
5
•
ELOCTATE - antihemophilic factor
(recomb) rfviiifc for inj 1000 unit
5
•
BEBULIN VH - factor ix complex for inj
200-1200 unit
5
•
ELOCTATE - antihemophilic factor
(recomb) rfviiifc for inj 1500 unit
5
•
BENEFIX - coagulation factor ix
(recombinant) for inj 250 unit
5
•
ELOCTATE - antihemophilic factor
(recomb) rfviiifc for inj 2000 unit
5
•
BENEFIX - coagulation factor ix
(recombinant) for inj 500 unit
5
•
ELOCTATE - antihemophilic factor
(recomb) rfviiifc for inj 3000 unit
5
•
BENEFIX - coagulation factor ix
(recombinant) for inj 1000 unit
5
•
FEIBA - antiinhibitor coagulant complex
for inj
5
•
BENEFIX - coagulation factor ix
(recombinant) for inj 2000 unit
5
•
FEIBA NF - antiinhibitor coagulant
complex for inj
5
•
BENEFIX - coagulation factor ix
(recombinant) for inj 3000 unit
5
•
FIRAZYR - icatibant acetate inj 30
mg/3ml (base equivalent)
5
•
BERINERT - c1 esterase inhibitor
(human) for iv inj kit 500 unit
5
•
HELIXATE FS - antihemophilic factor
(recombinant) for inj kit 250 unit
HELIXATE FS - antihemophilic factor
(recombinant) for inj kit 500 unit
5
•
BRILINTA - ticagrelor tab 90 mg
4
•
cilostazol tab 50 mg (Pletal)
HELIXATE FS - antihemophilic factor
(recombinant) for inj kit 1000 unit
5
1
cilostazol tab 100 mg (Pletal)
1
134
•
•
•
Dispensing Limits
Step Therapy
ALPHANINE SD - coagulation factor ix
for inj 500 unit
5
Prior Authorization
•
Drug Name
Drug Tier
5
Dispensing Limits
Prior Authorization
ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for
inj 2000 unit
Drug Name
Step Therapy
Drug Tier
2015
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
KOGENATE FS - antihemophilic factor
(recombinant) for inj kit 500 unit
5
•
HELIXATE FS - antihemophilic factor
(recombinant) for inj kit 3000 unit
5
•
KOGENATE FS - antihemophilic factor
(recombinant) for inj kit 1000 unit
5
•
HEMOFIL M - antihemophilic factor
(human) for inj 220-400 unit
5
•
KOGENATE FS - antihemophilic factor
(recombinant) for inj kit 2000 unit
5
•
HEMOFIL M - antihemophilic factor
(human) for inj 250 unit
5
•
KOGENATE FS - antihemophilic factor
(recombinant) for inj kit 3000 unit
5
•
HEMOFIL M - antihemophilic factor
(human) for inj 401-800 unit
5
•
5
•
HEMOFIL M - antihemophilic factor
(human) for inj 500 unit
5
•
KOGENATE FS BIO-SET antihemophilic factor (recombinant)
for inj kit 250 unit
5
•
HEMOFIL M - antihemophilic factor
(human) for inj 1000 unit
5
•
KOGENATE FS BIO-SET antihemophilic factor (recombinant)
for inj kit 500 unit
HEMOFIL M - antihemophilic factor
(human) for inj 1700 unit
5
•
5
•
HEMOFIL M - antihemophilic factor
(human) for inj 801-1500 unit
5
•
KOGENATE FS BIO-SET antihemophilic factor (recombinant)
for inj kit 1000 unit
5
•
HEMOFIL M - antihemophilic factor
(human) for inj 1501-2000 unit
5
•
KOGENATE FS BIO-SET antihemophilic factor (recombinant)
for inj kit 2000 unit
5
•
•
HUMATE-P - antihemophilic factor/vwf
(human) for inj 500-1200 unit
5
•
KOGENATE FS BIO-SET antihemophilic factor (recombinant)
for inj kit 3000 unit
5
HUMATE-P - antihemophilic factor/vwf
(human) for inj 250-600 unit
5
•
HUMATE-P - antihemophilic factor/vwf
(human) for inj 1000-2400 unit
5
•
MONOCLATE-P - antihemophilic factor
(human) for inj kit 250 unit
5
•
IXINITY - coagulation factor ix
(recombinant) for inj 500 unit
5
•
MONOCLATE-P - antihemophilic factor
(human) for inj kit 500 unit
5
•
IXINITY - coagulation factor ix
(recombinant) for inj 1000 unit
5
•
MONOCLATE-P - antihemophilic factor
(human) for inj kit 1000 unit
5
•
IXINITY - coagulation factor ix
(recombinant) for inj 1500 unit
5
•
MONOCLATE-P - antihemophilic factor
(human) for inj kit 1500 unit
5
•
KOATE-DVI - antihemophilic factor
(human) for inj 250 unit
5
•
MONONINE - coagulation factor ix for
inj 250 unit
5
•
KOATE-DVI - antihemophilic factor
(human) for inj 500 unit
5
•
MONONINE - coagulation factor ix for
inj 500 unit
5
•
KOATE-DVI - antihemophilic factor
(human) for inj 1000 unit
5
•
MONONINE - coagulation factor ix for
inj 1000 unit
5
•
KOGENATE FS - antihemophilic factor
(recombinant) for inj kit 250 unit
5
•
NOVOEIGHT - antihemophilic factor
(recombinant) for inj 250 unit
NOVOEIGHT - antihemophilic factor
(recombinant) for inj 500 unit
5
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
5
Dispensing Limits
Prior Authorization
HELIXATE FS - antihemophilic factor
(recombinant) for inj kit 2000 unit
Drug Name
Step Therapy
Drug Tier
2015
135
PROFILNINE SD - factor ix complex for
inj 1500 unit
5
•
NOVOEIGHT - antihemophilic factor
(recombinant) for inj 1500 unit
5
•
RECOMBINATE - antihemophilic factor
(recombinant) for inj 220-400 unit
5
•
NOVOEIGHT - antihemophilic factor
(recombinant) for inj 2000 unit
5
•
RECOMBINATE - antihemophilic factor
(recombinant) for inj 401-800 unit
5
•
NOVOEIGHT - antihemophilic factor
(recombinant) for inj 3000 unit
5
•
RECOMBINATE - antihemophilic factor
(recombinant) for inj 801-1240 unit
5
•
NOVOSEVEN - coagulation factor viia
(recomb) for inj 2.4 mg (2400 mcg)
5
•
RECOMBINATE - antihemophilic factor
(recombinant) for inj 1241-1800 unit
5
•
NOVOSEVEN RT - coagulation factor
viia (recomb) for inj 1 mg (1000 mcg)
5
•
RECOMBINATE - antihemophilic factor
(recombinant) for inj 1801-2400 unit
5
•
NOVOSEVEN RT - coagulation factor
viia (recomb) for inj 2 mg (2000 mcg)
5
•
RIXUBIS - coagulation factor ix
(recombinant) for inj 250 unit
5
•
NOVOSEVEN RT - coagulation factor
viia (recomb) for inj 5 mg (5000 mcg)
5
•
RIXUBIS - coagulation factor ix
(recombinant) for inj 500 unit
5
•
NOVOSEVEN RT - coagulation factor
viia (recomb) for inj 8 mg (8000 mcg)
5
•
RIXUBIS - coagulation factor ix
(recombinant) for inj 1000 unit
5
•
pentoxifylline tab cr 400 mg
1
5
•
PERSANTINE - dipyridamole tab 25 mg
4
RIXUBIS - coagulation factor ix
(recombinant) for inj 2000 unit
PERSANTINE - dipyridamole tab 50 mg
4
5
•
PERSANTINE - dipyridamole tab 75 mg
4
RIXUBIS - coagulation factor ix
(recombinant) for inj 3000 unit
ticlopidine hcl tab 250 mg
2
TRETTEN - coagulation factor xiii asubunit for inj 2000-3125 unit
5
•
WILATE - antihemophilic factor/vwf
(human) for inj 500-500 unit
5
•
WILATE - antihemophilic factor/vwf
(human) for inj 1000-1000 unit
5
•
XYNTHA - antihemophilic factor
recombinant paf for inj kit 250 unit
5
•
XYNTHA - antihemophilic factor
recombinant paf for inj kit 500 unit
5
•
XYNTHA - antihemophilic factor
recombinant paf for inj kit 1000 unit
5
•
XYNTHA - antihemophilic factor
recombinant paf for inj kit 2000 unit
5
•
XYNTHA SOLOFUSE - antihemophilic
factor recombinant paf for inj kit 250
unit
5
•
PLAVIX - clopidogrel bisulfate tab 75 mg 4
(base equiv)
4
PLAVIX - clopidogrel bisulfate tab 300
mg (base equiv)
4
PLETAL - cilostazol tab 50 mg
PLETAL - cilostazol tab 100 mg
4
PROFILNINE - factor ix complex for inj
500 unit
5
•
PROFILNINE - factor ix complex for inj
1000 unit
5
•
PROFILNINE - factor ix complex for inj
1500 unit
5
•
PROFILNINE SD - factor ix complex for
inj 500 unit
5
•
PROFILNINE SD - factor ix complex for
inj 1000 unit
5
•
136
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
5
Dispensing Limits
Prior Authorization
NOVOEIGHT - antihemophilic factor
(recombinant) for inj 1000 unit
Drug Name
Step Therapy
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
XYNTHA SOLOFUSE - antihemophilic
factor recombinant paf for inj kit 2000
unit
5
•
XYNTHA SOLOFUSE - antihemophilic
factor recombinant paf for inj kit 3000
unit
5
•
ZONTIVITY - vorapaxar sulfate tab 2.08
mg (base equivalent)
4
TOPICAL PRODUCTS
OPHTHALMIC AGENTS
AZASITE - azithromycin ophth soln 1%
4
azelastine hcl ophth soln 0.05%
(Optivar)
2
AZOPT - brinzolamide ophth susp 1%
4
Dispensing Limits
•
1
Step Therapy
XYNTHA SOLOFUSE - antihemophilic
factor recombinant paf for inj kit 1000
unit
5
atropine sulfate ophth soln 1%
(Isopto atropine)
Prior Authorization
•
Drug Name
Drug Tier
5
Dispensing Limits
Prior Authorization
XYNTHA SOLOFUSE - antihemophilic
factor recombinant paf for inj kit 500
unit
Drug Name
Step Therapy
Drug Tier
2015
BACITRACIN - bacitracin ophth oint 500 3
unit/gm
1
bacitracin-polymyxin b ophth oint
bacitracin-polymyxin-neomycin-hc
ophth oint 1%
2
BEPREVE - bepotastine besilate ophth
soln 1.5%
4
BESIVANCE - besifloxacin hcl ophth
susp 0.6% (base equiv)
4
ACULAR - ketorolac tromethamine
ophth soln 0.5%
4
BETADINE OPHTHALMIC PREP povidone-iodine ophth soln 5%
4
ACULAR LS - ketorolac tromethamine
ophth soln 0.4%
4
BETAGAN - levobunolol hcl ophth soln
0.5%
4
ACUVAIL - ketorolac tromethamine
ophth soln 0.45%
4
betaxolol hcl ophth soln 0.5%
2
BETIMOL - timolol ophth soln 0.25%
4
AKTEN - lidocaine hcl ophth gel 3.5%
4
BETIMOL - timolol ophth soln 0.5%
4
ALCAINE - proparacaine hcl ophth soln
0.5%
4
BETOPTIC-S - betaxolol hcl ophth susp
0.25%
4
ALOCRIL - nedocromil sodium ophth
soln 2%
4
BIMATOPROST - bimatoprost ophth
soln 0.03%
4
ALOMIDE - lodoxamide tromethamine
ophth soln 0.1%
4
BLEPH-10 - sulfacetamide sodium
ophth soln 10%
4
ALPHAGAN P - brimonidine tartrate
ophth soln 0.1%
4
BLEPHAMIDE - sulfacetamide sodiumprednisolone ophth susp 10-0.2%
4
ALPHAGAN P - brimonidine tartrate
ophth soln 0.15%
4
4
ALREX - loteprednol etabonate ophth
susp 0.2%
4
BLEPHAMIDE S.O.P. - sulfacetamide
sodium-prednisolone ophth oint
10-0.2%
2
apraclonidine hcl ophth soln 0.5%
(base equivalent) (Iopidine)
2
brimonidine tartrate ophth soln
0.15% (Alphagan p)
brimonidine tartrate ophth soln 0.2%
1
ATROPINE SULFATE - atropine sulfate
ophth oint 1%
4
bromfenac sodium ophth soln 0.09%
(base equivalent)
2
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
137
bromfenac sodium ophth soln 0.09%
(base equiv) (once-daily)
2
ELESTAT - epinastine hcl ophth soln
0.05%
4
carteolol hcl ophth soln 1%
1
4
CILOXAN - ciprofloxacin hcl ophth soln
0.3%
4
EMADINE - emedastine difumarate
ophth soln 0.05% (base equiv)
2
CILOXAN - ciprofloxacin hcl ophth oint
0.3%
4
epinastine hcl ophth soln 0.05%
(Elestat)
erythromycin ophth oint 5 mg/gm
1
ciprofloxacin hcl ophth soln 0.3%
(Ciloxan)
1
FLAREX - fluorometholone acetate
ophth susp 0.1%
4
COMBIGAN - brimonidine tartratetimolol maleate ophth soln 0.2-0.5%
4
fluorometholone ophth susp 0.1%
(Fml liquifilm)
1
COSOPT - dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8 mg/ml
4
flurbiprofen sodium ophth soln
0.03% (Ocufen)
1
COSOPT PF - dorzolamide hcl-timolol
maleate ophth sol 22.3-6.8 mg/ml pf
4
FML - fluorometholone ophth oint 0.1%
4
1
FML FORTE - fluorometholone ophth
susp 0.25%
4
cromolyn sodium ophth soln 4%
CYCLOGYL - cyclopentolate hcl ophth
soln 0.5%
4
FML LIQUIFILM - fluorometholone
ophth susp 0.1%
4
CYCLOGYL - cyclopentolate hcl ophth
soln 1%
4
GARAMYCIN - gentamicin sulfate ophth
soln 0.3%
4
CYCLOGYL - cyclopentolate hcl ophth
soln 2%
4
gatifloxacin ophth soln 0.5%
(Zymaxid)
2
CYCLOMYDRIL - cyclopentolate w/
phenylephrine ophth soln 0.2-1%
4
cyclopentolate hcl ophth soln 1%
(Cyclogyl)
1
GELFILM OP - gelatin adsorbable ophth 4
film
1
gentamicin sulfate ophth oint 0.3%
2
gentamicin sulfate ophth soln 0.3%
(Garamycin)
1
cyclopentolate hcl ophth soln 2%
(Cyclogyl)
homatropine hbr ophth soln 5%
(Isopto homatropine)
1
ILEVRO - nepafenac ophth susp 0.3%
4
IOPIDINE - apraclonidine hcl ophth soln
0.5% (base equivalent)
4
4
CYSTARAN - cysteamine hcl ophth soln 5
0.44% (base equivalent)
1
dexamethasone sodium phosphate
ophth soln 0.1%
1
diclofenac sodium ophth soln 0.1%
•
dorzolamide hcl ophth soln 2%
(Trusopt)
2
IOPIDINE - apraclonidine hcl ophth soln
1% (base equivalent)
1
ISOPTO ATROPINE - atropine sulfate
ophth soln 1%
4
dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml (Cosopt)
DUREZOL - difluprednate ophth
emulsion 0.05%
ISOPTO CARBACHOL - carbachol
ophth soln 1.5%
4
4
ISOPTO CARBACHOL - carbachol
ophth soln 3%
4
138
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
ISOPTO CARPINE - pilocarpine hcl
ophth soln 1%
4
MAXITROL - neomycin-polymyxindexamethasone ophth oint 0.1%
4
ISOPTO CARPINE - pilocarpine hcl
ophth soln 2%
4
METIPRANOLOL - metipranolol ophth
soln 0.3%
4
ISOPTO CARPINE - pilocarpine hcl
ophth soln 4%
4
MITOSOL - mitomycin for ophth soln kit
0.2 mg
4
MOXEZA - moxifloxacin hcl ophth soln
0.5% (base eq) (2 times daily)
4
MYDRIACYL - tropicamide ophth soln
1%
4
NAPHAZOLINE HCL - naphazoline hcl
ophth soln 0.1%
4
NATACYN - natamycin ophth susp 5%
3
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin
2
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
(Neosporin)
2
neomycin-polymyxindexamethasone ophth oint 0.1%
(Maxitrol)
1
neomycin-polymyxindexamethasone ophth susp 0.1%
(Maxitrol)
1
NEOMYCIN/POLYMYXIN/HYDROC neomycin-polymyxin-hc ophth susp
4
NEOSPORIN - neomycin-polymygramicid op sol 1.75-10000-0.025mgunt-mg/ml
4
NEVANAC - nepafenac ophth susp
0.1%
4
OCUFEN - flurbiprofen sodium ophth
soln 0.03%
4
OCUFLOX - ofloxacin ophth soln 0.3%
4
ofloxacin ophth soln 0.3% (Ocuflox)
1
OMNIPRED - prednisolone acetate
ophth susp 1%
4
PATADAY - olopatadine hcl ophth soln
0.2%
4
ISOPTO HOMATROPINE - homatropine 4
hbr ophth soln 2%
ISOPTO HOMATROPINE - homatropine 4
hbr ophth soln 5%
ISOPTO HYOSCINE - scopolamine hbr 4
ophth soln 0.25%
4
ISTALOL - timolol maleate ophth soln
0.5% (once-daily)
2
ketorolac tromethamine ophth soln
0.4% (Acular ls)
2
ketorolac tromethamine ophth soln
0.5% (Acular)
LACRISERT - artificial tear ophth insert 4
LASTACAFT - alcaftadine ophth soln
0.25%
4
latanoprost ophth soln 0.005%
(Xalatan)
1
LEVOBUNOLOL HCL - levobunolol hcl
ophth soln 0.25%
4
levobunolol hcl ophth soln 0.5%
(Betagan)
1
levofloxacin ophth soln 0.5%
2
LOTEMAX - loteprednol etabonate
ophth gel 0.5%
4
LOTEMAX - loteprednol etabonate
ophth oint 0.5%
4
LOTEMAX - loteprednol etabonate
ophth susp 0.5%
4
LUMIGAN - bimatoprost ophth soln
0.01%
4
MAXIDEX - dexamethasone ophth susp
0.1%
4
MAXITROL - neomycin-polymyxindexamethasone ophth susp 0.1%
4
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
139
PATANOL - olopatadine hcl ophth soln
0.1%
4
SIMBRINZA - brinzolamide-brimonidine
tartrate ophth susp 1-0.2%
4
PAZEO - olopatadine hcl ophth soln
0.7% (base equivalent)
4
SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint 10%
4
phenylephrine hcl ophth soln 2.5%
1
2
phenylephrine hcl ophth soln 10%
1
sulfacetamide sodium ophth soln
10% (Bleph-10)
PHOSPHOLINE IODIDE echothiophate iodide ophth for soln
0.125%
4
sulfacetamide sodium-prednisolone
ophth soln 10-0.23(0.25)%
1
tetracaine hcl ophth soln 0.5%
1
pilocarpine hcl ophth soln 1% (Isopto
carpine)
2
timolol maleate ophth gel forming
soln 0.25% (Timoptic-xe)
2
pilocarpine hcl ophth soln 2% (Isopto
carpine)
2
timolol maleate ophth gel forming
soln 0.5% (Timoptic-xe)
2
pilocarpine hcl ophth soln 4% (Isopto
carpine)
2
timolol maleate ophth soln 0.25%
(Timoptic)
1
polymyxin b-trimethoprim ophth
soln 10000 unit/ml-0.1% (Polytrim)
1
timolol maleate ophth soln 0.5%
(Timoptic)
1
POLYTRIM - polymyxin b-trimethoprim
ophth soln 10000 unit/ml-0.1%
4
TIMOPTIC - timolol maleate ophth soln
0.25%
4
PRED FORTE - prednisolone acetate
ophth susp 1%
4
TIMOPTIC - timolol maleate ophth soln
0.5%
4
PRED MILD - prednisolone acetate
ophth susp 0.12%
4
TIMOPTIC OCUDOSE - timolol maleate
preservative free ophth soln 0.25%
4
PRED-G - gentamicin-prednisolone ace
ophth susp 0.3-1%
4
TIMOPTIC OCUDOSE - timolol maleate
preservative free ophth soln 0.5%
4
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint 0.3-0.6%
4
TIMOPTIC-XE - timolol maleate ophth
gel forming soln 0.25%
4
prednisolone acetate ophth susp 1%
(Pred forte)
2
TIMOPTIC-XE - timolol maleate ophth
gel forming soln 0.5%
4
PREDNISOLONE SODIUM PHOSP prednisolone sodium phosphate
ophth soln 1%
4
TOBRADEX - tobramycindexamethasone ophth oint 0.3-0.1%
4
PROLENSA - bromfenac sodium ophth
soln 0.07% (base equivalent)
TOBRADEX - tobramycindexamethasone ophth susp 0.3-0.1%
4
4
4
proparacaine hcl ophth soln 0.5%
(Alcaine)
1
TOBRADEX ST - tobramycindexamethasone ophth susp
0.3-0.05%
RESCULA - unoprostone isopropyl
ophth soln 0.15%
4
tobramycin ophth soln 0.3% (Tobrex)
1
RESTASIS - cyclosporine (ophth)
emulsion 0.05%
tobramycin-dexamethasone ophth
susp 0.3-0.1% (Tobradex)
2
4
TOBREX - tobramycin ophth soln 0.3%
4
140
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
4
CIPROFLOXACIN - ciprofloxacin hcl
otic soln 0.2% (base equivalent)
4
COLY-MYCIN S - neomycin-colistin-hcthonzonium otic susp 3.3-3-10-0.5
mg/ml
4
CORTANE-B AQUEOUS - pramoxinehc-chloroxylenol aqueous otic soln
10-10-1 mg/ml
4
CORTANE-B-OTIC - pramoxine-hcchloroxylenol otic soln 10-10-1 mg/ml
4
CORTISPORIN - neomycin-polymyxinhc otic soln 1%
4
•
CORTISPORIN-TC - neomycin-colistinhc-thonzonium otic susp 3.3-3-10-0.5
mg/ml
4
•
4
4
DERMOTIC - fluocinolone acetonide
(otic) oil 0.01%
2
4
fluocinolone acetonide (otic) oil
0.01% (Dermotic)
hydrocortisone w/ acetic acid otic
soln 1-2% (Vosol hc)
2
MYOXIN - benzocaine-chloroxylenol-hc
otic susp 15-1-10 mg/ml
4
neomycin-polymyxin-hc otic soln 1%
(Cortisporin)
2
neomycin-polymyxin-hc otic susp
3.5 mg/ml-10000 unit/ml-1%
2
ofloxacin otic soln 0.3%
2
OTICIN HC NR - pramoxine-hcchloroxylenol otic soln 10-10-1 mg/ml
4
OTOZIN - antipyrine-benzocaineglycerin-zinc ace otic liqd 5.4-1-2-1%
4
PINNACAINE OTIC - benzocaine otic
soln 20%
4
TRAVOPROST - travoprost ophth soln
0.004%
4
trifluridine ophth soln 1% (Viroptic)
2
tropicamide ophth soln 0.5%
1
tropicamide ophth soln 1%
(Mydriacyl)
1
TRUSOPT - dorzolamide hcl ophth soln
2%
4
VEXOL - rimexolone ophth susp 1%
4
VIGAMOX - moxifloxacin hcl ophth soln
0.5% (base equiv)
4
VIROPTIC - trifluridine ophth soln 1%
4
XALATAN - latanoprost ophth soln
0.005%
4
ZIOPTAN - tafluprost ophth soln
0.0015%
4
ZIRGAN - ganciclovir ophth gel 0.15%
4
ZYLET - loteprednol etabonatetobramycin ophth susp 0.5-0.3%
ZYMAXID - gatifloxacin ophth soln 0.5%
OTIC AGENTS
acetic acid otic soln 2%
2
ACETIC ACID/ALUMINUM ACET acetic acid 2% in aluminum acetate
otic soln
4
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
1
antipyrine-benzocaine-polycosanol
otic sol 5.4-1.4-0.0097% (Treagan
otic)
2
ANTIPYRINE/BENZOCAINE antipyrine-benzocaine otic soln 55-14
mg/ml (5.5-1.4%)
4
AURALGAN - antipyrine-benzocaine
otic soln 55-14 mg/ml (5.5-1.4%)
4
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
CIPRODEX - ciprofloxacindexamethasone otic susp 0.3-0.1%
4
Step Therapy
4
TRAVATAN Z - travoprost ophth soln
0.004% (benzalkonium free) (bak
free)
Prior Authorization
CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1%
4
Drug Tier
4
•
CETRAXAL - ciprofloxacin hcl otic soln
0.2% (base equivalent)
TOBREX - tobramycin ophth oint 0.3%
Step Therapy
Drug Name
Drug Name
Drug Tier
Dispensing Limits
Prior Authorization
2015
141
PRAMOTIC - pramoxine-chloroxylenol
otic liquid 1-0.1%
4
pramoxine-chloroxylenol otic liquid
1-0.1% (Pramotic)
4
2
LISTERINE ESSENTIAL CARE - sod
monofluorophosph-eucal-men-methyl
sal-thymol gel 0.76%
4
pramoxine-hc-chloroxylenol otic
soln 10-10-1 mg/ml (Cortane-b-otic)
1
LISTERINE RESTORING - sodium
fluoride rinse 0.0221% (0.01% f)
4
TREAGAN OTIC - antipyrinebenzocaine-polycosanol otic sol
5.4-1.4-0.0097%
4
LISTERINE SMART RINSE - sodium
fluoride rinse 0.0221% (0.01% f)
LISTERINE SMART RINSE ANT sodium fluoride rinse 0.02%
4
4
MOUTH/THROAT/DENTAL AGENTS
ACT TOTAL CARE DRY MOUTH sodium fluoride rinse 0.02%
4
LISTERINE TOOTH DEFENSE sodium fluoride rinse 0.0221%
(0.01% f)
AQUORAL - artificial saliva - aero soln
4
4
benzocaine dental soln 20%
1
LISTERINE TOTAL CARE - sodium
fluoride rinse 0.0221% (0.01% f)
4
cevimeline hcl cap 30 mg (Evoxac)
2
LISTERINE TOTAL CARE PLUS sodium fluoride rinse 0.0221%
(0.01% f)
4
CAPHOSOL - artificial saliva - solution
chlorhexidine gluconate soln 0.12%
(Peridex)
1
LISTERINE TOTAL CARE ZERO sodium fluoride rinse 0.02%
4
clotrimazole troche 10 mg
2
4
COLGATE DRY MOUTH RELIEF sodium fluoride mouthwash 2.1
mg/10ml
4
LISTERINE WHITENING/RESTO sodium fluoride rinse 0.0221%
(0.01% f)
LTA 360 KIT - lidocaine hcl
laryngotracheal soln 4%
4
mouthwashes - liquid
2
DEBACTEROL - sulfuric acid-sulfonated 4
phenolics soln 30-50%
4
EVOXAC - cevimeline hcl cap 30 mg
FLUORIDEX DAILY DEFENSE S sodium fluoride-potassium nitrate gel
1.1-5%
4
GEL-KAM - stannous fluoride gel 0.4%
4
GEL-KAM ORAL CARE RINSE stannous fluoride conc 0.63%
4
GELCLAIR - povidone-sodium
hyaluronate-glycyrrhetinic acid gel
4
GELX - oral wound care products - gel
4
MUCOTROL - oral wound care products 4
- wafer
4
NAFRINSE DAILY/ACIDULATED sodium fluoride-phosphoric acid for
soln 1 mg/5ml (f equiv)
4
NAFRINSE DAILY/NEUTRAL - sodium
fluoride for soln rinse 0.05%
4
NAFRINSE WEEKLY - sodium fluoride
for soln rinse 0.2%
4
NEUTRASAL - artificial saliva - packet
lidocaine hcl laryngotracheal soln
4% (Lta 360 kit)
2
NUMOISYN - artificial saliva - lozenge
4
NUMOISYN - artificial saliva - solution
4
lidocaine hcl viscous soln 2%
1
nystatin susp 100000 unit/ml
2
OMNI GEL - stannous fluoride gel 0.4%
4
142
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
ORAFATE - sucralfate-malate paste
10%
4
ORAMAGICRX - oral wound care
products - for susp rinse
ORAVIG - miconazole buccal tab 50 mg
(mouth-throat)
4
4
REMBRANDT DEEPLY WHITE+PE sodium monofluorophosphate paste
0.884%
4
4
REMBRANDT INTENSE STAIN sodium fluoride paste 0.243%
REMBRANDT WHITENING - sodium
fluoride rinse 0.02%
4
SALAGEN - pilocarpine hcl tab 5 mg
4
SALAGEN - pilocarpine hcl tab 7.5 mg
4
SALICEPT - oral wound care products for susp rinse
4
sodium fluoride cream 1.1%
(Prevident 5000 plus)
1
1
PERIDEX - chlorhexidine gluconate soln 4
0.12%
4
PHOS FLUR - sodium fluoride rinse
0.044%
4
PHOS-FLUR ORTHO DEFENSE sodium fluoride rinse 0.044%
2
pilocarpine hcl tab 5 mg (Salagen)
pilocarpine hcl tab 7.5 mg (Salagen)
2
PREVIDENT - sodium fluoride rinse
0.2%
4
sodium fluoride gel 1.1% (0.5% f)
(Prevident fluoride)
1
PREVIDENT FLUORIDE - sodium
fluoride gel 1.1% (0.5% f)
4
sodium fluoride paste 1.1%
(Prevident 5000 boost)
2
PREVIDENT 5000 BOOSTER - sodium
fluoride paste 1.1%
4
sodium fluoride rinse 0.0221%
(0.01% f)
sodium fluoride rinse 0.05%
2
PREVIDENT 5000 BOOSTER PL sodium fluoride paste 1.1%
4
sodium fluoride rinse 0.2%
(Prevident)
1
PREVIDENT 5000 DRY MOUTH sodium fluoride gel 1.1% (0.5% f)
4
sodium fluoride-potassium nitrate
paste 1.1-5% (Prevident 5000 sensi)
1
PREVIDENT 5000 ENAMEL PRO sodium fluoride-potassium nitrate
paste 1.1-5%
4
stannous fluoride conc 0.63% (Gelkam oral care ri)
1
stannous fluoride gel 0.4%
2
PREVIDENT 5000 PLUS - sodium
fluoride cream 1.1%
4
STANNOUS FLUORIDE RINSE stannous fluoride liq 0.1%
4
THERA-FLUR-N - sodium fluoride gel
1.1% (0.5% f)
4
triamcinolone acetonide dental paste
0.1%
2
PREVIDENT 5000 SENSITIVE - sodium 4
fluoride-potassium nitrate paste
1.1-5%
PROTHELIAL - sucralfate-malate paste 4
10%
4
REACH KIDS - sodium fluoride paste
0.15%
4
REMBRANDT CANKER SORE sodium fluoride paste 0.243%
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
ANORECTAL AGENTS
ANALPRAM ADVANCED - hcpramoxine cr & diet manage prod tab
& cleans wipe kit
4
ANALPRAM E - hc-pramoxine emol
cream 2.5-1% & pramoxine wipe 1%
kit
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
143
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal lotn
2.5-1%
4
LIDOCAINE HCL-HYDROCORTIS lidocaine-hydrocortisone acetate
rectal gel 2.8-0.55%
4
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal cream
1-1%
4
lidocaine-hydrocortisone acetate
rectal cream kit 2-2%
2
2
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal cream
2.5-1%
4
lidocaine-hydrocortisone acetate
rectal cream kit 3-0.5%
lidocaine-hydrocortisone acetate
rectal cream kit 3-1%
2
ANALPRAM-HC SINGLES hydrocortisone acetate w/ pramoxine
rectal cream 1-1%
4
lidocaine-hydrocortisone acetate
rectal cream 3-0.5%
2
4
lidocaine-hydrocortisone acetate
rectal gel kit 3-2.5%
2
ANALPRAM-HC SINGLES hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1%
4
ANUSOL-HC - hydrocortisone rectal
cream 2.5%
4
PROCORT - hydrocortisone acetate w/
pramoxine rectal cream 1.85-1.15%
4
ANUSOL-HC - hydrocortisone acetate
suppos 25 mg
4
PROCTOCORT - hydrocortisone rectal
cream 1%
4
CORTENEMA - hydrocortisone enema
100 mg/60ml
4
PROCTOCORT - hydrocortisone
acetate suppos 30 mg
4
CORTIFOAM - hydrocortisone acetate
rectal foam 90 mg/dose
3
PROCTOFOAM HC - hydrocortisone
acetate w/ pramoxine rectal foam
1-1%
RECTIV - nitroglycerin oint 0.4%
4
2
hc-pramoxine emol cream 2.5-1% &
pramoxine wipe 1% kit (Analpram e)
2
hydrocortisone acetate suppos
25 mg (Anusol-hc)
2
hydrocortisone acetate suppos
30 mg (Proctocort)
hydrocortisone acetate w/ pramoxine 2
rectal cream 1-1% (Analpram-hc)
hydrocortisone acetate w/ pramoxine 2
rectal cream 2.5-1% (Analpram-hc)
2
hydrocortisone enema 100 mg/60ml
(Cortenema)
2
hydrocortisone rectal cream 1%
(Proctocort)
1
hydrocortisone rectal cream 2.5%
(Anusol-hc)
144
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
UCERIS - budesonide rectal foam 2 mg/ 4
act
DERMATOLOGICALS
ABSORICA - isotretinoin cap 10 mg
4
ABSORICA - isotretinoin cap 20 mg
4
ABSORICA - isotretinoin cap 25 mg
4
ABSORICA - isotretinoin cap 30 mg
4
ABSORICA - isotretinoin cap 35 mg
4
ABSORICA - isotretinoin cap 40 mg
4
ACANYA - clindamycin phosphatebenzoyl peroxide gel 1.2-2.5%
4
acitretin cap 10 mg (Soriatane)
2
acitretin cap 17.5 mg (Soriatane)
2
acitretin cap 25 mg (Soriatane)
2
ACLOVATE - alclometasone
dipropionate cream 0.05%
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
ACUICYN DAILY EYELID & EY - eyelid
cleansers - liquid
4
ALOQUIN - iodoquinol-aloe
polysaccharides gel 1.25-1%
4
acyclovir oint 5% (Zovirax)
2
ALTABAX - retapamulin oint 1%
4
ACZONE - dapsone gel 5%
4
4
ADAPALENE - adapalene lotion 0.1%
4
ALUMINUM ACETATE - aluminum
acetate soln
adapalene cream 0.1% (Differin)
2
ALUVEA - urea cream 39%
4
adapalene gel 0.1% (Differin)
2
2
adapalene gel 0.3% (Differin)
2
AMCINONIDE - amcinonide cream
0.1%
4
AMCINONIDE - amcinonide lotion 0.1%
4
ADAZIN - benzo-capsaicin-lido-methyl
salicylate cream 2-0.035-2-10%
AMCINONIDE - amcinonide oint 0.1%
4
ADVANCED ALLERGY COLLECTI hydrocortisone cream kit 2.5%
4
ANACAINE - benzocaine oint 10%
4
4
ALA QUIN - clioquinol-hc cream 3-0.5%
4
ANODYNERX - capsaicin-lidocainementhol patch 0.05-2.5-5%
ALA SCALP - hydrocortisone lotion 2%
4
4
alclometasone dipropionate cream
0.05% (Aclovate)
2
ANODYNZ - capsaicin-menthol disk
0.0375-5%
4
alclometasone dipropionate oint
0.05%
2
APEXICON E - diflorasone diacetate
emollient base cream 0.05%
4
ALCORTIN A - iodoquinolhydrocortisone-aloe polysaccharide
gel 1-2-1%
4
ARZOL SILVER NITRATE APP - silver
nitrate-potassium nitrate applicator
75-25%
4
ALDARA - imiquimod cream 5%
4
ATENDIA - lidocaine-menthol patch
4-3%
4
ATOPICLAIR - dermatological products
misc - cream
4
ALEGENIX - capsaicin-menthol disk
0.0375-5%
4
ATRALIN - tretinoin gel 0.05%
4
ALEVEER - capsaicin-menthol topical
patch 0.0375-5%
ATRAPRO CP - wound dressings - kit
4
ALEVICYN DERMAL SPRAY - wound
dressings - soln
4
ATRAPRO DERMAL SPRAY - wound
cleansers - liquid
4
ALLEVYN AG ADHESIVE - wound
dressings - pads
4
AURSTAT - dermatological products
misc - kit
4
ALLEVYN AG GENTLE BORDER wound dressings - pads
4
AURSTAT ANTI-ITCH HYDROGE dermatological products misc - kit
4
AVALIN-RX - lidocaine-menthol patch
4-1%
4
AVAR - sulfacetamide sodium w/ sulfur
foam 9.5-5%
4
AVAR - sulfacetamide sodium w/ sulfur
cleansing pad 9.5-5%
4
ALLEVYN AG NON-ADHESIVE - wound 4
dressings - pads
4
ALLEVYN AG SACRUM - wound
dressings - pads
ALLEVYN GENTLE - wound dressings - 4
pads
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
145
4
AVAR LS - sulfacetamide sodium w/
sulfur cleansing pad 10-2%
4
AVAR LS CLEANSER - sulfacetamide
sodium w/ sulfur cleanser 10-2%
4
AVAR-E LS - sulfacetamide sodium w/
sulfur cream 10-2%
4
AVENOVA - hypochlorous acid cleanser 4
soln 0.01%
4
AZELEX - azelaic acid cream 20%
BACTROBAN - mupirocin calcium
cream 2%
4
BACTROBAN - mupirocin oint 2%
4
BENSAL HP - salicylic acid & benzoic
acid oint 3-6%
4
BENZACLIN - clindamycin phosphatebenzoyl peroxide gel 1-5%
4
BENZACLIN WITH PUMP - clindamycin
phosphate-benzoyl peroxide gel 1-5%
4
BENZAMYCIN - benzoyl peroxideerythromycin gel 5-3%
4
BENZAMYCINPAK - benzoyl peroxideerythromycin gel pack 5-3%
4
BENZEFOAM - benzoyl peroxide foam
5.3%
4
BENZEFOAMULTRA - benzoyl peroxide 4
foam 9.8%
4
BENZIQ - benzoyl peroxide gel 5.25 %
benzoyl peroxide liq 7%
2
benzoyl peroxide liq 5.25%
2
benzoyl peroxide lotion 6%
2
benzoyl peroxide-erythromycin gel
5-3% (Benzamycin)
2
betamethasone dipropionate
augmented cream 0.05% (Diprolene
af)
2
betamethasone dipropionate
augmented gel 0.05%
2
2
betamethasone dipropionate
augmented lotion 0.05% (Diprolene)
2
betamethasone dipropionate
augmented oint 0.05% (Diprolene)
2
betamethasone dipropionate cream
0.05%
2
betamethasone dipropionate lotion
0.05%
2
betamethasone dipropionate oint
0.05%
2
betamethasone valerate aerosol
foam 0.12% (Luxiq)
2
betamethasone valerate cream 0.1%
betamethasone valerate lotion 0.1%
2
betamethasone valerate oint 0.1%
2
BP CLEANSING WASH - sulfacetamide
sodium-sulfur in urea emulsion 10-4%
2
BPO - benzoyl peroxide gel 4%
4
BPO - benzoyl peroxide gel 8%
4
BPO CREAMY WASH COMPLETE benzoyl peroxide creamy wash 8%
&benzoyl peroxide bar 5% kit
4
BPO 3% FOAMING CLOTHS - benzoyl
peroxide cloth 3%
4
BENZIQ LS - benzoyl peroxide gel
2.75%
4
benzoyl peroxide creamy wash 4%
&benzoyl peroxide bar 5% kit
2
benzoyl peroxide creamy wash 8%
&benzoyl peroxide bar 5% kit (Bpo
creamy wash comp)
2
benzoyl peroxide foam 5.3%
(Benzefoam)
2
BPO 9% FOAMING CLOTHS - benzoyl
peroxide cloth 9%
4
benzoyl peroxide foam 9.8%
(Benzefoamultra)
2
calcipotriene cream 0.005%
(Dovonex)
2
146
Dispensing Limits
2
Step Therapy
benzoyl peroxide liq 2.5%
Prior Authorization
Dispensing Limits
Drug Name
Drug Tier
AVAR LS - sulfacetamide sodium w/
sulfur foam 10-2%
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
4
calcipotriene soln 0.005% (50 mcg/
ml)
2
calcipotriene-betamethasone
dipropionate oint 0.005-0.064%
(Taclonex)
2
CALCITRIOL - calcitriol oint 3 mcg/gm
4
CAMPHOMEX - camphor-histaminementhol liqd spray 4-0.025-10%
4
CAPEX - fluocinolone acetonide
shampoo 0.01%
4
CAPSIDERM - capsaicin-menthol
topical patch 0.0375-5%
4
CLARIFOAM EF - sulfacetamide sodium 4
w/ sulfur foam 10-5%
4
CLEOCIN-T - clindamycin phosphate
soln 1%
4
CLEOCIN-T - clindamycin phosphate
lotion 1%
4
CLEOCIN-T - clindamycin phosphate
swab 1%
4
CLEOCIN-T - clindamycin phosphate
gel 1%
4
CLEVER CHOICE COMFORT EZ methyl salicylate-lidocaine-menthol
patch 2-4-1%
4
CLEVER CHOICE COMFORT EZ methyl salicylate-lidocaine-menthol
patch 20-4-1%
4
CLINDACIN ETZ - clindamycin
phosphate swab 1% & cleanser kit
4
CLINDACIN PAC - clindamycin
phosphate swab 1% & cleanser kit
4
CLINDAGEL - clindamycin phosphate
gel 1%
2
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
2
clindamycin phosphate foam 1%
(Evoclin)
2
clindamycin phosphate gel 1%
(Cleocin-t)
2
clindamycin phosphate lotion 1%
(Cleocin-t)
2
clindamycin phosphate soln 1%
(Cleocin-t)
2
clindamycin phosphate swab 1%
(Cleocin-t)
2
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
2
clobetasol propionate cream 0.05%
(Temovate)
CAPTRACIN - capsaicin-menthol topical 4
patch 0.0375-5%
4
CARAC - fluorouracil cream 0.5%
CEM-UREA - urea soln 45%
4
CENTANY - mupirocin oint 2%
4
CENTANY AT - mupirocin oint kit 2%
4
CETACAINE - butamben-tetracainebenzocaine aerosol spray 2-2-14%
4
CICLODAN CREAM KIT - ciclopirox
olamine cream 0.77% (base equiv) &
cleanser kit
4
CICLODAN SOLUTION KIT - ciclopirox
solution kit 8%
4
ciclopirox gel 0.77%
2
ciclopirox olamine cream 0.77%
(base equiv)
2
ciclopirox olamine susp 0.77% (base
equiv)
2
ciclopirox shampoo 1% (Loprox
shampoo)
2
ciclopirox solution kit 8% (Ciclodan
solution ki)
2
ciclopirox solution 8% (Penlac Nail
Lacquer)
2
CICLOPIROX TOPICAL SOLUTI ciclopirox solution 8% & vitamin e 5%
topical kit
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
CLARAVIS - isotretinoin cap 30 mg
Step Therapy
2
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
calcipotriene oint 0.005%
Prior Authorization
Drug Name
Drug Tier
2015
147
COCAINE HCL - cocaine hcl soln 4%
4
COCAINE HCL - cocaine hcl soln 10%
4
CONDYLOX - podofilox soln 0.5%
4
CONDYLOX - podofilox gel 0.5%
4
Dispensing Limits
4
Step Therapy
COAL TAR - coal tar soln 20%
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
clobetasol propionate emollient base
cream 0.05% (Temovate e)
2
clobetasol propionate emulsion
foam 0.05% (Olux-e)
2
clobetasol propionate foam 0.05%
(Olux)
2
clobetasol propionate gel 0.05%
(Temovate)
2
COPASIL - emollient - gel
4
4
clobetasol propionate lotion 0.05%
(Clobex)
2
CORDRAN - flurandrenolide cream
0.05%
4
clobetasol propionate oint 0.05%
(Temovate)
2
CORDRAN - flurandrenolide lotion
0.05%
CORDRAN - flurandrenolide oint 0.05%
4
clobetasol propionate shampoo
0.05% (Clobex)
2
CORDRAN TAPE - flurandrenolide tape
4 mcg/sqcm
4
clobetasol propionate soln 0.05%
(Temovate)
2
CORTALO - hydrocortisone acetatealoe vera gel 2%
2
clobetasol propionate spray 0.05%
(Clobex)
2
4
CLOBEX - clobetasol propionate spray
0.05%
4
CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot
10-10-1mg/ml
4
CLOBEX - clobetasol propionate lotion
0.05%
4
CORTISPORIN - neomycin-polymyxinhc cream 0.5%
4
CLOBEX - clobetasol propionate
shampoo 0.05%
4
CORTISPORIN - bacitracin-polymyxinneomycin hc oint 1%
4
• •
CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1%
4
COSENTYX - secukinumab
subcutaneous soln prefilled syringe
150 mg/ml
CLOCORTOLONE PIVALATE PUM clocortolone pivalate cream 0.1%
4
4
• •
CLODAN KIT - clobetasol propionate
shampoo 0.05% & cleanser kit
4
COSENTYX SENSOREADY PEN secukinumab subcutaneous soln
auto-injector 150 mg/ml
4
CLODERM - clocortolone pivalate
cream 0.1%
4
CURITY HYPERTONIC SODIUM wound dressings - misc
4
CLODERM PUMP - clocortolone
pivalate cream 0.1%
4
CURITY SODIUM CHLORIDE DR wound dressings - pads
4
clotrimazole w/ betamethasone
cream 1-0.05% (Lotrisone)
2
CUTIVATE - fluticasone propionate
cream 0.05%
4
clotrimazole w/ betamethasone
lotion 1-0.05%
2
CUTIVATE - fluticasone propionate
lotion 0.05%
DENAVIR - penciclovir cream 1%
4
CNL8 NAIL KIT - ciclopirox soln 8% &
lacquer removal pads kit
4
DERMA SILKRX SDS PAK triamcinolone acet cr 0.1% & dimeth
cr 5% & silicone tape
4
148
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
4
DERMA-SMOOTHE/FS BODY OIL fluocinolone acetonide oil 0.01%
(body oil)
4
DERMA-SMOOTHE/FS SCALP fluocinolone acetonide oil 0.01%
(scalp oil)
4
DERMA-SMOOTHE/FS SCALP OI fluocinolone acetonide oil 0.01%
(scalp oil)
4
DERMACINRX DUOPATCH PHARM lidocaine patch 5% & menthol-methyl
sal patch 3-10% ther pak
4
DERMACINRX LEXITRAL PHARM diclofenac sod soln 1.5% & capsaicin
cream 0.025% ther pack
4
DERMACINRX NEUROTRAL PHAR lidocaine patch 5% & capsaicin
cream 0.025% therapy pack
4
DERMACINRX SILAPAK triamcinolone acet cr 0.1% & dimeth
cr 5% & silicone tape
4
DERMACINRX SURGICAL COMBO chlorhexidine soln-dimeth cr-silicone
tape-homeopathic kit
4
DERMACINRX SURGICAL PHARM chlorhexidine sol-mupirocin cr-dimeth
cr-silicone tape kit
4
DERMASORB AF - clioquinol-hc cream
3-0.5% & emollient liqd kit
4
DERMASORB HC - hydrocortisone lot
2% & cleanser liq kit
4
DERMASORB TA - triamcinolone cream 4
0.1% & emollient cream kit
DERMASORB XM - urea cream 39% & 4
emollient cream kit
4
DERMATOP - prednicarbate cream
0.1%
4
DERMATOP - prednicarbate oint 0.1%
desonide cream 0.05% (Desowen)
2
desonide lotion 0.05% (Desowen)
2
desonide oint 0.05% (Desowen)
2
DESOWEN - desonide cream 0.05%
4
DESOWEN - desonide lotion 0.05%
4
DESOWEN - desonide oint 0.05%
4
DESOXIMETASONE - desoximetasone
cream 0.05%
4
DESOXIMETASONE - desoximetasone
oint 0.05%
4
desoximetasone cream 0.25%
(Topicort)
2
desoximetasone gel 0.05% (Topicort)
2
Dispensing Limits
4
Step Therapy
DESONATE - desonide gel 0.05%
Prior Authorization
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
DERMA-SMOOTHE/FS BODY fluocinolone acetonide oil 0.01%
(body oil)
Prior Authorization
Drug Name
Drug Tier
2015
desoximetasone oint 0.25% (Topicort) 2
2
diclofenac sodium (actinic
keratoses) gel 3% (Solaraze)
2
diclofenac sodium soln 1.5%
(Pennsaid)
4
DIFFERIN - adapalene cream 0.1%
DIFFERIN - adapalene gel 0.1%
4
DIFFERIN - adapalene gel 0.3%
4
DIFFERIN - adapalene lotion 0.1%
4
DIFLORASONE DIACETATE diflorasone diacetate oint 0.05%
2
DIFLORASONE DIACETATE diflorasone diacetate cream 0.05%
4
DIPROLENE - betamethasone
dipropionate augmented lotion 0.05%
4
DIPROLENE - betamethasone
dipropionate augmented oint 0.05%
4
DIPROLENE AF - betamethasone
dipropionate augmented cream
0.05%
4
DOVONEX - calcipotriene cream
0.005%
4
DOXYCYCLINE - doxycycline (rosacea)
cap delayed release 40 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
149
DRITHO-CREME HP - anthralin cream
1%
4
erythromycin soln 2%
2
DRYSOL - aluminum chloride soln 20%
ESSENTRA WIPES 9X9" CLEAN isopropyl alcohol wipes 70%
4
4
DUAC - clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
4
ETHYL CHLORIDE - ethyl chloride
aerosol spray
4
econazole nitrate cream 1%
2
4
ECOZA - econazole nitrate foam 1%
4
ETHYL CHLORIDE/FINE PINPO - ethyl
chloride aerosol spray
EFUDEX - fluorouracil cream 5%
4
ELENZAPATCH - lidocaine-menthol
patch 4-1%
4
ELETONE - dermatological products
misc - cream
4
ELETONE TWINPACK - dermatological
products misc - cream
4
ELIDEL - pimecrolimus cream 1%
4
ELIMITE - permethrin cream 5%
4
ELOCON - mometasone furoate
solution 0.1% (lotion)
4
ELOCON - mometasone furoate cream
0.1%
4
ELOCON - mometasone furoate oint
0.1%
4
EMLA - lidocaine-prilocaine cream
2.5-2.5%
4
EMULSION SB - dermatological
products misc - emulsion
4
EPICERAM - dermatological products
misc - emulsion
4
EPIDUO - adapalene-benzoyl peroxide
gel 0.1-2.5%
Dispensing Limits
Step Therapy
ETHYL CHLORIDE/FINE STREA - ethyl 4
chloride aerosol spray
4
ETHYL CHLORIDE/MEDIUM JET ethyl chloride aerosol spray
4
ETHYL CHLORIDE/MEDIUM STR ethyl chloride aerosol spray
4
ETHYL CHLORIDE/MIST - ethyl
chloride aerosol spray
4
EURAX - crotamiton cream 10%
EURAX - crotamiton lotion 10%
4
EVOCLIN - clindamycin phosphate foam 4
1%
4
EXELDERM - sulconazole nitrate
solution 1%
EXELDERM - sulconazole nitrate cream 4
1%
EXODERM - sodium thiosulfate-salicylic 2
acid lotion 25-1%
4
EXTINA - ketoconazole foam 2%
FABIOR - tazarotene (acne) foam 0.1%
4
FINACEA - azelaic acid gel 15%
3
4
FIRST-HYDROCORTISONE hydrocortisone gel 10% (cmpd kit)
4
EPIDUO FORTE - adapalene-benzoyl
peroxide gel 0.3-2.5%
4
FLECTOR - diclofenac epolamine patch
1.3%
4
EPIFOAM - pramoxine-hc aerosol foam
1-1%
4
FLEXIN - capsaicin-menthol topical
patch 0.0375-5%
4
ERTACZO - sertaconazole nitrate
cream 2%
4
fluocinolone acetonide cream 0.01%
2
ERYGEL - erythromycin gel 2%
fluocinolone acetonide cream
0.025% (Synalar)
2
4
erythromycin gel 2% (Erygel)
2
2
erythromycin pads 2%
2
fluocinolone acetonide oil 0.01%
(body oil) (Derma-smoothe/fs bod)
150
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
fluocinolone acetonide oil 0.01%
(scalp oil) (Derma-smoothe/fs sca)
2
GENTAMICIN SULFATE - gentamicin
sulfate oint 0.1%
4
fluocinolone acetonide oint 0.025%
(Synalar)
2
GORDOFILM - salicylic & lactic acids
soln 16.7-16.7%
4
fluocinolone acetonide soln 0.01%
(Synalar)
2
GORDONS UREA - urea ointment 40%
4
2
GRANULEX - trypsin w/ castor oil &
peruvian balsam spray
4
fluocinonide cream 0.05%
fluocinonide cream 0.1% (Vanos)
2
2
fluocinonide emulsified base cream
0.05%
2
HALAC - halobetasol prop oint 0.05% &
ammonium lactate lot 12% kit
2
fluocinonide gel 0.05%
2
halobetasol propionate cream 0.05%
(Ultravate)
fluocinonide oint 0.05%
2
2
fluocinonide soln 0.05%
2
halobetasol propionate oint 0.05%
(Ultravate)
4
HALOG - halcinonide cream 0.1%
4
FLUORAC - fluorouracil-diclofenac
sodium cream 5-1%
HALOG - halcinonide oint 0.1%
4
FLUOROPLEX - fluorouracil cream 1%
4
HALOTIN - haloprogin cream 1%
4
FLUOROURACIL - fluorouracil cream
0.5%
4
HPR - emollient - aerosol foam
4
HPR PLUS - emollient - aerosol foam
4
fluorouracil cream 5% (Efudex)
2
4
fluorouracil soln 2%
2
HPR PLUS - dermatological products
misc - cream
fluorouracil soln 5%
2
4
fluticasone propionate cream 0.05%
(Cutivate)
2
HPR PLUS HYDROGEL KIT dermatological products misc - kit
4
fluticasone propionate lotion 0.05%
(Cutivate)
2
HPR PLUS/MB HYDROGEL - emollient
foam & wound dressing gel kit
2
fluticasone propionate oint 0.005%
(Cutivate)
2
hyaluronate sodium (emollient) gel
0.2% (Hylira)
4
GEBAUERS PAIN EASE pentafluoropropane-tetrafluoroethane
aero spray
4
HYDRO 35 - urea in lactic acid vehicle
foam 35%
HYDRO 40 FOAM - urea foam 40%
4
2
GEBAUERS SPRAY AND STRETC pentafluoropropane-tetrafluoroethane
aero spray
4
hydrocortisone butyrate cream 0.1%
(Locoid)
2
GENADUR - dermatological products
misc - liquid
4
hydrocortisone butyrate hydrophilic
lipo base cream 0.1% (Locoid
lipocream)
2
GENADUR KIT - dermatological
products misc topical/oral - kit
4
hydrocortisone butyrate oint 0.1%
(Locoid)
1
GENTAMICIN SULFATE - gentamicin
sulfate cream 0.1%
4
hydrocortisone butyrate soln 0.1%
(Locoid)
hydrocortisone cream 2.5%
1
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
151
2
hydrocortisone lotion 2.5%
2
isotretinoin cap 20 mg
2
hydrocortisone oint 2.5%
1
isotretinoin cap 40 mg
2
hydrocortisone valerate cream 0.2%
2
JUBLIA - efinaconazole soln 10%
4
hydrocortisone valerate oint 0.2%
(Westcort)
2
KENALOG - triamcinolone acetonide
aerosol soln
4
HYDROFERA BLUE FOAM DRESS wound dressings - pads
4
KENDALL HYDROGEL IMPREGNA hydroactive (sterile) dressing
4
HYDROFERA BLUE HEAVY DRAI wound dressings - pads
4
KENDALL HYDROGEL WOUND DR hydroactive (sterile) dressing
4
HYDROFERA BLUE READY FOAM wound dressings - pads
4
KENDALL ZINC CALCIUM ALGI wound dressings - pads
4
HYDROFERA BLUE 4"X4" - wound
dressings - pads
4
KENDALL ZINC CALCIUM ALGI wound dressings - misc
4
HYLASE WOUND - hyaluronate sodium
gel
4
KERAFOAM - urea foam 30%
4
KERAFOAM 42 - urea foam 42%
4
HYLATOPIC - emollient - aerosol foam
4
KERALAC - urea cream 47%
4
HYLATOPIC PLUS - emollient - aerosol
foam
4
KERALYT - salicylic acid gel 6%
4
4
KERALYT SCALP - salicylic acid
shampoo 6% & salicylic acid gel 6%
kit
4
HYLATOPIC PLUS - dermatological
products misc - cream
HYLIRA - hyaluronate sodium
(emollient) gel 0.2%
4
KERYDIN - tavaborole soln 5%
4
4
ketoconazole cream 2%
1
HYLIRA - hyaluronate sodium
(emollient) lotion 0.1%
ketoconazole foam 2% (Extina)
2
imiquimod cream 5% (Aldara)
2
ketoconazole shampoo 2% (Nizoral)
2
INOVA - benzoyl peroxide pad 4% &
vitamin e topical 5% kit
4
KETODAN KIT - ketoconazole foam 2%
& cleanser kit
4
INOVA - benzoyl peroxide pad 8% &
vitamin e topical 5% kit
4
KLARON - sulfacetamide sodium lotion
10% (acne)
4
INOVA 4/1 ACNE CONTROL TH benzoyl perox pad 4% & salicylic ac
pad 1% & vit e 5% kit
4
K2K PAIN RELIEVING PATCH lidocaine-menthol patch 4-4%
4
4
INOVA 8/2 ACNE CONTROL TH benzoyl perox pad 8% & salicylic ac
pad 2% & vit e 5% kit
4
LAC-HYDRIN - lactic acid (ammonium
lactate) lotion 12%
LAC-HYDRIN - lactic acid (ammonium
lactate) cream 12%
4
iodoquinol-hc cream 1%
2
1
iodoquinol-hydrocortisone in aloe
vehicle cream 1-1.9% (Vytone)
2
lactic acid (ammonium lactate)
cream 12% (Lac-hydrin)
lactic acid (ammonium lactate) lotion
10%
1
152
•
Dispensing Limits
isotretinoin cap 10 mg
Step Therapy
2
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
hydrocortisone lotion 2% (Ala scalp)
Prior Authorization
Drug Name
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
lactic acid (ammonium lactate) lotion
12% (Lac-hydrin)
1
LIDORX - lidocaine hcl gel 3%
4
lactic acid w/ vitamin e cream
10%-3500 unit/30gm
LIDOTHOL - lidocaine-menthol patch
4.5-5%
4
1
LIDOVEX - lidocaine cream 3.75%
4
LIDOVIN - lidocaine hcl cream 3.95%
4
LIDOZOL - lidocaine hcl cream 3.75%
4
lindane lotion 1%
2
lindane shampoo 1%
2
LOCOID - hydrocortisone butyrate soln
0.1%
4
LOCOID - hydrocortisone butyrate
cream 0.1%
4
LATRIX XM - urea in zinc undecylenate- 4
lactic acid vehicle emulsion 45%
4
LAVARE WOUND WASH - wound
cleansers - gel
4
LAVOCLEN-4 CREAMY WASH benzoyl peroxide liq 4%
4
LAVOCLEN-8 CREAMY WASH benzoyl peroxide liq 8%
4
LEVATIO PATCH - capsaicin-menthol
topical patch 0.03-5%
LEVULAN KERASTICK - aminolevulinic 4
acid hcl for soln 20% (stick applicator)
4
LIDENZA PATCH - lidocaine-menthol
patch 4-1%
4
LIDOCAINE AND TETRACAINE lidocaine-tetracaine cream 7-7%
4
LIDOCAINE HCL - lidocaine hcl lotion
3%
2
lidocaine hcl cream 3%
lidocaine hcl gel 2%
1
lidocaine hcl soln 4% (Xylocaine)
1
lidocaine oint 5%
2
lidocaine patch 5% (700 mg)
(Lidoderm)
2
lidocaine-menthol patch 4-5%
2
lidocaine-prilocaine cream 2.5-2.5%
(Emla)
2
lidocaine-prilocaine kit 2.5-2.5%
2
LOCOID - hydrocortisone butyrate lotion 4
0.1%
4
LOCOID - hydrocortisone butyrate oint
0.1%
LOCOID LIPOCREAM - hydrocortisone 4
butyrate hydrophilic lipo base cream
0.1%
4
LOPROX SHAMPOO - ciclopirox
shampoo 1%
4
LORENZA - lidocaine-menthol patch
4-1%
4
LOTRIMIN ULTRA - butenafine hcl
cream 1%
4
LOTRISONE - clotrimazole w/
betamethasone cream 1-0.05%
4
LOUTREX - antiseborrheic products
misc - cream
4
LUXIQ - betamethasone valerate
aerosol foam 0.12%
4
LUZU - luliconazole cream 1%
lidocaine-prilocaine kit 2.5-2.5%
4
LYCELLE - nit remover - gel
4
LIDOCIN - lidocaine hcl gel 3%
4
4
LIDODERM - lidocaine patch 5% (700
mg)
4
MAC PATCH - capsaicin-menthol
topical patch 0.0375-5%
malathion lotion 0.5% (Ovide)
2
LIDODEXTRAPINE - lidocaine-menthol
patch 4-1%
4
MB HYDROGEL - dermatological
products misc - kit
4
LIDOPIN - lidocaine hcl cream 3.25%
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
153
MEDI-DERM-RX - capsaicin-mentholmethyl salicylate cream 0.035-5-20%
4
MIGRYL - capsaicin-menthol disk
0.0375-5%
4
MEDI-DERM/L-RX - lidocainecapsaicin-menthol-methyl sal cream
2-0.035-5-20%
4
MIRVASO - brimonidine tartrate gel
0.33% (base equivalent)
4
MEDI-PATCH RX - lidocainecapsaicin-menthol-methyl sal patch
0.5-0.035-5-20%
mometasone furoate cream 0.1%
(Elocon)
2
4
mometasone furoate oint 0.1%
(Elocon)
2
MEDIHONEY CALCIUM ALGINAT wound dressings - pads
4
mometasone furoate solution 0.1%
(lotion) (Elocon)
2
MEDIHONEY WOUND & BURN DR wound dressings - pads
4
mupirocin calcium cream 2%
(Bactroban)
2
MEDROX-RX - capsaicin-mentholmethyl salicylate oint 0.05-7-20%
4
mupirocin oint 2% (Bactroban)
1
4
naftifine hcl cream 1% (Naftin)
2
MEGRIX - capsaicin-menthol disk
0.0375-5%
NAFTIN - naftifine hcl cream 1%
4
MENTAX - butenafine hcl cream 1%
4
NAFTIN - naftifine hcl cream 2%
4
MENTHOCIN PATCH/LIDOCAINE lidocaine-capsaicin-menthol-methyl
sal patch 0.5-0.035-5-20%
4
NAFTIN - naftifine hcl gel 1%
4
NAFTIN - naftifine hcl gel 2%
4
NATROBA - spinosad susp 0.9%
4
MENTHOCIN PATCH/LIDOCAINE lidocaine-capsaicin-men-methyl sal
patch 0.5-0.0375-5-20%
4
NEO-SYNALAR - neomycinfluocinolone cream 0.35-0.025%
4
4
methoxsalen rapid cap 10 mg
(Oxsoralen ultra)
2
NEO-SYNALAR KIT - neomycinfluocinolone cream 0.35-0.025% &
emollient cr kit
4
MENTHOLIX - lidocaine-menthol liquid
spray 4-1%
NEOSALUS - emollient - aerosol foam
4
4
NEOSALUS - emollient - lotion
4
METROCREAM - metronidazole cream
0.75%
4
METROGEL - metronidazole gel 1%
4
NEOSALUS - dermatological products
misc - cream
4
NEOSALUS CP - dermatological
products misc - cream
4
METROLOTION - metronidazole lotion
0.75%
2
NEUAC KIT - clindamycin-benzoyl
perox gel 1.2-5% & moisturizer cr kit
4
metronidazole cream 0.75%
(Metrocream)
2
metronidazole gel 1% (Metrogel)
2
NEUVAXIN - capsaicin-menthol topical
patch 0.0375-5%
4
metronidazole gel 0.75%
2
NIVATOPIC PLUS - dermatological
products misc - cream
4
metronidazole lotion 0.75%
(Metrolotion)
NIZORAL - ketoconazole shampoo 2%
4
METVIXIA - methyl aminolevulinate hcl
cream 16.8% (base equiv)
4
NOBLE MYSTIQUE EMU-LAC - lactic
acid (ammonium lactate) cream 10%
4
154
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
NUCORT - hydrocortisone acetate lotion 4
2%
4
NUOX - benzoyl peroxide-sulfur gel
6-3%
NUVAIL - dermatological products misc 4
- solution
4
NUZON - hydrocortisone acetate-aloe
vera gel 2%
2
nystatin cream 100000 unit/gm
OVACE WASH - sulfacetamide sodium
liquid 10%
4
OVIDE - malathion lotion 0.5%
4
OXISTAT - oxiconazole nitrate cream
1%
4
Dispensing Limits
Step Therapy
Prior Authorization
4
Drug Name
Drug Tier
NOVACORT - hydrocortisone acepramoxine-aloe polysacch gel 2-1-1%
Dispensing Limits
4
Step Therapy
NORITATE - metronidazole cream 1%
Prior Authorization
Drug Name
Drug Tier
2015
OXISTAT - oxiconazole nitrate lotion 1% 4
4
OXSORALEN - methoxsalen lotion 1%
OXSORALEN ULTRA - methoxsalen
rapid cap 10 mg
4
PAIN RELIEF PATCH - capsaicinmenthol topical patch 0.0375-5%
4
PAIN RELIEF PATCH - lidocainementhol patch 5-1%
4
PANDEL - hydrocortisone probutate
cream 0.1%
4
PANRETIN - alitretinoin gel 0.1%
4
4
nystatin oint 100000 unit/gm
2
nystatin topical powder
2
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
2
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
2
OLUX - clobetasol propionate foam
0.05%
4
PEDIADERM AF COMPLETE KIT nystatin cream 100000 unit/gm &
diaper rash cream kit
4
OLUX-E - clobetasol propionate
emulsion foam 0.05%
4
PEDIADERM HC - hydrocortisone lot
2% & emollient cream kit
4
ONEXTON - clindamycin phosphatebenzoyl peroxide gel 1.2-3.75%
4
PEDIADERM TA - triamcinolone cream
0.1% & emollient cream kit
4
OPTASE - trypsin w/ castor oil &
peruvian balsam gel
4
PENLAC NAIL LACQUER - ciclopirox
solution 8%
ORACEA - doxycycline (rosacea) cap
delayed release 40 mg
4
OVACE PLUS - sulfacetamide sodium
cream 10%
4
OVACE PLUS - sulfacetamide sodium
foam 9.8%
4
OVACE PLUS - sulfacetamide sodium
shampoo 10%
4
OVACE PLUS - sulfacetamide sodium
lotion 9.8%
4
OVACE PLUS WASH - sulfacetamide
sodium cleansing gel 10%
4
OVACE PLUS WASH - sulfacetamide
sodium liquid 10%
4
•
PENNSAID - diclofenac sodium soln 2% 4
4
PERMAVAN EXTERNAL PATCH lidocaine-dm-trolamine salicylate
patch 4-4-10%
2
permethrin cream 5% (Elimite)
PHARMACIST CHOICE TSX PAT methyl salicylate-lidocaine-menthol
patch 2-4-1%
4
PICATO - ingenol mebutate gel 0.015%
4
PICATO - ingenol mebutate gel 0.05%
4
•
•
PICO SINGLE USE NEGATIVE - wound 4
dressings - kit
4
PLEXION - sulfacetamide sodium w/
sulfur lotion 9.8-4.8%
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
155
PLEXION - sulfacetamide sodium w/
sulfur cream 9.8-4.8%
4
PROLIDA - lidocaine-menthol patch
4-1%
4
PLEXION CLEANSER - sulfacetamide
sodium w/ sulfur cleanser 9.8-4.8%
4
PROMISEB - antiseborrheic products
misc - cream
4
PLEXION CLEANSING CLOTHS sulfacetamide sodium w/ sulfur
cleansing cloth 9.8-4.8%
4
PROMISEB COMPLETE antiseborrheic products misc - kit
4
PROTOPIC - tacrolimus oint 0.03%
4
PLIAGLIS - lidocaine-tetracaine cream
7-7%
4
PROTOPIC - tacrolimus oint 0.1%
4
4
PROVENZA - lidocaine-menthol patch
4-1%
4
PODOCON 25 IN BENZOIN TIN podophyllum resin soln 25%
2
PROZENA - lidocaine patch 4%
4
podofilox soln 0.5% (Condylox)
4
PRUCLAIR - dermatological products
misc - cream
4
PR CREAM - dermatological products
misc - kit
4
PRUDOXIN - doxepin hcl cream 5%
4
PRAMOSONE - pramoxine-hc cream
1-1%
4
PRAMOSONE - pramoxine-hc cream
1-2.5%
4
PRUMYX - dermatological products
misc - cream
4
PRAMOSONE - pramoxine-hc lotion
1-1%
4
PSORCON - diflorasone diacetate
cream 0.05%
4
PRAMOSONE - pramoxine-hc lotion
1-2.5%
4
PYROGALLIC ACID - pyrogallolchlorobutanol oint 25-2%
QROXIN - capsaicin-menthol topical
patch 0.0375-5%
4
QUTENZA - capsaicin patch 8% &
cleansing gel kit
4
RECIPHEXAMINE - lidocaine-menthol
patch 4-1%
4
REGENECARE - lidocaine hcl-collagenaloe vera gel 2%
4
REGRANEX - becaplermin gel 0.01%
4
RELEEVIA - capsaicin-menthol topical
patch 0.0375-5%
4
RELEEVIA MC - capsaicin-menthol
topical patch 0.0375-5%
4
RELEEVIA ML - lidocaine-menthol
patch 4-1%
4
PRAMOSONE - pramoxine-hc oint 1-1% 4
4
PRAMOSONE - pramoxine-hc oint
1-2.5%
4
PRAMOSONE E - pramoxine-hc
emollient base cream 1-2.5%
1
pramoxine hcl gel 1%
pramoxine-hc cream 1-2.5%
(Pramosone)
2
PRASCION RA WITH SUNSCREE sulfacetamide sodium-sulfursunscreen cream 10-5%
2
prednicarbate cream 0.1%
(Dermatop)
2
prednicarbate oint 0.1% (Dermatop)
2
4
RELYYT - capsaicin-menthol topical
patch 0.025-5%
4
PREMIUM SCAR PATCH - allantoinlidocaine-petrolatum patch 2-4-30%
4
REMATEX - capsaicin-menthol-methyl
salicylate cream 0.035-6-30%
4
PRESERA - emollient - aerosol foam
156
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
REMAXAZON EXTERNAL PATCH lidocaine-capsaicin-chondroitinglucos patch 4-0.0285-3-5%
4
ROSADAN KIT - metronidazole cream
0.75% w/ cleanser kit
4
RENOVO - capsaicin-menthol topical
patch 0.0375-5%
ROSANIL - sulfacetamide sod-sulfur
emul 10-5% & skin cleanser kit
4
4
RENOVO LIDO 5 - lidocaine-capsaicin
cream 5-0.05%
ROSULA - sulfacetamide sodium w/
sulfur wash 10-4.5%
4
4
4
RTD WOUND CARE DRESSING wound dressings - pads
4
RENUU NL - allantoin-petrolatum patch
2-30%
SALEX - salicylic acid shampoo 6%
4
RENUU PATCH - allantoin-lidocainepetrolatum patch 2-5-30%
4
SALEX CREAM - salicylic acid cream
6% & cleanser liqd kit
4
RESTORE SILVER DRESSING 2 wound dressings - pads
4
SALEX LOTION - salicylic acid lotion
6% & cleanser liqd kit
4
RESTORE SILVER DRESSING 4 wound dressings - pads
4
SALICYLIC ACID - salicylic acid soln
26%
4
RESTORE SILVER DRESSING 6 wound dressings - pads
4
salicylic acid cream 6%
2
4
salicylic acid cream 6% & cleanser
liqd kit (Salex cream)
2
RETIN-A - tretinoin cream 0.025%
RETIN-A - tretinoin cream 0.05%
4
RETIN-A - tretinoin cream 0.1%
salicylic acid film forming liquid
27.5% (Virasal)
2
4
RETIN-A - tretinoin gel 0.01%
4
2
RETIN-A - tretinoin gel 0.025%
4
salicylic acid film-forming soln
28.5% (Ultrasal-er)
salicylic acid foam 6% (Salvax)
2
salicylic acid gel 6% (Keralyt)
2
SALICYLIC ACID IN AMMONIU salicylic acid in ammonium lactate
vehicle foam 6%
4
salicylic acid lotion 6%
2
salicylic acid lotion 6% & cleanser
liqd kit (Salex lotion)
2
salicylic acid shampoo 6% (Salex)
2
SALKERA - salicylic acid in ammonium
lactate vehicle foam 6%
4
SALVAX - salicylic acid foam 6%
4
SALVAX DUO PLUS - salicylic acid
foam 6% & urea in lactic acid foam
35% kit
4
SANTYL - collagenase oint 250 unit/gm
4
RETIN-A MICRO - tretinoin microsphere 4
gel 0.04%
RETIN-A MICRO - tretinoin microsphere 4
gel 0.1%
4
RETIN-A MICRO PUMP - tretinoin
microsphere gel 0.04%
4
RETIN-A MICRO PUMP - tretinoin
microsphere gel 0.08%
4
RETIN-A MICRO PUMP - tretinoin
microsphere gel 0.1%
4
REXAPHENAC - diclofenac sodium
cream 1%
4
RIAX - benzoyl peroxide foam 5.5%
RIAX - benzoyl peroxide foam 9.5%
4
ROSADAN KIT - metronidazole gel
0.75% w/ cleanser kit
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
157
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
SCALACORT DK - hc lot 2% & sal acidsulfur shampoo 2-2% & shampoo kit
4
SINELEE - capsaicin-menthol topical
patch 0.05-5%
4
SCAR PATCH - allantoin-lidocainepetrolatum patch 2-4-30%
4
SKLICE - ivermectin lotion 0.5%
4
SCAR PATCH - allantoin-lidocainepetrolatum patch 2-5-30%
SODIUM SULFACETAMIDE WASH sulfacetamide sodium in bakuchiol
vehicle wash 10%
4
4
scar treatment products - gel
2
4
selenium sulfide lotion 2.5%
1
SELRX - selenium sulfide-pyrithione
zinc in urea shampoo 2.3%
4
SODIUM SULFACETAMIDE/SULF sulfacetamide sodium-sulfur in urea
gel 10-5%
4
SILMANIX PAIN RELIEIVING capsaicin-menthol-histamine cream
0.0375-3-0.035%
4
SODIUM SULFACETAMIDE/SULF sulfacetamide sodium w/ sulfur susp
10-5%
4
SILVADENE - silver sulfadiazine cream
1%
4
SODIUM SULFACETAMIDE/SULF sulfacetamide sodium-sulfur in urea
emulsion 10-5%
4
SOLAICE - capsaicin-menthol topical
patch 0.05-5%
4
SILVER NITRATE - silver nitrate oint
10%
4
SOLARAZE - diclofenac sodium (actinic
keratoses) gel 3%
4
SILVER NITRATE - silver nitrate soln
0.5%
4
SOOLANTRA - ivermectin cream 1%
4
SILVER NITRATE - silver nitrate soln
10%
4
SILVER NITRATE - silver nitrate soln
25%
4
SOOTHEE - lidocaine-capsaicin-menmethyl sal patch 0.5-0.0375-5-20%
SORIATANE - acitretin cap 10 mg
4
SILVER NITRATE - silver nitrate soln
50%
4
SORIATANE - acitretin cap 17.5 mg
4
SORIATANE - acitretin cap 25 mg
4
silver nitrate-potassium nitrate
applicator 75-25% (Arzol silver
nitrate)
1
SORILUX - calcipotriene foam 0.005%
4
SPINOSAD - spinosad susp 0.9%
4
1
STELARA - ustekinumab soln prefilled
syringe 45 mg/0.5ml
5
silver sulfadiazine cream 1%
(Silvadene)
• •
4
STELARA - ustekinumab soln prefilled
syringe 90 mg/ml
5
SILVERA PAIN RELIEF - capsaicinlidocaine-menthol patch 0.0375-1-5%
• •
4
sulfacetamide sod-sulfur wash
9-4.5% & skin cleanser kit
(Sumadan kit)
2
SILVERSEAL HYDROGEL DRESS silver - pad 2"x3"
SILVERSEAL HYDROGEL DRESS silver - pad 4"x5"
4
2
SILVRSTAT WOUND DRESSING silver - gel
4
sulfacetamide sod-sulfur wash
9-4.5% & sunscreen kit (Sumadan
xlt)
SINELEE - capsaicin-menthol topical
patch 0.0375-5%
sulfacetamide sodium cleansing gel
10% (Ovace plus wash)
2
4
158
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
sulfacetamide sodium liquid 10%
(Ovace wash)
2
SULFOAM - sulfur shampoo 2%
4
sulfacetamide sodium lotion 10%
(acne) (Klaron)
SULFURATED LIME - sulfurated lime
solution
4
2
sulfacetamide sodium shampoo 10%
(Ovace plus)
SUMADAN KIT - sulfacetamide sodsulfur wash 9-4.5% & skin cleanser
kit
4
2
sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8% (Plexion cleanser)
2
SUMADAN WASH - sulfacetamide
sodium w/ sulfur wash 9-4.5%
4
sulfacetamide sodium w/ sulfur
cleanser 10-2% (Avar ls cleanser)
2
SUMADAN XLT - sulfacetamide sodsulfur wash 9-4.5% & sunscreen kit
4
sulfacetamide sodium w/ sulfur
cleansing cloth 10-5%
2
SUMAXIN - sulfacetamide sodium w/
sulfur cleansing pad 10-4%
4
sulfacetamide sodium w/ sulfur
cleansing pad 10-4% (Sumaxin)
2
SUMAXIN CP KIT - sulfacetamide sodsulfur pad 10-4% & skin cleanser kit
4
sulfacetamide sodium w/ sulfur
cream 9.8-4.8% (Plexion)
2
sulfacetamide sodium w/ sulfur
cream 10-2% (Avar-e ls)
2
sulfacetamide sodium w/ sulfur
cream 10-5%
2
sulfacetamide sodium w/ sulfur
emulsion 10-1%
2
sulfacetamide sodium w/ sulfur
emulsion 10-5%
2
sulfacetamide sodium w/ sulfur foam
10-5% (Clarifoam ef)
2
sulfacetamide sodium w/ sulfur
lotion 9.8-4.8% (Plexion)
2
sulfacetamide sodium w/ sulfur
lotion 10-5%
2
sulfacetamide sodium w/ sulfur susp
8-4% (Sumaxin ts)
2
sulfacetamide sodium w/ sulfur wash
9-4% (Sumaxin wash)
2
sulfacetamide sodium w/ sulfur wash
9-4.5% (Sumadan wash)
2
SULFAMYLON - mafenide acetate
packet for topical soln 5% (50 gm)
4
SULFAMYLON - mafenide acetate
cream 85 mg/gm
4
SUMAXIN TS - sulfacetamide sodium w/ 4
sulfur susp 8-4%
4
SUMAXIN WASH - sulfacetamide
sodium w/ sulfur wash 9-4%
SYNALAR - fluocinolone acetonide soln 4
0.01%
4
SYNALAR - fluocinolone acetonide
cream 0.025%
SYNALAR - fluocinolone acetonide oint 4
0.025%
4
SYNALAR CREAM KIT - fluocinolone
cream 0.025%-emollient cream kit
4
SYNALAR OINTMENT KIT fluocinolone oint 0.025%-emollient
cream kit
4
SYNALAR TS - fluocinolone acetonide
soln 0.01% & cleanser kit
4
SYNERA - lidocaine-tetracaine topical
patch 70-70 mg
4
SYNVEXIA - lidocaine-menthol patch
4-1%
4
SYNVEXIA TC - lidocaine-menthol
cream 4-1%
4
TACLONEX - calcipotrienebetamethasone dipropionate susp
0.005-0.064%
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
159
TACLONEX - calcipotrienebetamethasone dipropionate oint
0.005-0.064%
4
tacrolimus oint 0.03% (Protopic)
2
tacrolimus oint 0.1% (Protopic)
2
TARGRETIN - bexarotene gel 1%
5
TAZORAC - tazarotene cream 0.05%
TOPICORT - desoximetasone cream
0.25%
4
TOPICORT - desoximetasone oint
0.05%
4
TOPICORT - desoximetasone oint
0.25%
4
3
TRETIN-X - tretinoin cream 0.075%
4
TAZORAC - tazarotene cream 0.1%
3
4
TAZORAC - tazarotene gel 0.05%
3
TRETIN-X - tretinoin cream 0.025% w/
cleanser & moisturizer kit
3
TRETIN-X - tretinoin cream 0.05% w/
cleanser & moisturizer kit
4
TAZORAC - tazarotene gel 0.1%
TEGADERM AG MESH DRESSING wound dressings - pads
4
TRETIN-X - tretinoin cream 0.1% w/
cleanser & moisturizer kit
4
TEMOVATE - clobetasol propionate
soln 0.05%
4
tretinoin cream 0.025% (Retin-a)
2
4
tretinoin cream 0.05% (Retin-a)
2
TEMOVATE - clobetasol propionate
cream 0.05%
tretinoin cream 0.1% (Retin-a)
2
TEMOVATE - clobetasol propionate gel
0.05%
4
tretinoin gel 0.01% (Retin-a)
2
tretinoin gel 0.025% (Retin-a)
2
TEMOVATE - clobetasol propionate oint
0.05%
4
tretinoin microsphere gel 0.04%
(Retin-a micro)
2
TEMOVATE E - clobetasol propionate
emollient base cream 0.05%
4
tretinoin microsphere gel 0.1%
(Retin-a micro)
2
TERSI FOAM - selenium sulfide foam
2.25%
4
TRI-CHLOR - trichloroacetic acid liqd
80%
4
TETRAMEX - tetracaine-mentholcamphor liqd spray 2-1-3%
4
TRIAMCINOLONE ACETONIDE triamcinolone acetonide oint 0.5%
4
TETRIX - dermatological products misc
- kit
4
triamcinolone acetonide aerosol soln
(Kenalog)
2
TEXACORT - hydrocortisone soln 2.5%
4
1
TL TRISEB - antiseborrheic products
misc - cream
4
triamcinolone acetonide cream
0.025%
triamcinolone acetonide cream 0.1%
1
TL-CERMIDE - dermatological products
misc - emulsion
4
triamcinolone acetonide cream 0.5%
1
4
triamcinolone acetonide lotion
0.025%
2
TOPICORT - desoximetasone spray
0.25%
triamcinolone acetonide lotion 0.1%
2
TOPICORT - desoximetasone gel
0.05%
4
triamcinolone acetonide oint 0.025%
1
4
triamcinolone acetonide oint 0.1%
1
TOPICORT - desoximetasone cream
0.05%
TRIANEX - triamcinolone acetonide oint
0.05%
4
160
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2
trypsin w/ castor oil & peruvian
balsam spray (Granulex)
1
urea in lactic acid vehicle foam 35%
(Hydro 35)
2
ULESFIA - benzyl alcohol lotion 5%
4
2
ULTRASAL-ER - salicylic acid filmforming soln 28.5%
4
urea in lactic acid-salicylic acid
vehicle susp 50%
2
ULTRAVATE - halobetasol propionate
cream 0.05%
4
urea in zinc undecylenate-lactic acid
vehicle emulsion 50%
urea lotion 40%
2
ULTRAVATE - halobetasol propionate
oint 0.05%
4
urea lotion 45% (Uramaxin)
2
ULTRAVATE X - halobetasol prop
cream 0.05% & lactic acid cream
10% kit
4
ULTRAVATE X - halobetasol prop oint
0.05% & lactic acid cream 10% kit
4
UMECTA - urea emulsion 40%
4
UMECTA - urea suspension 40%
4
UMECTA NAIL FILM - urea suspension
40%
4
UMECTA PD - urea-hyaluronate sodium 4
emulsion 40-0.3%
UMECTA PD - urea-hyaluronate sodium 4
susp 40-0.3%
4
URAMAXIN - urea lotion 45%
Dispensing Limits
urea gel 45% (Uramaxin)
Step Therapy
4
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
TROPAZONE - emollient - lotion
Prior Authorization
Drug Name
Drug Tier
2015
UREA NAIL - urea in zinc undecylenate- 4
lactic acid vehicle stick 50%
4
UREA NAIL KIT - urea susp 40% &
hyaluronate sodium gel 0.2% kit
2
urea suspension 40% (Umecta)
UREVAZ - urea cream 44%
4
UTOPIC - urea cream 41%
4
VALCHLOR - mechlorethamine hcl gel
0.016% (base equivalent)
5
VANOS - fluocinonide cream 0.1%
4
VANOXIDE-HC - benzoyl peroxide-hc
lotion 5-0.5%
4
VASCUDERM STASIS KIT - wound
dressings - kit
4
VECTICAL - calcitriol oint 3 mcg/gm
4
VELMA PAIN RELIEF - methyl
salicylate-lidocaine-menthol patch
16-4-2%
4
URAMAXIN - urea in ammonium lactate
vehicle foam 20%
4
URAMAXIN - urea cream 45%
4
URAMAXIN - urea gel 45%
4
URAMAXIN GT - urea gel 45%
VELTIN - clindamycin phosphatetretinoin gel 1.2-0.025%
4
4
URAMAXIN GT KIT - urea gel 45% &
emollient cream kit
4
VENELEX - balsam peru-castor oil oint
4
VERDESO - desonide foam 0.05%
4
urea cream 39% (Aluvea)
2
VEREGEN - sinecatechins oint 15%
4
urea cream 40%
2
2
VEXA - allantoin-lidocaine-petrolatum
patch 2-4-30%
4
urea cream 45% (Uramaxin)
urea cream 47% (Keralac)
2
4
urea cream 50%
2
VIRASAL - salicylic acid film forming
liquid 27.5%
urea foam 40% (Hydro 40 foam)
2
VOLTAREN - diclofenac sodium gel 1%
4
urea gel 40%
2
VUSION - miconazole-zinc oxide-white
petrolatum oint 0.25-15-81.35%
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
161
VYTONE - iodoquinol-hydrocortisone in
aloe vehicle cream 1-1.9%
4
WESTCORT - hydrocortisone valerate
oint 0.2%
4
WITCH HAZEL - witch hazel
(hamamelis virginiana) liqd
(hamamelis water)
4
wound dressings - cream
2
XCLAIR - dermatological products misc
- cream
4
XENADERM - trypsin w/ castor oil &
peruvian balsam oint
XOLEGEL DUO/XOLEX - ketoconazole
gel 2% & pyrithione zinc shampoo 1%
kit
4
XYLOCAINE - lidocaine hcl soln 4%
4
XYPHEX - capsaicin-menthol disk
0.0375-5%
4
ZACARE 4% KIT - benzoyl peroxide
lotion 4% & hyaluronate sodium gel
0.2% kit
4
4
4
ZACARE 8% KIT - benzoyl peroxide
lotion 8% & hyaluronate sodium gel
0.2% kit
XERAC AC - aluminum chloride in
alcohol solution 6.25%
4
ZACLIR CLEANSING - benzoyl
peroxide lotion 8%
4
XERESE - acyclovir-hydrocortisone
cream 5-1%
4
ZENATANE - isotretinoin cap 30 mg
4
4
XEROFORM NON-OCCLUSIVE OI bismuth tribromophenate-petrolatum
dressing pads
4
ZERUVIA - lidocaine-menthol patch
4-1%
XEROFORM NON-OCCLUSIVE OI bismuth tribromophenate-petrolatum
dressing - misc
4
ZIANA - clindamycin phosphate-tretinoin 4
gel 1.2-0.025%
4
ZITHRANOL - anthralin shampoo 1%
XEROFORM OCCLUSIVE PETROL bismuth tribromophenate-petrolatum
dressing pads
4
XEROFORM OCCLUSIVE PETROL bismuth tribromophenate-petrolatum
dressing - misc
4
XEROFORM PETROLATUM DRESS bismuth tribromophenate-petrolatum
dressing pads
4
XEROFORM PETROLATUM DRESS bismuth tribromophenate-petrolatum
dressing - misc
4
XOLEGEL - ketoconazole gel 2%
4
XOLEGEL COREPAK - ketoconazole
gel 2% & hydrocortisone gel 1% kit
XOLEGEL DUO/HEAD & SHOULD ketoconazole gel 2% & pyrithione
zinc shampoo 1% kit
162
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2015
ZITHRANOL-RR - anthralin cream 1.2%
4
ZONALON - doxepin hcl cream 5%
4
ZOVIRAX - acyclovir cream 5%
4
ZOVIRAX - acyclovir oint 5%
4
ZYCLARA - imiquimod cream 3.75%
4
ZYCLARA PUMP - imiquimod cream
2.5%
4
•
•
ZYCLARA PUMP - imiquimod cream
3.75%
4
•
8-MOP - methoxsalen cap 10 mg
4
MISCELLANEOUS PRODUCTS
ANTISEPTICS & DISINFECTANTS
4
4
ANASEPT - sodium hypochlorite liquid
0.057%
4
4
BENZALKONIUM CHLORIDE benzalkonium chloride soln
BENZALKONIUM CHLORIDE benzalkonium chloride soln 50%
4
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
Dispensing Limits
4
Step Therapy
REVIA - naltrexone hcl tab 50 mg
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2015
FORMA-RAY - formaldehyde solution
20%
4
formaldehyde solution 10%
2
•
GLUTARALDEHYDE - glutaral soln
25%
ASCENSIA AUTODISC TEST ST glucose blood test disk
2
4
2
•
IODINE TINCTURE - iodine tincture
4
BAYER BREEZE 2 TEST DISC glucose blood test disk
IODINE TINCTURE MILD - iodine
tincture
4
BAYER CONTOUR BLOOD GLUCO glucose blood test strip
2
•
IODINE TINCTURE STRONG - iodine
tincture strong
4
BAYER CONTOUR NEXT BLOOD glucose blood test strip
2
•
IODINE TINCTURE STRONG DE iodine tincture strong
4
4
KERR TRIPLE DYE - triple dye swabs
4
GLUCAGEN DIAGNOSTIC - glucagon
hcl (rdna) diagnostic for inj 1 mg
(base equiv)
LUGOLS STRONG IODINE - iodine
solution
4
GLUCOSE BLOOD TEST STRIPS –
VARIOUS
4
TRIPLE DYE - triple dye solution
4
KETONE BLOOD TEST STRIPS –
VARIOUS
4
URINE TEST STRIPS – VARIOUS
4
DIAGNOSTIC PRODUCTS
ANTIDOTES
CHEMET - succimer cap 100 mg
3
EVZIO - naloxone hcl solution autoinjector 0.4 mg/0.4ml
4
EXJADE - deferasirox tab for oral susp
125 mg
5
•
EXJADE - deferasirox tab for oral susp
250 mg
5
•
EXJADE - deferasirox tab for oral susp
500 mg
5
FERRIPROX - deferiprone tab 500 mg
5
JADENU - deferasirox tab 90 mg
5
JADENU - deferasirox tab 180 mg
5
JADENU - deferasirox tab 360 mg
5
naltrexone hcl tab 50 mg (Revia)
2
PENTETATE CALCIUM TRISODI pentetate calcium trisodium iv or
inhalation soln 200 mg/ml
4
PENTETATE ZINC TRISODIUM pentetate zinc trisodium iv or
inhalation soln 200 mg/ml
4
RADIOGARDASE - prussian blue
insoluble cap 0.5 gm
4
• •
ALTERNATIVE MEDICINES
CITRUS BERGAMOT - citrus bergamot
oral powder 250 mg/0.25 gm
4
QUINZYME - coenzyme q10 tab disp 90 4
mg
MEDICAL DEVICES
•
•
BLOOD GLUCOSE CALIBRATION
LIQUID – VARIOUS
4
HURRISEAL - dental desensitizing
product - solution
4
INSULIN PEN NEEDLES-VARIOUS
3
INSULIN SYRINGES-VARIOUS
4
LANCETS-VARIOUS
3
RESPIRATORY THERAPY SUPPLIES
– VARIOUS
4
SPACERS – VARIOUS
4
SANARE SCAR THERAPY - cream
base
4
•
•
ASSORTED CLASSES
ASTAGRAF XL - tacrolimus cap sr 24hr
0.5 mg
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
4
•
163
•
ATGAM - lymphocyte immune globulin
anti-thymocyte g inj 50 mg/ml(eq)
4
AZASAN - azathioprine tab 75 mg
4
AZASAN - azathioprine tab 100 mg
4
azathioprine tab 50 mg (Imuran)
2
CELLCEPT - mycophenolate mofetil cap 4
250 mg
CELLCEPT - mycophenolate mofetil tab 4
500 mg
CELLCEPT - mycophenolate mofetil for 3
oral susp 200 mg/ml
CUPRIMINE - penicillamine cap 250 mg 5
cyclosporine cap 25 mg
(Sandimmune)
2
cyclosporine cap 100 mg
(Sandimmune)
2
CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg
3
cyclosporine modified cap 25 mg
(Neoral)
2
cyclosporine modified cap 100 mg
(Neoral)
2
cyclosporine modified oral soln
100 mg/ml (Neoral)
2
DEPEN TITRATABS - penicillamine tab
250 mg
5
IMURAN - azathioprine tab 50 mg
4
KAYEXALATE - sodium polystyrene
sulfonate powder
4
mycophenolate mofetil cap 250 mg
(Cellcept)
•
mycophenolate sodium tab dr
360 mg (mycophenolic acid equiv)
(Myfortic)
2
MYFORTIC - mycophenolate sodium
tab dr 180 mg (mycophenolic acid
equiv)
4
MYFORTIC - mycophenolate sodium
tab dr 360 mg (mycophenolic acid
equiv)
4
NEORAL - cyclosporine modified oral
soln 100 mg/ml
4
NEORAL - cyclosporine modified cap 25 4
mg
4
NEORAL - cyclosporine modified cap
100 mg
4
PROGRAF - tacrolimus cap 0.5 mg
PROGRAF - tacrolimus cap 1 mg
4
PROGRAF - tacrolimus cap 5 mg
4
RAPAMUNE - sirolimus oral soln 1 mg/
ml
3
RAPAMUNE - sirolimus tab 0.5 mg
4
RAPAMUNE - sirolimus tab 1 mg
3
RAPAMUNE - sirolimus tab 2 mg
3
REVLIMID - lenalidomide caps 2.5 mg
5
REVLIMID - lenalidomide cap 5 mg
5
REVLIMID - lenalidomide cap 10 mg
5
REVLIMID - lenalidomide cap 15 mg
5
REVLIMID - lenalidomide cap 20 mg
5
REVLIMID - lenalidomide cap 25 mg
5
2
SANDIMMUNE - cyclosporine oral soln
100 mg/ml
4
2
SANDIMMUNE - cyclosporine cap 25
mg
4
mycophenolate mofetil for oral susp
200 mg/ml (Cellcept)
2
SANDIMMUNE - cyclosporine cap 100
mg
4
mycophenolate mofetil tab 500 mg
(Cellcept)
sirolimus tab 0.5 mg (Rapamune)
2
164
•
Dispensing Limits
4
2
Step Therapy
ASTAGRAF XL - tacrolimus cap sr 24hr
5 mg
mycophenolate sodium tab dr
180 mg (mycophenolic acid equiv)
(Myfortic)
Prior Authorization
•
Drug Name
Drug Tier
4
Dispensing Limits
Prior Authorization
ASTAGRAF XL - tacrolimus cap sr 24hr
1 mg
Drug Name
Step Therapy
Drug Tier
2015
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
•
•
•
•
•
•
sirolimus tab 2 mg (Rapamune)
2
sodium polystyrene sulfonate oral
susp 15 gm/60ml (Sps)
2
sodium polystyrene sulfonate
powder (Kayexalate)
2
sodium polystyrene sulfonate rectal
susp 30 gm/120ml
2
SPS - sodium polystyrene sulfonate oral
susp 15 gm/60ml
4
SYPRINE - trientine hcl cap 250 mg
5
tacrolimus cap 0.5 mg (Prograf)
2
tacrolimus cap 1 mg (Prograf)
2
tacrolimus cap 5 mg (Prograf)
2
THALOMID - thalidomide cap 50 mg
5
THALOMID - thalidomide cap 100 mg
5
THALOMID - thalidomide cap 150 mg
5
THALOMID - thalidomide cap 200 mg
5
ZORTRESS - everolimus tab 0.25 mg
4
ZORTRESS - everolimus tab 0.5 mg
4
ZORTRESS - everolimus tab 0.75 mg
4
Dispensing Limits
2
Step Therapy
sirolimus tab 1 mg (Rapamune)
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
165
2015
INDEX
8-MOP -methoxsalen cap 10 mg.....................................162
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir)................................................. 7
abacavir sulfate tab 300 mg (base equiv) (Ziagen)......... 7
ABANEU-SL -cyanocobalamin-methylcobalamin tab sl
600-600 mcg.................................................................. 128
ABILIFY -aripiprazole tab 10 mg....................................... 81
ABILIFY -aripiprazole tab 15 mg....................................... 81
ABILIFY -aripiprazole tab 20 mg....................................... 81
ABILIFY -aripiprazole tab 2 mg......................................... 81
ABILIFY -aripiprazole tab 30 mg....................................... 81
ABILIFY -aripiprazole tab 5 mg......................................... 81
ABSORICA -isotretinoin cap 10 mg.................................144
ABSORICA -isotretinoin cap 20 mg.................................144
ABSORICA -isotretinoin cap 25 mg.................................144
ABSORICA -isotretinoin cap 30 mg.................................144
ABSORICA -isotretinoin cap 35 mg.................................144
ABSORICA -isotretinoin cap 40 mg.................................144
ABSTRAL -fentanyl citrate sl tab 100 mcg (base
equiv)................................................................................93
ABSTRAL -fentanyl citrate sl tab 200 mcg (base
equiv)................................................................................93
ABSTRAL -fentanyl citrate sl tab 300 mcg (base
equiv)................................................................................93
ABSTRAL -fentanyl citrate sl tab 400 mcg (base
equiv)................................................................................94
ABSTRAL -fentanyl citrate sl tab 600 mcg (base
equiv)................................................................................94
ABSTRAL -fentanyl citrate sl tab 800 mcg (base
equiv)................................................................................94
acamprosate calcium tab delayed release 333 mg
(Campral).........................................................................89
ACANYA -clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%......................................................................... 144
acarbose tab 100 mg (Precose)..................................... 27
acarbose tab 25 mg (Precose)....................................... 27
acarbose tab 50 mg (Precose)....................................... 27
ACCOLATE -zafirlukast tab 10 mg....................................62
ACCOLATE -zafirlukast tab 20 mg....................................62
ACCUPRIL -quinapril hcl tab 10 mg..................................45
ACCUPRIL -quinapril hcl tab 20 mg..................................45
ACCUPRIL -quinapril hcl tab 40 mg..................................45
ACCUPRIL -quinapril hcl tab 5 mg....................................45
ACCURETIC -quinapril-hydrochlorothiazide tab 10-12.5
mg.................................................................................... 45
ACCURETIC -quinapril-hydrochlorothiazide tab 20-12.5
mg.................................................................................... 45
ACCURETIC -quinapril-hydrochlorothiazide tab 20-25
mg.................................................................................... 45
acebutolol hcl cap 200 mg (Sectral).............................. 40
acebutolol hcl cap 400 mg (Sectral).............................. 40
166
ACEON -perindopril erbumine tab 4 mg............................45
ACEON -perindopril erbumine tab 8 mg............................45
acetaminophen-isometheptene-dichloral cap
325-65-100 mg.............................................................. 104
acetaminophen-salicylamide-phenyltoloxamine cap
300-200-20mg..................................................................93
acetaminophen w/ codeine soln 120-12 mg/5ml........... 94
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine)...........................................................................94
acetaminophen w/ codeine tab 300-30 mg (Tylenol/
codeine #3)..................................................................... 94
acetaminophen w/ codeine tab 300-60 mg (Tylenol/
codeine #4)..................................................................... 94
ACETAZOLAMIDE -acetazolamide tab 125 mg................ 52
acetazolamide cap sr 12hr 500 mg (Diamox)................ 52
acetazolamide tab 250 mg.............................................. 52
ACETIC ACID/ALUMINUM ACET -acetic acid 2% in
aluminum acetate otic soln............................................ 141
acetic acid otic soln 2%................................................141
acetylcysteine cap 600 mg........................................... 126
acetylcysteine inhal soln 10%........................................ 59
acetylcysteine inhal soln 20%........................................ 59
ACIPHEX -rabeprazole sodium ec tab 20 mg................... 66
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 10 mg.............................................................66
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 5 mg...............................................................66
acitretin cap 10 mg (Soriatane).................................... 144
acitretin cap 17.5 mg (Soriatane)................................. 144
acitretin cap 25 mg (Soriatane).................................... 144
ACLOVATE -alclometasone dipropionate cream
0.05%............................................................................. 144
ACTEMRA -tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml.................................................... 101
ACTHAR HP -corticotropin inj gel 80 unit/ml..................... 35
ACTICLATE -doxycycline hyclate tab 150 mg.....................3
ACTICLATE -doxycycline hyclate tab 75 mg.......................3
ACTIGALL -ursodiol cap 300 mg...................................... 70
ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)........................................................ 16
ACTIQ -fentanyl citrate lozenge on a handle 1200
mcg...................................................................................94
ACTIQ -fentanyl citrate lozenge on a handle 1600
mcg...................................................................................94
ACTIQ -fentanyl citrate lozenge on a handle 200 mcg...... 94
ACTIQ -fentanyl citrate lozenge on a handle 400 mcg...... 94
ACTIQ -fentanyl citrate lozenge on a handle 600 mcg...... 94
ACTIQ -fentanyl citrate lozenge on a handle 800 mcg...... 94
ACTIVE FE -fe carbonyl-fa-b complex-a-c-d-e-min tab
75-1.25 mg.....................................................................128
ACTIVELLA -estradiol & norethindrone acetate tab 0.5-0.1
mg.................................................................................... 22
ACTIVELLA -estradiol & norethindrone acetate tab 1-0.5
mg.................................................................................... 22
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
ACTIVE OB -prenatal w/o a w/fe cbn-fa-dha cap 20-1-320
mg.................................................................................. 115
ACTIVE-PAC/GABAPENTIN -gabapentin oral cap 300 mg
& lidocaine-menthol gel ther pk....................................... 89
ACTONEL -risedronate sodium tab 150 mg......................35
ACTONEL -risedronate sodium tab 30 mg........................35
ACTONEL -risedronate sodium tab 35 mg........................35
ACTONEL -risedronate sodium tab 5 mg..........................35
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-500 mg........................................................................27
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-850 mg........................................................................27
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr
24hr 15-1000 mg............................................................. 27
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr
24hr 30-1000 mg............................................................. 27
ACTOS -pioglitazone hcl tab 15 mg (base equiv)..............27
ACTOS -pioglitazone hcl tab 30 mg (base equiv)..............27
ACTOS -pioglitazone hcl tab 45 mg (base equiv)..............27
ACT TOTAL CARE DRY MOUTH -sodium fluoride rinse
0.02%............................................................................. 142
ACUICYN DAILY EYELID & EY -eyelid cleansers liquid............................................................................... 145
ACULAR -ketorolac tromethamine ophth soln 0.5%........137
ACULAR LS -ketorolac tromethamine ophth soln
0.4%............................................................................... 137
ACUVAIL -ketorolac tromethamine ophth soln 0.45%..... 137
acyclovir cap 200 mg (Zovirax)........................................ 7
acyclovir oint 5% (Zovirax)........................................... 145
acyclovir susp 200 mg/5ml (Zovirax)...............................7
acyclovir tab 400 mg (Zovirax).........................................7
acyclovir tab 800 mg (Zovirax).........................................7
ACZONE -dapsone gel 5%............................................. 145
ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml.........................................................................15
ADALAT CC -nifedipine tab sr 24hr 30 mg....................... 42
ADALAT CC -nifedipine tab sr 24hr 60 mg....................... 42
ADALAT CC -nifedipine tab sr 24hr 90 mg....................... 42
ADAPALENE -adapalene lotion 0.1%............................. 145
adapalene cream 0.1% (Differin).................................. 145
adapalene gel 0.1% (Differin)........................................145
adapalene gel 0.3% (Differin)........................................145
ADASUVE -loxapine aerosol powder breath activated 10
mg.................................................................................... 81
ADAZIN -benzo-capsaicin-lido-methyl salicylate cream
2-0.035-2-10%................................................................145
ADCIRCA -tadalafil tab 20 mg (pah)................................. 57
ADDERALL -amphetamine-dextroamphetamine tab 10
mg.................................................................................... 85
ADDERALL -amphetamine-dextroamphetamine tab 12.5
mg.................................................................................... 85
ADDERALL -amphetamine-dextroamphetamine tab 15
mg.................................................................................... 85
ADDERALL -amphetamine-dextroamphetamine tab 20
mg.................................................................................... 85
ADDERALL -amphetamine-dextroamphetamine tab 30
mg.................................................................................... 85
ADDERALL -amphetamine-dextroamphetamine tab 5
mg.................................................................................... 85
ADDERALL -amphetamine-dextroamphetamine tab 7.5
mg.................................................................................... 85
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 10 mg...................................................................... 85
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 15 mg...................................................................... 85
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 20 mg...................................................................... 85
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 25 mg...................................................................... 86
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 30 mg...................................................................... 86
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 5 mg........................................................................ 85
adefovir dipivoxil tab 10 mg (Hepsera)........................... 7
ADEMPAS -riociguat tab 0.5 mg....................................... 57
ADEMPAS -riociguat tab 1.5 mg....................................... 57
ADEMPAS -riociguat tab 1 mg.......................................... 57
ADEMPAS -riociguat tab 2.5 mg....................................... 57
ADEMPAS -riociguat tab 2 mg.......................................... 57
ADOXA -doxycycline monohydrate cap 150 mg..................3
ADOXA -doxycycline monohydrate tab 100 mg.................. 3
ADOXA -doxycycline monohydrate tab 50 mg.................... 3
ADOXA -doxycycline monohydrate tab 75 mg.................... 3
ADOXA PAK 1/100 -doxycycline monohydrate tab 100
mg...................................................................................... 3
ADOXA PAK 1/150 -doxycycline monohydrate tab 150
mg...................................................................................... 4
ADOXA PAK 2/100 -doxycycline monohydrate tab 100
mg...................................................................................... 4
ADRENACLICK -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000).......................................................... 53
ADRENACLICK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................53
ADRENAL C FORMULA -bioflavonoid products tab........115
ADRENALIN -epinephrine hcl nasal soln 0.1%................. 59
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................. 62
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
250-50 mcg/dose............................................................. 62
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
500-50 mcg/dose............................................................. 62
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21
mcg/act.............................................................................62
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 230-21
mcg/act.............................................................................62
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21
mcg/act.............................................................................62
ADVANCED ALLERGY COLLECTI -hydrocortisone cream
kit 2.5%.......................................................................... 145
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
167
2015
ADVANCED AM/PM -multiple vitamins w/ calcium therapy
pack................................................................................115
ADVATE -antihemophilic factor rahf-pfm for inj 1000
unit..................................................................................133
ADVATE -antihemophilic factor rahf-pfm for inj 1500
unit..................................................................................133
ADVATE -antihemophilic factor rahf-pfm for inj 2000
unit..................................................................................133
ADVATE -antihemophilic factor rahf-pfm for inj 250
unit..................................................................................133
ADVATE -antihemophilic factor rahf-pfm for inj 3000
unit..................................................................................133
ADVATE -antihemophilic factor rahf-pfm for inj 4000
unit..................................................................................133
ADVATE -antihemophilic factor rahf-pfm for inj 500
unit..................................................................................133
ADVICOR -niacin-lovastatin tab sr 24hr 1000-20 mg........ 54
ADVICOR -niacin-lovastatin tab sr 24hr 1000-40 mg........ 54
ADVICOR -niacin-lovastatin tab sr 24hr 500-20 mg.......... 54
ADVICOR -niacin-lovastatin tab sr 24hr 750-20 mg.......... 54
AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act....... 62
AFINITOR DISPERZ -everolimus tab for oral susp 2
mg.................................................................................... 16
AFINITOR DISPERZ -everolimus tab for oral susp 3
mg.................................................................................... 16
AFINITOR DISPERZ -everolimus tab for oral susp 5
mg.................................................................................... 16
AFINITOR -everolimus tab 10 mg..................................... 16
AFINITOR -everolimus tab 2.5 mg.................................... 16
AFINITOR -everolimus tab 5 mg....................................... 16
AFINITOR -everolimus tab 7.5 mg.................................... 16
AFLURIA 2011-2012 -influenza virus vaccine split im
susp..................................................................................13
AFLURIA 2012-2013 -influenza virus vaccine split im
susp..................................................................................13
AFLURIA 2013-2014 -influenza virus vaccine split im
susp..................................................................................13
AFLURIA 2014-2015 -influenza virus vaccine split im
susp..................................................................................13
AFLURIA 2015-2016 -influenza virus vaccine split im
susp..................................................................................13
AFLURIA PF 2011-2012 -influenza virus vaccine split pf
susp pref syringe 0.5 ml.................................................. 12
AFLURIA PF 2012-2013 -influenza virus vaccine split pf
susp pref syringe 0.5 ml.................................................. 12
AFLURIA PF 2013-2014 -influenza virus vaccine split pf
susp pref syringe 0.5 ml.................................................. 12
AFLURIA PF 2014-2015 -influenza virus vaccine split pf
susp pref syringe 0.5 ml.................................................. 13
AFLURIA PF 2015-2016 -influenza virus vaccine split pf
susp pref syringe 0.5 ml.................................................. 13
AFREZZA -insulin regular (human) inhalation powder 4
unit/cartridge.....................................................................32
AFREZZA -insulin regular (human) inhal powd 4 (30) & 8
(60) unit/cart.....................................................................32
168
AFREZZA -insulin regular (human) inhal powd 4 (60) & 8
(30) unit/cart.....................................................................32
AFREZZA -insulin regular (human) inh powd 8 (60) & 12
(30) unit/cart.....................................................................32
AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................. 133
AGRYLIN -anagrelide hcl cap 0.5 mg............................. 133
AKTEN -lidocaine hcl ophth gel 3.5%............................. 137
AKYNZEO -netupitant-palonosetron cap 300-0.5 mg........ 69
ALA QUIN -clioquinol-hc cream 3-0.5%.......................... 145
ALA SCALP -hydrocortisone lotion 2%........................... 145
ALBENZA -albendazole tab 200 mg................................. 11
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).......... 62
albuterol sulfate soln nebu 0.5% (5 mg/ml)...................62
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv)...............................................................................62
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv)...............................................................................62
albuterol sulfate syrup 2 mg/5ml................................... 62
albuterol sulfate tab 2 mg...............................................62
albuterol sulfate tab 4 mg...............................................62
albuterol sulfate tab sr 12hr 4 mg (Vospire er)............. 62
albuterol sulfate tab sr 12hr 8 mg (Vospire er)............. 62
ALCAINE -proparacaine hcl ophth soln 0.5%..................137
alclometasone dipropionate cream 0.05%
(Aclovate)...................................................................... 145
alclometasone dipropionate oint 0.05%...................... 145
ALCORTIN A -iodoquinol-hydrocortisone-aloe
polysaccharide gel 1-2-1%.............................................145
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
25-25 mg..........................................................................52
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
50-50 mg..........................................................................52
ALDACTONE -spironolactone tab 100 mg........................ 52
ALDACTONE -spironolactone tab 25 mg.......................... 52
ALDACTONE -spironolactone tab 50 mg.......................... 52
ALDARA -imiquimod cream 5%...................................... 145
ALEGENIX -capsaicin-menthol disk 0.0375-5%.............. 145
ALENDRONATE SODIUM -alendronate sodium oral soln
70 mg/75ml...................................................................... 35
ALENDRONATE SODIUM -alendronate sodium tab 40
mg.................................................................................... 35
alendronate sodium tab 10 mg...................................... 35
alendronate sodium tab 35 mg...................................... 35
alendronate sodium tab 5 mg........................................ 35
alendronate sodium tab 70 mg (Fosamax)....................35
ALEVEER -capsaicin-menthol topical patch
0.0375-5%...................................................................... 145
ALEVICYN DERMAL SPRAY -wound dressings soln.................................................................................145
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)...................74
ALINIA -nitazoxanide for susp 100 mg/5ml....................... 11
ALINIA -nitazoxanide tab 500 mg......................................11
ALKERAN -melphalan tab 2 mg........................................16
ALLEVYN AG ADHESIVE -wound dressings - pads....... 145
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
ALLEVYN AG GENTLE BORDER -wound dressings pads................................................................................145
ALLEVYN AG NON-ADHESIVE -wound dressings pads................................................................................145
ALLEVYN AG SACRUM -wound dressings - pads..........145
ALLEVYN GENTLE -wound dressings - pads................. 145
allopurinol tab 100 mg (Zyloprim)................................106
allopurinol tab 300 mg (Zyloprim)................................106
almotriptan malate tab 12.5 mg (Axert)....................... 104
almotriptan malate tab 6.25 mg (Axert)....................... 104
ALOCRIL -nedocromil sodium ophth soln 2%................. 137
ALOMIDE -lodoxamide tromethamine ophth soln
0.1%............................................................................... 137
ALOQUIN -iodoquinol-aloe polysaccharides gel
1.25-1%.......................................................................... 145
ALORA -estradiol td patch twice weekly 0.025
mg/24hr............................................................................ 22
ALORA -estradiol td patch twice weekly 0.05 mg/24hr...... 22
ALORA -estradiol td patch twice weekly 0.075
mg/24hr............................................................................ 22
ALORA -estradiol td patch twice weekly 0.1 mg/24hr........22
alosetron hcl tab 0.5 mg (base equiv) (Lotronex)......... 70
alosetron hcl tab 1 mg (base equiv) (Lotronex)............ 70
ALPHAGAN P -brimonidine tartrate ophth soln 0.1%...... 137
ALPHAGAN P -brimonidine tartrate ophth soln
0.15%............................................................................. 137
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 1000 unit......................................... 133
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 1500 unit......................................... 133
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 2000 unit......................................... 134
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 250 unit........................................... 133
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 500 unit........................................... 133
ALPHANINE SD -coagulation factor ix for inj 1000
unit..................................................................................134
ALPHANINE SD -coagulation factor ix for inj 1500
unit..................................................................................134
ALPHANINE SD -coagulation factor ix for inj 500 unit..... 134
ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/ml......75
alprazolam orally disintegrating tab 0.25 mg
(Niravam).........................................................................75
alprazolam orally disintegrating tab 0.5 mg..................75
alprazolam orally disintegrating tab 1 mg.....................75
alprazolam orally disintegrating tab 2 mg.....................75
alprazolam tab 0.25 mg (Xanax).....................................75
alprazolam tab 0.5 mg (Xanax).......................................75
alprazolam tab 1 mg (Xanax)..........................................75
alprazolam tab 2 mg (Xanax)..........................................75
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 75
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 75
alprazolam tab sr 24hr 2 mg (Xanax xr)........................ 75
alprazolam tab sr 24hr 3 mg (Xanax xr)........................ 75
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
1000 unit........................................................................ 134
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
2000 unit........................................................................ 134
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
3000 unit........................................................................ 134
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
500 unit.......................................................................... 134
ALREX -loteprednol etabonate ophth susp 0.2%............ 137
ALSUMA -sumatriptan succinate solution auto-injector 6
mg/0.5ml.........................................................................104
ALTABAX -retapamulin oint 1%...................................... 145
ALTACE -ramipril cap 1.25 mg......................................... 45
ALTACE -ramipril cap 10 mg............................................ 45
ALTACE -ramipril cap 2.5 mg........................................... 45
ALTACE -ramipril cap 5 mg.............................................. 45
ALTOPREV -lovastatin tab sr 24hr 20 mg.........................54
ALTOPREV -lovastatin tab sr 24hr 40 mg.........................54
ALTOPREV -lovastatin tab sr 24hr 60 mg.........................54
ALUMINUM ACETATE -aluminum acetate soln.............. 145
ALUVEA -urea cream 39%..............................................145
ALVESCO -ciclesonide inhal aerosol 160 mcg/act............ 62
ALVESCO -ciclesonide inhal aerosol 80 mcg/act.............. 62
ALZ-NAC -l-methylfolate-methylcobalamin-acetylcyst tab
6-2-600 mg.....................................................................126
AMANTADINE HCL -amantadine hcl tab 100 mg............111
amantadine hcl cap 100 mg......................................... 111
amantadine hcl syrup 50 mg/5ml................................. 111
AMARYL -glimepiride tab 1 mg......................................... 27
AMARYL -glimepiride tab 2 mg......................................... 27
AMARYL -glimepiride tab 4 mg......................................... 27
AMBIEN CR -zolpidem tartrate tab cr 12.5 mg..................84
AMBIEN CR -zolpidem tartrate tab cr 6.25 mg..................84
AMBIEN -zolpidem tartrate tab 10 mg...............................84
AMBIEN -zolpidem tartrate tab 5 mg.................................84
AMCINONIDE -amcinonide cream 0.1%......................... 145
AMCINONIDE -amcinonide lotion 0.1%.......................... 145
AMCINONIDE -amcinonide oint 0.1%............................. 145
AMERGE -naratriptan hcl tab 1 mg (base equiv)............ 104
AMERGE -naratriptan hcl tab 2.5 mg (base equiv)..........104
AMICAR -aminocaproic acid oral soln 0.25 gm/ml.......... 133
AMICAR -aminocaproic acid syrup 25%......................... 133
AMICAR -aminocaproic acid tab 1000 mg...................... 133
AMICAR -aminocaproic acid tab 500 mg........................ 133
amiloride & hydrochlorothiazide tab 5-50 mg............... 52
amiloride hcl tab 5 mg.................................................... 52
AMINOBENZOATE POTASSIUM -potassium
aminobenzoate packet 2 gm..........................................115
AMINOCAPROIC ACID -aminocaproic acid tab 1000
mg.................................................................................. 133
amiodarone hcl tab 100 mg............................................44
amiodarone hcl tab 200 mg (Cordarone).......................44
amiodarone hcl tab 400 mg............................................44
AMITIZA -lubiprostone cap 24 mcg...................................70
AMITIZA -lubiprostone cap 8 mcg.....................................70
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
169
2015
amitriptyline hcl tab 100 mg...........................................76
amitriptyline hcl tab 10 mg.............................................76
amitriptyline hcl tab 150 mg........................................... 76
amitriptyline hcl tab 25 mg.............................................76
amitriptyline hcl tab 50 mg.............................................76
amitriptyline hcl tab 75 mg.............................................76
amlodipine besylate-atorvastatin calcium tab 10-10 mg
(Caduet)...........................................................................57
amlodipine besylate-atorvastatin calcium tab 10-20 mg
(Caduet)...........................................................................57
amlodipine besylate-atorvastatin calcium tab 10-40 mg
(Caduet)...........................................................................57
amlodipine besylate-atorvastatin calcium tab 10-80 mg
(Caduet)...........................................................................57
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet).................................................................... 57
amlodipine besylate-atorvastatin calcium tab 2.5-20
mg (Caduet).................................................................... 57
amlodipine besylate-atorvastatin calcium tab 2.5-40
mg (Caduet).................................................................... 57
amlodipine besylate-atorvastatin calcium tab 5-10 mg
(Caduet)...........................................................................57
amlodipine besylate-atorvastatin calcium tab 5-20 mg
(Caduet)...........................................................................57
amlodipine besylate-atorvastatin calcium tab 5-40 mg
(Caduet)...........................................................................57
amlodipine besylate-atorvastatin calcium tab 5-80 mg
(Caduet)...........................................................................57
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel)............................................................................. 45
amlodipine besylate-benazepril hcl cap 10-40 mg
(Lotrel)............................................................................. 45
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel)............................................................................. 45
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel)............................................................................. 45
amlodipine besylate-benazepril hcl cap 5-20 mg
(Lotrel)............................................................................. 45
amlodipine besylate-benazepril hcl cap 5-40 mg
(Lotrel)............................................................................. 45
amlodipine besylate tab 10 mg (Norvasc)..................... 42
amlodipine besylate tab 2.5 mg (Norvasc).................... 42
amlodipine besylate tab 5 mg (Norvasc).......................42
amlodipine besylate-valsartan tab 10-160 mg
(Exforge)..........................................................................45
amlodipine besylate-valsartan tab 10-320 mg
(Exforge)..........................................................................45
amlodipine besylate-valsartan tab 5-160 mg
(Exforge)..........................................................................45
amlodipine besylate-valsartan tab 5-320 mg
(Exforge)..........................................................................45
amlodipine-valsartan-hydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)........................................45
amlodipine-valsartan-hydrochlorothiazide tab
10-160-25 mg (Exforge hct)...........................................45
170
amlodipine-valsartan-hydrochlorothiazide tab
10-320-25 mg (Exforge hct)...........................................46
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)..........................................45
amlodipine-valsartan-hydrochlorothiazide tab 5-160-25
mg (Exforge hct)............................................................ 45
AMOXAPINE -amoxapine tab 100 mg.............................. 76
AMOXAPINE -amoxapine tab 150 mg.............................. 76
AMOXAPINE -amoxapine tab 25 mg................................ 76
AMOXAPINE -amoxapine tab 50 mg................................ 76
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml.................. 1
amoxicillin (trihydrate) for susp 200 mg/5ml.................. 1
amoxicillin (trihydrate) for susp 250 mg/5ml.................. 1
amoxicillin (trihydrate) for susp 400 mg/5ml.................. 1
amoxicillin (trihydrate) tab 500 mg.................................. 1
amoxicillin (trihydrate) tab 875 mg.................................. 1
amoxicillin & k clavulanate chew tab 200-28.5 mg......... 1
amoxicillin & k clavulanate chew tab 400-57 mg............ 1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml...............................................................................1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)...................................................................... 1
amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)..........................................................1
amoxicillin & k clavulanate tab 250-125 mg....................1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)...................................................................... 1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)...................................................................... 1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................. 1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 125 mg.....1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 250 mg.....1
amoxicillin cap-clarithro tab-lansopraz cap dr therapy
pack (Prevpac)............................................................... 66
AMOXICILLIN ER -amoxicillin (trihydrate) tab sr 24hr 775
mg...................................................................................... 1
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)....................................................................86
amphetamine-dextroamphetamine cap sr 24hr 15 mg
(Adderall xr)....................................................................86
amphetamine-dextroamphetamine cap sr 24hr 20 mg
(Adderall xr)....................................................................86
amphetamine-dextroamphetamine cap sr 24hr 25 mg
(Adderall xr)....................................................................86
amphetamine-dextroamphetamine cap sr 24hr 30 mg
(Adderall xr)....................................................................86
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(Adderall xr)....................................................................86
amphetamine-dextroamphetamine tab 10 mg
(Adderall).........................................................................86
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall).........................................................................86
amphetamine-dextroamphetamine tab 15 mg
(Adderall).........................................................................86
amphetamine-dextroamphetamine tab 20 mg
(Adderall).........................................................................86
amphetamine-dextroamphetamine tab 30 mg
(Adderall).........................................................................86
amphetamine-dextroamphetamine tab 5 mg
(Adderall).........................................................................86
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall).........................................................................86
AMPICILLIN -ampicillin for susp 125 mg/5ml...................... 1
AMPICILLIN -ampicillin for susp 250 mg/5ml...................... 1
ampicillin cap 250 mg....................................................... 1
ampicillin cap 500 mg....................................................... 1
AMPYRA -dalfampridine tab sr 12hr 10 mg...................... 89
AMRIX -cyclobenzaprine hcl cap sr 24hr 15 mg..............113
AMRIX -cyclobenzaprine hcl cap sr 24hr 30 mg..............113
ANACAINE -benzocaine oint 10%...................................145
ANADROL-50 -oxymetholone tab 50 mg.......................... 21
ANAFRANIL -clomipramine hcl cap 25 mg....................... 76
ANAFRANIL -clomipramine hcl cap 50 mg....................... 76
ANAFRANIL -clomipramine hcl cap 75 mg....................... 76
anagrelide hcl cap 0.5 mg (Agrylin).............................134
anagrelide hcl cap 1 mg............................................... 134
ANALPRAM ADVANCED -hc-pramoxine cr & diet manage
prod tab & cleans wipe kit............................................. 143
ANALPRAM E -hc-pramoxine emol cream 2.5-1% &
pramoxine wipe 1% kit...................................................143
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal cream 1-1%..........................................................144
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1%.......................................................144
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal lotn 2.5-1%...........................................................144
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 1-1%........................................144
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%.....................................144
ANAPROX DS -naproxen sodium tab 550 mg................ 101
ANAPROX -naproxen sodium tab 275 mg...................... 101
ANASEPT -sodium hypochlorite liquid 0.057%............... 162
ANASPAZ -hyoscyamine sulfate tab disp 0.125 mg..........66
anastrozole tab 1 mg (Arimidex)....................................16
ANCOBON -flucytosine cap 250 mg................................... 6
ANCOBON -flucytosine cap 500 mg................................... 6
ANDRODERM -testosterone td patch 24hr 2 mg/24hr...... 21
ANDRODERM -testosterone td patch 24hr 4 mg/24hr...... 21
ANDROGEL PUMP -testosterone td gel 12.5 mg/act
(1%)..................................................................................21
ANDROGEL PUMP -testosterone td gel 20.25 mg/act
(1.62%).............................................................................21
ANDROGEL -testosterone td gel 20.25 mg/1.25gm
(1.62%).............................................................................21
ANDROGEL -testosterone td gel 25 mg/2.5gm (1%)........ 21
ANDROGEL -testosterone td gel 40.5 mg/2.5gm
(1.62%).............................................................................21
ANDROGEL -testosterone td gel 50 mg/5gm (1%)........... 21
ANDROID -methyltestosterone cap 10 mg........................21
ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg...........22
ANGELIQ -drospirenone-estradiol tab 0.5-1 mg................22
ANIMI-3/VITAMIN D -folic acid-b6-b12-d-omega 3phytosterols cap 1 mg................................................... 128
ANIMI-3 -folic acid-b6-b12-d-omega 3-phytosterols cap 1
mg.................................................................................. 128
ANIMI-3 -folic acid-vit b6-vit b12-omega 3-phytosterols cap
1 mg............................................................................... 128
ANODYNERX -capsaicin-lidocaine-menthol patch
0.05-2.5-5%....................................................................145
ANODYNZ -capsaicin-menthol disk 0.0375-5%.............. 145
ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh............................................................... 62
ANTABUSE -disulfiram tab 250 mg.................................. 89
ANTABUSE -disulfiram tab 500 mg.................................. 89
ANTARA -fenofibrate micronized cap 30 mg.....................54
ANTARA -fenofibrate micronized cap 90 mg.....................54
ANTIPYRINE/BENZOCAINE -antipyrine-benzocaine otic
soln 55-14 mg/ml (5.5-1.4%)......................................... 141
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%).......................................................................141
antipyrine-benzocaine-polycosanol otic sol
5.4-1.4-0.0097% (Treagan otic)....................................141
ANUSOL-HC -hydrocortisone acetate suppos 25 mg......144
ANUSOL-HC -hydrocortisone rectal cream 2.5%............ 144
ANZEMET -dolasetron mesylate tab 100 mg.................... 69
ANZEMET -dolasetron mesylate tab 50 mg...................... 69
APEXICON E -diflorasone diacetate emollient base cream
0.05%............................................................................. 145
APIDRA -insulin glulisine inj 100 unit/ml........................... 31
APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj
100 unit/ml....................................................................... 31
APLENZIN -bupropion hbr tab sr 24hr 174 mg................. 76
APLENZIN -bupropion hbr tab sr 24hr 348 mg................. 76
APLENZIN -bupropion hbr tab sr 24hr 522 mg................. 76
APOKYN -apomorphine hydrochloride inj 10 mg/ml........111
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)....................................................................... 137
APRISO -mesalamine cap sr 24hr 0.375 gm.................... 70
APTENSIO XR -methylphenidate hcl cap er 24hr 10 mg
(xr).................................................................................... 86
APTENSIO XR -methylphenidate hcl cap er 24hr 15 mg
(xr).................................................................................... 86
APTENSIO XR -methylphenidate hcl cap er 24hr 20 mg
(xr).................................................................................... 86
APTENSIO XR -methylphenidate hcl cap er 24hr 30 mg
(xr).................................................................................... 86
APTENSIO XR -methylphenidate hcl cap er 24hr 40 mg
(xr).................................................................................... 86
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
171
2015
APTENSIO XR -methylphenidate hcl cap er 24hr 50 mg
(xr).................................................................................... 86
APTENSIO XR -methylphenidate hcl cap er 24hr 60 mg
(xr).................................................................................... 86
APTIOM -eslicarbazepine acetate tab 200 mg................ 106
APTIOM -eslicarbazepine acetate tab 400 mg................ 106
APTIOM -eslicarbazepine acetate tab 600 mg................ 106
APTIOM -eslicarbazepine acetate tab 800 mg................ 106
APTIVUS -tipranavir cap 250 mg........................................ 7
APTIVUS -tipranavir oral soln 100 mg/ml............................7
AQUORAL -artificial saliva - aero soln............................ 142
ARALEN -chloroquine phosphate tab 500 mg...................11
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 100 mcg/0.5ml..............................................128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 100 mcg/ml...................................................128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 10 mcg/0.4ml................................................128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 150 mcg/0.3ml..............................................128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 200 mcg/0.4ml..............................................128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 200 mcg/ml...................................................128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 25 mcg/0.42ml..............................................128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 25 mcg/ml.................................................... 128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 300 mcg/0.6ml..............................................128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 300 mcg/ml...................................................128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 40 mcg/0.4ml................................................128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 40 mcg/ml.................................................... 128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 500 mcg/ml...................................................128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 60 mcg/0.3ml................................................128
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 60 mcg/ml.................................................... 128
ARAVA -leflunomide tab 10 mg.......................................101
ARAVA -leflunomide tab 20 mg.......................................101
ARCALYST -rilonacept for inj 220 mg.............................101
ARCAPTA NEOHALER -indacaterol maleate inhal powder
cap 75 mcg (base equiv)................................................. 63
ARICEPT -donepezil hydrochloride tab 10 mg.................. 89
ARICEPT -donepezil hydrochloride tab 23 mg.................. 89
ARICEPT -donepezil hydrochloride tab 5 mg.................... 89
ARIMIDEX -anastrozole tab 1 mg..................................... 16
aripiprazole tab 10 mg (Abilify)...................................... 81
aripiprazole tab 15 mg (Abilify)...................................... 81
aripiprazole tab 20 mg (Abilify)...................................... 81
aripiprazole tab 2 mg (Abilify)........................................ 81
172
aripiprazole tab 30 mg (Abilify)...................................... 81
aripiprazole tab 5 mg (Abilify)........................................ 81
ARIXTRA -fondaparinux sodium subcutaneous inj 10
mg/0.8ml.........................................................................131
ARIXTRA -fondaparinux sodium subcutaneous inj 2.5
mg/0.5ml.........................................................................131
ARIXTRA -fondaparinux sodium subcutaneous inj 5
mg/0.4ml.........................................................................131
ARIXTRA -fondaparinux sodium subcutaneous inj 7.5
mg/0.6ml.........................................................................131
ARMOUR THYROID -thyroid tab 120 mg (2 grain)........... 33
ARMOUR THYROID -thyroid tab 15 mg (1/4 grain).......... 33
ARMOUR THYROID -thyroid tab 180 mg (3 grain)........... 33
ARMOUR THYROID -thyroid tab 240 mg (4 grain)........... 33
ARMOUR THYROID -thyroid tab 300 mg (5 grain)........... 33
ARMOUR THYROID -thyroid tab 30 mg (1/2 grain).......... 33
ARMOUR THYROID -thyroid tab 60 mg (1 grain)............. 33
ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)....... 33
ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 100 mcg/act................................................. 63
ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 200 mcg/act................................................. 63
AROMASIN -exemestane tab 25 mg.................................16
ARTHROTEC 50 -diclofenac w/ misoprostol tab delayed
release 50-0.2 mg..........................................................101
ARTHROTEC 75 -diclofenac w/ misoprostol tab delayed
release 75-0.2 mg..........................................................101
ARZOL SILVER NITRATE APP -silver nitrate-potassium
nitrate applicator 75-25%............................................... 145
ASACOL HD -mesalamine tab delayed release 800
mg.................................................................................... 70
ASCENSIA AUTODISC TEST ST -glucose blood test
disk................................................................................. 163
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 100 mcg/act.................................................. 63
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 200 mcg/act.................................................. 63
ASMANEX TWISTHALER 120 ME -mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 63
ASMANEX TWISTHALER 30 MET -mometasone furoate
inhal powd 110 mcg/inh (breath activated)...................... 63
ASMANEX TWISTHALER 30 MET -mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 63
ASMANEX TWISTHALER 60 MET -mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 63
ASPIRIN/DIPYRIDAMOLE -aspirin-dipyridamole cap sr
12hr 25-200 mg............................................................. 134
ASPIRIN-CAFFEINE-DIHYDROC -aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg............................... 94
aspirin chew tab 81 mg.................................................. 93
ASPIRIN LOW DOSE -aspirin tab 81 mg..........................93
aspirin tab delayed release 81 mg................................. 93
ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 163
ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 164
ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 164
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
ASTEPRO -azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)............................................................................... 59
ATABEX EC -prenatal vit w/ dss-iron carbonyl-fa tab dr
29-1 mg..........................................................................115
ATACAND -candesartan cilexetil tab 16 mg......................46
ATACAND -candesartan cilexetil tab 32 mg......................46
ATACAND -candesartan cilexetil tab 4 mg........................46
ATACAND -candesartan cilexetil tab 8 mg........................46
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 16-12.5 mg................................................................ 46
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 32-12.5 mg................................................................ 46
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 32-25 mg................................................................... 46
ATELVIA -risedronate sodium tab delayed release 35
mg.................................................................................... 35
ATENDIA -lidocaine-menthol patch 4-3%........................145
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100).................................................................................. 46
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50).................................................................................... 46
atenolol tab 100 mg (Tenormin)..................................... 40
atenolol tab 25 mg (Tenormin)....................................... 40
atenolol tab 50 mg (Tenormin)....................................... 40
ATGAM -lymphocyte immune globulin anti-thymocyte g inj
50 mg/ml(eq)..................................................................164
ATIVAN -lorazepam tab 0.5 mg........................................ 75
ATIVAN -lorazepam tab 1 mg........................................... 75
ATIVAN -lorazepam tab 2 mg........................................... 75
ATOPICLAIR -dermatological products misc - cream......145
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)............................................................................54
atorvastatin calcium tab 20 mg (base equivalent)
(Lipitor)............................................................................54
atorvastatin calcium tab 40 mg (base equivalent)
(Lipitor)............................................................................54
atorvastatin calcium tab 80 mg (base equivalent)
(Lipitor)............................................................................54
atovaquone-proguanil hcl tab 250-100 mg
(Malarone)....................................................................... 11
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone)....................................................................... 11
atovaquone susp 750 mg/5ml (Mepron)........................ 12
ATRALIN -tretinoin gel 0.05%......................................... 145
ATRAPRO CP -wound dressings - kit............................. 145
ATRAPRO DERMAL SPRAY -wound cleansers liquid............................................................................... 145
ATRIPLA -efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg.................................................................7
ATROPINE SULFATE -atropine sulfate ophth oint
1%.................................................................................. 137
atropine sulfate ophth soln 1% (Isopto atropine)....... 137
ATROVENT HFA -ipratropium bromide hfa inhal aerosol
17 mcg/act....................................................................... 63
ATROVENT -ipratropium bromide nasal soln 0.03% (21
mcg/spray)........................................................................59
ATROVENT -ipratropium bromide nasal soln 0.06% (42
mcg/spray)........................................................................59
AUBAGIO -teriflunomide tab 14 mg.................................. 89
AUBAGIO -teriflunomide tab 7 mg.................................... 89
AUGMENTIN -amoxicillin & k clavulanate for susp
125-31.25 mg/5ml.............................................................. 1
AUGMENTIN -amoxicillin & k clavulanate for susp
250-62.5 mg/5ml................................................................ 1
AUGMENTIN -amoxicillin & k clavulanate tab 500-125
mg...................................................................................... 1
AUGMENTIN -amoxicillin & k clavulanate tab 875-125
mg...................................................................................... 1
AUGMENTIN ES-600 -amoxicillin & k clavulanate for susp
600-42.9 mg/5ml................................................................ 1
AUGMENTIN XR -amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg.....................................................................1
AURALGAN -antipyrine-benzocaine otic soln 55-14 mg/ml
(5.5-1.4%).......................................................................141
AURSTAT ANTI-ITCH HYDROGE -dermatological
products misc - kit......................................................... 145
AURSTAT -dermatological products misc - kit................ 145
AURYXIA -ferric citrate tab 1 gm (210 mg ferric iron)........70
AUVI-Q -epinephrine solution auto-injector 0.15 mg/0.15ml
(1:1000)............................................................................ 53
AUVI-Q -epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)............................................................................ 53
AVAILNEX -carbocysteine chew tab 750 mg.................. 126
AVALIDE -irbesartan-hydrochlorothiazide tab 150-12.5
mg.................................................................................... 46
AVALIDE -irbesartan-hydrochlorothiazide tab 300-12.5
mg.................................................................................... 46
AVALIN-RX -lidocaine-menthol patch 4-1%.................... 145
AVANDAMET -rosiglitazone maleate-metformin hcl tab
2-1000 mg........................................................................27
AVANDIA -rosiglitazone maleate tab 2 mg (base
equiv)................................................................................27
AVANDIA -rosiglitazone maleate tab 4 mg (base
equiv)................................................................................27
AVANDIA -rosiglitazone maleate tab 8 mg (base
equiv)................................................................................27
AVAPRO -irbesartan tab 150 mg...................................... 46
AVAPRO -irbesartan tab 300 mg...................................... 46
AVAPRO -irbesartan tab 75 mg........................................ 46
AVAR-E LS -sulfacetamide sodium w/ sulfur cream
10-2%............................................................................. 146
AVAR LS CLEANSER -sulfacetamide sodium w/ sulfur
cleanser 10-2%.............................................................. 146
AVAR LS -sulfacetamide sodium w/ sulfur cleansing pad
10-2%............................................................................. 146
AVAR LS -sulfacetamide sodium w/ sulfur foam
10-2%............................................................................. 146
AVAR -sulfacetamide sodium w/ sulfur cleansing pad
9.5-5%............................................................................ 145
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
173
2015
AVAR -sulfacetamide sodium w/ sulfur foam 9.5-5%...... 145
AVC -sulfanilamide vaginal cream 15%............................ 73
AVEED -testosterone undecanoate im inj in oil 750 mg/3ml
(250mg/ml)....................................................................... 21
AVELOX ABC PACK -moxifloxacin hcl tab 400 mg (base
equiv)..................................................................................5
AVELOX -moxifloxacin hcl tab 400 mg (base equiv)........... 5
AVENOVA -hypochlorous acid cleanser soln 0.01%....... 146
AVIDOXY DK -doxycycline tab 100 mg & suncreen & sal
acid wash 2% kit................................................................4
AVINZA -morphine sulfate beads cap sr 24hr 120 mg...... 94
AVINZA -morphine sulfate beads cap sr 24hr 30 mg........ 94
AVINZA -morphine sulfate beads cap sr 24hr 45 mg........ 94
AVINZA -morphine sulfate beads cap sr 24hr 60 mg........ 94
AVINZA -morphine sulfate beads cap sr 24hr 75 mg........ 94
AVINZA -morphine sulfate beads cap sr 24hr 90 mg........ 94
AVODART -dutasteride cap 0.5 mg.................................. 74
AVONEX -interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)........................................................ 89
AVONEX -interferon beta-1a im inj kit 30 mcg/0.5ml.........89
AVONEX PEN -interferon beta-1a im inj kit 30
mcg/0.5ml.........................................................................89
AXERT -almotriptan malate tab 12.5 mg.........................104
AXERT -almotriptan malate tab 6.25 mg.........................104
AXID -nizatidine cap 300 mg.............................................66
AXIRON -testosterone td soln 30 mg/act.......................... 21
AYGESTIN -norethindrone acetate tab 5 mg.................... 26
AZASAN -azathioprine tab 100 mg................................. 164
AZASAN -azathioprine tab 75 mg................................... 164
AZASITE -azithromycin ophth soln 1%........................... 137
azathioprine tab 50 mg (Imuran).................................. 164
azelastine hcl nasal spray 0.1% (137 mcg/spray)......... 59
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro)......................................................................... 59
azelastine hcl ophth soln 0.05% (Optivar)...................137
AZELEX -azelaic acid cream 20%.................................. 146
AZILECT -rasagiline mesylate tab 0.5 mg (base
equiv)..............................................................................111
AZILECT -rasagiline mesylate tab 1 mg (base equiv)......111
AZITHROMYCIN -azithromycin powd pack for susp 1
gm...................................................................................... 2
azithromycin for susp 100 mg/5ml (Zithromax).............. 2
azithromycin for susp 200 mg/5ml (Zithromax).............. 2
azithromycin tab 250 mg (Zithromax)..............................2
azithromycin tab 500 mg (Zithromax)..............................2
azithromycin tab 600 mg (Zithromax)..............................3
AZOPT -brinzolamide ophth susp 1%............................. 137
AZOR -amlodipine besylate-olmesartan medoxomil tab
10-20 mg..........................................................................46
AZOR -amlodipine besylate-olmesartan medoxomil tab
10-40 mg..........................................................................46
AZOR -amlodipine besylate-olmesartan medoxomil tab
5-20 mg............................................................................46
AZOR -amlodipine besylate-olmesartan medoxomil tab
5-40 mg............................................................................46
174
AZULFIDINE EN-TABS -sulfasalazine tab delayed release
500 mg............................................................................. 70
AZULFIDINE -sulfasalazine tab 500 mg............................70
B
B-6 FOLIC ACID -cobalamine combination cap.............. 128
BABY DDROPS -cholecalciferol drops 400 unit/0.03ml
(per drop)....................................................................... 115
BACITRACIN -bacitracin ophth oint 500 unit/gm............. 137
bacitracin-polymyxin b ophth oint............................... 137
bacitracin-polymyxin-neomycin-hc ophth oint 1%..... 137
baclofen tab 10 mg........................................................113
baclofen tab 20 mg........................................................113
BACTRIM DS -sulfamethoxazole-trimethoprim tab 800-160
mg.................................................................................... 12
BACTRIM -sulfamethoxazole-trimethoprim tab 400-80
mg.................................................................................... 12
BACTROBAN -mupirocin calcium cream 2%.................. 146
BACTROBAN -mupirocin oint 2%................................... 146
BACTROBAN NASAL -mupirocin calcium nasal oint
2%.................................................................................... 59
BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg.....................................................115
balsalazide disodium cap 750 mg (Colazal).................. 70
BANZEL -rufinamide susp 40 mg/ml............................... 106
BANZEL -rufinamide tab 200 mg.................................... 106
BANZEL -rufinamide tab 400 mg.................................... 106
BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 7
BARACLUDE -entecavir tab 0.5 mg....................................7
BARACLUDE -entecavir tab 1 mg.......................................7
BAYER BREEZE 2 TEST DISC -glucose blood test
disk................................................................................. 163
BAYER CONTOUR BLOOD GLUCO -glucose blood test
strip.................................................................................163
BAYER CONTOUR NEXT BLOOD -glucose blood test
strip.................................................................................163
b-complex w/ c & folic acid cap 1 mg
(Nephrocaps)................................................................ 115
b-complex w/ c & folic acid tab 1 mg (Nephro-vite
rx)...................................................................................115
b-complex w/ c & folic acid tab 5 mg.......................... 115
b-complex w/ c-biotin-minerals & folic acid tab 5 mg
(Diatx zn).......................................................................115
BD GLUCOSE -glucose chew tab 5 gm............................27
BEBULIN -factor ix complex for inj 200-1200 unit........... 134
BEBULIN VH -factor ix complex for inj 200-1200 unit......134
BECONASE AQ -beclomethasone dipropionate monohyd
nasal susp 42 mcg/spray.................................................59
BELLADONNA & OPIUM -belladonna alkaloids & opium
suppos 16.2-30 mg.......................................................... 66
BELLADONNA ALKALOIDS & OP -belladonna alkaloids &
opium suppos 16.2-60 mg............................................... 66
BELSOMRA -suvorexant tab 10 mg..................................84
BELSOMRA -suvorexant tab 15 mg..................................84
BELSOMRA -suvorexant tab 20 mg..................................84
BELSOMRA -suvorexant tab 5 mg....................................84
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................. 46
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................. 46
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................. 46
benazepril & hydrochlorothiazide tab 5-6.25 mg.......... 46
benazepril hcl tab 10 mg (Lotensin).............................. 46
benazepril hcl tab 20 mg (Lotensin).............................. 46
benazepril hcl tab 40 mg (Lotensin).............................. 46
benazepril hcl tab 5 mg.................................................. 46
BENEFIX -coagulation factor ix (recombinant) for inj 1000
unit..................................................................................134
BENEFIX -coagulation factor ix (recombinant) for inj 2000
unit..................................................................................134
BENEFIX -coagulation factor ix (recombinant) for inj 250
unit..................................................................................134
BENEFIX -coagulation factor ix (recombinant) for inj 3000
unit..................................................................................134
BENEFIX -coagulation factor ix (recombinant) for inj 500
unit..................................................................................134
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg................................ 46
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg................................ 46
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-25 mg................................... 46
BENICAR -olmesartan medoxomil tab 20 mg................... 46
BENICAR -olmesartan medoxomil tab 40 mg................... 46
BENICAR -olmesartan medoxomil tab 5 mg..................... 46
BENSAL HP -salicylic acid & benzoic acid oint 3-6%...... 146
BENTYL -dicyclomine hcl cap 10 mg................................ 66
BENTYL -dicyclomine hcl tab 20 mg.................................66
BENZACLIN -clindamycin phosphate-benzoyl peroxide gel
1-5%............................................................................... 146
BENZACLIN WITH PUMP -clindamycin phosphatebenzoyl peroxide gel 1-5%............................................ 146
BENZALKONIUM CHLORIDE -benzalkonium chloride
soln.................................................................................162
BENZALKONIUM CHLORIDE -benzalkonium chloride soln
50%................................................................................ 162
BENZAMYCIN -benzoyl peroxide-erythromycin gel
5-3%............................................................................... 146
BENZAMYCINPAK -benzoyl peroxide-erythromycin gel
pack 5-3%...................................................................... 146
BENZEFOAM -benzoyl peroxide foam 5.3%...................146
BENZEFOAMULTRA -benzoyl peroxide foam 9.8%....... 146
BENZIQ -benzoyl peroxide gel 5.25 %............................146
BENZIQ LS -benzoyl peroxide gel 2.75%....................... 146
benzocaine dental soln 20%.........................................142
benzonatate cap 100 mg (Tessalon perles)...................59
benzonatate cap 150 mg (Zonatuss)..............................59
benzonatate cap 200 mg.................................................59
benzoyl peroxide creamy wash 4% &benzoyl peroxide
bar 5% kit......................................................................146
benzoyl peroxide creamy wash 8% &benzoyl peroxide
bar 5% kit (Bpo creamy wash comp)......................... 146
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)................................................................ 146
benzoyl peroxide foam 5.3% (Benzefoam).................. 146
benzoyl peroxide foam 9.8% (Benzefoamultra).......... 146
benzoyl peroxide liq 2.5%.............................................146
benzoyl peroxide liq 5.25%...........................................146
benzoyl peroxide liq 7%................................................146
benzoyl peroxide lotion 6%.......................................... 146
benztropine mesylate tab 0.5 mg................................. 111
benztropine mesylate tab 1 mg....................................111
benztropine mesylate tab 2 mg....................................111
BEPREVE -bepotastine besilate ophth soln 1.5%........... 137
BERINERT -c1 esterase inhibitor (human) for iv inj kit 500
unit..................................................................................134
BESIVANCE -besifloxacin hcl ophth susp 0.6% (base
equiv)..............................................................................137
BETADINE OPHTHALMIC PREP -povidone-iodine ophth
soln 5%.......................................................................... 137
BETAGAN -levobunolol hcl ophth soln 0.5%...................137
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)................................................................146
betamethasone dipropionate augmented gel
0.05%............................................................................. 146
betamethasone dipropionate augmented lotion 0.05%
(Diprolene).................................................................... 146
betamethasone dipropionate augmented oint 0.05%
(Diprolene).................................................................... 146
betamethasone dipropionate cream 0.05%................. 146
betamethasone dipropionate lotion 0.05%..................146
betamethasone dipropionate oint 0.05%..................... 146
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 146
betamethasone valerate cream 0.1%........................... 146
betamethasone valerate lotion 0.1%............................146
betamethasone valerate oint 0.1%............................... 146
BETAPACE AF -sotalol hcl (afib/afl) tab 120 mg...............40
BETAPACE AF -sotalol hcl (afib/afl) tab 160 mg...............40
BETAPACE AF -sotalol hcl (afib/afl) tab 80 mg.................40
BETAPACE -sotalol hcl tab 120 mg.................................. 40
BETAPACE -sotalol hcl tab 160 mg.................................. 40
BETAPACE -sotalol hcl tab 80 mg....................................40
BETASERON -interferon beta-1b for inj kit 0.3 mg............89
betaxolol hcl ophth soln 0.5%......................................137
betaxolol hcl tab 10 mg (Kerlone)..................................40
betaxolol hcl tab 20 mg (Kerlone)..................................40
bethanechol chloride tab 10 mg (Urecholine)............... 72
bethanechol chloride tab 25 mg (Urecholine)............... 72
bethanechol chloride tab 50 mg (Urecholine)............... 72
bethanechol chloride tab 5 mg (Urecholine).................72
BETHKIS -tobramycin nebu soln 300 mg/4ml..................... 5
BETIMOL -timolol ophth soln 0.25%............................... 137
BETIMOL -timolol ophth soln 0.5%................................. 137
BETOPTIC-S -betaxolol hcl ophth susp 0.25%............... 137
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
175
2015
bexarotene cap 75 mg (Targretin)..................................16
BEYAZ -drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg...............................................................24
BIAXIN -clarithromycin for susp 250 mg/5ml.......................3
BIAXIN -clarithromycin tab 250 mg..................................... 3
BIAXIN -clarithromycin tab 500 mg..................................... 3
BIAXIN XL -clarithromycin tab sr 24hr 500 mg....................3
BIAXIN XL PAC -clarithromycin tab sr 24hr 500 mg............3
bicalutamide tab 50 mg (Casodex)................................ 16
BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 57
BIFERARX -polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg............................................................ 128
BILTRICIDE -praziquantel tab 600 mg.............................. 11
BIMATOPROST -bimatoprost ophth soln 0.03%............. 137
BINOSTO -alendronate sodium effervescent tab 70
mg.................................................................................... 35
BIO-STATIN -nystatin cap 1000000 unit............................. 6
BIO-STATIN -nystatin cap 500000 unit............................... 6
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit..................................................................................... 65
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)................................................................................46
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)................................................................................46
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)................................................................................46
bisoprolol fumarate tab 10 mg (Zebeta)........................ 40
bisoprolol fumarate tab 5 mg (Zebeta).......................... 40
BLEPH-10 -sulfacetamide sodium ophth soln 10%......... 137
BLEPHAMIDE S.O.P. -sulfacetamide sodium-prednisolone
ophth oint 10-0.2%.........................................................137
BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth
susp 10-0.2%................................................................. 137
BLOOD GLUCOSE CALIBRATION LIQUID –
VARIOUS....................................................................... 163
B-NEXA -prenatal w/ calcium-vit b6-fa-ginger tab 1.22
mg.................................................................................. 115
BONIVA -ibandronate sodium tab 150 mg (base
equivalent)........................................................................35
BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lflf-mcg/0.5ml......................................................................15
BOSULIF -bosutinib tab 100 mg....................................... 16
BOSULIF -bosutinib tab 500 mg....................................... 16
BP CLEANSING WASH -sulfacetamide sodium-sulfur in
urea emulsion 10-4%.....................................................146
BP FOLINATAL PLUS B -prenatal w/ calcium carbonateb6-b12-fa tab 1 mg........................................................ 115
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fumaratefa tab 30-1 mg............................................................... 115
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fum-fa tab
chew 40-1 mg................................................................ 115
BPO 3% FOAMING CLOTHS -benzoyl peroxide cloth
3%.................................................................................. 146
176
BPO 9% FOAMING CLOTHS -benzoyl peroxide cloth
9%.................................................................................. 146
BPO -benzoyl peroxide gel 4%....................................... 146
BPO -benzoyl peroxide gel 8%....................................... 146
BPO CREAMY WASH COMPLETE -benzoyl peroxide
creamy wash 8% &benzoyl peroxide bar 5% kit............ 146
BP VIT 3 -folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg........................................................................128
BP VIT 3 PLUS -folic acid-b6-b12-d-omega 3-phytosterols
cap 1 mg........................................................................128
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh........................................................... 63
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh........................................................... 63
BREVICON-28 -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg....................................................................... 24
BRILINTA -ticagrelor tab 90 mg...................................... 134
brimonidine tartrate ophth soln 0.15% (Alphagan
p).................................................................................... 137
brimonidine tartrate ophth soln 0.2%.......................... 137
BRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)...... 76
BRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)...... 76
BRINTELLIX -vortioxetine hbr tab 5 mg (base equiv)........76
BRISDELLE -paroxetine mesylate cap 7.5 mg (base
equiv)................................................................................89
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily)................................................................... 138
bromfenac sodium ophth soln 0.09% (base
equivalent).................................................................... 137
bromocriptine mesylate cap 5 mg (Parlodel).............. 111
bromocriptine mesylate tab 2.5 mg............................. 111
brompheniramine & pseudoephedrine tab sr 12hr 6-45
mg.................................................................................... 59
brompheniramine maleate tab sr 12hr 6 mg................. 58
BROMPHENIRAMINE TANNATE -brompheniramine
tannate chew tab 12 mg.................................................. 58
BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml
(base equiv)..................................................................... 63
budesonide cap sr 24hr 3 mg (Entocort ec)..................19
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)...................................................................... 63
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)...................................................................... 63
budesonide inhalation susp 1 mg/2ml (Pulmicort)....... 63
budesonide nasal susp 32 mcg/act (Rhinocort
aqua)................................................................................59
bumetanide tab 0.5 mg................................................... 52
bumetanide tab 1 mg...................................................... 52
bumetanide tab 2 mg...................................................... 52
BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3
mg (base equiv)............................................................... 94
BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7
mg (base equiv)............................................................... 94
BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg
(base equiv)..................................................................... 94
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
BUPAP -butalbital-acetaminophen tab 50-300 mg............ 93
BUPHENYL -sodium phenylbutyrate oral powder 3 gm/
teaspoonful.......................................................................35
BUPHENYL -sodium phenylbutyrate tab 500 mg.............. 35
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv)...............................................................................94
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv)...............................................................................94
buprenorphine hcl sl tab 2 mg (base equiv)................. 94
buprenorphine hcl sl tab 8 mg (base equiv)................. 94
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 89
bupropion hcl tab 100 mg (Wellbutrin)..........................76
bupropion hcl tab 75 mg (Wellbutrin)............................76
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr).........76
bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr).........76
bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr).........76
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)......... 76
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)......... 76
buspirone hcl tab 10 mg.................................................75
buspirone hcl tab 15 mg.................................................75
buspirone hcl tab 30 mg.................................................75
buspirone hcl tab 5 mg...................................................75
buspirone hcl tab 7.5 mg................................................75
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet).......................................................................... 93
butalbital-acetaminophen-caffeine cap 50-325-40
mg.................................................................................... 93
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)............................................................................. 93
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30
mg (Fioricet/codeine).....................................................94
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
mg.................................................................................... 94
butalbital-acetaminophen tab 50-325 mg...................... 93
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal).......................................................................... 93
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)...................................................... 94
BUTISOL SODIUM -butabarbital sodium tab 30 mg..........84
BUTISOL SODIUM -butabarbital sodium tab 50 mg..........84
butorphanol tartrate nasal soln 10 mg/ml..................... 94
BUTRANS -buprenorphine td patch weekly 10 mcg/hr......94
BUTRANS -buprenorphine td patch weekly 15 mcg/hr......94
BUTRANS -buprenorphine td patch weekly 20 mcg/hr......94
BUTRANS -buprenorphine td patch weekly 5 mcg/hr........94
BUTRANS -buprenorphine td patch weekly 7.5 mcg/hr.....94
BYDUREON -exenatide extended release for inj susp 2
mg.................................................................................... 27
BYDUREON -exenatide extended release for susp peninjector 2 mg.................................................................... 27
BYETTA -exenatide soln pen-injector 10 mcg/0.04ml....... 27
BYETTA -exenatide soln pen-injector 5 mcg/0.02ml......... 27
BYSTOLIC -nebivolol hcl tab 10 mg (base equivalent)......40
BYSTOLIC -nebivolol hcl tab 2.5 mg (base equivalent).....40
BYSTOLIC -nebivolol hcl tab 20 mg (base equivalent)......40
BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent)........40
C
cabergoline tab 0.5 mg................................................... 35
CADUET -amlodipine besylate-atorvastatin calcium tab
10-10 mg..........................................................................57
CADUET -amlodipine besylate-atorvastatin calcium tab
10-20 mg..........................................................................57
CADUET -amlodipine besylate-atorvastatin calcium tab
10-40 mg..........................................................................57
CADUET -amlodipine besylate-atorvastatin calcium tab
10-80 mg..........................................................................57
CADUET -amlodipine besylate-atorvastatin calcium tab
2.5-10 mg.........................................................................57
CADUET -amlodipine besylate-atorvastatin calcium tab
2.5-20 mg.........................................................................57
CADUET -amlodipine besylate-atorvastatin calcium tab
2.5-40 mg.........................................................................57
CADUET -amlodipine besylate-atorvastatin calcium tab
5-10 mg............................................................................57
CADUET -amlodipine besylate-atorvastatin calcium tab
5-20 mg............................................................................57
CADUET -amlodipine besylate-atorvastatin calcium tab
5-40 mg............................................................................57
CADUET -amlodipine besylate-atorvastatin calcium tab
5-80 mg............................................................................57
CAFERGOT -ergotamine w/ caffeine tab 1-100 mg........ 104
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv) (Cafcit)................................................................. 86
CALAN SR -verapamil hcl tab cr 120 mg.......................... 42
CALAN SR -verapamil hcl tab cr 180 mg.......................... 42
CALAN SR -verapamil hcl tab cr 240 mg.......................... 42
CALAN -verapamil hcl tab 120 mg....................................42
CALAN -verapamil hcl tab 80 mg......................................42
CALCIFOL -ca carb-folic acid-vit d-b6-b12-boron-mag
wafer 1342-1.6 mg.........................................................124
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)..............................................147
calcipotriene cream 0.005% (Dovonex)....................... 146
calcipotriene oint 0.005%..............................................147
calcipotriene soln 0.005% (50 mcg/ml)........................ 147
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin).......................................................................35
CALCITRIOL -calcitriol oint 3 mcg/gm.............................147
calcitriol cap 0.25 mcg (Rocaltrol)................................. 35
calcitriol cap 0.5 mcg (Rocaltrol)................................... 35
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................ 35
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)..............................................................70
calcium acetate (phosphate binder) tab 667 mg
(Eliphos).......................................................................... 70
CALCIUM-FOLIC ACID PLUS D -ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg............................. 124
CALCIUM PNV -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg............................................................116
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
177
2015
CAMBIA -diclofenac potassium packet 50 mg.................104
CAMPHOMEX -camphor-histamine-menthol liqd spray
4-0.025-10%...................................................................147
CANASA -mesalamine suppos 1000 mg...........................70
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct)........................................................... 46
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct)........................................................... 47
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct)........................................................... 47
candesartan cilexetil tab 16 mg (Atacand).................... 46
candesartan cilexetil tab 32 mg (Atacand).................... 46
candesartan cilexetil tab 4 mg (Atacand)......................46
candesartan cilexetil tab 8 mg (Atacand)......................46
CANTIL -mepenzolate bromide tab 25 mg........................ 66
CAPCOF -phenylephrine-chlorphen w/ codeine syrup
5-2-10 mg/5ml..................................................................59
capecitabine tab 150 mg (Xeloda)..................................16
capecitabine tab 500 mg (Xeloda)..................................16
CAPEX -fluocinolone acetonide shampoo 0.01%............147
CAPHOSOL -artificial saliva - solution............................ 142
CAPITAL/CODEINE -acetaminophen w/ codeine susp
120-12 mg/5ml................................................................. 94
CAPRELSA -vandetanib tab 100 mg................................ 16
CAPRELSA -vandetanib tab 300 mg................................ 16
CAPSIDERM -capsaicin-menthol topical patch
0.0375-5%...................................................................... 147
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-15 mg................................... 47
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-25 mg................................... 47
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 50-15 mg................................... 47
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 50-25 mg................................... 47
captopril tab 100 mg....................................................... 47
captopril tab 12.5 mg...................................................... 47
captopril tab 25 mg......................................................... 47
captopril tab 50 mg......................................................... 47
CAPTRACIN -capsaicin-menthol topical patch
0.0375-5%...................................................................... 147
CARAC -fluorouracil cream 0.5%.................................... 147
CARAFATE -sucralfate susp 1 gm/10ml........................... 66
CARAFATE -sucralfate tab 1 gm...................................... 66
CARBAGLU -carglumic acid tab 200 mg...........................35
carbamazepine cap sr 12hr 100 mg (Carbatrol).......... 106
carbamazepine cap sr 12hr 200 mg (Carbatrol).......... 106
carbamazepine cap sr 12hr 300 mg (Carbatrol).......... 106
carbamazepine chew tab 100 mg.................................106
carbamazepine susp 100 mg/5ml (Tegretol)............... 106
carbamazepine tab 200 mg (Tegretol)......................... 106
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)........ 106
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)........ 106
CARBAPHEN 12 PED -phenyleph-chlorphencarbetapentane susp 2.5-1.25-7.5 mg/ml........................ 59
178
CARBAPHEN 12 -phenyleph-chlorphen-carbetapentane
liqd 10-4-27.5 mg/5ml...................................................... 59
CARBATROL -carbamazepine cap sr 12hr 100 mg........ 106
CARBATROL -carbamazepine cap sr 12hr 200 mg........ 106
CARBATROL -carbamazepine cap sr 12hr 300 mg........ 106
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg.................................. 111
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg................................ 111
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg...................................111
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg.............................. 111
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg................................ 111
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg...................................111
carbidopa & levodopa orally disintegrating tab 10-100
mg.................................................................................. 111
carbidopa & levodopa orally disintegrating tab 25-100
mg.................................................................................. 111
carbidopa & levodopa orally disintegrating tab 25-250
mg.................................................................................. 111
carbidopa & levodopa tab 10-100 mg (Sinemet)......... 111
carbidopa & levodopa tab 25-100 mg (Sinemet)......... 111
carbidopa & levodopa tab 25-250 mg (Sinemet)......... 111
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr)...................................................................................111
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr)...................................................................................111
carbidopa tab 25 mg (Lodosyn)................................... 111
carbinoxamine maleate soln 4 mg/5ml..........................58
carbinoxamine maleate tab 4 mg...................................58
carbonyl iron susp 15 mg/1.25ml (elemental iron)......128
CARDIOTEK-RX -folic acid-b12-b6-arginine-black pepper
tab.................................................................................. 126
CARDIOVID PLUS -dha-epa-vit b6-b12-folic acid cap
240-360-20-0.5-0.8 mg.................................................. 126
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
120 mg............................................................................. 42
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
180 mg............................................................................. 42
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
240 mg............................................................................. 42
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
300 mg............................................................................. 42
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
360 mg............................................................................. 42
CARDIZEM -diltiazem hcl tab 120 mg...............................42
CARDIZEM -diltiazem hcl tab 30 mg.................................42
CARDIZEM -diltiazem hcl tab 60 mg.................................42
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
120 mg............................................................................. 42
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
180 mg............................................................................. 42
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
240 mg............................................................................. 42
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
300 mg............................................................................. 42
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
360 mg............................................................................. 42
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
420 mg............................................................................. 42
CARDURA -doxazosin mesylate tab 1 mg........................ 47
CARDURA -doxazosin mesylate tab 2 mg........................ 47
CARDURA -doxazosin mesylate tab 4 mg........................ 47
CARDURA -doxazosin mesylate tab 8 mg........................ 47
CARDURA XL -doxazosin mesylate tab sr 24 hr 4 mg
(base equiv)..................................................................... 74
CARDURA XL -doxazosin mesylate tab sr 24 hr 8 mg
(base equiv)..................................................................... 74
CARISOPRODOL -carisoprodol tab 250 mg................... 113
carisoprodol tab 350 mg (Soma)..................................113
carisoprodol w/ aspirin & codeine tab 200-325-16
mg.................................................................................. 114
carisoprodol w/ aspirin tab 200-325 mg...................... 114
CARNITOR -levocarnitine oral soln 1 gm/10ml (10%)....... 35
CARNITOR -levocarnitine tab 330 mg.............................. 35
CARNITOR SF -levocarnitine oral soln 1 gm/10ml
(10%)................................................................................35
carteolol hcl ophth soln 1%......................................... 138
carvedilol tab 12.5 mg (Coreg)....................................... 40
carvedilol tab 25 mg (Coreg).......................................... 40
carvedilol tab 3.125 mg (Coreg)..................................... 40
carvedilol tab 6.25 mg (Coreg)....................................... 40
CASCARA SAGRADA -cascara sagrada fl ext 1 gm/
ml......................................................................................65
CASODEX -bicalutamide tab 50 mg................................. 16
CATAPRES -clonidine hcl tab 0.1 mg............................... 47
CATAPRES -clonidine hcl tab 0.2 mg............................... 47
CATAPRES -clonidine hcl tab 0.3 mg............................... 47
CATAPRES-TTS-1 -clonidine hcl td patch weekly 0.1
mg/24hr............................................................................ 47
CATAPRES-TTS-2 -clonidine hcl td patch weekly 0.2
mg/24hr............................................................................ 47
CATAPRES-TTS-3 -clonidine hcl td patch weekly 0.3
mg/24hr............................................................................ 47
CAYSTON -aztreonam lysine for inhal soln 75 mg (base
equivalent)........................................................................12
CEDAX -ceftibuten cap 400 mg.......................................... 1
CEDAX -ceftibuten for susp 180 mg/5ml.............................1
CEDAX -ceftibuten for susp 90 mg/5ml...............................1
CEENU -lomustine cap 100 mg........................................ 16
CEENU -lomustine cap 10 mg.......................................... 16
CEENU -lomustine cap 40 mg.......................................... 16
cefaclor cap 250 mg..........................................................2
cefaclor cap 500 mg..........................................................2
CEFACLOR -cefaclor for susp 125 mg/5ml.........................1
CEFACLOR -cefaclor for susp 250 mg/5ml.........................2
CEFACLOR -cefaclor for susp 375 mg/5ml.........................2
CEFACLOR ER -cefaclor monohydrate tab sr 12hr 500
mg...................................................................................... 2
cefadroxil cap 500 mg.......................................................2
cefadroxil for susp 250 mg/5ml........................................2
cefadroxil for susp 500 mg/5ml........................................2
cefadroxil tab 1 gm........................................................... 2
cefdinir cap 300 mg...........................................................2
cefdinir for susp 125 mg/5ml........................................... 2
cefdinir for susp 250 mg/5ml........................................... 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg
(base equivalent)............................................................... 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg
(base equivalent)............................................................... 2
cefixime for susp 100 mg/5ml (Suprax)...........................2
cefixime for susp 200 mg/5ml (Suprax)...........................2
cefpodoxime proxetil for susp 100 mg/5ml.....................2
cefpodoxime proxetil for susp 50 mg/5ml.......................2
cefpodoxime proxetil tab 100 mg.................................... 2
cefpodoxime proxetil tab 200 mg.................................... 2
cefprozil for susp 125 mg/5ml..........................................2
cefprozil for susp 250 mg/5ml..........................................2
cefprozil tab 250 mg..........................................................2
cefprozil tab 500 mg..........................................................2
CEFTIBUTEN -ceftibuten cap 400 mg................................ 2
CEFTIBUTEN -ceftibuten for susp 180 mg/5ml...................2
CEFTIN -cefuroxime axetil for susp 125 mg/5ml................. 2
CEFTIN -cefuroxime axetil for susp 250 mg/5ml................. 2
CEFTIN -cefuroxime axetil tab 250 mg............................... 2
CEFTIN -cefuroxime axetil tab 500 mg............................... 2
cefuroxime axetil tab 250 mg (Ceftin)..............................2
cefuroxime axetil tab 500 mg (Ceftin)..............................2
CELEBREX -celecoxib cap 100 mg................................ 101
CELEBREX -celecoxib cap 200 mg................................ 101
CELEBREX -celecoxib cap 400 mg................................ 101
CELEBREX -celecoxib cap 50 mg.................................. 101
celecoxib cap 100 mg (Celebrex)................................. 101
celecoxib cap 200 mg (Celebrex)................................. 101
celecoxib cap 400 mg (Celebrex)................................. 101
celecoxib cap 50 mg (Celebrex)...................................101
CELEXA -citalopram hydrobromide tab 10 mg (base
equiv)................................................................................76
CELEXA -citalopram hydrobromide tab 20 mg (base
equiv)................................................................................76
CELEXA -citalopram hydrobromide tab 40 mg (base
equiv)................................................................................77
CELLCEPT -mycophenolate mofetil cap 250 mg............ 164
CELLCEPT -mycophenolate mofetil for oral susp 200 mg/
ml....................................................................................164
CELLCEPT -mycophenolate mofetil tab 500 mg............. 164
CELONTIN -methsuximide cap 300 mg.......................... 106
CEM-UREA -urea soln 45%............................................ 147
CENFOL -folic acid-vitamin b6-vitamin b12 tab 2.3-24.5-2
mg.................................................................................. 128
CENTANY AT -mupirocin oint kit 2%.............................. 147
CENTANY -mupirocin oint 2%.........................................147
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
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2015
CENTRATEX -ferrous fumarate-fa-b complex-c-zn-mg-mncu cap 106-1 mg............................................................128
cephalexin cap 250 mg (Keflex)....................................... 2
cephalexin cap 500 mg (Keflex)....................................... 2
cephalexin cap 750 mg (Keflex)....................................... 2
CEPHALEXIN -cephalexin tab 250 mg............................... 2
CEPHALEXIN -cephalexin tab 500 mg............................... 2
cephalexin for susp 125 mg/5ml...................................... 2
cephalexin for susp 250 mg/5ml...................................... 2
CERDELGA -eliglustat tartrate cap 84 mg (base
equivalent)......................................................................128
CEREFOLIN -l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg................................................................... 126
CEREFOLIN NAC -l-methylfolate-algae-b12-acetylcyst tab
6-90.314-2-600mg..........................................................126
CEREFOLIN NAC -l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg............................................. 126
CERVIDIL -dinoprostone vaginal inserts 10 mg................ 35
CESAMET -nabilone cap 1 mg......................................... 69
CETACAINE -butamben-tetracaine-benzocaine aerosol
spray 2-2-14%................................................................147
CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base
equivalent)......................................................................141
cevimeline hcl cap 30 mg (Evoxac)............................. 142
CHANTIX CONTINUING MONTH -varenicline tartrate tab
1 mg (base equiv)............................................................90
CHANTIX STARTING MONTH PA -varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42 pack.................................. 90
CHANTIX -varenicline tartrate tab 0.5 mg (base equiv).....90
CHANTIX -varenicline tartrate tab 1 mg (base equiv)........90
CHEMET -succimer cap 100 mg.....................................163
CHENODAL -chenodiol tab 250 mg.................................. 70
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg............................................... 90
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg.............................................. 90
chlordiazepoxide hcl cap 10 mg.................................... 75
chlordiazepoxide hcl cap 25 mg.................................... 75
chlordiazepoxide hcl cap 5 mg...................................... 75
chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg
(Librax)............................................................................ 66
chlorhexidine gluconate soln 0.12% (Peridex)............142
chloroquine phosphate tab 250 mg............................... 11
chloroquine phosphate tab 500 mg (Aralen).................11
CHLOROTHIAZIDE -chlorothiazide tab 250 mg................52
chlorothiazide tab 500 mg.............................................. 52
chlorpromazine hcl tab 100 mg......................................81
chlorpromazine hcl tab 10 mg........................................81
chlorpromazine hcl tab 200 mg......................................81
chlorpromazine hcl tab 25 mg........................................81
chlorpromazine hcl tab 50 mg........................................81
CHLORPROPAMIDE -chlorpropamide tab 100 mg...........27
CHLORPROPAMIDE -chlorpropamide tab 250 mg...........27
CHLORTHALIDONE -chlorthalidone tab 100 mg.............. 52
CHLORTHALIDONE -chlorthalidone tab 25 mg................ 52
180
CHLORTHALIDONE -chlorthalidone tab 50 mg................ 52
chlorzoxazone tab 500 mg (Parafon forte dsc)........... 114
CHOICE-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak.................................................. 116
CHOLBAM -cholic acid cap 250 mg..................................70
CHOLBAM -cholic acid cap 50 mg....................................70
cholecalciferol cap 1000 unit........................................115
cholecalciferol cap 400 unit..........................................115
cholecalciferol cap 50000 unit......................................115
cholecalciferol chew tab 1000 unit.............................. 115
cholecalciferol chew tab 400 unit................................ 115
cholecalciferol drops 400 unit/0.03ml (per drop)........ 115
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml)..................................................................... 115
cholecalciferol oral liquid 400 unit/ml......................... 115
cholecalciferol tab 1000 unit........................................ 115
cholecalciferol tab 400 unit.......................................... 115
cholestyramine light powder 4 gm/dose (Questran
light).................................................................................54
cholestyramine light powder packets 4 gm.................. 54
cholestyramine powder 4 gm/dose (Questran).............54
cholestyramine powder packets 4 gm (Questran)........54
choline & magnesium salicylates liq 500 mg/5ml.........93
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix)............................................................... 54
choline fenofibrate cap dr 45 mg (fenofibric acid equiv)
(Trilipix)........................................................................... 54
CHOLINE MAGNESIUM TRISALI -choline & magnesium
salicylates tab 1000 mg................................................... 93
CIALIS -tadalafil tab 2.5 mg.............................................. 57
CIALIS -tadalafil tab 2.5 mg.............................................. 58
CIALIS -tadalafil tab 5 mg................................................. 57
CIALIS -tadalafil tab 5 mg................................................. 58
CICLODAN CREAM KIT -ciclopirox olamine cream 0.77%
(base equiv) & cleanser kit............................................ 147
CICLODAN SOLUTION KIT -ciclopirox solution kit
8%.................................................................................. 147
ciclopirox gel 0.77%...................................................... 147
ciclopirox olamine cream 0.77% (base equiv).............147
ciclopirox olamine susp 0.77% (base equiv)...............147
ciclopirox shampoo 1% (Loprox shampoo)................ 147
ciclopirox solution 8% (Penlac Nail Lacquer)............. 147
ciclopirox solution kit 8% (Ciclodan solution ki)........ 147
CICLOPIROX TOPICAL SOLUTI -ciclopirox solution 8% &
vitamin e 5% topical kit..................................................147
CIFEREX -folic acid-cholecalciferol cap 1 mg-3775
unit..................................................................................128
cilostazol tab 100 mg (Pletal)....................................... 134
cilostazol tab 50 mg (Pletal)......................................... 134
CILOXAN -ciprofloxacin hcl ophth oint 0.3%................... 138
CILOXAN -ciprofloxacin hcl ophth soln 0.3%.................. 138
cimetidine hcl soln 300 mg/5ml..................................... 66
cimetidine tab 300 mg.....................................................66
cimetidine tab 400 mg.....................................................66
cimetidine tab 800 mg.....................................................66
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............. 70
CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200
mg/ml................................................................................70
CIPRO -ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml).......................................................................... 5
CIPRO -ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml).......................................................................... 5
CIPRO -ciprofloxacin hcl tab 250 mg (base equiv)..............5
CIPRO -ciprofloxacin hcl tab 500 mg (base equiv)..............5
CIPRODEX -ciprofloxacin-dexamethasone otic susp
0.3-0.1%......................................................................... 141
CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base
equivalent)......................................................................141
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr).................................................... 5
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)......................................................... 5
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro)............................................................ 5
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)............................................................ 5
CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg
(base equiv)....................................................................... 5
ciprofloxacin hcl ophth soln 0.3% (Ciloxan)............... 138
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)..........5
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)..........5
ciprofloxacin hcl tab 750 mg (base equiv)...................... 5
CIPRO HC -ciprofloxacin-hydrocortisone otic susp
0.2-1%............................................................................ 141
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq).......................................................................5
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500
mg (base eq)..................................................................... 5
citalopram hydrobromide oral soln 10 mg/5ml............. 77
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 77
citalopram hydrobromide tab 20 mg (base equiv)
(Celexa)........................................................................... 77
citalopram hydrobromide tab 40 mg (base equiv)
(Celexa)........................................................................... 77
CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak......................................... 116
CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack.......................................... 116
CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak............................................... 116
CITRANATAL B-CALM -prenat w/o a w/ fe cbnyl-fa tab
20-1 mg & vit b6 tab pak............................................... 116
CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack.................................................... 116
CITRANATAL HARMONY -prenatal w/o a w/fe cbn-dss-fadha cap 29-1-265 mg.................................................... 116
CITRANATAL HARMONY -prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg..........................................116
CITRANATAL RX -prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg..........................................................116
CITRUS BERGAMOT -citrus bergamot oral powder 250
mg/0.25 gm.................................................................... 163
CLARAVIS -isotretinoin cap 30 mg................................. 147
CLARIFOAM EF -sulfacetamide sodium w/ sulfur foam
10-5%............................................................................. 147
CLARINEX-D 12 HOUR -desloratadine &
pseudoephedrine tab sr 12hr 2.5-120 mg........................60
CLARINEX -desloratadine syrup 0.5 mg/ml...................... 58
CLARINEX -desloratadine tab 5 mg..................................58
CLARINEX REDITABS -desloratadine tab orally
disintegrating 2.5 mg....................................................... 58
CLARINEX REDITABS -desloratadine tab orally
disintegrating 5 mg.......................................................... 58
clarithromycin for susp 125 mg/5ml................................ 3
clarithromycin for susp 250 mg/5ml (Biaxin).................. 3
clarithromycin tab 250 mg (Biaxin)..................................3
clarithromycin tab 500 mg (Biaxin)..................................3
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac).......... 3
CLEMASTINE FUMARATE -clemastine fumarate syrup
0.67 mg/5ml (0.5 mg/5ml base eq)..................................58
clemastine fumarate tab 2.68 mg...................................58
CLEOCIN -clindamycin hcl cap 150 mg............................ 12
CLEOCIN -clindamycin hcl cap 300 mg............................ 12
CLEOCIN -clindamycin hcl cap 75 mg.............................. 12
CLEOCIN -clindamycin phosphate vaginal cream 2%.......73
CLEOCIN -clindamycin phosphate vaginal suppos 100
mg.................................................................................... 73
CLEOCIN PEDIATRIC GRANULE -clindamycin palmitate
hcl for soln 75 mg/5ml (base equiv)................................ 12
CLEOCIN-T -clindamycin phosphate gel 1%...................147
CLEOCIN-T -clindamycin phosphate lotion 1%............... 147
CLEOCIN-T -clindamycin phosphate soln 1%................. 147
CLEOCIN-T -clindamycin phosphate swab 1%............... 147
CLEVER CHOICE COMFORT EZ -methyl salicylatelidocaine-menthol patch 20-4-1%.................................. 147
CLEVER CHOICE COMFORT EZ -methyl salicylatelidocaine-menthol patch 2-4-1%.................................... 147
CLIMARA -estradiol td patch weekly 0.025 mg/24hr......... 22
CLIMARA -estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr)......................................................................... 22
CLIMARA -estradiol td patch weekly 0.05 mg/24hr........... 22
CLIMARA -estradiol td patch weekly 0.06 mg/24hr........... 22
CLIMARA -estradiol td patch weekly 0.075 mg/24hr......... 22
CLIMARA -estradiol td patch weekly 0.1 mg/24hr............. 22
CLIMARA PRO -estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day......................................................... 22
CLINDACIN ETZ -clindamycin phosphate swab 1% &
cleanser kit.....................................................................147
CLINDACIN PAC -clindamycin phosphate swab 1% &
cleanser kit.....................................................................147
CLINDAGEL -clindamycin phosphate gel 1%..................147
clindamycin hcl cap 150 mg (Cleocin)...........................12
clindamycin hcl cap 300 mg (Cleocin)...........................12
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
181
2015
clindamycin hcl cap 75 mg (Cleocin)............................ 12
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)......................................... 12
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin).................................................................... 147
clindamycin phosphate foam 1% (Evoclin)................. 147
clindamycin phosphate gel 1% (Cleocin-t)..................147
clindamycin phosphate lotion 1% (Cleocin-t)............. 147
clindamycin phosphate soln 1% (Cleocin-t)................147
clindamycin phosphate swab 1% (Cleocin-t).............. 147
clindamycin phosphate vaginal cream 2%
(Cleocin).......................................................................... 73
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)................................................................ 147
CLINDESSE -clindamycin phosphate (one dose) vaginal
cream 2%.........................................................................73
clobetasol propionate cream 0.05% (Temovate).........147
clobetasol propionate emollient base cream 0.05%
(Temovate e).................................................................148
clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 148
clobetasol propionate foam 0.05% (Olux)................... 148
clobetasol propionate gel 0.05% (Temovate).............. 148
clobetasol propionate lotion 0.05% (Clobex).............. 148
clobetasol propionate oint 0.05% (Temovate).............148
clobetasol propionate shampoo 0.05% (Clobex)........ 148
clobetasol propionate soln 0.05% (Temovate)............148
clobetasol propionate spray 0.05% (Clobex).............. 148
CLOBEX -clobetasol propionate lotion 0.05%................. 148
CLOBEX -clobetasol propionate shampoo 0.05%........... 148
CLOBEX -clobetasol propionate spray 0.05%.................148
CLOCORTOLONE PIVALATE -clocortolone pivalate
cream 0.1%....................................................................148
CLOCORTOLONE PIVALATE PUM -clocortolone pivalate
cream 0.1%....................................................................148
CLODAN KIT -clobetasol propionate shampoo 0.05% &
cleanser kit.....................................................................148
CLODERM -clocortolone pivalate cream 0.1%................148
CLODERM PUMP -clocortolone pivalate cream 0.1%.....148
clomipramine hcl cap 25 mg (Anafranil)....................... 77
clomipramine hcl cap 50 mg (Anafranil)....................... 77
clomipramine hcl cap 75 mg (Anafranil)....................... 77
clonazepam orally disintegrating tab 0.125 mg.......... 106
clonazepam orally disintegrating tab 0.25 mg............ 107
clonazepam orally disintegrating tab 0.5 mg.............. 107
clonazepam orally disintegrating tab 1 mg................. 107
clonazepam orally disintegrating tab 2 mg................. 107
clonazepam tab 0.5 mg (Klonopin).............................. 107
clonazepam tab 1 mg (Klonopin)................................. 107
clonazepam tab 2 mg (Klonopin)................................. 107
clonidine hcl tab 0.1 mg (Catapres)...............................47
clonidine hcl tab 0.2 mg (Catapres)...............................47
clonidine hcl tab 0.3 mg (Catapres)...............................47
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).....................86
182
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1).................................................................................47
clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2).................................................................................47
clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3).................................................................................47
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix)...........................................................................134
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix)...........................................................................134
clorazepate dipotassium tab 15 mg (Tranxene t)..........75
clorazepate dipotassium tab 3.75 mg (Tranxene t).......75
clorazepate dipotassium tab 7.5 mg (Tranxene t).........75
CLORPRES -clonidine & chlorthalidone tab 0.1-15 mg..... 47
CLORPRES -clonidine & chlorthalidone tab 0.2-15 mg..... 47
CLORPRES -clonidine & chlorthalidone tab 0.3-15 mg..... 47
clotrimazole troche 10 mg............................................ 142
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).....................................................................148
clotrimazole w/ betamethasone lotion 1-0.05%...........148
CLOZAPINE ODT -clozapine orally disintegrating tab 100
mg.................................................................................... 81
CLOZAPINE ODT -clozapine orally disintegrating tab 12.5
mg.................................................................................... 81
CLOZAPINE ODT -clozapine orally disintegrating tab 150
mg.................................................................................... 81
CLOZAPINE ODT -clozapine orally disintegrating tab 200
mg.................................................................................... 81
CLOZAPINE ODT -clozapine orally disintegrating tab 25
mg.................................................................................... 81
clozapine tab 100 mg (Clozaril)......................................81
clozapine tab 200 mg...................................................... 81
clozapine tab 25 mg (Clozaril)........................................81
clozapine tab 50 mg........................................................ 81
CLOZARIL -clozapine tab 100 mg.................................... 81
CLOZARIL -clozapine tab 25 mg...................................... 81
C-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg...................................................................116
CNL8 NAIL KIT -ciclopirox soln 8% & lacquer removal
pads kit...........................................................................148
COAL TAR -coal tar soln 20%........................................ 148
COARTEM -artemether-lumefantrine tab 20-120 mg........ 11
COCAINE HCL -cocaine hcl soln 10%............................ 148
COCAINE HCL -cocaine hcl soln 4%..............................148
CODAR AR -chlorpheniramine w/ codeine liquid 2-8
mg/5ml..............................................................................60
CODAR D -pseudoephedrine w/ codeine liquid 30-8
mg/5ml..............................................................................60
CODEINE SULFATE -codeine sulfate tab 15 mg..............94
CODEINE SULFATE -codeine sulfate tab 30 mg..............95
CODEINE SULFATE -codeine sulfate tab 60 mg..............95
codeine sulfate tab 15 mg (Codeine sulfate).................95
codeine sulfate tab 30 mg.............................................. 95
codeine sulfate tab 60 mg.............................................. 95
COLAZAL -balsalazide disodium cap 750 mg................... 70
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
COLCHICINE -colchicine cap 0.6 mg..............................106
COLCHICINE -colchicine tab 0.6 mg.............................. 106
colchicine w/ probenecid tab 0.5-500 mg.................... 106
COLCRYS -colchicine tab 0.6 mg................................... 106
COLESTID -colestipol hcl granule packets 5 gm...............54
COLESTID -colestipol hcl granules 5 gm.......................... 54
COLESTID -colestipol hcl tab 1 gm.................................. 54
COLESTID FLAVORED -colestipol hcl granule packets 5
gm.................................................................................... 54
COLESTID FLAVORED -colestipol hcl granules 5 gm...... 54
colestipol hcl granule packets 5 gm (Colestid
flavored).......................................................................... 54
colestipol hcl granules 5 gm (Colestid flavored).......... 54
colestipol hcl tab 1 gm (Colestid).................................. 54
COLGATE DRY MOUTH RELIEF -sodium fluoride
mouthwash 2.1 mg/10ml................................................142
COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml................................................ 141
COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 227.1 gm............................................65
COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm...............................................65
COMBIGAN -brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%................................................................. 138
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.14 mg/day............................................................. 22
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.25 mg/day............................................................. 22
COMBIVENT RESPIMAT -ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act............................................63
COMBIVIR -lamivudine-zidovudine tab 150-300 mg........... 7
COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg
dose) kit........................................................................... 16
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit.............................................................16
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit.............................................................16
COMMIT -nicotine polacrilex lozenge 2 mg.......................90
COMMIT -nicotine polacrilex lozenge 4 mg.......................90
COMPAZINE -prochlorperazine maleate tab 10 mg (base
equivalent)........................................................................81
COMPAZINE -prochlorperazine maleate tab 5 mg (base
equivalent)........................................................................81
COMPLERA -emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg...................................................................7
COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 250 pk............................................ 116
COMPLETENATE -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg..........................................................................116
COMTAN -entacapone tab 200 mg................................. 111
CO-NATAL FA -prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................. 116
CONCEPT DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg...........................................................116
CONCEPT OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg................................................................116
CONCERTA -methylphenidate hcl tab sa osm 18 mg....... 86
CONCERTA -methylphenidate hcl tab sa osm 27 mg....... 86
CONCERTA -methylphenidate hcl tab sa osm 36 mg....... 86
CONCERTA -methylphenidate hcl tab sa osm 54 mg....... 86
CONDYLOX -podofilox gel 0.5%.....................................148
CONDYLOX -podofilox soln 0.5%................................... 148
CONZIP -tramadol hcl cap sr 24hr biphasic release 100
mg.................................................................................... 95
CONZIP -tramadol hcl cap sr 24hr biphasic release 200
mg.................................................................................... 95
CONZIP -tramadol hcl cap sr 24hr biphasic release 300
mg.................................................................................... 95
COPASIL -emollient - gel................................................ 148
COPAXONE -glatiramer acetate soln prefilled syringe 20
mg/ml................................................................................90
COPAXONE -glatiramer acetate soln prefilled syringe 40
mg/ml................................................................................90
COPEGUS -ribavirin tab 200 mg.........................................7
CORDARONE -amiodarone hcl tab 200 mg..................... 44
CORDRAN -flurandrenolide cream 0.05%...................... 148
CORDRAN -flurandrenolide lotion 0.05%........................148
CORDRAN -flurandrenolide oint 0.05%...........................148
CORDRAN TAPE -flurandrenolide tape 4 mcg/sqcm...... 148
COREG -carvedilol tab 12.5 mg........................................40
COREG -carvedilol tab 25 mg...........................................40
COREG -carvedilol tab 3.125 mg......................................40
COREG -carvedilol tab 6.25 mg........................................40
COREG CR -carvedilol phosphate cap sr 24hr 10 mg...... 40
COREG CR -carvedilol phosphate cap sr 24hr 20 mg...... 40
COREG CR -carvedilol phosphate cap sr 24hr 40 mg...... 40
COREG CR -carvedilol phosphate cap sr 24hr 80 mg...... 40
CORGARD -nadolol tab 20 mg......................................... 40
CORGARD -nadolol tab 40 mg......................................... 40
CORGARD -nadolol tab 80 mg......................................... 40
CORIFACT -factor xiii concentrate (human) for inj kit
1000-1600 unit............................................................... 134
CORLANOR -ivabradine hcl tab 5 mg (base equiv).......... 57
CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)....... 57
CORTALO -hydrocortisone acetate-aloe vera gel 2%..... 148
CORTANE-B AQUEOUS -pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml.................................. 141
CORTANE-B -hydrocortisone-pramoxine-chloroxylenol lot
10-10-1mg/ml................................................................. 148
CORTANE-B-OTIC -pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml................................................................141
CORTEF -hydrocortisone tab 10 mg................................. 19
CORTEF -hydrocortisone tab 20 mg................................. 19
CORTEF -hydrocortisone tab 5 mg...................................19
CORTENEMA -hydrocortisone enema 100 mg/60ml.......144
CORTIFOAM -hydrocortisone acetate rectal foam 90 mg/
dose................................................................................144
CORTISONE ACETATE -cortisone acetate tab 25 mg......19
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
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CORTISPORIN -bacitracin-polymyxin-neomycin hc oint
1%.................................................................................. 148
CORTISPORIN -neomycin-polymyxin-hc cream
0.5%............................................................................... 148
CORTISPORIN -neomycin-polymyxin-hc otic soln
1%.................................................................................. 141
CORTISPORIN-TC -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml................................................ 141
CORVITE 150 -iron combination tab............................... 129
CORVITE 150 -iron-folic acid-vit c-vit b6-vit b12-zinc tab
150-1.25 mg...................................................................129
CORVITE FE -iron combination tab................................ 129
CORVITE -multiple vitamins w/ minerals & fa tab 1.25
mg.................................................................................. 116
CORZIDE -nadolol & bendroflumethiazide tab 40-5
mg.................................................................................... 47
CORZIDE -nadolol & bendroflumethiazide tab 80-5
mg.................................................................................... 47
COSENTYX -secukinumab subcutaneous soln prefilled
syringe 150 mg/ml......................................................... 148
COSENTYX SENSOREADY PEN -secukinumab
subcutaneous soln auto-injector 150 mg/ml.................. 148
COSOPT -dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml............................................................... 138
COSOPT PF -dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf...........................................................138
COUMADIN -warfarin sodium tab 10 mg........................ 132
COUMADIN -warfarin sodium tab 1 mg.......................... 131
COUMADIN -warfarin sodium tab 2.5 mg....................... 132
COUMADIN -warfarin sodium tab 2 mg.......................... 132
COUMADIN -warfarin sodium tab 3 mg.......................... 132
COUMADIN -warfarin sodium tab 4 mg.......................... 132
COUMADIN -warfarin sodium tab 5 mg.......................... 132
COUMADIN -warfarin sodium tab 6 mg.......................... 132
COUMADIN -warfarin sodium tab 7.5 mg....................... 132
COZAAR -losartan potassium tab 100 mg........................ 47
COZAAR -losartan potassium tab 25 mg.......................... 47
COZAAR -losartan potassium tab 50 mg.......................... 47
CPB WC -pseudoephedrine-bromphen-codeine liq
10-1.3-6.3 mg/5ml............................................................60
CREON -pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit.................................................. 69
CREON -pancrelipase (lip-prot-amyl) dr cap
24000-76000-120000 unit................................................ 69
CREON -pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit...................................................... 69
CREON -pancrelipase (lip-prot-amyl) dr cap
36000-114000-180000 unit.............................................. 69
CREON -pancrelipase (lip-prot-amyl) dr cap
6000-19000-30000 unit.................................................... 69
CRESEMBA -isavuconazonium sulfate cap 186 mg........... 6
CRESTOR -rosuvastatin calcium tab 10 mg..................... 54
CRESTOR -rosuvastatin calcium tab 20 mg..................... 54
CRESTOR -rosuvastatin calcium tab 40 mg..................... 54
CRESTOR -rosuvastatin calcium tab 5 mg....................... 54
184
CRIXIVAN -indinavir sulfate cap 200 mg............................ 7
CRIXIVAN -indinavir sulfate cap 400 mg............................ 7
CROMOLYN SODIUM -cromolyn sodium soln nebu 20
mg/2ml..............................................................................63
cromolyn sodium ophth soln 4%................................. 138
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom)...................................................................70
CUPRIMINE -penicillamine cap 250 mg..........................164
CURITY HYPERTONIC SODIUM -wound dressings misc................................................................................ 148
CURITY SODIUM CHLORIDE DR -wound dressings pads................................................................................148
CUROSURF -poractant alfa intratracheal susp 80 mg/
ml......................................................................................65
CUTIVATE -fluticasone propionate cream 0.05%............148
CUTIVATE -fluticasone propionate lotion 0.05%............. 148
CUVPOSA -glycopyrrolate oral soln 1 mg/5ml.................. 66
CVS GLUCOSE BITS -glucose chew tab 1 gm.................27
CVS GLUCOSE -glucose chew tab 4 gm......................... 27
CVS GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 27
CYANOCOBALAMIN/LEVOMEFOLA -l-methylfolate w/ vit
b6-vit b12 tab 1.13-25-2 mg.......................................... 126
cyanocobalamin inj 1000 mcg/ml.................................129
CYCLESSA -desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg.........................24
CYCLOBENZAPRINE COMFORT P -cyclobenzaprine hcl
tab 10 mg & liniment topical gel kit................................114
cyclobenzaprine hcl tab 10 mg.................................... 114
cyclobenzaprine hcl tab 5 mg...................................... 114
cyclobenzaprine hcl tab 7.5 mg (Fexmid)....................114
CYCLOGYL -cyclopentolate hcl ophth soln 0.5%............138
CYCLOGYL -cyclopentolate hcl ophth soln 1%...............138
CYCLOGYL -cyclopentolate hcl ophth soln 2%...............138
CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth
soln 0.2-1%.................................................................... 138
cyclopentolate hcl ophth soln 1% (Cyclogyl)..............138
cyclopentolate hcl ophth soln 2% (Cyclogyl)..............138
CYCLOPHOSPHAMIDE -cyclophosphamide cap 25
mg.................................................................................... 16
CYCLOPHOSPHAMIDE -cyclophosphamide cap 50
mg.................................................................................... 16
CYCLOSERINE -cycloserine cap 250 mg...........................6
CYCLOSET -bromocriptine mesylate tab 0.8 mg (base
equivalent)........................................................................27
cyclosporine cap 100 mg (Sandimmune).................... 164
cyclosporine cap 25 mg (Sandimmune)...................... 164
cyclosporine modified cap 100 mg (Neoral)............... 164
cyclosporine modified cap 25 mg (Neoral)................. 164
CYCLOSPORINE MODIFIED -cyclosporine modified cap
50 mg............................................................................. 164
cyclosporine modified oral soln 100 mg/ml
(Neoral)..........................................................................164
CYMBALTA -duloxetine hcl enteric coated pellets cap 20
mg.................................................................................... 77
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
CYMBALTA -duloxetine hcl enteric coated pellets cap 30
mg.................................................................................... 77
CYMBALTA -duloxetine hcl enteric coated pellets cap 60
mg.................................................................................... 77
cyproheptadine hcl syrup 2 mg/5ml.............................. 58
cyproheptadine hcl tab 4 mg......................................... 58
CYSTADANE -betaine powder for oral solution................ 35
CYSTAGON -cysteamine bitartrate cap 150 mg............... 74
CYSTAGON -cysteamine bitartrate cap 50 mg................. 74
CYSTARAN -cysteamine hcl ophth soln 0.44% (base
equivalent)......................................................................138
CYTOMEL -liothyronine sodium tab 25 mcg..................... 33
CYTOMEL -liothyronine sodium tab 50 mcg..................... 33
CYTOMEL -liothyronine sodium tab 5 mcg....................... 33
CYTOTEC -misoprostol tab 100 mcg................................ 66
CYTOTEC -misoprostol tab 200 mcg................................ 66
CYTRA-3 -pot & sod citrates w/ cit ac syrup 550-500-334
mg/5ml..............................................................................74
D
DAKLINZA -daclatasvir dihydrochloride tab 30 mg (base
equivalent)..........................................................................7
DAKLINZA -daclatasvir dihydrochloride tab 60 mg (base
equivalent)..........................................................................7
DALIRESP -roflumilast tab 500 mcg................................. 63
danazol cap 100 mg........................................................ 21
danazol cap 200 mg........................................................ 21
danazol cap 50 mg.......................................................... 21
DANTRIUM -dantrolene sodium cap 100 mg.................. 114
DANTRIUM -dantrolene sodium cap 25 mg.................... 114
DANTRIUM -dantrolene sodium cap 50 mg.................... 114
dantrolene sodium cap 25 mg (Dantrium)...................114
dantrolene sodium cap 50 mg (Dantrium)...................114
DANTROLENE SODIUM -dantrolene sodium cap 100
mg.................................................................................. 114
DAPSONE -dapsone tab 100 mg......................................12
DAPSONE -dapsone tab 25 mg........................................12
DAPTACEL -diph, acellular pert & tet tox inj 15 lf-10 mcg-5
lf/0.5ml..............................................................................15
DARAPRIM -pyrimethamine tab 25 mg.............................11
DAYPRO -oxaprozin tab 600 mg.................................... 101
DAYTRANA -methylphenidate td patch 10 mg/9hr............86
DAYTRANA -methylphenidate td patch 15 mg/9hr............86
DAYTRANA -methylphenidate td patch 20 mg/9hr............86
DAYTRANA -methylphenidate td patch 30 mg/9hr............86
DDAVP -desmopressin acetate inj 4 mcg/ml.....................36
DDAVP -desmopressin acetate nasal soln 0.01%
(refrigerated).....................................................................35
DDAVP -desmopressin acetate nasal spray soln
0.01%............................................................................... 36
DDAVP -desmopressin acetate tab 0.1 mg.......................36
DDAVP -desmopressin acetate tab 0.2 mg.......................36
DDROPS -cholecalciferol drops 1000 unit/0.03ml (per
drop)............................................................................... 115
DEBACTEROL -sulfuric acid-sulfonated phenolics soln
30-50%........................................................................... 142
DECARA -cholecalciferol cap 25000 unit........................ 115
DECON-A -brompheniramine & phenylephrine elixir 2-5
mg/5ml..............................................................................60
DECON-G -phenylephrine-brompheniramine-guaifenesin
liqd 2-1-40 mg/ml............................................................. 60
DELZICOL -mesalamine cap dr 400 mg........................... 70
DEMADEX -torsemide tab 10 mg......................................52
DEMADEX -torsemide tab 20 mg......................................53
DEMADEX -torsemide tab 5 mg........................................52
demeclocycline hcl tab 150 mg........................................4
demeclocycline hcl tab 300 mg........................................4
DEMEROL -meperidine hcl tab 100 mg............................ 95
DEMEROL -meperidine hcl tab 50 mg.............................. 95
DEMSER -metyrosine cap 250 mg................................... 47
DENAVIR -penciclovir cream 1%.................................... 148
DEPAKENE -valproate sodium syrup 250 mg/5ml (base
equiv)..............................................................................107
DEPAKENE -valproic acid cap 250 mg........................... 107
DEPAKOTE -divalproex sodium tab delayed release 125
mg.................................................................................. 107
DEPAKOTE -divalproex sodium tab delayed release 250
mg.................................................................................. 107
DEPAKOTE -divalproex sodium tab delayed release 500
mg.................................................................................. 107
DEPAKOTE ER -divalproex sodium tab sr 24 hr 250
mg.................................................................................. 107
DEPAKOTE ER -divalproex sodium tab sr 24 hr 500
mg.................................................................................. 107
DEPAKOTE SPRINKLES -divalproex sodium cap sprinkle
125 mg........................................................................... 107
DEPEN TITRATABS -penicillamine tab 250 mg..............164
DEPLIN 15 -l-methylfolate-algae cap 15-90.314 mg....... 126
DEPLIN 7.5 -l-methylfolate-algae cap 7.5-90.314 mg......126
DEPLIN -l-methylfolate tab 15 mg...................................126
DEPLIN -l-methylfolate tab 7.5 mg.................................. 126
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml.......... 24
DEPO-SUBQ PROVERA 104 -medroxyprogesterone
acetate subcutaneous susp 104 mg/0.65ml.................... 24
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 100 mg/ml................................................................... 21
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 200 mg/ml................................................................... 21
DERMACINRX ANALGESIC COMB -diclofenac sod tab dr
75 mg & lido-men-methyl sal ptch kit.............................101
DERMACINRX DUOPATCH PHARM -lidocaine patch 5%
& menthol-methyl sal patch 3-10% ther pak.................. 149
DERMACINRX INFLAMMATRAL P -diclofen dr tab 75mgranitidine tab 150mg-capsaicin cr thpk.......................... 101
DERMACINRX LEXITRAL PHARM -diclofenac sod soln
1.5% & capsaicin cream 0.025% ther pack................... 149
DERMACINRX NEUROTRAL PHAR -lidocaine patch 5%
& capsaicin cream 0.025% therapy pack.......................149
DERMACINRX SILAPAK -triamcinolone acet cr 0.1% &
dimeth cr 5% & silicone tape......................................... 149
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
185
2015
DERMACINRX SURGICAL COMBO -chlorhexidine solndimeth cr-silicone tape-homeopathic kit.........................149
DERMACINRX SURGICAL PHARM -chlorhexidine solmupirocin cr-dimeth cr-silicone tape kit..........................149
DERMA SILKRX ANODYNEXA PA -diclofen dr tab 75mgranitidine tab 150mg-capsaicin cr thpk.......................... 101
DERMA SILKRX SDS PAK -triamcinolone acet cr 0.1% &
dimeth cr 5% & silicone tape......................................... 148
DERMA-SMOOTHE/FS BODY -fluocinolone acetonide oil
0.01% (body oil).............................................................149
DERMA-SMOOTHE/FS BODY OIL -fluocinolone
acetonide oil 0.01% (body oil)....................................... 149
DERMA-SMOOTHE/FS SCALP -fluocinolone acetonide oil
0.01% (scalp oil)............................................................ 149
DERMA-SMOOTHE/FS SCALP OI -fluocinolone acetonide
oil 0.01% (scalp oil)....................................................... 149
DERMASORB AF -clioquinol-hc cream 3-0.5% & emollient
liqd kit.............................................................................149
DERMASORB HC -hydrocortisone lot 2% & cleanser liq
kit....................................................................................149
DERMASORB TA -triamcinolone cream 0.1% & emollient
cream kit........................................................................ 149
DERMASORB XM -urea cream 39% & emollient cream
kit....................................................................................149
DERMATOP -prednicarbate cream 0.1%........................ 149
DERMATOP -prednicarbate oint 0.1%............................ 149
DERMOTIC -fluocinolone acetonide (otic) oil 0.01%....... 141
desipramine hcl tab 100 mg (Norpramin)......................77
desipramine hcl tab 10 mg (Norpramin)........................77
desipramine hcl tab 150 mg (Norpramin)......................77
desipramine hcl tab 25 mg (Norpramin)........................77
desipramine hcl tab 50 mg (Norpramin)........................77
desipramine hcl tab 75 mg (Norpramin)........................77
desloratadine tab 5 mg (Clarinex)..................................58
desloratadine tab orally disintegrating 2.5 mg
(Clarinex reditabs)......................................................... 58
desloratadine tab orally disintegrating 5 mg (Clarinex
reditabs).......................................................................... 58
desmopressin acetate inj 4 mcg/ml (Ddavp).................36
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)............................................................................ 36
desmopressin acetate nasal spray soln 0.01%
(Ddavp)............................................................................ 36
desmopressin acetate nasal spray soln 0.01%
(refrigerated)................................................................... 36
desmopressin acetate tab 0.1 mg (Ddavp)....................36
desmopressin acetate tab 0.2 mg (Ddavp)....................36
DESOGEN -desogestrel & ethinyl estradiol tab 0.15 mg-30
mcg...................................................................................24
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette)......................................................... 24
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa).....24
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)........................................................................24
186
DESONATE -desonide gel 0.05%................................... 149
desonide cream 0.05% (Desowen)............................... 149
desonide lotion 0.05% (Desowen)................................149
desonide oint 0.05% (Desowen)...................................149
DESOWEN -desonide cream 0.05%............................... 149
DESOWEN -desonide lotion 0.05%................................ 149
DESOWEN -desonide oint 0.05%................................... 149
desoximetasone cream 0.25% (Topicort).................... 149
DESOXIMETASONE -desoximetasone cream 0.05%.....149
DESOXIMETASONE -desoximetasone oint 0.05%......... 149
desoximetasone gel 0.05% (Topicort)......................... 149
desoximetasone oint 0.25% (Topicort)........................ 149
DESOXYN -methamphetamine hcl tab 5 mg.................... 86
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv)............................................... 77
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)................................................. 77
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 100
mg.................................................................................... 77
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 50
mg.................................................................................... 77
DETROL LA -tolterodine tartrate cap sr 24hr 2 mg........... 72
DETROL LA -tolterodine tartrate cap sr 24hr 4 mg........... 73
DETROL -tolterodine tartrate tab 1 mg............................. 72
DETROL -tolterodine tartrate tab 2 mg............................. 72
DEX4 FAST ACTING GLUCOSE -glucose gel 15
gm/33gm.......................................................................... 27
DEX4 FAST ACTING GLUCOSE -glucose oral liquid 15
gm/59ml............................................................................27
DEX4 FAST ACTING GLUCOSE -glucose-vitamin c chew
tab 4-0.006 gm................................................................ 27
DEX4 -glucose chew tab 1 gm..........................................27
DEX4 GLUCOSE -glucose chew tab 4 gm....................... 27
DEX4 GLUCOSE -glucose oral liquid 15 gm/59ml............ 27
DEX4 -glucose-vitamin c chew tab 4-0.006 gm.................27
DEX4 NATURALS -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 27
DEX4 POUCH PACK -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 27
DEX4 QUICK DISSOLVE GLUCO -glucose chew tab 4
gm.................................................................................... 27
DEXAMETHASONE -dexamethasone soln 0.5
mg/5ml..............................................................................19
DEXAMETHASONE -dexamethasone tab 1 mg............... 19
DEXAMETHASONE -dexamethasone tab 2 mg............... 19
dexamethasone elixir 0.5 mg/5ml.................................. 19
DEXAMETHASONE INTENSOL -dexamethasone conc 1
mg/ml................................................................................19
dexamethasone sodium phosphate ophth soln
0.1%............................................................................... 138
dexamethasone tab 0.5 mg............................................ 20
dexamethasone tab 0.75 mg.......................................... 20
dexamethasone tab 1.5 mg............................................ 20
dexamethasone tab 4 mg............................................... 20
dexamethasone tab 6 mg............................................... 20
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 10
mg.................................................................................... 86
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 15
mg.................................................................................... 86
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 5
mg.................................................................................... 86
DEXILANT -dexlansoprazole cap delayed release 30
mg.................................................................................... 66
DEXILANT -dexlansoprazole cap delayed release 60
mg.................................................................................... 66
dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin
xr).....................................................................................86
dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin
xr).....................................................................................86
dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin
xr).....................................................................................87
dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin
xr).....................................................................................87
dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin
xr).....................................................................................87
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr).....................................................................................86
dexmethylphenidate hcl tab 10 mg (Focalin)................ 87
dexmethylphenidate hcl tab 2.5 mg (Focalin)............... 87
dexmethylphenidate hcl tab 5 mg (Focalin).................. 87
DEXPAK 10 DAY -dexamethasone tab 1.5 mg taper
pack..................................................................................20
DEXPAK 13 DAY -dexamethasone tab 1.5 mg taper
pack..................................................................................20
DEXPAK 6 DAY -dexamethasone tab 1.5 mg taper
pack..................................................................................20
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)......................................................................87
dextroamphetamine sulfate cap sr 24hr 15 mg
(Dexedrine)......................................................................87
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)......................................................................87
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)...................................................................... 87
dextroamphetamine sulfate tab 10 mg.......................... 87
dextroamphetamine sulfate tab 5 mg............................ 87
DEXTROMETHORPHAN HBR/CHLO -phenylephrinechlorphen-dm liquid 1.75-0.75-2.75 mg/ml...................... 60
DEX-TUSS -guaifenesin-codeine liquid 300-10
mg/5ml..............................................................................60
DIABETA -glyburide tab 1.25 mg...................................... 27
DIABETA -glyburide tab 2.5 mg........................................ 27
DIABETA -glyburide tab 5 mg........................................... 27
DIALYVITE/ZINC -b-complex w/ c-zn & folic acid tab 1
mg.................................................................................. 116
DIALYVITE 3000 -b-complex w/ c-biotin-e-minerals & folic
acid tab 3 mg.................................................................116
DIALYVITE 5000 -b-complex w/ c-biotin-e-minerals & folic
acid tab 5 mg.................................................................116
DIALYVITE SUPREME D -multiple vitamins w/ minerals &
fa tab 3 mg.................................................................... 116
DIAMOX -acetazolamide cap sr 12hr 500 mg................... 53
DIASTAT ACUDIAL -diazepam rectal gel delivery system
10 mg............................................................................. 107
DIASTAT ACUDIAL -diazepam rectal gel delivery system
20 mg............................................................................. 107
DIASTAT PEDIATRIC -diazepam rectal gel delivery
system 2.5 mg............................................................... 107
DIATX ZN -b-complex w/ c-biotin-minerals & folic acid tab
5 mg............................................................................... 116
diazepam conc 5 mg/ml.................................................. 75
DIAZEPAM -diazepam rectal gel delivery system 10
mg.................................................................................. 107
DIAZEPAM -diazepam rectal gel delivery system 2.5
mg.................................................................................. 107
DIAZEPAM -diazepam rectal gel delivery system 20
mg.................................................................................. 107
DIAZEPAM -diazepam soln 1 mg/ml................................. 75
diazepam tab 10 mg (Valium)......................................... 75
diazepam tab 2 mg (Valium)...........................................75
diazepam tab 5 mg (Valium)........................................... 75
DIBENZYLINE -phenoxybenzamine hcl cap 10 mg...........47
DICLEGIS -doxylamine-pyridoxine tab delayed release
10-10 mg..........................................................................69
diclofenac potassium tab 50 mg (Cataflam)................101
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)...................................................................... 149
diclofenac sodium ophth soln 0.1%............................ 138
diclofenac sodium soln 1.5% (Pennsaid).................... 149
diclofenac sodium tab delayed release 25 mg............101
diclofenac sodium tab delayed release 50 mg............101
diclofenac sodium tab delayed release 75 mg............101
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr)...................................................................................102
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50).........................................................102
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75).........................................................102
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 66
dicyclomine hcl oral soln 10 mg/5ml.............................67
dicyclomine hcl tab 20 mg (Bentyl)............................... 67
didanosine delayed release capsule 125 mg (Videx
ec)...................................................................................... 7
didanosine delayed release capsule 200 mg (Videx
ec)...................................................................................... 7
didanosine delayed release capsule 250 mg (Videx
ec)...................................................................................... 7
didanosine delayed release capsule 400 mg (Videx
ec)...................................................................................... 7
DIDRONEL -etidronate disodium tab 400 mg....................36
DIFFERIN -adapalene cream 0.1%.................................149
DIFFERIN -adapalene gel 0.1%...................................... 149
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
187
2015
DIFFERIN -adapalene gel 0.3%...................................... 149
DIFFERIN -adapalene lotion 0.1%.................................. 149
DIFICID -fidaxomicin tab 200 mg........................................ 3
DIFLORASONE DIACETATE -diflorasone diacetate cream
0.05%............................................................................. 149
DIFLORASONE DIACETATE -diflorasone diacetate oint
0.05%............................................................................. 149
DIFLUCAN -fluconazole for susp 10 mg/ml.........................6
DIFLUCAN -fluconazole for susp 40 mg/ml.........................6
DIFLUCAN -fluconazole tab 100 mg................................... 6
DIFLUCAN -fluconazole tab 150 mg................................... 6
DIFLUCAN -fluconazole tab 200 mg................................... 6
DIFLUCAN -fluconazole tab 50 mg..................................... 6
diflunisal tab 500 mg.......................................................93
DIGEX NF -hyoscyamine-phenyltoloxamine cap 0.0625-15
mg.................................................................................... 67
DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 39
digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 39
digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 39
DIHYDROERGOTAMINE MESYLAT -dihydroergotamine
mesylate nasal spray 4 mg/ml....................................... 104
DILANTIN-125 -phenytoin susp 125 mg/5ml................... 107
DILANTIN INFATABS -phenytoin chew tab 50 mg..........107
DILANTIN -phenytoin sodium extended cap 100 mg.......107
DILANTIN -phenytoin sodium extended cap 30 mg.........107
DILATRATE SR -isosorbide dinitrate cap cr 40 mg........... 39
DILAUDID -hydromorphone hcl liqd 1 mg/ml.................... 95
DILAUDID -hydromorphone hcl tab 2 mg..........................95
DILAUDID -hydromorphone hcl tab 4 mg..........................95
DILAUDID -hydromorphone hcl tab 8 mg..........................95
diltiazem hcl cap sr 12hr 120 mg................................... 42
diltiazem hcl cap sr 12hr 60 mg.....................................42
diltiazem hcl cap sr 12hr 90 mg.....................................42
diltiazem hcl cap sr 24hr 120 mg................................... 42
diltiazem hcl cap sr 24hr 180 mg................................... 42
diltiazem hcl cap sr 24hr 240 mg................................... 42
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................. 42
diltiazem hcl coated beads cap sr 24hr 180 mg
(Cardizem cd)................................................................. 42
diltiazem hcl coated beads cap sr 24hr 240 mg
(Cardizem cd)................................................................. 42
diltiazem hcl coated beads cap sr 24hr 300 mg
(Cardizem cd)................................................................. 42
diltiazem hcl coated beads cap sr 24hr 360 mg
(Cardizem cd)................................................................. 42
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la).................................................................. 42
diltiazem hcl coated beads tab sr 24hr 240 mg
(Cardizem la).................................................................. 42
diltiazem hcl coated beads tab sr 24hr 300 mg
(Cardizem la).................................................................. 42
diltiazem hcl coated beads tab sr 24hr 360 mg
(Cardizem la).................................................................. 42
188
diltiazem hcl coated beads tab sr 24hr 420 mg
(Cardizem la).................................................................. 42
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac)..................................................................... 43
diltiazem hcl extended release beads cap sr 24hr 180
mg (Tiazac)..................................................................... 43
diltiazem hcl extended release beads cap sr 24hr 240
mg (Tiazac)..................................................................... 43
diltiazem hcl extended release beads cap sr 24hr 300
mg (Tiazac)..................................................................... 43
diltiazem hcl extended release beads cap sr 24hr 360
mg (Tiazac)..................................................................... 43
diltiazem hcl extended release beads cap sr 24hr 420
mg (Tiazac)..................................................................... 43
diltiazem hcl tab 120 mg (Cardizem)............................. 43
diltiazem hcl tab 30 mg (Cardizem)............................... 43
diltiazem hcl tab 60 mg (Cardizem)............................... 43
diltiazem hcl tab 90 mg...................................................43
DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-12.5
mg.................................................................................... 47
DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-25
mg.................................................................................... 47
DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-12.5
mg.................................................................................... 47
DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-25
mg.................................................................................... 48
DIOVAN HCT -valsartan-hydrochlorothiazide tab 80-12.5
mg.................................................................................... 47
DIOVAN -valsartan tab 160 mg.........................................47
DIOVAN -valsartan tab 320 mg.........................................47
DIOVAN -valsartan tab 40 mg...........................................47
DIOVAN -valsartan tab 80 mg...........................................47
DIPENTUM -olsalazine sodium cap 250 mg..................... 70
DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine
liq 2.5-0.025 mg/5ml........................................................ 66
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil).......................................................................... 66
DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox
adsorbed (dt) im inj 25-5 unit/0.5ml................................. 15
DIPROLENE AF -betamethasone dipropionate augmented
cream 0.05%..................................................................149
DIPROLENE -betamethasone dipropionate augmented
lotion 0.05%................................................................... 149
DIPROLENE -betamethasone dipropionate augmented
oint 0.05%...................................................................... 149
dipyridamole tab 25 mg (Persantine)...........................134
dipyridamole tab 50 mg (Persantine)...........................134
dipyridamole tab 75 mg (Persantine)...........................134
DISALCID -salsalate tab 500 mg...................................... 93
DISALCID -salsalate tab 750 mg...................................... 93
disopyramide phosphate cap 100 mg (Norpace).......... 44
disopyramide phosphate cap 150 mg (Norpace).......... 44
disulfiram tab 250 mg (Antabuse)..................................90
disulfiram tab 500 mg (Antabuse)..................................90
DITROPAN XL -oxybutynin chloride tab sr 24hr 10 mg..... 73
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
DITROPAN XL -oxybutynin chloride tab sr 24hr 15 mg..... 73
DITROPAN XL -oxybutynin chloride tab sr 24hr 5 mg.......73
DIURIL -chlorothiazide susp 250 mg/5ml.......................... 53
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles)...................................................................... 107
divalproex sodium tab delayed release 125 mg
(Depakote).....................................................................107
divalproex sodium tab delayed release 250 mg
(Depakote).....................................................................107
divalproex sodium tab delayed release 500 mg
(Depakote).....................................................................107
divalproex sodium tab sr 24 hr 250 mg (Depakote
er)...................................................................................107
divalproex sodium tab sr 24 hr 500 mg (Depakote
er)...................................................................................107
DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)............ 22
DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)................ 22
DIVIGEL -estradiol td gel 1 mg/gm (0.1%)........................ 22
DIVISTA -folic acid-vit b6-vit b12-omega 3-biotin-cr cap 1
mg.................................................................................. 129
DOLOPHINE HCL -methadone hcl tab 5 mg.................... 95
DOLOPHINE -methadone hcl tab 10 mg...........................95
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt)............................................................. 90
donepezil hydrochloride orally disintegrating tab 5
mg.................................................................................... 90
donepezil hydrochloride tab 10 mg (Aricept)................90
donepezil hydrochloride tab 23 mg (Aricept)................90
donepezil hydrochloride tab 5 mg (Aricept)..................90
DONNATAL EXTENTABS -pb-hyoscy-atrop-scopol tab cr
48.6-0.3111-0.0582-0.0195 mg........................................67
DONNATAL -pb-hyoscy-atrop-scopol elix
16.2-0.1037-0.0194-0.0065 mg/5ml.................................67
DONNATAL -pb-hyoscy-atrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg........................................67
DORAL -quazepam tab 15 mg.......................................... 84
DORYX -doxycycline hyclate tab delayed release 200
mg...................................................................................... 4
DORYX -doxycycline hyclate tab delayed release 50
mg...................................................................................... 4
dorzolamide hcl ophth soln 2% (Trusopt)................... 138
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt).............................................................138
DOVONEX -calcipotriene cream 0.005%........................ 149
doxazosin mesylate tab 1 mg (Cardura)........................48
doxazosin mesylate tab 2 mg (Cardura)........................48
doxazosin mesylate tab 4 mg (Cardura)........................48
doxazosin mesylate tab 8 mg (Cardura)........................48
doxepin hcl cap 100 mg..................................................77
doxepin hcl cap 10 mg................................................... 77
doxepin hcl cap 150 mg..................................................77
doxepin hcl cap 25 mg................................................... 77
doxepin hcl cap 50 mg................................................... 77
doxepin hcl conc 10 mg/ml............................................ 77
DOXEPIN HCL -doxepin hcl cap 75 mg............................77
doxercalciferol cap 0.5 mcg (Hectorol)......................... 36
doxercalciferol cap 1 mcg (Hectorol)............................ 36
doxercalciferol cap 2.5 mcg (Hectorol)......................... 36
DOXYCYCLINE -doxycycline (rosacea) cap delayed
release 40 mg................................................................ 149
doxycycline hyclate cap 100 mg (Vibramycin)............... 4
doxycycline hyclate cap 50 mg........................................4
doxycycline hyclate tab 100 mg.......................................4
doxycycline hyclate tab 20 mg.........................................4
doxycycline hyclate tab delayed release 100 mg........... 4
doxycycline hyclate tab delayed release 150 mg
(Doryx)...............................................................................4
doxycycline hyclate tab delayed release 75 mg............. 4
doxycycline monohydrate cap 100 mg (Monodox).........4
doxycycline monohydrate cap 150 mg (Adoxa)............. 4
doxycycline monohydrate cap 50 mg..............................4
doxycycline monohydrate cap 75 mg (Monodox)...........4
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)......................................................................4
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100)................................................................................. 4
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150)................................................................................. 4
doxycycline monohydrate tab 50 mg (Adoxa)................ 4
doxycycline monohydrate tab 75 mg (Adoxa)................ 4
DRISDOL -ergocalciferol cap 50000 unit........................ 115
DRITHO-CREME HP -anthralin cream 1%......................150
dronabinol cap 10 mg (Marinol)..................................... 69
dronabinol cap 2.5 mg (Marinol).................................... 69
dronabinol cap 5 mg (Marinol)....................................... 69
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)......24
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28).................................................................................... 24
DROXIA -hydroxyurea cap 200 mg................................. 129
DROXIA -hydroxyurea cap 300 mg................................. 129
DROXIA -hydroxyurea cap 400 mg................................. 129
DRUG MART GLUCOSE -glucose chew tab 4 gm........... 27
DRUG MART GLUCOSE -glucose-vitamin c chew tab
4-0.006 gm.......................................................................27
DRYSOL -aluminum chloride soln 20%...........................150
DUAC -clindamycin phosph-benzoyl peroxide (refrig) gel
1.2 (1)-5%...................................................................... 150
DUAVEE -conjugated estrogens-bazedoxifene tab 0.45-20
mg.................................................................................... 22
DUETACT -pioglitazone hcl-glimepiride tab 30-2 mg........ 27
DUETACT -pioglitazone hcl-glimepiride tab 30-4 mg........ 28
DUET DHA 400 -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg........................................................116
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
25-1 & omega cap 267 mg............................................116
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 380mg.........................................116
DUET DHA -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg........................................................116
DUEXIS -ibuprofen-famotidine tab 800-26.6 mg............. 102
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
189
2015
DULERA -mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act..................................................... 63
DULERA -mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act..................................................... 63
DULOXETINE HCL -duloxetine hcl enteric coated pellets
cap 40 mg........................................................................77
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta).......................................................................77
duloxetine hcl enteric coated pellets cap 30 mg
(Cymbalta).......................................................................77
duloxetine hcl enteric coated pellets cap 60 mg
(Cymbalta).......................................................................77
DUOPA -carbidopa-levodopa enteral susp 4.63-20 mg/
ml....................................................................................111
DURACHOL -folic acid-cholecalciferol cap 1 mg-3775
unit..................................................................................129
DURAGESIC -fentanyl td patch 72hr 100 mcg/hr..............95
DURAGESIC -fentanyl td patch 72hr 12 mcg/hr................95
DURAGESIC -fentanyl td patch 72hr 25 mcg/hr................95
DURAGESIC -fentanyl td patch 72hr 50 mcg/hr................95
DURAGESIC -fentanyl td patch 72hr 75 mcg/hr................95
DUREZOL -difluprednate ophth emulsion 0.05%............ 138
DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr
100-12.5 mg.....................................................................48
DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr
25-12.5 mg.......................................................................48
DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr
50-12.5 mg.......................................................................48
D-VI-SOL -cholecalciferol oral liquid 400 unit/ml............. 115
DYAZIDE -triamterene & hydrochlorothiazide cap 37.5-25
mg.................................................................................... 53
DYMISTA -azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act................................................................ 59
dyphylline-guaifenesin liqd 100-100 mg/5ml.................63
DYRENIUM -triamterene cap 100 mg............................... 53
DYRENIUM -triamterene cap 50 mg................................. 53
E
E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg.......... 3
E.E.S. GRANULES -erythromycin ethylsuccinate for susp
200 mg/5ml........................................................................ 3
EC-NAPROSYN -naproxen tab ec 375 mg..................... 102
EC-NAPROSYN -naproxen tab ec 500 mg..................... 102
econazole nitrate cream 1%......................................... 150
ECOZA -econazole nitrate foam 1%............................... 150
EDARBI -azilsartan medoxomil tab 40 mg........................ 48
EDARBI -azilsartan medoxomil tab 80 mg........................ 48
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-12.5 mg.......................................................................48
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-25 mg..........................................................................48
ED CYTE F -ferrous fumarate-folic acid-docusate sodium
tab 324-1-50 mg............................................................ 129
EDECRIN -ethacrynic acid tab 25 mg............................... 53
EDLUAR -zolpidem tartrate sl tab 10 mg.......................... 84
EDLUAR -zolpidem tartrate sl tab 5 mg............................ 84
190
EDURANT -rilpivirine hcl tab 25 mg (base equivalent)........ 7
EFFER-K -potassium bicarbonate-citric acid effer tab 10
meq................................................................................ 124
EFFER-K -potassium bicarbonate-citric acid effer tab 20
meq................................................................................ 124
EFFEXOR XR -venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)........................................................................77
EFFEXOR XR -venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)........................................................................77
EFFEXOR XR -venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)........................................................................77
EFFIENT -prasugrel hcl tab 10 mg (base equiv)............. 134
EFFIENT -prasugrel hcl tab 5 mg (base equiv)............... 134
EFUDEX -fluorouracil cream 5%..................................... 150
EGRIFTA -tesamorelin acetate for inj 1 mg (base
equiv)................................................................................36
EGRIFTA -tesamorelin acetate for inj 2 mg (base
equiv)................................................................................36
ELDEPRYL -selegiline hcl cap 5 mg............................... 111
ELENZAPATCH -lidocaine-menthol patch 4-1%............. 150
ELESTAT -epinastine hcl ophth soln 0.05%....................138
ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)........................................................22
ELETONE -dermatological products misc - cream.......... 150
ELETONE TWINPACK -dermatological products misc cream............................................................................. 150
ELIDEL -pimecrolimus cream 1%....................................150
ELIGARD -leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg................................................................... 16
ELIGARD -leuprolide acetate (4 month) for subcutaneous
inj kit 30 mg..................................................................... 16
ELIGARD -leuprolide acetate (6 month) for subcutaneous
inj kit 45 mg..................................................................... 17
ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5
mg.................................................................................... 16
ELIGEN B12 -cyanocobalamin-salcaprozate sodium tab
1000 mcg-100 mg..........................................................126
ELIMITE -permethrin cream 5%...................................... 150
ELIPHOS -calcium acetate (phosphate binder) tab 667
mg.................................................................................... 70
ELIQUIS -apixaban tab 2.5 mg....................................... 132
ELIQUIS -apixaban tab 5 mg.......................................... 132
ELITE-OB -prenatal vit w/ iron carbonyl-fa tab 50-1.25
mg.................................................................................. 116
ELIXOPHYLLIN -theophylline elixir 80 mg/15ml................63
ELLA -ulipristal acetate tab 30 mg.................................... 24
ELMIRON -pentosan polysulfate sodium caps 100 mg..... 74
ELOCON -mometasone furoate cream 0.1%.................. 150
ELOCON -mometasone furoate oint 0.1%...................... 150
ELOCON -mometasone furoate solution 0.1%
(lotion)............................................................................ 150
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
1000 unit........................................................................ 134
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
1500 unit........................................................................ 134
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
2000 unit........................................................................ 134
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
250 unit.......................................................................... 134
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
3000 unit........................................................................ 134
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
500 unit.......................................................................... 134
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
750 unit.......................................................................... 134
EMADINE -emedastine difumarate ophth soln 0.05%
(base equiv)................................................................... 138
EMBEDA -morphine-naltrexone cap cr 100-4 mg............. 95
EMBEDA -morphine-naltrexone cap cr 20-0.8 mg.............95
EMBEDA -morphine-naltrexone cap cr 30-1.2 mg.............95
EMBEDA -morphine-naltrexone cap cr 50-2 mg............... 95
EMBEDA -morphine-naltrexone cap cr 60-2.4 mg.............95
EMBEDA -morphine-naltrexone cap cr 80-3.2 mg.............95
EMCYT -estramustine phosphate sodium cap 140 mg......17
EMEND -aprepitant capsule 125 mg................................. 69
EMEND -aprepitant capsule 40 mg...................................69
EMEND -aprepitant capsule 80 mg...................................69
EMEND -aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 69
EMLA -lidocaine-prilocaine cream 2.5-2.5%....................150
EMSAM -selegiline td patch 24hr 12 mg/24hr................... 77
EMSAM -selegiline td patch 24hr 6 mg/24hr..................... 77
EMSAM -selegiline td patch 24hr 9 mg/24hr..................... 77
EMTRIVA -emtricitabine caps 200 mg................................ 7
EMTRIVA -emtricitabine soln 10 mg/ml...............................7
EMULSION SB -dermatological products misc emulsion......................................................................... 150
ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv)..................................................................... 73
ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv)..................................................................... 73
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)....................................................................... 48
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg.................................................................................... 48
enalapril maleate tab 10 mg (Vasotec).......................... 48
enalapril maleate tab 2.5 mg (Vasotec)......................... 48
enalapril maleate tab 20 mg (Vasotec).......................... 48
enalapril maleate tab 5 mg (Vasotec)............................ 48
ENBRACE HR -prenatal vit w/ fe gly cys-fa-omega 3 fatty
acids cap........................................................................116
ENBREL -etanercept for subcutaneous inj kit 25 mg.......102
ENBREL -etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml................................................................... 102
ENBREL -etanercept subcutaneous soln prefilled syringe
50 mg/ml........................................................................ 102
ENBREL SURECLICK -etanercept subcutaneous solution
auto-injector 50 mg/ml................................................... 102
ENGERIX-B -hepatitis b vaccine (recombinant) 10
mcg/0.5ml.........................................................................13
ENGERIX-B -hepatitis b vaccine (recombinant) 20 mcg/
ml......................................................................................13
ENGERIX-B -hepatitis b vaccine (recombinant) susp 10
mcg/0.5ml.........................................................................13
ENGERIX-B -hepatitis b vaccine (recombinant) susp 20
mcg/ml..............................................................................13
ENJUVIA -estrogens, conjugated synthetic b tab 0.3
mg.................................................................................... 22
ENJUVIA -estrogens, conjugated synthetic b tab 0.45
mg.................................................................................... 22
ENJUVIA -estrogens, conjugated synthetic b tab 0.625
mg.................................................................................... 22
ENJUVIA -estrogens, conjugated synthetic b tab 0.9
mg.................................................................................... 22
ENJUVIA -estrogens, conjugated synthetic b tab 1.25
mg.................................................................................... 22
enoxaparin sodium inj 100 mg/ml (Lovenox).............. 132
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)......... 132
enoxaparin sodium inj 150 mg/ml (Lovenox).............. 132
enoxaparin sodium inj 300 mg/3ml (Lovenox)............ 132
enoxaparin sodium inj 30 mg/0.3ml (Lovenox)........... 132
enoxaparin sodium inj 40 mg/0.4ml (Lovenox)........... 132
enoxaparin sodium inj 60 mg/0.6ml (Lovenox)........... 132
enoxaparin sodium inj 80 mg/0.8ml (Lovenox)........... 132
entacapone tab 200 mg (Comtan)................................ 111
entecavir tab 0.5 mg (Baraclude)..................................... 7
entecavir tab 1 mg (Baraclude)........................................ 7
ENTERAGAM -serum-derived bovine immunoglob/protein
isolate 5 gm packet....................................................... 126
ENTEREG -alvimopan cap 12 mg.....................................70
ENTOCORT EC -budesonide cap sr 24hr 3 mg................20
ENTRESTO -sacubitril-valsartan tab 24-26 mg................. 57
ENTRESTO -sacubitril-valsartan tab 49-51 mg................. 57
ENTRESTO -sacubitril-valsartan tab 97-103 mg............... 57
EPANED -enalapril maleate for oral soln 1 mg/ml.............48
EPICERAM -dermatological products misc emulsion......................................................................... 150
EPIDUO -adapalene-benzoyl peroxide gel 0.1-2.5%.......150
EPIDUO FORTE -adapalene-benzoyl peroxide gel
0.3-2.5%......................................................................... 150
EPIFOAM -pramoxine-hc aerosol foam 1-1%................. 150
epinastine hcl ophth soln 0.05% (Elestat)................... 138
EPINEPHRINE -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000).......................................................... 53
EPINEPHRINE -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................54
EPIPEN 2-PAK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................54
EPIPEN-JR 2-PAK -epinephrine solution auto-injector 0.15
mg/0.3ml (1:2000)............................................................54
EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)................8
EPIVIR HBV -lamivudine tab 100 mg (hbv).........................8
EPIVIR -lamivudine oral soln 10 mg/ml...............................7
EPIVIR -lamivudine tab 150 mg.......................................... 7
EPIVIR -lamivudine tab 300 mg.......................................... 7
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
191
2015
eplerenone tab 25 mg (Inspra)....................................... 48
eplerenone tab 50 mg (Inspra)....................................... 48
EPOGEN -epoetin alfa inj 10000 unit/ml......................... 129
EPOGEN -epoetin alfa inj 20000 unit/ml......................... 129
EPOGEN -epoetin alfa inj 2000 unit/ml........................... 129
EPOGEN -epoetin alfa inj 3000 unit/ml........................... 129
EPOGEN -epoetin alfa inj 4000 unit/ml........................... 129
EPROSARTAN MESYLATE -eprosartan mesylate tab 600
mg.................................................................................... 48
EPZICOM -abacavir sulfate-lamivudine tab 600-300 mg.....8
EQUAGESIC -meprobamate-aspirin tab 200-325 mg....... 93
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
100 mg............................................................................. 81
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
200 mg............................................................................. 81
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
300 mg............................................................................. 81
ergocalciferol cap 50000 unit (Drisdol)........................115
ergoloid mesylates tab 1 mg.......................................... 90
ERGOMAR -ergotamine tartrate sl tab 2 mg...................104
ERIVEDGE -vismodegib cap 150 mg................................17
ERTACZO -sertaconazole nitrate cream 2%...................150
ERYGEL -erythromycin gel 2%....................................... 150
ERYPED 200 -erythromycin ethylsuccinate for susp 200
mg/5ml................................................................................3
ERYPED 400 -erythromycin ethylsuccinate for susp 400
mg/5ml................................................................................3
ERY-TAB -erythromycin tab delayed release 250 mg......... 3
ERY-TAB -erythromycin tab delayed release 333 mg......... 3
ERY-TAB -erythromycin tab delayed release 500 mg......... 3
ERYTHROCIN STEARATE -erythromycin stearate tab 250
mg...................................................................................... 3
ERYTHROMYCIN BASE -erythromycin tab 250 mg........... 3
ERYTHROMYCIN BASE -erythromycin tab 500 mg........... 3
ERYTHROMYCIN ETHYLSUCCINA -erythromycin
ethylsuccinate tab 400 mg.................................................3
erythromycin gel 2% (Erygel)....................................... 150
erythromycin ophth oint 5 mg/gm............................... 138
erythromycin pads 2%.................................................. 150
erythromycin soln 2%................................................... 150
erythromycin w/ delayed release particles cap 250
mg...................................................................................... 3
ESBRIET -pirfenidone cap 267 mg................................... 65
ESCAVITE D -pediatric multiple vitamins w/ fl-fe chew tab
0.25-6 mg.......................................................................116
ESCAVITE LQ -pediatric multiple vitamins w/ fl-fe drops
0.25-6 mg/ml.................................................................. 116
ESCAVITE -pediatric multiple vitamins w/ fl-fe chew tab
0.25-7.5 mg....................................................................116
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)......................................................................... 77
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro)......................................................................... 77
escitalopram oxalate tab 20 mg (base equiv)
(Lexapro)......................................................................... 78
192
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro)......................................................................... 77
ESGIC -butalbital-acetaminophen-caffeine tab 50-325-40
mg.................................................................................... 93
esomeprazole magnesium cap delayed release 20 mg
(base eq) (Nexium).........................................................67
esomeprazole magnesium cap delayed release 40 mg
(base eq) (Nexium).........................................................67
ESSENTRA WIPES 9X9" CLEAN -isopropyl alcohol wipes
70%................................................................................ 150
estazolam tab 1 mg......................................................... 84
estazolam tab 2 mg......................................................... 84
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................. 22
esterified estrogens & methyltestosterone tab 1.25-2.5
mg.................................................................................... 23
ESTRACE -estradiol tab 0.5 mg........................................23
ESTRACE -estradiol tab 1 mg.......................................... 23
ESTRACE -estradiol tab 2 mg.......................................... 23
ESTRACE -estradiol vaginal cream 0.1 mg/gm.................73
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)........................................................................ 23
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)........................................................................ 23
estradiol tab 0.5 mg (Estrace)........................................ 23
estradiol tab 1 mg (Estrace)........................................... 23
estradiol tab 2 mg (Estrace)........................................... 23
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot)...................................................................................23
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot).....................................................................23
estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot)...................................................................................23
estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot)...................................................................................23
estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot)...................................................................................23
estradiol td patch weekly 0.025 mg/24hr (Climara).......23
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)....................................................... 23
estradiol td patch weekly 0.05 mg/24hr (Climara).........23
estradiol td patch weekly 0.06 mg/24hr (Climara).........23
estradiol td patch weekly 0.075 mg/24hr (Climara).......23
estradiol td patch weekly 0.1 mg/24hr (Climara)...........23
ESTRING -estradiol vaginal ring 2 mg (7.5 mcg/24hrs).....73
ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)........................................................23
ESTROPIPATE -estropipate tab 3 mg.............................. 23
estropipate tab 0.75 mg.................................................. 23
estropipate tab 1.5 mg.................................................... 23
ESTROSTEP FE -norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg....................................................24
eszopiclone tab 1 mg (Lunesta).....................................84
eszopiclone tab 2 mg (Lunesta).....................................84
eszopiclone tab 3 mg (Lunesta).....................................84
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
ethambutol hcl tab 100 mg (Myambutol).........................6
ethambutol hcl tab 400 mg (Myambutol).........................6
ethosuximide cap 250 mg (Zarontin)........................... 107
ethosuximide soln 250 mg/5ml (Zarontin)...................107
ETHYL CHLORIDE/FINE PINPO -ethyl chloride aerosol
spray...............................................................................150
ETHYL CHLORIDE/FINE STREA -ethyl chloride aerosol
spray...............................................................................150
ETHYL CHLORIDE/MEDIUM JET -ethyl chloride aerosol
spray...............................................................................150
ETHYL CHLORIDE/MEDIUM STR -ethyl chloride aerosol
spray...............................................................................150
ETHYL CHLORIDE/MIST -ethyl chloride aerosol
spray...............................................................................150
ETHYL CHLORIDE -ethyl chloride aerosol spray............150
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg.................................................................................. 24
ETIDRONATE DISODIUM -etidronate disodium tab 200
mg.................................................................................... 36
ETIDRONATE DISODIUM -etidronate disodium tab 400
mg.................................................................................... 36
etodolac cap 200 mg..................................................... 102
etodolac cap 300 mg..................................................... 102
etodolac tab 400 mg......................................................102
etodolac tab 500 mg......................................................102
etodolac tab sr 24hr 400 mg.........................................102
etodolac tab sr 24hr 500 mg.........................................102
etodolac tab sr 24hr 600 mg.........................................102
ETOPOSIDE -etoposide cap 50 mg..................................17
EURAX -crotamiton cream 10%...................................... 150
EURAX -crotamiton lotion 10%....................................... 150
EVAMIST -estradiol transdermal spray 1.53 mg/spray...... 23
EVEKEO -amphetamine sulfate tab 10 mg....................... 87
EVEKEO -amphetamine sulfate tab 5 mg......................... 87
EVISTA -raloxifene hcl tab 60 mg..................................... 36
EVOCLIN -clindamycin phosphate foam 1%................... 150
EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv)....................................................................... 8
EVOXAC -cevimeline hcl cap 30 mg...............................142
EVZIO -naloxone hcl solution auto-injector 0.4
mg/0.4ml.........................................................................163
EXACTUSS -phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml..............................................................................60
EXALGO -hydromorphone hcl tab er 24hr deter 12 mg.....95
EXALGO -hydromorphone hcl tab er 24hr deter 16 mg.....95
EXALGO -hydromorphone hcl tab er 24hr deter 32 mg.....95
EXALGO -hydromorphone hcl tab er 24hr deter 8 mg.......95
EXELDERM -sulconazole nitrate cream 1%....................150
EXELDERM -sulconazole nitrate solution 1%................. 150
EXELON -rivastigmine tartrate cap 1.5 mg....................... 90
EXELON -rivastigmine tartrate cap 3 mg.......................... 90
EXELON -rivastigmine tartrate cap 4.5 mg....................... 90
EXELON -rivastigmine tartrate cap 6 mg.......................... 90
EXELON -rivastigmine td patch 24hr 13.3 mg/24hr...........90
EXELON -rivastigmine td patch 24hr 4.6 mg/24hr.............90
EXELON -rivastigmine td patch 24hr 9.5 mg/24hr.............90
exemestane tab 25 mg (Aromasin)................................ 17
EXFORGE -amlodipine besylate-valsartan tab 10-160
mg.................................................................................... 48
EXFORGE -amlodipine besylate-valsartan tab 10-320
mg.................................................................................... 48
EXFORGE -amlodipine besylate-valsartan tab 5-160
mg.................................................................................... 48
EXFORGE -amlodipine besylate-valsartan tab 5-320
mg.................................................................................... 48
EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide
tab 10-160-12.5 mg......................................................... 48
EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide
tab 10-160-25 mg............................................................ 48
EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide
tab 10-320-25 mg............................................................ 48
EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide
tab 5-160-12.5 mg........................................................... 48
EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide
tab 5-160-25 mg.............................................................. 48
EXJADE -deferasirox tab for oral susp 125 mg............... 163
EXJADE -deferasirox tab for oral susp 250 mg............... 163
EXJADE -deferasirox tab for oral susp 500 mg............... 163
EXODERM -sodium thiosulfate-salicylic acid lotion
25-1%............................................................................. 150
EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 90
EXTINA -ketoconazole foam 2%..................................... 150
EXTRA-VIRT PLUS DHA -prenatal w/o vit a w/ fe fum-docfa-dha cap 29-1.25-350 mg........................................... 116
F
FA-8 -folic acid cap 0.8 mg............................................. 129
FABIOR -tazarotene (acne) foam 0.1%...........................150
FACTIVE -gemifloxacin mesylate tab 320 mg (base
equiv)..................................................................................5
FALESSA -levomefolate glucosamine tab 1 mg (folate
equivalent)......................................................................126
FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa
tab 1 mg kit......................................................................24
famciclovir tab 125 mg (Famvir)...................................... 8
famciclovir tab 250 mg (Famvir)...................................... 8
famciclovir tab 500 mg (Famvir)...................................... 8
famotidine for susp 40 mg/5ml (Pepcid)....................... 67
famotidine tab 40 mg (Pepcid)....................................... 67
FAMVIR -famciclovir tab 125 mg.........................................8
FAMVIR -famciclovir tab 250 mg.........................................8
FAMVIR -famciclovir tab 500 mg.........................................8
FANAPT -iloperidone tab 10 mg....................................... 81
FANAPT -iloperidone tab 12 mg....................................... 81
FANAPT -iloperidone tab 1 mg......................................... 81
FANAPT -iloperidone tab 2 mg......................................... 81
FANAPT -iloperidone tab 4 mg......................................... 81
FANAPT -iloperidone tab 6 mg......................................... 81
FANAPT -iloperidone tab 8 mg......................................... 81
FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak............................................ 81
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
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2015
FARESTON -toremifene citrate tab 60 mg (base
equivalent)........................................................................17
FARXIGA -dapagliflozin propanediol tab 10 mg (base
equivalent)........................................................................28
FARYDAK -panobinostat lactate cap 10 mg (base
equivalent)........................................................................17
FARYDAK -panobinostat lactate cap 15 mg (base
equivalent)........................................................................17
FARYDAK -panobinostat lactate cap 20 mg (base
equivalent)........................................................................17
FAZACLO -clozapine orally disintegrating tab 100 mg...... 82
FAZACLO -clozapine orally disintegrating tab 12.5 mg..... 81
FAZACLO -clozapine orally disintegrating tab 150 mg...... 82
FAZACLO -clozapine orally disintegrating tab 200 mg...... 82
FAZACLO -clozapine orally disintegrating tab 25 mg........ 82
FE 90 PLUS -fe carbonyl-fe gluconate-fa-vit b12-vit c-dss
tab 90-1 mg................................................................... 129
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
mg.................................................................................. 129
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg.................................................................................. 129
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu
cap (Tandem plus)....................................................... 129
FEIBA -antiinhibitor coagulant complex for inj................. 134
FEIBA NF -antiinhibitor coagulant complex for inj........... 134
felbamate susp 600 mg/5ml (Felbatol).........................107
felbamate tab 400 mg (Felbatol)...................................107
felbamate tab 600 mg (Felbatol)...................................107
FELBATOL -felbamate susp 600 mg/5ml........................ 107
FELBATOL -felbamate tab 400 mg................................. 107
FELBATOL -felbamate tab 600 mg................................. 107
FELDENE -piroxicam cap 10 mg.................................... 102
FELDENE -piroxicam cap 20 mg.................................... 102
felodipine tab sr 24hr 10 mg.......................................... 43
felodipine tab sr 24hr 2.5 mg......................................... 43
felodipine tab sr 24hr 5 mg............................................ 43
FEMARA -letrozole tab 2.5 mg......................................... 17
FEMCON FE -norethindrone & ethinyl estradiol-fe chew
tab 0.4 mg-35 mcg.......................................................... 24
FEMHRT LOW DOSE -norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg........................................... 23
FEM PH -acetic acid-oxyquinoline vaginal gel
0.9-0.025%....................................................................... 73
FEMRING -estradiol acetate vaginal ring 0.05
mg/24hr............................................................................ 73
FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr...... 73
FENOFIBRATE -fenofibrate cap 150 mg.......................... 54
FENOFIBRATE -fenofibrate cap 50 mg............................ 54
FENOFIBRATE -fenofibrate tab 120 mg........................... 54
fenofibrate micronized cap 130 mg............................... 55
fenofibrate micronized cap 134 mg (Lofibra)................ 55
fenofibrate micronized cap 200 mg (Lofibra)................ 55
fenofibrate micronized cap 43 mg................................. 55
fenofibrate micronized cap 67 mg (Lofibra).................. 55
fenofibrate tab 145 mg (Tricor)...................................... 55
194
fenofibrate tab 160 mg (Lofibra).................................... 55
fenofibrate tab 48 mg (Tricor)........................................ 55
fenofibrate tab 54 mg (Lofibra)...................................... 55
FENOFIBRIC ACID -fenofibric acid tab 105 mg................ 55
FENOFIBRIC ACID -fenofibric acid tab 35 mg.................. 55
FENOGLIDE -fenofibrate tab 120 mg................................55
FENOGLIDE -fenofibrate tab 40 mg................................. 55
FENOPROFEN CALCIUM -fenoprofen calcium cap 400
mg.................................................................................. 102
FENOPROFEN CALCIUM -fenoprofen calcium tab 600
mg.................................................................................. 102
fentanyl citrate lozenge on a handle 1200 mcg
(Actiq).............................................................................. 95
fentanyl citrate lozenge on a handle 1600 mcg
(Actiq).............................................................................. 95
fentanyl citrate lozenge on a handle 200 mcg
(Actiq).............................................................................. 95
fentanyl citrate lozenge on a handle 400 mcg
(Actiq).............................................................................. 95
fentanyl citrate lozenge on a handle 600 mcg
(Actiq).............................................................................. 95
fentanyl citrate lozenge on a handle 800 mcg
(Actiq).............................................................................. 95
FENTANYL -fentanyl td patch 72hr 37.5 mcg/hr............... 95
FENTANYL -fentanyl td patch 72hr 62.5 mcg/hr............... 95
FENTANYL -fentanyl td patch 72hr 87.5 mcg/hr............... 95
fentanyl td patch 72hr 100 mcg/hr (Duragesic).............96
fentanyl td patch 72hr 12 mcg/hr (Duragesic)...............95
fentanyl td patch 72hr 25 mcg/hr (Duragesic)...............95
fentanyl td patch 72hr 50 mcg/hr (Duragesic)...............96
fentanyl td patch 72hr 75 mcg/hr (Duragesic)...............96
FENTORA -fentanyl citrate buccal tab 100 mcg (base
equiv)................................................................................96
FENTORA -fentanyl citrate buccal tab 200 mcg (base
equiv)................................................................................96
FENTORA -fentanyl citrate buccal tab 400 mcg (base
equiv)................................................................................96
FENTORA -fentanyl citrate buccal tab 600 mcg (base
equiv)................................................................................96
FENTORA -fentanyl citrate buccal tab 800 mcg (base
equiv)................................................................................96
FER-IN-SOL -ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe).................................................................. 129
FERIVA 21/7 -fe asparto gly-b12-fa-c-dss-succinic acid-zn
tab 75-1 mg................................................................... 129
FERIVAFA -iron-c-fa-b12-biotin-copper-docusate cap
110-1 mg........................................................................129
FERIVA -fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap
75-1 mg..........................................................................129
FERRALET 90 -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg.............................................................129
FERRAPLUS 90 -iron-folic acid-vit b12-vit c-docusate sod
tab 90-1 mg................................................................... 129
FERRETTS CHEWABLE IRON -carbonyl iron chew tab 18
mg (elemental iron)........................................................129
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
FERREX 150 FORTE PLUS -fe asp gly-fe polysacch-succ
ac-c-threon ac-b12-fa cap..............................................129
FERREX 28 -fe asparto gly-fe fum-b12-fa-c-succinic ac tab
ther pack........................................................................ 129
FERRIPROX -deferiprone tab 500 mg............................ 163
FERRO-PLEX HEMATINIC -fe fum-dss-vit c-vit e-vit b12if-fa tab 115-1 mg.......................................................... 129
FERROTRIN -iron w/ b12-vit c-fa-ifc cap
36-0.015-75-0.5-240 mg................................................ 129
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab
106-1 mg....................................................................... 129
ferrous fumarate-folic acid tab 324-1 mg.................... 129
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe)................................................................................... 129
FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)...............................................129
FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml
(60 mg/5ml elemental fe)...............................................129
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe)................................................................................... 129
FETZIMA -levomilnacipran hcl cap sr 24hr 120 mg (base
equivalent)........................................................................78
FETZIMA -levomilnacipran hcl cap sr 24hr 20 mg (base
equivalent)........................................................................78
FETZIMA -levomilnacipran hcl cap sr 24hr 40 mg (base
equivalent)........................................................................78
FETZIMA -levomilnacipran hcl cap sr 24hr 80 mg (base
equivalent)........................................................................78
FETZIMA TITRATION PACK -levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack........................................ 78
FEXMID -cyclobenzaprine hcl tab 7.5 mg....................... 114
FIBRICOR -fenofibric acid tab 105 mg..............................55
FIBRICOR -fenofibric acid tab 35 mg................................55
FINACEA -azelaic acid gel 15%......................................150
finasteride tab 5 mg (Proscar)........................................74
FIORICET/CODEINE -butalbital-acetaminophen-caff w/
cod cap 50-300-40-30 mg............................................... 96
FIORICET -butalbital-acetaminophen-caffeine cap
50-300-40 mg...................................................................93
FIORICET -butalbital-acetaminophen-caffeine tab
50-325-40 mg...................................................................93
FIORINAL/CODEINE #3 -butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg...................................................... 96
FIORINAL -butalbital-aspirin-caffeine cap 50-325-40
mg.................................................................................... 93
FIRAZYR -icatibant acetate inj 30 mg/3ml (base
equivalent)......................................................................134
FIRST-HYDROCORTISONE -hydrocortisone gel 10%
(cmpd kit)....................................................................... 150
FIRST-LANSOPRAZOLE -lansoprazole susp 3 mg/ml
(compound kit)................................................................. 67
FIRST-OMEPRAZOLE -omeprazole susp 2 mg/ml
(compound kit)................................................................. 67
FLAGYL ER -metronidazole tab sr 24hr 750 mg............... 12
FLAGYL -metronidazole cap 375 mg................................ 12
FLAGYL -metronidazole tab 250 mg................................. 12
FLAGYL -metronidazole tab 500 mg................................. 12
FLAREX -fluorometholone acetate ophth susp 0.1%...... 138
flavoxate hcl tab 100 mg.................................................73
flaxseed oil-evening primrose-bilberry cap 1000-500-40
mg (Tears again hydrate)............................................ 126
flecainide acetate tab 100 mg.........................................44
flecainide acetate tab 150 mg.........................................44
flecainide acetate tab 50 mg.......................................... 44
FLECTOR -diclofenac epolamine patch 1.3%................. 150
FLEXIN -capsaicin-menthol topical patch 0.0375-5%......150
FLOMAX -tamsulosin hcl cap 0.4 mg................................74
FLONASE -fluticasone propionate nasal susp 50 mcg/
act.....................................................................................59
FLO-PRED -prednisolone acetate oral susp 16.7 mg/5ml
(15 mg/5ml base).............................................................20
FLORICAL -sodium fluoride w/ calcium carb cap 8.3-364
mg.................................................................................. 124
FLORICAL -sodium fluoride w/ calcium carb tab 8.3-364
mg.................................................................................. 124
FLORIVA -ped multiple vitamins & minerals w/ fl chew tab
0.5 mg............................................................................ 116
FLORIVA -ped multiple vitamins & minerals w/ fl chew tab
1 mg............................................................................... 116
FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/
ml-400 unit/ml................................................................ 124
FLOVENT DISKUS -fluticasone propionate aer pow ba
100 mcg/blister.................................................................63
FLOVENT DISKUS -fluticasone propionate aer pow ba
250 mcg/blister.................................................................63
FLOVENT DISKUS -fluticasone propionate aer pow ba 50
mcg/blister........................................................................ 63
FLOVENT HFA -fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)..........................................................63
FLOVENT HFA -fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)..........................................................63
FLOVENT HFA -fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)............................................................63
FLUARIX 2011-2012 -influenza virus vaccine split pf susp
pref syringe 0.5 ml...........................................................13
FLUARIX 2012-2013 -influenza virus vaccine split pf susp
pref syringe 0.5 ml...........................................................13
FLUARIX 2013-2014 -influenza virus vaccine split pf susp
pref syringe 0.5 ml...........................................................13
FLUARIX 2014-2015 -influenza virus vaccine split pf susp
pref syringe 0.5 ml...........................................................13
FLUARIX QUADRIVALENT 2013 -influenza virus vac split
quadrivalent susp pref syr 0.5ml......................................13
FLUARIX QUADRIVALENT 2014 -influenza virus vac split
quadrivalent susp pref syr 0.5ml......................................13
FLUARIX QUADRIVALENT 2015 -influenza virus vac split
quadrivalent susp pref syr 0.5ml......................................13
FLUBLOK 2013-2014 -influenza virus vac recombinant
hemagglutinin (ha) inj...................................................... 13
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
195
2015
FLUBLOK 2014-2015 -influenza virus vac recombinant
hemagglutinin (ha) inj...................................................... 13
FLUBLOK 2015-2016 -influenza virus vac recombinant
hemagglutinin (ha) inj...................................................... 13
FLUCELVAX 2012-2013 -influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml............................................ 13
FLUCELVAX 2013-2014 -influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml............................................ 13
FLUCELVAX 2014-2015 -influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml............................................ 13
FLUCELVAX 2015-2016 -influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml............................................ 13
fluconazole for susp 10 mg/ml (Diflucan)....................... 6
fluconazole for susp 40 mg/ml (Diflucan)....................... 6
fluconazole tab 100 mg (Diflucan)................................... 6
fluconazole tab 150 mg (Diflucan)................................... 6
fluconazole tab 200 mg (Diflucan)................................... 6
fluconazole tab 50 mg (Diflucan)..................................... 6
flucytosine cap 250 mg (Ancobon).................................. 6
flucytosine cap 500 mg (Ancobon).................................. 6
fludrocortisone acetate tab 0.1 mg................................ 20
FLULAVAL 2011-2012 -influenza virus vaccine split im
susp..................................................................................13
FLULAVAL 2012-2013 -influenza virus vaccine split im
susp..................................................................................13
FLULAVAL 2013-2014 -influenza virus vaccine split im
susp..................................................................................13
FLULAVAL 2014-2015 -influenza virus vaccine split im
susp..................................................................................13
FLULAVAL QUADRIVALENT 201 -influenza virus vaccine
split quadrivalent im inj.................................................... 13
FLULAVAL QUADRIVALENT 201 -influenza virus vac split
quadrivalent susp pref syr 0.5ml......................................13
FLUMADINE -rimantadine hydrochloride tab 100 mg..........8
FLUMIST QUADRIVALENT -influenza virus vaccine live
quadrivalent intranasal susp............................................ 14
FLUNISOLIDE -flunisolide nasal soln 25 mcg/act
(0.025%)...........................................................................59
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide).................................................................... 59
fluocinolone acetonide (otic) oil 0.01% (Dermotic).....141
fluocinolone acetonide cream 0.01%...........................150
fluocinolone acetonide cream 0.025% (Synalar).........150
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod)........................................................... 150
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)............................................................151
fluocinolone acetonide oint 0.025% (Synalar).............151
fluocinolone acetonide soln 0.01% (Synalar)..............151
fluocinonide cream 0.05%............................................ 151
fluocinonide cream 0.1% (Vanos)................................ 151
fluocinonide emulsified base cream 0.05%.................151
fluocinonide gel 0.05%..................................................151
fluocinonide oint 0.05%................................................ 151
fluocinonide soln 0.05%................................................151
196
FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf).........................................................124
FLUORAC -fluorouracil-diclofenac sodium cream
5-1%............................................................................... 151
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55 (0.25
mg f)-236.79 mg............................................................ 124
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 1.1 (0.5
mg f)-236.79 mg............................................................ 124
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg
f)-236.79 mg...................................................................124
FLUORIDEX DAILY DEFENSE S -sodium fluoridepotassium nitrate gel 1.1-5%......................................... 142
fluorometholone ophth susp 0.1% (Fml liquifilm).......138
FLUOROPLEX -fluorouracil cream 1%............................151
fluorouracil cream 5% (Efudex)....................................151
FLUOROURACIL -fluorouracil cream 0.5%.....................151
fluorouracil soln 2%...................................................... 151
fluorouracil soln 5%...................................................... 151
fluoxetine hcl (pmdd) cap 10 mg................................... 90
fluoxetine hcl (pmdd) cap 20 mg................................... 90
fluoxetine hcl cap 10 mg (Prozac)................................. 78
fluoxetine hcl cap 20 mg (Prozac)................................. 78
fluoxetine hcl cap 40 mg (Prozac)................................. 78
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly)............................................................................ 78
FLUOXETINE HCL -fluoxetine hcl tab 60 mg....................78
fluoxetine hcl solution 20 mg/5ml..................................78
fluoxetine hcl tab 10 mg................................................. 78
fluoxetine hcl tab 20 mg................................................. 78
FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5
mg/5ml..............................................................................82
FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/
ml......................................................................................82
fluphenazine hcl tab 10 mg............................................ 82
fluphenazine hcl tab 1 mg.............................................. 82
fluphenazine hcl tab 2.5 mg........................................... 82
fluphenazine hcl tab 5 mg.............................................. 82
FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f (from
0.55 mg/drop naf).......................................................... 124
FLURAZEPAM HCL -flurazepam hcl cap 15 mg............... 84
FLURAZEPAM HCL -flurazepam hcl cap 30 mg............... 84
flurbiprofen sodium ophth soln 0.03% (Ocufen).........138
flurbiprofen tab 100 mg................................................ 102
flurbiprofen tab 50 mg.................................................. 102
flutamide cap 125 mg......................................................17
fluticasone propionate cream 0.05% (Cutivate).......... 151
fluticasone propionate lotion 0.05% (Cutivate)...........151
fluticasone propionate nasal susp 50 mcg/act
(Flonase)......................................................................... 59
fluticasone propionate oint 0.005% (Cutivate)............ 151
fluvastatin sodium cap 20 mg (Lescol)......................... 55
fluvastatin sodium cap 40 mg (Lescol)......................... 55
FLUVIRIN 2011-2012 -influenza virus vaccine types a & b
surface antigen im susp...................................................14
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
FLUVIRIN 2012-2013 -influenza virus vaccine types a & b
surface antigen im susp...................................................14
FLUVIRIN 2013-2014 -influenza virus vaccine types a & b
surface antigen im susp...................................................14
FLUVIRIN 2014-2015 -influenza virus vaccine types a & b
surface antigen im susp...................................................14
FLUVIRIN 2015-2016 -influenza virus vaccine types a & b
surface antigen im susp...................................................14
FLUVIRIN PF 2011-2012 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml.............................................. 14
FLUVIRIN PF 2012-2013 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml.............................................. 14
FLUVIRIN PF 2013-2014 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml.............................................. 14
FLUVIRIN PF 2014-2015 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml.............................................. 14
fluvoxamine maleate cap sr 24hr 100 mg (Luvox
cr).....................................................................................78
fluvoxamine maleate cap sr 24hr 150 mg (Luvox
cr).....................................................................................78
fluvoxamine maleate tab 100 mg................................... 78
fluvoxamine maleate tab 25 mg..................................... 78
fluvoxamine maleate tab 50 mg..................................... 78
FLUZONE HIGH-DOSE PF 2012 -influenza virus vac split
high-dose pf susp pref syr 0.5ml..................................... 14
FLUZONE HIGH-DOSE PF 2013 -influenza virus vac split
high-dose pf susp pref syr 0.5ml..................................... 14
FLUZONE HIGH-DOSE PF 2014 -influenza virus vac split
high-dose pf susp pref syr 0.5ml..................................... 14
FLUZONE HIGH-DOSE PF 2015 -influenza virus vac split
high-dose pf susp pref syr 0.5ml..................................... 14
FLUZONE INTRADERMAL QUADR -influenza virus vac
split quad intradermal pen 9 mcg/strain...........................14
FLUZONE PF 2012-2013 -influenza virus vaccine split pf
susp pref syringe 0.5 ml.................................................. 14
FLUZONE PF 2013-2014 -influenza virus vaccine split pf
susp pref syringe 0.5 ml.................................................. 14
FLUZONE PF 2014-2015 -influenza virus vaccine split pf
susp pref syringe 0.5 ml.................................................. 14
FLUZONE QUADRIVALENT 2013 -influenza virus vaccine
split quadrivalent inj 0.5 ml.............................................. 14
FLUZONE QUADRIVALENT 2013 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml........................... 14
FLUZONE QUADRIVALENT 2013 -influenza virus vac
split quadrivalent susp pref syr 0.5ml.............................. 14
FLUZONE QUADRIVALENT 2014 -influenza virus vaccine
split quadrivalent im inj.................................................... 14
FLUZONE QUADRIVALENT 2014 -influenza virus vaccine
split quadrivalent inj 0.5 ml.............................................. 14
FLUZONE QUADRIVALENT 2014 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml........................... 14
FLUZONE QUADRIVALENT 2014 -influenza virus vac
split quadrivalent susp pref syr 0.5ml.............................. 14
FLUZONE QUADRIVALENT 2015 -influenza virus vaccine
split quadrivalent im inj.................................................... 14
FLUZONE QUADRIVALENT 2015 -influenza virus vaccine
split quadrivalent inj 0.5 ml.............................................. 15
FLUZONE QUADRIVALENT 2015 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml........................... 14
FLUZONE QUADRIVALENT 2015 -influenza virus vac
split quadrivalent susp pref syr 0.5ml.............................. 14
FLUZONE SPLIT 2012-2013 -influenza virus vaccine split
im susp.............................................................................15
FLUZONE SPLIT 2013-2014 -influenza virus vaccine split
im susp.............................................................................15
FLUZONE SPLIT 2014-2015 -influenza virus vaccine split
im susp.............................................................................15
FLUZONE SPLIT 2015-2016 -influenza virus vaccine split
im susp.............................................................................15
FML -fluorometholone ophth oint 0.1%........................... 138
FML FORTE -fluorometholone ophth susp 0.25%...........138
FML LIQUIFILM -fluorometholone ophth susp 0.1%....... 138
FOCALGIN 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak............................................... 117
FOCALGIN-B -prenatal w/ calcium-vit b6-fa-ginger tab
1.22 mg.......................................................................... 117
FOCALGIN CA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack.................................................... 117
FOCALGIN DSS -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg.............................................................129
FOCALIN -dexmethylphenidate hcl tab 10 mg.................. 87
FOCALIN -dexmethylphenidate hcl tab 2.5 mg................. 87
FOCALIN -dexmethylphenidate hcl tab 5 mg.................... 87
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 10
mg.................................................................................... 87
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 15
mg.................................................................................... 87
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 20
mg.................................................................................... 87
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 25
mg.................................................................................... 87
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 30
mg.................................................................................... 87
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 35
mg.................................................................................... 87
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 40
mg.................................................................................... 87
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 5
mg.................................................................................... 87
FOLBECAL -prenatal w/ calcium carbonate-b6-b12-fa tab
1 mg............................................................................... 117
FOLBEE AR -folic acid-b12-b6-arginine-black pepper
tab.................................................................................. 126
FOLBIC RF -l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2
mg.................................................................................. 126
FOLCAL DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg..............................................................117
FOLCAPS OMEGA 3 -prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg.....................................................117
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
197
2015
FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr &
dha cap pak................................................................... 117
FOLET ONE -prenat w/o a w/fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg............................................................117
FOLGARD OS -multiple vit w/ min & calcium-folic acid tab
500-1.1 mg.....................................................................117
FOLGARD RX -folic acid-vitamin b6-vitamin b12 tab
2.2-25-1 mg....................................................................129
folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2
mg.................................................................................. 126
folic acid tab 1 mg.........................................................129
folic acid tab 400 mcg...................................................129
folic acid tab 800 mcg...................................................129
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5
mg.................................................................................. 130
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg
(Folgard rx)................................................................... 130
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg...... 130
FOLIVANE-F -fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe).....................................130
FOLIVANE-OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg................................................................117
FOLIVANE-PLUS -fe fum-iron polysacch complex-fa-b
complex-c-biotin cap...................................................... 130
FOLTANX -l-methylfolate w/ vit b6-vit b12 tab 3-35-2
mg.................................................................................. 126
FOLTANX RF -l-methylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg.......................................................... 126
FOLTX -l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2
mg.................................................................................. 126
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra)......................................................................... 132
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
(Arixtra)......................................................................... 132
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra)......................................................................... 132
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra)......................................................................... 132
FORADIL AEROLIZER -formoterol fumarate inhal cap 12
mcg...................................................................................63
FORFIVO XL -bupropion hcl tab sr 24hr 450 mg.............. 78
formaldehyde solution 10%.......................................... 163
FORMA-RAY -formaldehyde solution 20%......................163
FORTAMET -metformin hcl tab sr 24hr osmotic 1000
mg.................................................................................... 28
FORTAMET -metformin hcl tab sr 24hr osmotic 500
mg.................................................................................... 28
FORTEO -teriparatide (recombinant) inj 600
mcg/2.4ml.........................................................................36
FORTESTA -testosterone td gel 10mg/act (2%)............... 21
FORTICAL -calcitonin (salmon) nasal soln 200 unit/
act.....................................................................................36
FOSAMAX -alendronate sodium tab 70 mg...................... 36
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-2800 mg-unit.........................................................36
198
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-5600 mg-unit.........................................................36
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg.................................................................................... 48
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg.................................................................................... 48
fosinopril sodium tab 10 mg.......................................... 48
fosinopril sodium tab 20 mg.......................................... 48
fosinopril sodium tab 40 mg.......................................... 48
FOSRENOL -lanthanum carbonate chew tab 1000 mg
(elemental)....................................................................... 71
FOSRENOL -lanthanum carbonate chew tab 500 mg
(elemental)....................................................................... 71
FOSRENOL -lanthanum carbonate chew tab 750 mg
(elemental)....................................................................... 71
FOSRENOL -lanthanum carbonate oral powder pack 1000
mg (elemental)................................................................. 71
FOSRENOL -lanthanum carbonate oral powder pack 750
mg (elemental)................................................................. 71
FOSTEUM -genistein-zinc amino acid chelate-vitamin d
cap..................................................................................126
FRAGMIN -dalteparin sodium inj 10000 unit/ml.............. 132
FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml..........132
FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml..........132
FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml........132
FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml............132
FRAGMIN -dalteparin sodium inj 5000 unit/0.2ml............132
FRAGMIN -dalteparin sodium inj 7500 unit/0.3ml............132
FRAGMIN -dalteparin sodium inj 95000 unit/3.8ml..........132
FROVA -frovatriptan succinate tab 2.5 mg (base
equivalent)......................................................................104
FULYZAQ -crofelemer tab delayed release 125 mg..........66
FURADANTIN -nitrofurantoin susp 25 mg/5ml.................. 72
FUROSEMIDE -furosemide oral soln 8 mg/ml.................. 53
furosemide oral soln 10 mg/ml...................................... 53
furosemide tab 20 mg (Lasix).........................................53
furosemide tab 40 mg (Lasix).........................................53
furosemide tab 80 mg (Lasix).........................................53
FUSION PLUS -fe fum-iron poly cmplx-fa-b cmplx-c-biotinprobiotic cap...................................................................130
FUZEON -enfuvirtide for inj 90 mg......................................8
FYCOMPA -perampanel tab 10 mg.................................107
FYCOMPA -perampanel tab 12 mg.................................107
FYCOMPA -perampanel tab 2 mg.................................. 107
FYCOMPA -perampanel tab 4 mg.................................. 107
FYCOMPA -perampanel tab 6 mg.................................. 107
FYCOMPA -perampanel tab 8 mg.................................. 107
G
gabapentin cap 100 mg (Neurontin)............................ 107
gabapentin cap 300 mg (Neurontin)............................ 107
gabapentin cap 400 mg (Neurontin)............................ 107
gabapentin oral soln 250 mg/5ml (Neurontin).............108
gabapentin tab 600 mg (Neurontin)............................. 108
gabapentin tab 800 mg (Neurontin)............................. 108
GABITRIL -tiagabine hcl tab 12 mg.................................108
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
GABITRIL -tiagabine hcl tab 16 mg.................................108
GABITRIL -tiagabine hcl tab 2 mg.................................. 108
GABITRIL -tiagabine hcl tab 4 mg.................................. 108
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)................................................................. 90
galantamine hydrobromide cap sr 24hr 24 mg
(Razadyne er)................................................................. 90
galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne er)................................................................. 90
GALANTAMINE HYDROBROMIDE -galantamine
hydrobromide oral soln 4 mg/ml...................................... 90
galantamine hydrobromide tab 12 mg (Razadyne)....... 90
galantamine hydrobromide tab 4 mg (Razadyne).........90
galantamine hydrobromide tab 8 mg (Razadyne).........90
GALZIN -zinc acetate cap 25 mg (elemental zinc).......... 124
GALZIN -zinc acetate cap 50 mg (elemental zinc).......... 125
GARAMYCIN -gentamicin sulfate ophth soln 0.3%......... 138
GASTRINEX NF -hyoscyamine-phenyltoloxamine cap
0.0625-15 mg...................................................................67
GASTROCROM -cromolyn sodium oral conc 100
mg/5ml..............................................................................71
gatifloxacin ophth soln 0.5% (Zymaxid)...................... 138
GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 71
GEBAUERS PAIN EASE -pentafluoropropanetetrafluoroethane aero spray..........................................151
GEBAUERS SPRAY AND STRETC -pentafluoropropanetetrafluoroethane aero spray..........................................151
GELCLAIR -povidone-sodium hyaluronate-glycyrrhetinic
acid gel...........................................................................142
GELFILM OP -gelatin adsorbable ophth film................... 138
GEL-KAM ORAL CARE RINSE -stannous fluoride conc
0.63%............................................................................. 142
GEL-KAM -stannous fluoride gel 0.4%............................142
GELNIQUE -oxybutynin chloride td gel 10%..................... 73
GELNIQUE -oxybutynin td gel 3% (28 mg/act metereddose pump)...................................................................... 73
GELX -oral wound care products - gel............................ 142
gemfibrozil tab 600 mg (Lopid)...................................... 55
GENADUR -dermatological products misc - liquid...........151
GENADUR KIT -dermatological products misc topical/oral
- kit................................................................................. 151
GENERESS FE -norethindrone & ethinyl estradiol-fe chew
tab 0.8 mg-25 mcg.......................................................... 24
GENOTROPIN MINIQUICK -somatropin for inj 0.2 mg..... 36
GENOTROPIN MINIQUICK -somatropin for inj 0.4 mg..... 36
GENOTROPIN MINIQUICK -somatropin for inj 0.6 mg..... 36
GENOTROPIN MINIQUICK -somatropin for inj 0.8 mg..... 36
GENOTROPIN MINIQUICK -somatropin for inj 1.2 mg..... 36
GENOTROPIN MINIQUICK -somatropin for inj 1.4 mg..... 36
GENOTROPIN MINIQUICK -somatropin for inj 1.6 mg..... 36
GENOTROPIN MINIQUICK -somatropin for inj 1.8 mg..... 36
GENOTROPIN MINIQUICK -somatropin for inj 1 mg........ 36
GENOTROPIN MINIQUICK -somatropin for inj 2 mg........ 36
GENOTROPIN -somatropin for inj 12 mg (13.8 mg
overfill)..............................................................................36
GENOTROPIN -somatropin for subcutaneous inj 5 mg.....36
GENTAMICIN SULFATE -gentamicin sulfate cream
0.1%............................................................................... 151
GENTAMICIN SULFATE -gentamicin sulfate oint
0.1%............................................................................... 151
gentamicin sulfate ophth oint 0.3%............................. 138
gentamicin sulfate ophth soln 0.3% (Garamycin)....... 138
GEODON -ziprasidone hcl cap 20 mg.............................. 82
GEODON -ziprasidone hcl cap 40 mg.............................. 82
GEODON -ziprasidone hcl cap 60 mg.............................. 82
GEODON -ziprasidone hcl cap 80 mg.............................. 82
GIAZO -balsalazide disodium tab 1.1 gm..........................71
GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 90
GILOTRIF -afatinib dimaleate tab 20 mg (base
equivalent)........................................................................17
GILOTRIF -afatinib dimaleate tab 30 mg (base
equivalent)........................................................................17
GILOTRIF -afatinib dimaleate tab 40 mg (base
equivalent)........................................................................17
GILPHEX TR -phenylephrine-guaifenesin tab 10-388
mg.................................................................................... 60
GILTUSS PED-C -phenylephrine w/ codeine-gg liquid
2.5-3-50 mg/ml.................................................................60
GILTUSS -phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml..............................................................................60
GILTUSS TR -phenylephrine w/ dm-gg tab 10-28-388
mg.................................................................................... 60
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)......................................................................90
GLEEVEC -imatinib mesylate tab 100 mg (base
equivalent)........................................................................17
GLEEVEC -imatinib mesylate tab 400 mg (base
equivalent)........................................................................17
GLEOSTINE -lomustine cap 100 mg.................................17
GLEOSTINE -lomustine cap 10 mg.................................. 17
GLEOSTINE -lomustine cap 40 mg.................................. 17
glimepiride tab 1 mg (Amaryl)........................................28
glimepiride tab 2 mg (Amaryl)........................................28
glimepiride tab 4 mg (Amaryl)........................................28
glipizide-metformin hcl tab 2.5-250 mg......................... 28
glipizide-metformin hcl tab 2.5-500 mg......................... 28
glipizide-metformin hcl tab 5-500 mg............................ 28
glipizide tab 10 mg (Glucotrol).......................................28
glipizide tab 5 mg (Glucotrol).........................................28
glipizide tab sr 24hr 10 mg (Glucotrol xl)......................28
glipizide tab sr 24hr 2.5 mg (Glucotrol xl)..................... 28
glipizide tab sr 24hr 5 mg (Glucotrol xl)........................28
GLUCAGEN DIAGNOSTIC -glucagon hcl (rdna) diagnostic
for inj 1 mg (base equiv)................................................163
GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg
(base equiv)..................................................................... 28
GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj kit
1 mg................................................................................. 28
GLUCOPHAGE -metformin hcl tab 1000 mg.................... 28
GLUCOPHAGE -metformin hcl tab 500 mg...................... 28
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
199
2015
GLUCOPHAGE -metformin hcl tab 850 mg...................... 28
GLUCOPHAGE XR -metformin hcl tab sr 24hr 500 mg.....28
GLUCOPHAGE XR -metformin hcl tab sr 24hr 750 mg.....28
GLUCOSE BLOOD TEST STRIPS – VARIOUS............. 163
glucose gel 40%.............................................................. 28
GLUCOSE -glucose chew tab 4 gm..................................28
GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.........28
glucose oral liquid 15 gm/59ml...................................... 28
GLUCOTROL -glipizide tab 10 mg....................................28
GLUCOTROL -glipizide tab 5 mg......................................28
GLUCOTROL XL -glipizide tab sr 24hr 10 mg.................. 28
GLUCOTROL XL -glipizide tab sr 24hr 2.5 mg................. 28
GLUCOTROL XL -glipizide tab sr 24hr 5 mg.................... 28
GLUCOVANCE -glyburide-metformin tab 1.25-250 mg.....28
GLUCOVANCE -glyburide-metformin tab 2.5-500 mg.......28
GLUCOVANCE -glyburide-metformin tab 5-500 mg..........28
GLUMETZA -metformin hcl tab sr 24hr modified release
1000 mg........................................................................... 28
GLUMETZA -metformin hcl tab sr 24hr modified release
500 mg............................................................................. 28
GLUTARALDEHYDE -glutaral soln 25%......................... 163
GLYBURIDE -glyburide tab 1.25 mg................................. 28
GLYBURIDE -glyburide tab 2.5 mg...................................28
GLYBURIDE -glyburide tab 5 mg......................................28
glyburide-metformin tab 1.25-250 mg
(Glucovance)...................................................................28
glyburide-metformin tab 2.5-500 mg (Glucovance)...... 28
glyburide-metformin tab 5-500 mg (Glucovance)......... 29
glyburide micronized tab 1.5 mg (Glynase).................. 28
glyburide micronized tab 3 mg (Glynase)..................... 28
glyburide micronized tab 6 mg (Glynase)..................... 28
glyburide tab 1.25 mg..................................................... 28
glyburide tab 2.5 mg....................................................... 28
glyburide tab 5 mg.......................................................... 28
GLYCATE -glycopyrrolate tab 1.5 mg............................... 67
glycopyrrolate tab 1 mg (Robinul)................................. 67
glycopyrrolate tab 2 mg (Robinul forte)........................ 67
GLYNASE -glyburide micronized tab 1.5 mg.................... 29
GLYNASE -glyburide micronized tab 3 mg....................... 29
GLYNASE -glyburide micronized tab 6 mg....................... 29
GLYSET -miglitol tab 100 mg............................................29
GLYSET -miglitol tab 25 mg..............................................29
GLYSET -miglitol tab 50 mg..............................................29
GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............. 29
GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............. 29
GNP GLUCOSE -glucose chew tab 4 gm......................... 29
GNP GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 29
GNP QUICK DISSOLVE GLUCOS -glucose chew tab 4
gm.................................................................................... 29
GNP VITAMIN D-400 -calcium carbonate-cholecalciferol
tab 90 mg-400 unit........................................................ 125
GNP VITAMIN D-400 -calcium carbonate-cholecalciferol
tab 90 mg-400 unit........................................................ 125
200
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm..................................................................... 65
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm.............................................................. 65
GORDOFILM -salicylic & lactic acids soln
16.7-16.7%..................................................................... 151
GORDONS UREA -urea ointment 40%...........................151
GRALISE -gabapentin (phn) tab 300 mg...........................90
GRALISE -gabapentin (phn) tab 600 mg...........................90
GRALISE STARTER -gabapentin (phn) tab starter pack
300 mg (9) & 600 mg (69)...............................................91
granisetron hcl tab 1 mg................................................ 69
GRANIX -tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml.......................................................................130
GRANIX -tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml.......................................................................130
GRANULEX -trypsin w/ castor oil & peruvian balsam
spray...............................................................................151
GRASTEK -timothy grass pollen allergen ext tab sl 2800
bau................................................................................... 16
GRIFULVIN V -griseofulvin microsize tab 500 mg...............6
griseofulvin microsize susp 125 mg/5ml.........................6
griseofulvin microsize tab 500 mg (Grifulvin v)..............6
griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 6
griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 6
GRIS-PEG -griseofulvin ultramicrosize tab 125 mg.............6
GRIS-PEG -griseofulvin ultramicrosize tab 250 mg.............6
guaifenesin-codeine liquid 200-8 mg/5ml......................60
guaifenesin-codeine liquid 225-7.5 mg/5ml...................60
guaifenesin-codeine soln 100-10 mg/5ml......................60
guaifenesin-codeine soln 100-6.3 mg/5ml..................... 60
guanfacine hcl tab 1 mg (Tenex)................................... 48
guanfacine hcl tab 2 mg (Tenex)................................... 48
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv)........................................................................... 87
guanfacine hcl tab sr 24hr 2 mg (base equiv)
(Intuniv)........................................................................... 87
guanfacine hcl tab sr 24hr 3 mg (base equiv)
(Intuniv)........................................................................... 87
guanfacine hcl tab sr 24hr 4 mg (base equiv)
(Intuniv)........................................................................... 87
GUANIDINE HCL -guanidine hcl tab 125 mg.................. 114
GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal
cream 2%.........................................................................73
H
H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 36
HALAC -halobetasol prop oint 0.05% & ammonium lactate
lot 12% kit...................................................................... 151
HALCION -triazolam tab 0.25 mg......................................84
halobetasol propionate cream 0.05% (Ultravate)........ 151
halobetasol propionate oint 0.05% (Ultravate)............151
HALOG -halcinonide cream 0.1%................................... 151
HALOG -halcinonide oint 0.1%........................................151
haloperidol lactate oral conc 2 mg/ml........................... 82
haloperidol tab 0.5 mg.................................................... 82
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
haloperidol tab 10 mg..................................................... 82
haloperidol tab 1 mg....................................................... 82
haloperidol tab 20 mg..................................................... 82
haloperidol tab 2 mg....................................................... 82
haloperidol tab 5 mg....................................................... 82
HALOTIN -haloprogin cream 1%.....................................151
HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................. 8
hc-pramoxine emol cream 2.5-1% & pramoxine wipe
1% kit (Analpram e)..................................................... 144
HECTOROL -doxercalciferol cap 0.5 mcg.........................36
HECTOROL -doxercalciferol cap 1 mcg............................36
HECTOROL -doxercalciferol cap 2.5 mcg.........................36
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 1000 unit................................................................... 134
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 2000 unit................................................................... 135
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 250 unit..................................................................... 134
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 3000 unit................................................................... 135
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 500 unit..................................................................... 134
HEMANGEOL -propranolol hcl oral soln 4.28 mg/ml.........40
HEMATOGEN FA -fe fumarate-vit c-vit b12-fa cap
200-250-0.01-1 mg........................................................ 130
HEMATRON-AF -iron-docusate-b12-folic acid-c-e-cu-biotin
tab 150-1 mg................................................................. 130
HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck......................................117
HEMENATAL OB -prenat vit-fe poly cmplx-fe heme poly-fa
tab 28-6-1 mg................................................................ 117
HEMETAB -polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg............................................................ 130
HEMOCYTE PLUS -ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg............................................... 130
HEMOFIL M -antihemophilic factor (human) for inj 1000
unit..................................................................................135
HEMOFIL M -antihemophilic factor (human) for inj
1501-2000 unit............................................................... 135
HEMOFIL M -antihemophilic factor (human) for inj 1700
unit..................................................................................135
HEMOFIL M -antihemophilic factor (human) for inj 220-400
unit..................................................................................135
HEMOFIL M -antihemophilic factor (human) for inj 250
unit..................................................................................135
HEMOFIL M -antihemophilic factor (human) for inj 401-800
unit..................................................................................135
HEMOFIL M -antihemophilic factor (human) for inj 500
unit..................................................................................135
HEMOFIL M -antihemophilic factor (human) for inj
801-1500 unit................................................................. 135
HEPAGAM B -hepatitis b immune globulin (human) inj
soln...................................................................................15
heparin sodium (porcine) inj 10000 unit/ml.................132
heparin sodium (porcine) inj 1000 unit/ml...................132
heparin sodium (porcine) inj 20000 unit/ml.................132
heparin sodium (porcine) inj 5000 unit/ml...................132
heparin sodium (porcine) pf inj 5000 unit/0.5ml......... 132
HEPARIN SODIUM -heparin sodium (porcine) inj 2000
unit/ml.............................................................................132
HEPARIN SODIUM -heparin sodium (porcine) inj 2500
unit/ml.............................................................................132
HEPSERA -adefovir dipivoxil tab 10 mg............................. 8
HETLIOZ -tasimelteon capsule 20 mg.............................. 84
HEXALEN -altretamine cap 50 mg....................................17
HIPREX -methenamine hippurate tab 1 gm...................... 72
HM GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 29
homatropine hbr ophth soln 5% (Isopto
homatropine)................................................................ 138
HORIZANT -gabapentin enacarbil tab cr 300 mg..............91
HORIZANT -gabapentin enacarbil tab cr 600 mg..............91
HPR -emollient - aerosol foam........................................ 151
HPR PLUS/MB HYDROGEL -emollient foam & wound
dressing gel kit...............................................................151
HPR PLUS -dermatological products misc - cream......... 151
HPR PLUS -emollient - aerosol foam..............................151
HPR PLUS HYDROGEL KIT -dermatological products
misc - kit........................................................................ 151
HUMALOG -insulin lispro (human) inj 100 unit/ml............. 31
HUMALOG -insulin lispro (human) soln cartridge 100 unit/
ml......................................................................................31
HUMALOG KWIKPEN -insulin lispro (human) soln peninjector 100 unit/ml...........................................................31
HUMALOG KWIKPEN -insulin lispro (human) soln peninjector 200 unit/ml...........................................................31
HUMALOG MIX 50/50 -insulin lispro prot & lispro (human)
inj 100 unit/ml (50-50)......................................................32
HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................. 32
HUMALOG MIX 75/25 -insulin lispro prot & lispro (human)
inj 100 unit/ml (75-25)......................................................32
HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................. 32
HUMATE-P -antihemophilic factor/vwf (human) for inj
1000-2400 unit............................................................... 135
HUMATE-P -antihemophilic factor/vwf (human) for inj
250-600 unit................................................................... 135
HUMATE-P -antihemophilic factor/vwf (human) for inj
500-1200 unit................................................................. 135
HUMATROPE COMBO PACK -somatropin for inj 5
mg.................................................................................... 37
HUMATROPE -somatropin for inj 12 mg (36 unit).............37
HUMATROPE -somatropin for inj 24 mg...........................37
HUMATROPE -somatropin for inj 5 mg.............................36
HUMATROPE -somatropin for inj 6 mg (18 unit)...............37
HUMIRA -adalimumab prefilled syringe kit 10
mg/0.2ml.........................................................................102
HUMIRA -adalimumab prefilled syringe kit 20
mg/0.4ml.........................................................................102
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
201
2015
HUMIRA -adalimumab prefilled syringe kit 40
mg/0.8ml.........................................................................102
HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled
syringe kit 40 mg/0.8ml..................................................102
HUMIRA PEN -adalimumab pen-injector kit 40
mg/0.8ml.........................................................................102
HUMIRA PEN-CROHNS DISEASE -adalimumab peninjector kit 40 mg/0.8ml..................................................102
HUMIRA PEN-PSORIASIS STAR -adalimumab peninjector kit 40 mg/0.8ml..................................................102
HUMULIN 70/30 -insulin nph isophane & regular human inj
100 unit/ml (70-30)...........................................................32
HUMULIN 70/30 KWIKPEN -insulin nph & regular susp
pen-inj 100 unit/ml (70-30)...............................................32
HUMULIN 70/30 PEN -insulin nph & regular susp pen-inj
100 unit/ml (70-30)...........................................................32
HUMULIN N -insulin nph (human) (isophane) inj 100 unit/
ml......................................................................................32
HUMULIN N KWIKPEN -insulin nph (human) (isophane)
susp pen-injector 100 unit/ml...........................................32
HUMULIN N U-100 PEN -insulin nph (human) (isophane)
susp pen-injector 100 unit/ml...........................................32
HUMULIN R -insulin regular (human) inj 100 unit/ml.........32
HUMULIN R U-500 (CONCENTR -insulin regular (human)
inj 500 unit/ml.................................................................. 32
HURRISEAL -dental desensitizing product - solution...... 163
hyaluronate sodium (emollient) gel 0.2% (Hylira)....... 151
HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)....... 17
HYCAMTIN -topotecan hcl cap 1 mg (base equiv)............17
HYCET -hydrocodone-acetaminophen soln 7.5-325
mg/15ml............................................................................96
hydralazine hcl tab 100 mg............................................ 48
hydralazine hcl tab 10 mg.............................................. 48
hydralazine hcl tab 25 mg.............................................. 48
hydralazine hcl tab 50 mg.............................................. 48
HYDREA -hydroxyurea cap 500 mg..................................17
HYDRO 35 -urea in lactic acid vehicle foam 35%........... 151
HYDRO 40 FOAM -urea foam 40%................................ 151
hydrochlorothiazide cap 12.5 mg (Microzide)............... 53
hydrochlorothiazide tab 12.5 mg................................... 53
hydrochlorothiazide tab 25 mg...................................... 53
hydrochlorothiazide tab 50 mg...................................... 53
HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen soln 10-325 mg/15ml..............................96
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet)............................................................................. 96
hydrocodone-acetaminophen tab 10-300 mg
(Xodol)............................................................................. 96
hydrocodone-acetaminophen tab 10-325 mg
(Norco).............................................................................96
hydrocodone-acetaminophen tab 2.5-325 mg...............96
hydrocodone-acetaminophen tab 5-300 mg
(Xodol)............................................................................. 96
hydrocodone-acetaminophen tab 5-325 mg
(Norco).............................................................................96
202
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol)............................................................................. 96
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco).............................................................................96
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........ 96
hydrocodone-ibuprofen tab 2.5-200 mg
(Reprexain)......................................................................96
hydrocodone-ibuprofen tab 5-200 mg (Reprexain).......96
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen).................................................................... 96
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml....... 60
hydrocodone w/ homatropine tab 5-1.5 mg.................. 60
hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml
(Tussionex pennkineti).................................................. 60
hydrocortisone acetate suppos 25 mg (Anusolhc).................................................................................. 144
hydrocortisone acetate suppos 30 mg
(Proctocort)...................................................................144
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc)..................................................... 144
hydrocortisone acetate w/ pramoxine rectal cream
2.5-1% (Analpram-hc).................................................. 144
hydrocortisone butyrate cream 0.1% (Locoid)............151
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)..............................................151
hydrocortisone butyrate oint 0.1% (Locoid)................151
hydrocortisone butyrate soln 0.1% (Locoid)...............151
hydrocortisone cream 2.5%..........................................151
hydrocortisone enema 100 mg/60ml (Cortenema)......144
hydrocortisone lotion 2.5%...........................................152
hydrocortisone lotion 2% (Ala scalp).......................... 152
hydrocortisone oint 2.5%..............................................152
hydrocortisone rectal cream 1% (Proctocort).............144
hydrocortisone rectal cream 2.5% (Anusol-hc).......... 144
hydrocortisone tab 10 mg (Cortef).................................20
hydrocortisone tab 20 mg (Cortef).................................20
hydrocortisone tab 5 mg (Cortef).................................. 20
hydrocortisone valerate cream 0.2%........................... 152
hydrocortisone valerate oint 0.2% (Westcort).............152
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc).................................................................................. 141
HYDROFERA BLUE 4"X4" -wound dressings - pads...... 152
HYDROFERA BLUE FOAM DRESS -wound dressings pads................................................................................152
HYDROFERA BLUE HEAVY DRAI -wound dressings pads................................................................................152
HYDROFERA BLUE READY FOAM -wound dressings pads................................................................................152
HYDROMORPHONE HCL ER -hydromorphone hcl tab er
24hr deter 32 mg............................................................. 96
HYDROMORPHONE HCL -hydromorphone hcl suppos 3
mg.................................................................................... 96
hydromorphone hcl liqd 1 mg/ml (Dilaudid)................. 96
hydromorphone hcl tab 2 mg (Dilaudid)....................... 96
hydromorphone hcl tab 4 mg (Dilaudid)....................... 96
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
hydromorphone hcl tab 8 mg (Dilaudid)....................... 96
hydromorphone hcl tab er 24hr deter 12 mg
(Exalgo)........................................................................... 96
hydromorphone hcl tab er 24hr deter 16 mg
(Exalgo)........................................................................... 96
hydromorphone hcl tab er 24hr deter 8 mg
(Exalgo)........................................................................... 96
hydroxychloroquine sulfate tab 200 mg (Plaquenil).....11
hydroxyurea cap 500 mg (Hydrea).................................17
hydroxyzine hcl syrup 10 mg/5ml.................................. 75
hydroxyzine hcl tab 10 mg............................................. 75
hydroxyzine hcl tab 25 mg............................................. 75
hydroxyzine hcl tab 50 mg............................................. 75
hydroxyzine pamoate cap 25 mg (Vistaril).................... 75
hydroxyzine pamoate cap 50 mg (Vistaril).................... 75
HYDROXYZINE PAMOATE -hydroxyzine pamoate cap
100 mg............................................................................. 75
HYLASE WOUND -hyaluronate sodium gel.................... 152
HYLATOPIC -emollient - aerosol foam............................152
HYLATOPIC PLUS -dermatological products misc cream............................................................................. 152
HYLATOPIC PLUS -emollient - aerosol foam................. 152
HYLIRA -hyaluronate sodium (emollient) gel 0.2%..........152
HYLIRA -hyaluronate sodium (emollient) lotion 0.1%...... 152
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 67
hyoscyamine sulfate soln 0.125 mg/ml......................... 67
hyoscyamine sulfate tab 0.125 mg (Levsin)..................67
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 67
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl).......... 67
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid)..... 67
HYPERHEP B S/D -hepatitis b immune globulin (human)
im inj soln.........................................................................15
HYPERRAB S/D -rabies immune globulin (human) inj 150
unit/ml...............................................................................15
HYPERSAL -sodium chloride soln nebu 3.5%.................. 60
HYPERSAL -sodium chloride soln nebu 7%..................... 60
HYPER-SAL -sodium chloride soln nebu 7%.................... 60
HYPERTET S/D -tetanus immune globulin (human) inj 250
unit/ml...............................................................................15
HYQVIA -immun glob inj 10 gm/100ml-hyaluron inj 800
unt/5 ml kit....................................................................... 16
HYQVIA -immun glob inj 2.5 gm/25ml-hyaluron inj 200
unt/1.25 ml kit.................................................................. 15
HYQVIA -immun glob inj 20 gm/200ml-hyaluron inj 1600
unt/10 ml kit..................................................................... 16
HYQVIA -immun glob inj 30 gm/300ml-hyaluron inj 2400
unt/15 ml kit..................................................................... 16
HYQVIA -immun glob inj 5 gm/50ml-hyaluron inj 400
unt/2.5 ml kit.................................................................... 15
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
100 mg............................................................................. 97
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
120 mg............................................................................. 97
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
20 mg............................................................................... 96
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
30 mg............................................................................... 96
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
40 mg............................................................................... 96
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
60 mg............................................................................... 96
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
80 mg............................................................................... 96
HY-VEE GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 29
HYZAAR -losartan potassium & hydrochlorothiazide tab
100-12.5 mg.....................................................................49
HYZAAR -losartan potassium & hydrochlorothiazide tab
100-25 mg........................................................................49
HYZAAR -losartan potassium & hydrochlorothiazide tab
50-12.5 mg.......................................................................49
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)........................................................................... 37
IBRANCE -palbociclib cap 100 mg....................................17
IBRANCE -palbociclib cap 125 mg....................................17
IBRANCE -palbociclib cap 75 mg......................................17
IBUDONE -hydrocodone-ibuprofen tab 10-200 mg........... 97
IBUPROFEN COMFORT PAC -ibuprofen tab 800 mg &
liniment topical gel kit.................................................... 102
ibuprofen tab 400 mg.................................................... 102
ibuprofen tab 600 mg.................................................... 102
ibuprofen tab 800 mg.................................................... 102
IC 400 -ibuprofen tab 400 mg & caffeine-vitamins cap
kit....................................................................................102
IC 800 -ibuprofen tab 800 mg & caffeine-vitamins cap
kit....................................................................................102
ICAR -carbonyl iron chew tab 15 mg (elemental iron)..... 130
ICAR-C PLUS -iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg...................................................... 130
ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml
(elemental iron).............................................................. 130
ICLUSIG -ponatinib hcl tab 15 mg (base equiv)................ 17
ICLUSIG -ponatinib hcl tab 45 mg (base equiv)................ 17
ILEVRO -nepafenac ophth susp 0.3%.............................138
IMBRUVICA -ibrutinib cap 140 mg....................................17
imipramine hcl tab 10 mg (Tofranil)...............................78
imipramine hcl tab 25 mg (Tofranil)...............................78
imipramine hcl tab 50 mg (Tofranil)...............................78
imipramine pamoate cap 100 mg (Tofranil-pm)............ 78
imipramine pamoate cap 125 mg (Tofranil-pm)............ 78
imipramine pamoate cap 150 mg (Tofranil-pm)............ 78
imipramine pamoate cap 75 mg (Tofranil-pm).............. 78
imiquimod cream 5% (Aldara)...................................... 152
IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 4 mg/0.5ml.........................................105
IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 6 mg/0.5ml.........................................105
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 4 mg/0.5ml...................................105
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
203
2015
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 6 mg/0.5ml...................................105
IMITREX -sumatriptan nasal spray 20 mg/act................. 104
IMITREX -sumatriptan nasal spray 5 mg/act................... 104
IMITREX -sumatriptan succinate inj 6 mg/0.5ml..............105
IMITREX -sumatriptan succinate tab 100 mg.................. 105
IMITREX -sumatriptan succinate tab 25 mg.................... 105
IMITREX -sumatriptan succinate tab 50 mg.................... 105
IMOGAM RABIES-HT -rabies immune globulin (human) inj
150 unit/ml....................................................................... 16
IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc
inj......................................................................................15
IMURAN -azathioprine tab 50 mg................................... 164
INATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg................................................................... 117
INATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg.................................................................................. 117
INATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg..........................................................................117
INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)...........37
INCRUSE ELLIPTA -umeclidinium br aero powd breath act
62.5 mcg/inh (base eq)....................................................63
indapamide tab 1.25 mg..................................................53
indapamide tab 2.5 mg....................................................53
INDERAL LA -propranolol hcl cap sr 24hr 120 mg............ 40
INDERAL LA -propranolol hcl cap sr 24hr 160 mg............ 40
INDERAL LA -propranolol hcl cap sr 24hr 60 mg.............. 40
INDERAL LA -propranolol hcl cap sr 24hr 80 mg.............. 40
INDERAL XL -propranolol hcl sustained-release beads cap
sr 24hr 120 mg................................................................ 40
INDERAL XL -propranolol hcl sustained-release beads cap
sr 24hr 80 mg.................................................................. 40
INDOCIN -indomethacin suppos 50 mg.......................... 102
INDOCIN -indomethacin susp 25 mg/5ml........................102
indomethacin cap 25 mg.............................................. 102
indomethacin cap 50 mg.............................................. 102
indomethacin cap cr 75 mg.......................................... 102
INFANATE BALANCE -prenatal w/o a w/fe cbn-dss-fa-dha
cap 29-1-265 mg............................................................117
INFANATE PLUS -prenat w/o a w/fe fum-fe cbn-dss-fadha cap 27-1-260 mg.................................................... 117
INFANRIX -diph, acellular pert & tet tox inj 25 lf-58 mcg-10
lf/0.5ml..............................................................................15
INFASURF -calfactant in nacl 0.9% intratracheal susp 35
mg/ml................................................................................65
INLYTA -axitinib tab 1 mg................................................. 17
INLYTA -axitinib tab 5 mg................................................. 17
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg......................................................... 40
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg........................................................... 40
INOVA 4/1 ACNE CONTROL TH -benzoyl perox pad 4% &
salicylic ac pad 1% & vit e 5% kit..................................152
INOVA 8/2 ACNE CONTROL TH -benzoyl perox pad 8% &
salicylic ac pad 2% & vit e 5% kit..................................152
204
INOVA -benzoyl peroxide pad 4% & vitamin e topical 5%
kit....................................................................................152
INOVA -benzoyl peroxide pad 8% & vitamin e topical 5%
kit....................................................................................152
INSPRA -eplerenone tab 25 mg........................................49
INSPRA -eplerenone tab 50 mg........................................49
INSTA-GLUCOSE -glucose gel 77.4%..............................29
INSULIN PEN NEEDLES-VARIOUS............................... 163
INSULIN SYRINGES-VARIOUS......................................163
INTEGRA F -fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe).....................................130
INTEGRA PLUS -fe fum-iron polysacch complex-fa-b
complex-c-biotin cap...................................................... 130
INTELENCE -etravirine tab 100 mg.................................... 8
INTELENCE -etravirine tab 200 mg.................................... 8
INTELENCE -etravirine tab 25 mg...................................... 8
INTERARTICULAR JOINT KIT -triamcinolone inj 40 mg/ml
& lidocaine 1% & ammonia inh kit................................... 20
INTERMEZZO -zolpidem tartrate sl tab 1.75 mg...............84
INTERMEZZO -zolpidem tartrate sl tab 3.5 mg.................85
INTROL -glycerin soln 75%...............................................53
INTRON A -interferon alfa-2b for inj 10000000 unit...........17
INTRON A -interferon alfa-2b for inj 18000000 unit...........17
INTRON A -interferon alfa-2b for inj 50000000 unit...........17
INTRON A -interferon alfa-2b inj 10000000 unit/ml........... 17
INTRON A -interferon alfa-2b inj 6000000 unit/ml............. 17
INTRON A W/DILUENT -interferon alfa-2b for inj
10000000 unit.................................................................. 17
INTRON A W/DILUENT -interferon alfa-2b for inj
18000000 unit.................................................................. 17
INTRON A W/DILUENT -interferon alfa-2b for inj
50000000 unit.................................................................. 17
INTUNIV -guanfacine hcl tab sr 24hr 1 mg (base
equiv)................................................................................87
INTUNIV -guanfacine hcl tab sr 24hr 2 mg (base
equiv)................................................................................87
INTUNIV -guanfacine hcl tab sr 24hr 3 mg (base
equiv)................................................................................87
INTUNIV -guanfacine hcl tab sr 24hr 4 mg (base
equiv)................................................................................87
INVEGA -paliperidone tab sr 24hr 1.5 mg.........................82
INVEGA -paliperidone tab sr 24hr 3 mg............................82
INVEGA -paliperidone tab sr 24hr 6 mg............................82
INVEGA -paliperidone tab sr 24hr 9 mg............................82
INVIRASE -saquinavir mesylate cap 200 mg...................... 8
INVIRASE -saquinavir mesylate tab 500 mg.......................8
INVOKAMET -canagliflozin-metformin hcl tab 150-1000
mg.................................................................................... 29
INVOKAMET -canagliflozin-metformin hcl tab 150-500
mg.................................................................................... 29
INVOKAMET -canagliflozin-metformin hcl tab 50-1000
mg.................................................................................... 29
INVOKAMET -canagliflozin-metformin hcl tab 50-500
mg.................................................................................... 29
INVOKANA -canagliflozin tab 100 mg............................... 29
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
INVOKANA -canagliflozin tab 300 mg............................... 29
IODINE STRONG -iodine solution strong 5%
(lugol's)........................................................................... 125
IODINE TINCTURE -iodine tincture................................ 163
IODINE TINCTURE MILD -iodine tincture....................... 163
IODINE TINCTURE STRONG DE -iodine tincture
strong............................................................................. 163
IODINE TINCTURE STRONG -iodine tincture strong......163
iodoquinol-hc cream 1%............................................... 152
iodoquinol-hydrocortisone in aloe vehicle cream
1-1.9% (Vytone)............................................................ 152
IONSYS -fentanyl hcl iontophoretic td system 40 mcg/act
(base equiv)..................................................................... 97
IOPIDINE -apraclonidine hcl ophth soln 0.5% (base
equivalent)......................................................................138
IOPIDINE -apraclonidine hcl ophth soln 1% (base
equivalent)......................................................................138
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml.......63
ipratropium bromide inhal soln 0.02%.......................... 63
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)........................................................................ 59
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)........................................................................ 59
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide).......................................................................... 49
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide).......................................................................... 49
irbesartan tab 150 mg (Avapro)..................................... 49
irbesartan tab 300 mg (Avapro)..................................... 49
irbesartan tab 75 mg (Avapro)....................................... 49
IRENKA -duloxetine hcl enteric coated pellets cap 40
mg.................................................................................... 78
IRESSA -gefitinib tab 250 mg........................................... 17
IRON ASP GLY/ POLYSACCH C -fe asp gly-fe polysacchsucc ac-c-threon ac-b12-fa cap..................................... 130
IRON CHEWS PEDIATRIC -carbonyl iron chew tab 15 mg
(elemental iron).............................................................. 130
iron combination cap.................................................... 130
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg
(Hematron-af)................................................................130
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Corvite 150)................................................................. 130
iron polysacch complex-vit b12-fa cap 150-0.025-1
mg.................................................................................. 130
iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg
(Icar-c plus)...................................................................130
IROSPAN 24/6 -fe bisglyc-fe polys-succ acd-b cmplx-c-cafa tab ther pk................................................................. 130
IS 24/6 -fe bisglyc-fe polys-succ acd-b cmplx-c-ca-fa tab
ther pk............................................................................ 130
ISENTRESS -raltegravir potassium chew tab 100 mg
(base equiv)....................................................................... 8
ISENTRESS -raltegravir potassium chew tab 25 mg (base
equiv)..................................................................................8
ISENTRESS -raltegravir potassium packet for susp 100
mg (base equiv)................................................................. 8
ISENTRESS -raltegravir potassium tab 400 mg (base
equiv)..................................................................................8
isometheptene-caffeine-acetaminophen tab 65-20-325
mg (Prodrin)................................................................. 105
ISONIAZID -isoniazid syrup 50 mg/5ml...............................6
isoniazid tab 100 mg......................................................... 6
isoniazid tab 300 mg......................................................... 6
ISOPTIN SR -verapamil hcl tab cr 120 mg........................43
ISOPTIN SR -verapamil hcl tab cr 180 mg........................43
ISOPTIN SR -verapamil hcl tab cr 240 mg........................43
ISOPTO ATROPINE -atropine sulfate ophth soln 1%......138
ISOPTO CARBACHOL -carbachol ophth soln 1.5%....... 138
ISOPTO CARBACHOL -carbachol ophth soln 3%.......... 138
ISOPTO CARPINE -pilocarpine hcl ophth soln 1%......... 139
ISOPTO CARPINE -pilocarpine hcl ophth soln 2%......... 139
ISOPTO CARPINE -pilocarpine hcl ophth soln 4%......... 139
ISOPTO HOMATROPINE -homatropine hbr ophth soln
2%.................................................................................. 139
ISOPTO HOMATROPINE -homatropine hbr ophth soln
5%.................................................................................. 139
ISOPTO HYOSCINE -scopolamine hbr ophth soln
0.25%............................................................................. 139
ISORDIL TITRADOSE -isosorbide dinitrate tab 40 mg......39
ISORDIL TITRADOSE -isosorbide dinitrate tab 5 mg........39
ISOSORBIDE DINITRATE -isosorbide dinitrate tab 30
mg.................................................................................... 39
isosorbide dinitrate tab 10 mg....................................... 39
isosorbide dinitrate tab 20 mg....................................... 39
isosorbide dinitrate tab 5 mg (Isordil titradose)........... 39
isosorbide dinitrate tab cr 40 mg...................................39
isosorbide mononitrate tab 10 mg.................................39
isosorbide mononitrate tab 20 mg.................................39
isosorbide mononitrate tab sr 24hr 120 mg (Imdur)..... 39
isosorbide mononitrate tab sr 24hr 30 mg (Imdur)....... 39
isosorbide mononitrate tab sr 24hr 60 mg (Imdur)....... 39
isotretinoin cap 10 mg.................................................. 152
isotretinoin cap 20 mg.................................................. 152
isotretinoin cap 40 mg.................................................. 152
ISOXSUPRINE HCL -isoxsuprine hcl tab 20 mg............... 57
isoxsuprine hcl tab 10 mg.............................................. 57
isradipine cap 2.5 mg......................................................43
isradipine cap 5 mg.........................................................43
ISTALOL -timolol maleate ophth soln 0.5% (oncedaily)...............................................................................139
itraconazole cap 100 mg (Sporanox)............................... 6
ivermectin tab 3 mg (Stromectol).................................. 11
IXINITY -coagulation factor ix (recombinant) for inj 1000
unit..................................................................................135
IXINITY -coagulation factor ix (recombinant) for inj 1500
unit..................................................................................135
IXINITY -coagulation factor ix (recombinant) for inj 500
unit..................................................................................135
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
205
2015
J
JADENU -deferasirox tab 180 mg................................... 163
JADENU -deferasirox tab 360 mg................................... 163
JADENU -deferasirox tab 90 mg..................................... 163
JAKAFI -ruxolitinib phosphate tab 10 mg (base
equivalent)........................................................................17
JAKAFI -ruxolitinib phosphate tab 15 mg (base
equivalent)........................................................................17
JAKAFI -ruxolitinib phosphate tab 20 mg (base
equivalent)........................................................................17
JAKAFI -ruxolitinib phosphate tab 25 mg (base
equivalent)........................................................................17
JAKAFI -ruxolitinib phosphate tab 5 mg (base
equivalent)........................................................................17
JALYN -dutasteride-tamsulosin hcl cap 0.5-0.4 mg...........74
JANUMET -sitagliptin-metformin hcl tab 50-1000 mg........ 29
JANUMET -sitagliptin-metformin hcl tab 50-500 mg..........29
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
100-1000 mg....................................................................29
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-1000 mg......................................................................29
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 50-500
mg.................................................................................... 29
JANUVIA -sitagliptin phosphate tab 100 mg (base
equiv)................................................................................29
JANUVIA -sitagliptin phosphate tab 25 mg (base
equiv)................................................................................29
JANUVIA -sitagliptin phosphate tab 50 mg (base
equiv)................................................................................29
JARDIANCE -empagliflozin tab 10 mg.............................. 29
JARDIANCE -empagliflozin tab 25 mg.............................. 29
JENTADUETO -linagliptin-metformin hcl tab 2.5-1000
mg.................................................................................... 29
JENTADUETO -linagliptin-metformin hcl tab 2.5-500
mg.................................................................................... 29
JENTADUETO -linagliptin-metformin hcl tab 2.5-850
mg.................................................................................... 29
JUBLIA -efinaconazole soln 10%.................................... 152
JUXTAPID -lomitapide mesylate cap 10 mg (base
equiv)................................................................................55
JUXTAPID -lomitapide mesylate cap 20 mg (base
equiv)................................................................................55
JUXTAPID -lomitapide mesylate cap 30 mg (base
equiv)................................................................................55
JUXTAPID -lomitapide mesylate cap 40 mg (base
equiv)................................................................................55
JUXTAPID -lomitapide mesylate cap 5 mg (base
equiv)................................................................................55
JUXTAPID -lomitapide mesylate cap 60 mg (base
equiv)................................................................................55
K
K2K PAIN RELIEVING PATCH -lidocaine-menthol patch
4-4%............................................................................... 152
KADIAN -morphine sulfate cap sr 24hr 100 mg................ 97
206
KADIAN -morphine sulfate cap sr 24hr 10 mg.................. 97
KADIAN -morphine sulfate cap sr 24hr 200 mg................ 97
KADIAN -morphine sulfate cap sr 24hr 20 mg.................. 97
KADIAN -morphine sulfate cap sr 24hr 30 mg.................. 97
KADIAN -morphine sulfate cap sr 24hr 40 mg.................. 97
KADIAN -morphine sulfate cap sr 24hr 50 mg.................. 97
KADIAN -morphine sulfate cap sr 24hr 60 mg.................. 97
KADIAN -morphine sulfate cap sr 24hr 80 mg.................. 97
KALETRA -lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml)................................................................................ 8
KALETRA -lopinavir-ritonavir tab 100-25 mg.......................8
KALETRA -lopinavir-ritonavir tab 200-50 mg.......................8
KALYDECO -ivacaftor packet 50 mg.................................65
KALYDECO -ivacaftor packet 75 mg.................................65
KALYDECO -ivacaftor tab 150 mg.................................... 65
KAPVAY -clonidine hcl tab sr 12hr 0.1 mg........................87
KARBINAL ER -carbinoxamine maleate er susp 4
mg/5ml..............................................................................58
KAYEXALATE -sodium polystyrene sulfonate
powder............................................................................164
KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg........29
KAZANO -alogliptin-metformin hcl tab 12.5-500 mg..........29
KEFLEX -cephalexin cap 250 mg....................................... 2
KEFLEX -cephalexin cap 500 mg....................................... 2
KEFLEX -cephalexin cap 750 mg....................................... 2
KENALOG -triamcinolone acetonide aerosol soln........... 152
KENDALL HYDROGEL IMPREGNA -hydroactive (sterile)
dressing..........................................................................152
KENDALL HYDROGEL WOUND DR -hydroactive (sterile)
dressing..........................................................................152
KENDALL ZINC CALCIUM ALGI -wound dressings misc................................................................................ 152
KENDALL ZINC CALCIUM ALGI -wound dressings pads................................................................................152
KEPPRA -levetiracetam oral soln 100 mg/ml.................. 108
KEPPRA -levetiracetam tab 1000 mg............................. 108
KEPPRA -levetiracetam tab 250 mg............................... 108
KEPPRA -levetiracetam tab 500 mg............................... 108
KEPPRA -levetiracetam tab 750 mg............................... 108
KEPPRA XR -levetiracetam tab sr 24hr 500 mg............. 108
KEPPRA XR -levetiracetam tab sr 24hr 750 mg............. 108
KERAFOAM 42 -urea foam 42%.....................................152
KERAFOAM -urea foam 30%..........................................152
KERALAC -urea cream 47%........................................... 152
KERALYT -salicylic acid gel 6%......................................152
KERALYT SCALP -salicylic acid shampoo 6% & salicylic
acid gel 6% kit............................................................... 152
KERLONE -betaxolol hcl tab 10 mg.................................. 40
KERLONE -betaxolol hcl tab 20 mg.................................. 41
KERR TRIPLE DYE -triple dye swabs............................ 163
KERYDIN -tavaborole soln 5%........................................152
KETEK -telithromycin tab 300 mg..................................... 12
KETEK -telithromycin tab 400 mg..................................... 12
ketoconazole cream 2%................................................ 152
ketoconazole foam 2% (Extina)....................................152
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
ketoconazole shampoo 2% (Nizoral)........................... 152
ketoconazole tab 200 mg..................................................6
KETODAN KIT -ketoconazole foam 2% & cleanser
kit....................................................................................152
KETONE BLOOD TEST STRIPS – VARIOUS................ 163
ketoprofen cap 50 mg................................................... 102
ketoprofen cap 75 mg................................................... 102
KETOPROFEN ER -ketoprofen cap sr 24hr 200 mg....... 102
ketorolac tromethamine ophth soln 0.4% (Acular
ls)................................................................................... 139
ketorolac tromethamine ophth soln 0.5% (Acular)..... 139
ketorolac tromethamine tab 10 mg.............................. 102
KHEDEZLA -desvenlafaxine tab sr 24hr 100 mg.............. 78
KHEDEZLA -desvenlafaxine tab sr 24hr 50 mg................ 78
KINERET -anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml............................................................... 103
KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj...............................................................................15
KITABIS PAK -tobramycin nebu soln 300 mg/5ml...............5
KLARON -sulfacetamide sodium lotion 10% (acne)........ 152
KLONOPIN -clonazepam tab 0.5 mg.............................. 108
KLONOPIN -clonazepam tab 1 mg................................. 108
KLONOPIN -clonazepam tab 2 mg................................. 108
KLOR-CON/25 -potassium chloride powder packet 25
meq................................................................................ 125
KLOR-CON 25 -potassium chloride powder packet 25
meq................................................................................ 125
KLOR-CON M15 -potassium chloride microencapsulated
crys cr tab 15 meq.........................................................125
KOATE-DVI -antihemophilic factor (human) for inj 1000
unit..................................................................................135
KOATE-DVI -antihemophilic factor (human) for inj 250
unit..................................................................................135
KOATE-DVI -antihemophilic factor (human) for inj 500
unit..................................................................................135
KOGENATE FS -antihemophilic factor (recombinant) for inj
kit 1000 unit................................................................... 135
KOGENATE FS -antihemophilic factor (recombinant) for inj
kit 2000 unit................................................................... 135
KOGENATE FS -antihemophilic factor (recombinant) for inj
kit 250 unit..................................................................... 135
KOGENATE FS -antihemophilic factor (recombinant) for inj
kit 3000 unit................................................................... 135
KOGENATE FS -antihemophilic factor (recombinant) for inj
kit 500 unit..................................................................... 135
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 1000 unit.................................. 135
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 2000 unit.................................. 135
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 250 unit.................................... 135
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 3000 unit.................................. 135
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 500 unit.................................... 135
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.....................................................................29
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
5-1000 mg........................................................................29
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
5-500 mg..........................................................................29
KORLYM -mifepristone tab 300 mg.................................. 29
K-PHOS NEUTRAL -pot phos monobasic w/sod phos di &
monobas tab 155-852-130mg........................................125
K-PHOS NO 2 -potassium & sodium acid phosphates tab
305-700 mg......................................................................74
K-PHOS -potassium phosphate monobasic tab 500
mg.................................................................................. 125
KRISTALOSE -lactulose oral crystal packet 10 gm........... 65
KRISTALOSE -lactulose oral crystal packet 20 gm........... 65
KROGER GLUCOSE -glucose chew tab 4 gm..................29
KROGER GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 29
K-TAB -potassium chloride tab cr 10 meq.......................125
K-TAB -potassium chloride tab cr 20 meq (1500 mg)...... 125
K-TAB -potassium chloride tab cr 8 meq (600 mg)..........125
KUVAN -sapropterin dihydrochloride powder packet 100
mg.................................................................................... 37
KUVAN -sapropterin dihydrochloride powder packet 500
mg.................................................................................... 37
KUVAN -sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 37
KYNAMRO -mipomersen sodium soln prefilled syringe 200
mg/ml................................................................................55
L
labetalol hcl tab 100 mg (Trandate)............................... 41
labetalol hcl tab 200 mg (Trandate)............................... 41
labetalol hcl tab 300 mg (Trandate)............................... 41
LAC-HYDRIN -lactic acid (ammonium lactate) cream
12%................................................................................ 152
LAC-HYDRIN -lactic acid (ammonium lactate) lotion
12%................................................................................ 152
LACRISERT -artificial tear ophth insert........................... 139
lactic acid (ammonium lactate) cream 12% (Lachydrin)........................................................................... 152
lactic acid (ammonium lactate) lotion 10%................. 152
lactic acid (ammonium lactate) lotion 12% (Lachydrin)........................................................................... 153
lactic acid w/ vitamin e cream 10%-3500
unit/30gm...................................................................... 153
lactulose (encephalopathy) solution 10 gm/15ml......... 71
lactulose solution 10 gm/15ml....................................... 65
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 25 mg.......................................... 108
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 5 mg............................................ 108
LAMICTAL -lamotrigine tab 100 mg................................ 108
LAMICTAL -lamotrigine tab 150 mg................................ 108
LAMICTAL -lamotrigine tab 200 mg................................ 108
LAMICTAL -lamotrigine tab 25 mg.................................. 108
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
207
2015
LAMICTAL ODT -lamotrigine orally disintegrating tab 100
mg.................................................................................. 108
LAMICTAL ODT -lamotrigine orally disintegrating tab 200
mg.................................................................................. 108
LAMICTAL ODT -lamotrigine orally disintegrating tab 25
mg.................................................................................. 108
LAMICTAL ODT -lamotrigine orally disintegrating tab 50
mg.................................................................................. 108
LAMICTAL ODT -lamotrigine tab disp 25 (14) & 50 mg (14)
& 100 mg (7) kit.............................................................108
LAMICTAL ODT -lamotrigine tab disp 25 mg (21) & 50 mg
(7) titration kit................................................................. 108
LAMICTAL ODT -lamotrigine tab disp 50 mg (42) & 100
mg (14) titration kit.........................................................108
LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit.......................................... 108
LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit........................................ 108
LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg
(35) starter kit................................................................ 108
LAMICTAL XR -lamotrigine tab sr 24hr 100 mg.............. 108
LAMICTAL XR -lamotrigine tab sr 24hr 200 mg.............. 108
LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit...................................................... 108
LAMICTAL XR -lamotrigine tab sr 24hr 250 mg.............. 108
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg................ 108
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit...........................................................108
LAMICTAL XR -lamotrigine tab sr 24hr 300 mg.............. 108
LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit..................................................108
LAMICTAL XR -lamotrigine tab sr 24hr 50 mg................ 108
LAMISIL -terbinafine hcl oral granules packet 125 mg........ 7
LAMISIL -terbinafine hcl oral granules packet 187.5 mg..... 7
LAMISIL -terbinafine hcl tab 250 mg................................... 6
lamivudine oral soln 10 mg/ml (Epivir)............................8
lamivudine tab 100 mg (hbv) (Epivir hbv)....................... 8
lamivudine tab 150 mg (Epivir)........................................ 8
lamivudine tab 300 mg (Epivir)........................................ 8
lamivudine-zidovudine tab 150-300 mg (Combivir)........ 8
lamotrigine orally disintegrating tab 100 mg (Lamictal
odt).................................................................................108
lamotrigine orally disintegrating tab 200 mg (Lamictal
odt).................................................................................109
lamotrigine orally disintegrating tab 25 mg (Lamictal
odt).................................................................................108
lamotrigine orally disintegrating tab 50 mg (Lamictal
odt).................................................................................108
lamotrigine tab 100 mg (Lamictal)............................... 109
lamotrigine tab 150 mg (Lamictal)............................... 109
lamotrigine tab 200 mg (Lamictal)............................... 109
lamotrigine tab 25 mg (Lamictal)................................. 109
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................. 109
208
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................. 109
lamotrigine tab sr 24hr 100 mg (Lamictal xr).............. 109
lamotrigine tab sr 24hr 200 mg (Lamictal xr).............. 109
lamotrigine tab sr 24hr 250 mg (Lamictal xr).............. 109
lamotrigine tab sr 24hr 25 mg (Lamictal xr)................ 109
lamotrigine tab sr 24hr 300 mg (Lamictal xr).............. 109
lamotrigine tab sr 24hr 50 mg (Lamictal xr)................ 109
LANCETS-VARIOUS....................................................... 163
LANOXIN -digoxin tab 125 mcg (0.125 mg)...................... 39
LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................. 39
LANOXIN -digoxin tab 250 mcg (0.25 mg)........................ 39
LANOXIN -digoxin tab 62.5 mcg (0.0625 mg)................... 39
lansoprazole cap delayed release 15 mg
(Prevacid)........................................................................ 67
lansoprazole cap delayed release 30 mg
(Prevacid)........................................................................ 67
LANTUS -insulin glargine inj 100 unit/ml........................... 32
LANTUS SOLOSTAR -insulin glargine soln pen-injector
100 unit/ml....................................................................... 32
LASIX -furosemide tab 20 mg........................................... 53
LASIX -furosemide tab 40 mg........................................... 53
LASIX -furosemide tab 80 mg........................................... 53
LASTACAFT -alcaftadine ophth soln 0.25%....................139
latanoprost ophth soln 0.005% (Xalatan).................... 139
LATRIX XM -urea in zinc undecylenate-lactic acid vehicle
emulsion 45%................................................................ 153
LATUDA -lurasidone hcl tab 120 mg.................................82
LATUDA -lurasidone hcl tab 20 mg...................................82
LATUDA -lurasidone hcl tab 40 mg...................................82
LATUDA -lurasidone hcl tab 60 mg...................................82
LATUDA -lurasidone hcl tab 80 mg...................................82
LAVARE WOUND WASH -wound cleansers - gel...........153
LAVOCLEN-4 CREAMY WASH -benzoyl peroxide liq
4%.................................................................................. 153
LAVOCLEN-8 CREAMY WASH -benzoyl peroxide liq
8%.................................................................................. 153
LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base
equiv)................................................................................97
LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base
equiv)................................................................................97
LEADER GLUCOSE -glucose chew tab 4 gm...................29
LEADER GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 30
LEADER QUICK DISSOLVE GLU -glucose chew tab 4
gm.................................................................................... 30
LECITHIN -lecithin granules............................................ 126
leflunomide tab 10 mg (Arava)..................................... 103
leflunomide tab 20 mg (Arava)..................................... 103
LENVIMA 10MG DAILY DOSE -lenvatinib cap therapy
pack 10 mg (10 mg daily dose)....................................... 17
LENVIMA 14MG DAILY DOSE -lenvatinib cap therapy
pack 10 & 4 mg (14 mg daily dose)................................ 18
LENVIMA 20MG DAILY DOSE -lenvatinib cap therapy
pack 10 (2) mg (20 mg daily dose)..................................18
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
LENVIMA 24MG DAILY DOSE -lenvatinib cap therapy
pack 10 (2) & 4 mg (24 mg daily dose)........................... 18
LESCOL -fluvastatin sodium cap 20 mg........................... 55
LESCOL -fluvastatin sodium cap 40 mg........................... 55
LESCOL XL -fluvastatin sodium tab sr 24 hr 80 mg.......... 55
LETAIRIS -ambrisentan tab 10 mg................................... 58
LETAIRIS -ambrisentan tab 5 mg..................................... 57
letrozole tab 2.5 mg (Femara).........................................18
LEUCOVORIN CALCIUM -leucovorin calcium tab 10
mg.................................................................................... 18
LEUCOVORIN CALCIUM -leucovorin calcium tab 15
mg.................................................................................... 18
leucovorin calcium tab 25 mg........................................ 18
leucovorin calcium tab 5 mg.......................................... 18
LEUKERAN -chlorambucil tab 2 mg..................................18
LEUKINE -sargramostim lyophilized for inj 250 mcg....... 130
leuprolide acetate inj kit 5 mg/ml...................................18
LEVACET -aspirin-apap-salicylamide-caffeine tab
500-250-150-32.5 mg...................................................... 93
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)........................................................................ 64
levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)
(Xopenex)........................................................................ 64
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)
(Xopenex)........................................................................ 64
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv)...............................................................................63
LEVAQUIN -levofloxacin oral soln 25 mg/ml....................... 5
LEVAQUIN -levofloxacin tab 250 mg.................................. 5
LEVAQUIN -levofloxacin tab 500 mg.................................. 5
LEVAQUIN -levofloxacin tab 750 mg.................................. 5
LEVATIO PATCH -capsaicin-menthol topical patch
0.03-5%.......................................................................... 153
LEVATOL -penbutolol sulfate tab 20 mg........................... 41
LEVBID -hyoscyamine sulfate tab sr 12hr 0.375 mg......... 67
LEVEMIR FLEXPEN -insulin detemir soln pen-injector 100
unit/ml...............................................................................32
LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector
100 unit/ml....................................................................... 33
LEVEMIR -insulin detemir inj 100 unit/ml.......................... 32
levetiracetam oral soln 100 mg/ml (Keppra)............... 109
levetiracetam tab 1000 mg (Keppra)............................ 109
levetiracetam tab 250 mg (Keppra).............................. 109
levetiracetam tab 500 mg (Keppra).............................. 109
levetiracetam tab 750 mg (Keppra).............................. 109
levetiracetam tab sr 24hr 500 mg (Keppra xr).............109
levetiracetam tab sr 24hr 750 mg (Keppra xr).............109
LEVOBUNOLOL HCL -levobunolol hcl ophth soln
0.25%............................................................................. 139
levobunolol hcl ophth soln 0.5% (Betagan)................ 139
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 37
levocarnitine tab 330 mg (Carnitor)............................... 37
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/
ml) (Xyzal)....................................................................... 58
levocetirizine dihydrochloride tab 5 mg (Xyzal)............58
levofloxacin ophth soln 0.5%....................................... 139
levofloxacin oral soln 25 mg/ml (Levaquin).................... 5
levofloxacin tab 250 mg (Levaquin).................................5
levofloxacin tab 500 mg (Levaquin).................................5
levofloxacin tab 750 mg (Levaquin).................................5
LEVOMEFOLATE CALCIUM/ACET -l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg............................127
LEVOMEFOLATE CALCIUM/ALGA -l-methylfolate-algae
cap 15-90.314 mg..........................................................127
LEVOMEFOLATE CALCIUM/ALGA -l-methylfolate-algae
cap 7.5-90.314 mg.........................................................127
LEVOMEFOLATE CALCIUM/PYRI -l-methylfolate-algaevit b12-b6 cap 3-90.314-2-35 mg.................................. 127
LEVOMEFOLATE DHA -prenat w/fe fum-l methylfolate-fadha cap 27-1.13-0.4 mg................................................ 117
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg................................................................... 24
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg.................................................................................. 24
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg.................................................................................. 24
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg.................................25
levonorgestrel-ethinyl estradiol (continuous) tab 90-20
mcg.................................................................................. 25
levonorgestrel tab 1.5 mg (Plan b one-step)................. 24
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique).............................................24
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique).................................................24
LEVORPHANOL TARTRATE -levorphanol tartrate tab 2
mg.................................................................................... 97
levothyroxine sodium tab 100 mcg (Synthroid)............33
levothyroxine sodium tab 112 mcg (Synthroid)............33
levothyroxine sodium tab 125 mcg (Synthroid)............33
levothyroxine sodium tab 137 mcg (Synthroid)............33
levothyroxine sodium tab 150 mcg (Synthroid)............33
levothyroxine sodium tab 175 mcg (Synthroid)............33
levothyroxine sodium tab 200 mcg (Synthroid)............33
levothyroxine sodium tab 25 mcg (Synthroid)..............33
levothyroxine sodium tab 300 mcg (Synthroid)............33
levothyroxine sodium tab 50 mcg (Synthroid)..............33
levothyroxine sodium tab 75 mcg (Synthroid)..............33
levothyroxine sodium tab 88 mcg (Synthroid)..............33
LEVSIN/SL -hyoscyamine sulfate tab sl 0.125 mg............ 67
LEVSIN -hyoscyamine sulfate tab 0.125 mg..................... 67
LEVULAN KERASTICK -aminolevulinic acid hcl for soln
20% (stick applicator).................................................... 153
LEXAPRO -escitalopram oxalate soln 5 mg/5ml (base
equiv)................................................................................78
LEXAPRO -escitalopram oxalate tab 10 mg (base
equiv)................................................................................78
LEXAPRO -escitalopram oxalate tab 20 mg (base
equiv)................................................................................78
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
209
2015
LEXAPRO -escitalopram oxalate tab 5 mg (base
equiv)................................................................................78
LEXIVA -fosamprenavir calcium susp 50 mg/ml (base
equiv)..................................................................................8
LEXIVA -fosamprenavir calcium tab 700 mg (base
equiv)..................................................................................8
LEXUSS 210 -chlorpheniramine w/ codeine liquid 2-10
mg/5ml..............................................................................60
LIALDA -mesalamine tab delayed release 1.2 gm............ 71
LIBRAX -chlordiazepoxide hcl-clidinium bromide cap 5-2.5
mg.................................................................................... 67
LIDENZA PATCH -lidocaine-menthol patch 4-1%........... 153
LIDOCAINE AND TETRACAINE -lidocaine-tetracaine
cream 7-7%....................................................................153
lidocaine hcl cream 3%.................................................153
lidocaine hcl gel 2%...................................................... 153
LIDOCAINE HCL-HYDROCORTIS -lidocainehydrocortisone acetate rectal gel 2.8-0.55%..................144
lidocaine hcl laryngotracheal soln 4% (Lta 360
kit).................................................................................. 142
LIDOCAINE HCL -lidocaine hcl lotion 3%....................... 153
lidocaine hcl soln 4% (Xylocaine)................................ 153
lidocaine hcl viscous soln 2%......................................142
lidocaine-hydrocortisone acetate rectal cream
3-0.5%............................................................................ 144
lidocaine-hydrocortisone acetate rectal cream kit
2-2%............................................................................... 144
lidocaine-hydrocortisone acetate rectal cream kit
3-0.5%............................................................................ 144
lidocaine-hydrocortisone acetate rectal cream kit
3-1%............................................................................... 144
lidocaine-hydrocortisone acetate rectal gel kit
3-2.5%............................................................................ 144
lidocaine-menthol patch 4-5%...................................... 153
lidocaine oint 5%........................................................... 153
lidocaine patch 5% (700 mg) (Lidoderm).....................153
lidocaine-prilocaine cream 2.5-2.5% (Emla)................ 153
lidocaine-prilocaine kit 2.5-2.5%.................................. 153
lidocaine-prilocaine kit 2.5-2.5%.................................. 153
LIDOCIN -lidocaine hcl gel 3%........................................153
LIDODERM -lidocaine patch 5% (700 mg)......................153
LIDODEXTRAPINE -lidocaine-menthol patch 4-1%........ 153
LIDOPIN -lidocaine hcl cream 3.25%.............................. 153
LIDORX -lidocaine hcl gel 3%......................................... 153
LIDOTHOL -lidocaine-menthol patch 4.5-5%.................. 153
LIDOVEX -lidocaine cream 3.75%.................................. 153
LIDOVIN -lidocaine hcl cream 3.95%.............................. 153
LIDOZOL -lidocaine hcl cream 3.75%............................. 153
LIMBREL250 -flavocoxid-citrated zinc bisglycinate cap
250-50 mg......................................................................127
LIMBREL500 -flavocoxid-citrated zinc bisglycinate cap
500-50 mg......................................................................127
LIMBREL -flavocoxid cap 250 mg................................... 127
LIMBREL -flavocoxid cap 500 mg................................... 127
lindane lotion 1%........................................................... 153
210
lindane shampoo 1%.....................................................153
linezolid tab 600 mg (Zyvox).......................................... 12
LINZESS -linaclotide cap 145 mcg....................................71
LINZESS -linaclotide cap 290 mcg....................................71
liothyronine sodium tab 25 mcg (Cytomel)................... 33
liothyronine sodium tab 50 mcg (Cytomel)................... 33
liothyronine sodium tab 5 mcg (Cytomel)..................... 33
LIPITOR -atorvastatin calcium tab 10 mg (base
equivalent)........................................................................55
LIPITOR -atorvastatin calcium tab 20 mg (base
equivalent)........................................................................55
LIPITOR -atorvastatin calcium tab 40 mg (base
equivalent)........................................................................55
LIPITOR -atorvastatin calcium tab 80 mg (base
equivalent)........................................................................55
LIPOFEN -fenofibrate cap 150 mg.................................... 55
LIPOFEN -fenofibrate cap 50 mg...................................... 55
LIPTRUZET -ezetimibe-atorvastatin tab 10-10 mg............55
LIPTRUZET -ezetimibe-atorvastatin tab 10-20 mg............55
LIPTRUZET -ezetimibe-atorvastatin tab 10-40 mg............55
LIPTRUZET -ezetimibe-atorvastatin tab 10-80 mg............55
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)......................................................................49
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)......................................................................49
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)......................................................................49
lisinopril tab 10 mg (Prinivil).......................................... 49
lisinopril tab 2.5 mg (Zestril).......................................... 49
lisinopril tab 20 mg (Prinivil).......................................... 49
lisinopril tab 30 mg (Zestril)........................................... 49
lisinopril tab 40 mg (Zestril)........................................... 49
lisinopril tab 5 mg (Prinivil)............................................ 49
LISTERINE ESSENTIAL CARE -sod monofluorophospheucal-men-methyl sal-thymol gel 0.76%........................ 142
LISTERINE RESTORING -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................ 142
LISTERINE SMART RINSE ANT -sodium fluoride rinse
0.02%............................................................................. 142
LISTERINE SMART RINSE -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 142
LISTERINE TOOTH DEFENSE -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 142
LISTERINE TOTAL CARE PLUS -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 142
LISTERINE TOTAL CARE -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................ 142
LISTERINE TOTAL CARE ZERO -sodium fluoride rinse
0.02%............................................................................. 142
LISTERINE WHITENING/RESTO -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 142
lithium carbonate cap 150 mg (Lithium carbonate)...... 82
lithium carbonate cap 300 mg........................................82
lithium carbonate cap 600 mg (Lithium carbonate)...... 82
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
LITHIUM CARBONATE -lithium carbonate cap 150
mg.................................................................................... 82
LITHIUM CARBONATE -lithium carbonate cap 600
mg.................................................................................... 82
lithium carbonate tab 300 mg.........................................82
lithium carbonate tab cr 300 mg (Lithobid)................... 82
lithium carbonate tab cr 450 mg.................................... 82
LITHIUM -lithium oral solution 8 meq/5ml......................... 82
LITHOBID -lithium carbonate tab cr 300 mg..................... 82
LITHOSTAT -acetohydroxamic acid tab 250 mg............... 74
LIVALO -pitavastatin calcium tab 1 mg (base equiv)......... 55
LIVALO -pitavastatin calcium tab 2 mg (base equiv)......... 55
LIVALO -pitavastatin calcium tab 4 mg (base equiv)......... 55
L-METHYL-B6-B12 -l-methylfolate w/ vit b6-vit b12 tab
3-35-2 mg.......................................................................126
L-METHYLFOLATE CA/ME-CBL/ -l-methylfolatemethylcobalamin-acetylcyst tab 6-2-600 mg..................127
L-METHYLFOLATE CA/P-5-P/M -l-methylfolate-algae-vit
b12-b6 cap 3-90.314-2-35 mg....................................... 127
L-METHYLFOLATE CA/P-5-P/M -l-methylfolate w/ vit b6vit b12 tab 3-35-2 mg.................................................... 127
L-METHYLFOLATE CALCIUM -l-methylfolate tab 15
mg.................................................................................. 127
L-METHYLFOLATE CALCIUM -l-methylfolate tab 7.5
mg.................................................................................. 127
L-METHYLFOLATE CA ME-CBL -l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg............................127
L-METHYLFOLATE FORMULA 15 -l-methylfolate-algae
cap 15-90.314 mg..........................................................127
L-METHYLFOLATE FORMULA 7. -l-methylfolate-algae
cap 7.5-90.314 mg.........................................................127
L-METHYLFOLATE FORTE -l-methylfolate-algae cap
15-90.314 mg.................................................................127
L-METHYLFOLATE FORTE -l-methylfolate-algae cap
7.5-90.314 mg................................................................127
L-METHYLFOLATE -l-methylfolate tab 15 mg................ 127
L-METHYLFOLATE -l-methylfolate tab 7.5 mg................127
L-METHYLFOLATE PNV DHA -prenat w/fe fum-l
methylfolate-fa-dha cap 27-1.13-0.4 mg........................ 117
L-METHYL-MC -l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg................................................................... 126
L-METHYL-MC NAC -l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg............................................. 126
LMTHF/PYRIDOXINE HCL/CYAN -l-methylfolate w/ vit b6vit b12 tab 1.13-25-2 mg............................................... 127
LOCOID -hydrocortisone butyrate cream 0.1%............... 153
LOCOID -hydrocortisone butyrate lotion 0.1%................ 153
LOCOID -hydrocortisone butyrate oint 0.1%................... 153
LOCOID -hydrocortisone butyrate soln 0.1%.................. 153
LOCOID LIPOCREAM -hydrocortisone butyrate
hydrophilic lipo base cream 0.1%.................................. 153
LODOSYN -carbidopa tab 25 mg....................................111
LOESTRIN 1/20-21 -norethindrone ace & ethinyl estradiol
tab 1 mg-20 mcg............................................................. 25
LOESTRIN 1.5/30-21 -norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg............................................ 25
LOESTRIN FE 1/20 -norethindrone ace & ethinyl estradiolfe tab 1 mg-20 mcg......................................................... 25
LOESTRIN FE 1.5/30 -norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg........................................25
LOFIBRA -fenofibrate micronized cap 134 mg.................. 55
LOFIBRA -fenofibrate micronized cap 200 mg.................. 55
LOFIBRA -fenofibrate micronized cap 67 mg.................... 55
LOFIBRA -fenofibrate tab 160 mg.....................................55
LOFIBRA -fenofibrate tab 54 mg.......................................55
LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)........................................................ 25
LOMOTIL -diphenoxylate w/ atropine tab 2.5-0.025
mg.................................................................................... 66
LOMUSTINE -lomustine cap 100 mg................................ 18
LOMUSTINE -lomustine cap 10 mg.................................. 18
LOMUSTINE -lomustine cap 40 mg.................................. 18
LONGS GLUCOSE -glucose chew tab 4 gm.................... 30
LONGS GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 30
LOPID -gemfibrozil tab 600 mg......................................... 55
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
100-25 mg........................................................................49
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
50-25 mg..........................................................................49
LOPRESSOR -metoprolol tartrate tab 100 mg.................. 41
LOPRESSOR -metoprolol tartrate tab 50 mg.................... 41
LOPROX SHAMPOO -ciclopirox shampoo 1%............... 153
lorazepam conc 2 mg/ml (Lorazepam intensol)............ 75
LORAZEPAM INTENSOL -lorazepam conc 2 mg/ml........ 75
lorazepam tab 0.5 mg (Ativan)....................................... 75
lorazepam tab 1 mg (Ativan).......................................... 75
lorazepam tab 2 mg (Ativan).......................................... 75
LORENZA -lidocaine-menthol patch 4-1%...................... 153
LORTUSS EX -pseudoephedrine w/ cod-gg liquid
30-10-100 mg/5ml............................................................60
LORZONE -chlorzoxazone tab 375 mg...........................114
LORZONE -chlorzoxazone tab 750 mg...........................114
losartan potassium & hydrochlorothiazide tab 100-12.5
mg (Hyzaar).................................................................... 49
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar).................................................................... 49
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar).................................................................... 49
losartan potassium tab 100 mg (Cozaar)...................... 49
losartan potassium tab 25 mg (Cozaar)........................ 49
losartan potassium tab 50 mg (Cozaar)........................ 49
LOSEASONIQUE -levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)...................................................... 25
LOTEMAX -loteprednol etabonate ophth gel 0.5%..........139
LOTEMAX -loteprednol etabonate ophth oint 0.5%.........139
LOTEMAX -loteprednol etabonate ophth susp 0.5%....... 139
LOTENSIN -benazepril hcl tab 10 mg............................... 49
LOTENSIN -benazepril hcl tab 20 mg............................... 49
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
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LOTENSIN -benazepril hcl tab 40 mg............................... 49
LOTENSIN HCT -benazepril & hydrochlorothiazide tab
10-12.5 mg.......................................................................49
LOTENSIN HCT -benazepril & hydrochlorothiazide tab
20-12.5 mg.......................................................................49
LOTENSIN HCT -benazepril & hydrochlorothiazide tab
20-25 mg..........................................................................49
LOTREL -amlodipine besylate-benazepril hcl cap 10-20
mg.................................................................................... 49
LOTREL -amlodipine besylate-benazepril hcl cap 10-40
mg.................................................................................... 49
LOTREL -amlodipine besylate-benazepril hcl cap 2.5-10
mg.................................................................................... 49
LOTREL -amlodipine besylate-benazepril hcl cap 5-10
mg.................................................................................... 49
LOTREL -amlodipine besylate-benazepril hcl cap 5-20
mg.................................................................................... 49
LOTRIMIN ULTRA -butenafine hcl cream 1%................. 153
LOTRISONE -clotrimazole w/ betamethasone cream
1-0.05%.......................................................................... 153
LOTRONEX -alosetron hcl tab 0.5 mg (base equiv)..........71
LOTRONEX -alosetron hcl tab 1 mg (base equiv).............71
LOUTREX -antiseborrheic products misc - cream...........153
lovastatin tab 10 mg........................................................55
lovastatin tab 20 mg (Mevacor)......................................55
lovastatin tab 40 mg (Mevacor)......................................56
LOVAZA -omega-3-acid ethyl esters cap 1 gm................. 56
LOVENOX -enoxaparin sodium inj 100 mg/ml................ 132
LOVENOX -enoxaparin sodium inj 120 mg/0.8ml............132
LOVENOX -enoxaparin sodium inj 150 mg/ml................ 133
LOVENOX -enoxaparin sodium inj 300 mg/3ml.............. 133
LOVENOX -enoxaparin sodium inj 30 mg/0.3ml............. 132
LOVENOX -enoxaparin sodium inj 40 mg/0.4ml............. 132
LOVENOX -enoxaparin sodium inj 60 mg/0.6ml............. 132
LOVENOX -enoxaparin sodium inj 80 mg/0.8ml............. 132
loxapine succinate cap 10 mg........................................82
loxapine succinate cap 25 mg........................................82
loxapine succinate cap 50 mg........................................82
loxapine succinate cap 5 mg......................................... 82
LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg
naf)................................................................................. 125
LTA 360 KIT -lidocaine hcl laryngotracheal soln 4%....... 142
LUFYLLIN -dyphylline tab 400 mg.................................... 64
LUGOLS STRONG IODINE -iodine solution................... 163
LUMIGAN -bimatoprost ophth soln 0.01%.......................139
LUNESTA -eszopiclone tab 1 mg......................................85
LUNESTA -eszopiclone tab 2 mg......................................85
LUNESTA -eszopiclone tab 3 mg......................................85
LURIDE -sodium fluoride chew tab 0.25 mg f (from 0.55
mg naf)...........................................................................125
LURIDE -sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf)................................................................................. 125
LURIDE -sodium fluoride chew tab 1 mg f (from 2.2 mg
naf)................................................................................. 125
212
LURIDE -sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf)................................................................................. 125
LUXIQ -betamethasone valerate aerosol foam 0.12%.....153
LUZU -luliconazole cream 1%......................................... 153
LYCELLE -nit remover - gel............................................ 153
LYNPARZA -olaparib cap 50 mg.......................................18
LYRICA -pregabalin cap 100 mg.....................................109
LYRICA -pregabalin cap 150 mg.....................................109
LYRICA -pregabalin cap 200 mg.....................................109
LYRICA -pregabalin cap 225 mg.....................................109
LYRICA -pregabalin cap 25 mg.......................................109
LYRICA -pregabalin cap 300 mg.....................................109
LYRICA -pregabalin cap 50 mg.......................................109
LYRICA -pregabalin cap 75 mg.......................................109
LYRICA -pregabalin soln 20 mg/ml................................. 109
LYSODREN -mitotane tab 500 mg....................................18
LYSTEDA -tranexamic acid tab 650 mg..........................133
M
MACNATAL CN DHA -prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg............................................................117
MAC PATCH -capsaicin-menthol topical patch
0.0375-5%...................................................................... 153
MACROBID -nitrofurantoin monohydrate macrocrystalline
cap 100 mg......................................................................72
MACRODANTIN -nitrofurantoin macrocrystalline cap 100
mg.................................................................................... 72
MACRODANTIN -nitrofurantoin macrocrystalline cap 25
mg.................................................................................... 72
MACRODANTIN -nitrofurantoin macrocrystalline cap 50
mg.................................................................................... 72
MAGNEBIND 400 -magnesium-calcium-folic acid tab
400-200-1 mg.................................................................125
MALARONE -atovaquone-proguanil hcl tab 250-100
mg.................................................................................... 11
MALARONE -atovaquone-proguanil hcl tab 62.5-25
mg.................................................................................... 11
malathion lotion 0.5% (Ovide)...................................... 153
MAPROTILINE HCL -maprotiline hcl tab 25 mg................78
MAPROTILINE HCL -maprotiline hcl tab 50 mg................78
MAPROTILINE HCL -maprotiline hcl tab 75 mg................78
MAR-COF BP -pseudoephedrine-bromphen-codeine liqd
30-2-7.5 mg/5ml...............................................................60
MAR-COF CG EXPECTORANT -guaifenesin-codeine
liquid 225-7.5 mg/5ml...................................................... 60
MARINOL -dronabinol cap 10 mg..................................... 69
MARINOL -dronabinol cap 2.5 mg.................................... 69
MARINOL -dronabinol cap 5 mg....................................... 69
MARNATAL-F -prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg...................................................................117
MARPLAN -isocarboxazid tab 10 mg................................ 78
MATULANE -procarbazine hcl cap 50 mg.........................18
MAVIK -trandolapril tab 1 mg............................................ 49
MAVIK -trandolapril tab 2 mg............................................ 49
MAVIK -trandolapril tab 4 mg............................................ 49
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
MAXALT-MLT -rizatriptan benzoate orally disintegrating
tab 10 mg.......................................................................105
MAXALT-MLT -rizatriptan benzoate orally disintegrating
tab 5 mg.........................................................................105
MAXALT -rizatriptan benzoate tab 10 mg....................... 105
MAXALT -rizatriptan benzoate tab 5 mg......................... 105
MAXARON FORTE -fe gly-fe fum-vit c-vit b12-methylfolate
tab.................................................................................. 130
MAXFE -iron-fa-vit b12-biotin-vit c-docusate-mg-zn tab
160-1 mg........................................................................130
MAXIDEX -dexamethasone ophth susp 0.1%................. 139
MAXITROL -neomycin-polymyxin-dexamethasone ophth
oint 0.1%........................................................................ 139
MAXITROL -neomycin-polymyxin-dexamethasone ophth
susp 0.1%...................................................................... 139
MAXZIDE-25 -triamterene & hydrochlorothiazide tab
37.5-25 mg.......................................................................53
MAXZIDE -triamterene & hydrochlorothiazide tab 75-50
mg.................................................................................... 53
MB HYDROGEL -dermatological products misc - kit....... 153
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 100 mg....................................................................103
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 50 mg......................................................................103
MEDICAL PROVIDER EZ FLU S -influenza virus vac tisscult subunit pref syr kit 0.5 ml..........................................15
MEDICAL PROVIDER EZ FLU S -influenza virus vac
types a & b pf pref syringe kit 0.5 ml...............................15
MEDICINE SHOPPE GLUCOSE -glucose chew tab 4
gm.................................................................................... 30
MEDI-DERM/L-RX -lidocaine-capsaicin-menthol-methyl
sal cream 2-0.035-5-20%...............................................154
MEDI-DERM-RX -capsaicin-menthol-methyl salicylate
cream 0.035-5-20%....................................................... 154
MEDIHONEY CALCIUM ALGINAT -wound dressings pads................................................................................154
MEDIHONEY WOUND & BURN DR -wound dressings pads................................................................................154
MEDI-PATCH RX -lidocaine-capsaicin-menthol-methyl sal
patch 0.5-0.035-5-20%...................................................154
MEDROL DOSEPAK -methylprednisolone tab 4 mg dose
pack..................................................................................20
MEDROL -methylprednisolone tab 16 mg......................... 20
MEDROL -methylprednisolone tab 2 mg...........................20
MEDROL -methylprednisolone tab 32 mg......................... 20
MEDROL -methylprednisolone tab 4 mg...........................20
MEDROL -methylprednisolone tab 8 mg...........................20
MEDROX-RX -capsaicin-menthol-methyl salicylate oint
0.05-7-20%.....................................................................154
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................. 25
medroxyprogesterone acetate tab 10 mg (Provera)..... 26
medroxyprogesterone acetate tab 2.5 mg
(Provera)..........................................................................26
medroxyprogesterone acetate tab 5 mg (Provera)....... 26
mefenamic acid cap 250 mg (Ponstel).........................103
mefloquine hcl tab 250 mg............................................. 11
MEGACE ES -megestrol acetate susp 625 mg/5ml.......... 26
MEGACE ORAL -megestrol acetate susp 40 mg/ml......... 18
megestrol acetate susp 40 mg/ml (Megace oral).......... 18
megestrol acetate susp 625 mg/5ml (Megace es).........26
megestrol acetate tab 20 mg.......................................... 18
megestrol acetate tab 40 mg.......................................... 18
MEGRIX -capsaicin-menthol disk 0.0375-5%..................154
MEIJER GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 30
MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg (base
equivalent)........................................................................18
MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)........................................................................18
MELOXICAM COMFORT PAC -meloxicam tab 15 mg &
liniment topical gel kit.................................................... 103
MELOXICAM -meloxicam susp 7.5 mg/5ml.................... 103
meloxicam tab 15 mg (Mobic)...................................... 103
meloxicam tab 7.5 mg (Mobic)..................................... 103
memantine hcl tab 10 mg (Namenda)............................ 91
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa)...................................................91
memantine hcl tab 5 mg (Namenda)..............................91
M-END MAX D -pseudoephedrine-dexbromphen-codeine
liqd 20-0.667-6 mg/5ml.................................................... 60
M-END PE -phenylephrine-bromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml..................................................... 60
MENEST -esterified estrogens tab 0.3 mg........................ 23
MENEST -esterified estrogens tab 0.625 mg.................... 23
MENEST -esterified estrogens tab 1.25 mg...................... 23
MENEST -esterified estrogens tab 2.5 mg........................ 23
MENOSTAR -estradiol td patch weekly 14 mcg/24hr........ 23
MENTAX -butenafine hcl cream 1%................................154
MENTHOCIN PATCH/LIDOCAINE -lidocaine-capsaicinmen-methyl sal patch 0.5-0.0375-5-20%....................... 154
MENTHOCIN PATCH/LIDOCAINE -lidocaine-capsaicinmenthol-methyl sal patch 0.5-0.035-5-20%................... 154
MENTHOLIX -lidocaine-menthol liquid spray 4-1%......... 154
MEPERIDINE HCL/PROMETHAZI -meperidine w/
promethazine cap 50-25 mg............................................ 97
MEPERIDINE HCL -meperidine hcl oral soln 50
mg/5ml..............................................................................97
meperidine hcl tab 100 mg (Demerol)........................... 97
meperidine hcl tab 50 mg (Demerol)............................. 97
MEPHYTON -phytonadione tab 5 mg............................. 115
meprobamate tab 200 mg............................................... 76
meprobamate tab 400 mg............................................... 76
MEPRON -atovaquone susp 750 mg/5ml......................... 12
mercaptopurine tab 50 mg (Purinethol).........................18
mesalamine enema 4 gm................................................ 71
mesalamine rectal enema 4 gm & cleanser wipe kit
(Rowasa)......................................................................... 71
MESNEX -mesna tab 400 mg........................................... 18
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MESTINON -pyridostigmine bromide syrup 60
mg/5ml............................................................................114
MESTINON -pyridostigmine bromide tab 60 mg............. 114
MESTINON TIMESPAN -pyridostigmine bromide tab cr
180 mg........................................................................... 114
METADATE CD -methylphenidate hcl cap cr 10 mg......... 87
METADATE CD -methylphenidate hcl cap cr 20 mg......... 87
METADATE CD -methylphenidate hcl cap cr 30 mg......... 87
METADATE CD -methylphenidate hcl cap cr 40 mg......... 87
METADATE CD -methylphenidate hcl cap cr 50 mg......... 87
METADATE CD -methylphenidate hcl cap cr 60 mg......... 87
METAFOLBIC -l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg................................................................... 127
METAFOLBIC PLUS -l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg............................................. 127
METAFOLBIC PLUS RF -l-methylfolate-algae-b12acetylcyst tab 6-90.314-2-600mg...................................127
METANX -l-methylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg.......................................................... 127
METANX -l-methylfolate w/ vit b6-vit b12 tab 3-35-2
mg.................................................................................. 127
METAPROTERENOL SULFATE -metaproterenol sulfate
syrup 10 mg/5ml.............................................................. 64
METAPROTERENOL SULFATE -metaproterenol sulfate
tab 10 mg.........................................................................64
METAPROTERENOL SULFATE -metaproterenol sulfate
tab 20 mg.........................................................................64
METAXALONE -metaxalone tab 400 mg........................ 114
metaxalone tab 800 mg (Skelaxin)............................... 114
metformin hcl tab 1000 mg (Glucophage)..................... 30
metformin hcl tab 500 mg (Glucophage).......................30
metformin hcl tab 850 mg (Glucophage).......................30
metformin hcl tab sr 24hr 500 mg (Glucophage xr)...... 30
metformin hcl tab sr 24hr 750 mg (Glucophage xr)...... 30
metformin hcl tab sr 24hr osmotic 1000 mg
(Fortamet)........................................................................30
metformin hcl tab sr 24hr osmotic 500 mg
(Fortamet)........................................................................30
methadone hcl conc 10 mg/ml (Methadose)................. 97
METHADONE HCL -methadone hcl soln 10 mg/5ml.........97
METHADONE HCL -methadone hcl soln 5 mg/5ml...........97
methadone hcl soln 10 mg/5ml (Methadone hcl).......... 97
methadone hcl soln 5 mg/5ml (Methadone hcl)............ 97
methadone hcl tab 10 mg (Dolophine).......................... 97
methadone hcl tab 5 mg (Dolophine hcl)...................... 97
methadone hcl tab for oral susp 40 mg........................ 97
METHADOSE -methadone hcl conc 10 mg/ml..................97
METHADOSE SUGAR-FREE -methadone hcl conc 10 mg/
ml......................................................................................97
methamphetamine hcl tab 5 mg (Desoxyn)...................88
methazolamide tab 25 mg (Neptazane)......................... 53
methazolamide tab 50 mg (Neptazane)......................... 53
methenamine hippurate tab 1 gm (Hiprex)....................72
methenamine-hyoscamine-meth blue-sod phos tab
81.6 mg (Urogesic-blue)................................................ 72
214
methenamine-hyosc-meth blue-benz acid-phenyl sal
tab 81.6mg (Prosed/ds)................................................. 72
methenamine-hyosc-meth blue-sod phos-phen sal cap
118 mg.............................................................................72
methenamine-hyosc-meth blue-sod phos-phen sal cap
120 mg.............................................................................72
methenamine-hyosc-meth blue-sod phos-phen sal tab
81 mg...............................................................................72
methenamine-hyos-meth blue-sod phos-phen sal tab
81.6 mg............................................................................72
METHENAMINE MANDELATE -methenamine mandelate
tab 0.5 gm........................................................................72
methenamine mandelate tab 1 gm.................................72
methimazole tab 10 mg (Tapazole)................................ 33
methimazole tab 5 mg (Tapazole).................................. 33
METHITEST -methyltestosterone oral tab 10 mg.............. 21
methocarbamol tab 500 mg (Robaxin)........................ 114
methocarbamol tab 750 mg (Robaxin-750)................. 114
methotrexate sodium for inj 1 gm..................................18
methotrexate sodium inj 25 mg/ml................................ 18
methotrexate sodium inj pf 25 mg/ml............................ 18
methotrexate sodium tab 2.5 mg (base equiv)..............18
methoxsalen rapid cap 10 mg (Oxsoralen ultra).........154
methscopolamine bromide tab 2.5 mg (Pamine).......... 67
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................ 67
METHYCLOTHIAZIDE -methyclothiazide tab 5 mg...........53
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-15 mg................................. 49
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-25 mg................................. 49
methyldopa tab 250 mg.................................................. 49
methyldopa tab 500 mg.................................................. 49
methylergonovine maleate tab 0.2 mg.......................... 35
METHYLFOL-ALGAE-B12-ACETY -l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg............................127
METHYLIN -methylphenidate hcl chew tab 10 mg............ 88
METHYLIN -methylphenidate hcl chew tab 2.5 mg........... 88
METHYLIN -methylphenidate hcl chew tab 5 mg.............. 88
METHYLIN -methylphenidate hcl soln 10 mg/5ml............. 88
METHYLIN -methylphenidate hcl soln 5 mg/5ml............... 88
methylphenidate hcl cap cr 10 mg (Metadate cd)......... 88
methylphenidate hcl cap cr 20 mg (Metadate cd)......... 88
methylphenidate hcl cap cr 30 mg (Metadate cd)......... 88
methylphenidate hcl cap cr 40 mg (Metadate cd)......... 88
methylphenidate hcl cap cr 50 mg (Metadate cd)......... 88
methylphenidate hcl cap cr 60 mg (Metadate cd)......... 88
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin
la)..................................................................................... 88
methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin
la)..................................................................................... 88
methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin
la)..................................................................................... 88
methylphenidate hcl chew tab 10 mg (Methylin).......... 88
methylphenidate hcl chew tab 2.5 mg (Methylin)......... 88
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
methylphenidate hcl chew tab 5 mg (Methylin)............ 88
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sa osm 18 mg..................................................................88
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sa osm 27 mg..................................................................88
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sa osm 36 mg..................................................................88
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sa osm 54 mg..................................................................88
methylphenidate hcl soln 10 mg/5ml (Methylin)........... 88
methylphenidate hcl soln 5 mg/5ml (Methylin)............. 88
methylphenidate hcl tab 10 mg (Ritalin)........................88
methylphenidate hcl tab 20 mg (Ritalin)........................88
methylphenidate hcl tab 5 mg (Ritalin)..........................88
methylphenidate hcl tab cr 10 mg................................. 88
methylphenidate hcl tab cr 20 mg (Ritalin sr)............... 88
methylprednisolone tab 16 mg (Medrol)........................20
methylprednisolone tab 32 mg (Medrol)........................20
methylprednisolone tab 4 mg (Medrol)......................... 20
methylprednisolone tab 4 mg dose pack (Medrol
dosepak)..........................................................................20
methylprednisolone tab 8 mg (Medrol)......................... 20
METIPRANOLOL -metipranolol ophth soln 0.3%............ 139
metoclopramide hcl orally disintegrating tab 5 mg
(Metozolv odt).................................................................71
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)......... 71
metoclopramide hcl tab 10 mg (Reglan)....................... 71
metoclopramide hcl tab 5 mg (Reglan)......................... 71
metolazone tab 10 mg.....................................................53
metolazone tab 2.5 mg (Zaroxolyn)............................... 53
metolazone tab 5 mg (Zaroxolyn).................................. 53
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct)...............................................................50
metoprolol & hydrochlorothiazide tab 100-50 mg........ 50
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)...............................................................50
metoprolol succinate tab sr 24hr 100 mg (Toprol
xl)..................................................................................... 41
metoprolol succinate tab sr 24hr 200 mg (Toprol
xl)..................................................................................... 41
metoprolol succinate tab sr 24hr 25 mg (Toprol xl)......41
metoprolol succinate tab sr 24hr 50 mg (Toprol xl)......41
metoprolol tartrate tab 100 mg (Lopressor).................. 41
metoprolol tartrate tab 25 mg.........................................41
metoprolol tartrate tab 50 mg (Lopressor).................... 41
METOZOLV ODT -metoclopramide hcl orally disintegrating
tab 5 mg...........................................................................71
METROCREAM -metronidazole cream 0.75%................ 154
METROGEL -metronidazole gel 1%................................154
METROGEL-VAGINAL -metronidazole vaginal gel
0.75%............................................................................... 73
METROLOTION -metronidazole lotion 0.75%................. 154
metronidazole cap 375 mg (Flagyl)................................12
metronidazole cream 0.75% (Metrocream).................. 154
metronidazole gel 0.75%...............................................154
metronidazole gel 1% (Metrogel)................................. 154
metronidazole lotion 0.75% (Metrolotion)....................154
metronidazole tab 250 mg (Flagyl).................................12
metronidazole tab 500 mg (Flagyl).................................12
metronidazole vaginal gel 0.75% (Metrogelvaginal)............................................................................74
METVIXIA -methyl aminolevulinate hcl cream 16.8% (base
equiv)..............................................................................154
MEVACOR -lovastatin tab 40 mg......................................56
mexiletine hcl cap 150 mg..............................................44
mexiletine hcl cap 200 mg..............................................44
mexiletine hcl cap 250 mg..............................................44
MIACALCIN -calcitonin (salmon) inj 200 unit/ml................37
MIACALCIN -calcitonin (salmon) nasal soln 200 unit/
act.....................................................................................37
MICARDIS HCT -telmisartan-hydrochlorothiazide tab
40-12.5 mg.......................................................................50
MICARDIS HCT -telmisartan-hydrochlorothiazide tab
80-12.5 mg.......................................................................50
MICARDIS HCT -telmisartan-hydrochlorothiazide tab
80-25 mg..........................................................................50
MICARDIS -telmisartan tab 20 mg.................................... 50
MICARDIS -telmisartan tab 40 mg.................................... 50
MICARDIS -telmisartan tab 80 mg.................................... 50
MICONAZOLE 3 -miconazole nitrate vaginal suppos 200
mg.................................................................................... 74
miconazole nitrate vaginal supp 200 mg & 2% cream 9
gm kit.............................................................................. 74
MICRO-K -potassium chloride cap cr 10 meq................. 125
MICRO-K -potassium chloride cap cr 8 meq................... 125
MICROZIDE -hydrochlorothiazide cap 12.5 mg................ 53
midazolam hcl syrup 2 mg/ml (base equivalent).......... 85
midodrine hcl tab 10 mg.................................................54
midodrine hcl tab 2.5 mg................................................54
midodrine hcl tab 5 mg...................................................54
MIGERGOT -ergotamine w/ caffeine suppos 2-100
mg.................................................................................. 105
MIGRANAL -dihydroergotamine mesylate nasal spray 4
mg/ml..............................................................................105
MIGRYL -capsaicin-menthol disk 0.0375-5%.................. 154
MILLIPRED DP -prednisolone tab 5 mg dose pack...........20
MILLIPRED -prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)........................................................ 20
MILLIPRED -prednisolone tab 5 mg..................................20
MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24)............................................ 25
MINERAL OIL HEAVY -mineral oil....................................65
MINIPRESS -prazosin hcl cap 1 mg................................. 50
MINIPRESS -prazosin hcl cap 2 mg................................. 50
MINIPRESS -prazosin hcl cap 5 mg................................. 50
MINIVELLE -estradiol td patch twice weekly 0.025
mg/24hr............................................................................ 23
MINIVELLE -estradiol td patch twice weekly 0.0375
mg/24hr............................................................................ 23
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
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MINIVELLE -estradiol td patch twice weekly 0.05
mg/24hr............................................................................ 23
MINIVELLE -estradiol td patch twice weekly 0.075
mg/24hr............................................................................ 23
MINIVELLE -estradiol td patch twice weekly 0.1
mg/24hr............................................................................ 23
MINOCIN KIT -minocycline hcl cap 100 mg w/ acne care
products kit.........................................................................4
MINOCIN KIT -minocycline hcl cap 50 mg w/ acne care
products kit.........................................................................4
MINOCIN -minocycline hcl cap 100 mg.............................. 4
MINOCIN -minocycline hcl cap 50 mg................................ 4
MINOCIN -minocycline hcl cap 75 mg................................ 4
minocycline hcl cap 100 mg (Minocin)............................ 4
minocycline hcl cap 50 mg (Minocin)..............................4
minocycline hcl cap 75 mg (Minocin)..............................4
minocycline hcl tab 100 mg............................................. 4
minocycline hcl tab 50 mg............................................... 4
minocycline hcl tab 75 mg............................................... 4
minocycline hcl tab sr 24hr 135 mg................................ 4
minocycline hcl tab sr 24hr 45 mg.................................. 4
minocycline hcl tab sr 24hr 90 mg.................................. 4
minoxidil tab 10 mg.........................................................50
minoxidil tab 2.5 mg........................................................50
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
0.375 mg........................................................................ 112
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
0.75 mg.......................................................................... 112
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 1.5
mg.................................................................................. 112
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
2.25 mg.......................................................................... 112
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
3.75 mg.......................................................................... 112
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3
mg.................................................................................. 112
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 4.5
mg.................................................................................. 112
MIRAPEX -pramipexole dihydrochloride tab 0.125
mg.................................................................................. 111
MIRAPEX -pramipexole dihydrochloride tab 0.25 mg......112
MIRAPEX -pramipexole dihydrochloride tab 0.5 mg........112
MIRAPEX -pramipexole dihydrochloride tab 0.75 mg......112
MIRAPEX -pramipexole dihydrochloride tab 1.5 mg........112
MIRAPEX -pramipexole dihydrochloride tab 1 mg...........112
MIRCERA -methoxy polyethylene glycol-epoetin beta inj
100 mcg/0.3ml............................................................... 130
MIRCERA -methoxy polyethylene glycol-epoetin beta inj
200 mcg/0.3ml............................................................... 130
MIRCERA -methoxy polyethylene glycol-epoetin beta inj
50 mcg/0.3ml................................................................. 130
MIRCERA -methoxy polyethylene glycol-epoetin beta inj
75 mcg/0.3ml................................................................. 130
MIRCETTE -desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5)...................................................25
216
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)..............................................................................78
mirtazapine orally disintegrating tab 30 mg (Remeron
soltab)..............................................................................78
mirtazapine orally disintegrating tab 45 mg (Remeron
soltab)..............................................................................78
mirtazapine tab 15 mg (Remeron)..................................78
mirtazapine tab 30 mg (Remeron)..................................78
mirtazapine tab 45 mg (Remeron)..................................78
mirtazapine tab 7.5 mg....................................................78
MIRVASO -brimonidine tartrate gel 0.33% (base
equivalent)......................................................................154
misoprostol tab 100 mcg (Cytotec)................................67
misoprostol tab 200 mcg (Cytotec)................................67
MITIGARE -colchicine cap 0.6 mg.................................. 106
MITOSOL -mitomycin for ophth soln kit 0.2 mg...............139
MOBIC -meloxicam susp 7.5 mg/5ml.............................. 103
MOBIC -meloxicam tab 15 mg........................................ 103
MOBIC -meloxicam tab 7.5 mg....................................... 103
modafinil tab 100 mg (Provigil)...................................... 88
modafinil tab 200 mg (Provigil)...................................... 88
MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg......... 8
MODERIBA 800 DOSE PACK -ribavirin tab 400 mg........... 8
MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg
dose pack...........................................................................8
MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack...........................................................................8
MODICON -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg....................................................................... 25
moexipril hcl tab 15 mg (Univasc)................................. 50
moexipril hcl tab 7.5 mg (Univasc)................................ 50
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)..........................................................................50
moexipril-hydrochlorothiazide tab 15-25 mg................ 50
moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ 50
mometasone furoate cream 0.1% (Elocon)................. 154
mometasone furoate oint 0.1% (Elocon)..................... 154
mometasone furoate solution 0.1% (lotion)
(Elocon)......................................................................... 154
MONOCAL -sodium monofluorophosphate-calcium carb
tab 22.75-625 mg...........................................................125
MONOCLATE-P -antihemophilic factor (human) for inj kit
1000 unit........................................................................ 135
MONOCLATE-P -antihemophilic factor (human) for inj kit
1500 unit........................................................................ 135
MONOCLATE-P -antihemophilic factor (human) for inj kit
250 unit.......................................................................... 135
MONOCLATE-P -antihemophilic factor (human) for inj kit
500 unit.......................................................................... 135
MONODOX -doxycycline monohydrate cap 100 mg........... 4
MONODOX -doxycycline monohydrate cap 75 mg............. 4
MONONINE -coagulation factor ix for inj 1000 unit......... 135
MONONINE -coagulation factor ix for inj 250 unit........... 135
MONONINE -coagulation factor ix for inj 500 unit........... 135
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)........................................................................64
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)........................................................................64
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)............................................................64
montelukast sodium tab 10 mg (base equiv)
(Singulair)........................................................................64
MONUROL -fosfomycin tromethamine powd pack 3 gm
(base equivalent)............................................................. 72
MORGIDOX 1X100MG -doxycycline hyclate cap 1 x 100
mg w/ cleanser kit..............................................................4
MORGIDOX 2X100MG -doxycycline hyclate cap 2 x 100
mg w/ cleanser kit..............................................................4
morphine sulfate (concentrate) oral soln 20 mg/ml......97
morphine sulfate cap sr 24hr 100 mg (Kadian).............98
morphine sulfate cap sr 24hr 10 mg (Kadian)...............97
morphine sulfate cap sr 24hr 20 mg (Kadian)...............97
morphine sulfate cap sr 24hr 30 mg (Kadian)...............97
morphine sulfate cap sr 24hr 50 mg (Kadian)...............98
morphine sulfate cap sr 24hr 60 mg (Kadian)...............98
morphine sulfate cap sr 24hr 80 mg (Kadian)...............98
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 120 mg.................................................................... 98
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 30 mg...................................................................... 98
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 45 mg...................................................................... 98
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 60 mg...................................................................... 98
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 75 mg...................................................................... 98
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 90 mg...................................................................... 98
MORPHINE SULFATE -morphine sulfate suppos 10
mg.................................................................................... 97
MORPHINE SULFATE -morphine sulfate suppos 20
mg.................................................................................... 97
MORPHINE SULFATE -morphine sulfate suppos 30
mg.................................................................................... 97
MORPHINE SULFATE -morphine sulfate suppos 5
mg.................................................................................... 97
MORPHINE SULFATE -morphine sulfate tab 15 mg.........97
MORPHINE SULFATE -morphine sulfate tab 30 mg.........97
morphine sulfate oral soln 10 mg/5ml........................... 98
morphine sulfate oral soln 20 mg/5ml........................... 98
morphine sulfate tab cr 100 mg (Ms contin)................. 98
morphine sulfate tab cr 15 mg (Ms contin)................... 98
morphine sulfate tab cr 200 mg (Ms contin)................. 98
morphine sulfate tab cr 30 mg (Ms contin)................... 98
morphine sulfate tab cr 60 mg (Ms contin)................... 98
MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............ 66
mouthwashes - liquid....................................................142
MOVANTIK -naloxegol oxalate tab 12.5 mg (base
equivalent)........................................................................71
MOVANTIK -naloxegol oxalate tab 25 mg (base
equivalent)........................................................................71
MOVIPREP -peg 3350-kcl-nacl-na sulfate-na ascorbate-c
for soln 100 gm................................................................65
MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg.......1
MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2
times daily).....................................................................139
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)........5
MS CONTIN -morphine sulfate tab cr 100 mg...................98
MS CONTIN -morphine sulfate tab cr 15 mg.....................98
MS CONTIN -morphine sulfate tab cr 200 mg...................98
MS CONTIN -morphine sulfate tab cr 30 mg.....................98
MS CONTIN -morphine sulfate tab cr 60 mg.....................98
MS QUICK DISSOLVE GLUCOSE -glucose chew tab 4
gm.................................................................................... 30
MUCOTROL -oral wound care products - wafer..............142
MULTAQ -dronedarone hcl tab 400 mg (base
equivalent)........................................................................44
MULTIGEN -fe asparto gly-succ acd-c-threonic acd-b12des stom tab.................................................................. 130
MULTIGEN FOLIC -fe asparto gly-succinic acd-vit cthreonic acd-b12-fa tab..................................................130
MULTIGEN PLUS -fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab..................................................130
multiple vitamins w/ minerals & fa tab 1.25 mg
(Corvite).........................................................................117
mupirocin calcium cream 2% (Bactroban).................. 154
mupirocin oint 2% (Bactroban).................................... 154
MV FE ASPARTO GLY/FE FUM/ -fe aspart gly-fe fumsucc acd-c-threonic acd-b12-fa tab................................130
MV FE ASPARTO GLY/VIT C/V -fe asparto gly-succ acdc-threonic acd-b12-des stom tab................................... 131
M-VIT -prenatal vit w/ fe fumarate-fa tab 27-1 mg........... 117
MYALEPT -metreleptin for subcutaneous inj 11.3 mg....... 37
MYAMBUTOL -ethambutol hcl tab 100 mg......................... 6
MYAMBUTOL -ethambutol hcl tab 400 mg......................... 6
MYCOBUTIN -rifabutin cap 150 mg.................................... 6
mycophenolate mofetil cap 250 mg (Cellcept)............164
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept)....................................................................... 164
mycophenolate mofetil tab 500 mg (Cellcept).............164
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic)...................................................164
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic)...................................................164
MYDRIACYL -tropicamide ophth soln 1%....................... 139
MYFORTIC -mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)............................................. 164
MYFORTIC -mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)............................................. 164
MYKIDZ IRON 10 -iron susp 15 mg/1.5ml...................... 131
MYKIDZ IRON FL -pediatric vitamins acd fluoride & fe
susp 0.25-10 mg/2ml..................................................... 117
MYLERAN -busulfan tab 2 mg.......................................... 18
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
217
2015
MYNATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg................................................................... 117
MYNATAL PLUS -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 117
MYNATAL -prenatal multivitamins & minerals w/ iron & fa
cap 1 mg........................................................................117
MYNATAL ULTRACAPLET -prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg.................................................117
MYNATAL-Z -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 117
MYNATE 90 PLUS -prenatal vit w/ dss-fe fumarate-fa tab
cr 90-1 mg..................................................................... 117
MYOXIN -benzocaine-chloroxylenol-hc otic susp 15-1-10
mg/ml..............................................................................141
MYRBETRIQ -mirabegron tab sr 24 hr 25 mg...................73
MYRBETRIQ -mirabegron tab sr 24 hr 50 mg...................73
MYSOLINE -primidone tab 250 mg................................. 109
MYSOLINE -primidone tab 50 mg...................................109
N
NABI-HB -hepatitis b immune globulin (human) im inj
soln...................................................................................16
nabumetone tab 500 mg............................................... 103
nabumetone tab 750 mg............................................... 103
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)..........................................................................50
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)..........................................................................50
nadolol tab 20 mg (Corgard).......................................... 41
nadolol tab 40 mg (Corgard).......................................... 41
nadolol tab 80 mg (Corgard).......................................... 41
NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................... 142
NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln
rinse 0.05%.................................................................... 142
NAFRINSE WEEKLY -sodium fluoride for soln rinse
0.2%............................................................................... 142
naftifine hcl cream 1% (Naftin).....................................154
NAFTIN -naftifine hcl cream 1%......................................154
NAFTIN -naftifine hcl cream 2%......................................154
NAFTIN -naftifine hcl gel 1%...........................................154
NAFTIN -naftifine hcl gel 2%...........................................154
NALFON -fenoprofen calcium cap 400 mg......................103
naltrexone hcl tab 50 mg (Revia)................................. 163
NAMENDA -memantine hcl oral solution 2 mg/ml............. 91
NAMENDA -memantine hcl tab 10 mg..............................91
NAMENDA -memantine hcl tab 5 mg................................91
NAMENDA TITRATION PAK -memantine hcl tab 5 mg
(28) & 10 mg (21) titration pak........................................ 91
NAMENDA XR -memantine hcl cap sr 24hr 14 mg........... 91
NAMENDA XR -memantine hcl cap sr 24hr 21 mg........... 91
NAMENDA XR -memantine hcl cap sr 24hr 28 mg........... 91
NAMENDA XR -memantine hcl cap sr 24hr 7 mg............. 91
NAMENDA XR TITRATION PACK -memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................... 91
218
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
14-10 mg..........................................................................91
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
28-10 mg..........................................................................91
NAPHAZOLINE HCL -naphazoline hcl ophth soln
0.1%............................................................................... 139
NAPRELAN -naproxen sodium tab sr 24hr 375 mg (base
equiv)..............................................................................103
NAPRELAN -naproxen sodium tab sr 24hr 500 mg (base
equiv)..............................................................................103
NAPRELAN -naproxen sodium tab sr 24hr 750 mg (base
equiv)..............................................................................103
NAPROSYN -naproxen susp 125 mg/5ml....................... 103
NAPROSYN -naproxen tab 250 mg................................ 103
NAPROSYN -naproxen tab 375 mg................................ 103
NAPROSYN -naproxen tab 500 mg................................ 103
NAPROXEN COMFORT PAC -naproxen tab 500 mg &
liniment topical gel kit.................................................... 103
NAPROXEN -naproxen susp 125 mg/5ml....................... 103
naproxen sodium tab 275 mg (Anaprox)..................... 103
naproxen sodium tab 550 mg (Anaprox ds)................103
naproxen sodium tab sr 24hr 500 mg (base equiv)
(Naprelan)......................................................................103
naproxen tab 250 mg (Naprosyn).................................103
naproxen tab 375 mg (Naprosyn).................................103
naproxen tab 500 mg (Naprosyn).................................103
naproxen tab ec 375 mg (Ec-naprosyn)...................... 103
naproxen tab ec 500 mg (Ec-naprosyn)...................... 103
naratriptan hcl tab 1 mg (base equiv) (Amerge)......... 105
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)...... 105
NARDIL -phenelzine sulfate tab 15 mg............................. 78
NASCOBAL -cyanocobalamin nasal spray 500
mcg/0.1ml.......................................................................131
NASONEX -mometasone furoate nasal susp 50 mcg/
act.....................................................................................59
NATACHEW -prenatal vit w/ fe fum-fe bisglycin-fa chew
tab 28-1 mg................................................................... 117
NATACYN -natamycin ophth susp 5%............................ 139
NATALVIRT 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak............................................... 117
NATALVIRT CA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack.................................................... 117
NATALVIRT FLT -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg.............................................................131
NATALVIT -prenatal vit w/ fe fumarate-fa tab 75-1
mg.................................................................................. 117
NATAL-V RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 117
NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2
mg/2-3 mg/1 mg...............................................................25
nateglinide tab 120 mg (Starlix)..................................... 30
nateglinide tab 60 mg (Starlix)....................................... 30
NATELLE ONE -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg............................................................118
NATESTO -testosterone nasal gel 5.5 mg/act...................21
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 100 mcg............................................................ 37
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 25 mcg.............................................................. 37
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 50 mcg.............................................................. 37
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 75 mcg.............................................................. 37
NATROBA -spinosad susp 0.9%.....................................154
NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2
grain)................................................................................ 34
NATURE-THROID -thyroid tab 113.75 mg........................ 33
NATURE-THROID -thyroid tab 130 mg.............................33
NATURE-THROID -thyroid tab 146.25 mg........................ 33
NATURE-THROID -thyroid tab 16.25 mg.......................... 33
NATURE-THROID -thyroid tab 195 mg.............................33
NATURE-THROID -thyroid tab 260 mg.............................33
NATURE-THROID -thyroid tab 32.5 mg............................33
NATURE-THROID -thyroid tab 325 mg (5 grain)...............33
NATURE-THROID -thyroid tab 48.75 mg (3/4 grain).........33
NATURE-THROID -thyroid tab 65 mg...............................33
NATURE-THROID -thyroid tab 81.25 mg.......................... 33
NATURE-THROID -thyroid tab 97.5 mg............................33
NEBUPENT -pentamidine isethionate for nebulization soln
300 mg............................................................................. 12
NEBUSAL -sodium chloride soln nebu 6%........................60
NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50
mcg...................................................................................25
NECON 10/11-28 -norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)............................................ 25
NEEVO DHA -prenat w/o a w/fefum-methylfol-omegas cap
27-1.13 mg.....................................................................118
NEFAZODONE HCL -nefazodone hcl tab 100 mg............ 79
NEFAZODONE HCL -nefazodone hcl tab 150 mg............ 79
NEFAZODONE HCL -nefazodone hcl tab 200 mg............ 79
NEFAZODONE HCL -nefazodone hcl tab 50 mg.............. 78
nefazodone hcl tab 250 mg............................................ 79
NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp............................................... 139
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin............................... 139
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)..............139
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)....................................................................... 139
neomycin-polymyxin-dexamethasone ophth susp 0.1%
(Maxitrol)....................................................................... 139
neomycin-polymyxin-hc otic soln 1%
(Cortisporin)..................................................................141
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%..................................................................... 141
neomycin sulfate tab 500 mg........................................... 5
NEORAL -cyclosporine modified cap 100 mg................. 164
NEORAL -cyclosporine modified cap 25 mg................... 164
NEORAL -cyclosporine modified oral soln 100 mg/ml..... 164
NEOSALUS CP -dermatological products misc cream............................................................................. 154
NEOSALUS -dermatological products misc - cream....... 154
NEOSALUS -emollient - aerosol foam............................ 154
NEOSALUS -emollient - lotion.........................................154
NEOSPORIN -neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml.....................................139
NEO-SYNALAR KIT -neomycin-fluocinolone cream
0.35-0.025% & emollient cr kit.......................................154
NEO-SYNALAR -neomycin-fluocinolone cream
0.35-0.025%................................................................... 154
NEOTUSS-D -pseudoephed-chlorphen w/ dm-gg liqd
30-2-30-200 mg/5ml.........................................................60
NEOTUSS PLUS -phenylephrine-chlorphen-dm liquid
7.5-4-30 mg/5ml...............................................................60
NEPHPLEX RX -b-complex w/ c-zn & folic acid tab 1
mg.................................................................................. 118
NEPHROCAPS -b-complex w/ c & folic acid cap 1
mg.................................................................................. 118
NEPHROCAPS QT -b-complex w/ c-biotin-d & folic acid
tab disp 1 mg.................................................................118
NEPHRON FA -ferrous fumarate w/ fa-dss-b complex-vit c
tab.................................................................................. 131
NEPHRO-VITE RX -b-complex w/ c & folic acid tab 1
mg.................................................................................. 118
NEPTAZANE -methazolamide tab 25 mg......................... 53
NEPTAZANE -methazolamide tab 50 mg......................... 53
NESINA -alogliptin benzoate tab 12.5 mg (base equiv).....30
NESINA -alogliptin benzoate tab 25 mg (base equiv)........30
NESINA -alogliptin benzoate tab 6.25 mg (base equiv).....30
NESTABS ABC -prenatal w/o vit a w/fe polysac-fa-ca tab
& omega 3 cap.............................................................. 118
NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack.........................................................118
NESTABS -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg..........................................................................118
NEUAC KIT -clindamycin-benzoyl perox gel 1.2-5% &
moisturizer cr kit.............................................................154
NEULASTA DELIVERY KIT -pegfilgrastim inj 6
mg/0.6ml.........................................................................131
NEULASTA -pegfilgrastim inj 6 mg/0.6ml........................131
NEUMEGA -oprelvekin for inj 5 mg.................................131
NEUPOGEN -filgrastim inj 300 mcg/0.5ml (600 mcg/
ml).................................................................................. 131
NEUPOGEN -filgrastim inj 300 mcg/ml........................... 131
NEUPOGEN -filgrastim inj 480 mcg/0.8ml (600 mcg/
ml).................................................................................. 131
NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/
ml).................................................................................. 131
NEUPRO -rotigotine td patch 24hr 1 mg/24hr................. 112
NEUPRO -rotigotine td patch 24hr 2 mg/24hr................. 112
NEUPRO -rotigotine td patch 24hr 3 mg/24hr................. 112
NEUPRO -rotigotine td patch 24hr 4 mg/24hr................. 112
NEUPRO -rotigotine td patch 24hr 6 mg/24hr................. 112
NEUPRO -rotigotine td patch 24hr 8 mg/24hr................. 112
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
219
2015
NEURIN-SL -cyanocobalamin-methylcobalamin tab sl
600-600 mcg.................................................................. 131
NEURONTIN -gabapentin cap 100 mg........................... 109
NEURONTIN -gabapentin cap 300 mg........................... 109
NEURONTIN -gabapentin cap 400 mg........................... 109
NEURONTIN -gabapentin oral soln 250 mg/5ml............. 109
NEURONTIN -gabapentin tab 600 mg............................ 109
NEURONTIN -gabapentin tab 800 mg............................ 109
NEUTRASAL -artificial saliva - packet.............................142
NEUVAXIN -capsaicin-menthol topical patch
0.0375-5%...................................................................... 154
NEVANAC -nepafenac ophth susp 0.1%........................ 139
NEVIRAPINE -nevirapine susp 50 mg/5ml..........................8
nevirapine tab 200 mg (Viramune)...................................8
nevirapine tab sr 24hr 400 mg (Viramune xr)..................8
NEWGEN -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg..........................................................................118
NEXA PLUS -prenatal w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg..............................................................118
NEXA SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg.......................................................118
NEXAVAR -sorafenib tosylate tab 200 mg (base
equivalent)........................................................................18
NEXIUM -esomeprazole magnesium cap delayed release
20 mg (base eq).............................................................. 67
NEXIUM -esomeprazole magnesium cap delayed release
40 mg (base eq).............................................................. 67
NEXIUM -esomeprazole magnesium for delayed release
susp pack 2.5 mg............................................................ 67
NEXIUM -esomeprazole magnesium for delayed release
susp packet 10 mg.......................................................... 67
NEXIUM -esomeprazole magnesium for delayed release
susp packet 20 mg.......................................................... 67
NEXIUM -esomeprazole magnesium for delayed release
susp packet 40 mg.......................................................... 67
NEXIUM -esomeprazole magnesium for delayed release
susp packet 5 mg............................................................ 67
niacin tab cr 1000 mg (antihyperlipidemic)
(Niaspan)......................................................................... 56
niacin tab cr 500 mg (antihyperlipidemic)
(Niaspan)......................................................................... 56
niacin tab cr 750 mg (antihyperlipidemic)
(Niaspan)......................................................................... 56
NIASPAN -niacin tab cr 1000 mg (antihyperlipidemic)...... 56
NIASPAN -niacin tab cr 500 mg (antihyperlipidemic)........ 56
NIASPAN -niacin tab cr 750 mg (antihyperlipidemic)........ 56
nicardipine hcl cap 20 mg.............................................. 43
nicardipine hcl cap 30 mg.............................................. 43
NICODERM CQ -nicotine td patch 24hr 14 mg/24hr......... 91
NICODERM CQ -nicotine td patch 24hr 21 mg/24hr......... 91
NICODERM CQ -nicotine td patch 24hr 7 mg/24hr........... 91
NICOMIDE -niacinamide w/ zn-cu-methylfol-se-cr tab
750-27-2-0.5 mg............................................................ 118
NICORETTE MINI -nicotine polacrilex lozenge 2 mg........ 91
NICORETTE MINI -nicotine polacrilex lozenge 4 mg........ 91
220
NICORETTE -nicotine polacrilex gum 2 mg...................... 91
NICORETTE -nicotine polacrilex gum 4 mg...................... 91
NICORETTE -nicotine polacrilex lozenge 2 mg.................91
NICORETTE -nicotine polacrilex lozenge 4 mg.................91
NICORETTE STARTER KIT -nicotine polacrilex gum 2
mg.................................................................................... 91
NICORETTE STARTER KIT -nicotine polacrilex gum 4
mg.................................................................................... 91
nicotine polacrilex gum 2 mg.........................................91
nicotine polacrilex gum 4 mg.........................................91
nicotine polacrilex lozenge 2 mg................................... 91
nicotine polacrilex lozenge 4 mg................................... 91
nicotine td patch 24hr 14 mg/24hr................................. 91
nicotine td patch 24hr 21 mg/24hr................................. 91
nicotine td patch 24hr 7 mg/24hr................................... 91
NICOTINE TRANSDERMAL SYST -nicotine td patch 24 hr
kit 21-14-7 mg/24hr..........................................................91
NICOTROL INHALER -nicotine inhaler system 10 mg (4
mg delivered)................................................................... 91
NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/
spray)............................................................................... 91
nifedipine cap 10 mg (Procardia)...................................43
nifedipine cap 20 mg.......................................................43
nifedipine tab sr 24hr 30 mg (Adalat cc)....................... 43
nifedipine tab sr 24hr 60 mg (Adalat cc)....................... 43
nifedipine tab sr 24hr 90 mg (Adalat cc)....................... 43
nifedipine tab sr 24hr osmotic 30 mg (Procardia xl).....43
nifedipine tab sr 24hr osmotic 60 mg (Procardia xl).....43
nifedipine tab sr 24hr osmotic 90 mg (Procardia xl).....43
NILANDRON -nilutamide tab 150 mg................................18
nimodipine cap 30 mg.....................................................43
NIRAVAM -alprazolam orally disintegrating tab 0.25
mg.................................................................................... 76
NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg...........43
NISOLDIPINE -nisoldipine tab sr 24hr 20 mg................... 43
NISOLDIPINE -nisoldipine tab sr 24hr 30 mg................... 43
NISOLDIPINE -nisoldipine tab sr 24hr 40 mg................... 43
nisoldipine tab sr 24hr 17 mg (Sular)............................ 43
nisoldipine tab sr 24hr 34 mg (Sular)............................ 43
nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 43
NITRO-BID -nitroglycerin oint 2%......................................39
NITRO-DUR -nitroglycerin td patch 24hr 0.1 mg/hr........... 39
NITRO-DUR -nitroglycerin td patch 24hr 0.2 mg/hr........... 39
NITRO-DUR -nitroglycerin td patch 24hr 0.3 mg/hr........... 39
NITRO-DUR -nitroglycerin td patch 24hr 0.4 mg/hr........... 39
NITRO-DUR -nitroglycerin td patch 24hr 0.6 mg/hr........... 39
NITRO-DUR -nitroglycerin td patch 24hr 0.8 mg/hr........... 39
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin)..................................................................72
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin)..................................................................72
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)................................................................ 72
nitrofurantoin susp 25 mg/5ml (Furadantin)................. 72
nitroglycerin cap cr 2.5 mg............................................ 39
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
nitroglycerin cap cr 6.5 mg............................................ 39
nitroglycerin cap cr 9 mg............................................... 39
NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol
400 mcg/spray................................................................. 39
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)..........39
nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)..........39
nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)..........39
nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)..........39
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
(Nitrolingual pumpspr).................................................. 39
NITROLINGUAL PUMPSPRAY -nitroglycerin tl soln 0.4
mg/spray (400 mcg/spray)............................................... 39
NITROMIST -nitroglycerin lingual aerosol 400 mcg/
spray.................................................................................39
NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 39
NITROSTAT -nitroglycerin sl tab 0.4 mg........................... 40
NITROSTAT -nitroglycerin sl tab 0.6 mg........................... 40
NIVA-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 118
NIVATOPIC PLUS -dermatological products misc cream............................................................................. 154
nizatidine cap 150 mg..................................................... 67
nizatidine cap 300 mg (Axid).......................................... 67
nizatidine oral soln 15 mg/ml (Axid).............................. 67
NIZORAL -ketoconazole shampoo 2%............................154
NOBLE MYSTIQUE EMU-LAC -lactic acid (ammonium
lactate) cream 10%........................................................154
NORCO -hydrocodone-acetaminophen tab 10-325 mg.....98
NORCO -hydrocodone-acetaminophen tab 5-325 mg.......98
NORCO -hydrocodone-acetaminophen tab 7.5-325
mg.................................................................................... 98
NORDITROPIN CARTRIDGE -somatropin inj 5
mg/1.5ml...........................................................................37
NORDITROPIN FLEXPRO -somatropin inj 10
mg/1.5ml...........................................................................37
NORDITROPIN FLEXPRO -somatropin inj 15
mg/1.5ml...........................................................................37
NORDITROPIN FLEXPRO -somatropin inj 30 mg/3ml......37
NORDITROPIN FLEXPRO -somatropin inj 5 mg/1.5ml.....37
NORDITROPIN NORDIFLEX PEN -somatropin inj 30
mg/3ml..............................................................................37
norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr (Ortho evra)................................................... 25
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg (Femcon fe)................................................ 25
norethindrone & ethinyl estradiol-fe chew tab 0.8
mg-25 mcg (Generess fe)..............................................25
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
(Ovcon-35).......................................................................25
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
(Brevicon-28).................................................................. 25
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
(Norinyl 1+35)................................................................. 25
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)................................................ 25
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg (Loestrin fe 1/20)................................................... 25
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg (Loestrin 1.5/30-21)................................................25
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)........................................................... 25
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20
mcg (24) (Lomedia 24 fe).............................................. 25
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose)................................................. 23
norethindrone acetate tab 5 mg (Aygestin)...................26
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg (Estrostep fe)...................................................25
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mgmcg (Ortho-novum 7/7/7).............................................. 25
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)....................................................... 25
norethindrone tab 0.35 mg (Nor-qd).............................. 25
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
(Ortho-cyclen).................................................................25
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg (Ortho tri-cyclen).............................................25
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg.........26
NORINYL 1+35 -norethindrone & ethinyl estradiol tab 1
mg-35 mcg....................................................................... 26
NORINYL 1+50 -norethindrone & mestranol tab 1 mg-50
mcg...................................................................................26
NORITATE -metronidazole cream 1%.............................155
NORPACE CR -disopyramide phosphate cap sr 12hr 100
mg.................................................................................... 44
NORPACE CR -disopyramide phosphate cap sr 12hr 150
mg.................................................................................... 44
NORPACE -disopyramide phosphate cap 100 mg............ 44
NORPACE -disopyramide phosphate cap 150 mg............ 44
NORPRAMIN -desipramine hcl tab 100 mg...................... 79
NORPRAMIN -desipramine hcl tab 10 mg........................ 79
NORPRAMIN -desipramine hcl tab 150 mg...................... 79
NORPRAMIN -desipramine hcl tab 25 mg........................ 79
NORPRAMIN -desipramine hcl tab 50 mg........................ 79
NORPRAMIN -desipramine hcl tab 75 mg........................ 79
NOR-QD -norethindrone tab 0.35 mg................................25
NORTHERA -droxidopa cap 100 mg.................................54
NORTHERA -droxidopa cap 200 mg.................................54
NORTHERA -droxidopa cap 300 mg.................................54
nortriptyline hcl cap 10 mg (Pamelor)........................... 79
nortriptyline hcl cap 25 mg (Pamelor)........................... 79
nortriptyline hcl cap 50 mg (Pamelor)........................... 79
nortriptyline hcl cap 75 mg (Pamelor)........................... 79
NORTRIPTYLINE HCL -nortriptyline hcl soln 10
mg/5ml..............................................................................79
NORTUSS-EX -dextromethorphan-guaifenesin liquid
20-200 mg/5ml................................................................. 60
NORVASC -amlodipine besylate tab 10 mg......................43
NORVASC -amlodipine besylate tab 2.5 mg..................... 43
NORVASC -amlodipine besylate tab 5 mg........................43
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
221
2015
NORVIR -ritonavir cap 100 mg........................................... 8
NORVIR -ritonavir oral soln 80 mg/ml................................. 8
NORVIR -ritonavir tab 100 mg............................................ 8
NOTUSS-NX -codeine-chlorcyclizine liquid 10-9.375
mg/5ml..............................................................................60
NOTUSS-NXD -codeine-pseudoephedrine-chlorcyclizine
liq 10-30-9.375mg/5ml..................................................... 60
NOVACORT -hydrocortisone ace-pramoxine-aloe
polysacch gel 2-1-1%.................................................... 155
NOVAFERRUM -polysacch iron complex-vit c-fa for soln
100-60-1 mg/5ml............................................................131
NOVOEIGHT -antihemophilic factor (recombinant) for inj
1000 unit........................................................................ 136
NOVOEIGHT -antihemophilic factor (recombinant) for inj
1500 unit........................................................................ 136
NOVOEIGHT -antihemophilic factor (recombinant) for inj
2000 unit........................................................................ 136
NOVOEIGHT -antihemophilic factor (recombinant) for inj
250 unit.......................................................................... 135
NOVOEIGHT -antihemophilic factor (recombinant) for inj
3000 unit........................................................................ 136
NOVOEIGHT -antihemophilic factor (recombinant) for inj
500 unit.......................................................................... 135
NOVOLIN 70/30 -insulin nph isophane & regular human inj
100 unit/ml (70-30)...........................................................32
NOVOLIN 70/30 RELION -insulin nph isophane & regular
human inj 100 unit/ml (70-30)..........................................32
NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/
ml......................................................................................32
NOVOLIN N RELION -insulin nph (human) (isophane) inj
100 unit/ml....................................................................... 32
NOVOLIN R -insulin regular (human) inj 100 unit/ml......... 32
NOVOLIN R RELION -insulin regular (human) inj 100 unit/
ml......................................................................................32
NOVOLOG FLEXPEN -insulin aspart soln pen-injector 100
unit/ml...............................................................................32
NOVOLOG -insulin aspart inj 100 unit/ml..........................32
NOVOLOG MIX 70/30 -insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)....................................... 32
NOVOLOG MIX 70/30 PREFILL -insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)............................. 32
NOVOLOG PENFILL -insulin aspart inj 100 unit/ml...........32
NOVOLOG PENFILL -insulin aspart soln cartridge 100
unit/ml...............................................................................32
NOVOSEVEN -coagulation factor viia (recomb) for inj 2.4
mg (2400 mcg)...............................................................136
NOVOSEVEN RT -coagulation factor viia (recomb) for inj 1
mg (1000 mcg)...............................................................136
NOVOSEVEN RT -coagulation factor viia (recomb) for inj 2
mg (2000 mcg)...............................................................136
NOVOSEVEN RT -coagulation factor viia (recomb) for inj 5
mg (5000 mcg)...............................................................136
NOVOSEVEN RT -coagulation factor viia (recomb) for inj 8
mg (8000 mcg)...............................................................136
NOXAFIL -posaconazole susp 40 mg/ml............................ 7
222
NOXAFIL -posaconazole tab delayed release 100 mg........7
NUCORT -hydrocortisone acetate lotion 2%................... 155
NUCYNTA ER -tapentadol hcl tab sr 12hr 100 mg............98
NUCYNTA ER -tapentadol hcl tab sr 12hr 150 mg............98
NUCYNTA ER -tapentadol hcl tab sr 12hr 200 mg............98
NUCYNTA ER -tapentadol hcl tab sr 12hr 250 mg............98
NUCYNTA ER -tapentadol hcl tab sr 12hr 50 mg..............98
NUCYNTA -tapentadol hcl tab 100 mg............................. 98
NUCYNTA -tapentadol hcl tab 50 mg............................... 98
NUCYNTA -tapentadol hcl tab 75 mg............................... 98
NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap
20-10 mg..........................................................................91
NULYTELY/FLAVOR PACKS -peg 3350-kcl-sod bicarbnacl for soln 420 gm........................................................66
NUMOISYN -artificial saliva - lozenge.............................142
NUMOISYN -artificial saliva - solution............................. 142
NUOX -benzoyl peroxide-sulfur gel 6-3%........................155
NUTRESTORE -glutamine powd pack 5 gm................... 126
NUTRIDOX -doxycycline monohyd cap 75 mg w/ omega
3-vit e cap kit..................................................................... 4
NUTRI-TAB OB + DHA -prenat w/o a w/ fe bisglyc-fa tab
32-1 mg & omega cap pack.......................................... 118
NUTRI-TAB OB -prenatal vit w/o vit a w/ fe bisglycinate-fa
tab 32-1 mg................................................................... 118
NUTRIVIT -b-complex w/ lysine-min-fe & fa liqd 800-15-1
mg/15ml..........................................................................118
NUTROPIN AQ NUSPIN 10 -somatropin inj 10
mg/2ml..............................................................................37
NUTROPIN AQ NUSPIN 20 -somatropin inj 20
mg/2ml..............................................................................37
NUTROPIN AQ NUSPIN 5 -somatropin inj 5 mg/2ml........ 37
NUTROPIN AQ PEN -somatropin inj 10 mg/2ml............... 37
NUTROPIN AQ PEN -somatropin inj 20 mg/2ml............... 37
NUVAIL -dermatological products misc - solution............155
NUVARING -etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr........................................................26
NUVESSA -metronidazole vaginal gel 1.3%..................... 74
NUVIGIL -armodafinil tab 150 mg..................................... 88
NUVIGIL -armodafinil tab 200 mg..................................... 88
NUVIGIL -armodafinil tab 250 mg..................................... 88
NUVIGIL -armodafinil tab 50 mg....................................... 88
NUZON -hydrocortisone acetate-aloe vera gel 2%..........155
NYMALIZE -nimodipine oral soln 60 mg/20ml...................43
nystatin cream 100000 unit/gm.................................... 155
nystatin oint 100000 unit/gm........................................ 155
nystatin oral powder......................................................... 7
nystatin susp 100000 unit/ml........................................142
nystatin tab 500000 unit....................................................7
nystatin topical powder................................................ 155
nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 155
nystatin-triamcinolone oint 100000-0.1 unit/gm-%..... 155
O
OB COMPLETE/DHA -prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg.......................................... 118
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
OB COMPLETE ONE -prenatal w/o a w/fecbn-fe asp glycfa-fish cap 50-1-476 mg.................................................118
OB COMPLETE PETITE -prenat w/o a w/fecbn-feaspglycfa-omega cap 35-5-1-200 mg........................................ 118
OB COMPLETE PREMIER -prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg...................................................118
OB COMPLETE -prenatal vit w/ iron carbonyl-fa tab
50-1.25 mg.....................................................................118
OB-NATAL ONE -prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg.....................................................118
OBREDON -hydrocodone-guaifenesin soln 2.5-200
mg/5ml..............................................................................60
OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak..............................................118
OBSTETRIX EC -prenatal vit w/ dss-iron carbonyl-fa tab
29-1 mg..........................................................................118
O-CAL FA -prenatal vit w/ fe fumarate-fa tab 27-1 mg.....118
O-CAL PRENATAL -prenatal vit w/ fe fumarate-fa tab 15-1
mg.................................................................................. 118
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin).................................................................. 37
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin).................................................................. 37
octreotide acetate inj 200 mcg/ml (0.2 mg/ml)
(Sandostatin).................................................................. 37
octreotide acetate inj 500 mcg/ml (0.5 mg/ml)
(Sandostatin).................................................................. 37
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
(Sandostatin).................................................................. 37
OCUFEN -flurbiprofen sodium ophth soln 0.03%............ 139
OCUFLOX -ofloxacin ophth soln 0.3%............................ 139
OCUVEL -multiple vitamins w/ minerals & fa cap 0.5
mg.................................................................................. 118
OFEV -nintedanib esylate cap 100 mg (base
equivalent)........................................................................65
OFEV -nintedanib esylate cap 150 mg (base
equivalent)........................................................................65
OFLOXACIN -ofloxacin tab 400 mg.................................... 5
ofloxacin ophth soln 0.3% (Ocuflox)........................... 139
ofloxacin otic soln 0.3%................................................141
OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg...................................................................................26
olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax)..... 92
olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)..... 92
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)....... 91
olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)....... 91
olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)....... 91
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)............................................................................... 82
olanzapine orally disintegrating tab 15 mg (Zyprexa
zydis)............................................................................... 82
olanzapine orally disintegrating tab 20 mg (Zyprexa
zydis)............................................................................... 82
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis)............................................................................... 82
olanzapine tab 10 mg (Zyprexa).....................................82
olanzapine tab 15 mg (Zyprexa).....................................82
olanzapine tab 2.5 mg (Zyprexa)....................................82
olanzapine tab 20 mg (Zyprexa).....................................82
olanzapine tab 5 mg (Zyprexa).......................................82
olanzapine tab 7.5 mg (Zyprexa)....................................82
OLEPTRO -trazodone hcl tab sr 24hr 150 mg.................. 79
OLEPTRO -trazodone hcl tab sr 24hr 300 mg.................. 79
olopatadine hcl nasal soln 0.6% (Patanase)................. 59
OLUX -clobetasol propionate foam 0.05%...................... 155
OLUX-E -clobetasol propionate emulsion foam
0.05%............................................................................. 155
OLYSIO -simeprevir sodium cap 150 mg (base
equivalent)..........................................................................8
OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/
omepraz cap dr therapy pack.......................................... 68
omega-3-acid ethyl esters cap 1 gm (Lovaza).............. 56
OMEPRAZOLE + SYRSPEND SF -omeprazole susp 2
mg/ml (compound kit)...................................................... 68
omeprazole cap delayed release 10 mg (Prilosec)....... 68
omeprazole cap delayed release 20 mg (Prilosec)....... 68
omeprazole cap delayed release 40 mg (Prilosec)....... 68
omeprazole-sodium bicarbonate cap 20-1100 mg
(Zegerid).......................................................................... 68
omeprazole-sodium bicarbonate cap 40-1100 mg
(Zegerid).......................................................................... 68
OMNARIS -ciclesonide nasal susp 50 mcg/act................. 59
OMNI GEL -stannous fluoride gel 0.4%.......................... 142
OMNIPRED -prednisolone acetate ophth susp 1%......... 139
OMNITROPE -somatropin for inj 5.8 mg........................... 37
OMNITROPE -somatropin inj 10 mg/1.5ml........................37
OMNITROPE -somatropin inj 5 mg/1.5ml......................... 37
ondansetron hcl oral soln 4 mg/5ml (Zofran)................69
ondansetron hcl tab 24 mg............................................ 69
ondansetron hcl tab 4 mg (Zofran)................................ 69
ondansetron hcl tab 8 mg (Zofran)................................ 69
ondansetron orally disintegrating tab 4 mg (Zofran
odt)...................................................................................69
ondansetron orally disintegrating tab 8 mg (Zofran
odt)...................................................................................69
ONEXTON -clindamycin phosphate-benzoyl peroxide gel
1.2-3.75%....................................................................... 155
ONFI -clobazam suspension 2.5 mg/ml.......................... 109
ONFI -clobazam tab 10 mg............................................. 109
ONFI -clobazam tab 20 mg............................................. 109
ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv).......... 30
ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............. 30
ONMEL -itraconazole tab 200 mg....................................... 7
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 10 mg.........................................................98
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 15 mg.........................................................98
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 20 mg.........................................................98
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
223
2015
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 30 mg.........................................................99
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 40 mg.........................................................99
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 5 mg...........................................................98
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 7.5 mg........................................................98
OPANA -oxymorphone hcl tab 10 mg............................... 98
OPANA -oxymorphone hcl tab 5 mg................................. 98
opium tincture 1% (10 mg/ml) (morphine equiv)...........66
OPSUMIT -macitentan tab 10 mg..................................... 58
OPTASE -trypsin w/ castor oil & peruvian balsam gel..... 155
ORACEA -doxycycline (rosacea) cap delayed release 40
mg.................................................................................. 155
ORACIT -sodium citrate & citric acid soln 490-640
mg/5ml..............................................................................74
ORAFATE -sucralfate-malate paste 10%........................ 143
ORALAIR ADULT SAMPLE KIT -grass mixed pollen ext
tab sl 300 ir (index of reactivity)...................................... 16
ORALAIR ADULT STARTER PAC -grass mixed pollen ext
tab sl 300 ir (index of reactivity)...................................... 16
ORALAIR CHILDREN/ADOLESCE -grass mixed pollen ext
tab sl 100 ir (index of reactivity)...................................... 16
ORALAIR CHILDREN/ADOLESCE -grass mixed pollen
tab sl therpak 100 (3) ir & 300 (6) ir................................ 16
ORALAIR -grass mixed pollen ext tab sl 300 ir (index of
reactivity).......................................................................... 16
ORAMAGICRX -oral wound care products - for susp
rinse................................................................................143
ORAP -pimozide tab 1 mg................................................ 92
ORAP -pimozide tab 2 mg................................................ 92
ORAPRED ODT -prednisolone sod phos orally disintegr
tab 10 mg (base eq)........................................................ 20
ORAPRED ODT -prednisolone sod phos orally disintegr
tab 15 mg (base eq)........................................................ 20
ORAPRED ODT -prednisolone sod phos orally disintegr
tab 30 mg (base eq)........................................................ 20
ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................. 143
ORBIVAN -butalbital-acetaminophen-caffeine cap
50-300-40 mg...................................................................93
ORBIVAN CF -butalbital-acetaminophen tab 50-300
mg.................................................................................... 93
ORENCIA -abatacept subcutaneous soln prefilled syringe
125 mg/ml...................................................................... 103
ORENITRAM -treprostinil diolamine tab cr 0.125 mg (base
equiv)................................................................................58
ORENITRAM -treprostinil diolamine tab cr 0.25 mg (base
equiv)................................................................................58
ORENITRAM -treprostinil diolamine tab cr 1 mg (base
equiv)................................................................................58
ORENITRAM -treprostinil diolamine tab cr 2.5 mg (base
equiv)................................................................................58
ORFADIN -nitisinone cap 10 mg....................................... 37
224
ORFADIN -nitisinone cap 2 mg......................................... 37
ORFADIN -nitisinone cap 5 mg......................................... 37
ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg.............. 65
orphenadrine citrate tab sr 12hr 100 mg..................... 114
orphenadrine w/ aspirin & caffeine tab 25-385-30
mg.................................................................................. 114
ORTHO-CEPT -desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg....................................................................... 26
ORTHO-CYCLEN -norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg...............................................................26
ORTHO EVRA -norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr..............................................................26
ORTHO MICRONOR -norethindrone tab 0.35 mg.............26
ORTHO-NOVUM 1/35 -norethindrone & ethinyl estradiol
tab 1 mg-35 mcg............................................................. 26
ORTHO-NOVUM 7/7/7 -norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg............................................26
ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg...................................26
ORTHO TRI-CYCLEN -norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg...................................26
OSENI -alogliptin-pioglitazone tab 12.5-15 mg..................30
OSENI -alogliptin-pioglitazone tab 12.5-30 mg..................30
OSENI -alogliptin-pioglitazone tab 12.5-45 mg..................30
OSENI -alogliptin-pioglitazone tab 25-15 mg.....................30
OSENI -alogliptin-pioglitazone tab 25-30 mg.....................30
OSENI -alogliptin-pioglitazone tab 25-45 mg.....................30
OSMOPREP -sod phos mono-sod phos di tabs
1.102-0.398 gm(1.5gm na phos)..................................... 66
OSPHENA -ospemifene tab 60 mg................................... 37
OTEZLA -apremilast tab 30 mg.......................................103
OTEZLA -apremilast tab starter therapy pack 10 mg & 20
mg & 30 mg................................................................... 103
OTICIN HC NR -pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml................................................................141
OTOZIN -antipyrine-benzocaine-glycerin-zinc ace otic liqd
5.4-1-2-1%......................................................................141
OTREXUP -methotrexate soln pf auto-injector 10
mg/0.4ml.........................................................................103
OTREXUP -methotrexate soln pf auto-injector 15
mg/0.4ml.........................................................................103
OTREXUP -methotrexate soln pf auto-injector 20
mg/0.4ml.........................................................................103
OTREXUP -methotrexate soln pf auto-injector 25
mg/0.4ml.........................................................................103
OVACE PLUS -sulfacetamide sodium cream 10%..........155
OVACE PLUS -sulfacetamide sodium foam 9.8%...........155
OVACE PLUS -sulfacetamide sodium lotion 9.8%.......... 155
OVACE PLUS -sulfacetamide sodium shampoo 10%..... 155
OVACE PLUS WASH -sulfacetamide sodium cleansing gel
10%................................................................................ 155
OVACE PLUS WASH -sulfacetamide sodium liquid
10%................................................................................ 155
OVACE WASH -sulfacetamide sodium liquid 10%.......... 155
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
OVCON-35 -norethindrone & ethinyl estradiol tab 0.4
mg-35 mcg....................................................................... 26
OVIDE -malathion lotion 0.5%.........................................155
OXANDRIN -oxandrolone tab 10 mg.................................21
OXANDRIN -oxandrolone tab 2.5 mg................................21
oxandrolone tab 10 mg (Oxandrin)................................ 21
oxandrolone tab 2.5 mg (Oxandrin)............................... 21
oxaprozin tab 600 mg (Daypro)....................................103
oxazepam cap 10 mg...................................................... 76
oxazepam cap 15 mg...................................................... 76
oxazepam cap 30 mg...................................................... 76
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)....................................................................... 109
oxcarbazepine tab 150 mg (Trileptal).......................... 109
oxcarbazepine tab 300 mg (Trileptal).......................... 109
oxcarbazepine tab 600 mg (Trileptal).......................... 109
OXISTAT -oxiconazole nitrate cream 1%........................ 155
OXISTAT -oxiconazole nitrate lotion 1%......................... 155
OXSORALEN -methoxsalen lotion 1%............................ 155
OXSORALEN ULTRA -methoxsalen rapid cap 10 mg.....155
OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg....... 109
OXTELLAR XR -oxcarbazepine tab sr 24hr 300 mg....... 109
OXTELLAR XR -oxcarbazepine tab sr 24hr 600 mg....... 109
oxybutynin chloride syrup 5 mg/5ml............................. 73
oxybutynin chloride tab 5 mg........................................ 73
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl)..................................................................................... 73
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl)..................................................................................... 73
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)...... 73
oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 99
oxycodone hcl cap 5 mg................................................ 99
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl).............................................................99
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
10 mg............................................................................... 99
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
20 mg............................................................................... 99
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
40 mg............................................................................... 99
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
80 mg............................................................................... 99
OXYCODONE HCL -oxycodone hcl conc 100 mg/5ml (20
mg/ml).............................................................................. 99
OXYCODONE HCL -oxycodone hcl soln 5 mg/5ml...........99
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)............99
oxycodone hcl tab 10 mg............................................... 99
oxycodone hcl tab 15 mg (Roxicodone)........................99
oxycodone hcl tab 20 mg............................................... 99
oxycodone hcl tab 30 mg (Roxicodone)........................99
oxycodone hcl tab 5 mg (Roxicodone)..........................99
oxycodone-ibuprofen tab 5-400 mg............................... 99
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)........................................................................99
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)........................................................................99
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)........................................................................99
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)........................................................................99
OXYCONTIN -oxycodone hcl tab er 12hr deter 10 mg...... 99
OXYCONTIN -oxycodone hcl tab er 12hr deter 15 mg...... 99
OXYCONTIN -oxycodone hcl tab er 12hr deter 20 mg...... 99
OXYCONTIN -oxycodone hcl tab er 12hr deter 30 mg...... 99
OXYCONTIN -oxycodone hcl tab er 12hr deter 40 mg...... 99
OXYCONTIN -oxycodone hcl tab er 12hr deter 60 mg...... 99
OXYCONTIN -oxycodone hcl tab er 12hr deter 80 mg...... 99
oxymorphone hcl tab 10 mg (Opana)............................ 99
oxymorphone hcl tab 5 mg (Opana).............................. 99
oxymorphone hcl tab sr 12hr 10 mg............................. 99
oxymorphone hcl tab sr 12hr 15 mg............................. 99
oxymorphone hcl tab sr 12hr 20 mg............................. 99
oxymorphone hcl tab sr 12hr 30 mg............................. 99
oxymorphone hcl tab sr 12hr 40 mg............................. 99
oxymorphone hcl tab sr 12hr 5 mg............................... 99
oxymorphone hcl tab sr 12hr 7.5 mg.............................99
OXYTROL -oxybutynin td patch twice weekly 3.9
mg/24hr............................................................................ 73
P
PAIN RELIEF PATCH -capsaicin-menthol topical patch
0.0375-5%...................................................................... 155
PAIN RELIEF PATCH -lidocaine-menthol patch
5-1%............................................................................... 155
PAIRE OB -prenat w/ fe poly cmplx-fe asp-fe gly-fa tab &
dha cap pak................................................................... 118
PAMELOR -nortriptyline hcl cap 10 mg.............................79
PAMELOR -nortriptyline hcl cap 25 mg.............................79
PAMELOR -nortriptyline hcl cap 50 mg.............................79
PAMELOR -nortriptyline hcl cap 75 mg.............................79
PAMINE FORTE -methscopolamine bromide tab 5 mg.....68
PAMINE FQ -methscopolamine tab 5 mg & misc intestinal
flora reg cap.....................................................................68
PAMINE -methscopolamine bromide tab 2.5 mg...............68
PANATUSS DXP -phenylephrine-dexbromphen-dm-gg
liquid 5-1-15-100 mg/5ml................................................. 61
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
10500-25000-43750 unit.................................................. 69
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
16800-40000-70000 unit.................................................. 69
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
21000-37000-61000 unit.................................................. 70
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
4200-10000-17500 unit.................................................... 69
PANCRELIPASE -pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit.................................................... 70
PANDEL -hydrocortisone probutate cream 0.1%............ 155
PANRETIN -alitretinoin gel 0.1%.....................................155
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................ 68
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
225
2015
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................ 68
PARAFON FORTE DSC -chlorzoxazone tab 500 mg......114
paricalcitol cap 1 mcg (Zemplar)................................... 37
paricalcitol cap 2 mcg (Zemplar)................................... 37
paricalcitol cap 4 mcg (Zemplar)................................... 38
PARLODEL -bromocriptine mesylate cap 5 mg.............. 112
PARNATE -tranylcypromine sulfate tab 10 mg..................79
paromomycin sulfate cap 250 mg....................................5
paroxetine hcl tab 10 mg (Paxil).................................... 79
paroxetine hcl tab 20 mg (Paxil).................................... 79
paroxetine hcl tab 30 mg (Paxil).................................... 79
paroxetine hcl tab 40 mg (Paxil).................................... 79
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 79
paroxetine hcl tab sr 24hr 25 mg (Paxil cr)................... 79
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 79
PASER -aminosalicylic acid cr granules packet 4 gm......... 6
PATADAY -olopatadine hcl ophth soln 0.2%...................139
PATANASE -olopatadine hcl nasal soln 0.6%...................59
PATANOL -olopatadine hcl ophth soln 0.1%...................140
PAXIL CR -paroxetine hcl tab sr 24hr 12.5 mg................. 79
PAXIL CR -paroxetine hcl tab sr 24hr 25 mg.................... 79
PAXIL CR -paroxetine hcl tab sr 24hr 37.5 mg................. 79
PAXIL -paroxetine hcl oral susp 10 mg/5ml (base
equiv)................................................................................79
PAXIL -paroxetine hcl tab 10 mg...................................... 79
PAXIL -paroxetine hcl tab 20 mg...................................... 79
PAXIL -paroxetine hcl tab 30 mg...................................... 79
PAXIL -paroxetine hcl tab 40 mg...................................... 79
PAZEO -olopatadine hcl ophth soln 0.7% (base
equivalent)......................................................................140
PCE -erythromycin w/ enteric coated particles tab 333
mg...................................................................................... 3
PCE -erythromycin w/ enteric coated particles tab 500
mg...................................................................................... 3
PCP 100 -mag cit-bisacodyl-petrolat-peg-metoclopramideelectrol kit.........................................................................66
PEDIADERM AF COMPLETE KIT -nystatin cream 100000
unit/gm & diaper rash cream kit.....................................155
PEDIADERM HC -hydrocortisone lot 2% & emollient
cream kit........................................................................ 155
PEDIADERM TA -triamcinolone cream 0.1% & emollient
cream kit........................................................................ 155
PEDIAPRED -prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)..................................................20
PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv
vac inj...............................................................................15
PEDIATEX TDM -pseudoephed-triprolidine-dm susp
10-0.938-4 mg/ml.............................................................61
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/
ml................................................................................... 118
pediatric multiple vitamins w/ fluoride chew tab 0.25
mg.................................................................................. 118
pediatric multiple vitamins w/ fluoride chew tab 0.5
mg.................................................................................. 118
226
pediatric multiple vitamins w/ fluoride chew tab 1
mg.................................................................................. 118
pediatric multiple vitamins w/ fluoride soln 0.25 mg/
ml................................................................................... 118
pediatric multiple vitamins w/ fluoride soln 0.5 mg/
ml................................................................................... 118
pediatric vitamins acd w/ fluoride soln 0.25 mg/
ml................................................................................... 118
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml...... 118
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely).........................................................................66
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
(Colyte-flavor packs)......................................................66
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack).....................................................66
PEGANONE -ethotoin tab 250 mg.................................. 109
PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml........... 9
PEGASYS -peginterferon alfa-2a inj 180 mcg/ml................ 9
PEGASYS PROCLICK -peginterferon alfa-2a inj 135
mcg/0.5ml...........................................................................9
PEGASYS PROCLICK -peginterferon alfa-2a inj 180
mcg/0.5ml...........................................................................9
PEGINTRON -peginterferon alfa-2b for inj kit 120
mcg/0.5ml...........................................................................9
PEG-INTRON -peginterferon alfa-2b for inj kit 120
mcg/0.5ml...........................................................................8
PEGINTRON -peginterferon alfa-2b for inj kit 150
mcg/0.5ml...........................................................................9
PEG-INTRON -peginterferon alfa-2b for inj kit 150
mcg/0.5ml...........................................................................9
PEGINTRON -peginterferon alfa-2b for inj kit 50
mcg/0.5ml...........................................................................9
PEG-INTRON -peginterferon alfa-2b for inj kit 50
mcg/0.5ml...........................................................................8
PEGINTRON -peginterferon alfa-2b for inj kit 80
mcg/0.5ml...........................................................................9
PEG-INTRON -peginterferon alfa-2b for inj kit 80
mcg/0.5ml...........................................................................8
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 120 mcg/0.5ml..........................................................9
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 150 mcg/0.5ml..........................................................9
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 50 mcg/0.5ml............................................................9
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 80 mcg/0.5ml............................................................9
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
120 mcg/0.5ml................................................................... 9
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
150 mcg/0.5ml................................................................... 9
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
50 mcg/0.5ml..................................................................... 9
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
80 mcg/0.5ml..................................................................... 9
penicillin v potassium for soln 125 mg/5ml.................... 1
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
penicillin v potassium for soln 250 mg/5ml.................... 1
penicillin v potassium tab 250 mg................................... 1
penicillin v potassium tab 500 mg................................... 1
PENLAC NAIL LACQUER -ciclopirox solution 8%.......... 155
PENNSAID -diclofenac sodium soln 2%......................... 155
PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly
vac for im susp................................................................ 15
PENTASA -mesalamine cap cr 250 mg............................ 71
PENTASA -mesalamine cap cr 500 mg............................ 71
pentazocine w/ naloxone tab 50-0.5 mg........................ 99
PENTETATE CALCIUM TRISODI -pentetate calcium
trisodium iv or inhalation soln 200 mg/ml.......................163
PENTETATE ZINC TRISODIUM -pentetate zinc trisodium
iv or inhalation soln 200 mg/ml......................................163
pentoxifylline tab cr 400 mg......................................... 136
PEPCID -famotidine for susp 40 mg/5ml...........................68
PEPCID -famotidine tab 40 mg......................................... 68
PERCOCET -oxycodone w/ acetaminophen tab 10-325
mg.................................................................................... 99
PERCOCET -oxycodone w/ acetaminophen tab 2.5-325
mg.................................................................................... 99
PERCOCET -oxycodone w/ acetaminophen tab 5-325
mg.................................................................................... 99
PERCOCET -oxycodone w/ acetaminophen tab 7.5-325
mg.................................................................................... 99
PERCODAN -oxycodone-aspirin tab 4.8355-325 mg........ 99
PERFOROMIST -formoterol fumarate soln nebu 20
mcg/2ml............................................................................64
PERIDEX -chlorhexidine gluconate soln 0.12%.............. 143
perindopril erbumine tab 2 mg.......................................50
perindopril erbumine tab 4 mg (Aceon)........................ 50
perindopril erbumine tab 8 mg (Aceon)........................ 50
PERMAVAN EXTERNAL PATCH -lidocaine-dm-trolamine
salicylate patch 4-4-10%................................................155
permethrin cream 5% (Elimite).....................................155
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg................................................. 92
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-25 mg................................................. 92
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-10 mg................................................. 92
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-25 mg................................................. 92
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-50 mg................................................. 92
perphenazine tab 16 mg................................................. 83
perphenazine tab 2 mg................................................... 82
perphenazine tab 4 mg................................................... 82
perphenazine tab 8 mg................................................... 82
PERSANTINE -dipyridamole tab 25 mg.......................... 136
PERSANTINE -dipyridamole tab 50 mg.......................... 136
PERSANTINE -dipyridamole tab 75 mg.......................... 136
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
16000-57500-60500 unit.................................................. 70
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
8000-28750-30250 unit.................................................... 70
PEXEVA -paroxetine mesylate tab 10 mg (base equiv).....79
PEXEVA -paroxetine mesylate tab 20 mg (base equiv).....79
PEXEVA -paroxetine mesylate tab 30 mg (base equiv).....79
PEXEVA -paroxetine mesylate tab 40 mg (base equiv).....79
PHARMACIST CHOICE TSX PAT -methyl salicylatelidocaine-menthol patch 2-4-1%.................................... 155
phenazopyridine hcl tab 100 mg (Pyridium)................. 74
phenazopyridine hcl tab 200 mg (Pyridium)................. 74
phenelzine sulfate tab 15 mg (Nardil)............................ 79
phenobarbital elixir 20 mg/5ml.......................................85
PHENOBARBITAL -phenobarbital tab 100 mg..................85
PHENOBARBITAL -phenobarbital tab 15 mg....................85
PHENOBARBITAL -phenobarbital tab 30 mg....................85
PHENOBARBITAL -phenobarbital tab 60 mg....................85
phenobarbital tab 16.2 mg..............................................85
phenobarbital tab 32.4 mg..............................................85
phenobarbital tab 64.8 mg..............................................85
phenobarbital tab 97.2 mg..............................................85
phenylephrine-brompheniramine-dm liquid 7.5-4-15
mg/5ml.............................................................................61
phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20
mg/ml)..............................................................................61
phenylephrine hcl ophth soln 10%.............................. 140
phenylephrine hcl ophth soln 2.5%............................. 140
phenylephrine-promethazine w/ codeine syrup
5-6.25-10 mg/5ml............................................................ 61
phenylephrine w/ dm-gg liqd 10-30-200 mg/5ml........... 61
phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml............. 61
PHENYLHISTINE DH -pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml............................................. 61
PHENYTEK -phenytoin sodium extended cap 200
mg.................................................................................. 109
PHENYTEK -phenytoin sodium extended cap 300
mg.................................................................................. 109
phenytoin chew tab 50 mg (Dilantin infatabs)............ 109
phenytoin sodium extended cap 100 mg
(Dilantin)........................................................................109
phenytoin susp 125 mg/5ml (Dilantin)......................... 109
PHOS-FLUR ORTHO DEFENSE -sodium fluoride rinse
0.044%........................................................................... 143
PHOS FLUR -sodium fluoride rinse 0.044%....................143
PHOSLO -calcium acetate (phosphate binder) cap 667 mg
(169 mg ca)..................................................................... 71
PHOSLYRA -calcium acetate (phosphate binder) oral soln
667 mg/5ml...................................................................... 71
PHOSPHOLINE IODIDE -echothiophate iodide ophth for
soln 0.125%................................................................... 140
PHYSICIANS EZ USE JOINT T -triamcinolone inj 40 mg/
ml & lidocaine 1% & ammonia inh kit.............................. 20
phytonadione inj 1 mg/0.5ml (2 mg/ml)....................... 115
PICATO -ingenol mebutate gel 0.015%.......................... 155
PICATO -ingenol mebutate gel 0.05%............................ 155
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
227
2015
PICO SINGLE USE NEGATIVE -wound dressings kit....................................................................................155
pilocarpine hcl ophth soln 1% (Isopto carpine).......... 140
pilocarpine hcl ophth soln 2% (Isopto carpine).......... 140
pilocarpine hcl ophth soln 4% (Isopto carpine).......... 140
pilocarpine hcl tab 5 mg (Salagen).............................. 143
pilocarpine hcl tab 7.5 mg (Salagen)........................... 143
pindolol tab 10 mg.......................................................... 41
pindolol tab 5 mg............................................................ 41
PINNACAINE OTIC -benzocaine otic soln 20%.............. 141
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)...... 30
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)...... 30
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)................................................................30
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)................................................................30
pioglitazone hcl tab 15 mg (base equiv) (Actos)...........30
pioglitazone hcl tab 30 mg (base equiv) (Actos)...........30
pioglitazone hcl tab 45 mg (base equiv) (Actos)...........30
piroxicam cap 10 mg (Feldene)....................................103
piroxicam cap 20 mg (Feldene)....................................103
PKU EASY MICROTABS -nutritional supplement tabs
delayed release..............................................................127
PLAN B ONE-STEP -levonorgestrel tab 1.5 mg................26
PLAQUENIL -hydroxychloroquine sulfate tab 200 mg....... 11
PLAVIX -clopidogrel bisulfate tab 300 mg (base
equiv)..............................................................................136
PLAVIX -clopidogrel bisulfate tab 75 mg (base equiv).....136
PLEGRIDY -peginterferon beta-1a soln pen-injector 125
mcg/0.5ml.........................................................................92
PLEGRIDY -peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml................................................................. 92
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack...................................... 92
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack.....................................92
PLETAL -cilostazol tab 100 mg....................................... 136
PLETAL -cilostazol tab 50 mg......................................... 136
PLEXION CLEANSER -sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8%.......................................................... 156
PLEXION CLEANSING CLOTHS -sulfacetamide sodium
w/ sulfur cleansing cloth 9.8-4.8%................................. 156
PLEXION -sulfacetamide sodium w/ sulfur cream
9.8-4.8%......................................................................... 156
PLEXION -sulfacetamide sodium w/ sulfur lotion
9.8-4.8%......................................................................... 155
PLIAGLIS -lidocaine-tetracaine cream 7-7%................... 156
PNEUMOVAX 23/1 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................. 15
PNEUMOVAX 23/5 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................. 15
PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj 25
mcg/0.5ml.........................................................................15
PNV-DHA+DOCUSATE -prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg........................................... 119
228
PNV-DHA -prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg......................................................... 119
PNV FERROUS FUMARATE/DOCU -prenatal vit w/ dss-fe
fumarate-fa tab 29-1 mg................................................ 119
PNV-FIRST -prenatal mv w/ fe polysac cmplx-fa-dha cap
29-1-200 mg...................................................................119
PNV FOLIC ACID + IRON MUL -prenatal vit w/ fe
fumarate-fa tab 27-1 mg................................................ 119
PNV-OB/DHA -prenatal mv w/fe fum-fa tab 65-1 mg & dha
cap 250 mg pack........................................................... 119
PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack........................................................... 119
PNV-OMEGA -prenat w/o a w/ fe fumerate-methylfolate-faomega 3 cap..................................................................119
PNV PRENATAL PLUS MULTIVI -prenatal vit w/ fe
fumarate-fa tab 27-1 mg................................................ 119
PNV-SELECT -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg.................................................................119
PNV TABS 29-1 -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 119
PNV-TOTAL -prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg....................................................................119
PNV-VP-U -prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg.....................................................................119
PODIAPN -l-methylfolate-b12-b6-alpha lipoic ac cap
5-2-35-300 mg............................................................... 127
PODOCON 25 IN BENZOIN TIN -podophyllum resin soln
25%................................................................................ 156
podofilox soln 0.5% (Condylox)................................... 156
polyethylene glycol 3350 oral packet............................ 66
polyethylene glycol 3350 oral powder...........................66
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)........................................................140
POLYTRIM -polymyxin b-trimethoprim ophth soln 10000
unit/ml-0.1%................................................................... 140
POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine
liquid 10-4-10 mg/5ml...................................................... 61
POLY-TUSSIN -codeine-chlorcyclizine liquid 10-9.375
mg/5ml..............................................................................61
POLY-TUSSIN D -codeine-pseudoephedrinechlorcyclizine liq 10-30-9.375mg/5ml............................... 61
POLY-VI-FLOR/IRON -ped multiple vitamin w/ fl-fe
biphasic susp 0.25-7 mg/ml........................................... 119
POLY-VI-FLOR/IRON -ped multiple vit w/ fl-fe biphasic
chew tab 0.5-10 mg....................................................... 119
POLY-VI-FLOR FS -pediatric multiple vitamins w/ fluoride
oral strip 1 mg................................................................119
POLY-VI-FLOR FS -pediatric multiple vit w/ fluoride oral
strip 0.25 mg.................................................................. 119
POLY-VI-FLOR FS -pediatric multiple vit w/ fluoride oral
strip 0.5 mg....................................................................119
POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic chew
tab 0.25 mg....................................................................119
POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic chew
tab 0.5 mg......................................................................119
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic chew
tab 1 mg.........................................................................119
POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic susp
0.25 mg/ml..................................................................... 119
POMALYST -pomalidomide cap 1 mg...............................18
POMALYST -pomalidomide cap 2 mg...............................18
POMALYST -pomalidomide cap 3 mg...............................18
POMALYST -pomalidomide cap 4 mg...............................18
PONSTEL -mefenamic acid cap 250 mg.........................103
pot & sod citrates w/ cit ac soln 550-500-334
mg/5ml.............................................................................74
POTABA -potassium aminobenzoate cap 500 mg.......... 115
POTABA -potassium aminobenzoate tab 500 mg........... 115
potassium bicarbonate effer tab 25 meq.....................125
potassium chloride cap cr 10 meq (Micro-k)...............125
potassium chloride cap cr 8 meq (Micro-k).................125
POTASSIUM CHLORIDE ER -potassium chloride tab cr
20 meq (1500 mg)......................................................... 125
POTASSIUM CHLORIDE ER -potassium chloride tab cr 8
meq (600 mg)................................................................ 125
potassium chloride microencapsulated crys cr tab 10
meq................................................................................ 125
potassium chloride microencapsulated crys cr tab 20
meq................................................................................ 125
potassium chloride oral liq 10% (20 meq/15ml).......... 125
potassium chloride oral liq 20% (40 meq/15ml).......... 125
potassium chloride powder packet 20 meq................ 125
potassium chloride tab cr 10 meq (K-tab)................... 125
potassium chloride tab cr 8 meq (600 mg)..................125
potassium citrate & citric acid powder pack 3300-1002
mg.................................................................................... 74
potassium citrate & citric acid soln 1100-334
mg/5ml.............................................................................74
potassium citrate tab cr 10 meq (1080 mg) (Urocit-k
10).................................................................................... 74
potassium citrate tab cr 15 meq (1620 mg) (Urocit-k
15).................................................................................... 74
potassium citrate tab cr 5 meq (540 mg) (Urocit-k
5)...................................................................................... 74
pot bicarbonate & chloride effer tab 25 meq...............125
POTIGA -ezogabine tab 200 mg..................................... 110
POTIGA -ezogabine tab 300 mg..................................... 110
POTIGA -ezogabine tab 400 mg..................................... 110
POTIGA -ezogabine tab 50 mg....................................... 109
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)................................ 125
PRADAXA -dabigatran etexilate mesylate cap 150 mg
(etexilate base eq)......................................................... 133
PRADAXA -dabigatran etexilate mesylate cap 75 mg
(etexilate base eq)......................................................... 133
PRALUENT -alirocumab subcutaneous soln pen-injector
150 mg/ml........................................................................ 56
PRALUENT -alirocumab subcutaneous soln pen-injector
75 mg/ml.......................................................................... 56
PRALUENT -alirocumab subcutaneous soln prefilled
syringe 150 mg/ml........................................................... 56
PRALUENT -alirocumab subcutaneous soln prefilled
syringe 75 mg/ml............................................................. 56
pramipexole dihydrochloride tab 0.125 mg
(Mirapex)....................................................................... 112
pramipexole dihydrochloride tab 0.25 mg
(Mirapex)....................................................................... 112
pramipexole dihydrochloride tab 0.5 mg
(Mirapex)....................................................................... 112
pramipexole dihydrochloride tab 0.75 mg
(Mirapex)....................................................................... 112
pramipexole dihydrochloride tab 1.5 mg
(Mirapex)....................................................................... 112
pramipexole dihydrochloride tab 1 mg (Mirapex)....... 112
pramipexole dihydrochloride tab sr 24hr 0.375 mg
(Mirapex er)...................................................................112
pramipexole dihydrochloride tab sr 24hr 0.75 mg
(Mirapex er)...................................................................112
pramipexole dihydrochloride tab sr 24hr 1.5 mg
(Mirapex er)...................................................................112
pramipexole dihydrochloride tab sr 24hr 3 mg
(Mirapex er)...................................................................112
PRAMOSONE E -pramoxine-hc emollient base cream
1-2.5%............................................................................ 156
PRAMOSONE -pramoxine-hc cream 1-1%..................... 156
PRAMOSONE -pramoxine-hc cream 1-2.5%.................. 156
PRAMOSONE -pramoxine-hc lotion 1-1%...................... 156
PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 156
PRAMOSONE -pramoxine-hc oint 1-1%......................... 156
PRAMOSONE -pramoxine-hc oint 1-2.5%...................... 156
PRAMOTIC -pramoxine-chloroxylenol otic liquid
1-0.1%............................................................................ 142
pramoxine-chloroxylenol otic liquid 1-0.1%
(Pramotic)......................................................................142
pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml
(Cortane-b-otic)............................................................ 142
pramoxine-hc cream 1-2.5% (Pramosone).................. 156
pramoxine hcl gel 1%....................................................156
PRANDIMET -repaglinide-metformin hcl tab 1-500 mg..... 30
PRANDIMET -repaglinide-metformin hcl tab 2-500 mg..... 30
PRANDIN -repaglinide tab 0.5 mg.................................... 30
PRANDIN -repaglinide tab 1 mg....................................... 30
PRANDIN -repaglinide tab 2 mg....................................... 30
PRASCION RA WITH SUNSCREE -sulfacetamide
sodium-sulfur-sunscreen cream 10-5%......................... 156
PRASTERA -prasterone cap 200 mg & ibuprofen tab 400
mg kit............................................................................. 103
PRAVACHOL -pravastatin sodium tab 20 mg................... 56
PRAVACHOL -pravastatin sodium tab 40 mg................... 56
PRAVACHOL -pravastatin sodium tab 80 mg................... 56
pravastatin sodium tab 10 mg........................................56
pravastatin sodium tab 20 mg (Pravachol)................... 56
pravastatin sodium tab 40 mg (Pravachol)................... 56
pravastatin sodium tab 80 mg (Pravachol)................... 56
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
229
2015
prazosin hcl cap 1 mg (Minipress).................................50
prazosin hcl cap 2 mg (Minipress).................................50
prazosin hcl cap 5 mg (Minipress).................................50
PR CREAM -dermatological products misc - kit.............. 156
PRECOSE -acarbose tab 100 mg.....................................30
PRECOSE -acarbose tab 25 mg.......................................30
PRECOSE -acarbose tab 50 mg.......................................30
PRED FORTE -prednisolone acetate ophth susp 1%......140
PRED-G -gentamicin-prednisolone ace ophth susp
0.3-1%............................................................................ 140
PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint
0.3-0.6%......................................................................... 140
PRED MILD -prednisolone acetate ophth susp
0.12%............................................................................. 140
prednicarbate cream 0.1% (Dermatop)........................ 156
prednicarbate oint 0.1% (Dermatop)............................ 156
prednisolone acetate ophth susp 1% (Pred forte)...... 140
PREDNISOLONE SODIUM PHOSP -prednisolone sodium
phosphate ophth soln 1%.............................................. 140
PREDNISOLONE SODIUM PHOSP -prednisolone sodium
phosphate oral soln 25 mg/5ml (base eq)....................... 21
prednisolone sod phos orally disintegr tab 10 mg
(base eq) (Orapred odt).................................................20
prednisolone sod phos orally disintegr tab 15 mg
(base eq) (Orapred odt).................................................20
prednisolone sod phos orally disintegr tab 30 mg
(base eq) (Orapred odt).................................................20
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv).................................................................... 20
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred)............................................. 20
prednisolone syrup 15 mg/5ml (usp solution
equivalent) (Prelone)......................................................21
PREDNISONE INTENSOL -prednisone conc 5 mg/ml...... 21
PREDNISONE -prednisone oral soln 5 mg/5ml.................21
PREDNISONE -prednisone tab 10 mg dose pack.............21
PREDNISONE -prednisone tab 50 mg..............................21
PREDNISONE -prednisone tab 5 mg dose pack...............21
prednisone tab 10 mg..................................................... 21
prednisone tab 1 mg....................................................... 21
prednisone tab 2.5 mg.................................................... 21
prednisone tab 20 mg..................................................... 21
prednisone tab 5 mg....................................................... 21
PREFERAOB +DHA -prenat-fe poly cmplx 28mg-fe heme
poly-fa tab&dha cap pack.............................................. 119
PREFERA OB + DHA -prenat-fe poly cmplx-fe heme polyfa tab & omega 3 cap pck............................................. 119
PREFERAOB ONE -prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg................................................. 119
PREFERA OB -prenat vit-fe poly cmplx-fe heme poly-fa
tab 28-6-1 mg................................................................ 119
PREFERRED PLUS GLUCOSE -glucose chew tab 4
gm.................................................................................... 30
PREFERRED PLUS GLUCOSE -glucose-vitamin c chew
tab 4-0.006 gm................................................................ 31
230
PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate tab
1-0.09mg(15)....................................................................23
PREFOL-DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg................................................................119
PRE-FOLIC -folic acid-vitamin c tab 1-100 mg................131
PREMARIN -estrogens, conjugated tab 0.3 mg................ 23
PREMARIN -estrogens, conjugated tab 0.45 mg.............. 23
PREMARIN -estrogens, conjugated tab 0.625 mg............ 23
PREMARIN -estrogens, conjugated tab 0.9 mg................ 23
PREMARIN -estrogens, conjugated tab 1.25 mg.............. 24
PREMARIN -estrogens, conjugated vaginal cream 0.625
mg/gm.............................................................................. 74
PREMIUM SCAR PATCH -allantoin-lidocaine-petrolatum
patch 2-4-30%................................................................156
PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac
tab 0.625-5mg(14)........................................................... 24
PREMPRO -conjugated estrogen-medroxyprogest acetate
tab 0.3-1.5 mg................................................................. 24
PREMPRO -conjugated estrogen-medroxyprogest acetate
tab 0.45-1.5 mg............................................................... 24
PREMPRO -conjugated estrogen-medroxyprogest acetate
tab 0.625-2.5 mg..............................................................24
PREMPRO -conjugated estrogen-medroxyprogest acetate
tab 0.625-5 mg................................................................ 24
PRENA1/QUATREFOLIC -prenat w/o a w/fefum-methfolfa-dha cap 30-0.6-0.4-200 mg....................................... 121
PRENA1 CHEW -prenat w/ b2-b6-b12-d3-folic acid chew
tab 1.4 mg......................................................................120
PRENA1 PEARL -prenat w/oa w/fefum-na fered-fa-dha
cap cr 30-1.4-200 mg.................................................... 121
PRENA1 PLUS/QUATREFOLIC -prenat w/o a w/ fe
chelate-l methylfol-fa tab & dha cap pk......................... 121
PRENAISSANCE 90 DHA -prenat w/o a w/fecbn-fegl-dssfa tab 90 &dha cap 300mg pak..................................... 120
PRENAISSANCE BALANCE -prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg..........................................119
PRENAISSANCE DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 250 mg pack.......................................... 120
PRENAISSANCE HARMONY DHA -prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr 380mg......................120
PRENAISSANCE NEXT-B -prenatal w/ calcium-vit b6-faginger tab 1.22 mg........................................................ 120
PRENAISSANCE NEXT -prenatal w/ calcium-vit b6-faginger tab 1.2 mg.......................................................... 120
PRENAISSANCE PLUS -prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg.................................................... 120
PRENAISSANCE -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg.......................................................119
PRENAISSANCE PROMISE -prenat w/o a w/fecbn-fegldss-fa tab & dha cap 300 mg pack................................120
PRENAPLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 120
PRENATABS FA -prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................. 120
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
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PRENATABS RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 120
PRENATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 120
PRENATAL 19 -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg..........................................................................120
PRENATAL AD -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg..........................................................................120
PRENATAL LOW IRON -prenatal vit w/ fe fumarate-fa tab
27-1 mg..........................................................................120
PRENATAL PLUS IRON -prenatal vit w/ iron carbonyl-fa
tab 29-1 mg................................................................... 120
PRENATAL PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 120
PRENATAL -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 120
PRENATAL-U -prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg.....................................................................120
PRENATAL VITAMINS PLUS -prenatal vit w/ fe fumaratefa tab 27-1 mg............................................................... 120
PRENATA -prenatal w/o a vit w/ fe fum-fa tab chew 29-1
mg.................................................................................. 120
PRENATE AM -prenatal w/ calcium-vit b6-vit b12-fa-ginger
tab 1 mg.........................................................................120
PRENATE DHA -prenat w/o a w/feaspg-methfol-fa-dha
cap 18-0.6-0.4-300 mg.................................................. 120
PRENATE DHA -prenat w/o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg......................................................... 120
PRENATE ELITE -prenatal vit w/ fe fum-methylfolate-fa
tab 26-0.6-0.4 mg.......................................................... 120
PRENATE ELITE -prenatal w/ fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg.................................................................120
PRENATE ENHANCE -prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg........................................... 120
PRENATE ESSENTIAL -prenat w/o a w/feaspg-methfol-fadha cap 18-0.6-0.4-300 mg........................................... 120
PRENATE ESSENTIAL -prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg........................................ 120
PRENATE MINI -prenat w/oa w/fecb-feasp-meth-fa-dha
cap 18-0.6-0.4-350 mg.................................................. 120
PRENATE PIXIE -prenat w/o a w/feaspg-methfol-fa-dha
cap 10-0.6-0.4-200 mg.................................................. 120
PRENATE -prenat mv & min w/ l-methylfolate-fa chew tab
0.6-0.4 mg......................................................................120
PRENATE RESTORE -prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg........................................... 120
PRENATE STAR -prenatal vit w/ fe asparto glycinate-fa
tab 20-1 mg................................................................... 120
PRENEXA -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg..............................................................121
PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm.............35
PREPLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 121
PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10
mg-3.5 gm-12 gm............................................................ 66
PREQUE 10 -prenatal mv w/fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg............................................................ 121
PRESERA -emollient - aerosol foam...............................156
PRESTALIA -perindopril arginine-amlodipine besylate tab
14-10 mg..........................................................................50
PRESTALIA -perindopril arginine-amlodipine besylate tab
3.5-2.5 mg........................................................................50
PRESTALIA -perindopril arginine-amlodipine besylate tab
7-5 mg..............................................................................50
PRETAB -prenatal vit w/ fe fumarate-fa tab 29-1 mg.......121
PREVACID -lansoprazole cap delayed release 15 mg...... 68
PREVACID -lansoprazole cap delayed release 30 mg...... 68
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 15 mg...............................................68
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 30 mg...............................................68
PREVIDENT 5000 BOOSTER PL -sodium fluoride paste
1.1%............................................................................... 143
PREVIDENT 5000 BOOSTER -sodium fluoride paste
1.1%............................................................................... 143
PREVIDENT 5000 DRY MOUTH -sodium fluoride gel
1.1% (0.5% f)................................................................. 143
PREVIDENT 5000 ENAMEL PRO -sodium fluoridepotassium nitrate paste 1.1-5%..................................... 143
PREVIDENT 5000 PLUS -sodium fluoride cream
1.1%............................................................................... 143
PREVIDENT 5000 SENSITIVE -sodium fluoride-potassium
nitrate paste 1.1-5%.......................................................143
PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5%
f)..................................................................................... 143
PREVIDENT -sodium fluoride rinse 0.2%........................143
PREVNAR 13 -pneumococcal 13-valent conjugate vaccine
inj......................................................................................15
PREVPAC -amoxicillin cap-clarithro tab-lansopraz cap dr
therapy pack.................................................................... 68
PREZCOBIX -darunavir-cobicistat tab 800-150 mg.............9
PREZISTA -darunavir ethanolate susp 100 mg/ml (base
equiv)..................................................................................9
PREZISTA -darunavir ethanolate tab 150 mg (base
equiv)..................................................................................9
PREZISTA -darunavir ethanolate tab 600 mg (base
equiv)..................................................................................9
PREZISTA -darunavir ethanolate tab 75 mg (base
equiv)..................................................................................9
PREZISTA -darunavir ethanolate tab 800 mg (base
equiv)..................................................................................9
PRIFTIN -rifapentine tab 150 mg........................................ 6
PRILOSEC -omeprazole cap delayed release 10 mg........68
PRILOSEC -omeprazole cap delayed release 20 mg........68
PRILOSEC -omeprazole cap delayed release 40 mg........68
PRILOSEC -omeprazole magnesium for delayed release
susp packet 10 mg.......................................................... 68
PRILOSEC -omeprazole magnesium for delayed release
susp packet 2.5 mg......................................................... 68
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
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2015
PRIMAQUINE PHOSPHATE -primaquine phosphate tab
26.3 mg (15 mg base)..................................................... 11
primidone tab 250 mg (Mysoline).................................110
primidone tab 50 mg (Mysoline).................................. 110
PRIMLEV -oxycodone w/ acetaminophen tab 10-300
mg.................................................................................. 100
PRIMLEV -oxycodone w/ acetaminophen tab 5-300
mg.................................................................................... 99
PRIMLEV -oxycodone w/ acetaminophen tab 7.5-300
mg.................................................................................. 100
PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base
equiv)................................................................................12
PRINIVIL -lisinopril tab 10 mg........................................... 50
PRINIVIL -lisinopril tab 20 mg........................................... 50
PRINIVIL -lisinopril tab 5 mg............................................. 50
PRINZIDE -lisinopril & hydrochlorothiazide tab 10-12.5
mg.................................................................................... 50
PRISTIQ -desvenlafaxine succinate tab sr 24hr 100 mg
(base equiv)..................................................................... 79
PRISTIQ -desvenlafaxine succinate tab sr 24hr 25 mg
(base equiv)..................................................................... 79
PRISTIQ -desvenlafaxine succinate tab sr 24hr 50 mg
(base equiv)..................................................................... 79
PR NATAL 400 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk.................................................... 119
PR NATAL 400 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk......................................................119
PR NATAL 430 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk.................................................... 119
PR NATAL 430 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 430 pk......................................................119
PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)......................................................... 64
PROAIR RESPICLICK -albuterol sulfate aer pow ba 108
mcg/act (90 mcg base equiv).......................................... 64
probenecid tab 500 mg................................................. 106
PROCARDIA -nifedipine cap 10 mg..................................43
PROCARDIA XL -nifedipine tab sr 24hr osmotic 30
mg.................................................................................... 43
PROCARDIA XL -nifedipine tab sr 24hr osmotic 60
mg.................................................................................... 43
PROCARDIA XL -nifedipine tab sr 24hr osmotic 90
mg.................................................................................... 43
PROCENTRA -dextroamphetamine sulfate oral solution 5
mg/5ml..............................................................................88
prochlorperazine maleate tab 10 mg (base equivalent)
(Compazine)....................................................................83
prochlorperazine maleate tab 5 mg (base equivalent)
(Compazine)....................................................................83
prochlorperazine suppos 25 mg.................................... 83
PRO-CLEAR AC -codeine-pyrilamine syrup 9-8.33
mg/5ml..............................................................................61
PROCORT -hydrocortisone acetate w/ pramoxine rectal
cream 1.85-1.15%..........................................................144
PROCRIT -epoetin alfa inj 10000 unit/ml........................ 131
232
PROCRIT -epoetin alfa inj 20000 unit/ml........................ 131
PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 131
PROCRIT -epoetin alfa inj 3000 unit/ml.......................... 131
PROCRIT -epoetin alfa inj 40000 unit/ml........................ 131
PROCRIT -epoetin alfa inj 4000 unit/ml.......................... 131
PROCTOCORT -hydrocortisone acetate suppos 30
mg.................................................................................. 144
PROCTOCORT -hydrocortisone rectal cream 1%...........144
PROCTOFOAM HC -hydrocortisone acetate w/ pramoxine
rectal foam 1-1%............................................................144
PROCYSBI -cysteamine bitartrate cap delayed release 25
mg (base equiv)............................................................... 74
PROCYSBI -cysteamine bitartrate cap delayed release 75
mg (base equiv)............................................................... 74
PRODRIN -isometheptene-caffeine-acetaminophen tab
65-20-325 mg.................................................................105
PROFERRIN-FORTE -iron heme polypeptide-folic acid tab
12-1 mg (fe equiv)......................................................... 131
PROFILNINE -factor ix complex for inj 1000 unit............ 136
PROFILNINE -factor ix complex for inj 1500 unit............ 136
PROFILNINE -factor ix complex for inj 500 unit.............. 136
PROFILNINE SD -factor ix complex for inj 1000 unit.......136
PROFILNINE SD -factor ix complex for inj 1500 unit.......136
PROFILNINE SD -factor ix complex for inj 500 unit.........136
progesterone im in oil 50 mg/ml.................................... 26
progesterone micronized cap 100 mg
(Prometrium)...................................................................26
progesterone micronized cap 200 mg
(Prometrium)...................................................................26
PROGLYCEM -diazoxide susp 50 mg/ml..........................31
PROGRAF -tacrolimus cap 0.5 mg................................. 164
PROGRAF -tacrolimus cap 1 mg.................................... 164
PROGRAF -tacrolimus cap 5 mg.................................... 164
PROLENSA -bromfenac sodium ophth soln 0.07% (base
equivalent)......................................................................140
PROLIDA -lidocaine-menthol patch 4-1%....................... 156
PROMACTA -eltrombopag olamine tab 12.5 mg (base
equiv)..............................................................................131
PROMACTA -eltrombopag olamine tab 25 mg (base
equiv)..............................................................................131
PROMACTA -eltrombopag olamine tab 50 mg (base
equiv)..............................................................................131
PROMACTA -eltrombopag olamine tab 75 mg (base
equiv)..............................................................................131
promethazine-dm syrup 6.25-15 mg/5ml....................... 61
promethazine hcl suppos 12.5 mg.................................58
promethazine hcl suppos 25 mg....................................58
promethazine hcl suppos 50 mg....................................58
promethazine hcl syrup 6.25 mg/5ml.............................58
promethazine hcl tab 12.5 mg........................................ 58
promethazine hcl tab 25 mg........................................... 58
promethazine hcl tab 50 mg...........................................58
PROMETHAZINE VC PLAIN -promethazine &
phenylephrine syrup 6.25-5 mg/5ml.................................61
promethazine w/ codeine syrup 6.25-10 mg/5ml...........61
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
PROMETRIUM -progesterone micronized cap 100 mg..... 26
PROMETRIUM -progesterone micronized cap 200 mg..... 26
PROMISEB -antiseborrheic products misc - cream.........156
PROMISEB COMPLETE -antiseborrheic products misc kit....................................................................................156
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 44
propafenone hcl cap sr 12hr 325 mg (Rythmol sr)....... 44
propafenone hcl cap sr 12hr 425 mg (Rythmol sr)....... 45
propafenone hcl tab 150 mg (Rythmol)......................... 45
propafenone hcl tab 225 mg (Rythmol)......................... 45
propafenone hcl tab 300 mg.......................................... 45
PROPANTHELINE BROMIDE -propantheline bromide tab
15 mg............................................................................... 68
proparacaine hcl ophth soln 0.5% (Alcaine)............... 140
PROPRANOLOL/HYDROCHLOROTH -propranolol &
hydrochlorothiazide tab 40-25 mg................................... 50
PROPRANOLOL/HYDROCHLOROTH -propranolol &
hydrochlorothiazide tab 80-25 mg................................... 50
propranolol hcl cap sr 24hr 120 mg (Inderal la)............41
propranolol hcl cap sr 24hr 160 mg (Inderal la)............41
propranolol hcl cap sr 24hr 60 mg (Inderal la)..............41
propranolol hcl cap sr 24hr 80 mg (Inderal la)..............41
PROPRANOLOL HCL -propranolol hcl oral soln 20
mg/5ml..............................................................................41
PROPRANOLOL HCL -propranolol hcl oral soln 40
mg/5ml..............................................................................41
propranolol hcl tab 10 mg.............................................. 41
propranolol hcl tab 20 mg.............................................. 41
propranolol hcl tab 40 mg.............................................. 41
propranolol hcl tab 60 mg.............................................. 41
propranolol hcl tab 80 mg.............................................. 41
propylthiouracil tab 50 mg............................................. 34
PRO-RED AC -phenylephrine-dexchlorphenir-codeine
syrup 5-1-9 mg/5ml..........................................................61
PROSCAR -finasteride tab 5 mg.......................................74
PROSED/DS -methenamine-hyosc-meth blue-benz acidphenyl sal tab 81.6mg..................................................... 72
PROSTIN E2 -dinoprostone vaginal suppos 20 mg...........35
PROTECTIRON -iron polysacch-fa-b complex-vit c-e &
minerals tab 60-1 mg.....................................................131
PROTHELIAL -sucralfate-malate paste 10%...................143
PROTONIX -pantoprazole sodium ec tab 20 mg (base
equiv)................................................................................68
PROTONIX -pantoprazole sodium ec tab 40 mg (base
equiv)................................................................................68
PROTONIX -pantoprazole sodium for delayed release
susp packet 40 mg.......................................................... 68
PROTOPIC -tacrolimus oint 0.03%................................. 156
PROTOPIC -tacrolimus oint 0.1%................................... 156
protriptyline hcl tab 10 mg (Vivactil)............................. 79
protriptyline hcl tab 5 mg (Vivactil)............................... 79
PROVENTIL HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)......................................................... 64
PROVENZA -lidocaine-menthol patch 4-1%................... 156
PROVERA -medroxyprogesterone acetate tab 10 mg...... 26
PROVERA -medroxyprogesterone acetate tab 2.5 mg......26
PROVERA -medroxyprogesterone acetate tab 5 mg........ 26
PROVIDA DHA -prenat w/o a w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg........................................................ 121
PROVIDA OB -prenatal w/o a w/fe fum-fe poly-fa cap
20-20-1.25 mg................................................................121
PROVIGIL -modafinil tab 100 mg......................................88
PROVIGIL -modafinil tab 200 mg......................................88
PROZAC -fluoxetine hcl cap 10 mg.................................. 79
PROZAC -fluoxetine hcl cap 20 mg.................................. 79
PROZAC -fluoxetine hcl cap 40 mg.................................. 79
PROZAC WEEKLY -fluoxetine hcl cap delayed release 90
mg.................................................................................... 80
PROZENA -lidocaine patch 4%.......................................156
PRUCLAIR -dermatological products misc - cream.........156
PRUDOXIN -doxepin hcl cream 5%................................ 156
PRUMYX -dermatological products misc - cream............156
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5
mg/5ml (Zutripro)........................................................... 61
pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml.....61
pseudoephedrine-bromphen-codeine liq 10-1.33-6.33
mg/5ml.............................................................................61
pseudoephedrine w/ cod-gg soln 30-10-100
mg/5ml.............................................................................61
pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml
(Suttar-sf)........................................................................ 61
PSORCON -diflorasone diacetate cream 0.05%............. 156
PULMICORT -budesonide inhalation susp 0.25
mg/2ml..............................................................................64
PULMICORT -budesonide inhalation susp 0.5 mg/2ml..... 64
PULMICORT -budesonide inhalation susp 1 mg/2ml........ 64
PULMICORT FLEXHALER -budesonide inhal aero powd
180 mcg/act (breath activated)........................................ 64
PULMICORT FLEXHALER -budesonide inhal aero powd
90 mcg/act (breath activated).......................................... 64
PULMOZYME -dornase alfa inhal soln 1 mg/ml................ 65
PUREFE OB PLUS -prenatal w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg..............................................................121
PUREFE PLUS -ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg......................................................131
PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/
ml).................................................................................... 18
PX GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 31
PYLERA -bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg...............................................................68
pyrazinamide tab 500 mg..................................................6
PYRIDIUM -phenazopyridine hcl tab 100 mg.................... 74
PYRIDIUM -phenazopyridine hcl tab 200 mg.................... 74
pyridostigmine bromide tab 60 mg (Mestinon)........... 115
pyridostigmine bromide tab cr 180 mg (Mestinon
timespan)...................................................................... 114
PYROGALLIC ACID -pyrogallol-chlorobutanol oint
25-2%............................................................................. 156
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
233
2015
Q
QNASL -beclomethasone dipropionate nasal aerosol 80
mcg/act.............................................................................59
QNASL CHILDRENS -beclomethasone dipropionate nasal
aerosol 40 mcg/act.......................................................... 59
QROXIN -capsaicin-menthol topical patch
0.0375-5%...................................................................... 156
Q-TABS -levomefolate glucosamine tab 1 mg (folate
equivalent)......................................................................127
QUADRACEL -diph-tetanus tox ad-acell pert & polio virus,
ipv vac inj.........................................................................15
QUALAQUIN -quinine sulfate cap 324 mg........................ 11
QUARTETTE -levonor-eth est tab 0.15-0.02/0.025/0.03
mg &eth est 0.01 mg....................................................... 26
QUAZEPAM -quazepam tab 15 mg.................................. 85
QUDEXY XR -topiramate cap er 24hr sprinkle 100
mg.................................................................................. 110
QUDEXY XR -topiramate cap er 24hr sprinkle 150
mg.................................................................................. 110
QUDEXY XR -topiramate cap er 24hr sprinkle 200
mg.................................................................................. 110
QUDEXY XR -topiramate cap er 24hr sprinkle 25 mg..... 110
QUDEXY XR -topiramate cap er 24hr sprinkle 50 mg..... 110
QUESTRAN -cholestyramine powder 4 gm/dose.............. 56
QUESTRAN -cholestyramine powder packets 4 gm......... 56
QUESTRAN LIGHT -cholestyramine light powder 4 gm/
dose..................................................................................56
quetiapine fumarate tab 100 mg (Seroquel).................. 83
quetiapine fumarate tab 200 mg (Seroquel).................. 83
quetiapine fumarate tab 25 mg (Seroquel).................... 83
quetiapine fumarate tab 300 mg (Seroquel).................. 83
quetiapine fumarate tab 400 mg (Seroquel).................. 83
quetiapine fumarate tab 50 mg (Seroquel).................... 83
QUFLORA PEDIATRIC -pediatric multiple vitamins w/
fluoride chew tab 0.25 mg............................................. 121
QUFLORA PEDIATRIC -pediatric multiple vitamins w/
fluoride chew tab 0.5 mg............................................... 121
QUFLORA PEDIATRIC -pediatric multiple vitamins w/
fluoride chew tab 1 mg.................................................. 121
QUFLORA PEDIATRIC -pediatric multiple vitamins w/
fluoride soln 0.25 mg/ml................................................ 121
QUFLORA PEDIATRIC -pediatric multiple vitamins w/
fluoride soln 0.5 mg/ml.................................................. 121
QUILLIVANT XR -methylphenidate hcl for er susp 25
mg/5ml (5 mg/ml).............................................................88
quinapril hcl tab 10 mg (Accupril)................................. 50
quinapril hcl tab 20 mg (Accupril)................................. 50
quinapril hcl tab 40 mg (Accupril)................................. 50
quinapril hcl tab 5 mg (Accupril)................................... 50
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic).......................................................................50
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic).......................................................................50
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic).......................................................................50
234
quinidine gluconate tab cr 324 mg................................ 45
QUINIDINE SULFATE ER -quinidine sulfate tab cr 300
mg.................................................................................... 45
QUINIDINE SULFATE -quinidine sulfate tab 200 mg........ 45
quinidine sulfate tab 300 mg.......................................... 45
quinine sulfate cap 324 mg (Qualaquin)........................11
QUINZYME -coenzyme q10 tab disp 90 mg................... 163
QUTENZA -capsaicin patch 8% & cleansing gel kit.........156
QVAR -beclomethasone dipropionate inhal aero soln 40
mcg/act.............................................................................64
QVAR -beclomethasone dipropionate inhal aero soln 80
mcg/act.............................................................................64
R
RABAVERT -rabies vaccine, pcec for inj...........................15
rabeprazole sodium ec tab 20 mg (Aciphex).................68
RADIOGARDASE -prussian blue insoluble cap 0.5
gm.................................................................................. 163
RA GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 31
RAGWITEK -short ragweed pollen allergen extract tab sl
12 amb a 1-u................................................................... 16
raloxifene hcl tab 60 mg (Evista)................................... 38
ramipril cap 1.25 mg (Altace)......................................... 50
ramipril cap 10 mg (Altace)............................................ 50
ramipril cap 2.5 mg (Altace)........................................... 50
ramipril cap 5 mg (Altace).............................................. 50
RANEXA -ranolazine tab sr 12hr 1000 mg........................40
RANEXA -ranolazine tab sr 12hr 500 mg..........................40
ranitidine hcl cap 150 mg............................................... 68
ranitidine hcl cap 300 mg............................................... 68
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)....................68
ranitidine hcl tab 300 mg (Zantac)................................. 68
RAPAFLO -silodosin cap 4 mg......................................... 74
RAPAFLO -silodosin cap 8 mg......................................... 74
RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 164
RAPAMUNE -sirolimus tab 0.5 mg..................................164
RAPAMUNE -sirolimus tab 1 mg.....................................164
RAPAMUNE -sirolimus tab 2 mg.....................................164
RASUVO -methotrexate soln pf auto-injector 10
mg/0.2ml.........................................................................103
RASUVO -methotrexate soln pf auto-injector 12.5
mg/0.25ml.......................................................................103
RASUVO -methotrexate soln pf auto-injector 15
mg/0.3ml.........................................................................104
RASUVO -methotrexate soln pf auto-injector 17.5
mg/0.35ml.......................................................................104
RASUVO -methotrexate soln pf auto-injector 20
mg/0.4ml.........................................................................104
RASUVO -methotrexate soln pf auto-injector 22.5
mg/0.45ml.......................................................................104
RASUVO -methotrexate soln pf auto-injector 25
mg/0.5ml.........................................................................104
RASUVO -methotrexate soln pf auto-injector 27.5
mg/0.55ml.......................................................................104
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
RASUVO -methotrexate soln pf auto-injector 30
mg/0.6ml.........................................................................104
RASUVO -methotrexate soln pf auto-injector 7.5
mg/0.15ml.......................................................................103
RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml........... 38
RAYOS -prednisone tab delayed release 1 mg.................21
RAYOS -prednisone tab delayed release 2 mg.................21
RAYOS -prednisone tab delayed release 5 mg.................21
RAZADYNE ER -galantamine hydrobromide cap sr 24hr
16 mg............................................................................... 92
RAZADYNE ER -galantamine hydrobromide cap sr 24hr
24 mg............................................................................... 92
RAZADYNE ER -galantamine hydrobromide cap sr 24hr 8
mg.................................................................................... 92
RAZADYNE -galantamine hydrobromide oral soln 4 mg/
ml......................................................................................92
RAZADYNE -galantamine hydrobromide tab 12 mg..........92
RAZADYNE -galantamine hydrobromide tab 4 mg............92
RAZADYNE -galantamine hydrobromide tab 8 mg............92
REACH KIDS -sodium fluoride paste 0.15%................... 143
REBETOL -ribavirin cap 200 mg......................................... 9
REBETOL -ribavirin soln 40 mg/ml..................................... 9
REBIF -interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44
mcg/ml).............................................................................92
REBIF -interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88
mcg/ml).............................................................................92
REBIF REBIDOSE -interferon beta-1a inj 22 mcg/0.5ml
(12mu/ml) (44 mcg/ml).....................................................92
REBIF REBIDOSE -interferon beta-1a inj 44 mcg/0.5ml
(24mu/ml) (88 mcg/ml).....................................................92
REBIF REBIDOSE TITRATION -interferon beta-1a inj 6 x
8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml.................................. 92
REBIF TITRATION PACK -interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml........................................ 92
RECIPHEXAMINE -lidocaine-menthol patch 4-1%..........156
RECOMBINATE -antihemophilic factor (recombinant) for
inj 1241-1800 unit.......................................................... 136
RECOMBINATE -antihemophilic factor (recombinant) for
inj 1801-2400 unit.......................................................... 136
RECOMBINATE -antihemophilic factor (recombinant) for
inj 220-400 unit.............................................................. 136
RECOMBINATE -antihemophilic factor (recombinant) for
inj 401-800 unit.............................................................. 136
RECOMBINATE -antihemophilic factor (recombinant) for
inj 801-1240 unit............................................................ 136
RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp
10 mcg/ml........................................................................ 15
RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp
40 mcg/ml........................................................................ 15
RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp
5 mcg/0.5ml..................................................................... 15
RECTIV -nitroglycerin oint 0.4%......................................144
REGENECARE -lidocaine hcl-collagen-aloe vera gel
2%.................................................................................. 156
REGLAN -metoclopramide hcl tab 10 mg......................... 71
REGLAN -metoclopramide hcl tab 5 mg........................... 71
REGRANEX -becaplermin gel 0.01%..............................156
RELAGARD -acetic acid-oxyquinoline vaginal gel
0.9-0.025%....................................................................... 74
RELEEVIA -capsaicin-menthol topical patch
0.0375-5%...................................................................... 156
RELEEVIA MC -capsaicin-menthol topical patch
0.0375-5%...................................................................... 156
RELEEVIA ML -lidocaine-menthol patch 4-1%................156
RELENZA DISKHALER -zanamivir aero powder breath
activated 5 mg/blister.........................................................9
RELHIST -bromphen tan-phenyleph tan chew tab 6-15
mg.................................................................................... 61
RELION GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 31
RELION R -insulin regular (human) inj 100 unit/ml............32
RELISTOR -methylnaltrexone bromide inj 12 mg/0.6ml (20
mg/ml).............................................................................. 71
RELISTOR -methylnaltrexone bromide inj 8 mg/0.4ml (20
mg/ml).............................................................................. 71
RELNATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg...................................................................121
RELPAX -eletriptan hydrobromide tab 20 mg (base
equivalent)......................................................................105
RELPAX -eletriptan hydrobromide tab 40 mg (base
equivalent)......................................................................105
RELYYT -capsaicin-menthol topical patch 0.025-5%...... 156
REMATEX -capsaicin-menthol-methyl salicylate cream
0.035-6-30%...................................................................156
REMAXAZON EXTERNAL PATCH -lidocaine-capsaicinchondroitin-glucos patch 4-0.0285-3-5%....................... 157
REMBRANDT CANKER SORE -sodium fluoride paste
0.243%........................................................................... 143
REMBRANDT DEEPLY WHITE+PE -sodium
monofluorophosphate paste 0.884%............................. 143
REMBRANDT INTENSE STAIN -sodium fluoride paste
0.243%........................................................................... 143
REMBRANDT WHITENING -sodium fluoride rinse
0.02%............................................................................. 143
REMERON -mirtazapine tab 15 mg.................................. 80
REMERON -mirtazapine tab 30 mg.................................. 80
REMERON -mirtazapine tab 45 mg.................................. 80
REMERON SOLTAB -mirtazapine orally disintegrating tab
15 mg............................................................................... 80
REMERON SOLTAB -mirtazapine orally disintegrating tab
30 mg............................................................................... 80
REMERON SOLTAB -mirtazapine orally disintegrating tab
45 mg............................................................................... 80
RENAGEL -sevelamer hcl tab 400 mg..............................71
RENAGEL -sevelamer hcl tab 800 mg..............................71
RENATABS -b-complex w/ c-biotin-vit e & folic acid tab 1
mg.................................................................................. 121
RENATABS WITH IRON -b complex-c-biotin-e-fa tab 1mg
& fe cbn tab 100 mg pack............................................. 121
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
235
2015
RENOVO -capsaicin-menthol topical patch
0.0375-5%...................................................................... 157
RENOVO LIDO 5 -lidocaine-capsaicin cream
5-0.05%.......................................................................... 157
RENUU NL -allantoin-petrolatum patch 2-30%................157
RENUU PATCH -allantoin-lidocaine-petrolatum patch
2-5-30%..........................................................................157
RENVELA -sevelamer carbonate packet 0.8 gm...............71
RENVELA -sevelamer carbonate packet 2.4 gm...............71
RENVELA -sevelamer carbonate tab 800 mg................... 71
repaglinide tab 0.5 mg (Prandin)....................................31
repaglinide tab 1 mg (Prandin).......................................31
repaglinide tab 2 mg (Prandin).......................................31
REPREXAIN -hydrocodone-ibuprofen tab 2.5-200
mg.................................................................................. 100
REPREXAIN -hydrocodone-ibuprofen tab 5-200 mg....... 100
REQUIP -ropinirole hydrochloride tab 0.25 mg............... 112
REQUIP -ropinirole hydrochloride tab 0.5 mg................. 112
REQUIP -ropinirole hydrochloride tab 1 mg.................... 112
REQUIP -ropinirole hydrochloride tab 2 mg.................... 112
REQUIP -ropinirole hydrochloride tab 3 mg.................... 112
REQUIP -ropinirole hydrochloride tab 4 mg.................... 112
REQUIP -ropinirole hydrochloride tab 5 mg.................... 112
REQUIP XL -ropinirole hydrochloride tab sr 24hr 12 mg
(base equivalent)........................................................... 113
REQUIP XL -ropinirole hydrochloride tab sr 24hr 2 mg
(base equivalent)........................................................... 112
REQUIP XL -ropinirole hydrochloride tab sr 24hr 4 mg
(base equivalent)........................................................... 112
REQUIP XL -ropinirole hydrochloride tab sr 24hr 6 mg
(base equivalent)........................................................... 112
REQUIP XL -ropinirole hydrochloride tab sr 24hr 8 mg
(base equivalent)........................................................... 112
RESCON-MX -dexchlorpheniramine-phenylephrine tab sr
12hr 6-40 mg................................................................... 61
RESCRIPTOR -delavirdine mesylate tab 100 mg............... 9
RESCRIPTOR -delavirdine mesylate tab 200 mg............... 9
RESCULA -unoprostone isopropyl ophth soln 0.15%......140
RESERPINE -reserpine tab 0.1 mg.................................. 50
RESERPINE -reserpine tab 0.25 mg.................................50
RESPA-BR -brompheniramine maleate tab sr 12hr 11
mg.................................................................................... 58
RESPIRATORY THERAPY SUPPLIES – VARIOUS.......163
RESTASIS -cyclosporine (ophth) emulsion 0.05%.......... 140
RESTORA RX -lactobacillus casei-folic acid cap 60-1.25
mg.................................................................................... 66
RESTORE SILVER DRESSING 2 -wound dressings pads................................................................................157
RESTORE SILVER DRESSING 4 -wound dressings pads................................................................................157
RESTORE SILVER DRESSING 6 -wound dressings pads................................................................................157
RESTORIL -temazepam cap 15 mg..................................85
RESTORIL -temazepam cap 22.5 mg...............................85
RESTORIL -temazepam cap 30 mg..................................85
236
RESTORIL -temazepam cap 7.5 mg.................................85
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.04%............................................................................. 157
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.08%............................................................................. 157
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.1%............................................................................... 157
RETIN-A MICRO -tretinoin microsphere gel 0.04%.........157
RETIN-A MICRO -tretinoin microsphere gel 0.1%...........157
RETIN-A -tretinoin cream 0.025%................................... 157
RETIN-A -tretinoin cream 0.05%..................................... 157
RETIN-A -tretinoin cream 0.1%....................................... 157
RETIN-A -tretinoin gel 0.01%.......................................... 157
RETIN-A -tretinoin gel 0.025%........................................ 157
RETROVIR -zidovudine cap 100 mg...................................9
RETROVIR -zidovudine syrup 10 mg/ml............................. 9
REVATIO -sildenafil citrate for suspension 10 mg/ml........ 58
REVATIO -sildenafil citrate tab 20 mg...............................58
REVESTA -folic acid-cholecalciferol cap 1 mg-5750
unit..................................................................................131
REVIA -naltrexone hcl tab 50 mg....................................163
REVLIMID -lenalidomide cap 10 mg............................... 164
REVLIMID -lenalidomide cap 15 mg............................... 164
REVLIMID -lenalidomide cap 20 mg............................... 164
REVLIMID -lenalidomide cap 25 mg............................... 164
REVLIMID -lenalidomide cap 5 mg................................. 164
REVLIMID -lenalidomide caps 2.5 mg.............................164
REXAPHENAC -diclofenac sodium cream 1%................ 157
REXULTI -brexpiprazole tab 0.25 mg................................83
REXULTI -brexpiprazole tab 0.5 mg................................. 83
REXULTI -brexpiprazole tab 1 mg.................................... 83
REXULTI -brexpiprazole tab 2 mg.................................... 83
REXULTI -brexpiprazole tab 3 mg.................................... 83
REXULTI -brexpiprazole tab 4 mg.................................... 83
REYATAZ -atazanavir sulfate cap 150 mg (base equiv)......9
REYATAZ -atazanavir sulfate cap 200 mg (base equiv)......9
REYATAZ -atazanavir sulfate cap 300 mg (base equiv)......9
REYATAZ -atazanavir sulfate oral powder packet 50 mg
(base equiv)....................................................................... 9
REZIRA -pseudoephedrine w/ hydrocodone soln 60-5
mg/5ml..............................................................................61
RHEUMATREX -methotrexate sodium tab 2.5 mg
(antirheumatic)............................................................... 104
RHINOCORT AQUA -budesonide nasal susp 32 mcg/
act.....................................................................................59
RIAX -benzoyl peroxide foam 5.5%................................ 157
RIAX -benzoyl peroxide foam 9.5%................................ 157
RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin
tab 400 mg dose pack.......................................................9
RIBASPHERE RIBAPAK -ribavirin tab 400 mg................... 9
RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin
tab 600 mg dose pack.....................................................10
RIBASPHERE RIBAPAK -ribavirin tab 600 mg................... 9
RIBASPHERE -ribavirin tab 400 mg................................... 9
RIBASPHERE -ribavirin tab 600 mg................................... 9
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
RIBATAB -ribavirin tab 400 mg......................................... 10
RIBATAB -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.........................................................................10
RIBATAB -ribavirin tab 600 mg......................................... 10
ribavirin cap 200 mg (Rebetol)....................................... 10
ribavirin tab 200 mg (Copegus)......................................10
RIDAURA -auranofin cap 3 mg....................................... 104
rifabutin cap 150 mg (Mycobutin).................................... 6
RIFADIN -rifampin cap 150 mg........................................... 6
RIFADIN -rifampin cap 300 mg........................................... 6
RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 6
rifampin cap 150 mg (Rifadin).......................................... 6
rifampin cap 300 mg (Rifadin).......................................... 6
RIFATER -isoniazid-rifampin w/ pyrazinamide tab
50-120-300 mg...................................................................6
RILUTEK -riluzole tab 50 mg.......................................... 113
riluzole tab 50 mg (Rilutek).......................................... 113
rimantadine hydrochloride tab 100 mg (Flumadine).....10
RIOMET -metformin hcl oral soln 500 mg/5ml.................. 31
risedronate sodium tab 150 mg (Actonel)..................... 38
risedronate sodium tab 30 mg (Actonel).......................38
risedronate sodium tab 35 mg (Actonel).......................38
risedronate sodium tab 5 mg (Actonel).........................38
risedronate sodium tab delayed release 35 mg
(Atelvia)........................................................................... 38
RISPERDAL M-TAB -risperidone orally disintegrating tab
0.5 mg.............................................................................. 83
RISPERDAL M-TAB -risperidone orally disintegrating tab 1
mg.................................................................................... 83
RISPERDAL M-TAB -risperidone orally disintegrating tab 2
mg.................................................................................... 83
RISPERDAL M-TAB -risperidone orally disintegrating tab 3
mg.................................................................................... 83
RISPERDAL M-TAB -risperidone orally disintegrating tab 4
mg.................................................................................... 83
RISPERDAL -risperidone soln 1 mg/ml.............................83
RISPERDAL -risperidone tab 0.25 mg.............................. 83
RISPERDAL -risperidone tab 0.5 mg................................ 83
RISPERDAL -risperidone tab 1 mg................................... 83
RISPERDAL -risperidone tab 2 mg................................... 83
RISPERDAL -risperidone tab 3 mg................................... 83
RISPERDAL -risperidone tab 4 mg................................... 83
risperidone orally disintegrating tab 0.25 mg............... 83
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab).............................................................................. 83
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab).............................................................................. 83
risperidone orally disintegrating tab 2 mg (Risperdal
m-tab).............................................................................. 83
risperidone orally disintegrating tab 3 mg (Risperdal
m-tab).............................................................................. 83
risperidone orally disintegrating tab 4 mg (Risperdal
m-tab).............................................................................. 83
risperidone soln 1 mg/ml (Risperdal)............................ 83
risperidone tab 0.25 mg (Risperdal).............................. 83
risperidone tab 0.5 mg (Risperdal)................................ 83
risperidone tab 1 mg (Risperdal)................................... 83
risperidone tab 2 mg (Risperdal)................................... 83
risperidone tab 3 mg (Risperdal)................................... 83
risperidone tab 4 mg (Risperdal)................................... 83
RITALIN LA -methylphenidate hcl cap sr 24hr 10 mg
(la).................................................................................... 89
RITALIN LA -methylphenidate hcl cap sr 24hr 20 mg
(la).................................................................................... 89
RITALIN LA -methylphenidate hcl cap sr 24hr 30 mg
(la).................................................................................... 89
RITALIN LA -methylphenidate hcl cap sr 24hr 40 mg
(la).................................................................................... 89
RITALIN LA -methylphenidate hcl cap sr 24hr 60 mg
(la).................................................................................... 89
RITALIN -methylphenidate hcl tab 10 mg..........................88
RITALIN -methylphenidate hcl tab 20 mg..........................88
RITALIN -methylphenidate hcl tab 5 mg........................... 88
rivastigmine tartrate cap 1.5 mg (Exelon)..................... 92
rivastigmine tartrate cap 3 mg (Exelon)........................ 92
rivastigmine tartrate cap 4.5 mg (Exelon)..................... 92
rivastigmine tartrate cap 6 mg (Exelon)........................ 92
RIXUBIS -coagulation factor ix (recombinant) for inj 1000
unit..................................................................................136
RIXUBIS -coagulation factor ix (recombinant) for inj 2000
unit..................................................................................136
RIXUBIS -coagulation factor ix (recombinant) for inj 250
unit..................................................................................136
RIXUBIS -coagulation factor ix (recombinant) for inj 3000
unit..................................................................................136
RIXUBIS -coagulation factor ix (recombinant) for inj 500
unit..................................................................................136
rizatriptan benzoate orally disintegrating tab 10 mg
(Maxalt-mlt)................................................................... 105
rizatriptan benzoate orally disintegrating tab 5 mg
(Maxalt-mlt)................................................................... 105
rizatriptan benzoate tab 10 mg (Maxalt)...................... 105
rizatriptan benzoate tab 5 mg (Maxalt)........................ 105
R-NATAL OB -prenatal w/o a w/fe cbn-fa-dha cap
20-1-320 mg...................................................................121
ROBAXIN-750 -methocarbamol tab 750 mg................... 114
ROBAXIN -methocarbamol tab 500 mg.......................... 114
ROBINUL FORTE -glycopyrrolate tab 2 mg......................68
ROBINUL -glycopyrrolate tab 1 mg...................................68
ROCALTROL -calcitriol cap 0.25 mcg...............................38
ROCALTROL -calcitriol cap 0.5 mcg.................................38
ROCALTROL -calcitriol oral soln 1 mcg/ml....................... 38
ropinirole hydrochloride tab 0.25 mg (Requip)........... 113
ropinirole hydrochloride tab 0.5 mg (Requip)............. 113
ropinirole hydrochloride tab 1 mg (Requip)................113
ropinirole hydrochloride tab 2 mg (Requip)................113
ropinirole hydrochloride tab 3 mg (Requip)................113
ropinirole hydrochloride tab 4 mg (Requip)................113
ropinirole hydrochloride tab 5 mg (Requip)................113
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
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2015
ropinirole hydrochloride tab sr 24hr 12 mg (base
equivalent) (Requip xl)................................................ 113
ropinirole hydrochloride tab sr 24hr 2 mg (base
equivalent) (Requip xl)................................................ 113
ropinirole hydrochloride tab sr 24hr 4 mg (base
equivalent) (Requip xl)................................................ 113
ropinirole hydrochloride tab sr 24hr 6 mg (base
equivalent) (Requip xl)................................................ 113
ropinirole hydrochloride tab sr 24hr 8 mg (base
equivalent) (Requip xl)................................................ 113
ROSADAN KIT -metronidazole cream 0.75% w/ cleanser
kit....................................................................................157
ROSADAN KIT -metronidazole gel 0.75% w/ cleanser
kit....................................................................................157
ROSANIL -sulfacetamide sod-sulfur emul 10-5% & skin
cleanser kit.....................................................................157
ROSULA -sulfacetamide sodium w/ sulfur wash
10-4.5%.......................................................................... 157
ROWASA -mesalamine rectal enema 4 gm & cleanser
wipe kit............................................................................. 71
ROXICET -oxycodone w/ acetaminophen soln 5-325
mg/5ml............................................................................100
ROXICODONE -oxycodone hcl tab 15 mg......................100
ROXICODONE -oxycodone hcl tab 30 mg......................100
ROXICODONE -oxycodone hcl tab 5 mg........................100
ROZEREM -ramelteon tab 8 mg....................................... 85
RTD WOUND CARE DRESSING -wound dressings pads................................................................................157
RYDEX -pseudoephedrine-bromphen-codeine liq
10-1.33-6.33 mg/5ml........................................................ 61
RYTARY -carbidopa & levodopa cap cr 23.75-95 mg......113
RYTARY -carbidopa & levodopa cap cr 36.25-145
mg.................................................................................. 113
RYTARY -carbidopa & levodopa cap cr 48.75-195
mg.................................................................................. 113
RYTARY -carbidopa & levodopa cap cr 61.25-245
mg.................................................................................. 113
RYTHMOL -propafenone hcl tab 150 mg.......................... 45
RYTHMOL -propafenone hcl tab 225 mg.......................... 45
RYTHMOL SR -propafenone hcl cap sr 12hr 225 mg....... 45
RYTHMOL SR -propafenone hcl cap sr 12hr 325 mg....... 45
RYTHMOL SR -propafenone hcl cap sr 12hr 425 mg....... 45
S
SABRIL -vigabatrin powd pack 500 mg...........................110
SABRIL -vigabatrin tab 500 mg.......................................110
SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab
3-0.03-0.451 mg...............................................................26
SAIZEN CLICK.EASY -somatropin (non-refrigerated) for
inj 8.8 mg......................................................................... 38
SAIZEN -somatropin (non-refrigerated) for inj 5 mg.......... 38
SAIZEN -somatropin (non-refrigerated) for inj 8.8 mg....... 38
SALAGEN -pilocarpine hcl tab 5 mg............................... 143
SALAGEN -pilocarpine hcl tab 7.5 mg............................ 143
SALEX CREAM -salicylic acid cream 6% & cleanser liqd
kit....................................................................................157
238
SALEX LOTION -salicylic acid lotion 6% & cleanser liqd
kit....................................................................................157
SALEX -salicylic acid shampoo 6%.................................157
SALICEPT -oral wound care products - for susp
rinse................................................................................143
salicylic acid cream 6%................................................ 157
salicylic acid cream 6% & cleanser liqd kit (Salex
cream)............................................................................157
salicylic acid film forming liquid 27.5% (Virasal)........ 157
salicylic acid film-forming soln 28.5% (Ultrasaler)...................................................................................157
salicylic acid foam 6% (Salvax)....................................157
salicylic acid gel 6% (Keralyt)...................................... 157
SALICYLIC ACID IN AMMONIU -salicylic acid in
ammonium lactate vehicle foam 6%.............................. 157
salicylic acid lotion 6%................................................. 157
salicylic acid lotion 6% & cleanser liqd kit (Salex
lotion)............................................................................ 157
SALICYLIC ACID -salicylic acid soln 26%.......................157
salicylic acid shampoo 6% (Salex).............................. 157
SALKERA -salicylic acid in ammonium lactate vehicle
foam 6%.........................................................................157
salsalate tab 500 mg....................................................... 93
salsalate tab 750 mg....................................................... 93
SALVAX DUO PLUS -salicylic acid foam 6% & urea in
lactic acid foam 35% kit.................................................157
SALVAX -salicylic acid foam 6%..................................... 157
SAMSCA -tolvaptan tab 15 mg......................................... 38
SAMSCA -tolvaptan tab 30 mg......................................... 38
SANARE SCAR THERAPY -cream base........................ 163
SANCUSO -granisetron td patch 3.1 mg/24hr (contains
34.3 mg)...........................................................................69
SANDIMMUNE -cyclosporine cap 100 mg...................... 164
SANDIMMUNE -cyclosporine cap 25 mg........................ 164
SANDIMMUNE -cyclosporine oral soln 100 mg/ml..........164
SANDOSTATIN -octreotide acetate inj 1000 mcg/ml (1 mg/
ml).................................................................................... 38
SANDOSTATIN -octreotide acetate inj 100 mcg/ml (0.1
mg/ml).............................................................................. 38
SANDOSTATIN -octreotide acetate inj 200 mcg/ml (0.2
mg/ml).............................................................................. 38
SANDOSTATIN -octreotide acetate inj 500 mcg/ml (0.5
mg/ml).............................................................................. 38
SANDOSTATIN -octreotide acetate inj 50 mcg/ml (0.05
mg/ml).............................................................................. 38
SANTYL -collagenase oint 250 unit/gm...........................157
SAPHRIS -asenapine maleate sl tab 10 mg (base
equiv)................................................................................83
SAPHRIS -asenapine maleate sl tab 2.5 mg (base
equiv)................................................................................83
SAPHRIS -asenapine maleate sl tab 5 mg (base
equiv)................................................................................83
SARAFEM -fluoxetine hcl (pmdd) tab 10 mg.....................92
SARAFEM -fluoxetine hcl (pmdd) tab 20 mg.....................92
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
SAVAYSA -edoxaban tosylate tab 15 mg (base
equivalent)......................................................................133
SAVAYSA -edoxaban tosylate tab 30 mg (base
equivalent)......................................................................133
SAVAYSA -edoxaban tosylate tab 60 mg (base
equivalent)......................................................................133
SAVELLA -milnacipran hcl tab 100 mg............................. 92
SAVELLA -milnacipran hcl tab 12.5 mg............................ 92
SAVELLA -milnacipran hcl tab 25 mg............................... 92
SAVELLA -milnacipran hcl tab 50 mg............................... 92
SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg
(5) & 25 mg (8) & 50 mg (42) pak................................... 92
SCALACORT DK -hc lot 2% & sal acid-sulfur shampoo
2-2% & shampoo kit...................................................... 158
SCAR PATCH -allantoin-lidocaine-petrolatum patch
2-4-30%..........................................................................158
SCAR PATCH -allantoin-lidocaine-petrolatum patch
2-5-30%..........................................................................158
scar treatment products - gel.......................................158
SEASONIQUE -levonorg-eth est tab 0.15-0.03mg(84) &
eth est tab 0.01mg(7)...................................................... 26
SECONAL -secobarbital sodium cap 100 mg....................85
SECTRAL -acebutolol hcl cap 200 mg..............................41
SECTRAL -acebutolol hcl cap 400 mg..............................41
SELECT-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak.................................................. 121
SELECT-OB -prenatal vit w/ fe polysac cmplx-fa chew tab
29-1 mg..........................................................................121
SELECT-OB -prenat w/ fepolycmplx-methylfol-fa chew tab
29-0.6-0.4 mg.................................................................121
selegiline hcl cap 5 mg (Eldepryl)................................113
selegiline hcl tab 5 mg..................................................113
selenium sulfide lotion 2.5%........................................ 158
SELRX -selenium sulfide-pyrithione zinc in urea shampoo
2.3%............................................................................... 158
SELZENTRY -maraviroc tab 150 mg................................ 10
SELZENTRY -maraviroc tab 300 mg................................ 10
SEMPREX-D -acrivastine & pseudoephedrine cap 8-60
mg.................................................................................... 61
SE-NATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 121
SE-NATAL 19 -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg..........................................................................121
SENNA LEAVES -senna leaves........................................66
SENSIPAR -cinacalcet hcl tab 30 mg (base equiv)........... 38
SENSIPAR -cinacalcet hcl tab 60 mg (base equiv)........... 38
SENSIPAR -cinacalcet hcl tab 90 mg (base equiv)........... 38
SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50
mcg/dose (base equiv).................................................... 64
SEROMYCIN -cycloserine cap 250 mg...............................6
SEROQUEL -quetiapine fumarate tab 100 mg..................83
SEROQUEL -quetiapine fumarate tab 200 mg..................83
SEROQUEL -quetiapine fumarate tab 25 mg....................83
SEROQUEL -quetiapine fumarate tab 300 mg..................83
SEROQUEL -quetiapine fumarate tab 400 mg..................84
SEROQUEL -quetiapine fumarate tab 50 mg....................83
SEROQUEL XR -quetiapine fumarate tab sr 24hr 150
mg.................................................................................... 84
SEROQUEL XR -quetiapine fumarate tab sr 24hr 200
mg.................................................................................... 84
SEROQUEL XR -quetiapine fumarate tab sr 24hr 300
mg.................................................................................... 84
SEROQUEL XR -quetiapine fumarate tab sr 24hr 400
mg.................................................................................... 84
SEROQUEL XR -quetiapine fumarate tab sr 24hr 50
mg.................................................................................... 84
SEROSTIM -somatropin (non-refrigerated) for
subcutaneous inj 4 mg.....................................................38
SEROSTIM -somatropin (non-refrigerated) for
subcutaneous inj 5 mg.....................................................38
SEROSTIM -somatropin (non-refrigerated) for
subcutaneous inj 6 mg.....................................................38
sertraline hcl oral conc 20 mg/ml (Zoloft)..................... 80
sertraline hcl tab 100 mg (Zoloft)...................................80
sertraline hcl tab 25 mg (Zoloft).....................................80
sertraline hcl tab 50 mg (Zoloft).....................................80
SE-TAN DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap
15-15-1 mg.....................................................................121
SETON ET-EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk.................................................... 121
SETONET -prenat-fe bis-fe prot succ-fa-ca tab & omega 3
cap 430 pk..................................................................... 121
SEVELAMER CARBONATE -sevelamer carbonate tab
800 mg............................................................................. 71
SFROWASA -mesalamine sulfite-free (sf) enema 4
gm/60ml............................................................................71
SHOHLS SOLUTION MODIFIED -sodium citrate & citric
acid soln 500-334 mg/5ml............................................... 74
SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base
equiv)................................................................................38
SIGNIFOR -pasireotide diaspartate inj 0.6 mg/ml (base
equiv)................................................................................38
SIGNIFOR -pasireotide diaspartate inj 0.9 mg/ml (base
equiv)................................................................................38
sildenafil citrate tab 20 mg (Revatio).............................58
SILENOR -doxepin hcl (sleep) tab 3 mg (base equiv)....... 85
SILENOR -doxepin hcl (sleep) tab 6 mg (base equiv)....... 85
SILMANIX PAIN RELIEIVING -capsaicin-mentholhistamine cream 0.0375-3-0.035%................................ 158
SILVADENE -silver sulfadiazine cream 1%.....................158
SILVERA PAIN RELIEF -capsaicin-lidocaine-menthol
patch 0.0375-1-5%.........................................................158
silver nitrate-potassium nitrate applicator 75-25%
(Arzol silver nitrate)..................................................... 158
SILVER NITRATE -silver nitrate oint 10%.......................158
SILVER NITRATE -silver nitrate soln 0.5%..................... 158
SILVER NITRATE -silver nitrate soln 10%...................... 158
SILVER NITRATE -silver nitrate soln 25%...................... 158
SILVER NITRATE -silver nitrate soln 50%...................... 158
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
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2015
SILVERSEAL HYDROGEL DRESS -silver - pad
2"x3"............................................................................... 158
SILVERSEAL HYDROGEL DRESS -silver - pad
4"x5"............................................................................... 158
silver sulfadiazine cream 1% (Silvadene)....................158
SILVRSTAT WOUND DRESSING -silver - gel................158
SIMBRINZA -brinzolamide-brimonidine tartrate ophth susp
1-0.2%............................................................................ 140
SIMCOR -niacin-simvastatin tab sr 24hr 1000-20 mg....... 56
SIMCOR -niacin-simvastatin tab sr 24hr 1000-40 mg....... 56
SIMCOR -niacin-simvastatin tab sr 24hr 500-20 mg......... 56
SIMCOR -niacin-simvastatin tab sr 24hr 500-40 mg......... 56
SIMCOR -niacin-simvastatin tab sr 24hr 750-20 mg......... 56
SIMPONI -golimumab subcutaneous soln auto-injector 100
mg/ml..............................................................................104
SIMPONI -golimumab subcutaneous soln auto-injector 50
mg/0.5ml.........................................................................104
SIMPONI -golimumab subcutaneous soln prefilled syringe
100 mg/ml...................................................................... 104
SIMPONI -golimumab subcutaneous soln prefilled syringe
50 mg/0.5ml................................................................... 104
simvastatin tab 10 mg (Zocor)....................................... 56
simvastatin tab 20 mg (Zocor)....................................... 56
simvastatin tab 40 mg (Zocor)....................................... 56
simvastatin tab 5 mg (Zocor)......................................... 56
simvastatin tab 80 mg (Zocor)....................................... 56
SINELEE -capsaicin-menthol topical patch
0.0375-5%...................................................................... 158
SINELEE -capsaicin-menthol topical patch 0.05-5%....... 158
SINEMET -carbidopa & levodopa tab 10-100 mg............113
SINEMET -carbidopa & levodopa tab 25-100 mg............113
SINEMET -carbidopa & levodopa tab 25-250 mg............113
SINEMET CR -carbidopa & levodopa tab cr 25-100
mg.................................................................................. 113
SINEMET CR -carbidopa & levodopa tab cr 50-200
mg.................................................................................. 113
SINGULAIR -montelukast sodium chew tab 4 mg (base
equiv)................................................................................64
SINGULAIR -montelukast sodium chew tab 5 mg (base
equiv)................................................................................64
SINGULAIR -montelukast sodium oral granules packet 4
mg (base equiv)............................................................... 64
SINGULAIR -montelukast sodium tab 10 mg (base
equiv)................................................................................64
sirolimus tab 0.5 mg (Rapamune)................................ 164
sirolimus tab 1 mg (Rapamune)...................................165
sirolimus tab 2 mg (Rapamune)...................................165
SIRTURO -bedaquiline fumarate tab 100 mg (base
equiv)..................................................................................6
SITAVIG -acyclovir buccal tab 50 mg................................10
SIVEXTRO -tedizolid phosphate tab 200 mg.................... 12
SKELAXIN -metaxalone tab 800 mg............................... 114
SKLICE -ivermectin lotion 0.5%...................................... 158
SMART SENSE GLUCOSE -glucose-vitamin c chew tab
4-0.006 gm.......................................................................31
240
SM GLUCOSE -glucose chew tab 4 gm........................... 31
SM GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 31
sodium chloride soln nebu 0.9%................................... 61
sodium chloride soln nebu 10%.................................... 61
sodium chloride soln nebu 3%...................................... 61
sodium chloride soln nebu 7% (Hyper-sal)................... 61
sodium citrate & citric acid soln 500-334 mg/5ml
(Shohls solution modi).................................................. 75
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride).......................................................................... 126
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride).......................................................................... 126
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride).......................................................................... 126
sodium fluoride cream 1.1% (Prevident 5000
plus)...............................................................................143
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)......................................................................... 143
sodium fluoride paste 1.1% (Prevident 5000
boost)............................................................................ 143
sodium fluoride-potassium nitrate paste 1.1-5%
(Prevident 5000 sensi)................................................. 143
sodium fluoride rinse 0.0221% (0.01% f)..................... 143
sodium fluoride rinse 0.05%.........................................143
sodium fluoride rinse 0.2% (Prevident)....................... 143
SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from
1.1 mg naf).................................................................... 126
SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from 2.2
mg naf)...........................................................................126
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf).................................................................................126
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride).......................................................................... 126
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl).......................................................................38
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps).............................................................................. 165
sodium polystyrene sulfonate powder
(Kayexalate).................................................................. 165
sodium polystyrene sulfonate rectal susp 30
gm/120ml.......................................................................165
SODIUM SULFACETAMIDE/SULF -sulfacetamide
sodium-sulfur in urea emulsion 10-5%.......................... 158
SODIUM SULFACETAMIDE/SULF -sulfacetamide
sodium-sulfur in urea gel 10-5%....................................158
SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium
w/ sulfur susp 10-5%..................................................... 158
SODIUM SULFACETAMIDE WASH -sulfacetamide
sodium in bakuchiol vehicle wash 10%......................... 158
SOLAICE -capsaicin-menthol topical patch 0.05-5%.......158
SOLARAZE -diclofenac sodium (actinic keratoses) gel
3%.................................................................................. 158
SOLODYN -minocycline hcl tab sr 24hr 105 mg................. 4
SOLODYN -minocycline hcl tab sr 24hr 115 mg................. 5
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
SOLODYN -minocycline hcl tab sr 24hr 55 mg................... 4
SOLODYN -minocycline hcl tab sr 24hr 65 mg................... 4
SOLODYN -minocycline hcl tab sr 24hr 80 mg................... 4
SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base
equivalent)........................................................................18
SOMA -carisoprodol tab 250 mg..................................... 114
SOMA -carisoprodol tab 350 mg..................................... 114
SOMAVERT -pegvisomant for inj 10 mg (as protein)........ 38
SOMAVERT -pegvisomant for inj 15 mg (as protein)........ 38
SOMAVERT -pegvisomant for inj 20 mg (as protein)........ 38
SOMAVERT -pegvisomant for inj 25 mg (as protein)........ 38
SOMAVERT -pegvisomant for inj 30 mg (as protein)........ 38
SONATA -zaleplon cap 10 mg.......................................... 85
SONATA -zaleplon cap 5 mg............................................ 85
SOOLANTRA -ivermectin cream 1%...............................158
SOOTHEE -lidocaine-capsaicin-men-methyl sal patch
0.5-0.0375-5-20%...........................................................158
SORIATANE -acitretin cap 10 mg................................... 158
SORIATANE -acitretin cap 17.5 mg................................ 158
SORIATANE -acitretin cap 25 mg................................... 158
SORILUX -calcipotriene foam 0.005%............................ 158
sotalol hcl (afib/afl) tab 120 mg (Betapace af)...............41
sotalol hcl (afib/afl) tab 160 mg (Betapace af)...............41
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 41
sotalol hcl tab 120 mg (Betapace)................................. 41
sotalol hcl tab 160 mg (Betapace)................................. 41
sotalol hcl tab 240 mg.................................................... 41
sotalol hcl tab 80 mg (Betapace)................................... 41
SOTYLIZE -sotalol hcl oral solution 5 mg/ml.....................41
SOVALDI -sofosbuvir tab 400 mg..................................... 10
SPACERS – VARIOUS................................................... 163
SPATONE PUR-ABSORB IRON -ferrous sulfate liquid 5
mg/20ml (elemental iron)............................................... 131
SPECTRACEF -cefditoren pivoxil tab 200 mg (base
equivalent)..........................................................................2
SPECTRACEF -cefditoren pivoxil tab 400 mg (base
equivalent)..........................................................................2
SPINOSAD -spinosad susp 0.9%....................................158
SPIRIVA HANDIHALER -tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)........................................ 64
SPIRIVA RESPIMAT -tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act.................................................64
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide)................................................................... 53
spironolactone tab 100 mg (Aldactone)........................ 53
spironolactone tab 25 mg (Aldactone).......................... 53
spironolactone tab 50 mg (Aldactone).......................... 53
SPORANOX -itraconazole cap 100 mg...............................7
SPORANOX -itraconazole oral soln 10 mg/ml.................... 7
SPORANOX PULSEPAK -itraconazole cap 100 mg........... 7
SPRIX -ketorolac tromethamine nasal spray 15.75 mg/
spray...............................................................................104
SPRYCEL -dasatinib tab 100 mg...................................... 18
SPRYCEL -dasatinib tab 140 mg...................................... 18
SPRYCEL -dasatinib tab 20 mg........................................ 18
SPRYCEL -dasatinib tab 50 mg........................................ 18
SPRYCEL -dasatinib tab 70 mg........................................ 18
SPRYCEL -dasatinib tab 80 mg........................................ 18
SPS -sodium polystyrene sulfonate oral susp 15
gm/60ml..........................................................................165
SSKI -potassium iodide soln 1 gm/ml..............................126
STALEVO 100 -carbidopa-levodopa-entacapone tabs
25-100-200 mg...............................................................113
STALEVO 125 -carbidopa-levodopa-entacapone tabs
31.25-125-200 mg..........................................................113
STALEVO 150 -carbidopa-levodopa-entacapone tabs
37.5-150-200 mg............................................................113
STALEVO 200 -carbidopa-levodopa-entacapone tabs
50-200-200 mg...............................................................113
STALEVO 50 -carbidopa-levodopa-entacapone tabs
12.5-50-200 mg..............................................................113
STALEVO 75 -carbidopa-levodopa-entacapone tabs
18.75-75-200 mg............................................................113
stannous fluoride conc 0.63% (Gel-kam oral care
ri)....................................................................................143
stannous fluoride gel 0.4%........................................... 143
STANNOUS FLUORIDE RINSE -stannous fluoride liq
0.1%............................................................................... 143
STARLIX -nateglinide tab 120 mg.....................................31
STARLIX -nateglinide tab 60 mg.......................................31
STATUSS GREEN -codeine-pseudoephedrinechlorcyclizine liq 9-30-12.5 mg/5ml..................................61
stavudine cap 15 mg (Zerit)............................................10
stavudine cap 20 mg (Zerit)............................................10
stavudine cap 30 mg (Zerit)............................................10
stavudine cap 40 mg (Zerit)............................................10
stavudine for oral soln 1 mg/ml (Zerit).......................... 10
STAVZOR -valproic acid cap delayed release 125
mg.................................................................................. 110
STAVZOR -valproic acid cap delayed release 250
mg.................................................................................. 110
STAVZOR -valproic acid cap delayed release 500
mg.................................................................................. 110
STELARA -ustekinumab soln prefilled syringe 45
mg/0.5ml.........................................................................158
STELARA -ustekinumab soln prefilled syringe 90 mg/
ml....................................................................................158
STIMATE -desmopressin acetate nasal soln 1.5 mg/
ml......................................................................................38
STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aero
soln 2.5-2.5 mcg/act........................................................ 64
STIVARGA -regorafenib tab 40 mg...................................18
STRATTERA -atomoxetine hcl cap 100 mg (base
equiv)................................................................................89
STRATTERA -atomoxetine hcl cap 10 mg (base
equiv)................................................................................89
STRATTERA -atomoxetine hcl cap 18 mg (base
equiv)................................................................................89
STRATTERA -atomoxetine hcl cap 25 mg (base
equiv)................................................................................89
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
241
2015
STRATTERA -atomoxetine hcl cap 40 mg (base
equiv)................................................................................89
STRATTERA -atomoxetine hcl cap 60 mg (base
equiv)................................................................................89
STRATTERA -atomoxetine hcl cap 80 mg (base
equiv)................................................................................89
STRIANT -testosterone buccal mucoadhesive system 30
mg.................................................................................... 21
STRIBILD -elvitegrav-cobicis-emtricitab-tenofov tab
150-150-200-300 mg....................................................... 10
STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln
2.5 mcg/act (base equiv)................................................. 64
STROMECTOL -ivermectin tab 3 mg................................ 11
STROVITE FORTE -multiple vitamins w/ minerals & fa
syrup 1 mg/15ml............................................................ 121
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 12-3
mg (base equiv)............................................................. 100
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5
mg (base equiv)............................................................. 100
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv)............................................................. 100
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 8-2
mg (base equiv)............................................................. 100
SUBSYS -fentanyl sublingual spray 100 mcg..................100
SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x
2).................................................................................... 100
SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x
2).................................................................................... 100
SUBSYS -fentanyl sublingual spray 200 mcg..................100
SUBSYS -fentanyl sublingual spray 400 mcg..................100
SUBSYS -fentanyl sublingual spray 600 mcg..................100
SUBSYS -fentanyl sublingual spray 800 mcg..................100
SUCRAID -sacrosidase soln 8500 unit/ml......................... 70
sucralfate tab 1 gm (Carafate)........................................68
SULAR -nisoldipine tab sr 24hr 17 mg.............................. 43
SULAR -nisoldipine tab sr 24hr 34 mg.............................. 43
SULAR -nisoldipine tab sr 24hr 8.5 mg............................. 43
sulfacetamide sodium cleansing gel 10% (Ovace plus
wash)............................................................................. 158
sulfacetamide sodium liquid 10% (Ovace wash)........ 159
sulfacetamide sodium lotion 10% (acne) (Klaron)...... 159
sulfacetamide sodium ophth soln 10% (Bleph-10)..... 140
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%...............................................................140
sulfacetamide sodium shampoo 10% (Ovace
plus)...............................................................................159
SULFACETAMIDE SODIUM -sulfacetamide sodium ophth
oint 10%......................................................................... 140
sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar
ls cleanser)................................................................... 159
sulfacetamide sodium w/ sulfur cleanser 9.8-4.8%
(Plexion cleanser)........................................................ 159
sulfacetamide sodium w/ sulfur cleansing cloth
10-5%............................................................................. 159
242
sulfacetamide sodium w/ sulfur cleansing pad 10-4%
(Sumaxin)...................................................................... 159
sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e
ls)................................................................................... 159
sulfacetamide sodium w/ sulfur cream 10-5%............ 159
sulfacetamide sodium w/ sulfur cream 9.8-4.8%
(Plexion)........................................................................ 159
sulfacetamide sodium w/ sulfur emulsion 10-1%....... 159
sulfacetamide sodium w/ sulfur emulsion 10-5%....... 159
sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam
ef)................................................................................... 159
sulfacetamide sodium w/ sulfur lotion 10-5%............. 159
sulfacetamide sodium w/ sulfur lotion 9.8-4.8%
(Plexion)........................................................................ 159
sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin
ts)................................................................................... 159
sulfacetamide sodium w/ sulfur wash 9-4.5%
(Sumadan wash).......................................................... 159
sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin
wash)............................................................................. 159
sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser
kit (Sumadan kit)..........................................................158
sulfacetamide sod-sulfur wash 9-4.5% & sunscreen kit
(Sumadan xlt)............................................................... 158
SULFADIAZINE -sulfadiazine tab 500 mg...........................6
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml.............................................................................12
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)..........................................................................12
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds).................................................................... 12
SULFAMYLON -mafenide acetate cream 85 mg/gm....... 159
SULFAMYLON -mafenide acetate packet for topical soln
5% (50 gm).................................................................... 159
sulfasalazine tab 500 mg (Azulfidine)............................71
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 71
SULFOAM -sulfur shampoo 2%...................................... 159
SULFURATED LIME -sulfurated lime solution................ 159
sulindac tab 150 mg...................................................... 104
sulindac tab 200 mg...................................................... 104
SUMADAN KIT -sulfacetamide sod-sulfur wash 9-4.5% &
skin cleanser kit............................................................. 159
SUMADAN WASH -sulfacetamide sodium w/ sulfur wash
9-4.5%............................................................................ 159
SUMADAN XLT -sulfacetamide sod-sulfur wash 9-4.5% &
sunscreen kit..................................................................159
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)...........105
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)................................. 105
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)................................. 105
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref)................................................... 105
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref)................................................... 105
SUMATRIPTAN SUCCINATE -sumatriptan succinate inj 4
mg/0.5ml.........................................................................105
SUMATRIPTAN SUCCINATE -sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml............................. 105
sumatriptan succinate tab 100 mg (Imitrex)................106
sumatriptan succinate tab 25 mg (Imitrex)..................105
sumatriptan succinate tab 50 mg (Imitrex)..................105
SUMATRIPTAN -sumatriptan nasal spray 20 mg/act...... 105
SUMATRIPTAN -sumatriptan nasal spray 5 mg/act........ 105
SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 4 mg/0.5ml........................................................ 106
SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 6 mg/0.5ml........................................................ 106
SUMAXIN CP KIT -sulfacetamide sod-sulfur pad 10-4% &
skin cleanser kit............................................................. 159
SUMAXIN -sulfacetamide sodium w/ sulfur cleansing pad
10-4%............................................................................. 159
SUMAXIN TS -sulfacetamide sodium w/ sulfur susp
8-4%............................................................................... 159
SUMAXIN WASH -sulfacetamide sodium w/ sulfur wash
9-4%............................................................................... 159
SUPER DAILY D3 -cholecalciferol drops 1000 unit/0.03ml
(per drop)....................................................................... 115
SUPERVITE -b-complex w/ lysine-zn & folic acid
liquid............................................................................... 121
SUPERVITE EC -multiple vitamins w/ minerals & fa tab dr
1 mg............................................................................... 121
SUPRAX -cefixime cap 400 mg.......................................... 2
SUPRAX -cefixime chew tab 100 mg..................................2
SUPRAX -cefixime chew tab 200 mg..................................2
SUPRAX -cefixime for susp 100 mg/5ml.............................2
SUPRAX -cefixime for susp 200 mg/5ml.............................2
SUPRAX -cefixime for susp 500 mg/5ml.............................2
SUPREP BOWEL PREP -sodium sulfate-potassium
sulfate-magnesium sulfate oral soln................................ 66
SURFAXIN -lucinactant intratracheal susp 30 mg/ml........ 65
SURMONTIL -trimipramine maleate cap 100 mg.............. 80
SURMONTIL -trimipramine maleate cap 25 mg................ 80
SURMONTIL -trimipramine maleate cap 50 mg................ 80
SURVANTA INTRATRACHEAL -beractant in nacl 0.9%
intratracheal susp 25 mg/ml............................................ 65
SUSTIVA -efavirenz cap 200 mg...................................... 10
SUSTIVA -efavirenz cap 50 mg........................................ 10
SUSTIVA -efavirenz tab 600 mg....................................... 10
SUTENT -sunitinib malate cap 12.5 mg (base
equivalent)........................................................................18
SUTENT -sunitinib malate cap 25 mg (base
equivalent)........................................................................18
SUTENT -sunitinib malate cap 37.5 mg (base
equivalent)........................................................................18
SUTENT -sunitinib malate cap 50 mg (base
equivalent)........................................................................18
SUTTAR-2 -pseudoephedrine w/ cod-gg syrup 30-10-100
mg/5ml..............................................................................61
SUTTAR-SF -pseudoephedrine w/ cod-gg syrup
30-10-100 mg/5ml............................................................61
SYLATRON -peginterferon alfa-2b for inj kit 200 mcg....... 18
SYLATRON -peginterferon alfa-2b for inj kit 300 mcg....... 18
SYLATRON -peginterferon alfa-2b for inj kit 600 mcg....... 18
SYMAX DUOTAB -hyoscyamine sulfate tab cr 0.375 mg
(0.125 mg ir/0.25 mg cr).................................................. 68
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act.................................................. 64
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act.................................................... 64
SYMBYAX -olanzapine-fluoxetine hcl cap 12-25 mg.........93
SYMBYAX -olanzapine-fluoxetine hcl cap 12-50 mg.........93
SYMBYAX -olanzapine-fluoxetine hcl cap 3-25 mg...........93
SYMBYAX -olanzapine-fluoxetine hcl cap 6-25 mg...........93
SYMBYAX -olanzapine-fluoxetine hcl cap 6-50 mg...........93
SYMLINPEN 120 -pramlintide acetate pen-inj 2700
mcg/2.7ml (1000 mcg/ml)................................................ 31
SYMLINPEN 60 -pramlintide acetate pen-inj 1500
mcg/1.5ml (1000 mcg/ml)................................................ 31
SYNAGEX -multiple vitamins w/ minerals & fa cap 1.25
mg.................................................................................. 121
SYNALAR CREAM KIT -fluocinolone cream 0.025%emollient cream kit.........................................................159
SYNALAR -fluocinolone acetonide cream 0.025%.......... 159
SYNALAR -fluocinolone acetonide oint 0.025%.............. 159
SYNALAR -fluocinolone acetonide soln 0.01%............... 159
SYNALAR OINTMENT KIT -fluocinolone oint 0.025%emollient cream kit.........................................................159
SYNALAR TS -fluocinolone acetonide soln 0.01% &
cleanser kit.....................................................................159
SYNALGOS-DC -aspirin-caffeine-dihydrocodeine cap
356.4-30-16 mg..............................................................100
SYNAREL -nafarelin acetate nasal soln 2 mg/ml.............. 38
SYNATEK -multiple vitamins w/ minerals & fa cap 1.25
mg.................................................................................. 121
SYNERA -lidocaine-tetracaine topical patch 70-70
mg.................................................................................. 159
SYNTHROID -levothyroxine sodium tab 100 mcg............. 34
SYNTHROID -levothyroxine sodium tab 112 mcg............. 34
SYNTHROID -levothyroxine sodium tab 125 mcg............. 34
SYNTHROID -levothyroxine sodium tab 137 mcg............. 34
SYNTHROID -levothyroxine sodium tab 150 mcg............. 34
SYNTHROID -levothyroxine sodium tab 175 mcg............. 34
SYNTHROID -levothyroxine sodium tab 200 mcg............. 34
SYNTHROID -levothyroxine sodium tab 25 mcg...............34
SYNTHROID -levothyroxine sodium tab 300 mcg............. 34
SYNTHROID -levothyroxine sodium tab 50 mcg...............34
SYNTHROID -levothyroxine sodium tab 75 mcg...............34
SYNTHROID -levothyroxine sodium tab 88 mcg...............34
SYNVEXIA -lidocaine-menthol patch 4-1%..................... 159
SYNVEXIA TC -lidocaine-menthol cream 4-1%.............. 159
SYPRINE -trientine hcl cap 250 mg................................ 165
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
243
2015
T
TABLOID -thioguanine tab 40 mg..................................... 19
TACLONEX -calcipotriene-betamethasone dipropionate
oint 0.005-0.064%..........................................................160
TACLONEX -calcipotriene-betamethasone dipropionate
susp 0.005-0.064%........................................................ 159
tacrolimus cap 0.5 mg (Prograf).................................. 165
tacrolimus cap 1 mg (Prograf)..................................... 165
tacrolimus cap 5 mg (Prograf)..................................... 165
tacrolimus oint 0.03% (Protopic)..................................160
tacrolimus oint 0.1% (Protopic)....................................160
TAFINLAR -dabrafenib mesylate cap 50 mg (base
equivalent)........................................................................19
TAFINLAR -dabrafenib mesylate cap 75 mg (base
equivalent)........................................................................19
TAMIFLU -oseltamivir phosphate cap 30 mg (base
equiv)................................................................................10
TAMIFLU -oseltamivir phosphate cap 45 mg (base
equiv)................................................................................10
TAMIFLU -oseltamivir phosphate cap 75 mg (base
equiv)................................................................................10
TAMIFLU -oseltamivir phosphate for susp 6 mg/ml (base
equiv)................................................................................10
tamoxifen citrate tab 10 mg (base equivalent)..............19
tamoxifen citrate tab 20 mg (base equivalent)..............19
tamsulosin hcl cap 0.4 mg (Flomax)..............................75
TANDEM F -ferrous fum-iron polysacch-fa cap
162-115.2-1 mg (106 mg fe)..........................................131
TANDEM PLUS -fe fum-iron polysacch complex-fa-b
cmplx-c-zn-mn-cu cap....................................................131
TANZEUM -albiglutide for soln pen-injector 30 mg............31
TANZEUM -albiglutide for soln pen-injector 50 mg............31
TAPAZOLE -methimazole tab 10 mg................................ 34
TAPAZOLE -methimazole tab 5 mg.................................. 34
TARCEVA -erlotinib hcl tab 100 mg (base equivalent)...... 19
TARCEVA -erlotinib hcl tab 150 mg (base equivalent)...... 19
TARCEVA -erlotinib hcl tab 25 mg (base equivalent)........ 19
TARGADOX -doxycycline hyclate tab 50 mg...................... 5
TARGRETIN -bexarotene cap 75 mg................................19
TARGRETIN -bexarotene gel 1%....................................160
TARKA -trandolapril-verapamil hcl tab cr 1-240 mg.......... 50
TARKA -trandolapril-verapamil hcl tab cr 2-180 mg.......... 51
TARKA -trandolapril-verapamil hcl tab cr 2-240 mg.......... 51
TARKA -trandolapril-verapamil hcl tab cr 4-240 mg.......... 51
TARON-BC -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit
b6 tab pak......................................................................121
TARON-C DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap
53.5-38-1 mg..................................................................121
TARON-DUO EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk.................................................... 122
TARON FORTE -fe bisglycinate-fe polysacch-vit c-vit b12fa cap............................................................................. 131
TARON-PREX -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
30-1.2-265 mg................................................................122
TASIGNA -nilotinib hcl cap 150 mg (base equivalent).......19
244
TASIGNA -nilotinib hcl cap 200 mg (base equivalent).......19
TASMAR -tolcapone tab 100 mg.....................................113
TAZORAC -tazarotene cream 0.05%.............................. 160
TAZORAC -tazarotene cream 0.1%................................ 160
TAZORAC -tazarotene gel 0.05%................................... 160
TAZORAC -tazarotene gel 0.1%..................................... 160
TEARS AGAIN HYDRATE -flaxseed oil-evening primrosebilberry cap 1000-500-40 mg.........................................127
TECFIDERA -dimethyl fumarate capsule delayed release
120 mg............................................................................. 93
TECFIDERA -dimethyl fumarate capsule delayed release
240 mg............................................................................. 93
TECFIDERA STARTER PACK -dimethyl fumarate capsule
dr starter pack 120 mg & 240 mg....................................93
TECHNIVIE -ombitasvir-paritaprevir-ritonavir tab
12.5-75-50 mg..................................................................10
TEGADERM AG MESH DRESSING -wound dressings pads................................................................................160
TEGRETOL -carbamazepine susp 100 mg/5ml.............. 110
TEGRETOL -carbamazepine tab 200 mg........................110
TEGRETOL-XR -carbamazepine tab sr 12hr 100 mg......110
TEGRETOL-XR -carbamazepine tab sr 12hr 200 mg......110
TEGRETOL-XR -carbamazepine tab sr 12hr 400 mg......110
TEKTURNA -aliskiren fumarate tab 150 mg (base
equivalent)........................................................................51
TEKTURNA -aliskiren fumarate tab 300 mg (base
equivalent)........................................................................51
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
150-12.5 mg.....................................................................51
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 150-25
mg.................................................................................... 51
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
300-12.5 mg.....................................................................51
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 300-25
mg.................................................................................... 51
telmisartan-amlodipine tab 40-10 mg (Twynsta)...........51
telmisartan-amlodipine tab 40-5 mg (Twynsta).............51
telmisartan-amlodipine tab 80-10 mg (Twynsta)...........51
telmisartan-amlodipine tab 80-5 mg (Twynsta).............51
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)..................................................................51
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)..................................................................51
telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)..................................................................51
telmisartan tab 20 mg (Micardis)................................... 51
telmisartan tab 40 mg (Micardis)................................... 51
telmisartan tab 80 mg (Micardis)................................... 51
temazepam cap 15 mg (Restoril)................................... 85
temazepam cap 22.5 mg (Restoril).................................85
temazepam cap 30 mg (Restoril)................................... 85
temazepam cap 7.5 mg (Restoril).................................. 85
TEMODAR -temozolomide cap 100 mg............................ 19
TEMODAR -temozolomide cap 140 mg............................ 19
TEMODAR -temozolomide cap 180 mg............................ 19
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
TEMODAR -temozolomide cap 20 mg.............................. 19
TEMODAR -temozolomide cap 250 mg............................ 19
TEMODAR -temozolomide cap 5 mg................................ 19
TEMOVATE -clobetasol propionate cream 0.05%...........160
TEMOVATE -clobetasol propionate gel 0.05%................160
TEMOVATE -clobetasol propionate oint 0.05%...............160
TEMOVATE -clobetasol propionate soln 0.05%.............. 160
TEMOVATE E -clobetasol propionate emollient base
cream 0.05%..................................................................160
temozolomide cap 100 mg (Temodar)........................... 19
temozolomide cap 140 mg (Temodar)........................... 19
temozolomide cap 180 mg (Temodar)........................... 19
temozolomide cap 20 mg (Temodar)............................. 19
temozolomide cap 250 mg (Temodar)........................... 19
temozolomide cap 5 mg (Temodar)............................... 19
TENEX -guanfacine hcl tab 1 mg......................................51
TENEX -guanfacine hcl tab 2 mg......................................51
TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu.......... 15
TENORETIC 100 -atenolol & chlorthalidone tab 100-25
mg.................................................................................... 51
TENORETIC 50 -atenolol & chlorthalidone tab 50-25
mg.................................................................................... 51
TENORMIN -atenolol tab 100 mg..................................... 41
TENORMIN -atenolol tab 25 mg....................................... 41
TENORMIN -atenolol tab 50 mg....................................... 41
TERAZOL 3 -terconazole vaginal cream 0.8%..................74
TERAZOL 7 -terconazole vaginal cream 0.4%..................74
terazosin hcl cap 10 mg..................................................51
terazosin hcl cap 1 mg................................................... 51
terazosin hcl cap 2 mg................................................... 51
terazosin hcl cap 5 mg................................................... 51
terbinafine hcl tab 250 mg (Lamisil)................................ 7
terbutaline sulfate tab 2.5 mg.........................................64
terbutaline sulfate tab 5 mg........................................... 64
terconazole vaginal cream 0.4% (Terazol 7)..................74
terconazole vaginal cream 0.8% (Terazol 3)..................74
terconazole vaginal suppos 80 mg................................ 74
TERSI FOAM -selenium sulfide foam 2.25%...................160
TESSALON PERLES -benzonatate cap 100 mg...............61
TESTIM -testosterone td gel 50 mg/5gm (1%).................. 21
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone)...................................................................22
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone)...................................................................22
testosterone enanthate im inj in oil 200 mg/ml.............22
TESTOSTERONE PUMP -testosterone td gel 12.5 mg/act
(1%)..................................................................................22
TESTOSTERONE -testosterone cypionate im inj in oil 250
mg/ml................................................................................22
TESTOSTERONE -testosterone td gel 10mg/act (2%)......22
TESTOSTERONE -testosterone td gel 25 mg/2.5gm
(1%)..................................................................................21
TESTOSTERONE -testosterone td gel 50 mg/5gm
(1%)..................................................................................22
TESTRED -methyltestosterone cap 10 mg........................22
TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria
toxoids (td) inj 2-2 lf/0.5ml............................................... 15
tetracaine hcl ophth soln 0.5%.....................................140
TETRACYCLINE HCL -tetracycline hcl cap 250 mg............5
TETRACYCLINE HCL -tetracycline hcl cap 500 mg............5
TETRAMEX -tetracaine-menthol-camphor liqd spray
2-1-3%............................................................................160
TETRIX -dermatological products misc - kit.................... 160
TEVETEN -eprosartan mesylate tab 600 mg.................... 51
TEVETEN HCT -eprosartan mesylate-hydrochlorothiazide
tab 600-25 mg................................................................. 51
TEV-TROPIN -somatropin for subcutaneous inj 5 mg....... 38
TEXACORT -hydrocortisone soln 2.5%...........................160
TEXAVITE LQ -pediatric multivitamins w/fl-fe-zn drops
0.25-7-3 mg/ml...............................................................122
TGQ 15DM/5PEH/2CPM -phenylephrine-chlorphen-dm
syrup 5-2-15 mg/5ml........................................................61
TGQ 30PSE/150GFN/15DM -pseudoephedrine w/ dm-gg
syrup 30-15-150 mg/5ml..................................................62
TGQ 30PSE/3BRM/15DM -pseudoephed-bromphen-dm
syrup 30-3-15 mg/5ml......................................................62
TGQ 50PSE/3BRM/30DM -pseudoephed-bromphen-dm
syrup 50-3-30 mg/5ml......................................................62
TGT GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 31
THALOMID -thalidomide cap 100 mg..............................165
THALOMID -thalidomide cap 150 mg..............................165
THALOMID -thalidomide cap 200 mg..............................165
THALOMID -thalidomide cap 50 mg................................165
THEO-24 -theophylline cap sr 24hr 100 mg...................... 64
THEO-24 -theophylline cap sr 24hr 200 mg...................... 65
THEO-24 -theophylline cap sr 24hr 300 mg...................... 65
THEO-24 -theophylline cap sr 24hr 400 mg...................... 65
theophylline soln 80 mg/15ml........................................ 65
theophylline tab sr 12hr 100 mg.................................... 65
theophylline tab sr 12hr 200 mg.................................... 65
theophylline tab sr 12hr 300 mg.................................... 65
theophylline tab sr 12hr 450 mg.................................... 65
theophylline tab sr 24hr 400 mg.................................... 65
theophylline tab sr 24hr 600 mg.................................... 65
THERA-FLUR-N -sodium fluoride gel 1.1% (0.5% f)....... 143
THIOLA -tiopronin tab 100 mg.......................................... 75
thioridazine hcl tab 100 mg............................................ 84
thioridazine hcl tab 10 mg.............................................. 84
thioridazine hcl tab 25 mg.............................................. 84
thioridazine hcl tab 50 mg.............................................. 84
thiothixene cap 10 mg.....................................................84
thiothixene cap 1 mg...................................................... 84
thiothixene cap 2 mg...................................................... 84
thiothixene cap 5 mg...................................................... 84
THRIVITE 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 122
thyroid tab 30 mg (1/2 grain) (Armour thyroid)............. 34
thyroid tab 60 mg (1 grain) (Armour thyroid)................ 34
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid).......... 34
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
245
2015
THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25
mcg)................................................................................. 34
THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5
mcg)................................................................................. 34
THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg).......34
THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100 mcg)......34
THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150
mcg)................................................................................. 34
tiagabine hcl tab 2 mg (Gabitril).................................. 110
tiagabine hcl tab 4 mg (Gabitril).................................. 110
TIAZAC -diltiazem hcl extended release beads cap sr 24hr
120 mg............................................................................. 43
TIAZAC -diltiazem hcl extended release beads cap sr 24hr
180 mg............................................................................. 44
TIAZAC -diltiazem hcl extended release beads cap sr 24hr
240 mg............................................................................. 44
TIAZAC -diltiazem hcl extended release beads cap sr 24hr
300 mg............................................................................. 44
TIAZAC -diltiazem hcl extended release beads cap sr 24hr
360 mg............................................................................. 44
TIAZAC -diltiazem hcl extended release beads cap sr 24hr
420 mg............................................................................. 44
ticlopidine hcl tab 250 mg............................................ 136
TIGAN -trimethobenzamide hcl cap 300 mg..................... 69
TIKOSYN -dofetilide cap 125 mcg (0.125 mg).................. 45
TIKOSYN -dofetilide cap 250 mcg (0.25 mg).................... 45
TIKOSYN -dofetilide cap 500 mcg (0.5 mg)...................... 45
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe).................................................................140
timolol maleate ophth gel forming soln 0.5% (Timopticxe).................................................................................. 140
timolol maleate ophth soln 0.25% (Timoptic)..............140
timolol maleate ophth soln 0.5% (Timoptic)................140
TIMOLOL MALEATE -timolol maleate tab 10 mg..............41
TIMOLOL MALEATE -timolol maleate tab 20 mg..............41
TIMOLOL MALEATE -timolol maleate tab 5 mg................41
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.25%........................................................... 140
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.5%............................................................. 140
TIMOPTIC -timolol maleate ophth soln 0.25%................ 140
TIMOPTIC -timolol maleate ophth soln 0.5%.................. 140
TIMOPTIC-XE -timolol maleate ophth gel forming soln
0.25%............................................................................. 140
TIMOPTIC-XE -timolol maleate ophth gel forming soln
0.5%............................................................................... 140
TINDAMAX -tinidazole tab 250 mg................................... 12
TINDAMAX -tinidazole tab 500 mg................................... 12
tinidazole tab 250 mg (Tindamax).................................. 12
tinidazole tab 500 mg (Tindamax).................................. 12
TIROSINT -levothyroxine sodium cap 100 mcg................ 34
TIROSINT -levothyroxine sodium cap 112 mcg................ 34
TIROSINT -levothyroxine sodium cap 125 mcg................ 34
TIROSINT -levothyroxine sodium cap 137 mcg................ 34
TIROSINT -levothyroxine sodium cap 13 mcg.................. 34
246
TIROSINT -levothyroxine sodium cap 150 mcg................ 34
TIROSINT -levothyroxine sodium cap 25 mcg.................. 34
TIROSINT -levothyroxine sodium cap 50 mcg.................. 34
TIROSINT -levothyroxine sodium cap 75 mcg.................. 34
TIROSINT -levothyroxine sodium cap 88 mcg.................. 34
TIVICAY -dolutegravir sodium tab 50 mg (base equiv)......10
TIVORBEX -indomethacin cap 20 mg............................. 104
TIVORBEX -indomethacin cap 40 mg............................. 104
TIZANIDINE COMFORT PAC -tizanidine tab 4 mg &
liniment topical gel pack................................................ 114
tizanidine hcl cap 2 mg (base equivalent)
(Zanaflex)...................................................................... 114
tizanidine hcl cap 4 mg (base equivalent)
(Zanaflex)...................................................................... 114
tizanidine hcl cap 6 mg (base equivalent)
(Zanaflex)...................................................................... 114
tizanidine hcl tab 2 mg (base equivalent)....................114
tizanidine hcl tab 4 mg (base equivalent)
(Zanaflex)...................................................................... 114
TL-CARE DHA -prenatal w/fe fumarate-fa-dss-fish oil cap
27-1-500 mg...................................................................122
TL-CERMIDE -dermatological products misc emulsion......................................................................... 160
TL-FLUORIVITE -pediatric multiple vitamins w/ fl-fe chew
tab 0.25-7.5 mg..............................................................122
TL FOLATE -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.5-0.5 mg.................................................................122
TL G-FOL OS -multiple vit w/ min & calcium-folic acid tab
500-1.1 mg.....................................................................122
TL-SELECT DHA -prenatal w/o vit a w/ fe fum-doc-fa-dha
cap 29-1.25-350 mg.......................................................122
TL-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg..............................................................122
TL TRISEB -antiseborrheic products misc - cream..........160
TOBI PODHALER -tobramycin inhal cap 28 mg................. 5
TOBI -tobramycin nebu soln 300 mg/5ml............................ 5
TOBRADEX ST -tobramycin-dexamethasone ophth susp
0.3-0.05%....................................................................... 140
TOBRADEX -tobramycin-dexamethasone ophth oint
0.3-0.1%......................................................................... 140
TOBRADEX -tobramycin-dexamethasone ophth susp
0.3-0.1%......................................................................... 140
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex).....................................................................140
tobramycin nebu soln 300 mg/5ml (Tobi)........................5
tobramycin ophth soln 0.3% (Tobrex)......................... 140
TOBREX -tobramycin ophth oint 0.3%............................ 141
TOBREX -tobramycin ophth soln 0.3%........................... 140
TOFRANIL -imipramine hcl tab 10 mg.............................. 80
TOFRANIL -imipramine hcl tab 25 mg.............................. 80
TOFRANIL -imipramine hcl tab 50 mg.............................. 80
TOFRANIL-PM -imipramine pamoate cap 100 mg............ 80
TOFRANIL-PM -imipramine pamoate cap 125 mg............ 80
TOFRANIL-PM -imipramine pamoate cap 150 mg............ 80
TOFRANIL-PM -imipramine pamoate cap 75 mg.............. 80
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
tolazamide tab 250 mg.................................................... 31
TOLAZAMIDE -tolazamide tab 500 mg............................. 31
TOLBUTAMIDE -tolbutamide tab 500 mg......................... 31
tolcapone tab 100 mg (Tasmar)................................... 113
tolmetin sodium cap 400 mg........................................ 104
TOLMETIN SODIUM -tolmetin sodium tab 200 mg......... 104
TOLMETIN SODIUM -tolmetin sodium tab 600 mg......... 104
tolterodine tartrate cap sr 24hr 2 mg (Detrol la)........... 73
tolterodine tartrate cap sr 24hr 4 mg (Detrol la)........... 73
tolterodine tartrate tab 1 mg (Detrol)............................. 73
tolterodine tartrate tab 2 mg (Detrol).............................73
TOPAMAX SPRINKLE -topiramate sprinkle cap 15
mg.................................................................................. 110
TOPAMAX SPRINKLE -topiramate sprinkle cap 25
mg.................................................................................. 110
TOPAMAX -topiramate tab 100 mg.................................110
TOPAMAX -topiramate tab 200 mg.................................110
TOPAMAX -topiramate tab 25 mg...................................110
TOPAMAX -topiramate tab 50 mg...................................110
TOPICORT -desoximetasone cream 0.05%....................160
TOPICORT -desoximetasone cream 0.25%....................160
TOPICORT -desoximetasone gel 0.05%.........................160
TOPICORT -desoximetasone oint 0.05%........................160
TOPICORT -desoximetasone oint 0.25%........................160
TOPICORT -desoximetasone spray 0.25%..................... 160
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 100
mg.................................................................................. 110
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 150
mg.................................................................................. 110
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 200
mg.................................................................................. 110
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25
mg.................................................................................. 110
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 50
mg.................................................................................. 110
topiramate sprinkle cap 15 mg (Topamax
sprinkle)........................................................................ 110
topiramate sprinkle cap 25 mg (Topamax
sprinkle)........................................................................ 110
topiramate tab 100 mg (Topamax)............................... 110
topiramate tab 200 mg (Topamax)............................... 110
topiramate tab 25 mg (Topamax)................................. 110
topiramate tab 50 mg (Topamax)................................. 110
TOPROL XL -metoprolol succinate tab sr 24hr 100 mg.....41
TOPROL XL -metoprolol succinate tab sr 24hr 200 mg.....41
TOPROL XL -metoprolol succinate tab sr 24hr 25 mg...... 41
TOPROL XL -metoprolol succinate tab sr 24hr 50 mg...... 41
torsemide tab 100 mg (Demadex).................................. 53
torsemide tab 10 mg (Demadex).................................... 53
torsemide tab 20 mg (Demadex).................................... 53
torsemide tab 5 mg (Demadex)...................................... 53
TOUJEO SOLOSTAR -insulin glargine soln pen-injector
300 unit/ml....................................................................... 33
TOVIAZ -fesoterodine fumarate tab sr 24hr 4 mg............. 73
TOVIAZ -fesoterodine fumarate tab sr 24hr 8 mg............. 73
TRACLEER -bosentan tab 125 mg................................... 58
TRACLEER -bosentan tab 62.5 mg.................................. 58
TRADJENTA -linagliptin tab 5 mg..................................... 31
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)........................................................................100
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 100 mg.............................................................. 100
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 150 mg.............................................................. 100
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 200 mg.............................................................. 100
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 300 mg.............................................................. 100
tramadol hcl tab 50 mg (Ultram).................................. 100
tramadol hcl tab sr 24hr 100 mg (Ultram er)............... 100
tramadol hcl tab sr 24hr 200 mg (Ultram er)............... 100
tramadol hcl tab sr 24hr 300 mg (Ultram er)............... 100
tramadol hcl tab sr 24hr biphasic release 100 mg...... 100
tramadol hcl tab sr 24hr biphasic release 200 mg...... 100
tramadol hcl tab sr 24hr biphasic release 300 mg...... 100
TRANDATE -labetalol hcl tab 100 mg...............................41
TRANDATE -labetalol hcl tab 200 mg...............................41
TRANDATE -labetalol hcl tab 300 mg...............................42
trandolapril tab 1 mg (Mavik)......................................... 51
trandolapril tab 2 mg (Mavik)......................................... 51
trandolapril tab 4 mg (Mavik)......................................... 51
trandolapril-verapamil hcl tab cr 1-240 mg (Tarka).......51
trandolapril-verapamil hcl tab cr 2-180 mg (Tarka).......51
trandolapril-verapamil hcl tab cr 2-240 mg (Tarka).......51
trandolapril-verapamil hcl tab cr 4-240 mg (Tarka).......51
tranexamic acid tab 650 mg (Lysteda).........................133
TRANSDERM-SCOP -scopolamine td patch 72hr 1
mg/3days..........................................................................69
TRANXENE T -clorazepate dipotassium tab 15 mg.......... 76
TRANXENE T -clorazepate dipotassium tab 3.75 mg....... 76
TRANXENE T -clorazepate dipotassium tab 7.5 mg......... 76
tranylcypromine sulfate tab 10 mg (Parnate)................80
TRAVATAN Z -travoprost ophth soln 0.004%
(benzalkonium free) (bak free).......................................141
TRAVOPROST -travoprost ophth soln 0.004%............... 141
trazodone hcl tab 100 mg............................................... 80
trazodone hcl tab 150 mg............................................... 80
trazodone hcl tab 300 mg............................................... 80
trazodone hcl tab 50 mg................................................. 80
TREAGAN OTIC -antipyrine-benzocaine-polycosanol otic
sol 5.4-1.4-0.0097%....................................................... 142
TRECATOR -ethionamide tab 250 mg................................ 6
tretinoin cap 10 mg......................................................... 19
tretinoin cream 0.025% (Retin-a)..................................160
tretinoin cream 0.05% (Retin-a)....................................160
tretinoin cream 0.1% (Retin-a)......................................160
tretinoin gel 0.01% (Retin-a)......................................... 160
tretinoin gel 0.025% (Retin-a)....................................... 160
tretinoin microsphere gel 0.04% (Retin-a micro)........ 160
tretinoin microsphere gel 0.1% (Retin-a micro).......... 160
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
247
2015
TRETIN-X -tretinoin cream 0.025% w/ cleanser &
moisturizer kit.................................................................160
TRETIN-X -tretinoin cream 0.05% w/ cleanser &
moisturizer kit.................................................................160
TRETIN-X -tretinoin cream 0.075%.................................160
TRETIN-X -tretinoin cream 0.1% w/ cleanser & moisturizer
kit....................................................................................160
TRETTEN -coagulation factor xiii a-subunit for inj
2000-3125 unit............................................................... 136
TREXALL -methotrexate sodium tab 10 mg (base
equiv)................................................................................19
TREXALL -methotrexate sodium tab 15 mg (base
equiv)................................................................................19
TREXALL -methotrexate sodium tab 5 mg (base
equiv)................................................................................19
TREXALL -methotrexate sodium tab 7.5 mg (base
equiv)................................................................................19
TREXIMET -sumatriptan-naproxen sodium tab 85-500
mg.................................................................................. 106
TREZIX -acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg..............................................................100
TRIADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg..........................................................................122
triamcinolone acetonide aerosol soln (Kenalog)........ 160
triamcinolone acetonide cream 0.025%.......................160
triamcinolone acetonide cream 0.1%...........................160
triamcinolone acetonide cream 0.5%...........................160
triamcinolone acetonide dental paste 0.1%................ 143
triamcinolone acetonide lotion 0.025%....................... 160
triamcinolone acetonide lotion 0.1%........................... 160
triamcinolone acetonide nasal aerosol suspension 55
mcg/act (Nasacort aq)................................................... 59
triamcinolone acetonide oint 0.025%...........................160
triamcinolone acetonide oint 0.1%...............................160
TRIAMCINOLONE ACETONIDE -triamcinolone acetonide
oint 0.5%........................................................................ 160
TRIAMTERENE/HYDROCHLOROTH -triamterene &
hydrochlorothiazide cap 50-25 mg...................................53
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide)......................................................................... 53
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)....................................................................53
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)......................................................................... 53
TRIANEX -triamcinolone acetonide oint 0.05%............... 160
triazolam tab 0.125 mg....................................................85
triazolam tab 0.25 mg (Halcion)..................................... 85
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 20-5-12.5 mg............................................................. 51
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 40-10-12.5 mg........................................................... 51
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 40-10-25 mg.............................................................. 51
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 40-5-12.5 mg............................................................. 51
248
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 40-5-25 mg................................................................ 51
TRICARE PRENATAL COMPLEAT -prenat w/o a fefum-fa
tab 27-1 mg & fish oil chew cap pak............................. 122
TRICARE PRENATAL DHA ONE -prenatal w/fe fumaratefa-dss-fish oil cap 27-1-500 mg..................................... 122
TRICARE -prenatal vit w/ fe fumarate-fa tab 27-1 mg..... 122
TRI-CHLOR -trichloroacetic acid liqd 80%...................... 160
TRICODE AR -pseudoephedrine-chlorphen w/ codeine liq
30-2-8 mg/5ml..................................................................62
TRICODE GF -pseudoephedrine w/ cod-gg liquid 30-8-200
mg/5ml..............................................................................62
TRICOR -fenofibrate tab 145 mg...................................... 56
TRICOR -fenofibrate tab 48 mg........................................ 56
trifluoperazine hcl tab 10 mg......................................... 84
trifluoperazine hcl tab 1 mg........................................... 84
trifluoperazine hcl tab 2 mg........................................... 84
trifluoperazine hcl tab 5 mg........................................... 84
trifluridine ophth soln 1% (Viroptic)............................ 141
TRIGLIDE -fenofibrate tab 160 mg....................................56
trihexyphenidyl hcl elixir 0.4 mg/ml.............................113
trihexyphenidyl hcl tab 2 mg........................................113
trihexyphenidyl hcl tab 5 mg........................................113
TRILEPTAL -oxcarbazepine susp 300 mg/5ml (60 mg/
ml).................................................................................. 110
TRILEPTAL -oxcarbazepine tab 150 mg......................... 110
TRILEPTAL -oxcarbazepine tab 300 mg......................... 110
TRILEPTAL -oxcarbazepine tab 600 mg......................... 110
TRILIPIX -choline fenofibrate cap dr 135 mg (fenofibric
acid equiv)........................................................................56
TRILIPIX -choline fenofibrate cap dr 45 mg (fenofibric acid
equiv)................................................................................56
trimethobenzamide hcl cap 300 mg (Tigan).................. 69
trimethoprim tab 100 mg................................................ 12
TRINATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg..........................................................................122
TRINATAL RX 1 -prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................. 122
TRINATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg..........................................................................122
TRINATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg......122
TRI-NORINYL 28 -norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg..............................................26
TRIPLE DYE -triple dye solution..................................... 163
TRISTART DHA -prenat w/o a w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg......................................................... 122
TRI-TABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack.........................................................122
TRIUMEQ -abacavir-dolutegravir-lamivudine tab
600-50-300 mg.................................................................10
TRIVEEN-DUO DHA -prenat-fe bis-fe prot succ-fa-ca tab
& omega 3 cap 400 pk.................................................. 122
TRIVEEN-PRX RNF -prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg................................................. 122
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015
2015
TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic
susp 0.25 mg/ml............................................................ 122
TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic
susp 0.5 mg/ml.............................................................. 122
TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp
0.25 mg/ml..................................................................... 122
TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp
0.5 mg/ml....................................................................... 122
TRI-VIT/FLUORIDE/IRON -pediatric vitamins acd fluoride
& fe drops 0.25-10 mg/ml.............................................. 122
TRIZIVIR -abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg...............................................................10
TROKENDI XR -topiramate cap sr 24hr 100 mg............. 110
TROKENDI XR -topiramate cap sr 24hr 200 mg............. 110
TROKENDI XR -topiramate cap sr 24hr 25 mg............... 110
TROKENDI XR -topiramate cap sr 24hr 50 mg............... 110
TROPAZONE -emollient - lotion......................................161
tropicamide ophth soln 0.5%........................................141
tropicamide ophth soln 1% (Mydriacyl).......................141
trospium chloride cap sr 24hr 60 mg............................ 73
trospium chloride tab 20 mg.......................................... 73
TRULICITY -dulaglutide soln pen-injector 0.75
mg/0.5ml...........................................................................31
TRULICITY -dulaglutide soln pen-injector 1.5
mg/0.5ml...........................................................................31
TRUSOPT -dorzolamide hcl ophth soln 2%.................... 141
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
200-300 mg......................................................................10
trypsin w/ castor oil & peruvian balsam spray
(Granulex)..................................................................... 161
TUDORZA PRESSAIR -aclidinium bromide aerosol powd
breath activated 400 mcg/act...........................................65
TUSNEL -brompheniramine w/ dm-gg cap 2-15-200
mg.................................................................................... 62
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
10-8 mg............................................................................62
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
5-4 mg..............................................................................62
TUSSIONEX PENNKINETIC EXT -hydrocod polstchlorphen polst cr susp 10-8 mg/5ml...............................62
TUZISTRA XR -codeine polist-chlorphen polist er susp
14.7-2.8 mg/5ml............................................................... 62
TWYNSTA -telmisartan-amlodipine tab 40-10 mg.............51
TWYNSTA -telmisartan-amlodipine tab 40-5 mg...............51
TWYNSTA -telmisartan-amlodipine tab 80-10 mg.............52
TWYNSTA -telmisartan-amlodipine tab 80-5 mg...............51
TYBOST -cobicistat tab 150 mg........................................10
TYKERB -lapatinib ditosylate tab 250 mg (base equiv)..... 19
TYLENOL/CODEINE #3 -acetaminophen w/ codeine tab
300-30 mg......................................................................100
TYLENOL/CODEINE #4 -acetaminophen w/ codeine tab
300-60 mg......................................................................100
TYLENOL/CODEINE -acetaminophen w/ codeine tab
300-15 mg......................................................................100
TYVASO REFILL -treprostinil inhalation solution 0.6 mg/
ml......................................................................................58
TYVASO STARTER -treprostinil inhalation solution 0.6
mg/ml................................................................................58
TYVASO -treprostinil inhalation solution 0.6 mg/ml........... 58
TYZEKA -telbivudine tab 600 mg...................................... 10
TYZINE PEDIATRIC NASAL DR -